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Telemedicine Guide: A Low Back Case Study Matt Callison & Brian Lau

Hello and thanks for joining us today. This is the first of a series of webinars that we’re going to be doing discussing issues, topics, and featuring guests in sports and orthopedic acupuncture.

I’m here with my colleague, Matt Callison. Many of you probably know Matt. Matt’s been around for a long time. He’s sort of a fixture, especially in the sports acupuncture community. Many of you probably know him from various articles and books that he’s written. Matt is the President of AcuSport Education. He’s also the President of Sports Medicine Acupuncture Certification. He’s recently published his lifelong, really, work, it’s been over multiple decades of work, the Sports Medicine Acupuncture: An Integrated Approach Combining Sports Medicine and Traditional Chinese Medicine. Really a monumental amount of work, so a lot of congratulations goes to Matt. It’s going to be a game changer for the field. It’s so nice to see such important work coming out in field.

So, I’ve been working with Matt, initially as a student, when I took the program Sports Medicine Acupuncture Certification. Then I was asked to teach in 2014, quite an honor for me. Fortunately, despite the fact that the program is an incredible program, Matt gave me a lot of flexibility to also add and integrate information that I had coming from my field in structural integration, also in my work with qi gong and tai chi and tendon changing.

We worked to integrate a lot of work to build a model for the channel sinews. I’ve written quite a bit about the channel sinews. We feature a lot of that work in the Sports Medicine Acupuncture Certification.

We’ll start today. Matt’s going to set us up and discuss the case study for low back pain.

Brian, thank you very much, but the honor is mine just to be able to work with you, seriously. You are not only a brilliant academic, but you’ve got that combination of a true clinician and also an academic, so it’s great to be able to call you my friend as well.

Can we start the slides? Why don’t we actually go to the first slide here. Let’s talk about a quick, brief history of what we’re about to see here. This webinar is an abridged version of a blog article and also an accompanying video that shows highlights of our experience with developing, designing, and working through some of the logistical issues of a telemedicine consultation.

Initially, the information in this article and video that you can find on the Sports Medicine Acupuncture website, www.sportsmedicineacupuncture.com, blog article and also video in the April issue. It was initially intended to be presented as a live webinar, so this was like a trial run for us. We wanted to have a live webinar that contained the content for students and graduates of the SMAC program. It was intended to be a review of the recently completed module two, which was the low back, hip, and groin, held in New Jersey, which was right before actually New Jersey closed its door and the COVID-19 shutdown.

Our intention with this is try and be able to show practitioners how to apply some of the principles taught in SMAC and also our experience through telemedicine format, which was brand new for us. We wanted to go through the logistics of it and help practitioners to learn from what our mistakes and what was the best way of setting up patients, lighting, making sure the patient has consent forms, preparing the space for the patient. All of those categories that you see in the bullets here is in that article with explanation as well.

Now, the reason why we decided to publish this trial run was because the surge of demand for telemedicine consultations, we decided just to get it out there. When you do see the video, I really apologize because, like we said, this was a trial run. It was not intended to go public, and I just got out of bed. I don’t think I brushed my teeth. I have bed head. You can tell that this was a rough run for us. Brian, he’s always beautiful looking, so I’m not going to apologize for him at all with that.

Yeah, my hair looked about the same in this one as it did in this test.

What you’re about to see now, this next slide is going to be a video. The blog article and video contains us observing a patient with low back pain, which is something that practitioners could go ahead and do, asking her to perform static and functional assessments so that we get a working hypothesis of her injury and eventually develop a diagnosis, a virtual diagnosis, really.

Then, we can develop an acupuncture and motor point prescription for self-massage acupressure, and then prescribing corrective exercises based on her postural anomalies that we saw through the assessments.

Again, this short webinar is going to be the highlights of what you can find on the video and on the article. Should we go right into the video? Yeah, let’s do that.

Yeah.

It feels like here.

Okay.

And, that kind of feels bilateral.

That’s good.

[crosstalk 00:06:23]

That’s like a facet joint sign, okay.

When I walk, it’s more here.

Yeah.

And then it could even go straight in here. This whole line even here and it goes into this ischial tuberosity.

All right, so with that, listening to the patient, describe this. Brian do you want to go ahead and share our thought process with that?

Yeah, I mean of course she’s just said a few words, she kind of gave a pathway of where the pain is. A couple of simple things. But you should already be starting to think what could be causing the pain, where is this next pain site coming from? And we haven’t tested yet, we haven’t done anything to rule out things or we haven’t done anything to confirm ideas. But already just from the body language, how she was saying it spreads across the back, that’s a very typical sign of facet joint injury. The referral that she was showing down, maybe not lumbar disc involvement, based on just going down to the behind, but we should definitely rule it out and check for it. Thoracolumbar junction syndrome is a common injury that’s becoming more common. Based on the pathway of pain as you’ll see in the coming up slides, that could be an issue. Sacroiliac joint injury could be an issue and also soft tissue strain. So again, we have to rule these out or confirm them, but they’re just preliminary thoughts based on her explanation of the pain.

Okay, good. So the postural observations. We observed the patient in a static and also functional positions. In the static position we asked the patient to move from left and right, so we could see the lateral view, look at the posterior view, look at the anterior sides. Just trying to gain as much information as possible. From there we surmised that the patient had the following postural disparities. She has, what would look like a bilateral anterior pelvic tilt, it was greater on the right. Slight posterior tilt of the ribcage. An anterior hip shift that we’re going to be talking about a little bit more real soon here and it’s relevance to qi and blood deficiency and kidney qi deficiency.

On the posterior view we could surmise that she’s got an elevated right ilium, also known as a left pelvic tilt. We could also see a left tilt of the L4-L5 vertebrae, which really helped to confirm the elevated ilium. Additional postural imbalances to check in the second and third office visit could be looking at the head, the scapula, the knee the feet positions and also the possible contributions to overall postural and myofascial imbalances.

Because this is a telemedicine conference, it was a little challenging to look at the entire picture, but we want to be able to see as much as we possibly could and design a protocol for her so we can get her out of pain. And like we said we can look at the other aspects on the second and third visit.

Brian we’ve got a video coming up here. Let’s go ahead and show that and do you want to chat afterward?

Sure.

What I see is an anterior hip shift.

Yeah, me too.

I see a possible pelvic rotation to the right.

A little bit of the ribcage coming back, it’s not extreme, but a little bit of the kidney qi, qi and blood deficiency posture.

I agree. Should we look at her other side?

Sure. Yeah more noticeable this side is the traction.

What I see is-

So, first of all the video clip doesn’t show the whole picture, because this was our first chance to look at her from the side view. And if you caught this Matt was talking when I was talking, that was maybe he did the recording, but not just this moment. So when we did the recording, the first time lining up sometimes you don’t see things correctly and now we have the added challenge of having a video camera and maybe the angle not being set up properly. Matt mentioned it looks like there was a right rotation to the pelvis as if the pelvis is turning and looking to the right. But as we switched over to the left, if that video would have played longer you would’ve heard us say, “No it actually looks like a left rotation.” And all the other assessments we’re doing later on we confirm that left rotation. Pelvis looking to the left.

The other main thing we’re talking about is this anterior hip shift where, if you look at this images on the screen now, especially the second image. Second and third you really see it, but the second image is the most like patient you’ll be working with. The hip is shifting anterior to a line that’s dropping through gallbladder 40. This anterior hip shift can have multiple implications, but when the ribcage starts going backwards, that’s consistent with people who have signs and symptoms of kidney qi deficiency, qi and blood deficiency. Matt presented on this information at the Pacific Symposium before, we can’t go into the whole details in the time frame that we have today, but each of these postures have a strong correlation with the various zang organ pathologies that are listed underneath them.

So this patient was most like, maybe not as severe as number two, but most like the kidney qi, qi and blood deficiency posture. I think we can go to the next slide, unless you wanted to add something to that, Matt?

Yeah, something real quick. When you see postures like this, you can pretty much predict what the tongue and the pulse is going to end up being, which is really a great thing. That helps the practitioner to direct their questioning to what organs could be contributing to this type of posture. This was a lot of research, I started in 2010, I presented at 2011 symposium and also in 2019. We talk about it in a module in the SMAC program, it itself is its own webinar for sure.

We asked the patient to show us her tongue and lighting was a big issue with this. When there was poor lighting, you can’t be able to see the tongue very well, so she was able to move her device closer to a window and we were able to see… Now obviously this is a screenshot from the video, so you can’t see it very well, but when you look at the video, that’s online at the website you can clearly see a pale tongue, teeth marks qi and blood deficiency in that tongue. Also, what’s helpful, if you have a white card you could put that card right next to the tongue, it gives a little color differentiation as well. Let’s go to the next slide. Brian you want to go for that?

Yeah, so I’ll just follow up to the tongue. The rest of the video is going to be focusing on posture, focusing on orthopedic evaluation, functional tests, that kind of stuff, which in enough themselves are testing the channel sinews. But if this was a full evaluation, and the video doesn’t reflect this, because it was really set up as a webinar for a review for low back and hip injuries. As Matt said you’d be asking questions based on multiple things that we were looking at, so looking at a full picture. We’re going to go back now to look at some of the indications that we saw from where she had pain. We both didn’t think that there was lumbar disc involvement with it, but it’s good to be thorough and rule it out.

We have the patient get on the floor and do a straight leg raise. Normally in clinic you would do this to the patient, but she was able to bring her leg up, it was negative. We asked her to do a passive one, which is more like the test you would do clinically, if the practitioner was doing it and again it was negative, but it was good to rule out that there didn’t seem to be any signs of lumbar disc involvement based on straight leg raise.

And if, by chance this was going to be a positive test, the practitioner would need to guide the patient through the different steps of straight leg raise. All right so let’s go to the next one.

Okay, so we were thinking that, with this particular video that you saw and with information that’s coming, facet joint injury seemed like it was going to be more the primary pain generator. Again, we’re just on a working hypothesis right now. We asked the patient to perform lumbar extension, because the facet joints usually get aggravated with extension. Because she has a bilateral anterior pelvic tilt, she’s already going to have a jamming of those facet joints. So the picture is really starting to make sense.

There’s two common body movements when describing facet joint pain that patients will commonly do. One is you’ll see there on the left where a fist or some kind of indication there at the spine and also that body language of starting at the spine and then going out lateral. So I believe we’ve got another video that we can watch to go see more information.

Matt, before you switch that. Just to highlight, also Matt mentioned the bilateral anterior tilt, also the elevation of the right ilium that she gets into when we look at the postural assessment. But you can see it in both those views, I would start to side bend the lumbar spine to the right and also approximate those facets on the right, which is primarily where she was describing the pain.

Yeah, good, thanks Brian. Okay, ready video?

Can you go into extension please? Does that cause pain?

Yeah, a little bit.

And where’s the pain?

Right there.

Can you go into extension please-

Okay, she already did. I have it on loop. All right, so she indicated, so we’re kind of leaning more toward facet joints. So let’s use some more examinations that can aggravate the facet. Do you want to talk about stork standing Brian?

I’ll let you continue with it, because it’s kind of a similar theme to the extension.

All right, so a stork standing test. You’re going to have to describe to your patient how to perform these tests, and this particular one because it requires balance is to have them close to a wall or a chair of course would be very useful. In stork standing test you can see how she’s going into lumbar extension and also rotation. This particular image on the left is aggravated the pain. Now here, what’s really interesting, she didn’t take her fist and put it into the spine at all, she actually went lateral. Where she’s indicating there is giving us a lot of information. So let’s go to the next slide and Brian we can start chatting about that and then set the sinew channels. Or maybe we should just say it now, do you want to describe the three sinew channels there that can be-

Yeah, so in the Sports Medicine Acupuncture Certification program we talk about… First of all we have a very developed model of the channel sinews and when you look at the descriptions or you look at images and there’s a line across the body, it doesn’t give the precise anatomy, we’re working on a model to really hone in on what particular structures are in which channel.

So when she points to an area like this, you might be pointing to the iliocostalis lumborum, that would be on the urinary bladder channel, part of the continuous myofascial plane up the body, from foot to head. Maybe deeper, because she’s also at the attachment of the quadratus lumborum at the top end. The quadratus lumborum would be on a continuous myofascial plane which is part of the liver sinew channel. And there’s also a plane of tissue that’s coming up through the quadriceps and up through the abdominals and to the side and into and wrapping around to the back, which forms a seam where all the fascia come together, that’s called the lateral raphe. And that’s affected and part of the stomach sinew channel. So there’s really three potential sinew channels that this one little spot can be pointed op based on the precise location in the back.

So this helps a lot because the practitioner’s now starting to think about those three different channels and what acupressure points that we can be able to use. Xi-cleft, luo points, for example. In order to be able to move qi and blood. Brian, I just noticed that we’re kind of running behind, because we love talking about this so much, but it’s such a short webinar. So I’m going to fly through these next four, and then we’ll get you back up on that rotation, is that all right?

Okay, sure.

So here we’ve got the injury assessment. If you look at the image on the left, these are lumbar facet joint referral patterns. So this is where the actual facet joint itself, when it’s degenerative can be able to have its own referral patterns. You can see she’s indicating the areas of L3-L4, L4-L5, possibly L5-S1. Knowing these patterns, we’re really starting to go down the road of this injury coming from facet joint, having postural imbalances which lead to myofascial sinew channel imbalances.

In addition, is that her tracing going into the gluteal area and also toward the greater trochanter, it could be thoracolumbar junction syndrome. The assessment for this is for the practitioner to actually be there on site and trying to be able to provoke that thoracolumbar junction syndrome pain by doing some mobilizations of the spine. We can’t do that, obviously so we have to try to be able to see it. When we had her go into a lumbopelvic rhythm, what we noticed on the image to the right, you can see the thoracolumbar junction of T11-T12, L1-L2 kind of pops up a little bit. It actually goes into extension. When she was moving into trunk flexion, that part of her spine actually didn’t move as well, and popped up. That could be a sign of a possibility of instability in the region, causing thoracolumbar junction syndrome. We put that into our back pocket as part of the assessment.

The practitioner can also examine the sacroiliac joint with various functional exams. We weren’t thinking it was going to be SI joint, but we might as well. We ran her through a number of different examinations for the sacroiliac joint. Practitioners that are experienced with this, you know that these particular examinations can also provoke pain in other places. Your idea’s trying to provoke pain in the sacroiliac joint, and see if that’s going to be positive, but each one of these exams also caused other pain that was indicative of possibly facet joint or hip joint problem.

And actually I don’t think it did cause SI joint pain, specifically.

Yeah, none of them did. The lower image on the right is Gillet’s test, which is a video that we’re going to show you right now. This is an easy one for a practitioner to do with a patient. Let’s show you this Gillet’s test, you’ll see that it’s positive on the left.

You really see the elevated ilium om the right, so lateral tilt of the pelvis. You can see L4-L5 tilting to the left. And then coming back to midline around L3?

Yeah that’s what it looks like. It doesn’t seem to go up really high.

Uh-huh (affirmative). So, Lily can you weight bear on one leg and then on the opposite leg, raise it at least 90 degrees, slowly. A little bit higher. Okay, thank you and down. Yeah there it is. So you could see that left hip innominate bone raising up. Brian do you want to take it from here?

Yeah, so the Gillet’s was positive on the left, the PSIS wasn’t able to drop down when she brought the hip into flexion. That does show that there is a jamming of the SI joint. We’re moving on now to looking at rotation. Rotation would just be a functional test. There would give us some ideas of imbalances of the channel sinews in the body, but it could also suggest things like thoracolumbar junction syndrome.

We’ve confirmed through postural assessment that she had a left rotation of the pelvis, the pelvis is turning to the left. It’s very typical then that the torso would start turning back towards the right. We have a seated test to be able to confirm this. Because if she has the torso turning back to the right, the tissue shortens in a way that allows her to turn more easily to the right, and it starts to pull on that shortening of tissues and the abdominal obliques as she turns to the left.

You can see as she turns to the right she has greater range of the motion. As she turns to the left she is not able to turn as far. The patient mentioned herself that she felt like she couldn’t turn as far to the left. That indicates a right rotation of the trunk in relationship to the pelvis. There are certain tissues that are associated with that shortness.

The other test on the right where she has her hands out is starting to involve more of the lats. As she turns to the left, the right latissimus dorsi has to lengthen, and she has limited range of motion, she should be able to turn about 80 to 90 degrees. Then we have her cross the left ankle over the right knee, which starts to engage the glutes and multiple things could happen. In her case she was able to turn a little bit more, suggests an inhibition of the glute max. Those tissues, the lats to the contralateral glute max communicate with each other through the thoracolumbar fascia and they can form a sort of sling through the body that can have dysfunction.

So we have shortness in the right lats, there’s actually shortness in the left lats too, which you don’t see because in the still she’s not turning in that direction. Then there’s suggestion of inhibited glute max. I think we can go to the next one.

Good. So the diagnosis and what we’ve found so far with the patient is, because of her posture and also from the TCM differential diagnosis questioning that we do not have on the video, something that practitioners can go ahead and do of course, looking at the zang organs. Kidney qi and qi and blood deficiency is her posture and also her tongue did support that as well. The questions that we had supported that as well. Long term knee pain and so on and so forth. I don’t want to go into this because our time is flying by as my light source just flew by.

Here we are. So let’s just go back. So we’ve got a right elevated ilium and myofascial channel imbalances. If it’s alright you can see that this image on the right is an anterior view, what we’ve been showing you is a posterior view. There is a particular combination of locked long abductors and locked short abductors. Locked long adductors, locked short adductors. With liver jingjin and gallbladder jingjin that has its own protocol, not only with acupuncture, but also with corrective exercises. Brian I know we could talk about this all day, but we have to keep moving.

Okay.

Brian do you want to do this one?

So this is just reviewing what we just talked about, really. That there’s rotation, the pelvis going to the left so that would mean your right ASIS is forward and the whole pelvic structure is turning to the left. And then the torso is coming back to the right. You can almost see at liver 13, the left side going down to about gallbladder 27 on the right, towards the ASIS on the right. That line from left to right ASIS is shorter than it is from the right liver 13 to the left ASIS. That shows that shortening in the obliques and that kind of tightening and screwing, and like a jar tightened too much it starts to put compression into the trunk and into the spine. So we want to unwind her with the exercises and acupressure. Also, with self-massage you want to untwist that jar if it’s too tight.

Brian wouldn’t that this is a common finding to have a pelvic rotation, also a trunk rotation?

Yeah. When the pelvis is rotated to the left, it’s unlikely that the person’s going to be working and steering themselves over to that direction. So somewhere it’s going to come back to midline, most often the trunk. If things are really locked up I guess it could be the neck, or somewhere else, but it’s more often than not it’s going to be the trunk that starts to come back on midline. It’s just part of the way that the body finds balance when there’s injury that caused imbalance, overuse or whatever it is. It’s just the way the body gets itself oriented back to the front.

This is a common posture found in low back pain. Next, here we go. Bilateral anterior pelvic tilt, more on the right. That tells us point prescription gallbladder 39 and a half and liver 4, which we really need to be able to get to soon here. We’ve got possible thoracolumbar junction syndrome. I talked about earlier, watching the lumbopelvic rhythm, seeing that thoracolumbar junction pop up, not moving smoothly in the lumbopelvic rhythm. We’re looking at a L2 to L4 region facet joint from the patient’s description of the pain and also the referral pattern and worse with extension. Actually flexion makes it better and alleviates some of the pain, so we can put that in our back pocket as far as giving corrective exercises.

The treatment plan protocol with this, putting it all together. Of course strengthen kidney qi and systemic qi and blood with this, we’ve got to be able to do this so that we can be able to hold the treatments. Otherwise, the patient just won’t hold the treatment, we’ve got to build the internal to help the external. We need to balance the postural deviations. By balancing the posture deviations it’s going to help with the pulley lever system, the musculoskeletal system, but it would also decrease the amount of internal torsion of the organs. Let’s think about also what postural disparities do to the internal organs. Decrease pain in the UB, stomach and gallbladder jingjin of the low back. That’s what we saw from the assessment.

The treatment protocol, we’re going to give acupressure prescriptions. There are ways of doing acupressure, you can find some suggestions that we have in the blog article on sportsmedicineacupuncture.com. Dietary recommendations we normally can do this. Chinese herbal medicine, let’s make sure that we can send the patient the Chinese herbs. Corrective exercises which we have the patient go ahead and do, we watch them do the exercises, make sure they’re performing them. And also qi gong exercises would be wonderful to be able to show the patient. I’m going to give a little highlight to Brian here. He’s teaching, three times a week, some really wonderful qi gong classes. If you wanted more information on that anatomyofthesinewchannels.com. You can actually have your patient go to that, it’s excellent I’ve been doing it with him for a long time, it’s really great, Brian’s an excellent teacher with this.

Oh thanks, Matt. It’s sinewchannels.com but the blog is called Anatomy of the Sinew Channels, but I don’t think that will bring it up, just sinewchannels.com will have the schedule on it. Thanks for mentioning that.

Let’s go into the acupressure point protocol. You want to start that off?

These are based on the assessment that we had, so gallbladder 41, San Jiao 5, is on the left. For multiple reasons you could think about for the channel sinews, but specifically for the Gillet’s test. Those points will change a positive Gillet’s. We do this in sports medicine acupuncture of course with needles, where we’ll do it just to highlight this where somebody has a positive Gillet’s, we put those points in and it changes instantly. That’s the good news, the problem is those by themselves, you take them out or you have the person massage them and they got it changed and they walked around for a second and came back. The positive Gillet’s will often come back. So by themselves these points have an influence on the movement of the sacrum and the movement of the SI joint, but it needs to be reinforced with a full, comprehensive treatment. It’s going to be part of the treatment, nonetheless.

I’ll go ahead and take the next one too Matt, we have kidney 3 and kidney 4. In this case you want to massage that whole region and affect the kidney low channel, because that goes through the region of the facet, it’s probably having a strong effect on the deep lumbar multifidi muscles. That can be a really good combination to reduce pain in the facets, also with the kidney qi and qi blood deficiency signs, this would be a good combination, working with that aspect too. Particularly on the right, but we have the bilateral because we weren’t able to in and palpate and put our finger right on, let’s say it was a facet in L3 or L4 that’s causing the pain, we weren’t able to go and confirm that with palpation. So we just went ahead and included that bilateral in this treatment.

I’m not sure if we’re still live or not, because it’s after the time left, so I don’t know if just you and I are doing this or if everybody’s still there. I don’t know. We’ll try to fly through this as fast as possible, because I know we’re very strict on time here.

We’re on still.

Oh, okay. Spleen 3, stomach 4 being the source or luo point combination which helps with the abdominal muscles. UB 58, liver 5, stomach 40, as we know luo points that can be able to move qi and blood through those channels when we saw the patient indicating with her fist on the lateral aspect of her back, looking at the iliocostalis, the lateral raphe tissue and the quadratus lumborum. We’re looking at the luo points there to try to be able to change that pain pattern.

Using gallbladder 39.5, which is located halfway between 39 and 40, in addition to liver 4, does decrease the innominate bone of an anterior pelvic tilt. That’s been shown numerous times, we’ve got a YouTube video on that and there’s a whole story behind that, how I was able to come up with that. Another day, another story.

You’ve got a classic point combination to be able to tonify qi and blood, calm the spirit and also move liver qi there from the liver 3, spleen 6, P6, stomach 36, LI 10. Yoga tune up balls are excellent to be able to have your patient get them. The link for them is going to be in the contact, it’s the very last slide of this presentation. We can also have that person do some massage with yoga tune up balls there, or a foam roller if you’d like. Also, having do yoga tune up balls or a foam roller on the piriformis motor point, bilateral will help to set the structure well.

Matt, I know we don’t have a lot of time, I just want to mention this will take a second, one thing. That resource it’s in the slide, but the blog post which really has the full case study on sportsmedicineacupuncture.com, and the video on our YouTube channel has the full case study, the full video. And all of those resources are listed both on the YouTube video in the description, but also in the blog posts. I think that’s what people will have… You won’t be getting the slides for the presentation, because this is very truncated, better off to look at the old blog posts, it has all the information.

Excellent, that’s a good point, thanks Brian. The corrective exercises for the initial visit. We prescribe the exercises to prioritize the patient’s postural imbalances that’s contributing to the pain. The patient had disparities which was a bilateral anterior pelvic tilt that we saw, an elevated ilium, which is going to offset the lumbars and increase facet joint jamming with an anterior pelvic tilt. And also the pelvic and the trunk rotation, we need to be able to try to be able to change that as fast as possible.

These exercises help to balance the structural deviations by activating the biao-li pairs, the internal external pairs of UB and kidney, liver and gallbladder and spleen and stomach. This is in our thought process, not only by prescribing exercises to the core and to postural anomalies or dysfunctions, but what’s happening with the myofascial sinew channels and how they communicate.

As discussed previously, also having the patient apply acupressure massage to the suggested points prior to the exercise helps the proprioceptive signaling. How do we know that, because we do that in the SMAC program. We see that consistently by using intradermal needles on points and how it changes the exercise before and after, dramatically. That’s a big one, have your patient perform these right before the exercises, that would be really good.

Here are some of the exercises that we were giving. The exercise on the left here is figure for a cross-over which is an excellent exercise to work on the liver and the gallbladder sinew channels and decrease that elevated ilium. The center image is a foam roll on some ashi points on the lock sure glute medius side, excess, localized gallbladder sinew channel. And then strengthening the weakened gallbladder sinew channel on the opposite side with some clam shells. This is not all the exercises, this is just a highlight. All of the exercises for this particular patient is in the blog article on the website, so there you can be able to see the whole thing, again this is just the highlights.

Brian do you want to say anything real quick before we go-

No, I think we’re probably getting close to time. I think that’s the last slide just real quick on the prognosis.

The prognosis, make sure in the follow up visits is in the next few days that they’re doing the exercises correctly. You want to make sure that the posture and the orthopedic and the functional exams are hopefully about 20 to 30 percent better. It’s a positive sign, also when the patient is not tracing that referral pain. They’re not doing that body language of tracing down her buttock or into the greater trochanter. Maybe it’s just going to be more localized in the back. So it’s not peripheralization, it’s now centralization which is a much better sign.

Make sure that they’ve received herbs in the mail, make sure they’re doing the dietary changes, are they doing their qi gong exercises that Brian has…

I know we’re flying through this real quick, we didn’t have very much time, but we have to go ahead and say thank you very much to the American Acupuncture Council for hosting this webinar, we really appreciate that. And also to Lesley Spencer that took a lot of time with the video and putting it all together. Brian to you as well, this was not a one day feed, this was not a two day feed or a week. We put a lot of work into this and we really hope that it helps practitioners to gain some insight to be able to help their patients during this very challenging time. Brian?

Thanks Matt, and we have the guests coming next week?

Virginia Duran?

Virginia Doran, yes. So tune in next week for that and we will be back then in a few episodes and probably with a guest and we’ll be looking at some more topics within the sports and orthopedic acupuncture world.

I want to say one more thing, there’s a lot of digital formats that are out there, platforms that you can be able to use for telehealth, telemedicine. Unified Practice subscribers, they have one that’s brand new, they’ve worked out all of the kinks, it’s actually working really well and it’s free to Unified Practice subscribers. So you might want to check that out. Zoom is a popular one, it’s got really nice features, but if you’re already a subscriber to Unified Practice you might want to go ahead and just give them a jingle and contact them and see what they have.

Thank you everybody, we really appreciate all your time.

Yes, thank you.

Okay, bye-bye now.

Not sure if people are still on, but if they are, then these resources are found on the webpage blog.

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Using Chinese Herbs in the Various Stages of Toxic-Heat Invasion

Hi, I’m Virginia Doran, your host this week for To The Point, a show very generously produced by the American Acupuncture Council. We had another show scheduled for today, but considering the time that we’re living in right now with COVID-19, we decided to have another guest, and that is someone that many of you will be familiar with, Jake Fratkin. He’s going to talk about Chinese herbal treatment in different stages of the virus and various practical tips of products that are available from various sources. And he’s been an educator, an author in the field for decades, and practices out in Boulder, Colorado.

Many accomplishments, too many to list here, maybe he will enlighten us, or you can see on his website. And because there’s so much information to cover, I want to turn it right over to him. So, Jake, please inform us practitioners of your ideas for Chinese herbal treatment for this virus.

Okay, I’m ready to talk. Am I on? I’m on. You can hear me. Okay, so hi, everybody. I want to thank the American Acupuncture Council for inviting me. It was kind of short notice, but I’m happy to share the information that I’ve been pursuing about how to address the various stages of the virus with Chinese herbal formulas or herbal products. Now some of you out there do raw herb customizing or work with powders and do raw herb customizing, and so about the half the information or more is going to be directed to you, because you have the ability to customize formulas to patients at the various stages.

If you don’t customize formulas, you have two choices, one of them is to get herbal products that are already made and we’re going to talk about, or to ask one of the companies that does make formulas like Crane, and Lotus, and Mayway, that they’ll make the formulas up for you to give to your patients, so that’s one caveat there. We have a lot of groundwork to cover. I am certainly not going to go into detail, but the whole PowerPoint lecture that you’re going to see can be downloaded off my website. You’ll see it. If you go to my website you’ll see it in the lower right-hand corner, the way to download the lecture notes from this lecture. So that’s what we’re going to do.

And that’s called fratkin.com?

No, it’s at the end of the lecture, but it’s drjakefratkin.com.

Okay.

D-R, no period. Okay, let’s get started.

And you know, we want to just remind our viewers if you don’t have Chinese herbal training then you shouldn’t be doing this. You will want to do everything in accordance with your license in the states where you live or licensed in. And we’re not curing, and we want to be very careful not to state or misinform our patients that we are curing.

Yeah. The COVID-19 virus is very patent-protected by the FDA. You can’t advertise that you’re treating COVID-19. You can’t mention the words, because they will go after you, so I’m just calling it toxic heat invasion and working at it from there. I don’t know if my PowerPoint’s up because on my screen I can’t see what’s exactly up. I don’t see my face yet.

They’re not up yet.

They’re not up yet. And is my face up on the screen, or no?

Allen says they are up, but I don’t see them yet.

Yeah, you have the yellow box around you, but I don’t. So I don’t know if my face-

He says we’re up.

So I want to get my face up. I want to get the PowerPoint up. So let me know when you see the PowerPoint, Virginia.

Okay.

Do you see it? No.

No.

No. Okay, let’s just start it now.

Allen, you see it, but we don’t.

Okay. In general, the worst is going to come starting in about two weeks. Some of you may be seeing corona patients right now. I am over the phone. Everything I’m doing is by phone, webinar, phone consultation, and then I’m working from the material to send people herbal products. Now the way I work is I combine herbal extract powders. I use extract powders, and when I make a formula I make 100 grams. So I never like to make a formula that has more than 10 or 12 ingredients in it, 12 would be my max just because in 100 gram mix, you just can’t get the strength of enough herbs if you go more than 10 or 12 herbs. In a decoction you can put in 20 or 30 herbs, they don’t care, you just add it to the pot.

Virginia, do you see my face or no?

Yeah.

You do? [inaudible 00:06:30].

He’s saying that the audience can see things that we can’t.

Okay. All right. So I’m working with 100 gram powders and the formulas that I’m going to show are very large, they’re huge formulas, 15, 20 herb formulas, so I really recommend that if you have training in Chinese herbs, don’t give the whole formula unless you’re going to do raw soup decoction, which most of you don’t do. If you’re going to do powder extractions, then you have to whittle down the suggested 15 herbs or so into 10 or 11 herbs or so. So that’s up to you. I would not go the full formulas that they’re recommending unless you’re doing raw herb. If you don’t do powders or custom, then you default to the products.

Now, we’re going to have some products to offer, they’re not going to be as strong as these other formulas. Virginia, do you see my PowerPoint up?

Yes.

Okay, good. So these things come from two sources from China, one is Guidance for Coronavirus Disease. This is a wonderful, 140-page manual. It’s actually available on eLotus down here. I think they have a download so you can see the whole thing. Which if you’re a raw herb prescriber, there’s a lot of notes in there I’m not including, so you might want to get that document. The other document is what John Chen and Lori Hsu did, which is called, How COVID-19 is Currently Treated in China. So there’s two Chinese sources we’re working with here.

The first group is called Medical Observation Period. There’s been no lab confirmation of COVID. This is where people suspect, they have a couple symptoms, they’re not sure. So we divided those into two groups, not we, the Chinese. One is fatigue with GI upset, so there’ll be some diarrhea, there’ll be some abdominal cramping. There may or may not be fever. There’s fatigue. The formula of choice is Huo Xiang Zheng Qi Pian. These are, if you go to my book, this book which we’ll talk about, it has all the manufacturers of any formula, so it says Huo Xiang, it’ll name every manufacturer that makes it. Another phase will be-

Including American brands?

Yeah. It’s mostly, in this book there’s only GMP formulas.

Okay.

It’s only products made, pretty much put together in America, or they’re GMP otherwise. So the other one is fatigue with fever. We can’t get any of these recommendations that they’re talking about, but they’re very similar to one of these three, Gan Mao Ling, Zhong Gan Ling, or Yin Qiao. If you are not familiar with those, my book will talk about them in detail. Now for what they call confirmed or highly suspected cases, they throughout, they have this foundation formula so I can’t see… yeah, it’s hard to see the ingredients there, hard to see the ingredients. Can we move the pictures over a little so-

No, we can see.

Oh, okay, okay. So the lung-clearing detox soup is kind of like a foundation formula that they will use in all cases, mild to severe, but this is too many herbs. You have to reduce them according to how much heat you see and how much dampness you see. So this is really going to be an interplay between heat, between dampness, and between toxic heat. So toxic heat are herbs that go after viruses, and regular heat is heat in the qi, so for example Shi Gao is used a lot to bring down fever. So in this stage there’ll be coughs, there’ll be maybe some dampness. And then, of course, kind of a foundation there, Xiao Chai Hu Tang. If you’re going to work with products, probably the best combo here is Xiao Chai Hu Tang, mixing it with something called San Ren Tang, and not a lot of people have San Ren Tang, so I think you can mix it with Huo Xiang Zheng Qi Pian, Xiao Chai Hu Tang and Huo Xiang.

But as you’ll see when I go back to my other references, you always want to give toxic heat herbs, so you can always use these Gan Mao Ling, Zhong Gan Lings as part of it. Yin Qiao’s not strong enough, but it’s helpful in other ways.

I just want to ask a question here. Some people are getting it or at least starting with more of a wind cold damp scenario.

Yeah. Yeah, yeah. We go into that.

Okay.

Okay. So now in the early stage where it’s mild, there’s two presentations that I’ll show, cold dampness into the lungs, and the second one is damp heat into the lungs. So for cold damp they’re using this formula. Again, if you’re making it, really reduce it. You can’t put all these into a 100 gram bottle, there’s no way. They recommend Ephedra in all these cases, Ma Huang, which we cannot get in this country, so I’m substituting Cinnamomum, Gui Zhi, instead. This will reduce heat, it’ll dispel wind, and it will clear damp, so it’s a good general formula, cold dampness affecting the lungs. There’s maybe slight fever, it’s not real bad. There’s some cough, the chest is tight. The key symptom is nausea, nausea. So if there’s nausea, we think that there’s a damp accumulation and the stomach qi is not descending, so this formula addresses that.

If you’re going to do it with product, you use Huo Xiang Zheng Qi with something called Jing Fang Bai Du, which is in my book. For the heat stage, still the difference isn’t the fever, but now their body’s very achy. You have headache, you’re achy. There’s a dry cough, maybe a sore throat. The mouth is dry, the chest is tight, again, nausea. The stools could be loose or constipated. So this one is more cooling with herbs like Huang Qin and Lian Qiao, Qing Hao, Ban Lan Gen. So now we’re really starting to address the heat toxins, the viral toxins, Isatis, Ban Lan Gen, Forsythia, Lian Qiao, plus you also have a Xiao Chai Hu Tang basis in there with Chai Hu Huang Qin. For products, can use Xiao Chai Hu Tang with either Gan Mao Ling or Zhong Gan Ling for that stage. This is early, still considered an early stage.

In the general stage, now this is the bigger stage, it’s not hospital-level, but this is where people are sick. So this stage is called damp toxin, stagnating the lung. The fever is now starting to go up. The cough is getting more. There’s difficulty breathing. The abdomen is uncomfortable. The tongue will probably start to be more red with a slight yellow coat, but not always. Tongue doesn’t always, tongue confirms, but it doesn’t rule out. If the tongue is not red or not greasy it doesn’t mean they don’t have this, it just means it hasn’t shown on the tongue yet, so don’t require the tongue to confirm. But if it does confirm, then more power to you. The pulse is more rapid and slippery due to heat. Again, they’re using Ma Huang, again I’m substituting.

Now we’re addressing cough with Xing Ren and getting heat out of the lungs, Shi Gao, so there’s still an attention to dampness. If you have to go with products, you want to use Huo Xiang Zheng Qi, but now we’re going to use Qing Zao Jiu Fei, or things like that. I’ll talk about this stage a little bit in a minute. Cold dampness, no fever or very low fever, but again you have this cough and chest tightness and nausea. But the tongue is not red, the pulse is not rapid. And we give this, which is much more addressing cold and dampness, and again here we can use Ban Xia Hou Po Tang with Ge Gen Tang or Gui Zhi Tang. Ge Gen Tang and Gui Zhi Tang will push out the wind cold, Ban Xia Hou Po will neutralize the phlegm and dampness.

All these are on these notes which you can download from my website. Now when it gets really severe, this is the stage people want to go to the hospital. In two or three or four weeks, the hospitals are not going to take everybody. There’s going to be someone at the door saying, “Okay, you, not you.” It’s because they don’t have the beds. They don’t have the beds. Here the fever is high. This is the lung blocked by epidemic toxin. This is where the viral toxin really cranks, and this is usually seven days after their first symptom, after their first symptom of feeling fatigue and achy. After about seven days it’ll crank, and you’ll get a high fever with redness, a harsh cough because the heat now is going into the lung.

There may be some sticky phlegm, there may not. Very hard to breathe, painful to breathe. Dry mouth, there may be damp symptoms such as nausea. Now a lot of these Chinese formulas come out of Wuhan and Hubei, very damp place. Now if you live in the East Coast, that’s going to relate to you. I live in a very dry area in Colorado. We don’t see that much, we just don’t see that much dampness, but here they’re very sick. Now we have high fever, harsh cough. This is the recommended formula. They’re still trying to get rid of wind cold with Ma Huang and Xing Ren, but they’re moving again to Shi Gao. It’s a very similar formula. If there’s constipation, you work with the Da Huang, and here we can use Chai Ge Jie Ji Tang combined with Bai Hu Tang and Liang Ge San.

I talk about who has these products later. Flaring heat in the qi and yin is beyond just the lungs, this is very high fever. People will be trying to get into the hospital, but there are going to be people turned away from the hospital, and this kind of has a Bai Hu Tang foundation, Shi Gao, Zhi Mu. They’re using Shui Niu Jiao, which you’ll only get if you’re a raw herb herbalist. I think you can get this by powder form. Okay. They have cooling herbs, Xuan Shen, Lian Qiao, and Huang Lian, Lophatherum and Zhu Ye will bring down systemic heat. So if you have fever, this Zhu Ye is an important herb and Shi Gao is an important herb. You’ll see on the raw herbs that they’ll be going 30 to 60 grams in a decoction. That’s a lot. That’s a lot.

We’ll never approximate that in a extract powder, you’ll never get that much. But I would, on an extract powder, do at least 12 grams of Shi Gao. Here we would use Bai Hu Tang with either Gan Mao Ling or Zhong Gan Ling or one of the other anti-viral formulas that I’m going to talk about.

Critical stage, you’re not going to see this. This is where they’ve collapsed, they’ve collapsed. They’re not going to survive without a ventilator. The TCM people are recommending the combination of Ren Shen and Fu Zi for collapsed yang and qi, Shan Zhu Yu to bring it into the body. You won’t be seeing these patients. They’ll be in the hospital or dead.

Now my recommendations for illness with fever, you want to use heat toxin herbs. You want to use Wu Wei Xiao Du, and here’s the availability. This is everybody that carries that product. This is how my yellow book is organized. I’ll take a formula, I’ll say, who’s got it? So an asterisk means it’s based on, it’s a variation on a theme. Chuan Xin Lian is very good anti-viral, it’s a three-herb combo of Isatis, Ban Lan Gen, and Andrographis, Chuan Xin Lian and Tara Xacum, Pu Gong Ying. These are all the people that have it. Gan Mao Ling, here’s who has it. Zhong Gan Ling, here’s who has it. But there are a lot of products that are in my book that people don’t know about. All of these are anti-viral, all of these products.

I put asterisks in the ones that I think are stronger and more appropriate. Okay, Seven Forest has a lot of these products. They have Patrinia 7, Paris 7, so on. But all these companies, and then Golden Flower has Viola Clear Fire, it’s a great, great product. But all these are good, and they’re just heat toxin herbs, so you add this into what you’re doing. Let’s say you’re on a Huo Xiang stage, but you want to get the heat toxins, the virus, you really have to default to one of those or one of these. Those are very important to combine heat toxin herbs with the more classical formulas.

Lung fire, this is a painful, barking, dry, harsh cough. Qing Zao Jiu Fei is helpful, Huang Lian Shang Qing is helpful, and Qing Fei Yi Huo is very helpful. American-made products, Seven Forest has two products, Bellamcanda 15 and Stemona, they’re very good for heat. I have a product called SVP Lung. It’s good, it sort of like medium. And then here’s the codes, if I said GC it means Guang Ci Tang, if I said GF, it means Golden Flower, so on. These products can be found at Crane, Golden Needle will have them, other distributors will have all of them. But-

And what are you hearing about availability with the demand?

Don’t know. It’s not yet running out, but it will be. That’s why if you have a raw herb pharmacy or extract granule pharmacy, you can work with that. I had trouble getting some extract granules from my supplier so I went to another supplier and was able to get what I wanted. You can either stock up, or you’re going to reach a point where you’re just out of herbs. eLotus, that’s John Chen’s and Tina Chen’s group, Evergreen, they translated numerous articles from China for treating COVID-19. This is that link, or you just go to their website, eLotus.

And they have a wonderful hour and a half free presentation about it, when-

Oh, yeah. Yeah, yeah. So this sums up their information. So they took a document called How COVID-19 is Currently Treated in China, they translated it. They divided that into four phases, prevention, influenza, pneumonia, and recovery. So I’m just summing up their stuff here because they give a lot more detail, but pneumonia prevention number one, they had this formula. Influenza phase, they said patent medicine you can combine Ge Gen Tang or Chai Ge Jie Ji Tang. I would combine it with one of the anti-viral formulas based around Gan Mao Ling. Flu formula number one with headache, with dry throat. These are not strong enough in my mind. They’re good, but I would combine them with a strong heat toxin formula that we just talked about.

Then toxic heat attacks the lungs, they give a recommended formula. This is a good formula, I like this formula. Damp cold in the lung, it’s not going to be acute. I mean, it might be. It’s a difficult differentiation here, because when they’re feverish, you think everything is heat, but here there’s more of the damp side, the distension, nausea, diarrhea. Remember in China, they have a lot more damp presentations than they have in most places in America, but that’s their recommended formula. With this again, you could default to Huo Xiang Zheng Qi or Ban Xia Hou Po Tang.

I understand that the testing of people’s lungs who had severe cases of it, they found like thick, rubbery, congealed phlegm blocking the airways. So yeah, phlegm is really important to treat.

Pneumonia phase, this is a special phase. It’s kind of a Shaoyang stage with accumulation of damp. Herbal formulas you can use are Xiao Chai Hu Tang, San Ren Tang, or Gan Lu Xiao Du. Pneumonia phase, again it’s Xiao Chai Hu Tang with some, it’s sort of like what you see up here but in a customized formula. Finally, damp heat, another pneumonia formula. You download this, print it out, keep this as your reference. Now these are smaller formulas, so you can just make this just like it is, changing these doses here for soup. You have to adjust that for 100 gram bottle if that’s what you’re doing.

Toxic stagnation, this is where there’s a lot of fever, here’s the formula. You’ll have to look at it and look at it closely. This is the end-stage abandonment. You won’t see this, this is definitely in the hospital or dying. These patent medicines you cannot get anymore in the United States. I had them in my original patent medicine book, An Gong Niu Huang and Zi Xue San for fever that’s killing you. And you can get them in Chinatown, but you’re not going to get them from any of the GMP-type distributors.

This last phase is just collapse. It’s ginseng Ren Shen and Aconiti Fu Zi. There is a recovery phase, and they’re basically recommending Sha Shen Mai Dong Tang as a recovery formula. That’s available. A lot of people have it. Here is if you customize it, that’s how you would do it. All right. So all those products that I mentioned, they’re in my book. You can see who’s got it, you can see what’s the applications, what are the contraindications, what’s the historical origins, and so on. I guess that’s about it.

The handout notes are available from that link, which is drjakefratkin.com/toxic-heat-invasion/. But if you go to my site, it’ll be on there. All right. Virginia, any questions?

I really want to thank you for putting this together on such short notice and bringing your expertise. Your original patent book was the first book I read on Chinese herbs in the early ’90s before I studied it in-depth and it was really invaluable, and now I’m glad to see that you have another, more in-depth version. You really contributed a lot to the field, so I want to thank you for that, as well as what you’ve done for the show and what you’re doing right now.

Only one thing I want to say about this book. I made the mistake of not calling it essential Chinese patent medicines because it’s just about products that are available in our country, so there’s 133 classical formulas, and 83 modern formulas. These modern formulas, people who just study the classics have missed out on what China’s been doing since 1950, which is developing a lot of new products. The best ones have come out as patent medicines, so there’s 83 of them in this book that are GMP. Everything in this book is GMP. They’re GMP in China, but then usually a lot of them are tested when they come to this country. I can guarantee you they’re clean. There’s no heavy metals, there’s no pharmaceuticals, and so on.

And a lot of companies sell these, and so you want to look at this document and stock up on what you think you’re going to need, okay? All right. Thanks for your time. I hope this was helpful, and I want to really thank American Acupuncture Council for sponsoring these shows and for giving me an opportunity to talk and share my information. And it’s not mine, I just compiled it, I just compiled what’s out there.

And for people who do have an hour and a half to watch John Chen’s webinar, it’s really useful, and he gives some research studies behind things. And he talks about how, for practitioners, it’s really early-stage and recovery that we are probably best apt to treat and most likely to be treating. But it’s good to know this, because as you say, if the hospitals are full, people will be desperate for something. So I’m grateful, and thank you again to the American Acupuncture Council, and we will see you again soon.

Slides: https://aacttp.click/ov7

Phlegm – Etiology pathology and treatment Moshe Heller

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Medicare and Acupuncture 2020 American Acupuncture Council

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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