7. THERAPY IN TCM
All methods aim to correct imbalances of Qi. Where the cause is bad lifestyle (XS eating; XS work; insufficient food or sleep; XS alcohol etc) steps are taken to advise on moderating this. As far as possible, the patient is advised on environmental, behaviourial or dietary changes etc which may be necessary to alleviate or remove the cause. To restore the normal balance of Qi (resistance), many methods are used alone or in combination.
TCM relies heavily on herbal medicine (HM). The Chinese herbal pharmacopoeia is very extensive, running into thousands of plants, herbs, venoms, inorganic compounds, animal by-products etc. These remedies are prepared as decoctions, concoctions, powders, ointments etc and a typical prescription would contain 4-10+ separate components. Many of the crude extracts have been purified in recent years and the active alkaloids or other compounds have been isolated. Several HMs, or extracts of them, have potent antitoxic effects in patients on cytotoxic radiotherapy or chemotherapy (cisplatin etc) for cancer. Herbal products and HM extracts have many high-ranking pharmacological properties, including immunomodulators, hypoglycaemic, anticancer, antiinflammatory, antiviral, antibacterial, antiprotozoal, antiasthmatic, antioxidant, antihypertensive and anti-liver disease activities.
Other methods include physiotherapy (exercises; massage; moxibustion (cautery of the AP points); Taichi (ritual slow movements to utilise every muscle of the body in conjunction with breathing exercises) and psychotherapy (Qi Kung (visualisation-meditation of the energy flow through the Channel circuits, together with specific slow deep breathing exercises, inhalation for centripetal Channels and exhalation for centrifugal Channels); mental/emotional exercises to balance the emotions).
AP is only a small part (maybe 20%) of the total TCM system.
8. AP METHODS
For proper use, AP, moxibustion and Chinese massage (acupressure) depend on a detailed knowledge of the point and Channel system. Having selected the points most suitable for the patient, these points are stimulated by many different methods, depending on the training and preferences of the practitioner and the equipment available. The most common type of AP uses fine stainless steel, solid, needles 1-6 cm long and 25-32 gauge. The most common needle is about 3.5 cm long, 30 gauge, but others (including some barbaric-looking instruments) are occasionally used in remote, rural areas. In veterinary AP, the needles vary with the species. For experimental work in small animals and laboratory animals, the finest human-type needles may be used. For clinical work in the dog-cats, one usually uses 1-6 cm, 28-30 gauge needles. In larger animals (pigs, ruminants, horses, mules etc), larger and thicker needles are used (2.5-15 cm needles 18-28 gauge, depending on the preferences of the practitioner and the depth of the points).
The skin around the point is prepared as aseptically as possible. Sterile needles are inserted to the correct depth and are stimulated (by twirling and pecking) to obtain DeQi. This phenomenon ("the arrival of Qi") is regarded as crucial to AP success. It is similar to the "funny bone sensation": paraesthesia, tingling, numbness, heaviness, "sour feeling" etc in the vicinity of the point.
In humans, the objective and subjective sensations are unmistakable - the verbal feedback from the patient ensures this. It is not uncommon for human patients to invoke the name of the founder of the Christian religion when Qi arrives! In animals, however (because they cannot relate their subjective feelings), the main signs of DeQi are: sudden change in the animal's behaviour: a temporarily fractious animal suddenly standing quite motionless or a quiet animal suddenly beginning to tremble or vocalise. Respiration may be temporarily inhibited or accelerated. Local muscle spasms or twitches may be seen.
DeQi is more often obvious when the point is directly over a peripheral nerve (such as with the Great Points of AP, for instance: LI04; PC06; TH05; LI11; ST36; GB34; BL40 etc or directly over motor points (places where the motor nerve plunges into the muscle).
Once DeQi is obtained, the needle is left for 30 seconds to 20 minutes. In general, acute conditions require only short periods of needling and chronic conditions require 20 minutes or more. Before removal of the needle, it is twirled/pecked again.
Classical AP demands specific types of needle manipulation depending on whether the condition is diagnosed as a Shi (Excess) or Xu (Deficiency) type. These specific Syndromes of manipulation are described in standard texts but the issue is controversial in that many successful practitioners ignore them still obtain excellent results - the use the simple method described above.
The most comprehensive textbook on techniques of AP is "Current AP Therapy" by Lee and Cheung (1978). This is an excellent text and is recommended as ESSENTIAL reading for serious students.
Apart from simple needling, cautery and massage, other methods are common. They include electro-AP (with or without needles); injection of the points; ultrasound-, microwave-, laser-, cryo-, faradic-, static field-, magnetic field- and other therapies applied to the specific points. They also include implants, incisions direct massage of the exposed nerves etc.
In general, the simple needling technique is adequate for most purposes and expensive pieces of equipment (electro stimulators, lasers etc) are luxuries to impress the public rather than to enhance the results. There are some exceptions to this which will be discussed in other seminars.
The number of sessions and the intervals between sessions vary with the condition. Chronic conditions are normally treated 1-2 times per week for 4-20 sessions. In general, if there is not an obvious response by session 4-6, the chances of ultimate success are poor. Acute (but simple) conditions are treated every 6-48 hours, depending on the condition. For instance, acute traumatic pain could be treated for 20 minutes daily (GB34 on the affected side and 1 or 2 local points). Expect 70% success after 1 session and >90% after 3 sessions. Acute conditions usually require 1 to 5 sessions.
9. METHODS OF CHOOSING EFFECTIVE AP POINTS
Which methods are chosen will depend on the training, skill and experience of the practitioner. Classical AP has more than 14 laws for consideration, apart from the use of the Five Phase balancing method:
a. local points
b. distant points
c. points on affected Channel
d. points on related Channels (Husband-Wife pair of Channels or Channels passing near the affected one)
e. one point on each of the 4 limbs
f. encircling the affected area
g. Ahshi points
h. Mu and Shu points
i. the source point of affected Channel and the Passage (Luo) point of its linked Channel
j. "Fore and Aft" points ((in front of and behind the affected area)
k. a chain of points along the affected Channel
l. points long recognised as highly effective for specific symptoms or body areas (eg) PC06, ST36 for nausea and vomiting; LI04 for mouth, nose and throat
m. Xi (cleft) points.
On top of these, modern AP adds
n. needling points in the affected dermatome or along the innervation of the affected area
o. needling Scalp, Ear, Face, Nose, Hand or Foot Zone points associated with the affected area (e.g.) Scalp zone "Lower Motor Area" for leg paralysis; Hand point "Loin and leg" for lumbago/sciatica etc.
By far the most common prescription is a combination of Ahshi points and local points and distant points on the affected Channel. This may seem to be a simple matter to resolve but a look at any standard chart will show the difficulties. One must limit the number of needles to 6-12 in most sessions. Therefore one must discriminate which local and distant points are most relevant). The textbooks (as individual texts) do not help much either. A careful study of the texts shows that there is major variation between them in their choice of points for specific conditions. One solution to the problem is to construct a database from many textbooks and to use the computer to do a frequency ranking on the points for specific conditions. In this way, the most commonly recommended points for any specific condition can be output in seconds.
COOKBOOK AND MODERN AP
Although Classical AP is also practised in Europe, USA, Soviet countries, Taiwan and Japan most countries, MODERN AP in those countries is a much simplified version. It needs less study of the more difficult classical concepts but it demands competence in western medicine as the foundation for sound diagnosis good clinical success. The following aspects will be discussed:
1. WESTERN CONCEPTS OF REFLEX DIAGNOSIS AND THERAPY
2. COMPUTER DATABASES
3. COOKBOOKS
4. TAIWANESE/JAPANESE APPROACH TO AP
5. COMBINATION OF MODERN AP AND WESTERN MEDICINE
6. THE FUTURE ?
1. WESTERN CONCEPTS OF REFLEX DIAGNOSIS AND THERAPY
The body is a unit. Each organ and part belongs to the whole and can influence the whole. The peripheral, central and autonomic nervous system, together with the endocrine system controls the harmony of the whole.
American, German, Scandinavian, Eastern European and Soviet (as well as Oriental) research in recent years has confirmed the enormous potential measuring deviations in of the autonomic-endocrine system as a diagnostic aid and of stimulating the system to obtain therapeutic results.
Research with infra-red thermography, Voll-Akabane-Ryodoraku measurements of altered sensitivity at peripheral points etc has confirmed the diagnostic claim of TCM: that organs project information of their dis-ease to the periphery via the autonomic nervous system. Clinical detection of the altered sensitivity aids in diagnosis. Any method (including AP) which speeds up the return to normal sensitivity is a good therapeutic method and monitoring the speed of return to normal sensitivity has prognostic value.
2. COMPUTER DATABASES
In every sphere of technology the computer is used to store vast amounts of data. The stored data can then be sorted, searched, analyzed and output (to screen, printer or graphics plotter or screen) as required. Many serious students of AP have observed the variation between texts mentioned in the last section. To overcome the difficulty and to assist in their final selection of points, they have cross-referenced every indication given for every point in as many authoritative sources as possible. This was usually done on a card-index or loose-leaf notebook system. When presented with an unfamiliar problem (say post-CVA aphasia), the practitioner could consult the card or loose-leaf for "Aphasia" and visually assess the most important points by frequency-ranking methods. This procedure can take lO-20 minutes for each condition in a good database. This system worked very well for static databases (i.e.) ones which were not altered by additions or deletions. Every time a new reference goes in or out, the ranking would possibly change. Furthermore, the manual system was rather inflexible, for instance, if a researcher wished to examine the most frequently used points for "head" (using all the conditions coded under "head") it could take hours to get the result.
This is a simple problem for modern computers. Having collected data from >50 textbooks and many clinical articles on AP over the past 10 years, I have stored it on computer. The database has >1170 clinical conditions and can generate prescriptions for any or all conditions. Every point listed anywhere in the source material is output and the score is also output. One can see at a glance how well or how badly the point is represented in the database. One can also see how often the condition is cited; conditions with very few citations are less likely to respond to AP therapy than those with many citations.
3. COOKBOOKS
Cookbooks usually provide instant details of the ingredients needed to prepare the required dish. They are used mainly by cooks who (a) have bad memories or (b) have not tried to prepare the dish before. Either way, they are very useful and many an enjoyable meal was prepared in this way. Really expert cooks however, through experience and good memory, seldom need to refer to the cookbook.
Cookbook AP is basically "prescription AP". It is suitable for statistical medicine (standardised approach to all "similar" cases). It is quite unsuitable for difficult, complicated or atypical cases, especially in man. To treat such cases successfully by AP would require a deep study of the classical concepts. Having said that, Cookbook AP is ideal for routine and simple cases. It is the quickest, least painful way of introducing busy professionals to the AP techniques. Whether right or wrong, many busy professionals are not prepared to devote the effort and time to a deep study of AP. Without the cookbook approach, most of these would never be able to attempt AP therapy, except for the simplest type (TP therapy or Ahshi therapy).
The main problem with Cookbook AP is which book to use. None of the AP texts available (even the most comprehensive ones, such as the "Essentials of Chinese AP", "Barefoot Doctor's Manual", "Acupuncture, a Comprehensive Text" or "Current AP Therapy") lists all the conditions which can be helped by AP, and there are considerable differences within and between texts. Thus, the serious student is forced either to construct a personal database (as already discussed) or to purchase a commercial card-index database (such as that by Shenberger). The latter is good but is very incomplete - being based on only a few textbooks.
At this time, micro-computer AP databases are available commercially.
One way to use the cookbook method is to select the 6 or 7 points with the highest scores. I have discussed this method with several highly trained and skilled AP practitioners. There is general consensus that while this will give useful clinical success ratios, it will not achieve the success ratio which would be possible if the points were selected from the cookbook not only by their scores but also keeping the Classical concepts and the laws of choosing points in mind. This pre-supposes that the user knows these concepts. Thus, in summary:
Cookbook + little AP knowledge = good clinical success
Cookbook + good basic AP " = better clinical success
4. TAIWANESE/JAPANESE APPROACH TO AP
Having discussed some of the fundamental concepts of TCM and TAP we should now consider how much of the Traditional approach is actually used in modern AP today. This is a very difficult question to answer and it largely depends on the training and experience of the respondent.
First, let us examine some of the characteristics of modern AP.
Medical diagnosis in China Today: Side by side with traditional systems, highly scientific, western oriented medical systems co-exist. This also applies in India, Japan, Taiwan, and most of the Far East. In the same city, you may find the back-street charlatan, the high-street Oriental Doctor (Traditional) and the western-style trained medical specialist.
Many Chinese and Japanese doctors, trained in western medicine but also trained (and expert) in AP ignore or dismiss much of the Five Phase Theory, the Chinese pulse diagnosis method etc as irrelevant to modern medicine. Lined up against them, as (many or more) of their colleagues hold fast to these concepts. Thus, a westerner asking "How important are the traditional concepts today"? cannot arrive at firm conclusions based on talking to these persons.
We can also try to assess the problem by examining the amount of text space devoted to Traditional Concepts in the English versions of the AP textbooks from the far East. In general, few of these texts issued in the past 10 years give more than a cursory nod towards the traditional concepts. Most of them approach the treatment of clinical disorders from a pragmatic viewpoint (i.e.) Cookbook AP. Many modern AP textbooks place little importance on the Six Evils, the Five Phase Theory and its uses etc. Many successful AP practitioners do not use those concepts in diagnosis or therapy.
However, one should ask the question: why was the traditional aspect understated? Was it because the authors believed it to be irrelevant or was it because they thought that full discussion would "turn off" western readers? I believe the latter is nearer the truth. Because of conceptual differences, there are no words in our languages for many of the Chinese concepts! Full discussion would be tedious: like trying to discuss nuclear physics with a theology student. In support of this argument, we must note that some of the authoritative texts place considerable emphasis on the traditional (Essentials of Chinese AP; AP a Comprehensive text; Current AP Therapy; Pathogene et Pathologie Energetiques en Medicine Chinoise - Van Nghi 1971). The fact that the Barefoot Doctor's Manual gives little attention to it is probably because it is for the barefoot doctor, whose training is too short to assimilate the complex traditional concepts.
Thus, the terminology and concepts used in medical diagnosis depend largely on where the patient becomes ill and which doctor is consulted, as is the case in Ireland!
5. COMBINATION OF MODERN AP AND WESTERN MEDICINE
In the Veteran's General Hospital, a huge, excellently equipped Army-Navy-Airforce Hospital in Taipei, one finds specialists in Oriental Medicine, specialists in western medicine and (more significantly) specialists in both systems. It follows that the diagnostic and therapeutic methods depend largely on which doctors are consulted. All the standard lab tests, clinical and neurological tests etc, are available, if required.
In China, the Barefoot Doctor is a technician with limited training, capable of diagnosing and treating the common and simple day to day conditions with reasonable accuracy. Where treatment is unsuccessful or the case appears to be more complex, the patient is referred one step higher to persons who have a longer, more formal training in Oriental and/or western medicine. If they need help, the patient is referred further up the pyramid, which is topped by first rate physicians, surgeons and oriental medical specialists.
Effective therapy is more important than putting traditional or modern names on the origin and nature of the clinical condition. AP therapy, as is the case with diagnosis, is an art-science as varied as there are practitioners. However, most medical AP practitioners (including those at the Veterans General Hospital, Taipei) use pragmatic or Cookbook AP in the majority of their cases: knee problems GB34, SP09, ST35, Hsi Yen (Knee Eyes), BL40; sciatica BL23,37,40,60, GB30,34 etc. They use their favourite prescriptions for each type of case, always including any Ahshi points found. This is also the case with practitioners of western medicine or veterinary medicine.
Thus, we see marked similarities between the actual field problems of diagnosis and therapy in the East and West. The bottom line for all therapists is "what will I use to treat this case of osteoarthritis?" etc, or "My patient's sciatica did not respond to BL23....GB34; what should I try now?".
6. THE FUTURE ?
Computers have invaded social, academic, professional and business aspects of our lives. Information technology is likely to become a commodity as valuable as oil or gold.
Clerics are using databases of the Gospels/Bible to construct sermons on "war", "love", justice" etc. Summaries of research papers on medicine, vet medicine, biology etc are already on databases and available to database subscribers for searches using any key-words of interest.
In the near future, we will have access at reasonable price to computers of enormous speed and storage space. Voice input and output will replace/supplement the keyboard/screen. With advances in computer graphics, the receptionist will be capable of taking a preliminary case history, to indicate the location of lesions (by interaction with the database and graphic display unit) and to generate a list of possible diagnoses (from by comparison of signs/lesions with the database lists). He/she will be able to output graphic charts of relevant points for the patient's complaints on the plotter.
At that stage, the patient and charts will be presented to the doctor, whose job will be to check (or alter) the facts on the computerised case-history. The doctor will scan the patient, using computer-controlled Kirlian-Voll-Akabane methods to determine which Channels are imbalanced.
When the most appropriate diagnosis is selected, the appropriate therapy (including the AP point prescription) will be selected and the patient will be directed to the therapy room for treatment. There, computer-controlled robots, assisted by optical scanners, will insert the needles at the appropriate points and will monitor the clinical response using electro-magnetic measurements of the vital energy at the AP points. George Orwell, eat your heart out!
Joking aside, to get the best mental satisfaction from Cookbook AP, the practitioner must know the basic rules of choosing points, so that the Cookbook recipe can be best modified to the patient's needs. Computers can store vast amounts of data (more than a human brain can recall accurately) but the "dead" information must be assessed and adapted by a trained human mind to be made really "alive".
Finally, the computer can not give the most vital of all therapies: the gift of unselfish love and compassion in response to the plea for help from a suffering patient.
CONCLUSION
Rambo attitudes ("Let's kill the Bastards !" or "Attack is the best means of defence" etc) are justified by many governments and generals as sound Defence Policy against perceived attack.
Ramboism may succeed for a time but, unless the attacked group and its genetic code is exterminated, that policy usually fails in the long-term, as is shown by the history of invaded lands. The wheel turns and the natives survive to rise again. (Ireland was occupied but won back its independence after more than 800 years).
Rambo policy is used in medicine and vet medicine (antibiotics against bacterial diseases, test and slaughter policy against bovine tuberculosis etc). Although it is very successful in some cases, it has failed to eradicate many of the infectious diseases (especially chronic diseases). TCM and holistic medical philosophies of ecology (avoidance of perceived attack and enhancement of apt adaptive responses) are more likely to succeed.
In western concepts, Avoidance of the Evitable and Adaptation to the Inevitable imply a fine-tuned balance of the immune, autonomic and neuro-endocrine systems, which can be brought under a degree of voluntary control (even in animals) by conditioning/self training/biofeedback/visceral learning. Active pursuit of passive defence is also in line with Judaeo-Christian guidelines for physical and mental health/wellbeing: a balanced life, in tune with nature; good diet/fasting, physical/mental work, relaxation/meditation, love of self/love of others etc. Yin-Yang concepts were not confined to the East.
Non-specific parasites and their reluctant human and animal hosts must learn, or be helped to learn, to co-exist in some form of harmony/balance. Otherwise, it seems the parasites will thrive long after the hosts shall have become extinct. But, as Murphy's Law prevails ("If something can go wrong, it will, at the worst possible time"), Rambo is unlikely to quit.
Meanwhile:
1. The basis for AP lies in a knowledge of the position and functions of the AP points and in relationships between the Channels, the direction and time sequence of Qi flow in the Channel circuits and the MASTER (energy transfer) points.
2. Few (if any) Master Acupuncturists know all the points. (There are over 1000 points if all AP systems are included). However, to claim to be an acupuncturist and not know the main points is tantamount to charlatanism, if not fraud.
3. Beginners can get good clinical results by Trigger Point (TP) Therapy, Scar Therapy, Neural Therapy, Dermatomal/Segmental Nerve Stimulation. These are all part of AP therapy but they are the simplest part and need no knowledge of Oriental medical concepts or AP principles. Thus, a TP therapist is not always an acupuncturist but an acupuncturist always uses TP therapy, where appropriate.
4. As a prospective acupuncturist, you can be as good or as mediocre as you wish to be. There are four main options in the study of AP therapy:
a. TP and allied therapy (very simple, little study needed).
b. Classical AP therapy (very complex; needs years of study; may not be essential; adequate training difficult to get in some countries).
c. Cookbook AP (Incorporates TP therapy. Relatively simple, if you have good charts, system - and a minimum of home study of AP methods).
d. Intermediate AP (Cookbook system plus a minimum of formal lectures on basic AP principles, plus a 6-12 months of part-time home study). The minimum requirement for proper use of AP is study of the location, function, uses and contraindications of the main AP points.
I suggest that option 4 is the best for most busy professionals. Your National AP association can help you to select a suitable course.
OR