In the footsteps of the Yellow Empress.

This article is dedicated to Sarah Key my teacher and friend.

There is a wonderful Chinese parable that goes something like this;

A traveller has lost his way in the wilderness. Eventually he meets a Daoist monk and asks for direction. The Daoist monk stretches out his left arm and points to the west. “Your destination is in this direction,” he says.

The traveller looks to the west and sees many indistinct paths. In the distance is a huge mountain range that seems to go on forever. The traveller shrugs his shoulders wearily, thanks the monk and is just about to set off. However, the monk bids him to wait a moment; then stretches out his right arm and points to the east saying;

“But the shorter path lies in this direction.”

The traveller looks to the east and sees a well trodden path and there in the distance the faint outline of his destination.

There is a lot of wisdom in this parable. On a physical level there are many ways we can reach our destination. We live on a globe, so if I want to go to London I can do the ‘round the world trip,’ cross the mountains of Siberia, the frozen wastes of Alaska, the plains of Arizona and the vast Atlantic ocean, or I can jump on a train and do the shorter route; Colchester to Liverpool Street in under an hour.  

On a mental and spiritual level the parable takes on broader meanings. In our professional lives, as students, practitioners or even teachers our journey will take us along the paths of learning. Usually these are paths that have been trodden by many travellers before us. Our destination is knowledge and skill. The skill that we hope we can utilise for the benefit of our patients. There are many paths to choose from in our search for these skills. If we are lucky our journey will be along shorter ones. Some of us will follow longer paths. Some will get lost on the way.

My study of back pain is a good example of a journey that has led me along many paths and even up a few blind alleys. Fortunately I met someone who showed me the shorter path to my destination. My story and my experience may help other therapists in their study of this complaint. My story may possibly help some of their patients.

In my case, my ‘Daoist monk’ was an Australian physiotherapist called Sarah Key. I was one of her patients some twenty years ago when I had lost my way and was going round in circles in a wilderness of chronic back pain. I had been lost for so long I was on the verge of giving up. Then, as often happens when we are lost, the Universe puts out a helping hand. My helping hand was in the form of a newspaper article I read. In it, I learnt that Sarah, using what was described as ‘unconventional methods’ was treating Prince Charles for his back pain. I reasoned if her methods were good enough for him they were good enough for me and so moved heaven and earth to see her.

It was a strange experience when we finally met for she didn’t seem at all concerned about my previous surgery or my x rays. It was a stranger experience being treated by her. She made me lie on the floor. She used her feet and walked up and down my spine and even though she was several months pregnant at the time the experience was not unpleasant. She gave me some strange exercises to do at home. Then she dropped the bomb shell; she told me my poor back that had undergone operations, injections, lasers, electricity and every highly prized modality known to western science, was suffering nothing more than……. stiffness.

I couldn’t believe all this at the time, but something deep inside me said that I must listen. Even in those days my intuition was looking after me and I persevered with the treatment and the exercises, one of which entailed lying over a block of wood and seemed to amuse my family quite a lot. But despite their reservations and despite the fact that my orthopaedic consultant saw no hope for me, and wanted me to travel a different path, namely more surgery, I gradually, bit by bit, came to experience some relief from my pain and saw some hope on my horizon.

The experience inspired me and changed my direction in life. I studied shiatsu, trained as a physiotherapist and then as an acupuncturist. I felt a very deep need to help others after my experience.  I used simple methods; treating people on a mat on the floor; using my hands and my elbows; giving them exercises. I used acupuncture in my treatments to strengthen their spirit and their constitution and to improve the flow of qi through their damaged spines. My methods were mocked by some and ridiculed by others. In those days acupuncture was still highly controversial. But my simple methods seemed to help. My patients seemed to get better.

Many years have passed since then but recently I met Sarah again. This time it was at Highgrove, the Prince of Wales residence. On this occasion I wasn’t a patient, but a delegate on Sarah’s Problem Back Master Class, an event organised by the NHS Alliance under the auspices of the Prince of Wales’s foundation for Integrated Health; a course attended by physiotherapists and doctors from all corners of His Realm.  

Sarah’s message is still the same and she continues to point us in the same direction. In her lighter moments she says of herself and her treatment of back pain “I could be a cave woman….earthy….primitive…I use my feet and a block of wood.” She still believes that stiffness is the root cause of most back problems. Stiffness caused by compression leading to breakdown of spinal segments. Her treatment and the exercises that she gives her patients are all designed to decompress the spine and tease out this stiffness in a simple, non invasive way that she has used successfully for over twenty five years.  

To stimulate the healing process she uses her feet. She prefers feet to hands for this type of therapy (much to the approval of those physiotherapists present who were suffering from stress injuries to their fingers and thumbs) for she says that the base of the heel is the ideal shape for this type of work. She carries out her treatment by standing on the patient’s back and with one foot firmly positioned on the sacrum she slides the other foot from one vertebra to another, feeling for problems in a manner she describes as “just cruising around….…looking for trouble”. Once this ‘trouble’ has been located, Sarah uses her heel in a gentle, but persuasive manner to try and encourage some movement in those  areas of the patient’s spine that feel, as she puts it “ like  plugs of cement in a rubber hose.” Once this process is started it is then up to the patient to do their homework; a series of simple exercises based on Iyenagar yoga principles that stretch and stimulate compressed spinal joints and strengthen the muscles that support them.

Sarah goes a step further than sheer anecdotal stories of success to prove her case and uses the most powerful weapon at her disposal and the weapon that all of us are trying to get  to grips with; namely, research based evidence. In the process she dispels most of the fashionable myths that surround bad backs with well researched and challenging facts. We can all learn from her example.

Much of her evidence is obtained from the works of two leading researchers in the field of back pain, namely M.A Adams and Nikolai Bogduk, who have come up with some startling figures about back pain. These two researchers are probably unknown to most acupuncturists, but their message is one that can benefit both us and our patients. Translated into everyday language their figures suggest that up to 80% of the population have asymptomatic disc hernias or bulges that cause no pain and that disc prolapse actually accounts for less than 5% of low back pain. These are the facts and the message is loud and clear for those who care to listen. Discs are not the culprit and just like the fashionable villains before them; the sacroiliac strain; the trapped nerve; the ligamentous strain; the arthritic spine, we should stop blaming discs for the crime of back pain. They don’t slip, they don’t pop, bending is not bad for them and lifting can be pretty beneficial. The guilt for back pain may lie elsewhere and the disc may be nothing more than the innocent bystander caught up in the aftermath of the crime. The erstwhile ‘detective’ Bogduk suggests that 90% of simple back pain is caused by spinal stiffness. Others agree and point the finger of guilt quite logically at the amount of time we spend sitting. Sarah and others, myself included, have been pointing to the stiff spinal segment for years.

Our message is simple and clear. It tells us that the spine is a wonderful, intelligent, adaptive and self healing structure. Make it move in a way that stretches and strengthens its structure; increase the circulation to its tissues; give it water and nutrients that can be sucked into the discs and even the most recalcitrant problems may be reversed. The back can heal itself.

Now isn’t this the sort of thing that physios and acupuncturists are taught? The answer should be a resounding yes. Stimulate the flow of qi with our needles, provide adequate nutrition and hydration, exercise a little and even chronic conditions can improve. We are not only taught it but we see it in our every day work. We tell our colleagues and students. We write about it in our journals.

Well now it has been researched; it is ‘scientifically’ proven and we can shout about it.

Simple is best and it works.

Furthermore, in presenting their evidence, the researchers Adams and Bogduk conclude that the on/off pressure changes of lifting stimulate disc metabolism; the on/off pumping pressure of walking increases the absorption of nutrients through cartilage (by up to100%) and x rays are pretty hopeless when it comes to locating the source of back pain.

In other words; sitting and a lack of movement (a poor flow of qi) is bad for us but lots of movement especially walking (a smooth flow of qi) is good for us. Furthermore lifting and stretching may be good……even for a bad back….…long periods of bed rest are unhelpful and must be discouraged….and unless you have an associated bowel or bladder dysfunction an x ray can be completely misleading.

Research based evidence confirming simple truths. Truths we need to repeat to our patients with conviction.

As I sat there in that wonderful setting at Highgrove, in front of the huge fireplace and a roaring log fire that spoke of a deserved rest after a long journey, I listened to Sarah and remembered once again the parable of the lost man and the Daoist monk. I thought of the many individuals who have tried to guide me during my journey and I thought how lucky I was to firmly believe that simplicity is often the best way forward and to have met so many people who believe the same. Back pain and its treatment is not a daunting task, even though some ‘experts’ would have us believe it is. Simple and safe treatment is well within our abilities and can have amazing results. Given the right conditions the back can and will heal itself. Speak to some of Sarah’s patients who have spent thousands of pounds being injected, wired up and cut up only to find that some nifty footwork and a substantial dose of exercise was all that they needed. Speak to some of your own patients who have been wracked with chronic pain only to find that a few well placed needles have given relief. We have much to learn from western medicine, but western medicine has much to learn from us. This is what real integration is all about.

 I also thought back to my own journey and my first teacher, Sarah, and how  I was lost in a wilderness when we came together.  Fortunately she found me in that wilderness and showed me the way. For me, her way was the right way and I will always be grateful for her timely intervention.

Footnote: The Yellow Emperor  is a legendary Chinese sovereign who is considered to be the founder of Traditional Chinese medicine.His interest in natural health and the prevention and treatment of diseases, according to historical sources allowed him to live a healthy life until the age of 100, and attain immortality after his physical death.

This article appeared in the European Journal of Oriental medicine; Skill magazine and CTA news.

Barefoot in Honduras

The shot gun went off a few feet from my head. Fortunately there was a plate glass window between me and the armed guard who had fired the shot. I was in a roadside diner at the time eating a sandwich. The armed guard was outside protecting a security van. He had fired his gun as a warning to a group of thugs who appeared on the scene in a beaten up station wagon. The thugs changed their minds and turned tail. The security van and the guard headed off in the opposite direction. This was my first day in Tegucigalpa, the capital of Honduras, a country that has a rising crime rate ten times higher than the U.S.A. (photo 1)

I was invited to Honduras by Kathy Rubio, an ex Chicago paramedic who set up a medical clinic in the town of Danli shortly after Hurricane Mitch devastated the country in 1998. Kathy runs the clinic with medical volunteers who come from all parts of the globe. Kathy read about my work for Physiomed Overseas that I set up after the Asian tsunami and asked if I would be prepared to come out for a month to help her and also spend some time training staff at the local rehabilitation centre. Kathy wrote to me beforehand to warn me that the rehabilitation center had little equipment and that most of my teaching must be based on ‘hands on’ therapy. I relished this challenge. It is always a wonderful experience to practice all of those techniques that I have at my fingertips that don’t cost a penny!

 I always pay my my own fares and living costs when I work as a volunteer. Any money that I raise for my charity Physiomed Overseas goes directly to the needs of the patient. For this trip I took a range of joint supports (as I had been warned there were a lot of repetitive stress injuries) over 1000 acupuncture needles, strappings and bandages, a model of the human spine and all of my yoga books. Within a few hours of landing in Honduras I was working as part of Kathy’s medical team that comprised two doctors from America and two dental students from Sheffield. All of us volunteers (photo 17) Conditions we worked in were often reminiscent of scenes from Mash as we traveled into the remoter parts of Honduras where medical facilities are scarce. The first time we did this our theatre of operations was a Catholic church. The two young dentists dressed in face masks, goggles and Bermuda shorts performed complicated oral surgery using head torches and a plastic chair where they would normally have overhead lighting and a hydraulic couch. As for me, I used the church altar as a treatment table for my shiatsu and acupuncture. One has to be resourceful in these situations (and I hope that God has a sense of humour and a tolerance of Daoism) (Photo 2)

During these excursions that are nicknamed ‘Brigades’ I treated a stream of back problems, joint injuries and repetitive stress injuries. Bread and butter stuff for a U.K therapist and most of these conditions were straightforward to treat with shiatsu mobilization techniques, yoga exercises or acupuncture. But paralysis following gun shot wounds (Photo 3) adolescents that have suffered stroke, stunted growth from malnutrition, deformity in fractured limbs that have never been set properly? (Photo 4) These were problems that I am unlikely to come across at home and tested all of my skills and resources. On my second day in Honduras I had to bind a 10 year old who had fallen out of a tree and fractured his collar bone. A week later I had to treat a farmers wife who had fractured her forearm but could not afford the cost of going to a hospital   (photo 5 6)  and I was glad that I had kept up with my study of First Aid in the U.K. Working in Honduras tested my resources. Fortunately my acupuncture is a passport into any medical territory and whenever my physiotherapy skills seemed inadequate my knowledge of acupuncture always gave me a direction especially in the treatment of chronic pain and mental trauma. I was even called upon to treat one of the British dentists in our team who developed a mysterious and prolific rash on both arms. From the perspective of Chinese medicine this condition is caused by an invasion of wind heat and is treated by using points to release this pathogen. (photo 7) 

When I was not doing Brigade work for Kathy Rubio I spent my time training the physiotherapists at the Danli rehabilitation center. Danli has a small hospital but no physiotherapy department and the rehabilitation center caters for a population of 180,000. The team of six therapists led by Anselmo Rodriguez is run by a charity funded by local business people.  There are no osteopaths, chiropractors, acupuncturists or qualified alternative practitioners in the area and the local population are reliant on Anselmo and his dedicated team. To put the enormity of their task in perspective I always compare the resources available to the people of Danli with the resources available to the people of my home town near Ipswich. In Danli there is one therapist per 30000 people. In Ipswich there is approximately one therapist per 300 people.

Why is Danli so under resourced? Quite simply the health services in Honduras are under funded. The country is the third poorest country in the western hemisphere and most Hondurans live in poverty. Why is this so? Guidebooks tell us that Honduras is a stunningly beautiful country with a tremendous potential for tourism and that there are eight different ecosystems that include rain forest, cloud forest, coral, mangroves, wilderness and swamplands. There is a very active group of conservationists within the country that are trying to preserve this incredible environment and bolster the country’s economy through tourism. Their task is not an easy one and they are finding it difficult to convince their countrymen that the short term profits from slash and burn farming, timber deforestation and intensive cattle ranching is not the way to long term prosperity. Those far sighted enough to see past the next strike of a match realize that the way to improve the living conditions of the seven million inhabitants of Honduras is through tourism. Unfortunately the total number of tourists that visited Honduras in 2006 was less than it was in 1998. Then it was four million. Now it is two million. The reason for this may have something to do with Hurricane Mitch that devastated the country in 1998, but it is more likely to be the result of the alarming crime rate in Honduras. Ten times higher than the U.S and rising. One American guidebook compares the capital of Honduras, Tegucigalpa to ‘downtown Baghdad’ Most Hondurans carry guns and it is unsafe for a ‘gringo’ to wander out at night. Poverty is of course the root of the problem that is the legacy of a weak agricultural economy. There is little industry in Honduras and drugs, arms trafficking and robbery are the growing economy here. Gangs set the rules and guns and machetes are the tools of their trade. This coupled with the fact that Honduras is tainted by its past associations with Guatemala, El Salvador and Nicaragua doesn’t paint a pretty picture for the discerning entrepreneur or visitor who prefer to take their investments and their holiday money to the safer shores of nearby Costa Rica.

A weak economy has a knock on effect in any society and at the rehabilitation center in Danli the lack of public funding means that Anselmo and his team of physiotherapists have minimal equipment and are totally reliant on hand outs. They have no ultrasound or interferential apparatus that is standard equipment for physiotherapists in the U.K.   All that is available to them are heat pads, ice packs and three old Tens machines that were donated by a visiting American doctor. (Photo 8) When I asked Anselmo what equipment would help him in his work he told me that he prays for some exercise equipment to help with the rehabilitation of stroke patients. A second hand ultrasound or interferential unit would be of even greater benefit.

My reason for writing this article is in the hope that someone will answer this prayer.

Despite the absence of modern equipment the physiotherapists do a remarkable job. They are dedicated and gifted individuals.  They get good results. They use heat, cold, their hands and exercise techniques. They inspire their patients with good humour and hope. (Photo 9) Enthusiasm, commitment and their hands are their greatest tools and it was a joy for me, with my own ‘holistic’ background, to work with them.  Part of my small contribution to Anselmo and his team was to teach them some yoga exercises for their patients and introduce them to shiatsu mobilization techniques (photo 10) These techniques are very similar to the Maitland mobilization techniques taught to qualified Chartered physiotherapists and are simple and safe methods for the treatment of most joint problems. Anselmo and his team put a lot of reliance in hot and cold packs for the treatment of most injuries; particularly low back pain and sciatica and they were very interested in my own theory that most back pain comes from compression of the spinal joints. When I demonstrated some of the shiatsu and yoga stretches for relieving compression they were very quick to put these into practice. The decompression exercises of Sarah Key, in which patients lie over a block of wood to unbind stiff spinal segments took a little bit longer to be accepted, but by the time I left Danli the team were also using these techniques.. In my opinion Sarah’s decompression exercises are as good as any traction machine and provide an effective and inexpensive way to treat neck, thoracic and lumbar problems. I also trained one of the physiotherapists to use a very simple acupuncture protocol that can be used on patients that have suffered a stroke. Rosa was the physiotherapist’s name and together, we practiced the art of needling for several hours using an orange as a ‘recipient’ (photo 11) Rosa learnt quickly and was soon needling real patients (photo 13) Together we were able to set up a pilot study. In January I will return to the clinic and expand this study into a research based project to study acupuncture as a primary therapy in the treatment of stroke. This could have significant repercussions. Currently in the U.K the western medical treatment of stroke concentrates on prevention by treating the disease conditions which predispose to stroke. After a stroke has occurred immediate treatment focuses on stabilizing the patient and keeping them alive. 35% of patients die in the hospital and those that survive are generally referred to physical rehabilitation therapists. However there is no conclusive evidence to prove that rehabilitation improves recovery rate and it may have little more than a placebo effect. In China, acupuncture is given as part of primary care to stroke patients and the anecdotal evidence from that country suggests that the survival and recovery rate of these patients is better than their western counterparts. This needs to be researched and could offer an important treatment option for those patients that have suffered this devastating condition.

I will go back to Danli next year. But why go back to Honduras when there is so much poverty and so much danger? The answer is simply that they need our help. Most of the Hondurans that I met were honest hard working people. People who live to serve and give rather than take. Their poverty is out of their control. Many of them work 18 hour days to exist on a dollar a day. Many of the patients that I treated would set off at 3 in the morning from their mountain homes to get to the clinic where Kathy Rubio and her team work throughout the day or to the rehabilitation centre in Danli where Anselmo and his team perform their miracles. I am frequently touched by the faith that these patients have in us volunteers. One patient who had suffered trigeminal neuralgia for twenty years followed me from one town to another as my acupuncture has given her the only relief she has ever experienced. (Photo 14) The local community would greatly benefit from back awareness classes, or a stroke club or a yoga class run on a regular basis and need volunteers to get these projects up and running. Unfortunately they cannot afford the money to start these projects and volunteers are their only hope. Most Hondurans do not have the comforts that we have in our country. They do not have the medical facilities or the benefits that we take for granted. People like Kathy Rubio and Anselmo Rodriguez and his team are a reminder to us all that there are people in the world that have the heart and the time and the courage to give a helping hand. (photo 16)

These dedicated people don’t work to make a fortune. They work to make a difference.

We must support them.

Richard Graham

This article appeared in the magazine Positive Health in November 2008

After the Tsunami

Indonesia January 2005

Two years ago I joined International Medical Volunteers Overseas and my first assignment was teaching Rehabilitation therapy in the Shastin hospital, Ulaanbatuur, Mongolia. Each day I treated a number of patients in the morning and in the afternoon gave practical lessons to the medical staff. I paid all my own flights and expenses throughout my stay but I learnt a lot, the experience was a rewarding one and I am due to go back later this year having been awarded a visiting 'Professorship' from the University of Health Sciences. 

When I returned to the U.K in July 2004, another invitation was awaiting me. An invitation to go to Indonesia on January 1st 2005. This time to work for a charity, once again teaching Rehabilitation to the medical team, at the Walujo Jati centre, Surabaya.

None of us had any idea of the disaster that was to befall Indonesia on 26th December; of a wall of water that was to change the lives of millions of people throughout S.E.Asia, the effects of which would reach throughout the world and touch the hearts of so many. When the news was first broadcast and the extent of that horror became known my family asked me not to go; some of my  patients rang to check that I was not already over there; friends shook their head in disbelief when I told them my plans were unaltered but I knew that I had to be there and so I left the land of grey that sombre January morning totally unaware of what lay around the corner.

When I landed in Surabaya and had made contact with my hosts at the clinic I started to make enquiries about getting out to Bandah Aceh, the centre of the tsunami disaster area in Indonesia. I was told that this was not possible. There were already too many medical personnell in the area and there was no accommodation, not even spare tents, for any extra medical personnel. 80 physiotherapists had just been flown in from Switzerland and so I realised that working in the middle of the disaster zone was not meant to be, I might well be more of a help than a hindrance, and so settled my mind to stay in Surabaya; which in itself, I soon realised, also needed much aid and support.

The clinic where I worked was poorly equipped and run down (and so is most of Surabaya). It was the middle of the 'rainy' season and every couple of days the heavens opened  and everywhere flooded. Fortunately the clinic is above water level and everyone gets about their business as if this sort of flooding is an everyday occurrence (which I guess this time of the year it is) This was not some idyllic part of Indonesia; but a polluted, traffic filled, overpopulated, underresourced, noisy, sprawling city.  Whilst the city is well away from the tsunami area, every television was full of the news and pictures of the devastation. It was quite harrowing to be out walking in the street and passing shops showing pictures of the misery and devastation. I hoped my family were not worrying.

It soon became clear to me that there is very little organised physiotherapy and hardly any rehabilitation services, not only in Surabaya (which is the second largest city in Indonesia) but throughout the whole of Indonesia. The general level of healthcare leaves a lot to be desired here. People have to pay 3 pounds to see a Doctor and in a country where for many people this is a months wages, it is simply too much. Therefore, many canot afford to get to their GP and often the GP's are not sufficiently trained, nor have sufficient back up, to give the patient the help they need. If an Indonesian wants an operation, or diagnostic tests beyond the most simple ones, they will prefer to go to Singapore and this, for them, costs a small fortune. There is some physiotherapy available in the hospitals, but once again this is beyond the financial means of most and the services and skill of the physiotherapists are not in any way comparable to the skills of their western counterparts. Other than the physiotherapists working in the hospitals  the people appear to have no resources for rehabilitation services apart from traditional medicine and the use of herbs and poultices. There are no physical therapists, no manipulative therapists, osteopaths or chiropractors. Some of the patients who came to see me had heard that a European was 'in town' and had travelled several hundred miles to see me. The divide in the health care between the rich and poor is enormous and iniquitous. Then there is the corruption which appears to be endemic in a society where a back hander seems to be the norm if you want anything 'special' and where many of the Doctors are obtaining commission from the drug companies. I concluded that we are very lucky in the UK with our Health service.

Each day I worked with one of three doctors and gradually taught them the basics of physical therapy. I wanted to leave some sort of legacy given the short period of time that I was there and so I kept things as simple as I possibly could. I focussed their training on diagnosis; watching how the patient 'moved'; testing muscles, ligaments and joint mobility. Treatment techniques concentrated on neuro muscular massage techniques and simple exercises for the patients. The system worked well. During the 4 weeks  that I was there we treated over 160 patients. We initiated some basis research and  did some simple analysis of our results. Our findings showed  that 80% of the patients that came for treatment  showed some improvement. We spent one day making a CD of simple home exercise for the patients to use. We also spent some of our time visiting some of the patients who were housebound and unable to reach the clinic.

It was on one of these 'house calls' that I met Marta. She lived, together with her blind grandson, in a shelter that is about the size of my garden shed. They lived on an income of about a dollar a week. Their furniture was bits of old wood nailed together to form two beds and a small table. Their luxury was two flasks that kept their drinking water cool. Martas other luxury was a wooden crate with a cushion on top. Her 'armchair'. Marta could hardly walk. Her knees were so bad. Together with her grandson she spends the day in their shelter in temperatures over 100degrees. They have no future; no way of escaping the poverty; no comforts. They manage to survive.

Some kind soul had told the clinic about Marta's knee problem. One problem amongst many thousands, but the Universe had sent hers to us and we were able to spend a little time with her. It became clear to me that her knees were so bad due to the 'armchair' that she was sitting on. The wooden box was only a few inches off the ground and so whenever she sat down her hamstrings were overflexed, her quadriceps were overextended and there was a full compression of her patella against the femur. Rising from this position put enormous stresses on all these structures. We gave her some massage; a few knee strengthening exercises that she could do in bed; which would also help with the pain, some words of encouragement and I bought her a new chair. A much higher one. It cost about £2. There was no need for electrotherapy; no ultrasound; no injections, no operations; no anti inflammatories; no expensive exercise equipment. We were able to make a difference with some simple massage, self help exercises, a minor change to her environment and a smile. I realised that we had made some improvement in the quality of her life for only £2. How easy it can sometimes be, I thought.

Now that I am back in the U.K I think a lot about Marta. I realise that we can all make a difference and the basic skills that we have been taught can change the lives of others for the better. For my part I have decided to set up a charity in this country. I will be going out to Indonesia again in May. Who knows, maybe I will settle there for some time.

This article appeared in Skill magazine, The Colchester Express, the Acupuncturist and the CTA News .

This article appeared in the European Journal, Skill magazine and the Suffolk Free Press

A Very Big Refresher Course - in Myanmar (Burma)  

This report is reproduced with the kind permission of my friend and collegue Dr John Hamwee.

About twenty years ago a young American sat in meditation for long months in the hills of Sagaing, an important centre for Burmese Buddhism, overlooking the Ayeyarwady river near Mandalay.  One day he came down to the village and a woman, a perfect stranger, seeing this Westerner and apparently taking pity in him, gave him a bottle of Coca Cola.

He was deeply touched by the gesture and thought, 'I must gave something back'.  He found many ways to do so, and one of those ways was to institute an annual visit of Western Acupuncturists to the nearby hospital.  This was the eleventh annual visit.  There were five of us, four from the UK and one from the USA.  For one of our party it was her fifth visit; for another the second.   It was my first time, though it won't be my last.  I worked harder than I have ever worked in my life, I paid all my own expenses to get there and back, and I can't wait to go again.     

The set up was that we worked for a week in the hospital where there are two rooms given over to acupuncture - one with about twelve beds in it and the other with about ten.  Then we moved to work in a village where there were no beds, strictly speaking, so we worked on raised platforms in the monks' dormitory, or outside.  I didn't count, but I suppose there were about the same number of spaces available to patients.    

And we needed them.  There were almost a hundred people the first day, more each day afterwards, and, we were told, nearly five hundred on the last day.  That may have been an exaggeration, but the patients certainly came in waves and we did have to find new spaces to work.  That last day was all a bit of a blur - partly because were so busy and also because we were all very tired by then - but as far as I can tell I treated twenty six people myself and I supervised a further forty treatments or so.  

Which brings me on to how we worked.  We had with us three local acupuncturists who had been qualified for some years and about sixteen young practitioners, in their twenties, who had qualified recently.  It was a big part of our remit to act as teachers to the young people; mainly in the clinic, but also with a lecture each day.  They were pretty good, so by the time the numbers really hit the roof we Westerners were able to spend as little as five or ten minutes with each patient, agreeing a diagnosis and treatment plan with one of the students, and then leaving it to her or him to do the treatment; coming back to check the pulses at the end.  In that way, the five of us managed five or six patients at once all day long; which is how we coped with such enormous numbers.  Although some of the students were delegated to crowd control, and the senior people were usually otherwise occupied, there were still about twenty of us, each treating, say, three people an hour for about seven and a half hours - so that's how we made up the numbers.   

Naturally, there were translation problems.  Huge numbers of patients complained about 'numbness', for example, but were normally sensitive as far as we could tell.  We never really got to the bottom of what they were trying to tell us.  More generally, because we couldn't take much of a case history, we had to work with a simple diagnosis of the state of the patient's energy system; and it was refreshing to see how much we could do with very few words.  

It was a very steep learning curve for me.  Normally I have one hour appointments, and rarely see more than eight people in a day.  Also, in my own practice, I tend to use Zero Balancing rather than Acupuncture for muscular-skeletal problems - of which there were many; but as it wouldn't have been any use to the students if I had done so there, I struggled to remember Bi Syndromes and shoulder points and was pretty rusty for the first day or two - which the students noticed and charmingly forgave.   It felt like learning acupuncture all over again.  

All this it re-affirmed my deep respect for this system of medicine.  It really did work on conditions for which I would normally use Zero Balancing, or recommend Osteopathy.  It also seemed to work on conditions which I never see at home and which, as a result, I had to treat simply from first principles.  After nearly twenty years in practice I hadn't realised that I had become very limited in my thinking about acupuncture; assuming, in rather lazy way, that it was good for what I used it for, and a few specialisms like pedatrics and obstetrics, but not much else.  Wrong.  

Secondly, it taught me, as if I needed to learn, the value of having to explain a treatment before doing it.  At the beginning of the work the students wanted to know why I was planning to do what I was planning to do.  Sometimes, in explaining, I came to understand my rationale - one which I'd never spelt out clearly to myself, and which I could then apply to other patients and other conditions.  Very satisfying.  And sometimes, of course, when pushed to explain myself I found that my thinking was wooly or inadequate, and it was a pleasure and a relief to be made to think again and to come up with a better treatment than the one I first thought of.   

By the end I made the students write down their proposed treatments before I would tell them what I would do, and I learned a lot from seeing two different, but plausible, sets of points.  I often let the students do what they  proposed, even when it didn't seem to me ideal, and it was instructive to see the results of those treatments which, of course, I never do!  

Finally, there was the whole process of working in a multi-bed setting.  I loved it.  I loved the noise and the bustle.  I loved glancing up at one of the students taking pulses on the opposite side, and seeing in her eyes an agreement about what we were noticing.  I loved people coming round to have a look at me needling Liv 14, Lu 1 - not a treatment they knew - and their interest in the resulting pulse change.  I loved calling a colleague over to assess a hip joint which moved, or rather failed to move, in a way I'd never felt before.  I liked having to talk less (it was tedious to wait for long translations) and having to sense Qi more.  And I liked the whole idea of seeing more people, more often, more quickly, for less money.    

The whole experience has made me a much better practitioner and it will change the way I work from now on.  I recommend it to those of you who feel like taking a very big refresher course.  

* Thanks to all  especially U Win Ko and U Aung Min, and the students; to Kirsten Germann for leading us, and my colleagues Richard Graham, Dudley Kent and John Renna.