Category Archives: Live Event

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.

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). 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/.

Yair Maimon thumbnail

The Spark and Evidence of Acupuncture


Hello, everybody. My name is Yair Maimon. I want, first of all, to thank the American Acupuncture Council to be kind to put up this show. It’s the first show for me on this platform, so it’s great to be here. I’ve called the show the Spark and Evidence of Acupuncture. Later, you will see why. I think I want to focus the show a lot on the evidence and on the confidence we should have in this medicine, but even more on the spark, I think on the uniqueness of Chinese medicine.

I’ve been a student and an inspirer of Chinese medicine for over 30 years. So it’s quite a while. I’m doing different things. My interest in is on two extremes. One is cancer, where I’m a head of a cancer research institute in the biggest hospital in Israel, in Sheba Medical Center, when I researched the effect of herbal medicine even to the molecular level, both on cancer and the immune system. I’ve published more than 20 peer-reviewed medical journals, so papers. So you can read them up. Although this show, and especially today, will be focused more on acupuncture, but also on the clinical thing.

I’ve been teaching also worldwide, I think, in the last more than 20 years. I have also my own clinical center in Israel, I’m from Israel, where we are about a group of 20 practitioners working together. I must say that, still, the practice is my passion, although teaching and researching all building up the full approach and understanding of Chinese medicine.

So I’m glad to be on this special show and share with you some of my experience, which I hope you will find useful for yourself, for your own clinic today or tomorrow. The idea is really to do a practical and in the same time I hope a little bit magical show. So I’ll put some slides. So please can you put this first slide on? That will be great.

This lecture is called What Do You Do When You Don’t Know What To Do? I chose this topic for a reason. I’ve been practicing, as I said, for 30 years, and I think it’s almost a daily phenomenon, not just for acupuncturist but for any healthcare provider. There is a lot of situation when you don’t know what to do.

So I set up on this small mission of asking colleagues who are at least 15 years in practice. I’ve asked 25 colleagues what they do when they don’t know what to do, and try to conclude something from my experience and other people’s experience. I’ve put it eventually all into one presentation and divided it a bit, I hope, in a special way. I took, I can say, the essence of what my colleagues are practicing Chinese medicine for many years, have kind of were willing to share.

I think, as we know, it is a great clinical dilemma. One of our problems is to move from uncertainty to certainty. We wish sometimes in the clinic we’ll have this kind of crystal ball that can look into the future. If we’ll do this point, this will happen. If we’ll do another point, this will happen. Therefore, let’s choose this one.

But that’s not the clinical reality. We have to take the pulse, check the patients, and then decide upon the diagnosis. What will be the best treatment and the best way to do it? We’d love to be certain. As I say, I put a dice, yes, no, maybe, on each dilemma, but this seems not seems to work.

In western medicine, it’s much easier. As I said, I’ve been all my life also in western medical setups. The thinking is linear, so there’s a much more comfortable solution, like in oncology, one of the fields that I’m excelling in in Chinese medicine and working in Chinese medicine.

In western medicine, eventually there is a diagnosis, there is a protocol, and there is some comfortability about it, which is very different to the way in Chinese medicine, because in western medicine, once you have a diagnosis, you have a protocol, and you proceed in what seems the linear way, which makes the physician comfortable and more feeling certain.

In Chinese medicine, the situation is very different. We’ll look at system, we’ll look at a much wider picture. So for us, there is much more options to make a clinical decision. This is really what the lecture is focusing on. In this kind of what seems to be very open space, how do we make the best clinical decision for patients, especially when we feel that I would say not uncertain, but we feel we don’t really know. We don’t have a final decision of what is the best to do.

I divided this lecture on purpose to three levels, to heaven, man, and earth kind of approach, because in the science of Chinese medicine, we divide things to a number, to one, two. When we reach three, we are really on the place of men on earth and we are on the real dilemma of human life. So in a man situation, we are between heaven and earth making our decisions.

As you will see, when I looked at the three layers of approaching this uncertainty, there will be a different answer. On a heavenly level, there’ll be an answer which more relates to the dao into a path. On a man level, more to the movement, into the qi. And on the earth level, more in material solution. Sometimes we need all of them together. Sometimes we choose one solution to the situation in the clinic. Therefore, we can look at the shen affecting the shen or affecting the qi or affecting the jing.

Each one has a different play in the clinic, and usually we are trying to affect this model, the three layers model, and get the best benefit to the patient. That’s why the shen, qi, and jing are called the three treasures.

When we manage to put them all together, we have a three-dimensional picture of the patient. I always say when you look at the past, then we see all the problems and pains that the patient bring. When we look at the present, we look at their symptoms. But when we look at the future, we look at their healing. So when we can put past, present, and future together in the clinic at one point, we are reaching the depth of treatments and the depths of human experience.

So let’s start with the solution of what do we do when we don’t know what to do in a heavenly level, on the shen level. That means that on that level, we’re allowing a presence of the shen, because for us, shen is one of the five substances in Chinese medicine.

So the spirit to us is not something strange or unreal. It’s a real essence of the body. It’s the most young, the most strong, the most effective, the one that connects us to oneness into the strongest abilities. Therefore, it’s present in the clinic and it’s present in creating healing. It’s definitely one of the key things.

When we are reaching the level of the shen and we don’t know what to do, we listen and we wait. We allow something which we understand is the dao, or the dao or the path of the patient to be present. We do, I think, the most interesting waiting. To me, the Chinese science present I think one of the most mind-blowing idea, is you do nothing. Wu wei means doing a non-doing.

So in a way, when we want to look deeper, we allow this moment of just not being involved, of just being present. In the clinic, it happens many time when I tell … And every practitioner is always … Have this experience. You decide on a certain point, you get to the patient, and you do something else. You realize that this change was exactly what the patient was needed.

So this doing a non-doing, it’s a new concept for us as western people, but it’s embedded in the core of Chinese medicine and Chinese medicine thinking. So on that level, we listen and wait. We allow something of the presence, the presence of the patient, his own path to be there. We’re just waiting.

Waiting is not just a Chinese medical idea because to me wu wei’s the source and essence of Chinese medicine. I took this slide and put also Bion [inaudible 00:10:23], who was a psychologist talking about nonverbal communication, and very much focused on this aspect of just seeing and listening and being present in a nonverbal way, which is strongly affecting the clinical situation. He called this book A Beam of Intense Darkness, because we always talk about light, but actually darkness allows everything to come out and appear in it.

So to me this idea is very strong in the clinic because when I don’t know what to do, I must say my own first thing is just to sit and wait, to put this beam of darkness or to put this endless space and to see what is coming up, and always something will come up.

But this practice, I think it’s one of the best way to start when you don’t know what to do. Instead of convincing yourself, “Oh, there is dampness, there is cold,” or something that you see in the patient and immediately jumping on a diagnosis when, in reality, there is a lot of option at that moment, and we don’t know which one to choose from.

So on the shen level, I think getting this inspiration also from the nonverbal communication, just waiting there, is perfect. I teach a lot what I call one minute diagnosis, because there’s so much we see in one minute. This is the one minute that we allow the whole complexity of the patient just to be present there and us being totally empty and trying to understand and connect and seeing the whole full layers of the patient.

A lot of time in this space, we move from uncertainty to certainty. We move from this deep darkness. Everything is possible into light and into something very specific. This space is a very healing space because in the silent, something comes up. This thing that comes out in the spur of the moment is probably a key for the healing and for the treatment.

A healing environment is very sacred and special. If it allows something happens there, sometimes we know what to do. It’s like almost obvious that this lecture focuses on this space, which is always important to hear, but definitely important when we want to see what’s the most core to the patient at this point when we treat him.

So to summarize this level and the way we can approach it is we start from darkness. We still remain uncertain, and we are fine with it. That’s not always easy to remain fine with uncertainty. We don’t move to certainty. We will use wu wei. We are not doing anything and we are not expecting anything. We’re not putting any pressure.

Then the second step usually comes. There is some movement to light. There is some kind of something that is emerging and coming up. I call it an insight and, a new word in English, enlight. Suddenly something emerging and suddenly we have some certainty in the direction of what to do.

This is really a place when we stay in stillness and something emerge and we approach it or we allow it. To me this level is one of the core levels when we don’t know what to do, and to allow this level in a kind of very, oh, we say almost scientific or didactic or diagnostic way, because we live in the western world. Everything needs to be certain, and uncertainty leaves us a kind of suddenly uncomfortable. I think that allowing this uncomfortable feeling and emerging from it with healing is the key for the level of the shen.

Now we’ll move to the second level, to the level of man. So to the level of man, we move to qi and we move to the movement of qi. In a basic way, when we move to this movement, I got a lot of response from the people I interviewed, and then they realize that a lot of great masters actually created different formulas to what to do and they don’t know what to do, or create different formulas of points that are moving the qi, harmonizing the qi in a very wide way that allows healing.

So when we move to the second level, I actually look upon different masters along the history of Chinese medicine, and I will present some kind of idea from us to tung and maybe even stop with the four command points.

The four command points are very simple and very easy. We can easily understand them. They are each directed to an area. Like we do stomach 36, if there’s something in the abdomen, if there’s something in the head and neck, you do lung seven. If there is a back, especially lower back, bladder 40. If there is something in the face and mouth, you do large intestine four. So you don’t know what to do, but you know these points will guide you to an area or will move qi in an area.

Therefore, it’s a good place to start when you don’t know what to do, because sometimes it’s like peeling an onion. We just move the qi, we peel this first layer, and then something deeper emerges or better clarity comes.

There’s two additional points usually for the four command points. For the chest and the heart, pericardium six. For fainting and collapse, actually also for lower back pain, DU-26. So this will be like a set of point. When you don’t know what to do and you want to move a qi in a certain area in a larger way, this is a good resource to start with in just generally moving the qi.

I looked very deeply at the five points, the 10 needles that Professor Tung suggested, and Miriam Lee, who was one of the first practitioners actually in the States, who was a very, very active practitioner, she saw about hundred patients a day and mainly treating just with this formula. This is the formula that she was using. Very known point, but if we go deeper, very clever point.

I think with acupuncture, we can be very elaborated with points. I’m doing a project, learning the points in depth, but sometimes using a simple point when we know why we are using them is extremely powerful. When we use them all the time, I think we are losing the sense of acupuncture and the fine-tuning of needling. But this lecture more focuses, you don’t know what to do, so this is a very interesting prescription.

It’s not superficial. It allows harmonizing the qi on that level in many ways. So stomach that is six, spleen six, large intestine for large intestine 11, and lung seven are the points of the five points and there’s 10 needles that can be used.

I’ll go very quickly point-by-point to explain how they are combined together. Sometimes we can use the whole five or inner combination, obviously with additional point, a bit like what we do in herbal medicine.

I’ll start with spleen six. Obviously, everybody know and use this points. It’s the meeting of the three yin of the leg. This point, if you look at the combination of them, we’ll see that the sum of the combination will be lung and spleen. We have stomach 36, spleen six. We have large intestine and stomach. So we have TaiYin and we have YangMing. So we have large intestine for large intestine 11 and lung seven. So we have this TaiYin, YangMing combination. We have a specific earth yin and yang combination and metal yin and yang combination. So we have both the qi, the yin qi and the wei qi presented in this combination.

I’ll briefly introduce my two colleagues there, Rani Ayal and Bartosz Chmielnicki. Together, we formed the group called the CAM team. We are producing the special book called The Gate of Life. The Gate of Life book goes deeper into the understanding of acupuncture points with a painter from Poland, Martina [Yankee 00:18:54]. She is painting these points.

Actually, here you can see the whole picture. This is a meridian, so all the meridians are painted. This is the spleen meridian. As you can see, it will start with spleen one and slowly, slowly we go through different points to the point that we are talking now, spleen six, when we have the three yin meeting.

Here you can see them. You can see the three yin women meeting and all the interaction with other meridians, et cetera, and turtle because it’s to do with the deep aspects of yin. I won’t go into all the symbolization, but just to give you this general sense of this book and the points. Probably in future shows, I’ll show some more pictures and going into different less known points and try to explain the dynamic of qi there.

So as we know, spleen six has a very strong dynamic. It both works on postnatal qi, working on the blood and damp. It’s connected with the liver and the kidney. So it will move blood. It will work on yin and jing. So we get a wide variety of effects on the body just using this point, when we don’t know what to do and we … Or we want to affect an area rather than a specific diagnosis. So we are moving from working on a specific diagnosis into affecting a whole area.

It will work on the lower jiao and the energy and everything that’s on the lower part of the body and, specifically this point and especially when combined with the stomach, will also affect especially the dampness in the lower jiao.

So this tung combination, when we look at this point, will be stomach 36 and spleen six working on earth. But not just working on the earth element, but also stabilizing, vitalizing the earth, affecting digestion in a big way, affecting the metabolism of fluids and dampness.

So you can see there’s already inherent combination that works on earth, and another combination that works … So it works on earth and digestion and another combination that works on breathing. Obviously, when we come to life, the first thing we do is we breathe and we need to eat.

So this combination affects this two fundamental aspect of postnatal life, of digestive system, and of the lung system. The combination of spleen six and lung seven will affect breathing and will affect the wei qi. We work also on the RenMai meridian in this respect. So from the tung combination, you can see how wide it is. The same with large intestine four.

I won’t go into each point in too many details because I think some of the points are more familiar, but it’s yuan point, so it’s a command point that affect, as we see, the face and mouth. It’s also a LU point, so it works closely with large intestine four, lung seven. Again, a great combination.

So we’re slowly moving into this tung combination system, and understanding this inner combination of large intestine four and lung seven, like this two command point, releasing also exterior, working on wind, working on the sweat. Our large intestine four and large intestine 11 working on the head, face, also affecting all the orifices and also releasing heat.

So you see how this tung combination, the deeper we go into it, the more and more we see how clever it is and how it affects so many aspects when we don’t know what to do, or sometimes just because there’s a lot of things present, and we want to affect all of them.

So large intestine 11, being in earth and he, uniting point, and taking also heat and affecting deeply the metal and the large intestine. Large intestine 11 and stomach 36 tonifies the qi and blood. It’s the Yang Ming meridian, which is so rich in qi and blood and, with large intestine four, also taking heat out. Again, you can add another points like Du-14 if there is extreme heat. Lung seven, one of the almost last points that I want to present here, again a luo point, opening of the RenMai. In a way, we are even tapping an extra meridian system.

Lastly, we are moving with stomach 36 into this kind of final part of this combination, looking at stomach 36, which is an earth point. But it’s not the normal earth point. It’s an earth point of the earth. I think this is the key of understanding this point.

By the way, this is the picture from our book. It always remind me because when I look at a picture, when I was taught stomach 36, suddenly everybody was saying it’s a three li. If somebody is tired, you puncture this point, and there’s the story. People can walk another three miles, three li. But in reality, the three li have different meanings. One of the li is like a small village that can sustain itself. So three lis is actually three villages that can sustain themselves. It talks about the vitality in this point.

Also, it talks about the three parts, as we can see here, of the abdomen, which are the avenues of the yuan qi that goes to the triple warmer. The three li can also refer to this very deep vitality in the body. But obviously being the earth of earth is the reason why this point is doing so much and it has so many indication, clinical indication.

So we looked at these points, and now I would like to move to the last part. We look at the shen part. We look at moving the qi in a general way, like in one combination, I think, which summarize it nicely and, the last one, through stomach 36, we move to the earth level.

Tapping into the yuan qi, tapping into the earth and the fundamental part of living on earth, because all the elements are surrounding the earth. So whenever we use points of the earth element, especially the yuan source points, we are really helping to stabilize human on earth and we are able to tap on some deep authenticity. We are able to tap on the resource of both qi, blood, and jing to help the patient to recover and regain health.

Stomach 36, that’s the reason why this point is so effective. As I said, it’s the earth of earth. Otherwise, there’s no other explanation why the use of this point is so strong and so critical. Then if you look at all the yin points on the yuan points on the yin meridians, the zang meridian, all of them are earth points and all of them are soul-balancing points.

Again, when we don’t know what to do, yuan points will be the first one we will consider affecting directly the element itself, but also deeply the qi and the yuan qi. Here I’m just showing a simple combination. Liver three, stomach 36, lung nine, all earth point. So we work on this axis. The same way can be heart seven and kidney three with stomach 36, working on the creation axis. So both we can work on the formation or creation axis, just using yuan points, and achieving something very deep.

So to finalize, when we don’t know what to do in the clinic, we can relax. Nothing is under control. It’s a normal situation. But I think if we follow this kind of deep logic of looking at shen, qi, and jing, something unfolds. Then we move from uncertainty to certainty.

So I would like to thank you for watching this. I hope you enjoyed it. Be well. Thank you very much. All the best to you. I want to add maybe some … I can stop the slideshow and maybe just add some final note.

First of all, I want to mention that next week on this show, there’ll be a good friend of mine, Moshe Heller. Also, you can follow the next shows that I will do on the American Acupuncture Council. I hope you enjoyed it. Do write comments. I promise I’ll try to answer. All the very best to you and be well. Thank you very much.

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). 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/.

 

Sam Collins for HJ Ross

Proving Medical Necessity Dr. Sam Collins & HJ Ross

 

Hi, everyone. Happy New Year and welcome to 2020 and to the first episode of To the Point for the American Acupuncture Council. I welcome you in, and I want to make sure we have a clear vision for the year. Of course, I’m going to probably overuse the 2020 reference, but nonetheless, let’s make this a good year and let’s make sure we’re understanding what’s going on [inaudible 00:01:16] make sure our practices are doing okay and better, but also how do we make sure we’re dealing with when someone says, “Are your services medically necessary?” How do we determine that? What does an insurance look for? What does it really mean? I think ultimately we know what it means in the sense that we have to show the patient is better, but ultimately what does an insurance company want? So let’s really focus on that today.

So let’s go to the slides. Take a look here, and I start off with insurance medical necessity for acupuncture. And this is really based upon an insurance company. Whether we agree, disagree for the most part doesn’t matter because it’s what the insurance companies say. So here are the medical necessity factors as per insurance, and this is specifically through Cigna, though you’ll see this is a repeat with almost every insurance. It says “Medically necessary services must be delivered toward defined, reasonable, and evidence-based goals.” In other words, they want to see that we’re going towards something that we can have an expectation of reaching a specific goal.

“Decisions must be based on patient presentation, including diagnosis, severity, and documented clinical findings.” So if you think of it, diagnosis and severity are only a part. The clinical findings help determine the severity and the diagnosis. So what I will say is it’s always ultimately best to have something that you can quantify clinical findings to show the patient is better.

One of those clinical findings could be a pain scale, but that’s not as accurate because I’m sure you’ve noticed, some people will tell you their pain is a nine, but yet clearly it’s not a nine based on their function. So I want to focus a little bit more than that. It goes on to say, “Continuation of treatment is contingent upon progression towards defined treatment goals and evidenced by specific significant objective functional improvements.” And I think it’s interesting to note here it doesn’t really focus as much on pain as we might think, but more about functional change or outcome assessments. And the reason why I think is that’s something we can measure. A pain scale, though it’s something that gives us a feeling of where the patient is at, it’s subjective. We want to try to focus more on objective factors, so outcome assessment scales and range of motion certainly will do that.

In addition, realize that certain conditions could be severe enough, maybe they’re going to be co-managed. By example, the company Evercore, which manages a lot of the Anthem policies, now covers things like mental disorders, post-traumatic stress disorders, anxiety, but you probably won’t be treating that just by yourself, but part of a co-treating. So, in those instances, making sure if you’re getting a diagnosis of say post-traumatic stress disorder, you’re not making it alone but co-managing along with another healthcare professional.

But it says, “Medically necessary services, including monitoring of outcomes and progress with a change in treatment or withdrawal of treatment if the patient is not improving or regressing.” So the idea is that the patient should get better with care, and if we withdraw care, they’re not getting any better or worse, clearly it shows the care as not medically necessary.

So that all sounds well and good, but really what are they looking for? They’re looking for the patient to have a treatment plan individualized. Now, obviously there’s going to be a lot of similarities with similar conditions, but it should correlate with the clinical findings. The more severe condition, the longer the plan may be, the more intense the care. Think of someone with simple back pain. They just woke up with a little back pain. It’s not going to require as much care as someone with say cervical disc degeneration. That’s chronic. So realize that some of those goals are going to be based on some of those factors as well and how much.

So ultimately, those should be this. Treatment is expected to result in significant therapeutic improvement over a clearly defined period of time. So, when you’re making a treatment plan, please make a plan. Tell me how many visits you’re expecting to see this patient. For instance, you might say, “I want to see them two times a week for four weeks,” meaning a total of eight visits. But then what are the expectations of that? Make sure you’re defining what do you expect to see? Do you expect 100% improvement or maybe a 50%? And that’s kind of where you want to go with it. Don’t have expectations that always says, “I expect the patient to be pain-free within X number of visits.” But you should see a clearly defined improvement.

So, by example, maybe after three to six visits, a 25 to 50% improvement in the pain, as well as a 25 to 50% improvement in function. The difficulty is the pain scale is easy, but how do we define function? And that’s what I really want to emphasize, what insurances will look for.

So, when planning, they say they want therapeutic goals that are functionally oriented, realistic, measurable, and evidence-based. So my takeaway here is to make sure that, when we’re writing a treatment plan, don’t simply focus on the patient having a decrease in pain. That’s certainly fine, but it’s not enough because they want something that they can measure, and it’s evidence-based. And again, the pain scale is too subjective to really accomplish that.

There should also be kind of a proposed release date or end time. That doesn’t mean that’s going to be the absolute. If I say I’m going to treat someone two times a week for four weeks, certainly, hopefully I’ll get them well sooner than four weeks or at least by four, but that’s not carved in stone. Realize potentially, after four weeks, the patient may have improved 75% but may still have a little bit more. The point here is have at least something that kind of gives an approximation.

What insurances are leery of is when someone says, “Well, I don’t know, I’m just going to treat until they get better.” There should be something that kind of gives you some type of feeling towards what are your expectations, and a lot of that is just based on your good old experience as a practitioner. What has been your practical experience for when patients have similar conditions how long it takes to respond? And, of course, there’s always all types of complicating factors.

So here’s what we need to do. In fact, this is what is directly stated in the Cigna guideline for medical necessity. It says, “Functional Outcome Measures, when used, demonstrates Minimal Clinically Important Differences from the baseline results through periodic reassessments.” So, in other words, what an outcome assessment does, it’s an easy way of measuring function. It’s not so much how much does the pain hurt, but how does the pain affect you doing certain tasks, maybe getting in and out of bed, sitting for long periods, doing your work, doing home chores, and those are things that we can certainly measure and manage.

And then it says, of course, “Documentation substantiates the practitioner’s diagnosis and treatment.” That’s kind of a given. Certainly what we’re going to be treating with the exam should demonstrate that. What I’m going to emphasize to you today is start implementing something beginning this year where every patient that you’re going to treat with insurance and going to treat for any extended period of time, you want to begin using outcome measures, and these are things like [inaudible 00:07:40], neck disabilities, which frankly are a little complicated for most patients. But nonetheless, you want to have some type of instrument to help you do that because here’s what they want is demonstration of progress towards an active home care, meaning the patient gets to a point where they can help themselves at home. Maybe you’re going to start with back pain and then eventually get to where they’re going to do more stretching, yoga, Tai Chi, so they can really kind of deal with it on their own, or they really maximize it.

Ultimately, they want to make sure that, if you’re going to continue care, maximum therapeutic benefit has not been reached. How can we measure that maximum therapeutic benefit has not been reached without an outcome assessment? Think of it much like a person on a diet. If you put someone on a diet, the only way to show that they’re losing weight is to measure that, and you want to measure it in a way that is quantified. So clearly, the simplest thing for weight loss would be putting someone on a scale, and that scale will say they weigh 150 pounds, and as they lose weight, they obviously will lose weight, 150 to 145.

The key is it has to be significant. We can’t certainly say the patient weighed 150 pounds, and now they weigh 149 and eight ounces. That’s really not going to be a significant amount. So we want to have something a little bit more than just that, but something that we can measure.

So here’s another example. Now, I just gave you what was Cigna’s. This is the one from the company Evercore. So, if any of you deal with a lot of the Anthem Blue Crosses, and I’ll let you know also United Healthcare and Optum Health use this company. And here’s what they say for when it comes to functional assessment. And it says, “Documentation of a patient’s level of function is an important aspect of patient care. The documentation is required in order to establish the medical necessity of ongoing acupuncture treatment.” And they go on to state, “The patient’s specific functional scale is a patient-reported outcome assessment that is easy and appropriate for acupuncturists to use. This so-called PSFS has been studied in peer-reviewed scientific literature and has been proven to be a valid, reliable, and responsive measure for a variety of pain symptoms, including neck, back, knee.” I would say you name it. It probably works with anything, even headaches.

But notice that they’re giving us a tool. They’re saying they want to see the patient’s specific functional scale. So my rule would be, if that is the type of protocol they want to see, let’s make sure we give that because notice they’re going to give you the objective findings that they also want to see. Notice it says, “inspection, palpation, range of motion, motion palpation of spine, orthopedic testing, neurologic testing.” Now, this, of course, would be a person with back pain, but I want you to notice none of this really focuses on the pain as much as the result of pain, their level of dysfunction.

So I’ll give one more. The veterans program, I’m sure you’re familiar. Many of you are probably treating VA patients through the PC3 program, formerly known as Veterans Choice. And here’s the two things they say on the standard episode of care for acupuncture. It says, “The result of care should result in significant durable pain intensity decrease,” and they actually say on a VAS scale of zero to 10, so that’s good. We still want to use that. But to go beyond that, we have to have a little bit more because notice the next thing they want is also “functional improvement by clinically meaningful improvement on validated disease specific and outcome instruments or return to work or improvement in activities of daily living.”

So you’ll notice the pain scale is a part, and when that pain scale is positive, we’re going to have improvements here. So, at the very least, even if you’re not using a validated form, please make sure you’re documenting maybe three or four activities that are being affected by their condition and as that condition improves, how those improve as well.

Do always make sure you compare apples to apples. I used earlier the example of weight loss. So let’s say you put someone on a diet, and week one you put them on a scale, and you weigh them. But then week two, you don’t weigh them. You measure their waist circumference. Well, unfortunately, because we’re doing two different types of measurements, comparing those two will give us no idea of how the patient’s changed. So do be consistent. If you’re going to do some functional things that are not on a validated scale, please make sure to make them consistent. Whether or not it’s the activity you come up with or the patient does, so long as we have some consistency, it’s going to show the functional change.

The other thing the VA says though, and this is something that is worthwhile to do with any patient as well, is “documented decrease utilization of pain-related medications.” Now, of course, we’re not going to tell a patient that they should or should not take them, but we want to monitor the levels. When a patient’s in a lot of pain, they’re probably taking many more. As they’re getting your care and improving, all of a sudden they may say, “Hey, I’m no longer taking it at all, or maybe taking far, far less.” Notice all these demonstrate the changes of the patient. Instead of relying on “I feel better,” let’s rely on something that we can measure that no one can dispute.

So, by example, here is the patient-specific functional scale. And you’ll see here it’s simply just a questionnaire. And what this questionnaire does, it talks about your initial assessment, followup assessments. But what I want to focus on, notice it has a scale here that says “patient-specific activity scheme.” If it’s a zero, they can’t perform it at all. If it’s a 10, they can perform it fully.

But what’s nice here is notice you’re just going to score this maybe every two weeks, but you have to indicate what type of activity. The activity could be sleeping. The activity could be how long you’re sitting, lifting, bending, carrying for home activities, any of those. It’s your choice to come up with it, but notice what this allows you to do is to take something specific to your patient and then beginning to grade their changes because all they’re looking for is did you make the patient better? The easiest way is by function.

So this is the patient-specific functional scale. I like it, but because it takes a little bit of extra work to come up with those activities, you may well like something like this one. This is called a general pain index. Now, general pain index, you’ll notice at the top, it says, “We would like to take a moment to see how your pain presently prevents you from doing what you would normally do.” Notice it’s not talking about how much it hurts but activities.

But just like the patient-specific functional scale, you’ll notice this one already has the activities listed. Notice, family, recreation, social, employment, self-care and so forth, and if you go to the bottom here, life support. The one thing that is different though with this one, completely able to function is a zero, unable to function is a 10, so it’s a little bit opposite from that standpoint. But notice what it simply does is give us a way of measuring how the patient is doing. I really like this one because I pretty much don’t care what I’m treating the patient for. Whatever you have, even abdominal pain is going to affect these things, and as those get better, the function’s going to improve.

Now, along with that, the VA has given us, of course, a pain scale. The one thing about this pain scale that I think you want to see is it’s not the traditional pain scale many of you are used to about, well, the 10 is when its at its worse. But I’ll just have you notice these indicate things more about activities. Look at number five. Their pain level is five because it interrupts some activities, whereas number seven, the focus of attention of the pain prevents you from doing daily activities. So it’s not that it’s not pain, but it’s more functionally based. And what’s very nice about this type of form, it’s two-sided, and there’s four questions on the back that goes over how it affects your activity, your sleep, your mood, or your stress from a zero to 10 scale.

Now I’m going to offer you this one, if you’d like. Just text AAC Network. You’re going to text to the number you see 714-332-6926. And when you text that number, you’ll get a little bounce back that’s saying, “Hi, how are you, what’s your email?” And then once you send your email, we will then send you a copy of this form, and then that way what I would suggest to do is print it out and use this now as your pain scale, which means you’re getting away from talking about how much it hurts, but also how much it hurts and how the patient is functioning as a result of that.

And I do like this one quite a bit because it doesn’t just focus on activities of daily living, but sleep, the patient’s mood, their stress level, and those all certainly are going to play a factor, and I think many acupuncturists ask those questions. So certainly, if you have a moment, go ahead and text us. We’ll send you a free copy, no charge to you. It’ll be in color. I suggest print it out, maybe blow it up to a poster size.

Ultimately, do keep one thing in mind. Acupuncture is considered not medically necessary for these two things, and do bear in mind treatment intended to improve or maintain general physical condition. Now, as a person that likes to keep himself healthy, I think this is the thing most people should do, but this is just not something that we do directly with treatment. But this is lifestyle. So once a patient has reached a point where you’re doing this, certainly you want to put them on maintenance. And I do believe there’s a benefit to getting care, but it has to be paid by the patient, not insurance.

And then, of course, it says maintenance services when significant therapeutic is not expected. Now, one thing I would suggest on this last one, there are times that could be supportive care, so by example, the VA even indicates this and will allow chronic care. Let’s say you withdraw the services. When you withdraw the services, maybe after two to four weeks, the symptoms get much worse. They may well allow supportive care. And I want to be clear, I’m saying supportive, not maintenance.

Ultimately, medical necessity for acupuncture, in my opinion, is quite simple. Acupuncture really helps a patient decrease their level of pain, and as a result an increase in function. If you focus on both factors, the pain and the function, that is the easiest way to demonstrate true medical necessity because it’s not just the reliance on “I feel better.”

So I wish you the best. Please take a moment to download some of those forms. Ultimately, American Acupuncture Council is here for you. We offer lots of programs, whether it’s coding, billing online, whether it’s a live seminar with [inaudible 00:17:45]. but we also are online. If you want to go to Instagram or Facebook, we’re there, and we put out news. We’re not there just to promote a program, but to really make sure that you’re doing well. Our goal at American Acupuncture Council is to make sure you’re successful. Ultimately, if you’re not successful, we don’t have our own ways of dealing with making sure we have a business. We want to make sure this profession moves forward, and to give you a highlight, the acupuncture towards Medicare is still moving forward, so there’s a lot of positive things happening. And I’ll see you next time. This is Sam Collins, the coding and billing expert for the American Acupuncture Council, and I wish you the best.

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). 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/.

Best of TCM Research in 2019 – Drs. Doran and Barzilay

 

Hi, I’m Virginia Doran, host of To The Point, generously hosted by the American Acupuncture Council. Today, my guest is Gil Barzilay, and if you haven’t heard him speak, you’re in for a treat. He has a big following internationally, and besides a diploma in Chinese Medicine, he also has studied Chinese and Macrobiotic Nutrition, Kiiko Matsumoto-style Japanese acupuncture and he actually went to college in London at the Imperial College there at the University of London. Has a PhD in from Oxford in Cancer Research and European Medical Biology, post-doctoral fellowship at the Weitzman Institute. He’s got 11 peer-reviewed publications in leading medical journals.

He brings a special dual knowledge in the field of cancer research as well as other kinds of research. He works in Tel Aviv in Israel’s leading complimentary alternative medicine clinic, Rehovot, and he teaches acupuncture, Chinese medicine, research issues all around the world. He’s part of the International Committee of Chinese Medicine, ICCM, which holds an annual conference, which I hear is just fabulous. He also works with the Evidence-Based Acupuncture Foundation and writes regularly, reviews and newsletters.

You can see him on Facebook at DrGilTCM and/or contact him through the ICCM or Evidence-Based Acupuncture. Anyway, without further ado, I would like to introduce everyone to Gil Barzilay.

Thank you, Virginia.

Sure.

What a long introduction. Yeah, that’s all right.

Well, you have a lot of credentials.

Thanks for that.

I wanted to ask you, what makes a good research study in your opinion and why? The studies that you’re going to speak about today, why are those your best of?

Okay. There’s about a thousand, I think, publications that are published on Chinese medicine every year. I get those alerts on Google twice a week. There’s a lot of information, but I think [inaudible 00:03:41] Western medicine research apply for Chinese medicine research without going into the debates, include having randomized controlled studies. So having a control, comparing a compounder to something.

There’s been a lot of debate on sham acupuncture, and I’ve seen some of the speakers that you’ve had before. I’m sure the debate of what sham acupuncture is and whether it should be controlled has been up there, so I’m not going to go into that, but there has to be a good control of some of the subs that have chosen to date had not been in any could control. They have to have a good number of patients. So of course if these Jersey studies are made in China, they sometimes can have thousands that are conducted in North America or in Europe. We’re probably talking about a hundred patient, maybe a few hundred patients.

Also, the third component of whether the study is good or not in my opinion, is having objective and [inaudible 00:04:47]. So we’ve seen a lot of placebo research that has been conducted actually in other universities around the world. One of the ways to better understand whether something works or doesn’t work is having objective and subjective measures. Because when you ask patients only, “Has your quality of life improved?” or something like that, it really depends on the data in the hospital or the clinic, so the answers can be so confusing and really not good enough for measuring the effect of an intervention.

Having a mix of both of them, these are the three that I’ve chosen have these within them.

Mm-hmm (affirmative). You know, I just wanted to interrupt for a second. I’m hearing a reverb. I don’t know, are you hearing it at your end, kind of like an echoing with the technology?

I’m fine. I can’t hear anything.

Well, hopefully the viewer won’t hear it. Okay, good. I guess there’s a little bit of one, but as long as we can still understand you. So tell us about your criteria for a good research study and why these ones are your best.

So, these are the three that I’ve chosen, but I wanted to start with putting things in little bit in a context of where we are now in terms of, not the world we live in, never talk about global warming, but I did want to share some slides. So let’s move into the slides that I’ve created. One second. Have I done something wrong?

Thank you so much for making these slides because it really helps the viewer to anchor that information.

One second. I need to put my glasses… new share.

Oh, I see the slides. Alan sees the slides.

See the slides, but they’re not moving forward.

You can’t see them.

No, I see them, but they’re not moving forward. Oh, now they are. Okay. Okay, no, something’s not working.

I see the title but not the content.

What’s up with the slide?

It says stopped sharing.

Okay.

All right, good.

Now it is on, but okay, let’s see. Okay, so I wanted to put things in context because I wanted to say that one of those things that has been… One second. Not working, yeah, I know. Okay, so one of the things that we’ve seen this year is that of course there’s some things coming about Chinese medicine for the fact that is making it into the clinics with the World Health Organization a categorization of acupuncture as a medicine. Of course that got some good headlines, and then some nasty headlines like the integration of quackery with real medicine.

We have, of course, on the right side you can see Novak Djokovic during the tennis U.S. Open bragging about being treated with acupuncture and the moxa. You see Lady Gaga showing you off her cosmetic acupuncture, but at the same time you have some bad news like Spain planning to ban alternative medicine in health centers. You have an article here that was published the Forbes Magazine that says, “Don’t do this: 156 medical practices that are all failures,” and saying that acupuncture is quackery again. Then you have this silly photo on the bottom right hand that shows guy and says that veterans deserve better than as something that doesn’t work like acupuncture.

On one hand you have some good news, but on the other hand you have some… And some people supporting us like Novak can maybe Lady Gaga and others. On the other hand you have some bad headlines as well. At the same time though, the treatment landscape is really changing. There’s a lot of issues with the opioids, you know it very well, especially in the States, but also in Europe, very high numbers of people dying and if not at least coming to the ER.

But it’s not only the opioids, FDA has put additional box warnings and contraindications on the insomnia medications. You have Xanax, which is now the number two problem after the opioids.

Really?

Yeah, and of course the nonsteroidal antiinflammatory drugs that look like Advil or Neurophin, that look very innocent, but actually increased double and even more than double the chances of having a heart attack. Even more common drugs like Advil and others have have real health issues coming in with them.

That means that people are seeking out alternative. When we have the evidence with research, whether we are really interested in conducting research or not, it can actually support our case with the different organizations and with the health authorities. You can see that treatment guidelines all over are now embracing acupuncture as well when the evidence was solid enough.

You have here the American College of Physicians are clearly stating that acupuncture is one of the treatment options guidelines with clear recommendations on a first and second level that acupuncture should be one of the ways to treat chronic and acute pain. You have NICE, which is the British body of excellence, clinical excellence, recommending that treatment will be given prophylactically for migraines. You have ASCO, you know the American Society for Clinical Oncology in dosing, acupuncture for breast cancer patients.

We have the American College of Rheumatology embracing acupuncture, and now you also have the Adult Stroke Rehabilitation and Recovery using acupuncture. So when you have research, perhaps not all the doctors, perhaps not all the medical community’s aware of it, but when you have evidence bodies and health authorities listen to you, and then they recommend it and may even include it, and I’ve seen throughout this year that several insurance companies in insurance bodies in America have also included acupuncture now as one of the modalities of frequent, so that can only happen when you have good research.

Absolutely.

After all of this introduction, I’m going to go into my top three for this year. So I chose top three that are not within a typical pain and migraine and other areas that we already have enough evidence that acupuncture works and there’s no point in repeating with an additional study that may demonstrate that acupuncture works for pain. We know it does.

I wanted to show some studies that perhaps not everyone is aware that exist, and are pretty solid, and I recommend that people go and read them in full. The first one is a study from Italy that looked at the effectiveness of acupuncture on pain and functional disability for people with rheumatoid arthritis. The studies from a group of medical doctors in Rome, they included 105 rheumatoid arthritis patients that were divided to get either real acupuncture or [inaudible 00:12:53] acupuncture, which I don’t usually like, but they included that. Acupuncture outside meridians or have a wait list, so not receive any acupuncture at all, while at the same time the entire group were continuing with their own treatment, whatever they had already for the RA. Either it was a nonsteroidal drug or a disease-modifying or biologics or any other analgesics that they were getting for their RA.

They received a treatment for three weeks and they were followed for additional four weeks and the points that they use there adjusting people are short of reading the study itself, it was Triple Burner five and Goldwater 39, Hartswean Keeper seven. Just to show you when I was talking about objective and subjective measures, I know this look complicated but it’s actually quite easy to read.

You have in a solid line those who receive real acupuncture, and the dash line, those who receive control acupuncture. You can see that they were doing some auger battery and arm strength as well and quality of life and pain. They were trying to assess pain. They were trying to assess the ability of people to move their hands and to feel pressure and how much pressure they can take on their hands. Of course also asking questions about quality of life. You know all these parameters acupuncture was better than a wait list or sham acupuncture. In fact, they were also looking at the number of swollen and tender joints, and there were also significantly decrease in those who received real acupuncture.

We know that acupuncture is good for lower back pain, for knee pain, whatever. This is one of the few studies that I’ve seen on rheumatoid arthritis, and it’s good also to see that it’s not only the pain but the also the functional, mobility of the patients to do things, to do normal things we do every day. That’s the first study.

Well, that’s good. I was going to ask you to explain to the audience what control acupuncture is. I haven’t heard that.

So control acupuncture, in this case it’s the sham acupuncture. They were asking if you saw on the first slide they were using acupuncture points that were not on the meridians that were relevant to RA. So that’s one of the options. One of the issues, of course, with that type of control or what is called sham acupuncture that we’ve seen in the past it doesn’t work. When you stick a needle in someone, something happens, it talks to the brain and it tells the brain, “Oh my God, you know, something has happened. React.” So just because it’s outside of the Meridian doesn’t mean there’s no reaction. That’s what we’ve seen over the years when the original studies came 30 or 20 years ago with acupuncture, we’re comparing to what they call placebo puncture.

They were comparing to needles that are at two points that are not supposed to be relevant to the disease that we’re talking, but they did actually work in a way. And so all the ones that don’t like us and think that we’re quackery or with some sort of holistic voodoo medicine, we’re saying, “You see, it doesn’t really work.” It works, even when you put needles in a place that shouldn’t work, it does work a little bit. So this whole thing, acupuncture is just not real medicine.

When they moved into doing better controls and/or comparing to people who are continuing to just take their medicine or not receiving any additional treatment, they could actually see the real effect. That’s how, in my opinion, studies should be conducted. But in this group took the double approach. They did a sham control and they did a waiting list as well. In both cases it was working better than either. So that was a good control.

Great.

Okay, so the second study, it’s actually something, and that’s why I put two studies here, but I’m not going to go through both of them, is a phenomenon that we’ve seen over the last almost 10 years. When you do acupuncture to patients who are depressed and are taking SSRIs, the results are faster, better and with less side effects. Some of the reasons from a mechanistic point of view, people have said that if you put needles then since we have seen already the effect that needles do on increasing serotonin levels in the brain, that could relate to that, don’t really understand the [inaudible 00:17:47] of why acupuncture actually helps for patients who are depressed and are already taking SSRI, but that’s effect.

This is a study that was trying to compare manual versus electro acupuncture as an add-on therapy to SSRIs. What they did, it was more than 400 patients. 156 were taking SSRIs only. 161 were receiving manual acupuncture, and 160 patients were receiving treatment with needles, with electro acupuncture. The patients were all on the usual dose of Paxil and Seroxat statin they were taking for six weeks, and the patients received treatment over six weeks with three sessions a week, and they were followed up for an additional four weeks. The points that they were using, you can see here is GV20, the Yintang, GV16, bilateral Goldwater 20, GB14 and bilateral pericardium six and spleen six. When you look at the results, they both showed that manual acupuncture together with the SSRIs or electro acupuncture were both significantly better than SSRI.

At six weeks the response rate for the SSRIs was better. There was an early onset. The level of depression that was assessed is one of the markers as well. Side effects were lower and also the number of patients that had to have their SSRI dosage increased was lower with those who received acupuncture. So acupuncture really does good for patients. I think it’s a good thing to know because I’m pretty sure that there are quite a few acupuncturists that when the patients ask them, “Do treat depression?” or “Is it going to interfere with my therapy that I’m taking now?” The answer is clearly, “No, actually probably it’s going to work better.”

Mm-hmm (affirmative). Now, would it affect the dosage they would need to be taking?

It may affect over time. In this specific study, they actually showed that the number of patients who had to have their SSRI dosage increased over time was less when they received acupuncture, so there was no need to even go and increase your dosage. It’s only one study that actually assessed this. I wouldn’t see that as the key outcome of this study. But the fact that it’s keep on repeating yourself is quite interesting. I think that many people, we’re all very easy sometimes on treating pain because we know it works, but some of the more, life [inaudible 00:20:41] it’s good to know that if a patient or a relative asks, “Does it work with [inaudible 00:20:47] or clear with my therapy?” The answer is definitely not. It may actually even enhance it, and you may even have less side effects.

Mm-hmm (affirmative).

So that’s good news.

Yeah. Definitely.

Okay, let’s go to the third study. This study made a lot of noise in the last year because it was published in JAMA internal medicine, which is a very important journal. It was looking again at acupuncture as adjunct therapy for chronic stable angina. The reason why it caught some attention is because the results were too good or there was a community to relieve. So there was some nasty headlines I’m not going to go into, but if you just Google it yourself, you’ll see some nasty headlines on WebMD and other website of people really unhappy with the results.

Mm-hmm (affirmative).

Yeah.

Antithetical to what it should be. Instead of being happy there was something for patients, they’re more concerned about the political aspects of it.

Well, the thing is that I never really understand it because if the results were choose acupuncture, don’t take drugs, I would have understood it. But actually this studies acupuncture together with the existing drugs. So there’s no competition here. Always saying is, Let’s integrate,” or “Let’s see whether acupuncture actually even improves what the drugs are doing,” because the drugs can only do up to a certain point and they don’t even work very well. [inaudible 00:22:31] we’re not taking off the presses. Don’t worry about it.

[inaudible 00:22:36] pharmaceutical. We’re just suggesting that if you add acupuncture, you can even have better results and your patients will be happier. We’re not taking their job or their sales, but that’s the way it is. Yeah. So these were again, 400 patients. It’s a nice number. They were divided into receiving acupuncture on the disease on meridian. These are [inaudible 00:23:05] bunch on the non-affected meridian sham acupuncture, which was a not real points and no simulation and wait list. In my opinion they’ve done a little bit much [inaudible 00:23:19] after all, but the [inaudible 00:23:22] we had more patients than what they chose to do.

It was four weeks, three times a week, and then six weeks follow up. So that’s a long followup as well. You can see all in all, it’s about four months. And again, no harm to the patients. All received their anti-anginal whichever day were making them ready as recommended by the doctor. So you could be a bigger block. It could have been [inaudible 00:23:57]. So I feel safe.

Yeah.

Now, if you look at the results, you can see here the frequency of angina attacks, and you can see here that the patients who received the real acupuncture and the reduction is significant. [inaudible 00:24:14] well, attack to less those received and none acupuncture. Meridian had also some reduction, but down to 10. Sham acupuncture down to 10, and those who were on the wait list had a reduction of one attack, one and a half attack.

Now, the interesting thing is that, remember that all the patients are continuing to take their anti-angina drugs, but they don’t work. Because you can see they started with almost 14 attacks, and they ended up with about 12. When they had acupuncture, it was halved, so the number of angina attacks you had was down by half.

Like I said, WebMD, [inaudible 00:24:59] it didn’t matter, and you don’t call [inaudible 00:25:06] top cardiologists, Americans in Europe saying that this results are too good to be true. Since this study was not done in America, you never know what happened, who conducted this study and whatever the results were, made up or something. So that’s the way it is.

That’s amazing. That’s a really dramatic one. Yeah. I like that.

Yeah, and that’s a reason perhaps they didn’t like it is that you can see that since since the patients were taking the drug and it didn’t really work, they were seeking additional options, but there are no real additional options. You can go to natural path, you can go to your homeopath or I mean, or acupuncture. That’s about a few of the alternatives. [inaudible 00:26:10] do to drugs obstacle therapies. So yeah, the results are too good to be true, but that’s the way it is.

The reverb was a just occurring a lot. Alan said to ask you if you have a cell phone maybe nearby.

Near? No, no, no, it’s two rooms away from me.

Huh, okay. All right. I have one nearby, but I don’t know that that’s it. I can’t read what… Okay. So you know, with a little bit of time that we have left, can you talk about acupuncture and the research that’s relevant for the opioid crisis that we have. I mean it’s really an epidemic here. It’s so unfortunate and the politics don’t really support the real regulation of the drug companies with the pharmaceuticals that have… Not that that’s the whole root of the problem, but that’s a big portion of it, how it became so big. Can you speak about that from your knowledge?

Yeah, Alan has written something that is important. Cell phones should be off no matter where it is. Okay. It’s off. It really is off. I was a good boy before.

Yeah, so I’m just curious, is there much research for that? Things that we can give to doctors or patients? I mean, there is for pain, but what about addiction?

There is some research on addiction as well, especially the one that was done with veterans in the U.S. with the veterans’ associations and several of them. I think there isn’t enough research that has been done. That’s perhaps part of the problem, because I think in the first few years after the opiod crisis has become such a crisis that the people, you know, the American Physicians Association and others had to react to that and seek alternatives.

The first instance was for an alternative and so acupuncture would be an alternative for treating pain. And that’s correct, and that’s worked. The American ACP and also the American Medical Association, all the other associations, including a bunch of also one of the ways, one of the modalities people will notice. Then only since about 2016 or ’17 you start seeing research being developed and done now on whether [inaudible 00:29:16] in addiction.

We begin to see the results now. The results are interesting and positive, but I think the studies that I’ve seen to date are quite small, and so [inaudible 00:29:32] happy with with. It’s interesting and it’s going in the right direction and perhaps it’s even not even surprising but I don’t think there isn’t enough publications to wave and say, you know, we can also help with coming off addiction.

We can definitely do that and we know we do that, but the research is still, I think, [inaudible 00:30:00] to available. Talked about it.

Is there anything else you wanted to say in conclusion? We’ll have to have you back at another time to talk about things and get that sorted out.

I would just recommend for people to once in a while, I mean if you’re not interested in looking for research or if you don’t know where to look for it or read it, look at for example, the summaries that we are doing the evidence-based acupuncture website, because that has a lot of resources for people who don’t have the time to read or really not interested in research, it’s too complicated. [inaudible 00:30:47] and all of it is okay.

We summarized the highlight and we tried to make it accessible so that every therapist, wherever they are in the world can actually discuss it also with their patients, because we know that when patients sit in our office or lie on the bed with needles, they start asking questions for their brother, sister, mother, son, neighbor, and sometimes it’s beyond what they themselves came for. But there’s a lot of evidence out there and so if you can’t be bothered and that’s totally okay, go for example the DBA website and have a look at that, or look for research courses.

I’m sure there are in America, there’s some online as well and there’s plenty of research around that we can use and convince people. Local hospitals, local clinics. [inaudible 00:31:47] integration. No one is saying that acupuncture is better than drugs or that drugs are better that well. pharmaceutical companies are saying that drugs are better than [inaudible 00:31:58], but I think that if we integrate, it going to work really well. This is where we have integration in all hospitals, it’s really amazing, in oncology, in pain, in orthopedics and some psychiatric.

It’s working quite well. It took 10 or 15 years of fighting with the evidence. So you need to know the evidence for that.

But you know, we owe people like you and Mel Hopper Koppelman and John [inaudible 00:32:31], so many people, I can’t even name them all, but it’s really a gift, what they’re doing for the field, and we need to support that. It’s a really great organization and it’s for the sake of all of us.

So, anyway, thank you so much for coming, even though you’re in Tel Aviv and I’m in Connecticut, but thanks for taking your time to share your knowledge and we’ll hope to have you back again sometime.

Thanks so much for having me.

Yeah, I’ll just say goodbye to everyone. Again, I’m Virginia Duran, your host and my website’s LuminousBeauty.com and Gil Barzilay. You can see by his Facebook, DrGilBarzilay is it?

No, DrGilTCM is the easiest way to find it.

DrGilTCM on Facebook, and of course the Evidence-Based Acupuncture site. So thanks again, and we’ll see you after the New Year. Okay.

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). 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/.