hands-on practice aimed at eliciting a feltsense in the patient.

I. Acupuncture Know-How and the

Bodily Felt-Sense

Reflection Seven: Acupuncture

Needling & Tacit Knowing

This way of teaching and learning implies

internalization of skills so that they can be
replicated, in a way that is as immediate, and
mindful, as possible, without thinking about
them: embodied learning as Confucianists
would say.

THE PROBLEM:

At the same time that I was busy focusing on
the best ways to teach the APM approach,
which included extensive training in Travell
and Simons approach to myofacial pain and
trigger point referral patterns and TrP point
location and myofascial release, I tended to
emphasize the physical medicine side in a
way such as to lead some students and some
faculty to see my approach simply as trigger
point acupuncture, based mainly on Travells
trigger points and dry needling techniques to
release them. It took me several years to
realize that APM was being stripped of its
original classical Chinese jingluo way of
practicing. While I never stopped practicing
that classical way, and merely added
knowledge of trigger points and a needle
technique I modified for acupuncture
needles that allowed a far more shallow, wei
level depth for many points, this focus on
trigger points, and of this techniquewhich
takes some time to get a grasp of, diverted my
attention from what was being lost. I turned
my attention, once I realized this, to teaching
students how to perform needling, starting
not with TrP needling techniques, but with
classical tonification and dispersal techniques
to distal points of the regular meridians and
at mu and shu points of the front and back
in Year I. I also stress these classical needling
techniques as well as trigger point dry
needling throughout Year II APM/CCA
ACP sessions, and in my Grand Rounds and
Year Three clinical supervisions. This return
to classical regular, secondary and
extraordinary meridian needling techniques
brought with it a return to what was most
critical in the practice of acupuncture as a

Clinical supervisors at the college expect any

clinical intern to be able to articulate the
reasons for their APM/CCA treatment plan
(and again I am only sharing what I know
best, namely the teaching of the APM/CCA
approach, not the Japanese and TCM
approaches which are taught in their own
ways by other clinical faculty teams), citing
the evidence from the signs and symptoms
gathered in the four exams, based on the
APM/CCA foundational texts, that lead to
the working diagnosis, treatment principle
and plan
But during the physical examination, and
again once the treatment has been approved,
the 5 steps of APM/CCA treatment should
be done from a mindful place where tactic
knowledge on the part of the clinical interns,
and evocation of the bodily-felt sense, and
meaningful signs of change in the patient,
drive the way in which the treatment is
conducted.
Tacit Knowing
At one point in the development of the
teaching at the Tri-State College of
Acupuncture, I was struck by the fact that
while there were a small number of students
who could learn immediately from me how
to palpate the body, how to locate
depressions where acupuncture points were
located, how to locate tight constricted areas
in the musculature where excess areas were

located, and could just as quickly learn how

to needle these excess and deficient areas
with very little discussion just by watching
and doing, there were many, many more
students who seemed to need to have much
more explanation, much more theory, much
more explicit explanations of what was going
on. This was very bothersome to me and led
me to consult a prominent New York
clairvoyant who in an early session shared
with me what she was picking up, namely
that I appeared to be someone who knows
what I knew in an instant, who in doing what
I do takes in the whole and knows whether
or not that whole feels like it is accurate. It
was a strange meeting, a strange interaction,
but it led me to start looking very carefully at
how I and other faculty were teaching clinical
skills at the college, how we were teaching
theory, the texts we were using, the outcomes
our students were exhibiting.

not a diagnosis, this was not a running

through of differentiation of signs and
symptoms in our head, this was not an
explicit activity, this was not an activity, in
fact, that we could even say to each other,
and we found it very hard to be explicit and
articulate about what we were trying to share.
What we discovered was that, much like what
the clairvoyant explained to me, we were in
fact trusting a kind of knowledge that came
to us tacitlyknowledge we could feel,
knowledge we could see, a kind of know-how
that just seemed to come, obviously informed
by our study of acupuncture and Oriental
medicine, meridians, point locations,
diagnoses and needle techniques. We realized
that in the doing of acupuncture, in the
practice of acupuncture we made no use of
academic or intellectual activities to come up
with our treatment but rather seized on a
treatment, or rather seized on a moment,
where we felt that we had a sense of the
problem for that patient, and having a sense
of that problem already had a feeling that
certain acupuncture patterns, combinations
of points, treatments we had done in the
past, would be a good place to begin.

In this process, I engaged in several

experimental activities with colleagues,
among them Bryan Manuele, Co-founder
and then Director of the Midwest College of
Oriental Medicine in Chicago, Illinois. Once,
while I was in Chicago, we shared the
experience of treating patients while
watching each other at a distance without
intervening. The challenge was to see if we
could tell when in the interview our
colleague had a sense of what the diagnosis
was, what the treatment was going to be, and
whether or not, at that moment, he had an
explicit awareness of signs and symptoms and
differentiations, the meaning of these signs
and symptoms, specific acupuncture and
Oriental medical knowledge that he had
gathered together in a diagnostic assessment
in his head and then came up with logical
treatment principals and logical point
selection. Or, was something else going on?
That we in fact discovered, after sharing what
we observed, what we saw, what we felt, what
we noticed, what we took in, was that each of
us seemed at a certain point in an intake with
a patient to have a sense of where we wanted
to go to find a primary obstruction. This was

And so, after quickly palpating the body,

once we had this sense of the problem and
where, most importantly, this problem was
located, we would then go palpate and based
on finding areas of tightness, of deficiency,
perform an acupuncture treatment in rather
short order and know during the doing of
this treatment whether or not this treatment
was moving in the right direction. When we
realized that we felt it was moving in the right
direction, we would let the patient know that
this was great, we would let the patient lie
there for ten or fifteen minutes and would
actually be quite certain that this treatment
would have a positive effect. None of that
process involved intellectual operations that
confirmed a diagnosis, but rather a process
that looked more like reaching deep within
for a familiar pattern of treatment that in
some way matched the patients complaint as
a starting point for navigating the patients

bodymind. This was extremely helpful in the

elaboration of the teaching at the Tri-State
College of Acupuncture and led to the
development of what we call Acupuncture
Clinical Practice (ACP) and Grand Rounds
with Senior Faculty during all three years of
the Master of Science degree program in
Acupuncture.

practice, what was critical in the actual

acupuncture clinical practice on peer patients
first and then on community clinic patients,
was this ability to take in information with all
of the senses, to make sense of all of this
information in such a way as to have a feeling
or a sense of what the treatment should be.
And while we required that students be
explicit in explaining in their thinking,
explaining their treatment protocols,
explaining their treatment strategies and
point combinations to supervisors in the fist
semester in order to have a treatment
improved, the fact of the matter is that when
they observe senior and master practitioners
they often see people performing in a much
different way. That much different way of
performing has a name and was studied in
great detail by Michael Polanyi whose book,
The Tacit Dimension, is comprised of the
Terry lectures delivered at Yale University in
1962, where he developed his concept of
tacit knowledge and laid out the simple
premise that we can know more than we can
say, something that the late Donald Schon,
former Ford Professor Emeritus at
Massachusetts Institute of Technology
continued on with in his development of the
concept of reflective practice, which is
paramount in the clinical training at the
College.

Implications for Clinical Training

In Acupuncture Clinical Practice, which is
now a three-and-a-half hour class where
students begin their clinical training on peer
students and practice as one would rehearse
for a play, or rehearse kata in karate, that
they rehearse or practice full treatments from
three different styles of acupuncture, which
amounts to building up a repertory of whole
treatments that they could apply in given
situations as a place to start. In Year Two
they learn how to begin to modify somewhat
some of those protocols and in the actual
clinic in the final clinical senior year they of
course are helped with supervisors to step out
of the rigidity of protocols, to become flexible
and modify as need be those protocols to
adequately address all of the various
conditions that they are encountering, to
adapt to what they are actually seeing in front
of them, to their patients actual problems,
and to be creative in solving these clinical
problems starting with these repertories of
patterned responses or practiced or rehearsed
protocols that they have engaged in over the
first two years.

The Bodily-Felt Sense

The bodily felt-sense is a term coined by
Eugene Gendlin, PhD, to describe what the
client is feeling when she has what Freud
termed a psychotherapeutic AhHa
experience while, impossible to clearly
articulate in words, indicates that the client
has made, or is about to make a significant
therapeutic leap in understanding. While
Freud felt this had to be followed by analysis,
to state in language what had just been felt at
the deep, unconscious level, Gendlin argued
that the focus needed to just remain on the
felt-sense, and the understanding would

This investigation into how people learned

and more specifically how they were not
learning from going from the rather tedious
attempt at memorization of point indications
from Chinese textbooks, which we fast
abandoned, and even memorization of basic
signs and symptoms of different Chinese
patterns, we realized that while that was a
necessary activity in the lecture classes and
was foundational knowledge that they
needed to commit to memory in order to
have a foundation on which to learn and

follow on its own. Milton Erickson evolved a

similar concept in his approach to
hypnotherapy, where a focus on tapping into
the deep knowledge, the unconscious, was
the goal of treatment, to bypass the conscious
mind and initiate meaningful, therapeutic
changes.

seen from within, and the body, the outward

manifestation if the life of the spiritthe two
being really one (ibid, p. 4).
This concept of a deep wisdom of the body
that is spiritual at its core is parallel to the
Chinese concept of shen and shenming
translated as mind or spirit, and as mental or
spiritual clarity respectively. In the Chinese
concept, which is decidedly pragmatic, spirit
clarity amounts to the wisdom or intelligence
of existence, of being alive. Someone who
manifests spirit clarity, spiritual health, has
eyes that are bright and make contact, a shine
to the complexion, an alertness, a
presentness. This is in direct contrast to
someone whose spirit is marred by the
emotions and who exhibits either a Yang,
frantic, agitated stare, a frightened
countenance, a fired up complexion and
manner of being; or a Yin, empty, vacant,
absent stare, a lusterless complexion, a
depressed manner of being. These sorts of
signs of presence or absence of spirit are part
and parcel of a classical Chinese medical
examination. In acupuncture treatment,
where there are signs of a relative absence or
agitation of the spirit, this should begin to
improve with the first few needles, sometimes
even with the first few words exchanged
between practitioner and patient. On a very
basic level, then, much like in mindfulness
meditation, acupuncture thus seeks to prod a
person who is suffering from pain,
discomfort, distress, to turn toward life, to
embrace life, to say yes to life, by connecting
with this deep wisdom, experienced when it
is attained as a bodily-felt sense rather than
something to be expressed in words, an
AhHa! Life experience that we are all given to
understand all along.

This concept of a boldily-felt sense as a deep,

older form of knowing the world derived
from Nietzsche, who sought to think beyond
the body-mind split articulated by Descartes,
where the human spirit was obliterated, by
spiritualizing the body itself. After arguing
that the Judeo-Christian established religions
were no longer of help in orienting
mankinds spiritual endeavors, with his
celebrated proclamation God is Dead!, he
worked to articulate a new philosophy for
mankind in the coming 20th century, based
on a joyful wisdom, the title of the text
where he developed this concept.
Establishing himself as a diagnostician of the
spiritual sicknesses of his day, Nietzsche
stressed that we require for a new goal also a
new means, namely a new healthiness,
stronger, sharper, tougher, bolder and
merrier than any healthiness hitherto(cited
in BME, p. 4 and for a more detailed
discussion, ibid pages 236-237).
Nietzsche clarified many times in his writings
that such a new, bold way of thinking about
human healthiness, of what was best and
strongest about humankind, could only be
acquired through an active exercise of ones
will, and an active forgetting of old
knowledge that no longer served to shore this
decidedly spiritual quest.
With religion no longer seen as the way in
which humans could embrace their true
spirit, Nietzsche challenged us to take on this
quest personally, willfully, joyfully. Carl Jung
also stressed the need to rediscover the
wisdom of the body, too long a prisoner of
the spirit in organized religious teachings,
and to reconcile ourselves to the mysterious
truth that the spirit is the life of the body

I will address the similarities and differences

between the Western rationalistic and
essentialistic Mind focused on things in their
ever smaller parts, versus the Eastern Mind
aimed at attending to the way things change,
the process of change, a process approach, in
this months BLOG.

To me, as someone practicing acupuncture

for over 30 years, I can just say I do not know
how it would be possible not to touch the
spirit, understood in a classical Chinese
acupuncture way, when one seeks to be
attuned to each patient with the heart and
the mind (Ling Shu p. 17). Elsewhere, the
classics stress repeatedly The key to proper
needling is to first attend to ones own spirit
(Systematic Classic, p. 295). The first chapter
of this classic, in fact, is all about the 5 Spirits
and about the fact that when Qi arrives,
when Qi is obtained, the spirit may also be
touched, and so each needle must be
manipulated with great awareness of this fact:
One should remain calm and intent at all
times, observing the response to the needle
and awaiting the arrival of the qi. (The
response of qi) is said to be mysterious,
subtle, and without form. The appearance (of
qi) is like the soaring of flocks of birds or
swaying of millet in the fields, which, though
perceptible, cannot be discerned [] As if
perched above a fathomless abyss with ones
hand grasping a tiger, (when holding a needle
the spirit must not be distracted by anything)
(ibid, p. 296)

While mindbody medicine has become a

main field of CAM practice, in many
different forms, the bodymind versions of
this medicine have been downplayed. The
fact of the matter is, in the research on
Indian yogis conducted by Dr. Herbert
Benson at Harvard decades ago, too little
stress was place on the fact that these Eastern
practices were PHYSICAL disciplines.
Through a disciplined use of ones body, and
ones breath, it was possible to achieve
spiritual health. There was very little mentally
going on, except for developing a patient,
and mindful stance toward thoughts as they
would inevitably flit in and out of awareness
as one sought to practice Yoga, Tai Qi,
QiGong, or Mindfulness or Transcendental
meditation 40 years ago on this continent.
Why, then, was this referred to as mind-body
medicine, when in fact it was fundamentally
bodymind through and through? This is why
I chose the title bodymind energetics for
my first serious attempt at explaining what
acupuncture was in the West, and had to
keep correcting my editor as well as those
who wrote about the book when they would
correct it to read mind-body or at best
body/mind.

One does not have to keep talking about

spirit to practice the high skills of
acupuncture, but rather dedicate oneself to
mindful practice and practice this in everyday
life so that mindfulness becomes a part of
being with a patient. This is the topic of the
all future Reflections.

While the concept of bodymindspirit

which derived from the New Age Movement
in the 60s in this country was a way to avoid
the mind-body or body/mind split way of
discussing what is human, in the
acupuncture world this has lead to a certain
tendency to criticize any approach to healing
that fails to add spirit to the title as
deficient. Frequently over the past 30 years I
have had some students and some colleagues
criticize my use of the term bodymind (rather
than bodymindspirit) who would go on to say
I was good at treating the body, by which
they meant symptoms but could not treat
the whole person. Even Integrative
Medicine stresses treating the whole person
including the spiritual side.

II: The Way of the Needle

So now lets talk about how acupuncturists,
senior acupuncturists, master practitioners
are at one with the needle. When
acupuncturists pick up a needle, as opposed
to students who are just learning to needle,
they are not focusing on the feeling of the
needle in their hand; they have already
developed the skill of being very adept at

loosening the needle from the tube if its a

Japanese style disposable needle, and this
implement is just a part of their hand, not
something they have to think about for a
moment, and of course that is something
that only came about with practice, by
learning how to hold the needle in a graceful
way so that the needle and tube become one
with the hand. And so when an
acupuncturist, a senior acupuncturist or a
master practitioner picks up a needle, they
are not attending to the needle, they are not
attending to the tube, they are attending to
the point on the body that they have located
visually, or by palpation, and if visually, will
then go to the body and palpate to find the
point and in acupuncture physical medicine,
in classical Chinese acupuncture, in Japanese
meridian therapy, these points are moveable
points. These points are not textbook rigid
point locations. Rather these are things that
can be felt. So an acupuncturist who works
from a palpation based approach and who
trusts the tacit knowledge in their fingertips,
trusts what they see and feel and sense
through their hands. She will look for a point
and once finding a point, attending to the
point, will use the needle, which is just an
extension of her hand, to go into the point,
to search the point, to search the Cave,
(one of the meanings for the Chinese term
that denotes an acupuncture point). She will
search for the active area, for a certain kind
of sensation, a certain resistance, a certain
stuck feeling, a certain heaviness, a certain
denseness, depending on the kind of point.
When she feels this, through the tip of the
needle as an extension of the fingers feeling
this reaction, they she can apply the tonifying
or dispersing needle techniques to make the
tissue respond in the way in a disciplined and
predictable way. This happens through
practice, but all senior acupuncturists do this
effortlessly, and if they were to instead attend
to the minute mechanical and muscular
activities that their needling hand is going
through as well as their non-needling hand to
make the tissue respond in this way, they

might very easily become crippled and unable

to function.
That being said, where Schon goes I believe
further than Polanyi or, lets say, is more
pragmatic than Polanyi in the education of
professionals, in his idea of a reflective
practice and a reflective practicum with
senior practitioners. If ACP and clinic
supervisors, as well as students, were to pay
close attention to how senior and master
practitioners stand, manipulate the needle,
move their hands, they might be able to at
times watch students who are in ACP
training, look at how theyre using the
muscles in their hands, the muscles in their
forearms, their posture, their stance, whether
they are sinking into the tantien or held
tightly and rigidly, whether or not their arm
is strongly engaged or very weakly positioned
over the patient, if they are able in fact to
notice and attend to what they usually do not
attend to they may well be able to make
changes in the actions or practices of these
students in training that will make them be
able to indwell more quickly and more fully
in the needling process, and make the needle
an extension of the students so they can feel
and attend to what is underneath the tip of
the needle rather than what is held between
their fingers.
Ive been looking at this carefully, and this is
only my way of needling. There are many
different ways of holding a needle, using the
needling hand and a non-needling hand.
Mine are based on very classical descriptions
of these techniques, but these are just my
efforts, my way of making these techniques a
part of me, a part of my body, an extension
of my body, something that comes second
nature. So, recognizing that there are many
ways to do this, first of all, I believe that what
is critical in needling, if we now look at these
minute mechanical actions, is to see the wrist
as the pivot. The wrist is not rigid. Many
students needle either just with their fingers
trying to use it in a very tight way, almost like
children who are first learning how to write

with a pencil, which they grip far too tightly.

So what we need to do is help beginning
students have a very relaxed wrist. The wrist
is relaxed and the movement is fluid. So if
one keeps the wrist relaxed, the fact of the
matter is, if we look at the forearm muscles
while were doing this, if we were to do a
soaring crane type of movement with our
hand where we bring all of our fingers
together and then touch all of our fingers,
the pads of all of our fingers touching each
other toward the thumb, then the fingers
become a small pointed beak of a bird. And
if we now were to keep our wrist very fluid,
moving it first inward then extending it
outward, flexing it, extending it, moving it to
the right and the left very loosely, we can see,
if we look at our forearm muscles, that our
forearms muscles are very much a part of this
movement, even if the movement is small. So
if the reader tries this, moving first this hand
that has fingers that are very engaged
together, not hard but definitely with force as
if one were going to begin striking something
as in martial arts, this engaged hand also
involves engaged forearms, and in fact as I do
this and feel I can see that I am not engaging
the muscles of my upper arm, I am not
engaging the muscles of my shoulder, I am
not engaging the muscles of my chest, but all
of those musclesthe upper arm, the
shoulder, the chestin fact have settled into a
very strong position where they can hold the
forearm and hold the hand. So the posture
has to be erect, the shoulders have to be level.
The body can do this forever, the whole body
is strong, the stance is balanced, one foot
somewhat in front of the other or shoulder
width apart as in Qi Gong for example, or
Tui na massage, and in a strong stance like
this, with the whole forearm supported, the
forearm and especially the hand with the
help of the fulcrum of the wrist is able to
engage in such a way that the motion, either
flexing toward the patient or extending the
hand away from the patient is a strong
movement and is not just a movement from
the fingers and is not a rigid movement from
the whole arm.

So if we look at this for a moment, well see

that in the first instance of tonifying needle
technique, which is first slow IN then fast
OUT, if one imagines holding a needle, or
holds a toothpick for example, and starts
moving in a big movement in flexing the
muscles, the forearm flexor muscles are very
visibly activated. And a teacher coaching a
student in this technique could easily just go
ahead and hold the flexor muscles of the
forearm and make sure that the student is
engaging them, so that if the student is just
using the fingertips in sort of a rigid way that
is not using the forearm, the teacher as coach
could say to the student, just let these
muscles work, do this all the way from up
here, do this from the flexor muscles all the
way up at your elbow, use the entire muscle.
That will help them focus on the in and by
doing that, in fact, as Ive found in practicing
on myself, just the contraction of the forearm
muscles holding the needle in place creates
quite a strong sensation when done properly
because it is adding weight and force to the
needle on an inward movement, because the
wrist is allowing the heaviness of the hand to
move inward, to flex, and the movement is a
movement that is heavy on the in. I always
tell students when I am teaching this
technique, heavy on the in, because the
focus is on the in. It is an engagement of the
forearm muscles with a supple wrist. And the
final thing that is important whether
tonifying or dispersing is that the fingers are
together just as they were in this flying crane
technique. All of the fingers ideally, or at
least three of them, the index, the middle
finger, and the thumb, are holding the
handle of the needle, not pinching it, the
skin is not blanched, the nail beds are not
blanched, holding it very lightly in fact, and
the force that is holding the needle and the
weight that is in the hand, coming first from
the flexor muscles of the forearm is generated
through to the point, Large Intestine 4,
which is the first dorsal inner osseous muscle,
and that muscle is fully engaged. Many
students have trouble with this. If one

pinches the fingers very hard, that muscle

becomes engages and we can see that it
becomes hard. But that makes the needle
sharp, rigid, a piece of metal instead of an
extension of the fingers and of the whole
lower arm. So in releasing the grip on the
needle and having the fingers holding the
handle of the needle very gently in order to
prevent this from being a sharp technique,
the action during tonification has to come
from the flexor muscles, and the first dorsal
inner osseus muscle, at Large Intestine 4,
which has to be fully engaged, which creates
weight down through the fingers, through
the index and middle finger and thumb, and
this weight creates a reaction in the needle
that makes the subcutaneous tissue respond
in a characteristic way to grab at the tip of the
needle. Its a heavy motion that causes a
heavy slow response, not a fast response. This
is a slow in, slow response of the muscle,
even though the needle is only into
subcutaneous fascia. The Japanese often refer
to this as needle grasp.

forearm muscles, so its exactly the same use

of muscles as for tonification, but its done
quicker. And this kind of quick movement
causes a fast grab of the muscle, and the
fascia deep beneath the needlea fast
reaction rather than a slow one. And then,
still using the wrist as the pivot, one now uses
not the flexor muscles at all, but the extensor
muscle of the forearm on the top of the arm,
the yang aspect of the arm as opposed to the
yin flexor aspect. One uses the extensor
muscles, the extensor of the index, ring, and
middle fingers in the area of Large Intestine
10 and what Kiko Matsumoto calls Triple
Intestine 10, so on the triple meridian at the
same level as Large Intestine 10. If one feels
there, and as a coach if one feels there,
instead of engaging the flexor muscles, one
engages the extensor muscles all the way up
to the elbow, using the wrist as a fulcrum,
still keeping the fingers engaged, grasping the
needle lightly but with very engaged hand, a
strong hand, a hand that if somebody came
to hit it away as in martial arts, would be
there, stay put, a hand that is present, fully
engaged, weighted. So now, with the same
grasp on the needle, with the same
engagement of the Large Intestine 4 areas,
the first dorsal inner osseus, one simply uses
the extensor muscles which the teacher, the
coach, could but their fingers on, and with
the wrist as a pivot engage the extensor
muscles which creates a heavy focus on the
out. And the out movement should be slow,
so the extensor muscles are used very slowly
after having quickly gone into the point to
create a quick grab. And it is important that
it grab. If it doesnt grab, one goes out slowly
and then in rapidly again several times and
then out slowly again.

The classic texts describe this as a very gentle,

almost imperceptible manipulation:
Supplementation may be defined as
tracking. Tracking implies (insertion of the
needle) I a seemingly casual way, as if nothing
were being done, like the biting of the
mosquito. After retention, the needle should
be withdrawn quickly, like an arrow leaving a
bowstring (Systematic Classic, p. 292), and
the left hand closes the hole for several
moments. The result is a gathering of tissue,
a grasping of deeper muscle, a toning up of a
weakened or even somewhat flaccid tissue
area. Often there is a feeling or warmth, or
even of a weight that has sunk into place that
lasts for several minutes. That is tonification.

The classic texts describe it this way:

Dispersal then, and here we are talking about
twirling the needle, as well as moving it in
the opposite way, consists of wrist movement
creating a fast in/ slow out technique. What
one does in fast in slow out is the opposite
with the right hand. So one first inserts the
needle fast. This fast movement is with the

Drainage may be defined as head-on attack.

Head-on attack means (rapid) insertion (of
the needle) while twisting to enlarge the
hold, and (slowly) extracting it so as to
discharge the evil qi) (ibid, p. 291).

So this simple technique, based on the tactics

of fast in slow out uses a totally different set
of musclesyang muscles for yang technique,
extensor musclesand the fascia is slowly
pulled away from the point, the point that is
taut, the point that has too much tone. And
by pulling the fascia out and then letting the
needle stay shallow, the technique will
actually create a release of the fascia rather
than a toning up of the fascia. So through
these very precise uses of the forearm muscles
and engagement of the muscles of the hand,
engagement of the fingers without gripping
tightly, one actually extends the needle, it
becomes a part of the hand, an extension of
these fingers brought together. And by
bringing these three fingers together, the
thumb, the index, and the middle finger, one
is able to use the force either of the flexor
muscles to focus on the in or the extensor
muscles to focus on the out. This is
something that I believe is easy to teach and
easy to improve upon if one is still having
trouble doing tonification and dispersal
needle techniques.

something quite solid. The arms engaged that

way would be able to immediately protect
themselves and defend themselves. These
would not be arms that would be able to be
pushed away easily. I think in acupuncture
its the same thing, and Ive just come to this
realization in making this new attempt at
understanding the more tacit aspects of what
we do, that many students are hovering over
the body in a very light way. They somehow
feel that being extremely light and loose is
the way to be gentle.
In my experience its that type of needling
that is sharp and very much not engaged
needling and does not create the reactions in
the patient hat the student hopes for. So I
believe that the practice of acupuncture has
to be like Qi Gong, or AOM Bodywork
techniques, or even like a martial art in the
sense that the parts of the body that are being
extended and attending to the other person
have to be fully engaged, strong, weighted,
present. And by being strong and by having
strength and muscles engaged one is in fact
bringing a force to the needle. Some people
would say this is Qi Gong being applied to
the needle.

Thats it in a nutshell for the right hand.

Now, if one adds twirlingtwirling very much
engages the Large Intestine 4 area, it is very
difficult to twirl without. But in twirling, one
engages the flexor muscles with the wrist
flexed to tonify, or one can twirl with the
wrist extended away from the body to cause
dispersal. So twirling with the wrist either
flexed or extended will create different
reactions in the tissue, and if one lifts and
thrusts and twirls at the same time, these
processes can be done quicker, but it is by no
means necessary. A way to build up the
strength in the hand, to make it a strong
hand, and here I am thinking of acupuncture
like Qi Gong or like a martial art, the hand
must be and the forearm must be fully there.
In martial arts, even in Qi Gong, when
someone is doing different motions in Qi
Gong, the arms are engaged, the hands are
engaged. If someone were to come up against
those arms, which appear to be just floating
in space, they would come up against

So, in order to strengthen the hand and the

forearm muscles, what Ive recommended to
students is to get a rather thick dowel rod. It
could be just four inches longalmost like
the handle bar of a bicycle, and one might
even be able to find something like that in a
sporting goods store, or just get a hard rubber
cap that fits over handle barsin any case
something about an inch in diameter, round,
a dowel rod, so something much thicker than
a needle. And if one holds that like one
would hold a needleI do it with my cane,
for examplejust the holding of it can only
be done by engaging the Large Intestine 4
area, the first dorsal inner osseus muscle. Its
through that muscle that one holds a cane,
one cannot just pinch the fingersits in fact
impossibleeven though one can pinch just
the fingers around a needle and not engage
that muscle, which Ive seen many times with

students. So by using this thicker needle, this

dowel rod, one has to engage that muscle,
and then just twirling it back and forth is a
very strengthening activity. And one can twirl
it back and forth slowly, rapidly, clockwise,
counterclockwise, and watch, using a very
loose wrist, doing this first using the flexor
muscles at the same time to build the muscles
and to train the muscles and make these
muscular actions tacit rather than conscious.
And then do the same thing twirling the
dowel using the extensor muscles on the top f
the arm. And in this way one can very
quickly build the forearm and extensor
muscles. Mine are quite developed and I
never do anything in the gym to use these
muscles, this is all from having done
acupuncture for thirty years. So this would be
the way to strengthen the arm, make the
hand present, heavy, engaged, weighted, so
that there is force, weight in the hand ready
to make specific reactions happen from the
needling.

tube right at the bottom and then placing the

tube on the point, one places a lot of weight,
a very weighted left hand or non-needling
hand, and compresses the fascia so that the
tube is actually inserted quite distinctly into
the fascia and is not floating lightly on the
skin. This will prevent sharp insertion when
the needle is first tapped in. So in this kind
of technique, holding the tube at its tip
between the index and thumb and letting the
other forefingers fan out as wide apart as is
comfortable depending on the part of the
body or closer together almost like one holds
a pool cue, almost identical to that kind of
way of spreading ones fingers, the whole left
hand, the whole non-needling hand, the edge
of the palm, the edge of the pad of the
thumb, the whole heel of the hand is very
firmly weighted on the patient. This is not an
insignificant process, because by weighting
the areaand one can do it just with the
thumb and index finger as well, but its more
powerful if one weights it with the whole
handthen as soon as the needle is tapped
in, it is already at the proper depth where
stimulation can occur especially for
tonification. And once its tapped in and in
my style where needles are used that are 34
gauge in most cases, I find that the tap has to
be two or three taps, not just one, and ideally
the taps would tap in such a way that the
fingers do not touch the top of the tube, they
just touch the top of the handle of the
needle. And if one does it properly, the
needle is propelled fairly deeply into the tube
so that its deeper than the surface of the
tube. The needle has actually been propelled
somewhat deeper than if one just pushed it
in slowly, which is sharp and not a pleasant
way of needling. So tapping the needle a
couple of times rapidly, one spreads the
thumb and index fingers slightly apart on the
non-needling hand, and relaxes the weight of
the hand slightly where the thumb and index
finger are and stretches the skin and removes
the tube. Now, with this taught skin, one can
do the first stage of the needle technique,
which is to ensure that the needle is into the
fascia, the subcutaneous layer, which is called

That brings us the last part of the needling

process, which is what to do with the left
hand. I cannot speak for styles that dont use
the left hand, which certainly is often done.
But in my approach, and the Ling Shu already
states this very clearly:
The right hand is used to hold and push the
needle while the left hand assists and
controls (p. 5). And later on in the same
text:
The left hand fixes the bone position, the
right hand follows. Do not cause the flesh to
bunch up(ibid, p. 230).
Acupuncture, in the classics, is clearly a lefthanded affair. In Japanese meridian therapy,
which uses tubes, the role of the left hand is
extremely important, and thats where I
learned to use the left hand, was in learning
to hold the tube. One uses the left hand to
grasp the tube, the thumb and index finger
grasping the tube at the very bottom where
the needle tip will be. And by holding the

10

the Cou Li in Chinese. So the needle is in

this layer, which is also the Wei level, the
Yang level. At that point, one can let go of
the needle, let go of the left hand, and now
the needle is at a Wei level depth and now
one can direct the needle with the left hand
or the right hand. So what I now suggest that
students do is reposition themselves. If I
want to just tonify, I now just put down my
index finger very close to the needle and
create a slight weight on the area, compress
slightly, and tug very slightly so that the skin
is taught right where the needle is. I make it
taut like a druma very slight weight in, a
very slight tug, changing the direction of the
needle if desired, or just keeping it
perpendicular. With the skin and fascia
somewhat taut, I then do my needle
techniques: slow in, rapidly in, and so forth.
When Im doing trigger points, I use Travels
technique, which is to trap the muscle, which
I first have felt cross fiber, and once I find
the most tender part of that taught band, I
stretch my index and ring fingers slightly
apart. Actually, I do the same thing: I find
the point cross fiber, I place the tube right on
the most tender spot and hold it with the
thumb and index finger first, tap it in, spread
my thumb and index finger just slightly apart
and remove the tube. At this point, I
recommend to let go of the needle with both
hands, and then to put the left hand, the
non-needling hand, middle and index finger,
cross-fiber above and below the needle, so
surrounding the needle, straddling the
needle, cross fiber, finding the muscle again
and using the fingers to ensure that they are
placed right over the needle, but this time
not hard enough and heavy enough to find
the tender point, just to keep the muscle
trapped and that part of the muscle weighted
where the needle is located. And now, with
very little pressure but stretching the skin
again, I have students hold the needle again
with a very engaged hand and do quick
movements in two to three times, and then
slower out, hovering for a second or longer,
called sparrow pecking technique, like a a
bird pecking for seeds. So its quick pecks,

the pecks are in a staccato kind of fashion, so

not even pecks, not rhythmic pecks, jerky
pecks, pecks for a couple of grains and then
out, and then a couple more grains, and then
out. So to artificially show this at first to
students, I recommend three pecks in and
then one out. So peck, peck, peck, outHOVER, fast pecks in, slow out. Three pecks
in, slow out. This is a fast in slow out
technique, and the focus is on the fast in. If
one focuses on the slow out it will usually not
work. So its a focus on fast, fast, fast, slowHOVER, fast, fast, fast, slow,-HOVER
changing the direction slightly each time as if
one were pecking for different seeds each
time. This will, if theres a trigger point in the
area, cause the muscles to fasciculate and
twitch, often visibly, but even if not visibly,
perceptible to the non-needling hand, which
is resting lightly this time on the area. So in
dispersal, the left hand is resting lightly, still
with the skin taut where the needle is. In
tonification the hand is resting heavy because
in tonification the focus is on a heavy weight
dropping into the area. In dispersal, the focus
is on a rapid movement in and then a
relaxing of the fascia.
With these basic ideas and with some
coaching, everyone can learn to do proper
tonification and dispersal techniques. And
following Polanyis example of tacit knowing,
one can learn to attend to what lies at the tip
of the needle and attend to the reactions that
one is looking for at the tip of the needle,
rather than being distracted by the handle of
the needle or this implement awkwardly held
in the hand. The goal is to make the needle
an extension of the forearm, an extension of
the muscles of the forearm and the muscles
of the hand.

Tips When Needling the Root/Opening
Moves
I have several specific things that I focus on
when needling the first few points in a

11

treatment, points my dear friend and master

acupuncture practitioner Dr. Eric Stevens
always refers to as opening moves.

With my non-needling left hand I

tug with my fingers on SP 2 area,
until I can see the skin and
subcutaneous fascia tug/drag and
tighten all along the trajectory of the
meridian, right up to behind the
medial malleolus. I always tug this
way when I want to initiate a
propagating Qi sensation along a
channel, which facilitates the taut
fascia, making it more yang and
more reactive. If the skin is cold I
rub it to warm it, or even cover with
Mylar for a few minutes to warm it
up. Rubbing or tapping along the
trajectory where the propagation is to
occur will also hasten the desired
results. I then insert the needle very
slowly into the resistance at the
point, finding where it is most
reactive, dense, lime an eraser on a
pencil which Kiiko Matsumoto refers
to as a gummy or kori. Needling
in to this resistance until the needle
gets slightly stuck, I then twirl rapidly
into it, or twirling and lift and thrust
focusing on the out movement, and
the propagation is quick to arrive for
most people. Wherever the Hara has
been tight on the abdomen,
especially in the middle heater along
the Kidney, Stomach and even
Spleen or Liver pathways, this will
release. I look for exaggerated skin
creases on the abdomen, which
bespeaks constrained Qi at that level
and an upregulated sympathetic
nervous system (with signs and
symptoms of nervous or overactive
gut functions), and these will tend to
decrease markedly. The breathing
invariably starts to improve with
such initial Root points, a sign that
YinYang regulation is setting in.
There may be rumblings in the gut as
well, and a definite change in the
complexion. The eyes will also soften
and the persons demeanor will
normalize somewhat. The

Influenced again by Shudo Denmeis

pragmatic advice, that only a few needles
need special attention to set the Root
treatment in motion, I seek meaningful de qi
at the operational jing level points: SP 4, GB
41, LU 7, SI 3, and the source points for the
thre leg Yin, sometimes with Sp 6 instead or
added to the source points as follows:

SP 4: I needle this textbook location,

but between the bone and the
muscle (the adage to needle between
the red and white skin makes no
sense, as this differs with different
people, and can lead to needling the
often exquisitely tight, tender muscle
especially on people with flat feet or
plantar fasciitis-type problems. I
always needle this point on the right,
as I want to needle the paired Per 6
on the Heart Protector left side. I
run my index finger with distal
phalange relaxed as per Shudo
Denmeis suggestion for palpating
actual acupuncture points (as
opposed to indurations), from SP 2
for about an inch until I fall into the
hole just at the distal end of the
bone where the finger stops abruptly.
I retreat with the finger a touch to
place the needle on the exact spot,
angling the needle with tube
compressed firmly into the point
(supported by left hand thumb and
index finger rooted around the tube
at the base, into the flesh to prevent
a sharp insertion) and tap several
times to ensure the needle has
progressed all the way into the tube
with its handle top level with the top
of the tube. One should never tap
this point just once with the # 3
Serein needles I use, or it will not
insert deeply enough and be sharp
once the tube is removed.

12

propagating sensation will travel at

least 4-5 inches along the Spleen
pathway, up toward the medial
malleolus. If it can be made to
ascend to Sp 6 level, it will usually
travel up to the pelvic region and
even umbilicus or higher. Kiiko
would call this targeting the Qi, and
the change at gut level is what makes
such initial points have such a
powerful affect on the constructed
Hara. The rectus abdominus will be
much less constricted from the navel
to the subcostal region in most cases.
I needle the paired Per 6 on the left
with neutral stimulation to get the
slightest de Qi response travelling
toward the wrist;

GB 41: I insert the needle slowly in

the same fashion, on then left side,
angling under the bone into the
textbook location toward Liv 3. My
left hand tugs/drags the skin and
subcutaneous fascia again diagonally
away from/in the direction opposite
to Liv 3 until I can see the drag right
to Liv 3 and then insert slowly into
the resistance. As this is a Yang
meridian I needle more strongly
until there is a deep penetrating de
Qi response that is quite strong
(always within the patients tolerance
level however) spreading throughout
the dorsum of the lateral foot. This
will tend to relax the waist and pelvic
region and restrictions will begin to
release, sometimes totally along the
pathway of daimai (GB 26-28, and
the lower external obliques). I needle
the paired TH 5 neutrally for the
slightest de Qi sensation, or modify
this opening move by adding left Liv
3 needled until there is a definite but
tolerable de Qi sensation, and add
right LI 4 instead of TH 5 (thus
adding one diagnonal set of the four
gate points to GB 41). I do LI 4 like
Liv 3, until there is a definite but

13

tolerable de Qi sensation. I will often

do this combination together, so SP
4 on the right, Per 6 on the left, then
GB 41 and Liver 3 on the left, and
LI 4 on the right as a modified
Infinity Treatment) treating
chongmai and daimai to target
dysfunction and constriction in the
pelvic region and lower heater. I do
SP 4 and GB 41 on the same side as
hip pain and dysfunction to target
the hip area.
Lu 7: I needle Lu 7 to open renmai
at the exact textbook location, off the
trajectory of the rest of the Lung
regular meridian, dragging away from
the elbow with my non-needling
hand until I see the skin and
subcutaneous fascia tug all the way to
Lu 5 or even Lu 4-3. I needle slowly
into the dense area as for Sp 4, and
this will invariably create a rather
strong and spreading de Qi sensation
in the area or even up the channel
toward the elbow. When I want to
needle Lu 7 as the Luo point for
carpal tunnel area thumb and palm
pain and numbness, I use Travells
trigger point location for the flexor
pollucis longus, a good inch
proximal to the level of textbook Lu
7, this time along the Lu pathway,
tugging the same way. Even though
the needle is inserted up the
channel, this point will cause a deep
spreading muscle sensation down to
the thumb and palm, and even make
the thumb twitchidentical to what
one would want when treating the
Luo of the Lung for palm and thumb
pain. I needle the paired Kid 6 at the
textbook location, slowly and
carefully insinuating the needle
between the tendons to 1/8 or so,
and stimulate for a very slight de Qi
response;
SI 3: As a yang meridian point, I
needle for a stronger but tolerable de
Qi response, inserting the needle

almost across the interosseus

muscles of the palm toward LI 4. I
stimulate BL 62, about 1/8 into the
exact textbook location between the
two tendons, for a very slight de Qi
response.
The next set of Root points, this
time from the regular meridians to
target the Ying level, will usually
consist of the source point for
whatever leg Yin meridian in the
circuit in question: when treating the
Taiyin-Yangming circuit, this will be
SP 3 or Sp 6 as a common alternate;
For the Shaoyin-Taiyang circuit, Kid
3; and for the Jueyin-Shaoyang
circuit, Liv 3. This is classic needling
of the source point for the yin
meridians of the foot. I have learned
in thirty years of leading and
supervising students as they engage
in acupuncture clinical practice
treating student-patients for 200
hours over two years, to establish
treatment protocols that begin this
way, with distal leg ying level points
to avoid an overly strong reaction
with release of heat or yang rising
upward. If I have not already needled
Sp 6, I usually add it after Kid 3 or
Liv 3. I needle Kid 3 either side, as
there are two kidneys/adrenals, Sp 6
always on the right and Liv 3 always
on the left, opposite their respective
organs. When I needle source points,
I insert the needle very slowly after
tapping in with tube held firmly as
above, into the dense resistance. For
Kid 3 this will be very shallow, about
1/8. I use one finger f my left hand
after removing the tube to gently tug
the skin and subcutaneous fascia I
any direction just to make the skin
where the needle is inserted taut like
a drum but not enough to pull the
needle toward my finger. I then
needle slowly into the resistance, less
than 1/8 for SP 6 and Kid 3, and
to almost for Liv 3, which I

find reacts more like a Yang

meridian point. That said I see Liv 3
as a great point for Liver excess and
am not in the habit of treating Liv 8
for Liv deficiency, as the meridian
therapy practitioners like Shudo
Denmei do. They advocate a very
shallow insertion for Liv 8. When I
am treating yin deficiency, I prefer
Sp 6. At Sp 6, I insert very very
slowly into the resistance barely
encountered at first at the point, and
after hesitating a few second, pull the
needle quickly to the surface, then
reinsert extremely slowly and with a
very heavy needling hand rooted to
the area, edge of palm planted firmly
on the patients lower medial shin
and invariably notice the resistance
becoming more pronounced, and
more dense even though still very
shallow. Once that occurs, I needle
staying at that depth rapidly until
there is a pleasant mild de Qi
sensation spreading around the area.

14

Tips for Needling the Wei Level

Again Maciocia shows his bias against (and

deep ignorance about) the comprehensive
treatment of muscle channels, which any
practitioner of East Asian bodywork
including tui na, anma and shiatsu would
excel at.

This level of disorder is termed Wei Level by

Chamfrault and Van Nghi, and denotes
disorders of repetitive strain, physical trauma,
injury, and Wind/Cold/Damp Bi syndromes
affecting muscles, tendons and ligaments and
bones.

After listing the main local points per body

area, in his final chapter of the
aforementioned text, on bi syndrome,
including sports and repetitive strain injuries,
Maciocia makes this telling statement: Ah
Shi points (points which are tender on
pressure, are also local points and form an
important part of the acupuncture treatment
of Painful Obstruction Syndrome. In most
cases, these will coincide with normal
channel points, but if other points are tender
on pressure they can be needled in addition
to normal points (Ibid, p. 656). He then
proceeds to only list normal local points
over ashi points, except for one ah shi point
he labels the epicondyle point one cun
behind L.I. 11, Quchi, which appears to be
identical to Travells ring finger extensor
attachment trigger point.

In Acupuncture Physical Medicine, this level

of physical medicine practice is reinforced by
a comprehensive study of Travell and
Simons two-volume tome, Myofascial Pain &
Dysfunction: The Trigger Point Manual. In
my book, A New American Acupuncture:
Acupuncture Osteopathy I argue that by
including Travell and Simons entire
approach to palpation and needle release of
trigger points into the acupuncture study of
the tendinomuscular meridians (also known
as muscle channels in English), the
knowledge of how to palpate for, identify and
needle muscle ashi points is significantly
enhanced, with the side benefit of affording
the practitioner a more western medical way
of discussing such disorders with patients,
their caregivers and other medical
professionals.

If he were trained in trigger points, and how

to palpate cross fiber to identify the most
tender ones (as shi points), he would know
hundreds of such local points, all of which
would prove incredibly effective in clinical
practice on such conditions. The normal
acupuncture points he does list for the
muscle channel treatment of the elbow,
shoulder and knee are standardized points
that appear in the simplest modern TCM
discussion of bi syndrome, and fall far short
of what I would expect an expert in
acupuncture as a hands-on, physical medicine
to know. Concluding his ambitious effort at
presenting a detailed English-language text
on the secondary vessels in this way,
especially when including the major texts by
Drs. Yitian Ni, Andre Chamfrault and
Nguyen Van Nghi in his bibliography and
further reading list, does a great disservice to
those native English students and

I refer the reader to that text, where I list the

main trigger points for each of the three
zones of the body the Taiyang dorsal,
Shaoyang lateral, and Yangming venral zones.
I give basic classical Chinese acupuncture
protocols for distal points that then use
Travells trigger points as the local equivalent
of tender Ashi points. Any serious effort to
train in a comprehensive treatment of the
muscle channels, however, must include the
treatment table-side use of Travell and
Simons two volumes as ready reference to
facilitate clinical use, and internalization, of
these trigger points, what they feel like, how
to trap them, how to needle and release
them, in order that this knowledge might
become second nature.

15

practitioners who had hooped to find this a

useful clinical text.

of musculoskeletal problems and of Painful

Obstruction (Bi) Syndrome, they are
extremely important (p. 283).

As it is, regarding the clinical use of muscle

channels for pain musculoskeletal pain and
bi syndrome disorders, Maciocias text offers
nothing new, and misleads the reader with
images of the muscles in each muscle
channel, without ever indicating one should
learn how to identify the trigger points in
these muscles so laboriously presented by
Travell and Simons.

If musculoskeletal problems and Bi syndrome

disorders make up over 50% of an
acupuncturists practice, how could one ever
make such a statement? Unless, of course,
ones practice is predominantly comprised of
internal medical disorders, which would
appear to be the case in the North American
practice of TCM. A look at the key TCM
texts will show only very short sections on
painful obstruction/Bi syndrome, and the
muscle channels are seriously downplayed in
the English-language literature.

At the Tri-State College of Acupuncture,

students study the myology of trigger points
and gain clinical facility in utilizing these
invaluable texts in a myology course in Year
I, after their study of anatomy, that prepares
them for Acupuncture Clinical Practice with
me and my team in the second year as they
engage in two semesters using AOM
protocols that frequently incorporate Travell
and Simons trigger points into the practice.
Student clinic-interns routinely resort to
these Travell inspired APM treatment
strategies when confronted with simple to
complex, chronic pain disorders including
athletic and performance injuries, repetitive
strain and cumulative trauma disorders, as
well as chronic pain disorders stemming from
the full gamut of musculoskeletal disease.
These sorts of complaints comprise a good
50-55% of the conditions treated in the
colleges busy community acupuncture and
pain clinics, as well as in the practice of its
faculty.

In my experience over the past thirty years, I

have encountered TCM students and TCM
practitioners trained in North America at
other AOM colleges who appear to have little
if any knowledge of the muscle channels or
skills in palpating and treating tender/ashi
pointsthe central focus of muscle channel
treatment. Students report seeing virtually no
NCCAOM board examination questions on
bi syndrome for example, with the
preponderance of cases focused on ZangFu
internal medical conditions. Perhaps it is
time the NCCAOM initiate a survey to
ascertain what acupuncturists really treat,
which we did do at the college twice over the
past several years, and twice in faculty
practices. Each time we learned that these
disorders occupy over 50% of what our
clinics, and the clinics of our faculty, treat.

In APM, this myofascial pain knowledge

base, and trigger point dry needling
techniques are therefore clinically necessary
over half the time.

Another curious piece of evidence to suggest

that knowledge of, and acupuncture skills in
treating muscle channel disorders is not part
of every AOM colleges entry level
curriculum, is that the majority of ACAOM
candidate or accredited post-graduate
doctoral programs in AOM have pain
management as a specialization area,
indicating that they see this as a more
rarified, specialized area, not a basic entry
level set of knowledge and skills all
practitioners should have.

Once again Maciocias The Channels of

Acupuncture reveals a decided bias against
the muscle channels (jing jin). As Maciocia
states in the preface to Part 4 on these
channels, The Muscle channels are not as
important and as clinically relevant as the
Connecting channels. However, in the fields

16

hesitation of a bit less than a second on the

out after 3-5 pecks, so: FAST in-in-in (in-in), a
bit SLOWER out and hesitate almost a
second/ resume pecking like a sparrow, now
for gains a bit to the left or right or above or
below for more grains, FAST in-in-in (in-in),
a bit SLOWER out and hesitate almost a
second, and resume. This usually causes
twitching/fasciculation of the muscle
underneath the fascia being needled, even
without piercing the muscle. If the muscle is
slow to release in this fashion, go in slowly
again as in the beginning, and get de Qi,
then peck slower, fanning out in the 4
directions more deliberately (this is how
trigger point injections are done and are
described in great detail in Travell and
Simons manuals) until the muscle twitches.
At that point one can usually withdraw while
pecking back to the surface, pecking at the
superficial fascia just over the muscle in
question. Dry needling of trigger points in
most approaches just uses thicker longer
acupuncture needles, about 32 gauge and 1.52 long, so as to be able to approximate
Travell and Simons trigger point injection
technique. One can also take trigger point
dry needling courses with MyoPain Seminars,
which descended from the Travell Seminar
series and is still co-directed by Travells
protg/colleague, Dr. Robert Gerwin. In
this seminar, open to licensed acupuncturists
and medical professionals with the authority
to perform dry needling in their respective
states, participants learn how to locate,
identify and perform dry needling on the
main trigger points using acupuncture
needles as above. The Tri-State College of
Acupuncture which I founded also
occasionally runs a summer seminar series in
APM dry needling which is advertised on the
colleges website for CEU courses at
www.tsca.edu.

Acupuncture Physical Medicine treatment of

these wei level tendino-muscular meridians is
straightforward for the distal points: use
excess reactive points distal to the area of
pain and dysfunction, based on the principle,
the further the farther. The jing-well point
is therefore always indicated as the point
furthest from the symptomatic area, and then
moving up the channel, based on the
needling strategy of Bao Ci where one
needles one ashi or tender point after
another along the muscle pathway based on
palpation, one disperses with liftingthrusting-twirling technique focused on the
outward lifting motion to propagate Qi along
the muscle pathway. If the luo point is
tender, and especially if its target area is
within the area of the patients pain and
dysfunction, this is an excellent distal point
as well.
For local points, APM integrates Travell and
Simons myofascial and tendon attachment
trigger points. Any practitioner serious about
learning how to use these trigger points to
supplement their knowledge of treatment of
ashi points can readily use their two volume
trigger-point manual tableside and openbook, to guide careful cross-fiber palpation.
One can then either needle wei level oblique
shallor OVER these trigger points, a classic
Chinese acupuncture technique, or for deep
muscle pain especially when aggravated by
Cold, needle slowly into the belly of the
muscle until there is deep de Qi, or use
sparrow pecking technique after this last
technique and after de Qi has been achieved.
To do this, with the non-needling hand
straddle the point and apply a slight amount
of pressure inward, but mainly apply pressure
laterally away from the point to slightly
compress the underlying fascia, keep the
contours of the muscle clearly demarcated,
and stretch the tissue to make a more taut,
rather than bunched up, surface. Then
withdraw the needle to the skin level, and
begin to peck with a fast in, slightly slower
out motion, repeatedly with a slight

17

Tips on Needling the Three Yang

Zones/ Cutaneous Regions

propagates deep into the tendon, ligament or

bone. In the PRC, this technique would
actually needle into the structure involved to
cause bleeding, which would be considered a
surgical intervention in North America and
must be avoided due to risk of deep and
serious infection.

When focusing on needling of the chronic

myofascial holding patterns in the three Yang
Zones, as outlined in the previous chapter,
one can bring to bear any number of classical
and modern acupuncture techniques and
strategies:

2] stationary or moving cupping; guasha;

3] heating techniques like moxibustion
(direct or on the top of the needle or
indirect); hot packs, heat lamps; mylar
applied over the treated area (which just
floats on the needles and generates
tremendous heat when the skin is bare);

1] wei level or trigger point dry needling as

covered in the previous chapter; classical
Chinese and modern TCM bi-syndrome
techniques outlined by Dr. Ni in her
discussion of tendino-muscular meridian
treatment ( Navigating the Channels, pp. 910), especially:Bao Ci for muscle bi
syndrome that can affect a large area with
pains moving around (Taiyang scapula pains
at times, at other times Taiyang low back and
buttocks pain, and at yet other times Taiyang
hamstring and calf pain in a dancer for
example); Fu ci (the standard shallow,
oblique wei level technique where the needle
tip ends up over the affected ashi/trigger
points, but not into the muscle trigger point
itself and: He Gu Ci for a deep muscle bi
pain disorder, with one needle inserted
perpendicularly into the belly of the ashi
muscle point/center of the trigger point
itself, with two other needles inserted
obliquely, wei level over the tendon
attachment (what Travell and Simons refer to
as Attachment Trigger Points or ATrPs),
either angled toward the perpendicular
needle, or away from it depending on
sources. When there is involvement of
inflamed tendons or ligaments, or bone
(osteoarthritis), I prefer to use a modified
Duan Ci technique where one starts the
needle shallow and perpendicular, at the
yang, wei level. Then one inserts the needle
slowly to a deep level until very close to the
tendon, ligament or bone involved. Repeat
this a few times until a deep de Qi sensation
is obtained, and then stay at the depth where
this is felt, and apply very short and slow liftthrust manipulations until the sensation

4] Electro-stimulation without or applied to

needles;
5] Deep sustained acupressure techniques
from anma, tui na or shiatsu (ischemic
compression in Travell and Simons) to
ashi/trigger points followed by slow release
(strain/counterstrain);

Summary of Basic Needling Depths and

Skills
A] For the Jing and Ying levels, the integrated
APM/CCA approach makes use of classical
Chinese techniques consistent with TCM:
Jing Level: Extraordinary vessel distal
opening points (SI3/Bl62 etcetera) are close
to the bone (marrow, jing). In needling
shallowly, 1/3 of an inch at most, one is
already near bone. Needle into the
subcutaneous fascia over the bone, with
precise point location to enter the point.
Neutral mini lift and thrust, with twirling is
sufficient until there is a slight grab felt by
the practitioner. The patient will begin to feel
a heavy sensation. On Yin opening points,
stop at the first sign of deqi. That is enough.
On Yang opening points, the deqi can be
stronger. REMEMBER DE QI RESPONSE

18

MUST BE TAILORED TO THE

PATIENTS DE QI TOLERANCE
LEVEL. Do these points first to begin to
create/open the circuit involved. Leave these
points at the depth the grab was
encountered. Do not pull back to surface.

is no grab, quickly pull back to the surface

but do not pull out; redirect slow and heavy.
This is a modified warming technique. For
sensitive patients you can omit the twirling
and just thrust slow and heavy, then lift
quickly, then redirect slow and heavy. If the
response is very slow to come (low blood
pressure, low thyroid, cold) be careful as it
may hit like a hammer blow. For the average
reactor, you can go to the point of mild deqi
on these points. Leave the points at the
depth where the grab or deqi is encountered.
Do not pull to the surface.

Ying Level: Regular meridians are deeper

within the fascia and hidden from view.
The distal command points are places where
the meridian is closer to the surface and
easier to access with rather shallow needling.
The LING SHU lists distal command point
depths as follows:

For Yang Points, insert needle swiftly to the

required depth, about inch, with or
without twirling as you insert; maintain the
twirling, wider amplitude (yang tends toward
excess so you are doing mild dispersal here to
get things moving. If the point is very excess,
a stronger dispersal is required and will
generate a propagating qi sensation from the
point up or down) until there is a distinct de
qi sensation on the part of the patient
(within their de qi tolerance), and/or a
strong grab like a fish biting on the line for
the practitioner. You can also insert to
required depth quickly, then lift slow and
heavy, focusing on the lifting as if there were
a weight being pulled up out of the water,
like a bucket filled with water.

Foot Meridians:
Yin meridians: 1/10-1/3
Yang meridians: 2/5 to 3/5 (or slightly
more)
Hand Meridians:
Yin or Yang Meridians: 1/5
( 1 fen = 2.5 mm = 1/10: Needle Depths:
Liver =1 fen = 1/10
Gallbladder = 4 fen = 2/5
Kidney = 2 fen = 1/5
Bladder = 5 fen = 1/2
Spleen = 3 fen = 1/3
Stomach = 6 fen = 3/5 )
Approach these points perpendicularly to the
surface of the skin.

Mu and Shu points:

Mu points must be angled as per textbook
instructions, usually oblique. Insert slowly
until you meet resistance, and then twirl
gently into the resistance until heaviness
converges around the point to tonify. To
disperse, increase the amplitude of the
twirling and focus on the out/lift; or slowly
lift as if lifting a bucket of water out of the
water, as if there were a great weight being
pulled up. This can be repeated, fast
in/thrust, slow heavy lift/out movements.
Propagating qi sensations will usually occur.

For Yin points, use lift and thrust with or

without twirling with small amplitude and a
heavy hand on the in, as if pushing a weight
into a dense area. Feel for the resistance at
the tip of the needle. This is the beginning
response of the tissue under the needle as
forces converge around the needle tip. When
you reach the depth where resistance is
met/felt, stop inserting and just twirl until
there is a slight grab (yin tends toward
deficiency so you are doing a mild
tonification here. If the point is very deficient
or cold you do a strong tonification). If there

19

Shu points in APM are to be needled about

1/3-1/2 deep from Bl 11-22; 1/2 3/4
from Bl 23-25 , angled oblique slightly down
and in toward the spine. They can be
stimulated perpendicularly, paying careful
attention to depth, then redirected oblique if
they are to be left in situ. Some practitioners
stimulate perpendicularly, until the required
sensation is achieved, then remove. These
points can be tonified or dispersed as per mu
points. Do not do APM trigger point pecking
technique on these points or they will behave
like trigger points, not shu points. If a shu
point is a trigger point as well, you can
release the trigger point first with pecking
technique, then needle as a shu point, with
mild tonifying or dispersing technique,
directly into the muscle. Once stimulated,
withdraw to the surface and leave oblique so
that they cannot be pulled deeper by the
contracting tissue as the patient is lying there
unattended. In APM Mu and Shu-Point
Boogey obtains, which means that points are
picked for each of the three heaters based on
reactivity, not exact point location, and are
typically done according to Triple Heater
Regulatory technique where at least two
heaters are treated.

serve as distal wei level point to release the

lateral thigh and hip for example).
Local Ashi Points: Any ashi point may be
needled wei level shallow insertion, or slowly
straight into belly of TTP (TCM technique)
to develop these techniques and as per the
peer-patients tolerance level.
WHEN there is an actual trigger point
present, the preferred technique in these
APM/CCA ACP sessions (deqi tolerance
taken into account) will be the APM
fasciculation technique derived from Travell,
also known as sparrow pecking in classical
Chinese acupuncture.
After accurately locating the trigger point
with Travells text open to guide you, apply
dispersing acupressure for 10-30 seconds to
ready the point for release. Reassure the
patient that if this recreates part of their
referred pain pattern or feels like one of their
worst tender spots, that is verification that
this needs to be released. Show them how it
might twitch by manually creating a twitch
reaction. Tell them to let you know when
they feel the de qi response, and then when
they feel the twitch. Explain that you will
stop stimulating if they say the response is
too strong.

Always treat a lower heater mu or shu point

before doing any points in the upper heater,
to prevent strong releases of heat and liver
wind. If a strong reaction occurs with upper
heater points, calmly remove the upper
heater point and compress the area with
calming acupressure for a few seconds,
reassuring the patient. Then restimulate
distal yang needles to bring the qi down.
Pull over a supervisor immediately.

For new trigger points you have not

encountered, or is the peer-patient does not
actually have a trigger point at that site, and
if you cannot get a supervisors assistance, go
slowly and carefully so as to prevent shocking
the patient (and you!), with my version of
shallow Van Nghi technique first. After
tapping in the needle and with the tube
removed, release your left and right hands for
second, and with your non-needling hand
stretch the surface tissue away from the
needle tip, and then with the needling hand,
and a focused heavy insertion insert the
needle only 1/8 to 1/4 inch and keep the
heavy weight with the needling hand while
quickly releasing the surface tissue with the
non-needling hand. Let both hand go, and

B] Wei Level Distal and Local Points:

Distal Wei Level Points: These Yang Points
may be treated with TCM dispersal
technique, needling the actual point if
tender, propagating the qi downward; or as
trigger points into the actual trigger point
(peroneus longus trigger point near GB 34 to

20

flick the handle of the needle. It should be

ROOTED (ie; the tip is firmly embedded and
the needle is not wobbly).

technique may not be warranted. Or the area

may be fibrotic if the muscular contraction is
longstanding, and a twitch may not occur
until this fibrotic tissue is softened up(if it
can be) with tuina, guasha, or moving
cupping.

WHEREVER POSSIBLE, IF THERE IS AN

ACTUAL TRIGGER POINT PRESENT,
and with a supervisor present, insert slowly
trying various small changes in direction (not
fanning as in Travell), inserting to the
outside of the muscle or just into the muscle,
with the left hand compressing the fascia
over the point (which is acupressure being
applied along with the needling). This
compression is not as heavy or hard as when
you found the trigger point, just enough
pressure to compress the fascia into the
muscle. The twitch might come immediately,
or it might begin as a deqi sensation before
twitching.

You must inform the patient that there may

be soreness, especially where points
fasciculated, due to release of lactic acid after
the treatment, for up to 24-48 hours. If any
points started to bleed during removal of
needles, you must inform patient area might
bruise slightly while compressing point to
stop bleeding. Apply a band-aid if necessary
They should take a hot bath or shower
afterwards when they can and drink a lot
more water or diluted Gatorade to help flush
the lactic acid from the tissues. No exercise
or strenuous activity after the treatment and
until the post-treatment soreness has
subsided. They should also be told not to try
to test the sore area to see if it is looser or less
sore. Physical therapists can apply stretch
techniques a day after the treatment to good
effect, but no massage, ultrasound, ultrastim
or ice should be applied until the soreness
has worn off.

The goal of the left hand here is to

guide/knead the trigger point toward the
needle tip. In this way you are at the outside
of the muscle with quite shallow insertion for
most points. Maintaining this compression
with your left hand, which you ease off of
repeatedly to allow the muscle fasciculation
to occur, and once the patient has felt a de qi
sensation, start slowly pecking into the exact
direction that created the de qi response.
Peck unevenly, at different rates, to
surprise the muscle. In some muscles, like
the upper trapezius and levator and SCM,
you might need to insert into muscle belly to
get the beginning of a fasciculation. In most
cases (except for levator scapula), you can
then withdraw to just being slightly in the
muscle, or just at its surface, and apply the
above technique.

Andrew Nugent-Head Yin Style Ba Gua

Tangible Qi Hand Techniques
While I feel I have come to be able to teach
students how to do quite a decent job with
needling, over the past three decades, I am in
fact mainly self-taught. The faculty from the
Quebec Institute, and even Van Nghi, who
treated me a few times so I can experience
this, made little of needling, stance, posture,
as so many TCM practitioners I have met.

If a point does not start to respond rather

quickly, lift the needle to the surface with
dispersal technique (focusing with intention
on the lift/out movement) and leave shallow.
The there may be no actual trigger point
present. You may be needling into a trigger
point referral zone, which is part of the
tendinomuscular meridian, and shallow
needling is fine, but actual trigger point

Luckily, Andrew Nugent-Head, founder of

the Association for Traditional Studies, has
come forward after almost 25 years
experience training in classical, Yin Style Ba
Gua that includes self-cultivation Daoin
practices (8 healing sounds, point and
meridian rubbing and patting, and Qi Gong)

21

with acupuncture training, and that stresses

the ability to do repeatable strong techniques
that get predictable results, with a strong
focus in ashi point needling and hand
techniques.
Andrew has contracted with then college to
run CEU training for alumni, and will teach
students in the MS/Ac Program one day each
of the Spring Intensive over the 3 years.
Andrew has also agreed to offer his
comprehensive training in acupuncture,
focusing on ashi point treatment as well as a
classical set of yinyang regulatory points, as
the core of the Advanced Post-Masters course
in Acupuncture in Orthopedic and Trauma
Disorders, which will become one of the
majors a student in the eventual Doctor of
Acupuncture Program could select.
I strongly recommend that all second and
third year students watch the introductory
free video presentations by Andrew NugentHead on his website, for a view of his
approach to training in hand techniques, and
the tangible Qi lectures which give a good,
and very sophisticated sense of his approach
to training. I am honored, and humbled by
someone with this level of skills and
experience, and will be right alongside other
TSCA faculty and graduates when he teaches
at the college, starting this October 2011.

22