TCM: How I Choose Adjunct Therapies in Clinic
I’m an acupuncturist first and foremost, and acupuncture is my tool of choice.
When a patient comes into my clinic I diagnose them according to TCM-style and proceed to create a point prescription to heal what ails them. I truly believe that acupuncture, given time, has the power to help many conditions. However, I have just given everything away: ‘time’ is always of the essence.
Many of my colleagues lament to me that patients have no patience. New intakes want their aches and pains and stresses to start to disappear after their first visit. And who can blame them - the patients, I mean? If I were a new patient at a clinic, I’d want to see results after the first visit. The pressure as practitioners is upon us and we are not just carrying our own reputation, but that of Chinese medicine, on our backs.
I look at each of my patients as requiring a certain volume of treatment that their body can hear. Some patients need only for me to turn the treatment up to two out of ten. Some require a seven. Few, yet some, require a ten. I achieve each of these increments with either needle manipulation or adjunct therapies such as cupping, moxibustion, or gua sha.
The only time I don’t use acupuncture is if a patient is terrified of needles. If a patient has a mild aversion to needles I can usually bargain with them, placing one or two LI11 acupoints to show them they have nothing to fear.
No matter if a patient has had acupuncture before I always approach the first appointment gently. I keep my point prescriptions around eight to twelve total needles and am careful to not elicit any needle sensation (deqi). I love acupuncture. With many of my patients being elderly, and on a cocktail of medically-prescribed narcotics, I know that acupuncture works to remind their body to heal itself without the need to worry about herb-drug interactions. It is rare these days for me to find a patient on one or no pharmaceuticals. In these cases I do offer herbal therapy, while acupuncture is my mainstay.
It is my goal to get some sort of positive result within the first two visits. If the patient responds to my gentle approach I will continue on in the same manner. If the patient does not respond, or I feel that haven’t responded well enough, I will change my approach. Changing my approach may include double-checking my diagnosis. I have no shame in asking the very same questions I did during the initial intake. Oftentimes, patients will give me more (or different) information and I will glean a clearer picture of their whole-system health.
If a patient gets mild results and I am confident my diagnosis and treatment was accurate I may increase the number of local needles by two and increase the deqi.
If I need to turn up the volume more I will reach for my adjunct therapies of choice. I do not use electro-acupuncture in my practice. This is simply a personal preference. One of my clinical supervisors practiced Traditional Japanese Acupuncture and was a proponent of the practitioner manually stimulating needles instead of a machine. I adopted his outlook.
Cupping is not used on patients who are sensitive to pain or are already in a lot of pain. I am also careful when cupping patients who have a weak constitution. Pregnant woman are not cupped on the lower abdomen or lower back. Lastly, I am very careful when cupping patients who are on blood thinners.
The first time I employ cupping is for only five minutes. I want to see how the patient will respond, what their discomfort tolerance is, and how their blood circulation will react. Subsequent cupping is usually done for 15-20 minutes.
While I am comfortable using sliding cupping I do prefer a similar approach to my acupuncture - I like to set it and leave it for maximum comfort (in the case of acupuncture, especially with certain angles, setting the needle and leaving it ensures maximum safety). I like to cup all areas of the body, including the UB12/13 area for Wind-Cold, Wind-Heat, Phlegm in the Lungs, bronchitis, pneumonia, COPD and emphysema. Cupping over the Back-Shu of the Lung often pulls fluid to the surface in the form of blisters (I have also seen this while cupping over a hip which had been diagnosed with bursitis). I ask patients to leave the blisters alone as they will pop and heal on their own without interference.
I also enjoy cupping over large joints. In fact, this is one of my personal indications for cupping - when I have such a small tool (read: needle) for a large joint I prefer to cup over a needle that is on top of the joint.
Fire-cupping is my method of choice because of the comfort the glass jars bring, as well as Heat being a powerful tool to promote healing. I do not own an autoclave so blood-let cupping is out of the question.
Similar to cupping, moxa is not used on the lower abdomen or lower back of pregnant women. Moxa is also not recommended to be used over a large cluster of visible blood vessels.
In TCM-style acupuncture, we are advised that moxa not be used for Heat conditions. However, there is a Chinese medicine saying that in order to treat a poison sometimes a stronger poison must be used to counteract the previous poison. Also, moxibustion is revered to be a modality of choice when all else has failed for the patient.
Ice is for dead people. Heat is recommended to promote healing. Educating patients must be done if using moxibustion for recent injuries. The body creates Heat and swelling, and by adding Heat we are helping the body’s natural processes. The discomfort caused by Heat and swelling will be exacerbated and we will cause our patients more discomfort. Moving towards pain is a bad thing, but moving towards discomfort is where the healing happens. Time must be taken to reassure our patients and explain why we are choosing to use Heat instead of Cold.
When a patient communicates that Damp and/or Cold weather or settings seem to affect a certain area of their body I immediately think about moxa. I know that I can chase the Damp and Cold out by heating the area. I enjoy both moxa sticks and burning mugwort on the ends of needles. I tend to use 1.5” needles for moxa to ensure the patient’s skin doesn’t get too hot.
I am more than aware I am practicing Traditional Chinese Medicine in Canada. I am also very aware that we have some tools and methods of healing that could be considered barbaric. Granted, they work well, but I always put myself in my patient’s shoes and ask myself what I would tolerate on a first visit, third visit and even twentieth visit. With each patient visit I get to build more rapport. I get to use more of my tools. I get to learn about my patient’s expectations and comfort zones.
Some patients don’t want any needles in their face because of the off-chance it may cause a bruise. Others couldn’t care less and just want their eye problems to improve, allowing me to use ST1. Before using the scraping method I am very careful to explain to my patient what their skin will look like when I am done. Education, and repetition of the outcome, is key.
Gua sha is a tool that I personally like to use to get patients to let go. If I feel that a patient is in a pattern of pain or disfunction I find that scraping gets them out of their ‘thinking brain’ and into the area of concern.
Just like all other therapies, I start off slow, with little pressure, and the patient is left with very few red markings. Subsequent visits are met with compassion as there are just as many patients I have found who want more gua sha as there are who don’t.
Liniment plays a large part in my clinic. I think anything to promote Qi and Blood circulation, along with awareness of an area, is a great help. Tui Na is another therapy that I use in my clinic, albeit sparingly due to time constraints. Tui Na, just like acupuncture, is a very hands-on approach. I don’t pretend to be a massage therapist but I do enjoy the relief of pain, function or digestional problems Tui Na can bring. Plus, I get to palpate the area in a more thorough way which can influence the way I needle it.
My approach is not a definitive one, but it is mine and works for me. By detailing my approach to acupuncture and adjunct therapies I hope to kindle a spark in you - to think about how you use all the Chinese medicine tools you have.