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assessment

Chapter contents

5.1 Positioning the patient 46 5.2 Locating the radial artery 47

5.3 Locating the pulse positions for assessment 49 5.4 Practitioner positioning 51

5.5 Assessing the parameters 51 5.6 Locating the pulse depth 53 5.7 The normal pulse 56

5.8 Assessing health by the pulse 57 5.9 Channel, organ and levels of depth 58

5.10 Comparison of the overall force of the left and right radial pulse 58 5.11 Pulse method 59

5.12 Other considerations when assessing the pulse and interpreting the findings 61

5.13 Summary 68

Although an objective terminology is essential for radial pulse diagnosis, it is equally imperative to have reliable procedures and a consistent method when palpating the pulse. Pulse procedures refers to the processes preceding pulse assessment as well as the actual techniques used during this process. These procedures encompass:

• Positioning of the patient and practitioner • Procedure for locating the three pulse positions

• Techniques for locating and assessing the different levels of depth • Assessment of the arterial structure and pulse wave contour.

The ordering of these techniques and procedures is described as the pulse method. As we established in Chapter 4, pulse method refers to:

• How and when to apply the pulse taking

(depth, length, strength of application) and required body part (pulse position) • The consistent application of the pulse method and techniques used in the same way every time.

Identification of many of the specific CM pulse qualities depends on the measurement of pulse parameters in specific positions, so a consistent method is of vital importance. The objective for developing and using a consistent method of pulse palpation is to limit the variance of pulse findings attributable to technique. Once such variances are controlled, then any findings with palpation can be confidently attributed to the occurrence of actual pulse differences.

This chapter focuses extensively on the first stage of the pulse diagnosis process — the application of correct technique and procedures. A further stage of the pulse diagnosis process, interpreting pulse assessment findings diagnostically, is dealt with extensively in Chapter 6 and Chapter 7. We also investigate the organization of the techniques and procedures and their order of application, and discuss the benefits of developing a pulse method that is systematic in its application.

5.1. Positioning the patient

Before the pulse is assessed, the patient needs to be positioned appropriately. Appropriate patient positioning allows the practitioner maximal access to the radial artery for assessment purposes while preventing any postural changes that may affect blood flow. For example, if the patient slouches, their respiration will be poor and this will cause a corresponding decrease in pulse strength. Postural slouching and arterial compression from poor arrangement of the upper limbs impede blood flow from the central arteries into the peripheral arteries, limiting the propulsion effect that the pressure wave has on moving blood. In this situation any assessment of the pulse will be inaccurate and unreliable.

The pulse is most commonly taken when the patient is seated, but assessment can also occur when the patient is lying supine (Box 5.1). Irrespective of the positioning approach used, the arm is always placed at the level of the patient's heart. Holding the arm lower or higher than the heart level affects the pulse pressure, causing changes in the pulse wave. Ensuring that the arm is level will minimise these postural related pressure differences. Pulse examination is undertaken on both the left and right arms (Fig. 5.4).

Box 5.1

Positioning the patient for assessing the pulse • Arm level with the heart

• Patient's legs uncrossed

• Patient should be sitting upright or lying supine

• Support the wrist when extended with a towel or cushion

Figure 5.4Bilateral hand palpation. The practitioner's left hand is palpating the right pulse and the right hand is palpating the left hand the pulse.

Their posture should be relaxed but upright so that the thorax region is not constricted during respiration, allowing the lungs to expand and contract freely. The wrist should be extended straight with the palm facing upwards (Fig. 5.1). Similarly, when lying supine, the patient should have their legs uncrossed, wrist extended with the palm facing upwards (Fig. 5.2).

Figure 5.1Positioning of the practitioner taking the pulse when the patient is sitting. The patient's legs uncrossed, feet flat on floor, with palms upwards. The patient should be in a comfortable upright position and their wrists supported.

Figure 5.2Positioning of the practitioner taking the pulse when the patient is supine. Note that the patient's arm is by their side and the wrist is supported for maximal access to the artery.

A folded towel or small cushion can be used to support the wrist if necessary in either the supine or sitting positions. This ensures that the radial artery is easily accessible and that the blood flow is unimpeded. Additionally, such support limits any movement in the wrist that maybe introduced by the practitioner when applying finger pressure to assess the pulse at different levels of depth.

5.1.1. Speaking

Ideally there should be no speaking between the practitioner and patient during the pulse assessment process. When the patient speaks this will change their respiration, position of the diaphragm and oxygen requirements, also changing the pulse contour and pulse rate.

When the practitioner speaks during the pulse assessment, this often is a sign that they are not focused on the assessment process. Occasionally, speaking is required and is usually done in response to further elucidation of any pulse findings. For example, the presence of missed beats requires further questioning to determine whether the patient was aware of this. This should be kept to relevant questions if concurrently assessing the pulse.

5.2. Locating the radial artery

Once the patient and wrist region are appropriately positioned, the next step is to locate the artery, andin particular, the radial pulse sites used for pulse examination. As described in Chapter 2, the radial artery is located on the lateral portion of the anterior forearm. It extends from the elbow, where the brachial artery bifurcates, to the wrist crease, at which point the radial divides further into other arterial segments. (When seen from the perspective of channel physiology, the radial artery follows the course of the Lung channel.) The CM pulse sites used for pulse assessment are located in the wrist portion of the artery only. At this region, the radial artery is usually quite easily palpated because of its close proximity to the skin surface and its position over a hard surface — in this case the radial bone. The radial bone provides a firm support to the radial artery when external pressure is applied. If there were no support then it would be difficult to clearly distinguish the pulse parameters or apply different levels of pressure without the artery moving. The portion of the radial pulse used for assessment is located proximal to the wrist crease directly above the pulsation of the radial artery adjacent to the styloid process of the radius. This is known as the Cun Kou pulse, and from the time of the Nan Jing it was considered to be the convergence point of movement through all the conduit vessels. The Second Difficult Issue in the Nan Jing discusses the length of the Cun Kou position, describing it as 1.9 Cun in length. Proportionally, this is about one sixth of the area between the transverse elbow crease and the wrist crease, assuming the length of the forearm is 12 Cun (or anatomical units) (see Fig. 5.3). In metric measurement this is approximately 3–5 cm. However, exact measurements are not necessarily applied because locating the pulse positions primarily depends on the location of the styloid process and the relative size of the patient.

Figure 5.3Styloid process, the radial artery and location of the three pulse positions Cun, Guan and Chi and other related anatomical structures. The Cun (inch) measurements indicate the portion of the artery used for pulse assessment.

A clear and discernable rhythmic movement should be apparent at this region when palpated. If there is no pulse detectable then this can indicate:

• Incorrect anatomical region • Incorrect finger placement

• Correct location and finger placement but the radial artery is not located at the wrist. This is termed a deviated artery.

5.2.1. Deviated artery: abnormalities of the radial artery

In a small percentage of people the radial artery is anatomically deviated from the anterior to the lateral portion of the arm as it nears the wrist. In these individuals the artery winds laterally around the styloid process and travels on the posterior side of the wrist (in the anatomical position) as if following the path of the Large Intestine

channel through the anatomical snuffbox rather than the path of the Lung channel. This is termed a Fan Guan Mai or simply a ‘pulse on the back of the wrist’ pulse by Wiseman & Ye (1998: p. 473, p. 470).

5.2.2. When to look for a deviated radial artery

If the pulse appears to be absent or extremely faint, look for the presence of a pulsation on the posterior or lateral part of the wrist, in the vicinity of the radial styloid process. If there is a significant pulsation, this indicates a deviated radial artery. In this case, the radial artery runs very superficially and both the artery and pulsations can be easily observed. When the artery is located at this region, the pulse cannot be used for palpation purposes except for assessing rate and rhythm.

A deviated arterial artery is not considered pathological from either a CM or a biomedical perspective. Such deviations represent normal individual variation. However, if the pulsation is not felt in the Cun Kou area or an alternative position, then this may be perceived as pathological. The Cun Kou area should be re- examined, with particular attention to the deep level of depth.

5.2.3. Other abnormalities

Other ‘abnormalities’ that can similarly affect the presentation of the arterial pulsation include:

• Ganglions

• Bone spurs and growths

• Surgical procedures for carpal tunnel syndrome rearranging soft tissue structures • Other surgical procedures for arthritis in which carpal bones can be removed • Scarring, especially keloid tissue

• Inflammatory conditions of the tendons. 5.3. Locating the pulse positions for assessment

Once the Cun Kou region of the artery proximal to the wrist is located, the pulse positions used for pulse assessment must be identified. There are three of these positions, and they are found by dividing the Cun Kou region into three portions using the styloid process of the radius as a guide. The three positions are:

• Cun (inch): Located proximal (or closest) to the wrist crease • Guan (bar): Located medial to the styloid process of the radius • Chi (cubit): Most distal (furthermost) position from wrist crease.

Because the three pulse positions are determined proportionally according to an individual's size, this means that the same procedure needs to be followed every

time to ensure exact location of these positions within the same physique and between different physiques (Box 5.2). Of the three positions Cun, Guan and Chi, it is the central position Guan which is associated with a specific surface anatomical landmark; the styloid process. For this reason, the Guan position should always be located first as the locations of the Cun and Chi positions depend on the initial location of Guan.

Box 5.2

Locating the three positions

• Index finger is placed at the Cun position • Middle finger is placed at the Guan position • Ringer finger is placed at the Chi position • Thumb is placed on the underside of the wrist

5.3.1. Locating Guan

The Guan position is found first as it is easily located adjacent to the styloid process of the radius. The styloid process is a flaring of the radial bone, and can be identified as a bony protuberance on the lateral side of the wrist, proximal to the wrist crease (in the anatomical position). To locate the styloid process it is best to palpate the bone as it is not always easy to identify this landmark by observation alone. By gently running the index finger over the region a distinct ‘bump’ can be felt where the styloid process flares away from the shaft of the radius. The styloid process can also be clearer to palpate with radial/ulnar deviation, causing the soft tissue to stretch and expose the bone. Once it is located, the practitioner moves directly medial towards the soft skin of the anterior wrist above the radial artery. The arterial pulsations are often felt most distinctly in this position, and the outer border of the styloid process may be felt at the margin of the finger when positioned on the artery. This is the Guan position. When the middle finger is placed on the Guan position, the other two fingers should fall naturally into their positions: the index finger on Cun, located adjacent to the scaphoid bone, and the ring finger on Chi, proximal to Guan.

The actual finger placement is proportional to the size of the wrist: on a tall person the wrist is larger, and so the three positions and fingers are spaced further apart. Conversely, on a shorter person the wrist is proportionally smaller and so the three fingers are positioned closer together. However, for all patients the positioning of the fingers on the pulse should always be undertaken in reference to the styloid process and the location of the Guan position. Using either the Cun or the Chi

position for this purpose will lead to incorrect placement of the fingers. (This doesn't work with children.)

With the practitioner's thumb resting lightly on the back of the patient's wrist the fingers should be arranged so that the tips are level with one another. It is the tips of the fingers which should be used for palpation, exerting equal pressure to feel the three pulse positions simultaneously. The fingers can be used:

• Simultaneously to palpate all three pulse positions on one arm

• For comparative purposes, assessing the overall pulse in one side with the other • Individually to assess pulse positions at different levels of depth.

5.3.2. Placement of the thumb

In the process of placing the fingers on the appropriate pulse positions and undertaking assessment, the thumb is of particular importance. The thumb is used to stabilise the wrist against movement that may occur when different pressures are applied by the fingers to the pulse. If the patient's wrist moves during palpation this will render the reliability of the findings questionable. For example, if a particular amount of strength is used to move the fingers into the deep level of depth, but the wrist is unsupported, then the wrist may move so that rather than palpating the deep level the practitioner may assess only the middle level of depth without realising this is the case. For this reason, the thumb is placed on the posterior wrist region to provide support to the wrist and leverage for the fingers when palpating the pulse. 5.3.3. The anatomy of the radius and support of the radial artery

Because of the shape of the radial bone and the depression formed between it and the styloid process, the support provided by the styloid to the radial artery at the wrist varies. For example, at the Guan position the pulse wave and arterial structure are both felt more distinctly than at the Cun or Chi position alone. Because of the support offered by the styloid bone at the Guan position, the artery sits relatively superficial. Less skin, and thinner epidermal/fasciae layers, mean a ‘clearer’ pulse image when palpating and facilitates better detection of arterial parameters such as tension.

At the Chi position the radial bone sinks away from the surface with the artery similarly becoming deeper. In order to detect pulses clearly it is often necessary to provide support under the artery. Having the artery supported means it can be compressed and so the pulse is detectable for diagnostic purposes. If no support is provided then the artery and pulses remain indistinct. For this reason palpation of the Chi positions often results in a pulse that is felt deeper or less strongly when compared to the pulse at the Guan positions. It is only after pressure is applied and the artery is supported by the bone that the pulse is felt distinctly. Sometimes the

direction of finger pressure needs to be adjusted to ensure that the artery is being compressed into a firm surface, such as the tendons located medially to the radial artery. (This may account for the traditional description of the pulse at this position, the Kidney pulse, being located like a ‘pebble at the bottom of a stream’ or described as ‘insects crawling around the bone’.)

The Cun pulse positions are in a depression between two bony structures. These structures are the styloid process and the scaphoid bone. For this reason, the pulse and artery are less supported at the Cun position than at the Guan position, but are felt more distinctly than the Chi positions because of the stabilisation offered to the artery by these bones. However, as at the Chi position, the lack of direct underlying support under the cun positions often means the pulse and artery are not felt as distinctly at the Guan position, but are not as deeply located as the Chi position. 5.4. Practitioner positioning

When taking the pulse the practitioner should sit opposite or next to the patient. Using the tips of the fingers (Box 5.3), the practitioner's left hand is used to feel the pulses of the patient's right hand and the practitioner's right hand is used to feel the pulses on the patient's left (Box 5.4). Similarly, if the practitioner were to palpate their own pulses on the right wrist, the practitioner's left hand wraps under the wrist with the index, middle and ring fingers sequentially falling on the three pulse positions Cun, Guan and Chi. This is reversed if feeling the left hand pulses. This ensures that the same fingers are always used to palate the same pulse positions (Fig. 5.4). For example, the right index finger is always placed on the left Cun position, irrespective of whether the practitioner is palpating someone else's pulse or their own. This will assist in ensuring that a level of sensitivity and a reference range of pulses are built up for that particular finger and this in turn assists with reliable identification and assessment of any changes in the pulse parameters at the related pulse site.

Box 5.3

Fingertips and fingernails

• The fingertips are the most sensitive regions of the finger. Individuals who play the guitar will find that the skin thickens at the tips of the fingers and for this reason, sensitivity to the pulse is often substantially lessened, if not absent. In such instances the finger pads rather than the