An Examination of a Therapeutic Alliance: How the Acupuncture Experience Facilitates Treatment of the Modern Self Through the Methods of Intake and Self-Cultivation

Sharon Hennessey, DAOM, L.Ac.

Dr. Hennessey is Domain Chair of the Acupuncture Department at ACTCM @ CIIS with an interest in acupuncture research. She has published several articles in CJOM, and recently presented a poster at SAR’s Conference in 2015 and 2017. Her posters and articles can be viewed at sharonhennessey.com.

Abstract:

The concept of therapeutic alliance, i.e., the relationship between practitioner and patient, is identified as being historically rooted within the practice of traditional Chinese medicine. Within this context, this relationship is shown to serve the modern self — a recent construct favored in westernized industrial countries. While tracing the rise of the modern self, the value and limitations of this construct are evaluated.

In this essay both the acupuncture intake, comprised of ten questions, and the practice of the Chinese self-cultivation techniques are analyzed: the intake procedure as an effective therapy and practitioner self-cultivation as a source for patient inspiration. By re-appropriating archaic methods, Chinese medicine practitioners can guide patients in the formation of a valuable personal narrative to address a construct of modernity.

Key words:

acupuncture narrative, human potential, Yang Sheng self-cultivation.

An Archeological Discovery

Ancient Chinese culture may have eschewed the individual, but in the practice of Chinese medicine there has always been an emphasis on treating idiosyncratic pathologies, unique to each person. Elisabeth Hsu, in chapter 2 of Innovation of Chinese Medicine, describes twenty-five such medical case histories found in the biography of a Han doctor recorded in about 90 BC. Hsu asserts that illness was designated by the term bing rather than the term ji. Her investigation revealed that apart from other meanings, bing frequently referred to the emotional state of a distressed or aggrieved person, suggesting that bing referred to the mind-emotion-body complex.1 This concept of individualism, buried in Chinese medicine, functioned as a release valve for strictures in traditional Confucian culture, indicating a nod to the individual through pathology.

By using this strategy today, the modern acupuncture practitioner may covertly treat a wide range of disharmonies that effect the psychological or metaphysical through the medium of the physical body.

Evolution of the Modern Self

Once upon a time we were all part of a family, congregating within a community or tribe, bounded by rules and traditions that guided every aspect of our lives. But industrialization and other extraordinary successes of capitalism eventually managed to devastate these traditions and erode our connection with the past.

As now experienced, the concept of self is a unique and recent construct that has emerged in the past century, launching each individual on a quest for personal meaning that had been previously supplied by traditional communities. Add to that the Nietzschean demise of the creator, the startling new world of physics, and the material excess of capitalist production, there emerged from the divan of Sigmund Freud and other psychologists a new kind of self. In the BBC documentary, Century of the Self, Adam Curtis examines how we have moved from the ‘citizens with needs’ to ‘consumers with desire’. In this documentary, Curtis deconstructs how the Freudian concept of ‘unconscious’ desire was harnessed to the new business of marketing consumer goods, encouraging the emergence of a singular individual. This new self re-examined the constraints that had previously bound it to the precepts of religion and other dogma.

Jan Sloterdijk’s You Must Change Your Life describes our “withdrawal from this collective identity” as a directive demanding that all individuals must now stand beside themselves a priori, living their lives in front of the mirror, or function as actors of everyday life.2 He decrees that we were once part of a collective unity, bounded by religion, tradition, and family that functioned as additional immune system by guiding, signifying, and protecting us.2 Now, with only our self-created psyche to protect or direct us, humanity must face the numerous onslaughts of circumstance alone.

Christopher Macann states: “Ontological psychology ceases to be what Kant took it to be: a spurious deduction of the immortality of the soul from the principle of self-identity”3, and becomes instead what might be called a doctrine of self-actualization, a phrase made famous in Maslow’s Psychology of Being.4 Maslow describes self-actualization as “….what a man can be, a man must be…It refers to the desire for self-fulfillment, namely, to the tendency for him to become actualized in what he is potentially. This tendency might be phrased as the desire to become more and more what one is, to become everything that one is capable of becoming.”5

Authoring the Self or How to Live a Meaningful Life

The self has now become a center for experimentation and authorship. For a meaningful life, experiences must be accumulated and curated, and the personal narrative becomes a centerpiece for communication. Individual stories serve as guideposts for inspiration and transcendence in much the same way as The Confessions of Saint Augustine did 1700 years ago.2 Self-involvement is not new to western history, but it was traditionally used to serve as an example at the demand of some greater authority. Augustine’s Confessions are an early version of a transformational life story that permeates Hollywood dramas and soaps.

For the multitudes, the self-portrait, particularly illustrated by Rembrandt’s more than 90 painted images of himself, is now the “selfie”—a self that is not under the control of some special aegis. It is especially unsettling to many social critics, who claim it is a short jump from selfie to selfish. Great moral opprobrium is attached to this concept of self. Critics see self-involvement as shedding important shared traditions that have served to organize people or, in a spiritual context, preferring the self to the creator or the originator of that self. But this new self, while, yes, prideful and actively undermining tradition, still requires tending and guidance.

Jumping forward to our new, service-oriented economy, many kinds of practitioners are now engaged in mapping the ontology for this new individual self through the medium of the personal narrative. This new self has spawned a huge service industry that caters to its development, refinement, and care. This is important because other cultural institutions that once cultivated, sheltered, and groomed this aspect of our psyche are in retreat.

The Chinese Medicine Intake: The Practitioner Helps the Patient Write a Narrative

In my own specialty, acupuncture, the patient is encouraged to build their personnel narrative based on the ten intake questions, which provides an organizational template for their story. As the patient describes their digestion, sleep patterns, urination, breathing, and any other subjective sensations they may wish to include, these ten questions serve as a type of somatic confessional, whereby the patient is able to transpose their psychological and metaphysical anxiety into simple and comprehensible evaluation of autonomic vegetative functions. Rather than the soul or psyche, these functions then become the object of transformation. By the simple principle of adjusting the flow, intake, and expulsion of fluids, gases, and solids, the individual can be tuned to perform at a higher level.

In a secular world there is the obvious benefit to only adjudicating somatic function. Many pejorative moral and psychological implications can thus be averted, while such vegetative functions are modified or streamlined to a superior level of performance.

This strategy of using Chinese medicine to treat the somatic body by addressing the psyche is oddly akin6 to the James-Lange Theory of Emotion. This theory was put forth in 19th century initially by American psychologist and theosophist William James and later, separately, by Danish physician Carl Lange. In this theory, physiological changes actually precede emotions. The subjective emotion is experienced because of the underlying physiology: our autonomic nervous system generates the physiological events that we associate with an emotion such as heart rate, perspiration, dry mouth, muscular tension. This theory suggests that emotions are a result of physiology rather than the cause.6 The autonomic nervous system is primarily unconscious, associated with activating the flight or fight response. But new research also shows that the sympathetic nervous system is “part of a constant regulatory machinery that keeps body functions in a steady state equilibrium.”7

It has been recently demonstrated that the sympathetic nervous system and the hypo-pituitary axis are activated by antigenic activity. Local immune cells inform the central nervous system and vice versa; the door swings both ways. New research in bioelectronics suggests that inflammation can be suppressed by stimulating the vagus nerve with electrical impulses. The standard of care associated with inflammatory conditions, such as rheumatoid arthritis, Crohn’s disease, or other insidious autoimmune conditions, might very soon incorporate vagal stimulation. Increasing vagal tone can also be taught by using the biofeedback technique.8,9 Hence, research science is verifying that the underlying soma is an effective pathway to modulate the psyche and vice versa.

In a study (to be published) by Randy Gollub et al., a patient’s experience of pain relief was correlated to their perception of being cared for with empathetic understanding. Patients were asked to evaluate the level of interest shown by their practitioner. Results demonstrated that their pain relief was enhanced by practitioner empathy. 10

A trial designed by Ted Kaptchuk, presents the notion that the patient’s narrative about self is fundamental to their health. He discusses and demonstrates how a practitioner perceives a patient affects the outcome of their health.11 This study of patients with irritable bowel syndrome randomly divided them into three groups. Group one was put on a waiting list. Group two received placebo treatment from a disinterested clinician. The third group got the same placebo treatment from a clinician who asked them questions about symptoms, while describing the causes of irritable bowel and displaying optimism about them overcoming their condition. Not surprisingly, the health of those in the third group improved the most.

The Golub and Kaptchuk studies demonstrate the value of practitioner involvement. In recording the patient’s subjective narrative, practitioner empathy becomes part of substrate that influences the acupuncture patient’s outcome.

Acupuncturists stress which foods to eat, the temperature of the food to be consumed, how much to drink, what to drink, when to sleep, when to rise, how to dress, how often to have sexual intercourse, or how to massage internal organs. For patients who have never observed their bodily functions, discovering that the shape of a stool or the color of urine or nose phlegm can be a window into the interior can have profound effect on self-reflection. In a secular world, Chinese medicine provides support and instruction similar in some ways to the dietary and lifestyle guidelines once administered by other belief systems.

The acupuncture intake and diagnosis that generates this personal narrative with its pastiche of authentic Taoist and Confucian phrases represents an antique system of healing. This also can function successfully today as an intact nonreligious construct for evaluating the pilgrim/patient’s transcendent progress on their journey with their self, stressing behavior over belief.

Evolution of SelfCultivation

For Maslow, levels of self-actualization are the peak levels achieved by an individual. Often an evolved individual can by example pull the rest of humanity upward toward a higher level of proficiency or consciousness.

In his essay, The Neurology of Self-Awareness, Ramachandran suggests that mirror neurons have played a critical role in learning through imitation rather than trial and error, along with our strong ability to empathize. He proposes that extraordinary human progress, in which self-awareness is fundamental, is the result of the interplay of these mirror neurons.12 He also posits that because of mirror neurons, humans have the uncanny ability to imitate each other and understand each other’s feelings, “setting the stage for a complex Lamarckian or cultural inheritance that characterizes our species.”12

Rizzolatti discovered back in 1996 that mirror neurons are the pre-motor neurons that fire when a primate performs some object-directed actions, such as grasping, tearing, manipulating, or holding but also when the animal watches someone else perform the same actions.13

Additionally, it is not just the repetition of one but repetition of many, imitating and competing, that drives us forward. Take the simple example of the marathon: in 1921, best time was 3 hours and 18 minutes; in 2014, best time was 2 hours, 2 minutes and 57 seconds.14 This has been achieved over the span of many years, through the accumulated effort of many runners, competing against each other, and shaving the time, second by second, year by year. Each competed to be the best, inspired by and imitating the competitor whom they followed, and tended and coached by those who made running a practice.

This sort of consciousness-raising effort that pervades human behavior is described by Jan Sloterdijk in You Must Change Your Life. He lauds the Nietzschean doctrine of combining practice with cumulative knowledge or education and designates practicing and training as an original and uniquely human path, especially in seeking to transcend the self.2 Through Sloterdijk‘s lens, training, peak experiences, and performance crystallize the human experience, while conscious measurement, observation, and skill refinement are reflected in learning and practice.

Sloterdijk comments that such training and practice systems formed the core of Platonism, Brahmanic training, and Taoist alchemy and martial arts, guiding adepts up ‘the vertical wall of achievement’ in superhuman spiritual and athletic extremes that have shaped the image of what human potential can be.2

Chinese Practice and Self-Cultivation

In ancient China, Taoism embraced the belief that through breath and meditation they could transform their lives, by reaching for immortality. Joseph Needham describes how in ancient China the physiological alchemists believed they could “master their neuro-muscular coordination, and sexual activity as part of the Tao.”15 He describes such activities, listing how this was accomplished by employing respiratory exercises, counting heartbeats, experiencing the movement of inner qi, and using a myriad of other special techniques, which were designed prolong longevity or restore youth by internally transforming the practitioner.15 These early Taoists exercises evolved into complicated styles of self-cultivation.

During the early Han period, around 200-100 BC, medical understanding of the inner body was changing. By the time the Huang de Nei Jing was compiled, there was a formal system of channels known as the jing luo, which allowed different types of qi to circulate.1

Medical technology was also changing. Fine filament needles became the preferred method of treatment.16 The practitioner was guided by the Su Wen and Ling Shu on how to perform this new inner practice. He was encouraged to gather his qi, employing techniques of self-cultivation that acupuncture students are still taught to imitate today. Metaphors in the Su Wen, such as “use the hand as if holding a tiger” or “pouring over a deep abyss,” coach the practitioner on how to proceed in treatment.

Technique was conflated with rectitude and moral character, instructing the practitioner to influence the spirit of the patient or proceed to a deeper metaphysical exchange, using the needle as an instrument of transmutation.16 These special skills represented the fruits of self-cultivation for the practitioner.

By focusing on self-manipulation of qi and self-improvement in technique, acupuncturists have become default practitioners of Yang Sheng self-cultivation

skills.1 Modern Chinese medicine has become an odd mix of the esoteric internal practice methods combined with modern physiology. By simply reading through a list of continuing education courses or the advanced curriculum at institute of traditional Chinese medicine, this obsession with obscure Taoist practices can easily be verified.

Pursuing a practice under the guidance of a Chinese master, whose particular lineage defines their curriculum vitae, is the equivalent to pursuing a board certification in another profession. Even if personally refraining from a deliberate practice of self-cultivation, acupuncture students are exposed to such practices through curriculum requirements. It is inculcated in the rhythm of learning in a professional school, where either qi gong or tai chi are combined with esoteric poetry about nature.

It is normal to find a student of acupuncture involved in a deep meditative performance exercise such as tai chi. Mastery of practice-related performance is expected of these students. In this profession, self-cultivation and skill development go hand in hand; other medical professionals are not expected to harmonize their qi, learn mystical movements such as tai chi, or root their being, before interacting with their patient. The skills of self-cultivation as both a healing art and a moral virtue are embedded in Chinese medicine. This imbues the practitioner with leadership qualities that occur in other training modes such as sports, arts, or religion. The modern patient, typically lacking in ritual signifiers for lifestyle direction, can thus benefit from this personal example of their practitioner.

Conclusion

Western treatments based on statistical patterns and board declarations that direct standards of care often negate or ignore an individual’s metaphysical sense of being. In the context of eastern and western cultural norms, western culture employs treatment standards that are ironically more aligned with the statistical whole, whereas traditional Chinese medicine, aligned with a rigid Confucian social structure, embraces the individual. In this example of cultural syncretism, acupuncture offers the modern self the care and understanding that it currently lacks in the territory of western evidence-based treatment.

Despite being anchored in traditional principles of Taoist and Confucian philosophy, Chinese medicine is able to address the modern concept of self by creating a distinct diagnostic template for the treatment of each patient. This narrative template teaches individuals to observe and measure their soma in a practical, effective way against an intact system that encompasses philosophical underpinnings that reflect every aspect of patient behavior. It is composed of understandable natural metaphors that generally resonate well with the patient and can be transposed into simple behavioral modification.

As part of traditional culture, both the narrative and techniques of self-cultivation are able to furnish individual guidance and performance-activated behavior that are often lacking in both western therapy and modern cultural norms. When scientists try to evaluate the efficacy of the acupuncture treatment, they often fail to comprehend the value of these methods: the intake, which varnishes the diagnosis with a veneer of empathy, and examples of self-cultivation, which represent internal strength achieved through moral refinement. Together, these two essential components of an acupuncture treatment may contribute monumentally to a therapeutic alliance that successfully enhances the patient’s outcome.

References: 

  1. Ed. by Elisabeth Hsu, Innovation in Chinese Medicine, Needham Research Institute, Cambridge University Press, 2001; p. 16.
  2. Peter Sloterdijk, You Must change Your Life, Polity Press; 2013. pp. 211, 215, 322, 199.
  3. Referring to the Cartesian Objective
  4. Maccan, Being and Becoming: https://philosophy now.org/issues/61
  5. A.H.Maslow (1943); A Theory of Human Motivation, Originally published in Psychological Review, 50, p.370-396. http;//psychclassics.yorku.ca/Maslow/motivation.ht
  6. https:Wikipedia.org/wiki/James-Lange_theory
  7. http://medscape.com; Medscape: Arthritis Research & Therapy; Georg Pongratz; Rainer H Straub; The Sympathetic Nervous Response in Inflammation.
  8. http://www.newyorktimes.com: Michael Beharmay, Can the Nervous System Be Hacked?; Mar. 23, 2014.
  9. Torres-Rosas R, Yehia G, Peña G, Mishra P, del Rocio M,  Ulloa L, et al. Dopamine mediates vagal modulation of the immune system by electroacupuncture. Nature Medicine. 20, 291–295 (204) doi:10.1038/nm.3479
  10. Mawla I, Gerber J, Delibero S, Oriz A, Protsenko E,  Gollub R. Oral Abstract, Therapeutic Alliance between Patient and Practitioner Is Associated with Acupuncture Analgesia in Chronic Low Back Pain, Society for Acupuncture Research, 2015 Conference program, Boston, MA, USA, 11/12-13, 2015 , #SAR2015.
  11. T J Kaptchuk; Components of placebo effect: Randomised controlled trial in patients with irritable bowel syndrome; BMJ.April2008;336:999 doi:10.1136/bmj.39524.439618.25.
  12. Ramachandran V. [1.1.09]; Conversation: (title) Mind; Self Awareness: The Last Frontier; E. edge.org.
  13. Marco Iacoboni, Istvan Molnar-Szakacs, Vittorio Gallese, Giovanni Buccino, John C Mazziotta, and Giacomo Rizzolatti; Grasping the Intentions of Others with One’s Own Mirror Neuron System; Published: February 22, 2005; DOI:10.1371/journal.pbio.0030079
  14. https:/www.wikipedia.org/wiki/Marathon;_world_record_progression
  15. Joseph Needam, Volume V, Science and Civilisation in China: Chemistry and Chemical Technology, Part 5, Spagyrical Discovery and Invention: Physiological Alchemy, Science and Civilisation in China, Volume V:5; Cambridge University Press,1985; p. XXVIII, Introduction., p. 29
  16. Vivienne Lo, Spirit of Stone: Technical Considerations in the Treatment of the Jade Body; Bulletin of the School of Oriental and African Studies, University of London Vol. 65, No. 1 (2002), pp. 99-128, Published by: Cambridge University Press on behalf of School of Oriental and African Studies; Stable URL: http://www.jstor.org/stable/4145903

Metabolomics and Integrative Omics for the Development of Thai Traditional Medicine.

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Metabolomics and Integrative Omics for the Development of Thai Traditional Medicine.

Front Pharmacol. 2017;8:474

Authors: Khoomrung S, Wanichthanarak K, Nookaew I, Thamsermsang O, Seubnooch P, Laohapand T, Akarasereenont P

Abstract
In recent years, interest in studies of traditional medicine in Asian and African countries has gradually increased due to its potential to complement modern medicine. In this review, we provide an overview of Thai traditional medicine (TTM) current development, and ongoing research activities of TTM related to metabolomics. This review will also focus on three important elements of systems biology analysis of TTM including analytical techniques, statistical approaches and bioinformatics tools for handling and analyzing untargeted metabolomics data. The main objective of this data analysis is to gain a comprehensive understanding of the system wide effects that TTM has on individuals. Furthermore, potential applications of metabolomics and systems medicine in TTM will also be discussed.

PMID: 28769804 [PubMed]

Innocuousness of a polyherbal formulation: A case study using a traditional Thai antihypertensive herbal recipe in rodents.

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Innocuousness of a polyherbal formulation: A case study using a traditional Thai antihypertensive herbal recipe in rodents.

Food Chem Toxicol. 2017 Jul 27;:

Authors: Charoonratana T, Puntarat J, Vinyoocharoenkul S, Sudsai T, Bunluepuech K

Abstract
Recently, a traditional Thai antihypertensive herbal recipe has reportedly been used in Thailand. Its ingredients have long featured in traditional Thai medicine preparations; however, research indicates that the presence of one of them – Tinospora crispa – may have negative effects on the liver and kidneys. Thus, the safety data of this recipe must be proved in animal models prior to conducting any studies in humans. The present case study aims to evaluate the safety of this recipe in Swiss albino mice and Wistar rats through acute and sub-chronic toxicity studies, respectively. The quality control of this recipe was also achieved to guarantee the chemical consistency throughout the entire experiment. Results showed that this recipe did not cause death or any toxic signs in mice or rats. The oral LD50 value in mice was more than 5.0 g/kg. Some hematological and serum biochemical values of treated rats, such as hematocrit, hemoglobin, platelet, monocytes, aspartate aminotransferase, bilirubin, and creatinine, were found to be statistically different from the control group; however, all values were within the ranges of normal rats. Considering the histological study, no damage on liver and kidney tissues was observed in the treatment.

PMID: 28757462 [PubMed – as supplied by publisher]

The Effectiveness of Thai Massage and Joint Mobilization.

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The Effectiveness of Thai Massage and Joint Mobilization.

Int J Ther Massage Bodywork. 2017 Jun;10(2):3-8

Authors: Juntakarn C, Prasartritha T, Petrakard P

Abstract
BACKGROUND: Non-specific low back pain (LBP) is a common health problem resulting from many risk factors and human behaviors. Some of these may interact synergistically and have been implicated in the cause of low back pain. Massage both traditional Thai massage and joint mobilization as a common practice has been shown to be effective for some subgroup of nonspecific LBP patients.
PURPOSE AND SETTING: The trial compared the effectiveness between traditional Thai massage and joint mobilization for treating nonspecific LBP. Some associated factors were included. The study was conducted at the orthopedic outpatient department, Lerdsin General Hospital, Bangkok, Thailand.
METHODS: Prospective, randomized study was developed without control group. The required sample size was estimated based on previous comparative studies for effectiveness between techniques. Two primary outcome measures were a 0 to 10 visual analog scale (VAS) of pain and Oswestry Disability Index (ODI). Secondary outcome measures were satisfaction of patients and adverse effects of the treatment. The “intention to treat” (ITT) and per protocol approach were used to compare the significance of the difference between treatment groups.
PARTICIPANTS: One hundred and twenty hospital outpatients, 20 (16.7%) male and 100 (83.3%) female, were randomized into traditional Thai massage and joint mobilization therapy. The average age of traditional Thai massage and joint mobilization was 50.7 years and 48.3 years, respectively. Both groups received each treatment for approximately 30 minutes twice per week over a four-week period. Total course did not exceed eight sessions.
RESULT: With ITT, the mean VAS of traditional Thai massage group before treatment was 5.3 (SD = 1.7) and ODI was 24.9 (SD = 14.7), while in joint mobilization groups, the mean VAS was 5.0 (SD = 1.6) and ODI was 24.6 (SD = 15). After treatment, the mean VAS and ODI were significantly reduced (VAS = 0.51 (SD = 0.89) and ODI = 8.1 (SD = 10.7) for traditional Thai massage, VAS = 0.86 (SD = 1.49) and ODI = 8.26 (SD = 12.97) for joint mobilization). Constipation was found in 34 patients (28.3%).
CONCLUSION: The traditional Thai massage and joint mobilization used in this study were equally effective for short-term reduction of pain and disability in patients with chronic nonspecific LBP. Both techniques were safe with short term effect in a chosen group of patients.

PMID: 28690703 [PubMed – in process]

Hypoglycaemic activity of Mathurameha, a Thai traditional herbal formula aqueous extract, and its effect on biochemical profiles of streptozotocin-nicotinamide-induced diabetic rats.

Hypoglycaemic activity of Mathurameha, a Thai traditional herbal formula aqueous extract, and its effect on biochemical profiles of streptozotocin-nicotinamide-induced diabetic rats.

BMC Complement Altern Med. 2017 Jun 29;17(1):343

Authors: Chayarop K, Peungvicha P, Temsiririrkkul R, Wongkrajang Y, Chuakul W, Rojsanga P

Abstract
BACKGROUND: The Thai traditional herbal formula-Mathurameha, consisting of 26 medicinal plants, has been used as an alternative and complementary medicine for diabetes treatment in Wangnamyen Hospital, Thailand. To provide scientific evidences on the efficacy and safety of this herbal formula, in vivo hypoglycaemic activity, effect on serum biochemical profiles and acute toxicity were investigated.
METHODS: Experimental type 2 diabetes was induced in male Sprague-Dawley rats by intraperitoneal injection of nicotinamide 15 min prior to intravenous injection of streptozotocin. The most effective extract from the oral glucose tolerant test (OGTT) was administered daily via the oral route to diabetic rats for 2 weeks. Two-hour postprandial plasma glucose (2h-PPG) levels were measured on days 0, 7, and 14. Biochemical data were measured at the end of daily oral administration experiment.
RESULTS: Aqueous extract of the herbal formula was the most potent extract for improving glucose tolerance of streptozotocin-nicotinamide-induced diabetic rats after single oral administration. After 2 weeks of daily oral administration, the aqueous extract showed a dose-dependent glucose lowering effect. At doses of 12.5, 25, and 50 mg/kg, the 2h-PPG level of diabetic rats decreased by 3.32%, 15.78%, and 17.94%, respectively. Most of the biochemical profiles of diabetic rats were improved, including the total cholesterol (TC), alkaline phosphatase (ALP), total protein, albumin, globulin, creatinine, and uric acid levels. The significantly increased triglyceride (TG) level observed in treated diabetic rats indicated a lack of a beneficial effect of the extract on lipid homeostasis. Nevertheless, there were no signs or symptoms of acute toxicity observed after oral administration of aqueous extract (5 g/kg) to both male and female rats.
CONCLUSIONS: The results revealed that the herbal formula aqueous extract has hypoglycaemic activity, beneficial effects on biochemical profiles and a lack of acute toxicity. This study confirms the efficacy and safety of the Mathurameha herbal formula used for treating type 2 diabetes mellitus.

PMID: 28662699 [PubMed – in process]

Diospyros rhodocalyx (Tako-Na), a Thai folk medicine, associated with hypokalemia and generalized muscle weakness: a case series.

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Diospyros rhodocalyx (Tako-Na), a Thai folk medicine, associated with hypokalemia and generalized muscle weakness: a case series.

Clin Toxicol (Phila). 2017 Jun 15;:1-5

Authors: Othong R, Trakulsrichai S, Wananukul W

Abstract
INTRODUCTION: Diospyros rhodocalyx (Tako-Na) is a Thai folk medicine purported to promote longevity, treat impotence, etc. We present patients with hypokalemia, weakness and hypertension after consuming Tako-Na tea.
CASE SERIES: Case 1: A 61-year-old man was brought in nine hours after drinking 400-500 mL of Tako-Na tea. One handful of Tako-Na bark was boiled in water to make tea. He had vomiting and watery diarrhea six hours after drinking it. He took no medications and had no history of hypertension. The only remarkable vital sign was BP 167/90 mmHg. Physical examination revealed generalized muscle weakness. Laboratory findings were potassium 2.7 mmol/L, bicarbonate 24 mmol/L, and transtubular potassium gradient (TTKG) 5.6. He was discharged the next day with a BP 140/90 mmHg and potassium 4.2 mmol/L. Case 2: A 78-year-old man, a friend of case 1, also drank Tako-Na tea from the same pot at the same time as case 1. He also had vomiting and diarrhea six hours later. He took no medications despite past history of hypertension (baseline SBP 140-160). Initial BP was 230/70 mmHg. He also had muscle weakness. Laboratory findings were potassium 3.3 mmol/L, bicarbonate 24 mmol/L, TTKG 7.37 and normal thyroid function. He was also discharged the next day with a BP 148/70 mmHg and potassium 4.2 mmol/L. Case 3-7: These were patients reported to a poison center and their potassium concentrations were 1.4, 1.4, 3.3, 1.3 and 1.2 mmol/L, respectively. Three of them were intubated and case 3 died.
CONCLUSIONS: Tako-Na contains betulin, betulinic acid, taraxerone, lupeol, and lupenone. Their structures are similar to glycyrrhetic acid, the active metabolite of glycyrrhizic acid found in licorice which is well known to cause pseudoaldosteronism. Glycyrrhetic acid is potent in inhibiting 11-beta-hydroxysteroid dehydrogenase, and causes pseudoaldosteronism. We hypothesize that the compounds in Tako-Na act in the same way as glycyrrhetic acid in producing pseudoaldosteronism.

PMID: 28617146 [PubMed – as supplied by publisher]

Classical Formula Powders: Dosage and Application

Treatment periods are rarely discussed in classical Chinese medical literature.  While classics like the Shanghan Lun meticulously describe formula preparation and administration over the course of a day, the number of days a formula should be used for is never plainly described.  Due to this ambiguity, many physicians apply a saying that originates in the Huangdi Neijing to classical formula use, “after one dose one knows, after two doses there is resolution.”[i]

However, by examining powder and pill formula dosage, we can gain more specific insight into classical treatment timeframes.  Whereas with liquid decoctions the written herb weights compose a single day’s worth of formula, with powders the daily dose is fixed at a few grams and the herb weights define a formula’s projected treatment period.

This article is an exploration into the treatment periods and patterns for four foundational classical formula powders, accurate weights and measures based on Han period archeological evidence, and the drinks traditionally used to aid powder consumption. The goal is to provide insight into how and why classical clinicians used medical powders.

Classical Weights

A liang (兩) is the core unit of weight used in classical Han dynasty formulas.  Though there has been some debate as to the exact weight of a classical liang throughout Chinese history, and a great deal of inaccuracy in modern texts, recent archeological findings indicate that a liang weighed between 13.8 and 15.6 grams.  Contemporary doctors in mainland China generally simplify a classical liang’s weight to 15g.  A classical Liang can be subdivided into 24 zhu (銖) or four fen (分).  16 Liang combine to make one jin (斤)[iii].  The table below describes the weight of each measurement unit:

Table 1.  Han Period Weight Units

Measure Unit Approximate Weight Simplified Weight
Jin  220.8g to 249.6g 240g
Liang  13.8g to 15.6g 15g
Fen  3.45g to 3.9g 3.75g
Zhu  0.575g to 0.65g 0.625g

Single doses of powdered formulas were most commonly dosed by heaping powder onto a fangcunbi (方寸匕, Square Inch Spoon) or a qianbi (錢匕, Coin Spoon).  The cun (寸), a classical unit of measurement, is 2.32cm long.[iv]  Therefore, a square cun measures 5.4 cm2 in area.  The Zhongyao Da Cidian (中藥大辭典, Great Encyclopedia of Chinese Medicine) states that a fangcunbi weighs 2g for metal and stone powders and 1g for plant powders.  However, the actual tested weights are somewhat heavier, causing researcher Li Yuhang (李宇航) to conclude that plant powders should be dosed at 1-2g and mineral powders at 3-4g[v].  A portion of his findings is translated on the following table:

Table 2. Actual Fangcunbi Powder Weights

Formula Actual Weight
Wu Ling San 五苓散 1.59g
Muli Zexie San 牡蠣澤瀉散 1.27g
Banxia San 半夏散 1.46g
Sini San using Baishao 四逆散(白芍) 1.66g
Sini San using Chishao 四逆散(赤芍) 1.68g
Chishizhi (in Taohua Tang) 赤石脂(桃花湯) 3.31g
Wenge San 文蛤散 3.33g

The qianbi dose was measured using the Han Dynasty wuzhuqian (五銖錢, five zhu coin).  The coin’s radius measures 2.5cm and it has an approximately 1 cm2 square hole in the center.  Assuming a finger is used to plug the square hole in the center of the coin when used as a scoop, the area measures 4.9 cm2, giving it roughly 10% less area than the fangcunbi.

For the purposes of this article, I simplified unknown formula powder weights to 1.66g per dose for a fangcunbi and 1.5g for a qianbi.  Given that most formulas suggest three daily doses this works out to 5g total per day for the fangcunbi and 4.5g per day for the qianbi.

Intake Methods

Classically, powders are stirred into a warm liquid and drank.  The choice of liquid gives additional insight into the formula’s purpose and should be considered an essential part of powdered formula construction.  The main liquids used for powder administration in the Shanghan Lun and Jingui Yaolue are baiyin (白飲, the water from boiled rice[vi], also called miyin 米飲), maizhou (麥粥, wheat porridge), jiangshui (漿水, fermented millet water), jiu (酒 rice wine, likely analogous to modern huangjiu 黃酒) and water.  In formulas that don’t specifically mention what drink to use, Ge Hong and Sun Simiao suggest that any of the above can be used[vii], presumably leaving the choice of liquid assistant to the practitioner.

Table 3. Liquid Assistants for Powder Administration

Liquid Function Formulas
Baiyin (白飲, boiled rice water) Sweet, balanced.  Strengthens earth harmonizes the middle qi, separates clear from turbid, generates fluids;stops thirst; promotes urination. Sini San, Wu Ling San, San Wu Xiao Bai San, Muli Zexie San.Rice is also used in Baihu Tang, Taohua Tang, and Zhuye Shigao Tang.
Maizhou (麥粥, wheat porridge) Sweet, slightly bitter, cool.  Eliminates heat, stops thirst and dry throat, promotes urination, nourishes liver qi. Zhishi Shaoyao San, Baizhu San (modification).Wheat is also used in Gan Mai Dazao Tang.
Jiangshui (漿水, fermented millet water) Sweet, sour, cool.  Regulates the stomach, dissolves food obstructions, stops thirst. Chixiaodou Danggui San, Shuqi San, Banxia Ganjiang San, Baizhu San (modification).Jiangshui is also used in Zhishi Zhizichi Tang.
Jiu (酒, rice wine) Bitter, acrid, warm.  Invigorates the channels, unblocks obstruction syndrome, warms the blood, scatters blood stasis. Danggui Shaoyao San, Danggui San, Baizhu San, Tianxiong San, Zishi Han Shi San, Tuguagen San.

A Selection of Powdered Formulas

According to Dr. Li Yuming,[viii] Zhang Zhongjing uses internal powdered formulas primarily to treat diseases of the lower jiao, especially recalcitrant conditions that involve blood deficiency and or fluid accumulation.  Below I have selected four representative formulas that each demonstrate a specific lower jiao pathology and can be considered foundational building blocks for individualized powdered formula construction.

Sini San 四逆散, Frigid Extremities Powder

SiniSan SHL Text Weight Gram Weight
Zhi Gancao 炙甘草 10 Fen 37.5g
Zhishi 枳實 10 Fen 37.5g
Chaihu 柴胡 10 Fen 37.5g
Shaoyao 芍藥 10 Fen 37.5g
Total Formula Weight 40 Fen 150g (138g-156g)
Single Dose Weight 1 Fangcunbi 1.66g-1.68g
Daily Dose Weight 3 Fangcunbi 5g (4.98g-5.04g)
Treatment Period 30 Days (27.3-31.3days)
Administered With Baiyin白飲 (Boiled Rice Water)


Sini San
treats Liver qi stagnation that manifests with cold hands and feet, possibly with cough, palpitations, inhibited urination, abdominal pain, or diarrhea with tenesmus, emotional distress, depression, chest and rib distention or pain, or breast distention pain, with a white tongue coat, and a thin wiry pulse.[ix]

According to the Shennong Bencao Jing (《神農本草經》The Divine Husbandman’s Classic of Materia Medica), Chaihu’s bitter, balanced nature has the ability to eliminate knotted qi and food accumulations from the GI tract.[x] Zhishi’s bitter, cool, slightly acrid and sour nature assists Chaihu by breaking up stagnant qi, reducing distention and pain from accumulation and directing the qi of the GI tract downwards.  Shaoyao’s bitter, sour and slightly cool nature nourishes the liver, preserves yin, and according to the Mingyi Bielu (《名醫別錄》Miscellaneous Records of Famous Physicians) eliminates blood stasis, expels water, and benefits the bladder and intestines.[xi] Zhi Gancao’s sweet, warm nature nourishes the middle qi.  Rice water’s bland, sweet and balanced nature is used to administer the formula to build thin fluids, regulate fluid metabolism, and benefit the spleen and stomach.

The Sini San pattern shows signs of dryness, blood deficiency, qi knotting, and food accumulations in the GI tract, and resultant lower jiao yang qi depression.  The formula is overall cool and bitter, with hints of acrid, sour, and sweet and should be considered a light purgative with elements of qi and blood building.  Sini San’s light dose and ability to enter the lower jiao is aimed at slowly purging the intestines without stressing the body’s upright qi.  Due to the purgative nature, caution should be used when exceeding the projected treatment period of 30 days.

Wu Ling San 五苓散, Five Poria Powder

Wu Ling San SHL Text Weight JGYL Text Weight Gram Weight
Zexie 澤瀉 1 Liang 兩 6 Zhu  1Liang兩1Fen 18.75g
Zhuling 豬苓 18 Zhu 3Fen 11.25g
Fuling 茯苓 18 Zhu 3Fen 11.25g
Baizhu 白術 18 Zhu 3Fen 11.25g
Guizhi 桂枝 ½ Liang 2Fen 7.5g
Total Formula Weight 4 Liang 60g (55.2g-62.4g)
Single Dose Weight 1 Fangcunbi 1.59g
Daily Dose Weight 3 Fangcunbi 4.77g
Treatment Period 12 days (11.6 – 13.1 days)
Administered With Baiyin白飲 (Boiled Rice Water)


Wu Ling San
treats a number of symptom patterns, all of which revolve around dampness accumulation in the lower jiao resulting in some degree of yang qi depression and heat.  The primary acute pattern manifests with headache, low fever, irritability, aversion to cold, dry mouth and thirst, possibly with vomiting upon drinking, and urinary obstruction.  Other variants include diabetic thirst and edema patterns.

Zexie, Zhuling, and Fuling’s overall bland and cool natures act to leach out dampness, promote urination, and gently clear lower jiao heat.  Baizhu’s bitter warm nature strengthens the spleen by drying dampness and dissolving food and phlegm liquids[xii]. Guizhi’s acrid warm nature disperses yang and promotes the movement and ascent of yang out of the lower jiao.  Rice water’s bland, sweet and balanced nature is used to administer the formula to build thin fluids, regulate fluid metabolism, and benefit the spleen and stomach.

When taking the Wu Ling San the patient is advised to drink plenty of warm water and that the condition will resolve through gentle sweating which indicates that upright qi has regained control of the surface.  Presumably, the 12 day dose period is the expected term of resolution for the acute symptom pattern.

Danggui Shaoyao San 當歸芍藥散, Angelicae and Peony Powder

Danggui Shaoyao San JGYL Text Weight Gram Weight
Danggui 3 Liang 45g
Shaoyao 1 Jin 240g
Fuling 4 Liang 60g
Baizhu 4 Liang 60g
Zexie ½ Jin 120g
Chuanxiong ½ Jin (3 Liang*) 120g (45g*)
Total Formula Weight 43 Liang (38 Liang*) 645g (593.4g – 670.8g)

570g* (524.4g – 592.8g)

Single Dose Weight 1 Fangcunbi ~1.66g
Daily Dose Weight 3 Fangcunbi ~5g
Treatment Period 129days (118.7 days – 134.2 days)

114 days* (104.9 days – 118.6 days)

Administered With Jiu 酒 (Rice Wine)

*One Jingui Yaolue version states a 3 liang dose for Chuanxiong, all other versions state ½ jin.

Danggui Shaoyao San primarily treats blood deficiency with fluid accumulation in the lower jiao resulting in abdominal pain or cramping.  Though the pattern is more common among women, the formula can also be used for men.  Other possible symptoms include rib distention or pain, lack of appetite, dizziness, emotional constraint, and weakness of the limbs with a pale tongue, white tongue coating, and a deep, wiry pulse.[xiii]

The formula is composed of two main elements: Danggui, Chuanxiong and Shaoyao to nourish the blood and gently disperse blood stasis; and Fuling, Zexie, and Baizhu to regulate water metabolism, dry dampness, promote urination and fortify the spleen.  Together the two groups somewhat resemble a combination of Wu Ling San and Sini San but with a greater focus on blood level movement and nourishment.  To further promote blood movement, rice wine’s acrid, bitter and warm nature is used to administer the formula.  The Mingyi Bielu notes that Rice Wine has the specific ability to circulate a medicine’s strength[xiv] by unblocking the channels and invigorating the vessels.

While the formula is best known for treating acute stomach cramping during pregnancy, modern text books urge cautious use during pregnancy, “specifically because too high a dosage of Chuanxiong Rhizoma can affect the fetus, particularly in mothers who have deficient and weak Kidney qi”.[xv] The question of whether Danggui Shaoyao San’s daily dose of Chuanxiong at 0.93g is considered high must be left to the practitioner and further research. But clearly, it was classically thought of as a safe formula as it was dosed for around four months of use during pregnancy and is suited for long term blood and fluid regulation in the lower jiao.

Chixiaodou Danggui San 赤小豆當歸散, Adzuki and Angelicae Powder

Chixiaodou Danggui San JGYL Text Weight Gram Weight
Chixiaodou (adzuki bean, sprouted and dried) 3 Sheng* 510g
Danggui 10 Liang** 150g
Total Formula Weight 660g
Single Dose Weight 1 Fangcunbi ~1.66g
Daily Dose Weight 3 Fangcunbi ~5g
Treatment Period 132 days
Administered With Jiangshui 漿水 (Fermented Millet Water)

* A Sheng is a unit of volume that measures approximately 200ml.

** Some Jinggui Yaolue versions write 3 liang, others write 10 liang.

Chixiaodou Danggui San treats damp heat in the lower jiao which can lead to hemorrhoids, anal prolapse, excessive menstrual bleeding, ulceration, intestinal abscess, red eyes, rashes, irritability and other symptoms associated with damp head leading to blood toxicity presenting with a red tongue, yellow, greasy tongue coat, and rapid pulse.

Chixiaodou has a sweet/bland, slightly sour, and balanced nature, promotes urination, drains damp heat, stops bleeding and, as noted in the Shennong Bencao Jing, has the ability to expel the blood and pus from carbuncles and welling-abscess.[xvi]  Danggui’s sweet, acrid and warm nature nourishes the blood, disperses stasis, and promotes the healing of sores.  Fermented millet water is used to administer the powder and supports Chixiaodou by dissolving food accumulation and regulating the stomach with its sweet, sour, and cool nature.

Like Danggui Shaoyao San, Chixiaodou Danggui San has an intended dose period of around four months and aims to nourish blood in the lower jiao while simultaneously eliminating fluid accumulation.  Chixiaodou, a common food in China, is a particularly safe medicine for the slow, long term elimination of damp heat and blood toxicity.

Conclusion

From the above formulas, we can clearly see that Zhang Zhongjing favored using powders for the long-term treatment of recalcitrant lower jiao and gastrointestinal diseases that present with mixed excess and deficiency patterns.  According to the Jingfang Xiaopin (《經方小品》A Small Collection of Classical Formulas), powders and pills were used after a decoction formula had eliminated the primary pathogenic factors, presumably as a long term regulatory treatment, which could then be periodically assisted with decoction formulas.[xvii]  Sun Simiao believed powders were appropriate for slowly driving out pathogens, particularly wind and damp obstructions with symptoms that come and go without a static location,[xviii] as is characteristic with many gastrointestinal disorders.

Unfortunately, formula powders are rarely used in the modern clinic.  When used, they are often decocted as liquid formulas with little concern for difference in administration form or dose.  I hypothesize that powdered formulas may offer a better, cheaper, safer, and more convenient treatment method for the long-term resolution of many gastrointestinal and other lower jiao associated disorders, especially when used in conjunction with periodic decoction formula treatments.  As renewed interest in classical formula theory and application continues to grow in China and around the world I hope that modern practitioners will also renew research into formula powders for modern clinical use.

Endnotes

[i]《黄帝内经素问·腹中论篇第四十》云,“一剂知二剂已”。

[ii] 王付.经方用量秘旨. 人民军医出版社, 2015.62-64,98-100

[iii]《汉书·律历志·权衡》云,“权者,铢、两、斤、钧、石也……一龠容千二百黍,重十二铢,两之为两,二十四铢为两,十六两为斤”。

[iv] 李宇航.《伤寒论》方药剂量与配伍比例研究. 人民卫生出版社, 2015. 64

[v] 李宇航.《伤寒论》方药剂量与配伍比例研究. 人民卫生出版社, 2015. 68

[vi] 朱西杰、晋学仁、樊恒茂. “《伤寒论》“白饮”新解”,来源:《国医论坛》2000年第02期

[vii]《千金要方·论服饵第八》云,“凡服丸散,不云酒水饮者,本方如此,是可通用也”。《肘後備急方·華陽隱居《補闕肘後百一方》序》云,“凡下丸散,不雲酒水飲者,本方如此,而別說用酒水飲,則是可通用三物服也”。

[viii] 李宇铭.伤寒治内方证原意. 中国中医药出版社, 2014.

[ix] 王付《历代经方方论》.人民军医出版社, 2013. 515

[x]《神农本草经》云,“柴胡味苦平,主心腹,去肠胃中结气,饮食积聚,寒热邪气,推陈致新”。

[xi]《名医别录》云,“芍药味酸微寒有小毒,主通顺血脉,缓中,散恶血,逐贼血,去水气,利膀胱、大小肠,消痈肿,时行寒热,中恶,腹痛,腰痛”。

[xii]《神农本草经》云,“消食”。《名医别录》云,“消痰水……消谷嗜食”。

[xiii] 王付《历代经方方论》.人民军医出版社, 2013. 574

[xiv]《名医别录》云,“酒,味苦甘辛大热有毒,主行药势,杀邪恶气”。

[xv] Bensky Chinese Herbal Medicine – Formulas & Strategies, 2nd Ed. page 588

[xvi] 《神农本草经》云, “ 味甘、酸,平。主下水肿,排痈肿脓血。生平泽”。

[xvii]《小品方·述看方及逆合备急药决》云,“病源宜服利药治取除者服汤之后宜将丸散也时时服汤助丸散耳”

[xviii]《千金要方·论诊候第四》云,“散能逐邪风气湿痹表里移走居无常处者散当平之”

Applying the International Classification of Functioning, Disability and Health to guide home health care services planning and delivery in Thailand.

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Applying the International Classification of Functioning, Disability and Health to guide home health care services planning and delivery in Thailand.

Home Health Care Serv Q. 2017 May 08;:

Authors: Pimdee A, Nualnetr N

Abstract
Home health care is an essential service for home-bound patients in Thailand. In this action research study, we used the International Classification of Functioning, Disability and Health (ICF) framework to modify home health care services provided by a university hospital. Staff responsible for delivering the services (physical therapist, nurses, and Thai traditional medicine practitioners) participated in the development of an ICF-based assessment tool and home health care service procedure. After an 8-month trial of implementing these changes, professional satisfaction and empowerment were high among the home health care team members. Patients and their caregivers were also satisfied with the services. In conclusion, the ICF is an effective means of guiding home health care.

PMID: 28481683 [PubMed – as supplied by publisher]

Is ‘The Butcher of New England’ Harming Patients with Undisclosed Conflicts of Interest?

Migraine is a common, debilitating condition that is notoriously difficult to treat1. While conventional treatments offer a poor effectiveness versus safety profile, acupuncture has been demonstrated to be at least as effective if not more effective than medication with far fewer side-effects2. For this reason, acupuncture is recommended in official evidence-based clinical guidelines such as the UK’s NICE Guidelines for Headaches.

However, Harvard neurologist Paul G. Mathew, who appropriately refers to himself as ‘The Butcher of New England’, seems to have a different opinion on the matter. In his recent blog post on the Harvard Health blog, which was riddled with questionable puns but largely devoid of demonstrable familiarity with the research literature on the subject under discussion, Dr Mathew argued that the benefits of acupuncture were small while the evidence for conventional treatments strong, that physical therapy is a great alternative to drugs even when it doesn’t work, and ended with a questionable anecdote pointing to an undisclosed financial conflict of interest, rather than a good-willed desire to inform patients on their treatment options, as a possible motivation for steering migraine sufferers away from a treatment with a proven record of efficacy and safety.

Modest at Best

Dr Mathew’s discussion of the literature on treatments for migraines was on the whole anecdotal and unreferenced, leading one to ask what exactly was the point of writing the post in the first place. (Get it? Point? POINT?! It’s a pun on acupuncture. Two can play this game).

However, in an uncharacteristic move, Dr Mathew dabbled with using an actual citation to support his prose, referring to a recent clinical trial on acupuncture for migraine3. According to Dr Matthew: “Twelve weeks after treatment, the acupuncture group had on average 3.2 fewer attacks per month, the sham acupuncture group had 2.1 fewer attacks per month, and the wait-list group had 1.4 fewer attacks per month. These results are modest at best.”

Zhao, L., Chen, J., Li, Y., Sun, X., Chang, X., Zheng, H., et al. (2017). The Long-term Effect of Acupuncture for Migraine Prophylaxis. JAMA Internal Medicine, 177(4), 508–8. http://doi.org/10.1001/jamainternmed.2016.9378

So compared to sham needling, which is an active control with specific effects in the treatment of migraine4, true acupuncture was significantly more effective at reducing migraines at all time points while sham acupuncture was not significantly different from the waitlist control. Of course, normally, evidence-based practitioners prefer to use systematic reviews where available over individual studies. The most recent Cochrane review found that for reduction in headaches, acupuncture was associated with an effect size of 0.19 compared to active sham needling control 5, which to compare is greater than the effect size of SSRIs compared to placebo.6 Compared to usual care, the effect size is -0.56 in favor of acupuncture.

At 16 weeks, 200mg/day of Topiramate is associated with a reduction of 1.08 migraines per month7, whereas acupuncture has a 1.10 migraine reduction compared to sham needling.

Another migraine treatment, Botox injections, has even weaker support for its use. The PREEMPT trials, which were multi-armed Phase III trials funded by Allergan, the makers of Botox, found the following results for reduction in headaches per month: at 24 weeks, the Botox group had 5.2 fewer attacks and the placebo group had 4.9 fewer attacks, a difference of less than half a headache per month. At 56 weeks, the Botox group had 7.4 fewer attacks and the placebo group had 7.5 fewer attacks, a difference of precisely zero. Nada. Zilch.

So, Dr Mathew, if you describe the difference in reduction of headaches between acupuncture and active sham needling to be “modest at best,” then precisely how would describe the total lack of difference in headache reduction with Botox compared to placebo?

Butchering the Evidence on Standard Treatment

What’s interesting about the drugs used in the prevention of migraine, whether it’s an ACE inhibitor, alpha-blocker, beta-blocker, SSRI, serotonin agonist or tricyclic antidepressant, is that they all have something in common: none of them are actually migraine medications. They all fall into the category of ‘off-label prescribing.’ That’s when a drug approved for one use, such as an anti-depressant, is used for another entirely different use, such as migraine prevention, which it hasn’t been licensed or approved for. This situation arises because there aren’t really any medications that work very well for preventing migraines. Since this is pretty much common knowledge amongst clinicians, it was particularly surprising that as Dr Mathew argued against using acupuncture while pointing to evidence of its efficacy, he claimed that there’s good evidence for standard treatment, without pointing to any data at all.

Dr Mathew, not to be slowed down by actually reading the literature before summarizing it, tells us: “In general, the effectiveness of standard treatment (medication and injectable therapies) is supported by much stronger scientific evidence than acupuncture, including large clinical trials with thousands of subjects.” Fascinating. A 2015 meta-analysis8 of all drugs for the prevention of migraine, which included 126 randomized placebo-controlled clinical trials, found that the number of participants included in the studies was 112 on average, ranging from 9 to 783, making one wonder, pray tell, exactly which clinical trials with ‘thousands of subjects’ providing strong ‘scientific evidence’ for treating migraines with drugs Dr Mathew is referring to . . .

The results of this review are as follows: most of the drugs that are regularly used have no effectiveness beyond placebo. Drugs with at least 3 trials that were more effective than placebo for episodic migraines were as following:
– Amitriptyline: SMD: -1.2 (-1.7 to -0.82)
– Flunarizine: -1.1 headaches/month (-1.6 to -0.67)
– Fluoxetine: SMD: -0.57 (-0.97 to -0.17)
– Metoprolol: -0.94 headaches/month (CI -1.4 to -0.46)
– Pizotifen: -0.43 headaches/month (CI -0.6 to -0.21)
– Propranolol: 1.3 headaches/month (-2.0 to -0.62)
– Topiramate: -1.1 headaches/month (-1.9 to -0.73)
– Valproate: -1.5 headaches/month (-2.1 to -0.8)

So the studies on drugs that reported the results in terms of headaches per month had about the same advantage or perhaps less over placebo pill as acupuncture had over active sham control. And since the drugs were compared to an inert placebo and the acupuncture was compared to an active control, then it’s likely that acupuncture’s effectiveness is underestimated.

If that were the case, we’d expect acupuncture to outperform drugs when tested head to head, which is precisely what the literature shows.

A randomized trial of acupuncture versus topiramate9, an anticonvulsant often used to treat migraines, demonstrated that acupuncture resulted in a significantly larger decrease in moderate/severe headaches (from 20.2 down to 9.8 versus 19.8 to 12 in the topiramate group). Additionally, acupuncture was more effective than topiramate for all secondary outcomes, such as pain intensity and quality of life. While adverse events occurred in 66% of the topiramate group, they only occurred in 6% of the acupuncture group, demonstrating a far superior benefit to risk profile for acupuncture.

Yang, C.-P., Chang, M.-H., Liu, P.-E., Li, T.-C., Hsieh, C.-L., Hwang, K.-L., & Chang, H.-H. (2011). Acupuncture versus topiramate in chronic migraine prophylaxis: a randomized clinical trial. Cephalalgia : an International Journal of Headache, 31(15), 1510–1521. http://doi.org/10.1177/0333102411420585

A 2013 study evaluating acupuncture vs valproic acid, another anti-epileptic drug, showed that at 6 months, pain intensity was lower in the acupuncture group, pain relief was greater, and the acupuncture group was taking significantly less acute medication (Rizatriptan). The rate of adverse events in the group given valproic acid was 47.8%; in the acupuncture group it was 0%.10

A recent Cochrane Systematic review confirms the findings of these studies. Compared to drugs, acupuncture is associated with -0.49 fewer migraine attacks at 8 weeks, -0.32 fewer migraines at 4 months, and -0.31 migraines 3.5 to 6 months after randomization compared to drugs. All results are statistically significant.

While self-styled acupuncture “Skeptics” (those who argue that acupuncture doesn’t work regardless of considerable evidence to the contrary) are quick to point out that head to head comparisons are biased because they are unblinded, researchers and clinical experts are quicker to point out that so is real life, where the patients are. Acupuncture’s superiority over sham and its many known biochemical mechanisms demonstrate specific effects. But of course, all of this is purely academic; head to head studies are the ones that tell you which treatments are most likely to benefit real patients in the real world comparing the treatment options that they are actually faced with, provided in the way that they would actually receive the treatment. The best evidence shows that acupuncture is more effective than drugs.

Side-effects?

“Side effects are not just limited to medications; procedures can also have negative effects,” Dr Mathew reminds us. Excellent point! According to an analysis of the safety and tolerability of Botox for chronic migraine, adverse events (AEs) were reported in a whopping 74% of those who received Botox. In fact, neck pain is such a common side-effect of the treatment that it results in unblinding in trials, as subjects know whether or not they’ve received the real deal based on how much pain they’re in afterwards.

Serious adverse events, which “were any that resulted in death, a life-threatening event, hospitalization (initial or prolonged), disability, a congenital anomaly or a medical event that could require medical or surgical intervention to prevent the above outcomes” was reported in 5.4% of those who were injected with Botox. The most common serious AE was (wait for it . . .) migraine. It’s unclear whether the common occurrence of migraines triggered by Botox treatment were classed as serious AE’s simply by causing disability or if a significant number of test subjects had migraines caused by Botox that were so severe they required hospitalization. Either way, causing serious migraines seems like sort of a counter-productive effect for a migraine treatment.

So what the data suggests is that not only does Botox not seem to reduce migraines compared to placebo, but the data shows that it actually causes them.11

After recommending against acupuncture based on a high-quality study that supports its efficacy, Dr Mathew has this advice for those who want to steer away from medication: “For those averse to medications, physical therapy is a great alternative — one based on actual human anatomy and scientific principles. My patients often complain that they do not feel significantly better after the five to 10 sessions of physical therapy that insurance companies typically approve. I advise them that the true benefit of physical therapy comes when the stretching and strengthening routines taught by the therapist are continued at home on a long-term basis.”

So physical therapy is ‘a great alternative’, even though a recent systematic review failed to show any effect on reducing migraines compared to control12 and even when his patients are telling him that it’s not working.

What would possibly compel Dr Mathew to write this?

The literature shows that acupuncture is an effective and safe treatment for migraine prophylaxis; indeed, it is one of the only ones clinical experts know of. It is more effective than sham needling, demonstrating specific effects and it’s more effective and safer than drugs, demonstrating that it should be offered as a first-line treatment and often is.

So why would Dr Mathew write a largely unreferenced blog post on Harvard’s Health Blog based on anecdote, opinion and conjecture that’s directly contradicted by the medical literature?

A possible clue comes at the finale of the piece, where we learn that a) Dr Mathew provides Botox injections for migraines, b) that he trains others to perform the procedure and c) that he thinks it’s appropriate to mock patients about how painful this procedure is (the safety data confirms that pain is a common result of the treatment and teasing patients about it just seems cruel).

Ok, so he’s a bit biased. He provides Botox and wants to rib the competition. Not very professional, appropriate or ethical, but we all get our kicks in different ways. It’s not like he’s received payment from Allergan, I mean that would be highly unethical not to mention totally inappropriate to write something so libelous and inaccurate without making his conflicts of interest crystal clear.

Just to double-check, I headed over to ProPublica and it would seem that Dr Mathew has indeed received money from Allergan, the makers of Botox.

I suppose we’ll never know if Dr Mathew would have taken it upon himself to steer patients away from a safe and effective treatment for a debilitating neurological condition towards a treatment that suffers from lack of evidence and a risky side-effect profile if he wasn’t financially incentivized to do so. One wonders if it is even appropriate for someone who is receiving money from the pharmaceutical industry to be writing about a non-pharmacological treatment such as acupuncture at all when they apparently lack any familiarity with the subject matter.

But one thing is crystal clear: Harvard, for the sake of public health and academic integrity, a highly visible conflict of interest declaration needs to be added to the top of this ‘blog post’ post-haste.

Herbal and dietary supplements related to diarrhea and acute kidney injury: a case report.

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Herbal and dietary supplements related to diarrhea and acute kidney injury: a case report.

J Complement Integr Med. 2017 Mar 01;14(1):

Authors: Wanitsriphinyo S, Tangkiatkumjai M

Abstract
Background There is very little evidence relating to the association of herbal medicine with diarrhea and the development of acute kidney injury (AKI). This study reports a case of diarrhea-induced AKI, possibly related to an individual ingesting copious amounts of homemade mixed fruit and herb puree. Case presentation A 45-year-old Thai man with diabetes had diarrhea for 2 days, as a result of taking high amounts of a puree made up of eight mixed fruits and herbs over a 3-day period. He developed dehydration and stage 2 AKI, with a doubling of his serum creatinine. He had been receiving enalapril, as a prescribed medication, over one year. After he stopped taking both the puree and enalapril, and received fluid replacement therapy, within a week his serum creatinine had gradually decreased. The combination of puree, enalapril and AKI may also have induced hyperkalemia in this patient. Furthermore, the patient developed hyperphosphatemia due to his worsening kidney function, exacerbated by regularly taking some dietary supplements containing high levels of phosphate. His serum levels of potassium and phosphate returned to normal within a week, once the patient stopped both the puree and all dietary supplements, and had begun receiving treatment for hyperkalemia. Results The mixed fruit and herb puree taken by this man may have led to his diarrhea due to its effect; particularly if the patient was taking a high concentration of such a drink. Both the puree and enalapril are likely to attenuate the progression of kidney function. The causal relationship between the puree and AKI was probable (5 scores) assessed by the modified Naranjo algorithm. This is the first case report, as far as the authors are aware, relating the drinking of a mixed fruit and herbal puree to diarrhea and AKI in a patient with diabetes. Conclusions This case can alert health care providers to the possibility that herbal medicine could induce diarrhea and develop acute kidney injury.

PMID: 28282296 [PubMed – in process]