Class Notes 7

Quick quiz to demonstrate techniques.

Demonstration and practice of common manipulation techniques.

Passive movement of neck.

Passive movement of arms.

Passive movements of back, waist, spine.
All of these movements are indicated for low back, waist, spine problems.

It is best to perform back flexion movements when there is excessive LORDOSIS and tightness of the lower back, and weak abdominal muscles.  Back flexion should NOT be used in severe back pain, pain/tingling down leg, or bulging of discs.  #4 (Straight Leg Raise) is often used for diagnostic purposes of low back pain.

Back extension movements may be used for acute back pain, pain/tinglig down leg, or bulging discs, with caution.  Oftentimes these techniques are combined with focused deep-pressing on a problematic area or a significant point.

Twisting movements may also be used for acute back pain.  If the practitioner is able to palpate specific rotated sections of the spine, then pressure is applied to the side that "juts out", as the passive movement is applied.

Back flexion passive movements:
1) Jerk and drag to relax the waist.  (Patient supine)
a) Flex and press patient's knee toward chest (diseased side first).
b) Immediately drag down and pull.
c) Repeat on other side.
d) Can be done on both legs.

2) Deep-press bent legs to tug at the waist.  (Patient supine, healthy leg straight, diseased leg bent)
a) Hold diseased knee with one hand, grasp far side of table with other hand.
b) Gradually press knee into chest as far as it will go (using weight).
c) Repeat for healthy side.

3) Forward bend into sitting position.  (Patient starts off supine).
a) Stand at patient's feet.  Reach for patient's wrists, and grab with both hands (patient may also grab your wrists at the same time).
b) Pull toward you until patient is sitting upright.  Continue pulling until patient's upper body is facing down.  If you have an assistant, s/he may push on patient's back at the same time.

4) Straight leg raise.  (Patient is supine).
This is the traditional SLR technique.  It should be not be done past the point of discomfort.  It is often alternated with the pull-shake-rotate techniques.

Back Extension Passive Movements:
1) (Patient is prone).  Lower back extension, using the leg as the lever.
a) Deep-press problem area of back, waist or spine with one hand or knee.
b) Hold ankle of one leg with other hand and lift up or pull toward back to tug at the waist.  This can also be done with patient bending knees to touch the buttocks, and with practitioner lifting patient's leg at the knee.

2) (Patient is sitting).  Upper back extension, using the shoulders as the lever.
a) Deep-press problem area of back with one raised knee.
b) Hold both shoulders (hands over deltoids) and pull back moderately to expand chest and stretch back.

Back Twisting Passive Movements:
*Note: Twisting movements of the back can actually look very similar to Back Extension Passive Movements.  The difference is in the direction of the pull.  If the pull is straight back, then the technique is more oriented towards back flexion.  However, if the pull is oblique, or "on the angle," then the technique tends to be more oriented towards twisting.

1) (Patient is prone).  Upper back twist, using the shoulder as the lever.
a) Deep-press problem area of back with one hand.
b) Pull opposite shoulder with other hand (over deltoid) to twist spine and stretch shoulder as far back as possible.  Note that you are reaching across the table to the opposite shoulder to pull it.

*Variation: to work on rhomboids: (Patient is prone, with arm behind back in arm-bar position).  Either use a knife hand to slip in under the medial scapula, or use thumbs/fingers to press on rhomboids in region of medial scapula with one hand.  The other hand pulls opposite shoulder, as above.

2) (Patient is prone).  Lower back twist, using the leg as the lever.
a) Deep-press problem area of back/waist/hips with hand/elbow/etc.
b) Hold the front of the thigh of the opposite leg, and pull UP AND TOWARDS YOU.  Note that if you pull towards you, on the angle, this becomes more of a twist, and less of a simple back extension.

3) (Patient is side-lying).  Lower back twist, using the hip as the lever.
a) With the patient in side-lying position, and you standing at the patient's back, straighten the "lower" leg (the leg directly on the table), and bend the "upper" leg to an appropriate angle.  Note that the angle is important.  If you bend the "upper" leg so that the angle is more perpendicular to the body, then the twisting stretch is more extreme, involves the hips more, and tends to be more localized to the lower back.  If you bend the "upper" leg so that the angle is obtuse to the body, then the twisting stretch tends to be less extreme, involves the hips less, and tends to involve the entire back (and side of the body).
b) "Push" or press the hip forwards (away from you) while you "pull" the shoulder/arm back (towards you, or down towards the table surface).

*Note: a variation of this involves replacing the push forwards on the hip with a deep-press with hands/elbow on problem areas.

4) (Patient is side-lying).  Upper back twist, using the shoulder as the lever.
This is the opposite of #3, and is better for the upper back.

a) With the patient in side-lying position, and you standing at the patient's back, straighten the "upper" arm so that it is reaching for the upper corner of the table.  Straighten the "upper" leg so that it is hanging back behind the patient's body.
b) "Push" or press the shoulder forwards (away from you) while you "pull" the "upper" leg back.  Pull the upper leg back at the thigh or at the knee.

*Note: as for #3, you may replace the push forwards on the shoulder with a deep-press with hand on problem areas.

Passive Movements of Legs and Feet
We've already gone over many of the techniques for the legs and feet when we went over rectifying, pulling, rotation and shaking.

Keep in mind that rectifying, pulling, etc. can be applied to ALL joints of the legs and feet, not just the hips.  So the knees, ankles, and even each individual toe can be rectified, pulled, etc.

*****

HEAD AND FACE ROUTINE
Before we go into the actual description of the head and face routine, we need to familiarize ourselves with a few acupuncture points.  You will not need to use ALL of these points for every treatment, as each has somewhat specific indications.  ALTERNATIVELY, you may perform the routine by just following channel lines, without paying attention to specific points.  I will go over the channel method later.

Here are some important acupuncture points:

- DU 20 (sometimes written as GV or Governor Vessel 20): This point, for our purposes, lies at the vertex.  More specifically, it lies a bit behind the actual top of your head.  A shortcut for finding it is to draw a line up from the most posterior (back) part of the ear, up to the top of the head.

DU 20 or Baihui (100 Meetings) is where the energy of all meridians (directly or indirectly) meet.  This point is used to draw energy up, or sedate excess energy.  It can be used to calm the spirit, and treat headaches due to wind or heat.

- GB 20 Fengchi (Wind Pool): This point is located just below the occiput, between the origins of the trapezius and the sternocleidomastoid.  If you squeeze the back of your neck, you are, for the most part, feeling the borders of the trapezius muscle on your neck.  If you follow the trapezius up to the occiput, to the deep hole below it, you are on GB 20.

This point, as its name implies, is used to treat Wind (which involves all sorts of problems, from dizziness to headaches).  It is also an important point to treat eye disorders.

- Yintang (Hall of Impressions): This point is basically located at the third eye.  It is at the midpoint between the medial extremities of the eyebrows.  It is used to calm the shen, and to treat headaches, and nasal disorders.

- Du 26 (or GV 26: Man's Middle): This point is on the FRENULUM, that little valley between the nose and the upper lip.  It is about 2/3 of the way up (or 1/3 of the way down).  This point is a "balanced" resuscitation point, but in a larger sense, it unites the Yin and Yang energies of the body.

- Du 27 (or GV 27): This point is on the upper lip.  Used primarily for local lip issues.

- Ren 24 (CV 24 Chengjiang, Container of Fluids): This point is in the mentolabial groove, that dent between your chin and the lower lip.  Used for mouth disorders, including problems with salivation.

- UB 1 Jingming (Bright Eyes): This point is located just (0.1 cun) medial and superior to the inner canthus of your eyes (the inner corner of your eyes).  It is used, as the name implies, for eye disorders.

- LI 20 Yingxiang (Welcome Fragrance): This point is located at the top of the nasolabial grooves (the crevice that joins your nostrils to the edge of your lips).  It is technically about halfway up the ala nasi.  This point, as the name implies, is used for nasal disorders.

- St 4 Dicang (Earth Granary): located a little off the corner of the lips, at the bottom of the nasolabial groove.    Used, in conjunction with the next two points, for mouth disorders (deviations of the lips, Bell's palsy, etc.).

- St 7 Xiaguan (Below the Joint): feel the cheek bones (maxilla).  Now feel the hollow under the cheekbones.  Follow the underside of the cheekbones back towards the ear, until you stop because you hit bone (the condyloid process of the mandible).  This is St 7.

- St 6 Jiache (Jawbone): Have the patient clench their teeth.  The jaw muscles (near the angle of the mandible) should bulge up.  This point, St 6, is on the belly of those muscles (the masseters), about a finger's-breadth anterior to the angle of the mandible.

- Taiyang (Greater Yang): This point is located on the temple area.  Find the lateral extremity of the eyebrow (SJ 23) and the outer canthus of the eye.  Now take the midpoint of those two points, and slide your finger very slightly back into a depression.  This is Taiyang.  It is used for migraine headaches.

- SI 19 (Tinggong, Palace of Hearing): This point is level with the prominence of the tragus, which is the flap of cartilage that "lids" the ear.  It is used for hearing disorders.

- SJ 17 (Yifeng, Wind Screen): This point is located in a deep depression behind the ear lobe.  It too is used for ear disorders.

***

HEAD AND FACE ROUTINE
(Patient is sitting)
1) Stroke and caress the head to benefit the brain.

a) Stroke head front to back from hairline to hairline; start slow to fast, rubbing the scalp repeatedly.  Rub left side first, then right side, and then middle.

b) Interlace fingers and rub both GB 20 with thenar eminences joined together.

c) Clutch and grasp large handfuls of hair (don't PULL!!! BE GENTLE!).

d) Pound Du 20 with open fists lightly.

2) Open Passes and dredge Apertures

a) Divide the forehead by rubbing outwards with both thumbs from Yintang to lateral hairlines.

b) Pinch the browline between index finger and thumb of both hands, from Yintang out to the end of the eyebrows several times.

c) Nip and knead (30 small circles) the following points: Yintang, Du 26, Du 27, Ren 24 (Generally, for activating and balancing Yin and Yang); UB 1 (for eyes); LI 20 (for nose); St 4, 7, 6 (for jaw problems; you can use your thumb, index finger, and middle finger to hit all three points at once); Taiyang (for migraine headaches); SI 19 and SJ 17 (for ear problems).

d) Lift and pull both ears from behind several times.

ALTERNATIVELY, you may treat the head and face in supine position, using the chart provided.

***

Homework: Please practice the routine for the Head and Face, so that you can demonstrate it next week.

Apologies

Hi everyone,
I'm not sure how many of you access this blog (as the tracker does not register many views), but it is the best way to communicate. I apologize for having to miss this past week's class. I had a family emergency; my uncle was passing away due to pancreatic cancer. I will make up the class, either by extending the class one week longer, or by extending individual classes 30 minutes longer until the time is made up.

Re: the homework, please complete it and we'll go over it next week. I do want to have you demonstrate some of the individual techniques that we have gone over as well.

The plan for next class is to go over manipulations in greater detail (as I just briefly introduced them at the end of the last class). I also want to talk about combined techniques (that is, doing one technique with one hand, and another with the other hand). We will also be starting off routined (or set) segments to address the head.

Thank you for your understanding,
Randy

Videos for Class Notes 6

Class Notes 6

Class Notes 6
Tuina 1 Class Notes 6
Today we will talk about what are usually described as "manipulations," in which we attempt to improve the function of different joints of the body by traction or rotation of those joints. Manipulations are on the border between Tuina (a form of bodywork) and Zheng Gu (bonesetting). When we perform manipulations, keep in mind that we are primarily encouraging the SOFT TISSUE to lengthen to accommodate our manipulations; we are NOT forcibly trying to reset the bones. While resetting may occur as a result of our manipulations, this is not our chief aim.

REAL INJURY can result from attempting to forcibly perform any manipulation. Furthermore, manipulations designed to improve the function of a given joint CAN RESULT IN A WORSENING OF THE CONDITION if they are performed without proper sensitivity (forcibly). So keep the proper spirit when doing these techniques!!!

Usually, manipulations are performed at or near the end of a treatment. You want the tissues of the body to be as soft as possible, so that they can be more or less receptive to the manipulation. You may place manipulations at the very end, or before percussive techniques.

(NOTE: when we learn the routine, we may place certain manipulations at different points in the routine just for logistical purposes. It is inconvenient, after all, to work on the patient in prone position, then supine position, then have the patient get back into prone position to do manipulations. GENERALLY, however, for ANY GIVEN SECTION of the body, we will do all of our other softening techniques, and then perform a manipulation appropriate for that part of the body, in that particular posture.)

When you perform manipulations, you need to be aware of the natural movements of the joint you are working on. The elbows and knees, for example, are hinge joints, and can basically only open and close. Any techniques on them should only encourage opening and closing, NOT TWISTING. If you perform a manipulation on a joint that is not proper to the movement dimensions of that joint, then you are essentially injuring that joint (arguably, you would be doing joint-LOCKING, or even joint-BREAKING).

[Let me amend this: while the elbows and knees are hinge joints, the soft tissue surrounding them may allow and be capable of more dimensions of movement. Note that, with the elbow bent, you can still pronate and supinate the hand; this illustrates a “twisting” motion across a hinge joint.]

In addition to the above, you need to be able to FEEL the borders of a patient's range of motion. A good place to practice is the shoulder. Shoulders are ball and socket joints, and they generally have a wide (spherical) range of motion. With a patient seated, cradle the wrist of the patient's arm with one hand (between your thumb and index finger- tiger's mouth) and place your other hand on the patient's shoulder. First of all, as you extend the patient's arm out, try to feel the weight of the arm. Can you tell if it is relaxed or not? Experiment. Ask the patient to tense up, and see what that feels like. Then ask the patient to relax, and feel the difference.

[This is crucial for these manipulation techniques. Nothing obstructs these techniques more than a patient “superimposing” their volitional movements over your manipulations. Manipulations, in general, are intended to be passive. Note that there are situations in which you would want the patient to actively participate and move a part of the body while you are working on it. We may go over these situations later.]

Now, attempt to take the patient's arm through circles. Start off with very small circles, and gradually, gradually get larger and larger. Eventually, you may begin to reach the borders of the range of motion. You will "feel" it as a kind of resistance, like rubber bands holding back your motion. The sooner you can feel this without "going through it," the better. You may also be able to tell that you are reaching this border by observing your patient's reactions; s/he may tense up as you reach the border. HOWEVER, this is an unreliable marker, as a lot of patients try to mask their reactions (particularly men). Learn to read, through feeling, where the borders are.

So there are three general categories of techniques that I class under Manipulations: Shaking/Trembling (DIFFERENT FROM VIBRATING!), Rectifying/Pulling (basically, it can be thought of as Tractioning), and Rotating.

SHAKING/TREMBLING: This technique is only applicable on the limbs (arms and legs). You grasp the wrist or ankle with both hands, lift the limb slightly (off the table, with the legs, or about level with the shoulder with the arms), FEEL whether or not the limb is relaxed or not, and then, with repeated up and down motions, you SHAKE/TREMBLE the limb. Start off with small and gentle shakes, and gradually build up to larger shakes. DO NOT MAKE YOUR SHAKES TOO LARGE, particularly if the patient has some kind of injury in that limb; it could exacerbate the condition!

Throughout this technique, try to develop the feeling of passing waves through a jumprope.

Different forms include: single arm (usually in seated position), single leg (prone, or side-lying), both legs.

[Note: Just as it is difficult to pass a wave through a rope that is TOO slack, so too is it difficult to pass a wave through a limb that is so slack that it is bent/folded. Gently extend the limb prior to performing shaking/trembling.]

FLEXING/EXTENDING or FOLDING/UNFOLDING joints: This category comes from Maria Mercati's book. It is used for knees and elbows, the hinge joints of our body. All this involves is flexing and extending these joints. Sometimes you can use a fist in the joint, and fold the joint around it like a "nutcracker."

[As stated previously: the elbows and knees are hinge joints, but it is possible to perform other motions with them (or rather, through them) besides opening and closing. To be precise, these motions do not directly involve the hinge joints, but involve the soft tissue either proximal to or distal to the hinge joint. Let’s take the elbow:

Say you have the patient keep their upper arm next to the body, as though it were glued to it. Have the patient bend their elbow 90 degrees. Now, while keeping the upper arm next to the body, you can use the lower arm like a lever, and “turn” the arm in or out. This can also be performed with the upper arm at other angles, like 45 degrees out from the body, or 90 degrees out from the body. This type of motion actually involves what is called “internal or external rotation of the humerus,” and is actually a test for the flexibility and integrity of the rotator cuff muscles in the shoulder (and not the elbow).

Here’s another example. Again, start from the same position as above. Lock the patient’s elbow by gently wrapping your hand around it. Then, have the patient turn their hand palm up and palm down. These motions involve the muscles of the forearm, and are called “supination and pronation.”

Similar exercises can be performed around the knee (although the foot cannot really do the “supination and pronation” motions cleanly).]

ROTATION (YAO): This category involves taking joints through circular range of motions. In the experiment above, we basically did a Rotation technique for the shoulder. It is also possible to do Rotations on the wrist joint, or the hip joint (usually this is done with the patient in supine position), or the ankle joint. Variations for the hip joints include: single straight leg, double straight leg, single leg with the leg folded in towards the chest, both legs bent and together.

Note: Rotation is not performed on the neck. It's not that the neck is incapable of such motions, but it is not necessary for you to control them.

RECTIFYING/PULLING: This is basically traction, although for some reason, depending on the direction and the part of the body you are working on, it can resemble Rotating.

On the limbs, this is relatively simple; you are always pulling OUT from the body. A simple example of pulling is "snapping the fingers."

Note: this is a gentle PULL, NOT A YANK!!! It should feel as though you are pulling a heavy boat into dock with a rope. You don't jerk on the rope, rather, you feel the rope's full length, and THEN using your own body weight, you just allow your "influence" to transfer through the rope.

A slight modification involves combining a pulling motion with a pushing motion. If you want to focus on, say, the wrist joint, then you can use one hand to "push" proximal to the wrist while the other hand "pulls" the patient's hand (distal to the wrist). This "opens" the joint. You can do the same thing for the elbow.

Pulling/Pushing need not only be longitudinal/lengthwise. For example, you can turn the head to one side, "pulling" the head to one side with one hand while the other hand "pushes" on the shoulder.

One of the most critical areas to apply Pushing/Pulling is the back. The back moves in a variety of ways. It can, of course, flex and extend (bend forwards and backwards). Flexion can be "assisted" with the patient in supine position, reaching for his/her toes, while the practitioner (sometimes) works on the back. There are Thai versions of this, but they require the practitioner to "stand on the table." Overall, flexion can best be practiced on the patient in supine or standing positions (there are also side-lying options).

Extension, on the other hand, involves bending backwards (or, alternatively, "opening up the front"). Such exercises involve pulling up or back on corners of the back. The four corners of the back are the shoulders and the hips. If you decide to use the shoulder levers via the arms (particularly the wrists), then you need to be sure that the shoulders are flexible enough to accommodate your pulls (it is often the case that patients cannot extend their arms behind them). If they cannot accommodate your pulls at the wrist, then you may have to directly use the shoulders, which can involve a lot more work on your part. Again, there are a variety of Thai stretches that can provide assistance in this regard, notably the Cobra stretch variations, but they do require a bit of "balancing". There are also variations that can be done in the sitting position.

The back can also side-bend. The side can be worked on in the side-lying position, and it is possible to do some manipulations that open up the side (mostly via a cross pushing motion on the two levers, the rib cage and the pelvis). More extension side-bending can be accomplished in the sitting position, as the table isn't in the way: an elegant (if somewhat ambitious) Thai version is available for this.

The back can twist/rotate. This is by far the most complicated movement of the back. There are versions of twisting the back that can be approximated in both the prone and supine positions. If you think of the back as a rectangle, you are trying to "twist" the rectangle by either "folding back" individual corners, or having opposite corners move in opposite directions. For example, if the patient is prone, you can accomplish some degree of rotation and twist by "lifting" one shoulder (preferably as you "push" into the rhomboids). Or, if the patient is in side-lying position, you can have the top shoulder go "forwards," and the bottom leg go "backwards", and vice versa.

It is also, of course, possible to accomplish a twisting motion in a sitting position. There are varieties of this that can be accomplished in both Thai and Tuina formats.

DEMONSTRATED TECHNIQUES:
NECK: Seated Position, Prayer Hands, Flexion, Extension, Sidebending, Rotation

Supine Position, Cradle/Bridge Hands, Lifting with Slight Traction

Supine Position, Cradle/Bridge Hands under Occiput, Circles

Supine Position, Cross Hands Under Neck, Flexion

Supine Position, One Hand Cradles Occiput, Other Hand placed on Opposite Shoulder, Turning Stretch

SHOULDER TO WRIST:
Seated, Stand to one side and behind patient, Place one hand on top of shoulder (holding points like LI 15), Other hand grasps wrist. Pull at wrist, “Push” (anchor) at shoulder. Accomplish this mainly by turning your whole body slightly rather than by actually using your arms to “pull” or “push.”

In same position, try Shaking, first with very little waves, and then gradually larger and larger, and then Rotating, first with very little circles, and then gradually larger and larger. PAY ATTENTION TO PATIENT’S END RANGE OF MOTION.

*More advanced: Stand to one side of the patient. Step one leg up onto the working surface, such that your knee, if possible, goes into patient’s armpit. One hand goes on patient’s shoulder. The patient’s arm goes BEHIND your back, and you grasp the wrist with your hand. To accomplish traction, you slightly “push” up with your knee, and “pull” primarily by turning your body away from the patient (not by actually “pulling” with your hand).

*Other variations: Opening the Armpit, Finding Wings (using one hand to open front of shoulder while the other Presses in the space under shoulder blade), Water Pump.

Swimming/Brushing Back Hair: Seated, Stand to one side of patient, Support Patient’s Right forearm with your Left forearm (patient’s wrist at your tiger’s mouth), take Patient’s arm through swimming motion or brushing back hair motion to test internal/external rotation at humerus.

Supine. Stand at head of patient, Pull one arm up, Shake (either vertical or horizontal), Rotate. Alternatively, you can try both arms simultaneously.

Supine. Stand at side of patient, Pull one arm, Shake (either vertical or horizontal), Rotate.

ELBOW and WRIST: Pulling/Traction at the elbow and wrist can be accomplished by PULLING below the joint and PUSHING (or rather anchoring) above the joint.

The Elbow can be opened and closed via the Nutcracker technique.

The Wrist can also be flexed and extended, and go through rotation. There is also a technique called Water Faucet which helps with supination and pronation.

Videos for Class Notes 5

Class Notes 5

TUINA
Class Notes 5

Pile Standing Practice 4 minutes

Silk Reeling, Taiji Symbol, Teacup exercise

Stretching out Wrists and Forearms

Rooting Practice, Hand on shoulder

Review of Techniques:
Rubbing, Pressing, Pushing

Vibrating, Rolling, Swinging, Kneading

Grasping, Grabbing, Pinching, Nipping, Plucking, Lifting

We've worked on many of the fundamental techniques in Tuina. As is implied by the name "Tuina," the "core techniques" of this form of bodywork are Tui (or Pushing) and Na (or Grasping). Keep in mind that Tuina (as opposed to Anmo) emphasizes more the musculoskeletal aspect of the body, and the techniques of Tui and Na are really best at releasing tension in the muscles.

Today, we are going to be working on what I class as percussive techniques, techniques which involve "striking" the body repeatedly. What's the point of percussive techniques? To answer this, we should consider whether percussive techniques are Yin or Yang. As they remain on the surface (really, we're not trying to "break boards" here!) and as they are generally somewhat rapid (a percussive technique that simply pounds once is like the slap of one wet fish), we can definitely consider such techniques to be Yang. Yang techniques invigorate, and promote general circulation and relaxation.

In practice, I think it is best to apply percussive techniques towards the end of your treatment. Why? Percussive techniques tend to be a bit too jarring and invasive at the beginning of the treatment. They can in fact cause the patient to "tighten up" more, as it is somewhat uncomfortable to have someone strike tissue that is already tight. Percussive techniques are also inappropriate in the middle of the treatment; generally, the middle of the treatment is when you would like to be doing your deep, focused work, and is when you would like the patient to be as relaxed as possible. At the end of the treatment, when you want the patient to sort of revive and wake up, I think it's fine to perform your percussive techniques, particularly if you end with the patient in sitting position. By then, their tissues have been relaxed and prepared somewhat by everything preceding, AND the patient has grown accustomed to your touch; at that point, it's ideal to perform percussive techniques, to spread and invigorate the relaxing, warming sensations you've initiated.

Aside from invigorating/relaxing, etc. percussive techniques are also great for chest congestion and lung problems. It is a way to "jar" blockages in the chest loose.

There are MANY FORMS of percussive techniques. I will introduce the main classes from the Sun-Chengnan text, and introduce a few that I learned from my Shiatsu days.

Keep in mind a few principles:

1) you are not trying to "penetrate" so much as you are trying to lightly bounce off the tissue. If you have ever drummed, you know that "sticking" to the skin after impact deadens the sound; the best sound is produced when you are able to lightly glance off the surface, so the vibration of the impact can travel.

2) stay relaxed and loose. This actually follows from the previous point. You are trying to impart energy (whether you think of this as qi or as vibratory energy doesn't matter). If you are very tight when you do a percussive technique, then that energy stays locked up in YOU, not in your patient.

3) following upon #2, but perhaps deserving of a separate point: keep your hands LOOSE! This is true whether you use a fist or a chopping hand. While you want your hands to adopt a certain shape for any given technique, you do NOT want to hold that shape stiffly! This will again deaden the impact, and keep the vibration/qi locked up in YOU.

4) start off with a slow rhythm, just to get in a groove. I like to start off in a kind of syncopated rhythm, sort of like a limping horse. For some reason, starting off with a square, even rhythm feels really "clunky," and I have a harder time accelerating. Of course, this is just personal preference.

THE TECHNIQUES ACCORDING TO SUN-CHENGNAN
So the Sun-Chengnan text has three general categories for percussive techniques, and they are mainly differentiated from each other by the shape of the hand and the striking surface.

TAPPING (DOTTING): Dotting is performed with the tip of the middle finger as the striking surface. The middle finger is braced by the index finger "on top" and the thumb "below," such that it looks like a goose head (similar to "holding the single whip" in taijiquan). It is the only percussive technique that uses a single finger as the striking surface. It is primarily intended to be a form of stimulation for specific points. It can also be used over a larger area in cases of numbness, where the objective would be to restore sensation.

In the Sun-Chengnan text, for example, the indications list "Hemiplegia, numbness, flaccid paralysis, muscle wasting and atrophy" first.

KNOCKING: Knocking is performed with the fingertips (all of them, not just one), or with the large thenar mound, the small thenar mound and the heel of the hand. Actually, four techniques are specified: knocking with the finger tips apart (with your hands forming loose "claws"), knocking with the finger tips together (such that they form a single "point"), knocking with a cupped palm, and knocking with the back of the hand (which, oddly enough, should be considered a fist).

CHOPPING: Envision the karate chop, and you get an idea for this technique. You can chop with a single hand (using the ulnar edge), chop with both hands in alternation (perhaps the most common version of this technique), or chop with both hands together (this is called, in Japanese, "gassho," in that it resembles placing your hands together as if in prayer).

POUNDING: Pounding is performed with the fist. There are several striking surfaces of the fist, though the most common is the "ulnar edge" (in which the fist is used like a hammer). You can also use a "prone fist" (in which the palmar side strikes) or a "supine fist" (in which the back side of the fist strikes). You may also pad the fist by using your other hand as a cushion.

While you should ALWAYS keep your fist relatively loose, if you are striking certain areas (like the scalp), you should keep it particularly loose and open.

OTHER TECHNIQUES: Okay, so some of these are not technically percussive techniques. Some of them are actually Rubbing Techniques or Pinching/Plucking Techniques. I introduce them here because they are usually performed with percussive techniques at the end of a shiatsu treatment.

FISHTAILING: This is used on the crest of the trapezius (although it could very well be used in several other places). Place the ulnar edge of your hand on the patient's GB 21 area. Imagine that your hand is like a fish's tail. Allow it to "flap" back and forth rapidly, while rubbing the ulnar edge into the patient's skin.

CENTIPEDE AND CRAB: Use both hands to pluck the crest of the trapezius. Then, using your thumbs, walk straight up and down in the space between the scapula and the spine. This is the Centipede. After doing this for a few repetitions, you can walk laterally across the scapula. This is the Crab.

BALL OF AIR POUNDING: This is hard to describe and can be hard to perform. Cup both hands together to form a loose ball. Then, strike with the ball, using the back of one hand as the striking surface. Ideally, it should feel as though the ball "bounces" off the back, and as it strikes, all the air rushes out of the ball. You can actually "hear" this.

BUTTERFLY HANDS: No, this is not a reference to that cheerleading movie... Make your hands into a butterfly shape, with the thumbs of either hand on the paraspinals, and the fingers extended out and upwards. Then, let the butterfly "flutter" by rapidly rubbing your hands in and out, and up and down over the upper back.

WHERE should percussive techniques be performed? Most percussive techniques can be performed just about anywhere on the body. The central caveat is that you do not strike over bone. This is uncomfortable for both your patient, and for you (and can damage your hands). You also typically do not do percussive techniques over vulnerable areas of the body (like the abdomen or the groin or the front of the neck).

"Flatter" percussive techniques are best when you wish to stimulate the exterior. Think of the Hakka (the warrior dance used by the UH Warriors, aka the Mosquito Extermination Dance), which involves a great deal of slapping. Pre-game, or pre-battle, you would want energy/qi/blood to rise to the surface, and slapping accomplishes just this. You can use flatter techniques on just about any part of the body, but they probably are more "effective" on flat areas of the body (the back, the chest of men, etc.)

As your hands develop more specialized "shapes" (for example, a chop), your techniques tend to go deeper, and thus, tend to be more ideal for "shaped" areas of the body, like the limbs. Think about how you orient your "shaped" percussive tools on the body, as this can translate into very different effects. If you chop across tissue, then you tend to get a deeper (and sometimes more uncomfortable) effect, versus if you chop with the tissue.

PRACTICE ASSEMBLING A ROUTINE for the back and shoulders:
Think about what you have learned so far, regarding the fundamental techniques. Now, try to put what you’ve learned together to try to work on someone’s back and/or shoulders. Experiment with the order of techniques, the strength of techniques, etc., focusing on keeping a smooth flow to everything.

Videos for Class Notes 4

Class Notes 4

Zhan Zhuang (Pile Standing Practice 3 minutes)

Silk Reeling Practice

Grasping Sparrow’s Tail

Testing Structure (at hip, at shoulder, at forearm)

Leaning on wall with elbow, with palm, with fingers

Loosening Up: Shaking out wrists, Shaking out elbows, Shaking out shoulders; Wrist circles, Elbow Circles, Shoulder Circles; Finger/Wrist Extension, Finger/Wrist Flexion,
Twisted Stretch; “Pull my Finger”

A Review of GUN FA (Rolling, two forms), YI ZHI CHAN (One Finger Meditation), ZHEN FA (Vibrating), ROU FA (Kneading), MO FA (Other forms of Rubbing, like on the limbs).

Self-Massage Practice (Together)

ZHEN FA (Vibrating, with Palms)
Press palms together. They can either be fully contacting each other, or you can turn them so they are perpendicular to each other. Practice Zhen fa by tensing up one arm, from the chest to the palm. Then, alternate by doing the same thing with the other arm.

ROU FA (Kneading)
1) Press the thumb of one hand into the palm of the other hand. Use your fingers to wrap around the back of the hand being pressed. Sink the thumb into the heart of the palm, then make circular kneading motions with the thumb. You can vary the tempo of this. Try to cover the entire surface of the palm,

2) Do the same thing using the straight fingers.

3) Press the thumb into the thigh (around Spleen 10 is good). Try to sink in, and then move your thumb in circles. Switch to the opposite leg and opposite hand.

4) Same thing with straight fingers.

5) Same thing with knuckles.

6) Same thing with full palm.

7) Same thing with fist.

8) Same thing with forearms. (ipsilateral)

9) Same thing with elbows. (ipsilateral)

YI ZHI CHAN (One Finger Meditation)
Practice Yi Zhi Chan on a single point on your thigh. Use your nondominant hand as a guide.

Practice on Partner (Seated Next to You)
Other forms of MO FA (Rubbing)
Unscrew the partner’s arm. Indian burn partner’s arm.

Practice on Table Surface (Together)

GUN FA (Rolling, Two forms)

GRASPING/CROSS FIBER TECHNIQUES

Today, we will talk about "grasping techniques," techniques in which you grab a part of the body and apply pressure to it from at least two areas in towards one point (the center). This distinguishes these techniques from, say, PRESSING (AN), where the pressure is applied from one area (say the palm) into the body.

As you can imagine, a grasping technique is easier to perform on a part of the body that is contoured (not flat), and allows you to "wrap around" and apply pressure from different angles simultaneously. This doesn't mean that you can't apply a grasping technique on "flat" regions of the body (like the back or the chest); it just means that the grasping techniques tend to be more difficult to do.

Now, as with other techniques, there are different tools and different degrees to these sort of grasping techniques.

The primary tool we'll be using is, of course, the hand. But there are many different ways to grab with the hand. We can grasp with a full relaxed palm. Or we can grasp with the pads of the fingers and thumbs (with the palm NOT contacting the patient). Or to make things more intense, we can grasp with only the distal parts of our fingers touching the patient. We can even grasp with our fingernails.

Another variable we may impose is the AMOUNT of tissue we grasp. We can grasp a large amount of tissue; typically (thought not always!) this means our technique will be gentler and more diffuse. For example, when we grasp with the full palm (generally a softer technique), since we are covering more area, we grasp a larger amount of tissue. Or, by contrast, we can grasp (usually we use the word PINCH) a single tight, ropy tendon between our fingertips, and apply pressure from both sides; we may even PLUCK the tendon repeatedly.

Two related variables are the amount of force and the speed. As you might expect, gentler techniques tend to be performed with less force and faster. The more forceful the grasp, the slower the technique.

Now, once tissue is grasped, what do we do with it? This can also affect the nature of the technique. Sometimes, all we do is grasp and release tissue repeatedly. At other times, particularly when we are applying a more focused technique, we will want to grasp and hold the tissue for a certain amount of time. In other instances, we will want to actually "move" or "pluck" what we are holding. And in still other instances, we will want to "lift" what we grasp and pull it in various directions.

THE CONFUSING ENGLISH TRANSLATED NAMES
Okay, so there are a variety of English names for these techniques, and a lot of overlap and confusion as to how they differ. Let me list you some of the techniques and their descriptions from the Sun Chengnan text:

GRASPING: This involves grasping a part of the body with the pads of the thumb and fingers, or pressing an area from both sides with the entire hand.

PINCHING: Squeeze the appropriate part of the patient's body between the thumb and any one or all of the fingers. Keep the palm high, away from contact with the skin. Pinch and loosen the area repeatedly and nimbly (*unless you are focusing on one spot*)

GRABBING (+GRASPING): Control your breath, motivate Vital Energy through your fingers to form "Eagle's Talons" with your hand. Grasp and lift, applying force through the fingers with your palm raised. Take care not to injure the skin or underlying muscles.

NIPPING (+GRASPING): Bend the fingers of one or both hands into hooks. Probe the fissues, fossae and points around the joints. Nip and grasp nimbly and intermittently, pressing and relaxing in turn.

PLUCKING (+GRASPING): Apply force through your fingertips, palpating the soft tissues to find the selected tendon. Grasp the tendon and pluck it repeatedly. Proceed slowly and intermittently. Avoid nipping with fingernails or rubbing the skin with fingertips.

LIFTING (+GRASPING) [USED EXCLUSIVELY ON MUSCLES OF BACK AND ABDOMEN]: Grasp and lift the muscles of the abdomen or along the ribs with both hands, or hold them with the thenar mounds. Rotate them back and forth symmetrically several times. Repeat successively.

As you can see, it can be hard to tell what is meant by each of these terms. Let's try to put things into a continuum of sorts. Okay, first, let's consider the techniques that always use the entire hand (and not just one or two fingers):

1) First, Grasping may be seen as the name for many of these techniques as a whole. But when used alone and unspecified, think of this as a relatively gentle technique, where you use your whole palm to grasp a given area. You may do this quickly and repeatedly, or "squeeze" one area, but in general, this is the least penetrating.

2) Grabbing (+Grasping) may be seen as a harder form of Grasping. Your "palm" doesn't touch the patient; rather, your finger pads/tips (in the shape of talons) do. This tends to be a little more forceful than simple Grasping.

3) Nipping (+Grasping) is more forceful than Grabbing, in the sense that you use your fingertips (and even FINGERNAILS). In fact, Nipping is usually considered a form of Pressing (on a point) with fingernails.

4) Lifting (+Grasping). This technique is done almost exclusively on broad flat regions of the body. Here, you are grasping large regions of relatively superficial layers of fascia and LIFTING them off the body, and THEN "wringing" them by moving them in different directions... As you might imagine, this is not a very gentle technique. In fact, it is reserved for acute pain.

Okay, now let's look at the two techniques that do not necessarily utilize all five fingers:

1) Pinching: Here, think of pinching in the conventional sense; using your fingertips to "pinch" a relatively small area of tissue. There can be SOFT PINCHING, which is done gently and nimbly and quickly, or HARD PINCHING, which is done on a specific region or point, and is usually slow and penetrative.

2) Plucking: This can be seen as an extension of Grabbing or Nipping, only, you are fine tuning the technique to only find single bands of hard tissue. It can also be seen as another version of Lifting (+Grasping), only here you are isolating single bands, not entire fascial sheets. With Plucking, you can use just a few fingers (or all fingers, or even all fingers of both hands) to isolate and then "pluck" (like a guitar string) the tendon. This can be VERY UNCOMFORTABLE, so do it slowly and with intent.

WHAT ARE CROSS-FIBER TECHNIQUES?
Try to visualize muscles as bundles of ropes.

Normally, we think of a spasmed muscle as being a rope with a knot in it. The knot keeps the muscle/rope tight and short. So we try to work on the knot to soften it up, and thereby increase length in the muscle/rope.

Now, sometimes adjacent ropes in a bundle of ropes stick "laterally" to each other. This will also prevent the muscle/rope from lengthening, but to get at the problem, we need to "change our technique." Here's where cross-fiber techniques come in.

Examples of cross-fiber techniques include PLUCKING, because we isolate tight tendons, and we apply pressure "across" (at a right angle to) the grain of the fibers. This is like "rolling" or "twisting" the bundle of ropes to try to break the adhesions holding the ropes together.

Note: Cross-fiber techniques can be VERY UNCOMFORTABLE. So if you do them, do them with slowness and intent. Don't try to go too rough on your patient!!!

Videos of some techniques

RUBBING





ROUND RUBBING





PUSHING





PRESSING





YIZHICHAN





ROLLING (GUNFA)





KNEADING





VIBRATING

Class Notes 3

Class Notes 3
Zhan Zhuang (3 minutes)

Silk Reeling

Grasp Sparrow’s Tail: Peng-Lu-Ji-An (or Lead Tiger up Mountain, Lead Dragon down to Sea, Push the Yin-Yang Palm Out, Push the Doors Shut)

Testing Rooting: Pressure at Hip, Pressure at Shoulder

Extension Practice: Leaning against the Wall with Elbows, with Fists, with Palms, with Fingers, with Thumbs

Hints and Tips on Different Techniques
1) With Pushing (Tui) techniques, there is always the possibility of overextension. It is okay to bend at the waist slightly in order to perform pushing, but if you find yourself leaning far over, or even uprooting yourself (feet on tiptoe or leaving the ground entirely), then you need to change your position. Reposition yourself. If you are covering a large/long area (like the back), it is far better to work in segments than it is to overreach yourself.

2) Related to #1 is the issue of body contours. The body has natural slopes and valleys. Generally, it is easiest (most comfortable) to push UP a slope. On the other hand, pushing DOWN into a valley tends to be both less effective (you are sliding more than you are putting pressure into the patient’s body) and more prone to overextension. The answer to this is still the same as in #1. Reposition yourself. For example, the most common place for this sort of problem to occur is at the head of the prone patient, when you are pushing down the back. At mid-back, there is a down slope. Instead of trying to cross this down slope while standing at the head of the patient, try repositioning yourself further down, and to one side. Also, see #3.

3) When Pushing, think about using your other (nondominant) hand. One important role that the nondominant hand can play is as an anchor. It can (lightly) press the tissue while the other hand pushes and lengthens the tissue. This can be key in certain areas like the (down-sloping) mid-back region.

The nondominant hand can also act as a reinforcer, particularly if you are using one of the smaller tools (like the thumbs or the fingers). You can stack the nondominant hand atop your primary tool.

The nondominant hand can also act as a guide. This can be particularly important on “slippery” or “tight” areas, like the paraspinals, especially if you are using particularly penetrative tools like the elbow. You can use the “tiger’s mouth” (between the thumb and index finger) of one hand to serve as a “stencil” to guide the elbow.

4) The easiest surfaces to work on (and this is definitely open to debate!) are:

PALM: Full palm/heel. The thenar/hypothenar eminences are okay, but if you slant too much into either, you start to feel torque in your arms. The “balls” of the hand produce far too much tension to be particularly effective.

FIST: By far, the easiest surfaces to use are the ulnar surface (like you are stabbing someone) or the “top” (between the MCPs and PIPs) of the fist (perhaps even with a bias towards particular MCPs). The former (ulnar surface) seems better when you are Pushing, whie the latter seems better for Pressing (although it could be used for both). Using the palmar surface of the fist might seem okay (and similar to the palm), but it loses the surface area of the palm while adding tension at the wrist. The back of the fist and the radial (thumb-side) of the fist are far too awkward for normal uses (although the back of the fist can come into play as a percussive instrument on the patient in sitting position).

KNUCKLES: Think of two surfaces: the PIPs of the second and third knuckles combined, and the PIPS of the third, fourth, and fifth knuckles combined. There are many ways to arrange the knuckles, but by far the strongest involves twisting your arm slightly. For example, if you are using the second and third knuckles to PUSH, instead of arranging your hand palm down towards the point of contact, try turning your whole arm (from the shoulder down) as though you were turning a doorknob counterclockwise, thumb close to the body surface. If you were using the third, fourth, and fifth knuckles together, you would turn your arm the opposite direction.

The reason this orientation is stronger is this. If you were to push with your palm facing the patient’s body, then you have to FIGHT the natural tendency for the knuckles to fold under (as in a fist), as well as a similar tendency at the wrist. This leads to countertension, and tension is the enemy to effective technique and sensitivity.

It is possible to utilize individual knuckles, but you have to be careful that they are strong (reinforced) enough. Use your other hand as a guide if you need to! This can be particularly important on areas like the shin (tibialis anterior).

FINGERS: Avoid using the tips of the fingers, especially for a Pressing technique. There are ways you can use them, but they must be reinforced, and even reinforced, it is inadvisable to put your full weight upon them. I would definitely avoid putting sustained pressure on them (in other words, not really suitable for true Pressing).

Instead, consider using the pads of the fingers. Imagine your fingers are either like the branches of a tree root growing into the ground, or a blade sinking into butter. You can spread your fingers apart (for a more superficial Push), or put a few of them together (2nd and 3rd, for a narrow area), or even use all of them together as a knife blade to sink obliquely into different parts of the body (like the front of the shoulder blade, deep within the armpit).

Always keep your fingers slightly flexed. DON’T HYPEREXTEND YOUR FINGERS. Hyperextension is a sure way to damage your fingers.

Again, use your other hand effectively. You can stack both hands together to apply a “double finger blade.”

THUMBS: The thumbs are really easy to use. That’s their danger. If at all possible, try to get in the habit of using other tools before you rely upon your thumb.

The best surface on the thumb is halfway between the pad and the tip. Try to either align your thumb next to the hand to provide reinforcement, or use the other fingers (splayed out like a spider) to provide further support. Use your other hand to reinforce if need be. This can be accomplished in various ways: for example, you could use two thumbs adjacent to each other, or use the other hand as a sort of guide…

FOREARMS: This tool requires you to get closer to the body surface. Accomplish this by lowering yourself via your LEGS first, and then, if need be, by bending at the waist. The best surfaces to use are the ulnar edge and the dorsal surface. The ulnar edge is best for Pushing like a motor grader or a lathe; the dorsal surface/elbow can be used to travel like a train along a narrow set of train tracks. Obviously, this tool can only be used on large areas that have deep tissue. I would use this on the lower back, and the thighs (and sometimes, with certain patients, on the calves).

ELBOWS: By far this is the most dangerous tool to use. Reserve it for your most robust patients, and the deepest tissue. You have to get low, as for the forearms. Start with your elbow pretty wide open, and only gradually decrease the angle (make it acute). Feel your way in. DON’T STAB your way in!!!

When using your elbow with Pushing, it is important that you maintain control, and a clear pathway. Use the tiger’s mouth of the opposite hand to guide your elbow on its course!

Rating Techniques

Practice combining the techniques with the tools, as we did last week. Use each combination on different parts of the body, specifically, the upper back, the shoulders, the arms (no direct pressure on elbows!), the lower back, the hip/buttocks, the legs (no direct pressure on knees!).

We will attempt to “quantify” the combinations of Tui (Pushing) and An (Pressing) with the different tools by assigning numbers to them. As the GIVER, try to rate the ease of performing a technique with a given tool (1 is very easy, 5 is very difficult). Also think about what the best part of the body to use the technique-tool combo would be.

As the RECEIVER, try to rate the amount of pressure (1 is little pressure, 5 is too much pressure) and the level of specific penetration (1 is very shallow penetration, 5 is too deep) of a specific technique-tool combination.

Tool↓/Technique→ AN (Pushing) TUI (Pushing)
Palm
Fist
Knuckles
Fingers
Thumbs
Forearm
Elbow

We’ll compare our insights afterwards.

Being Soft and Loose and Vigorous

In the previous class, we discussed the techniques of pressing (An) and pushing (Tui) with tools other than the palms. For the most part, these techniques are NOT vigorous, because the use of pressure automatically makes them penetrative (to greater and lesser extents), and we do not want to be vigorous when we penetrate; we lose control, we may cause damage, etc.

In today's class, we will talk about techniques that are vigorous and loose and soft. These are Yang techniques, in the sense that they remain on the surface and are fast (I know, I know, "loose" and "soft" tend to be Yin words, but we're talking about what the effect is on the patient, not on the practitioner). These techniques are intended to soften up larger areas of the body than the penetrative Yin techniques. They can be used either BEFORE a penetrative Yin technique (to "prime" the area for deeper work) or AFTER (to "spread" the softening evenly).

When you are soft/loose/vigorous, while you should retain a sense of your body's structure, your joints do not need to be as aligned/stacked/open as in penetrative techniques. In fact, what distinguishes these soft/loose/vigorous techniques is the MOBILITY of the joints between your body and your patient's. As the joints do not need to stay fixed in any one position to deliver "force" into the patient, they are allowed (and, in fact, required) to keep moving.

Imagine that you are a tree in a fierce windstorm. Although your legs remain solidly rooted, your shoulders/elbows/wrists/hands must remain loose and mobile; if they aren't, then when the wind blows, the bough breaks. Even if your hands are loose, if ANY JOINT on the branch (your arms) retains tension, it will: 1) restrict the technique, and 2) invite injury.

Another thing with these vigorous techniques: Don't forget to breathe! I don't have a rule about the nature of your breathing, i.e. breathing fast or breathing slow. But if you forget to breathe, then your body WILL tense up and you won't be able to do these techniques well.

Now, as with everything, these techniques have degrees. Nothing is pure Yin or pure Yang. So some of these techniques, while "vigorous" or "moving," can be used in such a way that they are more or less penetrative. To the degree that a technique becomes penetrative, you may have to: 1) slow the technique down, and/or 2) "open" or stack some joints.

RUBBING (Other forms)
Rubbing can definitely be considered an exemplary form of soft/loose/vigorous technique. One form that we didn't cover is used primarily on limbs. I call this "unscrewing the pipe." It is also described as "foulage technique."

Imagine the arm is like a heavy lead pipe. You want to unscrew the pipe. So you put each hand on either side of the limb and "unscrew," moving each hand in a back-and-forth motion. Keep things light and fast.

Another similar form (also used on limbs) is called the "indian burn." There is a similar twisting motion with this form of rubbing, but here, hands are wrapped side by side on a segment of a limb and twisted in opposite directions. Again, keep things light and fast.

SWINGING
The most popular form of Swinging is called Yi Zhi Chan (or one finger meditation). You use your thumb, and "swing" from the tip to the pad, back and forth. Don't just "swing" your wrist, keep your whole arm loose.

ROLLING (GUN FA)
This technique can be thought of as a form of Swinging, but it feels "rounder." You "roll" from the hypothenar (pinky) side of the palm, to the dorsum of the third knuckle. Again, don't just use one joint, use your whole arm. And try to keep the motion "round." Ideally, it should feel as though someone were rolling a ball on your back.

This technique can be more penetrative, if you slow down and "press" with your knuckles.

Alternatively, you can do rolling in another way. This was recommended by Maria Mercati in her book on Chinese Massage. Imagine that your hands are like rolling pins. You can start out with your palms flat on the patient's body. Then, you roll over the tips of your fingers, over each successive knuckle, until your hands end up like fists. And you "unroll" again. This type of rolling has a more longitudinal feel to it.

KNEADING (sometimes described as Grinding)
Kneading is a very important group of techniques. These techniques are far more penetrative than the others, and are usually performed much slower and with more intention. To put it simply, kneading is simply Pressure plus a circular technique.

Kneading can actually be performed with any tool that applies pressure. It is most popularly performed with the pads of the thumbs or the thenar eminences.

It can be performed with the palm or fingers on the abdomen, where it is described as Grinding.

VIBRATING (ZHEN FA)
This technique is held more or less stationary. It actually isn't so much a soft/loose/vigorous technique as a technique that derives from internal tension. If you tense up your muscles, your body will vibrate subtly. If a part of your body is touching the patient, then that vibration will pass into the patient.

You can perform Vibration with your palms (relatively easy) or with your fingers (harder). You can also perform Vibration through a palm. Unlike most of the other techniques we've talked about today, it's probably best/easiest to do this by exhaling in a slow, controlled way.

Class Notes 2

Class Notes 2

Today, we will return to two techniques we introduced in the previous class: Tui (Pushing) and An (Pressing). But we will be using different tools with these techniques, thus transforming them from relatively superficial techniques to deeper and more penetrating techniques.

Before we go into this, we should return to issues of proper body mechanics, because these will be even more critical as we use certain tools (especially the fingers and thumbs).

BODY MECHANICS REVISITED
When you apply any sort of pressure to a patient's body:

1) Think of a way to open ALL (or as many) joints between you and the point of contact. When you "open a joint", don't open it too much (in other words, don't "lock" a joint) because it will tend to cause an obstruction in your body, and will lead to eventual injury. Instead, open each joint "just enough" to allow your weight/force to "flow through" into the patient's body.

Imagine that your arms are like tree roots, only these roots don't suck water up, they push water out (like a garden hose, only with more structure). You definitely don't want any "kinks" in your tree-root-arms, because then the water won't be able to flow out of you. "Kinks" can be caused by joints that are too closed (like a bent elbow) OR too open (like a locked elbow). You again want your arms to be open "just enough" to allow the water/force/weight to flow through.

Certain joints have a tendency to be "too open" and thus prone to injury: the thumbs, the fingers, and the wrist, for example. Some joints tend to be "too closed": the elbow sometimes, and also the shoulder. Try to experiment to find the optimum "flow" between your body and the point of contact. IT SHOULD FEEL RELAXED!!!

Hints: Try to keep your fingers slightly curled when using their tips. Fingers and thumbs in particularly are prone to injury due to hyper extension (too open). Also, always keep your elbows dropped. This is a key idea in Taijiquan, but it is effective here. If you ever raise your elbow, you will notice what a strain it puts on your shoulder. So keep them down!

WEIGHT SCALE DEMONSTRATION

2) Related to the idea of OPENING the joints is that of STACKING the joints. Imagine that you are building a tower out of a stack of building blocks. The tricky thing is that when you are using your thumbs/fingers, you are building this tower with a SMALL foundation. Nevertheless, if this tower is going to stand, each successive block (or joint) must be "centered" over the previous one.

Imagine if you were building a tower of blocks, and each successive block was stacked too far to the left. Eventually, the tower of blocks would have to fall to the left. Similarly, when we apply pressure, if we don't "stack" our joints in an even and consistent way, then the "bottom joints" will have to collapse (leading to ineffective techniques AND possible injury).

3) Reinforcement: If you are using small tools like your thumbs, then it is best to do some sort of reinforcement. You have two hands, so you might as well use them together to reinforce each other. For example, instead of applying pressure with only ONE THUMB, try putting two next to each other.

Other examples of reinforcement include the technique I demonstrated in the previous class, of bracing the elbow against the hip.

Still other examples include using one hand as a guide for an unsteady or wobbly tool (more on this later).

4) The issue of HEIGHT. Okay, this is probably the biggest issue most of us face when working on people. In the clinic, we are usually working on people ON TABLES. If we want to perform our techniques with any degree of success, we have to make sure our bodies and their bodies have the optimum height relationship. If the patient is too high, then your techniques will be much weaker. If the patient is too low, then you will likely strain your back from bending over him/her.

WHAT CAN YOU DO?

Here are some suggestions:
a) Lower/raise the table.
b) Use a chair to prop yourself up.
c) Get on the table.
d) Modify your posture/technique.

With regards to d: Let me give an example. Let's say I wanted to work on a patient's trapezius muscles. I could stand up straight and apply pressure down on GB 21 AT AN ANGLE. But what if I happen to be very tall relative to the patient? I can't mechanically apply as much direct pressure as I'd like without feeling some kind of pressure in my back.

So what can I do? I can KNEEL at the optimum height (maybe even using a stool if I'm uncomfortable kneeling). I can kneel so that my shoulders and the patient's GB 21 are at the same height. Then I can apply pressure more directly into the contact point.

Note: the astute may see that this seems to contradict the principle of keeping the hara close to the point of contact. But in reality, this is just maintaining that balance, but with more emphasis on opening the joints (this time, including the shoulder).

5) USE WEIGHT NOT FORCE whenever possible. AFTER you've opened up your joints, etc. THEN USE YOUR BODY WEIGHT to FLOW INTO THE PATIENT. Recall the image of the tree roots that POUR WATER. Once the roots are in place, THEN if you "lean" (tip the tree), the water/weight will naturally FLOW into the patient.

The order of this is, I think, essential. If you are not structurally prepared (i.e. open, stacked joints, etc.) then when you lean your weight, your arms/hands/fingers will be structurally unsound, and will tend to buckle or, in any case, suffer unnecessary stress.

ATTITUDE REVISITED
Last time I spoke about maintaining an attitude of exploration, not attack. Let's expand on this idea.

Oftentimes when we encounter hardness, our first instinct is to "strike it." Unfortunately, this is not a very healing way of doing things. Striking things tends to produce a single sharp penetrative "spike," with no endurance.

Think about cutting butter with your finger. What happens if you attempt to karate chop a stick of butter with your finger? More likely than not, you will get "butterfinger." (SORRY BAD JOKE). Seriously, you'll probably only end up with the butter stuck around your finger.

But what if instead, you applied slow and steady pressure on the butter? Gradually, the butter would open around your finger, until you were able to cut it in half. This is our ideal when we penetrate. We are not trying to "cut through" in one swift strike. We are instead trying to "sink in" through patience and "weight/wait."

You can also think of this in terms of Yin and Yang. Generally, if you really want to get into the Yin (or deep) part of the body, you need to sink in slowly. If, on the other hand, you only want to emphasize the Yang (or shallow) part of the body, you can use rapid, superficial techniques. Because of the way the body generally protects itself, if you use rapid, penetrative “attacks,” the body will tend to tense up and prevent you from going deep.

CORN STARCH EXPERIMENT

Okay, now let's practice some of our techniques.

PRESSING (AN)
Pressing is actually easier to practice, since it only involves putting weight into an object (there is no additional vector).

Last time, we used Palm Pressing.

Experiment with Pressing with other tools:

1) Different Parts of the PALM: the thenar eminence, the hypothenar eminence, the heel of the palm, the "knuckles"/head of the palm

2) Different Parts of the FIST: the palm side of the fist, the pinky side of the fist, the knuckle side of the fist, the back of the fist

3) The wrist (similar to the palm and the fist): the palmar side, the dorsal side

4) The PROXIMAL INTERPHALANGEAL JOINTS (the "second" knuckles of the fingers)

5) The fingers (THIS IS DIFFICULT!!!): first, try individual fingers, just to see how that feels; then, try different pairs or groups of fingers; then, try all fingers together or spread out; experiment with using different edges of the fingers (i.e., not just the finger tips, but also the pads and the lateral edges); FINALLY, try to figure out ways to REINFORCE the fingers (via other fingers of one hand, or with the other hand)

6) The thumb (AGAIN, DIFFICULT!!!): experiment with ways to use the thumb in such a way that it is not uncomfortable or hyperextended; think about how the other fingers act as support for the thumb; use different surfaces of the thumb; find ways to reinforce the thumb

7) The forearm: experiment with different sides of the forearm

8) The elbow (VERY VERY DANGEROUS!!!): please, at this point, experiment on a massage TABLE, not on a person. Until you feel comfortable and can exercise control with this tool, don't use it on a person. It really can cause significant injury if you're not careful. That being said, try: using different elbow surfaces, using different angles.

What are some other tools you can think of?

Okay, now let's move on to PUSHING (TUI).

This is a harder technique, because in addition to the pressure, you are adding a direction. This means several things:

First, make sure the patient is prepared. Usually, for the more penetrative forms of Tui, exposed skin is better. It's not that you can't do Tui on clothing, it's just that it tends to stretch or even tear things. As you might imagine, you can't just do Tui on exposed skin alone either. You need to use some kind of liniment, NOT TOO GREASY, or your technique will just slip around (it won't have any penetration).

Second, you need to make sure that you are able to Push a fair distance without feeling yourself get overextended. You may need to get closer to the table. You may need to prop yourself up over the patient. You may need to take a different stance.

Now, even though this technique has a directional element to it, don't forget: open/stack the joints first, then add weight (penetration), AND THEN (and only then) attempt to add a direction.

Please experiment with many of the same tools used for the Pressing exercise.

You may find some tools are more amenable to Pushing. For example, using the forearm seems great for Pushing, because it feels like you are a motor grader or a bulldozer.

PRACTICE
Work on the patient’s back, with the patient lying face down.

Start with some Rubbing (Mo Fa) with the Palm. Remember to find a good place to stand to practice your techniques.

Press (An Fa) the back with the Palm. There are different ways to do this. DO NOT PRESS DIRECTLY ON THE SPINE. Instead, press on the paraspinal muscles to either side of the spine.
Try to Press with both hands on either side of the spine. First, press with even pressure on both hands. Then, try to SLOWLY alternate pressure between one hand and the next (BE CAREFUL DOING THIS. Imagine you are Walking on eggshells, and too much pressure will cause things to crack). Start from the head of the table, and work your way down as far as is comfortable. When you feel yourself overreaching, switch to standing to one side of the table and work your way down.

*ALTERNATIVELY, only for those who are comfortable with this, you can go on the table, straddling the patient, and press the mid to lower back.

You may also START from one side of the table, and press on the contralateral (opposite) side of the spine, as though you are trying to push tissue away from the spine. You can “walk” your way down the spine.

Switch between the different tools: Palm, Fist, Wrist, Knuckles (PIPs), Fingers, Thumbs, Forearms, Elbows. Communicate with your patient to ask what each tool and technique feels like. Also, notice in yourself, what tools and techniques feel comfortable and effective.

Practice your Pushing (TUI) with different tools. This will require more Rooting, and more of a focus on your stance. It will also require a LIGHT amount of liniment. Work down the length of the back, and to keep things simple, just do one side at a time. Start with the Palm, then go on to the other tools: Fist, *Wrist, Knuckles, *Fingers, *Thumbs, Forearms. The tools with asterisks need to be done with caution. If you feel any discomfort, change something about how you’re doing the technique or discontinue it for now.

Practice with the Elbow only on the table surface for now. It is very dangerous...

Class Notes 1

CLASS NOTES 1
What is Tuina?

Tuina is often thought of as, simply, Chinese Massage. This is not entirely accurate, because there are other forms of Chinese Massage. Nevertheless, Tuina is perhaps the most well-known and general form of massage.

"Tui" means "Push" (not the push we usually think of, as in "push and shove"; we will talk about this later), and "Na" means "Grasp." These two techniques are considered important to this form of massage; however, Tuina encompasses several other kinds of techniques.

History of Tuina

* The earliest reference to any sort of bodywork in China occurs in the Huang Di Nei Jing Su Wen, when the Yellow Emperor asks his physician Qi Bo of the role of therapeutic massage and bodywork. Qi Bo says: "In the spring and summer, when food is plentiful and humans tend to become lazy and slothful, finger pressure is used to increase digestive fire and restore vigor."
* During the Qin Dynasty (3rd century BC), bodywork was known as Moshou (Hand Rubbing).
* During the Han Dynasty (206 BC - 220 AD), bodywork was known as Anmo (press and rub). It is believed that Chinese Anmo is the inspiration for many other Oriental forms of massage. During the 6th century, Anmo spread to Japan and Korea. In Japan, Anma (same characters) developed; nowadays, Japanese Anma is considered primarily a form of abdominal massage. It is believed that Shiatsu also developed from Chinese Anmo.
* By the 5th century AD, a doctoral degree was created specifically for Chinese Anmo at the Imperial College of Medicine in Xian (capital during the Tang Dynasty).
* It was only during the Ming Dynasty (1368-1644) that the term Tuina came to be used.
* TUI NA vs. AN MO. Although this is not a rough and ready rule, we may say (particularly if we look at Japanese Anma, a development of Chinese Anmo) that AN MO is a gentler form of massage, largely geared towards "rubbing" the superficial tissues; TUI NA incorporates AN MO, but seems geared more for treating musculoskeletal disorders with more aggressive techniques.

How is Tuina different from other types of bodywork?

First of all, it should be said that bodywork is a pretty universal practice, occurring in some form in all cultures. To say that one form of bodywork was spread from one place to another may be partially true, but to say that bodywork as a practice in its entirety did seems somewhat naive and arrogant.

Tuina differs from other forms of massage in that: 1) it can be performed with patients fully clothed (although it can perhaps be performed better with patients exposed); this differentiates it from, say, Swedish Massage; 2) while it can use oils and liniments, it also doesn't necessarily need those (again, this differentiates it from Swedish Massage); 3) its techniques are not limited to thumb and finger pressure, and while Shiatsu is not necessarily limited to this either, Tuina generally involves a greater variety of techniques than Shiatsu; 4) Tuina is USUALLY practiced on a table, whereas Shiatsu and Thai Massage are often practiced off the floor.

Bottom line: Tuina, like other forms of bodywork, differentiates itself in the body of techniques that are particular to it, and how those techniques are performed.

Proper Attitude

In general, it is best to adopt a gentle attitude when working on ANYONE (even "tough" patients). When you work on a patient, don't think about "working" him/her, like a piece of clay. Think instead that you are trying to explore and learn about the patient. Your hands, fingers, whatever are like the roots of a tree searching for water. If you think of your work as more a "growing out" and an "exploration," you are less likely to "stab" or "push" (and therefore hurt) your patients.

ALWAYS REMEMBER THIS... It is easy to forget, but it makes both YOUR and your patient's experience positive.

Contraindications

I reproduce this in its entirety, since it’s a substantial list. I don’t necessarily agree with all of these, by the way:

“Unknown diagnosis, overeating, excessive drinking, drunkenness, anger or rage, deep sorrow, being extremely tired or hungry.

“Infectious diseases such as leprosy, plague, hepatitis, open wounds or fractures, scalds, burns, various malignant tumors, disorders with tendency to hemorrhaging, tuberculosis, psychosis. Pregnant or menstruating women should be treated later or with great caution.

“Perfunctory manipulation, clumsy or harsh procedures, or making jokes are clinically inappropriate. (It is a good thing to use some levity to put a patient at ease, but a joking attitude undermines confidence and is not desirable.)”

Principles of Bodywork

You need to know the correct principles of bodywork in order to protect yourself from injury, and in order to make your techniques as effective as possible.

First of all, you need to relax your body as much as possible. Although it may seem like bodywork demands a lot of physical exertion, it really doesn't. Most of your "strength" or "power" comes from gravity and your body structure.

A good exercise to work on relaxation and grounding is Zhan Zhuang, or Pile Standing, from Tai Chi (and also other internal martial arts styles and Qi Gong). Simply stand with your feet roughly shoulder width apart, knees slightly bent. You may hold a variety of postures with your arms and hands. A common version says that you should position your arms as though you were holding a tree. Relax, keep your back relatively straight, and drop all tension down through your feet into the ground.

Now, we're not always going to keep our weight even on both feet. Sometimes we will be pushing weight forwards, other times we will be pulling weight back. So, we should be practicing other stances:

BOW STANCE
4-6 STANCE
CAT STANCE

The point is not to adopt these formal (and maybe inappropriate) stances while working on patients. The point is to BE AWARE of where you place your weight. FEEL your feet, FEEL where you place your emphasis as you stand. And try to match your weight with your technique.

A Complex and Simple Idea: Triangles

In physics, there is the theoretical idea of both the irresistible force and the immovable object (which would win?). Although we need to use some degree of force to achieve our aim of penetrating tissue, we do so not by emulating the "irresistible force," but by becoming the "immovable object." That is, we need to connect to the ground, which is the most "immovable object" in our immediate vicinity.

Whenever you apply pressure to an object, especially penetrative pressure, the object resists with a force of its own. If you are using your thumb to penetrate someone, for example, this force of resistance (or counter force) will put stress on your whole body through the thumb (ultimately, it will lodge itself at the weakest link, often, your thumb joint). If you are not well-connected to the ground and relaxed, then that counter force will either throw you off balance, or it will pass into a weak and tight part of your body, and perhaps injure you there.

We use our lower body to root ourselves. The best shape to emulate when rooting is a triangle, and in particular, the right triangle. One leg is always vertical, and it seems to carry most of the weight. The other leg, whether extended behind or before us, is the support leg. In the Bow Stance, for example, if the counter force is powerful, it can travel through the rear support leg, and back into the ground.

TO ACHIEVE PENETRATIVE FORCE, BALANCE TWO OPPOSING FACTORS: 1) Bringing the Hara (Dantien) close to the point of contact, and 2) Extending or opening the joints between the point of contact and the Hara.

This seems like a complicated statement, but it really isn't. To use force effortlessly, you need to balance two somewhat opposing tendencies. First of all, you need to bring your Hara as close as possible to the point of contact (wherever you are applying pressure). You can do this by leaning in, or even by turning your waist slightly. Of course, you can't just collapse the distance between your center and the point of contact; that wouldn't accomplish anything at all. You have to balance this with the second point: opening all the joints between the point of contact and the Hara. So, for example, if you are using your thumb to apply pressure, you can increase the force by opening your wrist joint (aligning or stacking it), and opening your elbow joint (this doesn't mean LOCKING the joint!). We DON'T open the shoulder joint, because this would INCREASE the distance between the Hara and the point of contact (and thus break the balance).

The other way to increase force without increasing effort is to use spiraling force. Imagine your whole body, your arms, legs, and torso, as being like a screw. A screw has penetrative power because it twists. You can increase your force simply by "turning screws" slightly, whether that means turning your legs, turning your waist, or turning your arms. This is all "heady stuff," but hopefully we can get it eventually.

HANDS ON WALL EXERCISE
SPIRAL TWINING OR SILK REELING EXERCISE

Another way to think about this is articulated by Ohashi, a Shiatsu teacher. According to Ohashi, each part of our body is linked to its exact contralateral opposite. So, for example, our left hand is connected to our right foot. What this means, in practice, is that the “strength” or “force” of any given part of our body is controlled/determined by the exact contralateral opposite part of our body. If you want to develop more “strength” in your left hand, then you sink/press down your right foot.

This is actually just another way of visualizing/conceptualizing the Triangle Idea or the Spiral Twining Idea from above. There are many ways to talk about this ideal feeling when working. The bottom line is, however you conceptualize it, that you remain as relaxed as possible while working on your patient, and use the least “stress/strain” with the most effective technique possible.

TAIJIQUAN: Peng-Lu-Ji-An (Grasp Sparrow’s Tail)

Slow Penetrative Force

This follows from all previous statements. In bodywork, our aim is not to develop powerful "strikes" as though our patient were some kind of punching bag. Rather, we are trying to sink into the tissues of the patient, the same way that a knife can cut through butter, given enough time. So our aim is to deliver slow but constant pressure.

Reinforcement

The weak links in our body are our joints. To protect these weak links, sometimes we reinforce our joints. For example, if we use the thumb joint of one hand, we can use the other to gently support that thumb joint. Or, we can use two thumbs next to each other. That way, the counter force is distributed over TWO joints, and not just one.

Your Tools

You can use different parts of your body. Note that the part of the body used VASTLY changes the nature of the technique employed. The more "pointy" parts of the body (... don't go there...) can be considered to be Yin in the sense that they tend to be more penetrative. The flatter parts of the body, meanwhile, can be considered Yang, in the sense that they stay on the surface. So the same technique changes drastically depending upon whether you use a Yin or a Yang tool. Here are the tools:

Palms (different parts)
Thumbs
Fingers
Knuckles
Fists
Forearm
Elbow
Knees
Feet

Yin and Yang in Bodywork

When thinking about bodywork, it is best to consider its Yin and Yang. What are the qualities of Yin and Yang that are relevant here?

Yin is deep, slow and sedating. Yang is shallow, fast and tonifying/invigorating.

As you perform bodywork, you need to think about the Yin/Yang of your techniques and your patients. Some techniques are best for certain kinds of patients; for example, Yin techniques might be better for "hypersensitive" patients, while Yang techniques might be better for patients with depressed, slow energy.

Mixing Yin and Yang qualities in single techniques can give them more "character" and specificity, but remember that it can also make them more dangerous. For example, it is inadvisable to perform a technique that is BOTH deep (Yin quality) and fast (Yang quality). Not many patients can tolerate it, and besides, you may lose control and do damage. A shallow (Yang) and slow (Yin) technique, on the other hand, may prove to be extremely calming for the right patient

EXERCISES FOR THE HANDS AND WRISTS
Open-Close Hands, Wrist Circles, Stretch Forearms
“Push ups” against Wall with Fingers, Thumbs
Pressing into Mattress with Fingers, Thumbs

TECHNIQUES:

RUBBING (MO FA)
Rubbing is a relatively superficial technique. It involves rubbing the skin lightly, and often rapidly. Its purpose is primarily to WARM the tissues.

Stick to the Surface!!!
Generally done with a circular motion.
Rate: 30-40 to 200 times a minute.

-with flat of thumbs:
example: on GB 20 (Fengchi)
example: on Back Shu line.

-with palm:
example: on large areas, like chest, abdomen, back

-with palm heel (the pads on either side of base of palm):
example: lower back region

PUSHING (TUI FA)
Pushing is the Tui from Tuina. It is basically pressure combined with a vector, or direction. In other words, you apply some pressure to the patient’s body AND you move or push that pressure in a line. You can go in one direction or back and forth with pushing.

-Depth: varies from superficial to deep, depending on tools and intent.
-Rate: 50-150 times a minute; generally start slow.
-Pushing can be done in a back-and-forth way, OR in one-directional strokes.

-with flat of thumbs, with side of thumbs, with tip of thumbs: on small areas, or on head (browline, Du line).

-with flat of palms: on limbs (distal to proximal).

-with base of palms: on back

PRESSING (AN FA)
Pressing is basically vertical pressure into the patient’s body.

-Depth: varies, but direction is always INTO the core of the patient’s body.
-Remember to be gradual in going in and out!!!
-Follow patient’s breath if you are working on the torso.

-with palm (single, two palm, two palm opposed): example: low back, abdomen, head.

-with thumb: example: Taiyang.

-with elbow: example: buttocks