APM Acupuncture in Clinical Practice Classical Approaches for the 21 st Century Mark D. Seem, PhD, LAc
© APM Acupuncture, P.C. and Mark D. Seem July 2012 TSCA students, faculty and alumni are free to scan or otherwise incorporate any parts of this book into any of their clinical devices/resources by simply citing this source. All others must obtain permission directly from the author at:
[email protected].
TABLE OF CONTENTS Dedication
3
Prologue
5
APM Acupuncture Jingluo Charts
9
!
Master Systems Chart
14
!
Regular Meridian/Circuit
!
Chart
20
Four Patterns Chart
37
APM and APM Acupuncture Defined
46
Introduction
52
PART ONE: PROFESSIONAL DIMENSION
54
Chapters: 1. APM Clinical Training
54
2. Human Centerdness
58
3. History of TCM Compromise
60
4. APM Big Picture
64
5. APM Charting
68
6. APM Learning Objectives
70
7. Human Dimension
72
8. APM Needling Techniques
73
9. Classical Chinese Acupuncture
78
PART II: PHILOSOPHICAL FOUNDATIONS 10. Beginning with the Ling Shu 11. Ordinary Skills
79 79 90
12. Yang Tends Toward Excess: Thorns, Stains, Knots, Obstructions
120
13. Acupuncture as Physical Medicine/ the Role of Location
140
14. The Spirit Uprooted
162
15. The Sages of Antiquity
188
16. Self Cultivation East and West
198
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PART III: APM ACUPUNCTURE PRAGMATICS
213
17. APM Case in Point
213
18. Acupuncture Needling and Tacit Knowing
238
CONCLUSION AND BEGINNING
266
a. Key APM Concepts
266
b. APM Clinical Katas
269
c. APM Clinical Readiness
304
APPENDICES 1. Etiology and Pathology in APM
308
2. APM Physical Assessment
318
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DEDICATION--ACUPUNCTURE DEDICATION--A CUPUNCTURE IMAGING IN CHART FORM The unusual prologue below to a new book, by way of revised APM Acupuncture charts, is dedicated to Bruce Park, MS/Ac, a serious and dedicated student of mine and now a graduate of the Tri-State College of Acupuncture. Bruce challenged me to clarify APM Acupuncture in book and chart form and introduced me, and others at the college, who were studying the Ling Shu together, to the Learning of the Mind-and-Heart through the Scroll known as ‘rooted in spirit’. This way of beginning to come to the present has the distinct advantage of putting the conclusion, the outcome first, showing what APM Acupuncture is as it has emerged until now. I did not always receive these challenges well, as I was deeply agitated at times by what I found to be wanting in my own APM Acupuncture teaching in particular, and in acupuncture practice in North American as a whole. I lashed out once in anger at Bruce in class, who had shown me various APM charts and forms of his own design over time, which he felt might be beneficial to all students. I realize now that this was because I did not feel like my own APM chart that figures in the back of Acupuncture Physical Medicine was correct and if I could not pinpoint what was wrong with this picture how could anyone else? I now know that Bruce’s efforts to clarify APM in chart form, and with class notes that he shared generously with other students, was done not out of disrespect for me and my teaching efforts, but out of reverence for what he found to be a style of practice that resonated deeply for him. He displayed that same reverence for deep, embodied learning in the Ling Shu class and it was infectious, and caused me for one to research and then dig deeply into the Neo-Confucian Learning of the Mind-and-Heart which is at the root of such embodied study and practice. The third step in this Neo-Confucian learning, derived from the Confucian classic The Great Learning , is to make the will sincere, to commit to this learning as a search for li , the principle or coherence in all things, which leads to a seriousness and a reverence for what one is studying which keeps one engaged in the Dao of human becoming ( ren ). ). In this way one learns the deep logic or coherence in what one is studying, and learns how to become a more authentic human being at the same time.
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After serious and reverent reflection I realize what Bruce was really challenging me to do was to transform the APM Acupuncture learning at the college to become more. I have come to realize that the only way to do that is to remove myself from the position of a ‘sage on the stage’ as is common to say in academe these days, to become at most a ‘guide on the side’ and mostly a serious student and practitioner myself, abiding in reverence for this amazing practice which has been a way of life for me for three decades. Bruce Park showed me reverence and I did not know how to receive it. That is the most valuable lesson I have ever learned in my AOM career, and perhaps in my life. I shall take that lesson to heart, literally, for the rest of my days. I will gladly consider myself a fellow traveler with Bruce, if he permits, whose serious Buddhist training has allowed him to walk much further along the way, and who will assuredly have much to share with us all about abiding in reverence for this wonderful practice. To Bruce Park, With Love and Gratitude, Mark Seem
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PROLOGUE DECLARATION OF INDEPENDENCE This is July 4 th, 2012. Close to Thanksgiving 2010 my search for the PRC Chinese-language original version of a text prepared by leading academies of Chinese Medicine to serve as a core textbook for the new TCM colleges bore fruit, and it became clear that the Zhongyi Xuegailun o f 1958 was the textbook translated in Hanoi in the 60s, which Dr. Nguyen Van Nghi translated into French in 1971, and which I translated into English (from the 1977 third edition) for the Quebec Institute of Acupuncture in 1979. I found this reference in Felix Mann’s Meridians of Acupuncture first written in the early 60’s, as presented in Mann’s complete work, Handbook of Acupuncture where he clarified that in studying this and other Chinese medicine academy texts during his research in PRC, that were being prepared for the same purpose, he was struck by differences between these PRC texts and the work of George Soulie de Morant whom he had relied heavily upon in his early writings on the meridians, as did most European acupuncturists in those early days. In my new book, APM Acupuncture in Clinical Practice I do my best to correct for errors in Van Nghi’s work, I place this early pre-TCM text in perspective as one that could have been adopted by the new TCM colleges, but was not, and show how the original teachings on ‘merdian acupuncture’ as it was often termed in those days, by Felix Mann, and taken up by Yitian Ni who cites him, who uses his way of differentiating the various meridian systems in terms of and based on the 12 meridians and their circuits, is critical for a clear understanding of Classical Chinese Acupuncture jingluo pattern differentiation and treatment. In writing this book, I am especially interested in correcting for errors which have crept into the training I have overseen at the Tri-State College of Acupuncture for the past 33 years, and which has in turn created confusion and obfuscation about
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meridian acupuncture, as I was fond of calling it for at least 2 decades, in other AOM colleges in the Tri-State region. I am referring specifically to the meridian teachings of Jeffrey Yuen, a former student who never graduated from the Tri-State College of Acupuncture when it was in Stamford, Connecticut twenty years ago, who went on to develop a teaching of allegedly secret Daoist lineage trainings that were, at least twenty years ago when he began this venture, derived from the Van Nghi text I was using when I taught in Stamford, and which I translated into English for the Quebec Institute of Acupuncture to assist non-French speaking students. The errors he inherited from this training in Van Nghi’s approach at the college I founded, based on this teaching as endorsed by the Montreal school, have followed him, as they have me, as he founded a curriculum at the now defunct Swedish Institute of Massage Acupuncture program, which he apparently transferred to the NYC branch of Pacific College of Oriental Medicine where what is referred to as a ‘Classical Chinese Acupuncture’ style overseen by some very senior faculty formerly from the Swedish institute who were trained at our college or other branches of the Montreal school, or who were subsequently taught by these senior faculty, a few of whom have been practicing for three decades. In making these points it is not my interest to criticize anyone. We all have done the best we could using sources in translation that have often gone out of print (the Chinese text, and Van Nghi’s translation of the Vietnamese version of it, and Felix Mann’s texts have all gone out of print). I am doing this because my introduction to Van Nghi’s work starting in 1978 to nonFrench speaking students, faculty and practitioners not only in the Tri-State region, but throughout North America, Canada, England and Holland, where I taught extensively for many years, has served as a foundation for a significant number of AOM practitioners who treat from a ‘meridian acupuncture’ perspective. If this book helps correct for errors they have undoubtedly come across in many cases themselves if they have been at it for more than a decade, or if it helps reignite interest in jingluo practice inspired by the classics which they may, like so many, have abandoned as TCM became the dominant form of acupuncture practice in English-speaking countries I will be very content.
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And in the meantime, this text shall serve as my declaration of independence from French-Vietnamese sources that were academically fascinating but clinically deficient because they were based on translations twice removed (Van Nghi’s Translation of the Vietnamese Trung Y Hoc , itself a translation of the 1958 PRC ZhongYi Xuegailun all of which are now out of print), but more importantly because they failed to clarify that this training was rooted in 1958, and never bore fruit in the new TCM colleges. Van Nghi suffered greatly from the cold shoulder the TCM college world showed to him when he petitioned to be recognized as a pioneer of European acupuncture and TCM. This was denied time and time again as the late Oscar Wexu, President of the Quebec Institute of Acupuncture shared with me then. They doubtless knew full well that his life’s work consisted merely in translating books from Hanoi, which were translations of books from China that the TCM academic world passed over in favor of ones that portrayed a ZangFu orientation. I have come to believe, and have based the training in Classical Chinese Acupuncture and APM at the college on the premise that acupuncture is a highly personal affair, and requires tacit and tactile understanding that can be called upon in an instant when treating because it has been internalized through deep learning and practice. This way of embodied learning is something that struck me when I trained with 8 th degree Japanese world champion Takahiko Ishikawa in judo in Philadelphia from 1965-1970, where he allowed me to assist in children’s classes. Here was a master of his art, who also had a PhD in religion and was a top ranking GO champion as well and it is only now that I appreciate the extent to which his martial arts training paralleled his training in GO and was also founded on training and study of East Asian religio-philosophy. It is to that ancient and classical Chinese literature and practice that I directed my attention this past year, as I realized that the French, following the Vietnamese and the PRC Chinese, in fact left out major aspects of what makes Classical Chinese Acupuncture and Medicine classical in the first place, and so powerful. These reflections are included for those who are interested in how physical selfcultivation, and spiritual cultivation of the mind-and-heart went hand in hand in the
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several hundred years leading up to the development of Acupuncture and Chinese Medicine as passed on in the early written texts, something the Su Wen bemoans in Scroll one as a lost tradition. The process that I have endured in digging deep into the issues and problems raised during and by this inquiry has been long and hard and has taken a certain toll. It has made me realize that while I was cast as an expert in French meridian acupuncture, too young and too early in my career, what that was was not clear then, or now. Furthermore, it has made me realize that the best I can offer is to keep looking for the li (principle, coherence) underneath jingluo acupuncture, which is still my passion. This task will be much less daunting now that several of us at the college and especially those on the APM Team will be studying with Andrew Nugent-Head, MSOM, who has spent 25 years in PRC learning Classical Chinese Medicine from the Yin Style Ba Gua tradition, which is founded on physical (Daoyin, martial arts) and mental (Daoism, Confucianism) approaches to self-cultivation, with a dedication to cultivating ones medical arts as a lifelong learning process. In the process of doing the research and reflection that lead to this book, I realized what is not included in Travell, perhaps because she struggled so vigorously to free physical medicine, as she was coming to see it, from its moorings in psychosomatic medicine and plant it squarely on the side of the soma, was the interplay nonetheless between ‘the psyche and the body process’ as Dr. Flanders Dunbar from Columbia University called it in her groundbreaking Emotions and Bodily Changes . APM Acupuncture corrects for this lack. This rigid demarcation of a somatic territory where myofascial pain and dysfunction would play out free from emotional turmoil, trauma and stress is as lopsided as the over-emphasis on the side of the psyche Travell fought against, where patients with chronic pain would be seen to suffer from a psychosomatic disorder best treated in psychotherapy.
)
It is my experience in the vast majority of cases of chronic pain that I treat, where the patients are also being treated by other physical medicine practitioners (orthopedists, neuroloigists, osteopaths, physical and occupational therapists and massage therapists) that the side of the psyche is being totally overlooked in favor of a narrow physical medical perspective. There is no reason why any acupuncturist woud make this mistake, if they adhere to the classical Chinese acupuncture teachings that the main cause of internal dysfunction and disease are the 7 emotions when they become inhibited or expressed excessively. Unfortunately, too many North American TCM practitioners ignore the side of the psyche as well, framing the patient’s problem from a much more materialist perspective that is dominant in PRC that is aligned with modern scientific medicine and so looks askance, in fact, at classical theory and practice, paying it lip service only in this regard. And unfortunately, too many North American TCM practitioners, especially if they ractice herbal medicine, see their terrain as ‘internal medicine’ and look down on any physical medicine approach to acupuncture and Chinese medicine as tantamount to tuina which they disdain or consider a lowly step-child of TCM. It is a frequent occurrence for APM practitioners trained at the Tri-State College of Acupuncture to see patients for chronic pain and dysfunction who were treated by TCM practitiners to no avail, who clearly had no phsyiocal medicine perspective or skills. APM practitioners, on the other hand, who ignore or even disdain getting involved on the side of the psyche without a network of some mindbody and bodymind practitioners are selling their patients short on the benefits they couod derive from a more comprehensive approach. And so after 25 years of developing an approach to acupuncture as physical medicine, which it was and always should have remained as Andrew Nugent-Head shows in his powerfuil ‘tangible Qi’ video and teachings, and knowing that the physical medicine training at the college is probably the strongest in North America and will only get that much more powerful and clinically effective under his ifluence and training, I am ready to return full force to the bodymind energetic approach I
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laid out in Bodymind Energetics in 1987, to bring back acupuncture as a powerful psychosomatic therapy that, by dint of being a physical medicine, can gain deep access to the inner reaches of the Mind-and-Heart and prod the bodymind to actualize its potential by restoring the equilibrium before the feelings are aroused as Confucius advocated. Acupuncture Physical Medicine (APM), as I have forged it over the past 20 years under the influence of Dr. Janet Travell and her amazing work, is now solidly grounded at the college and the APM faculty is strong, and in many cases quite young and so this training will survive well withioutn the need for me to watch over it. It is the foundational training at the college, built upon a Classical Chinese Acupuncture foundation in Year One that serves to support training in KM and TCM styes as well, and so I will stay a part of this training, but know whatever my involvement, I leave it in very capable hands. My work for the last phase of my life will be to develop APM Acupuncture, with the Learning of the Mind-and-Heart as central, from the same bodymind position I occupied in 1987, but with a little more know-how hopefully. I happily leave the “sage on the stage” position where I was thrust and latched on too early and too fast, to become a student again, now, and forever. I feel as if I am now re-entering the territory I confronted in my initial days in the South Bronx with sufficient experience and skills and life behind me to engage the bodymind fully with APM Acupuncture. This return will necessitate study with other bodymind and mindbody practitioners and students courageous enough to experiment and explore new ways, in North America for those who live here, of doing acupuncture as an alternative and compliment not only to physical medicine, but to the entire field of psychology and psychotherapy originally referred to as psychosomatic medicine, and now stress or mind-body medicine. Feeling this lack, psychology has spawned two new ‘fields’, somatic psychology and positive psychology which could be a good thing, or a sign of panic or decay. APM Acupuncture has the philosophical sophistication to add much to these new fields, if we have the stomach for new movements. In the meantime, APM Acupuncture and Neo-Confucian Learning of the Mind-and-Heart, which combine almost effortlessly, can serve as a powerful parallel practice for keeping the
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body(mind) and its capacity for life affirmation and self-actualization in the center of the therapeutic process. What has endured for me is the same passion I felt when I first encountered this strange practice from a foreign land which I was learning in the South Bronx with people very far removed from this exotic space. It was their passion, and ability to connect in a direct bodily-felt way when experiencing the changes from the needling that helped me free myself from overly intellectual and medicalized French approaches, and at the same time steer clear of anything that attempted to divorce this practice from the Earth where it is solidly rooted. Paraphrasing Confucius, if I were asked how to reach the deep level where the mind-and-heart obtain, I would say behold, it is all around: it is impossible to treat any patient without the mind-and-heart of practitioner and patient being engaged, and the calmer and more focused the xin , the mind-and-heart, the deeper and more relaxed the breathing and heartbeat, the more firmy rooted the body on the Earth, the more powerful this work can be. And that is something worth dedicating the rest of ones life to.
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APM Acupuncture JingLuo System Treatment & Charts Philosophical Prologue: 1. Thorns, Stains, Knots & Obstructions-Tough Love The LingShu ends Scroll One stating that it is said that acupuncture cannot treat chronic conditions, leading one to realize the bulk of Scroll One is about treating the “source or root’ instead. Once this has been achieved, the Ling Shu addresses how to address the more surface structure, the Small Body as Neo-Confucians would term it, which is comprised of signs and symptoms that can be detected with ones eyes, ears, and touch, and which reveal complex contortions of the bodymind which appear like banners waving in the wind to announce their presence (one of the primary meanings of biao ) as painful ‘thorns’, which need to be pulled out, ‘stains’ which need to be flushed with blood and fluids to course freely, ‘knots’, which need to be untied to ease constriction in the channels and collaterals so as to connect freely with the interior, and ‘obstruction’ which must be broken through to allow free-flow.
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While one can affect immediate change in the deep structure with a few distal needles stimulated properly and the inner being/becoming, this will not clear away chronic or complex structures which require more specific, often local attention and physical release. One cannot affect a person’s surface structure, small body, physical nature without attention at the surface were these stubborn holding patterns take hold. Such work, while less critical, takes longer than the ‘deep’ treatment, and take great skill: in this realm of relieving chronic, complex patient complaints, the more tools, and the better skills one possesses, the better for the patient and her pain and suffering.
As a former YMCA camp director and father of two now adult children, I know what ‘tough love’ is required in handling situations requiring immediate action— pulling out hundreds of thorns from running hands down a rough wooden railing to see how it feels or pulling off a Bandaid that has gotten stuck to a wound that needs the dressing changed; scrubbing dirt and gravel out of a bad scrape; untying chewing gum from the hair; breaking through a sailboat lead line that had suddenly tightened on a leg and cut through the skin to the bone as it broke free of the dock. Such situations need action without hesitation, a firm but compassionate hand that says this is going to hurt, and an iron will. The most compassionate and effective action in such cases is swift, no talking, and without hesitation.
2. Authentic Human Becoming -Compassion, Abiding in Reverence, Making the Will Sincere Given that the LingShu ends Scroll One stating that it is said that acupuncture cannot treat chronic conditions, this would lead one to conclude that the rest of Chapter One up until then, on promoting circulation of Qi and Blood by tonfying, dispersing and dredging stasis, on needle techniques to perform these three actions, on the use of source and some other distal points to connect with the Qi, and how to read changes in the patient, are about making immediate changes and handling acute situations. It is known owing to Dr. Catherine Hui’s research at Harvard on fMRI brain scans during acupuncture stimulation that once de qi is obtained at a few distal points on hands and legs, the deepest most primitive regions of the brain, pertaining to homeostasis, especially when the bodymind is suddenly challenged, floods with Blood and Qi from an AOM perspective). If this is
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true, then obtaining Qi, as Scroll One tells us, guarantees that acupuncture will be effective, and the bodymind of the patient will immediately start to shows signs of this auto(yinyang) regulation in the complexion and countenance, breathing, and other vital signs. This is the immediate effect of acupuncture and the bodymind starts to reorient itself, shift more toward balance. The skills of tonifying, dispersing and dredging stasis with needles, in order to achieve this auto-regulation, is the primary effect of acupuncture, and all acupuncturists mist possess these Ordinary Skills and achieve these ordinary changes. If the problem is new, or minor, then it may resolve with just a few distal needles thus stimulated in a heart-beat. This treatment is achieved quite quickly, is quite basic and yet affects the DEEP STRUCTURE of the bodymind, what Neo-Confucians refer to as the Big Body , man’s human nature which connects with and is infused by the Heavenly principle and the coherence of human becoming, at one with the coherence in Nature, in the cosmos. It is ironically quick and relatively straight-forward to touch this deep structure of the mind-and-heart with needling. At this deepest human level, needling is quite routine and relatively easy, yet one must treat, we are reminded over and over, with a ‘calm heart and mind’ which refers back to ancient religio-philosophical approaches to Learning of the Heart and Mind which I shall explore in this book. It is here that discussion and practical instructions for how to attend to ones feelings and emotions when agitated or aroused is presented, and seen as a lifelong practice as this ‘physical nature’ of human beings, the ‘small body’, which connects humans to all other animals under heaven, is full of powerful vital forces and one must be able to remain focused and calm like ‘holding a tiger by the tail over a great abyss’ when this animal energy is stirred. To work on this level of high Skills, it is not enough to be a skillful acupuncturist. One must also be engaged in daily cultivation of self on the physical and spiritual/moral levels, and ideally the patient too has seriously committed to such self-cultivation. And even here, Neo-Confucians stress, it is not a question of ‘soft talking, slow walking, silent sitting’ as many Chan Buddhists maintained, but rather of being capable of acting without hesitation as the situation dictates, with passion and the full force of ones feelings and emotions engaged appropriately (Cf. Tu Wei-ming’s discussion in his Humanity and Self- Cultivation of Yen Yuan’s approach to learning what is useful and can be out into action, pp. 198-202).
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3. Heaven, Earth and Humanity: Three Levels of Intervention: Regular Meridians, Secondary Vessels, Extraordinary Vessels /Three Circuits/ Three Zones/ Three Heaters Faced with a person’s manifestations (biao-as-symptoms of pain, discomfort, distress, complaint, condition and reason for seeking our care) or what we see, hear, feel, sense from our system(biao-as-signs) a classicaly informed acupuncturist will navigate the channels in jingluo pattern differentiation starting with the regular meridian(s), their pairings and circuits to detect where in the jingluo system things are obstructed and have gone awry to locate where we will begin to palpate as assessment, and then where we will treat, and then differentiate/locate the thorns, stains, knots and obstructions in the regular meridians, the secondary vessels and/or the extraordinary vessels: As an example, if a person comes complaining of tightness in the chest, some difficulty breathing and slight panic that something serious might have been amiss, but who was reassured by the cardiologist-internist who treats his mild asthma with inhalers only as needed that this is not a serious internal medical condition and who said the patient could most certainly do massage and acupuncture for this, our task in our jingluo pattern process, is to first locate it within: •
The regular taiyin-yangming circuit where the tightness in the chest is found on palpation to be worst at LU 1-2 to SP 20(Taiyin Meeting), and where, when asked to say where the panic and difficulty breathing resides, the patient points to ST 13-15 on both sides of the chest and also says he has a nervous stomach and holds all his stress there;
•
The yangming muscle channel near ST 13-18, when palpation reveals exquisitely tender ashi/trigger points in the pectoralis minor recreating pain in the nipple, and pectoralis major recreating diffuse chest pain from the area of Per 1 to ST 18 to CV 17 brought on by vigorous rowing in a row boat against a strong wind;
•
The yangming zone/Yangming-Taiyin Circuit in a patient exhibiting chronic protective constriction in the yangming zone and pectoral muscles, which she says comes from her readiness to protect the chest which started after a bad accident when she was 22 when a car literally ran over her chest; while she is aware of this, she feels she is unable to break this myofascial guarding
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reaction and that even Rolfing did not help and it is now affecting her lower rectus abdominus and rectus femoris; •
The middle heater aspect of Chongmai, with constraint of the diaphragm and abdomen with symptoms of GERD, IBS and bad acid reflux causing chest and abdominal pain, where the referring acupuncturist suggests it may be a ‘chongmai’ problem .
All of these patients might have similar chest pain and abdominal discomfort, similar symptoms of pain and distress, but can be addressed from an APM Acupuncture approach with four different treatment options depending on which aspect of the Taiyin-Yangming System writ-large is affected: regular meridian-circuit; tendinomuscular meridian; zone; upregulated extraordinary vessel systems of the back, and the front--middle, lower and upper heaters. The APM ACUPUNCTURE JUNGLUO SYSTEM CHART below is meant to capture in one chart form all of these options, with reference to the other APM Treatment Strategy Charts (Regular Meridians/Circuits, pp. 58-76; Four Patterns of Fatigue/Stress/Visceral Agitation, pp. 133-142) which follow behind it, and can be reinforced by reference to Dr. Ni’s clinical manual, Navigating the Channels .
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ONE APM ACUPUNCTURE JINGLUO SYSTEM CHART © APM Acupuncture PC
I. TAIYIN-YANGMING SYSTEM
LEVEL
TAIYIN-YANGMING
YANG MING
YANG MING
CIRCUIT
VENTRAL ZONE LOCAL
VENTRAL ZONE DISTAL
‘BEN’
‘BIAO’
‘BIAO’
LOCAL
LOCAL
DISTAL
N/A
TrPs and Ashi Points in: !
Masseter
!
Platysma
DISTAL
!
SCM
a. 4 Gates-LIV 3/LI 4; jing-well;
!
Subclavius
luo and tender ashi in Tendino-
!
Pectoralis (sternal and
Muscular Meridian Treatment;
WEI OR b. Other distal command
LI 4 and 10 and 11
!
Per 4-5 ashi
!
ST 13 and 30; and ST
clavicular divisions) !
Rectus abdominis
!
Quadriceps
!
Tibialis anterior
!
Extensor digitorum
abdominal
longus
manifestations
points per other styles for integrated approach
!
!
Biceps
!
Brachialis
!
Brachioradialis
!
Index extensor
!
1st dorsal interroseus
!
Other per Travell
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37-39 !
SP 4 (luo) for
LOCAL
N/A
N/A
“Ends” and “Beginnings” of the meridians. Local Lung and Spleen and Large intestine and
YING
Stomach Meridian Points in affected areas for relief of manifestations (patient complaints) such as: !
LU 1/SP 20-taiyin meeting/respiratory distress
!
CV 12, 17, ST 18-19 and ST 13-16, ST Fire, Xu-li
!
ST 13-16-mental agitation, mania, depression
!
LI 20, ST 2-3-nasal congestion
!
SP 1 and CV 12-root and node
DISTAL !
SP 3 and 2/ LU 9 and 10;
!
ST 40 (source luo);
!
ST 40-mania
!
ST 42-43, ST Fire, xu-li )
!
SEE CIRCUIT CHART for more options; and TCM and Five Phase Lung and Spleen and Large Intestine and Stomach point
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combinations
N/A
N/A
SHAOYIN-TAIYANG
TAIYANG
TAIYANG
CIRCUIT
DORSAL ZONE LOCAL
DORSAL ZONE DISTAL
‘BEN’
‘BIAO’
‘BIAO’
LOCAL •
KID 11-27/ST 30-13 chongmai
JING
DISTAL •
SP 4/Per 6 as chongmai- yinweimai
opening points; can add GB 41/TH 5 for infinity treatment OR •
LU 7/KID 6 for renmai-yinqiaomai for “cardiac
alarm”/with SI 3/BL 62 for dumai- yangchiaomai
(See 4 patterns chart for more local and distal options and details at jing level)
II. SHAOYIN-TAIYANG LEVEL
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LOCAL N/A
•
frontalis
•
occipitalis
•
upper, middle, lower
•
Bl 59
•
SI 8.5
•
BL 58.5
trapezius •
DISTAL
WEI
latissimus dorsi horizontal aspect
a. 4 Gates-LIV 3/LI 4; jing-well;
•
levator scapula
luo and tender ashi in Tendino-
•
infraspinatus
Muscular Meridian Treatment;
•
supraspinatus
•
teres major and minor
•
rhomboids
•
paraspinals
b. Other distal command
•
guadratus lumborum
points per other styles for
•
gluteals
integrated approach
•
piriformis
•
hamstrings
•
gastrocnemius
•
arm and leg taiyang
OR
muscle channel Ashi •
SI and Bl muscle channel TrPs per Travell
LOCAL
N/A
N/A
“Ends” and “Beginnings” of the meridians. Local Heart and Kidney and Small Intestine and Bladder Regular Meridian Points in affected areas for
YING
relief of manifestations (patient complaints) such as: •
HT 1-KID 27-shaoyin Meeting
•
BL 23-52/BL 14-43kidney yang/heart protector
•
BL 2 and SI 18 (taiyang meeting) for facial pain and sinuses
•
KID 1 and CV 23-root and node
DISTAL •
KID 3 and 2/ HT 7 and 8;
•
BL 58 (source luo);
•
SEE CIRCUIT CHART
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for more options; and TCM and Five Phase Heart, Small Intestine and Kidney, Bladder point combinations
LOCAL •
N/A
N/A
Du mai and HJJ and Bladder meridian
JING
DISTAL •
SI 3 and BL 62 for dumai-yangchiaomai
(can add Lu 7 and Kid 6 for renmai- yangchiaomai)
(See 4 patterns chart for more local and distal options and details at jing level)
III. JUEYIN-SHAOYANG
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LEVEL
JUEYIN-SHAOYANG
SHAOYANG
SHAOYANG
CIRCUIT
LATERAL ZONE LOCAL
LATERAL ZONE DISTAL
‘BEN’
‘BIAO’
‘BIAO’
LOCAL
•
temporalis
•
upper trapezius
N/A
•
“TI” 10 and TH 3
•
GB 41, 39, 38, 37
•
GB 34
•
TH 1, 3; GB 44, 43
anterior to GB 21 •
latissimus dorsi longitudinal aspect
WEI
DISTAL
•
serratus anterior
a. 4 Gates-LIV 3/LI 4; jing-well;
•
upper and lower
luo and tender ashi in Tendino-
external obliques
Muscular Meridian Treatment; OR
•
iliopsoas
•
tensor fascia latae
•
anterior gluteus minimus
b. Other distal command
•
iliotibial band
points per other styles for
•
vastus lateralis
integrated approach
•
peroneals
•
ring finger extensor
•
other arm and leg shaoyang muscle channel ashi and TrPs per Travell
LOCAL
N/A
N/A
“Ends” and “Beginnings” of the meridians. Local PER and LIV and TH and GB Regular Meridian Points in affected areas for relief of
YING
manifestations (patient complaints) such as: •
LIV 14 and PER 1 jueyin meeting
•
CV 17-constrained Qi in chest
•
CV 10-13-constrained Qi in abdomen
•
CV 2-3-constrtained Qi in pelvis
•
PER 1-2-chest pain, emotional distress
•
TH 22-23 and GB 1-2shaoyang meeting for temple pain, migraines, TMJ-like symptoms
•
CV 18 and LIV 1-root and node
DISTAL
"#
•
LIV 3 and 2/ PER 7 and 8;
•
GB 37 (source luo)
•
SEE CIRCUIT CHART for more options; and TCM and Five Phase Pericardium and Triple Heater and Liver and Gallbladder point combinations
LOCAL
JING
N/A
•
GB 26-28
•
GB 24
N/A
DISTAL •
GB 41 and TH 5 (can add SP 4 and Per 6 for infinity treatment)
(See 4 patterns chart for more local and distal options and details at jing level)
TWO REGULAR MERIDIAN/CIRCUIT PATTERN DIFFERENTIATION CHARTS "$
© APM Acupuncture PC
1. TAIYIN/YANGMING CIRCUIT – Regular Meridian (Jing Mai) Pattern Differentiation© APM Acupuncture PC
Body Area
Hand Taiyin/
Hand
Foot Yangming/
Foot
Lung
Yangming/
Stomach
Taiyin/Spleen
Toothache,
Facial pain,
Root of
swollen
ashen
tongue rigid,
cheeks,
complexion, hot
jaundice
yellow eyes,
face, nose bleed,
dry mouth,
nasal
nosebleed,
congestion,
swollen
cervical neck
throat/thirst
pain, skin rashes
Signs &
Large
Symptoms
Intestine
Face,
Flushing
Head, Neck Throat
Dry throat
Vertigo
around mouth, swollen painful throat, submandibular pain Perspires easily, General
Yawning,
Violent
warm diseases,
Whole body
sweating &
shivering
whole body
heavy
pain from
from cold,
chilled as if
wind-cold
inability to
doused by
warm up
water, frequent stretching and yawning
Cardio-
Shortness of
Respiratory,
No organ S&S
Breast pain,
Chest
breath,
heart pain (ST
irritability
Chest/Upper
irritable
18-15), flank pain
Back
breathing,
(SP 21), front of
"%
cough,
body hot
wheezing, fullness of chest, hugs oneself while shivering,
Gastrointestinal,
Gastric pain
Borborygmus,
Nausea from
No Organ
edema/distention
eating,
S&S
due to cold,
stomach pain,
Abdominal
belching,
discomfort,
passing gas
constant hunger,
and
ascites, area hot
defecating
or cold, pain in
brings great
intestines
relief,
Abdomen
diarrhea with mucous and blood Genito-urinary, Gynecological,
Frequent
No Organ
Yellow urine,
Reproductive,
urination
S&S
pain in lower
Lower Back
Scanty urine
abdomen (ST 2630) Lower abdomen and
channels
Heat in the
Pain along
extremities
palms, pain
Heat, swelling
channel (ST 32-
heavy, medial
along
and pain LI
43), rigidity of
thigh and
channels, esp.
12-15; index
knee, middle toe
knew swollen,
LU 3-10
finger
dysfunction
chilling and
dysfunction
numbness along SP channel of calf, big toe
"&
dysfunction
Mental Signs & Obsessions
Mental
Aversion to
Mental
Symptoms *
that are
confusion,
people and fire,
sluggishness,
future
defective
rapid heart beat,
melancholia,
directed,
elimination of
shuts oneself in
obsessive
feels
ideas,
when frightened,
thoughts of
vulnerable
stubbornness,
prone to mania,
the past, fixed
complacency
singing,
and rigid
in being
disrobing and
ideas,
wrong, rigid
running about,
sleepwalking,
thinking,
depression,
agitated
distressed by
death wishes,
sleep,
cold
mentally
nightmares
overwrought, mentally slow Point Palette
LU 7-luo
LI 2 –dispersal ST 44-43 ashi for
SP 3- source
LU 9 source
LI 4-source
heat/Xu Li
SP 2-
LU 6 – cleft
LI 6-luo for
ST 36, 37, 39-
tonification
LU 5-dispersal
Toothache
lower Sea points
SP 2&3-ying
ST 40-luo
and shu
Lu 3-4 window to
SP 4- luo
sky
ST 25-LI/ST
SP 5-dispersal
Lu 1-2/SP 20-
union
SP 6- three
Taiyin union
ST 18/xu li heart
leg Yin
pain/heart burn,
SP 8-cleft
Stomach Fire
SP 9-Sea SP 10-Blood SP 21-Great Luo
Associated channel points
Local for S&S
Local for S&S
Local for S&S
SP 20/Lu 1-
Ashi for pain
Ashi for pain
Taiyin union
Ashi for pain
Local for S&S Points from
"'
Points from LI,
Ashi for pain
Points from
ST, LU, SP
SP, LU for circuit
LI, ST, SP
channels for
Points from
channels for
circuit
ST, LI, LU for
circuit
circuit
(* Cf. Seem, citing Faubert, Acupuncture Imaging pages 27-28. These charts are derived from Shudo Denmei, with information from Ni, Seem, Faubert.)
Regular Meridian Treatment In the Ling Shu Chapter 9, treatment of the regular meridians is presented thus: 1] If Spleen is deficient, Stomach is excess (carotid pulse four times stronger than radial pulse): tonify Spleen with one needle; disperse ST with 2 needles. If carotid pulse is “restless”, disperse Large Intestine (for circuit). While the actual points are not indicated in this chapter, chapter One stresses needling the source point for yin meridians, and a later chapter suggests needling the ying (spring) and shu (stream) points for disorders of yin of yin. Dispersal points for Yang meridians could be dispersal points themselves, luo points, jing-well points, he-sea points, xi-cleft points for acute disorders, or fire points. So one could tonify Sp 2 or 3, or both, and disperse ST 40 and ST 36 for example, and disperse LI 2 and LI 5. If the reverse is true, with radial pulses stronger than carotid, this is Yin meridian/organ excess: 2] If Spleen is excess (radial four times stronger than carotid): disperse Spleen with one needle (Sp 5 for example); tonify Stomach with 2 needles (ST 38 Fire/Tonification Pt and ST 36). If radial pulse is “restless”, disperse Lung meridian (Lu 10 or Lu 5 for example for the circuit as above). We used to see the late Dr. Ki Min Kim, a master Korean constitutional acupuncture practitioner after whom the Tri-State College of Acupuncture Library is named, do this carotid/radial diagnosis, and root treatment based on this chapter of the classic
"(
text, using the Five Phase “4 needle technique” strategies as the base, followed by careful dispersal of local excess, constrained and stagnant points/pathways.
Regular Meridian Disorders for this Circuit from Dr. Ni Note: Any point on a regular meridian may be used as a local point for signs and symptoms in that area on that meridian. A] Hand Taiyin Lung meridian Exterior syndromes, the cold or flu; allergies with sneezing and itchy eyes and nose; immuno-deficiency/frequent colds, low energy, cold hands and feet, CFIDS, chronic diseases; respiratory disorders with cough, asthma, breathing difficulties; nose and throat disorders, rhinitis, sinusitis, pharyngitis, laryngitis, tonsillitis; edema, enuresis, retention of urine or urinary difficulty; diarrhea, constipation, hemorrhoids; GERD; sinus(ST 2-3), temporal (ST 7-8), Occipital headaches (all treated by LU 7); sighing, mental distress, weeping, grief; Bi syndrome along muscle channel.
B] Hand Yangming Large Intestine meridian: Toothache; Yangming headache; facial paralysis, trigeminal neuralgia and TMJ (ST 5-8); rhinitis, sinusitis (LI 20-ST 2); Nosebleed; sore throat and vocal cord disorders, thyroid disorders; diarrhea, facial edema, sweating/ dry mouth, throat, stool, concentrated urine, dry skin); yang ming febrile disorders; rashes, eczema, boils, psoriasis; abdominal pain, epigastric pain, nausea, vomiting, belching, cough, asthma, chest pain; lassitude, spontaneous sweating, low immunity; Bi syndrome along muscle channel.
C] Foot Yangming Stomach meridian: Excess and deficient digestive disorders with excess hunger or poor appetite, burning sensation or cold sensation in the stomach, and in either case epigastric
")
pain, abdominal fullness, distention, diarrhea constipation; yangming headache, sinusitis, rhinitis, stuffy nose, nose bleeds; sore, swollen throat, gums, toothache; facial paralysis, trigeminal neuralgia, TMJ; yangming febrile syndrome; general lassitude, sallow complexion, spontaneous sweating, palpitations; stomach fire; violent or withdrawn behavior (mania or depression); swollen, painful, cystic breasts; Bi syndrome along channel el; wei syndrome with whole body weakness and atrophy of the muscles.
D] Foot Taiyin Spleen meridian: Deficiency or excess digestive disorders as for stomach; edema, heavy sensation of face, head, whole body; post-prandial fatigue; dampness disorders and s&s; high cholesterol; obesity; atherosclerosis; masses and nodules; Qi & Blood deficiency; Spleen Qi sinking with prolapses, dizziness, vertigo, lightheadedness; constant worry, low spirits, difficulty concentrating, poor memory, depression, palpitations; Bi syndrome along channel; wei syndrome with whole body atrophy and flaccidity, especially of lower body and extremities.
Personality Patterns For a detailed summary of J.R. Worsley’s depiction of the 5 Element personality types, and Dr. Yves Requena’s 8 Temperaments, see my Bodymind Energetics, pages 85-107. While character typing is described in the classic texts, I caution against taking such depictions of complex human beings too literally. With that caution, and with the realization that a person may exhibit characteristics from more then one temperament or type, such information is useful in providing practitioners with another lens through which to view the people who seek their help. One can also juxtapose the emotional (shen) signs and symptoms presented in chart form from chapter 8 of the Ling Shu from last month’s Reflection to further narrow down the specific meridian-organ system or systems involved within a circuit. This applies to the next two circuits as well.
#+
2. SHAOYIN/TAIYANG CIRCUIT – Regular Meridian (Jing Mai) Pattern Differentiation
Body Area
Hand Shaoyin/
Hand Taiyang/
Foot Taiyang/
Foot
Heart
Small Intestine
Bladder
Shaoyin/Kidney
Yellow eyes,
Yellow eyes,
Yellow eyes,
Yellow eyes,
hearing loss,
eyes tearing,
dizziness,
swollen
eye pain as if
blurred vision,
cheeks,
popping out,
jaundice,
submandibular
vertex
flushed face,
swelling, neck
headache,
dark
pain, sore
occipital
comlexion, dry
throat
headache,
tongue, hot
nape of neck
mouth, dry and
pain, nose
sore throat,
bleed
hoarseness,
Alternating
appears as if
No desire to
chills and
about to be
drink
fever,
captured
Signs & Symptoms Face, Head, Neck Throat
General
Dry throat
epilepsy, derangement, Cardio-
Heart pain
Intense
Thoracic back Wheezing,
Respiratory,
posterior
pain
Chest/Upper
shoulder and
coughing up
Back,
arm pain (SI 8-
blood, heart
14) as if
pain, irritability
broken, inability to turn neck (stiffness at SI-14-17)
#*
cough,
Hand
Arm pain
Arm and hand
channels
(heart 3-7),
pain (SI 8-4)
heat in palms
Gastrointestinal,
Hypochondriac
Mid back pain
region pain
Hunger but no desire to eat,
Abdomen
watery diarrhea
Genito-urinary, Gynecological,
Hemorrhoids,
Reproductive,
Lumbar pain,
Lower Back,
gluteal area pain
Foot channels Tight
Lumbar spine
popliteal
pain, inner
fossa, hip
thigh pain, Pain
joint pain and
and cold along
inability to
leg channel
bend, pain in
(Kid 9-11, pain
calves as if
and heat in the
torn, little toe
soles
dysfunction Mental Signs & All shen
Poor mental
Changeable
Anxiety, pain in
Symptoms *
disturbances,
assimilation,
moods, over-
the pit of the
insomnia,
insecurity,
enthusiasm,
stomach,
suspicion,
sadness,
anxiety
#"
jealousy, lack
physical and
of
mental fatigue,
confidence,
antisocial
lassitude
tendencies, laziness
Point Palette
HT 8- fire
SI 2-water
Bl 67-
Kid 3-source
HT 7-source
SI 3-
tonification
Kid 2-fire
HT 7&8-ying
tonfication
BL 65-
Kid 2&3-ying
and shu
SI 4 –source
dispersal
and shu
HT 5-luo
SI 5-wrist
BL 64-source
Kid 4-luo
HT 6-cleft
SI 6-cleft
BL 58-luo
Kid 1-dispersal
HT 3 (Sea)
SI 7-luo
BL 40-Sea
Kid 7-tonify
SI 8 –Sea
Back Shu
Kid 10-Sea
SI 9-14-ashi
Points
Kid 15.5-
HT 1 and 2
adrenals Local for S&S Associated
Ashi for pain
channel points
Local for S&S Local for S&S Ashi for pain
From SI, Kid, Bl for circuit
Ashi for pain Local for S&S Ashi for pain
From HT, BL, Kid for circuit
From Bl, Ht, SI For circuit
From Kid, SI, HT for circuit
Treatment of Regular Meridians In Chapter 9 of Ling Shu: 1] If Kidney is deficient, Bladder is excess (carotid pulse three times stronger than radial pulse): tonify Kidney with one needle (Kid 7 for example); disperse BL with 2 needles (Bl 58 and BL 65 for example). If carotid pulse is “restless”, disperse Small Intestine (SI 1 and SI 6 for example) for the circuit. 2] If Kidney is excess, Bladder is deficient (radial pulse is three times stronger than carotid): disperse Kidney (Kid 1 for example) with one needle; tonify BL with 2
##
needles (Bl 67 and 60 for example). If radial pulse is “restless”, disperse Heart (Ht 9 and 8 for example) for the circuit.
Regular Meridian Disorders for this Circuit from Dr. Ni Note: Any point on a regular meridian may be used as a local point for signs and symptoms on that meridian. A] Hand Shaoyin Heart meridian: Heart and Lung disorders like cardiac pain and palpitations, arrhythmia, shortness of breath, cold extremities, sweating, red, purple or pale complexion; heat syndromes with whole body hot, dry mouth, red face, hot flashes, tongue ulcers, boils; red, painful, swollen eyes; mania, depression, fainting, schizophrenia, anxiety, hysteria, mood swings, laughing or crying without apparent reason, nervousness, restlessness, insomnia, scattered thinking; severe pain or spasm of internal organs, post-traumatic or post-surgical pain, cancer pain; skin rashes, itching, pain; pain along channel (Ht 1-8) and costochondritis/non-cardiac chest and upper back muscle pain.
B] Hand Taiyang Small Intestine meridian: Occipital headache, deafness, earache, tinnitus; red, swollen, painful inner and outer canthi of eyes, blurry vision, excessive tearing, yellow sclera; mouth and tongue sores and ulcers, toothache; swelling and pain of cheeks, lymph glands, parotid glands, TMJ syndrome; cold and flu, allergies; febrile diseases with yellow urine and night sweats; edema, retention of urine, painful and yellow urination; diarrhea, indigestion, stomach pain, abdominal pain and distention, constipation; pain of lower lateral abdomen referring to back and testicles, as with inguinal hernia, epididymitis, urethral stones, ovarian cysts; Bi syndrome, pain along muscle channel (scapula & posterior shoulder from SI 14-9, elbow near SI 8, forearm near SI 7-6, wrist near SI 5-4 and little finger dysfunction.
#$
C] Foot Taiyang Bladder meridian: Cold, flu, allergies; occipital headache; eye disorders with tearing and pain; rhinitis, sinusitis, nose bleed; urogenital, gynecological and male reproductive disorders; disorders of any ZangFu especially when chronic or deficient treated via the BackShu points (combined with Front-Mu points); mania, depression, epilepsy, schizophrenia; emotional disorders of any organ, treated with second line of Bladder meridian; Bi syndrome and pain affecting muscles, tendons, ligaments and joints throughout nape of neck, upper, middle, lower back, sacrum and hips, hamstrings, posterior calves and heels, little toe dysfunction; acute or traumatic in jury to neck, back, lumbar region, spine, lower extremities
D] Foot Shaoyin Kidney meridian: Kidney deficiency with fatigue, low back pain, pain along spinal column, muscular atrophy; deafness, tinnitus, chronic tooth, gum and throat disorders; poor memory, forgetfulness; hair loss; deficient yin and yang signs and symptoms; Kidney and Bladder disorders with edema, facial puffiness, impotence, infertility; treated for chronic disorders of the other ZangFu; channel deficiency and Bi syndrome with pain and weakness of the lower back, hip and knee, spinal column, degenerative disorders of bones and joints; wei syndrome with cold, pain or heat in the soles.
Personality Patterns See discussion under the first circuit above.
#%
3.JUEYIN/SHAOYANG CIRCUIT – Regular Meridian (Jing Mai) Pattern Differentiation
Body Area
Hand Jueyin/
Hand
Foot
Foot Jueyin/
Pericardium
Shaoyang/
Shaoyang/
Liver
Triple Heater
Gallbladder
Yellow eyes,
Hearing loss,
Dull, lusterless
Dull, lusterless
red
retro-
complexion,
complexion,
complexion
auricular pain,
headache,
dry throat
outer canthus
outer canthus
and cheek
pain, bitter
pain, tinnitus,
taste,
swollen sore
submandibular
throat
pain,
Signs & Symptoms Face, Head, Neck Throat
supraclavicuar pain (GB 21) Constant General
Sweating
laughing
Excessive sweating, chills and shivering, repeated sighing
Cardio-
Heart pain,
Posterior
Maxillary pain,
Distention in
Respiratory,
severe
shoulder pain
chest pain,
chest and
Chest/Upper
palpitations,
(TH 15)
breast pain,
hypochondriac
Back,
distention of
hypochondriac
region
chest, axillary
region pain
swelling
(GB 22-24), difficulty moving torso (GB24-Liv 14 stiffness)
Contraction
Posterior
#&
Hand
and pain in
arm, elbow,
channels
elbow and
wrist, hand
forearm (Per
pain (TH 14-
3-6), heat in
3), ring finger
palms
dysfunction
Gastrointestinal,
Distended
Vomiting
sub costal Abdomen
region
Genitorurinary,
Diarrhea with
Gynecological,
undigested
Reproductive,
food, inguinal
Lower Back,
hernia, scanty or dribbling
Foot channels
Hip, lateral
urine, swollen
thigh, knee,
scrotum,
ankle, and foot
“Shan”, pelvic
pain (GB 30-
pain, lower
40), heat in
back pain,
ankles and
inability to
feet, aversion
bend forwards
of foot, 4th toe
or backwards,
dysfunction
Liv 5-6 nodules
Mental Signs & Depression,
Emotional
Bitterness,
Irritability,
Symptoms *
sexual
upset at
lack of control,
anger,
perversion,
family/friend
irritability,
difficulty
aversions,
breakups,
unfaithfulness,
developing
phobias
depression,
lack of
ideas,
suspicion,
courage,
depression,
anxiety, poor
timidity,
lack of energy
elimination of
hypochondria
#'
harmful thoughts
Point Palette
Per 8-fire
TH 3-
GB 41-dai mai
Liv 3-source
Per 7-source
tonification
GB 40-source
Liv 2-
Per 7&8-ying
TH 4-source
GB 38-
fire/dispersal
and shu
TH 5-luo
fire/dispersal
Liv 2&3-ying
Per 6-luo
TH 7-cleft
GB 34-
and shu
Per 4-cleft
TH 10-
Sea/tonification
Liv 5-luo
Per 3-Sea
dispersal
GB 36-cleft
Liv 6-cleft
GB 26-daimai
Liv 8-he-sea/
GB 24-mu
tonification
Local for S&S
Local for S&S
Ashi for pain
Ashi for pain
From Liv, TH,
From GB, Per,
Per 1-2-heart
Associated
and breast
TH 17, 21-23-
pain
ears/tinnitus
Local for S&S
Local for S&S
Ashi for pain
Ashi for pain
channel points From TH, Liv,
From Per, GB, Per for circuit
GB for circuit
Liv for circuit
#(
TH for circuit
Treatment of Regular Meridians In Chapter 9 of the Ling Shu:
1] If Liver is deficient, Gallbladder is excess (carotid pulse twice as strong as radial pulse): tonify Liver with one needle (Liv 3 or Liv 8 for example) disperse GB with 2 needles (GB 38 and GB 34 for example). If the carotid pulse is also “restless”, disperse Triple heater (TH 1 and TH 10 for example) for the circuit. 2] If Liver is excess, Gallbladder is deficient (radial twice as strong as carotid): disperse Liver with one needle (Liv 2 for example); tonify Gallbladder with 2 needles (GB 43 and 40 for example). If radial pulse is “restless”, disperse Pericardium meridian (Per 8 and 9 for example) for the circuit.
Regular Meridian Disorders for this Circuit from Dr. Ni Note: Any point on a regular meridian may be used as a local point for signs and symptoms on that meridian. A] Hand Jueyin Pericardium meridian: Heart and blood vessel disorders with palpitations, cardiac pain, restlessness, high lipid levels; mental and emotional disorders, delirium, fainting, incessant laughter, depression, mania, anxiety; chest and lung disorders with stuffiness and restrictions in the chest, cough, restricted breathing, asthma; stomach disorders, stomach pain, epigastric distention, hiccups, nausea, vomiting, food poisoning; channel disorders with pain and swelling of the armpit, upper arm, elbow, forearm (Per 2-6), hot palms and hand and foot spasms; stiffness of the nape of the neck, chest and hypochondriac regions.
B] Hand Shaoyang Triple Heater meridian: Fluid disorders, edema, puffiness, enuresis, retention of urine, frequent urination; upper heater disorders like chest pain, palpitations, cough; middle heater disorders like epigastric pain, nausea and vomiting; lower heater disorders like lower abdominal distention, fullness, diarrhea, constipation; endocrine and lymphatic disorders like hypo or hyperthyroidism, diabetes, swollen glands; high lipid levels, fibroids, masses, tumors; channel disorders including shaoyang syndrome with chills and fever; channel disorders affecting the sense organs like migraine headache, ear pain, deafness, blocked feeling in ears, tinnitus, cheek and face pain along course of channel including TMJ syndrome and toothache, swollen glands, sore throat, pain in the mandible and around the ears, purely channel Bi syndrome pain with difficulty laterally flexing the neck and pain down medial deltoid, upper arm, elbow and forearm to top of hand, ring finger dysfunction. C] Foot Shaoyang Gallbladder meridian: Gallbladder and Liver disorders with bitter taste in the mouth, belching, nausea, vomiting, poor appetite, abnormal bowel movements, dark lusterless complexion, abnormal bowel movements, hypochondriac pain; Urogenital disorders with swelling and pain and itching of scrotum, external genitalia, inguinal hernia, leucorrhea, difficulty urinating; emotional disorders with depression, deep signing, poor judgment, indecision, mood swings, frequent anger, insomnia; shaoyang channel syndrome with alternating chills and fever; channel disorders affecting the sense organs with temporal headache, eye pain, pain in the cheek, swollen glands, swelling and pain in the neck, mandible, deafnesss, tinnitus; Bi syndrome affecting the lateral side of the body from lateral ribcage to lateral hip, ITB, peroneal distribution of lateral knee, lower legs and lateral ankle and foot with 4th toe dysfunction (GB 22, 29-30, 31, 34, 37-39, 40-44). D] Foot Jueyin Liver meridian: Liver Qi and yang disorders with fullness, distention, pain of hypochondriac region, dizziness, blurred vision, tinnitus, dry mouth with bitter taste, flushed face, jaundice; emotional disorders with depression, mood swings, nervousness, frequent anger,
$+
frustration, plum pit Qi in throat; stomach and spleen disorders with epigastric pain, distention, flatulence, belching, eating disorders, vomiting, diarrhea; lung and heart disorders with stuffiness of chest, cough, shallow breathing, deep sighing, palpitations, dream disturbed sleep; abnormal growth including cysts, nodules, masses; channel disorders with spasms of feet and hands, headache, low back and lumbar pain extending to scrotum, hernia pain, pain and swelling of lateral lower abdomen (dai mai), spasm and tightness of joints and muscles and pain along course of channel.
Personality Patterns See discussion under the first circuit above.
$*
3.FOUR PATTERNS OF FATIGUE/STRESS/VISCERAL AGITATION © APM Acupuncture. PC
$"
Spinal Irritation
Signs &
Point strategies
Symptoms ________________
Du Mai Excess Kidney Yang/Heart
Coaching
______________
_______________
______________
running on empty,
YinYang Regulation
Counsel patient to
type-A, adrenal
start stress
exhaustion (drops-
Jing: SI3/BL 62 for
reduction/relaxation
dead in bed at night)
du and yangwei Mai
response activity for
Protector Dysfunction Water/Fire Imbalance
AOM Lifestyle
overall agitation works and plays hard, lives world
Ying: Kid 2(Fire) and
Take hot bath with
muscularly, reacts to
3(source)/ying and
sleep inducing bath
world somatically
shu;
salts, sleepy time tea
Bl 58 (luo); BL 23
or other soporific
Precipitating factors may be trauma of a
very productive,
(tonify or disperse
while meditating or
physical or
very active at work,
carefully if lower
listening to soothing
emotional nature
sports, socially
back muscles are
music last hour
rigid) on right
before bedtime
(car accident, attack by dog, abuse)
Ever-Ready Bunny
especially, and BL 14-43 on left (Kidney
Stress importance of
Superman,
Yang/Heart Protector
solid sleep to restore
Superwoman,
dysfunction
adrenals
Supermom or Dad Patient Complaint End result—Adrenal collapse and CFS
To above add BL 18,
activities that distress
20/triple heater
muscles per exercise
regulatory; SP 6 and
tolerance level (do
Ht 7 for insomnia;
not exercise at night
Local multifidi if
if suffering from
Neck & back
spine is irritated
insomnia)
pain in stress
from stress
Patient Complaints:
o
Engage in physical
muscles o
Do stretching for
Lowback
Can turn over at end
tight neck, back,
syndrome
and do yintang for
lumbosacral
with adrenal
10 more minutes.
muscles
Wei level shallow
Get pillow-top
exhaustionback goes
$#
out under
oblique needling to
mattress or egg-
stress
most tender points in
crate mattress
o
Fibromyalgia
fibromyalgia or
cover; side lying
o
Insomnia and
highly sensitive or
pillow, or cervical
agitated
reactive patients,
pillow if sleeping
sleep
leave needles only 5
face up
minutes Suggest Release most
hypnotherapy,
symptomatic TrPs
EMDR,
per patient’s de Qi
psychotherapy to
tolerance in stress
deal with behavioral
muscles (traps,
and post-traumatic
paraspinals, gluteals,
issues
piriformis)
$$
Diaphragmatic
Signs &
Constriction/
Symptoms
Point strategies
AOM Lifestyle Coaching
GI Distress/ chong mai middle heater dysfunction
_______________ Constrained Liver Qi Up-regulated SNS overacts on PNS Taiyin/YAngming Circuit dysfunction Liver/Spleen dysfunction Spinal Irritation and up-regulated SNS
_______________
______________
YinYang Regulation Counsel patients that
tight rectus & oblique muscles-
Jing:
“their problem is their Life”
viscerosomatic SP 4(R)/Per 6(L) for tight chest
chong and yinwei
Dr. Shen advice- eat
(pectoralis level with
mai
regularly 3 x day, never late at night,
ST 18-Liv 14) Ying:
Qi)
LI 4/Liv 3 Liv 14 (and GB 22 or Per 1), SP 6
Patient Complaints:
Patient Complaint o
pattern of visceral agitation
o
o
never while working at desk or standing,
Tight SCM (plum pit
may be precipitating factors for this
_______________
IBS, bloating, undigested
ST 36-39 &
food,
ST 25; CV 10, 12, 13;
diarrhea
ST 24-18 on left
and/or
ST 25 (Bil) all where
constipation,
tight and constricted
abdominal
(dispersal, not TrP
pain, gas
needling)
Reflux or GERD
For Xu-Li, add CV 12,
Relief in
ST 14-16(left), ST 18
Crohn’s
(L); ST 44-43 where
Disease or
tender either or both
colitis
sides For heartburn to chest, add CV 18to
%$slowly, quietly Do not indulge in fatty foods or alcohol Check out if they are wheat, lactose, or corn intolerant or have celiac disease Do not drink ice-cold drinks In reflux and GERD, raise back of bed 6” to prevent acid reflux Above all, teach abdominal breathing as AM and PM stress reduction activity
17 and lateral Kid
before arising and
points; or Kid 22 and
falling asleep, while
Per I if left sided
in bed face up with
heartburn
knees bolstered with pillows, or whenever hyperventilating (5 minutes)
$&
Pelvic collapse
Signs &
chong, dai, ren
Symptoms
Point strategies
AOM Lifestyle Coaching
dysfunction Lower heater dysfunction
______________
_______________
______________
Flaccidity in middle
YinYang Regulation
Coach patients to
________________ Spleen Qi Sinking with or without Constrained Liver Qi in Middle heater as possible precipitating factors for this pattern of visceral agitation
heater abdominal
develop core
muscles, tightness
Jing:
and constriction
strengthening routine for middle
below navel,
Chong-Dai Infinity
heater; stretches for
pressure and pain at
Treatment: SP
lumbar region;
Kid 15.5 to Kid 11
4(R)/Per 6(L) for
and ST 26-30, and
chong mai; GB
Yoga or Qi gong for
CV 7-2 (chong mai
41(L)/TH 5 (R) for
lower heater
lower heater
dai mai
strengthening
Ying:
counseling/therapy
branch), tight lower external obliques (dai mai); tight linea alba (ren mai)
for sexual Three leg yin source
dysfunction
points SP 3, Kid 3, Liv 3; Sp 6 and 9; Liv
counsel women with
Patient
9 for constrained
vulvadynea to seek
Complaints:
Liver Qi in lower
PT specializing in
heater;
manual therapy who
o
Prolapsed
specialize in this
organs:
Patient Complaint
postbirthing; uterus,
Local chong, dai and
bladder, right kidney, hemorrhoids , hernias
lower heater; local Liv, Sp, Kid meridian points in lower
(Shan) o
ren mai points in
heater; local points
PMS, amenorrhea, disrupted
over visceral irritation (ST 30 for ovaries, CV 4-6 for
menses,
$'
o
infertility
uterus etcetera);
and
CV 2 down, to right
impotence
and left to propagate
prostatitis,
Qi for lower heater-it
vaginitis,
is.
cystitis, pelvic floor syndrome; o
sexual dysfunctions such as erectile dysfunction or frigidity
$(
Cardiac Alarm
Signs &
Upper-Lower heater
Symptoms
Point strategies
AOM Lifestyle Coaching
dysfunction
_______________ Kidney Yang/Heart Protector Dysfunction
Kidney/Lung Qi Dysfunction
Pelvic collapse and/or diaphragmatic constriction may be precipitating factors for this pattern of visceral agitation
______________
_______________
_______________
Free-floating
YinYang Regulation
Coach patients to do
anxiety, dread, fear
abdominal breathing
of impending doom
Jing:
as above
Shallow breathing,
Chong-Dai
Suggest stress
hyperventilation,
Treatment: SP
reduction or
heart palpitations
4(R)/Per 6(L) for
relaxation response
induced by stress
panic attack, anxiety,
programs for coping
palpitations in
with stress
Non-cardiac chest
patients with Kidney
tightness and
Yang & Heart
Suggest meditation,
discomfort from
Protector
yoga, Qi gong
diaphragm to under
dysfunction
armpits and sternum
Suggest mindfulness
(3 yin muscle
Ren & Yinchiao mai:
training for
channel referral
Lu 7/Kid 6 for
practicing anytime/
patterns) with
shallow breathing
anywhere
tightness in
and hyperventilation
rhomboids and
syndrome in patients
Suggest
paraspinals in upper
with Kid/Lu Qi
biofeedback,
back
dysfunction
hypnotherapy, EMDR, Psychotherapy for
Patient
Ying/Patient
behavioral and post-
Complaints:
Complaint:
traumatic issues
o
Anxiety,
Kid 15.5 for
panic attack,
adrenals;
heart o
palpitations;
Per 4 &5 with CV 18-
cardiac
17 for chest
neurosis;
constriction
$)
o
costroKid 22 and Per 1(L)
chondritis
for chest pain on left (cardiac neurosis) Xu-Li treatment for chest pain from reflux or GERD (see second pattern of fatigue above) SP 20 & LU 1, Kid 27, BL 13 and 42 for hyperventilation syndrome
%+
Definitions Acupuncture Physical Medicine (APM) is a North American approach to Acupuncture that stems from the program at the Quebec Institute of Acupuncture in Montreal founded by Dr. Oscar Wexu. Trained in acupuncture in Paris, Dr. Wexu maintained ties after moving his family to Montreal to French physician acupuncturists Drs. Nguyen Van Nghi and Jean Schatz and with sinologist colleagues of Dr. Schatz, Father Claude Larre and his protégé, Elizabeth Rochat de la Vallee from the Ricci Institute in Paris, who were experts in classical medical and philosophical Chinese translation. This French tradition of acupuncture informed the training at the European School of Acupuncture in Paris and was rooted in the classics of Chinese acupuncture and medicine. As founder of the Tri-State College of Acupuncture, I translated French materials for the Quebec Institute and its satellite Program, Lincoln Detox School of Acupuncture in the South Bronx run by Mutulu Shakur, Walter Bosque, Richard Delaney and Wafiya, who all graduated from the Montreal Program and which was originally established with the help of Mario Wexu, son of Oscar and director of education of the Quebec Institute who moved to New York City for a year to accomplish this. In lieu of a doctoral level thesis, I translated Van Nghi’s seminal work, Pathogenesis and Pathology in Traditional Chinese Medicine for the Montreal school so that students whose native language was English would have better access to these foundations. When Lincoln Detox School of Acupuncture was forced to leave the hospital space two divisions of the program emerged, and the Tri-State College of Acupuncture grew out of one of these groups as explained in more detail in a later chapter of this book. APM starts with the classical approach to meridian— jingluo —acupuncture treatment as espoused in the earliest classical Chinese acupuncture text, the Ling Shu . This approach is fortified by modern practical interpretations and applications of jingluo/meridian acupuncture based on the works of Felix Mann, now out of print, and the late Dr. Yitian Ni, whose clinical treasure house, Navigating the Channels forms an integral part of APM teaching and practice.
%*
APM is also unique in integrating Travell and Simons myofascial release of trigger points into classical Chinese tendino-muscular meridian treatment, thereby expanding greatly upon students’ knowledge and treatment of the muscles and tendon attachments in chronic as well as acute neuromusculoskeletal pain syndromes whether perpetuated by repetitive strain or stress overload. This is parallel to the later integration of trigger points into the French Association of Acupuncture training, but at the Tri-State College of Acupuncture this integration is far more comprehensive and leads to an approach that is consistent with classical Chinese medicine, rather than being reduced to trigger point dry-needling. APM also draws heavily from the original traditions that lead to bodymind integrative therapies and somatic psychology in North America in the 60s and 70s. The 19th century work of Friedrich Nietzsche on the body, Wilhelm Reich on character armor, Georg Groddeck on the “It” and the meaning of illness, and the modern North American work of Stanley Keleman on emotional anatomy and insults to form, Thomas Hanna on the body in revolt, David Lewin on recollection and the felt-sense, Eugene Gendlin on the bodily felt-sense, Milton Erickson on reframing and Arthur Kleinman on the experience of illness, which stem from the mind side of the Bodymind Continuum, but in a decidedly embodied way, are as pivotal to Acupuncture Physical Medicine in its approach to acupuncture treatment and the authentic doctor-patient relationship, as is Travell’s osteopathically derived focus on somato-visceral and viscero-somatic reflexes so close to the acupuncture and Chinese medicine interplay between the jingluo and the zangfu. Armed with this decidedly Western approach to psychosomatics and the bodymind, I suggested in Bodymind Energetics in 1987 that acupuncture and Chinese medicine were emerging as a part of the new integrative medicine known first as New Age Medicine, then Holistic Medicine, then Complementary and Alternative Medicine and its most recent iterations. From that perspective, which I still believe to be valid, Acupuncture and Oriental Medicine (AOM) is the most comprehensive and powerful member of Complementary and Alternative Medicine in North America. APM was developed, through integration of this classic Western psychosomatic foundational knowledge and core working principles, and through integration of modern North American work on Myofascial holding patterns, to bring classical acupuncture into the mainstream with a language that would
%"
facilitate communication, cooperation and collaboration with mainstream and integrative medical physicians and other health care providers of all persuasions. In this vein, APM has demonstrated over the past three decades the power of acupuncture as a stand-alone practice that equals those of classical osteopathy, chiropractic, physical and occupational therapy. Just as these other physical, handson medicines focus on treating somatic constrictions, blockages and weaknesses, even in the treatment of patients who also have visceral complaints, APM Acupuncture uses a decidedly hands-on physical medicine approach not only to neuro-musculoskeletal disorders, but also to visceral complaints, stress and fatigue, as well as emotional disorders. Over the past year and a half I have been correcting for an error in modern acupuncture and Oriental Medicine training in North America and at the college that failed to recognize that when the Su Wen o r the Ling Shu or later classical Chinese texts refer to treating with a ‘calm heart and mind’, this was a reference to the Learning of the Mind-and-Heart in the Confucian tradition, and specifically to the 8 steps of self-cultivation stemming from The Great Learning which Neo-Confucians believe was lost after the death of Mencius around 290 BCE, and was not resurrected as the “Learning of the Way” until 1000 CE by Neo-Confucians who made this there starting point for self-actualization and moral development for the common good. That is to say that this Way was lost, as stated in Scroll One of the Su Wen , for well over a thousand years and classical texts of Chinese acupuncture and medicine suffer from this loss, which was dealt a final death blow by the Nationalists and the Communists in mainland China in the 20 thc entury.
APM Acupuncture, as compared to Acupuncture Phsyical Medicine (APM) as described above, seeks to revive this Neo-Confucian Way, and is best practiced by those, I believe, who have a regular physical practice to regulate the bodymind from the side of the soma (East Asian Daoyin or Yoga practices for example), as well as a daily practice from the side of the psyche to calm the Mind-and-Heart which might entail sitting or moving meditation, chanting, breathwork, prayer, keeping a diary of ones interactions with Self and Others, sharing ones personal work at engaging, especially in ones AOM teaching and practice, with like-minded
%#
colleagues, close friends or a mentor, aimed at authentic human relatedness in all of ones encounters with self and other: the Dao of the Sage. I originally practiced Judo, then T’ai-Qi, then Qi Gong, from the physical side, and worked out at the gym, and ran and jumped horses until injuries made that impossible, and now swim daily while meditating or chanting/praying. My daily Daoyin practices originally learned from Tom Bisio and Marshall Wood are now informed by the 8 Healing Sounds and Storing Qi and Developing Sensitivity Practices that Andrew Nugent-Head, MSOM, has brought to the college recently and these practices have become much more tangible for me as a result of this happy encounter. As several APM faculty and I will be studying with Andrew in his Acupuncture in Orthopedics and Rehabilitation Program starting in July, 2012, this will allow APM training at the college to become that much more embodied and grounded in Daoyin physical self-cultivation with more tangible results. In my work as Director of Education at the college, I am working with focus groups of students and faculty to build back in the bodymind energetic approach that served as APM’s precursor, into a revived APM Acupuncture teaching and practice, with an Acupuncture Clinical Topic as an elective where students who are new to the bodily-felt sense will have discussions I initiate, followed up with several monthly bodymind therapy breathwork sessions with Jesse Torgerson, a highly experienced and gifted bodymind therapist, along with facilitated discussion groups lead by senior students or graduates who have worked with her, and with other bodymind integrative practices in a rigorous way. As part of the 4th year of the eventual First professional Doctorate, finally, senior doctorally prepared faculty (Linda Barnes, PhD, David Kailen, PhD, Mark Seem, PhD) will be running seminars on Eastern and Western approaches to “the life of the spirit” from interdisciplinary perspectives, and some of these will be piloted as early as the 2012-13 academic year. It is my goal as director of education, through the APM Acupuncture approach which will now be expanded to include the approaches from Yin Style Ba Gua that Andrew Nugent-Head will be training faculty in, and through the Neo-Confucian approach to Self-Cultivation, to establish the possibility for a classically inspired advanced training in Acupuncture, AOM bodywork and their adjunctive therapies
%$
worthy of the First Professional Doctorate, as a powerful partner in 21st century physical medicine writ-large. This training will require that participants engage in daily Daoyin, Yoga or parallel physical practices, as well as Mind-and-Heart cultivation practices as discussed above. And in all of this APM Acupuncture study, and in fact in all training at the college in the current Master’s Degree Program in Acupuncture and in Oriental Medicine, students will continue to be trained in critical and reflective practice, informed by the late Donald Schon’s work on Reflective Practice, with weekly, preferably daily self-reflection on Self and Others, derived from the innovative training at the former College for Human Services established by the late Audrey Cohen in the 70s, where I was on faculty. This was formally built into the masters entry-level training at the college in 2004, and is parallel in many respects to the Neo-Confucian Learning of the Mind-andHeart as I will discuss in this book, which will continue to serve as an inspiration for APM Acupuncture training and practice. In brief, Acupuncture Physical Medicine (APM) is a decidedly Western, specifically North American approach to bodymind integration, that is heavily influenced by Classical Chinese Chinese Acupuncture theory and practice, especially as presented in the “Spiritual Pivot”(Ling Pivot”(Ling Shu ) and was developed so that all MS degree students at the college could practice it competently and confidently to good effect. APM Acupuncture©, on the other hand, is a term I now reserve for the full practice of APM Acupuncture from the bodymind integrative approach developed 25 years ago, now fused with the Western approaches of Schon and Polanyi’s to tacit learning and the Neo-Confucian Learning of the Mind-and-Heart.
While many graduates hold themselves out as practitioners of APM, sometimes while mainly practicing trigger Point Dry Needling, what I mean by APM Acupuncture as a solo practice is laid out in its entirety in this current volume, directed first and foremost at the continued training in APM Acupuncture at the TriState College of Acupuncture, whose faculty, assistants, interns, alumni and
%%
students I wholeheratedly thank for engaging in this long and still fascinating Way with me.
%&
INTRODUCTION: APM ACUPUNCTURE KNOWLEDGE, SKILLS & ATTITUDES--TREATMENT OF THE 10,000 THINGS
Students who have seriously studied the philosophical foundations of APM Acupuncture presented in this book and earlier books I refer to, and who understand and can articulate the main concepts listed on pp. 153-154, and who understand how Ling Shu meridian acupuncture and Travell and Simon’s osteopathically informed approach figure in Acupuncture Physical Medicine (APM) possess the requisite knowledge to practice APM. Students who are serious and committed to palpation-informed practice and to needling as described in this book and who have mastered the 18 APM KATAS possess the requisite skills to practice APM. Finally, those who have approached and make a daily commitment to continue to approach APM practice with seriousness, reverence and awe for the capacity of each human being they treat to self-actualize and make necessary changes have the proper attitude to refer to themselves as APM Practitioners. These are the Ordinary Skills of APM, and with them one is equipped to generate creative strategies to treat the 10,000 things as a humane practitioner doing good work. As for the High Skills of “APM Acupuncture©” practice, which I differentiate from Acupuncture Physical Medicine (APM) as mentioned above, this involves a deep learning of the Mind-and-Heart on the part of the practitioner, first, and ideally of the patient as well. It also involves a deep understanding of acupuncture as a bodymind energetic approach first articulated in Bodymind Energetics , where study of parallel Western bodymind therapies is crucial.
%'
I have arrived at a place where I feel ready to strive for practicing such High Skills myself, after 33 years of study and practice. I am committed to this goal, knowing I will never achieve it to my satisfaction, and trusting that some who study with me will go much further than I am able. To my Acupuncture Physical Medicine faculty, assistants, interns, students, graduates and colleagues, I wish you all the satisfaction and joy and passion and love this medicine has afforded me thus far. I am a better human being from this practice, where the ‘spiritual pivot’ of the needle, which connects practitioner and patient, makes authentic human relatedness and human becoming a powerful affirmation of Life and of the ‘Heavenly Principle.’ And to those now engaged with me in striving to practice the High Skills of APM Acupuncture with similarly engaged colleagues and patients, I look forward to our journey along the t he Way.
%(
ONE Professional Dimension 1] Premise of APM ACUPUNCTURE Clinical Training: This is the place where one learns to engage in the ORDINARY SKILLS of acupuncture practice, and of authentic human relationship with Self and Others (team members, supervisors and peer patients) for best care.
The Professional and the Human Dimensions of Practice: The expectations regarding professional, professional, ethical and moral conduct at the Tri-State College of Acupuncture are informed by the following critical and core elements which together define what it is to be engaged in being a student, faculty member and graduate of the college, and serve as a necessary support for the sorts of Communities of Reflective Practice (CORP) the college seeks to foster: •
ACAOM STANDARDS: Established
as the national requirements for AOM
professional educational programs over 27 years ago, these masters degree entry level standards insure that accredited programs meet stringent criteria in all areas of its programs and operations and that graduates are Independent AOM providers eligible for state licensure and NCCAOM national board certification; •
CRITICAL THINKING AND REFLECTIVE PRACTICE STANDARDS AND ELEMENTS:
Adopted from the Center for Critical Thinking’s work on thinking about thinking, and Donald Schon’s work on Reflective Practice, the college has articulated the Western Disciplines of Mind that it seeks to foster in its students. •
MINDFULNESS:
Taught early in the first semester of Year I as an East-Asian
Learning of what Classical Chinese Medicine refers to as theMind-and-Heart, which embraces the tacit dimension of learning with ones whole body and mind and all the senses, in a way that fosters emotional intelligence intelligence from a center of calm and focused attention to ones learning, as the bridge to engagement in authentic human relatedness with self and others. This
%)
attitude lso entails a seriousness and reverence for the things one studies, as they all relate to the human condition. •
TSCA CORE VALUES:
The 7 core values, published with the code of ethics in
the college’s student and personnel manuals, constitute the central focus for AOM professional practice expectations, and are addressed in courses on ethics and practice management, counseling, and in the patient/practitioner interactions in all clinical experiences, from an interdisciplinary perspective (medical anthropology, sociology, philosophy, psychology, public health, education) that adds the human dimension to such a professional education and are: Compassion, Caring and Positive Regard; Accountability; Altruism; Excellence; Integrity; Professional Duty; Social Responsibility. The college has identified its premier core value as Compassion, Caring and Positive Regard from an East-West perspective. From a Western stance, the concept of acceptance, later articulated as positive regard, and later still, as unconditional positive regard were developed by Carl Rogers as the core of his humanistic psychology of the self-actualizing individual. In chapter 15 on Roger’s client-centred theory (in “Embracing non-directivity; reassessing person-centred theory and practice in the 21st century” edited by Brian E. Levitt), Kathryn A. Moon summarized Roger’s position thusly: “Carl Rogers founded client-centred theory upon the hypothesis that all living organisms are inherently motivated to maintain and fulfil themselves as best they can, each 'according to its nature' [...]This constructive life force is called the actualizing tendency. Actualization is believed to be the primary motivation, a universal need or drive to self-maintain, flourish, self-enhance and selfprotect [...]. Rogers posited six necessary and sufficient conditions for effective psychotherapy [...], three of which (the 'core' conditions) give therapists a facilitative way 'to be' with clients. These three conditions, sometimes referred to as the 'therapist conditions' [...] -unconditional positive regard, empathic understanding and congruence - when embodied in the therapist, meld together into a manner of therapeutic presence [...] that is trusting and respectful of the client. I consider this therapeutic presence to be protective and sheltering of the client's ways of being, doing and perceiving. Rogers' theory was put forward as inductively derived: given the universality of the actualizing tendency, if certain necessary and sufficient
&+
therapeutic conditions are present in a relationship, then the individual will self-maintain and flourish.” In the East-Asian, specifically Chinese Confucian and especially NeoConfucian formulations, the central concern, parallel to Rogers’ views, according to Tu Wei-ming, “is the process of becoming a sage, of becoming fully realized as an authentic human being [...] the distinction between authentic self and inauthentic self and that between partial self-realization and complete self-realization (Humanity and Self-Cultivation, p. 17).” While this might sound like an East Asian parallel and precursor to Roger’s decidedly western humanism, Tu Wei-ming underscores the centrality of Confucian “human-relatedness” and Neo-Confucian “unity of knowledge and actions”(Wang Yang- ming) in the world, to change the world. He further clarifies that in “many great spiritual traditions, human-relatedness as shown in ones attachment to the world is considered detrimental to man’s religiosity and therefore must be forsaken before one can fully experience ultimate reality either in the form of a union with the ‘wholly other’ or in the form of a unity with true selfhood” where the argument might run thus: “human-relatedness must be totally eliminated because it gives rise to a false perception of the self.” In this decidedly “antisocial” rendition, TuWei-ming suggests, “it has been widely held that one of the most salient characteristics of spiritual transcendence is to say ‘no’ to society at large (pp. 19-20).” The Confucian Way is different on this fundamental point, such that “sociality is not only a desirable trait but also a defining characteristic of the highest human attainment [based on] two interrelated assumptions”—that the “ultimate ground” of Man’s self-realization lies within. “Man has the inner strength to actualize the full potential of his being, and his creativity is inherent in his humanness”. Despite this natural self-sufficiency, “for man to become a fully actualized human being,” Tu Wei-ming concludes, “he must constantly engage in the process of becoming a sage (the highest form of authentic humanity) [...] not by detaching himself from the world of human relations but by making sincere attempts to harmonize his relationships with others (ibid, p. 20).” !
IOM CORE COMPETENCIES:
The Institute of Medicine identified five core
competencies to be embedded in all mainstream as well as complementary and alternative health professions education to meet the demands of 21st
&*
century health care. These competencies figure prominently in draft ACAOM First professional Doctoral standards and the college voluntarily upgraded its MS in Acupuncture Program to include these eventual doctoral elements, for a more comprehensive education that prepares its graduates not only for private practice, but for work in mainstream and integrative care settings. The five core competencies are: Provide patient-centered care (work to empower patients to play a central role in their healthcare plans and respect the patient’s own healthcare and other determining beliefs, needs and decisions without bias or discrimination); Work in
interdisciplinary teams (ability to communicate, cooperate and collaborate even if not in the same practice settings, based on patient needs and preferences); Employ evidence-based practice (be information literate and dedicated to obtaining best available authoritative evidence from textual and research areas, including expert experience; with awareness of limitations on research evidence in CAM fields in general (cf. IOM, Complementary & Alternative Medicine in the United States); Apply quality
improvement (work to improve quality of care and minimize risks); Utilize informatics.
&"
2] Human Centeredness, Positive Regard and Lifelong Learning While the ultimate goal of the college’s accredited Master’s Degree Programs in Acupuncture and in Oriental Medicine consists in graduating independent AOM providers qualified for licensure, the college aims much higher: through the example set by its most senior faculty in their Grand Rounds Master Classes, to the caring and compassionate coaching and supervision of its clinical practice faculty, and in every didactic classroom experience, the college faculty of practitioners works to help each student learn in her or his own way how to internalize and embody the art and science of Acupuncture and Oriental Medicine in a manner that empowers them to engage in lifelong learning. These elements together articulate an independent AOM provider as one who has internalized and exhibited (and been assessed on) professional (ACAOM required OSHA, HIPAA, CNT, AOM knowledge, skills, attitudes), ethical (adherence to code of ethics) and moral performance and behavior. Here moral behavior is defined as a dedication to an authentic human relationship with every person engaged in the clinical encounter (patients, teammates, supervisors, self) from a position of acceptance and positive regard. This moral dimension maintains that the patient-practitioner relationship must start from a salutogenic (health-making) perspective that aims at the patient’s selfactualization. Such a perspective is based on the belief that the patient’s experience of illness and narratives (Kleinman) are central, and care is centered on the patient’s desires, wishes and needs. Such care aims to prod each patient’s innate wisdom and will to thrive, to self-actualize, and to say yes to life. Such a stance on the patientpractitioner relationship is investigated at the college from interdisciplinary EasternWestern angles to provide a robust and flexible model that is adaptable to any person’s perspectives on the ethico-religious and spiritual dimensions, where the only belief that unifies them all is that human life is precious in all its transformations and elaborations. The Neo-Confucian Way, which I am slowly building into APM Acupuncture©, taken as a philosophy for how to live in the Real world, entails a code of ethics and moral conduct aimed at a more humane society and world at large. “Confucian
&#
physicians” held this perspective from the 11th to the 14th centuries in China. With the rise of Neo-Confucianism, the model of the “Sage- King” was internalized, such that each person was seen as capable, within her or his inborn limitations and stations in life, of becoming a sage, having been born wise, through an effort of body, mind and all the senses. This effort of self-cultivation required that one set out on the Way as Confucius instructed, with this inner Sage as the guide, passing through the developmental stages of “scholar-apprentices (shi)” and then “exemplary persons (junzi)” who command respect because they have “travelled a goodly distance along the way, and live[d] a goodly number of roles. A benefactor to many, [the junzi) is still a beneficiary of others like himself. While he is still capable of anger in the presence of inappropriateness and concomitant injustice, he is in his person tranquil (The Analects of Confucius: A Philosophical Translation by Roger T. Ames and Henry Rosemont, Jr., pp. 61-14).” Except in rare instances, these translators tell us, “the goal of the junzi is the highest to which we can aspire” as the “loftier human goal”, of becoming a “sage (shengren) [...] is a distant goal indeed (ibid, p. 62).” The way of human becoming (self-cultivation, “innately knowing the good” and embracing humaneness, ibid, pp. 48-49) that leads one from being a scholar-apprentice to an exemplary or “authoritative” person is a progression from apprenticeship as dedication and commitment to lifelong learning and selfcultivation, to that of the “exemplary” or “authoritative” person who engages in authentic human relatedness, “ ‘growing (sheng)’ these relationships into vital, robust, and healthy participation in the human community (ibid, p. 49).” This moral dimension, which starts from a position of positive regard toward all human beings, makes the training of professionals good at their art and science— their craft, also a training in human relatedness where students learn ways to communicate, cooperate and collaborate with others for the common good— by means of quality and humane AOM health care. From this viewpoint, independent AOM providers informed by the APM perspective are dedicated to AOM care as a servive to society, and as a way to foster the human dimension in health care in our country, where it is far too often neglected.
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3] The History of a Compromise—The TCM Organization of Acupuncture Practice THE PROBLEM : As I began meeting founders and educators from the other schools of acupuncture starting in 1982, during their formation of the National Council of Acupuncture Schools & Colleges (now CCAOM), I was struck by the absence of what I came to call the jingluo filter and jingluo pattern identification as a way to develop an acupuncture treatment plan. Most of the other schools focused on teaching the 14 meridians (where the two extraordinary vessels, du and ren mai were taught not as part of the 8 extraordinary vessel network with its own treatment applications and strategies, but as landmarks that demarcated the ventral and dorsal midline on the basis of which location of points on the torso could be taught), and the use of distal antique or command points combined with front-mu and back-shu points. As I began teaching in several of these other schools, and teachers from these schools began teaching in mine, I saw my role in these early days as a translator of what I perhaps erroneously referred to as French meridian acupuncture in the tradition of Nguyen Van Nghi, MD. There, one found a comprehensive presentation of the jingluo filter, with detailed exploration of the 12 “regular meridians”, and their associated “secondary vessels” (12 divergent, 12 transverse luo, 15 longitudinal luo, 12 tendinomuscular) and the 8 extraordinary vessels, comprising 71 jingluo (translated as “channels and collaterals” in most PRC texts that came much later). This puzzled me, because Felix Mann’s early text in English on the “meridians of acupuncture” from around the same time as Van Nghi’s earliest writings was widely available, and listed 59 meridians (he did not designate the 12 luo anastomosis-like pathways from each of the 12 regular meridian’s luo points to its paired meridian’s source point as actual meridians, even though all texts portrayed this little shunt as a dotted line without further mention). The earliest problem for me with this picture, was glaring. Where had all the meridians gone? What happened to the jingluo filter that reduced 71, or 59 meridians to 14? And what were the implications of this for acupuncture practice in North America?
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Correcting for an Error As Maciocia states in The Channels of Acupuncture , “The organs and their relevant channels form an invisible energetic unit: problems of the Internal Organs can effect the relevant channels, and, conversely, problems that start by affecting channels can penetrate the Interior and be transmitted to the organs (p. 97).” The fact that he starts this clarification by capitalizing “Internal Organs” displaces the total connection between a meridian and its internal branch, which connects to its paired meridian of the opposite polarity (Lung to Large Intestine etcetera). The role of the internal branches, rooted in the Sea of Blood and Qi, of enabling inside (the function of organs, glands, deep tissue, Blood and Qi) and outside to communicate is already distorted in Maciocia’s decidedly modern, TCM interpretation. Dr. Yitian Ni, in her Navigating the Channels , reminds us of the classical functions of the channels and collaterals, namely to: “Integrate the whole body” providing a network connecting Zang and Fu, the interior to the exterior, which “links each part of the body to every other part, creating an organic whole; “Circulate the Qi and Blood”, so that “the organs and tissues can be nourished and lubricated […], their functions can be regulated, and […] a relative equilibrium of normal life activities can be maintained; “Demonstrate the location of disorders” , such that the pathogenic effect from one organ or part of the body can pass to another area, and “meanwhile be reflected on the body surface through the channel system: hence in an attack on the lung regular meridian and organ (hand taiyin), the pathogenic factors can be transmitted to the paired large intestine, “resulting in a tenderness, or other abnormality on the body surface along the Lung and Large Intestine Channels (ibid, p. 1); “Transmit the needling sensation” , which can move along the channel system to the affected area: “When properly applied, this function regulates and activates the flow of Qi, balances Yin and Yang, and restores the normal function of the organs and channels (ibid).” Maciocia goes on to a study of the symptoms and signs of the twelve main channels ( jing mai ) (ibid, pp. 98-106), reminding us that channel problems can arise from: an exterior invasion of wind, cold or dampness leading to bi syndromes; overuse or repetitive strain; or sports and other injuries leading to Qi stagnation,
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which of course are the three causes of cutaneous region and muscle channel disorders (the “yang” or wei level of channel invasion). He then adds, almost as an afterthought that, finally “channel problems can of course spring from InternalOrgan disharmonies (ibid, p. 98).” He then moves on to the crux of the problem as I see it, with an “error” that is based on a ZangFu bias which is characteristic of modern TCM acupuncture. He states the obvious, that ”Channel Pattern Identification describes the pathological changes occurring in channels.” He then suggests that these signs and symptoms, from Chapter 10 of the LingShu , can be confusing as they may include “some from the relevant organ and sometimes even from other organs.” He cites the case of the main Lung channel, which might have signs and symptoms from: the Lung channel (pain in the upper arm, and fullness and distention in the chest); the Lung organ (cough); and the Large Intestine channel (pain in the supraclavicular fossa) which he notes is “related” to the Lung channel (ibid). What Dr. Ni took as a normal part of the internal /external and YinYang regulatory function of the main channels, connecting the external Lung channel to its internal Lung organ, and connecting the Lung organ to its paired yang Large Intestine bowel, which itself is connected to its Large Intestine channel, Maciocia decides to present as “confusing”. His choice of terms is precise, and meant to create this “confusion”: “sometimes even from other organs” and “is related” make it sound curious that Lung and Large Intestine organ and channel signs and symptoms would appear together in the classic description of the main channels. Once having created this confusion, which the reader certainly wants cleared up, Maciocia gives the TCM solution developed in the early 1960’s: “Thus channel patterns include some symptoms and signs from the organs themselves. These can safely be ignored, as for organ problems it is much better to use the Internal Organ (ZangFu) Pattern Identification (ibid).” He then proceeds, for each main channel, to give the “pure channel symptoms” and the “organ symptoms” in a manner that is incorrect and not in keeping with the LingShu Chapter 10, as it presents the classical signs and symptoms.
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This is either because Maciocia does not care to be clear, wishes to confound the confusion, or, which is entirely possible, is seriously confused himself. Whatever the case, Maciocia’s discussion of main channel Pattern Identification is clinically flawed, and underscores the fact then TCM acupuncture teachings over the past 47 years or so have replaced the differentiation of internal organ symptoms of main Jingluo patterns with ZangFu pattern differentiations. This process extended far beyond the PRC, as it affected the teaching of Main Channel Pattern Identification in the entire English-speaking world. In North America, as AOM colleges were obliged to keep up with new TCM texts from PRC, and as the NCCAOM national board examinations were developed based on TCM texts in large part, an error, or a deliberate oversight was built into jingluo education and practice with wide repercussions.
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4] The Big Picture: The hallmark of the Tri-State College of Acupuncture’s Program in Acupuncture lies in its commitment to diversity, and to training students to be able to compare and contrast, and ultimately integrate from the three main styles taught at the college that stem from classical and modern Chinese, Japanese and French styles of practice in North America today. APM Acupuncture is firmly dedicated to such an integrative and pluralistic approach to practice in North America. From this Persopective APM is already integrated with Classical Chinese Acupuncture (CCA) and informed by modern approaches from East and West as explained in the preface. The Knowledge, Skills and Attitudes of an integrated APM/CCA approach are delineated in Acupuncture Physical Medicine, Acupuncture Osteopathy, and BodyMind Energetics by Mark Seem, Ph.D. Note that APM ying level treatment utilizes many of the same treatment strategies as Classical Chinese Channel theory, as articulated in Yitian Ni’s Navigating the Channels, for selection of distal and local points of the regular meridians, and treatment strategies for the secondary vessels and eight extraordinary channels. Her text is based in large part, as is the work of Drs. Chamfrault and Van Nghi whose texts served as the foundational French texts of the Quebec Institute of Acupuncture curriculum in the late 1970’s. Likewise needle technique in APM at the Ying level is consistent with CCA and TCM. APM adds a jing level use of extraordinary vessels derived from French meridian acupuncture, as well as a wei level approach that includes CCA and TCM treatment of Bi syndromes with acupuncture, as well as more classical approaches to the secondary vessels as taught by Van Nghi, and a modern approach to trigger point myofascial release through acupuncture dry needling derived from Travell and Gunn. A good half of APM treatment is therefore consistent with the CCA approach, whence the label APM/CCA for Year II Acupuncture Clinical Practice (ACP) sessions. !
APM/CCA knowledge: This knowledge base assumes a solid grounding
in AOM foundations, namely the theory of acupuncture filters (yinyang, 5 phases, etcetera); the normal function of the 12 ZangFu; the 3 Heaters; acupuncture point location for the regular meridians, and acupuncture palpation examination for reactive points at the wei level, for mu and shu points and for reactive mu/shu-like points (mu-point boogey); the main
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trigger points in the Taiyang, Shaoyang and Yangming Zones ; meridians of the jing, ying and wei level and the APM acupuncture imaging protocol for use of meridian strategies at each of these 3 levels; the 3 zones; the 3 meridian circuits; the hypothesis that ‘yin tends toward deficiency/yang tends toward excess’; the 8 conditions that inform an APM physical examination during the palpation and treatment planning phases of APM treatment(upper/lower; front/back; right/left; yin/yang): all of the above constitute specific acupuncture factors of care in APM/CCA.
Acupuncture reframing/imaging; tongshenming; bodily felt sense; focusing (Gendlin); the experience of illness; bodymind continuum constitute the nonspecific factors of care in APM/CCA. !
APM/CCA Skills: these skills are delineated below as separate skills under
five broader categories of overall competency referred to here as Skills Sets. !
APM/CCA Attitudes and Values: Ones attitudes and values toward
health, illness, suffering and the role of the caregiver, as well as ones awareness of ones own position on the bodymind continuum [with a tendency to react more somatically, with physical symptoms, or psychologically, with emotional distress at the symptoms, or somewhere in between], inform how one practices acupuncture. In APM, ones intention begins with an enormous empathy for the litany of suffering and the experience of illness of those who endure chronic pain, chronic stress, and chronic emotional distress. Informed by this empathy, APM takes a humorous, salutogenic approach that asks each patient suffering from such chronic suffering to consider that it could be worse, that no one ever promised them a life free from suffering, that pain and suffering are part of the human condition, and that aging and illness include increased pain and suffering. A salutogenic intention challenges the patient to recognize that most of the time, they are healthy with no healthcare intervention, and that they are capable of coping more effectively, with less pain and distress. Within this intention is a value of the acupuncturist as change- agent, as catalyst to prod the patient’s will to be well. APM practitioners value the role of acupuncture in such chronic conditions, which constitute a good 70% of what they treat. In such cases, acupuncture is often of major, even primary importance.
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In the case of patients who have a serious diagnosed disease, APM practitioners are acutely aware of the relative role of acupuncture and Oriental medicine in such cases, and see APM as secondary or tertiary care, aimed at support, alleviation of pain and discomfort and distress. APM practitioners have tremendous respect for conventional medical care in such cases, and always encourage patients to seek the best medical care possible, never overstating acupuncture’s role in the overall plan of care. For patients who freely and knowingly refuse to undertake the standard of conventional medical care, APM practitioners discuss openly and frankly the worth of acupuncture care and decide with the patient whether or not to continue acupuncture treatment for their condition. APM practitioners are fully aware of their legal scope of practice in whatever states they practice, and never work outside of this scope. Finally, in the case of clients, who freely choose acupuncture for well-being or health maintenance, APM practitioners respect such free choice of wellness care, while never inflating acupuncture’s importance or making claims without evidence to back them up. Whether an APM/CCA practitioner is serving a primary, secondary or tertiary role in a patient’s overall plan of care, s/he is aware of this relative role, and also aware that the patient- practitioner relationship is such that proper use of somatic and verbal rapport, a good tableside manner, might initiate in even the most difficult situations an instance of “tongshenming [penetrating divine illumination]”, a classical TCM approach to the doctor-patient relationship, where something said or a simple touch by the practitioner can set up a space for healing that is safe and powerful at the same time. Ultimately, then, an APM/CCA practitioner’s intention in reframing a patient’s suffering into something that acupuncture might be able to address is that the patient is her or his own primary healthcare practitioner, and capable of healing from even the most serious physical or emotional illness. Confronted with the unexpected and the exceptional in their care of patients, APM /TCM practitioners will be dedicated to lifelong learning. It is expected that all students entering Year II APM/CCA ACP class will have the required knowledge base outlined above, and that they will do the required readings before each class and come with their copy of Travell and Simon’s text(s) for ready reference of trigger points (which is considered an open-book knowledge base until each trigger point has been mastered).
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It is understood that the attitudes and values of an APM/CCA practitioner will take more or less time depending on a student’s prior life and healthcare experience. The directed independent study Learning Portfolio will be the place where students can reflect on these values and demonstrate an appreciation, if not a total internalization at any given point, of these values which will continue to evolve and shape their behavior as more and more mature, and wise, independent acupuncture providers. Cf. Acupuncture Physical Medicine, pp. 9-60 for a discussion of APM’s specific perspective on empathy, suffering and chronic fatigue/visceral agitation. APM is often referred to as symptomatic by some who prefer to remain ignorant of the classical acupuncture approach as espoused in the end of Scroll One of the Ling Shu where we are taught that while some believe acupuncture is unable to treat chronic complaints, this is because they do not know how to wield a needle in such a fashion to ‘remove thorns, wash away stains, untie knots and breach obstructions’. Those who do know how to perform these dispersal techniques are able to clear the way, by first clearing away surface, ‘yang evil’, then a little deeper, to clear away ‘cou li’ subcutaneous level ‘yin evil’, so as to be able to promote grain Qi, thus enabling the body to build Qi and Blood (ying level, post-natal Qi)) from proper transformation and transportation of food and drink without overly tapping into prenatal Qi. These, classically inspired acupuncturists, know that treatment of a patient’s specific complaints, through distal and local specific strategies to clear away these excesses, are very capable of treating chronic and complex complaints solely with needles (and moxibustion) by treating the meridian system and clearing obstructed points and areas along those pathways.
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5] APM/ CCA Practice Guidelines for Charting Diagnoses for ACP and Clinic: 1] Visceral agitation patterns: with adrenal involvement, sympathetic nervous
system arousal and ANS signs and symptoms, are charted thus: •
Taiyang Excess/ Du Mo excess (‘spinal irritation’) Kidney/Heart Protector Meridian Dysfunction Treatment Principle: Disperse Taiyang Excess, disperse Du Mo, Regulate Kidney and Heart Protector Meridians
•
Chong Mai/middle heater branch Dysfunction/ Constrained Liver Qi (‘diaphragmatic constriction’ with possible Liver, Spleen, Gallbladder or Large Intestine Dysfunction) Treatment Principle: Regulate Chong Mai (middle heater branch), regulate Liver, Spleen, GB, LI
•
Chong/Dai/Ren Mai Disharmony/ Lower Heater Dysfunction (‘pelvic collpase’, possibly with dampness, heat, Blood Stasis, Constrained Qi) Treatment Principle: Harmonize Chong/Dai/Ren; Regulate lower heater (eliminate dampness, disperse Heat, clear Blood Stasis and move Blood and Qi)
•
Upper Heater Dysfunction (‘cardiac alarm’, with Lung, Heart or Heart Protector Dysfunction; Kidney/Heart Meridian Disharmony; Kidney/Lung Meridian Disharmony)
Treatment Principle: Regulate Upper Heater (Lung, Heart and/or Heart Protector)/ Harmonize Kidney and Heart Meridians or Kidney and Lung Meridians 2] The treatment of visceral dysfunction and functional disorders: (Foot
Yangming Excess for example in a case of reflux and IBS) may also be treated classically according to the Ling Shu as regular meridian disorders and treatment of the corresponding circuit: tonfication of the source point of the associated yin meridian, in this case Sp 3, or the ying and shu points, SP 2 and 3; dispersal of the paired yang meridian luo point, so ST 40 in this case; dispersal or tonification based on palpation of local points along any of the regular meridians within the circuit,
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with special attention to the yang meridians: so 19, 18, 16, 15, 14 on the left for abdominal and chest discomfort in that area from the reflux, bilateral ST 24-27 and SP 15 for IBS S&S of bloating. •
Taiyin/Yangming Circuit Dysfunction Treatment Principle: Regulate Taiyin/Yangming Circuit
•
Shaoyin/Taiyang Circuit Dysfunction Treatment Principle: Regulate Shaoyin/Taiyang Circuit
•
Jueyin/Shaoyang Dysfunction Treatment Principle: Regulate Jueyin/Shaoyang Circuit.
3] For Tendino-Muscular Meridian Conditions: ! (meridian
name) TM excess/ muscle channel bi syndrome (ie: Liver TM excess
OR Liver muscle channel bi syndrome) Treatment Principle: Disperse TM meridian excess, promote free-flow of Qi and Blood, Invigorate the muscle channels. If there is wind, dampness or cold, add to diagnosis: “with wind, dampness or cold”; add to treatment principle: “disperse wind from; resolve dampness in; or disperse cold and warm” the channel. 4] For Zone Conditions: !
Taiyang Zone Dysfunction/ Taiyang-Shaoyin Meridian Dysfunction Treatment Principle: Regulate Taiyang Zone, regulate Taiyang-Shaoyin
•
Shaoyang Zone Dysfunction/ Shaoyang-Jueyin Meridian dysfunction Treatment Principle: Regulate Shaoyang Zone, regulate Shaoyang-Jueyin
•
Yangming Zone Dysfunction/ Yangming-Taiyin Meridian Dysfunction Treatment Principle: Regulate Yangming Zone, regulate Yangming-Taiyin
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6] APM Learning Objectives By the end of this Year II ACP section on APM/CCA practice, students will be able to successfully perform the following 5 Skills Sets at a level of PASS or GOOD on two separate occasions on two different peer-patients, thus demonstrating readiness to progress to their first rotation in the college’s acupuncture community clinics. 1. APM PALPATION/ INTAKE
The palpation phase of the AOM physical examination is pivotal in APM. It is here that the patient-practitioner relationship is solidified through hands-on identification of the patient’s holding pattern. Locating the holding pattern with ones hands allows the practitioner to validate a patient’s experience of illness without labeling or interpreting it: “Here it is!” rather than “This is what it is!” In APM palpation, one starts locally, as close to the center of the holding pattern as possible. If the intake indicates probable upper trapezius involvement in temporal headaches, then the hands-on palpation would most effectively start by checking the temporalis TrPs to start where the patient is complaining, and then move immediately to the trapezius TrPs. The palpation moves to distal points, dispersing with firm acupressure the whole while, and ends with a brief location of all the other main jing and ying level points so that the patient has a sense of what is to come, and to begin the dispersal of Excess, by supporting the Root. 2. APM ACUPUNCTURE TREATMENT PLAN
Identify the Zone to be treated in widespread Musculoskeletal and Pain Disorders and state the complete APM Protocol for Jing, Ying and Wei Levels for that Zone; or Identify the tendinomuscular or other secondary vessel meridian(s) to be treated and a complete traditional Chinese or French meridian distal and local protocol for that meridian(s) with a simple root treatment; identify the Heater to be treated and an APM/CCA distal and local protocol including jing and ying levels. 3. APM/CCA ACUPUNCTURE TREATMENT/TECHNIQUES
APM/CCA integrated acupuncture techniques differentiate between neutral stimulation, which can be performed on any point and is best for highly reactive, needle sensitive patients; dispersal techniques which should only be used on Excess
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points found by palpation; and tonifying stimulation which should never be done on Excess points, and is especially indicated on deficient distal points like source points and tonification points, and local deficient mu or shu (like) points. 4. COMMUNICATION/EDUCATION/REFRAMING--VERBAL RAPPORT
Communication, education and reframing skills occur at the same time as the specific acupuncture skills are being performed, in order to: train patients what sensations to expect; encourage patients to be present and go with the experience; and reframe the person’s complaint(s) into acupuncture holding patterns. Verbal rapport is thus used to build trust, educate, and communicate with the patient to create a safe environment for the treatment. During the verbal reframing, every opportunity should be seized to inspire hope in the patient and encourage positive change that they will be able to resume more normal activities. Patients must understand that there is no talking during needle removal. 5) MAINTAINING SOMATIC RAPPORT
Somatic rapport skills occur at the same time as the specific acupuncture skills are being performed. Somatic rapport is sought for the same reasons as verbal rapport, to provide a safe environment for the treatment, to encourage the patient to go with the treatment, and to inspire hope and encourage positive change. 6) INSPIRING HOPE
Throughout the treatment an APM acupuncture practitioner engages the patient’s will to be well, from a salutogenic rather than a pathogenic perspective, so that language and silence are used as another tool to prod and to reframe a mind-set stuck in pathology into one of hope that change is possible. Clinic-interns at the college train in basic reframing techniques drawn from Eriksonian Hypnotherapy and Neuro-Linguistic Programing with Melissa Tiers to better inform this choice of language and silence, which is parallel to the classical Chinese concept of tongshenming -penetrating spirit clarity, where one prods the Mind-and-Heart to a place of equilibrium so that the inborn ‘intelligence of existence’ might emerge.
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7] PRIORITIZING THE HUMAN DIMENSION IN CARE: ACP is a safe, controlled, supervised environment where you learn the actual behaviors that constitute acupuncture care of patients. While you will be being treated by a peer-practitioner who may even be your friend, you must role play in ACP, as if you were the actual patient and the actual practitioner—the RECEIVER and the GIVER of care. Consider APM/CCA ACP clinical practice as the practice of specific treatment forms each week—called katas in Japanese Karate. Each week, you will practice a form (ie: Taiyang Low Back Pain Form) as exactly as you can, given the actual reactions and sensitivities of the peer- patient. In this way you will amass a repertory of over a dozen broad protocols that will serve you in every clinical condition you encounter in the summer acupuncture community clinical rotation. In your role as peer-practitioner, you must proceed with the palpation, the reframing, and the education of the patient while eliciting bodily-felt feedback as per the directions below. You must inform each peer-patient what is occurring at all phases of the treatment, educating them about the sensations they are feeling and what is happening, and what to expect after the treatment and how to care for post-treatment soreness. You must also seek to inspire hope that the condition can change and anchor the peer-patient on what they wish to do once their condition improves with simple “parting words”. In your role as peer-patient, it is your responsibility to provide constructive feedback on somatic and verbal cues from the peer-practitioner as you would hope a patient would, including sensations you are experiencing, reactions to techniques you are having and any emotional reactions that are distressing. This will greatly enhance students’ ability to improve their specific acupuncture related skills as well as the non-specific skills of verbal and somatic rapport, reframing, education and instilling hope that change can occur. Note that this all will feed into the RAP Learning Portfolio, where you will learn to record your experiences as giver and receiver of care as your repertoire of acupuncture experience grows.
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8] ACP PRACTICE GUIDELINES FOR NEEDLE TECHNIQUES A] For the Jing and Ying levels, the integrated APM/CCA approach makes use of
classical Chinese techniques consistent with TCM: Jing Level: Extraordinary vessel distal opening points (SI3/Bl62 etcetera) are close to the bone (marrow, jing). In needling shallowly, 1/3 of an inch at most, one is already near bone. Needle into the subcutaneous fascia over the bone, with precise point location to enter the point. Neutral mini lift and thrust, with twirling is sufficient until there is a slight grab felt by the practitioner. The patient will begin to feel a heavy sensation. On Yin opening points, stop at the first sign of deqi. That is enough. On Yang opening points, the deqi can be stronger. REMEMBER DE QI RESPONSE MUST BE TAILORED TO THE PATIENT’S “DE QI TOLERANCE LEVEL”. Do these points first to begin to create/open the circuit involved. Leave these points at the depth the grab was encountered. Do not pull back to surface. Ying Level: Regular meridians are deeper within the fascia and “hidden from view”. The distal command points are places where the meridian is closer to the surface and easier to access with rather shallow needling. The LING SHU lists distal command point depths as follows: Foot Meridians: Yin meridians: 1/10-1/3” Yang meridians: 2/5 to 3/5” (or slightly more) Hand Meridians: Yin or Yang Meridians: 1/5” 8/16/11 17 1 fen = 2.5 mm = 1/10”: Needle Depths: Liver =1 fen = 1/10” Gallbladder = 4 fen = 2/5” Kidney = 2 fen = 1/5” Bladder = 5 fen = 1/2” Spleen = 3 fen = 1/3” Stomach = 6 fen = 3/5” Approach these points perpendicularly to the surface of the skin. For Yin points, use lift and thrust with or without twirling with small amplitude and a focus on the slow thrust in, as if pushing a weight into a dense area. Feel for the resistance at the tip of the needle. This is the beginning response of the tissue under the needle as forces converge around the needle tip. When you reach the depth where resistance is met/felt, stop inserting and just twirl until there is a slight grab (yin tends toward deficiency so you are doing a mild stimulation here). If there
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is no grab, quickly pull back to the surface but do not pull out; redirect slowly in stages. This is a modified “warming” technique. For sensitive patients you can omit the twirling and just thrust slow and heavy, then lift quickly, then redirect slow and heavy. If the response is very slow to come (low blood pressure, low thyroid, cold) be careful as it may hit like a hammer blow. For the average reactor, you can go to the point of mild deqi on these points. Leave the points at the depth where the grab or deqi is encountered. Do not pull to the surface. For Yang Meridian excess Points, insert needle swiftly to the required depth, about 1 ⁄ 2 inch, with or without twirling as you insert and lift slowly to the surface, repeating until de qi is obtained; maintain the twirling, wider amplitude (yang tends toward excess so you are doing mild dispersal here to get things moving. If the point is very excess, a stronger dispersal is required and will generate a propagating qi sensation from the point up or down) until there is a distinct de qi sensation on the part of the patient (within their de qi tolerance), and/or a strong grab like a fish biting on the line for the practitioner. You can also insert to required depth quickly, then lift slow and heavy, focusing on the lifting as if there were a weight being pulled up out of the water, like a bucket filled with water. Mu and Shu points:
Mu points must be angled as per textbook instructions, usually oblique. Insert slowly until you meet resistance, and then twirl gently into the resistance until heaviness converges around the point to tonify. To disperse, increase the amplitude of the twirling and focus on the out/lift; or slowly lift as if lifting a bucket of water out of the water, as if there were a great weight being pulled up. This can be repeated, fast in/thrust, slow heavy lift/out movements. Propagating qi sensations will usually occur. Shu points in APM are to be needled about 1/3-1/2” deep from Bl 11-22; 1/2 – 3/4” from Bl 23- 25 , angled oblique slightly down and in toward the spine. They can be stimulated perpendicularly, paying careful attention to depth, then redirected oblique if they are to be left in situ. Some practitioners stimulate perpendicularly, until the required sensation is achieved, then remove. These points can be tonified or dispersed as per mu points. Do not do APM trigger point pecking technique on these points or they will behave like trigger points, not shu points. If a shu point is a trigger point as well, you can release the trigger point first with pecking technique, then needle as a shu point, with mild tonifying or dispersing technique, directly into the muscle. Once stimulated, withdraw to the surface and leave oblique so that they
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cannot be pulled deeper by the contracting tissue as the patient is lying there unattended. In APM Mu and Shu-Point Boogey obtains, which means that points are picked for each of the three heaters based on reactivity, not exact point location, and are typically done according to Triple H eater Regulatory technique where at least two heaters are treated. Always treat a lower heater mu or shu point before doing any points in the upper heater, to prevent strong releases of heat and liver wind. If a strong reaction occurs with upper heater points, calmly remove the upper heater point and compress the area with calming acupressure for a few seconds, reassuring the patient. Then restimulate distal yang needles to “bring the qi down”. Pull over a supervisor immediately. B] Wei Level Distal and Local Points:
Distal Wei Level Points: These Yang Points may be treated with TCM dispersal technique, needling the actual point if tender, propagating the qi downward; or as trigger points into the actual trigger point (peroneus longus trigger point near GB 34 to serve as distal wei level point to release the lateral thigh and hip for example). Local Ashi Points: Any ashi point may be needled wei level shallow oblique insertion, or slowly straight into belly of TTP (TCM technique) as per the peer-patient’s tolerance level. WHEN there is an actual trigger point present, the preferred technique in these APM/CCA ACP sessions (de qi tolerance taken into account) will be the APM fasciculation technique derived from Travell, also known as sparrow pecking in classical Chinese acupuncture. After accurately locating the trigger point with Travell’s text open to guide you, apply dispersing acupressure for 10-30 seconds to ready the point for release. Reassure the patient that if this recreates part of their referred pain pattern or feels like one of their worst tender spots, that is verification that this needs to be released. Show them how it might twitch by manually creating a twitch reaction. Tell them to let you know when they feel the de qi response, and then when they feel the twitch. Explain that you will stop stimulating if they say the response is too strong. For new trigger points you have not encountered, or is the peer-patient does not actually have a trigger point at that site, and if you cannot get a supervisor’s assistance, perform wei-level shallow oblique needling, tugging on the tissue and
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releasing fast. The needle should be ROOTED (ie; the tip is firmly embedded and the needle is not wobbly). WHEREVER POSSIBLE, IF THERE IS AN ACTUAL TRIGGER POINT PRESENT, and with a supervisor present, insert slowly trying various small changes in direction (not fanning as in Travell), inserting to the outside of the muscle or just into the muscle, with the left hand compressing the fascia over the point (which is acupressure being applied along with the needling). This compression is not as heavy or hard as when you found the trigger point, just enough pressure to compress the fascia into the muscle. The twitch might come immediately, or it might begin as a de qi sensation before twitching. The goal of the left hand here is to guide/knead the trigger point toward the needle tip. In this way you are at the outside of the muscle with quite shallow insertion for most points. Maintaining this compression with your left hand, which you ease off of repeatedly to allow the muscle fasciculation to occur, and once the patient has felt a de qi sensation, start slowly pecking into the exact direction that created the de qi response. Peck unevenly, at different rates, to “surprise” the muscle. In some muscles, like the upper trapezius and levator and SCM, you might need to insert into muscle belly to get the beginning of a fasciculation. In most cases (except for levator scapula), you can then withdraw to just being slightly in the muscle, or just at its surface, and apply the above technique. If a point does not start to respond rather quickly, lift the needle to the surface with dispersal technique (focusing with intention on the lift/out movement) and leave shallow. The there may be no actual trigger point present. You may be needling into a trigger point referral zone, which is part of the tendinomuscular meridian, and shallow needling is fine, but actual trigger point technique may not be warranted. Or the area may be fibrotic if the muscular contraction is longstanding, and a twitch may not occur until this fibrotic tissue is softened up(if it can be) with tuina, guasha, or moving cupping. You must inform the patient that there may be soreness, especially where points fasciculated, due to release of lactic acid after the treatment, for up to 24-48 hours. If any points started to bleed during removal of needles, you must inform patient area might bruise slightly while compressing point to stop bleeding. Apply a bandaid if necessary They should take a hot bath or shower afterwards when they can and drink a lot more water or diluted Gatorade to help flush the lactic acid from the
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tissues. No exercise or strenuous activity after the treatment and until the posttreatment soreness has subsided. They should also be told not to try to test the sore area to see if it is looser or less sore. Physical therapists can apply stretch techniques after the treatment to good effect, but no massage, ultrasound, ultrastim or ice until the soreness has worn off.
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9] Classical Chinese Acupuncture Jingluo Theory and APM: Jingluo Study At the College-- A Palpation-Based Approach:
What is evident as one studies the theory and learns the practice of acupuncture from a jingluo perspective, is that palpation plays a major role. In Japanese Acupuncture styles, palpation of the Abdomen (Hara) or radial artery pulses and other parts of the body is relatively gentle, as are some needle techniques. Contrariwise, in some classical Chinese acupuncture approaches, such as Dr. Wang’s “applied channel theory”, palpation starts and ends much deeper, as do many of his needling techniques. Where Japanese meridian therapists often try to elicit as little reaction to the needling as possible, judging if the needling has been adequate by what they themselves feel under their hands, practitioners of classical Chinese acupuncture, such as Dr. Wang, might seek a “de qi” response at every needle, which might be sore or achy to the patient compared to the Japanese approach. Many North American practitioners would situate themselves somewhere in between these two approaches to palpation and needling. In Years II and III, the Japanese Acupuncture curriculum will shift to study with arguably the most prominent North American Japanese acupuncture practitioner, Kiiko Matsumoto Sensei. In ACP sessions and a Spring Intensive each year, Sensei Matsumoto will engage you in a highly pragmatic approach to regulation of Yin (ventral aspect) and Yang (dorsal aspect), sections one and three of her typical treatment approach, as well as to treatment of the Patient’s Specific Complaint with distal-specific and local points and techniques (section two of treatment) aimed at reducing pressure and pain from the channels, thus clearing away knots and obstructions to restore free flow of Qi and Blood. Sensei practices in a manner less Yang, perhaps, than Acupuncture Physical Medicine, but decidedly more Yang than Meridian Therapy, that is aligned, like APM, with removal of holding patterns and clearing away of obstructions that block normal function and create painful and dysfunctional signs and symptoms of distress.
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TWO Philosophical Foundations of APM 10] APM: Beginning with the Ling Shu: “ …I am grieved by not being able to provide for those afflicted with disease”( Ling Shu , Scroll One, p. 1).
So begins the first line of the Ling Shu (“Spiritual Pivot”), the first complete account of the “way of the needles”. In this classical text, the Yellow Emperor, Huang Di, asks his court physician, Qi Bo, to elucidate the essentials of acupuncture, of the channels and collaterals and extraordinary vessels, of their pathways and points, and of the needling techniques for assembling the Qi, or dispersing it. In this account, we learn of the “Ordinary” and “High Skills” of acupuncture. Let us follow this first Scroll, where the story of acupuncture and the Way of the Needles is first laid down in its entirety. Huang Di continues his lament at not being able to properly care for the sick thus: “I wish they did not have to endure the poison of medicines and the use of stone probes. I prefer to use those fine needles that penetrate the channels, harmonize the blood and qi energy, manage the currents and countercurrents, and assemble the exits and entrances. Please unravel this for future generations and enlighten them in the proper methods so this therapy will not be destroyed for aeons. See to it that it is easy to use, difficult to forget, a classical record [ …] Begin with the fundamentals of classical acupuncture. I wish to hear of those essentials (Ibid).” Qi Bo goes on to elucidate the principles for using these fine needles which “are easy to say but difficult to master”, and he states the first over-riding principle thus: “Ordinary Skills of acupuncture maintain the physical body”. He clarifies this a few
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lines later, stating, “Ordinary techniques guard the gates”. Any acupuncturist, it would seem then, can treat the physical body and extremities (gates, especially from elbows to wrists and knees to ankles) that protect against external invasions that might threaten the kingdom within. “High Skills”, on the other hand, we are taught, “maintain the spirit” and one must learn how to “use spirit to reveal the spirit and the guest at the door (Ibid).” The translator of this modern version of the “Spiritual Pivot”, Wu Jing- Nuan, clarifies that “guest” in this context means the “invader” which, he states, “must be honored and shown respect”, lest its power be underestimated. “Shen”, the term translated typically as spirit, refers to the intelligence of existence, the deep knowledge and wisdom all living creatures carry within. In the West, mind-body traditions often articulate a very similar concept as “inner wisdom”, the knowledge we all carry deep inside which knows all that we need to know to thrive and embrace Life fully. In similar fashion, the Chinese language and Chinese medicine also speak of “shen ming”, or spirit clarity. After explaining how to tonify and disperse according to the imbalance of the patient, while attending to the spirit and spirit qi, Qi Bo stresses that one will be able to tell whether the treatment is having a proper effect by reading the vital signs of the patient, which indicate that the spirit, and spirit clarity, have been prodded to good effect: “Look at the patient’s color. Observe the eyes. Know how the Qi disperses and returns […] Listen to the patient’s movement or stillness. Know his balance and his imbalance (Ibid, p. 4).” This refers, I believe, to attending to: the patient’s complexion, which should normalize to a significant extent after the insertion of the first few distal needles to harmonize Yin and Yang, and again when the needles are removed, even though the complexion may well go through dramatic changes during the treatment, where the 5 colors appear, separate and finally blend into a more healthy complexion overall; of the the presence or absence of shen in the eyes and the return of shen, sparkle, brightness and color, often within the first few needle manipulations ;the reaction to needing, with the Qi effect gathering around the tip of the needle making it solidly rooted, or propagating Qi at a distance; the patient’s speech patterns, breathing and other sounds, which should grow more calm, quieter, at peace as the initial YinYang regulatory treatment is performed (often referred to as Root treatment);
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assessment of the patient’s pulses (carotid compared to radial as well as other arterial pulses) and the points themselves, showing excess, deficiency or stagnation. In their “ practical dictionary” of Chinese medical language, Wiseman and Feng define “Shen” or spirit in the wider sense as “that which is said to be present in individuals with healthy complexion, bright eyes, erect bearing, physical agility, and clear, coherent speech (p. 550).” When treating patients in Grand Rounds at the Tri-State College of Acupuncture, I will often focus, and the ceiling mounted video will follow, the changes in the patient when “the qi has been reached”, when spirit clarity is returning to a formerly lusterless complexion, where the patient’s eyes and gaze were dull, their breathing, shallow, and point out that this change toward spirit clarity actually often happens within the first minutes, even seconds of needling, when mild de Qi has been achieved on initial, distal points that were deficient ( causing the needling sensation to gather at the tip of the needle or even sink deeply into the point ), or stronger de Qi has been elicited to propagate the needling sensation ( “how the qi disperses and returns”). At that point, dull eyes whose color was hard to discern often become radiant and full of color, the complexion becomes full of luster and normal color returns, the breathing (“patient’s movement or stillness”) settles into a deeper, more relaxed state, and an agitated patient quiets down, while a lethargic patient starts to become more animated. One could also check the pulses (radial, carotid) or abdominal findings (hara) to see if they are more normal, but in fact once the qi has been reached and the vital signs change in this way, there is no need in my experience for further checking as the signs of return of spirit clarity radiate for any practitioner who takes a moment to mindfully look, listen and hear. The story gets a bit complex to follow at this point: ordinary skills seem to be less powerful, less essential than high skills, as they only guard the outer, physical body, and the “gates” (extremities and the joints, especially from wrists to ankles). This first Scroll lays out the distal, essential shu transporting and yuan source points, the critical points learned in all classically informed and modern TCM teachings, on the extremities from the fingers to the elbows, and from the toes to the knees. In this discussion, it would seem that these points, and especially the 12 source points, are Ordinary skills that can cure the diseases of the viscera when the channels have
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been injured and their organs have been reached, skills any acupuncturist must master. Thus we learn that ordinary skills are in fact essential skills, of treating the 12 distal shu-transporting and source points of the regular meridians when the disease has moved from the surface to impact on the respective viscera. What are these ordinary Skills? Actually, there appear to be four main ones: •
Needling techniques (tonification, dispersal, dredging);
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Obtaining the arrival of Qi (de Qi/Zhi Qi);
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Observing the patient’s vital signs for evidence of change (in complexion, shen returning to eyes, breathing improved, circulation of Qi and Blood improved and other signs of change, in pulse, etcetera;
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Pulling out Thorns, Washing away Stains, Untying knots, Breaching obstructions.
The first three skills aim to regulate Yin and Yang, with distal points. The last skill seems to refer to treatment of the patient’s complaint itself, identified by palpation as “thorns”—areas where Qi is stuck; “stains”—where the color of the skin, capillaries and veins (the cutaneous regions and minute luo vessels) is abnormal; “Knots”—where palpation reveals tight, hard indurations in fascia and muscle (ashi points, kori, trigger points, all signs of excess, in the luo vessels and muscle channels); and “Obstructions” where one must move Qi through, underneath or around the area, as in adhesions, scars, fibrotic tissue, or chronic ashi points. The first Scroll therefore emphasizes first regulating Yin and Yang with distal regular meridian points, which should yield improvement in vital signs, and then attending to thorns, stains, knots and obstructions, which are local signs of excess, stagnation, blockage. Whether a style prefers to focus more on distal points or local points to deal with these excesses, relieve symptoms, and address the patient’s specific complaints, the first chapter of the Ling Shu includes that this attention to the patient’s chronic complaints is a part of the Ordinary skills any acupuncturist should possess. In such treatment of local areas that are discolored, tight, inflamed, there should be signs of local improvement. This should be even more the case after a few treatment, when improved circulation of Qi and Blood, and release of excesses, leads, for example, to more normal color and texture in scars, or in the
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ankles, once brown with stagnation in elderly patients, or to less fibrotic soft tissue, or looser muscles. In my personal experience it is not enough to treat distal shutransporting, source, luo and xi-cleft points, to attain such changes in locally excess, inflamed or stagnant areas. In this, I see acupuncture as a physical medicine akin to tui na, anma, shiatsu, sotai, guasha and stationary and moving cupping. These obvious local techniques can be used instead of needles of course, but I have made a career of practicing acupuncture only, with excellent results in this physical medicine domain. I stopped using moxibustion early in my private practice, because the first building where I worked, and the one where I now work in my own cooperative apartment, forbade it, as do many buildings in the NYC area according to faculty and graduates of the college. I also stopped cupping and guasha, because many of my first elderly Jewish patients reacted quite negatively to a medical professional charging for what they saw as folk techniques their own mothers used on them, and because of the bruised-like marks which they found disagreeable. Finally, I quit doing acupressure and shiatsu early on as well, because I developed familial arthritis in my 30s, and massage made my hands ache and grow numb. One might say I have worked like the straight chiropractors of the old days who only did chiropractic manipulations, and with excellent results. I am a straight acupuncturist. That being said, I encourage students to use all AOM modalities they have learned, depending on the patient and their own proclivities. These ordinary skills are part of the curriculum of all North American colleges of Acupuncture and Oriental Medicine, whether TCM, 5 Element, or Meridian based. They seem to be the common knowledge, which is tested on North American national board examinations given by the NCCAOM and used by many states as the basis for licensure upon graduation from such colleges. Ordinary skills-- common knowledge--, and yet often referred to in North America as “Root” treatment, a designation which one would think would be reserved for discussion of the “High Skills”.
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So then what of these “High Skills” which, we are taught, “maintain the spirit” and “use spirit to reveal the spirit” while attending to the disease (guest at the door)? This theme, of attending to the patient and the patient’s disease with ones heart and spirit repeats itself throughout the discussions of needling in this classical text. It would therefore seem that a requirement for practicing High Skills would be for the practitioner to be able to navigate this relationship with the patient from a place of spirit clarity her or himself. Chinese medicine postulates that the heart stores the spirit, and so the practitioner must have a calm heart, not muddled by the seven emotions, and focus her or his spirit on that of the patient, attending to the deep intelligence and wisdom of existence, and the will to live and be well that dwells within all living beings. The change prodded by the informed manipulation of the needles, which must reach Qi to be effective, portends the “onset of a therapeutic effect [which] is faster than shooting an arrow (Ling Shu, p. 1)”. Elsewhere this classic text clarifies that once the Qi has been reached and the vital signs of the patient have improved as discussed above, even though the disease itself will not necessarily show signs of improvement, the disease will in fact already have lost some of its hold. And how are these “High Skills”, which control the “moving power and its Way”, the Yin and Yang Root of the Kidneys, the prenatal qi and the mingmen fire that support life, which is “inseparable from its space”, and which “is clear, quiet, and subtle (Ibid), the space of the Tantien, achieved? Again this first Scroll is full of paradox and complexity. In order to manifest High Skills, one must follow “the way of acupuncture” defined, simply, thus: “to tonify hollowness, to disperse fullness, to dredge stasis”. One does this, by paying attention to the movements of the needling: first “slow, then quick” which lead to tonification (slow in, fast out to sink the yang qi deeper, to yangify), or first “quick, then slow” which lead to dispersal (fast insertion, which elicits propagation away from the point, done repeatedly with slow withdrawal to enhance the propagation/dispersion, to withdraw the deep yin, to yinify). Thus, immediately after speaking of High Skills, and of the use of spirit to treat spirit, Qi Bo proceeds to detail how to tonify and disperse and dredge with needles,
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after first eliciting qi. For two pages, we learn of the nine needles and their use, how deep to needle, how to needle distal and local points, defined as “the manipulation and the way of the needles”. We learn how to use the needling hand to “make a vertical insertion”, stressing that “the spirit seems to be at the tip of the needle”, and finally, again with a calm heart and mind, to “focus awareness on the patient” so as to read the vital signs for evidence of therapeutic change, which will come fast. It appears that High skills are a concept that implies practicing Ordinary Skills with focused attention, mindfully, not distracted by anything, with spirit clarity and a mind not disturbed by the 7 emotions. High Skills, based as they are on the spirit clarity of the practitioner, would be hard to manifest as a beginner, who must learn over time how to remain mindful and focused as the needling has its, often powerful, effects. To do this, like any East Asian art, one must practice, and focus on the act of needling itself, looking at the skin, not allowing it to become bunched up, keeping the needling surface taut like the surface of a drum with the non-needling hand which maintains this taut surface, while the needling hand is ready for whatever effects the needling generates, which may reveal a tiger being held by its tail as we are told later in this classical text. High skills therefore seem to refer to focusing on the patient, not being distracted by anything, keeping ones attention on the skin, the flesh, the needle, the point one is stimulating, staying attentive for therapeutic changes in the patient’s vital signs. To be able to do these needle manipulations safely and effectively is required, as these constitute the common, very ordinary skills any practitioner must first master. And this takes time, and diligent practice. But with perseverance, and attention paid to ones own development of mindfulness and spirit clarity while needling, these Ordinary Skills can become High Skills. The first Scroll ends by addressing the critique of some people, who “say chronic disease cannot be cured. This is speaking incorrectly. The skillful acupuncturist can take hold of the disease in the same way that he pulls out thorns, washes out stains, unties knots, or breaches obstructions. Disease, although chronic, still can be ended. Those who say diseases are incurable have not mastered the technique of acupuncture (Ibid).”
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The next 80 Scrolls detail how to perform pattern differentiation of the regular meridians, the secondary collaterals and the extraordinary vessels, with detailed description of signs and symptoms of each type of meridian dysfunction, a story of the “jingluo”, of the channels of acupuncture and the way of the needles that contrasts starkly with the Traditional Chinese Medicine story. This modern TCM story, constructed only recently, in the 1960’s to 1970’s, first told in English in The Outline of Chinese Acupuncture, then in Essentials of Chinese Acupuncture and then in its successor volume, Chinese Acupuncture & Moxibustion was a story bereft of the jingluo, of discussions of Man between Heaven and Earth and influenced by the forces of the Cosmos, with no discussion of Shen or spirit of any significance. The original TCM approach developed in the 1960s to 1970s in the PRC seems to have stripped acupuncture of its High Skills, of its shen and of its soul. In the early days in the development of the North American AOM profession, the founders and key players of the schools at that time struggled with what texts should become the foundational, authoritative texts for accredited schools, on the basis of which national board and state licensure examinations might be developed. It was clear in those early days that many practitioners had been more influenced by European acupuncture traditions, like J.R Worsley, Van Buren and Mary Austin’s Five Element styles, Felix Mann’s texts based on translations of other, meridianbased texts from PRC from the earliest days of TCM, and French Meridian traditions, and a home-study program offered by the Occidental Institute of Oriental Medicine. As we founders and teachers of those North American schools of acupuncture met to develop the infrastructure for an AOM profession (AOM being chosen as the official designation, because it recognized that it was “Acupuncture”, first and foremost that had captured the North American public and medical imagination, and “Oriental Medicine” to make peace with all East Asian traditions which felt TCM was just one style, while “Oriental” was inclusive of Japanese, Korean, Vietnamese and other East Asian traditions, even if anthropologists at the time were already replacing “Oriental” with “East Asian”) . We struggled over the disparity between the European influences, some via Vietnam through France, which seemed to
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predominate in the schools on the East coast and in Chicago, and what we soon came to refer to as the California Model of TCM, where herbs and acupuncture were required in short order as part of State approved schools and for licensure. After much struggle, and owing to the fact that the main texts in English at the time from East Asia were TCM texts, and after the publication of The Web That Has No Weaver which made learning TCM much easier for North American students, these early pioneers, myself included, achieved a compromise where basic TCM foundations would serve as the basis for accredited schools, and national board examinations. At the same time, the council of AOM colleges was adamant, however, owing to the influence and steadfastness of the East Coast and Midwest schools, that AOM schools could teach whatever other styles of acupuncture they wished, as long as these TCM foundations were addressed in the core curriculum. During this period, in North America but also in Europe which seemed to follow suit a few years behind us, texts rich in more classical styles of practice, especially classical Chinese acupuncture, disappeared: Royston Low’s Secondary Vessels of Acupuncture, Felix Mann’s Meridians of Acupuncture and Chamfrault and Van Nghi’s texts detailing jingluo practice all went out of print. At the same time, a large number of TCM texts, in translation or by East Asian and Western English speaking authors, proliferated, making the TCM foundational knowledge base that much more secure. And then something interesting started to happen in about 1990. Other texts, from other styles of acupuncture that were based on Classical Chinese Acupuncture, started to emerge, in translation, and written in English by practitioners in North America, that told different parts of the way of the needles from meridian, five phase and other classical perspectives. During this time, several texts appeared in English on various Japanese styles, including the tradition of classical meridian therapy, as well as on European meridian acupuncture and new approaches in PRC based on more classical approaches. Dr. Yitian Ni’s seminal text Navigating the Channels of TCM appeared at that time, with a foreword that stressed that the advent of TCM as the main style in North America, while good for those wishing to practice Chinese herbology and ZangFu (organ) differential diagnosis and treatment, proved detrimental to those who wished to learn how to perform a
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jingluo differential diagnosis of the channels, collaterals and extraordinary vessels, specifically, as part of meridian-based acupuncture treatment. And so here we are, in 2011, with several new books on the meridians that are very different from TCM texts. Yet North America colleges must still teach TCM foundations, and national board examinations, and state licensure examinations, are still based primarily in that one, modern, Chinese tradition that began in the late 1950’s, and is already showing signs of potential demise in PRC, where new, younger voices are calling for discarding TCM differential diagnosis in favor of biomedical diagnosis, and for a “contemporary medical acupuncture”. There are more English language texts on different styles of acupuncture, especially meridian-based acupuncture and acupuncture treatment of pain, musculoskeletal and sports injuries, available in English today than there were texts in English on TCM acupuncture thirty years ago when the compromise to make TCM the foundational knowledge base was reached. What I would like to try to do with this Reflective Practicum is to start a movement for revisiting this biased TCM foundational knowledge base, thus loosening the hold this style has held on North American Acupuncture education, licensure and practice for 25 years. I hope to to illuminate the story of a forgotten path, the Other Acupuncture, that was based in texts just as authoritative as the ones that have become TCM primers, texts which made their way, through a curious and circuitous route, to England, and to France, via Vietnam, and to Montreal and the New York City region, which also existed and were written by experts in Classical Chinese Acupuncture from the academies of Chinese medicine, who were about to be replaced by State mandated colleges and teachers of TCM, with a unified, orthodox curriculum that extinguished the spirit, the power, and the elegance of Classical Chinese styles. It may well be that the time has come to revisit the foundational knowledge base that has ossified education in acupuncture in North America, to allow for a more comprehensive, and effective approach to treatment that is pragmatic, not orthodox, and able to adapt to actual clinical reality in the case of those patients we treat every day. In such a return to the beginning, we would do well to insure that
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our acupuncture education prepares our students to treat what they will encounter most frequently in their North American practices, namely chronic pain and its associated dysfunction, musculoskeletal and sports injuries, repetitive strain and cumulative trauma disorders, as well as chronic stress, fatigue disorders, and functional disorders affecting the autonomic, hormonal, cardio-respiratory, gastrointestinal, genito-urinary and reproductive systems. We could then select other authoritative texts to drive acupuncture education and examinations, where these common disorders would be represented in their proper proportion, thus displacing inappropriate internal medicine disorders and their ZangFu patterns, which belong to Oriental Medical (read, Chinese Herbology and Pharmacology) teachings and test
Alternative Medicine show that an enormous number of people avail themselves of these practices for their health, wellness and disease prevention, which I will return to in a later reflection. Such practices are consistent with, and complementary to Acupuncture and Oriental Medicine life nourishing practices, and AOM practitioners trained in such approaches will be in a better position to engage in wellness and health prevention lifestyle counseling with their patients in a way that is best suited to their patients needs. Such a combination of East Asian and Western approaches might well become a more and more practical way of bringing life-nurturing practices back into a Chinese medicine that would restore the soul and spirit of Western AOM practitioners and their patients, through creative conjunctions and collaborations for best care.
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11] Classical Chinese Acupuncture-Ordinary Skills THE PROBLEM : As I have looked closely over the past year or more at why and how the jingluo filter teachings at the college have been somewhat eroded at the college, something I saw in the practice of students in clinic but could not quite put my finger on, I realized that I had followed in the same process articulated by Maciocia, by allowing the teaching of the signs and symptoms of the regular meridians to be supplanted by those of the ZangFu.
Early North American Acupuncture Practice As I began writing this Reflection, I scoured over the earliest books in English that I used to teach my first students, when textbooks in English were scarce and the main TCM text in English was still Outline of Chinese Acupuncture . In those early PRC texts, there were only 14 meridians portrayed, with no classical signs and symptoms from Chapter 10 of the Ling Shu a nd where disorders were presented as more or less biomedical diagnoses with points with no TCM differentiation or rationale for the points either, or even a TCM pattern diagnosis in ZangFu terms. When this PRC text for the English-speaking world was republished in a new edition, in around 1981, it did contain TCM theory, and even a short description and pictures of the other secondary and extraordinary vessels, with insufficient information with which to be able to make a jingluo pattern identification. In the early days, when TCM texts first entered North America, the Five Element tradition developed by J.R. Worsley in Leamington Spa, England, had graduated some of the earliest trained practitioners of acupuncture in North America. This tradition was brought to the States by Bob Duggan and Diane Connelly, who founded the Traditional Acupuncture Institute (TAI) in affiliation with Worlsey’s institute, based on that tradition. I became close with Duggan, and other faculty from TAI as it was known then (now TAISophia) and was even a member of their advisory board at one point. I taught frequently at TAI, and Bob Duggan and later Jim McCormick, a
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classmate of Duggan’s from the first Leamington Spa class, and Lorie Dechar, even later, an early graduate of TAI, taught at Tri-State (and Jim and Lorie still do). I was struck by the difference in focus of their education, which was highly influenced by the humanistic psychology movement that existed in those days and that Duggan and Connelly and other TAI faculty were involved with, as compared to the TCM based education that was becoming the norm in California schools. Given that I was the first president of the new council of colleges, and intimately involved with establishing the first national board examinations in acupuncture through the NCCA (now NCCAOM), I was immersed in debates about schools of thought and traditions, and Duggan and I were immediate allies and fierce defenders of the right to diversity in acupuncture education, while some of the California schools were beginning to demand that the national standard in the United States be the TCM tradition from the PRC. I took on the role of mediating this debate, between what was being called the “5 Element” versus the “8 Principle” perspectives. In those days I developed a simple way of differentiating one style of practice and practitioner from another by simply paying attention to which of the main diagnostic filters each style, or practitioner, privileged over others that may have been shortchanged, or even ignored altogether. What became clear was that practitioners of the “5 element” tradition of Worsley’s used the 5 element filter far more frequently than the YinYang filter (which they resorted to just to differentiate between excess and deficiency conditions, and to perform tonification and dispersal needling techniques) whereas “8 principle” advocates expanded the YinYang filter to include far more detail about signs of Hot and Cold, Internal and External, and even Yin and Yang patterns. As for the Qi, Blood, Fluids, Shen and Essence filter as it was often referred to in those days (before Shen disappeared from TCM discussions as a way of assessing signs and symptoms in a diagnostic process), the 5 element practitioners talked extensively about Shen, ( given that Worsley reordered the regular meridian system to start with the Heart, rather than the Lung which controls Qi and its movement as in all classical and modern Chinese and Japanese texts—because the Heart “stores the Spirit-Mind”), but gave little mention of Blood or Fluids. Conversely, 8 principle practitioners of what soon became referred to as TCM acupuncture talked far less about Qi or
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Shen, and spoke in great detail about Blood, and of the thin and the thick fluids, phlegm and Fire. Finally, what both approaches had in common, much to their surprise, was that they centered their teaching and practice around ZangFu pattern identification: the 5 element practitioners preferring to focus more on the psychoemotional aspect of the 12 “officials” rather than on their visceral functions and disease signs and symptoms, while TCM practitioners of acupuncture ignored to a greater or lesser extent the emotional side which did appear in the classics as we saw in last month’s Reflection, focusing more strictly on the TCM detailed ZangFu pattern identification, and differentiation of Qi, Blood and Fluids to differentiate signs and symptoms of disease. What neither approach contained, which situated what I was trying to do at the TriState College of Acupuncture in yet a third position, was the jingluo filter which taught how to regulate Yin and Yang by means of appropriate use of treatment strategies from the regular meridians—where 5 element strategies were just one option among others, as well as from the secondary (especially luo and tendinomuscular meridians) and extraordinary vessels which these two main approaches seemed to not make use of at all. In this process, I became so involved in these debates, and invited to teach was most different about the “French meridian” traditions I had studied at other AOM colleges, that I focused most heavily on teaching the secondary and 8 extraordinary vessels, and allowed the regular meridians, and the principal foundation for the jingluo filter, to slip away and be replaced little by little, by TCM textual explanations. The only solution which it took me over two decades to realize was to return to the Ling Shu , and especially to Chapter 10 where regular meridian pattern identification, from a jingluo filter perspective, is laid out clearly.
Circuit-Needling There are three detailed clinical discussions in English of the Ling Shu , by Yitian Ni, Shudo Denmei and Zhao and Jun Wang. Giovanni Maciocia’s ambitious The Channels of Acupuncture must also be mentioned as an academic resource with useful charts, but the repetitive and at times over indulgent nature of the
)'
presentation makes it very difficult as a clinical text, which for instance hopelessly confuses any attempt at understanding the luo collateral, muscle channel, Cou Li layer, cutaneous regions and minute luo vessels and luo regions. Also, owing to an unfortunate dismissal of organ interior symptoms as part of regular meridian differentiation (in favor of TCM Zang Fu pattern differentiation as shared in last month’s Reflection Two), and an alarming misunderstanding about the critical role of ashi points and palpation for actual tender points versus favorite textbook points for muscle channel problems, I am lead to question whether Maciocia practices the acupuncture that he preaches in this unwieldy tome. Useful as background and additional reading for the initiated acupuncture educator or practitioner, it is misleading and confusing as a foundational, or clinical text for students or neophytes to the jingluo approach. What is clear in studying the Ling Shu i n these texts is that they are focused on what Paul Unschuld refers to as “circuit-needling” with the palpation phase of the four examinations focused on points, and arterial pulses, throughout the body as opposed to diagnosis of the meridians via the sole wrist pulses, as advanced for the first time in the Nan-Ching . Unschuld stresses that the interest in the Nan-Ching “remained restricted to theoretical discussions and the practice of pulse diagnosis. Actual clinical practice in traditional Chinese medicine hardly followed the “conceptual stringency” of this text, and of the “doctrines of systematic correspondence” or of pulse diagnosis at the wrist as the sole means of assessment of meridian circulation, Unschuld clarifies, concluding on this point: Therapeutic practice—that is, circuit-needling—continued along the lines dictated by experience, not theory ( NanChing: The Classic of Difficult Issues t ranslated and annotated by Paul U. Unschuld, University of California Press, 1986, pp. 40-41).” In Dr. Yitian Ni’s text, Navigating the Channels of Traditional Chinese Medicine she presents a summary of channel pathology from Chapter 10 of the LingShu which is fairly complete, which TCM has left out, and then detailed lists of disorders and their signs and symptoms of channel versus organ disorders, which derive from her vast clinical experience and other texts listed in her bibliography. Based on this approach, if one knows the basic signs and symptoms of the main or regular channels, it is easy to then reference the list of external, “channel” disorders versus internal, associated “organ” disorders, and then move to the clinical
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application section where she discusses the use of the main points from the meridian in question, in order of importance, and point combinations with other regular, secondary and extraordinary channel points. She even has an index of symptoms in the back of her book, taking one to the pages where such point combinations are discussed with specific disorders of the various systems of the body. She does not, however, discuss the point strategies she uses, so a careful study is in order to recognize, for example, that her favorite distal points for the regular Lung channel are the Luo point (Lu 7), the Source point (Lu 9), and the He-Sea point (Lu 5), and her favorite local points, Lu 1, the Mu point. A useful exercise for anyone interested in gaining a deeper appreciation for regular channel pattern identification, and secondary vessel and extraordinary channel differentiation would be to take each channel one by one, and analyze the point strategies of the points Dr. Navigating lists for recurrent strategic patterns. Regarding the use of local meridian points Dr. Ni stresses in her introduction that any local point from a meridian may be used to treat local symptoms in the area of that point, a primary principle of “circuit-needling” and meridian palpation as used extensively in APM.
A Japanese Meridian Approach In Shudo Denmei’s text, translated into English by Stephen Brown as Japanese Classical Acupuncture-- Introduction to MERIDIAN THERAPY , there is a detailed discussion of the symptomology of the twelve meridians, as this is often termed, as well as the five Yin organs. Shudo starts this study with the statement that “symptomology of the yin organs implies pathology of the yin aspect. The Li-Zhu school of Chinese medicine holds that the yin always tends toward deficiency, and the yang toward excess” and regarded the Spleen and Stomach, and the middle burner to be the most important focus of middle burner warming treatment (ibid, p108).
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Shudo adds that the meridian therapy schools of thought in Japan define this hypothesis as follows: “the yin organs and meridians have a tendency to become deficient, and the yang organs and meridians to develop excessive conditions (ibid).” Shudo Sensei continues by presenting the signs and symptoms for the “five yin organs” (Pericardium is deleted), from the Su Wen and the Nan-Ching Japanese translations. Certain symptoms from the Su Wen a re deleted in the Nan-Ching version. Shudo concludes that as for the yang organs, there is much less discussion in the classics, and their signs and symptoms “resemble those for diseases of the same organs in modern medicine (ibid, p. 110).” For these symptoms, he cites Chapter 4 of the LingShu . Shudo then lists the symptomology for the twelve regular meridians. He cites the discovery of the Ma Wang Tui manuscripts in 1973, which are thought to be a few centuries older than the Yellow Emperor’s Inner Classic (Huang Di Nei-Ching) comprised of the Su Wen and the LingShu. As he presents the signs and symptoms for the twelve regular meridians, then, Shudo cites both the Ma Wang Manuscripts and Chapter 10 from the LingShu. This presentation seems the closest to the original that is available in English. Shudo begins by citing two phrases from the Ling Shu , which were poorly understood until the discovery of those earlier documents. These phrases, which appear in Chapter 10 of the LingShu are: “ ‘when disturbed, disease occurs’ (shi dong ze bing ) and ‘when giving rise to disease’ (shuo sheng bing ). These two phrases are the way in which regular meridian symptoms are presented in Ling Shu Chapter 10: “when disturbed, disease occurs” refers to an external disruption in meridian Qi (channel symptoms) which can be treated by “treating the meridians involved”; “when giving rise to disease”, on the other hand, refers to internal conditions where channel Qi disruption “progresses beyond a certain point [and involves the organs]” (Ibid, p. 112, citing Kuwahara, 1976). These concepts are discussed in Chapter 22 of the Nanjing where “when giving rise to disease”(sousheng) denotes a disorder at the level of Blood, as clarified in a private communication with Stephen Brown regarding his translation above. In Wang and Wang’s text, there is a careful if sometimes rigid reading of the Ling Shu reorganized so as to allow for a clinical approach—“Ling Shu Acupuncture”. In
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their presentation, which unfortunately repeatedly claims to represent the true and correct acupuncture, with everything that came in later classics and modern TCM as aberrations, the organization of the discussion is immediately clinical: Diagnosis by Comparing Renying and Cunkou (carotid and radial artery) pulses for regular meridian dysfunction; the entire jingluo filter (regular meridians and secondary collaterals, finishing with 8 extraordinary meridians and the relationship between meridians and Zang-Fu organs; the muscle and cutaneous regions; acupoints; acupuncture techniques and contraindications. There are very useful charts and diagrams throughout, with a detailed list in chart form of the regular meridians (pp. 90-92) from Chapter 10 of the Ling Shu and translation of the Su Wen C hapter 22 on the ZangFu organs (p. 164). They do, however, following PRC/TCM texts, almost completely eliminate the role of the emotions and any discussion of Shen .
Regular Meridian Pattern Identification Following are the S&S of the Arm Taiyin Lung Meridian as an example of Chapter 10, (as cited in Shudo Denmei’s text, pp. 113-126; see also his detailed and excellent discussions of each set of signs and symptoms. Also see Ni’s text, pp. 17-103 for her detailed clinical applications). Shudo Denmei begins his study of Chapter 10 by shedding light on the terms used to differentiate between disorders affecting the meridian only (exterior), and those where the disorder has moved deeper to include the associated organ as above, which bears repeating in Shudo’s own words. This clarification was made possible when scholars compared the Ling Shu to the earlier Ma Wang Tui burial site manuscripts known as the “Moxibustion Classic”. Based on this comparison, the meaning of two critical terms--“When disturbed, disease occurs” (shi dong ze bing )” and “When giving rise to disease” ( suo sheng bing ) was elucidated: “ ‘When disturbed, disease occurs’ refers to abnormal conditions arising when the meridian [Qi] is disrupted, and the progress of this disturbance can be checked by treating the meridian involved…’When giving rise to disease’ refers to conditions in
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which the disruption [of Qi] in the meridian progresses beyond a certain point [and involves the organs]” (Ibid, p.112, citing Kuwahara, 1976). I will break out these two sets of symptoms, for clarity, as well as the last set of symptoms that relate to excess and deficiency of Qi. I refer the reader to Shudo’s text for the more detailed comparison of the Ma Wang Tui manuscript symptoms, compared to those in Chapter 10 of the LingShu (ibid, pp. 113-126. The reader is also referred to Shudo’s description of disorders of the sense organs and parts of the body, which are very useful clinically (ibid, pp. 126-132) and a similar discussion in Maciocia’s text cited above (ibid, p. 98) which are commonly learned in any acupuncture tradition. Let us follow Shudo and the translation he used for the arm Taiyin Lung Meridian: Arm Taiyin Lung Meridian Meridian (Exterior) S&S:
“When disturbed, disease occurs”: Distention and fullness of the lungs, wheezing, coughing, pain in the supraclavicular fossa. When severe, arms folded over the chest (while catching ones breath) and blurred vision. Organ (Interior) S&S:
”When giving rise to disease”: Heat in the face, wheezing, coughing, dry throat, irritability and fullness in the chest, pain along the channel, depletion, and heat in the palms. Excess and Deficiency:
”When the Qi is excessive”:
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Pain in shoulders and intrascapular region, sweating from wind-cold, frequent urination and yawning from wind.
”When the Qi is deficient”: Pain and coldness in the shoulders and intrascapular region, shortness of breath, inability to take in deep breath, urine color change.
Internalizing Jingluo Symptomology In his always pragmatic fashion, Shudo Denmei shares the difficulty he experienced in attempting to just commit to memory such symptoms, stating that he “drew in the location of all the symptoms on a figure of the body, and marked them with a simple notation for easy reference (p. 113).” Another useful tool, he suggests, and then supplies in his book, is a chart of symptoms organized by body region. Dr. Ni, on the other hand, provides charts that further differentiate and list symptoms of the Channel as opposed to the Organ. She then lists clinical applications such as exterior syndrome, immuno-deficiency, respiratory disorders, nose and throat disorders etcetera, with her point palette of lung meridian points in order of importance in her experience and based on classical sources. She concludes with point combination with points from other channels, and lists an index of symptoms in the back of the book that bring the reader back to these charts. Making the effort myself to learn the classical symptoms of the regular meridians, secondary vessels and extraordinary vessels, which make up the jingluo filter, as I first started translating and teaching from Van Nghi, I quickly realized that I could not retain the information unless I combined it with palpation of distal and local points from these pathways during the palpation aspect of the four examinations. I found it essential from the beginning to resist an overly academic study of the meridian system, and to focus instead on internalizing and embodying a tacit feel for each aspect of this system based on what one feels underneath ones fingertips, and what one sees in observing the body surface and patient’s structure and bearing.
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In refining this teaching, which I inherited from the Quebec Institute of Acupuncture and especially from its French-Vietnamese influence via Chamrault and Van Nghi’s texts and teachings, I followed these two French authors in their celebrated L’energetique humaine where they discussed the jingluo filter in three successive chapters, Wei, Ying and Jing, facilitating an understanding and clinical use of these classical treatment strategies: •
Wei level t reatment refers to the strategies for the muscle channels and
cutaneous regions for myofascial disorders, which I refer to as “surface energetics”. •
Ying level t reatment is the nutritive Qi level, the level that “promotes Grain
Qi”, and refers to the strategies for the regular meridians and their associated organs, which I refer to as “functional energetics”. •
Jing level t reatment refers to the strategies for the 8 extraordinary vessels,
mobilized according to Van Nghi’s teachings, when the regular meridians/organs are under assault such that two or more meridians/organs are targeted. This is a very modern reading, perhaps influenced by Hans Selye’s theory of the stress response, and his General Adaption Syndrome. In this model, the GAS enables a small group of internal functions to mount the defensive against unabated external stressors, in order to protect the majority of internal organ functions and structures from this onslaught. In the French-Vietnamese teachings perspective influenced by Van Nghi, it is the role of the extraordinary vessels to become operational in order to protect the 12 regular meridians/organs. I developed a set of 4 adrenal/stress patterns to map out protocols for using the extraordinary vessels in such chronic stress disorders, as shared in last month’s Reflection, based on these teachings, in my Acupuncture Physical Medicine (pp. 85-120) as I shared in chart form in last month’s Reflection.
The 12 Regular Meridian Circuits When teaching the 12 regular meridians (jingmai) it is essential to recognize the way in which they are comprised of three circuits of four meridians each that follow a parallel almost closed-circuit flow: from deep in the Sea of Qi and Blood of
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the interior, and the associated yin Organ (Zang), a circuit begins by exiting on the upper chest, next flowing down the inner arm (Yin aspect) to the finger; then transforms into its Yang paired meridian and flows up a parallel pathway on the dorsal, outer arm (Yang aspect) to the shoulder, neck, face and head; where it meets its Lower/Upper connected Yang meridian of the same name to flow down from the face to the neck, chest, or upper back, abdomen or mid and lower back, upper legs, lower legs and foot to the toe, where it transforms into its foot Yin meridian pair, then flowing back up the inner Yin aspect of the foot, lower leg, upper leg, front of the torso, making a descent deep in to the Sea of Blood and Qi again, and then starting all over in this semi-closed loop fashion, carrying Qi and Blood (oxygenated blood) to all areas of the body, carrying back deoxygenated blood, renewing itself with a fresh supply of nutritive Qi with each circuit loop.
Regular Meridian Symptomology: Below I will present the signs and symptoms of the 12 regular meridians as three circuits in this way, as another way of aiding in internalizing and embodying this data for ready clinical access, integrating signs and symptoms from Shudo and Ni’s presentations, based on the Ling Shu .
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TAIYIN/YANGMING CIRCUIT – Regular Meridian (Jing Mai) Pattern Differentiation
Body Area
Hand Taiyin/
Hand
Foot Yangming/
Foot
Lung
Yangming/
Stomach
Taiyin/Spleen
Toothache,
Facial pain,
Root of
swollen
ashen
tongue rigid,
cheeks,
complexion, hot
jaundice
yellow eyes,
face, nose bleed,
dry mouth,
nasal
nosebleed,
congestion,
swollen
cervical neck
throat/thirst
pain, skin rashes
Signs &
Large
Symptoms
Intestine
Face,
Flushing
Head, Neck Throat
Dry throat
Vertigo
around mouth, swollen painful throat, submandibular pain Perspires easily, General
Yawning,
Violent
warm diseases,
Whole body
sweating &
shivering
whole body
heavy
pain from
from cold,
chilled as if
wind-cold
inability to
doused by
warm up
water, frequent stretching and yawning
Cardio-
Shortness of
Respiratory,
No organ S&S
Breast pain,
Chest
breath,
heart pain (ST
irritability
Chest/Upper
irritable
18-15), flank pain
Back
breathing,
(SP 21), front of
cough,
body hot
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wheezing, fullness of chest, hugs oneself while shivering,
Gastrointestinal,
Gastric pain
Borborygmus,
Nausea from
No Organ
edema/distention
eating,
S&S
due to cold,
stomach pain,
Abdominal
belching,
discomfort,
passing gas
constant hunger,
and
ascites, area hot
defecating
or cold, pain in
brings great
intestines
relief,
Abdomen
diarrhea with mucous and blood Genito-urinary, Gynecological,
Frequent
No Organ
Yellow urine,
Reproductive,
urination
S&S
pain in lower
Lower Back
Scanty urine
abdomen (ST 2630) Lower abdomen and
channels
Heat in the
Pain along
extremities
palms, pain
Heat, swelling
channel (ST 32-
heavy, medial
along
and pain LI
43), rigidity of
thigh and
channels, esp.
12-15; index
knee, middle toe
knew swollen,
LU 3-10
finger
dysfunction
chilling and
dysfunction
numbness along SP channel of calf, big toe dysfunction
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Mental Signs & Obsessions
Mental
Aversion to
Mental
Symptoms *
that are
confusion,
people and fire,
sluggishness,
future
defective
rapid heart beat,
melancholia,
directed,
elimination of
shuts oneself in
obsessive
feels
ideas,
when frightened,
thoughts of
vulnerable
stubbornness,
prone to mania,
the past, fixed
complacency
singing,
and rigid
in being
disrobing and
ideas,
wrong, rigid
running about,
sleepwalking,
thinking,
depression,
agitated
distressed by
death wishes,
sleep,
cold
mentally
nightmares
overwrought, mentally slow Point Palette
LU 7-luo
LI 2 –dispersal ST 44-43 ashi for
SP 3- source
LU 9 source
LI 4-source
heat/Xu Li
SP 2-
LU 6 – cleft
LI 6-luo for
ST 36, 37, 39-
tonification
LU 5-dispersal
Toothache
lower Sea points
SP 2&3-ying
ST 40-luo
and shu
Lu 3-4 window to
SP 4- luo
sky
ST 25-LI/ST
SP 5-dispersal
Lu 1-2/SP 20-
union
SP 6- three
Taiyin union
ST 18/xu li heart
leg Yin
pain/heart burn,
SP 8-cleft
Stomach Fire
SP 9-Sea SP 10-Blood SP 21-Great Luo
Associated channel points
Local for S&S
Local for S&S
Local for S&S
SP 20/Lu 1-
Ashi for pain
Ashi for pain
Taiyin union
Ashi for pain
Local for S&S Points from
Points from LI,
Points from
ST, LU, SP
SP, LU for circuit
LI, ST, SP
channels for
Points from
channels for
circuit
ST, LI, LU for
circuit
Ashi for pain
circuit
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(* Cf. Seem, citing Faubert, Acupuncture Imaging pages 27-28. These charts are derived from Shudo Denmei, with information from Ni, Seem, Faubert.)
Regular Meridian Treatment In the Ling Shu Chapter 9, treatment of the regular meridians is presented thus: 1] If Spleen is deficient, Stomach is excess (carotid pulse four times stronger than radial pulse): tonify Spleen with one needle; disperse ST with 2 needles. If carotid pulse is “restless”, disperse Large Intestine (for circuit). While the actual points are not indicated in this chapter, chapter One stresses needling the source point for yin meridians, and a later chapter suggests needling the ying (spring) and shu (stream) points for disorders of yin of yin. Dispersal points for Yang meridians could be dispersal points themselves, luo points, jing-well points, he-sea points, xi-cleft points for acute disorders, or fire points. So one could tonify Sp 2 or 3, or both, and disperse ST 40 and ST 36 for example, and disperse LI 2 and LI 5. If the reverse is true, with radial pulses stronger than carotid, this is Yin meridian/organ excess: 2] If Spleen is excess (radial four times stronger than carotid): disperse Spleen with one needle (Sp 5 for example); tonify Stomach with 2 needles (ST 38 Fire/Tonification Pt and ST 36). If radial pulse is “restless”, disperse Lung meridian (Lu 10 or Lu 5 for example for the circuit as above). We used to see the late Dr. Ki Min Kim, a master Korean constitutional acupuncture practitioner after whom the Tri-State College of Acupuncture Library is named, do this carotid/radial diagnosis, and root treatment based on this chapter of the classic text, using the Five Phase “4 needle technique” strategies as the base, followed by careful dispersal of local excess, constrained and stagnant points/pathways.
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Regular Meridian Disorders for this Circuit from Dr. Ni Note: Any point on a regular meridian may be used as a local point for signs and symptoms in that area on that meridian. A] Hand Taiyin Lung meridian Exterior syndromes, the cold or flu; allergies with sneezing and itchy eyes and nose; immuno-deficiency/frequent colds, low energy, cold hands and feet, CFIDS, chronic diseases; respiratory disorders with cough, asthma, breathing difficulties; nose and throat disorders, rhinitis, sinusitis, pharyngitis, laryngitis, tonsillitis; edema, enuresis, retention of urine or urinary difficulty; diarrhea, constipation, hemorrhoids; GERD; sinus(ST 2-3), temporal (ST 7-8), Occipital headaches (all treated by LU 7); sighing, mental distress, weeping, grief; Bi syndrome along muscle channel.
B] Hand Yangming Large Intestine meridian: Toothache; Yangming headache; facial paralysis, trigeminal neuralgia and TMJ (ST 5-8); rhinitis, sinusitis (LI 20-ST 2); Nosebleed; sore throat and vocal cord disorders, thyroid disorders; diarrhea, facial edema, sweating/ dry mouth, throat, stool, concentrated urine, dry skin); yang ming febrile disorders; rashes, eczema, boils, psoriasis; abdominal pain, epigastric pain, nausea, vomiting, belching, cough, asthma, chest pain; lassitude, spontaneous sweating, low immunity; Bi syndrome along muscle channel.
C] Foot Yangming Stomach meridian: Excess and deficient digestive disorders with excess hunger or poor appetite, burning sensation or cold sensation in the stomach, and in either case epigastric pain, abdominal fullness, distention, diarrhea constipation; yangming headache, sinusitis, rhinitis, stuffy nose, nose bleeds; sore, swollen throat, gums, toothache; facial paralysis, trigeminal neuralgia, TMJ; yangming febrile syndrome; general lassitude, sallow complexion, spontaneous sweating, palpitations; stomach fire;
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violent or withdrawn behavior (mania or depression); swollen, painful, cystic breasts; Bi syndrome along channel el; wei syndrome with whole body weakness and atrophy of the muscles.
D] Foot Taiyin Spleen meridian: Deficiency or excess digestive disorders as for stomach; edema, heavy sensation of face, head, whole body; post-prandial fatigue; dampness disorders and s&s; high cholesterol; obesity; atherosclerosis; masses and nodules; Qi & Blood deficiency; Spleen Qi sinking with prolapses, dizziness, vertigo, lightheadedness; constant worry, low spirits, difficulty concentrating, poor memory, depression, palpitations; Bi syndrome along channel; wei syndrome with whole body atrophy and flaccidity, especially of lower body and extremities.
Personality Patterns For a detailed summary of J.R. Worsley’s depiction of the 5 Element personality types, and Dr. Yves Requena’s 8 Temperaments, see my Bodymind Energetics, pages 85-107. While character typing is described in the classic texts, I caution against taking such depictions of complex human beings too literally. With that caution, and with the realization that a person may exhibit characteristics from more then one temperament or type, such information is useful in providing practitioners with another lens through which to view the people who seek their help. One can also juxtapose the emotional (shen) signs and symptoms presented in chart form from chapter 8 of the Ling Shu from last month’s Reflection to further narrow down the specific meridian-organ system or systems involved within a circuit. This applies to the next two circuits as well.
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SHAOYIN/TAIYANG CIRCUIT – Regular Meridian (Jing Mai) Pattern Differentiation
Body Area
Hand Shaoyin/
Hand Taiyang/
Foot Taiyang/
Foot
Heart
Small Intestine
Bladder
Shaoyin/Kidney
Yellow eyes,
Yellow eyes,
Yellow eyes,
Yellow eyes,
hearing loss,
eyes tearing,
dizziness,
swollen
eye pain as if
blurred vision,
cheeks,
popping out,
jaundice,
submandibular
vertex
flushed face,
swelling, neck
headache,
dark
pain, sore
occipital
comlexion, dry
throat
headache,
tongue, hot
nape of neck
mouth, dry and
pain, nose
sore throat,
bleed
hoarseness,
Alternating
appears as if
No desire to
chills and
about to be
drink
fever,
captured
Signs & Symptoms Face, Head, Neck Throat
General
Dry throat
epilepsy, derangement, Cardio-
Heart pain
Intense
Thoracic back Wheezing,
Respiratory,
posterior
pain
Chest/Upper
shoulder and
coughing up
Back,
arm pain (SI 8-
blood, heart
14) as if
pain, irritability
broken, inability to turn neck (stiffness at SI-14-17)
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cough,
Hand
Arm pain
Arm and hand
channels
(heart 3-7),
pain (SI 8-4)
heat in palms
Gastrointestinal,
Hypochondriac
Mid back pain
region pain
Hunger but no desire to eat,
Abdomen
watery diarrhea
Genito-urinary, Gynecological,
Hemorrhoids,
Reproductive,
Lumbar pain,
Lower Back,
gluteal area pain
Foot channels Tight
Lumbar spine
popliteal
pain, inner
fossa, hip
thigh pain, Pain
joint pain and
and cold along
inability to
leg channel
bend, pain in
(Kid 9-11, pain
calves as if
and heat in the
torn, little toe
soles
dysfunction
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Mental Signs & All shen
Poor mental
Changeable
Anxiety, pain in
Symptoms *
disturbances,
assimilation,
moods, over-
the pit of the
insomnia,
insecurity,
enthusiasm,
stomach,
suspicion,
sadness,
jealousy, lack
physical and
of
mental fatigue,
confidence,
antisocial
lassitude
tendencies,
anxiety
laziness Point Palette
HT 8- fire
SI 2-water
Bl 67-
Kid 3-source
HT 7-source
SI 3-
tonification
Kid 2-fire
HT 7&8-ying
tonfication
BL 65-
Kid 2&3-ying
and shu
SI 4 –source
dispersal
and shu
HT 5-luo
SI 5-wrist
BL 64-source
Kid 4-luo
HT 6-cleft
SI 6-cleft
BL 58-luo
Kid 1-dispersal
HT 3 (Sea)
SI 7-luo
BL 40-Sea
Kid 7-tonify
SI 8 –Sea
Back Shu
Kid 10-Sea
SI 9-14-ashi
Points
Kid 15.5-
HT 1 and 2
adrenals Local for S&S Associated
Ashi for pain
channel points
Local for S&S Local for S&S Ashi for pain
From SI, Kid, Bl for circuit
Ashi for pain Local for S&S Ashi for pain
From HT, BL, Kid for circuit
From Bl, Ht, SI For circuit
From Kid, SI, HT for circuit
Treatment of Regular Meridians In Chapter 9 of Ling Shu: 1] If Kidney is deficient, Bladder is excess (carotid pulse three times stronger than radial pulse): tonify Kidney with one needle (Kid 7 for example); disperse BL with 2 needles (Bl 58 and BL 65 for example). If carotid pulse is “restless”, disperse Small Intestine (SI 1 and SI 6 for example) for the circuit.
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2] If Kidney is excess, Bladder is deficient (radial pulse is three times stronger than carotid): disperse Kidney (Kid 1 for example) with one needle; tonify BL with 2 needles (Bl 67 and 60 for example). If radial pulse is “restless”, disperse Heart (Ht 9 and 8 for example) for the circuit.
Regular Meridian Disorders for this Circuit from Dr. Ni Note: Any point on a regular meridian may be used as a local point for signs and symptoms on that meridian. A] Hand Shaoyin Heart meridian: Heart and Lung disorders like cardiac pain and palpitations, arrhythmia, shortness of breath, cold extremities, sweating, red, purple or pale complexion; heat syndromes with whole body hot, dry mouth, red face, hot flashes, tongue ulcers, boils; red, painful, swollen eyes; mania, depression, fainting, schizophrenia, anxiety, hysteria, mood swings, laughing or crying without apparent reason, nervousness, restlessness, insomnia, scattered thinking; severe pain or spasm of internal organs, post-traumatic or post-surgical pain, cancer pain; skin rashes, itching, pain; pain along channel (Ht 1-8) and costochondritis/non-cardiac chest and upper back muscle pain.
B] Hand Taiyang Small Intestine meridian: Occipital headache, deafness, earache, tinnitus; red, swollen, painful inner and outer canthi of eyes, blurry vision, excessive tearing, yellow sclera; mouth and tongue sores and ulcers, toothache; swelling and pain of cheeks, lymph glands, parotid glands, TMJ syndrome; cold and flu, allergies; febrile diseases with yellow urine and night sweats; edema, retention of urine, painful and yellow urination; diarrhea, indigestion, stomach pain, abdominal pain and distention, constipation; pain of lower lateral abdomen referring to back and testicles, as with inguinal hernia, epididymitis,
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urethral stones, ovarian cysts; Bi syndrome, pain along muscle channel (scapula & posterior shoulder from SI 14-9, elbow near SI 8, forearm near SI 7-6, wrist near SI 5-4 and little finger dysfunction.
C] Foot Taiyang Bladder meridian: Cold, flu, allergies; occipital headache; eye disorders with tearing and pain; rhinitis, sinusitis, nose bleed; urogenital, gynecological and male reproductive disorders; disorders of any ZangFu especially when chronic or deficient treated via the BackShu points (combined with Front-Mu points); mania, depression, epilepsy, schizophrenia; emotional disorders of any organ, treated with second line of Bladder meridian; Bi syndrome and pain affecting muscles, tendons, ligaments and joints throughout nape of neck, upper, middle, lower back, sacrum and hips, hamstrings, posterior calves and heels, little toe dysfunction; acute or traumatic in jury to neck, back, lumbar region, spine, lower extremities
D] Foot Shaoyin Kidney meridian: Kidney deficiency with fatigue, low back pain, pain along spinal column, muscular atrophy; deafness, tinnitus, chronic tooth, gum and throat disorders; poor memory, forgetfulness; hair loss; deficient yin and yang signs and symptoms; Kidney and Bladder disorders with edema, facial puffiness, impotence, infertility; treated for chronic disorders of the other ZangFu; channel deficiency and Bi syndrome with pain and weakness of the lower back, hip and knee, spinal column, degenerative disorders of bones and joints; wei syndrome with cold, pain or heat in the soles.
Personality Patterns See discussion under the first circuit above.
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JUEYIN/SHAOYANG CIRCUIT – Regular Meridian (Jing Mai) Pattern Differentiation
Body Area
Hand Jueyin/
Hand
Foot
Foot Jueyin/
Pericardium
Shaoyang/
Shaoyang/
Liver
Triple Heater
Gallbladder
Yellow eyes,
Hearing loss,
Dull, lusterless
Dull, lusterless
red
retro-
complexion,
complexion,
complexion
auricular pain,
headache,
dry throat
outer canthus
outer canthus
and cheek
pain, bitter
pain, tinnitus,
taste,
swollen sore
submandibular
throat
pain,
Signs & Symptoms Face, Head, Neck Throat
supraclavicuar pain (GB 21) Constant General
Sweating
laughing
Excessive sweating, chills and shivering, repeated sighing
Cardio-
Heart pain,
Posterior
Maxillary pain,
Distention in
Respiratory,
severe
shoulder pain
chest pain,
chest and
Chest/Upper
palpitations,
(TH 15)
breast pain,
hypochondriac
Back,
distention of
hypochondriac
region
chest, axillary
region pain
swelling
(GB 22-24), difficulty moving torso (GB24-Liv 14 stiffness)
**'
Contraction
Posterior
Hand
and pain in
arm, elbow,
channels
elbow and
wrist, hand
forearm (Per
pain (TH 14-
3-6), heat in
3), ring finger
palms
dysfunction
Gastrointestinal,
Distended
Vomiting
sub costal Abdomen
region
Genitorurinary,
Diarrhea with
Gynecological,
undigested
Reproductive,
food, inguinal
Lower Back,
hernia, scanty or dribbling
Foot channels
Hip, lateral
urine, swollen
thigh, knee,
scrotum,
ankle, and foot
“Shan”, pelvic
pain (GB 30-
pain, lower
40), heat in
back pain,
ankles and
inability to
feet, aversion
bend forwards
of foot, 4 th toe
or backwards,
dysfunction
Liv 5-6 nodules
Mental Signs & Depression,
Emotional
Bitterness,
Irritability,
Symptoms *
sexual
upset at
lack of control,
anger,
perversion,
family/friend
irritability,
difficulty
aversions,
breakups,
unfaithfulness,
developing
phobias
depression,
lack of
ideas,
suspicion,
courage,
depression,
anxiety, poor
timidity,
lack of energy
**(
elimination of
hypochondria
harmful thoughts
Point Palette
Per 8-fire
TH 3-
GB 41-dai mai
Liv 3-source
Per 7-source
tonification
GB 40-source
Liv 2-
Per 7&8-ying
TH 4-source
GB 38-
fire/dispersal
and shu
TH 5-luo
fire/dispersal
Liv 2&3-ying
Per 6-luo
TH 7-cleft
GB 34-
and shu
Per 4-cleft
TH 10-
Sea/tonification
Liv 5-luo
Per 3-Sea
dispersal
GB 36-cleft
Liv 6-cleft
GB 26-daimai
Liv 8-he-sea/
GB 24-mu
tonification
Local for S&S
Local for S&S
Ashi for pain
Ashi for pain
From Liv, TH,
From GB, Per,
Per 1-2-heart
Associated
and breast
TH 17, 21-23-
pain
ears/tinnitus
Local for S&S
Local for S&S
Ashi for pain
Ashi for pain
channel points From TH, Liv,
From Per, GB, Per for circuit
GB for circuit
Liv for circuit
**)
TH for circuit
Treatment of Regular Meridians In Chapter 9 of the Ling Shu:
1] If Liver is deficient, Gallbladder is excess (carotid pulse twice as strong as radial pulse): tonify Liver with one needle (Liv 3 or Liv 8 for example) disperse GB with 2 needles (GB 38 and GB 34 for example). If the carotid pulse is also “restless”, disperse Triple heater (TH 1 and TH 10 for example) for the circuit. 2] If Liver is excess, Gallbladder is deficient (radial twice as strong as carotid): disperse Liver with one needle (Liv 2 for example); tonify Gallbladder with 2 needles (GB 43 and 40 for example). If radial pulse is “restless”, disperse Pericardium meridian (Per 8 and 9 for example) for the circuit.
Regular Meridian Disorders for this Circuit from Dr. Ni Note: Any point on a regular meridian may be used as a local point for signs and symptoms on that meridian. A] Hand Jueyin Pericardium meridian: Heart and blood vessel disorders with palpitations, cardiac pain, restlessness, high lipid levels; mental and emotional disorders, delirium, fainting, incessant laughter, depression, mania, anxiety; chest and lung disorders with stuffiness and restrictions in the chest, cough, restricted breathing, asthma; stomach disorders, stomach pain, epigastric distention, hiccups, nausea, vomiting, food poisoning; channel disorders with pain and swelling of the armpit, upper arm, elbow, forearm (Per 2-6), hot palms and hand and foot spasms; stiffness of the nape of the neck, chest and hypochondriac regions.
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B] Hand Shaoyang Triple Heater meridian: Fluid disorders, edema, puffiness, enuresis, retention of urine, frequent urination; upper heater disorders like chest pain, palpitations, cough; middle heater disorders like epigastric pain, nausea and vomiting; lower heater disorders like lower abdominal distention, fullness, diarrhea, constipation; endocrine and lymphatic disorders like hypo or hyperthyroidism, diabetes, swollen glands; high lipid levels, fibroids, masses, tumors; channel disorders including shaoyang syndrome with chills and fever; channel disorders affecting the sense organs like migraine headache, ear pain, deafness, blocked feeling in ears, tinnitus, cheek and face pain along course of channel including TMJ syndrome and toothache, swollen glands, sore throat, pain in the mandible and around the ears, purely channel Bi syndrome pain with difficulty laterally flexing the neck and pain down medial deltoid, upper arm, elbow and forearm to top of hand, ring finger dysfunction. C] Foot Shaoyang Gallbladder meridian: Gallbladder and Liver disorders with bitter taste in the mouth, belching, nausea, vomiting, poor appetite, abnormal bowel movements, dark lusterless complexion, abnormal bowel movements, hypochondriac pain; Urogenital disorders with swelling and pain and itching of scrotum, external genitalia, inguinal hernia, leucorrhea, difficulty urinating; emotional disorders with depression, deep signing, poor judgment, indecision, mood swings, frequent anger, insomnia; shaoyang channel syndrome with alternating chills and fever; channel disorders affecting the sense organs with temporal headache, eye pain, pain in the cheek, swollen glands, swelling and pain in the neck, mandible, deafnesss, tinnitus; Bi syndrome affecting the lateral side of the body from lateral ribcage to lateral hip, ITB, peroneal distribution of lateral knee, lower legs and lateral ankle and foot with 4th toe dysfunction (GB 22, 29-30, 31, 34, 37-39, 40-44). D] Foot Jueyin Liver meridian: Liver Qi and yang disorders with fullness, distention, pain of hypochondriac region, dizziness, blurred vision, tinnitus, dry mouth with bitter taste, flushed face, jaundice; emotional disorders with depression, mood swings, nervousness, frequent anger,
*"*
frustration, plum pit Qi in throat; stomach and spleen disorders with epigastric pain, distention, flatulence, belching, eating disorders, vomiting, diarrhea; lung and heart disorders with stuffiness of chest, cough, shallow breathing, deep sighing, palpitations, dream disturbed sleep; abnormal growth including cysts, nodules, masses; channel disorders with spasms of feet and hands, headache, low back and lumbar pain extending to scrotum, hernia pain, pain and swelling of lateral lower abdomen (dai mai), spasm and tightness of joints and muscles and pain along course of channel.
Personality Patterns See discussion under the first circuit above.
Practicing Circuit-Needling Let’s take the example of a patient who presents on palpation with discomfort in the right hypochondriac region and tenderness on palpation near GB 24 and Liv 14, as well as tenderness at CV 10, where Liver Qi can become constrained in the middle heater, and CV 18, where Liver Qi Q i can become constrained in the upper heater, whose primary complaints are lateral migraine headache and dizziness with a strong wiry pulse. Observation shows shen to be clearly present, but with a moody disposition bordering on anger, a tendency to sigh and to breathe very shallowly, even hyperventilating when he grows animated, with a shouting quality to his voice. He also reports a frequent need to address serious anger issues in his therapy. The patient’s secondary complaint is frequent myofascial pain in the upper traps and lats and generalized muscle tightness. From a jing-luo perspective this matches foot Jueyin Liver regular meridian symptomology primarily, with additional symptoms of foot Shaoyang and hand
*""
Shaoyang regular meridian dysfunction leading to an APM diagnosis of Jueyin/Shaoyang Circuit Dysfunction and constrained Liver Qi, as well as foot and hand Shaoyang muscle channel excess. A] Yin-Yang Regulatory Treatment would begin with the source point of the foot
jueyin meridian, meridia n, as well as a s the ying and a nd shu points for disorders of yin of yin, Liver 3 (tonified) and 2 (dispersed), and the luo point of foot Shaoyang, GB 37 along with the Fire point of foot Shaoyang, GB 38 both dispersed) to bring down the rising yang symptoms and clear the lateral head Shaoyang and upper trapezius areas of blockage as well as promote Liver/Gallbladder harmony. Local points CV 10, where tender and where Liver Qi can become constrained in the middle heater, the tender area of GB 24 and Liv 14 on the right, and the tender area near CV 18 would all be dispersed to clear the hypochondriac region and ease the breathing. Patient-Complaint Treatment would select local points from the yang B] Patient-Complaint
channels in this circuit, where local symptoms tend to accumulate (yang protects yin) as follows: for the lateral headache, tender ashi points along the GB and TH pathways of the lateral scalp, including GB 8 and points along a line with it in the temporalis muscle and the Shaoyang area local lateral headache extra point, Taiyang, needled with TCM dispersal technique and never as muscle channel Trigger Points, with distal Triple Intestine 10 (Kiiko Matsumoto’s TH pathway point level with LI 10) and LI 4 to complete the 4 gates and as a powerful headache point; for the dizziness, GB 20, the extra point anmian (in the Shaoyang region between the GB 20 and TH 17 points) and GB 8 (already treated), with distal distal TH 3. If this were a chronic problem, given that there are three regular meridians and two ZangFu involved, I would add the extraordinary vessels as per Van Nghi’s use in such chronic conditions, using the infinity combination so suited for Jueyin/Shaoyang dysfunction: Sp 4/ Per 6 for the constrained Liver Qi in the ribcage, chest and CV 10 area, and GB 41 and TH 5 for the Shaoyang symptomology. This would comprise a jing level supportive treatment to regulate Jueyin/Shaoyang and relieve the Shaoyang area symptoms. In subsequent visits and once the primary complaint starts to resolve I might add release of the myofascial constraint areas with Trigger Point Dry Needling to the upper trapezius near GB 21, the supraspinatus near TH 15, and the lats near GB 22.
*"#
This could be supplemented at any time with the influential point for tendons, GB 34.
*"$
12] Yang Tends Toward Excess--thorns, stains, knots and obstructions THE PROBLEM : “ Ordinary skills of acupuncture maintain the physical body [ …] Some people say chronic disease cannot be cured. This is speaking incorrectly.” (LS, Scroll One)
During the course of this on-line project, I have come to realize as I shared in the Preface that the “ordinary skills of acupuncture” include the Ben (root) and Biao (symptomatic) aspect of routine acupuncture treatment, and that there has been much time spent discussing Root versus Symptomatic treatment, as if the former were more important than the latter, and required higher skills, when they are both in fact part and parcel of good solid acupuncture.
5 Element and 8 Principle Treatment In both the 5 element and the 8 principle discussions of 25 years ago, each of these approaches argued that it was treating the Root. In Worsley’s “Five Element” approach, practitioners were strongly dissuaded from using needles to treat symptoms (which would make one a “Local” doctor using local meridian points for symptoms), as it encouraged its students from the very beginning, after removing whatever basic blocks (which were, interestingly, often meridian blockages but not taught or appreciated as such) to keep a focus on the imbalanced Official (Zang or Fu) and the Causative Factor (CF), a concept Worsley borrowed from English homeopathy with its associated concept of “law of cure”. In doing this, there was
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frequent mention of treating the “bodymindspirit”, a New Age concept that had entered acupuncture circles, and especially with a focus on the Spirit which was privileged as a level of intervention. In the TCM approach, on the other hand, the focus was still on the primary ZangFu pattern, but from a decidedly physical perspective that gathered data about stools, urine, breathing, sleep, pain, weakness, etcetera, much more like an internal medical practitioner of western medicine with a similar focus in treating the patient on the physical level of organ dysfunction and disease. Lines were drawn, and those entering the study of AOM to help people deal with complaints started to lean much more heavily in the direction of “8 Principle” acupuncture, later referred to as TCM. While TCM played lip service to the classical notion that Internal ZangFu problems were caused by disorders of the 7 emotions, it was Worlsey’s approach that took this concept the furthest in those days. Each approach was certain it had the correct way of treating the Root, and each style, from my perspective, missed the main point of acupuncture, that in fact has to do with knowing how to navigate the channels to deal with those thorny, knotted, messy obstacles which present themselves as symptoms, which bind our patients in chronic holding patterns and which, once they become chronic, make escape quite difficult without some handson help. And it is especially there, in each of these two main style’s lack of education or training in palpation and touch, that treatment of the meridians (jingluo) got so seriously shoved into the background. Where Worsley himself was a gifted physical medicine practitioner before learning acupuncture, who resorted at every turn to physiotherapeutic and osteopathic manipulations to clear away these thorny obstacles and open the way for a Root acupuncture treatment, the North American teachings that derived from his work would have to wait for Fritz Smith’s brilliant “zero-balancing” method, developed to fill the gap in this 5 element training tradition, to learn how to lay on hands to promote “free-flow” through the channels and collaterals. While I grew to be quite impressed by the sincerity of the education in Worsley’s Five Element style, I became dizzy with the gyrations such practitioners would go
*"&
through to avoid inserting a needle in places that were knotted, obstructed, and screaming for relief, and confused and dismayed by the associated lack of interest in navigation and treatment of the meridians of acupuncture in their classical sense. It felt to me as if the Worsley tradition, in short, was intentionally not embodied, seeing itself instead operating on some rarified “spirit level”.
Root and Symptomatic Treatment During this period of development of North American acupuncture, the issue of Root versus Symptomatic treatment lead practitioners to galvanize under one or the other pole, with 5 Element practitioners claiming the higher, Root ground and stating that 8 principle/TCM acupuncture was purely “local doctor” treatment of symptoms. For a detailed, although decidedly TCM, internal medical (and therefore herbalized) perspective on Root and Manifestation in TCM, see Maciocia’s The Foundations of Chinese Medicine , pp. 312-323, which I will briefy summarize here. Maciocia stresses that treatment principles can be discussed in four distinct yet interrelated ways: !
As Root (Ben) and Manifestations (Biao): Upright Qi is the Root relative to Pathogenic Factors which are the Manifestation; Root is etiologically the root of a disease while the clinical manifestations are the Manifestation; Root is the initial condition while Manifestation is the later developments of the condition; Chronic disease is the Root relative to Acute disease which is the Manifestation. “They are not two separate entities, but two aspects of a contradiction, like Yin and Yang” (p. 312). Maciocia makes the oft-quoted statement that “[g]enerally speaking, treating the Root only is sufficient to clear all clinical manifestations in most cases”
…
”when the clinical
manifestations are not too severe”(p. 313”. The Root and the Manifestation would be treated together, an approach he admits is widely used in chronic conditions, “when the clinical manifestations are severe and distressing for the patient” or when “the clinical manifestations themselves are such that they would perpetuate the original problem”p. 314). When the
*"'
manifestations/symptoms are severe, usually in acute conditions, he goes on, it is often necessary to treat the manifestations first. You are referred to Maciocia’s chapter for the more detailed discussion regarding situations where there are more than one Root, in which case each Root must be treated; one Root giving rise to several different manifestations, where the treatment is still directed primarily at the Root; and situations where the Root and Manifestation coincide which he states “can only happen when the clinical manifestations are caused by external physical trauma, such as in an accident”(p. 315). Here the stagnation of Qi and Blood in the channels leads to pain because the pain is the stagnation of Qi and Blood. !
When to support Upright Qi, when to eliminate pathogenic factors: Maciocia defines upright Qi as the “body’s resistance to disease” […] “used only in relation and in contrast to pathogenic factors” (regardless of whether they are external such as wind, cold, damp, heat, or internal such as interior wind, blood stasis and stagnation of Qi, phlegm and fire). An Excess in this circumstance refers to the presence of an exterior or interior pathogenic factor, where the upright Qi is still intact enough to fight the pathogenic factors, he clarifies. A Deficiency, on the other hand, refers to a weakness of upright Qi and an absence of a pathogenic factor. Finally, a mixed Deficient/Excess condition, which he adds is far more frequent clinically than a purely excess condition, refers to a condition where upright Qi is weak, but pathogenic factors are also present. Treatment must therefore be directed at tonifying or dispersing (expelling) or both.
!
When to tonify, when to disperse: Tonifying upright Qi is only applicable, Maciocia underscores, in interior conditions. This can be accomplished with acupuncture, exercise, diet, Qi Gong, meditation, rest or herbs, he clarifies. He quotes the saying “support upright Qi, to eliminate the pathogenic factors”(p. 316). In exterior conditions it is almost always sufficient to expel the pathogenic factors and the upright Qi will be strengthened, whence the saying “eliminate the pathogenic factors to strengthen upright Qi”(p. 317) This can be done by using dispersing acupuncture techniques, cupping or bleeding. Maciocia concludes that a strategy commonly used for exterior and interior conditions, when the body’s upright Qi, its resistance, is low, is to expel the pathogenic factors first, then tonify the upright Qi (only when there are no more signs of pathogenic factors being fought off does one tonify upright Qi he states). While this is a required approach in acute or
*"(
urgent cases, it is also commonly used “in chronic cases where the symptoms do not have a character of urgency, but are nevertheless, very distressing and painful”(p. 319). This is the case in chronic visceral and pain disorders, and the APM/CCA integrated approach usually adopts this approach, of focusing on expelling the pathogenic factors, but also simultaneously supports the upright Qi for balance. I agree with Maciocia that one must be very careful when dispersing excess to suggest to patients not to overdue it with exercise or activities which may aggravate the dispersal and lead to undue soreness and fatigue. They would do well to rest, and/or meditate to calm the body and mind and gather resources. If there are signs of the body fighting something off, a fever, even if low grade, chills, a feeling that one is coming down with something or just getting over it, I do not treat their original chronic condition, say chronic Taiyang Zone pain in the low back and buttocks, as this would invite the current EPF to enter more deeply. This is also why physicians counsel patients not to work out during a cold or flu, but rather to stay home and rest. !
Treating the constitution. This refers, Maciocia stresses, to the “Three Treasures (San Bao)—Essence (Jing, prenatal, hereditary Qi and inherited constitution gauged by general vitality, symptoms, pulse and eyes- leading to strong bones and good mental faculties and memory); Qi (acquired or postnatal Qi, which can be gauged by symptomatology, tongue, pulse); and Shen (the state of mind is “primarily a result of the interaction of Jing and Qi and is also reflected in the eyes”). The heart pulse will also be strong but not overflowing. Constitution can also refer to treating according to the Five Elemental types. Maciocia raises the issue of whether one should treat the constitution in the absence of clinical manifestations, which he believes only an experienced practitioner can ascertain. He concludes that it is generally better to treat the constitution toward the end of the course of treatment to “consolidate the results. On the other hand, one must pay attention not to exceed in treating the constitution and stir up problems unnecessarily”(p. 323).
*")
Japanese and Acupuncture Physical Medicine Perspectives This issue of Root versus Symptomatic treatment has also been a major source of debate, at times heated, in the Japanese Acupuncture field over the last half decade, where conventional acupuncture practitioners and meridian therapists argue their views on the subject. In his seminal text, master practitioner Shudo Denmei summarizes the issues and debates, by first stating clearly: “It should be emphasized that both root and symptomatic treatment are necessary and important. No authority on meridian therapy claims that treatment of localized areas is unnecessary. Sometimes local, symptomatic treatment may even have a beneficial effect on the balance of Qi in the body as a whole (Japanese Classical Acupuncture: Introduction to Meridian Therapy , translated by Stephen Brown, Eastland Press, Seattle, 1990, p. 152). Shudo sensei then goes on to summarize the two opposite views, with some meridian therapists claiming that root treatment effectively deals with 70-80% of symptoms, while others state that “symptomatic treatment is necessary because practitioners of meridian therapy lack confidence in the effectiveness of root treatment (ibid),” even questioning the line drawn between root and symptomatic treatment “on the basis that some practitioners of meridian therapy actually spend more time on symptomatic treatment (ibid).” Shudo sensei concludes that there is a major misconception among some conventional acupuncture practitioners in Japan that “practitioners of meridian therapy believe that root treatment is all t hat is necessary, but the truth is that symptomatic treatment is by no means neglected in meridian therapy (ibid).” Shudo sensei then concludes: “The only real difference between meridian therapy and the conventional approaches to acupuncture in Japan is that root treatment is performed to balance the body energetically before the specific symptoms are treated ibid).” With that clarified, Shudo sensei’s own simplified approach to root treatment is presented, and consists in the treatment primarily of tonfication points, as well as master points on the “mother” meridian, to treat the primary yin meridian/organ
*#+
deficiency as phase one of treatment, based on Nan Jing f ive phase treatment strategies. Shudo sensei’s approach is consistent with the tonification at the ying level of the most deficient yin meridian/organ, and/or balance of the jing level extraordinary meridians before moving on to treat the local, symptomatic complaints of the patient, in APM, which incorporates Shudo sensei’s hypothesis that “yin tends toward deficiency, yang tends toward excess” as a central focus for chronic complex disorders specifically, as well as for internal visceral complaints in general. KM style acupuncture, likewise, begins phase one of treatment by regulating the Yin, ventral aspect of the body by needling distal points often selected based on Nan Jing five phase theory, to regulate constitutional and Organ imbalances before moving on to treatment of the patient complaint and the yang, dorsal aspect of the body. Finally, TCM, which has borne the brunt of five phase criticisms that it only treats symptoms, also often begins with treatment of distal essential points to address the underlying pattern of disharmony, and then adds local specific points to address the patient complaint. In selecting distal points for this first, YinYang regulatory phase of treatment, the term the college prefers to “Root treatment”, meridian therapy, as well as KM, APM and TCM styles of acupuncture as taught at the college, all teach to select from the 5 shu-transporting/5 phase elemental points, the yuan-source points, the luoconnecting points and the xi-cleft points. Where meridian therapy and KM style tend to select these distal “command” or essential points based on Nan Jing five phase theory, APM and TCM tend to select these points for their functions as jing-well, ying-spring …he-sea points more consistent with earlier Ling Shu theory. These four styles also have different ways of assessing if the treatment is proceeding in an effective fashion: with meridian therapy reassessing the pulse during the treatment to check for positive change; KM style rechecking the hara and other reflexes for this evidence of change during the treatment; APM looking for expected reactions to the needling of the first phase of points (sinking deeply
*#*
into the point for tonification, spreading out and/or propagating away from the point for dispersal); and TCM rechecking pulse and tongue the next visit. But all of these styles and practitioners are in fact also assessing the effectiveness of the treatment as it is being administered, whether consciously or tacitly, by looking for more general signs of positive change already enunciated in the first chapter of the Ling Shu : “Look at the patient’s color. Observe the eyes. Know how the qi disperses and returns. Each has its own form. Listen to the patient’s movement or stillness. Know his imbalance and his balance (Ling Shu or The Miraculous Pivot t ranslated by Wu Jing-Nuan, University of Hawai’i Press, 1993, p. 4).
Vital Signs of Change I believe too little is made of these observations of change, some of which I learned from practitioners at the Traditional Acupuncture Institute in Maryland almost three decades ago. And I believe there is a tendency to privilege assessment by the radial pulse, which is prone to very subjective interpretation by the acupuncturist, rather than learning to read the signs of energetic change in the circulation of Blood and Qi by observing these changes directly: looking for improved facial color, for the shen to return a sparkle to the eyes, and listening for more relaxed breathing and more relaxed speech, looking for a more relaxed demeanor, and listening, watching for and questioning how the qi and blood are moving, changing temperature, releasing constrictions (creases across the abdomen, x’s in the back of the neck, compressed wrinkles in areas of spinal stenosis, release of muscular holding patterns). These things can all be seen, and those observing will concur on the changes noted far more consistently, I would submit, than those checking the pulse. Finally, if one makes positive change in the pulse the sole arbiter of therapeutic change, the classical rules of assessment have been ignored, which call for assessing in as many fashions as possible, to glean as much information as one can, until this information is able to be assessed tacitly, which I believe is the case with all senior practitioners. And no practitioner taking the pulse during the treatment is failing to also take in changes in complexion, tone of voice, breathing patterns etcetera, all of which will influence how they interpret the pulse.
*#"
It might be interesting to devise a research study to see if assessing therapeutic change without taking the pulse by some practitioners coincides with therapeutic pulse changes assessed in that way by others. That being the case, Shudo Denmei makes a point that is a truism in APM, KM and TCM style practices as well: “When it comes to symptomatic treatment, there is practically no limit to the variety of approaches and techniques that can be employed. Symptomatic treatment is an area in which every practitioner can display his own talent and unique skills. Each of us must spend a lifetime developing our own treatment style (Shudo, ibid, p. 153).” This would certainly be true in the three main styles taught at the Tri-State College of Acupuncture, where local treatment of the patient complaint are varied indeed: •
KM style use of various needling techniques and depths, moxibustion, patchipatchi, ion chains and diode rings, sotai, etcetera;
•
APM use of classical Chinese bi-syndrome and modern trigger point dry needling techniques, pre-acupuncture palpation, pacing and leading ones therapeutic comments and silences to prod change (based on Ericksonian hypnotherapy and NLP techniques), and prodding of the “bodily felt-sense” (Gendlin), as well as education of the patient about their holding patterns and armoring (Reich, Keleman);
•
TCM use of stationary and moving cupping, guasha, indirect moxibustion, tui na, Qi Gong and Daoyin exercises.
Treating Excess: Surface Manifestations and the Patient-Complaint In excess disorders the jingluo, the soma, and especially the cutaneous regions (zones) and tendinomuscular meridians need to be dispersed as the primary strategy. In APM, YinYang regulatory treatment at the ying level in such cases simply consists in supporting the yin paired meridian’s primary Zang (supporting the Kidneys for Taiyang Zone, Liver for Shaoyang Zone and Spleen for Yangming Zone) and completing the circuit for zone excesses, or needling the 4 gates or
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distal jing-well and other tender points for tendinomuscular excess to clear the jingluo and promote smooth flow of Blood and Qi. In deficiency conditions the ZangFu are the main target of treatment, but the French acupuncture strategies that lie at the foundation of APM treat these visceral disorders and diseases through the extraordinary vessels as well, which are activated when the organism is confronted with the strain of chronic disease or dysfunction. Here a jing level treatment of the extraordinary vessels is done first, and then a ying level treatment of paired yin meridians to any yang zones affected is executed, to regulate yinyang circuits at the same time as removing chronic muscle channel obstructions by addressing ashi and trigger points. It is in this sense that APM focuses on the need to disperse excess in the three Yang Zones (the cutaneous regions) or the tendinomuscular (muscle) channels, thereby fortifying the body’s defenses/upright Qi. This is also why APM focuses on addressing up-regulation/hyper-reactivity in the extraordinary vessels, especially, chong, du, dai and ren, which are called into play, according to certain French acupuncture understandings, when the body is perpetually attacked, to protect the ZangFu against this steady onslaught. The point is, that excess conditions must be dispersed. I believe it is a mistake to treat the constitution alone in the presence of excess in the zones and/or muscle channels and luo vessels, as this excess will block Qi and Blood and the ensuing stagnation and constraint will create a vicious cycle of pathogenic activity that will generate more excess. Here is where lifestyle counseling, especially regarding getting proper rest, sleep and stress reducing activities like Yoga, meditation, Tai Qi and Qi Gong can be so critical. Tui-Na and massage, moving cupping and GuaSha are also a vital part of treatment of excess, to keep the body supple and functioning optimally. If Excess in the jingluo is left unaddressed, this will lead to stagnation of Blood, constrained Qi, Phlegm and Fire, the internal pathogenic factors. These, too, must be dispersed. This focus on dispersing Excess as a primary strategy is clear from the LingShu and later texts that develop this notion in the classic discussion of “tri-level” needling.
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Here is Huang-fu Mi’s version in the Jia Yi Jing or Systematic Classic of Acupuncture & Moxibustion (Blue Poppy, 1993): “As for that which is termed tri (level) insertion for promotion of grain qi (ie; the correct qi), one first inserts the needle shallowly, barely penetrating the skin to drive out yang evil. Next one needles to drive out yin evil [inserting the needle] slightly deeper to penetrate the skin and flesh but not penetrating the parting of the flesh. Finally, one needles still deeper, penetrating the parting of the flesh to promote the emergence of the grain qi (p. 279).” “The so-called arrival of the grain qi implies that supplementation has replenished (the channel) and drainage has evacuated (the channel). Thus one may know that the grain qi has been attained (p. 305).” “Once the evil qi has been removed, despite a failure to regulate yin and yang, the disease will display signs of improvement. This is why it is said that supplementation is sure to replenish, while drainage is sure to evacuate, and that although the disease may not appear to have diminished following acupuncture, it will have indeed been mollified (p. 306).” It takes a tough kind of compassion, and focus, to disperse Excess and evacuate evils in patients with chronic conditions, where the excess is laden with pain, suffering, and even at times abuse. The going can get rough at times. But the result, freeing patients from some of this excess, from holding patterns that have been constricting or suffocating them, is worth the effort for practitioner and patient alike. To focus on the constitution alone, then, to attempt to gently tonify patients with Excess conditions with acupuncture is, and here I agree totally with TCM and Maciocia, an error. This could be done if the patients were addressing the excesses in another somatic, physical practice, like Rolfing for example. But somewhere the Excess has to be dispersed, or these Exesses will build up and lead, potentially, to what yoga refers to as a Kundalini experience where the Excess remains trapped in the patient’s nervous system. This can lead in extreme cases to never-ending nervous system agitation.
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Beyond Root and Symptomatic Treatment After much reflection on how North Americans tend to ascribe more significance to Root, than to Symptomatic treatment, I discussed this issue with Kiiko Matsumoto, who was rather surprised at how one might think a tree might have only roots or branches and still be a tree! This lead to a decision at the college to refer instead to: “YinYang regulation, using the essential points (distal command and local Mu and Shu) to treat primary Organ or Constitutional patterns; and Treatment of the Patient-Complaint, using reactive points, which focuses on the complaint, and its signs and symptoms as manifested by the patient. This reformulation underscores the fact that one must address the patient’s complaint if one wishes to practice patient-centered care, as this part of the treatment focuses on the patient’s experience and story of illness and distress, not ours. This reformulation also hopefully puts to rest the fantasy, pronounced by those who profess to have the deep secrets, that one can treat chronic complex disorders by “root” treatment alone, a fantasy that has lead far too many practitioners to clinical failure after failure.
Treating the Patient-Complaint and Holding Patterns As I reorganized the curriculum of the Quebec Institute of Acupuncture into a more workable model that integrated in TCM ZangFu pattern identification (the “ZangFu diagnostic filter”) in the second year, and after a thorough grounding in jingluo pattern identification in Year I, that viewed visceral symptomology as part of the internal branch of the 12 regular meridians, I found Chamfrault and Van Nghi’s earlier categorization in L’energetique humaine more useful than Van Nghi’s later French-Vietnamese one based on the Vietnamese Trung Y Hoc, in his Pathogenie et pathologie energetique en medecine traditionnnelle chinoise. In the earlier text, Chamfrault and Van Nghi organized the teaching of the jingluo filter by category of meridian, and therefore category of point strategy, to be utilized in formulating a comprehensive treatment plan based on jingluo pattern identification. This categorization was broken down into Ying, Jing and Wei as follows.
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Ying & Jing Level Treatment The Ying level is comprised of the 12 regular meridians, and internal branches (parallel to the 12 divergent meridians) which function as a circuit as presented in the previous Reflection. Here, one identifies the regular meridian that is most affected, and its circuit, and utilizes the source, or ying and shu, or tonfication or other essential command point on the Yin meridians, and the luo, dispersal, xi-cleft, or other essential command point on the paired yang meridian. The yang meridians are primarily used to address the symptomatic presentation, while the yin meridians address the underlying regular meridian dysfunction. If one has already made a TCM ZangFu pattern diagnosis, say in preparation for an herbal recommendation, one can just select the corresponding regular meridian and its associated circuit to develop a jingluo treatment plan. When the internal associated organ and bowel are affected, resulting in internal visceral symptomology, one can add the local front-Mu and/or back-Shu points to address the ZangFu directly. A] Ying-Level Local Treatment of Patient-Complaint
The main difference in this jingluo approach, from TCM acupuncture treatment, is that points are selected based on their dynamic effect on the circulation of Qi (what the early French authors referred to as the ‘energetics’ of the points) rather than based on supposed indications, and that local points are selected from the meridians in the area of the complaint, by palpating for obstruction and excess. Thus one might palpate and find tightness and constriction over the lungs in a patient suffering from chronic obstructive pulmonary disease (COPD) in the following configurations, with the local obstruction guiding the distal YinYang regulatory treatment as well:
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Tight Tender Points (TTPS, not to be confused with Trigger Points or TrPs) in the area of the Taiyin union, Lu 1-2 and Sp 20 (beginning of hand taiyin lung and end of foot taiyin spleen), indicating a Taiyin dysfunction;
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The above TTPs, with exquisite tenderness at ST 14-16 and LI 17, indicating a taiyin/yangming dysfunction;
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TTPs at Lu 1 and Liv 14, indicating a blockage in the circulation of Qi from foot jueyin liver to hand taiyin lung OR in Metal and Wood (Metal controls Wood);
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TTPs at Lu 1-2 and Kidney 23-27, indicating a hand taiyin lung and foot shaoyin kidney dysfunction (disorder of Metal and Water/ Mother and Child);
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TTPs at CV 18-17 and CV 23 with plumpit Qi, indicating a dysfunction of Wood and Water/ Liver and Kidney/ Mother and Child.
This palpation of the target or symptomatic area has been a hallmark of the meridian approach I have practiced for three decades, and was most elegantly and simply stated by Dr. Ni in her clinical text, when she stressed that any local point on a meridian may be used to treat local symptoms in the area of that point. For those who palpate distally and locally, to assess the state of excess and deficiency of the “beginning and ends” of the meridians, a rich array of circuit palpation and treatment is readily available that is always patient-centered, because it starts by assessing that area of the body-person (shenti ) that brings the patient to our office and affords us the privileged opportunity to witness and support their efforts at change. I have started with this discussion of local treatment of the patient’s complaint in visceral disorders of the ZangFu to stress that in such cases, the local “symptomatic” treatment addresses the ying level of the regular meridians based on the classical notion of assessing and treating the beginnings and ends of the meridians, not trigger points in the muscle channels. In such ying level visceral disorders, one may add treatment of the 8 extraordinary vessels with their distal opening points, a characteristic of Van Nghi style French meridian acupuncture, but also of Manaka style Japanese style treatment, where ion-pumping cords are attached to the distal opening points instead of needles.
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I list common local ying and jing level points of union for addressing the patientcomplaint in my earlier Acupuncture Imaging , p. 26, and especially in chapter 7, on “bodymind-energetic palpation”, pp. 66-78, as well as in the drawings of the greater meridian units in my earlier BodyMind Energetics , chapter 2. Main union points that I routinely observe, assess and release are: •
TH 22-23 and GB 1-3 as well as the extra point “taiyang” for Shaoyang lateral head pain, dizziness, vertigo, headache, migraines;
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TH 15 and GB 21 for Shaoyang upper back, trapezius, supraspinatus pain and dysfunction;
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TH 16 and GB 20, as well as the extra point “anmian” for Shaoyang/Jueyin tinnitus, temperature problems including excess sweating and hot flashes, and neck pain;
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Bl 1 (not needled) and SI 18 for Taiyang facial pain, trigeminal neuralgia and sinusitis signs and symptoms, which has come to include Bl 2 and ST 2 where tender in the same area of facial pain and sinus symptoms;
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Bl 11 and SI 9-14 for rotator cuff disorders and shoulder pain and dysfunction;
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ST 2 and LI 20 for Yangming facial pain and sinus symptoms;
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ST 3-4 and LI 19 for trigeminal neuralgia;
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LU 1-2 and SP 20 for Taiyin chest pain, respiratory disorders, shoulder pain and dysfunction;
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Kid 27 and HT 1 (HT 1 replaced by subclavius trigger point near ST 13) for Shaoyin Thoracic Outlet-like signs and symptoms of neck pain and arm repetitive strain signs and symptoms;
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Liv 14 and Per 1-2 for Jueyin chest pain, panic disorder, shoulder pain and dysfunction, respiratory problems.
B] Jing-Level Local and Distal Treatment
The Jing level is comprised of the 8 extraordinary vessels, which function outside of the 12 main meridians but kick in when disorders are complex or chronic and two or more regular meridians, and their associated organs, are at risk. Treatment here is directed toward stimulation of key points to address dysfunction in the
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chong, dai, ren and du vessels (Sp 4, GB 41, Lu 7, SI 3), with their paired vessels’ key points (Per 6, TH 5, Kid 6 and Bl 62). Local points from the extraordinary vessels involved can also be selected to address visceral or somatic symptomology that constitute the patient’s complaint, distress and suffering. While APM has specific stress patterns (the Four Patterns of Fatigue/Visceral Agitation presented in Reflection II) to address common chronic adrenal patterns of our day, APM is predicated upon a solid grounding in jingluo theory and treatment, and I frequently resort to treatment of an extraordinary vessel or vessels on their own, with little or no treatment at the ying level. This is common for me in addressing gynecological and reproductive problems, where I treat distal opening points for chong, dai and ren, but also address excess and deficiency along the local points of these meridians, so GB 26-28 (dai), Kid 1115 and ST 30-26 (chong) and CV 2-4 (ren). I also often treat a series of local HJJ points in spine disorders, with the infinity opening point treatment for ren and du: Lu 7/Kid 6; SI 3/Bl 62, as a du mai treatment (HJJ and adjacent BL meridian points, as well as the muscle channel multifidi, being seen as part and parcel of du mai). I felt the need early in my teaching career to focus heavily on teaching the extraordinary vessels when English language texts did not exist and Chamfrault and Van Nghi’s texts were the main resources. When these texts went out of print, there was still Royston Low’s book on the secondary vessels, which then went out of print as well, and Felix Mann’s early text on the meridians of acupuncture, which recently went out of print but appears to be circulating in an unofficial on-line version, has also disappeared. Since Mann recanted all of his earlier books based on classical theory, support for training in the secondary vessels and extraordinary vessels was scanty indeed. And then Dr. Ni published her brilliant Navigating the Channels, which w e use as the main authoritative text at the college for jingluo clinical pattern differentiation and treatment. That said, any serious student of a jingluo approach should study Maciocia’s book on the channels carefully and repeatedly, as it is full of clinically useful and classically informed information, even if an awkward text to use in the clinic itself.
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His study of the extraordinary vessels alone contains everything Chamfrault and Van Nghi wrote, is consistent with Felix Mann’s early text on the jingluo, and with Ni’s text. His treatment of the extraordinary vessels fills 10 chapters and over 270 pages, and is a book unto itself that I highly recommend.
C] Wei Level Muscle Channel Local Treatment
Finally, APM focuses on Wei level treatment in all myofascial and many musculoskeletal Bi syndromes where the treatment is comprised of the 12 tendinomuscular meridians (muscle channels) and the 15 primary luo vessels, which are activated according to classical theory to protect the regular meridians and the skeletal system from external attack, injury, repetitive strain and wear and tear, thus diverting the brunt of the attack to the larger muscle channels and superficial cutaneous regions (Zones), which occupy the broadest area and thus serve best to offer this protection. In chronic emotional disorders, affecting the internal meridian/organ complex, the muscle channels and cutaneous regions often serve as a shock absorber to take on the bulk of the trauma, thus creating physical symptoms and myofascial holding patterns, which Wilhelm Reich referred to as “Character Armor” as a correlate to, and perhaps more manageable form of such complex emotionally laden problems. In its simplest version, one merely palpates along a muscle channel and performs wei level oblique shallow needling (a needling approach known as Bao Ci), to point after point in the symptomatic area as well as distally on the channel involved (jingwell and other tender ashi points), and this is done in APM most frequently on the Yang tendinomuscular meridians. One can also incorporate trigger point dry needling based on referral patterns, an extremely pragmatic addition to classical muscle channel treatment, and these muscle channels can be treated by region as well, with points from all three Yang or Yin meridians of the arm or leg depending on region affected. Distally, one can treat the jing-well point as the furthest point from the symptomatic area, the jing-river point if the problem has become chronic and rheumatic affecting the joints, the luo-connecting point if its target area is within the symptomatic region, or excess reactive points on palpation along the same channels.
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While release through a special “sparrow-pecking” needling technique is my preferred way to release active local trigger points, especially if acute, or if newly inflamed in a chronic condition, which I lay out in my A New American Acupuncture: Acupuncture Osteopathy, I also often simply use rapid lifting and thrusting to deep muscle ashi points if sparrow-pecking does not lead to rapid fasciculation and release, which can be the case in chronic pain where the fascia has become fibrotic, in women right before or during menstruation when their cou li layer is congested and full of damp Sha, or in patients with very low Blood Pressure or with Low Thyroid conditions. While some practitioners who have trained with me might make almost exclusive use of my APM Trigger Point Dry Needling technique for local excess ashi points, I discriminate much more than that, and reserve such a technique for actual myofascial trigger points, and rarely when I am treating ying level regular meridian or jing level extraordinary vessel local areas of the specific patient-complaint. I also incorporate trigger point release into full-scale jingluo acupuncture treatments for any complex or chronic disorder, based on my approach to the three Yang Zones as outlined in chart form and in clinical protocols in Acupuncture Physical Medicine . What characterizes APM style above all else is its focus on careful palpation not only distally, but locally along extraordinary vessel, regular meridian, and tendinomuscular meridian and luo vessel pathways for areas of excess and deficiency to be needled to relieve symptoms, remove obstructions, and promote the flow of Qi and Blood. Acupuncture PHYSICAL medicine is thus aptly named, to underscore a style akin to AOM bodywork, where laying on of hands is central and critical to clinical success.
The Jingluo Filter at a Glance Based on this way of categorizing the jingluo filter, jingluo pattern identification and APM treatment planning consists of the following elements: •
The 3 circuits (of the 12 regular meridians): select the circuit based on the primary Yin regular meridian involved, and treat its corresponding paired Yang meridians, thus treating at least 2 out of 3 meridians in a circuit;
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The 3 levels (ying, jing, wei ): to the above regular meridian/circuit treatment, add the corresponding extraordinary vessel treatment of key distal and local points, if the disorder is complex or chronic and involves two or more regular meridians and their associated organs; OR just treat the extraordinary vessel involved as the main root treatment;
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The 3 Zones (Taiyang, Shaoyang, Yangming): when a chronic myofascial or musculoskeletal pain and dysfunction condition is involved, especially when it is comprised of symptomatic areas at multiple sits within a zone and especially if there are regular meridian concomitants, treat and entire zone with its APM protocol, selecting wei, ying and jing level strategies to address the complex disorder from several angles;
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One hypothesis: Yang tends toward excess (so select the yang regular meridians to address local visceral symptomology (such as TH 23 and GB 1 for migraine headache and TH 16 and 17 and GB 20 for tinnitus; and the yang muscle and/or luo channels for bi syndrome and repetitive strain or injury); Yin tends toward deficiency: tonify the most deficient yin regular meridian (derived from Shudo Denmei’s simplified meridian therapy protocol);
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Combine and sequence needle selection and stimulation based on the 8 conditions: select points from the foot and the hand meridians, and from the right and the left, and from the front and the back, and from Yin and Yang meridians, to regulate Yin and Yang.
8 Conditions of Point Sequencing The 8 conditions figure into jingluo treatment planning at the point where one decides how to combine the selected treatment strategies in terms of location where each point is needled. Following the basic principle of treating on the diagonal to regulate Yin and Yang meridians, most common in the treatment of two paired extraordinary meridians (SP 4 on one side, and Per 6 on the opposite side, for example, thus regulating right and left and upper and lower with just two needles), I treat the distal ying meridian points in the same fashion: if doing the 4 gates, I needle Liver 3 on one side, and LI 4 on the other (thus regulating upper and lower, right and left and yin and yang with just two, or at most four needles). When multiple distal points are selected (say ST 36, 37 and 39 as lower he-sea points,
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and/or as distal points of chong mai, I just needle each point where most tender, or arrange them, perhaps ST 36 and 37 on one side, and ST 39 on the other, based on the number and location of the other needles so as to avoid unnecessary bilateral treatment. In brief, based on the 8 conditions, I alternate between distal leg/foot, and distal arm/hand points on the diagonal, and complete my distal points to regulate Yin and Yang meridians, from the extraordinary vessels and regular meridians, and then add local mu or shu points if the viscera are involved, as well as local points on these meridians to address local symptoms, and finally distal and local wei level excess yang points to disperse muscle channel excess and clear the obstructions. Maciocia presents numerous treatment strategies for treatment based on the 8 condition method of point sequencing in his The Channels of Acupuncture , Chapters 8-10, pp. 107-177, and especially in chapter 11, pp. 177-215.
Summing Up As I routinely tell students, a way to remember that one can treat from all three jingluo levels (jing, ying and wei) is imagine each level being done with different therapies and no acupuncture thusly •
The jing level, by the patient her or himself, in daily prescribed Qi Gong practice;
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The ying level, with herbal remedies and dietary recomendations followed daily;
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The wei level, with tui na in the office, and self-administered moxa at home by the patient.
All three levels can also be treated only with acupuncture, something Acupuncture Physical Medicine does routinely.
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13] Acupuncture as Physical Medicine—Location, Palpation, Living Points THE PROBLEM : While these early discussions of acupuncture practice, and later of Acupuncture & Oriental Medicine (a consensually agreed upon compromise term that, while cultural anthropologically incorrect, satisfied non-PRC East Asian practitioners as being the most inclusive, where Oriental Medicine was a code word for Chinese Herbal Medicine) focused on resolving this debate between 5 element and 8 principle practitioners, some Japanese-trained practitioners, most notably Kiiko Matsumoto, were beginning to teach around the nation. This brought with it in rather rapid fashion a preferred use of disposable Japanese needles inserted through tubes, and a major focus on palpation not only, or not even, on the pulses at the wrist, which both the 5 element and 8 principle practitioners performed, but palpation of the abdomen( Hara), the meridian pathways and the points themselves for reactivity. As Kiiko Matsumoto become a more and more frequent clinical faculty teacher at our college, I gladly distanced myself from this tiresome debate to focus on the acupuncture I had learned, and to learn new skills of palpationbased practice which, while stressed as a prelude to acupuncture treatment in the Montreal teachings, was far more advanced and discriminating in the Japanese approaches I was observing and reading about. The problem for me had ceased being about the absence of the jingluo filter in most other acupuncture traditions in this country, but of the lack of actual attention to palpation from the FrenchVietnamese meridian teachings of Van Nghi and other French physicians whom I observed and invited to teach at the college. The problem for me was to find ways to reinforce the training in jingluo practice with a strong hands-on focus, and the Japanese styles shared by Sensei Matsumoto with us all in the early days, were a great inspiration in that direction. This allowed me, and the college, to take a distance from the academic debates about theory that had plagued the 5 element/8 principle discussions.
________________ Before reflecting on these Japanese influences on APM palpation at the college, it is important to note that Kiiko Matsumoto’s introduction of a Japanese perspective also shifted radically the way in which I viewed where treatment of “ben” and “biao”, “roots” and “manifestations” figured in the treatment of chronic complex disorders of our time. Stemming from her study with Yoshio Manaka, MD, She taught how one could start with an extraordinary vessel treatment strategy to regulate the core, say with SI3/Bl 62 and Lu 7/Kid 6 as contralateral pairs (Infinity Treatments). Next, she would show how Manaka treated the regular meridians/organs to regulate Yin and Yang (treating Front and Back), ending with treatment of structural imbalances and elimination of tight tender points. Patients would then be taught self-care exercises and treatments to be carried on in between treatments. This way of treating extraordinary vessels, regular meridians and the surface (ashi points) was parallel to Chamfrault and Van Nghi’s way of framing the jingluo filter as 3 levels: jing (extraordinary vessels), ying (regular meridians) and wei( cutaneous regions and tendinomuscular meridians). Still today, Kiiko Matsumoto teaches that one can treat 3 or so Constitutional and Organ patterns with distal point combinations which is consistent with APM treatment of point combinations for the extraordinary vessels, and the regular meridians/organs, or with TCM treatment first of point combinations of 2-3 ZangFu in many cases. I all 3 styles, one then moves on to treatment of the “manifestations”, which is to say all the signs and symptoms that constitute the patient’s complaint TODAY. Point combinations include distal and local needling, and local use of ancillary techniques like cupping, guasha, magnets, electrical stimulation, diode rings and chains, tui na, etcetera. I say this just to clarify that when one really looks at each style, including TCM, there is no way to say one treats only Root or Manifestations, Ben or Biao, as each of the 3 styles treats both.
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What differentiates styles much more, I believe, is the role they assign to palpation of the body as a whole to gain information about where to treat and how to needle.
Informed Touch: In the first educational research colloquium sponsored by the Tri-State College of Acupuncture in 2002, the issue of needling technique and intention regarding obtaining qi, targeting qi, the arrival of qi, and propagation of qi were addressed by means of demonstrations by five senior practitioners with twenty or more years of experience each at that time practicing, and teaching: Wei Liu, trained in a family style of tui na and as a TCM orthopedic specialist, with expertise in classical needling techniques and their modern transformations; Kiiko Matsumoto, who has spent the previous two decades bringing an eclectic Japanese acupuncture to America, informed by modern Japanese masters and the classic texts; Arya Nielsen, a graduate of the first class from the New England School of Acupuncture where she studied and followed the combined acupuncture, moxibustion and guasha approaches of the late Dr. So and studied Chinese Herbology with Ted Kaptchuk; Mark Seem, who has developed Acupuncture Physical Medicine based on French meridian acupuncture traditions, Japanese acupuncture inspirations, especially regarding more superficial needling, and the late Dr. Travell’s needling of myofascial trigger points; William Skelton, trained in Taiwan in a traditional hands-on approach that emphasized distant points and working the affected area to free it up, with great focus on effective needling of reactive points versus needling according to theory. These five senior practitioners, each demonstrating for an hour before a panel of distinguished acupuncture researchers from Harvard, the University of Vermont, the University of Maryland and the private domain, and our faculty, all concurred, as some of the active participant researchers noted, that the goal, the intention of needling seemed to be to initiate change by creating some sort of feedback loop or circuit created by needling distant or distal points first, along with activation of local areas through palpation, stroking, needling, guasha and other techniques. It was also noted that all five placed great emphasis on treating “active” or “reactive” points that were palpable as points that are tight, tender, indurated, as opposed to textbook acupuncture point locations.
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In her seminal work, the late Janet Travell stressed that the X marks that appear in her pictures of muscular trigger points denote likely areas where one might find a trigger point, and are meant TO GUIDE THE PALPATION FOR REACTIVE POINTS, not to serve as precise locations. She stressed cross-fiber palpation to find indurated bands of taut muscle. Hong, a colleague of Travell from the University of California at Irvine, has recently commented that ‘while all trigger points are acupuncture points (ashi points), all acupuncture points are not trigger points’. There is more to acupuncture, it seemed clear, than tight, tender, reactive points, although such points appear to be a critical factor in effective treatment, especially when there is musculoskeletal pain, stiffness, and associated dysfunction. Proponents of Travell and Simon’s work are even suggesting doing away with the numbering sequences in Travell and Simon’s texts, which led some to the belief that trigger points do in fact have fixed locations, to further underscore the need to palpate for reactivity in the region of motor points.
Effective Acupuncture Points: In his two texts available in English, Shudo Denmei underscores the importance of locating effective acupuncture points. He differentiates between the Sawada traditional school, which emphasizes palpation and treatment of active, indurated points, and the meridian traditional schools that stress more subtle manipulation, very shallowly, especially of the “essential” command points (distal shutransporting/five phase, xi-cleft, source and luo, and local mu and shu). In his latest book, dedicated to the above issue of “finding effective acupuncture points”(the English name of his second book), Shudo Denmei stresses that for finding essential points, especially on the yin meridians, he palpates gently along the course of the meridian feeling for depressions (Yin tends toward deficiency), whereas for palpating yang meridians, he palpates for areas of excess, for indurations (Yang tends toward excess). While he treats excess and deficiency on such essential yin meridian points, he adds that he usually just needles the indurations for the yang meridian excess points. Palpation for depressions for the essential points from elbows and knees down, as well as for mu and shu points is how the classic texts teach point location for these points, and classics like the Ling Shu place great emphasis on the use of these “essential” points, which, as Shudo Denmei concludes in his text, can be quite amazing and seem to have a power all their own, with quite shallow needling and minimal stimulation.
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Like Shudo Denmei, I look for excess, especially in pain disorders, and teach the yang cutaneous regions (the zones and their corresponding tendinomuscular meridians), as the most expeditious way to hunt for these yang, excess tender points. In his text Finding Effective Acupuncture Points, translated by Stephen Brown, Shudo Denmei talks about three depths where reactive points and areas might be located: points on the surface, points between the surface and the subcutaneous tissues, and points in the fascia and muscle tissue, with even deeper points at the deepest layer (pp. 7-13). A] Points on the surface, which may feel cooler or warmer than surrounding areas, some points will feel depressed, some points will feel more moist or dryer (rougher) than surrounding areas, and some points at this level will be congested, especially on the abdomen, feeling like an inflatable pillow. To palpate points on the surface, skin layer, one may use either hand to stroke with the belly of the middle, index or thumb finger, or with two to four finger pads at once, stroking up and down, back and forth or in a circular motion with gentle pressure. B] Points between the Surface and the Subcutaneous Tissues may be approached in the same fashion, with a little more pressure and/or a kneading action, or even by pinching with fingertips, or a bigger grasp with the bellies of fingers and thumb, or even bigger grasp between the thumb and the index finger bent into a “J” shape. This layer is palpated for areas or points that are thicker than others, small lumps or nodules that can be felt by moving the thumb against them with the skin and adipose tissue pinched up, or hypersensitive points that sting when pinched. C] Points in the deeper fascia and muscle layers are palpated for “indurations”, that is to say knots, hardness of the tissue when palpated with deeper pressure. These can come in many shapes, “including lines, circles, and other odd shapes. Therefore it is sometimes difficult to distinguish the induration from the shape of the muscle itself.” This is parallel to trigger point palpation as presented by Travell and Simons.
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Shudo Denmei has a few approaches to palpation at this deeper layer: pressing with the tips of the thumb, index or middle finger, separately or two or three together, with the fingers straight; bend the finger (crooked) and pressing with the belly or pad of one of these fingers or thumb. One can apply vertical pressure up and down to feel the borders of the induration; apply circular pressure; press up and down and sideways (cross-fiber) with a kneading motion; or hook and dig in with finger(s) or thumb tips. Points in deeper areas like the abdomen, hips or lower back can be quite deep especially when practicing abdominal (hara) palpation and trigger point palpation.
The Yin and yang of Palpation: Starting from a Yin approach to palpation, regarding the amount of pressure to apply Shudo Denmei states clearly, “the less force that is used, the better.” He goes on, “[t]his applies regardless of the depth at which we palpate a point, but is especially true for tender or indurated points. When we use excessive pressure, every place we press might seem like a tender point (ibid, p. 11).” Master Shudo goes on to discuss the Chinese terms “men and xun” which appear in the Huang-di Nei Ching (Su Wen and Ling Shu) and mean to “stroke lightly”. In his approach, the surface itself is palpated gently feeling for “something catching on (or sticking to) our fingertips (ibid).” When palpating along meridian pathways, he strokes gently this way in the direction of the meridian flow, using the middle, or middle and one or two other fingers, “primarily around source points (ibid, p. 12).” This same gentle stroking of the meridian becomes more focused on specific depressed areas, when palpating for the actual acupuncture points. When feeling for excess and deficiency to apply dispersal or tonification techniques to regular meridians in Japanese meridian therapy, he clarifies, one palpates gently this way. Strong pressure, on the other hand, used for the third level of palpation of fascia and muscle, is aimed at detecting muscle channel tender (trigger) points.
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The Sawada style of Traditional Japanese Acupuncture, which Shudo Denmei first trained in, is known for its strong palpation of tender points in the muscle channels. Even then, Shudo Denmei stresses, his own teacher in this style used far less pressure than Sawada himself. There are therefore more yang approaches even within this overall quite Yin, Traditional Japanese approach to palpation and treatment. In his Applied Channel Theory with Jason Robertson, Dr. Wang shares a different approach based on the same Chinese terms, “men and xun” which he translates as “feeling” and “palpating”, along with “an”, which means “pressing” ( pp 337-338). He cites the same classical text. He then cites Huang-Fu Mi’s celebrated text several hundred years after the Huang Di Nei Ching, the Jia Yi Jing (Systematic Classic), where the technique of channel palpation and the significance of findings to disease are developed. Moving away from the Huang di Nei Ching in preference for the later Han dynasty classic, the NanChing, Dr. Wang reduces channel palpation to the channel pathways below elbows and knees, palpating with the lateral edge of the thumb belly, up the channels while holding the ankle or wrist with the other hand. In this approach, Dr. Wang advocates palpating the channel in three progressively deeper sweeps, “to discern structural changes along the course of the channels, which includes not only changes in muscle tension but also nodules, bumpiness, or granularity (ibid, p. 338).” While Dr. Wang does discuss the finding of “soft-weak” areas on the surface, denoting a deficiency, he states that this is found with “mild pressure”. The other findings, at the second and third levels, are hard and tight nodules, which Shudo Denmei would expect to find at third or even deeper level only. Wang’s approach therefore appears more in line with Sawada style muscle channel palpation, more appropriate, perhaps, to muscle channel tender point assessment and treatment. The biggest difference is in the palpation for the actual acupuncture points, which Shudo Denmei expects to find as depressions in the skin layer, where the fingertip gets stuck as it falls into the “hole”(acupuncture points are described as holes or caves in classical Chinese texts) during gentle palpation, whereas Dr. Wang advocates using pressing (“an”) for tenderness: “When searching an area for the precise location of an acupuncture point, it is often helpful to look for tenderness or pain (ibid ).” Having experienced both forms of palpation with practitioners of each of these, more Yin or more Yang styles, I can state that Dr. Wang’s palpation
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starts one or more levels deeper, and is quite uncomfortable throughout the channel palpation, compared to the meridian therapy approach to palpation.
Palpation Tolerance We have developed a simple concept at the Tri-State College of Acupuncture for dealing with this apparent contradiction, especially when practicing classical Chinese acupuncture, tui na and APM more yang styles and dispersal techniques. Since people’s reactions to pain and discomfort are very relative, with one person’s soreness not even phasing another person, we must teach patients how to share with us that level where, even if not pleasant, the palpation or needling technique is perfectly tolerable. We therefore do stronger techniques slowly, watching and feeling for the patient’s reaction and stopping if possible before it is too uncomfortable, hopefully “hurting good” as massage patients often remark. The strongest pressure at the deepest level, as well as more superficial levels, that one can tolerate, is that poerson’s “palpation tolerance” level. It is critical, in my opinion, to test the “de Qi tolerance level” with each new patient to insure needling and performing palpation and tui na within their comfort-zone. By training in more gentle and stronger styles of practice, practitioners will have palpation and treatment techniques that fit their patients’, and their own, proclivities and sensitivities. The ultimate challenge, and the sign of a good practitioner, is the ability to practice stronger palpation and techniques where required or where a patient prefers this, even if the practitioner her or himself prefers to be palpated and treated more gently, and vice versa, being able to practice gentle techniques even when you feel stronger ones might be more effective, when this is required to stay within a patient’s comfort level and safety zone.
Acupuncture Felt-Sense Regarding the sensation experienced, the modern Japanese traditions cited by Shudo and Matsumoto stress the “arrival of Qi”(zhi Qi) which is what the practitioner feels, over “obtaining qi” or deqi, which is what is stressed in Chinese and Korean traditions, and centers on what the patient feels. I have referred to the sensations patients feeling when de Qi or zhi Qi is obtained, as well as the internal
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shifts they and the practitioner becomes aware of, on a “bodily felt-sense” from Eugene Gendlin’s work on “focusing”. Chinese and European traditions have often stressed de Qi as at least as important, if not more important than zhi Qi. If one practices the above test for each patient’s “de Qi tolerance”, I believe we are in the presence of a continuum from zhi Qi, the initial reaction of muscle or fascia to the needling, and de Qi where this reaction is sufficient to be clearly felt by the patient as sore or achy but still tolerable. And since one person’s reaction to zhi Qi might be that this feels sore and achy already, this would in fact be de Qi for that patient. I now suggest to students that what is important is to learn to attend to what is happening underneath the top of the needle, and with more experience, I believe all practitioners start to feel the fascia responding and tacitly develop a “feel for” when this needling has already led to zhi Qi, which they can feel, within the patient’s tolerance level. But this just refers to the initial response to the needling, the first step as it were. I am always attending to the reaction I feel is most appropriate, and for some signs of appropriate change, a “shift” in the patient that I can always perceive but not necessarily name (a relaxing of fascia and muscle in the obstructed area, a more relaxed demeanor, a more normal breathing pattern, a settling of the patient into the table to “receive” the treatment rather than brace against it, etcetera. If this does not occur, and even if there has been zhi Qi or de Qi, I continue the stimulation a bit longer to get the desired results, which usually only takes seconds. I have watched Kiiko Matsumoto do the same thing, which she usually denotes to the patient by saying “Oh Sorry!” while still needling for a few seconds. I often simply say in such instances that they are going to feel this, stating “Here we go!” and in seconds the sought after effect arises, such as causing the Qi sensation to sink into the point, or to propagate away from the point, up or down the channel (as for Sp 4, or St 36 respectively). In the above-mentioned Needling Colloquium, Matsumoto stressed zhi Qi, and talked about classical focus on “targeting the Qi” carefully with the needle, getting the exact angle right. When she palpates for essential points like Kidney 4, she feels for the precise point, which is often tender, with her needling hand, while her other hand palpates for changes in Hara imbalances detected there. If the Hara changes by pressure on the distal point, such as Kidney 4, Qi has been correctly targeted,
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Matsumoto argued, and needling of that precise location at the exact same angle of pressure with a needle will produce the greatest effect. Liu, Nielsen, Seem and Skelton all placed emphasis on feeling a reaction with their supporting hand, like the fish biting on the line analogy from the Ling Shu, which Shudo also references (acupuncture as a “left-handed” affair), thus feeling for the arrival of Qi at the site of needling, as well as a de Qi sensation perceived by the patient as a mild to strong acing, distending sensation that could sink in the local area, or spread out around the point, or propagate away from the point, up or down .
Reframing Needling Sensation/Training Good Acupuncture Patients: Regarding Intention and reframing of the patient’s experience of such strange sensations, at least for their first few treatments, Matsumoto clearly reframes the patient around focusing on changes in the Hara, and uses palpation of distant points, and their effects on local Hara or other Reflexes, and the delicate interplay between these reactions (of distant active point to local reflex) as her way of reframing their experience of treatment: by the end, when she is able to initiate a change in a Hara or other key Reflex, the patient is clearly effected, impressed (“interesting, isn’t it!?” she often remarks when change occurs). She consolidates this focus on the “bodily felt-sense” of the patient to the needling when she removes the last pieces of tape from tight tender points she palpated initially, stating rather dramatically—“Take Away!” Liu and Seem seemed to place a lot of attention on creating movement and change right at the sight of needling, and propagating Qi sensations, reframing the patient’s experience by focusing on these sensations and movement induced by needling: Liu reframed often, in grand rounds the two days after the colloquium, by simply looking knowingly into the patient’s eyes when a significant sensation (de Qi) had been obtained, encouraging them to go with the bodily-felt sensations for a few moments, thus sharing his intention, that initiation of such sensations is good, therapeutic, and that change will ensue, by his silence, his concentration, and also his humor, which he pointed out he needed to develop to reframe his American patients’ reactions to such powerful de Qi sensations.
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I stressed that as the director of education and chief clinical instructor of my own acupuncture College for the first two decades, I had to struggle with how to teach de Qi and zhi Qi, and the reframing of these sensations, especially in light of a trend in America to brand acupuncture, as did the Serein needle company, as “the Painless One!” I clarified in this demonstration in front of my colleagues and these researchers that I reframe the patient’s experience of acupuncture needling sensations by helping them focus on the holding pattern of constrictions and deficiencies found on the initial palpation, with a focus on the sensations experienced from the needling to affect the holding pattern. I lead them to focus on the holding patterns, and then pace my needling and comments to their readiness to release the constrictions (a practice derived from Ericksonian hypnotherapy). I set up the process for change from the needling by teaching the patient what the de Qi sensations will feel like, and engage the patient in sharing his or her experience of needling, of feeling strange and sometimes strong, sometimes subtle, but often powerful sensations, sharing my intention that if they experience such de Qi sensations (the “bodily-felt sense”), or if Qi sensations propagate as anticipated and shared with the patient, the treatment will be effective. In this way I make a suggestion that change is what will occur, and that this is what I anticipate to initiate therapeutic changes, and then when de Qi is achieved (within then patient’s tolerance level), I always respond positively (“Great!” or “That is rally going to help!”), to reinforce the suggestion and allow it to sink in. I would suggest that patients can do this in short order if educated (led to) to attend to these changes from their shenming, their spirit clarity, their deep intelligence of existence, because all human beings have this ability to earn tacitly, as Polanyi argues, from all the senses, which feels to the patient like a bodily awareness that cannot be easily labeled, which Gendlin simply referred to as the bodily felt-sense. After reading Tu Wei-ming’s discussion of master Wang Yang-ming’s NeoConfucian concepts of “inner experience” I realized this was exactly in keeping with Polanyi’s concepts of “indwelling,” or “tacit knowing” which Schon later translated as “know-how” and “a feel for”.
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In Wang-Yang-ming’s teachings (1472-1529) the central notion is t’i which Tu Weiming translates as “to embody” bespeaking a “concerted theme of total commitment, involving the entire ‘body and mind’ [ …] T’i-hui t herefore means to understand experientially, as if one has ‘encountered’ or ‘met’ in person, that which is to be understood […] It points to a kind of “confirmation” in which the truthfulness of an idea cannot be demonstrated by logical argument but must be lived by concrete experience. However, such an experience is neither mysterious nor subjective, although its meaning can be readily acknowledged only by those who have tuned their minds and bodies to appreciate it […] As a result, when the NeoConfucian master suggests to his students that the only way to take hold of a certain dimension of his teaching is to ‘embody it’ (t’i-chih ), he is absolutely serious”. This involves thinking, or rather a discipline of mind that includes mindfulness and a reflective practice, rather than logical, critical thinking, where a student learns to think not only with his head but with his entire ‘body and mind’ [ …] To think with one’s whole being is not to cogitate on some external truth. It is a way of examining, tasting, comprehending, understanding, confirming, and verifying the quality of one’s life. Underlying this kind of reflection is a process of digging and drilling that necessarily leads to an awareness of the self not as a mental construct but as an experienced reality”( Tu-Wei-ming, Humanity and Self-Cultivation, pp. 103105). I would suggest that what we are teaching our students, and our/their patients, is how to tap into their inner intelligence, their shenming (spirit clarity) during the treatment, and to open up to receiving the changes that are heralded by a “bodily felt-sense” of what is referred to as zhi Qi or de Qi b ut which is much more than these Chinese medical concepts: it is a lived inner experience that, withal a few treatments and a little somatic education from the practitioner, becomes something the patient owns each treatment. We are teaching our patients each treatment how to be a better acupuncture patient, which is to say, how to allow their inner intelligence to make all the necessary changes to better tune or attune their Qi (tiao-qi) by yielding to and going with the bodily felt-sense provoked during the treatment and for days afterwards. I deal in great detail with this concept of “felt-sense” in the western literature in my Bodymind Energetics and refer the reader to that text for an elaboration of these western concepts.
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What has proven truly eye-opening to me in the process of studying the pre-TCM text that started off this series of reflections, the Zhong Yi Xue Gailun (which Yanhua Zhang, in her Transforming Emotions lists as the first formal textbook of Chinese Medicine in the PRC) is that the Confucian and Neo-Confucian ways of engaging in learning in an “embodied” way, with mind and body, was at the base of any serious study of Classical Chinese Acupuncture and Medicine for two thousand years, until this Confucian tradition, both as religion and as philosophy, was outlawed and uprooted from mainland China during the cultural revolution that followed.
Concurrence and Change: Returning to the colloquium in needling sensations mentioned above, Skelton also focused on making the patient feel something at the site of needling, but then would tap with his other hand along the body toward the symptomatic area, to get things moving, to reframe the patient to experience this dance of sensations and movement, having them move their affected arm or shoulder or hand or back, engaging them in observing, like a research scientist, to see if anything was changing. Nielsen quickly obtained deqi, distally, then focused on the counter-irritation effects of guasha to first congest, then decongest a symptomatic area to induce better flow of qi and blood, in a way similar to osteopathy’s notion of strain-counterstrain. She also used needles locally in the most reactive areas where guasha was to be administered, to further free up the flow. All five practitioners palpated carefully for the points they were going to treat, and engaged the patient in a somatic reframing, where the somatic rapport, as Nielsen stressed, was a clear part of the treatment, uniting the practitioner’s Intention on creating change, the patient’s will to heal, and the attention placed on what was happening throughout the treatment. “The Painless One!” branding of Acupuncture in America, which I jokingly refer to as the “whimpification of American Acupuncture”, is a big problem. This conception
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does not just come from the marketing of Japanese needles inserted through tubes, although the cultural effect of shifting American practitioners from Chinese or Korean, tubeless needles, where one had to have good insertion techniques, cannot be ignored. But many Chinese practitioners also explain to the patient, when the patient winces or cries out that the needling hurts, “That’s not pain!” As Flaws explains clearly in his excellent Sticking to the Point, in China the practitioner first asks if the patient is feeling the deqi sensation, and if so, will then add for clarification “does it hurt or not (Tong bu tong)? Thus, in China, “Acupuncture should be bu tong or painless. However, many Westerners will experience even proper deqi as pain. In English, soreness, cramping, and heaviness are species of pain. Whereas in Chinese, soreness (suan) or distention (zhang) is bu tong (p. 121)”. Tong refers, Flaws stresses, to “a sharp, cutting, biting pain” and suggests incorrect needle placement. If the patient feels tong, the needle is repositioned. To say “the painless one” misses this cultural clarification, and implies one will feel nothing, and in fact many of my patients who have been treated by other acupuncturists often say to me early on in the first session: “ I thought you weren’t supposed to feel anything?” This is further complicated by the fact that Japanese patients seem to prefer very little if any deqi sensation, perhaps due in part to acupuncture being a profession for the blind. To feel discomfort when being needled by someone who cannot see might more readily be interpreted as the blind practitioner hitting a nerve or vessel or tendon. This may in part explain why Japanese practitioners prefer to focus on zhi qi, which the practitioner can often feel before de qi is induced to a point where the patient feels it too strongly. All of the master practitioners in this colloquium caused the patient to feel many things, but did so in a way that was not threatening, not unbearable, even when the sensations were quite strong. Liu and Seem clearly sometimes created quite strong sensations, akin to the “It hurts good” sensations of deep therapeutic massage, but made it clear to the patients with their comments and body language that this effect was to be expected, and was a sign that treatment would be effective. Matsumoto, who prefers to use very thin needles and quite shallow insertions with little if any deqi sensations induced by the needle, still often creates quite powerful sensations with her pressure, or with patchi-patchi induced fasciculations, for pain or stroke patients, and the spreading sensations of her distal needling techniques can be experienced as quite strange, and powerful, by many patients, even though there is far less, if any, deqi. None of these practitioners was promising that patients would
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feel nothing, and seemed to imply by their presentations that to feel nothing would mean doing nothing for the patient. Sensations were induced, change was initiated, and the patients’ experiences were significant. Each practitioner seemed to work like Matsumoto, to encourage the patient to see how “interesting” this strange practice of needling and fire and scrapping was.
Selection of Points: In November, 2003 TSCA and its “center for acupuncture educational research (CAER) hosted a second colloquium, in conjunction with the Society for Acupuncture Research’s annual research meeting at Harvard, focusing on locating/utilizing active-reactive points as opposed to textbook points, a topic that derives logically from the first colloquium. At the College, we teach an amalgam of approaches to needling and to location of effective points, most influenced by Matsumoto’s and Seem’s approaches, as two very different styles, that encourages students to develop their own appreciation for locating and needling points effectively. While Shudo Denmei stresses “finding” effective points, at the College we stress “effectively locating and stimulating” points. Perhaps this is very similar. But given that each master practitioner will have her or his own “POINT PALETTE” of favorite points, which Shudo shares with us in his newest book from his own experience, a cynic might conclude, as some medical physician acupuncturists in England, following in Felix Mann’s direction, do, that any point can be effective if one finds actual, active/reactive points, or if one needles them properly. This is especially true of highly reactive patients, termed “strong reactors” in England, where the most minimal stimulation can yield fast and dramatic results. Such cynics believe one can dispense almost totally with classic acupuncture theory, and Skelton’s presentation at the colloquium underscored this view. So whereas practitioners of meridian therapy might always feel for “active and reactive points” whether on yin or yang meridians, I tend, more in line with TCM needling and point location, to needle actual essential points based on falling into the hole where they are classically described to exist, and then to stimulate to
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make the point active/reactive, as in the Ling Shu, by tonifying (first slow, then quick) or dispersing (first quick, then slow). I always do this on distal regular meridian points, mu and shu points and on local points along the regular meridians that I select to treat symptoms in that area (Lu 1 and Sp 20, with Liv 14 for chest congestion for example) which amounts to selecting empirical points for symptomatic relief, to address the patient’s “manifestations” (signs and symptoms) and to relieve their pain, dysfunction, discomfort and distress. This seems to me to be somewhat different from the Japanese approaches to needling cited above, in that it creates activity and reactivity, according to the patient’s tolerance level at TSCA thus tapping into the point’s potentiality or “readiness to react”. The Japanese traditions are highly influenced by the blind practitioner traditions and the reverence for as mild a stimulation as possible, something that appears to align better with Japanese patient expectations and preferences. While practitioners of Japanese meridian therapy often feel for change in the pulse, which can prove mystifying for patients and students observing such treatments, Kiiko Matsumoto, who has worked in this country the bulk of her long career, has developed a highly effective way of using changes in the Hara, which she uses as the centerpiece of her acupuncture reframings, that also prods the patient’s bodily felt sense of change. It is the patient reaction to the recheck of tapped tight tender points including the Hara findings who agrees whether the tenderness has changed, not the practitioner telling the patient the change has occurred based on what the practitioner is feeling in the pulse.
Needling Yang Versus Yin Meridians: I needle yang meridian tender points more strongly, until there is a propagation away from the point, either down toward the foot or hand, or up toward the knee or elbow depending on the location of the local obstruction. If the qi propagates all the way to the symptomatic site, that is excellent, but not necessary and not the most usual response. Research in China shows that qi can be made to propagate more readily, and over a longer distance, by warming the skin if the patient is cold (one could put mylar on the patient during the initial palpation and assessment phase to warm them up, and put it back on once the needles are in place if it is cold
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out, or if the room is chilly), by stroking along the skin in the direction one wishes to propagate the qi, and by applying pressure on one side of the point to induce the propagation in the other direction. If one can get the propagation to extend three inches or so, that is sufficient for a good effect. I agree with Shudo that one does not need to get major reactions at all points selected, and that a reaction at some key root as well as symptomatic points is all that is needed. Wei Liu stressed this as well. One should pay special attention to the essential distal points, and mu and shu (and related empirical) points, the root part of the treatment, to have an effect that begins to draw patients into the process (reframes them), engaging them in the change that is occurring, what they are feeling, how things are moving. I then end with a large focus on release of the local holding pattern, be it myofascial with a musculoskeletal or structural problem, much like Travell’s work, or more subtle in a viscerosomatic/somatovisceral problem with zangfu presentations, such as chronic fatigue or complex chronic respiratory, gastrointestinal, gynecological, genitourinary and stress disorders. Holding patterns in these cases are peeled away slower in most instances, especially by students and new practitioners, by focusing on yinyang regulation (tiao qi ). What is different in APM, is that I stress also releasing the local holding pattern of such internal and stress disorders, while a TCM approach might well just add local mu and shu points without any attention to releasing the actual constrictions in these areas. These local points are from the regular meridians, not the tendinomuscular meridians, and often amount to treating the beginnings and ends of the meridians (where taiyin, yangming etcetera come together, such as Lu 1 and Sp 20 for taiyin respiratory signs and symptoms (manifestations) and St 2 and 3 and LI 20 for yangming upper respiratory, sinus and allergy manifestations. This is based on Yitian Ni’s clarification regarding regular meridians and their manifestations that one can always treat local points for signs and symptoms in the area of that point, based on the dictum: “the closer the closer”. These points are invariably excess, and so I disperse with lifting and thrusting that focuses on the lifting motion and twirling rapidly to break through the regular meridian obstructions and get Qi and Xue moving. This is in marked contrast to dispersing local tendinomuscular meridian ashi or trigger points, where I use a technique I derived from trigger point dry needling a la
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Travell, to cause the muscle to fasciculate which is similar to Chinese “sparrow pecking” technique, except that it is always done directly over an identified (and strongly pressed to start the strain-counterstrain action at the site) trigger points, which consists in then releasing the grasp and stretching/compressing slightly the fascia over the trigger point with the non-needling hand, while pecking as if a bird going in for seeds, 2-3 times rapidly at the site, then lifting and hovering a moment before rapidly pecking again. This often causes the muscle trigger-point to fasciculate and release in a way the practitioner and patient can feel, and one can often observe. This issue became complicated over the years as I was trying to build Travell’s trigger points into the teachings here at the College, also because I jokingly refused to refer to qi in the second year, while students were practicing trigger points with me and my skills review staff. Students often become frustrated or confused as third year students when I entered their treatment booths and showed them how to cause qi to sink locally, or propagate, rather than seek a trigger point release. I started to realize three years ago that many students thought I treated most points as trigger points, because we spent so much time in year two skills practice together practicing trigger point release. For this reason I have now taken over direction of the three needling classes where first year students first learn how to needle, to stress these various approaches to different sorts of points and to instill a deep respect for the subtlety involved. It is hard for students to hold so many different perspectives in mind at the same time in clinic, and we are therefore attempting as much as possible, especially in grand rounds but in the new Acupuncture Clinical Practice (formerly skills review) classes as well, to instill a respect for classical Chinese and modern Chinese and Japanese needling techniques, along with myofascial trigger point techniques, that challenge students to take an energetic (classical) as well as a myofascial (modern) view of what is happening at the tip of the needle, and how this effects change in those they treat.
Expectations: In closing, it is essentially an issue of practice, and we now expect students, from the first year on, to try to emulate senior practitioners not just in their treatment strategies, but also in their actual techniques, and their ways of reframing what patients feel during the course of a treatment. To educate patients to become
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better and better at receiving, acting and reacting to each session, from their own bodily felt-sense of change. It is crucial in the art of acupuncture, to place ones intention, ones heart or shen, on the larger picture, with the goal of serving as a change-agent prodding the patient to heal herself by removing some obstructions and blockages, by releasing them from some part of their acute or chronic holding pattern. But as Shudo stresses in the conclusion to his second book, “[t]his can be compared to art or calligraphy where the work of an amateur and master is worlds apart even though the same materials and tools are used. This is why acupuncture is an art. This being the case, we can only needle each point with care on a daily basis to hone our skill (p. 241)” In other words, the art of acupuncture involves our Intention, but this Intention is what is omnipresent, in the background, how we start out each day, a silent mindfulness meditation to ourselves, or a prayer to set the tone. Our Attention on the other hand must be on the work, the practice, the art, the practice of doing, while seeming to do nothing or wuwei , thus placing our attention on the actual act of doing the practice, honing the skills that are essential to achieve mastery. Lofty intentions with no skill will not work. Contrariwise, Shudo concludes, “Technique is important, but the intention behind it is even more important (p. 242)”
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THREE High Skills & Self-Cultivation PREFACE: In Tu Wei-ming’s chapter 13 (Humanity and Self-Cultivation, pp. 186-215) on "Yen Yuan: From Inner Experience to Lived Concreteness" he shares a central NeoConfucian approach to inner work, meditation, and self-reflection focused on the relationship in self-cultivation between cultivation of inner experience and being at one with the 'great body (ta-t'i)' or deep structure of the Mind(and-heart) on the one hand; and cultivation of the 'small body (hsiac-t'i ) or surface-structure where feelings and emotions play out in the Real of the outside world (Yen Yuan) or transcendence beyond this body and the emotions where all 'human evils' reside according to Chu-Hsi (Reflections on Things at Hand ). (ibid pp. 205-211 especially). Yen Yuen has a radically different view of ritual and its role, as well as sitting and walking meditation, compared to Chu-Hsi which informed later Neo-Confucians like Wang Yang-ming. Whereas Chu-Hsi sees the 'reverence' and awe for All that Is (he Heavenly Principle, Coherence) as something one can only attain by cultivating the 'great body', and in silent meditation where one would ultimately connect with the All through this rarefied practice and embrace the good, while most people would remain at the surface where evil resides, Yen Yuen and WangYang-ming follow Mencius in positing the goodness of human nature and the belief that anyone can attain reverence by engaging in self-cultivation and renewing daily ones resolve to walk the Way of the Sage which seeks authentic human relatedness which, when attained, contains the heavenly principle. In this view, one could develop reverence and awe for the All (T'ai Qi, Ti'en), t he heavenly principle, the coherence in all things in daily affairs, as Yen Yuan taught: "The ancients taught men to do housework, and while doing housework to practice reverence. They taught the proper ways of dealing with people, and in these to practice reverence. They taught rituals, music, archery, riding, reading and
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mathematics, but in arranging the order of the rituals, in the law of the notes, in studying the bow, in control of the horse, in pounctuation, and in calculation, there was nothing without the practice of reverence. Therefore it is said, 'Be reverent in handling public affairs,' 'Be reverent in your daily affairs,' and 'Be truly reverent in your action.' All these emphasize the constant practice of reverence by the complete devotion of the body and the mind. If the traditional methods of the ancients are being laid aside and the practice of reverence is sought in quiet-sitting, meditative self-control, slow-walking, and soft-talking, it is like using the empty form of a Confucian term to do the real work of Buddhism (ibid, pp 208-209)." The discussion about the cultivation of 'inner experience' and 'lived concreteness' and Yen Yuan's critique of 'quiet-sitting' starting on pages 200-201, where he stressed that it is only by practice of something practical, something useful, something that can enable one to better engage authentically with self and others (the practices listed above, which some Daoists would add other martial arts to). The discussion of Yen Yuan's insistence on ritual practice in any of these arts as an 'incessant commitment to self-perfection' is "a daily, in fact hourly affair, and by necessity it has to assume a concrete form is also of critical importance: “Of course there is little excitement in such trifling acts as rising early, dressing properly, eating moderately, refraining from superfluous talking, walking at an unhurried pace, sitting straight, and keeping a diary consistently. But like the training of a lute virtuoso, to integrate all these seemingly fragmentary acts into a holistic expression of the ritualized personality requires a lifetime of commitment [...] The act of a specific ritual practice is not only a record but also a self-revealing gesture. It in a sense offers a solution to the perennial Confucian problem of 'inner' and 'outer' (nei-wei ), for it bridges the gap between an inner effort of self-cultivation and its outer manifestation in the family, the state, and, indeed, the entire universe. [...] After all, to study the lute is to acquire a skill, but to engage in ritual practice is to master oneself. The art one must learn in mastering oneself is that of selfcultivation. Unlike the study of the lute, one cannot for a minute lay down one's instrument and rest. The moment one forsakes ritual practice, one has already deviated from the course of self-cultivation. Constant practice does not guarantee a competent performance (ibid, pp. 200-201)."
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14] The Spirit Uprooted—Classical Chinese Medicine Loses its Humanity The Problem: As Part II will reveal, not only have the Ordinary Skills of Classical jing-luo Acupuncture suffered at the hands of this radical reshaping of Classical Chinese Medicine (in its new, communist, TCM version, taught in a simplified language with simplified theory accessible to new students at TCM Colleges with no grounding in the Classical concepts). In addition, Confucian and Daoist foundational knowledge, which informed mainland Chinese concepts of humanity, was stripped from Chinese medical texts as religious and feudal remnants of a past to be outlawed, forgotten and left behind, along with life nourishing and self-cultivation practices (Dao-Yin, Qi Gong) thought to be essential, in the Classics and up until the late 1950’s in the PRC, in order to aspire to become a practitioner of High Skills.
Rooted in Spirit: shen and xueqi
Sinologists Claude Larre and Elizabeth Rochat de la Vallee stress the near identical nature between the spirits (wushen ), and blood ( xue ) and qi . “Blood and qi are one of the best ways through which the spirits express themselves in a perceptible way. It is perceptible because it is always through the balance of xueqi t hat we have the indication for treatment. You know that there is excess or deficiency, so you tonify or disperse […] The blood and qi are the spirits of man, one cannot but pay great attention to their maintenance (Essence, Spirit, Blood and Qi , Monkey Press, London, 1999, pp. 121-123). This equation between xueqi -blood and qi --, and shen -spirit taken as a whole, also define shenming or spirit clarity (spirit light): “If the xueqi , the heart and the lungs are functioning well, and all the meridians and the zangfu are in harmony with this
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functioning, there is a kind of concentration of xueqi at this place, and there is a good impregnation of the layers of the skin. The eyes and vision are good, and the brain is alert. The bones are solid. All that is called shenming (ibid, p. 118).” Larre and de la Vallee paraphrase the oft-quoted concept that the practitioner of ordinary skills observes the body, while the practitioner of high skills observes the spirits: “This means that he observes the blood and qi of man, tonifying or dispersing, following excess or deficiency (ibid, p. 120).” This decidedly physical depiction of spirit is echoed in Maciocia’s study on the subject. Whereas the Western view of body and spirit depicts the spirit as that which animates the body, according to Maciocia, the spirit and body in Chinese medicine “are nothing but two different states of condensation and aggregation of Qi […] with the Qi being the most rarified form (The Psyche in Chinese Medicine , Churchill Livingston, 2009, pp.4-5).” He goes on to paraphrase the ancient concept that the body is able to stand erect due to the spirit within, and that the spirit requires the body for its existence and dies with the body (ibid). He translates from chapter 66 of the SuWen in a similar, and again decidedly embodied way, thus: “What is called shen? Qi and Blood are harmonious; Nutritive and Defense Qi circulate freely; the 5 Yin organs have been formed; the mind resides in the heart; the ethereal and corporeal souls have been formed. Where there is no shen, there is death. Where there is shen, there is life (ibid, p. 9).” Elisa Rossi comes to the same conclusion in her study of the classical and modern Chinese medical concept of Shen. In her text, Shen: Psycho-Emotional Aspects of Chinese Medicine , she stresses from the outset that the classics of Chinese medicine view the emotions, which can lead to a disturbance of shen when overly strong or in a person of weak constitution, as physiological events, a response of the Shen to stimuli of the outside world (p. 23).” She goes on to clarify that mind and body in Chinese medicine are perceived as an indivisible and dynamic unit: “Emotions can give rise to somatic disorders as well as psychic illnesses; organic illness can, in turn give rise to emotional alterations and psychic pathologies […] This implies that psychic disorders should be treated
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starting from the energetic system of channels and organs, utilizing the usual diagnostic process, the same principles, and the same therapeutic tools (ibid, p.24).” She stresses that emotions, when excessive or in a susceptible individual, alter the movement of Qi, leading to stagnation of Qi and functional disturbances of the viscera. If prolonged, this can lead to actual organ disorders and even death, as underscored in the oft-quoted Chapter 8 of the Lingshu: Benshen , often translated as “rooted in spirit”. In such serious disorders rooted in the spirit from emotional stagnation, as this chapter outlines, death will come in the season that dominates the organ in question: in Spring, for the Spleen for example (ibid, pp 26-27). She concludes in like fashion to Larre and de la Vallee, that to recognize and treat disorders rooted in spirit, one must recognize the disorders of qi that have arisen, and treat them with regular meridian strategies of point combinations and needling techniques to tonify or disperse. Rossi and Maciocia each lay out classical and modern categories of shen disorders (patterns of constraint and heat; fullness; and emptiness in Rossi; Lilium syndrome depression; emotional stagnation; plum-stone syndrome; visceral agitation; and excess and deficiency variants of palpitation and anxiety syndromes in Maciocia). The focus of each author, and Larre and de la Vallee is clear: a practitioner who aspires to practicing High Skills must learn to recognize, and regulate, excess, deficiency and stagnation of Qi and Blood, to treat the shen level with needles and moxa. The first chapter of the Ling Shu goes on for a few pages detailing the methods, ‘slow, then quick’ for tonification, and ‘quick, then slow’ for dispersion. As the text clarifies, this “is the manipulation and the way of the needles. Firmness is precious. The primary fingers make a vertical insertion; do not needle to the left or right. The spirit seems to be at the tip of the needle. Focus awareness on the patient. Investigate the blood pulses and the needle will not be dangerous. When inserting the needle, it is necessary to harmonize the yang and control both the yin and the yang. The spirit will follow. Do not go away [ …] The blood pulses are widely distributed at the shu points. They are clear to see and strong to touch (ibid, p. 2).”
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In this description, which I will return to in a later Reflection on Needling Technique, the Ling Shu stresses that only “when the qi is reached, will acupuncture be effective. This effect, it is said, is as if the winds blow away the clouds and clear the azure sky. These are all the Dao of acupuncture (ibid, p. 3).” So how does a practitioner know if the Qi (and hence the shen) has been reached? The Ling Shu provides a clear method of inspection of the patient’s ‘vital signs’ near the end of the first scroll thus: “Look at the patient’s color. Observe the eyes. Know how the qi disperses and returns. Each has its own form. Listen to the patient’s movement or stillness. Know his imbalance and his balance (ibid, p. 4).” Thus far, the Classical Chinese notion of shen or spirit sounds very embodied, and Wang Ju-Yi would seem to concur in his modern interpretation: “Remember that, to me, the character shen (character included in the original text) refers to the intelligence of existence. It is an innate intelligence that, when the heart is healthy, any person or animal might have. This intelligence is also present in the world at large ( Applied Channel Theory in Chinese Medicine , Wang Ju-Yi and Jason D. Robertson, Eastland Press, Seattle, 2008, p. 148).” He is speaking here, of course, of the shen o f the Heart-Mind. These various definitions of spirit are in keeping with Wiseman and Ye’s definition of shen in their text, A Practical Dictionary of CHINESE MEDICINE (second edition, Paradigm Publications, Brookline, MA, 2008, pp 550-551): “ 1. (In the narrow sense, that which is said to be stored by the heart […] 2. (In a wider sense) that which is said to present in individuals with healthy complexion, bright eyes, erect bearing, physical agility, and clear and coherent speech. It is said, ‘If the patient is spirited, he is fundamentally healthy; if he is spiritless, he is doomed.’ Thus, the spirit sheds useful light on the severity of a given complaint (ibid).” The authors of this dictionary go on to elaborate that there are three fundamental “conditions of the spirit”: •
Spiritedness : If the patient exhibits signs of being spirited as above,
indicating that the complaint is relatively minor, and that although “certain aspects of the patient’s health may be seriously affected, swift improvement may be expected (ibid, p. 551);”
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•
Spiritlessness : Lack of mental energy, abnormal breathing, apathy, “torpid
expression, dark complexion and dull eyes, low voice, slow, halting speech, and incoherent response to inquiry (ibid).” These signs indicate a relatively serious condition where extreme caution is necessary; •
False Spiritedness : The most classic sign is that of a fatally ill patient, who
suddenly and briefly exhibits a rosy complexion, talkativeness, and an animated spirit not in keeping with the seriousness of the patient’s condition. “It is a sign that the patient’s condition will soon deteriorate…(ibid).” In the Chart on the next page, I will list the main signs and symptoms of disordered shen in the five Zang as depicted in Rossi, pp. 26-27 as suggested by Bruce Park, a former Korean Buddhist monk and now teacher of Buddhism, during his presentation of a class on Chapter 8 of the Ling Shu known as BenShen (Roots of Spirit). I feel that Rossi gives a good feel for the effect of the emotions without getting overly bogged down in details of the five spirits which have little to do with Western patients and their emotional stresses.
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ZANG /Spirit
Heart/shen
EMOTION
S&S
DEFICIENCY
EXCESS
Anxiety,
Fear, terror,
Sadness
Uncontrollable
worry,
lost control,
thoughts and
the muscles
apprehension
are consumed
laughter
injure shen
Spleen/yi
Oppression
Restlessness
The four limbs
Abdomen
and anguish
and disorder,
do not
swollen,
that do not
the four limbs
function, the
difficult
dissolve injure
do not lift up
five organs
menstruation
are not in
and urination
yi
harmony
Mania and oblivion,
Liver/hun
Sadness and
abnormal
sorrow
behavior,
convulse the
genitals
center and
retract,
injure hun
muscles contract, ribs do not lift up
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Fear
Anger
Lung/po
Euphoria and
Mania, the
Nose
Laboured and
joy without
mind does not
obstructed,
hoarse
limits
see others,
passage of air
breathing,
injure po
the skin dries
difficult,
Fullness in the
out
breath short
chest, lifts the head to breath
Kidney zhi
Intense and
Forgetfulness,
incessant
flanks and
anger injure
spinal column
zhi
painful,
five zang are
Cannot bend
not calm
Kidney jing
Fear and
forward or
apprehension
backward
Reversal- jue
Swelling, the
injure jing
The Spirit by Any Other Name
In a discussion on Shen in Chinese medicine with senior interns at the college, I was at first struck by the fact that each person who spoke up seemed to have a different take on what spirit meant in the practice of acupuncture. Reflecting back, I realized two things: the college had not done a sufficient job in explaining what shen and spirit mean in classical Chinese medicine; North American students are not a homogeneous cohort, with the same moral and ethico-religious codes, such as would have existed in mainland China in Confucian, and perhaps even Daoist forms, until the PRC communist regime’s ruthless annihilation of the Chinese people’s philosophical and even religious heritage which endured for 4,500 years.
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In the Confucian and Neo-Confucian traditions, the latter incorporating elements of Buddhism and Daoism, the mainland Chinese people had a philosophical and even religious tradition, depending on the interpretation, that laid out basic codes of conduct and upright bearing that were especially applicable to doctors who sought to practice High Skills. In these traditions, which Confucian scholar Tu Wei-ming refers to as “humanity and self-cultivation” in a text by the same name, the relationship and tension between jen (goodness, humanity) and li ( propriety) bespeak a creative tension between an internal focus on “self-cultivation” and an external focus on realizing ones self in society, for the common good. A man, in our case a physician, who achieves the highest “human achievement ever reached through moral self-cultivation”, is a chun-zhu or gentleman, a superior person, a superior physician of high skills (Tu Wei-ming, Humanity and Self-Cultivation: Essays on Confucian Thought , Cheng & Tsui Co., Boston, 1978, pp 6-7). This issue of self-cultivation will be returned to in a later reflection on reflective practice. As a ‘religiophilosophy’, which is the way Confucian scholar Tu Wei-ming frames his argument, Confucianism seeks to “establish the ultimacy of man” and to study his unique “morality, sociality and religiosity” (ibid, pp 84-85). The focus here is on becoming the most authentic man or sage possible, which in Chinese Medicine would entail one who practices High Skills, the Superior Physician. Sagehood, in this Confucian sense, “rests on the belief that man is perfectible through his own effort. To know oneself as a form of self-cultivation is therefore deemed simultaneously an act of internal self-transformation (ibid, p. 85).” Leaving aside the questions raised by some scholars of Chinese thought regarding the legitimacy of claims by the Neo-Confucian masters to be “in the mainstream of Confucian thinking”, which revolve around the Neo-Confucian appropriation of many Daoist and Buddhist beliefs and values, Tu Wei-ming nonetheless concludes that, “despite its efforts to absorb inspiration from other spiritual systems, NeoConfucianism is a creative adaptation of classical Confucian insights, rather than a
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syncretic culmination of the ‘Three Teachings’ (ibid)” that spanned the 11 th to the 17thc enturies. In his detailed study of the Neo-Confucian Master Wang-Yang-ming (1472-1529), Tu-Wei-ming focuses on the development of the innate knowledge of the sage, only possible through a committed and never-ending effort of will entailing “a hundred deaths and a thousand hardships (ibid, p. 105)”, as a self-effort and a teaching which must be “embodied”—a “learning of the body and the mind”, to “think with ones whole being”. This is portrayed, relative to Yang-ming’s teachings, as an active and ongoing “decision to focus on the problem of how r ather than the cognitive issues of what and why” , thereby refraining “from converting issues of profound human existence into mere issues of speculation.” This is a way of understanding experientially, “as if one has ‘encountered’ or ‘met’ [ …] that which is to be understood by “deepening ones self-knowledge (ibid).” I have learned, from my long-time colleague Master Kiiko Matsumoto, how the question “why” during Grand Rounds where we each treat community patients in a clinical theater classroom setting, is inappropriate, jarring to the teaching-learning experience, and irrelevant. I once watched and listened as Sensei Matsumoto responded to a student’s question about why she just did what she did to the patient thus: “can you not see well, come up here in the front so you see better”. A little later in the same Grand Rounds day, another student asked what the diagnosis was for the treatment Sensei just completed and Sensei responded: “When she comes back next week, if she is better, the diagnosis is what I did today!” What I took to be a decidedly Japanese way of teaching in such clinical environments appears to have been quite consistent with this Neo-Confucian teaching which “points to a kind of ‘confirmation’ in which the truthfulness of an idea cannot be demonstrated by logical argument but must be lived by concrete experience” and whose “meaning can be readily acknowledged only by those who have tuned their minds and bodies to appreciate it (ibid, p. 104).” And like Wang Yang-ming, who stated that his process of ‘digging’ and ‘drilling’ as a “way of examining, tasting, comprehending, understanding, confirming, and verifying the quality of [his] life” made such knowing an “experienced reality”,
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Master Matsumoto has shown great reluctance to submit her teachings based on the sum total of her inner experience to rigid formulas. As Wang Yang-ming puts it, “I strongly fear that the student might easily grasp [this simple formulation of] it, treat it as a circumstantial notion, and play with it, without solidly dwelling in it and strenuously working at it (ibid p. 105).” After reviving myself from the exhaustive study of Maciocia’s The Psyche in Chinese Medicine , whose voluminous nature reproduces hundreds of pages from his ‘Foundations’ and ‘Practice of Chinese Medicine’ texts, and critically reflecting on his attempt to share his knowledge of the role of shen in Chinese Medicine in the way that he did, I realized I was distrustful of such a wordy, intellectual and academic discourse on a subject that is so foreign to his, and my, Western experiences of the psyche and the body process. Having struggled 28 years ago with the incongruity of Western notions of the inner Self and the issue of the Western Body-Mind split, as compared to the Chinese classical notion of self, I already came to the decision that I could not apply Chinese spiritual, philosophical or medical concepts to my Western patients’ experiences of illness, especially where matters of the spirit and the emotions are concerned. While I was able to liberate myself, in writing this book, from an infatuation with (often quite brilliant) Western psycho-somatic concepts, as derivative of the BodyMind split of Western psychology, in order to attempt to practice acupuncture as a bodymind practice like East-Asian martial arts, or meditation, or Sumi-E Japanese brush painting, it was through a constant struggle that I changed my own teachings at the college. In year-end faculty meetings, we often return to the fact that students are getting better and better at practicing what they are taught, but are still not necessarily able to clearly articulate what it is they are seeing, hearing, feeling and doing when they practice in clinic. And I inevitably come down on the side of better practice. Having taught Judo as a teenager, for the children’s class while Sensei Takahiko Ishikawa, an 8th degree black belt and the most advanced practitioner of Judo on the East coast, and twice world champion (sent from Tokyo by the Kodokan to bring judo to this part of the country) played GO (in which he was a highly ranked international expert), I was always in awe of this powerful man, whose ability to
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concentrate on GO and then move fluidly across the dojo as he taught us the way of judo, and totally appreciated the strict discipline he instilled by his example, and not by words. One could ask how he just did something, and he would painstakingly take you up and demonstrate the move on you. But if you asked ‘why’ he did something the way he did, you would be sent hurling through the air without knowing what hit you. Experience with your whole being, I realized, was the message here, and do not ask questions which takes you into a cognitive realm. For some reason, this way of learning was a relief from overly heady French intellectual studies I was pursuing. And it came naturally, as did the practice of acupuncture as I shared in the first month’s Blog. I realized when I started treating patients in the South Bronx with acupuncture that this was a similar way of knowing/learning, and that to teach this would be a great struggle. I have come to finally appreciate looking at the classic texts, even though I recognize the impossibility of knowing the reliability of their translation, while in fact sharing a deep affinity with many things I am reading, based on a whole bodymind felt-sense or tacit knowledge of how what I am reading resonates with my own inner experiences and tacit knowing of acupuncture, akin to the process elaborated by Tu-Wei-ming’s study of Neo-Confucian self-cultivation and learning. It is with that sense that I was struck by Tu Wei-ming’s elucidation of the view that “to ‘conquer oneself and return to propriety is humanity.’ Indeed, the ego has to be transcended and sometimes even denied for the sake of realizing the genuine self. For self-control, overcoming the ego, is the authentic way to gain inner experience. This path is universally open to every human being, but it ought to be traveled concretely by each person (ibid, pp 106-7).” This sort of process does not alienate one from society, Tu Wei-ming clarifies, but rather “impels one to enter into what may be called ‘the community of the like-minded’ or even ‘ the community of selfhood.’ In such a community one not only befriends one’s contemporaries, but one also establishes an immediate relationship with the ancients (ibid, p. 107).” I believe that this is how I come to “know” what Nigel Dawes, or David Kailen were saying in their Blog responses last month, or how I know what Kiiko Matsumoto means when I see, hear, watch and sense what she is doing. We have all been doing this acupuncture thing for three decades, and when things ring true, very few words of explanation are necessary.
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This way of knowing and achieving professional know-how through the doing of it is referred to by Polanyi as “the tacit dimension” which I will explore in my Blog next week. This feeling of community is exactly what I am seeking with this OTHER ACUPUNCTURE project, which has already led to connections with colleagues in such a way as to foster communication about each of our inner experiences with the classics and with our practice, in the form of Nigel Dawes’ and David Kailen’s responses to my Blog last month, and when I had a sit-down discussion with Linda Barnes, who steered me to Tu-Wei-ming ( her former Religious Studies PhD mentor at Harvard) and his work. What we can learn from Rossi and Maciocia is that we should not inject our Western notions of self, the sacred, and spirituality into the Chinese medical concepts, but rather attempt to understand these Classical Chinese concepts on their own terms. But we must struggle with these notions each in our own way, and especially when we take responsibility for teaching others.
Life Nourishing Practices
Texts examining the main forms of daoyin and yangsheng as the proper way to live, to nourish life, existed at the same time as, or even before the Su Wen , according to Rossi and Lu. It is for this reason that the first scroll of the Su Wen already refers to the ways the people in olden times conducted themselves in order to live out their proper life span of 120 years. The patients in those days were at the center of their own life nourishing and Daoyin self-development, on the basis of which the Chinese doctor would address issues of disordered emotions and the Five Shen. The patient, previously to the Su Wen , was, to sound very modern, an active participant in his own care where spiritual health and the moderation of emotions and lifestyle were concerned: 1. “One should take an easy-going attitude toward life and have few desires; 2. One should form good eating habits;
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3. One should lead a regular living pattern; 4. One should work adequately and avoid excessive fatigue; 5. One should control sexual desires; 6. One should live in harmony with the climate of the four seasons ( Su Wen , Chapter 1, in Henry C. Lu, A Complete Translation of the Yellow Emperor’s
Classics of Internal Medicine and the Difficult Classic(Nei-Jing and Nan-Jing , International College of Traditional Chinese Medicine, Vancouver, 2004, p. 65). After over a year interning with the celebrated late Chinese Doctor John Shen in Manhattan’s Chinatown, most Sundays, it became evident that this was a living example of the Superior physician of High Skills. Over two thirds of his patients, who came for his unique herbal remedies, would be denied the “poison of medicines” as the Ling Shu advises, because their problem, as he told each one in turn, was no problem, their disease was no disease; their problem was their Life. He would then proceed to tell them to regulate their eating times, the time they went to bed and arose, and to simplify their life to reduce stressors. He would tell them to get Chinese rice wine, and Chinese celery on the way to the subway from his office, and infuse the celery in the wine, drinking this at night to help with sleep. He would inevitably conclude with a new patient suffering such issues of lifestyle and stress: You take care of your car better than you take care of yourself. He would then give them a simple acupuncture treatment to calm the nervous system, and not suggest a return. He would not give herbal medicine because he did not consider them to have a disease, but rather a stress disorder that they could and should learn to manage on their own. In his later years, he would have tui na practitioners recently over from PRC, who became licensed in acupuncture, treat such patients with massage and acupuncture and again never prescribe herbal remedies. When I asked him if I would have to learn how to master the pulse and tongue as he did, he stated that since it was clear I wanted to specialize in acupuncture, there was no need to master these skills, which he relegated to the treatment of serious internal diseases with Chinese medicinals.
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This clarification between what acupuncture could best treat (the two thirds of what he saw where he did not prescribe herbal remedies)—chronic pain, stress disorders, functional disorders of the various organ systems without signs of disease-- are what I have come to specialize in, and it is here that mainstream medicine holds out the most hope for complementary and alternative medicine and healthcare. In such chronic musculoskeletal and internal functional and stress disorders, I have found acupuncture to be extremely beneficial with very few treatments at a time. In these disorders, the shen is always at issue, and when there is a central adrenal syndrome at the heart of what I term four patters of visceral agitation/fatigue, I resort to the extraordinary vessels as outlined in chapters VII and VIII of Acupuncture Physical Medicine . These four templates serve as exemplars for any stress disorders of the Zang organs. Where a central internal functional disorder, or emotionally driven disorder has no involvement of the adrenals, I simply use the normal treatment strategies of the regular meridian circuits, adding the outside line of the Bladder meridian for the shen aspect of the Zang involved as well as reactive chong mai points on the front (Kid 11-27; St 30-13) to regulate prenatal a nd postnatal qi , thereby restoring more normal function of the organs and the channels, and Qi and Blood. It is in this way that I address shen disorders when there is no actual, or serious, mental illness. I will present the chart for these four patterns in chart form on the next page:
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APM Acupuncture – 4 patterns of fatigue/stress Spinal Irritation
Signs &
Point strategies
Symptoms ________________
Du Mai Excess Kidney Yang/Heart
Coaching
______________
_______________
______________
running on empty,
YinYang Regulation
Counsel patient to
type-A, adrenal
start stress
exhaustion (drops-
Jing: SI3/BL 62 for
reduction/relaxation
dead in bed at night)
du and yangwei Mai
response activity for
Protector Dysfunction Water/Fire Imbalance
AOM Lifestyle
overall agitation works and plays hard, lives world
Ying: Kid 2(Fire) and
Take hot bath with
muscularly, reacts to
3(source)/ying and
sleep inducing bath
world somatically
shu;
salts, sleepy time tea
Bl 58 (luo); BL 23
or other soporific
Precipitating factors may be trauma of a
very productive,
(tonify or disperse
while meditating or
physical or
very active at work,
carefully if lower
listening to soothing
emotional nature
sports, socially
back muscles are
music last hour
rigid) on right
before bedtime
(car accident, attack by dog, abuse)
Ever-Ready Bunny
especially, and BL 14-43 on left (Kidney
Stress importance of
Superman,
Yang/Heart Protector
solid sleep to restore
Superwoman,
dysfunction
adrenals
Supermom or Dad Patient Complaint End result—Adrenal
Engage in physical
collapse and CFS
To above add BL 18,
activities that distress
20/triple heater
muscles per exercise
regulatory; SP 6 and
tolerance level (do
Ht 7 for insomnia;
not exercise at night
Local multifidi if
if suffering from
Neck & back
spine is irritated
insomnia)
pain in stress
from stress
Patient Complaints:
o
muscles o
Do stretching for
Lowback
Can turn over at end
tight neck, back,
syndrome
and do yintang for
lumbosacral
with adrenal
10 more minutes.
muscles
*(*
exhaustionback goes
Wei level shallow
Get pillow-top
out under
oblique needling to
mattress or egg-
stress
most tender points in
crate mattress
o
Fibromyalgia
fibromyalgia or
cover; side lying
o
Insomnia and
highly sensitive or
pillow, or cervical
agitated
reactive patients,
pillow if sleeping
sleep
leave needles only 5
face up
minutes Suggest Release most
hypnotherapy,
symptomatic TrPs
EMDR,
per patient’s de Qi
psychotherapy to
tolerance in stress
deal with behavioral
muscles (traps,
and post-traumatic
paraspinals, gluteals,
issues
piriformis)
*("
Diaphragmatic
Signs &
Constriction/
Symptoms
Point strategies
AOM Lifestyle Coaching
GI Distress/ chong mai middle heater dysfunction
_______________ Constrained Liver Qi Up-regulated SNS overacts on PNS Taiyin/YAngming Circuit dysfunction Liver/Spleen dysfunction Spinal Irritation and up-regulated SNS
_______________
______________
YinYang Regulation Counsel patients that
tight rectus & Jing:
oblique muscles-
“their problem is their Life”
viscerosomatic SP 4(R)/Per 6(L) for tight chest
chong and yinwei
Dr. Shen advice- eat
(pectoralis level with
mai
regularly 3 x day, never late at night,
ST 18-Liv 14) Ying:
Qi)
LI 4/Liv 3 Liv 14 (and GB 22 or Per 1), SP 6
Patient Complaints:
Patient Complaint o
pattern of visceral agitation
o
o
never while working at desk or standing,
Tight SCM (plum pit
may be precipitating factors for this
_______________
IBS, bloating, undigested
ST 36-39 &
food,
ST 25; CV 10, 12, 13;
diarrhea
ST 24-18 on left
and/or
ST 25 (Bil) all where
constipation,
tight and constricted
abdominal
(dispersal, not TrP
pain, gas
needling)
Reflux or GERD
For Xu-Li, add CV 12,
Relief in
ST 14-16(left), ST 18
Crohn’s
(L); ST 44-43 where
Disease or
tender either or both
colitis
sides For heartburn to chest, add CV 18to
*(#
slowly, quietly Do not indulge in fatty foods or alcohol Check out if they are wheat, lactose, or corn intolerant or have celiac disease Do not drink ice-cold drinks In reflux and GERD, raise back of bed 6” to prevent acid reflux Above all, teach abdominal breathing as AM and PM stress reduction activity
17 and lateral Kid
before arising and
points; or Kid 22 and
falling asleep, while
Per I if left sided
in bed face up with
heartburn
knees bolstered with pillows, or whenever hyperventilating (5 minutes)
*($
Pelvic collapse
Signs &
chong, dai, ren
Symptoms
Point strategies
AOM Lifestyle Coaching
dysfunction Lower heater dysfunction
______________
_______________
______________
Flaccidity in middle
YinYang Regulation
Coach patients to
________________ Spleen Qi Sinking with or without Constrained Liver Qi in Middle heater as possible precipitating factors for this pattern of visceral agitation
heater abdominal
develop core
muscles, tightness
Jing:
and constriction
strengthening routine for middle
below navel,
Chong-Dai Infinity
heater; stretches for
pressure and pain at
Treatment: SP
lumbar region;
Kid 15.5 to Kid 11
4(R)/Per 6(L) for
and ST 26-30, and
chong mai; GB
Yoga or Qi gong for
CV 7-2 (chong mai
41(L)/TH 5 (R) for
lower heater
lower heater
dai mai
strengthening
Ying:
counseling/therapy
branch), tight lower external obliques (dai mai); tight linea alba (ren mai)
for sexual Three leg yin source
dysfunction
points SP 3, Kid 3, Liv 3; Sp 6 and 9; Liv
counsel women with
Patient
9 for constrained
vulvadynea to seek
Complaints:
Liver Qi in lower
PT specializing in
heater;
manual therapy who
o
Prolapsed
specialize in this
organs:
Patient Complaint
postbirthing; uterus,
Local chong, dai and
bladder, right kidney, hemorrhoids , hernias
amenorrhea, menses,
Liv, Sp, Kid meridian heater; local points
PMS, disrupted
lower heater; local points in lower
(Shan) o
ren mai points in
over visceral irritation (ST 30 for ovaries, CV 4-6 for
*(%
o
infertility
uterus etcetera);
and
CV 2 down, to right
impotence
and left to propagate
prostatitis,
Qi for lower heater-it
vaginitis,
is.
cystitis, pelvic floor syndrome; o
sexual dysfunctions such as erectile dysfunction or frigidity
*(&
Cardiac Alarm
Signs &
Upper-Lower heater
Symptoms
Point strategies
AOM Lifestyle Coaching
dysfunction
_______________ Kidney Yang/Heart Protector Dysfunction
Kidney/Lung Qi Dysfunction
Pelvic collapse and/or diaphragmatic constriction may be precipitating factors for this pattern of visceral agitation
______________
_______________
_______________
Free-floating
YinYang Regulation
Coach patients to do
anxiety, dread, fear
abdominal breathing
of impending doom
Jing:
as above
Shallow breathing,
Chong-Dai
Suggest stress
hyperventilation,
Treatment: SP
reduction or
heart palpitations
4(R)/Per 6(L) for
relaxation response
induced by stress
panic attack, anxiety,
programs for coping
palpitations in
with stress
Non-cardiac chest
patients with Kidney
tightness and
Yang & Heart
Suggest meditation,
discomfort from
Protector
yoga, Qi gong
diaphragm to under
dysfunction
armpits and sternum
Suggest mindfulness
(3 yin muscle
Ren & Yinchiao mai:
training for
channel referral
Lu 7/Kid 6 for
practicing anytime/
patterns) with
shallow breathing
anywhere
tightness in
and hyperventilation
rhomboids and
syndrome in patients
Suggest
paraspinals in upper
with Kid/Lu Qi
biofeedback,
back
dysfunction
hypnotherapy, EMDR, Psychotherapy for
Patient
Ying/Patient
behavioral and post-
Complaints:
Complaint:
traumatic issues
o
Anxiety,
Kid 15.5 for
panic attack,
adrenals;
heart o
palpitations;
Per 4 &5 with CV 18-
cardiac
17 for chest
neurosis;
constriction
*('
o
costrochondritis
Kid 22 and Per 1(L) for chest pain on left (cardiac neurosis) Xu-Li treatment for chest pain from reflux or GERD (see second pattern of fatigue above) SP 20 & LU 1, Kid 27, BL 13 and 42 for hyperventilation syndrome
*((
*()
The Western Spirit Recovered
What I have realized in researching this topic and in reflecting at length on my senior students’ various approaches to and interpretations of spirit, is that unlike the Confucian Chinese, who had a centuries-old set of beliefs and practices based on an ideal social person who possessed the 5 virtues -- benevolence (ren ), propriety (li ), integrity ( xin ), decisiveness (zhi ), and right action ( yi ), our North American students come from varied cultural backgrounds that might derive from JudeoChristian, Moslem, and African roots to name but a few. It is therefore unrealistic to assume that North American students, or patients, of AOM would share the same notions of the self, the sacred, and what spirit means in their lives. The notions of the self, the sacred, spirituality and the relationship between humans and nature were heavily influenced by East-Asian traditions and practices at the height of the New Age Movement, which gave way to holistic medicine, and then to complementary and alternative medicine, and now integrative or functional medicine. These decidedly North American traditions yielded a rich array of approaches to the sacred and spirituality and went on to greatly influence the way mind-body medicine approached the role of the spirit in health and disease.
21st Century North American Search for the Sacred
In their primer, Textbook of FUNCTIONAL MEDICINE , the Institute of Functional Medicine lays out its approach to the relevance of the role and impact of spirituality and the “search for the sacred, the sense of being connected to something greater than self” on healthcare practitioners that is consistent with classical Chinese medicine, but more specific, perhaps, to the diverse needs of the North American student or patient of Acupuncture & Oriental Medicine (Institute for Functional Medicine, WA, 2006, pp. 669-685). In this 21stc entury approach to care, the relevance to the healthcare practitioner of Mind and Spirit, and the impact of a patient’s “spirituality” (“search for the sacred,
the sense of being connected to something greater than self”) and/or organized or institutionalized religious beliefs, is pivotal. Evidence on the beneficial effects to health of a patient’s spirituality and/or religion was gathered in a systematic review of the literature over the entire 20th century (Koenig HG. Religion and medicine IV: religion, physical health, and clinical implications. Int J Psychiatry Med. 2001; 31(3): 321-336): “While more research and better designed studies are needed, the vast majority of research completed to date indicates that religious beliefs and practices are associated with better mental and physical health (Textbook of FUNCTIONAL MEDICINE , p. 677). In another review of the evidence which looked at the religious/spiritual as compared to meditation/relaxation practices, Seeman et al concluded that: “1. Meditation/relaxation is associated with better health outcomes in clinical patient populations (…); 2. Meditation/relaxation is associated with lower blood pressure (…); 3. Religion/spirituality is associated with lower blood pressure, less hypertension, better immune function (…); 4. Meditation/relaxation is associated with lower cholesterol, lower stress hormone levels, and differential patterns of brain activity (…); 5. Meditation is associated with less oxidative stress, and less blood pressure and stress hormone reactivity under challenge (…) (ibid).” Other studies cited find that regular church attendance in healthy individuals reduces mortality by some 25%, and that regular church attendance can reduce cardio-vascular disease, which may be related to the “healthier lifestyles adopted by churchgoers (ibid, p. 678).” Citing the conclusions of a study by Hawks et al on three peer-reviewed spiritually based health intervention programs (Stress Reduction Clinic of Jon Kabat-Zinn at the University of Massachusetts Medical Center, The Lifestyle Heart Trial, and the Stamford University School of Medicine complex psycho-social intervention with metastatic breast cancer patients) the effects of “improved spiritual health may be associated with improved behavioral and emotional health in such areas as diet, activity levels, communication skills, treatment compliance, reduced anxiety and depression, and improved mood states. These positive behavioral and emotional improvements in turn may be associated with heart disease reversal, reduced
*)*
cancer mortality, enhanced immune function, and reductions in pain and other medical symptoms (ibid, p. 680).” While it is possible for North American AOM practitioners to develop Lifestyle and Life Nurturing programs for their patients, including Dao-Yin, Qi Gong and herbal practices, it may be more pragmatic and appealing to their Western patients to refer them to neighborhood programs in mind-body and spiritual practice, tailored to their desires and needs, as well as specialists specialists in the psyche (psychotherapy, cognitive-behavioral cognitive-behavioral therapy, body-centered psychotherapy) and the body (physical and occupational therapy, athletic training, Rolfing, massage, Feldenkrais Method, the Alexander Technique, Gyrotonics, Pilates) and programs in mind-body health (Yoga, Qi Gong, T’ai-Qi, Meditation etcetera). Recent studies on the use of mind-body practices as one form of Complementary and Alternative Medicine show that an enormous number of people avail themselves of these practices for their health, wellness and disease prevention, which I will return to in a later reflection. Such practices are consistent with, and complementary to Acupuncture and Oriental Medicine life nourishing practices, and AOM practitioners trained in such approaches will be in a better position to engage in wellness and health prevention lifestyle counseling with their patients in a way that is best suited to their patients needs. Such a combination of East Asian and Western approaches might well become a more and more practical way of bringing life-nurturing practices back into a Chinese medicine that would restore the soul and spirit of Western AOM practitioners and their patients, through creative conjunctions and collaborations for best care.
*)"
15] The Dao of the Sages of Antiquity THE PROBLEM: As I slowed down the process of these reflections in Thanksgiving, 2010, after having discovered the Chinese text, the Zhong Yi Xue Gai Lun ( that was translated into Vietnamese and then into French, and then by me for the Quebec Institute of Acupuncture into English), I started to realize an “error” had been made by Van Nghi in his translations of this text. Aiming his work at the French Medical acupuncturists, who were fascinated by the story of “human energetics” as laid down by Soulie de Morant, Lavier and Chamfrault, and who often practiced European natural therapies like herbology and homeopathy, Van Nghi omitted the sections of the Zhong Yi Xue Gai Lun on herbal medicine, thus making the text read mainly like an acupuncture textbook. Felix Mann, also a medical doctor in England, did the same years earlier, when his Meridians of Acupuncture , which drew heavily from the Zhong Yi Xue Gai Lun w hich he studied in PRC in 1962, only 4 years after its publication, also only referenced the sections on acupuncture, the meridian system and how to treat with needles and fire, and omitted herbal medicine or daoyin practices. The Zhong Yi Xue Gai Lun was, however, the first textbook for the new TCM colleges on Chinese Medicine (zhong (zhong yi ) as opposed to Chinese Acupuncture & Moxibustion (zhen (zhen jiu ). ). Prepared by academies of Chinese Medicine by scholars in the field, it contained the Daoist naturalist theories of Heaven, Earth and Man and the Taiji, Yin and Yang and the Five Phases, as well as theories on calculating the current stems and branches of the Chinese calendar to predict climate and weather patterns and live accordingly. This text also included detailed sections on five phase pattern discrimination and treatment, and on treatment of the entire meridian system of regular, divergent and luo vessels, muscle channels and the 8 extraordinary meridians. The early books on acupuncture that came out of the PRC omitted most of this naturalist theory, especially on the 5 phases and the meridian system as a whole. Qi Gong, G ong, which had a chapter devoted to its practice in the Zhong Yi Xue Gai Lun , was also omitted from these early TCM texts, apparently
*)#
because they were based on “feudal” (read Daoist/religious) theory that was not consistent with Maoist materialism. What had never occurred to me was that TCM, following Maoist doctrine, severed all references to the wisdom of the sages of antiquity, and the practices of selfcultivation that figured prominently in the works of Lao-Tzu and Confucius. Chinese medicine had not only lost its soul, but its very Chineseness.
Returning to the Sources/Setting out on the Way While few English-speaking scholars of Acupuncture and Chinese Medicine read classical Chinese, we are fortunate to have philosophical discussions of the key concepts of acupuncture and Chinese medicine from the late Claude Larre, a Jesuit priest and former president of the prestigious Institut Ricci, which is responsible for translation of classical Chinese texts, and Elisabeth Rochat de la Vallee, now president of the Institute and a long-time colleague of father Larre who both taught at the Quebec Institute of Acupuncture. We are also fortunate that Paul Unschuld, a German scholar of classical Chinese medicine, has overseen translations of the Huang Di Nei Jing Su Wen a nd the Nan Ching and is currently overseeing the team that is translating the Huang Di Nei Jing Ling Shu . We are also fortunate to have excellent philosophical translations of Daoist and Confucian texts by scholars Roger T. Ames and Henry Rosemont Jr, among others, and texts on Neo-Confucian masters, such as Wang Yang-ming by Tu Wei-ming, who served as a mentor to Linda Barnes during the religious studies part of her dual doctoral degree and who is now teaching his work on “humanity and self-cultivation” at the college. Starting near the beginning, the first chapter of the Su Wen finds Huang Di, the Yellow Emperor, asking Qi Bo, the “Heavenly Master” (ostensibly a Daoist sage) how it is that “the people of high antiquity” lived to be over 100 years old while the people today live only half that long. “Qi Bo responded: ‘The people of high antiquity, those who knew the Way, they modeled [their behavior] on yin and yang and they complied with the arts and the calculations. [Their] eating and drinking was moderate. [Their] rising and resting had regularity. They did not tax themselves with meaningless work. //Hence they were able to keep physical appearance and spirit together (SW, pp. 30-31).”
*)$
Wang Bing, the compiler of the edition of the Su Wen translated by Unschuld, was a Daoist, and felt that this discussion of following the Way was referring to selfcultivation, advocated by Daoists and Confucianists well before the Huang Di Nei Jing was compiled. Huang Di goes on to ask Qi Bo about the people of high antiquity who attained their full 100 years, including “true men”, “accomplished men”, “sages” and “exemplary men”(SW pp. 42-44). In their philosophical translation of The Analects of Confucius , informed by the Dingzhou fragments and other archeological finds, scholars Roger T. Ames and Henry Rosemont, Jr. define these stages of commitment to the Way of the sages in a way that sounds identical to this first chapter of the Su Wen , thus pointing to the fact that these concepts from antiquity were made their way into Daoist and Confucian teachings on the Way. Lest we think that this discussion of setting out on the Way of the sage is straightforward, Confucius himself is reported to have said: “In the niceties of culture [wen [wen , character included in the translation], I am perhaps like other people. But as far as personally succeeding in living the life of the exemplary person ( junzi, ( junzi, character included in the translation), I have accomplished little (Analects ( Analects 7.33, p. 118).” Confucius is reported to have continued thus: “How would I dare to consider myself a sage (sheng (sheng , character included in the translation) or an authoritative person (ren (ren , character included in the translation). What can be said about me is simply that I continue my studies without respite and instruct others without growing weary (AC, 7.34, p. 119). This “commitment” to staying on the Way, to lifelong learning is the key to the way of the Sage. One who has walked the Way a long time and practiced daily, and who becomes an exemplary person ( junzi junzi ) has achieved calmness of the “heart-and-mind” and “is calm and unperturbed; the petty person is always agitated and anxious (AC 7.37, p. 119).”
*)%
Ames and Rosemont, Jr. clarify that at least three of these concepts about “categories of persons” were in use before the time of Confucius and thus represent the wisdom of antiquity and serve as the very bedrock of what it means to be a human being in China. These three categories of persons who walk the Way as road builders are the shi (“scholar apprentice”), the junzi the junzi (“exemplary persons”) and the sheng or shengren (“sage”). (“sage”). These three are contrasted in the classics, and in Confucius’ work, to the xiaoren the xiaoren (“petty person”). The scholar apprentice (shi (shi ), ), Ames and Rosemont, Jr. clarify, “has set out on a path, a road, but he still has a long way to go, and there is much yet to be done (p. 61)”. This path is a spiritual path of self-cultivation, where material well being and “selfish desires” are extirpated. In the Analects , our translators clarify, passages about the scholar apprentice show that this person is striving to become an exemplary person ( junzi junzi ). ). The latter has travelled a longer way and has taken on several roles in society, making him a role model for others to learn from. “A benefactor to many, he is still a beneficiary of others like himself. While he is still capable of anger in the presence of inappropriateness and concomitant injustice, he is in his person tranquil [ …] and is therefore a respected author of the dao of humankind (ibid, p. 62).” Reaching the status of the junzi the junzi is as far as most of us can attain, but there is “an even loftier human goal, to become a ‘sage’ or shengren ”, ”, a “distant goal indeed (ibid).” What is striking about this Confucian view of one who sets out on the Way from being a scholar apprentice to aspiring to become an “authoritative person (ren (ren or shengren ) is that it is a project undertaken with others. “For Confucius, unless there are at least two human beings, there can be no human beings (ibid, p. 48).” The way or dao of the authoritative person “is not something we are; it is something that we do, and become. Perhaps ‘human becoming ’ might thus be a more appropriate term to capture the processional and emergent nature of what it means to become human. It is not an essential endowed potential, but what one is able to make of oneself given the interface between one’s initial conditions and one’s natural, social, and cultural environments (ibid, p.49).”
*)&
The authoritative person, the ren or shengren is engaged in the process of “growing” human relationships into vital, robust, and healthy participation in the human community (ibid).” Dao , seen in this Confucian sense as the “way of becoming human” is not a “given”. The “authoritative person must be a ‘road builder’, a participant in ‘authoring’ the culture for one’s place and time [ …]. It is this creative aspect of ren that is implicit in the process of becoming authoritative for one’s own community (ibid, p. 50).” This discussion based in antiquity and carried forth by Lao Tzu, Confucius and later Daoists and Confucians is most likely what the classical Chinese medical texts like the Yellow Emperor’s Classic are referring to. Grounded in such a rich and long historical foundation, classical Chinese medical texts need merely refer to the sage to evoke this entire Way of the sage. But this way has been lost, Qi Bo clarifies in the first chapter of the Su Wen . Doctors of antiquity were ostensibly treating people who were engaged in selfcultivation to achieve a calm heart-and-mind by transforming the emotions and following a life in tune with Heaven and Earth and the seasons, thus dealing themselves with the ordinary problems of the physical body through daoyin selfcultivation practices today referred to by some as qi gong, healing sounds and meridian patting. When they went to a doctor, it was with more serious problems requiring “high skills”, and doctors focused on these high skills that treated the shen (spirit). Today, Qi Bo clarifies, people are not engaged in self-cultivation, and hence they come to the doctor for all sorts of problems they should be able to handle themselves, which are not potentially fatal, but which now preoccupy the Han dynasty practitioner. I reread the first page of the Ling Shu very differently than I did a year ago, for the ordinary skills that preoccupy the typical doctor are what he must call upon to treat problems that, while not fatal, have caused undue pain and suffering for those suffering from a new city-state lifestyle. High skills, which would be out of place with such citified people, would slowly disappear without the need, or the knowledge to put them into action. The discussion of “ordinary” and “high” skills in
*)'
the first chapter of the Ling Shu , which is where I started the reflections in THE OTHER ACUPUNCTURE, is a repeat of the laments in the Su Wen f or a time when people doctored themselves and only called upon physicians when things were very serious. This sounds so remarkably similar to our own times, and should make us sit up and take notice. The lesson here is that if people learned daoyin self-cultivation and life nourishing practices and practiced these daily, and lived more in harmony with nature and followed moderation in all things, and focused on authentic human relatedness and becoming human in relationship with others, they would not suffer from many of the chronic disorders of stressful living. If this were true, practitioners of acupuncture and Chinese medicine would be able to devote more time to serious disorders and to pressing problems like weight, diabetes, asthma, and depression. One way of changing our current practice of Acupuncture and Oriental Medicine in North America would be for AOM colleges and their graduates to teach people how to engage in these Daoyin practices and become more self-reliant, hardier, less reliant on medical, CAM or AOM treatment for their own well-being, starting with Daoyin practice on the part of AOM practitioners. In the denigration of the “ordinary” skills of acupuncture in the Yellow Emperor’s Classics, I believe we must see a critique of how “petty” people were becoming in the new city-life, where they ignored the wisdom of the past and threw caution to the wind as the frenzy of this life-style took its toll. The Su Wen summarizes the Dao of living in tune with the wisdom of the sages of antiquity as quoted above, and goes on to lament how differently people of today are who have lost the Way: “The fact that people of today are different is because they take wine as an [ordinary] beverage, and they adopt absurd [behavior] as regular [behavior]. They are drunk when they enter the [women’s] chambers. Through their lust they exhaust their essence, through their wastefulness they dissipate their true [qi]. They do not know how to maintain fullness and they engage their spirit when it is not the right
*)(
time. They make every effort to please their hearts [but] they oppose the [true] happiness of life. Rising and resting miss their terms (SW p. 33).” The text goes on by clarifying that such a reckless and haphazard lifestyle and overwork lead people to only live to half their lifespan. The sages of antiquity stressed the importance of guarding ones essence and spirit, and of a calm heartand-mind. As the Su Wen goes on, in this way, “the mind is relaxed and one has few desires. The heart is at peace and one is not in fear. The physical appearance is taxed, but is not tired (ibid p. 34).” Commoners accepted what they had to eat and drink, and their clothing and station in life and did not long for a different lifestyle. In this way people knew true satisfaction. Unschuld adds Wang Bing’s decidedly Daoist take on this passage here: “They had reached a state of no request. That is the socalled ‘satisfaction of the heart’. Lao zi has stated: ‘There is no greater catastrophe than not to know satisfaction. And there is no grater calamity than to long for gains. Hence, those who know the satisfaction of satisfaction, they will be satisfied constantly.’ Hence, those who do not speak of being satisfied with material items, they have knowledge of [true] satisfaction. Those who are satisfied in their hearts, they know satisfaction. Not to give free rein to desires, this is identical with the natural state of things’ (Ibid, p. 35).”
Coping with Daily Life If Daoyin practices of self-cultivation are not medicine, then what they treat are not diseases strictly speaking. And if people before the Han dynasty and before the Yellow Emperor’s Classic was written routinely engaged in self-cultivation, of the body and mind and all the senses, and strove to attain a calm heart-and-mind, then the afflictions of the heart-and-mind would have been far fewer, and related to serious events, of loss, of suffering, of despair, rather than to the common travails of city-life and its stresses, to use a very modern but perhaps appropriate word. In such a Utopian vision the average person would not experience undue discomfort or distress from the strains of an active life, and would only seek medical care rarely and only when disease struck which could not be handled alone. In such a society, everyone would potentially possess ordinary skills of meridian
*))
and point patting, healing organs with sounds and breathing, maintaining a healthy sexual practice, while avoiding excesses. This is remarkably similar to modern day North American mind-body and stress reduction approaches, which advocate self-care of practitioner and patient alike with practices like meditation, yoga, T’ai-Qi, derived from the East; and Ericksonian hypnotherapy, NLP, Pilates and Gyrotonics from the west to name a few practices that have entered the domain from New Age Medicine, to Holistic Health, to Complementary and Alternative Medicine, to Integrative Medicine, and now to the m ore inclusive Complementary and Alternative Health Care. What is clear and quite remarkable is that Classical Chinese Medicine was predicated upon Self-Cultivation, which it lost as life became more focused on the busy city-state. AOM practitioners who return to these self-cultivation practices themselves, with the aim of sharing these practices with their patients while maintaining Self, would be in a position to offer an ancient approach to self-care consistent with their medicine, with an openness to parallel practices from East and West to suit the times and their patients’ proclivities.
Way of Learning Classical Chinese Medicine One of the most powerful things about the slow-down in writing THE OTHER ACUPUNCTURE, as a monthly affair, is that it gave me time to carefully reflect on how the college itself abandoned self-cultivation practices that it taught in the fist decade, as the North American TCM Cultural Revolution took its toll, making TCM an orthodoxy to be fought against, lest the ability to teach and learn anything more classical, or from other East Asian or European approaches, be shoved into oblivion. By April of 2011, several students asked the college and me to make some online resources available to them through our library and learning resources, to render possible access to information on a return to the classics and classical Chinese medical practices. This lead to a college subscription to Classical Chinese Medicine,
"++
a web-based resource founded by Heiner Fruehauf, PhD, director of the School of Classical Chinese Medicine of Portland’s National College of Naturopathic Medicine. This also lead, only recently, to a link from the college’s library webpage link to the Association for Traditional Studies video series of Classical Chinese Medicine and Daoyin practices with Andrew Nugent-Head, MSOM, ATS’s Founder and President. Through this interactive process, and a student’s familiarity with ATS and the videos of Andrew Nugent-Head, I contacted him about attending his San Francisco seminar slated for Spring 2011, introduced myself and asked if he and ATS would ever consider him teaching at the Tri-State College of Acupuncture In New York City. Within a few months of almost daily email dialogue between Andrew Nugent-Head and myself, he and ATS arranged for him to teach his MaDanyang Heavenly Star Points Seminar, and to spend 3 subsequent evenings with faculty and recent grads exposing them to the 8 Healing Sounds Daoyin Practice, and to a Grand Rounds treatment so that we might see how he worked. I attended all of this, was a demonstration model for the weekend seminar three times and was treated in the Grand Rounds. The synchronicity of where the college wished to go regarding a return to Classical Chinese Medicine and Daoyin self-cultivation practices, and of Andrew and my deep conviction that acupuncture is physical medicine and that all of Classical Chinese Medicine is rooted in an embodied way of learning and practicing, led to a joint venture between ATS and the college. In this collaboration, Andrew Nugent-Head has already committed to training our physical medicine clinical faculty in his tangible Qi approach, grounded in Daoyin practice, and to two cycles of a revived 300 hour post-masters advanced credit bearing course that will eventually be one of the major areas of concentration that graduates will be able to select as their major in the college’s eventual First professional Doctoral Program to start I July 2012 and run for 10 months each time. It is the aim of this collaboration that at the end of the second cycle, a sufficient number of college faculty will be trained so as to be able to train MSAC and eventual DAc students in the foundations of Andrew Nugent-Head’s training, so that he would focus on training 4thy ear doctoral students and other experienced licensed AOMpractitioners in more and more advanced skills.
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This will greatly enhance the college’s Strategic Plan goals of bringing the classics back into our training, including a study of Confucian and Neo-Confucian approaches to cultivation of the Heart-and-Mind, a required first year course in the “human dimension” that Confucianism represented throughout Chinese history and which constituted its Chineseness, and a revamping of AOM bodywork and Daoyin courses to be more tangible and integrated into the acupuncture training. As a core group of the college’s faculty embark on study with Andrew NugentHead, and engage in regular Daoyin practice themselves, the college will begin to be in a position to endorse and reinforce a very Confucian Way of Learning Classical Chinese Medicine. In this Way, these faculty, me included, will have to commit to becoming ‘scholarapprentices’(shi ), those who aim to become ‘exemplary practitioners’, role models for students, junzi . In this process, we will have to take a deep look at our commitment to lifelong learning, to our practice of self-cultivation, and to our goal of becoming inspirations for future practitioners. As I looked at the definitions of exemplary persons, of junzi , I realized I could never hope to attain a higher position than that. While I had indeed become a road builder in the AOM profession over the past three decades, and helped establish and usher along this new field, which the authoritative person (shengren) would be expected to do, I was still, and perhaps always will be prone to anger and will need to work at all times to attain a calm heart-and-mind. I recognize that like my own role model in all this, Neo-Confucian Wang Yang-ming, I must attend to my own self-cultivation at all times. I also have a lot to learn, as a scholar-apprentice, from those like Andrew Nugent-Head who have studied and learned in pre-PRC Chinese, with a sense of the classics one can never get otherwise. What is exciting is that the college is in a position to infuse its training in Disciplines of Mind with Neo-Confucian self-cultivation and Embodied Learning parallel to the Tacit Dimension espoused by the late Donald Schon, founder of Reflective Practice, and his precursor, Alfred Polaani.
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16] Self-Cultivation East and West—the Human imperative THE PROBLEM: It has been one year since I have been working on these Reflections. What started as a query into what Traditional Chinese Medicine cast out, or willfully forgot in order to forge a New Medicine for a new era in Chinese history, has transformed into a deep appreciation for the very Chineseness of classical Chinese medicine, informed by a Daoist for sure, but especially Confucian understanding of Humanity and Nature. As I dig deep into Neo-Confucian Wang-Yang-ming’s Instructions for Practical Living , which he demands, I feel as if I have encountered a colleague, a comrade in arms, a friend. I have only encountered this feeling once before when I was introduced to the work of Nietzsche, in spring 1973, starting with the Genealogy of Morals, a gift from Michel Foucault that inaugurated me into the Nietzschean project. As I read Wang-Yang-ming my training in Nietzsche resonates, and it was only a few weeks ago when I reread Part II of Michel Foucault’s last book, The Care of the Self , on “self cultivation” in the Golden age of Rome in the first two centuries of our era, that I recognized to what an extent Nietzsche before him, and Foucault came to focus heavily on what the ancient Romans and Chinese referred to as self-cultivation: the relation of Self with Self and Self with Others, ones humanity. In this Reflection, I will compare and contrast Foucault’s study of self-cultivation in Rome, and Wang-Yang-ming’s Neo-Confucian re-articulation of this ancient Chinese practice.
Self-Cultivation in Rome Foucault was known for musing that the only statement a human being could never utter is “I died”. The ability to speak about ones death, or after ones death seemed to intrigue Foucault, who was my mentor and friend from 1973 when he taught at State University of New York at Buffalo where I was pursuing a PhD in French Studies, until 1983 shortly before he became the first prominent Frenchman to die of the newly labeled AIDS. That was June 1984, and a few months later his last volume in the ‘history of sexuality’ appeared in French as Le souci de soi t ranslated two years later into English as The Care of the Self .
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Like Nietzsche’s last work, this last in a series by Foucault was published posthumously, and so each did find a way to have the last word, to speak from the grave as it were, to send their reflections into the future resonant with their powerful voices and minds. Why this preoccupation with Self after such groundbreaking philosophical works one might ask? Foucault would perhaps answer, as Confucians and Neo-Confucians would, that there is no preoccupation to match this one. “This ancient Western ‘cultivation of the self’ can be briefly characterized by the fact that in this case the art of existence—the techne tou biou in its different forms—is dominated by the principle that says one must ‘take care of oneself’”, which was a very ancient theme already in Greek culture Foucault tells us (The Care of the Self , p. 43).” And in his Apology , “it is clearly as a master of the care of the self that Socrates presents himself to his judges. The god has sent him to remind men that they need to concern themselves not with their riches, not with their honor, but with themselves and with their soul (ibid, p. 44).” While Greek and Roman philosophers, who saw their work as practicing the “art of existence”, where care of oneself figured prominently, were the first to engage in this practice, this became a rather widespread endeavor to which any learned person could aspire and entered into many different and competing doctrines that instructed one in the art of living. “It also,” Foucault tells us, “took the form of an attitude, a mode of behavior; it became instilled in ways of living; it evolved into procedures, practices and formulas that people reflected on, developed, perfected and taught. It thus came to constitute a social practice, giving rise to relationships between individuals, to exchanges and communications, and at times even to institutions. And it gave rise, finally, to a certain mode of knowledge and to the elaboration of a science (ibid, pp. 44-45).” In the first two centuries of the imperial epoch this “’art of living under the care of the self’ reaches its high point Foucault goes on, “it being understood, of course, that this phenomenon concerned only the social groups, very limited in number, that were bearers of culture (ibid).” This cura sui , this care of the self had several essential elements:
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As an injunction to philosophers in many doctrines that called for ‘turning and returning to oneself; in his Discourses , Epictetus stressed: ‘Man [ ] must attend to himself; not, however, as a consequence of some defect that would put him in a situation of need and make him in this respect inferior to the animals, but because the god [Zeus] deemed it right that he be able to make free use of himself; and it was for this purpose that he endowed him with reason (ibid p. 47).” Hence philosophers sought out others who might instruct them in this art and practice;
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It takes time, and one must decide what portions of the day to devote to it, upon rising, to reflect on what lies ahead, or in the evening, to reflect on what has transpired. The possession of oneself in such moments was viewed as central to a happy existence and time well spent. “This time is not empty; it is filled with exercises, practical tasks, various activities. Taking care of oneself is not a rest cure. There is the care of the body to consider, health regimens, physical exercises without overexertion, the carefully measured satisfaction of needs. There are the meditations, the readings, the notes that one takes on books or on the conversations one has heard, notes that one reads again later, the recollection of truths that one knows already but that need to be more fully adapted to one’s own life: a veritable ‘retreat within oneself’ as Marcus Aurelius argued—‘it is a sustained effort in which general principles are reactivated and arguments are adduced that persuade one not to let oneself become angry at others, at providence, or at things ibid p. 51)’.” One did this not as an act of solitude but as a social practice where philosophers seek counsel from other wise men, a true “soul service” bringing men together with “reciprocal obligations (ibid)”;
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The close correlation between care of the self already in ancient Greece, and medical thought and practice. In this tradition, which has enormous implications for the development of the notion of original sin in Christianity, as Foucault concludes, everyone must recognize “that he is in a state of need, that he needs to receive medication and assistance “ when it comes to disorders of the ‘soul’, a central preoccupation of the philosopher and the various schools of practical philosophy, which according to Epictetus are ‘dispensaries for the soul (ibid p. 55).’
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In this practice of the care of oneself as care of the soul, a whole ‘”art of self-knowledge developed, with precise recipes, specific forms of
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examination, and codified exercises (ibid, p. 58):” tests and exercises in abstinence to see what one can do without, ‘fancied poverty’ (ibid p.60); selfexamination, in the morning to be well prepared for what was to come, but especially the evening self-examination, alone with oneself, as one prepares for “blissful sleep ‘Can anything be more excellent than this practice of thoroughly sifting the whole day? And how delightful the sleep that follows this self-examination—how tranquil [ ], how deep [ ], and untroubled [ ], when the soul has either praised or admonished itself (ibid p. 61)’.” !
‘Conversion to Self’ as an ‘ethics of self-control’: “This is the part of our time that is sacred and set apart, put beyond the reach of all human mishaps, and removed from the dominion of fortune, the part that is disquieted by no want, by no fear, by no attack of disease; this can neither be troubled nor snatched away—it is an everlasting and unanxious possession, even a pleasure one takes with oneself (ibid p. 66).” What one guarded against in such practices was the danger of the desires, ‘voluptas ’, “undermined by the fear of loss, and to which we are drawn by the force of a desire that may or may not find satisfaction. In place of this kind of violent, uncertain, and conditional pleasure, access to self is capable of providing a form of what comes, in serenity and without fail, of the experience of oneself” or as Seneca phrases it, “your very self and the best part of you (ibid pp. 66-67).”
As Foucault concludes, from his vantage point in this history of sexuality, and how Western culture came to define it, shape it, pathologize it and treat it, the seeds for Christian original sin are already there in ancient Greece and the Golden Age of Rome where “[s]exual pleasure as an ethical substance continues to be governed by relations of force---the force against which one must struggle and over which the subject is expected to establish his dominion (ibid p. 67).” While the forces of sexual desire against which one must struggle are not yet associated with “evil”, Foucault goes on to trace the progress of these practices of self-cultivation and points to their transformation whereby the Catholic confessional, and much later the [Freudian] psychotherapeutic setting, view these forces as evil which the believer, or the patient, needs help to counter, with professionals of the soul who no longer educate their clients in self-cultivation, but in subservient admissions of guilt or desire that they are never really expected to conquer.
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Confucian and Neo-Confucian Self-Cultivation While practices of self-cultivation started much earlier in ancient China, they reached their epitome at about the same time as parallel practices in the first two centuries of the Christian era in Greece and Rome. But there are notable differences. As Tu Wei-ming argues from the start of his Humanity and Self-Cultivation , “if we take seriously the process of learning to be human, the Confucian persuasion, far from being a static adherence to a predetermined pattern, signifies an unceasing spiritual self-transformation (page xxi).” In his Forward to Tu Wei-ming’s text of 1998, Robert Cummings Neville states boldly: “For the first time in history, it is possible for any self-conscious participant in a world-wide philosophical culture to speak of Confucianism in the same breath with Platonism and Aristotelianism, phenomenology and analytic philosophy, as a philosophy from which to learn and perhaps to inhabit and extend (ibid, p. I).” He goes on to state how the worldwide philosophic culture “was almost exclusively Western in inspiration” even though Confucianism “has been perhaps the dominant intellectual influence in East Asian cultures (ibid).” That it now plays a role in that worldwide discussion “is the result in large measure of the work of Tu Wei-ming and a small group of colleagues (ibid).” Neville shares how a group of Western trained Chinese thinkers who write mainly in English joined with a group of Western professional philosophers and sinologists “that has entered the world culture of philosophy as ‘Confucians’ (ibid, p. III).” This group of thinkers, like those of the Kyoto school of philosophy founded by Japanese philosopher Kenji Nishitani who was a contemporary and colleague of Heidegger, the latter a student of Nietzsche, engages in a confrontation with their otherness: professionals in Chinese ethico-religious studies engage seriously with Nietzsche and Heidegger, while experts in these Western philosophies engage the otherness of Daoism and Confucianism. The goal is nothing less than a world philosophy that would bring a sense of urgency to the revival of humanity and self-
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cultivation, for the good of human beings and their environment (Heaven and Earth). Tu defines the Neo-Confucian approach to self-cultivation as decidedly Mencian in impetus thus: “man is a moral being who through self-effort extends his human sensitivity to all the beings of the universe so as to realize himself in the midst of the world and as an integral part of it, in the sense that his self-perception necessarily embodies the perfection of the universe as a whole (ibid, p. 79).” To this decidedly human view of self-cultivation, with no theistic notions of grace or divine intervention, Neville continues in his forward with regard to Tu’s own Confucianism, that the “impediments to self-cultivation are miseducation, selfishness and moral torpor (ibid, pp. VII-VIII).” Tu stresses the essential nature of the “fundamental choice” which requires a total commitment to the way of the sage and self-perfection as a ceaseless process of life-long learning requiring “constant reaffirmation (ibid, p. VIII).” The remainder of this reflection will focus, following Tu’s insights, on NeoConfucian Wang Yang-ming’s ‘instructions for practical (moral) living’ (cf. A.S.Cua, The Unity of Knowledge and Action: A Study in Wang-Yang Ming’s Moral Psychology ) and its focus on; ‘inner experience and embodied knowing’; the ‘unity of knowledge and action’; the ‘extension of knowledge’; ‘humanity’ or ‘ human becoming ( jen/ren ); the ‘regulation of human affairs’; ‘extirpation of human (selfish) desires’.
Inner Experience and Embodied Learning/Knowing “Wang Yang-ming,” Tu tells us, “once characterized his learning as the ‘learning of the body and mind (shen-hsin-chih-hsueh ). Tu appreciates the complexity of attempting to explain in the written word such an oral teaching and way of learning that might replace an ‘experiential’ knowing with a “conceptual understanding (ibid, p. 139)”. Believing the “exemplary” teacher (junzi in pinyin) who has walked a long way along the Dao but has far to go, “must try to transmit the content of the learning to his students through his entire body and mind”, Wang Yang-ming’s way of learning is not only a learning about whatever one is studying, but is also a
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learning how to become a human being, with sagehood as the guide. This focus on becoming a genuine person, one capable of authentic human relatedness, is tantamount to self-actualization, “of the universal humanity in oneself (ibid p. 140)”, seen as a never ending process that made him have to endure “a hundred deaths and a thousand hardships (ibid, p. 141).” Tu points out that this form of “self-learning” in no way conflicts with the famous Socratic dictum and practice, ‘Know thyself’. What is striking about Neo-Confucian “learning”, Bols informs us, is that a ‘theory about learning’ accompanied the commitment to learn: This is where internalization figures, for “what simply must be internalized, or believed, is a theory a bout how to understand, cultivate, and realize in practice something that we humans can experience personally because we possess it innately (Bols, pp. 157-158).” This theory of learning developed by the Neo-Confucians “gave those who internalized it a ready means of making sense out of the everyday human experience of acquiring knowledge, thinking, feeling, and making choices (ibid).” Learning how to learn, rather than memorizing the great texts, is what characterized Neo-Confucianism. This learning was infused with the Heavenly “principle” or coherence in all things. While desire is always desire attached to things, which involves selfish desire, the emotions are part of the human condition. “The process of creation includes all things without bias or partiality. So too, the sage: he responds emotionally to things as they actually are without personalizing the matter. Those of us who aspire to be sages through learning should aim to be broadly inclusive yet impartial. When something comes up, we respond spontaneously, in a simple and straightforward way without calculation or hesitation. If you focus instead in trying to block out external temptations and distractions, you will never get to the end of it (Ibid, p. 172).” The sage responds with emotions appropriate to the situation, and his emotions “are not tied to his own particular biases but to the state of the thing itself (ibid).” But what does this learning actually entail?
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The Extension of Knowledge In Neo-Confucianism, as Bols explains it, “Learning combined two kinds of effort. First, one needs to practice seeing the coherence of things outside the self, ‘extending knowledge by fully apprehending the coherence of things’ (or ‘investigating things’). Second, to see the coherence of things external to the self is simultaneously to become aware of that coherence in the self, as the coherence of one’s own mind.” In this Neo-Confucian perspective, which is quite extraordinary, someone who engages in learning with a full commitment of the mind, body and all the senses, already sees that the coherence in their mind is at one with the coherence in Nature, and identical to the Heavenly principle that sees coherence in all things. Coherence (li ), often translated as principle, is what serves as the foundation for the transformation of Qi, the mutations of yin and yang, the great taiji . If we take this into the realm of Classical Acupuncture/Moxibustion and Chinese Medicine, this would imply that the practitioner who commits to lifelong learning and who sees learning about Chinese medicine as, at one and the same time, learning about Self and Others, every clinical encounter is aimed at authentic human relatedness where the aim is to attain, prod, and initiate coherence as that which makes the therapeutic changes powerful, and meaningful. The practitioner does not make something happen, but rather initiates change that is at one with the coherence of all things: this change is immediately recognized by the patient as significant, because the patient already possesses a knowledge and deep experience of coherence. “This does not”, as the great master Neo-Confucian Zhu Xi pointed out, “preclude misapprehension in practice [whence] the corrective role of teachers and friends and of careful reading in order to reduce it (ibid).” This sort of mindful learning entails remaining aware of what is taking place in the world around us, so that we can respond appropriately to it. While Wang Yang-ming stressed an experiential approach to learning where book knowledge and cumulative knowledge were suspect, Zhu Xi and others argued for the importance
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of an external, cumulative process of learning through reading. “Internally, one shuts out distractions, brackets out presuppositions and prejudices, focuses attention on the text at hand, and proceeds to work through the text in an orderly manner. One may need to consult other interpretations, and one must aim to see how all the various elements form a whole, “but at a certain moment one ‘gets it’ and the text’s coherence becomes apparent (ibid, p. 174).”
The Unity of Knowledge and Action In his brilliant case study acclaimed philosophy professor A.S.Cua focuses closely on just one aspect of Neo-Confucian Master Wang Yang-ming’s philosophy as ‘instructions for practical living’, namely the doctrine of the ‘unity of knowledge and action. In this text, Cua stresses that Wang Yang-ming’s instructions for living a moral life, stemming from “innate knowledge of the good” (ibid, p. 2), focuses not on intellectual, but practical knowledge. While practical knowledge of this sort has a cognitive content that can be stated in theoretical terms, practical knowledge always presumes its ability to be enacted, to inform action. “But much of our practical knowledge is knowledge-how which, for the most part, is inchoate, and thus an agent may have it without being able to articulate his knowledge in a coherent way—say, in terms of a set of rules of skill (ibid, p. 4).” This concept of know-how is identical to what Michael Polanyi termed ‘tacit knowledge’, and Donald Schon, as the way professionals think-in-action, which I investigated in an earlier reflection. It is this concept of practical knowledge that informed my concept of reflective acupuncture practice (RAP), modeled after Schon’s work on professional knowledge, embodied knowing and ‘knowing more than one can say’. While I thought I was applying cutting edge western concepts of reflective practice to the training of AOM students, what might actually have happened is that I hit up against this problem of how to teach acupuncture and related techniques as practical versus intellectual knowledge in a way that is in fact inherent to this practice. In other words, I could have saved myself a lot of time if I had been trained in Wang Yang-ming’s philosophy of “practical” knowledge, namely
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knowledge that can immediately be enacted, at the start of my acupuncture education.
Humanity or Human Becoming The Neo-Confucian concept of the way of the sage is that of following ones innate knowledge of the good, working to rid oneself of selfish desires and evil, through a deliberate reflection on ones actions, conduct, and practice in the world with Self and Others. In the training of AOM practitioners at the Tri-State college of Acupuncture over the past decade, I have worked to integrate in reflective practice as part of the training, and this has been greatly facilitated this past year by study of Wang Yangming’s philosophy. While he did not practice medicine, he did practice Daoyin physical arts and hence was trained in a hands-on way that has doubtless influenced his teachings. In this approach, where one is expected to internalize the way of the sage, aiming to become someone capable of human becoming in its grandest sense, everything that one does with others, ideally, would be authentic human relatedness, free from selfish desires and self-interest. Whatever ones work, say in Acupuncture and Oriental Medicine, would also and at the same time entail practice in human becoming, where this practice would potentiate the “heavenly principle” that sees human nature and Nature as identical, and that brings coherence to all that one who walks the Way does. Such practical knowledge is identical to what is called shenming , spirit clarity and parallel to the knowledge of how to live a practical (engaged) life that is morally good (life embracing for self and others).
The Regulation of Human Affairs From the outset Wang-Yang-ming insisted that a prospective student make a prior commitment “to the vocation of becoming a sage” before he would take him in as a student. In Wang Yang-ming’s approach to the investigation of things, which becomes more a “regulation” or “rectification of human affairs” (ibid p. 150), Tu suggests, self-realization is seen as a dynamic process “in which man’s subjectivity
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becomes a real experience rather than an abstract concept” and underscores the inner dimension of ethico-religious cultivation (ibid, p. 145).” For Wang Yang-ming, as compared with Zhu Xi’s philosophy of teaching and learning, the focus is on manifesting the ‘inner sage’ in the real world at any moment, rather than seeing this as a gradual process. While some Neo-Confucian masters stressed the practice of quiet sitting, which Wang-Yang-ming also espoused for a brief period, he soon saw the real issue as the “sincerity of the will” aimed at “the examination of ones subtle thoughts and deliberations”, a more profound and rigorous kind of self-reflection to which he directed his teachings. What makes Wang Yang-ming’s approach to learning so relevant to the study and practice of acupuncture and Chinese medicine is that he, himself, was an adept of Daoist physical cultivation practices (Daoyin), the military arts and Buddhist meditation ( Bols, Neo-Confucianism in History, p. 188), and thus his practice encompassed cultivation of Body, Mind and Spirit. This practice is aimed at ‘preservation of the Heavenly principle (t’ien-li )’, which constitutes the coherence (Bol’s preferred translation, following Peterson, Ibid p. 163 of li , more commonly translated as “principle”) of Humanity, Heaven and Earth (the environment) and all things in between.
Positive Emotions and Ridding the Self of Selfish Desires In working to realize the coherence in all things, one runs up against the problematic of the human desires and a selfish attraction or attachment to things in the external world, which led Daoism to seek individual longevity and even advocate flight from society, while Buddhism taught that things of the world were not real and that enlightenment consisted in transcending this world of illusions. In opposition to this position, a “positive evaluation of the emotions, in distinction to selfish desire, allowed [Neo-Confucians] to claim that engagement with the world was essential to self-cultivation (Bols, p. 178).” The Neo-Confucians, and especially Zhu Xi and Wang Yang-ming, postulated a far more complex and multilayered role for the emotions, as opposed to selfish desires, in healthy human affairs.
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As Bols argues, “Neo-Confucians blamed the end of antiquity and the failure of people to realize their innate coherence on the human susceptibility to desire” which they understood “as the physical body’s instinctive response to external stimulation (ibid, p. 170).” While classical ideas suggested that all things, and all people are constituted of qi , Neo-Confucians suggested that since each person is endowed with a different qi , allowing individual qi to rule society would result in “violent competition for selfsatisfaction (ibid, p. 171).” The Neo-Confucians postulated that all humans are aware of coherence, the unity of things and that this coherence is what would allow people to respond spontaneously, with the full array of appropriate emotions, to external events (ibid). “The idea that the individual could learn to respond spontaneously to events because of his awareness of coherence allowed Neo-Confucians to make a distinction between desire ( yu ) and emotional responses (qing ). Feeling angry or happy about something can, of course, be prompted by mere physical stimulation, but when one responds with anger and joy from an awareness of coherence, by definition the response serves the common good. A person with this awareness does “not need to calculate, to think about what means best serve a desired end. Neo-Confucians reserved the term ‘emotion’ (or feeling) for emotional responses filtered through an awareness of coherence (ibid).” Learning, in the Neo-Confucian approach, does not attempt to rid one of the emotions, which should be able to be manifested when the conditions warrant, but to train us to be able to respond appropriately to events as they unfold. “When something comes up”, Bols translates, “we respond spontaneously, in a simple and straight forward way without calculation or hesitation.” In this way of the sage, where one acts from an inner sense of “rightness”, if one responds with happiness, it is because what “one is dealing with ought to make him feel happy, and when he is angry, it is because those things deserve anger (ibid, p. 172).”
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As someone educated and trained in Daoist and Buddhist practices, Wang Yangming’s critique of both as being self-interested (concerned with one’s own salvation rather than helping those in need) may have had more substance than the general Neo-Confucian critique. Whereas certain Daoist and, later, Buddhist teachings saw society as something to be avoided, or transcended, and where Buddhist teachings saw things as the “illusory product of their own desires”, Neo-Confucians like Wang Yang-ming claimed that “things were real in themselves” and also “that their way of learning enabled them to find in things themselves the norms for those things” and that differences in constitution, and corresponding emotional states, affected ones own effort’s at self-cultivation (ibid). Confucians even recognized, as clarified by Ames and Rosemont in the The Analects of Confucius , that the junzi , or “exemplary person” who has walked a good distance along the Dao, and can serve as role model for others, still benefits from others like himself to help him keep on the path as “he is still capable of anger in the presence of inappropriateness and concomitant injustice, [although] he is in his person tranquil (page 62).” This path consists in the commitment at the start to walk the Dao of the sage, striving to become if not an authoritative person (ren or shengren ), then at least an exemplary person who can serve as a role model, in our case as an AOM practitioner and teacher as an exemplary person ( junzi ). At bottom this way of engaging in ones life work, which includes work on self and with others (self-cultivation), starts by embracing the inner wisdom that knows the ‘equilibrium before the stirring of feelings’, that calm, mindful state of the heartand-mind that all East Asian meditation practices seek to instill. Knowing that this equilibrium is always possible, that AOM treatment and teaching can always return to this state of mindbody equilibrium, one is ready for anything that may come up for the patient, and within oneself in such a way as not to be distracted from the practice and the work. The bias in this Confucian and Neo-Confucian approach is that Humanity is precious, and that the inner wisdom people all possess from birth is the ‘heavenly principle (t'ien-li )’ that constitutes the ‘coherence’ of all things such that Human beings are at one with this coherence, which is Nature. And Nature is inherently good for Confucians, especially since Mencius, and one can reach the “innate knowing of the good” by achieving the equilibrium before the feelings are stirred.
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An AOM practitioner committed to being the best she can be, always embracing lifelong learning, who is engaged in daily Daoyin practice including meditation, and daily refection on how she managed human affairs, has clearly set out on this Way. This sort of reflection, on how she transformed emotions that threatened to become petty, selfish or even evil, so as to embrace the authentic human relatedness of the patient-practitioner encounter, constitutes walking the Dao, moving along the path. While she will most likely never become a sage, she stands a good chance of becoming an exemplary person, a junzi who works to rid herself of pettiness, selfish desires, and evil, so as to embrace and do good in her interactions and work with others and on behalf of herself. Such a way of teaching and practicing Acupuncture and Oriental Medicine constitutes the practice of High Skills, which these reflections started with a little over a year ago. And so my reflections have come full circle, and I have learned a great many things. I am now engaging on a daily basis not only with a larger set of Daoyin Practices (physical self-cultivation) thanks to the encounter with Andrew Nugent-Head, but a daily practice of digging deep into the Instructions for Practical Living by Wang Yang-Ming (translated with commentary by Wing-tsit Chan, Columbia university Press, NY, 1963) and working to build self-cultivation of mind and shen into my daily life. There are no church or institutional requirements for being a Neo-Confucian beyond the commitment to the Dao of the sage, and to lifelong learning as practice. I believe one who is in the process of human becoming , engaged in AOM practice as authentic human relatedness, and who engages in self-cultivation of body (Daoyin practices), mind (Mindful and Reflective Practice) and ones AOM art/craft could be considered to be a Neo-Confucian practitioner of Acupuncture and Oriental Medicine. In her provocative article on Neo-Confucianism and medicine, Charlotte Furth shares that the Neo-Confucian Master, Zhu Yi, “praised medicine as a ‘lesser Way ( xiao dao character in the original article)’ of learning (Furth, The Physician as Philosopher of the Way: Zhu Zhenhen [1282-1358] p . 423).
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Many historians, Furth tells us, saw this merely as “a vocational option for unsuccessful civil service examination candidates (ibid).” She cites Paul Unschuld’s claim 20 years ago in his Medicine in China: A History of Ideas ( pp.154-188 in 1985 edition) that Neo-Confucianism did in some ways shape the practice and even some innovations during that time. And so it may be that there was a time, from the 1100-s to the 1500’s, where some medical practitioners in China saw themselves as Neo-Confucian and dedicated themselves to authentic human relatedness, to the very human dimension of selfcultivation and self-actualization, for practitioner and patient, as central to the art and science of Chinese medicine. If one were to emulate that dual practice, of Neo-Confucian self-cultivation and perfection of ones art and science, this would constitute a practice informed by the wisdom of antiquity, that is remarkably parallel to similar efforts within Complementary and Integrative Health Care today, with an awareness that the Chinese practices of self-cultivation are at least 3000 years old and are a natural concomitant to Acupuncture and Oriental Medicine practice in North America in the 21stc entury.
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PART III APM ACUPUNCTURE CLINICAL PRAGMATICS
17] The Steps to APM/CCA Clinical Practice-- From the 4 Exams to Authentic Human Relatedness: A Case in Point THE PROBLEM : One of the big risks in developing basic protocols in order to teach students the “Ordinary Skills of Acupuncture” is that students and practitioners may miss the complexity of the process, and begin to merely apply these basic protocols with little attention to what is actually required, or to the larger changes that could take place, or that are taking place outside the practitioner’s awareness, thus selling their own practice, and their patients, short in many cases.
Protocols and Practice
The use of repetitive protocols and strategies can also lead to boredom or even burnout which might account for how some AOM graduates keep gravitating from one seminar to another without ever settling in on a personal style all their own. This issue is something Kiiko Matsumoto has also grappled with for the past 25 years, where many students have trouble following her deft and ever adaptable series of checks for reflexes, and needling, and surveillance for signs of significant changes that redirect how the needling and moxa and ancillary techniques are to be applied. Some who finally feel they are grasping it will grow despondent if Kiiko Matsumoto Sensei goes into their booth only to critique their time spent on a basic
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protocol, which they may be doing exactly as described in one of her recent books, when the actual problem the patient came with has not changed yet. She will often resort to a different series of techniques, which might include Sotai from her earlier practice days, or a different ordering of the needling and moxibustion, demonstrating in the real-world clinical arena that it is the actual patient, and her problem, that drives the treatment, not a rigid application of protocols. As someone who kept prodding Kiiko Matsumoto Sensei to develop a more clear series of steps for her approach, which I have done for APM/CCA, I find myself often discouraged by the overly rigid way in which some of my students, and graduates, and even faculty practice this approach. At times like those, I greatly appreciate her serious reservations against standardizing her approach in any way, and her readiness and ability to go outside the protocols that do emerge from her last two books whenever the clinical reality requires it. This series of Reflections so far has been my attempt to problematize the development of the APM/CCA approach over the past three decades, so as to reveal more of the depth and breadth such an approach can take on for anyone who grapples, as I had to, with the various traps and gaps that arose in the process. What I practice is based first of all on my own person, on my store of experiences in the world, good and bad, in sickness and in health, and no one has had the same personal experiences as someone else. Secondly, APM/CCA is based on everything I have learned about the body, the mind, and things spiritual, from within and outside of AOM studies, which again no one else would ever replicate in the same way. And finally, the things that continue to fascinate me about acupuncture, about needling, my allergy to moxa, my interest in having recourse only to those “fine needles”, without cupping, without guasha, without tui na, and in the Neo-Confucian approach to ‘embodied learning’ will not be replicated exactly by someone else, and numerous versions of this practice will emerge, by graduates, and even by people who just read my books, who will refer to their practice as APM, or something similar. After three decades of practice I am as convinced as I was a decade ago that I had to attach a name to my approach and I am comfortable with the one that I have chosen. It fits what I do, what I have developed over my professional career. It situates acupuncture as Wei Ke—External medicine aimed, as Yitian Ni says so elegantly, at ‘navigating the channels’, which is how it has always been articulated in
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China. But I have no interest in attempting to watch over how those who use this practice name what they do when they leave the college, if they ever even trained here. So as I end this Sixth Reflection, speaking about what I love, what I do, what I continue to practice without ever believing I will be done making changes if they seem necessary to teach this better, I realize that in the end no one trained at the Tri-State College of Acupuncture will ever practice exactly like any of the faculty they have trained with. In the very fertile atmosphere that we have created here, which breeds diversity and creativity, every faculty member, and each graduate, will eventually shape a practice that integrates in aspects from many sources, some from one main style, others from other styles, mixed with their own very special personal qualities, to exhibit an integrative approach that can pull from multiple sources to meet the challenges of the clinical realm. As practitioners gain more and more experience using these ordinary skills of acupuncture, and as they mature as clinicians and just with the passage of time and the wisdom greater experience affords, every practitioner will have experiences they cannot explain merely based on these ordinary skills. In such moments that will renew their sense of awe at what can transpire just with the twirling of a few needles, they will recognize that they knew the moment they said something, clarified something to the patient, perhaps while performing the physical examination or even while needling a point, but just as often before leaving the patient for 10 minutes or so after all the needles have been inserted, or even when saying a last thing to send the patient off, that spirit clarity has just been initiated, that the patient has just had a bodily-felt sense of their acupuncture holding pattern, of what was bringing them to this place and this practice to remove some of these obstructions: an experience that is so intense, so important as to be beyond words. At such moments, a practitioner totally in tune with the patient might say something no more articulate than: “Pretty intense, No?” – making any further conversation about what just happened redundant. In those moments, quite rare as a new practitioner and more and more frequent as one works on ones own self-development and ones own humanity as a practitioner and as a person, such instances of High Skills will reveal the deeper and more
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profound layer where the arrival of Qi and the encounter of the patient’s and the practitioner’s Shen converge, beyond logic, beyond theory, instances perhaps of what the Dao De Jing refers to as “wuwei” where much happens with apparently little action taking place, as if by itself. It is with that proviso that I will share aspects of a case, from the Four Exams through the patient’s final reflections on our work together, that proved quite complex, with a series of parallel conditions stemming from very different causes, some more physical, some more psychological, and some clearly spiritual, which were able to be treated, if one looks just at the acupuncture point strategies, in fairly similar ways. The meaning of this apparent paradox, and the way in which any experienced acupuncture practitioner can navigate the channels and treat complex conditions through what appear to be very similar “moves” , through the performance of apparently “ordinary skills of acupuncture”, making acupuncture nevertheless endlessly adaptable, is borne out in the real-world of human relatedness with our patients. This adaptability is at the crux of what makes acupuncture a practice situated in the ‘tacit dimension’ where one must always strive to know much more than one can say, to engage as Neo-Confucian Master Wang Yang-ming would stress by drilling into the depth of a practice and all its ‘moves’, to interiorize it, to embody it and to trust in that tacit dimension where we meet our patients in the raw. In such moments, any well trained practitioner knows that at any time, and with any needling technique, one might be about to be confronted by a fierce power, the power of the patient’s holding pattern, her pain, her suffering, her distress and the intense experience of all that, at a level of intensity that may prove quite overpowering. The ability to reflect back on such extraordinary moments in acupuncture practice, coupled with time and experience, will allow any acupuncturist well trained in the “Ordinary Skills of Acupuncture” to attain those “High Skills” that are called for in such challenging moments. And when that starts to happen, one has become a Reflective Acupuncture Practitioner, who never would have arrived at that point without first attaining the ordinary skills that serve as a prelude to those higher
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ones. To strive too early for the high skills, without going through the discipline of ordinary practice, will lead to a practice where the practitioner is quite impressed with his own skills, even as the patient and her experience of illness is being ignored. Introduction to Chaos: a litany of complaints—The Four Exams as Authentic Human Relatedness
Edith entered my office “originally skeptical about acupuncture”. She suffered from a litany of complaints centering around her right lower quadrant muscle spasms and discomfort, as diagnosed by her physical therapist. I was already engaged in the process of the Four Exams, attending to her manifestations, like flags flapping, some quietly, some more vigorously in the wind, as I observed her movements, watched her facial expressions as she shared something of her experience of illness. As she dove into a litany of complaints with a certain frenzy and frustration, I sank, as I always do when the signs and symptoms come too fast and furious, into a mindful space from which I could attend to what she was sharing without trying to figure out the logic of it all. In this mindful approach to the Four Exams, aimed at attending to the signs and symptoms as a composite whole, as a gift from the patient who is sharing her experience in her own way with me, there is no place for me for the clinical, professional approach one sees in TCM, where each sign and symptom has predetermined clinical meaning leading to a ‘logical’ diagnosis. Rather, I pay attention to what I hear, see, sense with my entire body and mind, and all my senses, waiting for a sense that I am starting to ‘get it’, to know where I want to begin the Palpation Exam to search for the ‘thorns, stains, knots and obstructions’ that are at the root of all chronic disorders as the Ling Shu t ells us at the end of Chapter I. There are some who turn some aspects of the Four Exams, meant to gather data in the form of relevant clinical manifestations, into “diagnosis”—leading to fundamental misnomers such as ‘pulse diagnosis’ or ‘tongue diagnosis’ or ‘facial
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diagnosis’. It is my considered opinion that privileging any of these data gathering/fact finding activities over others reifies them, and leads to a practice that is Practitioner-, not Patient-Centered. It may be that pulse and tongue assessment are closer to a diagnostic activity than the other aspects of the Four Exams, especially for a practitioner of Chinese Medicine (read, ‘internal’, herbal medicine). I can only speak to the tacit approach to intake, assessment and treatment planning in acupuncture as I have come to experience, and hence know it. It is this tacit experience that I wish to share in following Edith and her transformations in our work together. The Four Exams—Taking It All In
At 53, and now in the throes of menopause, this successful medical writer appeared weary, lacking in vitality, with a collapsed posture that mirrored her description of her experience of illness. Though she had no difficulty making eye contact, her glance was wary and she admitted feeling cynical about the possibility of a therapy like acupuncture being able to make sense of and alleviate complaints that had eluded “orthopedists, internists, gastroenterologists, a physiatrist, an ENT, an allergist, and a physical therapist”. As she described being “subjected to X-rays, MRIs, a sonogram, an endoscopy, a colonoscopy, and allergy tests” over the course of four months, her voice grew almost desperate, yet resigned, with a quickening pace in her verbal description that was accompanied by shallow, constricted breathing and a visible tightness in her throat muscles. Edith’s experience of her primary complaint was underscored by the fact that, having studied a wide array of biomedical clinical sciences and psychology, she had full faith in “the established medical profession” which, in this instance, “was unable to find a solution to [her] presenting problem: a severe abdominal spasm, lower back pain, and assorted upper and lower gastrointestinal complaints”. After months of testing, Edith ended up in the care of a physical therapist who began work on the
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muscular aspect of her problem, and who referred her to me for acupuncture, knowing that I, too, worked on releasing such muscular holding patterns. As Edith shared her story with me, I could not help but notice her agitation stemming from a fundamental skepticism about the treatment she was contemplating with me. I set about immediately reframing her complaints into acupuncture and myofascial images of constraint—holding patterns—that would ready her for the palpation phase of my initial examination. I remarked frequently that while her symptoms may have proved baffling to her physicians, she was describing acupuncture patterns that were classic and, hopefully therefore, treatable. In addition to her severe muscle spasm which the physical therapist had located in the right lower external oblique, she also suffered from lower back pain stemming apparently from an old herniated disc at L5-S1, irritable bowel, gastritis and reflux, a painful coccyx and a “cool” sensation in her throat, with secondary menopausal symptoms clouding the picture. Her appetite, which used to be fine, was reduced to eating “to get by”. She denied being thirsty and preferred hot drinks, and consumed 6 glasses of water a day, drinking alcohol only on weekends with meals. She preferred salty foods and disliked bitter as well as spicy food. Her gastrointestinal symptoms included belching, mouth ulcers, bloating, acid regurgitation and indigestion and the primary severe abdominal pain, with a feeling of “food stuck in the throat after swallowing”. Her bowel movements were painful, and she suffered from irregular bowel movements oscillating between constipation with hard stools and loose stools or diarrhea with undigested food present. She resorted to laxatives when constipated. Her urogenital symptoms included frequent urination and recurrent yeast and bladder infections, with “terrible” sexual energy. She suffered occasional discomfort during sexual relations, mainly due to vaginal dryness and irregular and uncomfortable menstrual symptoms associated with menopause, which included hot flashes and night sweats. She reported four pregnancies, and two deliveries, but made little mention of her children.
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Her energy, which used to be great, was “terrible now”. Her energy was best in the morning and peaked in the late afternoon. While she reported growing easily fatigued, she walked every day for exercise and kept to her regimen of back exercises as well. Emotionally, she felt “lousy right now -- very anxious, nervous”, and was experiencing occasional depression, anxiety, nervousness, and fear attacks. Her abdominal discomfort and the associated distress played a large role in these mood changes, as did her menopausal hormonal shifts. She reported enjoying her work, but found it “very stressful”. She suffered from disturbed sleep, and found it difficult to stay asleep due to shifting her position in bed owing to the abdominal pain and her husband’s snoring. This, coupled with the report of occasional painful sexual relations, were the only references to her husband. Both her lower back pain, which she reported as dull, and abdominal discomfort and spasms, which she reported as severe, were relieved somewhat by heat and were worse at the end of the day. She denied a history of smoking and reported normal to low blood pressure. In the past she had bouts of what her internist diagnosed as benign arrhythmia, with occasional irregular heartbeat and cold hands and feet. She had dry skin and scalp psoriasis. Her mother, still living, had high blood pressure, osteoporosis and thyroid problems, and her father died at the age of 45 from coronary disease. She had no siblings, and one of her grandparents had diabetes. Her medical tests revealed an old L5-S1 herniated disc, which did not explain her abdominal spasms according to her physicians, and reflux and gastritis. Edith’s medications included Acifed and carafate for the gastric distress, valium for what was clearly now being seen by her physicians as a nervous condition, the liboderm patch for her menopausal/ hormonal symptoms and motrin occasionally for her menstrual and other discomforts.
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Her pelvic and abdominal sonograms were normal and a later CT scan was also normal.
Feeling for Holding Patterns
I gather my symptoms in an exhaustive intake form that the patient fills out, which I scan for likely locations of holding patterns, patterns of somato-visceral or viscerosomatic constrictions, which might also entail what Wilhelm Reich referred to as “character armor”. After a brief face-to-face interview to go over the intake form and to begin to solidify the patient-practitioner relationship, I ask the patient to get ready and lie on the table while I go out to complete my “acupuncture imaging”, looking carefully at the form and the patient’s own drawing where they shade in the areas where they feel pain or discomfort, to visualize from an acupuncture meridian and three heater perspective, the most likely location of the patient’s holding patterns (jingluo obstructions). In this case palpation was facilitated by the fact that her physical therapist, whose work I knew well and who did in depth myofascial examinations of her patients, had lead Edith to identify muscular constrictions and dull discomfort in her lumbar muscles bilaterally, and in her coccyx area. Her right lower external oblique was the site of her severe abdominal pain, and my palpation confirmed bilateral quadratus lumborum trigger points, which did not reproduce the patient’s primary complaint when steady pressure was applied but rather dull discomfort locally. Palpation of her right lower external oblique and latissimus dorsi muscle trigger points, near GB 26, 27 and 28, and Spl 21 respectively, were exquisitely tender and did recreate her pain which I explained to her was a very optimistic sign that acupuncture release might well improve her symptoms. I showed her pictures of Travell’s referral patterns for the lower external oblique and latissimus dorsi muscles, and explained how the acupuncture meridians of dai mai and the great luo of the spleen had pain referral pathways that were identical. Further meridian and mu/shu palpation also revealed extreme tenderness at GB 41 bilaterally, right Spleen 4 and 6, and the Stomach meridian from Stomach 36-39, worse on the right, as well as deep tenderness at Kidney 16 area bilaterally, right worse, Stomach 24 and 25 on the right, conception vessel 10 (tight) and 12 (empty
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with no tone), Stomach 25-26 left, and the right mu points for the Liver and Gallbladder, namely Liver 14 and Gallbladder 24. This palpation was guided by the pathways of dai mai and chongmai, the Stomach leg yangming meridian and what I term mu-point boogey influenced long ago by grand rounds at the Tri-State College of Acupuncture with Kiiko Matsumoto. Her free-form abdominal Hara palpation and palpation to check distal points and local releases revolutionalized my own understanding of mu and shu points, and acupuncture points in general, which I came to see as moveable, living areas that had to be palpated for tight, tender or gel-like constrictions (kori, equivalent to adhesions, trigger points and fibrotic tissue, depending on severity and chronicity). This Japanese attention to palpatory findings has characterized the teachings of the college ever since, and corrected for an overly intellectual French meridian perspective, which was academically compelling but too often lacking in such palpatory sophistication. Given that Edith was a medical writer, I referenced Travell’s last chapter in the old volume I, on abdominal and thoracic trigger point referral patterns. I also gave her a 5 minute mini-course during the intake, which she followed easily, on viscerosomatic and somato-visceral interactions, according to Travel. I explained that her condition, which originally appeared viscero-somatic, where visceral dysfunction or disease creates somatic surface, myofascial discomfort (ruled out by the pelvic and abdominal sonograms and CT scan), might well be a case of somato-visceral distress where myofascial constrictions created her visceral discomfort and functional disturbance(what would even two decades ago have been labeled psychosomatic) . In that scenario, I explained to her, continuing my acupuncture reframing while palpating her oblique and lat muscles face up, it is possible the muscle constrictions, stemming perhaps over a long period of time from her posture while hunched over the desk writing, combined with her old back history, may have conspired to create this severe muscle spasm and discomfort. She agreed that her posture, which her physical therapist was working on with her, might be a contributing factor, but cited considerable stress as well. I suggested that her menopausal symptoms certainly did not help the situation, and mused, being the same age as Edith, that middle age angst was no thrill either. I joked that I could make my retirement fortune writing an amusing book on how middle age should come with a user’s manual, which was the first time she laughed in this initial encounter, even though I used humor repeatedly to try to bring some levity to the rather strong palpation for trigger points, to prepare her for possible discomfort
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during the acupuncture stimulation of these local areas of irritation and distress (which I refer to when teaching my students as assessment of a patient’s “deqi tolerance level”, which is to say their tolerance to feeling the needling sensations of acupuncture).
A Response of Guarded Optimism
By the end of the palpation phase of the examination, Edith expressed a willingness to give three treatments a “shot”, as she quipped, which was what I suggested to her, one that same day and two more spaced at weekly intervals. It is important to note that the treatment had already begun as the intake transformed into education and the palpation served to locate her holding pattern and validate her experience of illness and begin the release of these tight areas. In the concept of “tongshenming” which Ted Kaptchuk translates as “penetrating divine illumination” in his introduction to Acupuncture in Practice with Hugh MacPherson, it is thought that practitioners sometimes manage to set the healing process in motion during the initial encounter, even before initiating the acupuncture, massage or herbal treatments themselves. Some practitioners and texts refer to this as the patient’s and doctor’s shen connecting, to catalyze a healing response. Others, like Ted Kaptchuk, might refer to this as prodding the patient’s placebo capacity. If this relationship is forged during the palpation phase, it becomes impossible to distinguish palpatory examination from palpatory treatment, as palpation becomes therapeutic and begins to initiate therapeutic changes. Clinical Manifestations and their AOM differentiation
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Primary & secondary complaint: the patient was very specific in listing her complaints as follows: “oblique abdominal muscle spasm; lower back pain; ‘irritable bowel’; painful coccyx; occasional cool sensation in throat;
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menopausal symptoms, which started suddenly in November, 2001, four months before consulting me. !
Medical diagnoses of these complaints by patients’ physicians and other healthcare providers: gastritis, reflux, menopause, herniated L5-S1 disc, muscle spasm.
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Treatments to date for these complaints including medications: axid and carafate for the digestive symptoms, valium for the overall anxiety and discomfort/distress, liboderm patch for menopausal symptoms, occasional motrin for pain, physical therapy to loosen spasms and strengthen back.
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Relevant family medical history: her mother suffered from hypertension, osteoporosis and thyroid “problems”; her father died at age 45 of coronary disease; her grandparents suffered from diabetes.
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Past personal medical history: no injuries, accidents or surgeries were reported, but stress was underscored as a constant factor, growing more of late.
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Diet: “eats to get by”: bran and decaf coffee for breakfast; yogurt or ! sandwich for lunch; pasta, salad and juice for dinner; chicken 2-3 times per week, dairy 4 days a week; 6 glasses of water a day and 2 cups decaf coffee or tea; wine with dinner on the weekends only.
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Gastrointestinal S&S: belching, bloating, acid regurgitation, indigestion, food stuck in throat after eating, painful bowel movements, alternating hard and loose stools, undigested food in the stools, occasional laxative use.
AOM differentiation of above clinical manifestations: middle heater dysfunction/ constrained Liver qi/ Spleen Qi deficiency/diaphragmatic constriction. !
Urogenital and reproductive S&S: frequent urination, urinary tract infections, terrible” sexual energy, hot flashes, night sweats, vaginal dryness.
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AOM differentiation: lower heater dysfunction/ Kidney-Bladder imbalance/pelvic collapse. !
Energy and exercise levels: terrible energy which “used to be great”, easily fatigued but manages to walk and do back exercises every day.
AOM differentiation: deficient Kidney Qi . !
Emotions and sleep: emotionally “lousy right now-very anxious, nervous”, with fear attacks and disturbed sleep, waking 3-4 AM from shifting positions due to husband snoring.
AOM differentiation: constrained Liver Qi, diaphragmatic constriction.
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Musculoskeletal S&S: dull, aching pain, better with heat and worse at night in the lower back and right abdomen and ribcage.
AOM differentiation: cold bi right tendindomuscular meridian of Gallbladder and great luo of the Spleen deficiency.
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Cardiovascular S&S: normal to low blood pressure, benign arrythmias in the past, palpitations, occasional irregular heart beat.
AOM differentiation: deficient heart Qi. !
Skin and hair S&S: dry skin and scalp psoriasis.
AOM differentiation: deficient Yin.
APM Etiology & Pathology: The Bodymind Continuum
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While this patient worked as an editor of psychology textbooks and journals, she seemed to react to these new symptoms with physical symptoms of anxiety, palpitations and viscerally, in the digestive track especially. She did not attribute any of these symptoms to specific psychological factors, more generally referring to her experience of illness as signs of stress. In fact, she had reached menopause, was finding sexual relations painful and her sexual energy “terrible”, which many of my female patients would have situated more centrally in the overall picture as the distress that comes with aging, an end to reproductive capacity and the empty nest syndrome, and pending retirement. She therefore seemed to situate herself more on the body side of what I term the bodymind continuum, and sought physical solutions for these complaints.
Acupuncture Imaging:
From a meridian perspective, this patient’s primary holding pattern occupied the pathway of the belt channel, dai mai, which encircles the waist and travels along the lines of the external oblique musculature, on the right in this case. The great luo pathway of the Spleen was also implicated as this spreads throughout the lateral ribcage. From a zangfu perspective of the three heaters, I would call this a case of pelvic collapse, where constraint in the middle heater leads to collapse of Spleen Qi, and congestion in the lower heater. In classical acupuncture theory, yang, the meridian system, protects yin, the organ system. Thus attacks on the body from the outside, whether in the form of atmospheric assaults, repetitive strain, injury or any stressors that initiate the stress response and an overactive sympathetic system and musculature prepared for fight-or-flight(Selye), might lead to tendinomuscular excess. In the absence of signs of external pathogenic invasions in cases like this patient’s, and with comprehensive medical workups that were all negative, I started by seeing this perhaps as a case of a complex, “somatovisceral” holding pattern: myofascial/somatic constrictions encompassing visceral symptoms with the associated distress. Early on, given my training in Van Nghi’s French meridian perspective, I learned to appreciate that such disorders might be located within the
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superficial meridian systems, but might lead to deep-seated emotional distress as the resulting visceral (zangfu) symptomatology continued to elude medical diagnosis. Such patients who returned frequently to their physicians were more often than not seen as hypochondriacs in the age of psychosomatic medicine, and the modern version of this perspective would ignorantly assign the blame to “stress” without realizing that stress involves a very real physiological set of reactions that could exact a serious toll on the body if left unaddressed. Such a disorder as this had come to be seen as minor, something a physical therapist might address, thus ignoring the deep experience of distress this patient was experiencing, and the obvious fear that some serious, and perhaps life threatening disorder, was going undetected. After all, her father had died of a coronary at the age of 45. In looking at the meridian aspect of a disorder I incorporate Travell’s referred pathways of myofascial trigger points, as a much more detailed way of speaking about meridian energetics in general, and of the tendinomuscular meridians and cutaneous regions in particular, those aspects of the meridian system that can be seen and touched, in particular. Trigger point referrals:
In a careful review of Travell and Simon’s Myofascial Pain and Dysfunction: the Trigger Point Manual, the picture of myototic unit of interactive muscle trigger points emerged, implicating the external and internal abdominal obliques, psoas, erector spinae, multifidi, rotatores, serratus posterior inferior, all of which assist the quadratus lumborum in extension and may be activated by a side-bent, cross-legged posture like the one she described when she told me how she sat at work. Travell underscores the fact that poor elbow support at the desk can be a further contributory factor. Palpation of the psoas and paraspinal musculature yielded no tight or reactive trigger points, which one might have suspected had her lumbar disc problem been involved in this abdominal pain.
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The serratus posterior inferior was reactive, and trigger points here can cause nagging, annoying achiness in the lower thoracic region. The external obliques, lower near Gallbladder 26-28 and upper near Liver 14 to Gallbladder 24, including the serratus anterior near Spleen 21, were all exquisitely tender and tight. This corroborated the meridian assessment of dai mai and the luo of the Spleen. Travell and Simon’s explanation for visceral symptomatology from these abdominal and back trigger points is worth noting in its entirety: “Active TrPs in the upper portion of the abdominal external oblique muscle, which overlies the ribcage anteriorly, are likely to produce ‘heartburn’ and other symptoms commonly associated with hiatal hernia. These ‘costal’ and ‘subcostal’ TrPs in abdominal muscles also may produce deep epigatric pain that occasionally extends to other parts of the abdomen (MPD, vol. I, p. 941).” The picture grew more complicated as I learned from her in a followup treatment that she had been diagnosed with a small hiatal hernia at one point by a specialist, a clear Spleen Zang deficiency sign that would allow for Liver Zang invading Spleen dysfunction which she did exhibit, and Spleen Qi Sinking dysfunction as well. Travell and Simons stress how confusing and enigmatic such abdominal symptoms often prove. “Understanding the reciprocal somatovisceral and viscerosomatic effects of TrPs helps to unravel some of this uncertainty. Myofascial TrPs in an abdominal muscle may produce referred abdominal pain and visceral disorders (somatovisceral effects) that, together, closely mimic visceral disease. Conversely, visceral disease can profoundly influence somatic sensory perception and can activate TrPs in somatic structures that may perpetuate pain and other symptoms long after the patient has recovered from the initiating visceral disease(ibid, p. 951)” They go on to share their experience of active abdominal trigger points, especially in the rectus abdominus, which “may cause a lax, distended abdomen with excessive flatus. Contraction of the abdominal muscles is inhibited by the TrPs so that the patient cannot ‘pull the stomach in’. This apparent distension is readily distinguished from that due to ascites on physical examination(ibid, p. 952)”. They conclude that right upper quadrant pain caused by contracted upper external oblique trigger points might easily lead to pain and discomfort that might be confused with gallbladder disease.
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Travell and Simons site a series of common stress factors that might activate such abdominal trigger points: !
body fatigue
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over exercise of the abdominal muscles
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emotional tension
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straining during defecation due to constipation
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poor posture leaning forward for hours, thus tensing and shortening abdominal muscles with failure to properly support the back
The authors underscore the fact that it has “been recognized since the 1920s that persistent abdominal pain is as likely to originate in abdominal-wall muscles or be referred from chest-wall muscles as it is to originate in abdominal viscera”(ibid, p. 956). Differential diagnosis of visceral diseases that can cause the same symptoms of discomfort and distress as abdominal muscle trigger points include: !
articular dysfunctions
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fibromyalgia
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appendicitis
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peptic ulcer
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gallstone colic
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colitis
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painful rib syndrome
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intractable dysmenorrhea
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urinary tract disease
!
hiatal hernia
!
reflux esophagitis
!
gastric carcinoma
!
chronic cholecystitis or uretral colic
!
inguinal hernia
!
hepatitis
!
pancreatitis
!
ovarian cysts
!
diverticulosis
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!
umbilical hernia
!
thoracic radiculopathy
!
costrochondritis
!
ascariasis parasites
!
ascites
It is therefore essential that patients with undiagnosed abdominal pain be evaluated by a physician to rule out visceral disease (ibid, p. 956). The authors add that abdominal breathing, a common stress reduction technique, is extremely valuable for somatovisceral abdominal pain. ____________________________________
Round One of Treatment( 6 over 2 months, starting with once weekly for three
weeks):
Acupuncture Diagnosis: constrained chong mai and dai mai; diaphragmatic constriction(APM); Middle heater dysfunction. Treatment: Sp 4/ Per 6; GB 41/TH 5; LI4/ Liv3; Sp 6, St 36, 37, 39; Kid 2 and 3; GB 26-28, GB 24, Liv 14 Additional treatment for allergies in last treatment: Sp 5, LU 7, LI 4, LI 20, Bl 2, St 2
Round Two of Treatments (4 treatments over 4 months):
Reactions over the past 5 months: she received a diagnosis of genetic osteopenia, which was ruled out as a cause of her primary complaint that brought her for acupuncture, but clearly agitated her (growing older, developing genetic disease) and was put on fosamax. She presents this time with right hip pain primarily.
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Treatment 1: Did side lying for right QL, serratus, lower external oblique and GB 29, 30, 31, 34, 38, 41(possible hip involvement—the complexity of aging) with same root chong mai/dai mai treatment as initially. Reactions to Treatment: the new hip area pain was “definitely better”. Treatment 2: same root points but face down taiyang zone adding bilateral QL trigger points and bilateral Bl. 23 for Kidney Qi, and right GB 30 which was now symptomatic. Reactions to Treatment: the patient reported feeling “definitely better”. Treatment 3-4:
same taiyang zone treatment for QL and right hip.
Round Three of Treatments( patient returns for 4 treatments over 6 weeks):
Reaction over past one year: The hips have been fine, the patient is here for a follow-up up on right daimai area discomfort which is mildly symptomatic. When I mentioned that it seemed she had really become very clear about when she felt a return for more acupuncture made sense, she responded: “I’ve learned that when it starts to bother me, a series of 3 or so treatments takes care of it”. I told her perhaps one or at most two treatments might do it this time, as I always try to empower the patient to only come to treatment when they feel they need it. She answered very clearly that she felt safer planning on all three. Treatment: Same distal and local chong/daimai treatment as initially. Last treatment: The patient reported feeling “much better but not totally gone; I want one more treatment.” I repeated the same treatment and did not see her for quite some time.
Round 4 of Treatment:
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Reactions to Round Three of Treatment: Much better overall, the patient came 6 months later for a follow-up preventative series of 2-3 treatment on the right daimai area discomfort, which was barely noticeable, plus new flexor carpi ulnaris bilateral discomfort, from much more computer work . Treatments 1-2: GB 41, 27, left, Liver 3, bilateral flexor carpi ulnaris TrPs near SI 7 and distal to Ht 3, bilateral Kid 3 and Ht. 7 (SI muscle channel). Reactions to treatments 1-2: the new arm symptoms are totally gone, but she wants 3rd treatment as preventative for right daimai area. The same daimai treatment was administered. Reactions to Round 4: Right quadrant abdominal discomfort 95% better; bilateral flexor carpi ulnaris TrPs much better.
A Final Round:
Reactions to last series of treatments: The patient reported being fine for one and a half years, since her last treatment of Round 4. She is here today for mild rt LQ discomfort and some GI distress with abdominal discomfort. Treatment: treat dai and chong mai, distally and locally as before, and release local Sp 15, St 25 and Kid 16 on the right, where reactive, with distal St 36, 37 and 39.
Reactions to Treatment: Feels better but still concerned about return of right sided GB 25 area discomfort. Treatment: do side lying adding tender TrPs at iliac crest and GB 25 area and same distal chong/dai mai treatment. Reactions to Treatment: “Great for Two Days! I sense it is almost gone!”
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Last Treatment: do side lying as above, and then face down for QL bilateral and rt hip GB 30 area (piriformis TrP) with huge releases of all trigger points Then do face up for chongmai/daimai as before.
RAP-UP: Issues raised by this case from the patient’s and the practitioner’s perspectives:
In the palpation phase of the examination- as- treatment, which is pivotal in the Acupuncture Physical Medicine approach I have developed over the past two decades, I of course try to make the patient comfortable, and give them as accurate a feeling of what the acupuncture treatment is going to entail as possible to allay any fears. As I proceeded in this fashion with Edith, I did so keenly aware of her strong skepticism toward acupuncture for her condition. But I also try immediately to validate the person’s experience of illness by always by laying my hands on the areas of discomfort and distress that the patient identified on the chart’s diagrams of the body, and during the Four Exams, and try to match my verbal communication with my somatic communication, drawing on acupuncture or trigger-point images and three heater findings while I am palpating, to embody this phase in such a way that the patient has a more pronounced bodilyfelt sense, to quote Gendlin yet again, of their complaint. This phase of the palpation marked a shift in Edith’s attitude toward me in particular and toward acupuncture in general, as she displayed guarded surprise that I found the location of her complaint so readily. I capitulated to this patient’s clearly more physical explanations for her problems, and therefore did not probe into her marriage, her children, her likes and dislikes, her work, listening instead, and watching and sensing how she responded to this discussion of her emotional life. While I did make some passing remarks about the aging process and what the experience of menopause might entail, slipping in as it
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were signs of empathy and compassion for her experience into our discussions together, I made most of my communication center around what I located in her body, and around her “bodily felt-sense” of these somatic constrictions. I focused on the holding pattern that matched and validated her experience of right lower and upper quadrant pain and the associated distress. More like an osteopath than a psychotherapist, I found the strain in her body fabric, in the belt channel that choked her, and strained it further through informed touch and needling, to prod it to release, a few notches at a time, so that she might breathe more easily and feel more at ease in herself. I also avoided an overly psychological approach to my communication with her because of her career editing psychological materials, and the fact that she was skeptical of acupuncture from the start, and would have undoubtedly reacted with concern if I took on a psychotherapeutic air. The Human Dimension entailed in my work with Edith revolved around slipping in suggestions of how the emotional strains of menopause and the subsequent bodily changes, her children leaving home and the aging process in general could lead to the constrictions she was experiencing. These comments and reframes were performed during the actual palpation for her holding pattern and their acupuncture release, thus grounding the comments in the physical realm of the palpation and needling. A different patient responding to all these changes from the mind side of the bodymind continuum would have most certainly required more talk time, and a different way of reframing the holding pattern.
Progress to Date At the time of this writing, a year had passed since the last treatment. In her reflective assessment of her own initial intake form, Edith reported complete absence of the abdominal discomfort and lower back pain, which she rated as a 0 on her own VAS scale (0-10), that brought her for treatment. She also reported complete relief from the original painful coccyx , feeling of food stuck in the throat and cool throat sensation, all rated 0 on the VAS scale. Her written report of the other changes she experienced during and since acupuncture treatment display a wry sense of humor that was almost totally absent in the initial encounter, obscured
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as it was by her discomfort and distress. “ It is hard to believe”, she writes now, “that I reported a poor appetite in 2002. I certainly eat more than ‘to get by’, and have resumed nibbling (“when the warmer weather arrives, it will be time to get back to outdoor exercise to shed several pounds gained over the winter!”). She also reports greatly improved sleep, which she rated an 8 on her VAS scale four years ago and now puts at a 3, with greatly improved energy as well. She admits to still being a “type A person”, and still gets stressed over work and some family matters. But she is very reflective of the need to begin tapering down her work load, and is slowly utilizing the help of an assistant to step into her shoes during her absences or eventual retirement or resignation from her current position. The only prescription medication Edith takes now is Fosamax for osteopenia, as well as over the counter calcium and fiber. “All in all”, she states now, “I consider myself to be a ‘healthy specimen’”, in glaring contrast to her self-portrayal as a sufferer of a “staggering litany of complaints” four years ago which now loom as a distant, “albeit painful, memory, and I owe it to the acupuncture treatment I received”. Her menopausal symptoms have also lessened tremendously, with the passage of time, and she never felt the need to address those with acupuncture, rating them now a bearable 3 on the VAS scale.
Epilogue Edith was not an easy acupuncture patient. With a background in anatomy, neurology, biology, and psychology, and “a better than average understanding of how the mind and body work in health and illness”, she displayed more than a healthy skepticism toward acupuncture from the start. She would have never considered acupuncture treatment on her own, and it took a direct referral from her physical therapist, whom she respected tremendously, and who had excellent results for a cat allergy in her treatments with me, to bring her to my door. “Originally skeptical about acupuncture”, she soon became a “convert”.
My goal is to serve as a change-agent for my patients, helping to release problematic holding patterns, thereby prodding them to become their own healers.
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The renewed vitality liberated by acupuncture release of such blockages leads to emotional, spiritual as well as physical relief, as this case reveals. I believe that any seasoned acupuncturist from any style or tradition of practice sees this sort of change in their patients’ body, mind and spirit, and it is this sort of change that provides the impetus for our continued work in this direction. Edith reports being “thrilled to be included as a case study” for the faculty development course that lead to this study. Edith’s experience of acupuncture, which reframed her elusive, albeit severe, complaints, into acupuncture images that lead to positive change overall, is precisely what I hope for and of course do not always witness. Her final words about this experience made my day when I first read them, and such experiences of change through acupuncture continue to inspire and fascinate me after thirty two years of practice and teaching. “I have only superlatives when describing my acupuncture experience”, Edith now reports. “I had to take a ‘leap’ of sorts to go for acupuncture treatment, and now there’s no going back”. What I have learned with patients like Edith, and from the readings and reflections of the past 6 months, is that the Ordinary Skills are all those that allow us to take in what we are hearing, seeing, feeling, sensing, initiate an intervention with needles in the case of acupuncture, and attend to the changes that these interventions bring about, while attuning (tiao ) our interventions to these changes. In a bright, aware, spirited person like Edith, who did reflect hard on her plight, it takes small prods –Ordinary Skills, to set her own spirit and Heart-Mind in motion to restore normalcy. In other cases, a practitioner might need far more adept skills of reframing, education, and support to help a patient gain greater spirit clarity (shenming ). This takes us into the realm of High Skills, where a Neo-Confucian doctor, for example, would take it for granted that he must work at self-cultivation and attend to his own spirit clarity and Heart-Mind if he is ever to be able to prod spirit clarity (tongshenming ) in his patients; this will be the focus of coming Reflections.
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Sources: Seem, Mark. Bodymind Energetics: Toward a Dynamic Model of Health , Thorson’s Press, Rochester VT, 1990 Seem, Mark. ACUPUNCTURE Physical Medicine , Blue Poppy Press, Boulder, CO, 2000, especially pp. 91-92 and 112 – 114. Travell, Janet and Simons, David. Myofascial Pain and Dysfunction: the Trigger Point Manual , Volumes I and II (per muscle trigger points cited in this case study).
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18] Acupuncture Needling & Tacit Knowing: The Tangible Dimension
THE PROBLEM : At the same time that I was busy focusing on the best ways to teach the APM approach, which included extensive training in Travell and Simon’s approach to myofacial pain and trigger point referral patterns and TrP point location and myofascial release, I tended to emphasize the physical medicine side in a way such as to lead some students and some faculty to see my approach simply as trigger point acupuncture, based mainly on Travell’s trigger points and dry needling techniques to release them. It took me several years to realize that APM was being stripped of its original classical Chinese jingluo way of practicing. While I never stopped practicing that classical way, and merely added knowledge of trigger points and a needle technique I modified for acupuncture needles that allowed a far more shallow, wei level depth for many points, this focus on trigger points, and of this technique—which takes some time to get a grasp of, diverted my attention from what was being lost. I turned my attention, once I realized this, to teaching students how to perform needling, starting not with TrP needling techniques, but with classical tonification and dispersal techniques to distal points of the regular meridians and at mu and shu points of the front and back in Year I. I also stress these classical needling techniques as well as trigger point dry needling throughout Year II APM/CCA ACP sessions, and in my Grand Rounds and Year Three clinical supervisions. This return to classical regular, secondary and extraordinary meridian needling techniques brought with it a return to what was most critical in the practice of acupuncture as a hands-on practice aimed at eliciting a felt-sense in the patient.
I. Acupuncture Know-How and the Bodily Felt-Sense This way of teaching and learning implies internalization of skills so that they can be replicated, in a way that is as immediate, and mindful, as possible, without thinking about them: embodied learning as Confucianists would say.
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Clinical supervisors at the college expect any clinical intern to be able to articulate the reasons for their APM/CCA treatment plan (and again I am only sharing what I know best, namely the teaching of the APM/CCA approach, not the Japanese and TCM approaches which are taught in their own ways by other clinical faculty teams), citing the evidence from the signs and symptoms gathered in the four exams, based on the APM/CCA foundational texts, that lead to the working diagnosis, treatment principle and plan But during the physical examination, and again once the treatment has been approved, the 5 steps of APM/CCA treatment should be done from a mindful place where tactic knowledge on the part of the clinical interns, and evocation of the bodily-felt sense, and meaningful signs of change in the patient, drive the way in which the treatment is conducted.
Tacit Knowing
At one point in the development of the teaching at the Tri-State College of Acupuncture, I was struck by the fact that while there were a small number of students who could learn immediately from me how to palpate the body, how to locate depressions where acupuncture points were located, how to locate tight constricted areas in the musculature where excess areas were located, and could just as quickly learn how to needle these excess and deficient areas with very little discussion just by watching and doing, there were many, many more students who seemed to need to have much more explanation, much more theory, much more explicit explanations of what was going on. This was very bothersome to me and led me to consult a prominent New York clairvoyant who in an early session shared with me what she was picking up, namely that I appeared to be someone who knows what I knew in an instant, who in doing what I do takes in the whole and knows whether or not that whole feels like it is accurate. It was a strange meeting, a strange interaction, but it led me to start looking very carefully at how I and other faculty were teaching clinical skills at the college, how we were teaching theory, the
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texts we were using, the outcomes our students were exhibiting. In this process, I engaged in several experimental activities with colleagues, among them Bryan Manuele, Co-founder and then Director of the Midwest College of Oriental Medicine in Chicago, Illinois. Once, while I was in Chicago, we shared the experience of treating patients while watching each other at a distance without intervening. The challenge was to see if we could tell when in the interview our colleague had a sense of what the diagnosis was, what the treatment was going to be, and whether or not, at that moment, he had an explicit awareness of signs and symptoms and differentiations, the meaning of these signs and symptoms, specific acupuncture and Oriental medical knowledge that he had gathered together in a diagnostic assessment in his head and then came up with logical treatment principals and logical point selection. Or, was something else going on? That we in fact discovered, after sharing what we observed, what we saw, what we felt, what we noticed, what we took in, was that each of us seemed at a certain point in an intake with a patient to have a sense of where we wanted to go to find a primary obstruction. This was not a diagnosis, this was not a running through of differentiation of signs and symptoms in our head, this was not an explicit activity, this was not an activity, in fact, that we could even say to each other, and we found it very hard to be explicit and articulate about what we were trying to share. What we discovered was that, much like what the clairvoyant explained to me, we were in fact trusting a kind of knowledge that came to us tacitly—knowledge we could feel, knowledge we could see, a kind of know-how that just seemed to come, obviously informed by our study of acupuncture and Oriental medicine, meridians, point locations, diagnoses and needle techniques. We realized that in the doing of acupuncture, in the practice of acupuncture we made no use of academic or intellectual activities to come up with our treatment but rather seized on a treatment, or rather seized on a moment, where we felt that we had a sense of the problem for that patient, and having a sense of that problem already had a feeling that certain acupuncture patterns, combinations of points, treatments we had done in the past, would be a good place to begin. And so, after quickly palpating the body, once we had this sense of the problem and where, most importantly, this problem was located, we would then go palpate and based on finding areas of tightness, of deficiency, perform an acupuncture treatment in rather short order and know during the doing of this treatment
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%$ whether or not this treatment was moving in the right direction. When we realized that we felt it was moving in the right direction, we would let the patient know that this was great, we would let the patient lie there for ten or fifteen minutes and would actually be quite certain that this treatment would have a positive effect. None of that process involved intellectual operations that confirmed a diagnosis, but rather a process that looked more like reaching deep within for a familiar pattern of treatment that in some way matched the patient’s complaint as a starting point for navigating the patient’s bodymind. This was extremely helpful in the elaboration of the teaching at the Tri-State College of Acupuncture and led to the development of what we call Acupuncture Clinical Practice (ACP) and Grand Rounds with Senior Faculty during all three years of the Master of Science degree program in Acupuncture. Implications for Clinical Training
In Acupuncture Clinical Practice, which is now a three-and-a-half hour class where students begin their clinical training on peer students and practice as one would rehearse for a play, or rehearse kata in karate, that they rehearse or practice full treatments from three different styles of acupuncture, which amounts to building up a repertory of whole treatments that they could apply in given situations as a place to start. In Year Two they learn how to begin to modify somewhat some of those protocols and in the actual clinic in the final clinical senior year they of course are helped with supervisors to step out of the rigidity of protocols, to become flexible and modify as need be those protocols to adequately address all of the various conditions that they are encountering, to adapt to what they are actually seeing in front of them, to their patients’ actual problems, and to be creative in solving these clinical problems starting with these repertories of patterned responses or practiced or rehearsed protocols that they have engaged in over the first two years. This investigation into how people learned and more specifically how they were not learning from going from the rather tedious attempt at memorization of point indications from Chinese textbooks, which we fast abandoned, and even memorization of basic signs and symptoms of different Chinese patterns, we realized that while that was a necessary activity in the lecture classes and was foundational knowledge that they needed to commit to memory in order to have a
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foundation on which to learn and practice, what was critical in the actual acupuncture clinical practice on peer patients first and then on community clinic patients, was this ability to take in information with all of the senses, to make sense of all of this information in such a way as to have a feeling or a sense of what the treatment should be. And while we required that students be explicit in explaining in their thinking, explaining their treatment protocols, explaining their treatment strategies and point combinations to supervisors in the fist semester in order to have a treatment improved, the fact of the matter is that when they observe senior and master practitioners they often see people performing in a much different way. That much different way of performing has a name and was studied in great detail by Michael Polanyi whose book, The Tacit Dimension, is comprised of the Terry lectures delivered at Yale University in 1962, where he developed his concept of tacit knowledge and laid out the simple premise that we can know more than we can say, something that the late Donald Schon, former Ford Professor Emeritus at Massachusetts Institute of Technology continued on with in his development of the concept of “reflective practice,” which is paramount in the clinical training at the College. The Bodily-Felt Sense
The bodily felt-sense is a term coined by Eugene Gendlin, PhD, to describe what the client is feeling when she has what Freud termed a psychotherapeutic “AhHa” experience while, impossible to clearly articulate in words, indicates that the client has made, or is about to make a significant therapeutic leap in understanding. While Freud felt this had to be followed by analysis, to state in language what had just been felt at the deep, unconscious level, Gendlin argued that the focus needed to just remain on the felt-sense, and the understanding would follow on its own. Milton Erickson evolved a similar concept in his approach to hypnotherapy, where a focus on tapping into the deep knowledge, the unconscious, was the goal of treatment, to bypass the conscious mind and initiate meaningful, therapeutic changes. This concept of a boldily-felt sense as a deep, older form of knowing the world derived from Nietzsche, who sought to think beyond the body-mind split articulated by Descartes, where the human spirit was obliterated, by spiritualizing the body itself. After arguing that the Judeo-Christian established religions were no longer of help in orienting mankind’s spiritual endeavors, with his celebrated proclamation
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“God is Dead!”, he worked to articulate a new philosophy for mankind in the coming 20th century, based on a ‘joyful wisdom’, the title of the text where he developed this concept. Establishing himself as a diagnostician of the spiritual sicknesses of his day, Nietzsche stressed that “we require for a new goal also a new means, namely a new healthiness, stronger, sharper, tougher, bolder and merrier than any healthiness hitherto…(cited in BME, p. 4 and for a more detailed discussion, ibid pages 236-237).” Nietzsche clarified many times in his writings that such a new, bold way of thinking about human healthiness, of what was best and strongest about humankind, could only be acquired through an active exercise of one’s will, and an “active forgetting” of old knowledge that no longer served to shore this decidedly spiritual quest. With religion no longer seen as the way in which humans could embrace their true spirit, Nietzsche challenged us to take on this quest personally, willfully, joyfully. Carl Jung also stressed the need to rediscover the wisdom of the body, too long a prisoner of the spirit in organized religious teachings, and to “reconcile ourselves to the mysterious truth that the spirit is the life of the body seen from within, and the body, the outward manifestation if the life of the spirit—the two being really one (ibid, p. 4).” This concept of a deep wisdom of the body that is spiritual at its core is parallel to the Chinese concept of shen and shenming translated as mind or spirit, and as mental or spiritual clarity respectively. In the Chinese concept, which is decidedly pragmatic, spirit clarity amounts to the wisdom or intelligence of existence, of being alive. Someone who manifests spirit clarity, spiritual health, has eyes that are bright and make contact, a shine to the complexion, an alertness, a presentness. This is in direct contrast to someone whose spirit is marred by the emotions and who exhibits either a Yang, frantic, agitated stare, a frightened countenance, a fired up complexion and manner of being; or a Yin, empty, vacant, absent stare, a lusterless complexion, a depressed manner of being. These sorts of signs of presence or absence of spirit are part and parcel of a classical Chinese medical examination. In acupuncture treatment, where there are signs of a relative absence or agitation of the spirit, this should begin to improve with the first few needles, sometimes even with the first few words exchanged between practitioner and patient. On a very basic level, then, much like in mindfulness meditation,
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acupuncture thus seeks to prod a person who is suffering from pain, discomfort, distress, to turn toward life, to embrace life, to say yes to life, by connecting with this deep wisdom, experienced when it is attained as a bodily-felt sense rather than something to be expressed in words, an AhHa! Life experience that we are all given to understand all along. I will address the similarities and differences between the Western rationalistic and essentialistic Mind focused on things in their ever smaller parts, versus the Eastern Mind aimed at attending to the way things change, the process of change, a process approach, in this month’s BLOG.
While mindbody medicine has become a main field of CAM practice, in many different forms, the bodymind versions of this medicine have been downplayed. The fact of the matter is, in the research on Indian yogis conducted by Dr. Herbert Benson at Harvard decades ago, too little stress was place on the fact that these Eastern practices were PHYSICAL disciplines. Through a disciplined use of ones body, and ones breath, it was possible to achieve spiritual health. There was very little mentally going on, except for developing a patient, and mindful stance toward thoughts as they would inevitably flit in and out of awareness as one sought to practice Yoga, T’ai Qi, QiGong, or Mindfulness or Transcendental meditation 40 years ago on this continent. Why, then, was this referred to as mind-body medicine, when in fact it was fundamentally bodymind through and through? This is why I chose the title “bodymind” energetics for my first serious attempt at explaining what acupuncture was in the West, and had to keep correcting my editor as well as those who wrote about the book when they would “correct” it to read mind-body or at best body/mind. While the concept of “bodymindspirit” which derived from the New Age Movement in the 60’s in this country was a way to avoid the mind-body or body/mind split way of discussing what is human, in the acupuncture world this has lead to a certain tendency to criticize any approach to healing that fails to add “spirit” to the title as deficient. Frequently over the past 30 years I have had some students and some colleagues criticize my use of the term bodymind (rather than bodymindspirit) who would go on to say I was good at treating the body, by which they meant
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“symptoms” but could not treat “the whole person”. Even Integrative Medicine stresses treating the “whole person” including the “spiritual side”. To me, as someone practicing acupuncture for over 30 years, I can just say I do not know how it would be possible not to touch the spirit, understood in a classical Chinese acupuncture way, when one seeks to be attuned to each patient “with the heart and the mind” (Ling Shu p. 17). Elsewhere, the classics stress repeatedly “The key to proper needling is to first attend to one’s own spirit” (Systematic Classic, p. 295). The first chapter of this classic, in fact, is all about the 5 Spirits and about the fact that when Qi arrives, when Qi is obtained, the spirit may also be touched, and so each needle must be manipulated with great awareness of this fact: “One should remain calm and intent at all times, observing the response to the needle and awaiting the arrival of the qi. (The response of qi) is said to be mysterious, subtle, and without form. The appearance (of qi) is like the soaring of flocks of birds or swaying of millet in the fields, which, though perceptible, cannot be discerned […] As if perched above a fathomless abyss with one’s hand grasping a tiger, (when holding a needle the spirit must not be distracted by anything) (ibid, p. 296)” One does not have to keep talking about spirit to practice the high skills of acupuncture, but rather dedicate oneself to mindful practice and practice this in everyday life so that mindfulness becomes a part of being with a patient. This is the topic of the all future Reflections.
II: The Way of the Needle So now let’s talk about how acupuncturists, senior acupuncturists, master practitioners are at one with the needle. When acupuncturists pick up a needle, as opposed to students who are just learning to needle, they are not focusing on the feeling of the needle in their hand; they have already developed the skill of being very adept at loosening the needle from the tube if it’s a Japanese style disposable needle, and this implement is just a part of their hand, not something they have to think about for a moment, and of course that is something that only came about with practice, by learning how to hold the needle in a graceful way so that the needle and tube become one with the hand. And so when an acupuncturist, a senior acupuncturist or a master practitioner picks up a needle, they are not attending to
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the needle, they are not attending to the tube, they are attending to the point on the body that they have located visually, or by palpation, and if visually, will then go to the body and palpate to find the point and in acupuncture physical medicine, in classical Chinese acupuncture, in Japanese meridian therapy, these points are moveable points. These points are not textbook rigid point locations. Rather these are things that can be felt. So an acupuncturist who works from a palpation based approach and who trusts the tacit knowledge in their fingertips, trusts what they see and feel and sense through their hands. She will look for a point and once finding a point, attending to the point, will use the needle, which is just an extension of her hand, to go into the point, to search the point, to search the “Cave,” (one of the meanings for the Chinese term that denotes an acupuncture point). She will search for the active area, for a certain kind of sensation, a certain resistance, a certain stuck feeling, a certain heaviness, a certain denseness, depending on the kind of point. When she feels this, through the tip of the needle as an extension of the fingers feeling this reaction, they she can apply the tonifying or dispersing needle techniques to make the tissue respond in the way in a disciplined and predictable way. This happens through practice, but all senior acupuncturists do this effortlessly, and if they were to instead attend to the minute mechanical and muscular activities that their needling hand is going through as well as their nonneedling hand to make the tissue respond in this way, they might very easily become crippled and unable to function. That being said, where Schon goes I believe further than Polanyi or, let’s say, is more pragmatic than Polanyi in the education of professionals, in his idea of a reflective practice and a reflective practicum with senior practitioners. If ACP and clinic supervisors, as well as students, were to pay close attention to how senior and master practitioners stand, manipulate the needle, move their hands, they might be able to at times watch students who are in ACP training, look at how they’re using the muscles in their hands, the muscles in their forearms, their posture, their stance, whether they are sinking into the tantien or held tightly and rigidly, whether or not their arm is strongly engaged or very weakly positioned over the patient, if they are able in fact to notice and attend to what they usually do not attend to they may well be able to make changes in the actions or practices of these students in training that will make them be able to indwell more quickly and more fully in the needling process, and make the needle an extension of the students so they can
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feel and attend to what is underneath the tip of the needle rather than what is held between their fingers. I’ve been looking at this carefully, and this is only my way of needling. There are many different ways of holding a needle, using the needling hand and a nonneedling hand. Mine are based on very classical descriptions of these techniques, but these are just my efforts, my way of making these techniques a part of me, a part of my body, an extension of my body, something that comes second nature. So, recognizing that there are many ways to do this, first of all, I believe that what is critical in needling, if we now look at these minute mechanical actions, is to see the wrist as the pivot. The wrist is not rigid. Many students needle either just with their fingers trying to use it in a very tight way, almost like children who are first learning how to write with a pencil, which they grip far too tightly. So what we need to do is help beginning students have a very relaxed wrist. The wrist is relaxed and the movement is fluid. So if one keeps the wrist relaxed, the fact of the matter is, if we look at the forearm muscles while we’re doing this, if we were to do a soaring crane type of movement with our hand where we bring all of our fingers together and then touch all of our fingers, the pads of all of our fingers touching each other toward the thumb, then the fingers become a small pointed beak of a bird. And if we now were to keep our wrist very fluid, moving it first inward then extending it outward, flexing it, extending it, moving it to the right and the left very loosely, we can see, if we look at our forearm muscles, that our forearms muscles are very much a part of this movement, even if the movement is small. So if the reader tries this, moving first this hand that has fingers that are very engaged together, not hard but definitely with force as if one were going to begin striking something as in martial arts, this engaged hand also involves engaged forearms, and in fact as I do this and feel I can see that I am not engaging the muscles of my upper arm, I am not engaging the muscles of my shoulder, I am not engaging the muscles of my chest, but all of those muscles—the upper arm, the shoulder, the chest—in fact have settled into a very strong position where they can hold the forearm and hold the hand. So the posture has to be erect, the shoulders have to be level. The body can do this forever, the whole body is strong, the stance is balanced, one foot somewhat in front of the other or shoulder width apart as in Qi Gong for example, or Tui na massage, and in a strong stance like this, with the whole forearm supported, the forearm and especially the hand with the help of the fulcrum of the wrist is able to engage in such a way that the motion, either flexing toward the
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patient or extending the hand away from the patient is a strong movement and is not just a movement from the fingers and is not a rigid movement from the whole arm. So if we look at this for a moment, we’ll see that in the first instance of tonifying needle technique, which is first slow IN then fast OUT, if one imagines holding a needle, or holds a toothpick for example, and starts moving in a big movement in flexing the muscles, the forearm flexor muscles are very visibly activated. And a teacher coaching a student in this technique could easily just go ahead and hold the flexor muscles of the forearm and make sure that the student is engaging them, so that if the student is just using the fingertips in sort of a rigid way that is not using the forearm, the teacher as coach could say to the student, “just let these muscles work, do this all the way from up here, do this from the flexor muscles all the way up at your elbow, use the entire muscle.” That will help them focus on the “in” and by doing that, in fact, as I’ve found in practicing on myself, just the contraction of the forearm muscles holding the needle in place creates quite a strong sensation when done properly because it is adding weight and force to the needle on an inward movement, because the wrist is allowing the heaviness of the hand to move inward, to flex, and the movement is a movement that is heavy on the in. I always tell students when I am teaching this technique, “heavy on the in,” because the focus is on the in. It is an engagement of the forearm muscles with a supple wrist. And the final thing that is important whether tonifying or dispersing is that the fingers are together just as they were in this flying crane technique. All of the fingers ideally, or at least three of them, the index, the middle finger, and the thumb, are holding the handle of the needle, not pinching it, the skin is not blanched, the nail beds are not blanched, holding it very lightly in fact, and the force that is holding the needle and the weight that is in the hand, coming first from the flexor muscles of the forearm is generated through to the point, Large Intestine 4, which is the first dorsal inner osseous muscle, and that muscle is fully engaged. Many students have trouble with this. If one pinches the fingers very hard, that muscle becomes engages and we can see that it becomes hard. But that makes the needle sharp, rigid, a piece of metal instead of an extension of the fingers and of the whole lower arm. So in releasing the grip on the needle and having the fingers holding the handle of the needle very gently in order to prevent this from being a sharp technique, the action during tonification has to come from the flexor muscles, and the first dorsal inner osseus muscle, at Large Intestine 4, which has to
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be fully engaged, which creates weight down through the fingers, through the index and middle finger and thumb, and this weight creates a reaction in the needle that makes the subcutaneous tissue respond in a characteristic way to grab at the tip of the needle. It’s a heavy motion that causes a heavy slow response, not a fast response. This is a slow in, slow response of the muscle, even though the needle is only into subcutaneous fascia. The Japanese often refer to this as “needle grasp.” The classic texts describe this as a very gentle, almost imperceptible manipulation: “Supplementation may be defined as tracking. Tracking implies (insertion of the needle) I a seemingly casual way, as if nothing were being done, like the biting of the mosquito. After retention, the needle should be withdrawn quickly, like an arrow leaving a bowstring” (Systematic Classic, p. 292), and the left hand closes the hole for several moments. The result is a gathering of tissue, a grasping of deeper muscle, a toning up of a weakened or even somewhat flaccid tissue area. Often there is a feeling or warmth, or even of a weight that has sunk into place that lasts for several minutes. That is tonification. Dispersal then, and here we are talking about twirling the needle, as well as moving it in the opposite way, consists of wrist movement creating a fast in/ slow out technique. What one does in fast in slow out is the opposite with the right hand. So one first inserts the needle fast. This fast movement is with the forearm muscles, so it’s exactly the same use of muscles as for tonification, but it’s done quicker. And this kind of quick movement causes a fast grab of the muscle, and the fascia deep beneath the needle—a fast reaction rather than a slow one. And then, still using the wrist as the pivot, one now uses not the flexor muscles at all, but the extensor muscle of the forearm on the top of the arm, the yang aspect of the arm as opposed to the yin flexor aspect. One uses the extensor muscles, the extensor of the index, ring, and middle fingers in the area of Large Intestine 10 and what Kiko Matsumoto calls Triple Intestine 10, so on the triple meridian at the same level as Large Intestine 10. If one feels there, and as a coach if one feels there, instead of engaging the flexor muscles, one engages the extensor muscles all the way up to the elbow, using the wrist as a fulcrum, still keeping the fingers engaged, grasping the needle lightly but with very engaged hand, a strong hand, a hand that if somebody came to hit it away as in martial arts, would be there, stay put, a hand that is present, fully engaged, weighted. So now, with the same grasp on the needle, with the same engagement of the Large Intestine 4 areas, the first dorsal
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inner osseus, one simply uses the extensor muscles which the teacher, the coach, could but their fingers on, and with the wrist as a pivot engage the extensor muscles which creates a heavy focus on the out. And the out movement should be slow, so the extensor muscles are used very slowly after having quickly gone into the point to create a quick grab. And it is important that it grab. If it doesn’t grab, one goes out slowly and then in rapidly again several times and then out slowly again. The classic texts describe it this way: “Drainage may be defined as head-on attack. Head-on attack means (rapid) insertion (of the needle) while twisting to enlarge the hold, and (slowly) extracting it so as to discharge the evil qi)” (ibid, p. 291). So this simple technique, based on the tactics of fast in slow out uses a totally different set of muscles—yang muscles for yang technique, extensor muscles—and the fascia is slowly pulled away from the point, the point that is taut, the point that has too much tone. And by pulling the fascia out and then letting the needle stay shallow, the technique will actually create a release of the fascia rather than a toning up of the fascia. So through these very precise uses of the forearm muscles and engagement of the muscles of the hand, engagement of the fingers without gripping tightly, one actually extends the needle, it becomes a part of the hand, an extension of these fingers brought together. And by bringing these three fingers together, the thumb, the index, and the middle finger, one is able to use the force either of the flexor muscles to focus on the in or the extensor muscles to focus on the out. This is something that I believe is easy to teach and easy to improve upon if one is still having trouble doing tonification and dispersal needle techniques. That’s it in a nutshell for the right hand. Now, if one adds twirling—twirling very much engages the Large Intestine 4 area, it is very difficult to twirl without. But in twirling, one engages the flexor muscles with the wrist flexed to tonify, or one can twirl with the wrist extended away from the body to cause dispersal. So twirling with the wrist either flexed or extended will create different reactions in the tissue, and if one lifts and thrusts and twirls at the same time, these processes can be done quicker, but it is by no means necessary. A way to build up the strength in the hand, to make it a strong hand, and here I am thinking of acupuncture like Qi Gong or like
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a martial art, the hand must be and the forearm must be fully there. In martial arts, even in Qi Gong, when someone is doing different motions in Qi Gong, the arms are engaged, the hands are engaged. If someone were to come up against those arms, which appear to be just floating in space, they would come up against something quite solid. The arms engaged that way would be able to immediately protect themselves and defend themselves. These would not be arms that would be able to be pushed away easily. I think in acupuncture it’s the same thing, and I’ve just come to this realization in making this new attempt at understanding the more tacit aspects of what we do, that many students are hovering over the body in a very light way. They somehow feel that being extremely light and loose is the way to be gentle. In my experience it’s that type of needling that is sharp and very much not engaged needling and does not create the reactions in the patient hat the student hopes for. So I believe that the practice of acupuncture has to be like Qi Gong, or AOM Bodywork techniques, or even like a martial art in the sense that the parts of the body that are being extended and attending to the other person have to be fully engaged, strong, weighted, present. And by being strong and by having strength and muscles engaged one is in fact bringing a force to the needle. Some people would say this is Qi Gong being applied to the needle. So, in order to strengthen the hand and the forearm muscles, what I’ve recommended to students is to get a rather thick dowel rod. It could be just four inches long—almost like the handle bar of a bicycle, and one might even be able to find something like that in a sporting goods store, or just get a hard rubber cap that fits over handle bars—in any case something about an inch in diameter, round, a dowel rod, so something much thicker than a needle. And if one holds that like one would hold a needle—I do it with my cane, for example—just the holding of it can only be done by engaging the Large Intestine 4 area, the first dorsal inner osseus muscle. It’s through that muscle that one holds a cane, one cannot just pinch the fingers—it’s in fact impossible—even though one can pinch just the fingers around a needle and not engage that muscle, which I’ve seen many times with students. So by using this thicker needle, this dowel rod, one has to engage that muscle, and then just twirling it back and forth is a very strengthening activity. And one can twirl it back and forth slowly, rapidly, clockwise, counterclockwise, and watch, using a very loose wrist, doing this first using the flexor muscles at the same time to build
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the muscles and to train the muscles and make these muscular actions tacit rather than conscious. And then do the same thing twirling the dowel using the extensor muscles on the top f the arm. And in this way one can very quickly build the forearm and extensor muscles. Mine are quite developed and I never do anything in the gym to use these muscles, this is all from having done acupuncture for thirty years. So this would be the way to strengthen the arm, make the hand present, heavy, engaged, weighted, so that there is force, weight in the hand ready to make specific reactions happen from the needling. That brings us the last part of the needling process, which is what to do with the left hand. I cannot speak for styles that don’t use the left hand, which certainly is often done. But in my approach, and the Ling Shu already states this very clearly: “The right hand is used to hold and push the needle while the left hand assists and controls” (p. 5). And later on in the same text: “The left hand fixes the bone position, the right hand follows. Do not cause the flesh to bunch up”(ibid, p. 230). Acupuncture, in the classics, is clearly a left-handed affair. In Japanese meridian therapy, which uses tubes, the role of the left hand is extremely important, and that’s where I learned to use the left hand, was in learning to hold the tube. One uses the left hand to grasp the tube, the thumb and index finger grasping the tube at the very bottom where the needle tip will be. And by holding the tube right at the bottom and then placing the tube on the point, one places a lot of weight, a very weighted left hand or non-needling hand, and compresses the fascia so that the tube is actually inserted quite distinctly into the fascia and is not floating lightly on the skin. This will prevent sharp insertion when the needle is first tapped in. So in this kind of technique, holding the tube at its tip between the index and thumb and letting the other forefingers fan out as wide apart as is comfortable depending on the part of the body or closer together almost like one holds a pool cue, almost identical to that kind of way of spreading ones fingers, the whole left hand, the whole non-needling hand, the edge of the palm, the edge of the pad of the thumb, the whole heel of the hand is very firmly weighted on the patient. This is not an insignificant process, because by weighting the area—and one can do it just with the thumb and index finger as well, but it’s more powerful if one weights it with the
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whole hand—then as soon as the needle is tapped in, it is already at the proper depth where stimulation can occur especially for tonification. And once it’s tapped in and in my style where needles are used that are 34 gauge in most cases, I find that the tap has to be two or three taps, not just one, and ideally the taps would tap in such a way that the fingers do not touch the top of the tube, they just touch the top of the handle of the needle. And if one does it properly, the needle is propelled fairly deeply into the tube so that it’s deeper than the surface of the tube. The needle has actually been propelled somewhat deeper than if one just pushed it in slowly, which is sharp and not a pleasant way of needling. So tapping the needle a couple of times rapidly, one spreads the thumb and index fingers slightly apart on the non-needling hand, and relaxes the weight of the hand slightly where the thumb and index finger are and stretches the skin and removes the tube. Now, with this taught skin, one can do the first stage of the needle technique, which is to ensure that the needle is into the fascia, the subcutaneous layer, which is called the Cou Li in Chinese. So the needle is in this layer, which is also the Wei level, the Yang level. At that point, one can let go of the needle, let go of the left hand, and now the needle is at a Wei level depth and now one can direct the needle with the left hand or the right hand. So what I now suggest that students do is reposition themselves. If I want to just tonify, I now just put down my index finger very close to the needle and create a slight weight on the area, compress slightly, and tug very slightly so that the skin is taught right where the needle is. I make it taut like a drum—a very slight weight in, a very slight tug, changing the direction of the needle if desired, or just keeping it perpendicular. With the skin and fascia somewhat taut, I then do my needle techniques: slow in, rapidly in, and so forth. When I’m doing trigger points, I use Travel’s technique, which is to trap the muscle, which I first have felt cross fiber, and once I find the most tender part of that taught band, I stretch my index and ring fingers slightly apart. Actually, I do the same thing: I find the point cross fiber, I place the tube right on the most tender spot and hold it with the thumb and index finger first, tap it in, spread my thumb and index finger just slightly apart and remove the tube. At this point, I recommend to let go of the needle with both hands, and then to put the left hand, the non-needling hand, middle and index finger, cross-fiber above and below the needle, so surrounding the needle, straddling the needle, cross fiber, finding the muscle again and using the fingers to ensure that they are placed right over the needle, but this time not hard enough and heavy enough to find the tender point, just to keep the muscle trapped and that part of the muscle weighted where the needle is located. And now, with very little pressure
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but stretching the skin again, I have students hold the needle again with a very engaged hand and do quick movements in two to three times, and then slower out, hovering for a second or longer, called sparrow pecking technique, like a a bird pecking for seeds. So it’s quick pecks, the pecks are in a staccato kind of fashion, so not even pecks, not rhythmic pecks, jerky pecks, pecks for a couple of grains and then out, and then a couple more grains, and then out. So to artificially show this at first to students, I recommend three pecks in and then one out. So peck, peck, peck, out-HOVER, fast pecks in, slow out. Three pecks in, slow out. This is a fast in slow out technique, and the focus is on the fast in. If one focuses on the slow out it will usually not work. So it’s a focus on fast, fast, fast, slow-HOVER, fast, fast, fast, slow,-HOVER changing the direction slightly each time as if one were pecking for different seeds each time. This will, if there’s a trigger point in the area, cause the muscles to fasciculate and twitch, often visibly, but even if not visibly, perceptible to the non-needling hand, which is resting lightly this time on the area. So in dispersal, the left hand is resting lightly, still with the skin taut where the needle is. In tonification the hand is resting heavy because in tonification the focus is on a heavy weight dropping into the area. In dispersal, the focus is on a rapid movement in and then a relaxing of the fascia. With these basic ideas and with some coaching, everyone can learn to do proper tonification and dispersal techniques. And following Polanyi’s example of tacit knowing, one can learn to attend to what lies at the tip of the needle and attend to the reactions that one is looking for at the tip of the needle, rather than being distracted by the handle of the needle or this implement awkwardly held in the hand. The goal is to make the needle an extension of the forearm, an extension of the muscles of the forearm and the muscles of the hand .
Tips When Needling the Root/Opening Moves I have several specific things that I focus on when needling the first few points in a treatment, points my dear friend and master acupuncture practitioner Dr. Eric Stevens always refers to as “opening moves”. Influenced again by Shudo Denmei’s pragmatic advice, that only a few needles need special attention to set the Root treatment in motion, I seek meaningful de qi
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at the operational jing level points: SP 4, GB 41, LU 7, SI 3, and the source points for the thre leg Yin, sometimes with Sp 6 instead or added to the source points as follows: !
SP 4: I needle this textbook location, but between the bone and the muscle (the adage to needle between the red and white skin makes no sense, as this differs with different people, and can lead to needling the often exquisitely tight, tender muscle especially on people with flat feet or plantar fasciitistype problems. I always needle this point on the right, as I want to needle the paired Per 6 on the Heart Protector left side. I run my index finger with distal phalange relaxed as per Shudo Denmei’s suggestion for palpating actual acupuncture points (as opposed to indurations), from SP 2 for about an inch until I fall into the hole just at the distal end of the bone where the finger stops abruptly. I retreat with the finger a touch to place the needle on the exact spot, angling the needle with tube compressed firmly into the point (supported by left hand thumb and index finger rooted around the tube at the base, into the flesh to prevent a sharp insertion) and tap several times to ensure the needle has progressed all the way into the tube with its handle top level with the top of the tube. One should never tap this point just once with the # 3 Serein needles I use, or it will not insert deeply enough and be sharp once the tube is removed. With my non-needling left hand I tug with my fingers on SP 2 area, until I can see the skin and subcutaneous fascia tug/drag and tighten all along the trajectory of the meridian, right up to behind the medial malleolus. I always tug this way when I want to initiate a propagating Qi sensation along a channel, which “facilitates” the taut fascia, making it more yang and more reactive. If the skin is cold I rub it to warm it, or even cover with Mylar for a few minutes to warm it up. Rubbing or tapping along the trajectory where the propagation is to occur will also hasten the desired results. I then insert the needle very slowly into the resistance at the point, finding where it is most reactive, dense, lime an eraser on a pencil which Kiiko Matsumoto refers to as a “gummy” or “kori”. Needling in to this resistance until the needle gets slightly stuck, I then twirl rapidly into it, or twirling and lift and thrust focusing on the out movement, and the propagation is quick to arrive for most people. Wherever the Hara has been tight on the abdomen, especially in the middle heater along the Kidney, Stomach and even Spleen
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or Liver pathways, this will release. I look for exaggerated skin creases on the abdomen, which bespeaks constrained Qi at that level and an upregulated sympathetic nervous system (with signs and symptoms of nervous or overactive gut functions), and these will tend to decrease markedly. The breathing invariably starts to improve with such initial Root points, a sign that YinYang regulation is setting in. There may be rumblings in the gut as well, and a definite change in the complexion. The eyes will also soften and the person’s demeanor will normalize somewhat. The propagating sensation will travel at least 4-5 inches along the Spleen pathway, up toward the medial malleolus. If it can be made to ascend to Sp 6 level, it will usually travel up to the pelvic region and even umbilicus or higher. Kiiko would call this targeting the Qi, and the change at gut level is what makes such initial points have such a powerful affect on the constructed Hara. The rectus abdominus will be much less constricted from the navel to the subcostal region in most cases. I needle the paired Per 6 on the left with neutral stimulation to get the slightest de Qi response travelling toward the wrist; !
GB 41: I insert the needle slowly in the same fashion, on then left side, angling under the bone into the textbook location toward Liv 3. My left hand tugs/drags the skin and subcutaneous fascia again diagonally away from/in the direction opposite to Liv 3 until I can see the drag right to Liv 3 and then insert slowly into the resistance. As this is a Yang meridian I needle more strongly until there is a deep penetrating de Qi response that is quite strong (always within the patient’s tolerance level however) spreading throughout the dorsum of the lateral foot. This will tend to relax the waist and pelvic region and restrictions will begin to release, sometimes totally along the pathway of daimai (GB 26-28, and the lower external obliques). I needle the paired TH 5 neutrally for the slightest de Qi sensation, or modify this opening move by adding left Liv 3 needled until there is a definite but tolerable de Qi sensation, and add right LI 4 instead of TH 5 (thus adding one diagnonal set of the four gate points to GB 41). I do LI 4 like Liv 3, until there is a definite but tolerable de Qi sensation. I will often do this combination together, so SP 4 on the right, Per 6 on the left, then GB 41 and Liver 3 on the left, and LI 4 on the right as a modified “Infinity Treatment) treating chongmai and daimai to target dysfunction and constriction in the pelvic
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region and lower heater. I do SP 4 and GB 41 on the same side as hip pain and dysfunction to target the hip area. !
Lu 7: I needle Lu 7 to open renmai at the exact textbook location, off the trajectory of the rest of the Lung regular meridian, dragging away from the elbow with my non-needling hand until I see the skin and subcutaneous fascia tug all the way to Lu 5 or even Lu 4-3. I needle slowly into the dense area as for Sp 4, and this will invariably create a rather strong and spreading de Qi sensation in the area or even up the channel toward the elbow. When I want to needle Lu 7 as the Luo point for carpal tunnel area thumb and palm pain and numbness, I use Travell’s trigger point location for the flexor pollucis longus, a good inch proximal to the level of textbook Lu 7, this time along the Lu pathway, tugging the same way. Even though the needle is inserted up the channel, this point will cause a deep spreading muscle sensation down to the thumb and palm, and even make the thumb twitch—identical to what one would want when treating the Luo of the Lung for palm and thumb pain. I needle the paired Kid 6 at the textbook location, slowly and carefully insinuating the needle between the tendons to 1/8” or so, and stimulate for a very slight de Qi response;
!
SI 3: As a yang meridian point, I needle for a stronger but tolerable de Qi response, inserting the needle almost !” across the interosseus muscles of the palm toward LI 4. I stimulate BL 62, about 1/8” into the exact textbook location between the two tendons, for a very slight de Qi response.
!
The next set of Root points, this time from the regular meridians to target the Ying level, will usually consist of the source point for whatever leg Yin meridian in the circuit in question: when treating the Taiyin-Yangming circuit, this will be SP 3 or Sp 6 as a common alternate; For the Shaoyin-Taiyang circuit, Kid 3; and for the Jueyin-Shaoyang circuit, Liv 3. This is classic needling of the source point for the yin meridians of the foot. I have learned in thirty years of leading and supervising students as they engage in acupuncture clinical practice treating student-patients for 200 hours over two years, to establish treatment protocols that begin this way, with distal leg ying level points to avoid an overly strong reaction with release of heat or yang rising upward. If I have not already needled Sp 6, I usually add it after Kid 3 or Liv 3. I needle Kid 3 either side, as there are two kidneys/adrenals, Sp 6 always on the right and Liv 3 always on the left, opposite their respective organs. When I needle source points, I insert the
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needle very slowly after tapping in with tube held firmly as above, into the dense resistance. For Kid 3 this will be very shallow, about 1/8”. I use one finger f my left hand after removing the tube to gently tug the skin and subcutaneous fascia I any direction just to make the skin where the needle is inserted taut like a drum but not enough to pull the needle toward my finger. I then needle slowly into the resistance, less than 1/8” for SP 6 and Kid 3, and "”
to almost
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for Liv 3, which I find reacts more like a Yang meridian
point. That said I see Liv 3 as a great point for Liver excess and am not in the habit of treating Liv 8 for Liv deficiency, as the meridian therapy practitioners like Shudo Denmei do. They advocate a very shallow insertion for Liv 8. When I am treating yin deficiency, I prefer Sp 6. At Sp 6, I insert very very slowly into the resistance barely encountered at first at the point, and after hesitating a few second, pull the needle quickly to the surface, then reinsert extremely slowly and with a very heavy needling hand rooted to the area, edge of palm planted firmly on the patient’s lower medial shin and invariably notice the resistance becoming more pronounced, and more dense even though still very shallow. Once that occurs, I needle staying at that depth rapidly until there is a pleasant mild de Qi sensation spreading around the area.
Tips for Needling the Wei Level This level of disorder is termed Wei Level by Chamfrault and Van Nghi, and denotes disorders of repetitive strain, physical trauma, injury, and Wind/Cold/Damp Bi syndromes affecting muscles, tendons and ligaments and bones. In Acupuncture Physical Medicine, this level of physical medicine practice is reinforced by a comprehensive study of Travell and Simon’s two-volume tome, Myofascial Pain & Dysfunction: The Trigger Point Manual. In my book, A New American Acupuncture: Acupuncture Osteopathy I argue that by including Travell and Simon’s entire approach to palpation and needle release of trigger points into the acupuncture study of the tendinomuscular meridians (also known as muscle channels in English), the knowledge of how to palpate for, identify and needle muscle ashi points is significantly enhanced, with the side benefit of affording the
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practitioner a more western medical way of discussing such disorders with patients, their caregivers and other medical professionals. I refer the reader to that text, where I list the main trigger points for each of the three zones of the body –the Taiyang dorsal, Shaoyang lateral, and Yangming venral zones. I give basic classical Chinese acupuncture protocols for distal points that then use Travell’s trigger points as the local equivalent of tender Ashi points. Any serious effort to train in a comprehensive treatment of the muscle channels, however, must include the treatment table-side use of Travell and Simon’s two volumes as ready reference to facilitate clinical use, and internalization, of these trigger points, what they feel like, how to trap them, how to needle and release them, in order that this knowledge might become second nature. Again Maciocia shows his bias against (and deep ignorance about) the comprehensive treatment of muscle channels, which any practitioner of East Asian bodywork including tui na, anma and shiatsu would excel at. After listing the main local points per body area, in his final chapter of the aforementioned text, on bi syndrome, including sports and repetitive strain injuries, Maciocia makes this telling statement: “Ah Shi points (points which are tender on pressure, are also local points and form an important part of the acupuncture treatment of Painful Obstruction Syndrome. In most cases, these will coincide with normal channel points, but if other points are tender on pressure they can be needled in addition to normal points (Ibid, p. 656).” He then proceeds to only list “normal local points” over ashi points, except for one ah shi point he labels the “epicondyle” point one cun behind L.I. 11, Quchi, which appears to be identical to Travell’s ring finger extensor attachment trigger point. If he were trained in trigger points, and how to palpate cross fiber to identify the most tender ones (as shi points), he would know hundreds of such local points, all of which would prove incredibly effective in clinical practice on such conditions. The normal acupuncture points he does list for the muscle channel treatment of the elbow, shoulder and knee are standardized points that appear in the simplest modern TCM discussion of bi syndrome, and fall far short of what I would expect an expert in acupuncture as a hands-on, physical medicine to know. Concluding his ambitious effort at presenting a detailed English-language text on the secondary
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vessels in this way, especially when including the major texts by Drs. Yitian Ni, Andre Chamfrault and Nguyen Van Nghi in his bibliography and further reading list, does a great disservice to those native English students and practitioners who had hooped to find this a useful clinical text. As it is, regarding the clinical use of muscle channels for pain musculoskeletal pain and bi syndrome disorders, Maciocia’s text offers nothing new, and misleads the reader with images of the muscles in each muscle channel, without ever indicating one should learn how to identify the trigger points in these muscles so laboriously presented by Travell and Simons. At the Tri-State College of Acupuncture, students study the myology of trigger points and gain clinical facility in utilizing these invaluable texts in a myology course in Year I, after their study of anatomy, that prepares them for Acupuncture Clinical Practice with me and my team in the second year as they engage in two semesters using AOM protocols that frequently incorporate Travell and Simon’s trigger points into the practice. Student clinic-interns routinely resort to these Travell inspired APM treatment strategies when confronted with simple to complex, chronic pain disorders including athletic and performance injuries, repetitive strain and cumulative trauma disorders, as well as chronic pain disorders stemming from the full gamut of musculoskeletal disease. These sorts of complaints comprise a good 50-55% of the conditions treated in the college’s busy community acupuncture and pain clinics, as well as in the practice of its faculty. In APM, this myofascial pain knowledge base, and trigger point dry needling techniques are therefore clinically necessary over half the time. Once again Maciocia’s The Channels of Acupuncture reveals a decided bias against the muscle channels (jing jin). As Maciocia states in the preface to Part 4 on these channels, “The Muscle channels are not as important and as clinically relevant as the Connecting channels. However, in the fields of musculoskeletal problems and of Painful Obstruction (Bi ) Syndrome, they are extremely important (p. 283).” If musculoskeletal problems and Bi syndrome disorders make up over 50% of an acupuncturist’s practice, how could one ever make such a statement? Unless, of course, ones practice is predominantly comprised of internal medical disorders,
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which would appear to be the case in the North American practice of TCM. A look at the key TCM texts will show only very short sections on painful obstruction/Bi syndrome, and the muscle channels are seriously downplayed in the Englishlanguage literature. In my experience over the past thirty years, I have encountered TCM students and TCM practitioners trained in North America at other AOM colleges who appear to have little if any knowledge of the muscle channels or skills in palpating and treating tender/ashi points—the central focus of muscle channel treatment. Students report seeing virtually no NCCAOM board examination questions on bi syndrome for example, with the preponderance of cases focused on ZangFu internal medical conditions. Perhaps it is time the NCCAOM initiate a survey to ascertain what acupuncturists really treat, which we did do at the college twice over the past several years, and twice in faculty practices. Each time we learned that these disorders occupy over 50% of what our clinics, and the clinics of our faculty, treat. Another curious piece of evidence to suggest that knowledge of, and acupuncture skills in treating muscle channel disorders is not part of every AOM college’s entry level curriculum, is that the majority of ACAOM candidate or accredited postgraduate doctoral programs in AOM have pain management as a specialization area, indicating that they see this as a more rarified, specialized area, not a basic entry level set of knowledge and skills all practitioners should have. Acupuncture Physical Medicine treatment of these wei level tendino-muscular meridians is straightforward for the distal points: use excess reactive points distal to the area of pain and dysfunction, based on the principle, “the further the farther”. The jing-well point is therefore always indicated as the point furthest from the symptomatic area, and then moving up the channel, based on the needling strategy of “Bao Ci” where one needles one ashi or tender point after another along the muscle pathway based on palpation, one disperses with lifting- thrusting-twirling technique focused on the outward lifting motion to propagate Qi along the muscle pathway. If the luo point is tender, and especially if its target area is within the area of the patient’s pain and dysfunction, this is an excellent distal point as well. For local points, APM integrates Travell and Simon’s myofascial and tendon attachment trigger points. Any practitioner serious about learning how to use these
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trigger points to supplement their knowledge of treatment of ashi points can readily use their two volume “trigger-point manual” tableside and open-book, to guide careful cross-fiber palpation. One can then either needle wei level oblique shallor OVER these trigger points, a classic Chinese acupuncture technique, or for deep muscle pain especially when aggravated by Cold, needle slowly into the belly of the muscle until there is deep de Qi, or use sparrow pecking technique after this last technique and after de Qi has been achieved. To do this, with the non-needling hand straddle the point and apply a slight amount of pressure inward, but mainly apply pressure laterally away from the point to slightly compress the underlying fascia, keep the contours of the muscle clearly demarcated, and stretch the tissue to make a more taut, rather than bunched up, surface. Then withdraw the needle to the skin level, and begin to peck with a fast in, slightly slower out motion, repeatedly with a slight hesitation of a bit less than a second on the out after 3-5 pecks, so: FAST in-inin (in-in), a bit SLOWER out and hesitate almost a second/ resume pecking like a sparrow, now for gains a bit to the left or right or above or below for more grains, FAST in-in-in (in-in), a bit SLOWER out and hesitate almost a second, and resume. This usually causes twitching/fasciculation of the muscle underneath the fascia being needled, even without piercing the muscle. If the muscle is slow to release in this fashion, go in slowly again as in the beginning, and get de Qi, then peck slower, fanning out in the 4 directions more deliberately (this is how trigger point injections are done and are described in great detail in Travell and Simon’s manuals) until the muscle twitches. At that point one can usually withdraw while pecking back to the surface, pecking at the superficial fascia just over the muscle in question. Dry needling of trigger points in most approaches just uses thicker longer acupuncture needles, about 32 gauge and 1.5-2” long, so as to be able to approximate Travell and Simon’s trigger point injection technique. One can also take trigger point dry needling courses with MyoPain Seminars, which descended from the Travell Seminar series and is still co-directed by Travell’s protégé /colleague, Dr. Robert Gerwin. In this seminar, open to licensed acupuncturists and medical professionals with the authority to perform dry needling in their respective states, participants learn how to locate, identify and perform dry needling on the main trigger points using acupuncture needles as above. The Tri-State College of Acupuncture which I founded also occasionally runs a summer seminar series in APM dry needling which is advertised on the college’s website for CEU courses at www.tsca.edu.
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Tips on Needling the Three Yang Zones/ Cutaneous Regions When focusing on needling of the chronic myofascial holding patterns in the three Yang Zones, as outlined in the previous chapter, one can bring to bear any number of classical and modern acupuncture techniques and strategies: 1] wei level or trigger point dry needling as covered in the previous chapter; classical Chinese and modern TCM bi-syndrome techniques outlined by Dr. Ni in her discussion of tendino-muscular meridian treatment ( Navigating the Channels, pp. 9-10), especially:“Bao Ci” for muscle bi syndrome that can affect a large area with pains moving around (Taiyang scapula pains at times, at other times Taiyang low back and buttocks pain, and at yet other times Taiyang hamstring and calf pain in a dancer for example); “Fu ci” (the standard shallow, oblique wei level technique where the needle tip ends up over the affected ashi/trigger points, but not into the muscle trigger point itself and: “He Gu Ci” for a deep muscle bi pain disorder, with one needle inserted perpendicularly into the belly of the ashi muscle point/center of the trigger point itself, with two other needles inserted obliquely, wei level over the tendon attachment (what Travell and Simons refer to as Attachment Trigger Points or ATrPs), either angled toward the perpendicular needle, or away from it depending on sources. When there is involvement of inflamed tendons or ligaments, or bone (osteoarthritis), I prefer to use a modified “Duan Ci” technique where one starts the needle shallow and perpendicular, at the yang, wei level. Then one inserts the needle slowly to a deep level until very close to the tendon, ligament or bone involved. Repeat this a few times until a deep de Qi sensation is obtained, and then stay at the depth where this is felt, and apply very short and slow lift-thrust manipulations until the sensation propagates deep into the tendon, ligament or bone. In the PRC, this technique would actually needle into the structure involved to cause bleeding, which would be considered a surgical intervention in North America and must be avoided due to risk of deep and serious infection. 2] stationary or moving cupping; guasha; 3] heating techniques like moxibustion (direct or on the top of the needle or indirect); hot packs, heat lamps; mylar applied over the treated area (which just floats on the needles and generates tremendous heat when the skin is bare);
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4] Electro-stimulation without or applied to needles; 5] Deep sustained acupressure techniques from anma, tui na or shiatsu (ischemic compression in Travell and Simons) to ashi/trigger points followed by slow release (strain/counterstrain);
On Andrew Nugent-Head Yin Style Ba Gua Tangible Qi Needling Techniques While I feel I have come to be able to teach students how to do quite a decent job with needling, over the past three decades, I am in fact mainly self-taught. The faculty from the Quebec Institute, and even Van Nghi, who treated me a few times so I can experience this, made little of needling, stance, posture, as so many TCM practitioners I have met. Luckily, Andrew Nugent-Head, founder of the Association for Traditional Studies, has come forward after almost 25 years experience training in classical, Yin Style Ba Gua that includes self-cultivation Daoin practices (8 healing sounds, point and meridian rubbing and patting, and Qi Gong) with acupuncture training, and that stresses the ability to do repeatable strong techniques that get predictable results, with a strong focus in ashi point needling and hand techniques. Andrew has contracted with then college to run CEU training for alumni, and will teach students in the MS/Ac Program one day each of the Spring Intensive over the 3 years. Andrew has also agreed to offer his comprehensive training in acupuncture, focusing on ashi point treatment as well as a classical set of yinyang regulatory points, as the core of the Advanced Post-Masters course in Acupuncture in Orthopedic and Trauma Disorders, which will become one of the majors a student in the eventual Doctor of Acupuncture Program could select. I strongly recommend that all second and third year students watch the introductory free video presentations by Andrew Nugent-Head on his website, for a view of his approach to training in hand techniques, and the tangible Qi lectures which give a good, and very sophisticated sense of his approach to training. I am honored, and humbled by someone with this level of skills and experience, and will
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be right alongside other TSCA faculty and graduates when he teaches at the college, starting this October 2011.
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CONCLUSION AND BEGINNING APM CONCEPTS AND KATASDOWN TO BASICS
A. KEY THEORETICAL CONCEPTS OF APM ACUPUNCTURE Bodymind Energetics GROUP 1 !
Bodily-Felt Sense (Felt-Sense)
!
Recollection of Being
!
Bodymind Continuum (Side of the Psyche/Side of the Soma)
GROUP 2 !
Classical Western Psychosomatic Concepts and Selye’s Stress Theory (body language; conversion stream; somatic compliance; organ inferiority; vegetative neurosis/visceral agitation; stress response and coping; fight or flight (sympathetic dominance); rest and digest (parasympathetic dominance)
GROUP 3 !
Groddeck’s “the IT”;
!
The Will to Get Well;
!
Salutogenic vs. Pathogenic
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Acupuncture Imaging GROUP 4 !
Acupuncture Reframing/Imaging
GROUP 5 !
Wei (Surface) Energetics
!
Ying (Functional) Energetics
!
Jing (Core) Energetics
A New American Acupuncture: Acupuncture Osteopathy GROUP 6 !
Strain-Counterstrain
!
Myofascial Release
!
Somato-visceral/ Viscero-somatic
GROUP 7 !
Bi-lingual communication of tender points --i.e., Ashi points near SI 9-14(Chinese Acupuncture); Teres major, teres minor, supraspinatus, infraspinatus TrPs
!
(Travell and Simon’s Myofascial Trigger Point Theory)
Acupuncture Physical Medicine GROUP 8 !
Adrenal Syndrome/Chronic Fatigue Syndrome
!
Four Patterns of Fatigue
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GROUP 9 !
Repetitive Strain
!
Mu-Point Boogey
!
Visceral Agitation/Organs in an Uproar
APM Acupuncture: A Guide to Clinical Practice GROUP 10 !
Jingluo/Lingshu Acupuncture
!
YinYang regulation
!
Thorns, Stains, Knots, Obstructions
GROUP 11 !
Calm Mind-and-Heart
!
Neo-Confucian Learning of the Mind-and-Heart
!
The Great Learning and Self-Cultivation
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B. KATAS OF APM CLINICAL PRACTICE In discussing the Logic of Year II APM Acupuncture Clinical Practice sessions, Peter Dubitsky, MS, LAc, Director of Clinical Training and I landed on the martial arts concept of “katas” or forms in Japanese Karate which fit perfectly for what we were aiming to accomplish in this year, to ready students for the real world of community clinic at the end of the year. In katas, one usually practices alone, and the katas are meant to enable one to internalize, or embody a set of offensive and defensive moves directed against from one to several adversaries. Once one has internalized these forms or sets of movements, once one ‘embodies’ them, they serve as a repertory from which one can draw automatically in the real world of combat or competition or self-defense, once they have been mastered, because one has done these moves before. The late Donald Schon stressed, in his theory of Reflective Practice in the professions, that experts are those who have internalized, embodied, made tacit a large number of possible moves, so that they can react in what looks like an intuitive way to the complexities of real-world problems they face, because they have encountered and practiced responses to similar situations many times already. He stressed the need for students in any profession to recognize this need to move beyond book learning and logical thinking, to the tacit dimension (Polanyi) of automatic response based on this deep, embodied learning, just like one learns to drive a car, or ride a bike and it becomes second nature. The following 16 katas, or sets of moves or prototype treatments have proven sufficient to enable clinic interns at the college to adapt to most clinical situations they encounter in the summer community clinic at the end of Year II, with the support of a team, and access to clinical supervisors. While summer clinic requires that students stay very close to these sets of moves, it will be expected that by the end of their training, this internalized, embodied repertory of possible APM Acupuncture moves will be able to be accessed in a much more fluid and free-form
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way that allows for integration with the other main styles learned at the college, to make for ones own unique approach to acupuncture clinical practice. As you approach the study for, and practice of these 16 APM katas, do so with your deep commitment to internalizing them, and you will have a powerful set of clinical moves to enable you to navigate the channels as Dr. Ni would say.
SESSION ONE--INTRODUCTION: YINYANG REGULATORY AND PATIENT COMPLAINT TREATMENT IN APM/CCA This KATA is a reflective one: reflect on basic APM Acupuncture JIngluo Pattern Differentation as depicted below and come ready to work in small groups to discuss and arrive at treatments for cases. This presentation and sequencing for APM Acupuncture Jingluo pattern differentiation and treatment is based, following the Classical Chinese Acupuncture approach laid out in the LingShu and followed by Felix Mann and Yitian Ni, on the 12 regular meridians and their circuit systems. One starts first in APM Acupuncture pattern differentiation by ascertaining which circuit/system is involved: Shaoyin/Taoyang, Jueyin/Shaoyang or Taiyin/Yangming. One recognizes and appreciates that each circuit begins in the Upper Heater (Heart, Pericardium, Lung) where tian , the Heavenly principle and coherence in all things fuses as Qi/Breath with Blood which comes from the Earth, from what one eats and drinks. This fusion of Qi and Blood flows from the Heart and upper heater to the brain and to the torso and extremities and back again. Wherever Blood moves, shen is present as the intelligence of existence and deep wisdom we are born with, which knows how to affirm and choose life. Modern discoveries that the brain and the rest of the organism communicate via neuropeptides might be talking about the same thing, and if so, it is known that the reptilian, oldest part of the brain is where the bodymind attempts to keep on an even keel: responding to emergencies for sure, but most of the time in service of auto-regulation and
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homeostasis. As one reads about Confucian and Neo-Confucian Learning of the Mind-and-Heart in this book, it becomes possible to posit that what the ancients meant by saying one must hold the needle as if holding a tiger by the tail over a great abyss, with a calm mind-and-heart refers to attaining ‘the equilibrium before feelings are aroused’ through ones own self-cultivation, so as to be able to prod such auto-regulation and YinYang regulation in those we treat. In selecting a circuit, a group of two yin and two yang meridians that connect lower and upper, right and left, yin and yang, one is selecting a regular meridian system with great potential to create positive change. Once the system has been chosen, one determines whether to intervene at the level of the regular meridians/circuit, the tendinomuscular meridians/secondary vessels, the extraordinary vessels, or whether one needs to address the entire zone and its paired circuit. It is at this last level of intervention , treating the zone that has become chronically obstructed, and its paired yin meridians to make the circuit, with the option to also treat the related extraordinary vessel pair that I now speak in a much more focused manner about treating at the level of ying (regular meridians), wei (secondary vessels, especially tendinomuscular) and jing (extraordinary vessels). This re-conceptualization required grouping of APM Acupuncture Katas into the three JInguo Systems first: then providing prototype treatments for: the circuit; the tendinomuscular merdians; the related pattern of fatigue/stress/visceral agitation; ending with the zone and addressing at least two out of three levels (wei for sure, and Ying and/or jing for yinyang regulation). In this way it should be more readily understood how to move from location of a disorder in one of the three major regular meridian systems (circuits) to selection of a tendinomuscular meridian and then the extraordinary vessels and finally a zone. One has four basic options within each of the three regular meridian systems (circuits), and all of this can be endlessly tweaked to meet the real problems we encounter in service to our patients as follows: 1. Circuit Treatment for acute and chronic visceral dysfunction and symptoms of visceral disease (See Circuit Chart);
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2. Tendinomuscular (and luo) Meridian treatment of acute myofascial pain syndrome, localized dysfunction of muscles, tendons, ligaments, joint problems (muscle, tendon, bone bi syndromes); and acute flare-ups or symptomatic relief in chronic pain and dysfunction (see WEI level of Master APM Jinguo System Chart); 3. Exraordinary Vessel Treatment for the Four Phases of Stress/Fatigue/Visceral Agitation (*)for chronic/complex disorders where the adrenals and stress are a major component: ( the CNS via dumai, the ANS via the Three Heaters and Local Triple Heater Regulatory treatment (Mu- Point Boogey: spinal irritation; diaphragmatic constriction; pelvic collapse; cardiac alarm) using Chongmai on the front as Sea of Meridians, Sea of ZangFu, Sea of Blood; and Shu-Point Boogey treating Dumai and Foot Taiyang with Support of Kidneys for Taiyang Zone and autonomic nervous system regulation through the Back Shu-Points/spinal irritation); 4. Zone Treatment for complex and chronic neuromusculoskeletal disorders with preponderant stress and visceral agitation: treating all three levels, WEI, YING, JING; *Note that detailed treatments for some common functional patient complaints using the 4 patterns of fatigue/visceral agitation can be found in Acupuncture Physical Medicine in Chapter VIII, pages 97-130.
KATA 1: SHAOYIN/TAIYANG CIRCUIT DYSFUNCTION (REGULAR MERIDIANS) Anxiety, fatigue, pain in chest, upper and lower back, mood swings, restlessness, scattered thinking. •
Pain in one or more areas of the back
•
Anxiety, nervousness, sadness
•
All shen disturbances
•
Poor mental assimilation, mood changes, insecurity, over-enthusiasm
•
Physical and mental fatigue
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TREATMENT: Yin Yang Regulation: Kid 3/Bl 58 (source/luo) –tonify source; disperse luo points Kid 2 and 3 (ying and shu)-tonify shu; disperse ying/fire if indicated HT 7(source)-tonify HT 7 and 8 (ying and shu)-tonify shu; disperse yin/fire if indicated Distal: See circuit chart for comprehensive point palette
Treatment of Patient Complaint: Dr. Ni: Any local point may be used to treat signs and symptoms in the area of that point. This is especially relevant for viscero-somatic symptoms of pain (tong ) disorders that are not myofascial/musculoskeletal. Local: Kid 16 bilateral-disperse for Kid yang excess/adrenal up-regulation; tonify for KID/adrenal exhaustion Kid 22-27 where tender (disperse to propagate, not to fasciculate) for non-cardiac chest pain, tightness and emotional disorders; CV 17 (MU for Heart Protector, meeting area of yin arm muscle channels to open chest)-disperse to propagate down, to right, to left to open chest, leaving down in 4 th stimulation HT 1(for information only: advanced, for serious blockage, can provoke big panic/releases)-disperse BL 67-40 for lower extremity pain BL 54-22 for low back and buttocks pain BL 21-13 for paraspinal pain BL 10 for occipital pain BL 2-7 for frontal forehead pain SI 18 and BL 1-2 for sinus pain SI 16-17 for neck pain
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SI 9-14 for rotatator cuff area shoulder pain Distal: SI 1-8 for ulnar forearm and upper extremity pain BL 67-40 for lower extremity pain HT 9-3 for ulnar forearm pain Kid 1-10 for lower extremity pain
KATA 2: SHAOYIN OR TAIYANG TM MERIDIAN EXCESS (NOTE: For local ashi/trigger points, see appropriate wei level TrPs in master APM Acupuncture Jingluo System Chart and Travell and Simons). SHAOYIN: •
KIDNEY: myofascial pain and dysfunction in the inner foot muscles; soleus; adductor longus; rectus abdominus; pectoralis major sternal division (KID 22-25). HEART: Myofascial pain and dysfunction in the forearm flexors(TrPs near PER 4-5 and below HT 3); pectoralis minor.
TAIYANG •
BLADDER: myofascial pain and dysfunction in the lateral foot muscles; flexor hallucis longus (BL 59 area); lateral gastrocnemius (BL 58.5); Soleus (BL 57 area); gluteus maximus, medius, minimus (posterior aspect); QL; paraspinals; lower and middle trapezius; upper trapezius dorsal aspect; occipitalis; frontalis. SMALL INTESTINE: edge of palm muscles; forearm flexor carpi ulnaris; long head of the triceps; teres major and minor; infra- and supraspinatus; posterior SCM; posterior scalenes; zygomaticus.
TREATMENT Distal:
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Jing well points: HT 9, SI 1, Kid 1, BL 67; tender ashi/ trigger points near HT 8-3, SI 1-8, Kid 2-10, BL 66-40 Local: See Wei level Taiyang Zone from Master APM Jingluo Systems Chart and Travell and Simons for local ashi and trigger points. Note that in addressing the HT TM meridian, one should check PER and LU TM meridians as well for areas affected, and that all three arm yin TM meridians converge on the chest and hypochondriac regions and affect the yin aspect of the upper extremities. When treating Kid TM meridian one should likewise check SP and LIV TM meridians, and that all three yin leg TM meridians converge on the pubic region, and affect the yin aspect of the lower extremities and inner thigh. For the SI TM meridian always also check TH and LI TM meridians, and for the BL TM meridian, always check the GB and ST TM meridians.
KATA 3: “SPINAL IRRITATION”/ ADRENAL SYNDROME - TAIYANG EXCESS/ DU MAI EXCESS/ KIDNEY/HEART DYSFUNCTION Anxiety/Stress/Chronic Fatigue (excess phase)/ Insomnia. •
Type-A
•
Insomnia
•
Pain in one or more areas of the back
•
Fibromylgia
•
High Blood pressure
•
Adrenal sydrome/up-regulated Pre-class assignments/readings:
APM, pp. 101-108 Perform APM Assessment for this Pattern. TREATMENT: Yin Yang Regulation:
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Jing: SI3/BL62 Dumai/Yangchiaomai (For fibromyalgia with exquisite tenderness at ashi points, use local yangchiaomai points as local points, shallow wei-level technique so as not to irritate; many cases of so-called fibromyalgia are myofascial pain syndrome and benefit well from myofascial release of trigger points.) Ying: BL 58/ Kid 3 (luo/source); BL 23 and BL 52; BL 14 and BL 43 (For chronic fatigue with insomnia, heart palpitations, anxiety, overall stress; one can always add Shu points for Zang, namely BL 14-43 for upper heater, BL 18, 20, for middle heater as well, especially with gastric symptomatology. Treatment of Patient Complaint: Wei: Distal BL 59 and SI 8 1 ⁄ 2 if spinal irritation is accompanied by TTPs in occipital neck, upper back, rotator cuff region (SI 9-14; BL 10-11); Distal BL 58 1 ⁄ 2 to fasciculate to release lumbar region in low back pain; note: BL 58 is a ying level point as well as a distal wei level point, and serves to release the paraspinal musculature in general but I have found it best to needle to fasciculate for best affect. Local TrPs in areas of pain (typically lower and upper back; or lower back and neck); palpate as trigger points. Needle shallow wei-level to start. Go back to most reactive TrPs and palpate (index and middle fingers straddle the point and palpate by pressing straight down so as not to tug on needle and cause sharp pain). If still tender, proceed with trigger point dry needling technique to make point fasciculate. See above explanation of trigger point technique, which will be carefully demonstrated. Do trigger point dry needling technique with supervisor present.
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KATA 4: TAIYANG ZONE DYSFUNCTION Chronic myofascial pain and dysfunction in multiple areas of BL and /or SI TM meridians with visceral agitation, stress (HT and/or Kid) and/ or preponderant emotional component. •
Chronic myofascial pain and dysfunction in multiple upper and mid-back areas with anxiety, panic, emotional ups and downs where pain is not sufficiently alleviated by psychiatric, psychological, psychotherapeutic or mind-body therapies or medications and/or has eclipsed the emotional signs and symptoms
•
Chronic myofascial pain in lower back, gluteals, hamstrings, soleus, heel aggravated by stress and/or with fatigue and lack of drive
A] TAIYANG ZONE UPPER BACK PAIN •
Upper Back Pain
•
Upper extremity pain
•
Stenosis, DDD, DJD of the spine
•
Fibromyalgia
•
Neurological dysfunction Pre-class Assignment/Readings:
APM, pp. 122-126; MP&D, Vol I, chapters 21-25; Acu Handbook, Perform APM Myofascial Assessment. TREATMENT: YinYang regulation(Jing/Ying): Lu 7/Kid 6; SI3/Bl 62; Kid 2 and 3; Bl 58 (luo point); Bl 23 and/or 52 Treatment of Patient Complaint(Wei) Level:
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Distal: Bl 59 (upper back); SI 8 1 ⁄ 2 and SI 10(rotator cuff and upper back) Local Trigger Points: Infraspinatus; teres major and minor; supraspinatus (SI 9-14); Thoracic paraspinals; trapezius (lower, middle, upper). Wherever there are palpable trigger points, you should attempt APM trigger point technique on the most reactive trigger points. Start distal and move up to the main pain area(s). This is “surrounding the Dragon’s tail”. You finish with the most reactive trigger points that you palpated first—TO REVALIDATE THE PATIENT’ EXPERIENCE OF ILLNESS AND COMPLETE THE ACUPUNCTURE REFRAMING/IMAGING. (I often remark “we’re almost done; I save the best for last”. When the trigger points release I always use reassuring positive comments: “that’s great; that really released well; I think we got that one” to underscore the focus on myofascial release. Then I remind them how to care for the post-treatment soreness and what activities to avoid. REFRAMING (validating a person’s experience of illness and instilling hope that the condition can be changed through release of the holding pattern) AND EDUCATION (what is going on during treatment, what will happen after, what to expect over the course of a series of 3-4 treatments) ARE CRUCIAL PARTS OF APM. The final part is to ENGAGE THE PATIENT’s WILL TO HEAL by encouraging them to focus on those things they will do when their condition improves. The possibility of CHANGE FOR THE BETTER is the message. ) Note: In Fibromyalgia, be careful with local tender points; if mere palpation is exquisitely tender, limit these points to points on yangchiaomai, or most tender spots and do wei level technique; you can remove local needles, inserted after distal treatment, as soon as they are all in, or leave 5 minutes or so—never longer than 10 minutes and check in with patient. This same approach is true of all tender/trigger points on STRONG REACTORS. If time permits you may practice this simple, shallow needle treatment for fibromyalgia.
B] TAIYANG ZONE LOW BACK, BUTTOCKS, HAMSTRING, CALF AND HEEL PAIN •
Low back pain
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•
Sciatica/piriformis syndrome
•
QL spasm
•
Stenosis, DDD, DJD
•
Lower extremity pain
•
Calf pain
•
Heel pain
•
Neurological dysfunction PRE-CLASS ASSIGNMENT/READINGS:
MP&D, Vol 2, Chapters 3-10; Acu Handbook, pp. 205-215; pp. 175-183 Perform APM Myofascial Assessment
TREATMENT: YinYang Regulation (Jing/Ying): SI 3/Bl 62: Kid 3 and Bl 58(source/luo); Bl 23 Bilateral; Bl 18 on right, Bl 20 on left—all as Shu Points (Triple Heater Regulatory-one could always add any Shu points or even Aggressive Energy Treatment when treating Taiyang Zone). Treatment of Patient Complaint/Wei Level: Distal: Bl 58 1 ⁄ 2 APM trigger point technique to fasciculate (middle of outer head of gastrocnemius longitudinally and laterally, with mild compression with left hand after trigger point has been located with snapping palpation) for QL TrPs/Spasm/ Bl 40. Needle all reactive trigger points APM fasciculation style, or TCM into belly and/or surrounding in the following muscles. Where the peerpatient has no trigger points in one of these muscles, practice my version of wei level shallow (but rooted) needling:
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Quadratus lumborum Iliocostalis Paraspinals Gluteus Medius Gluteus Minimus Posterior Aspect Gluteus Maximus Piriformis Hamstrings Soleus Guadratus plantae Note that TCM would focus on Bl 23(gentle twirling while inserting up to 1” being careful to stay in muscle-muscle will often fasciculate: needle can then be removed, or left in situ shallow); Bl 54 and GB 30, strong lifting thrusting twirling with 3” needle, or simple lifting/thrusting with slight rotation of needle. _______________________________________________________________________ Note: In radiculopathy with spinal stenosis, herniated or bulging discs, arthritis, degenerative disc and degenerative joint disease, if inflammation is acute/severe, needles local to area of symptoms might be like hot pokers; in such cases do wei level technique—No fasciculations. Patient must be doing some sort of physical therapy/rehab to strengthen and stretch compromised areas of compression and acupuncture is adjunct to this permanent maintenance program that patient must be encouraged to continue. AOM Hit Medicine, including tui-na and qi gong, herbal linaments and wraps, internal herbal formulas and an exercise regimen are also indicated. Patient should not receive acupuncture the same day as physical therapy, chiropractic or other potentially inflammatory treatments. Patients often report significant relief of discomfort and symptoms with 7-10 minutes icing on the spinal levels involved, two to three times daily, which can be followed by moist heat/hotpack. In stenosis, huatuojiajia (multifidi) points often help but must be needled slowly (no twirling) lifting and re-thrusting a few times until pressure and some deqi develops. There will often be one or two small jumps. Avoid creating hot poker sensations. NOTE: in the presence of radiculopathy if any needling at multifidi level or along nerve pathways provoke poker-like hot reactions stop the local needling and stay distal or treat analogous areas or opposite side; consider referring patient to KM
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style where local non-needling treatment like diode chains and rings, magnets etcetera may be tried. In the presence of recalcitrant problems, and especially if there is muscular weakness and atrophy involved refer the patient to her or his PCP to see about consulting with a neurologist for EMG and other nerve conduction studies to rule out serious radicular or other nerve entrapments or neuromuscular disease (wei syndrome). Also consider referring the patient to a senior AOM herbal practitioner if patient refuses or receives little or no benefit from biomedical treatment.
C] TAIYANG ZONE NECK PAIN •
Headache (tension)
•
Neck pain
•
Stenosis, DDD, DJD
•
Upper back pain
•
Fibromyalgia
•
Anxiety/stress
•
Neurological dysfunction Pre-Class Assignment/Readings:
MP&D, Vol I, chapters 5,6,16,19; Acu Handbook, pp. 303-313 Perform APM Myofascial Assessment TREATMENT: YinYang Regulation (Jing/Ying): SI 3/BL 62; Kid 3 and/or 2; Ht 7; Bl 14 and/or Bl43 (versus 15); Bl 23and/ or 52 as Shu points. Treatment of Patient Complaint/Wei Level: Start with strong lifting/thrusting/twirling of Bl 59 and APM trigger point pecking to fasciculation of SI 8 1 ⁄ 2. SI 3 may be re-stimulated to disperse within patient’s de qi tolerance, best done with slight lifting thrusting and rapid twirling Proceed as in previous ACP sessions attempting APM fasciculation technique into palpable trigger points as per peer-patient’s de qi tolerance. You may also practice
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TCM into belly and/or surrounding ashi points. Use wei level technique to areas where trigger points are not present, in the following: Lower, Middle, Upper Trapezius; Levator Scapula; trapezius attachments 1 cun above BL 10-GB 20; all tender neck points. Go back to most tender trigger points if you were not able to make them release and attempt trigger point dry needling to fasciculate, especially at GB 21 and levator scapula with supervisor present. Note that levator scapula and trapezius and other deep cervicals can be released with one needle, most easily done face up as per Dr. Roberta Shapiro’s recommendation. You may remove all Taiyang zone needles, have peer-patient turn over and do this one point face up. Note: Same as for lower Taiyang zone regarding radiculopathy due to spinal stenosis/inflammation and need for rehab/maintenance/Daoyin program on ongoing basis.
KATA 5: JUEYIN/SHAOYANG CIRCUIT DYSFUNCTION (REGULAR MERIDIANS) Fullness, distention, pain of hypochondriac region, chest and throat, back pain spreading to pelvis, pain along inner calf and thigh, emotional disorders, pain in side of lower and upper extremities; side of ribcage and chest; shoulder pain, lateral neck pain; migraines; dizziness, depression, anger, irritability, hypochondria. JUEYIN !
Hypochondriac pain, fullness, distention;
!
GERD and IBS signs and symptoms like heartburn, chest and throat pain and tightness (‘plum-pit Qi’)
!
Lumbar pain spreading to pelvic region and scrotum; inguinal hernia pain
!
Spasms and tightness of joints and muscles
!
Mood swings, anger, depression, frustration
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!
Thyroid disorders
!
Migraines
!
Mania, ‘hysteria’, chest and lung disorders
!
TMJ-like pain and dysfunction
!
Dizziness
!
Tinnitus
TREATMENT: YinYang Regulatory: LIV 3/GB 37 (source/luo)-tonify source/disperse luo LIV 2 and 3 (ying ands shu)-tonify shu, disperse ying/fire if indicated PER 7(source)-tonify PER 7 and 8 (ying and shu)-tonify shu, disperse ying/fire
Treatment of Patient Complaint: Dr. Ni: Any local point may be used to treat signs and symptoms in the area of that point. This is especially relevant for viscero-somatic symptoms of pain (tong ) disorders that are not myofascial/musculoskeletal. Local: LIV 14-PER 1 for hypochondriac region and chest pain, anxiety, emotional disorders LIV 11-13 for abdominal pain GB 1-2 and TH 23-24 for migraines and TMJ-like pain GB 21 and TH 15 for shouder pain and tension headaches GB 22 and CV 17 (mu of PER) for chest pain GB 26-28 for inguinal and inner thigh pain TH 14-15 for shoulder pain Distal: LIV 1-8 for lower extremity pain LIV 9 for inner thigh pain PER 9-3 for medial yin aspect forearm pain
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GB 44-34 for lower extremity pain TH 1-10 for forearm and upper extremity pain
KATA 6: JUEYIN OR SHAOYANG TM MERIDIAN DYSFUNCTION (NOTE: For local ashi/trigger points, see appropriate wei level TrPs in master APM Acupuncture Jingluo System Chart and Travell and Simons). JUEYIN LIVER: Myofascial pain and dysfunction in the inner soleus; gluteus medius and sartorius; ilacus; rectus abdominus: in the pelvic region level with CV 2-3, in the abdominal region level with CV 10-11; in the upper external obliques near GB 24 and LIV 14; PERICARDIUM: in the lateral pectoralis major (near PER 1-2); in the sternalis area near CV 17-18; in the inner yin forearm flexors and hand muscles near PER 8.
SHAOYANG GALLBLADDER: peroneals; vastus lateralis; ITB; TFL; piriformis; lower external obliques; psoas; longitudinal aspect of latissimus dorsi; serratus anterior; anterior upper trapezius; suboccipital muscles; temporalis. TRIPLE HEATER: Myofascial pain and dysfunction in the ring finger extensor: short head of the triceps; medial deltoid; supraspinatus; posterior SCM; posterior scalenes; temporalis; TREATMENT Distal: Jing well points: PER 1, LIV 1, TH 1, GB 44; tender local ashi, trigger points aloing these tendinomuscular meridian pathways. Local: See Wei level Shaoyang Zone from Master APM Jingluo Systems Chart and Travell and Simons for local ashi and trigger points. Note that in addressing the PER
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TM meridian, one should check HT and LU TM meridians as well for areas affected, and that all three arm yin TM meridians converge on the chest and hypochondriac regions and affect the yin aspect of the upper extremities. When treating LIV TM meridian one should likewise check SP and KID TM meridians, and that all three yin leg TM meridians converge on the pubic region, and affect the yin aspect of the lower extremities and inner thigh. For the TH TM meridian always also check SI and LI TM meridians, and for the GB TM meridian, always check the BL and ST TM meridians.
KATA 7: ‘PELVIC COLLAPSE’: CHONG/ DAI / REN MAI DYSHARMONY NOTE: a revised version of this treatment can be done in the Taiyin/Yangming system relying on local points from the four meridians in that circuit for relief/release of manifestations instead. •
Abdominal Pain in pelvic region
•
Amenorrhea
•
Dysmenorrhea
•
Infertility
•
Irregular menstruation/menopausal-hormonal changes
•
Hernias, non-cancerous ovarian cysts, fibroid symptoms
•
Chronic prostatitis, cystitis, vaginitis Pre-class assignment/ Readings:
APM, pp. 112-114 Perform APM assessment for this pattern. TREATMENT: YinYang Regulation: Jing: Sp. 4/Per 6; GB 41/TH 5 Jing: Sp. 6 (shallow insertion heavy on the in until subtle resistance is felt; stay at that level and with weighted hand, twirl until a deep spreading sensation locally), Sp. 8, Sp 10 (for dysmenorrhea) with strong TCM dispersal (may propagate up to pelvic region); Liver 3 and 5; Liv 9
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Treatment of Patient Complaint: St 30-29 where tender, gentle stimulation, for amenorrhea; strong stimulation for dysmennorhea; GB 26 shallow, down toward GB 2728, twirling to propagate once kori is touched or mild deqi elicited (note these local ying points are also jing points as they are local chong and dai mai); tender ren mai points like CV 2-3 , 6-7 may be added as well and needled with heavy on the in and weighted hand to propagate down the channel or penetrate internally
KATA 8: ‘CARDIAC ALARM’/ UPPER HEATER DYSFUNCTION NOTE: a revised version of this treatment can be done in the Taiyin/Yangming system relying on local points from the four meridians in that circuit for relief/release of manifestations instead.
•
Asthma/breathing difficulties/dyspnea/hyperventilation syndrome/palpitations
•
Bronchitis/COPD
•
Anxiety/panic attack/stuck in stress reactivity affecting Lung and Heart functions
•
Chronic fatigue (Garden variety or CFIDS) Pre-class Assignment/ Readings:
APM, pp. 115-120 Perform APM Assessment TREATMENT: YinYang Regulation: Jing: Sp 4, Per 6 (panic attacks, anxiety, agitation) for Jueyin/Shaoyang System OR
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Lu 7/Kid 6 (hyperventilation syndrome, stress related breathing difficulties) for Taiyin/Yangming System Ying: Per 7, 6, 4-5, Liv 3, GB 38 for Jueyin/Shaoyang System; OR Lung 9 or LU 5, LI 4, SP 3 or 5 for Taiyin/Yangming System Treatment of Patient Complaint: CV 18 and CV 17, Per 1, Liv 14, Kid 22-27 for Jueyin/Shaoyang panic disorder, anxiety, agitation; OR Lu 1-Sp 20, St. 14-16, for Taiyin/Yangming dysfunction, where tender, for symptoms of stress related asthma, difficulty breathing, hyperventilation syndrome, poanic, anxiety, agitation
Additional Taiyin/Yangming and Shaoyin/Taiyang Circuit Points TAIYIN/YANGMING Lu 3-4(Window to Sky point for breathing difficulties and palpitations) Lu 5(dispersal point) for bronchitis, COPD, emphysema, lung congestion in general LI 4 (with Lu 7) to relieve exterior and for facial congestion for allergies/sinusitis/rhinitis SHAOYIN/TAIYANG
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Heart 7 and ear shen men for anxiety and panic attacks, with Kid 27; add Kid 15 1 ⁄ 216 where tender for Chronic fatigue or CFIDS or as lower heater regulatory for upper/lower heater distress/dysfunction Can turn patient over and do short treatment of Bladder meridian Shu points, Bl. 13, 14, 17, 18 and 23
KATA 9: SHAOYANG ZONE DYSFUNCTION A] LOWER SHAOYANG ZONE DYSFUNCTION •
Hip pain/lower Extremity Pain
•
Arthritis, bursitis, DJD of the hip
•
Sciatica
•
Neurological dysfunction Pre-class Assignment/Readings:
APM, pp. 126-127; MP&D, Vol II, chapters 9,14, 20 and 49; Acu Handbook, pp. 185-203; pp. 163-174 TREATMENT YinYang Regulation (Jing/Ying): GB 41/Sp 4(same side as hip complaint); Per 6 opposite Sp. 4; Liver 3 alone or with Liv 2- one side or bilateral; LI 4,contralateral to Liv 3 or bilateral. Treatment of Patient Complaint/Wei Level: Distal: Rework GB 41 and Sp 4 to strong de qi (per patient’s de qi tolerance level) if necessary. GB 41 should spread throughout lateral dorsal aspect of foot; Sp 4 can be done with modified stuck needle into kori, to propagate 4” or more along SP pathway upwards, ideally to inner calf, even inner thigh and pelvic region. Local (lateral lower extremities): Peroneus Longus, Brevis and Tertius Trigger Points: Iliotibial Band and Vastus Lateralis Trigger Points:
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Needle reactive distal yang meridian points with TCM strong dispersal technique until qi propagates downwards several inches into tender points near GB 34, 37-39, 31 and GB 32 or APM trigger point technique to fasciculate into those muscles’ trigger points (ITB/GB 31 must be done TCM style and should travel up and down thigh) Local (Hip): TFL; ITB (can be local if that is one of the pain areas of the hip region, or distal for the hip itself); Anterior Gluteus Minimus; Lower External Oblique; For Bursitis pain—surround most painful spot identified by patient over the bursa, and needle 4 needles equi-distant in a circle, shallow oblique toward the painful area without touching the painful area. Attempt APM trigger point technique to fasciculate wherever trigger points are present within peer-patient’s de qi tolerance; or do GB 29, 30 and 31 side-lying TCM strong dispersal technique, if problem was only on one side. _______________________________________________________________________ Note: Patients who begin to limp or have difficulty tying their shoes or pulling knee back to chest or rotating knee inward without pain should be referred back to the PCP for orthopedic evaluation for hip disease (labral tear, degenerative arthritis of hip). While acupuncture can help release the concomitant myofascial trigger points in such structural disease, the underlying structural irritation/degeneration will tend to perpetuate return of the trigger points as part of a muscular guarding or splinting. The more severe the tear or arthritic degeneration, the more rapid the trigger points will return, making local acupuncture too inflammatory and counter productive. Any form of physical therapy or manipulations to the region that the patient is receiving from other practitioners may have the same negative effect. Acupuncture is excellent pre- and post surgery for hip disease, to keep muscles released pre-surgery, to lossen up muscles and scars 4-6 weeks post-surgery (once surgeon OKs local myofascial release).
B] UPPER SHAOYANG ZONE DYSFUNCTION/ HEAD AND NECK PAIN/HEADACHE •
Headache
•
Neck pain
•
Facial pain (TMJ)
•
Upper back pain
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•
Repetitive strain injury
•
Anxiety/stress
•
High blood pressure
•
Neurological dysfunction
•
Tinnitus/vertigo Pre-class Assignment/Readings:
MP&D, Vol I, chapters 21 and 7. Perform APM Myofascial Assessment TREATMENT Distal: YinYang Regulation (Jing/Ying) Level: GB 41/TH 5 contralateral; Liver 3 and LI 4 contralateral opposite to GB 41/TH5; “Triple Intestine” ring finger extensor TCM dispersing stimulation; Liver 14 and/or GB 24; CV 6 and CV 10. Treatment of Patient Complaint(Wei/Ying): Local: TH 15-supraspinatus GB 21 Upper Trapezius TH 16-posterior SCM TCM and TrP techniques (tinnitus) ‘Taiyang’ point TCM technique) _______________________________________________________________________ Note: Other Local Points for Headache can be added to this treatment: GB 20 and 21, Temporalis TTPs level with GB 8, GV 20, Yintang; with strong stimulation first of LI 4. If a patient is having a headache or on the brink of one, local stimulation should be gentle either wei level technique or perform rapid medium amplitude with strong dispersal, within deqi tolerance, of distal points. Patients experiencing headaches or chest pain for the first time or out of character for them must be referred to their PCP to rule out a serious visceral cause of their disease.
KATA 10: TAIYIN/YANGMING CIRCUIT DYSFUNCTION (REGULAR MERIDIANS)
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Pain in throat, teeth, face, breast, flank, palms, shins; upper respiratory tract congestion; shortness of breath; gastric pain and distress; urinary dysfunction; mental confusion, mania, depression, obsessive thoughts. TAIYIN: •
Dry sore throat
•
Vertigo
•
Wind-cold S&S
•
Whole body, lower abdomen and extremities heavy
•
Shortness of breath, chest irritability, chest fullness
•
Gastric pain and dysfunction
•
Pain and stiffness along meridians YANG MING:
•
Toothache, facial pain, nasal and sinus congestion and pain
•
Perspires easily
•
Whole body cold, shivering
•
Chest and flank pain
•
Abdominal pain and dysfunction
•
Distention
•
Pain in lower abdomen
•
Mental confusion, stubbornness, rigid thinking, mania, depression, suicidal ideation
TREATMENT YinYang Regulation: SP 3/ST 40 (source/luo)-tonify source/disperse luo SP 2 and 3(ying and shu)-disperse ying if approprtiate, tonify shu LU 9 (source) – tonify LU 9 and10 (ying and shu)-tonify source, disperse shu if appropriate ST 36-39 and SP 6 transformation and transportation, all intestinal dysfunctions Treatment of Patient Complaint:
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Dr. Ni: Any local point may be used to treat signs and symptoms in the area of that point. This is especially relevant for viscero-somatic symptoms of pain (tong ) disorders that are not myofascial/musculoskeletal. Local: LI 18 throat pain ST 5-7 TMJ pain ST 2-3 lower sinus pain, facial pain LI 20 and ST 2 nasal congestion LU 1-2 and SP 20 Shortness of breath, chest irritability ST 18-13 Breast pain, heartburn, reflux ST 18 (with ST 44) xu-li ST 25-24, SP 15 GI distress, abdominal pain ST 26-30 Lower abdominal pain ST 13-16 mental and emotional disorders (with ST 40 for mania, obsessiveness, mental agitation)
KATA 11: TAIYIN OR YANGMING TENDINOMUSCULAR MERIDIAN DYSFUNCTION (NOTE: For local ashi/trigger points, see appropriate wei level TrPs in master APM Acupuncture Jingluo System Chart and Travell and Simons). TAIYIN: Myofascial pain and dysfunction in the flexor pollucis longus; forearm flexors; brachioradialis; biceps; brachialis; pectoralis major clavicular; inner soleus; vastus medialis, lower external oblique. YANGMING: Myofascial pain and dysfunction in the foot muscles on dorsum of the foot; tibialis anterior and extensor digitorum longus; rectus femoris; rectus abdominus; pectoralis major sternal division; SCM and anterior scalenes; masseter; frontalis.
TREATMENT
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Distal: Jing well points: SP 1, LU 11, ST 45, LI 1; LI 4/LIV 3 (four gates); distal tender points along the muscle channel Local: Tender local ashi, trigger points along these tendinomuscular meridian pathways. See Wei level Yangming Zone from Master APM Jingluo Systems Chart and Travell and Simons for local ashi and trigger points. Note that in addressing the LU TM meridian, one should check HT and PER TM meridians as well for areas affected, and that all three arm yin TM meridians converge on the chest and hypochondriac regions and affect the yin aspect of the upper extremities. When treating the SP TM meridian one should likewise check LIV and KID TM meridians, and that all three yin leg TM meridians converge on the pubic region, and affect the yin aspect of the lower extremities and inner thigh. For the LI TM meridian always also check SI and TH TM meridians, and for the ST TM meridian, always check the BL and GB TM meridians.
KATA 12: ‘DIAPHRAGMATIC CONSTRICTION’/CHONG MAI MIDDLE HEATER BRANCH DYSFUNCTION/ STOMACH/SPLEEN (INVADED BY LIVER) NOTE: One will also encounter Taiyin-Yangming System chronic disorders presenting as ‘Pelvic Collapse’ or ‘Cardiac Alarm’ where one would open jing level with ren and yinchiaomai at LU7 and Kid 6: and perform three leg Yin treatment of the lower heater for ‘pelvic collapse’; or triple heater regulatory treatment for Kidney-Lung disharmony in ‘cardiac alarm’. Conversely one might encounter a case of diaphragmatic constriction in the Jueyin/Shaoyang System and focus on local reactive points from LIV and GB regular meridians and MU points.
•
Abdominal Pain and discomfort in hypochondriac region/RUQ abdominal pain
")(
•
Constipation
•
Diarrhea
•
IBS
•
Anxiety/stress
•
Chronic fatigue
•
Anger issues with gastric distress Pre-class assignment/readings:
APM, pp. 109-112 Perform APM assessment for this pattern. TREATMENT: YinYang Regulation: Jing: Sp 4/Per 6 (chong mai/yinweimai) Ying: Liv 3, LI4; CV 10-13; Liv 14 right for constrained Liver Qi; St. 36, 37, 39; Sp. 6 Re-stimulate St 36-39: ideally there should be stomach noises resulting; Treatment of Patient Complaint: St 44-43 for reflux, nervous stomach, where tender, with strong TCM dispersal (bring down St. Fire); Local: CV 12, 6, 4 where tender; ST 25-24 where tender; Kid 15-16 where tender (for Stomach-Spleen dysfunction due to Liver Invading). (St Fire “Mu” points): rectus abdominus from ST 29-ST 19 level: needle shallow transverse toward midline with gentle thrusting into kori until needle gets stuck; then apply stuck needle technique with needling hand only, or compress rectus to bunch muscle up against linea alba and look for mild de qi response; once de qi is obtained, twirl into the direction that resulted in de qi, slightly downward and transverse. Propagation will often span several inches, and sometimes a trigger point release will occur if lifting/thrusting dominated over twirling, resulting potentially in a big snapping release. This occurs most readily at attachments over ribs, at and above St 19 level
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(commonly constrained in reflux patients) especially on the left; for xu-li needle St 18 on the left if it is much more tender than on the right/ especially if this releases heat in chest/neck/face (may release a lot of heat; needle as mu points, over rib oblique; be ready to restimulate St 44). NOTE: Patients with xu-li are often very tight in their chest and neck muscles and this treatment might begin to release Stomach Heat and Liver wind (benign neurological fasciculations). First the teeth will be clenched tight as they try to stop their teeth from chattering. They need to relax their jaw, which you can encourage by gently holding ST 5-6 area and asking them to relax into your fingers. Then whole body shaking may begin to occur, and possibly also a flush over their chest, neck and even face (ST Heat release). If this begins, stop needling but DO NOT REMOVE NEEDLES. Call over a supervisor while one team member has patient-peer breath abdominally, to begin to relax. When the supervisor arrives commence with Focusing, having peer-patient relax into their bodily-felt sense. Ask patient to feel where the emotional agitation is located, and to describe what that feels like (aloud or just to oneself). Once they have a HANDLE on where and what the sensation FEELS LIKE IN THEIR BODY, ask if they can remove this sensation from that location, by putting it “on a shelf” a few feet away, or better yet by placing it quite a distance away, “on a boat”, “in a building”, somewhere that it can be safely CONTAINED. Then ask if they feel they want to continue with the treatment, by lying there with mylar for 10 minutes or so, explaining that the shaking they are experiencing is a release and OK as long as they are OK with going through it, and that the release might get stronger, causing the mylar to “rattle”. If appropriate, I often muse that this is a mini “exorcism” and ask if they have seen the movie, in a humorous and upbeat voice. I stress that I have seen these releases before and that they will be fine. I also clarify that the needles can be slowly removed, but that this might make the release more agitated and might not be the best treatment. Either way reassure the peer-patient that one of you will remain during the whole time until needles are out and they are feeling fine. People who react like this once may be
#++
prone to any time a volatile area in their holding pattern is tapped into, or just if they are more tense than usual. If there is a big emotional event(s) behind this volatility, these emotional issues may resurface and the person might need to review these issues with a psychotherapist before continuing with more acupuncture or other forms of bodywork. The constant release of nonverbal CONTENT might have to be verbalized in a Talk Therapy before it is safe for the person to keep releasing somatically. Psychotherapists are also trained to look for and recognize signs of serious psychological deterioration, including suicidal ideation. It is extremely important not to take on such patients as a new practitioner. Refer them out to practitioners who have known experience in this area. NOTE: French Medical Acupuncture texts and Yitian Ni’s Navigating the Channels warn that xu-li pain can be a precursor to heart conditions. Any patient with new signs of heartburn or chest discomfort who is not under the care of a physician for these symptoms should be referred back to their PCP. Patients with reflux, heartburn and IBS need to learn what foods to avoid and reflux patients might do well raising the head of their bed 6” to avoid acid backup at night while sleeping.
KATA 13: YANG MING ZONE DYSFUNCTION A] YANGMING FACIAL AND JAW REGION PAIN •
Facial pain (TMJ, bruxism)
•
Headache (Atypical)
•
Neck pain
•
Anxiety/stress Pre-class Assignment/Readings:
MP&D, Vol I, chapters 42 and 8. Perform APM Myofascial Assessment TREATMENT YinYang Regulation (Jing/Ying):
#+*
Sp 4/Per 6; GB 41/TH 5 Infinity Treatment; Liver 3/LI4-Four Gates; St 25 and CV 10—12 where tight; Treatment of Patient Complaint (Wei Level): Distal: St 37 (“fullness of upper region”) strong TCM dispersal; Local: Subclavius trigger point (St. 13); needled obliquely toward shoulder with tip of needle angled at clavicle into kori; then stuck needle technique with one hand focusing on fascial tug with heel of hand and needle; or slow small pecking toward clavicle until sensation propagates toward shoulder, into shoulder blade, into the back or neck. When releasing needle, ensure it is positioned OVER the clavicle, or pull shallow oblique; St 12, gentle insertion into kori over bone, then stuck needle fascial tugging technique-- sensation will often spread to upper chest region (platsyma TrP referral) When releasing needle, be sure it is positioned OVER clavicle, not underneath it, or pull shallow oblique; SCM trigger points where tender at level of LI 18 or higher (to avoid brachial plexus which would cause electric shock sensation propagating far); needle shallow wei level,oblique; go back and attempt most tender points with APM trigger point release to fasciculate with supervisor present; or needle LI 18 slowly twirling gently into belly of SCM Masseter trigger points near St 5 and St 6; TCM first, slowly into belly of muscle technique first, followed by APM trigger point release to fasciculate if reactive; St 7 TCM dispersal technique as per CAM (some practitioners would just do this local point strongly until propagating qi spreads throughout jaw and neck). NOTE: this same treatment may add TH 3 and 5, strong stimulation and TH 16, 17 and anmian TCM technique to propagate toward ear and GB8 area (temporalis trigger points), for tinnitus. NOTE: If patient has popping or grinding when you feel inside their ear with your little finger as they open/close jaw, this might be sign of serious dental malocclusion or serious TMJ disease or dysfunction. Patient should be referred to their dentist for evaluation/referral to TMJ dental specialist.
#+"
B] YANGMING CHEST AND ABDOMINAL PAIN •
Same treatment as above except add trigger point release of sternal division of pectoralis major near ST 13-18;
•
LU1-SP 20 area clavicular division of pectoralis major and TrP of pectoralis minor;
•
Rectus abdominus and psoas.
C] YANGMING THIGH AND LOWER LEG PAIN •
Same treatment as above except add trigger point release of rectus femoris, tibialis anterior and extensor digitorum longus.
KATA 14: APM /TCM INTEGRATED TREATMENT OF SINUSES & ALLERGIES •
Chronic sinus discomfort, pain, sinus headache
•
Upper respiratory allergies (to pollen, grass, hayfever, animals, molds etcetera) Pre-class Assignment/Readings:
APM, pp. 119-120. Perform APM Assessment TREATMENT YinYang Regulation (Jing/Ying): Kid 6/Lu 7; LI 4; Sp 5; St 36; Sp. 6; CV 4 and 6; CV 12; Lu 1-2; Kid 15.5, Kid 27 Symtpomatic/Wei Level: Bl. 2, special location/needle technique (gently gather up frontalis muscle without creating a vertical wrinkle and place tube firmly, as skin here is oily and slippery, into frontalis muscle at the middle of the eyebrow (NEVER needle underneath the eyebrow or bruising might well occur). DO NOT PINCH with left hand, just keep frontalis muscle gathered away from bone. Tap in firmly, remove tube without letting go of non-needling hand, and without pinching frontalis muscle, slide
#+#
blue handled #3 Serein 1” needle one half the way, 1 ⁄ 2”, into the muscle and let go of both hands. St. 2, special location/needle technique (pull down cheek muscle firmly with non-needling hand. Place tube at tender point well below textbook St 2 angled downward. Remove tube and hold handle of blue #3 Serein needle against eyebrow, being careful to avoid the needle at Bl 2 if already needled. With a firm grasp on the needle and pushing slightly into cheek muscle, let go rapidly with non-needling hand WITHOUT budging with needling hand, which stays against eyebrow/bone. The needle will be inserted by the rapid elastic snapback of the cheek muscle and fascia. LI 20 (strong TCM de qi stimulation like “Afrin up nose/tearing”); Scalp point on GV line for face/head (Zhu)=Du 24
KATA 15: APM/TCM INTEGRATED TENDINOMUSCULAR MERIDIAN TREATMENT OF JOINT PAIN (ONE TO THREE TM MERIDIANS PER PAIN AREA OR TRIGGER POINT REFERRAL PATTERN OR JOINT PROBLEMS) •
Pain and discomfort
•
Anxiety/stress
•
Myofascial pain syndrome, arthritis pain, rheumatic pain, tendonitis, etcetera
•
Chronic fatigue with muscle pain
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Fibromyalgia Pre-class Assignment/Readings:
Dr. Ni on tendinomuscular meridian needling. Use Reaves open book for areas of TM meridian dysfunction. Perform APM Myofascial Assessment. TREATMENT: Distal: 4 gates strong stim; strong “big” yang distal points per area; jing-well points; luo points if their pain target area is involved Local:
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Ashi and trigger points, wei-level stimulation or APM fasciculation technique per patient’s deqi tolerance; or TCM Bi syndrome needling techniques (straight into ashi pt , or add surrounding [above, below, to right and left, angled at 45 degrees toward ashi point, all wei level) SEE WHITFIELD REAVES FOR DETAILED JOINT TREATMENTS
A] APM/TCM TREATMENT FOR KNEE PAIN AND DYSFUNCTION:
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Myofascial Pain Syndromes
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Arthritis of the knee, DJD
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Tendon-Ligament Strains/ Sprains;
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Tendonitis
•
Lower Extremity (knee) pain Pre-class Assignment/ Readings:
MP&D, Vol II, chapter 14; Acu Handbook, pp. 121-174 Perform APM Myofascial Assessment TREATMENT YinYang Regulation (Ying): Sp. 6, Liver 3, LI4; Distal: ST, 36, GB 34, Liver 7, Sp 9, where tender - dispersal technique (St 36 can be tibialis anterior TrP and GB 34, peroneus longus TrP with APM trigger point release technique); LI 11 (elbow for knee) strong dispersal, or actual elbow area tender points that “match” location of knee points- dispersal TCM technique; Wei Level/Local: Vastus medialis TrP (near Sp 10); APM trigger point release if reactive; Or TCM technique in to belly and/or surrounding; Vastus Lateralis TrP (near GB 32); same technique as for vastus medialis); add GB 31 TCM strong dispersal for iliotibial band if tight; GB 33 if lateral ligament problems or if tender, oblique into kori over bone; Eyes of knees, with knees on big bolster to open up the eyes, at an angle up and in with two needle tips almost converging – twirl in
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slowly until spreading de qi sensation; continue stimulation as per patient’s de qi tolerance by just twirling rapidly once needle has elicited de qi response, without lifting and thrusting; sensation should spread under patella; Extra Point at top center of kneecap (heding), for patellar tendon; needle into kori and twirl rapidly with minor lifting or thrusting; sensation should spread under patella;
Note: Patients with primary fatigue and muscle pain should have been checked for low thyroid. Their pain may disappear totally when low thyroid is treated with medication, naturopathy or TCM herbology. Patients with primary anxiety/stress who come for musculoskeletal release may react emotionally to any release and treatment should proceed cautiously so as not to agitate patient further. True fibromyalgia patients may not tolerate strong needling, especially locally, and shallow oblique wei level needling should be done first, adding stronger stimulation to de qi tolerance. B] APM/TCM TENDINO-MUSCULAR MERIDIAN TREATMENT OF ELBOW, WRIST, ANKLE REGIONS
Students will perform myofascial assessment, and treatment of common foot, hand and elbow pain for muscle, tendon and bone-bi syndromes following Whitefield Reave’s protocols for sport’s injuries. Pre-class Assignment/Readings:
Acu Handbook, pp. 75-99 (FOOT PAIN); pp. 217-226 (HAND PAIN/Carpal Tunnel Syndrome); pp. 227-247 (ELBOW PAIN).
KATA 16: YANGMING/TAIYIN DYSFUNCTION (BI and WEI SYNROME (RSI; TOS; RADICULOPATHY) •
Myofascial and neurological neck pain, numbness, discomfort
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Thoracic outlet syndrome-like pain
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Repetitive strain injury
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Cervical radiculopathy
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Frontal headache
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•
Atypical facial pain
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Trigeminal neuralgia-like pain Pre-class Assignment/ Readings:
APM, pp. 128-130; MP&D, Vol I, chapters 7, 28, 29, 34 and 42. Acu Handbook, pp. 217-226 Perform APM Myofascial Assessment TREATMENT YinYang Regulation (Ying): 4 Gates (Liv 3/LI 4); ST. 25 to ground Upper heater points; Treatment of Patient Complaint(Wei): Distal: St 37 and/or St38 where tender, strong dispersal technique; LI 10 area, strong dispersal technique; LI 2& 4 dispersal TCM technique; Lu 7 (luo of Lung for carpal tunnel, wrist and palm symptoms) AS FLEXOR POLLICUS LONGUS TRIGGER POINT—slow into tender point until mild de qi reponse; then careful pecking APM trigger point release technique. Local: Brachioradialis(Lu 3-4 area) MP&D, chapter 34; Coracobrachialis MP&D, chapter 29; Anterior deltoid MP&D, chapter 28; Clavicular aspect of pectoralis major (Lu 1-Sp 20) MP&D, chapter 42; Subclavius (St. 13 slowly into muscle after moving the trigger point onto the clavicle and needling it at the clavicle, NEVER UNDER THE CLAVICLE—then pull back to surface and leave shallow and ensure that it is not sucking back into the muscle; SCM (near LI 18) MP&D, chapter 7; APM trigger point release technique to fasciculate on any reactive trigger points according to peer-patient’s de qi tolerance level; or TCM into belly and/or surrounding; or wei level shallow but rooted technique. NOTE: in the presence of radiculopathy the same cautions as for spinal stenosis above pertain, and if any needling at multifidi level or along nerve pathways
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provokes poker-like hot reactions stop the local needling and stay distal or treat analogous areas or opposite side; consider referring patient to KM style where local non-needling treatment like diode chains and rings, magnets etcetera may be tried. In the presence of recalcitrant problems, and especially if there is muscular weakness and atrophy involved refer the patient to her or his PCP to see about consulting with a neurologist for EMG and other nerve conduction studies to rule out serious radicular or other nerve entrapments or neuromuscular disease (wei syndrome). Also consider referring the patient to a senior AOM herbal practitioner if patient refuses or receives little or no benefit from biomedical treatment.
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C. APM ACUPUNCTURE CLINICAL READINESS/PREPARATION FOR PRACTICE
Students versed in the above 17 KATAS, who have passed the Year II final APM oral practical are ready to practice APM Style in a team in the community clinics, and wirth focused practice in the final clinical year, will be in a position to encoiunter the 10,000 things with APM Style when they graduate, as well as integrate that style with other AOM, CAM and mainstream treatments for best patient-centered care. !
Chronic visceral agitation (stress and functional disorders of the viscera and symptomatic relief of visceral disease)—see Four Patterns of Stress, Visceral Agitation, Fatigue Chart;
!
Regular Meridian/Circuit dysfunction(other ZangFu disorders and functional complaints and symptomatic relief of visceral disease) – See Circuit Chart;
!
Acute, or single muscle, or joint musculoskeletal disorders of the tendinomuscuar meridians(muscle channels) integrating in Travell’s myofascial physical examination and needling release strategies—See Travell for muscle and tendo attachment trigger points;
!
Zone patterns (with chronic neuro-muscular symptoms and associated circuit symptoms of the paired Zang)—see Zone chart in the back of Acupuncture Physical Medicine and as revised in this book.
Based on differentiation into one of these four meridan sub-systems (extraordinary vessels; regular meridians; tendino-muscular merdians; cutaneous regions) one can focus on the point selections and treatment stretgeies and techniques approporiate to that sub-system, and the comprehensive Zone/Circuit protocol allows one to ‘image’ and perform treatment at all three levels addressing all three sets of complaints in the same treatment plan/series of treatments. Once these katas have been internalized, and techniques have been honed, and with a commitment to lifelong learning from ones patients, an APM practitioner can shape and transform these kata endlessly to meet the actual contingencies of the clinical situation as it unfolds. By establishing a franmewor of wei, ying ans jing level
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treatment options, for such complex and chrionic disorders, one could recommend and perform or refer out for other AOM ways of treating a level or levels, and also integrate in other CAM or mainstream medical care as follows: WEI LEVEL OPTIONS APM tendino-muscular and zone treatment AOM Bodywork (Anma, Tuina, Shiatsu) TCM Muscle, Tendon, Ligament, Bone Bi AcupunctureTreatments TCM External and Internal Herbal treatment Yin Style Ba Gua Acupuncture for Orthopedics and Rehabilitation Medicine KM Treatment of structural dysfunction and pain Cupping, Guasha, Moxibustion Daoyin practice of physical self-cultivation Yoga Western Bodywork Physical and Occupational Therapy Osteopathy Chiropractic Rolfing Feldenkrais Homeopathy Mind-body and bodymind therapies Biomedical Treatment including surgery Other YING LEVEL OPTIONS APM circuit and patterns of fatigue treatment TCM Acupuncture TCM Herbal Medicine Japanese Kampo Yin Style Ba Gua Internal Medicine Treatment KM Treatment of constitution, Organs, patient functional complaints 5 Element Acupuncture AOM dietary treatment CAM and western nutritional treatment Nutraceutical treatment
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Homeopathy Mind-body and bodymind therapies Daoyin practice of physical and mental self-cultivation Yoga meditation, breathwork, mental self-cultivation Biomedical Treatment including surgery
JING LEVEL
APM Acupuncture (ying and jing stratgeies) KM Acupuncture 5 Element Acupuncture Qi Gong/Daoyin Cultivation of the Mind-and-Heart Yoga Cutlivation of Mind and Heart Mind-body and bodymind therapies Western counseling, psychotherapy Psychiatry
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APPENDICES: 1. Etiology and Pathology in APM 2. APM Physical Assessment
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1. Etiology and Pathology in APM Yin tends toward deficiency/ yang tends toward excess:
This fundamental principle of APM style treatment, based on Shudo Denmei’s understanding of this etiological phenomenon from an acupuncture perspective, suggests that organ functions weaken, become deficient in their ability to work optimally, over time. All things being equal, APM presumes that every person has an underlying zangfu target area that would weaken over time merely due to the effects of aging, perhaps serving as the final cause of death in someone who “dies of old age”. Target zangfu functions can become disrupted much earlier than aging would have exacted its toll, due to trauma (physical or emotional), unabated stress (from physical overwork to emotional overload), or excessive or debilitating lifestyle issues (dietary, sleep, use of alcohol, drugs, nicotine, caring for sick loved ones, etcetera). While acupuncture can help with the effects of a disabling lifestyle, people in such situations often need some other sort of counseling, from psychotherapy to dietary therapy to legal counsel, which are beyond the scope of the following discussion. Based on the understanding that yin tends toward deficiency means that zangfu functions become dysfunctional over time or due to the above etiological factors, and that these yin functions are root imbalances, APM root treatment consists in determining which set of zangfu functions are deficient (read: dysfunctional). APM also posits that yang tends toward excess means that the meridians, and especially the yang tendinomuscular and cutaneous regions, become constricted and constrained over time or due to the above etiological factors, and that any person who presents with a root zangfu imbalance may also at the same time have a blockage in the tendinomuscular meridians or one of the three yang zones, namely Taiyang, Shaoyang or Yangming. The symptomatic tendinomuscular meridian(s) or zone will often explain the pain and discomfort that brings the patient in for acupuncture treatment, and release of this myofascial holding pattern will resolve their complaint, especially in musculoskeletal pain complaints. Patients with primarily root, zangfu disorders without pain as a primary complaint may have a visceral holding pattern in one or more of the three heaters which can be discovered upon palpation, and release of this visceral holding pattern will aid in the overall root treatment, as well as provide often significant relief from
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associated symptoms (gas pains, distention, dyspnea, PMS symptoms, nasal congestion, etcetera). The somatic contriction found on palpation of reactive mu or shu points, or hara findings, may entail congestion at the surface stemming from underlying visceral agitation/irritation: overactive organ functions (visceral agitation/organ neurosis). Rather than attempt myofascial release in such cases, APM applies dispersal at the ying level, with propogating needling deep within to disperse the internal excess. When the surface excess in such cases of visceral distress are so severe as to constitute what Wilhelm Reich termed character armor, where the person becomes a prisoner to a blocked, dysfunctional body that shapes or distorts their overall personality, strong myofascial release may be indicated, a sort of acupuncture Rolfing, but this is a very advanced intervention that can only be undertaken if the patient is ready for such a release, and the practitioner is emotionally up to the challenge. Such a release may entail shaking, crying fits and other emotional outbursts that may well leave patient and practitioner emotionally and physically drained. YinYang Imbalance:
In APM, YinYang Regulation for chronic functional disorders of the zangfu are understood and described from a three heaters perspective. Acute overload, or slow drain of the visceral system from overwork, lack of sleep, or an onslaught of multiple factors may constitute an extreme stressor that provokes an adrenal overload or excess, to use Hans Selye’s theory of the “stress of life”, or even an adrenal collapse. The body’s initial response to such stressors is in the form of spinal irritation, attacking the CNS and leading to constrictions in the yang musculature of the back, especially along the spine, in the trapezius, gluteals and quadratus lumborum. Such a patient will have difficulty falling asleep, until the adrenals collapse, at which point they will work and play hard all day, only to drop into bed without undressing, “dead to the world”. If this spinal, CNS irritation is prolonged, or too severe for the person to withstand, the visceral reaction to these extreme stressors will shift to the three heaters, effecting whichever one is most vulnerable in cases of target zangfu weakness, or following a typical route in many cases from middle heater to lower heater to upper heater, perhaps in a fashion similar to what Selye termed the General Adapation Syndrome (GAS), as follows. When chronic zangfu disorders develop in the middle heater, this will effect the Liver, Spleen and Stomach functions, entailing a diaphragmatic constriction upon
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palpation: the CV line from CV 10-12 will be tight, as will the Kidney and Stomach points from Kid. 17-20 and St. 24-19. This is the middle heater segment of chungmo, from an APM, meridian perspective, and chungmo is the excellent choice for such middle heater constrained qi disorders, at the jing root level (opened with Sp 4 and Per 6). Local points along the middle heater pathway of chungmo might be needled locally as mu points for the middle heater constraint involved, and are found by palpation for tightness and, or, tenderness (mu-point boogey). Ying level treatment would entail distal (ying and shu or based on TCM or five element strategies) points from Liver and Spleen and lower He-Sea points for the digestive functions (St 36, 37, 39), combined with local reactive points near Liver 14 to GB 24 and St 24-25 and CV 10-12. Liver, Spleen and Stomach TCM patterns of disharmony will be found in this case, and etiology could be further explained by detailing the TCM pattern(s) involved. If diaphragmatic constriction occurs over a long enough period of time, or is severe enough, or if a person is predisposed to dysfunction in the lower heater, then this diaphragmatic constriction might lead to Liver invading the Spleen, or Spleen invaded by the Liver, or Stomach heat disrupting the Spleen, each capable of weakening the Spleen’s holding functions leading to pelvic collapse, with congestion in the functions of the lower heater. This will lead to genitourinary and reproductive complaints, often marked by dampness and damp-heat, or deficient yang with cold, from a TCM pattern perspective, affecting the Kidneys, Bladder, and Small Intestine, with constraint in the meridians of daimo, and the lower heater branches of chungmo (Kid 11-16 and St 30-26) and renmo (Cv1-7). When the middle heater constriction generates significant heat, this can rise to the upper heater, disrupting the functions of the Lungs, Heart and Pericardium. Likewise if the lower heater collapse weakens the Kidneys sufficiently, this will disrupt the Kidneys autoregulatory relationship with the Heart, Pericardium or Lungs. In either of these etiological events, the main zangfu patterns will occur in the upper heater, with what APM terms signs and symptoms of cardiac alarm. This will entail problems in the Lung’s functions such as asthma and COPD, functional and organ dysfunctions of the Heart and Pericardium, and emotionally based stress disorders such as hyperventilation syndrome, anxiety disorder and panic attack. In brief, root etiology of chronic visceral dysfunction in APM can be understood and stated in terms of these four primary patterns: spinal irritation, and disorders of one or more of the three heaters: diaphragmatic constriction in the middle heater (Liver, Spleen, Stomach functions); pelvic collapse in the lower heater (Kidney,
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Bladder and Small Intestine); cardiac alarm in the upper heater (Lungs, Heart, Pericardium). The TCM patterns of disharmony in the zangfu functions involved may serve as further etiological elaboration of the pathologies involved from a zangfu perspective, but it is sufficient in an APM assessment to limit ones description to location of constraint in one or more of the three heaters, labeled as diaphragmatic constriction, pelvic collapse or cardiac alarm. The diagnosis (read: localization based on signs and symptoms including heat, cold or tightness and discomfort [constrained qi/stagnant blood] based on manual palpation) would be listed here as a root imbalance. The strategies chosen would be at the ying level, and reinforced if one wishes at the jing level. Mu points selected by palpation might be further described as local reactive points along the meridian pathway involved: hence local points along the Kidney and Stomach pathways from Kid 11 and St 30 to Kid 20 and St 19, namely chungmo; local points along the pelvic aspect of the Spleen and Liver pathways from Sp. 15Sp 21 and Liver 14-GB 24, with constraint at CV 10 and CV 12, for example. Yang tends toward excess:
The yang, excess part of the etiological discussion in APM is articulated at the wei level, in terms of myofascial constrictions (Travell’s trigger points), and/or surface meridian blockages (tendinomuscular and cutaneous region patterns or TCM bi syndromes) with ashi points (kori in Japanese acupuncture). This will be listed on the wei, symptomatic level of an intake form, and points will be selected based on Travell’s trigger point patterns (ie. Infraspinatus selected for its referred pathway to shoulder), or meridian pathways/ bi syndrome location (ie; ashi points and kori from SI 10-11). The symptomatic description (diagnosis/location) at the wei level might be framed as constrained qi in the scapular aspect of SI tendinomuscular meridian from SI 1011, involving the teres minor and infraspinatus muscles. One could go further and give a detailed description of Travell’s trigger point referral patterns, and an etiological discussion based on her understanding of perpetuating factors in such cases, right from Travell’s text; or a classical Chinese description of the meridians involved, such as tm of the small intestine and bladder, citing texts such as Ni’s Navigating the Channels. Inclusion in a case study of diagrams of these referred patterns would be indicated to visually depict the fact that the diagnosis of the holding pattern at the Wei level is an issue of LOCATION. The Presence of Disrupted Shen:
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In APM shen disruption may occur in any of the four patterns of visceral agitation, in any chronic tendinomuscular disorder or any chronic disturbance of a myofascial zone (the cutaneous regions). This is due to the concept that where qi is blocked, shen may be blocked and from the experience in acupuncture where needling of seemingly straightforward reactive points results in a big emotional release, as if the distressful experience were blocked in the taught fascia, which Upledgger terms “somato-emotional release”. Thus treatment at any of the three levels, wei, ying or jing, may also be treatment at the shen level, and care must be taken when awakening such a “tiger’s tail, grasped by the needle as it hangs over the great abyss”(Ling Shu). One must approach such situations mindfully, stopping for a moment to take a deep breath, observe what the patient is exhibiting and the feelings this engenders in you, and proceed, with a supervisor present to help guide you through such complex and emotionally laden terrains. For patients who are engaged in spiritual, transformational work of their own, they might well take treatment at any level as an aid in their spiritual journey. In a student clinic it would be inappropriate for interns to suggest to the patient that they are treating the spiritual level however, for this is a joint collaboration between a practitioner engaged in such a journey, and a patient already thus engaged, or ready to make such a commitment. This work would be outside the scope of interns in community clinical situations. It is appropriate to suggest that acupuncture might calm the spirit, relax the nervous system and dissipate the stress response and reactivity a patient might be stuck in. Also, by clearing blockages of Qi and Blood, the overall status of body, mind and spirit is improved.
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2] APM PHYSICAL ASSESSMENT APM Pain and Dysfunction History in Line with Travell: Preliminary Review of Records: (review patient’s initial intake form and any
materials provided by patient before the interview) " chronology
of life events and medical history, either before the first visit or at
that first visit, including medical events and a list of current and recent medications and supplements, including any that did not work or caused side effects; " The
psychosocial history data should include dates and places of residence,
education, marriages or other significant relationships, children, sports and other physical activities (with any repetitive physical activities carefully assessed such as computer or blackberry use, the playing of musical instruments, and sustained postures at work or play), travel and employment, leisure activities, hobbies, how they relieve stress, use of tobacco, recreational drugs, problems with weight, body image, age-related issues; " The
medical history should include childhood, adolescent and adult illnesses,
infections, surgeries or other procedures, accidents, dental procedures or conditions (including focal infections such as root canals and abscesses), pregnancies and miscarriages, allergies (airborne, chemical and food) and vaccinations. The Patient Interview: (an opportunity to demonstrate that the clinician has a
clinical understanding of the complaint, and to validate the patient’s experience of pain, discomfort and distress) " Listen
carefully as you encourage the patient to share the actual experience of
illness related to their primary complaint(s). Travell used to reposition the patient while conducting this initial interview for comfort, and to educate the patient about better body mechanics. I was interviewed by Travell in this fashion the first time I met her, while she slipped sponges under my short upper arms to make them meet the “Kennedy style rocking chair” arms, like the one she designed for the former president; a butt-lift on my right side, as she noticed a short hemipelvis when looking at me get into the chair; a small pillow tied loosely to the lumbar area of the rocker, to support my excessive lumbar curve. By the time she was through, as she
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describes in Volume One (Ibid, p. 105), she asked me if I was comfortable, which indeed I was, much more than usual when sitting for two hours talking; " Travell
also shares pearls of wisdom and her expertise with verbal rapport to
match the above somatic wizardry, which students would do well to study in detail, using Travell as a model for such verbal reframing. Travell especially stressed that when patients state they hurt all over, it is essential to map the actual pain pattern, which I usually show to patients from Travell’s texts for validation and to reassure them that what they have is real; •
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Travell also stressed a careful review of diet and food preparation and
eating habits ( food made at home, take-out, fast-food, restaurant setting); •
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Review of the workplace for ergonomic set-up, occupational exposures,
stressors, including how the patient feels about the job; " The
nature and timing of pain: Travell clarified that “most patients with
active TrPs experience intermittent pain that is characteristically aggravated by specific movements and may be alleviated at least temporarily by a certain position. [...] “Latent TrPs”, on the other hand, “give no primary pain clues, and must be identified by postural changes, muscle dysfunction, and physical examination. As the authors of the second edition of Volume 1 underscore, it is no longer their belief that latent trigger points will demonstrate the referred pain response when compressed, and the local twitch response has also been discontinued due to its unreliability in identifying active or latent TrPs; "Q uestions
about limited range of motion, which the patient may or may
not be aware of; uestions "Q
about weakness, which patients are more likely to be aware of
if they limit activities; " Questions
about any other non-pain symptoms, such as changes in sweat
patterns, cold extremities, excessive tearing or nasal secretions, dizziness, spatial disorientation, vertigo, tinnitus, and disturbed weight perception (Ibid pp. 109-110); " A
history of depression or sleep disturbance;
" Activation
of the pain syndrome: sudden onset is usually easily
remembered, and the traumatic event clearly identified; gradual onset is more difficult for many patients to identify, and it is here that Travell stressed the need for
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good detective work to uncover the repetitive motions that perpetuate such chronic overload syndromes (Ibid, p. 111). APM Physical Examination:
It is important to stress that this APM physical examination is done after the Four AOM Examinations, as the conclusion to the Palpation Examination to establish the holding pattern in the 3 reguar meridian circuits, the 12 tendinomuscular meridians, the 4 patterns of fatigue/stress/visceral agitation or the 3 zones(after palpation of pulses, Hara, and mu and shu points), or instead of these other palpation examinations when the myofascial/Bi-syndrome is straightforward. Steps of the Examination:
1] Patient mobility and posture, Travell stresses, should be carefully observed while walking, sitting and gesticulating during the history and palpation examination. While she was focused on musculoskeletal comportment, classical Chinese acupuncture teaches us to observe and sense the overall way of holding onself containing oneself (or not), presenting oneself in space with an Other. 2] Neuromuscular Functions should be assessed as follows according to Travell: Restricted movement by active or chronic TrPs: Boeve’s identification of relevant TrPs (Ibid, p. 113). This is consistent with muscle channel palpation for ashi points
performed in the Bao Ci or “leopard spot” needling technique where the practitioner moves up the muscle channel looking for signs of excess, or places the painful area in various positions that recreate pain, needling each point in succession and retesting for pain in each point before moving on; •
Neck ROM (seated patient places chin firmly on the chest, looks straight up at ceiling, tilts just the head at least 90 degrees sideways to the acromion on both sides, and places the ear close to the shoulder without cheating (shrugging);
•
Mouth Wrap-around Test for shoulder-girdle muscles (Fig. 18.2, Ibid, p. 489);
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Hand-to-shoulder-blade Test (Fig 22.3, Ibid, p. 557);
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Scalene-cramp Test (Fig 20.4, bid, p. 511);
•
NOTE that the “Patient Examination” section in volume one and corresponding
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sections in volume two give specific active tests the patient can be asked to perform while the practitioner records, such as the neck ROM, Mouth Wraparound and Scalene-cramp tests above. This section also lists passive tests for strength and joint play which should only be performed if the AOM practitioner has been trained in these tests, or the patient should be referred off to a physical therapist or similar physical medicine specialist for further examination. •
Referred Myofascial Pain Patterns: drawn by the acupuncturist on blank body forms (front, back, each side, head, bid pp. 98-99);
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Myotome referrals;
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Dermatographia for excessive histamine release, most commonly according to Travell in the muscles of the back of the neck, shoulders and the torso, but less frequently over the extremities. This is common in patients diagnosed with fibrositis or fibromyalgia, and they may need an antihistamine according to Travell (in line with the common description of this condition as being like an “allergy in the soft tissue”) or phytotherapeutic or neutraceutical regime to reduce this surface inflammation; !
Panniculosis, now associated very narrowly in rheumatology with a nodular condition of the skin seen in erythema nodosum, which Japanese acupuncture describes as “kori” or soft-tissue indurations/geloses. These are areas where the subcutaneous tissue has become more gummy, stuck, which breeds surface inflammation. Travell cites her extensive experience to identify a less discrete or pathological condition that I have identified repeatedly as well based on acupuncture soft tissue palpation for three decades. In this more generic “panniculosis”, as Travell clarifies, “one finds a broad, flat thickening of the subcutaneous tissue with an increased consistency that feels granular[…]usually identified by hypersensitivity of the skin and the resistance of the subcutaneous tissue to ‘skin rolling’ (Ibid, p. 115).” Acupuncturists who palpate carefully find this subcutaneous thickening frequently at Liver 14 and Gallbladder 24, and those who perform TrP dry needling frequently find this exact tissue density at the ischial tuberosity, at Bl. 35, which fasciculate like a trigger point when the needle is inserted carefully into this gelosis. Compression
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of these flat “myelogeloses” as the German rheumatological literature of the 1970’s referred to these findings, against an underlying rib or bone elicits exquisite tenderness and signs of inflammation (intense erythema surrounds the point thus palpated or needled and remains for quite some time). While Travell states that this sort of subcutaneous tissue finding is not a sign of inflammation, the acupuncture understanding of a mu point demonstrating a hot condition would tend to see a sign of heat. Likewise, the resistance to skin rolling is a commonly described acupuncture examination technique known as forearm testing, and this skin rolling technique is used as a treatment in neuromuscular massage according to the celebrated English osteopath and acupuncturist, Leon Chaitow, where skin rolling of the subcutaneous stuck fascia “over” a painful trigger point eliminates the trigger point sensitivity without touching the muscle. Travell clarifies that this form of “panniculosis” and increased viscosity is not to be confused with “adiposa dolorosa” or “fat herniations”. Travell concludes that a series of skin rolling, which can be accomplished in the manual fashion she recommends or with moving cupping, can normalize the tissue and make it more responsive to TrP needling; •
Compression Test (p. 116);
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Passive Muscle Testing: See comment above
•
Assessment of Joint Play: See comment above;
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Trigger Point Examination: palpation of suspected TrPs only, based on the history, the physical examination and the referred pain patterns checked against Travell’s text BEFORE palpating patient;
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Identification of central and attachment TrPs (Note on Key and Satellite TrPs: while Travell advocates identifying only the key, and not satellite, TrPs for injection, the acupuncture Bi-syndrome technique of “bao-ci” [leopard-spot needling of tender point after tender along a muscle pathway) of distal points while moving up toward the main ashi point(s) (“surrounding the dragon”), leads acupuncurists to disinhibit excess TrPs distally and proximally, especially in chronic obstruction syndromes, thus needling the referral area, not just the painful area);
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Assessment of possible entrapment: suspected entrapment, based on Travell and Simon’s text descriptions, should be identified and monitored. Where TrP release produces no improvement in the “aching pain[…], numbness and tingling, hypoesthesia, and sometimes hyperesthesia”, nerve entrapment may be relieved “by cold packs on the neurogenically painful area”, while pain of myofascial origin usually responds better to heat, and is aggravated by chilling. Pain and neurogenic signs and symptoms that do not improve with a course of 12 months of TrP and Bi-syndrome treatment should lead the practitioner to suspect a “wei”syndrome such as a nerve root compression, stenosis, neuropathy or myopathy and such patients should be referred for neuromuscular evaluation;
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Careful Review of the Differential Diagnosis Section 11 for each muscle (which was referred to as “associated trigger points” in the first edition of Volume 1 and in the only edition thus far of Volume 2) . In the first edition of both volumes, when differential diagnosis was discussed, this was usually in Section 7 (“Activation of Trigger Points”) or distributed unfortunately throughout the chapter, requiring a much closer read. This section is critical in aiding the acupuncturist in identifying red flags requiring referral so as not to exacerbate or miss an undiagnosed condition best treated in other ways.
Serious Lack in Travell
What is not included in Travell, perhaps because she struggled so vigorously to free physical medicine, as she was coming to see it, from its moorings in psychosomatic medicine and plant it squarely on the side of the soma, was the interplay nonetheless between ‘the psyche and the body process’ as Dr. Flanders Dunbar from Columbia University called it in her groundbreaking Emotions and Bodily Changes . APM acupuncture corrects for this lack. This rigid demarcation of a somatic territory where myofascial pain and dysfunction would play out free from emotional turmoil, trauma and stress is as lopsided as the over-emphasis on the side of the psyche Travell fought against,
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where patients with chronic pain would be seen to suffer from a psychosomatic disorder best treated in psychotherapy. It is my experience in the vast majority of cases of chronic pain that I treat, where the patients are also being treated by other physical medicine practitioners (orthopedists, neuroloigists, osteopaths, physical and occupational therapists and massage therapists) that the side of the psyche is being totally overlooked in favor of a narrow physical medical perspective. There is no reason why any acupuncturist woud make this mistake, if they adhere to the classical Chinese acupuncture teachings that the main cause of internal dysfunction and disease are the 7 emotions when they become inhibited or expressed excessively. Unfortunately, too many North American TCM practitioners ignore the side of the psyche as well, framing the patient’s problem from a much more materialist perspective that is dominant in PRC that is aligned with modern scientific medicine and so looks askance, in fact, at classical theory and practice, paying it lip service only in this regard. And unfortunately, too many North American TCM practitioners, especially if they ractice herbal medicine, see their terrain as ‘internal medicine’ and look down on any physical medicine approach to acupuncture and Chinese medicine as tantamount to tuina which they disdain or consider a lowly step-child of TCM. It is a frequent occurrence for APM practitioners trained at the Tri-State College of Acupuncture to see patients for chronic pain and dysfunction who were treated by TCM practitiners to no avail, who clearly had no phsyiocal medicine perspective or skills. APM practitioners, on the other hand, who ignore or even disdain getting involved on the side of the psyche without a network of some mindbody and bodymind practitioners are selling their patients short on the benefits they couod derive from a more comprehensive approach. And so after 25 years of developing an approach to acupuncture as physical medicine, which it was and always should have remained as Andrew Nugent-Head shows in his powerfuil ‘tangible Qi’ video and teachings, and knowing that the
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