Treating TMJ pain with Acupuncture and Eastern Medicine

by | May 16, 2022 | Acupuncture

What is TMJ Pain?

TMJ pain can be anywhere from distracting to debilitating.

TMJ stands for temporomandibular joints, referring to the anatomical structures that connect the jawbone to the skull. TMD is the term for temporomandibular joint disorders. According to the National Institute of Dental and Cranifascial Research “the prevalence of temporomandibular joint and muscle disorder (TMJD) is between 5% and 12%.” and while “there is no standard definition for TMJD; it is measured by asking about various types and durations of muscle, joint, and facial pain, difficulty with chewing, joint sounds, etc.”

Causes

The jaw area is a particularly complex meeting of several systems. In addition to this small but crucial joint there are myofascial connections from the scalp, neck, and shoulder all which attach nearby. There is the auditory tube and associated need for fluid passage deep behind these joints and muscles.

Therefore, there may be overlap with ear and sinus fluid congestion, issues with the joint itself, and the surrounding myofascia. Because of the close quarters of all of these different structures there can be several causes which perpetuate each other. Perhaps an initial trauma causes a dislocation, which lead to inflamation and tension. Or stress lead to unconscious clenching of the jaw causing trigger points and some degree of structural changes, etc.

TMD is generally classified by various causes including inflammation, structural changes, muscle tension, jaw dislocation, or degenerative conditions.

Eastern Medicine Perspective

The Eastern medicine perspective utilizes the above causes as additional data points in arriving at a pattern diagnosis. Individual diagnosis and treatment always takes the entire state of health into account.

An acupuncturist also asks other questions to determine best treatment: Are there other areas of inflammation in the body? Is there is tension in the neck, back, scalp, or shoulders? If there is a dislocation was it caused by external trauma or perhaps degeneration or laxity of the structures? If there are trigger points, adhesions, or other patterns of tension what is the underlying cause?

Stress can be a huge trigger in generating tension around the jaw and face, what are the factors contribute to holding stress in the body?

Is there fluid or heat stagnation in the area or in other parts of the body? Is pathological cold or wind a factor? Are there headaches, sinus issues, ear or throat congestion?

All of these together can help determine the best course of treatment.

Treatment with Acupuncture and Facial Gua Sha

In my practice I have found that directly addressing the areas of myofascial tension is tremendously helpful for the majority of TMJ pain. I release knots and areas of tension in and around the jaw, head, and neck using acupuncture. I use facial gua sha to coax residual tension out of the face and jaw and encourage circulation of blood and lymph. The acupuncture treatment in total addresses underlying imbalances while bringing about stress relief.

Self Care Strategies

Facial gua sha tools are easy to come by and use at home. The best tools for the face are the round edge semi-precious stone tools such as jade or quartz. Using a gently gliding motion, move from the chin along the jawline up to the area surrounding the ear. Use pressure as needed to give a massage to areas of tension.

If jaw clenching at night is an issue I receommend practicing letting your jaw go slack, literally having your mouth hang open, particularly before bed, and consciously letting all of those muscles relax. Taking several deep breaths with the jaw slack signals to the body what a relaxed jaw feels like before you fall asleep and help reset that pattern.

Work on any underlying condition whether it is inflammation, chronic stress, posture issues, or healing from an injury with the appropriate healthcare practitioner.

Sources

https://www.nidcr.nih.gov/research/data-statistics/facial-pain/prevalence

https://www.acupuncturetoday.com/mpacms/at/article.php?id=32862

Dry Needling is Acupuncture

by | Sep 16, 2019 | Acupuncture

There is a common misconception that dry needling is fundamentally different from acupuncture, that while dry needling treats pain, acupuncture works on supposedly imaginary acupuncture points and meridians.1 The reality is that dry needling is acupuncture, but not all acupuncture is dry needling.

The term dry needling originally came from the use of empty (“dry”) syringes to stimulate trigger points for pain relief. This technique was developed by Janet Travell MD, who distinguished it from “wet” needling which used substances such as lidocaine injected into the trigger points.

Depending on state laws, dry needling can now be practiced by medical doctors, chiropractors, nurse practitioners, and physical therapists using the same filiform needles that acupuncturists use.

Dry needling essentially developed in parallel with the rise of acupuncture and Chinese medicine in the United States over the past 50 years or so, crossing over with the use of the filiform acupuncture needle.

Although dry needling is a new term, it overlaps exactly with the traditional acupuncture technique of treating ashi points.

The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) Dry Needling Position Statement states, “Dry needling is a recently coined name for an acupuncture technique that involves the insertion of acupuncture needles directly into muscles and trigger points for the relief of musculoskeletal pain. Licensed acupuncturists have practiced and documented this acupuncture technique, now referred to as ‘dry needling’, for decades in the US.” 2

Acupuncture Approaches

Acupuncture is part of a system of Chinese and Eastern medicine used for thousands of years. But it is not an untouched fossil, this medicine is always evolving, just as Western medicine continues to grow based on clinical evidence and new research.

As a modality of medicine, acupuncture treats all manner of disorder and disease of the body, including musculoskeletal pain and dysfunction. Acupuncture tools are very simple: the filiform needle, but the methodology and application are very diverse.

Acupuncture may be applied according to any number of treatment theories, including: distal points on an affected channel, empirical points for a particular affliction, microsystems on the ear, scalp, hand, or foot, mirroring on the opposite side of the body, or opposite-analogous on the opposite but related joint. Acupuncture may also be applied directly to an affected area, focusing on a point of tension or soreness, called an ashi point.

Needling ashi points is a part of every acupuncturist’s training and scope of practice. Some acupuncturists get additional post-graduate training to specialize in orthopedic or sports acupuncture.

Trigger Points

Ashi points are found through palpation and are indistinguishable in function from trigger points. There is evidence that trigger points, as mapped out by Janet Travell MD in her book Myofascial Pain and Dysfunction: The Trigger Point Manual, have a high correspondence rate with traditional acupuncture points.3

Acupuncturists are trained to find traditional acupuncture points by way of physical anatomical landmarks, and all experienced acupuncturists know that the active point is ultimately found though palpation of the body.

Stimulating a tender and active point, (aka ashi point, aka trigger point) with a filiform needle to provide pain relief is a part of acupuncture theory, training, and practice.

Translation of Terms, Scope of Practice

There are efforts being made in several states to include the term dry needling in the acupuncture scope of practice, to protect this aspect of our medicine that is being taken out of context.

When the state scope of practice for acupuncturists is written with terms such as “ashi points” or “stimulation of qi” it is very difficult from outside the acupuncture profession to really qualify what type of medicine we are practicing.

As acupuncture moves more mainstream and its benefits become more widely accepted, there is a need for translation of language and concepts from Chinese medicine to Western medicine. This translation of language and concepts also has to be very conscientious to not lose the essence of what makes Chinese medicine so uniquely effective.

Acupuncture Training and Safety

One way to think about dry needling is that there are two kinds of acupuncturists practicing: licensed acupuncturists in the US who have completed at least 2000 hours of acupuncture-specific training, didactic material and supervised clinical training, as well as biomedical training; and practitioners of dry needling, who may be physical therapists, chiropractors, or medical doctors, but only complete up to 300 hours of acupuncture training, and in some states much less. 4

“As ‘dry needling’ is acupuncture, it presents the same inherent risks including but not limited to perforation of the lungs and other internal organs, nerve damage, and infection. Recent reports of serious and potentially life-threatening injuries associated with ‘dry needling’ include pneumothoraces and spinal cord injury. These and other injuries support the statement that ‘dry needling’ presents a substantial threat to public safety when performed without adequate education, training, and independent competency examination. Adequate training and competency testing are essential to public safety.“4

Dry Needling Billing Code

Currently the acupuncture CPT (Current Procedural Terminology) codes are based in units of 15 minutes. Acupuncture CPT codes did not used to be time-based, and since sometimes needles are not retained, particularly in ashi point treatment or trigger point treatment, there was a recent proposal of a Trigger Point Acupuncture code to the CPT committee, which is run by the American Medical Association. The proposal coincided with the submission by the physical therapists and chiropractors of a code for “Dry Needling” and so has been in discussion by the CPT committee.

The American Society of Acupuncturists (ASA) Report from the American Medical Association CPT Code Committee meeting 5  is worth reading in full, but the “Outcomes” and “Points to Take Home” sections are important so I am posting them here:

Outcomes

After much deliberation, the AMA Committee concluded the following:
1. Codes describing the procedure of needling with no needle retention are to be created.
2. The placement for these codes will be under the code set for trigger point injections. (This resides in the medical-surgical section of the code set, and not under either acupuncture nor physical medicine and rehabilitation.)
3. Accepted addition of codes 205X1, 205X2 to describe needle insertion(s) without injection(s). Codes will become active January 1, 2020
With these codes, representative vignettes were agreed upon. These vignettes make it absolutely clear that the intent of these codes is to describe a procedure with no needle retention and no auxiliary electric stimulation. These will become available upon the publication of the full code set, presumably just prior to 2020.

Points to take home

  • There is no “dry needling code”. There is now a code for “needle insertion(s) withoutinjection(s)”. This procedure is deemed identical to both Trigger Point Acupuncture and Dry Needling. The two are equated.
  • If there is needle retention or e-stim used, only the acupuncture codes are appropriate.
  • Every code in the code set can be used by any practitioner with that code’s procedure inscope. If a profession does not have a procedure in scope, it cannot use a code because of scope issues. Licensed Acupuncturists all by definition may use the new codes. Thereis no expansion of practice act language needed to protect scope.
  • If a profession does not have invasive needling in scope, it cannot use this code.
  • This is a non-time-based code usable by practitioners with often cursory training. Its valuation is the next step in the process, but it should not be as highly valued as the acupuncture codes.

 

References

About Acupuncture

by | May 1, 2019 | Acupuncture

Eastern medicine is a term to describe systems of medicine that developed over thousands of years throughout China, Japan, Korea, and Southeast Asia. Eastern medicine uses non-invasive yet effective diagnostic and treatment methods.

Eastern medicine treatment can include acupuncture, acupressure, massage, cupping, moxibustion, nutrition, exercises, and herbal medicine. While having a connection to an ancient lineage, Eastern medicine continues to evolve with high standards for education, research, and integrative care.

Acupuncture uses small needles, gently inserted into specific, responsive points to help regulate body functions. Acupuncture treats many health conditions without causing adverse side effects or interference with medications, and can bring a state of deep relaxation. Acupuncture is safe for people of all ages.

Pain

Cancer Treatment Support

Digestion

  • Bloating and cramping with eating
  • Acid reflux
  • Constipation
  • Diarrhea and loose stools
  • Nausea and vomiting

Energy Levels and Sleep

  • Insomnia
  • Sleep disorders
  • Fatigue and low energy

Emotional and Mental Distress

Seasonal Illness

  • Seasonal allergies
  • Colds
  • Influenza
  • Seasonal mood disorders

Women’s Health

  • Menstrual irregularities
  • Painful periods and PMS
  • Pregnancy support
  • Morning sickness and nausea
  • Perimenopausal support
  • Hot flashes and sweating

Neurological

  • Dizziness and vertigo
  • Tinnitus
  • Parasthesia and neuropathy
  • Bell’s palsy
  • Temperature disregulation

Acupuncture Tools

by | Apr 1, 2019 | Eastern Medicine

Balancing the Body Without Needles

Chinese medicine is most well known for acupuncture, using very thin, flexible needles inserted at specific points on the body to heal from any number of diseases and health issues. What is not as well known is that acupuncture can also be performed without inserting needles.

There are ancient methods including non-inserting needles in the Japanese tradition, moxibustion, and acupressure massage, and modern methods such as lasers, vibrational tuning forks, point injection therapy, and essential oils.

Ancient Methods

One of the oldest books of acupuncture called the Ling Shu describes nine different types of needles, only one or two of which were actually meant to pierce the skin. When the Ling Shu and other classical Chinese medicine texts made their way to Japan the medicine adapted in that particular culture.

Whereas acupuncture in China has focused on the filiform (insertive) needle, acupuncture in Japan has mastered the non-insertive needles in the many schools of traditional Japanese medicine, such as Shonishin, and Toyohari.

Teishin

There are many dimensions to the methodology and practice of traditional Japanese acupuncture, but I want to just to touch on a personal favorite tool of mine, the teishin.

A teishin is an elegant non-inserting tools made from copper, silver or gold. It is meant to gently stimulate acupuncture points, relieve muscle tension and knots, and to help balance the whole body. Gold and copper can be more tonifying, silver more sedating, but often it depends the method used that determines the result.

Teishin can be used very gently on points, brushed along channels, and even as a diagnostic tool for the practitioner to “read” the state of the given points or channels.

Minimal Intervention

Any practical medicine should be a good balance of science and an art. There is a science and methodology of acupuncture, it has its own complex system of anatomy, physiology, pathology, diagnosis, and treatment.

The art of practicing the medicine is connecting with the patient through listening, empathy, and touch. I am in continual awe of the human body, and its ability to respond to minimal intervention in the form of gentle stimulation of the acupuncture points.

 

Working as an Acupuncturist in Hospice

by | Feb 23, 2019 | Hospice Acupuncture

Available Now

Hospice and Home Health Acupuncture

Online Continuing Education Trainings for Acupuncturists

6 NCCAOM PDAs including Safety and Ethics

Gain clarity and confidence for working with patients at the end of life and home visits. Whether you work in hospice or simply want to have tools to provide comfort care for loved ones, patients, and their families.

In the Hospice and Home Health Acupuncture training you will learn:

  • Practical skills for safely treating medically fragile patients, which may require a different approach than treating patients in a clinical setting.
  • Strategies to connect compassionately with patients at the end of life.
  • Ways to navigate home healthcare, including travel, general safety, and interactions with family and other caregivers.
  • About the role of acupuncture in hospice care, both as a unique medical service and integrating within the hospice system and hospice team.
  • About the stages of dying from the Eastern and Western perspective.
GET THE TRAINING

Hospice work is a calling. To care for people with a terminal diagnosis and less than six months to live requires a different approach to medicine and healing. Whether we are a nurse, doctor, social worker or acupuncturist, we want to help the patient feel comfortable, whole, and human.

I worked for several years as an acupuncturist in hospice. I visited patients in their homes or care facilities, using acupuncture and gentle touch to help with symptom management. I collaborated with hospice administration to craft policies and procedures, and worked to educate the medical and care team about acupuncture services. Most of this post is based on my personal experience, with the goal of helping other acupuncturists connect with this kind of work.

Every Hospice is Different

Every hospice organization is different. In size, location, philosophy, direction, management, funding, culture, etc.

A hospice may be small and local, part of a large hospital system, or a nationwide company. The hospice may provide extensive training and support for providers, or hardly any.

Some hospices have acupuncturists attend the weekly Interdisciplinary Group (IDG) meetings, and others do not. Pay rate can vary quite a bit. Charting and data collection is different from place to place.

How Acupuncture is Funded in Hospice

Most hospice patients use Medicare* to cover hospice services. This allows patients to receive medical care including nursing, occupational therapy, medications and home medical supplies.

In the meantime, for a hospice to include acupuncture services it may be paid through alternative means such as a grant or special fund from donations. The existence of these grants and funds are due to dedicated efforts from medical directors, grant writers, private donors, and other advocates.

Volunteering

Volunteering is always a great way to gain experience, network, and serve the community.

While it is possible that volunteer positions can lead to, or turn into, paid positions, it is not a guarantee. I once had a mentor caution me against volunteering as an acupuncturist in hospice because it could perpetuate an unpaid track in the system. I have seen this to an extent with massage therapy in hospice and oncology, where there is an established track of massage volunteer positions and a lack of paid ones in some hospice organizations and hospitals. I don’t know if this is causation or correlation but it’s worth noting.

On the other hand, I have heard of at least one case of a volunteer acupuncturist being offered a full-time paid position in hospice. So it can happen if the administration is willing to set aside funding and prioritize acupuncture services.

In the Hospital Handbook Project, acupuncturist Megan Gale suggests volunteering in a hospital (can also apply to hospice) in a non-acupuncturist role. She said that it allows you to become familiar with hospital protocols and culture, while meeting people and helping out, but not giving away your acupuncture services for free on a regular basis.

In either case, it is important to be advocating for reimbursement for our expertise, training, and services, just like any other healthcare provider.

Private Practice

It is possible to have a private practice working with hospice patients. Here are some tips for hospice private practice:

  • Most hospice patients are in their homes or care facilities, you will be going to them rather than them coming to your clinic.
  • Keep in mind that these patients will have to pay out of pocket since Medicare does not cover acupuncture.*
  • It may be possible to bill a patient’s private insurance, but find out if it covers home visits.
  • If there is no insurance coverage, find a price point you feel comfortable with, that will be accessible to patients and also cover your costs.
  • Reach out to cardiologists, oncologists, pulmonologists, and dialysis clinics with information about how acupuncture can help terminally ill patients with symptom management. You can also connect with retirement homes and senior centers and offer services there.
  • Look up “home health bag technique” and tips for home health nursing online so that you can maintain clean technique in the home environment.

A Job in Hospice, Gaining Experience

I worked with two different hospice organizations as a contracter. Even though these positions are not full-time employment, I gained valuable experience in this field including working with patients directly, navigating different hospice organizations, and learning how to advocate and promote acupuncture as a service.

If you can take a contract position, shadow with another acupuncturist, see patients in private practice, or volunteer, it can open doors such as:

  • Meeting other providers in hospice who can become part of your professional network as mentors, colleagues, and references.
  • Building a good reputation in your community as the “hospice acupuncturist” and gaining multiple referral sources.
  • If you are contracting with a hospice organization, advocating for a raise in your contract rate, or for full-time employment.
  • If you are volunteering, advocating for a paid position.
  • Having relevant experience on your resume that can lead to employment at another hospice or hospital.
  • Working in a challenging and rewarding field that opens up opportunities you may not yet know of.

My advice is to take advantages of opportunities to treat patients and learn about the hospice field. At the same time advocating to turn contract, part-time, or underpaid work into full-time, well-paid positions.

Some Things I’ve Done to Work in Hospice

Here is some of what I’ve done over the years to be involved in hospice:

  • Volunteered in hospice providing massage therapy for the nursing staff and patients.
  • Worked in hospice as a nurse assistant.
  • Researched acupuncture in hospice and palliative care while in the masters program at acupuncture school.
  • Asked around constantly if anyone knew anyone who did acupuncture in hospice, and eventually connected with an acupuncturist working in hospice who became my mentor.
  • Joined the Washington State Hospice and Palliative Care Organization (WSHPCO).
  • Cold-called and cold-emailed every hospice I could find in the area, asking if they had acupuncture positions or were interested in learning about the benefits of acupuncture.
  • Connected with the Hospital Handbook Project.
  • Connected with the medical director of a hospice and palliative care organization who was interested in starting an acupuncture pilot program. I helped create policies and procedures for acupuncture, educate the healthcare team about acupuncture, bring another acupuncturist on the team, and find ways to gather outcome data. After 6 months the pilot program was considered successful and the medical director has asked all departments to refer patients to acupuncture.
  • Connected with a local hospice that already had a grant-funded program in place for integrative therapies, but no acupuncturist. They just needed an acupuncturist to help create policies and procedures for acupuncture, particularly for home visits. I work with some excellent people and have learned a lot about hospice.
  • Wrote an article for Acupuncture Today interviewing the founder and director of the NAHPCA. This was a chance to spread the word about this organization and also learn more from someone who has worked in this field for many years.
  • Shadowed with an acupuncturist who has a full time job in hospice to learn more about what she does.
  • Presented about acupuncture in hospice for the WSHPCO, and the Washington Acupuncture and Eastern Medicine Association.

If you feel called to do this work, then start to network, reach out to people and organizations that you think could benefit from acupuncture services. Write grants to start a pilot program. Talk to practitioners that work in the hospice field and ask if they know of any opportunities for mentorship, shadowing, or otherwise getting involved.

 

*As of 2020 acupuncture for low back pain is covered by Medicare. There is momentum toward advocating for acupuncturists to be Medicare providers, but how all of this will play out in general, or in hospice in particular, remains to be seen. More information on Medicare and acupuncture here.