FIVE PHASE PULSE DIAGNOSIS: The Art of Science Or The Science of Art? |
This paper is reproduced with permission from the Editor, Pacific Journal of Oriental Medicine.
The process of pulse diagnosis as utilised in traditional Chinese medicine was examined in a sample of one hundred patients randomly selected from the author's acupuncture clinic. Patient's symptoms, pulses (as described in traditional Chinese medicine), diagnostic criteria (pertaining to Five Phase acupuncture), acupuncture points selected and patient's comments after each treatment were coded into a numerical format suitable for stepwise multiple regression and cross-tabulation analysis.The analysis indicated that the interpretation of pulse qualities, from which the treatment protocol was based, predicted the diagnostic criteria when used in accordance with the theories pertaining to acupuncture. Statistically, the selection of acupuncture points could not be predicted from the diagnostic criteria when using pulse diagnosis. Additionally the analysis indicated that the patient's comments after acupuncture were independent of the initial patient symptoms.
More research is needed to more fully understand the process of pulse diagnosis. However the analysis does suggest that pulse diagnosis should be incorporated into acupuncture curricula in both traditional acupuncture courses and medical acupuncture courses.
The National Health and Medical Research Council (NH&MRC, 1989) suggest that the education and training a practitioner receives is important in insuring the safety of the patients receiving such care.
However debate exists as to whether medical acupuncturists, or acupuncturists versed in the traditional approach, should practise acupuncture (Richardson and Vincent, 1989; Stephen, 1978; Hadley, 1988; Rogers, 1985b; Christie, 1991; Lewith, 1986; Rogers, 1991a). Medical acupuncturists do not learn pulse diagnosis in their courses and generally apply what is termed 'cookbook' acupuncture within their clinic.
It has been suggested that acupuncture practised in this way is generally less efficacious than the more traditional approach (Ng, 1978). The author considers this to be so because there does not appear to be an adequate methodology with medical acupuncture to account for the relationships linking the patient symptoms, the diagnostic criteria, the points selected and the resultant patient comments at the conclusion of the process of acupuncture.
Acupuncture education in Australia is offered in two forms and to two different groups (NH&MRC, 1989). Courses teach acupuncture as a therapy or acupuncture as a total system of health care, and, the students are either already trained and practising as health care providers or have no previous training or expertise (NH&MRC, 1989). Some courses teach acupuncture to trainees already otherwise trained as health practitioners (NH&MRC, 1989). Acupuncture taught and practised to those medically trained is regarded as an auxiliary or adjunct to the conventional medical techniques utilised by that person.
Other courses purport to teach acupuncture as a complete system of medicine (NH&MRC, 1989). These particular courses offer both basic training over a four year period as an acupuncture therapist. In May 1987, official ratification of accreditation was granted by the Department of Education in New South Wales to Acupuncture Colleges (Australia) for their four year acupuncture training programme, which, at that time, was presented in conjunction with the Institute of Nursing Studies, Sydney College of Advanced Education (Acupuncture Ethics and Standards Organisation Submission to the Minister for Health for the Registration of Acupuncture, 1988).
The emphasis of the course curricula for acupuncture of the University of Technology Sydney, for example, is to teach the philosophies and techniques of acupuncture as taught and practised in the Peoples Republic of China. Moreover the establishment of two university courses of traditional acupuncture is in accordance with the recommendations of the National Health and Medical Research Council (NH&MRC, 1989).
In 1987 the Acupuncture Ethics and Standards Organisation (AESO) were requested by the Peoples Republic of China to apply for membership of the World Federation of Acupuncture/Moxibustion Societies as the representatives of acupuncture in Australia (AESO Submission to the Ministers of Health for the Registration of Acupuncture in Australia, 1988).
Each of the above teaching methodologies, that is, medical compared with traditional acupuncture, differ in the emphasis placed on applying the traditional process of pulse diagnosis as a diagnostic method. The NH&MRC (1989, p.66) suggested that the theoretical concepts behind traditional Chinese acupuncture cannot be sustained scientifically. However Rogers (1991, pp.151-152) suggests that scepticism and/or vested interest among the more influential members of the medical profession inhibit active promotion of acupuncture and such procedures for a number of reasons:
The author has used pulse diagnosis as the main method of obtaining an indication of the points necessary to treat various conditions in a Primary Health Care setting. The author's use of pulse diagnosis is based upon the Five Phase theories underpinning acupuncture rather than the classic 28 pulse qualities commonly described in acupuncture texts. It is within the context of a traditional acupuncture clinic that the treatments have emerged.
The debate is compounded by many versed in the scientific method suggesting that most of the so-called scientific papers concerning acupuncture do not adequately satisfy the scientific method. Therefore the results of many acupuncture studies are seen to be non-scientific or largely anecdotal. Those acupuncturists pursuing the more traditional approach invariably respond by suggesting that the process of acupuncture cannot be considered within the scientific framework without compromising its integrity as an holistic form of therapy (Chu, 1979). In particular the Chinese diagnostic method of pulse diagnosis is regarded by traditionalists as being integral to the process of acupuncture. Traditionalists consider that pulse diagnosis allows assessment of the patient's state of well-being within the framework of Chinese medicine in order that the most appropriate acupuncture points be selected at the time of the consultation.
The author has found in clinical practice that acupuncture point selection based on the diagnostic process of pulse diagnosis tends to suggest the need for selecting different points for different patients who may present with similar symptoms.
It is from the subjective interpretation by the author of the iconography gained from pulse diagnosis, in accordance with the theories underpinning acupuncture, that the ensuing process of acupuncture occurs. That is, within the author's clinic, the process of acupuncture involves the procedures of eliciting diagnostic criteria from pulse diagnosis, followed by the selection of appropriate acupuncture points and, finally, determining the efficacy of the treatment. Figure 1 illustrates the process of acupuncture utilised by the author in his statistical analysis of pulse diagnosis:
The problem then was to indicate whether patient symptoms improved after having a course of acupuncture using points selected from pulse diagnosis. The diagnostic criteria obtained from pulse diagnosis was considered the key to point selection and subsequent improvement in symptoms rather than the selection of acupuncture points based on the patients' symptoms alone.
The palpation of various pulses on the radial arteries of the wrists and at other sites around the body served as the main form of diagnosis for this study. Pulses were palpated at seven of the Nine Continent Pulse sites around the body in the order listed:
Various qualities within the pulses were subjectively interpreted by the author to reflect the patients' health within the framework of traditional Chinese acupuncture. A maximum of 10 diagnostic criteria (DC1-10) were allowed for each patient as interpreted by the author from either the Nine Content Pulses or the wrist pulses. A total of 150 different pulse qualities were recorded and listed alphabetically along with the frequency of occurrence. The author used two or three needles for the majority of the treatments. However there were some treatments which required only one needle and others which may have required four or five. Hence the points were given the coding of PUF1 to PUF5 to allow for the possibility of five needles being used for one treatment.
Table 1 summarises the number of criteria pertaining to each of the major variables under consideration in the study:
Variable | Number of Criteria |
---|---|
Patient Symptoms | 267 |
Diagnostic Criteria (taken from Pulses) | 150 |
Points First Treatment | 64 |
Points Second Treatment | 70 |
Comments First Treatment | 116 |
Comments Second Treatment | 105 |
Table 1: Number of Criteria Pertaining to Each Variable
Patient symptoms (NPS) were divided into six categories with an appropriate numerical code as follows:
Pulse diagnosis is a complex art and, as such, requires a considerable degree of sensitivity in the finger tips. This is because a large number of qualities may be discerned from each individual pulse as well as the combination of pulses collectively. Resulting from this is a profile of the patient's health within the parameters of TCM. Pulse diagnosis assists the practitioner to select and stimulate the most appropriate points from a range of suitable points in order to effect a corresponding improvement in that person's health.
It is due to the complexity of interpreting the pulse qualities that the pulses discerned from around the patient's body (known collectively as the Nine Continent Pulses) have been listed individually and separately from the six pulses which are discerned from each wrist. The Nine Content Pulses have been listed as P1 to P7 respectively while the wrist pulses have been listed collectively as P8. This means that P8 represents all of the diagnostic criteria deduced from the pulse diagnosis other than that information gained from the Nine Continent Pulses. The author considered that the complexity of attempting to quantify the myriad permutations and combinations of the wrist pulses (P8) alone into meaningful data was beyond the scope of the study.
The results from the SPSS-X analysis were categorised into two sections as follows:
The information concerning the Stepwise Multiple Regression is summarised below in the form of a matrix showing those predictions which were statistically significant at 0.05 level of significance:
DC | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
---|---|---|---|---|---|---|---|---|---|---|
P1 | * | * | * | * | ||||||
P2 | ||||||||||
P3 | * | |||||||||
P4 | * | * | * | |||||||
P5 | ||||||||||
P6 | ||||||||||
P7 | * | * | ||||||||
P8 | * | * | * | * | * | * | * | * | * |
Table 3 summarises the results of the Stepwise Multiple Regression:
Entered Variable | Dependent Variable | Significance |
---|---|---|
DC-DC9 | PUF | .7015 |
DC6 | PUF2 | .0463 |
DC-DC5; DC7-DC9 | PUF2 | .4310 |
DC-DC9 | PUF3 | .9173 |
DC-DC9 | PUF4 | .9172 |
Table 3. DC-DC10 predicting PUF-5
Crosstabulation of NPC against Symptoms (S1-6)
The results pertaining to the cross-tabulation of NPC against S2 have been deleted from the analysis due to S2 representing Comments Not Recorded. The cross-tabulation utilised fifty-nine percent of the data pertaining to NPC due to the author only considering those patients who improved or did not improve. Table 4 summarises the relevant data:
Variable | Significance | Contingency Coeff. |
---|---|---|
NPC-S1 | 0.9564 | 0.04324 |
NPC-S3 | 1.0000 | 0.01611 |
NPC-S4 | 0.7996 | 0.06833 |
NPC-S5 | 0.7374 | 0.07777 |
Table 4: Cross-tabulation of NPC against Symptoms (S1-6)
The iconography of the qualities of the pulses is interpreted by the practitioner and represents a profile of the patient's health in terms of Chinese medicine. It makes sematic sense that the bulk of the diagnostic criteria are predicted by the wrist pulses(P8) due to the greater iconography associated with taking those wrist pulses.
More research however is needed to determine the efficacy of the wrist pulses as a diagnostic method. However the results also indicated that several of the Nine Continent Pulses are also predicted various diagnostic criteria. The data does suggest that the Nine Continent Pulses are useful as diagnostic tools in combination with the wrist pulses. More research is needed to accurately determine the frequency of prediction of the diagnostic criteria by the Nine Continent Pulses.
The stepwise multiple regression indicated that the diagnostic criteria did not predict the points used for the treatment. The only exception to this was DC6 (sixth diagnostic criteria) predicting the second point used in the treatment (PUF2). The author considered the prediction of PUF2 by DC6 to be an aberration.
Pulse diagnosis is considered by the author to pertain to that individual patient at the specific time of diagnosis. Literally any acupuncture point may be used by the practitioner if it is in accordance with the complex matrix of diagnosis as indicated by the pulses. The individual point functions are not the only criteria to be considered by the practitioner in the selection process (Smith, 1993).
The intricate relationships of one point to all of the others chosen means that the prediction and ultimate selection of points is an extremely subtle and subjective task. While there is some statistical evidence to suggest that the pulses predict the diagnostic criteria, the relationship of the diagnostic criteria to the final selection of acupuncture points is complicated and diverse when using pulse diagnosis as the major form of diagnosis from which points are selected.
While the author acknowledges that the determination of the diagnostic criteria precedes the selection of the most suitable acupuncture points, the complexity of interpreting the subtlety and subjectivity of such a process suggests that a different research model other than Ex Post Facto may need to be utilised to obtain more meaningful data.
More research is needed to determine the statistical relationship of the diagnostic criteria with the points selected. Crosstabulating patient symptoms against patient comments indicated that the comments at the end of the treatments were independent of whether the patients symptoms improved or not. Although the study did provide some evidence that the process of traditional acupuncture begins with the patient elucidating various symptoms it is the patients comments that conclude the process.
The results of the study suggests that the patients' symptoms are not related to the actual process of traditional acupuncture when pulse diagnosis is used as the predominant form of diagnosis. This makes sematic sense due to the author's treatments being based on the diagnostic criteria as described by the pulses rather than the patient's symptoms.
While it is clear that further research is required into pulse diagnosis as a diagnostic technique, the study does indicate that there is a possibility that pulse diagnosis does in fact have a scientific basis. This in itself may indicate that educational institutions which teach acupuncture may find it useful to include in their curricula the theory and practice of pulse diagnosis if not already doing so.
The author was unable to determine that the diagnostic criteria predict the points used for the treatment. A more sophisticated computer programme may be required over and above the SPSS-X to determine further this particular relationship.
The author also found that the patient comments after the treatment were statistically independent of whether the patient improved or not.
Quite clearly more research is needed in this field to determine the efficacy of the wrist pulses as a diagnostic tool. Furthermore, research is needed to clarify the frequency of prediction of the diagnostic criteria by the Nine Continent Pulses and the specific clustering which occurred of the diagnostic criteria in relation to the pulses.
The fact that statistical significances occurred in this study does suggest there may be a scientific framework underpinning pulse diagnosis. Furthermore pulses taken in accordance with Five Phase theory rather than the classic 28 pulse qualities, may be a more appropriate method of taking pulses as a means of traditional Chinese medical diagnosis. The evidence suggests that Five Phase pulse diagnosis is a valid form of pulse diagnosis.
The qualitative approach to acupuncture utilises philosophical considerations borne of thousands of years of clinical use. However, it does appear that the diagnostic art of pulse diagnosis is centred on a coherent methodology which may have a scientific basis. While the Ex Post Facto method of research has proved useful for the study, it does not seem to be wholly adequate to account for the qualitative paradigm to which pulse diagnosis and acupuncture appear to belong.
Educational institutions which teach acupuncture may find it useful to include in their curricula the theory and practice of pulse diagnosis if not already doing so. Integrating pulse diagnosis into the medical and veterinary acupuncture courses may help to juxtapose the many advantages of acupuncture with the advantages of modern medicine. It may also help the graduates of acupuncture courses to better understand the mechanisms underpinning the acupuncture effect within the qualitative paradigm of traditional acupuncture.
Understanding that acupuncture appears to have a coherent methodology while still being inherently different from western medicine may assist people in developing the confidence to learn more about their health within the paradigm of traditional Chinese medicine. It then behoves the acupuncture and medical professions to work together to disseminate information about the benefits of acupuncture that may be appealing to the general public. Combining the many benefits of western medicine with the drug-free and low cost advantages of acupuncture may improve the quality of choice and accessibility of well-being in the provision of primary health care within Australia.
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