Project Pulse: A Dance Research Project

Project Pulse: A Dance Research Project: Overview and Beta Test Results Section (published by permisson of Pine Street Clinic & Michael Broffman)

Section 1: Why traditional Chinese medical practitioners palpate the pulse:
Traditional Chinese medical (TCM) practitioners use palpation to differentiate the 30 individual pulse patterns (some historical and modern pulse palpation systems have described more or less than 30 individual pulse patterns). Between the two radial arteries, one on each wrist, there are 18 wrist positions. This is the combining of 9 positions of depth from the left radial artery and 9 positions of depth from the right radial artery. The clinical compounding of the basic 30 individual pulses into unique combinations generate approximately 200 (depending on the system) clinically relevant combinations of these pulses, referred to as “doublets, triplets, etc.

Traditional pulse palpation technique provides the TCM practitioner:

1) An opportunity to discover an early diagnosis of functional disorders, which, if left untreated, eventually will produce gross and demonstrable degenerative and adverse organic changes.

2) An opportunity to comprehensively catalogue an all-inclusive determination of all factors having a bearing on complex pathological processes which are at the roots of chronic or constitutional diseases in traditional Chinese medicine.

3) An opportunity to specifically and directly apply therapeutic measures and determine the immediate effects of an intervention (herbs, acupuncture, nutrition, massage, movement, meditation, etc..).

It is a common understanding that traditional Chinese pulse diagnosis is the single most important technique in traditional Chinese medical diagnostics.

Section 2: What we at Pine Street feel is the problem:

It has been a long time concern of many TCM practitioners and students worldwide, that as fundamental to traditional Chinese diagnostics that pulse palpation in the clinical setting is, it is nonetheless insufficiently taught, leaving practitioners and students feeling a lack of confidence in their ability to use it successfully in the clinic.

The problem, as we are seeing it, is not so much in the didactics of what the different pulses mean clinically, but rather in the ability of the practitioner to tactilely feel the different pulses at all. In other words, memorization of pulse patterns and their clinical relevance is meaningless, if your fingertip to brain sensitivity to interpretive understanding is not giving you accurate and reliable information to begin with.

Advocates of traditional Chinese pulse diagnosis contend that the essential problem lies in the learning of the technique. Instructors of pulse palpation argue that:

a. Pulse diagnosis is extremely difficult to learn because few medical practitioners have the tactile acuity to detect subtle variations at three levels of palpation pressure.

b. Few medical practitioners are willing to devote the necessary time to master the technique as 5-10 years of close supervision is often needed.

A result of insufficiently trained practitioners in traditional Chinese pulse diagnosis in the United Sates is that it tends to be unreliable with rarely any two practitioners consistently coming up with identical pulse assessments for a given patient. This circumstance has:

Discouraged practitioners from performing comprehensive pulse examinations on their patients jeopardizing treatment success.
Increased skepticism toward Traditional Chinese medicine (pulse diagnosis and other aspects of Traditional Chinese medicine are suspected of being invalid).
Been a barrier to the scholarly investigation of Traditional Chinese medicine (clinical trials which are not based on accurate and comprehensive pulse diagnoses are inconclusive).

Section 3: Pine Street’s hypothesis:
Our essential hypothesis, which has led to this research, is attempting to test a different pedagogical approach to expedite the teaching and learning of traditional pulse palpation.

We have “translated” the 30 different classical Chinese pulses into simple choreographed dance movements that are taught to the practitioner by a professional dance instructor. Over two days the practitioner learns the dance movements to all 30 of the classically defined pulses, plus many doublet and triplet combinations of those pulses.

The question that we are attempting to answer in this research experiment is: If you are able to “feel” in your body the 30 different individual pulse movements, will this assist your fingertips and your brain (sensory motor strip) to better feel as well? If so, does this help you tactilely feel the pulse with greater accuracy and reliability that assists in learning and ultimately clinical application?

The 30 Pulses taught through choreographed movements include:

Normal Pulse
Simple Floating Pulse
Simple Deep Pulse
Scattered Pulse
Hidden Pulse
Firm Pulse
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Scallion Stalk Pulse
Fine Pulse
Simple Fast Pulse
Simple Slow Pulse
Moderate Pulse
Extremely Fast Pulse
Simple Weak Pulse
Weak & Floating Pulse
Faint Pulse
“Qi” Deficient Pulse
“Qi” Excess Pulse
Flooding Pulse
Large Pulse
Slippery Pulse
Rough Pulse
Stirred Pulse
23. Simple Bowstring Pulse

Taut Bowstring Pulse
Drum skin Pulse
Fast Irregularly Interrupted Pulse
Slow Irregularly Interrupted Pulse
Regularly Interrupted Pulse
Long Pulse
Short Pulse
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Section 4: Why Pine Street think’s this is a new pedagogy of learning traditional Chinese pulse palpation and diagnostics:

This new pedagogy highlights the importance of including physical learning (dance movement) and not just classroom didactic learning. Physical learning allows for a deeper “feel” for the complexity of the traditional Chinese pulses.

Verbal descriptions of the 30 different Chinese pulses, which are the cornerstone of the student’s learning, do not adequately describe the complexity and subtlety of the pulses. When the pulse combinations become very complex, a student’s capacity to apply verbal descriptions decreases. Words are too slow and too general to convey all the details of a precise pulse description.

Our research shows that teaching, using a physical dance model, greatly improves learning more than verbal descriptions alone. We also have demonstrated that students acquire a pulse palpation sensitivity, which is a type of motor skill, more rapidly and precisely if the student is instructed by a professional dance instructor. A dance instructor is able to adapt the choreographed dance pulse movements to student’s individual strengths and weaknesses.

While words can help us start to learn the vocabulary of traditional pulse diagnostics, we have found that to expedite the learning process, we need to form nonverbal knowledge to deeply understand the complexity of feeling the pulses. It is clear to us that brain networks store memories of movements such as our choreographed pulse dance movements. These memories are called “motor memories” (not to be confused with “muscle memory” used by athletes) because they are specific to movement and are fundamentally different from memories of verbal descriptions of these same actions.

Teaching students choreographed pulse movements creates motor memories. The heightened motor memory in the brain translates to an increased sensitivity at the fingertips for pulse palpation.

Dance movement is a powerful technique for stimulating brain motor networks which allows the student to deeply feel the traditional Chinese pulses. The science often refers to this as “motor simulation theory”. This means that we use our own motor memories to figure out what we are feeling. Research tells us that dancers perceive the world differently because they have a special capacity to simulate (feel) what they observe. We are applying this theory to learning traditional Chinese pulse diagnostics where performing the choreographed pulse dance movement amplifies the student’s ability to “embody” the pulse using one’s fingertips.

Motor learning, in the context of learning traditional pulse palpation skills, is defined as an internal process that creates for the practitioner a capability of activating heightened fingertip sensitivity through a motor skill. The practice and experience of repetition of motor skills (dance movement) creates sensitivity changes in the brain that are relatively permanent, that is, stored in long-term memory. What also seems apparent, is that, whereas the result of this learning is permanent, the motor system remains ‘plastic’ or capable of change throughout the practitioner’s clinical application of pulse palpation overtime. This dance driven motor learning allows the practitioner to learn and feel more and more complex, subtle and sophisticated combinations of pulse qualities that go beyond the basic introduction of the pulse dance movements.
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The goal of this new pedagogy, for the practitioner, is not simply to learn a basic skill, but to become skilled to a level of deeper proficiency that enhances the ability to feel ever more complex combinations of pulses.

There are various stages that are essential in the motor learning process that we employed in our research:

a. Perception (observation) of a demonstrated dance movement:

As the professional dance instructor demonstrates the choreographed pulse movement to the student, the process of motor learning starts with perception. Perception is dependent on several components:

–  First, the student simply observes the dance instructor demonstrate the pulse movement. For example the dance movement for the…..Floating Pulse
–  Second, meaning is attached to that observation. For example the Floating Pulse upon light fingertip pressure feels “springy” or, “higher” than normal as if “dancing”, “like a light breeze blowing over a feather on the back of a bird” and a feeling of “exuberance”, like “wood floating on water”.
–  Third, the student hears the music for the movement, giving the movement a temporal context. For example ……
b. Choreography is also remembered through a combination of visual cues, referred to as visualization and imagery. Connecting the movements to mental imagery creates a storyline which aids in retention and recall. Mental practice (seeing oneself doing the movement before execution) is another strategy in the training to enhance learning. When students practice pulse combinations mentally, certain areas of the brain that fire on the muscles used for these movements will activate the brain to fingertip connection. It has been demonstrated that mental practice can enhance skill development beyond what can be accomplished through physical practice alone.

When a student physically performs the steps of a choreographed pulse movement by both observing and imitating a dance instructor doing them we feel that the brain’s “action observation network”, (AON) is dramatically switched on. The action observation network occurs when watching another person’s actions, a network of sensorimotor brain regions, is engaged.

When we observe the pulse dance movement of the dance instructor, we activate the same neural circuitry responsible for planning and executing our own actions. Previous studies have shown that during action observation (AO) we use specialized motor representations to understand the observed actions. The familiarity of the observed action is directly correlated with the degree of activation of this “mirrored system”. Processing observed actions involves matching these actions not only to a predefined perceptual template in the brain, but to pulse patterns that are being palpated in the patient.
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c. Replication (execution) of what has been perceived (From Perception to Movement):

Motor learning is set in motion by perception and continues with replication. The dance instructor makes the most critical aspects of the movement clearly apparent to the student. This is demonstrated and explained. The student then performs the movements, and those movements are encoded in the student’s mind. With repetition, that movement becomes a part of the student’s long-term memory.

The human body with its bones, muscles, tendons, ligaments, joints, and skin all have specialized tissues (nerve cells) that receive information during movement. The transmission of this information to the brain, and the processing of this information, is called proprioception.

The integration of all these physical experiences and ascribed meanings form the basis of perception and these skills are enhanced by replication (training).

d. Feedback and Repetition:

After the initial perception and replication (watching and doing) of the pulse movements, the next step in the learning process involves considerable repetition. Once the appropriate neurological pattern is set up (the movement is being done correctly and efficiently), repetition will ingrain the skill into long term memory.

Creating structures through which to draw up kinesthetic memories was also key to retaining and remembering dance movement choreography. Movement-based cues include the musicality or rhythm aspects of the movement, the feelings of the movement and the kinesthetic feedback received while performing the movement. The student’s integration of the choreography occurs on a cellular level so that it lives in the body and is accessible for longer periods of time.

Examples of creating structures through which to draw up kinesthetic memories
a.
We created a dozen “mystery” tactile sensation boxes (each box 8x12x15 / 1440 cubic inches) On one side of the box is a round opening in which the student can reach their hand inside and “feel with their fingers a variety of objects placed inside the box that would generate different tactile sensations. After feeling the contents inside the box the student would self generated movements in response to a felt texture (improvisation). Improvisation involves listening to and trusting ones own impulses and innate intelligence to move – We also enlist the ability to recall different improvised responses from earlier in the class, for instance responding to the texture a participant just felt and then switching on a dime to responding to the texture they had felt before – they recall up to 10 different ‘textures’ – memorization of their own impressions is a practiced skill.

Creation/Collaboration – In games – Collaborating with a partner or group to create choreographed movement sequences representing composites of pulses learned during our games – This involves verbalizing movement ideas with peers, creative problem solving, team work, and physical contact with peers in some instances – This is a chance to demonstrate mastery/understanding of the 30 learned choreographed pulses while pushing that further by asking the participants to layer 2 or more pulses on top of one
b.
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another aka creating a composite – this pushes students to be clear – can they clearly show us how 2 or more pulses would move simultaneously in one body? In a group of a bodies? It also pushes students to be creators and movement innovators themselves. They get to practice the skill of generating new movement ideas and impressions of what they have learned.

c. Performance and the recognition of dance subject matter in peers – In games – The practice of performing for others in the class is an expression of competency, and also a challenge of vulnerability and self-expression/offering of one’s own creativity either as an individual or as a part of a group – The practitioners grapple with seeing and being seen – The audience/observers are also forced to exercise their eyes to recognize the dance subject matter, or not, by guessing what the composite pulse is that the group/individual is performing – This helps everyone work on clarity and recognition of movement ideas, aka pulse ideas.

d. Qualitative Analysis//Variations on Effort – Not only are participants learning and memorizing choreographed movement patterns or sequences, they are also understanding dynamic qualities of different movements – They learn ‘what’ and they learn ‘how’ – for instance the feeling/the quality/the dynamic of a flooding pulse is qualitatively different from _____ – They are learning how to feel subtle variations in the energy behind different movements, and are feeling that spectrum of qualities in their own bodies as they move

It is at this stage that verbal input (commentary on clinical pulse diagnosis from the Nan Jing Classic) can be an important factor in the learning process. “Knowledge of results” is the term used in motor learning when the student is given information relating to what the pulse pattern means in the clinical context. In the beginning of the dance movement learning process, the student is thinking a lot more, so the dance instructor has to say, ‘Okay this step, now this step.’ By learning this verbal script, it is easier to learn, retain and recall choreography, particularly when the implicit, non- verbal memories have not been established.
The final goal of the motor learning process is the ability for the student to “self- instruct”.
When combinations of pulses movements are required, the student recalls the movements mentally and then transfer it to a physical execution of that movement. By the time the motor skill is imbedded in long-term memory, it is an image of the task that is recalled at this level of execution, rather than a complicated series of details, multiple body movements, or individual muscle activation.

The instructor can accomplish this progression initially by asking the student various questions, such as:

What emotions do you feel when you do this movement?
Where in your body do you feel this movement?
When you repeat this movement do you consistently have that feeling represented? Do you have any inhibitions that interfere with your ability to execute the movement?
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As students become more advanced in their movement capacity, they become less and less dependent on the instructor for actual teaching of skills, but make use of the instructor’s expertise for coaching the detailed idiosyncratic elements of the pulse movements (tilt of the head, positioning of the arms and feet, timing, rhythm, etc. ) and information regarding clinical qualities of the pulse patterns.

At this stage in the training by using structured choreographed dance movements, the movement patterns have already been committed to memory and associated with specific didactic terminology. The synaptic connections between the networks of neurons associated with the movement are already in place and need only be strengthened and associated with that choreography through practice. This makes the process of retrieving easier because the student needs to simply associate the existing memories with the particular choreography for recall.,

Section 6: What we did:

In 2017 we conducted several beta tests of this new pedagogy with different groups of traditional Chinese medicine practitioners and students. Experience ranged from 1 year to over 20 years of clinical practice. We even recruited students currently enrolled in TCM school programs and we recruited practitioners of various allied medical therapies such as Tai Chi-chuan and Qi-Gung instructors.

To test the student’s ability to learn the pulse in a more efficient and expedient manner we used the “inter-rater reliability test” (IRR) as a useful way in helping us determine if and to what extent the learning of the pulses through dance movement is helpful to learning. Inter-rater reliability also referred to as inter-rater agreement, or concordance, is the degree of agreement among all students/practitioners who are participating. It gives a score of how

much homogeneity, or consensus, there is in the ratings and it is one of the aspects of determining our research validity.

Each group of students that we recruited for our beta tests started the research on day 1 by taking the inter-rater reliability test and again took the same test (with the same group of “patient” volunteers at the end of day 2). We prearranged with ten “patient” volunteers to show up at our beta test site to have their pulses palpated by the students. The patient volunteers were seated at a table across from a student. The students were given a printed pulse evaluation form to fill out for each patient volunteer. They had 5 minutes to take the patient volunteers pulse, fill out the form and then go on to the next patient volunteer to complete all ten patients. This procedure was repeated with the same group of patient volunteers at the end of the second day of training.

Section 7: Results:
The kappa statistic (specifically we used Gwet AC – which additionally, statistically accounts for
practitioner’s guessing what the pulse is, referred to as “chance” agreement) is frequently used to
test interrater reliability. The importance of rater reliability lies in the fact that it represents the
extent to which the data collected in the study are correct representations of the variables
measured. Measurement of the extent to which student data collectors (raters) assign the same
score to the same variable is called interrater reliability.
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In our research we rely on multiple practitioners to collect pulse data on volunteer patients. The
question of consistency, or
agreement
among the individuals collecting data immediately arises
due to the variability among human observers. Well-designed research studies must therefore
include procedures that measure agreement among the various data collectors. Study designs
typically involve training the data collectors, and measuring the extent to which they record the
same scores for the same phenomena. What we have found from our beta tests in analyzing the
before and after dance training weekend is that the before IRR test had more practitioner
disagreement and the after IRR test had greater practitioner agreement. Before IRR test had
greater uncertainty and error among the practitioners and the after IRR had a greater confidence
and consistency among the practitioner data collectors. The extent of agreement among data
collectors is called, “
inter-rater reliability”.

We have found that learning and practicing the dance movements, resulted in a high degree of statistical agreement between the least experienced student and the most experienced practitioner in the group.

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