Guest guest Posted March 19, 2003 Report Share Posted March 19, 2003 Jim and Phil - Phil: "Until now, the little of of what I have seen on pulse characteristics suggested to me that TCM Pulse-Taking was mainly a subjective sensation with poor inter- rater repeatability. Some pulse-takers even seemed to disagree on the pulse locations that they assign to the 12 main zang-fu!" Thanks to Jim for finding it and to Phil for tracking more material down. I enjoyed seeing the research project The Reliable Measurement of Radial Pulse Characteristics. This is a significant development in our field. My experience with Dr Hammer was around 80 percentile inter-rater reliability. However, the people in the room had a high level of calibration with respect to technique, this included depth and a fair amount of minutia regarding special positions. It also included remarkably subtle distinctions compared to the average slippery-wiry dross we often find in schools (where the inter-rater reliability is often remarkably low). I now often wish we had conducted studies in the midst of the advanced trainings because the level of reliability was 80% based on casual observation. I wonder if anyone might be interested in generating some multi-center trials? Will Morris Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 19, 2003 Report Share Posted March 19, 2003 Hi All, & Hi Jim, James Ramholz wrote to Will Morris: > http://www.medical-acupuncture.co.uk/journal/2002(4)/150.shtml > Have you read this or have an opinion? Jim Ramholz Here is the summary: The Reliable Measurement of Radial Pulse Characteristics Emma King, Deirdre Cobbin, Sean Walsh, Damien Ryan Acupuncture in Medicine DECEMBER 2002 VOL 20(4) Page 150 The use of the radial pulse as a diagnostic tool is an integral part of the Traditional (TCM) patient evaluation. In spite of its long history of use, there is little systematic information available to support the many claims about the relationship between pulse qualities and physiological condition contained in the ancient Chinese texts and echoed in modern pulse terminology. This study reports the development of a reliable means of measuring and recording pulse characteristics. This was achieved by reporting on the physical sensations that are detected under the fingertips when the radial pulse is palpated, rather than attempting to translate these into the complex and typically ambiguously defined TCM pulse qualities. The study involved development of a standardised pulse taking procedure and development of concrete operational definitions for each of the characteristics of the pulse being measured. The inter-rater reliability of the pulse taking procedure and operational definitions was assessed by determining agreement levels between two independent pulse assessors for each characteristic. Inter-rater agreement averaged 80% between the two assessors in both the initial data collection (66 subjects) and in a replication collection (30 subjects) completed two months later. Demonstrating reliability of the procedure represents an essential first step for examining the validity of TCM pulse diagnosis assumptions. Key Words: Inter-rater reliability, TCM, pulse diagnosis, radial pulse, palpation, diagnostic techniques. Authors: Emma J King, Clinical Tutor; Deirdre M Cobbin, Senior Lecturer; Sean Walsh, Lecturer, College of Traditional , Department of Health Sciences, Faculty of Science, University of Technology, Sydney, Australia. Damien Ryan, Senior Lecturer, Department of Complementary Therapies Victoria University, Melbourne, Australia Correspondence: Deirdre Cobbin <d.cobbin Jim, many thanks for the alert. IMO, this is an important paper, in that it claimed c 80% inter-rater repeatability in describing the pulse characteristics. Until now, the little of of what I have seen on pulse characteristics suggested to me that TCM Pulse-Taking was mainly a subjective sensation with poor inter- rater repeatability. Some pulse-takers even seemed to disagree on the pulse locations that they assign to the 12 main zang-fu! Would the ListMaster care to invite the authors to join the List to discuss the paper in depth? Deirdre Cobbin <d.cobbin surely will have the authors' email addresses. Best regards, WORK : Teagasc Staff Development Unit, Sandymount Ave., Dublin 4, Ireland WWW : Email: < Tel : 353-; [in the Republic: 0] HOME : 1 Esker Lawns, Lucan, Dublin, Ireland WWW : http://homepage.eircom.net/~progers/searchap.htm Email: < Tel : 353-; [in the Republic: 0] Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 19, 2003 Report Share Posted March 19, 2003 Hi All, & Hi Will, Will wrote: > I enjoyed seeing the research project The Reliable Measurement of > Radial Pulse Characteristics. This is a significant development in > our field. My experience with Dr Hammer was around 80 percentile > inter-rater reliability. However, the people in the room had a > high level of calibration with respect to technique, this included > depth and a fair amount of minutia regarding special positions. It > also included remarkably subtle distinctions compared to the > average slippery-wiry dross we often find in schools (where the > inter-rater reliability is often remarkably low). I now often wish > we had conducted studies in the midst of the advanced trainings > because the level of reliability was 80% based on casual > observation. I wonder if anyone might be interested in generating > some multi-center trials? Will Morris Query (wearing my SciFi hat): Does anyone know if any group in China or elsewhere is attempting to construct a computer- controlled model of the physical pulses? What I have in mind is a pump-driven system to generate pre- programmable types of pulse in an elastic-walled tube of similar diameter to the radial artery. The pulse could (?) be controlled via a PC to have variable amplitude, rate and systolic and diastolic pressure, and modulated to produce the main forms of superficial, middle and deep anomalies described by expert TCM pulse-takers. If it could be developed at reasonable price, such a model would be a fantastic learning tool for use in schools, and as a research tool to evaluate inter-rater repeatability, both within AND between centres. Best regards, WORK : Teagasc Staff Development Unit, Sandymount Ave., Dublin 4, Ireland WWW : Email: < Tel : 353-; [in the Republic: 0] HOME : 1 Esker Lawns, Lucan, Dublin, Ireland WWW : http://homepage.eircom.net/~progers/searchap.htm Email: < Tel : 353-; [in the Republic: 0] Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 19, 2003 Report Share Posted March 19, 2003 , " " <@e...> wrote: This was achieved by reporting > on the physical sensations that are detected under the fingertips when the > radial pulse is palpated, rather than attempting to translate these into the > complex and typically ambiguously defined TCM pulse qualities. Interestingly, identifying the characteristics of the pulse as opposed to just labeling the pulse is the method Bob Flwas has proposed in his book on pulse diagnosis. He says these qualities are easy to identify (fast, slow, deep, floating) and the main problem is people do not remember what pulses these characteristics define and that is why pulse qualites often vary when one " shoots from the hip " . for example, I see pulses described by students and grads as weak even though when are floating and empty even when they are sinking. I believe the empty pulse (floating and big) is often called soft or slippery and weak, even though a soft or soggy pulse is actually thin and floating. But if I ask students to tell me is it big or small, etc., they can answer those questions much of the time. The very high agreement in this study was no doubt due to prestudy calibration, which is essential in such studies. Will suggests a multicenter study, but I would suggest that without calibration, the results will be disappointing. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 19, 2003 Report Share Posted March 19, 2003 , " " <@e...> wrote: > > What I have in mind is a pump-driven system to generate pre- > programmable types of pulse in an elastic-walled tube of similar > diameter to the radial artery. The pulse could (?) be controlled via a > PC to have variable amplitude, rate and systolic and diastolic > pressure, and modulated to produce the main forms of superficial, > middle and deep anomalies described by expert TCM pulse-takers. I bet with modern computer control abilites, something pretty accurate could be possible. If you can create a machine that creates accurate pulses, than does it follow another machine could accurately detect those waves in a living subject. Are there other examples of phenomena we can mechanically or electronically reproduce but not also measure. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 19, 2003 Report Share Posted March 19, 2003 , " " wrote: > Interestingly, identifying the characteristics of the pulse as opposed to just labeling the pulse is the method Bob Flwas has proposed in his book on pulse diagnosis. He says these qualities are easy to identify (fast, slow, deep, floating) and the main problem is people do not remember what pulses these characteristics define and that is why pulse qualites often vary when one " shoots from the hip " .>>> Li Shi Zhen first proposed that all the pulses are derived from fast, slow, deep, floating---he wrote his book in rhyme and meter to help facilitate remembering it (I suspect because the art of pulse reading had degenerated so far). Bob is correct that this is a good place to start. But the main reason that people cannot read pulses is not that they don't memorize the definitions---I wish it were it that simple. People have different degrees of physical sensitivity, attention span, and ability to concentration. Hence the wide variability in descriptions. Like playing a musical instrument, people don't just play bad because they don't remember how the song goes. Pulse reading involves both halves of the brain. > The very high agreement in this study was no doubt due to prestudy > calibration, which is essential in such studies. Will suggests a > multicenter study, but I would suggest that without calibration, the results will be disappointing. >>> I believe you are correct about precalibration before any multicenter study. Studies should probably be within systems at first. For example, it was several months before I realized that my discussion about the knotting pulse was different. I and the few others who learned the Dong Han system had no problem finding the same features and describing the same diagnosis. But we learned it over many years and in relative isolation; so there were no distractions from other systems. Exposure to many different systems of working can become confusing. Jim Ramholz Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 19, 2003 Report Share Posted March 19, 2003 Jim, and All, A comment... One of the most effective drills I was given many years ago by a doctor in Chengdu was just taking the pulse of patient after patient, dozens every morning, for months and distinguishing between two characteristics: normal/not normal and a question... > People have different degrees of physical sensitivity, > attention span, and ability to concentration. Hence the wide > variability in descriptions. Like playing a musical instrument, > people don't just play bad because they don't remember how the song > goes. Pulse reading involves both halves of the brain. Jim, how do you account for such factors in teaching/training students? Ken Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 19, 2003 Report Share Posted March 19, 2003 My teacher changed the traditional way the examination is done by using only the one (usually left) hand to check pulses. It has several advantages. The difference in sensitivities between hands is eliminated, mental focus is sharpened, and the sensitivity of the one hand is greatly enhanced by constant use. Jim - I have observed many senior practitioners practice this way including Dr Shen. He was 87 and said it conserved his qi. The only problem I see with this is the loss of a phenomena I call 'filters'. The brain tends to merge data depending on the fingers that are used. So when using all fingers at once, a global assessment occurs. Placing all the fingers on one side speaks to the processes one understands to be occurring when a quality is uniform thorough one side. Or - the conjoining of the fingers on either side to evaluate a burner i.e. using both index fingers at the same time to evaluate the upper burner, both middle for the middle and both ring fingers at the same time to evaluate the lower burner. The information extracted in this fashion can be different from when evaluating one side at a time with one hand which has the clear advantages you cite. Will Morris Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 19, 2003 Report Share Posted March 19, 2003 , " dragon90405 " wrote: > Jim, how do you account for such factors in teaching/training students? >>> Ken: It's done in several different ways. We go back and forth between theory and what they sense physically, so that the the theory fits dovetail with the physical examination. And I always point out specific features in the pulse that I want them to observe so they can learn to focus, find, and observe them. Like learning a musical instrument, it's constant repetition and practice. My teacher changed the traditional way the examination is done by using only the one (usually left) hand to check pulses. It has several advantages. The difference in sensitivities between hands is eliminated, mental focus is sharpened, and the sensitivity of the one hand is greatly enhanced by constant use. And, while needling with the other hand, you can observe the specific changes in the pulse you are trying to create; so treatment and pulse reading are dovetailed, too. Jim Ramholz Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 20, 2003 Report Share Posted March 20, 2003 , WMorris116@A... wrote: Placing all the fingers on one side speaks to the processes one understands to be occurring when a quality is uniform thorough one side. Or - the conjoining of the fingers on either side to evaluate a burner i.e. using both index fingers at the same time to evaluate the upper burner, both middle for the middle and both ring fingers at the same time to evaluate the lower burner. The information extracted in this fashion can be different from when evaluating one side at a time with one hand which has the clear advantages you cite.>>> Will: Keep in mind that we do not separate or roll fingers in your manner-- -all three may be slightly shifted or slide around the wrist but are kept together as a single unit. So, there is always a uniform approach to each wrist. I have never known this to be a problem--- was it with Dr. Shen? In fact, I think it helps develop the skill to improve examining the 3-D features of the pulse---like walking around a sculpture to see it from different angles while keeping your attention fixed on it. It would be fun to compare notes from each system on the same patient sometime. Jim Ramholz Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 20, 2003 Report Share Posted March 20, 2003 We can mechanically reproduce sounds and voices, which we have incredibly subtle ways of distinguishing, yet we can barely get a computer to understand one person speaking in a monotone. It might be interesting to start looking at patterns of timber and pitch in voices in terms of five element diagnosis, seeing as imaging those and isolating various components is now fairly easy. Par - Wednesday, March 19, 2003 9:06 AM Re: Pulse inter-rater agreement , ""<@e...> wrote:> > What I have in mind is a pump-driven system to generate pre-> programmable types of pulse in an elastic-walled tube of similar > diameter to the radial artery. The pulse could (?) be controlled via a > PC to have variable amplitude, rate and systolic and diastolic > pressure, and modulated to produce the main forms of superficial, > middle and deep anomalies described by expert TCM pulse-takers.I bet with modern computer control abilites, something pretty accuratecould be possible. If you can create a machine that creates accuratepulses, than does it follow another machine could accurately detectthose waves in a living subject. Are there other examples ofphenomena we can mechanically or electronically reproduce but not alsomeasure.ToddChinese Herbal Medicine, a voluntary organization of licensed healthcare practitioners, matriculated students and postgraduate academics specializing in Chinese Herbal Medicine, provides a variety of professional services, including board approved online continuing education. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 20, 2003 Report Share Posted March 20, 2003 , WMorris116@A... wrote: > My teacher changed the traditional way the examination is done by > using only the one (usually left) hand to check pulses. > I have observed many senior practitioners practice this way including Dr Shen. He was 87 and said it conserved his qi. >>> Will: My teacher changed from the traditional way that his teacher did it, using both hands. He wanted to watch specific pulses change as he did an acupunctue technique. It's interesting to me to see how all these systems start conceptually---say using the Nan Jing or Mai Jing material as their framework---and then see how they diverge in their development as different aspects and methods are emphasized. Otherwise, I prefer to work ahistorically and abstractly to include pulse material into our system that does not immediately conflict with it. I think that is how my teacher often worked, too. Jim Ramholz Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 20, 2003 Report Share Posted March 20, 2003 , " Par Scott " <parufus@e...> wrote: > We can mechanically reproduce sounds and voices, which we have incredibly subtle ways of distinguishing, yet we can barely get a computer to understand one person speaking in a monotone. It might be interesting to start looking at patterns of timber and pitch in voices in terms of five element diagnosis, seeing as imaging those and isolating various components is now fairly easy. > > Par good point. so just because we can reproduce something does NOT mean we can measure it accurately. I am sure others are relieved to hear this. :-) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 20, 2003 Report Share Posted March 20, 2003 > , " Par Scott " wrote: It might be interesting to start looking at patterns of timber and pitch in voices in terms of five element diagnosis, seeing as imaging those and isolating various components is now fairly easy.>>> Par: Worsely-style 5 Elements emphasizes just this diagnosis---and smell, too. But they don't do classical 5 Element pulse diagnosis---go figure. Jim Ramholz Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 21, 2003 Report Share Posted March 21, 2003 Sorry I'm late to this discussion but I've been preoccupied with other interests. Last weekend I taught a class on pulse diagnosis in NYC and we achieved a very high rate or inter-rater reliability. This was one of our goals and the class was attended by a research design specialist. So we emphasized this outcome. Students were actually surprised that they could feel the various different pulse images after only a few hours of class when they had been confused for many months or, in some cases, years. In my experience, the issue is not just memorizing the definitions but understanding in clear-cut, unambiguous palpatory terminology what those definitions mean. For instance, da, " large " means wide. Wide is an unambiguous palpatory experience, whereas the term large can be interpreted in a number of different way. While I agree that people vary in their senitivity, attention span, etc., as a teacher I do not find it all that difficult to achieve 90% inter-rater reliability with all the common pulse images. There are some people who just don't get it no matter what you do. But, in our experience, meaning my wife's and my experience (we always co-teach this class), thankfully, that number is quite small. There are also a small number of pulses where there are simply a number of different, mutually exclusive opinions about what the traditional definitions means as palpatory experiences. Thankfully also, there are only a few of these where one is forced to choose between competing traditional explanations of the Chinese definitions. Bob Quote Link to comment Share on other sites More sharing options...
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