4 Patterns, 8 Steps: Part 2
The 8 Steps
Now that we have an understanding of the four types of tissue and their primary dysfunctions, we have to figure out how to apply this model to treating patients.
As great as the four tissue model is for making sense of the patient’s symptoms, it is rare that you will see a patient who fits perfectly into any one of the four patterns.
Most patients with chronic illness will present with aspects of all four patterns at the same time. They will have aspects of autonomic dystonia, hyper sympathetic tone, chronic inflammation, and lactic acidosis affecting different body areas and creating different symptoms all at the same time.
When a patient has 20 different symptoms, where do you begin to treat them? Do you try to treat all 20 symptoms at the same time with 20 different pills? Do you treat the one that they are most bothered by? Do you pick one at random and start there?
Trying to treat all of the symptoms at the same time doesn’t work in my experience. You end up overstimulating the body and overtaxing their digestive tract with too many herbs/supplements. Every pill that you swallow, even if it’s good for you, requires energy to break down and absorb. Your body must expend energy to process the remedy. If the patient is already in a weakened state, taking the remedies can actually make them worse even if it’s the correct remedy.
Treating the symptom that the patient is most bothered by is also a mistake. Because symptoms are interrelated, you have to figure out what the primary dysfunction is and begin there…regardless of what the patient’s chief complaint is. I know this might sound rude from a customer service standpoint, but practicing medicine is not like going to Burger King. Having it your way is not always the best thing for you.
What if the person wants help for chronic fatigue but they also can’t sleep. The patient doesn’t care about sleeping well, they just want more energy. By that rationale you’ll start giving the person herbs/supplements that are stimulatory in nature. This will give them a temporary boost of energy but will make their insomnia even worse.
What if the patient is a male who wants help for low back pain but he also has prostatitis? The patient doesn’t care about the prostatitis, they just want the back pain gone. But prostate inflammation is often a cause for back pain especially if range of motion and MRI exams are negative. If you just try to make the back feel better without addressing the prostatitis, any relief he feels will be temporary at best.
Just like building a house from scratch, you have to start with a stable foundation and build from there. You don’t work on the roof if you haven’t even laid the foundation. It’s the same with treating chronic illness. No matter what the diagnosis or chief complaint (which is completely subjective, btw), you have to start with the most important aspects of body function and work upwards from there. Otherwise you’ll waste precious time chasing symptoms.
Physiology
There are two ways to approach medicine:
Chinese Medicine, at least as I see it, is almost 100% physiology based since it is only concerned with restoring the healthy function of body systems (digestion, neurological, hormonal) and pays little attention to disease labels and even lab reports.
What’s the difference between anatomy and physiology?
Anatomy refers to body parts such as organs, tissues, and cells. Anatomy is the study of nouns.
Physiology refers to how those body parts interact and behave as an interdependent system. Physiology is thus the study of verbs. It is the study of how the body functions and behaves in states of sickness and health.
As an example, the liver, stomach, and intestines are nouns and thus considered anatomy. Digestion refers to how those nouns behave and interact with each other to form verbs. This applies to all body functions.
The word “physiology” refers to the normal/healthy functioning of the body while “pathophysiology” refers to the pathological/unhealthy functioning of the body.
It’s easy to learn physiology because the normal functioning of the body falls into a very limited range:
The rules of physiology do not change very much. The parameters you use for defining healthy physiology will most likely be the same 20 or even 50 years from now.
If physiology is correct, then anatomy is correct too
Contrast this to pathophysiology, which is the study of unhealthy and pathological behavior of body systems.
How many different ways can each body system malfunction?
There are hundreds, if not thousands of different ways that each body part can malfunction and this is proven through the many disease labels currently in use. The eye alone has over 200 disease labels and the number grows each year!
Many clinicians start by focusing on the pathophysiology or disease label. Once that disease label is found they prescribe a treatment for it. There’s a few problems with this approach:
With all that said, I get a regular physical exam every year and encourage my patients to do the same. I do not feel that lab tests and disease labels are useless. For emergency conditions they can be lifesaving and this is something that I feel Western medicine handles better than wholistic medicine.
But for the correction of chronic, complex illness that is not a life-threatening emergency, I find that focusing on the disease label (pathophysiology) is not as effective as focusing on restoring physiology in a progressive manner.
All disease labels are an attempt to describe the progressive breakdown of physiology. Don’t focus on the details of the breakdown, just focus on restoring physiology at a systemic level and the disease label will become irrelevant.
Organization of the body according to physiology
If the 4 tissue types is a way of organizing the body by anatomy, the 8 steps is a way of organizing the body by physiology.
The 8 steps is a flow chart algorithm that can be used to organize the patient’s symptoms, then identify the tissue pattern associated with each symptom.
At our clinic, the 8 steps is only one of three different ways that we use to assess the patient. But the other two methods are centered on acupuncture point palpation and I’m not able to describe it in writing.
Problem solving algorithm
The 8 steps is a problem solving algorithm applied to physiology. The 8 steps is a way of taking all of the patient’s symptoms, no matter how numerous, and figuring out where to begin. When there are a multitude of problems, the 8 steps lets us figure out which one is the most important to focus on if we are to bring the patient back to full health.
Here is the complete 8 step algorithm for reference:
Think of this as a flow chart for guiding a patient, all patients regardless of their chief complaint, from sickness to health.
For each patient case begin at step 1 and see if it applies towards them. If it does then fully implement the corrections for step 1 until the issue is resolved. Do not implement any therapeutic steps from later steps until the first step is completed. This means that if they have a gastric ulcer, don’t try also work on their hormonal issues. That’s like trying to build a roof on a house before the walls are put up.
This is a very important point. The 8 step algorithm is designed to simplify and focus our treatment efforts on restoring systemic physiology so that total health is achieved. In order to do this the body requires that we work in a very specific order and this is what the algorithm offers us.
If step one does not apply to the patient then we move to step 2 (bowel movements). If there’s no issues with bowel movements then proceed to step 3, but if there are issues with bowel movements then we focus on correcting that before moving to step 3, etc., etc.
We have found that correcting the initial step of a patient’s condition will have therapeutic effects on many other aspects of their health which do not seem related to the step being treated. Correcting bowel movements will often correct sleep problems. Correcting sleep problems will also improve hormonal regulation etc. Many times you will find that after correcting the initial step you will have to look 2-3 steps forward to find the next area to work on.
This is because we are not just treating symptoms, we are restoring the body’s ability to heal itself and maintain homeostasis.
What follows is a brief description of the 8 steps and how they relate to the 4 tissue patterns. Keep in mind the 8 steps is only one of several assessment methods we use, it’s just the one that we can describe in writing. Also keep in mind that I won’t be giving specific treatment recommendations regarding herbs/acupuncture for the 8 steps. The reason why is because the treatment method has to be tailored to each individual patient, and I don’t want people using this document as a substitute for a licensed health care professional.
Step 1: Rule out gastric ulcer
A gastric ulcer (also called “peptic ulcer) is an open sore in the lining of the stomach or duodenum (duodenum is the first part of the small intestine). If you imagine your stomach as a bag and the small intestine as a tube, an ulcer is a hole in the lining of the bag or tube.
These are the most common causes for an ulcer:
Gastric ulcer is a block to starting the entire healing process
Having a hole in your stomach (which is essentially what an ulcer is) or small intestine is a block to healing because it interferes with your ability to digest food and absorb nutrients.
The inner lining of the stomach is supposed to have a mucous membrane to protect the epithelial lining from being damaged by hydrochloric acid (HCL). If this mucous lining is broken then your HCL will burn a hole through your stomach. This creates pain, irritation, indigestion, and eventually internal bleeding. The internal bleeding and tissue damage involved with an ulcer compromises the digestive process and reduces the healing effect of foods and supplements.
Let me say this in another way: if you have a gastric ulcer there is no point in taking supplements as they will not be digested properly because your stomach is broken.
I see this all the time. A new patient with a multitude of health issues and has been taking thousands of dollars’ worth of herbs and supplements yet is either the same or getting worse. Many times they will have symptoms of a gastric ulcer that was not addressed and which is preventing anything from being absorbed properly.
Your stomach needs to produce HCL for digestion as well as preventing infections from entering the intestine. But if you have an ulcer you end up further damaging your stomach and small intestine when you produce HCL.
People end up taking proton pump inhibitors (PPI) like Nexium to inhibit the production of HCL so that the ulcer does not become irritated. But if you’re not producing HCL then how are you supposed to digest your food??
Taking Nexium will give short-term relief from the symptoms of an ulcer but will then create long-term problems because you are depriving the body of HCL (with all it’s vital functions).
Finding a gastric ulcer
The standard approach in Western medicine is to perform an endoscopy where they insert a camera down your throat and look for an ulcer. Many clinicians (myself included) have found this to be unreliable as the patient can have symptoms of an ulcer, respond well to treatment for an ulcer, and yet have nothing show up on an endoscopy.
Most Western doctors diagnose an ulcer simply through the patient’s symptoms and then offer treatment. If the treatment reduces their symptoms then an ulcer is confirmed without endoscopy.
Heartburn is considered a sign of a gastric ulcer but I disagree with this. Most cases of heartburn are due to a deficiency of HCL which then causes your food to rot in the stomach and produce metabolic waste.
Two important indicators
There are two indicators that can be used when trying to rule out a gastric ulcer:
First, there is always a sharp, stabbing type pain with the gastric ulcer patient. Ulcer pain tends to be severe and the patient will almost always use the word “stabbing”. The nature of an ulcer is a small wound in the stomach that is irritated by HCL. When we ask the patient to show us where the pain is they will point to it with a fingertip, not with their palm. This is really important. Ulcer pain is pinpointed and localized, general gastritis pain is diffuse and more spread out.
If there is an ulcer the patient will use a fingertip to show where the pain is and it tends to always be in the same spot. For non-ulcerative gastritis the patient will use a palm to show where the pain is and it will tend to move around.
Second, ulcer pain tends to be worse before meals when the patient has an empty stomach and is hungry. The pain feels better after they eat something bland and starchy like pasta or bread. This is because when the stomach is empty the HCL can irritate the ulcer, but eating a bagel or bowl of pasta will soak up the HCL and keep it away from the ulcer.
If the pain is in a pinpoint location, worse before meals, and better after eating starchy foods = very good chance there’s a gastric ulcer.
Vinegar test
Another way to detect an ulcer is to ask the patient if they can tolerate vinegar. Vinegar has a similar nature to HCL in that its acidic pH will irritate an ulcer. If the patient reports that they get sharp pain after eating anything with vinegar then that’s an indicator of gastric ulcer.
If the patient is not aware of how they respond to vinegar, an old test is to have them drink 2 tbs. of apple cider vinegar in one cup of water on an empty stomach. If they experience sharp stomach pain within 10 minutes then it suggests the presence of an ulcer.
If a gastric ulcer is suspected, we focus on resolving that first before moving to anything else. Sure the patient may have a dozen other problems that are more important to him/her. But it doesn’t matter. A gastric ulcer will block the healing effect of any therapy that involves swallowing something and this includes a healthy diet. This has to be resolved first or else nothing works reliably.
Step 2: Correct bowel movements
It is only after ruling out and/or resolving a gastric ulcer that we can move to step 2 and assess bowel movements/elimination. Don’t go to step 2 until step 1 is completed!
Bowel movements as a reflection of internal health
If you cannot eliminate waste properly, how can your body heal?
All of the ancient healing systems from China, India, Egypt, and Greece viewed the quality of the bowels as a reflection of internal health. This was especially so in ancient Egypt where the word they used for “doctor” literally translated as “one who inspects and cares for the colon”.
Healthy bowel movements are a reflection of healthy digestion, detoxification, liver function, cardiac function, and especially neurological function since most of our neurotransmitters are made in the bowel.
By restoring healthy bowel movements you can make the assumption that the entire body is being benefited. You can assume an improvement in detoxification, digestion, and autonomic function which then sets the stage for healing throughout the entire body.
I recommend that you focus on correcting bowel movements before looking at upper digestive complaints. The reason is that by correcting the bowel you usually correct upper digestive issues although the reverse is not necessarily so.
Criteria for healthy bowel movements
The two primary bowel disorders are constipation and diarrhea.
Constipation and autotoxemia
“Autotoxemia” is when the body becomes poisoned by its own waste products. The primary source of autotoxemia is from constipation where the person has less than one complete bowel movement per day.
If you are having less than one complete bowel movement per day, there is most likely undischarged fecal matter rotting in your colon. Proteins putrefy, carbohydrates ferment (and give off alcohol compounds), and fats become rancid. This toxic waste not only becomes a breeding ground for infections but it spreads into the liver and bloodstream. Once it diffuses into the bloodstream it then affects all of your organs and body functions.
It is for this reason that constipation, and the resultant autotoxemia of the blood, can be the cause of almost any internal medicine problem. If the autotoxemia affects the brain it causes neurological problems. If it affects the heart it causes cardiac problems. If it affects the skin then it gives you a rash. If it affects the joints it causes arthritis and so on.
In the case of chronic illness that also has constipation, good results will not be seen unless the constipation is first addressed. It doesn’t matter what the disease label is whether it’s arthritis or hypothyroid, or migraines, etc. The toxic waste in the bowel creates an enormous burden on all of the body’s energy systems. If this burden can be relieved then it frees up energy that can then be used for the healing process.
Constipation and the 4 tissue patterns
For most cases of constipation, the tissue pattern involved is either nerve or epithelial.
For the nerve pattern patient, there is also the presence of autonomic dystonia with paradoxical response to stimuli. In this patient there is a dysfunction of the enteric nervous system and its ability to regulate peristalsis (often due to issues with heart rhythm). There will often be issues with the cardiovascular system, orthostatic hypotension, and circulatory disorders. There can also be neurological issues as well. Remember that the nerve pattern involves primarily the gut, heart, and brain.
For the epithelial pattern patient there is an excess of sympathetic nervous system (SNS) tone with a corresponding deficiency of parasympathetic nervous system (PNS) tone. The PNS is needed for digestion, sleep, and elimination. Basically if your body is too tense, you can’t poop. This patient will also exhibit other signs of high SNS/low PNS such as anxiety, hormonal disorders, and skin problems. Remember that the epithelial pattern involves the adrenals, skin, endocrine system, and sympathetic nerves. You will thus see signs of these other body elements along with the constipation.
The key to treating constipation is to identify the tissue pattern that is involved and focus on that. Focus on correcting the behavior of the tissue pattern as it relates to the whole body, the constipation will follow. We do not give laxatives of any kind because that doesn’t address the source of the problem. It also can make you dependent on the laxative.
Because we focus on the tissue pattern, the patient will begin to see improvements in other body areas as the constipation begins to resolve. The idea is to identify a key symptom (constipation) and then relate it to a behavior pattern that affects the body as a whole. We then monitor the symptom but treat it using a method that affects a large portion of the body.
Diarrhea and autotoxemia
The patient has diarrhea if any of the following are present:
I view diarrhea as an alternate expression of autotoxemia. Similar principles apply but the way the body reacts to the toxic situation is different.
Diarrhea is a sign that the body is trying (unsuccessfully) to eliminate something from the colon. This can be a toxin (exogenous or endogenous) or infection. The body sends excess fluid to the intestine in an attempt to flush out the irritant. It’s ok for this to happen once or even several times in response to the presence of an irritant (like when you get food poisoning). However if it happens on a long-term basis or is severe to the point of debilitation, it means that the body needs assistance in eliminating the irritant from the intestine.
Diarrhea is also seen in cases of kidney congestion. The kidneys and bladder excrete water soluble waste while the liver and intestine excrete fat soluble waste, generally speaking. If the kidneys are congested the body will send the water soluble waste to the intestine for excretion. The excess water in the colon creates diarrhea. This is a bad situation since the intestine is not designed to excrete urea and this will damage the colon.
Thus it is important to address kidney congestion when the patient has diarrhea.
Long-term diarrhea creates a state of dehydration and electrolyte imbalance. The body loses electrolytes (calcium, magnesium, sodium, potassium) during diarrhea and this can impair cardiac and neurological function. Many neurological, cardiac, and dermatological conditions can be traced back to diarrhea often seen in IBS, Chron’s, and ulcerative colitis. The diarrhea must be addressed first before proceeding to other issues or else results will be sporadic at best.
Key Signs of Kidney Congestion (Impaired Kidney Function)
Many diarrhea cases involve kidney congestion. There are numerous possible signs of kidney congestion and many of those signs (i.e. nausea, fatigue, lightheaded) are very general and overlap with other disorders. Many symptoms of kidney congestion overlap with heart failure so it’s important to know how to differentiate between the two (and refer out for medical evaluation when appropriate).
Diarrhea and the 4 tissue patterns
Most cases of diarrhea are due to the epithelial pattern.
Epithelial tissue is responsible for secretion of fluids and this includes fluid waste in the intestine. The epithelial pattern is also linked to the kidney which tends to play a role in chronic diarrhea. Chronic diarrhea represents a derangement in the excretion of fluids be it intestinal fluid or water soluble waste from the kidneys (which then gets excreted through the bowel and damages the gut flora).
Just like we did with constipation, we do not treat “diarrhea”. We focus and monitor the symptom of diarrhea but we treat the pattern of “epithelial tissue”. The symptom is used as a clue to figure out which tissue pattern is causing the overall illness but treatment is performed on a broad, systemic level to heal the entire body, not just the diarrhea.
The 4 tissue patterns is a concept that explains general body dysfunction. The 8 steps is a flow-chart that can be used to apply the 4 tissue patterns in a step-by-step manner that removes ambiguity from the treatment procedure.
Step 3: Correct Digestion
It is only after making sure that the patient is having healthy bowel movements (no constipation or diarrhea) that we look at their upper digestive functions. If there are any problems with bowel movements we focus on that first.
And also, we don’t focus on bowel movements if there are signs of a gastric ulcer. The value of the 8 step algorithm is that the entire body is rehabilitated starting with the most important functions, and in a specific order that optimizes efficiency.
Elimination and Digestion are connected
By assessing and correcting bowel elimination you will often simultaneously correct any upper digestive issues. This is because the digestive tract is one continuous tube from mouth to anus.
Some people have normal bowel movements yet they have upper digestive complaints. The most common upper digestive complaints include:
These symptoms reflect a weakness in the upper digestive organs including the stomach, liver, pancreas, and duodenum (first part of the small intestine). They indicate sluggish activity which results in the food not moving fast enough through the first part of the digestive tract. The food then rots in the digestive tract which then creates gas and metabolic waste products.
If the patient has upper digestive issues you can assume that they are not extracting nutrients from their food. They can be eating the best food in the world but if it’s not getting broken down into vitamins, minerals, amino acids, and fatty acids for absorption then it does them no good. It just ends up turning into expensive poop!
If the patient is not absorbing nutrients from their food they will not heal from whatever illness they have. They will not be able to rebuild and repair tissue. They will manifest symptoms of malnutrition even if they are eating plenty of good food.
This also applies to the people that are taking numerous supplements for multiple symptoms and diagnoses. For most of these patients they do not have a treatment plan or specific goalposts they are trying to reach. They have been sold on the idea that they can’t live without thousands of dollars’ worth of pills. If this person has trouble digesting food, then of course they’re going to have trouble digesting supplements. They are not only wasting their money, they are making themselves sicker by further taxing an already dysfunctional digestive system!
Upper digestion and the 4 tissue patterns
Digestive problems can be a result of either nerve or epithelial patterns.
The nerve pattern can be involved because the gut is connected to the heart and brain through a dominant nerve pattern. Peristalsis is also dependent on proper heart rhythm.
The epithelial pattern can be involved because too much sympathetic tone in the nervous system will decrease parasympathetic tone needed for digestion. Digestion requires a relaxed state of the nervous system which is why you have trouble digesting when you’re anxious.
Just like when trying to determine the tissue pattern for constipation, we have two possible choices and need to look at the rest of the patient to figure out what the dominant tissue pattern is. However, this is step 3 of the algorithm and we are assuming that there are no issues with gastric ulcers or bowel movements. So what we are looking at is an upper digestive issue that does not have any problems with bowel elimination, otherwise you need to go back to step 2.
Because the gut is a key player in the nerve pattern, most upper digestive issues without bowel problems will be nerve tissue patterns. Not all of them, you still need to look at the rest of the patient picture, but most “step 3” cases will be nerve pattern in nature.
It’s true that high sympathetic tone (epithelial pattern) can cause upper digestion problems, but in those cases there will usually be simultaneous problems with bowel movements, which we have ruled out if we are at step 3.
Step 4: Correct Sleep
If you arrive at step 4 the following prerequisites must be fulfilled:
If not, then go back to step 3. Do not try to correct sleep if there are any problems with digestion or elimination.
The Second Brain
I need to emphasize that you should not try to correct sleep issues if you have digestive or eliminative problems. If you give a patient with digestive problems an herbal remedy for sleep guess what? They will not be able to digest it!
Fix digestion and elimination before trying to fix sleep. Often by correcting digestion/elimination you will simultaneously correct sleep although the reverse is not true.
We previously discussed a concept called “The Second Brain”, popularized by Dr. Michael Gerson who wrote a book with the same name. In the 1990’s it was discovered that over 90% of your neurotransmitters are produced in the gut. This implies that gut disorders can cause neurotransmitter deficiencies and imbalances.
Since neurotransmitters such as GABA and acetylcholine are needed for proper sleep and neurological function it would make sense that correcting gut function would enhance neurotransmitters and thus improve sleep.
This concept of the digestive tract having a direct effect on brain and neurological function has been taught in TCM for thousands of years. It is only within the last 20 years that it has now been confirmed by western medical science.
Healing happens during sleep
It is during deep, restful sleep that we rebuild tissue and detoxify waste. It is also during sleep that the cognitive mind shuts down enabling the subconscious mind to process deep seated thoughts and emotions.
It is not just the physical body that heals during sleep but the mental and emotional body as well.
If a patient is not able to achieve restful sleep on a regular basis it negatively affects every single aspect of their physiology. They cannot heal if they cannot sleep and this must be addressed after digestion/elimination issues are corrected.
The main problems that a lack of sleep creates includes:
In a state of chronic illness, any illness, what good is it trying to address specific complaints when you’re not able to sleep? Fix the sleep first and you will find that many of your other complaints will begin to resolve without direct treatment.
What constitutes healthy sleep?
How much sleep does a person need?
This is going to vary depending on the individual and how much stress they are putting their body and mind through. It also depends on their level of health.
You are getting enough sleep if two criteria are met:
Some people feel great on only 5 hours of sleep per night while others need 10 or more. What matters most is that they wake up feeling rested and without needing an alarm. As a patient’s health improves they will often find that they need less sleep.
Blood glucose and inability to stay asleep
From a biomedical standpoint, the number one cause of not being able to stay asleep through the night is blood glucose (BG) dysregulation. This is a bit different than not being able to fall asleep. The number two cause is orthopedic pain waking you up at night but that needs to be addressed as a separate issue.
If BG is too high during sleep the body will concentrate the excess glucose into the urine and the patient will have to wake up and pee. This is what happens in diabetic cases. It is also a primary cause of pediatric bedwetting. The child’s nervous system (specifically the sacral parasympathetic nerves) is not developed enough for the bladder reflex to wake them yet the body feels the need to excrete the excess glucose through the urine.
This is also what happens a lot with men who wake up to pee many times in the night…but have healthy prostates on medical exam. Many times it’s an issue with excess glucose being excreted through the urine.
With every elevation of BG there is a corresponding crash in BG. If the patient falls asleep and the BG becomes too low the brain goes into an alarm state (brain is most dependent on BG) and tells the liver to make more BG. The liver can make BG either by converting glycogen (the stored form of glucose) or a process called gluconeogenesis (where the body converts protein to glucose). This process is very active and wakes the patient up. The patient will not be able to fall back asleep until the liver makes enough BG to get the brain to come out of the alarm state. This can take a few minutes or it can take the rest of the night depending on how severe the BG fluctuation and the efficiency of the liver to make BG. This is the reason why people will drink juice if they wake in the middle of the night to fall back asleep. The juice provides a quick source of glucose which satisfies the brain (although this shouldn’t be needed if you’re healthy).
One effect of low BG (hypoglycemia) is muscle twitching. In the context of sleep this results in restless leg syndrome. Many cases of restless leg (especially if isolated during the night) are due to BG dysregulation.
If the patient says they can fall asleep easily but can’t stay asleep without waking up a lot, we suspect issues with blood glucose regulation. Often this person is eating too much sugar and starchy carbohydrates. The person will have to cut back on the carbs if they want to get better.
Sleep and the 4 tissue patterns
Sleep disorders at this stage of the algorithm are usually due to an epithelial pattern. In the epithelial pattern there is too much sympathetic tone and not enough parasympathetic tone. The patient is constantly wired and not able to calm down. This prevents them from relaxing and thus sleeping.
It can be argued that sleep issues are due to autonomic dystonia associated with the nerve pattern. In autonomic dystonia the body responds unpredictably to stimuli, so when the person tries to lie down it has the effect of energizing them instead of relaxing them.
However, because we are at step 4 in the algorithm, it is assumed that the patient has a healthy digestive/eliminative tract. The gut is a large part of the nerve pattern and it is assumed that there are no problems with the gut, otherwise you need to go back to step 3 or even earlier. Because the gut is fine, the probability shifts towards this being an epithelial pattern. Of course it’s possible that it’s still a nerve pattern and this has to be discerned by the clinician, but the beauty of this 8 step algorithm is that as you move further in the process the possible patterns become easier to identify by process of elimination. With each step certain assumptions about the patient can be made because the previous steps indicate a certain degree of function.
60% of all chronic illness begins to heal after step 4
My acupuncture teacher used to say “as long as the patient can eat, sleep, and poop, they will be ok.” He was right. After completing this step of the algorithm most cases of chronic illness begin to heal. They are not cured right away, but they now hit a degree of momentum where each week feels a bit better than the week before.
At this stage they are able to absorb nutrients, detoxify waste, and repair tissue damage during sleep. What more do you need to recover?
Step 5: Correct Energy/Cardiovascular
If you arrive at this step I am going to assume the following:
If not, then go back to the appropriate step and stay there till it is corrected. Do not attempt to improve energy/cardiovascular in a patient who has difficulty sleeping. Correcting sleep problems will often simultaneously correct energy and cardiovascular issues.
All illness begins and ends with fatigue
This concept is further discussed in our patient handout “The Primary Function of a Living Organism is to Produce Energy”.
The inability to produce energy is an underlying factor in all forms of illness regardless of whether it is early or end stage. Energy represents the amount of biological currency that your body has to heal tissue and overcome disease factors such as infections or toxicity.
Your energy levels are indicative of your mitochondria function (ATP production), hormonal balance, adrenal reserves, and cardiovascular function. In Chinese Medicine it is indicative of your level of Qi and essence.
Relevant clinical signs
The most important clinical sign is that you have good elimination, digestion, and sleep, yet you still have fatigue or cardiovascular (CV) issues. Many CV issues are secondary due to poor sleep or gastro-intestinal function. If you are at this step in the algorithm it is assumed that those issues are either not present or have been corrected…yet you still have CV issues and low energy.
Resting pulse rate higher than 70bpm: I view this as the most important clinical sign of poor CV function. Ideally the pulse rate should be between 50-70 beats per minute. A resting pulse higher than 70bpm can indicate: high sympathetic tone, weak ventricular contraction, and poor circulation, among other things. It also means the patient has a poor level of fitness and adaptive ability to stress.
The best way to monitor resting pulse is to buy a pulse oximeter (Amazon sells them for $20) and measure your pulse first thing in the morning. This is the most accurate reading.
Blood oxygenation less than 95%: this can be measured in a few seconds by using a pulse oximeter. Again you can get one of these at Amazon for a low cost. Note: if blood oxygenation is less than 90% I insist the patient see their primary care physician for assessment. It doesn’t mean I won’t treat them as a patient, but I insist they also see their primary care physician to rule out any emergency condition.
Shortness of breath is another sign of poor CV, especially if it’s worse after exertion (flight of stairs).
Blood glucose (BG) and CV
What’s your diet like? Are you eating too much processed carbs? Are you eating enough protein and healthy fats? Are you eating trans fats which directly harm the heart? This needs to be addressed before taking supplements as it will prevent the treatment from working.
Many CV disorders are actually due to BG dysregulation and the two are often confused for each other. Many CV disorders started out as BG dysregulation then progressed to something more severe.
The heart runs almost exclusively on fat as a fuel source and is not able to utilize carbohydrates as a form of energy. It is theorized that this is the reason why the heart does not develop cancer (the heart is the only organ that is not prone to cancer) since cancer cells have a dominant anaerobic/glucose based metabolism while healthy cells have a dominant aerobic/oxygen based metabolism.
People today eat too much sugar and carbohydrates. Patients need to realize that the heart runs almost exclusively on fat as a fuel source and is weakened by too much sugar in the blood. Excess BG is toxic to the heart and mitochondria. What often starts out as a poor diet with BG dysregulation ends up damaging heart and mitochondrial function.
Key symptoms of BG dysregulation:
All patients who present at this step of the algorithm need to reduce their consumption of sugar and starchy carbs (especially “white” carbs). This must be done in conjunction with Chinese medicine.
Energy/Cardiovascular and the 4 tissue patterns
At this stage of the algorithm, the problem is due to either a nerve or muscle tissue pattern.
The heart is a primary element of the nerve pattern, yet it’s also a muscle. The heart is the “king” of all muscles so it is also part of the muscle tissue pattern. To differentiate which pattern is responsible the clinician needs to look at the rest of the patient’s body to figure out which pattern is most relevant, nerve or muscle.
Are there neurological issues present (nerve)? Are there symptoms of lactic acidosis such as fibromyalgia (muscle)? Does the patient have a tendency to constantly get sick and suffer from chronic infections (muscle)?
In the clinic, we usually end up seeing this step as a nerve tissue pattern in our patients. The reason why is because they often needed to start in one of the earlier steps (digestion, elimination, sleep) using a treatment for the nerve tissue pattern. As the earlier step resolved (digestion and sleep getting better) the patient then begins to see their energy levels improve so we stay with the same nerve tissue pattern as long as the patient is moving through the 8 steps.
The beauty of seeing chronic illness from the lens of 4 tissue patterns is that each pattern represents fundamental, systemic behavior traits of the entire body. If you correctly identify the primary pattern it resolves many symptoms in a step-by-step manner.
Step 6: Correct male/female hormonal issues
If you arrive at this step I am going to assume the following:
If not, then go back to the appropriate prior step and stay there until it is corrected. Do not attempt to improve male/female hormonal issues if you have cardiovascular issues. Correcting cardiovascular problems will often simultaneously correct male/female hormonal issues.
Sexual Energy = Disposable Income
In financial terms, disposable income is the money you have left over after all of your bills are paid. If after you pay for basic needs such as food and housing you have money left over, that money can be spent on wants such as vacations, movie tickets, and eating at restaurants. The money that is spent on wants is known as “disposable income”.
If a person has plenty of disposable income you can assume they have enough money to pay for their basic necessities. If they have zero disposable income you can assume that they only have just enough to pay for basic needs…or they do not have enough money for basic needs and are moving into debt.
Physical vitality, or “Qi” as the Chinese say, works the same way.
If your body has enough Qi to satisfy basic functions such as cardiac, respiratory, and immune, then the Qi that is left over is like disposable income. This “disposable Qi” can be used for non-essentials such as athletic pursuits, mental acuity, a full head of hair, youthful skin, and sex. None of these assets are necessary for survival, but just like fancy cars and gold watches, they are nice to have and represent a surplus of health.
In this context I equate sexual energy with the ability to reproduce and have offspring. When a patient has good reproductive function it is a sign that there is a surplus of vitality in the body, thus basic body functions are being cared for. Even if the patient is beyond childbearing years the healthy desire and ability to have sex is a sign of vitality surplus.
As the body begins to deteriorate through chronic illness it is like a person who is not making enough money to pay their bills. Just as this person will stop taking vacations and eating at restaurants, the body will divert energy away from non-essential functions in order to secure the health of the vital organs such as heart and brain.
Of all the non-essential body functions, one of the first ones to become depleted in chronic illness is sexual/reproductive function. This is because sexuality is not needed for immediate survival, yet it requires a large amount of energy to maintain. To the body, sexual function is like that large boat that your uncle bought. Nice to have, yet unnecessary and expensive to maintain. A decline in sexual/reproductive function is a sign that the body does not have surplus vitality. The body does not have disposable income.
The lower energy centers are the prostate and testes in a man, and the uterus and ovaries in a woman. These lower energy centers are the manifestation of the ability to reproduce and thus reflect sexuality. Clinical signs regarding these organs relate to male/female hormonal issues and can be used as a marker for progress.
As the health of the lower energy centers improves you can assume that the vitality of the entire body, especially the overall endocrine system, is improving since it represents surplus vitality.
Male hormonal signs
In my experience, loss of libido is usually due to the prostate and testes interfering with hormonal function while erectile dysfunction is due to the heart not being able to regulate blood flow. If you are at this stage of the algorithm it is assumed that there are no cardiovascular signs and thus there should be no issues with erectile dysfunction.
Erectile dysfunction responds beautifully to our cardiovascular/nerve tissue protocols and its relationship to the heart is agreed upon by many doctors.
When you have a patient who does not have erectile dysfunction but lacks the desire for sex, it is more likely due to a hormonal deficiency. Loss of libido (assuming no issues with elimination, digestion, sleep, and cardiovascular) at this stage of the algorithm is usually due to the prostate and testes.
When working with a male patient who has issues relating to the prostate, testosterone levels, or sexual function, the hardest part for me is having to explain to him that we cannot fix his hormonal issues unless we first resolve more foundational problems related to the digestive tract, sleep patterns, and cardiovascular health. Guys tend to be very stubborn and impatient (I’m saying this as a male). When they have an issue related to the prostate or testosterone they want it fixed immediately and don’t care if they have stomach, sleep, or heart issues. But good Chinese medicine does not work that way, not if you want to fix the problem at the source. I’m hoping that this (long) paper will help explain to people why we work the way we do. If you’re looking for a quick (and often temporary) fix for male hormonal issues then I’m not the right clinician for you.
Female hormonal signs
Any of the above signs indicates an issue with sexual/reproductive energy and thus a deficit of overall vitality. It represents a lack of “disposable income” for the body.
Menstrual irregularities are very common in my office with a wide range of symptoms. The menstrual cycle should be 28-30 days long and the actual period should be between 3-5 days. PMS is not normal and there should be no issues with cramping, excess bleeding, clotting, or mood swings. Any of these issues is a sign of female hormonal issues and should be corrected.
When treating infertility patients I explain to them this concept of “disposable income” and that having a baby is an extreme form of disposable income for the body. If the woman’s basic body systems are not functioning well then it’s going to be hard to convince the body to carry a child for 9 months. Pregnancy is exhausting for the woman’s body and used to be a major cause of death in women. The body will not allow a pregnancy to happen unless it feels it has the necessary health resources to do it safely. The key to success with infertility patients is to maximize their overall health (including menstrual regularity) and create a surplus of vitality. This surplus will then be used to conceive and deliver a healthy baby.
Even if the woman is past childbearing age she should still have good sexual energy relative for her age. This means no hot flashes or menopausal symptoms in addition to good sexual function.
Why hormones are at step 6
For the hormonal system to be healthy, so many other aspects of the body need to be in place for it to happen. Healthy hormones are like the flower on a tree. For the flower to be there the rest of the tree (especially the roots) has to be healthy first.
Bowel movements: If the blood is toxic due to autotoxemia it will poison the endocrine glands and compromise hormonal production. The prostate and uterus are also adjacent to the lower colon. Toxicity that is diffused from the lower colon will immediately affect the reproductive system due to proximity.
Digestion: Hormones are primarily synthesized from fatty acids and cholesterol. If you cannot absorb these nutrients, how are you going to make hormones?
Sleep: Not getting proper sleep tends to raise cortisol levels and create issues with blood glucose dysregulation (including insulin). Dysregulation of insulin and glucose is a precursor to diabetes and has a direct negative effect on your ability to produce and regulate hormones. You can’t have healthy hormones if you’re not sleeping properly.
Energy/cardiovascular: Hormones require an enormous amount of energy for the body to produce. If you barely have enough energy for your heart and other vital organs, how do you expect your body to have the energy to produce hormones?
And that’s why hormones are at step 6 of the algorithm.
Male/female hormonal issues and the 4 tissue patterns
If you are diligent in following this 8 step algorithm and not skipping prior steps (which is the biggest mistake), male/female hormonal issues are usually due to the epithelial pattern.
Sure it could be due to autonomic dystonia found in a nerve tissue pattern, but we are assuming that there are no issues with digestion, elimination, sleep, and cardiovascular…all of which are signs of healthy nerve tissue. At this step it’s possible that it’s a nerve tissue pattern, but not probable.
It’s also possible that it’s a muscle tissue pattern with lactic acidosis. But we are assuming there are no issues with energy and cardiovascular which is almost always seen in a muscle tissue pattern. If you’re looking at hormonal issues but there are problems with energy/cardiovascular then that means you skipped a step (shame on you). So again it’s possible but not probable.
At this point the problem is most likely due to an epithelial tissue pattern. Remember the epithelial pattern includes the skin, adrenals, endocrine system, and sympathetic nerves. Your glands are mostly made out of epithelial tissue. The primary dysfunction of epithelial tissue is too much sympathetic tone which then suppresses parasympathetic tone.
Parasympathetic tone (the ability to relax) is necessary for sexual functions to occur (as anyone who’s been extremely stressed out can relate to). It is also necessary for hormonal production and regulation. An excess amount of sympathetic tone will flood cortisol and epinephrine into the blood stream which also suppresses reproductive hormones.
Step 7: Correct Autoimmune and Inflammatory Issues
If you arrive at this step I am going to assume the following:
If not, then go back to the relevant previous step and stay there until it is corrected. Do not attempt to improve autoimmune and inflammatory issues in a patient who has hormonal issues. Hormonal issues must be addressed before autoimmune issues to create predictable healing results.
Autoimmune disorders
An autoimmune state is when the body begins attacking its own tissue instead of foreign pathogens such as bacteria and viruses. The autoimmune state is a form of internal confusion where the body becomes reckless and self-destructive.
The type of tissue that the body ends up attacking will determine the diagnosis. If the body attacks nerve cells it is called Multiple Sclerosis. If it attacks the joints it is called Rheumatoid Arthritis. If it attacks the pancreas it is called Diabetes. If it attacks the skin it is called Psoriasis. If it attacks the thyroid it is called Hashimoto’s Thyroiditis, etc.
In my practice I am less concerned with the tissue that is being attacked and more concerned with the fact that the body has begun to actively self-destruct and return itself to the Earth. Whether it does this by attacking the skin vs. the thyroid is not as important to me. What’s important is to figure out why the body is attacking itself.
My observation is that the autoimmune state is usually induced by chronic inflammation that stems from a dysfunctional extracellular matrix (ECM). We discussed this in the 4 tissue patterns under connective tissue. What originally started as a normal healing response to tissue trauma became prolonged and chronic in nature. This prolonged trauma can be self-induced by the patient due to poor diet, alcohol, smoking, lack of exercise, etc. or it can be due to a dysfunction in the ECM’s ability to regulate the healing response.
Again, it doesn’t matter from my standpoint what the specific autoimmune diagnosis or even the body area that is being attacked. What matters is the dysfunction of the ECM in regulating the inflammatory response. This is the root of the autoimmune state.
Autoimmune and the 4 tissue patterns
At this stage in the algorithm if there is still evidence of autoimmunity, it is usually due to a connective tissue pattern and treated as such. At this step the focus of treatment is to restore function to the ECM and thus regulate the healing and inflammatory response.
Could the autoimmune state be due to autonomic dystonia and a nerve tissue pattern? Sure, but remember we are at step 7 of the algorithm. This means that the patient has healthy digestion, bowel movements, sleep, and energy levels. All of these suggest normal nerve tissue function so at this stage it’s not likely to be a nerve tissue pattern.
Could it be an epithelial pattern with high sympathetic tone? Again it could be. But this is a person with healthy sleep and hormonal function (if not then you skipped a step and made a mistake). Because healthy epithelial tissue is needed for sleep and hormonal function, it’s not likely to be an epithelial pattern.
Could it be a muscle tissue pattern with lactic acidosis? Could be, but this is a person with good energy levels (step 5) and no shortness of breath. It’s possible that the pain associated with the autoimmune state is due to lactic acidosis, but the lactic acidosis state is usually resolved after step 5 of the algorithm.
So that leaves us with the connective tissue pattern and its relationship to inflammation. Remember the 8 step algorithm is purposefully designed to address physiology from foundational levels to more specified levels. As you move through the 8 steps the tissue patterns become clearer through process of elimination.
Step 8: Correct any remaining issues
If you arrive at this final step in the algorithm and you still have health issues I need to ask you a question:
Are you sure?
Are you sure:
If you are sure that none of the above issues are present then you are looking at a very healthy person, correct? If you are still struggling with health issues, after all the foundational body functions are working well, then it is probably one of two possibilities:
Assuming it’s a localized issue that’s capable of responding to Chinese medicine, we then assess the problem from the lens of the 4 tissue patterns to determine the behavior of the problem.
Is it a nerve tissue pattern with autonomic dystonia?
Is it an epithelial pattern with high sympathetic tone?
Is it a connective tissue pattern with chronic inflammatory and autoimmune issues?
Is it a muscle tissue pattern with lactic acidosis?
Almost everything you see is going to fall into one or more of those 4 tissue patterns. I’m not saying that this method works 100% of the time, nothing does. But if the problem is capable of responding to natural care then this model is the most comprehensive I have seen.
Summary of the 8 steps
Medicine is complicated.
The body is complicated.
Chronic illness is complicated.
People are complicated!
Complexity can bring confusion. Confusion then brings disorganization. Disorganization then leads to haphazard and unpredictable results. When you are working with really sick patients, this type of disorganization is unacceptable.
The 4 patterns and 8 steps is my attempt to bring clarity and organization to the riddle of internal medicine. The 4 patterns organize the body according to anatomy, while the 8 steps organize the body according to physiology. The concept allows you to categorize chronic illness in terms of broad tissue patterns that affect the entire body. The 8 steps then give you a starting point for beginning the healing process in a manner that is that focused and efficient.
The 8 steps are organized so that you begin with what is most important, then move towards functions that rely on the previous steps to build upon. What happens is that fixing step 1 will often fix step 2 and even 3 or 4 without even focusing on the later steps. This is because the 8 steps are designed to restore self-regulation and homeostasis to the body. They are not designed to chase symptoms or placate disease labels.
What about my disease label?
While moving through the 8 steps will restore health and vitality (it will give you your life back), people ask questions like:
What about lyme? Will it change my blood work so that I no longer have lyme?
What about heavy metal toxicity? Will it remove the heavy metals from my blood report?
What about parasites?
What about:
I usually respond to such questions by asking:
“What if your body was restored to total health and functionality, you felt like a young kid again, but the lab report still said you were sick because you had XYZ diagnosis? Would you place more value on how you felt, or what a piece of paper said?”
If what the piece of paper says is more important to you than your ability to function…then our clinic is not the right place for you.
Remember that Chinese medicine is physiology based, not disease based. You can feel great yet have a horrible lab report. Conversely, all doctors who’ve been in practice for a long time have seen patients with perfect blood work, yet the patient is dying right in front of them.
I’m not saying that there isn’t any value to a disease based approach. When used correctly such an approach can be lifesaving in emergency conditions. But our clinic does not treat according to disease labels. Our approach is based on restoring physiological function regardless of the disease label. Whether the disease label is still there or not after health is restored is not something we place attention on.
The diagnosis is a theory as to why your health is failing. In my humble opinion, it is actually not just a theory…it is an opinion. It is an opinion that changes every few years according to the medical community while people remain sick and non-functioning. Even with things like lyme or vitamin D deficiency the criteria for what constitutes the diagnosis constantly changes and is not in agreement between experts.
What does not change is how your body functions. What does not change is human physiology and how a healthy body behaves. It is this restoration of healthy physiology that the 8 steps is designed to bring.
Now that we have an understanding of the four types of tissue and their primary dysfunctions, we have to figure out how to apply this model to treating patients.
As great as the four tissue model is for making sense of the patient’s symptoms, it is rare that you will see a patient who fits perfectly into any one of the four patterns.
Most patients with chronic illness will present with aspects of all four patterns at the same time. They will have aspects of autonomic dystonia, hyper sympathetic tone, chronic inflammation, and lactic acidosis affecting different body areas and creating different symptoms all at the same time.
When a patient has 20 different symptoms, where do you begin to treat them? Do you try to treat all 20 symptoms at the same time with 20 different pills? Do you treat the one that they are most bothered by? Do you pick one at random and start there?
Trying to treat all of the symptoms at the same time doesn’t work in my experience. You end up overstimulating the body and overtaxing their digestive tract with too many herbs/supplements. Every pill that you swallow, even if it’s good for you, requires energy to break down and absorb. Your body must expend energy to process the remedy. If the patient is already in a weakened state, taking the remedies can actually make them worse even if it’s the correct remedy.
Treating the symptom that the patient is most bothered by is also a mistake. Because symptoms are interrelated, you have to figure out what the primary dysfunction is and begin there…regardless of what the patient’s chief complaint is. I know this might sound rude from a customer service standpoint, but practicing medicine is not like going to Burger King. Having it your way is not always the best thing for you.
What if the person wants help for chronic fatigue but they also can’t sleep. The patient doesn’t care about sleeping well, they just want more energy. By that rationale you’ll start giving the person herbs/supplements that are stimulatory in nature. This will give them a temporary boost of energy but will make their insomnia even worse.
What if the patient is a male who wants help for low back pain but he also has prostatitis? The patient doesn’t care about the prostatitis, they just want the back pain gone. But prostate inflammation is often a cause for back pain especially if range of motion and MRI exams are negative. If you just try to make the back feel better without addressing the prostatitis, any relief he feels will be temporary at best.
Just like building a house from scratch, you have to start with a stable foundation and build from there. You don’t work on the roof if you haven’t even laid the foundation. It’s the same with treating chronic illness. No matter what the diagnosis or chief complaint (which is completely subjective, btw), you have to start with the most important aspects of body function and work upwards from there. Otherwise you’ll waste precious time chasing symptoms.
Physiology
There are two ways to approach medicine:
- Disease based: First you diagnose the illness based on symptoms and medical tests. Then you prescribe a treatment based upon the diagnosis.
- Physiology based: This involves the progressive rehabilitation of the patients’ body functions regardless of the disease label.
Chinese Medicine, at least as I see it, is almost 100% physiology based since it is only concerned with restoring the healthy function of body systems (digestion, neurological, hormonal) and pays little attention to disease labels and even lab reports.
What’s the difference between anatomy and physiology?
Anatomy refers to body parts such as organs, tissues, and cells. Anatomy is the study of nouns.
Physiology refers to how those body parts interact and behave as an interdependent system. Physiology is thus the study of verbs. It is the study of how the body functions and behaves in states of sickness and health.
As an example, the liver, stomach, and intestines are nouns and thus considered anatomy. Digestion refers to how those nouns behave and interact with each other to form verbs. This applies to all body functions.
The word “physiology” refers to the normal/healthy functioning of the body while “pathophysiology” refers to the pathological/unhealthy functioning of the body.
It’s easy to learn physiology because the normal functioning of the body falls into a very limited range:
- You are supposed to have 1-3 bowel movements per day that are well formed and a certain color.
- You are supposed to be able to sleep for 6-9 hours per night with minimal difficulty and interruption. You should feel rested when you wake.
- Heart beat should be between 50-70 beats per minute.
- The joints of the body all have a specific range of motion they should be able to perform.
- A woman’s cycle should be 28-30 days with a menstrual period of about 3 days. There should be moderate bleeding with minimal clotting.
- Etc.
The rules of physiology do not change very much. The parameters you use for defining healthy physiology will most likely be the same 20 or even 50 years from now.
If physiology is correct, then anatomy is correct too
Contrast this to pathophysiology, which is the study of unhealthy and pathological behavior of body systems.
How many different ways can each body system malfunction?
There are hundreds, if not thousands of different ways that each body part can malfunction and this is proven through the many disease labels currently in use. The eye alone has over 200 disease labels and the number grows each year!
Many clinicians start by focusing on the pathophysiology or disease label. Once that disease label is found they prescribe a treatment for it. There’s a few problems with this approach:
- Disease labels constantly change and become redefined, thus making the treatment ineffective. An example of this is how the Lyme diagnosis has become more complicated each year with the discovery of new co-infections (babesia, bartonella, etc.)
- It’s very difficult to become familiar with all aspects of pathophysiology as it relates to each disease label. The amount of studying and memorization required is not realistic for most people.
- Treating a disease label does not take into account the interaction between body systems and how that may be contributing to the disease. An example of this is how liver congestion can cause the thyroid to become hypoactive and produce a low T3 level. By focusing on the disease label the clinician may start giving the patient iodine and direct thyroid support but if the underlying cause is liver congestion it won’t work. The liver congestion can be easily inferred by assessing elimination and digestion. By addressing the liver congestion the thyroid will often return to normal function.
With all that said, I get a regular physical exam every year and encourage my patients to do the same. I do not feel that lab tests and disease labels are useless. For emergency conditions they can be lifesaving and this is something that I feel Western medicine handles better than wholistic medicine.
But for the correction of chronic, complex illness that is not a life-threatening emergency, I find that focusing on the disease label (pathophysiology) is not as effective as focusing on restoring physiology in a progressive manner.
All disease labels are an attempt to describe the progressive breakdown of physiology. Don’t focus on the details of the breakdown, just focus on restoring physiology at a systemic level and the disease label will become irrelevant.
Organization of the body according to physiology
If the 4 tissue types is a way of organizing the body by anatomy, the 8 steps is a way of organizing the body by physiology.
The 8 steps is a flow chart algorithm that can be used to organize the patient’s symptoms, then identify the tissue pattern associated with each symptom.
At our clinic, the 8 steps is only one of three different ways that we use to assess the patient. But the other two methods are centered on acupuncture point palpation and I’m not able to describe it in writing.
Problem solving algorithm
The 8 steps is a problem solving algorithm applied to physiology. The 8 steps is a way of taking all of the patient’s symptoms, no matter how numerous, and figuring out where to begin. When there are a multitude of problems, the 8 steps lets us figure out which one is the most important to focus on if we are to bring the patient back to full health.
Here is the complete 8 step algorithm for reference:
- Rule out gastric ulcers
- Correct bowel movements (constipation and diarrhea)
- Correct digestion (indigestion, reflux, gas, etc.)
- Correct sleep (trouble falling and/or staying asleep, not waking rested)
- Correct energy and cardiovascular
- Correct male/female hormonal issues (dysmenhorrea, prostate, menopause, andropause)
- Correct autoimmune and inflammatory issues
- Address any remaining symptoms
Think of this as a flow chart for guiding a patient, all patients regardless of their chief complaint, from sickness to health.
For each patient case begin at step 1 and see if it applies towards them. If it does then fully implement the corrections for step 1 until the issue is resolved. Do not implement any therapeutic steps from later steps until the first step is completed. This means that if they have a gastric ulcer, don’t try also work on their hormonal issues. That’s like trying to build a roof on a house before the walls are put up.
This is a very important point. The 8 step algorithm is designed to simplify and focus our treatment efforts on restoring systemic physiology so that total health is achieved. In order to do this the body requires that we work in a very specific order and this is what the algorithm offers us.
If step one does not apply to the patient then we move to step 2 (bowel movements). If there’s no issues with bowel movements then proceed to step 3, but if there are issues with bowel movements then we focus on correcting that before moving to step 3, etc., etc.
We have found that correcting the initial step of a patient’s condition will have therapeutic effects on many other aspects of their health which do not seem related to the step being treated. Correcting bowel movements will often correct sleep problems. Correcting sleep problems will also improve hormonal regulation etc. Many times you will find that after correcting the initial step you will have to look 2-3 steps forward to find the next area to work on.
This is because we are not just treating symptoms, we are restoring the body’s ability to heal itself and maintain homeostasis.
What follows is a brief description of the 8 steps and how they relate to the 4 tissue patterns. Keep in mind the 8 steps is only one of several assessment methods we use, it’s just the one that we can describe in writing. Also keep in mind that I won’t be giving specific treatment recommendations regarding herbs/acupuncture for the 8 steps. The reason why is because the treatment method has to be tailored to each individual patient, and I don’t want people using this document as a substitute for a licensed health care professional.
Step 1: Rule out gastric ulcer
A gastric ulcer (also called “peptic ulcer) is an open sore in the lining of the stomach or duodenum (duodenum is the first part of the small intestine). If you imagine your stomach as a bag and the small intestine as a tube, an ulcer is a hole in the lining of the bag or tube.
These are the most common causes for an ulcer:
- Excess alcohol
- Excess use of NSAIDs and aspirin
- Smoking
- Radiation treatment to the area (I see this a lot in cancer patients)
- Infections (notably H. pylori.)
- As a progression of overall health deterioration and weakening of tissue
- I’ve seen ulcers occur as a result of martial arts injuries (punch to the stomach), so I assume they can happen after any blunt trauma
Gastric ulcer is a block to starting the entire healing process
Having a hole in your stomach (which is essentially what an ulcer is) or small intestine is a block to healing because it interferes with your ability to digest food and absorb nutrients.
The inner lining of the stomach is supposed to have a mucous membrane to protect the epithelial lining from being damaged by hydrochloric acid (HCL). If this mucous lining is broken then your HCL will burn a hole through your stomach. This creates pain, irritation, indigestion, and eventually internal bleeding. The internal bleeding and tissue damage involved with an ulcer compromises the digestive process and reduces the healing effect of foods and supplements.
Let me say this in another way: if you have a gastric ulcer there is no point in taking supplements as they will not be digested properly because your stomach is broken.
I see this all the time. A new patient with a multitude of health issues and has been taking thousands of dollars’ worth of herbs and supplements yet is either the same or getting worse. Many times they will have symptoms of a gastric ulcer that was not addressed and which is preventing anything from being absorbed properly.
Your stomach needs to produce HCL for digestion as well as preventing infections from entering the intestine. But if you have an ulcer you end up further damaging your stomach and small intestine when you produce HCL.
People end up taking proton pump inhibitors (PPI) like Nexium to inhibit the production of HCL so that the ulcer does not become irritated. But if you’re not producing HCL then how are you supposed to digest your food??
Taking Nexium will give short-term relief from the symptoms of an ulcer but will then create long-term problems because you are depriving the body of HCL (with all it’s vital functions).
Finding a gastric ulcer
The standard approach in Western medicine is to perform an endoscopy where they insert a camera down your throat and look for an ulcer. Many clinicians (myself included) have found this to be unreliable as the patient can have symptoms of an ulcer, respond well to treatment for an ulcer, and yet have nothing show up on an endoscopy.
Most Western doctors diagnose an ulcer simply through the patient’s symptoms and then offer treatment. If the treatment reduces their symptoms then an ulcer is confirmed without endoscopy.
Heartburn is considered a sign of a gastric ulcer but I disagree with this. Most cases of heartburn are due to a deficiency of HCL which then causes your food to rot in the stomach and produce metabolic waste.
Two important indicators
There are two indicators that can be used when trying to rule out a gastric ulcer:
First, there is always a sharp, stabbing type pain with the gastric ulcer patient. Ulcer pain tends to be severe and the patient will almost always use the word “stabbing”. The nature of an ulcer is a small wound in the stomach that is irritated by HCL. When we ask the patient to show us where the pain is they will point to it with a fingertip, not with their palm. This is really important. Ulcer pain is pinpointed and localized, general gastritis pain is diffuse and more spread out.
If there is an ulcer the patient will use a fingertip to show where the pain is and it tends to always be in the same spot. For non-ulcerative gastritis the patient will use a palm to show where the pain is and it will tend to move around.
Second, ulcer pain tends to be worse before meals when the patient has an empty stomach and is hungry. The pain feels better after they eat something bland and starchy like pasta or bread. This is because when the stomach is empty the HCL can irritate the ulcer, but eating a bagel or bowl of pasta will soak up the HCL and keep it away from the ulcer.
If the pain is in a pinpoint location, worse before meals, and better after eating starchy foods = very good chance there’s a gastric ulcer.
Vinegar test
Another way to detect an ulcer is to ask the patient if they can tolerate vinegar. Vinegar has a similar nature to HCL in that its acidic pH will irritate an ulcer. If the patient reports that they get sharp pain after eating anything with vinegar then that’s an indicator of gastric ulcer.
If the patient is not aware of how they respond to vinegar, an old test is to have them drink 2 tbs. of apple cider vinegar in one cup of water on an empty stomach. If they experience sharp stomach pain within 10 minutes then it suggests the presence of an ulcer.
If a gastric ulcer is suspected, we focus on resolving that first before moving to anything else. Sure the patient may have a dozen other problems that are more important to him/her. But it doesn’t matter. A gastric ulcer will block the healing effect of any therapy that involves swallowing something and this includes a healthy diet. This has to be resolved first or else nothing works reliably.
Step 2: Correct bowel movements
It is only after ruling out and/or resolving a gastric ulcer that we can move to step 2 and assess bowel movements/elimination. Don’t go to step 2 until step 1 is completed!
Bowel movements as a reflection of internal health
If you cannot eliminate waste properly, how can your body heal?
All of the ancient healing systems from China, India, Egypt, and Greece viewed the quality of the bowels as a reflection of internal health. This was especially so in ancient Egypt where the word they used for “doctor” literally translated as “one who inspects and cares for the colon”.
Healthy bowel movements are a reflection of healthy digestion, detoxification, liver function, cardiac function, and especially neurological function since most of our neurotransmitters are made in the bowel.
By restoring healthy bowel movements you can make the assumption that the entire body is being benefited. You can assume an improvement in detoxification, digestion, and autonomic function which then sets the stage for healing throughout the entire body.
I recommend that you focus on correcting bowel movements before looking at upper digestive complaints. The reason is that by correcting the bowel you usually correct upper digestive issues although the reverse is not necessarily so.
Criteria for healthy bowel movements
- At least 1-3 bowel movements per day. You should feel “empty” after the movement and there should be no difficulty or straining.
- Stool should be formed, brownish in color, and not liquid.
- Since the colon is about 2 feet long, patient should eliminate at least 1 foot of stool each day.
The two primary bowel disorders are constipation and diarrhea.
Constipation and autotoxemia
“Autotoxemia” is when the body becomes poisoned by its own waste products. The primary source of autotoxemia is from constipation where the person has less than one complete bowel movement per day.
If you are having less than one complete bowel movement per day, there is most likely undischarged fecal matter rotting in your colon. Proteins putrefy, carbohydrates ferment (and give off alcohol compounds), and fats become rancid. This toxic waste not only becomes a breeding ground for infections but it spreads into the liver and bloodstream. Once it diffuses into the bloodstream it then affects all of your organs and body functions.
It is for this reason that constipation, and the resultant autotoxemia of the blood, can be the cause of almost any internal medicine problem. If the autotoxemia affects the brain it causes neurological problems. If it affects the heart it causes cardiac problems. If it affects the skin then it gives you a rash. If it affects the joints it causes arthritis and so on.
In the case of chronic illness that also has constipation, good results will not be seen unless the constipation is first addressed. It doesn’t matter what the disease label is whether it’s arthritis or hypothyroid, or migraines, etc. The toxic waste in the bowel creates an enormous burden on all of the body’s energy systems. If this burden can be relieved then it frees up energy that can then be used for the healing process.
Constipation and the 4 tissue patterns
For most cases of constipation, the tissue pattern involved is either nerve or epithelial.
For the nerve pattern patient, there is also the presence of autonomic dystonia with paradoxical response to stimuli. In this patient there is a dysfunction of the enteric nervous system and its ability to regulate peristalsis (often due to issues with heart rhythm). There will often be issues with the cardiovascular system, orthostatic hypotension, and circulatory disorders. There can also be neurological issues as well. Remember that the nerve pattern involves primarily the gut, heart, and brain.
For the epithelial pattern patient there is an excess of sympathetic nervous system (SNS) tone with a corresponding deficiency of parasympathetic nervous system (PNS) tone. The PNS is needed for digestion, sleep, and elimination. Basically if your body is too tense, you can’t poop. This patient will also exhibit other signs of high SNS/low PNS such as anxiety, hormonal disorders, and skin problems. Remember that the epithelial pattern involves the adrenals, skin, endocrine system, and sympathetic nerves. You will thus see signs of these other body elements along with the constipation.
The key to treating constipation is to identify the tissue pattern that is involved and focus on that. Focus on correcting the behavior of the tissue pattern as it relates to the whole body, the constipation will follow. We do not give laxatives of any kind because that doesn’t address the source of the problem. It also can make you dependent on the laxative.
Because we focus on the tissue pattern, the patient will begin to see improvements in other body areas as the constipation begins to resolve. The idea is to identify a key symptom (constipation) and then relate it to a behavior pattern that affects the body as a whole. We then monitor the symptom but treat it using a method that affects a large portion of the body.
Diarrhea and autotoxemia
The patient has diarrhea if any of the following are present:
- Bowel movements in excess of 3 per day
- Loose stools that are unformed, watery, or have undigested food particles
- Excess mucous or oil in the stool
I view diarrhea as an alternate expression of autotoxemia. Similar principles apply but the way the body reacts to the toxic situation is different.
Diarrhea is a sign that the body is trying (unsuccessfully) to eliminate something from the colon. This can be a toxin (exogenous or endogenous) or infection. The body sends excess fluid to the intestine in an attempt to flush out the irritant. It’s ok for this to happen once or even several times in response to the presence of an irritant (like when you get food poisoning). However if it happens on a long-term basis or is severe to the point of debilitation, it means that the body needs assistance in eliminating the irritant from the intestine.
Diarrhea is also seen in cases of kidney congestion. The kidneys and bladder excrete water soluble waste while the liver and intestine excrete fat soluble waste, generally speaking. If the kidneys are congested the body will send the water soluble waste to the intestine for excretion. The excess water in the colon creates diarrhea. This is a bad situation since the intestine is not designed to excrete urea and this will damage the colon.
Thus it is important to address kidney congestion when the patient has diarrhea.
Long-term diarrhea creates a state of dehydration and electrolyte imbalance. The body loses electrolytes (calcium, magnesium, sodium, potassium) during diarrhea and this can impair cardiac and neurological function. Many neurological, cardiac, and dermatological conditions can be traced back to diarrhea often seen in IBS, Chron’s, and ulcerative colitis. The diarrhea must be addressed first before proceeding to other issues or else results will be sporadic at best.
Key Signs of Kidney Congestion (Impaired Kidney Function)
Many diarrhea cases involve kidney congestion. There are numerous possible signs of kidney congestion and many of those signs (i.e. nausea, fatigue, lightheaded) are very general and overlap with other disorders. Many symptoms of kidney congestion overlap with heart failure so it’s important to know how to differentiate between the two (and refer out for medical evaluation when appropriate).
- Swelling in the ankles and feet: when the kidneys cannot eliminate fluid waste it builds up in the body and will be first seen in the ankles and feet (due to venous congestion). Keep in mind though, you also see this happen in heart failure.
- Changes in urination: sudden changes in urination (more frequent, less frequent) suggest problems with the kidneys.
- Skin rashes: the skin and the kidneys are very similar in that they both excrete water soluble waste (urea). They are both part of the epithelial pattern. When the kidneys are congested the body may divert water soluble waste to the skin for excretion and this will create rashes.
- Urine/ammonia odor in body or breath: If the body cannot secrete urea through the kidneys it will try to push it out through the skin and breath. The patient will smell like urine.
- Dizziness when lying down: the kidneys play a key role in blood pressure regulation. When you lie down your blood pressure should drop slightly to prevent body fluids from flooding into the head. Imagine taking a bottle of water and laying it on its side. The water floods to the tip of the bottle and increases pressure there. The kidneys are responsible for regulating fluid distribution and thus preventing you from getting dizzy when you lie down. Note that this is different from dizziness when standing up from a lying position (orthostatic dizziness), that type of dizziness is more suggestive of heart and adrenal issues.
- Chronic low back ache that does not present with range of motion or stability deficits: if the patient has chronic, dull back ache yet they do well on range of motion and stability tests for the back, it suggests the back pain is not due to an orthopedic issue but a visceral (organ based) issue. A common cause of low back ache with minimal orthopedic deficits is kidney congestion.
Diarrhea and the 4 tissue patterns
Most cases of diarrhea are due to the epithelial pattern.
Epithelial tissue is responsible for secretion of fluids and this includes fluid waste in the intestine. The epithelial pattern is also linked to the kidney which tends to play a role in chronic diarrhea. Chronic diarrhea represents a derangement in the excretion of fluids be it intestinal fluid or water soluble waste from the kidneys (which then gets excreted through the bowel and damages the gut flora).
Just like we did with constipation, we do not treat “diarrhea”. We focus and monitor the symptom of diarrhea but we treat the pattern of “epithelial tissue”. The symptom is used as a clue to figure out which tissue pattern is causing the overall illness but treatment is performed on a broad, systemic level to heal the entire body, not just the diarrhea.
The 4 tissue patterns is a concept that explains general body dysfunction. The 8 steps is a flow-chart that can be used to apply the 4 tissue patterns in a step-by-step manner that removes ambiguity from the treatment procedure.
Step 3: Correct Digestion
It is only after making sure that the patient is having healthy bowel movements (no constipation or diarrhea) that we look at their upper digestive functions. If there are any problems with bowel movements we focus on that first.
And also, we don’t focus on bowel movements if there are signs of a gastric ulcer. The value of the 8 step algorithm is that the entire body is rehabilitated starting with the most important functions, and in a specific order that optimizes efficiency.
Elimination and Digestion are connected
By assessing and correcting bowel elimination you will often simultaneously correct any upper digestive issues. This is because the digestive tract is one continuous tube from mouth to anus.
Some people have normal bowel movements yet they have upper digestive complaints. The most common upper digestive complaints include:
- Heartburn (also known as acid reflux or GERD)
- Stomach pain after eating (sharp stomach pain before eating is usually ulcer)
- Sluggish upper digestion
- Gas and bloating
These symptoms reflect a weakness in the upper digestive organs including the stomach, liver, pancreas, and duodenum (first part of the small intestine). They indicate sluggish activity which results in the food not moving fast enough through the first part of the digestive tract. The food then rots in the digestive tract which then creates gas and metabolic waste products.
If the patient has upper digestive issues you can assume that they are not extracting nutrients from their food. They can be eating the best food in the world but if it’s not getting broken down into vitamins, minerals, amino acids, and fatty acids for absorption then it does them no good. It just ends up turning into expensive poop!
If the patient is not absorbing nutrients from their food they will not heal from whatever illness they have. They will not be able to rebuild and repair tissue. They will manifest symptoms of malnutrition even if they are eating plenty of good food.
This also applies to the people that are taking numerous supplements for multiple symptoms and diagnoses. For most of these patients they do not have a treatment plan or specific goalposts they are trying to reach. They have been sold on the idea that they can’t live without thousands of dollars’ worth of pills. If this person has trouble digesting food, then of course they’re going to have trouble digesting supplements. They are not only wasting their money, they are making themselves sicker by further taxing an already dysfunctional digestive system!
Upper digestion and the 4 tissue patterns
Digestive problems can be a result of either nerve or epithelial patterns.
The nerve pattern can be involved because the gut is connected to the heart and brain through a dominant nerve pattern. Peristalsis is also dependent on proper heart rhythm.
The epithelial pattern can be involved because too much sympathetic tone in the nervous system will decrease parasympathetic tone needed for digestion. Digestion requires a relaxed state of the nervous system which is why you have trouble digesting when you’re anxious.
Just like when trying to determine the tissue pattern for constipation, we have two possible choices and need to look at the rest of the patient to figure out what the dominant tissue pattern is. However, this is step 3 of the algorithm and we are assuming that there are no issues with gastric ulcers or bowel movements. So what we are looking at is an upper digestive issue that does not have any problems with bowel elimination, otherwise you need to go back to step 2.
Because the gut is a key player in the nerve pattern, most upper digestive issues without bowel problems will be nerve tissue patterns. Not all of them, you still need to look at the rest of the patient picture, but most “step 3” cases will be nerve pattern in nature.
It’s true that high sympathetic tone (epithelial pattern) can cause upper digestion problems, but in those cases there will usually be simultaneous problems with bowel movements, which we have ruled out if we are at step 3.
Step 4: Correct Sleep
If you arrive at step 4 the following prerequisites must be fulfilled:
- You have healthy bowel movements. No constipation or diarrhea.
- There are no upper digestive complaints and no signs of gastric ulcer.
If not, then go back to step 3. Do not try to correct sleep if there are any problems with digestion or elimination.
The Second Brain
I need to emphasize that you should not try to correct sleep issues if you have digestive or eliminative problems. If you give a patient with digestive problems an herbal remedy for sleep guess what? They will not be able to digest it!
Fix digestion and elimination before trying to fix sleep. Often by correcting digestion/elimination you will simultaneously correct sleep although the reverse is not true.
We previously discussed a concept called “The Second Brain”, popularized by Dr. Michael Gerson who wrote a book with the same name. In the 1990’s it was discovered that over 90% of your neurotransmitters are produced in the gut. This implies that gut disorders can cause neurotransmitter deficiencies and imbalances.
Since neurotransmitters such as GABA and acetylcholine are needed for proper sleep and neurological function it would make sense that correcting gut function would enhance neurotransmitters and thus improve sleep.
This concept of the digestive tract having a direct effect on brain and neurological function has been taught in TCM for thousands of years. It is only within the last 20 years that it has now been confirmed by western medical science.
Healing happens during sleep
It is during deep, restful sleep that we rebuild tissue and detoxify waste. It is also during sleep that the cognitive mind shuts down enabling the subconscious mind to process deep seated thoughts and emotions.
It is not just the physical body that heals during sleep but the mental and emotional body as well.
If a patient is not able to achieve restful sleep on a regular basis it negatively affects every single aspect of their physiology. They cannot heal if they cannot sleep and this must be addressed after digestion/elimination issues are corrected.
The main problems that a lack of sleep creates includes:
- Fatigue: obviously a patient will be fatigued if they can’t sleep. It drives me crazy when I see doctors giving a patient ginseng for their fatigue when they overlooked that the person has insomnia.
- Hormonal imbalance: sleep deprivation causes excess cortisol to be excreted into the blood. This causes a particular type of weight gain around the abdomen and disrupts thyroid and adrenal function.
- Blood sugar disorders: excess cortisol affects insulin which then contributes to blood sugar disorders. This sets the stage for diabetes. Blood sugar disorders can also affect sleep thus becoming a vicious cycle.
- Neurological disorders: anxiety, depression, ADHD, and poor memory are common results of sleep deprivation.
- Immune disorders: lack of sleep increases the risk of infections and reduces the ability to heal from chronic infections
- Cardiovascular: insomnia is a risk factor for cardiovascular disease. If a patient has heart problems as well as insomnia, you must correct insomnia before addressing the heart directly.
In a state of chronic illness, any illness, what good is it trying to address specific complaints when you’re not able to sleep? Fix the sleep first and you will find that many of your other complaints will begin to resolve without direct treatment.
What constitutes healthy sleep?
- Being able to fall asleep easily (within 20 minutes at most).
- Being able to stay asleep throughout the night. Waking up to pee is ok if it’s limited to once or twice a night and the patient can fall back asleep easily. If they are peeing more than twice a night and/or can’t get back to sleep easily then something is wrong.
- Waking up feeling rested in the morning. Not waking up rested means that the quality of sleep was poor. This is often due to snoring, sleep apnea, restless leg syndrome, and sometimes orthopedic pain.
How much sleep does a person need?
This is going to vary depending on the individual and how much stress they are putting their body and mind through. It also depends on their level of health.
You are getting enough sleep if two criteria are met:
- You wake up without the need for an alarm. This means that the body naturally wakes itself after it gets enough rest. Being forced out of bed by an alarm means that your body was not ready to wake up. You should go to bed earlier.
- You feel rested upon waking.
Some people feel great on only 5 hours of sleep per night while others need 10 or more. What matters most is that they wake up feeling rested and without needing an alarm. As a patient’s health improves they will often find that they need less sleep.
Blood glucose and inability to stay asleep
From a biomedical standpoint, the number one cause of not being able to stay asleep through the night is blood glucose (BG) dysregulation. This is a bit different than not being able to fall asleep. The number two cause is orthopedic pain waking you up at night but that needs to be addressed as a separate issue.
If BG is too high during sleep the body will concentrate the excess glucose into the urine and the patient will have to wake up and pee. This is what happens in diabetic cases. It is also a primary cause of pediatric bedwetting. The child’s nervous system (specifically the sacral parasympathetic nerves) is not developed enough for the bladder reflex to wake them yet the body feels the need to excrete the excess glucose through the urine.
This is also what happens a lot with men who wake up to pee many times in the night…but have healthy prostates on medical exam. Many times it’s an issue with excess glucose being excreted through the urine.
With every elevation of BG there is a corresponding crash in BG. If the patient falls asleep and the BG becomes too low the brain goes into an alarm state (brain is most dependent on BG) and tells the liver to make more BG. The liver can make BG either by converting glycogen (the stored form of glucose) or a process called gluconeogenesis (where the body converts protein to glucose). This process is very active and wakes the patient up. The patient will not be able to fall back asleep until the liver makes enough BG to get the brain to come out of the alarm state. This can take a few minutes or it can take the rest of the night depending on how severe the BG fluctuation and the efficiency of the liver to make BG. This is the reason why people will drink juice if they wake in the middle of the night to fall back asleep. The juice provides a quick source of glucose which satisfies the brain (although this shouldn’t be needed if you’re healthy).
One effect of low BG (hypoglycemia) is muscle twitching. In the context of sleep this results in restless leg syndrome. Many cases of restless leg (especially if isolated during the night) are due to BG dysregulation.
If the patient says they can fall asleep easily but can’t stay asleep without waking up a lot, we suspect issues with blood glucose regulation. Often this person is eating too much sugar and starchy carbohydrates. The person will have to cut back on the carbs if they want to get better.
Sleep and the 4 tissue patterns
Sleep disorders at this stage of the algorithm are usually due to an epithelial pattern. In the epithelial pattern there is too much sympathetic tone and not enough parasympathetic tone. The patient is constantly wired and not able to calm down. This prevents them from relaxing and thus sleeping.
It can be argued that sleep issues are due to autonomic dystonia associated with the nerve pattern. In autonomic dystonia the body responds unpredictably to stimuli, so when the person tries to lie down it has the effect of energizing them instead of relaxing them.
However, because we are at step 4 in the algorithm, it is assumed that the patient has a healthy digestive/eliminative tract. The gut is a large part of the nerve pattern and it is assumed that there are no problems with the gut, otherwise you need to go back to step 3 or even earlier. Because the gut is fine, the probability shifts towards this being an epithelial pattern. Of course it’s possible that it’s still a nerve pattern and this has to be discerned by the clinician, but the beauty of this 8 step algorithm is that as you move further in the process the possible patterns become easier to identify by process of elimination. With each step certain assumptions about the patient can be made because the previous steps indicate a certain degree of function.
60% of all chronic illness begins to heal after step 4
My acupuncture teacher used to say “as long as the patient can eat, sleep, and poop, they will be ok.” He was right. After completing this step of the algorithm most cases of chronic illness begin to heal. They are not cured right away, but they now hit a degree of momentum where each week feels a bit better than the week before.
At this stage they are able to absorb nutrients, detoxify waste, and repair tissue damage during sleep. What more do you need to recover?
Step 5: Correct Energy/Cardiovascular
If you arrive at this step I am going to assume the following:
- You have no difficulty falling or staying asleep
- Healthy upper digestion
- Healthy bowel movements (no constipation or diarrhea)
- No signs of gastric ulcer
If not, then go back to the appropriate step and stay there till it is corrected. Do not attempt to improve energy/cardiovascular in a patient who has difficulty sleeping. Correcting sleep problems will often simultaneously correct energy and cardiovascular issues.
All illness begins and ends with fatigue
This concept is further discussed in our patient handout “The Primary Function of a Living Organism is to Produce Energy”.
The inability to produce energy is an underlying factor in all forms of illness regardless of whether it is early or end stage. Energy represents the amount of biological currency that your body has to heal tissue and overcome disease factors such as infections or toxicity.
Your energy levels are indicative of your mitochondria function (ATP production), hormonal balance, adrenal reserves, and cardiovascular function. In Chinese Medicine it is indicative of your level of Qi and essence.
Relevant clinical signs
The most important clinical sign is that you have good elimination, digestion, and sleep, yet you still have fatigue or cardiovascular (CV) issues. Many CV issues are secondary due to poor sleep or gastro-intestinal function. If you are at this step in the algorithm it is assumed that those issues are either not present or have been corrected…yet you still have CV issues and low energy.
Resting pulse rate higher than 70bpm: I view this as the most important clinical sign of poor CV function. Ideally the pulse rate should be between 50-70 beats per minute. A resting pulse higher than 70bpm can indicate: high sympathetic tone, weak ventricular contraction, and poor circulation, among other things. It also means the patient has a poor level of fitness and adaptive ability to stress.
The best way to monitor resting pulse is to buy a pulse oximeter (Amazon sells them for $20) and measure your pulse first thing in the morning. This is the most accurate reading.
Blood oxygenation less than 95%: this can be measured in a few seconds by using a pulse oximeter. Again you can get one of these at Amazon for a low cost. Note: if blood oxygenation is less than 90% I insist the patient see their primary care physician for assessment. It doesn’t mean I won’t treat them as a patient, but I insist they also see their primary care physician to rule out any emergency condition.
Shortness of breath is another sign of poor CV, especially if it’s worse after exertion (flight of stairs).
Blood glucose (BG) and CV
What’s your diet like? Are you eating too much processed carbs? Are you eating enough protein and healthy fats? Are you eating trans fats which directly harm the heart? This needs to be addressed before taking supplements as it will prevent the treatment from working.
Many CV disorders are actually due to BG dysregulation and the two are often confused for each other. Many CV disorders started out as BG dysregulation then progressed to something more severe.
The heart runs almost exclusively on fat as a fuel source and is not able to utilize carbohydrates as a form of energy. It is theorized that this is the reason why the heart does not develop cancer (the heart is the only organ that is not prone to cancer) since cancer cells have a dominant anaerobic/glucose based metabolism while healthy cells have a dominant aerobic/oxygen based metabolism.
People today eat too much sugar and carbohydrates. Patients need to realize that the heart runs almost exclusively on fat as a fuel source and is weakened by too much sugar in the blood. Excess BG is toxic to the heart and mitochondria. What often starts out as a poor diet with BG dysregulation ends up damaging heart and mitochondrial function.
Key symptoms of BG dysregulation:
- Energy fluctuations especially energy crashes around 3pm.
- Sweet cravings
- A thick tongue coating suggests systemic fungal overgrowth and thus high BG since fungus feeds on sugar
- Inability skip meals
- Mood swings and severe fatigue if meals are skipped. The word for this is “hangry” (hungry + angry).
- Inability to stay asleep during the night (but this should already be corrected if you are at this step in the algorithm)
All patients who present at this step of the algorithm need to reduce their consumption of sugar and starchy carbs (especially “white” carbs). This must be done in conjunction with Chinese medicine.
Energy/Cardiovascular and the 4 tissue patterns
At this stage of the algorithm, the problem is due to either a nerve or muscle tissue pattern.
The heart is a primary element of the nerve pattern, yet it’s also a muscle. The heart is the “king” of all muscles so it is also part of the muscle tissue pattern. To differentiate which pattern is responsible the clinician needs to look at the rest of the patient’s body to figure out which pattern is most relevant, nerve or muscle.
Are there neurological issues present (nerve)? Are there symptoms of lactic acidosis such as fibromyalgia (muscle)? Does the patient have a tendency to constantly get sick and suffer from chronic infections (muscle)?
In the clinic, we usually end up seeing this step as a nerve tissue pattern in our patients. The reason why is because they often needed to start in one of the earlier steps (digestion, elimination, sleep) using a treatment for the nerve tissue pattern. As the earlier step resolved (digestion and sleep getting better) the patient then begins to see their energy levels improve so we stay with the same nerve tissue pattern as long as the patient is moving through the 8 steps.
The beauty of seeing chronic illness from the lens of 4 tissue patterns is that each pattern represents fundamental, systemic behavior traits of the entire body. If you correctly identify the primary pattern it resolves many symptoms in a step-by-step manner.
Step 6: Correct male/female hormonal issues
If you arrive at this step I am going to assume the following:
- You have good energy and no problems with fatigue
- You have no cardiovascular problems such as pulse irregularities, lightheadedness, or poor circulation.
- You have a resting pulse below 70bpm
- You have no problems with sleep, digestion, bowel movements, or any symptoms of gastric ulcer.
If not, then go back to the appropriate prior step and stay there until it is corrected. Do not attempt to improve male/female hormonal issues if you have cardiovascular issues. Correcting cardiovascular problems will often simultaneously correct male/female hormonal issues.
Sexual Energy = Disposable Income
In financial terms, disposable income is the money you have left over after all of your bills are paid. If after you pay for basic needs such as food and housing you have money left over, that money can be spent on wants such as vacations, movie tickets, and eating at restaurants. The money that is spent on wants is known as “disposable income”.
If a person has plenty of disposable income you can assume they have enough money to pay for their basic necessities. If they have zero disposable income you can assume that they only have just enough to pay for basic needs…or they do not have enough money for basic needs and are moving into debt.
Physical vitality, or “Qi” as the Chinese say, works the same way.
If your body has enough Qi to satisfy basic functions such as cardiac, respiratory, and immune, then the Qi that is left over is like disposable income. This “disposable Qi” can be used for non-essentials such as athletic pursuits, mental acuity, a full head of hair, youthful skin, and sex. None of these assets are necessary for survival, but just like fancy cars and gold watches, they are nice to have and represent a surplus of health.
In this context I equate sexual energy with the ability to reproduce and have offspring. When a patient has good reproductive function it is a sign that there is a surplus of vitality in the body, thus basic body functions are being cared for. Even if the patient is beyond childbearing years the healthy desire and ability to have sex is a sign of vitality surplus.
As the body begins to deteriorate through chronic illness it is like a person who is not making enough money to pay their bills. Just as this person will stop taking vacations and eating at restaurants, the body will divert energy away from non-essential functions in order to secure the health of the vital organs such as heart and brain.
Of all the non-essential body functions, one of the first ones to become depleted in chronic illness is sexual/reproductive function. This is because sexuality is not needed for immediate survival, yet it requires a large amount of energy to maintain. To the body, sexual function is like that large boat that your uncle bought. Nice to have, yet unnecessary and expensive to maintain. A decline in sexual/reproductive function is a sign that the body does not have surplus vitality. The body does not have disposable income.
The lower energy centers are the prostate and testes in a man, and the uterus and ovaries in a woman. These lower energy centers are the manifestation of the ability to reproduce and thus reflect sexuality. Clinical signs regarding these organs relate to male/female hormonal issues and can be used as a marker for progress.
As the health of the lower energy centers improves you can assume that the vitality of the entire body, especially the overall endocrine system, is improving since it represents surplus vitality.
Male hormonal signs
- Pain in the perineum
- Frequent and/or difficult urination
- Loss of libido
- Erectile dysfunction
In my experience, loss of libido is usually due to the prostate and testes interfering with hormonal function while erectile dysfunction is due to the heart not being able to regulate blood flow. If you are at this stage of the algorithm it is assumed that there are no cardiovascular signs and thus there should be no issues with erectile dysfunction.
Erectile dysfunction responds beautifully to our cardiovascular/nerve tissue protocols and its relationship to the heart is agreed upon by many doctors.
When you have a patient who does not have erectile dysfunction but lacks the desire for sex, it is more likely due to a hormonal deficiency. Loss of libido (assuming no issues with elimination, digestion, sleep, and cardiovascular) at this stage of the algorithm is usually due to the prostate and testes.
When working with a male patient who has issues relating to the prostate, testosterone levels, or sexual function, the hardest part for me is having to explain to him that we cannot fix his hormonal issues unless we first resolve more foundational problems related to the digestive tract, sleep patterns, and cardiovascular health. Guys tend to be very stubborn and impatient (I’m saying this as a male). When they have an issue related to the prostate or testosterone they want it fixed immediately and don’t care if they have stomach, sleep, or heart issues. But good Chinese medicine does not work that way, not if you want to fix the problem at the source. I’m hoping that this (long) paper will help explain to people why we work the way we do. If you’re looking for a quick (and often temporary) fix for male hormonal issues then I’m not the right clinician for you.
Female hormonal signs
- Menstrual irregularities
- Ovulatory pain and irregularities
- Infertility
- Hot flashes
- Loss of libido
- Vaginal dryness
Any of the above signs indicates an issue with sexual/reproductive energy and thus a deficit of overall vitality. It represents a lack of “disposable income” for the body.
Menstrual irregularities are very common in my office with a wide range of symptoms. The menstrual cycle should be 28-30 days long and the actual period should be between 3-5 days. PMS is not normal and there should be no issues with cramping, excess bleeding, clotting, or mood swings. Any of these issues is a sign of female hormonal issues and should be corrected.
When treating infertility patients I explain to them this concept of “disposable income” and that having a baby is an extreme form of disposable income for the body. If the woman’s basic body systems are not functioning well then it’s going to be hard to convince the body to carry a child for 9 months. Pregnancy is exhausting for the woman’s body and used to be a major cause of death in women. The body will not allow a pregnancy to happen unless it feels it has the necessary health resources to do it safely. The key to success with infertility patients is to maximize their overall health (including menstrual regularity) and create a surplus of vitality. This surplus will then be used to conceive and deliver a healthy baby.
Even if the woman is past childbearing age she should still have good sexual energy relative for her age. This means no hot flashes or menopausal symptoms in addition to good sexual function.
Why hormones are at step 6
For the hormonal system to be healthy, so many other aspects of the body need to be in place for it to happen. Healthy hormones are like the flower on a tree. For the flower to be there the rest of the tree (especially the roots) has to be healthy first.
Bowel movements: If the blood is toxic due to autotoxemia it will poison the endocrine glands and compromise hormonal production. The prostate and uterus are also adjacent to the lower colon. Toxicity that is diffused from the lower colon will immediately affect the reproductive system due to proximity.
Digestion: Hormones are primarily synthesized from fatty acids and cholesterol. If you cannot absorb these nutrients, how are you going to make hormones?
Sleep: Not getting proper sleep tends to raise cortisol levels and create issues with blood glucose dysregulation (including insulin). Dysregulation of insulin and glucose is a precursor to diabetes and has a direct negative effect on your ability to produce and regulate hormones. You can’t have healthy hormones if you’re not sleeping properly.
Energy/cardiovascular: Hormones require an enormous amount of energy for the body to produce. If you barely have enough energy for your heart and other vital organs, how do you expect your body to have the energy to produce hormones?
And that’s why hormones are at step 6 of the algorithm.
Male/female hormonal issues and the 4 tissue patterns
If you are diligent in following this 8 step algorithm and not skipping prior steps (which is the biggest mistake), male/female hormonal issues are usually due to the epithelial pattern.
Sure it could be due to autonomic dystonia found in a nerve tissue pattern, but we are assuming that there are no issues with digestion, elimination, sleep, and cardiovascular…all of which are signs of healthy nerve tissue. At this step it’s possible that it’s a nerve tissue pattern, but not probable.
It’s also possible that it’s a muscle tissue pattern with lactic acidosis. But we are assuming there are no issues with energy and cardiovascular which is almost always seen in a muscle tissue pattern. If you’re looking at hormonal issues but there are problems with energy/cardiovascular then that means you skipped a step (shame on you). So again it’s possible but not probable.
At this point the problem is most likely due to an epithelial tissue pattern. Remember the epithelial pattern includes the skin, adrenals, endocrine system, and sympathetic nerves. Your glands are mostly made out of epithelial tissue. The primary dysfunction of epithelial tissue is too much sympathetic tone which then suppresses parasympathetic tone.
Parasympathetic tone (the ability to relax) is necessary for sexual functions to occur (as anyone who’s been extremely stressed out can relate to). It is also necessary for hormonal production and regulation. An excess amount of sympathetic tone will flood cortisol and epinephrine into the blood stream which also suppresses reproductive hormones.
Step 7: Correct Autoimmune and Inflammatory Issues
If you arrive at this step I am going to assume the following:
- If the patient is male he has no prostate issues or trouble urinating. He has a healthy libido and good sexual function relative to his age.
- If the patient is female she has a normal menstrual cycle and period. She has no symptoms of PMS or dysmenorrhea. If she no longer menstruates she has no hot flashes or other symptoms of menopausal discomfort. She has a healthy libido and good sexual function relative to her age.
- No issues with digestion, bowel movements, sleep, or energy levels.
If not, then go back to the relevant previous step and stay there until it is corrected. Do not attempt to improve autoimmune and inflammatory issues in a patient who has hormonal issues. Hormonal issues must be addressed before autoimmune issues to create predictable healing results.
Autoimmune disorders
An autoimmune state is when the body begins attacking its own tissue instead of foreign pathogens such as bacteria and viruses. The autoimmune state is a form of internal confusion where the body becomes reckless and self-destructive.
The type of tissue that the body ends up attacking will determine the diagnosis. If the body attacks nerve cells it is called Multiple Sclerosis. If it attacks the joints it is called Rheumatoid Arthritis. If it attacks the pancreas it is called Diabetes. If it attacks the skin it is called Psoriasis. If it attacks the thyroid it is called Hashimoto’s Thyroiditis, etc.
In my practice I am less concerned with the tissue that is being attacked and more concerned with the fact that the body has begun to actively self-destruct and return itself to the Earth. Whether it does this by attacking the skin vs. the thyroid is not as important to me. What’s important is to figure out why the body is attacking itself.
My observation is that the autoimmune state is usually induced by chronic inflammation that stems from a dysfunctional extracellular matrix (ECM). We discussed this in the 4 tissue patterns under connective tissue. What originally started as a normal healing response to tissue trauma became prolonged and chronic in nature. This prolonged trauma can be self-induced by the patient due to poor diet, alcohol, smoking, lack of exercise, etc. or it can be due to a dysfunction in the ECM’s ability to regulate the healing response.
Again, it doesn’t matter from my standpoint what the specific autoimmune diagnosis or even the body area that is being attacked. What matters is the dysfunction of the ECM in regulating the inflammatory response. This is the root of the autoimmune state.
Autoimmune and the 4 tissue patterns
At this stage in the algorithm if there is still evidence of autoimmunity, it is usually due to a connective tissue pattern and treated as such. At this step the focus of treatment is to restore function to the ECM and thus regulate the healing and inflammatory response.
Could the autoimmune state be due to autonomic dystonia and a nerve tissue pattern? Sure, but remember we are at step 7 of the algorithm. This means that the patient has healthy digestion, bowel movements, sleep, and energy levels. All of these suggest normal nerve tissue function so at this stage it’s not likely to be a nerve tissue pattern.
Could it be an epithelial pattern with high sympathetic tone? Again it could be. But this is a person with healthy sleep and hormonal function (if not then you skipped a step and made a mistake). Because healthy epithelial tissue is needed for sleep and hormonal function, it’s not likely to be an epithelial pattern.
Could it be a muscle tissue pattern with lactic acidosis? Could be, but this is a person with good energy levels (step 5) and no shortness of breath. It’s possible that the pain associated with the autoimmune state is due to lactic acidosis, but the lactic acidosis state is usually resolved after step 5 of the algorithm.
So that leaves us with the connective tissue pattern and its relationship to inflammation. Remember the 8 step algorithm is purposefully designed to address physiology from foundational levels to more specified levels. As you move through the 8 steps the tissue patterns become clearer through process of elimination.
Step 8: Correct any remaining issues
If you arrive at this final step in the algorithm and you still have health issues I need to ask you a question:
Are you sure?
Are you sure:
- No signs of gastric ulcer?
- No constipation, diarrhea, or digestive issues?
- No problems falling asleep, staying asleep, waking up rested?
- No cardiovascular or circulatory issues and you have good energy?
- No male/female hormonal problems?
- No autoimmune or inflammatory issues?
If you are sure that none of the above issues are present then you are looking at a very healthy person, correct? If you are still struggling with health issues, after all the foundational body functions are working well, then it is probably one of two possibilities:
- The health issue is localized and just needs a small amount of targeted treatment.
- The health issue is beyond the scope of natural medicine (at least what this system of healing can offer) and needs Western allopathic care.
Assuming it’s a localized issue that’s capable of responding to Chinese medicine, we then assess the problem from the lens of the 4 tissue patterns to determine the behavior of the problem.
Is it a nerve tissue pattern with autonomic dystonia?
Is it an epithelial pattern with high sympathetic tone?
Is it a connective tissue pattern with chronic inflammatory and autoimmune issues?
Is it a muscle tissue pattern with lactic acidosis?
Almost everything you see is going to fall into one or more of those 4 tissue patterns. I’m not saying that this method works 100% of the time, nothing does. But if the problem is capable of responding to natural care then this model is the most comprehensive I have seen.
Summary of the 8 steps
Medicine is complicated.
The body is complicated.
Chronic illness is complicated.
People are complicated!
Complexity can bring confusion. Confusion then brings disorganization. Disorganization then leads to haphazard and unpredictable results. When you are working with really sick patients, this type of disorganization is unacceptable.
The 4 patterns and 8 steps is my attempt to bring clarity and organization to the riddle of internal medicine. The 4 patterns organize the body according to anatomy, while the 8 steps organize the body according to physiology. The concept allows you to categorize chronic illness in terms of broad tissue patterns that affect the entire body. The 8 steps then give you a starting point for beginning the healing process in a manner that is that focused and efficient.
The 8 steps are organized so that you begin with what is most important, then move towards functions that rely on the previous steps to build upon. What happens is that fixing step 1 will often fix step 2 and even 3 or 4 without even focusing on the later steps. This is because the 8 steps are designed to restore self-regulation and homeostasis to the body. They are not designed to chase symptoms or placate disease labels.
What about my disease label?
While moving through the 8 steps will restore health and vitality (it will give you your life back), people ask questions like:
What about lyme? Will it change my blood work so that I no longer have lyme?
What about heavy metal toxicity? Will it remove the heavy metals from my blood report?
What about parasites?
What about:
- Candida?
- Leaky gut?
- SIBO?
- MTHFR?
- Vitamin D deficiency?
- B12 deficiency?
- Whatever other diagnosis is currently in vogue?
I usually respond to such questions by asking:
“What if your body was restored to total health and functionality, you felt like a young kid again, but the lab report still said you were sick because you had XYZ diagnosis? Would you place more value on how you felt, or what a piece of paper said?”
If what the piece of paper says is more important to you than your ability to function…then our clinic is not the right place for you.
Remember that Chinese medicine is physiology based, not disease based. You can feel great yet have a horrible lab report. Conversely, all doctors who’ve been in practice for a long time have seen patients with perfect blood work, yet the patient is dying right in front of them.
I’m not saying that there isn’t any value to a disease based approach. When used correctly such an approach can be lifesaving in emergency conditions. But our clinic does not treat according to disease labels. Our approach is based on restoring physiological function regardless of the disease label. Whether the disease label is still there or not after health is restored is not something we place attention on.
The diagnosis is a theory as to why your health is failing. In my humble opinion, it is actually not just a theory…it is an opinion. It is an opinion that changes every few years according to the medical community while people remain sick and non-functioning. Even with things like lyme or vitamin D deficiency the criteria for what constitutes the diagnosis constantly changes and is not in agreement between experts.
What does not change is how your body functions. What does not change is human physiology and how a healthy body behaves. It is this restoration of healthy physiology that the 8 steps is designed to bring.