pregnancy related

PELVIC INSTABILITY

TCM treatment with acupuncture

Katya Polhaupessy

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pregnancy related

PELVIC INSTABILITY

TCM treatment with acupuncture

Essay presented to the Academy for Traditional Chinese Medicine

Qing Bai

for the purpose of obtaining the Certificate of Acupuncture Academic year 2006-2007

Amsterdam

by Katya Polhaupessy supervision Martine Cornelissen

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Preface Pelvic Instability changed my life and the life of my dearest persons in my surrounding as well. Two deliveries of my loving daughters and a skiing accident in between resulted in a nightmare during many years. Visits to several gynaecologists, orthopaedics and neurologists only led to painkillers, injections and muscle-relaxing medication but unfortunately the pain reappeared again after so many sessions. Additional complaints such as exhaustion and burn-out completed this scenario. I was partly categorised as a disabled person by the medical officer and the UWV (Dutch social security organisation). As a consequence I lost my job after almost 20 years of working history for KLM. A new way of lifestyle I had to discover and with the help and support of a remarkable osteopath I started to recapture my daily activities. It was an unbearable situation and I refused to believe that no cure was possible because of the fact that western doctors still don’t know how to diagnose and treat. Instead of working I started to study TCM. In the second year I met Martine Cornelissen, she is a special person and a very inspiring teacher at the Qing Bai Academy. I also made an appointment for a consultation at her practice because of her expertise and specialism in gynaecological complaints. This was my first TCM experience and I learned that the TCM treatments I received from Martine were a major step forward in the medical treatment of Pelvic Instability. Finally I started to regain vitality, I persevered with my study and again my whole life changed. I especially would like to thank Martine who helped me to improve the quality of my life during these years of recovery. Your enthusiasm and fighting spirit for Life moves me deeply. With the loving care, support and patience of my husband and daughters I finished this study. Dear Rogier, first of all you give me love and trust to stabilize my own medical condition but you also give me the confidence and strength to help and support other women in need. I am extremely grateful to you. Katya Polhaupessy

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Table of contents Preface 3 Table of contents 4 Introduction 6 Part 1: Western Medicine Chapter 1 Introduction 8 Chapter 2 Anatomy of the female pelvis 10 2.1 Physiology and pathofysiology during pregnancy 10 2.2 Relationship between the pelvis and the back 11 2.3 The mobility of the pelvis joints 11 Chapter 3 Complaints of Pelvic Instability 12 Chapter 4 Symptoms of Pelvic Instability 13 Chapter 5 General causes of Pelvic Instability 15 Chapter 6 Treatment Strategy 16 Part 2: Traditional Chinese Medicine Chapter 7 Introduction 18

7.1 Pregnancy 18 7.2 Women’s physiology 18 7.3 Physiological changes in pregnancy 19 Chapter 8 Women’s pathology 22

8.1 Pelvic Instability in relation to the Vital Substances 22 8.1.1 Qi 22 8.1.2 Xue 23 8.1.3 Jing 24

8.2 Pelvic Instability in relation to Zang Fu 26 8.2.1 Kidneys 26 8.2.2 Liver 26 8.2.3 Spleen 26 8.2.4 Heart 27 8.3 Pelvic Instability in relation to Pathogenic Factors 28 8.3.1 Wai Yin - External Pathogenic Factors 28 8.3.2 Nei Yin - Internal Pathogenic Factors 28 8.4 Pelvic Instability in relation to neither internal nor external causes 29 8.4.1 Pregnancy and Childbirth 29 8.4.2 Lifestyle 29 8.4.3 Trauma 29 8.4.4 Constitution 30

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Chapter 9 TCM Diagnosis 31 9.1 Methods of diagnosis 31 9.1.1 Diagnosis by Interrogation 31 9.1.2 Diagnosis by Palpation 32 9.1.2.1 Pulse 32 9.1.2.2 Skin 32 9.1.2.3 Abdomen 32 9.1.2.4 Pubic bone 33 9.1.2.5 Ah Shi points 33 9.1.3 Diagnosis by Observation 33 9.2 The channels 34 9.3 Qi Jing Ba Mai 36 9.3.1 Du Mai 36 9.3.2 Ren Mai 36 9.3.3 Chong Mai 37 9.3.4 Dai Mai 38 9.3.5 Yang Qiao Mai and Yin Qiao Mai 40 9.4 Pelvic Instability and acupuncture 41 Chapter 10 TCM Pattern differentiation and treatment 43

10.1 Shen Yang Xu - Kidney Yang deficiency with Gan Xue Xu - Liver Blood deficiency 43

10.2 Shen Yin Xu - Kidney Yin deficiency 43 10.3 Shen Jing Xu - Kidney Jing deficiency 44 10.4 Gan Qi Yu - Liver Qi stagnation 45 10.5 Xue Xu - Blood deficiency 45 10.6 Xue Yu - Blood stasis 46 10.7 Pi Qi Xu – Spleen Qi deficiency 46 10.8 Pi Qi Xian – Spleen Xi sinking 47 10.9 Invasion of Wind, Cold or Dampness 47

Chapter 11 Common musculoskeletal conditions 49 11.1 Pain of the symphysis pubis 49 11.2 Lower backpain, sciatica, hip pain and leg cramps 49 11.3 Sacral pain and coccygeal pain 50 11.4 Case history 50 Chapter 12 Patient advice 52 Part 3: Conclusion 53 Bibliography 54 Appendix 56

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Introduction Pelvic Instability is nowadays still not recognised by the Dutch Ministry of Health, Welfare and Sport. Women in the Netherlands with Pelvic Instability are classified under ‘difficult objectively disorder’ group. The complaints are mostly related to pregnancy and are usually seen as temporarily. In case the woman is not recovered after childbirth, low back pain is easily diagnosed. I’m of the opinion that the information given by Dutch obstetrics, gynaecologists and/or orthopedics is very limited. In Scandinavian countries for example the welfare for pregnant women is arranged in a much broader and more open-minded way. Little information is known in the Netherlands about prevalence, incidence, aetiology and prognosis of pregnancy-related pelvic pain. It is hypothesized that during pregnancy 80% of women experience some degree of pain in the pelvic region and/or in the low back and that some of these patients the pain becomes chronic or recurrent. Very often the symptoms do have serious impact on activities of daily life, participation in society, planning of next pregnancies and sometimes lead to a chronic disabling condition. In this essay I will answer the following hypothesis: ‘Do acupuncture treatments offer improvement to women suffering from Pelvic Instability?’ To answer this question I will discuss the different aspects of this disorder from a western point of view classified in Part 1. The anatomy of the pelvis, complaints, symptoms, general causes and the western treatment strategy are highlighted. Part 2 details a TCM approach discussing pregnancy in general and the related pathologies which influence Pelvic Instability. TCM diagnosis, differentiations and treatments are here emphasized in order to get a clear view on how to offer a drug-free relief and healing with acupuncture to achieve a better quality of life.

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Part 1: Western Medicine

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Chapter 1: Introduction There are a variety of musculoskeletal conditions such as backache, sciatica, rib, hip and pelvic pain that are all too often viewed as part of the normal discomforts of pregnancy. Even early in pregnancy when there are very few changes in body shape, musculoskeletal problems are often present due to the hormonal effects of progesterone on the ligaments. As the pregnancy progresses these conditions become more prevalent. In addition to the weight of the growing foetus which needs to be compensated for by the woman’s muscles and joints, there is also the fact that this weight is distributed in the abdomen rather than evenly over the entire body. This in effect throws off the woman’s centre of gravity, leading to a variety of pelvic, back, shoulder and neck problems. Specific problems also arise due to pressure on the limited physical space. The ribs often become an area of discomfort, as they have to compensate and expand as the growing uterus pushes upwards. Added to this there is often hip and pelvic pain from the ligament structures loosening within the pelvis and from the added physical pressure as the baby engages into the pelvis. While for some women this musculoskeletal pain is a minor inconvenience and a reminder to treat the body with greater care by lifting cautiously or resting more, for others it results in complete disruption to their lives, involving daily pain and lack of sleep and restricting their everyday activities.1 Defining Pelvic Instability Pelvic Instability is a musculoskeletal condition which causes pain and mobility problems during and/or after pregnancy. In normal pregnancy a hormone called relaxin softens the ligaments around the joints of the pelvis. This natural process allows the pelvis to open slightly during childbirth for delivery and usually does not cause lasting discomfort. For some women this natural process seems to go wrong. The effect of the hormone on the ligaments can be so strong that the joints of the pelvis become unstable or out of alignment. The pelvis is a closed system of bone and muscle so any change in movement at one joint can affect the function of all the others. 2 Pelvic pain is a common complaint among pregnant women worldwide and it causes severe pain in one third of affected women. Strenuous work, previous low back pain and previous pelvic girdle pain are known risk factors.3 Pain in the lumbar spine and pelvic region is a frequent complication during pregnancy, delivery and post-partum. The prevalence of pregnancy related pelvic pain varies between 14.2% and 56% 4. Pelvic instability is an explicitly excessive mobility of the one of the joints (the SI joints of the pubic symphysis) of the pelvic ring. This causes a biomechanical dysfunction of the form and force closure. Mostly it is caused by strain or actvities which put these joints on prolonged stress. The SI joints are than an important source of pain and activity intolerance.

1 Debra Betts, Acupuncture in pregnancy and childbirth, Hoove, 2006, p55 2 http://www.pelvicinstability.org 3 Helen Elden a.o., Effects of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain, march 2005 4 Mirthe de Groot, thesis Objective Measures for pregnancy related low back pain and pelvic pain, december 2005

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During walking unilateral loading of the legs introduces shear forces and the muscles, ligaments and fascia system are required to stabilize the pelvis by compressing the SI joints. Restraining of the activities leads to weakness of the muscles and ligaments and to a viscious circle. The pattern of complaints is very differing from women to women and varies according to the location of pain, the severity of pain and also the interference of doing daily activities. It is obvious that pregnancy related Pelvic Instability is currently not an entity that can be clearly diagnosed and described; therefore different terms are used to describe Pelvic Instability such as:

• Peripartum Pelvic Pain Syndrome (PPPS) • Symphysis Pubis Dysfunction (SPD) • Pregnancy-related pelvic joint pain • Posterior pelvic pain in pregnancy • Peri partum pelvic pain • Pelvic girdle relaxation • Pelvic girdle syndrome • Pelvic girdle pain (PGP) • Pelvic instability • Pelvic insufficiency • Pelvic dysfunction • Pelvic arthropathy • Pelvic osteoarthropathy • Pubic symphysis instability • Sacro-Illiac (SI) joint syndrome • Dislocated pelvis • A divided pelvis

The reason why I have chosen to name this disorder Pelvic Instability is because all terms above mentioned express different locations of pain. The term ‘Pelvic Instability’ especially embodies all of these terms and is mainly used.

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Chapter 2: Anatomy of the female pelvis The pelvis forms the base of the trunk and consists of four bones: Two hipbones, the sacrum and the coccyx. Each hipbone is a fusion of the ilium, ischium and pubic bone. The two pubic bones are connected anteriorly in the symphysis pubis, with a disc in between. Posteriorly, the ilium is connected to the sacrum at the sacroiliac joints (SI-joints). The SI-joint is surrounded by a capsule and is strengthened by a complex entity of several ligaments and muscles. The pelvis forms the intermediary between the spinal column and the lower extremities and plays an essential role in load transfer from the trunk to the legs and vice versa.

Pelvic girdle posterior

2.1 Physiology and pathofysiology during pregnancy During pregnancy, a woman develops postural changes that are necessary for her to maintain balance in the upright position. The average weight gain with a single fetus is 10 to 12 kg. The increasing weight is distributed primarily in the woman's abdominal girth. After 12 weeks of pregnancy, the uterus can no longer be contained within the pelvis and the mass moves superiorly and anteriorly. As the abdominal muscles are stretched and tone is diminished, they lose their ability to contribute effectively to the maintenance of neutral posture. With these biomechanical changes, it was thought that lumbar lordosis increased. However, studies have shown that the lordosis remains the same or increases only slightly. Instead, what seems to happen is that the entire spine shifts to a more posterior position and the centre of gravity as a whole tends to move in a posterior and caudal direction. As pregnancy continues, production of the hormone relaxin increases ten-fold, reaching its peak between weeks 38 and 42. Relaxin creates joint laxity, which is necessary to allow the pelvis to accommodate the enlarging uterus. Joint laxity is more pronounced in multiparous women than it is in nulliparous women. In the lumbar spine, joint laxity is most notable in the anterior and posterior longitudinal ligaments. This weakens the ability of static supports in the lumbar spine to withstand the shearing forces. As a result, there may be an increase in discogenic

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symptoms and/or pain coming from the facet joints. In the pelvis, joint laxity is most prominent in the symphysis pubis and the sacroiliac joints. The symphysis pubis continues to widen throughout pregnancy from its normal width of 0.5mm to a maximum of approximately 12mm. With this widening, there is the risk of vertical displacement of the pubis and the possibility of rotatory stress on the SI-joints. The SI-joints themselves tend to be extremely stable joints; they have anterior and posterior tight ligamentous structures as well as a curved and sigmoid articular surface that limits movement. Movement in the sacroiliac joint can be dramatically increased throughout pregnancy, however. This movement can stretch pain-sensitive structures, causing sacroiliac pain.5 2.2 Relationship between the pelvis and the back The two lowest lumbar vertebrae are connected to the pelvis by ligaments (ilio-lumbale). For this reason the two lowest lumbal vertebrae move together with the three parts of the pelvis in one system. It is impossible to move just one joint at the time. In most situations all joints move at the same time, or all are motionless. They function like small cogs in a clock. That’s why they could hinder each other. In other words, if one joint moves abnormal, for example because of an injury of the ligaments, the other joints will have troubles as well.6 2.3 The mobility of the pelvis joints During pregnancy the cartilago and the ligaments, which form the connection between the different parts of the pelvis, will soften and become more weak. It happens under influence of the hormones of oestrogen, progesterone and relaxine. This is a physiological change and this is in a certain point of view very favourable. It controls an increase of mobility in the pelvis and therefore the child can pass the pelvic ring. It is extremely difficult to measure the scope of the movements in the SI-joints, as these movements are so minimal. Women who gave birth do have more mobility in their pelvic joints than nulliparae. If women give birth in a natural way it will be more pronounced than women who had birth via sectio caesarea.

5 http://www.medscape.com/viewarticle/408838_3 6 Translation of Bekkeninstabiliteit /dr, Jan Mens/ anatomie H.1.3, p1

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Chapter 3: Complaints of Pelvic Instability According to the ‘Stichting voor Bekkenproblemen’ most complaints originate between the third and seventh month of pregnancy. The development of Pelvic Instability is not predictable. The pattern of complaints differs considerably from: 1. The location and the severity of pain 2. The degree of impediment during the daily activities of a patient ‘Stichting voor Bekkenproblemen’ has listed the most common complaints as follows: • A mushy, tired feeling or pain around the symphysis. Radiating pain towards the inside of

the upper leg or to the groin. • Lumbar back pain can radiate from the backside to the knee. In case the pain radiates to

the lower leg, you may also consider a combination of another disorder, like a hernia possibly. In such a case lose of strength and/or numbness in the leg may appear.

• A common symptom is ‘starterpain’, which means the pain starts mostly at the beginning

of an activity. • Increase of pain during pre-menstrual period, having a full bladder, when defecation is

hold up. • The woman may become incontinent. • Fatigue appears quickly. • Headache and neck pain are common occurrences. • Hypermobility of the joints, there is a laxity in the joints. A survey held under female members of the Stichting voor Bekkenproblemen most patients do have trouble or experience pain during or after the following activities: - Sitting - Going up or down stairs - Standing on one leg - Lying down - Closing and raising the legs - Riding a bike - Getting out of bed - Driving a car - Having sexual intercourse - Swimming - Turning over in bed - Standing - Bending down, reaching - Lifting

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Chapter 4: Symptoms of Pelvic Instability The symptoms of Pelvic Instability vary greatly from person to person but almost all women experience substantial pubic pain. Tenderness and pain down low in the front is common, but often this pain feels as if it's inside. The pubic area is generally very tender to the touch; many pregnant women find it painful when the doctor or midwife pushes down on the pubic bone while measuring the uterus (fundal height). Any activity that involves lifting one leg at a time or parting the legs tends to be particularly painful. Raising the leg to put on clothes, getting out of a car, bending over, sitting down or getting up, walking up stairs, standing on one leg, lifting heavy objects, and walking in general tend to be difficult at times. Many women report that moving or turning over in bed is especially excruciating. Many movements become difficult when the pubic symphysis area is affected. Although the greatest pain is associated with movements of lifting one leg or parting the legs, some women experience a 'freezing', where they get up out of bed and find it hard to get their bodies moving right away - the hip bone seems stuck in place and won't move at first. Or they describe having to wait for it to 'pop into place' before being able to walk. The range of hip movement is usually affected, and abduction of the hips especially painful. Many women also report sciatica (pain that shoots down the buttocks and leg) when pubic pain is present. Pelvic Instability can also be associated with bladder dysfunction, especially when going from lying down (or squatting) to a standing position. Some women also feel a 'clicking' when they walk or shift just 'so', or lots of pressure down low near the pubic area. Some women with Pelvic Instability also report very strong round ligament pain (pulling or tearing feelings in the abdomen when rolling over, moving suddenly, sneezing, coughing, getting up, etc.). Some chiropractors feel that round ligament pain can be an early symptom of pelvic problems, and indicate the need for adjustments. Other providers consider round ligament pain normal, part of the body adjusting to the growing uterus. If experienced with pubic and/or low back pain, it probably is associated with Pelvic Instability. Pelvic Instability can be divided into the following types of pain: - Pubic pain - Lumbar back pain - Posterior pelvic pain - Sacral pain (Sacro-Iliac joints) - Hip pain - Radiating pain in groins and legs - Buttock pain - Coccyx pain - Symphysiolysis* The term Symphysiolysis is sometimes used when pain is located at the symphysis area, however this disorder is morely a physical deviation of both os pubis. Symptomatology The symptoms of Pelvic Instability in the first place is mainly manifested as pain, consisting waggling, tingling, numbness, feelings of powerlessness with the consequences not being able to perform the daily activities. Beside this, complications and/or additional problems can slow down a reasonable quick recovery. In any case the patients have pain around the three joints of the pelvic ring: the area around the symphyse, or the area around the left of right SI-joints. It is common to have pain of the joints in combination. Some patients experience the pain daily or part of the day changing from the left to the right side.

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The pain of the SI-joint is located in the lower back at the level of the sacrum, next to the midline of the spine. If both SI-joints are painful the patient can experience this as one extended area around the midline. The pain from the SI-joints may radiate to the side of the pelvis, to the ischium, the side of the coccyx, the groin and to the backside of the legs. The more the pain, the more the radiation extends. Dr. J. Mens describes in his diagnosis that in rare cases the pain radiates to the lower abdomen. In practice I do see woman with this kind of pain and have to add that another complication is underlying which usually is not acknowledged or recognised by western doctors. Western Diagnosis Accurate diagnoses is usually made by symptoms, however sometimes it can be confirmed through Ultrasound, X-Ray (after pregnancy, especially in flamingo position / standing on one leg), CT Scan or MRI Scan. Unfortunately Pelvic Instability is sometimes misdiagnosed as ‘aches and pains of pregnancy’ and women can miss out on the help they really need. One of the difficulties concerning diagnosis is the names which are given to the phenomenon of Pelvic Instability. Physical examination can be performed by a orthopedic, gynaecologist, physiotherapist or osteopath. Physical examination - Powerful abduction of the hips (i.e. spreading of the legs) causes weakness and/or pain - Powerful abduction of the hips (i.e. closing of the widely-spread legs) causes weakness

and/or pain - The Posterior Pelvic Pain Provocation (PPPP) test is positive - The Active Straight Leg Raising (ASLR) test is positive - A pelvic girdle belt has a positive influence on the pain and strength - The patient uses stabilising muscles for the pelvic girdle in an incorrect way The Posterior Pelvic Pain Provocation (PPPP) Test This test is performed with the patient lying flat on her back on the examination couch. The examiner then positions the leg in 90 degrees of hip flexion, after which pressure is placed on the knee in the direction of the couch. The test is positive if this pressure produces pain around the buttocks. The Active Straight Leg Raise Test (ASLR test) The ASLR test is performed lying flat on the examination couch with straight legs and the feet 20 cm apart. The following instructions are given: try to raise your legs, one after the other, above the couch for 20 cm without bending the knee. The test is positive when raising the leg appears to be more difficult than is normal.7 Anamnese Medical history of the patient must asked for, specific questions about trauma, illness, pregnancy, delivery, miscarriage, post-partum, children, menstruation, medication and surgery.

7 J.M.A. Mens, e.a., Reliability and validity of the Active Straight Leg Raise Test, Spine 2001;26:1167

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Chapter 5: General causes of Pelvic Instability The cause of Pelvic Instability is unknown. It is thought that hormonal changes in pregnancy, changes in weight and posture in pregnancy, sporting or accidental injury may all play a role in making Pelvic Instability worse. It is also thought that some women with Pelvic Instability may have genetic factors that make them more susceptible such as hypermobile joints. Because of the relatively unknown aetiology of pregnancy related pelvic girdle pain and the lack of an all-embracing definition, we will use an extensive description of PPGP. We expect that during pregnancy almost all women experience some form of pain in the lower back, the buttocks, the symphysis, the groins and/or radiation into the legs. This pain is probably caused by hormonal and physiological changes which are considered normal during pregnancy. However, some women experience pain in a very early stage of pregnancy while others only experience pain in the final stages of pregnancy. In addition, some women are more limited in their activities (due to pain) than others. This suggests that other factors might influence the hormonal or physiological changes during pregnancy. Most women who had developed PPGP during pregnancy quickly recover after delivery.8

8 JM Bastiaanssen e.a., Etiology and prognosis of pregnancy-related pelvic girdle pain, jan. 2005 BMC, pag.3

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Chapter 6: Treatment Strategy Western medical treatment usually involves physiotherapy, specific exercises to help with problem areas and advice on rest. If the pain is severe, bed rest in hospital, medication or a medical induction may be considered. Activity has a positive influence on the muscles and ligaments however when the activities are overloaded it induces the ligaments to become irritating. Treatment may consist out of Caesar or physiotherapy and exercises to improve strength and mobility and to help postural alignment and body balance. Common western treatment strategies used are: • Physiotherapy • Use of a pelvic belt • Excercise at home • Balance between activity and rest • Operation

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Part 2: Traditional Chinese Medicine

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Chapter 7: Introduction 7.1 Pregnancy Traditional Chinese Medicine has a long history of advocating that women modify their lifestyle throughout pregnancy, to ensure healthy babies and efficient births. This has involved advice on regulating physical activity, following dietary guidelines and maintaining a calm emotional state. An early reference to this practice exists is the Records of the Historian which tells how the mother of the first emperor the Western Zhou dynasty (11th century to 771 B.C.E.) refused to look upon adverse colours, hear indecent sounds, or the utterance of any arrogant words, and because of this she gave birth to a son who achieved great things9. Later references to what became known as ‘foetal education’ included recommendations that pregnant women abstain from the use of non-prescribed medications, all alcohol and lifting heavy objects. Advice was also given on taking frequent leisurely walks and regulating sleep (avoiding both excessive sleep and undue fatigue). Abstaining from the seven passions, the five unfavourable tastes and all sexual activity was also seen as essential10. Dr. Xu Zi Cai (493-572 C.E.) detailed beneficial and detrimental foods for each month of pregnancy, for example, the mother should avoid pungent hot or drying foods, and if women experienced abdominal or umbilical fullness and a bearing down sensation in the third month, rooster soup should be taken11. As a woman approached the completion of her pregnancy, Dr. Xu Zi Cai advised that she concentrate her qi in the lower Dan Tian, three cun below her umbilicus, to promote the growth of the foetus’s joints and its mental development. This interest in promoting optimal conditions during pregnancy and in preparing for an efficient birth has continued to the present day in TCM, with the emphasis on a woman’s Qi and Blood prior to delivery. “If the qi is correct and if the blood is circulating well labour is described as harmonious’’12. Acupuncture treatments prior to labour provide and ideal opportunity to ensure that the Qi and Blood, the five emotions and the ZangFu are all in harmony. 7.2 Women’s physiology Maciocia describes in his book Obstetrics & Gynaecology in Chinese Medicine: Women’s physiology is dominated by Blood as the Lower Burner houses the Uterus which stores Blood. Blood is not only the source of the periods but also of fertility, conception, pregnancy and childbirth. The Uterus The Uterus received many different names like: Zi Bao, Bao Gong, Zi Zang, Zi Chu, Xue Zang. The next passage clearly shows that Bao is a structure common to woman being the Uterus in women. The Qi Jing Ba Mai (Extraordinary Vessels) arise from this area which will be discussed in chapter 9.3.

9 Zhang Ting-Liang, a Handbook of Traditional Chinese Gynaecology, Blue Poppy Press,1987,p4 10 Ibid. 11 G. Maciocia, Obstetrics & Gynaecology in Chinese Medicine, Churchill Livingstone, 1998, p. 447-49 12 B. Auteroche, R. Navailh, Acupuncture en Gynaecology et Obstetrique, Chapter 11, Maloine 1996

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The Golden Mirror of Medicine (Yi Zong Jin Jian, 1742) says: “The Governing Vessel arises within the lower abdomen, externally in the abdomen, internally in the Bao … also called Dan Tian in both men and women: in women it is the Uterus, in men it is the Room of Sperm”. The Uterus is one of the extra Fu, is has the shape of a Yang organ and the function of a Yin organ as the shape of the uterus is hollow, menstruation and labour (discharging) and the Uterus stores Blood and nourishes the fetus during pregnancy. The Uterus is related to the Kidneys via a channel called Bao Luo (Uterus Channel), it is also physiologically related to the Heart via a channel called Bao Mai (Uterus Vessel). The Kidneys have a significant important role in relation to the Pelvic Instability which will be discussed in chapter 8.2.1. With regard to Pelvic Instability, a Kidney deficiency is one of the primary causes. The bones, like all other Extra Fu, are also related to the Kidneys because they store Bone-Marrow. If Kidney Jing and Marrow are deficient the bones lose nourishment, can not sustain the body and there will be inability to walk or stand. This is one of the mayor complaints of Pelvic Instability. 7.3 Physiological changes pregnancy During pregnancy a lot of physical changes occur. There is no longer a monthly blood loss and there is a gradual increase in fluids and there is a excess of Yang because the absence of periods also leads to an accumulation of Minister Fire. As a result of the cessation of the menses, Chong Mai and Ren Mai undergo many changes which are typical of pregnancy. From an energetic point of view, pregnancy has a dual effect on the Kidneys, namely It poses a strain on the Kidneys as their Qi and Jing go to feed the fetus. However ‘menstrual Blood’ which is not actually Blood but a precious fluid, can go now to feed the body itself (as well as the fetus). Blood is transformed into Jing which nourishes the body and the fetus. Under normal circumstances and a healthy pregnancy, a pregnant woman looks very florid and healthy and not at all Blood deficient (especially between 4th-7th months).The transformation of Blood into Jing during pregnancy is mirrored, from a Western point of view, by the secretion of large amounts of oestrogen, progesterone and chorionic gonadotropin by the placenta, which explains why some women are healthier in pregnancy and others deteriorate. The difference depends both on the pre-existing state of Kindney-Qi and on how well the woman looks after herself during the pregnancy.13 As mentioned before, pregnancy involves natural changes in the quality and quantity of Qi and Blood and changes within the ZangFu. These are not to be confused with pathological developments. I will summarise these changes briefly: • An increase in blood • Increased Heat • Increased Dampness • Increased Liver Qi • Decreased Kidney Qi

13 G. Maciocia, Obstetrics and Gynaecology in Chinese Medicine, 1998, p27

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This means that tongue and pulse presentations may differ throughout pregnancy compared to non-pregnancy patient or a woman pre-pregnancy presentation. It is normal, for example, for a pregnant woman’s pulse at six months to be Hua Mai (slippery); it may be a little faster than her pre-pregnancy pulse and Xian Mai (wiry) in the left guan-position (middle). This does not mean that treatment must be immediately commenced to remove heat and disperse the Liver, unless of course there are patterns of disharmony that would justify it. Likewise it is to be expected that the tongue will reflect the presence of increased heat as the pregnancy progresses14 During pregnancy Musculoskeletal pain, in particular Pelvic Pain, during pregnancy is seen as a disruption to the flow of Qi or Blood in the channels passing through a specific area. This can arise from invasion of pathogenic factors (such as Wind, Cold, Damp or Heat), overuse, trauma or from an internal ZangFu transmitting to a channel. In clinical practice the aetiology can be mixed, for example lower back problems frequently result from an underlying Kidney deficiency as well as an acute channel presentation arising during pregnancy. This may happen when a woman suddenly slips in the shower and suffers a traumatic injury, or when the channels are invaded by pathogenic cold as a result of the swimming she has recently started in the middle of winter in an effort to keep fit. Diagnostically, blockages and stagnation in the channels will manifest as pain along the channel pathway, while any ZangFu disharmony will be revealed by additional systemic symptoms and tongue and pulse examination. Musculoskeletal conditions in pregnancy commonly present with pain and tenderness along the Bladder and Gall Bladder channel pathways. The most frequently ZangFu disharmonies are Kidney deficiency and Liver Qi stagnation.15 Post-partum Joint pain after childbirth includes pain, ache, soreness, numbness or feeling of heaviness in the pelvic area, joints, back, hip, knees or legs. It pertains to the broad disease category of Painful Obstruction Syndrome but it has specific characteristics and pathology when it occurs after giving birth. The most common aetiology and pathology are summarised as follows16: • Excessive Blood loss during labour • Invasion of external Wind • Emotional problems • Weak body condition Profuse blood loss during labour leads to severe Blood deficiency after childbirth; the deficient Blood fails to nourish the channels and the sinews and this causes a dull ache of a deficient nature.

14 Debra Betts, Acupuncture in pregnancy and childbirth, Hove, 2006, p6-7 15 Ibid., p55-56 16 G. Maciocia, Obstetrics & Gynaecology in Chinese Medicine,1998,p651-52

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A woman is more prone to an invasion of external Wind invading the channels and settling in the joints. After childbirth the channels are in a weakened state due to Blood deficiency and the space between the skin and muscles is empty due to Qi deficiency. To cause pain Wind usually combines with either Cold or Dampness. Emotional problems cause stagnation of Qi, which may lead to Blood stasis after childbirth. The pain is especially in the joints of a stabbing nature. A pre-existing weakness of the Kidneys and Liver will aggravate the medical condition after childbirth. The bones are influenced by the Kidneys and the Liver influences the sinews and these two issues will lack nourishment. Especially in the lower back and knees a dull pain of a deficient nature will be felt.

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Chapter 8: Women’s Pathology 8.1 Pelvic Instability in relation to the Vital Substances There are several major patterns of Qi, Xue and Jing disharmonies which have an important influence on the pelvic condition during pregnancy and after childbirth. 8.1.1 Qi The basis functions of Qi are: • Transforming • Transporting • Holding • Raising • Protecting • Warming Pathology of Qi Qi deficiency Qi can be deficient from various causes, especially Kidney Qi but the Spleen is involved as well because of its function in making Blood, to nourish and protect the fetus when the woman is pregnant. Secondly the Spleen controls the raising of Qi by producing a lifting effect along the midline of the body. This force makes sure that the ZangFu are in the proper place. Yuan Qi (Original Qi) is the basis for Kidney Qi and is therefore closely related to all the Kidneys functional activities. The main Kidney function is that of storing Jing and governing birth, growth and reproduction. In a further stage of Pelvic Instability, as a chronic disease, a pattern of Kidney Yin or Kidney Yang or a mixed pattern can nearly always be seen. The reason why Kidney Yin en Kidney Yang deficiencies often occur simultaneously in women is because of the connection Chong Mai – Blood – Uterus – Kidneys. Qi stagnation A complex balance relies not only among the ZangFu and the Yin-Yang character of Qi but also on the direction of movement of Qi. The normal functioning of the organs depends on the correct direction of Qi, for example: The Qi fails in its movement and stagnates, it does not flow smoothly in all directions or it can ascend out of control. Pelvic pain, back pain, hip pain, pubic pain, buttock pain etc. mostly implies Liver Qi stagnation and is extremely common in gynaecology. Of course pain in general is not always caused by Qi stagnation, which is an excess pain. In case it arises from a deficiency pattern the pain will be rather dull and less pronounced.

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8.1.2 Xue Xue itself is a very dense and material form of Qi; it is mostly derived from the Gu Qi (Food Qi) produced by the Spleen. There is a very close relationship between Qi and Xue17 1. Qi generates Xue 2. Qi moves Xue (When Qi moves Xue follows) 3. Qi holds Xue (Qi is the commander of Xue) 4. Xue nourishes Qi (Xue is the mother of Qi) The basis functions of Blood are: • Xue nourishes the body • Xue has a moistening function • Xue provides the material foundation for the Shen (Mind). Pathology of Blood Blood deficiency Seen from TCM perspective the physiological changes of pregnancy are mirrored in the idea that the Blood increases, because the menses stop, but is deviated from the Sea of Blood to nourish and protect the fetus. Whilst from a Western point of view the mother may be said to suffer from anaemia.18 Excessive Blood loss during labour is one of the causes of severe Blood deficiency after childbirth, consequently the deficient Blood fails to nourish the channels and the sinews (Liver Blood deficiency) causing a dull ache of a deficient nature especially in the pelvic area. Blood stasis Emotional problems such as irritation, frustration, worry and resentment cause stagnation of Qi, which after childbirth may easily led to Blood stasis. If Blood stagnates in the channels, especially in the pelvic joints, it causes pain of a stabbing nature. Liver Blood and Kidney Yang deficiency (mixed pattern) The woman suffers from dull joint-ache, especially in the pelvis joints, lower back or knees during pregnancy or after childbirth. The close relationship between the Liver and Kidneys is based on the mutual exchange between Blood and Jing. A well known Chinese statement is: ‘Liver and Kidneys have a common source’, meaning Liver Blood nourishes and replenishes Jing and this in turn contributes to produce Blood via the Bone Marrow which makes Blood.

17 G. Maciocia, The foundations of Chinese Medicine, 1989, p35-52 18 G. Maciocia, Obstetrics & Gynaecology in Chinese Medicine, 1998, p27

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Pathology of Qi and Blood related to Pelvic Pain Consequently the following differentiation is made of Qí and Xuè19. As a diagnostic tool it is necessary to identify the patterns by asking the patient about the type of pain. Qí deficiency Xuè deficiency Pain is relative minor, becoming worse now and then Pain is vague, not severe, especially with exertion and throughout the day. numbness feeling. Pain improves by taking a rest. Weakness of muscles and joints, slight stiffness.

Pain aggravates after menstruation (postnatal).

Pí Qí deficiency Gān Xuè deficiency ‘Pí-Qí nourishes the muscles’ ‘Gān-Xuè nourishes the tendons’ The extremities are painful and tired Pain, tremors, spasms of muscles, Relative minor development of muscles. tics, muscle cramp, paraesthesia

and disesthesia in arms and legs. Qí stagnation Xuè stasis Generally chronic pain, gradual aggravation Boring pain, fixed location, with feeling of tension, distension, radiating possible previous trauma or numbness feeling, emotional related . operation, restricted movement Some few painful points or none. Pain aggravates at night, in the Pain improves by relaxing. early morning, pre-menstrual, by pressure and improves during daytime by movement. Qí deficiency and Xuè deficiency Qí stagnation and Xuè stasis Chronic pain, vague, relatively slight feeling Intermittent pain, strongly of distension, numbness and weakness, emotional influence, aggravates at usually bilateral, local tiredness. night, sometimes boring pain, tics, Pain aggravates by exertion and tiredness numbness, stiffness, deformation Pain improves by pressure, rest and relaxation. of the small joints. 8.1.3 Jing Jing is extremely important in human physiology. It derives form both the Pre-Heaven (inherited from the parents at conception) and Post-Heaven Jing (produced by Stomach and Spleen after birth). It is a hereditary energy which determines the constitution, the strength and vitality of a pregnant woman. The functions of Jing are: • Growth, reproduction and development • Jing as basis of Kidney Qi • Jing produces Marrow • Jing as the basis of constitutional strength

19 Qing Bai, Syllabus Acu II, Topic Pain, IH, 2005-2006

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Pathology of Jing Kidney Jing deficiency The pregnant woman or mother may have a hereditary weakness. The pre-heaven Jing nourishes the embryo and fetus during pregnancy and is also dependent on nourishment derived from the mother’s Kidneys. Jing is stored in the Kidneys, having a fluid nature it also circulates all over the body, particularly in the Qi Jing Ba Mai. This part will also be discussed in chapter 8.4.4. With regard to Pelvic Instability there are some specific clinical manifestations such as softening of bones, soreness of the back, weakness of knees and legs, etc. which are very commonly seen. Therefore we cannot rule out the importance of the role of Qi Jing Ba Mai in relation to Pelvic Instability. Relationship Blood and Jing Blood and Jing mutually affect each other, each of them can transform into the other. Jing plays an important role in the formation of Blood and on the other hand, Blood continually nourishes and replenishes Jing.

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8.2 Pelvic Instability in relation to ZangFu The ZangFu mostly involved will have a strong influence on the pelvis and the pelvic floor during pregnancy and/or after childbirth: • Kidney deficiency • Liver excess • Liver deficiency • Spleen deficiency • Heart disharmony These ZangFu and their main functions with regard to Pelvic Instability will be described below. 8.2.1 Kidneys • Store Jing, govern Birth, Growth, Reproduction and Development. • Produce Marrow, fill up the Brain and control Bones. The Jing determines our basic constitution, strength and vitality and the state of Jing determines the state of the Kidneys. Marrow is the substance which is the common matrix of bones, bone marrow, brain and spinal cord and is also the basis for the formation of bone marrow which nourishes the bones. If Jing is strong, the pelvis will be strong, if Jing is weak, the pelvis will be weaker. 8.2.2 Liver • Stores Blood • Ensures the smooth flow of Qi • Controls the Sinews The Liver regulates the volume of Blood in the whole body at any time. It regulates the Blood volume according to physical activity and it regulates menstruation. When the body rests, Blood flows back to the Liver. When the body is active the Blood flows to the muscles as a self-regulating progress. Liver Blood deficiency is fundamental in gynaecology as it provides Blood to the Uterus in close coordination with the Chong Mai. The normal direction of movement of Liver Qi is upwards and outwards in all directions to ensure the smooth and impeded flow of Qi everywhere. Liver Qi stagnation obstructs the smooth flow of Qi which causes pain in the pelvic area, back, buttocks, symphyse, hips or legs. The sinews and tendons in the pelvis might be malnourished because of the physiological changes during pregnancy. The state of the sinews affects the capacity for movement and physical activity. One of the complaints of women with a Pelvic Instability disorder is the pain the woman experiences with all normal daily activities, such as standing, walking, sitting, etc.

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8.2.3 Spleen • Controls the Muscles and the four Limbs • Controls the raising of Qi Spleen Qi is also involved in gynaecological problems as it is the origin of Qi and Blood and thus Blood deficiency may occur. This affects the Liver and causes Liver blood deficiency and has for that reason an important influence to the Uterus and the Chong Mai directly. In practice other complaints are seen in combination with Pelvic Instability, for instance the pelvic floor muscles can be weakened or damaged. Spleen Qi deficiency contributes to pelvic floor muscles weakness. This type of deficiency is Spleen Qi sinking which is characterized by Spleen Qi strongly descending. This imbalance may cause incontinence, prolapse of the uterus, bladder, intestines or other ZangFu. In case there is a disfunction in the controlling function of the Spleen problems will arise also with the under limbs. Women do have difficulty in standing on one leg only and/or have problems to close and lift their legs, so may the activities as lifting, reaching or bending down induce complaints. 8.2.4 Heart • Governs Blood • Houses the Mind The Heart has an influence on gynaecological problems as it plays a role in the formation of menstrual Blood and it is connected to the Uterus via the Bao Mai (Uterus vessel). Due to this connection and since the Heart houses the Shen (Mind) and governs Blood, mental-emotional problems have a direct influence on pregnancy and childbirth and the menstrual function. The connection between the Heart, the Uterus and menstruation (after childbirth) explains the strong influence of emotional stress on this function. For example, a mother who gave birth, but due to the Pelvic Instability not being able to take good care of her child. Disappointment, frustration, grief or worry about not being a ‘good and healthy mum’ will deeply affect her mental-emotional state. The Golden Mirror of Medicine20 says: ‘Women cannot control themselves and are frequently affected by worry, pensiveness, anger or depression: this make the Blood move, stop, rebel or conform, which is all due to Qi movement’ 21

20 The Golden Mirror, p9 21 G. Maciocia, Obstetrics & Gynaecology in Chinese Medicine,p55

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8.3 Pelvic Instability in relation to Pathogenic Factors 8.3.1 Wai Yin - External Pathogenic Factors Women should take special care to avoid exposure to extreme weather, particularly Wind, Cold and Damp. Cold Exposure to Cold during childbirth may lead to stasis of Blood. As the woman already suffers from an exhaustion of Qi, the pathogene Cold may easily invade in the channels and the Uterus. Especially after labour, the Luo Mai (Blood-Connecting channels) are open and the space between skin and muscles is especially vulnerable to invasions of Wind-Cold. A sharp, boring and deep pain may arise in the pelvic area. Dampness The invasion of Dampness is also facilitated after labour and is a major pathogenic factor in gynaecology. It invades the channels of the legs and creeps upwards to settle in the reproductive system. Once inside her body, Dampness will become an Internal Pathogenic Factor which easily combines with Heat to form Damp-Heat. Dampness causes sensation of heaviness in the pelvic floor muscles which aggravates pain and/or discomfort in the pelvic area. 8.3.2 Nei Yin - Internal Pathogenic Factors Emotional Factors Women are also particularly vulnerable during pregnancy and after childbirth. Following childbirth a woman has multiple emotional and physicals adjustments to make as she recovers. Pre-existing deficiency of Qi and Blood, or deficiency of Qi and Blood arising from complications during labour can influence the ZangFu, especially the Heart, Liver, Spleen and Kidneys. This results in a variety of disharmonies. From a TCM point of view each of these emotions is associated with a particular ZangFu. These internal causes can harm the free flow of particularly to the Liver resulting in Liver Yang rising, Liver Qi stagnation and may deplete other internal organs as well.

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• 8.4 Pelvic Instability in relation to neither internal nor external causes The most important causes are: • Pregnancy • Childbirth • Lifestyle • Trauma • Constitution 8.4.1 Pregnancy and Childbirth These issues are not necessarily causes of disease but may become so in the following circumstances: Under influence of the hormones relaxine, oestrogene and progesteron the cartilago and ligaments are becoming more flexible and softer. This will affect the passage of the child through the pelvic ring during labour. Being in labour can cause a reinforced mobility. The size of the baby may play an important role in regard with the relative small pelvis of the mother. If a woman has too many children too close together without spacing out the pregnancies, this may cause problems with the pelvis as well. 8.4.2 Lifestyle When the pelvis gets more mobile, the muscles around the pelvis have to work much harder in order to guarantee the stability of the joints. The ligaments can be overstressed or overloaded caused by excessive physical work, exercise or sports during pregnancy or even top-class sport before pregnancy. This weakens the ZangFu, especially the Spleen, Liver and Kidneys and therefore muscles, sinews, tendons and bones are weakened. It also adversely affects the Chong Mai (Penetrating vessel) and the Ren Mai (Directing vessel) by causing Qi stagnation and/or Blood stagnation. The Simple Questions (Ch.23) says: ‘...excessive standing injures the bones [and therefore the Kidneys], excessive exercise and [physical] work injures the sinews [and therefore the Liver]...’22 When the mother does not have enough rest during pregnancy or after labour, this induces a weakness of the space between skin and muscles which predisposes her to invasions of Wind. Besides this, lack of rest after labour causes Blood and Kidney deficiency. The mother suffers from tiredness and exhaustion which aggravate the pain around the SI-joints, symphysis, coccyx en around the hips. 8.4.3 Trauma Falls, jumps or other traumas may injure the pelvis, back, neck, head, legs, etc. In the Pelvic ring a shift appears from one half of the pelvis in relation to the other half. Pelvic Instability is caused when the ligaments, which maintain the bones in place, are weakened. Therefore the ligaments starts to irritate and are overused, sometimes damaged. The more ligaments are weakened the more parts of the pelvis will shift between themselves. The pain caused by Qi stagnation and/or Blood stagnation is located around the symphyse and hips or there might be a radiating pain or numbness in the legs. A threatened miscarriage must not be ruled out and treatment must be started as soon as possible if the circumstances it allows. Since the

22 G. Maciocia, Obstetrics & Gynaecology,1998, p58, /SimpleQuestions, p154

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Chong Mai is the Sea of Blood and the Ren Mai influences the fetus, a weakness of these two vessels leads to a deficiency of Blood nourishing the fetus. 8.4.4 Constitution The basis constitutional strength and resistance to Exterior Pathogenic Factors is determined by Jing. It is a hereditary energy which determines the person’s constitution. This Jing is stored in the Kidneys, but having a fluid nature, it also circulates all over the body, especially in the Qi Jing Ba Mai. The state of Jing can to so some degree be deduced from the patient’s past. For example23 • A history of serious childhood diseases • Overwork without adequate rest • Excessive physical work or sport activities, especially at puberty when a young girl is in a

vulnerable state • Excessive sexual activity (before and during puberty and up to about 18 years) • Invasion of Cold are very common in young women

All circumstances above mentioned seriously weaken the Kidneys and damages the Ren Mai and Chong Mai and may therefore cause Pelvic Instability during or after pregnancy or even in a later stage of life. From a TCM point of view I would like to emphasize again the importance of the Kidneys and therefore the precious vital substances such as Kidney Qi and Jing when we are dealing with Pelvic Instability. It is easily diagnosed as a temporary discomfort because it is mainly related to physiological changes during pregnancy. It is mostly seen as just a lower back pain, hip pain or pubic pain which will pass away within a few months after childbirth. It is essential to see that the Qi Jing Ba Mai play an important role in the circulation of Jing and they represent a deeper level of treatment that allow us to treat a patient’s constitution after childbirth.

23 G. Maciocia,The Foundations of Chinese Medicine, p39-40/ Obstetrics&Gynaecology, p691

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Chapter 9: TCM Diagnosis 9.1 Methods of diagnosis TCM Diagnosis in gynaecology and obstetrics follow the same basis principles as in other diseases. Concerning Pelvic Instability methods like interrogation, palpation and observation might be useful. 9.1.1 Diagnosis by Interrogation The first discussion found about pain is from the ‘Huang Ti Nei Jing Su Wen’. Chapter 35 for example describes the aetiology, pathology and the different symptoms of pain. Pain is here being reduced to a disruption in the circulation of Qí and Xuè:24 Asking the patient about any sensation experienced such as pain, soreness, tingling, numbness, cold or heat will reveal the kind of blockage of a channel. What matters most is the correct diagnosis and differentiation of the pattern according to the Ba Gang - Eight Basic Principles, i.e. Internal, External, Full, Empty, Heat, Cold, Yin or Yang conditions. Differentiation according to Ba Gang in relation to pain: Biăo Lĭ External pain localized in skin, muscles Pain originates from ZangFu and meridians and bones Rè Hán Sensation of burning (Full Heat) Cold pain is severe, deep, boring Mild sensation of heat (Empty Heat) and sharp (Full Cold)

Dull pain (Empty Cold) Improves by cooling Improves by warmth Shí Xū Radiating pain, boring pain, colic pain, Light pain, intermittent pain, dull sharp pain, cramping pain and constant pain pain and empty pain Yīn Yáng Dull, deep pain, tend to chronic condition Severe, sharp, shallow pain,

cramps and spasms It is also important to ask about the development of fertility and pregnancy in general, previous childbirth, miscarriage or abortion. Miscarriage and abortion weaken a woman’s body. There is a saying in Chinese gynaecology: ‘Miscarriage is more serious than childbirth’. During a miscarriage there is a heavy loss of Blood and from a mental-emotional view, it means a great loss the woman with ensuing sadness and grief. Abortion is also weakening but to a lesser degree, there is less loss of Blood. Miscarriage before three months indicates a Kidney deficiency and after three months denotes sinking of Spleen Qi, Liver Blood stasis or Blood Heat.

24 Qing Bai, Syllabus Acu II, TopicPain, IH, 2005-2006

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9.1.2 Diagnosis by Palpation Diagnosis by palpation includes feeling the pulse and skin, abdomen, pubic area, hip, back, sacrum, buttocks and legs. It reflects the state of the channels. 9.1.2.1 Pulse The right pulse in women should be slightly stronger than the left one. The chi (rear) positions should also be stronger than the cun (front position). Li Shi Zhen says in his book The Study of the Pulse of the Pin Hu Lake: ‘there are differences in the Rear position in men and women: in women the Yang [i.e. the Front position] is weak and the Yin [i.e. the Rear position] is strong’25. Particularly the middle level in depth of the pulse is important in women as it corresponds to Blood. If the pulse feels at the middle level rather weak and soft at the guan (middle) position it indicates Blood deficiency. If the pulse feels Xian (wiry) or Lao (firm) at this level it means Blood stasis. The chi (rear) position of the pulse assumes particular importance in women. It corresponds to the Kidneys, Ming Men (Fire of the Gate of Life), the Minister Fire and the Uterus. If Kidneys are very deficient the chi (rear) positions are often weak and soft. On the basis of the tongue a distinction can be made between Kidney Yin or Kidney Yang. During pregnancy, the pulse becomes Hua (slippery). It is not a good sign if it lacks this quality. The whole pulse becomes Hua (slippery) and both chi (rear) position become Da (big) and the left cun (front) position become Hong (overflowing). 9.1.2.2 Skin In connection with Pelvic Instability I found some useful information described by Maciocia as follows: ‘One should palpate the skin in order to check the temperature, moisture and possible swelling. The temperature of the abdomen will indicate immediately the state of the Ren Mai and Chong Mai. In case the lower abdomen feels cold to the touch it indicates Cold in the Uterus and in the Ren Mai and Chong Mai. If the abdomen feels dry to the touch it indicates Blood and/or Yin deficiency’. ‘Stroking the skin reveals the texture and firmness of the skin and flesh and reflects the state of the Luo Mai. A weakness in the Luo Mai is indicated by a flaccid feel, when hardness is palpated stagnation in the Luo Mai is indicated’. ‘Pressing the muscles reveals the firmness of the muscles and sinews. Hardness and stiffness indicate a Full condition in the Luo Mai while flaccidity indicates an Empty condition in the Luo Mai’. 9.1.2.3 Abdomen In case you work together with an obstetrician or a midwife ask to palpate the abdomen by one of them as they are educated and experienced to perform during pregnancy. When a woman already gave birth, after a few days palpation in a soft and gentle way of the abdomen is allowed. The lower abdomen in women reflects the state of the Kidneys, the Uterus, the Chong Mai and Ren Mai. A Kidney deficiency is diagnosed when the abdomen feels too soft and the hand sinks in very easily. When it is more pronounced in the centre there is exhaustion of the Ren Mai, if it is a matter of exhaustion of the Chong Mai it is more on the lateral sides26. When the abdomen feels hard and tight this indicates stasis of Blood and if it is distended it indicates stagnation of Qi. 25 Maciocia, Obstetrics and Gynaecology, 1998, p 74 26 Ibid., p77

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9.1.2.4 Pubic bone Pain of the symphysis pubis is located around the pubic bone, perhaps radiating into the lower back or groin. It is often described as a painful grating sensation. The tenderest area is around the point Qugu Ren2 (Meeting point of Ren Mai and Liver channel). Debra Betts is the only therapist I found during my study who describes and acknowledges in her book ‘Acupuncture in Pregnancy & Childbirth’ treatment to this specific area around the symphysis. She asks the woman to locate the tenderest area and to massage it by the person herself before treatment starts. In practice I found this a very useful advice. With regard to the palpation of the other related body parts, differentiation should be made according to the differentiations of the Ba Gang, the Substances, the ZangFu, the Pathogenic Factors and Jing Luo or Qi Jing Ba Mai. 9.1.2.5 Ah Shi points When palpating the channels with light pressure very tender points can be felt, when this specific point is located, the woman will let you know as a ‘That’s it!’ exclamation. A very common Ah Shi point is for example around the symphysis or pubic bone. 9.1.3 Diagnosis by Observation Tongue diagnosis in gynaecology generally does not differ from that of other internal medicine. I will summarize the main aspects in relation to Pelvic Instability. Kidney Yang deficiency: Pale, swollen and wet tongue. Kidney Yin deficiency: Red tongue, no coating and cracks. Kidney Jing deficiency: Red and peeled tongue. Liver Qi stagnation: Body colour might be normal or red sides. Blood deficiency: Pale tongue body especially the sides,

sometimes an orange colour (Liver Blood), thin and dry.

Blood stasis: Purple or purple sides (Liver Blood). Spleen Qi deficiency: Pale or normal coloured, sometimes

swollen sides in chronic cases, transversal cracks possible.

Spleen Qi sinking: Pale tongue, sides might be swollen in chronic cases.

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9.2 The channels In order to influence the pelvic area with acupuncture we will have a look to the pathways of the channels. The superficial pathways is the part of the channel that flows under the skin and in between muscles and tendons, the acupuncture points are located on this part. The internal trajectories of the main channels flow in the interior of the body and into the ZangFu themselves. Therefore we can affect Qi and Blood through the superficial part of the pathway and we can affect the ZangFu through the deep pathways. Pathway of the channels As mentioned before pain occurs when the flow of Qi and/or Blood are blocked, in the first place we have to seek by manipulation of needle technique to establish a more harmonious flow of Qi through the system of channels allowing the body to heal itself naturally. The following channels influence the pelvic region27: • Uterus - The Conception vessel. - The Penetrating vessel. • Pubis - The Stomach sinew channel binds in the pelvic region above the genitals. - The Spleen sinew channel converges at the external genitalia. - The Kidney sinew channel binds at the genitalia. - The Gall Bladder primary channel encircles the genitals and runs superficially along the

margin of the pubic hair. - The Liver primary channel encircles the genitals. - The Liver sinew channel connects with the other sinew channels at the genitals. - The Liver luo-connecting channel ascends to the genitals. - The Governing vessel winds around the external genitalia. - The Yin Motility vessel ascends to the external genitalia. • Hips - The Stomach sinew channel ascends to bind at the hip joint. - The Spleen sinew channel binds in the anterior region of the hip. - The Gall Bladder primary channel enters deeply in the hip at Huantiao GB30. - The Gall Bladder divergent channel crosses over the hip joint. - The Yang Motility vessel ascends to the hip at Juliao GB29. - The Yank Linking vessel passes through the hip region. - The Girdle vessel encircles the waist and in the back it connects with the Kidney

divergent channel. • Sacrum - The Bladder primary channel. - The Kidney primary channel. - The Gall Bladder primary channel. - The Gall Bladder sinew channel. - The Governing vessel.

27 Peter Deadman a.o., A manual of Acupuncture, 2001, p613

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• Buttock - The Bladder primary channel crosses the buttock to join with Huantiao GB30. - The Bladder sinew channel binds at the buttock. - The Gall Bladder primary channel emerges on the buttock at Huantiao GB30. • Lower back, coccyx - The Stomach sinew channel. - The Spleen sinew channel. - The Bladder primary channel descends alongside the spine. - The Bladder divergent channel ascends along the spine. - The Bladder sinew channel ascends laterally along the spine to the nape of the neck. - The Kidney primary channel threads through the spine. - The Kidney luo-connecting channel spreads into the lumbar vertebrae. - The Kidney sinew channel travels internally to the spinal vertebrae and ascends the inner

aspect of the spine to the nape of the neck. - The Gall Bladder primary channel. - The Sanjiao primary channel. - The Governing vessel ascends the interior of the spinal column. - A branch of the Governing vessel descends either side of the spine to the Kidneys. - The Governing luo-connecting channel ascends bilaterally alongside the spine, and

subsequently threads through the spine at the level of the scapulae. - The Conception vessel enters the spine and ascends along the back. - A branch of the Penetrating vessel ascends inside the spinal column.

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9.3 Qi Jing Ba Mai We learned that Pelvic Instability has a very close relationship to the Vital Substances. As this essay will be read by TCM acupuncturists and/or TCM students I will give a short description about the Qi Jing Ba Mai most involved in order to treat Pelvic Instability mainly. 9.3.1 Du Mai Sea of Yang It originates in between the two Kidneys together with the Ren Mai and Chong Mai, it then flows downwards to the perineum and emerges at Ren1. From here it goes to Du1 and all along the spine to the head, down to the upper lip. Chapter 60 of the ‘Simple Questions’ gives the Du Mai the following pathway: It starts in the lower abdomen, goes down to the pubic bone, in women to the vagina. It’s Connecting channel goes around the vagina, passes the perineum, then the buttocks, down to meet the Kidney and Bladder channels inside the upper thighs; it then rises up the spine and wraps around the kidneys....the main vessel starts in the lower abdomen, goes up to the umblilicus, passes the heart, throat, chin, around lips and then reaches the eyes.28 The clinical applications of the Du Mai with regard to Pelvic Instability are to tonify Kidney Yang, strengthen the back with inability to bend forwards or backwards, nourish the Brain and Marrow, strengthens the Shen (Mind), lift Qi, in gynaecological disorders. In connection with the Fire of Gate of Life (Ming Men), it is the root of Yuan Qi and it is the source of Fire for all ZangFu. 9.3.2 Ren Mai Sea of Yin It starts inside the lower abdomen between the Kidneys, it flows through the Uterus and emerges at the perineum, from there it rises up the abdomen on the midline; it connects with the Chong Mai at Ren4 and Ren7. The clinical applications are to tonify Yin, gynaecological disorders like regulating the Uterus and genitalia, problems of pregnancy or after childbirth (post-partum backache), regulate life cycles (7 years in women), moves Qi in the Lower Burner, combination of Du Mai and Ren Mai points. Regarding the combination of Du Mai and Ren Mai points, both are like two branches of one channel, one Yang and the other Yin. Therefore the balancing of points from these two channels is a very important aspect of Yin-Yang. As the Du Mai is in the back and the Ren Mai in the front, balancing of the front and back part of the body is very effective.

28 G. Maciocia, The Channels of Acupuncture, 2006, p416

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9.3.3 Chong Mai Sea of Blood, Sea of the 12 Channels, Sea of the five Yin and six Yang organs It originates inside the lower abdomen (in the Uterus in women), it emerges at the perineum at Ren1, one branch ascends inside the spinal column, another branch emerges at ST 30, connects with the Kidney channel at KID11 and ascends through the Kidney channel to KID21, then disperses in the chest. From there, a third branch ascends alongside the throat, curves around the lips and terminates below the eyes. A fourth branch emerges at ST30, descends the medial side of the lower leg, runs posterior to the malleolus and terminates on the sole of the foot. A fifth branch separates from the leg branch at the heel, crosses the foot and terminates at the big toe. I found an interesting summary of the energetic sphere of action of the Chong Mai (Classic Categories) and it explains in more depth the meaning of this vessel being the ‘Sea of the 12 Channels’:26 ‘The Penetrating Vessel is the Sea of the 12 Channels, it goes upwards to connect with Bl-11 Dashu and downwards to connect with ST-37 Shangjuxu and ST-39 Xiajuxu. The Penetrating Vessel goes down to ST-30 Qichong and up to connect with the Kidney channel. It goes up to the eyes and head and down to the feet, it goes to the back [in the lumbar spine] and to the front in the abdomen. It goes into the Interior in the rivers and valleys [the big and small muscles of the abdomen] and into the Exterior in the skin and muscles. It therefore connects with both Yin and Yang and both Interior and Exterior ...100 diseases originates from the Penetrating Vessel because it is the most ‘penetrating’ [of the channels]. It controls the Qi and Blood of the 12 Channels which nourish the whole body and for this reason it is called the Sea of the five Yin and six Yang Organs’.29 The clinical applications for the Chong Mai are as follows: - An internal branch - An abdominal branch - A head branch - A spinal branch - A descending branch Particularly the internal, spinal and descending branches are very important in relation to the clinical manifestations such as pain in the pubic area, vagina (internal branch) lower backache in the spinal column to the level of BL23 (spinal branch) and pain in the groins and the inner aspect of the leg downwards (descending branch) are in this context also understandable. Furthermore the Chong Mai has a deep influence on the gynaecological system because it originates from between the Kidneys, it is responsible for the 7-year cycles of women and for the transformation of Jing into menstrual blood and it flows through the Uterus. Being the Sea of Blood means the Chong Mai affects many Blood pathologies which are extremely common in gynaecological disorders. During pregnancy or after childbirth the main pathology are Blood deficiency, Blood stasis or Blood Heat. The Chong Mai also affects all the Blood Luo channels; it explains the connection between disharmony of Blood in the Uterus and the development of muscular pains which is often occurring after childbirth. Whilst being in labour a woman may suffer from invasions of External Pathogenic Factors.

29 G. Maciocia, The Channels of Acupuncture, 2006, p490/Classic Categories, p281

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The depletion of Blood in the Chong Mai induces an emptiness of the Blood Luo channels. This affects the superficial Luo vessels and therefore the space between skin and muscles becomes empty so an invasion of a Wind Cold or Dampness is easily caused. The Chong Mai controls all Luo vessels and goes to the exterior of the body. Because of the connection between Chong Mai and the Heart in relation to Blood, they both govern Blood. Points of the Chong Mai may also be used to treat palpitations and anxiety during labour or after childbirth. Since it is both the Sea of Blood and the Sea of the 12 Channels, the Chong Mai influences the movement of Qi and Blood in the whole body. Another remarkable statement I found in the ‘Channels of Acupuncture’ of Maciocia about the Chong Mai and the Zong Jin - ‘Ancestral Muscles’: There are two interpretations to which the term Zong Jin refers to, on the one hand to the rectus abdominis muscles (running each side of the midline) and on the other hand referring to the penis. I understand there are passages in the old texts that would support both views. Chapter 44 of the ‘Simple Questions’ mentions the ancestral muscles: ‘The Penetrating Vessel is the Sea of the Channels, it irrigates the rivers and valleys and it connects with the Bright Yang [Stomach channel] in the Ancestral Muscle. Thus Yin and Yang meet in the Ancestral Muscles and connect with the avenues of the abdomen which are under the control of the Stomach: they are all restrained by the Girdle Vessel [Dai Mai] and connect with the Governing Vessel [Du Mai]’.30 Another passage in the same chapter of the ‘Simple Questions’: ‘The Bright Yang is the Sea of the five Yin and sex Yang organs, it irrigates the Ancestral muscle which runs to the pubic bone and up the spine in the back’.31 Both statements are very interesting in case of Pelvic Instability during pregnancy, due to physiological changes of the abdomen of the pregnant woman becoming more extended, growing in weight and by that the muscles related have to work much harder. This implicates that the ancestral muscles of the abdomen and the Chong Mai are closely related; meaning If the Chong Mai is not flourishing the ancestral muscles are slack and a slackness of the ancestral muscles may cause prolapse of the uterus and some kind of sinking Qi of the muscles around the abdomen, pelvic and lower back areas. 9.3.4 Dai Mai It originates in the region of LIV13 and then circles around just below the hypochondriac region. It runs obliquely downwards through GB26, GB27 and GB28, encircling the waist like a belt. The Dai Mai is the only horizontal vessel of the body; it encircles the channels in the abdomen and in the back. As it is closely related to the Liver and Gallbladder and connected to the Kidney Divergent channel (at the height of BL23), it guides and supports the Qi of the Spleen and Kidneys. The Dai Mai interrelates with and restrains the smooth flow of Qi (Liver) and harmonizes the ascending Qi (Spleen) and the ascending and/or descending of Kidney Qi. Sinking Qi, as from Spleen as well as from Kidney, is one of the pathological conditions of the Dai Mai. Another important pathology from the Dai Mai is Dampness in the Lower Burner which may arise from a Full condition or from a Deficiency and sinking of Spleen and Kidney Qi. In the treatment of some gynaecological complaints the Dai Mai is important. This vessel is closely related to the Ren Mai and the Chong Mai.

30 G. Maciocia, The Channels of Acupuncture, 2006, p508 31 Ibid., p508

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Some authors say that the Deficiency pathology of the Dai Mai is secondary to that of the Ren Mai, while an Excess pathology is secondary to an Excess in the Chong Mai. The pathology of the Dai Mai can be classified as a Full or Empty condition. As it encircles the waist, a Full condition occurs when the belt is too tight and its Empty condition when the belt is too slack. In case of a Full condition, related to the Chong Mai, a woman with Pelvic Instability has the feeling of heaviness of the body (as if sitting in water) and her backache is radiating to the abdomen or reverse. An Empty condition, related to the Ren Mai, is due to Qi deficiency (Kidney and Liver). The Dai Mai is not restraining the Jing, Spleen Qi is sinking. There is usually a long-term deficiency and sinking of Qi, Post-en Pre-Natal Qi deficiency, clear Qi descending, rather than ascending and the Dai Mai being too slack. As the Dai Mai flows through the waist it has a great influence to the hip. It can also be used for hip pain. Hip pain is also a remarkable complaint, particularly in combination of Dampness located in the Lower Burner. In severe cases some women can hardly walk or stand when the pelvis is in such an unstable condition, they have difficulty in lifting and moving the legs. They need to use a wheelchair or crutches to support the movements of the legs. The Dai Mai regulates the circulation of Qi in the legs as well. I found a passage of ‘Simple Questions’ described by Maciocia: Chapter 44 prescribes the use of the Bright-Yang channel to treat Atrophy Syndrome. It says: ‘The Bright Yang is the Sea of the five Yin and six Yang organs, it irritates the Ancestral Muscle which runs to the pubic bone an up the spine in the back’.32 It caught my attention because it is a very interesting statement in which the Ancestral Muscle is described as running not only up to the abdomen from the pubic bone to the xiphoid process but also up the back along the spine. It sounds like the Ancestral Muscle is not only the rectus abdominis muscle but also the spinal muscles erector spinae. The Ancestral Muscle which has its insertion in the pubis and the point ST30 (located on the superior border of the pubic bone) are strategic intersections of the Chong Mai, Du Mai and Dai Mai: • The Chong Mai emerges from the point ST30 and controls the Ancestral Muscle, not only

the rectus abdominis but also the erector spinae through its spinal branch. • The Du Mai flows in between the Ancestral Muscle of the back (erector spinae) and is

encircled by the Dai Mai. • The Dai Mai encircles the Du Mai in the back and the Chong Mai and Stomach channel in

the front. In order to promote the circulation of the Qi in the Stomach channel downwards to the legs and upwards to the sinews and ligaments alongside the spine, strengthen the Dai Mai and the Stomach channel.

32 G. Maciocia, The Channels of Acupuncture, 2006, p536

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9.3.5 Yang Qiao Mai and Yin Qiao Mai Yang Qiao Mai originates at BL62, at the lateral side of the heel and ascends along the lateral malleolus and the posterior border of the fibula. Then it passes up the lateral side of the thigh to GB 29, the hip and the postero-lateral costal region to the posterior axillary fold. It zig-zags across the top of the shoulder and where it connects via the neck to the corner of the mouth. From here it ascends the cheek and alongside the nose to the inner canthus and communicates with the Yin Qiao Mai and the Bladder channel and intersects with BL1. It continues upwards to the forehead then curves across the parietal region and descends to meet with GB20 and enters the brain. Yin Qiao Mai starts at KID2 or some authors claim at KID6 below the medial malleolus and then travels up along the medial aspect of the leg to thigh and the external genitalia. From here it ascends the abdomen and chest to the supraclavicular fossa untill ST12. It ascends through the throat and emerges anterior to ST9 and passes up the anterior cheek, mouth and nose to the inner canthus where it meets with the Yang Qiao Mai and Bladder channel at BL1. It ascends with these vessels to enter the brain. Both vessels influence the pelvic and hip area and are also used in connection with hip pain, lumbar pain and the rigidity of the body. Also the flaccidity of the muscles of the medial or inner leg and also the tightness of the muscles of the lateral or medial leg are controlled by them. The Yang Qiao Mai is very useful and indicated when several channels are involved, if the pain is located in the Bladder, Gall Bladder and Stomach channels for example. One of the complaints we have seen with Pelvic Instability are hip pain, backpain and sciatica. The Bladder and Gall Bladder channels are influenced by this vessel as it flows through GB29. Furthermore when the Yang Qiao Mai is diseased, the lateral muscles of the leg are tight and stiff, on the other hand the medial muscles are too relaxed. Maciocia describes some useful point combinations which can be needled in addition to BL62 and SI3. 33 • Rigidity of lumbar region, unable to flex or turn the hip: DU2, BL43, BL40. • Lower backache, difficulty in moving: KID2, BL43, BL40, BL23. In order to balance the tension of the inner and outer leg muscles, for example when a woman has a great difficulty to walk or stand, the Yin Qiao Mai can be used. Li Zhi Zhen describes the pathway through ST12 specifically. Maciocia mentions that Li Zhi Zhen is the only doctor who noticed the strategic importance of this point knowing that ST12 is a meeting point of several muscle channels.34 The Yin Qiao Mai is particularly used in gynaecology and obstetrics, especially for problems after birth with an Excess pattern like Qi or/and Blood stagnation in the abdomen or medial legs. In addition to KID6 and LU7, other useful point combinations can be used in connection with Pelvic Instability. • Leg pain from Cold Dampness: LIV3, BL40, SP6 (contraindicated in pregnancy). • Leg pain and swelling from Kidney deficiency: ST30, KID3, SP4, SP6 (contraindicated in

pregnancy), REN6 (not during pregnancy) and BL40.35

33 Maciocia, The Channels of Acupuncture, 2006, p576 34 ibid, p 551 35 ibid, p 559

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9.4 Pelvic Instability and acupuncture The pelvic bones, joints, ligaments, sinews, cartilago, muscles can be influenced via the Zang Fu and therefore via their related channels. The transportation of Qi, Blood and Jing takes place in the Qi Jing Ba Mai, however these channels do not connect the ZangFu directly. In terms of channels, the exterior of the body comprises the Luo (connecting) Mai and the interior comprises the Jing (main) Mai and the Jing Bie (divergent) and the Qi Jing Ba Mai (extraordinary vessels). Although it is through the superficial part of the pathway that we can affect Qi and Blood, it is only through the deep pathways we can affect the ZangFu. Safe treatment during pregnancy During this study, I have read different opinions about points which are considered to be dangerous to use in pregnancy. Some points I learned to avoid at any time during nine months and some are warned not to use during the first three months. Sometimes it is confusing, so I collected information from different sources and considered this information to be safe in use. Contraindicated points and combinations The following points are indicated for use in difficult of delayed labour, so if they are used for any other reason during pregnancy extreme caution must be taken or to be avoided: • LI4 Hegu (it induces labour). • SP6 Sanyinjiao (it induces labour). • GB21 Jianjing (expedites delivery). • BL60 Kunlun (promotes labour). • BL67 Zhiyin (turns the foetus and facilitates labour). • Points on the lower abdomen. • Points on the lumbal-sacral area, such as BL31 Shangliao and BL32 Ciliao (induction). Within this essay points such as ST30 Qichong and Ren4 Guanyuan are sometimes recommended, these points should be needled with caution and only in the specific circumstances discussed. For example SP6 Sanyinjiao in some circumstances is indicated in pregnancy, however it must never be needled with a reduction method and the following combinations should never be used together during pregnancy: • LI4 Hegu and SP6 Sanyinjiao • LIV3 Taichong and SP6 Sanyinjiao • BL60 Kunlun and SP6 Sanyinjiao During pregnancy it is best to keep the number of needles and the needle stimulation as minimal as possible. To prevent any excessive stimulation limiting of the number of needles is recommended, not more than six to eight. Women with deficiency conditions fewer needles should be used. In my practice I found out that the needling technique Xie Fa (reducing method) when treating musculoskeletal pain during pregnancy is not really necessary. Most women respond well when I used the even method which means after obtaining Deqi, the needle is left in place without manipulation. The use of moxa in pregnancy should be applied with caution as some women develop internal Heat normally and if not used appropriate this may aggreviate the condition.

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Some points are to be avoided during pregnancy because they can provoke labour or miscarriage may occur, also a sufficient knowledge of anatomy is required so that appropriate techniques are used when needling points that lie over the growing uterus. We have to realise that treatment can have an enormous effect on the development of the pregnancy itself. In the first place the use of point SP6 is given as a ‘contraindicated’ point during pregnancy as this point promotes labour. For that reason it can be used in the last weeks of pregnancy. I start to give prebirth treatments in the final weeks of pregnancy to prepare women for childbirth. I learned from Debra Betts that the acupuncture sessions given prior to labour provide an ideal opportunity to ensure that Qi and Blood, the ZangFu and the emotions are all in harmony. So point SP6 is used as a prebirth point to aid in cervical dilatation from 37 or 38 weeks once a week untill delivery. With regard to the use of the Qi Jing Ba Mai in pregnancy I could not find one note in literature, affirming my doubts about using the opening with or without its associated point. One exception I found is the use of SP4 and P6 which are the opening and associated points of the Chong Mai in order to treat morning sickness and vomiting. However, in my practice I’ve seen that the use of GB41 (opening point of the Dai Mai) can give such a relief or improvement in a condition such as pelvic pain. I’m convinced that in case points of the Qi Jing Ba Mai are used for treatment during pregnancy it will affect the mother and the fetus on a constitutional level. Personally I prefer not to do so with the exception of the use of GB41 as minimal as possible or when specific indicated to ensure safe and effective treatment during pregnancy. Treatment of Qi Jing Ba Mai The opening point of one vessel is usually used in conjunction with the opening point of the paired vessel. Not all practitioners use the point as a couple. Another way to needle is to use the opening point whithout its associated point, also points on the vessel can be used. To use the opening point one would insert the needle first on the right in a woman and its associated point if necessary on the opposite side. Retain the needles for about 20 minutes and withdrawn in reverse order.

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Chapter 10: TCM Pattern differentiation and treatment The main ZangFu disharmonies in musculoskeletal problems including Pelvic Instability are Kidney deficiency and Liver Qi stagnation with pain and tenderness along the pathways of the Bladder and Gallbladder channels. 10.1 Shen Yang Xu - Kidney Yang deficiency in combination with Gan Xue Xu –

Liver Blood deficiency Clinical manifestations Soreness of the back, persistent cold sensation and dull aching in the lower back and or knees, weak legs, tiredness, dizziness, tinnitus, a possible history of previous early miscarriage or fertility problems, dull pale complexion and lips, muscular weakness, muscle spasm, cramps. Tongue: pale, swollen, wet and/or pale especially on the sides, dry. Pulse: Chen (deep) and Ruo (weak) and/or Xi (fine) or Se (choppy). Treatment principle Tonify the Kidneys and Liver, remove stagnation from the Luo (connecting) channels, warm the channels and stop the pain. Point selection BL23, BL18, REN4 during pregnancy with moxa only, this point can be needled post-partum. LIV8, KID10, LIV7, DU4, KID3, KID7, BL52 and extra point Jinggong [0.5 cun lateral to BL52], GB34, GB39. Method Bu Fa (tonifying method) with moxa. Explanation BL23 and BL18 tonify the Kidneys and Liver. REN4 tonifies Liver and Kidneys, it tonifies Kidney Yang with moxa. LIV8 nourishes Liver Blood. KID10 with moxa tonifies Kidney Yang and benefits the knees. LIV7 tonifies the Liver and benefits the knees. DU4 strengthens the Fire of Mingmen (Gate of Life). KID3 tonifies the Kidneys. KID7 tonifies Kidney Yang. BL52 tonifies the Kidneys and in particular the Will power. E.P. Jinggong tonifies Kidney Yang and warms the Jing. GB34 benefits the sinews. GB39 benefits the Bones and expels Wind. 10.2 Shen Yin Xu - Kidney Yin deficiency Clinical manifestations Persistent lower backache, slightly red or flushed cheeks in the afternoon, thirst with a dry mouth in the evening, heat in the palms, soles of the feet or chest, night sweats or waking at night with feelings of heat, ache in bones, dizziness, poor memory, deafness, tinnitus. Tongue: red, no coating, cracks. Pulse: Fu (floating) - Xu (empty) and Shuo (rapid).

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Treatment principal Nourish Kidney Yin Point selection During pregnancy: BL23, KID3, KID6, KID10, KID9 After childbirth to be added: SP6, REN4 Method Bu Fa (tonifying), no moxa. Explanation BL23 and KID3 tonify the Kidneys. KID6 tonifies Kidney Yin, particularly for dry mouth in the evening or night. KID10 tonifies Kidney Yin. KID9 tonifies Kidney Yin, very useful in case of emotional tension. SP6 tonifies Liver and Kidney Yin and calms the Shen (Mind). REN4 without moxa tonifies Kidney Yin and Jing. As Kidney Jing is part of Yin (and also on a background of Kidney Yang deficiency) I will also discuss the treatment of Kidney Jing deficiency 10.3 Shen Jing Xu - Kidney Jing deficiency Clinical manifestations Softening of bones, weakness of knees and legs, poor memory, soreness of the back, night-sweating, 5-palm Heat, dizziness, tinnitus. Tongue: red without coating. Pulse: Fu (floating)-Xu (empty) or Shuo (rapid)-Xi (fine). Treatment principal Nourish Kidney Yin and Kidney Jing. Point Selection During pregnancy: KID3, BL23, BL52 After childbirth to be added: REN4, KID13, REN7, SP6, LU7 (right side) and KID6 (left side). Method Bu Fa (tonifying method), no moxa should be used unless the tongue is not very red and the pulse is very fine. Explanation KID3 and BL23 tonify the Kidneys. REN4 tonifies the Kidneys, nourishes Yin, strengthens the Uterus and the Ren Mai and the Chong Mai. KID13 nourishes Jing. REN7 nourishes Yin. SP6 nourishes Kidney Yin. KID13 tonifies the Kidneys, strengthens the Uterus and nourishes the Chong Mai (being a point of the Chong Mai itself). LU7 and KID6 regulate the Ren Mai and nourish the Kidneys. BL52 nourishes the Jing.

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10.4 Gan Qi Yu - Liver Qi stagnation Clinical manifestations Feelings of distension and pain in the hypochondrium and chest, a tendency to sigh, melancholy, depression, irritability. Tongue: the body colour may be normal. Pulse: Xian (wiry) especially on the left guan (second) position. Treatment principal Smooth the Liver, regulate the Qi stagnation. Point selection LIV3, GB34, SJ6, P6. Method Xie Fa (reducing method), no moxa. During pregnancy even method is applied. Explanation LIV3 regulates Liver Qi, as a distal point for the Liver channel which encircles the pubic area. GB34 regulates Liver Qi, benefits the sinews and joints. SJ6 regulates Liver Qi, particularly the sides of the body. P6 regulates Liver Qi, particularly when the Liver Qi stagnation is caused by emotional imbalance. 10.5 Xue Xu - Blood deficiency Clinical manifestations Dull ache in the pelvic joints during or after childbirth, muscular weakness, numbness and tingling of legs, muscle cramps, dull complexion, dizziness, blurred vision, insomnia, tiredness, dull pale complexion. Tongue: pale, especially on the sides in case of Liver Blood deficiency, thin, slightly dry. Pulse: Se (choppy) or Xi (fine). Treatment principal Nourish Blood, nourish and relax the sinews. Point selection During pregnancy: BL18, BL20, BL23, BL17, ST36, LIV8, BL11, GB34. Moxa to be used on BL17 and ST36. After childbirth following points can be added: LU7 (right sided) and KID6 (left sided), Ren4, SP6. Method Bu Fa (tonifying method), even method during pregnancy. Explanation BL18 regulates and nourishes Liver Blood. BL20 and BL23 in combination with direct moxa cones tonify Qi and Blood. BL17 nourishes and harmonizes Blood being a Hui (meeting) point of Blood. ST36, SP6 and LIV8 nourish Blood. BL11 with direct moxa cones it nourishes Blood (point of Sea of Blood). GB34 nourishes the sinews and joints, it is also a Hui (meeting) point of Sinews. LU7 and REN6 open and regulate the Ren Mai which nourishes the Uterus and Blood. REN4 nourishes Blood and the Uterus. Remark Besides needling as outlined above, moxibustion to BL17 and ST36 for 5 minutes for ten days provide the most effective results in terms of assisting the body to enhance blood production. Of course the woman will need assistance to apply moxa on the point BL17.

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10.6 Xue Yu - Blood stasis Clinical manifestations Severe aches and pain during or after pregnancy with pronounced pain (boring, fixed and stabbing pain) more in the joints than in the muscles, prolonged ligamental pain, dark complexion. After childbirth painful periods with dark and clotted blood. Tongue: purple (in case of Liver Blood stasis, purple sides of the tongue). Pulse: Se (choppy) or Lao (firm) or Xian (wiry). Treatment principle Invigorate Blood, eliminate stasis and benefit the sinews. Point selection During pregnancy: BL17, SP10, BL11, SJ5, P6, LIV8, LIV3, GB34, GB26 After childbirth to be added: SP6. Method Xie Fa (reducing method), no moxa. Explanation BL17 and SP10 invigorate Blood and eliminate stasis. BL11, invigorates Blood being the point of Sea of Blood. P6 and SP6 invigorate Blood. LIV8 nourishes Blood. LIV3 invigorates Liver Blood and regulates Liver Qi. GB34 regulates Liver Qi in order to regulate Blood. GB26 regulates the Dai Mai and resolves Qi stagnation if derived from the Liver, it is also useful in case of Qi sinking. Stasis of Blood may arise from many different conditions, which among is Qi deficiency. The Spleen together with the Stomach is the source of post-natal Qi and Blood. In this case I have to underline the importance to tonify the Spleen as it transports Qi direct to the muscles. If Spleen Qi is weak, the refined Qi cannot be transported and the woman feels weary and the muscles will be weak. So the Spleen supports to enhance the condition during and after pregnancy by strengthening the mother. 10.7 Pi Qi Xu – Spleen Qi deficiency Clinical manifestations Fatigue particularly after exertion, it improves with rest. In case of Pelvic Instability woman do feel exhausted quickly after a daily activity, weakness of the limbs, pale complexion, no appetite, loose stools. Tongue: pale, sides might be swollen in chronic cases. Pulse: Xu (empty). Treatment principle Tonify Spleen Qi. Point selection During pregnancy: REN12 (first three months only), ST36, SP3, BL20, BL21. After childbirth points to be added: SP6. Method Bu Fa (tonifying method). ST 36 and SP6 with moxa to tonify Qi and Yang.

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Explanation REN12 tonifies Spleen Qi. ST36 tonifies Spleen Qi. SP3 tonifies Spleen Qi being the Yuan (source) point. BL20 and BL21 in combination tonify Spleen Qi. SP6 tonifies Spleen Qi 10.8 Pi Qi Xian – Spleen Xi sinking This type of Spleen Qi deficiency is characterized by a dragging down or bearing down feeling, prolapses, slightly or frequent incontinence of urination and long standing discharges. It is a common pattern seen when a woman suffers from Pelvic Instability. As Qi is sinking it has not only effect on the organs but on a mental emotional level as well. It causes low moods and depressions. By treating the Spleen it is possible to help achieve more balanced emotional states. Clinical manifestations Symptoms and signs of Spleen Qi deficiency with addition of a bearing down sensation, prolaps of organs, frequent urination, feeling of weakness in the pelvis. Treatment principle Tonify Spleen Qi and raise Qi. Point selection During pregnancy: ST 36, BL20, BL21, DU20, REN12 (first three months only). After childbirth points to be added: SP6, REN6. Method Bu Fa (tonifying) method. Explanation REN6 and DU20 in combination tonify and raise Qi, particularly used for prolaps of the Uterus. 10.9 Invasion of Wind, Cold or Dampness Clinical manifestations Pain in the back or joints with sudden onset, contractions of joints, pain relieved by movement. If Cold predominates, pain is fixed. If Wind predominates the pain wanders from joint to joint. If Dampness predominates the ache is dull with a feeling of heaviness and tingling. Tongue: no change. Pulse: no change. Treatment principle Nourish Blood, expel Wind, scatter Cold, resolve Dampness. Point selection During pregnancy: LIV8, GB34, ST36, BL11, DU14, BL12, SJ5, ST43, BL17, SP9, REN12 (first three months only). After childbirth points to be added: SP6, REN4, REN6.

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Explanation LIV8, ST36, SP6, REN4and BL17 nourish Blood. GB34 benefits the sinews. BL11 with moxa, nourishes Blood and expels Wind. BL12 with cupping expels Wind. DU14, SJ5 and ST43 expel Wind. SP9 and REN12 resolve Dampness. REN6 with moxa expels Cold.

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Chapter 11: Common musculoskeletal conditions 11.1 Pain of the symphysis pubis This is pain is located around the pubic bone sometimes radiating into the lower back or groin and is often described as a painful grating sensation. It will always become more noticeable after prolonged walking or after mobilising the pelvis. For instance when getting out of bed or a car, getting off the toilet, etc. The symphysis pubis joint, although normally stable, can begin to separately slightly in the later stages of pregnancy to prepare for easier passage of the baby through the pelvic ring. If this separating process leads to inflammation within the symphysis pubis, pain occurs. This pain can range from mild discomfort on walking or getting out of a chair, to pain of such severity that a woman will need crutches to walk or even enforced bed rest because of the intense pain on movement. In less severe cases, women will usually be advised to rest and a supporting belt may be given to wear in order to stabilise the pelvis. In cases of severe pain, medical treatment involves admission to hospital for bed rest and analgesics or possibly an early induction. Debra Betts advices in her book ‘Acupuncture in Pregnancy & Childbirth’ to use GB34, LIV5, LIV3, GB41 and REN2. After treatment the tenderness of point REN2 is usually diminished. Furthermore she advises to place ear press needles on the distal point GB41 (opening point of the Dai Mai) for several days to further enhance the treatment effects. Remark Point GB41 is the opening point of the Dai Mai which encircles the waist and binds the Chong Mai and Ren Mai and the Kidney, Liver and Spleen channels. It spreads Liver Qi and I use it also when headache or pain on the lateral sides of the neck is present. In addition during pregnancy the fetus depends on the Kidneys and Ren Mai but also on the Dai Mai. If the Dai Mai is slack, Qi cannot rise, the fetus is not stabilized and the mother may miscarry. One of my patients had besides Pelvic Instability also a prolapse of her Uterus after childbirth. In order to ‘tight the belt’ I needled the points GB28 together with Ren6 and DU20 which was very useful for her condition. 11.2 Lower backpain, sciatica, hip pain and leg cramps During the last few months this is a common presentation. Nevertheless determination if External Pathological Factors such as Wind, Cold or Dampness are present in which case moxa can be used locally therefore the specific affected channels can be treated. In practice with some women the pain is often getting worse at night and I give instructions how to massage certain points such as GB41 or BL62 and LIV3. Debra Betts suggests again to use ear press needles on distal points to boost treatment results until the next visit. Point BL40 is effective for chronic or acute lower back pain, whatever the aetiology, and for sciatic pain radiating down the Bladder channel. Another vessel to be discussed is the Yang Qiao Mai. This vessel is very useful for treating unilateral backache and sciatica in case the pain affects the Bladder, Gallbladder and Stomach channels or just the first two channels. After childbirth the point BL62 (opening point) can be needled on the affected side and SI3 (associated point) on the opposite side. In case there is a pronounced stiffness BL59 (Xi-cleft point) can be added. After 20 minutes the local points on the back can be treated. The Yang Qiao Mai is particularly indicated against a background of a Full condition and when the pulse is Xian (wiry) and Shi (full). Due to the taxing effect of pregnancy on Kidney energy, treatment to tonify the Kidneys will always be beneficial. BL23 is needled with a Bu Fa (tonifying) method, if there is a Kidney Yang deficiency moxa is very useful. A moxa stick can then be given to the woman along with clear

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instruction on how to use this at home with the assistance of her partner or somebody close to her. Contraindicated point is BL60 as it promotes labour. Hip pain usually occurs in combination with pain in the buttocks and sometimes combined with radiating pain to the lateral sides of the legs. Mostly the pain is manifested on one side and sometimes the pain changes from side. The point combination commonly used is BL23, GB30, GB34, GB41, LIV3, BL57, BL58 and BL62 (preferable use after childbirth). When needling avoid strong reduction and use minimal needles. 11.3 Sacral pain and coccygeal pain Because of the location, treatment of the points in this area is not advisable during pregnancy. The sacral area is where the Bladder and Gall Bladder channels meet. These specific local points are primarily used to activate the circulation of Qi and treat pain of the lumbar region and sacrum, pain of the lumbar region and hip and especially pain of the coccyx. However, extreme caution has to be taken in using these specific points such as Bl30 up to and including Bl34. Particularly Bl32 is common used to promote labour, this point aids in cervical dilation, relieves a cervical lip and provides pain relief. In that case I do not use any of these points untill delivery takes place. On the other hand, when treating the mother after childbirth, these points are very useful as these points benefit the lumbar region and legs. To relief pain the primary point to be used is BL30 in combination with LI4 and LIV3. Alternatively, point BL40 is very useful and BL54 is an indispensable point in the treatment of pain of the lumbar region, sacrum and buttocks and of sciatica. Furthermore is the use of moxa along the Bladder and Gall Bladder channels very effective in case there is a background of deficiency. 11.4 Case history Nathalie, aged 37, married and mother of two children, professional teacher in gymnastics at elementary school. Nathalie came to my practice when she was 11 weeks pregnant. Her main complaint was low back pain accompanied with pain around the Sacro-Iliac joints and sometimes a radiating pain to the buttocks. She was very tired and particularly nervous and restless. During her previous pregnancies she had the same symptoms although they were presented in a later stage of pregnancy. Several times she had inflammations in the S-I joints, Diclofenac was given and she went to a physiotherapist. During nine months she was advised to take medication to improve her iron deficiency anaemia. With respect to her profession I recommended Natalie absolutely not to lift weight during classes and also advised her to ask the students and colleagues to help her when needed. When she made an appointment she told me that she was a runner. I asked her to stop and to keep it relaxed like walking instead. At the moment she is very anxious about her physical condition not being the same as before. She also has personal doubts on this pregnancy. She is very enthusiastic about her job and doesn’t want to give up when she feels limited in her performing. When she entered the room immediately I noticed a strong rancid odour around her. The pain she described has a dull and deep character; the pain got worsened with tiredness. She can’t sleep well at night merely caused by overthinking. During the day she feels constantly cold, she also described being nervous and irritated. When she relaxes the pain diminishes. Nathalie’s face is very pale and her lips are dry. Her tongue showed a pale colour, a swollen and dry tongue with barely any fur. Her pulse was Chen (deep), Hua (slippery). The left pulse was also Xi (fine) and the right pulse Xian (wiry). Right chi (rear) position was Ruo (weak).

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The main pattern is one of Liver Qi stagnation with Blood deficiency and Kidney Yang deficiency. Her treatment consists in dispersing the Liver, regulating the smooth flow of Qi, invigorating and nourishing Blood, tonifying Spleen and Kidney Yang and calming the Shen (Mind). The point combination I firstly used was: LIV3 combined with GB34 [left-right, crossing] to promote the smooth flow of Liver Qi, it benefits the sinews and calms the Mind. KID3 to nourish the Kidneys combined with LIV8 [left-right, crossing] to nourish Liver Blood. ST36 to nourish Blood and to tonify Spleen Qi (bilateral). P6 and YinTang to relieve emotional stress and to calm the Mind. All points were needled with even method. During her next visits I alternated the points: Again LIV3 and GB34, even method needling. BL17 to invigorate Blood, BL18 only moxa applied to invigorate Blood, BL20 to tonify Spleen and Blood and BL23 to tonify the Kidneys and to strengthen the lower back (with moxa). After two sessions the lower back pain was still present but with more of a constant dull character. She noticed she became calmer after the acupuncture treatments She admits having problems to relax physically caused by emotional stress. She had an Ah-Shi point nearly to GB30 and she shouted when I pressed that point lightly. Lying on her side, GB30 was very shortly needled with a strong reducing method and I removed the needle immediately. When I pressed again she was relieved and a few weeks later she told me the pain didn’t reappear. I still see her every three weeks, her treatment is primarily based on removal of Qi stagnation and to regulate the free flow of Qi, furthermore all the aspects of Blood and Qi with their related ZangFu are nourished. I asked her to consider to follow Qigong classes in order to relax her sinews and for her well-being during pregnancy.

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Chapter 12: Patient advice Healthy pregnancy From a TCM point of view a healthy pregnancy depends on adequate rest, a suitable diet and emotional well being. This provides a welcome alternative middle ground to the two prevalent approaches, found in modern western culture: that pregnancy is a medical problem that medicine should control, on the one hand, and that pregnancy is something that no healthy woman should let change her daily life, on the other.36 Diet Dietary recommendations include avoiding spicy, pungent and greasy foods. In practice you will find there is a problem with excessive mucus production in the later stages of pregnancy, as women tend to increase their consumption of damp producing foods, for example dairy products, rich meats, bananas and concentrated juices, especially orange and tomato, in the belief that these are healthy and that they need the extra calcium or iron these foods provide. Emotions While women may not want to go to the extent of avoiding all of the ‘five emotions’, it is useful to ask women to pay attention to activities that upset them, instead of dismissing these feelings as ‘just hormonal’. It might be helpful to avoid watching disturbing films, reading sad books, or listening to negative news reports and instead where possible concentrate on more positive events. Physical activity Normal physical activities during pregnancy are beneficial to the flow of Blood and Qi, helping to maintain health and strengthening the body's ability to resist disease. Proper rest can relieve the weariness of the body and mind as well as restore physical strength and mental power. A balance between work and rest is what a normal life needs. Any excess or insufficiency in either will harm the body and result in disease. It is necessary to have regular exercise but only to a moderate degree, as overdoing it can impair the Liver and Kidneys as tendons and bones are ruled by these organs. Suggestions include walking, swimming, Tai Chi, Qigong or yoga classes designed for pregnancy. Whatever a woman’s experience of labour is going to be, it will not be enhanced by feelings of tiredness and exhaustion.

36 Journal of Chinese Medicine, nr. 76, october 2004, Debra Betts

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Part 3: Conclusion This essay is dedicated to the discussion of treating Pelvic Instability with acupuncture. During this study I wondered about not finding TCM literature about this specific disorder. Thus one of the questions arises whether these specific complaints are only presented particularly in the Western world or whether it is a modern life style problem world-wide. The studies and research published on the internet are written in the United States or Europe. In the Netherlands the importance of pregnancy, post-partum care and lifestyle after childbirth is changing nowadays. A great percentage of women have a job beside their home tasks and responsibilities as a new mother. The maternity leave in general is about ten weeks. Six weeks after labour the new mom is to be expected to work again. However in China exists a traditional regimen called Zuo Yuezi i.e. ‘doing the month’. The Chinese tradition of ‘Zuo Yuezi’ dictates that for 40 days from the birth of their children, mothers must stay inside and avoid bathing, washing their hair or brushing their teeth. They must cover their heads to prevent chills, keep the windows closed, and remain in bed for as long as possible. Zuo Yuezi also requires mothers to avoid all forms of stress, including crying, shouting and talking for an entire cycle of the moon. While ‘doing the month,’ mothers can not eat Cold foods such as cool drinks, ice cream, fruits or vegetables. Instead, they must load up on Hot foods like boiled eggs and chicken and fish soup. Along with the tradition is a famous Chinese postpartum ‘decoction’ known as Shenghua Tang, an herbal cleansing and purifying remedy. Medical writings about Zuo Yuezi can be traced to the Qing Dynasty (1644 –1911). Essentially, ‘doing the month’ was a primitive form of quarantine to prevent postpartum complications. This interesting additional information taught me not to focus on Pelvic Instability only but on pregnancy, pre- and post-natal care as well. The Chinese tradition ‘Zuo Yuezi’ should be remembered when we are treating woman during pregnancy or postpartum. I’m very pleased and proud that TCM therapists are able to diagnose and treat from a different angle. Treatments with acupuncture have an enormous positive influence on pain and discomfort from which women suffer. At end we all aim the same goal, namely to bring these women in balance again, physically as well as emotionally in order to regain a good health in all sentences of life. Hopefully this essay will contribute towards a specific TCM treatment in order to treat Pelvic Instability.

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BIBLIOGRAPHY Auteroche B (1986). Acupuncture en Gynecologie et Obstretique. Maloine, Paris Betts D (2006). The essential guide to Acupuncture in Pregnancy & Childbirth. The Journal of

Chinese Medicine, Hove. Deadman P, a.o. (1998). A Manual of Acupuncture. Journal of Chinese Medicine

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Edinburgh. Maciocia G (1989). The Foundations of Chinese Medicine. Churchill Livingstone, Edinburgh. Maciocia G (1994). The Practice of Chinese Medicine. Churchill Livingstone, Edinburgh. Maciocia G (2006). The Channels of Acupuncture. Churchill Livingstone, Edinburgh. Marieb E (2007). Human Anatomy & Physiology. Pearson International Edition, San Francisco. Mens J (2007). Bekkeninstabiliteit – Diagnostiek en Therapie. Bohn Stafleu van Loghum,

Houten. Oderkerk R (2006). Syllabi ABC van de Geneeskunde. School voor Homeopathie. Soest. Röst C (1999). Bekkenpijn tijdens en na de zwangerschap. Elsevier/De Tijdstroom, Maarssen. Li Jie a.o. (2004-2006). Syllabi Acupunctuur I en II. Academy for TCM Qing Bai, Nijmegen. INTERNET www.medscape.com www.pelvicinstability.org www.spineuniverse.com ARTICLES Bastiaanssen J e.a. (2005). Etiology and prognosis of pregnancy-related pelvic girdle Pain. BMC. Elden H e.a. (2005) Effects of acupuncture and stabilising exercises as adjunct to

standard treatment in pregnant women with pelvic girdle pain. Groot de M (2005) Thesis Objective Measures for pregnancy related low back pain and

pelvic pain.

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Mens J (2001). Reliability and validity of the Active Straight Leg Raise Test. Spine. Stichting voor Bekkenproblemen (2004). Bekkeninstabiliteit tijdens en/of na de

zwangerschap of na een ongeval.

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APPENDIX Effects of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain. Helen Elden a.o. / BMJ 2005.

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