Diagnosis and Treatment of Non-Mechanical Back and Neck Pain
Using Microcosmic Theory of Chinese Medicine

Samuel Wang, Ph.D., L.Ac.
Deirdra Claiborne, L.Ac.

Overview

Back and neck pain is one of the most common medical complaints. Its causes are clinically divided into two aspects: mechanical and non-mechanical origins. Mechanical origins simply result from overuse or violent injury of the spine and/or its adjacent soft tissues. Contrarily, non-mechanical origins are very complicated, involving a wide variety of diseases, such as degenerative joint diseases, rheumatologic diseases, infections, tumors, visceral conditions referring pain to back and neck, and many other systemic disorders. However, degenerative joint diseases and rheumatologic diseases cause more than 99% of the non-mechanical back and neck pain.

The following synopsis presents a new approach in treating non-mechanical back and neck pain developed by Dr. Samuel Wang at Acupuncture Herbal Center, San Rafael, California. The paper in its entirety was awarded Grand Prize for Outstanding Achievements at the Fifth World Conference of Traditional Medicine in 2000.

Dr. Samuel Wang and Deirdra Claiborne are the founders of the latest microcosmic theory of Chinese medicine. In light of this, they have developed their unique Wang’s Classification for the diagnosis and treatment of degenerative joint diseases and rheumatologic diseases. According to Wang’s classification, all the degenerative joint diseases and rheumatologic diseases are divided into two main categories: Yang deficiency type and External Pathogenic Factor type, plus a borderline type between these two main categories. Clinical studies show that using Wang’s classification has significantly increased the success rates of treatment, and has succeeded in many difficult cases that had previously failed to respond to either conventional Western or classical Chinese medicine.

Many past scholars in Chinese medicine have achieved great accomplishments in mechanical back and neck pain, but none of them have made a breakthrough in comprehensive studies of non-mechanical back and neck pain. Dr. Wang and Claiborne have bridged these gaps.

1. The Microcosmic Theory and Wang's Classification

In the past, the pattern differentiations in Chinese medicine for degenerative joint diseases and rheumatologic diseases were so confusing that different Oriental scholars classified the same Western disease into quite contradictory patterns of Chinese medicine. Although they created so many different patterns for degenerative joint diseases and rheumatologic diseases, none of them saw the real causes of these diseases. These Oriental scholars only used the viewpoint of classical Chinese medicine (and the research methodology thereof), i.e., the macrocosmic projection to analyze each individual Western disease. However, they completely neglected the microcosmic view of each individual disease, and their pattern differentiations in Chinese medicine were completely dissociated with the achievements in modern Western medical sciences.

To solve this limited perspective, Dr. Wang and Claiborne have applied the unique dialectical philosophy of Chinese medicine in microcosmic view to explore the achievements in modern Western medicine. They have discussed this new research methodology in detail in their previous article, The Research Methodology of Chinese Medicine. With this new methodology, they have developed the latest microcosmic theory of Chinese medicine, which enables Chinese medicine to be naturally integrated with modern Western medicine. Generally, microcosmic theory of Chinese medicine is quite similar to classical Chinese medicine in its macrocosmic aspect, emphasizing the coordination of the whole body. However, its microcosmic patterns are focused on the local pathological changes or on the function of a specific system of the body. Pulse, tongue and facial complexion diagnoses are routinely used in classical Chinese medicine, but they only reflect the macrocosmic patterns of Chinese medicine. The microcosmic patterns of Chinese medicine mostly correlate with the individual Western diseases. Therefore, in the same patient, the microcosmic patterns may not always be compatible with the macrocosmic ones. Applying the microcosmic theory of Chinese medicine to degenerative joint diseases and rheumatologic diseases that cause non-mechanical back and neck pain, Dr. Wang and his associate have developed a new classification, named Wang's classification, which is summarized in Table 1.

Table 1 shows that all the degenerative joint diseases and rheumatologic diseases are classified into two major types: Yang deficiency type and external pathogenic factor type, plus a borderline type between these two major types.

The Yang deficiency type covers all the degenerative joint diseases: lumbar spondylopathy, cervical spondylopathy, DISH (diffuse idiopathic skeletal hyperostosis) and osteitis condensans ilii. Its microcosmic view in Chinese medicine is cold Bi and deficiency dominance in joints and bones. Its main cause is Kidney Yang deficiency, which subsequently results in Qi and blood deficiency and stagnation or deficiency of other internal organs. The milder forms of Yang deficiency type are Kidney Qi deficiency, and Kidney Qi and Yin deficiency. The latter shows the paradoxical patterns, i.e., deficient heat in macrocosmic projection versus true cold in microcosmic view—most commonly seen in menopausal women aged between 45 and 55. In non-mechanical back and neck pain, several common forms of Kidney Yang deficiency type are combined organ deficiency, e.g., kidney and spleen Yang or Qi deficiency, kidney and lung Qi or Yang deficiency, kidney and lung Qi and Yin deficiency, and kidney and liver Qi and Yin deficiency. The secondary causes of Yang deficiency type are those external pathogenic factors like cold, damp and wind. Clinically, Yang deficiency type has the following common characteristics: (1) most patients are over 40 years when the kidney Yang Qi declines; (2) the affected pain spots are cold and pale with compensatory proliferation, but without significant inflammation; (3) patients have no systemic symptoms such as fever, malaise or chill, nor do they have extra articular manifestations like subcutaneous nodules, skin rashes, splenomegaly, pericarditis, uveitis and lesions of other mucous membranes; (4) laboratory studies such as ESR, blood counts, g-globulins, serum chemistry and urinalysis are all within the normal range; (5) HLA-B27, HLA-DR4 and HLA-DR1 are usually negative.

The external pathogenic factor type includes most rheumatologic diseases causing non-mechanical back and neck pain: rheumatoid arthritis, polymyalgia rheumatica, post Lyme disease syndrome, and the whole family of seronegative spondyloarthropathy (ankylosing spondylitis, Reiter's syndrome, psoriatic arthritis and inflammatory bowel disease). In contrast to Yang deficiency type, its microcosmic view in Chinese medicine is hot Bi, excess dominance in joints and bones or in muscles and tendons. Its main causes are such external pathogenic factors as wind, cold and damp or latent pathogenic influences or epidemic pathogenic influences. Its minor causes are Wei Qi (defense Qi) deficiency, lung Qi deficiency, spleen deficiency and kidney deficiency. Particularly, congenital Wei Qi (defense Qi) deficiency has been attested by the discovery of positive HLA-B27, -DR4 or -DR1, which may confer the genetic susceptibility to the external pathogenic factors. Although deficiency is not the direct cause, as the clinical stage of external pathogenic type advances for years and the disease turns chronic, deficiency in various internal organs will become more and more prominent.

Unlike Yang deficiency type, the external pathogenic factor type initiates its clinical onset before age 40 in most cases. Its common characteristics are quite different from those of Yang deficiency type: (1) the affected pain spots are warm and red with destruction or obvious inflammation; (2) patients may have systemic symptoms like fever, malaise and chill, as well as extra articular manifestations like subcutaneous nodules, skin rashes, splenomegaly, pericarditis, uveitis and lesions of other mucous membranes; (3) ESR and serum g-globulin are usually elevated; (4) HLA-B27, HLA-DR4 and HLA-DR1 are positive in most cases.

The borderline type is between Yang deficiency type and external pathogenic factor type, comprising only two rheumatologic diseases: fibromyalgia and fascitis of the back and neck. Its main cause can be deficiency while the minor cause is external pathogenic factors, and vise versa. The microcosmic view of borderline type is hot Bi, excess dominance or cold Bi, Deficiency dominance, but the affected locations are usually shallower than those of the other two types, i.e., the borderline type merely affects muscles and tendons or the tissues underneath the skin, but the joints and bones are usually not involved. Therefore, the borderline type may be considered a shallower form of external pathogenic factor type or milder form of Yang deficiency type. Its clinical features include: (1) the affected spots may be either cold and pale or warm and red, compatible with either cold Bi or hot Bi; (2) systemic symptoms and extra articular manifestations are usually absent or mild; (3) ESR, HLA-B27, HLA-DR4 and HLA-DR1 are all negative. The latter two features are similar to those of Yang deficiency type.

Wang's classification is based on the microcosmic view of Chinese medicine, irrespective of the patterns of pulse, tongue and facial complexion, which usually reveal the macrocosmic conditions of the human body. It has the following clinical significance: (1) it reveals the objective reality of degenerative joint diseases and rheumatologic diseases in a much more accurate and all inclusive way; (2) it leads to the correct diagnosis and effective treatment of the above diseases and it allows for more rational guidance. This will be discussed in the next several sections.

2. The Importance of Wang's Classification in Diagnosis and Treatment of
Degenerative Joint Diseases and Rheumatologic Diseases

Chinese medicine can effectively treat many disorders causing non-mechanical back and neck pain, including herpes zoster, Lyme disease, chronic urinary infection, small urinary stones, prostatitis, cystitis, endometriosis, chronic pelvic inflammatory diseases, chronic angina, menstrual cramps, chronic pancreatitis, peptic ulcer, chronic diverticulitis and osteoporosis. Furthermore, those serious underlying diseases causing non-mechanical back and neck pain, such as cancer and acute infection, may also respond positively to the integrated treatments of both Western and Chinese medicines. For the above diseases, the diagnostic procedures first follow the protocol of Western medical diagnosis, and then each Western diagnosis is subdivided into different microcosmic patterns of Chinese medicine. All the degenerative joint diseases and rheumatologic diseases are effectively treated by Chinese medicine. However, the above diagnostic procedures will be complicated and often confusing. Especially at the early stages of degenerative joint diseases and rheumatologic diseases, it may be difficult to make a positive Western diagnosis according to the above. Interestingly, Wang's classification of degenerative joint diseases and rheumatologic diseases employs another way to approach the diagnosis and treatment. This new classification is straightforward, concise and comprehensive, directly giving significant guidelines to treatment in Chinese medicine without making a concrete Western diagnosis. Therefore, when Wang’s classification is applied, the complicated Western diagnostic procedures may be bypassed. Here are some examples:

Case 1. A 44-year-old single Caucasian male came to see Dr. Wang with the chief complaints of low back pain and left hip pain, aggravated in the winter. The patient previously saw a physician, who gave him an X-ray exam of his hip and low back, which showed nothing particular except minimal osteophytes in his lumbar spine. ESR was normal. The physician believed the minimal osteophytes were not the cause of his pain, and sent him for physical therapy. The physical therapist employed ice and strong mechanical traction, which made his symptoms even worse. The initial physical examination by Dr. Wang revealed that the lumbar range of motion was diminished, Trendelenburg’s test was positive on the left hip, both low back and hip were cool to the touch but not swollen, and his pulse was weak and tongue slightly pale. Dr. Wang considered this case Yang deficiency type, cold Bi in both microcosmic and macrocosmic views. The patient received acupuncture at all the AR Shi or bone gap points, twice a week in conjunction with moxibustion and frequency heat lamp. Moxibustion and tonifying method were also employed at acu-points Shenshu and Mingmen. Meanwhile, he was also given a modified herbal formula Yougueiwan plus Wujiaolong, Kuanjinteng, Bajitian, Yanghuo, Chuantuan, and Dangshen to strengthen his Kidney Yang. Three months later, all of his pain symptoms subsided, and his lumbar range of motion was normal.

In fact, this patient suffered from lumbar osteoarthritis at an early stage, which was difficult to be diagnosed by Western medicine, because the insignificant X-ray changes were not compatible with his clinical pain. Many patients with early stage of osteoarthritis may have minimum or insignificant X-ray changes. However, with Wang’s classification, the correct diagnosis was easily made, and the right treatment principles were clearly established. Since ice and strenuous traction were contraindicated in Yang deficiency type, the patient’s symptoms were aggravated by the previous physical therapy treatment. As long as the principles of diagnosis and treatment were correct according to Wang’s classification, the patient quickly recovered from his pain.

Case 2. A Chinese female aged 34, complained of neck pain and multiple joint pain five months after she immigrated to the San Francisco Bay Area, where there is more humidity than in the part of China where she was from. She also experienced fatigue and low-grade fever in the afternoon. A Western physician first treated her with anti-inflammatory drugs, which did not improve her symptoms. He suspected she might have rheumatoid arthritis but could not reach such a diagnosis, because her rheumatoid factor remained negative at that time. Her ESR was moderately elevated. Initial examination by Dr. Wang showed redness, mild swelling and a warm feeling in metacarpophalangeal joints and right ankle, and a borderline positive cervical distraction test. According to Wang’s classification, the diagnosis of external pathogenic factor type with hot Bi and excess dominance in both microcosmic and macrocosmic views was clearly established. The treatment principle in Chinese medicine was eliminating the hot Bi, so she was given modified combination of Baifutang, Guijitang and Shanmiaosan. She responded to this treatment dramatically, and her pain symptoms disappeared in two months. She was then asked to take another formula to strengthen her Weiqi, but she failed to follow the advice, because she thought she had been “cured” already. She had a relapse of her symptoms with positive rheumatoid factor six months after she discontinued the herbs. Her Western physician made a positive diagnosis of rheumatoid arthritis and prescribed steroids, but she could not tolerate the side effects, such as weight increase, muscle loss, dysmenorrhea and insomnia. She resumed the previous modified combination herbal formula and again had a similar positive response. After her symptoms completely subsided, she continued to take another herbal formula for one more year to strengthen her Weiqi. The patient was monitored for five years, during which time she remained free from joint pain, and both her rheumatoid factor and ESR were consistently normal.

Case two was typical rheumatoid arthritis, but the Western diagnosis could not be made until eight months later when rheumatoid factor became positive. Because of the unclear diagnosis, the Western physician did not use potent steroids at the beginning, and the initial results of Western medical treatments were poor. Despite the effectiveness of steroids in the treatment of rheumatoid arthritis, many patients feel it is difficult to tolerate the side effects. In contrast, Wang’s classification is able to give a clear diagnosis even at the very early stages of rheumatoid arthritis, irrespective of negative RF. Because of the correct diagnosis at the early stage, the results of treatment according to Wang’s classification are usually good.

3. Acupuncture Treatment of Degenerative Joint Diseases and
Rheumatologic Diseases According to Wang's Classification

Acupuncture is one of the most powerful tools in treating non-mechanical back and neck pain. However, Dr. Wang and Claiborne emphasize using acupuncture to treat degenerative joint diseases and rheumatologic diseases in microcosmic view, although acupuncture can treat macrocosmic causes as well.

Acupuncture Treatment of Yang Deficiency Type

Acupuncture point selection for cold Bi at the cervical region: Point selections for cold Bi at the cervical region is documented in classical Chinese medical literature. In Thousand Golden Prescriptions (Qian Jin Yao Fang), Shaoze (SI 1), Qiangu (SI 2), Houxi (SI 3), Yanggu (SI 5), Wangu (GB 12), Kunlun (EL 60), Xiaohai (SI 8) and Zanzhu (EL 2) are used for cervical rigidity, pain and diminished range of motion. In Experience on Acupuncture and Moxibustion Therapy (Zhen Jiu Zi Sheng Jing), Jinggu (EL 64) and Dazhu (DU 14) are selected for neck rigidity and difficulty in extension and flexion, Pohu (EL 42) and Jianjing (GB 21) for inability to rotate the head, Tianzhu (EL 10) for neck rigidity and difficulty in extension and flexion, Tianjing (SJ 10) for pain of the neck and shoulder. In Classic of Jade Dragon (Yu Long Jing), for neck rigidity with difficulty in extension and flexion, Jinggu (EL 64) and Dazhui (DU 14) are used for neck pain and rigidity or inability to rotate the head; Shaoshang (LU 11), Chengjiang (RN 24), Houxi (SI 3) and Weizhong (EL 40) may be selected. According to microcosmic theory, Dr. Wang and Claiborne focus the treatment principles on eliminating cold, damp and wind, and on relaxing the tendons and collaterals of the cervical region. As main points, they select Houxi (SI 3), Xuanzhong (GB 39), Fengchi (GB 20), Dazhui (DU 14), Tianzhu (BL 10), Jianwaishu (SI 14), Jianzhongshu (SI 15), Jianjing (GB 21) and Laozhen (EX-UB) or Bone Gap points. For difficulty in extending and flexing the neck, in addition to the above points, they also use Kunlun (BL 60) and Lieque (LU 7), and for inability to rotate the neck, Zhizheng (SI 7). Laozhen is an empirical point in the treatment of cervicalgia. Houxi and Xuanzhong belong to distal points of the meridian. Houxi is a point of the small intestine meridian and the confluent point communicating with the Du meridian. Xuanzhong is a point of the gallbladder meridian and the influential point of marrow. Needling these two points regulates Qi and blood, ease the tendons and collaterals and relieve pain. Fengehi can eliminate wind cold, and Dazhui expels superficial pathogenic influences and regulates meridian Qi. Tianzhu, Jianwaishu and Jianjing are local points. Kunlun and Lieque have the function of easing the tendons and collaterals in the neck, and Zhizheng can dredge the Taiyang meridians of the hands. Furthermore, ear points such as Neck, Cervical Vertebrae and Ear Shenmen may be used. They should be punctured with mild to moderate stimulation, and the needles should be retained in the ear for 10-20 minutes. Bai Jie Zi seeds may be taped to the surface of the ear points for 1-3 days. This is called auricular plater therapy.

Acupuncture point selection for cold Bi at the lumbar region: Point selections for cold Bi at the lumbar region is also documented in classical Chinese medical literature. In Great Compendium of Acupuncture and Moxibustion (Zhen Jiu Da Cheng), for lumbar pain due to kidney deficiency, Shenshu (BL 23), Weizhong (BL 40), Taixi (KI 3) and Baihuanshu (BL 30) are used; for rigidity and pain along the spinal column, Shuigou (DU 26) and Weizhong (BL 40). In A Collection of Gems in Acupuncture and Moxibustion (Zhen Jiu Ju Ying), for lumbar pain due to stagnation of blood in the lower part of the body, Weizhong (BL 40) (bleeding), Shenshu (BL 23) and Kunlun (BL 60) are selected with moxibustion. According to the microcosmic theory, Dr. Wang and Claiborne focus the treatment principle on eliminating cold, resolving damp, and warming the meridians for cold & damp Bi at the lumbar region. They choose Shenshu (BL 23), Weizhong (BL 40), Yaoyangguan (DU 3) and bone gap points as main points, while Huantiao (GB 30), Yanglingquan (GB 34), Kunlun (BL 60), Yaoyan (EX-B 7), Ciliao (BL 32), Dachangshu (BL 25) and Jiaji (EX-B 2) as supplemental points. Needling Shenshu can reinforce the kidney Qi, while moxibustion to this point helps disperse cold and damp in the local area. Needling Weizhong, a distal point, promotes the Qi circulation at the urinary bladder meridian and is also an important point for the treatment of lumbar pain. Yaoyangguan, located in the lower back, may activate the Qi of the Du meridian. Other points can promote the circulation of Qi and blood in the affected area and eliminate the pathogenic cold and damp. Ear points such as Lumbar Vertebra, Sacral Vertebra, Kidney, Adrenal Gland, Subcortex and Shenmen are chosen for low back pain as well.

Acupuncture techniques for Yang deficiency type causing non-mechanical back and neck pain: For the cold spots, the technique of setting the mountain on fire is used. After insertion, the needle is repeatedly thrust three times according to the superficial, medium and deep sequences and is lifted once in order to make the patient feel warm. This technique is a tonifying method from triple puncture on heaven, earth and human, documented in Standard Needles, Spiritual Axis. The most important method to treat cold Bi is to use heat. Moxibustion or far infrared heat lamp or frequency heat lamp is always applicable in conjunction with acupuncture. Warm needling technique may be applied as well, i.e., moxa cone is directly placed on the handle of the acupuncture needle after insertion in order to conduct heat to the cold spot. Other than conventional moxa stick, the Great Monad herbal moxa stick and Thunder-fire herbal moxa stick may be used for more serious cold Bi.

For electro-acupuncture, the general rule is to use lower amplitude and higher frequency for cold Bi. However, the electric frequency and electric amplitude are highly individualized, in other words, different patients may require different frequencies and electro-amplitude to reach the same goal.

Fire needling technique is an ancient technique to treat intractable cold Bi. A red-hot needle of very small gauge is inserted into the cold spot and withdrawn quickly to avoid scar formation. Avoiding overheating the needle is another important way to prevent scar formation.

Triple puncture technique is used for relatively small and deep areas of pain caused by cold Bi. The center area is punctured with one needle and the adjacent sides with two other needles.

Quintuple puncture technique is applicable for a relatively large and shallow pain area caused by cold Bi. One needle is punctured in the middle of the affected area and the other four are superficially inserted around it.

Subcutaneous puncture technique is used to treat relatively shallow pain areas caused by cold Bi. The skin is lifted and needles are subcutaneously inserted.

Superficial puncture technique is for treating cold Bi in the muscular layer. A shallow insertion is administered on the sides of the affected muscle.

Acupuncture Treatment of External Pathogenic Factor Type

Acupuncture points used for external pathogenic factor types are quite similar to those for Yang deficiency types either in local or remote regions. The main difference between these two types is the techniques of acupuncture. Since hot Bi and excess dominance are the microcosmic conditions of this type, the acupuncture techniques should be focused on cooling down the heat and sedating the excess as mentioned in Spiritual Axis. To reach the above goals, Dr. Wang and his associate recommend the following techniques.

Pricking blood therapy: An acupuncture point or superficial veins or a hot spot that looks red and swollen is pricked with a big needle or a triple-edged needle in order to withdraw a few drops of blood or body fluid. In Section Standard Needles of Spiritual Axis, leopard-spot puncture, collateral puncture, evacuation puncture and repeated puncture are introduced. All these techniques are to prick the collaterals and to trigger bleeding in order to reduce the hot pressure. The leopard-spot puncture is performed by needling spots of the front, back, left and right sides, and the puncture is made on the capillary to bleed. Repeated shallow puncture means the needle is repeatedly inserted vertically and superficially, then withdrawn rapidly to trigger bleeding of the affected spot. The puncture is conducted right in the swollen spot, then the blood and edema can be drained out, and heat pressure can be reduced. The evacuation puncture is used with the sword-shaped needle and to perform the surgical operation and remove purulent blood. The collateral puncture is to puncture the blood vessels of the small collaterals. All the above techniques are to trigger bleeding and to reduce hot pressure. They are applicable to microcosmic hot Bi, excess dominance, especially due to serious conditions.

The technique of cooling like a clear-sky night: After the needle is inserted into a certain depth, it is repeatedly twisted according to deep, medium and superficial sequences, which should make the patient feel cool. This technique is a sedating method from triple puncture on heaven, earth and human, documented in Standard Needles, Spiritual Axis. It can be used alone for mild to moderate hot Bi.

Trigger puncture technique: This technique is to treat both hot and wind Bi not localized in one definite area. The most painful trigger point, usually the same as bone gap point, is located first and punctured directly. The needle is retained therein until another less painful point is found, then the needle is withdrawn and the second painful trigger point is punctured.

Shu-point puncture technique: The acupuncture points, such as well, spring, stream, river and sea points and the transporting points on the back may be used. This technique is applicable to the treatment of excess and hot Bi either in the internal organs or in macrocosmic conditions.

Lateral puncture technique: One side of the painful muscle is needled. The needle is shaken upward, downward, anteriorly, posteriorly, right and left in order to relax the muscle. It is a sedating method for hot Bi in the muscles.

Conventional sedating techniques: sedating by opening and closing the puncture hole, needling along and against the direction of the meridian, following different phase of respiration, inserting and withdrawing the needle with different speeds, different ways of lifting and thrusting, and by twirling the needle. All these conventional sedating techniques may be applied to microcosmic hot Bi, excess dominance.

For electro-acupuncture: The general rule is to use higher amplitude but lower frequency for hot Bi. As mentioned, the adequacy of frequency and electric amplitude is highly individualized, i.e., different patients may require different frequencies and electro-amplitude in order to reach the same goal.

The following two cases are examples of acupuncture treatment of degenerative joint diseases and rheumatologic diseases according to Wang's classification.

Case 3: A 56-year-old Asian male complained of serious pain of the left lumbar and hip region, radiating downward along the posterior thigh and lateral leg for three months. The patient said he had no history of lumbar injury. The pain was persistent, aggravated at night and deteriorated paroxysmally, especially during coughing and sneezing. He had difficulty in turning his body and had aversion to cold climate. His lower extremities felt cold. X-ray of the lumbar region showed narrowing between L4 and L5 intervertebral space and osteophytes, and MRI revealed degenerative and bulging intervertebral disk between L4 and L5. The above findings were compatible with degenerative lumbar disease or lumbar spondylopathy, nerve root type. He had been treated in another acupuncture clinic with the points along Taiyang and Shaoyang Meridians, such as Dachangshu (B 25), Huantiao (G 30), Yinmen (B 37) and Yanglingquan (G 34) with a sedating method. Moxibustion was combined with acupuncture. The needling sensation was felt along the meridian. The pain was alleviated after ten treatments, but he still felt soreness and weakness over the lower back and the lower extremities, and had a distended ache in his leg. Ten more treatments, using the same methods, were given but no further improvement was achieved. The patient was referred to Dr. Wang and Claiborne for further evaluation and treatment. The diagnosis according to Wang’s classification was Yang deficiency Type, cold Bi and deficiency dominance in both microcosmic and macrocosmic views. Because of the deficiency of the kidney Yang, microcosmic insufficient Qi and blood failed to nourish the intervertebral disks and lumbar spine, resulting in disk degeneration and compensatory osteophytes which subsequently caused sciatica when pathogenic factor cold was present. Macrocosmic kidney Yang deficiency is related to the elderly. It manifests as aversion to cold climate as well as cold extremities. Although the serious pain symptoms were slightly alleviated at the previous acupuncture clinic, the soreness and weakness in the muscles of back and leg remained. The real cause was kidney Yang deficiency, which had not yet been treated. So Dr. Wang and Claiborne changed the treatment strategy to mainly strengthen the Kidney Yang and secondarily expelling the pathogenic cold factor. They selected Mingmen (DU 4), Yaoyan (EX-B7), Yaoyanguan (DU3), Geshu (B 17), Pishu (B 20), Shenshu (B 23), Dachangshu (B 25), Guangyuanshu (B 26), Yaoyangguan (Du 3), Weizhong (B 40), Feiyang (B 58), Yanglingquan (G 34), Waiqiu (G 36), Yangjiao (G 25), Xuanzhong (G 39), Taixi (K 3), Zusanli (S 36), Shangjuxu (S 37), Taichong (LV 3) and Xiajuxu (S 39). They inserted needles shallowly in the above points with the tonifying method and used frequency heat lamp. They treated the patient three times a week. The patient’s symptoms completely subsided after eight treatments.

Case 4: A 30-year-old physically active single Caucasian female was suffering from low back pain for several days, after sleeping on a damp and cold ground during a camping trip in the mountains. Her condition became worse one day before her acupuncture consultation. Physical examination revealed that her lumbar range of motion was seriously diminished; no external trauma was visible; there was tenderness and spasmic spots at L4 and L5 without redness or swelling; her tongue looked normal and her pulse felt of tight. The diagnosis was lumbar fascitis, which belongs to borderline type according to Wang’s classification. This borderline type case may be regarded as a milder, shallower and more localized form of Yang deficiency type, cold Bi in microcosmic view, even though her tongue and pulse patterns were not compatible with Yang deficiency in macrocosmic projection. Obviously, the external pathogenic influences of cold and damp only invaded the local meridians and collaterals in the muscles and fascias, and the macrocosmic Kidney Qi was not seriously affected. Therefore, the treatment principles were focused mainly on eliminating cold and damp from the meridians and collaterals. Supporting the Kidney Qi was the secondary treatment strategy. Weizhong (BL 4) Dachangshu (BL 25) and Yaoyangguan were punctured with the technique of setting the mountain on fire. Frequency heat lamp was also used during the acupuncture treatment. After the first treatment, the patient had more lumbar range of motion. After five treatments, all her symptoms completely subsided. Shenshu (UB 23) and Taixi (K 5) were used with tonifying method in the last two treatments.

4. Herbal Therapy of Degenerative Joint Diseases and Rheumatologic Diseases
According to Wang’s Classification

Chinese herbs plays an important role in the treatment of degenerative joint diseases and rheumatologic diseases in both microcosmic and macrocosmic aspects, particularly in the macrocosmic aspect when the herbs are taken internally, since most of the degenerative joint diseases and rheumatologic diseases are systemic conditions. In addition, Chinese herbs can be used topically to treat the microcosmic conditions as well.

Herbal Formulas for Yang Deficiency Cold Bi Type

Strengthening Kidney Yang: In Chinese medicine, B.L. Liu was the pioneer in treating degenerative joint diseases by means of strengthening the Kidney Yang. In 1973, he gathered 34,571 cases of which 1,181 were systematically reviewed. There were 820 cases of lumbar spondylopathy, 120 cases of cervical spinal disease, 110 cases of bone spurs of the calcaneus and 131 cases of large joint disease. All were treated with a concentrated pill of his own formula called Osteophyte Pill (gu zhi zeng sheng wan). This formula was composed of Radix Rehmanniae Glutinosae Conquitae (shu di huang), Herba Pyrolae Rotundifoliae (lu xian cao), Rhizoma Drynariae (gu sui bu), Herba Cistanches (rou cong rong), Radix et Caulis Jixueteng (ji xue teng), Herba Epimedii (yin yang huo) and Semen Raphani Sativi (laifuzi). The routine dosage was 5g (grams) each time, taken orally two or three times a day. The longest course of treatment before any effect occurred was five months; the shortest was five days. In most cases, the effects were felt after one or two months of treatment, with the cases of lumbar spondylopathy obtaining the fastest and most stable results. According to Liu, these afflictions are due to deficiency of the kidney Yang – the inability to generate bone marrow, causing bone problems. Osteophyte Pill (gu zhi xeng sheng wan) clearly controls the generation of osteophytes and alleviates pain. The altered bone mass is somewhat restored to normal limit. Since Liu’s report, kidney Yang deficiency as the main cause of degenerative joint diseases has drawn attention in the society of Chinese medicine.

For Yang deficiency type: Dr. Wang and Claiborne use the combination of two typical classical formulas, You Guei Yin and Du Zhong Tang Yang for Yang deficiency type according to Wang’s classification. These two formulas consist of Shoudi 15g, Shanyao 6g, Shangzhuru 3g, Goujizi 6g, ganchao 6g, Duzhong 6g, Yuguei 6g, cooked Fuzi 9g, Chishao 9g, Taoyen 6g, Danpi 3g, Yianhozhuo 6g, Chuanduan 9g and Danguei 9g. If both macrocosmic Qi and Yin are deficient, they add Gouji 12g, Jimu 10g, Huangpo 10 g Shendihuang 10g, and Tusizi 12g to the above basic formula. If the spleen or lung Qi is deficient, they add huangqi 15g, Dangshen 15g, Baishu or Wujiaolong 24g. If the liver Qi is congested, adds Baoshao 12g, Chaihu 4.5g and raw Shuanjiaoren.

For cold Bi in microcosmic view, Dr. Wang and Claiborne use modified Jiang Huo Sheng Shi Tang including the following herbs: Jianhuo 9g, Duhu 9g, Fangfeng 6g, Ganchao 6g, Chuanxiong 6g, Chuanwu 6g and Guizi 9g. If Damp is predominant in addition to cold, they add Fangji 6g, Faxia 9g and Changshu 9g.

Yang Essence: Dr. Wang and Claiborne have developed a new formula named Yang Essence as the basis to treat Yang deficiency type with great success. Yang Essence formula contains Tusizi 15g, Yinyanghuo 9g, Bijitian 9g, Gojizi 9g, Hoshouwu 9g, Luchenzi 9g, Danpi 6g, Wuweizi 6g, Fupanzi 6g, Huangqi 9g, Ginseng 12g, Nuxi 6g, Yujing 9g, Lujiaoshuan 9g, Cheqianzi 4.5g, Hanlianchao 8g, Rouzhongrong 9g, Duzhong 9g, Chenpi 4.5g. This prescription is considered an improved formula of Liu’s Osteophyte Pill. Yang Essence is for filling the kidney essence. They originally used this formula to treat certain patterns of male or female infertility. They have found that this formula can effectively treat Yang deficiency type, because it not only fills the kidney essence, but strengthens the Kidney Yang energy as well. For this formula, there is a concentrated herbal capsule preparation. Each capsule contains 0.5 grams of concentrated herb powder equivalent to 2.5 grams of raw herbs. The routine dosage is 3-4 capsules each time, 3 times daily. The above formula is the basic prescription for Yang deficiency type, but if the following patterns coexist, they may modify the formula or herbal combination:

For kidney Qi and Yin deficiency, or kidney & liver Qi and Yin deficiency plus liver congestion, they add their unique Yin Essence formula to the treatment. Yin Essence consists of Shendihuang 15g, Shoudihuang 9g, Shanzhuyu 12g, Shanyao 9g, Zexie 9g, Danpi 9g, Fuling 9g, Tusizi 12g, Goujizi 12g, Luzhengzi 9g, Hanlianchao 9g, Heshouwu 9g, Yujing 15g, Baoshao 12g, Raw Shuanjiaoren 18g, Zimu 6g, Zhiheche 15g, Chenpi 4.5g and Baishu 9g. There is also concentrated capsule preparation for this formula. Each capsule contains 0.5 gram concentrated herb powder equivalent to 2.5 grams of raw herbs. A more effective treatment strategy would be to take the Yang herbal formula in the morning and the Yin herbal formula later on for balancing the yin and yang of the body.

External use of herbs for Yang deficiency type: The principles of topical use of herbs to treat Yang deficiency type are to improve the local microcirculation and eliminate the cold and damp. Using warm herbs are the general rule. There are several formulas available:

Modified Zhen Gu Tang: Danggui, Jianghuo, Duhuo, Gushuipu, Chuantuan, Chuanjiao, Touguchao, Gangfen, Kuizi, Fuzi, Yushang, Moyao, Mugua and Baici.

Modified Wen Jing Dong Luo Gao: Yushang, Moyao, Mahuang, Machianzi, Xixing, Yugui and Chuanwu.

Xiao Tong Shan: Chuanwu, Fuzi, Jianhuo, Yugui and Chuanjiao.

Herbal Formulas for External Pathogenic Factor Type

For acute episode or early stage, Dr. Wang and Claiborne use Guizitang plus Baihutang, containing the following herbs: Shigao 20-30g, Zimu 10g, Guizi 6-10g, Raw Yiren 15-30g, Fangfen 10g, Hanfangji 10g, Lianqiao 10g, Chinjiao 10g, jingyinhuatang 30g and Huangpo 10g. If there is fever and chill, they add Jingjie to the above formula and increase the dosage of Chinjiao to 15-20g. If there is fever and thirst, they add Shendihuang, Yuanshen, Xiqianchao and Luoshiteng. If dampness is prominent, add Huoxiang, peilan and Changshu. If there is mucous membrane lesions, add Shendihuang, Danpi and Chishao. If there is sputum, such as subcutaneous nodules or intractable swelling pain in back and neck, add Chuanpeimu, jiebamu and Jiangchan. Leigonteng has certain toxicity; therefore, it should be used with caution.

During the remission phase, Dr. Wang and Claiborne employ modified Yu Ping Feng Shan to strengthen the Wei Qi (defense Qi) of the Lungs. It includes Honey Huangqi 15g, Fang feng 10g, Baishu 10g, Dangshen 15g, Muxiang 6g, Wujiaolong 15g, Shendi 10g, Yuangshen 6g and Ganchao 3g.

For chronic stages, Dr. Wang and Claiborne recommend modified Du Huo Ji Shen Tang comprising Shangjishen 12g, Duzhong 9g, Nuxi 6g, Duhuo 9g, Jianghuo 6g, Chinjiao 15g, Xiqianchao 12g, Luoshiteng 12g, Fuling 15g, Fangfeng 9g, Chuanxiong 4.5g, Dangshen 12g, Raw Ganchao 6g, Danggui 6-9g, Baishao 10g and Shendihuang 10g. If Weiqi or spleen Qi is deficient, they add Baishu, Honey Huangchi 15g or Wujaolong 20g to the above formula. If both kidney Qi and Yin are deficient, they increase the dosage of Shendihuang to 15-20g and add Shoudihuang 12g, Zimu 6g, Huangpo 6g, Danpi 9g, Chenpi 3.5g and Cheqianzi 9g to the above formula.

External use of herbs for external pathogenic factor type: The principles of topical use of herbs to treat external pathogenic factor type are to improve the local microcirculation and to eliminate the heat and damp. Using cold herbs is the general rule. There is Modified Wan Ling Gao formula: Touguchao, Shenjinchao, Luoshitang, Dangui, Chuanxing, Chishao, Honghua, Chinjiao, Shexiang, Binpian, Bohe and Fangfeng.

Chinese herbs can be used both internally and externally at the same time to enhance the therapeutic results. Furthermore, Chinese herbs used in combination with acupuncture can most effectively treat degenerative joint diseases and rheumatologic diseases. The case below is an example.

Case 5: A 52-year-old female had back and neck pain, as well as menopausal symptoms, including hot flashes, irritability, low energy and insomnia. Her primary physician diagnosed degenerative spondylopathy as the cause of her back and neck pain, and gave her anti-inflammatory drugs. Because she could not tolerate the side effects of the medication, she saw Dr. Wang and Claiborne. The diagnosis according to Wang's classification was Yang deficiency type, cold Bi in microcosmic view, but kidney and liver Qi and Yin deficiency and deficient heat in macrocosmic projection. This case demonstrated contradicted heat and cold patterns of Chinese medicine between microcosmic and macrocosmic aspects. To solve this contradiction, Dr. Wang Claiborne employed the corresponding acupuncture techniques for cold Bi as mentioned previously to mainly treat her microcosmic aspect. They also externally applied the corresponding herbal plaster for cold Bi at the pain spots of her back and neck. In conjunction, they internally used both Yang Essence and Yin Essence capsules to treat both her macrocosmic and microcosmic conditions and advised her to take Yang Essence in the morning and Yin Essence in the afternoon and before bedtime. Three months later, not only did she achieve complete remission of her back and neck pain, but she had tremendous improvement of her menopausal symptoms as well.

5. Summary

From 1993 to 1998, Dr. Wang and Claiborne treated 108 patients of non-mechanical back and neck pain, who were diagnosed as Yang deficiency type according to Wang’s classification. All the patients received Yang Essence capsule preparation as the basic treatment strategy for at least three months. Of these 108 patients, 105 had cervical and/or lumbar spondylopathies, two osteitis condensans ilii, and one DISH. Obviously, cervical and lumbar spondylopathies account for more then 97% of the Yang deficiency type, while osteitis condensans ilii and DISH are very uncommon or rare (Fig. One). In addition to Yang Essence, Dr. Wang and his associate administered Yin Essence capsules for those patients with kidney Qi and Yin deficiency. They also used acupuncture techniques and topical herbal plasters for cold B, as mentioned, to treat the microcosmic conditions for most of the patients. After three months of the treatments, 53 patients (49%) achieved total remission and 47 (44%) marked improvement (Fig. Two). The overall effective rate was 93% (Fig. Two). Interestingly, in this group of 108, 32 cases had adverse response to the previous ice therapy given by physical therapists, but all responded well to the treatments according to Wang's classification, achieving 100% effective rate (Fig. Three). Clinical studies demonstrate that kidney Yang deficiency and cold Bi in microscopic view are the main causes of osteoarthritis, osteitis condensans ilii and DISH. Furthermore, Dr. Wang and Claiborne treated hundreds of cases of non-mechanical back and neck pain who belonged to the category of external pathogenic type. The overall effective rate for this type was more than 90%.

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