[Yvonne Farrell]

Hi Tamra,

I think this a very worthwhile discussion but there is also no one definitive answer to many of your concerns.

I said that acupuncture and herbal treatments need to be coordinated with the oncology team, and blood work results are useful so that the patient and partner would have the impression that collaboration between Eastern and Western medical team is key. I said Eastern medicine can be part of your cancer care support team, but it does not “treat” cancer. There are many ways to treat patients with cancer. Most of the time, depending on where you live we are not actually legally allowed to say we treat cancer. In most states the scope of practice includes the “side effects of cancer treatment”. Chinese medicine is actually quite effective for cancer patients but most of those patients have oncologists that are very particular about other forms of treatment so it is always best to be as well informed as possible so you don’t make things worse or injure/impede the patient’s relationship with their primary cancer doc.

I attended a TCM Academy webinar and learned some from cancer care experts and I have a couple of books, notably one by Simon Becker that offers herbal guidance for blood cancers and chemo-disturbed blood. The cancer care experts readily spoke about having “specialized training” for oncology support. I think in some ways this is very much like treating fertility. The allopathic approach that oncologists take is considered to be the primary form of treatment so having specialized training in oncology support helps both you and the patient.

I remember you saying that you don’t like treating people with cancer. There is hardly a time in my practice when I am not treating at least one or two cancer patients. I typically treat patients once they have completed their most invasive treatments. The reason I don’t like it is because both of my parents died because of cancer, so it is a little close for me. I have over the last 30 years lost a few patients to that battle. I don’t enjoy it. When a patient is first diagnosed, I usually refer out. Early treatment is typically much more aggressive and I am not really comfortable with that. I am fortunate that one of my teachers when I was in school is a brilliant diagnostician and herbalist and he also treats a lot of cancer patients. He was trained as an MD so he fully understands western treatment. So I usually send them to him.

Where do we find the cancer care experts in our medicine? I actually googled “oncology acupuncture support” just before I responded and that is as good a start as any. Of course, you would need to check and see what type of extra training they have. I am not aware of any board like ABORM for cancer/acupuncture. I know of no directories for this specialty. I just know a few people who do this, mostly in my area.

I don’t believe that I want to seek the additional credential at this time, but perhaps in the future. I just want to know what falls within best practices and how to progress with patient care safely; to avoid causing harm and to alleviate stress and assist in restoring people to a measure of vitality when that is possible. I think if you focus on supporting the patient’s resources and dealing with stress you likely cannot go wrong. Based on your earlier comments I think it unlikely you would overstep in a way that could cause harm. I think herbs are tricky with chemo but pretty safe with radiation and surgery. Acupuncture only becomes an issue with certain types of tumors and only if you try to treat locally. Creating bodywide circulation and keeping needles away from tumor sites is safe.

This patient has stage 4 stomach cancer with liver involvement diagnosed roughly two weeks ago and I am not the Mayo Clinic specialist. He reported mid-thoracic pain on the right side. see above. You can treat both the liver and stomach channels but do not put needles locally. This is a very serious cancer and the prognosis is not great. There is likely little you could do that would make it worse and probably a lot you could do to bring comfort and improve quality of life.

Does every acupuncturist stand in my shoes at some point and figure out how to help or is it wiser to punt and avoid such patients? I can’t speak for all acupuncturists but I can tell you I have stood in those shoes and many of my friends have too. At some point you just need to recognize when you are in over your head. You need to feel comfortable that you will be able to access information if something comes up. So you need resources to do this. Books are good, practitioners with experience…better.

I remember hearing you say “just try” among many other things. Maybe you wouldn’t offer this advice to this situation. The answer to this is dependent on what the patient intends to do. If they are ready and willing to fight for their lives then you should refer out. They are going to need very aggressive treatment. If they are looking for comfort and maybe a little more time then you can likely help with the comfort part by treating what you see.

I just did TCM prescription, but likely will refer out from here. Chemo has not started yet. They suggest they will try to shrink the tumor with chemo, but surgery was not posited by his doctor as next step (due to liver involvement). Like all other conditions it is important to get some sense of what the patient is willing to do or what their expectations are. I think you were very honest and compassionate but I think maybe you undersold yourself a bit. This is way better than over-selling. If you treat the patient, not the disease you can definitely help.

[Yvonne Farrell]

Hi Elaine,

Divergents are the most complex system when it comes to diagnosis. That is because you are diagnosing 2 separate levels of qi (wei & yuan) plus the vital substance being used to create and maintain latency. It can take a while to get comfortable with them.

So let’s have a look at your case:

Patient is mid-50s female with unilateral pain in three locations. When we say “unilateral pain” we are saying that the body creates latency on one side of the body first, then as resources diminish the pain moves to the other side. So right away, some of these things are not connected. Some of the joint pain is on the left and some on the right.

Oldest is Left knee. Orthopedist says bone-on-bone arthritis and needs knee replacement. More recent is a Left wrist/forearm (about a month and a half). Visible swelling in the Lu 7 to Lu 9/ LI 5 area. It could be de Cuervain’s tenosynovitis, or arthritis, or in my opinion most likely both. Initially pain was in whole forearm, even sometimes in elbow. It has reduced to the de Cuervain’s area with ZF treatment, rest from use, herbal liniments, and cold laser. She uses her hands all the time in her work. The third unilateral pain is about a month/month and a half. Right hip/sacrum area. Deep pain in ischial tuberosity/”sit” bone, but also along whole edge of sacrum, wraps to trochanter. Originally also wrapped to front and radiated down GB channel/IT band and anterior and lateral quads. Psoas and hip flexors are tight and she stretches them regularly. With massage, chiropractic including cold laser, and stretching, pain has focused to more the sit bone and hip. Stands all the time for work, and is generally fine but is very aggravated by even minimal sitting and driving. So basically, if this is a Divergent then it is 2 different ones or it is a Divergent and something else, like a sinew treatment. That means we would need to know if she wants to work on first, the knee and wrist or the hip?

Patient is active with a regular exercise: yoga, spinning, walking. Healthy diet and lifestyle.

“Menopausal hip” pain has been bandied about, but she has not seen a western medical practitioner for either the hip/buttock or the wrist.

Knee: Is it even worth working on the knee if the arthritis is this far progressed? If so, would the divergent treatment be appropriate? You are not actually working on the knee, you are trying to release the latency so her vital substances are not burdened by the latency OR you are trying maintain the latency in order to give her more time to generate resources. Her other knee is also headed this direction, so I could always use it on that one. This is really the first thing you have said that makes me think it really could be a divergent issue. As her resources diminishes the pain starts to move to the other side. She can’t get the replacement immediately, so I would like to do what I can to help her remain mobile and working with as little pain as possible. Pain is primarily medial. So now you need to look at the ZONES, I suspect it is a UB/Ki issue but it could also be the 2nd or 3rd confluence. So you need to see where her wei qi is holding.

Wrist: Even though her pain is primarily in the Lu channel with a bit in the LI (LI 5 and slightly proximal). When I look at the Lu/LI divergent information, it seems like it is the end of the line! Quite dire. I am not sure where this fits in with what is overuse over long time for her work. Her tongue is NOT blue or purple. Her pulses are NOT slow. I would not say her “Yang is all lost.” Pain is in primarily Lu channel, a little LI channel, so the Zonal theory isn’t fitting. I do not think that the wrist is a LI/Lu divergent. It may not be a divergent at all. I would be inclined to treat it as a sinew channel issue or as part of the left-sided latency of the knee stuff.

Hip: This is both BL and GB channels, so how would I work with the two levels? You would not work with 2 levels at once. You would need to decide between the 2. That is done in 4 ways: what channel is involved? Where is the restriction in wei qi (zones), what type of movement makes the pain worse? what is the state of her vital resources? I also was thinking maybe a sinews channel treatment might be more appropriate here? It is hard to tell if there is arthritis, but it is possible. My sense is that this may be better served with a Sinews Channel treatment. Then you should try that.

If I do use divergent treatments on multiple body parts, how do I start? You don’t. You start with what the patient wants to work on. But then you also need to decide if these are divergent issues. With the most superficial level? Or the most painful/ bothersome part? I am also unsure about how to construct the treatments effectively. Probably Horseshoe is the safest. The safest is always to maintain latency (D-S-D) but the horeshoe has the least agenda. It lets the patient decide. Your patient is young enough that they likely have enough resources to release so a horseshoe makes sense.

I would like to get a handle on this system so I stop avoiding it! 😁 Or if there is another more appropriate system? That’s the tricky part really, you have to be able to diagnose the patterns associated with the system and you need to understand how the system works. Again, mastering the Divergents takes a long time and significant effort. The diagnostic parameters are extensive and you have to check them all.

And, last but not least, I treat many patients with knee and hip replacement surgery. What do you think would be most helpful POST-surgery? My inclination is to move blood to help healing and inflammation. reasonable thing to focus on both before and after surgery. I can do that with ZF treatments, but is there something in our work that might be more helpful? The sinews are very good at restoring function and range of motion. Chong Mai deals with Blood, and Yin Wei with microcirculation. Choosing an 8 EV for blood circulation alone is not enough. These are archetypal vessels that disseminate jing and support curriculum. The Chong and Yin wei both deal with blood flow but they have a much more profound effect on consciousness than that. You really need to see existential suffering. Otherwise use the primary channels to move blood or the luos for micro-circulation. Basically you are looking for people being stuck in events or experiences that present as themes. I will have to think more on it and would welcome thoughts. I have also found they need help with muscles (sinew channels) as they are in PT and also compensating until they can move more naturally.

[Yvonne Farrell]

Welcome back.

It’s a little hard to have a discussion about this without the details of the patient.

It is fair to say that if the diagnosis is idiopathic neuropathy that one should at the very least investigate micro-circulation. It is also going to be important to look at the low back and sacral area (thus the back treatment) to see how much the soft tissues are involved in this.

Onset and a history for several months before the symptoms began important.

Also important to know if the whole foot is involved or are specific areas of the foot worse.

I am assuming they have done blood work and ruled out metabolic issues.

It will be worth your while to look at this patient through the lens of the Divergents as well as the 8 EV.

There is something about his reaction to having his back treated that makes me want to know more about his demeanor and character style. If this guy has “a stick up his butt” that will affect the circulation in his legs. 😉

I would love to hear what you see when he comes in.

[Yvonne Farrell]

Hard to tell from the photo but those could be signs of the luo emptying. It makes sense with the history. Usually the bumps a little more squishy (damp-phlegmy than those appear to be, like a lipoma).

Sounds like you made very clear choices. Gu treatments are appropriate for long covid and can be quite helpful in chronic respiratory conditions. If you wanted to do something to release the UB luo you could have done guasha around the luo point or used a plum blossom needle.

You could also deal with the long term grief by doing a luo treatment for grief at the level of ying or yuan.

You can also use the Ren mai for the loss and the lungs. You can do that and help the UB by balancing the Ren & Du: Left Lu-7, Right Ki-2, Left UB-62 and Right SI-3. Using Ki-26 in a treatment like this could deal with the grief and as a Kidney shu point it will consolidte blood in the chest and help the luo.

So many choices.😉

[Yvonne Farrell]

Hi Tamra,

I don’t recognize the syndrome you mention. Typically after zoster you can get post-herpetic neuralgia, encephalitis or Ramsey-hunt syndrome (this is rare).

What is it that makes you think it is Gu? Does he have a greasy tongue coat? Chronic digestive problems with cold-damp?

Most cases of this post-viral syndrome tend to be a combination of shao yang heat plus blood stasis.

I would try bleeding the appropriate jing-wells first, then I would look at the Yang wei.

[Yvonne Farrell]

Hi Vibeke,

I’d love to see that kind of socialized care in this country.

Your instincts are right. Radiation treatment causes heat that burns through yin. You will see superficial heat (burning on the skin) also heat in the ying and blood. You will definitely need to work on cooling those different levels of qi.

Also, heat depletes qi. So in the beginning you might see agitation from the heat especially when it hits the blood level but over time you will begin to see sign of qi depletion. This may become more obvious if there is blood deficiency too.

The medications can cause nausea and other digestive issues, especially early on. Often the body will adapt over time.

I think your patient is wise to want to deal with this early on. Patients who have acupuncture during radiation do better than people who wait to have acupuncture until the tissues are more damaged after the fact. Good for her for being proactive. She is lucky to have you.

[Yvonne Farrell]

Hi Heather,

Sorry to take so long to respond. I just got back from Belgium.

Inability to internalize is basically an inability to take things in. Physiologically it might mean inability to swallow, eat or even breathe deeply. Or it might, from an emotional or cognitive point of view, mean you cannot process or cannot accept or understand an interaction or emotional challenge. In a way, you could say that it means some difficulty being fully embodied.

There is no room in these patients. They cannot take any more in and that is typically accompanied by feelings of discontent. Discontent with their current situation, especially when they compare to the circumstances of others. They are unhappy with their reality but they cannot receive so they are stuck. They may daydream about a possible future but their discontent and inability to internalize inhibits their ability to change their circumstances and move towards that future.

[Yvonne Farrell]

If it is a metabloic issue treating blood circulation alone will not suffice. You are going to have to treat the middle, maybe even Yin fire.

[Yvonne Farrell]

Hi Heather,

Thanks for the reminder. I often forget that my mind makes connections that come from years of doing this.

The sinews were actually implied in much of what I said and they are indeed the first choice for neuropathy. When I asked about where in the foot the neuropathy is experienced that is a sinew issue. When I mentioned the Divergents, that’s a sinew issue. You cannot choose a divergent unless you assess the sinews. When I asked about his demeanor, that’s a sinew issue.

Also, I think your assessment of male patients is valid.

I was trying to cover the big stuff since we have no in-person info about this patient. In that way, Elaine would be prepared to get all the info she needed to make a good treatment plan.

Thanks for the input.

[Yvonne Farrell]

Does Ki26 always help with grief? Ki-26 is the Metal point of the Kidney shu points. It governs the Po. So yes, it can help with grief.

Ki-26: Metal

Ki-25: Fire

Ki-24: Wood

Ki-23: Earth

Ki-22: Water

As in with a Ki trauma Tx – is that a reason to choose Ki26 over Ki 27? Yes, it is one reason. I choose it also because the Po governs Wei qi and the physical sensations associated with trauma. The Po helps us to become more embodied after shock & trauma.

Or does it need to be coupled in a treatment with luo points ie Lu 7 in this case (although this point is being used for the Ren opening, not as the luo, so maybe it doesn’t have to be coupled with a luo)… It does not need to be coupled with a luo. The kidney shu points on the chest are on the pathway of the Chong Mai. Their job is similar to the back shu points. The back shu points consolidate Yuan qi for organ function. The Front shu points consolidate blood and Jing in the chest. Because of their location in the chest and on the kidney channel they have the unique ability to impact the relationship between the heart and kidney. So they are effective for emotional distress.

[Yvonne Farrell]

For the sake of clarity, I am not suggesting that it isn’t Gu. Just wanting to know if there are confirming symtoms. Typically with Gu we see more of what you are experiencing and more damp & phlegm s/s. Like a post-viral malaise. This blood stasis pain could be associated with that but it does sound more like a heat pattern.

Hope you feel better soon.

[Yvonne Farrell]

Well done. Your intent must have been very clear! Congrats to you both!

[Yvonne Farrell]

I don’t think it is a mental gap. I think the truama/mental-emotional stuff is how I focus on them when I teach.

In a case like this I think it is an important thing to remember that the 8 EV (with the exception of the Du Mai) have no direct pathway connection to the Zangfu. They access the Zang fu and primary channel system in 2 ways; vital substances and extraordinary fu (like the bones). In fact, the whole first ancestry (Chong, Du & Ren) have a profound and direct influence on the bones.

Also, cancer has the ability to create terrible blood stasis but it is also a perversion of yuan qi (jing) so the 8 EV seem very important for restoring sovereignty through the rectification of yuan qi.

[Yvonne Farrell]

Bone pain is the worst. If you want to make considerable changes in the level of his pain you will need to address the bones. Moving qi & blood will address the secondary pain and it will help his quality of life but if you want to help him reduce the morphine, you will need to access the bones. The best way to do that is with the 8 EV. Sounds like, based on the location of the pain that you will need the Du & or the Dai. But you have insight I do not.

Relieving that pain may increase his peace of mind but if it doesn’t you might look at the Chong. Not only will it resolve qi & blood stasis and give him access to yuan qi but it is also the “going home” vessel. This may bring him to a deeper sence of peace, purpose and acceptance.

[Yvonne Farrell]

Hi Dani,

when you say “improve quality of life” what do you mean by that? Is that what he wants too? What would that look like to him? to you?