Painful+Obstructive+Syndrome

Painful Obstructive syndrome, bi syndrome, or //Bi Zheng//, is caused by invasion of exterior pathogenic factors, such as wind, cold, dampness, and heat, which obstruct the channels and collaterals, disturbing the blood circulation and Qi flow. The syndrome is characterized by localized discomforts in the muscles, joints and tendons. Major complaints include soreness & pain, numbness, heaviness, difficulty in movement, and/or swollen joints that are warm to the touch. In some cases, deformity of the joints is apparent. Bì Zhèng may affect the muscles, tendons, bones and joints

Relevant Western Diseases
Rheaumatoid Arthritis, Rheumatic Arthritis, Degenerative Arthritis, Osteoarthritis, Gout, Sciatica, Subacromial Bursitis, Olecranal Bursitis, Carpal Tunnel Syndrome, Fibromyalgia

Pathogenesis & Etiology
-Vacuous zheng Qi is the underlying etiology of Painful Obstruction Syndrome. -Unconsolidated interstitial layers between the muscles and skin allow for invasion of exogenous Wind, Cold, Dampness, or Heat. -These pathogens obstruct the flow of Qi and Blood in the channels and collaterals, causing pain and restricted movement. -Exogenous Wind, Cold, and Dampness invade causing obstruction of the channels and collaterals, muscles and joints. This can result from one’s living or working environment or from sudden exposure to cold or rainy weather. -Exogenous Heat invades, usually in combination with Wind and Dampness, causing Wind-Damp-Heat Bì. Heat Bì can also form when Wind-Cold-Damp invade a body that has pre-existing Heat, either through Yang excess or Yin vacuity. Qi stagnation itself can potentially generate Heat, and in individuals with pre-existing Heat this process is greatly facilitated.
 * Invasion of Exogenous Pathogenic Factors:**

Distinguishing Pathogens
Wind/Wandering Bì: characterized by pain that migrates from joint to joint; pain tends to be sore and aching Cold/Painful Bì : characterized by severe, excruciating pain in the affected joints with limited ROM Damp/Fixed Bì : characterized by heavy aching with possible swelling and numbness in the joints and limbs Heat Bì: characterized by red, swollen, painful joints that are warm to the touch

Complicating Factors
The following complications are usually seen in chronic cases: -Phlegm accumulation and Blood stasis: long-standing Bì Zhèng affects Qi and Blood flow. Blood stasis forms obstruction and Phlegm accumulates in the channels. -Qi and Blood vacuity: chronic, intractable Bì Zhèng leads to depletion of Qi and Blood. -Various degrees of Liver and Kidney vacuity with Blood and Essence vacuity are also common.

Differential Diagnosis
Atrophy Syndrome (Wĕi Zhèng) is characterized by weakness and flaccidity of the limbs and atrophy of the muscles, leading to loss of musculoskeletal function. Pain is not common

General Treatment Principles
Acute/Excess Stage: Expel Wind, scatter Cold, eliminate Dampness, clear Heat, open the channels and collaterals, stop pain. -Wind Bì: Expel Wind while nourishing Blood. “Treat the Blood prior to expelling Wind. As Blood circulation is restored, Wind is inevitably arrested.” -Cold Bì : Scatter Cold while fortifying Yang. “Warmth can unblock congealed Cold.” -Damp Bì : Drying and draining Dampness are the primary strategies, along with tonifying the Spleen. “Bank up Earth to check Water.” -Heat Bì: Clear Heat and employ other strategies according to the pathogens that are present. -Chronic stage (mixed excess and deficiency): Tonify underlying deficiencies (Qi, Blood, Essence, Liver, and/or Kidney), eliminate pathogenic factors and stop pain.

Wind Bi
Soreness & pain that migrates from joint to joint, pain in indeterminate location, difficulty in flexion/extention of joints, aversion to cold & in some cases, fever Auxiliary Points: For general pain over the entire body: + SI-3, BL-62, SP-21, LI-15, LI-11,LI-4, TW-4,GB-30, GB-34, GB-39, ST-41 Mainly affecting the upper extremities: +Qiang Huo (9), Bai Zhi (6), Jiang Huang (9), Chuan Xiong (6), Wei Ling Xian (9) Mainly affecting the lower limbs: + Du Huo (9), Niu Xi (9), Mu Gua, Fang Ji (6), Bai Xie (6) Mainly affecting the lower back or spine: +Du Zhong (12), Sang Ji Sheng (12), Ba Ji Tian (9), Xu Duan (9), Yin Yang Huo (9) In cases presenting swollen painful joints, dry sore throat, and a thin yellow tongue coat, the evils are undergoing transformation into heat. The Prescription is changed to dispel wind-dampness, clear heat and relieve pain. Use: Gui Zhi Shao Yao Zhi Mu Tang
 * Symptoms:** Aversion to wind, fever & limited range of movement
 * Tongue:** Thin White Coating
 * Pulse:** Floating, possibly wiry
 * Treatment Method:** Expel wind, scatter cold, eliminate dampness, unblock collaterals, & relieve pain
 * Acupuncture**: reducing method: BL-12, BL-17, SP-10
 * Herbs:** Fang Feng Tang
 * Modifications:**

Cold Bi
Excruciating pain in the affected joints & limbs. Pain is localized and aggravated by cold, pain decreased w/ heat, difficulty moving the affected parts Complicated by constitutional yang deficiency causing stubborn cold: + Rou Gui, Xi Xin Pain of the elbow or shoulder joints is predominant: + Qiang Huo (9), Wei Ling Xian (9), Jiang Huang (9) Pain of the knee & ankle joints is predominant: + Niu Xi (9), Du Huo (9), Mu Gua (9) Pain in the lumbar region is predominant: + Du Zhong (12), Sang Ji Sheng (12), Xu Duan (9) To enforce invigorating the blood and opening the collaterals: + Ji Xue Teng (12), Dang Gui (9), Luo Shi Teng (6)
 * Symptoms**:Stiffness of the joints w/ difficulty in movement, possible EPI symptoms
 * Tongue:** Thin White or Moist White Coating
 * Pulse:** Floating & Tight, slippery or slow, often wiry
 * Treatment Method:** Scatter cold, Warm the channels, dispel wind & eliminate dampness, relieve pain
 * Acupuncture:** moxa is primary. reducing method with deep insertion & long retention time BL-23, CV-4
 * Herbs:** Wu Tou Tang
 * Modifications:**

Damp Bi
Swollen heavy, painful joints & numbness of the affected limbs, distention & swelling in some cases, pain in fixed location, limited ROM, worse w/ cloudy or rainy weather Significant swelling in the joints: + Bi Xie (9), Mu Tong (6), Mu Gua, Fang Ji, Jiang Huang (9) Significant Numbness: + Hai Tong (9), Xi Xian Cao (9), Ji Xue Teng (12) In cases where the dominant predominance of wind, cold or dampness is not apparent use: Juan Bi Tang
 * Symptoms:** General soreness & heaviness, fatigue & lack of strength w/ difficult movement, possible EPI symptoms
 * Tongue:** White, Greasy Coating
 * Pulse:** Soft & decelerating, slippery
 * Treatment Method:** Eliminate dampness, unblock obstruction in the channels, dispel wind-cold,. relieve pain
 * Acupuncture:** acupuncture & moxa. ST-36, BL-20, SP-5, SP-9
 * Herbs:** Yi Yi Ren Tang
 * Modifications:**

Heat Bi
Redness, swelling, and burning pain in joints that are warm to the touch, pain aggravated by pressure, & preference for cold, limited ROM To reinforce clearing heat & relieving toxicity: + Ren Dong Teng, Lian Qiao (12), Huang Bai (9), Jin Yin Hua (15) To enhance effects of invigorating the blood, unblocking the collaterals, dispelling wind, & eliminating dampness: + Hai Tong Pi (9), Jiang Huang (9), Wei Ling Xian (6), Fang Ji (9), Sang Zhi (15) Erythema marginatum or circinatum: + Mu Dan Pi (9), Sheng Di Huang (12), Di Fu Zi (9), Chi Shao Yao (9) -In cases where heat bi has given rise to fire w/ injury to Yin, prescription is altered to clear heat, resolve toxin, cool the blood, nourish Yin, and relieve pain. Symptoms include severe pain, redness/swelling of joints, increased pain at night, high fever, thirst, red tongue w/ little coat, and rapid, wiry pulse: Use Xi-Jiao San -In cases where damp-heat has descended to the lower burner, resulting in swelling and pain in the lower limbs, dark burning urine, yellow slimy tongue coat and soft rapid pulse, the prescription is changed to clear heat, dispel dampness, disperse swelling & relieve pain: Use San Miao Wan
 * Symptoms**:Aversion to wind/heat, fever, sweating, thirst, irritability & restlessness, sore throat, dark scanty urine
 * Tongue:** Red tongue w/ yellow dry or possibly greasy coat
 * Pulse:** Slippery & Rapid
 * Treatment Method:** Clear heat & unblock the collaterals, dispel wind, eliminate dampness, relieve pain
 * Acupuncture:** Reducing method. GV-14, LI-11
 * Herbs:** Bai Hu Jia Gui Zhi Tang
 * Modifications:**

Phlegm Accumulation & Blood Stasis
Swollen joints w/ intermittent pain, possible deformity, stiffness, difficulty in movement, & subcutaneous nodules Strengthen transforming phlegm & dissipating nodules effect: + Bai Jie Zi(9), Dan Nan Xing (4.5) To enhance effects of invigorating the blood, expelling stasis, & unblocking the collaterals: + Chuan Shan Jia (9), Di Long (9), Zhe Chong (9) Reinforce gathering wind & unblocking the collaterals effects: + Quan Xie (4.5), Wu Shao She (9)
 * Tongue:** Purple or dark tongue w/ White, Greasy Coat
 * Pulse:** Thready & Choppy, Deep-rough, or Deep-slippery
 * Treatment Method:** Transform phlegm, move Blood, expel stasis, unblock channels, & stop pain
 * Herbs:** Sheng Tong Zhu Yu Tang or Tao Hong Yin
 * Modifications:**

Qi and Blood vacuity
chronic, aching pain in joints that is worse at night and better with light movement, difficult movement with limited ROM, possible numbness or loss of sensation in affected areas
 * Secondary Symptoms**: fatigue, pale complexion, SOB, palpitations, spontaneous sweating
 * Tongue:** pale with thin, white coat
 * Pulse:** thin, weak
 * Treatment Method**: Boost Qi, nourish Blood, expel Wind, eliminate Dampness, scatter Cold, stop pain
 * Herbal Treatment:** Huang Qi Gui Zhi Wu Wu Tang

Qi and Blood Deficiency (Liver & Kidney)
Intermittent joint pain w/ difficulty in movement, numbness of the limbs, soreness & weakness of the lower back, cold intolerance, preference for warmth, fatigue, lassitude & shortness of breath Significant Pain: + Zhi Chuan Wu, Di Long, Hong Hua, Bai Hua She Preponderance of cold: + Fu Zi Preponderance of dampness: + Fang Ji
 * Tongue:** Pale tongue w/ White Coat
 * Pulse:** Thready & Weak
 * Treatment Method:** Expel wind-dampness & unblock the obstruction to alleviate pain; tonify the Qi and Blood, & nourish the Liver & Kidney
 * Herbs:** Du Huo Ji Sheng Tang or San Bi Tang
 * Modifications:**

[Heart Bi]
Palpitations & shortness of breath aggravated by exertion, oppression of the chest, edema, pale or purplish complexion, nails & lips Strengthen nourishing the Heart & calming the Shen effects: + Yuan Zhi, Wu Wei Zi Significant palpations & dyspnea: + Huang Qi, Bai Zhu Accompanied by chest congestion & chest pain: + Dan Shen, Yu Jin
 * Tongue:** Pale or purplish tongue
 * Pulse:** Intermittent & Knotted or rapid forceless intermittent
 * Treatment Method:**Augment the Qi, nourish the Heart, warm the Yang & restore the regular pulse
 * Acupuncture:** address palpitations and fatigue
 * Herbs:** Zhi Gan Cao Tang
 * Modifications:**

Further Herbal Modification According to Affected Limbs
Shoulders, elbows or joints of the upper extremities: + Qiang Huo, Bai Zhi, Gao Ben, Sang Zhi, Jiang Huang, Chuan Xiong, Wei Ling Xian Knees, ankles or joints of the lower extremities: + Du Huo, Niu Xi, Fang Ji, Mu Gua Lower back or lumbar intervertebral joints: + Du Zhong, Sang Ji Sheng, Yin Yang Huo, Ba Ji Tian, Xu Duan Red, swollen & painful joints that are warm to the touch: + Ren Dong Teng, Shi Gao, Zhi Mu, Lian Qiao, Qin Jiao

In //chronic cases of Bi patterns// that manifest spasmodic pain and spastic contraction of limbs, entomological medicines such as Quan Xie (2.5) and Wu Gong (1-3) are use to free the collaterals and relieve pain [Wu]

Acupuncture Treatment
Shoulder: LI15, TB14, SI10, SI9, Jian Qian Elbow: LI11, LU5, PC3, HT3, LI10, TB10, SI8 Wrist: LI5, TB4, PC7, LI4, TB5 Fingers: Ba Xie, LI4, LI3, TB3, Si Feng Hip: GB30, GB29, GB34, ST31, Huan Zhong Acupuncture for Bì Zhèng Sacrum: BL32, BL27, BL28 Low back: BL23, BL27, BL28 Knee: ST35, Nei Xi Yan, ST34, BL40, GB33, LV8, GB34, SP9, KI10, SP10, He Ding Ankle: BL60, KI3, ST41, GB40, SP5, KI6 Toes : Ba Feng, ST44, SP3 Spine: GV14, GV12, GV3, Jia Ji Neck: GB20, BL10, BL11, Jia Ji
 * Wind-Cold-Damp Bi, Differentiation of Syndrome:**
 * Wind:** BL12, BL17, SP10, GB31, LI4
 * Cold**: GV4, CV4, BL23 + moxa
 * Damp**: SP9, SP6, ST36, BL20
 * Local points (based on the location of pain):**

General points: GV14, LI11 Local points: same as Wind-Cold-Damp
 * Wind-Damp-Heat Bi**

General for Phlegm: ST40, SP9, SP6, CV12, CV9, BL20 General for Blood stasis: SP10, BL17, BL11, (GB39), SP6 Local points: same as Wind-Cold-Damp
 * Stagnation of Phlegm and Blood**

General points for Qi and Blood Xu: CV4, CV6, SP6, ST36, BL20, BL17 General points for LV and KI Xu: BL18, BL23, GV4, K13, LV3, Sp6 Local points: same as Wind-Cold-Damp
 * Zheng Xu with Xie obstruction**

Ear Acupuncture: points corresponding to affected parts, Sympathetic, Shen Men Plum Blossom: used where swelling and distention are significant

Sources: Essentials of Chinese Medicine: Internal Medicine, Shi; Practical Therapeutics of Traditional Chinese Medicine, Wu Martin Kidwell: TCM Pathology Course

External Chinese Formulas
Grind all herbs into a powder, mix with hot cooking alcohol, make paste & place on teabag or cook and use as soak or steam. 1 bag = 1 week
 * Muscle and Tendon Bi, Wind-cold-damp, esp. when acute:** Chuan Wu 1unit, Cao Wu 1unit, Sheng Nan Xing 1unit, Fu Zi 1unit, Pao Jiang 3units, Chi Shao 3units, Rou Guo 0.5unit, Bai Zhi 0.5unit, Xi Xin 0.5unit -

Wheat Bran 500g. (varies on size of area), Cang Zhu Fen 30, Mu Xiang Fen 30 , Ru Xiang Fen 30g., Mo Yao Fen 15 1 bag = 1 week, each day pour everything into a wok/oven and dry fry
 * Muscle & Tendon Bi, cold and damp -> blood stagnation**

Ru Xiang 2, Mo Yao 2, Hong Hua 1, Tu Bie Chong 1, San Qi 1, Chuan Wu 1, Cao Wu 1, Dang Gui 1, Du Zhong 1, Xu Duan 1, Tou Gu Cao 1 Grind into powder, put in cheesecloth/gauze, soak bag in 80 proof alcohol for 1-2 hours then place over affected area and use tdp lamp/ blow dryer or heating pad 1 bag = 1 week
 * Boney Bi**

Hong Hua 30g., Chi Shao 30g., Bai Zhi 30g., Zhi Zi 30g., Tao Ren 30g., Ru Xiang 30g., Mo Yao 30g., Da Huang 60g. Cook herbs and use as soak when still warm. 1 Bag = 2 days
 * Wind-Damp-Heat, arthritis or gout flare up, vessel Bi, acute sprain**

Ru Xiang (3g.), Mo Yao (3g.), Bai Shao (3g.), Chuan Wu (3g.), Tao Ren (10g.), Xing Ren (10g.), Gu Sui Bu (10g.), Jiu Cai Zi (6g.) Make paste, vinegar may work well as medium
 * Boney Bi, Scars after surgery, joint replacement surgery**

Huang Bai, Sheng Ban Xia, Wu Bei Zi Make paste with vinegar or decoct and soak
 * Damp-Heat Bi with swelling, good for scar tissue, more lower extremity, gout**