[Precise application of Traditional Chinese Medicine in minimally-invasive techniques]

Fu-Hui Dong
Zhongguo Gu Shang, China Journal of Orthopaedics and Traumatology 2018 June 25, 31 (6): 493-496
The miminally-invasive techniques of traditional Chinese medicine(TCM) uses different types of acupuncture needles to treat diseased locations with special techniques. These techniques include different methods of insertion and closed incision (press cutting, sliding cutting, scrape cutting, etc.). This needling technique is based on the traditional Chinese medicine theories of Pi Bu (cutaneous), Jing Jin (sinew), Jing Luo (meridian), Wu Ti (five body structure components) and Zang Fu (organ system). Commonly used needles include: needle Dao , needle with edge, Pi needle, Shui needle, Ren needle, Gou needle, Chang Yuan needle, Bo needle and so on. The principle of this minimally-invasive technique of TCM is to achieve the greatest healing benefit with the least amount of anatomical and physiological intervention. This will result in the highest standard of health care with the lowest rehabilitative need and burden of care. In the past 20 years, through the collaborative research of several hundred hospitals across China, we systemically reviewed the best minimally invasive technique of TCM and the first line treatments for selective conditions. In 2013, the Department of Medical Affairs of the State Administration of Traditional Chinese Medicine created "Traditional Chinese Medicine Technical Manual"(General Version) and released it nationwide, its contents include: (1)Minimally invasive scar tissue release. ¹Suitable for Bi and pain syndromes of neck, shoulder, waist, buttocks and extremities. ²Degeneration causes local hypertrophy and inflammation, creating local tissue adhesion. ³There are two kind incision methods-press cutting and slide cutting. (2)Minimally invasive fascial tension release. ¹Suitable for localized fascial tension caused by trauma, overuse, or wind-cold-dampness, leading to compensatory hyperplasia. ²Long term high-stress stimulation to local fascia creates compensatory hyperplasia, Ashi points, and tissue texture changes (cords, nodules, masses). ³According to the different structural features of the needles, there are two incision methods: penetrating from the outside to the inside and pulling from inside to outside. (3)Minimally invasive decompression technique. ¹Suitable for internal pressure changes within organ cavities caused by trauma, degeneration, inflammation, such as compartment syndrome, bone marrow edema, increased intraluminal pressure in the bone marrow. ²According to the different tissues, it is categorized into soft tissue decompression, and bone decompression. (4)Minimally invasive orthopedic surgery. Applicable to some postural, developmental deformity correction, mainly through the dynamic balance method and/or static balance method. (5)Minimally invasive dissection. Suitable for fractures, tendons injury caused by deep soft tissue adhesion. (6)Minimally invasive separation. ¹Suitable for cutaneous, sinew regions, superficial adhesions due to lesions, and local post-operative incision adhesions. ²According to the structure of the needle tip, the methods are divided into sharp separation and blunt dissection. (7)Minimally invasive sustained pressure technique. ¹Suitable for neuromuscular dysfunction which causes JING (spasm) syndrome and WEI (atrophy) syndrome. ²The needle is applied with sustained pressure, without penetrating select tissue surface. This includes: nerve root sustained pressure technique; peripheral nerve sustained pressure technique; muscle sustained pressure technique; fascial contact procedure; cutaneous sustained pressure technique.(8)Minimally invasive insertion technique. ¹Suitable for systemic regulation to treat disease. ²Different organs are connected to different layers of tissue. Therefore, to treat specific conditions, specific tissues must be targeted. ³For example, back Shu points are used to treat vertigo from cervical spine issues, and spinal degeneration associated digestion issue. ⁴The internal organs can be regulated by the pathways that runs along the different layers of tissue. The types of stimulation include: meridian acupoint stimulation; cutaneous stimulation; fascia stimulation; mucle stimulation; periosteum stimulation. The clinical application of these techniques has enriched the drug-free therapies of traditional Chinese medicine and achieved excellent outcomes, but at the same time it also raises an important question. How can we apply these minimally invasive techniques to clinical practice so it can be safe and effective? In addition, how can practitioners, individually and further develop their understanding of this minimally invasive technique progressive manner? We make the following recommendations. (1)Clear diagnosis and precise application. Any approach has specific indications and choosing the correct technique comes from a comprehensive understanding of its advantages and disadvantages. Moreover, the accurate application of the technique depends the expertise of the practitioner. Through systematic review and clinical observation, we formulated the First Line Treatment, the Second Line Treatment, and the Third Line Treatment for specific conditions. Using the information gathered from research, practitioners can decide on which point is appropriate to use based on the stage of disease progression. For example, common conditions like the nerve ending tension pain(i.e. cutaneous nerve entrapment syndrome) is caused by stress concentration. There are two types of treatment for this condition: ¹Change in the response to stress state (i.e.non-invasive approach such as manual therapy and physiotherapy). ²Change in state of surrounding environment (i.e. invasive approach such as Pi Needle). Before tissue texture changes to pain point, cord, nodules, the former approach is effective. Once tissue texture changes, the latter approach is First Line Treatment. (2)Systematic training and disease progression training. The minimally invasive techniques of traditional Chinese medicine can treat many kinds of disease. To ensure its safety, organization, progressive development, practitioners are trained systematically and manage their treatment approach through disease hierarchy. Moreover, this technique should be conducted according to its technical difficulty, operating conditions, and expertise of the practitioner. The application of minimally invasive techniques of traditional Chinese medicine does not depend on the hospitals' administration system or the regulatory college of medical professionals. The minimally invasive techniques of TCM should be taught from easy to difficult, simple to complicated, and requires gradual progression by the practitioners. Eventually, the minimally invasive techniques of TCM's diagnostic and treatment protocol can be created. These protocols are currently available for reference: ¹Forming diagnosis and differential diagnosis for the conditions below requires expert diagnostic and application skills: cerebral palsy; cervical vertigo; cervical headache; cervical precordial pain; other spine-related diseases. ²The requirements for the diagnosis and differential diagnosis of such techniques are relatively high, and special training is required for the practitioner who performs this technique. The conditions below uses minimally invasive orthopedic surgery and dissection: scar contracture deformity; congenital developmental malformations; cervical Bi -syndrome; shoulder pain syndrome; knee Bi -syndrome; low back pain; cervical spondylosis; lumbar disc herniation; avascular necrosis of the femoral head; ankylosing spondylitis. ³There are no special requirements for the diagnosis and differential diagnosis of such techniques, and special training is required for the practitioner who performs this technique. The technical content is mainly decompression and scar tissue release. a)Muscle strain diseases: levator scapulae, splenius capitis, splenius cervicis, supraspinatus, infraspinatus, teres minor, teres major, serratus posterior superior, serratus posterior inferior, piriformis, gluteus maximus, gluteus medius, and gluteus minimus, erector spinae. b)Joint degenerative disorders: frozen shoulder, tennis elbow, tenosynovitis, knee osteoarthritis, and plantar fascitis. c) JING-JIN PI-BU pain syndrome (cutaneous nerve entrapment syndrome): occipital great nerve entrapment syndrome, occipital small nerve entrapment syndrome, great auricular nerve entrapment syndrome, suprascapular nerve entrapment syndrome, transverse cutaneous nerve of neck entrapment syndrome. (3)People-centred practice. The most attractive feature of the minimally invasive techniques of TCM is that they do not rely on expensive medical equipment and operating conditions. The key to applying this technique is the practitioners' technique, skill, and expertise. The necessary conditions required to successfully apply this technique is ¹practitioner understands disease progression and diagnosis; ²practitioners' skill in applying technique. We require patient-centered approach, which uses evidence based approach as the focus. We aim to seek the truth from facts, to understand the comprehensive picture, to include pertinent details, to be observant, to be goal oriented, from one to another, from outside to inside, from top to the bottom, compare right from left, through active movement and passive movements and weight-bearing movements, and assisted passive movements to determine instantaneous centre to diagnose stress concentration points. The operating technique is based on the response of patient's tissues to this technique. We must pay attention to diagnosis through palpation: layers, structure, texture, deformity, dislocation, movement characteristic, rhythmic changes. To achieve SHOU MO XIN HUI WU WEI : position, quantify, quantity, timing, and pattern. Accurate grasp of timeliness and dose efficiency. Can distinguish between local or systemic effects of treatment. Through comprehensive judgment of hands feeling, acupuncture needle feeling, and inspiration, to achieve the precious treatment requirements as indicated by the "Huangdi Neijing·Suwen" : "Puncture the bone without damaging tendons, and puncture tendons without damaging muscles, puncture the muscle without damaging pulse, puncture pulse without damaging skin, puncture skin without damaging muscle. Puncture muscle without damage tendons, puncture tendons without damaging bone... Puncture bone without damaging tendons and it means the needle passes through the tendons and arrives at the bone and work on the bone. Puncture tendons without damaging muscles, and it means the needle passes through the muscles and arrives close to the tendon. Puncture the muscle without damaging pulse and it means the needle passes the pulse and does not touch the muscle. Puncture pulse without damaging skin and it means, the needle passes through the skin without penetrating pulse. Puncture skin without damaging muscle and it means, the disease is in the skin and the needles insert into skin but does not damage muscle. Puncture muscle without damage tendons, and it means, the needle passes through the muscle and arrive on the tendon. Puncture tendons without damaging bone."

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