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• To assess rate and rhythm.
• Simultaneously with femoral to detect delay.
• Not good for pulse character.

• Medial border of humerus at elbow medial to biceps tendon.
• Either with thumb of examiner's right hand or index and middle of left hand.

• To assess cardiac output.
• To detect radiofemoral delay.
• To assess peripheral vascular disease.

• Deep within the popliteal fossa.
• Compress against posterior of distal femur with knee slightly flexed.

• As above.

• With the flat of the hand per abdomen, as body habitus allows.

What is the pulse rate?

• A normal pulse rate after a period of rest is between 60 and 80 beats per minute (bpm). It is faster in children. However, if tachycardia is defined as a pulse rate in excess of 100 bpm and bradycardia is less than 60 bpm then between 60 and 100 bpm must be seen as normal.
• An irregular pulse or a slow pulse should be measured over a longer time. As a guide, it is unwise to measure a regular rate for less than 20 seconds (30 seconds being preferable) and an irregular pulse should not be measured over less than 30 seconds, preferably a full minute.
• Bradycardia may be physiological in a trained athlete, even if training was many years ago.
• Paroxysmal tachycardia can last a few minutes to several hours. It might be too transient to allow an ECG recording during an attack so that only clinical examination is available.
• Paroxysmal atrial fibrillation (AF) or, more rarely, atrial flutter, produces a ventricular rate that is dependent upon the refractory time of the A-V node.
• Re-entry tachycardia such as Wolff-Parkinson-White syndrome can produce a very fast rate in the region of 200 bpm.
• As a general rule, supraventricular tachycardia (SVT) produces a rate above 160 bpm and ventricular tachycardia (VT) below 160 bpm.
• Even in young people, very fast rates of 200 bpm or more can precipitate heart failure.

What is the pulse rhythm?

Location Of Pulses

• Sinus arrhythmia occurs when there is variation of rate with breathing. It accelerates a little on inspiration and slows a little on expiration. This can be quite marked in children and adolescents but is uncommon over the age of 30. It can persist a little longer in the physically fit.
• Pulsus paradoxus:
• The pulse slows on inspiration in pulsus paradoxus and it can occur with pericardial effusion, constrictive pericarditis and severe pneumothorax, especially tension pneumothorax, severe asthma and severe chronic obstructive pulmonary disease (COPD).^[1]
• In normal circumstances, the systolic blood pressure often falls slightly, by less than 10 mm Hg on inspiration; however, in pulsus paradoxus it falls by more than this.^[2]This fall can be used to assess the severity of cardiac tamponade.
• Irregularity is more difficult to discern if the rate is fast.
• Note if it is regularly irregular of irregularly irregular:
  • Variable heart block or premature ventricular excitation will cause either an extra beat or a missed one. Premature ventricular contraction may cause a missed beat because the ventricle has not had time to fill adequately and so the stroke volume is low. The beat following a missed beat, whether due to premature excitation or failure of the ventricle to beat, may be rather stronger than the others, as the ventricle has filled more in the longer diastole. This irregularity will follow a regular pattern.
  • A much more random irregularity is a feature of AF. If the rate is fast in AF, it may be difficult to note if the irregularity is random or even if there is irregularity at all. It may be helpful to measure the rate at both the cardiac apex and the wrist and in AF there is usually a deficit at the radial pulse. This is usually done with two people timing simultaneously but it can be done alone, not timing but merely noting if the rates differ. The rate in AF and the rarer atrial flutter depends upon the degree of A-V block but it can be very fast.
  • It has been suggested that a way to distinguish between causes of irregularity is to get the patient to exercise to increase the pulse rate. In premature ventricular excitation it will reduce or disappear. In AF it will increase the irregularity or at least not reduce it.
  • Currently, most clinicians would use the ECG for a more reliable means of distinction.

What is the character of the pulse?

Finally, note the character of the pulse. This incorporates an assessment of the pulse volume (the movement imparted to the finger by the pulse) and what has been described as the 'form of the pulse wave'. The pulse character must be interpreted in the light of pulse rate.

• Cardiac output is the product of stroke volume and heart rate. Thus, a slow pulse may be associated with a high stroke volume and, as there is a long time between each ejection, the pulse pressure (the difference between systolic and diastolic pressure) will be high.
• In shock, the pulse will be fast but weak. This might be from hypovolaemia or cardiogenic. In congestive heart failure one of the first features is tachycardia.
• A hyperdynamic circulation occurs in emotion, heat, exercise, anxiety, pregnancy, fever, anaemia and thyrotoxicosis. The pulse rate is raised but the pulse is full and bounding. Cardiac output is high and peripheral resistance is low.
• Disease of the aortic valve will affect the nature of the pulse wave:
  • In aortic stenosis, the wave is slow to rise and the pattern of the arterial pressure is rather flat - the slow rising pulse.
  • In aortic regurgitation, the stroke volume is high because a significant amount of blood sinks back into the ventricle and has to be pumped again. Furthermore, the incompetent valve will let the arterial pressure fall markedly in diastole. Hence, a bounding, dynamic pulse collapses to give a very wide pulse pressure. This is called a collapsing or water hammer pulse. The water hammer is a piece of Victorian engineering that is rarely seen these days. The collapse of the pulse pressure can be felt with even greater effect if the patient's hand is raised over his or her head so that the radial artery is palpated at a level rather above the heart. Severe aortic regurgitation, classical of syphilitic aortitis, can cause the head to jerk with each pulse (de Musset's sign).
  • In mild aortic stenosis with reflux, the pulse detected may have two peaks as well as being slow rising. This is the so called bisferiens pulse.

Studies have correlated markers of arterial stiffness (eg, pulse-wave velocity and pulse pressure) with risk for the development of fatal and non-fatal cardiovascular events.^{[3, 4]}

The next step

This systematic examination of the pulse will give a great deal of information. Examination of the rest of the cardiovascular system should give a very clear idea of the diagnosis or at least put the examiner in a position to make a rational request for further investigations. Systematic examination of the pulse remains an essential part of clinical practice.

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1. Khasnis A, Lokhandwala Y; Clinical signs in medicine: pulsus paradoxus. J Postgrad Med 200248:46-9

2. Hamzaoui O, Monnet X, Teboul JL; Pulsus paradoxus. Eur Respir J. 2013 Dec42(6):1696-705. doi: 10.1183/09031936.00138912. Epub 2012 Dec 6.

3. Liao J, Farmer J; Arterial stiffness as a risk factor for coronary artery disease. Curr Atheroscler Rep. 2014 Feb16(2):387. doi: 10.1007/s11883-013-0387-8.

4. Boutouyrie P, Fliser D, Goldsmith D, et al; Assessment of arterial stiffness for clinical and epidemiological studies: methodological considerations for validation and entry into the European Renal and Cardiovascular Medicine registry. Nephrol Dial Transplant. 2014 Feb29(2):232-9. doi: 10.1093/ndt/gft309. Epub 2013 Sep 30.

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By Jennifer Dubowsky, LAc

Diagram Of Pulse Point Locations

In both Eastern and Western medicine, a patient’s pulse plays an important role because it is a valuable indicator of their well-being. We’ve all been to Western doctors who checked our pulse rates as one method of determining heart health. A normal rate is considered to be between 60-90 beats per minute and a rate that is considerably faster or slower may signal a problem.

InChinese medicine, pulse diagnosis is also a very important diagnostic tool that provides your practitioner with information about the state of your health but in different ways. Chinese medicine (also known as TCM) pulse diagnosis is a more detailed and subtle process; we are looking for much more than your pulse rate.

Why is pulse diagnosis such a large part of traditional Chinese medicine (TCM)? Because thousands of years ago when Chinese medicine theories began to develop, there were no x-rays or MRIs available to produce pictures of the insides of our bodies. Therefore, in their wisdom, the ancient Chinese doctors created external methods designed to understand the body’s interior, including: observation; careful questioning; tongue diagnosis; and pulse diagnosis. Today we’re focusing on the pulse.

The basics of Chinese pulse diagnosis

Chinese pulse diagnosis is complex but let’s begin with some of the basics. When I take your pulse, I place three fingers over the radial artery in your wrist. Each of my fingers rests on a different section of the pulse: front; middle; and rear. Each section correlates with different organs. I feel for the pulse rate, but my fingers also search for pulse length, depth and quality because these pulse attributes are equally important. When I put all this information together, I learn more about your wellness.

Pulse length: Pulse length is thought of as shorter vs. longer and provides indications of the strength and balance of blood and energy flow. All three fingers resting on your artery feel for pulse length. If the pulse is not felt under all 3 fingers, it is considered shorter; if the pulse exceeds the 3 fingers it is considered to be longer. A longer pulse could be normal if there are no other disquieting signs, but if a pulse is a combination of short and weak, it means that the energy is not strong enough to move your blood. In contrast, a short and forceful pulse would reflect more of a stagnant condition, of blood not flowing well because there are blockages.

Pulse depth: When I feel for the depth of the pulse, at first I apply almost no pressure at the superficial level, a bit more to the middle level, and the most pressure to the deep level to determine where the pulse is felt. The depth of the pulse reflects the level of Qi in the body and indicates the type of pathological condition that might be present. For example: a pulse felt at the more superficial level is often indicative of an exterior illness, like a cold or flu, whereas a deep pulse reflects the state of the organs and more internal conditions.

Pulse quality: Another way to think of pulse quality is to imagine that your pulse has texture. In TCM, there are 28 different pulse qualities. Two common examples of texture or quality include: choppy, a rougher pulse with an uneven flow, and slippery, a pulse that feels like little ripples or beads are running underneath my fingers.

Examples of different pulses

Want a closer look? Click the chart to expand or download it.

When your practitioner gathers all this pulse information, and there are hundreds of variations, she assembles it in order to understand the condition of your body. Let me provide an example that incorporates the different pulses I have explained: a patient has a slower pulse (rate) that I feel at a deep level (depth) and it is slippery (quality). This indicates a condition of interior cold with dampness in the body. Contrast this patient with another person who has a rapid (rate), floating (depth) pulse that signifies an exterior heat condition such as a cold with a sore throat.

This pulse information, and much more, helps your practitioner choose the most appropriate acupuncture points, herbal formula and form a treatment plan and that will best suit your body’s needs.

Name Of Pulse Points

Take your own pulse

There are many TCM practices that I advise people to practice at home but detailed pulse taking is not one of them. If you would like to test something simpler in order to understand your pulses better, take your own pulse and compare it to a friend’s to see what differences you are able to feel. Or, the next time you are coming down with a cold, rest three fingers ever so lightly on your wrist to see if you feel a more superficial pulse than usual. Don’t be disappointed if you only feel a gentle beat; pulse taking is an art that has been studied for many years and even those of us who have been trained in pulse taking, are constantly refining our skills.

**This post was originally published in 2012

Location Of Pulse Sites

Jennifer Dubowsky, LAc, is a licensed acupuncturist with a practice in downtown Chicago, Illinois, since 2002. Dubowsky earned her Bachelor of Science degree in Kinesiology from University of Illinois in Chicago and her Master of Science degree in Oriental Medicine from Southwest Acupuncture College in Boulder, Colorado. During her studies, she completed an internship at the Sino-Japanese Friendship Hospital in Beijing, China. Dubowsky has researched and written articles on Chinese medicine and has given talks on the topic. She maintains a popular blog about health and Chinese medicine at Acupuncture Blog Chicago. Adventures in Chinese Medicine is her first book. You can find her on www.tcm007.com.