Back and neck pain is the most common complaint encountered in routine acupuncture practice in the U.S. Its importance is underscored by the following: (1) the annual nationwide cost of back and neck pain is estimated to be between $20 and $50 billion, (2) back and neck symptoms are the most common cause of disability in patients under 45 years of age, (3) over 98% of the Americans are affected with one or more attacks of debilitating back or neck pain during their lifetime, and (4) approximately one to two percent of the U.S. population is chronically disabled because of back and neck pain. Obviously, DAOM have faced a challenge of providing effective and economical care for back & neck pain.
Back and neck pain is only a symptom. Its causes are clinically divided into two major aspects: mechanical origins and non-mechanical origins. Mechanical back and neck pain may be defined as pain secondary to overuse of normal anatomic structure like muscle strain or pain secondary to injury or deformity of an anatomic structure like acute sprain, herniated nucleus pulposus and vertebral fractures. The diagnosis and treatment of mechanical back and neck pain have been thoroughly documented in a large number of oriental medical literature, since mechanical origins are simply limited to chronic or acute mechanical injuries of the spine, its nearby muscles and ligaments.
Contrarily, non-mechanical back and neck pain is a very complicated issue, involving a wide variety of diseases, such as degenerative joint disease, rheumatologic arthritis, infections, visceral conditions referring pain to back and neck, primary and metastatic tumors, and many other systemic disorders, etc. In fact, traditional Chinese medicine can very effectively and economically treat many disorders with non-mechanical back and neck pain. However, some back and neck pain of non-mechanical origins may cover up serious underlying diseases, such as metastatic cancers, infections and acute visceral conditions, which need immediate referral to medical doctors or hospital emergency. Therefore, for non-mechanical back and neck pain, it is essential for DAOM to make correct diagnosis and differential diagnosis as well as to give rational and efficient treatment.
In the past, however, most oriental medical scholars have focused their studies on the diagnosis and treatment of back and neck pain in mechanical origins. Despite they have done numerous researches on non-mechanical back and neck pain, these researches are merely in scattered pieces. Few of our forbears have really made comprehensive studies of non-mechanical origins. Moreover, in this aspect, TCM pattern classifications are still confusing, there is still lack of practical guidelines for DAOM to make differential diagnosis of serious underlying causes, and the tactics and strategies of TCM treatments are still incomplete.
To fill the above gaps, in this article, I will present comprehensive discussion about non-mechanical back and neck pain, in the view of integration of traditional Chinese and western medicine. I will employ my new research methodology of TCM to analyze the latest western medical achievements in non-mechanical back and neck pain, i.e., the dialectical concept of TCM to explore the western medical field from basic sciences to clinical practice and from macrocosmic projection to microcosmic view. As I have mentioned in my previous article–The Research Methodology of TCM, traditional Chinese medicine is essentially characterized by its dialectical concept, without which it is not traditional Chinese medicine. However, microcosmic theory of Chinese medicine I have developed, is different from classical Chinese medicine in some approaches. My microcosmic theory not only inherits classical Chinese medicine, but also absorbs the achievements of western medicine, using the TCM method of dialectical analysis. Since its essence is not changed, microcosmic theory is still traditional Chinese medicine, except for its merging with modern medical sciences. In this article, with the viewpoint of microcosmic theory, I will respectively discuss those diseases associated with non-mechanical back and neck pain, emphasizing on the most common ones. Furthermore, I will propose the new pattern classifications according to my new theory, particularly the classification of degenerative joint diseases and rheumatologic diseases, as well as the new guidelines for differential diagnosis of serious underlying diseases. Traditional Chinese medicine maintains its superiority in treating many disorders of non-mechanical back and neck pain. Accordingly, for those diseases treatable within the scope of acupuncture practice in this country, I will also introduce every detail of TCM therapeutics, including different acupuncture techniques, Tuina methods, and internal and external applications of medicinal herbs.
I hope this article will be valuable to doctoral candidates in acupuncture & oriental medicine in better diagnosis and treatment of` non-mechanical back and neck pain.
Diseases Causing Non-Mechanical
Back & Neck Pain
- Degenerative Joint Diseases
Degenerative joint diseases may be a confusing concept. In modern western medicine, they usually mean osteoarthritis (OA), including peripheral type like OA in finger joints, hip joints and knee joints etc, as well as central type like cervical spondylopathy and lumbar spondylopathy. Whether diffuse idiopathic skeletal hyperostosis (DISH) belongs to the family of degenerative joint diseases, is still controversial in the western medical society. Many western physicians consider it a variant of degenerative joint diseases because DISH is similar to OA in osteo proliferation, but some regard it as a separate disease. In the western medical society, osteitis condensans Ilii is definitely an independent disease from degenerative joint diseases. However, in the viewpoint of microcosmic theory of Traditional Chinese medicine, I classify all the above diseases–OA, DISH and osteitis condensans ilii into the family of degenerative joint diseases, since they have the most important common character in TCM, i.e. Yang deficiency, which I will discuss in detail in Chapter III, Professor Wang’s Classification of Degenerative Joint Diseases and Rheumatologic Diseases. Accordingly, in this article, degenerative joint diseases include osteoarthritis (OA), DISH and osteitis condensans Ilii.
Another controversy is if degenerative joint diseases belong to rheumatologic diseases. Some western scholars say yes, but the others no. Because the pathogenesis of degenerative joint diseases in TCM is different from that of the most of the rheumatologic diseases, I agree upon the latter, separating them from rheumatologic diseases.
Osteoarthritis, as one form of degenerative joint diseases, has to be emphasized, since it is the most common joint diseases of humans. It affects multiple joints, characterized by degeneration of cartilage and by the hypertrophy of bone at the articular margins. Spine involvement is very common, usually occurring in the cervical and lumbosacral regions, named degenerative cervical spondylopathy and lumbar spondylopathy respectively. Spondylopathy is one of the major causes of back and neck pain. It is divided into two types: primary and secondary. The latter type can be secondary to mechanical injuries, such as vertebral strain, sprain, subluxation, and ruptured intervertebral disks, etc. This is why quite a few western physicians categorize spondylopathy in mechanical origin. My arguments are as follows:
(1). The majority of spondylopathy are primary while the secondary type only occupies a small percentage. Although they are very uncommon, the causes of secondary type of OA involve a wide range of diseases, such as trauma, congenital defects, metabolic disorders like ochronosis, hyperparathyroidism, calcium deposit disease, and osteochondritis, etc.
(2). Despite it is the initial factor to trigger spondylopathy in some cases, mechanical injury is not the direct pathological consequences of spondylopathy.
(3). Osteophytes, wear of cartilage in apophyseal joints and degeneration of the intervertebral disk are the direct pathological changes of spondylopathy.
(4). In contemporary Chinese medicine, kidney Yang deficiency plays the most important role in pathogenesis of spondylopathy either in microscopic view or in macroscopic aspect, while mechanical injury is much less important. For example, vertebral subluxation occurs in young children quite often, but the children themselves can spontaneously correct most of subluxation without the development of spondylopathy since their kidney Yang energy is sufficient. However, almost all the elderly people suffer from spondylopathy in different degrees even without any evidence of mechanical injury since their kidney Yang energy has been down by age.
Therefore, for clinical convenience, I believe that spondylopathy is still in the category of non-mechanical origin. Of course, there is no clear distinction between mechanical origin and non-mechanical origin in certain circumstances. There are still some grey areas between the two.
The Epidemiology of Osteoarthritis
Osteoarthritis is chronic and noninflammatory, clinically featured by slowly developing joint pain, stiffness, deformity, and limitation of motion in cervical spine, lumbosacral spine and other joints. The prevalence of OA is increasing with the age of population. OA is almost universally present in individuals over 75 years of age. Men and women are affected by this illness. Among individuals under 45 years of age more men have the disease, while women develop the disease to a greater degree than men after 55 years of age.
The western etiology of osteoarthritis is multifactorial. Genetic, biochemical, and biomechanical factors play a role. Familial aggregation of generalized osteoarthritis, including involvement of the cervical and lumbar spine, has been reported. Thirty-six per cent of relatives of men with generalized osteoarthritis and 49% of relatives of women with the disorder showed the disease, as compared with expected values of 17% and 26%, respectively, for the same age group of the general populations
Racial differences exist in both the prevalence of OA and the joint involvement. The Chinese in Hong Kong have a lower incident of hip OA than the whites; OA is more frequent in Native American than in whites. Whether these differences are due to genetics or differences in joint usage related to life-style is still unknown.
Cold climate may be one of the risk factor as well. Some report that the prevalence of OA increases by the higher latitude. In Toronto, the incidence of OA is significantly higher and the symptoms of OA are more severe than in southern California, according to some reports by acupuncturists
Modern Western Pathogenesis and Pathology of Osteoarthritis
Biochemical and metabolic alterations in cartilage play a role in the pathogenesis of osteoarthritis. Proteoglycans present in cartilage matrix develop altered composition over time. The glycosaminoglycans, which are part of the proteoglycans, act as sponges in the cartilage. They absorb water. The shock absorbency of cartilage is proportional to the proteoglycan content and its ability to bind water. In osteoarthritis, proteoglycan content is reduced along with a relative reduction of keratan sulfate and an increase in chondroitin sulfate (both glycosaminoglycans). Proteoglycans containing abnormal proportions of keratan and chondroitin sulfate form smaller subunits that retard glycosaminoglycan aggregation. The result of these alterations in the biochemical characteristics of osteoarthritic cartilage is retention of excess water in cartilage. In this state, the shock absorbency of cartilage is diminished and the collagen matrix of the cartilage is disrupted. Growth factors, including fibroblast, transforming and insulin-like, have a role in the repair of damaged cartilage. Investigation of how growth factor synthesis is regulated in traumatized articular cartilage would be beneficial to the understanding of the underlying mechanisms central to the pathogenesis of osteoarthritis.
Biomechanical factors may play a role in the development of osteoarthritis. Investigators have suggested that stiffening of subchondral bone associated with microfractures results in articular cartilage disruption. Whether genetic, biochemical, or biomechanical abnormality, osteoarthritis causes articular cartilage degeneration. As the cartilage is worn away, chondrocytes attempt to replace the cartilage. Degradation is more rapid than repair, and erosion of the articular surface evolves. In response to abnormal mechanical stresses to joint surfaces, bony appendages namely osteophytes appear. In the cervical and lumbar spine, the location of osteoarthritis is primarily in the facet joints.
Genetic defect or genetic susceptibility has drawn attention recently. Point mutations in the cDNA coding for articular cartilage collagen have been identified in families with chondrodysplasia and polyarticular secondary OA. However, primary OA is the most common form of OA, accounting for much higher prevalence rate than that of secondary OA or chondrodysplasia. The relationship between genetics primary OA needs to be further studied.
The degenerative changes that occur in the facet joints in association with alterations in intervertebral disc and soft tissue structures decrease the size of the spinal canal. The interaction of the two facet joints and the intervertebral articulation has been conceptualized into the triple joint complex pathogenesis of spinal stenosis. Narrowing of the spinal canal, whether on a congenital, developmental, or degenerative basis, is referred to as spinal stenosis. If the decrease in the spinal canal volume is severe, mechanical pressure on neural structures may occur.
In the first few decades of life, the gross appearance of the spine and its components will remain basically unchanged. The intervertebral discs will maintain their full height, with a thickened, laminated annulus fibrosus and a tense nucleus pulposus. The vertebrae are completely ossified except for their apophyseal rings and are essentially square in shape. The facets are well defined, with smooth capsules and normal articular cartilage. The ligament flava is only a few millimeters thick, and the space that is available for the neural elements within the canal and the foramina is capacious, containing abnormal proportions of keratan and chondroitin sulfate form smaller subunits that retard glycosaminoglycan aggregation. The result of these alterations in the biochemical characteristics of osteoarthritic cartilage is retention of excess water in cartilage. In this state, the shock absorbency of cartilage is diminished and the collagen matrix of the cartilage is disrupted. Growth factors, including fibroblast, transforming, and insulin-like, have a role in the repair of damaged cartilage. Investigation of how growth factor synthesis is regulated in traumatized articular cartilage would be beneficial to the understanding of the underlying mechanisms central to the pathogenesis of osteoarthritis. Symptoms are unusual even though some developmentally and congenitally narrow canals have much less space available even early in life. Major changes occur in the cervical or lumbar spine between the third and fifth decades of life. The first manifestations of aging develop in the intervertebral discs. In the early years, the nucleus loses its vigor and the annulus fissures and degenerates. The first stage of cervical or lumbar stenosis is the degeneration of the intervertebral disc. In an evaluation of 330 discs and 390 facet joints with MRI and CT, degenerative disc alterations on MRI occur in the absence of changes of facet joint on CT. Facet joint changes in the absence of disc alterations do not occur. The resulting biomechanical insufficiency inevitably results in a transfer of stresses posteriorly to the facet joints and ligaments, which are ill suited to assume compressive, tensile, and shear loads. Capsular strains, hypermobility, and degenerative changes develop. These changes are often manifested radiologically by traction spurs, which form anteriorly, I to 2 millimeters from the disc. The ligamentum flavum is compelled to assume unnatural tensile loads in spite of having become redundant as the total spine length decreases with disc degeneration. The vertebrae themselves also tend to collapse and spread, so as to further compromise the space available for the neural elements. Disc degeneration in and of itself may not be a painful process. Patients with disc degeneration may be asymptomatic until alterations in facet joint alignment result in the onset of articular pain. This stage of the illness may be characterized by pain localized to an area just lateral to the midline, over an apophyseal joint, and exacerbated by extension of the spine without radicular radiation of pain.
If a disc herniation occurs in a spinal canal that is relatively small, compression of the neural elements will result. The patient will experience symptoms not only of neck pain or low back pain, as mediated through the sinuvertebral nerve supply to the outer margin of the annulus, but also of radiating pain in the distribution of the compressed neural elements. In pure terms, this can be thought of as a relative spinal stenosis, since the herniated nucleus pulposus is occupying space in an already small spinal canal. On the other hand, a similar-sized disc herniation in a large spinal canal may cause no symptoms at all because the neural elements have enough room to escape pressure. Thus, symptoms in this age group result from a combination of the disc herniation itself and the volume of the canal with which the person was born.
Patients in their 40s and older can show the hypermobile end-plate changes of the aging process. Degeneration both of the facet joints (osteoarthritis) and of the intervertebral discs leads to narrowing of the spinal canal. The canal is rimmed by large osteophytes that have developed as a result of the excessive load on the now incompetent intervertebral disc. The facets are hypertrophic and deformed by osteophytic spurs that are encased within the joint capsule. The ligamentum flavum becomes redundant and, in combination with the aforementioned changes, encroaches on the spinal canal and foramina. Although such distortion of the spinal canal occurs to some degree in all active people, not everyone suffers significant disability. The symptoms a person will have depend on the original size of the canal; if the spinal canal is small, the changes caused by aging of the disc and facet joints can lead to an absolute stenosis with compression of the neural elements. If, however, the spinal canal is large to begin with, the aging process will lead to only asymptomatic relative spinal stenosis without neural compression.
In some individuals, the final pathologic end-stage of disc degeneration is a fibrous ankylosis between two adjacent vertebrae along with osteophyte formation and a marked narrowing of the disc space. If this is a stable phenomenon, the patient may be relatively free of symptoms or will be aware only of a sense of stiffness in the spine.
As the spine ages, one can also encounter postural alterations with reduction in lordosis in either the lumbar region or the cervical region or both. This is an attempt by the body to decompress the degenerated articular facets by maintaining a flexed rather than an extended posture; however, such postural alterations can lead to chronic muscle tension and become symptomatic. This flexed position also provides more room for the sensitive neural elements that are dynamically compressed in extension.
Although most of the described changes in the motor segment units progress from decade to decade, there is a wide range in the rate of deterioration. It is important to understand that these anatomic alterations do not necessarily dictate symptoms, define disability, or determine prognosis. As the spine ages, these phenomena appear to be tolerated to some degree by all.
The pathogenesis of the symptoms of spinal stenosis remains undetermined. Some authors suggest the symptoms associated with pseudoclaudication, stem from compression of vascular structures, which results in diminished blood flow to the nerve roots. The compression may affect arteries, capillaries, or veins. Initially, the vascular abnormalities may result in no permanent change. However, over time, venous obstruction causes hypoxia that is associated with perineural fibrosis resulting in more persistent symptoms. Others believe that the symptoms are related directly to mechanical compression of neural structures. In the later stage of this disorder, patients develop increasing radicular pain with walking in either cervical spondylopathy or in lumbar spondylopathy.
Laboratory Findings of OA
No laboratory studies are diagnostic of OA, but some specific laboratory tests may help to identify some underlying courses of secondary OA. In Primary OA, the erythrocyte sedimentation rate, serum chemistry determinations, blood counts and urinalysis are all normal. The synovial fluid is cool and relatively clear in color, revealing only mild leukocytosis, i.e. less than 2,000 WBC per microliter, with a predominance of mononuclear cells.
TCM Etiology and TCM Pathogenesis of Osteoarthritis
Primary osteoarthritis involves partly, or in their entirety, several interlocking and mutually supporting energetic mechanisms. These mechanisms contribute to the chronic progressive and degenerative nature of the disorder.
Innate energies: Innate energies (Yuanqi) are those which underlie certain familiar genetic predispositions over which we have no control. Tonifying the source Qi is recommended in all patients by applying moxa at BL-23 (shen shu), GV-4 (ming men) and CV-4 (guan yuan). Innate energies (Yuanqi) are congenital and genetical, stemming from kidney Qi. Kidney Qi is the primary source of innate energies. More and more evidence has surfaced that osteoarthritis is associated with genetic defect or genetic susceptibility. So modern western medicine supports this TCM hypothesis that OA is related to the deficiency of innate energy.
Pathogenic factors: In TCM, osteoarthritis belongs to the Bi pattern (painful obstruction), in which three pathogenic factors–Wind, Cold and Dampness, are involved more or less. Clinically, the diseased joints are usually pale in appearance, cold by palpation, and lack of obvious inflammation. The symptoms of OA are alleviated by heat but aggravated by cold temperature. Therefore, I believe that Cold dominates within the Bi (painful obstruction) framework. Besides conventional western diagnosis, a radiological examination adds, in our experience, a very useful investigational tool to identify the involved pathogenic Qi. X-rays showing different degrees of pinching in the joint structure, marginal osteophytosis and subchondral densification of the bone with synovial cysts (geodes) point to the presence of Cold when they are well-defined and their shapes are clearly visible, whereas prevalent Dampness makes the contours blurry, dappled and irregular. Fig. 10 is the diagram showing these changes in x-ray. Therefore, there is no doubt that Cold is always the main pathogenic factor of OA in microcosmic view of contemporary Chinese medicine. In macrocosmic view of contemporary Chinese medicine, Cold is still the main pathogenic factor or influence under most circumstances, but occasionally Heat is presented by tongue and pulse diagnosis. However, tongue and pulse more reveal the macrocosmic aspect, so there is the possibility that the patient’s macrocosmic pattern is Heat while the microcosmic one in the diseases local joint is still Cold (Fig. 11). Rarely, joint suffering from OA appears red and feels warm, but the above X-ray findings are not changed. This is called false Heat and true Cold. In fact, the red color is neither deep nor fresh, and behind the warm feeling, there is a cold background. Another evidence supporting that OA is at least microcosmic Cold Bi, is the epidemiology. As mentioned early in this section, the prevalence of OA and the severity of symptoms of OA are proportionally increased by higher latitude, where the climate is colder.
Summarily, the microcosmic pattern of OA is almost always Cold Bi despite the macrocosmic one can be either Cold or Heat. Dampness also plays the second important role in OA and Wind stays at the third position. Cold, Dampness and Wind are Excessive pathogenic factors. They, particularly Cold, are usually the direct causes of pain in OA, since they result in the stagnation of Qi and Blood in the joints as discussed previously in Part One. The obstruction of Qi and Blood circulation generates pain; if there is pain, there is obstruction. However, osteophytes do not directly trigger pain under most circumstances in OA. This can explain why some patients affected by serious osteophytes of OA or by late stage of vertebral stenosis remain asymptomatic, while others showing little evidence of osteophytes complain of serious back and neck pain. In addition, osteophytes are a compensatory mechanism to balance the stability of bones, so it implicates deficiency. Therefore, the microcosmic view of OA shows both Cold Bi and deficiency dominance despite Excess pattern is involved.
Fluid: Fluids drain and nourish the joints, bones, brain and marrow. A passage in chapter 36 of Spiritual Axis (Lingshu) describes what happens when this function is disrupted:
When the Yin and Yang are not harmonized, the Fluid deviates and drains into the Yin (lower orifices). The marrow fluid decreases on the whole and goes down; when they drop too low, deficiency occurs. Due to this deficiency, the hips and lower back hurt and the neck is painful.
Another passage in chapter 30 of Spiritual Axis (Lingshu) notes that, “When the Fluids are exhausted, the bones and joints have difficulty flexing and extending”
Qi and blood: Similarly, a passage in chapter 29 of Simple Questions explains the role of the Spleen Qi in this pathology:
If the limbs cannot receive the Qi from food and water, they become weaker and weaker every day. The Yin pathways close down, the vessel pathways are not open, and the sinews, bones and flesh, deprived of their life-giving Qi, become disabled.
Therefore, Qi and blood play an important role in circulating the Fluid, maintaining it in the right level, and preventing it from drying up. They both depend on the normal function of the Spleen.
Kidneys: There is enough evidence indicating that Kidney Yang deficiency plays the most important role in the development of OA:
(1). The Kidneys are the governors of bones. When kidney Yang energy is going down, bones and joints start to degenerate. Proliferation of the bones is only a compensatory mechanism to the degeneration. Therefore, proliferation of bones is associated with kidney Yang deficiency (Fig. 10).
(2). Kidneys also govern the bone marrow and preserve the Essence. When Kidney Yang is deficient, both of the bone marrow and the Essence are exhausted. According to the Bone Gap Theory (骨空論) as mentioned in The Yellow Emperor of Classic Internal Medicine (皇帝內經), the bones and joints will loss the circulation of blood and normal Qi, so pathogenic factors will stay in the joints and bones. This will cause further deterioration of the deterioration of the process of degeneration and osteophyte.
(3). Accordingly, microcosmically, Qi and Blood deficiency and stagnation of the OA stem from Kidney Yang deficiency, i.e. Kidney Yang deficiency results in deficiency and stagnation of Qi and Blood in the diseased joints.
(4). OA progresses with age when the Kidney Yang energy becomes weaker. Primary OA has never happened in children since children’s body is filled up with pure Yang energy. It rarely occurs in young adults either, since their Yang energy is still abundant. Yang energy is from the kidney originally.
(5). OA always demonstrates Cold Bi pattern in microcosmic view. It not only has a very chronic process, but also presents multiple joint involvement. Furthermore, in OA internal Cold is usually the main cause of Cold while external cold is only minor. Therefore, only Kidney Yang deficiency will be the most appropriate pattern to interpret the above phenomena. Although Cold is the most important pathogenic factor in OA, the real internal cause of OA is still Kidney Yang deficiency.
(6). Kidneys are the congenital source for innate energy (Yuanqi). When Kidney Yang is deficient, in fact, the innate energy deficiency is originated from Kidney Yang deficiency.
(7). Kidneys control the Fluid. All the above Fluid problems also stem from Kidney Yang deficiency. When is Kidney Yang becomes deficient, Fluids that drain and nourish the joints and, cannot function properly, either causing excessive fluid accumulation or exhaustion of the Fluid in the joints.
(8). Clinically, kidney Yang deficiency alone is rare. It usually affects other internal organs, creating a complicated picture of multiple organ deficiency and disharmony. The Kidneys are the roots of congenital, while the Spleen is the root of the post-natal. Kidney Yang deficiency deteriorates the Spleen function directly, further causing Spleen Qi deficiency as mentioned above.
Kidney Yang deficiency also influences the Lung Wei Qi, rendering the Lung to be more susceptible to the external pathogenic factors like Cold, Dampness and Wind.
Kidneys and the Liver originate from the same source. Kidney Yang deficiency almost simultaneously affects the Liver that controls the ligaments and tendons and storages the blood. When Kidney Yang is deficient, the adjacent tendons and ligaments of the joints become atrophy and malfunctioning; there is not enough blood supply from the Liver, causing blood deficiency as well. The above processes also further aggravate the symptoms of OA.
(9). Laboratory findings are also compatible with Kidney Yang deficiency. In Primary OA, the normality of erythrocyte sedimentation rate, serum chemistry, blood counts and urinalysis indicates Cold and Deficient pattern. The cool and clear synovial fluid without significant leukocytosis demonstrates that Yang deficiency causes fluid retention in the synovial cavity (Fig. 10).
In the past, the TCM causes of OA have been controversial. Some authors attributed to External pathogenic factors like Cold, Dampness and Wind; some to Qi and Blood deficiency and stagnation; the others to a blend of factors, in which Kidney Yang deficiency was only one of the causes. My argument is that Kidney Yang deficiency is the true primary main cause of OA; the rest of the causes as mentioned above by other authors are only secondary to Kidney Yang deficiency.
General Diagnostic Essentials of Spondylopathy
Spondylopathy is a special form of OA affecting the spine. Its diagnostic essentials are as follows:
(1) Degenerative spondylopathy in the neck and low back usually occurs in later life. Patients often complain of pain in either neck or lower back that is increased by motion and associated with stiffness and limitation of motion. The relationship between clinical symptoms and radiological changes is not straightforward, i.e., pain may be severe while X-ray findings are minimal or large morphological changes can be seen in X-ray in asymptomatic patients of middle and late ages.
(2) The pathological changes in degenerative spondylopathy involve: disk degeneration with or without herniation of disk material, degenerative changes in the apophysial joints, osteophytic outgrowths, bone spurs, and spinal canal stenosis. So X-ray findings reveal narrowed intervertebral space and non-uniform decrease in apophysial and other movable joint space, osteophytes, vertebral stenosis, subchondral sclerosis or subchondral bone cyst, etc.
(3) Inflammation is usually insignificant or minimal, and systemic manifestation absent. So ESR, RF, ANA, and other laboratory signs of inflammation are all negative.
(4) Osteoarthritis chiefly affects the distal and proximal interphalangeal joints (except at the thumb), and the joint enlargement is bony-hard and cool (Fig. 11).
TCM Pattern Diagnosis and Treatment Principles for OA
The conclusions from the above discussion are the following: Kidney Yang deficiency is the main cause or root of OA; Cold, either Internal or External, is the main pathogenic factor of OA; At least OA is Cold Bi in microcosmic view; other pathogenic factors like Dampness and Wind are also involved; Kidney Yang deficiency usually affects other internal organs, making them deficient as well. Therefore, there may be the following patterns:
(1) Kidney Yang deficiency plus microscopic Cold Bi and microcosmic deficiency dominance;
(2) Kidney Qi and Yin deficiency, plus microscopic Cold Bi and deficiency dominance.
Kidney Qi deficiency is the less severe form of Kidney Yang deficiency and may be together with Kidney Yin deficiency. For the latter pattern, there are paradoxical clinical manifestations; i.e. microscopic view shows Cold in affected joints while macroscopic projection reveals systemic false Heat. The latter pattern of OA is most commonly seen in premenopausal, perimenopausal or postmenopausal women between age 45-55. This group of women may have hot flash, five center heat, dry mouth, irritability, fast and small pulse, etc, indicating false Heat macrocosmically; while local joints of OA are pale, cold and lack of inflammation, etc, revealing microcosmic true Cold.
In OA, the combined patterns of internal organs of Kidney Yang deficiency include: Kidney and Heart Qi and Yin deficiency and disharmony, Kidney and Heart Yang deficiency, Kidney and lung Qi and Yin deficiency, Liver and kidney Qi and Yin deficiency, and Spleen and kidney Yang deficiency, tec.
The combined patterns of pathogenic factors in OA are Cold and Damp Bi, Cold and Wind Bi, or Cold, Damp and Wind Bi.
TCM treatments, such as acupuncture, tuina and herbs usually have good results in early osteoarthritis, either in peripheral joints or in central vertebrae like cervical or lumbar spondylopathy. The improvement from TCM treatment decreases as the stage of osteoarthritis advances. For acute pain from OA, the TCM treatment is focused on eliminating the pathogenic factors like Cold, Dampness and Wind in order to reliving the symptoms. However, for chronic conditions of OA, tonification of the Kidney yang as treating the root or cause of OA needs to be emphasized. Of course, if there are both Qi deficiency and Yin deficiency in the macroscopic aspect of OA, Yin deficiency also needs to be corrected in additions to the treatment of Qi deficiency. If there are combined patterns of internal organs, other involved organs than kidney should also be under consideration in the treatment program.
Prognosis of OA
With the conventional western treatments, most patients with OA have a relapsing course with recurrent episodes of back pain, but most patients respond to medical and physical therapy and do not require surgical intervention. For the most severe form of OA-spinal stenosis, a 4 -year prospective study reported by western physicians that conservative, nonsurgical therapy was effective in decreasing or controlling symptoms of spinal stenosis. The natural course of cervical and lumbar spondylopathy is to improvement. A western study of 32 patients with spondylopathy, who did not receive therapy, revealed a decrease of symptoms in 15%, no change in 70%, and worsening in 15%. No severe deterioration requiring surgery occurred during the study period.
Traditional Chinese medicine apparently has better results in the treatment of OA, especially in the treatment of cervical and lumbar spondylopathy including stenosis type. TCM involves such comprehensive procedures of therapies as acupuncture, herbal medicine and Tuina techniques. According to the oriental medical literature reported, the effective rate of acupuncture, herbs or Tuina is usually 90% or even higher in short term. However, there is still lack of statistical analysis to prove the long-term effectiveness either in western medicine or in TCM.
Fig. 10. Diagram of Osteoarthritis (OA):
The pathological changes of OA demonstrate Cold Bi, Deficiency dominance in microcosmic view of contemporary Chinese medicine. However, the main cause of OA is Kidney Yang deficiency. Osteophytes of OA are one kind of compensatory mechanism implicating Kidney Yang deficiency. (From Dieppe, P., et al: Atlas of Rheumatology, Lea & Febiger, 1986)
Fig. 2. Periferal type of OA:
Peripheral type of osteoarthritis chiefly affects the distal and proximal interphalangeal joints. The joint enlargement is bony-hard due to proliferation and cool in temperature, indicating the microcosmic view of OA is almost always Cold Bi and Deficiency dominance, irrespective of the macroscopic aspect which can be either Yang deficiency, Cold pattern or Qi & Yin deficiency, false Heat pattern. (From Dieppe, P., et al: Atlas of Rheumatology, Lea & Febiger, 1986)
- Diffuse Idiopathic Skeletal Hyperostosis (DISH)
In contemporary Chinese medicine, diffuse idiopathic skeletal hyperostosis (DISH) is considered a variation of degenerative joint diseases, characterized by marked calcification and ossification of paraspinous ligaments. The Sl joint, apophyseal joint and the disk are not affected in DISH. Clinically DISH is rare, in comparison with the common type of central osteoarthritis that often affects both intervertebral disk and apophyseal joint. Despite impressive radiographic abnormalities, patients rarely have significant loss of function or disability from the illness except for the rare individual who develops difficulty swallowing (dysphagia) secondary to cervical spine involvement. This disease has been known by many different names, including spondylitis ossificans ligamentosa, vertebral osteophytosis, ankylosing hyperostosis of Forestier and Forestier’s disease. DISH was suggested in 1975 by Resnick as a more appropriate name in light of the diffuse bone growth that develops in both spinal and extraspinal locations.
The Epidemiology of DISH
DISH is a common entity found in 6% to 28% of an autopsy population, but it has rarely been reported in the oriental medical literature. Clinically, DISH may be under-diagnosed. The usual patient is a man between the ages of 48 and 85 years. The ratio of men to women is 2:1. The disease occurs most commonly in Caucasians and rarely in blacks in the U.S.
The Modern Western Pathogenesis of DISH
The etiology of DISH is unknown. The patients reporting such stress or trauma usually had occupations such as construction, ranching, or roofing that required at least a moderate degree of physical activity. Other individuals in the same study had no history of occupational or accidental trauma. Endocrinologic abnormalities associated with bony hyperostosis, acromegaly, and hypoparathyroidism, have been suggested as causes of DISH. No abnormalities in growth hormone (acromegaly) or parathormone (hypoparathyroidism) have been found. Diabetes mellitus occurs in 30% of patients with the disease; however, this frequency of diabetes mellitus may be related to the age of the population rather than a true association of the two disorders. Elevated levels of endogenous retinoic acids are present in DISH patients compared to controls. The elevation in 13-cis and all trans retinoic acid may be similar to the hyperostosis associated with retinoids used in the treatment of psoriasis and acne.
A specific genetic predisposition to the development of the problem has not been identified. HLA-B27 positivity was found in 34% of DISH patients in one study, but a subsequent study found no significant association with HLA antigens. Until further data are obtained to the contrary, DISH should not be classified with the HLA-B27-positive, seronegative spondyloarthropathy like AS or Reiter’s syndrome.
Clinical Manifestations of DISH
The principal musculoskeletal complaint in 80% of patients is spinal stiffness. The duration of back stiffness before diagnosis may be 10 to 20 years, with onset when the patient’s age is in the 40s. Morning stiffness dissipates within an hour, only to recur in the late evening. Back pain in the thoracolumbar spine occurs in 57% of patients as their initial complaint. Back pain is usually mild and intermittent and rarely radiating. In one study, 67% of DISH patients had lumbar spine pain. In some study populations with DISH, back pain may occur with the same frequency as age matched controls. DISH is clinically silent in some patients. Occasionally, patients will have cervical spine pain as their initial complaint. Dysphagia is seen in 17% to 28% of patients. Dysphagia occurs secondary to constriction of the esophagus by anteriorly located cervical osteophytes.
Extraspinal manifestations of DISH occur in 37% of patients. In 20%, extraspinal pain was the initial or predominant complaint. The most common extraspinal skeletal areas involved include the shoulders, knees, elbows, and heels.
Western Physical Examination for DISH
Physical examination usually reveals mild limitation of motion in the lumbar spine. Occasionally, a slight decrease in lumbar lordosis and a small increase in dorsal kyphosis may be present. Limitation of motion in the thoracic and cervical spine may also be found. A minority of the patients will show tenderness to percussion over the sacroiliac joints.
Laboratory and Radiologic Findings of DISH
Laboratory parameters are essentially normal in patients with DISH. Since patients who develop the disease are elderly, laboratory abnormalities may be secondary to another illness affecting the patient.
DISH is diagnosed radiographically. It is made, not uncommonly, in asymptomatic people who happen to have characteristic bony changes in the thoracic spine on a chest radiograph. The three criteria for spinal involvement include: flowing calcification along the anterolateral aspect of four contiguous vertebral bodies; preservation of inter-vertebral disc height; and absence of apophyseal joint bony ankylosis and sacroiliac joint sclerosis, erosion, or fusion (Fig. 21). These criteria help differentiate it from spondylosis deformans, intervertebral disc degeneration, and AS. The fact that the posterior spinal elements are not affected permits almost normal range of motion on physical examination.
In the lumbar spine, the upper vertebrae (first through third) are most commonly affected. Calcification occurs initially along the anterior aspect of the vertebral body. Bony excrescences are in an anterosuperior position near the disc margin and extend upward across the intervertebral disc space. The excrescences are thick in comparison to syndesmophytes. Careful observation will identify a thin radiolucent line that separates the vertebral body proper from the anterior calcification. The right-sided predilection of DISH in the thoracic spine is not continued in the lumbar spine, where bilateral or left-sided involvement is frequently seen.
The principles of Tuina therapy for local lumbar type of lumbar spondylopathy are applicable to osteitis condensans ilii. Regarding the acupuncture and herbal treatments, please
Diagnosis of DISH
The diagnosis of DISH is based on the presence of characteristic radiographic changes and an absence of clinical abnormalities suggestive of another illness. The western criteria for the diagnosis of DISH are as follows:
(1). Flowing calcification and ossification along the anterolateral aspect of four contiguous vertebral bodies with or without associated localized pointed excrescences at the intervening vertebral body or intervertebral disc junctions.
(2). Relative preservation of intervertebral disc height in the involved vertebral segment and the absence of radiographic evidence of degenerative disc disease.
(3). Absence of apophyseal joints bony ankylosis and sacroiliac joint erosion, sclerosis, or intra-articular osseous fusion. There are a number of causes of bony out growths of the spine, including spondyloarthropathy, acromegaly, hypoparathyroidism, fluorosis, ochronosis, neuropathic arthropathy, and trauma.
Conventional Western Treatment of DISH
Western treatment is directed to relieving pain and maximizing function. In patients with back pain and stiffness, nonsteroidal anti-inflammatory agents may be helpful. Exercise programs are designed to encourage maximum ranges of motion throughout the axial skeleton. Local injections of lidocaine and corticosteroids are used in areas of bony overgrowth, such as the heel, for pain relief. Patients with severe dysphagia may require removal of the offending hyperostosis.
TCM Considerations of DISH
In the latest 1998 edition of Harrison’s Principles of Internal Medicine, DISH is discussed in the OA section. Undoubtedly, the main stream of western medical society still believes that DISH is a variant of OA, although some western medical scholars may have different thought about it. Contemporary Chinese medicine at this point agrees upon the opinion of the main stream of western medical society. In DISH, osteo proliferation and calcification are the most prominent pathological changes, which are also the characteristics of regular OA. In fact, either in DISH or regular OA, these pathological changes are one kind of compensatory mechanism to maintain the biomechanical balance of the diseased vertebrae. In TCM, Kidneys control the bone, particularly the low back. Therefore, like OA, Kidney Yang deficiency is the main internal cause of DISH, and Cold Bi is the microcosmic cause of DISH (Fig. 21).
All the Tuina principles for spondylopathy as mentioned previously, are applied to DISH. Regarding acupuncture and herbal therapy for DISH, please refer to TCM treatment of Yang Deficiency Cold Bi, in later Chapter, Professor Wang’s Classification of Degenerative Joint Diseases and Rheumatologic Diseases.
Prognosis of DISH
The course of DISH is usually benign. Confusion may occur in diagnosis of patients who present in their 40s with back pain with no physical findings or early radiographic changes. The patients with DISH will have a very slow progressive course. They may have aching low back pain and stiffness for 20 years or longer but will rarely develop any limitations in their activities or morbidity from their illness. Patients with DISH may develop symptoms of spinal stenosis. Ligamentous and capsular calcifications cause canal stenosis secondary to DISH.
Fig. 21. DISH:
X-ray AP and Lateral views show pathological changes of DISH, in which osteo proliferation and calcification are most prominent. Like OA, these pathological changes are one kind of compensatory mechanism to maintain the biomechanical balance of the diseased vertebrae, implicating Kidney Yang deficiency and microscosmic Cold Bi.(From Borenstein, D.G., et al: Low Back Pain, W.B. Saunders, 1995)
- Osteitis Condensans Ilii
The Prevalence and Modern Western Pathogenesis of Osteitis Condensans Ilii
Osteitis condensans ilii is mostly seen in postpartum women. The illness is not progressive and not associated with functional disability. The major difficulty with osteitis condensans ilii is that it is frequently confused with ankylosing spondylitis.
The prevalence of osteitis condensans ilii has been estimated to be 1.6% in the Japanese and 3% in Scandinavians. The usual patient is a woman in the age range of 20 to 40 years. The ratio of women to men is 9:1 or greater. So osteitis condensans ilii is not rare, but may be under-diagnosed, or misdiagnosed as other diseases.
The modern western pathogenesis of osteitis condensans ilii is unknown. Inflammatory diseases of the sacroiliac joint and abnormal mechanical stresses have been suggested as possible etiologies of this illness.
Clinical Manifestations of Osteitis Condensans Ilii
Patients complain of persistent low back pain, occasionally radiating down to the buttocks and posterior thighs. The pain is not exacerbated by coughing, sneezing, or straining at stool, but may be increased with menstruation in women. Not uncommonly, women notice the onset of pain during pregnancy or the postpartum period. Morning stiffness is usually mild, lasting less than an hour. The episodes of pain may have duration of weeks to months. The disease may then go into a complete or partial remission, which may last for years. A small proportion of patients may com- plain of fibrositic symptoms characterized by widespread musculoskeletal aching and local point tenderness.
Western Physical Examination and Laboratory Findings of Osteitis Condensans Ilii
Physical examination may demonstrate tenderness on sacroiliac joint percussion, pain with sacroiliac joint motion, and mild limitation of motion. The rest of the physical examination is normal. Laboratory values are generally normal in patients with osteitis condensans ilii. Hematocrit, ESR, WBC, platelets, urinalysis, and chemistry studies are normal. Rheumatoid factor and antinuclear antibody are negative.
Radiographic Findings of Osteitis Condensans Ilii
The radiographic findings include an area of tri- angular sclerosis on the iliac aspect of the sacroiliac joint. The bony sclerosis is unassociated with joint erosions or extensive involvement of the sacrum (Fig. 22). The radiographic changes may resolve over time. There are no characteristic abnormalities in other portions of the lumbar, thoracic, or cervical spine.
Modern Western Diagnosis of Osteitis Condensans Ilii
The diagnosis of osteitis condensans ilii is based upon the presence of radiographic changes on the iliac side of the sacroiliac joint and absence of findings consistent with spondylitis. Patients with spondyloarthropathy have more persistent low back pain associated with more stiffness and limitation of motion. Radiographic changes of spondyloarthropathy are characterized by erosion on both sides of the sacroiliac joints. Other processes that might cause confusion in diagnosis include septic arthritis with bacteria or tuberculosis, Paget’s disease, or tumor. The clinical features of these illnesses and the associated radiographic changes help distinguish the specific diseases.
Modern Western Therapy for Osteitis Condensans Ilii
The majority of patients benefit from a conservative regimen of a firm mattress for sleeping, local wet or dry heat, and exercises. Non-steroidal anti-inflammatory drugs are rarely required. Surgical intervention for pelvic instability is reserved for patients with severe symptoms. Internal fixation of the sacroiliac joint and symphysis pubis may be necessary.
TCM Considerations of Osteitis Condensans Ilii
Some western medical scholars have suggested that osteitis condensans ilii is a subset of ankylosing spondylitis, but histocompatibility testing for HLA-B27 has not documented increased incidence of this antigen in osteitis patients. In addition, part of the confusion of differentiating osteitis condensans ilii and ankylosing spondylitis is the milder form of the latter illness in women. When careful review of the clinical symptoms and radiographic findings of the groups of patients demonstrates the clear-cut differences that exist between the two illnesses, the main stream of modern western medicine still separates osteitis condensans ilii from ankylosing spondylitis. Modern western medicine also positively considers osteitis condensans ilii a separate disease from degenerative joint disease without any debate. However, the considerations of osteitis condensans ilii in TCM are completely different.
Since its laboratory tests like ESR, WBC, ANA and other inflammatory parameters are all negative, osteitis condensans demonstrates Deficiency and Cold in TCM. The sclerosis of the hip near the SI joint (Fig. 22) is a variant of bone proliferation similar to OA. The proliferation of OA is an outgrowth while that of osteitis condensans ilii is one kind of ingrowth within the pelvic bone. However, their implication is the same, i.e. the compensatory mechanism, usually indicating Kidney Yang deficiency and microcosmic Cold pattern. Moreover, Kidneys control the lower back including the hip area near the SI joint and patients with osteitis condensans ilii are usually postpartum women complaining of low backache. This is also the strong implication of Kidney Yang deficiency and Cold pattern as well as Qi and Blood deficiency and stagnation. Accordingly, in the view of microcosmic theory of Chinese medicine, I categorize osteitis condensans ilii into degenerative joint diseases and its pattern diagnosis is the same as OA, Yang deficiency in macrocosmic aspect and Cold Bi in microcosmic view.
The principles of Tuina therapy for local lumbar type of lumbar spondylopathy are applicable to osteitis condensans ilii. Regarding acupuncture and herbal therapy for this disease, please refer to TCM treatment of Yang deficiency type, Cold Bi, in the later Chapter, Professor Wang’s Classification of Degenerative Joint Diseases and Rheumatologic Diseases.
Prognosis of Osteitis Condensans Ilii
The course of osteitis condensans ilii is benign. In many circumstances the radiographic changes may reverse to normal. Low back pain may persist for months, but is responsive to therapy. Low back pain of osteitis condensans ilii does not cause decreased motion of the lumbosacral spine. This illness is not associated with disability, and patients are able to continue to work even though they experience symptoms of the illness.
Fig. 22. Osteitis condensans ilii:
Radiographic findings of osteitis condensans ilii show increased density, i. e. sclerosis near the SI joints, but the SI joints themselves are still spared. TCM interprets this sclerosis as a variant of bone proliferation, implicating microcosmic Cold Bi and macroscopic Kidney Yang deficiency. (From Borenstein, D.G., et al: Low Back Pain, W.B. Saunders, 1995)