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Strategies for post-COVID-19 infection associated neurological dysfunctions

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Hi, welcome to this week’s live show brought to you by American Acupuncture Council. I’m your host for today, Poney Chiang, coming to you from Toronto Canada. I’m a continuing education provider, and if you’d like more information about me, you can find it on the title slide.

Today, I’m going to talk to you about strategies for dealing with neurological complications and neurological symptoms as a direct result of patients that have unfortunately been afflicted with COVID-19. And there’s actually a growing amount of literature in this area and since my interest and expertise in the area of neurology and acupuncture, naturally this is a area that I’m very passionate about. So I’d like to show you some of the readings and research and strategies that are applied in my own clinic.

The first paper that we’re going to look at comes to us directly from [Wuhan 00:01:43]. This paper was published in just March, and it is a retrospective observational study conducted from three different centers. So these patients were tested positive for COVID in the month of January and February this year, and there were a total of 200 plus patients. And they were all assessed by neurologists, and their neurological manifestations were categorized into three different subtypes.

The first type is called the central type, and the central nervous system type gives you symptoms such as headache, impaired consciousness, if you can have an acute cerebrovascular disease, that’s another word for stroke, and you can have ataxia and seizures. The second type of classification is peripheral nervous system symptoms. And the most famous one that you may have already heard about is lack of smell or lack of taste. And sometimes there can be vision-related impairment as well. The third type of dysfunction is have to do with skeletal muscle injury. So patients would complain about pain. Those of us that know people who have been infected with COVID will tell you it’s like a flu like none other. You’re just hit with it. Your entire body hurts. I even had a friend tell me that it feels like shards of glass in his joints. That’s how painful it is. Okay?

So those are the three main neurological classifications. And as I said, this is a study of 214 people. And what the research found was that 36% of these patients all exhibited neurological symptoms. And what was interesting is that those with more severe infections, defined by having more poor respiratory status, which was in this case 41% of the patients in this study, they were more likely to develop neurological problems. So somehow, the harder you’re being hit by this disease, the more likely you’re going to have neurological symptoms. Just so you have a breakdown of roughly the proportions of the three different classifications I mentioned, about 25% of these patients had central nervous system symptoms. About 10% of the patients had peripheral nervous system symptoms, and another 10% or so have muscular skeletal symptoms. So, you can see why this is something that we as acupuncturists should be aware of because oftentimes patients with CMS and peripheral nervous and now of course muscle-related problems, want to come to us for support.

Of the central nervous system symptoms, the most common ones were headache and dizziness. Whereas, in the group for the peripheral nervous system, the most common symptoms were impaired taste, which is called dysgeusia, and impaired smell which is anosmia. And a patient who had muscle injury as compared to those who had no muscular pain symptoms, were found to have higher C-reactive protein levels and higher D-dimer levels. C-reactive protein is a marker for systemic inflammation in the body. So, patients who had more inflammation in the body was more likely to have muscle pain. And D-dimers is a breakdown product that the body makes when blood clots have been broken down, which is indirectly a measure of how much coagulation there is in the body.

So in other words, those with more coagulation, think in terms of [T-blastocysts 00:05:26] and TCM, those with C-reactive protein, indicative inflammation, thinking in terms of blood heat in TCM. These patients are far more likely to develop muscle injury related symptoms. Now, I want to emphasize that neurological symptoms is not just limited to the central nervous system. We mentioned it’s the peripheral and there’s the musculoskeletal. So I don’t want you to have an impression that show COVID patients are more, are oft being afflicted with strokes. Okay? That was the picture that was being passed around in the early stages when we didn’t know what was happening. But now we’re seeing, it seems to be that they are more likely to develop central nervous system symptoms, such as acute cerebrovascular disease like stroke, but it’s not the entire spectrum of neurological symptomologies that these COVID patients have.

So, as an example, in the Wuhan study, there are six patients out of only 200, only six patients out of 214 had acute cerebrovascular disease. And two of them actually arrived at the ER with sudden hemiplegia, paralysis, weakness of one side of the body, but they did not have many COVID symptoms. That is to say, no fever, no cough, no anorexia, no diarrhea. And they were only found to be suspected of having COVID from CT scans of the lung that found there’s some lesions. And then they were subsequently tested with PCR based assays to confirm that they had indeed were infected with COVID. So this is important because one, we need to realize that patients may never have gone to the hospital because they’re afraid of going to the hospital because they were going to get COVID, you can contract COVID in a hospital, they may have neurological symptoms and they will go to the community for care, even though they are positive and not because they’re, but being asymptomatic positive.

Another interesting finding was that some patients that did present with fever and headache were presented to neurologic ward in Wuhan, and they were initially positive-negative. So either their viral titers were high enough to be detected by the assays, or it was a false negative. And then only when the symptoms really started come on like coughs, and the dyspnea, then they were retest [inaudible 00:08:00] found to be positive. So that’s important to keep in mind as conditions that we need to be aware of. Possibly the patient come to us with neurological symptoms, but may actually be symptom negative, but in fact positive COVID patients.

So in summary, from this paper, they found that all the patients that had neurological problems, tend to have lower lymphocyte counts, white blood cell counts, which is indicative of some level of immunosuppression, and therefore, they are more likely, for mechanisms that scientists are still starting to study, more likely to be afflicted with central nervous system symptoms.

And now patients who have more severe infections, meaning worse outcomes with their respiratory integrity, have higher D-dimer levels. That, again, it’s a measure of how much coagulation there was in the patient’s body, and this can explain why those with more severe infection, meaning more worse lung function, having more D-dimers, are they more likely to develop occlusion or clot-type of strokes.

[inaudible 00:09:16] reminder that the authors of this paper wanted to show us is that… I put this in red, in quotation, that during the epidemical period of COVID-19, when seeing patients with neurological manifestations, physicians should consider the COVID-19 infection as a differential diagnosis. You want to avoid the late diagnosis or misdiagnosing and prevention of transmission. So this is an important wisdom for all of us to take to heart as practices start to open and you’re seeing patients with neurological issues. You might want to gently remind them to go get tested, because it’s possibly that they could be positive and just be asymptomatic.

Now, a group in Spain replicated this type of study, but this time with a larger n size of 841 patients, and this time around with a larger sample size, they actually found that close to 60% of COVID-positive patients now presented with neurological symptoms. And this was data collected across two different institutions.

And Harvard, okay, I don’t want to be an alumnus, not all neurological symptoms associated with COVID are struck. If you look at these numbers here, only 11 out of 840 actually presented with ischemic stroke and three presented with hemorrhagic stroke. So that’s only 14 out of 840.

The mean time of occurrence was approximately 10 days after the development of the COVID symptoms. So they started having stroke 10 days later after personally having a cough, [inaudible 00:11:07] a fever and as such. And again, there was a very strong correlation between those that who had the stroke, in other words, the cerebrovascular disease, and those with higher D-dimer levels, meaning that’s the byproduct of the breakdown [inaudible 00:11:23] in the body. So in other words, no surprise, more [inaudible 00:11:26] in their body, more likely to have a stroke presentation.

Now on this side, we’re looking at a paper published in Germany, and this paper was a attempt to summarizing the amount of ischemic stroke that was being seen in patients with the COVID from three different countries. As in first column you can see from the United States, second column from China.

So this China column is actually the paper I just presented from Wuhan. And then another paper, which I’m not presenting today, is of n size of 206 from Singapore. And what I wish to point out, is that you can see the number of people having strokes in relation to the total [inaudible 00:12:22] positive number of COVID patients. It’s relatively small. Now they all have associated risk factors that we know of: have they been hypertensive, being obese, be having diabetes mellitus. These are predisposed youth to more higher incidents or infection in this diseases.

And what these researchers have found was that, in the overall picture, if you look at the type of stroke, that the patients are having, there is a preference or a more heavily weighted manifestation of large artery occlusions in contrast to small vessel types, in contrast to blockages in their heart or cardiac embolisms. Okay.

So even though the number of strokes that COVID patients have is not very high, and it really depends on the severity of the infection, it depends on how much D-dimers they have, if they were to get a stroke, based on the limited amount of data we have to date, it appears that there is a preponderance towards large artery occlusion type. And now let’s take a look at the outcome of these patients.

In China, of the 11 people that had stroke-related presentations, four of them died. In Singapore of the five people, three of them died. In the United States, none of them died, and they were then subsequently sent to ICU stroke units we have, or went to go home. So we can potentially, as acupuncture, be seeing these patients that are being sent back to the community for rehabilitation purposes.

Now, I want to talk a little bit more about this large party ischemic stroke. This paper that was talking about the five people from the United States is summarized in this tabulated form in the next slide. So this is a paper that was published in “The New England Journal of Medicine”. And this is physicians in New York were noticing that, “Wait a minute, young people are getting strokes. This is not expected.” So if you look at the first row, you can see the patients one through five. These are patients that are under the fifties. Most of them actually in their thirties or early forties. Young people should not be getting stroke. So even though I said repeatedly, that strokes are not the most predominant type of neurological symptoms in patients with COVID, it is kind of sad and devastating that these can affect young people. And not all of them had the risk factors we talked about, such as hypertension and diabetes. Look at the second, third row here.

Medical history and risk factors for stroke, there was none, these people had none, undiagnosed … One of them has undiagnosed diabetes and some of them have hypertension, but some people had no symptoms whatsoever. A lot of them weren’t even on any medication. So relatively healthy people, young people can get this.

So another thing I wanted to bring to your attention, is look at the symptoms that these patients present. So they present with hemiplegia, loss of consciousness. They can have difficulty speaking, or they can have altered sensation. They can have something called gaze preference, issues to do with the eyes, we’re going to go … and also hemianopia, which is also a vision [inaudible 00:16:47] symptom. We’re going to talk a little bit more about the visual aspect of stroke and have some strategies you can deal with that in the upcoming slides.

If you look at the vascular territory, the ones that the strokes involve, you’ll see that it is affecting the internal carotid, infecting the middle cerebral artery. Most of them are affecting middle cerebral artery with one exception here, here is affecting posterior cerebral artery. I’m going to also talk a lot about that. It means that patient that have stroke, these large vessel type of strokes, tend to be getting it in the internal carotid and its derivative, such as the middle cerebral artery.

Let’s look at the symptoms of these patients. So some patients have cough, headache and chills in the first column, patient one. Patient two has no symptoms. Patient three had no symptoms. Patient four was tired, that’s it. Other than that, no fever, no cough. I want to just stress upon you, maybe you want to take this into consideration when you screen patients, whether you accept these type of patients in your clinic or not. If somebody comes in with neurological symptoms needing help and this developed in the last two, three months, it could very possibly be asymptomatic COVID patients who’ve had this, and they’ve never had a reason to go get tested because they had no symptoms. So it’s up to you whether you want to open up your clinic to help these type of patients, or maybe request they’re tested before that you’re able to help them, et cetera.

So a little bit more about this large occlusion, artery type of occlusion. What is it exactly? [inaudible 00:18:40] saw some embolization of atherosclerotic debris. So if you think about plaques inside your blood vessel and embolization means these plaques have become free, dislodged. Usually they originated from the common or internal carotid artery in your neck, the common carotid artery divides into internal, external. I’m going to show you some pictures about that in a moment. Sometimes it can actually come from the heart itself, the vessels of the heart and they become dislodged. The large vessel ischemic strokes that develop are most likely to affect the medial cerebral artery territory.

In other words, the symptoms, the neurological symptoms the patients are going to manifest, are going to be whichever part of the cortex that the medial cerebral artery supplies. So this is why it’s important to know the anatomy, knowing which part of the vessels are more likely to be affected in COVID stroke type of patients, we can then predict what is the most likely type of symptoms or neurological dysfunctions that this patient going to have based on the vascularization of relevant function area, corresponding function areas in the brain.

So this is just a quick review of the circulation of the brain. What you see here in the center is the circle of Willis that we all learn about in school. What I love about this slide is that they color coded it as such that in purple, I’ll call the posterior circulation, and it’s called posterior circulation because comes from the vertebral artery in the back. If you look at the patient on the right side over here, VA stands for vertebral artery. Whereas the green shade, called the interior circulation, which subsequently divided into anterior cerebral and medial cerebral, also, ICS stands for internal carotid artery. These green ones come from … so you’ve color coded over here, comes from the carotid, common carotid artery, which divides into ECA, CCA is the common carotid artery, which divides into ECA for external carotid artery, this goes round the face, outside your skull and then the internal carotid artery, which as you can see is now green, and then goes into the brain and divides into enter in medial carotid artery.

So here is the picture of the internal carotid artery label over here, this big one over here in green, the biggest one, the biggest cross-section green. You can see it divides into anterior … the anterior cerebral artery, ACA over here. Then going left and right laterally, this one here is the middle cerebral artery.

So patients are most likely to have clots in here before the division, or somewhere in the neck here. Or after the internal carotid has bifurcated into the middle cerebral artery, you can have occlusions in the middle cerebral artery.

So now we’re going to take a look at where the middle cerebral artery supplies. So this is a very nice picture that shows you in a color coded manner different areas of the brain compartmentalized, based on its source of vascularization. So on the bottom here, you can see A, this is turquoise color, A part. These all supply the interior cerebral artery, it’s not relevant to our discussion. All the P part, all the red parts are all supplied by the posterior circulation. That’s also not relevant to what we’re talking about here. All the yellow ones, labeled N, shows us where the middle cerebral artery supplies.

So as you can see, it supplies a large portion of the lateral surface of the cortex, both the frontal, the parietal, and even the temporal lobe. So it is a very important area. If you look at the cross-section over here, you can see here’s the internal carotid artery and it divides into … this tiny little guy here is the anterior cerebral artery, and then it divides into common carotid artery. So patients with COVID are most likely having large vessel strokes, what that means is that most likely cause is in here before bifurcation, or in here in the middle cerebral artery. Why is it not in the interior? Because the interior is small. So therefore it doesn’t qualify as the large vessel type.

Now, as you can see, the middle cerebral artery then divides and wraps upwards to cover the parietal lobes and wraps downwards here to cover that the temporary lobes. So here’s a side view of this side here, very beautiful picture, I love this picture. You can see that if the occlusion is happening in the common carotid or middle cerebral, then all of these [inaudible 00:23:49] are going to be shut off. That means all the neuro cortical areas that are in this region are going to be hypoxic, and therefore going to go show [inaudible 00:24:00]

Now what’s in this area. If you remember your scalp acupuncture, there is the sensory line, the motor line, and that’s in relation to the central sulcus. So, where is the central sulcus? The central socket is in here. Okay. There’s just most promise sulcus over here. So interior that to the motor [inaudible 00:24:23], that is a somato sensory. So this means that somebody who suffers with a middle cerebral artery stroke is going to have sensory and motor dysfunction.

Okay. And even though the medial part, which is the blue “A” part, this is the region that’s more where the lower extremities are located, even though it is not part of the middle cerebral artery distribution, there is some overlap. So you can still expect patients to have lower extremity problems. And I’m of course, referring to the homonculus map, along the central sulcus, where if you recall the medial one-fifth is supposed to be the lower extremity, the middle two-fifth would be the upper extremity, and the lateral one-fifth would be the face.

So let’s approximate that on the picture here on the top right, in this area over here would probably be the lower extremity around here. Around here, would be the upper extremity. And when you get down to the park, closer to the Sylvian fissure over here, which separates the parietal lobe and the temporal lobe, you’re going to get closer to the facial areas. So these patients can obviously expect facial drooping, facial motor deficit, upper extremity, and to some extent, low extremity also.

Now I’m going to take a little segue now and talk about what other things are involved other than just the occlusion. There’s something that is called SIC, which stands for Sepsis Induced Coagulopathy. So this means it is a coagulation of blood clot that’s induced by having a bloodborne infection. So scientists now know how the virus gets into our bodies, through a type of receptor and uncertain cells called ACE2 receptors. “ACE” stands for Angiotensin Converting Enzyme. And these type of cells I’ve found on lung cells. So no surprise COVID is primarily an upper respiratory airway disease. It’s found in the small intestine. So perhaps this can explain why some patients have gastrointestinal symptoms with this disease. It’s found in endothelial cells, meaning these are the lining cells of your blood vessels in the dyadic system.

So now we can see how this actually can attack the vascular system and lead to severe vascular events. And it’s found in smooth muscles in the brain. So no wonder people can develop neurological central member system symptoms as a result of this infection. Now I’m no expert on the complicated receptor cascade that regulates the inflammation and coagulation in the body. So I’ll just summarize it for you: it’s two types of receptors are known to activate cardio-protected or neuro-protected effects inside the body. Now, when COVID-19 infects us through ACE2 receptors, it depletes the receptors. Meaning whichever function that these receptors are supposed to do physiologically can no longer be accessed. So what this means is that our body is in a less, or more compromised cardio-protected in your particular state, leaving us one type of receptor to act unopposed thinking about Yin and Yang regulation.

So what is one activating? A swine type of receptor, ultimately results in cascades, sickening cascades, that activate genes that lead to inflammation, and coagulation, and even hypertension’s that embody. So, as the cognition is not bad enough, now you have high blood pressure – you’re more likely to cause a stroke, right? So it is because this virus has the taste for these two receptors that is supposed to be neuroprotective for us. But, as a consequence of these receptors being also found in the brain, it’s a double whammy. You are now set up for inflammatory and coagulatory disaster.

Now scientists are proposing different ideas of how this lead to damage to the brain. We now know that there is more inflammation in the body, because of the unopposed ACE1 cascades inside the body. But what that inflammation does, is that it can actually lead to damage, or breakdown of the blood brain barrier. So the bumping barrier is a very delicate piece of barrier inside our body. And if it is broken down because of inflammation, that spells doom. What happens is then the inflammatory cytokines in your body, now can cross the blood brain barrier, and reach the central nervous system. So it’s, it’s just bad on top of that. You may have heard about cytokine storms that happen in this patient is actually your body’s immune response. That is hyper immunity response towards the virus that is actually causing damage to tissues and organs that certainly can also affect the brain now ,because it’s got causing breakdown of the blood brain barrier.

So I think that’s really interesting information about the neuro-physiological mechanism. How this virus affects us and it gives us a epidemiological appreciation of how this disease can manifest in neurological ways. Now I’m going to share with you some of my ideas about how we can help these type of patients using areas in my research that I’ve done about the peripheral nervous system and the [inaudible 00:30:54] system. This is a map called a Brahman area map where the different processes of the brain had been compartmentalized based on different functions. I showed that here, just as a quick reference for you, because in my upcoming slides, I will be talking a little bit about some of these areas.

So one of the most common peripheral nervous system functions was Anosmia, which is loss of smell and Ageusia, or hypergeusia, which is loss of taste. So how can we possibly help patients with this? First of all, we need to say the [inaudible 00:31:38] nerve one, which is our olefactory nerve, is way deep inside the brain. It’s not accessible. And unfortunately the olfactory cortex is also not accessible. It’s not posting up to the surface in the brain for us to be able to affect it through scalp cap acupuncture. If you go back to the previous slide, you’ll see that olfactory is a dark orange. The dark orange is actually area 34.

Okay, so if you see this, this is actually in the midline. This is the lateral surface, this is the midline. So it’s actually on the inside of the temporal lobe. It’s not accessible, to too far in for acupuncture, [inaudible 00:32:11] . So what can we do? Fortunately, we have points that have been passed down that are supposed to have some effect on the nose and sense of smell. That’s over, located on the midline of the scalp. But let’s take a look at the new anatomy and see if it actually makes sense based on what we know about the new anatomy of the nerve supply for the nose. I want to talk about the anterior ethmoid nerve, which is actually from the opthalmic division V one of cranial nerve five. And, let’s take a look at that.

So, anterior ethmoid nerve, here’s the ganglion of the trigeminal nerve and there’s, there’s your V one, V two and V three. So as part of the V one, you have this nerve here that branches into the posterior ethmoid, anterior ethmoid, see how it goes and makes it a little hole in the foramen, in the back of the eyes. So from here, it goes into the cranial vault. I’m going to give you a different view at the next slide here.

So it comes out of these foramens over here and these nerves actually supply the meninges. So here’s the interior meningial branches and anterior ethmoid nerve, that supplies the meninges. But, because this cross section is horizontal, you don’t appreciate how high up this innovation goes. So this next picture shows you that the opthalmic division of V one and specifically the anterior ethmoid nerve, innovate this bony membrane called the falx cerebri along the midline.

And, it gives credence to the notion that these points that have been passed down to us, global area 20, all the way to 23, 24, which is on the midline, or which is innovated by the anterior ethmoid nerve, can possibly affect this nerve. So, what’s the big deal about affecting these nerves? Well, this anterior ethmoid nerve not only just innovates the meniges, these same nerves or branches now innovate the nasal cavity and septum. So as you can see here, the anterior ethmoid nerve, after it innovates the meninges up here, comes very close to the olfactory ball, by the way. So, we don’t currently don’t have permission to confirm this, but normally what we know about the nervous system, oftentimes there are communication branches that might be able to affect the cranial nerve of one olfactory nerve.

But, even if it doesn’t, this nerve, has an external branch that goes outside the [inaudible 00:34:59] of skin, but an internal branch that innovates the septum and also the nasal cavity. So this nerve gets information about the amount of mucus or dryness there is in the nasal cavity, and, presumably, your nervous system can regulate the amount of moisture in your cavity. And, we know that dry nose is related to, mucus member is needed, moisture is needed for fragrance particles to adhere, and therefore more likely for us to detect the smell. Perhaps by modifying the internal conditions of the nasal cavity, even though we’re not affecting the cranial nerve one directly, we are making it more favorable for the cranial nerve one to actually be able to detect smells and fragrances. I thought it was pretty crazy that these points that we learned on the anterior aspect of the midline of the scalp, to do with the nose, actually has hard cranial nerve-related explanations for how they can affect the nose.

Now, a couple of case. The gustatory cortex is something that is accessible. So, the gustatory cortex is actually Brodmann area 43. It’s a tiny, tiny little area, basically at the junction of the Sylvian fissure and the central sulcus. So you can see here, this part here is the central sulcus. So, anterior to that is a motor, posterior is a motor sensory. If you continue all the way down, where the motor sensory and the temporary lobe meets, that’s Brodmann area 43, which is the gustatory cortex.

And, based on the MRI research that I’ve done, and talked about it elsewhere, we have a chance to affect this area, but it requires a special needle technique, called a cross threading technique, where you would thread down from global area five and thread anteriorly from global area six, and that will allow you to cross intersect of over Brodmann area 43, which is a gustatory cortex. So if you’ve reviewed the vascularization of the middle cerebral artery, and with the parts that it affects, you can see why it would affect the taste, because that’s the gustatory area is part of the middle cerebral artery domain. And, therefore can explain why patients with COVID may have loss of taste, if they developed central nervous system type of symptoms.

Now, another way we can possibly affect the taste is using nerves called lingual nerves. And, these lingual nerves ara a branch of the mandibular division of the trigeminal nerve. So remember, the trigeminal nerve has three divisions, the mandibular is V3. Now, even though this is, strictly speaking again, a sensory nerve, it is not responsible for taste. In fact, the tastes of the anterior third of the tongue, as the comments here are written down for you, is supplied by the facial nerve. So, just sensation is supplied by the lingual nerve, but the taste, special sense taste, it’s essentially beneficial there. However, the facial nerve relies on the lingual nerve to convey its nerve fibers back to the brain. So, this is the reason why patients who have damage in the lingual nerve, either due to dental procedures and whatnot, can oftentimes cause them to feel like there’s a metallic taste in their mouth, or a foreign taste, or a lack of ability to taste.

And, so fortunately for us, we have acupuncture points located right below the tongue to affect these lingual nerves, and that’s the extra points Gingy [inaudible 00:39:01] . So, puncturing these points, even though it doesn’t affect the special sense directly, it provides conveyance of the special sense nerve fibers back to the brain, which might be able to help to receive more signal about taste to the brain. Now, early on, patient people also published ocular motor dysfunctions associated with patients who have COVID-19. Two different research groups have presented information how these patients may develop ocular motility deficits or ocular motor palsies. And, even though the case number is not very high at this point, again, you’ve got to think about this. People who present with either of the issues, and if they’re asymptomatic, are not going to be sent to isolation or sent to the infectious diseases.

They’re going to be going to the neurologist, or even in this case, ophthalmologist. By the way, the first doctor in China who blew the alarm on the COVID-19 was an Asian ophthalmologist. So, don’t let the fact that these cases don’t seem very high dissuade you, because it might simply be a case of lack of reporting. So in any case, how may we as acupuncturists help patients who are suffering Oculomotor Palsy, possibly as a consequence of having neurological dysfunctions from COVID infections?

I need to briefly introduce you to something called a frontal eye field. The frontal eye field, we talk of the Brodmann areas, right? It’s located in Brodmann area 6, so you can have a look at that in the map in a moment. And what happens is that this part of the brain is responsible for controlling rapid changes in your eyes in the left and right direction. It’s called saccadic movements. So patients who have dysfunction in this areas of the brain, affecting this area of the brain, may manifest inability to have rapid eye movements. This is also called contralateral horizontal conjugate gaze palsy. So if you recall, the American paper show you the five different patient cases. One of the symptoms that they had was gaze preference. Okay? It’s because they are lacking the ability to see both sides so they have a preference for one side.

Now, how does this affect the parts of the brain that actually controls cranial nerves III, IV, and VI, that actually is responsible for the eye movement? Based on tractology or connectivity studies, neurologists have found that the frontal eye field actually makes connections with the midbrain, where these cranial nerves can make the eyes form.

So again, these midbrain structures and cranial nerves are too deep for us to get affect directly. But pressed indirectly through the cortical connections, neurocortical connections, we can have a fighting chance to affect ocular motor systems. I’m going to show you my research about this. You’re looking at the correspondence of the scalp and the cortex, specifically operators 16. And I was really cool about this and I love the chorus, but that when, when the Eastern West converged gallbladder 16 in Chinese is more strong. It means I window. Hello? The name is telling you that this point can do with the vision and that it actually correspond to frontal eye field, based on modern research, is just too good to be true. So where is this specific to this front IFU in humans? A lot of research in animals suggest that it’s in Brodmann eight, but we now know that’s incorrect.

It’s in problem in six. And so where is that? If you look at the yellow data line, it’s where the superior frontal sulcus meets the precentral sulcus. So here’s the central sulcus, okay. Where we divide the motor sensory and there’s an OMP. So, and then you have the premotor area or the pieces of gyrus right in front of that, it’s called a precentral sulcus where the precentral sulcus meets the superior frontal sulcus. This is superior frontal sulcus there. This one over here look other broken is the inferior frontal sulcus. So in a case where the front end superior from this office meets the precentral sulcus. Now the bird side view superior frontal sulcus meets the precentral sulcus. This area is where Brodmann six or prefrontal sorry the frontal eye field is located. And we have a point called LAR 16, which is just right in this area. If you thread it, if you’re familiar, scalp acupuncture along the Meridian, you will cover this area beautifully. And therefore you will be able to affect from the eye field and affect ibogaine and movements.

I’m going to just finish up with a case that I recently saw of a showcase. I tongue in cheek, call it the case of shotgun at time of Corona. And this was an 86 year old male patient who in early April, he, he and his family cannot be exactly sure exactly. When, where he started have developed slurred speech. Now he has the risk factors such as hypertension, diabetes, mellitus, and other non directly related symptoms. And nursing does comorbidities such as them freaking urination as a result of enlarged prostate. He’s had a history of Bell’s Palsy in his forties. Now several weeks before he had a stroke, he has some poor sleep. So it’s not sure whether that sleep was related to that’s just a coincidence or related to poor sleep having caused hypertension poorly managed by any case, he was admitted to the hospital for one night.

And because of symptoms was start to already showing signs of very fortunate men or already showing signs of improvement. He was discharged the next day. And, and which is atypical should typically, when you have a symptom of stroke, you are in the hospital for very longer. Not sure this is change in policies is dependent on the fact that there’s some lack of resources and the staffing during this time of COVID that the patient, since it was not life threatening was sent back home, by any case in addition to star specie also presented with left sided arm and leg paresis, and he felt extremely tired. I remember one of the symptoms, one of the only symptoms that, one of the five Americans that had the show with just lethargy, right? There’s no other covert, listen to this, man didn’t have any respiratory problems’ fever and such, but it doesn’t mean he’s not positive.

And for all the research that we’ve seen so far and the family noticed that ever since having a stroke is, can seem to have Mark and the aged. And, is just complaining about tiring all the time. He has a dark tongue okay a dark purple tongue [inaudible 00:46:46] that we talked about things like coral coding, which means a lot of phlegm cold phlegm inside of the body, which is we know cold, also contributes to [inaudible 00:46:58], right? So the pictures are triangulating quite nicely, unfortunately this is actually a family friend of my receptionist, and because the clinics closed due to mandating to be closed because of public health policies, he’s unable to make an acupuncture appointment with me or with anybody.

So it wasn’t until we will reopen on June 2nd, he was able to get his appointment. And so on the very first day that I was back on June 6th, he saw me for acupuncture and to date, we’ve had four sessions so far, and I’m happy to say that the results have been quite favorable after one treatment he said that his left leg, which is the afflictive site actually now feel stronger than in his right side. Okay. So patients, maybe there’s a little bit of a, a good patient and practice rapport there, maybe a little bit of psychological effect, but Hey, I’ll take it. And, but so far there’s no change in the arm strength just yet, which is actually expected those of us that have experience doing neuro rehab know that arm loss of function or paralysis is harder to regain than leg paralysis. But by the end of the fourth session, patient Ashley left the treatment room without taking or, quote unquote, needing his cane. So presumably that is indicative that his legs felt so strong that he forgot that he needed the cane.

So, that’s the latest case I can share with you all. I don’t know for certain that it is a case of COVID, but I’m using extreme PPE precautions, and I am suggesting that this case should go get tested despite being asymptomatic. So I thank you very much for your attention. And if you have any questions, just message me. If you like this presentation, don’t forget to tell your colleagues, don’t forget to let others know about it. And if you enjoyed it, show us some love. Thank you very much.

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Re-opening and Bringing Patients in the Door Now

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Thank you again to the AAC for inviting me to present on these informative webinars. My name is Lorne Brown. I’m a doctor of traditional Chinese medicine. I am the Clinical Director of AcuBalance Wellness Center, I’m the founder of healthyseminars.com, and also the author of Missing the Point, Why Acupuncturists Fail and What You Need to Know to Succeed.

Today’s webinar, I have a special guest, Chen Yen. Many of you may know of he. For those that do not, a pharmacist by trade. Entrepreneur is her gig now. And she’s been helping health professionals for years be successful and build their practices so they can be of service to their community. Because as you know in my book, Missing the Point, when the yin and yang are out of balance, when it’s all clinical, you don’t have the business skills, even though you have the potential to help so many people, if you don’t have a running clinic, if you don’t have patients coming in, you’re not able to help them. And she’s created a business around helping people like ourselves so we could thrive and see the people that we want to serve.

And so, I asked Chen Yen to come in because she’s been sharing a lot about reopening your practice. We’ve been in isolation for a while because of COVID-19. And now as we reopen, the question is how do we invite and bring back patients into our practice, how do we build our practice. And so, what I plan to do now is I’m going to cue up a video in a moment of an interview that I did with Chen Yen. And the reason she’s not alive is right now she’s in Taiwan,. and it would have been in the middle of the night for her, for her. But again, her being and having that entrepreneurial spirit.

Just the other day, we got on the Zoom, we did this recording’s about 13 minutes. And she’s going to share with you marketing strategies that are working in this climate, some of the strategic planning that you could do now in the coming months, and then just some of the critical keys to bringing your patients back into your practice. And then after the video, I’m going to share with you what I’ve been doing in my practice at AcuBalance in Vancouver. And so I’m also going to share how we reopened and some of the things that we’re noticing and that we’re doing so we can be of service to our communities. So, let’s start that video now, and please stay tuned because I’m going to give you about five minutes after this some more pearls to support you in your reopening.

… how helpful acupuncture. You talk about how helpful acupuncture is. So, those are …

So, what are some of the marketing strategies that you’ve been sharing in your mentorship that you can share with our audience to help them, again, get their practice going and attractive again to patients that are, well, now that their practice is open. So, I’d love to hear some of your marketing tips, because I know that you got some gems.

Yeah, so I would say at first looking at low hanging fruit, and then looking for new areas of opportunity to reach potential new patients. So low hanging fruit, a couple of key things. One is how can you keep your existing patient base in understanding of how just overall even outside of these COVID-19 times the different health issues that could be beneficial to where acupuncture can help with. And then reminding people to book appointments if they want to come in. So, for example, in our opening email templates. So, you can send out emails, you could send out texts. You could also be educating or encouraging people to come in on Facebook or social media posts if it’s kosher with the laws of your state and profession to be doing things like that. And then in terms of emails, for example, it could be book your appointments.

And so, what I was going to say about emails is, first, a piece about something that educates about the issue, and then something with a call to action with a reason to come in. So, for example, it might be book your appointment now and get in for first line … I mean get yourself first in line for your choice of appointments as we’re reopening here, or it might be something like take care of yourself by putting yourself first and book an appointment, especially still as important now to take care of your health as it has ever been, or it might be that book your appointment space because of the health issue that you’ve been having that you haven’t been able to get checked out or get help with until now because we’ve been closed. So, there’s just kind of a reason why to be rebooking that that is brought up, and that can be helpful.

You could also look at collaborating with other practitioners. So, our clients who’ve been doing really well in getting referrals from other providers, whether it’s medical doctors or other kinds of practitioners, holistic practitioners, other kinds of practitioners is as they reopen, many times they had a good relationship with them even prior to opening. So, if those of you who have relationships with providers who’ve been referring you before, reaching out to those providers and reminding them that you’re there and how you could be of benefit to their patients is one way to go.

If you haven’t had a relationship with other providers before, for example, maybe you would like to be getting referrals more from MDs because medical doctors could be a great source of referrals for you. They have many patients who could benefit from what you have to offer, but many times their patients don’t really know about you or the doctor doesn’t really think about referring people to.

So, what can you do in those situations to build new relationships? So, something that I was working with one of my clients on was to create a short video. Because the thing is, doctors are really busy. Right? And so, if you’re able to create a very short couple minute video that starts to explain something about your area of expertise and some research tied into why this could be beneficial for those kinds of health issues or with helping support immunity, then that can also be sent off to a physician. And that way it’s just you’re more on the top of their awareness. So, really, the key is concise, short, and really to the point of how you can help their patients get better outcomes.

Another thing is to look at … you can look at interviewing other practitioners, too. So, in times where people are getting back into reopening, there’s a lot of opportunity for you to collaborate with other practitioners, because people still need help with their health issues, whether it’s during these times or not during these times of COVID. And so, it’s a matter of how can you continue to educate the public about different kinds of issues and what your services can really help with and your modality. And so, then being able to collaboratively interview other practitioners about, perhaps in particular, health topics.

So, looking at whether it’s interviewing medical doctors or nurses, nurse practitioners, tied into the different of health issues that you treat can also bring in more visibility for your practice. And it can automatically be an opportunity where if you’re interviewing another practitioner, you can encourage them to share that interview with their patient base, too. So, you’re ending up being able to reach more people with your message collaboratively there. So, that’s more of, I would say, lower hanging kind of fruit, because it doesn’t take up a lot of your energy and time to really set up.

And then other kinds of things that you can look into beyond that initial low hanging fruit could be writing Facebook ads. So, I’ve had clients, acupuncturists, who are running a combination of Facebook ads that are bringing them … It’s amazing the kind of return on investment that they’re getting for it right now. And it’s a combination, as far as what’s working right now, combination of Facebook Live video with using some of the strategies that I work with our clients on, being really strategic about what’s said in the video, plus Facebook posts alternating with that. And then, again, getting people educated, getting people to build that relationship with your practice. Yes, and then also having people be interested in booking.

Another thing is anything tied to speaking. So, we talked a little bit about interviewing. And whether it’s during these times or beyond these times, one thing that you’ll always have is your mouth. And one thing you will always have is what’s in between your years, which has been all the knowledge and training that you’ve garnered all over the years and the expertise that you have which could still be helping people, even if your practice was to be closed down in the fall, because we really don’t know if that might happen. And so, when you are able to continue to educate just as it were pre COVID-19 times as well, the more you’re able to educate people and reach more people. There’s still people who have a need and can benefit from your services. So, anything tied to speaking, for example, webinars, doing interviews, doing podcasts can be good online. And then as we get back into reopening, even doing small kinds of things even with just a handful of people can still be helpful to … to be helping others and your practice.

And then one thing I would say in terms of marketing wise. Whatever you do, there’s an education process involved. And a couple of quick tips in terms of as you think about … Because have you ever, whether it’s written an article or you have spoken about something, you’ve educated people about something, or you’ve done whatever, think about all the kinds of different marketing that you’ve done in the past. Have you ever felt like you have been so good with teaching people about things, but then they don’t necessarily book? So, here are a couple of questions that you can think about working into what you educate people about so that they end up getting more interested in booking and coming in.

Let me actually just show this to you also briefly, to pull this up here for you to see as well, which is … Let’s see here. So, this is the five stages of the buying process. And so, people need to first have awareness about that they actually do have a problem. And then they might be considering it and looking into different options at the next stage, but they’re still gathering information here. And then then they might be evaluating, for example, in terms of, okay, maybe this option and this option, what are the details of that and which provider am I going to be seeing. Then finally, more of the decision making and then the post-purchase evaluation.

But what sometimes we don’t think about as much is that there might be people in different parts of the spectrum, whether from problem awareness, who don’t even realize they have a problem, right, or they are further along in the process, but they don’t really understand what to look for between different providers and that kind of thing. So, whenever you’re making educational kinds of things available to people, think about what different stages that they might be, and how can you provide content or educational things that can help educate in those areas.

And one thing, also, a couple of quick questions to think about would be like, what do they need to believe about their health, or what do they need to believe about themselves? What do they need to believe about you? Because if these questions aren’t answered in a way that they feel comfortable with, they’re not going to come in, no matter how helpful you talk about how helpful acupuncture is. So, there’s just a few quick tips about as we look at marketing and reopening that are working well for our clients right now.

Chen, I want to thank you very much for those tips and points. And I think we’re going to have to get you on healthyseminars.com so we can spend more time with you, because we just got a little bit and this was quite valuable. What’s the best way for people to reach you? Because I’m familiar you have like the Introverted Visionary website and your Fill Your Holistic Practice. Can you share the best website so people can get more information and learn how to contact you, please?

Sure. You can go to introvertedvisionary.com/AAC. And so, introvertdivisionary.com/AAC. And then you can … I’m going to make available some templates that are going to be helpful for you, for example, reopening email templates that you could use for email or texts. And also, we brought up a couple of situations of what people might be concerned about with coming in. And there are other ones that I’m going to share with you as well that acupuncturists clients of ours have been experiencing. And then also like a cheat sheet for that, right? Like how do you address these kinds of common objections that people might be having about coming in as well. So, I’ll include that.

Excellent. So, to be continued, she’s going to provide us with more value. So, you just go to introvertedvisionary.com/AAC, and she’s going to have some more handouts for you to help you prepare yourself as you build up your practice again, it’s great news for most of us just to remind everybody that you’re not starting your practice over again. You just kind of took a holiday that you didn’t choose to take, and now people are getting ready to come back. And these are just great tips that you can use any time of your practice, not just after a pandemic. So, Chen, I really appreciate you making the time to tune in and share this with our audience today. Thank you very much.

Yeah, it was great to be here today. Thanks for having me here.

Great. And we’ll get you on Healthy Seminars so we can get you to expand on a lot of this and more, because you’ve got really good marketing tips. And for the introverted, because a lot of people don’t want to do public speaking or they say, “I can’t, I’m not outgoing. I can’t do this.” And I know you’re introverted and you have techniques and tools for people that want to educate, but feel I’m too shy to do that. And the takeaways here from earlier on, you talked about outreach. So, email contact, like start contacting your patients on a regular basis again. You talked about education, so keep educating them on the benefits and what you can do to support them during these times. And you talked about collaboration as well. So, collaboration is great. And some of the way you even outreach is through webinars, Facebook, emails, talks, so that’s great. So, thanks for sharing those tips with us today.

All right. So, again, thank you to Chen. And as I promised, I want to add a few more pearls for you guys as you open up your practices. Some of you are getting ready to open and some of you have. So, in my clinic at AcuBalance, and just to prepare some of those that are just getting ready to, I will let you know that it was more stressful in the preparation of getting all the PPE, all the safety equipment and policies in place than it actually was implementing it, so that’s great news. If you’re really overwhelmed about what’s going to happen, it’s nothing like … it’s much worse preparing for it and anticipating than it actually was doing it.

Now, what we did at our clinic when we started, we opened up on May 19, so after being closed for two months, and we decided … So, I’m going to share with you the attitude because it will make a difference for how you experience your reopening, and then I’m going to share with you some tips on rebuilding your practice. So, first of all, our attitude was safe, soft reopening, emphasis on safe. So, we got all of our equipment, we set up our policies, and what we did is we chose to open up our clinic at 25% capacity only. And we did this so we could be calm as we cleaned rooms and figured out how long it took getting our masks, getting the patients to sign their consent and wash their hands, all that stuff, we didn’t want to feel rushed or tense about it.

So, we really set up that first week with very little expectation for profit. We did not care, actually. Our goal was, let’s be safe and can we be of service to others? So, that’s what I invite you to have that mindset. You’re not going to have when you reopen, most people are not going to have what they had pre COVID. And so, just to have that expectation, to be kind to yourself so you can enjoy this reopening. And so, we were a soft, safe launch.

And so, that first week at 25% capacity only, it allowed us to work through our policies and see where we could streamline things. And then the second week we were open, we went to 50% capacity because we saw now how quickly we could clean the rooms properly and put patients in and out of the rooms. And a big part of the process for us was for the physical distancing. Everybody has their own room, so they’re distanced. And we’ve timed it so we don’t have a bunch of people in the waiting room. However, the key was in the clinic how the doctors are all situated so we had physical distancing. That was what the main criteria was, how is it that we’re in a clinic all day that we’re properly physical distancing as much as possible.

And I will let you know because our energy was calm, the patients that came to us … I was going to compare it to a colleague that had a different experience. We came in with the attitude of service to others. My colleague came in needy, like, “I need to be busy now,” pretty stressed. Our patients came with their own mask. We asked them to, and almost everybody came with their own mask. Now what we did is we bought cloth masks and we had surgical mass. The doctors all wear the surgical masks, our patients can choose surgical or cloth, but they must wear a mask in our clinic, that was one of the recommendations policies we have. And if a patient did not have a mask, they had two options. One is they could get a surgical mask which they take with them, $2 fee, or they could get a cloth mask. And if they leave the cloth mask for us to laundry, that it’s free. If they don’t leave it and they want their own, because some wanted their own, it’s a $5 charge. So, we just passed the cost onto our patients. We had zero complaints.

And our patients were great coming in. They were so happy to see us. The energy was great. They signed the consent. And it’s been a very positive experience for my team and my patients. And we didn’t come in like needy, “We need to see our patients.” We came in, “Let’s be of service to others. Let’s see who’s ready to come back out of isolation here in British Columbia.” Where my colleague really tried to pressure their patients to come back and was coming from neediness and they were quite stressed and stressing out their patients, their patients were fighting about the mask. It was just a totally different experience. And I believe the reason is the attitude, the vibration energy that you’re putting out, for one.

Now, when patients contact us and they’re a little stressed about what’s going on, we educate them. So, we let them know all the things we’re doing, all the cleaning, et cetera, how we’re doing the physical distancing, what we’re doing to minimize the risk. But what we’re not doing is telling them, “Oh, come, don’t worry. You’re going to be safe.” Actually, we do the opposite. If any patient comes across on the phone or email as concerned, worried, or stressed about COVID and coming to our clinic, we encourage them not to come because we know we can’t guarantee your safety. All we can do is minimize the risk as best we can, and that does not mean that COVID will be prevented. We can’t guarantee that, we cannot do that, nobody can do that.

And so, we realized half the population … I’m making up the number … but half the population will be comfortable coming into our clinic and half the population will not, but they all pretty much want to know what we were doing for safe measures. So, rather than trying to over impress them, like “You need to come in and this is what we’re doing,” we let them know all the safety measures we’ve put in place, all the systems we have in place. And they get to even see it on the back of one of the doors where they’re in the room, the door that holds the needles, there’s a checklist to show that the practitioner’s checking off all the cleaning things we do so it’s not forgotten, we have a system, and they get to see that.

But we don’t pressure our patients to come back. If their worried, we say, stay home. If you’re worried about COVID, then do not leave your house. As soon as you leave your house, you’re put at risk. And because we’re not pressuring them to come in, a lot of those patients, once they hear what we’re doing, still choose to come back. And those that are really worried, we don’t want them in the office. We don’t want that energy, that tension in the office anyhow. And so, we realized some people are going to be ready early on to come back and some people not.

The other thing I want to remind you is, it’s still the same education marketing practices you always do. People are going to come and seek you out if you are a benefit to them, if you are a value to them. So, it still goes back to the same model of just good education. Now what I think is important is to work on the stress response that your patients are going through. Because of the change in the loss of control and some loss of liberty in a very short period of time, some people consciously are aware of their anxiety and stress and some people are not. So, if you ask them first to educate them about stress and how it impacts the immune system, how stress impacts sleep. So, check in with your patients via email or phone calls, “How’s your sleep, your digestion, muscle tension or headaches? We know how it can lead to inflammation which can cause other health issues.”

So, maybe your patients, like Chen said, that first thing, maybe they’re not even aware they have a problem. So check in. Are your patient’s having sleep issues? Are they having digestive issues? Are they having muscle tension, headaches? See if they’re having these and let them know, this could be related to stress and how you can support them in reducing the stress, because we know stress, exasperates many diseases and leads to many symptoms. And so, your goal is to help them with their quality of life and to show them that you have value and you have tools.

Right now, conventional Orthodox medicine does not have a solution for COVID except for isolate as much as you can, right? Physical distancing as much as you can. And so, you can educate them on the lifestyle and things that they can do to help give their body the best chance of being healthy, radical well being. We’re great at talking about diet. So, you can set up consulates for diet and lifestyle, exercise, sleep, and meditation, acupuncture for circulation and stress reduction and hormone balance. So, there’s a lot of things that you can do to help with the radical well being.

And that way if they are out and about, at least their relationship with their environment, because that’s what we’re doing with Chinese medicine, is strong so they can hopefully handle whatever comes into their external environment, whether it’s CNN News you’re watching causing stress, or it’s a virus that’s out there, that your body is at its peak radical well being so it can deal with it as best as they can. And you can’t tell them or promise them that if you come to my clinic that you will prevent COVID or you’re treating COVID, because there’s not evidence that exists yet that you could do that. However, you can definitely help them with radical well being.

A great example is obesity. We know in general obesity leads to many health issues and diseases. And with COVID-19, we know obesity is a comorbidity. That is not a good thing to be, no matter what your age is. If you’re overweight, this is a time to lose weight. So maybe in your practice, you can start doing getting fit and healthy in the summer so people have the best chance of being healthy, whether they get any virus including COVID-19.

So, remember, people choose you because they see you have value, you have benefit. And so, first of all, do you have value and benefits? So figure out where you do, because you do. And then communicate. As Chen said, send out emails, do talks, collaborate and do stuff, and just take your time. The good news is, for most of you, this is not like you just started your practice. You had a forced holiday, as I mentioned in the video, and now you’re reopening, and people are just getting comfortable in certain places where you live to go out.

And so, read the room. Don’t dismiss their concerns or fear. If you can read the room and realize some of your patients, even though you may not be, are very concerned about this pandemic and come to your clinic. Hear them, and hear their concerns, and validate their concerns. Let them know what you’re doing to mitigate risk and be transparent and let them know that you cannot guarantee safety. And if concern or safety is their main issue, then they should stay inside. Okay? They should isolate. And if they’re comfortable going out to the grocery stores and other things that are not essential, grocery store is essential, but if they’re going out, then they may be comfortable coming to your practice as well.

And you want to keep your safe, so have your boundaries with your patients. We have some patients that don’t believe mask waring is necessary, but it’s a policy in our clinic. We don’t challenge their beliefs, whether masks are valid or not. The science as you go, as of today, the science is masks can mitigate the risk because it limits your exposure time. The amount is dosage and time. So, if you’re going to be in the room with somebody for 20 minutes, 20 minutes without a mask is much more exposure than 20 minutes with a mask, and so that’s why it’s being recommended. And in our practice, it’s okay if you don’t want to wear a mask in general and you don’t believe in masks. However, you can’t get treated in our clinic at this point in time unless you wear a mask. That’s not negotiable.

So, we have our policies, we’re strict with them. And so, I encourage you, too, to have your policies, have kindness in your heart, focus on being of service to your patients. Don’t worry about your bottom line now. In July, hopefully your practice is definitely back and you’re seeing it profitable. But if you just opened in late May or beginning of June, just be of service to people, educate them, be a value, and trust within a few weeks you will be back to hopefully 75% or more of what you were before COVID and profitable again. And therefore you can exist and be of service to your community, which this is all about.

If you’re looking for more information on COVID-19 and being back to practice. Under the healthyseminars.com website, it’s healthyseminars.com/resources., we have several past talks, verbal and acupuncture, and more coming up. We’re constantly listing them all the time. We’ve got lots of free resources for you, stuff on telehealth as well. So, do check out healthyseminars.com. And also, if you’re looking for all my assets, my clinic information, Healthy Seminars, and the conscious talks I do on lornebrown.com, go to that website, lorenbrown.com, because that links to all the things that I’m involved with.

Again, I want to thank you for listening. I want to thank the AAC for inviting me for this practice management series. Some of you don’t know, but my background before a doctor of Chinese medicine is a CPA, so a public accountant. So, I like to bring both hats to the room for you guys to share both as a clinician and then as an entrepreneur and accountant so I can share what I know with you so you can be prosperous and successful and serve your community. Stay tuned to next week’s webinar because there’s more coming. AAC’s got great webinars and they got great hosts. So, make sure you come back, like their Facebook posts, and tune into their next webinar. Thank you very much.

The Scope and Opportunity of Oncology Acupuncture

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Hello, everybody. I am Dr. Yair Maimon, and I would like first to thank the American Acupuncture Council for hosting this show. Today I will focus on something which is very close to my practice and my experience, which is oncology acupuncture. In the last years, I can say there’s been an amazing opportunity for acupuncture because there is so much evidence and because we can do so much for oncology patients. So the whole field of oncology has been opening up. I’ve been practicing all my life, also in hospital setups and being a head of oncology, integrative oncology acupuncture departments. So I can see both from my practice, I can see from the response of the other oncologists and regular medical care that is seeing more and more the importance of acupuncture in this field.

It’s almost hard to believe how much we can help in oncology. I can just tell you it just now I’ve seen a patient, I’m still just after my clinic, she came with so much pain. She has a sarcoma in her lower abdomen that was just removed. Recently. She came all kinds of hunched in with her husband and I said just lie down, and I just need column four, stomach 37, stomach 39, and waited a few minutes. And then she started to look at me and said, “Wow, this is the first time in days that I’m back to my power, back to myself,” and this kind of changes, especially in oncology, because the patients are very deficient. They’re very weak.

We’ll talk more about the indications that we see. They’re responding both extremely well, they’re able to tolerate their cancer, their treatments, cope better with the disease emotionally and mentally. So to me, this has been an amazing kind of journey, which I didn’t really plan, but I saw how much I just found myself doing oncology acupuncture is … Actually, especially because about almost 20 years ago when I started, everybody were afraid of treating oncology with acupuncture. I was in China, saw the amazing results and went back and started to treat patients. And since then, I’ve been treating a lot of oncology patients, doing a lot of research. If you’re interested, you can read my research. I have more than 20 peer reviewed publications, most of it around the oncology, but also around other areas. So in this talk, I would like to speak about the opportunity and the scope of oncology acupuncture, because the scope is quite remarkable. So, I will start with the slideshow, please.

First of all, the reason there is so much awareness about oncology and the field of acupuncture is because we get more and more evidence. The amount of evidence is even … I think even people are practicing Chinese medicine and not aware to the amount of evidence of the effectiveness and the safety that oncology acupuncture has. So, first I’ll say just some words about evidence, because when people say evidence, they always expect human studies, comparable studies in human, but the world of evidence, I just want to point out, is actually based also on clinical experience. It’s based on patients and patients’ report. And also obviously the best external evidence that we can have, by peer review by different studies that were done. Oncology is one of the really robust area where there’s more and more studies that are repetitively showing their effectiveness.

When we’re talking about studies, we’re talking about the pyramid of evidence, and in the top of the pyramid there is systemic reviews. Under this, there is the randomized controlled trials, then there’s cohort studies case reports. So, all of these are building the evidence that is trusted in Western medicine. And one of the things that we have to understand that the higher we go on this pyramid, the strongest the evidence of what we are showing and what we are knowing. So for us, it’s really translating then what we know in the clinic, which has been known for years to be effective, into a scientific kind of objective and reflection. So I just want to point out that if there is enough randomized clinical trial, you can do a systemic review. It means you can take a lot of trials together and look at them from above and see if a field is effective.

From a scientific point of view, it’s a very kind of robust and high way to look at Chinese medicine. So I decided to start and we’ll talk about especially the amount of studies that are in oncology acupuncture, also to show you there’s quite a lot of studies in the acupuncture overall. I just recently looked, there’s 32,000 studies in PubMed and I think around about … I can estimate around 1400 studied just in cancer care. That’s quite a lot more than usually people would think there is.

When I want to talk about the scope, I would like actually to show one of the quite recent, it’s only been around for a few years, one of the systemic review of the effectiveness of acupuncture on related therapies, [inaudible 00:07:05] acupuncture, and it’s an overview of systemic reviews. So this is like, if we talk about systemic reviews, this is even one above it, and it was published in one of the publications of Nature, Scientific Report. We have a very high level looking at effectiveness of a field and on the scope of a field.

Let me explain. This is the overview of systemic reviews. This is this paper that I’m going to present. It looks on systemic reviews, which is based on individual studies. So, if there is enough individual studies let’s say on nausea and vomiting, they do a systemic review. Enough studies on pain, they do a systemic review on the studies on pain. In this one there’s been enough systemic reviews, so it overviews them. In this study, they took 23 systemic reviews, which included almost 250 individual research studies and about 17,000 people who have been involved in these individual studies.

So, this is kind of quite a big pyramid to look at the way acupuncture is effective in oncology. So we are looking really at the top of the top of the pyramid, really this kind of tip of the pyramid. We look at 23 systemic reviews, which is looking at almost 250 individual research. Most of them are actually randomized clinical trials, and it looks on a population of 1700 cancer patients.

This is the type of scope that they’re looking at. So there is enough research. It doesn’t mean that everything reached the level of saying, okay, the evidence are extremely conclusive, but there is enough research in these areas and that shows you the scope of acupuncture in cancer care. So, if you look at fatigue and by the way, if fatigue is one of the most common. Almost all cancer patients suffer from fatigue, either chronically or at some period, and acupuncture is extremely effective in relieving fatigue. This in itself is a phenomena. And then reducing those and vomiting, but also in leukopenia. These three I marked in red here, because in this systemic reviews, they found out that these three indications have enough scientific rigorous studies to show the effectiveness. So just these three are quite impressive. So we see the effect in fatigue. We see nausea and vomiting, which is related to a lot of chemotherapies and other therapies that patients are getting. And also sometimes for the cancer itself, if they’re in the digestive system, and to reduction of leukopenia, white blood cells.

I’ve done extensive research in herbal medicine for leukopenia and in neutropenia. So, Chinese medicine is very good in really protecting and invigorating the bone marrow, which is producing the white and red blood cells. Then cancer related pain and pain is accompanying many cancer or cancer treatments. Hot flashes. We’ll talk about hot flashes in this show or in this lecture. Hot flashes is side effect, especially for gynecological cancer and breast cancer, because many of these patients are receiving anti-hormonal therapy and suffering from severe hot flashes, which are really every part of it. But this is just a good example. And I’ll talk about it more extensively later. It’s really reducing the quality of life, and sometimes to the point where patients want to stop the anti-hormonal therapy, which has its own effect, because the quality of life is diminished.

Then hiccups. I had a few cases of hiccups that nothing stopping it and believe me if you have hiccups all the time, it’s a real terror. So this is like … and the acupuncture can stop it just usually within a treatment or two. They’re quite rare, but if there are, remember that acupuncture is very effective. Improving patient general quality of life management, management of the xerostomia, which is the dryness of mouth, especially from radiation. There’s many studies on this. Acupuncture is one of the effective treatment for that and large intestine too, which I extensively also lecture about studying of the large intestine, too. It’s actually been proven to increase the salivation in the mouth and it’s good, not just for cancer, all of it. Also, when you learn how to treat it, you also learn how to treat it in other patients that suffer from these symptoms. The same with shortness of breath.

Lymphedema actually hasn’t shown up to be extremely good, but was studied extensively. This is where the lymph system is not working well, especially for patients with breast cancer, that some of their lymph nodes were removed, so they have this kind of [inaudible 00:12:46] edema and lymphedema, so they tried acupuncture for it. I generally don’t treat lymphedema, but it was part of what they reviewed in this study. Then general improvement of physical wellbeing. So, you can see quite a lot of indication that there is a lot of studies. Like I said, the top ones are the ones that there is enough evidence to say that we can conclude that this intervention, which is acupuncture, is helpful, but the scope is actually what we see in the clinic and the scope is what you see coming up more and more in different research.

One of the most important things is safety, and acupuncture has been strongly proven safety, and here is a study of 1700 people that says that there is no serious side effects that were reported in any of the studies. So, acupuncture could be considered as a very safe complementary in cancer care. When we’re talking about any intervention to medical system, then there’s two concerns, efficacy and safety. And definitely for safety, we are winning. There’s more studies on safety actually, but this study is just a great example, which is specific for cancer care, showing the level of safety that acupuncture has. To us maybe it’s obvious, but if you communicate with the medical community and you can say this word, we have proven safety, it is very meaningful. That’s what I find acupuncture is now, and especially in the United States has been practiced more and more in different medical centers and hospitals, and it provides today the knowledge and ability to treat oncology patients. I think it’s a great opportunity for acupuncturists and I’ve been extensively teaching courses and specialization all around the world and in the States. If you’re interested, probably follow my website and see when a course is coming soon and if it’s interesting for you.

Even when we look at the NCI, the National Cancer Institute, I can say overall acupuncture has been reviewed in a very positive way. You have to read it always because it’s updating, changing. I’ve been following this webpage so I can see there is always the work there, but just for the scope also they’re stating that cancer patient is using acupuncture and they’re giving you the scope from pain management to nausea, vomiting, fatigue, hot flashes, dryness of mouth. Neuropathy is another big field which has been proven that acupuncture is helping neuropathies, these kind of pains and lack of sensations that patients get, especially from chemotherapy and especially from different taxanes and other chemos. If it’s become chronic, it is a really debilitating condition and acupuncture is one of the best thing to help it and also help to recover from it to prevent a chronic state. There’ve been a lot of studies on the neuropathy.

Anxiety. The whole field of anxiety and the whole field of emotional side, this is very close to my heart and practice. To me, acupuncture is a transformative medicine. It can really transform on the very deep level how patients to get in touch with their Shen, with their spirit. And one of the worst thing that follows cancer patients is fear. It’s understandable for a certain period, but it’s definitely taking away one’s power from getting healed and even the opposite. When there is a lot of fear, to me, the prognosis is not good. I see very difficult patients with difficult cancers in very difficult stages. When I see no fear there, I know they will do well. Even if they won’t live full span of whatever we can say about life, they will have a better quality of life and they will exceed usually what is expected. In my clinic, we’ve been looking at many patients and we recall there is a lot of what you call exceptional patients. I think exceptional patients, a lot of them, are due to this connection of Shen to the body and that’s where healing is really coming from.

So, acupuncture has been studied for anxiety, depression, but also general wellbeing and also sleep. So obviously if the Shen is disturbed, the sleep is difficult. So this is from the NCI. You can go, there is more evidence there. This is just for the scope of this lecture. I’m more talking about scope or opportunities. We don’t go deep into all their research projects and all the research that we have. And even they’re showing the laboratory animal studies on different aspects of cancer care and they show that acupuncture has a very strong effect on the immune system, on immune regulation.

Immune modulation is really the key thing. If you help the immune system to reach a better balance, you are helping another also pathway of treating cancer, helping another way of patient to avoid secondary infection, to deal better with their medication if they’re taking. You’re preventing a lot of other potential side effects. Now we are seeing different pathways, how acupuncture is affecting immune system and in animal models there’s been a lot of studies that has been out there, but there’s also a few studies in humans. One of them is from Dana-Farber Hospital. That was part of Harvard Medical Center that was published by Weidong a few years ago, but we see more and more studies coming up on the effect of acupuncture on immune system and obviously I, a lot of time, combine with herbal medicine or specific formulas which I am studying.

From the JCO, the Journal of Clinical Oncology, again if you want to talk about scope, especially with oncologist or medical team, you have to quote very reputable journals. This is definitely a very reputable journal. It has a lot of studies on acupuncture, surprisingly. This was a systemic review of acupuncture, not the one I liked the best, but again some papers you like the design more than others, but again it’s a good review and you can see more showing the scope. So again, most of the things that we talk about are coming up, but there is prolonged postoperative ileus, which is another area of study. A lot of patients, and especially cancer patients, undergo surgery. And because of the anesthesia, there is lack of bowel movement. So acupuncture can really increase bowel movement. And that’s also what I find in the clinic. We have a very strong effect on bowel movement and a lot of patients are suffering from constipation because of their antiemetic medicine or because of their cancer or other disturbances, especially lack of appetite, which is sometimes the killer because people are really dying from malnutrition.

So, acupuncture has very strong effect on the justice system. So I brought also the scope, to show the scope from different studies. So this is a systemic review before I’ve shown systemic reviews and also the NCI view on that field. So you can see from many different directions, what we call conventional points of view. It’s quite surprising how acupuncture is accepted and is looked into the science that we can see by now. Even when I looked at clinicaltrial.gov, where you register clinical trials, there is almost 150 registered trials on oncology acupuncture. So there is a vast amount of effort in proving the efficacy of acupuncture in oncology and even some phase three trials. Phase three means … Usually a trial will go from a pilot, phase one, phase two. That’s randomized clinical trial. Phase three means there is enough people to compare between two groups, usually placebo and real or control and real.

And after a phase three trial, in Western medicine, it’s almost a level of this is what patients should get. So this is like beyond any doubt that this intervention is proven effective and that’s when we talk evidence. So we see that acupuncture is moving up in oncology acupuncture in phase three trials and this is a very interesting. I’m actually now in the midst of taking all the trials that we have until now and putting it into a book, which is evidence based oncology acupuncture. It will summarize the trials, but not just would summarize, but also would show the acupuncture points and what we can learn from different trials, if there’s interesting acupuncture points that we use. And also the frequency. I think many times we have to understand the frequency of treatments and when we don’t see good results, a lot of time it relates either to the frequency of treatment, the design of the trial.

So we are now kind of compiling, me and a colleague of mine, Dr. [inaudible 00:23:13], are compiling all the current and the good trials to see what we can learn from them as far as points and the evidence and then also that you can show … learn for yourself, but also show people who are in regular medical care the amount and kind of depth of studies in oncology acupuncture. I want to go to one trial. I like it very much. Also the people who did it, to me, very active at the SIO, which is the Society of Integrity of Oncology, both in their clinical practice, in their acupuncture. We have a special acupuncture group there and a research group and Eleanor Walker, she’s the head of the department of radiation oncology in Henry Ford Hospital in Detroit, and she carried a few trials with her team. They’re very good team there.

This is not … It’s one of the what we call older, if there is such few years as older, but actually it’s not true. It’s still very relevant. I like the trial, and I like that the design and also what we can learn from it. So I would like to share with you this trial and some points that we use, so maybe there’s some take home message from here. There have been few trials on the same idea of the reduction of hot flashes, and especially the reduction of hot flashes in cancer patients is important because it’s very common, especially in breast cancer and other gynecological cancer, especially if they’re hormone sensitive, to give this patient anti-hormonal therapy, and this anti-hormonal therapy creates different side effects.

The main one is hot flashes. The other one is joint pain. Both have been shown to be effectively treated by acupuncture. Many patients are stopping their treatment, this anti-hormonal treatment, which is designed to prevent reoccurrence of their cancer because of the side effects. So we are both increasing their quality of life, but also allowing them to adhere to the treatment, which is important for them. And so in this trial, although not big, but they’re interesting, they did what we call it head to head trial. So, they compared venlafaxine, which is an irregular SNRI drug. Here we call it Effexor, so I’ll call it Effexor, comparing to acupuncture. So it’s a head to head, drug intervention compared to acupuncture intervention. So you’re looking which one is more side effect, which one is better. But interestingly enough, they also follow this trial a year later. So, this was 12 weeks. So for 12 weeks, patients receive either acupuncture or venlafaxine and they looked at different outcomes and they measured it also and followed one year later. So, after 12 weeks, both were stopped and then they’re following up the effect, if there is any of the effect in the group of the acupuncture or of the venlafaxine.

So the results, especially immediately after when they administered both the acupuncture and the drug, both groups had significant decrease in hot flushes, so both were effective, so they had less symptoms and better quality of life. The first thing is acupuncture was as effective as venlafaxine, so that’s quite impressive. But two weeks after the treatment, when they stopped the both acupuncture and the drug, there was an increase in hot flashes in the venlafaxine group, but not in the acupuncture group. So, in the acupuncture group there was still a effect of the treatment also two weeks after the it was stopped, while in the drug, once you stop the drug, you stop the effect. Which carries always a lot of thought about acupuncture, because acupuncture is a curative medicine. It’s not a palliative. So it doesn’t just affect that the moment that you are given the treatment. It changes something in the body, allowing it better healing mechanism.

And when we look deeper at the result, venlafaxine had a lot of adverse effects. So there was nausea, dry mouth, dizziness, anxiety. There’s a lot of symptoms that patient that took it experienced. While with the acupuncture, there was no negative side effects, even the opposite. They had some additional benefits like increase in sex drive in some women and most reported improvement in their energy, clarity of thoughts, a sense of wellbeing. This is from the real article, so this is a good reflection on the total effect that we see from acupuncture, which is different than drugs. Again, for us, an acupuncturist, people who do Chinese medicine, it’s obvious. But believe me, to see this kind of results in a trial, in a high reputable journal, it is very impressive and to me, it’s the beginning of a change. Beginning of a change that the scope of our medicine and the effectiveness are viewed in a different way.

That’s why I’m I call this a lecture the scope, but also the opportunity. Once you see more and more respect to this form of medicine, there’s a greater opportunity for us, both to effect patient, and to enter into a best care. And to me, the best care is always integrity of care. So the conclusion, acupuncture is appeared to be equivalent to the drug therapy in these patients. It is safe. Again, we see safety, effective and durable. Treatment for vasomotor symptoms, which means hot flushes secondary to longterm anti-estrogen hormone used in patients with breast cancer. So, this kind of summary, this kind of a conclusion in this type of journal, it’s definitely meaningful and meaningful to the whole profession. Now let’s look at the points they use. I mean, nothing outstanding, but they did a good design, which means they gave … Some points were all the acupuncturists used and some were like secondary points that the practitioner could choose a point according to the condition.

And to me, this is a much better design of trials than fixed points because we know acupuncture, we don’t give the same treatment to all the patients. We adjust and we do personalized medicine. So if you do a trial, you can take this aspect out and suddenly create a fixed treatment and just hope that it’s always worked. I can talk about it quite a lot. I think in herbal medicine, some things we can do. In acupuncture, certain places maybe a little bit. But overall a better design is a design like this, which is closer to real life and closer to good acupuncture when we are able to adjust and tailor the treatment to the patient. So they use different points. I kind of group them in my own way. The grouping is my grouping in the article is just a list and explanation.

So when there was more Yang, probably more Heat, they added Du-14, especially if there’s a lot of Heat in the patient. Or Du-20 to [inaudible 00:31:56]. If there mores Qi complaints, then use stomach 36, Ren-6 and Lung-9. And I put Hun, but a lot of mental side and difficulty in sleeping can be treated through the Hun. I extensively teach about the Hun and palm and how they interact, and I think it’s a core understanding of how to use points in Chinese medicine. So gallbladder-20, liver-3 for pains and for Hun and for the liver, and for the Shen, pericardium-7 and heart-7. So this is the points that they could choose one point out of this in order to make a personalized approach. It was carried for 12 weeks at the beginning, for the first four weeks, twice a week, and then another, I think, four weeks, once a week.

So this is kind of completing a good … I think 12 sessions is a good period to have a sustainable change. And I mean sustainable, when they looked at one year later there was still difference obviously between the group and still many women that got this 12 week treatment are experiencing the benefit of it and also in general wellbeing. So, I think this is impressive. Again, there’s more trials, but if you want to follow me, you will see me talking about more trials and more possibilities how to treat oncology patients. But I think it is showing the scope, showing the opportunity and really strengthening this, that we can feel very confident about the effect of acupuncture and especially in this group of patient and for these kind of conditions.

So I would like to finish up with one of my mentors, Father Larre. I was lucky to have two very good mentors along my studies and really to take us a bit above just research, but into the worth of acupuncture in the 21st century, in the words of Chinese medicine in this century, especially with Western medicine on one hand is very developing, but on the other hand, I think there is a great need to integrate with what we are doing in there’s a great need for what we can provide to patients. “By returning to the classical roots of Chinese medicine, we can make a truly significant contribution to the medicine of the future.”

And to me, combining the medicine that we are doing that comes from an ancient roots with the modern medicine and its ability also to look at in a kind of objective way, where we are effective or not effective. That’s why I’m carrying a lot of research. And I have my own lab and we look even on a cellular level and we look at different biomarkers. All this it’s strengthening what we are seeing in the clinic and all this is helping to create a better future medicine. So to me, whatever we are doing is key and important.

Thank you for joining the show and I will just wish you all the best of health, especially in these times. Be well and safe and healthy. Thank you very much for watching it. All the very best.

COVID-19 Documents for the Practicing Acupuncturist

The American Acupuncture Council has made available the following documents so you are well prepared to continue to serve as many patients as possible during the COVID-19 Pandemic. Feel free to click on any and all of the images below to download each of the below.

Stop the Spread

Office Safety

Informed Consent

Caring for Patients

Palpation in Assessment and Treatment

Click here to download the transcript.

Hello, I’m Brian Lau. Welcome. I’m here today with Matt Callison. We’re both with AcuSport Education. Also here today with Chad Bong. Many of you know Chad Bong. He’s one of the founding members of the Sports Acupuncture Alliance. There’s been three summits so far. Chad, you can let us know about the state of any upcoming ones. We’re in the midst of COVID-19 pandemic, so I believe that’s on hold. But we’ll have a chance to chat about that.

Chad’s also the host of PinPoint Performance Podcast. Just had a recent edition out with Jamie Chavez. I was interviewed for that. That’ll be coming out in a little bit. I think Matt’s been a past guest of that also. Whitfield Reaves, a bunch of other really great educators have been a guests of that podcast. Chad, do you want to say anything about the upcoming summits or possibilities of that?

I don’t know. We’re a little nervous about trying to get a hundred people in a room in our current state.

Yeah, sure.

So I don’t know. We have a lot of decisions to make with that. So as things start to get clear, maybe as a vaccine comes out, then we’ll be able to set it down the line. But it’s a big project. I was very thankful we didn’t have one set for this spring because-

Yeah, timing is not good for your live.

… I couldn’t have imagined having canceled something like that. So I’m glad that that worked out in our favor, but I’m a little nervous about setting one up right now. So we’ll see what the future holds there. But we’ll definitely keep with the podcast. We have a fair amount of them recorded-

Great.

… so we’ll be able to be turning some of them out every two weeks.

Awesome.

Yeah. So, Chad, just a little bit of background. Chad, you have a Master’s in Exercise Science.

Correct.

Also a massage therapist, studied massage therapy. A graduate of Southwest Acupuncture College. You’ve taught at a number of schools, Southwest, you’re currently at the WON Institute, and you’ve taught at Tri-State College of Acupuncture.

Yes.

Then in addition to that, of course you teach a lot of continuing education classes. So many folks who are listening might have attended some of those-

Possibly.

… or highly recommended to attend at some point in the future when we’re back doing live stuff.

Yeah, I definitely prefer the live stuff because I like the hands-on stuff, like what we’re talking about today, the palpation stuff. I don’t know how you teach that over the internet. Although I have to teach that over the internet because The WON is on 100% online classes right now.

Yeah, sure.

In the next couple of weeks here, I have to start teaching, three, four-hour classes on palpation.

Yeah. We’re going to be doing some online stuff with palpation, too.

It’s going to be tough.

It’s tough, but it challenges you in a different way. It brings out some sides that puts the spotlight on and makes you observe a little bit more. I mean it’s good to be positive about it. But I agree. Ideally, there’s no substitution for palpation live.

Yeah. I can’t put my hand on their hand and help them feel what they’re trying to feel. Once you teach this stuff for long enough, you can place your hand on top of somebody else’s finger and feel what they’re feeling through their fingers.

Sure.

So you can be like, “Not that thing right there, that thing right there.” You just can’t do that over the internet. So at least I haven’t figured that out yet.

Hey, Brian. I was looking at our list for the introduction for Chad, and it looks like there’s one line here. So Chad’s also a licensed acupuncturist and he’s completed Whit Reaves’ apprenticeship program. You also co-authored a book with Whit, right?

I helped with his book.

Yeah. So maybe that’s a good segue to go into your article from coracobrachialis that you just spoke about with Lhasa. I think it was last week or two weeks ago. Do you want to segue right into that, Chad?

Sure, we can move into that. So I did a coracobrachialis. We’re trying to put out some information for people during the COVID thing here. So I tried to pick something that I think just gets missed sometimes, I think, that other acupuncturists send me patients for that, for whatever reason, they haven’t figured out or haven’t gotten.

So that’s where we got into the coracobrachialis. It’s an interesting one as far as the palpation stuff because it’s an important muscle to be able to palpate not only the tissue of the muscle, because it’s not super easy to palpate the coracobrachialis versus the short head of the biceps without some practice. Then you also have to really know where that whole neurovascular bundle is that’s sitting right underneath it.

So when you do go in there, the needle, you’re not whacking away on that. Although I know some acupuncturists who purposely hit things like that, but I’m not one of them.

So I think it’s important to really be able to feel the difference between tissues. A pulse would be a real easy one to feel there. Then feel the septum in between the short head of the biceps and the coracobrachialis.

Then we’ll find bony landmarks, the coracoid process, and having some way to think through that, and then be able to see where the muscle ends and where the muscle begins and being able to continue that line down so you can feel the tissue all the way I think is important. So I think that’s pretty good into this whole idea of palpation.

Yeah. The discussion of that, what you were pointing out, is something that I note quite a bit working with acupuncturists, and I think this makes sense. We learn points and we learn an anatomy of points, whether that’s specific muscular anatomy or just bone landmarks and palpation and feel for indentation.

So I think acupuncture is often, understandably so, thinking points and they lose sometimes sight of that real estate of the muscle attaches from here and travels through this region of the arm or whatever structure you’re palpating, and thinking of it as a space and a region and relationship from this muscle to another muscle where the neurovascular bundle is all of those things together. It’s easy to lose sight of when you’re used to feeling for individual points. So I know what-

I agree. If I think back to acupuncture school, it was just like you learn all of this stuff, but it’s just this one point and this is another point and another point. It’s not all of the tissue in between and what all that tissue feels like and the depths of the tissue and the three-dimensionality of the body, being able to think about the body in more than just the surface area. You can get to the same spot inside the body from different angles, different points.

Yeah, sure.

Going back to the coracobrachialis, wouldn’t you guys agree that sometimes coracobrachialis strains seems like it’s a bicipital tenosynovitis. It’s easy to go to a bicipital tenosynovitis when, in reality, it’s actually a coracobrachialis strain.

So that’s where palpation comes in. It’s so important to understand what you’re feeling. Is it really the bicipital tendon and you cross-fiber that? If that doesn’t really cause the pain, then go deeper into the coracobrachialis, especially after some resistance, so you can feel it pop up. So palpation is everything in assessment. It’s what builds a treatment protocol, right?

I find it very important. I bring in the whole massage therapy world to it. Although my concept on palpation and feeling and tissue has evolved quite a bit from what I would have just called myself a massage therapist versus after going through acupuncture school and spending all of that time working with Whit and just getting much more specific and precise with what I’m doing palpation-wise. Whereas in the beginning of massage school, it’s just sliding strokes.

Yeah, sure.

You don’t get quite so precise. But, over time, I think if you keep practicing, you get super precise.

Yeah, yeah. Whit’s very big into palpation, thank goodness, because palpation is a missing link in our training in school, that’s for sure. So with palpation, I mean, isn’t it a lifetime skill also? I mean we should continue to learn all the time, especially the more that you actually consciously know about anatomy. The more that you can actually see anatomy and know what the underlying structures are, then you can start to actually see it in their palpation. So it seems to me that it’s just a lifetime skill development.

Yeah. I think like most things, the deeper you go into it, the bigger the hole is. So you can just keep learning more and more. I sat down and wrote some notes about things that I wanted to talk about during this thing, and building your anatomy base to understand where all of those tissues are. Then, on top of that, building the palpation base.

Both of those are endless processes, things that you could go on learning for the rest of your life, the details of anatomy. I think my anatomy is pretty good, but I know there’s people out there who know their anatomy better. I think I could spend a lot more time with cadavers and ultrasound and things like that and try to develop my feel and the view of this tissue even better. So I think there’s always room for learning.

Sure.

Then palpation, I have students in the beginning, when I first started with them, do the thing where you put a one-inch piece of thread underneath sheets of paper and then they palpate it. People, when they begin, maybe can feel that under 15, 20, maybe a really good person might get 40 in the beginning. But if you keep practicing, you can get up near a hundred sheets of paper with that little piece of thread under there and you’ll be able to find it.

So just developing that sense so that when you feel something different in the tissue, you can start to feel the actual differences in texture, which is really what I’m looking for is changes in texture in the tissue that I’m trying to feel to be able to tell that there’s something different going on in that specific spot.

Wouldn’t you say that then you could also quantify to excess, deficient, damp, hot, cold, which would then set up your needle technique and also your application of acupuncture and moxibustion, right? So if it feels real excess, we’re going to be feeling it with palpation and then needling it as a reducing method. So palpation is … It’s so incredibly deep. Hey, Chad. I think you and I have been bogarting this, and we haven’t been letting Brian speak.

Oh, no, I’m good. [crosstalk 00:11:37].

You’ve just to jump in, Brian.

Yeah, yeah, yeah.

It’s a first come first serve show here.

Yeah. I do want to segue a little off of Chad giving tips because I had a few thoughts for this podcast of giving maybe some tips. We don’t have a ton of time to go into that, but we can talk about some guidelines or tips since that is an area within the acupuncture profession that could be improved on. You already gave a tip basically, was increasing sensitivity by having some method that you can start to add sheets of paper and feel through those sheets of paper to where you have greater and greater depth that you’re feeling through.

Yeah. If you want to talk about how, I think somebody could get better and better at palpation. First, I think you have to have a basis in anatomy, right?

Yeah, sure.

I think we all have. We’ve all been thinking about anatomy a lot. I think you need to learn that base so you can understand what tissues you’re trying to feel. Then I think you should build on that with learn what all the functions are, learn where the major neurovascular bundles are going through things, and maybe learn the functions of those muscles by practicing your manual muscle test, so that you can see what those muscles are actually doing.

Then you’re building multiple brain connections where you’re not just trying to memorize, “Oh, the biceps does elbow flexion,” you’re actually doing the elbow flexion or you’re having somebody else do the elbow flexion while you resist them.

So I think building your anatomy base, and thinking of it from small to big. Don’t just like, “I’ve got to learn all of the anatomy.”

Yeah, sure.

Just put pieces on top of pieces, layer it. But then once you have the … And I think you should do some range of motion stuff in there so you can see how people move. Then start feeling things. Really, the more different types of bodies, the more different tissue you feel, the better idea you’re going to have on what this tissue should feel like and what is different about the tissue?

Watch the students going through the three semesters of palpation stuff with me, and in the beginning, they can tell their auto-muscle and that’s about it. By the end, they’re like, “Is it that thing or is it that thing?” which is cool to watch the progression with them. Is that what you’re looking for?

Yeah. Well, I mean I have one. We were mentioning the coracobrachialis when you mentioned that doing a contraction to bring that muscle up. A tip that I often teach when I’m talking with students about a little bit more certainty for what they’re palpating is, yes, you can get the muscle to come up by a certain action, but you can be a little bit more precise on what action you use.

Coracobrachialis is a great example because it does really two major actions, but one of them, shoulder flexion. Well, it’s also right next to the bicep. So if you put your finger and span down and get on what you think is the coracobrachialis and have the person do shoulder flexion, it’s not going to tell you a whole lot because it’s going to contract, the biceps are going to contract. And what am I feeling? I don’t know. But if you recall that it also does adduction, [adeduction 00:00:14:46], adeduction is a much better-

Horizontal.

Horizontal adeduction. But also just straight adduction. That’s going to-

It tends to position your arms in, I guess, but-

Yeah, but that’s going to bring it up a little bit more different. It’s going to differentiate it a little bit more from the biceps just based on the action that it’s doing.

Yeah, a mechanism of injury, like, for example, you see usually this injury with people doing too many pushups or bench press or something like that. What else refers to the anterior shoulder, though? Doesn’t the lower motorpoint, which is also the same location of a trigger point of infraspinatus? [crosstalk 00:15:19].

It definitely refers to the front of the shoulder. The story I told at the beginning of the coracobrachialis thing, that’s what I thought it was. I pushed on her infraspinatus, I felt around back there, and I found a spot that just referred right to the front of her shoulder. So I was like, “Well, there we go. This is our thing.” She was a backstroke swimmer. So I was like I’ll treat her. Infraspinatus is the main concept muscle-wise, and this’ll get better pretty quickly, and it didn’t.

Don’t you hate that?

It doesn’t happen that often, but, well, it does.

Did they get somewhat better?

I learned something, though, right? I learned something by having her not get better. She didn’t get better basically.

At all. At all. Okay.

A couple of times actually. So I did some work on the infraspinatus and I did some work on the biceps and the deltoid, and I just wasn’t getting anywhere. Then, finally, I was like, well, I’m going to try the coracobrachialis. Once I needled the coracobrachialis, the next time she was 90% better when she came in. Then she was back to swimming. She’d missed swimming for years, basically, as far as competitive swimming.

How do you needle the coracobrachialis? We teach it as needling the motor innervation [ju pi 00:00:16:36], which is one tsun below [jan ayling 00:16:39]. How do you needle it?

So I’ll come pretty close to there. I’ll find it off of the coracoid process and then palpate out, making sure I’m on the right line by … People can see me, right?

Mm-hmm (affirmative).

Making sure I’m on the right line by coming and finding it in here, and then palpating all the way up here and then needling going out and down. But not super deep. You just want to get through whatever you happen to be under there, either the anterior delt or a little bit of the pec major. But, again, all of that neurovascular bundle there is sitting behind the coracobrachialis there. So you’ve got to be a little bit careful.

So I’ll needle it there, but you can also get into it inside the arm here, which is what I talked about when I did the coracobrachialis presentation. But here you really have to know your palpation, right?

Yeah, sure.

You have to be able to separate … I don’t know if you can see my screen right now, but if you do a light flex, you can see that septum in there. If you flex it a ton, it’ll just go away and it’ll just feel like the bicep.

But you can get this little space right here, but then you have to know right behind it. In this position, inferior to it is that whole neurovascular bundle. You can feel the brachial artery right there. So you’ve got to make sure you don’t hit that thing.

But this would be by palpation in here to see if I can find a spot that’s really interesting. Then I’d usually get two needles into it. You don’t have to needle deep. That muscle is basically right at the surface, so you don’t have to go crazy, again because you want to be careful of all the neuro stuff back there.

Then I would just get two needles into that tissue, some light e-stims just until either the patient feels it or you see a little tiny bit of a twitch. Then if you have needles in up here and needles here, you might see these needles moving and these needles moving, if you have a light twitch going on.

Brian, how do you like to palpate it?

Well, I use the motorpoint ju pi quite a bit. But like Chad mentioned, I sometimes do look for trigger points, or ashi points, a little bit more inferior. I don’t discuss that as much with people just because it takes a lot of set up in terms of students. It takes a lot of set up, and there is a little bit more risk. You have to be a little more mindful of the palpation.

But, yeah, I do sometimes needle it in that more inferior aspect. I do find that that’s a pretty common area of congestion. I also do a lot of manual work in that area. I probably more frequently do manual work at that part of the muscle than I do needling it and separating the coracobrachialis.

This is where it comes really having the palpation skills there because you can separate it from the septum. It can create a lot of congestion in that septum between the biceps and the triceps and being able to open that septum up.

Something else that we do when we teach … Chad, you probably know that we use a lot of models with sinew channels. The coracobrachialis is on the pericardium sinew channel, palpating it and then going and needling either a point like [piece X 00:19:44] or something. But in that case, I’d probably go with another muscle on the pericardium sinew channel like the pronator teres, maybe pronator quadratus, and see, when you go back and return to palpation, if that diminishes. Usually it’ll be about by 50% that you can diminish some of the sensitivity to palpation from a distal point. It doesn’t mean you won’t needle it locally, but-

So I’m glad you brought that up because David Legge, in his book, he basically puts it on the lung channel.

Yeah, that’s great.

And I was like I don’t necessarily agree with that. So I’m glad I got somebody else on my corner here [crosstalk 00:20:20] pericardium.

Yes.

It’s all opinion, of course, right?

Yeah, I mean you’re trying to decipher some pretty ancient language that’s been translated.

It’s in a different myofascial bag than the lungs, the lung channels. Yeah, it’s different.

Yeah, I agree.

Yeah, we have the biceps on the lung channel and then how that relates down the arm, the pericardium on the … I mean coracobrachialis on the pericardium channel. I think we have a video where we do on a cadaver specimen, where we have a needle in the … I don’t think this is up on our YouTube channel, but the needle in the coracobrachialis motorpoint and pronator teres motorpoint.

I forget now which one we turned and wrapped, but more aggressive than you do on a person. This isn’t a technique demonstration, but turning the needle to where it really, really grabbed a hold of the tissue. Obviously it’s a cadaver specimen, so there’s no sensation.

But you really want to get the needle stuck and then pull and see if it transmits force. I think it was from coracobrachialis down to pronator teres. You pull on coracobrachialis and you’ll see that [crosstalk 00:21:26].

You saw them both move.

Yeah.

That’s pretty cool.

Yeah.

Now we needled it the way that we needle it in SMAC, which is supposed to meet at the bicipital tendon, going in at an angle distal into that area, into the innervation site, which is common area for strain in that region. It seems like going from what Chad was showing, going from the medial intermuscular septum, in between the bicipital septum, going that way. It seems like we’re just going to the same spot, but at two different angles.

Like I said, it’s a 3D thing. We’re working from three dimensions. So you wanted tips. I think a great tip is for people who … The first time you’re trying to work on a muscle or find a muscle is to break open the Motorpoint Index book and be like, okay, ju pi is right here. So I know that I’m all on that muscle if I go to this point, or at least I’m really close to it depending on some other person’s anatomy. But I’m right on this muscle. So you could find that spot.

Even if you’re not a motorpoint needling person, or if you are, but at least it gets you on the muscle so you can start in a spot that’s in a good spot, and then you can palpate from there. It’d be a good way to find, say, like a popliteal muscle or coracobrachialis or something like that. Just use the Motorpoint Index wording and description of the location to find the actual point on the muscle, I think, is a great way to go about it.

Well, gosh, since we’re talking about that, you might as well go ahead and get the Sports Medicine Acupuncture Textbook because the images have not just individual, but it’s grouped together. So you can see the motorpoints all together. Thanks for that, Chad. That was a nice segue, buddy.

No problem. Anytime.

Yeah, and I think it’s important to see it in relationships too, because it’s good when you’re learning anatomy to see that isolated muscle on a skeletal structure and get a clear picture of where it attaches to and where it lives, but then to be able to see it in relationship to the other structures … Because that’s going to be more like when you’re actually going to palpate because you have to differentiate between blood vessels and other muscles and just the whole picture.

Yeah. I think it just helps people who don’t have quite the palpation background to find a certain spot, but then we also know like, okay, that’s a relatively safe spot to put a needle essentially, is into where the motorpoint is marked out. So you have both a point that’s relatively safe to put a needle in and it gets you on the muscle. So I think it’s a good way to learn where each of these muscles are and where there’s points you could access them as you go about learning this stuff.

Now I want to bring one thing up, is that, remember, our founding fathers really didn’t know the anatomy so well. There is some literature that does show they had … They were doing dissections, for sure. But the anatomy knowledge is not like how it is today.

So not knowing the underlying anatomy then gives the practitioner so much of a feel of what’s happening in the skin over the muscle itself. How well can you move the skin of an acupuncture point or a motorpoint or a lesion or something? How well does that skin move over that muscle or adhere to it because of the skin ligaments and the subcutaneous tissue onto the fascia profunda?

So there’s so many different things that can be developed just by not knowing the anatomy, but by going by what’s happening within the skin. I think that’s how we started, right?

Sure.

Then with dissection then came more anatomy and such, because we’re feeling for excess and deficiency, and I already talked about all of that. But I think that was really quite traditionally was how it began.

I’m sure it was just, again, layers on top of layers of learning over a long time for our [inaudible 00:25:23].

Matt, I just saw a question come in about the name of the book you mentioned.

Oh, great. Awesome. Thank you. It’s called Sports Medicine Acupuncture. If you go to SMAtextbook.com, SMAtextbook.com, there’s information about it. Thank you very much for that.

Yeah, and I guess we can mention Whitfield Reaves’ book. Chad, you had some interaction with that book also, if you wanted to mention that, because another great resource for acupuncturists who are transitioning into a more orthopedic or sports model.

Yeah, the Acupuncture Handbook of Sports Injuries and Pain. Yeah, it’s a great concise book about 25 really common injuries that people … If you’re going to work in sports injuries kind of world, those are the injuries, the 25 of the most common injuries, you’re going to see. So it lays out a really simple way of going about treating those injuries. I’m not a very good [crosstalk 00:26:29].

Yeah, more and more resources are out there now for sports and orthopedic-based acupuncture, which is great. I think there’s more on the horizon, too. So it seems like it’s a really growing field right now.

Yeah, the amount of people who are into this and posting things that they’re trying has grown exponentially since we started.

Hey, guys, there’s only about four minutes left. Is there anything that you want to wrap up with or any other questions that we can be able to take?

I think-

I can give one quick … We’re on some tips. This is an easy tip and it won’t take long. But when we’re palpating muscles, also being able to effectively palpate bone is quite important. What I frequently see when I’m teaching palpation is people tend to go in very quick and jab you when they’re palpating for bone. Just a general tip is when you’re doing it to use a flatter surface.

If you’re using your fingertips and you’re trying to palpate the coracoid process, you can’t really tell if you’re on the head of the humerus, if you’re on the coracoid process. You’re on maybe attachments that can feel hard if you go in too quick.

Whereas if you come in and match the shape of the bone, it has like a little hook. So if you can get your finger around that little hook and get more surface on the bone, and also wait a little bit of time and let that density of the bone … As the tissue softens around your hand, that density of the bone really comes to your hand more. It’s a really good strategy for palpating bone.

Then once you’re on that, you can do a little back and forth movement to get a little more clarity to it. But bone palpation, I find for a lot of people who are not really taught outpatient well, they’re too quick, too quick on the point of their finger. So just imagine how much information … You can’t really bring in as much information on a point as you can on a flatter surface.

Yes, I would-

[crosstalk 00:28:26]. Go ahead, Chad.

I would carry that into muscle as well.

Sure.

I mean, if you go in there really quick, the people are just going to tense up. They’re going to have constant pain, especially if you’re working on bigger muscles, if you use a bigger surface, like I’ll use a fist or an arm or something like that. Then I’ll just find something I’m interested in and just keep working into a smaller thing so then I eventually get down to my finger or something.

But you can feel a lot of very interesting things that you might miss with just a finger with a wider surface on, say, a bigger muscle. So don’t forget to do that. And work your way in. So you can put a lot of pressure on a human being if you work your way in there slow. If you go in fast, they’re just going to jump off your table.

Yes, I agree. Something that I’ve said for a long, long time is if you use a number of different anchors, following up with what you just said, Chad, but specifically your pericardium nine, because, in my mind, what works for me is that allows intuition to come up. It seems like I get a lot of messages when I feel with my pericardium nine finger. Maybe that’s just [Mattism 00:29:29], but I believe that’s actually fairly true for a lot of people.

Yeah. I have people practice with all their fingers, like figure out what finger works for you.

It works better than the elbow, that’s for sure.

I don’t know, man. You can train an elbow pretty well.

Yeah, I agree.

That’s true.

I agree.

That’s true.

I agree.

My elbow sensation 20 years ago was nothing. I could tell I was on a human body. But, no, man, I can feel a ton of stuff. It’s just because I’ve used them a lot to find things. That doesn’t mean I’m using them to cause an immense amount of pressure on somebody. But on big areas, a forearm shaft, a shaft of your ulna, you can find a lot of stuff with it.

Yeah.

Hey, I know we don’t have a ton of time, but there are a couple of reoccurring questions refining palpation, and two that I’ve seen come up quite a bit is palpation on people who are obese, because it can create a little bit more challenge. I mean I’ve worked with plenty of obese people that had just great muscle tone, very easy to palpate, and some very thin people who had very … Very difficult to palpate. But, generally, generally, it’s much more difficult to palpate people who have extra weight. Any tips or thoughts on that?

Matt?

Sure. Move it to the side as much as you can, knead it as much as you can, and also put the patient into a position to allow gravity to move the subcutaneous fat out of the way. For example, if you want to go to the lateral side of the body or into the obliques or something like that, instead of having them being supine, have them roll to the side so you can have that tissue with gravity move out of the way. Different tips like that is fine, but it takes a while. It will start to melt, but it takes time to do that.

Yeah. I think there’s different levels of connective tissue inside adipose tissue, too. So I think there’s a difference in how some of these things are going to feel. Some of it’s pretty easy to move through, some of it’s more difficult to move through.

Retinacular cutis.

Yeah.

Again, it’s practice. That’s why I say you need to try on a lot of bodies. You can’t just practice on one person because, yeah, you’ll get good at palpating that person, but you need to practice on all shapes and sizes of people to really get good at this skill.

Yeah. Having done a lot of dissection, you get to see, with people who are obese, how much subcutaneous fat there is, but also how much internal visceral fat there can be. Even when you’re seeing what you’re doing, sometimes differentiating structures on a cadaver specimen can be very difficult with people who are obese.

These are all great tips, but at some level you just have to do your best and understand that it’s inherently more challenging. That’s why sometimes people who are more obese, sometimes they don’t do certain surgical procedures because it’s … I mean this is when you’re in there seeing things. It’s hard to differentiate.

Now imagine you can’t see anything and you’re going in with your hand trying to differentiate the structures. It’s harder. You just have to understand that it’s harder. But [crosstalk 00:32:38].

But it can be [inaudible 00:32:38] a lot of stuff.

Sure. But you have to also understand that, at some capacity, with some people that you just have to do your best and feel your best and trust that you’re on the right structure. If you are in a risky area, maybe choose not to do those certain points that you can’t safely differentiate where you’re at and needle safely.

Definitely.

Yeah. Now the palpation is followed by needling. Then the needling density also helps, wouldn’t you say?

Yeah.

So then if you’re palpating … Are we still on the obese, I guess?

Yeah.

I mean this is a whole another podcast or webinar.

Sure.

Yeah, it is. [crosstalk 00:33:17].

You’re talking about density of tissue when you’re dealing with a needle. That’s a whole … Like we could talk about another half an hour, probably an hour, about just how a tissue feels and how you need to learn that when you’re practicing your needle. What does it feel like to go through fat? What does it feel like to go through fascia? What does it feel like to go through muscle, both healthy muscle and not healthy muscle? You talked about like you could diagnose somebody off of palpation with excess, deficient, whatever. You could do the same thing with a needle.

Absolutely. Absolutely. That would be fun to do. That’d be a fun discussion to have.

Yeah.

I’m ready.

Well-

You guys, it’s 10:33. So another question or … Yeah.

It doesn’t matter to me.

We’ll also be looking at questions on Facebook and can answer those via written responses. But I think we’re probably about ready to wrap up.

All right. Some closing comments. Chad, I just want to say thank you very much for doing this with us. That was really, really fun. It’s always great to get your insight on this. Also, so, Brian, it’s great always being with you as well.

Yeah, of course.

Let’s make sure that next week that you stay tuned to this because you’ve got Yair Maimon that’s coming in. If you have not had an opportunity to be able to listen to him, he is a brilliant speaker, a real bright light. He’s an excellent person to tune in with. He’s got all kinds of different insights with acupuncture and traditional Chinese medicine. So I hope you enjoy that. Brian, anything else that we need to say, thanking American Acupuncture Council?

Yeah, thanks to American Acupuncture Council, of course. We’ll be back then in a few weeks down the road for some more discussion of orthopedic and sports acupuncture.

Yeah, this is a topic that Brian and I hit on the podcast that we did. So if you’re interested in this, stay tuned for when we release Brian’s podcast, because Brian gets into his thought process on this a little bit more in the podcast.

Awesome.

I agree.

That’s great. When is that podcast, Chad?

I don’t know.

Okay.

We have a pretty big queue of podcasts right now.

Yeah, yeah, yeah. The one with Jamie Chavez, there was a little discussion on palpation, too. It wasn’t the centerpiece of the whole thing. It covered a lot of topics, but there’s a little bit in that also.

Josh, our goal is we get into it a little bit more, because he’s more of a bodyworker. You, we got into it quite a bit because you’re more of a bodyworker, too. So those are probably the two biggest ones we talked about palpation stuff.

Got you, okay.

Josh is … I don’t know when we’re going to release that either, but it’s coming to PinPoint.

Okay. Yeah, I was about to say I hadn’t heard his yet, but that’s why.

Yeah.

All right.

Thanks, guys.

All right, thanks very much, and we’ll see you next time.

See you.

Okay, bye bye.

Bye bye.

We done, Brian?

AAC-Telemedicine and Facial Acupuncture-diagnosis & treatment strategies

Click here to download the transcript.

Hi, everyone my name’s Michelle Gellis. I am an acupuncture physician and I teach facial acupuncture classes internationally. I would like to thank the American Acupuncture Council for giving me this opportunity to present a webinar to all of you, on how we can best support our patients, our cosmetic patients, our neuromuscular facial patients now through telemedicine and also once we start opening up, how we can continue to support our patients safely in our treatment rooms if we’re doing any points on their face. So this is one example of how we can actually work on someone’s face. This was me teaching a class… A portion of the class was watching me do some face lifting techniques that are unique to what I teach, and I’m going to talk about that in a moment.

I found this cartoon which I thought was very fitting and it’s supposed to be someone doing long distance acupuncture, and I thought during this time it would be funny… not funny, but many of us have found ourselves trying to kind of scramble figure out how are we going to support our patients if we are in a place where we can’t treat them, and especially if you specialize in cosmetic acupuncture or you have any patients who are new or current patients who have any sort of neuromuscular facial condition, how can you help them? This is a slide from one of my classes and what it is, is a quote from Coco Chanel and she’s saying that from birth until age 25 you have the face that your mother gave you. From 25 to 50 you have your own face that you create, and then from 50 on you have the face that you deserve. I put this slide into this presentation because so many of us are missing that care that we’re used to getting from outside, whether it’s for our bodies, for our faces, for our skin, for our hair, many of us and our patients are used to going outside for these services. I’m in Maryland in the USA and here everything is completely shut down and has been, we’re on week eight now of complete shutdown.

So there are ways that we can support our patients during this time. Telemedicine is actually a wonderful way that you can support your patients, not just with needles like you normally would but there are methods that you can use to help them physically, emotionally… And I’m going to go through a few of those possibilities with you. One of the most important things to think about when you’re thinking about treating the face is how the face is connected to the rest of the body, and when you’re treating the outside you’re treating the inside. So by treating a person’s face you’re treating all of them, and the same goes for if you’re doing body points it also helps to treat their outside.

In my classes I teach a full body protocol for facial acupuncture. It’s not just working on the face which will help if you’re doing cosmetic acupuncture, you can kind of get around… work around some of the things that maybe you’re used to doing by providing some of that full body work. Additionally, now is a great time to do a telemedicine intake for your new patients. Assuming that some of us will be opening up, it’s coming up in the next few weeks coming into summer, really getting prepared so that when you do see your new patients you can limit or reduce the amount of time that you have to spend doing the face to face intake, I’m going to talk about that as well. How can you support your existing facial patients, whether or not they have a neuro condition like bell’s palsy, trigeminal neuralgia, stroke, Ms ptosis. Any condition that affects them here there are things that you can do now to get… to set the stage for when they do come in. Chinese medicine is uniquely suited to help our patients body, mind, spirit and so we really are at quite an advantage over some other modalities.

As I said I’m also going to talk a little bit about what we can do when we do open. So I touched upon that a lot of our patients who are used to getting different services, whether it is their Botox or filler or their lasers or peels, or just a facial amongst other things they have not been able or they are still not able to have these services, but there are things that we can do to help them and any of you who are on social media, know the myriad of jokes that have been going around people and their inability to care for themselves saying they can’t wait. The first thing they’re going to do is get their hair done or their nails done.

So this kind of points to that. So telemedicine in general is great because it does give us an opportunity to work on some skills that maybe we would have never spent a lot of time developing for those patients who are afraid of needles, don’t like needles. It’s a nice, safe way for us to be able to practice our art. Our patients are not… for many of them not taking really good care of themselves right now. So you can speak to them during telemedicine about what’s going on with you as far as yourself care. Have you increased your alcohol consumption? Have you been following your regular hygiene routine? Are you getting enough sleep? How is your stress level? And all of these are very much a part of what your regular telemedicine sessions can be. I’m a Worsley trained five element acupuncturist. So a big part of my background and my training when I’m working with my patients, whether they’re my cosmetic patients or my pain patients is too check in with them about all of their systems to see how they’re going, and certainly you can do that through telehealth.

The reason why I… part of the reason why I was able to really make the jump from in-person to a telemedicine for cosmetic purposes is that the… so the skin on our face is the only place on our body where our muscle is attached to skin. So you can move the skin on your face and what this means to us as practitioners when we’re doing a session like this, we can look at our patients faces and we can see the different signs of their emotions. We can diagnose them constitutionally… and I’m going to break this down in a moment, but all of these emotions will get launched in the face. Since telemedicine is done through a camera, you have a unique opportunity really to look at your patient’s face and diagnose them that way. People are dealing with a lot of emotional issues, loneliness, isolation, fear, grief, people. Parents are having to homeschool their kids.

There’s a lot of over nurturing that’s going on for people that are in families, a lot of togetherness and in some cases there’s a lot of anger and frustration. So all of this is going to show up right here and this is all going to help you with your diagnosis. Also, really talking to them about what’s going on and giving them some self care skills, self-nurturing skills some of which you already know and some of which you might need to be a little creative as far as how can you take your skills whatever they are meditation or [qigong 00:12:44] and deliver those things to your patients. As far as offerings, speak to your patients about their nutritional habits, lifestyle support, are they getting enough exercise? What are the eating? What are they drinking? And as far as actually caring for their skin, you can teach your patients acupressure.

So for your current and your new facial patients, it can be acupressure on facial points and it can also be some body points that affect the face. So anything that you might be needling you can teach them some acupressure, and what I’ve done is I’ve just taken charts and highlighted or circled things, either taken a picture, scanned it and sent it to them. And then the next time I meet with them I’ll do a little training session with them, I’ll ask them how it’s going. I check in from week to week and it really keeps you engaged with your patients, and it makes them know that you care. So facial cupping, if you’ve never done facial cupping before I have a website where all of my live lectures are recorded, they’re all CEU recorded webinars and I teach facial cupping.

I also have a live stream class coming up, I was supposed to be teaching it in London. It is the first weekend in June and all that information is on my website, it’s facialacupunctureclasses.com and part of that class is a facial cupping. So this is what a facial cup looks like and it’s relatively easy to teach your patients how to do facial cupping and also facial Gua sha. The Gua sha tools I like look like this, and I’m going to talk a little bit more about those in a second. Also, micro needling is something that you can train them to do at home with a Derma roller as well. Any of my live stream classes are also recorded as well, I did want to mention.

I put this picture of myself… This is me teaching. I do make a lot of jokes when I teach our time is limited here so I’m going to keep the jokes and stories to an absolute minimum, but I put this picture up because you can see the lines on my face and those are very typical or someone who smiles and laughs a lot. When I’m teaching I go through all the different lines and what they mean and where they come from but I’m going to give you guys just a quick overview right now, and things that you can talk about with your patients or just use them as your own diagnostic tools. So on the left here is more of a picture of the different areas of the face and the organs that they correspond to, and this picture on the right is from Lillian Bridge’s book Face Reading, and I actually don’t… I personally don’t teach either one of these, I have a recording of one of my friends who is licensed to teach her class.

I have a section of that, that I include on Chinese face reading but there are a lot of different types of lines on the face that you can use when you’re diagnosing. There are a five element tools if you know five element acupuncture or if you’re interested, I go over a lot of this as well but looking at your patient’s facial color, the sound of their voice and the overlying emotion these are things that you can actually do with your patient through telemedicine. If the camera or their lighting isn’t good, they can take a picture of themselves with their cell phone and send it to you, and you can get a better idea of their color. You can also do tongue diagnosis and this can give you more information, same thing have them take a photo and compare it. Although you cannot feel their pulse, you can certainly get an idea of the pulse rate.

So if they’re wearing one of those Apple watches or whatever, whether it’s their pulse is slow or fast and if they don’t have a device, one of those Fitbits then you could just ask them to feel their pulse and count it for you. There are a lot of physical signs of aging that you can use through telemedicine to help diagnose what’s going on with your patient. If I have time I’ll get back to all of these, but I just wanted to put some of these up. These are slides from… I think they’re in their first module of my recorded webinar about diagnosis, and some liver and gallbladder lines. Some signs of kidney out of balance, [spleen 00:19:27] deficiency and then all the different facial lines and signs of aging and what they mean. These are things that you can look for when you are diagnosing your patient through telemedicine.

So, that’s a lot about diagnosis now What about treatment? What can you actually do for your patient? Well, by treating their spirit you’re going to treat their face, right? If someone is stressed it’s going to show up on their face. If someone is angry it’s going to show up on their face. If someone is fearful… if they’re grieving all of this is going to show up right here. So using ear seeds and teaching your patient… I have one of these little ears that I use and I’ll show my patient where to put the ears seeds, and then I’ll give them a diagram of the ear and I’ll put little dots. You can… here’s a great point for relaxation and then there were actually points right on the ear lobe that treat different areas of the face, the endocrine system to help with their complexion can help to balance their hormones. I’ve had patients call me their hair’s falling out, their face is breaking out. So the ear seeds can be great and they can even put them on acupuncture points. If they’re home they’re not going out which a lot of us aren’t, they could just put the seeds right on points. As far as the cupping and Gua sha, you can either take one of my webinars, you could… as long as you credit me you could use some of the pictures from that.

You could draw a picture for your patient and just show them it’s relatively easy and just because your teaching them doesn’t mean they’re not going to come to you afterwards. Because they will enjoy having you do this to them much more than doing it to themselves, but just teaching them some simple facial cupping, some facial Gua sha, how to really use the Gua sha tools and learning how to prescreen your patients for whose a candidate is important.

So I do recommend that you get trained, you don’t just try to wing it. There are some pictures from some of my classes and some acupressure that your patients can do. If you have current cosmetic patients and they’re contacting you going, “I got to get in, I got to get in.” You can teach them some acupressure on different points on their face that they can use to help to stimulate some of these points, and these are some common points that I use in my classes, and also some distal points that would be part of a facial acupuncture protocol. I found this picture online, I liked it because it was color coded and it made it easy to share with my patients. Of course, herbs are something that you can recommend for acne, rosacea, different cheek deficiencies, blood deficiency, stagnation any of these things are going to show up on the face. Puffy eyes, redness.

Any sort of skin condition usually can be helped through herbs, and I am not an herbalist so I’m not going to go into a lecture. There are prescriptions and formulations that can help with different skin conditions. As far as micro needling you can get a microneedle device. I sell them through AcuLift skincare, my company the AcuLift Derma roller and Lhasa has them, but you can buy them sell them to your patients or ask your patients to get one. These are great when you are practicing for your patients to use them between treatments or during this time when they’re looking for a really low tech way to treat their skin. It’s roller with titanium needles and it doesn’t damage the skin at all, it’s very gentle and they could just roll it on their skin. It stimulates collagen and elastin, and it can really go a long way to keep their skin looking good. When they’re at home you could teach them how to use it and again these are safe.

They are approved by the American Acupuncture Council, the AcuLift brand is approved by AAC for use in the treatment room. It is the only brand that is approved by AAC, and they can be used if their hair is falling out, you can use it on your scalp to help to stimulate blood flow, reduce [inaudible 00:25:14] excess testosterone, balance the hormones in the scalp. They’re great for pitted scars, acne scars and a lot of other things and I teach microneedling as well.

I don’t want to spend a lot of time on all this. You can go to my website and look up all of this. I want to make sure I have time for once you open. So I have noticed that a lot of people are going back to work in the next couple of weeks. So one of the big questions is, what do you do once you reopen? If your patient is supposed to be wearing a mask, how are you going to treat their face? Well, there are a few options.

So first when you think about a mask, there’s really only a certain part of the face that a mask covers, right? So if your patient is wearing a mask, the areas that you’re going to have difficulty reaching will be anything around their lips or kind of the gel area. So doing points like stomach 8, [inaudible 00:26:42], gallbladder 2 which you can still reach, and distal points, large intestine four, stomach 36, stomach 40. These points will all help the lower [Hussey 00:27:01] points will help to access this area of the face. Also, using Dr. Tan, if you use Dr. Tans you can do body imaging and you can treat their body.

So even if they are wearing a mask of course you can still treat everything here, and you can do ear points, you can do scalp acupuncture and these can all work to treat all of this, and then using some of your other tools of some of these other points can help with the rest.

So some of the… one of the skills that I teach in my class is using… utilizing the auricular muscles and doing submuscular needling, and this also helps to lift the face. Even if your patient is wearing a mask, you can still access these as well as doing points along the gallbladder 18, which works on the galea aponeurotica up which connects the occipital and frontal bellies of the occipitofrontalis muscle. These are all things that really work to lift the face. What about if you’re trying to… if you are practicing five element, and you need to do some entry exit points on the face? Well, you can access all of them actually except LI20, and in that case you would go down to the next accessible point, which was large intestine 18 which is in line with stomach nine and right behind the SCM.

Lastly, some other alternatives if you feel comfortable having your… if you’ve check their temperature and you screen them thoroughly, and they are asymptomatic and you are wearing a mask and a face shield depending on what the regulations are in your state, you could have them remove their mask or move their mask and treat their face that way, and the last thing is I did find this face shield if you could see here on the right. It was designed for estheticians to be able to treat their clients. It’s a giant sneeze guard and when I first I saw it I thought it was a joke, but I just ordered one. So we’ll see how it goes but again it’s a possibility because if you have on a mask and a face shield, you’re safe but you also want to protect your treatment space. If your patient did cough or sneeze, that it wouldn’t be spread throughout the treatment space.

So again a lot of the stuff I talked about was for cosmetics, but definitely for your neuro patients utilizing body points… any points you can access and I also have a two part webinar on treating neurovascular facial conditions, and a big part of treating a lot of these conditions is scalp acupuncture and body points with some facial points incorporated in. So, that is the end of my lecture and I want to thank the American Acupuncture Council for giving me this opportunity to share everything that I shared. If you have any questions you can go to my Facebook group which is Facial Acupuncture, I’m also on Instagram Facial Acupuncture. I have a Facebook page, Facial Acupuncture classes and my website where you can also write to me is facialacupunctureclasses.com and next week we will… AAC will be hosting Matt Callison and Brian Lau. So, that should be a great lecture and I want to thank all of you for your time, and I’ll be more than happy to answer your questions as best as I can. Thank you so much.

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