Paraplegia / Tai Acupuncture

PARAPLEGIA

SCI at or inferior of T1 the thoracic spinal levels down to sacrum level is results in paraplegia.

All type of SCI in which is lesion to spinal cord is occurs paralyzed the lower extremities. ACU treatment correctly managing the paralyzed lower limbs is significant for SCI patient stand and mobile out of wheelchair.

THORACIC CAGE & RESPIRATION

In general all types spinal cord injuries are involved to and damage to the thoracic cage. Thus, managing the damage thorax is an important treatment for the recovery of the spinal cord. Furthermore, the recovery of the lesion segmental spinal cord is initiated at the lesion section, gradually, going down to the below segmental of the cord. Most of paraplegia patients are involved trauma to the thoracic vertebrae. In SCI ACU treatment of thorax and thoracic vertebrae essentially is via neural path reconnected the upper and lower portion lost function of spinal cord.

Structurally, the thoracic cage and thoracic vertebral column are a strong and stable structure to maintain body posture and spine. SCI in thoracic vertebrae region: the traumatic forces direct impact must be severed, frequently, could be a severe thoracic spine trauma— Complete paraplegia.

Severe spine trauma damages the thoracic vertebrae and thoracic cage, moreover, causing the whole spine curvature. Furthermore, severs thoracic spinal cord lesion also severely lesion to ascending and descending tracts: the complete lesion to the cord cases for example; the lower extremities are difficulty to recover.

ACU treatment

The respiratory muscles and the breathing mechanism of respiration is an important factor in ACU treatment of SCI in which is applied the diaphragm respiration and the abdominal muscles coordinate with erector spinae muscles mobile and stabilize the spine.

Anatomy

Surface landmarks:

Thoracic vertebrae

Sternum

Ribs

Pectoral girdle; include the clavicles and scapula

Respiratory mechanics:

Mechanical respiration: Ventilation can be divided into two categories—costal and diaphragmatic.

The muscle organization, essentially, is involved muscle of inspiration and expiration and diaphragm.

The inspiration muscles: include external intercostals, internal intercostals, diaphragm, pectoralis major, and pectoralis minor, sternomastiod and scalenes muscles.

The expiration muscles: include internal intercostals, transverse thoracic, rectus abdominis, external oblique, internal oblique, transverse abdominis and quadratus lumborum.

The anatomy provided the version of point selection and needle insertion method. Such as in treating the disorder is involved the expiration mainly is focused on the abdominal wall muscle and the point on the side of the muscles. Essentially the needle is inserted into the skin and muscles where the muscle origin, the belly and the insertion of the muscles.

Point selection and needle insertion method:

In thoracic cage there are Kidney meridian and ST meridian run on the chest BL meridian GV and JIAJI on the back and the GB meridian on the lateral. Generally when treating SCI all of these meridian points are need considered and provide needle insertion.

The spinal nerve is initialed the thoracic vertebral column run toward the ribs. The needle is inserted into the skin and connective tissues along the vertebrae toward the ribs.

Tai Acupuncture

PARAPLEGIA

SCI at or inferior of T1 the thoracic spinal levels down to sacrum level is results in paraplegia.

THORACIC CAGE & RESPIRATION

ACU treatment

Anatomy

Surface landmarks:

Thoracic vertebrae

Sternum

Ribs

Pectoral girdle; include the clavicles and scapula

Respiratory mechanics:

Mechanical respiration: Ventilation can be divided into two categories—costal and diaphragmatic.

The muscle organization, essentially, is involved muscle of inspiration and expiration and diaphragm.

The inspiration muscles: include external intercostals, internal intercostals, diaphragm, pectoralis major, and pectoralis minor, sternomastiod and scalenes muscles.

The expiration muscles: include internal intercostals, transverse thoracic, rectus abdominis, external oblique, internal oblique, transverse abdominis and quadratus lumborum.

Point selection and needle insertion method:

The spinal nerve is initialed the thoracic vertebral column run toward the ribs. The needle is inserted into the skin and connective tissues along the vertebrae toward the ribs.

The point is initials the vertebrae toward the lateral ribs

The points above the nipple involved the upper fifth ribs. The point is located at between two ribs initial the sternum toward the edge of the rib.

The needle is inserted perpendicularly into the skin and the fascia of the muscles. The depth of the needle insertion is above of the internal intercostals muscle and avoid deep into the lung. Not manipulated the needle, the needle is inserted into the point is at 50mm interval, frequently, is using rapid shallow needle stimulation method.

After needle insertion a deep respiration actively stretching the ribs cage can observe increasing movement of the ribs cage. Particularly, needle is inserted into the points of the chest after needling increased the chest and rib cages movement.

The location of the points below the fifth ribs also are involved the ribs, the skin and the muscles.

The needle insertion is initiated from first rib to the 12^th thoracic vertebral column between the two ribs and forward to the edge of the rib. It is included the 11^th 10^th and 9^th thoracic vertebrae and the floating ribs. The points in the chest below the fifth rib is initiated the sternum between the two ribs toward the lateral of the rib, end to the external oblique abdominals muscle.

Needle insertion to the points of inferior five ribs more involved to the muscles attached to the ribs especially the abdominal walls and diaphragm so the needle is inserted to the skin and the side of the muscles.

Needle insertion to the abdominal wall muscle:

The landmark

The edge of the rib cage

The lumber vertebral column

The pelvis

Needle insertion method into the abdominal wall muscles:

The needle is inserted obliquely into the skin, the fascia of the muscle and terminated to above of peritoneum. The points located at the line initiated the 3^rd and the 5^th lumber vertebral column toward the linea alba at 50mm interval.

Needling to Aponeurosis

The point is located at the center of two muscles (SP meridian line) in which is initiated the edge of the rib straight downward to the pelvis.

Making a straight line from the edge of the rib down to pelvis, the point is located at the line the needle is inserted perpendicularly into the aponeurosis and above the peritoneum.

Needle insertion into rectus abdominis:

There are three Meridians (SP. SM. CV.) run through the rectus abdominis muscle.

There are two methods can be selected:

The needle is inserted perpendicularly follow the meridian straight line from the edge of the rib downward to the pelvis at SM points.

Making a transverse line from the point of CV to SP, the needle is obliquely inserted in to the point. The needle mainly is inserted into the skin and fascia of the muscle.

It is preferred the needle is longitudinally and obliquely inserted into the skin, and the fascia transverse the muscle fiber. After needle insertion is using the breathing exercises stretching the muscles.

The basic needling technique is:

Needling into the ‘Rectus Abdominis’ for example

Origin: Cartilage of fifth, sixth and seventh ribs and xiphoid process

Insertion: cress of pubis and pubic symphysis

Action: Flexes vertebral column and compresses abdomen

Tendinous bends divide each rectus three to four bellies, lateral is aponeurosis and in centrally to form the linea alba.

Needle insertion method:

Abdominal walls muscles-fascia-Aponeurosis

Needle is focused on Rectus abdominis muscle, which is involved the skin, connective tissues, fascia and aponeurosis.

The needle is inserted into the skin connective tissues and fascia at the origin insertion of the muscle. The needle also along the lateral of the aponeurosis ACU SP meridian points and medial of lines alba go with CV ACU points. Between the central is SM meridian points. The needle is inserted into skin connective tissues obliquely and get in to the side fascia of the muscle initiated the muscle origin down to insertion. When needling into the tendinous bands, which is preferred the needle is inserted into skin connective tissues and both side of the tendinous bends obliquely.

After needling applies deep breathing stretching exercises to elongate the length of rectus abdomini.

Needling can balance the vertebral column and abdominal walls muscles maintain body in straight postural position.

The Chinese breathing exercises is focused on the respiration, using inspiration and expiration muscles and diaphragm movement, stretching the chest and abdominal wall muscles: to power the muscles, to improve the correlative movement of the front and back muscles, rib cage and the thoracic vertebral column to stabilized the spine.

The actually results are more than external reaction in which included increases the internal organs lung and heart function.

In the case of SCI in cervical vertebrae, frequently, is interfered the phernic nerve [C3-C5] and twigs fromT12-L2. Thus, needle insertion to release the obstruction of the neural path at the neck and chest; the needle also stimulated the nerve tissues: all are target on the skin and muscles via sensory neurons and reflexes mechanism.

In a case of severe T4-T5 SCI—motor cycle complete paraplegia, the vertebrae fracture dislocation and severe wound at the T4 to scapula, the spine is curved to one side, especially, the lumber vertebrae curvature and unstable the patient occur severe lower limb muscle contraction. Pain syndrome occur in the shoulder, the patient is difficult to manage the simple regular life and stressful. In many instances, the patient is dependent upon heavier drug usage to maintain every day life.

This is a most difficult managed case, in which need the strength patience and knowledge to achieve the results.

Acupuncture only acupuncture treatment able to help the patient even a long period of acupuncture management the patient regain a good quality of life style. (Case study David Waterson)

LUMBERAL VERTEBAE

Lesion to the lumber vertebrae more often is located at T12-L1. According to the medical sciences the spinal cord is terminated at T12 and L1 inferior this region mainly is involved to the spinal nerves especially the lumbosacral plexus. Theologically lesion in this region the patient has better chance to stand and mobile again. Unfortunately in clinical practice the results are not better then general SCI.

Because of postoperative scar tissues and severity lesion to the sacral nerve the pain symptoms below the leg tissues is severed and the patient could not correctly located the exact pain location. In other case, both feet lost skin sensation and muscle movement and the gluteus group muscles are atrophies.

SCI in lumber region, acupuncture treatment go after the medical science is focuses on lumber vertebrae, lumbosacral plexus, hip and thigh region of the muscles, joint, and bone, and the correlation with the neurovascular pathway.

The lumbar vertebrae, particularly, the fifth lumbar vertebral column is wedged into the sacrum and the sacroiliac joints are tightly bound by strong ligaments. Body weight is transferred through the pelvis to the lower extremities. In this area, the body structure is provided a large movement and supports to the lumber, pelvis, and lower extremities. This region, frequently, becomes a high risk of trauma, and the trauma can be severed and affected to the lumber vertebrae and the lumbosacral plexus and the stability of the spine.

The lumbar enlargement and lumbosacral plexus provides the somatic innervations to the pelvis and lower extremities.

All type of SCI, the main aim of needle insertion technique is attempts and focused on regaining the skin sensation and musculature movement of the paraplegia limbs. The treatment in this region is vital for the paralyzed limbs mobile and satisfaction to the patient requirement.

Acupuncture treatment of SCI, the treatment and the nature of the recovery healing processes—regain the skin sensation and muscles movement should be initialed the lesion section of the cord. Gradually, extents to the below lesion of the cord, and the proper recovery should be from one segmental of the cord down to the below segmental of the cord—the spine is stabled, the whole spinal cord is functioned and reconnected to CNS.

However, there may be another possibility in recovery, a specific treatment, such as strong stimulation to lumber and lower limbs region, the result is through the quick response via CNS that can regain the lower limbs muscle movements and actively mobile the lower limbs. The treatment only need a short treatment times, such as SCI—Incomplete Quadriplegia, the patient recovery from paraplegia may needs one year of acupuncture treatment. After one year of acupuncture treatment the participant is able to stand with the support of the calipers and walk. Many patients may satisfy in this level and hope exercises able to keep going well, unfortunately, the result is not as wait for.

Because of the lesion to the cervical vertebrae are not heal and the upper extremity unable to correctly support the whole body movement in which may damage the upper extremities and nerve control pain symptoms is the main complaint.

It is truth, without proper acupuncture management the long-term result, frequently, is uncertain. In some cases, there can be have good potential to rapidly achieve stand result, but because of some interruption still remain in the spinal cord; the patient will sit back to the wheelchair.

The proper acupuncture treatment should make sure the whole segmental of the cord is completely recovery, and the whole skin sensation and muscles coordinated movements are regained. The patient can walk independently without any aid.

LUMBOSACRAL PLEXUS

Lumbosacral trunk:

The lumbar plexus—T12-L4

Anterior division—tibial portion of the sciatic nerve

Posterior division—gluteal nerve and common peroneal portion of the sciatic nerve

Sacral plexus—L4-S3

The pelvic splanchnic nerve

The coccygeal plexus—S4-Cx1

Bony landmark:

Lumber vertebrae—L1-L5

Sacrum

Pelvic

Bony attachments of muscles of hip and thigh

LUMBER VERTEBRAE

The treatment in this region, it is preferred initial T7 down to coccyx. The superficial muscles are included the latissimus dorsi, trapezius, thoracolumbar fascia, and gluteus muscles. The deep muscles mainly are eractor spinae, post abdominal wall muscles.

As the needle insertion method to the cervical vertebral column, the needle is inserted into the points: at between the two spinous process, the side of the spinous process, and the transverse process. Acupuncture point—GV points, BL Meridian points, and HUA TAU JIAJI points.

A special treatment is combination derma hammer, needle insertion, and moxa. The needle insertion method is reinforced the deficiency.

Needle insertion is focuses on the thoracolumbar fascia—strong support to the vertebrae. After SCI, because of the fascia lack of blood supplies, may causing the skin, fascia, and the below tissues adhesion or degenerated. The needle is obliquely inserted into the skin and over the skin into the fascia, further deeper get into the inferior tissues. Needle insertion direction is from the edge between muscle and fascia to-ward the vertebra.

ILLUSTRATION—thoracolumbar fascia

From the tight to the legs all muscles are large and strong, an adequate acupuncture treatment can maintain, and rapidly improved the muscles tone and function. The treatment is focus on the needle insertion into the skin, connective tissues, the side of the muscle-fascia and transverse the tendon. The purpose of the treatment is provided good blood supplies to the muscles and tendon, in particular, stimulated the origin the belly and the insertion of the muscle to improve muscles tone and regain the movement.

The muscles are included the anterior, lateral, and posterior muscles. Another needle insertion method to the thigh muscles is go with the neurovascular pathway—dermatomes, cutaneous nerve distribution area, and the superficial nerves and veins of the lower limb.

In acupuncture points selection and needle insertion method may consider follow the Meridian Line selected the point and perpendicularly inserted needle into the point.

Muscle function at the hip joint

Most of the movements of the hip joint are accomplished by combination of many groups of muscles.

Flexion: The major flexor muscle of the hip is the iliopsoas, assisted by the sartorius, rectus femoris, pectineus, and tensor fasciae latae, and the adductor longus.

Extension: These extensors of the hip include two group muscles the gluteus maximus and the hamstring group—long head of the biceps femoris, semitendinosus, semimembrenosus and adductor magnus.

Needle insertion method: The needle is targeted on the skin and connective tissues and the side of the muscle. The landmark is the sacrum, the greater trochanter, femur, and the ischial tuberosity. Where the muscles are attached. The needle is stimulated the receptors and removed the tissue obstruction relieved the tension in the skin and muscles.

Needle insertion into the gluteus maximus for example:

The needle is inserted into the skin and the side of the muscle at the point of the origin—posteriosuperior ilium and sacrum and the point at the muscle is inserted in the gluteal tuberosity of femur.

The hamstring muscles the needle is inserted into the point at the ischial tuberosity.

Needle insertion to the Tensor fascia latae:

The needle is inserted into the skin and the side of the fascia—initial the anterior-superior iliac spine and iliac crest the needle is longitudinally along the fascia down to the iliotibial tract and lateral fibular head. Tensor fascia latae is a strong fixation muscle that holds on the thigh in straight position: it is need to exams and provides the treatment to correct the interruption for maintaining body stands straight.

Tensor fascia latae Quadriceps femoris Neurovascular path

THE FIVE SHU POINTS OF LOWER LIMBS

Three Yang Meridian points of foot

Stomach ST45 ST44 ST43 ST41 ST36

Gall Bladder GB44 GB43 GB41 GB38 GB34

Bladder BL67 BL66 BL65 BL60 BL40

Three Yin Meridians points of foot

Spleen SP1 SP2 SP3 SP5 SP9

Liver Liv1 Liv2 Liv3 Liv4 Liv8

Kidney K1 K2 K3 K7 K10

The treatment below the knee, the Five SHU points of the foot is selected. Similar to the FIVE SHU points of the hand: The neural network of reflexes activities are essential in the needle insertion to the tip of the toe, the side of the nail, the web, the sensitive points of the plantar.

The lymphatic capillary arteries, and venous and peripheral nerve networks, form a neurovascular network, which is located at the apex of the toes and fingers. The neurovascular pathway and the lymphatic pathway pass through the web.

The cerebral motor cortex is directly related to distal limb activity. The supplementary cortex is intimately involved in the initiation of delicate, skilful movement. Bilateral lesions result in long-term loss of movement in the hands or feet, and long-term loss of speech.

Strong stimulation to the premotor area can produce muscle movements similar to the primary motor area. Stimulation of the supplementary area results in the movement of the contralateral limbs, but a stronger stimulus is required than in the primary motor area.

Needle insertion into the Five Shu points of the fingers or toes can produce a strong impulse connected the skin sensory neuron to Thalamus and convey to Premotor cortex or/and supplementary area. When the motor cortex received the impulse that will contract the lower limb and lift the leg up. The result is the same as the ‘Withdrawn Flexion Reflexes.’

In acupuncture treatment for SCI, needle insertion into the plantar produces ‘Flexion Reflexes’ can help rebuild the correlative neural network connections, between the sensory neuron, centre nuclei and motor system.

The Toe

The lymphatic capillary arteries, and venous and peripheral nerve networks, form a network, which is located at the apex of the toes. The neurovascular pathway and the lymphatic pathway pass through the web.

The muscle tendons are attached to the phalanges and joint. The toes are structurally and functionally the same as the fingers. They are sensitive and can be easily traumatized.

The point located at the apex of the toe is sensitive to needle insertion, and can be used to treat edema, specifically because lymphatic obstruction or trauma factors are interrupted the lymphatic circulation.

The point on the sides of the corner of the toe, acupuncture point SP1, is called the JING-WELL point. This point is very sensitive to needle insertion. In acupuncture texts this point is used to revive the patient from unconsciousness.

The points located at the apex of the toe, on the side of the corner of the toe, at the side of the interphalangeal joint or tendon attached to the phalanges, can be used to treat local tissue disorders. More often it is used to treat nervous system disorders, to release neurovascular and lymphatic pathway interruption.

For example, needle insertion into the sensitive points on the fingers, palm, toes, plantar, can produce a strong impulse which can send messages to the thalamus, reticular formation, cerebellum and the cerebral cortex via the ascending tract.

When the cerebral motor cortex receives the information may via the descending tract, stimulating the lower motor system the result is muscle contraction.

Needle insertion into the web can relieve the interruption to the neurovascular pathway and lymphatic pathway, allowing the nerve tissue get through, and so improve the blood and lymphatic circulation.

The Tendon

The tendon of the foot crosses the joint between the ankle and the foot. The tendon is mainly attached to the phalanges of the foot joint. For most SCI patients because of lack of muscles movement in the limbs causes poor blood and lymphatic circulation, and the pressure of gravity in carrying the body weight, results in the feet and ankles swelling. A chronic inflammation may form tissues adhesion interrupted the tendon and joint movement. The restriction of the joint and lack of blood supplies may cause toe swollen or atrophy.

Attempts regain muscles movement of the legs without correct the interruption of the tendons, which is difficult achieved the result. A satisfactory treatment is released all the interruption surrounding the tendon especially at the ankle region where most of tendon are passed through and the reticular covering on the tendon.

Patients with incomplete lesion of the cord, who are able to move part of the muscle, hence, the muscle is lost coordinate muscle movement and the ankles and feet tendon is interrupted more often may cause ankle swollen.

The tendon and the leg muscle is strongly links together individually.

The treatment with the tendon is inserted needle into the point where the tendon attached to the bone or joint following the tendon fibers one direction. The needle is inserted into the skin longitudinally on the side of the tendon and than the needle direction is transverse inferior to the tendon.

The needle is targeted on released the adhesion restriction, in which is interrupted the tendon and joint movement.

The needle is also focused on the point at the junction of the tendon and the muscle.

The needle insertion method for SCI patient is concerned needle stimulation to the muscles and tendons spindles.

At the point two tendons crossing, frequently, there are blood vessels enlargements and tissues adhesion interrupted the tendon movement.

The needle is inserted into the point and released the obstruction.

Inflammation occurs in the tendon of the ankle is in the tendon sheath the needle is inserted into the tendon sheath where the inflammation is located.

It seems as Chinese version the strength of the leg is initialed the foot, it is at the dorsal and the plantar of the tendons, in which is cooperated with the correlative muscles such as the calcanous tendon, tibialis anterior and posterior.

The paraplegia patient is more interested in observed the reaction and mobile the leg; the strong needle insertion techniques are targets on stimulation the tendon and muscle spindles to improve muscles tone and movement.

For example: The needle is inserted into the point at the dorsal of the foot tendon ST41 ST42 GB40 GB41 and BL62 BL67, or at the plantar at KI1 KI2 and SP1 SP2.

When needle is immediately inserted at the point ST36 or ST40 and GB34 that can observe the foot ankle and leg muscle involuntary movement.

The Muscles

The extensor group of muscles consists of –

Tibialis anterior

Extensor hallucis longus

Extensor digitorum

The flexor group of muscles consists of –

Superficial group:

Gastrocnemius

Soleus

Plantaris

Deep group:

Flexor hallucis longus

Tibialis posterior

Flexor digitorum longus

The extensor group muscles are coordinate movement with the flexor group muscles. Interruption to either group of muscles can cause pain in the leg and foot.

The SCI patients because lost of skin sensation did not show any pain symptom more often is causing knee ankle joint swollen. That is inflammation response.

The patients need to advice not put heavy weight to the leg and foot. The patients need slowly and gradually do gentle and short time exercises. Only when the muscle is tone and the nerve is innervated into the muscle in which able to improve the voluntary movement. Continue acupuncture treatment is essential.

Needle insertion method

The needle is inserted into the skin and the side of the muscles to stimulate the receptors to restore the nerve function. Relevant points are ST36, located at the origin of the Tibialis anterior, ST37 located at the belly of the Tibialis anterior, and ST39 and ST40 located at the muscle and tendon junction.
The treatment needs to coordinate the flexor muscle – Tibialis posterior.
Usually the point for needle insertion is involves to a group of muscles.
The tendon is a continuation of the muscle, and they need to be treated together.

Actual Clinical Needle Insertion Method

There are five points on the apex of the toes or fingers. The needle is rapidly inserted into the points, with no needle retention.

Two points are located on each side of the corner of the toe or fingers. The needle is rapidly inserted into the point, with no needle retention.

Four points are located on the web. Usually, the needle is inserted at the point located at the dorsal section of the web. If the needle is inserted at the plantar side the reaction will be stronger.

Two points are located on both sides of the metatarsal-phalangeal joint. The needle is inserted perpendicularly into the joint capsule. Needle insertion can also involve the tendons and interosseous muscle attached to the joint.

There are ligaments and tendons attached to or crossing the tarsometatarsal joint and transverse tarsal joint. Superficial veins run between the two tendons. The dorsal pedis artery is located on the side of extensor hallucis longus muscle and extensor hallucis longus tendon.

Needle insertion into the tarsometatarsal joints and transverse tarsal joints, and between the two tendons, may stimulate the joints and between the two tendons receptors. It may also affect the joints and tendons movement and improve blood circulation, particularly on the dorsal of the foot. [Illustration of foot]

After SCI, because of the lack of muscle movement in the extremities and reduced blood supply to the joint and tendon, the tissues degenerate rapidly, causing tissue adhesion and obstruction to joint and tendon movement. Thus, after SCI the immediately treatment of the toes and foot and muscle tendon of the leg is significance for SCI patient regain skin sensation and muscles movement.

The Ankle Joint

The ankle joint has a limited range of movement, and the pressure of supporting the body weight may easily cause trauma. This area contains bone, joint, tendon, ligament, muscle, skin, retinacolum, and the neurovascular pathway. Needle insertion in this area, as illustrated below [Plate511 512 514 516], is a complex needling technique.

The muscles below the knee:

That is group of muscles go together the needle insertion methods need inserted into a group muscle such as the needle is inserted at the point of GB34 the needle insertion is included the peroneus longus and extensor digitorum longus. The point ST36 is involved the anterior tibialis a single individual muscle.

The needle is inserted into the skin and obliquely inserted into the side of the peroneus longus and deep goes through the extensor digitorum longus.

The needle is inserted into the ST36 targets on the origin of the anterior tibialis.

The flexor digitorum is coordinated with the extensor digitorum in which is the same as posterior tibialis is coordinated with anterior tibialis.

That needs differentiation needling into the muscle fibers or the tendon.

Needle insertion method is as illustration.

Below illustration explanation is in 6. Dr. K P Tai books

The whole-foot the points on the tip of the toes, the web, the joint the tendons, tendon sheet, the reticular, the ankle joint up to the tendon and muscles junction all of them are significance in ACU treatment.

PREVIEW BOOK—(ACUPUNCTURE—A comprehensive guide to clinical applications of acupuncture 1997)

SPINAL CORD INJURY

Excessive traumatic force that damages the vertebral column leads to spinal cord injury.

Paralysis of the lower limbs is known as paraplegia. Injury to the second thoracic cord segment and below results in paraplegia. Quadriplegia refers to paralysis of the upper and lower limbs. Injury to the first thoracic cord segment or above the result is in quadriplegia.

Complete transaction lesion of the cord means that no motor descending impulses can reach the section of the cord below the level of lesion and ascending impulses concerned with sensations from parts of the body below the level of the lesion will not be able to reach the brain. The result is that the body, below the level of the lesion is devoid of all sensation.

Incomplete transverse lesion of the cord may differ markedly from one case to another. There may be muscular weakness with little loss of sensation or combinations of sensory and motor loss. The extent of damage will depend upon which tracts have been damaged and how severe the damage is.

Immediate surgery remains controversial and should only be performed if the patient’s life is in danger.

ACUPUNCTURE AND SPINAL CORD INJURY

In ancient China the first choice of treatment for spinal cord injury was acupuncture.

The ancient practitioner’s believed that spinal cord injury could be treated by firstly, returning the vertebrae back to the correct position and then encouraging the blood and QI to flow over the whole spine and into the whole body.

Acupuncture treatment of spinal cord injury should begin as soon as emergency medical treatment is over.

To treat spinal cord injury:

A thorough examination of the injury should be undertaken in order to determine the extent of damage.

Care must be taken to avoid further damage.

The remaining functions of the nervous system must be maintained to improve the healing process of the patient.

The patient should be informed as to what is involved in acupuncture treatment. As natural regeneration of an injured nerve is slow, the patient needs to be psychologically prepared. They must also understand that the treatment is an active one and that motivation must be maintained.

Knowledge of the two following anatomical mechanisms is essential for designing the appropriate treatment:

Maintaining the functions of the surviving part of the peripheral nerves and providing continuous acupuncture treatment to allow them to heal and connect with the damaged part of the spinal cord and brain.

Stabilizing the spine and correcting the position of the vertebral column and is allowing the vertebrae to return to the correct position.

CLINICAL TREATEMENT OF SPINAL CORD INJURY WITH ACUPUNCTURE

Acupuncture needles can act as a surgical knife or they can be used to stimulate the body tissues. Correct needle technique can return the vertebrae back to their correct position and restores the functions of the paralyze limbs and allows the peripheral nerves to function again. In which is reconnecting the damaged nerves with the spinal cord and the central nervous system. With correct acupuncture treatment the patient will be able to walk again.

In order to provide successful acupuncture treatment:

The severity of the lesion of the spinal cord needs to be recognized. A complete transaction lesion of the cord will be far more difficult to treat than incomplete transverse lesions of the cord.

Acupuncture treatment of spinal cord injury should begin as soon as possible after emergency medical treatment. If treatment begins a few years after the accident skin and muscle atrophy will have occurred and improvement is less likely. Therefore, the practitioner needs to consider the amount of time that has elapsed between the accident and the initial acupuncture treatment.

The best results will be obtained when the patient has a good standard of health, a positive attitude and exercises regularly. The practitioner must also have mastered acupuncture needle technique.

The patient should be informed and accept that treatment may continue for several years. This means: the patient and practitioner both must maintain patience and courage.

IMMEDIATE MANAGEMENT

Following a spinal cord injury, any incorrect or forceful handling in order to manipulate the spine may increase instability of the spine and cause secondary injury. If the paraplegic patient is moved incorrectly strong muscle contraction in the limbs can occur. The muscle contraction is caused by displacement of the spine, which compresses on the spinal cord or nerve root. To avoid further injury and to protect the spinal cord some form of external immobilization, such as a cervical collar or an extension type brace at the level of the dorsolumbar spine should be used. Nursing services must also receive appropriate instruction in relation to this.

Temporary use of external support should be continued for approximately six weeks after the injury has occurred. This will maintain the spine in a stable position and protect the cord from pressure in which may occur from recurrent angulation or displacement of fragments at the damaged site. If the brace support is used for patients with a sensory deficit, frequent monitoring for potential pressure necrosis of skin requires that the brace be removable to permit examination of the body surface at appropriate intervals.

Following recovery from spinal shock, dysfunction of the lower portions of the limbs causes failure of conduction to the peripheral nerves, but the patient may still retain axonal continuity. In this case, prompt acupuncture treatment can ensure the survival of the peripheral nerves.

Neurotmesis may occur to the peripheral nerves due to the traumatic lesion, lack of adequate movement and paralysis of the body below the level of the lesion of the spinal cord. When voluntary contraction of the muscle ceases, the lost innervate portion of the skin and muscles at lower limbs may atrophy and atrophic skin changes will develop. Before the muscle atrophies there may still be a chance to improve the muscle tone and function. If the nerve tissues have been cut there is little possibility of regaining muscle tone and function.

THE DERMATOMES AND REFLEXES CONCEPTS

Immediate acupuncture treatment for spinal cord injury can provide stimulation to the body below the level of the lesion, allowing the skin receptors and muscular motor unit to continue surviving and functioning.

DERMATOME

A dermatome is a region of the body wall that is supplied by a single pair of dorsal root ganglia. The dermatome map is used for detecting the level and extent of sensory defects resulting from segmental nerve or spinal cord damage.

Acupuncture treatment is used to stimulate the dermatome mechanism. Inserting needles into the skin and deep tissues provides continuous stimulation to the receptors in the skin and muscles. This can improve blood circulation and maintain and increase the skin and muscle functions.

In Chinese philosophy the relationship of blood and QI is equated to Yin and Yang:

QI MOVES BLOOD

Ý ß

ORGANS PRODUCE QI Ü BLOOD NOURISHES ORGANS

Active QI flow will increase regular blood circulation. For a paraplegic patient acupuncture is used to improve blood circulation, which will nourish the skin and muscles hence create favorable conditions for nerve regeneration.

Needle technique into the skin or subcutaneous is as follows. The needle should be promptly inserted into the skin at an adequate depth and rapidly withdrawn, analogous to picking hair out of the skin. This technique will provide strong stimulation to the skin and allow the blood to escape from the skin. Locations for needle insertion include the large area along the spine or the region of dermatome, particularly the points on the fingers and toes.

REFLEXES

Reflexes are automatic stimulus-response mechanisms. This mechanism is known as a simple reflex arc. When a sensory receptor is stimulated a nerve impulse travels along an afferent neuron to the spinal cord. At the spinal cord the associated neuron transfers the impulse to an efferent neuron. The motor neuron carries the impulse to a muscle, which contracts and moves a body part.

The segmental spinal reflex involves the afferent neuron and a motor unit at the same level. The motor unit may be excited by one afferent neuron. When any one section of the simple reflex arc is damaged there will be no response from external stimulation, unless the reflex arc is rebuilt.

The flexion reflex provides the body with a withdrawal mechanism. This means that the extremities will be removed from a strong or harmful stimulus. A single afferent neuron may stimulate many motor units. In general, the skin is more effective then the deep sensory nerves in exciting flexor motor units.

Following the flexion reflex withdrawal mechanism, needle insertion into the skin, origin and insertion of the muscle, neuro-muscular junction and neurotendinous can reconnect the pathway between the skin receptors, spinal cord and motor units of the muscles. This will maintain and restore their functions. For example, needle insertion into the points on the toes of a paraplegic patient, such as Bl 67 or Sp1 will allow the patient to move his leg.

Immediate and continual acupuncture treatment can ensure the survival and maintain the functions of the peripheral nerve. Peripheral nerve regeneration can also be improved. With time and skillful treatment the groundwork can be prepared for the reconnection of the peripheral nerves to the spinal cord and the brain.

VERTEBRA DISLOCATION

A spinal cord injury patient will have sustained shock to the body and the spinal cord, vertebra dislocation and a fractured bone. Severe tissue damage may also be present in the injured area. Injuries which are due to the impact of mechanical forces may lead to vertebra dislocation, fractured bones, splitting and tearing of soft tissues (such as skin, tendons, muscles, joints, ligaments and periosteum), injured blood vessels and damage to the peripheral nerves. The first priority in emergency treatment and treatment in the early stages is saving the patients life. After emergency treatment other treatment should be considered.

Currently, when vertebra dislocation occurs there is a tendency to use manipulation techniques in the hope of forcing the vertebra back to its regular, normal position. In practical terms the manipulation technique may be able to force the vertebra back into position, but at the same time may create secondary shock or further damage to the spinal cord.

Chinese medical knowledge asserts that the main cause of vertebra dislocation is external forces (such as excessive impact of a mechanical force) combined with internal forces (particularly muscle spasm which will continuously overstretch the vertebral column). The damage is not necessarily confined to one vertebra. Often several vertebrae will sway to one side. It may be the case that only one of the vertebrae is clearly revealed to be out of position.

Acupuncture management of dislocation of the vertebral column should:

Immediately stop muscle spasm to avoid the continuous overstretch of the muscles on the vertebral column.

Equalize muscle movement in the area where the vertebral column is dislocated.

Improve the wound healing process, particularly in the severely damaged area.

Remove tissue adhesion, especially in the region where dislocation of the vertebral column has occurred.

Immobility and external support of the vertebral column, in conjunction with acupuncture treatment is needed to stabilize the spine.

Gentle massage and body stretching will allow the vertebral column to gradually return to its normal, regular position.

VERTEBRAL COLUMN- DISLOCATION IN THE CERVICAL REGION

Head injury and excessive force impacting to the neck and shoulder frequently causes cervical vertebral column dislocation. Traumatic lesion often occurs in C1-2 or C5-6-7. When dislocation of the cervical vertebral column has occurred, immobilization and careful management of the neck and shoulder are very important in order to avoid secondary damage. Approximately 6-8 weeks of complete bed rest is needed for the patient to recover from the shock of the accident and for the wound healing process of the spinal cord to take place.

Ten weeks after the accident, when the mental and physical condition of the patient has improved gentle exercise may begin. Heavy exercise should be avoided as any strenuous movement of the arms and hands may continue to damage the already unstable cervical vertebral column.

Obviously the patient will find it difficult to use his arms or hands so massage and gentle exercise may be very helpful in the recovery of the muscles in the arms and hands.

ACUPUNCTURE TREATMENT

In the acute stage, acupuncture treatment should concentrate on relieving mental and physical stress and provide pain relief.

Relieve muscle spasm, particularly in the trapezius, levator scapulae, rhomboideus and sternocleidomastoideus muscles. This will provide pain relief and avoid continuous overstretching of the muscles on the vertebral column. It will also reduce pressure on the spinal cord.

Strengthen the anterior and lateral vertebral muscles and suboccopital and neck muscles. This will help stabilize the vertebral column.

After muscle spasm has been relieved and the wound is healed the muscles and ligaments of the vertebral column need to be loosened. Points along the spinous process and transverse process of the dislocated vertebrae should be used to return the vertebral column to its normal regular position.

Body motion should be used to stretch the vertebra back to its correct position. Coordinated movement of the muscles must also be recovered in order to stabilize the vertebra.

VERTEBRAL COLUMN- DISLOCATION IN THE THORACIC VERTEBRA

The result of injury in the thoracic region always involves a large area. Even though it may include the thoracic cage, the ribs, the sternum, the muscles and the vertebral column the obvious symptom may only be revealed as one dislocated vertebra.

Damage to the vertebral column always involves several vertebrae. These unstable vertebrae frequently follow the movement of the thoracic cage in which is curved to the other side. This curvature of the vertebrae is not a normal structure but it seems to provide protection to the damaged part of the spinal cord, avoiding further damage and reducing spinal cord angulations. Manipulation technique or attempting to stand will create more damage to the spinal cord due to the unstable vertebrae.

When dislocation of the vertebral column in the thoracic region occurs, immobility of the thoracic cage is important. In the acute stage it is preferable for the patient to have bed rest rather than assume a sitting position.

In the thoracic region the muscles often pull the ribs, which will in turn affect the unstable vertebral column. For example, in the case of fourth thoracic vertebral column dislocation, the severe external impact is in the thoracic vertebrae and lower portion of the scapulae, including the 5^th, 6^th and 7^th ribs. The primary internal force is through the muscles of the scapulae and the arm against the injured ribs (below the scapulae), which pull the thoracic vertebral column out of position. This may be the mechanical cause of fourth thoracic vertebra dislocation.

ACUPUNCTURE TREATMENT

The first step in treatment is to improve the wound healing process and to stop muscle spasm. Secondly, coordinated movement of the muscles should be restored to allow the thoracic cage to remain in its regular, balanced position. Thirdly, the dislocated vertebral column needs to be corrected. The patient should be allowed to use his own body movement to stretch the vertebrae, allowing it to return to its correct position and to strengthen the muscles around the vertebra. This will stabilize the spine.

Treatment should focus in these areas:

The scapulae and shoulder joint and the muscles that are attached to it, such as the trapezius, rhomboidieus muscles and rotator cuff muscles

The manubrium and sterno-clavicular joint and the associated muscles, such as pectoralis major and trapezius muscles

The lateral 1-12^th ribs and associated intercostal space muscles, and axilla region including latissimus dorsi and external oblique abdominis muscles

Lumbar spine, sacrum, posterior superior iliac spine, iliac crest and the connected muscles

The muscles of the abdominal wall

The vertebral column, spinous process and transverse processes and the muscles around the spine

VERTEBRAL COLUMN-DISLOCATION IN THE LUMBER REGION

Compression or fracture of the vertebral column in the lumber region occurs more frequently than dislocation of the vertebral column.

When spinal cord injury occurs in the lumber region, body weight and the pressure of gravity will cause more severe angular compression to the injured spinal cord. Therefore surgery in the lumber region in order to provide internal support and stabilize this area should be considered.

The principles of acupuncture treatment are as follows:

Operation or strong external support for immobility of the lumber region is important.

After the operation, acupuncture treatment should be provided as soon as possible.

Adequate stimulation to the lumbosacral region should be provided.

Adequate stimulation should be provided to the skin, muscles, and tendons of the lower extremities to maintain and improve the active life of these tissues.

Restore coordinated movement of the muscles in the lumber and abdominal regions.

Improve the wound healing process in the damaged area.

Improve the functioning of the internal organs in the abdominal area.

Gentle body exercises should begin quite early. If the patient has retained the thigh function, movement of the legs should begin as early as possible.

WOUND HEALING IN THE SPINAL CORD INJURY

Correct wound management will diminish continued damage to the spinal cord and body tissues. Pain will also be relieved and the body’s healing process will be improved.

In the first few weeks following injury, the response to the wound/healing is firstly inflammation and then tissue adhesion. In the early stages of treatment, needle insertion should relieve the shock of the injury, calm the nervous system, reduce pressure on the spinal cord and improve the healing process in the spinal cord. Treatment should also be considered on the body tissue where the lesion has occurred. This involves relieving blood congestion by improving blood circulation. Reducing and stopping severe muscle spasm will provide pain relief for the patient and will stop the muscle from continually pulling the vertebral column. This will reduce pressure on the spinal cord.

Generally, approximately 8-12 weeks after spinal cord injury has occurred the damaged parts of the body and spine may heal by tissue adhesion. Tissue adhesion can occur between ligaments and vertebrae, ligaments and muscle, muscle and muscle, muscle and skin and between the muscles and the periosteum. These adhesive tissues may increase the stability of the post-traumatic parts of the spine but often they disturb the whole spinal movements and the peripheral nerve activities. Post-traumatic tissue adhesions can be reduced by early mobilization of the patient, providing the patient is able to do this. Where severe spinal cord injury has been sustained (for example, complete transversal cord damage), early mobilization of the patient is too difficult and may result in secondary traumatic lesions.

If spinal cord injury is severe, the local tissues around the injured area always become a large traumatic wound. For example, 4^th thoracic vertebral dislocation is usually accompanied by:

Ribs dislocation and/or fracture of the ribs

Muscle spasm, including the erector spinae and rhomboideus muscles

Diminish or obstructed movement of the scapula

Few weeks after the injury at the bruised area will become large, hard scar tissues. The muscles below the level of the lesion will atrophy and become a mass, while the muscles above the lesion may spasm continuously. At this stage malformation of the thoracic cage will become obvious.

Correct and adequate acupuncture treatment should start early. The practitioner should:

Stop muscle spasm.

Quickly stop any bleeding and remove blood congestion.

Advise the patient on some form of external support to limit the movement of the ribs and to allow the ribs to return to the correct position.

Correct the upper limb function by returning the scapulae to the correct position.

If tissue adhesion is already apparent treatment will become difficult. Tissue adhesion can occur between the intercostal muscles and ribs, the ribs and the muscles, the muscle and muscle and between the muscle and skin. Additional treatment will be needed to break down hard, large scar tissues.

In the case of spinal cord injury, acupuncture needles can be used to remove tissue adhesion. Before doing this it is necessary to improve the functions of the superficial and deeper muscles which stabilize the vertebrae and the muscles which balance the flexion, lateral flexion, extension and rotation movements of the spine.

In addition to this the patient should make his own efforts stretching the muscles to stretch the spine and stabilizing and moving the body. This all contributes to the recovery of the spine and the return of the vertebrae to their normal positions.

Adhesion can occur between skin and muscles, particularly in loose connective tissues and fascia. This can disrupt the muscle movement, blood vessels and nerve functions in the subcutaneous and the metabolic functions of the skin.

TREATMENT

Use the needle as a surgical knife. Pinching the skin up, insert the needle rapidly through the skin at a perpendicular angle. (The tip of the needle should be in the subcutaneous region where the adhesion is.) Lift and thrust the needle a few times, allowing the tip of the needle to cut off the adhesion area.

ADHESION BETWEEN MUSCLE AND MUSCLE:

Insert the needle into the fascia between two muscles.

ADHESION BETWEEN THE JUNCTIONS OF THE TWO MUSCLES:

Insert three needles in a line, with the middle needle inserted perpendicularly and the side pair obliquely.

ADHESION BETWEEN LIGAMENT AND BONE:

Insert the needle into the periosteum. Pinching up the skin and muscle, the needle is inserted perpendicularly, as close to the bone as possible-deeply into the periosteum, with a few gentle lift and thrusts of the needle. The multiple direction needle technique is often used.

THE CONNECTION OF THE PERIPHERAL NERVES, SPINAL CORD AND BRAIN

The result of continuous acupuncture treatment in the dermatomes and reflexes mechanisms is regeneration of the peripheral nerves and strong functioning of the skin sensation, muscle tone and movement. This is one way of increasing the surviving activity below the segmental lesion of the spinal cord. The vertebrae will return to their regular, correct positions when messages begin to pass through the lesion area of the cord and build up a new ‘passage’ or ‘pathway’ to and from the brain.

The following two examples show the pathway through which the peripheral nerves and spinal cord can be reconnected to the brain.

EXAMPLE 1.

A motor neuron located in the anterior gray horn of the first thoracic segment of the spinal cord, gives rise to an axon that passes through the anterior root of the first thoracic nerve, through the brachial plexus, down the arm and forearm in the ulna nerve and finally reaches the motor end plates on several muscle fibers of a small muscle of the hand, a total distance of about 90cm (3 feet).

EXAMPLE 2.

Consider the sensation of touch felt on the lateral side of the little toe. The skin is supplied the first sacral segment of the spinal cord. The fine terminal branches of the sensory axon, called dendrites, leave the sensory organs of the skin and unite to form the axon in the sural nerve, and then in the tibial and sciatic nerves to the lumbosacral plexus. It then passes through the posterior root of the first sacral nerve to reach the cell body in the posterior axon. Next, it enters the posterior white column of the spinal cord and passes up to the nucleus gracilis in the medulla oblongata- a total distance of about 1.5m (5 ft). Thus, a single neuron extends from the little toe to the inside of the skull. (Richard S. Small, Clinical Anatomy for Medical Students, 1986, p28).

In considering the above two examples, it would be possible to connect the descending and ascending impulses through the level of the lesion segmental area by stimulating the muscle and skin through acupuncture. This will allow the nervous system to function again.

Surprisingly in Huang-Di Nei-Jing (“The Yellow Emperor’s Classic of Internal Medicine”), written over 4000 years ago, it states:

“The Bladder Meridian of Foot Tai-Yang: In this meridian, the QI flow

origins at the inner canthus BL1 to end at the little toe, BL67.”

Four thousand years ago the Chinese philosophers were unable to study the body scientifically as autopsies were forbidden, but they believed that ‘although all the organs are hidden in the body, their condition can be observed externally.’ From the vision of the Ancient Chinese, the Bladder Meridian is similar to the second example. In clinical practice stimulation of the point in the little toe can move the paraplegic patient’s leg.

We may use different words or have different ways of expressing ourselves, but really we speak the same language in caring for and curing our patients.

SUMMARY

Spinal cord injury is a severe disorder of the body. Over the centuries, different methods of treatment have been used in an attempt to help people with spinal cord injury. Acupuncture treatment is one form of treatment that has been used in China to treat spinal cord injury. In Chinese medicine, an understanding of the nature of the disorder, the healing process and the provision of skillful treatment are considered essential in treating spinal cord injury.

The human body is very complicated and cannot be treated like a machine. Human beings will not allow their body to be treated like a machine unless there is no alternative. Today knowledge of the human body and medical knowledge is abundant but unfortunately, this knowledge remains in the texts book or laboratories and is seldom incorporated into clinical practices.

When a body is divided into separate units, it is very easy to lose the correct vision. Management of spinal cord injury has been based exclusively on management of the vertebral column, through operations and manipulation. The obvious symptoms and result of injury are in the spinal cord, but other factors such as muscle spasm, the wound around the vertebrae, ligaments and tendons are also severely and continuously affected, damaging the spine and the spinal cord. Correction of only one or two vertebrae will not address these effects and hence the result of treatment will be poor.

An important aspect of the wound healing process to be learnt from clinical practice is that nerve damage wounds are always difficult to heal. For example, an open wound in which the nerve tissue has been damaged can be closed up by suture, but this closed up wound tissue will remain as unhealthy tissue in the body and frequently becomes large scar tissue after a period of time.

When spinal cord injury occurs, there is severe damage in the spinal cord, a large area of wound tissue around the damaged spine exists and the nerve tissues are in a severely damaged condition. An operation at this point will only increase damage to the spinal cord and peripheral nerves and create new wound damage to the body.

In general medical treatment there has been no effective method to manage the wound and muscle or tendon spasm. Medication may help temporarily stop the spasm or pain but may also have adverse affects. This includes putting the tendon and muscle to sleep and as a result normal functioning of these tendons and muscles will be lost. Cutting the tendon in order to stop muscle spasm may lead to other difficulties for the patient.

It is extremely important to stop muscle and tendon spasm. Constant muscle spasm will continuously overstretch the spine, damage the spinal cord and also affect the daily life of the patient. Obviously the damaged region of the spinal cord is still under compression so before attempting to stop muscle spasm the position of the damaged region of the vertebrae and the wounds in the tendons and muscles needs to be considered. External support, correct nursing services and advising the patient on correct body movement to avoid recurrent angulations or displacement of the damaged vertebrae is crucial.

Correct acupuncture treatment can stop muscle and tendon spasm and assist the wound healing process. This will help avoid continued damage to the spinal cord and will allow the peripheral nerves to continue to survive and function. It will provide a better environment for the healing of the internal spinal cord and allow it to begin functioning again.

In general, the simple reflex arc involves the necessary receptor, the efferent neuron, the spinal cord, afferent and motor neuron. When the limb is paralyzed, there is no sensation as the pathway to the receptors is damaged. Muscle contraction below the lesion segmental spinal cord area shows that the motor unit and the afferent neuron from the gray horn of the spinal cord are still functioning.

Acupuncture needles inserted into the skin, the connective tissue, the neurotendinous and the spindle of the muscles below the damaged part of the spinal cord will provide a blood supply to these tissues. This will nourish the nerves and organs, improving their regeneration and function, stimulate the pathway of the still surviving receptors, spinal cord and motor unit and maintain their functions.

When the paraplegic limb responds to needle stimulation, in the form of sensitivity or muscle contraction, this means that the spinal cord below the level of the damaged section is still surviving and functioning. Only when the muscle contraction ceases will muscle atrophy occur. In this case, the motor neuron is dead and needle insertion into the skin or muscles will produce no response from the patient. If a sharp object cuts off the nerve tissues, including the peripheral nerve, the spinal cord and the brain tissue, the neuron has very little chance of surviving or recovering. Continuous pressure to the nerve may also totally damage the neuron if the hard pressure to the nerve tissue is not alleviated or eliminated quickly.

The timing and correct method of returning the vertebral column to its correct position and also reducing hard pressure on the nerves is very important when attempting to save the spinal cord from total damage.

Acupuncture treatment follows the joint, bone and muscles, treating them as one unit. Acupuncture can gradually return the vertebral column to its regular normal position and provide a better environment for the peripheral nerve, spinal cord and brain to connect together and function again. Treatment focuses on stabilizing the spine through body functions and body posture and allowing the patient to return to their regular life.

According to Chinese medical knowledge, when significant traumatic lesion has occurred one must learn to be patient and accept that it will take time to heal and recover. The practitioner must address the lesion as soon as possible and do their best to heal the patient. They must also follow the nature of the wound healing process and provide the correct treatment.

It may seem to be a dream, but patience and hard work will allow the dream to become a reality.

CASE STUDY 1

Patient Name: David Waterson

Date of Birth: 24.11.66

Date of Accident: 31.8.87

Diagnosis (Professor T.A.F. Taylor): Complete T5 paraplegia

Fracture and dislocation of T4/T5

Serious damage to spinal cord at T4/T5

Complete loss of motor power and sensation below T5 spinal cord

MAIN MEDICAL HISTORY:

The patient was admitted to the Spinal Injuries Unit on the 31.8.87 after being involved in a motorcycle accident. He sustained a spinal cord injury and lost consciousness.

The patient was admitted to the Spinal Injuries Unit of the Royal North Shore Hospital on 31.8.87, where he came under the care of Professor Taylor and Dr. J.D. Yeo, the Unit Director.

No surgery was performed.

The patient remained flat on his back for about eight weeks. He was given physiotherapy and occupational therapy.

He was discharged on 1.2.88.

– DISCHARGE SUMMARY: The patient will remain a paraplegic permanently and will require a wheelchair for mobility.

– TRANSFER TO COORABEL REHABILITATION HOSPTIAL: The patient remained at the Coorabel Rehabilitation Hospital for three months where he received physiotherapy and occupational therapy. The discharge summary confirms that the patient remained poorly motivated whilst there between 1.2.88 and 22.4.88.

X-RAY EXAMINATION-15.7.88

“There has been a post-traumatic subluxation at D4, D5 level. It would appear that there is a marked degree of compression of the body at D5 with forward subluxation of D4 on D5 and also there is some displacement to the left of D4 on D5.

The AP view shows that there is a cervico-thoracic scoliosis concave to the right and a mid and lower thoracic curve concave to the left.”

RESULTS OF PHYSICAL EXAMINATION (PERFORMED BY DR. JOHN VOSS-10.8.90):

He has no controlled movement below the upper chest. Both legs may spasm, but this has never thrown him from his wheelchair.

He has no feeling in his body from the nipples down – no sexual, no anal and no bladder sensation.

He experiences back pain at the level of the fracture, which passes from the back around either side to the front of the chest. The pain is deep and severe, becoming worse if he sits long.

There was no stability of the trunk below the upper third of the thoracic region. Breathing was diaphragmatic and upper costal, but there was no evidence of the use of the lower intercostal muscles or abdominal muscles during respiration.

There was no voluntary movement of the body below the upper third of the chest.

Handling the legs tended to produce distal spasm.

The subject was unable to appreciate the pinprick, vibration or deep pressure of the body and legs, below the 3^rd to 4^th thoracic dermatome level.

The normal thoracic curve was flattened, there being a scoliosis concave to the left commencing at the lower thoracic region. The spines of the lumbar vertebrae were prominent, compared to the lower thoracic spines.

Neck movements and arm movements were normal. Ocular movements were normal as was visual acuity for near and distance vision without glasses.

His intelligence would be no better than low/average.

The blood pressure was 105/80. There was no clinical abnormality of the heart.

He was receiving L’Oreal, 10 mg four time’s daily (to prevent distal spasm in the legs). Whilst at Coorbel Rehabilitation Centre, from 1.2.88 until 13.9.89 it is noted that he was still taking Lioresal.

Psychometric testing reveals the patient’s current general level of intelligence to be at an upper borderline/low average level, his perceptual/organizational skills being slightly stronger than his verbal abilities.

OPINION: There will be no further recovery of neuronal function, the subject remaining paraplegic, without sensation or control of the bladder or bowel, or normal sexual functions below a high level in the chest for the rest of his life.

SEVERAL IMPORTANT FEATURES WERE NOTED BY DR. JOHN VOSS:

This is a high thoracic lesion, as a result of which the subject almost certainly would have lost the normal capacity for his basal centres in the brain to mediate normal blood pressure changes, variation in skin circulation, sweating, etc. necessary to adapt to environmental temperature changes and postural changes and also normal adaptive changes in blood distribution associated with the demands of exercise.

Lost of his abdominal muscles to assist with breathing. He has also lost the use of his lower intercostal muscles, thus limiting his breathing capacity.

The high level of the lesion also interferes significantly with the stability of his trunk, thus making his independence in transfers more difficult.

The occurrence of his back pain which is dependent almost certainly on two mechanisms, arising from the postural variation affecting the joints between the injured and adjacent vertebrae, but also almost certainly due to nerve root compression. This particular form of back pain often proves intractable to management.

It is likely that it will trouble him significantly for the rest of his days, seriously interfering with his capacity to undertake long periods of sitting and requiring him to be recumbent periodically.

The spasm of the subject’s legs, would compound his physical problem attempting transfers etc, and would certainly make him more dependent upon others.

It is noted that previously he was using Lioresal. It should be noted that a common side effect of Lioresal is changes in one’s emotional state, depression and other mental problems commonly being produced.

I would debit his life expectancy between 5 and 10%.

MAGNETIC RESONANCE COMPUTED TOMOGRAPHY-29.11.90

A syrinx (pathological cavity in the spinal cord) was revealed, which extended from C1 level to T4. His orthopedic and trauma surgeon advised the patient that the syrinx would need to be drained. He was told even if this was done the syrinx might extend, causing more damage to the spinal cord. Soon afterwards, the neurosurgeon at North Shore medical centre diagnosed the patient as having syringo-myelia and recommended surgical drainage of the syrinx in the form of a syringe pleural shunt. He believed that if the procedure was not done it was likely that the patient’s upper limbs would progressively weaken and there may be sensory loss in both upper limbs. If the syrinx extended to the lower brain stem he believed the patient may develope impairment of facial sensation and have difficulty coughing or swallowing.

After the accident no x-ray or scan was taken of the patient’s cervical vertebrae. The MRCT, which revealed the syrinx, was taken 2 years after the accident. At the time of the MRCT no new clinical symptoms in relation to the syrinx had been revealed. Therefore, it is highly likely that the syrinx had occurred at the time of the accident. One year after the MRCT the suggestion of the syringe pleura shunt was withdrawn. This shows that the procedures recommended were unnecessary. If undertaken, secondary trauma to the spine and spinal cord may have resulted. It is fortunate that the patient was otherwise advised to not undertake the procedures immediately.

ACUPUNCTURE

Acupuncture treatment begins on 9/7/1988.

Diagnosis: Spinal cord injury

Fracture and dislocation of T4 and T5

Complete transaction lesion of T5 paraplegia

Syringo-myelia extending from C1 level to T4

CLINICAL FINDING:

The patient was in a wheelchair and had been advised by his doctor to accept that he will remain in a wheelchair for the rest of his life.

The patient’s main concern was pain relief in the back and reducing muscle spasm in the lower limbs.

– The back pain experienced by the patient seems to result from the original traumatic lesion of the thoracic vertebral column and the wound around the spine and scapula.

– The wound is most severe on the right side of the thoracic region, between T4-5-6 and the medial border of the scapula. The connection between T4-5 and the ribs is fractured and dislocated.

– The lower part of the trapezius muscle is in spasm. Tissue adhesion is present between the trapezius and rhomboideus, latissimus dorsi and the internal muscles around the spine, including the splenius capitus, splenius cervicis, iliocostalis cervicis, longissimus cervicis, spinalis thoracis and semispinalis cervicis.

– The wound involves the thoracic vertebral column, the ribs and the muscles around the scapula. The direct impact of the traumatic lesion caused the thoracic vertebral column and ribs to fracture and dislocate. It also caused the local blood vessels to break and hemorrhage and damaged the peripheral nerve tissues. The skin, muscles, and connective tissues were all inflamed and tissue adhesion had formed between them.

– The right arm had no skin sensation but the muscles continued to function.

– The right scapula retained its regular movement, but when the scapula was in motion tissue adhesion between the muscles between the scapula and thoracic vertebrae caused the muscles to spasm. This resulted in the thoracic vertebrae being pulled to an incorrect position.

– Pain symptoms were mostly caused by local muscle spasm and muscle pull on the upper traumatic lesion section of the spine, which would compress on the peripheral nerve tissues.

– Muscle spasm of the lower limbs revealed that the whole spinal cord is situated in an unstable position, in particular compressing on the region of the spinal cord where the traumatic lesion was sustained.

– Taking all the above into consideration, pain relief for the back was very important. The continuous pull of the muscles on the spine, which continued to damage the spinal cord, needed to be stopped.

It is highly likely that the syrinx-myela in the spinal cord occurred at the time of the accident. The MRCT examination was taken more than two years after the accident and at this time the patient had not developed any acute clinical symptoms to support the claim that there was pressure in the high level of the cervical spinal cord and hence, his life was in danger.

Muscle spasm of the lower limbs indicates that the motor unit in the lower portion of the lesion of the spinal cord was not as yet totally damaged. Muscle spasm seemed to be connected with movement of the injured section of the spinal cord. Often, when severe pain occurred in the back it was accompanied by spasm of the lower limbs.

Medication can be used to reduce muscle spasm but as indicated side affects such as depressed brain function or other emotional disturbances may result. Medication will also have an adverse affect on the damaged region of the spinal cord and may affect the survival of the motor unit. In many cases, high dosages of medication can stop muscle spasm but this will cause muscle atrophy and atrophic skin changes.

ACUPUNCTURE TREATMENT:

Encourage the patient to have a positive attitude towards treatment and to regularly exercise and mobilize his body.

Because of insurance problems and disagreement over management of the syrinx-myelia the patient’s mental and physical condition were affected. The patient was stressed and emotional for a period of between one to two years. During this time acupuncture treatment could only be used to relieve the patient’s stress. Adequate management for his paraplegia had to be delayed.

ESSENTIALS OF ACUPUNCTURE TREATMENT

To maintain the blood circulation to the tissues, improve the function of the tissues and ensure their survival needles were inserted into the skin, muscles, tendons and joints below the level of the transection lesion.

BACK PAIN RELIEF: Pain symptoms in the back were caused by the original excessive damage to the spine, spinal cord, ribs, skin, muscles, tendons, blood vessels and nerve tissues. The severe wound area was between the thoracic spine and the scapula. If the practitioner is able to adequately manage all of these damaged tissues then pain will be relieved and the spinal cord will have a chance to recover.

WOUND MANAGEMENT:

Wound Healing: Approximately 8-12 weeks after a spinal cord injury has been sustained the damaged area may heal. A lack of nerve and blood supplies within the wound area may delay the healing process or often the wound will heal in an inappropriate way.

The aims of acupuncture treatment in relation to the wound area are to:

Ease and remove blood congestion in and around the damaged tissues.

Improve blood circulation in order to give the damaged tissues a better chance to recover.

Stop chronic muscle spasm.

Remove tissue adhesion in order to allow the joints and muscles to move freely.

ACTUAL NEEDLE TECHNIQUE:

To correct the disorder and improve the condition needles are inserted into:

– BL 10-17 and BL 41-46

– GV 9-14

– Hua Tou points on the side of T1-7

The needle is inserted deep into the ribs or intercostal spaces. Needle direction follows individual muscle shape. It is particularly important to remove tissue adhesion between the muscles, muscles and rib bones and between the skin and muscles. This will allow the individual muscles, ribs, skin and the vertebral column to move freely.

After needle insertion gentle or deep tissue massage is important to relieve and remove the local obstruction or tissue adhesion. When the wound has healed the muscle spasm will stop. At this time the muscle movement of both sides of the body should be balanced to allow the spine to return to its correct position. The patient should gently and correctly stretch their-own spine in order to facilitate this process.

After the accident the right upper limb had no skin sensation but the muscles continued to function. This meant that the cutaneous nerve of the upper limb had been damaged but that the function of the motor unit and muscle splinders remained.

To recover skin sensation needles were inserted into:

– Jing-Well points of the fingers

– Skin receptors

– Points that are close to the coracoid process, such as Lu 1-2

– Needle insertion into points on the side of the cervical vertebral column (Hua Tuo Jia-Ji points) is also important.

In this particular case there is cervico-thoracic scoliosis, concave to the right and a mid and lower thoracic curve concave to the left.

The patient’s body was big and heavy. After the accident, while the patient was still in hospital, the practitioners attempted to stand the patient up while the patient lay on a standing table. As this led to severe muscle spasm of the lower limbs they discontinued this practice.

In general, scoliosis of the vertebral column is an important way in which the body adapts to avoid continued traumatic damage but it may interrupt the regular function of the spinal cord. Treatment should be used to remove the causes of vertebral column concavity, such as, incorrect body posture or muscle spasm, and return the vertebral column to its correct position. This will allow the vertebral column to function properly.

Tissue adhesion around the vertebrae, particularly C 3-6, T3-6, T7-12 and L1-3 must be removed. Harmonious movement of the trapezius and latissimus dorsi muscles should be restored. Needle insertion into points between the two spinous processes (such as Governor Vessel Meridian points) and points between the transverse processes and intercostal spaces (Bladder meridian points) are important. After needle insertion gentle massage and body stretching will allow the vertebral column to return to its normal position and allow the spinal cord to function properly.

SUMMARY:

The spinal cord injury was caused by excessive traumatic lesion to the thoracic vertebral column. The tissues between T 3-5 vertebrae and the medial border of the right scapula were badly wounded. The patient had sustained a complete transection lesion of T5, resulting in paraplegia. A syrinx-myelia, extending from C1 level to T4 was also present.

After the spinal cord injury several specialists remarked that the patient’s future was uncertain and may be very difficult. Dr. John Voss debited the patient’s life expectancy between 5 and 10%.

The patient began to attend acupuncture treatment approximately 1 year after the accident. The damaged part of the nerve tissues, muscles and skin had already fixed and begun to degenerate. During the initial period of treatment there were several difficulties for the patient, including the patient’s acceptance of acupuncture treatment, insurance problems and disagreement over the management of the syrinx-myelia. After the insurance payment had been settled and the suggestion of a syringo pleural shunt was withdrawn the patient was more relaxed and able to concentrate on acupuncture treatment. At this stage better progress was made.

A damaged spinal cord has a strong capacity to continue surviving and to recover, even after a severe injury. It is extremely important to be able to provide correct and adequate management after the injury. If a sharp object has cut the spinal cord stretched too far or severely compressed over a long period of time there is little chance for the spinal cord to survive and function.

For the spinal cord to recover the spine must be maintained in a correct and stable position. The badly damaged wound area must be managed correctly in order to avoid further damage to the spine and spinal cord.

The natural healing process of the spinal cord takes time. A strong and healthy physical body and mental attitude, determination and family support are important factors in the progress of treatment.

At this point in treatment David does not experience any more muscle spasm, he is able to stand up with calipers, can move independently from his wheelchair to his bed, can turn his body and is able to drive a modified car and motor-bike. In time, he will be able to stand up and walk again. He is now looking forward to a long and healthy future.

CASE STUDY 2

Patient Name: Eddie Tsang

Date of Birth: 8/12/1975

Date of accident: 5/1/1995

Former Diagnosis: C6 Complete Quadriplegia

Main Medical History: Summary completed by Dr. Derek Leaper (Royal Rehabilitation Centre Sydney):

The patient was the driver of a car, which collided head on with another vehicle. He suffered a fractured C6 and forward subluxation of C5 and C6.

MRI on 07/02/95 showed a large zone of myelomalacia and areas of focal residual heamorrhage in the cervical region.

Treatment was by traction.

The patient had a CMG at R.N.S.H, which showed a mild increase in pressure and no response to tapping.

Complications at R.N.S.H. included recurrent U.T.I’s (he had IDC in place), postural dizziness despite abdominal binder and occasional spasms in his lower limbs.

-Examination on Admission:

His level was C6 complete with some wrist flexion bilaterally and a flicker of his left middle finger in flexion; his lower limbs were hypotonic with no clonus.

-Therapy and Progress:

The patient had decreased motivation for physical improvement to achieve functional independence. This was because he was hoping for a cure to his injury through acupuncture treatment and because his family wanted to do everything for him.

ACUPUNCTURE:

Acupuncture treatment begins 22/3/95.

Diagnosis: Spinal Cord Injury.

Fracture C6

Forward subluxation of C5 on C6

C6 complete transection lesion quadriplegia

Myelomalacia and areas of focal residual heamorrhage in the cervical region

CLINICAL FINDING:

The patient required a wheelchair for mobility.

Breathing was short and shallow, limited to about the first to third upper costal level of the chest. There was no sign that the intercostal and abdominal muscles below the third costal level were used during respiration. The patient complained of difficulty breathing.

The patient felt a chill in the hot summer environment and had difficulty adapting to temperature changes.

During body movement the patient complained of dizziness and