AC501: Special Topics in Acupuncture Spring 2020 Week 1 Agenda for today ● ● ● ● ● ● Personal introduction Learning objectives Syllabus Introduction to the course Urinary Syndrome Q&A 2 Online Learning Addendum ● ● ● ● This is new for all of us Lectures are being recorded Your presence and attention is being monitored Quizzes and exams through Populi 3 Yaron Cohen MATCM, L.Ac., Dipl.OM. ycohen18@vuim.edu 4 Learning Objectives and Syllabus 5 ● Learning Objectives Develop necessary critical thinking and analytic skills ● ● Demonstrate understanding of and articulate basic theory, principles and techniques of TCM Demonstrate knowledge of how to treat and prevent common internal disease with TCM Communicate the etiology, pathology, and treatment of diseases subject to this course 6 Syllabus 1. 2. Urinary Syndrome Enuresis/Incontinence/Urinary Retention/Interstitial Cystitis a. 3. 4. 5. Quiz BPH/Prostatitis/Prostatodynia Edema a. 6. 7. a. 8. 9. Quiz Lower Backache/Sciatica a. Mid-Term Exam Painful Obstruction Syndrome Fibromyalgia/Chronic Fatigue/ Erectile Dysfunction Parkinson’s Disease/Stroke Atrophy Syndrome/Multiple Sclerosis a. 10. Quiz Quiz Final Exam 7 Format of the class This is how we do it ● ● ● ● ● ● Lecture 4 Quizzes 2 Exams Quiz review Case studies Q&A 8 Introduction to this course 9 Introduction 1. Definition of Symptom, Syndrome & Disease in TCM Internal Medicine a. b. c. 2. Symptom - 4 diagnostic methods Syndrome - Pattern differentiation. The essence of TCM Disease - Western medical diagnosis. “Headline” Etiology & Pathology a. Etiology i. 6 Exogenous (Climactic) Factors: Heat, Cold, Fire, Wind, Dampness, Dryness ii. 7 Endogenous (Emotional) Factors: Joy, Anger, Worry, Sadness, Fear, Grief, Fright iii. Diet (Post-Heaven Qi) iv. Work & Rest (Lifestyle Balance) v. Phlegm retention & Blood stasis 10 b. Pathology i. Basic Pathogenesis 1. Excess & Deficiency of Evil & Vital Qi 2. Imbalance of Yin & Yang 3. Abnormal movement of Qi a. Ascending & Descending b. Entering & Exiting ii. Qi & Blood Pathogenesis 1. Qi: Qi-deficiency, Qi-collapse, Qi-stagnation, Qi-reversed flow 2. Blood: Bleeding, Blood-stasis, Blood-deficiency iii. Internal Wind, Cold, Dryness & Fire 1. Internal Wind - Liver-Yang transforms into Liver-Wind, Fire courses Wind, Yin/Blood Deficiency leading to Wind 2. Internal Cold - Excess Internal Yin-Cold, Spleen & Kidney Yang Deficiency Cold 11 1. iv. v. Internal Dryness - Lung & Stomach Fluid Deficiency, Liver & Kidney Yin Deficiency 2. Internal Fire - Excess Fire (Heart, Liver), Deficiency Fire (Kidney, Lung) Dampness, Phlegm & Fluid retention 1. Dampness - Cold Damp disturbing Spleen, Damp Heat in Middle Jiao, Damp retention due to Spleen Deficiency 2. Phlegm - Phlegm blocking the Lungs, Turbid-Phlegm blocking the Heart-orifice, Phlegm accumulation in Spleen & Stomach, Phlegm stagnation in meridians & joints 3. Fluid retention - physiological fluids Zang-Fu Pathogenesis 12 3. Principles of Treatment a. b. c. d. e. 4. Routine Treatment method Treatment contrary to routine method, ie tonify for bloating, astringing diarrhea Branch and root, insidious and acute Strengthen the body resistance to eliminate pathogenic factor Tonify and eliminate according to Zang-Fu organs Procedure of differentiation & treatment a. b. c. d. e. f. g. Four diagnostic methods Differentiating the nature of disease Differentiating the location of disease Identification of etiology according to differentiation of signs & symptoms Selecting therapy Choose the formula Modification 13 Urinary Syndrome Lin Zheng 14 Definition: Lin Syndrome Urinary Syndrome, called Lin Zheng in TCM, is a condition of urinary dysfunction characterized by: Frequency, scanty or excessive, painful, difficult, urgent, burning and/or incomplete urination. Associated with hypogastric or lower back cramps. The pain may also radiate down to the legs. 15 Western Medical Diseases ❖ Urinary tract infections - cystitis, urethritis, prostatitis, pyelonephritis, renal tuberculosis, etc. ❖ Urinary tract obstructions: ➢ ➢ ➢ Urinary calculus (kidney stone, bladder stone, ureter stone, etc.) Urinary tumor (tumor of renal pelvis, bladder cancer, etc.) Tumor of prostate ❖ Chylous urine - cloudy (fat, lymph) 16 Organ Involvement: Lin Syndrome 1. Urinary Bladder - Stores/excretes urine. Qi transformation 2. Spleen - transform/transport fluid. Formation of Dampness 3. Kidneys - Yin/Yang regulate amount of urine excreted. Qi controls lower orifice 4. Lungs - Qi provides strength for urination, propulsion of Qi 5. Liver - Regulate the smooth flow of Qi 6. San Jiao - Regulate water passages 7. Small Intestine - Separate clear from turbid. Transfers Heart Fire 17 Etiology 1. 2. 3. 4. 5. 6. 7. 8. External Dampness - Damp accumulation Poor Diet - Damp and/or Heat accumulation Emotional Stress - Liver Qi Stagnation Excessive lifting or standing - Qi Stagnation Poor hygiene or sexual contact - Damp and/or Heat accumulation Excessive sexual activity - Kidney Deficiency Constitutional Deficiency, chronic illness, old age - Kidney Deficiency Overthink / overwork - Heart Yin Deficiency 18 Pathology 1. Dampness and Damp Heat a. Difficult urination, pain, cloudy urination 2. Qi Stagnation a. Hypogastric distention, pain before micturition 3. Qi Deficiency a. Frequency, slight incontinence 4. Kidney Deficiency a. Frequency, slight incontinence 19 Diagnostic Differentiation ● Color ○ ○ ○ ○ ● Dark, concentrated: Heat, Damp Heat, Yin Deficiency Pale: Kidney Yang Deficiency, Spleen Qi Deficiency, Qi Stagnation Cloudy, turbid: Dampness, Damp Heat Pale pink to bright red or purple: bleeding due to Fire, Damp Heat, Blood stasis, Kidney Yin Deficiency or stones Pain ○ ○ ○ Burning: Severe - Heat, Damp Heat. Mild - Yin Deficiency Stabbing or localised: Blood stasis, Stones Mild or dragging, empty discomfort following urination: Qi Deficiency 20 Diagnostic Differentiation ● Frequency ○ Frequent, urgent, concentrated: Heat, Damp Heat ○ Frequent, pale: Kidney Yang or Qi Deficiency ○ Frequent, pale with weak or broken stream: Kidney Yang Deficiency ● Timing of the pain ○ During urination: excess condition ○ Before urination: Qi Stagnation ○ After urination: deficient condition 21 6 Lin Patterns All Lin: difficulty and pain, dribbling, frequency, sacral/hypogastric ache. 1. 2. 3. 4. 5. 6. Heat Lin: painful, burning, urgent urination. Excess or Deficient Stone Lin: stones or sand in urine. Excess only Qi Lin: hypogastric bloating & distention, incomplete urination. Excess or Deficient Blood Lin: blood in urine. Excess or Deficient Gao Lin: cloudy or turbid urine. Excess or Deficient Lao Lin: sxn induced by exertion, chronic, exhaustion. Deficient only 22 Heat Lin Symptoms: Frequent, scanty, burning & difficult urination. Dark-yellow urine with strong foul odor. Lower back and/or hypogastric pain, aversion to pressure. Bitter taste, thirst, constipation. Fever & chills. ● ● Tongue: yellow greasy coat at root, possible red spots. Pulse: slippery, rapid Treatment principle: Clear Heat, Drain Dampness, Open water passages. Acupuncture: Ren3, UB28, UB22, ST28, SP9, UB66, UB63, LI11. ○ Liver Fire: LV2, SP6 ○ Heart Fire: HT8, SI2 ○ Exterior: LI4, LU7, SJ5 Formulas: ○ Ba Zheng San - Classic ○ Long Dan Xie Gan San - Liver Fire ○ Huang Lian Jie Du Tang - Toxic Heat ○ Dao Chi San - Heart Fire ○ Zhu Ling Tang - Damp>Heat ○ Wu Lin San - Blood stasis 23 Stone Lin Symptoms: Stone/sand in urine. Severe stabbing painful, difficult urination that may stop suddenly. Lower back / hypogastric pain, cramps that may radiate down leg. Blood in urine. ● Acupuncture: UB22, ST28, SP9, Ren6, Ren3, UB28, UB63, UB39, K2 Tongue: Red with yellow coat ● Formulas: ○ Shi Wei San - Damp Heat ○ San Jin Pai Shi Tang - Dampness, stones ○ Niao Lu Pai Shi Tang - Moves Qi ○ Zhi Shi Lin Fang - Tonify Kidney Yang Pulse: wiry, rapid Treatment principle: Clear Heat, Drain Dampness, Open the Water passages, Expel stone. 24 Qi Lin Symptoms: Excess - Difficult, painful, incomplete urination. Hypogastric pain and distention. Irritability. Deficiency - Difficult urination, weak stream. Slight hypogastric distention, fatigue. ● Acupuncture: Ren3, Ren5, UB28, LV3, LV5, LV8, UB64, SP6, ST36, Ren6, Du20, LU7, K6, SI3 ● Formulas: ○ Chen Xiang San - Excess ○ Bu Zhong Yi Qi Tang Deficiency Tongue: Excess - no change or sl red. Deficiency Pale Pulse: Excess - deep, wiry. Deficiency - weak, thready Treatment principle: Excess - Smooth Qi, Eliminate stagnation, open Water passages. Deficiency - Tonify & raise Qi, open Water passage 25 Blood Lin Symptoms: Excess - painful, urgent, burning urination. Blood in urine or small clots. Hypogastric fullness and pain. Irritability. Deficiency - Pale blood in urine, sl discomfort on urination. Soreness & weakness of lower back & knees. Fatigue. 5 heart heat at night. Tongue: Red. Less coat with deficiency Pulse: Rapid. Thready with deficiency Treatment principle: Excess - Clear Heat, Cool Blood, Stop Bleeding, Open Water passages. Deficiency Clear Empty Heat, Cool Blood, Nourish Yin, Stop Bleeding, Open Water passages ● Acupuncture: LV3, KD2, Ren3, UB28, UB63, SP10, UB17, SP6, Ren4, K6 ● Formulas: ○ Xiao Ji Yin Zi - Excess ○ Zhi Bai Ba Wei Wan Deficiency 26 Gao Lin Symptoms: Excess - Turbid or cloudy urine like rice soup. Painful, burning, urgent urination. Deficiency - Cloudy or turbid urine. Sl difficulty. Fatigue, dizziness, sore lower back & knees. Tongue: Excess - red, yellow greasy coat. Deficiency pale, sticky greasy coat Pulse: Excess - slippery, rapid. Deficiency - soft, thin, weak Treatment principle: Excess - Drain Dampness, Clear Heat, Separate clear from turbid, Open the Water passages. Deficiency - Tonify Qi, Strengthen Kidneys, Separate clear from turbid, Drain Dampness, Open the Water passages. ● ● Acupuncture: Ren3, UB22, UB28, UB23, K7, Ren6, Ren9, ST28, SP9, SP6. Formulas: ○ Excess ■ Cheng Shi Bi Xie Yin - Damp Heat ■ Bi Xie Fen Qing Yin - Cold Damp ○ Deficiency ■ Gao Lin Tang - Qi Xu w/ Dampness ■ Bu Zhong Yi Qi Tang + Qi Wei Du Qi Tang - Qi Sinking with Yin Xu 27 Lao Lin Symptoms: Sl difficult urination, no burning, frequency, dribbling urination. Dragging feeling in hypogastrium, exhaustion, depression, feeling cold. Weakness of lower back & knees. Induced by exertion & overwork Tongue: pale Pulse: weak Treatment principle: Tonify and Raise Qi, Strengthen Kidneys, Open the Water passages ● ● Acupuncture: UB23, Ren4, UB28, Du20, ST36, SP6, SP9, Ren6, K3, Du4 Formulas: ○ Wu Bi Shan Yao Wan - Kidney Yang Xu Dampness ○ Bu Zhong Yi Qi Tang - Spleen Qi Xu Sinking ○ Zhi Bai Di Huang Wan - Kidney Yin Xu Heat ○ You Gui Wan - pronounced Kidney Yang Xu ○ Qing Xin Lian Zi Yin - Heart Qi Xu 28 Remarks ● ● ● Acupuncture and herbs are quite effective at treating most Lin syndromes Stone tends to be more complicated Prevention includes avoiding those triggers which exacerbate the root cause ○ ○ Deficient ■ Avoiding overindulgence in sex (men) ■ Avoiding overwork and lifting heavy objects ■ Avoid standing too long Excess ■ Avoid sex with a full bladder ■ Avoid hot spicy food, alcohol ■ Avoid overindulgence in sex (women) ■ Urinating after sex ■ Maintaining personal hygiene 29 Appendix: Urinary Calculi Characterization ● ● ● Stones or sand precipitated by Heat in Dampness Characterized by deficiency of Spleen and Kidneys, and Heat Acute vs Chronic stages 30 Etiology ● Excessive Sexual activity ○ ● Diet ○ ○ ○ ○ ○ ● Consumption of stone forming foods or Damp forming foods Calcium - cheese, milk Oxalate - spinach, rhubarb Uric acid - liver, kidney, fish roe, sardines Phosphate - many foods Lack of exercise ○ ● Weakening Kidney Yin creating Heat that concentrates urine Stagnation in Lower Jiao Loss of fluids ○ Concentrating urine 31 Pathology ● Deficient Spleen and Kidney fail to transform leading to accumulation of Dampness ● Heat evaporates fluids and condenses the Dampness ● Acute stage - colicky pain, stone moving ● Chronic stage - recurring stones, or stone not moving 32 Treatment - Acute Stage Symptoms: Intense colicky pain that comes in waves located where the stone is. Restlessness, sweating, shock. Burning urination, interrupted flow, frequency, urgency, blood. Shivering, fever, thirst, lumbago, lassitude. Tongue: Thick yellow coat with red papules at the root Pulse: Rapid and Wiry in the Chi position Treatment principle: Expel Stone, Stop Pain Acupuncture: UB23, ST25, Ren6, SP9, LV3, K3. ● Local Points: ○ ○ ○ ○ ● Kidney: UB23, UB22, GB25, UB52 Upper ureter: ST25, SP15, UB23, UB24 Mid-lower ureter: ST27, ST28, ST29, UB26 Bladder: Ren3, Ren2, UB32, UB28 According to channel: ○ ○ ○ Liver - LV3, LV8 Stomach - ST36 Kidney - K10, SP9, UB39 Formula: Shi Wei San - Clear Damp Heat, Open water passages, Relieve urinary dysfunction 33 Treatment - Chronic Stage Damp Heat Symptoms: Burning urination, difficult urination, dark urine Tongue: Yellow greasy coat at the root Pulse: Rapid Slippery Treatment principle: Clear Damp Heat ● Acupuncture: UB22, ST28, SP9, ST26, Ren6 ● Formula ○ Zhi Bo Ba Wei Wan ■ Nourish Kidney Yin, Resolve Damp Heat 34 Treatment - Chronic Stage Kidney Xu Symptoms: Repeated attacks of colicky pain, dull backache. Yin Xu - dark urine, prickly pain with urination, insomnia, dry mouth, night sweats. Yang Xu - chilliness, exhaustion, depression ● Acupuncture: UB23, Ren6, Ren4, SP6, K3. Moxa for Yang Xu ● Formula Tongue: Yin Xu - Red, coatless. Yang Xu - Pale Pulse: Yin Xu - Floating, Empty. Yang Xu - Deep, Weak ○ Treatment principle: Tonify Kidney ○ Zhi Bo Ba Wei Wan ■ Nourish Kidney Yin, Resolve Damp Heat Jin Gui Shen Qi Wan and Wu Ling San ■ Tonify Kidney Yang, drain Dampness 35 Prognosis ● Prognosis primarily depends on multiple factors: ○ ○ ○ ○ Location: the higher the stone the more difficult Shape and size: the rounder the easier, the larger the more difficult Time of tx: acupuncture works best when pain is present. Pain after needling indicates the stone is being expelled Body condition: the weaker the patient the more difficult ● Stay hydrated, stay active 36 Acupoint Review 37 UB / Water Metabolism Dysfunction Point Review ● ● ● ● ● ● ● ● Ren3 UB28 ST28 UB22 UB63 SP9 Ren9 K7 38 42 43 44 45 46 Heat Clearing Point Review ● ● ● ● ● LI11 UB66 LV2 HT8 SI2 47 48 49 50 51 52 Release Exterior ● ● ● LI4 LU7 SJ5 Point Review 53 54 55 56 Stone ● ● UB39 K2 Point Review 57 58 59 Regulate Qi Point Review ● ● ● ● ● ● ● Ren5 Ren6 LV3 LV5 LV8 SP6 Du20 60 61 62 63 64 65 66 67 Regulate Blood ● ● SP10 UB17 Point Review 68 69 70 Tonify Deficiency Point Review ● ● ● ● ● ● ● ● ST36 K3 Du4 Ren4 UB23 UB64 LU7/K6 SI3/UB62 71 72 73 74 75 76 77 78 79