Dan Bensky, D.O.

One of the things that I enjoy most about studying Oriental medicine is the wide variety of insights into diagnosis and treatment available to us. We have access to wonderful work from many countries, including the original cauldrons of Oriental medicine China, Korea, and Japan. In addition, we can also learn from the work of modern experts in Europe (where acupuncture has had a 60 year head start) as well as other people in this field in the United States. All this work goes into the mix -- it is interesting to be part of the soup and speculate on how it will taste in the end.

In any case, one of the most interesting and useful concepts that I have learned is the local application of the eight parameters to musculoskeletal pain and the related system of barrier points. These concepts originated in the study groups and workshops of the French Acupuncture Association (AFA) over the last twenty years or so under the leadership of Jean-Marc Kespi, M.D. and imparted to me by Gérard Guillaume, M.D.¹ Peter Eckman, M.D. has also been helpful in clarifying important aspects of this concept to me. I would like to present, in an extremely over-simplified manner, some of the basic information about these ideas. Finally, I will give a short clinical example that demonstrates their usefulness.

EIGHT DIAGNOSTIC PARAMETERS

Most often the eight parameters are applied in a global, systemic manner. That is they are used to describe a snapshot picture of how the entire organism is functioning (or dysfunctioning) at present. As this is part of the basic understanding of all people in our field, I will omit any discussion of this application here.

The interesting thing that the French have done is apply these ideas to the diagnosis of local musculoskeletal pain. Simply, in terms of the eight diagnostic patterns, joint pain that is lessened with pressure or support is classified as deficient while that which gets worse is considered to be of an excess nature. Pain that is lessened by heat and increased by cold is considered to be of a cold nature. This can be due to either yang deficiency or yin excess. Pain that is lessened by cold and increased by heat is considered to be of a hot type. This can be either due to yin deficiency or yang excess. While exterior and interior can be described also, by and large, they do not come into play here.

Finally, there is the overall type of pain, which is classified as yin or yang. A yin-type pain is dull, throbbing, constant, of moderate intensity, chronic, occurring or aggravated at night, deep. A yang-type pain is sharp, violent, paroxysmal, stabbing, burning, intense, acute, diurnal, superficial. Putting all these things together, we can often (though by no means always) describe a specific patient's pain with such terms as yin deficiency, yang excess, etc. (see table 1).

AXES

The French place a very strong emphasis on the channels. One way in which this focus on the channels plays out is their belief that the twelve channels are more appropriately viewed as six pairs of channels. Each pair of channels is marked with the name of the same level. There are two greater yin channels, two lesser yang channels, etc. The functions of these pairs are related and so are the manifestations of their disharmonies. For this reason, instead of looking at something as a Lung Organ problem, they will view it as a Metal greater yin channel. This is in contrast to the Earth leg greater yin channel (Spleen). Both in diagnosis and treatment, this viewpoint opens up many very useful possibilities.

These pairs of channels are considered to resonate with six types of cosmic energy. In humans, when viewed as units, each of these pairs is known as an axis or great channel. The constitutions, functions, etc. of each pair is related not only to their description in the Inner Classic but also to the schema of the Book of Changes, Discussion of Cold-induced Disorders, and other sources. The understanding of these axes has been continuously developed, both is Asia and Europe, so that they now encompass both constitutions as well as specific disorders.

DIALECTIC OF MOTION

Another key idea in this school of French acupuncture is that there are several dialectical rules dealing with the phenomena of the organism. Most of these are implicit in the Inner Classic and other important traditional texts, although few are specifically stated there. Based on their analyses of these texts and their own clinical experience, Kespi and others have developed different ways at looking at channel flow and other physiological and pathological events. Most of these dialectics deal with motion or transformations involving three sets. These three sets are a further distillation of the six axes described above. Each set contains a yin and a yang axis. The sets are composed of channels the names of which includes the same (or similar) qualifier:

* Tài - greatest, the first, larger, oldest, mature, supreme, extreme. This refers to the greater yin and yang;

* Shào - lesser, a little, lacking, immature, young. This refers to the lesser yin and yang.

* Jué - to stumble, to fall, to collapse, to diminish, to exhaust, attenuated, terminal. This refers to the terminal yin and yang brightness.

Using each of these qualifiers, we can characterize the progression of various types of dialectics involving different aspects of life. Here, I will briefly discuss their dialectic of state as this is the one that it used to describe the movements of yin and yang that come into play within the system of barrier points.

Quantitatively, the state of phenomena can be classified in terms of one of these three sets as a function of their being relatively more or less yin or more or less yang. The most intense is tài, the least intense is jué, and the intermediate is shào. This relates to the meaning of the respective characters as greatest, exhausted, and lesser. Qualitatively, phenomena are defined in relation to their origins. What set they belong to depends on whether they are more or less characteristic or their origin. The most characteristic is tài, the least characteristic is jué, and the intermediate is shào. This relates to the meaning of the respective characters as supreme, exhausted or used up, and to lack.

For example, quantitatively the head is the most yang part of the body, so it is considered greater yang. Qualitatively, if one looks at the yang energy that leaves the trunk for the head, it is most characteristic of its origin where it leaves the trunk. Therefore, this area is considered to be greater yang. It is less so at the neck which is considered to be, in this context, lesser yang, and less still at the head which is then yang brightness. This way of looking at the movement of yin and yang is the basis of the barrier point system. When we describe a pain in a way that helps us decide how to treat it, deficiency of yang, excess of yin, etc., the mechanism for this description comes from this set of concepts.

BARRIER POINTS

The idea of barrier comes from the Chinese word guän , often translated as barrier or gate. Dr. Kespi and his associates were struck by the number of points that have this word in their name (either primary or alternate). They also noted the importance of the concept of barriers or gates in the discussion of joint problems in chapter 60 of the Basic Questions (Su wen).

In this view, each joint is considered as a place through which physiologic energies pass and which, under certain pathological circumstances, can turn into a barrier that obstructs the circulation of these energies. The yin and yang qi enter and exit the joints according to a centripetal and centrifugal pattern. It is important to note here that "yin qi" and "yang qi" here, to the best of my knowledge, does not refer to flow in the channels, nor flow in the yin or yang channels, nor even the difference between the protective qi (yang) and the nutritive qi (yin). Rather it refers to the sum total of all the various types of qi and other energies that circulate throught the human organism.

Grasping this this somewhat vague concept is crucial to utilizing the barier points. From this particular perspective, the qi is described in relation to its origin: greater yang or greater yin when it is close (proximal) to its origin, yang brightness or terminal yin when it is removed from (distal to) its origin, and lesser yang or lesser yin when it is in between.

Taking all the above together we can, for example, describe the qi circulation between the trunk and the limbs:

The yang qi that emerges from the trunk is:

* greater yang at the shoulders and hips,

* lesser yang at the elbows and knees,

* yang brightness at the wrists and ankles.

The yang qi that enters the trunk is:

* greater yang at the wrists and ankles,

* lesser yang at the elbows and knees,

* yang brightness at the shoulders and hips.

The yin qi that emerges from the trunk is:

* greater yin at the shoulders and hips,

* lesser yin at the elbows and knees,

* terminal yin at the wrists and ankles.

The yin qi that enters the trunk is:

* greater yin at the wrists and ankles,

* lesser yin at the elbows and knees,

* terminal yin at the shoulders and hips.

The point of view of this system is always looking at the body from the outside. A blockage of the qi in its outward movement causes an excess upstream (proximal) from the pathological joint and deficiency downstream (distal). An obstruction of the qi in its inward movement creates an excess upstream (distal) from the joint and a deficiency downstream. For example, if there is a blockage of the yang qi from the trunk toward the upper extremity it will manifest at the level of the shoulder with a yang excess upstream (at the scapula) and a yang deficiency downstream (in the arm). Conversely, if there is a problem with the entry of yang from the upper extremity to the trunk, it will manifest at the shoulder with a deficiency pain and excess in the arm. In any given patient, determining the direction in which the circulation is impaired can only be achieved through an analysis of pain according to the eight parameters.

As noted above, I have to admit that it is very unclear to me at this time what exactly is meant by yang emerging from the trunk or entering into the trunk. Is it a subset of qi; is it related to the various centripetal and centrifugal trajectories of the channels; or is it something else? What I can say is that the simple understanding that I do have enables me to clearly see how to treat some patients who were previously opaque to me.

With this idea in place, Kespi and his associates then postulated a system of "Barrier" points that rule the inward and outward movement of the yin and yang at the level of each joint. These are all located on their related primary channels. These points were first chosen on the basis of the indications attributed to them in traditional texts as well as the primary or secondary names. They were then used clinically to test their utility. Sometimes, it has not been clear what point, if any, should serve as a specific barrier point. When this happens, they use the cleft point on the corresponding channel. (see table 2)

When using this system, it has been easier for me to look at it as describing resonances, rather than actual circulation. That is problems of a "greater" level, yin or yang, looked at from the perspective of the trunk to the extremities, resonate at the shoulders and hips. This way of looking at the barrier point system is reinforced when we realize that many of the points are "downstream" from joints they unblock. For example, HT-6 (yin xi), is used for elbow problems whether from a problem with yin emerging from the trunk or entering it. In fact, most of the yin barrier points are cleft points.

I want to point out that the barrier point system is not limited to the peripheral joints. There are also barrier points described between the trunk and head and between the skull and face. These are useful for understanding such problems as headache and TMJ syndromes.

Using the barrier system according to the eight diagnostic parameters is based on a couple of premises. The most important can be summarized in the following manner, "Excess is defined by nonentry and deficiency is defined as nonexit." That is, viewed from the perspective of the outside, if the yang or yin cannot gain entry to the body, the extremities, which are distal or "upstream," become excessive (while the trunk may develop deficiency). Similarly, when there is a problem with the exit of yin or yang from the trunk, there is deficiency in the extremities (while there may be excess in the trunk). Based on this we can give a simple scheme for treating different types of shoulder pain: for yin excess use PC-2 (tian quan), for yin deficiency use LU-2 (yun men), for yang excess use LI-15 (jian yu), and for yang deficiency use SI-11 (tian zong).

CLINICAL EXAMPLE

One remarkable characteristic of the barrier points is that, when correctly chosen, their use can lead to almost immediate disappearance of pain. Of course, long-lasting relief depends on a treatment which includes addressing the underlying disharmonies.

Let us go briefly through a clinical example to demonstrate how the local application of the eight diagnostic parameters and the concept of barrier points are used in practice. A patient presents with right knee pain. The pain is worse with activity but also worse at night: these are signs of deficiency. Cool compresses help and the pain is worse in hot weather: this points to local heat. It feels good to rub the knee and the patient always wears an elastic brace when he runs or plays sports. This improvement with local support is another sign of deficiency. At the same time, he has abdominal distention, a sign of lesser yin excess. The diagnosis would be a nonexit of yin from the trunk to the lower extremities at the level of the lesser yin, leading to yin excess in the abdomen and a yin deficiency type of knee pain. For this type of knee pain, the barrier point to use would be KI-5 (shui quan). In my own experience, it is common to see immediate results from this treatment. Interestingly, people with this type of knee pain often have underlying Kidney problems or disharmony between the Kidneys and Heart.

SUMMARY

The barrier point system is an interesting and useful set of points and treatments. They were developed recently by physicians in France, based on their understanding of classical references and clinical experience. While merely treating the barrier points is not sufficient to obtain a lasting resolution of a problem, their proper utilization can give immediate relief. In addition, the selection of the correct barrier point helps us understand what the root of the problem might be and how best to treat it.