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Poney Chiang Thumb

Strategies for post-COVID-19 infection associated neurological dysfunctions

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Hi, welcome to this week’s live show brought to you by American Acupuncture Council. I’m your host for today, Poney Chiang, coming to you from Toronto Canada. I’m a continuing education provider, and if you’d like more information about me, you can find it on the title slide.

Today, I’m going to talk to you about strategies for dealing with neurological complications and neurological symptoms as a direct result of patients that have unfortunately been afflicted with COVID-19. And there’s actually a growing amount of literature in this area and since my interest and expertise in the area of neurology and acupuncture, naturally this is a area that I’m very passionate about. So I’d like to show you some of the readings and research and strategies that are applied in my own clinic.

The first paper that we’re going to look at comes to us directly from [Wuhan 00:01:43]. This paper was published in just March, and it is a retrospective observational study conducted from three different centers. So these patients were tested positive for COVID in the month of January and February this year, and there were a total of 200 plus patients. And they were all assessed by neurologists, and their neurological manifestations were categorized into three different subtypes.

The first type is called the central type, and the central nervous system type gives you symptoms such as headache, impaired consciousness, if you can have an acute cerebrovascular disease, that’s another word for stroke, and you can have ataxia and seizures. The second type of classification is peripheral nervous system symptoms. And the most famous one that you may have already heard about is lack of smell or lack of taste. And sometimes there can be vision-related impairment as well. The third type of dysfunction is have to do with skeletal muscle injury. So patients would complain about pain. Those of us that know people who have been infected with COVID will tell you it’s like a flu like none other. You’re just hit with it. Your entire body hurts. I even had a friend tell me that it feels like shards of glass in his joints. That’s how painful it is. Okay?

So those are the three main neurological classifications. And as I said, this is a study of 214 people. And what the research found was that 36% of these patients all exhibited neurological symptoms. And what was interesting is that those with more severe infections, defined by having more poor respiratory status, which was in this case 41% of the patients in this study, they were more likely to develop neurological problems. So somehow, the harder you’re being hit by this disease, the more likely you’re going to have neurological symptoms. Just so you have a breakdown of roughly the proportions of the three different classifications I mentioned, about 25% of these patients had central nervous system symptoms. About 10% of the patients had peripheral nervous system symptoms, and another 10% or so have muscular skeletal symptoms. So, you can see why this is something that we as acupuncturists should be aware of because oftentimes patients with CMS and peripheral nervous and now of course muscle-related problems, want to come to us for support.

Of the central nervous system symptoms, the most common ones were headache and dizziness. Whereas, in the group for the peripheral nervous system, the most common symptoms were impaired taste, which is called dysgeusia, and impaired smell which is anosmia. And a patient who had muscle injury as compared to those who had no muscular pain symptoms, were found to have higher C-reactive protein levels and higher D-dimer levels. C-reactive protein is a marker for systemic inflammation in the body. So, patients who had more inflammation in the body was more likely to have muscle pain. And D-dimers is a breakdown product that the body makes when blood clots have been broken down, which is indirectly a measure of how much coagulation there is in the body.

So in other words, those with more coagulation, think in terms of [T-blastocysts 00:05:26] and TCM, those with C-reactive protein, indicative inflammation, thinking in terms of blood heat in TCM. These patients are far more likely to develop muscle injury related symptoms. Now, I want to emphasize that neurological symptoms is not just limited to the central nervous system. We mentioned it’s the peripheral and there’s the musculoskeletal. So I don’t want you to have an impression that show COVID patients are more, are oft being afflicted with strokes. Okay? That was the picture that was being passed around in the early stages when we didn’t know what was happening. But now we’re seeing, it seems to be that they are more likely to develop central nervous system symptoms, such as acute cerebrovascular disease like stroke, but it’s not the entire spectrum of neurological symptomologies that these COVID patients have.

So, as an example, in the Wuhan study, there are six patients out of only 200, only six patients out of 214 had acute cerebrovascular disease. And two of them actually arrived at the ER with sudden hemiplegia, paralysis, weakness of one side of the body, but they did not have many COVID symptoms. That is to say, no fever, no cough, no anorexia, no diarrhea. And they were only found to be suspected of having COVID from CT scans of the lung that found there’s some lesions. And then they were subsequently tested with PCR based assays to confirm that they had indeed were infected with COVID. So this is important because one, we need to realize that patients may never have gone to the hospital because they’re afraid of going to the hospital because they were going to get COVID, you can contract COVID in a hospital, they may have neurological symptoms and they will go to the community for care, even though they are positive and not because they’re, but being asymptomatic positive.

Another interesting finding was that some patients that did present with fever and headache were presented to neurologic ward in Wuhan, and they were initially positive-negative. So either their viral titers were high enough to be detected by the assays, or it was a false negative. And then only when the symptoms really started come on like coughs, and the dyspnea, then they were retest [inaudible 00:08:00] found to be positive. So that’s important to keep in mind as conditions that we need to be aware of. Possibly the patient come to us with neurological symptoms, but may actually be symptom negative, but in fact positive COVID patients.

So in summary, from this paper, they found that all the patients that had neurological problems, tend to have lower lymphocyte counts, white blood cell counts, which is indicative of some level of immunosuppression, and therefore, they are more likely, for mechanisms that scientists are still starting to study, more likely to be afflicted with central nervous system symptoms.

And now patients who have more severe infections, meaning worse outcomes with their respiratory integrity, have higher D-dimer levels. That, again, it’s a measure of how much coagulation there was in the patient’s body, and this can explain why those with more severe infection, meaning more worse lung function, having more D-dimers, are they more likely to develop occlusion or clot-type of strokes.

[inaudible 00:09:16] reminder that the authors of this paper wanted to show us is that… I put this in red, in quotation, that during the epidemical period of COVID-19, when seeing patients with neurological manifestations, physicians should consider the COVID-19 infection as a differential diagnosis. You want to avoid the late diagnosis or misdiagnosing and prevention of transmission. So this is an important wisdom for all of us to take to heart as practices start to open and you’re seeing patients with neurological issues. You might want to gently remind them to go get tested, because it’s possibly that they could be positive and just be asymptomatic.

Now, a group in Spain replicated this type of study, but this time with a larger n size of 841 patients, and this time around with a larger sample size, they actually found that close to 60% of COVID-positive patients now presented with neurological symptoms. And this was data collected across two different institutions.

And Harvard, okay, I don’t want to be an alumnus, not all neurological symptoms associated with COVID are struck. If you look at these numbers here, only 11 out of 840 actually presented with ischemic stroke and three presented with hemorrhagic stroke. So that’s only 14 out of 840.

The mean time of occurrence was approximately 10 days after the development of the COVID symptoms. So they started having stroke 10 days later after personally having a cough, [inaudible 00:11:07] a fever and as such. And again, there was a very strong correlation between those that who had the stroke, in other words, the cerebrovascular disease, and those with higher D-dimer levels, meaning that’s the byproduct of the breakdown [inaudible 00:11:23] in the body. So in other words, no surprise, more [inaudible 00:11:26] in their body, more likely to have a stroke presentation.

Now on this side, we’re looking at a paper published in Germany, and this paper was a attempt to summarizing the amount of ischemic stroke that was being seen in patients with the COVID from three different countries. As in first column you can see from the United States, second column from China.

So this China column is actually the paper I just presented from Wuhan. And then another paper, which I’m not presenting today, is of n size of 206 from Singapore. And what I wish to point out, is that you can see the number of people having strokes in relation to the total [inaudible 00:12:22] positive number of COVID patients. It’s relatively small. Now they all have associated risk factors that we know of: have they been hypertensive, being obese, be having diabetes mellitus. These are predisposed youth to more higher incidents or infection in this diseases.

And what these researchers have found was that, in the overall picture, if you look at the type of stroke, that the patients are having, there is a preference or a more heavily weighted manifestation of large artery occlusions in contrast to small vessel types, in contrast to blockages in their heart or cardiac embolisms. Okay.

So even though the number of strokes that COVID patients have is not very high, and it really depends on the severity of the infection, it depends on how much D-dimers they have, if they were to get a stroke, based on the limited amount of data we have to date, it appears that there is a preponderance towards large artery occlusion type. And now let’s take a look at the outcome of these patients.

In China, of the 11 people that had stroke-related presentations, four of them died. In Singapore of the five people, three of them died. In the United States, none of them died, and they were then subsequently sent to ICU stroke units we have, or went to go home. So we can potentially, as acupuncture, be seeing these patients that are being sent back to the community for rehabilitation purposes.

Now, I want to talk a little bit more about this large party ischemic stroke. This paper that was talking about the five people from the United States is summarized in this tabulated form in the next slide. So this is a paper that was published in “The New England Journal of Medicine”. And this is physicians in New York were noticing that, “Wait a minute, young people are getting strokes. This is not expected.” So if you look at the first row, you can see the patients one through five. These are patients that are under the fifties. Most of them actually in their thirties or early forties. Young people should not be getting stroke. So even though I said repeatedly, that strokes are not the most predominant type of neurological symptoms in patients with COVID, it is kind of sad and devastating that these can affect young people. And not all of them had the risk factors we talked about, such as hypertension and diabetes. Look at the second, third row here.

Medical history and risk factors for stroke, there was none, these people had none, undiagnosed … One of them has undiagnosed diabetes and some of them have hypertension, but some people had no symptoms whatsoever. A lot of them weren’t even on any medication. So relatively healthy people, young people can get this.

So another thing I wanted to bring to your attention, is look at the symptoms that these patients present. So they present with hemiplegia, loss of consciousness. They can have difficulty speaking, or they can have altered sensation. They can have something called gaze preference, issues to do with the eyes, we’re going to go … and also hemianopia, which is also a vision [inaudible 00:16:47] symptom. We’re going to talk a little bit more about the visual aspect of stroke and have some strategies you can deal with that in the upcoming slides.

If you look at the vascular territory, the ones that the strokes involve, you’ll see that it is affecting the internal carotid, infecting the middle cerebral artery. Most of them are affecting middle cerebral artery with one exception here, here is affecting posterior cerebral artery. I’m going to also talk a lot about that. It means that patient that have stroke, these large vessel type of strokes, tend to be getting it in the internal carotid and its derivative, such as the middle cerebral artery.

Let’s look at the symptoms of these patients. So some patients have cough, headache and chills in the first column, patient one. Patient two has no symptoms. Patient three had no symptoms. Patient four was tired, that’s it. Other than that, no fever, no cough. I want to just stress upon you, maybe you want to take this into consideration when you screen patients, whether you accept these type of patients in your clinic or not. If somebody comes in with neurological symptoms needing help and this developed in the last two, three months, it could very possibly be asymptomatic COVID patients who’ve had this, and they’ve never had a reason to go get tested because they had no symptoms. So it’s up to you whether you want to open up your clinic to help these type of patients, or maybe request they’re tested before that you’re able to help them, et cetera.

So a little bit more about this large occlusion, artery type of occlusion. What is it exactly? [inaudible 00:18:40] saw some embolization of atherosclerotic debris. So if you think about plaques inside your blood vessel and embolization means these plaques have become free, dislodged. Usually they originated from the common or internal carotid artery in your neck, the common carotid artery divides into internal, external. I’m going to show you some pictures about that in a moment. Sometimes it can actually come from the heart itself, the vessels of the heart and they become dislodged. The large vessel ischemic strokes that develop are most likely to affect the medial cerebral artery territory.

In other words, the symptoms, the neurological symptoms the patients are going to manifest, are going to be whichever part of the cortex that the medial cerebral artery supplies. So this is why it’s important to know the anatomy, knowing which part of the vessels are more likely to be affected in COVID stroke type of patients, we can then predict what is the most likely type of symptoms or neurological dysfunctions that this patient going to have based on the vascularization of relevant function area, corresponding function areas in the brain.

So this is just a quick review of the circulation of the brain. What you see here in the center is the circle of Willis that we all learn about in school. What I love about this slide is that they color coded it as such that in purple, I’ll call the posterior circulation, and it’s called posterior circulation because comes from the vertebral artery in the back. If you look at the patient on the right side over here, VA stands for vertebral artery. Whereas the green shade, called the interior circulation, which subsequently divided into anterior cerebral and medial cerebral, also, ICS stands for internal carotid artery. These green ones come from … so you’ve color coded over here, comes from the carotid, common carotid artery, which divides into ECA, CCA is the common carotid artery, which divides into ECA for external carotid artery, this goes round the face, outside your skull and then the internal carotid artery, which as you can see is now green, and then goes into the brain and divides into enter in medial carotid artery.

So here is the picture of the internal carotid artery label over here, this big one over here in green, the biggest one, the biggest cross-section green. You can see it divides into anterior … the anterior cerebral artery, ACA over here. Then going left and right laterally, this one here is the middle cerebral artery.

So patients are most likely to have clots in here before the division, or somewhere in the neck here. Or after the internal carotid has bifurcated into the middle cerebral artery, you can have occlusions in the middle cerebral artery.

So now we’re going to take a look at where the middle cerebral artery supplies. So this is a very nice picture that shows you in a color coded manner different areas of the brain compartmentalized, based on its source of vascularization. So on the bottom here, you can see A, this is turquoise color, A part. These all supply the interior cerebral artery, it’s not relevant to our discussion. All the P part, all the red parts are all supplied by the posterior circulation. That’s also not relevant to what we’re talking about here. All the yellow ones, labeled N, shows us where the middle cerebral artery supplies.

So as you can see, it supplies a large portion of the lateral surface of the cortex, both the frontal, the parietal, and even the temporal lobe. So it is a very important area. If you look at the cross-section over here, you can see here’s the internal carotid artery and it divides into … this tiny little guy here is the anterior cerebral artery, and then it divides into common carotid artery. So patients with COVID are most likely having large vessel strokes, what that means is that most likely cause is in here before bifurcation, or in here in the middle cerebral artery. Why is it not in the interior? Because the interior is small. So therefore it doesn’t qualify as the large vessel type.

Now, as you can see, the middle cerebral artery then divides and wraps upwards to cover the parietal lobes and wraps downwards here to cover that the temporary lobes. So here’s a side view of this side here, very beautiful picture, I love this picture. You can see that if the occlusion is happening in the common carotid or middle cerebral, then all of these [inaudible 00:23:49] are going to be shut off. That means all the neuro cortical areas that are in this region are going to be hypoxic, and therefore going to go show [inaudible 00:24:00]

Now what’s in this area. If you remember your scalp acupuncture, there is the sensory line, the motor line, and that’s in relation to the central sulcus. So, where is the central sulcus? The central socket is in here. Okay. There’s just most promise sulcus over here. So interior that to the motor [inaudible 00:24:23], that is a somato sensory. So this means that somebody who suffers with a middle cerebral artery stroke is going to have sensory and motor dysfunction.

Okay. And even though the medial part, which is the blue “A” part, this is the region that’s more where the lower extremities are located, even though it is not part of the middle cerebral artery distribution, there is some overlap. So you can still expect patients to have lower extremity problems. And I’m of course, referring to the homonculus map, along the central sulcus, where if you recall the medial one-fifth is supposed to be the lower extremity, the middle two-fifth would be the upper extremity, and the lateral one-fifth would be the face.

So let’s approximate that on the picture here on the top right, in this area over here would probably be the lower extremity around here. Around here, would be the upper extremity. And when you get down to the park, closer to the Sylvian fissure over here, which separates the parietal lobe and the temporal lobe, you’re going to get closer to the facial areas. So these patients can obviously expect facial drooping, facial motor deficit, upper extremity, and to some extent, low extremity also.

Now I’m going to take a little segue now and talk about what other things are involved other than just the occlusion. There’s something that is called SIC, which stands for Sepsis Induced Coagulopathy. So this means it is a coagulation of blood clot that’s induced by having a bloodborne infection. So scientists now know how the virus gets into our bodies, through a type of receptor and uncertain cells called ACE2 receptors. “ACE” stands for Angiotensin Converting Enzyme. And these type of cells I’ve found on lung cells. So no surprise COVID is primarily an upper respiratory airway disease. It’s found in the small intestine. So perhaps this can explain why some patients have gastrointestinal symptoms with this disease. It’s found in endothelial cells, meaning these are the lining cells of your blood vessels in the dyadic system.

So now we can see how this actually can attack the vascular system and lead to severe vascular events. And it’s found in smooth muscles in the brain. So no wonder people can develop neurological central member system symptoms as a result of this infection. Now I’m no expert on the complicated receptor cascade that regulates the inflammation and coagulation in the body. So I’ll just summarize it for you: it’s two types of receptors are known to activate cardio-protected or neuro-protected effects inside the body. Now, when COVID-19 infects us through ACE2 receptors, it depletes the receptors. Meaning whichever function that these receptors are supposed to do physiologically can no longer be accessed. So what this means is that our body is in a less, or more compromised cardio-protected in your particular state, leaving us one type of receptor to act unopposed thinking about Yin and Yang regulation.

So what is one activating? A swine type of receptor, ultimately results in cascades, sickening cascades, that activate genes that lead to inflammation, and coagulation, and even hypertension’s that embody. So, as the cognition is not bad enough, now you have high blood pressure – you’re more likely to cause a stroke, right? So it is because this virus has the taste for these two receptors that is supposed to be neuroprotective for us. But, as a consequence of these receptors being also found in the brain, it’s a double whammy. You are now set up for inflammatory and coagulatory disaster.

Now scientists are proposing different ideas of how this lead to damage to the brain. We now know that there is more inflammation in the body, because of the unopposed ACE1 cascades inside the body. But what that inflammation does, is that it can actually lead to damage, or breakdown of the blood brain barrier. So the bumping barrier is a very delicate piece of barrier inside our body. And if it is broken down because of inflammation, that spells doom. What happens is then the inflammatory cytokines in your body, now can cross the blood brain barrier, and reach the central nervous system. So it’s, it’s just bad on top of that. You may have heard about cytokine storms that happen in this patient is actually your body’s immune response. That is hyper immunity response towards the virus that is actually causing damage to tissues and organs that certainly can also affect the brain now ,because it’s got causing breakdown of the blood brain barrier.

So I think that’s really interesting information about the neuro-physiological mechanism. How this virus affects us and it gives us a epidemiological appreciation of how this disease can manifest in neurological ways. Now I’m going to share with you some of my ideas about how we can help these type of patients using areas in my research that I’ve done about the peripheral nervous system and the [inaudible 00:30:54] system. This is a map called a Brahman area map where the different processes of the brain had been compartmentalized based on different functions. I showed that here, just as a quick reference for you, because in my upcoming slides, I will be talking a little bit about some of these areas.

So one of the most common peripheral nervous system functions was Anosmia, which is loss of smell and Ageusia, or hypergeusia, which is loss of taste. So how can we possibly help patients with this? First of all, we need to say the [inaudible 00:31:38] nerve one, which is our olefactory nerve, is way deep inside the brain. It’s not accessible. And unfortunately the olfactory cortex is also not accessible. It’s not posting up to the surface in the brain for us to be able to affect it through scalp cap acupuncture. If you go back to the previous slide, you’ll see that olfactory is a dark orange. The dark orange is actually area 34.

Okay, so if you see this, this is actually in the midline. This is the lateral surface, this is the midline. So it’s actually on the inside of the temporal lobe. It’s not accessible, to too far in for acupuncture, [inaudible 00:32:11] . So what can we do? Fortunately, we have points that have been passed down that are supposed to have some effect on the nose and sense of smell. That’s over, located on the midline of the scalp. But let’s take a look at the new anatomy and see if it actually makes sense based on what we know about the new anatomy of the nerve supply for the nose. I want to talk about the anterior ethmoid nerve, which is actually from the opthalmic division V one of cranial nerve five. And, let’s take a look at that.

So, anterior ethmoid nerve, here’s the ganglion of the trigeminal nerve and there’s, there’s your V one, V two and V three. So as part of the V one, you have this nerve here that branches into the posterior ethmoid, anterior ethmoid, see how it goes and makes it a little hole in the foramen, in the back of the eyes. So from here, it goes into the cranial vault. I’m going to give you a different view at the next slide here.

So it comes out of these foramens over here and these nerves actually supply the meninges. So here’s the interior meningial branches and anterior ethmoid nerve, that supplies the meninges. But, because this cross section is horizontal, you don’t appreciate how high up this innovation goes. So this next picture shows you that the opthalmic division of V one and specifically the anterior ethmoid nerve, innovate this bony membrane called the falx cerebri along the midline.

And, it gives credence to the notion that these points that have been passed down to us, global area 20, all the way to 23, 24, which is on the midline, or which is innovated by the anterior ethmoid nerve, can possibly affect this nerve. So, what’s the big deal about affecting these nerves? Well, this anterior ethmoid nerve not only just innovates the meniges, these same nerves or branches now innovate the nasal cavity and septum. So as you can see here, the anterior ethmoid nerve, after it innovates the meninges up here, comes very close to the olfactory ball, by the way. So, we don’t currently don’t have permission to confirm this, but normally what we know about the nervous system, oftentimes there are communication branches that might be able to affect the cranial nerve of one olfactory nerve.

But, even if it doesn’t, this nerve, has an external branch that goes outside the [inaudible 00:34:59] of skin, but an internal branch that innovates the septum and also the nasal cavity. So this nerve gets information about the amount of mucus or dryness there is in the nasal cavity, and, presumably, your nervous system can regulate the amount of moisture in your cavity. And, we know that dry nose is related to, mucus member is needed, moisture is needed for fragrance particles to adhere, and therefore more likely for us to detect the smell. Perhaps by modifying the internal conditions of the nasal cavity, even though we’re not affecting the cranial nerve one directly, we are making it more favorable for the cranial nerve one to actually be able to detect smells and fragrances. I thought it was pretty crazy that these points that we learned on the anterior aspect of the midline of the scalp, to do with the nose, actually has hard cranial nerve-related explanations for how they can affect the nose.

Now, a couple of case. The gustatory cortex is something that is accessible. So, the gustatory cortex is actually Brodmann area 43. It’s a tiny, tiny little area, basically at the junction of the Sylvian fissure and the central sulcus. So you can see here, this part here is the central sulcus. So, anterior to that is a motor, posterior is a motor sensory. If you continue all the way down, where the motor sensory and the temporary lobe meets, that’s Brodmann area 43, which is the gustatory cortex.

And, based on the MRI research that I’ve done, and talked about it elsewhere, we have a chance to affect this area, but it requires a special needle technique, called a cross threading technique, where you would thread down from global area five and thread anteriorly from global area six, and that will allow you to cross intersect of over Brodmann area 43, which is a gustatory cortex. So if you’ve reviewed the vascularization of the middle cerebral artery, and with the parts that it affects, you can see why it would affect the taste, because that’s the gustatory area is part of the middle cerebral artery domain. And, therefore can explain why patients with COVID may have loss of taste, if they developed central nervous system type of symptoms.

Now, another way we can possibly affect the taste is using nerves called lingual nerves. And, these lingual nerves ara a branch of the mandibular division of the trigeminal nerve. So remember, the trigeminal nerve has three divisions, the mandibular is V3. Now, even though this is, strictly speaking again, a sensory nerve, it is not responsible for taste. In fact, the tastes of the anterior third of the tongue, as the comments here are written down for you, is supplied by the facial nerve. So, just sensation is supplied by the lingual nerve, but the taste, special sense taste, it’s essentially beneficial there. However, the facial nerve relies on the lingual nerve to convey its nerve fibers back to the brain. So, this is the reason why patients who have damage in the lingual nerve, either due to dental procedures and whatnot, can oftentimes cause them to feel like there’s a metallic taste in their mouth, or a foreign taste, or a lack of ability to taste.

And, so fortunately for us, we have acupuncture points located right below the tongue to affect these lingual nerves, and that’s the extra points Gingy [inaudible 00:39:01] . So, puncturing these points, even though it doesn’t affect the special sense directly, it provides conveyance of the special sense nerve fibers back to the brain, which might be able to help to receive more signal about taste to the brain. Now, early on, patient people also published ocular motor dysfunctions associated with patients who have COVID-19. Two different research groups have presented information how these patients may develop ocular motility deficits or ocular motor palsies. And, even though the case number is not very high at this point, again, you’ve got to think about this. People who present with either of the issues, and if they’re asymptomatic, are not going to be sent to isolation or sent to the infectious diseases.

They’re going to be going to the neurologist, or even in this case, ophthalmologist. By the way, the first doctor in China who blew the alarm on the COVID-19 was an Asian ophthalmologist. So, don’t let the fact that these cases don’t seem very high dissuade you, because it might simply be a case of lack of reporting. So in any case, how may we as acupuncturists help patients who are suffering Oculomotor Palsy, possibly as a consequence of having neurological dysfunctions from COVID infections?

I need to briefly introduce you to something called a frontal eye field. The frontal eye field, we talk of the Brodmann areas, right? It’s located in Brodmann area 6, so you can have a look at that in the map in a moment. And what happens is that this part of the brain is responsible for controlling rapid changes in your eyes in the left and right direction. It’s called saccadic movements. So patients who have dysfunction in this areas of the brain, affecting this area of the brain, may manifest inability to have rapid eye movements. This is also called contralateral horizontal conjugate gaze palsy. So if you recall, the American paper show you the five different patient cases. One of the symptoms that they had was gaze preference. Okay? It’s because they are lacking the ability to see both sides so they have a preference for one side.

Now, how does this affect the parts of the brain that actually controls cranial nerves III, IV, and VI, that actually is responsible for the eye movement? Based on tractology or connectivity studies, neurologists have found that the frontal eye field actually makes connections with the midbrain, where these cranial nerves can make the eyes form.

So again, these midbrain structures and cranial nerves are too deep for us to get affect directly. But pressed indirectly through the cortical connections, neurocortical connections, we can have a fighting chance to affect ocular motor systems. I’m going to show you my research about this. You’re looking at the correspondence of the scalp and the cortex, specifically operators 16. And I was really cool about this and I love the chorus, but that when, when the Eastern West converged gallbladder 16 in Chinese is more strong. It means I window. Hello? The name is telling you that this point can do with the vision and that it actually correspond to frontal eye field, based on modern research, is just too good to be true. So where is this specific to this front IFU in humans? A lot of research in animals suggest that it’s in Brodmann eight, but we now know that’s incorrect.

It’s in problem in six. And so where is that? If you look at the yellow data line, it’s where the superior frontal sulcus meets the precentral sulcus. So here’s the central sulcus, okay. Where we divide the motor sensory and there’s an OMP. So, and then you have the premotor area or the pieces of gyrus right in front of that, it’s called a precentral sulcus where the precentral sulcus meets the superior frontal sulcus. This is superior frontal sulcus there. This one over here look other broken is the inferior frontal sulcus. So in a case where the front end superior from this office meets the precentral sulcus. Now the bird side view superior frontal sulcus meets the precentral sulcus. This area is where Brodmann six or prefrontal sorry the frontal eye field is located. And we have a point called LAR 16, which is just right in this area. If you thread it, if you’re familiar, scalp acupuncture along the Meridian, you will cover this area beautifully. And therefore you will be able to affect from the eye field and affect ibogaine and movements.

I’m going to just finish up with a case that I recently saw of a showcase. I tongue in cheek, call it the case of shotgun at time of Corona. And this was an 86 year old male patient who in early April, he, he and his family cannot be exactly sure exactly. When, where he started have developed slurred speech. Now he has the risk factors such as hypertension, diabetes, mellitus, and other non directly related symptoms. And nursing does comorbidities such as them freaking urination as a result of enlarged prostate. He’s had a history of Bell’s Palsy in his forties. Now several weeks before he had a stroke, he has some poor sleep. So it’s not sure whether that sleep was related to that’s just a coincidence or related to poor sleep having caused hypertension poorly managed by any case, he was admitted to the hospital for one night.

And because of symptoms was start to already showing signs of very fortunate men or already showing signs of improvement. He was discharged the next day. And, and which is atypical should typically, when you have a symptom of stroke, you are in the hospital for very longer. Not sure this is change in policies is dependent on the fact that there’s some lack of resources and the staffing during this time of COVID that the patient, since it was not life threatening was sent back home, by any case in addition to star specie also presented with left sided arm and leg paresis, and he felt extremely tired. I remember one of the symptoms, one of the only symptoms that, one of the five Americans that had the show with just lethargy, right? There’s no other covert, listen to this, man didn’t have any respiratory problems’ fever and such, but it doesn’t mean he’s not positive.

And for all the research that we’ve seen so far and the family noticed that ever since having a stroke is, can seem to have Mark and the aged. And, is just complaining about tiring all the time. He has a dark tongue okay a dark purple tongue [inaudible 00:46:46] that we talked about things like coral coding, which means a lot of phlegm cold phlegm inside of the body, which is we know cold, also contributes to [inaudible 00:46:58], right? So the pictures are triangulating quite nicely, unfortunately this is actually a family friend of my receptionist, and because the clinics closed due to mandating to be closed because of public health policies, he’s unable to make an acupuncture appointment with me or with anybody.

So it wasn’t until we will reopen on June 2nd, he was able to get his appointment. And so on the very first day that I was back on June 6th, he saw me for acupuncture and to date, we’ve had four sessions so far, and I’m happy to say that the results have been quite favorable after one treatment he said that his left leg, which is the afflictive site actually now feel stronger than in his right side. Okay. So patients, maybe there’s a little bit of a, a good patient and practice rapport there, maybe a little bit of psychological effect, but Hey, I’ll take it. And, but so far there’s no change in the arm strength just yet, which is actually expected those of us that have experience doing neuro rehab know that arm loss of function or paralysis is harder to regain than leg paralysis. But by the end of the fourth session, patient Ashley left the treatment room without taking or, quote unquote, needing his cane. So presumably that is indicative that his legs felt so strong that he forgot that he needed the cane.

So, that’s the latest case I can share with you all. I don’t know for certain that it is a case of COVID, but I’m using extreme PPE precautions, and I am suggesting that this case should go get tested despite being asymptomatic. So I thank you very much for your attention. And if you have any questions, just message me. If you like this presentation, don’t forget to tell your colleagues, don’t forget to let others know about it. And if you enjoyed it, show us some love. Thank you very much.

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Dr. Virginia Doran

AAC-Beyond Heart 7: Alternative Approaches to Insomnia Repair

Click here to download the transcript.  Click here to download the slides.

Hi, I’m Virginia Doran, your host for another edition of, To The Point. Very generously produced by the American Acupuncture Council. Today, my guest is Daniel Bernstein. He’s been a licensed acupuncturist in New York city since 1995, and around 2008, he started specializing in insomnia. And this year, 2020, he came out with a book called, Rewired for Sleep: The 28-Day Insomnia Repair Program. And he’s soon also to release a book dedicated to practitioners called, something like beyond hard seven alternate strategies for treating insomnia.

I think you’ll find it very interesting, and it’s something if you don’t have yourself, certainly some of your patients do, especially at this time. So Dan, please welcome, and tell us about your approaches to insomnia, because I know it goes beyond just TCM. Tell us what you think as practitioners we ought to know.

Great. Thank you so much, Virginia. I really appreciate you inviting me to share what I have gathered over the years. And thanks also to the American Acupuncture Council for setting this all up. It’s a great service that you all do. And yes, I’m Daniel Bernstein. I’ve been a licensed acupuncturist since 1995. I have a practice Blue Phoenix Wellness in New York city. And again for the last 12 years or so, I’ve been focusing on sleep and sleep related issues. In February of this year, I was pleased to release a book and I’m going to bring it up, here it is. It’s called, Rewired for Sleep: The 28-Day Insomnia Repair Program.

I’m just going to go to this quote here, which is, “Put your thoughts to sleep, do not let them cast a shadow over the moon of your heart. Let go of thinking.” And I love this quote by the Persian poet Rumi, because, as someone who’s patients are often caught in the crossfire of self-talk when they’re trying to sleep, this quote sings to me, it has an elegance to it that calms my heart down and puts me almost into a meditative state as it is. So I’m going to go on here. Let’s go to the slides please.

And I’m assuming we’re at the slides. So that’s the quote I was talking about, “Put your thoughts to sleep, do not let them cast a shadow over the moon of your heart. Let go of thinking.” Today’s goals are going to be pretty simple. We’re going to talk about the importance of sleep, why healthy sleep matters, treating insomnia, an overview. We’re going to talk about a case history. I’m going to talk about mind traps, is what I call them. And then I’m going to show you all a simple exercise that I show to my patients who have a hard time sleeping.

So, how sleep has changed. This healthy sleep means sleeping eight hours nonstop. And in my first go around with the book, I wanted to do a comprehensive, even exhaustive book on treating sleep issues, including acupuncture strategies, herbs. And instead I wrote a book that was targeted for the lay person, but that acupuncturists can use as a template for helping their patients get a good night’s sleep. Now I’m working on the second one.

And while I was doing research for that book, I began to question what healthy sleep is? Among the ideas that we take for granted right now, is a belief that in order to be fully rested, we’re supposed to sleep continuously for seven and a half, eight, eight and a half hours a night. But this idea that we’re supposed to sleep continuously is really a recent one. And it’s a construct of the industrial revolution. It wasn’t until a vast numbers of people had a report for work at eight o’clock in the morning, that the idea of sleeping eight hours through the night even existed.

You see before that, what was common, was people had first sleep and second sleep. Okay? And in that more natural cycle, a person might wake up at one o’clock in the morning or two or 2:30, and use that in between time, they’d get up and they might feel feed livestock. They might talk, they might meditate. They might eat something and then gently and easily go back to sleep. So this recent idea that we need eight hours continuously and that anything else is frankly wrong, implies that if our sleep patterns stray from the norm, we’re somehow failing at sleep, okay.

Now what that does is, it creates an immediate anxiety. If I wake up 2:30 in the morning, and I think I’m supposed to be sleeping, kicks in some cortisol. It feels like I just drank two cups of espresso and I’m off to the races. So one of the things I tell my patients is, it’s okay if you wake up. In fact, you can just say to yourself, it’s okay if I don’t sleep, you can get up and you can rummage around for 10, 15 minutes. I tell them that they can actually, just do a little odds and ends and then naturally and easily go back to sleep.

When did they start saying that it didn’t have to be uninterrupted?

When did they say that it had to be interrupted? You’re saying.

I hadn’t heard that before, that it doesn’t matter. I know in certain cultures, people have their siesta, you traditionally have a nap in the afternoon and therefore you’re…

Right. So, you’re asking, when did people say that?

Yeah, I just wondered, where you’ve seen that as a resource or if that’s a standard.

That it need not be eight hours you’re saying?

Or that it need not be uninterrupted.

Well, as I said, historically, it has been such that people did not necessarily need eight hours sleep. That uninterruptedly, it was common. My resource was the New York times. And it is talked about by Cervantes and Don Quixote, where he talks about Pancho, censor, all eight hours in without problem. But he would get up in the middle of the night and rummage around and then go back to sleep. So it’s part of the historical norm. Certainly people who worked in farms and such would understand that it was all part of the larger cycle. Does that answer the question?

Yeah. Can people go into deeper levels of sleep if they are sleeping for shorter periods at a time?

Well, an hour and a half is typically a REM cycle, typical four stage cycle. So if you’re sleeping three hours, then you’ve completed two stages and then you can go back and sleep another two or even three cycles. So yes, as long as you’re working within an hour and a half cycle of the REM cycle, you’re good. It’s just, it’s something people don’t get enough of those cycles in. So in other words, for them, they might get only two cycles in. And so they’re feeling depleted.

I have another question. Are you a proponent of people taking naps? Because some people seem to believe in it. Some their bodies just don’t really work that way. They feel better, not taking naps, some people it’s-

Sure. I am a proponent of somebody knowing their body enough to know what works. I know I’ve had gotten some patients who came from a Cognitive Behavioral Therapy or CBT, which often uses restrictive sleep, not allowing naps, making sure people get in bed a particular hour and out of bed at a particular hour as a way of retraining the body. I’m not a fan of that. But as for naps, I think everybody’s just different. And the body changes. Some people can never take naps, and then 20 years later, all of a sudden they nap beautifully. So, we’re capable of changing our circadian rhythms in that way.

So, and we’re talking about circadian rhythms, they’ve been thrown off by artificial lighting, of course street lights were boon to society and culture, but they also meshed with the pineal gland. And suddenly we were no longer going to sleep at dusk and waking up at dawn. So that was totally out of the window. So that on top of recently, having our iPhones, our tablets, our computers at night, adds another layer of messing with the pineal gland.

So these things have really tended to mess with that most curious organ, the brain. Some sleep facts. Okay. So 44% of Americans report having insomnia, for half of them, the conditions chronic. That’s an interesting thing, because half the people with sleep issues have slept poorly for a long time. They’ve tried every drug under the sun, they’ve done sleep nitrous, they still can’t sleep. Whereas the other half, the acute insomnia sufferers, for them it’s more situational. Okay. Maybe a loss of a job, the death of a loved one, too much responsibility and it’s situational.

And the good news for them is that, it’s easier for them to go back to normal sleep, usually, sometimes not. Over 9 million Americans are addicted to sleep aids. That’s an incredible number. And the tragedy is that most doctors, almost every patient I’ve ever had, I asked them, did your doctor tell you that after 21 days you would be addicted? And to a person, they said no, but that is the simple fact that, after 21 days a person’s, whether it’s Lexapro, Ambien, any of those drugs that are used for sleep, then the person then has to get off that drug, and they are no longer on top of that.

I asked doctors, are sleep aids, risk restorative? Do they actually help the person recuperate? Usually I got a blank stare or a shrug shoulders. It was like, I don’t know. What we do know is that sleep aids, do not take a person past stage two. So this gets us into talking about the stages of sleep. Okay. So stage one is basically, the drowsiness you feel when you’re about to or you’re watching TV. Stage two is like a power nap. Stage three is where all the action is. The restorative stage of sleep, or our brain waves are slow, your body’s busy fortifying your immune system. You’re building tissue and preparing your body for the next day.

This is where also you can add muscle mass. If you’re reaching level three, then the body can add muscle mass. Stage four is REM sleep. This plays an integral part in processing, learning, and memory. And also as a response to stress. So given the stress levels we’ve got these days, it’s a wonderful thing when we get to dreaming. Personally, I think melaton gets a bad rep. Sometimes people talk about job, all these lucid dreams.

And it’s like, yeah, that means you’re actually getting to REM sleep. That’s a good thing. So if you can handle it, I’m not a proponent of knowledge on it, but I also don’t knock it, because a lot of people do. So acupuncture and herbs and self care are bridges to healthy sleep. So that is the response. I wanted to put this in here, it’s maybe a little self serving, but it’s regards to what’s going on with COVID right now.

Okay. This is a quote from Dr. Matthew Walker, author of, why we sleep. “Natural killer cells are critical components of the body’s immune system response, serving as the first line of defense against cancer cells, microbes, and other potential threats. A single night of poor sleep can impair natural killer cells activity by as much as 70%. In the short term, this can put us at risk for developing acute illnesses colds and flu, but in the longterm, it increases our risk for much more serious threats.” And so this is where I say, make sleep a really important part of your practice, because we’re doing so much more than just helping people sleep, we’re really, not only we are increasing their metabolism, we’re really helping their immune system.

That right now is so crucial. And the opposite is well, what happens with lack of nourishing sleep? Well, depression, anxiety, diminished learning, diminished immune system, toxins remain in the body. Nutrients, not going to their intended muscles, an increase in hormones that break down muscle. I believe that’s the catabolic hormones and an increase in the hormones that make us want to eat, which I guess are gremlin. We call it gremlins, but I know it’s not. So treatment strategies. Oops.

I have a question Dan.

Yes.

You miss some sleep, say, normally you get seven, eight hours sleep. And then because of whatever reason, it may not even be insomnia, it might be travel or whatever, you get four or five hours sleep. Can you make up those hours or is that the little bit of damage to the body that can’t be redone?

I think it’s an interesting question, because science tells us, no, you cannot make up that sleep. That is what sleep scientists tell us. But I think it is a two dimensional way of looking at it, because somebody who’s really not taking care of themselves and they lose those eight hours, that’s going to mess them up. However, somebody is really doing self care, perhaps they’re meditating, maybe doing two gong, maybe eating, well, it sort of gets, I would say, absorbed in the greater good. So, theoretically, technically, no, but that’s a soft no. And I would say that if we’re taking care of ourselves, then it’s not a big deal.

So, getting 10 hours the next night, won’t…

That’s what they tell us. That’s what science tells us. They may find something else out next year, but I don’t worry about it. I’ve certainly lost a lot of sleep, I take. So maybe it’s just deluding myself, but I’d to believe that it all comes out in the wash as long as we’re doing self care.

How did you get into focusing on insomnia or sleep patterns?

Sure. Well, briefly, I had my own sleep issues. I went through a bunch of stuff around 1990, that put me on high anxiety, insomnia, and I went to acupuncture and it helped a lot. There was insomnia in my family, and it took me years to really see that, that I often would wake up in the morning and my mother would be in the dining room, finishing a dress that she’d spent all night working on. And so, it was a pattern of insomnia there in my family and I saw it up close. And so I do believe that, it’s a cliche almost to say, the work we do sometimes as healing our own wounds.

I think there’s a certain truth to that. And whether that is true for me or not, I don’t know, but I do find it interesting going back over many years and seeing that it was something that used to be… It would make me feel weird, because on one hand, you had this very productive mom and she’d make this dress, on the other hand, part of me was like, my God, she’s been up all night and that can’t feel too good. So whether it plays into it, I don’t know, but I think it is interesting.

So, treatment strategies. Over the longer term, helping patients sleep and to be participants in that sleeping process brings greater than success than nearly, and I won’t say merely acupuncture and herbs, because we can definitely get people sleeping again. But as we all know, we go in and out of balance, okay. It’s part of the human condition. And so as we go out of balance, people then start sleeping, not so well again.

And so in my treatment practice, I like to teach them simple stuff, diaphragmatic breathing, what can be better than just teaching somebody who breathes from their chest, to start breathing from their belly? That’s like 50% of everything, right? If they’re open to it, Qi Gong, use of magnets and Japanese tiger warmers. I have that in my book, acupressure, Yintang, Anmian, kidney one, pericardium six, kidney six, the standard sleep points.

And I just tell them to just either use the moxa with tiger warmer or acupressure. At the end, I have complimentary tools for self repair, including an exercise I’ll get into later called the five, five and five. This is Yogi. This is my nemesis. He’s my cat. And essentially he’s also, his attitude is the way most of my patients look when I first suggest that they can actually start taking care of themselves. So I thought, I think we all have patients like Yogi.

And cats have problems with insomnia.

Definitely strange. They definitely have oddball sleep issues. And the beautiful thing about when I work with patients, is if they go for it, when I first suggest they can actually help themselves, the beautiful part is that, if they do, they start getting a sense that they’re not victims, okay. It opens up all sorts of possibilities for that person. I mean, they’re going from, I’m doomed to, what can I do next? Maybe I can quit smoking. Maybe I can lose those 10 pounds. Let’s work on those things too.

And it’s my belief that the more aware our patients are, that they have this ability, the more they see the value of the subtle, yet powerful work that we do. So I don’t believe it’s like, well, they won’t need us later if they’re able to help themselves. No, that means that they will, instead of being 3% of the populous coming to acupuncture, it will be 30% or 50%. And I think it does help to help people, help themselves. Thank you, Yogi. So insomnia is not a disease, it’s a symptom, treat the root and that’s the theme for today.

We know that Western diagnosis tells us a little, and we also know that the main organ systems involved in Chinese medicine or the heart and the liver to a lesser degree, the kidney, the spleen, and perhaps the gallbladder. Okay. And often we see mixed pathologies, perhaps heart yin deficiency with Liberace stagnation. And so we treat those things that we see, and they’re all incredibly valuable.

I would suggest that before we treat what we see, when it comes to sleep, a root treatment is really important. And so unless, we treat the deeper energetic issue involved, the patient will have a much harder, getting better. So some of the root treatments are five elements, eight extraordinary vessels. I call it Kiiko style. Okay. I studied, as did Virginia. We both studied with Kiiko Matsumoto, and she does a lot of root treatments, adrenal deficiency, sympathetic dominance, blood stagnation, all of it is root treatments and then going on to symptom based treatments.

I believe that Dr. Tan’s balanced style is really a combination, as some others are calling doctor, master Tong as well, are a combination root and branch treatments, because they’re rooted in the i-ching and in the five elements. So, treating the extraordinary vessels. And by the way, give me five minutes, if I’m getting dangerously close to going over my 20. So a quote from the Nan Jing, and it talks about the extraordinary vessels being a root treatment. And the ones that are most involved with sleep are Yin and Yang Qiao and the Yin Wei.

The Qiao’s are involved with opening and closing the eyes. And this gets into, it’s not how many hours we sleep, but how rested we are when we wake up. I get people who sleep eight hours and are exhausted. They tell me, I feel I just ran a 10K, while I was sleeping and other people sleep four hours and feel incredible. So it’s clearly not always about time, the distinction is one that’s made clear by Dr. Hamid Montakab in his book, acupuncture for sleep.

He talks about differentiating the quality of sleep versus the quantity of sleep. And we can use the extraordinary vessels as regulators of that sleep. So if it’s an issue of the person, simply not being able to sleep enough, not being able to keep their eyes closed, either theoretically or metaphorically, or literally it tends to be a Qiao issue. And what we want to do, is we may palpate kidney eight, which is the Xi-Cleft or the Qiao. And if it’s tender and everything lines up, then we may treat the Qiao. We may drain UB-62, tonify Yin Qiao.

We may add points to that, since it’s around the kidneys, kidney 27 points, along the kidney channel. However, if there’s more an emotional issue and perhaps a person’s exhausted, emotionally wrung out, they’re anxious, depressed, lethargic. These are all symptoms that the Nan Jing refers to in talking about Wei issues. So, that’s an issue of depth, meaning they’re not sleeping deeply enough. And so, we look to the ways.

And so the way that we look at that is we may palpate kidney nine, which is the Xi-Cleft of the Wei channel, the Yin Wei. And if that’s tender and we look to which one is the most tender, is it the right or left? We needle that, and then we continue treating the Wei channel. So the opening point of the Yin Wei, pericardium six, and we couple that with spleen four. Again, I talk here about, verifying that Yin Wei is the correct treatment, aside from the fact that they’re typically depleted, depressed, wrung out.

Certainly Dr. Manaca used to use the Wei to start a treatment almost constantly. If you read, chasing the Dragon’s tail, he used the Yin Wei a whole lot. So then we may needle PC-6 and spleen four bilaterally, and this is the root treatment, let the patient rest for 15 minutes. At that point, we may expand the treatment in modular fashion. Some people believe in just letting the entire treatment be the root treatment and that’s okay. Certainly it’s the five elements, we see that whether an aggressive energy treatment or external dragons, that treatment is a full treatment in their root treatment.

I have no problem with that. I typically check the pulses and, go from there. What else did I want to say about that? Yeah, I always found it interesting. Let me go back to this, excuse me, considering that the heart is the emperor, I always thought it odd that why is it that there is not a heart point on the extraordinary vessels? You’d think that that would be, top of the list there. And so I went back and I see that a lot of Japanese acupuncturists do not treat the heart typically, they will go to the pericardium and protector of the heart, and certainly points along the pericardium are crucial for sleep, anxiety, palpitations, heat, all the heart stuff.

So for me, opening the Yin Wei, is such a powerful way to begin treating someone who’s having those issues. So let me continue here to, Marianne, this is a case for Yin Wei and Buddha triangle. 38 year old woman, complained of waking up during the night, agitated, palpitations, feeling heat, et cetera. My voice is going. So I’m going to keep it simple. As you can see, those are the fairly often seen pulse tongue, palpatian issues that lead us to believe that it’s a fire and water disharmony, repletion above, vacuity below. Water is not nourishing heart.

So there’s heat above. And so one option is more of, I’ll call it a TCM style. Certainly it’s a wonderful treatment, heart seven, heart six, which does clear heat. Pericardium seven for palpitations and insomnia. Yin Tang, which is a great sleep point, CV-17, heart, et cetera, et cetera. So it’s a terrific treatment. My tendency is, if I were to go that route, I might start with a year, Yin Wei or another would treatment and then go to that. Option two, go to the root treatment, open the Yin Wei, followed by Buddha’s triangle.

So, we start on the dominant hand, pericardium six on the opposite foot, spleen four. Now what I would do often, is expand that to Buddha’s triangle. So I might start first with just the two points, and then I’d expanded to pericardium six, heart seven and long nine, which is also a root treatment. However, I don’t think you can go wrong with it. And then I would add contra-laterally. Some people believe in just those three points and they make a perfect triangle on the wrist. I to add liver four, spleen six and kidney three contra-laterally.

And that is a beautiful treatment. It really handles insomnia, anxiety, palpitations, dream disturbed sleep, and it’s a full treatment. Another one since I promised that I would give them tan treatment, I’m just going to add another one for Fir-Water disharmony, that comes from the playbook of the balance method, Dr. Tan, which is a Shao Yin/Shao Yang treatment. And this goes to heart three and heart seven on the right, gallbladder 34 and 41. And then the left side, we’re treating kidney three and kidney 10 and triple burner three and triple burner 10.

And I’ve used this and it’s a good treatment. It’s an effective treatment. You have to keep doing it. You really need to see the patient for this. You need to see patient like twice a week. It’s true for all. I mean sleep is not an easy fix. Okay. I like to joke that since Sim Yao talked about, that he’d rather treat 10 men than one woman, because of the plumbing. And I to say that as he was leaving, he muttered that I’d rather treat 10 women than one insomnia patient, because they’re paying him my gallbladder 30. I don’t know if that’s true or not, but we move on.

Where does triangle protocol come from?

I think it’s part of the five elements universe, that is where I saw it originally and I couldn’t swear to it. So I hope a lot of 5E people don’t bite me on the neck for claiming it’s part of them. But I do use it as part of that, because I do believe it’s a beautiful… To me it’s a crossover between five element and balance method, it’s got a lot of stuff going for it. I didn’t get into it, but I also will add to that, sometimes again, contra-laterally, Yang points to those two, right hand, left foot. I will add, typical as to Richard Tan, I’ll do a right foot, Yang points, left hand Yang points, depending on the secondary stuff that needs to be treated.

So, herb formula for Marianne would be, Tian Wang Bu Xin Dan. Okay. That is typically for people with heart and kidney issues that wakes them up, their palpitations. They can’t sleep, they have heat issues. And just to differentiate that, let’s say from something that’s just more kidney, like Jo bi di wang wang, that’s more kidney or something that is more blood based. That would be Suan Zao Ren Tang. The Suan Zao Ren Tang is terrific, because it also addresses heat issues. But again, it’s more blood rather than Yin deficiency, which I think Marianne was presenting with.

Again, some food cures, asparagus, chicken egg, wheat, if you want to go the Chinese formula style, banana, bamboo shoot, these are all for Yin deficiency. And then finally I gave Marianne some homework. In this case, it was the five, five and five exercise. Before we get to it. Actually, I’m just going to skip it over, we may be running out of time. Yes. Or how are we doing?

I think they’re pretty self explanatory those.

Yes. Okay. So basically I treat the sleep-disordered mind a lot, and it falls into those five categories, distractions, daily regrets, real life problems, overwhelms, things I didn’t do yesterday and things I won’t be able to get done tomorrow. And then finally disconnecting from phone, computer and TV. So one of the treatments that I like to do is, and it’s so simple. It’s called the five, five and five. Okay. It helps unwind the sympathetic nervous system and it takes 15 minutes. Okay.

Basically for five minutes I have the person write down regrets, resentments fears, overwhelms clogging their mind, all this stuff that we typically start churning at night. We’re great during the day, but when we close our eyes, they start unfolding. So I tell them, spend five minutes and no more, then fold the paper, place it aside and say, out loud. “These are tomorrow’s problems.” For five minutes, close the eyes and gently massage Yintang, whatever you wish to do. I like Yintang. And at the same time, I’d tell the person, imagine that you’re in a garden, a rain forest, someplace where you feel safe, it could be in your little den.

And then for the last five minutes, I tell them to become mindful of breath. And so these are ways that we open them up to the idea of meditation without having to call it meditation. So just follow the path of your breath with your mind, down into your lungs, back up through your nostrils and just keep doing that for five minutes. And so these are, I feel stress free ways of getting someone to begin the process of unwinding the sympathetic nervous system and engaging their parasympathetic nerve system at night.

And then finally, I use something called autogenic training, and it was invented by a German cardiologists in 1931, who frankly was tired of seeing his patients dying. So he invented a calming technique that would reduce their levels of stress. It’s an eight week program. And it really helped in the way that no other Western method had, using a version of a progressive muscle relaxation.

And so I have that on my website, which is rewiredforsleep.com. If you go to the Explorer page, you’ll see that, and I think three other recordings, that’s all free to listen to. And well, I mentioned before the exercise and rewired to give for the sleep disorder, I think any acupuncturist wanting to provide their patients with tools to combat insomnia, anxiety, stress, and PTSD can really benefit from it as well for their patients and for themselves.

Have I missed anything? So, finally, I have already popped my little book. I’ll do it one more time. Rewired for Sleep: The 28-Day Insomnia Repair Program. It’s available on Amazon in both digital and paper. And if you’d to know when the next book is coming out, please feel free to email me at daniel@bluephoenixwellness.com. I’m going to say one last, thank you to American Acupuncture Council and to Virginia for allowing me to visit and give my little talk. Thanks again.

Thanks Dan. It was really lovely having you and I’m sure people will get a lot of benefit from this book, practitioners and patients.

Thank you. Thanks.

All right, so we’ll see you all soon. Thanks for tuning in, again, I’m Virginia Doran, luminousbeauty.com , and sayonara.

See you.

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Brian Lau and Matt Callison

Palpation in Assessment and Treatment

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

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

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

Yeah, sure.

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

Yeah, timing is not good for your live.

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

Great.

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

Awesome.

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

Correct.

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

Yes.

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

Possibly.

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

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

Yeah, sure.

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

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

It’s going to be tough.

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

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

Sure.

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

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

I helped with his book.

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

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

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

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

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

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

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

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

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

Yeah, sure.

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

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

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

Yeah, sure.

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

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

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

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

Sure.

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

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

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

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

You’ve just to jump in, Brian.

Yeah, yeah, yeah.

It’s a first come first serve show here.

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

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

Yeah, sure.

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

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

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

Yeah, sure.

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

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

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

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

Horizontal.

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

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

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

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

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

Don’t you hate that?

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

Did they get somewhat better?

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

At all. At all. Okay.

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

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

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

Mm-hmm (affirmative).

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

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

Yeah, sure.

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

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

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

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

Brian, how do you like to palpate it?

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

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

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

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

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

Yeah, that’s great.

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

Yes.

It’s all opinion, of course, right?

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

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

Yeah, I agree.

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

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

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

You saw them both move.

Yeah.

That’s pretty cool.

Yeah.

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

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

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

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

No problem. Anytime.

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

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

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

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

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

Sure.

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

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

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

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

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

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

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

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

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

I think-

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

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

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

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

Yes, I would-

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

I would carry that into muscle as well.

Sure.

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

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

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

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

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

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

Yeah, I agree.

That’s true.

I agree.

That’s true.

I agree.

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

Yeah.

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

Matt?

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

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

Retinacular cutis.

Yeah.

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

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

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

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

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

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

Definitely.

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

Yeah.

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

Yeah.

I mean this is a whole another podcast or webinar.

Sure.

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

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

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

Yeah.

I’m ready.

Well-

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

It doesn’t matter to me.

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

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

Yeah, of course.

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

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

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

Awesome.

I agree.

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

I don’t know.

Okay.

We have a pretty big queue of podcasts right now.

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

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

Got you, okay.

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

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

Yeah.

All right.

Thanks, guys.

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

See you.

Okay, bye bye.

Bye bye.

We done, Brian?

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Dr. Virginia Doran

The Science Behind Promoting Digestive & Cardiopulmonary Balance with Acupuncture

Click here to download the transcript.

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

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

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

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

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

– Okay

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

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

– Okay.

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

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

– Bye bye.

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Poney Chiang Thumb

Neuro-scientific Posturology – Poney Chiang and Annette Verpillot

Hi, welcome to today’s Facebook live [inaudible 00:01:08] show for American Acupuncture Council. My name is Poney Chiang, your host for today, and I’m coming from Toronto, Canada. I’m a continuing education provider, and acupuncture practitioner and herbalist. Today it is my honor to have the opportunity to interview our special guest for today, Annette Verpillot. Annette is a founder of a company called Posture Pro, a health company specializing in restoring the brain body connection. She’s a Canadian entrepreneur, therapist, public speaker and internationally recognized posture specialist.

Annette has developed some of the world’s most advanced rehabilitation and injury prevention techniques, and she teaches this method called Posture Pro to professionals in various fields. Her unique posture evaluation system is recognized throughout the world for eliminating chronic pain, increasing strength and improving sports proficiency. Through her teaching, speaking and research, Annette tackles global health issues and trains professionals to have a lasting impact on clients and patients. Thank you very much for joining us today, Annette.

Thank you so much Poney, for having me on the show. It’s a true honor and pleasure.

Can you tell us where you’re joining us from today?

I’m located in Montreal, Canada. You and I are not too far away from each other.

It’s only five, seven hours drive maybe.

Yeah, I prefer taking the plane. But yeah, it’s fairly close.

Yeah. So the reason why I wanted to invite you to our show today is that I understand that you have a very special way of addressing posture. And what fascinated me about your method is that you incorporate a lot of application of the understanding the peripheral nervous system, the central nervous system, and even using cranial nerves as such. Would you be able to tell us how did you become interested? Were you always interested in posture aspects or interested in neurological things?

Yeah. I come from a family of neurosurgeons that from France moved to Canada at the time when I was much younger. So I was raised in a medical environment where I would always listen to my aunt and uncle talk to my father about the latest in neuroscience. I was always very much interested in the medical field. I recently found a book of myself, a book that they had asked us to draw a picture of yourself of where you saw yourself in the future. And in this book I wanted to be a surgeon, a neurosurgeon, and then I found the picture. It was actually really quite funny. So I’ve always been, I guess indirectly involved, not really realizing it in the world of neuroscience, of course through my family.

But at the same time I was always very much involved in movement in sports and very quickly became aware of the aspect of movement and performance, and of course injury because I could remember my father saying to me, at the time I made it to the Games of Quebec, and he was like, you can’t go to this because the ultimate goal is for you to make it to the Olympics. This is how it starts, and by the age of 30 your body will be ruined. And I remember not being very sad about this because he literally interrupted the whole process. But now that I think back, I guess the myth of movement, and training, and athleticism and injury go hand in hand.

May I ask a what was your area of focus specialization in sports?

The 100 meter sprint was my specialty. No one can catch me.

Very impressive. I know it’s a very diverse, and broad and in depth topic, can you tell us a little bit about Posture Pro?

Yeah. So Posture Pro opened its doors in 2004. The idea was to combine training with rehabilitation. At the time I had studied different types of rehabilitation therapies to be able to accommodate my clients. I myself went through some injuries while I was training. I’ve always been involved in fitness and trainings as far as I can remember, and for me was something that was very important to be able to try to address injury. So of course I naturally learned rehabilitation methods and techniques to be able to apply them with my clients in practice. Very quickly realized that working manually was only providing temporary results, not really understanding why that was actually happening and kind of following the flow that everybody does. They teach us to do A, B, C, D when you find that there is different types of local problems, but I guess that part of the problem that eventually I came to realize was that they were not really telling us why the problem existed to begin with. So the cause behind the symptoms that we are taught to manage. So, a quick Google search kind of got me going on the way, and then associating myself with different professionals and specialists in their fields, really some of the best in their field as far as rehabilitation, to try to combine all of this knowledge together to create what we call today the Posture Pro Method.

Can you tell us a little bit about the approach or the rational in it, how is it different or what makes it more effective, for example?

Yeah. So combining the knowledge of neuroscience, and biomechanics and movement all together, but also the knowledge of how the brain develops in the first place in human beings and working with a method that allows us to kind of connect which brain part, brain, body connection parts are broken is what I find makes our method unique. We work on what we call specific sensory receptors. Yes, we do work with the eyes, obviously the cranial nerves that innovate the eyes. But where I think our strength lies is in all the links that we make within those different cranial nerves and the symptoms that we’re seeing in clinic with our clients, but also the fact that we address one component that I think is the missing link in most therapies, which is the weight bearing surfaces of the clients that we’re working with.

We never really take into account, I mean in North America when we talk about the feet, we tend to think of feet specialists or podiatrists, but in reality what we’re looking for is the way that this person learned how to walk in the first stages of their lives, which we know is ultimately between zero to 12 months of life, and the postural strategies then that the clients will then develop and the links between the symptoms that they’re presently experiencing, the posture that they have today and the brain connection or the broken brain connection, if I may say, that they are living with which are creating the symptoms that we are seeing in our practice on a daily basis. And this holds true for children as well as adults.

So there’s a lot of emphasis on the information inputs coming from the feet. You mentioned about the vision. What are some of other important inputs that you take the time to assess or provide exercises for?

Yeah. So another really interesting link is the position of the mandible, the position of the jaw, and how the actual stomatognathic system will develop how the motor acted, the tongue posture, if you wish, nasal breathing, all of that complex has the potential to influence head posture, position of the head on the shoulders, which will challenge your center of gravity. The ultimate goal for us, what makes us human as humans is the fact that we’re bipedal, and fighting this we’re constantly fighting against gravity. And how we fight gravity ultimately will dictate how much energy we have throughout our day. So for example, someone who has what dentists call a class two occlusion, which is where the upper teeth of the maxillary will cover the lower teeth by more than one third, this will bring about, how can I say, the mandible will move up and back pushing the head forward.

And this would be a permanent state of disequilibrium that the client would be living with, which we can very easily imagine how this can cause lower back pain. But there’s also missing teeth, there’s also tongue posture and there’s also many other links that could be made within the TMJ in itself. As well we work with pathological scars. This is any type of surgical intervention that someone may have had. We treat it with either essential oils or with laser therapy. Would love to learn about acupuncture. I know that acupuncture is absolutely phenomenal when it comes to pathological scars. But where we try to make the link is again with the symptoms that the client is experiencing and whether or not the scar is actually creating a postural, a muscular imbalance in the context of the session.

That’s very interesting. So you mentioned the tongue posture. Most of our listeners are acupuncturist, and we actually really love to diagnose each other’s tongue and our patients’ tongues. I think they would be very interested to be able to add a dimension of postural analysis from the tongue. You also talked about equilibrium. I was wondering if the vestibular or the years come into play in this system, or is more focused on jaws and other inputs?

No, we do absolutely consider the vestibular, the vestibular ocular reflex. But what we’ve tend to see is when we actually realign someone’s posture by working on their feet, we really always start with the two extremities, the sole of the feet, the eyes. Is there anything going on with the jaw? If there is, we must neutralize it. We like to work by process of elimination. What’s causing what? Is it the feet, is it the eyes? But we know that ultimately all of these sensory receptors together have the potential to affect our posture and our stability. So what we’re going to try to basically, how can I say, what we’re going to try to determine is, is the client clenching even? Are they excessively stressed? We know that stress is psycho-emotional. When I’m stressed, I’m going to clench my teeth. But some clients who are doing this or patients who are doing this on a daily basis are not fully aware of the negative impacts that this can have, not only on their posture, on their hormone production, but on all of the different physiological systems of the body, really.

Right. Fascinating. That’s definitely something, clenching and a tight muscles of mastication, temporalis muscles. Those are actually a lot of things that acupuncturists see on a daily basis. So I think there’s definitely a lot of opportunity for an acupuncturist to employ some of this diagnostics, perhaps even use that to not just reduce the stress and the pain, but actually improve posture from that. As you know, acupuncturists is kind of well known for treating pain, and now there is actually more of a movement in the acupuncture community where we’re trying to start to use acupuncture to affect neurological issues. So Parkinson’s diseases and stroke rehabilitation. And obviously there’s a lot of gate problems in these visuals, postural problems in these individuals. So that’s really why I became interested in your work. Could you help our fellow listeners understand how might your work or being an expert in posturology make them better at what they’re doing?

Yeah. Well I mean, as you know, Meridian’s is kind of like an energy highway that flows within our body, and if we look at the way that someone’s posture has developed, and I put the emphasis on this, because understanding how someone developed their postural strategies from the get go is a really important factor in determining where they are at today. So I’m not an acupuncturist, but it’s very easy to imagine and understand if someone has a forward displacement of their center of gravity, a lower shoulder, a rotated pelvis, vertebraes that are in a subluxed state 24/7, poor body posture, I mean in that context, can poor body posture affect the energy flow within our body? We know that it can affect many other factors from our sympathetic to parasympathetic, to our circadian cycle, digestion, blood flow, stress, and of course energy within our bodies. So I think there would be many benefits of incorporating the Posture Pro Method with any type of therapy, but also Meridian therapy and acupuncture because it will simply just enhanced and double the therapeutic effect. If someone’s posture is better aligned, you’re actually giving them the chance to be able to fully recuperate and tap in into that healing process that they have within themselves, and of course the natural flow of energy that we all have within us.

I’m just going to sprinkle a little bit of Chinese medicine terms for the benefit of our listeners. For us, we talked about points around the neck that are called window to the sky points. These points directly affect psycho and emotional presence and awareness in health. So you imagine how problems in your neck can actually cause psycho emotional issues. For acupuncturist thinking in terms of those points around the spine called the back shoot points which affect individual organs. So if you are having subluxations or you’re having abnormal curvatures, it would affect the energy aspect of the bladder Meridian or affect those back shoot points and they can actually cause internal somatovisceral problems. So I think knowledge of this posture analysis comes hand and hand with acupuncture, and I think there’s a lot of things to be excited about, about how we can actually combine these knowledge to actually improve our ability to help patients, both physically as a posture aspect, but also internal viscerally. Because after all, the nervous system is [inaudible 00:16:49] and she controls all of our autonomic systems also.

If I may just add to to what you just said, I very much appreciate the description that you just gave. So within this complex as we know, and again, from the method that we’re working with, if there’s a crossbite, for example, or poor breathing habits that have been acquired since the beginning of life, or eyes that are not tracking properly through the cranial nerves within the brainstem, we know that just these two components alone can affect the stability of our suboccipitals and C1 and C2, which hence can this have an impact on the energy flow? And as you’ve just explained, my guess is is that it can. So if we’re starting from the perspective that you can’t build a house on a crooked foundation, so trying to align structure as quickly, and as fast and as best as possible, 24 hours a day, seven days week, so this work is actually being done without you having to think about it when you work with a brain based approach. And then incorporating any other types of therapy, like acupuncture, is always at a greater benefit to the patient.

What you just mentioned gave me a couple of more ideas I want to share with our listeners. Eyes for Chinese medicine practitioners have very much to do with the liver and has to do something to call wind and movement. So isn’t it interesting that by analyzing eye movement, which we are basically looking at its connection to the liver and wind. So you can see how there’s a lot to the ancient teachings about how eyes have to do with wind, because by analyzing eye movement you have the entire ability to assess a nervous system, which a lot of nervous problems are due to wind, but also relationship to coming and going and movement issues. Tongue. Again, back to the eyes. Eyes are supposed to be where is the spirits or the from Shen emanates. So you can have added tools to assess the patient’s state of Shen and spirit.

Their tongue is supposed to be the opening of the heart. And so by looking at the tongue posture, you have an indirect way of gauge into the Chinese business date of the heart’s health. So these are all the thing that’s [inaudible 00:19:14] and I’m really looking forward to finding out and learning more about this from you. Now, I know you have a lot of experience working with athletes, working with people with chronic pain, and even children and developmental problems, people with central nervous system problems, and I would love to hear all your experience. But because of limitation of the time we have today, could you just share with us with one maybe from recently that you’ve seen that was really highlighted to the power of this method? Something that’s really meant a lot to you personally as a therapist, you’re really able to transform somebody. Or something’s just really neat and something that was very cool that even surprised you for so many years of practice. Just a story. Basically just tell us a story, we want a nice story.

Oh, I have many stories to tell you. What I love about the Posture Pro Method is that there is not a week that goes by where I don’t have shivers on my arms because we realize that we’re actually changing the lives of people. And when I say, we like to use the hashtag changing lives, is when you give someone the ability to be able to regain their pain free living and live a life free of pain so that they can enjoy their lives, that for me is the ultimate reward. The case that I could think of, the first case that I sat on for a long time was when I got contacted by someone called Diane Murphy, and this is going back maybe over 10 years. And she left a message at Posture Pro saying, I’ve just recently been diagnosed with Parkinson’s disease stage one. I’ve tried everything, I’m desperate, please can you help?

And this was really the first case of Parkinson’s disease that I would ever encounter in my practice. And not knowing how far I can actually push the nervous system and really being afraid of the unknown, I didn’t respond to her call for three weeks. After the third week, I said to myself, Annette this is silly. Face your fears. The worst thing that can happen is that nothing happens and so be it. But at least try. And I did try. And I’ve put the video on my YouTube channel of that first consultation originally. Well, obviously the full consultation was recorded, but we trimmed it down to five to six minutes. Was the most rewarding moment that I ever had. You could hear Diane saying how her entire symptoms in the session completely disappearing. And funny enough, what did it the most for her was a scar that she had in her lower back.

So we proceeded in correcting the foot, we worked with the eyes, we actually looked at the jaw. We’re going through this in the video, we’re going through this step by step as we’re explaining what’s happening. But what really worked for her was, so we had to do all of that first, and then lastly we looked at the scar. I said to her, Diane, do you have any scars? And she goes, yes, I had lower back surgery years ago. And just by working on the scar she was like, her testimonial was overwhelming. I mean, I could not express it more how she was so verbal and expressive. So that was really one of the most ooh ha moments for me in my practice. And I’m lucky enough to say that these moments have followed and continued to follow every week of my life and in practice here. So this is, again, I’m so grateful to be on your podcast because ultimately I think that everyone should have the right to know what is out there and choose the best therapy treatment for themselves and for their loved ones really.

Thank you. That was a great, very heartfelt story. Unfortunately, due to time limitations we have to wrap up real soon. Could you give us a little appetizer or a little bit of amorous goose, a little bit of teaser, something that, I don’t know it’s very complicated or if it’s even possible, but something that is a little technique or something like that we might start to incorporate and to get us to see the power of posturology?

Yeah. So doing simple eye exercises as I demonstrated in my Ted Talk, which consists of doing simple circles and trying to converge, trying to focus on a specific target as your eyes are moving in 360 degrees. Some people find that very challenging. If they feel dizzy while they’re doing it, simply just pull away the finger and continue doing those eye exercises. This a great way to start working out your eyes on a daily basis. And quite frankly, I think it should be incorporated in for everyone. Regardless of the context, I think everyone should work out their eyes in the morning when they wake up.

I think I’ll also add to that, being aware of whether or not you clench your teeth. I love to have people become aware, just awareness of whether or not the teeth are in constant contact by putting red dots on the wall, and when you see the dot in that moment, you will say to yourself, are my teeth touching? And if they are, simply taking a moment to just stop whatever you’re doing if you can, position your tongue on top of your palette, hold it there with your lips closed and breathe for one minute. I think that doing those two things already is a great way to calm your parasympathetic, your sympathetic system down. Tap into parasympathetic, give yourself a break, disconnect. And of course if you retrain your eyes, you’re also retraining your muscular system.

Thank you very much. So if people out there would like to learn more about your methods and your teachings, where can we go to find out more about this information?

Our website is posturepro.co, and we’re very active on social media. We post daily tips, and specifically before and after cases on our Instagram channel, which you can find us very easily at @posturepro. Same address for Facebook.

Great. Thank you very much for joining us today, it’s been an absolute pleasure.

Thank you so much, Poney. It was a pleasure meeting you.

I look forward to studying with you soon in the very near future.

God bless.

Thank you.

Bye-bye.

Bye.

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