By Honora Lee Wolfe

Repetitive strain injuries such as carpal tunnel syndrome and tendonitis represent 56% of all workers compensation claims in the US at this time. In my acupuncture practice, hand, wrist, and forearm pain and numbness is possibly the most common pain pattern that I see on a regular basis. It is most often related to the type of work that a person is doing and, in my practice at least, is twice as common in women as in men. Hair dressers, musicians, aestheticians, massage therapists, manicurists, and anyone who works for extended hours on a computer seem to be particularly prone to this type of overuse injury. And since it threatens their livelihood, such people often find these injuries as frightening as they are physically painful. Unfortunately, it may be true that a patient with a severe case of hand/wrist tendinitis or full blown carpal tunnel syndrome may have to stop the work that aggravates the condition at least for a while. Less severe cases can be treated quite successfully with Chinese medicine for a very reasonable cost and kept from becoming debilitating and, therefore, threatening to someone's livelihood.

In the last several years, I have treated many people with this problem in varying stages of severity and I have developed an effective approach to diagnosis and treatment that may be useful to other practitioners.

Western medical etiological factors

In Western medicine, the continuum leading to full blown carpal tunnel syndrome starts with any repetitive, complex set of motions placing very specialized demands on this specific region of the upper extremities. Further, because of the tremendous variability of their movement, the great number of articulations and intrinsic and extrinsic muscles, and their use as a major sensory as well as a motor organ, the hand and wrist is particularly vulnerable to injury and difficult to treat successfully. According to Western medical theory, tendinitis in the hand and wrist is a process which begins with tendinomuscular fatigue leading to micro-tears which becomes chronic inflammation as they are aggravated over and over again without adequate rest. Without rest, muscles do not receive enough oxygen and other nutrients from the blood and are unable to flush lactic acid and other metabolic wastes. When the nervous system becomes involved, the muscle tendon bundles remain hypertonic and pain reflexes in the area are activated. This becomes a chronic inflammatory/pain cycle and is the same for any part of the body.

Chinese medical etiological factors

The causes of muscle and sinew pain have been well described in many Chinese medical texts, as early as the "The Treatise on Bi" in the Nei Jing Su Wen. In Huang-fu Mi's Systematic Classic of Acupuncture & Moxibustion, there are several chapters devoted specifically to these types of problems. In more modern books such as Bi Syndromes by Vangermeersch and Sun, theories about muscle/sinew pain have been synthesized into a format that is quite accessible for Western students and practitioners.

1. Bi

Classically, many types of muscle or sinew pain may be classified as bi or blockage pattern. According to Drs. Vangermeersch and Sun, "In TCM, the term bi is specifically used to indicate obstruction of qi and blood in the channels and collaterals due to several kinds of pathogenic factors, such as wind, coldness, dampness, etc... and leading mainly to pain, numbness, and impairment of movement." In the same book, the authors state that in order for external pathogenic qi to invade the tissue, correct or righteous qi must be weak, as is often the case in elderly or weakened patients.

While blockage patterns are definitely a co-factor to be considered when confronted with a patient presenting pain in the forearm, wrist, and hand, it is my experience that there are usually other factors of equal importance involved. These may include vacuity of qi and blood, weakness or one or another organ, and possibly blood stasis.

2. Qi and blood vacuity due to spleen qi vacuity

Chinese medicine says that the spleen rules the muscles and flesh and the four limbs. If a patient with wrist, hand, and/or arm pain has other signs and symptoms indicating spleen qi vacuity as well, this will definitely have an impact on their dysfunction. If the patient has numbness as well as pain, spleen vacuity may be participating in this problem as well. We know this because Chinese medicine says that the spleen is the organ of transformation of qi and blood. A weak spleen may not be able to transform enough qi and blood to circulate the extremities adequately.

Further, qi is required to transform dampness. If the spleen is unable to generate enough qi to transform and transport dampness, it may congeal in the tissues and hinder the normal flow of qi. The patient will describe this as pain which feels heavy or worsens in damp weather. Also, since dampness is one of the three factors in bi patterns, this is another example of how qi vacuity can be contribute to a bi or blockage pattern.

As a person gets older, the spleen function weakens and less qi and blood is created to circulate to the extremities. This inadequate flow of qi and blood makes older people more prone to pain, weakness, and/or numbness. Also, as stated by Vangermeersch and Sun above, an elderly person whose qi and blood are weak is also made more vulnerable to invasion of external evils.

Lastly, it is important to remember that for most people who present with hand/wrist/arm pain and numbness, overwork or repetitive work is a major contributor to their problem. Overwork depletes the qi and blood and therefore complicates any situation in which spleen (or kidney) qi vacuity plays a part.

3. Blood stasis

In his book on aging and blood stasis, Zhong Guo Li Dai Zhong Yi Kang Shuai Lao Mi Yao, Yan De-xin describes in great detail how blood stasis may participate in a variety of geriatric diseases, including muscle and skin numbness, limb and body aching and pain. He quotes "The Treatise on Bi" from the Nei Jing Su Wen, "If there is bi in the vessels, blood will congeal and does not flow." Thus we can see that blood stasis can complicate muscle or sinew pain anywhere in the body or be a secondary factor in a bi pattern. Of course, pain due to blood stasis will usually be fixed and stabbing in nature. This quality of pain may alternate with other qualities, depending upon what other factors are involved in a particular patient’s case.

4. Liver depression qi stagnation

In my experience, most of the patients who present with this problem are under stress in connection with their work. It is my feeling that the stress plays a role in their pain and dysfunction. This is because emotional stress can cause liver depression qi stagnation. When this happens, the liver cannot properly perform its function of coursing and discharging. This may exacerbate local qi stagnation anywhere in the body. Another Chinese medical statement of fact about the liver is that it governs the sinews and movement, and that when the liver receives blood, the sinews stretch. If the liver’s functions are negatively impacted by emotional stress, both qi stagnation and impairment of the sinews may affect hand/wrist/arm pain and dysfunction.

Most cases of hand/wrist tendinitis or carpal tunnel syndrome that I have seen are a combination of local qi stagnation, internally or externally generated dampness and/or cold, possible blood stasis, and blood and/or qi vacuity manifesting as pain, numbness, and weakness. True bi or blockage (wind, dampness, and cold together), rarely is the main etiological factor.

Patients may also manifest signs and symptoms of spleen qi vacuity, kidney qi vacuity, or liver depression qi stagnation. These patterns may complicate the successful treatment of the problem if not taken into consideration. In such cases, proper herbal therapy may also be necessary to ensure success and diet and lifestyle suggestions must be part of the treatment plan as well.

However, in my practice I largely focus on acupuncture, moxibustion, and tuina therapy. Therefore, while I treat any organ dysfunctions that I discover upon diagnosis as the root aspect of my treatment, my major emphasis is usually on branch treatments that affect the channels and network vessels quite directly.

Questions to ask

I have developed a list of questions that I always ask a patient who presents with this type of dysfunction. It will give me as much information as possible about the causes and progression of the problem, and what possible methods of treatment may be helpful.

1. Exactly where is the pain (weakness, numbness) located? (Determine channels involved.) Is there numbness or tingling (a sign of blood vacuity or blood stasis, at least locally)
2. What makes it better, worse? (any particular weather, cold, heat, dampness) (Worse with cold or dampness, use moxa and massage; worse with heat, use needles, liniments, very little or no massage)
3. What other treatments have you tried?
4. Does the pain move around or remain in one place?
5. Does movement improve or worsen the pain?(Worse with movement = local stagnation; worse with rest = local vacuity.)
6. Can you/have you rested the arm from work?
7. Does massage make it better or worse?
8. Regular "10 Questions" of Chinese medical diagnosis. These will help to determine what constitutional weaknesses, organ/bowel dysfunctions, or other factors may play a role in the patient’s pain or dysfunction.

Locations for hand, wrist/forearm pain

After treating thirty or more of these cases in the recent years, I have noted that the pain more often involves certain channels and less often involves others. I have listed these below in the order of frequency that is most common in my patient population.

1. Jue yin spreading to tai yin and yang ming

2. Yang ming spreading to shao yang

3. Tai yang and shao yang

4. Tai yin and yang ming only

In many cases, the neck and shoulders are also involved. This is especially true if the tai yang and/or shao yang channels are the most affected. Also, it is my experience that if the jue yin is the main channel affected, the whole hand may go numb and there is almost always pain. If the shao yang and tai yang are the main channels affected, only the 4th and 5th digits seem to go numb and there may or may not be any pain. Also, in almost all of my cases, pain may vary in intensity depending upon the activity, but it is more often fixed than wandering.

Basic treatment plan for hand, wrist, arm pain

1. Palpate entire length of affected channels looking for tender points.

Treat tender points with very gentle needling to release if stagnation/stasis is main problem. Use thread moxibustion on these points (3-5 threads) if vacuity is the main issue. A combination of needles and moxibustion can be used where there is both stagnation/stasis and vacuity.

2. Apply needles at main points for the affected channel. This may be on the affected or the unaffected side depending on various factors which we will discuss later in this article:

Per 7 (Da Ling) = jue yin This point is especially important and seems often to make the difference in effective treatment. It is mandatory to needle it if there has been carpal tunnel surgery since the surgery can hinder the normal flow of qi and blood in the area. My experience with this point is interesting in that it can have a positive affect on wrist and hand numbness no matter which of the channels are involved according to the patient’s subjective experience. This seems to be a sort of "master point" for wrist/hand pain and numbness.

LI 4 (He Gu), 10 (San Li), or 11 (Qu Chi) = yang ming

Ba Xie points = numbness in the fingers and hand

SI 3 (Hou Xi) and SI 8 (Xiao Hai) = tai yang

Lu 5 (Chi Ze) or Lu 9 (Tai Yuan) = tai yin

I have found that LI 10 (Shou San Li) is almost always tender no matter what other channels are involved. I almost always needle it on the unaffected side and often use moxa on the needle.

3. Choose one pair of extraordinary channel points if they seem appropriate. This can serve as one style of root treatment. Choose a pair of extraordinary channel points based on the location of the pain and numbness. For example if the problem is on the:

jue yin, you may add very shallow needles with IP cords at Per 6 (Nei Guan) and Sp 4 (Gong Sun).

shao yang, you may add TH 5 (Wai Guan) and GB 41 (Zu Lin Qi), same tx

tai yin and yang ming add Lu 7 (Lie Que) and Ki 6 (Shao Hai), same tx

tai yang add SI 3 (Hou Xi) and Bl 62 (Shen Mai), same tx.

These are especially appropriate if there is tenderness and/or pain on at least one of the paired points.

4. If you determine that there is spleen vacuity, kidney vacuity, liver blood vacuity, liver depression qi stagnation, or any other organ/bowel involvement complicating the problem, choose the supplementation point, source point, and/or back shu point as a root treatment to support what you are doing as a branch treatment. In addition to a better long term affect on the specific problem for which the patient requests help, other, less troubling symptoms may improve as well.

5. If the pain is on either the tai yang, shao yang, or yang ming, palpate up into the neck and shoulder regions following the channel. Look for tender points at TH 16, 17, LI 18, SI 9, 10, 13, and ah si points in these areas. Use thread moxa or needles to relax tenderness.

6. If the pain improves or relaxes with warmth, or if the pain is worse at night or if the arm and hand become numb at night, add the use of indirect moxa with a liniment. The moxa encourages the liniment to penetrate and increases any pain-relieving affect. This treatment can be administered every day by the patient as homework in some cases to strengthen what you are doing during treatments.

7. If there has been surgery on the medial wrist, use a deep needle into Per 7 plus seven star hammer of the entire wrist area.

8. If there is no inflammation (heat, swelling, redness, sensitivity to massage) end the treatment with massage: tuina, mild kneading and squeezing. It is my experience that it is important not to forget the healing power of touch when treating patients for almost any type of problem.

9. Suggest series of 4-6 treatments over a 2-3 week period.

You may be unable do all these things in each patient visit. Pick and choose the ones that seems most appropriate for each case. However, I strongly suggest that you not forget the use of moxibustion in treating musculoskeletal pain of any kind. For me, it is a vital part of my protocol and I’m sure that it increases good results.

Using the affected or unaffected side

One of my teachers, Dr. Miriam Lee, quotes an old Chinese medical saying, "If a child is hurt, don’t punish it." This means not to needle right on top of the area of pain. Dr. Lee frequently does not even needle on the same side as where the pain exists. While I consider Dr. Lee’s saying carefully with each patient, I sometimes treat on the same side as hand pain and numbness appear and sometimes on the opposite side. While it is somewhat difficult to describe how I make this choice, I will try to give some general guidelines.

If there is numbness, I mostly treat the affected side with both needles and moxa. Whereas the use of needles can activate or manipulate the qi and blood, they cannot directly create fresh qi and blood. Only with internal herbal medicine or the use of moxibustion can something be added to the body. Since numbness may often involve at least local blood vacuity, I like to use moxibustion directly on the numb areas to add qi and encourage the infusion of blood into the area. Needling of numb areas encourages the increased flow of qi to them.

If there is no numbness but the pain is chronic, my usual procedure is to use thread moxa in the local area and needle either the exact area of pain on the opposite arm and/or choose a point on the corresponding channel on the contralateral leg. For example, if the pain is on the yang ming channel of the left arm, I would needle any tender point below the knee on the foot yang ming channel on the right leg.

Other considerations may include how chronic or acute the problem is and what makes it worse or better. If the pain is worse with movement (local qi stagnation) and relatively acute, I am more like to use needles in the local area. The more chronic and long term the problem or if it worsens during sleep or rest, the less likely I am to do so. If the problem is definitely adversely affected by cold, indirect moxibustion and local massage seem to give better results than local needles. Beyond these recommendations, each practitioner must experiment and use a combination of intuition and Chinese medical theory to decide how best to treat.

What to try if treatments are unsuccessful

1. Akabane testing/stimulation to balance the channels of the arm/hand will help you confirm your diagnosis of which channels are replete and which ones are vacuous.

2. Ear needles in points for Wrist, Fingers, Pain Master, and Neurogate (Shen Men). You can use mild electrical stimulation if you have it. Use the ear on the affected side.

3. If there are any purple/black veins, if there has been surgery, or if the pain is fixed and stabbing, consider bleeding one or two points, removing one drop of blood at each.

4. Pay more attention to treating the root. Reexamine the patient’s pulse and tongue and go back over what questions you asked to see if you overlooked any factors that may contribute to the condition.

5. Go over self-care techniques with the patient if you have not already done so. Find out if their work habits have changed or if their work-related stress levels have worsened. Suggest dietary changes to support your root treatment.

Self-care

There are a variety of things that patients can do to help themselves. Here are a few that I suggest patients may try.

1. Wearing a splint at night (many patients will already have one of these) or during work can help maintain proper blood circulation to the area. Rest the affected part as much as possible.

2. Patients may want to take extra doses of B5, B6, and Vitamin C. For inflammatory stage of pain, high doses of bioflavonoids may be helpful.

3. Using indirect moxibustion with liniments at home is a good way to extend the therapy they receive during an acupuncture treatment.

Chinese herbal medicines:

I am not well trained in the use of internal Chinese medicinals and rarely use them in my practice. I do, however, use a variety of external applications to promote healing of soft tissue pain and numbness.

1. A variety of herbal soaks are described in books such as Shaolin Secret Formulas for the Treatment of External Injury from Blue Poppy Press. These may contain herbs with a variety of properties to stop pain, activate the qi, remove blood stasis, open and warm the channels and vessels, dry dampness. If your clinic does not have a bulk herb pharmacy, one or two such formulas are available from Crane Enterprises.

2. Green Willow Liniment (from Ancient Principles) is very good for treating the jin level of tissues. I suggest its use with indirect moxibustion to help it penetrate.

3. Dr. Shir's Liniment, Sinew Soothing Application (from Crane Enterprises) has similar properties.

4. Zheng Gu Shui or Musk Zheng Gu Shui relieves the surface in acute injuries, clears heat and stops pain. It is effective when used with direct moxa to help it penetrate.

Case Histories

Case #1

Female, age 29, esthetician

This woman worked 30 hours per week or more doing facials and massage. She had had a Western diagnosis of carpal tunnel syndrome 4 years ago and had had surgery at that time only on the right wrist. She experienced pain, loss of strength, numbness, and fatigue in hands especially after working long hours, and continuous mild pain all the time. The often awakened in the night with severe numbness in the right hand especially. The pain was worst in the thumb and little finger. Her neck felt sore all the time. There were no heat, swelling, or obvious color changes in the skin of the affected area. The patient had no other complaints and was otherwise in good health. Her menstrual cycle, digestion, elimination, and sleep were normal.

Other symptoms: None

Tender points: entire neck area on all channels; hands and wrist not tender to palpation; responded well to massage.

Tongue: I did not use tongue diagnosis for this patient.

Pulse: somewhat wiry, otherwise not remarkable

Diagnosis: local qi stagnation and counterflow into neck region; jue yin, shao yin, and tai yang channels, mostly on right hand and wrist

First Treatment:

1. Manaka Whiplash Treatment to relax all yang channels into neck and upper back and normalize flow of qi and blood. This treatment involves the use of all four yang extraordinary channels on both sides with ion pumping cords. The reds clips are attached to Hou Xi (SI3) and Zu Lin Qi (GB 41), black clips attached to Shen Mai (Bl 62) and Wai Guan (TH 5). These needles were left in place for 12-15 minutes.

2. Next, needles were applied to the Ba Xie points between 5th-4th and 4th-3rd metacarpals. Thread moxa on the Shang Ba Xie points in the same areas.

3. Indirect moxa over entire hands after rubbing in Green Willow™ liniment using tuina techniques for five minutes on each hand and up into neck area.

Second Treatment:

Her hands were some better after the first Tx; neck and back also improved. Work was very stressful, however, and her hands felt tired. I repeated the same Tx and sent the patient home with a moxa stick and liniment to do daily home therapy.

Third Treatment:

Her hands felt continuously better but still had numbness and a dead feeling in the right hand in 4th and 5th metacarpals, especially at night; similar but less sensation on the left. I applied needles in right Da Ling (Per 7), Qu Ze (Per 3), Ba Xie points, with indirect moxa on the medial forearm; needles in left Shou San Li (LI 10), Da Ling (Per 7), and Qu Chi (LI 11). No moxa was used on the left side.

After six similar treatments, the patient reported that the numbness and pain were completely gone and she was sleeping through the night witn no numbness and able to work without fatigue.

The patient did not return for over a year, at which time we repeated a similar Tx with the addition of He Gu (LI 4) and Wai Guan (TH 5) which again alleviated all symptoms.

Case #2

Female, age 37, secretary

This woman had numbness and tingling in both arms, much worse on the right side and worse with work or when she was tired. Arms feel heavy. She had a one year old child and worked full time at a stressful job. She was quite overweight and had had depression on and off since the birth of her child. She found exercise very difficult.

Other symptoms: Debilitating headaches at the end of her menstrual periods. Always fatigued since the birth of her child. Overweight since her pregnancy.

Tongue: Pale, fluted and a little puffy, red-tipped

Pulse: fine, deep, and slightly irregular

Tender Points: Shou San Li (LI 10), Zu Ling Qi (GB 41), Wai Guan (TH 5), Hou Xi (SI 3)

Diagnosis: systemic qi and blood vacuity and spleen qi vacuity with dampness impeding normal flow of qi and blood

First treatment: I used direct thread moxa on Shang Ba Xie points; needles in SI 3 and Per 7 on the affected side and Shou San Li (LI 10) and Shen Mai (Bl 62) on the opposite side; gentle tuina was applied on the entire arm and shoulder on both sides.

Second treatment: The patient experienced great improvement after the first Tx. I added IP cord Tx with GB 41 (red clip) to GB 14 (black clip) for her headache on the side opposite to the hand numbness and Hwa Tuo Jia Ji points bilaterally along her neck vertebrae, more tuina, and Gui Pi Wan in pill form on a continuing basis until the next menstruation.

Third treatment: The Treatment without Per 7 was less effective for her hand, but the herbs and previous Tx helped her headaches significantly. I needled Per 7 and the Ba Xie points with thread moxa at Zhong Chong (Per 9) and Shang Ba Xie on the affected side, and applied indirect moxa to her entire forearm.

Prognosis: This patient has had eight or nine treatments over a period of three months in which we used similar therapies as described above. She usually reports improvement in symptoms after each treatment. However, symptoms do return. Her job continues to be very stressful and she has neither lost weight nor begun to exercise. While acumoxa therapy can help her keep her symptoms under control, I do not feel that her situation will improve permanently until she deals more effectively with her job stress and her weight problem. This hypothesis is supported by a study done at the San Francisco Chronicle which showed that even when workers have ergonomically correct computer work stations, they are more prone to repetitive strain injuries if they work in a negative psychological environment than those with poor ergonomics but a positive psychological environment.