Sweat Lodge: Temazcal - The Traditional Mexican Sweat Bath

Dr. Horacio Rojas Alba
Instituto Mexicano de Medicinas Tradicionales Tlahuilli A.C.
Introduction
Some ten years or so ago, a renewed interest in the ancient sweat bath, still called by the name given to by the Aztecs, the Temazcal, sprang up in Mexico, a part of the movement, now so widespread in this country, to return, once again to the healing practices preserved in their traditional medicine. These sweat baths, still a living tradition in many parts of the country, are usually small round stone or mud structures looking rather like old fashioned bee-hives. Many more began to be constructed everywhere, and more and more often, people who are ailing will turn to them for relief from their complaints.

Sweat baths, of course, are used known in many cultures of the world, both ancient and modern. The sauna of Scandinavia is famous, as is the hamem of north Africa and Turkey. In the ruins of Pompeii there are the remains of sweat baths, and in India, people lay in the sun, covered with leaves to protect themselves from the burning rays of the sun, to bring on sweating. It is, of course, a well-known part of the culture of our own Indians, and in this form, the sweat lodge, they, too, are enjoying renewed popularity.

The traditional Mexican sweat bath, however, differs in several ways from the others. It is not primarily used for ceremonial purposes, as is the sweat lodge of our indians, nor for relaxation or bodily cleansing or for general well-being, as are most of the other sweat baths, It is and was, as far back as we can trace it, a therapeutic instrument, an arm of the medical practices developed in what anthropologists like to call, Mesoamerica, that vast area that now includes Mexico, Guatemala and Belice. We know it best, in its ancient forms, through the Aztecs, and Temazcal, as it is still called in contemporary Mexico, is a Nahuatl word, taken from their language.

It was, when the Spanish conquerors arrived in this, for them, New World, an integral and important part of the medicine which they found here. If was, as best we can make out from the sources still left to us, used in the healing and easing of almost all kinds of medical conditions, including, as we sail see, pregnancy and child birth, it still is.

The Spaniards were appalled and outraged by this, to them, barbaric practice. Not only was it inextricably interwoven with pagan beliefs and ritual, as is all ancient traditional medicine, but, most shocking of all, the bathers entered into these small, dark chambers, all sexes and size together, naked as the day on which they were born. The Spaniards were convinced that some sort of unspeakable orgiastic rites were taking place, and so they set themselves to forbidding the practice and destroying the baths wherever they found them. In the Penal Code and Order for Governing of the Indians, proclaimed by Charles the Fifth, the emperor of Spain, it was declared "that Indians who are not sick shall not bathe in hot baths under penalty of one hundred lashes to be followed by two hours bound in the marketplace..." Later, the proscription was extended to the sick as well.

But there were some among the conquerors who were impressed more favorably by this practice and, fortunately for us, recorded their impressions of what they had seen. It is from these accounts that most of what we know of ancient practice has come down, and it is worth quoting some of their observations. In the Magliabechi Codex, one of the few books which come down to us from those days, a caption under a native drawing of a Temazcal observes, "This is a drawing of the baths of these Indians which they call the temazcalli. At the door of the bath there is an Indian who is the advocate for the sick, and when a sick person goes to the baths he makes an offering and stretches his body on the ground in veneration of the idol which they call Tezcatopocatl and who is one of their principal gods. They used in these baths other Infamous reliquaries and many naked Indians bathed and committed great ugliness and sins in this bath".

Sahagun, the industrious Franciscan friar who recorded so many of the indian customs of his day, tells us that: "It [the Temazcal] is used firstly in the convalescence of many sicknesses, so that they should finish healing more rapidly... All sick people benefit from these baths..." And he goes on to list sicknesses that he throught especially responsive to the sweat bath: traumas, broken bones, contusions, skin problems and growths, among others. He mentions, as well, that it is also good for "pregnant women who are close to giving birth as there the midwives can do certain things so that the birth is easier... ", and it is "good for the mother shortly after giving birth so that she heals and to purify the milk..." Another of the early commentators on indian customs of those times, Clavijero, observes that "...the temazcalli has always been used in many sicknesses, especially in fevers caused by some form of constipation of the pores... and those who have been injured or stung by some poisonous animal. It is also a remedy which is effective for those who need to get rid of thick and tenacious humors. When a more copious sweating is needed, the sick person is placed near the ceiling where the vapor is thicker. It was also used in the treatment of fractured bones, syphilis, lepra, pains in the chest and back, spots and growths on the skin, blows and contusions, stiff necks,..."

Temazcaltoci: The grandmother of the bathsThe name Temazcal, or temazcalli is made of two Nahuatl words, temas, which means bath, and calli, meaning house. At the time of the Conquest, they were found everywhere in almost all of central and southern Mexico. They were so common that the same Clavijero was led to remark that "...there is no town, however small it might be, that does not have many of them."

Although the Spanish did their best to wipe out this custom, they failed. The battered Indians preserved the custom secretly in remote places, as they did with so much of the their traditional medical skills and practices. In this way, the Temazcal has come down to modern times, and on the basis of the knowledge so carefully preserved, the contemporary revival of this healing swat bath has taken place.

In the Nahuatl culture of central Mexico, the goddess of the sweat bath was Temazcalteci, "the grandmother of the baths". She was, really, one of the manifestations of the goddess Teteoinan, "the mother of the gods", or, as she is also called, "our grandmother", the principal goddess among the higher Nahuatl divinities. Sahagun says of her that "...this goddess was the goddess of medicine and of the medicinal herbs; she was adored by doctors and surgeons, and bleeders, and also by midwives... She was also adored by those who had baths, or temazcals in their houses. All placed the image of this goddess in their baths". The cult of this goddess of the Temazcal extended throughout Mesoamerica and it is found in the other great cultures of the region --the Mixteca, the Zapoteca and the Maya. It was in great part because of this close relationship between the worship of a goddess and the Temazcal that the Spaniards found it so important to ban the use of the bath.

The Temazcal not only involved the worship of a goddess, but it incorporated all the elements of the ancient cosmology, both in the manner of its construction and the way in which it is used; and most of these conceptions have been preserved in traditional thought and practice down to our own day. The Temazcal is a microcosm reproducing in itself the characteristics of the universe, the macrocosm. So we find in the Temazcal all elements of the different eras or cycles (known as suns) throught which, according to Aztec mythology, the world has passed and continues to pass: earth, wind, fire and water (we now live in the fifth 'sun') and through whose constant movement and life is manifest.

More, the Temazcal is oriented according to the cosmic directions: the fire which heats its stones is placed towards the east where our Father, the sun, the god called Tonatiuh, arises; he is the light or masculine element which comes and fertilizes the womb of the mother earth (the chamber of the Temazcal itself), and so life is conceived. The doorway through which the bathers enter and leave is oriented toward the south, "the pathway of the dead", which begins with birth and ends in death, to the right of the path of Sun. In this way, the ever present duality of traditional Mexican thought is manifested. Just as there are mother and father, sun and earth, hot and cold, so we are born and, in being born, we begin our path towards death.

Aztec cosmology presents us with several different levels of the heavens, and these are considered to be present in the different levels of temperatures found inside the Temazcal: the highest in the upper part of the chamber where the temperature is the lowest.

When we enter the Temazcal, according to this ancient doctrine, we return once again to our mother's womb, presided over by the great goddess, Tonantzin or Temazcaltoci, the great mother of both gods and humans. She is our beloved mother, concerned with the health of the children and she receives us into her womb - of which our own mother's womb is but a microcosmic manifestation - to cure us of physical and spiritual ills. The entrance way is low and small, and through it we enter a small, dark, warm and humid space, in this way recreating the uterus, cutting off the outside world and giving us a chance to look inside and find ourselves again. Our re-emergence through this narrow opening represents our rebirth from the darkness and silence of the womb. It is no wonder that the Spaniards were so shocked by what they found!



Temazcal produces a series of physical reactionsPhysical cleanliness has always, and still continues to be, a matter of great importance to the people of Mexico. When the Spaniards arrived, the people of Mexico bathed daily when it was possible; the Europeans of those days, on the other hand, placed little importance on personal cleanliness and it was not uncommon for a month to pass between baths. Andres de Tapia observed that "Motecuhzoma washed his body every day two times.

"Clavijero noted that bathing in the Temazcal "was only a little less frequent" than regular bathing among the Mexicans.

The practice of inducing sweat has long been known to be beneficial in sicknesses of the skin, liver and circulation, in problems of rheumatism, arthritis, gout, and other chronic diseases, as well as acute problems like muscular pains, colds and congestions, and sweat baths are but of the ways used to bring about healthful sweating. The Temazcal, because of its special methods, is perhaps the most effective of this kind of curative technique, certainly the list of conditions for which it has been used in the course of centuries is the most extensive.

Overheating of the body (during the bath, the body temperature may reach one hundred and four degrees) produces a series of reactions: it stimulates both the superficial and the deep blood circulation, accelerates the frequency of heartbeats, as well as increases their force, calls into action the mechanisms of thermal regulation, activates the metabolism, and promotes sweating. All of these effects produce a great internal movement of energy and liquids, somewhat similar to the way in which strenuous exercise does, bringing increased circulation to all the muscles, organs and tissues. While all sweat baths produce these effects, the Temazcal, because of the way it works and the precision with which it can be regulated by the healer in charge of the bath, controls these body reactions to high heat to maximize the curative effects of the bath.

Its basic advantage as a sweat bath consists in the way high heat and high humidity are combined. The sauna, for example, reaches much higher temperature but the bath is drier and consequently, its curative capacities are lower. Other types of steam bath also combine heat and humidity, but the Temazcal surpasses them in effectiveness for two reasons: the person in charge of the bath can adjust -increase, diminish or direct- both heat and humidity to meet the specific needs of the patient he is treating, and the vapor is made from herbal teas, the herbs chosen for their effects on each individual patient.

The high heat and the high humidity, taken together, produce their healing effects, basically, through reducing or impeding the body's mechanism for cooling itself. The heat, higher than normal body temperature, induces sweating; the high humidity inhibits the evaporation of the sweat, the chief method through which the body normally cools itself, and thereby, blood circulation is increased, sweating is increased, and the elimination of toxins is maximized. It is said that every liter of sweat lost in the Temazcal is equivalent to a full days' work by the kidneys!

There are two others special characteristics of the Temazcal as a sweat bath that must be mentioned. The first is that every bath is directed by a specially trained healer, most often a woman (called in Mexico, the Temazcalera). She examines the patient, makes her diagnosis, chooses the herbs that are indicated, decides on the levels of heat and humidity that are to be used, prepares the Temazcal, and then enters the chamber with the patient to oversee and manage the course of the bath. She can raise or lower the intensity of the heat during the bath through ventilating the chamber using the entranceway or the vent that is in the roof of the Temazcal, or by fanning with the fan made up of branches of a suitable herb that she has chosen, or raising or lowering the height at which the patient is placed to do the bath (heat rise, and the Temazcal is much cooler at floor level than it is towards the root, and with all gradations in between). A good Temazcalera is amazingly skillful in handling her herbal fan; she can bring down heat for the upper parts to the lower parts of the chamber at will, and if she wishes, direct currents of heat to whatever part of the body wants special attention. Extra heat can be put on your leg, for example, to deal with sciatica, or on your back to get rid of back pain. If necessary, she will use her fan to beat gently on any part of the body to increase circulation at that spot, should it be necessary. She is, by the way, trained to do massages using a variety of traditional techniques, in the Temazcal, for any condition that might require such treatment.

The Temazcal is a Mexican pre-Hispanic traditional sweat bath. Its oldest vestiges are found in the Mayan zones of Palenque in Mexico. Its use through history has been as much therapeutic as ritual and ceremonial. Its practice survives at the present time thanks to the oral tradition of the different indigenous communities of Mexico. The nahuatl word “Temazcal” means “House of steam”.


Even that sweat baths are used by many cultures of the world, both ancient, and modern, the traditional Mexican bath differs from others in that, as far as we know, its main purpose was therapeuticall. The Temazcal was an important and integral part of pre-Hispanic medicine. It was used in the healing and easing of almost all kinds of medical conditions.

The practice of inducing sweat has long been known to be beneficial in sicknesses of the skin, liver and circulation, in problems of rheumatism, arthritis, gout, and other chronic diseases, as well as acute problems like muscular pains, colds and congestions, and sweat baths are but of the ways used to bring about healthful sweating. The Temazcal, because of its special methods, is perhaps the most effective of this kind of curative technique, certainly the list of conditions for which it has been used in the course of centuries is the most extensive.


Overheating of the body (during the bath, the body temperature may reach one hundred and four degrees) produces a series of reactions: it stimulates both the superficial and the deep blood circulation, accelerates the frequency of heartbeats, as well as increases their force, calls into action the mechanisms of thermal regulation, activates the metabolism, and promotes sweating. All of these effects produce a great internal movement of energy and liquids, somewhat similar to the way in which strenuous exercise does, bringing increased circulation to all the muscles, organs and tissues. While all sweat baths produce these effects, the Temazcal, because of the way it works and the precision with which it can be regulated by the healer in charge of the bath, controls these body reactions to high heat to maximize the curative effects of the bath.


Its basic advantage as a sweat bath consists in the way high heat and high humidity are combined. The sauna, for example, reaches much higher temperature but the bath is drier and consequently, its curative capacities are lower. Other types of steam bath also combine heat and humidity, but the Temazcal surpasses them in effectiveness for two reasons: the person in charge of the bath can adjust -increase, diminish or direct- both heat and humidity to meet the specific needs of the patient he is treating, and the vapor is made from herbal teas, the herbs chosen for their effects on each individual patient.

The high heat and the high humidity, taken together, produce their healing effects, basically, through reducing or impeding the body's mechanism for cooling itself. The heat, higher than normal body temperature, induces sweating; the high humidity inhibits the evaporation of the sweat, the chief method through which the body normally cools itself, and thereby, blood circulation is increased, sweating is increased, and the elimination of toxins is maximized.

MethodsEvery bath is directed by a specially trained healer, most often a woman (called in Mexico, the Temazcalera). She chooses the herbs that are indicated, decides on the levels of heat and humidity that are to be used, prepares the Temazcal, and then enters the chamber with the patient to oversee and manage the course of the bath. She can raise or lower the intensity of the heat during the bath through ventilating the chamber using the entranceway or the vent that is in the roof of the Temazcal, or by fanning with the fan made up of branches of a suitable herb that she has chosen, or raising or lowering the height at which the patient is placed to do the bath (heat rise, and the Temazcal is much cooler at floor level than it is towards the root, and with all gradations in between).

A good Temazcalera is amazingly skillful in handling her herbal fan; she can bring down heat for the upper parts to the lower parts of the chamber at will, and if she wishes, direct currents of heat to whatever part of the body wants special attention. Extra heat can be put on your leg, for example, to deal with sciatica, or on your back to get rid of back pain. She will use her fan to beat gently on any part of the body to increase circulation at that spot, should it be necessary. She is, by the way, trained to do massages using a variety of traditional techniques, in the Temazcal, for any condition that might require such treatment.

Found only in the Mexican method of using sweat baths for curative purposes, when the patient comes out of the bath, he is carefully wrapped in a sheet or blanket, and made to lie down and rest, usually in a room or place specially prepared for this purpose, until the body completes its cycle of sweating. Most people fall sleep during this rest period, and awaken feeling refreshed and strengthened.


These two special features of the traditional Mexican sweat bath -the skills of the Temazcalera and the mandatory rest period after the bath- may go a long way in explaining its impressive curative powers.

Roman Baths

Roman baths were a central part of Roman social life, as well as a way for the citizens of Rome to stay healthy. Roman baths were located in almost all Roman cities; most certainly in the largest and most prominent. Far from simply being a place for people to cleanse themselves, Romans baths provided an opportunity for citizens to socialize, exercise, and unwind after a day's or week's work. Today, some of the larger ancient Roman baths can still be viewed at various locations; the largest and most spectacular bath can be found in Bath, England. Transportation to Bath from London is convenient, and a coach makes trips between the cities each day.

The history of the Roman bath began during the height of the Roman Empire. Ancient Roman baths served many community and social functions within Roman society. Everyone in Rome used Roman public baths, regardless of socioeconomic status. Rich folk tended to use the Roman public baths daily, while poorer folk generally visited the Roman public baths on a weekly basis. Entrance fees to the Roman bath houses were moderate, and the houses were owned and operated by the government.

Roman bath houses were a feat of engineering at the time. Drawing on natural hot springs from beneath the ground, a system of pumps brought water up and into the large pool areas, wherever springs existed. Heaters were also created to maintain warm temperatures in the baths. Although Roman bath houses were intended for use by everyone, there were separate houses designated for men and women and regulations in place to keep bathing between the sexes a major taboo.

For the most part, the history of the Roman bath reflects the idea that the baths were a community gathering place. In addition, many bathhouses also had workout equipment nearby for men to strength train with weights or toss around a discus. Men also brought and used oils after bathing, and those in the upper classes brought along servants to carry their towels, oils, and clothing. Most bath houses were quite large (some could hold up to 3,000 people at one time) and theft was always a possibility.

Although the most recent history of the Roman bath does not involve any actual bathers, tourists today can view the baths, and even have lunch or dinner overlooking the most famous bathhouse remains in the city of Bath. The bathhouses were discovered, exhumed, and somewhat restored during the reign of Queen Victoria and have been a popular spot for tourists and residents alike ever since.

The bathhouse in Rome is open daily throughout the year with extended hours during the summer. The Pump Room is the café overlooking the bathhouse where guests can sip coffee and enjoy the view. Tickets to tour the baths can be purchased online, in London, or at the bathhouse itself upon arrival. For any tourists with an interest in ancient Rome, or even the beauty of this gorgeous structure, the baths in England are a great place to stop.

Contemporary Chinese Pulse Diagnosis and Pain

by Ross Rosen and Brandt Stickley


At first glance practitioners may not see the importance or relevance of diagnosing pain, a subjective sensation of one's patient, from reading the pulse as patients tend to report any experience of pain to their practitioner. This article, however, will address pain from multiple approaches and organ systems and demonstrate the value of perceiving the imbalances that lead to, contribute to, and reflect the manifestation of pain directly from the pulse at the radial artery using Contemporary Chinese Pulse Diagnosis (CCPD). Utilizing a diagnostic tool as sensitive as CCPD, one is not limited to the two common explanations of pain, i.e. Qi and/or blood stagnation, and bi obstruction syndrome. While we can indeed diagnose these from the pulse, using the 28 pulse positions and 80 qualities from CCPD, as well as some unique concepts from Contemporary Oriental Medicine® (COM), we can broaden our concepts to include the pulse diagnostic categories for pain as described below.

Before addressing the diagnosis of pain from the pulse, it is incumbent upon us to assert our belief in the intrinsic knowledge of our bodies and the importance of our symptoms as reflecting messages that should not be discarded. Pain, or any other symptom, is not some annoyance to simply be eradicated. It is a clue, a signal of a deeper imbalance that must be understood prior to a treatment strategy designed to eliminate its symptom. Pain has multiple causes and the eradication of the pain with symptomatic branch treatments eliminates a vital message and opportunity to treat a deeper level of imbalance and can be a disservice to our patients. CCPD enables the practitioner to delineate the root cause of one's pain and target treatment accordingly.

This ecological understanding of our symptoms and our bodies is imperative considering that pain treatment is one of the most commonly accepted areas for patients to seek acupuncture. Moreover, there are a variety of different acupuncture pain systems being practiced today, as well as in the continuing education arena, like the Balance Method, western anatomical approaches, medical acupuncture, and others. We are not suggesting these systems aren't effective for pain (indeed, the authors are both trained in and utilize some of these systems on occasion), or even that they can't be used to address underlying root causes, but rather they are often aren't considered from that vantage point. An obvious example is that we can treat a patient's chest pain balancing the meridians or releasing the sinews, yet have no diagnosis or treatment of the potential heart blood stagnation that may be underlying. To treat in this way can be life-threatening to the patient. The chest pain may be eliminated, but we are missing an opportunity to address a potentially life-threatening condition. Understanding the root causes and uncovering the details via CCPD, one can treat pain and simultaneously treat the root with a pointed acupuncture prescription that incorporates the varied facets of the individual's diagnoses. It is also important to note that the following examples of pulse qualities and interpretations are not fixed; they are open to broader interpretations that are explained below. What follows is some of the most common examples found from the collective clinical experiences of CCPD practitioners.

It is by no means an exhaustive list.

1. Tight-Wiry: The Tight-Wiry quality in an individual pulse position can reflect pain, other than the typical association of yin deficiency (Tight) and yin-essence deficiency (Wiry). In this regard, it is usually attributed to (a) an inflammatory process or (b) an excess cold condition. Other presenting signs and symptoms will assist in the differentiation. We note also that the Wiry quality, as we define it "thin, hard and cutting to the touch" (Hammer 2005, p. 349), indicates an extreme level of pain.

2. Choppy: The Choppy quality wherever it is found is indicative of blood stagnation (and under specific conditions suggests an overwhelming burden of chemical toxicity). Wherever this quality is seen, pain can be a likely result. Common positions include: the left distal position with chest and left shoulder pain due to occlusion of the coronary arteries, the Proximal positions and Pelvic Lower Body (PLB) positions with lower abdominal pain due to endometriosis and uterine fibroids, the Oesophagus position with reflux associated pain and/or Barrette's oesophagus, and the Gall Bladder complementary position with abdominal pain [hypochondriac and right shoulder] and the sequel of symptoms resulting from gall stones. The Choppy quality in the proximal positions and PLB has been significant with dyspyrunia.

3. Tense and Robust Pounding: These qualities suggest Qi stagnation with concomitant excess heat that develops from the struggle between the attempt to eradicate the stagnation and an immovable object. Typically, this type of pain will be characteristic of a Qi disorder and present with dissention and a feeling of fullness, whereby the Choppy quality discussed above will reflect more blood stagnation and fixed pain that’s sharp in nature.

4. Increased Rate on Exertion and Heart Blood deficiency: Early in one of the author's careers while growing his practice he spent a few days per week treating patients in a physiatrist's office. These patients would generally come in as their last resort in a process that spanned close to a year, first trying numerous pain medications and injections, then at least two rounds of physical therapy, each lasting a few months, then referred to acupuncture. Some had been in the 'system' for many years with no relief of their pain. These were the motor vehicle accident patients that sustained injuries that did not heal, that left their victims in significant chronic constant pain. While all completely unique in their presentations, background, histories, and review of systems, one of the findings that was consistently found in every patient was a moderate to severe Heart blood deficiency as diagnosed by CCPD wherein their heart rates would elevate greater than the normal 8-12 beats after exertion. Typically, these patients would have rates that increased at least 25 to 30 beats above their resting rates, and quite often patients' rates would increase in the 30s and 40s. We measure this by having the patient stand up and swing their arm vigorously 10 times then count their rate for 10 seconds and multiply by 6. It is not uncommon in chronic pain patients for their rate on exertion to increase well above the normal 8-12 beats. This becomes a very significant finding. It suggests inadequate blood supply and circulatory capacity and an impaired ability to heal.

5. Complementary positions on lateral radial aspect: Within CCPD exists a set of pulse locations dedicated to more of the structural aspects of the body wherein the radial aspect of the distal positions will reflect more of the head and upper body; between the distal and middle positions reflects the diaphragm, chest and back; between the middle and proximal positions represents the lower abdomen and back; whilst below the proximal positions represents the knees.

6. Flooding Excess and Infection: This pulse wave when found in an individual position can reflect local pain from an infectious process. One of the more common places to find this is in the Right Proximal Position with a urinary tract infection or a prostate infection. This can often occur with Tight, Robust Pounding and Rapid qualities. Infection in the pelvic area is usually indicated by the Slippery quality in the Pelvic Lower Body positions and usually is venereal in origin. The Flooding Excess quality in the Right Proximal position has also been associated often with Crohn’s disease (Regional Ileitis) as well as bladder infection, and in the Left Proximal Position with ulcerative colitis. All of these can be painful.

7. Complementary positions: There are 22 complementary positions in CCPD in addition to the 6 principal positions of the major organ systems. A few of the most commonly found in the context of pulses signifying pain include:
a) Gall Bladder: Tight-Wiry and Choppy --> indicates presence of pain due to gall stones; Choppy here is a sign of micro bleeding and the deterioration (necrosis) of the GB wall.
b) Oesophagus: Tight, Rough, Inflated and Choppy --> reflux pain;
c) Stomach Pylorus Extension: very Tight-Wiry and Choppy --> pain and micro bleeding probably due to an ulcer; Slippery at the Stomach Pylorus Extension position is the most significant sign of an ulcer.
d) Pelvic Lower Body: Choppy Tight or Muffled --> pain due to fibroids, cysts, endometriosis, etc; dyspyrunia.
e) Neuropsychological: very Tight --> pain due to intractable headache often due to trauma, which is a very important finding due to the gross underestimation of trauma with chronic headaches.

8. Tight Empty and Vertex Headache: The Liver yang rising scenario is a deficient condition; it results from a lack of yin, not an abundance of yang. At the point where the Liver yin is no longer able to anchor the Liver yang, we encounter a Tight Empty quality in the Left Middle position (reflecting a 'separation of yin and yang' in the Liver; see The Separation of Yin and Yang, Part Two, by same authors, Chinese Medicine Times Vol. 3, Issue 2, 2008). One textbook symptom of this condition is the vertex headache.

9. Choppy and Chest pain: While chest pain can have multiple aetiologies, one of the more critical presentations includes a Choppy quality in the Left Distal Position reflecting blood stagnation in the coronary arteries. Being able to identify this configuration is of significant importance. Other presentations include a positive Pleura. It is also important to reiterate the sensitivity of the pulse as a tool for preventive medicine; the pulse often exhibits signs of the underlying condition before the symptoms are advanced. This degree of discernment is considered an indication of advanced clinical skill from the days of Bian Que to the present.

10. Deep or Hidden and Low back pain: We are all familiar with the association of the lumbar area and the spine/skeletal system to the Kidney organ system. When we encounter a Deep or Hidden quality in the proximals it is a sign of Kidney Qi-yang deficiency (8th stage) and trapped cold internally, respectively. A hallmark symptom with this finding will be lower back/sacral pain and/or knee pain. In addition to this association, because of the Kidney Qi-yang deficiency, we will see an overall lack of metabolic heat to drive the Qi and a potential for pain in multiple regions, depending on the patient's underlying constitutional weaknesses, areas of past trauma, etc.

11. Choppy and Endometriosis: When we encounter a Choppy quality in the Liver, Proximal positions and Pelvic Lower Body one can make a fair assumption as to the presence of lower abdominal pain, in women often a sign of endometriosis and/or other signs of blood stagnation in the uterus and pelvic organs.

12. Liver Blood and Heart Qi Deficiency and fibromyalgia. Dr. Hammer has written on this topic (see Medical Acupuncture, September 1, 2008, 20(3): 141-145.) Essentially, this is a function of inadequate Liver Blood to nourish the sinews and/or a Heart Qi deficiency with impaired delivery/circulation to the surface and peripheral nervous system. Signs on the pulse of Liver Blood deficiency include a Thin or Tight quality at the Left Middle position and/or a Hollow quality and/or Reduced Substance and/or Leather. The signs of Heart Qi deficiency were outlined above.

13. Choppy and Pain due to toxicity: One of the principal conditions associated with an overwhelming burden of chemical toxicity is joint pain that moves from large joint to large joint. It is commonly encountered in those exposed through work, where repetitive stress also creates an increased vulnerability, and a further deleterious influence on the circulation. In addition, the symptoms of fatigue can often complicate the picture. Patients with this will find little relief of their symptoms through conventional treatment, either with ubiquitous herbal formulas, such as Bu Zhong Yi Qi tang (Tonify the Middle and Augment the Qi Decoction) for a supposed Qi deficiency, or formulas that are designed to address symptoms of Wind-Cold Damp, such as Du Huo Ji Sheng Tang (Angelica Pubescens and Sangjisheng Decoction). Furthermore, the conventional treatment through Western medicine often further complicates the symptom picture through the administration of pharmaceutical chemicals that are potentially toxic to some degree, and that more importantly, the patient is ill-suited to metabolize. The path out of this lies in identifying the Choppy pulse quality as a First Impression at the onset of the CCPD pulse diagnosis methodology, or at the Left Middle Position (and often at the Special Lung positions and Right Middle position). A novel method of evaluating the pulse while releasing pressure from the Organ through the Blood and Qi depths may also reveal a quality termed Blood Unclear. As one releases pressure, the width of the sensation slightly expands at the Blood Depth reflecting some turbulence and quickly returns to the normal sine wave shape. Over time the pulse becomes Deep. Dr. John Shen likened this pulse quality to a glass of water with some sediment in it. Another confirming sign is observed by assessing the mucosa of the lower eyelid, where the blood vessels will be of varying length and width, and may have a slightly brown hue. Examining the tongue one finds either a slightly red body with a moist yellow coat, or a withered tongue body and a slightly purple colour, and especially dark vertical lines indicating the toxicity. The veracity of these methods for assessing chemical toxicity can often provide an immediate inroad to achieving the correct diagnosis. What follows illustrates the readiness with which it can be readily established.

A patient presents with a history of intractable migraine headaches. After completing a thorough history, which indeed supported a number of potential diagnoses according to normative practice, including Liver Qi Stagnation, attention was focused on the time period when the patient first experienced the migraines. While it also coincided with her marriage, the only other obvious correlation was with the oral contraceptive she continues to take. The pulse revealed immediate evidence of toxicity, as described above, as well as the unique findings in the mucosa of the lower eyelid. The patient was urged to discontinue the oral contraceptive. She declined. Nevertheless, the treatment was based on the principle of relieving this burden of toxicity, and her headaches were readily relieved. The role of the Divergent channels to translocate Retained Toxic Pathogens to joints causing pain is also a significant diagnostic aspect of CCPD.

14. Temporal factors in pain syndromes: There are many approaches to understanding the temporal influences in painful conditions. One of the most prominent relies on an understanding of the daily rhythm of Yin and Yang. But Yin and Yang can also be approached in terms of the level of activity of an individual, and not just in terms of macrocosmic cycles. In this reading, the most telling issue is the balance between the Yang of activity and the Yin of rest. So, in terms of the microcosm, we turn our attention to the Sun of the body: the Heart. Patients often present with pains that are at worst upon waking, and usually marked by stiffness. They will note how the level of pain and stiffness is ameliorated by daily activities, only to become aggravated upon the culmination of activity at the end of the day. Then, fatigued, that patient retires, only to begin the cycle anew the following day without relief. The telling issue here is the role of the Heart in governing the circulation. In effect, this is a pattern that demonstrated the deficiency of Heart Qi, because as the body rests and the heart begins to work less, even against a reduced demand for peripheral circulation, the circulation slows and gives rise to stiffness and pain derived from a lack of movement. Upon awaking, the patient's activity increases giving an almost mechanical boost to the circulation, and thus ameliorating the symptoms. However, again due to the degree of deficiency, the activities of daily living can be taxing to the deficient patient, and the symptoms then worsen by the end of the day. In terms of treatment, it is absolutely necessary to address the Heart Qi deficiency to resolve the pain and stiffness. From the pulse there are many indications of Heart Qi deficiency. Some of the most common include (1) a slow heart rate; (2) an increase in rate on exertion of less than 8 beats per minute (this is a more serious sign of Heart Qi deficiency); (3) Change in Intensity/Amplitude in the Left Distal position of a four or five; (4) any Reduced qualities in the Left Distal position (Reduced Substance, Deep, Diminished, etc.); and (5) the Unstable quality.

15. Heart/Circulation: We have written previously about the role of shock to the heart and its effect on circulation. Trauma can be divided into physical and emotional aspects. It is noted that physical traumas usually involves an emotional component. Pulse qualities such as Inflated, Flat, Choppy and Rough Vibration can be used to isolate the location of a physical trauma. Signs such as horizontal lines in the mucosa under the eyelid and purple ecchymosis on the tongue can be found ipsilaterally. In peripheral, physical trauma, the face will be pale when compared to the hands. As the heart works to overcome the stagnating effects of trauma on Qi and Blood, it weakens over time, causing a Slow rate and more deficient qualities as described above. In emotional shock, the effect on the heart is more direct. Signs include Rough Vibration over the whole pulse encountered as a First Impression, an elevated rate, and signs at the Left Distal Position including Flat, Inflated, and even Absent, depending upon other pulse signs and the state of the body condition at the time of the insult. The first effect of shock to the heart is a Yin deficiency. With shock and with very severe pain associated with any organ, solid or hollow, Dr. Hammer has reported the Spinning Bean that feels like a splinter in the affected position (Hammer, personal communication November 2008). Pain conditions often arise secondary to a disruption of circulation and include conditions as varied as myofascial pain syndromes, migraine, reflex sympathetic dystrophy, and Irritable Bowel Syndrome, all of which can be predicated upon a disruption of the Heart's role in circulation, and likewise its role in housing the Shen. In western terms this implies a disruption of the balance between sympathetic and parasympathetic activity as they affect the circulatory system, and cause dilation and constriction of blood vessels (Scaer 2005, p. 213).

16. The Liver: As described above, often imbalances in the Liver can reflect in areas in which the Liver presides. Very often, however, the Liver will not keep its own pathology, but rather attacks wherever it finds a vulnerability. Very common scenarios involve the Liver invading the Spleen and Stomach with digestive symptoms resulting. Another very common clinical scenario is where the Liver will attack the pelvic organs causing an interstitial cystitis. In both pathologies, the Left Middle position will show excess, i.e. significant Robust Pounding, often accompanied by signs of Liver Blood stagnation. In the scenario of Liver invading the digestive system, often a positive Ulnar Liver Engorgement position is found, as well as deficiency in the Right Middle position making the digestive organs vulnerable to the excess Liver energies. With the interstitial cystitis often Tight and Choppy qualities will be found in the Pelvic Lower Body positions as well as in the Proximals, reflecting the Bladder. A note to keep in mind is that Liver Qi deficiency is more of a cause of sluggish digestion [food and Qi stagnation] than Liver Qi stagnation and `attacking’ Liver Qi. Liver Qi controls the vectors of Qi dynamic for all organs, including moving Stomach Qi downward and when it is deficient the Stomach Qi will be hampered.

17. Nervous System Tense: The hyper vigilance that accompanies the Nervous System Tense personality often presents with the ubiquitous aching neck and sore trapezius syndrome. A discussion on Nervous System Tense can be found in our previous article, An Introduction to Contemporary Chinese Pulse Diagnosis, Chinese Medicine Times, Vol. 2, Issue 5, 2007. The CCPD configuration would be a Tense quality in the principal positions as well as a Tight quality at the Qi depth.

18. Sudden cessation of exercise: The Yielding Hollow Full-Overflowing pulse, accompanied by a normal to slightly Rapid rate, indicates the sudden cessation of often intense over-exercise. This is classified as a Qi Wild condition. The aetiology, which is seen with increasing frequency, involves a disruption of the functional relationship between the diameter of the blood vessel and the volume of blood circulating. "The yin blood and the yang vessel walls become functionally dissociated" (Hammer 2005, p. 261). It is often the case that the presenting symptom is migrating joint and muscle sprain that may also accompany cold extremities. As an indication of a Qi Wild state, however, the more pressing concerns are the symptoms that accompany the pain: namely fatigue, anxiety, panic, depersonalization, dissociation and explosive anger.

19. Heart Full and "whole body discomfort": Trapped Qi in the heart is a condition Dr. Shen termed Heart Full. The Inflated pulse, particularly at the Left Distal Position, indicates the condition. The condition evolves from prolonged birth with the head in the birth canal, such as in breech presentations, or from overwhelming experiences at a time when the person is relatively robust or trauma to the chest. One pain condition associated with the disruption of Qi and Blood circulation is a pervasive feeling of whole body discomfort (Hammer 2005, p. 414).

20. Spinning bean: The Spinning Bean quality can often signify extreme pain, typically of a traumatic nature (Hammer 2005, p.375). This quality was also found once by Dr. Hammer with an intractable stomach ulcer (personal communication Dr. Hammer Oct. 2008). Wherever it is found will represent significant pathology. While certainly not exhaustive, our purpose in this article is to demonstrate the role that a thorough going examination of the pulse often reveals causes and effects of typical and commonly encountered pain conditions. As such, CCPD fulfils a need for the practitioner, namely providing the insight that leads from a set of symptoms and signs, especially gleaned from the pulse, directly to a diagnosis, treatment principle and treatment. In other words, it is "the dream of every Chinese medicine practitioner," as Heiner Fruehauf has written of the Six Conformation model (Liujing Bianzheng). The importance of diagnosing in this way brings reverence back to the art of Chinese medicine and eliminates the common misunderstanding that acupuncturists are technicians, but rather that we are clinicians of the highest calibre.

References

Fruehauf, Heiner. retrieved from: http://classicalchinesemedicine.org/scienceofsymbols/six_confirmations.htm

Hammer, Leon I., How Do You Treat Fibromyalgia in Your Practice?, Medical Acupuncture, September 1, 2008, 20(3): 141-145

Hammer, Leon I., Chinese Pulse Diagnosis: A Contemporary Approach, Revised Edition. Eastland, 2005.

Rosen, Ross and Stickley, Brandt, An Introduction to Contemporary Chinese Pulse Diagnosis, Chinese Medicine Times, Vol. 2, Issue 5, 2007

Scaer, Robert. The Trauma Spectrum: hidden wounds and human resiliency. Norton, 2005.

Stickley, Brandt and Rosen, Ross, The Separation of Yin and Yang, Part Two, Chinese Medicine Times, Vol. 3, Issue 2, 2008

The Treatment of Plantar Fasciitis with Traditional Chinese Medicine

by Scott R. Smith


Definition

Plantar fasciitis is the inflammationii of the fascia (fibrous band of connective tissue) that connects the heel bone to the base of the toes. Stretching from the heel bone (calcaneous), the plantar fascia attaches to the bottom of the metatarsal bones around the ball of the foot. Acting as a bowstring, the plantar fascia provides support for the bottom of the foot (arch) (Sauer and Cooper 2007, p478). Pain is usually reported under the medial heel throughout weight bearing (Irving et al, 2007), but may be found along any portion of the plantar fascia. Pain can range from mild to debilitating. Some may use the terms plantar fasciitis and heel spurs interchangeably but this is inaccurate since heel spurs are a result, not the cause of the discomfort (Waller and Maddalo 1995, p351).iii The condition may last a short time, come and go, resolve by itself, or become chronic for unknown reasons. Most cases respond well to conservative treatment eliminating the need for surgery or any other invasive therapy.

Symptoms
Symptoms may develop gradually or come on suddenly and be severe. The classic sign is to feel pain with the first few steps out of bed in the morning due to the fascia tightening overnight. Pain decreases as the fascia loosens up or may hurt more as the day goes on. Pain can be characterized as sharp, stabbing, or burning and most common on the inside bottom of the heel. Pain is not only felt with the first few steps in the morning, but also after long periods of sitting, standing, climbing stairs, and after exercise. If left untreated, plantar fasciitis affects the foot, knee, hip, and back from the change in gait (Wapner and Puri 2004, p189).

Causes
Many causative factors can lead to plantar fasciitis. The most frequent cause is excessive foot pronation (Pribut, 2008). Shoes that are too tight, loose, require arch support, have soles that are too thin and are without sufficient heel cushioning can be the cause and should be changed. Patients should be examined for tight calf muscles as well. A higher risk of developing plantar fasciitis exists for patients with flat feet and high archesiv (AAOS, 2001). Overuse in the form of improper athletic training, certain work or play actions, intense training, prolonged standing, weight bearing for long periods, inactivity, new aggressive training regimens and previous injury can cause plantar fasciitis. Runners and walkers should be aware of the running surface, speed, frequency and distance covered each week particularly if ankle flexion is limited due to tight calf muscles (AAOS, 2001). Also check for limited range of motion of the first metatarsophalangeal joint, ankle dorsiflexion range of motion, leg length incongruity, heel pad thickness and calf strength. Other factors include weight gainv, obesity, elderlyviand pregnancyvii.

Diagnosis
Diagnosis is based on history and symptoms together with a physical examination that involves palpating the foot and observing the patient walk. Reproduction of the pain by palpating the plantar fascia over the medial calcaneal tuberosity or along the course of the plantar fascia is especially important for diagnosis (Richardson 2008, p4816). In severe cases, passive dorsiflexion of the toes may aggravate the symptoms of plantar fasciitis (Foye, 2008). Questions about past and recent injuries, location of pain, when it hurts most, and activities the patient participates in are especially significant. If diagnosis is uncertain then a foot x-ray, bone scan, or nerve conduction test may be performed to rule out a stress fracture or nerve problem (InteliHealth, 2007).

Treatment
Patients must be active participants in treatment. Warn them that failure to do so can result in constant pain when standing or walking. Conservative treatment is recommended for 6 to 8 weeks. Active individuals are encouraged to temporarily eliminate any exercise or sport that has running and jumping. Instead, change to bicycling or swimming to remain active while reducing the strain on the plantar fascia (Jones and Singer 1995, p453). Any delay in treatment or even a lack of compliance by the patient could extend treatment time from 6 months to a year and a half.

Conventional treatment usually begins with recommending rest, ice, compression, elevation (cold compression therapy) and NSAIDs for acute flare-ups. Next, the patient is advised to discontinue any aggravating activity and to stay off the foot to decrease inflammation. Exercises to stretch the Achilles tendon and plantar fascia are shown to the patient and shoes are inspected to consider orthoticsviii, arch support, and heel liftsix (Wapner and Puri 2004, p190). Depending on aetiology, other treatments may include contrast bath therapy, weight loss, physical therapyx, taping, corticosteroid injections, and night splintsxi. When plantar fasciitis does not respond to conservative treatment, extracorporeal shockwave therapyxii (ESWT), surgical release (plantar fasciotomy)xiii, iontophoresisxiv, botulinum toxin type A injection, and cryosurgeryxv (Foye, 2008) maybe used.

Prevention
Maintain a healthy weight. Choose shoes with proper support and discard worn-out athletic shoes. Start all sports activities slow and gradually increase intensity. Wake up with a stretch (see Exercises above) and stretch the calves regularly. Seek treatment with the first signs of pain.

Differential diagnosisTendinitis, arthritis, nerve irritation or a cyst (Mayoclinic.com, 2008), calcaneal neuritis, calcaneal stress fracture, lumbosacral radiculopathy of S1 nerve root (Foye, 2008). Heel spur, plantar fascia rupture, nerve entrapment (Pribut, 2008), insertional Achilles tendonitis, calcaneal apophysitis (Sever’s disease)xvii, sciatica, lower back nerve compression or disc origin, IBS, men under the age of 40 with bilateral symptoms should be examined to rule out Reiter’s disease and ankylosing spondylitis (Richardson 2008, p4815), lateral plantar nerve 1st branch entrapment, tarsal tunnel syndrome, neoplasm, gout, infection (Pribut, 2008).

Risk factors

The underlying cause of plantar fasciitis must be remedied regardless of the type of treatment that is sought. That means shoes must be changed, arches must be supported, activity or work must be modified, a healthy weight be maintained, etc. Many sources contend that the correct shoe wear and orthotics are the foundation for successful long-term resolution of plantar fasciitis (FootPhysicians.com, 2008). Patients must be educated about risk factors, exercises, behaviour changes, and preventive measures in order to stop future occurrence. That means relating to the individual’s activity, sport, and work or health issues.

Pattern differentiation

Chinese medicine breaks plantar fasciitis into several patterns: Wind Cold Damp Obstruction

Weak constitution, intense activity, overuse, trauma; all weaken the channels and involve a deficiency of qi and blood or impair the circulation of qi and blood from the invasion of exterior wind, cold, and damp.

Many outdoor sports are played regardless of the weather condition and can expose athletes to wind, cold, and damp. Intense activity, pre-existing injury and open pores from sweating are possible openings for the invasion of wind, cold, and damp.

Intense or excessive activity or sport leads to strain; standing for prolonged periods without proper rest or footwear; inactivity; certain, unvarying recurring movements.

Symptoms:
Cold feet with a heavy feeling, symptoms worse with cold damp weather and relieved by warmth, aversion to cold, fatigue, and oedema.

Acupuncture points:
Use 0.20mm x 0.25mm needles. Anything less is too flimsy to insert into the foot. The wear on peoples feet varies (some have tougher skin than others) so to make a pain reduced insertion a thicker needle is recommended. That gauge for me is a personal favourite. Insert into Yongquan KID-1 (see figure 1); another approximately 1 cun below Gongsun SP-4 (see figure 2); another approximately 0.5 cun below Jinggu BL-64, all directed towards the centre arch, an ashi point in the proximal heel (perpendicular), an ashi point 3 cun below the tip of the medial malleoulus (perpendicular), and an ashi point approximately 1-1.5 cun below Zhaohai KID-6 (perpendicular). All points should be needled to the depth of 0.5 cun at the minimum. xviii


Moxibustion:
Instead of electro-stimulation, moxa cones or press moxa technique may be applied to the appropriate points. Moxa may also be used after electro-stimulation.


•Zusanli ST-36 Spleen, tonify qi, nourish blood, reduce atrophy and painful obstruction. (moxa)
•Sanyinjiao SP-6 influence the Spleen and Liver, resolves damp and moves the blood.
•Yinlingquan SP-9 resolves damp and painful obstruction. (moxa)
•Qihai REN-6 moves qi and damp and influences yang. (moxa)
•Shangqiu SP-5 Damp obstruction of the ankle and foot, influences sinews and muscles.
•Kunlun BL-60 removes channel obstruction, relaxes sinews.

Qi and Blood deficiency

A deficiency means a lack of nourishment, especially in the channels open to invasion of external wind, cold, and damp. Intense exercise and physical stress without adequate time for recovery depletes the qi and blood as does an intense moment of physical activity in a person who already has a weak constitution. The undernourished tendon, or plantar fascia, becomes overworked resulting in pain and stiffness.

Symptoms:
Stiffness, cramping or numbness of the limbs, fatigue, pallid complexion and lips, insomnia, , dizziness, a pale tongue and a soggy pulse.

Acupuncture points: Using 0.20mm x 0.25mm needles, insert into Yongquan KID-1, (see figure 1); another approximately 1 cun below Gongsun SP-4; another approximately 0.5 cun below Jinggu BL-64, all directed towards the centre arch, an ashi point in the proximal heel (perpendicular), an ashi point 3 cun below the tip of the medial malleoulus (perpendicular), and an ashi point approximately 1-1.5 cun below Zhaohai KID-6 (perpendicular). All points should be needled to the depth of 0.5 cun at the minimum.


•Zusanli ST-36 Spleen, tonify qi, nourish blood and reduce atrophy.
•Sanyinjiao SP-6 influence the Spleen and Liver, qi and blood.
•Pishu BL-20 tonifies the Spleen.
•Yanglingquan GB-34 relieves pain, swelling and numbness of muscles and sinews.
•Pucan BL-61 heel pain.
•Tanzhong REN-17 influential point of qi.

Liver and Spleen
The Spleen is in charge of qi and blood formation and if impaired will not properly nourish the muscles. The blood accessible to the muscles, tendons and sinews is also reliant on the Liver’s ability to store blood.

Symptoms:

Stiffness, spasms, weakness and numbness, decreased muscle and arch strength, atrophy; particularly of the lower limb, impaired ankle joint range of motion from undernourished sinew contraction and relaxation function. Dizziness, dry eyes, fatigue, pallid complexion, hypochondriac pain, irregular menstruation, slightly pale, flabby, dry tongue with pale tapered sides. The pulse is empty, thin, wiry or choppy.

Acupuncture points:

Using 0.20mm x 0.25mm needles, insert into Yongquan KID-1, (see figure 1); another approximately 1 cun below Gongsun SP-4, (see figure 2); another approximately 0.5 cun below Jinggu BL-64, all directed towards the centre arch, an ashi point in the proximal heel (perpendicular), an ashi point 3 cun below the tip of the medial malleoulus (perpendicular), and an ashi point approximately 1-1.5 cun below Zhaohai KID-6 (perpendicular). All points should be needled to the depth of 0.5 cun at the minimum.


•Taichong LIV-3 nourishes Liver blood and Liver yin.
•Ququan LIV-8 nourishes blood and yin.
•Zusanli ST-36 Spleen, tonify qi, nourish blood, reduce atrophy and painful obstruction.
•Sanyinjiao SP-6 influence the Spleen and Liver, resolves damp and moves the blood.
•Ganshu BL-18 nourishes Liver blood and benefits the sinews.
•Pishu BL-20 tonifies the Spleen.

Qi and Blood stagnation

Trauma to the plantar fascia may reduce the flow of qi and blood to the foot and allow external wind, cold, and damp to invade the area. Poor diet and stress can also lead to qi and blood deficiencies which will impact upon the flow of qi and blood in the vessels.

Symptoms:
If qi stagnation predominates, the location of pain may move around the heel and foot and feel distended and sore. In this case the tongue may be pink/purple and the pulse tight. If blood stagnation predominates, the location of pain is fixed, severe and worse with touch. In this case a purple colour is more pronounced on the tongue and the pulse is choppy.

Acupuncture points:Using 0.20mm x 0.25mm needles, insert into Yongquan KID-1; another approximately 1 cun below Gongsun SP-4; another approximately 0.5 cun below Jinggu BL-64, all directed towards the centre arch, an ashi point in the proximal heel (perpendicular), an ashi point 3 cun below the tip of the medial malleoulus (perpendicular), and an ashi point approximately 1-1.5 cun below Zhaohai KID-6 (perpendicular). All points should be needled to the depth of 0.5 cun at the minimum.


•Hegu L.I.-4 and Taichong LIV-3: move qi and blood
•Zhongwan REN-12 moves qi stagnation.
•Zusanli ST-36 moves qi and blood.
•Geshu BL-17 painful obstruction and dispels blood stasis.
•Sanyinjiao SP-6 nourish and move blood.
•Shuiquan KID-5 promotes blood circulation.

General Acupuncture Points
Using 0.20mm x 0.25mm needles, insert into Yongquan KID-1, (see figure 1); another approximately 1 cun below Gongsun SP-4, (see figure 2); another approximately 0.5 cun below Jinggu BL-64, all directed towards the centre arch, an ashi point in the proximal heel (perpendicular), an ashi point 3 cun below the tip of the medial malleoulus (perpendicular), and an ashi point approximately 1-1.5 cun below Zhaohai KID-6 (perpendicular). All points should be needled to a minimum depth of 0.5 cu.

Points along the Urinary Bladder line as it descends through the calf should be palpated for tenderness; particularly Chengjin BL-56, Chengshan BL-57, Fuyang BL-59 and Kunlun BL-60.

Exercises
Stretching your Achilles tendon and plantar fascia are the foundation of treating the condition and lessening the chance of recurrence.

Towel stretching: This exercise is best for patients with pain that is most severe with the first steps out of bed in the morning. Set the midpoint of a towel in the arch of the foot, just under the fore foot. Using both hands, gently pull the towel toward you to cause passive dorsiflexion of the ankle. Hold stretch for 30 seconds. Follow with massage or foot roller.

Towel grip:Place a towel on the floor and with a barefoot, grip the towel underneath the toes and flex the foot. This strengthens the arch. Follow with massage or foot roller.

Foot roller: A wooden ravioli rolling pinxix is recommended. The notches work especially well for loosening specific tight spots in the arch as well as moving qi and blood stagnation in the heel.

Standing calf/heel stretch:
Face a wall, standing about 3 feet away. Keeping your right foot planted, step forward with your left foot and place both palms on the wall in front of you, shoulder height. Keeping the right leg straight and the heel on the ground, slowly lean forward, bending your elbows, until you feel a stretch in your right calf. Hold 30 seconds and repeat other side.

Other treatments

Electro-stimulation:

Channel 1 connect the black clip (negative) to Yongquan KID-1 and red (positive) to the ashi point in the proximal heel. Channel 2 connects the black clip to the point approximate to Gongsun SP-4 and red to the point approximate to Jinggu BL-64. Channel 3 connect black to the ashi point 3 cun below the tip of the medial malleoulus and red to the ashi point about 1-1.5 cun below Zhaohai KID 6. Use mild stimulation for 20-30 minutes at 2-4Hz.

Massage: Massage starting at the top of the calf and follow the Urinary Bladder channel to the bottom and sides of the heel. Start light and slow, gradually increasing the depth and strength of each stroke, particularly from the bottom of the heel to Yongquan KID-1.

Exercise:
Patients must incorporate at least two of the stretches described above along with the foot roller into their daily routine.

Foot baths:Epsom salt foot baths are recommended at the end of the day to decrease inflammation, move qi and blood and promote healing.

Case study
Main complaint: Plantar fasciitis of the right foot. 51 year-old male. Severity: 6-7/10. Chronic pain from the time he steps foot on the floor in the morning up until bedtime. The heel is stiff; the arch is painful, all worse in the morning. He does a lot of forefoot movements at work and during after work activity. Pain is relieved when shoes are off and when he is off his feet. He reports that stepping on the foot feels like stepping on a marble located lateral to the middle of the arch (perhaps a Morton’s neuroma). Numbness, tingling or any shooting sensations throughout the foot are not present, only pain and stiffness. He reports no other significant health concerns.

History: Since 2004 (4 years duration). Patient is in law enforcement and is on his feet 8-12 hours at a time. A podiatrist administered a cortisone injection which provided 3-4 months relief. A 2nd cortisone injection provided the same results. A custom orthotic insole was added to provide arch support.

Other: Foot pain has decreased the patients’ quality of life due to the severity and duration.

Observations: I noticed that upon standing to walk to the treatment room, he was slow to rise and put weight on the foot. Limping proceeded until he reached the chair in the examining room. Mood was slightly irritated due to annoyance of the right foot pain.

Pulse: Sluggish.

Tongue: Pink red with white coat.

Diagnosis: Qi and blood stagnation, Spleen qi deficiency, Wind, Cold, Dampness painful obstruction.

First Treatment: Acupuncture and electro-stimulation described above plus Zusanli ST-36, Yanglingquan GB-34, Yinlingquan SP-9, Hegu LI-4, Taichong LIV-3.

Post-treatment: Reported immediate improvement.

Advice: Avoid activities that aggravate the condition, use the foot roller every day, towel grip exercise, Epsom salt foot baths and schedule a second treatment for no more than one week.

Second treatment: (5 days later)
60-80% improved overall. Emotions improved as well. He was doing exercises every night, but no foot baths as advised; he just found no time. He reported that the custom orthotics now felt better in his shoes. Decrease in tenderness, marble feeling, stiffness and morning pain.

Treatment: Same protocol as first treatment.

Advice: Continue exercises and schedule another treatment for no more than one week.

Third treatment: (5 days later)

Patient reports feeling improved. Reports a 0/10 pain scale. He has continued with exercises and foot roller but still no foot baths. “Everything has improved and holding” he says. Patient reported that the foot roller was initially painful but has now gotten to be tender with a “good pain” feeling.

Treatment: Same protocol as the first and second treatment.

OutcomeAt a three month follow-up with the patient he reports that plantar fasciitis has resolved. No reoccurrences of pain but occasional tenderness that he now knows how to manage with stretching, foot baths and the foot roller.

Conclusion

Chinese medicine provides lasting relief for a common foot problem with the specific use of acupuncture, electro-stimulation and the appropriate points based on pattern discrimination.

Here is a review of a few points to consider for a successful treatment outcome:


•Plantar fasciitis acupuncture protocol with electro-stimulation and appropriate points based on the pattern.
•Patient advised that they need to have active participation in treatment and to follow advice given in order for the condition to resolve.
•Modify exercise if that is a causative factor.
•Engage in a daily stretching regimen combined with foot baths and the foot roller.
•Schedule weekly visits.

BiographyScott R. Smith is a licensed acupuncturist and herbalist (Dipl. OM, NCCAOM) practicing in Rapid City, SD. He can be emailed at srsmithom@gmail.com.


References

American Academy of Orthopaedic Surgeons (AAOS), (2001). Plantar Fasciitis. http://orthoinfo.aaos.org/topic.cfm?topic=A00149 (Accessed 6 June 2008)

Irving, D.B., Cook, J.L., Young, M.A., Menz, H.B. (2007). Obesity and Pronated Foot Type May Increase the Risk of Chronic Plantar Heel Pain: A Matched Case-Control Study. http://www.medscape.com/viewarticle/559871 (Accessed 19 May 2008)

FootPhysicians.com (2008). Heel Pain. http://www.footphysicians.com/footankleinfo/heel-pain.htm (Accessed 5 June 2008)

Foye, P.M. (2008). Plantar Fasciitis. http://www.emedicine.com/pmr/topic107.htm (Accessed 5 June 2008)

InteliHealth.com (2007). Plantar Fasciitis. http://www.intelihealth.com/IH/ihtIH/WSIHW000/9339/10550.html (Accessed 5 June 2008)

Jones, Donald C., Singer, Kenneth M. (1995). The Lower Extremity & Spine in Sports Medicine: Soft Tissue Conditions of the Ankle and Foot. (2nd ed). St. Louis: Mosby.

Mayoclinic.com (2008). Plantar fasciitis. http://www.mayoclinic.com/health/plantar-fasciitis/DS00508 (Accessed 5 June 2008)

Pribut, S.M. (2008). Heel Pain: Plantar Fasciitis and Plantar Heel Pain Syndrome. http://www.drpribut.com/sports/heelhtm.htm (Accessed 9 June 2008)

Richardson, E. Greer. (2008). Campbell’s Operative Orthopaedics. (11th ed). Philadelphia: Mosby Elsevier.

Sauer, Scott T., Cooper, Paul S. (2007). Essentials of Orthopedic Surgery. (3rd ed). New York: Springer.

Waller Jr., John F., Maddalo, Anthony V. (1995). The Lower Extremity & Spine in Sports Medicine: Foot and Ankle Linkage System. (2nd ed). St. Louis: Mosby.

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Tradition of Turkish Bath

The tradition of the Turkish bath extends far back, to a time before Turks had reached Anatolia. When the Turks arrived in Anatolia, they brought with them one bathing tradition, and were confronted with another, that of Romans and Byzantines, with certain local variants. The traditions merged, and with the addition of the Moslem concern for cleanliness and its concomitant respect for the uses of water, there arose an entirely new concept, that of the Turkish Bath. In time it became an institution, with its system of ineradicable customs.

For the Turkish bath was much more than just a place to cleanse the skin. It was intimately bound up with everyday life, a place where people of every rank and station, young and old, rich an poor, townsman or villager, could come freely. Women as well as men made use of the "hamam", as the bath is known in Turkish, although of course at separate hours.

History of Russian Bath

Apostle Andrew wrote in 1113:
"Wondrous to relate, I saw the land of the Slavs, and while I was among them, I noticed their wooden bath-houses. They warm themselves to extreme heat, then undress, and after anointing themselves with tallow, take young reeds and lash their bodies. They actually lash themselves so violently that they barely escape alive. They then drench themselves with cold water, and thus are revived. They think nothing of doing this every day and actually inflict such voluntary torture upon themselves. They make of the act not a mere washing but a veritable torment." Going to bania is a very old Russian custom. From medieval limes it was popularly seen as a national institution, and not to bathe in one at least three times a week was practically taken as a proof of foreign origins.

Most villagers in Russia had a bathhouse, usually some way off from the rest of the houses in the village, where possible near water. The bathhouse had its own resident sprite, the bannik, the most hostile of the Russian domestic goblins, and was not a place to visit alone. The bannik was envisaged as a naked dwarf or a little old man. The proper time for people to use it was the five or seven hours before the midday . Only three or two bathing sessions were safe, after that it was Devil's turn and no peasant would go in after the third session or after the sundown. A site of former bathhouse was considered to be unclean, even evil and new houses were not built there.

Every noble household had its own steam house. In towns and villages there was invariably a communal bath, where men and women sat steaming themselves, beating one another, rolling around together in the snow. Because of its reputation as a place for sex and wild behavior, Peter the Great attempted to stamp out the bania as a relic of medieval Russia and encouraged the building of Western bathrooms in the palaces and mansions of St. Petersburg . But, despite heavy taxes on it, noblemen continued to prefer the Russian bath and, by the end of the eighteenth century, nearly every palace in St. Petersburg had one.

Going to the bathhouse often was, and is regarded as a way of getting rid of illnesses - it was called the "people's first doctor'"(vodka was the second, raw garlic the third). There were all types of magical beliefs associated with it in folklore. To go to bania was to give both your body and your soul a good cleaning, and it was the custom to perform this purge as a part of important rituals. Bathhouse was the place for the ritual pre-marriage bathe and for the delivery of babies. It was warm and clean and private, and in a series of bathing rituals that lasted forty days, it purified the mother from the bleeding of the birth which, according to the Church and the popular belief that held to the idea of Christ's bloodless birth, symbolized the fallen stale of womanhood. The records about the seventeenth-century Tsar Aleksei Mikhailovich mention that when tsarina (his wife) went into labor, she was taken off to the bathhouse, where she remained with only her midwife and female attendants until her child was born.

The bania's role in prenuptial rituals was also to ensure the woman's purity: the bride was washed in the bania by her maids on the eve of her wedding. It was a custom in some places for the bride and the groom to go to the bath house before their wedding night. These were not just peasant rituals. They were shared by the provincial nobility and even by the court in the final decades of the seventeenth century. This intermingling of pagan bathing rites with Christian rituals was equally pronounced as Epiphany and Shrovetide ('Clean Monday'), when ablution and devotion were the order of the day. On these holy days it was customary for the Russian family, or whatever social class, to clean the house, washing all the floors, clearing out the cupboards, purging the establishment of any rotten or unholy foods, and then, when this was done, to visit the bath house and clean the body, too.

Yoga Therapy : Obesity

Obesity or excessive fat in the body is becoming one of the major problems of this century. There are three stages of obesity–enviable, laughable and pitiable. If you are a little over-weight then your face will look round and smooth and beautiful (although concept of beauty changes from time to time). This is the enviable stage. If you put on some more fat and you look ugly, people will laugh at you. But there are people who cannot move their body because it is so bulky and they need help even to get in and out of the body. This is the pitiable stage.

Excessive fat that accumulates and makes you obese could be due to several causes. A small percentage of these cases could be due to some organic cause like lack of thyroid hormone, too much of adrenal cortisone or female sex hormones. Rarely it can be due to damage to a part of the lower brain which controls hunger and satisfaction. But the majority of cases do not belong to this category. The major cause of obesity is clearly recognized to be due to the modern lifestyle.

What are the factors in the modern life style that contribute to obesity? Our body is like an elastic bag. What you put inside the bag (high calorie food) and what you take out of the bag (exercises) decides the size of the bag. In the present day lifestyle with advanced technology and busy schedules, life has become sedentary; hence there is no time or the need to do any physical work. Most of us are involved in brain work which consumes much less calories than muscular activity as in walking, running, playing etc.

The present day lifestyle also has led to wrong eating habits. Consumption of high calorie foods such as fried foods, bakery items, sweets, and chocolates (junk foods ) available in very attractive tasty presentations, is clearly the cause of this malady.

Is there a role of heredity? Yes, you have many friends who can eat any amount of junk food but still are underweight, whereas some of you find it extremely difficult to reduce weight in spite of sincere dieting. This is due to the hereditary tendency. The underweight families are called rapid metabolizers and the obese are slow metabolizers. Please remember that it is more important to reduce the weight if you have a strong tendency in the family for overweight although you need to try a little harder.

Where do we start? All obese people know what you need to do. It is very simple information to know–avoid high calorie food, eat more fiber and exercise more. But why is it so difficult to reduce weight? It is all in your mind. Mind controls every function of the body. There are two centers in the brain (hypothalamus) that are responsible for sensing the hunger (appetite center) and fullness after eating (satiety center). These two centers function in perfect coordination under healthy, natural conditions to maintain normal weight. The functioning of these lower centers is modifiable by our mind (higher brain centers – cortex). In other words, in human race the eating habit is more controlled by the state of the mind than by the instinct of hunger unlike animals. Gluttony and Obesity are unknown in animals (except pets). Since it is all in the mind and we have the freedom at the mind level to eat more or less; we should be able to control our eating habits through voluntary awareness rather than as a reflex. But as one becomes guided by the weakness of sense pleasure (taste buds) the control is lost and he becomes a slave to the cravings. If the mind is disturbed due to longstanding stress and speed, it can lead to abnormal eating pattern. Thus, loss of control over emotions results in disturbed balance of appetite – satiety centers. It is a common experience that you may gain or lose a lot of weight if you are depressed or anxious. Hence the most important component in management of obesity is mind management. Yoga is the right tool to develop a healthy and happy way of controlling the weight through cittavrtti nirodhaç. (mastery over the mind is yoga). (PYS:1:2)

In the present day competitive world where everyone is racing with time, it becomes almost impossible to find time for exercises. Many a times even if you find time laziness takes over. Again, it is all in the mind and hence yoga gives the necessary willpower to adhere to the regularity of exercises which is very essential for a steady maintenance of the weight.

Yoga understands that obesity is also a problem that starts in the manomaya kosa just like many other ádhija vyadhis that we have seen. This results in excessively speeded up activity first in the manomaya kosa in the form of cravings or laziness or suppressed intense loop of worry during depression.This results in disturbed prána that shows up as imbalance of the rhythm and rate of breathing. This may also show as excessive dominance of left nostril breathing .When we try to correct the problem we make note of these facts and work at all the kosas to bring about balance through deep rest and relaxation and activation of the energy-expenditure channels.
The set of practices for one hour should include 30 to 40 minutes of physical practices selected to bring about stretching followed by relaxation of different parts of the body so that fat can be mobilized and used up for the additional extra work during walking or any other vigorous exercises. In other words one needs to practise any other physical activity like walking or jogging or sports in addition to the practice of ásanas to get the full benefit of the program. Yoga basically helps in overcoming the tension and laziness.

Integrated approach of yoga therapy includes techniques that correct the imbalances at physical, mental, emotional and notional levels. The physical yoga practices (ásanas) have advantages over other forms of physical exercises. yoga ásanas are to be performed indoor .on an empty stomach, early in the morning or evening when you are not too hungry. Yoga practices are to be maintained in the final posture with ease and effortlessness (sthiram and sukham) (PYS: 2.46) for a comfortable duration of time (one to three minutes) without much strain or pain. Most of the asanas involve bending or twisting of the spine in different ways, maintained without exhaustion, and helps in mobilizing the fat in the trunk region. The fat tends to accumulate in abdomen, thighs, waist and buttocks where there is loose space under the skin. Yoga practices are of special value to cut down the fat in these areas. For example for reducing the fat on the abdomen, the practice of straight leg raising and dorsal stretch as exercises followed by navásana is useful.

Naukásana, Salabhásana and Dhanurásana are useful for reduction of fat in the buttocks. To reduce excess fat on the waist there are ásanas like Trikonásana, Parivrtta trikonásana, spinal twist etc., To reduce the fat on arms one can use some loosening practices such as shoulder rotation and elbow movements followed by Vakrasana, Ardhamatsyendrásaná, Tiger breathing. All these practices help in stretching, exercising and or compressing the area where excess fat has accumulated.This promotes better blood flow and rapid mobilization of the fat from these loose tissues under the skin.

Another important component of yoga is to have deep internal awareness (with slow breathing) of the part of the body that is stretched during the practice. While you are in the final posture of the asana you are expected to bring your total attention to the part that is being stretched. This phase of focusing of the mind on the zone is called Dháraná (Desa bandhaç cittasya dháranám - pataòjali). (PYS:3.1) After you have done intense concentration (Dháraná) on the painful stretched part of the body, you are advised to practice defocusing of attention.

In other words you release or relax the stretched part while you still maintain in the final posture of the ásana. This process is indicated by the suiggestion by patanjali who says practice prayatna shaithilya and anantha Samapathi after you have attained the final position. This means do sithilikarana of prayatna -let go of all effort or relax in the final posture. Then go on to merge your mind in the expansion (Antarahita sthiti-anantata) (PYS:2.47) by imagining that you have come out of the body to merge yourself in the vast sky umbrella under which you are doing the ásana. This process of ‘let go’ in the final posture is the most beneficial component of any asana practice. This allows the necessary structural changes of mobilization of fat from the area of focused attention.


Most of the postures are called cultural postures as they culture (facilitate) the functions of the organ underneath through deep rest to that part of the body. Thus, the yogic concept of weight reduction is not through violence and fight. Please do not hate your body or the mind. Yoga therapy for obesity is a smooth and easy way to consciously detach from the body, remove or wash away the deep seated blocked feelings and stresses (Citta Sudhi) and allow the body to do its job of restoring its healthy way of functioning.

An ideal healthy body weight becomes a possibility when you learn to function with deep internal rest with effortless eternal activity through out the day. Yoga is a way of life. It is not just doing some ásanas or vigorous exercises. It requires a deep commitment and internal awareness to change your lifestyle to one of softness, ease, acceptance and stability. A balanced state of mind is to be practiced under all situations. Thus a balance between the rate of energy production (consumption) and expenditure is restored in a pleasant natural way resulting in total personality growth at both physical and mental levels.