MingLang

Constipation is difficulty in passing stools, prolonged intervals between stools, or a desire to defecate without the ability to do partially or completely. The stools may be hard, dry and pebble like, or essentially normal (this is, moist and well formed).

People have widely varying ideas as to what constitutes a normal bowel pattern. To some individuals, one motion per week is normal, while others consider themselves to be constipated if the defecate only once daily. In TCM the baseline for ‘normal’ is at least one unforced stool everyday or second day.

Constipation is a common problem, and in the western world appears to be largely related to diet and sedentary habits. Constipation can also an acute event associated with other primary illnesses, typically those characterised by fever or dehydration. In these situations however, the constipation itself is unlikely to be the presenting problem, although it will certainly be considered in the treatment strategy.

Constipation can be broadly divided into two types, excess and deficient. the excess patterns are characterised by the presence of a pathogen (typically Heat or Phlegm) or by pathological accumulation of qi that blocks the qi mechanism and the decent of Large Intestine qi. The deficient patterns are characterised by dryness from insufficient fluid lubrication in the form of body fluids, Blood or yin, or lack of propulsion through the digestive tract from deficiency of qi or yang.

Heat
Heat causing constipation can be external or internal origin. When external Heat causes constipation, it may be systemic Heat (as in Heat in the Blood), or more commonly, Heat in the qi level, this is, Heat invasion of the Lungs and/or Stomach and Intestines.

External Heat
Heat in the Lungs
Invasion of an external Heat pathogen, or other pathogen which transforms into heat once the body, will dry body fluids and parch those parts of the body most sensitive to dryness, the Lungs and Intestines.

Heat in the Stomach and Intestines
Heat invasion of the Stomach and Large Intestine is described ad yang ming syndrome.

Internal Heat
The most common cause of internal Heat type constipation is diet (see below). Internal Heat can also be generated by prolonged frustration, resentment, or other emotional turmoil that impends the movement of Liver qi. The transformation of stagnant qi into Heat is aided by consumption of heating foods and beverages, especially alcohol, rich, fatty or supplementing foods. In addition, cigarette smoking, or working in a very dry or dehumidified environment can dry the Lungs, and by extension, the Large Intestine.

Diet
The type of food consumed and the way it is consumed are important factors in the genesis of constipation. the western diet is, for the most part, heavy in protein and fat, and light in dietary fibre. Dietary fibre, from the cell walls of grains, vegetables and fruits is largely composed of cellulose, and is indigestible in humans. Fibre acts as a bulking agent, increasing the volume of the stool, thus triggering the stretch receptors in the intestinal wall. This in turn stimulates intestinal peristalsis and decreases transit time of waste material through the intestine. Insufficient fibre and high proportion of fat, which slows transit time, contribute significantly to sluggish movement of waste material through the bowel, and thus constipation.

Emotion
The Stomach and Intestine rely on the smooth passage of Liver qi for their orderly function, and to some extent on the unimpeded descent of Lung qi. A combination of stress and inactivity or sedentary occupation which weakens Lung qi and causes a general sluggishness of qi, can lead to general derangement of gastrointestinal function.

Yin, Blood and Fluid Deficiency
Yin, Blood and fluid deficiency patterns are very common causes of chronic constipation and are due to insufficient lubrication of the bowel by yin fluids, including Blood. Yin and Blood deficiency patterns frequently occur in elderly and postpartum patients because their yin is naturally depleted.

Qi and Yang Deficiency
Qi and yang deficiency types of constipation are due to a lack of qi movement in the Intestines, compounded in the case of yang deficiency by Cold which ‘freezes and constricts’ movement through the intestines, further slowing the passage of stools.

Lack of Exercise
Insufficient physical activity can contribute to constipation. People who sit all day tend to have systemically sluggish qi, which impends movement of qi and thus waste material through the Intestines. Similarly, lack of exercise weakens the Spleen and Lungs. When the Spleen is weak, the qi mechanism is easily disrupted, stomach qi fails to descend properly and qi movement through the abdomen slows.

Diagnosis
Of the excess patterns, the most frequent cause of constipation in the western world is insufficient dietary fibre. With rich, high density, supplementing foods like fats and meat. colonic transit time is slowed and food stagnates.

Treatment
Traditional Chinese herbs and acupuncture can be useful in speeding recovery.

Abdominal pain is a common presenting symptom in the TCM clinic. The pain can be acute or chronic, diffuse or well localised. When acute and sever, surgical referral may be necessary. When analysing a patient with acute pain, it is important to keep in mind those conditions considered medical emergencies. Also note that textbook descriptions of pain are limited due to the different responses of individuals to pain. Obese and elderly patients tend to tolerate pain better than others, while in highly strung individuals the experience of pain may be magnified. Patients with chronic pain are most likely to seek TCM treatment. There are many biomedical causes of abdominal pain, many of which are amenable to TCM treatment.

Pain in TCM terms is always due to some impediment to the circulation of qi and Blood , hence the adage where there is obstruction there is pain, where there is no obstruction there is no pain. This important principle provides a guide for treatment of all types of pain. Pain can be broadly divided into two types – excess and deficient.

Excess pain is caused by the presence of a pathogen which physically obstructs qi and Blood flow. Any pathogen can hinder the flow of qi and Blood, but Cold, qi stagnation and Blood stagnation are the most likely to produce pain. The general principle of treatment for excess pain is to identify the obstructing pathogen and eliminate it.

Deficient pain is the result of insufficient motive force behind the circulation of low levels of qi and Blood, so that they become sluggish and begin to pool. This is likened to the stagnant pools that form in a riverbed as the water level drops during drought. Pain results, and the solution is to restore the qi, yang and Blood.

Cold
Cold is an extremely common cause of both acute and chronic abdominal pain, as the nature of cold is to ‘freeze and constrict’. By freezing and constricting abdominal structures, the circulation of qi and Blood is reduced and pain is easily produced.

External Cold
Cold can be introduced into the body by association with Wind, by ingesting cold foods or drinks, or by direct exposure of the body to cold. A common example of the latter is invasion of the Uterus by cold while swimming during menstruation. Cold has an affinity with both the Intestines and the Uterus, and in both cases cause quite severe cramping or colicky pain that is significantly alleviated by application of heat. External Cold may be associated with Dampness, or may transform into Heat pathogen once in the body.

Internal Cold
Internal Cold is the product of Spleen and/or Kidney yang deficiency patterns, where yin Cold becomes predominant relative to warming active yang. The manifestation of the pattern will vary depending on the degree of deficiency relative to the strength of the excess Cold. When the deficient aspects are dominant, the pain produced will be of a deficient Cold type (mild and dull, relieved by warmth and pressure). When yin Cold is ascendant, the pain will tend to be severe, relieved by warmth but worse with pressure. The background yang deficiency patterns are chronic conditions. Spleen yang is primarily weakened by diet. Weak Kidney yang or qi may be an inherited condition, or may develop as a result of age, chronic illness, too much exposure to cold conditions, or excessive lifting or standing. Kidney yang or qi may also be damaged by excessive or premature sexual activity (especially in men, but also women), or specifically in women by many pregnancies, miscarriages and/or terminations.

Heat
Heat that causes abdominal pain includes invasion of external Heat, external and internally generated Damp Heat, Toxic Heat and Summerheat.

External Heat
External Heat can invade directly into the Intestines, or transform from a Cold invasion (also known as yang ming fu syndrome). The Heat parches the Intestine and stool causing constipation and pain. External Damp Heat can invade the Intestines or Uterus. Damp Heat in the Intestines can be a product of the season, commonly occurring during hot or humid weather, and more common in tropical climates. Damp Heat pathogens can also invade with spoiled food, or by sudden overindulgence in Damp Hot substances, such as alcohol, fats, and greasy rich foods. Damp Heat in the Uterus can result from an external Damp Heat pathogens that invades through the tai yang (Urinary Bladder) channel, the leg yin channels or the local luo channels. In practice, transmission of Damp Heat through the luo channels is probably the most common mode of entry (especially in sexually active individuals). It also occurs in postpartum women due to their relative deficiency and thus their vulnerability to external invasion.

Internal Heat
Internally generated Heat or Damp Heat can also cause abdominal pain. Damp Heat generated in the middle jiao by over consumption of rich, greasy or spicy foods and alcohol can simply sink and settle in the intestines. Damp Heat can also be generated in the lower jiao by any prolonged Heat in the system, such as the deficient Heat arising from yin deficiency, the stagnant Heat from liver qi stagnation, prolonged stagnation of Dampness or transformation of Cold.

Emotion
Liver qi stagnation is caused by repressed emotion, frustration, anger and resentment. These emotions, especially when chronically unexpressed, cause a low grade spasm and tension in the smooth muscles of the gut – a classic emotional ‘holding pattern’. Patients with chronic qi stagnation type digestive problems will often note that their stress and tension is reflected in their gut and be aware of the consequences of stress – the knot in the stomach, cramps, loss of appetite, diarrhea etc. This type of abdominal pain tends to be intermittent and is clearly related to the emotional state. Prolonged qi stagnation can contribute to several complications which also cause pain – Blood stagnation, stagnant Heat and Spleen deficiency with the eventual generation of internal Cold or Phlegm Damp. In addition, qi stagnation leads to a generalized hyper toxicity of both skeletal and smooth muscle, further restricting the circulation of qi and Blood to the tissues.

Blood Stagnation
Blood stagnation type abdominal pain may be acute or chronic. Acute pain may follow abdominal trauma or surgery. Chronic pain follows some other prolonged disorder affecting the abdomen. Any pathology, excess or deficient, if long lasting enough, may lead to Blood stagnation. Cold pathologies (Cold and yang deficiency) can cause Blood stagnation by ‘freezing and constricting’ the vessels and slowing circulation of qi and Blood. Hot pathologies (Heat, Damp Heat, Phlegm Heat and yin deficiency) can cause stagnation by ‘evaporating’ Blood and increasing the viscosity and sickness of Blood. Chronic Liver qi stagnation fails to lead the Blood and is a very common precursor to Blood stagnation.

Diet
The type of food consumed and the way it is consumed are important factors in the genesis of abdominal pain. Eating spoiled or contaminated food can produce acute pain, which in TCM terms may resemble an invasion of external Cold Damp or Damp Heat. Too much cold natured or raw food can introduce Cold and weaken Spleen qi and yang. Some drugs weaken the Spleen and deplete Spleen and qi yang. These include purgative laxatives, antibiotics, non-steroidal anti inflammatory drugs (NSAIDs), and the anti-retroviral drugs and protein inhibitors used to treat HIV infection. Reduced food intake as a result of strict dieting, or prolonged starvation and digestive insult, seriously damages Spleen yang. This can occur in patients with history of anorexia nervosa, bulimia, or during famine. Over consumption in general, and excessive consumption of rich, heating or supplementing foods in particular, can lead to the accumulation of stagnant food and Heat or Damp Heat in the Stomach and Intestines. Food stagnation is a common precursor to a host of pathologies that may give rise to abdominal pain. An excess of heating foods, such as chilli, coffee, spirits, spices, fats and meat can introduce Heat and Damp, or damage yin. Sugar and dairy products create Dampness and Phlegm.

Treatment
TCM treatment of abdominal pain would start with the diagnoses of which of the above is causing the pain. Once the cause is identified, a combination of acupuncture and Chinese herbs will be prescribed.

Obesity is on the rise worldwide and is the most common nutrition related disorder in the developed world. Most commonly, it is associated with an increase in the energy value and quantity of food consumed, coupled with a decrease in activity. There are however, some diseases that can contribute to increased weight. Some of these include:

Endocrine
> hypothyroidism
> Cushing’s syndrome
> acromegaly
> hypogonadism
> hyperprolactinoma
> insulin secreting tumors
> polycystic ovarian syndrome

Other
> cardiac failure
> liver failure
> nephrotic syndrome
> hypothalamic tumors
> premenstrual syndrome
> early pregnancy
> depression

Drugs
> tricyclic antidepressants
> oral contraceptive pill, hormone replacement therapy
> corticosteroids

While there are no quick fixes, and no substitute for the basic therapeutic principle of eating less and exercising more, Chinese medicine can play a valuable supportive role, and can improve some of the physiological components that contribute to obesity, specifically slow metabolism, digestive inefficiency, problems with insulin metabolism and the fatigue that prevents activity.

The main cause of obesity is taking in more energy than is used by activity. Weakness and inefficiency in harvesting, transforming, distributing and utilizing the qi derived from food resulting from poor organ system function, can further compound weight gain.

Weakness of the Spleen and Stomach leads to inefficient digestion, causing build up of damp and phlegm in the form of fat and fluid in the tissue

Chronic Liver qi constraint can weaken the Spleen, retard fluid movement and lead to accumulation of damp and phlegm.

As we age and our Kidney yang declines, the metabolic fire that underpins the yang functions of the other organ system diminishes. Spleen yang, the basis of efficient digestion is weakened, and damp, phlegm and blood stasis occur more readily. A decline in Kidney yin reduces yin fluids and leads to deficient heat, which causes thickening of fluids, accumulation of phlegm and blood stasis. In addition, the general decline of yang qi often leads to a decrease in overall activity and more sedentary habits.

A Chinese practitioner would start by diagnosing the patients internal issues and would then treat the above with acupuncture and/or herbal medicines, which would intern, support weight loss.

The line between a healthy weight and obesity is usually clear but there are standard parameters that can be useful in determining the progress of treatment. These are based on the body mass index (BMI), and the waist to hip circumference ratio (W/H ratio). The body mass index is calculated by dividing the weight (kg) by the square of the height (m2).

The waist to hip circumference ratio is derived by dividing the waist measurement by the hip measurement, for which a healthy range is less than 0.9.

In terms of the general health of obese individuals, the standard classification can be too rigidly applied, and the BMI should always be considered in the context of the individual concerned. There are many people with a BMI outside the consensus healthy range who are perfectly well. However, the risk levels for some chronic illnesses can be increased significantly with increasing BMI. These include diabetes and metabolic syndrome, cardiovascular and gall bladder disease, osteoarthritis and infertility.

The treatment of obesity can be challenging. In many cases the reason for overeating are complex, and intertwined with social and emotional factors. For sustained success, treatment requires a substantial commitment from both patient and practitioner, and is usually prolonged. Initial weight loss is often dramatic, but this is largely fluid. Real weight loss i.e. decrease in fat deposits, should be gradual and ideally no more than 0.25kg per week. In this way, the metabolic changes necessary to keep the weight off can be embedded. During this process, regular support and encouragement, reinforcement of goals and monitoring of progress are key to success. The Chinese medicine clinic is an ideal environment to provide such a framework. Regular appointments for acupuncture treatments provide a good forum for encouraging motivation a reviewing progress, as well as improving physiological function. A typical treatment course will run over 3-12 months, during which time acupuncture is given weekly.

A food diary is a useful way of assessing the nature and volume of food consumed and the relative energy expenditure. This can help not only in tailoring a rational plan, but creates awareness in the patient of what is being ingested and what is being used. People generally underestimate, unintentionally or otherwise, the amount of food they eat. Be aware, however, that for patients with Spleen deficiency, a food diary may become a source of obsession and encourage a counterproductive preoccupation with food and diet.

A diet that reflects the pathology being treated should be advised and introduced gradually. Radical or sudden changes in diet are not advised since they generally do not last.

Some simple dietary guidelines can apply to all people wishing to lose weight.

1. Cut down volume of food by 30%. Having small meals which include some protein at regular times though out the day will regulate blood sugar levels and reduce appetite.

2. Avoid fatty or fried foods. Eat more fresh fruits and vegetables.

3. Avoid soft drinks and fruit juices.

4. High protein (or low GI) meals are often recommended because they are relatively low calorie, don’t raise blood sugar or produce so much insulin and they help to better manage hunger. However, any diet which reduces calories will help reduce weight.

5. Breakfast and lunch are the more important meals as their energy value will be consumed in daily activity, while the calories from a large evening meal will tend to be stored as fat. The old saying ‘eat like a king at breakfast, a prince at lunch and a pauper at dinner’ is excellent advice. Chinese medicine with its understanding of the flow of qi in the 12 channels has long recognized that it is in the early part of the day that the digestive organs are at their peak. The time of maximal energy available for digestion is between 7-11am (Stomach and Spleen time).

6. Snacking between meals should be avoided.

7. Good digestion and regular bowel movements are also an important part of weight control.

8. A disciplined and persistent approach is essential, but rigidity is counterproductive, especially for those with Spleen deficiency.

9. The 80/20 rule could be applied here – do the right thing 80% of the time and 20% of the time you can get away with small indiscretions.

A realistic and regular program of exercise is an essential part of any weight loss plan. Exercise consumes calories, but more importantly it makes muscle tissue more insulin sensitive, so the pancreas can reduce its output, and less sugar is shunted to fat deposits.

The goal should be for a minimum of 30-40 minutes of sustained aerobic activity every day, or at least several times a week. This means getting the heart rate up to about 50% above the resting rate and keeping it there for 30-40 minutes. Walking is ideal. The benefits of regular aerobic activity are cumulative and become self sustaining over time.

Around ten years ago, an impromptu scar tissue treatment from a massage teacher in the UK impacted my life in a massive way. Writes scar tissue massage therapist and educator Christine Knox.

The benefits from that one treatment were so remarkable it began my learning journey and fascination with the world of scars. This gentle modality has been known to give quick, long lasting results to help client out of chronic pain and into pain free functional movement quickly.

Some scars have the ability to impact their owners’ lives in many ways. For example, Mrs M came to my treatment room to have the scars on her face treated after removal of a few skin cancers. When observing and assessing the scars, I could barely notice them but the client, a 52-year-old wife and mother of two daughters, the scars were very noticeable. She works in an educational establishment comes into contact with many people daily and outwardly she appears outgoing and happy. However, she said she felt as though everyone was staring at her scars and didn’t see her. This had lowered her self-confidence.

Upon palpation, the scars did have areas of fascial bind, which seemed to be causing a pulling sensation close to the corner of her eye. I applied some gentle scar tissue techniques on her delicate facial areas where the scars were located for no more than 15 minutes. When massaging scars, no lubrication is required, the pressure used is light similar to lymphatic work although the tissue connected is deeper and from fascial perspective. The result was that the bind and pull of the scar had gone. More impressively, Mrs M experienced a diminished perception of the scars and she said her face felt like her face again.

She also mentioned that her knee had a scar as a result of a skin cancer removal that she would like me to look at. When I asked her how this scar affected her, she said she couldn’t bend her knee because of it. When I asked her to show me how much movement she had, there was a discernible restriction in the knee flexion under 45 degrees of flexion.

I asked how long this has been this way. She replied ‘since the surgical removal of the skin cancer. They bandaged me up and said just don’t bend it, so I didn’t bend it and haven’t been able to from that day – two years ago’.

She told me she had been unable to go to line dancing because when she tried to bend her knee it hurt.

‘I have put on weight and I miss the girls we had such a laugh, traveling to competitions together. It has really got me down’.

At this point I am thinking this scar must be huge. However, the scar was under 2cm in length, white in colour with a little pink lump on the medial aspect. It was situated inferior and medial to the knee.

I gently used some scar massage techniques for no more than 10 minutes and asked her to stand up and gently bend. There was a positive reaction to the treatment techniques and asked her to bend her knee again. A dramatic result: more range of motion and pain free bending! I applied some broader work in order to integrate the scar massage.

In the follow-up treatment a week later she had returned to line dancing and was knee bending pain free. Her mood was lifted with the return to her social and exercise activity.

The scars on her face didn’t have the same tightness or pull that they once had. In fact, she reported that to her they were flatter and less noticeable.

It is always surprising and rewarding how transformative this gentle modality can be. In the case of Mrs M’s scars they were small in size but large in terms of long-term effects and impact on her quality of life.

The small scars on her face had altered her body image and sense of self, the scar on her knee had affected her ability to connect with her social circle and as a direct result, had negatively impacted her physical and mental wellbeing.

This report shows a growing number of surgical procedures in Australia every year, making it more likely that therapists will encounter more clients with scars in the future.

Four stages of healing:
Healing has four precise stages, which overlap: Homeostasis, Inflammation, Proliferation and Re-modelling.

For success healing, a wound must go through each stage in the set order for an exact period of time. The problems occur when there is a variance in the healing process resulting in abnormal scars.

Research has demonstrated that abnormal scars can impact function within and beyond their physical borders and present considerations outside of the physical and physiological aspects of the scar tissue. This means that when scars do behave atypically there is a possibility of experiencing far-reaching effects to areas distant to the scar resulting in dysfunction to the bio tensegrity of the fascia.

Think of a rabbit warren: what we see on the surface is nothing compared to the unseen below and beyond what we perceive to be the boundary of the scar.

Scars have the potential to negatively affect nerves, fascia, lymph and muscles – all of which are within the domain of massage and myotherapists. Scar tissue massage can offer an avenue of potential treatment that some therapists are as yet unaware, yet this treatment modality could result in longer lasting results or even total resolution for clients.

There is evidence to support the claim that manual scar management techniques do positively affect the impact of pain, function and quality of life.

The Australian Government reports that in 2017-18 there were over 2.3 million elective surgeries with an additional 352,000 emergency surgeries performed. Figures in this report show a growing number of surgical procedures in Australia every year, making it more likely that therapists will encounter more clients with scars in the future.

Introducing scar tissue massage into treatments would impact how therapists handle stubborn chronic pain cases. Most therapists encounter clients experiencing chronic pain or dysfunction of movement and many therapists don not consider treating scars.

The majority of the time, the treatment protocols applied do help clients to reduce their aches and pains and restore their movements – but sometimes the treatment outcomes can be disappointingly short lived with results diminishing from a few hours to a weeks.

This disheartening situation can have the therapist doubt their skills and refer on the client, believing another allied health practitioner will get a superior result. I suspect that in many of these cases the client has undisclosed abdominal scar, possible because they have forgotten about the scar or simply do not think it has anything to do with their lower back pain.

Scar tissue massage techniques aim to impact clients by:
> reducing stress responses in the nervous system
> increasing vascular flow
> increasing lymphatic flow
> minimizing the aesthetic impact of scars
> restoring function, and
> addressing fascial restrictions.

When working with clients who have experienced trauma, the manual therapist does not need to know every detail of the trauma in order to provide a productive treatment.

In fact, having your client give you a blow-by-blow account of the scar source and subsequent treatment can actually be detrimental to the outcome of integrating the soft tissue structures. It can bring the injury trauma whether physical or emotional to the surface. It can also affect the therapist by bringing any of their unresolved traumas to the surface too.

Which is why grounding and therapeutic boundaries are essential in this modality. Unless otherwise trained, massage therapist and myotherapists are not counselors or psychotherapists. Talking therapy is outside our scope of practice.

Skills essential for this work are holding the space, energetic boundaries and compassion to ourselves and others.

I have found it helpful to create a network of psychotherapists, councilors, play and music therapists to whom I refer my clients. This also opens the door of reciprocal referrals.

This is an article written by Christine Knox and was published in the Massage & Myotherapy Journal – volume 18 | Issue 1 | 2020. Christine Knox is a presenter at the Massage & Myotherapy Australia National Conference Pre-Conference workshop for Abnormal Scars on 22 May in Adelaide. Christine is a Remedial Massage Therapist with 10 years’ industry experience in the UK and Australia, who has had the opportunity to deliver massage treatments in many settings from rock concerts to hospitals and also train therapists in Australia and the UK in Remedial Hot Stone and Scar Treatments.

In our opinion, both massage and acupuncture treatments can be beneficial treatment methods in the treatment of scar tissue and their related issues.

References:
Marieb EN (2003) Human Anatomy and Physiology 5^th edn. Redwood City, CA: Benjamin Cummings Publishing
Lewit K,Olasnska S (2004) clinical importance of active scars: abnormal scars cause pf Myofascial pain. Journal of Manipulative and physiological Therapeutics 27(6):399-402
Bordani B, Zanier E, (2014) Skin, fascias, scars: symptoms and systemic connections. Journal of Multidisciplinary Heathcare 7:11.
Fourie W (2012) Surgery and scarring. In: Schleip R et al(eds) Fascia: The tensional network of the human body. Ch7.17,pp411-420. Edinburgh: Chirchill Livingstone Elsever.
www.aihw.gov.au/reports/hospitals/hospitals-at-a-glance-2017-18/contents/surgery-in-australias-hospitals

Whiplash sufferers: the nemesis of many a manual therapist. Let’s start by defining whiplash. Although there have been many descriptions over the years, this definition by Barnsley et al in 1994 has stood the test of time:

‘An injury to one or more of the cervical spine that arises from inertial forces being applied to the head in the course of a MVA that results in the perception of the neck pain.’

There have been numerous phases, titles and acronyms used to describe the neck pain arising from a motor vehicle accident (MVA), ranging from: ADI = Acceleration/Deceleration injury to CNP = Chronic Neck Pain, and more. The most widely acceptable term clinically (and in the literature) that encompasses debilitating neck pain arising from trauma in WAD = Whiplash Associated Disorder.

It is important to remember that whiplash is not a diagnosis but a mechanism of injury. The most common cause of WAD presenting to clinics around the world is from motor vehicle accidents, particularly, a rear end collision. It is this mechanism of injury that will be the focus of this article. However, we cannot overlook an increasing cause of WAD in today’s modern society which is that of overuse (and abuse) of technology. But let’s save that discussion for another time.

According to the Australian Institute of Health and Welfare website, here are some statistics related to car accidents in 2016:

> there were 145 accidents per 100,000 of population in Australia
> with approximately 33,000 MVAs in Australia, which equates to
> 8000 serious injuries in the state of Victoria alone

These injuries come with debilitating costs in both economic and non-economic terms and certainly present a clinical challenge for manual therapists.

Mechanism of injury
Here is an actual time frame of events leading to neck trauma in a rear collision. You will note that the average rear end collision occurs in about 250 milliseconds or one quarter second. The injury causing portion of the collision occurs in the first 75 milliseconds, or in the blink of an eye.

At 50 milliseconds post-impact, the car seat back pushes the torso forward, the spine moves forward, resulting in the straightening of the thoracic and cervical spine.

At 75 milliseconds pot-impact of the collision, the car seat is rapidly pushing the occupant’s torso forward, while the head remains stationary due to inertia. This difference in motion between the neck and torso results in an S-shaped curve, where nearly all of the bending in the cervical spine takes place in the lower cervical spine. This rapid bending in just a few joints can result in ligament damage in the lower spine. The rapid motion of the neck during a crash can result in a number of injuries – many of which are impossible to see on x-rays or MRI.

Defining WAD
In 1995, the Quebec Task Force (QTF) developed a classification system that was designed to improve the management of WAD by providing a guide to the sign and symptoms of whiplash indicative of the seriousness of the injury sustained (see below). This system helps guide the assessment and diagnosis of WAD. It is important that clinicians can identify signs and symptoms indicative of the various levels of severity of WAD so that appropriate management can be undertaken. Systems and disorders that can manifest in all grades include, but are not limited to, dizziness, tinnitus, headache, memory loss, dysphagia and temporomandibular joint pain.

Below is a copy of that classification system.
0 – No complaint about neck. No physical sign(s).
I – Neck complaint of pain, stiffness or tenderness only. No physical sign(s).
II – Neck complaint AND musculoskeletal sign(s). Musculoskeletal signs include decreased range of motion and point tenderness.
III – Neck complaint AND neurological sign(s). Neurological signs include decreased or absent deep tendon reflexes, weakness and sensory deficits.
IV – Neck complaint AND fracture or dislocation.

To further assist clinicians in the management of acute WAD, stiell et al in 2001 described and published the Canadian C-Spine rule for radiography in alert and stable trauma patients. This rule has the potential to significantly reduce the clinical practice variation and ED inefficiency in Cx spine radiography. Further details on how to apply this early assessment tool can be found in the article by Stiell.

Acute Management of WAD
When a patient presents with WAD it is important to take an extensive history as well as gather baseline data via self-administered questionnaires (which should be repeated periodically to determine the clinical efficiency of treatment interventions and patient management plans). At a minimum, you should collect the following details:

> Thorough history relating to the accident, including speed at which the car was hit, and an idea of weight differential between the vehicles (for example, if a 1000kg vehicle hi a 500kg vehicle at 50km/hr, then the article force is doubled)
> When did the patient first feel symptoms after the accident? If immediately, this typically indicates a more significant pathology. Typically, it is over the next few days as swelling, stiffness and muscle guarding take effect.
> Past history is also very relevant: has your patient had previous neck issues, history of headaches, previous MVAs and if so, what impact did they have at that time?
> It is also recommended that practitioners complete at least 2-3 questionnaires such as:
1: Neck Disability Index (Vernon & Mior 1991)
2: Symptom Intensity Rating (Davidson & De Nardis 2011) and the
3: Impact of Events Scale (IES)(Weiss, 2007)
Note: these questionnaires should be repeated periodically to determine the clinical efficiency of treatment intervention and patient management plans.

MVA guidelines
The following guidelines stem from several reference sources as well as over 20 years’ clinical experience in assessing and treating clients suffering with acute and chronic WAD ate the Melbourne Whiplash Centre. There is adequate research to suggest that active interventions are preferable to passive interventions (Verhagen et al Cochrane review 2000, NSW Govt endorsed review 2014)

Guidelines include:
> Acute us considered in the first 12 weeks post MVA
> Easrly active interventions, such as simple cervical rotations actively performed on the hour is important to maintain the neck range of mobilise neural structures (Rosenfeld 2003)
> Consider take home information, written details to educate the patients
> Reassure client that the majority of MVA victims recover within a 12-week time frame
> Encourage normal activity but not strenuous activity in first 7-10 days
> Consider imaging via Canadian C-spine rule
> Referral to GP for pain reliving medication, blocking the pain encouraging movement is important
> Sensible use of neck collars – certainly not establishing a reliance on one, but wearing a collar for short periods of the day or when traveling can offer relied from pain sensitive structures and assist recovery
> Close monitoring is important, consider questionnaires, phone calls
> Manual hands-on treatment should not commence until the patient can confidently tell you that for at least 48 hours their symptoms have stabilized. This may be more then several days post-impact. Regular monitoring of the patient during this time is recommended and should symptoms deteriorate then referral to a specialist or GP is required.

Acute Whiplash Guidelines
To consider…
>Patient education/take home written information
> Sensible use of collars
> Encourage normal activity
> Imaging
> Medication for pain relief
> Sick leave
> Website (www.whiplashcentre.com)
> Specialist referral

Early WAS Management at the Melbourne Whiplash Centre (Grades I-III)
Scenario:
> Patients present for an appointment or by phone 24-48 hours
> Ma y or may not already have plain radiographs

Stage 1: Inflammatory Stage
> Educate
> Respect pathology
> Offload structures

Consider
> re-assurance, diagrams, providing information and advice
> Manage as acute spinal disc
> Decrease weight bearing , sensible use of collars, extended periods in supine
> Analgesics as required
> Instruct to take two days away from work

Home program
> Hourly routine of active range of motion exercises
> 6-10 Cervical rotations
> 6-10 Shoulder shrugs/circles
> 6-10 Arm/shoulder basic ROM
> Walk 3 X 15-20 minute periods

Advice
> Rest in supine, not on couch: cervical rotations can be performed in supine
> Encourage to do light home duties
> Refrain from sport or moderate intensity.. No contact sport
> sensible use of collars – as you may use crutches for a sprained ankle
> Instruct on use of heat/cold
Note
> Avoid aggressive retraction in assessment or treatment with WAD
> Immediate movement may reduce the fear of serious injury
> Rotations may be important to mobilise the contralateral neural structures
> Gentle cervical/shoulder movements may decrease the inhibition of neurovascular blood flow
> During this phase, patient should call daily, sometimes twice per day to monitor symptoms

This phase may last 1-4 days. It is strongly recommended that you refrain from manual intervention until 24 hours after symptoms have stabilized.

This information is provided by courtesy of the Melbourne Whiplash Centre

Tiredness is a common complaint in the Chinese medicine clinic, and is featured in many different disorders. Tiredness can be expressed in many ways, such as lack of physical and mental energy, lack of motivation, excessive sleepiness, exhaustion, weariness, listlessness, feeling flat or a devastating inability to perform even the simplest of tasks. In Chinese medicine, tiredness falls under the heading of diseases such as ‘deficiency and overwork’, which can result in exhaustion and chronic debilitating illness.

Why Do People Feel Tired?

There are two causes of tiredness according the Chinese medicine. Either patients have too little of one or more of the fundamental physiological substances (qi, blood, yin and yang) or the distribution of these substances is impaired. If the distribution of qi and blood is impaired, there must be a pathogen or pathological accumulation of some sort blocking their movement. Pathogens can be external and lingering, or generated internally.

Different Types of Tiredness

There are certain clues that can help identify the nature of the tiredness. One of the most important is the response of the tiredness to rest. Tiredness that is worse after, or at least no better for, rest or prolonged inactivity, indicates an excess pattern.

Tiredness that is alleviated by sleep or rest is usually of a deficient type, as rest enables the body to replenish some of the deficit. Low reserves of energy are easily spent in activity.

Tiredness following eating points to Spleen deficiency or damp. Tiredness with an emotional component points to Liver or Spleen qi constraint. Tiredness aggravated by cold weather indicates deficiency of the Kidneys.

Emotional Factors

Emotional stress is an important cause of disruption to the Liver, Spleen and qi dynamic. The Liver is affected by anger, frustration and repressed emotion, while worry, obsessive thinking and prolonged concentration, in combination with a sedentary lifestyle and poor diet, weaken the Spleen. Any of these emotional factors, if prolonged or extreme, may disrupt the relationship between the Liver and the Spleen. Failure of the Liver to evenly distribute qi causes tiredness that fluctuates with the emotional state and activity levels.

Prolonged worry, grief and sadness can deplete Lung and Spleen qi, and diminish qi and blood production. The weakened Spleen can produce damp, further impeding the disruption of qi and blood.

A sudden or severe shock can sever the connection between the Heart and Kidneys, drain them of vitality and damage yang qi and yin.

Diet and Medications

Inadequacies or irregularities in diet and digestion are important components of persistent tiredness. If the diet is lacking in essential nutrients, or if the food ingested is not being processed efficiently, qi a blood production will suffer.

Poor or erratic protein intake, restrictive or fad diets, or excessive intake of poor quality ‘fast foods’ lead to relative malnutrition, weaken the Spleen and reduce qi and blood production.

Excessive intake of food and alcohol in general, or diet overly rich in heating or supplementing foods like meat and fat, can lead to dampness, heat and phlegm. Food allergy, lactose intolerance and coeliac disease are often unrecognized, especially when mild or sub-clinical, and can be important factors in chronic tiredness.

Some other causes of tiredness include:

• Overwork or exhaustion
• Poor sleep cycle
• Qi deficiency
• Blood deficiency, pregnancy or childbirth
• Yin deficiency
• Yang deficiency
• Blood stasis

Biomedical Conditional where Tiredness is a Major Component

The subjective experience of tiredness can be part of almost any disease, however there are a variety of illnesses, imbalances and compulsions in which tiredness is a major complain.

Endocrine

• Thyroid dysfunction
• Diabetes
• Adrenal (Addison’s disease, Cushing’s syndrome)
• Hyperparathyroidism
• Changing hormone levels (menopause, puberty, pregnancy)

Cardiovascular

• Cardiomyopathy
• Arrhythmia
• Congestive cardiac failure
• Anemia

Nauromuscular

• Parkinson’s disease
• Multiple sclerosis
• myasthenia gravis
• Post head injury

Drugs

• Alcohol and nicotine
• Amphetamines
• Antibiotics
• Anticonvulsants
• Antidepressants
• Antihistamines
• Anti hypertensives, beta blockers
• Steroids
• Hormones (oral contraceptives, hormone replacement therapy)|
• Digoxin
• Sedatives and hypnotics

Other

• Depression, anxiety, bereavement
• Chronic fatigue syndrome
• Fibromyalgia
• Malignancy, leukemia, lymphoma
• Chronic infection (Glandular fever, HIV, Lyme disease, cryptosporidum, hepatitis)
• Malnutrition, obesity
• Auto immune disease (Lupus, Behcets disease)
• Sleep disorders (sleep apnea, myoclonus, shift work, sleepwalking, asthma, orthopnea, reflux (GERD))

As stated above, there are a lot of causes for tiredness and Chinese medicine aims to treat the root cause, not just the symptom. To get an individual diagnosis and treatment plan, book a consultation with a qualified Traditional Chinese Medical practitioner.

Eating Your Way to Health

Rehabilitation with diet, also called dietotherapy, is a method in which rational diet is applied to promote recuperation from diseases.

Living in a world with countless healthy diet theories are flying around, it’s sometimes hard to know what is really good for our bodies.

Traditional Chinese Medicine has its own answer to healthy eating. The Chinese are probably the biggest supporters of the saying “You are what you eat,” regardless of whether they really follow that advice.

Food is Medicine, Medicine is Food

In traditional Chinese medicine, the role of food and medicine overlap. For example, a water melon is food, but it can also have a medical effect during hot days because of its hydrating properties.

The ancient clans of China, dating back to 2200 BC, started to discover the different medical values of herbs while they were still hunting and gathering. Some foods relieved their illness, some caused death. Over time, and in concourse with the growth of Chinese philosophy, medical theories were developed.

However, there are also some foods that are considered more “medicine” than “food,” for example, ginseng. When it comes to this “medicine,” a person should consult a practitioner, since eating it could make your body worse. Why? Foods have different natures, and all of us have different bodies that interact differently with different foods.

The four natures of food

In traditional Chinese medicine, food and herbal medicines are divided into five natures, called “siqi”: cold, cool, neutral, warm and hot. The nature of food is not determined by their actual temperature, but rather by what effects they have on a person’s body after consumption. When a person continually eats one type of food, it creates an imbalance in their body, and affects their immune system. Thus, one of the keys in Chinese medicine is to keep our body “neutral.” In Traditional Chinese Medicine, the body is considered healthy when it is in a harmonious state.

Foods that are warm and hot bring heat to our bodies — e.g. beef, coffee, ginger, hot chilies and fried foods — while cold and cool foods cool down our bodies– think of salad, cheese, green tea, and beer. Neutral foods are foods like oil, rice, pork and most kinds of fishes.

A person who has too much heat in their body usually feels hot, sweats all the time, is grumpy, has a swollen tongue, or could be constipated. People who have too much cold in their bodies appear pale, have cold hands and feet, might feel weak, or have bad blood circulation. When this happens, we are advised to stop eating that kind of food.

Its More Than Just a Taste

Similarly in the western world, the Chinese divide tastes into five different kinds (Wuwei): sour, bitter, sweet, spicy and salty. But for the Chinese, these are more than just senses. In traditional Chinese medicine, each bite of foods sends the nutrition to corresponding organs: sour food enters liver and helps stop sweating, eases coughing; salt enters the kidneys, and can drain, purge and soften masses; bitter food enters the heart and the small intestine and helps cool heat and dry any dampness; spicy food enters the lungs and large intestine and helps stimulate appetite; sweet food enters the stomach and spleen and helps lubricate the body. Thus, it is important to have each flavor in the diet.

Does that mean to be healthy we just eat just neutral food in all flavors? Not necessarily. Food choices are affected by your body’s construction, the season and the place where you live. The condition of the body could also be affected by age and sex. In other words, Chinese medical practitioners adapt their recommendations to different conditions.

One Size Does Not Fit All

Just like we all have different personalities, we also all have different body constitutions (tizhi). And just like you cannot communicate with all people in the same way, we also cannot feed our bodies with the same food in the same way.

What is a “constitution”? The categorizations have been in constant flux ever since traditional Chinese medicine first began. Currently, one of the most popular divisions is developed by Huang Qi, who introduced nine types of bodies in 1978.

A person with a lot of “dampness and phlegm” (tanshi) in their body tends to be overweight, might sweat a lot and might have an oily face. These people are usually more mild-tempered.

However, a person with a lot of “dampness and heat” (Shi-Re) is usually short-tempered and often presents with an oily and acned face. Both of these people need different food to take away their dampness, which means sweets, which “lubricate” the body, might worsen the situation.

Each type of food, depending on its nature, might better or worsen the situation. There is no substance which is good for everybody. Many consider ginger to be healthy, but when you are already a very dry person and you have so much heat in your body, the more ginger tea you drink, the drier you get.

Eating According to the Season

The season and time of year is another factor when it comes to food choices. For instance, spring is often wet and sticky in China, which means we need food that can take away the dampness in our body, such as corn, white beans and onion.

Summer is hot, so we need food to cool us down, such as watermelon and cucumber. Autumn is dry, which means we need food to “lubricate” us, such as snow peas and honey. Winter is cold, so we need food which warms up the body, such as beef or shrimps.

In the globalized world, one can easily buy foods that are not in season. But traditional Chinese practices dictate might not be that best way to feed ourselves, since seasonal foods bring us the nutrition that we need in that particular season. A similar concept also exists generally in the western world.

Medicinal Foods

Here’s a brief list of medicinal foods and what they are used for:

Neutral food
Black beans – to blacken hair and to ease post-partum pain
Soybeans – for anemia, asthma and to promote lactation
Carrots – to prevent night blindness and promotes digestive function
Chrysanthemum – for fever, also relieves dizziness

Cold food
Banana – for constipation and hemorrhoids
Freshwater clams – for fever and detoxifying
Cucumber – for fever, sore throat and red eyes
Pear – for thirst and constipation

Cool food
Bitter almond – for chronic bronchitis
Celery – for hypertension
Duck – hypertension with dizziness
Watermelon – for sore throat and to relieve summer heat

Hot food
Chili – to stimulate the appetite
Black and white pepper – warms up the body
Clove – warms the spleen and stomach, stops vomiting

Warm food
Aniseed – relieves intestinal spasm
Beef – for the tendons and bones
Garlic – for dysentery
Coriander – for skin rashes

Sources
– Health Preservation and Rehabilitation – Publishing House of Shanghai University of Traditional Chinese Medicine
– dw.com
– chineseculture.org

Wondering what “Jing” is in Traditional Chinese Medicine (TCM)? It’s one of the “3 treasures” and your overall health largely depends on preserving it. Here’s how….

You’re probably familiar with the western concept of body, mind, and spirit. The TCM equivalent of this trio is called The 3 Treasures. The 3 Treasures are the esoteric substances that nurture the organ systems and keep the mind, body, and spirit in balance.

Qi, one of the 3 Treasures, is the life force that supplies the body with energy. The second treasure is “Shen”, which is loosely means “spirit”. The third treasure is “Jing”.

What is Jing in TCM

Jing has no exact English translation, although many people attempt to define it as “essence.” In a way, “essence” is an accurate description. Jing is indeed what makes you, you. Even before you’re born, it determines your physical and energetic attributes. You inherit this treasure from your parents.

Everybody has a set amount of Jing at birth. A healthy newborn has a lifetime of it accrued in an energy savings account. Your essence enters your body and like a network of tree roots, it anchors all the energy you’ll expend in your lifetime.

So why should you care about Jing if there’s nothing you can do about the essence you’ve inherited? Why should you care about it if you’re born with a predetermined amount of it?

Over the course of your life, if you live a life of moderation, you’ll likely keep a good chunk of it stored in your energy savings account. But if you take out too many withdrawals, your ‘financial essence future’ might not be so bright.

Pre-Heaven Essence

Conception is a blending of the sexual energies of a man and women to form what the ancient Chinese called the “pre-Heaven Essence” of the newly conceived human being. This essence nourishes the embryo and fetus during pregnancy and is also dependent on nourishment derived from the mothers Kidneys. The pre-Heaven Essence is the only kind of essence present in the fetus, as it does not have independent physiological activity. This Pre-Heaven Essence is what determines each persons basic constitutional make-up, strength and vitality. It is what each individual unique.

Since it is inherited from the parents at conception, the Pre-Heaven Essence can be influenced only with difficulty in the course of adult life. Some say this Essence is “fixed” in quantity and quality. However, it can be positively affected, even if not quantitatively increased.

The best way to affect positively ones Pre-Heaven Essence is by striving for balance in one’s life activities: balance between work and rest, restraint in sexual activity and balanced diet. Any irregular or excess in these spheres is bound to diminish the Pre-Heaven Essence. A direct way to positively influence one’s Essence is through breathing exercises and such exercises such as Tai Ji Quan and Qi Gong.

Post-Heaven Essence

This is the essence which is refined and extracted from food and fluids by the Stomach and Spleen after birth. After birth, the baby starts eating, drinking and breathing, its Lungs, Stomach and Spleen start functioning to produce Qi from food, drink and air.

The complex of essence refined and extracted from the food are collectively known as “Post-Heaven Essence”. Because the Stomach and Spleen are responsible for the digestion of food essence ultimately leading to the production of Qi, the Post-Heaven Essence is closely related to Stomach and Spleen.

The Post-Heaven Essence is therefore not a specific type of essence, but simply a general term to indicate the essences produced by the Stomach and Spleen after birth, as opposed to Pre-Heaven Essence which is formed before birth.

The Essence

The functions of Essence are as follows:

1) Growth, reproduction and development
Essence is the organic substance which forms the basis for growth, reproduction and development. It controls the growth of bones in children, teeth, hair, normal brain development and sexual maturation. After puberty, it controls the reproduction function and fertility. It forms the basis for successful conception and pregnancy. The natural decline of the Essence during our lifetime, leads to the natural decline of sexual energy and fertility.

2) The Essence as basis of Kidney-Qi
There is a close interaction among the various aspects of Kidney energy, i.e Kidney-Essence, Kidney-Yin, Kidney-Yang and Kidney-Qi. Essence is fluid-like and naturally belongs to Yin; it can therefore be considered as an aspect of Kidney-Yin. In addition, it provides the material basis for Kidney- Yin to produce Kidney-Qi by the heating action of Kidney-Yang. In other words, the Kidneys can be compared to a large cauldron full of water. The fire under the cauldron is provided by Kidney-Yang and the Gate of Vitality, the water inside the cauldron corresponds to the Kidney-Essence, and the resulting steam (i.e. Qi), corresponds to Kidney-Qi. Thus, Kidney-Essence is necessary for the transformation of Kidney-Yin into Kidney-Qi through the warming action of Kidney-Yang.

3) The Essence Produces Marrow
The concept of Marrow in Chinese Medicine is different from that in Western Medicine, and does not correspond to bone marrow. The Essence produces Marrow, which, in turn, produces bone marrow and fills the spinal cord and the brain. Thus, “Marrow” is a substance which is the common matrix of the bone marrow, brain and spinal cord: it has no equivalent in Western Medicine.

If the Kidney-Essence is weak, the brain may lack concentration and memory and suffer from dizziness and a feeling of emptiness of the head.

4) The Essence as The Basis of Constitutional Strength|
Finally, the Essence determines our basic constitutional strength and resistance to exterior pathogenic factors. although the Defensive Qi is mostly responsible for protection from exterior pathogenic factors, it also draws its strength and has its root in the Kidney-Essence. Thus the Kidney-Essence also plays a fundamental role in the protection against exterior pathogenic factors.

From these four main functions of the Essence, one may deduce the kind of problems that may derive from a deficiency of Essence.

Top 5 Things That Drain Your Jing

Here are a few ways that your essence can leak from the body:

• Excessive sexual ejaculation
• Lack of sleep and staying up late
• Anger
• Chronic stress
• Drugs and alcohol abuse

Signs That Your Jing is Leaking Excessively

Here are some tell-tale signs that your Jing is draining precipitously:

• Accelerated aging (looking older than your real age)
• Looking and feeling tired all day
• Habitual trouble focusing
• Loss of hair
• Loss of purpose

If you waste your essence, in theory, your health can suffer because your immunity will be lowered, and will be more vulnerable to the so-called external pathogenic “6 Evils” such as Wind and Cold (or Wind-Cold). Healthy people who maintain their essence, generally speaking, are able to fight off more effectively colds, flus, and allergies.

How Can You Increase Your Jing?

So it is disheartening to think that your life essence is consumed virtually every day. Isn’t it? The good news is there are ways you can preserve or even replenish your Jing. You can prevent your inherited Jing bank account from being drained by eating nutritious foods. Some foods that are especially beneficial for supporting Jing include eggs (both poultry and roe, aka fish eggs), organ meats, bone broth, bee pollen, kidney beans, sea vegetables, royal jelly, black rice, and seeds.

Some Chinese herbs, according to TCM theory can actually replenish Jing. You’re probably familiar with at least a couple of these Jing-regenerating herbs such as goji berry and mulberry. There’s also the legendary anti-aging herb, he shou wu as well as shan yao. Here are some other ways to preserve or replenish your Jing:

• Refrain from frequent masturbation and sexual intercourse
• Practice Qi-building therapeutic modalities such as Tai Chi, Qigong
• Meditation
• Acupuncture

Jing, Qi and Shen Working Harmoniously

Jing is the densest, physical matter within the body. Similarly to DNA, it determines our constitution. In fact, according to TCM theory, it nourishes, fuels, and cools the body. When our lifestyles are moderate and we’re eating well, getting enough sleep and managing stress, we support our Qi.

When we contain Jing and don’t let it leak, we possess abundant Qi. Moreover, we feel energetic and vivacious. And when both Jing and Qi are vital, according to TCM logic, our spirit (shen) will also be high.