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Moshe Heller & Stephen Cowan

Phlegm – Etiology pathology and treatment Moshe Heller

Hi, my name is Moshe Heller. First I’d like to thank the American Acupuncture Council for hosting this show, and providing this really wonderful platform for writing information.

I’d like to start talking today, and today’s lecture would be, I will talk a little bit about pediatric phlegm, or phlegm in general. I want to just have a short discussion about etiological factors, pathology, and also the treatment. Since phlegm is actually a very, very common thing nowadays because of, as we know, a lot of … The flu is very common and upon us. As disease progresses, I see many children presenting with phlegm presentations in the past few weeks.

Let’s start. I think the slides are on, and you’re seeing it. The first thing I’d like to just talk about is that … Why do children actually have phlegm, or tend to have phlegm? There’s a famous saying that children produce phlegm very easily, and there’s a few reasons for that.

It all starts with the fact that, actually, children are born with very weak spleens. We assume that, at the beginning of their life, they will always have spleen vacuity. That presents with their tendency to have difficulty digesting, also having very soft stools. That’s a normal thing for them, and that’s a very clear sign their spleen is deficient. Therefore, when you have a spleen deficiency, dampness can easily accumulate and therefore transform into phlegm.

Also there’s another saying that the exterior of children is not secure, and they contract pathogens very easily. WHen the child contracts a pathogen, it influences the way that the lung functions, and the spleen. Therefore, also, the end result could be an accumulation of phlegm, or dampness and then phlegm.

There are a few other supportive factors to the production of phlegm, and one of them has to do with … What I see very commonly now is that the feeding schedule is not as … Parents tend to feed babies on what we call “on demand”. Therefore their scheduling of feedings are random, and sometimes cause this eating on various times, and end up a lot of times overeating. That in itself can also cause an issue with or become a burden on the spleen, and therefore produce more phlegm.

Also, as the children grow, and we start to introduce new foods, a lot of times wrong foods can be presented to them. Meaning either they’re too cold or difficult on the digestive system, and that could be because one of the most common thing is introducing fruits earlier on, or too early. As we believe in Chinese medicine, that fruits are cold and therefore can really burden the spleen, also.

There’s also the issue of formula. I think that sometimes the formula is very heavy and is actually over rich, and therefore not so easy to digest. A lot of children, once they’re put on formulas, actually start developing phlegm. It’s a very interesting thing to watch, because we have then the issue of, what to we do if there’s no other sources of food, and we have to look at different formulas as solutions?

I also want to mention one other thing that’s really commonly seen in my office is that a lot of times antibiotics are given inappropriately, meaning that … Antibiotics definitely have a place and a time to be used, and they are very important. Nonetheless, if they’re used inappropriately, they can produce a dampness very easily because of their nature. As we know, from a Chinese medical perspective, antibiotics are cold and bitter, and therefore they are hard on the spleen. If we have a cold condition, and it’s a cold exterior condition, and we give out antibiotics, the end result will be that there will be some phlegm developing, or damp and then phlegm.

How do we diagnose? How do we know that there is phlegm in the body? Sometimes in children the easiest way is that we see it. As we saw in the first picture of the slides, sometimes it’s very visible, but sometimes it isn’t. If there’s no discharge, there are other telling signs that are important to realize.

One thing ends up as a result of this, especially if the phlegm is stuck in the sinuses, the child becomes a mouth breather. A lot of times we’ll see that their lower lip is a little saggy. Especially if they’re trying to concentrate, you’ll see that their lower lip opens and falls down, and it doesn’t shut down. A lot of times it will also result with some more drooling, or a tendency to drool, heavier if they’re at the teething age.

We have this drooped lower lip, and then mouth breathing. Then we can hear them breathing a lot of times. Another telling sign is snoring at night. Snoring at night usually indicates there’s something that’s blocking, and that phlegm is one of the causes of snoring in kids. Mouth breathing, heavy breathing, or snoring at night, those are all really strong signs.

Of course, palpating the lymph glands is a very important diagnostic procedure in children, because if the lymph glands are swollen, that’s a really strong sign that there is some phlegm accumulating, and a very particular type of phlegm, which we’ll talk in a second. Then, also, the actual history itself of the disease. If there’s chronic sinusitis, or chronic ear infection, or tonsillitis, all these are signs that maybe there’s this phlegm that’s lingering, and is a part of the pathology of the disease.

Another thing that’s really important to use as a tool is listening to the lung sounds. That’s something that, if you’re seeing children, you should probably have a stethoscope with you, because listening to the lung sounds can help in your diagnosis, another sign that can help you in the diagnosis of the patient.

For example, if you hear wheezing when you listen to the lung, you know that that is a constriction of the bronchials. That means that there’s Chi stagnation. But, if you hear crackles, crackles are the sounds like little balloons popping, that is a sound that there is phlegm in the lung. I use it as a diagnostic technique. I listen to the lung. If I hear those crackles, I know that I’m going to need to clear phlegm from the lung.

I want to go over two patterns, this is diagnostic patterns, that are very common in children. The first one I want to discuss is accumulation disorders. We discussed this many times before, but I’m just want to remind you that a lot of times accumulation disorders are the reason that children are presenting with phlegm.

What it is is that … It’s like food stagnation in adults, but its difference is that this could be just from either overeating or eating things that are very difficult for them to digest, and then that accumulates in the stomach and creates this heat and phlegm. The heat symptoms manifest with these red cheeks that are there all the time. This is heat rising from the stomach, and you’ll see these little, almost like stop lights, with the two red cheeks. They’re very distinct. It’s a sign that the digestion is a little overheating and stagnant.

Of course, that will also affect their … They’ll be a little more cranky and irritable, and maybe have difficulty falling, or staying, or waking up frequently. These children don’t sleep as well because something’s not digesting well.

Of course, once these fluids go up and stagnate, they can cause phlegm to accumulate. Then you’ll see this green nasal discharge, exactly like you saw in the first picture. Then you’ll probably see cough involved with it that is very rattly, and maybe some slippery coughs. These are all phlegm signs that come from the accumulation disorder.

When we recognize or diagnose accumulation disorder as the source, we always need to think of Si Feng as the treatment points. Of course, Stomach 36, Stomach 25, and CV-12 are also really important to help, and San Jiao 6, which really helps to move the Chi and resolve the blockage in the digestive system. These are all really important points, but the main treatment point will be Si Feng.

Then the formula that you might be considering has to do with helping the digestion. I have a great formula that’s based on Bao He Wan in my new motion line. I have a website that will be at the end of the slideshow. You can log on and look at digest. It’s a really fantastic formula for supporting the digestive system in situations just like that.

The other aspect is lingering pathogenic factors. Lingering pathogenic factor, a lot of times either cause phlegm or are the phlegm itself. When we diagnose lingering pathogenic factors, we usually have three types or three syndromes under that. One is more of a deficient kind that’s a little more rare, and it involves spleen Chi deficiency. The other one is called retention of phlegm, and retention of very thick phlegm.

We’ll go over the last two just to remind you how we diagnose them. When we only have retention of phlegm, usually you’ll see that there’s this recurring infection, and it can be anywhere from the sinuses, to the throat, to the chest, to the ears. There’ll be a lot of phlegm or discharge from the nose, or cough with a gurgling or rattling sound. There’ll be mouth breathing, like we discussed earlier. There’s emotional state where they want things, but they don’t really want them. They’ll say, “I want this,” but when you give it to them, they’ll throw it away. That’s a very typical sign of that. Then, also very choosy, and wanting only sweet or white foods.

Sometimes you’ll see a manifestation of that phlegm on the stool itself. That’s question we have to ask parents. How does the stool look? Does it change color? Have you noticed any changes in … If there’s this glistening, or it’s a little bit shiny, that’s a sign that there’s phlegm in the stool. Then, of course, enlarged lymph glands, which is really a very important sign for the lingering pathogenic factor.

When it becomes thick phlegm, there’s a lot of the same symptoms. A lot of times the thing that triggers me is that, when I ask, when we discuss the illness history with the parents, they’ll always say a sentence like, “Since their illness, they haven’t been really the same.” The underlying mechanism is that the child’s character is altered or really changed. There’s something either subtly or really more significant change in their character.

Then, that’s very typical of that, when we think that phlegm is becoming so distinct that it actually changes the spirit, or changes … With an adult, we’ll say that there’s phlegm blocking the heart orifices, and then the Shen is not as clear. That’s when we start seeing that in children.

A lot of times there’ll be two other signs that I want to say. They’ll have these energy crashes. They’ll suddenly have periods where they just are really cranky, and they only want to really rest. Also it is sometimes associated with intermittent abdominal pain. These are all signs of the lingering pathogenic factor with very thick phlegm.

The treatment, when you recognize that, is combination of four points, Bai Lao, which is an extra point in the back, UB13, 18, and 20. This is the basic protocol. Sometimes I combine it with the Shao Yang combination of Gallbladder 41 and Triple Warmer 5. Also I will palpate UB43. If it feels very full and excess, I might needle that also.

The main form that I use for that is a combination of Xiao Chai Hu Tang. We’ll talk a little bit about Xiao Chai Hu Tang, because it’s not the first formula that you would think for phlegm, but I found it really helpful with many children, especially with children, to resolve phlegm. I guess because [Ban Xia 00:21:00] is in that formula, but it really is a mild way to resolve phlegm. Helps the children resolve it. I’ve used it many times. You can see that, once Xiao Chai Hu Tang is used in its correct formula, you will see a slow drying of that phlegm, and the symptoms are reduced. I really want you to remember Xiao Chai Hu Tang, especially with kids when they have phlegm.

I want to give a case example that I was treating, actually, a few days ago, last week. There’s this two-year-old boy that came to my office that the parents were saying that was experiencing back-to-back ear infections. Again and again, the ear infections would repeat. Also it always comes with fever and pain. The child really is two years, but still is talking already, and expressing pain in the ear. He mostly tugs and pulls on the left ear, but both ears is something that he’s experienced.

His mother says that everything was normal during pregnancy. The delivery was fine. At the end he needed to be vacuumed, but he was healthy otherwise. Around nine months of age, something around then, she had to stop breastfeeding, go back to work. Although she was giving him formula beforehand as a supplement, at around nine months, around that time, formula was a the only thing she was giving, of course and the introduction of solids.

At that time, there was a lot of dairy products that were introduced. That created a lot of wheezing, or he started to have these episodes of wheezing, almost like asthma. Went to the doctor, the doctor gave steroids in a nebulizer, an inhaler. That really calmed the wheezing, as the mother was reporting.

Then, a few months later, he got another really bad cold. Then that developed into an ear infection, and he was given antibiotics. Since then, it’s been repeated ear infections and rounds of antibiotics. Last round of antibiotics was about three weeks ago. He was given Amaxicillin, and he is currently still complaining of ear infection, although there’s no fevers, which the mother was relieved. She took her to the pediatrician a few days before the appointment, and there was still accumulation of fluids behind the ear drum. The doctor was saying that they may need to consider doing ear plug operation. That’s why they were looking for an alternative way to treat him.

The mother was saying that the baby is a very picky eater, and in the last month they were trying to get him off of dairy, because they thought that that could be a problem, and that’s why he’s having the ear infections, which I agreed. We also agreed that, from now on, they should probably stop wheat.

Bowel movements are two to three times a day. The mother thinks it’s pretty normal, and they don’t seem to be too soft or hard. He doesn’t complain of stomach aches. But, his sleep is not good. He wakes very frequently. He drinks a lot of water throughout the night, and also the mother reports that he’s addicted to the pacifier throughout the day. She’s wanting him to stop, or trying to wean him off of that.

On examination, I found submandibular lymph nodes that were positive or enlarged. His finger vein, which is something that I observed, was very dark, which means heat, and wide. That means that the pathogen is strong, and it’s reached the wind gate. It hasn’t really penetrated extremely deep. Therefore we could address it by resolving it on the [Yan 00:26:43] layers. I’ll explain in a second. Also, when I was examining him, it was clearly that his breathing was heavy and he sounded very congested.

Out of that, I was very clear that his diagnosis was that he had what we call thick phlegm LPF. I believe that it had developed from what we might call a food accumulation, or an accumulation disorder prior to that. I needled the points San Jiao 5 and Gallbladder 41. That is a combination I use for ear infections, because when we address the Shao Yang, it opens up the flow of Chi around the ear. That could be, in itself, the treatment for the ear part of the disorder.

I also added Bai Lao UB13, 18, and 20, as we know, because of the lingering pathogenic factor. I also prescribed Xiao Chai Hu Tang. The first days after the treatment, I got a report that the child was sleeping much better, which was I think a very important sign to see.

I’m running out of time, but I wanted to just mention a few formulas that we usually use for phlegm. Including Er Chen Tang, is an important basic formula for phlegm that we know. Sometimes you can combine that with Xiao Chai Hu Tang. I usually think of Er Chen Tang when I see a spleen deficient at the background of the phlegm accumulation. If there’s spleen deficiency at the background, Er Chen Tang is what I would think for.

Ban Xia Hou Po Tang, another really important formula for phlegm. The difference between that and Er Chen Tang is that Er Chen Tang is more spleen-y, and whereas Ban Xia Hou Po Tang is more liver-y. If the spleen is really deficient and is the cause of the phlegm accumulation, then we can use Shen Ling Bai Zhu San. Or, if there’s an accumulation disorder at the background, Bao He Wan is the choice. As I mentioned, you can check my variation of Bao He Wan in the motion herbs website.

There’s other two formulas I just want to mention that is related to cough. Qing Qi Hua Tan Wan is the famous phlegm heat, or sometimes called Pinellia Expectorant. That clears phlegm heat from the lung. That’s when you have a lot of this cough, which is productive with yellow phlegm. But, if there’s more phlegm dryness, we think of Bei Mu Gua Lou San as the formula for resolving phlegm and dryness.

I think that’s about the time that I have for this presentation. Thank you very much for joining me, and I hope we will meet again in our next session.

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Poney Chiang Thumb

Wear Your Heart on Your Sleeve: Neuro-anatomy of HT-4 to HT-7 – Poney Chiang

Hi, good afternoon. My name is Poney Chiang. I’m a practitioner of acupuncture and traditional Chinese medicine from Toronto, Canada. Welcome to today’s American Acupuncture Council live Facebook podcast show. I’m your host for today. And since this video is taking place on the week of Valentine’s Day, I thought I would do something fun and present something that is heart-related or heart region-related. So, let’s get started with today’s presentation.

The title of my presentation is Wear Your Heart on Your Sleeve. And the subtitle, Neuro-Anatomy of Heart-Four to Heart-Seven. It’s kind of a tongue-in-cheek idea that Heart-Four and Heart-Seven are very close to our wrist, so it’s very close to the sleeve and obviously because it’s Valentine’s Day, I chose to talk about the heart meridian.

The painting you’re looking at is the painting that was done in the year 1900, and it was painted by artist named Edmund Leighton. It is, as you can see, a princess or a fair lady tying a scarf or handkerchief to the sleeve or the arm of a knight. This is supposedly one of the origins behind the English expression to wear one’s heart on your sleeve, which of course means somebody who speaks their mind, somebody has no agenda, who is very direct. What you see is what you get. And here, this knight, by wearing the sleeve from the lady, from the princess, means that he is fighting for the princess’ honor. And therefore, he is identified as vouching or speaking or defending the lady pictured here in the painting.

What we’re going to do first is we’re going to look at the historical development of these points, particularly heart meridian points in the early classics. What I mean by early classics are works around the time of the Han Dynasty or shortly after. So, as you know, the LingShu or the Yellow Emperor’s Classic of internal medicine has two volumes, the plain question, which is the Suwen and the LingShu, which is spiritual pivot. And in chapter 10 the spiritual pivot we learn about the channel theory… And the channel pathways of the different channels on the body. And there is one paragraph that is focuses on the heart channel. Now in this paragraph, on the chapter 10 of the LingShu, entitled Channel Vessel, it says that there is a Luo Channel or what the classic described as a separation.

So if you look at the second bullet under it says “Pathway: the separation of the hand, lesser yin or shao yin is named Heart Five”. And so here we actually have a point identified by its name. Of course then there’s your classic, it would be called Tong Li, the Chinese name of the point instead of heart-five. It says that it’s located one and a half cun from the wrist, separates and course upwards, follow the channel enters into the heart, connects to the tongue root, joins the eye connection and so on and so forth.

Now if you are very good at point location, you might be scratching your head a little bit and wondering, hey, wait a minute. Tong Li, it’s not one point five cun, it’s actually supposed to be one cun from the wrist. So this is an example, a lot of discrepancies we see in the classics at the time of the LingShu, heart-five was actually considered a one point five cun on their wrist, as opposed to the way it is currently taught as one cun from the wrist crease.

But that’s another reason why I’m talking about this. That’s just kind of interesting trivia. I’m introducing to the idea that in the time of the suspicion pivot, we’re starting to have a little bit of introduction to certain points in the heart Meridian, and we know at least our heart file Tong Li is supposed to be in the heart meridian or the hand lesser yin meridian. But you may be surprised that very few points from the heart Meridian are actually recognize by name and location at the time of the yellow in person internal medicine. The only other place that hints at a location of a heart point from the heart Meridian is in the insert chapter 52. The title of that chapter is called Wei Qi as in defensive Qi and there they talk about, if you look at the fourth bullet on the page: the root of the hand shao yin, it’s at the tip of the sharp bone manifest at the back shu.

So here are the top of the hand shao yin, which is the heart meridian and that the root of this Meridian, it’s at the tip of the sharp bone. We modern scholars believe that the sharp bone refers to the pisiform bone in the wrist, in the carpals of the hand which has a bony protrusion and what I want you to notice is that they’ve located this point where we would consider a heart-seven but there’s no mention of shenmen or the name or the Chinese name for heart-seven itself.

And so what that means is that at the time of the Yi Jing, we only have one point for the heart Meridian mentioned by name and location, which happened to even be in disagreement with what is taught later on. And even heart-seven or shenmen, it’s simply just described by location and as names are not mentioned at all.

So that’s only a two out of the nine points in the heart meridian that has been passed down to us today. So the other seven points and not even mentioned by name or location. They don’t actually appear in the knowledge of Chinese medicine textual history until, if you look at the last final bullet in the Jia Yi Jing. This is the meta classic of acumoxa [inaudible 00:07:49] which is probably around the third century.

I put down eight points because heart-seven wasn’t actually mentioned by name. This is why it’s a meta classic where Jia Yi Jing considered the first complete acupuncture manual. There are points that are not described at the time of the of the yellow emperor.

This a nice little zoomed in view of the points on the wrist and the center of the photo is as you can see, heart-four, five, six, seven closely juxtaposed to each other. In fact, heart-seven is right on the crease line. Heart-six said to be half a cun from the crease line, heart-five is one cun from the crease line, and heart-four is one point five cun from the crease line.

And we just saw that even that is disputed because back in chapter 10 where the LingShu, they actually say heart-five is one and a half cun, which is where we look at heart-four today. So the reason why I decided to talk about the heart Meridian points in the wrist. You know obviously you tongue in cheek play on words about the one issue one wears the heart on one’s sleeve and it happens to be Valentine’s day.

But I love examples like this because it really highlights for us the specificity and the lack of redundancy that goes behind how ancient acupuncturists and who I like to call ancient anatomist pass down these points. A lot of people would ask me in my workshops is heart-four or five, six, seven just one point. Because one looks at them as so close and any reasonably educated person would ask that question, why would you have four points? That’s such a tiny little space. Now this is where the brilliance of the ancient acu-anatomist comes in. They pass on these points for very specific reasons is because in fact they are different anatomically. And this is the focus of our presentation today.

Before we jump into very new anatomical, I’d like to just acknowledge William Shakespeare in his work, the Othello at point scene 1. Is this the first textual? A record of the saying wearing my heart upon my sleeve. So there’s a character in the play, Othello’s play, who says that “when my outward action doth demonstrate the native act and figure of my heart in compliment extern, ’tis not long but I will wear my heart upon my sleeve, for daws to peck at”, daws are apparently some kind of Ravens and not what I am.

So if I am not consistent internally and externally I’m not what I seem to be, I am therefore not worthy and deserve to be pecked at by these ravens or and as such. So just in case you were wondering what the expression means and I like to share these kind of food for thought information. It gives a little more context and also helps give us some association when we think about these points.

Now we’re going to jump into the real anatomical and this diagram here comes from Grey’s Anatomy and I would like you to note that there’s two red boxes here on the very top of the page is the ulnar nerve box. And then in the lower box if you read closely, there’s actually two different branches here. One says superficial branch ulnar nerve, the other one says the deep branch of the ulnar nerve. So what I would like you to appreciate is that if you follow the deep branch of the ulnar nerve, you can see that it kind of plunges into the thin arm muscles. And then it actually kicks across towards the left side of the slide, that horizontal branch, that is as also labeled, it’s called deep branch ulnar nerve, it innovates the interior osseous muscles.

These are the muscles that allow you to abduct and adduct the fingers. And it actually makes it all the way into the abductor pollicis muscle. And that’s the muscle that allows you to abduct the thumb. So just another [inaudible 00:12:26] muscle. But because it’s associated with the thumb we call it abductor pollicis instead of interosseous pollicis. So all these branches become important because in a moment we’re going to see how brilliant ancient acupuncturists are in their knowledge of this anatomy and assign different points to each of these specific branches.

So in this video I’m going to show you the needle is inserted into heart-four, and heart-four is assigned the ulnar nerve trunk. Obviously you can stimulate heart, the nerve channel front, I’d say small intestine eight in the elbow, but at that level, the anatomy, it also innovates some wrist extensor muscles. But once you come distally to the level of heart-four it is sort of the first stop before it branches into this deep and superficial branches I just mentioned.

Now because it is superior to the deep motor branch, which I just described, innovates the interosseous muscles, when the electric stimulates that it would stimulate everything downstream of it. So including the superficial branch, which is responsible for the cutaneous sensation of the palmar in the back of the hand, but only for the median one half fingers. Okay, so according to ulnar nerve distribution, but unfortunately because the video cannot demonstrate parasthesia or tingling sensation that the subject is feeling. All we’re going to see is the motor aspect of this mixed nerve trunk at heart-four.

So when I play this video, you’re going to see that there is movement of the fingers. The thumb is moving. In fact, when they sustain a stimulation, what you can see is that there’s an opposition. So the thumb and fingers are coming together by virtue of contraction of the Athena and hypothenar muscles. Sorry, by virtue of the contraction of the hypothenar and abductor pollicis muscles, not the hypothenar muscles. That actually is in fact innovative of the meridian, not the ulnar nerve. I’ll play the video one more time, so you can see. But in addition to the motor aspect you’re seeing with interosseous muscles moving, this subject is feeding tremendous paresthesias or numbness and tingling into the palmar side of the hypothenar and also into the dorsal side of the median one half fingers.

So this color coded image is meant to remind everybody how the ulnar nerve and median nerve covers different terrain in the hand. If I can draw your attention to the left side of the slide, you’ll see the dorsal aspect of the hand. And you can see that in pink, that’s the distribution of the meat of the radial nerve. Now, whereas in green is a distribution of the ulnar nerve. But if you look closely at the dotted line that’s pointing to the back of the hand in the green section, it actually says the dorsal branch. So we haven’t talked about that branch yet. There’s a dorsal cutaneous branch that goes to the back of the hand, but only the one and half fingers. In some people it can be two and a half fingers. Okay. As you can see by the separation where the pink and green separates in the center of the middle finger in this diagram.

Now if I can draw your attention to the right side, now we’re looking at the palmer side of the hand, and you will notice that the palmer side is innovated not by the radial nerve anymore in Brown color. We see that is innovated by the median nerve. So the median nerve is in fact responsible for the palmer innovation, including the palm and fingers of the lateral, three and a half fingers. And then whereas in green you see that the ulnar nerve, if you look at where the dotted line is pointed to the palm, you’ll see that there’s actually two sections. There’s a cross hatch section closer to the heel of the hand that is labeled as the ulnar nerve palmer branch. But when we look at the dotted line as pointing to more kind of the ball of the palm, that is innovative as the ulnar nerve digital branches.

So all in all we have seen palmer branches, digital branches, dorsal branches. Let’s take a look at how these all perfectly super impose on these acupuncture points around the wrist. This slide talks about heart-five and heart-five is also the low point, which means that it’s supposed to connect into an exterior relationship. So the exterior relationship to the heart is there is none other than the small intestine the hand tai Yin. So as a point, it is supposed to traverse from the yin side of the wrist and hand into the yang side of the wrist and the hand going from in other words, the heart to the small intestine or from the shao yin to the [foreign language 00:17:38]. And now what’s very beautiful is that there is exactly a nerve branch of the ulnar nerve that does that.

If you look at the black and white photo on the bottom portion of the slide, you can see on the left side, I have two points as labeled heart-five and small intestine five. The dotted white line on the left side of the photo here represents the outer contours of the ulnar bone. And you can see that the ulnar nerve is labeled in white here with the arrow, is continued into the hypothenar, but on its way to doing that, we have this brand exactly where heart-five is located, where the red dot is on a slide. It branches towards small intestine five in other branches from the yin side to the yang side of the body. So this branch is called the dorsal cutaneous branch and it perfectly satisfies channel theory that is a low meridian point.

This is a dissection. That is from The work that we’d done, the nerves are not naturally yellow like this. They’ve been colored in by an artist to make it more easily visible. And so I want to just start by helping you orientate yourself. You look at the legend on the bottom right, you’ll see that the arrow pointing down is distal. Arrow pointing up is proximal. So imagine this is somebody’s arm pointing downwards and then the ulnar side is actually the right side of the slide and the left side of the slide is the radial side. Let me just help orient you again. This metallic probe you see towards the left side of the wrist here is lifting up the tendon of flexor carpi ulnaris to expose the neurovascular bundle of the ulnar nerve and artery.

In this slide here, C would be the flexor carpi ulnaris muscle. B is pointed to the neurovascular bundle and A is pointing to that [inaudible 00:19:53] branch that is now going to become heart-five. Just as an aside, [inaudible] is actually ultimately bifurcates and becomes small intestine six and small intestine five later on. But that’s beyond the scope of our [inaudible 00:20:08] and discussion for today. If I can draw your attention to heart-six, the arrow heart-six, you’ll see that it is centered over the vessel and we’ll talk more about that. And then heart-seven is on the wrist line.

What’s interesting about the heart-six is that this point has an unusual location. Remember I said these points other than heart-five was just identified by name or location in the special pivot. Points like heart-four, heart-six and seven are not even mentioned by name in the yi jang. So the first time that heart-six ever appears is in the jia yi jang systematic classic and its location is kind of unusual. If you look at the description at the top of the slide I’ve bolded it and highlight it for you in red. It tells us that this point is in the pulse behind the palm, five fen towards the wrist. A fen is a 0.1 cun so, five fen basically means half a cun. But it’s interesting is that is located at a pulse. Now if you can take a look at this black and white photo.

This photograph is taken from the article, The Nerve of Henle: An anatomical & immunohistochemical study for the general hand surgery. And these hand surgeons were interested in finding out more about the anatomy of the ulnar nerve. And you can see it labeled in this diagram here. A, if you look at the left side of the black and white photo, A is the ulnar artery, n is the ulnar nerve. But you see that there’s a star labeled. That star, see how I try for a case on the right side of the photo, that’s actually the branch that goes to the palm and if you remember the colored photo of the distribution of the nerves in the hands, I talked about a cross hash portion around the heel portion of the hand. That’s in fact where those three branches towards the right side goes through.

That’s called a palmer branch. But notice that they’re asterix in addition to the star in this photo and notice how those small branches that represent labeled by the asterix are actually intimately touching the ulnar artery itself. So the significance of this is that the ulnar nerve gives innovations to the ulnar artery. What kind of innovations? Sympathetic innovations, a type of autonomic innovation that controls the smooth muscles of the ulnar artery to control its vasal constriction. And that the classics is the meta classic, we’ve mentioned that this point is in the pulse is telling us that they are more concerned about stimulation of the rich autonomic fibers associated with the artery.

Now it is of no coincidence then that we have learned through pre-occurring experience and knowledge passed on by our mentors that heart-six is one of the most important points to regulate sweating inside of body together with kidney-seven. And why would that be? Because these points are intimately related, associated with the vessels and by stimulating the vessel you are stimulating the sympathetic aspect of the nervous system and sweating is indeed a part of our physiology that is controlled by the sympathetic nervous system. Isn’t that very interesting how the function and anatomy and the historical point locations all perfectly intersect.

The last point is heart-seven. If you look at the color photo on the bottom of the slide here, you’ll see heart-seven clearly labeled. But if you just look a little bit to the right of where heart-seven’s located, you’ll see that there are three branches, right? So the letter C is pointed to two branches that corresponds to the digital branches of the palmer side of the ring, the index and the pinky finger. And then there’s our breads B. That B branch is actually that deep motor branch, the one that actually innovates interosseus muscles.

We saw how stimulation of the the mixed nerve trunk, which contains a sensory and motor aspect. What activate the interosseous and adductor pollicis muscles. So the significance of heart-three or seven, my apologies, is that it is the beginning of the superficial branches of the ulnar nerve. I hope you can see that every single location differ slightly in terms of what nerve has already left the main trunk. So that there is very, very high degree of specificity in the rationale behind why these points are passed down individually and so close to each other.

So I’d just like to finish by giving you a little bit of clinical applications. Anatomy is interesting, exciting, but at the end of the day, that information is to give us more intention, clarity and specificity in our needling. And so we want to talk about how that can be used in a day to day situation. If you are familiar with the type of nerve entrapment called Guyon’s Canal Entrapment. If you look at the picture on the bottom right, it’s also called a handlebar entrapment it’s very common in cyclists that might press the weight of their entire upper body onto the heel of their hand. And as you can see if on the red little lightening symbols, that’s where the pressure and people can feel a nervy electrical sensation. And so if you have some understanding of the… it can differentiate diagnose this type of entrapment.

One way for you to deirritate and improve neural conductance, restore proper neural conductance back into his nerves because it was impeded by pressure. You can needle points like heart-seven, points like heart-four and apply electricity to help deirritate this nerve that has been impinged. One situation that often used the heart-four point for is actually is for restoration of fine motor function. This can happen in patients who have multiple sclerosis. This can happen in patient who has suffered a stroke and they lose the ability to do fine opposition movements and I have found that electrical stimulation of their mixed nerve trunk allows a reactivation of the interosseous muscles and the adductor muscles and hypothenar muscles so that patients can increase their motor control or motor activation of these muscles so that when they do occupational therapy exercises or hand specific fine motor exercises or games, they are going to get more out of those exercises because now the nervous system is firing at it’s optimal efficiency.

Heart-five, it’s name is called Tongli which translates, that’s penetrating interior. It’s traditionally associated with the treatment of aphasia because as you know, the heart orifice is the tongue and the channel theory pathway tells us that heart-five has control and dominance on the heart. But because these points are so close, heart-four to seven, how do you know you actually stimulate heart-five? What if you stimulate heart-seven instead, right? Heart-seven stimulation would feel like palm numbness and parasthesia in the pinky and the ring finger and the palmer side. But whereas heart-five there’s just sensation or parasthesia, ought to feel like numbness and sensation on the dorsal side because of the dorsal cutaneous branch that covers that territory.

So if you are really wanting to use this point to benefit aphasia and tongue and speech and so forth, or to just open the lower vessel, the proper sensation needs to be parasthesia and numbness on the dorsal part of the hand as opposed to the Palmer side of the hand. Finally, heart-seven is called shenmen or a spirit gate, is associated with calming the nervous system. And we already talked about how things like… Points like heart-six because close association to the vessel as very rigid RNI fibers. We saw that how we can conceptualize how that can have effect on sweating, which is a sudomotor response where they get regulated by the automatic nervous system. But similarly heart-seven being able to calm their shenmen, helping insomnia means that by regularly the automatic nervous system is somehow puts the body into a parasympathetic state to improve various type of autonomic dysfunctions.

I want to finish that up this last slide as example of how to use this for a neuro rehab situation. So what you’re still about to see is a patient who has multiple sclerosis at a time that she saw me in the clinic, it’s been about four or five years. She’s developing a lot of spasticities. She has some drop foot happening and upon physical examination we noticed that she was losing fine motor dexterity of her hand. So the top video I will play to you, will demonstrate to you that she’s been instructed to open and close her fingers. The effected side is her right side and then she’s instructed to open and close her fingers. Then she’s going to be instructed to abduct and adduct her fingers. And you can notice that there’s some contracture in the index and middle finger. That’s her attempt to abduct and look at how well the left side works.

The right side cannot abduct at all. And now she’s shaking out her hand because you’d probably be embarrassed. Okay, so just play that one more time so you can just compare for yourself. I’ll stop talking. There’s not much abduction and adduction of the fingers whereas the left hand side is completely normal. And this is important because the deep motor branch of the ulnar nerve is that responsible for the innovation of those interosseous muscles. And so what I did is I put needle heart-four, apply electrical current and because heart-four is the mixed nerve trunk, it will get everything downstream. They’ll get the sensation on the palmer side, on the dorsal side. You’ll get the deep motor branch, you’ll get the supervision branches and immediately after the first treatment and there is that. Now the ability abduct and adduct the fingers is immediately improved.

And that just goes to show you how adaptive are plastic our nervous system is even for something that’s been going on for several years. One treatment, as long as you’re able to have high specificity, you can really do a lot to help these patients. So that’s all I have prepared for you guys today. I hope you enjoyed that. I hope you learn something interesting about the heart points around the wrist and that they are in fact not the same point. They are very, very specific information that ancients have passed down for us. I hope that inspires you to review anatomy. Because I firmly believe that the more you understand neural anatomy, the more specificity you can have with your needling and then the better outcome you can deliver to your patients. Thank you very much everybody for listening. I wish you have a happy Valentine’s Day and don’t forget to join us next week. Our speaker for next week is Sam Collins. Thank you.

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Sam Collins for HJ Ross

Medicare and Acupuncture 2020 American Acupuncture Council

Hi, everyone. This is Samuel Collins, your coding and billing expert for acupuncture at the American Acupuncture Council, our seminars, our networks, and all that. And I welcome you to another program of To The Point. In fact, let’s do that. Let’s get to the point. My goal, as always, is to make sure to give you information that’s up-to-date, current, and keep your office practice going strongly.

So what’s going on? Well, of course, what’s going on right now, of course, is Medicare. And of course, Medicare and acupuncture has had a lot of confusion, and I want to clear up that confusion and kind of give you some insight as to where you can fit what we can do and what we can do for the future. So where are we going with Medicare and acupuncture? Well, let’s take a look, go to the slides.

So we start off with just simply Medicare and acupuncture. Always know that my email is here for you as well. But let’s talk about what has occurred for Medicare. July 15th of last year, the Trump administration proposed a plan to cover acupuncture for Medicare patients with chronic low back pain, framing it as a step that could more safely treat pain without supplying patients with opioids. And of course, this is kind of what happened because of the VA. Opioids have become a big problem. They’re looking for something else that can be helpful. So credit to that, we’re working towards a proposal.

So this is what happened in July. The Trump administration proposed this for patients with chronic low back pain, so they could safely treat without using opioids. Okay. So what does safely treat mean? Well, acupuncture. The proposal released, though, would only be for patients enrolled in clinical trials. So this is what initially happened, just clinical trials and under the National Institute of Health. In its statements, CMS acknowledged the evidence base for acupuncture has grown in recent years. However, questions remain.

So what they did was they said “We’re going to open up a dialogue,” and they allowed everyone to send in information to see whether or not it would be helpful. And the idea first, and as I was told by many people in NIH, it was solely going to be just a study. They were going to put a few people in a clinical trial. Well, after all this information, lo and behold, I put fireworks here, January 21st, what I thought wasn’t going to happen happened.

But I’ll give a note. Marilyn Allen, who many of you may be aware of, and I had spoken with a few people at NIH that said something the week before. They said, “When you get acupuncture.” They didn’t say, “If,” they said, “When.” And we thought that was a little puzzling because we thought, “Okay, it’s going to be a study. We have to see where it’s going to go.”

Well, what happened on January 21st is they made this announcement. “The Centers for Medicare and Medicaid services finalized a decision to cover acupuncture for Medicare patients with chronic low back pain. Before this final National Coverage reconsideration, acupuncture was nationally non-covered by Medicare. CMS conducted evidence reviews and examined the coverage policies of private payers to inform today’s decisions.” So what they did was they got enough information from private payers and others to just decide, “We’re going to cover it.” They didn’t need to do a study. They’re just flat out going to cover it for chronic low back pain.

So what does this mean for us? Well, the decision regarding coverage takes into account the assessment benefits and the harms of opioids. It says, “While a small number of adults age 65 or older have been enrolled in published acupuncture studies, patients with chronic low back pain in these studies showed improvements in function and pain. The evidence reviewed for this decision supports clinical strategies that include nonpharmacologic therapies for chronic low back pain.” While there is variations in indications, the bottom line is they said, “No, we’re going to cover chronic low back pain for acupuncture.”

This decision was published in a memo, if you will, and it’s the CAG-00452N, so if you want to look it up. But here’s it in a nutshell, and what it says is this. “The Centers for Medicaid & Medicare Services will cover acupuncture for chronic low back pain under section 1862(a)(1)(A),” which is the Social Security Act, that will cover up to 12 visits in 90 days covered for Medicare beneficiaries so long as the following circumstances are met.

For the purpose that means chronic low back pain is defined by Medicare means it’s lasting longer than 12 weeks, so you’ve got to make sure in the chart notes and history, this patient didn’t just wake up with back pain, but it’s some back pain they’ve had off and on for 12 weeks or greater.

It’s nonspecific that it has no identifiable systemic cause, not associated with metastatic inflammatory infections or other diseases of course, not associated with surgery, and not associated with pregnancy. Now, I will say this, I doubt we’re going to have very many 65 year olds with pregnancy, but that of course is based on some of the other guidelines.

However, beyond the 12 visits they will authorize within in the first 90, an additional eight sessions will be covered for those patients demonstrating improvement, but it says no more than 20 acupuncture treatments may be administered annual. Bear in mind that these 12 visits or initial 12 visits are within 90 days. If you use those up, you certainly could get approved for more. The exciting part here is that the acceptance and how quickly it was to deal with acupuncture and low back pain.

Now, some of you are aware, I have a chiropractic background, but technically if you look at some of the studies, by a small percentage, acupuncture has shown potentially greater outcomes for back pain than does chiropractic adjustments alone. That being said, it also indicates treatment must be discontinued if patient is not improving or regressing. Well, here’s the good news. When someone comes to an acupuncturist with back pain, generally what happens within one to three visits, they’re already showing some levels of improvement. So I don’t think it’s going to be very difficult, though you want to focus on two things: pain reduction and increase in function.

Now, in general, this is the guideline under section 30.3 for acupuncture in Medicare that never covered it. And it says, “Acupuncture,” of course, “is a selection and manipulation of specific acupuncture points.” And it says effective for dates of service January 21st. So actually, when did this begin? January 21st.

Now, the good news is yes, but there are some restrictions, and this is what most people assume that maybe an acupuncturist could bill directly. Well, let’s talk about what is the billing provider versus the performing provider? Because under this provision, this still does not give any indication that an acupuncturist can join Medicare. That’s something that’s going to require an act of Congress. But the billing provider must still be a provider that’s enrolled in Medicare. So that’s going to be a physician as defined by Medicare, which means essentially an MD. So a physician as [inaudible 00:07:08] by 1861 is going to be your medical doctors within their state requirements.

However, it’s also going to allow physician assistants, nurse practitioners, clinical nurse specialists, and other auxiliary personnel to furnish acupuncture if they meet the applicable state requirements. So remember, acupuncturists are going to fit under this auxiliary personnel, which means yes, you can work on Medicare, but under the supervision or direction of the MD as so long as the person, and this is the nurse practitioner, has a master’s or doctoral level or degree in acupuncture or Oriental Medicine by an accredited school or a current, full, and active, unrestricted license to practice in a state or a territory of the United States.

In other words, they must be a licensed acupuncturist, if not an MD. An MD can do acupuncture should they choose. Obviously, most won’t. They’re going to refer to someone. So that referral could go to a nurse practitioner, but of course, the nurse practitioner can only do it if they also are licensed for acupuncture. Therefore, this is the opportunity for acupuncturists to work within an MD setting where the MD prescribes, the acupuncturist performs, and it’s billed directly to Medicare.

Now, auxiliary persons performing it must be under, and I’ve underlined it, “the appropriate level of supervision.” Now, what’s important to see here is this distinction. The term “appropriate level” is a little bit different from what others will often state. Generally, what it’ll say is “direct supervision,” and of course, it needs supervision, but “appropriate level” doesn’t mean that you need as much intervention by the doctor, if you will, the medical doctor in order to provide the service. That’s going to still be more up to the practitioner of acupuncture.

But this can be the supervision, bear in mind, of a physician assistant, a nurse practitioner, or a clinical nurse specialist. So this certainly could be an opportunity where you may have a nurse practitioner that practices with an MD overseeing them, but then has a separate business where you work with them, either they come to your office or you go to theirs, and can furnish these services.

The bottom line is the type of supervision required was changed at the request of the acupuncture profession from direct to appropriate level. This accommodation adds a tremendous amount of latitude for collaborative agreements between LAcs and MD providers or even DOs, nurse practitioners and all. While nurse practitioners and clinical nurse specialists and physicians assistant may not practice acupuncture, their supervisory availability also vastly expands the potential for collaborative agreements, which means it doesn’t necessarily need to be an MD. It could be under a nurse practitioner, physician assistant, and so forth. So it means you don’t necessarily have to work directly for an MD but might be working in a clinic setting where there’s a nurse practitioner or other type of provider that can be registered with Medicare.

The difference here, though, is it’s obviously, an acupuncturist cannot bill directly, so you’re going to hear this term a lot called “incident to.” So in order to bill acupuncture, an acupuncturist must be working incident to this provider. So what does “incident to” mean? It means the service must take place in a noninstitutional setting, which in simple terms means not in a hospital. Number two, it must be a Medicare-credentialed physician that must initiate the patient’s care. So we have to make sure the supervising personnel, if you will, examines, determines, “Yes, I believe they can be helped by acupuncture.”

Subsequent to the initial encounter to which the physician can arrive at the diagnosis, this nonphysician practitioner, meaning auxiliary personnel, may provide the follow-up care. So then the acupuncturer does their work, and then once every thirty days or approximately thereof, this supervising person will just check to see how the patient’s improving or not improving.

Then the next step is the care must occur with direct supervision or the appropriate level. Per the Benefit Policy of Medicare, what does that actually mean? Does that mean you could have someone just give you a referral for acupuncture and you do it in your office? The answer to that is no. Direct supervision in the office setting does not mean the physician must be present in the same room with his or her aide or auxiliary personnel. However, the practitioner must be present in the office suite or immediately available to provide assistance and direction throughout the time the aide is performing the services.

So now this is going to get a little bit different here because notice it says, “Immediately available.” For instance, under auxiliary personnel such as a nurse practitioner, it doesn’t necessarily mean in the office. Under this guise, I’m going to state at this point, you want to make sure you’re working with direct supervision, they’re in the facility, and I think you’re going to be at your safest bet.

However, Medicare will begin paying for acupuncture. And I have not any practitioners yet, but I certainly have a few that are already working with the MD setting, so I’m waiting to see the bills come in.

Ultimately, this. The physician or the supervisor must be actively participating and must be working in the management in the course of care. They can’t just prescribe and not be involved at all. Both the credentialed and physician may qualify for this incident to so long as you’re employed by the group. So remember, you’re going to be working as an employee in some way to this person. You’re not going to be working as an independent contractor. In order to be supervised, you have to work as an employee. Independent contractor means it’s billed under your own name; therefore, that’s not going to fit here.

Now, is this as good as everyone was hoping or wanting? I would say not. However, bear in mind this. This was only supposed to be a study, and it started in July, but by January they decided, “Nope, we don’t need the study. We’re just going to cover it.” So I see this as neither a slight to the profession nor an error in any way. Provider types outside of Medicare are by the CMS definition of auxiliary personnel, must be supervised by Medicare providers. But remember, it doesn’t necessarily have to be an MD. This is the maximum freedom that can be granted until the Social Security Act is amended to include acupuncturists.

Now, here is the big problem for us. We need to make sure that acupuncturists, by an act of Congress, can become providers under Medicare. Once that happens, there will be direct billing, and I think that certainly will be the area that we’re looking towards that’s going to be more cost effective. The bigger issue for us, though, the power does not rest with CMS as much, it rests with our profession and dealing with Congress, meaning we need to make sure as a profession we have some type of national certification where we make sure that they can be trusted, that these services are under a guideline that’s standardized on a national level. Not to say that you can’t do things differently, but that we’re going to have to have some national standards, if you will.

The excellent news here is that they’re going to cover acupuncture. Now, some people are going to wonder, “Well, what do they mean by cover?” Well, they’re going to cover the acupuncture codes themselves, meaning they’re going to cover 97810 to 97814. And you may question, what would be the prices of these codes? Well, to give you an idea, the Medicare uses a conversion factor for their codes. The conversion factor is roughly between 37 to $40 depending on the region you’re in, and they base it on the relative value unit. The relative value unit for manual acupuncture is about 1.03, and for electroacupuncture is about 1.15, which means you can assume the first set is going to be paid somewhere in the $40-plus range, the additional sets likely in the $30 range. For many of you, that generally is going to mean what you’re seeing for VA in many instances.

This is a real great step forward, but I do want to warn that it is not for direct billing. We still cannot join Medicare. However, what about working collaboratively? What about talking to some MDs in your area where possibly you work in their office a few hours a week or even just a few hours a month, if you will, to start treating some of these patients to see how they’re doing? Remember, Medicare is a big insurer. Everyone over 65. And how many people that have Medicare probably have a little back pain? It’s a tremendous number. And what they’re trying to do is to give persons an alternative.

Here’s what I will say. Acupuncture works well. Once we start getting more and more of these services provided, you’re going to see where Medicare is going to come on board, allow acupuncturists to join and bill directly. But as of now, what about working collaboratively? So is Medicare perfect for us? No. But think of this step. Who could have imagined even a few years ago that this would have occurred?

I want to thank you for spending some time with me. Please take a note, if you go to our website, the American Acupuncture Council Network, and go to our news section, we have this information and much more on upcoming changes and things happening with coding. I suggest go there, sign up for our email service. What we provide are lots of news items.

I’m going to give you a couple of quick items that are occurring. UnitedHealthcare is requiring modifier GP on all physical medicine codes regardless of the profession. As of note for any practitioner in the New York area, New York Empire is also now beginning this GP modifier. And as I’m sure you’re aware, the VA is doing so as well. In addition, of course, things are changing for the VA. Of course, on the East Coast, they’re now using a company called OptumHealth. The West Coast continues with TriWest.

As always, we want to be the most effective place for your information. Take a look at all of our sites. And I welcome you to always come in and say hi to me. Also, coming up next week will be Moshe Heller. And I wish you all the best, and continue your practices strong. We want to be with you and To The Point. This is Sam Collins.

Please subscribe to our YouTube Channel (http://www.youtube.com/c/Acupuncturecouncil ) Follow us on Instagram (https://www.instagram.com/acupuncturecouncil/), LinkedIn (https://www.linkedin.com/company/american-acupuncture-council-information-network/) Periscope (https://www.pscp.tv/TopAcupuncture). Twitter (https://twitter.com/TopAcupuncture) If you have any questions about today’s show or want to know why the American Acupuncture Council is your best choice for malpractice insurance, call us at (800) 838-0383. or find out just how much you can save with AAC by visiting: https://acupuncturecouncil.com/acupuncture-malpractice-quick-quote/.

Moshe Heller & Stephen Cowan

Harmonize the Earth To Treat Many Disorders

 

Hello and welcome to the show. I’d like to first thank the American Acupuncture Council for hosting this show. It’s great to be here and my name is Moshe Heller. For those of you who have seen me before here I teach, together with Dr. Cowan, a course on Chinese pediatric acupuncture. And today I’d like to speak about harmonizing the earth to treat many disorders. So let’s dive in. I hope that the slides are up.

When we talk about children especially, and we believe that children are born with a really weak digestive system and therefore the digestive disorders are usually the root of many childhood disorders. And so that’s an important thing to remember when we are treating children because although we may see various different disorders, the root cause or the reason that they are suffering from whatever, we’ll see a little later what these might be, are rooted in a weak digestive system so we have to support that in order to resolve the issue.

What we will see is since these kind of patterns of digestive dysfunctions cause different issues in the child such as accumulation disorders or exposure to foods that are not appropriate, those cause different issues of poor transformation and therefore affect the child’s ability to transform. And therefore this accumulation can cause heat and we can see that affecting the fire or the heart with overreacting and overstimulation. We can see also that it can affect the lung and cause issues of accumulation of dampness in the lung and also affecting the kidneys with cold. The cold foods can create different types of issues such as inability to resolve toxicity. And also we can affect, of course, the liver that will cause also wind and affect the emotional state of the child as having different anger issues and so on and so forth.

We can see that although the root cause is in the earth, it can affect any of the five other organs to cause issues of imbalance. I also wanted to point out and remember for those of you who have heard our previous lectures about this really important triad that we call the gastro immune, neuro triangle that each one of these parts are affected by or help to be regulated by the others. So when one part of this is not functioning correctly, then it can affect the others. We have the gastro part, which means that the gut, the digestive system, our gut biome, all that can affect our immune system and also our neurological function.

It can cause issues with either imbalanced immunity or different neurological disorders starting from having inability to focus, to even inability to communicate. So we can see that kind of triangle and really a very important triangle in treating children.

I also wanted to point out that there are many books starting with traditional books like the Pi Wei Lun where Li Dong Yuan talks about the importance of balancing spleen and stomach to resolve many, many disorders both in children and adults. This doesn’t stop at at the child. It can affect also many disorders in adults and I think that even if you are treating an adult and a really important aspect of of that is to look at their diet and see what’s going on in the digestive system to to support many of the treatment many of the conditions that you might be treating. I also wanted to point out that that Li Dong Yuan talks about another concept of what he determines is yin fire, which is a little bit like a yin vacuity of the spleen.

We don’t think of that in general, but also at the end of this I will point out an article by Steven Clavey, which is a really good source to read about this concept of a spleen yin vacuity. Also in more modern books we can see Bob Flaws in his handbooks of TCM pediatrics points out that a weak digestion is the cause for many childhood diseases such as colic, earache, cough, swollen glands, allergies and pediatric asthma and eczema. And that’s what we are going to see also as we continue. Julian Scott in his book on pediatric acupuncture points out that there are five really common patterns of illness that that are at the root of many disorders. And the interesting thing is that three of them are issues of spleen vacuity and all of them in the treatment, you will see that they’re really focused on supporting the spleen.

I’d like to stay with Julian a little bit and just to point out these five common patterns, he names them as spleen qi vacuity, hyperactive spleen qi vacuity, accumulation disorder, hyperactive kidney qi vacuity and lingering pathogenic factor. And if you look in his book and see each one of them addresses the spleen vacuity as the main treatment principle. So whichever one of these five disorders, you’ll see that spleen is something that’s in the treatment protocol.

But I want to look at two of them for this lecture. The first one of course is the diagnosis of spleen qi deficiency. So although when we see this diagnosis, we’ll see that the child will have a sallow complexion or being very pale. Their skin tones and limbs are flabby. By the way, one of the disorders that I see frequently in in my office is low muscle tone in kids and that’s very closely linked to spleen qi deficiency as of course, we know that the spleen is in charge of muscles and when the muscle tone is low, it does point for me, it’s a strong indication that there is a spleen deficiency that needs to be addressed.

The lips are pale. Another really important, very common thing that I note is that I look at the lips and if the lower lip is a little bit protruding or I call it flabby, it kind of falls forward and and a lot of times you will see that the child is drooling very easily because they’re not able to close the lips appropriately. That’s another really strong indication for a spleen qi vacuity. Of course we’ll see either frequent loose stools or constipation, diarrhea alternating. But one of the most important things is that when we have a spleen deficiency that is pure spleen deficiency, the stools don’t usually smell bad. And that’s an important differentiation because sometimes the spleen deficiency can be, or it can look like a spleen deficiency, but there’s actually an accumulation disorder and in this case the stools will have a stronger smell to them.

You’ll see that there’s also a lot of times issues of sleep. The pure spleen deficient child will prefer to sleep during the day and always have difficulty falling asleep and would all kinds of manipulations in order not to go to sleep. And another important thing to see when you have a spleen qi deficiency is that these children always have a lot of phlegm and dampness, so they’ll have a tendency to get colds, coughs and other illnesses that’s associated with phlegm or damp accumulation.

And now the really, really important issue too that needs a lot of times to be addressed is their very poor appetite and picky about food. They are the classical what we call mono diet. They only eat one thing. A lot of times it’s sweet and when I say sweet, it’s not necessarily candy or something like that, but even pasta that is called a sweet food, right? It’s something a lot of times I see they’ll only eat pasta, even not with cheese or anything, but that’s what we call a mono diet. They are not open to a variety of tastes. They’re very strict on on eating things that have a sweet property and that’s something we really need to work on, and we’ll see a little later about different things that help to open up that appetite and have a little more variety.

There’s also sometimes a tendency for vomiting and gag reflex being very easily created and we’ll see, of course, the body, the tongue will be pale. There may be a white or thick or greasy tongue coating and the pulse is usually weak or slippery. And one other thing is, especially if they’re young and below or under a two year old, I always look at the finger vein. Finger vein diagnosis is very helpful I think. And the differentiation between a spleen deficiency and something that involves more stagnation and heat will determine the shade of blue that you will see in the finger vein. As a reminder, when we look at the finger vein, we rub the finger a little bit and there are three gates. We call them the wind gate, the qi gate and the life gate. And we see how far the finger vein continues. If it passes the wind gate, it means that the pathogen is starting to affect the qi. If it passes the qi gate, it is affecting the qi. And if it is reaching the life gate, it means that it is actually life threatening, so we have to be careful of that.

But the most important thing is that when we look at the shade of the blue, if it’s a pale blue, that is considered more of a cold condition, whereas where it is more of a dark blue, then that’s a sign of heat. When it’s almost black, that’s really a sign that there’s a lot of heat going on. And if you see a black and purplish hue to it, that means there’s heat and stagnation. In this case, when it’s spleen qi deficiency, we’re talking about more of a cold condition.

When we look at treatment, the points are pretty standard and these are points we use a lot. And the important thing is that we have to understand, although they are points that are very common, they are very effective, especially with children. When we combine large intestine 10 for example, with stomach 36, we are tonifying both qi and blood and that’s a really important combination. Stomach 36, shou san li of course tonifies the qi and large intestine 10 helps to regulate the stomach and intestine and reduce digestive stagnation, which is a tendency that children have. This is a very, very important combination for kids who have spleen deficiency.

We also can consider using spleen six. It regulates and strengthens and tonifies the spleen and also regulates the stomach. This again supports this combination of large intestine 10 and stomach 36. We’re supporting it by adding spleen 6. I also really like using CV-12. It strengthens the spleen and again regulates and strengthens the function of the stomach. I wanted to point out a very helpful treatment protocol that was passed on to me by Alex Tiberi. He always used to say that when we can address our digestive capability or strengthen our digestion by using spleen one for problems with digesting fat, spleen two with problems for digesting protein and spleen three for problems with digesting carbohydrates.

These are things to remember because a lot of times you’ll see that children might have difficulty digesting fat or the parent will say every time he eats avocado, for example, you will see that his stomach is bloated or that there is some issues with bowel movements or every time they eat some type of protein. Then you can use these points appropriately to help in that digestion.

I really like the last combination that you’ll see here, which is a combination of spleen three and spleen eight for those children who really have these sugar cravings. Combining spleen three and spleen eight will help reduce sugar craving, according to Alex Tiberi, and I’ve seen it work really well throughout the years of using them.

I also wanted to remind you all of this four-needle technique. We sometimes call it the Korean four-needle technique in which when we recognize that there is a weakness or an excess in a channel or organ system, then we can use the four needle technique to support that. And sometimes you can use these four needle techniques as a take home treatment with using magnets, for example, because with magnets we can clearly create tonification or dispersion by using the bio north or bio south. And when we have the four needle technique ideas that when we have a spleen vacuity and we need to strengthen the spleen, we use supplementation on heart eight and spleen two and then we have to drain liver one and spleen one and we can do that by either leaving little magnets or by during the treatment just connecting these magnets to the points and then taking them off because heart eight for example, is a weird point to leave. I mean the child may peel it or won’t continue to leave it for the treatment and it will support during supplementing the spleen.

A lot of times the reason I like to use this combination is we’ll see that there is an imbalance between the spleen and the stomach where the spleen will be deficient yet the stomach will be excess and Li Dong Yuan talks a lot about this in the Pei Wei Lun about this kind of the stomach tends to be more excess, whereas the spleen tends to be more deficient and so you might need to combine a strengthening treatment combination for the spleen, whereas you will use a dispersing treatment for the stomach.

You can see those points all listed here and this is a great technique to use in the clinic. I also very frequently either perform or teach the parents Tuina or pediatric Tuina, and I really love this hand technique where you can see that there is actually the presentation of each of the organs at the tip of the fingers. So for example, you see here on the little finger, on the pinky, the top part is Shen Jing, meaning that represents the kidney. On the ring finger, it’s Fei Jing, which represents the lung and Shin Jing here is the heart, Guan Jing the liver and on the thumb this is where we see Pi Jing, which is the spleen.

Generally speaking, in this technique, when we do rotations, when we take the thumb and we rotate, usually with our thumb, this rotation is supplementation, whereas where we are pulling upwards, this is considered dispersion. So we can either disperse this spleen or strengthen the spleen and as we can see that the stomach is actually just below the spleen so we can disperse the stomach by pulling upwards and we can strengthen the spleen by doing rotations. I’ve noted this here and on the slide. You can see that. And the arrow is pointing downwards, but it could be upwards or downwards. It doesn’t really matter. I prefer upwards actually. And I combine that with clockwise rotation around the umbilicus, which is also a great way to support the spleen.

As in abdominal diagnosis, we know that the spleen is manifest around the umbilicus. Of course on the left side we will have the liver. On the right side, this is the lung, the heart is on top and kidney is below. I also always look at the abdomen while I’m working to see any issues and palpate it to see what I’m feeling to support the diagnosis.

I also wanted to mention one other thing is the use of tiger warmer. This is a great way to treat kids. You can create heat and pressure at the same time and they respond really, really well to tiger warmer and you can use both supplementation points. You can use, for example, when you see a spleen Qi deficiency strengthen bladder 20 or bladder 21, the [inaudible 00:26:29] of the spleen and stomach, CV 12 and stomach 36 this is a great way to work the points. We’re applying both heat and pressure and it is great way to stimulate the points and kids usually respond really well to it.

Also, you can use regular moxa salt, on spleen CV8 is a great supplementation of Yuan Qi and also this kind of connection between kidney and spleen where you can strengthen the kidneys’ relationship with the spleen by using salt moxa on the umbilicus.

Last thing when we were talking about spleen Qi vacuity of course we can use herbal treatment and there are many formulas, depending on the little symptoms that you want to address. For example, our classical strengthen the spleen formula is Liu Jun Zi Tang, although technically I always prefer to use the Xiang Sha with kids. Xiang Sha means that we have the Liu Jun Zi Tang plus [inaudible 00:28:04] and [inaudible 00:28:04] that is [inaudible 00:28:04] Xiang is the Qi moving. It helps to move the intestines, it moves Jian in the belly and that’s a great addition to this formula and Sha Ren is extremely important in promoting appetite and so it’s a really important herb, especially for those kids who have this mono diet where they are not open to to experiencing other tastes. I think of Sha Ren. Also Shen Ling Bai Zhu San, which is the best formula, I think, for spleen dampness. If you you see a damp spleen, so a combination of spleen Qi vacuity with dampness, there’s nothing like Shen Ling Bai Zhu San.It’s an amazing formula for that condition and the two main symptoms is diarrhea and soft stools and lack of appetite, low appetite. These are really the two main symptoms for Shen Ling Bai Zhu San.

Of course we can also use Gui Pi Tang, which is this kind of relationship between where the spleen is actually deficient, but the heart has some what we might see as a blood vacuity or a heart Qi vacuity with some irritability, difficulty sleeping, and the Gui Pi Tang combination addresses that kind of both heart and spleen.

Bu Zhong Yi Qi Tang, of course is for lifting the central Qi. That’s very important. And Xiao Jian Zhong Tang also is a great formula, a very simple formula for this kind of when the spleen is really deficient, the center is a week. I also want to point point out I’ve developed a combination of herbs, a line of herbs actually that I’ve called Moshen herbs. It plays on the word Moshen and the word Moshen and the word shen there is affecting the spirit. But the idea is that I’ve created a few pediatric formulas that are really helpful for… I’ve found them really effective for different disorders.

One of them I’ve called Digest and this is a combination that will address children with spleen Qi acuity and or the the next pattern that we will see, which is an accumulation disorder. It’s a formula that addresses both things and and very effectively. Please check it out on moshenherbs.com and you can read the ingredients and see how the functions of this formula. But it is a formula that I use for digestive disorders in children when those… it could be even that when I suspect that when a child comes in with eczema that I suspect comes from this weak spleen that we can use Digest to address that. And especially if they have a tendency to get asthma, for example, or a lot of phlegm disease, then we can still use Digest to resolve that.

Let’s move to the next common disorder and we call it accumulation disorder. It is pretty much similar to the concept of food accumulation in adults, but it’s manifestation in children is a little different and it is is associated with exposure to foods that are not appropriate to or are difficult for the child to digest. One of the most common reasons for an accumulation disorder, unfortunately, is the use of formula in kids. I think that the issues with the formula is that it is over rich. Therefore, it’s very hard on the digestive system and therefore it causes a lot of issues. I know sometimes we need to use it, but we have to recognize or realize that it can cause a problem. Another issue is that children are sometimes offered food too early when they’re not really ready for food and therefore that causes also issues.

It’s very common that we see accumulation disorders around six months of age. That’s when solids are being introduced to the diet. And this is a period where accumulation disorders can develop. One of the most important symptoms that I see for accumulation disorder is this redness in the cheeks. And I can almost see that, I can suspect it already when I see the patient in the waiting room and I see those two red lights as cheeks. They’re really red. I have a picture in the next slide so you will see that. And that’s a really common symptom. A lot of times you have to ask the parent, “Oh, does he have these red cheeks all the time, or is he just hot or something like that?”

A lot of times when it’s an accumulation disorder, they’re pretty much consistent. The cheeks are red most of the time. They’ll also suffer from a lot of irritability, insomnia and a lot of lingering illnesses, especially this green nasal discharge. When you see this little kid with the green nasal discharge in his nostril and that’s something that the parents are complaining about.They’ll say this child is always sick. Everything that’s around, he immediately gets it. And he immediately gets this kind of nasal green nasal discharge. That’s a another very typical accumulation disorder symptom.

The interesting thing is that this accumulation disorder pattern usually can transfer or develop into a lot of what we would categorize or Western doctors will categorize as food allergies. So we’ll see how that develops in a second. These are the main symptoms. We can see here that this kind of red cheek, you see this baby with these kind of red cheeks, looks really cute. You think this is a a healthy little kid, but actually this is sign of a problem a lot of times, especially when it’s been going on for a little bit, you’ll see that then the skin becomes a little bumpy around the the cheeks. And when you see this kind of little bumpy area as well as red cheeks, it’s pretty much a food accumulation involvement.

We can see that in babies, the reason why you’ll have an accumulation disorder is overfeeding cow milk formulas. As we said, poor sleep and and dysbiosis are really the major causes in babies. In children we look at poor quality of foods, cold, raw foods, sugars, or sugar can be a cause for an accumulation disorder and a lot of this kind of very what we call children food are usually like pizza. Amazing. A great way to cause food accumulation in a child is give them lots of pizza. That’s something that we have to pay attention to.

Definitely also a general poor eating habit and I think one of the things that we have to remember is that one of the things that’s really strengthening to the spleen is the creation of a routine of eating, so that eating at the regular times and creating this kind of a regular pattern of eating is something that is not necessarily something that we need to teach our kids. And I think that’s a problem with a lot of parents that they don’t enforce it so that the tendency is to feed children as they want or on demand as we call it, on demand feeding, where that actually sets the grounds or creating an accumulation disorder.

It’s about eating mindfully and creating these mealtimes and involving children in that process is really, really part of strengthening the spleen and preventing food accumulation. What we’ll see is this hunger with no real desire to eat. They’ll say, “I want this”, and then they won’t eat it. And then there’s this kind of sensation that you’re hungry but you don’t know what to eat. Never satisfied. Sometimes reflux. You’ll hear them eating and then they’ll have a lot of burping up of gas, these red cheeks, green stools babies. This is another really very important sign, yellow nasal discharge and congestion and also chronic ear infections, chronic cough, chronic or even asthma. Sometimes the breath sounds like a little sour, so it is affecting the stomach and you can actually smell it. Eczema, cradle cap. The skin is starting to be affected by that and a lot of restlessness, hyperactivity and sometimes behavioral issues develop from this kind of accumulation disorder. Although it starts out in the digestive system, it affects many, many areas of imbalance.

The best time to, to catch or to address this food accumulation is when the children are really young and the best treatment the Sifengwen points, the four points. And you can see their location here and the bends. I know that traditionally they’re saying that you need to prick it and squeeze it until some yellow fluid comes out. I just insert the needle in all four areas and I get great results. You don’t really need to stand and squeeze it. I also recommend to use these points at the end of the treatment so when it hurts and the baby’s not crying in the room, you can do it and have them go and that’s a really a good way to use these points.

I teach the parents this kind of a massage of the thenar eminence that helps to reduce food accumulation and then also disperse the stomach. These are all techniques that really help to resolve food accumulation. With older kids, we can look at using CB 12 and stomach 36 as we remember. Large intestine 10 also helps with this kind of regulating of the stomach. Oops, sorry about that. And another combination that I really like to use is the combination of CV10, CV12 and CV13 that helps to regulate the flow of stomach and opening and closing of the sphincters. This is a really important thing. Stomach 36 of course is a great point for stomach pain and if there’s a lot of phlegm we do need to use stomach 40. If there’s a lot of phlegm in the lung, I usually don’t start with using stomach 40. I start with using CV 22 to start kind of resolving the phlegm in the lungs and only then I will use stomach 40, so that’s another important thing to remember.

What herbs? There’s Bao He Wan. This is the classical formula for food accumulation and, as I said, if there’s a lot of them, if the spleen is deficient and there is accumulation of dampness, I always think of Shen Ling Bai Zhu San. In this case it’s mostly when there’s soft stool. So if there’s this kind of a stinky diarrhea most of the time then I would use Shen Ling Bai Zhu San. Otherwise I’ll use Bao He Wan if there’s this alternating constipation diarrhea. Then Digest, again, is the herbal formula that I developed and you can read about it in moshenherbs.com and I wanted to point out another formula that I’ve been working with. It’s called React. I called it React but it’s based on Wu Mae Wan and I know that Wu Mae Wan is usually a parasite formula, but I’ve used it very effectively for for for food allergies, food sensitivities and in general this kind of tendency to be very allergic, whether it’s allergic asthma or allergic skin reaction.

All these things are really very affected, can be addressed by the use of React, which is an herbal formula based on Wu Mei Chuan and I’ve changed it a bit to be very well used with children. Please take a look at that because it’s a very good tool to use for different types of conditions in pediatrics and also adults actually can use React in this case, especially where there’s food allergies as a basis for many problems.

I also wanted to point you to a very interesting article about this kind of spleen and stomach yin deficiency. It’s not something we see so frequently. But Stephen Clavey wrote a wonderful article about the differentiation and treatment of spleen and stomach yin vacuity, so please read it. It’s from the journal of Chinese medicine from January of 1995. I know it’s a while ago, but it’s a great article, and I wanted to point out that these are things that you will see very frequently with children is that they’ll have trouble digesting food, easily full after eating small amounts, typical right? Bloating and feeling of uncomfortable fullness after eating, loss of taste discrimination, so they only want to eat sweet things, dry lips, different type of ulcerations in the mouth.

Look at these symptoms. These are things that I see very frequently and in this article he will help you differentiate between them and the use of different formulas. So a very good resource. Okay. I think I went over time, but I’m not sure. Anyway, I want you to thank you for listening and being with me today. I have here, if you want more information about Moshen herbs, please go to moshenherbs.com and also I wanted to point out that this is the certification course that’s going to start in March, jingshenpediatrics.com.Thank you very much and I will see you again in, I think it is in February.

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AAC To The Point - Lorne Brown

The Magic Word That Gets You Committed Patients – Lorne Brown & Chris Axelrad

Lorne Brown, I’m your host. I’m a doctor of traditional Chinese medicine. I have my practice in Vancouver, British Columbia, and Canada. I’m also a CPA and an author of Missing the Point: Why Acupuncturists Fail and What They Need to Know to Succeed.

I’m very excited and fortunate to have a colleague and friend on today, Chris Axelrad. Chris is a leader in the industry. He has been the president of the American Board of Oriental Reproductive Medicine. I can tell you he knows his stuff and he shares his stuff, evident by the fact that he’s taught all around the world in US, Canada, and Europe. He’s spoken on healthyseminars.com. He’s been a presenter at the Integrative Fertility Symposium as well. This man, this practitioner follows his heart. He beats to his own drum. This is also evident by the fact that his family, his late father, his siblings, his uncles are all medical doctors, and he chose to go into acupuncture against their will and their desire. So there’s the man that follows his heart, his dream. He is very successful, and that’s why we have him on the show. He has at least four clinics, the Axelrad Clinics and growing with many associates. Now he also mentors acupuncturists so they can be successful. Chris, welcome to the show.

Thanks man. It’s awesome to be here. Appreciate you inviting me.

I want to hear about this topic that we chatted about that you’re going to share today on the magic, the magic word that gets you committed to patients. Can you start off with what do you mean by a committed patient?

Well, committed patient is somebody who shows up and is really serious about getting help. So they’re not kicking tires or just kind of looking, to see what it might be like to get some acupuncture or to get some herbal medicine or whatever. They have a serious problem. They’re seriously interested in solving the problem, and that in and of itself just lends itself to a different kind of attitude, a different kind of willingness to be led and to be really taught about the things that are going to help them to escape their problems. As opposed to patients, and I know all of us have had these kinds of patients before that are just sort of kind of showing up but then asking a lot of questions and constantly having doubts and constantly never know if they’re going to show up for their next appointment, things like that. So that’s really after a while of being in practice.

I think most of us start to realize that it’s going to be really tough to have not just a successful practice but a practice that we enjoy and a practice that we really feel is fulfilling if that’s the type of people that we’re attracting into our practice all the time, people who are just not at a place where they’re really serious about the process that we have for them. So to me is someone who’s committed.

It reminds me of one of my teachers that used to say, “The client has to want it more than you do, and the client has to work harder than you do.” You’re still showing up giving 110%, Chris, but you’re saying you want that patient not only to match it but to exceed that.

Well, here’s the thing, I mean, to a point, to a point. I think that for most, most people are just not aware of the amount of self-care and kind of work on themselves that goes into their process of healing, especially if they have a really serious medical condition. So sometimes we can’t just like in any way in my process, which has proven to be pretty successful by the fact that we do have four clinics, and I’ve trained three other people in my process and they do it pretty well. Our process is really predicated on not overwhelming people with and making them work, like they don’t even realize they’re working that hard. So it’s like this stealth kind of way that we go about it that gets them on board doing the most important things.

A lot of times they don’t realize how many things they are changing but, yeah. I mean, the bottom line is that you’re right. I mean, a patient can’t want it… If a patient doesn’t want it, we can’t want it for them. We can’t want the results on their behalf. A lot of people do make that mistake, and it’s a very draining way to go about practice because at the end of the day when you want it more than your patient wants it, you’re just going to a well that has no water in it trying to get water. So it just gets to a point where it’s fruitless.

So in this magic word, they get you committed patients. You mentioned when we have a committed patient then so they do want to do the self-care, and you have a system in place that stealth-like. So they’re making the changes and it’s not considered extremely hard work. What is this magic word you’re referring to when you say the magic word that gets you committed patients?

Well, I thought about it after I presented that idea. There’s really two magic words, but the first magic word is the name of their problem, the name of their problem that they were told by doctors, right? So I think what happens in our industry a lot is people avoid common terminology for diseases. Because sometimes maybe it feels like, “Oh, that’s not really Chinese medicine. That’s not really holistic. That’s not…” So we aren’t going to use that term. What we have to understand is that someone who doesn’t know anything about Chinese medicine, which by the way is 99.999999999 many nines you want to think about, a percentage of people in the West don’t know anything about Chinese medicine. So the terminology that we put out there if it’s not in their language and in their sort of meets them where they are, then they don’t pay attention to it.

So someone goes to a doctor and they’re told that they have, let’s say infertility, you’re in fertile. Okay, granted. I know in the fertility world there’s a lot of people who think that that’s a bad word, infertility, and I get that. The key is that to a person who has been told that by their doctor, that’s the label that has been sort of put on them and that’s the key word that’s going to get their attention when they’re starting to look for help. That’s the word that’s going to get their attention.

At same thing with, for instance, Crohn’s disease. So there’s a lot of people who want to brand themselves like, “I help people with digestive problems. I help people to have awesome digestion.” Well, no one’s looking for help with digestive problems per se. I mean, if it’s a digestive problem, what most people think of is, “Oh, a little reflux, a little upset tummy,” a little whatever. I can just go to the drugstore and spend five bucks and buy an over-the-counter medicine for that. Like I always say, if you’re competing with Zantac, Advil, Tylenol and all these things, Claritin, you’re losing. You’re going to lose because that’s not a fair fight.

When you start to call out the names of serious problems that people can’t go to the drugstore and buy a pill to fix Crohn’s disease, ulcerative colitis, not just headaches, not just neck pain but migraine, chronic, recurrent, severe, some type of severe headache; I’m not an expert in headaches but I’m sure there’s a million different terms for headaches besides migraines, or spondylosis or herniated disk, not back pain. Because again, the average person with back pain, yeah, back pain it sucks. No one likes to have back pain. At the same time, the average person with back pain is probably just taking over-the-counter meds or stretching or doing something like that.

When we start to call out real problems that have a connotation of a different level of severity, number one, when those are the words that we’re using, the terms that we’re using all the time whether it’s in our marketing or advertising or public speaking, whatever, then it connotes a different level of expertise, connotes a different level of skill and a different willingness to solve serious problems. That’s how we want to position ourselves. I mean, we don’t want to position ourselves as an accessory, as an alternative, as the cute little acupuncturist down the street that helps people relax. I mean, I don’t take that personally. Of course, I’m happy to help anybody who comes into my office.

When it comes to building a big practice, if you’re not really reaching out and offering to solve serious problems, it’s going to be a tough row. Because, again, the level of commitment. If someone comes in and it’s like their back hurts a little bit, you can probably fix that. I know for sure I can fix that in one or two treatments almost every single time, and then you just had patient come through and do two visits. It’s like, “Well, okay, now I’ve got to get another patient.” When that person goes out and just tells their buddy or their friend whether it’s a guy or a woman or a man, “Hey, my back’s better now. I went to acupuncture,” and all their only friend reference is this really easy problem that you help them fix and they tell their friend who has easy problems, “Well, guess what,” you might get a few more people in. They’re going to do three or four visits, and they’re going to quit. Why? Because they’re better, which is fine. That’s totally cool.

If we really want to have successful practice, we have committed patients that are coming back that are really working on a problem, then we have to actually use the names of those problems and not be afraid to use the big scary words like Crohn’s disease, again, getting into eczema, psoriasis. Again, infertility is a big one, endometriosis, you name it. If you call out these big problems, then people will start to pay attention and people who are really actually in need of our help. Because at the end of the day, a lot of these are chronic problems that Western medicine has no answer for. Because, as we all know, not that Western medicine is inherently bad, not that we should avoid Western medicine all together, however, Western medicine is like a sledgehammer sometimes. Sometimes you’re applying a nuclear bomb to a problem that just requires like just a basic, “Oh, no. I don’t want to use an analogy of a pistol.”

I am in Texas by the way, so you know. So you don’t need to bring a nuclear bomb to a gunfight, okay? If one little bullet will fix it, there’s no point in bringing all this power. That’s where Western medicine sometimes has a problem. That’s where we can come in and do amazing things to help people’s natural, innate healing process to kick in and fix the problem itself. The people who need that help the most are people who have had Crohn’s disease for 15 years and are on five medications, and the medications themselves are almost as bad as the condition itself. They’re really tired of that, and they really want something that’s going to give them a real way out.

When you start to brand yourself that way and you start to use those words, it brands you as an expert. It brands you as a high-level authority, and that’s what gets you the reputation and then, of course, you have to actually treat people. What I’ve found honestly is that our medicine, despite what a lot of people would tell you and even people in our own field might say, our medicine is immensely capable of helping people with these kinds of problems and in not that long of a period of time. So people will really, really start to buy into what we do more and more as we call out these serious problems and are willing to go out there and actually attack these serious problems and build ourselves that reputation of being able to solve these serious problems, so.

Let me see if I got this then I’m going to summarize what I think I’m hearing. You’re talking about a committed patient and also known as a motivated patient. So if you’re going to treat, you talked about eczema aforementioned. Eczema is something that somebody really wants to get rid of that usually. It’s more of a complicated serious problem versus somebody who got hives from eating something. If somebody’s got hives, they’re going to try something over-the-counter antihistamine and see if that would work. If somebody’s got a chronic condition, people with chronic like migraines or eczema or infertility, then looking to get good at even specialized like you’ve done with fertility is find an area where the patient is committed. So skin conditions, somebody has skin conditions especially around summertime, they’re going to want to make that clear if they’re going to put on T-shirts and shorts if it’s on their arms and legs or even on their face.

So am I hearing that right? You’re committed patient, you’re motivated patient, you’re looking for things where there’s not great alternatives for them. There’s not this over-the-counter quick fix. These are people that have chronic conditions, and they’re going to be motivated because of their condition. It’s interfering with their quality of life. They’re going to be seeking out help and a lot of these chronic conditions, although allopathic conventional medicine has done wonders. We’re alive here past age 40. It does great things. Cubed carrot is great. Some chronic conditions, Chinese medicine can treat effectively also, and we’re an option for that. So did I get that correct?

Yeah, exactly. I think it just has to do with, again, using these terms that are very specific and that connote a different level of problem. So it’d be like saying, “I treat allergies.” Allergies is a very general term most people don’t really feel. If you just say allergies to somebody, they’re going to think, “Oh, hay fever,” or just a little bit of a head cold one day taking antihistamine. When you start saying things like eczema, when you start saying things like severe allergic recurrent rhinitis or severe allergic sinusitis, I mean, again, I’m not an expert allergist, but there are lots of different conditions that are allergic conditions that we can certainly help people to balance their immune system more, help their immune system be less reactive so they may not need as much medication, things like that. But we’ve got to actually call that out.

Now the other secondary benefit of that is that if you say, “I can treat Crohn’s disease. I can help you with the symptoms of Crohn’s disease,” or, “I can help you to feel better with Crohn’s disease,” right, what does that say to the person who doesn’t have Crohn’s disease but has some type of digestive problem as well? It may not be Crohn’s disease, but maybe, I don’t know. They haven’t been diagnosed with that, but they just know they don’t feel well. They’ve been to doctors, whatever. What does it say to those people? Well, it says… It’s this kind of thing where it’s like, “Wow. If this person is offering to help people with Crohn’s disease, my problem’s going to be pretty easy for them.” Like I should definitely like check this out, right? So you kind of get this bigger benefit.

It’s called aspirational marketing, where you really call the big shot and what that does is it, and even people who don’t necessarily need that much help will still see you as an expert and someone capable of helping them.

For the practitioner, you’re going to want to have some, for me anyhow, some form of passion in treating that area. So Chris is sharing that. Use the terminology that the patient’s going to be familiar with, so be patient-centered focus. So use the terminology and the terminology will be some of the Western diagnosis they have received from their medical doctor. For example, if it’s Crohn’s that they received from their Western medical doctor, well, in Chinese medicine that is a disease category diarrhea, bloody diarrhea. This is something, it’s not called Crohn’s in Chinese medicine. However, we’re able to pattern differentiate the symptoms into your Chinese medicine and so you’re still treating the Chinese medicine pattern. You’re treating the individual. You’re not treating Crohn’s. That’s just the map that Western medicine has given that body, right, but that’s what the patient’s going to understand.

So that’s what I’m hearing. You say, Chris, is use the terminology that they’re familiar with. I’m adding that because Chris does a lot of work with fertility as do I in my clinic. We’re passionate about helping bring in healthy babies into the world and helping this population. We find it fun to work with hormonal imbalances and work with women and men wanting to have children. So it’s something that you’re going to need to have passion for because you’re going to want to do all that additional learning and studying, and you’re going to see so much of it. You’re really going to want to like it if you’re going to see that much of it.

Yeah. But I would say also I’ve gotten to a point, Lorne, for me anyway, this is just me and maybe it’s because I’ve been so heavily involved in helping people with their marketing and their practice management stuff over the last three years since I started my program. To me, the passion is seeing that smile on someone’s face when they start to realize like they found something that’s working. The fulfillment of the fertility thing is amazing to know that you’ve changed someone’s life in that way. It’s just as life-changing for someone who has suffered with a severe chronic illness for years and has not really been able to have a really good quality of life to suddenly feel empowered and realize that they’ve got something that is really truly changing their life.

So I always encourage my clients not to focus so much on the specific thing, the problems so to speak. Because sometimes we can’t decide what problems are going to come to us. I mean, it’s like the market is going in some ways make that decision as well. The main thing is to have a positive attitude and not focus so much on what you’re getting out of it and your own thrills, but focusing on like just the service aspect and certain people and empowering people. So when we’re more focused on that, then the specifics of exactly what we’re specializing in, to me, that’s what drives any successful practitioners, just the joy of knowing that you’ve changed someone’s life.

Sometimes that life change is very subtle. It’s not this really big obvious thing like a child, which is a super obvious change. Sometimes it’s a very subtle change that they’re no longer having trouble sleeping through the night. They’re waking up every day. They’re able to focus more, and that’s going to change their life in millions of ways going forward, I mean, so-

I think you hit it with the service to others. Because in the spiritual books, they talk about service to others. In the law of attraction books, it service to others. In the entrepreneur books, to be an entrepreneur, it’s about service to others. I think one in the Bible said, “Do unto others as you want them to do on to you.” It’s all about service to others. If you can do something that’s going to help the masses and it’s more about them than yourself, you’re on the right track. That seems to be a common theme in most of [crosstalk 00:22:01].

That’s it, man. So like there’s a lot of people who want to have a specialty fertility practice and maybe that’s just not going to happen because of several factors. Could be competitive factors. Could be just that in their city or their market, there’s just not enough people that have that problem to really have a whole practice revolving around that. So we’ve got to learn how to be humble and not want to make it all about ourselves and [crosstalk 00:22:34]. This is amazing that I’m helping you with this really simple, easy problem, but watching you grow and watching you overcome this. I’m not saying I’m saying this in patients, right, but just in my own mind. I mean, that to me gives me a lot of fulfillment.

I wanted to say real quick because I know we’re up against time-wise, but the other magic word that’s really important is actually a magic phrase is, “Yes, I can help you.” You need to learn how to say that even when you’re not sure, and here’s why. Because nobody’s ever sure. Even when someone goes in for IVF or someone goes in for a sinus surgery or someone goes in for to take a medication for that, as much evidence as there is that that procedure works, no one’s ever sure it’s going to work for that person until we try it. So we just say, “Yes, I can help you,” so that people will trust us and will be willing to try it out.

What I always do, look, and this is very counter what most people would say to do, but let me tell you why. Let me tell you why. I have chosen and I have realized that I always want to be the person who believes my patient can heal and be wrong. If I’m wrong, I will accept that. But when my patient is sitting here, I believe in them 100% and I’m not going to hold that back. I’m going to tell them, “Yes, I can help you. Yes, we make this happen. Yes, well, let’s do this.” I will take the hit of being wrong rather than being the person who holds back and says, “Well, I’m not sure. Maybe da, da,” and be right.

That’s not who I want to be. I don’t want to be the one that predicts or hedges against failure. I’m going to be the one that hedges for success. So you’d be surprised, man. I’ve never had a patient come back to me who didn’t get pregnant when I told them that I was really confident they could get pregnant. Honestly, I felt that way. I’m not lying. I feel that way, and we can’t control who gets pregnant. We can’t control who overcomes their Crohn’s disease or overcomes their eczema, but I’ve never had a single patient come back to me and tell me and tell me I lie to them or anything like that. In fact, I’ve had a lot of my patients who never got pregnant working with me, they still referred to me to this day. They refer people for other stuff. They even refer people to me for fertility.

So what they want from us is full effort. They want to know that we’re on board, and we believe in them. In my opinion, not one shift can bring you, I mean, at least double your referral rate if you just show up that way, because people want to know that you’re an advocate for them.

Speaking of the referrals. So you’re looking for the motivated, the committed patient, and you’re a practitioner that you feel you can help people with certain conditions you want to serve others. What are you suggesting they reach these patients to let them know they exist to get them into their clinic, this idea of the magic word to get committed patients? Do you have some suggestions for our listeners?

Well, yeah. I mean, we use a lot of paid advertising in my clinic. We’re hardcore about that. Last year, I want to say for 2018; I don’t have my books for 2019 yet, but for 2018 we spent almost $40,000 on advertising. What you have to understand is that’s for the entire year. Our monthly revenue is somewhere between 80 and $100,000, so you take that 40 grand we spent for the whole year. The point is, is that we’re spending that money and we’re paying Facebook and Google. We don’t do YouTube ads yet, but I want to be doing that this year.

To put the word out there in front of thousands of people every single day, every single day, here’s what we can help people with. Here are the things we help people with. What’s really cool about that is when you do that, you do it consistently over a period of time and you don’t like stop. That’s the thing. A lot of people make the mistakes like, “I run an ad for a month. It didn’t quite work. I’m going to stop.” Well, number one, you got to say the right thing in your ad. Number two, you can’t just advertise then disappear. Sometimes it takes six weeks, eight weeks, two months for people to see your name and get comfortable with you enough to actually take action. So you have to be consistent, especially at the outset.

What I was going to say is that we use those terms, we put them in ads so that people will see that word which applies to them. That’s like the leak in the chain that makes them stop and go, “Oh, wait, this is about me. Let me read this. Let me pay attention to this. Let me watch this video. Let me click this link and go see what this person has to say.”

When you know how to build this ecosystem of advertising and remarketed stuff and all that, you build a really powerful system to get people into your clinic. Like I said, we spent half of one month’s revenue per year on our ads. We never worry. We never ever, ever, ever, ever worry about whether we’re getting new patients. We get at least three to five new patient requests every single day, some days more, every single day.

You know what I’m doing? I’m in here treating patients. I’m at home. I treat patients two days a week. I see about 50 to 60 patients a week in two days. I have my associates. None of my associates are seeing less than 40 patients a week. One of them sees 70 patients a week, and it just rolls like that. I’ll have to check my ads every couple of weeks just to make sure they’re not getting stale, especially on Facebook. But other than that, man, I mean, it’s fun.

You’re having fun, and that’s a big part of it as well, having fun while you’re doing all this.

Yeah, it’s fun, man.

I want to thank you, Chris, for coming on and sharing. People, if they want to get to know more about some of the mentorship that you’re doing for acupuncturists on building practices, can you give us a website please?

Yeah, it’s chrisaxelrad.com. Axelrad is spelled A-X-E-L-R-A-D, so chrisaxelrad.com. I don’t have a big fancy website. Actually, the homepage is just a video, because I have a busy practice. I don’t have this whole thing, this whole big fancy operation-

His picture, it was good. I had a chance to see some of his material. So you’re right on, Chris. I know colleagues that have been doing your program and you’re transforming their practices, and I care about that because I want prosperous healers. I have a mission to help heal the planet, and you heal the planet by healing yourself, that was a self-care. So I think Chinese medicine is part of that as other modalities are as well, but Chinese medicine is part of that. It’s part of the plan. I think it has so much to offer on a spiritual, emotional, mental, physical level. So thank you for joining us.

For those you want to check out, I have healthyseminars.com is my website for Lorne Brown. I also just opened up lornebrown.com where I have conscious talk, so you can check that out at lornebrown.com. Next week, checkout To the Point. I’m at the AAC webinar series. We got Virginia Doran. Thank you guys very much.

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