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Chinese DiagnosticsMicrosystemsTobacco Cessation ProtocolDoris Hubbs, MD, FACPApril 27, 2013Chinese DiagnosticsTraditional diagnosis:

InspectionAuscultation and OlfactionInquiringPalpationTraditional diagnosisThe acupuncturist decides which points to treat by observing and questioning the patient in order to make a diagnosis according to the tradition which he or she utilizes. In TCM, there are four diagnostic methods: inspection, auscultation and olfaction, inquiring, and palpation.[69]Inspection focuses on the face and particularly on the tongue, including analysis of the tongue size, shape, tension, color and coating, and the absence or presence of teeth marks around the edge.Auscultation and olfaction refer, respectively, to listening for particular sounds (such as wheezing) and attending to body odor.Inquiring focuses on the "seven inquiries", which are: chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; andmensesandleukorrhea.Palpation includes feeling the body for tenderA-shi points, and palpation of the left and right radial pulses .

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Chinese Diagnostics: patients voice has clues to diagnosisWall Street Journal: April 24, 2013Chinese Diagnostics:angry, excited, worried, depressed, paranoid speech patterns

Wall Street Journal, April 24, 2013Chinese Diagnostics TongueTraditional diagnosis:

Inspection of face, body, and especially the tongue:

S: tongue size and shape C: tongue color and coating U: tongue underside (true color) M: tongue markings and moisture

Traditional diagnosisThe acupuncturist decides which points to treat by observing and questioning the patient in order to make a diagnosis according to the tradition which he or she utilizes. In TCM, there are four diagnostic methods: inspection, auscultation and olfaction, inquiring, and palpation.[69]Inspection focuses on the face and particularly on the tongue, including analysis of the tongue size, shape, tension, color and coating, and the absence or presence of teeth marks around the edge.Auscultation and olfaction refer, respectively, to listening for particular sounds (such as wheezing) and attending to body odor.Inquiring focuses on the "seven inquiries", which are: chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; andmensesandleukorrhea.Palpation includes feeling the body for tenderA-shi points, and palpation of the left and right radial pulses .

5Tongue Diagnosis by Maciocia 1987 & 1995

Shape: (p. 66-86)Swollen : Spleen chi def.yang def. (spleen and/or kidney yang def. with dampness)Thin tongue: pale: blood def. red: yin def.Hammer-shaped: ST, SP, KI deficiencyCracks: horizontal cracks:red: kidney yin def.normal color: ST and LU def.vertical cracks: in center midline: ST chi def.Tooth marked: Spleen chi deficiencyquivering (p.82):pale: spleen chi deficiencyred and dry: extreme heat, internal windCoat: (p. 87-117)Normal coat: thin, white, light moistYellow, thick: heatWhite, thick: yang deficiencyabsent: Stomach yin deficiencycoat without root: deficiency of ST/SP/KIColor: (p. 41-65)Normal: pink to light redPale: blood deficiency and/or yang deficiencyRed: abnormal heatPurple: blood stasis

6Tongue diagnosisPrincipal meridians (and internal organs) are reflected on specific tongue areaskidneyGB-stomach-spleen-liverHeart-lungBranches from the principal meridians go through the oropharynx and to the tongue.So the internal organs will affect the condition of the tongue.The tongue reflects the basic condition of the patient and the underlying problem at the time of exam.The condition of the tongue helps to predict the results of acupuncture treatments and prognosis.The tongue is an indicator of change as patients develop through their illness and treatments.The tongue is easy to observe.

Each organ has a zone on the tongue where its activities are reflected.The tongue, especially the tip, reflects the state of the FTs energy and may show evidence of emotional conflict.The digestive system is represented in the midline along the length of the tongue.KI is found at the base of the tongue.

7Tongue DiagnosisColor

Light red or pink: normal Red: abnormal heatPale: yang deficiency or blood deficiencyPurple tongue: stasis

Tongue Color can be affected by food or natural pigmentationColor of tongue is the most important aspect of tongue observation.Color of the body of the tongue reflects the state of the Yin organs, Blood, and Rong Qi.8Tongue ColorPale tongueLight red tongue

Shape:

Thin tongue: pale: blood def. red: yin def.

Swollen : Sp chi def.yang def.

Cracks: long horizontal cracks:red: kidney yin def.9Tongue ColorNeed good lighting,

preferably natural light

For adequate inspection of color

How to examine the tongue:

Ask when and what they last ate or drank (or smoked)Ask if they scrape their tonguesCheck tongue at the beginning of each treatmentNatural lighting is best (not reliable under fluorescent lights or near colored walls)Tongue should be extended without straining or gagging and opened wide enough to see the baseNot longer than 15 secondsCompare between treatments10Tongue ColorLIGHT red tongueRed tongue

Color: (p. 41-65)Normal: pink to light redPale: blood deficiency and/or yang deficiencyRed: abnormal heatPurple: blood stasis

11Tongue ColorDark Red TonguePink tongue

Normal Tongue ColorPink to light redUnderside : true color

Tongue Size and Shape Thick TongueNormal Full Size tongueslightly swollen edges

Size and shape: Blood and Rong Qi.Normal tongue: full, but not thickThin (and pale): Blood deficiencyThin (and red): Yin deficiencySwollen (and pale): Yang deficiency (often SP & KI) causing dampnessSwollen (and normal or red): Yang excess with retention of Damp & Heat

14Tongue Size and ShapeSwollen edges Thin Tongue?

Shape: (p. 66-86)Swollen : Spleen chi def.yang def. (spleen and/or kidney yang def. with dampness)Thin tongue: pale: blood def. red: yin def.Hammer-shaped: ST, SP, KI deficiencyCracks: horizontal cracks:red: kidney yin def.normal color: ST and LU def.vertical cracks: in center midline: ST chi def.Tooth marked: Spleen chi deficiencyquivering (p.82):pale: spleen chi deficiencyred and dry: extreme heat, internal windCoat: (p. 87-117)Normal coat: thin, white, light moistYellow, thick: heatWhite, thick: yang deficiencyabsent: Stomach yin deficiencycoat without root: deficiency of ST/SP/KIColor: (p. 41-65)Normal: pink to light redPale: blood deficiency and/or yang deficiencyRed: abnormal heatPurple: blood stasis

15Tongue Size and ShapeHammer tongueLong tongue

Tongue Coating Uneven coatNormal thin, white moist coat

Yang organs, especially STPresence, thickness, color, texture and distribution of coatNormal: thin, white, slightly moist coatAbsence of a coat: deficiency of ST Yin and possibly KI YinThick coat: pathogenic process in the internal organsWhite coat: Dampness or Cold or slow digestionYellow coat: Heat due to excess Yang (or coffee or tobacco)Sticky or slippery: Dampness or phlegmIn acute conditions check the distribution and colorCoatings can be mixed representing multiple pathological processesMedications, food, and tobacco can affect the coating

17Tongue CoatingYellowish, thick, dry coatWhite coat without root

Tongue Underside Shows True Tongue ColorNote teeth marks and red tipLook for venous congestion

Underside of the tongue: shows the true color of the tongue bodyLook for venous congestionLook for teeth marks

Markings: state of the internal organsSwollen tongue with scalloped edges: SP deficiencyRed points and spots: HeatGeographic tongue can indicate constitutional ST Qi deficiencyRawness: acute = Yang condition; chronic erosion = Yin deficiencyCracks and fissures: Yin or jing deficiency or extreme drynessRemember: medications can cause fissuring of the tongue19Tongue Underside Shows True Tongue ColorLight redDarker red

Patient after 4 weeks of acupuncture treatmentLess swollen; fewer cracksTeeth marks remain;But tip of tongue better

Tai Yin/Yang Ming PM TherapyKi 3 and Sp6 connected with4 Hz electrotherapy to Lu 5

After 5 weeks of acupuncture txCoat is less peeledTip is less dented

Tongue MovementsQuivering

..\power point presentations 042713\tongue quiveringquivering (p.82):pale: spleen chi deficiencyred and dry: extreme heat, internal wind24Chinese Diagnostics TongueTraditional diagnosis:

Inspection of face, body, and especially the tongue:

S: tongue size and shape C: tongue color and coating U: tongue underside M: tongue markings and moisture

Traditional diagnosisThe acupuncturist decides which points to treat by observing and questioning the patient in order to make a diagnosis according to the tradition which he or she utilizes. In TCM, there are four diagnostic methods: inspection, auscultation and olfaction, inquiring, and palpation.[69]Inspection focuses on the face and particularly on the tongue, including analysis of the tongue size, shape, tension, color and coating, and the absence or presence of teeth marks around the edge.Auscultation and olfaction refer, respectively, to listening for particular sounds (such as wheezing) and attending to body odor.Inquiring focuses on the "seven inquiries", which are: chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; andmensesandleukorrhea.Palpation includes feeling the body for tenderA-shi points, and palpation of the left and right radial pulses .

25Chinese DiagnosticsTraditional diagnosis:

InspectionAuscultation and OlfactionInquiringPalpationTraditional diagnosisThe acupuncturist decides which points to treat by observing and questioning the patient in order to make a diagnosis according to the tradition which he or she utilizes. In TCM, there are four diagnostic methods: inspection, auscultation and olfaction, inquiring, and palpation.[69]Inspection focuses on the face and particularly on the tongue, including analysis of the tongue size, shape, tension, color and coating, and the absence or presence of teeth marks around the edge.Auscultation and olfaction refer, respectively, to listening for particular sounds (such as wheezing) and attending to body odor.Inquiring focuses on the "seven inquiries", which are: chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; andmensesandleukorrhea.Palpation includes feeling the body for tenderA-shi points, and palpation of the left and right radial pulses .

26Bargain Acupuncture!

Microsystems

Ear (auricular)Hand Scalp(Tongue)Microsystems: The whole body is represented in one area of the body: in the ear, hand, scalp, tongue, etc.28Microsystems

29Many different forms of microsystem acupunctureHand acupuncture: Korean, Chinese,

Scalp acupuncture: Japanese, Chinese,

Ear acupuncture: French, Chinese, Korean Hand AcupunctureEntire body on handAll meridians on hand

Korean Hand AcupuncturePosterior body on handAnterior body on hand

Scalp AcupunctureChinese Scalp AcupunctureJapanese scalp acupuncture

Scalp AcupunctureStroke Rehab

Difficult pain conditions

Neurodegenerative disordersScalp AcupunctureFind the motor area& the sensory cortex

Scalp acupuncture

Acupuncture in the NewsAARP Bulletin April 2013Acupuncture for Pain

At best, people get about a 20 to 30 percent reduction in pain from opioid pain medicationA recent study of acupuncture, for instance, found that it helped ease pain in patients with osteoarthritis of the knee.37Dr. Terry Oleson in Californiaresearched and taught ear acupunture

Dr. Nogier mapped points

Auriculotherapy was developed by the FrenchneurologistPaul Nogierin 1957[citation needed]using aphrenologicalmethod of projection of afetalHomunculuson the ear for reference of complaints and points for treatment. The method is an offshoot of Phrenology.

Ear acupuncture did not develop originally in the Orient, as is often thought. A French physician, Dr. Nogier, was intrigued by the folk remedy of cauterizing points on the ear for back pain, and as a result, sought to "map" the relationship of points on the ear to points on the body.

39Inverted fetus mapped to ear

Ear Map

Auriculoacupuncture TherapiesAnxietySubstance abuse (detox protocols): NADA ProtocolNausea and GI sxPain Specific pointsBattlefield Acupuncture Protocol

Many more conditions can be treated

Treatment of musculoskeletal pain

Needle the ear point associated with the part of the body in painAuricular Diagnosis and TxObserve abnormal ear markings, discolorations, abnormal skin

Palpate for tenderness at specific points

Use electrodermal point finder to locate regions with low skin resistance (high skin conductance)Acupoint Finder

Auriculotherapy Tx OptionsAcupressure with seeds or pellets

Acupuncture needles: Short needles, 15 mm (0.2 mm)ASP needles (stay in for 1-2 days)

ElectroacupunctureLaser stimulation

Using press tacks or seeds

Auriculotherapy with regular acupuncture needlesFour points for anxietyInserted in shoulder point of ear

Treatment of nausea and GI sx

Four ASP gold needles in the autonomic pt., LI, SI, stomach pts.Patient felt better and less nauseated immediately afterwards.Patient presented with N&V and diarrhea for one day, probably acute GE.She was in a hurry, so elected to do ear acupuncture with ASP needles.Picqued autonomic point, stomach, SI, LI points.

She immediately felt better with resolution of nausea.50ASP needles can stay in ear for 1-2 days until they fall out naturally

NADA protocol for drug withdrawal

Acupuncture Group Therapy

NADA protocol

What is the "NADA protocol"?At five designated ear points in each auricle (outer ear), clinicians trained through NADA apply fine gauge, sterilized, one-time use stainless steel needles just under the skin, where they remain for up to an hour while the client (in most circumstances) relaxes quietly in a comfortable chair. Ordinarily, groups of clients sit together while undergoing the treatment. The procedure functions as an adjunct to a comprehensive treatment program offering the basic therapeutic elements of counseling, education, family involvement, mutual support group involvement, supportivehealth care ofgeneral nature. Clients in all types of treatment settings including inpatient, outpatient, incarcerated, shelters, harm reduction and street outreach can utilize this treatment. Among the benefits reported by clients and clinicians are improved program retention, a more optimistic and cooperative attitude toward the process of recovery, as well as reductions in cravings, anxiety, sleep disturbance and need for pharmaceuticals.

NADA celebrated its 25th anniversary this year. Incorporated in 1985 in the state of New York, NADA has helped spread acudetoxfar and wide, nationally and internationally.In 1985, following 10 years of their experience developing the basic five ear-points NADA protocol for treatment of addiction, the staff and other professionals associated with the South Bronx's Lincoln Hospital determined a need for a national-level organization to expand training capacity and awareness of the value of acupuncture as a tool of recovery.NADA was then established toenrollmembers, establish a collection of related reference materials, codify a training curriculum and develop a flexible system for registering qualified trainers and delivering trainings. NADA has since trained more than 10,000 health professionals, including counselors, social workers, nurses, medical doctors, psychologists, acupuncturists, chiropractors, outreach workers, drug court judges, corrections officers and others to use the protocol.

NADA Annual Conference: Denver 2013 May 2-4

http://www.acudetox.com/about-nada/12-faqs54NADA protocol

NADA ProtocolNational Acupuncture Detoxification Association Protocol

Works for withdrawal of opiates & other

Shen MenAutonomic PointLung 1 or 2 (use the more reactive)LiverKidney

56Auriculotherapy for weight loss?

Battlefield Auricular ProtocolFive ear acupoints in specific order:

Cingulate gyrusThalamusOmega 2Point zero primeShen men

For acute painDeveloped by Dr. Niemtzow in 2001 in the course of researching a more efficient auriculotherapy system for the rapid relief of pain. Many civilian and military acupuncturists utilize this protocol daily in medical practice in the clinic and in the field.

Delivers significant attenuation of pain in just a few miutes. Lasts for varying periods of time (minutes to months, depending on the the pathology, etc.)

Most likely favors the processing and modulation of pain in the CNS involving the hypothalamus, thalamus, cingulate gyrus, and cerebral cortex structions.

Typically use ASP gold needles.

After placing in CG, the patient is allowed to ambulate for about 2 minutes to determine whether the pain is improved. If no improvement, an ASP needle is inserted into the CG of the opposite ear, and the patient ambulates again to determine the new pain level.

Another ASP needle is placed in the thalamus point in the ear that has produced the most pain relief. The patient ambulates and the new pain level is determined.

Whichever ear produces greater attenuation, ASP needles are place in sequential manner for Omega 2, point zero, and shenmen.

After the dominant ear has received ASP needles in all the battlefield acupuncture points, the pain level is evaluated. If the pain level is above 1/10, the other ear is needled in a similar manner.

Dr. N. uses Omega 2, Shenmen, and Point zero bilaterally without walking the patient but with fast insertion of the needles for resolving most migraine HA/s (first regular needles, then ASP after migraine resolved.)

58Battlefield Acupuncture ProtocolFive ear pointsUsing ASP gold semi-permanent needles

Battlefield Acupuncture Protocol5 ear pointsMilitary is using this

Data from Dr. Niemtzow Medical Acupuncture vol. 19, no. 4, 2007PATIENTSAll Failed Western Pain Medications

A. 40 y/o M Sciatic LBP 10/10 4 weeks TX: 1/10 F/U: 3 days 9/10B. 52 y/o M Shoulder Bursitis 7/10 1 month TX: 0/10 F/U: 10 days: 2-3/10C. 36 y/o F 5 years Elbow and Leg Pain 7/10 TX: 1/10 F/U:8 days: 3/10D. 43 y/o F 9 years TMJ 4/10 TX: 0/10 F/U: 2 days 5/10E. 77 y/o F 10 months Fibromyalgia 6/10 pain TS: 2/10 F/U:2 days: 3/10F. 24 y/o F 5 years Carpal Tunnel bilat 4-5/10 TX: 0/10 F/U:4 days: 4/10G. 21 y/o F 2 years TMJ 4/10 TX: 1/10 F/U: 2 days: 2/10H. 78 y/o F 7-8 years Left Hip/DJD pain 8/10 TX: 2/10 F/U:3 days: 1/10I. 50 y/o F 17 years Fibromyalgia Pain 9/10 TX: 0/10 F/U: 5 days: 6.5/10

The Military Adopts Acupuncture

December 2011Auricular Trauma Protocol

Developed by Dr. Helms et al.Auricular Trauma ProtocolATP6 ear points in specific orderTargets auricular areas that correspond to parts of brain hurt by stress/ trauma

Thought to help balance or normalize brain dysfunction caused by stress/ trauma

Helms, et. Al., HMI Auricular Trauma Protocol: An Acupuncture Approach for Trauma Spectrum Symptoms, Medical Acupuncture, Vol.23:4, 2011.Auricular Trauma ProtocolATP6 ear points in specific orderUse regular or ASP needles(or press tacks or pellets)

Leave needles in for 30-120 minutes

Used successfully for:PTSDPainAcute/chronic conditionsMilitary or civilian

Helms, et. Al., HMI Auricular Trauma Protocol: An Acupuncture Approach for Trauma Spectrum Symptoms, Medical Acupuncture, Vol.23:4, 2011.SummaryThe tongue can be valuable for diagnosisThe radial pulse can be important for diagnosis but is more difficult to masterAuriculotherapy is one type of microsystem acupuncture that is relatively easy to useOther microsystems of acupuncture include (Korean) hand acupuncture and Japanese and Chinese scalp acupunctureCigarette Cessation ProtocolsMore than one protocol available for decreasing withdrawal symptomsBody acupuncture and ear acupuncture

Does NOT keep the person from smoking or buying cigarettesOnly helps with the w/d symptoms: craving, irritability, nervousness, etc.Cigarette Cessation ProtocolQuit cigarettes the night before (day 0)Day 1: give full treatment protocolDay 2 or 3: repeat full tx protocolOpen door for ear protocol for 1st wkDay 8: give full tx protocolWeek 3: repeat full tx protocolWeek 5 or 6: repeat full tx protocol

Modified from Medical Acupuncture for Physicians: A Pocket Clinical Reference Guide(Complied by Carlos Vargas, MD)6945 min. protocol for cigarette cessationGb 8, Gb 18, (and GV 20)SP 3 on each foot with4 HZ electricity

70Cigarette Cessation Protocol(Core Treatment Days 0, 1, 8, 22, 40)Insert acupuncture needles intoGB 8 and GB 18 (both sides of head)SP 3 (both feet and connect electrical stimulation from one foot to the other with 4 HZ)

Patient is comfortably semi-reclined and treatment continues for about 45 minutes

GV 20 is often added to the acupoints aboveOpen door for auriculotherapyfor anxiety for one weekAuriculotherapy for anxiety NADA Protocol

Is there objective evidence that it results in long-term quitting? Cochrane review of acupuncture for cigarette cessation: no evidence of benefit

Acupuncture may improve withdrawal symptoms, but patients need to be committed to stopping cigarettes in order to be successful.SummaryCigarette protocols and auriculotherapy can be helpful for withdrawal symptoms, including craving, irritability, and anxiety

Patients need to be committed to stop smoking in order to have long term success