Article

the neglected art of channel palpation

part 2

by

tony reid

In this connection I would also like to mention Benskys comments. He reports that as a result of practising a technique that he calls Listening to the Channels for over 10 years: Channel flow is almost always experienced as being centripetal, that is going from the extremities towards the trunk. (36) Some time during the early Han period the contemporary theory of a closed circuit pattern of circulation of Qi within the Channels overshadowed the previous paradigm which emphasized mans connection with the universe. The new paradigm reflected the dominant view of man as a social being, whose physiology reflected the man-made world rather than Nature and whose relations with members of his own species were more important than his connection with the universe. This particular paradigm is elaborated in the 10th chapter of the Ling Shu. (37) Thus the move towards social conformity brought with it the tendency to trust authority rather than ones own thoughts and perceptions. Here, too we can see an early example of Acupuncture theory moving away from hands-on direct perception to a more cerebral and dogmatic model. Modern palpatory approaches Japanese Meridian Therapy (JMT) is a classical approach that is based on the Nan Jing, and was revived in Japan in the 1930s. JMT places

methods: pulse diagnosis, abdominal diagnosis and Meridian palpation...

..... Palpation includes three

great importance on palpation. Out of the four diagnostic methods, pulse diagnosis and palpation receive the greatest emphasis. Diagnosis is directed towards detecting imbalances in the Meridians, which are ascertained through (palpation of) the pulse, depressions and sensitive points located along the Meridians ... Palpation includes three methods: pulse diagnosis, abdominal diagnosis and Meridian palpation. the mastery of which requires years of practise (38). The selection of points for treatment is based partly on theoretical considerations, e.g. which point or points will tonify a specific Meridian when deficient, and partly on findings from palpation, e.g. treatment of reactive points or areas. (39) Such points or areas exhibit changes in the skin texture, skin temperature; subcutaneous nodules, indurations or tight bands of tension; tenderness,

hyperaesthesia, depression (i.e. a small hollow) or congestion (i.e. a slightly bloated area). (40) Contemporary Meridian Style Acupuncture (MSA) advocates the primacy of the palpatory approach within the context of TCM. According to Pirog, it is defined as any form of Acupuncture that derives its strategies from classical energetic theory as found in the Nei Jing and Nan Jing, rather than the theories of herbalism or modern science. (41) The key features of MSA are highlighted with reference to the treatment of local pain: Points are located uniquely in each patient according to tenderness or tissue change. These reactive points take precedence over the textbook points, even if they are very close to them. The needles are stimulated mildly

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the neglected art of channel palpation

part 2
and more needles are used It is generally not necessary to elicit Qi sensations. The needles are not manipulated much, if at all Shallow needle insertion All painful points must be needled.
(42)

by

tony reid

is taught and practised in China and the West, when describing the difficulties he encountered with his proposal to introduce Japanese Meridian Acupuncture into the curriculum of the Tri-State Institute of Traditional Chinese Acupuncture: In my experience, once one has

Acupuncture would instill a clinical pragmatism that was lacking in TCM Acupuncture. (44) The place of palpation in Chinese Medicine There are three major issues that pertain to this discussion. The broader one being how to present Chinese Medicine to students in such a way that the student is exposed to the heterogenous nature of traditional Chinese Medicine (and Acupuncture in particular) without the student being overwhelmed or confused by the multitude of different theoretical and practical paradigms, so that he/she may come away with an ability to begin to utilize them. Secondly: to what extent has palpation of the body surface been a feature of Chinese Medicine throughout the last 2,000 years? Thirdly, from a clinical practice perspective how does the adoption of a tactile approach influence clinical outcomes? Taking an historical perspective, one can see that throughout its recorded history Chinese Medicine has been characterised by herterogeneity and plurality. As a consequence, competing individuals and groups espousing one aspect or a limited number of aspects of Chinese medical theory and practice, vie with one another for prominence. (2) In addition, one of the notable features of this tradition is that it has continually been in a process of change and development. At times (such as during the Jin-Yuan period and also during the modern era) this has been quite rapid. (45) It is therefore not my intention to try

Another eminent author and practitioner, Dr Mark Seem, has developed a unique system of Acupuncture that is also palpation based. Dr Seem developed an approach to diagnosis and treatment that integrates Japanese and French Acupuncture with the kinesthetic logic of manual osteopathy and trigger point release. The author has developed a protocol using Acupuncture as a tool for releasing holding patterns in the body-mind in order to restore functional and structural balance and to relieve chronic pain. The methodology places great importance on palpation by the practitioner to locate local and distant treatment points within the framework of the six Channel system and the eight extra Channels. (43) Dr Seem argues for a return to the body and the importance of touch in the opening chapter of his major work on this approach. Describing his meeting with Dr Janet Travell (who developed trigger point therapy within Western medicine), he summarises the essence of his system: the key to pain and its complex dysfunctions is not to be found in the physicians preconceived, objective knowledge but, time and again, in the very bodies of patients. He also summarised the current dilemma within Acupuncture as it

had too great a taste of TCM Acupuncture with its heady logic, facile abstractions and even more facile repetitive point combinations, a hands-on Meridian-based approach often seems inferior. In response to members of his faculty who opposed this move on the grounds that students would become confused and that TCM should be the focus of the curriculum: Japanese

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the neglected art of channel palpation

part 2
prominence than it is in present day TCM Acupuncture. The references to palpation in the Ling Shu and Nan Jing, cited above, would serve to lend at least some weight to this argument. On the other hand, I have looked at forces both cultural and academic that have tended to force Acupuncture into the herbal medicine mold, discouraging and minimising the use of palpation in clinical practise within China. This is not to say that the palpatory approach to Acupuncture is no longer practiced in mainland China. Examples of such practitioners may be found in recent Chinese publications, e.g. Essentials of Contemporary Chinese Acupuncturists Clinical Experiences. (47) In October-November, 2000, I had the good fortune to train under one such practitioner in Hangzhou, China. However, I can attest to the difficulty if not sheer impossibility for such a practitioner to explain what he is doing in terms of any of the items of a physicians preconceived, objective knowledge. It is obviously harder to teach and assess palpation skills, as they rely to a large extent on the ability of the practitioner to develop the requisite sensitivity as well as the ability to interpret his/her findings appropriately. In addition, the process of treatment also involves a level of sensitivity that naturally varies from one individual to another and that also requires ongoing practise over many years in order to develop proficiency. To use the term coined by Volker Scheid, (48) this is one of the problematiques that underlie our tradition: the fact that effective clinical outcomes depend on both a deep and detailed knowledge

by

tony reid

to prove that palpation of the body surface is the key to discovering the one and only true Acupuncture. I have simply aimed to show that this approach comprises a significant strand of thought and practice that forms an important part of the rich tapestry of the Acupuncture tradition. At the one extreme we have the imperial physician who examined the pulse by means of a thread tied around the royal ladys wrist and inserted needles through her garments. While on the other we have the Japanese approach to Acupuncture, strongly influenced by that cultures less significant taboos against physical touch, emphasising body palpation and Channel based pathologies. (46) Thus, through observing the way in which Acupuncture has developed in Japan as an example of a school of thought within the Acupuncture tradition that has been allowed to develop outside of the cultural influences which have shaped the modern version of traditional Chinese Medicine, we can speculate that in pre-modern, and especially in pre Jin-Yuan China, palpation was given greater

of theory, as well as an equally deep and refined sensitivity, which needs to be cultivated over a lifetime. Such considerations are anathema to modern scientific reductionism, empiricism, intellectualism and evidence based philosophies. It would seem that the ease of structuring courses, teaching and assessing students as well as the predominantly intellectual approach that is provided by the TCM paradigm has made it very attractive to those who develop, implement and administer courses both in China and the West. One may also consider the fact that after the devastation of the cultural revolution, Chinese academics, policy makers and administrators, conscious of the backwardness of their nation, have rushed to modernise in an attempt to appear acceptable to the more technologically advanced Western nations. This would also contribute to the limiting of a physicians reliance on palpation in Chinese Medicine. As far as clinical practice is concerned, at present the only evidence that I have been able to find is empirical. Practitioners of palpation based Acupuncture cite numerous examples of the clinical efficacy of this approach, particularly in the treatment of chronic pain. (49, 50, 51) In addition, there is the argument put forth by Brown in his preface to Introduction to Meridian Therapy that in Japan the practitioners have to compete professionally against Western style doctors and practitioners of Herbal Medicine, both of whom are covered by the National Health Program. (52) This speaks for the efficacy of such treatments although in a very general sense.

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the neglected art of channel palpation

part 2
In addition, we also need to consider the evidence that comes from the experience of experts in the field, such as Dr Seem. His opinion is that hands-on Meridian Acupuncture styles are vastly superior to TCM Acupuncture and indeed any of the other forms of physical based therapies. (53) Research into Acupuncture is still in its infancy. So far there is reasonable scientific evidence supporting Acupuncture for very few indications, e.g. peri-operative dental pain, neck pain, nausea and vomiting. (54, 55) However, there are several key methodological challenges inherent to Acupuncture trials, such as placebo control and blinding, which are currently being discussed in the literature. (56, 57) Therefore it is a little premature to expect any direct comparison between the clinical outcomes of TCM based Acupuncture treatment and that of a Meridian based approach in the literature. However, as far as future directions in research are concerned, it may be worthwhile to consider such comparative studies as they would be useful in determining standards for best practice in Acupuncture. Looking briefly at teaching and assessing student outcomes, it would not present a major challenge, neither intellectually nor logistically,

by

tony reid

for Acupuncture teachers to require students to demonstrate knowledge of the standardised locations of Acupuncture points as well as to be able to show the skills in palpation that would enable the location of alternative points in a real-life patient. Similarly, students can be taught various ways of reading the radial pulses, some of which are more appropriate for TCM Acupuncture, Meridian style Acupuncture or Chinese herbal treatment. In keeping with the heterogenous nature of traditional Chinese Medicine, I believe that students and practitioners are both personally enriched as well as better equipped to serve their

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Article

the neglected art of channel palpation

part 2
patients effectively when they are exposed to several paradigms of both theory and practise. The Seattle Institute of Oriental Medicine adopts this approach and it has proven effective, with no failures in the National Certification Commission for Acupuncture and Oriental Medicines written exam and over 90% of graduates in practice. (58) Similarly, the Tri-State Institute of Traditional Chinese Acupuncture, although predominantly TCM oriented, also exposes students to Japanese Meridian style Acupuncture as well as Dr Seems approach, Acupuncture Physical Medicine. Approximately 90% of the students who enter the program go on to graduate of these 99% go on to work in the field. (59) Conlcuding remarks There is one major issue that I have not yet discussed. This is in regard to the future of Acupuncture, i.e. Acupuncture as a discipline that is independent of and distinct from Chinese Herbal Medicine. According to Seem, (53) Acupuncture is in serious danger of being lost partly because it has been reduced to an herbalised form in Western colleges of Chinese Medicine and partly because other healthcare providers such as medical practitioners and chiropractors are taking it up with only minimal training. The first part of this thrust sees Acupuncture as a mere part of Oriental Medicine, in which Oriental Medicine is a code word for herbal practice. In this perspective, born when traditional Chinese medicine hit the U.S., Acupuncture is reframed as internal medicine akin to herbs, rather than a hands-on therapy designed as a physical medicine that, through informed touch, can restore integrity not only to the body, but to the body, mind and spirit as a whole. (53) Colleges teach only a watered down version of Acupuncture in which informed touch plays virtually no role at all, which has ended up becoming the major form of Acupuncture practised in the West. On the other hand there has been the development of medical Acupuncture (Acupuncture practised by medical doctors with only 200300 hours of training) as well as chiropractic Acupuncture (often practised with only 100 hours of study). Because the general public is ill-equipped to distinguish between practitioners, who have had minimal and inadequate training (who also generally refer to themselves as Doctor, thus conferring an elevated social status upon themselves) and those with suitable training, it is inevitable that Acupuncture will eventually come to be regarded as having only a very limited therapeutic value. In addition, because most practitioners of Chinese/Oriental Medicine follow the watered down approach, Acupuncture is in serious danger of decline. In Seems opinion: No other physical medicine perspective I am familiar with has as comprehensive and systematic a therapeutic approach, nor as comprehensive a therapeutic effect (as hands-on Meridian Acupuncture styles). (53) I would agree with Dr Seems concluding remarks in the article just cited, that it behooves our profession to rescue Acupuncture and restore it to its rightful place as a powerful therapeutic modality that requires specialist training and the simultaneous development of tactile skills, sensitivity and needling

by

tony reid

skills along with a broad knowledge base that encompasses the various styles of Acupuncture that have been practised in the past, together with modern developments.
REFERENCES 1. Cheng, X. (chief Ed.) (1999). Chinese Acupuncture & Moxibustion (Revised/ Enlarged). Beijing: Foreign Languages Press 2. Scheid, V., Bensky, D. Medicine is Signification - Moving Towards Healing Power in the Chinese Medical Tradition (reprinted from the European Journal of Oriental Medicine. Retrieved from: http://www.siom. edu/resources/faculty/v-sheid/yizhe 3. Yin, G. & Liu, Z. (2000). Advanced Modern Chinese Acupuncture Therapy A Practical handbook for Intermediate and Advanced Study. Beijing: New World Press. 4. Flaws, B. & Sionneau, P. (2001). The Treatment of Modern Western Diseases With Chinese Medicine: A Textbook & Clinical Manual. Boulder, CO: Blue Poppy Press 5. Flaws, B. & Lake, J. (2001). Chinese Medical Psychiatry: A Textbook & Clinical Manual. Boulder: Blue Poppy Press 6. Ellis, A., Wiseman, N., Boss, K. (1991). Fundamentals of Chinese Acupuncture. Brookline, Massachusetts: Paradigm Publications (pp.59-60) 7. Deadman, P., Al-Khafaji, M. (1998). A Manual of Acupuncture. Hove, East Essex: JMC Publications. 8. Ibid. (pp.57-61) 9. Ibid.p.44 10. Ibid. p.61 11. Sivin, N. (1987). Traditional Medicine in Contemporary China. Ann Arbor: Centre for Chinese Studies, the University of Michigan. 12. Ibid. pp.326-327, p.257 13. Chai, K. (Chief Ed.) (1998). University textbooks of Traditional Chinese Medicine for Overseas Advanced Students. Basic Theory of Traditional Chinese Medicine. Beijing: Peoples Medical Publishing House. 14. Ibid. p. 12

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the neglected art of channel palpation

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15. Wu, X.(Chief Ed.) (1999). University textbooks of Traditional Chinese Medicine for Overseas Advanced Students. Traditional Chinese Diagnostics. Beijing: Peoples Medical Publishing House, p. 211 16. Ibid. pp. 304-309 17. Wiseman, N., Ellis (transl.), A., Zmiewski, P. (Ed.) (1985) Fundamentals of Chinese Medicine. Brookline: Paradigm Publications 18. Ibid. pp.150-152 19. Kaptchuk, T. (Revised Ed. 2001). Chinese Medicine: The Web That Has No Weaver. London: Rider Books, p.194 20. Maciocia, G. (1989). The Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturists & Herbalists. Edinburgh: Churchill Livingstone 21. Ibid. pp.171-174 22. Ibid. pp.307-310 23. Ibid. pp.367-477 24. Deng, T. ( trans. Yi, S. & Ergiul, M., Ed Ergil, K.) (1999). Practical Diagnosis in Traditional Chinese Medicine . London: Churchill Livingstone 25. Ibid. pp.155-162 26. Ibid. pp.305-323 27. Chen, P. (2004). Diagnosis in Traditional Chinese Medicine. Taos: Complementary Medicine Press, pp.120-126 28. Maciocia. G. (2004). Diagnosis in Chinese Medicine: A Comprehensive Guide. Edinburgh: Churchill Livingstone, pp.525-537 29. Ibid. pp.509-522 30. Ibid. pp.525-537 31. Dharmananda, S. (2001). The Jin-Yuan Medical Reforms. ITM Online Articles. From: http://www.itmonline.org/arts/jinyuan.htm 32. Unschuld, P. (translated & annotated) (1998). Forgotten Traditions of Ancient Chinese Medicine. Brookline, Massachusetts: Paradigm Publications, p.72 33. Wang, J., Robertson, J. (2007). Channel Palpation. J Chinese Medicine. 83, 18-24 34. Unschuld, P. (translated & annotated) (1998). Forgotten Traditions of Ancient Chinese Medicine. Brookline, Massachusetts: Paradigm Publications, p.244 35. Pirog, J. (1996). A Practical Application of Meridian Style Acupuncture. Berkeley, CA: Pacific View Press, p.33 36. Bensky, D. Listening to the Channels: Preliminary Reflections on the Adaptation of One Form of Osteopathic Palpation to Acupuncture. From SIOM website http://www. siom.edu/resources/faculty/d-bensky/palpation 37. Pirog, J. (1996). A Practical Application of Meridian Style Acupuncture. Berkeley, CA: Pacific View Press, p.35 38. Shudo, D. & Brown (transl.) (1990). Introduction to Meridian Therapy. Seattle: Eastland Press, pp.12, 45 39. Ikeda, M. (2005). The Practice of Japanese Acupuncture and Moxibustion. Classic Principles in Action. Seattle: Eastland Press, pp.65-66 40. Shudo, D. & Brown (transl.) (1990). Introduction to Meridian Therapy. Seattle: Eastland Press, pp.168, 169 41. Pirog, J. (1996). A Practical Application of Meridian Style Acupuncture. Berkeley, CA: Pacific View Press, p.xiv 42. Ibid., p.7 43. Seem, M. (1993). New American Acupuncture: Acupuncture Osteopathy. Boulder: Blue Poppy Press 44. Ibid., pp.vi-vii 45. Sivin, N. (1987). Traditional Medicine in Contemporary China. Ann Arbor: Centre for Chinese Studies, the University of Michigan, p.xx 46. MacPherson, H. (1994). Body Palpation and Diagnosis. J Chinese Medicine. 44, 1-7. 47. Chen, Y., Deng, L. (chief eds.), Zhang, K. (chief English ed.). (1989). Essentials of Contemporary Chinese Acupuncturists Clinical Experiences. Beijing: Foreign Languages Press.

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48. Rossi, E. (2007). Shen Psycho-emotional aspects of Chinese Medicine. Edinburgh: Churchill Livingstone, Elsevier Ltd., pp. ix-xi 49. MacPherson, H. (1994). Body Palpation and Diagnosis. J Chinese Medicine., p.5 50. Seem, M. (1993). New American Acupuncture: Acupuncture Osteopathy. Boulder: Blue Poppy Press, pp.117, 132-133 51. Shudo, D. & Brown (transl.) (1990). Introduction to Meridian Therapy. Seattle: Eastland Press, pp.209-235 52. Ibid., p. ix 53. Seem, M. (2000) Message from the Front Lines. Acupuncture Today., Vol. 01, Issue 09. From: http://www.Acupuncturetoday.com/ mpacms/at/article.php?id=27690 54. Acupuncture. NIH Consensus Statement Online 1997 Nov 3-5. 15(5),1-34. Retrieved April 25, 2007 from: http://consensus.nih. gov/1997/1997Acupuncture107html.htm 55. Cochrane review search conducted April 2007 56. Birch, S. (2006). A review and Analysis of Placebo Treatments, Placebo Effects and Placebo Controls in Trials of Medical Procedures When Sham is not Inert. J Alt Complem Med. 12(3), 303-310 57. Birch, S. (2007). Reflections on the German Acupuncture Studies. J Chinese Medicine. 83, 12-17 58. Seattle Institue of Oriental Medicine Staff (2004). The Seattle Institute of Oriental Medicine: An Experiment in Acupuncture Education, 10 Years Later. Acupuncture Today., 5(12) fromwww.Acupuncturetoday.com 59. Tri-State College of Acupuncture (2004). Answers to Frequently Asked Questions. From: http://www.tsca.edu/h1-2.htm 60. Cheng, X. (Chief Editor). (1996). Chinese Acupuncture and Moxibustion. Beijing: Foreign Language Press