THERAPEUTIC EFFECTIVENESS
ractitioners agree that the aim of every acu
puncture treatment should be to restore balance and wholeness and thus to relieve the patient's "disease. " In acupuncture, the ability to do this is ultimately through the needle.
Thus, excellent needle technique is extremely impor
tant in the treatment process. Needless to say, even the best needle techniques cannot compensate for an inaccurate diagnosis or a faulty treatment plan, so these skills need to be equally developed. And the ability to arrive at a correct diagnosis is correspondingly depen
dent on the ability to collect the necessary diagnostic information through the classical methods of diagnosis:
inspection, auscultation, olfaction, palpation, and inquiry. Also, the practitioner must be able to weave the signs and symptoms into a synergetic whole that portrays each individual's unique constellation of energy.
Within classical Chinese medicine there is an intrin
sic diagnostic logic that pervades the process from the first gathering of data through to therapeutic effective
ness. These related steps are discussed here and sum
marized in Table 1 , "Intake to Improvement: The Inherent Logic of the Chinese Diagnostic and Delivery Systems. "
2 CHAPTER 1 Holding The Tiger's Tai l
Goal. Health of the patient.
Step 1. Collect the data necessary to arrive at a diagno
sis through inspection, auscultation, olfaction, palpa
tion, and inquiry. Together, these methods, organized around the senses, allow the practitioner to gather the fullest possible range of data.
Step 2. Assess the situation, that is, organize the data into the appropriate and/or preferred diagnostic frame
work. Each framework, like a lens, helps the practitio
ner to view the person from a unique perspective.
Preferred paradigms are often a function of how much exposure the practitioner has had to them. Their effectiveness is directly linked to the ability of that paradigm to contribute to seeing the "picture" of the patient.
Pictures of reality, ways of viewing the world, can range from photographic preciseness to impressionistic imagery to the obscurity of modern art. Each picture, like a paradigm, is a vision, no better and no worse than the other, simply a way of organizing experience.
Acupuncture paradigms, the "pictures" we use to orga
nize our experience of the patient, include the follow
ing:
a. yin/yang b. qi and blood
c. three treasures (qi, j ing, shen) d. four levels (wei, qi, ying, xue)
e. five elements (wood, fire, earth, metal, water) f. six divisions (Tai yang, Shaoyang, Yangming,
Taiyin, Shaoyin, Jueyin) g. zang-fu
h. essential substances (qi, blood, body fluid, jing, shen, marrow)
i. eight principles (internal-external, excess-defi
cient, yin-yang, hot-cold) j . extraordinary vessels k. j ing luo (meridian therapy)
The Relationship Between the Methods of Diagnosis and Therapeutic Effectiveness
1. luo vessels m. San Jiao
n. exogenous pathogens (wind, cold, damp, dry
ness, heat, summer-heat)
o. endogenous pathogens (the emotions: anger, joy, fear, fright, grief, worry, and melancholy)
p. miscellaneous pathogens (neither exogenous or endogenous, they include factors such as dietary indiscretions, exercise habits, trauma, scars, radiation, and so on)
q. secondary pathological products (stagnant blood, damp-phlegm)
r. energetic layers (skin, muscle, meridian, blood, organ, bone)
s. Western medical model and its etiological factors t. Japanese systems
u. palpatory findings v. heaven-man-earth
In order to come to a diagnosis, the practitioner must artistically and carefully weave the material data from the physical exam with the voluminous informa
tion revealed in the interview. Thus, a coherent and accurate assessment can be achieved. The interview process can give the practitioner and the patient a glimpse of the human spirit that underlies the context of any individual life. But it must be conducted with an openness and rapport that allows the richness as well as the sickness of the person to emerge. Likewise, if the meaning of the illness can be captured and con
veyed to the patient, true healing can begin and both the patient and the practitioner can work together to remedy the disease. The questions should not become an obstacle to seeing who the person really is. The history, if clearly elicited, can be as therapeutic as the treatment itself.
Step 3. Identify the problem, that is, arrive at a diag
nostic statement. Like an hypothesis, this statement is
C HAPTER 1 3
4 CHAPTER 1 Holding The Tiger's Tail
an educated guess, a tentative assumption based on facts, about what is going on with the person. It should be an artful, clear, simple statement, a summary of the patient's present as it relates to his or her past-for example, Liver blood deficiency that has become Liver qi stagnation.
The fact that a diagnosis is not final, just as no hypothesis is final until it has been verified, is an im
portant guiding principle in treatment. The practi
tioner must evaluate this hypothesis and modify it every time the patient is seen.
Step 4. Formulate a treatment principle that is a thera
peutic and educational plan directly related to the diagnosis. For example, a diagnostic statement of
"Spleen qi deficiency" has a treatment plan of "tonify the qi of the Spleen. "
Step 5. Select the appropriate treatment modalities that have known clinical effectiveness in treating the diag
nosed condition. The most common modalities in
clude, but are not limited to, the following:
a. acupuncture and its microsystems, such as auricular therapy, scalp acupuncture, hand acupuncture, and so on.
b. moxibustion c. cupping
d. Plum Blossom needle therapy e. gwa sha
f. herbal medicine g. tuina
h. massage
i. nutritional therapy
j . exercise/breathing therapy k. lifestyle changes
Step 6. If acupuncture is used, select the points to be needled. Provide the rationale for each point's use and determine the method of needling, that is, tonification
The Relationship Between the Methods of Diagnosis and Therapeutic Effectiveness
or dispersion. For example, tonify BL 1 8 (Ganshu), Back Shu point of the Liver to nourish the Liver Blood and tonify LR 4 ( Zhongfeng), the metal point on the wood meridian to move the Liver qi stagnation, because metal controls wood.
Step 7. Administer treatment. Verify that there is a correlation between the treatment plan and what is actually done. That is, if the strategy is to tonify, make sure that the needle technique is indeed a tonification technique.
Step 8. Evaluate therapeutic effectiveness for the major complaint after administering each treatment.
Step 9. Continually reassess other active problems in subsequent visits.
Table 1. I ntake to Improvement: The I nherent Logic of the Chinese Diagnostic and Del ivery Systems
Step 2 Organize the data i nto a diagnostic framework Step 3 Arrive at a diag nosis
Step 4 Formulate a treatment principle
Step 5 Select the app_ropriate treatment modal ity Step 6 Select the points to be needled
Provide the rationale for each point's use, and determ ine the method of needling Step 7 Ad minister treatment
Step 8 Eval uate therapeutic effectiveness Step 9 Continually reassess
Although the steps detailed here are expressed linearly, they are actually cyclically related to each other. Each step leads to and prompts the next one, influencing it so the circle of wholeness and health is achieved. The interrelated steps bend into circles, all organized around the goal of treatment, which is to restore the patient to balance. Health is a reflection of
CHAPTER 1 5
6
6. Select the points, their rationale and method
Holding The Tiger's Tai l
that balance. (See Figure 1, Intake to Improvement: The Cyclic Relationship of the Components of the Chinese Diagnostic and Delivery Systems.)
This is the exquisite logic of Oriental medicine that must guide the practitioner in treatment. If the results are not satisfactory, the practitioner is encouraged to look back at all of these steps to see if:
1 . They are all being performed to the best of one's ability.
2. They are mutually related to each other.
3 . The intent i s actually being achieved. For in
stance, is a tonification or a dispersion technique being applied to the needle?
From the preface of this book and from its title, it should be clear that the focus is neither on how to perform the methods of diagnosis nor on what the data
collected from these
treatment modalit treatment modalities from
the acupuncture tech
nostic and Delivery Systems
treatment of select disease patterns with which I am familiar.
Still, it is imperative to remind practitioners that the diagnostic process is full of intricacies and that these can be controlled by healthcare providers. This knowl
edge helps practitioners develop the ability to critique their performance so that the best interests of their patients are served.
The Relationship Between the Methods of Diagnosis and Therapeutic Effectiveness
Practitioners also need to be mindful that the suc
cess of any treatment is not simply a function of the steps listed above, although these are critical variables.
Experienced practitioners are aware that the practition
er/patient relationship is the context within which the delivery of healthcare is provided. This relationship, according to classical Chinese medicine, is not operat
ing at its most effective level when it is only a mechani
cal process of gathering information and administering a treatment. A caring atmosphere of concern and confidentiality, mutual respect and rapport, profession
alism and attention to the patient's presence is as meaningful to bringing the patient back to health and balance as the steps given in Table 1 . The practitioner's belief in the medicine and in her or his own abilities are also empowering and will create a mindset where the patient receives the best the practitioner has to give.
If we agree with the Neijing that healing represents a change and moves the patient's spirit, 1 then there are almost unlimited modalities to effect that change.
Obviously, acupuncture is a powerful healing tool and the allied Chinese medical arts are also effective as both independent and supplementary modalities. But some
times such change can be elicited from touch, talk, and laughter, in short, from the ability of the practitioner to engage the patient's spirit. The highest level of the practice of healing, then, is not exclusively the logical aspect of diagnosis and treatment but the ability of one human spirit to make meaningful contact with another.
As such, healing is a sacred and noble endeavor.
Case 1 provides an example of the complexity of the diagnostic and delivery system.
1. Laree C a n d Rochat de la Vallee E: The practitioner-patient relationship : wisdom from the Chinese classics. J Trad Acu, Winter, 1 990-9 1 ; 14-1 7, 48-50.
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8 CHAPTER 1 Holding The Tiger's Tai l
Case 1. Pulses at the adaptive level
The reading of emotions through the pulse had never been my focus until the following case. True, had always noticed a strong correlation between grief and Lung pulses as well as between fear and Kidney pulses. Of course, a particularly wiry pulse seemed to have aggravation, irritability, or anger associated with it. The case presented below however was one of the most difficult I ever treated.
There were many reasons for this, but the lack of patient compliance was the major problem. It also illustrates how to interpret very deep pulses as manifestations of emotions that are habitual or have been adapted to.
Sleep disorders are America's most frequent, deadliest, and costliest malady. A particular strength of the Chinese medical paradigm is that it gives an internal perspective on why insomnia develops. It is this precise differentiation that assists the practitioner in successful treatment. However, it is important to keep in mind that the emotions that accompany insomnia often make it difficult to cure. The patients are tired, frequently irritable, and sometimes desperate during their waking hours to get some rest.
The patient in this case was a fifty-seven-year-old female who had developed a sleeping disorder about four months previously. Her sleep pattern was characterized by an intense desire to go to bed early only to wake up three to five times during the night. She was clearly frantic.
Her insomnia was primarily of a deficient origin. In particular it was caused by a lack of the essential substances of qi and blood that were failing to anchor the spirit. Her variety of sleeplessness was also characterized by poor memory, lassitude, day-time drowsiness, dizziness, poor appetite, being easily frightened, shortness of breath, pallor, dry skin, and a stifling sensation in the chest. In addition, one of her arms twitched involuntarily. The pulse was deep and thready with an irregularity. The tongue, which was slightly purple with a red tip and almost no coat, was slightly deviated, wet, and quivery.
One year previously she had experienced an unidentified illness in which the symptoms were fever, swollen glands, and lethargy. She had worked extremely hard for a number of years (because it was necessary) and at that time her energy was "super." It had been a difficult time emotionally yet, "That is just the way it was," she reported. She clearly did not want to elaborate. About three years before seeing me she became noticeably colder, particularly in the evening. She lives in a very cold house in the mountains with no source of heat.
Her spirit needed to be treated-quieted and calmed-so that it would descend and become anchored in the material substrates of qi and blood. The problem was, of course, that qi and blood were inadequate and hence could not fulfill this function. The treatment strategy was a delicate balancing act of bringing the energy down from the head and rooting it, while simultaneously securing it by building qi and blood. To bring down the energy was rather easy, but to hold it there was difficult and lasted only temporarily because of the deficiency of qi and blood.
The patient demanded immediate and long-lasting results. Every successful step in treatment was a morsel, a promise of what was to come and the patient voraciously clamored for more. In addition, the patient did things that I thought could be exacerbating her condition. These activities included inversion therapy, hypnosis, hot baths before bed, sleeping on a magnetic bed, cranial-sacral therapy, elixir drinks, sleeping pills, and bizarre "blood purification" techniques. Because the patient moved from therapy to therapy, it was impossible to determine the effects of the therapies, positive or nega
tive, if there were any at all.
The patient responded very well to acupuncture and moderately well to Chinese herbs. She always slept very well after a treatment. This pattern continued to improve for several months, but the results would only last for a few days at a time. More frequent visits were indicated, but were limited because the patient lived quite a distance away and was very conservative with her money.
The Relationship Between the Methods of Diagnosis and Therapeutic Effectiveness CHAPTER 1
After two months, the pulse, which had been so thin, but more importantly too deep, began to rise. There was a palpable Kidney pulse and the pulse in general was rising to the level appropriate for that time of year. At this point, I requested that the patient undergo some Western medical tests to refine the diagnosis. Even though significant improvement had been made in a short time with very little treatment, the patient was more dissatisfied and difficult to work with than ever. Her dalliance with other therapies made it hard for me to achieve stability in her case. There were other factors, such as hysteria, personal onslaughts on me as to why she could not sleep better, and the need to travel to my office that complicated the case. Also, she refused to see a Western physician because she was sure a medical condition would be discovered that her insurance company would not cover. All this set up the dynamics for a therapeutic relationship that reached an impasse.
This case presents several different lessons, not the least of which is to do the best we can and not become too attached to the outcome (which is not controlled by the practitioner anyway). But looking at the pathology, it was obvious that this patient's difficulties, supported by numerous signs and symptoms, centered around the Heart, its willingness to give, to receive, to laugh, to rest, to harmonize with the social world. The deep weak pulses indicated that her problem was related to the internal organs and to the yin organs in particular. It was a chronic problem that had been adapted to. As the recuperative energy of the body was tapped and strengthened, the pulse became stronger and higher.
The emotions, even if in the form of complaints, began to surface, to be expressed, instead of being buried at the deep, hidden, adaptive level of the pulse. Now the patient needed to attend to her feelings. This remains the area that the patient needs to work on.
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