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Balancing Yin and Yang Meridians in Treating Spastic Hemiplegia from Stroke Patients
By Ning Ma, L.Ac. Stroke remains one of the leading causes of mortality and morbidity in the United States. Each year 500,000 Americans are effected by stroke. 350,000 of these people survive, many with at least some degree of neurological impairment. It is currently a significant cause of disability. Over the past several decades, acupuncture treatment has been clinically and experimentally demonstrated to be an important method in the rehabilitation of stroke patients in China. In over ten years of experience in neurology, treating multiple stroke patients, I developed an approach to treat stroke hemiplegia with acupuncture that integrates ancient theory and biomedicine concepts. This involves balancing yin and yang meridians in the treatment of hemiplegia, specifically the spastic hemiplegia. This approach has significantly improved recovery of function and enhanced independence in activity of daily living. The following case study illustrates this approach. What is extraordinary in this discussion is that it seamlessly integrates information from both an acupuncture/channel-connecting vessel perspective, and an internal medicine viscera/bowel perspective in one pulse map.1 History and ConditionA 42 year-old Caucasian male has a history of valvular heart disease, hyperlipidemia, and use of alcohol and cocaine in unknown quantities. He had no known history of hypertension, diabetes or artherosclerosis. At the time of presentation he had been experiencing paralysis on his right side and aphasia for eight weeks. His caretaker reported that he had been in a coma for three days. After regaining consciousness, he was unable to move his right arm and leg, and was unable to speak. His MRI was reported to show an ischemic lesion in the left basal ganglia region. He was diagnosed with ischemic stroke, and was hospitalized for two months for treatment in the departments of neurology and rehabilitation. The patient appeared severely anxious. His caretaker reported he had difficulty sleeping and agitation. He had a dry mouth and throat with yellow urine and dry stools. Physical examination of the patient revealed total right-sided hemiplegia. His right shoulder was dropped with a 15 mm gap between the acromium and the proximal head of the humerus. The flexure muscles of the upper extremity were spastic and the extensor muscles were flaccid. His elbow was flexed at a 120-degree angle, and his hand was contracted into a fist. Muscle strength was zero in all muscle groups of the upper extremity. The right lower extremity demonstrated spasticity of the extensor muscle and flaccidity of the flexor muscles, resulting in full extension of the knee and inversion of the foot. The strength of the hip flexor and knee extensor was two out of five. The muscle strength of the hip extensor, knee flexor and ankle flexor and extensor muscles were zero. Muscle tendon reflexes in the brachial, triceps, brachioradialis, patellar and Achilles tendons were 3+. He exhibited ankle clonus and a positive Babinski sign on the right side. He ambulated with difficulty with the aid of a left-sided crutch. His mouth was slightly deviated to the left side with mild drooling. He exhibited aphasia with the ability to vocalize only several simple sounds. His tongue was red with lack of moisture, and there was no coat. His pulse was rapid and wiry. The next section of the Eighteenth Difficult Issue, however, takes another perspective on palpating the vessels: The Chinese medicine diagnosis for this patient was "Stroke - Attacking the channels and collaterals". The etiology was liver yang rising with underlying liver and kidney yin deficiency. Treatment and EvaluationAcupuncture treatment was started eight weeks after the stroke. It consisted of three sessions of acupuncture treatment a week plus three sessions of physical therapy a week. The patient was treated in the prone position and also lying on his left side depending on the treatment. Electrical stimulation using low frequency with high intensity waveforms was applied for 20 minutes each session to pairs of needles, such as Li15 and Li11, Te5 and Li4, Gb30 and Gb31, St36 and Gb34, Gb39 and St41. The electrical stimulator is G6805-2A, made in Shanghai, China. The points used were alternately chosen from the following groups Group 1. Tonifying Li15, Li11, Te15, Li4, and Baxie (E27) Group 2. Tonifying Gb30, Gb31, St31, St36, Gb34, Gb39, and St41 Group 3. Draining lu5, Pc6, Lv9 and Sp6. Each treatment session would include at least four points each from Groups 1 and 2. The points in Group 3 were applied in every treatment session. Weeks 1 and 2The basic treatments continued to use the points from the groups previously described. In order to treat the frozen shoulder and the severe shoulder pain, the following group of the points was added. At least four points were included from group 6. roup 6: Jianqian (E23), Li15, Sj14, and Si9, Si10, Si11 and St16. The patient was encouraged to use a shoulder sling to help relieve the shoulder pain. After week 3 of treatment the patient started to develop the ability to flex the elbow and extend the knee. All other muscle groups remained the same. Weeks 5 and 6A new group of points was used since the patient was unable to make a flexion on his right knee joint. At least four points were chosen each session of treatment. Group 7: Ub54, Ub36, Ub37, Ub40. Lr8 and Gb31. During week 6, the patient was able to extend his elbow to a moderate degree with the ability to mildly move his fingers. He was able to use a cane for ambulation to assist with stability as needed. Week 7 to week 8Treatment was continued using the above groups of points. After 8 weeks of treatment, the patient regained his motor functions. The shoulder abduction was increased to a 30-degree angle. The elbow had full active range of motion and could be voluntarily flexed and extended in the full range of motion. The thumb and fingers were able to flex and slightly extend. The hip recovered full range of motion. The knee joint could fully extend with slight flexion ability, which enabled the patient to lift his heel off the ground. Foot inversion was improved using a plastic splint. Strengthen of the affected muscles after eight weeks of treatment are shown in table 1. Discussion:Hemiplegia in stroke patients significantly affects their quality of life. Stroke patients with basal ganglia lesions typically demonstrate a spastic hemiplegia, which has the feature of rigid paralysis on the flexor muscles in the upper limbs and extensor muscles of the lower limbs. These are the major muscle groups maintaining the basic motor functions in the human body. "It is important to only use Yangming to treat muscular atrophy". This statement has been principle since ancient times. The acupoints on the upper limb, Li15, Li11, and Li4, and the acupoints on the lower limb, St31, St36, and St41, were historically chosen at the classical and empirical points to treat the conditions of muscular atrophy. Because Yangming meridian is the richest in Qi and blood, it is used to nourish and reanimate the channels, muscles and tendons. The modern application of this statement includes the treatment of weakness, paralysis and atrophy with not only the Yangming channel but also other yang channels. All of the referenced points are located at the muscles that control the flexion in the upper limb and extension in the lower limb. Points on the yang meridians have dramatic effects on stimulating and motivating the paralyzed muscles, especially flexion in the arm and extension in the leg. However, needling the yang meridians alone will not relieve spasticity because the dominating muscles will not be able to relax, and the antagonistic muscle group will not overcome the rigidity of the agonistic muscles. Therefore, full range of motion will not be achieved. Using the points on the Yin meridian Generally a stroke patient with a basal ganglia lesion demonstrates more difficulty in recovering elbow extension and knee flexion. Treatment won't be effective when you only enhance the strength of the upper extremity extensors and lower extremity flexors. It is important to relieve the rigidity from the dominating muscles, which are the flexors in the upper limb and extensor in the lower limb. Yin meridian points commonly chosen are Lu5 and Pc6 on the upper limb and Lv9 and Sp6 on the lower limb. When the draining method is used on those points, it reduces the rigidity of those muscles. This effect demonstrates that points on the yin meridians may play an important role to relax muscular tone. Therefore, the key for enhancing elbow extension and knee flexion is controlled by the relaxing the muscular tone from the dominating muscles, not just enhancing the muscular strength from the antagonistic muscles. The method of needling the points on the yin meridians is key to reducing the muscular rigidity. ConclusionThe technique of the "balancing the yin and yang meridians" in treating hemiplegia is specifically designed for stroke patients with spasticity. I'd like to emphasize the importance of draining points on the yin meridians and tonifying points on the yang meridian. This will not only stimulate the strength of dominating muscles, but also relieve their rigidity. Therefore, the antagonistic muscles are able to compensate for the agonistic muscles, and enhance the range of motion. Furthermore, this technique stimulates nerves and muscle to regain motor movement control, providing a more appropriate muscular response to motor demands. Thus, it rebuilds the ability of the subtle motor function from the hemiplegia. Ning Ma, L. Ac., is Department Chair of Clinical Practice at the New York campus of Pacific College of Oriental Medicine.
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