Principles, Methods, Channels, Points

On Constructing an Acupuncture Treatment

I was watching some lectures from a CEU course by Heiner Fruehauf the other night. It was first-rate stuff, as one might expect, and, as I find is always the case with Dr. Fruehauf’s lectures, quite thought-provoking. So I’m going to share one of the thoughts thus provoked with you, kind reader, here.

Principles, Methods, Formulas, and Medicinals

Dr. Fruehauf gave a quick rundown of the concept of lǐ fǎ fāng yào [理法方藥], which could be translated as “principles, methods, formulas and medicinals”. It is a brief description of the process of diagnosis and treatment with Chinese herbal medicine. Yao, et al. (2015) provide a typical summary:

“In the clinical practice of TCM, the rules of “Li-Fa-Fang-Yao” are of critical importance. Li-Fa-Fang-Yao, which means principles, methods, prescriptions and Chinese herbal medicines, indicates basic steps of diagnosis and treatment: determine the cause and mechanism of diseases according to medical theories and principles, then decide treatment principles and methods, and finally select a prescription as well as proper Chinese herbal medicines.” (Yao, et al., 2015)

Here is a really basic example, which I give to my students in 2^nd-3^rd year:

Sample Herb Case

A patient comes to you with symptoms like: tiredness, bloating after eating, hot painful swelling in the knees, scanty dark urine, a swollen tongue with teethmarks and a yellowish coat in the rear, and a soggy rapid pulse.

·       Lǐ: After reviewing the signs and symptoms, you conclude that the diagnosis is spleen qì deficiency with damp heat accumulated in the lower burner.

·       Fǎ: Tonify spleen qì, drain dampness and clear heat from the lower burner.

·       Fāng: Now you need to find a remedy, so you open the formulary to the Tonify Qì chapter, and you pick a formula which checks off as many treatment methods as possible. So you decide to pick Sì Jūn Zǐ Tāng, Four Gentlemen Decoction, to tonify spleen qì. But it has a fairly mild ability to drain dampness and nothing in it to clear heat.

·       Yào: Then you get out the Materia Medica and go to the chapter on Herbs that Dry Dampness. You choose Yǐ Rén [Sm Coicis]. Then go to the Clear Heat Dry Dampness subcategory to find something that specifically clears heat and drains damp from the lower burner: Huáng Bǎi [Cx Phellodendri]. You add those to your base formula of Four Gentlemen Decoction.

Applications for Acumoxa

So, Dr. Fruehauf’s lecture got me to thinking about what an equivalent would be for acupuncture and moxibustion. In TCM terms, all the various modalities follow the lǐ and fǎ, the principles and methods. As for the rest of it, I figured channels and points would be the closest equivalent.

Thus, lǐ fǎ jīng xué [理法經穴], or principles, methods, channels, and points.

·       Lǐ: Framing of the presenting clinical picture through whichever seems most appropriate to comprehend the etiology and pathomechanisms at hand. This can include, though not necessarily be limited to: eight principles, five phases, six evils, five vital substances, six systems, four aspects, three burners, eight extraordinary vessels, secondary channel systems, etc.

·       Fǎ: Apply the principles to therapeutic actions. This can include, though not necessarily be limited to: principle-specific actions such as might be used in Chinese herbal medicine (i.e.: clear heat, supplement qì, transform phlegm), treating engendering and controlling cycles in five phases, treating same or opposite side, treating locally and/or distally, treating above to heal below, using moxibustion of various kinds, using other modalities (such as cupping), etc.

·       Jīng: This is a step that is maybe a bit contentious, as most TCM books like Maciocia (2015) go straight from pattern and treatment method to points. I think this step may have varying importance depending on what comes up in the first two steps; if you frame the problem in terms of channels and the fǎ step includes treating opposite or distally, as we might see with something like Balance Method, then choice of channels becomes rather more important. My own modus operandi is to treat yin channels in five-phase mother-child pairs and yang channels according to distribution of signs and symptoms, which comes from many years of practicing Japanese keiraku chiryo.

·       Xué: Choice of individual treatment points is the next step. This can be drawn from classical categories (five shu points, for example), point actions (many of which derive from the classical categories), empirical findings, local anatomy, palpation, feedback mechanisms (such as is found in many Japanese styles), and so forth. Ideally it should line up with the first two steps.

To extend this thought exercise, I will analyze a previous case of mine. I posted about it during the Lurking Pathogens series. I had previously put up a 30-minute video presentation on the internet as well :

I will give a brief summary:

Case Summary

A male in his early 40s and a background of Crohn’s disease presented with a chief complaint of sinusitis. The sinus infection would periodically progress to a lung infection, which if left unchecked would result in a Crohn’s flare with abdominal pain and bloody stools. Signs and symptoms were consistent with a picture of dampness and heat. Since the progression of symptoms brought to mind Wú Jūtōng’s axiom of warm diseases developing from upper to middle and lower burner, I framed the problem in terms of warm disease theory.

Lǐ: Damp-heat lodged in the qì aspect. Prior disease process has left the wèi aspect and upper burner open to pathogenic invasion; the pathogen has a damp nature which gives it a tropism for the spleen, qì aspect and middle burner. Once it enters, it will disrupt the qì dynamic and the lung’s governance of the waterways, transforming into heat and steaming the turbid fluids in the upper burner. Periodically the dampness and heat would fall to the yíng aspect and lower burner, causing pain and bleeding.

Fǎ: Dry dampness and clear heat from the triple burner, rectify the qì dynamic, vent the pathogens from the qì aspect; diffuse and downbear the lung. Acupuncture is the primary modality.

Jīng: Apply channel pairings from the 3-4-5 map.

Lung and spleen channels are primary to treat the underlying pathology. Yángmíng and shàoyáng channels are treated to help clear the pathogen and alleviate the symptoms.

Xué: Choose from among the following points for each treatment session. Watch for shifts in location of pathogenic processes and adjust accordingly. [Points and actions from Ellis et al., 2004; Maclean et al., 2018; Hayden, 2021]

Yīn Channels

• LU-7 (liè quē): Vents pathogens from the qì and wèi level

• LU-5 (chǐ zé): Downbears Lung qì, opens water passages

• SP-4 (gōng sūn): Rectifies the qì dynamic

• SP-5 (shāng qiū): Metal point (acrid) dries dampness from the fleshy exterior

• SP-8 (dì jī): Rectifies the qì dynamic

• SP-9 (yīn líng qúan): Drains dampness, regulates the waterways

Yáng Channels

• LI-4 (hé gǔ): Releases exterior, frees stomach and intestines

• LI-11 (qū chí): Clears heat

• TB-5 (wài guān): Vents pathogens, regulates triple burner

• TB-6 (zhī gōu): Fire point on fire channel drains heat (bitter) from triple burner

• ST-43 (xiàn gǔ): Fortifies spleen, disinhibits damp, drains dampness from the face

• ST-36 (zú sān lǐ): Regulates central qì, harmonizes intestines, disperses stagnation

• REN-6 (qì hǎi): Regulates the lower burner

• REN-12 (zhōng wǎn): Regulates the middle burner

• REN-17 (shān zhōng): Regulates the upper burner

Add local points for the sinuses and back points as needed to reinforce the treatment effects.

Why Bother?

Why should we bother with this process if we are treating with acupuncture? Indeed, a lot of practitioners don’t think too much about this and just treat. Some go through the process intuitively, more or less, and if you asked them to describe how they arrived at what points to treat, they would give you some variation on this framework. Others just go ahead and treat general or complaint-centered protocols without investigating the idea of an underlying mechanism; and that’s fine, I’ve done that myself at times, depending on the situation. But as an aid for students to learn to construct a treatment, or to check in on your treatment process when things are not quite working and you are struggling to understand why, this might be a useful way to step back and look at the flow of diagnosis and therapy in practicing acupuncture.

Quick reminder:

I’m having a no-cost one-hour live session on headache - in which I give some of the handy complaint-centered protocols - to kick off a course where I discuss the pathomechanism and treatment of headaches in depth. The session is scheduled for next Saturday, December 16^th. You can sign up here if you are interested.

Anyway, that’s enough thoughts provoked for today. As always, thanks for reading.

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Note: this publication is for information purposes only and is not intended as medical advice. Please seek the opinion of a health care professional for any specific medical issues you may have.

References

Ellis, A., Wiseman, N., Boss, K., & Cleaver, J. (2004). Fundamentals of Chinese acupuncture (Revised ed). Paradigm Publications.

Hayden, R. (2021). Five phases, four levels, three burners: Building resistance in the pandemic era. North American Journal of Oriental Medicine. 27(83). 5-6.

Maciocia, G. (2015). Foundations of Chinese medicine: A comprehensive text (3rd edition). Elsevier Health Sciences (US).

Maclean, W., Lyttleton, J., Bayley, M., & Taylor, K. (2018). Clinical handbook of internal medicine: The treatment of disease with traditional Chinese medicine. Eastland Press.

Yao, L., Zhang, Y., Wei, B., Wang, W., Zhang, Y., Ren, X., & Bian, Y. (2015). Discovering treatment pattern in traditional Chinese medicine clinical cases by exploiting supervised topic model and domain knowledge. Journal of Biomedical Informatics, 58, 260-267. https://doi.org/10.1016/j.jbi.2015.10.012.

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