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Integrating Chinese Medicine with Physical Therapy
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Integrating Chinese Medicine with Physical Therapy

Instructor:  Kenneth Luke, L.Ac.


Introduction         

          In seeking new patients, TCM practitioners have historically looked to generate referrals from health practitioners of other specialties.  Chiropractors and massage therapists have been the popular place to turn when trying to build these relationships but haven’t necessarily been very successful.  Some specialties in Western medicine such as obstetrics and gynecology are recognizing the benefits TCM can provide to their patients, and many L.Ac.'s have been able to develop successful referral relationships with fertility doctors.  Unfortunately, orthopedic physicians and physical therapists tend to be quite skeptical of alternative treatments, ironic because patient interest in using TCM for rehabilitation is quite high, as many of us can attest in our practices.  If we can prove our treaments potentiate, not take away from, the physical therapy treatments, successful referral relationships can be accomplished.

         Historically, doctors have stayed within the Western medical arena when referring their patients out for rehabilitative treatment to physical therapists, orthopedists, physical medicine practitioners, and the like.  It is the patients who have become increasingly frustrated with poor results that have demanded alternatives, helping to garner the acceptance of acupuncture as an effective and low-cost form of rehabilitative therapy.  Insurance companies are catching on;  many have expanded the services available to their patients to include acupuncture, in an effort to retain patient loyalty and increase revenue.  This translates into an advantageous opportunity for acupuncturists if the acupuncturists can demonstrate to the Western medical team that they are necessary and knowledgable players in an integrated healthcare team.

 

        


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What is Physical Therapy?

          The American Physical Therapy Association (APTA) defines physical therapy as “clinical applications in the restoration, maintenance, and promotion of optimal physical function”(1).  In plainer terms, physical therapists diagnose and treat individuals with health related conditions that limit their abilities to move or perform functional activities as well as they would like in their daily lives (2).  Their patients are of all ages and include congenital disabilities, brain injuries, cardiac episodes, spine injuries and orthopedic injuries of all types. Although the focus of this course is on orthopedic physical therapy, many physical therapists specialize in pediatrics, cardio/pulmonary, and neurological conditions and work in a variety of settings including inpatient, outpatient, nursing homes, hospitals, and rehabilitation facilities.

     Over the years, as specialty fields in Western medicine continue to evolve and insurance companies have gained more power to steer healthcare, physical therapists’ roles have become more and more limited.  Not only are they expected to produce results in decreasing numbers of patient visits, they are also limited to only practicing “evidence based practice”.  This means the techniques they use must have shown statistically measurable, positive outcomes in the past, and produce measurable progress in current cases.  Failure to follow this model can result in denials from the insurance companies paying for their services.  This is not to imply that physical therapists don’t provide excellent care to their patients.  On the contrary, they are able to do amazing things with the limitations placed upon how they can apply their craft.

 

 


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Physical Therapy and Chinese Medicine - The Connection

          Basic Western physical therapy rehabilitation protocol consists or four phases.  Each phase roughly corresponds to physiological processes that must occur in order to complete the healing process. The phases are somewhat defined by time but mostly by goals within each phase.  Depending on the nature of the condition being treated, these times and goals can vary widely.  For instance, the treatment goals and timeframe for a 20 year old, healthy, active, college student who tripped over their roommate’s backpack and sustained a knee injury may be very different than those of a 70 year old, overweight, retired accountant who experienced a cardio-vascular attack.  Their lifestyles and motivations as well as their ability to rehabilitate and their eventual goals will have a significant effect on their healing processes and physical therapy treatment plans.  Depending of the situation, a physical therapist will vary the length of each phase and often overlap the different phases in order to optimize the patients recovery and maintain their motivation.

          Within the parameters of this protocol are many opportunities for acupuncturists to become involved in the patient’s treatment.  Ideally, this would be done with the physical therapist and acupuncturist in direct contact and working together for the best outcomes for the patient.  In situations where a working relationship has not yet been established with the physical therapist, it is still important for the acupuncturist to be able to plan treatments that coordinate with what the patient is doing in their physical therapy sessions.  This will not only produce better results for the patient, but help to demonstrate the effectiveness of TCM treatment to the physical therapist during the rehabilitation process.

          In order to offer acupuncture and other TCM therapies that complement the physical therapy treatments, you need to understand the following:

The four phases of a basic physical therapy protocol

The goals of each phase of rehabilitation

• Methods of treatment, modalities and techniques used within each phase to achieve the goals

• Criteria for progression

• TCM Strategies to enhance each phase of the physical therapy treatments

 

 


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The Four Phases of Physical Therapy

Phase I - Acute

          Phase I is also known as the acute phase.  This is the period that begins immediately following the injury.  It can also be the period immediately following surgery.  A patient who sustains an injury that later requires surgery may have two separate acute phases in their rehabilitation process. During the acute phase the inflammatory process is in full gear.  This is the time when vascular reaction and exudate work to protect the traumatized tissues and begin the repair.  The patient will exhibit redness, swelling, pain, and increased local temperature.  As the inflammatory process progresses to the proliferative phase of the healing process, fibroblasts begin laying down the matrix of collagen (scar tissue).  Although pain may still be present, the redness and heat of the inflammatory process should be reduced and the swelling less evident.  The treatment goals of Phase I are to protect the area from further injury or infection, reduce pain, and control swelling in order to allow the healing processes to occur.  Strategies for accomplishing these goals include immobilization, if indicated, and RICE (rest, ice, compression, elevation).  This allows clotting to occur and the proliferative phase of healing to begin while reducing adjacent tissue damage that is caused by excessive swelling and tissue temperature.

          Unfortunately, this is the phase where patients tend to receive little or no care.  There are many reasons for this.  Often patients won’t go to the doctor right away when they sustain an injury.  They will wait until it is “not getting any better” before seeking medical care.  Those who do decide to call the doctor have to navigate the process of scheduling an appointment which may not be available for weeks or months.  If it happens at all, they then might have to wait for approval from an insurance company in order to continue trying to schedule an appointment with the physical therapist or, in some cases, the orthopedic surgeon so that they can refer the patient for physical therapy.  Even post-surgery, outpatient surgery centers dress the area and send the patient home with equipment and instructions to which they may or may not adhere properly or diligently.  Whatever the reason, a poorly managed acute phase creates longer, more complicated subsequent phases.

 

 


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Phase I - Integrating Chinese Medicine

          If the area is not properly immobilized or protected, the inflammatory process can be extended which retards the healing process. Excess and prolonged local swelling increases pain, decreases function, and extends the amount of time that tissues are hypoxic causing greater collateral damage. The longer inflammatory phase creates more metabolic waste and debris in the injured area as well as increased adhesions and larger, more disorganized fibroblastic activity.  An exuberance of fibroblastic proliferation can result in hypertrophic or keloid scar formations.

          Patients may not seek treatment from their acupuncturist during this phase either, for the same reasons described previously.  If they do, however, it is important to apply the same treatment goals as the physical therapist.  Wrap or splint the injured area to protect against further injury and to allow clotting to occur and scar tissue formation to begin with minimal disruption.  Do not take the attitude often heard in the Chinese medicine community that ”immobilization causes stagnation!”  To an extent this is true, but for the first 72 hours to one week, local stagnation is the goal.  Treatment can still be done to move qi and blood systemically and control swelling when the injured area is immobilized, and treatment should also be done to control tissue temperature.  Local hypoxia as a result of swelling and excess heat created by the inflammatory process can damage the surrounding cells.  The basic treatment principle would be to clear heat and toxin or drain fire.  Don’t be afraid to cool the area with herbs, liniments, poultices, or ice. 

          Finally, in this phase, treat to reduce the patient’s pain.  Given that "pain is a reflection of the shen," it is vital to calm the shen.  Some points used to calm the shen and heart include HT 3 (Shaohai), HT 7 (Shenmen), PC-6 (Neiguan), GB 20 (Fengchi), Du 20 (Baihui) and the extra point Shishencong (3).  For herbal prescriptions, see Appendix 1.

          Not to be confused with the four phases of rehabilitation, the wound healing process consists of four phases as well:  Hemostasis, Inflammatory, Proliferative, and Remodeling.  Each of the phases follow a relatively predictable timeline and consist of a complex series of events that run concurrent to the rehabilitation process, the majority of which occur within the acute phase.  For your review, the four phases of wound healing are listed below:

 

   
   
   
   
 Hemostasis

Hemostasis begins with vasoconstriction at the moment of injury.  Platelet aggregation promotes thrombocyte coagulation which work together to dam the wound and staunch bleeding.  Cytokines and histamine are relased which will trigger the start of the next phase of wound healing and stimulate vasodilation

 Inflammatory   

The inflammatory phase begins within the first few hours of the insult and lasts 2-5 days.  As with the rehabilitation process, there is some overlap in the phases and the inflammatory phase is started before hemostasis is complete.  Vasodilation is triggered during phase I which allows exudate to flood the area with leukocytes including neutrophils and macrophages, which will perform phagocytosis to rid the area of bacteria and debris.  The macrophages also release a multitude of growth factors which will progress the healing to phase III.

 Proliferative

The proliferative phase begins approximately day 3 and is in full swing by day 7.  In this phase, fibroblasts that have been summoned to the area by the macrophages in the previous phase initiate the process of granulation.  The bed of remedial, type III collagen is formed across the wound and angiogenesis occurs to provide blood supply to the new tissue.  Contraction of the wound edges pulls the uninjured tissues closer together in an effort to reduce the defect allowing epithelialization of the repaired tissue to begin.  The proliferative phase is an ongoing process that can last up to 3 or 4 weeks

 Remodeling

The final phase of the healing process is the remodeling phase.  This phase can last up to 2 years before it is complete.  In this phase the collagen in the original scar tissue is exchanged for new, type I collagen.  This continuous degradation of the original scar tissue and replacement with new collagen organizes the direction of the fibers in regards to the direction of stress on the tissue to increase its tensile strength and decrease the size of the scar tissue patch.

 


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Phase II - Movement Retraining

          Phase II of the rehabilitation process is to restore range of motion, proprioception and balance.  This doesn’t mean to return to full activity, but to restore basic functions to the injured areas.  The wounds are mostly healed, the pain is minimal or absent during normal, non-stressful motion, and braces and splinting devices have been removed. This is the phase where physical therapists perform the most treatment in the current medical model.  Goals of Phase II are to restore range of motion, proprioception, and neurological response including muscle contraction and relaxation.  Physiologically the fibroblastic activity is continuing to mature the scar tissue and there may be some residual swelling and pain from the end stages of Phase I.  Progression from Phase I to II can be aggressive as long as the practitioner is careful to protect against over-stressing any tissues that are undergoing repair.  This is especially true when there is more than one practitioner involved in treatment.  Too much treatment without allowing adequate time for the tissues to recover from the challenges placed upon them during the rehabilitation process can recreate an acute phase or delay the completion of Phase I. 

Communication and a good understanding of what other practitioners are doing will help to avoid overtreating.  Ideally the acupuncturist will have a relationship with the physical therapist where they each understand what the other does and are able to discuss how each of their strengths can be best utilized to achieve the goals of treatment without over stressing the patient’s condition.  If this isn’t the situation, then one of the practitioners at least needs to be able to understand what the other is doing and adjust their own treatments appropriately.  Hopefully by completing this course, we are moving more towards the former scenario.

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Phase II:  Physical Therapy Techniques

          In Phase II, physical therapists will be choosing from many different modalities and techniques to accomplish their goals.  Range of motion is addressed with manual techniques like passive and facilitated stretching (as shown in the photo). 

          Facilitated stretching is an active, assisted stretching technique based on the principles of proprioceptive neuromuscular facilitation, or PNF (4).  The patient and the practitioner work together utilizing a combination of stretching and muscle contraction in order to trigger the reflexive responses of the proprioceptors within the target muscle and tendon in order to increase range of motion.

 

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Physical Therapy Techniques

          Other modalities used to address restricted range of motion used in physical therapy are Continuous Passive Motion machines, wall pulleys, and even pilates equipment.  Ultrasound, an electrical modality that utilizes sound waves to warm tissues, is a popular treatment.  Ultrasound can be compared to moxibustion, as both treatments produce a localized heating of tissues (see photo).

 

 

 

 

 

 

 

 

 

 

 

 

 


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Phyiscal Therapy Techniques Continued

          If range of motion is restricted as a result of muscular or soft tissue dysfunction, the stretching techniques and electrical modalities listed on the previous pages are often used.  In addition, myofascial release techniques including instrument assisted soft-tissue mobilization like the Graston technique or SASTM method, active release therapy, spray and stretch, trigger point release and massage therapy are used.

          The Graston Technique (see photos) and SASTM Method are licensed techniques that utilize patented instruments to reduce adhesions and improve function and are worth highlighting because of their similarity to gua sha. There are different sizes and shapes of tools to conform to every body part.  The practitioner scrapes the tools across the skin with a lubricant similar to the way a TCM practitioner administers gua sha.  The instruments are designed to provide “feedback” to the practitioner as to the condition of the tissues as the treatment is being administered.  The result is decreased pain and adhesions, increased range of motion and function, and decreased swelling.  Like gua sha, the patient can experience local bruising or redness as a byproduct of treatment.

    

 

 


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Physical Therapy Techniques Continued - Joint Restriction

         If the source of restricted range of motion obstruction is in the joint, physical therapists use joint mobilization techniques like manual joint mobilization or electric modalities such as lasers, electric stimulation, and ultrasound to reduce adhesions and swelling. 

       The most common form of e-stim a physical therapist will use is in the form of a TENS unit, as shown to the left.

 

 

 

 

 

 

 

 

 

 

 

 


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Physical Therapy Techniques, Continued

          Proprioception issues are typically addressed through simple exercises such as balancing with various progressions of difficulty, sorting, or hand-eye coordination drills.  There are also machines and video game type computer programs that address these skills.  Some examples are shown below.

bosu

 

 

 



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Physical Therapy Techniques, Neurological Deficits

          Neurological deficits can also be treated with proprioception challenge therapies listed on the previous page, but can be more specifically treated with the technique proprioceptive neuromuscular facilitation (PNF).   Mobilization techniques like nerve flossing are also used, which works to free the nerves from adhesions. 

          Biofeedback and electrical stimulation is also used with movement to help re-educate and facilitate nerve transmissions during exercise and postural stress. Where the goal is to restore muscle function, isometric contractions can be prescribed in conjunction with the biofeedback or electrical stimulation.

 

 


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Phase II - Integrating Chinese Medicine

          With a good awareness of what the physical therapist is doing with the patient in order to avoid over-treatment, the acupuncturist can be an effective addition to the Phase II treatment plan.  Because there is usually some overlap and/or lack of treatment in Phase I, residual swelling, scar tissue formation/organization, and pain often still need to be addressed.  With limited number of patient visits, physical therapists often spend their treatment time working with the goals of Phase II rather than completing the final stages of Phase I. 

          Besides treatment for overall well-being and support though the rehabilitation process, a patient visiting an acupuncturist during their Phase II physical therapy appointments can be treated for the resultant qi and blood stasis which will help to soften the adhesions of the scar formation, as evidenced by the remarkable photo above.  Acupuncture also works well to stimulate nerve transmission and rebalancing the musculo-skeletal system in general.  Scalp acupuncture, motorpoint acupuncture and balance method treatments all address these types of treatment goals without repeating the treatment methods of the physical therapists.  By staying informed about the treatments the patient is receiving during their physical therapy appointments, the acupuncturist can importantly avoid using methods similar to the physical therapist before sufficient recovery has occurred and avoid overstressing the tissues. 

For example, if a patient received a Graston technique treatment the day before their acupuncture treatment, gua sha treatment would be contraindicated.  Or if the physical therapist performed strong electrical stimulation to facilitate contraction of the vastus medialis, motor point treatment to the same muscle would be best avoided for 2-3 days.  In both cases other treatment such as moxa, distal acupuncture or tui na could be indicated.  Always be aware of what the physical therapist’s treatment goals and methods are in order to provide the most effective and comprehensive care to the patient.

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Phase III - Strengthening

          In Phase III the patient begins the strengthening phase.  At this point the scar formations are complete but not completely mature.  The patient has regained full or near full range of motion, relearned how to move properly, and retrained their proprioceptors to provide improved balance and stability.  Now the goals of physical therapy are to increase strength in order for the injured tissues to carry out the tasks required of them. 

The muscle tissue needs to be overloaded in order to increase in both size and strength, and the nerves and sensory receptors need to be challenged in order to optimize their response.  As the tissues enter the remodeling phase of the healing process, the reorganization or the scar tissue that aligns the new collagen fibers to provide the necessary elasticity and strength also depends on the proper stressors being systematically introduced.  The physical therapist accomplishes this with a series of progressive resistive exercises. Depending on the area involved and type of dysfunction, there will be a specific protocol that the patient will follow.  In some cases the early exercises will seem very remedial, however this is to make certain that the subsequent exercises are done in a biomechanically correct manner.  For example, if a patient is instructed to do a sit-up, they will probably be able to do one, although they might be doing it incorrectly.  Without first performing the prescribed remedial exercise that strengthens the lower aspect of the rectus abdominus, the action will predominantly be completed utilizing the upper aspect of the rectus abdominus.  This makes the lumbar spine unstable and vulnerable to injury.  Or, with a shoulder rehabilitation program, the patient will be instructed to do simple rotation exercises with only 2-3 pounds of weight.  This might seem very easy to them.  However, if they progress to heavier weights before specifically strengthening the muscles of the rotator cuff with the light weight exercises, the larger muscles of the shoulder like the deltoid and the pectoralis major will overpower the rotator cuff’s ability to stabilize the humeral head during movement.

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Phase lll - Home Exercise Program

          Often this phase involves very little patient-therapist contact and patients are often left to follow the prescribed exercise program on their own.  It’s different for conditions such as CVA, MI, or brain or spinal cord injury where rehabilitation is much more long term and the outcome expectations are constantly changing.  And in the case of an orthopedic injury, limitations in visits affect the amount of time the physical therapist can spend with a patient doing therapeutic exercise.  Insurance company reimbursement policies have created a situation where patients in phase III of rehabilitation will typically receive a list of exercises with instructions for frequency and progression after a quick lesson from the physical therapist and an expectation that they will complete this part of their rehabilitation on their own.  Some do well with this method while others either don’t keep up with their “homework” or don’t have enough experience with the exercises and do them incorrectly.  Both cases result in incomplete rehabilitation and possible complications including reinjury, incomplete healing, or a new condition caused by the deficit left by the original injury.  Below is an example of a real home exercise sheet, courtesy of Rob Brandon, MPT.

home exercise routine

 

 

 


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Phase III:  Integrating Chinese Medicine

          An acupuncturist working with a patient in Phase III of their rehabilitation may become the only practitioner with whom the patient is having regular contact.

          Continuing with regularly scheduled appointments places the acupuncturist in a position to monitor any difficulties or discomfort the patient may be experiencing as a result of the home exercise program.  Regular acupuncture visits also serve to survey the patient's overall condition.  Familiarity with the exercises and/or a good relationship with the physical therapist will allow the acupuncturist to confirm the patient's understanding of their exercise program and to raise any concerns or precautions you may have detected.  As the current practitioner, the acupuncturist is in the position to recommend that the patient return to their physical therapist or post-op appointment at an earlier date than was scheduled, call the physical therapist for clarification on their exercises, or to consult with the physical therapist on behalf of the patient.  Patients will sometimes become less proactive in contacting their physical therapist at this point in the rehabilitation process once they feel they have progressed enough to be sent home with their exercises rather than having to go to an appointment.  This is especially true if their insurance has denied further appointments.

 

 


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Phase III Continued

          TCM treatment in Phase III continues to follow the philosophy of treatment for the previous phases with the practitioner utilizing TCM methods and personal experience and expertise to achieve the goals of rehabilitation.  The act of strengthening muscles may produce pain and stiffness,  therefore treatment should be performed to help the patient recover from their exercises as well as to help to execute the exercises successfully.  The maturation of the scar formation involves reorganization of the collagen fibers and breaking down of adhesions.  Many TCM techniques effectively aid this process including tui na, acupuncture, moxa, gua sha, and herbal compresses.  Constitutionally this is the phase where underlying deficiencies become apparent as the relative excess of trauma recedes.  The body has quickly worked to control, repair and rebuild damaged tissue and, emotionally, the patient has been through the ups and downs of sustaining a trauma, temporary restructuring of how they approach their day to day life, and motivating themselves to rehabilitate.  Treatment to address these imbalances and supplement the patient will not only help them successfully achieve their goals for Phase III, but also prepare them for Phase IV.

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Phase IV - Return to Activity

          Phase IV is functional rehabilitation.  This is when patients are conditioned to return to the necessary activities of their daily lives.  Again, this phase is widely varied based on the condition being treated and the patient’s lifestyle.  Functional rehabilitation for a person who sustained a spinal cord injury in a motor vehicle accident that resulted in quadriplegia is going to be very different from a college soccer player who is recovering from a non-surgical ankle injury.  In either case, the goals of Phase IV have to be specific, appropriate, and realistic.  The specific goal of hopping on one foot while changing direction on an uneven surface would be an unrealistic and inappropriate goal for the spinal cord patient.  The specific goal of holding a pencil would be an inappropriate goal for the soccer player, as holding a pencil (even if he could no longer do so) is not a necessary skill for returning to competitive soccer.

 

 


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Phase IV - Integrating Chinese Medicine

         Certain patients would most likely have very involved care during Phase IV, like an athlete in the form of coaches and certified athletic trainers, and the quadriplegia patient with occupational therapists and physical therapists.  However, the average patient who is expected to recover fully and return to their everyday lives and jobs is often left to continue this phase of rehabilitation on their own.  Administration of Phase IV is similar to the take home model of Phase III only less specific.  The patient will usually be discharged from treatment with their final instructions for continuing their exercise program and precautions with the expectation that just doing those life- or work-specific tasks will provide the necessary functional rehabilitation for them to complete their recovery.  In most cases this turns out to be sufficient, especially if the previous phases were successful. 

For the acupuncturist in this process it’s important to remember that this phase may still need to be completed upon discharge from physical therapy.  Monitoring the patients return to activity and addressing any difficulties that present as they gradually increase their work load and activity level is the main strategy for most patients.  If they complain of difficulty performing tasks that they could easily complete pre-injury, remind them that there is still specific strengthening and retraining that has to occur relative to that particular task.  Provide support and encouragement while keeping the patient from returning to their pre-injury activities too aggressively.  Also continue to administer treatment to support their recovery process and to deter any new aggravation or injury from their Phase IV activities.  In the cases where the patient is continuing to receive regular physical therapy treatments during Phase IV, the treatment strategies for the acupuncturist remain to support the goals of physical therapy and support the patient’s recovery.

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Conclusion

          By understanding and being able to work with the standard protocol that is followed by physical therapists, acupuncturists can easily establish their importance in the injury rehabilitation process.  Knowing the goals of the four phases of rehabilitation allows the acupuncturist to work together with the physical therapist and to supplement a patient’s treatment with the many skills and modalities available to the TCM practitioner.  Administering early management of the inflammatory process during the acute phase, reducing swelling and improving function in the second phase, building strength in the third phase, and supporting the patient as they return to normal activities of their lives in the fourth phase are all things that acupuncturists do for their patients everyday.  The ability to show how TCM treatments accomplish these goals within the physical therapy model of rehabilitation will provide countless opportunities to increase referrals from Western medical providers, advocate for the benefits of TCM, and provide the best care for patients recovering from injuries.

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References

1.  www.APTA.org
2.  “Physical Therapists”. US Department of Labor.
3.  Sun, P. ed.. 2002. The Treatment of Pain with Chinese Herbs and Acupuncture. London: Churchill Livingstone.
4.  McAtee, R. and Charland, J.  2007. Facilitated Stretching, 3rd ed. Champaign, IL: Human Kinetics.
5.  www.grastontechnique.com
6.  www.sastm.com
7.  White, A. 2011. Acupuncture for Keloid Scar. Acupuncture in Medicine 29 (1).
8.  Courtesy of Robert Brandon, MPT. 2011.

 

 


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Appendix I: Common Prescriptions for Traumatology

Qi-li Powder
Remove blood stasis, stop pain and bleeding

Sanguis Draconis, 30g
Flos Carthami Tinctorii, 4.5g
Gummi Olibanum, 4.5g
Myrrha, 4.5g
Secretio Moschus, .36g
Borneol, .36g
Acacia seu Uncaria, 7.5g
Cinnabaris, 3.6g

Grind ingredients into a fine powder.  Take .2g orally 1-2 times a day.
In addition, mix powdered ingredients with egg white, red wine or vegetable oil and use paste topically as a poultice 2 times a day for 30 minutes or overnight.

Trauma Linament
Cinnamomum Camphora, 10g
Gardenia Jasminoides Fruit, 5g
Aconiti Kusnezofii, 25g
Aconitii Carmichaeli, 25g
Arisaema Consanguineum, 25g
Pinellia Ternata, 25g
Pollen Typhae, 25g
Fructus Chaenomelis, 200g
Rhizoma Rhei, 150g
Notopterygium Incisum, 200g
Acanthopanax Graciliistylus, 200g
Angelica Pubescens, 200g
Paeoniae Rubrae, 150g

Soak all ingredients in a sealed jar filled with wine for a minimum of 15 days.  Apply to injured area as a massage medium or via a gauze pad soaked in liquid and secured over the injured area 2-3 times a day.

 

 


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