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 Reflection Seven: Acupuncture Needling & Tacit Knowing THE PROBLEM:  At the same time that I was busy focusing on the best ways to teach the APM approach, which included extensive training in Travell and Simon’s approach to myofacial pain and trigger point referral patterns and TrP point location and myofascial release, I tended to emphasize the physical medicine side in a way such as to lead some students and some faculty to see my approach simply as trigger point acupuncture, based mainly on Travell’s trigger points and dry needling techniques to release them. It took me several years to realize that APM was being stripped of its original classical Chinese jingluo way of practicing. While I never stopped practicing that classical way, and merely added knowledge of trigger points and a needle technique I modified for acupuncture needles that allowed a far more shallow, wei level depth for many points, this focus on trigger points, and of this technique—which takes some time to get a grasp of, diverted my attention from what was being lost. I turned my attention, once I realized this, to teaching students how to perform needling, starting not with TrP needling techniques, but with classical tonification and dispersal techniques to distal points of the regular meridians and at mu and shu points of the front and back in Year I. I also stress these classical needling techniques as well as trigger point dry needling throughout Year II APM/CCA ACP sessions, and in my Grand Rounds and Year Three clinical supervisions. This return to classical regular, secondary and extraordinary meridian needling techniques brought with it a return to what was most critical in the practice of acupuncture as a

hands-on practice aimed at eliciting a felt-sense in the patient.    I. Acupuncture Know-How and the Bodily Felt-Sense This way of teaching and learning implies internalization of skills so that they can be replicated, in a way that is as immediate, and mindful, as possible, without thinking about them: embodied learning as Confucianists would say. Clinical supervisors at the college expect any clinical intern to be able to articulate the reasons for their APM/CCA treatment plan (and again I am only sharing what I know best, namely the teaching of the APM/CCA approach, not the Japanese and TCM approaches which are taught in their own ways by other clinical faculty teams), citing the evidence from the signs and symptoms gathered in the four exams, based on the APM/CCA foundational texts, that lead to the working diagnosis, treatment principle and plan But during the physical examination, and again once the treatment has been approved, the 5 steps of APM/CCA treatment should be done from a mindful place where tactic knowledge on the part of the clinical interns, and evocation of the bodily-felt sense, and meaningful signs of change in the patient, drive the way in which the treatment is conducted. Tacit Knowing At one point in the development of the teaching at the Tri-State College of Acupuncture, I was struck by the fact that while there were a small number of students who could learn immediately from me how to palpate the body, how to locate depressions where acupuncture points were located, how to locate tight constricted areas in the musculature where excess areas were

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located, and could just as quickly learn how to needle these excess and deficient areas with very little discussion just by watching and doing, there were many, many more students who seemed to need to have much more explanation, much more theory, much more explicit explanations of what was going on. This was very bothersome to me and led me to consult a prominent New York clairvoyant who in an early session shared with me what she was picking up, namely that I appeared to be someone who knows what I knew in an instant, who in doing what I do takes in the whole and knows whether or not that whole feels like it is accurate. It was a strange meeting, a strange interaction, but it led me to start looking very carefully at how I and other faculty were teaching clinical skills at the college, how we were teaching theory, the texts we were using, the outcomes our students were exhibiting. In this process, I engaged in several experimental activities with colleagues, among them Bryan Manuele, Co-founder and then Director of the Midwest College of Oriental Medicine in Chicago, Illinois. Once, while I was in Chicago, we shared the experience of treating patients while watching each other at a distance without intervening. The challenge was to see if we could tell when in the interview our colleague had a sense of what the diagnosis was, what the treatment was going to be, and whether or not, at that moment, he had an explicit awareness of signs and symptoms and differentiations, the meaning of these signs and symptoms, specific acupuncture and Oriental medical knowledge that he had gathered together in a diagnostic assessment in his head and then came up with logical treatment principals and logical point selection. Or, was something else going on? That we in fact discovered, after sharing what we observed, what we saw, what we felt, what we noticed, what we took in, was that each of us seemed at a certain point in an intake with a patient to have a sense of where we wanted to go to find a primary obstruction. This was

not a diagnosis, this was not a running through of differentiation of signs and symptoms in our head, this was not an explicit activity, this was not an activity, in fact, that we could even say to each other, and we found it very hard to be explicit and articulate about what we were trying to share. What we discovered was that, much like what the clairvoyant explained to me, we were in fact trusting a kind of knowledge that came to us tacitly—knowledge we could feel, knowledge we could see, a kind of know-how that just seemed to come, obviously informed by our study of acupuncture and Oriental medicine, meridians, point locations, diagnoses and needle techniques. We realized that in the doing of acupuncture, in the practice of acupuncture we made no use of academic or intellectual activities to come up with our treatment but rather seized on a treatment, or rather seized on a moment, where we felt that we had a sense of the problem for that patient, and having a sense of that problem already had a feeling that certain acupuncture patterns, combinations of points, treatments we had done in the past, would be a good place to begin. And so, after quickly palpating the body, once we had this sense of the problem and where, most importantly, this problem was located, we would then go palpate and based on finding areas of tightness, of deficiency, perform an acupuncture treatment in rather short order and know during the doing of this treatment whether or not this treatment was moving in the right direction. When we realized that we felt it was moving in the right direction, we would let the patient know that this was great, we would let the patient lie there for ten or fifteen minutes and would actually be quite certain that this treatment would have a positive effect. None of that process involved intellectual operations that confirmed a diagnosis, but rather a process that looked more like reaching deep within for a familiar pattern of treatment that in some way matched the patient’s complaint as a starting point for navigating the patient’s

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bodymind. This was extremely helpful in the elaboration of the teaching at the Tri-State College of Acupuncture and led to the development of what we call Acupuncture Clinical Practice (ACP) and Grand Rounds with Senior Faculty during all three years of the Master of Science degree program in Acupuncture. Implications for Clinical Training In Acupuncture Clinical Practice, which is now a three-and-a-half hour class where students begin their clinical training on peer students and practice as one would rehearse for a play, or rehearse kata in karate, that they rehearse or practice full treatments from three different styles of acupuncture, which amounts to building up a repertory of whole treatments that they could apply in given situations as a place to start. In Year Two they learn how to begin to modify somewhat some of those protocols and in the actual clinic in the final clinical senior year they of course are helped with supervisors to step out of the rigidity of protocols, to become flexible and modify as need be those protocols to adequately address all of the various conditions that they are encountering, to adapt to what they are actually seeing in front of them, to their patients’ actual problems, and to be creative in solving these clinical problems starting with these repertories of patterned responses or practiced or rehearsed protocols that they have engaged in over the first two years. This investigation into how people learned and more specifically how they were not learning from going from the rather tedious attempt at memorization of point indications from Chinese textbooks, which we fast abandoned, and even memorization of basic signs and symptoms of different Chinese patterns, we realized that while that was a necessary activity in the lecture classes and was foundational knowledge that they needed to commit to memory in order to have a foundation on which to learn and

practice, what was critical in the actual acupuncture clinical practice on peer patients first and then on community clinic patients, was this ability to take in information with all of the senses, to make sense of all of this information in such a way as to have a feeling or a sense of what the treatment should be. And while we required that students be explicit in explaining in their thinking, explaining their treatment protocols, explaining their treatment strategies and point combinations to supervisors in the fist semester in order to have a treatment improved, the fact of the matter is that when they observe senior and master practitioners they often see people performing in a much different way. That much different way of performing has a name and was studied in great detail by Michael Polanyi whose book, The Tacit Dimension, is comprised of the Terry lectures delivered at Yale University in 1962, where he developed his concept of tacit knowledge and laid out the simple premise that we can know more than we can say, something that the late Donald Schon, former Ford Professor Emeritus at Massachusetts Institute of Technology continued on with in his development of the concept of “reflective practice,” which is paramount in the clinical training at the College. The Bodily-Felt Sense The bodily felt-sense is a term coined by Eugene Gendlin, PhD, to describe what the client is feeling when she has what Freud termed a psychotherapeutic “AhHa” experience while, impossible to clearly articulate in words, indicates that the client has made, or is about to make a significant therapeutic leap in understanding. While Freud felt this had to be followed by analysis, to state in language what had just been felt at the deep, unconscious level, Gendlin argued that the focus needed to just remain on the felt-sense, and the understanding would

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follow on its own. Milton Erickson evolved a similar concept in his approach to hypnotherapy, where a focus on tapping into the deep knowledge, the unconscious, was the goal of treatment, to bypass the conscious mind and initiate meaningful, therapeutic changes. This concept of a boldily-felt sense as a deep, older form of knowing the world derived from Nietzsche, who sought to think beyond the body-mind split articulated by Descartes, where the human spirit was obliterated, by spiritualizing the body itself. After arguing that the Judeo-Christian established religions were no longer of help in orienting mankind’s spiritual endeavors, with his celebrated proclamation “God is Dead!”, he worked to articulate a new philosophy for mankind in the coming 20th century, based on a ‘joyful wisdom’, the title of the text where he developed this concept. Establishing himself as a diagnostician of the spiritual sicknesses of his day, Nietzsche stressed that “we require for a new goal also a new means, namely a new healthiness, stronger, sharper, tougher, bolder and merrier than any healthiness hitherto…(cited in BME, p. 4 and for a more detailed discussion, ibid pages 236-237).” Nietzsche clarified many times in his writings that such a new, bold way of thinking about human healthiness, of what was best and strongest about humankind, could only be acquired through an active exercise of one’s will, and an “active forgetting” of old knowledge that no longer served to shore this decidedly spiritual quest. With religion no longer seen as the way in which humans could embrace their true spirit, Nietzsche challenged us to take on this quest personally, willfully, joyfully. Carl Jung also stressed the need to rediscover the wisdom of the body, too long a prisoner of the spirit in organized religious teachings, and to “reconcile ourselves to the mysterious truth that the spirit is the life of the body

seen from within, and the body, the outward manifestation if the life of the spirit—the two being really one (ibid, p. 4).” This concept of a deep wisdom of the body that is spiritual at its core is parallel to the Chinese concept of shen and shenming translated as mind or spirit, and as mental or spiritual clarity respectively. In the Chinese concept, which is decidedly pragmatic, spirit clarity amounts to the wisdom or intelligence of existence, of being alive. Someone who manifests spirit clarity, spiritual health, has eyes that are bright and make contact, a shine to the complexion, an alertness, a presentness. This is in direct contrast to someone whose spirit is marred by the emotions and who exhibits either a Yang, frantic, agitated stare, a frightened countenance, a fired up complexion and manner of being; or a Yin, empty, vacant, absent stare, a lusterless complexion, a depressed manner of being. These sorts of signs of presence or absence of spirit are part and parcel of a classical Chinese medical examination. In acupuncture treatment, where there are signs of a relative absence or agitation of the spirit, this should begin to improve with the first few needles, sometimes even with the first few words exchanged between practitioner and patient. On a very basic level, then, much like in mindfulness meditation, acupuncture thus seeks to prod a person who is suffering from pain, discomfort, distress, to turn toward life, to embrace life, to say yes to life, by connecting with this deep wisdom, experienced when it is attained as a bodily-felt sense rather than something to be expressed in words, an AhHa! Life experience that we are all given to understand all along. I will address the similarities and differences between the Western rationalistic and essentialistic Mind focused on things in their ever smaller parts, versus the Eastern Mind aimed at attending to the way things change, the process of change, a process approach, in this month’s BLOG.

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While mindbody medicine has become a main field of CAM practice, in many different forms, the bodymind versions of this medicine have been downplayed. The fact of the matter is, in the research on Indian yogis conducted by Dr. Herbert Benson at Harvard decades ago, too little stress was place on the fact that these Eastern practices were PHYSICAL disciplines. Through a disciplined use of ones body, and ones breath, it was possible to achieve spiritual health. There was very little mentally going on, except for developing a patient, and mindful stance toward thoughts as they would inevitably flit in and out of awareness as one sought to practice Yoga, T’ai Qi, QiGong, or Mindfulness or Transcendental meditation 40 years ago on this continent. Why, then, was this referred to as mind-body medicine, when in fact it was fundamentally bodymind through and through? This is why I chose the title “bodymind” energetics for my first serious attempt at explaining what acupuncture was in the West, and had to keep correcting my editor as well as those who wrote about the book when they would “correct” it to read mind-body or at best body/mind. While the concept of “bodymindspirit” which derived from the New Age Movement in the 60’s in this country was a way to avoid the mind-body or body/mind split way of discussing what is human, in the acupuncture world this has lead to a certain tendency to criticize any approach to healing that fails to add “spirit” to the title as deficient. Frequently over the past 30 years I have had some students and some colleagues criticize my use of the term bodymind (rather than bodymindspirit) who would go on to say I was good at treating the body, by which they meant “symptoms” but could not treat “the whole person”. Even Integrative Medicine stresses treating the “whole person” including the “spiritual side”.

To me, as someone practicing acupuncture for over 30 years, I can just say I do not know how it would be possible not to touch the spirit, understood in a classical Chinese acupuncture way, when one seeks to be attuned to each patient “with the heart and the mind” (Ling Shu p. 17). Elsewhere, the classics stress repeatedly “The key to proper needling is to first attend to one’s own spirit” (Systematic Classic, p. 295). The first chapter of this classic, in fact, is all about the 5 Spirits and about the fact that when Qi arrives, when Qi is obtained, the spirit may also be touched, and so each needle must be manipulated with great awareness of this fact: “One should remain calm and intent at all times, observing the response to the needle and awaiting the arrival of the qi. (The response of qi) is said to be mysterious, subtle, and without form. The appearance (of qi) is like the soaring of flocks of birds or swaying of millet in the fields, which, though perceptible, cannot be discerned […] As if perched above a fathomless abyss with one’s hand grasping a tiger, (when holding a needle the spirit must not be distracted by anything) (ibid, p. 296)” One does not have to keep talking about spirit to practice the high skills of acupuncture, but rather dedicate oneself to mindful practice and practice this in everyday life so that mindfulness becomes a part of being with a patient. This is the topic of the all future Reflections. II: The Way of the Needle So now let’s talk about how acupuncturists, senior acupuncturists, master practitioners are at one with the needle. When acupuncturists pick up a needle, as opposed to students who are just learning to needle, they are not focusing on the feeling of the needle in their hand; they have already developed the skill of being very adept at

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loosening the needle from the tube if it’s a Japanese style disposable needle, and this implement is just a part of their hand, not something they have to think about for a moment, and of course that is something that only came about with practice, by learning how to hold the needle in a graceful way so that the needle and tube become one with the hand. And so when an acupuncturist, a senior acupuncturist or a master practitioner picks up a needle, they are not attending to the needle, they are not attending to the tube, they are attending to the point on the body that they have located visually, or by palpation, and if visually, will then go to the body and palpate to find the point and in acupuncture physical medicine, in classical Chinese acupuncture, in Japanese meridian therapy, these points are moveable points. These points are not textbook rigid point locations. Rather these are things that can be felt. So an acupuncturist who works from a palpation based approach and who trusts the tacit knowledge in their fingertips, trusts what they see and feel and sense through their hands. She will look for a point and once finding a point, attending to the point, will use the needle, which is just an extension of her hand, to go into the point, to search the point, to search the “Cave,” (one of the meanings for the Chinese term that denotes an acupuncture point). She will search for the active area, for a certain kind of sensation, a certain resistance, a certain stuck feeling, a certain heaviness, a certain denseness, depending on the kind of point. When she feels this, through the tip of the needle as an extension of the fingers feeling this reaction, they she can apply the tonifying or dispersing needle techniques to make the tissue respond in the way in a disciplined and predictable way. This happens through practice, but all senior acupuncturists do this effortlessly, and if they were to instead attend to the minute mechanical and muscular activities that their needling hand is going through as well as their non-needling hand to make the tissue respond in this way, they

might very easily become crippled and unable to function. That being said, where Schon goes I believe further than Polanyi or, let’s say, is more pragmatic than Polanyi in the education of professionals, in his idea of a reflective practice and a reflective practicum with senior practitioners. If ACP and clinic supervisors, as well as students, were to pay close attention to how senior and master practitioners stand, manipulate the needle, move their hands, they might be able to at times watch students who are in ACP training, look at how they’re using the muscles in their hands, the muscles in their forearms, their posture, their stance, whether they are sinking into the tantien or held tightly and rigidly, whether or not their arm is strongly engaged or very weakly positioned over the patient, if they are able in fact to notice and attend to what they usually do not attend to they may well be able to make changes in the actions or practices of these students in training that will make them be able to indwell more quickly and more fully in the needling process, and make the needle an extension of the students so they can feel and attend to what is underneath the tip of the needle rather than what is held between their fingers. I’ve been looking at this carefully, and this is only my way of needling. There are many different ways of holding a needle, using the needling hand and a non-needling hand. Mine are based on very classical descriptions of these techniques, but these are just my efforts, my way of making these techniques a part of me, a part of my body, an extension of my body, something that comes second nature. So, recognizing that there are many ways to do this, first of all, I believe that what is critical in needling, if we now look at these minute mechanical actions, is to see the wrist as the pivot. The wrist is not rigid. Many students needle either just with their fingers trying to use it in a very tight way, almost like children who are first learning how to write

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with a pencil, which they grip far too tightly. So what we need to do is help beginning students have a very relaxed wrist. The wrist is relaxed and the movement is fluid. So if one keeps the wrist relaxed, the fact of the matter is, if we look at the forearm muscles while we’re doing this, if we were to do a soaring crane type of movement with our hand where we bring all of our fingers together and then touch all of our fingers, the pads of all of our fingers touching each other toward the thumb, then the fingers become a small pointed beak of a bird. And if we now were to keep our wrist very fluid, moving it first inward then extending it outward, flexing it, extending it, moving it to the right and the left very loosely, we can see, if we look at our forearm muscles, that our forearms muscles are very much a part of this movement, even if the movement is small. So if the reader tries this, moving first this hand that has fingers that are very engaged together, not hard but definitely with force as if one were going to begin striking something as in martial arts, this engaged hand also involves engaged forearms, and in fact as I do this and feel I can see that I am not engaging the muscles of my upper arm, I am not engaging the muscles of my shoulder, I am not engaging the muscles of my chest, but all of those muscles—the upper arm, the shoulder, the chest—in fact have settled into a very strong position where they can hold the forearm and hold the hand. So the posture has to be erect, the shoulders have to be level. The body can do this forever, the whole body is strong, the stance is balanced, one foot somewhat in front of the other or shoulder width apart as in Qi Gong for example, or Tui na massage, and in a strong stance like this, with the whole forearm supported, the forearm and especially the hand with the help of the fulcrum of the wrist is able to engage in such a way that the motion, either flexing toward the patient or extending the hand away from the patient is a strong movement and is not just a movement from the fingers and is not a rigid movement from the whole arm.

So if we look at this for a moment, we’ll see that in the first instance of tonifying needle technique, which is first slow IN then fast OUT, if one imagines holding a needle, or holds a toothpick for example, and starts moving in a big movement in flexing the muscles, the forearm flexor muscles are very visibly activated. And a teacher coaching a student in this technique could easily just go ahead and hold the flexor muscles of the forearm and make sure that the student is engaging them, so that if the student is just using the fingertips in sort of a rigid way that is not using the forearm, the teacher as coach could say to the student, “just let these muscles work, do this all the way from up here, do this from the flexor muscles all the way up at your elbow, use the entire muscle.” That will help them focus on the “in” and by doing that, in fact, as I’ve found in practicing on myself, just the contraction of the forearm muscles holding the needle in place creates quite a strong sensation when done properly because it is adding weight and force to the needle on an inward movement, because the wrist is allowing the heaviness of the hand to move inward, to flex, and the movement is a movement that is heavy on the in. I always tell students when I am teaching this technique, “heavy on the in,” because the focus is on the in. It is an engagement of the forearm muscles with a supple wrist. And the final thing that is important whether tonifying or dispersing is that the fingers are together just as they were in this flying crane technique. All of the fingers ideally, or at least three of them, the index, the middle finger, and the thumb, are holding the handle of the needle, not pinching it, the skin is not blanched, the nail beds are not blanched, holding it very lightly in fact, and the force that is holding the needle and the weight that is in the hand, coming first from the flexor muscles of the forearm is generated through to the point, Large Intestine 4, which is the first dorsal inner osseous muscle, and that muscle is fully engaged. Many students have trouble with this. If one

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pinches the fingers very hard, that muscle becomes engages and we can see that it becomes hard. But that makes the needle sharp, rigid, a piece of metal instead of an extension of the fingers and of the whole lower arm. So in releasing the grip on the needle and having the fingers holding the handle of the needle very gently in order to prevent this from being a sharp technique, the action during tonification has to come from the flexor muscles, and the first dorsal inner osseus muscle, at Large Intestine 4, which has to be fully engaged, which creates weight down through the fingers, through the index and middle finger and thumb, and this weight creates a reaction in the needle that makes the subcutaneous tissue respond in a characteristic way to grab at the tip of the needle. It’s a heavy motion that causes a heavy slow response, not a fast response. This is a slow in, slow response of the muscle, even though the needle is only into subcutaneous fascia. The Japanese often refer to this as “needle grasp.” The classic texts describe this as a very gentle, almost imperceptible manipulation: “Supplementation may be defined as tracking. Tracking implies (insertion of the needle) I a seemingly casual way, as if nothing were being done, like the biting of the mosquito. After retention, the needle should be withdrawn quickly, like an arrow leaving a bowstring” (Systematic Classic, p. 292), and the left hand closes the hole for several moments. The result is a gathering of tissue, a grasping of deeper muscle, a toning up of a weakened or even somewhat flaccid tissue area. Often there is a feeling or warmth, or even of a weight that has sunk into place that lasts for several minutes. That is tonification. Dispersal then, and here we are talking about twirling the needle, as well as moving it in the opposite way, consists of wrist movement creating a fast in/ slow out technique. What one does in fast in slow out is the opposite with the right hand. So one first inserts the needle fast. This fast movement is with the

forearm muscles, so it’s exactly the same use of muscles as for tonification, but it’s done quicker. And this kind of quick movement causes a fast grab of the muscle, and the fascia deep beneath the needle—a fast reaction rather than a slow one. And then, still using the wrist as the pivot, one now uses not the flexor muscles at all, but the extensor muscle of the forearm on the top of the arm, the yang aspect of the arm as opposed to the yin flexor aspect. One uses the extensor muscles, the extensor of the index, ring, and middle fingers in the area of Large Intestine 10 and what Kiko Matsumoto calls Triple Intestine 10, so on the triple meridian at the same level as Large Intestine 10. If one feels there, and as a coach if one feels there, instead of engaging the flexor muscles, one engages the extensor muscles all the way up to the elbow, using the wrist as a fulcrum, still keeping the fingers engaged, grasping the needle lightly but with very engaged hand, a strong hand, a hand that if somebody came to hit it away as in martial arts, would be there, stay put, a hand that is present, fully engaged, weighted. So now, with the same grasp on the needle, with the same engagement of the Large Intestine 4 areas, the first dorsal inner osseus, one simply uses the extensor muscles which the teacher, the coach, could but their fingers on, and with the wrist as a pivot engage the extensor muscles which creates a heavy focus on the out. And the out movement should be slow, so the extensor muscles are used very slowly after having quickly gone into the point to create a quick grab. And it is important that it grab. If it doesn’t grab, one goes out slowly and then in rapidly again several times and then out slowly again. The classic texts describe it this way: “Drainage may be defined as head-on attack. Head-on attack means (rapid) insertion (of the needle) while twisting to enlarge the hold, and (slowly) extracting it so as to discharge the evil qi)” (ibid, p. 291).

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So this simple technique, based on the tactics of fast in slow out uses a totally different set of muscles—yang muscles for yang technique, extensor muscles—and the fascia is slowly pulled away from the point, the point that is taut, the point that has too much tone. And by pulling the fascia out and then letting the needle stay shallow, the technique will actually create a release of the fascia rather than a toning up of the fascia. So through these very precise uses of the forearm muscles and engagement of the muscles of the hand, engagement of the fingers without gripping tightly, one actually extends the needle, it becomes a part of the hand, an extension of these fingers brought together. And by bringing these three fingers together, the thumb, the index, and the middle finger, one is able to use the force either of the flexor muscles to focus on the in or the extensor muscles to focus on the out. This is something that I believe is easy to teach and easy to improve upon if one is still having trouble doing tonification and dispersal needle techniques. That’s it in a nutshell for the right hand. Now, if one adds twirling—twirling very much engages the Large Intestine 4 area, it is very difficult to twirl without. But in twirling, one engages the flexor muscles with the wrist flexed to tonify, or one can twirl with the wrist extended away from the body to cause dispersal. So twirling with the wrist either flexed or extended will create different reactions in the tissue, and if one lifts and thrusts and twirls at the same time, these processes can be done quicker, but it is by no means necessary. A way to build up the strength in the hand, to make it a strong hand, and here I am thinking of acupuncture like Qi Gong or like a martial art, the hand must be and the forearm must be fully there. In martial arts, even in Qi Gong, when someone is doing different motions in Qi Gong, the arms are engaged, the hands are engaged. If someone were to come up against those arms, which appear to be just floating in space, they would come up against

something quite solid. The arms engaged that way would be able to immediately protect themselves and defend themselves. These would not be arms that would be able to be pushed away easily. I think in acupuncture it’s the same thing, and I’ve just come to this realization in making this new attempt at understanding the more tacit aspects of what we do, that many students are hovering over the body in a very light way. They somehow feel that being extremely light and loose is the way to be gentle. In my experience it’s that type of needling that is sharp and very much not engaged needling and does not create the reactions in the patient hat the student hopes for. So I believe that the practice of acupuncture has to be like Qi Gong, or AOM Bodywork techniques, or even like a martial art in the sense that the parts of the body that are being extended and attending to the other person have to be fully engaged, strong, weighted, present. And by being strong and by having strength and muscles engaged one is in fact bringing a force to the needle. Some people would say this is Qi Gong being applied to the needle. So, in order to strengthen the hand and the forearm muscles, what I’ve recommended to students is to get a rather thick dowel rod. It could be just four inches long—almost like the handle bar of a bicycle, and one might even be able to find something like that in a sporting goods store, or just get a hard rubber cap that fits over handle bars—in any case something about an inch in diameter, round, a dowel rod, so something much thicker than a needle. And if one holds that like one would hold a needle—I do it with my cane, for example—just the holding of it can only be done by engaging the Large Intestine 4 area, the first dorsal inner osseus muscle. It’s through that muscle that one holds a cane, one cannot just pinch the fingers—it’s in fact impossible—even though one can pinch just the fingers around a needle and not engage that muscle, which I’ve seen many times with

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students. So by using this thicker needle, this dowel rod, one has to engage that muscle, and then just twirling it back and forth is a very strengthening activity. And one can twirl it back and forth slowly, rapidly, clockwise, counterclockwise, and watch, using a very loose wrist, doing this first using the flexor muscles at the same time to build the muscles and to train the muscles and make these muscular actions tacit rather than conscious. And then do the same thing twirling the dowel using the extensor muscles on the top f the arm. And in this way one can very quickly build the forearm and extensor muscles. Mine are quite developed and I never do anything in the gym to use these muscles, this is all from having done acupuncture for thirty years. So this would be the way to strengthen the arm, make the hand present, heavy, engaged, weighted, so that there is force, weight in the hand ready to make specific reactions happen from the needling. That brings us the last part of the needling process, which is what to do with the left hand. I cannot speak for styles that don’t use the left hand, which certainly is often done. But in my approach, and the Ling Shu already states this very clearly: “The right hand is used to hold and push the needle while the left hand assists and controls” (p. 5). And later on in the same text: “The left hand fixes the bone position, the right hand follows. Do not cause the flesh to bunch up”(ibid, p. 230). Acupuncture, in the classics, is clearly a left-handed affair. In Japanese meridian therapy, which uses tubes, the role of the left hand is extremely important, and that’s where I learned to use the left hand, was in learning to hold the tube. One uses the left hand to grasp the tube, the thumb and index finger grasping the tube at the very bottom where the needle tip will be. And by holding the

tube right at the bottom and then placing the tube on the point, one places a lot of weight, a very weighted left hand or non-needling hand, and compresses the fascia so that the tube is actually inserted quite distinctly into the fascia and is not floating lightly on the skin. This will prevent sharp insertion when the needle is first tapped in. So in this kind of technique, holding the tube at its tip between the index and thumb and letting the other forefingers fan out as wide apart as is comfortable depending on the part of the body or closer together almost like one holds a pool cue, almost identical to that kind of way of spreading ones fingers, the whole left hand, the whole non-needling hand, the edge of the palm, the edge of the pad of the thumb, the whole heel of the hand is very firmly weighted on the patient. This is not an insignificant process, because by weighting the area—and one can do it just with the thumb and index finger as well, but it’s more powerful if one weights it with the whole hand—then as soon as the needle is tapped in, it is already at the proper depth where stimulation can occur especially for tonification. And once it’s tapped in and in my style where needles are used that are 34 gauge in most cases, I find that the tap has to be two or three taps, not just one, and ideally the taps would tap in such a way that the fingers do not touch the top of the tube, they just touch the top of the handle of the needle. And if one does it properly, the needle is propelled fairly deeply into the tube so that it’s deeper than the surface of the tube. The needle has actually been propelled somewhat deeper than if one just pushed it in slowly, which is sharp and not a pleasant way of needling. So tapping the needle a couple of times rapidly, one spreads the thumb and index fingers slightly apart on the non-needling hand, and relaxes the weight of the hand slightly where the thumb and index finger are and stretches the skin and removes the tube. Now, with this taught skin, one can do the first stage of the needle technique, which is to ensure that the needle is into the fascia, the subcutaneous layer, which is called

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the Cou Li in Chinese. So the needle is in this layer, which is also the Wei level, the Yang level. At that point, one can let go of the needle, let go of the left hand, and now the needle is at a Wei level depth and now one can direct the needle with the left hand or the right hand. So what I now suggest that students do is reposition themselves. If I want to just tonify, I now just put down my index finger very close to the needle and create a slight weight on the area, compress slightly, and tug very slightly so that the skin is taught right where the needle is. I make it taut like a drum—a very slight weight in, a very slight tug, changing the direction of the needle if desired, or just keeping it perpendicular. With the skin and fascia somewhat taut, I then do my needle techniques: slow in, rapidly in, and so forth. When I’m doing trigger points, I use Travel’s technique, which is to trap the muscle, which I first have felt cross fiber, and once I find the most tender part of that taught band, I stretch my index and ring fingers slightly apart. Actually, I do the same thing: I find the point cross fiber, I place the tube right on the most tender spot and hold it with the thumb and index finger first, tap it in, spread my thumb and index finger just slightly apart and remove the tube. At this point, I recommend to let go of the needle with both hands, and then to put the left hand, the non-needling hand, middle and index finger, cross-fiber above and below the needle, so surrounding the needle, straddling the needle, cross fiber, finding the muscle again and using the fingers to ensure that they are placed right over the needle, but this time not hard enough and heavy enough to find the tender point, just to keep the muscle trapped and that part of the muscle weighted where the needle is located. And now, with very little pressure but stretching the skin again, I have students hold the needle again with a very engaged hand and do quick movements in two to three times, and then slower out, hovering for a second or longer, called sparrow pecking technique, like a a bird pecking for seeds. So it’s quick pecks,

the pecks are in a staccato kind of fashion, so not even pecks, not rhythmic pecks, jerky pecks, pecks for a couple of grains and then out, and then a couple more grains, and then out. So to artificially show this at first to students, I recommend three pecks in and then one out. So peck, peck, peck, out-HOVER, fast pecks in, slow out. Three pecks in, slow out. This is a fast in slow out technique, and the focus is on the fast in. If one focuses on the slow out it will usually not work. So it’s a focus on fast, fast, fast, slow-HOVER, fast, fast, fast, slow,-HOVER changing the direction slightly each time as if one were pecking for different seeds each time. This will, if there’s a trigger point in the area, cause the muscles to fasciculate and twitch, often visibly, but even if not visibly, perceptible to the non-needling hand, which is resting lightly this time on the area. So in dispersal, the left hand is resting lightly, still with the skin taut where the needle is. In tonification the hand is resting heavy because in tonification the focus is on a heavy weight dropping into the area. In dispersal, the focus is on a rapid movement in and then a relaxing of the fascia. With these basic ideas and with some coaching, everyone can learn to do proper tonification and dispersal techniques. And following Polanyi’s example of tacit knowing, one can learn to attend to what lies at the tip of the needle and attend to the reactions that one is looking for at the tip of the needle, rather than being distracted by the handle of the needle or this implement awkwardly held in the hand. The goal is to make the needle an extension of the forearm, an extension of the muscles of the forearm and the muscles of the hand.   Tips When Needling the Root/Opening Moves I have several specific things that I focus on when needling the first few points in a

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treatment, points my dear friend and master acupuncture practitioner Dr. Eric Stevens always refers to as “opening moves”. Influenced again by Shudo Denmei’s pragmatic advice, that only a few needles need special attention to set the Root treatment in motion, I seek meaningful de qi at the operational jing level points: SP 4, GB 41, LU 7, SI 3, and the source points for the thre leg Yin, sometimes with Sp 6 instead or added to the source points as follows:

SP 4: I needle this textbook location, but between the bone and the muscle (the adage to needle between the red and white skin makes no sense, as this differs with different people, and can lead to needling the often exquisitely tight, tender muscle especially on people with flat feet or plantar fasciitis-type problems. I always needle this point on the right, as I want to needle the paired Per 6 on the Heart Protector left side. I run my index finger with distal phalange relaxed as per Shudo Denmei’s suggestion for palpating actual acupuncture points (as opposed to indurations), from SP 2 for about an inch until I fall into the hole just at the distal end of the bone where the finger stops abruptly. I retreat with the finger a touch to place the needle on the exact spot, angling the needle with tube compressed firmly into the point (supported by left hand thumb and index finger rooted around the tube at the base, into the flesh to prevent a sharp insertion) and tap several times to ensure the needle has progressed all the way into the tube with its handle top level with the top of the tube. One should never tap this point just once with the # 3 Serein needles I use, or it will not insert deeply enough and be sharp once the tube is removed.

With my non-needling left hand I tug with my fingers on SP 2 area, until I can see the skin and subcutaneous fascia tug/drag and tighten all along the trajectory of the meridian, right up to behind the medial malleolus. I always tug this way when I want to initiate a propagating Qi sensation along a channel, which “facilitates” the taut fascia, making it more yang and more reactive. If the skin is cold I rub it to warm it, or even cover with Mylar for a few minutes to warm it up. Rubbing or tapping along the trajectory where the propagation is to occur will also hasten the desired results. I then insert the needle very slowly into the resistance at the point, finding where it is most reactive, dense, lime an eraser on a pencil which Kiiko Matsumoto refers to as a “gummy” or “kori”. Needling in to this resistance until the needle gets slightly stuck, I then twirl rapidly into it, or twirling and lift and thrust focusing on the out movement, and the propagation is quick to arrive for most people. Wherever the Hara has been tight on the abdomen, especially in the middle heater along the Kidney, Stomach and even Spleen or Liver pathways, this will release. I look for exaggerated skin creases on the abdomen, which bespeaks constrained Qi at that level and an upregulated sympathetic nervous system (with signs and symptoms of nervous or overactive gut functions), and these will tend to decrease markedly. The breathing invariably starts to improve with such initial Root points, a sign that YinYang regulation is setting in. There may be rumblings in the gut as well, and a definite change in the complexion. The eyes will also soften and the person’s demeanor will normalize somewhat. The

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propagating sensation will travel at least 4-5 inches along the Spleen pathway, up toward the medial malleolus. If it can be made to ascend to Sp 6 level, it will usually travel up to the pelvic region and even umbilicus or higher. Kiiko would call this targeting the Qi, and the change at gut level is what makes such initial points have such a powerful affect on the constructed Hara. The rectus abdominus will be much less constricted from the navel to the subcostal region in most cases. I needle the paired Per 6 on the left with neutral stimulation to get the slightest de Qi response travelling toward the wrist;

GB 41: I insert the needle slowly in the same fashion, on then left side, angling under the bone into the textbook location toward Liv 3. My left hand tugs/drags the skin and subcutaneous fascia again diagonally away from/in the direction opposite to Liv 3 until I can see the drag right to Liv 3 and then insert slowly into the resistance. As this is a Yang meridian I needle more strongly until there is a deep penetrating de Qi response that is quite strong (always within the patient’s tolerance level however) spreading throughout the dorsum of the lateral foot. This will tend to relax the waist and pelvic region and restrictions will begin to release, sometimes totally along the pathway of daimai (GB 26-28, and the lower external obliques). I needle the paired TH 5 neutrally for the slightest de Qi sensation, or modify this opening move by adding left Liv 3 needled until there is a definite but tolerable de Qi sensation, and add right LI 4 instead of TH 5 (thus adding one diagnonal set of the four gate points to GB 41). I do LI 4 like Liv 3, until there is a definite but

tolerable de Qi sensation. I will often do this combination together, so SP 4 on the right, Per 6 on the left, then GB 41 and Liver 3 on the left, and LI 4 on the right as a modified “Infinity Treatment) treating chongmai and daimai to target dysfunction and constriction in the pelvic region and lower heater. I do SP 4 and GB 41 on the same side as hip pain and dysfunction to target the hip area.

Lu 7: I needle Lu 7 to open renmai at the exact textbook location, off the trajectory of the rest of the Lung regular meridian, dragging away from the elbow with my non-needling hand until I see the skin and subcutaneous fascia tug all the way to Lu 5 or even Lu 4-3. I needle slowly into the dense area as for Sp 4, and this will invariably create a rather strong and spreading de Qi sensation in the area or even up the channel toward the elbow. When I want to needle Lu 7 as the Luo point for carpal tunnel area thumb and palm pain and numbness, I use Travell’s trigger point location for the flexor pollucis longus, a good inch proximal to the level of textbook Lu 7, this time along the Lu pathway, tugging the same way. Even though the needle is inserted up the channel, this point will cause a deep spreading muscle sensation down to the thumb and palm, and even make the thumb twitch—identical to what one would want when treating the Luo of the Lung for palm and thumb pain. I needle the paired Kid 6 at the textbook location, slowly and carefully insinuating the needle between the tendons to 1/8” or so, and stimulate for a very slight de Qi response;

SI 3: As a yang meridian point, I needle for a stronger but tolerable de Qi response, inserting the needle

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almost ½” across the interosseus muscles of the palm toward LI 4. I stimulate BL 62, about 1/8” into the exact textbook location between the two tendons, for a very slight de Qi response.

The next set of Root points, this time from the regular meridians to target the Ying level, will usually consist of the source point for whatever leg Yin meridian in the circuit in question: when treating the Taiyin-Yangming circuit, this will be SP 3 or Sp 6 as a common alternate; For the Shaoyin-Taiyang circuit, Kid 3; and for the Jueyin-Shaoyang circuit, Liv 3. This is classic needling of the source point for the yin meridians of the foot. I have learned in thirty years of leading and supervising students as they engage in acupuncture clinical practice treating student-patients for 200 hours over two years, to establish treatment protocols that begin this way, with distal leg ying level points to avoid an overly strong reaction with release of heat or yang rising upward. If I have not already needled Sp 6, I usually add it after Kid 3 or Liv 3. I needle Kid 3 either side, as there are two kidneys/adrenals, Sp 6 always on the right and Liv 3 always on the left, opposite their respective organs. When I needle source points, I insert the needle very slowly after tapping in with tube held firmly as above, into the dense resistance. For Kid 3 this will be very shallow, about 1/8”. I use one finger f my left hand after removing the tube to gently tug the skin and subcutaneous fascia I any direction just to make the skin where the needle is inserted taut like a drum but not enough to pull the needle toward my finger. I then needle slowly into the resistance, less than 1/8” for SP 6 and Kid 3, and ¼” to almost ½” for Liv 3, which I

find reacts more like a Yang meridian point. That said I see Liv 3 as a great point for Liver excess and am not in the habit of treating Liv 8 for Liv deficiency, as the meridian therapy practitioners like Shudo Denmei do. They advocate a very shallow insertion for Liv 8. When I am treating yin deficiency, I prefer Sp 6. At Sp 6, I insert very very slowly into the resistance barely encountered at first at the point, and after hesitating a few second, pull the needle quickly to the surface, then reinsert extremely slowly and with a very heavy needling hand rooted to the area, edge of palm planted firmly on the patient’s lower medial shin and invariably notice the resistance becoming more pronounced, and more dense even though still very shallow. Once that occurs, I needle staying at that depth rapidly until there is a pleasant mild de Qi sensation spreading around the area.

                                         

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Tips for Needling the Wei Level This level of disorder is termed Wei Level by Chamfrault and Van Nghi, and denotes disorders of repetitive strain, physical trauma, injury, and Wind/Cold/Damp Bi syndromes affecting muscles, tendons and ligaments and bones. In Acupuncture Physical Medicine, this level of physical medicine practice is reinforced by a comprehensive study of Travell and Simon’s two-volume tome, Myofascial Pain & Dysfunction: The Trigger Point Manual. In my book, A New American Acupuncture: Acupuncture Osteopathy I argue that by including Travell and Simon’s entire approach to palpation and needle release of trigger points into the acupuncture study of the tendinomuscular meridians (also known as muscle channels in English), the knowledge of how to palpate for, identify and needle muscle ashi points is significantly enhanced, with the side benefit of affording the practitioner a more western medical way of discussing such disorders with patients, their caregivers and other medical professionals. I refer the reader to that text, where I list the main trigger points for each of the three zones of the body –the Taiyang dorsal, Shaoyang lateral, and Yangming venral zones. I give basic classical Chinese acupuncture protocols for distal points that then use Travell’s trigger points as the local equivalent of tender Ashi points. Any serious effort to train in a comprehensive treatment of the muscle channels, however, must include the treatment table-side use of Travell and Simon’s two volumes as ready reference to facilitate clinical use, and internalization, of these trigger points, what they feel like, how to trap them, how to needle and release them, in order that this knowledge might become second nature.

Again Maciocia shows his bias against (and deep ignorance about) the comprehensive treatment of muscle channels, which any practitioner of East Asian bodywork including tui na, anma and shiatsu would excel at. After listing the main local points per body area, in his final chapter of the aforementioned text, on bi syndrome, including sports and repetitive strain injuries, Maciocia makes this telling statement: “Ah Shi points (points which are tender on pressure, are also local points and form an important part of the acupuncture treatment of Painful Obstruction Syndrome. In most cases, these will coincide with normal channel points, but if other points are tender on pressure they can be needled in addition to normal points (Ibid, p. 656).” He then proceeds to only list “normal local points” over ashi points, except for one ah shi point he labels the “epicondyle” point one cun behind L.I. 11, Quchi, which appears to be identical to Travell’s ring finger extensor attachment trigger point. If he were trained in trigger points, and how to palpate cross fiber to identify the most tender ones (as shi points), he would know hundreds of such local points, all of which would prove incredibly effective in clinical practice on such conditions. The normal acupuncture points he does list for the muscle channel treatment of the elbow, shoulder and knee are standardized points that appear in the simplest modern TCM discussion of bi syndrome, and fall far short of what I would expect an expert in acupuncture as a hands-on, physical medicine to know. Concluding his ambitious effort at presenting a detailed English-language text on the secondary vessels in this way, especially when including the major texts by Drs. Yitian Ni, Andre Chamfrault and Nguyen Van Nghi in his bibliography and further reading list, does a great disservice to those native English students and

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practitioners who had hooped to find this a useful clinical text. As it is, regarding the clinical use of muscle channels for pain musculoskeletal pain and bi syndrome disorders, Maciocia’s text offers nothing new, and misleads the reader with images of the muscles in each muscle channel, without ever indicating one should learn how to identify the trigger points in these muscles so laboriously presented by Travell and Simons. At the Tri-State College of Acupuncture, students study the myology of trigger points and gain clinical facility in utilizing these invaluable texts in a myology course in Year I, after their study of anatomy, that prepares them for Acupuncture Clinical Practice with me and my team in the second year as they engage in two semesters using AOM protocols that frequently incorporate Travell and Simon’s trigger points into the practice. Student clinic-interns routinely resort to these Travell inspired APM treatment strategies when confronted with simple to complex, chronic pain disorders including athletic and performance injuries, repetitive strain and cumulative trauma disorders, as well as chronic pain disorders stemming from the full gamut of musculoskeletal disease. These sorts of complaints comprise a good 50-55% of the conditions treated in the college’s busy community acupuncture and pain clinics, as well as in the practice of its faculty. In APM, this myofascial pain knowledge base, and trigger point dry needling techniques are therefore clinically necessary over half the time. Once again Maciocia’s The Channels of Acupuncture reveals a decided bias against the muscle channels (jing jin). As Maciocia states in the preface to Part 4 on these channels, “The Muscle channels are not as important and as clinically relevant as the Connecting channels. However, in the fields

of musculoskeletal problems and of Painful Obstruction (Bi) Syndrome, they are extremely important (p. 283).” If musculoskeletal problems and Bi syndrome disorders make up over 50% of an acupuncturist’s practice, how could one ever make such a statement? Unless, of course, ones practice is predominantly comprised of internal medical disorders, which would appear to be the case in the North American practice of TCM. A look at the key TCM texts will show only very short sections on painful obstruction/Bi syndrome, and the muscle channels are seriously downplayed in the English-language literature. In my experience over the past thirty years, I have encountered TCM students and TCM practitioners trained in North America at other AOM colleges who appear to have little if any knowledge of the muscle channels or skills in palpating and treating tender/ashi points—the central focus of muscle channel treatment. Students report seeing virtually no NCCAOM board examination questions on bi syndrome for example, with the preponderance of cases focused on ZangFu internal medical conditions. Perhaps it is time the NCCAOM initiate a survey to ascertain what acupuncturists really treat, which we did do at the college twice over the past several years, and twice in faculty practices. Each time we learned that these disorders occupy over 50% of what our clinics, and the clinics of our faculty, treat. Another curious piece of evidence to suggest that knowledge of, and acupuncture skills in treating muscle channel disorders is not part of every AOM college’s entry level curriculum, is that the majority of ACAOM candidate or accredited post-graduate doctoral programs in AOM have pain management as a specialization area, indicating that they see this as a more rarified, specialized area, not a basic entry level set of knowledge and skills all practitioners should have.

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Acupuncture Physical Medicine treatment of these wei level tendino-muscular meridians is straightforward for the distal points: use excess reactive points distal to the area of pain and dysfunction, based on the principle, “the further the farther”. The jing-well point is therefore always indicated as the point furthest from the symptomatic area, and then moving up the channel, based on the needling strategy of “Bao Ci” where one needles one ashi or tender point after another along the muscle pathway based on palpation, one disperses with lifting- thrusting-twirling technique focused on the outward lifting motion to propagate Qi along the muscle pathway. If the luo point is tender, and especially if its target area is within the area of the patient’s pain and dysfunction, this is an excellent distal point as well. For local points, APM integrates Travell and Simon’s myofascial and tendon attachment trigger points. Any practitioner serious about learning how to use these trigger points to supplement their knowledge of treatment of ashi points can readily use their two volume “trigger-point manual” tableside and open-book, to guide careful cross-fiber palpation. One can then either needle wei level oblique shallor OVER these trigger points, a classic Chinese acupuncture technique, or for deep muscle pain especially when aggravated by Cold, needle slowly into the belly of the muscle until there is deep de Qi, or use sparrow pecking technique after this last technique and after de Qi has been achieved. To do this, with the non-needling hand straddle the point and apply a slight amount of pressure inward, but mainly apply pressure laterally away from the point to slightly compress the underlying fascia, keep the contours of the muscle clearly demarcated, and stretch the tissue to make a more taut, rather than bunched up, surface. Then withdraw the needle to the skin level, and begin to peck with a fast in, slightly slower out motion, repeatedly with a slight

hesitation of a bit less than a second on the out after 3-5 pecks, so: FAST in-in-in (in-in), a bit SLOWER out and hesitate almost a second/ resume pecking like a sparrow, now for gains a bit to the left or right or above or below for more grains, FAST in-in-in (in-in), a bit SLOWER out and hesitate almost a second, and resume. This usually causes twitching/fasciculation of the muscle underneath the fascia being needled, even without piercing the muscle. If the muscle is slow to release in this fashion, go in slowly again as in the beginning, and get de Qi, then peck slower, fanning out in the 4 directions more deliberately (this is how trigger point injections are done and are described in great detail in Travell and Simon’s manuals) until the muscle twitches. At that point one can usually withdraw while pecking back to the surface, pecking at the superficial fascia just over the muscle in question. Dry needling of trigger points in most approaches just uses thicker longer acupuncture needles, about 32 gauge and 1.5-2” long, so as to be able to approximate Travell and Simon’s trigger point injection technique. One can also take trigger point dry needling courses with MyoPain Seminars, which descended from the Travell Seminar series and is still co-directed by Travell’s protégé/colleague, Dr. Robert Gerwin. In this seminar, open to licensed acupuncturists and medical professionals with the authority to perform dry needling in their respective states, participants learn how to locate, identify and perform dry needling on the main trigger points using acupuncture needles as above. The Tri-State College of Acupuncture which I founded also occasionally runs a summer seminar series in APM dry needling which is advertised on the college’s website for CEU courses at www.tsca.edu.

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Tips on Needling the Three Yang Zones/ Cutaneous Regions When focusing on needling of the chronic myofascial holding patterns in the three Yang Zones, as outlined in the previous chapter, one can bring to bear any number of classical and modern acupuncture techniques and strategies: 1] wei level or trigger point dry needling as covered in the previous chapter; classical Chinese and modern TCM bi-syndrome techniques outlined by Dr. Ni in her discussion of tendino-muscular meridian treatment ( Navigating the Channels, pp. 9-10), especially:“Bao Ci” for muscle bi syndrome that can affect a large area with pains moving around (Taiyang scapula pains at times, at other times Taiyang low back and buttocks pain, and at yet other times Taiyang hamstring and calf pain in a dancer for example); “Fu ci” (the standard shallow, oblique wei level technique where the needle tip ends up over the affected ashi/trigger points, but not into the muscle trigger point itself and: “He Gu Ci” for a deep muscle bi pain disorder, with one needle inserted perpendicularly into the belly of the ashi muscle point/center of the trigger point itself, with two other needles inserted obliquely, wei level over the tendon attachment (what Travell and Simons refer to as Attachment Trigger Points or ATrPs), either angled toward the perpendicular needle, or away from it depending on sources. When there is involvement of inflamed tendons or ligaments, or bone (osteoarthritis), I prefer to use a modified “Duan Ci” technique where one starts the needle shallow and perpendicular, at the yang, wei level. Then one inserts the needle slowly to a deep level until very close to the tendon, ligament or bone involved. Repeat this a few times until a deep de Qi sensation is obtained, and then stay at the depth where this is felt, and apply very short and slow lift-thrust manipulations until the sensation

propagates deep into the tendon, ligament or bone. In the PRC, this technique would actually needle into the structure involved to cause bleeding, which would be considered a surgical intervention in North America and must be avoided due to risk of deep and serious infection. 2] stationary or moving cupping; guasha; 3] heating techniques like moxibustion (direct or on the top of the needle or indirect); hot packs, heat lamps; mylar applied over the treated area (which just floats on the needles and generates tremendous heat when the skin is bare); 4] Electro-stimulation without or applied to needles; 5] Deep sustained acupressure techniques from anma, tui na or shiatsu (ischemic compression in Travell and Simons) to ashi/trigger points followed by slow release (strain/counterstrain); Summary of Basic Needling Depths and Skills A] For the Jing and Ying levels, the integrated APM/CCA approach makes use of classical Chinese techniques consistent with TCM: Jing Level: Extraordinary vessel distal opening points (SI3/Bl62 etcetera) are close to the bone (marrow, jing). In needling shallowly, 1/3 of an inch at most, one is already near bone. Needle into the subcutaneous fascia over the bone, with precise point location to enter the point. Neutral mini lift and thrust, with twirling is sufficient until there is a slight grab felt by the practitioner. The patient will begin to feel a heavy sensation. On Yin opening points, stop at the first sign of deqi. That is enough. On Yang opening points, the deqi can be stronger. REMEMBER DE QI RESPONSE

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MUST BE TAILORED TO THE PATIENT’S “DE QI TOLERANCE LEVEL”. Do these points first to begin to create/open the circuit involved. Leave these points at the depth the grab was encountered. Do not pull back to surface. Ying Level: Regular meridians are deeper within the fascia and “hidden from view”. The distal command points are places where the meridian is closer to the surface and easier to access with rather shallow needling. The LING SHU lists distal command point depths as follows: Foot Meridians: Yin meridians: 1/10-1/3” Yang meridians: 2/5 to 3/5” (or slightly more) Hand Meridians: Yin or Yang Meridians: 1/5” ( 1 fen = 2.5 mm = 1/10”: Needle Depths: Liver =1 fen = 1/10” Gallbladder = 4 fen = 2/5” Kidney = 2 fen = 1/5” Bladder = 5 fen = 1/2” Spleen = 3 fen = 1/3” Stomach = 6 fen = 3/5” ) Approach these points perpendicularly to the surface of the skin. For Yin points, use lift and thrust with or without twirling with small amplitude and a heavy hand on the in, as if pushing a weight into a dense area. Feel for the resistance at the tip of the needle. This is the beginning response of the tissue under the needle as forces converge around the needle tip. When you reach the depth where resistance is met/felt, stop inserting and just twirl until there is a slight grab (yin tends toward deficiency so you are doing a mild tonification here. If the point is very deficient or cold you do a strong tonification). If there

is no grab, quickly pull back to the surface but do not pull out; redirect slow and heavy. This is a modified “warming” technique. For sensitive patients you can omit the twirling and just thrust slow and heavy, then lift quickly, then redirect slow and heavy. If the response is very slow to come (low blood pressure, low thyroid, cold) be careful as it may hit like a hammer blow. For the average reactor, you can go to the point of mild deqi on these points. Leave the points at the depth where the grab or deqi is encountered. Do not pull to the surface. For Yang Points, insert needle swiftly to the required depth, about ½ inch, with or without twirling as you insert; maintain the twirling, wider amplitude (yang tends toward excess so you are doing mild dispersal here to get things moving. If the point is very excess, a stronger dispersal is required and will generate a propagating qi sensation from the point up or down) until there is a distinct de qi sensation on the part of the patient (within their de qi tolerance), and/or a strong grab like a fish biting on the line for the practitioner. You can also insert to required depth quickly, then lift slow and heavy, focusing on the lifting as if there were a weight being pulled up out of the water, like a bucket filled with water. Mu and Shu points: Mu points must be angled as per textbook instructions, usually oblique. Insert slowly until you meet resistance, and then twirl gently into the resistance until heaviness converges around the point to tonify. To disperse, increase the amplitude of the twirling and focus on the out/lift; or slowly lift as if lifting a bucket of water out of the water, as if there were a great weight being pulled up. This can be repeated, fast in/thrust, slow heavy lift/out movements. Propagating qi sensations will usually occur.

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Shu points in APM are to be needled about 1/3-1/2” deep from Bl 11-22; 1/2 – 3/4” from Bl 23-25 , angled oblique slightly down and in toward the spine. They can be stimulated perpendicularly, paying careful attention to depth, then redirected oblique if they are to be left in situ. Some practitioners stimulate perpendicularly, until the required sensation is achieved, then remove. These points can be tonified or dispersed as per mu points. Do not do APM trigger point pecking technique on these points or they will behave like trigger points, not shu points. If a shu point is a trigger point as well, you can release the trigger point first with pecking technique, then needle as a shu point, with mild tonifying or dispersing technique, directly into the muscle. Once stimulated, withdraw to the surface and leave oblique so that they cannot be pulled deeper by the contracting tissue as the patient is lying there unattended. In APM Mu and Shu-Point Boogey obtains, which means that points are picked for each of the three heaters based on reactivity, not exact point location, and are typically done according to Triple Heater Regulatory technique where at least two heaters are treated. Always treat a lower heater mu or shu point before doing any points in the upper heater, to prevent strong releases of heat and liver wind. If a strong reaction occurs with upper heater points, calmly remove the upper heater point and compress the area with calming acupressure for a few seconds, reassuring the patient. Then restimulate distal yang needles to “bring the qi down”. Pull over a supervisor immediately. B] Wei Level Distal and Local Points: Distal Wei Level Points: These Yang Points may be treated with TCM dispersal technique, needling the actual point if tender, propagating the qi downward; or as trigger points into the actual trigger point (peroneus longus trigger point near GB 34 to

serve as distal wei level point to release the lateral thigh and hip for example). Local Ashi Points: Any ashi point may be needled wei level shallow insertion, or slowly straight into belly of TTP (TCM technique) to develop these techniques and as per the peer-patient’s tolerance level. WHEN there is an actual trigger point present, the preferred technique in these APM/CCA ACP sessions (deqi tolerance taken into account) will be the APM fasciculation technique derived from Travell, also known as sparrow pecking in classical Chinese acupuncture. After accurately locating the trigger point with Travell’s text open to guide you, apply dispersing acupressure for 10-30 seconds to ready the point for release. Reassure the patient that if this recreates part of their referred pain pattern or feels like one of their worst tender spots, that is verification that this needs to be released. Show them how it might twitch by manually creating a twitch reaction. Tell them to let you know when they feel the de qi response, and then when they feel the twitch. Explain that you will stop stimulating if they say the response is too strong. For new trigger points you have not encountered, or is the peer-patient does not actually have a trigger point at that site, and if you cannot get a supervisor’s assistance, go slowly and carefully so as to prevent shocking the patient (and you!), with my version of shallow Van Nghi technique first. After tapping in the needle and with the tube removed, release your left and right hands for second, and with your non-needling hand stretch the surface tissue away from the needle tip, and then with the needling hand, and a focused heavy insertion insert the needle only 1/8 to 1/4 inch and keep the heavy weight with the needling hand while quickly releasing the surface tissue with the non-needling hand. Let both hand go, and

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flick the handle of the needle. It should be ROOTED (ie; the tip is firmly embedded and the needle is not wobbly). WHEREVER POSSIBLE, IF THERE IS AN ACTUAL TRIGGER POINT PRESENT, and with a supervisor present, insert slowly trying various small changes in direction (not fanning as in Travell), inserting to the outside of the muscle or just into the muscle, with the left hand compressing the fascia over the point (which is acupressure being applied along with the needling). This compression is not as heavy or hard as when you found the trigger point, just enough pressure to compress the fascia into the muscle. The twitch might come immediately, or it might begin as a deqi sensation before twitching. The goal of the left hand here is to guide/knead the trigger point toward the needle tip. In this way you are at the outside of the muscle with quite shallow insertion for most points. Maintaining this compression with your left hand, which you ease off of repeatedly to allow the muscle fasciculation to occur, and once the patient has felt a de qi sensation, start slowly pecking into the exact direction that created the de qi response. Peck unevenly, at different rates, to “surprise” the muscle. In some muscles, like the upper trapezius and levator and SCM, you might need to insert into muscle belly to get the beginning of a fasciculation. In most cases (except for levator scapula), you can then withdraw to just being slightly in the muscle, or just at its surface, and apply the above technique. If a point does not start to respond rather quickly, lift the needle to the surface with dispersal technique (focusing with intention on the lift/out movement) and leave shallow. The there may be no actual trigger point present. You may be needling into a trigger point referral zone, which is part of the tendinomuscular meridian, and shallow needling is fine, but actual trigger point

technique may not be warranted. Or the area may be fibrotic if the muscular contraction is longstanding, and a twitch may not occur until this fibrotic tissue is softened up(if it can be) with tuina, guasha, or moving cupping. You must inform the patient that there may be soreness, especially where points fasciculated, due to release of lactic acid after the treatment, for up to 24-48 hours. If any points started to bleed during removal of needles, you must inform patient area might bruise slightly while compressing point to stop bleeding. Apply a band-aid if necessary They should take a hot bath or shower afterwards when they can and drink a lot more water or diluted Gatorade to help flush the lactic acid from the tissues. No exercise or strenuous activity after the treatment and until the post-treatment soreness has subsided. They should also be told not to try to test the sore area to see if it is looser or less sore. Physical therapists can apply stretch techniques a day after the treatment to good effect, but no massage, ultrasound, ultrastim or ice should be applied until the soreness has worn off.

Andrew Nugent-Head Yin Style Ba Gua Tangible Qi Hand Techniques While I feel I have come to be able to teach students how to do quite a decent job with needling, over the past three decades, I am in fact mainly self-taught. The faculty from the Quebec Institute, and even Van Nghi, who treated me a few times so I can experience this, made little of needling, stance, posture, as so many TCM practitioners I have met. Luckily, Andrew Nugent-Head, founder of the Association for Traditional Studies, has come forward after almost 25 years experience training in classical, Yin Style Ba Gua that includes self-cultivation Daoin practices (8 healing sounds, point and meridian rubbing and patting, and Qi Gong)

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with acupuncture training, and that stresses the ability to do repeatable strong techniques that get predictable results, with a strong focus in ashi point needling and hand techniques. Andrew has contracted with then college to run CEU training for alumni, and will teach students in the MS/Ac Program one day each of the Spring Intensive over the 3 years. Andrew has also agreed to offer his comprehensive training in acupuncture, focusing on ashi point treatment as well as a classical set of yinyang regulatory points, as the core of the Advanced Post-Masters course in Acupuncture in Orthopedic and Trauma Disorders, which will become one of the majors a student in the eventual Doctor of Acupuncture Program could select. I strongly recommend that all second and third year students watch the introductory free video presentations by Andrew Nugent-Head on his website, for a view of his approach to training in hand techniques, and the tangible Qi lectures which give a good, and very sophisticated sense of his approach to training. I am honored, and humbled by someone with this level of skills and experience, and will be right alongside other TSCA faculty and graduates when he teaches at the college, starting this October 2011.