Treating wrist pain successfully can be challenging. Whether the biomedical diagnosis is carpal tunnel syndrome, repetitive strain disorder, trauma, reflex sympathetic dystrophy, osteoarthritis, or another cause of this common complaint, many acupuncturists have found their typical treatments do not always achieve the expected results.

For this reason, for wrist pain (as for any other type of orthopedic complaint), it is important to have a storehouse of other treatment approaches. One approach I would recommend for wrist pain in particular is the use of French barrier points as part of a treatment protocol.

As qi travels through the meridians, it invariably passes through joints as well. For example, the qi of the lung meridian passes through the wrist, elbow and shoulder. While there is normally a free flow of energy through the joints, either articular or meridian dysfunction may result in a particular joint becoming a point of blockage for the flow of qi. When this occurs, pain results, and acupuncture may be used to clear the blockage.

According to the French approach to acupuncture, particular points (many of whom have the word "guan," meaning gate or barrier, in their name) for each joint effectively clear this blockage of qi, which in this system is divided by the categories of yin qi or yang qi and by whether the qi flows distally or proximally.

These points are termed barrier points. Effective treatment depends on the their use to free the qi obstruction. Each joint, therefore, has four barrier points (or xi-cleft points used in a barrier point's absence) that may be selected according to dysfunction in the categories discussed above and their relationship to the French method of applying eight parameters diagnosis to such qi obstruction.

It should be clear from the above paragraph that this is a complex treatment system that requires a different orientation than most acupuncturists have regarding the meridian system and the diagnosis of qi obstruction in the joints. Indeed, it is too complex to summarize in a short article. Readers interested in learning more about this diagnostic system are encouraged to consult Guillaume and Chieu's Rheumatology in Chinese Medicine (Eastland, 1996) or videos produced by medical acupuncture publishers.

In clinical practice, however, it is not necessary to fully understand this system in order to put it to practical and effective use. In other words, for most acupuncturists the usefulness of the barrier point system will be in suggesting a series of points they have not considered in their previous treatments that might prove effective in relieving pain and decreasing joint dysfunction.

Since theory and clinical practice do not always coincide, and since acupuncture points that require needling are typically sore or provide some indication of "sickness," I would propose instead that acupuncturists simply palpate all barrier points for any given joint and, by palpation, determine whether they are appropriate to use in treatment. For the wrist, the barrier points are: large intestine 9; lung 6; small intestine 6; and pericardium 4. With the exception of large intestine 9, all of these points are xi-cleft points and as such would make theoretical sense in most acupuncture treatments if diagnosis indicated involvement of their particular meridian.

I would suggest the following treatment protocol for wrist pain and dysfunction not responding to other types of acupuncture treatment.

1. Identify the cause of the pain or dysfunction both in terms of TCM and orthopedic-neurological examination to determine whether acupuncture is appropriate or whether a referral is indicated.

2. If acupuncture is indicated, palpate the wrist barrier points and check for sensitivity and whether or not the points are on the channel(s) corresponding to the dysfunction. If one or more points are sensitive, then they are indicated and should be needled to obtain de qi.

3. Palpate the four contralateral barrier points on the channels traversing the ankle according to the midday-midnight theory discussed in my last column. These points are: stomach 37; urinary bladder 63; liver 6; and spleen 8. If one or more of these barrier points are sensitive and, in particular, reduce the discomfort at the wrist, needle to obtain de qi whether or not the points are on a channel corresponding to the one associated with the wrist discomfort. Since there is a powerful contralateral wrist-ankle relationship in the body, sensitive barrier points on the ankle can be particularly effective for the wrist.

4. Use local wrist points and other modalities such as electrical stimulation, massage or diathermy according to your particular treatment style or preferences.

5. If the patient consents, mark the barrier points needled so that they may be gently massaged between acupuncture treatments.

Fifteen to 20 minutes should be sufficient for needle retention. If this approach will be effective, the patient should notice some improvement after treatment. While this is a useful form of treatment, it is not necessarily complete within itself. For example, if there are underlying excesses and deficiencies in the meridian or zang-fu system, or if major trigger points are responsible for the pain, they must be treated as well for the patient to experience long-term relief.