Foundations for Integrative Musculoskeletal Medicine An East-West Approach ae Alon Marcus PU mn rer es ae eee Methods from Chinese Medicine, Orthopaedic ere a ken ey ate CMe CecFoundations for Integrative Musculoskeletal Medicine An East-West Approach Alon Marcus D.O.M., L.Ac., D.A.A.P.M. Foreword by Michael L. Kuchera D.O., FA.A.O. 0 North Atlantic Books Berkeley, California‘Copyright © 2004 by Alon Marcus All rights reserved. No portion of this book, except for brief review, may be reproduced, stored in 3 retrieval system, cr transmitted in any form or by any means—clectronic ‘mechanical, photocopying, recording, or otherwise—without the written permission of the publisher. For information contact North Atlantic Books. Published by North Atlantic Books Rook design by Alon Marcus PO. Box 12327 Cover design by Jan Camp Berkeley, California 94712 Graphics by Joseph Marcus, Enrique Goldenberg, Puja Donak Printed in the United States of America Foundations for Integrative Musculoskeletal Medicine: An East-West Approach is sponsored by the Society for the Study of Native Ans and Sciences, a nonprofit educational corporation whose gosls are to develop. an educational and cross-cultural perspective linking various scientific, social, and artistic fields: to nur- ture a holistic view of arts sciences, humanities, and healing: and to publish and distribute Iiterature on the relationship of mind, body, and nature, North Atlantic Books’ publications are available through most bookstores. For further infor- ‘mation, visit our website at wwww.northatlantcbooks.com or call $00-733-3000, Note: Medical knowledge is constantly changing. As new information becomes availible.changes in treat iment, procedures equipment, and the use of drugs become necessary. The editors/authorscontebutors and. ‘the publisher have, as far sit is posable, taken care to ensure that the information given inthis text is accu rate and up to date, However, readers are strongly advised to confirm that information, especially with regard to medicine usage, complies with the lates! legislation and standards of practice. Neither the pub- lishersnor the author will be liable for loss or damage of any nature oecasioned to or suffered by any per- ‘son acting oF refraining from acting asa result of reliance on the material contsined in this publication ISBN 81 -$5683-540-9 Library of Congress Cataloging-in-Publication Data Marcus, Alon, Foundations for integrative musculoskeletal medicine : an east-west approach /by Alon Marcus : foreword by Michael L. Kuchera. p.:en. ‘Summary:"An in-depth discussion of approacaes to muskuleskeletal and physical medicine integrating Eastern and Western perspectives"—Provided by publisher. Incudes bibliographical references and index. BN 1-55643-540-1 (hardcover) 1. Musculoskeletal system—Diseases. 2, Medicine, Oriental [DNLME: 1. Musculoskeletal Diseases—therapy. 2. Medicine, Chinese ‘Traditional—methods. WE 140 M322 2008] 1. Title. C925,M33 2004 6167 06—e22 2004023285 2.3.4.5 67.8 9 SHERIDAN 17 16 IS M13 12Contents Boreword sv2:steeienncminciernaenanrenernaene cena xiii Preface . . ox Background and Acknowledgements voce XV LL FOUNDATIONS FOR INTEGRATIVE ORIENTAL MEDICINE gf Essentials of Oriental Medicine .......2..6..+ , ol Basic Principles of Chinese Medicine: The Body Milieu... 8 Blood (Xue) 14 Essence (Jing) ... : fees ve dT Fluids (Jin and Ye)..........2 sBoveven's z aif Vin and Yeng:.cerereennrveras nero ester TAREE 19 Disease Etiologies 22 Eight Principles (Ba Gang) . . . 243 Five Phases (Wu Xing) ......--..2 00005 1 4B The Channels (Meridians/Vessels) (Jing-Luo) ..........+ seeseeens seas ve 3 Organs .. . 81 Diagnosis — ‘ 98, Typical TCM Intake Form ...... solders 7 2—FOUNDATIONS FOR INTEGRATIVE PAIN AND PHYSICAL MEDICINE | 123 Neural Mechanisms of Pain eaters eee wee sea eeee ae + 125 Pain Mechanism: 136 Aspects of Pain... 0... cess eects eee 143 Pain Perception and Localization . 150 ASH Pall sscwrverosrossmanmmouarenian ey incarennoooeves ESS Pain in TCM . 159 TCM Treatments of Pain 161 F 1 PATHOLOGY... eke 165, TCM Classification of Soft Tissues 165 TCM Pathology and Etiology .. - 167vik Contents Important Tissues: Biomedical Perspective . . sees 169 Joints ..... veseeeeeeeeeeee ceveeeeees 169 MUBELEE osu aecesemenmnne ovensunene striae WIR Tendons .. . 179 Fascia _ 180 Ligaments 180 Bone and Periosteum srommmrrerveacesoeee AEG THES Pike os orsrcrccssvscesameve eters aenMnerreTeNcseY vows BL Normal Gait 3 196 A Systems Science Model For Biomechanical Construction... ++ ++- +++. 1 sss 1ss 200 FOUNDATIONS FOR INTEGRATIVE ORTHOPAEDIC AND PHYSICAL MEDI: CINE ASSESSMENTS 5 += 205 ReTabI IGE hE ANA -are cll naan noniwsniad vas Meret eaacenesso ROS TheDidgnesteProceatte voces var Punanwer aul Moimetnteauea en ei DOE Physical Examination em General Orthopedic Testing: Joints 2.0.00... eseeeeesveseeeeeeseeeeeeseese ees 222 Neurological Testing ....... = 232 Screening Examination * . * z . . 238 Laboratory and Technical Testing 243 Additional Tests 246 Imaging and Radiology 247 Imaging the Spine. Wrist Imaging Ankle Imaging ..... Knee Imaging ...........+. Shoulder and Elbow Imaging TREATMENT PRI i 7 ‘ a 5 sexes 261 Acupuneture and Dry Needling ..........202+5 - 264 Acupuncture Mechanisms - 267 Acupuncture Therapeutic Systems and Techniques... - 276 Main Channels... , 299 materialw Conients ‘Connecting Channels/Network Vessels . . . 299 Divergent Channels . 300 The Sinew Channels. - cerntermnncn samc 300. Extra Channels HMC NUES ala eR eeeNETaUS Woe vee 308. Point Gateways and General Treatment Methods ...... ina OF 6—ADDITIONAL ACUPUNCTURE SYSTEMS AND RELATED TECHNIQUES . . 333 Abdominal Assessment . . 333 Meridian Therapy (Keiraku Chiryo) ... . 339, Auricular Therapy - 343 Metacarpal Bone Systems - 346 Wrist and Ankle Acupuncture... 2347 Korean Hand Acupuncture : : . : 350 ‘TotipiLeetiiVle ACIpURONHE Yoo er seen de ts seeeree sider sy BSD Other OM and Related Western Therapies ......060.cecs0ecesseeteeesetseeeee - 368 7. ROUNDATIONS FOR INTEGRATIVE HERBAL MEDICINE .... . 375 Chinese Herbal Therapy... ..-..0ssc00ceees ae 375 Treatment of Blood Cheulition :swavrrewonee name STS Commonly-Used Herbs In Painful Obstruction Syndromes .......... - 381 8 FOUNDATIONS FOR INTEGRATIVE ELECTROTHERAPUTICS ........... 423 Bioenergetic Field Therapy = rz 423 Introduction to Electromagnetic and Electrical Stimulation Therapy 430 Electroacupuncture - 438 Static Magnetic Therapy. » 443 Laser and Photonic Therapy... . -447 THERAPY, <..<¢0202e0c0yesnrseceeenessvessersueveevesctsisaciencrn ewes 98 sage/Manipulation ....... cect eee eee cece cece eee ee eee 453 Western Manual Therapies cen 460 Osteopathic Medicine c.crcccssnesinncesweaverccerses 460 Functionally Oriented Screen Tests ....0..cccccecsecseseceeeeeestheeceneeeues - 470 Osteopathic Treatment MethOdS oot tenet tenet tet entecneeee - 484: Contents Manipulation with Impulse and Other Western Techniques . . . . 499 Additional Commonly Used Techniques . . . . eens eens we 504 Rehabilitation and Exercise ......-.....secsseeeseeeseeeeesscnsrseereeseseneees SUB The McKenzie System .. = 526 Orthotics and Restraints. - $29 10—THE MANAGEMENT OF SPRAINS, STRAINS AND TRAUMA + 537 Ligamentous Sprain . . 537 Muscle Strain .. 6.2... eee eee eet eine eee . 538 Treatment of Acute Sprain/Strain 539) u—M' “ULOSKELETAL DISORDERS: INTEGRATIVE PRACTICE rey 531 Inflammation .. ae a . . a . a . . SSI Three Phases of Degeneration . . 556 Joint Disorders . . 560 Ligamentous Disorders. . 579 MYORSCUA DIE enn ssc ereeunneereamemener ses: seuss SOE Fibromyalgia and Myofascial Pain Syndrome ..........06000ceec0cceseseeceeeneses S97 Nerve Disorders .. - 632 Dise Disorders ......... sesanpatidscPoasecduenthessiies Earth—> Water—>Fire—>Metal The Classic of Categories states: If there is no generation, then there is no growth and develop. ment. If there is no restriction, then endless growth and devel: ‘opment will beoome hari ‘Therefore, the movement and change of all things exists through treir mutually generating and controlling relation- ships, These relationships are the basis of the never ending circulation of natural elements Five Phases Disorders Five Phases theory is wed also to demonstrate the transmis sion of pathological influences. In discussion om the tras mission of diseases via the control cycle, the Classic of Internal Medicine sates When the Liver is diseased, the Liver will transmit [the dis ease] to the Spleen, and s0 one should replenish the Qi ofthe Spleso..When the Heart is diseased, first there is pain in the Hear, and in one day it results in coughing (transferred to the Lung), within tree day there is pain in the ribs (transfered to theo Liver), and in five days ther is blockage causing pain and heaviness inthe body (transferred tothe Spleen). If the patiene {does not ecover in three days, death will ensue. In winter the patient will die-at midnight, a the summer at nan Discases ofthe Liver and Spleet/pancreas often interact with each other. For example, Liver disease may affect the Spleen/pancreas because Wood can over-control (Sheng) Earth, while Splecn/pancreas illness may affect the Liver because Earth can courter-control Wood (insult, Wu, and the disease ean move contrary to its regular course, Ni Liver disease may alo influence the Heart by affecting son” illess, If Liver disease is transmitted to the Lung, it can be categorized as Wood counter-controlling {nsulting/invading) Metal. If tis transmitted tothe Kidney, then it is considered a “son affecting mother” illness. ‘other Organs follow the same principlesimage not availableimage not availableimage not available4 ‘Table 1-13: Channel Orientations. CHANNELS _ DISTRIBUTION ‘Main Longtudnat Join te Main Yang channel its pred Main Yin ‘chanel aneropstriry (serial t deep They also form the vascular te and therefore ont al areas ofthe body. Divewent ‘Cover the sagt and axial plain and aio have an anteroposterior (upericial ep connections). Ex Ad diagonal ei opened feedback system, each channel has its own physio- logic activity and pathologic manifestations. TCM attribu- tion of many distal symptoms to the Organs can be traced to the existence of the channels (Biomedicine: visceratcme, ver vation and cirlation), All channels, regardless of their location, are_more superficial “energetically” than the Organ system. Often Painful Obstruction (2) syndromes (Biomedicine: musculosk: eletal diserders) are obstructive channel disorders affecting the “body shell” only. When a patient has musculoskeletal pain without any Organ symptoms, the condition can be con- sidered purely of channel/vessel andlor other bodily milieu origin (however not Organic). Because the channels and Organs are interrelated, and because channel Qi enters into the deeper Organ system at the Sea points,!°* Organic symp- toms can be a part of the pattern discriminations of the inter- nal course of the channels. Spiriual Axis states: “The twelve channels and vessels inside are ascribed to the Organs, the outside network to the limbs and joints," Importance in Musculoskeletal Medicine Channel discrimination is especially important in muscu- loskeletal medicine and in acupuncture, The chaanels and network-vessels/collaterals can be invaded by exogenous pathogens, or they can develop dysfunctions due to endoge- hous disharmonies, both of which can result in symptoms and signs that appear along the course of the channel(s). Exogenous Pathogenic Factors, by and large, penetrate the body from the more superficial channels and travel through the channels and connecting network-vessels sysiems into ‘or anatomical levels 152. Acupuncture pointat the levelof knee and elbow. 153, Many racttonrs tnd i implicate TCM Organic malficion in ‘muaculakelal dorder, and use Organ ype diagoors of te pulse td Tongue t determin the paint pottery diagnosis: Musculoskeletal ‘nord oft afc only the oy tell Exterior and are prt of “Extervemelicin” In Extrioemeticng, skin disorders for example, sch diagnonie approaches are often secondary to divet examination fof the skin (he. thpule tongue sta ther Ori impure tia thesame appliss often to musedoskeltal dsorde's. Tse texture tft should fen be coneiared frst Chapter 1: Foundations for Integrative Oriental Medicine ‘The musculoskeletal system, including several aspects of the joints, is part of the Exterior system and of the extemal pathways of the Main channels. Other aspects of the muscu- loskeletal system that relate to structure and biochemistry may relate more tothe deeper channel and vessel systems. Table 1-12 on page 50 describes the physiologic activi tics ofthe channels and Table 1-13 their orientation. ‘The Sinew Channel The most superficial of the channels, the Sinew (tendino- musculan channels are the locus for circulation of Defense- i. With the muscies the Sinew channels: + Provide a protective layer ofthe body. * Govern movement and sustain the body in its erect pos- ture. + Connect the “100 bones” + Serve as the connection between the Main and Divergent channels 10 the muscles, connective tissues, joints and skin, + Serve to integrate the connections between the Yang channels and between the Yin channels. * Closely related to the nvele Cuaneous regions which share Sinow channel functions of circulating Qi and Blood tothe surface, nourishing the skin and pores, and protecting the body from external Pathogenic Factors The eatancous regions are the combinations of the terrax res ofthe leg and arm regions; i, hand Tai Yin and leg Tai Yin, ete. The close relationship between the skin areas of the twelve cutaneous regions withthe channels and Organs is important in many aspects of disgnosis by ‘observation and palpation, An affected region can reflect viscero-cutancous (Organ/viscere-somatic) reflexes and pathologies. Signs such as pain, discoloration, dryness, or ‘excessive moisture of skin, skin rashes, darkening or sa sis of veins or venales, contraction of muscles, ete. are In Spiritual Avis the Sinew channels were mostly asso- ciated with muscular spasm and weakness and treated with Fire needle techniques. Defensive-Qi circulates through the inew channels. Patients who have myofascial pain syn- {dromes and fibromyalgia often develop stagnation of Defen- siveOi (especially its Fluid quality). Fluid-stagnation transforms to Phlegn/Blood/Qi stasis that becomes nodular (Bionedicine: fbrestie nodules) called myotascial tigger points in biomedicine and Kori in Japanese OM. If only pressure sensitive they may be called “Ashi points.” Treat ment of local Ashi (painful or wigger) points mobilizes the Sinew channel Qi and disperses staznation,'*4 1S,.Not lasica dscns,image not availableimage not availableimage not availableimage not availableimage not availableimage not availableimage not available‘Chapter 1: Foundations for Integrative Oriental Medicine Figure 1-13: Spiral tine (vith permission Chitow 20, Figure 1-14: Back ar ie (wil permission Ch 20 the subhyoid muscles, and tho fascia pretrachealis between the hyoid and the cranium/mandible, involving the suprahyoid muscles. +The muscles of the jaw linking the mandible te the face and cranium. Additional smaller chains involving the arms are described as follows. Back of the arm lines (possibly the SI, LI, TW and extra channels): +The Broad sweep of trapezius links the occipital ridge and the cervical spinous processes to the spine of the scapula and the clavicle. +The deltoid, together with the lateral intennuseular sep- tum, connects the scapula and clavicle with the lateral epicondyle, +The lateral epicondyle is joined to the hand and fingers by the common extensor tendon. “+ Another track on the back of the arm can arise from the ‘thomboids, which link the thoracic transverse processes to the medial border of the seapula Figure 1-15: Frontarm line vith permission Chaiton 200) +The scapula in turn is linked to the olecraron of the ulna by infraspinatus and the triceps. +The olecranon ofthe ulna connects to the small finger via the periosteum of the ulna lization feature in the back of the arm involves 1us dorsi and the thoracolumbar faseia, which con- rects the arm with the spinous processes, the contalat ‘eral sacral fascia and gluteus maximus, which in turn attaches to the shaft of the femur, + Nastus lateralis connects the femur shal 10 the tibial tuberosity and (via this) to the periosteum of the tibia (Figure 1-14), Front ofthe arm lines (possibly H, P, Lu and extra channels): + Latissimus dors, teres major and pectoralis major attach to the humerus close to the medial intramuscular septum, connecting it to the back of the trunk, +The medial intramuscular septum connects the humerus to the medial epicondyle whieh connects with the palmar hand and fingers by means of the common flexor tendon. + An additional fine onthe front ofthe arm involves pecto: rls minor, the costocoracoid ligement, the brachial neu- rovascular bundle and the fascia elavipectoralis, which attach tothe coracoid process. +The coracoid process also provides the attachment for biceps brachii (or brachialis) linking this tothe radius and the thumb via the flexor compartment of the forearm. +A stabilization fine on the front of the arm involves pee toralis major attaching to the ribs, as do the external ‘bliques. which then run to the pubic tubercle, where 3 connection is made to the contralateral adductor longus, racils, pes anserinus, and the tibial periosteum (Figure 1-15).image not availableimage not availableimage not available6 influence, The internal aspects relate to the viscera. The accessory channels (Divergent, Connecting, and Extra) sup- plement and share points with the Main channels. ‘Chapter 1: Foundations for Integrative Oriental Medicine OF the Main channels, six are Yin and six are Yang, three each on the upper and lower extremities. Each Yin channel has a paired Yang counterpart, and viee versa. The balance of the Main channels determines health. Table 1-15 describe the principal symptoms and signs thet indicate dys- function of the Main channels (Figure 1-17).image not availableimage not availableimage not available70 Each Extra channel is associated wit specific patholo ical signs. Of particular importance for musculoskeletal di orders ar: + The Governing (Du) channel is used often in disorders of the head, neck, and back, especially midline pai, Mental and cognitive symptoms, psychosomatic pains, and isor- ders of locomotion and articulation (mostly in men) are treated by combining the Governing (Du) and. Yang Motility (Qiao) channels, The channel is used for foot isorders and pain, especialy when associated with «cot lapsed arch ot heel pain. A sense as though one cannot hold-up the head is often associated with the Goveming (Du) channel. With the Girdle (Dai) channel, the Govern- ing (Du) channel is also used for many neurological dis- ‘orders, especially when manifested with weakness (ocuriis with palsy, muliple sclerosis, et). Conception (Ren) chanvel is used in patients with poor abdominal muscle tone and tight lumbar muscles as well 48 pains that have an allergic component with periumbii cal sensitivity Girdle (Dsi) and Yang Linking (Wei) channels suppor and keep the muscles and Sinews strong and tight. The Girdle (Dai) chanel influences the low back and pelvis, while the Yang Linking (Wei) has more generalized clfecs. Bath of these channels are associated with pain clicited by rotation, tn musculoskeletal disorders they are ‘sed to teat weakness and instability The Girdle (Dai) channel is particularly wed for lum bav/ip pains and low back pains that radiate tothe abdo- ‘men/ pelvis, genitals and/or medial thigh (inthe author's experience, disorders of T12 0 L5 feves, often with 1soas tension, and innominate dysfunctions) The Girdle (Dai) channel canbe affected by life stresses and used as 4 adepiogenic or stess fighter. Disorders sccomparid by motor deficit (paralysis) are weated often via this channel “The Yang Linking (Wei) channel is used in patents with athriie pains that worsen on rainy days (Wird-Damp- Bip; headaches that radiate from the base of the neck to tte eye, unilateral symptoms, lateral neck and shouldct pins, upper extremity pains and swelling Yin Linking (Wei) channel is used to treat patients with poor coordination between the upper and lower body, expecially with weakness of an upper extremity and con tralateral lower extrem, The chanel ean be used in ptiens with back pain due to desiccated dises and cireu- Ietory problems, especially when seen with abdominal wall (fascial) sympioms (“oily membranes” symptoms). Itis used also ia patients with restlessness, general weak- ‘ess, and shortness of breath on light exertion. This chan- nel is said to closely relate to the parasympathetic ‘nervous system is thus used to teat Heart and digestive Aisorders and is often used in patents with musculoskele- tal disorders, Chapter 1: Foundations for Integrative Oriental Medicine + Yin and Yang (Qiso) Motility channels are associated ‘often with imbalances between the medial and lateral sides of the legs and postero-lateral and antero-medial areas with difficult in walking or standing (Yin and Yang aspects of body). Symptom that are worse in the day or night are associated as well, Fullness in the Yin Motility (Qiao) is associated with limpness of the (Yang) postero-lateral aspects of the leg and tack and with symptoms inereasing during the day. Fullness in the Yang Motility (Qiao) is essociated with limpness of the (Yin) antro-medial aspects of the leg and back and with symp- toms increasing during the night. These two channels are often used to treat muscular hypertonicity. (spasms), sedating the Yang (Qiao) Motility if Yang sinew chan: nel(s) is hypertonic and tonifying the Yin (Qiao) Motility channel. For hypertonic Yin Sinew channel(s) the Yin (Qiao) Motility channel is sedated while the Yang (Qiao) Motility channel is tonifid. ‘Yang Motility (Qino) is associated ako with acute Wind, headaches, and muscular problems of a Yang. nature (spasms). Patients with low back pain. a tight ilioibial tract, and ‘weak abdominal muscles, may be treated via the Yang Motility (Qiao), This channel is said to release ACTH and may be used in most inflammatory disorders. In patients with occipiial pain, the channel is combined with Governing (Du) points ‘The Yin Motility (Qiao) channel is related to tightness of the back muscles and weakness of the abdominal mus: cles as well. Here the quality of movement i affceted and the muscles are stiff but not spastic This channel ciated with unilateral headaches near the eye. Patients swith weak thyroid, often associated with myofascial pain syndromes, may be treated via the Yin Motility (Qiao) chanel ‘The Peneirating (Chong) channel, which controls the Blood and its ability to penetrate tissues, is associated with an inability to express a source for symptoms (vague symptoms), often duc to intemnal-Wind arising from det ient-Blood and poor vascular supply (and possibly symptoms arising from comective tissues). Confusing, conflicting, and various combined pathogenetic pro- cesses, such as Heat above and Cold below and combined Deficiency and Excess, are often treated using the Pene- tuating (Chong) channel, The channel is used for moving: pains, autonomic and inflammatory joint disorders, and in patients over forty years of age. This channel is said to activate a deep Kidney pathway. Table 1-17 through Table 1-23 on page 79 summarize the Extra chamnels'vessels, the principal symptoms and signs associated with them, and their Master (Mecting/Conf cence), Activating, and Departure points, The tables integrate Various ideas and sources, both modem and elessie, with per sonal experience. Table 1-24 on page 80 summarizes the dif ferent approaches in pulse diagnosis as it pertains to the Extra channels,image not availableimage not availableimage not available4 ‘Chapter 1: Foundations for Integrative Oriental Medicine ‘Table 1-18: Penetrating (Chong) Channel ‘The Cental eset (Sc) of Blond and Essence; weas ll disodsrsoF bod Calle the Sou ofthe Twelve chansls and threfore has bon elated comnostive teats ari ning regulate, ond ‘peas te 12 channels important in ean a sts and blockages, spec of Blo. Sours of i for shane Governs seal characte. Regulates menstuatio Connects rent and postal Q, overs rerodution, Ales gastrointestinal system and Heathear Geveral Syatrroms, Urogenital disorder, Sexusl syns, bath exes, Extra izemalO disharmony Rebelious Qi (ashing upwids) lading toa wide range oF syapoms affecting he whole tuo including nervousness nd “utes i the toma Complex syndromes and rtp pathologies. {habit tcapres a orur for earn (por), rly ang an evimecve-dive, Aslominalpain and distension, ches fullnes and erpresion,plpttions, mental symptoms paic disorders with he feeling of sfoaton nd ashing ypwatd feeling (5 called “nang pig syne cold Below ho above EXCESVFULLNESS SYMPTOMS, ‘Sensation as though bay is increasing size (ris targe and pay), constant thinking and wo awareness shat heres sca Decent station, mponce. “Menstrual regulates. DEsicueNcy/EMPTINESs Syurrous, Sensation as though bay is decressing i size ri minshing in si) disci Pain Prost, Urthits, Orci Semis risson Mencia. Hemstemesi. }, anstat thinking and no awareness fa there is Puysicat,Fivpinos, Puls tight and uninteruptedin al re (proximal cui idle (br), al dis (ic) poston; wity and fl (Or very dep, cee oboe, nd ht (Or proximal [ei and distal ich) beth strong a fr at the dey Level (Or pring and foretl inthe Ong dep (deep ‘Tendemestaroutd the umbilicus, SP channel, in patil SP4,4, 13.1 16,21, €V.17 at posblysuprapubi, MasTERMEETING POINT 'SP-4(+) (ore on) on o igh side [may be pat of ess syndrome, Court Powt P-6 (or lack on) olen on tgh side aay be pst of cross sydeoe) ACTIVATING Pont Ka,image not availableimage not availableimage not available1s Chapter 1: Foundations for Integrative Oriental Medicine ling Ineo spoil Hear, Lung, Stomach, ad Spon Organs balaoos the motions Links the Vin ofthe body ‘Together with Yang Wei connects and regulates ll Yin-Yangchanne of ty GENERAL SymtoMs, EXCESS/PULLNESS Dertcreyey/EMPTINEss SyMProMs Prysteat, FINDINGS MASTER/MEETING Powe Courts Pot Aca ‘Lumbar or zeit pain. ‘age thoracic negates (chest oppression) and pan dspace, Circulator proiems. Distenson in subcostal regi, pai in Heathoar region flless of shest. ‘Ache in waist Tesora ad ether emotions symptonns low selestcm, weak will power Nightmares Restless, amet, ar: iit, lack of wil power, depression. Easily angered Palpiations Deliv, ‘Weslnes f homolatal upper extremity and contalatel lower extremity, Delium. Nighimares, Weakness of homolatcral uperestremiy and contalten lover extremity Dysmea, (Ces oppression. Pain ia howolateral upper extremity and contalatel lover exten Hypotension, Hypothyroidism Iipetence Rectal prose Depression. Tuite Fe [Nervous Ings, Pals a the proximal o¥2i) poston sens ool koa the oun (aly) up toward dtl (on) mith as that are sinking big a Fall ‘Or foatingat prexial (ew) wn sunken a isa anh) poston. Wit excess deep pulses stronger tan superficial ‘ones. With deficency, deep pulses weaker thn superticil one. ‘Or beating rom radial portion ofthe proximal (ui tothe ular poston ofthe distal nc) positon (0c proximal (cuit) ner slanting upward avn athe distal (inch. ‘Subcptal tndemess or ighness, especially on right (Liv-14, GB-24), CV.17 (female, P-1 (mae Possibly teuemess of meal elite suprapubic. perumbilcl and SP-6 6 (or blackion con) usualy on ght may be part eros syne! ‘Sp-4(+) (or black ion cord usualy on it (nay be part oF eras sara) 9.image not availableimage not availableimage not availableimage not availableimage not availableimage not availableimage not available%6 shown n patients with superficial gastritis and Spleen disor- ders. The turnover rate of epithelial cells has a short life span, and differences in the mucosal lamina propria have been shown, In Splect-deficiency patients, glandlar atro- phy was more severe, intestinal metaplasia more frequent, Whereas in patients with cisharmonie Liver and Stomach type the metaplasia was modest, Ultrastructural studies revealed reduced microvilli of epithelial cells, increased junctional width, membrane damage, swollen mitochondria With disrupted cristae and dilated endoplasm in parietal cells, decreased pepsinogen granules within chief cells, and increased plasma cell infiltation in lammia propria. These changes were not seen in disharmonie Liver and Stomach type patients. Substance P end VIP were found inereased in sigmoid colon, correlated with loose bowel movement (a symptom of Spleen-deficiency). Elevated cAMP levels in gastric mucosa and plasina of Spleen-deficiency patients Were found, and plasma cAMP/CGMP ratio was decreased markedly in those patients with intestinal metaplasia, Like- wise, gastric mucosal SOD content and plasma LPO also decreased significantly and may have correlated with meta- plas. Studies have also shown varying dhsfimetions of the vegetative (awonomic) nervous system of the gastrointestinal tract in relation to Spleen-deficiency. Cerebral cortical fune- tion was extensively suppressed and presented with unstable somatic evoked potential, diminished amplitude, and poor reproducibility. The hypofunetion of sympathetic nervous activity manifested a decrease in skin electric potential activ- ity, reactivity of peripheral vessels to cold, urine VMA con- tent as well as plasma dopamine hydroxylase; all of which increased after adequate treatment. In these patients, blood acetylcholine level was elevated, usually accompanied by bradycardia and lower systolic and diastolic blood pressure; these indicated the presence of relative hyperfunction of parasympatheiie nervous activity. Studies of immunologic functional changes in Spleen- deficient patients showed the peripberal blood lymphocyte count to be lower than normal. Patients with chronic hepati- tis B, Liver-congestion (depression), and Spleen- ‘ors... never had a teacher tell me a pulse was anything other «han wiry, slippery, fst, slow, loating, deep or fine..jt seems that many mods Chinese TCM practitioners relegate pulse examination toa minor, confirmatory role... bel ‘ery of puke examinations vitally important o making a eor- rect TCM pattsm discrimination, And, 1 believe the pulss examination i, perhaps, even more important io Western prac: Siioners than for our Chinese counterpart... his book, Flaws goes on to argue thatthe importance of the pulse in moders practice Tiss with the complexity of chronie conditions su fered by many patients who turn to acupuncture in the West, 162. La the tat The Testment of Maders Weston Ducane with Chinse ‘Medicine, however. wen discussing reliable signs al symptoms in ‘este patente, Flows aad Sten st: “in patieuarthe loge sep ate not god indicabrs of coli the DodyInptcus, ‘thon here a dua kidney yin and yang vacuity the ongur and ple ‘apically show thesignsof the vatty heat rahe than the acuity ou" pyrial100 The idea is that these patents typically presenta picture dat is Aificult to sort out, end thatthe pulse can provide information| that resolves the dilemma. I would argue, contarily, that this complexity of the patients makes pulse diagnosis more diff cult to rely on, rather than more valuable. One ean eome to this view by reading the indications of the pulses in the Mai ing in which the imerpreations are very suecinet and focused this pulses common in te spring, this pulse means taiyn disease, ihis pulse means a fever, ete. By contrast, the complexity of modern pation, especially those who are older and suffer from numerous diseases, means that within one individual there isa complex of deficiencies and excesses of internal and surface disorders, of stagnation and looseness, and influsnoos of drugs, surgery and daily habits that don’ fit any traditional pattem. The resulting puke is more difficult to analyze and loss informative On the other hand in Unschuld's Medical Ethics in Imperial China Chang Chan states Nowalays we have diseases which take a similar curse with “itferent patients, yet from the outside they appear tobe if. nt; and there ae others, which take «different course with Afferent persons, yet from the outside, they appear to be simi lac, For this reason, it will never suffice to examine exclusively with the eyes and ears the symptoms of excess and deficiency im the five granaries and six palaces as well as the flow or blocking of the blood und the ‘he protective influences. Inthe firs place, one has w examine the symptoms ofan illness which can be felt in the pulses to determine the specific illest. Only someone who gives h undivided mental attention can begin to elaborate on these symptoms, This undivide attention must be given even to the last tails which are related tothe imegilaries nthe depth and the marking of various kinds of pulsations, which cond tions the variations in the acupuncture points, and which are responsible for the deviations inthe thickness and strength of Mlesh and bones. Today, however, the prevailing effort is to _rasp the most subtle details with the crudest and most swperti- cial thought. This is truly dangerous! ne and the constructive and THE MOST IMPORTANT QUALITIES ARE PULSE RATE, DEPTH, STRENGTH AND STABILITY, + A pulse that is quick, superficial, and strong may indicate «a Yang condition and acute disease, but not always. + A pulse that is slow, deep, and weak may indicate » Yin condition and a chronic disease, but not always. + A pulse that is not congruent withthe patient's disease is said to be a sign of poor prognosis and a disease that is difficult to treat, Therefore, « patient with a chronic dis- cease should have a Yin-type pulse while a patient with an acute and short-lived disease a Yang-type pulse. + An unstable. rootless, and “spirtless” pulse (i.e. lacking Stomach-Qi)'®? may indicate severe Deficiency (*separa- tion of Yin and Yang") or Heart and Kidney (or biomed: srmpaihetiefparcsympathec) disorders. The normal Earth ‘Chapter |: Foundations for Integrative Oriental Medicine (StomaelvSpleen) pulse is said to be moderate/leisurety and thus to contain a moderate amount of the charactris- tic ofall the Onzan pulses, and therefore reflec the body ‘whole (Righteous) Qi. This quality is also refered t0 as having spirit and root. The moderate pulse is often used to describe a leisurely rate as well IN MUSCULOSKELETAL PRACTICE THE MOST FREQUENTLY ENCOUNTERED PULSES ARE: + Tight or wiry, soen most commonly in patients with pain ‘due to Cold, Empty-Heat, stagnation in general, or Liver disorders. Sometimes one ean feel a double wiry pulse ‘may be interpreted as Phleym and Qi-stagnation. IF a small, thin wiry pulse is felt within the larger vessel (pulse within a pulse) this may be interpreted as Excess- Cold and Deficient Orgon systems. * Slippery pulse, seen in patients with pain due to Damp- ness, Phlegm and Heat disorders, or other obstructions causing Blood turbulence including strong anxicty. + Difficult/Chopny pulse. seen most often in patients with pain from Blood-stasis, and/or Deficiency of Qi and Blood. + Floating pulse, seen most often in patients with pain from an Exterior pathogen, and/or a Deficiency of Yin or Yang. * Deep pulse, seen most often in patients with pain from severe or chronic disowers, deep obstructions, and/or Cold and Interior conditions. In the classic of Difficult Issues, different depths within the radial artery are said 10 represent various tissues and ‘Ongens. The fifth difficult issue states: The [movement in the] vessels may be light oF heavy. What {does that mean? I is lke this. First one iouches the vessel [at inch-opening!™ by exerting a pressure) as heavy as three beans and one will reach the Lung seetion on the [level of the} skin [and its} bait, If fone exerts pressure] as heavy as sis the [level of the} Blood vessels, If fone exerts a pressure] as heavy as nine beans, one will reach the Spleen section on the level of the flesh, Iffone exerts a presure) as heavy as twelve beans, one will each the Liver section on the level of the muscles, {Fone presses down tthe bones and then ifs the fingers entil swift (movement of influences] arives, (the Ivel eeached] is the Kidneys section). Hence, one speaks of light and heavy. beans, one will reach the Heart seston Spiritual Axis states: 113.-The “oot” ofthe pals most commun refers te the pronimal postions (idney). Having rot means thatthe postions dep, even, moderate, feu Teel A lack pals athe proxi postion, bower, ahs fest rom chstraton inthe wer bums and dos not necesaly ‘acan weakness and Deficiency. A spies ube is scattered, cht, es present and sometimes nl and ray change its ses on ti clled "Qh pulse” he Shet-Hammer ‘ystem, 184. locaton on them artery Soe Meridian Therapy in chapter 5 for ‘basteDiagnosis The left pulse a the inh [stl] position superficially reflects the Heart. Deeper it reflects CV-17 [ehest gi. At the let bar |iidate} position, the surface reflects the Liver, the deeper pulse the diaphragm. AC the lef fot [proximal] position, the superficial pulse is the Kidney, the deeper puke is inside the abdomen. In the right pulse atthe ich position, the Lungs are reflected atthe surface, the deeper pulse reflects the chest. At the right bar positon, the superficial pulse isthe Stomach, the deeper pulse is the Spleea. Beth bar positions reflect the rib cage In the ight foot position, the Kidneys are refleted atthe sure, the deeper pulse isthe abdomen, Table 1-39 summarizes the pulses and indications and integrates various sehools of thought, both modern and casi cal, The general qualities ofthe pulse can be assessed st the carotid artery as Well. in Spiritual Avis, the relative sizes of the carotid (Ren ying)""* and radial pulses are said to show which channel is involved. For example, when the carotid pulse is twice as large as the radial pulse, the disease is said to be located inthe leg Shao-Yang; when twice as large and rough, the disease is said 10 be located in the arm Shao- Yang. The Rea ying pulse is also said to govem the Exterior While the wrist pulses the Interior. The classic of Dificult Issues and Spiritual Axis also state thatthe skin of the ventral forearm may be used, with the same priniplesas pulse diag- nosis. Spiral Axis stat A hse pulse meass the skin atthe elbow isalso hurried. A slow pulse meaas the skin atthe elbow als small. large pulse means the skin at the ebow is abso thick ard slow. A slippery pulse means the skin atthe elbow is als slippery. A ‘ough pulse means the ski atthe ellow i also rough, Pulses that relate to conditions of the Organs, channels, and regions ean be palpated at arteries in the vicinity of specitic acupuncture points summarized in Table 1-3 on page 219. For more information on pulse diagnosis, see Meridian Ther- apy in chapter 6 Diagnostic and Treatment Priorities Since TCM dingnesis is established by the history and phys- ical alone (with no “objective” lab work), the practitioner must rely upon data collected through the five senses. Often 18.°Ren yng” (man pognass isthe name ofan acupuncture point on the fiont ofthe nck and therefore may be interpreted as the atti ary. However, some intrprelations claim Ren ying tbe th pulse of the lef «tal (cn) positon (refecting Exterior or Stowach-Gi, withthe Fight ‘Uta eu) position (Kan cn) beng the poten hat eects the Interior In dscussing the condition of Stomach-Qt in pats with ehronicdscass, Zhu Dan-Xi states that, ii females the et cur piston is stonger than the ight, the patient's Stomach stil rong id the aisease curable: In mals, ithe ght con position Sronger than the et, the Stomach-Q\ x stong and the disease is Cambie Thee areconsitent wih men having more Qs and women Blood, The Pulse Classic, however, atesthe oppositsand Zhu a ht Wat eat te ies eer oe pics 186. t2 moder tines, aboratry work isheing incorporated increasingly into the OM paradigm, 101 patients present with conflicting information that must be prioritized. While at times necessary, itis unwise to overly theorize and combine elaborate mechanisms that may sound rational but ignore one of nature's basic principles: simplic ity. Nature's problem solving is more often simple—asis so commonly demonstrated by biological sciences. If possibl 4 simple and hisorieally substantiated solution treatment should be used.'*” Complex and multisystem disorders are often said to involve the Eighi-Extra channels, Divergent channels andior to be of Essence-Qi!™ On the other hand, in discussing Deficiency Damage, the master physician Wu ‘Cheng of the Qing Dynasty (1644-1908) stated that “multi- ple pattem manifestations are the rule. The determination of primary and secondary pattems is notan easy matter, but it is fan absolute requirement in order to form an effective for- mul ‘THE FOLLOWING ARE GENERAL RULES THAT CAN AID 1 THE DIAGNOSTIC AND TREATMENT PROCESS THAT THE AUTHOR HAS FOUND 10 BE HELPFUI * Physical signs take precedence over symptoms often, + Information concerning the entire body takes precedence over data conceming any one part of the body, except when treating acute and severe disorders, For example, a patient with low tolerance of physical activity (becoming fatigued and developing symptoms afler physical activity, especially Spirit-atigue with a ‘weak pulse) is often of a weak confirmation even though his/her body (or affected area/joint) may look muscular and strong. They may however, have Interior or Exterior Pathogenic Factors accounting for their fatigue, and then often should be treated as Excess or mixed confirmation, ‘A strong patient thar as a result of hisher disease, is now fatigued and weak can sill be characterized as strong but depleted. (This often occurs in musculoskeletal disorders ‘duc to severe pain, such as dise herniation resulking from lifting in a constitutionally song patient.) Such a patient can usually still tolerate strong and possibly sedating techniques. If, however, the pulse has become very deficient, the patient should be tonifid first and then sedating and strong methods used 187-This may sound ile a entation na text that emphasis the evelopment of ideas, however it isconsistent wth much ofthe story ‘of OM Using pathomechniscprinepls in OM is ot jus the ‘tacking up of pater, but understanding he itracion betwee fystenn. As master Wu Cheng state, whe seeing evidence for tems itis always important to ascertain whats cereal snd what cconcryand teria. TCM fa lgie-sptem-neine ‘which reatment isoflena log (eoretcal) continuation ofthe “dsgnostie process, Theretor, while “loge” conclaons may te ‘nade fom sympa ad sighs, every eaten is tll an experiment era tha should Beans flowed by re-examination and evelation. 1 i therefore portant 9 tetgettapin proces an tne eset 188. At the same ime complex ormulasand tieatment approaches may be recon al apprise02 Patient with pulses, tongue, abdomen (see abdominal diagnosis chapter 6). nails, ané general body that sugaest a ‘weakness, Cold and Deficieney, is often treated es such ‘even though he’she may have an inflamed and warm joint (unless acute or severe). Zhang Jie Bing (Warm Yang school) approaches are often useful. At the same time a mikd-neutral approach to herbal therapy may be needed. Individual consideration 3s to the degree of attention to localized (or secondary) symptoms is always applicable and depending on severity may take precedence +The patient’s general constitution and body type (or the primary disease mechanism) s often more important than ‘aay information concerning exeretion and secretion (or ciher “branch” sympioms’signs), except when treating acute-infective, Exterior, or severe disorders in. which aitention to localized (acute) secretion oF excretion (or area) may be more important. This is known as treating the root first and branch second. In general, it is sai that ‘one should frst elear any Pathogen intemal, before using tonifying or astringent herbs or acupuncture techniques. However, if pathogenic accumu lations are caused by Deficiency (secondary to Defi ciency), it may be impossible to remove the Pathogenic Factors without the addition of, or sometimes emphasiz~ ing, tonifying herbs (especially in de Phe, i.., Phlegm (an Excess pathogen] in an underlying Defi- cient patient). Sometimes it is necessary to tonify first and only when the patient is stronger to use sedating methods. Tonification is often (but not always) empha- sized in protracted ehronic eases as Pathogenic Factors are said to eventually damage the Organs. According to the Classic of Internal Medicine, the Five Tissue Bi {painful obstructions) are caused by Yin ard Blood dei ciency and the use of strong sedating methods that cause excessive sweating, urination, or purging is discouraged. ‘Therefore, reatment of a chronic musculoskeletal disor- der in 2 weak patient with a weak pulse that also has some yellow phlegm, constipation/hard stools, and strong local point tendemess (possible signs of Excess ane Heat) is offen mostly by strengthening (usually done in Interior conditions, ie, not acute or traumatic), Herbs that deal with Exeesses oF Heat may be added (ie. trating both root and branch). Thus it is said, “Different diseases same paitern, same pattem different diseases.” Again, a mild- neutral approach to berbal prescription may be best, espe cially if side-effects develop or the patient does not toler- ate stronger formulas. If, however, for example, an acute ‘warm joint with a capsular pattern and with signs of Excess (severe tendemess fo pressure and limitation of ROM)is seen ina weak patient, one may need to strongly resolve local Excess before attending ta the patient's gen eral constitution or condition. This is known as “attending, tothe branch first and root second,” Also, one always needs to keep in mind that Pathogenic Factors may be responsible for or lead to Deticieney, and tonifying @ actors, external ot patient with retained Pathogenic Factors may resalt in an ‘Chapter |: Foundations for Integrative Oriental Medicine aagaravation of the Deficiency (even if symptoms are not severe or particularly acute). It may be difficult i ascer- ‘ain if intemal Damage mimies External contraction or External contraction simulates Internal Damage. A good history is often the key to resolving such a question. In protracted and chronic diseases, the tonification of Qi, using high dosage (up to 60g) of Astragali (luang Qi.) is needed often, as tis herb is indicated for “strong-Win« and can assists Defensive-Qi and Yangiin eliminating pothogens. In such situations, this herb is ofien combined. with variations of Cinnamon Twig Decoetion (Gui Zhi Tange) that can treat Pathogenic Factors while atthe same time treating Vin, Yang, Defensive, and Nutritive-Qi and can easily be altered to clear Heat or Warm and expel Cold and Dampness. ‘The balance of treating root and branch symptoms is one ofthe more dificult issues one must resolve clinically (especially when using herbs) ‘There are no hard rules, and opinions defer greatly. For example, the famous phy sician Zhu Dan-xi (Nourishing Yin School) often empha sized the supplementation of Righteous-Qi-Yin (over climination of pathogenic influences) while others such as Liu Wansu (Cold/Cooling Schoo!) and Zhang Cong~ zhen (Purge and Attack School) emphasized the direct elimination of Pathosenie Factors First (andor clear Fiee) Which may then result in automatic recovery of Righ- teous-Qi.!"” ‘The questions of root and branch (primary and second ary) are not always elear and should not be viewed as two separate entities, but, rather, as two aspeets of the same condition, Diseases that arise from the Interior often have Organ (or Blood and Nutritive-Qi) related sympioms at the onset while diseases that arise from the outside may not, Csteful history is therefore novessary to understnd ‘hich i primary and which is secondary: Pure tonification is usually used only in Interior conditions where Righ- teous-Qi is weak, Since most musculoskeletal disorders are not purely Interior or Deficient (particularly where Deficieney, Excess and possibly Interior/Exterior are mixed), iti thisauthor’s general (but flexible) rule to treat clearly identified obstructions (or Excesses/Exterior and Pathogenic Factors) frst, and only secondly to treat under: lying root-Deficieney. As the saying goes, “First treat the Exterior, then the Interior,”'*" especially if there is Damp- ness. I the patient is, however, severely or clearly Defi cient (showing clear patterns with symptoms and signs of| 149, Although Lis Wars designed treatments with eganto time and place the patents health condition (e¢ consititiona fact) andthe sharackrisie of the disease, e stad tht atthe sae ie fthognic-Fie Heat was an underving fre hat often ha to be dealt With using cool and cold hers. He often nifedYVinas wel 190 Togethsr wie the hoo} OF Speen and Slama hese are the four school of he Jn-Yuan poo. 191. IsSpvimal Axis, bower it ass: “One shoul frst treat the ot tem Iter tet the symptomsDiagnosis Deficiency), iis this author's approach to use mild tral herbal tonic formulas with the addition of secondary herbs, and, at lower dosages, to treat Excesses ard obstructions. This is done in order to minimize unwanted side-effects and maximize patient compliance. This is important when treating protracted diseases, because the patient may need to take herbs for extended periods. Man- ual therapies and acupuncture (with which the above rules are less important) ate aimed at obstructions, restrictions of flow, restricted movements'motions ane! Pathog Factors (i.e. Excesses and Exteion). Atthe same time, for example, when treating back pain due to “malalignment”™ (vertebral dysfunctions) one may use massage to trea the ‘muscle spasm which isthe branch and manipulation to treat malalignment which is the root. As the channels are ‘more superficial than the Organ systems and thersfor more Yang, and Yang tends towards Excess, iis not a mistake tosedate Excesses in somatic areas (channels) using acu- puncture ina generally weak and Deficient patient To ascertain if symptoms are so-called “false,” or to dis- cem if Excess or Deficiency is predominant, both general information such as pulse tongue. nails. abdomen, spirit, chronicity, age, and localized tissue-feel and funtion should be considered carefully. Again, a good history is offen the key to successful treatment. + Almost all chronic disorders are Internal conditions, often with Blood-stasis, Phlegm, involvement of network-ves- sels and Kidneys. If degenerative in nature, they often involve Essence-Qi as well. The patient’ digestive sys- tem must first be restored in many such cases, as normal digestion is needed to absorb and tolerate many of the herbs that treat the Interior, especially tonics. The use of modem digestive enzymes and addressing. abnormal intestinal flora is often helpful. The stessfil effects caused by chronic disease or pain almost always result in Qi-stagnation and Liver disorders which nevd to be addressed: and also help with digestive functions. + Almost all acute disorders are External conditions. How- ever, many diseases such as nuclear dise herniations tor ‘example, ae Internal oF mixed + When both: Yang and Yin are deficient, the patient may show symptoms and signs of both Heat and Cold, which should not be confused with Shao-Yang (external patho: genic) disease. The key is a more regular appearance (iming) of Heat symptoms (eg., nightly fever) as ‘opposed to the erratic character of Exterior conditions (although Shao-Yang is often characterized by cvelical manifestations as well. The cyclical nature is, however, said to be not as regular, except that, for example, malaria, often a Shao-Yang disease, can manifest regular- ity), Prolonged stress (pain) can exhaust Righteous and Defensive Qi. An extemal pathogen can then be con- cealed in the Connecting channels (Network-vessels), membranes, and muscles without any manifestation of 103 Exterior syndrome, and is ssid capable of injuring Yin and Essence. Later, often with additional weakness or 2 new exposure to pathogens, symptoms arise and simulate Internal Damage. Io Warm-diseases, this type of manifes- tation is considered to manifest inthe Interor, and appro- priate Interior therapies are given. In. musculoskeletal disorders, however, attention to Pathogenic Factors first ‘or in combination may be more appropriate. The patho gens are usually guided outwards (a layered approach). Signs and symptoms of Heat are common, as all stagna- tionsicongestions (depressions) and Deficiency (Qi, Yang, Blond, Yin, or Essence) can result in: transforma- tive/congested-Heat, Exterior or Interior pathogenic- Heat, Empty-Heat or un-rooted Yang syndromes (false: Heat) Most mosculoskeletal disorders of Excess-Heat are acute, come on quickly, and usually hove aclear precipitating factor that can be identified. This may be due to internal or external origin, except in lurking! hidden Warm-diseases. Most musculoskeletal disorders caused by Empty-Heat come-on slowly and arise from chronic physiological or disease processes which are due to Deficiencies and insidious processes (except when they are a result of acute Heatfever damaging Fluids). + True Excess results often in persistent (constant) symp: toms. Deficiencies often result in. symptoms that come and go. Thus, sympioms such as distension, fullness, and sirong point tendemess, that may be interpreted as Exess but that come and go, may still be due to (or rooted in) Deficiency. The conditions of uppermost areas (trunk, head, upper hack) often take precedence over the conditions of the lower parts, when using acupuncture. For example, a patient with red complexion, a feeling of ‘warm in the head, tight subcostal areas, and with cold feet (a possible Cold-Deficient sign), often has a primary Heat or Qistagnation (Excess) disorder that accounts for the cold extremities. One, for example, should not con- clude that patient is Kidney Yang-