The medicine of east Asia is based on a science that does not hold itself separate from the phenomenon that it seeks to understand our medicine did not grow out of Petri dish experimentation, or double blind studies. It arose from observing nature and our part in it east Asian medicine evolves not from the examination of dead structures, but rather from living systems with their complex mutually entangled interactions. Welcome to qiological. I'm Michael Macs, the host of this podcast that goes in depth on issues, pertinent to practitioners and. Of east Asian medicine, dialogue and discussion have always been elemental to Chinese and other east Asian medicines. Listening to these conversations with experienced practitioners that go deep into how this ancient medicine is alive and unfolding modern clinic. Have you ever had the experience in clinic when a patient says something and it just stops you in your tracks? There's a kind of gravity and brilliance about what they just said. That completely resonates with you. The feeling in the room changes I had that happen the other day, when a patient of mine said a listening heart perceives me. It really got me thinking about the importance of listening and it reminded me how ting, the Chinese character for listen. At least the traditional form of it actually tells you what's involved in deeply listening. I'll be back a little later in the show to unpack that character for you. Hey folks. Welcome back to qiological. I've got Josh Lerner with me. So if you might be familiar with Josh Lerner, if you're listening to everyday acupuncture podcast, he was on there not once, but twice in that first show, we got to talking about fat and then we came and did a second Encore. Follow-up about chewing the fat, healthy fats and that kind of stuff. It was good stuff. So you might already be familiar with Josh. If you're not. Josh is an acupuncturist and a 29 guy in the Seattle area. Today, our subject is acupuncture and a little thing called trigger points, dry needling, and intramuscular therapy. You know, there's a lot of talk about this stuff. Josh has some insights because he's gone and done some study on both sides of this. So welcome back, Josh. Great to have you here on qiological.

Thanks, Michael. It's great to be back here. I think we talked a little bit about some of this and the first thing we did on everyday acupuncture. Cause that was about orthopedic acupuncture. That's right.

That's what it was. You know, I've got 80 plus episodes over there. I can't keep them straight anymore.

You're just too prolific for your own. Good, Michael.

I don't know if I'm prolific, I've just done it a long time. You know, you do something, you do a little bit of something on a regular basis and the next thing. No the years go by and you got a bunch of it. It's like not cleaning out the garage.

Excellent.

So you're an acupuncturist. In fact, we first met when I had just graduated from acupuncture school and you were still in it, and we got to share some time in a clinic in Seattle some years ago. So you're an acupuncture first and foremost. And I know that you've had a deep interest in body work over the years. You know, you've done a lot of the work that with the guys from New York, amazing 29, holy smokes. And you've gone into looking at the work that you know is often called dry needling. I guess I got a bunch of different names for it these days. What, what are they calling it anyway?

Well, the standard terminology for the use of needling to treat trigger points is still pretty much called dry needling. Although there are other groups calling it, other things there is like you mentioned the, uh, intramuscular therapy that is taught based on the theories of, uh, of a physician named Chon gun. You know, interestingly, my introduction to trigger point theory actually started back when I was in acupuncture school back probably about 1998 or so. Uh, one of my teachers back when I was at the Northwest Institute of acupuncture and Oriental medicine back when that was still around as a acupuncturist named Sarah Bayer and the neuromusculoskeletal class that she taught, she introduced us to the idea of trigger points. She recommended that we get a copy of the main textbook that was written by the woman who. It was really responsible for the spread of interest in trigger points, a woman named Janet Trevell who died in 97, the year I actually entered acupuncture school. So I'd known about them when I was still in school, back in the late nineties. And I had a kind of a vague concept of them and a vague idea of the importance of them and some of the similarities between trigger point theory and acupuncture theory. Well, we have

our SharePoints.

Right, right. But we also have this idea that a problem in one area of the body might produce symptoms pretty far away from where the problem is. And that's one of the whole ideas behind trigger point referral patterns is you might have pain in the wrist that might get diagnosed as carpal tunnel syndrome, or like a tendonitis or tennis synovitis. And the pain is actually referred from maybe one of the rotator cuff muscles up in the. Or from a muscle in the neck. And the problem itself is a contraction in the neck that we can talk about the whole physiological process of why that causes pain in the wrist. But this idea that there are these pretty consistent referral patterns that you can map out. Um, and that you can also recreate if you have a problem in one of the rotator cuff muscles, for instance, like on the infraspinatus and problems often occur somewhere around like small intestine, 11 on the back of the shoulder blade. And if there's a problem in that muscle and you press around small intestine, 11, you can then cause that referral pattern, that pain to radiate sometimes into the front of the shoulder around like large intestine, 15, they can go down to the elbow even into the fingers sometimes. And so they, the referral patterns overlap with acupuncture, meridians quite a bit. And so there's definitely a similarity in the view of how sensations kind of travel. Through the body in that kind of a pathological sense between trigger point theory and traditional Chinese medicine.

I find it so interesting that we have our ideas of channel theory, and we have these ideas that you can work distally and where something shows up is not necessarily the place where the problem is. I mean, that's very elemental to Chinese medicine. And then here we have this stuff looking very physiologically from a anatomical point of view, Western biomedicine. And we come up with this same thing. I mean, it's really not a surprise. Right? We're all looking at the same thing. We're just coming up with, uh, you know, different stories about what's going on.

Yeah. But that's really true. We are, we're looking at the same bodies, everybody. For the most part, we have the same physiology. We tend to have the same problems that tend to arise just as part of our physiology. And we have basically different languages to describe. What's happening to our body. So I think of being an acupuncturist who's really interested in, in the Western medicine side of things. It's like just being bilingual. No, wait, we have two different languages. We're having to kind of translate between each other, but both languages are describing the real world. It's just the, each language tends to clump phenomena together differently. Right? You have different ways of describing, like how do you define a tree in one language versus a tree in another? Like, is, is there a difference between different types of maple trees in one language? Are they all just considered one thing? Whereas in another language it might be a very fine distinction based on, you know, the cultural needs of the people who will evolve that language. Right? Same thing with medicine.

I want to come back to that a little bit later in the show, because this is an area that's a little bit near and dear to my heart in terms of how we can use. What we're doing with our patients and the languages that we use, but I want to come back to that a little bit later. What I'd like to continue with here

is

what you've been learning through this other side of the house, so to speak, although of course, acupuncturist don't even want to think of us being in the same house with people doing try kneeling, but you know, we're all working with the same stuff here. I don't want to get political here, but you know, when people go, oh yeah, we just shouldn't do that. Just don't go there. But it's here.

Yeah. It was an interesting process getting involved in this because I guess I could really say that I ended up really getting more deeply into trigger points after hearing about the Michelin because of my wife. So my wife is a physical therapist, although she doesn't do any orthopedic work. She functions more like a neurologist who focuses on. Vestibular disorders. And in the past has done a lot of like neuro rehab, but she gets a lot of mail, like advertisements for continuing education classes. And she got one once. This is probably about 10 years ago now nine or 10 years ago, she got a flyer for a class on manual trigger point therapy being taught by an occupational therapist out of Aberdeen, Washington. And it was a class that was just down the road from where we live. And it was a two day class on treating trigger points with massage, basically with manual therapy. And so she got it addressed to her and I looked at it and like, you know, I used to really be interested in trigger points. I thought they were fascinating. Maybe I'll take this class. So I did that. I was in a class with PTs and massage therapists and OTs, and the teacher was really fantastic woman named Laurie Connolly, who just, I think she is retired, uh, earlier this year, so she's not teaching anymore, but it really opened up my eyes to. This whole new way of looking at pain and dysfunction and the class was really all manual techniques. So diagnosing what muscle is probably muscle or muscles is probably the cause of the problem. And then doing a specific kind of massage technique where you palpate the muscle for these very tight bands of tissue, these kind of ropey bits in the muscle, you find the most tender part of it. You press on it and you hold it until the muscle relaxes and then the referral pattern goes away. And so I was an acupuncturist at this time for probably six or seven years of using needles for that long. I was in school for four years, but still there's something about the manual approach that I found very compelling, partly because I had already started doing twine with Tom Bizzio and Frank Butler at that time. So I'd had about a year of experience doing lots of manual therapy with train on techniques. But I actually spent probably the next two years after that initial class. And I did a full series of about four or five weekend classes with her. There was a kind of a general intro class and upper body class, lower body class, a head neck class, and a specific temporomandibular joint class, like treating jaw issues with trigger point stuff. And I did this whole series of classes over the course of a year or two. And I spent the first two years with my patients really focusing on just doing the manual techniques. I didn't really start needling trigger points. I mean, consistently for two or three years after I started doing this, because I found the manual practice of releasing trigger points taught me so much about palpation and about anatomy that I hadn't really known before just doing needling it, doing trigger point work like that really requires a very. Layer of attention than we normally do an acupuncture school. So it was several years after that, I started also then teaching that material at the Seattle Institute of Oriental medicine. Um, when I started supervising the clinic there, and then it was really just about three years ago when I, I was starting to needle trigger points on my own, but then I actually decided to take a series of classes that are taught by physical therapists, by the micro pain seminars, people, which is the continuation of the original seminar series that was taught by Janet Trevell. We can talk about if you want kind of a historical context, but I, so I took the series of classes that focused specifically on using needles, the quote, unquote, dry needle in classes, and then really started focusing much more on, on needling the trigger points in that particular context, because the very specific technique that they

use, I am struck by what you had to say. About putting your hands on people and feeling what's going on, really paying attention to the tissues, paying attention, to what, to what your hands have to say and how that gave you a different kind of palpatory awareness of what was going on in the body. And then later you took that and added the needles.

Yeah. You know, it's really interesting because in some ways the type of palpation that you have to do for trigger points is much coarser or more gross in the technical sense of that term than what we normally do in acupuncture. Most acupuncturists have very refined palpation skills for. For even something like taking the pulse I've had classes with. Yeah. Even like at Siam, when we have PTs come and taking classes, or even like a simple first aid class, like a CPR class being taught by someone who knows where acupuncturists, a lot of these Western trained people will say, yeah, you acupuncturist are much better taking pulses than we are. You know, I sometimes I can't feel someone's pulse at the wrist, which is why I always take it at the neck. So we have great training for feeling things like pulse or just like subtle changes in the tissue and feeling the chia and the channels. But a lot of acupuncturists actually have a much harder time palpating some of just the big, obvious structures of the body, unless they've done a lot of orthopedic work. And I remember my, the first time I noticed this was when I was still an acupuncture. Uh, Gingy Misa Tawny. Who's an acupuncturist up in Canada. He's he runs her edits, the, the north American journal of Oriental medicine, kind of the bilingual Japanese English journal. Uh, and he's a big teacher, like on moxibustion, he's kind of an expert on Japanese styles of moxibustion. And he came down to school at night when I was there and taught a one day class on Japanese moxa techniques. And one of the techniques that he was showing was the way that he does, I think we were doing, uh, like needle mocks. So, uh, Cuto sheen in Japanese. And so we had a class of about, I know, 15 to 20 acupuncturists combination of students and people who've been in practice a long time, and Gingy wanted us to needle tight areas in the muscle. And your Japanese acupuncture is very palpatory based. And so he was, he show palpating the muscle. He was kind of pressing in deeply and finding these tight bands and putting a needle in and then doing mocks on him. And then he had us do it. I watched him walk around the class and for pretty much every group of students that he walked up to, he would have to put his hands on their hand and like pushing deeper into the tissue and roll his fingers back and forth. He's like, no, feel deep. There's this big knot right there. But all the acupuncturists were kind of going in very gently and subtly and feeling for these much more subtle changes. And he was like, no, you're missing it. It's not that subtle. It's really obvious. You just have to press harder. And really, and so that was the first time that I saw, oh, they're actually different ways of palpating. And if you're not paying attention to a certain type of information coming from the body, you're going to miss it. And I run into the same thing. Teaching this material at school, I've gotten away from introducing needling trigger points to the students too early in. Time in school because I want them to spend more time palpating muscles deeply, and really understanding the fiber direction of each individual muscle, figuring out what is a, like a pathological type end of tissue. And it really requires for the most part people to be much less shy about pressing in deeply and really, you know, kind of cross fiber massaging some of these muscles. Cause that's how you figure out where the actual type bands are. I mean, I've had a lot

of study around palpation. It's a really interesting area for me. And yet we're having this conversation here today and I realize, yeah, that, that more surface stuff or that more subtle stuff. That's one thing, but really getting in to the meat. I realize I've got a big deficiency there. Where, where could I go? To start filling out that portion of my palpatory vocabulary.

The first thing that you can just start doing on your own is pick some of the really important muscles that tend to be problematic in most people. So for instance, the upper trapezius, like Runyon called gallbladder 21, the infraspinatus covering the entire back of the scapula, not just the pair of spinals, but like the quadratus lumborum and the lower back the gluteus medius. And see if you can actually feel the different layers of the muscle. Some of the muscles are easy to feel. Some of them are, are less easy to feel, but aside from kind of doing it on your own, any good class on manual techniques is going to kind of force you to start palpating. At that level. I sometimes view our bodies, like we're a radio and that we're re we can receive. Different frequencies of information and some of the subtle palpatory techniques, or like just a very, uh, kind of much higher up on the dial. Whereas some of these types of palpatory techniques that I'm talking about are pretty low frequency and everybody who practices manual medicine like this, you're going to have a certain range of radio stations that you are really good at picking up naturally. And that's going to be the center of gravity of where your attention tends to get pulled back to. And you can learn to kind of expand that range. Like I can do the subtle stuff to a certain degree. I've done visceral manipulation classes I work with in the school founded by Dan Penske. And I've learned a lot from Marguerite and from Craig and other people who do subtle stuff. That's not my. Natural center of gravity for what I'm paying attention to so I can shift there, but that requires more attention and energy for me to maintain that. Whereas feeling joints and muscles and bones is kind of where I'm most comfortable, you can develop the facility for kind of changing radio stations or changing the frequency of the information that you're getting, but it just takes some conscious practice and effort.

Well, and it sounds like it's helpful to recognize, and I love your term here where your center of gravity is where you tend to go, or even where you like to go. I mean, I'm reminded of decades ago at this point, it's weird sand decades ago, being in a clinic. And, you know, student clinic and someone had just come in and was talking with one of the teachers. I made a comment about how she really liked to treatments that she did on the patient. And the supervisor's response was, I'm glad you're happy. I hope it's what the patient needed. Right. Right. The meaning being, are you able to get out of your own center? Gravity? Yeah. Great, great phrase. Can you get out of the thing that you like and open up enough to see what is it that the person in front of you actually needs? You know, it might not be the center of your dial,

right. And it's also then even more important to recognize when someone needs something that you're not going to be very good at giving them. And so that's when, like, if I have some patients who I know need a different type of work than I normally do, which I could do, but it's not something that I do regularly. Then that's when you have to refer out to your network of people who you trust, if people who have much. Ranges then you do, and then you have those same people. If they have. And I've had referrals from acupuncturist who tend to do very subtle things. They have a patient who they realize, oh, they basically need some trigger point work done. And so they will refer to me. And so it's, it's an interesting conundrum because in one sense, you want to feel like you're constantly pushing and exploring the areas where your weaknesses are, but at the same time, recognizing that you can't do everything all the time, which is, you know, one of my biggest problems, I feel like I have to be able to do everything. So I'm going to do the subtle stuff and I'm going to do the kind of course or muscle stuff. So it's a, it's an interesting dynamic to me between recognizing what you're good at and focusing on that while still pushing the boundaries and not letting yourself get stagnant and kind of forcing yourself to work in the areas that are outside of your center of gravity. Uh, but that's a whole topic for another podcast.

I remember when I was in acupuncture school. I mean, we talked about usher points. I don't think we call them trigger points. I think we just called them Osher points. And you know, we're told that's one aspect of Chinese medicine. It's one thing to work with. I don't remember getting much more instruction than sticking a needle in it and disperse it. If

it hurts, stick a needle in it,

something like that. Yeah. It sounds like you've got much more finesse given the study that you've been doing, walk us through how you would, first of all, find out where the right points are, right? Where that, where that trigger point is like you were saying, they may have an issue with their wrist or their hand in, you might be working up in their shoulders or neck. Why walk us through a case.

So to do that, we need to take about 30 seconds and have a brief discussion about all the different aspects of. Trigger point activity because it's not just about muscles causing pain. So the physiology of trigger points, what a trigger point is, maybe we'll start with that. Cause that will set up the foundation for discussing like a case study or things like that. What a trigger point is, is a pathological small localized contracture within a muscle. So really what we're talking about is a, is a shortening of the muscle part of the muscle, not the entire muscle. It's not a muscle contraction. I mean, it's not a muscle like a cramp or a spasm. Uh, which is a function of the entire muscle shortening because of electrical activity coming from the nerves, right? So that's called an electrogenic contraction. That's a normal muscle contraction. The nerve fires, a signal, the muscle fires and the, all of the different motor units in the muscle fire. And you raise your coffee cup or whatever. What a trigger point is, is a small localized contraction of the sarcomeres within the muscle. That happens for a number of reasons that I have a whole lecture I give to students on. Um, but it's basically small little bits of the muscle are caught in kind of a feedback loop of contraction. They can't relax for a number of, of biochemical reasons. And that shortening is the kind of the tightening and the, not that you feel like if you palpate gallbladder 21 and those usually that not most people have their right or small test in 11, small intestine 11. Yeah, exactly. Yeah, what that means is the muscle itself is short, which means that the muscle isn't functioning normally, which means that it's normal jobs, like in the case of small intestine, 11 and the infraspinatus, the shortening, it can stimulate the nociceptive nerve endings and our vendings at signal damage. They're the ones that are called pain receptors. Although it's not really pain that that signaling needs it's tissue damage. So there's the relationship with the central nervous system and the nociceptive pathways, and that causes referred pain, but also what that then starts doing, because the infraspinatus now can't contract normally because it's in a partially pre contracted state. And then when it does contract, the order of firing of the motor units within the muscle is disorganized. So it can't contract strongly. And with the rotator cuff muscles in general, one of their really important functions is not just in rotating the upper arm and doing the rotation. Of the humerus and the glenoid fossa, but they actually stabilize the shoulder joint. Right? The shoulder joint is a very shallow ball and socket joint. It's more like a, a golf ball sitting on a T than like a deep socket like the hip is. And so the rotator cuff muscles, including the infraspinatus are very important for keeping the head of the humerus stabilized in the joint. So now you've got a potentially less stable shoulder joint because of the trigger point in the infraspinatus. So then the shoulder becomes unstable and then other things start like the bicep might start to tighten up more because the bicep tendon runs over the front of the shoulder. And that might be doing that in an attempt to try to provide some stability with the bicep tendon over the front of the, of the, uh, the joint capsule. And so you can have this kind of cascading series of biomechanical effects that are completely separate in a sense from the actual referral. So having, having said, all that patient comes in, they've got pain in the wrist. That's been diagnosed as like carpal tunnel syndrome, maybe it's pain at the base of the thumb. And it's radiating up into like the index finger. I've got one of those. Yeah. They're whole list of muscles that can, if they have trigger points in the can refer pain in that area, uh, the scalings could be another one, but let's say that it's turns out that it's an infraspinatus trigger point, you know, with that patient, they come in, they say they have this pain. The first thing you can do is just palpate. The muscle itself kind of visualize the direction of the fibers of the muscle. You palpate across like 90 degrees to the direction of the fibers across fiber, uh, muscle fibers. It helps to kind of throw the edges of the tight bands into sharp relief when you do that. So you can actually feel them and you press on the muscle. It's really. And you might actually recreate their pain when you press on that muscle, if you're in the right spot. So you press on like small intestine, 11 or some point right near there. And all of a sudden they feel the pain in the wrist. Bingo. Then you know, you're in the right spot, but the patient also might come in with some other issue. Like, um, they may have an elbow problem because they're an athlete and they have, uh, maybe they're a pitcher in like they're pitching baseball or maybe they're doing a lot of pull-ups or pushups and they have some problem in the elbow and you look at their biomechanics and you figure out that the reason they're having elbow pain is because their shoulder isn't very stable and they're doing some weird thing with the muscles that control the scapula to compensate for the fact that their shoulder joint itself isn't. And so they're unconsciously guarding to kind of help try to keep the shoulder joints stable. And it's not stable because they have trigger points in the infraspinatus or other rotator cuff muscles that are contributing to the instability because they can't function normally because they have these short things in the muscle. So that's a case where you have to be a kind of a detective and trace back this chain of biomechanical effects. And try to figure out, you know, is looking at the trigger points of the muscles that are responsible for this instability, going to be really kind of helpful and efficient way of looking at the patient. So the referral patterns are really the best way to get started with this. Just anytime someone has pain, if you get either like posters that are books that have lists of the different, uh, trigger point referral patterns in them, the two main books written by Janet trivia. The red Bibles, what they're called. They have extensive lists of muscles by body part. So there's like a list of muscles that all refer pain to the front of the shoulder. There might be, you know, 10 muscles that do that. And they're often listed in order of most to least likely. So any patient that you have that comes in that has pain in the front of the shoulder, you can just start palpating those muscles that are likely to refer that area

time for a quick break. I promised you I'd explain how the Chinese character for listen actually instructs you in what's involved in listening. The character is pronounced ting and the traditional form is made of the characters for ears, eyes, and you're ready for this heart. Makes sense. Doesn't it to listen to really listen. It involves all of these senses. I hope that you find listening to qiological stimulates your mind and heart and helps you to better help your patients. All right, let's get back now to the second half of the shark. So this is the way you could really teach us. You wouldn't necessarily have to start doing treatments right away. But if you have one of those posters around and someone complains of this, you know, in the process of doing whatever you're doing, you could just, you know, check it out, see what you notice.

Absolutely.

And, and then, I mean, treat, however you're going to treat, I mean, you might want to needle the point, but you might just want to go do whatever treatment you're going to do. And then, and then go back and check what happens if I press on these points later and are they still active or have they, have they changed?

Yeah. And that's, that's how a lot of people end up learning how to treat trigger points. They kind of hear about them. They get one or two resources, even just their websites online that you can go to. I think there's one that's called like trigger point.net that has all of these lists and pictures of all the referral patterns. And just with people who show up in your clinic, you can just start using these resources yourself. But you brought up a really interesting point, which is the. You can do the treatments you would normally do, or you can start kind of incorporating how you would affect particular muscles with the techniques you already know how to do and do those techniques and then palpate and recheck. And that's the thing about the trigger point work is that the changes should be immediate. And you're looking at trying to find an immediate decrease in the sensitivity of the tissue and a decrease in the referral pattern, uh, sometimes within seconds of, of doing it. And this is, it's not a subtle thing. It should be a pretty obvious, but change that doesn't require too much of interpretation on your part. I mean, I think with

any of these palpatory findings, whether it's subtle or the more gross type that we're talking about now, the great thing about palpation is that we can use to check our.

Yeah, that's, that's just absolutely vital, especially for orthopedic conditions and musculoskeletal conditions. One of the interesting discussions around trigger points, even in the Western medicine field is the discussion of, of what is causing them to begin with. Basically, the, there are different schools of thought, but they basically come down to whether or not the, the trigger point is a problem specifically that local to the muscle that is not dependent on it being fed by a problem. I coming from the nervous system versus people who feel like it's really a problem ultimately, of the nervous system and that the, either the peripheral nerves, um, or the central nervous system are what is causing the trigger points to form. And depending on what your take on that is, it's going to change how you. So there's

one school of thought that says trigger points are the cause. And there's another school of thought that says the trigger points for the effect,

uh, kind of, yeah, basically. And so the trigger points by saying the trigger points are the, cause what I'm saying is that when trigger points form, they can form because of muscle overused, muscle overload, there can be endocrin or other changes, basically anything that interferes with the energy supply to the muscle, but the ones that trigger point forms, it is kind of its own physiological or pathological entity there's things that are happening in the muscle itself that keep. Continuing, but the other schools of thought, for instance, the intramuscular therapy by Chon gun, they say, well, the trigger points in muscles form because there is, it's basically like a ridiculous apathy. So there's some compression of the nerve roots at the spine. Often from like tightening of the paraspinal muscles. It compresses the nerves in a certain myotome. So for instance, with the infraspinatus, maybe C5, C6 nerve roots, and that causes a pathological functioning of the muscle that manifests as a trigger point. So in that case, you can treat the muscle itself, but you also have to treat the spine. So the muscles around the, so back in those cases, they need to what we would consider like the Quatro Jaji points at the effected spinal level. Yeah.

I mean, we're talking root and branch here. Right?

And so the, the difference in the two ideas is that, you know, when the trigger points are being caused by something else so that the trigger points are kind of more of a. Have an effect or a branch than the actual cause then if you treat the, cause the trigger points should go away. And that means you could do any kind of distal type of treatment, whether it's like a sheet cleft point on the same channel that the trigger point is on. Like you could use small intestine six to treat the trigger point in infraspinatus, right? And that often works very well, especially for trigger points that aren't, that deeply entrenched. But once they get to a certain point, then they become more. What we would really consider blood status in Chinese medicine, as opposed to cheese faces with blood. Stace is one of the, one of the ways of differentiating between those two that I learned from that Callison is it with bloodstains that you have to do something locally in the tissue, once there's blood status there, you have to get in with the needle into the actual blood Stacy's itself, or you do guash or you do moxa, whereas things that are just cheese stagnating. Tend to respond well to distal treatment. So you can do like needling a Juul point on a muscular, uh, senior channel or muscular tendinous channel. And that can clear it up. But once they're at the blood status, you have to do something locally. And the trigger points often are this kind of blood status and physiologically. They are, there's actually a restriction of blood flow in the area because of the tightening of the muscle. If all of your treatments that you normally have available to you are just distill treatments, just channel treatments. And you're not, you don't have some way of addressing really tight, local Oscher points directly, which mean most active punctures do. So I don't, I can't imagine that really be a problem for most people, but there are going to be times when the distal treatments or if you're doing like the balance method, which I love, um, Richard tan stuff for the master, Don points, some type of distal or far away treatment. Okay. It can be really, really helpful, but there are times when you still have to go in locally with trigger points and, and disrupt the feedback loop. That's keeping the trigger point active busted up. Yup.

The shop with us here. We were talking about somebody with, with hand pain. Maybe you trace it back to the shoulder. What do you do to resolve it? I'm I heard you say you could needle. You can squash shot. You can moxa it. Fill us in a little bit on this.

Okay. So I can actually use a really interesting case that I had a number of years ago. That's can be a little bit more of a complicated one, but it kind of shows the range of things that you can do. So I had a patient come into my clinic, probably about six or seven years ago who had really bad shoulder pain and arm pain, following a very bad motorcycle accident. He was thrown from his bike and his scapula was shattered into about seven pieces. Reconstructive surgery has scapular had all these bolts in it and all this hardware that he'd had in there for a long time. There's probably still hardware in there actually, when he came to see me and that had been maybe a couple of years before I saw him, the problem was really a traumatic injury to the shoulder itself. I wasn't worried as much to begin with that, you know, is this like some guy who sits at a computer all day and he's got problems in his shoulder from poor posture, whatever. So I start palpating and sure enough, he's got incredibly active trigger points all over his, the infraspinatus supraspinatus, the cherries, minor, uh, cherries, major the rhomboids, the levator scapula, trapezius, the middle and lower and upper trapezius, all the muscles in that area. And so I did okay. I thought to myself, this is great. Cause I have a definite local problem where I can really focus on clearing up the local tissue first and not worry too much about the complexities. All the other compensations that have happened until we start making at least a little bit of headway with the local blood Stacey's problem. So I started with doing some manual trigger point releases. So I'd find really tender spots in the muscles around small intestine, 11, small intestine, 12, 13, all the outer UV points around the rhomboids and the, the middle and lower trapezius. And I would find these points and I would do a lot of manual therapy on them and I do train off and it would either not help or actually make things worse. And so then I thought, well, let me just I'll let me needle them. Uh, maybe the manual therapy is a little bit too intense because the manual therapy is no treating trigger points. You're actually pressing into the point enough to really cause a fair amount of discomfort and you hold it until the discomfort goes down. Um, it can take 30 seconds to like a minute and a half in those cases. And for sensitive patients, they can be sore afterwards for days. So that will let me just do some needling. So I did some needling and not very aggressive needling, like the way that you do the quote unquote dry needling, where you're repeatedly lifting and thrusting the needle, but just finding the tender spots, putting needle in the tender spot and just letting it rest. And I would do that. And again, that would either not help or make it worse following the treatment. And I did a bunch of other things where I finally realized was going to put the most helpful thing for him was to actually do rice grain moxa on the trigger points that I found as if I was needling them. So I would do maybe five cones of rice, grain moxa on the trigger points. And that was what kind of turned the corner. And all of a sudden started recovering and all of his patients. Um, he started getting much better range of motion in the shoulder, but for him, it was still important to actually treat the Osher points and the trigger points in the area that were causing the pain in the front of the shoulder. And he was having pain down the arm, but it was the specifics of the technique that I was using that were really making the biggest difference. The needling was too much for him. The manual technique was too much, but the, the heat from the moxa and the blood moving quality of, of the Makso were really what was necessary. Yeah. It was actually

more deficient than excess there. I mean, when I hear using pressure, you're going to go in there with your fingers. You're going to break it up. Didn't help or made it worse. Needling, you know, again too much, but a little bit of rice screen mocks. I mean, I'm thinking to myself, guys got this injury from motorcycle accident. He's all bound up, you know, I'm thinking, God, you got to get in there with blasting caps, but it was actually the opposite.

Wasn't it? Uh, yeah. And so you can look at that a few different ways. In one sense, you can look at the mock sta as a more kind of a warming tonifying treatment, but I was really doing rice grain mocks, and trying to be trying to use it the way I would use needles and the thing with really chronic injuries like that is that what ends up happening, especially if treatments just don't work the way that you expect them to, um, or maybe they get better briefly, but it keeps coming back as there's usually an element of deep rooted cold stasis that is causing this continued contraction. And so part of me was using the moxa to help try to. Heat kind of deep into the area because you know, that rice grown has this very penetrating heat. So it wasn't

excess condition after all.

It was definitely, it was local, excess, but then, you know, you get into that, that thing that we have to get into as, as acupuncturists, where you have to figure out what, what layer is excess, what layers deficient, and you can have multiple layers of excess and deficiency. Um, and with chronic pain like this, you know, there's that phrase from the name Jane who combed your tongue. tons of blue pong. If there's no free flow, then that's what pain is. If there's pain, then there's a lack of free flow. And so at some level with pain and TCM, we're always looking at stagnation. But with the interesting thing with looking at trigger points and muscles is we kind of have to do the same thing, that there are types of pain coming from muscles that are coming from the muscle. Not functioning well, they're, they're weak, they're hypo. They, they lactone. And you can have people who are kind of hyper mobile and very loosey goosey, but still have muscle pain. And you're gonna have people who are really tight and have excess tension in the muscles and excess trigger points. And they can also have muscle pain and the treatment for those two different types of people can be very different, even though both of the treatments might involve releasing trigger points. Because if in the case of someone who is, who has low tone and is hyper mobile, they're going to have trigger points and muscles that especially tend to stabilize joints because the muscles are having to work extra hard just to keep joints stable. I've had a lot of patients like this.

We probably see people like with Ehlers Daniels syndrome who have that kind of thing. Right. You know, they're, they're like totally loosey goosey. And then they've got these trigger points. Cause they're their muscles, her trying to make up for what their tendons won't.

Right. And so the important thing in cases like that is figuring out, okay, how much of the treatment do I want to do as a, kind of a dispersing treatment, trying to get the trigger point to relax, or do I want to just do things to focus on strengthening the deficiencies? Because the trigger points in the muscles may be the one thing that's kind of keeping the joint stable. That's the really interesting thing about working with muscles and trigger points to, well, the interesting

thing about doing Chinese medicine, that we have this particular perspective, you can have things inner woven as deficiency and excess. And we have to be clear about what is, where if we want to get somewhere with it. Now, I want to take just a little sidetrack here. Cause I know that you've done some study with, for lack of a better word, dry needling, or the intramuscular therapy to these folks. Talk about sufficiency and excess, the way that we do. And if not, how do they make sense of these kinds of complex situations?

They talk about it. In the broader context of orthopedic assessment. I just took a class about a month ago. It wasn't a trigger point class, but it was a class full of about 80 physical therapists. It was a particular way of assessing and diagnosing movement and structural disorders in the body. So it's kind of a screening method for a, you look at someone how someone moves a few basic movements. You have them touch their toes, you have them kind of rotate left and right. They've moved their head. And then if they have particular problems with a certain gross motor movement, you kind of break it down and figure out, okay, is the, if they can't reach down and touch their toes in a way that's healthy, is it coming from tightness in the hip? Is it coming from a hamstring tightness? Is it coming from a lack of motor control of their core? Is it a lack of motor control of the hip flexors that they kind of don't know how to fold at the hip? Do they have stiffness in the upper right. Or a stiffness in the lower back. That's not allowing your spine to then normally. And all of those types of diagnosis come down to figuring out how much of their problem is coming from what we would call excess like stiffness and a movement dysfunction. That's coming from a tightness and how much of it is coming from what we would call a deficiency, which in their world is a stability or a motor control issue with like their body doesn't know how to function normally teasing out. What part of the problem is a mobility dysfunction with stiffness and how much of it is a stability dysfunction of a weakness. And interestingly in their world. Also, they find that it's most important to treat the, the stiffness and the mobility dysfunction first. So if someone has weakness in an area like they have weakness in the rotator cuff muscle, the infraspinatus is weak. They have trigger points in the infraspinatus. If they have stiffness in the thoracic spine. So the rib cage and thoracic spine, they're really stiff and doesn't move very well. You actually have to treat that before you treat the weakness further out in the limb because the stiffness, the excess in this case is going to create the deficiency further out. So that's not dealing with trigger points per se, but that is in the general wheelhouse of, of certain types of orthopedic medicine, like in, especially in physical therapy, but in terms of the trigger point classes that I've done with them, it's not as obvious. There's not as much of a distinction between that. There's just the trigger point. The muscle is either has a trigger point or not. The subtlety from their perspective comes from looking at all the various factors that can be contributing to it. Because some of them, if it's like overuse of the muscle itself, we would consider that more kind of an excess there's tightness in the muscle because the. Overusing it, and it tightens up in response. But then from the Western medicine point of view, trigger points can also occur from psychological and emotional stress. They can occur from bacterial and viral infections. They can occur from metabolic disorders from like, you know, diabetes or hyperglycemia from lupus. All of those things can also contribute to the formation of trigger points and muscles. And so in those cases, you have to address those underlying factors like sleep disturbance, for instance. So those are cases where you wouldn't necessarily go in from the Western point of view and just noodle the trigger points, because they're going to keep coming back and forming because you have this other engine that's driving them that may have nothing to do with the actual excess in the muscle itself. So in that sense, I wouldn't call it excess and deficiency the way that I have some

ways of getting a bigger sense of like the texture of the product. How the thing

hangs together. And actually if you read Trevell the books that she wrote, and even if you just look up some of the quotes, um, from her, uh, she was really pushing very hard back in the sixties and the seventies, even to really look at the entire person because looking at trigger point. So Trevell was a cardiologist. She went to medical school in the twenties at like Columbia university. I think one of the very rare for women to graduate from medical school in like 1927 or whenever it was that she graduated. Um, but she very quickly in the thirties became interested in muscle pain and muscle dysfunction in the process of looking at some of the studies from the 1930s by California. Uh, like muscle referral patterns and muscle pain. She started getting interested in muscle dysfunction and started really also looking at all the various factors involved in producing muscle dysfunction. And she really was stressing a lot through the, through the I'm assuming to the fifties, but at least in the sixties and seventies, how you have to look at the entire person and not just focus on the dysfunctional muscle. And a lot of her, the things that she would say back then sound like they're right out of the traditional Chinese medicine text, that it's, you have to look at their emotional health. You have to look at how their, how their bodies fit into their environment. Like if someone has short upper arms, right, their humorous is a little bit shorter than average. Like if their elbow doesn't quite reach down to their iliac crest, when they're sitting in a chair that has arm rests, if their arms are too short, they're going to constantly be having to kind of lean forward to rest their elbows on the arm rest. Instead of being able to stay more upright and that's going to do. Trigger points in like the suboccipital muscles and the trapezius and have this head forward posture, but it's not just from the problem in the muscles. It's from the way that the person fits into their environment. There is that idea in the Western approach to trigger point therapy that is looking at the whole person and not just focusing on the problem in the muscle. But I think that usually gets probably lost in the discussion because with when you start talking about trigger points, everybody focuses on the local muscular problem itself, and it can become even, you know, as a, as an acupuncturist, I know acupuncturist myself included to go through a period of time where once you learn about trigger points, it's such a compelling and powerful clinical tool that you just get really hyper-focused on that. And it takes a few years until you start being able to expand your perception and your awareness, and start looking at all the other factors involved and not just be obsessed with the results you're getting. Like needling tight muscles.

Well, and of course we love it when we get good results and we want to keep doing more of that because it helps people and we like to see them help and, you know, and then we feel good. And we like that. I'm struck here listening to this bit of history. I didn't realize that Janet Trevell graduated in the twenties. Holy smokes. She must've been an amazing character to, first of all, get into medical school and get through it back in that time. But once a hear how she put this stuff together, you know, through her own observation, through her own work, put together something that like you said, this sounds like something right out of Chinese medicine. How does a person fit into their environment? If I just took one thing away from our discussion today, how does this person fit into their environment? If I just took that away today and started really looking at that with my patient. Holy smokes. I bet I'm going to notice all kinds of things that I was blind to

before. Well, Trevell was really fascinating because, you know, she ended up becoming the personal physician of John F. Kennedy and she was appointed the white house physician really first. Yeah. The first woman to ever be in that position. So she was like the Imperial doctor. She was, and you know, Kennedy was not a healthy man. I've got the name of the condition that he had, that he was diagnosed with as a young boy, but he had all sorts of problems and he had a series of physical injuries. He had a series of like four back surgeries starting from like a football injury when he was in college. And then he was in, uh, in world war II. He was in one of the boats that got ran by a Japanese ship. There's a movie about it, really famous world war II movie. That was the story of Kennedy. Anyway. So his, his, you both got rammed and most of that was a PT boat, PT boat, sorry. It was a PT boat, PT 1 0 9. Right. I think that was about Kennedy, right? And so he had this, he'd had a back injury before and a couple of surgeries and then his PT boat gets hit. And he actually saves one of his crew members by keeping them from drowning and like swimming for five hours. And that completely screws up his back. And he has series of other surgeries later on to correct problems from the first surgeries and infections Trevell was treating him with a number of different things, but she was also treating trigger points and muscles. And it was actually a letter from, uh, Robert Kennedy to Trevell that you can find online that the text of which basically says, I think he's the letters to someone else it's not to Trevell it's to Johnson or someone. And he says that, you know, president Kennedy is doing well under the care of travel. If it wasn't for her and for her work, he would probably not be president of the United States right now. So she was a really pivotal figure. And then the, one of the theories about why trigger point theory really didn't catch on until really recently, it was kind of overlooked for decades was because when Kennedy was shot, she didn't stay on very long after that as the white house physician. Whereas if she had, and if Kennedy had not been assassinated, a lot of her ideas about the importance of looking at muscles probably would have spread through the medical community much more and be given a lot more importance, but there's a whole very interesting series of reasons why trigger point theory, even though it's a Western medicine idea is really, really overlooked and why we as acupuncturists in some ways are in a really good position to be able to address this in a way that a lot of Western people in the Western medicine field of pain management. So I want

to come back to this thing about language, cause there's, there's a lot of, you know, I mean there's conflict, right? Between acupuncturists and PTs and you know, we've got our ways of thinking about it. We kind of bristle that, that they're using a more scientific language to describe something as well. It occurs to me that our patients actually, they don't care about whatever languaging anybody's using, but here's what they do care about. They care that they understand what's going on for them, and they care that their doctor gets them so to speak. And I'm all about thinking with our Chinese medicine mind, but it seems that if we go always speaking, our Chinese medicine mind, it doesn't help people to understand how we might be able to help them. And I, it seems to me that the folks that are doing the dry needling and these other therapies for that matter. You're doing a great job of using Western language Western thought that, you know, that overlay, that you know, that we all have, that we grew up with and speaking it in a very holistic, connected

way. Yeah. And to take it back to something, we were just talking about a couple of minutes ago, you can look at not only how well is the patient fitting into their environment, but how well is the practitioner fitting into their environment? Right, right. Yes. As a practitioner, if you're speaking in a language that's alienating your patients or, or almost as bad, but not in the same way that is misleading your patients and getting them excited. But for the wrong reasons, like, just because they love esoteric terminology, then that can really have a detrimental long-term effect on even, I think you as a practitioner, because you know, having a really clear type of communication between you and your patients and your patients having an underlying. Fundamental sense that, like you said, you know, you get them, that's just invaluable. Even when you have patients who you think you're not going to be able to help because you have an idea of something that's wrong with them and it's outside of your area of expertise. I can't tell you how many people I've had. Who've called me up and talked about, they wanted to come in and have an appointment with me and just talking to them over the phone. I can tell that I'm not the person they need to see and that I I'll refer them out. Either tell them to, you know, you need to go see, uh, a good physical therapist or you need to see another acupuncturist. I've got colleagues who are good herbalists who really gonna match better at treating what you have going on. Then, you know, the type of verbalisms they do as much more geared on what you have going on. Then the herbs that I use or the way that I look at herbs and people are so appreciative of being taught to clear. And having things explained to them in a way they can understand. And that really is one of the reasons when I teach at school, that I really focus on a lot of the Western stuff. And the trigger point stuff is because it gives the students vocabulary that they can use with patients that will just really have the really help the patients to feel confidence in the student as a practitioner, because they're using words that make sense to the patient. And that really reflect in a lot of ways, the subjective experience of the patient, because all of our patients were coming in there. They grew up in this culture. And so most of the patients are thinking in terms of their muscles. Tendons and ligaments and nerves and all the other nerves. Exactly. And they've been probably been given three or four different diagnoses for their problem. And so being able to navigate the various diagnoses that the patient has and explained to them why you think this one might be right, this one might be wrong or not wrong, but why you think though, these other things we can look at that haven't been addressed by the doctor that you saw, or the chiropractor or the PT who were looking at trigger points for whatever reason. Yeah. Patients really usually express this, this really profound sense of relief and gratitude that someone's finally getting to the, to the problem. And then once you actually start palpating and you palpate the trigger point and you recreate their pain, I mean, it's over and over again. And I try to make sure that the students have this experience as well. The patient says you're the first person that's actually gotten to where I feel the problem. No. And that comes from understanding how to get into like some of the deep, hidden fibers of certain muscles and understanding if someone has pain in the front of the shoulder, the problem could be coming from the back of the shoulder and like patient that's really, to me, that's the Osher point where the patient goes, not just like, oh, that hurts, but that's the, that's the focus of my problem. Right.

I love that definition. I had not thought of an usher point as this is where the problem is. I've always thought of it as, oh yeah. It's tight. It's tender. But that, that gives a whole different perspective on what an Osher point actually is.

Well, at least what it could be, you know, it's, it's hard to say, like what was going on in the minds of the people originally, who said it, but like, for me, that's the significance of it is that when you find the right spot, that especially when it recreates their pain far away in their body, like you press on small intestine 11 and they're the risk lights. Um, and they go, ah, that's the spot it's like, they literally say that. Right. Ah, that's it. They literally say that. And I think that's really cross-cultural and that's a really satisfying way of practicing. And so it will, for the patient, it's really enlightening because they finally have that feeling after having been through several different diagnoses and a bunch of different doctors and pain specialists and maybe orthopedic surgeons and manual therapists and massage therapists. And you're the first person who's looked at that particular thing and they go, okay, finally, someone gets it.

You bothered to put your hands on and you used your hands in a way that led you to where, to where the issue was. Exactly great. Well, Dr. Alana, it's always a pleasure.

It is always pleasure for me to Michael. This is really so much fun. If

you have any, uh, resources that you'd like to share with the listeners, just send that stuff to me and y'all know I'll put it on the show notes page for. Pop on over to qiological and it'll be waiting for you. Cool. I will do that. All right, man. I'll see ya.

All right. See you later.