The Wrong Treatment
On Mistakes
This past Saturday, I launched my headache course with a live webinar for TCM Academy. It seemed to go over well. I think a few of our regular Mulch readers were in attendance, so thanks to you for coming out and to everyone who has watched the presentation either live and/or on replay, I am grateful as well. The replay is available until December 21st at TCM Academy.
Among the things I mentioned in the presentation was an article I wrote for the North American Journal of Oriental Medicine (NAJOM) early in my career – it came out in the March 1998 issue – entitled “Treating Chronic Headaches with Meridian Therapy.” It had been a while since I had read the article, and in re-reading it, I was reminded of a subject I had wanted to address for a long time.
The Wrong Treatment
If you have been in practice for any amount of time, you are going to have made mistakes. If we are honest with ourselves, we will admit this and try to learn something from them, if only to avoid making them again. As one matures and gains experience, the mistakes are hopefully less frequent, but that does not mean that one becomes magically immune from error. However, I have found that I am better able to recognize when something is going wrong in treatment and take measures to rectify the situation.
Case 1
I’ll give two examples here. The first is from the NAJOM article, which I will quote here, with some light edits:
She had migraines 2-3 times a week, mostly in the temporal and frontal regions, and positional vertigo. As this was her first experience with acupuncture, I told her I would give her a light treatment. Her pulse was somewhat sinking and hard, and her anterior-medial neck area was a little dry on the surface with very tense musculature underneath. Her pattern seemed to be Liver Deficiency, so I tonified LR3 and KD3. I applied the ion-pumping cords to TB5 and GB41, inserting the needle over a little lump of knotted tissue at TB5. I performed the anterior-medial neck treatment, and, as the back of her neck was very tight, I used a zanshin (a sort of “cutting” and “scraping” tool, similar to shonishin) on the back of her neck.
I saw her again three weeks later, and she informed me that my “light treatment” had given her a severe migraine and three subsequent attacks since. Not only that, they were occipital headaches, which were very uncommon for her. I very carefully reexamined her, and concluded that I had mistaken her pattern, which now seemed to be a Spleen Deficiency with Liver Excess, as well as overdoing the extraordinary vessel and anterior-medial neck treatments.
I carefully located the points for the LI4 and TB5 pairs with a copper teishin, and marked them with a pen. Then I placed the #1 stainless needles in the non-penetrating manner described above, and hooked up the IP cords. I left them in place for a few minutes, and went ahead with the root treatment. SP3 and PC7 were tonified on the right, and LR3 was dispersed on the left. The anterior-medial neck area was still hard beneath the surface, but the skin was a little more moist, so I needled a few points on either side, avoiding the back of the neck.
A week later, she reported no unusual symptoms after the treatment. In addition, she had not had any migraines that week; though she had experienced some transient headaches. I saw her twice after that, and her migraines had subsided.
Mulch comments:
This case was so long ago that I forgotten about it until I re-read the article. The issues were identified as wrong pattern and overtreatment. I mentioned in the webinar that in my experience migraine patients are really easy to overtreat, and that I have triggered migraines even by leaving the needles in too long. In addition, the patient had been diagnosed with fibromyalgia syndrome, which has been shown to be associated with hyper-responsiveness to sensory stimuli, not only pain but touch, heat, and sound as well (Wilbarger & Cook, 2011). Of course in Chinese medicine we aim to treat the person rather than a biomedical disease category, but at the same time it strikes me as foolish to ignore the possibility of adverse effects associated with a given condition, particularly in a patient who is receiving acupuncture for the first time and whose response to treatment has yet to be established. I don’t recall the particulars of the case; given what I wrote, liver deficiency does not appear to be way off the mark. I suspect the reaction was more likely overtreatment.
Case 2
The second example is from a few years ago. By this time I had been in practice for more than 25 years.
The patient was comparable in age to the previous example (mid-30s). This was her first treatment with acupuncture. She presented with a complaint of neck and shoulder tension. She had been through a bout of infectious illness about a year earlier, and still experienced fatigue as well as anxiety especially around her menstrual period. She had experienced PMS symptoms for many years. She had upper GI symptoms - reflux, especially with acidic foods, burning and eructation. Her pulse was moderate, and empty in the proximal (lower burner) positions. Her tongue was a dusky red, slightly swollen, with a yellowish coat. Abdominal diagnosis revealed a glomus (focal distension) in the Ren12-14 area, and some tightness in the right subcostal area.
The picture seemed to be pretty straightforward wood-earth disharmony, liver overacting on spleen and stomach. The PMS and perimenstrual anxiety were suggestive of liver issues, as was the subcostal tension. The glomus and reflux were typical of liver invading the stomach, and the moderate pulse and swollen tongue body indicated an underlying spleen deficiency. The red tongue with yellowish coat were signs that there was heat brewing in the middle burner.
I inserted needles superficially into Ren6, 12, and 14. I needled SP4 and 6 along with PC3 and 6 on the right, and LR2, TB5, GB41, and LI11 on the left. I capped it off with Yìn Táng. I used .12x15 or .12x30 mm needles throughout. I made sure she was comfortable and left her with the needles in place.
When I returned, I could tell something was wrong. The patient said she felt very hot, as if heat were rushing upwards to her head, her mind was racing and she felt extremely anxious. She was sweating over her whole body, and her feet felt cold.
I pulled all of the needles, had her sit up, and gave her some water to drink. I checked her pulse, which was still empty in the proximal positions. I asked her if she wanted to continue, and she said yes. I had her turn face down. Her upper back was sweating and hot, and the pores of her skin were open.
I immediately needled KD3 bilaterally, and palpated her back. Within about 30 seconds the sweating had stopped, and the skin became cooler with more normal surface tone. I needled UB14, 17, 18, and 23 along with SI14, and told her to let me know if her anxiety had returned. She relaxed for another 10 or 15 minutes, after which I removed the needles. She felt much calmer at the conclusion of the treatment.
She returned several days later, much less agitated. Her pulses were still weak in the lower burner positions. I needled KD3, ST36, LI11, and Ren12&6, and afterward repeated the back points I had treated previously. She did not experience any of the adverse effects of the first half of the first treatment, and felt much more calm after the session.
What Happened?
So what happened in this case? There are a number of possibilities, none of them mutually exclusive. On the one hand, the pattern seemed to be clear from a diagnostic point of view: this looked very much like a standard Dān Zhī Xiāo Yáo Sǎn case, liver qì stagnation transforming into heat and overacting on the stomach and spleen, with the heat ascending through the shàoyáng channels causing the shoulder tension. The one thing I chose to overlook – for the sake of a nice, neat pattern - was the emptiness in the kidney position. As soon as I saw how the patient had reacted to the treatment, I knew that was where I had gone wrong, and as soon as I corrected the mistake, the counterflow normalized and the patient was at ease. In a sense, the pattern I needled to correct the problem was liver deficiency with a lack of orderly reaching, in other words I had originally treated a qì-level pathology where treating a blood and essence-level pathology was called for.
In simpler terms, one could say that I didn’t sufficiently root the patient. She was an energetic, talkative person with a primarily upper-body constellation of symptoms and an empty pulse in the lower burner position. Once the qì got moving, it was bound to go up. I started the follow-up treatment with KD3 and the lower body points first, and everything went well.
Another possibility, which has come up occasionally over the years: some patients just don’t do well with unilateral (or asymmetrical) needling. I’ve used different points on the right and left sides of the body on hundreds of patients over the years with no adverse effects, but I have seen patients who clearly don’t tolerate it at all and need to be treated with all points needled bilaterally or along the midline. I think of asymmetrical needling patterns as having a more moving or dynamic effect, which can work in one’s favor for treating conditions like pain or stagnation, where bilateral or symmetrical needling seems to me more stabilizing in nature. That’s more a conjecture than anything one can conclusively prove, of course, and others I’m sure have differing opinions on this, but that is what my experience suggests.
Conclusion
We all make mistakes; we are all too human, and our missteps are a part of life. Ideally, they are kept to a minimum, cause us to reflect and to learn and keep growing. It can be painful to admit our mistakes – I had been thinking about writing this essay for quite some time but kept putting it off as it is not something any of us like to talk about. But if anyone reading this is then able to avoid similar errors, then it is worth discussing. As always, thanks for reading.
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
Hayden, R. (1998). Treating chronic headaches with meridian therapy. North American journal of oriental medicine, 5(12), 7-8.
Wilbarger, J. L., & Cook, D. B. (2011). Multisensory hypersensitivity in women with fibromyalgia: implications for well being and intervention. Archives of physical medicine and rehabilitation, 92(4), 653–656. https://doi.org/10.1016/j.apmr.2010.10.029
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