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Hi Again!
I have an interesting case to share: a family I am close with and have treated has a 15 year old daughter who is an elite athlete (cross country running, track, nordic skiing, soccer, etc). On October 2nd she came home from school due to back pain, her father asked if I could see her that day because she has never asked to come home due to pain. I scheduled her, then 20 minutes later he called to say she could no longer stand up and that her hands were also not working. She had experienced no trauma, illness, chemical exposure, or other notable trauma. I referred them to the ER and later that night they were airlifted to University of Michigan Children’s Hospital (we reside about 600 miles from Ann Arbor) for further work up.
My friend reported yesterday that the hospital has excluded subtypes of transverse myelitis and has settled on diagnosing her with “only” TM. Acute Flaccid Myelitis is in the running as well, as it is difficult to exclude, but she lacks the viral markers for it so they aren’t considering it the diagnosis right now. Via MRI, she has inflammation from C6-T3, she has regained usage of her right arm and is able to move her right leg slightly. Her left side is recovering much slower – roughly 2-3 weeks behind her right side – she has some flexion of the left fingers, very little extension, especially the thumb, all her distal phalangeal joints are stiffer and less mobile than the proximal and metacarpal-phalangeal joints. She is unable to move the left leg yet at all, she has no sensation from the xiphoid process down. She has reflexes with electrical stimulation.
She has a fantastic and cheerful attitude with an enviable work ethic – virtually a medical dream patient. Her doctors have given a prognosis or 6-12 months for recovery and is hoping to leave the hospital for home by Thanksgiving.
I just drove her mom down to Ann Arbor today and was able to visit for a few minutes and take her pulse very quickly. Her right side does show a tight/wiry pulse at the PC sinew level, no other pulses were tight or wiry; the pulses on her left side felt slightly empty – she has a tendency to Blood and fluid deficiency because she doesn’t eat enough or drink enough water.
Her parents have asked me if I can treat her while I’m in town, so I have the chance to try a few sinew treatments! I would love advice, wise words, etc. Should I just treat PC sinew? add Kidney? I don’t know if anyone will see this in time, as I’ll be driving back home with her father on Tuesday morning. I will try just PC tomorrow if I don’t hear from anyone. I will have plenty more opportunities to treat her once she’s back home.
Hello Elizabeth,
I’m no expert on the subject, but I’ll try my best. From my understanding you can use the PC sinew as it fits the paralysis description of your patient. I would also add the LV sinew, due to the fact that you have a paralysis in the left leg and when the arm yin sinew are affected it means a weakness in the leg yin sinew as well. Maybe first tonify the deficiencies she has. But the fact that she has no sensation below the xiphoid process hints maybe another channel system that the sinews, and also the fact that it happened without any trauma. Maybe divergents ? I am not enough confortable with the other channels system so I’ll leave this to someone more competent that me to explain it.
Hope your patient gets better soon,
AntoineHi Antione,
Thank you for your timely response! I was wondering about the LR channel and how to assess PC vs LR against PC + LR, PC + KI, and PC+LR+KI based on her presentation. I’m heading over to treat her in about an hour and I am thinking to try the PC/LR/KI combo depending on what her pulses are saying and how her deficiencies present and respond prior to treatment.
I don’t feel comfortable diving into a divergent assessment/tx since I haven’t finished reading that section of the book and am really unsure how to make those decisions. I’m hoping that since her pulse is showing a sinew pulse that matches her presentation that the issue is still exterior and is therefore best treated with a sinew tx. But if someone with more experience tells me exactly what to do I am willing to try anything!
I’m excited and grateful for this opportunity and so happy to have this community for support!
Unfortunately there was no noticeable change after the sinew treatment. I was unable to get the LU pulse to feel like it was fully dispersing. I tried needling Lieque with my attempt at the flying technique, as described in the book, but I wasn’t able to boost it much. I went ahead and did PC/LR/KI on the more effected side (L) of her body. There were lots of twitches while I was doing the needling, very few noticeable resistant/obstructed areas to release other than just distal to Quze on her left arm. She was very cold to the touch and I don’t have any smokeless moxa with me so I was unable to warm her other than with a heating pad and keeping her as covered as possible.
I also did not attempt to needle down her spine at all because I wanted to see if just doing the KI channel would be enough. I’m not sure if that omission would be enough to make the treatment ineffective.
I did detect a thin – maybe tight? deep pulse in the guan and chi positions, but I annoyingly did not take notes and I realized on my drive that I don’t remember which side it was on – would that be indicative of Divergent or 8 Extra? Other than that her pulse was similar to yesterday with a wiriness in the PC sinew. The pulses on her left side were more full today.
Hi Elizabeth,
I, too, am relatively new to all of this but I’ll do my best for now. I agree with Antoine that you would want to use the Liver Sinew as well. Regardless of the pulses, given that it’s a paralysis situation, Jueyin would be indicated. For the treatment to be successful, you would need to address the main deficiencies, and if she’s very cold, then moxa would need to be used (on Kid 3, and possibly Du 4 and 14 to build up the yang further, especially if the Kd yang pulse is very weak)
Given that this is a paralysis and a numbness condition, I would make sure to focus on tonifying the channels, that is going from the jingwell upwards on the channel, making sure your jing well point is pointing upwards for tonification. Also, as you pointed out, there aren’t too many hard, ahshi type points along the channels, indicating weakness and flaccidity that would ideally be tonified using moxa on each deficient/flaccid point. In the absence of moxa, you would tonify by turning the needle towards the midline and cover the point soon as you withdraw the needle with your thumb.
As for the pulses, if by pericardium sinew, you are referring to the right Chi position having a sinew pulse, then I would try to make sure that it’s the Jueyin and not Yangming sinew, the latter would be more superficial (1-3 beans) while the former would be slightly deeper at 3-6 beans. You would need to cover the Jueyin anyway, so chances are that the yangming would be indicated in this case which is full of qi and blood and would help with paralysis (or is this too TCM and not indicated….not sure, just throwing it out there:) ) Could make sense given that she can not even support her own weight at the moment; that would be yangming!
Anyway, just brainstorming here.
Hope it goes better next time.
Hi Armin, thanks for your input, I really appreciate it!
Last night (Sunday) she had a shift where she became able to bend the knee of her right leg while turning on her side. After the spontaneous movement while trying to roll over she was able to move it intentionally before fatiguing. Her left leg remains unresponsive but has been having more involuntary twitching. She is able to wiggle the toes of her left foot if light stimulation is applied to the underside of her toes, like a light tickling.
I returned for one last session this evening.
Armin, in regards to your suggestion regarding tonifying her sinews, I decided against that because she doesn’t present with flaccidity that I could tell – she has great muscle tone, which is being maintained medically. I think they hook up electrodes to her muscles and get them to fire – she biked 6 miles today during her PT/OT, prior to my visit. I read 0-3 beans on the right chi pulse as the san jiao/shaoyang, what is the yangming channel you’re referring to?
I repeated the treatment I did on Saturday, but on the right side of the body this time, just to see what happens. This time I added tianfu (LU3) and kongzui (LU6) to lieque (LU7) to get the LU pulse to disperse and added some guasha along her spine before releasing the KI channel. She became noticeably warmer during the treatment this time, her cheeks were rosy but no sweat expressed.
Heading back north tomorrow with her dad so any new treatment ideas will have to wait for Thanksgiving or for when she returns home, whichever is first!
Elizabeth, the only thing I’d like to chip in in addition to Armin and Antoine’s excellent suggestions is that you might cup SI-12 as part of the treatments. I wonder had she had a vaccine recently. The distal joints are stiffest because she’s trying to eliminate through the Jing-wells but there isn’t anough Yang qi to push the pathogen all the way out. As was suggested, moxa on KI-3, DU-4 and DU-14 is important to restore Yang to the exterior. Armin is talking about another lens through which you can diagnose sinew pulses. In that method, Yang Ming shows up in the chi position at between 1 and 3 beans of pressure. But no need to worry about which method to use. All the best with this case, Elizabeth. You sound strong in your resolve to get to the bottom of it. Very warmly, Ann x
Hi Everyone,
The second treatment unfortunately did not seem to have much, if any effect. It will be nice to see her in my office where I can use all methods to assure strength of Yang, especially.
Ann, thanks for the clarification on the yangming position for sinew pulses – so much to learn!
Best,
LHey Elizabeth! Thank you for sharing this case. Very interesting! I hesitate to chime in with this, since Ann responded re: the application of the sinews. While I see the application of the jueyin sinews, you mentioned a tight pulse that was deep in the guan or chi position. (There are really helpful pulse taking directions on 227/228 and also a great pulse cheat sheet in the red book:)). I was wondering if when you listen to her pulses again, if you could let us know if the deep pulse you were feeling was actually an 8x–either yin qiao mai (chi only) or yin wei mai (guan & chi).
Re: yin qiao mai, even though she presents outwardly as extremely motivated and a dedicated athlete–not what we might think of as yin qiao mai–could that excessive activity be resulting in damp restricting yang qi and the resulting paralysis be her body yelling at her to slow down? Low back pain, numbness, and back pain are possibilities with yin qiao.
Re: yin wei mai, the description of the channel also might not be a fit at first glance, but it does include the potential for low back pain, and there’s the anxiety components that sometimes accompanies a very dedicated athlete, as the exercise is what we love to do, not realizing it’s how we have been managing the anxiety–or maybe I’m just speaking from personal experience 🙂
Full disclosure: I find it very difficult to discern what channel to use without the pulse. 1) Possibly because I don’t have the knowledge or experience to operate otherwise, but 2) because almost any presentation could fall under any of the complement channels, but I feel like the pulse is the body’s voice and takes me out of the equation. Hope that makes sense.
I’d love to hear what you think, and please keep us updated. I’m late to the party, but this is really interesting and helpful! Best wishes!
Hi MG – Thanks for your interest – I really want to help this young lady have a shift! Thank you for your suggestions regarding the 8 Extras – I had not been considering them with her and will definitely do so asap.
I saw her again two weeks ago and was really trying to pay attention to her pulses so I could update here. I’m very new to the classical pulse taking techniques and am struggling not to be overwhelmed by all the new information. This latest reading was rather hastily done, not at all the slow quiet listening I was hoping for as I’d accidentally double booked myself and had to scramble. She is slowly able to move more, but is certainly unable to bear weight and has little ability to direct motion other than wiggling her legs. Her right arm continues to be strong and mostly, if not completely recovered. Her left arm and hand are recovering more slowly (she is right handed), similarly, her right leg is more mobile than her left. She is complaining mostly of lack of bladder and bowel control as that is the thing that is most impacting her quality of life and sense of independence and privacy. She alternates between retention of urine and bowels and occasional incontinence. Mostly there is retention. I wondered if this detail has any significance for sinew assessment with the Yin channels?
She continues to be cold to the touch – especially along the left leg Yin channels with the coldest area being the ankle. I tried using the small smokeless moxa I have to warm Mingmen (Du 4), Kidney shu, and along the areas where she was the coldest but was not able to engender much of a shift. I also did some general massage and cupping on her because her shoulders are tight from pushing herself along in the wheelchair. She has been very uncomfortable being touched (she tenses) – likely due to puberty and not receiving much touch from people outside her family – but her limbs were much more noticeably warm after the quick massage than they were after the moxa. I also forgot to mention she has some significant scoliosis.
In regards to her pulses, the most noticeable thing for me was that for the most part, her pulses are scattered – if I’m reading that what scattered means is that you feel a pulse, strong or weak, but there are no defined edges of the blood vessel. I felt this at all positions last time and have since first seeing her. Her right cun position would consolidate and disperse some during this last visit whereas there was no noticeable dispersion at the hospital. I noticed some tightness/wiryness in the right chi, not right at the surface of 1-3 beans but maybe at 3 beans or slightly deeper, certainly not into the 6-9 bean range – no longer certain if this is PC or not as I am wholly confused on how you know which system to pay attention to when connecting (really looking forward to that pulse class in Chicago, 2020). Her left cun pulse felt okay to me, and I also felt some of that tight/wiry sense in the guan and chi positions on the left, around the same depth as on the right. Other than that I did not note anything.
I did not attempt another sinew treatment because I have been feeling like there is something I must not be understanding since the last two have not accomplished anything obvious. I wanted to know from the community here how I would know if there was something else I should be doing or whether the fact that there is paralysis/difficulty moving disqualifies treatments other than sinew. I understand that has to come from the pulse and I’ve been trying hard to read the pulse book and adjust but it’s a lot of information and so different from what I was taught in school so my confidence is poor and it’s tough to keep everything in mind and not take 45 mins just on the pulse, haha! I really identify with Henry from the Chats – I get too mental about it.
Sorry this is so long, thanks to everyone for their thoughts.
Hey Elizabeth,
First, the pulse class is absolutely incredible, and I’d like to take it again as many times as possible; having said that, Ann’s description and directions on page 228 have been so helpful to me in the way that it is condensed to the basics. This is how I avoid getting “too mental” about it; I know I’ve said this before, but I honestly don’t “think” a whole lot about what’s going on with the patient unless they have pain, in which case I ask movement questions. I just leave it all to the pulse. Obviously, I could be wrong in my pulse taking–and there is SO MUCH more to learn–but I’ve just seen patients get really good results when I follow the pulse, whereas if I would have gone with my “thoughts”, the treatment may not have been as effective. So I just let go of the fact that I know so little, rely on the pulse, treat, and keep studying. I share this to encourage you to not doubt your ability. It’s a practice, and you can totally do this pulse taking!
If you’re not feeling the pulse at 15 beans, then you probably don’t have an 8x. (Also, I reference the red book ALL THE TIME in clinic, too).
Re: the failed sinew treatments, were you able to tonify all the deficiencies prior to doing the sinew treatment? If yes and to no avail, my “thoughts” would take me back to 8x:) But if not, make sure you get those tonified before you do another sinew, if you decide to go that route again.
Your note about constipation and incontinence made me think KD Luo. Does she have any vessels, etc around KD 4?
Thanks again for sharing!
I saw her this morning and here’s the update: she has seen her chiropractor twice since I last saw her. The chiro works with the neurofascial system instead of doing high velocity manipulation. This has helped her by improving finger extension, tenderness and spasm in her left hand and arm, plus has seemed to help with speed up her recovery body-wide. In addition to now having much more mobility in her left arm (still isn’t quite 100%), she is now able to extend her knees voluntarily when sitting or lying down and is able to pull her leg in (knee to chest). These movements continue to be stronger on her right than left. She still has little to no sensation below her chest. She can bear weight with assistance as long as her legs are locked, additionally she is able to keep her hips in position now – a couple of weeks ago her hips would fall back and make her fall. Now, the situation is that if she tries to take a step, she collapses.
In regards to the bladder and bowels, she is the same. She doesn’t feel any urge to either urinate or have a BM, but is able to feel that’s she’s going when it happens. She is also able to “choose” to go on a toilet if she’s placed on one, but again, will not know that she needs to go.
MG – I did not notice any pulses at 15 beans or see any luos at KI4.
I read the section on sinew pulses in the black book prior to her visit and noticed that there was wiry/tightness in the right chi (0-6 beans) and left chi (3-6 beans) and diagnosed this as PC, LR, ST sinews, because she has inflammation in her spinal cord, I also added the KI sinew. She is also most cold to the touch in the KI/LR primary channel areas. I could not feel the Lungs or Liver dispersing, she seemed to have enough body fluids, and her KI Yang pulse was not strong.
I moxaed Mingmen (Du 4) and Feishu (UB13), needled Geshu (UB17) Huato points and moxaed (according to the red book), this did release the Liver and helped the KI Yang, but the Lungs were stubborn – I tried doing the flying technique on Lieque, and it took quite a few tries to get the Lungs to disperse.
I did the sinew tx in the right order, adding moxa to the LR channel where cold. I did everything on the left side because that side is weaker. She had lots of involuntary movement during the treatment – like her body knew something was painful but she did not experience the pain at all. These movements were especially strong on the LR and KI channels. Her legs felt almost normal temp after the treatment but we did not notice any difference immediately after treatment. I told them it would be active for 3 days and to do the Epsom baths as directed in the red book.
I feel like asking about expectations is limiting, but to those of you who have more experience than I do – how much of a shift would you expect after a sinew treatment in a patient like this with paralysis? If I really knew my stuff about the pulses and all the techniques – like if I had given a “perfect” treatment and the patient was the same, let’s say – what’s the range? Would you expect incremental improvement or would you think there’s a real possibility that she’d be able to get up off the table and walk if her mind and body were ready for that?
Hello Elizabeth,
Yes, that’s a trap, you’re quite right… we can’t know what healing means for anyone. for her, healing could mean getting up and walking, but it could mean acceptance. If we create ideas about what should be for an individual, those ideas could be anywhere from limiting, to being wide of the mark. Then we get disappointed, the patient senses the disappointment and feels that they and the practitioner have failed and we are worse off than before the treatment. So I agree, better to just let the treatments take their course, confident that the invitation they present is taken up to the maximum degree they can be by that patient at that time, and that all is well and good. This is not meant to come across as negative or hopeless, but as honoring of the patient. A
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