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Hello, I’m Brian Lau. Welcome. I’m here today with Matt Callison. We’re both with AcuSport Education. Also here today with Chad Bong. Many of you know Chad Bong. He’s one of the founding members of the Sports Acupuncture Alliance. There’s been three summits so far. Chad, you can let us know about the state of any upcoming ones. We’re in the midst of COVID-19 pandemic, so I believe that’s on hold. But we’ll have a chance to chat about that.

Chad’s also the host of PinPoint Performance Podcast. Just had a recent edition out with Jamie Chavez. I was interviewed for that. That’ll be coming out in a little bit. I think Matt’s been a past guest of that also. Whitfield Reaves, a bunch of other really great educators have been a guests of that podcast. Chad, do you want to say anything about the upcoming summits or possibilities of that?

I don’t know. We’re a little nervous about trying to get a hundred people in a room in our current state.

Yeah, sure.

So I don’t know. We have a lot of decisions to make with that. So as things start to get clear, maybe as a vaccine comes out, then we’ll be able to set it down the line. But it’s a big project. I was very thankful we didn’t have one set for this spring because-

Yeah, timing is not good for your live.

… I couldn’t have imagined having canceled something like that. So I’m glad that that worked out in our favor, but I’m a little nervous about setting one up right now. So we’ll see what the future holds there. But we’ll definitely keep with the podcast. We have a fair amount of them recorded-

Great.

… so we’ll be able to be turning some of them out every two weeks.

Awesome.

Yeah. So, Chad, just a little bit of background. Chad, you have a Master’s in Exercise Science.

Correct.

Also a massage therapist, studied massage therapy. A graduate of Southwest Acupuncture College. You’ve taught at a number of schools, Southwest, you’re currently at the WON Institute, and you’ve taught at Tri-State College of Acupuncture.

Yes.

Then in addition to that, of course you teach a lot of continuing education classes. So many folks who are listening might have attended some of those-

Possibly.

… or highly recommended to attend at some point in the future when we’re back doing live stuff.

Yeah, I definitely prefer the live stuff because I like the hands-on stuff, like what we’re talking about today, the palpation stuff. I don’t know how you teach that over the internet. Although I have to teach that over the internet because The WON is on 100% online classes right now.

Yeah, sure.

In the next couple of weeks here, I have to start teaching, three, four-hour classes on palpation.

Yeah. We’re going to be doing some online stuff with palpation, too.

It’s going to be tough.

It’s tough, but it challenges you in a different way. It brings out some sides that puts the spotlight on and makes you observe a little bit more. I mean it’s good to be positive about it. But I agree. Ideally, there’s no substitution for palpation live.

Yeah. I can’t put my hand on their hand and help them feel what they’re trying to feel. Once you teach this stuff for long enough, you can place your hand on top of somebody else’s finger and feel what they’re feeling through their fingers.

Sure.

So you can be like, “Not that thing right there, that thing right there.” You just can’t do that over the internet. So at least I haven’t figured that out yet.

Hey, Brian. I was looking at our list for the introduction for Chad, and it looks like there’s one line here. So Chad’s also a licensed acupuncturist and he’s completed Whit Reaves’ apprenticeship program. You also co-authored a book with Whit, right?

I helped with his book.

Yeah. So maybe that’s a good segue to go into your article from coracobrachialis that you just spoke about with Lhasa. I think it was last week or two weeks ago. Do you want to segue right into that, Chad?

Sure, we can move into that. So I did a coracobrachialis. We’re trying to put out some information for people during the COVID thing here. So I tried to pick something that I think just gets missed sometimes, I think, that other acupuncturists send me patients for that, for whatever reason, they haven’t figured out or haven’t gotten.

So that’s where we got into the coracobrachialis. It’s an interesting one as far as the palpation stuff because it’s an important muscle to be able to palpate not only the tissue of the muscle, because it’s not super easy to palpate the coracobrachialis versus the short head of the biceps without some practice. Then you also have to really know where that whole neurovascular bundle is that’s sitting right underneath it.

So when you do go in there, the needle, you’re not whacking away on that. Although I know some acupuncturists who purposely hit things like that, but I’m not one of them.

So I think it’s important to really be able to feel the difference between tissues. A pulse would be a real easy one to feel there. Then feel the septum in between the short head of the biceps and the coracobrachialis.

Then we’ll find bony landmarks, the coracoid process, and having some way to think through that, and then be able to see where the muscle ends and where the muscle begins and being able to continue that line down so you can feel the tissue all the way I think is important. So I think that’s pretty good into this whole idea of palpation.

Yeah. The discussion of that, what you were pointing out, is something that I note quite a bit working with acupuncturists, and I think this makes sense. We learn points and we learn an anatomy of points, whether that’s specific muscular anatomy or just bone landmarks and palpation and feel for indentation.

So I think acupuncture is often, understandably so, thinking points and they lose sometimes sight of that real estate of the muscle attaches from here and travels through this region of the arm or whatever structure you’re palpating, and thinking of it as a space and a region and relationship from this muscle to another muscle where the neurovascular bundle is all of those things together. It’s easy to lose sight of when you’re used to feeling for individual points. So I know what-

I agree. If I think back to acupuncture school, it was just like you learn all of this stuff, but it’s just this one point and this is another point and another point. It’s not all of the tissue in between and what all that tissue feels like and the depths of the tissue and the three-dimensionality of the body, being able to think about the body in more than just the surface area. You can get to the same spot inside the body from different angles, different points.

Yeah, sure.

Going back to the coracobrachialis, wouldn’t you guys agree that sometimes coracobrachialis strains seems like it’s a bicipital tenosynovitis. It’s easy to go to a bicipital tenosynovitis when, in reality, it’s actually a coracobrachialis strain.

So that’s where palpation comes in. It’s so important to understand what you’re feeling. Is it really the bicipital tendon and you cross-fiber that? If that doesn’t really cause the pain, then go deeper into the coracobrachialis, especially after some resistance, so you can feel it pop up. So palpation is everything in assessment. It’s what builds a treatment protocol, right?

I find it very important. I bring in the whole massage therapy world to it. Although my concept on palpation and feeling and tissue has evolved quite a bit from what I would have just called myself a massage therapist versus after going through acupuncture school and spending all of that time working with Whit and just getting much more specific and precise with what I’m doing palpation-wise. Whereas in the beginning of massage school, it’s just sliding strokes.

Yeah, sure.

You don’t get quite so precise. But, over time, I think if you keep practicing, you get super precise.

Yeah, yeah. Whit’s very big into palpation, thank goodness, because palpation is a missing link in our training in school, that’s for sure. So with palpation, I mean, isn’t it a lifetime skill also? I mean we should continue to learn all the time, especially the more that you actually consciously know about anatomy. The more that you can actually see anatomy and know what the underlying structures are, then you can start to actually see it in their palpation. So it seems to me that it’s just a lifetime skill development.

Yeah. I think like most things, the deeper you go into it, the bigger the hole is. So you can just keep learning more and more. I sat down and wrote some notes about things that I wanted to talk about during this thing, and building your anatomy base to understand where all of those tissues are. Then, on top of that, building the palpation base.

Both of those are endless processes, things that you could go on learning for the rest of your life, the details of anatomy. I think my anatomy is pretty good, but I know there’s people out there who know their anatomy better. I think I could spend a lot more time with cadavers and ultrasound and things like that and try to develop my feel and the view of this tissue even better. So I think there’s always room for learning.

Sure.

Then palpation, I have students in the beginning, when I first started with them, do the thing where you put a one-inch piece of thread underneath sheets of paper and then they palpate it. People, when they begin, maybe can feel that under 15, 20, maybe a really good person might get 40 in the beginning. But if you keep practicing, you can get up near a hundred sheets of paper with that little piece of thread under there and you’ll be able to find it.

So just developing that sense so that when you feel something different in the tissue, you can start to feel the actual differences in texture, which is really what I’m looking for is changes in texture in the tissue that I’m trying to feel to be able to tell that there’s something different going on in that specific spot.

Wouldn’t you say that then you could also quantify to excess, deficient, damp, hot, cold, which would then set up your needle technique and also your application of acupuncture and moxibustion, right? So if it feels real excess, we’re going to be feeling it with palpation and then needling it as a reducing method. So palpation is … It’s so incredibly deep. Hey, Chad. I think you and I have been bogarting this, and we haven’t been letting Brian speak.

Oh, no, I’m good. [crosstalk 00:11:37].

You’ve just to jump in, Brian.

Yeah, yeah, yeah.

It’s a first come first serve show here.

Yeah. I do want to segue a little off of Chad giving tips because I had a few thoughts for this podcast of giving maybe some tips. We don’t have a ton of time to go into that, but we can talk about some guidelines or tips since that is an area within the acupuncture profession that could be improved on. You already gave a tip basically, was increasing sensitivity by having some method that you can start to add sheets of paper and feel through those sheets of paper to where you have greater and greater depth that you’re feeling through.

Yeah. If you want to talk about how, I think somebody could get better and better at palpation. First, I think you have to have a basis in anatomy, right?

Yeah, sure.

I think we all have. We’ve all been thinking about anatomy a lot. I think you need to learn that base so you can understand what tissues you’re trying to feel. Then I think you should build on that with learn what all the functions are, learn where the major neurovascular bundles are going through things, and maybe learn the functions of those muscles by practicing your manual muscle test, so that you can see what those muscles are actually doing.

Then you’re building multiple brain connections where you’re not just trying to memorize, “Oh, the biceps does elbow flexion,” you’re actually doing the elbow flexion or you’re having somebody else do the elbow flexion while you resist them.

So I think building your anatomy base, and thinking of it from small to big. Don’t just like, “I’ve got to learn all of the anatomy.”

Yeah, sure.

Just put pieces on top of pieces, layer it. But then once you have the … And I think you should do some range of motion stuff in there so you can see how people move. Then start feeling things. Really, the more different types of bodies, the more different tissue you feel, the better idea you’re going to have on what this tissue should feel like and what is different about the tissue?

Watch the students going through the three semesters of palpation stuff with me, and in the beginning, they can tell their auto-muscle and that’s about it. By the end, they’re like, “Is it that thing or is it that thing?” which is cool to watch the progression with them. Is that what you’re looking for?

Yeah. Well, I mean I have one. We were mentioning the coracobrachialis when you mentioned that doing a contraction to bring that muscle up. A tip that I often teach when I’m talking with students about a little bit more certainty for what they’re palpating is, yes, you can get the muscle to come up by a certain action, but you can be a little bit more precise on what action you use.

Coracobrachialis is a great example because it does really two major actions, but one of them, shoulder flexion. Well, it’s also right next to the bicep. So if you put your finger and span down and get on what you think is the coracobrachialis and have the person do shoulder flexion, it’s not going to tell you a whole lot because it’s going to contract, the biceps are going to contract. And what am I feeling? I don’t know. But if you recall that it also does adduction, [adeduction 00:00:14:46], adeduction is a much better-

Horizontal.

Horizontal adeduction. But also just straight adduction. That’s going to-

It tends to position your arms in, I guess, but-

Yeah, but that’s going to bring it up a little bit more different. It’s going to differentiate it a little bit more from the biceps just based on the action that it’s doing.

Yeah, a mechanism of injury, like, for example, you see usually this injury with people doing too many pushups or bench press or something like that. What else refers to the anterior shoulder, though? Doesn’t the lower motorpoint, which is also the same location of a trigger point of infraspinatus? [crosstalk 00:15:19].

It definitely refers to the front of the shoulder. The story I told at the beginning of the coracobrachialis thing, that’s what I thought it was. I pushed on her infraspinatus, I felt around back there, and I found a spot that just referred right to the front of her shoulder. So I was like, “Well, there we go. This is our thing.” She was a backstroke swimmer. So I was like I’ll treat her. Infraspinatus is the main concept muscle-wise, and this’ll get better pretty quickly, and it didn’t.

Don’t you hate that?

It doesn’t happen that often, but, well, it does.

Did they get somewhat better?

I learned something, though, right? I learned something by having her not get better. She didn’t get better basically.

At all. At all. Okay.

A couple of times actually. So I did some work on the infraspinatus and I did some work on the biceps and the deltoid, and I just wasn’t getting anywhere. Then, finally, I was like, well, I’m going to try the coracobrachialis. Once I needled the coracobrachialis, the next time she was 90% better when she came in. Then she was back to swimming. She’d missed swimming for years, basically, as far as competitive swimming.

How do you needle the coracobrachialis? We teach it as needling the motor innervation [ju pi 00:00:16:36], which is one tsun below [jan ayling 00:16:39]. How do you needle it?

So I’ll come pretty close to there. I’ll find it off of the coracoid process and then palpate out, making sure I’m on the right line by … People can see me, right?

Mm-hmm (affirmative).

Making sure I’m on the right line by coming and finding it in here, and then palpating all the way up here and then needling going out and down. But not super deep. You just want to get through whatever you happen to be under there, either the anterior delt or a little bit of the pec major. But, again, all of that neurovascular bundle there is sitting behind the coracobrachialis there. So you’ve got to be a little bit careful.

So I’ll needle it there, but you can also get into it inside the arm here, which is what I talked about when I did the coracobrachialis presentation. But here you really have to know your palpation, right?

Yeah, sure.

You have to be able to separate … I don’t know if you can see my screen right now, but if you do a light flex, you can see that septum in there. If you flex it a ton, it’ll just go away and it’ll just feel like the bicep.

But you can get this little space right here, but then you have to know right behind it. In this position, inferior to it is that whole neurovascular bundle. You can feel the brachial artery right there. So you’ve got to make sure you don’t hit that thing.

But this would be by palpation in here to see if I can find a spot that’s really interesting. Then I’d usually get two needles into it. You don’t have to needle deep. That muscle is basically right at the surface, so you don’t have to go crazy, again because you want to be careful of all the neuro stuff back there.

Then I would just get two needles into that tissue, some light e-stims just until either the patient feels it or you see a little tiny bit of a twitch. Then if you have needles in up here and needles here, you might see these needles moving and these needles moving, if you have a light twitch going on.

Brian, how do you like to palpate it?

Well, I use the motorpoint ju pi quite a bit. But like Chad mentioned, I sometimes do look for trigger points, or ashi points, a little bit more inferior. I don’t discuss that as much with people just because it takes a lot of set up in terms of students. It takes a lot of set up, and there is a little bit more risk. You have to be a little more mindful of the palpation.

But, yeah, I do sometimes needle it in that more inferior aspect. I do find that that’s a pretty common area of congestion. I also do a lot of manual work in that area. I probably more frequently do manual work at that part of the muscle than I do needling it and separating the coracobrachialis.

This is where it comes really having the palpation skills there because you can separate it from the septum. It can create a lot of congestion in that septum between the biceps and the triceps and being able to open that septum up.

Something else that we do when we teach … Chad, you probably know that we use a lot of models with sinew channels. The coracobrachialis is on the pericardium sinew channel, palpating it and then going and needling either a point like [piece X 00:19:44] or something. But in that case, I’d probably go with another muscle on the pericardium sinew channel like the pronator teres, maybe pronator quadratus, and see, when you go back and return to palpation, if that diminishes. Usually it’ll be about by 50% that you can diminish some of the sensitivity to palpation from a distal point. It doesn’t mean you won’t needle it locally, but-

So I’m glad you brought that up because David Legge, in his book, he basically puts it on the lung channel.

Yeah, that’s great.

And I was like I don’t necessarily agree with that. So I’m glad I got somebody else on my corner here [crosstalk 00:20:20] pericardium.

Yes.

It’s all opinion, of course, right?

Yeah, I mean you’re trying to decipher some pretty ancient language that’s been translated.

It’s in a different myofascial bag than the lungs, the lung channels. Yeah, it’s different.

Yeah, I agree.

Yeah, we have the biceps on the lung channel and then how that relates down the arm, the pericardium on the … I mean coracobrachialis on the pericardium channel. I think we have a video where we do on a cadaver specimen, where we have a needle in the … I don’t think this is up on our YouTube channel, but the needle in the coracobrachialis motorpoint and pronator teres motorpoint.

I forget now which one we turned and wrapped, but more aggressive than you do on a person. This isn’t a technique demonstration, but turning the needle to where it really, really grabbed a hold of the tissue. Obviously it’s a cadaver specimen, so there’s no sensation.

But you really want to get the needle stuck and then pull and see if it transmits force. I think it was from coracobrachialis down to pronator teres. You pull on coracobrachialis and you’ll see that [crosstalk 00:21:26].

You saw them both move.

Yeah.

That’s pretty cool.

Yeah.

Now we needled it the way that we needle it in SMAC, which is supposed to meet at the bicipital tendon, going in at an angle distal into that area, into the innervation site, which is common area for strain in that region. It seems like going from what Chad was showing, going from the medial intermuscular septum, in between the bicipital septum, going that way. It seems like we’re just going to the same spot, but at two different angles.

Like I said, it’s a 3D thing. We’re working from three dimensions. So you wanted tips. I think a great tip is for people who … The first time you’re trying to work on a muscle or find a muscle is to break open the Motorpoint Index book and be like, okay, ju pi is right here. So I know that I’m all on that muscle if I go to this point, or at least I’m really close to it depending on some other person’s anatomy. But I’m right on this muscle. So you could find that spot.

Even if you’re not a motorpoint needling person, or if you are, but at least it gets you on the muscle so you can start in a spot that’s in a good spot, and then you can palpate from there. It’d be a good way to find, say, like a popliteal muscle or coracobrachialis or something like that. Just use the Motorpoint Index wording and description of the location to find the actual point on the muscle, I think, is a great way to go about it.

Well, gosh, since we’re talking about that, you might as well go ahead and get the Sports Medicine Acupuncture Textbook because the images have not just individual, but it’s grouped together. So you can see the motorpoints all together. Thanks for that, Chad. That was a nice segue, buddy.

No problem. Anytime.

Yeah, and I think it’s important to see it in relationships too, because it’s good when you’re learning anatomy to see that isolated muscle on a skeletal structure and get a clear picture of where it attaches to and where it lives, but then to be able to see it in relationship to the other structures … Because that’s going to be more like when you’re actually going to palpate because you have to differentiate between blood vessels and other muscles and just the whole picture.

Yeah. I think it just helps people who don’t have quite the palpation background to find a certain spot, but then we also know like, okay, that’s a relatively safe spot to put a needle essentially, is into where the motorpoint is marked out. So you have both a point that’s relatively safe to put a needle in and it gets you on the muscle. So I think it’s a good way to learn where each of these muscles are and where there’s points you could access them as you go about learning this stuff.

Now I want to bring one thing up, is that, remember, our founding fathers really didn’t know the anatomy so well. There is some literature that does show they had … They were doing dissections, for sure. But the anatomy knowledge is not like how it is today.

So not knowing the underlying anatomy then gives the practitioner so much of a feel of what’s happening in the skin over the muscle itself. How well can you move the skin of an acupuncture point or a motorpoint or a lesion or something? How well does that skin move over that muscle or adhere to it because of the skin ligaments and the subcutaneous tissue onto the fascia profunda?

So there’s so many different things that can be developed just by not knowing the anatomy, but by going by what’s happening within the skin. I think that’s how we started, right?

Sure.

Then with dissection then came more anatomy and such, because we’re feeling for excess and deficiency, and I already talked about all of that. But I think that was really quite traditionally was how it began.

I’m sure it was just, again, layers on top of layers of learning over a long time for our [inaudible 00:25:23].

Matt, I just saw a question come in about the name of the book you mentioned.

Oh, great. Awesome. Thank you. It’s called Sports Medicine Acupuncture. If you go to SMAtextbook.com, SMAtextbook.com, there’s information about it. Thank you very much for that.

Yeah, and I guess we can mention Whitfield Reaves’ book. Chad, you had some interaction with that book also, if you wanted to mention that, because another great resource for acupuncturists who are transitioning into a more orthopedic or sports model.

Yeah, the Acupuncture Handbook of Sports Injuries and Pain. Yeah, it’s a great concise book about 25 really common injuries that people … If you’re going to work in sports injuries kind of world, those are the injuries, the 25 of the most common injuries, you’re going to see. So it lays out a really simple way of going about treating those injuries. I’m not a very good [crosstalk 00:26:29].

Yeah, more and more resources are out there now for sports and orthopedic-based acupuncture, which is great. I think there’s more on the horizon, too. So it seems like it’s a really growing field right now.

Yeah, the amount of people who are into this and posting things that they’re trying has grown exponentially since we started.

Hey, guys, there’s only about four minutes left. Is there anything that you want to wrap up with or any other questions that we can be able to take?

I think-

I can give one quick … We’re on some tips. This is an easy tip and it won’t take long. But when we’re palpating muscles, also being able to effectively palpate bone is quite important. What I frequently see when I’m teaching palpation is people tend to go in very quick and jab you when they’re palpating for bone. Just a general tip is when you’re doing it to use a flatter surface.

If you’re using your fingertips and you’re trying to palpate the coracoid process, you can’t really tell if you’re on the head of the humerus, if you’re on the coracoid process. You’re on maybe attachments that can feel hard if you go in too quick.

Whereas if you come in and match the shape of the bone, it has like a little hook. So if you can get your finger around that little hook and get more surface on the bone, and also wait a little bit of time and let that density of the bone … As the tissue softens around your hand, that density of the bone really comes to your hand more. It’s a really good strategy for palpating bone.

Then once you’re on that, you can do a little back and forth movement to get a little more clarity to it. But bone palpation, I find for a lot of people who are not really taught outpatient well, they’re too quick, too quick on the point of their finger. So just imagine how much information … You can’t really bring in as much information on a point as you can on a flatter surface.

Yes, I would-

[crosstalk 00:28:26]. Go ahead, Chad.

I would carry that into muscle as well.

Sure.

I mean, if you go in there really quick, the people are just going to tense up. They’re going to have constant pain, especially if you’re working on bigger muscles, if you use a bigger surface, like I’ll use a fist or an arm or something like that. Then I’ll just find something I’m interested in and just keep working into a smaller thing so then I eventually get down to my finger or something.

But you can feel a lot of very interesting things that you might miss with just a finger with a wider surface on, say, a bigger muscle. So don’t forget to do that. And work your way in. So you can put a lot of pressure on a human being if you work your way in there slow. If you go in fast, they’re just going to jump off your table.

Yes, I agree. Something that I’ve said for a long, long time is if you use a number of different anchors, following up with what you just said, Chad, but specifically your pericardium nine, because, in my mind, what works for me is that allows intuition to come up. It seems like I get a lot of messages when I feel with my pericardium nine finger. Maybe that’s just [Mattism 00:29:29], but I believe that’s actually fairly true for a lot of people.

Yeah. I have people practice with all their fingers, like figure out what finger works for you.

It works better than the elbow, that’s for sure.

I don’t know, man. You can train an elbow pretty well.

Yeah, I agree.

That’s true.

I agree.

That’s true.

I agree.

My elbow sensation 20 years ago was nothing. I could tell I was on a human body. But, no, man, I can feel a ton of stuff. It’s just because I’ve used them a lot to find things. That doesn’t mean I’m using them to cause an immense amount of pressure on somebody. But on big areas, a forearm shaft, a shaft of your ulna, you can find a lot of stuff with it.

Yeah.

Hey, I know we don’t have a ton of time, but there are a couple of reoccurring questions refining palpation, and two that I’ve seen come up quite a bit is palpation on people who are obese, because it can create a little bit more challenge. I mean I’ve worked with plenty of obese people that had just great muscle tone, very easy to palpate, and some very thin people who had very … Very difficult to palpate. But, generally, generally, it’s much more difficult to palpate people who have extra weight. Any tips or thoughts on that?

Matt?

Sure. Move it to the side as much as you can, knead it as much as you can, and also put the patient into a position to allow gravity to move the subcutaneous fat out of the way. For example, if you want to go to the lateral side of the body or into the obliques or something like that, instead of having them being supine, have them roll to the side so you can have that tissue with gravity move out of the way. Different tips like that is fine, but it takes a while. It will start to melt, but it takes time to do that.

Yeah. I think there’s different levels of connective tissue inside adipose tissue, too. So I think there’s a difference in how some of these things are going to feel. Some of it’s pretty easy to move through, some of it’s more difficult to move through.

Retinacular cutis.

Yeah.

Again, it’s practice. That’s why I say you need to try on a lot of bodies. You can’t just practice on one person because, yeah, you’ll get good at palpating that person, but you need to practice on all shapes and sizes of people to really get good at this skill.

Yeah. Having done a lot of dissection, you get to see, with people who are obese, how much subcutaneous fat there is, but also how much internal visceral fat there can be. Even when you’re seeing what you’re doing, sometimes differentiating structures on a cadaver specimen can be very difficult with people who are obese.

These are all great tips, but at some level you just have to do your best and understand that it’s inherently more challenging. That’s why sometimes people who are more obese, sometimes they don’t do certain surgical procedures because it’s … I mean this is when you’re in there seeing things. It’s hard to differentiate.

Now imagine you can’t see anything and you’re going in with your hand trying to differentiate the structures. It’s harder. You just have to understand that it’s harder. But [crosstalk 00:32:38].

But it can be [inaudible 00:32:38] a lot of stuff.

Sure. But you have to also understand that, at some capacity, with some people that you just have to do your best and feel your best and trust that you’re on the right structure. If you are in a risky area, maybe choose not to do those certain points that you can’t safely differentiate where you’re at and needle safely.

Definitely.

Yeah. Now the palpation is followed by needling. Then the needling density also helps, wouldn’t you say?

Yeah.

So then if you’re palpating … Are we still on the obese, I guess?

Yeah.

I mean this is a whole another podcast or webinar.

Sure.

Yeah, it is. [crosstalk 00:33:17].

You’re talking about density of tissue when you’re dealing with a needle. That’s a whole … Like we could talk about another half an hour, probably an hour, about just how a tissue feels and how you need to learn that when you’re practicing your needle. What does it feel like to go through fat? What does it feel like to go through fascia? What does it feel like to go through muscle, both healthy muscle and not healthy muscle? You talked about like you could diagnose somebody off of palpation with excess, deficient, whatever. You could do the same thing with a needle.

Absolutely. Absolutely. That would be fun to do. That’d be a fun discussion to have.

Yeah.

I’m ready.

Well-

You guys, it’s 10:33. So another question or … Yeah.

It doesn’t matter to me.

We’ll also be looking at questions on Facebook and can answer those via written responses. But I think we’re probably about ready to wrap up.

All right. Some closing comments. Chad, I just want to say thank you very much for doing this with us. That was really, really fun. It’s always great to get your insight on this. Also, so, Brian, it’s great always being with you as well.

Yeah, of course.

Let’s make sure that next week that you stay tuned to this because you’ve got Yair Maimon that’s coming in. If you have not had an opportunity to be able to listen to him, he is a brilliant speaker, a real bright light. He’s an excellent person to tune in with. He’s got all kinds of different insights with acupuncture and traditional Chinese medicine. So I hope you enjoy that. Brian, anything else that we need to say, thanking American Acupuncture Council?

Yeah, thanks to American Acupuncture Council, of course. We’ll be back then in a few weeks down the road for some more discussion of orthopedic and sports acupuncture.

Yeah, this is a topic that Brian and I hit on the podcast that we did. So if you’re interested in this, stay tuned for when we release Brian’s podcast, because Brian gets into his thought process on this a little bit more in the podcast.

Awesome.

I agree.

That’s great. When is that podcast, Chad?

I don’t know.

Okay.

We have a pretty big queue of podcasts right now.

Yeah, yeah, yeah. The one with Jamie Chavez, there was a little discussion on palpation, too. It wasn’t the centerpiece of the whole thing. It covered a lot of topics, but there’s a little bit in that also.

Josh, our goal is we get into it a little bit more, because he’s more of a bodyworker. You, we got into it quite a bit because you’re more of a bodyworker, too. So those are probably the two biggest ones we talked about palpation stuff.

Got you, okay.

Josh is … I don’t know when we’re going to release that either, but it’s coming to PinPoint.

Okay. Yeah, I was about to say I hadn’t heard his yet, but that’s why.

Yeah.

All right.

Thanks, guys.

All right, thanks very much, and we’ll see you next time.

See you.

Okay, bye bye.

Bye bye.

We done, Brian?

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Click here to download the transcript.

– Hi, I’m Virginia Doran, your host for this episode of “To The Point” very generously produced by the American Acupuncture Council. Today our show is called A Fresh Perspective on Zu San Li, Stomach 36, and Neiguan, Pericardium 6. The science behind promoting digestive and cardiopulmonary balance with acupuncture. And I am so honored and pleased that we have as our guest today, Narda Robinson. Narda has a very interesting history and approach with this. She has a Bachelor of Arts from Harvard, Radcliffe, a Doctorate in Osteopathic Medicine, a Doctorate in Veterinary Medicine and Masters Degree in Biomedical Sciences. She’s a Fellow of The American Academy of Medical Acupuncture, Vice Chair of the American Board of Medical Acupuncture and a former member of their board of directors. She has launched the first Integrative Medicine Service at Colorado State University and for eight years has directed Colorado State University’s Center for Comparative and Integrated Pain Medicine. She’s taught a variety of scientifically-based continuing ed courses ranging from medical acupuncture and massage to botanical treatment and photo medicine. She’s a leading authority on Scientific Integrated Medicine from a One Health perspective, having over two decades of practicing, teaching and writing about integrative medicine approaches in both veterinary and human osteopathic medicine. She’s the founder, CEO and Lead Faculty and Course Director for the CuraCore MED and CuraCore VET based in Fort Collins, Colorado. And she’s also the author of a most wonderful book called “Interactive Medical Acupuncture Anatomy”. It’s very comprehensive. She has a very interesting neuroanatomical and evidence-based approach. So I don’t know how she’s done that all in just a couple of decades because it’s really quite formidable her accomplishments. So for anybody who hasn’t seen it or who can possibly get it and now that you’re home staying in place, you might actually have time to read it. I really recommend the book. You can find it on Amazon and see some excerpts there, as well as if you search on Google, you’ll see some highlights from it as well. It really adds to our field by putting a lot of the scientific point-based research altogether with the points in, it’s a book of points basically, and explains with a really comprehensive describing of the neuro, not just neuroanatomy, of all the anatomy that contribute to the points and how that actually affects the uses of it, and basically verifies what we’ve learned from, you know, classical sources. So, I guess how I found the book was a student took my class and he was an osteopath and he came up on a break and he said, “Oh, you have to see this book.” And I was kind of like, “Yeah, yeah, whatever,” he was new at it and I just didn’t expect much. And then he showed me, I was like, “Oh my gosh.” And then I had to buy it. It’s not an inexpensive book, but with the work that’s in it and the information that has been assembled all in one place like that, it’s very valuable book, I really recommend it. It can be used however you think about things, but it can help verify things for your patients and the field of Western medicine. So without further ado I’d like to introduce Narda, and give it to her to explain this from her experience and knowledge which is formidable. So Narda, thank you very much for being here.

– Thank you, thank you Virginia, it’s great to be here. We’ll be talking about, Zu San Li and Neiguan and while I am presenting a big focus on the points themselves, I am going… In clinical practice of course we use other points that are mandated or suggested by the patient’s presentation. So this is though is an opportunity to see how some of the mainstay approaches or the mainstay points such as Stomach 36 and Pericardium 6 work from a neuroanatomic perspective. So as you can see here on the left, we have Pericardium 6 in the forearm and Stomach 36 here on the pelvic limb. And just in a different form here is the individual with a different view of the hand so of course when we move around the point locations change, here’s Stomach 36, in just part of the larger context because when we again want to use these clinically for something like Stomach 36 we might want to treat knee pain, we might want to treat pain in the calf, we might be addressing immune function. But if we are working with something for digestion from my scientific neuroanatomic connective tissue approach, I am going to be interested in how stimulation of this point, whether we’re using needling, pressure, heat, laser, whatever it is, how is that going to affect internal organ function? Because I think that that is one of the perplexing ideas from Chinese medicine where we can say it balances Yin and Yang or moves Qi, but we also have information now on exactly how this is going to affect internal organ function. So the objectives for today are three. We’re gonna review some of the Chinese medicine indications and mechanisms for these two points, we’re going to identify key neuroanatomic connections between each of the points and areas of the spinal cord and, or brain. And describe how knowing the structural underpinnings, which was everything my book was about, but of these two specific points, how we can link that directly to the physiologic outcomes that happen from needling, which I as a clinician, as a veterinarian and an osteopathic physician, I appreciate knowing how the points are going to influence my patient and to know that there’s quite a bit of scientific background and backing for what I’m expecting to see. And I will talk as we go forward about how to search for scientific literature so that when you want to come up with papers that substantiate what you’re doing, that you can see how easy it is to do that. So with the images that I use in this, if they are not from Shutterstock photos that I have it mentioned here, so this is from TCM Wiki. But just looking at the stomach channel as a whole, we can see that there is often described in the Chinese medicine kind of literature, a divergent branch that goes to the organ after which it’s named. I mean I learned acupuncture from I mean a variety of perspectives. The Chinese component, the French energetics, the scientific approach, neuroanatomic connective tissue. So I had that as a background. And so this idea suggests that you have energy or Qi going into the stomach somehow and hence the stomach line is a name. And that maybe the idea from that would be that, okay, you stimulate Qi and somehow there’s a branch that takes that to the organ. But what I’m going to add to that is the knowledge about the actual structures that we can dissect and feel and test that give us objective understanding of what these sites of stimulation will do. So again, this is one of the images from my book and it’s with all the different layers on. Because what happened was this was from the Visible Human Anatomy Database and there were computer animators that put it all back together so that as I was photo editing for 15 years, I could add in muscles or take away muscles and just see vessels and nerves or organs or things like that. So by starting with the points on the surface and then going down and removing the skin layer from photo editing, then I could see the different structures that I would be stimulating as an acupuncturist, plus using neuroanatomic information from other sources as well. But this is Stomach 36, as you would see with the skin gone. And the description being on the anterior aspect of the lower leg, three cun below Stomach 35 which is up here in green and one finger breath from the anterior crest of the tibia, which we can also look at as a tibial tuberosity right here. And this is a cross section which I really appreciated learning by dealing with these cross sections, learning the different depths of muscles and fascia and vessels and nerves once you go into the skin, both from a safety perspective as well as a tissue activation perspective. So here on the left, I have cross section through Stomach 36 and I’m showing that, sometimes I’ll say cranial tibialis ’cause that’s what the terminology is as a vet, but the anterior tibial, and it points to how at least in an individual like the person that made up the Visible Human Database was, how far in depth we can go where it’s safe versus when we start to get into other structures. But the point of this slide being that research has shown also that we have all the different muscle afferents available to us at the point. So groups one, two, three and four, which have different levels of myelination and whether they are mechanoreceptors, so transmitting information about light touch or vibration or the subtle activation from an acupuncture needle or nociceptors, so they don’t have any myelin and they’re more conveying pain. So typically what we are thinking about as far as Stomach 36 for indications are have to do a lot of times with digestive things; gastric pain, vomiting, abdominal distension, diarrhea or constipation. But then some mood-based things, even epilepsy or depression or insomnia. Then of course local things for the knee pain or we have leg weakness or paralysis, maybe even a fibular or used to be called peroneal nerve injury. So just coming into acupuncture, one might think, “Okay, how does one point do all these things?” And so that’s what I loved in the process of those 15 years of putting this book together. Coming from a standpoint of just really relying on the Qi in the Chinese medicine approach with some of the scientific background in there. But then seeing as I would start with the neurologic connections local at the point and then put together where they hit in other reflex zones within the central peripheral or autonomic nervous system. It to me explained the effects that were these conventional indications. And so it didn’t leave anything more for me to wonder about. But just to review that the point Zu San Li changes to Leg Three Miles when we convert that to English, which has a lot of different interpretations that we don’t have time to go into. But the Chinese medicine description is that it will tonify Qi and blood, harmonize and strengthen the spleen and stomach, strengthen the body as a whole, and the Wei Qi raises Yang, calms a Shen, activates the meridian, stops pain. Okay, so that’s quite a bit of complexity there. And so what can we start to see? So–

– You know I always say that Stomach 36 does everything except wash windows.

– Yeah, yeah, that’s good. Or like with laser therapy, sometimes when we lecture, talk about it treats everything but death. So I guess maybe you could, I mean you say it tongue in cheek, but that’s a good point, Virginia, yes. So with Helene Langevin’s work, from the ’90s that the needle-tissue interface has been described as, as you see here being able to wind around the collagen that’s in that connective tissue, and then with that we are deforming fibroblasts which is activating their metabolism, causing them to make all kinds of changes through their structure function, just alterations, but there are also nerves in the vicinity. So while we are doing some connective revisions or interactions causing some fascial relaxation, even several centimeters away, there’s also that profound effect which is on the nerves which is neuromodulation. And that will get us into some of the analgesic effects and some of the autonomics or the parasympathetic, sympathetic or the digestive system, the Yin-Yang general balance. And then just taking this from a website talking about modulation, like what is modulation? Well, it is putting in your own signal that is going to interface with what is already there. And so you are modulating or you are changing the status, the resting tone of what that organism is going through. So that when there’s an imbalance, we can come in with our somatic afferent stimulation, meaning on the surface, the somatic afferent, the afferents, the nerves are coming into the nervous system equation and then we are stimulating it initially, but the body is going to respond with a modulating effect. So we are relying on the intrinsic healing mechanisms, self-maintaining mechanisms of the body to take our input, our somatic afferent stimulation with the needling and do what it normally does, bring it back to normal. So it’s like, “Oh yeah, right, this is what normal is.” And we’ll talk about how that happens. And it’s comprised of some neurotransmitter shifts, whether peripherally or in the spinal cord or in the brain, and then other things that happen with larger brain networks. For the analgesia or the pain relieving approach, we can distill some of it down to what happens from our input. So not a pain causing, that’s where having a nice gentle approach with acupuncture is so important where we’re subtly manipulating the needle and that is going to activate the mechanoreceptors preferentially. And what that means, so those receptors respond to light touch or vibration. Think of just a nice gentle soothing electroacupuncture. These are thicker well myelinated fibers that are important in pain control when they get to this dorsal root ganglion. So they’re the good guys. I mean the ones that convey, they’re also good guys ’cause they convey information, or tissue deformation. But let’s say you had some kind of pain elsewhere or if you needle too aggressively, that is sending information through these other types of fibers, the nociceptors. So we really wanna touch or inputs in the way I teach is to be gentle and well-received. There are gonna be some responses in the dorsal horn of the spinal cord that connect to that hand in this case. And those light touch receptors, the mechanical receptors, I think through the next side we’ll see the gate control idea of pain. They can help shut down pain influencers that are coming into that same location in the spinal cord. Of course the big complexity of the whole thing with acupuncture analgesia is that we’re gonna be affecting the whole brain and different pain networks and the thalamus and limbic system, all kinds of areas with our acupuncture analgesia. But just to distill it down right now we have those three initial areas that we’re concerned about. This is just an expansion of that spinal cord dorsal horn area where if we have acupuncture here, they have skin massage. If we just say that’s acupuncture, acupressure done gently that we’re bringing that information through these mechanoreceptors, the well-myelinated mechanoreceptors coming in here. And they are helping to block the pain impulses from on that same ultimate neuron that’s going to come up and then send impulses to the brain. So that’s just a peripheral way to block the pain impulses. This is a Stock photo. This is not necessarily how I would approach knee pain ’cause I would be tailoring it to the exact expression and location. But in general, this is electroacupuncture and I’m bringing that in because here’s Stomach 36 more or less. And they’re doing a typical four treatment before needling approach around the knee, and took it up to electroacupuncture. So if we look at knee pain, how is Stomach 36 participating in that? Well, there’s some local pain shutting down, so peripherally, but then there’s also going to be affects, I like to consider all the anatomy that’s being affected, but we don’t have really time to go into that much here. But there’s also even for knee pain going to be impulses that are going into the spinal cord so that ascending to the spinal cord and brain that are also going to be pain alleviating. And so that’s important to know from a neuroanatomic perspective ’cause we can reinforce that with points on the back and the spine that will help shut down pain information that’s being communicated in the relevant levels of the spinal cord and really reduce what we call peripheral sensitization of nerves that are going to the knee. But it’s never really knee pain. It’s we, I as an osteopath and a veterinarian, I mean we look at the whole body and what are the compensatory biomechanical alterations? Where are the myofascial restrictions? It’s really a whole body kind of thing that in clinical appreciation. But if we’re talking about digestion, one of the things that we can be aware of is that Stomach 36 afferent information is coming into the cord at the sort of the lumbosacral junction. And so when impulses arrive into the cord, there’s something called somatovisceral and visceralsomatic reflexes that we’ll look at as the next slide. Then there’s another component that goes to the brain that will cover. But seems a little bit confusing here. But let’s say we have a dysfunctional viscous, so a problematic organ in on our belly somewhere and that is sending afferent pain impulses into the cord. If those go unabated then we could get tenderness to palpation. This is the whole rationale with the diagnostic exam with the Back-Shu and Front-Mu points. So that is crosstalking with somatic or muscles, skin and subacute areas so that we get essentially spinal reflexes that are originating in a viscera of viscous. And then having a somatic presentation where we can go along the back and find tenderness to palpation and think, “Okay, is that local on the back “or is that from something inside?” And we put that together with the whole patient presentation. So there are lots of reflexes like that to consider whether we’re coming from a viscous and going into the muscles or we would come from the muscles and the external. So if we’re doing a treatment and we are involving low back points, then through these reflexes working the other way, somatovisceral reflexes, we can help to shut down some of that internal pain. So that is why I would use those baby back points in addition to a Stomach 36, I’d be palpating and seeing what’s involved. But here are typical bladder points that are associated with the spinal nerves that in my framework that somatic afferent stimulation is being picked up by the spinal nerves going into the spinal cord and having repercussions there as well as going to the brain. But if we’re talking about where’s that impulse from Stomach 36 coming, then we talked about local peripheral nerve effects very briefly ’cause of not much time and then spinal cord effects and reflexes. But then we’re gonna go up to the brain and this is really what explains a whole bunch of Stomach 36 effects. There’s a little site in the brain stem in the medulla called the nucleus tractus solitarius. Here’s just the brain stem looking at that. And the interesting thing about this brain stem center is it sits side by side with this vagus nerve, which is actually longer than this. And the vagus nerve is what is covering, you know that’s doing most of our parasympathetic nervous system. So versus the sympathetic system, which is fight or flight, this is more you’re vegging out, restorative, calming down kind of thing. And so it has effects that are going to balance out that fight or flight sympathetic system. So it’s gonna slow your heart rate, it’s going to help digestion flow and all the secretions from the gland, stimulate bile release, help regulate blood glucose, help you with elimination and digestion and all that. And for the cognitive effects, I mean, vagus nerve stimulation, so this parasympathetic medic effect is so good that it’s like they implanted vagus nerve stimulators for things like depression and epilepsy and different things. But it’s like we have the ability with Stomach 36 and some other points to actually give parasympathetic benefits because of these long loop reflexes that we now understand. And these are… So the nucleus track, the solitarius is one of the two main somatoautonomic convergence sites. What do we mean by that? This is where the somato, so the somatic input from Stomach 36 is going to join at this site in the brain stem called the nucleus tractus solitarius with inputs from the vagus nerve. So 80% of the vagus nerve that’s coming into the brain, which we just saw a bit ago, is afferent information. So the brain really needs to know a whole bunch of information about what’s going on elsewhere. And so that is coming into this site, the nucleus tractus solitarius along with information from the body of which the Stomach 36 has a nice big connection there. And then it’s like this operator here. So if she’s the nucleus tractus solitarius, she’s getting information from the Soma, which could be Stomach 36, and the viscera, which is your guts and things, and then making decisions. So, what she has to do is, well what she does, who knows how this all happen, but it because of her side-by-side connection to the vagus nerve, the nucleus tractus solitarius can up or down regulate vagal nerve output. So that means if you have constipation, you can change it and the vagus nerve can change its activity so that it speeds up digestion. So this is a structural piece of how, might call it Yin-Yang balance, but it’s how our body keeps things stable. Our temperature, our blood pressure relatively, we have these real estate centers in our brain that are in command of doing all this and keeping us alive on a day-to-day basis. And it’s really very amazing that we know this and that we can have pathways with acupuncture to deal with it. So Stomach 36 for GI problems. It’s that homeostatic balance whether we’re dealing with the long loop reflexes to the brain stem or and the lumbar segments as well. So it’s a way that we can understand how even disorders like this, which is our representation of inflammatory bowel disease. When the nucleus tractus solitarius is not doing its thing, then there is a, and with its parasympathetic effects for the vagal nerve, then things can get out of balance. And when the sympathetic nervous system, the fight or flight area takes over too much, then we get a pro-inflammatory state. So not just fire or too much Yang but its actual inflammatory state and if it’s going to affect the GI track, then we can get an inflammatory bowel condition. So by having Stomach 36 in there, then we are pushing the balance of the body to a parasympathetic level, calming things down. So if you just go to pubmed.gov you can do, see this as well. And all I did was I did Stomach 36 and NTS for nucleus tractus solitarius. And you can see various research articles, you can select for free full text if you want so that you can get this whole article for free. It’s online shopping. You don’t have to take out your credit card. So there are so many studies that support this idea that it’s a great way to move forward and to be evidence-based with acupuncture. So we just have a few minutes and just–

– You want to, I don’t know how much you have to speak about Pericardium.

– Okay

– Do you want, anything else to, you wanna discuss about Stomach 36 and do Pericardium 6 another time? Or do you wanna move on?

– No. I think we can show like that there’s another point that has similar effects.

– Okay.

– But I think we’re good. Because it has a different brain stem center for the most part and a different, I don’t know, just clinical applications. So Neiguan, Pericardium 6, again, instead of just thinking maybe there’s an energy connection there, we can look at here and its proximity to the median nerve and indication. Some of which overlap. So the nausea, vomiting piece, that’s because the fibers from the median nerve, from PC6 ultimately go to a very nearby center in the brain stem. It’s called the rostral ventrolateral medulla. But a lot of fibers go there. But some of them go to the nucleus tractus solitarius, which for me explains the GI piece here. But otherwise we’ve got cardiopulmonary indications and we can see how Chinese medicine explains it. But if we look at the science and begin again at the site, just like with Stomach 36, we know that there’s muscles and tissues and fascia and bones and here’s a cross section and especially that median nerve is nearby. But when we get to the rostral ventrolateral medulla, which is not far from the nucleus tractus solitarius, we it… that site is more concerned with cardiac, just antiarrhythmic effects and the pulmonary influences. That’s why it’s this master point for the chest. And so we look at a paper like this, for example, “Cardioprotective effects “of transcutaneous electrical acupuncture point “stimulation on perioperative elderly patients “with coronary heart disease” showing that just to cut to the chase here, that electroacupuncture at PC6 and PC4 can reduce postoperative troponin concentration so limiting heart damage and change the autonomic balance to a much improved state. And PC4 makes sense here because that was right along the median nerve if you saw that in the picture from my book before. It’s median nerve stimulation that hooks up to long loop reflexes in the brain. Here’s “The effectiveness of PC6 acupuncture “for the prevention of postoperative nausea “and vomiting in children” Again, just seeing that yes, there are brain stem connections and that is what helps us understand how physiologically, how anatomically we’re put together so that we can understand that you stimulate here and you get effects kind of body-wide or internally, and we’re not sticking needles in organs. To me it helps to really understand this wiring diagram. So the key points of all this are the anatomy or structure and physiology or function are inextricably interrelated. It’s with architecture and it’s with acupuncture and anatomy. So the more we know about the anatomy of the acupuncture points and their physiologic effects, that’s how we can better understand what the Chinese acupuncturists from way back when and Japanese and whoever else was doing acupuncture back then. They might’ve described it using metaphorical language, but if so inclined one can also understand a lot of it now scientifically. And that then informs my needling protocols, because I can take what my hands say, what my heart says and what my mind says and make treatment protocols that are very tailored to my patient based on what I feel, what I know and just a certain level of intuition but not having to have just a belief somewhere, but really having a clear expectation with objective endpoints that I can rely on. So with that , I am ready for any further questions or if you’d like, you can email me at narda@curacore.org.

– Yeah, I think, I don’t know, Alan, you can tell us if there’s any questions or if we’ll leave that for after the show. But there’s just so much you’ve presented . That’s why I couldn’t look up at the camera. I was like, my eyes were glued to the slides. Well I think we’ll, in this case, I hope you can come back another time because I feel like we’ve just touched on the surface of something’s really interesting. Some people will ask questions and they can be addressed after the show. Thank you again for coming and thank you to the American Acupuncture Council and to all our viewers and hope to see you next time. All right, bye now.

– Bye bye.

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