INTRODUCTION TO MEDICAL ACUPUNCTURE STUDY GUIDE

Transcription

1 INTRODUCTION TO MEDICAL ACUPUNCTURE STUDY GUIDE EAST TENNESSEE STATE UNIVERSITY JAN 7TH-9TH 2011 DR. CARLOS A. SUAREZ MD, DABMA

2 Table of Contents Cover 1 Table of Contents 2 Welcome letter 3 An Overview of Medical Acupuncture 4 Acupunture Theory 16 The Chinese Perspective of Health and Disease 17 An Introduction to Chinese Measurements 28 Acupuncture Meridian Points 29 2

3 October 2010 WELCOME LETTER Introduction to Medical Acupuncture Course Study Guide Dear Participants: I want to thank you for registering on the Introduction to Medical Acupuncture course. This course represents a joint project between East Tennessee State University and myself to provide physicians with the basic knowledge and kinesthetic ability to perform basic acupuncture treatments. Even though Acupuncture is useful for many clinical conditions, we will focus on treatment of pain and anxiety in this course. It will be carried out along 3 intensive days of theory and practice. Due to the time constrains, I wish you to read the material enclosed so as to become acquainted to the history, terminology and some acupuncture points that will be taught in class. This homework reading of the material will definitively make the lectures easier and faster to present. This home study guide has got 3 parts to it. The first part will give you an overview of what Medical Acupuncture is. The second part will go over basic concepts of Chinese medicine and the third part will go over the meridians and some important acupuncture points on them. You do not need to memorize all the information, just go over it so as to familiarize yourself with it. If you have any questions about the contents of the course please contact me at the following address: [email protected] or call at Carlos A. Suarez MD, DABMA 3

4 October 2010 STUDY GUIDE An Overview of Medical Acupuncture by Joseph M Helms, M.D. Modified from Essentials of Complementary and Alternative Medicine (Jonas WB, Levin JS, eds. Baltimore, Md: Williams & Wilkins; in press). Joseph M Helms is the author of Acupuncture Energetics: A Clinical Approach for Physicians. He is the chairman of physician acupuncture training programs of the Office of Continuing Medical Education, University of California-Los Angeles School of Medicine, and the founding president of the American Academy of Medical Acupuncture. Dr Helms is in private practice in Berkeley, Calif. This article defines the theoretical matrix and clinical value of the emerging complementary discipline of medical acupuncture. The acupuncture approach most commonly integrated by physicians into conventional medical practice. Medical acupuncture respects our contemporary understanding of neuromuscular anatomy and pain physiology while embracing the classical Chinese perception of a subtle circulation network of a vivifying force called qi. This hybrid acupuncture approach expresses the best of both worlds by describing a context in which to organize patient symptoms that usually escape attention in the standard medical evaluation. Musculoskeletal problems have been shown to be the most frequently and successfully treated disorders; however medical acupuncture is adaptable to most clinical practices and can be used either as the primary or a complementary treatment. The physician acupuncturist can creatively intervene in a spectrum of medical disorders from early pre-morbid manifestations to chronic organic or musculoskeletal lesions by activating the appropriate subunit of qi circulation. (Altern Ther HealthMed. 1998;4(3):35-45) Medical acupuncture is acupuncture that has been successfully incorporated into medical or allied health practices in Western countries. It is derived from Asian and European sources, and is practiced in both pure and hybrid forms. Therapeutic insertion of solid needles in various combinations and patterns is the foundation of medical acupuncture. The choice of needle patterns can be based on traditional principles such as encouraging the flow of qi (pronounced chee), a subtle vivifying energy, through classically described acupuncture channels, modern concepts such as recruiting neuroanatomical activities in segmental distributions, or a combination of these two principles. The adaptability of classical and hybrid acupuncture approaches in Western medical environments is the key to their clinical success and popular appeal. HISTORY AND DEVELOPMENT In the United States, acupuncture has been increasingly embraced by practitioners and patients since the appearance of James Reston's landmark article describing his experience with successful post appendectomy pain management using acupuncture needles (The New York Times. July 26, 1971:1,6). Before that time, acupuncture had been practiced only in urban Asian communities, discreetly and primarily by and for Asians. In the early 1970s, widespread enthusiasm for acupuncture was fueled by reports from physician visitors to China, who witnessed surgical analgesia using only acupuncture needles. Respect for the technique grew in the medical and scientific communities in the late1970s, when it was shown that acupuncture analgesia was linked to the central nervous system activities of endogenous opioid peptides and biogenic amines. Since the 1970s, guidelines for education, practice, and regulation in acupuncture have been established and implemented. State, regional, national, and international societies have evolved to represent the interests of affinity groups of practitioners. Acupuncture is one discipline extracted from a complex heritage of Chinese medicine-a tradition that also includes massage and manipulation, stretching and breathing exercises, and herbal formulae, as well as exorcism of demons and magical correspondences. The earliest major source of acupuncture's theory is the Huang Di Nei Jing (Yellow Emperor's Inner Classic), whose oldest portions date from the Han dynasty in the 2nd century BC. The Nei Jing authors regarded the human body as a microcosmic reflection of the universe and considered the physician's role that of maintaining the body's harmonious balance, both internally and in relation to the external environment. The Nan Jing (Classic of Difficult Issues) was written in the1st and 2nd centuries AD, also during the Han dynasty. This text presented a unified and comprehensive system that advanced the theories of points and channels and addressed the etiology of illness, diagnosis, and therapeutic needling. The Zhen Jiu Jia Yi Jing (Comprehensive Manual of Acupuncture and Moxibustion), attributed to Huang-Fu Mi in 282 AD and based on the previous texts, is the oldest existing classical text devoted entirely to acupuncture and moxibustion (heating the acupuncture points and needles with smoldering mugwort, a dried herb). Between the Han dynasty (206 BC-200 AD) and the Ming Dynasty ( AD), acupuncture practice was refined and its literature underwent continual exegesis. Research, education, clinical refinement, and collation and commentary on previous classics flourished in the Ming dynasty. The Zhen Jiu Da Cheng (Great Compendium of Acupuncture and Moxibustion) of Yang Ji Zhou, published in 1601, synthesized many classical texts as well as unwritten traditions 4

5 of practice, and became the most influential medical text for later generations in Asia and Europe. The Da Cheng was the source of acupuncture information transmitted to Europe in the 17th through the 19th centuries via Latin translations by Portuguese, French, Dutch, and Danish missionaries, traders, and physicians traveling and working in China and Japan. It was also the primary source translated into French in the 20th century. There was a flurry of primitive acupuncture experimentation by physicians in France, England, Germany, Italy, Sweden, and the United States in the first three decades of the 19th century, which did not renew itself in Europe until a century later and in the United States until the 1970s. The most influential impact on the development of 20th-century European acupuncture was the work of George Soulie de Morant, a scholar-diplomat engaged in the French diplomatic service in China between 1901 and Soulie de Morant published articles and French translations of Chinese and Japanese medical texts, and on his return to France taught clinical applications of acupuncture to French physicians. He systematically introduced acupuncture theory from the classical texts to the French and European medical community. The commonly used terms "meridian and "energy" both originated in his texts as translations for the two fundamental tenets of acupuncture: anatomy and physiology. In 20 th century France and throughout much of Europe since the 1950s, clinical acupuncture has codeveloped with biomedical science. Europe has thus served as another influence for acupuncture approaches that integrate into the practice of conventional Western medicine. 1 PRINCIPAL CLASSICAL CONCEPTS Acupuncture has evolved over 2 millennia, both through refinements based on treatment responses and through adaptations to changing social situations. The language in classical Chinese medicine texts reflects nature and agrarian village metaphors and describes a philosophy of man functioning harmoniously within an orderly universe. The models of health, disease, and treatment are presented in terms of patients' harmony or disharmony within this larger order, and involve their responses to external extremes of wind, heat, damp, dryness, and cold, as well as to internal extremes of anger, excitement, worry, sadness, and fear. Illnesses likewise are described and defined poetically, by divisions of the yin and yang polar opposites (interior or exterior, cold or hot, deficient or excessive), by descriptors attached to elemental qualities (wood, fire, earth, metal, and water), and by the functional influences traditionally associated with each of the internal organs. The classical anatomy of acupuncture consists of energy channels traversing the body. The principal energy pathways are named for organs whose realms of influence are expanded from their conventional biomedical physiology to include functional, energetic, and metaphorical qualities (eg, Kidney supervises bones, marrow, joints, hearing, head hair, will, and motivation; Spleen oversees digestion, blood production, blood-related functions such as menstruation, and nurturing and introspection). Acupuncture anatomy is a multilayered, interconnecting network of channels that establishes an interface between an individual's internal and external environments, permitting energy to move through the muscles and the various organs. The most superficial of these pathways are the tendinomuscular meridians, which serve as an interface between the organism and its external environment. They provide the first defense for the body's response to climatic conditions and external traumas. The principal meridians travel through the muscles and provide nourishment to all tissues and vitality for animation and physical activity. The distinct meridians go directly from the surface of the body deep to the organs, and allow the nourishment and the energy produced by the organs to circulate throughout the body. Finally, a system of pathways called the curious meridians create connections among the principal acupuncture channels and serve as energy reservoirs for extreme conditions of emptiness or fullness. The network of energy circulation is organized into three bilaterally symmetrical plates that divide the body into six sagittal territories of influence. Each plate manifests the energy derived from four organs as it circulates in their anatomical territory of influence. Figure 1 (not present) represents the schematic organization of one plate in the acupuncture energy circulation. The core rectangle is the principal meridian subcircuit, from which the subdivisions of energy circulation are derived: tendinomuscular meridians on the surface, distinct meridians going to the organs, and curious meridians creating connections among several principal meridian subcircuits. Figure 2 (not present) shows the bilateral surface tracing of one principal meridian subcircuit. Figure 3 (not present) provides the organ associations, and thus the names, for these energy channels: Kidney-Heart (shao yin) and Small Intestine-Bladder (tai yang). Figure 4 (not present) shows the surface location of the Kidney and Bladder tendinomuscular meridians, associated with two of the four organs involved in the shao yin-tai yang principal meridian subcircuit. Figure 5 (not present) shows the deep pathways of the distinct meridians for the same two organs. Each of the three bilaterally symmetrical subcircuits has a similar schematic organization. The anatomical territory of influence shifts with the location of its sagittal plate and the organs involved in its energy circulation. 5

6 The classical physiology of acupuncture involves a dozen internal organs that interact to produce basic energy and blood from ingested solid and liquid nourishment, then mix in the energy from inspired air and propel the transformed energy and blood through all the body's organs and tissues. The organs are divided into six parenchymal, energy-producing organs (solid, yin), and six visceral, substance-transporting organs (hollow, yang). These organs are coupled into groups (one yin and one yang) to make up the three symmetrical energy circulation plates. Pathology in acupuncture involves an early manifestation of disharmony associated with the subtle influences of an organ, a disruption of the qi flow in one of the subdivisions of the circulation network associated with an organ, or a frank disturbance in an organ's metabolic or transport function. Diagnosis in acupuncture involves recognizing the level of manifestation of a disturbance. Premorbid symptomatology is organized according to the organs' subtle spheres of influence, where early energetic and functional symptoms are linked to the organ that supervises the disturbed anatomical region or physiological function (eg, Kidney energy supervises head hair; premature graying or balding reflects a deficient Kidney vitality). Obstruction of the flow of energy or blood through the principal meridians manifests as musculoskeletal pain in the territory of the channel (eg, the Bladder principal meridian passes through the lower back; lumbar pain reflects an obstruction of qi and blood flow through that channel). Organ pathology is identified either in conventional biomedical terms or as a disturbance in the organ's physiological activities according to acupuncture terms (eg, nephrolithiasis is a disturbance in both Kidney and Bladder organs and spheres of influence). Treatment in acupuncture involves the insertion of needles along the channels of the involved organs to stimulate energy circulation that can influence the problem at its level of manifestation, thus restoring energetic balance and organ function in the organism. PRINCIPAL MODERN CONCEPTS Since the late 1970s, acupuncture analgesia has been demonstrated to activate the endogenous opioid peptide system and thereby influence the body's pain regulatory system by changing the processing and perception of noxious information at various levels of the central nervous system. Two model systems of acupuncture analgesia have been advanced: an endorphin-dependent system involving low-frequency, high-intensity electrical stimulation of acupuncture needles (2~4 Hz) that is slow in onset, generalized through the body, and cumulative on subsequent stimulation; and a monoamine-dependent system involving high-frequency, low-intensity electrical stimulation of acupuncture needles (70 Hz or greater) that is rapid in onset, segmental, and not cumulative. 2 By combining the neurohumoral models with other observations and speculations about the mechanism of acupuncture's impact, a model is created of an acupuncture needle simultaneously activating multiple systems in the body's physiology: the nervous system, which includes peripheral afferent transmission, perivascular sympathetic fiber conduction, and the central neurohumoral and neuropeptide mechanisms the blood circulation system, which transmits the biomolecular elements locally and centrally, along with the biochemical and cellular changes stimulated by acupuncture the lymphatic system, which serves as a medium for ionic flow along fascial planes and perivascular interstitial fluid circulation the electromagnetic bio-information system, which consists of static electricity on the surface, ionic migration in the interstitial fluid between the needles and as currents of injury at the needled site, and fascial and perineural semiconduction throughout the body. 1 The above hybrid assemblage of descriptions creates a contemporary working model of a multisystem information network that obliges the medical acupuncture practitioner to consider not only classical paradigms to arrive at diagnostic and therapeutic decisions, but also to take into account neuroanatomical and neurophysiological parameters. These considerations are of special importance in acupuncture's application in pain management, where knowledge of dermatomal, myotomal, scierotomal, and autonomic innervation patterns is indispensable. Back to TOP 6

7 PROVIDER-PATIENT INTERACTIONS History and Physical Examination In an acupuncture evaluation, the initial encounter with the patient is similar to that of a conventional allopathic medical interview and examination. The patient is encouraged to speak candidly and thoroughly about the presenting problems and their background. In addition to a conventional assessment and differential diagnosis, the practitioner explores the characteristics and behaviors of the problems in an effort to link them with the gross or subtle spheres of influence of one or several of the internal organs. In the case of musculoskeletal pain problems, the location of the pain is identified neuroanatomically and according to the acupuncture channel in whose territory it lies. The goal of the interview is to identify the organs and energy circulation divisions involved in the patient's disorder, whether the association be with the subtle symptoms linked to the traditional sphere of influence of the organs, with the trajectory of a meridian through a painful region, with a dense organ lesion, or with a combination of these factors. The patient's past medical history, childhood illnesses, family history, and review of systems are elicited during the interview, and all information is tagged with the organ or meridian under whose supervision it falls. During this period the acupuncturist poses questions of particular importance: possible cyclicity in the appearance of the symptoms, seasonal exacerbations, general seasonal preferences or dislikes, positive or negative flavor affinities and color affinities, response of symptoms to external climatic environments, and the lesion's response to pressure, movement, heat, or cold. A standard physical examination appropriate for the patient and the problem is undertaken, with several additional acupuncture inspections included. The musculoskeletal evaluation includes identification of painful muscle knots and trigger points as well as subcutaneous nodules and bands overlying contracted muscles. Specific reflex points on the front and back of the trunk (mu points and shu points) correspond to the organs associated with them. If any mu or shu points are sensitive to palpation during the physical examination, those findings also are recorded. In acupuncture, several diagnostic somatotopic systems that microcosmically reflect the internal organs are routinely used to evaluate the balance of relative strengths and weaknesses within the organs. Those most commonly employed are the reflex systems of the tongue, the radial pulse, and the external ear, inspections of which are undertaken as part of the routine physical evaluation. The tongue reflects the basic condition and underlying problem of the patient at the time of examination by way of its color, body, coating, and surface irregularities. Changes in tongue qualities are easily noted from week to week and often day to day. The tongue serves as an indicator of change in the patients as they evolve through illness and respond to medical interventions. The diagnostic microsystem of the radial pulse provides another means of evaluating the patient's overall condition, and of comparing the relative strengths of energetic activity in the organs and their meridians. The pulse changes from minute to minute and therefore can be used to verify whether an input has had its intended effect before one continues or concludes the treatment. The pulses also serve as a subjective measurement from visit to visit, revealing the stability of the changes made through the acupuncture treatments. Evaluation of the external ear confirms findings from the physical exam or other reflex systems, and may indicate new directions for exploration during the interview and examination. The diagnostic examination includes visual inspection, palpation with a probe, or scanning with a battery-powered electrical resistance detector. The external ear also can be used as a treatment system in isolation or as an adjunct to body acupuncture points. Medical Acupuncture Differential Diagnosis and Treatment Planning Before concluding the diagnostic process, a review of past medical records, radiographs, and laboratory studies is undertaken, and appropriate new studies are requested to confirm and specify mechanical and organic disorders. From all available information, subtle and gross symptoms and characteristics are organized into affinity 7

8 clusters, and patterns of disharmony are identified. The organ or organ's influence that is most disturbed is then defined, as is the level of manifestation of this greatest disturbance. The energy-functional level of disturbance involves the balance of energetic and metabolic activities of the organs and their spheres of influence, including, especially, their psycho-emotional expressions; the channel-structural level involves skin, fascia, muscles, and bones; and the organ level involves the metabolic or transport junctions of the organs themselves. A decision is then made as to which division of the energy circulation network gives best access to the level of greatest disturbance. The initial interview affords an understanding of the manifestations and course of the disorder as well as the patient's constitutional strengths and weaknesses. The ideal diagnostic conclusion is a clear perception of the patient's health course: the presenting problems and their origins as well as the likely future health events. An algorithm of treatment approaches should be constructed. The goal of the overall treatment strategy must be kept in mind while working with the various tactics at each session. For example, the immediate treatment plan may address only relief of the most urgent symptoms, and long-standing problems can be addressed after change in the presenting symptoms. Treatment Design The first steps in treatment design involve identifying the levels of manifestation of the patient's complaints and establishing an order of treating the problems. Treatment strategy involves activating the appropriate layers of the energy circulation network to address each problem on its own level of manifestation. A simple strain or sprain may need nothing more than dispersion with needles surrounding the local lesion and an activation of the appropriate tendinomuscular meridian. Musculoskeletal pain of long-standing duration will need placement of needles around one of the principal meridian subcircuits to encourage energy flow, in addition to local needles to focus on the site of the problem. Such a treatment may involve electrical stimulation of the points needled to move the energy through the subcircuit as well as the local points. Psychosomatic or premorbid problems may respond to the needling of several front or back mu or sho points, to a rarefied equilibration treatment based on more arcane models of organ and energy interactions, or perhaps to an activation of energy flow through the disturbed principal meridian subcircuit. It is important to aim treatment at the level of manifestation of the problem being addressed. The circulation levels being activated may be changed during a series of treatments to better address the presenting problem or to introduce treatment for secondary problems. It is better to proceed slowly than with vigor, so that the patient's response to the treatment can be properly evaluated. As with any other medical intervention, factors influencing the outcome of a treatment include the patient's age; the duration and complexity of the presenting problem; the presence of concurrent acute or chronic illness, medications, history of surgical interventions, lifestyle, and personal health factors; and the patient's emotional state and basic vitality. The patient's attitude toward acupuncture usually does not affect the result, as it is not necessary to believe in acupuncture for it to be effective. THERAPY AND OUTCOMES Treatment Options Along with the majority of physician acupuncturists in the United States, the author uses the hybrid model of combining energy movement through the channels with local or focusing treatment. This model, known as "acupuncture energetics," is derived from European interpretations of the Chinese classics and blended with neuromuscular anatomy of trigger points and segmental innervation for pain treatments. Traditional Japanese meridian acupuncture is akin to the linear energy movement programs represented in the following section, although Japanese practitioners commonly needle more superficially than do Europeans or Americans. Of the acupuncture systems currently practiced in the United States, the traditional Chinese medicine that is taught at the training colleges in China is the most widespread. This approach to acupuncture is linked with traditional herbal prescribing as the core of the discipline, which can be an effective approach for internal medicine 8

9 problems. The acupuncture points are selected for their traditional functions to reinforce the goals of herbal therapy, rather than to move energy through the circulation network. Five elements acupuncture is another widely practiced discipline. Imported from England, five elements acupuncture reflects French and other European interpretations of classical information. The greatest value of this approach lies in its potential to assist in the repair of problems that originate in the psycho-emotional sphere. Three somatotopic systems have established themselves as valuable disciplines, used either as exclusive approaches to acupuncture or as adjuncts to body acupuncture. Auricular acupuncture, developed in France, offers a homuncular reflex organization of all body parts on the external ear. Korean hand acupuncture identifies a microsystem on the hand of the complete meridian circulation. Scalp acupuncture is another recent development, several systems of which divide cranial territories into neurological regions corresponding to cerebrocortical influences on the body structures. These somatotopic systems appear to be effective for modifying neurological problems that can be elusive to body acupuncture. Description of Treatment The acupuncture treatment consists of inserting fine needles into the body in patterns designed to influence the flow of qi in one of the subdivisions of the energy circulation network. Usually only one energy subdivision is selected to stimulate energy movement, along with a collection of local points to focus the attention of the energy movement. Each subdivision of the circulation has a unique therapeutic point combination necessary for activation. The combinations involve the insertion of at least three needles - the energy moving needles - that are usually in the extremities and usually inserted bilaterally. The focusing needles are Inserted at trunk points that influence the organs being stimulated, or at muscular points tender to palpation in the region of the pain. Needles are inserted to the depth necessary to elicit the patient's sensation of de qi, or needle grab, a dull ache that radiates from the point. This can be 0.5 cm to 8 cm, depending on the location. The patient is positioned comfortably', usually lying supine or prone. The acupuncture needles are left in place for 5 to 20 minutes. It is crucial to protect the patient from energy depletion during an acupuncture treatment. The older or more fatigued the patient, the shorter the duration of treatment must be. The energy-moving needles may be stimulated when an additional activation of the acupuncture system is desired, such as when the problem is one of deficiency according to acupuncture principles or when the patient has low vitality. This additional activation is accomplished through manual manipulation, by heating the needle with burning mugwort (moxibustion), or by connecting the needles to an electrical stimulating device. Focusing needles can likewise be stimulated through manual, thermal, or electrical means. It is common to treat the patient using front, back, and extremity points during the course of a single treatment session. This means that the treatment is typically divided into two sections: the energy movement section using extremity points to activate flow through the meridians, and the section to focus the energy on one or several organs or to influence a pain problem. An example of preventive intervention that makes use of the traditional influences of the organs would be that of a 33-year-old man who complains of a general diminution of energy, including decreased sexual interest, increased sensitivity to cold weather, mild generalized joint aches, and a new affinity for salt. He is wearing a black T-shirt and black underpants and has significant graying in his temples (such symptoms and presentation are features of Kidney influence). This man's medical evaluation and laboratory tests are negative. His case is a premorbid manifestation of weakness in the Kidney sphere of influence. An appropriate treatment would be to activate Kidney energy with needles and moxibustion at the shu points for Kidney on the back, bilaterally, as the first section of the treatment. The second section could consist of creating an energy flow through the shao yin (Kidney-Heart) and tai yang (Small Intestin~Bladder) principal meridian subcircuit by placing one needle in the Kidney meridian, one in the Heart meridian, and one in the Bladder meridian, bilaterally in the extremities, and manually stimulating them in addition to moxibustion. Each section would last 5 to 10 minutes, and would take place in one session. The local treatments for pain problems can be quite complex because, in addition to honoring the classical directive of encouraging the flow of qi and blood through the channels that traverse the painful area, neuromuscular 9

10 anatomy must be considered. Deliberately searching for and deactivating intramuscular trigger points in the region of pain and along the myotomal distribution of the spinal segments involved in the pain is a necessary component of the local treatment. Likewise, recruiting the neurological activity of the spinal origins of the dermatomal, myotomal, sclerotomal, and sympathetic innervation of the pain problem is a common local treatment for chronic pain. In these cases, electrical stimulation is commonly used, with the frequencies ranging between 2 Hz and 150 Hz. If the above 33-year-old man also has chronic lumbar pain with an occasional L-5 radicular component, the acupuncture treatment will consist of an initial energy moving section involving two needles bilaterally in the extremities on the Kidney meridian, one in the Heart meridian, one in Small Intestine, and one in Bladder. The two needles in the Kidney' meridian to enhance the energetic activity in the subcircuit as well as moxa can be applied to the other points. This section of the treatment lasts approximately 10 minutes. The second section is the local treatment for the lumbar pain, and involves needles placed on the Bladder meridian, for example, at the L-2 level (somatic sympathetics for lower extremities), L-4 and L-5 levels (myotomal and dermatomal levels of pain), and at the 5-2 level (parasympathetics for lower extremities) to recruit the spinal segments involved in his pain. Electrical stimulation at 4 Hz or 15 Hz can be connected among these needles. This second section lasts for 20 minutes. Schedules and Results Patient visits are usually scheduled once weekly, although two or three visits each week are not uncommon, especially during the initial stages of an acute problem. When a favorable response lasts for the full week between visits, the interval is opened to 2 weeks. As the response stabilizes for a 2-week period, the interval is opened again to 3 weeks, then 4 weeks. When the symptoms are stable for 4 weeks, a decision is made as to whether the patient should return for a maintenance treatment in another month or 6 weeks or call for an appointment only if the condition returns. Chronic pain problems typically require maintenance treatments at 1- month, 6-week, or 2-month intervals. Medical problems of lesser severity and chronicity can often be resolved adequately and do not require maintenance treatments, although chronic medical problems-even when they respond well to acupuncture-typically call for quarterly maintenance treatments. Treatment Evaluation During initial treatments, any change, even a transient exacerbation of symptoms, is considered a favorable response. No response to the initial treatment can mean that the therapeutic input was not strong enough, that the problem is deep seated and requires several treatments to influence, that the treatment design is inappropriate, or that the problem is not accessible to acupuncture intervention. An exacerbation of symptoms after the initial treatment usually means that the treatment decision is accurate, but that the manipulation or the duration of the needles was too extensive. An examination of diagnostic microsystems such as the radial pulse and the tongue gives another means for the practitioner to subjectively evaluate change in the patient's condition from visit to visit, and thereby decide whether a change in treatment is indicated. With the cumulative effect of the treatments, enduring improvement is the desired goal. Enduring improvement may mean a thorough resolution of the presenting problem, or it may mean enabling the patient to function on a plateau of discomfort that is less incapacitating or requires less medication than at the time of initial presentation. Ideally, a dozen visits are scheduled to follow the course of the disorder and its response to acupuncture. Usually, the extent of response can be approximated by six or eight visits, but an enduring response often requires the full schedule of visits. After the first dozen treatments, the problem and its response to acupuncture are reevaluated and the acupuncturist and patient decide whether to continue intensive treatments, maintain treatments, or abandon the acupuncture intervention. Acupuncture treatments are as individual as the patients and their responses to acupuncture. It is common to stay with an initial treatment approach for at least three or four visits before modifying the approach. It is common for the patient to report changes in general well-being and vitality, or a reduction in medication, before a 10

11 clear change in the presenting symptoms occurs. if no progress has been made by the sixth visit, it is reasonable to consider including additional modalities to complement the acupuncture. It is best not to abandon a case that shows reasonable hope for response to acupuncture before a full trial of 12 visits has been completed. TREATMENT USES OF MEDICAL ACUPUNCTURE Most Useful as Primary Therapy: Musculoskeletal Pain In the United States, acupuncture has found its greatest acceptance and success in the management of musculoskeletal pain. Acute musculoskeletal lesions such as soft tissue contusions, acute muscle spasms, musculotendinous sprains and strains, and the pain of acute nerve entrapments are among the problems most frequently and successfully addressed with acupuncture. In such cases, acupuncture can legitimately serve as the initiating therapy. Chronic musculoskeletal pain problems are also commonly and appropriately treated with acupuncture, although not usually as the only approach. Those problems likely to be responsive to acupuncture intervention include repetitive strain disorders (eg, carpal tunnel syndrome, tennis elbow, plantar fascutis), myofascial pain patterns (eg, temporomandibular joint pain, muscle tension headaches, cervical and thoracic soft tissue pain, regional shoulder pain), arthralgias (particularly osteoarthritic in nature), degenerative disc disease with or without radicular pain, and pain following surgical intervention (both musculoskeletal and visceral). In the management of chronic musculoskeletal pain, acupuncture offers a broad range of potential value between the conventional therapy poles of pharmaceuticals and invasive procedures. Other chronic pain problems commonly responsive to acupuncture include postherpetic neuralgia, peripheral neuropathic pain, and headaches from other causes. Least Useful as Primary Therapy Although acupuncture has been established as an effective tool to treat many forms of musculoskeletal pain, its limitations must be recognized in dealing with the consequences of spinal cord injuries and cerebrovascular accidents. In these conditions, acupuncture's effectiveness is diminished, and the frequency of treatments is increased and protracted over a longer time. Furthermore, acupuncture is usually not useful for thalamically mediated pain and, apart from symptom management and general vivifying effects, is not of great value in the treatment of chronic neurodegenerative diseases. Acupuncture as a sole therapy has not shown itself to be of substantial value in severe and chronic inflammatory and immune-mediated disorders such as ulcerative colitis, asthma, rheumatoid arthritis, and collagen-vascular diseases, especially if those conditions have advanced to require systemic corticosteroid medication. Likewise, acupuncture is not appropriate as the primary intervention for chronic fatigue states or HIV disease. There can be general value, however, for the symptom control and vitality-promoting effects of acupuncture in all of these conditions. In malignancies, acupuncture can be considered as an additional therapy to combat the secondary effects of conventional therapy, and as an adjunct in pain management. Adverse Effects of Acupuncture In the hands of a medically trained practitioner, acupuncture is a fairly safe and forgiving discipline. It is difficult to introduce new and lasting problems with an acupuncture treatment, even if the treatment is not designed as skillfully as an experienced provider would desire. Many patients report a sensation of well-being or relaxation following an acupuncture treatment, especially if electrical stimulation has been used. That sense of relaxation, however, sometimes evolves into a feeling of fatigue or depression that lasts for several days. Other transient psychophysiological responses can be light-headedness, anxiety, agitation, and tearfulness. 11

12 The possible risks and complications of an acupuncture treatment are undesirable consequences of penetrating the body with a sharp instrument: syncope, puncture of an organ, infection, a retained needle. These risks can be reduced by scrupulous sterilizing of needles, acquiring good clinical skills, understanding surface and internal anatomy, and executing responsible clinical judgment. Pneumothorax is the most frequently reported and the most easily produced visceral complication of acupuncture needling. Pneumoperitoneum, hemothorax, cardiac tamponade, and penetration of the kidney, bladder, and spinal medulla have been reported, although infrequently. Contact dermatitis to stainless steel needles, local inflammation, and bacterial abscesses can occur, as can chondritis from needling points on the ear. Outbreaks of hepatitis B documented in Europe and America have been traced to single practitioners reusing unsterilized needles.3 There have been no epidemiologically responsible reports of HIV transmission through the use of acupuncture. Preventive Value of Medical Acupuncture Perhaps the most fertile ground for acupuncture intervention is for disorders in their premorbid state, problems commonly encountered by primary care providers but rarely associated with positive laboratory findings, definitive medical diagnoses, or successful therapies. Such states often can be described within the acupuncture diagnostic paradigms, and then modified through activation of the appropriate level of energy circulation. These disorders can be loosely categorized into three groups: aesthenic states, autonomic dysregulation disorders, and immune dysregulation disorders. Aesthenic states include ill-defined fatigue (eg, "tired all the time, low energy"), mild depression, stress-related myofascial symptoms (eg upper thoracic and cervical myofascial pain, muscle tension headache), and early functional disturbances (eg. diminished libido). Autonomic dysregulation disorders may manifest as anxiety, sleep disturbances, and bowel dysfunction. Immune dysregulation disorders include recurrent infectious and inflammatory states without underlying frank immunodeficiency: sinusitis, pharyngitis, bronchitis, gastroenteritis, and viral illnesses. Some conscientious patients consult the acupuncture practitioner with what might be considered, from an allopathic perspective, minor symptoms, requesting assistance to attain better health and vitality. In such instances, the general characteristics of the patient, the presenting symptoms, the patient's past and family medical histories, and the acupuncture examination allow the acupuncturist to identify minor imbalances in the energetic activity of the organs and energy axes. This level of subtle pathology, for which allopathic medicine has little more than lifestyle counseling to offer, is commonly overlooked in a conventional setting. The acupuncture diagnostic and therapeutic system, however, usually allows for an understanding of the patient and early disturbances, and an appropriate intervention can be formulated. This form of preventive maintenance is a valuable dimension of the subtle aspects of acupuncture. Scope of Practice of Medical Acupuncture Medical acupuncture is a highly adaptable discipline, and is of potential therapeutic value in many pain and general medical conditions. Whether it is introduced as the primary or the complementary therapy depends on the nature and severity of the presenting problem as well as the training, orientation, and practice environment of the provider. The physician trained in medical acupuncture who sees patients early in the course of their disturbances can initiate treatment of a pain or medical problem with acupuncture, and introduce additional therapies if acupuncture proves insufficient as the sole treatment. The physician who receives cases later in their evolution and after conventional treatments have been initiated can add acupuncture to assist, or possibly replace, conventional treatments. Many patients seeking attention from acupuncture providers demand acupuncture or other unconventional interventions as the starting treatment, agreeing to conventional methods only later in their management. Other patients and many physicians wait until conventional therapies have been exhausted, and then resort to acupunc- 12

13 ture intervention. Acupuncture therapy is not miraculous. It has its appropriate range of applications, and, like any other medical intervention, yields good results in well-selected early problems and less successful results when chronicity and complexity of the presenting problems increase. Usually the best moment to initiate acupuncture therapy is early in the evolution of a problem; however, the flexibility and adaptability of acupuncture allow it to be integrated at almost any stage of treatment. In addition to the treatment of acute and chronic musculoskeletal pain and premorbid or functional problems, medical acupuncture can be used successfully to address many diagnosable medical conditions, although it may need to be used in collaboration with other therapies, whether conventional or unconventional. The four divisions of medicine that appear to be most responsive to acupuncture intervention in this country are respiratory, gastrointestinal, gynecologic, and genitourinary. Respiratory ailments potentially accessible to acupuncture intervention include allergic rhinitis, sinusitis, and bronchitis. Gastrointestinal ailments include gastritis, irritable bowel syndrome, hepatitis, and hemorrhoids. Gynecological problems include dysmenorrhea and infertility. Genitourinary problems include irritable bladder, prostatitis, male infertility, and some forms of impotence. Acupuncture, particularly when applied to the external ear, has proven valuable for managing substance abuse problems and reducing prescription narcotic analgesics. One of the most socially visible for acupuncture, this application has gained the respect of rehabilitation programs internationally. 4 For mental and emotional disturbances, acupuncture can be useful as a transient aid in early and acute emotional states such as anxiety, excitability, worry, early stages of depression, and fearful states. Acupuncture should not be considered as a primary or ongoing therapy for deep-seated or chronic psychoemotional illness, because its effect on these conditions is not enduring. Acupuncture as Complement, Complements to Acupuncture Acupuncture's adaptability to the changing requirements of the patient's condition extends to its adaptability when combined with other modalities of healthcare. This integration is an expression of the training, orientation, and creativity of the practitioner. Acupuncture can be used as the initiating therapy for many common medical problems and can be combined with other modalities and disciplines according to the needs of the patient and the availability of other services. There are medical modalities in addition to allopathic pharmaceutical and surgical interventions that particularly complement the effects of acupuncture, or that acupuncture can complement. These include physical medicine techniques in pain management, osteopathic manipulation, movement training, herbal therapy, homeopathic remedies, and psychiatric or psychological intervention. Management of chronic musculoskeletal pain offers many occasions in which therapeutic modalities can be combined. A physical therapist experienced in myotherapy can extend the impact of an acupuncture treatment directed at relaxation of contracted muscles and fascial tension patterns. The conventional spray and stretch, trigger point infiltration, and transcutaneous electrical nerve stimulation techniques of physical medicine combine well with acupuncture therapy. Osteopathic manipulative therapy and its subspecialty of cranial therapy also can be productively combined with the musculoskeletal applications of acupuncture. Hatha yoga postures assist patients with biomechanical rehabilitation and maintenance of results, and the breathing exercises assist with relaxation and stress reduction. Movement therapy such as the Feldenkrais, Alexander, and Aston approaches also can be useful adjunctive activities during rehabilitation. With chronic medical problems, the traditions of herbal therapies and homeopathic remedies can be usefully combined with acupuncture treatments. Chinese herbal formulae, when prescribed according to the classical patterns of disharmony of internal organs, can serve as protopharmaceutical substrates to enhance and prolong the effects of acupuncture treatments. Herbal formulae can accomplish lasting change or maintenance that cannot be achieved with needles alone. Homeopathic remedies are generally used in low-potency form to treat acute problems, middle-potency form to treat chronic medical problems, and high-potency form to treat problems that have a core psycho-emotional dis- 13

14 turbance. These remedies can be used to specify and enhance the acupuncture treatments and have capability in high potency to effect enduring changes in the patient's emotional configuration. It is sometimes necessary to work in collaboration with a psychiatrist or psychotherapist who is both sensitive to the acupuncture process and can serve in a guiding role for the patient. ORGANIZATION Training and Quality Assurance In the United States, acupuncture is performed by physician as well as nonphysician practitioners. In 35 states, the practice of acupuncture is included in the scope of a physician's medical or osteopathic license, and no regulations or restrictions are imposed on medical practitioners. The 15 other states require physicians practicing acupuncture either to demonstrate evidence of participation in training programs of 200 to 300 hours or simply to register with the board of medicine with evidence of formal training. From these loose regulations of physician practitioners, it is clear that the degree of acupuncture training and experience among physicians varies from state to state and individual to individual. The American Academy of Medical Acupuncture (AAMA) represents the education, legislation, and professional interests of physicians who are well trained in acupuncture. Full membership in the AAMA requires 220 hours of formal training and 2 years of clinical experience. This standard follows the physician-training guidelines established in the constitution of the World Federation of Acupuncture-Moxibustion Societies, an international society guided by the World Health Organization. The AAMA has established a proficiency examination as the first of a two-part board certification examination. Membership eligibility in the AAMA has become the standard of physician credentialing for state registration, hospital privileges, liability insurance, and third-party reimbursement. It is likely that the proficiency examination will also become a requirement for participation in managed care programs (American Academy of Medical Acupuncture; Los Angeles, Calif). The practice of acupuncture by nonphysicians is regulated in at least 33 states, and another dozen states have statutes pending. The educational prerequisites and training requirements vary widely from state to state, and have been in a flux of improvement during the past decade. Approximately 30 colleges are accredited by the National Accreditation Commission for Schools and Colleges of Acupuncture and Oriental Medicine. Most of the programs span 3 years of didactic and clinical training. All states except California and Nevada that license nonphysician acupuncturists recognize the national examination developed by the National Commission for the Certification of Acupuncture and Oriental Medicine. There are two main national societies (the American Association of Acupuncture and Oriental Medicine in Catasaugua, Pa; and the National Acupuncture and Oriental Medicine Alliance in Olalla, Wash), together with many regional, state, and local organizations, that represent the interests of the licensed acupuncturist communities. The World Health Organization has adopted guidelines on basic training for physician and nonphysician providers, standards for safe practice, and clinical indications for acupuncture. The training guidelines reflect the minimum hours expected in most member nations and are consistent with regulations enacted in the United States; 2500 hours for nonphysician acupuncturists and 200 hours for physicians. The basic curriculum is founded on the classical tradition of acupuncture requiring a firm knowledge of the acupuncture points and channels and the traditional models of diagnosis and treatment. A basic knowledge of Western biomedical science is also encouraged in the curriculum. 5 Reimbursement Status Whereas no national standard currently exists for the third-party insurance industry regarding acupuncture, many policies recognize acupuncture as a legitimate and reimbursable procedure. Because of the popular and professional demand for acupuncture services, it is likely that insurance reimbursement will become more uniform with time. Medical acupuncture, particularly as practiced by an experienced medical provider, integrates creatively into many of the disciplines of medicine. Traditional Chinese medicine integrates less smoothly into 14

15 conventional settings because the herbal diagnostic model that is fundamental to traditional Chinese medicine is alien to most Western physicians' thinking. Back to TOP PROSPECTS FOR THE FUTURE The potential for medical acupuncture is just beginning to be understood. Future clinical research and utilization evaluations should clarify, how best to integrate acupuncture into the conventional healthcare system. Medical acupuncture offers the opportunity to expand contemporary medicine to treat conditions for which current interventions are either ineffective or have undesirable secondary effects. Because of its usefulness and adaptability to so many aspects of allopathic medicine, medical acupuncture will likely' be integrated with increasing frequency into private and institutional practices. References (To return to reading after referencing footnote, use the Back button of your browser.) 1. Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. Berkeley, Calif: Medical Acupuncture Publishers: Stux G. Pomeranz B. Acupuncture: Textbook and Atlas. Berlin, Germany: Springer-Verlag: 1987; Norheim AJ. Adverse effects of acupuncture: a study of the literature for the years J Altern Complement Med. 1996; 2(2) Culliton PD, Kiresuk TJ. Overview of substance abuse acupuncture treatment research. J Altern Complement Med. 1996; 2(1): Helms JM. Report on the World Health Organization's consultation on acupuncture. Med Acupunct. 1997; 9(1):

16 The Chinese Perspective of Health and Disease Health is a state of balance. Illness and disease are states of being out of balance. It is interesting to note that in Western medicine there is no broad or all-encompassing theory with which to understand illness and disease. There are some good models such as the bacterial or viral understanding of infectious diseases, with not good understanding that links together different diseases. Eastern modalities, such as Chinese medicine, Tibetan medicine and Aryuvedic medicine, in contrast with Western medicine, have broad theories of health and disease. The concept of balance is central to the notion of health. When the body falls off balance, then disease and illness arise. Health is defined as a state of balance or harmony in the body and mind. In contrast, in Western medicine, health is described as the absence of disease. Implicit within the notion that health means balance, is the idea that the treatment methods should bring the body INTO A STATE OF BALANCE. While Western medicine excels in emergency medicine and acute conditions, Chinese medicine deals better with chronic, lower level problems. Rather than concentrating on individual or a group of symptoms, Chinese medicine focuses on patterns of imbalance. For a Western medicine practitioner, a urinary tract infection is basically caused by bacteria in urine. For the Chinese medicine practitioner it makes all the difference the environmental factors that surround the problem and the associated symptoms. The Chinese practitioner will be interested in knowing if there is frequency, dysuria, scanty urination, dark colored urine and if the patient feels angry and has a headache. This pattern, for example is called Liver Qi stagnation descending as damp heat. So, for the Chinese practitioner, the bladder environment was that of damp heat. While Chinese practitioners do not deny there are bacteria in the urine, they also are interested in what is out of balance in the body and the bladder ) to encourage the bacteria to be present. Another example would be a man diagnosed with gastric ulcer. For a Western medicine practitioner the treatment might be with a proton pump inhibitor or H2 blocker. The Chinese practitioner will go even further and asking him if he felt hot or cold. Heat is an obvious indication of an excess condition. Cold is an indicator of a deficiency. This apparently simple question makes all the difference to treat the patient. If, for example, the patient feels cold and has an ulcer, the classic recommendation of drinking a glass of cold milk out of the refrigerator would generate MORE PAIN for the patient. Milk is good to soothe HOT ulcers. For COLD ulcers, it makes them worse. Chinese Medicine Basics Please bear in mind that due to how old Chinese medicine is, most of these concepts are theoretical. In ancient China, human body dissections were not popular, so most of these notions and concepts belong to an elaborate and somewhat poetic rationalization of how the body works. Chinese medicine explains how the body works and then explains how things get out of balance. Then, through acupuncture or Chinese herbs, the balance is restored. 16

17 October 2010 ACUPUNCTURE THEORY In this section we will go over 3 important aspects of Chinese medicine. 1. We will go over basic aspects of it, including philosophy and use of each meridian. 2. We will go over the Chinese measurements. 3. We will go over the main acupuncture points within each meridian. 17

18 The Chinese Perspective of Health and Disease Health is a state of balance. Illness and disease are states of being out of balance. It is interesting to note that in Western medicine there is no broad or all-encompassing theory with which to understand illness and disease. There are some good models such as the bacterial or viral understanding of infectious diseases, with not good understanding that links together different diseases. Eastern modalities, such as Chinese medicine, Tibetan medicine and Aryuvedic medicine, in contrast with Western medicine, have broad theories of health and disease. The concept of balance is central to the notion of health. When the body falls off balance, then disease and illness arise. Health is defined as a state of balance or harmony in the body and mind. In contrast, in Western medicine, health is described as the absence of disease. Implicit within the notion that health means balance, is the idea that the treatment methods should bring the body INTO A STATE OF BALANCE. While Western medicine excels in emergency medicine and acute conditions, Chinese medicine deals better with chronic, lower level problems. Rather than concentrating on individual or a group of symptoms, Chinese medicine focuses on patterns of imbalance. For a Western medicine practitioner, a urinary tract infection is basically caused by bacteria in urine. For the Chinese medicine practitioner it makes all the difference the environmental factors that surround the problem and the associated symptoms. The Chinese practitioner will be interested in knowing if there is frequency, dysuria, scanty urination, dark colored urine and if the patient feels angry and has a headache. This pattern, for example is called Liver Qi stagnation descending as damp heat. So, for the Chinese practitioner, the bladder environment was that of damp heat. While Chinese practitioners do not deny there are bacteria in the urine, they also are interested in what is out of balance in the body and the bladder ) to encourage the bacteria to be present. Another example would be a man diagnosed with a gastric ulcer. For a Western medicine practitioner the treatment might be with a proton pump inhibitor or H2 blocker. The Chinese practitioner will go even further and asking him if he felt hot or cold. Heat is an obvious indication of an excess condition. Cold is an indicator of a deficiency. This apparently simple question makes all the difference to treat the patient. If, for example, the patient feels cold and has an ulcer, the classic recommendation of drinking a glass of cold milk out of the refrigerator would generate MORE PAIN for the patient. Milk is good to soothe HOT ulcers. For COLD ulcers, it makes them worse. Chinese Medicine Basics Please bear in mind that due to how old Chinese medicine is, most of these concepts are theoretical. In ancient China, human body dissections were not popular, so most of these notions and concepts belong to an elaborate and somewhat poetic rationalization of how the body works. Chinese medicine explains how the body works and then explains how things get out of balance. Then, through acupuncture or Chinese herbs, the balance is restored. 18

19 Let s define first the basic substances in Chinese medicine. 1. Qi (Vital Energy or Life Force) Qi is the vital energy or life force that flows through the body's Meridians, Yin Yang organs, and is responsible for moving the blood. It has got a myriad of subtypes. Qi can transform, transport, hold, raise, protect, and warm. Qi also has a normal flow or direction of movement associated with each Yin and Yang organ. 2. Xue (Blood) Blood is the densest of the vital substances, flowing through the vessels to moisten and nourish the Yin Yang organs, the tendons and muscles, the skin, and the sensory organs. Blood is the mother of Qi, and houses the Shen (Mind). 3. Jing (Essence) The refined and precious substance that is the material basis for all life. It influences our constitution, reproduction, growth and development, and our longevity. It is the foundation for the production of Qi and aids in the production of marrow. There is both Prenatal and Postnatal Jing. 4. Shen ( Mind/Spirit ) Manifests in the eyes. Housed by the heart. The Ten Principles of Chinese Medicine The Ten Principles are four pairs of polar opposites: Yin-Yang, Interior-Exterior, Deficiency-Excess, Hot Cold and Wetness-dryness. Let s explain YIN and YANG. The ancient Chinese subscribe to a concept called Yin and Yang which is a belief that there exist two complementary forces in the universe. One is Yang which represents everything positive or masculine and the other is Yin which is characterized as negative or feminine. One is not better than the other. Instead they are both necessary and a balance of both is highly desirable. This thinking is different from the duality of most religion where one state overcomes the other e.g. good over evil. In the concept of YIN and YANG, too much of either one is bad. The ideal is a balance of both. The hot Saharan desert for example is an example of extreme Yang while the bitter cold Antarctica is extreme Yin. Neither is desirable. Please take a look at the table from Medscape below: 19

20 Yin and Yang need to be in balance. If they are represents balance between Yin and Yang. There Yin ( bottom ) and intermediate steps that have that both are tightly connected and cannot exist not, then disease will appear. The symbol of tao are states of maximum Yang ( top ) and maximum both Yang and Yin. From the picture you can infer one without each other. Qi circulates on the meridians on a given pattern and goes from Yang to Yin and then from Yin to Yang on a circular and endless movement through the day and the night. On the body, the downflowing Yang Channels connect with the upflowing Yin Channels at both fingertips and toetips ( please see diagrams ). In Chinese medicine anatomical position is with a patient standing with his upper extremities up and palms above his/ her head ( palms to the front ). In this position, the heavens are Yang and the earth is Yin. Man is the cross linking be- 20

21 Antero Posterior view of Qi Circulation.. On the front it goes from bottom to top, and on the back goes from top to bottom. Circulation of Qi. 21

22 tween heaven and earth. However in a man, both Yang and Yin coexist. The head is Yang with respect to the feet, but Yin with respect to the heavens. The feet are Yin with respect to the head, but Yang with respect to the earth. The abdomen is Yin, while the back is Yang ( frontal structures are Yin, back structures are Yang ). The skin is Yang, while internal organs are Yin ( internal structures are Yin, external structures are Yang ). Heat vs Cold These are 2 ways of our body to get out of balance. Heat and cold refer to to the sensations we have when we feel hot or cold, but the concept goes beyond it. Having a fever or just feeling warm when the weather is hot are two examples of heat, but most people with a Heat pattern are not aware of it. Most symptoms of disease can be catalogued as hot or cold. For example a headache might have either a hot or a cold pattern. In general, we can say that cold is associated with diminished physical functions, decreased energy and decreased body metabolism. Heat is associated to a hyperfunction of physiological functions, increased energy and metabolism. In cold, there is a decreased resistance to pathogenic elements with low or mild fevers when sick. In heat there may be an overreaction to the body to pathogenic elements and thus a high fever. Please take a look at the table below. A condition can be classified as cold or hot if more than 3 of these conditions are met. There are times in which you can find heat characteristics within a mostly cold pattern and viceversa. Cold Pale face Feeling cold Cold limbs, cold hands Fear and avoidance of cold Wears more clothes Absence of thirst Wetness or dampness in body Preference for warm drinks and foods Slow movements Withdrawn manners Curls up Body secretions are clear, watery, odorless Pain is worse with cold Pain gets better with warmth Hot Red or flushed face Feeling warm Warm hands, warm body Aversion and avoidance of heat Wears less clothes Thirst Dryness in body Preference for cold drinks and foods Quick and active movements Active, and out there Restless, agitated Body secretions are yellow, strong and foul odor Pain gets worse with heat Pain gets better with cold Wetness vs Dryness 22

23 Another two important concepts in Chinese medicine. Wetness is a condition where fluids congest and accumulate in the body. Dryness is the opposite condition. Dryness if often a symptom of heat, but sometimes it can happen without the heat. Examples of wetness could be swelling and edema of lower limbs, pulmonary edema, sinus infections, etc. Examples of dryness would be dry brittle skin, dry mouth and tongue, etc. Please take a look at the chart below for more examples: Wetness Feeling of heaviness, stickiness Heaviness of head Heaviness of arms and legs Oppression of chest Body secretions white or clear Wetness in lungs produce cough with abundant sputum. Loss of appetite Dryness Dryness of skin, hair, mouth, throat, lips Reduced or absent secretions Dryness in lugs produces dry coughs with little or no sputum Localized accumulations of fluids: edema, skin swelling, vaginal discharge Interior vs Exterior For Chinese medicine, where disease is coming will make a difference in the treatment the practitioner gives. Please take a look at the chart for some examples: Interior Chronic Illness Gradual Onset Deap Weak Pulse Deep pain Exterior Acute Illness Sudden Onset Strong Superficial pulse myalgia Excess vs Deficiency 23

24 Likely to be the most important concept in Chinese medicine. Please take a look at these examples: 1. Two women present with lung infections, low grade fevers, coughing up green-yellowish sputum. Both receive antibiotics. The first woman gets better quickly, the second develops a chronic cough with copious sputum, difficulty breathing, severe fatigue and low energy. The first woman had an excess condition, which responded nicely to antibiotics. The second woman had a deficiency condition. The reason why antibiotics do not work on the second woman is that there is a fundamental weakness ( deficiency ) in the body. To explain this through western terms, she may have a weak and deficient immune system and the pathogenic element never goes away. Her lung Qi ( energy ) is also weak and so, her lungs do not work properly. She has also got Qi deficiency ( fatigue and low energy ). Antibiotics do not work because the problem is not the bacteria as much as how WEAK and UNDERFUNCTIONING the body is. 2. A man suffers from mild stomach pains when he feels hungry. The pains reduce after eating or applying pressure to the abdomen. He feels generally tired, weak and has poor appetite. He has got deficiency condition in his digestive system. 3. A woman suffers from severe menstrual cramps the first day of her period. The pains are sharp and stabbing and have a fixed location. Pressure applied to the lower abdomen makes the pain feel worse. This is an excess condition. The pains are related to stagnation or blockage of blood in the body. 4. A man develops dysentery after a trip to India. When he returns he has recurrent problems with loose stools and diarrhea and even worse when he eats spicy or greasy foods. Tests positive for bacteria and parasites two times and receives 2 courses of anti parasitic and antibiotics. Yet, he still has a problem with diarrhea. The diagnosis is a deficiency condition. The bacteria/parasite exists in the body due to a weakness. The body immune reaction is underfunctioning, thus allowing the pathogens to remain in the body. Please take a look at this table to further clarify deficiency and excess patterns: 24

25 Deficiency Symptoms of chronic disease Diseases tend to be less intense, less sharp and less critical Pain is dull and diffuse Weakness on chest and abdomen Excess Acute disease Diseases more intense, sharper and critical Pain is sharper, severe and localized Fullness of chest and abdomen, with pressure Pain feels better with pressure or after eating Body is underactive Pain feels worse with pressure or after eating Body is hyperactive The Four Deficiencies of Chinese medicine 1. Qi deficiency: All body functions require Qi: Digestion, elimination, immune reactions, etc. The most classic symptoms for Qi deficiency is fatigue, weakness, shortness of breath, low voice and poor appetite. 2. Blood deficiency: The Chinese concept of blood includes our notion of blood, however, as with Qi, it is broader. Blood is also thought to flow through the meridians. Blood has also the function of nourishing, maintaining and moisturizing the organs ( including hair and skin ). Symptoms can include dizziness ( not enough blood to fill the brain ), scanty menstruation, insomnia, dry skin and hair. 3. Yang deficiency: Yang has got to do with the metabolic activity of the body that produces heat. If there is no Yang, there is no heat and the person feels cold. Yang makes fluids circulate, so if there is little Yang, there will be fluid collection ( swelling ). The patient will prefer hot drinks, will be fearful of cold, will have cold limbs, diarrhea, discharge of bodily fluis, edema. 4. Yin deficiency It is a little more difficult to define than Yang. It could be described as the overall fluid, water, substance balance of the body ( as opposed to Yang which represents metabolism and function ). The Yin balances the Yang, so if there is Yin deficiency, then the body cannot balance the fire ( Yang ) of the body and the person feels hot and dry. Other symptoms would be thirsty, aversion to heat, constipation ( dryness ), dry body fluids, red cheeks, dark and concentrated urine, night sweats. 25

26 The Yin ( ZANG ) Organs on Chinese Medicine Spleen: Unlike Western medicine, the spleen is not an accessory organ. It is used principally for digestion and assimilation of food into energy and metabolism of water. The Spleen raises the Qi, thus holds the organs up ( organs falling down : prolapsed ) and keeps the blood on the vessels ( when blood goes out, you get edema ). Spleen disharmony symptoms: Loss of appetite, weight loss, fatigue, heaviness, bloating, mild abdominal pain, diarrhea or loose stools and organ prolapse. Lungs: Similar to Western medicine, in charged of breathing. Also bringing in the air Qi and moving air and Qi down into the body. Lung disharmony symptoms: coughing and phlegm accumulation. Heart: Has got two sides. The Yang would represent the left side of the heart, in charged of circulating blood. The Yin side of the heart houses the Shen ( Spirit ). Heart disharmony symptoms: palpitations, agitation, hysteria, delirium, mania, insomnia, nightmares. Liver: The liver in Chinese medicine has several and diverse functions. It spreads and regulates the flow of Qi in the body. It can be considered the great regulator for it regulates and controls Qi and blood. It makes things happen smoothly, so it has got to do with emotions and the nervous system. When we are under a lot of stress, the body physical functioning is not smooth. The Qi doesn t circulate smoothly. The liver also STORES blood and regulates menstruation. Liver disharmony symptoms: tension and diffuse pain ( fibromyalgia ), tension and pain on chest and ribs, anger, irritability, anxiety, depression and stress, menstrual irregularities, headaches, dizziness, ringing on ears, spasms, seizures, tremors. Kidney: The root of body Qi, Yin and Yang. It is the storehouse of the body. IT is linked to lower back, bones, knees and legs. The Kidney Yang fire regulates water metabolism including urination, Yang deficiency generates abundant clear excess urination and occasionally swelling. Yin deficiency generates fatigue and heat symptoms. 26

27 Kidney disharmony symptoms: weak, sore and painful backs, chronic urinary reproductive and sexual functions, bone problems. Pericardium ( or Master of the Heart ): Its functions are very similar to the ones of the heart. It is there to protect the Heart from external pathogenic invasions. The pericardium governs blood, and houses the mind, both functions being the same as the Heart. The Yang (FU) Organs in Chinese Medicine Gallbladder ( related to Liver ): The Gallbladder is a Yang organ; its paired with the Liver. The pair is associated with the element of Wood. While the Liver is associated with the emotion of anger, the Gallbladder is associated with indecision or decisiveness Small Intestine ( related to Heart ): The Small intestine and its paired organ, the Heart, are associated with the element of fire and the emotions of joy or agitation. The small intestine governs the separation of the clear from the turbid. The small intestine further digests food decomposed initially by the stomach. The clear, referring to the essence of water and grain and to the large amount of fluid, is absorbed by the spleen and distributed to the whole, body. The turbid is sent downwards to the large intestine, while the useless water is infused to the bladder. The disorders of the small intestine are attributable to failure to separate the clear from the turbid dirt the digesting process, manifesting stool and urinary disturbance, such as abdominal pain, diarrhea, scanty urine, etc Stomach ( related to Spleen ): The Stomach and its paired organ, the Spleen, are associated with the element of earth and the emotions of worry and stress. Large Intestine ( related to Lung ): Large Intestine is ayang organ and paired to Lung. The function of the Large Intestine is to control the passage and conduction of stools. In the process, it transforms the stools and reabsorbs fluids from them. It receives food and drink from the Small Intestine, conducts the food and drink down, and after absorbing some of the fluids, it excretes the stools. The Large Intestine is closely related to the Lungs, in the way that Lung Qi aids in its downward movement, therefore influencing defecation. As the Lungs control the skin, the Large Intestine also has influence on it. Bladder ( related to Kidney ) : The Bladder is a Yang organ paired with the Kidney. Both are associated with the element of water and the emotion of fear. Triple Energizer or Triple Heater ( related to Pericardium ). San Jiao has been translated as "triple heater," triple warmer (or three warmers)," and "triple burner," the latter of which is probably favored because of the involvement of the San Jiao in metabolism. The current WHO standard term is "Triple Energizer" (TE), but many authors still prefer to use San Jiao. There are three "burning spaces": 27

28 The upper burner - corresponding to the thoracic cavity. This space includes Fei (lungs) and Xin (Heart), and is associated with respiration. The middle burner - corresponding to the upper part of the dorsal cavity. This space includes Stomach, Spleen, Hepatic Portal System, various secretory pancreatic cells, perhaps the duodenum, portions of the lymphatic system and is associated with digestion. The lower burner - corresponding to the lower part of the dorsal cavity. This space includes small intestine, large intestine, Kidneys and Bladder and is associated with elimination. 28

29 An Introduction to Chinese Measurements In Medical Acupuncture, we speak of a Chinese Inch or a cun. This is a measurement that is dependant on the patient s size. We can define one CUN as the width of a person's thumb at the knuckle, whereas the width of the two forefingers denotes 1.5 cun and the width of 4 fingers side-by-side is three cuns. If we go to the actual body, you will find that certain lengths of the body measure a certain number of cuns. This way it becomes easier to calculate where a point will be from a set location. SET Distances: 1. Axillar Fold to elbow: 9 cun 2. Elbow to wrist: 12 cun 3. Center of sternum to end of clavicle: 8 cun 4. Nipple to nipple: 8 cun 5. Xiphoid process to umbilicus: 8 cun. 6. Umbilicus to symphysis pubis: 5 cun 7. Greater trochanter to Center of patella: 19 cun 8. Center of patella to Lateral maleolus: 16 cun. 29

30 Lung Meridian Points The lung meridian is a yin meridian and is paired with the large intestine yang meridian. The lung meridian governs the lungs and breathing. On the inhale, the lungs take air from the universe and turn it into energy in the body and on the exhale they expel waste from the body. The lungs are very sensitive to emotional feelings and turmoil. When people are experiencing excessive sadness and grief, this can lead to imbalances and illness in the lungs. The lungs are also sensitive to changes in the environment such wind, dampness and coldness. There is very little protection between the air we breathe and our lungs leaving them susceptible to imbalances in the lungs and the lung meridian when conditions are extreme. The lung channel originates from the lateral aspect of the chest near the arm pit. It then travels along the anterior-medial aspect of the upper arm, passing the cubital region and arrives at the radial side of the wrist containing the radial artery for pulse palpation. Passing the thenar eminence, it travels along the radial border of the palm ending at the medial side of the tip of the thumb. Important lung meridian points- LU-1 Central Treasury Use: This is an alarm point and is usually tender and sensitive when respiratory problems are present. Location: 6 cun lateral to anterior midline level with the 1st intercostal space, 1 cun below LU 2. Caution: needle oblique to avoid lungs. LU-2 Cloud Gate Use: Regulates Lung, disperses lung heat, good for asthma. Location: 6 cun lateral to the anterior midline below the clavicle in the depression medial to the coracoid process. needle oblique to avoid lungs. 29

31 LU-5 Cubit Marsh Use: This is a sedative point used for a calming affect and to cool excess energy. Location: On the cubital crease, in the depression lateral to biceps brachii tendon. LU-7 Broken Sequence Use: This point is a powerful lung point and opens the surface of the body and can be used to get rid of excess cold and wind. It also connects to the large intestine. Location: 1.5 cun above the transverse crease of the wrist, superior to the styloid process of the radius. LU-8 Channel Ditch Use: Disperses Heat in lung, good for throat, stops cough. Location: 1 cun above the transverse crease of the wrist in the hollow on the lateral side of the radial artery. LU-9 Great Abyss Use: This is an influential point for the vessels and one of the 8 influential points in the body. This point is a confluence for the lungs and the large intestine making it possible for both channels to be stimulated here. Location: On transverse crease of the wrist on the lateral side of the radial artery. LU11 Lesser Merchant Use: This point can be good for removing excess energy and can have a calming affect. This is a TING POINT, which are usually only used in emergencies such as fainting or more sever acute problems because they are painful areas to needle. Location: 0.1 cun posterior to the nail on the radial side of the nail. 30

32 Large Intestine Meridian Points The large intestine meridian is a yang meridian and is paired with the lung yin meridian. The main function of the large intestine and its meridian is to process waste and pass it through the body. When there are blockages in the large intestine meridian, they often manifest as digestion and abdominal trouble because these processes are closely tied together. The large intestine channel starts from the tip of the index finger. Running upward along the radical aspect of the index finger, it passes through the inter-space of the first and second metacarpal bones, and ascends along the lateral anterior aspect of the upper arm to the highest point of the shoulder. It then travels along the anterior border of the acromion, then descends to the supraclavicular fossa. From the supraclavicular fossa it travels upward to the neck and to the cheek, then it curves around the upper lip and exits at the corner of the mouth, where it crosses the opposite large intestine channel at the philtrum. it ends at the side of the nose, where is connects with the stomach channel. LI-1 Shangyang: Useful for heat, pain, stagnation, especially at the opposite end of the channel, for eye and ear pain and inflammation, toothache. 0.1 cun posterior to the corner of the nail on the radial side of the index finger. TING POINT LI-4 Union Valley- This is one of the most used points in acupuncture and it is a very important analgesic point. This point is often used in treating pain and can be used to treat pain in all parts of the body, specially the head. It also promotes the flow of energy in the upper body and is good for treating coldness and dampness in the head and lungs. Location 4 cun inferior to the anterior axillary fold, 1 cun inferior to LU3 on radial side of biceps brachii muscle. MASTER POINT 31

33 LI-11 Pool at the Bend- This is a very important point in enhancing the immune system and is frequently used to treat colds and infections. Location 0.1 cun posterior to the nail on the radial side of the nail. MASTER POINT. LI-15 Jianyu. Use : rotator cuff injuries, adhesive capsulitis, frozen shoulder, any ROM issues. Location: Anterior and inferior to the acromion, on the upper portion of the deltoid muscle, in a depression formed when the arm is in full abduction. 32

34 Stomach Meridian Points The stomach meridian is a yang meridian and paired with the spleen yin meridian. Both meridians are earth elements and work together to process nutrients and feed the body. Unbalances in the stomach meridian can manifest as problems such upset stomach, excessive hunger, or poor appetite. The stomach channel starts directly below the pupil between the eyeball and the infraorbital ridge. Running downward along the lateral side of the nose, to the lateral corner of the mouth. Curving posterior to the anterior angle of the mandible. Then it travels to the posterior aspect of the mandible ascending in front of the ear and following the anterior hairline, it reaches the forehead. It then runs along the throat and enters the supraclavicular fossa. The straight line of the channels separates the supraclavicular fossa and runs downward along the middle mammillary line. It travels to the side of the umbilicus and descends to the inguinal groove. Running downward it travels along the anterior aspect of the thigh and reaches the knee. From there is continues further down along the anterior border of the lateral aspect of the tibia to the dorsum of the foot and reaches the lateral side of the tip of the second toe. Important Stomach Meridian points ST1 thru ST8 - Use: These points are all on the face and head and are often used for the many disorders in the head and face area such as toothaches, headaches, eye disorders and sinus problems. Location: Face and Head. ST-1-Tear Container Use: As a Replacement for Bl-1 in Tendinomuscular meridians. Eye problems. Directly below the pupil between the eyeball and the infraorbital ridge. ST-21 Beam Gate - Use: Location: 2 cun lateral to the midline lateral to CV12, 4 cun above the umbilicus. ST-25 Celestial Pivot - Use: Location: 2 cun lateral to the midline lateral to CV8 at the level of the umbilicus. ST-30 Surging Qi Use: Location: 2 cun lateral to the midline lateral to CV2, level with symphysis pubis. 33

35 ST-36 - Zusanli Leg Three Li: Use: This is a very powerful and frequently used acupuncture point that is helpful for a number of imbalances in the abdominal region as well as strengthening the blood and the energy in the stomach meridian, tonifies Qi and blood, psychological and emotional disorders. Location: 3 cun below ST35 one finger width lateral from the anterior crest of the tibia, in the tibialis anterior muscle. COMMAND POINT. Strongest point in the body. ST-40 Bountiful Bulge - Use: this point is often used to dissipate excessive heat and dampness from the stomach meridian and helps clear unfocused thinking and many abdominal disorders. Location: 8 cun superior to the tip of the external malleous, one finger width lateral to ST38. ST-44 Inner Court - Use: This is a very important and wellused general analgesic point used for toothaches, headaches, as well as discomforts in the abdominal region. Location: At the proximal end of the web between the 2nd and 3rd toes in the depression distal and lateral to the 2nd metatarsodigital joint. ST-45 Severe Mouth - TING POINT. Use: Release heat a/or move stagnation from the channel and organ - headaches, toothaches, facial pain, TMJ, breast pain. Agitation and insomnia with heat signs - calms the spirit. Location: 0.1 cun posterior to the corner of nail on the lateral side of the 2nd toe. 34

36 Spleen Meridian Points The spleen meridian is a yin meridian and is paired with the stomach yang meridian. The spleen meridian is an earth element and has strong nurturing qualities. Being paired to the stomach meridian and having nourishment qualities, imbalances in this meridian can manifest as digestive and stomach problems. The stomach channel starts directly below the pupil between the eyeball and the infraorbital ridge. Running downward along the lateral side of the nose, to the lateral corner of the mouth. Curving posterior to the anterior angle of the mandible. Then it travels to the posterior aspect of the mandible ascending in front of the ear and following the anterior hairline, it reaches the forehead. It then runs along the throat and enters the supraclavicular fossa. The straight line of the channels separates the supraclavicular fossa and runs downward along the middle mammillary line. It travels to the side of the umbilicus and descends to the inguinal groove. Running downward it travels along the anterior aspect of the thigh and reaches the knee. From there is continues further down along the anterior border of the lateral aspect of the tibia to the dorsum of the foot and reaches the lateral side of the tip of the second toe. Important Spleen Meridian points SP-1 Hidden White - Use: Local Point and Tendinomuscular meridian. Location: 0.1 cun posterior to the corner of the nail, on the medial side of the great toe. TING POINT SP-4 Yellow Emperor- Use: This point passes to the stomach meridian and is used to treat a number of imbalances associated with the digestive system. It also dispenses excess heat and dampness in the spleen meridian. Location: In a depression distal and inferior to the 1st metatarsal bone at the junction of the red and white skin. SP-6 Three Yin Crossing- Use: This point is where the 3 yin meridians in the ankles (spleen, kidney, liver) cross. This point is used in many acupuncture treatments for disorders in all 3 of the meridians that cross here. Location: 3 cun directly above the tip of the medial malleolus on the posterior border of the tibia. Contraindicated to needle during pregnancy. 35

37 SP-9 Yin Mound Spring- Use: This point is used to clear dampness in the spleen meridian and also for knee problems such as inflammation and pain. Location: On the lower border of the medial condyle of the tibia, in the depression between the posterior border of the tibia and gastrocnemius muscle. SP-10 Sea of Blood- Use: This is an important immune strengthening point and is used for a variety of disorders such as blood infections, allergies and skin infections. Location: With the knee in flexion, 2 cun superior to the superior border of the patella, on the budge of the medial portion of the quadriceps femoris muscle. SP-21 Great Embracement-Use: Great Luo of the Spleen. Mentioned classically that when this point is deficient, all the joints are flaccid, and when excess, pain all over the body.pain of the thoracic region. Location: On the midaxillary line, 6 cun inferior to the anterior axillary crease. Midway between the axilla and the free end of the eleventh rib. 36

38 Heart Meridian The heart meridian is a yin meridian and is paired with the small intestine yang meridian. The heart s physical job is to move blood, pumping and moving blood non-stop with every heartbeat. The heart has to be physically very strong and powerful because it has a constant job to keep pumping blood throughout the entire life of a person. The mental and spiritual qualities of the heart are very powerful. A person with a healthy heart is a happy and grateful person and a person with a weak heart often leads a miserable life. In today's modern societies, many people suffer from imbalances of the heart due to living lifestyles that are not in our hearts just to "pay the bills". Modern society can also be very lonely for many people, which can also lead to a weak heart. The heart channel starts in the center of axilla. From there is goes along the posterior border of the medial aspect of the upper arm. Passing through the cubital region, it descends to the pisiform region proximal to the palm and enters the palm. Then it ends at the medial aspect of the tip of the little finger. Important Heart meridian points- HT-1 Highest Spring. Uses: Regulate Qi flow from the torso to the arm and vice versa - cold, numbness, pain in shoulder a/or arm, Frozen shoulder, Pain a/or distention of the upper thoracic area.location: Center of axilla on the medial side of the axillary artery. Avoid axillary artery! HT-3 Lesser Sea. Uses: Pain, numbness, tremors, etc. of the lower arms a/or hands - Parkinson's, stroke. Spirit disorders as - epilepsy, depression, anxiety, nervousness, poor memory, fuzzy thinking, redness of the eyes, mouth ulcerations. Location: With elbow flexed, at the medial end of the transverse cubital crease. MASTER POINT 37

39 HT-7 Spirit Gate This point can be very effective in treating many emotional and mental disorders such as addiction, anxiety, sleeplessness and depression. On the ulnar end of the transversecrease of the wrist, in the small depression between the pisiform and ulna bones. MASTER POINT HT-9 Lesser Surge This is a TING POINT and is usually only used in emergencies such as fainting or other extreme disorders caused by excessive heat. 0.1 cun posterior to the corner of the nail on the radial side of the little finger. 38

40 Small Intestine Meridian The small intestine is a yang meridian and is paired with the heart yin meridian. The main job of the small intestine is to process the nutrients out of food for use by the body. Imbalances in the small intestine meridian can lead to problems such as digestion troubles, abdominal pain and also appetite problems such as over eating or poor appetite. The small intestine channel starts at the ulnar aspect of the tip of the little finger, and travels along the ulnar border of the hand dorsum upward to the posterior border of the lateral aspect of the upper arm. It passes through the cubital region curving around the scapular region. Then turning downward to the supraclavicular fossa and ascends to the neck. Travels up to the cheek going through the outer canthus of the eye, and ends anterior to the tragus of the ear. Important Small Intestine meridian points SI-1 Lesser Marsh Uses: clear heat from the opposite end of the channel, for eye redness, earache, tinnitus, sore throat, stiff tongue. Location: 0.1 cun posterior to the corner of the nail on the ulnar side of the little finger. TING POINT SI-3 Back Ravine Uses: This point is used frequently to clear wind and dampness. It is also used to help relieve tension in the neck area. Pain in the scapula, arm a/or hand combine with local points. Stiff neck, cervical strain/sprain, pain of the back or neck.occipital headaches, Night sweats, Clears heat and excess from the ears and eyes, eye redness, inflammation, visual dizziness, earache, tinnitus. Calms the spirit. Location: When a loose fist is made, at the ulnar end of the distal palmar crease proximal to the 5th metacarpal phalangeal joint at the junction of the red & white skin. MASTER POINT 39

41 SI-6 Nursing the Aged Use: This point is used to help clear tension from the neck and shoulder area. Location: Dorsal to the head of the ulna in the body cleft on the radial side of the styloid process, found with the palm facing the chest. SI-9 True Shoulder Use: this point is used frequently to relieve shoulder problems such as stiffness and aches in the shoulder joint. Location: 1 cun above the posterior end of the axillary fold, posterior and inferior to the shoulder joint, found with the arm adducted. SI-10 Upper Arm Shu SI-11 Celestial Gathering SI-12 Grasping the Wind SI-13 Crooked Wall SI-14 Outer Shoulder Shu SI-15 Central Shoulder Shu These Points are useful as LOCAL POINTS ONLY FOR SHOULDER PAIN. SI-18 Cheek Bone Hole Use: this point is used often to clear wind from the facial area and treat problems such as toothaches, frontal headaches and sinus problems. Location: Directly below the outer canthus of the eye in a depression on the lower border of the zygoma. 40

42 Urinary Bladder Meridian Points The urinary bladder meridian is a yang channel and is paired kidney yin channel. The element is water and the urinary bladder system controls the storage and excrement of urine from the body. The urinary bladder meridian is the largest meridian in the body. The Shu points have strong connections to the corresponding organs and can be used to treat certain conditions in the organs. The urinary bladder channel of the Foot-Taiyang originates from the inner canthus of the eye. Passing through the forehead, it flows up to the vertex. It bifurcates above the posterior hairline into two lines. One line runs from the posterior aspect of the neck downward along the medial border of the scapula (3 cun lateral to the back mid-line). Passing through the gluteal region. Another line runs straight downward (1.5 cun lateral to the mid-line of the back) to the lumbar region. From there it descends along the posterior aspect of the thigh to the popliteal fossa. Descending to the posterior aspect of the gastrocnemius muscle and further to the posterior inferior aspect of the lateral malleolus. Ending at lateral posterior side of the tip of the little toe. Important Urinary Bladder meridian points- BL-1- Bright Eyes - Use: Main point for all eye disorders especially from wind (internal or external), excess, heat. Eye pain, strain, redness, swelling, itching, twitching, blurry vision, etc. Location: In a depression,.1 cun above the inner canthus of the eye. BL-2- Bamboo Gathering Use: Can be used to relieve pain and pressure from the sinuses and the front of the head. Also for red eyes. Location: On the medial end of the eyebrow, directly above the inner canthus of the eye (on the supraorbital notch). BL-10 - Celestial Pillar Use: This point is frequently used to clear wind and can be used to treat migraines and neck aches. Neck issues, stiffness, occipital headache. Location: 1.3 cun lateral 41

43 to GV15 and 0.5 cun above the posterior hairline, in a depression on the lateral aspect of the trapezius muscle. BL-11 - Great Shuttle Use: Has a variety of uses such as treating asthma, cough, occipital headaches and joint disorders. Special Point for bones ( HUI Point ) Location: 1.5 cun lateral to GV13 level with the spinous process of T1. (from the midline to the medial border of the scapula is considered 3 cun). BL-13 - Lung Shu Use: is a Shu point of the lung and can be used to treat asthma, cough and various other lung illnesses. Location: 1.5 cun lateral to GV12 level with the spinous process of T3. BL-14 Pericardium Shu - Use: For all heart conditions: palpitations, anxiety, stress, etc. Location: 1.5 cun lateral to midline level with the spinous process of T4. BL Heart Shu Use: is a Shu point of the heart and can be used to treat heart diseases and mental imbalances such as anxiety and depression. Main point for all heart, blood and circulatory related issues of an excess or deficient nature. Main point for all heart related emotional issues: palpitations, anxiety, stress, poor memory and insomnia. Location: 1.5 cun lateral to GV11 level with the spinous process of T5. BL-18 - Liver Shu Use: Main point for all Liver related conditions: hepatitis, jaundice, cirrhosis, Blood stagnation, Qi stagnation, etc. Main point for eye problems, pain, itching, dryness, redness, blurred vision, visual dizziness, twitching. anger, depression, irritability, frustration, stress a/or PMS. Location: 1.5 cun lateral to GV 8 level with the spinous process of T9. BL-19 - Gall Bladder Shu - Use: is a Shu point of the gall bladder and can be used to relieve excess heat and dampness from the gall bladder and treat fever, chills and nausea, hepatitis, cholecystitis, jaundice, vomiting, flank pain and distension, bitter taste in the mouth. Pain along the GB meridian (sides of the body) from any etiology, intercostal neuralgia, rib pain, trauma, herpes zoster, indecision, timidity. Location: 1.5 cun lateral to GV 7, level with T10. BL-20 - Spleen Shu Use: is a Shu point of the spleen and can be used to strengthen the spleen and stomach, nourishes the blood, and is beneficial for many stomach disorders. low energy, fatigue, prolapses, damp related conditions a/or bleeding disorders. Also for fatigue, lack of appetite, abdominal bloating a/or distention, undigested food in the stools, chronic diarrhea a/or belching. Location: 1.5 cun lateral to GV 6, level with T11. 42

44 BL-21 - Stomach Shu Use: is a Shu point of the stomach and can be used to treat a wide variety of stomach disorders such as digestion problems and gas, food stagnation, abdominal distention, borborygmus, mouth ulcers, vomiting, belching, nausea, etc. Location: 1.5 cun lateral to GV line, level with T12. BL-23 - Kidney Shu Use: is a Shu point of the kidney and can be very beneficial for urogenital disorders. For all Kidney related issues which effect the brain, bone, hair, teeth a/or hearing. Male deficiency related sexual problems: impotence, premature ejaculation, sterility, exhaustion following ejaculation. Female sexual and reproductive disorders: dysmenorrhea, amenorrhea, cold uterus, frigidity, infertility, leukorrhea. Tonification point in deficiency conditions: exhaustion, weakness and chronic fatique. Main point for acute or chronic low back pain, sprains or strains. Useful for Kidney related ear issues: tinnitus, deafness, chronic ear infections. Location: 1.5 cun lateral to GV 4, level with L2. BL-25 - Large Intestine Shu Use: is a Shu point of the large intestine and can be used to treat disorders in the large intestine such as diarrhea and constipation also menstruation. Location: 1.5 cun lateral to GV 3, level with L4. BL-27 - Small Intestine Shu Use: is a Shu point of the small intestine and can be used to treat intestinal disorders and is a beneficial point for sciatica. Main point for all Small Intestine related issues: damp heat effecting the bladder (difficult or painful urination, hematuria, dark urine), damp heat effecting the intestines (diarrhea, dysentery). Location: 1.5 cun lateral to midline level with the first posterior sacral foramen. BL-28 - Bladder Shu Use: is a Shu point of the bladder and can be used to treat urogenital disorders, lower back pain and sciatica. Main point for all Bladder issues: from damp heat (painful a/or dark urination), from cold (frequent urination, incontinence). For dampness anywhere in the body, 43

45 combine with SP 9 to expel dampness through urination. Location: 1.5 cun lateral to midline level with the second posterior sacral foramen. BL-40 - Bend Middle Use: As the Lumbar Command Point, useful for all lumbar related issues: acute low back pain, sprain, muscle spasms, etc. Main point for heat conditions such as summer heat, heatstroke and heat exhaustion. Good local point for leg or knee pain. Location: Midpoint of the transverse crease of the popliteal fossa, between the tendons of biceps femoris and semitendinosis. BL-60 - Kun Lun Mountains - Use: Main point for pain anywhere along the spine. Main point for chronic low back pain a/or problems of pain a/or numbness in the lower limbs.main point for headache and other excesses effecting the head. Induce labor or promote discharge of a retained placenta. Location: In a depression between the tip of the external malleolus and the achilles tendon. BL-62 - Extending Vessel Use: this point is frequently used to help with mental imbalances and sleep disorders. With SI 3 for low back pain, difficulty walking, spinal problems as well as wind-cold effecting the taiyang channels: stiff neck a/or shoulders, occipital headache, etc. Insomnia, nervousness.location: In a depression directly below the external malleolus. BL-67 - Reaching Yin Use: Clears pain a/or stagnation from the opposite end of the channel: headache, eye pain, sinus pain, etc. Use with moxa to adjust breech fetal position (generally indirect moxa for minutes 1x/day). Location: 0.1 cun posterior to the corner of the nail on the lateral side of the little toe. TING POINT. 44

46 Kidney Meridian Points The kidney meridian is a yin meridian and is paired with the urinary bladder yang meridian. It is a water element and is very important in maintaining and processing your body s fluids. One of the important functions the kidneys provide is to filter toxins out of the blood supply. Many illnesses, especially in the lungs, can be traced back to weak kidney energy and functions. The kidney channel starts from the interior aspect of the little toe (On the sole of the foot, depending on the text.), and runs through a depression in the lower aspect of the tuberosity of the navicular bone. It travels behind the medial malleolus and encircles the malleolus. Ascending along the medial side of the leg, it passes the medial side of the popliteal fossa and goes further upward along the posterior-medial aspect of the thigh. Traveling to the superior border of the symphysis pubis forming a straight line 0.5 cun from the midline. It ascends diverging at the diaphragm, ending In a depression on lower border of clavicle 2 cun from the midline. Important Kidney Meridian points KI-1 Gushing Spring Use: descends rising LR fire and excess LR Yang, headaches, tinnitus, cools empty heat from KI Yin Deficiency, chronic sore throat, tonify Kidney Yin, insomnia, palpitations, rage, loss of consciousness. Location: On the sole of the foot, in a depression when the foot is in plantar flexion at the junction of the anterior 1/3 and posterior 2/3 of line connecting base of 2nd and 3rd toes and the heel. TING POINT. *A point called KI-1 is described to exist on the medial aspect of the distal phalanx of the 5 th toe at 0.1 inch from the toe nail and is used more frequently clinically. 45

47 KI-3 Great Ravine Use: This is a helpful point for many urogenital disorders and helps strengthen and balance the energy in the kidney meridian. Location: In depression midway between the tip of the medial malleolus and the attachment of the achilles tendon, level with the tip of the medial malleolus KI-7 Recover Flown Use: this point is helpful to strengthen the yang energy in the kidney meridian and is helpful for treating lower back pain and bladder problems. Location: 2 cun above KI3 on the anterior border of the achilles tendon. KI-10 Yin Valley - Use: clear damp-heat in the lower warmer, urgent/difficult urination, genital pain/itching, uterine bleeding. Location: at the medial side of the popliteal fossa when the knee is flexed, between the tendons of semitendinosus and semimembranosus muscles level with BL54. KI-27 Shu Mansion Use: open and relax the chest, asthma, constricted breathing, cough, tonify KI deficiency in adrenal exhaustion, fatigue, lowered immunity, local for neck a/or jaw pain. Location: In depression on lower border of clavicle, 2 cun lateral to the midline. 46

48 Pericardium or Master of the Heart Meridian The pericardium is a yin meridian a paired with the triple heater yang meridian. The main job of the pericardium meridian is to work with the heart and control excessive energy in the heart. Imbalances in the pericardium meridian can often times lead to cardiac and blood circulation problems. The pericardium channel originates in the chest lateral to the nipple. It then ascends to the axillary fossa and runs along the medial aspect of the upper arm, passing through the cubital fossa. It goes further downward to the forearm between the tendons of the m. palmaris longus and m. flexor carpi radialis. It enters the palm and passes along the middle finger to its tip. Important Pericardium meridian points- PC-1 Celestial Pool Use: Window of the Sky Point, fullness of the chest, headache, axillary sweating, blurred vision. Breast disorders, insufficient lactation. Location: 1 cun lateral to the nipple in the 4th ICS. PC-6 Inner Pass Use: is a helpful point in treating excessive heat in the upper abdominal region such as heartburn and ulcers. Opens and relaxes the chest, chest tightness, asthma, angina, palpitations. Insomnia and other spirit disorders of an excess or deficient nature, mania, nervousness, stress, poor memory. Nausea, seasickness, motion sickness, vomiting, epigastric pain. Carpal Tunnel Syndrome. Location: 2 cun above the wrist crease between the tendons of palmaris longus and flexor carpi radialis. MASTER POINT PC-7 Great Mound Use: this is a sedative point and is frequently used to treat mental conditions such as insomnia, schizophrenia and bi-polar conditions. Cooling heat that is effecting the Heart of a deficient or excess nature. Clears Ying and Blood heat, fever deep in the body that is drying up fluids. 47

49 Carpal Tunnel Syndrome. Sweat issues (too much or too little), hot flashes.. Location: In the middle of the wrist crease between the tendons of palmaris longus and flexor carpi radialis. PC-9 Central Hub- Use: Clearing heat in the Heart. Stiff tongue, speech disorders, especially those arising after a stroke. Restoring consciousness. Location: In the center of the tip of the middle finger ( some locate it 0.1 cun posterior to the corner of the nail on the carpal side of the middle finger). TING POINT. 48

50 Triple Heater or San Jiao Meridian The triple heater meridian is a yang meridian and is paired with the pericardium yin meridian. The triple heater meridian gets its name from having 3 heating sections. The upper section is in the head and neck area, the middle section is in the chest area and the bottom section is in the navel area. The job of the Triple Heater Meridian is to regulate the flow of energy in these three regions. The triple heater channel originates from the tip of the ring finger. It travels upward between the fourth and fifth metacarpal bones and along the dorsal side of the wrist and the lateral side of the forearm between the radius and ulna, it passes through the olecranon. Then it runs along the lateral aspect of the upper arm and reaches the shoulder region. Crossing over the shoulder, it enters the supraclavicular fossa. It then ascends to the neck, running along the posterior border of the ear. It crosses from the superior aspect of the ear to the corner of the forehead. Then it turns downward to the cheek and terminates In the depression at the lateral end of the eyebrow. Important Triple Heater Meridian points- TH-1 Passage Hub- Uses: Entry Point. Use similar to TH-3. Location: 0.1 cun posterior to the corner of the nail on the ulnar side of the ring finger. TING POINT. TH-3 Central Islet Uses: This point is frequently used for disorders in the ears such as tinnitus and deafness especially those arising from a Liver issue such as Qi Stagnation or Liver Yin Deficiency. Distal point for temporal headaches, shoulder a/or upper back pain, pain a/or inflammation in the throat. Location: With fist clenched on dorsum of the hand between the 4th and 5th metacarpal bones in a depression proximal to the 4th Metacarpalphalangeal joint. 49

51 TH-5 Outer Pass Uses: this is a very important point for many general imbalances such as migraines, common colds, fevers and arthritis, stiffness or pain in the posterior and lateral aspects of the neck. Location: 2 cun above TH 4 between the radius and the ulna on the TH 4 - TH 10 line. MASTER POINT. TH-8 Three Yang Connection Uses: this is an important point for treating various types of chest pain, sudden deafness, acute or chronic loss of voice, aphasia. Location: 4 cun above TH 4 between the radius and ulna. TH-14 Shoulder Bone Hole Use: this is an important point that can be used to help shoulder problems and pain. Location: On shoulder, posterior to LI 15, in a depression inferior and posterior to the acromion when arm is abducted. TH-17 Wind Screen Use: this point is frequently used to treat ear conditions such as aches, infections and ringing. Location: Posterior to lobule of ear in depression between the mandible and mastoid process. TH-23 Silk Bamboo Hole Use: Eye pain, redness, swelling, twitching, drooping eyelid. Liver Wind or Liver Fire headache, combine with local points. Location: In a depression at the lateral end of the eyebrow. 50

52 Gall Bladder Meridian Points The gall bladder meridian is a yang meridian and is paired with the liver yin meridian. The gall bladder helps digest food and stores bile produced by the liver. The gall bladders element is wood, the color is green and the sense organ is the eye. The gall bladder channel starts from the outer canthus of the eye, and desends to the anterior aspect of the ear. Then ascends to the corner of the forehead, and then winds downward posterior to th ear. Then arches forward to the forehead at the midpoint of the eyebrow. It then runs above the hairline to the lateral side of the neck. Travels highest point of the trapezius muscle. From there it further descends to the axilla and enters the chest. It then travels interiorly in the hypochondriac region, emerging at the lateral side of the lower abdomen near the femoral artery in the inguinal region. Then it curves along the margin of the public hair and runs transversely into the hip region. It then travels downward along the lateral side of thigh to the lateral side of the knee. Further descending along the anterior aspect of the fibula, it reaches the lower end of the fibula, and the anterior aspect of the lateral malleolus. Following the dorsum of the foot, it terminates at the lateral side of the fourth toe's tip. Important Gall Bladder meridian points- GB-1 Pupil Bone Hole Use: this is a useful point for treating frontal headaches and eye disorders. Location: 0.5 cun lateral to the outer canthus of the eye in a depression on the lateral side of the orbit. GB-2 Auditory Convergence Use: this point is used frequently to treat ear problems and dizziness. Location: Anterior to the intertragic notch at the posterior border of the condyloid process of the mandible with the mouth open. GB-13 Use: Collecting Point for tendinomuscular meridians Yang arm. Location: 0.5 cun within the hairline on the forehead, 3 cun lateral to GV4. Midway between ST8 and BL4. 51

53 GB-14 Yang White Use: this is a very important point for treating eye disorders and headaches. Location: On the forehead directly above the pupil, 1 cun above the midpoint of the eyebrow. GB-20 Wind Pool Use: this point can help eliminate wind and cold and treat disorders such as common cold, dizziness and eye problems. Location: In the depression created between the origins of the Sternocleidomastoid and Trapezius muscles, at the junction of the occipital and nuchal regions. Lateral and level with GV16. GB-21 Shoulder Well Use: this point can be used to treat shoulder pain, occipital headaches and imbalances in the chest such as asthma. Location: Midway between the spinous process of C7 (GV14) and the acromion process at the highest point of the trapezius muscle. GB-24 Sun and Moon Use: this point can be used to treat certain upper abdominal symptoms such as vomiting, heartburn and acid reflux. Location: Directly below the nipple in the 7th intercostal space, inferior to LV14. GB-25 Capital Gate Use: this point can be used to dispel dampness from the kidney meridian and is useful for treating symptoms such as diarrhea and urinary retention. Location: On the lateral side of the abdomen, at the lower border of the free end of the 12th rib. GB-30 Jumping Round Use: this point can be used to help treat lower back pain and pain in the legs. Location: At the junction of the lateral 1/3 and medial 2/3 of the distance between the greater trocanter and the hiatus of the sacrum (GV2) GB-34 Yang Mound Spring Use: is a very important point in treating liver and mental disorders and is a useful point for pain in the joints and tendons. Location: In a depression anterior and inferior to the head of the fibula. 52

54 GB-39 Suspended Bell Use: this point is frequently used to nourish the kidney yin, and the marrow in blood disorders. Location: 3 cun above the tip of the lateral malleous in a depression between the posterior border of the fibula and the tendons of peroneous longus and brevis muscles. GB-40 Hill Ruins Use: this point can be useful in treating disorders and pain in the ankle joints. Location: Anterior and inferior to the lateral malleous in a depression on the lateral side of the extensor digitorum longus tendon. GB-41 Foot Overlooking Tears Use: this point is sometimes used to treat headaches, migraines and disorders in the ears. Location: On the dorsum of the foot, in the depression between the fourth and fifth metatarsal bones. GB-44 Use: insomnia w/nightmares, LR/GB heat, fullness below the heart, sense organ issues, pain, inflammation, speech disorders, stiff tongue. Location: 0.1 cun posterior to the corner of the nail on the lateral side of the fourth toe. TING POINT. 53

55 Liver Meridian Points The liver meridian is a yin meridian and is paired with the gall bladder yang meridian. The main job of the liver meridian is to keep the energy in the entire body regulated. When there are deficiencies in the liver meridian, it can lead to depression and sluggishness. Over abundance of energy in the liver meridian can lead to anger, shouting and conflicts. The liver channel originates on the lateral side of the great toe. Ascending along the dorsum of the foot, it flows further upward to the anterior aspect of the medial malleolus. Then it runs upward to the medial side of the knee and along the medial aspect of the thigh into the pubic region. From there it curves around the external genitalia and crosses the midline up to the lower abdomen. Ending directly below the nipple. Important Liver meridian points- LR-1 Large Pile Use: revival; moves Qi in genital region; menstrual bleeding from excess or deficiency; LR Qi stagnation; emotional imbalances. Location: On the lateral side of the great toe, 0.1 cun from the corner of the nail. TING POINT. LR-3 Great Surge Use: this is a very important point for the liver and gall bladder meridian. It is used to dissipate wind and treat a number of things such as headaches, hypertension and mental disorders. Location: On dorsum of the foot in a depression distal to the junction of the 1st and 2nd metatarsal bones. 54

56 LR-8 Spring at the Bend Use: this point can be used to strengthen the blood, expel excess heat and treat ailments such as knee pain and mental disturbances. Location: When the knee is flexed, the point is found above the medial end of the transverse popliteal crease, posterior to the medial epicondyle of the tibia in a depression on the anterior border of the insertions of the semimembraneous and semitendoneous muscles. LR-13 Item Gate Use: this point can be used to treat digestion disorders such as vomiting, constipation and diarrhea. Location: On the lateral side of the abdomen below the free end of the 11th rib. LR-14 Cycle Gate Use: this point can be used for many imbalances in the chest area such as cough, chest pain and emotional problems like anger and irritability. Location: Directly below the nipple, 4 cun lateral to the midline in the 6th intercostal groove. 55