Something to clarify before reading on.
What's included in the blog?
There are three sections to this blog. Section A is for acupuncturists who haven't heard/learned PONAMS regardless of background, and that's. Section B is for PONAMS alumni (a lot shorter). Section C is the answer to the case analysis.
Types of Numbness
This article is limited to meridian-originate numbness in the foot in early-stage (roughly less than two months, varies with individuals) featured by 1) no identifiable nerve damage and 2) the numbness locations are almost all in the non-injured areas.
There are two more types of numbness (not included in the analysis) on top of meridian-originate numbness in PONAMS. One is the Central-originate numbness (e.g., stroke with brain cell damage, BelBell'slsy, spinal cord injury, a part of the central nervous system). Another is the regional-originate numbness (e.g., carpal tunnel syndrome, peripheral nervous system). Either major or minor nerve damage can be identified in these two types of numbness. All three types of numbness are subject to symptomatic change throughout the illness and can demonstrate differently at the time of intervention. Therefore, knowing the dynamics behind the physiological and pathological change is fundamental to successful numbness treatments. 𝘝𝘪𝘦𝘸 𝘢𝘯𝘥 𝘛𝘳𝘦𝘢𝘵 𝘕𝘶𝘮𝘣𝘯𝘦𝘴𝘴 𝘗𝘳𝘢𝘤𝘵𝘪𝘤𝘢𝘭𝘭𝘺 — 𝘍𝘢𝘤𝘦 𝘍𝘢𝘤𝘵𝘴
The must-have mindset for a successful numbness treatment is to incorporate and integrate two major medical systems, Chinese and conventional medicine — one of the PONPONAMS'sre beliefs. The truth is that, in TCM, there has been no concept of the "nervous system" in the first place. Only descriptions of symptoms such as "Ma (麻/tingling)" and "Mu (木/numb)" can be found in the medicinal literature. And yet, many of us are treating "sciatica," "neuropathy," and "neuritis" sorts of disorders using conventional medicine's diagnosis. Aren't we acupuncturists? Aren't knowing Qi & Blood stasis, Qi & blood deficiency, and Bi syndrome good enough to gain numbness treatment success? Why do many of us include those "medicine stuff into practice? Can acupuncture ease the pain and numbness when the spinal cord is terribly pinched, as in the x-ray film below? Shouldn't we treat patients solely with syndrome differentiation over an imaging exam?
Some expanded the definition of numbness in modern TCM to a broader extent and claimed that the nervous system was actually included. If that is true, what did it practically grant the numbness treatment? Can we see through the underlying mechanisms? Have we ever reached a correct diagnosis? Most importantly, have we found treatment strategies that lead to consistent and successful outcomes based on the diagnosis? Literally, the expanded interpretation is nothing more than a weak defense of a flawed theory and a self-satisfied statement. In the real world of medical practice, how can one possibly be successful in treating nerve-associated disorders, numbness included, without implementing the nervous system concept in the first place, to begin with? Can a neurosurgeon fix your pinched nerve not knowing what the spinal cord and spinal nerves are? LeLAren'tce the fact, like it or not. We acupuncturists incorporate many "LeLAren'tceare "ingredients"" from Western medicine and apply them to our practice. It is even more apparent when countless posts use conventional medicine's agnosis and seek treatment advice on Facebook and other platforms. All healthcare providers treat the same human body, just with different approaches. So what's the point of denying the evidence that has proven to exist and is valuable in other professions? All the anatomical and physiologic knowledge and the associated medical facts matter to acupuncture practice and should not be ignored. There is nothing wrong with collecting all information from as many aspects as possible to interpret and treat patients' medical conditions.
Summary: Acknowledge and accept what's been missing in TCM and renew our minds to transcend clinical and academic boundaries.
𝘒𝘯𝘰𝘸 𝘠𝘰𝘶𝘳 𝘌𝘯𝘦𝘮𝘺
Knowing what you are dealing with is the key to a successful treatment. Seeing through the underlying mechanisms of different types of numbness is the first step you should take. Section A — for general acupuncture practitioners
1. Physical Examination — Injured area and severity check
Look carefully at the photos in Part I. The injured areas are ST, GB, and BL, and the severity grade is GB>ST>BL.
Keep the above info in mind, for it matters to the manifestation of symptoms, the course of symptom transmission (CST), diagnosis, treatment protocol formation, and even prognosis prediction in the late stage.
2. Five-element model — the meridian flow in an endless loop
The 5-element model is not just an illustration that tells the generating/controlling and other relationships between elements. It also shows the direction of how the meridian flows from one to another, either clockwise (direct sequence) or counterclockwise (reverse sequence) direction, in an endless flow circle. (Fig. 1 and 2)
a. Direct Sequence Deficiency
When applying the 5-element model to lower limb diagnosis, you need only three elements (or six meridians) that travel to the leg. They are BL/KI, GB/LR, and ST/SP. You cannot find any of the rest meridians in the lower limb. (Fig. 2)
It makes the “di"" "gnostic map" a "lot simpler by using only three elements instead of five.
The direct sequence of meridian flow is from BL/KI to GB/LR to ST/SP, while the reverse sequence is from ST/SP to GB/LR to BL/KI.
When an element is partially or entirely blocked, say BL/KI. The amount and speed of flow are reduced downstream while accumulation starts upstream to the blockage. A "direct sequence deficiency" and a "reverse sequence excess" are therefore formed by a blocked element regardless of the cause. (Fig. 3)
The concepts of "direct sequence deficiency" and "reverse sequence excess" apply to all individual elements and their up-/down- stream element(s).
Since the downstream element's deficiency is from no or reduced meridian flow, this kind of meridian-originated numbness is called the "true deficiency (or numbness)."
True excess/deficiency can happen in any element, resulting in subsequent presenting symptoms. For an excess, the symptoms may include but are not limited to soreness, tightness, tenderness, skin hypersensitivity, etc. For a deficiency, the symptoms can demonstrate as tingling, numbness, skin hyposensitivity, low muscle tone, weakened muscle power, etc.
b. Relative deficiency
A relative deficiency is created by excess on its exterior-interior meridian. One way of explaining it is the two-barrel model (Fig. 4). There are two essential concepts in this particular meridian relationship. Once there is an excess on a meridian, say BL (Yang), it will create a relative deficiency on its exterior-interior related KI (Yin) meridian and manifest deficient symptoms even though the KI is actually normal and free of blockage. Since the symptomatic meridian (KI) is normal, the numbness it exhibits is called the "fa" se deficiency" ("r numbness).
Now we have two new terms, true numbness, and false numbness. The best and most well-known example of relative excess/deficiency is the Liver Yang rising, with the underlying mechanism being the Liver/Kidney Yin deficiency. So how do we treat a liver Yang rising? Are we suppressing the LR Yang from soaring? If that's your case, you might want to think again.
In an exterior-interior relationship, the relative deficiency on KI will be created almost immediately by an excess BL, regardless of the cause. A relative excess on the BL meridian can also be formed by a KI deficiency, even if BL is intact with no blockage.
Keep in mind that these two particular meridian interactions can happen in all five elements and is crucial to numbness treatment.
c. Correct vs. incorrect treatment strategy for numbness
With the concepts in a and b, treating a meridian-originate numbness becomes evident if you see the mechanisms.
Incorrect treatment strategy
Often, acupuncturists treat numbness as a deficiency caused by either Qi or insufficient blood that fails to nourish the affected area. Sometimes, it is the case. However, when it is, the treatment progress should be amazingly swift since acupuncture is excellent at moving Qi, resolving blood stasis, and increasing blood circulation.
Why are we encountering many poor results, inconsistent outcomes, slow progress, and persisting relapse over time in numbness cases?
𝘐𝘵’𝘴 𝘈𝘭𝘭 𝘈𝘣𝘰𝘶𝘵 𝘊𝘢𝘶𝘴𝘦 𝘔𝘢𝘯𝘢𝘨𝘦𝘮𝘦𝘯𝘵
The answer is evident and straightforward — not understanding the underlying mechanisms of the numbness you treat.
You will not win any battles if you do not know who your enemy is and prepare yourself accordingly. An off-track diagnosis or symptomatic relief is destined to end up with repeated recurrence as the cause remains unattended.
Tonifying a deficiency (true or false) will temporarily reduce or even disappear symptoms if you do it hard enough. However, tonifying all deficiencies without identifying the root can be risky and further worsen the condition. In addition, the symptomatic relief will mislead practitioners and leave the source of numbness unresolved.
𝘕𝘰𝘵 𝘈𝘭𝘭 𝘋𝘦𝘧𝘪𝘤𝘪𝘦𝘯𝘤𝘪𝘦𝘴 𝘈𝘳𝘦 𝘛𝘩𝘦 𝘚𝘢𝘮𝘦 Take direct sequence deficiency (true numbness), for example.
This type of numbness is caused by a blocked upstream meridian that reduces/shuts down meridian flow and demonstrates deficiency symptoms (numbness) on the downstream meridian(s). Suppose practitioners fail to spot the source and focus on deficiency using tonification methods. Yes, the numbness will diminish if you do it right.
But, when the self-healing process kicks in and partially opens up the blockage, the resumed meridian flow may "fl" od" t" e downstream meridians and creates excess symptoms on them.
Though the excess symptoms may be temporary and can be resolved as the meridian flow reaches a steady state again, the unattended blockage will induce deficiency on the following meridians, once again manifesting as a relapse in the clinic.
When tonifying a relative deficiency (false numbness) induced by an exterior-interior excess meridian, the numbness will diminish after the treatment. However, doing so creates a new yet escalated new balance forcefully. The state of" escalated balance" is even worse than that of tonifying the true deficiency from a blocked upstream meridian.
When Yin-Yang reaches a raised balance level, the numbness as a symptom is reduced even if the opposite meridian's excess is not cleared up. However, two consequences will develop if the situation continues for an extended period — poor results with repeated relapse and muscle power loss.
Why?
Keep in mind that the symptomatic meridian itself is normal in the case of a relative deficiency. A free-flowing meridian will not respond well to tonification methods as it should in a true deficiency. In other words, trying to fill up a healthy, unblocked meridian with more flow volume is almost unattainable in most cases. The numbness may be lower during the session. However, it will still return as quickly as the meridian flow does its job and resumes the balance again.
Even if there is a way to forcefully achieve and maintain the state of "flooded excess" on a relative deficient meridian to being asymptomatic, the muscles along the symptomatic meridian will start atrophic change due to the manipulated excess preventing Qi/blood from nourishing the area. As a result, loss of muscle tone, weakened grip, failure to hold objects with fingers (thumb vs. index or pinky), and even muscle atrophy may happen as the artificial excess prolongs.
𝘕𝘰𝘵 𝘔𝘶𝘤𝘩 𝘛𝘰 𝘋𝘰 𝘞𝘪𝘵𝘩 𝘍𝘢𝘯𝘤𝘺 𝘚𝘬𝘪𝘭𝘭𝘴 𝘖𝘳 𝘎𝘦𝘢𝘳𝘴
One of the universal concepts in medical practice is that just because the symptoms have been relieved doesn't mean we find the cause and have it treated properly. Reaching an escalated new balance, symptom-free, can mislead practitioners and worsen the medical condition over time. Finding the root and tackling it accordingly is the only way to gain clinical success and long-term results.
In TCM, unblocking the meridian and restoring the free flow has been the most critical and fundamental principle of treating all painful disorders, including numbness. The question is: Are we doing so when it comes to numbness? What and how many fundamentals have been applied to numbness treatment?
Being an acupuncturist, the skill level has never been a problem that impedes clinical success if you keep practicing. Unfortunately, high-tech innovations and fancy toys offer nothing more than time-saving and procedural convenience when diagnosis and treatment strategies are based on an unsound basis.
In most cases, an incorrect diagnosis with the subsequent deviated treatment is the primary factor of undesired outcomes and constant relapse.
Correct treatment strategy
𝘜𝘯𝘣𝘭𝘰𝘤𝘬𝘪𝘯𝘨 𝘔𝘦𝘳𝘪𝘥𝘪𝘢𝘯𝘴 𝘈𝘯𝘥 𝘙𝘦𝘴𝘰𝘭𝘷𝘪𝘯𝘨 𝘌𝘹𝘤𝘦𝘴𝘴
For numbness caused by either the blocked upstream meridian(s) (true) or an excess exterior-interior meridian (false), the correct treatment strategy is to unblock the blockage or reduce the excess on the meridian that creates deficiency.
Fundamentals are fundamentals, and that's all that matters. Restoring meridian's free flow is the most critical fundamental principle of treating all painful disorders, including numbness.
1) 𝘛𝘳𝘦𝘢𝘵𝘪𝘯𝘨 𝘛𝘳𝘶𝘦 𝘋𝘦𝘧𝘪𝘤𝘪𝘦𝘯𝘤𝘪𝘦𝘴 (𝘉𝘭𝘰𝘤𝘬𝘦𝘥 𝘜𝘱𝘴𝘵𝘳𝘦𝘢𝘮 𝘔𝘦𝘳𝘪𝘥𝘪𝘢𝘯(𝘚)) The correct treatment strategy appears as the underlying mechanism of a true deficiency is understood. It is to resolve the excess on the blocked upstream meridian(s) and restore the free flow.
The best way to re-establish a blocked meridian's free flow is to provide a detour/meridian linkage, like a service road, while fixing the blockage by self-healing or acupuncture techniques.
The meridian system is an endless circle of flow. There are several types of connections or linkage between two meridians. The exterior-interior relationship is the most known among all and the right choice for treating a deficiency of this type (imagining a car wreck on a highway and a service road).
Hence, the Luo-connecting point on the exterior-interior meridian (the portal of a service road) is the only point required to instantly relieve a true numbness significantly in one session with the least relapse.
For example:
LU 7, the Luo-connecting point of LU, relieves the excess on LI. PC 6 for SJ excess, and SP 4 for ST excess, etc.
A reducing method is highly recommended to expedite the flow speed when the excess is severe or chronic. When utilizing the meridian linkage, the principle of choosing the same/opposite side should be applied. The same side when the connected meridian (service road) is a Yang meridian. The opposite side, when the connected meridian is a Yin meridian.
When the tissue or meridian damage is beyond the body's healing ability, a meridian linkage becomes necessary as a bypass before healing completes and the meridian resumes the flow. Moving vehicles bumper to bumper on either end of a broken bridge does not decongest the traffic. Trying to re-establish the flow on a badly damaged meridian by any means at this time may not be a practical option, for the damage can be too severe to be fixed any time soon. A meridian linkage (detour) and repair-expediting interventions should be incorporated simultaneously to restore the flow and speed up the healing process as well.
2) 𝘛𝘳𝘦𝘢𝘵𝘪𝘯𝘨 𝘛𝘩𝘦 𝘍𝘢𝘭𝘴𝘦 𝘋𝘦𝘧𝘪𝘤𝘪𝘦𝘯𝘤𝘪𝘦𝘴 (𝘌𝘹𝘤𝘦𝘴𝘴 𝘌𝘹𝘵𝘦𝘳𝘪𝘰𝘳-𝘐𝘯𝘵𝘦𝘳𝘪𝘰𝘳 𝘔𝘦𝘳𝘪𝘥𝘪𝘢𝘯)
Relative deficiency is an overlooked and rarely discussed subject in academic curriculum and clinical practice. Diagnosing an excess or a deficiency is not much of a problem for most practitioners. Still, only a tiny fraction have paid enough attention to the relative deficiency.
Since the source of a false numbness on a meridian is from the excess on its exterior-interior meridian, the affected meridian itself is actually free of flow without disorders. Therefore, any tonifying methods applied individually or aggregately to a normal meridian cannot solve the problem for obvious reasons.
The sensible and logical treatment strategy for treating a false numbness is to resolve its exterior-interior meridian excess. The best way is to utilize the namesake meridian linkage and reduction method(s).
There are two more types of meridian linkages on top of the exterior-interior relationship: Namesake and Zang-Fu crossover. But, again, those two types of meridian linkages did not present in the modern TCM education system as much as in ancient Chinese medical literature. Namesake linkage is to use a meridian that shares the same six-meridian name as a treating meridian, i.e., TaiYang (BL and SI), ShaoYang (GB and SJ), YangMing (ST and LI), ShaoYin (KI and HT), JueYin (LR and PC), and TaiYin (SP and LU). By accelerating the meridian flow, the excess can be reduced quickly. Two useful points on the namesake meridian are recommended. One is the Yuan-source point due to its universal indications regardless of excess/deficiency/cold/heat syndromes. Another is the horary point for its powerful momentum in driving meridian flow.
Again, tonification of the symptomatic meridian is not the correct way of treating false numbness and should be avoided.
If a normal, free-flow meridian is artificially "filled up" by tonification methods (though challenging but doable) and forcefully reaches the same escalated excess level as that of the exterior-interior meridian, yes, the symptoms reduce or disappear. However, the manipulated excess can impede Qi and blood flow and result in weakened muscle power or even atrophic change if the "flooded" status continues over time. It would be an iatrogenic complication created by a wrong diagnosis and treatment.
d. Summary
True or false numbness is not uncommon in our practice. It baffles many acupuncture practitioners in terms of diagnosis and treatment protocol formation. Seeing through the underlying mechanisms of numbness is the only way to simultaneously accomplish the cause management and symptomatic relief.
e. Behind the scene of the case analysis
If we can't boil an egg well, a cutting-edge pot won't make us a better chef. In this case analysis, the content includes nothing more than the most basic principles and fundamentals if you look into it mindfully.
1) Resuming the free flow and restoring the balance. 2) The five-element model. 3) The exterior-interior relationship. 4) Meridian linkages (though not drawing much attention in modern times) 5) Relative excess vs. deficiency (LR yang rising cases) 6) Yuan-source, Horary, and Luo-connecting points. 7) Tonification and reduction methods.
No mysterious points, wicked tricks, or fancy gears are required for a successful numbness treatment. Instead, we need to see through and understand the underlying mechanism to successfully treat meridian-originate numbness. It is just as simple yet critically important as the fundamental can be.
Section B — for PONAMS alumni
The following list is all you need:
Applying the modified 5-element model for lower limbs to your diagnosis.
The same injured area and severity check, as stated in Part A.
The concept of direct and reverse sequence and the relative deficiency.
Meridian linkage plus TAE (Tonify Assisting Element) for immediate numbness relief.
Most importantly, TP (Tonify Parents) for repairing the injured tissues (including nerves) and expediting the healing process in corresponding areas.
Section C — Case Analysis and Answers
Case study:
Chief complaint:
Motorbike accident with a right foot injury (see photos).
Present illness:
A 28 y/o female had a motorbike accident and hurt her right foot/ankle by landing on the curb and sliding on it for about 5 feet. Painful and bleeding ankle injuries were noted immediately. She was sent to the hospital for emergent treatment.
Past history:
This is the first significant accident and injury in her life. She lives a disciplined life with a regular and sound dietary/sleeping/activity pattern. She reports no history of cigarette smoking or alcohol drinking and has been a vegetarian for 10 years.
Physical exam:
Two L-shape lacerative flaps in the right foot above and below the lateral malleolus.
Irregular laceration wounds with foreign body contamination.
Swollen and bleeding open wounds with underlying muscles and tendons exposed.
A crack line, not broken, on the lower end of the right tibia.
No visible or noticeable ruptured tendons with limited ROM on all toes.
There are no visible major or minor nerve injuries, but it requires an additional exam to rule out potential nerve damage.
Twenty-one (21) days after the injury and five (5) days before stitches removal, she demonstrated the following symptoms as new chief complaints:
Numbness, right big toe from tip to the ball area.
Unable to flex up and down her right big toe.
Upon physical exam:
Numbness locations:
Five days before the stitch removal: Between the right big and the second toes, top of the foot (LR) > bottom of right foot (KI) > medial surface of the right big toe from tip to SP 3 (SP).
Seven days after the stitch removal: Numbness areas remain the same, but the intensity changed to LR > SP > KI with mild tingling (electric shock) on ST in the ankle between two wounds.
Lack of voluntary up/down movement of the right big toe as the rest of the toes remain limited mobility due to the tightness and tension from incomplete healing.
Conventional medicine has ruled out the possibility of major and minor nerve injuries.
Tenderness and skin hypersensitivity in the right foot and ankle over the injured areas.
Slight pale tongue with thin white coating, mild sublingual vein engorgement, mild wiry and slippery pulse on the left and right Guan-sections, respectively.
Please try to answer the following questions based on the above symptoms and the course of symptom transmission:
Why did the numbness happen only in non-injured areas?
Why the intensity of numbness changed from LR > KI > SP to LR > SP > KI?
What does the intensity change mean clinically?
What is your diagnosis?
What is the rationale for reaching the diagnosis?
What is your treatment protocol for numbness?
Hints:
The answer lies in the following fundamentals:
Careful history intake and physical examination (I did it for you already).
The five-element model and sequence of elements.
The area and severity of the injury (look carefully into the photos).
The exterior and interior relationship.
Answers:
1. Why did the numbness happen only in non-injured areas?
Because their excess exterior meridians cause deficiencies (numbness).
2. Why the intensity of numbness change from LR>KI>SP to LR>SP>KI?
It results from 1) direct vs. reverse sequence meridian flow and 2) the healing process of injured meridians/areas.
a. The injury severity on three Foot-Yang meridians, at first, was GB>ST>BL. So, GB generated the most reverse excess back to BL, adding more excess on top of BL's problem. It made BL, though less injured than ST, have more excess than that of ST and created more numbness on KI than SP. b. As the healing process began, the excess on all three Yang meridians started to reduce and flowed to the next meridian. The severely blocked GB received excess from BL on top of its own excess, making it the worst among the three. The less injured BL healed faster and cleared more excess up than ST, while ST received excess from GB. These changes re-prioritized the intensity of numbness from LR>KI>SP to LR>SP>KI.
3. What does the intensity change mean clinically?
The most significant meaning of the change is to predict where the injury and healing process leads. It also provides information about the diagnosis, treatment protocol formation, and the course of symptom transmission (CST) at the time of diagnosis. 4. What is your diagnosis?
In this case, the diagnosis is the relative deficiency (numbness) caused by their exterior-interior excess meridians.
5. What is the rationale for reaching the diagnosis? The diagnosis is reached by understanding the direct and reverse sequence of meridian flow, the exterior-interior relationship between meridians, and their clinical manifestations.
6. What is your treatment protocol for numbness? a. For general practitioners — Restoring the free flow of blocked meridians by using namesake linkage and reduction methods on Yuan-source or Horary points:
SI 4, SJ 4, LI 4 (Yuan) and BL 66, GB 41, ST 36 (Horary)
b. For PONAMS alumni — Applying linkage, TAE, TP, and corresponding F-points to restore free flow (Linkage), increase the meridian flow capacity (TAE), and repair the damaged tissues (TP). This case is a pure regional issue.
rAyIII/a/a rAyII/3+a+c/3+a+c rAyI/a+c/a+c
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