45. Treatment planning
Chapter contents
Introduction346
The three main stages of treatment planning346
Some guidelines for treatment planning348
Dealing with patients who are not progressing sufficiently354
Introduction
Having taken the patient’s case history and made a diagnosis, the practitioner is now ready to plan the treatment. The first section describes the three main stages of treatment planning. The second section takes this to a greater depth and describes some guidelines for treatment planning. The third section then describes how to deal with patients who are not progressing sufficiently.
The three main stages of treatment planning
These are:
1 summarising the diagnosis
2 forming an overall treatment strategy
3 planning the individual treatments
Summarising the diagnosis
When making the diagnosis the practitioner picks out the significant findings from the case history and answers some basic questions such as:
• What is the patient’s CF?
• Which other Elements are in distress?
• Are there any important blocks to treatment?
• What is the primary level of body, mind or spirit?
The case history should be detailed and if possible written in the patient’s own words. It should give the specifics of the patient’s complaint(s) and also information about the main systems such as sleep, appetite, bowels, etc. It should additionally contain details of the patient’s health, personal and family history, relationships and present situation as well as a physical examination (see Chapter 24; see also checklist for a traditional diagnosis in Appendix F).
At this stage of treatment planning it is useful to have a summary of the answers to the questions listed above. An example of this appears below. Variations in the headings may occur, but most of these headings are essential. The example below is written in some depth and many practitioners will write this in a more shorthand form.
Diagnosis Sheet
Name: Josephine Bloggs, Age 46
Patient’s main complaint: Poor sleep, anxiety, lack of confidence.
Secondary complaints: Headaches prior to periods. Occasional backache.
CF: Fire. Josephine looks lack of red beside her eyes. Although she appeared to enjoy interacting with me she only stayed animated if I kept contact with her. The rest of the time she seemed to drop into a flat and sad state with a joyless voice tone. Occasionally a brilliant smile would fleetingly light up her whole face, but it would quickly fade and the rest of the time she found it hard to raise a smile. When carrying out the physical examination I smelt a scorched odour.
Pulses: Her third position and her Ht and SI pulses were very deficient.
| Left | Right | ||
|---|---|---|---|
| SI −2 | Ht −2 | Lu −1 | LI −1 |
| GB +½ | Liv +½ | Sp −1 | St −1 |
| Bl −2 | Kid −2 | PC −2 | TB −2 |
Next most likely CF: Wood. She has a green colour around her mouth. At times she can seem overly assertive. At other times her ability to assert herself seems normal. She expresses a lot of frustration about her personal life. Wood may need additional help later on in treatment. Her Liv and GB pulses felt slightly full.
Other Elements: Earth. She took sympathy well and I could not see any yellow colour or hear any singing. Water. She gets anxious but this seems more to do with her Heart. She showed appropriate fear when asked about the future. No blue colour. Metal. She seemed to take in respect well. Could go back and do more tests on Metal.
Blocks:
H–W: No reason to suspect.
AE: Possible, need to test.
Possession: Internal: Possible, eyes glazed over and has many ‘spooky dreams’ External: Unlikely
Entry–Exit: Possibly between Wood and Metal, re-evaluate after first few treatments.
Level
Body: No apparent reason to think so. Problems seem to arise from internal rather than external or miscellaneous causes.
Mind: Josephine often does not think clearly, but there are many times in her work and when chatting in the treatment room where her mind works well.
Spirit: Josephine has a worn, hurt look, deep in her eyes. It is not always there, but shows when she is unattended and I look back. Primary level is spirit.
Physical examination: Upper and Lower Burners are cold. Front mu point for Heart – Ren 14 – is tender. Akabane: Heart 15/7; Spleen 5/10.
Any uncertainty about the diagnosis should be expressed on this sheet. For example, if practitioners can’t decide between two CFs, then they may state which one it is more likely to be and give a case for both. Indeed, in the full text of the case history, any information gained from each Element should be noted. This may include colour, sound, emotion, odour, ‘golden keys’ or any other secondary diagnostic information.
Forming an overall treatment strategy
When the summary of the diagnosis is complete, the practitioner can plan the treatment strategy. The diagnosis indicates the general direction of treatment. The treatment strategy then specifies the overall way that the treatments might be carried out.
Planning a treatment strategy
Planning an effective treatment strategy involves discussion of these questions:
1 Which treatment principles to use and order of priority?
2 What are the appropriate points to use?
3 What is the appropriate number of points to use?
4 Is moxa appropriate? If so, how much, and on which points?
5 Might there be any patient variations? For example, the patient may be particularly irritable and have other pre-menstrual signs prior to her period.
6 Are there lifestyle changes that the patient needs to make?
7 What change might the practitioner expect to see when the patient gets better?
Treatment principles
Treatment principles describe the treatment that will be carried out and help the practitioner to choose which points to use. The practitioner formulates the treatment principles from the areas listed on the diagnosis sheet and the case history. Each treatment principle will be different according to the patients’ diagnoses. Here are some examples:
1 strengthen and warm the Earth CF
2 balance Husband–Wife imbalance
3 remove Aggressive Energy
4 strengthen Metal CF at the level of the Spirit
Below is an example of a treatment strategy made by Josephine’s practitioner before her treatment began. Once the main treatment principles have been formed, they should also be prioritised and listed in the order that the treatment might be carried out.
Treatment Strategy for Josephine
Treatment principles and order of priority
• Release the Internal Dragons.
• Check for Aggressive Energy.
• Balance Akabane.
• Strengthen and warm Fire CF at the spirit level.
• Treat Wood Element if necessary.
Examples of appropriate points to use
1. Release Internal Dragons: Point below Ren 15, St 25, St 32, St 41
2. Clear Aggressive Energy: Bl 13, 14, 18, 20 and 23
3. Balance Akabane: Ht 5 Right side
4. Warm Fire CF: Examples could be TB 4 and PC 7, TB 3 and PC 9, TB 5 and PC 6, Bl 14 and 22 with moxa and needle. If need to treat Heart and Small Intestine side of Fire use SI 4 and Ht 7, SI 3 and Ht 9, SI 5 and Ht 8, Bl 27 and 15, etc. Later spirit points such as Bl 43, Ren 15, PC 2, etc. or Ht 1, SI 11, Ren 14, etc., might be included.
5. Treat Wood: Liv 3, GB 40 and other points on the Wood channels.
Appropriate number of points to use
Small number of points as treatment is directed to spirit level.
Moxa, if appropriate how much, and on which points?
Patient feels the cold and upper and lower jiao are cold so moxa is appropriate. Use on points of Fire Element.
Patient variations
May need to treat her Wood Element prior to her period.
Lifestyle changes that the patient may need to make
Suggest she finishes working and has some quiet time before going to bed in order to help sleep. Suggest she eats a nourishing diet and not on the run.
How to assess if the patient is improving
The deep look of hurt in her eyes will be lessened. She will be able to laugh more. She will be able to consider entering a relationship. Her sleep will be better. Her periods will be heavier. She will be calmer and less anxious. Her pulses will become stronger and more settled.
Planning the individual treatments
Having created a treatment strategy, practitioners can then plan what they will do on the actual day of treatment.
Planning the first treatment
The first treatment is different from subsequent treatments. This is because the practitioner is not yet certain about the diagnosis and is still at the stage of testing the CF. Some blocks may also need to be cleared before treatment can progress.
Planning subsequent treatments
At the start of all subsequent treatments practitioners obtain feedback from patients about their progress. Based on this feedback, the practitioner then plans the next treatment. According to the patient’s progress the treatment principles may be reassessed and changed. Alternatively they may be kept the same. The skill of taking feedback and assessing the patient’s response to an individual treatment is a crucial part of the planning process. Failure to do this can result in irrelevant and ineffective treatments. The more carefully the options are considered, the quicker the practitioner’s experience accumulates. This process also enables practitioners to take a fresh approach to every treatment and ensures that they don’t become stale or routine after seeing a patient over a period of time. Once the CF has been established the Five Element Constitutional Acupuncturist may change the points used at the treatment. These will vary according to the state of the patient.
Some guidelines for treatment planning
When deciding which treatment to carry out, the practitioner follows various guidelines. Some of these may be irrelevant for a particular treatment, but the practitioner should consider them all and be guided by them in the right circumstances. Some different areas that are considered are:
1 clearing blocks first
2 treating the CF
3 correcting left/right imbalances (Akabane)
4 how many points to use in one treatment
5 the frequency of treatment
6 if treatment is not sufficiently effective, what are the possibilities?
7 responding to a patient’s lack of progress
8 prognosis
Clearing blocks first
The process of clearing and strengthening
If any of the four blocks to treatment discussed in Chapters 29, 30, 31, 32 and 33 are present, they must be cleared first. Without clearing one or more of the four blocks first, the normal strengthening or balancing treatments are less likely to be effective. The ‘blocks’ are:
• Possession
• Aggressive Energy
• Husband–Wife imbalance
• Entry–Exit blocks
The process for clearing a block is given in the chapters on blocks to treatment (Chapters 29, 30, 31, 32 and 33, this volume).
If more than one block is present, then they should be cleared in the order listed above. The order of priority implies that some blocks are more pervasive than others. For example, it may be difficult to clear Aggressive Energy if the patient is possessed.
Do the blocks get cleared in one treatment?
A block is frequently cleared in a single treatment. On the other hand some blocks such as a Husband–Wife imbalance can take more than one treatment to resolve completely.
Sometimes blocks can return after they have been cleared and the practitioner should then be prepared to repeat the treatment. At the same time, the practitioner needs to attempt to understand why the block has recurred. For example, a block between Liv 14 and Lu 1 may reappear for a number of different reasons. One reason may be a serious condition, such as a tumour, existing in the lungs. Alternatively it may be because a person frequently becomes overwhelmed by resentment because of an ongoing life situation.
The reappearance of a block may raise further questions about the patient’s state of health. In the case of possession, one treatment is often sufficient, but there are cases where the treatment is repeated to very good effect. Patients whose spirit is weak and who are still in the situation that caused the possession can become possessed again. If this occurs, the treatment is repeated. When the patient is clear again, there is a new urgency to begin the strengthening process to avoid a further regression.
Clearing blocks during ongoing treatment
Normally practitioners clear any blocks they think are present before moving on to treating the patient’s CF. There are two situations, however, when a block may need to be treated at a later stage in the patient’s treatment.
Firstly, the block may have been present when treatment commenced, but was not apparent to the practitioner. It may only emerge later that this block is preventing the treatment from progressing at its normal rate. Clearing the block then allows treatment to progress normally.
Secondly, but less commonly, a block may arise after treatment has begun. In this case it is usually because the patient’s physical or psychological health has deteriorated significantly. For example, if the patient contracts a major illness it may be worth re-testing for Aggressive Energy. If the patient becomes extremely psychologically traumatised, possession should at least be considered. A Husband–Wife imbalance may arise if the patient becomes very distressed, especially if it is concerning an intimate relationship. Husband–Wife imbalances may also arise if the patient’s health deteriorates to such an extent that their grip on life itself is starting to loosen.
Entry–Exit blocks are the exception to this rule. They are often not apparent at the beginning of treatment and become evident as treatment progresses. This sometimes occurs when a patient has previously been making good progress. As extra qi is generated from treatment an Entry or Exit connection that was previously partially blocked can become seriously blocked because a greater amount of qi is travelling through it. In this case the treatment may stop working until the block has been cleared.
Correcting left/right imbalances
If a patient has an imbalance between the channel on the left and right sides (an Akabane imbalance), this can be corrected by treating the side of the patient that is the weakest. This imbalance is found by heating the nail points of the channels. Its presence is indicated when there is a disparity between the time it takes to warm the nail point on one side as opposed to the other. For example, if the number of passes on the Spleen nail points is 10 on the left and 5 on the right, then the left side is weaker. This is notated as 10/5. To treat the above imbalance, the Spleen luo junction point (Sp 4) is tonified on the left side. The test is then carried out again and the practitioner usually finds that the Akabane has become balanced. If it is still imbalanced then the yuan source point of the affected side can also be treated. (See Chapter 28, this volume, for more about the Akabane test.)
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
