3 Ways to Think About Integration
by Kailey Brennan L.Ac
Integration is a big juicy topic for those of us working with the Engaging Vitality (EV) material. As EV brings together and synthesizes various perspectives and palpation tools from both the Western osteopathic and East Asian medicinal traditions, for those of us practicing acupuncture we may find it difficult to adequately articulate to ourselves and skillfully frame what we are gathering from palpation against the backdrop of our East Asian medicine understanding.
Quite often it may not be entirely clear how to think about or make use of what we discover from palpation alongside our patient’s chief presenting problem, their overall health picture, concomitant symptoms or secondary complaints, and how we fit this into the various models or styles of acupuncture and herbal medicine that most inform our clinical thinking.
Below are 3 ways I’ve come to think about working with integrating the EV work into my practice, accompanied with case examples to illustrate my own thinking process in these matters.
Foreground and Background
During the first office visit I let each patient know that I’d like to perform a palpation exam before we sit down to talk about their reason(s) for coming in so that I can get some unbiased information from their body, free of my own preconceptions of what I think might be going on.
Patient #1 has a Global Listening while standing which goes anterior and to the left. Global Listening while sitting on the treatment table is different, landing somewhere into the anterior pelvis closer to the midline. This lets me know that her Problem Place is somewhere in the lower half of her body, but there is evidently something going on in her pelvis.
Her Yang Rhythm is the “most least” at her left ankle. Her Qi Signal Layer is fairly low overall, and it’s a tie for me between the Upper and Lower Burners. Her pulse is generally weak and thready, especially in the right cun and guan positions. Her tongue is slightly pale and puffy with slight teethmarks on the sides with an indentation towards the back and slight puffiness towards the front. Transiently Opening ST41 seems to increase the Yang Rhythm in her left ankle. Globally, her Yang Rhythm feels a bit sluggish and it’s not feeling like there’s much propulsion in her Fluids. The Fluid bag feels a bit boggy.
Patient #1’s chief complaint is the formation of a neuroma on her left foot between the second and third toes subsequent to fracturing that foot the previous year. She’s continuing to experience considerable pain and now some numbness on left lateral side of her foot as well as discomfort in the right knee which she believes is due to compensating for the foot pain. The foot pain is limiting her ability to engage in her favorite exercise - walking - and this is causing her increasing distress.
Additionally, Patient #1 is coming off of a very stressful and exhausting year of caretaking for relatives amidst the backdrop of the global pandemic. She is also dealing with pelvic organ prolapse that leads to using the bathroom quite frequently to urinate, at times waking up every half an hour during the night. This disruption in sleep feeds into a continuing sense of being frazzled and exhausted.
In the foreground there is the chief complaint of musculoskeletal pain, with the Problem Place showing up as the patient’s left ankle. In the background there are concomitant signs and symptoms painting a clinical picture of both Qi Deficiency and Qi Sinking.
Early on I discovered that Patient #1 seemed to benefit from an approach that focused on tonifying her Qi at the beginning of the treatment before attending to moving Qi and Blood in the left ankle in an attempt to open up the Yang Rhythm in that area.
For example, needling LU9 and SP3 at the beginning of the treatment accompanied by moxibustion at REN6, ST36, and SP6 brought positive and quantifiable palpatory changes to the patient’s Qi - her Shape of Qi became more settled, supple, and integrated, her Qi Signal Layer came up at a all 3 Burners, and it felt like there was a little bit more oomph behind her Yang Rhythm and propelling her Fluids.
With this foundation set it felt as though there was then a more skillful opportunity to go in and attend to opening up the Yang Rhythm in the left ankle by treating the sinew channels of the blocked meridians, local needling around the affected tendons in the joint as well as the neuroma, lineaments, heat therapy, and other adjunctive therapies to address musculoskeletal concerns. Addressing the left ankle necessitated checking in with her Yang Rhythm after each needle to make sure beneficial palpatory changes were taking place systemically and to avoid the always real possibility of moving into over-treatment, especially given her background of Qi Deficiency.
From week to week the Problem Place seemed to be less situated in the left ankle and more so in the pelvis. Treatment focus started to center more around the pelvis and pelvic prolapse. What was initially somewhat of a background issue (pelvic prolapse, Qi Deficiency and Sinking) moved to the foreground, while the left ankle started to move to the background. With a few starts and stops, she was gradually able to get back to walking 3 miles per day without experiencing considerables pain in the left foot afterwards. The patient bought an orthotic to decrease some of the pressure she felt from the neuroma. Bu Zhong Yi Qi Tang with the addition of Wu Wei Zi and Mu Li was prescribed to help Raise and Tonify Sunken Qi, as well as secure urination. The urinary frequency experienced at night decreased dramatically, allowing for the patient to be able to sleep consecutive hours throughout the night and get her energy reserves back up.
Discussion
It can be useful to simultaneously hold both the foreground and the background details of the patient’s clinical situation as we go about performing our acupuncture treatment and prescribing herbs with the aim of effectively engaging with the intelligence of the patient’s body and its capacity for moving towards self-regulation, health maintenance, and healing.
As with the example above, it was useful to think bout titrating the most useful amount of stimulation to open up the Yang Rhythm in the ankle after tonifying her Qi (with needles and moxa) and while keeping in mind the patient’s overall insufficiency of Qi during treatment. Attending to both the foreground and the background in the clinical situation can give some guidance around how to think about structuring a treatment and help us to discern if we’re finding the right balance of providing a therapeutic stimulus to effectively engage with the patient’s system and garner a beneficial response without tipping into over-treatment.
Appreciating Both the Forest and the Trees
Patient #2 has a Global Listening that goes anterior and to the left while both standing and seated. Her Qi Signal Layer is simultaneously low in both the Middle and Lower Burners. Her Yang Rhythm is low in both the upper left ribcage and seems to be constrained and diminished from her right hip on down through her lower limb to the ankle. She has a Listening in in her right hip which seems to be in the area of the acetabulum. She also has a Local Listening at what might be the splenic flexure of her Large Intestine as it seems to connect with her Large Intestine channel and LI4 on the right side appears to release the Listening. She has tight rectus abdominis muscles and her abdomen seems to show Liver signs. Her pulse is deep, weak, and thready, especially in the left guan and chi positions. Her tongue is overall very dry with a darkish red body, puffy and peeled sides, and purplish red papillae at the tip. Systemically her Yang Rhythm feels somewhat wispy and evanescent, her Fluid Bag feels slightly dry, lacking in abundant moisture.
Patient #2 is seeking support with an upcoming round of IVF after struggling to conceive for two years and a diagnosis of unexplained infertility. She has a tendency towards constipation, night sweats, insomnia with very vivid dreams and night terrors, as well scanty and short menses. She struggles with intermittent pain and tightness in her right hip. She is highly attached to her work, extremely fastidious and focused on details, and has a difficult time passing on projects or assuming her colleagues will be as attentive as she is. Needless to say this approach to her work causes her a lot of stress.
Discussion
Patient #2 presents with a potpourri of signs, symptoms, and palpatory findings. Integration in this case can be thought of as appreciating both the forest and the trees - which is to say you can appreciate both the seemingly disparate and unique details that stand out (the trees) without hyper-fixating on one in particular, as well as how it all relates to the larger context of the patient’s clinical presentation (the forest).
Patient #2’s symptoms as well as tongue and pulse seem to show fairly definitive signs of Heat in her system that looks to be drying up her Yin. Might the Heat be drying up the sinews and causing further pathology with the right hip? And what to make of the Local Listening in the splenic flexure of the Large Intestine? Could the tension in this area be related to Qi Stagnation and the pathological drying up of fluids that may be playing into the tendency towards constipation? In East Asian medicine, we sometimes relate a tendency to be overly fastidious, detail-oriented, and struggling to “let go” as a psycho-emotional correspondence with the Large Intestine organ. Heat can impede fertility by drying up physiological Yin, leading to scanty menses and insufficient cervical mucous.
This is to say that integrating our palpatory findings with our East Asian medicine understanding can open up interesting questions and areas of exploration that can help guide our treatment approach. If we can hold both the details (the trees in this case being the Local Listenings in both the upper left quadrant and the hip) as well the larger background (the forest in this case being a backdrop of pathological Heat and accompanying symptoms), without prioritizing one at the expense of the other, we can use integration as a way to think more broadly and creatively with respect to our patient’s clinical presentation.
Interrelationship of Qi and Structure
Patient #3 presented with a Global Listening that went to his left temporal area on his head. His Qi Signal Layer was lowest at his Middle Burner. His Yang Rhythm was overall very tight and ratchety, almost as if his whole system was like a rubber band that was very overstretched. His Yang Rhythm was lowest in his head and secondarily to that it was low in his upper right quadrant, with a Local Listening situated at his Liver. His left squamous suture above his temporal bone seemed to be locked in, exhibiting a Local Listening in that area. His GB, SJ, KD, and LV channels, especially on the left, all felt significantly blocked comparatively to the rest. SJ2, KD1, LV2, GB40, GB2, and GB1 all had distinct Qi Signal Assessment readings and when Transiently Opened seemed to diminish the Local Listening on the left side of his cranium and open up the Yang Rhythm systemically, dramatically reducing the overall ratchety quality his system was exhibiting. His pulses were tight overall, slightly rapid, and considerably wiry in the left guan at both the superficial and middle positions.
Patient #3 had chief complaints of consistent pressure in the left ear accompanied by tinnitus as well as depression, low energy, irritability, trouble sleeping, and mild dizziness. He had experienced a significant TBI in 2014 from a motorcycle incident that left him with intermittent headaches as well as pressure, tinnitus, and hearing loss in the left ear. A very stressful couple of months of working 50-60 hour weeks along with increased alcohol and caffeine use had caused the tinnitus and ear pressure to increase in severity and intensity.
Discussion
A core principle in osteopathy is that structures and their functions are reciprocally interrelated. Structures and their functions have a reciprocal influence on one another. Reciprocal interrelationship in this sense means that the structures of the body can both reflect changes in and can produce changes in other systems of the body. In EV we are very much interested in how this dynamic illuminates the interrelationship between Qi and structure in our medicine.
Was Patient #3 exhibiting a case of exuberant Liver Yang which was interfacing with the effects of a prior TBI and constriction in the cranium? Did the prior TBI, which seemed to have inhibited the movement of his squamous suture and blocked his GB and SJ channels on that side, along with the effects of acute stress, create the conditions for a Shaoyang pathology? Did the jammed squamous suture give rise to blocked GB/SJ channels and subsequent pathological signs and symptoms, or vice versa?
It’s not necessary to come to a complete understanding of the etiology of a patient’s presentation in order to be of help to help our patients. Orienting to the reciprocal interrelationship of Qi and structure in the body, the warp and weft of what makes us and how pathological kinks and disturbances in the web can create, feed into, and sustain unpleasant downstream effects can be a very interesting and engaging edge to work with in integrating the EV palpation tools into our clinical practices. If we can locate and provide a release to the kink in the web (the Problem Place) healthy physiological motion can be restored and the intelligence of the body can take over.
Conclusion
Integration approached solely as an attempt to find some kind of perfect and gratifying understanding of the marriage between Western osteopathy and East Asian medicine can sometimes feel like the intellectual equivalent of fitting a square peg in a round hole. Fixating on this kind of approach can open up the rather disquieting possibility that we lack the requisite palpation skills and necessary understanding of both traditions in order to make what we feel should be obvious, clear, and satisfying connections. Simply put, it altogether feels like a big bummer.
A different and far more interesting approach is to come at the issue of integration with a softer gaze, to be flexible in our orientation and see the process of integration as an exercise in ever-deepening and creative meaning making - a chance to start to see and appreciate the connections, dynamics, reciprocal relationships, associations, and resonances that come together not only in our patient’s bodies but that also inform the larger webs that undergird our understanding of Western and East Asian anatomy and medical theory.
It isn’t a problem at all if the connections we make in our clinical practice in regards to integration feel fuzzy or tenuous and leave us scratching our heads most days. It can only serve as a springboard for deeper learning.