Pulling it all together (CCPD, COM, CCM, Classical pulse, etc.)

Today an initial patient visit highlighted the integration of Contemporary Chinese Pulse Diagnosis, Contemporary Oriental Medicine, Classical Chinese medicine and Classical pulse diagnosis.

The patient, a 66 year old female artist (retired mostly due to jealousy of her now deceased husband and fear), complains of severe left hip pain and osteoarthritis. The pain began 5 years ago after her husband’s death, a long drawn out illness of Alzheimer’s and complications, in which the patient was the primary caregiver. She is a former yoga instructor (not in many years) and is troubled that she can no longer move her body freely. She is overly controlled by her aggressive daughter, as she was by her first husband (divorced, then re-married) and her sister in childhood. Her pain is on the left Gall Bladder channel around GB 29-30. Pain is localized, but is also felt around the knee cap and lateral shin, mostly Stomach channel. In addition, she has lost muscle tone in her left thigh. The hip pain is worsened upon walking and putting pressure on the leg during a full stride. Balance and posture have been affected.

Patient experiences anxiety and some panic, and fear since the death of her husband. When stressed, she experiences occipital tension and loss of smell and appetite with some nausea and occasional vomiting.

Childhood history: corrective procedure for being tongue-tied; polio age 13 (miracle cure by local healer); sled accident and back injury age 15.

A few relevant findings on the pulse:
1. CCPD:
HT qi deficiency (changing intensity (3-3+), Interrupted pulse, Changing Intensity (2) over Uniform Impressions)
HT blood deficiency (increase rate on exertion 28)
Yin-Jing-Essence deficiency (Ropy)
LR qi stagnation (Tense Robust Pounding (3+ to 4))
LR blood stagnation (Choppy, engorged distally (2+) and ulnar engorgement)
GB qi and blood stagnation (Choppy Inflated)
SP deficiency/connective tissue weakness (Squirmy entire right side, especially middle)(see comments for description of Squirmy)
ST qi stagnation with heat (Tense Robust Pounding (3+ to 4))
Blood Thick

2. CCM pulse:
HT not expressing its Shen
LU not diffusing wei qi to the surface
BL/KI sinew meridian activity
BL/KI divergent meridian activity
ST luo vessel heat/stagnation
LR blood stagnation

Analysis and Integration:
Seeing the connections between these two pulse systems and diagnoses and how they each relate and explain the patient’s symptoms and findings are interesting.

Arthritis in COM has much to do with the HT and its ability to control the circulation and dissemination of blood to the distal regions of the body. It is very common to see HT qi deficiency on the pulse with arthritis. HT blood deficiency is another very common characteristic. I have written on this in the past in my journal article with Chinese Medicine Times. You can find that article here.

Arthritis in CCM is often the result of bi obstruction syndrome resulting from an invasion of wind-cold-dampness. Often the initial location affects the tai yang system. There are different interpretations on progression, the Su Wen detailing a longer history towards the formation of the bi syndrome (penetration from the head, to the throat, chest, abdomen, sacrum, Kidneys, triple burner mechanism to the Bladder shu points). The Divergent meridians are another theory on progression wherein the bodymind is unable to resist a pathogenic external invasion allowing for the yuan qi to come to the assistance of wei qi and translocate the pathogen to the interior (typically at the level of the joints). Resources are diverted to allow for this latency and over time are depleted resulting in more chronic degenerative conditions. Initially, the resource that is used up is yin-jing fluids at the level of the BL/KI. When taxed, the jing converts to blood at the second confluence (GB/LR), then to thin fluids-jin (ST/SP), then to thick fluids-ye (SI/HT), etc. So, looking at the BL/KI divergent meridian problem with degeneration, we are seeing a yin-jing-essence condition. This is also reflected in the Ropy pulse (CCPD).

So we can see the connection with the HT deficiency, Ropy pulse and the BL/KI divergent meridian activity. They reflect lack of resources and degeneration of structure.

One can look at the muscle pain that the patient experiences from a sinew meridian perspective as well. Pain with movement, particularly extension, relates to the tai yang sinew meridian of the leg. (Pain elicited by rotation would suggest shao yang (if seated shaoyin), pain with weight bearing, yang ming, etc.) When flaccidity is present with weakness it implicates a more chronic picture in which the pathogen has affected the yin internal pair, here the Kidneys. So yang and yin sinew meridians are involved in this case.

So, putting it together we see the location of the pain as relating to the GB channel at the hip (qi and blood stagnation on the pulse) and knee cap (yang ming) and lateral leg (GB and ST channels) with the nature of that pain being related to the tai yang leg sinew meridian (BL: BL sinew meridian pulse) and leg shao yin (due to it’s chronicity). The chronic nature is demonstrated by the lack of muscle tone and weakness, a yin deficiency according to CCM creating lack of fluid volume and resources to nourish the muscles/connective tissue, etc. This is further evidenced by the Squirmy pulse (CCPD) reflecting the connective tissue weakness and SP involvement. The ST heat shows up from a luo vessel perspective from internal factors (lifestyle, diet, emotions). The ST luo vessel psychological make-up from a CCM pespective is a retreat from stimulation, weak lower limbs (can’t move to the places to provide you with the experiences you want); feeling of emptiness, no enthusiasm or animation. The 2nd trajectory of the ST luo vessel goes to the KI channel and deals with fear even to the point where the legs can paralyze (ie loss of tone). This is emptiness of the ST luo. The patient does show some of the major themes, especially of the second trajectory. Fear has been a major issue for her since her second husband died 5 years ago. This is the exact time frame that her pain started as well. The heat from the ST also contributes to the yin deficiency and lack of nourishment of the earth element which controls the 4 limbs and the connective tissue. This exacerbates the sinew meridian lack of tone. After all, wei qi has its origin not just in Du mai/Kidney yang, but also via ST yin (the pure nourishes the sensory orifices and the turbid the sinews and skin).

Emotionally, the anxiety and panic can be explained in COM as an imbalance of the HT and KI. Being tongue-tied at birth suggests HT as well.

The symptoms of occipital tension and loss of smell with stress and accompanied nausea/vomting can be seen as BL sinew meridian symptoms (occiput and nasal area) involvement with the LR/GB internal organ imbalances of qi and blood stagnation with rebellious qi into the vulnerable earth organs.

The polio can be seen potentially as the first major challenge to yuan qi weakening the taiyang and shaoyin conformations.

And of course, the initial trauma to the patient’s back setting the stage for where the chronic degeneration would manifest.

What is significant in tying these systems of diagnostics together is the richness of the information that they provide. The depth at which one can understand a patient’s complaints and experience of suffering only enhances one’s options therapeutically. Understanding all of this from multiple paradigms also allows for increased treatment options and modalities and more specific as well as varied interventions. Using CCM, one’s options in treatment are extended to the use of not just the primary meridians, but also the sinews, divergents and luo vessels. Each of these secondary channels has a greater affinity towards a specific level of imbalance and allows for a more targeted approach. Of course, this is not an in depth discussion of either system of CM, either in general or as it pertains to this case…

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  1. Ross, I'm not familiar with the Squirmy pulse. Is this a new quality? If not, is it in the book? Where is the reference? Thanks.

  2. Hi David,
    The Squirmy pulse is something that I have labeled. I have demonstrated this quality to Leon and others at intensives. There are three varieties, but essentially it is a quality wherein that pulse eludes ones finger as pressure is applied; ie it Squirms away from your pressure. You try pressing on it and it moves lateral and away or medial and away. There is a lack of connective tissue integrity to hold the vessel in its place. Other varieties are where it presents with a Ropy pulse and is what is called a 'wandering artery.' This means the vessel feels like an S, not a straight line. The last variety is similar to the second, only it happens on a vertical, rather than a horizontal plane. So, it has peaks and valleys. I correlate this with weakness in the earth phase, and it typically presents with some sort of prolapse, lack of tone, etc.

  3. So…much…information…
    I've long been sufficiently pleased with the amount of information we can come up with in our assorted disciplines, especially CCPD. However to this point I am somewhat underwhelmed with our treatment efficacy as a whole, hence why I have been working to understand that Other Modality. As this patient improves, I'd be curious to hear what approaches were taken, what results are obtained, etc. CM in the USA in my experience does a lot of talking but comparatively little walking, so it would be nice to observe the work of someone who actually backs up all the theory.

  4. Well Ross – this is a lot of information. 🙂 I'm impressed by the depth that is possible when one combines more than one system, and I have observed it in my own scant clinical practice as well.

    I'd be very interested to hear about treatment. I find that I have zero problem going back and forth between different systems (or, rather, combining them) when considering the case and diagnosing, but I get somewhat stymied when I have to develop a treatment plan. I think this has more to do with my immaturity in clinic and less to do with some actual problem with the process.

    So, how do you do it? Tell us! 🙂


  5. Thanks for your comments, guys. I think one's paradigm is crucially important and inexorably linked to the treatment options one has in clinic.

    So, I agree wholeheartedly that what we learn in school mostly is that diagnosis is one issue and treatment another. Or that the treatments become protocols and have little individuality.

    But what I have found is that certain paradigms have a greater link between the two. In the Classical Chinese Medicine that I am studying/learning/practicing as taught by Jeffrey Yuen and rooted in the Classics and the Daoist lineage, when one has a good grasp on the theory, the treatment can follow using any modality, ie acupuncture, herbal medicine, dietary therapy, essential oils, etc. So, if we are diagnosing via the Sinew meridians, certain treatment options follow. If we diagnose instead via the Divergent meridians, other treatments follow. Not rote protocols, but it orients one in a different roadmap, a different lens in which to view and treat the patient. This is very different in modern CM wherein one only really utilizes the Primary meridians.

    And if I am using the Sinew meridians, different theoretical frameworks for herbal prescriptions will emerge than if I am prescribing herbs based on the Divergent meridians or the Luo meridians, etc.

    Same goes if I will use Essential oils. The modality that is being used is tailored to the paradigm and the energetic level that we are treating.

    So, in this case, should I just be diagnosing via CCPD or COM maybe I am only accessing the Primary channels. But, when I bring in the CCM approach and diagnostics, I can get more specificity for the treatment aspect, and of course it provides additional perspectives on the diagnosis as well. So, it really opens up treatment options in a profound way.

    So, in this case, my first attempts are geared toward the Sinew meridian and Divergent meridian aspects. First, dealing with the acuteness of the pain, then dealing with the structure and the retained pathogens at the root. What is great is that by doing so and utilizing these meridians, I can also address the CCPD/COM aspects of the diagnoses, ie the HT, SP, LR/GB issues. For the HT, all the Divergents home to the chest. And especially when utilizing the BL/KI Divergent, we have access to the back shu points, and for the KI we also have access to the front shu points, ie KI 22-27, as well as typical points we would use for HT/KI imbalances like KI 16, etc. Using the Sinews I of course will be working directly on the ashi areas of the GB and rectifying qi/blood stagnation and toxicity in these areas from the retained pathogen and reducing auto intoxication from this. The SP issues are dealt with also via the Bladder shu points as well as the KI Sinew meridian treatment aspect. So, it all ties in together very nicely/neatly.

    I'll keep you guys posted on the treatments, but would love to hear further comments from you…