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1 1 Editor: Dr. Holmes Keikobad MBBS DPH Dip Ac NCCAOM L Ac Vol VI Issue 11 July 2009 Copyright acu-free.com LLC Free Online Edition Published by acufree.com INC

2 2 TERMS OF USE This Bulletin can be studied only as a download from its home on the web page It is OK to download a copy to your computer for your own personal use. Making hard copies for distribution in any way without written permission violates Federal Copyright Laws creating a liability which could result in steep fines or worse. If you want a colleague to be informed of the publication of Issues on a regular basis, request them to send an to that effect to ceus@acu-free.com or for sporadic access, simply have them access the web page It is not OK to excerpt material, part or whole, to teach, or include in a course. If you wish to do so, send in a request to the ceus@acu-free.com and we will gladly consider it. If you are an Association of Acupuncture for a State, you can get a hard copy of the Issue mailed to you free of cost. To receive that send an to ceus@acu-free.com making the request inputting full details of your organization. We acu-free.com really go to great INC. lengths All rights to research reserved. and write expert discussions and get the Bulletin to you, free of any cost or encumbrance. You can help us incredibly by making certain the Terms of Use are respected. In every sense of the word, Acupuncture is everyone s heritage. This Bulletin continues to guard and expand that great wisdom. With best wishes Dr. Holmes Keikobad Editor

3 3 The previous parts in earlier Issues went well, it is hoped you had a chance to study those. Over centuries medical students have begun their first day holding on to, gingerly, a femur or humerus, while the Dissection Assistant explains its mysteries. It is possible some in the alternate fields did not get as much exposure, and this Bulletin tries in part to remedy that. The images as explained earlier are obtained at great difficulty, and where permitted by the owner, to be amended. The anatomical insight into the location in the body you are working on gives you grounding, so you can deal with a problem more effectively. Please be kind to the images and use these only in the framework of this Bulletin. Make it a point to have fun on your journey.

4 4 By Dr. Holmes Keikobad Bachelor of Medicine & Surgery, Diplomate in Public Health Dip AC NCCAOM LAc Imagine the weight of the skull and the pull it must make on the neck, most of it occurring at the interface of the skull with the Cervical 1 vertebra, picturesquely called the Atlas. Next imagine the force exerted during a car accident or when a swimmer dives in shallow waters, on the Atlas or the Axis, C 2, or the rest of the vertebrae C 3 to C 7, and Thoracic 1 with which the latter is associated in conditions of trauma, and one wonders at the exquisite mechanism of the neck, with its central vertebral column, ligaments, discs, muscles and fascia, as well the nerves, arteries, veins, lymphatics, which keep the neck safe, stable and functional throughout life. A primary sign in cases of neck pain is restricted movement. Can you enumerate the normal movements possible at the neck, like flexion, extension etc? Note that when we say neck we mean part or whole of the cervical column, it being well nigh impossible to make a movement exclusively at the C1 - skull interface and not involve all Cervicals, or at least the upper ones. Answer next page.

5 5 Answer Movements at the neck: 1. Flexion, a forward movement from a vertical position 2. Extension, a backward movement from a vertical position 3. Abduction, bending neck left and right from a vertical position 4. Adduction, returning neck back to vertical from abducted position 5. A combination movement of flexion and abduction to left 6. A combination movement of flexion and abduction to right 7. A combination movement of extension and abduction to left 8. A combination movement of extension and abduction to right 9. A rotation of neck on central axis from left to right [looking to right] 10. A rotation of neck on central axis from right to left [looking to left] Movements 1 and 2 take place predominantly at the joint between Atlas and the skull, the atalanto-occipital joint. Movements 9 and 10 happens almost entirely at the joint between C1 and C2, the atlanto-axial joint. When examining your patients for a neck problem make it a practice, with due safeguards, to have them go through all the movements. If one or more are restricted or cause pain, this will localize the area you would look at for problems. What kind of cases are you likely to see in your clinic? i. A neck sprain ii. A whiplash injury from a car accident iii. An occupation-related pain such as working on computers iv. Pain of a slipped disc v. Pain from a degenerative change in vertebrae vi. Rheumatic pain in neck vii. The fairly common acu-free.com Cold invasion INC. in a All weak rights channel reserved. viii. Same thing but with Damp invading, as when sleeping in the open ix. Pain from a pulled ligament, more common in athletes and the sporadic worker outer x. Not to forget the fairly common reflected pain from a carpal tunnel situation xi. Same, from an avid Blackberry user or frequent text message exponent Don t forget, in a case of neck pain where no other etiology is found, to look at the feet, to check if the patient has fallen arches. Flat feet sooner or later upset the equilibrium of the spine and upper body to cause misalignment and pain, particularly of the neck. [Exception, 80% of black folk have naturally flat feet with no ill effects]. In terms of pathogens in the Traditional sense, look for an invasion by Cold, then Damp, then Wind. Heat and Fire rarely invade but come up from within, in which case you are looking at a Deficiency pretending to be an Excess. In neck problems also rule out Weak or Empty Qi in the channel pervading that area. A common picture: Organ Weak > channel Empty > something Invading.

6 6 The neck is structured around its axis, the vertebral column. This is composed of a series of specialized bones with appendages on the outside and the canal to carry the spinal nerve bundle, the spinal chord, inside, and discs in between. When you work with the neck, keep in mind the basic structure of a typical single vertebra found say in the thoraco lumbar section, and set it of against the various cervical vertebrae, most of which have a very different structure. Here is a typical thoraco lumbar vertebra with an antero posterior orientation [ap] which will be symmetrical with the Saggital plane, and a lateral one [lat] with the coronal plane. How many parts can you identify off hand? Answers next page. ap lat lat ap

7 7 Parts of a vertebra a. Anterior to the coronal plane [lat], the body b. On the coronal plane, the transverse processes c. Posterior to the coronal plane, the spine and articular surfaces We could, based on the obliging geometry, further subdivide the arrangement to obtain 4 sectors; i. Antero lateral right & left ii. Postero lateral right & left You will notice that most of the protruding bony appendages fall into postero lateral sectors. As a consequence most powerful of the muscles in the neck are found here. When there are problems such as whiplash injury, or the dramatic acute Sprain in the neck, the postero lateral aspect of the neck are the place to look for, for the injury. Anterior quadrants? Bony injury such a fracture; rupture of disc and degenerative changes such as osteo arthritis. By the way this is what the writer means about the importance of Applied Anatomy in Acupuncture when he teaches it, where dry bones come alive with vivid usages which help to diagnose and treat. ap Body Transverse process lat lat Articular surfaces Spine ap

8 8 C1 cervical vertebrae Cervical vertebrae C1, C2 and C7 See the typical vertebra and see the marked differences with the 3 cervical vertebrae, C1 C2 and C7. C2 C1 foramen The most marked difference is in the spine which in C1 is minute and nearly redundant, and hugely prominent in C7. Next the body, in C1 it is minuscule, in C2 somewhat developed, in C7 well marked but nowhere near the size of the typical vertebra from thoraco lumbar region at the bottom. See the variation in the transverse processes with C7 nearly conforming to the size and shape seen in lower typical vertebrae. Now notice the most remarkable feature in the cervical vertebrae which you don t see in the typical one. Did you find it? It is the foramen, which you see only in the neck vertebrae and nowhere else. C7 From C1 to C6 this gives passage to the vertebral artery and vein and a plexus of sympathetic nerves. Any pathology which affects the structure of these vertebrae will sooner or later disturb the blood flow and cause anomalous reactions of a sympathetic nature. Typical non cervical vertebra Often you will have to order X-Rays to exclude anything from a hairline fracture to degenerative changes to a slipped disc to even a slipped vertebra, which is actually a dislocated vertebra which has become unanchored and has slipped anteriorly, or there was a collapse of the body of the vertebra due to infection or degenerative changes. On the next page there is a plain X-Ray of the neck where all the vertebrae are seen in their natural state.

9 9 Typical thoracic vertebrae 1, lateral view See the spines, formidable and prominent This is a probe which signifies the spinal chord Next check the body, tough and broad The articular surfaces for the ribs Articular surfaces for vertebrae above and below Now that you have a fair idea of variations in vertebrae, lets look at the actual bones in an X-Ray [see overleaf]

10 10 X-Ray Neck The most common exposures usually ordered are Posterior Antero (PA), and Lateral (Lat). The most common conditions this is done for are: 1. A fracture or dislocation. 2. A ruptured disk. 3. A degenerated vertebra. 4. A misaligned vertebra This is a plain X-Ray of the normal neck taken in R Lat position: how many structures that you normally see can you now identify? Answer next page.

11 11 Structures visible: 1 base of skull; 2 Atlas - skull joint; 3 maxillary sinus; 4 mandible connecting to skull; 5 angle of mandible; 6 teeth; 7 fillings in teeth; 8 transverse process of Atlas over lapping Axis; 9 intervertebral discs; 10 spine of Atlas; 11 spine of Axis; 12 collectively, spines of C3 to C6; 13 spine of C13; 14 larynx; 15 trachea and air in it C C2 5 C3 12 C4 9 C5 14 C6 6 7 C7 15

12 12 How to surface-mark vertebrae in the neck Sometimes you will need to narrow down a particular vertebra in the neck, and in a bulky person that can be difficult. Here are some time honored markers in the anterior aspect of face and neck which can help do that: Have the patient sit at the table with back and neck straight and the head held steady looking directly forwards: An imaginary horizontal line at the base of the nose projecting posteriorly will correspond to C1 One at the teeth with mouth shut will corresponds to C2 One at mandible and hyoid bone correspond to C3 One at the thyroid cartilage will correspond to C4 - C5 One at the cricoid cartilage will correspond to C6 - C7. Thyroid cartilage is the voice box the two plates of which meet in the midline to form the prominence in men, Adam s Apple. Slip your finger down the midline and over the thyroid cartilage till it meets a ring like structure just inferior to it, that is the cricoid. Channels in the neck See these in 3 groups, posterior; anterior and lateral. In practice you may hardly ever find occasion to use a point on a channel on any one of the groups, it being expedient, because of the critical underlying structures, to use remote points to create the same effect you might get from a local point. Here are the channels with their elemental attributes: Channels on posterior aspect of neck: The Du channel in midline; the near chain and far chain of UB Channels on lateral aspect of neck: GB; SI; LI Channels on anterior aspect of neck: Ren channel in midline; ST Elemental disposition of neck sectors For problems on posterior aspect of neck treat UB channel [UB rules the back] For problems on lateral aspect of neck treat GB channel [GB rules the sides] For problems on anterior aspect of neck treat ST channel [ST rules the front] Space restricts going into clinical conditions and actual point prescriptions; perhaps in another issue.

13 13 How to assess a spinal injury based on cervical lordosis As you noticed that the cervical spine has a curvature towards the antero posterior aspect in the Saggital plane. This is a normal curve which is concave anteriorly and is termed a lordosis type of curve. Lower down on the spine the curvature reverses to become convex and continues to change till it reaches the coccyx. You might be called upon to treat a case of neck injury such as from a whiplash due to a car injury. In which case at history taking stage you will have to measure the cervical curve and match the C2 degree of curvature against the normal of and decide if it is increased or decreased. At final assessment when treatment has completed you will take another X-Ray and compute a reading to assess if the curve has improved or is still there. One easy way to do an assessment is by plotting the curve on the plain X-Ray taken in the R or L lateral position. For this you can either plot directly on a plate, or get a download of the plate as an image file into your computer and do the same with a desk top program. C7 Here are the steps: 1. Locate C2 and its posterior border [med students in viva voce often mark the anterior border much to the joy of the burly Assistant Professor who is examining them in the final run to graduation] 2. On the physical X-Ray or more preferably in the plate in your computer screen, using a ruler, draw a straight line which just adjoins the posterior border, extending it below and across where C7 is located 3. Now locate the posterior border of C7 and draw another line so that it bisects the first one 4. You will notice that the two make an angle, and that it is decidedly an acute one 5. Now use the protractor to measure the angle, either on the physical plate, or on the screen where your image must be in full screen mode Reading results: i. If the angle is between 21 and 34 a normal cervical lordosis is indicated ii. If the angle is <21 or >34 a pathological cervical lordosis is indicated When the cervical lordosis is reported pathological, insurance company allows compensation, and pays for the treatment. The lordosis can also serve to assess permanent disability. In next Issue: anterior aspect of neck and structures within it such as larynx, trachea etc

14 14 Here are some questions you can test your knowledge against. Answers in bottom of page: Q. 1 A primary sign in cases of neck pain is A. An overly flexible joint. B. Restricted movement. Q. 2 The second cervical vertebra is also called: A. The Atlas B. The Axis. Q. 3 Cervical vertebrae differ from the rest by the: A. The large spine. B. Foramen they have in the transverse processes. Q. 4 The normal degree of lordosis curve in the cervical vertebrae is: A. 67 degrees. B. 21 to 34 degrees. Q. 5 The one cervical vertebra with a redundant spine is: A. C1 B. C7 We will work with structures in the neck in the anterior aspect such as larynx, trachea, esophagus, the thyroid and s on. There are hardly any points there that one is likely to use because of the structures which are vulnerable to accidents, yet the Qi pathways are paramount and need study. For instance the Ren rises in that area, while the Stomach descends. One is an Extraordinary vessel which is in a loop with the Du vessel posteriorly, both rising and almost coming together when the lips are apposed; the other is the great Yang Ming, taking Qi from the face to the feet. In a sense the tapestry of the body, the canvas which carries the Qi trajectories, is the most intense in the neck, particularly in its anterior aspect, which is also its ventral Yin aspect. Correct answers: Q 1. B; Q 2. B; Q 3. B; Q 4. B; Q 5. A

15 15 BY CAROL ANDRADE MS PhD LAc TRANSFERENCE AND COUNTER-TRANSFERENCE This the second in our three part series on working with Elders, an honor that we all may have the good fortune to deal with, on the other side of the equation, if we live long enough to tell the tale. In this discussion, we will work on two inner issues as they apply to the seniors who which seek out our care. Transference, Counter-transference, are Psychological terms, which outline a series of ways of thinking, feeling and behaving. It is always helpful to understand your own relationship to these issues in any relationship, but doubly important in a therapeutic one. All of these processes are not necessary pathological. But as as a medical professional, it is important to be aware of, understand and monitor them continuously. 1. Transference is the redirection of feelings that the client has for another person in their life, for instance towards a professional who is caring for them. 2. Counter-transference is the redirection of feelings that the professional has toward another person in their life, for instance towards a patient. Transference is a common, everyday experience in all of our lives. Your son reminds you of your uncle. Your wife wears her hair just like your first girlfriend. Your best friend makes a face, or has a voice like your favorite teacher from grade school. You may acknowledge the similarity and experience a bleed through for an instant but you do not act out the feelings of the original relationship, or unconsciously mix up who is who.

16 16 These are all transferences that you aware of, but not vulnerable to. As in, you do not regress into that other relationship, nor have unrealistic expectations concerning the present one. In truth, you may merely look on with bemused awareness or wonder at the similarities amidst the characters in your own human drama. Now, let us look at transference by a client to you as the healing professional that is not so fortunate. Mary Doe who is in her eighties, but has all of her wits about her, enters your office, and immediately sees or hears something in you, that reminds her of her long lost son. She then transfers all of her feelings towards her son upon you, but is unconscious she has done so. She is not senile at all, but you, without your permission, consent, or awareness, are now in her world view, her son. This fantasy relationship will mar the professional healing relationship you are working so hard to set up. At first, it appears that all is well, as Mary Doe adores you. She does everything that you suggest and is more than happy with your care. However, lo and behold, suddenly, when you forget her birthday (an event that happened to great detriment 40 years ago with the real son in question) suddenly you are to be treated with disapproval. She is furious, you are now not a caring professional at all! It seems counter intuitive, but if someone for no reason utterly adores you you are in for trouble. What is to be done? You are not in a position to process out her feelings, but it is always important to verify your real role with her, as in reminding her gracefully and gently who you really are to her, and what your plan of action is for your interactions. You might apologize, acu-free.com (not that INC. you All have rights hurt reserved. her, but that she feels hurt), but also remind her that NONE OF YOUR OTHER PATIENTS GET BIRTHDAY CARDS EITHER. But, she may be even more insulted now that you have called the real nature of the relationship into play. Hopefully, she suddenly recalls that this event now reminds her of her son s behavior, and come into the present or not. Be ready for either scenario with patience, and great observational skill. If suddenly, for no reason that you can discern you are persona non grata, or suddenly removed from the pedestal with a diminishing sweep of the hand, or worse, she leaves your care, then you might want to see her exit with complete equanimity, as a transference gone wrong. This does not mean that you do not feel disappointment, or recognize that you have attempted to do your best, no matter how things transpired. It just means that you are aware that her issues may be getting in the way of the care you offer, and you do not take it personally, because after all, it does not really have anything to do with you either personally or professionally. You were just an inadvertent trigger.

17 17 Now let us turn it the other way around. Joe Doe enters your office. He is an elderly man with many issues and he needs your help, but he reminds you of a man who molested you as a child. It is not an obvious resemblance, and you are not conscious of why you dislike him on sight. When you work with him, you think him demanding and difficult. You react briskly and try to take control of the situation, but his complaints do not cause compassion in you. In addition, he is a difficult case, and not the most pleasant of people, but that is not the issue. If you do not internally check to see if there is counter-transference going on with you, you may inadvertently dismiss his complaints out of hand, or get truly angry with him when he is not grateful. In all cases, if there are feelings or experiences over which you do not seem to have understanding and control, then simply ask yourself, DOES THIS PERSON REMIND ME OF SOMEONE? Make sure you check out how they move, speak, behave, the way they dress, their hair, even the way they smell. Then work on yourself by acknowledging that they remind you of that person, but THEY ARE NOT THAT PERSON. Usually when you work out your own counter transference issues, then a truly amazing thing happens, you suddenly can clearly see how this person is different than the historical person, and you are free to experience the new person as an individual. You are still free to dislike this person, or find them difficult, if that is how you actually feel, but that reaction is based on reality, instead of a fantasy projection. If you feel you are incapable of managing this, then it is also very professional for you to make a referral. Admitting your difficulty with this hurdle is a caring and concerned response for both your client and yourself. If it is a significant event, then get help with it. acu-free.com Process it with INC. a therapist, All rights mentor reserved. or professional that understands these issues, and let someone else who does not have these counter-transference issues, help the patient. It makes you a better professional when you can admit your humanity, instead of seeing this as a detriment. When you are working with seniors, it is very understandable that countertransference issues surrounding parents, grandparents, and the elders of your youth, may come into play for you. In addition, if you are younger than your patients are, transference issues surrounding their children, grandchildren, or their own childhood may come into play. When you begin to see things from this perspective, then many of the relational issues you become involved with begin to make sense. The very highest human interaction occurs when the two people interacting are completely clear who they are to each other, and there are no ghosts in the room. [Conclusion in next Issue]

18 18 Advertisement - Ads appear only on this page so your reading pleasure is not interrupted. Acufree.Com, the sponsors of this Bulletin, offer expert distance learning courses created by the same team which authors many of the articles in the Bulletin. Courses accepted with NCCAOM & approved in AK AR FL GA ID IN MA ME MD MT NC NH NM RI TX & most States. AZ accepts NCCAOM. Check out specific approval Most Workbooks delivered by , some by Priority USPS at no extra cost. Economical. Treating Low Back Pain 25 CREDITS - $ NCCAOM CA MA MD & Most States - downloaded same day. Send Quiz by and get Certificate same day by . No extra cost Course content - 4 Parts, 82 pages. Topics include: * demarcation of back pain; * curves in spinal cord; * structure of vertebrae; * inter vertebral discs; * anatomy of spine, shoulder and hip girdles; * structural weaknesses in skeleton; * risk factors;* Back pain in Western Medicine; * role fallen arches and shoulder-hip differences in back pain; * Qi Transfer System; * relationships between 5 elements; * the 50th Difficult Issue; * the Back Pain Elemental Pattern; * conditions which require surgical intervention; * diagnosis in Western Medicine & Traditional Medicine; * Signs and Symptoms in Traditional Medicine; * tongue profiles; face color signs; * reading X-Rays and MRI scans, actual patients. * includes treatment Also included, a discussion on neck and shoulder pain, sprain of back acufree.com LLC. All rights reserved. Check out many other courses earning credits: Or call TRU.SELF

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