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Thoughts on teaching Meridian Therapy to TCM students by Robert Hayden, L.Ac.

Originally published in NAJOM Volume 8, Number 2 (July, 2001)

As both a practitioner of primarily Japanese channel-based palpatory approaches to acupuncture and moxibustion as well as an educator in a decidedly TCM-based Oriental Medicine college I am in a unique position to help shape the understanding of some of the forthcoming generation of new clinicians just coming into practice. My own basic education, as well as that of many of my peers in North America, was in TCM acupuncture. I studied TCM rather intensively before going into acupuncture school, and as a result I was restless and bored long before graduation. I became interested in Japanese approaches and sought out opportunities to learn them early in my education, knowing that habits learned early tend to become ingrained far more easily than habits learned late (old dogs can't learn new tricks). My rst real clinical experiences were with longtime NAJOM member Augusto Romano, who taught me the basics of ion-pumping cords and Shudo-style meridian therapy, both of which are approaches I commonly use to this day. At the time, practitioners who knew such things were rare in the Midwest, so I was very fortunate to have had a chance to study with Augusto. Since then, I have done a fair bit of traveling and have studied with a number of very senior clinicians, but if I hadn't had the opportunity to begin while still in school, I may never have had such experiences which ultimately make my practice what it is today. These are things which run through my mind today as I teach classes in TCM. I think it is important to give students information which will lead to licensure and assimilation into the profession as it is today, that is to say students need to learn what Bob Flaws calls "standard professional Chinese medicine", another name for TCM. Since licensure is, for better or worse, based on this information, and since the nomenclature

associated with TCM is becoming the lingua franca of the profession (setting aside the terminology translation debate currently going on), I think it is a disservice to students not to give instruction in these things. On the other hand, though I am quite familiar with the concepts and terminology of TCM and teach them on an ongoing basis many hours per week, I do not base my own practice on TCM (though I do not ignore it when it is useful clinically). Students are naturally curious to know why not and what exactly is the difference between my practice and the practice of the other instructors who do use primarily TCM acupuncture, and so I make available a series of introductory classes into Japanese acupuncture and moxibustion based largely on simplied Keiraku Chiryo. In doing so, there are a number of issues which arise in reorienting the student towards Meridian Therapy. I will mention just a few of them here, though I am interested in further dialogue with other teachers about this process. I will start by saying that I am no master of Keiraku Chiryo and my classes are really designed to teach a very basic form of fourpattern Meridian Therapy -- which might be considered passe -- in order to give it some exposure and hopefully excite students to seek out more advanced training. Also I must say that I have no interest in rekindling the debate over who does and does not practice "real" Meridian Therapy. What I am interested in is meeting the challenge of promoting a more hands-on, technically sophisticated and clinically relevant acupuncture methodology within the framework of the current situation of acupuncture education in North America today. A couple of issues that I would like to briey discuss regarding this matter: 1) The "live point" concept 2) The importance of theory Live points I will say here that I currently believe live point location to be the single

most important concept in Japanese palpatory acupuncture. I recently reread a 1992 article by Augusto Romano in the American Journal of Acupuncture (1), on personalizing one's practice by using a variety of approaches. In it, he makes the case for using TCM theory with a Keiraku Chiryo concept of technique: "Needling according to principles of TCM... may be performed, but at a much reduced depth." I would add here that it is critical if one is to employ the methodology of supercial needling to use a similar methodology of locating points which will optimally respond to supercial needling. This is I believe the reason why many practitioners of my acquaintance tell me that they have tried using "Japanese acupuncture" (i.e., supercial needling with no de qi sensation) but got no results from it. Standard points used in TCM are often standard points used in Japanese approaches as well, but the location may vary considerably. Textbook anatomical points taught in TCM curricula are optimized for deep needling and likely will not work with more subtle techniques. This comes as something of a shock to students who believe they are "nished" studying point location after the rst year of school. If the concept is difcult for students to grasp it is even more knotty to teach. The live point concepts I rst learned came mostly from the Toyohari association; point location is corroborated by pulse quality changes, a method which works well for contact needling. However, the same phenomena may not occur when using different forms of needling, not to mention moxibustion or other methods. In addition to attending Toyohari trainings I have found studying with Drs Shudo and Tanioka to be very helpful in differentiating effective point location methods for various techniques. In my opinion, this is one of the most important ways in which we can get students to become better acupuncturists. Once the student has the concept of palpating for tissue changes along the channels in place of merely for anatomical landmarks, a new meridian therapist is already in the making.

The question of theory The usefulness of theories outside the basic Nan Jing paradigm to Keiraku Chiryo is a source of some heated debate. The fact that there are highly skilled, intelligent and articulate advocates on both sides of the question insure that there is little hope of resolving this issue anytime soon. To me, it is immediately apparent that, since TCM is the dominant paradigm in this hemisphere and since TCM is largely based on theory, there is little viability in telling students to simply ignore the body of theory that they have learned and presumably have had some clinically effective results with. We cannot ignore the fact that students will make their own connections between TCM theory and meridian therapy, just as students who come to TCM from the world of biomedicine will inevitably try to connect those two disciplines in a meaningful way. Just as I believe teachers of TCM theory need to bridge this biomedicine/ TCM gap in a meaningful way -- rather than simply telling the medically-trained students to stop thinking "Western"-- I believe we as communicators of basic Meridian Therapy need to nd ways to facilitate understanding based on what the student has already learned. One possible example of this is the case of "Liver Deciency". The concept of Liver Deciency/Vacuity is always a surprise to TCM students; after all, the most common pattern students seem to see clinically is Liver Qi Depression, which is an excess/repletion pattern. There are of course Liver Deciency syndromes in TCM as well: Liver Blood Deciency and Liver Yin Deciency are usually mentioned in texbooks. But the symptomology associated with Liver Deciency in the basic literature we have in Meridian Therapy often coincides with Liver Qi Depression in TCM. At best it is a mixture of Excess and Deciency symptoms; while this is mighty useful clinically to be able to cut through commonly encountered symptom/sign complexes to the heart of the pattern, it often proves confusing to the student. Of course, it is easy enough to tell students that if the six-position pulse diagnosis and abdominal conformation both suggest Liver Deciency, then forget

about the explanation and just treat LR8. But I think students of TCM require an explanation, so I usually tell them either a) the nature of the Liver is to freecourse Qi and Blood, and if the Liver is unable to do so then we consider this a deciency in its abilitity to function or b) the paradigm is that of a deciency of the Zhen Qi in which the Liver channel is primarily indicated for treatment. I'm not sure either of these is wholly satisfactory, so I'm open to suggestions in this area (or any other area for that matter). Again, I'm of the opinion that one can't simply tell students to either forget about symptoms on the one hand or on the other to suspend one's practice for several years in order to fully study classical sources; students will most likely become discouraged and forget about Meridian Therapy entirely. Another problem in transmitting Keiraku Chiryo to TCM students is the question of pathomechanism. TCM pattern theory is based on pathomechanism, that is to say a large part of teaching TCM is postulating the reason for an appearance of a given set of signs and symptoms in a given individual. As has been noted in these pages before (2), standard "old-style" four-pattern Meridian Therapy lacks a rationale for explaining symptoms, instead focusing on a staged treatment methodology in which the whole body's fundamental imbalance is rst treated to the satisfaction of the therapist and only afterwards are the patient's symptoms addressed. The concept of pathomechanism is noticeably absent in standard Meridian Therapy, and to the TCM student it seems unsatisfactory to say "don't worry about why the symptoms appeared, just treat the pattern". In addition, pathomechanism is a very handy thing to consider when counselling patients, as Americans generally want to know why their symptoms have appeared. Some pathomechanical theories may be particularly useful in treatment as well, a primary example being phlegm. I have found phlegm theory to be very helpful in the clinic, both in explaining a wide variety of contradictory issues which arise in human pathology as well as providing a material basis for helping the patient understand and gauge their own progress -- it is very difcult to get patients to recognize pulse

changes but very easy to get them to see that the slimy coat is disappearing from their tongue. As for other pathomechanisms, some have found their way into Meridian Therapy, most notably the blood stasis concept which is similarly useful in its scope. Translating these pathomechanisms into Meridian Therapy is, I think, a useful area for further exploration. Perhaps phlegm is not so important in Japan, but in the Midwestern United States it is ubiquitous. I believe the future of Meridian Therapy in the Americas depends in part on reconciling some of these concepts. Who has the best explanation has yet to be decided, in my opinion. Meridian Therapy and similar Japanese palpatory approaches have a lot of advantages in clinical application in the West, as patients are seeking more individualized, informed and attentive treatment without the tissue stress of many TCM acupuncture modalities. Getting more new clinicians on board means we need to meet the challenges of the probing questions they have been taught to ask in their professional training. In closing, I'd like to state my wish for not only increased understanding between practitioners of TCM and Japanese styles, but within the Japanese acupuncture community itself. While I think I have some understanding of the root of many disagreements between various parties, I believe we risk sabotaging the goal of fostering this marvelous form of therapy in North America. If we can come to some consensus about how to proceed, we can overcome adverse situations such as the banning of direct moxibustion, ion-pumping cords, microbleeding or other techniques in certain jurisdictions, as well as lack of liability coverage for these procedures. I'm happy that NAJOM exists as a forum for us to air our ideas and debates, and I hope that publicly we can increase support for our Japanese medicine community as a whole as well as our individual agendas. (1) Augusto Romano, "Toward Your Own Style of Acupuncture", American Journal of Acupuncture, Vol. 20, No. 2, 1992

(2) See Stephen Birch, "Keiraku Chiryo - Japanese Meridian Therapy", NAJOM, Vol 6, No 15, March 1999, and Masakazu Ikeda, "Resolving the Misunderstanding of Stephen Birch", NAJOM, Vol 6, No 16, July 1999