1. Pathogenesis and Tuina Treatment of Shoulder Disorders East West Healing Center By Dr. Leon Chen www.eastwesthealingcenter.net

2. Review of Tuina History Warring States Period: from 475 BC to 221 BC. Tuina manipulation has been recorded in the “Huangdi Neijing” or call “Inner Canon of Yellow Emperor” that is a earliest medicine book in China. Three Kingdoms period, The Jin Dynasty: from 220 A.D to 581 A.D. Tuina technique was improved and Tuina books been appeared, such as “Zhou Hou Fang”. From Song Dynasty to Qing Dynasty: from 960 to 1911, had a lot of Tuina books been appeared and technique much better. Since 1958, Tuina has been get comprehensive development, especially to use modern science approach to the study of Tuina.

3. ZhouHouFang

7. 元代 - 危亦林（ 1277-1347 A.D ）《世医得效方》 Yuan Dynasty Counter traction for treatment of back pain

8. 元代 - 危亦林（ 1277-1347 A.D ）《世医得效方》 Yuan Dynasty Waist belt for back pain

9. TuiNa Actions 1) To reduce the pain. 2) To flow blood to particular area. 3) To activate the Qi in the channels. 4) To reduce muscle spasm. 5) To repair the damaged soft tissue. 6) To adjust joints, reset bone.

10. How Does Tuina Work? The tuina can improve the skin and muscle the blood circulation, strengthen the metabolism of tissues and organs, and promote gastrointestinal motility and anti- inflammatory effect.

11. How Does Tuina Work of Anti-inflammatory? 1) Increase content of Beta- endorphin (END) and Catecholamine (CA) in blood to help the pain. 2) Decrease content of 5-hydroxytryptamine (5- HT) in blood to reduce the pain.

12. TuiNa Methods 1.Single manipulation: 1)Tui: pushing. ① Finger pushing. ② Palm pushing. ③ Twin palms pushing. 2)Na: Grasping. ① Fingers. ② Twin palms. 3)An: pressing. ① Finger pressing. ② Palm pressing. ③ Elbow pressing. 4)Mo: Rubbing. 5)Rou: Kneading. 6)Gun: Rolling. ① Side fist. ② Fist. 7)Dou: Shaking. 8)Da: Patting and pound. 9)YaoHuang: Rotating.

13. Tui ( pushing): ① Finger pushing. ② Palm pushing. ③ Twin palms pushing.

14. Na: Grasping. ① Fingers. ② Twin palms.

15. An (pressing): ① Finger pressing. ② Palm pressing. ③ Elbow pressing.

16. Mo: Rubbing

17. Gun: Rolling. ① Side fist. ② Fist.

18. Da: Patting and pound.

19. YaoHuang: Rotating

20. 2. Combined manipulation: AnGunRou: Pressing, Rolling and Kneading. NaRou: Grasping and Kneading. Wave: Grasping, Pushing and Rolling. AnMo: Pressing and Rubbing.

21. 3. Manipulation for the Spine or Joints 1)BaShen: Counter traction ①Joints traction. ②Cervical traction. ③ Lumbar traction. 2) Ban: Adjustment spine or joints.

22. BaShen (Counter traction): Joints traction. Cervical traction. Lumbar traction.

23. Ban: Adjustment

24. Ⅰ Local Anatomy 1.The Structure of Shoulder (1)Bones: Clavicl Humerus Scapula Coracoid process Acromion Glenohumeral joint Coracoid process

25. (2) Ligaments: ① Coracoacromial ligament. ② Coracoclavicular ligament. ③ Glenohumeral ligament. ④ Coracohumeral ligament. (3) Articular capsule

26. (4) Bursa: Sub-acromial bursa and Sub-deltoid bursa

27. Deep: Supraspinatus, Infraspinatus, Teres minor and Subscapularis, those are called Rotator cuff. (5) Muscles

28. Superficial: Pectoral major, Biceps, Deltoid, Triceps, Trapezius. Posterior musclesAnterior muscles Biceps Pectoral major

29. (6) Tendons: Supraspinatus Tendon, Bicipital Tendon, Subscapularis Tendon

30. (7) Blood Vessels and Brachial plexus Axillary artery Brachial plexus

31. Brachial plexus: The brachial plexus is composed C5, C6, C7, C8 and T1 spinal nerves. Those include a radial nerve, a median nerve, a ulnar nerve. ① The radial nerve: C5-C8,T1 of spinal nerves. ② The Ulnar nerve: C8 and T1 of spinal nerves. ③ The median nerve: C5-C8,T1 of spinal nerves

33. Relationship of Cervical Vertebrae and Nerve Roots Conus medullaris Cervical vertebraesNerve roots Brachial plexus

34. S2 S1 4 5 C 3 4 5 6 7 8 3 4 5 C S2 L1 L2 L3 L4 L5 S1 T1 2 3 12 4 5 6 7 8 9 10 11 C5 C6 C8 C7 C8 C7 C6 S2 L5 L4 L5 L4 L5 L4 3

36. 2. Shoulder Movements Extension:0-60° Adduction: 0-45° Abduction: 0-90° Lateral Rotation:0-90° (External Rotation) Medial Rotation:0-90° (Internal Rotation) Flexion:0-180°

37. Ⅱ Differential Diagnosis and Treatment of Shoulder Pain ① Supraspinatus Tendinitis ② Bicipital Tendinitis ③ Frozen Shoulder ④ Sub-Acromial Bursitis (Sub-deltoid bursitis) ⑤ Arthritis of the Shoulder ⑥ Cervical Spondylosis

38. 1 Supraspinatus Tendinitis Definition: The tendinitis is an inflammation of the tendons of the Supraspinatus tendon. The causes of supraspinatus tendonitis can be chronic impingement and degeneracy of the tendon.

39. Symptoms ① Pain associated with arm movement. ② Pain in the shoulder at night, especially when lying on the affected shoulder. ③ Weakness with raising the arm above the head, or pain with overhead activity.

40. Examination Tests ① Trigger point on the acromion. ② Lateral of Shoulder pain, or the pain radiate to neck or arm. ③ Examination test of shoulder abduction: passive abduction the pain eliminated with shoulder in medial rotation. The other way round, active abduction shoulder in medial rotation posture the pain start 60° to 120° ( pain radian), under 60° and above 120° then the pain disappear.

42. Ossification of Supraspinatus tendon MRIX-ray

43. Tuina Treatment (1)GunRou (Rolling and Kneading) on the Deltoid for 3 minutes. (2)AnRou (Pressing and Kneading) by thumb on the Supraspinatus tendon for 3 minutes. (3)YaoHuang (Rotating): passive rotate shoulder for 2 minutes. (4)Abduction of shoulder by passive associate with Pressing and Kneading for 3 minutes. (5)Dou (Shaking) the arm for 1 minutes. (6)Using heating pad 2-3 per day.

47. Acupuncture treatment Ashi point, IL15, TE14, SI10, SI11, IL4. Retaining needles for 20 minutes.

48. 2 Bicipital Tendinitis Definition: Inflammation of the bicipital tendon which is long head tendon of the biceps. It is often associated with some sort of trauma or overuse, and usually associated with rotator cuff disease.

49. Symptoms ① Aching shoulder ② Shoulder pain when lifting heavy objects ③ Shoulder pain when performing overhead activities ④ Tenderness over bicipital groove.

50. bicipital tendonHumeral bicipital groove

51. Yergason test Neer test Hawkins test Speed test Examination Tests

52. Tuina Treatment ①GunRou: Rolling and Kneading. ②An: Finger pressing. ③Na: Grasping. ④Dou: Shaking. ⑤Yao: Rotating. ⑥ Using heating pad 2-3 per day.

53. Acupuncture Ashi point, IL15, SI10, TE14, LU2, LU3.

54. 3 Frozen Shoulder Definition: causes limitation of motion in the shoulder joint, that also called adhesive capsulitis. In Chinese medicine, is called Bi Zheng of wind cold, also called “fifty shoulder”.

55. Etiology of Frozen Shoulder Age and gender Endocrine (hormones) disorders Shoulder trauma or surgery Other systemic conditions

56. Symptoms Pain in the should. Most commonly affects patients between the ages of 40 to 60 years old, and it is twice as common in women than in men. Beginning the shoulder pain, and worse in the night. Later pain less but shoulder movement has been limited.

58. Tuina Treatment GunRou: Rolling and Kneading. NaRou: Grasping and Kneading. Flexion and external rotation of the shoulder associated with pressing and kneading. Rotating. Shaking. Using heating pad 2-3 per day.

62. Acupuncture Ashi point, IL15, SI10, TE14, LU2, IL4.

63. 4 Sub-acromial Bursitis (Sub-deltoid bursitis) Definition: Inflammation of the bursa which is located in the sub-acromial or sub-deltoid. It is most often caused by some sort of trauma or overuse of the shoulder.

64. Symptoms Pain and weakness when the arm is lifted up sideways through a 60 degree arc. Pain point at acromion or deltoid. Active arm movement is often restricted in abduction only.

65. Subacromial Bursa Bursa of the Coracobrachialis bursa deltoid Supraspinatus

66. X-ray with contrast medium

67. Tuina Treatment GunRou: Rolling and Kneading. Finger pressing. Mo: Rubbing. Passive lifted up arm with Finger pressing and kneading. Rotating. Shaking. Using heating pad 2-3 per day.

68. Acupuncture Ashi point, IL15, TE14, SI10, SI11, IL4. Retaining needles for 20 minutes.

69. 5 Shoulder Arthritis Definition: Osteoarthritis is characterized by progressive wearing away of the cartilage of the glenohumeral joint. Also called wear and tear arthritis or degenerative joint disease.

70. Diagnosis Age: It usually affects people over 50 years of age. Physical examination of the arthritic shoulder usually demonstrates limited motion in all directions with pain. Crepitus (the crunching sensation inside a joint) is frequently found in shoulder arthritis. X-ray demonstrates evaluation of the arthritic shoulder.

71. glenohumeral joint

72. Tuina Treatment GunRou: Rolling and Kneading. NaRou: Grasping and Kneading. Flexion and external rotation of the shoulder associated with pressing and kneading. Rotating. Shaking. Using heating pad 2-3 per day.

73. Acupuncture Ashi point, IL15, TE14, SI10, SI11, IL4. Retaining needles for 20 minutes.

74. 6 Cervical Spondylosis Definition: that is due to deterioration related wear and tear on the cervical vertebrae (bones) and cartilage or disc of the neck. That affects the brachial plexus lead to nerves pain also.

75. Symptoms Cervical spondylosis typically affects only the neck, causing pain and stiffness. When nerve compression also is present, signs and symptoms of cervical spondylosis may include: A stiff, painful neck Shoulder, arm or chest pain Tingling and pinprick sensations in the arms, hands. Numbness and weakness in the arms, hands.

76. Pathogenesis 1)Intervertebral disc herniation: ① Injury; ② degenerative changes. 2) Degeneration of cervical vertebrae: ① Osteophytosis of the vertebral bodies. ② Hypertrophy of the facets and laminal arches. 3) ligamentous and segmental instability.

81. Radiation of cervical nerves

85. Physical Examination 1) Cervical movement: Flexion 35-45°; Extension 35-45°; Lateral bending 45°; Rotation 60-80°. 2) Tension arm test. 3) Percussion head test. 4) Spurling test. 5) Jackson test. 6) Compression shoulder test. 7) Traction test.

86. Tension arm test

87. Percuss head test

88. Jackson test

89. Compression shoulder test

90. Traction test

91. Imaging A spine or neck x-ray shows abnormalities that indicate cervical spondylosis. A CT scan or spine MRI confirms the diagnosis. A myelogram (x-ray or CT scan after injection of dye into the spinal column) may be recommended to clearly identify the extent of injury. An EMG may also be recommended.

96. Treatment by TCM 1)TuiNa: RouGun (rolling and kneading), NaRou (Grasping and kneading), An (pressing), Ban (adjustment). 2)Acupuncture: GB20 ( 风池 ) ， GB21 ( 肩井 ) ， DU14 ( 大 椎 ) ， SI11 ( 天宗 ) ， LI12 ( 曲池 ) ， TE 14 ( 外关 ) ， LI 4 ( 合 谷 ) ， DU20 ( 百会 ) ， DU ( 上星 ). 3)Chinese herbs: ① Wind Bi: FangFengTongShenWan,DuHuoJiShengWan. ② Blood stagnation: FuFangDanShengWan. ③ ShenYang deficiency: ShenQiWan, BuYangHuanWuWan, TanWangBuXinWan. 4) Traction.

102. Ⅲ Cautions or Contraindication Acute injury. Fracture. Tear ligament. Ulcer. Eczema. Hemophilia.

103. Thank you Phone ： 630-916-0781 E-mail: drchen@eastwesthealingcenter.net drchen@eastwesthealingcenter.net Web ： www.eastwesthealingcenter.net www.eastwesthealingcenter.net