Inhibitory effect of Phlai capsules on skin test responses among allergic rhinitis patients: a randomized, three-way crossover study.

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Inhibitory effect of Phlai capsules on skin test responses among allergic rhinitis patients: a randomized, three-way crossover study.

J Integr Med. 2017 Nov;15(6):462-468

Authors: Tanticharoenwiwat P, Kulalert P, Dechatiwongse Na Ayudhya T, Koontongkaew S, Jiratchariyakul W, Soawakontha R, Booncong P, Poachanukoon O

Abstract
BACKGROUND: Zingiber cassumunar Roxb., commonly known as Phlai in Thai, has been used as a traditional medicine in Thailand for the treatment of various diseases, including inflammation and chronic airway disease.
OBJECTIVE: The purpose of this study was to assess the antihistaminic effect of Phlai on skin testing.
DESIGN, SETTING, PARTICIPANTS AND INTERVENTION: This was a randomized, open-label, three-way crossover study. Twenty allergic rhinitis (AR) patients were enrolled. In randomized sequence, patients received a single dose of Phlai capsules (100 or 200 mg) or loratadine (10 mg) with a washout period of 1 week between each treatment.
MAIN OUTCOME MEASURES: Skin prick testing for histamine and common aeroallergen (house dust mite) were performed before treatment and after 1, 2, 3, 4, 6, 8, 12 and 24 hours of treatment. The main treatment outcomes were the mean wheal and flare responses to the skin prick test after treatment.
RESULTS: Both 100 mg and 200 mg Phlai doses suppressed wheal and flare responses to house dust mite allergen, but only 200 mg of Phlai capsules significantly suppressed wheal and flare responses to histamine. Repeated measures analysis of variance showed that loratadine caused more wheal and flare suppression than Phlai capsules in responses to the histamine skin prick test. However, there were no significant differences among the effects of 100 mg Phlai capsules, 200 mg Phlai capsules and loratadine in suppression of wheal and flare induced by the mite skin prick test. Both doses of Phlai were well-tolerated with no adverse events.
CONCLUSION: Both 100 mg (compound D 4 mg) and 200 mg (compound D 8 mg) Phlai capsules, when taken as a single therapeutic dose, inhibited skin reactivity to histamine and mite skin prick tests in AR patients.
TRIAL REGISTRATION: Thai clinical trial registry (TCTR20160510001).

PMID: 29103416 [PubMed – in process]

Lupinifolin from Albizia myriophylla wood: A study on its antibacterial mechanisms against cariogenic Streptococcus mutans.

Lupinifolin from Albizia myriophylla wood: A study on its antibacterial mechanisms against cariogenic Streptococcus mutans.

Arch Oral Biol. 2017 Oct 18;:

Authors: Limsuwan S, Moosigapong K, Jarukitsakul S, Joycharat N, Chusri S, Jaisamut P, Voravuthikunchai SP

Abstract
OBJECTIVE: To determine the anti-Streptococcus mutans mechanisms of action of lupinifolin from Albizia myriophylla Benth. (Fabaceae) wood and provide scientific evidence to support the traditional use of the plant against dental caries.
METHODS: The minimum inhibitory concentration (MIC) was evaluated using the broth micro-dilution method. The effects of lupinifolin on bactericidal activity, bacterial cell walls, and membranes were investigated by time-kill, lysis, and leakage assays, respectively. Electron microscopy was utilized to observe any cell morphological changes caused by the compound. Localization of lupinifolin in S. mutans was detected using the thin layer chromatography technique.
RESULTS: The MIC range of lupinifolin against S. mutans (n=6) was 2-4 μg/ml. This compound displayed bactericidal effects on S. mutans ATCC 25175 by 90-99.9% killing at 4MIC-16MIC after 8-24 hours. Lupinifolin-treated cells demonstrated no lysis. However, significant cytoplasmic leakage through the bacterial membrane was observed after treatment with lupinifolin at 4MIC-16MIC. As revealed by ultrastructural analysis, lupinifolin produced some changes in bacterial cell walls and membranes. Moreover, the compound was observed in the cytoplasmic fraction of the lupinifolin-treated cells. These results suggest that lupinifolin can enter the cell of bacteria but does not accumulate in the cell envelope and subsequently disrupts the integrity of the cytoplasmic membrane, leading to cell death.
CONCLUSION: The scientific evidence from this study offers valuable insights into the potential role of lupinifolin in pharmaceutical and antibiotic applications and supports the therapeutic effects of A. myriophylla, which has traditionally been used as an alternative treatment for dental caries.

PMID: 29102025 [PubMed – as supplied by publisher]

What is the ‘Science-based’ treatment for the prevention of migraine?

Dear Science Based Medicine,

Over the years, I’ve followed your work with great interest in an effort to better understand ‘real’ medicine and how it is that treatments can consistently do well in trials and yet, according to ‘Science,’ not really work at all. It’s been very informative and I think I’m getting the hang of it.

While I’m pretty clear on what Science Based Medicine recommends against (pretty much anything that seems silly to the authors), I am more or less in the dark as to what it does recommend. It’s almost as if your site should be called ’Definitely not science-based medicine’ since that’s the preferred topic.

But I’m sure the public would be really interested to know, with real patients in the real world, which treatments does Science Based Medicine actually recommend? Because this is a very large topic, let’s specifically take the example of migraine prevention, partly because Dr Novella is a neurologist so he has clinical expertise here and partly because you specifically recommend against acupuncture, even when it outperforms other treatments. So I think it would help me, not to mention the public and healthcare policy makers, who also recommend acupuncture1, to understand if acupuncture is not a ‘science-based’ treatment for migraine, what in your estimation is?

What is ‘Science Based’ Medicine?

For those who are unfamiliar, a helpful place to begin our discussion is with what it means for medicine to be ‘Science based’ vs ‘Evidence based,’ which is the dominant paradigm in medicine. What follows is a genuine attempt to accurately summarise the SBM position (no intended straw men here) but I welcome clarification and correction, where needed.

In 2015, Dr Novella gave a talk on this very subject entitled ‘Science-Based Medicine: Beyond Integrative Medicine’, where he explained what Science Based Medicine is and how it goes a much needed step beyond Evidence Base Medicine.

He described ‘science’ in terms of five intellectual virtues, not specific to science, but emblematic of science, as follows:

1) Reasonably accounts for all available evidence. “What that means is that you can’t just pick and choose the evidence that you want. You have to account for all the evidence that’s available.”
2) Utilizes valid and internally consistent logic. “If you make an internally inconsistent logical statement, you’re not going to be led to a valid conclusion.”
3) Intellectually thorough, rigorous and methodical
4) Reasonably fair and unbiased in judgments
5) Adheres to standards of ethics and professionalism

When describing Evidence Based Medicine, in contrast, Dr Novella explained that EBM ‘assumes that products and practices that work and are safe are better than those that do not work or are unsafe.’ If you’re a patient, doctor or healthcare policy maker, you might be thinking this sounds like a pretty good way to go. But unfortunately while this approach may lead to safe and effective treatment options, it wouldn’t be appropriately labeled ‘science-based’ and would demonstrate a sad lack of critical thinking.

The main problem with the EBM approach, Dr Novella points out, is that it ignores ‘prior probability’ and does not adequately consider the ‘big picture’ of the entire literature. In other words, in randomized clinical trials, patients might have excellent results from a treatment like, say, acupuncture compared to usual care, pharmaceuticals, even sham needling. But if you don’t stop to consider how silly acupuncture seems in theory to a conventionally trained doctor, then you might incorrectly recommend it when you could recommend treatments that don’t work as well but seem more rational because they involve chemicals.

So EBM’s main weakness, according to SBM, is that it doesn’t go far enough, which is to say that it currently focuses too much on clinical evidence (how treatments effect patients), comparitive effectiveness (which treatments work better than others) and safety and not enough on logic and prior probability (which treatments in theory should work). “Good science considers both.”

“Reasonably accounts for all available evidence”

The first virtue of Science Based Medicine, and the one that according to Science Based Medicine most distinguishes it from plain old Evidence Based Medicine, which is too focused unscientific things like clinical evidence for what works and minimizes harm to patients, is that it “reasonably accounts for all available evidence. What that means is that you can’t just pick and choose the evidence that you want. You have to account for all the evidence that’s available.”

This approach sounds reasonable, if not a bit less relevant to patients than EBM.

So what I don’t understand, and hopefully you can provide some insight, is in the 2013 opinion piece, ‘Acupuncture is a Theatrical Placebo’, Colqhoun and Novella write that the number one thing NOT relevant to the discussion as to whether acupuncture is effective is the basic science research into acupuncture’s biochemical and neurological mechanisms: “We see no point in discussing surrogate outcomes, such as functional magnetic resonance imaging studies or endorphine release studies, until such time as it has been shown that patients get a useful degree of relief.” In other words, they only want to look at clinical evidence of their choosing, and completely ignore the entirety of the basic science literature for acupuncture. This approach is precisely the thing they accuse EBM of doing and what they claim makes them superior and more ‘Science’-based than their medical colleagues. When it’s pointed out that the clinical evidence for acupuncture is moderate to strong for dozens of clinical conditions2, they explain the results through placebo, non-specific effects, and regression to the mean (aspects of all treatments), having deemed the mechanism literature irrelevant.

What the basic science literature tells us is that acupuncture needling functions at least in part as a mechanical stimulus that results in a number of local and central effects (‘local’ being where you’re inserting the needle and ‘central’ being in the brain and spinal cord, both clinically helpful!). It causes fibroblasts (cells responsible for communication, remodeling and healing of the fascia) to stretch and degranulate, releasing a number of signaling molecules that act on local afferent nerves, which are more dense at acupuncture points.3 It also initiates purinergic signaling through the release of ATP and adenosine, which provides local anti-inflammatory effects as well as binding to local afferents that carry central signals. Interestingly, this release was found at an acupuncture point but not at the control point, lending support for specific effects.4

Downstream of the purines, other biochemicals involved in disease resolution, such as nitric oxide,5 BDNF6 and CGRP7 are released and regulated. Furthermore, unlike traditional ‘placebos’ that are known (sometimes but not always) to result in endorphin release, acupuncture, but not sham acupuncture needling, has been shown to increase receptivity to endorphins in the brain.8

So how is leaving out this literature consistent with considering all available evidence? Isn’t this the complete diametric opposite of your position to reasonably account for all available evidence and not rely solely on clinical evidence? A recent review of all available systematic review evidence (which Harriet Hall recently referred to as ‘cherry-picking,’ suggesting she may want a refresher on what the term means) found moderate or high-quality evidence that acupuncture provides a ‘useful degree of relief’ for 46 different conditions.9 On what grounds can you declare that this is entirely due to placebo if you consider the basic science literature on the physiological and biochemical effects of needling irrelevant? Is this internally logical, consistent, unbiased and ethical?

Equally, we could look at the other available treatments for migraine prophylaxis, at least some of which Dr Novella and others at SBM presumambly recommend. Looking at the most common treatments for migraine prophylaxis, what does the basic science research say about beta-blockers for migraine? Is migraine caused by an over-activation of the sympathetic nervous system, such that chemically castrating this system is a logical recourse? Or anti-epileptics such as topiramate and valproate? Can you point me to the basic science research that demonstrates how these work for migraine? Do you test your migraine patients for serotonin deficiency before putting them on SSRI’s and pizotifen? Do drugs have biological plausability for any condition no matter how they work because they’re drugs? If so, is that really scientific?

Or might this concept of ‘biological plausibility,’ the key feature that separates Science Based Medicine from the majority of mainstream medicine that just ‘doesn’t get it,’ actually a subjective judgment based on what you choose to read?

‘Utilizes valid and internally consistent logic’

‘If you make an internally inconsistent logical statement, you’re not going to be led to a valid conclusion.’

The second virtue of Science, and Science Based Medicine by extension, is that it utilizes valid and internally consistent logic. I agree that logical consistency is a very helpful concept when studying medicine. Of course, as pointed out previously, one might ask how classifying all basic science research into acupuncture as irrelevant to a discussion of its mode of action can be considered internally consistent and logical, but I’m sure a valid explanation is forthcoming.

But let’s take another simple example of what is usually meant by ‘logical consistency.’ Let’s say you have a treatment that we’ll call Treatment A and you test it against another treatment, which we’ll call Treatment B. We might test these two against each other and discover that patients who were given Treatment A were significantly more likely to have a 50% reduction in their migraines than those given Treatment B. We could summarise these results by saying that Treatment A is more effective than Treatment B.

Further, if Treatment B is a sugar pill controlling for the effects of placebo, we might say ‘Treatment A is more effective than Placebo.’

Now, let’s say you have a further experiment, where one group gets Treatment A and another group gets a 3rd treatment, Treatment C (we might even have Waitlist Control D, to control for regression to the mean). And in this experiment, more patients who received Treatment C, had a 50% reduction in migraine than those receiving Treatment A.

So using a very simple model of internally consistent logic (applying what is known in geeky math-speak as Transitive Law), we would say that, by definition, Treatment C works better than placebo. If A is better than placebo and C is better than A, C is also better than placebo. If pharmaceuticals are better than placebo and acupuncture is better than pharmaceuticals, acupuncture is better than placebo. This is how logic works.

‘But, Mel,’ you say, ‘complex physical interventions have larger placebo effects than pills. In theory, acupuncture could work better at preventing migraine than sugar pill and the real drug and still be a theatrical placebo. Sure, in adequately powered trials, acupuncture does significanlty outperform sham needling, but only by a little. This difference could be completely down to lack of blinding of the practitioner.’

Sure, that’s a possibility. But is that the most likely explanation based on the evidence? Are acupuncture’s results for reducing migraines consistent with other placebos? What the heck do we know about placebos anyway?

There seems to be a lot of misunderstanding around what the placebos are and how to accurately tease out their effects from other specific and non-specific phenomena10 but there are two things that we do know: “In reality, placebos don’t do much; their effects tend to be small in magnitude and short in duration.” 11

Small in magnitude and short in duration. In other words, placebos have small effect sizes and only work in the short-term. A 2010 Cochrane systematic review of placebo treatments for all conditions supports this first point. They found that compared to no-treatment, placebos were associated with small effect sizes.12 In contrast, for migraine prevention, acupuncture is associated with moderate to large effects. Whether the outcome measure is headache frequency, responder rate, migraine attacks or migraine days, unlike a placebo, acupuncture demonstrates large effect sizes compared to no treatment.13

The placebo review also found that compared to no-treatment, sham-acupuncture needling has large effect sizes, whereas other sham treatments like TENS, had little to no effect. This data supports the contention of experts that sham-needling is not a placebo or inert sham control14 and that the difference between acupuncture and sham-needling is not the measure of its true effect size.15

We also know from research into placebos that they only work in the short-term; this finding is equally true for migraine reduction. A recent systematic review and meta-anlaysis looked at the effects of placebo for migraines in 78 studies that includeed 4,579 episodic migraine sufferers randomized to placebo. Before treatment, these patients averaged 5.3 headaches/month. After taking the placebo, they had a significant reduction in headache frequency one month into the study that persisted at 12 weeks. However, by weeks 16, 20, and 24, the patients were having just as many headaches as before.16

Jackson, J. L., Cogbill, E., Santana-Davila, R., & Eldredge, C. (2015). A comparative effectiveness meta-analysis of drugs for the prophylaxis of migraine headache. PLoS ONE. http://doi.org/10.1371/journal.pone.0130733.s001

In contrast, acupuncture has significant effects compared with no treatment, sham needling and drug-intervention at 3-4 month follow-up.17 Likewise, a recent review found that the majoriy of acupuncture’s clinical effects are maintained one year after treatment.18

So looking at this again, placebos and shams have small effects over no treatment and only work in the short term. Acupuncture has large effects over no treatment and its clinical effects persist in the long-term.

Applying that internally consistent logic thingy again, wouldn’t you have to conclude that acupuncture is not a placebo? Especially if you decide to include all the evidence and look at all that ‘irrelevant’ basic science research?

You seem to argue that, despite the basic science research demonstrating mechanisms through mechanotransduction and other neurological and biochemical effects of acupuncture needling, that acupuncture’s superiority to drugs is still fully placebo and other non-specific effects. It’s just an uncharacteristically large and long-acting, perhaps paradoxical and unique, placebo, which sounds a little bit like special pleading (a practice that uninterested and unbiased parties don’t tend to engage in).

No matter how you slice it, meta-analyses demonstrate that whatever acupuncturists are offering, it’s working as well as if not better and more safely than the alternatives when it comes to migraine prevention. If it’s not down to empathy, then what is it? How is it that acupuncture, which you argue is a placebo, outperforms conventional treatment? Which itself outperforms placebo? Which brings us to the virtue of ‘ethics’ in making recommendations. But first, let’s look at Virtue Number 3.

‘Intellectually thorough, rigorous and methodical’

Yep, this also sounds good. If it were available in a 12 oz can, I’d happily chug the whole thing.

So let’s be intellectually thorough, rigorous and methodical about reasonable treatment options for migraine prophylaxis. From my understanding, your main objection is that acupuncture doesn’t work because there’s no such thing as Qi or channels. Hopefully, that’s a fair categorization. If it’s not, no doubt you can clarify your position.

Assuming that’s a fair categorization, then let me clarify something first. If what you’re saying is that there isn’t an invisible ‘life force energy’ that flows through some as yet undiscovered physical structure referred to as a ‘channel’, I’m actually with you on that. That description simply isn’t a good translation or characterization of the Chinese medical model and certainly not been what’s been discussed at any research conferences that I’ve attended.

However, if we’re going to take a stab at being ‘methodical,’ answer me this: can you explain the logic involved in the position that despite copious clinical research to the contrary, acupuncture doesn’t work because there’s no such thing as an invisible life force energy? Isn’t it possible that there’s no invisible, hitherto undiscovered life force energy AND AT THE SAME TIME acupuncture is effective at reducing migraines, as the best evidence supports?

Apparently, claiming that if an argument for some conclusion is fallacious, then the conclusion is false, is known as the ‘fallacy fallacy.‘ I love the way you skeptics name these things! Now, just because your position contains false logic, doesn’t in itself mean that acupuncture is effective for migraine prevention (that would actually be the ‘fallacy fallacy fallacy’, I kid you not). No, for that we have clinical research.

However you slice it, arguing that something doesn’t work despite ample evidence to the contrary because you perceive the model used to explain how it works as an inaccurate isn’t exactly intellectually thorough, rigorous or methodical (if not downright logically fallacious!)

This faulty reasoning reminds me of a video I recently watched about a new light that runs on a kinetic motor so it’s powered simply using a weight and some gravity. (How frickin’ cool is that!) This one item is revolutionizing people’s lives and allowing people in remote villages to have reliable access to light without the use of expensive and harmful kerosene.

In some regions of Kenya where the light is being distributed, the villagers, not understanding the mechanics of how the light works off the grid, are said to believe that it works using ‘supernatural power.’

If this situation were analogous to your current arguments about acupuncture, you’d be saying that the light doesn’t work because it can’t work since there’s no such thing as supernatural forces, even though everyone can clearly see that it does work (but perhaps then you’d be arguing that they just think they see light, that it’s another example of post hoc ergo propter hoc. I mean, just because they turned on the light and things got brighter, doesn’t mean that turning on the light caused illumination), not to mention that we can measure the photons it emits and that other explanations, consistent with dominant models explain how it works, at least to the extent that most drugs are understood. Such an argument would be clearly non-sensical. Whether or not the light works has nothing to do with whether the villagers explain that it works via these supernatural powers or not.

And there’s also the possibility, since we’re being thorough and rigour in our approach and examining the phenomenon from all sides, that the villagers aren’t actually simpletons who lack the intellectual rigor to understand how the light works. It’s possible that the villagers speak a rare and poorly understood dialect of their language and that the people translating those explanations into English didn’t understand what the villagers were actually saying and mis-represented their position, making them look ‘pre-scientific’ and ‘supersticious’. It’s possible that a more accurate and nuanced, albeit less popular, translation of their worldview demonstrates a perspective that’s remarkably prescient and perhaps even includes models that have better explanatory power than the ones most widely used in conventional medicine. <Cue eyerolls>

Let me anticipate your next objection: that if acupuncture doesn’t work by accessing ‘life force energy’ in ‘channels’ than those who are describing it as such are misleading the public and committing fraud. Or in your words: “it is misleading to say that such mechanisms (purinergic signaling, nitric oxide release, phosphorylation of collagen, etc) could explain “acupuncture.” Acupuncture is the needling of acupuncture points to affect the flow and balance of chi. Using needles to mechanically produce a temporary local counter-irritation effect is not acupuncture.”

Well, not to be whatever, but who died and made ‘Science Based Medicine’ the Supreme Arbiter of acupuncture definitions? This is a classic argumentum ad dicitonarium fallacy and very unscientific. Wouldn’t you be less at risk of being mistaken on this issue if you asked, for example, some of your tens of thousands of colleagues who are dually trained MDs and acupunturists? Sure, it’s possible that all of them suffered brain aneurysms after medical school (oy, the stress!) and lost their ability to think critically. But you might just find that you have a lot more common ground than you’d expect and it’s also possible, if not probable, that those who have trained in acupuncture are in a better position to discuss definitions than those simply looking at ways to discredit it. It is simply incorrect to say that there is one, singular definition of acupuncture that relies on scientifically unvalidated concepts. The only reason for making such a claim is to disprove it, which not only reflects a strong bias, but one that prevents joining understanding with empiricism. Which leads us to the next ‘virtue’ in your shiny, ‘science-based’ halo.

‘Reasonably fair and unbiased in judgments’

Science, and the medicine it’s based on, should be reasonably fair and unbiased in judgments.

This point is another that sounds wonderful in theory but may be a bit hard to demonstrate it’s validity in practice. From where I’m sitting, science can’t make judgments. Only people can do that. And furthermore, science demonstrates that the study of science is biased and that the best we can do is be intellectually honest and aware of our biases in order to minimize them and do the best by our patients.19

Let’s say for example, that your intention is to improve public health by informing patients about their treatment options and drawing attention to the problems with certain treatments, using science and research. If that’s the goal, then can you explain any reason why your top priority wouldn’t be drawing attention to and recommending against the treatments that have the poorest benefit to harm ratios first? Why would you start with treatments that consistently demonstrate a superior benefit to harm profile, which you hypothesize is due to placebo and that basic science research demonstrates is due to mechano-transduction, rather than treatments that usually don’t work and have really nasty side-effects?

Is there a possibility that by choosing to focus on and criticise treatments with demonstrated effectiveness that seem illogical and silly to you (but not to the majority of your colleagues), that you might possibly be encouraging the use of more dangerous, and less effective treatments? And that this might be arising from the mistaken (and unscientific belief) that you can be unbiased? That you’re communicating a scientific perspective rather than spreading the good Gospel of Science?

Or we can put it another way. Your bias is that we shouldn’t recommend treatments based solely on demonstrated effectiveness and efficacy as Evidence Based Medicine suggests; treatments should also have known mechanisms and a reasonable level of prior plausibility, a measure that in itself is highly subjective. That’s your prerogative but isn’t that something that patients should get to decide for themselves?

From familiarizing myself with your work, the biggest assumption that I’ve seen you repeat without testing is this idea that there even are ‘treatments that work’ and ‘treatments that don’t’ in any absolute sense. If that’s a fair categorization, that you believe that a treatment can ‘work’ in an absolute binary sense, rather than a comparative ‘at a population level, the group that had this treatment had significantly better results than the other group but not so good as this 3rd group and none of this tells us how my patient, Jane Smith, is going to do on this treatment’, are you able to provide scientific support for this viewpoint? On the basis of what evidence are you supporting this theory of absolute, rather than relative, effectiveness?

Let’s look at an example.

A recent systematic review looked at responder rates amongst various drugs commonly used for migraine prevention, where a responder was defined as someone who had at least a 50% reduction in their migraines. Even amongst the drugs that had significantly more responders than placebo pill, none of them achieved a response in greater than half of those who took them. In other words, if you say that a drug ‘works’ in some sort of theoretical absolute Platonic sense when it significantly outperforms placebo, by that definition these drugs ‘work.’ But the best research also shows that when given to a group of migraine patients, they usually don’t work. So even migraine drugs that ‘work’ usually don’t work. How does that work? How does that work with the whole ‘internally consistent logic’ thing?

Now again, I honestly don’t know what the ‘Science-based’ recommendation is for migraine prophylaxis and I’m eager to hear what it is and what evidence this is based on. But systematic reviews and medical guidelines tend to conclude something like this: “Selection of prophylactic medication should be tailored according to patient preferences, characteristics and side effect profiles.” 20 If that does indeed echo your position, then on what basis can you recommend these treatments as science-based? Unless you’re now broadening your definition of science-based medicine to include the old n=1 ‘none of these drugs work particularly well and all of these have pretty nasty side-effects so let’s just try something and see how we get on?’

On the same token, the most recent Cochrane systematic review demonstrates that acupuncture has greater than 50% responder rate, or in other words, acupuncture usually works for migraine prevention (by ‘works’, I mean both that in systematic reviews of randomised controlled trials, patients with migraines who have acupuncture are more likely to be a responder than those who don’t in a way statistically unlikely due to chance and comparatively, patients who receive acupuncture have better results than those who receive drugs). I know that your position is that this due to placebo rather than mechanano-ransduction, purinergic signaling, and CGRP regulation, but are you sure that recommending a trial and error approach of treatments that usually don’t work and have unpleasant and often dangerous side-effects over a treatment that usually works and is very safe represents a ‘reasonably fair and unbiased judgment’ and puts patient safety and results over theory and your own personal beliefs?

‘Adheres to standards of ethics and professionalism’

Science Based Medicine consistently takes the position that offering placebos to patients, even without deception, is unethical. Personally, I believe that medical ethics (and the law) indicate that patients have a right to informed consent, including knowing when a treatment with a worse benefit to harm profile is out performed by a treatment that you call a placebo.

But lets leave the ethics of prescribing placebos aside for a moment and let me ask you a different question. What is the ethics of prescribing a treatment that is inferior to placebo. If acupuncture is just a placebo and outperforms conventional pharmaceuticals, which have their own significant placebo built right in, then doesn’t internally consistent logic tell us quite clearly that these treatment are not only not helping but causing overt harm to patients?

Aside from the harm of not being as effective as acupuncture, these treatments used for migraine prophylaxis come with other harms that are relevant to a discussion of what Science Based Medicine recommends for these patients.

A recent review of prophylactic drugs for migraine found the following: “Drowsiness was the most common side effect, increased among patients taking gabapentin, pizotifen, topiramate, TCA and valproate. Tricyclic antidepressants also caused dry mouth and weight gain. Beta-blockers were associated with feeling depressed, dizzy and insomnia. Topiramate increased rates of nausea and paresthesia. Pizotifen had marked increased rates of weight gain with participants averaging 4.3 kg.” 21 Of course, medical treatment isn’t all about the harm it can cause as all treatment carries some risk. However, the balance between benefits and harms of preventative migraine drugs is a poor one, leading to frequent discontinuation.

While NSAIDs were not included in the above Jackson review, the JAMA summary of migraine prevention does mention them based on a clinical guideline from the American Academy of Neurology22. While it’s nice to include NSAIDs, presumably to increase the number of options as there’s no evidence that they work, they’re not without their risks. They can cause everything from peptic ulcer and GI bleeding, to hepatitis, cirrhosis, renal stenosis, congestive heart failure, and asthma.23 According to one review in the United States, regular NSAID use causes 200,000-400,000 hospitalizations from upper GI disease a year with an annual cost of 0.8-1.6 billion dollars.24 These staggering figures don’t even include the incidence and cost of heart attacks caused by NSAIDs. A recent review found that taking any dose of NSAIDs for even short periods was associated with an increased risk of heart attack.25 Of course all of this makes sense, since the prostaglandins that NSAIDs lower actually do kind of important things in the body, like protect the gastric mucosa, regulate renal blood flow, support healthy lung function and regulate vasoconstriction and platelet aggregation. So based on how they work, we wouldn’t really expect them to be safe.

In contrast to acupuncture which is considered safe in pregnancy,26 none of the pharmaceutical preventatives are considered to be safe, as they can lead to congenital malformations, miscarriage and seizures in newborns.

To be sure, just because there aren’t any overwhelmingly effective or safe pharmaceutical treatments for migraine prevention doesn’t necessarily mean that acupuncture works; the evidence for that comes from systematic reviews of clinical trials. But if you’re choosing amongst treatments that don’t ‘work’ anyways, shouldn’t you at least be recommending the safest ones first? Especially when they work better than the more dangerous ones? Or is that somehow inconsistent with the ‘Science-based’ medical model?

Wrap up

“In theory, theory and practice are the same. In practice, they’re not.” Attributed to Albert Einstein, Yogi Bera, and others.

Looking at the practice of acupuncture as a whole, I will concede that there’s great heterogeneity in treatment styles and it would interesting, if not useful, to study which techniques, theories and aspects of treatment work best, particularly in a way that is faithful to actual practice. I will also concede that while many Chinese medical theories are clinically useful and are consistent with modern science, some descriptions and understandings may be past their sell-by date or are based on a misunderstanding of the original theory. Just like with conventional medicine or any category of thought, we find the good, the bad, and the ugly and logic nor science supports equating any category with the worst that one can find within it (known as the ‘fallacy of composition‘).

That said, when it comes to migraine prevention, acupuncture clearly works, both in the ‘absolute’ sense (those who have acupuncture are more likely to have a significant reduction in migraine than those who don’t, unlike those who take pharmaceutical treatments for migraine) and in the more relevant, relative sense (acupuncture is more effective than pharmaceuticals, usual care, and sham needling for migraine prevention).27

It also doesn’t share the defining clinical features of placebos, in that unlike placebos, which only have small effects compared to no treatment and only work in the short-term, acupuncture has large effects compared to no treatment and has meaningful long-term clinical effects. It doesn’t walk or talk like a placebo; thus, it ain’t no placebo.

In light of the above, it may be worthwhile to review what makes Science ‘scientific’? What are science’s defining characteristics?

In his internationally best-selling book ‘Sapiens’, Yuval Noah Harari’s explains that:

“modern science differs from all previous traditions of knowledge in . . . critical ways:

a. The willingness to admit ignorance. Modern science is based on the Latin injunction ignoramus – ‘we do not know’. It assumes that we don’t know everything. Even more critically, it accepts that the things that we think we know could be proven wrong as we gain more knowledge. No concept, idea or theory is sacred and beyond challenge.

b. The centrality of observation and mathematics. Having admitted ignorance, modern science aims to obtain new knowledge. It does so by gathering observations and then using mathematical tools to connect these observations into comprehensive theories.”28

If there’s any truth to the above, then Science Based Medicine’s focus verging on obsession with prior plausibility is actually completely unscientific. Rather than admit that we don’t know and then use empiricism to understand what’s happening in the world and make new theories, the prior plausibility of Science Based Medicine starts by saying ‘aren’t we clever, we may not know everything but we know enough’ and then uses this view to argue with the data. The numbers say that patients get better with acupuncture compared to meds and that they’re put at far less risk of harm in the process. Let us tell you why the numbers are wrong according to our prior models.

The fact that science is based on the foundation of our awareness of our own ignorance is not a get out of jail free card to explain anything and everything as ‘possible’ or ‘scientific’. It is, however, a helpful reminder in the context of systematic reviews of thousands of randomised patients demonstrating an effective treatment for a common, debilitating treatment for which satisfactory treatment options are scarce.

I hope you don’t mind all the questions and I’m really looking forward to increasing my knowledge of the Science Based Medicine approach to treating a clinical condition like migraine. From reading your blog and watching your videos, it was hard not to get the impression that you were more inclined to recommend treatments that don’t work well because you felt they should in theory and recommend against treatments that do work, such as acupuncture, because in theory you felt that they shouldn’t based on your own narrow definition, which would be pretty unhelpful for patients (not to mention unnecessary, unethical and dangerous!) but I’m sure you’ll be able to enlighten us on all the Science-y nuance that we’ve hitherto lacked the rigor to grasp.

 

Pain, poison, and surgery in fouteenth-century China

This is a syndicated post that first appeared at http://recipes.hypotheses.org/9936

By Yi-Li Wu

It’s hard to set a compound fracture when the patient is in so much pain that he won’t let you touch him. For such situations, the Chinese doctor Wei Yilin (1277-1347) recommended giving the patient a dose of “numbing medicine” (ma yao).  This would make him “fall into a stupor,” after which the doctor could carry out the needed surgical procedures: “using a knife to cut open [flesh], or using scissors to cut away the sharp ends of bone.” Numbing medicine was also useful when extracting arrowheads from bones, Wei said, enabling the practitioner to “use iron tongs to pull it out, or use an auger to bore open [the bone] and thus extract it.” More generally, Wei recommended using numbing medicines for all fractures and dislocation, for it would allow the doctor to manipulate the patient’s body at will.

Wei’s preferred numbing medicine was “Wild Aconite Powder” (cao wu san), and he detailed the recipe in his influential compendium, Efficacious Formulas of a Hereditary Medical Family (Shiyi dexiao fang), completed in 1337 and printed by the Imperial Medical Academy of the Yuan dynasty (1271-1368). In his preface, Wei affirmed that medical formulas were the foundation of medicine and that a doctor’s ability to cure depended on his ability to use these tools skillfully. Wei’s family had practiced medicine for five generations, and he synthesized their knowledge with that of other doctors to produce a comprehensive treatise encompassing internal medicine; the diseases of women and children; eye diseases; illnesses of the mouth, teeth, and throat; ulcers and swellings; and diseases caused by invasions of “wind” (ailments with sudden onset, including febrile epidemics and paralytic strokes). Numbing medicine appeared in Wei’s chapters on bone setting and weapon wounds.

Wei’s Wild Aconite Powder is the earliest datable recipe that I have found for surgical anesthesia in a Chinese text, and it is a valuable window onto practices that were largely transmitted orally, whether in medical families or from master to disciple.  Dynastic histories relate that the legendary doctor Hua Tuo (110-207) employed a formula called mafeisan  to render his patients insensible prior to cutting them, even opening up their abdomens to excise rotting flesh and noxious accumulations. Some scholars have hypothesized that mafeisan (literally “hemp-boil-powder) may have contained morphine or cannabis (ma), but its ingredients remain a mystery.  A text attributed to the twelfth-century physician Dou Cai (ca. 1146) recommended using a mixture of powdered cannabis and datura flowers (shan qie zi, also called man tuo luo hua) to put patients to sleep prior to moxibustion treatments, which in this text could involve a hundred or more cones of burning mugwort placed directly on the patient’s skin.  Wei Yilin’s recipe provides important additional textual evidence for a tradition of anesthetic formulas based on toxic plants, one that was clearly in circulation long before he wrote it down.

At least as far back as the Divine Farmer’s Classic of Materia Medica(3rd c.), medical authors had described aconite as highly toxic (for contemporary Roman views of aconite, see blogpost by Molly Jones-Lewis). In the right hands, however, aconite was a powerful drug, and part of the Chinese practice of using poisons to cure (see blogpost by Yan Liu).  Warm and acrid, aconite could drive out pathogenic wind and cold from the body, break up stagnant accumulations, and invigorate the body’s vitalities. In the language of Chinese yin-yang cosmology, it nourished yang—all that was active, heating, external, and ascending. The main aconite root was considered more toxic than the subsidiary roots (designated by the separate name fu zi, “appended offspring”), and the wild form was more potent than the cultivated variety.

Images of toxic medicinal plants from China’s most celebrated pharmacological work, Li Shizhen (1518-93), Compendium of Materia Medica (author’s preface dated 1590). Woodblock edition of 1603. Wild aconite is the middle image in the top row. Cultivated aconite (main and subsidiary roots) are in the bottom right corner. Image credit: National Library of China. Posted on-line at the World Digital Library.

Images of toxic medicinal plants from China’s most celebrated pharmacological work, Li Shizhen (1518-93), Compendium of Materia Medica (author’s preface dated 1590). Woodblock edition of 1603. Wild aconite is the middle image in the top row. Cultivated aconite (main and subsidiary roots) are in the bottom right corner. Image credit: National Library of China. Posted on-line at the World Digital Library.

Wei’s numbing recipe consisted of 13 plant ingredients, including the main roots of both wild and cultivated (Sichuanese) aconite, along with drugs known as good for treating wounds:

Young fruit of the honey locust (zhu yao zao jiao)
Momordica seeds (mu bie zi)
Tripterygium (zi jin pi)
Dahurian angelica (bai zhi)
Pinellia (ban xia)
Lindera (wu yao)
Sichuanese lovage (chuan xiong)
Aralia (tu dang gui)
Sichuanese aconite (chuan wu)
Five taels each[1]

Star anise (bo shang hui xiang)
“Sit-grasp” plant (zuo ru), simmered in wine until hot
Wild aconite (cao wu)
Two taels each

Costus (mu xiang), three mace

Combine the above ingredients. Without pre-roasting, make into a powder. In all cases of crushed or broken or dislocated bones, use two mace, mixed into high quality red liquor.

Wei most likely learned this formula from his great-uncle Zimei, a specialist in bonesetting and wounds. Its local origins are also suggested by its use of zuo ru, literally “sit-grasp”, a toxic plant whose botanical identity is unclear. However, according to the eighteenth-century Gazetteer of Jiangxi (Jiangxi tong zhi), sit-grasp was native to Jiangxi, Wei’s home province, and was used by indigenes to treat injuries from blows and falls.  While classical pharmacology focused on the curative effects of aconite, Wei’s anesthetic relied on aconite’s ability to stupefy and numb, while curbing its ability to kill. If an initial dose failed to make the patient go under, Wei said, the doctor could carefully administer additional doses of wild aconite, sit-grasp herb and the datura flower.

Additional images of toxic medicinal plants from Li Shizhen, Compendium of Materia Medica. Sit-grasp herb is in the middle of the top row, and datura flower in the middle of the bottom. Image credit: National Library of China. Posted on-line at the World Digital Library.

Additional images of toxic medicinal plants from Li Shizhen, Compendium of Materia Medica. Sit-grasp herb is in the middle of the top row, and datura flower in the middle of the bottom. Image credit: National Library of China. Posted on-line at the World Digital Library.

In subsequent centuries, as medical texts proliferated, we find additional examples of numbing medicines that employed aconite, datura, and other toxic plants, employed when setting bones and draining abscesses, and to numb injured flesh before repairing tears and lacerations to ears, noses, lips, and scrotums.  Such manual and surgical therapies are an integral part of the history of healing in China.

Yi-Li Wu is a Center Associate of the Lieberthal-Rogel Center for Chinese Studies at the University of Michigan, Ann Arbor (US) and an affiliated researcher of EASTmedicine, University of Westminster, London (UK).  She earned a Ph.D. in history from Yale University and was previously a history professor at Albion College (USA) for 13 years.  Her publications include Reproducing Women: Medicine, Metaphor, and Childbirth in Late Imperial China (University of California Press, 2010) and articles on medical illustration, forensic medicine, and Chinese views of Western anatomical science.  She is currently completing a book on the history of wound medicine in China.

Acknowledgements
This research was funded by the Wellcome Trust Medical Humanities Award “Beyond Tradition: Ways of Knowing and Styles of Practice in East Asian Medicines, 1000 to the present” (097918/Z/11/Z). I am also grateful to Lorraine Wilcox for directing me to the work of Dou Cai.

*****

[1] The weight of the tael (Ch. liang) has varied over time, but during Wei’s lifetime would have been equivalent to 40 grams.  A mace (Ch. qian) is one-tenth of a tael.

Concealed use of herbal and dietary supplements among Thai patients with type 2 diabetes mellitus.

Related Articles

Concealed use of herbal and dietary supplements among Thai patients with type 2 diabetes mellitus.

J Diabetes Metab Disord. 2017;16:36

Authors: Putthapiban P, Sukhumthammarat W, Sriphrapradang C

Abstract
BACKGROUND: Diabetes mellitus (DM) has been one of the most common chronic diseases that create great impacts on both morbidities and mortalities. Many patients who suffering from this disease seek for complementary and alternative medicine. The aim of this study was to determine the prevalence and related factors of herbal and dietary supplement (HDS) use in patients with DM type 2 at a single university hospital in Thailand.
METHODS: A cross-sectional study was performed in 200 type 2 DM patients via face-to-face structured interviews using developed questionnaires comprised of demographic data, diabetes-specific information, details on HDS use, and medical adherence.
RESULTS: From the endocrinology clinic, 61% of total patients reported HDS exposure and 28% were currently consuming. More than two-thirds of HDS users did not notify their physicians, mainly because of a lack of doctor concern; 73% of cases had no awareness of potential drug-herb interaction. The use of drumstick tree, turmeric and bitter gourd and holy mushroom were most frequently reported. The main reasons for HDS use were friend and relative suggestions and social media. Comparisons of demographic characteristics, medical adherence, and hemoglobin A1c among these non-HDS users, as well as current and former users, were not statistically significantly different.
CONCLUSIONS: This study revealed a great number of DM patients interested in HDS use. The use of HDS for glycemic control is an emerging public health concern given the potential adverse effects, drug interactions and benefits associated with its use. Health care professionals should aware of HDS use and hence incorporate this aspect into the clinical practice.

PMID: 28852643 [PubMed]

A Lactation Consultant’s Perspective on Placenta Encapsulation

This is a syndicated post that first appeared at https://www.happygoatproductions.com/blog/2017/9/6/a-lactation-consultants-perspective-on-placenta-encapsulation
A photo by Meghan Joy Yancy of her fourth baby. See www.meghanjoyyancy.com for her blog.

A photo by Meghan Joy Yancy of her fourth baby. See www.meghanjoyyancy.com for her blog.

The following is a guest post by Sarah Hollister RN, PHN, IBCLC. Sarah contacted me a few weeks ago after coming across my own blog post on maternal placentophagy while doing research on the Chinese medicine roots of this practice. We both are excited to collaborate and share her experiences and research here since we believe that it is important to approach this sensitive subject with as much solid information as possible. It is my hope that the Chinese medicine community might benefit from Sarah’s extensive experience as a nurse and lactation consultant. For references cited and used in the following article, see this handout in pdf format, which Sarah shares with clients and colleagues. We both welcome your comments, feedback, and constructive criticism of our contributions to this evolving discussion. Please feel free to share our writings with your patients, colleagues, family, and friends.


Sarah Hollister

Sarah Hollister

As a nurse and an International Board Certified Lactation Consultant (IBCLC), I have the opportunity to work with nearly every pregnant woman and new mom and baby at a group of four primary care health centers in Northern California. I would like to share my experience, concerns and request for collaboration to closely examine the new practice of placenta encapsulation, as it has grown to become a component of the postpartum experience for the new moms who I work with and throughout the United States. I have encountered assumptions that placenta consumption increases milk production, is a prevention for postpartum depression, and has existed in history as an ancient human practice. I will provide a summary here of the work I do and what I have found with my clients involving this practice.

In my role providing perinatal services, I work both within the community clinics offering prenatal education, and in the mom’s home doing the initial exams for the newborns and breastfeeding assessments for moms after every birth as the standard of care, whether things are going well with breastfeeding or not. When there are challenges with breastfeeding, I am able to offer unlimited lactation consultations. All of my services are free of charge to the moms, as they are provided through our clinics’ primary care services. I also hold a weekly drop-in lactation clinic and postpartum support group. In addition, I have one-on-one assessments scheduled with all moms at four weeks postpartum as a routine visit. My visit notes are immediately available to their primary care physicians. I have access to the babies’ growth charts as well. I work closely with the family practice doctors, who are very supportive of breastfeeding and are trained to do interventions for breastfeeding challenges such as frenotomies for tongue-ties and osteopathic craniosacral therapy to help with latching issues related to the birth. With all of this, I have full access to our community of moms and babies over the long term of their care, and great resources to support breastfeeding success. Our patient population is quite varied, with women giving birth in hospitals, birth centers, and at home.

Photo credit to Beautiful Beginnings.

Photo credit to Beautiful Beginnings.

Over the past five years, I have noticed an alarming trend of moms with low milk supply and failure-to-thrive babies. It was initially a puzzle to me, as the majority of these cases were with healthy moms who had given birth at home or at a birth center, or at least had a doula supporting them in the hospital, all factors that should set a mom up for an optimal start to breastfeeding. They usually had no explainable reason why their milk supply was so low, as I worked diligently with them on resolving any factors that could be contributing. It was another lactation consultant who was consulting with me on one of these cases who brought up the fact that the mom was consuming her encapsulated placenta. I had assumed that this was a healthy and even traditional practice of which I was supportive, and brushed it off as having nothing to do with her low milk supply. However, in discussing it more deeply, and looking into the physiological connection between pregnancy hormones and lactation hormones, my colleague’s concern began to make sense to me. We know very well that the dominant pregnancy hormone, progesterone, inhibits the dominant lactation hormone, prolactin, from binding to the prolactin receptor sites, thereby inhibiting milk production during pregnancy. A woman’s milk comes in at approximately three days after the birth because of the rapid drop in progesterone due to the expulsion of the placenta from the body. This is the hormonal trigger that allows prolactin levels to rise and milk production to begin. If there are retained placental fragments in the uterus after the birth, a woman’s milk is likely to be delayed coming in because of the inhibitory effect of the progesterone on prolactin, thereby halting Lactogenesis II (i.e., the onset of copious milk production on day 3 after the birth). Estrogen is the other dominant hormone of pregnancy, and it is also a potent suppressor of prolactin during lactation. When a nursing mom gets pregnant with a new baby, her milk is at risk of drying up due to the hormones of the new placenta growing. We know of the detrimental effects hormonal birth control can have on milk supply. This is a very basic fact of lactation physiology: progesterone and estrogen are inhibitors of prolactin (Academy of Breastfeeding Medicine, Protocol #13, 2015; Neville et al., 2001; Riordin, 2005; Walker 2017).

I went back to the previous cases I had encountered of moms who never established a full milk supply or whose babies took 4-6 weeks to regain their birthweight despite immediate and extensive lactation support, and interviewed them about this piece of information. I found that nearly all had consumed their encapsulated placenta. I started paying attention to this possible correlation, and asking all the new moms I worked with whether they were consuming their placenta.  Over the past four years that I have been aware of this issue, I have noted many cases with a clear negative effect of placenta pill consumption on milk supply. I find that the sooner a woman stops taking her placenta capsules, the sooner her milk supply will begin to increase. However, if I don’t find out about this fact until after she has consumed the entire 4-6 week course of them, the milk supply often cannot be fully established. Based on my personal experience, placenta pills are likely to suppress a woman’s milk supply by approximately 50%. In addition, I have been hearing increasing reports from other lactation consultants, both locally and nationally, that confirm these same findings of low milk supply associated with placenta consumption.

I now discuss this information with all women who I see in their pregnancy, and advise them against consuming their placenta. I point out to them that there are no valid research studies that prove that placenta consumption either improves or suppresses lactation, but that risking milk supply is not a decision to be taken lightly and that my colleagues and I are seeing a concerning trend. I share with them the recent research papers on this topic, including literature reviews that show that postpartum placenta consumption is actually a new trend and has not been a human tradition found in any culture (Young et al.,2010; Cole, 2014; Coyle et al., 2015; and Hayes et al., 2016).

Artwork originally by Mara Berendt Friedman, cited as placenta burial art in Nurturing Our Wildness

Artwork originally by Mara Berendt Friedman, cited as placenta burial art in Nurturing Our Wildness

I show them a recent study that offers data on the hormonal content retained in placenta pills after the processing and encapsulation (Young et al., 2016). The authors of this study found that there are only estrogens and progesterone remaining in the pills and that these reach physiological effect thresholds. This fact helps us understand the hormonal picture we are seeing with the suppression of milk supply. Another recent study shows that there is no iron benefit to consuming placenta vs a placebo, which debunks one of the claimed benefits of consuming placenta that is promoted by encapsulators (Gryder et al., 2016). The doctors at our clinics are giving the same message to all pregnant women to not consume their placenta, based on these cases we have seen. With this prenatal education, the cases I now see of low milk supply have markedly decreased. I still get women coming into my lactation clinic who are new to our health center, referred to me for low milk supply and failure-to-thrive babies and again, placenta encapsulation is the most common reason that I find for this problem.

Sarah's now 18-years-old son at 4 months

Sarah’s now 18-years-old son at 4 months

I had my own two babies with midwives, the first at a Birth Center and the second as a home birth. I have experience both personally and professionally with the high quality of midwifery care, and I remain very supportive of the traditional work that midwives and doulas do. A large percentage of my clients give birth with our local midwives and doulas, so I have many opportunities to share the care with them postpartum. Yet I have encountered resistance from some doulas and midwives upon hearing my concerns about placenta encapsulation. The response I often get is that placenta pills are “medicine” for postpartum depression and boost milk supply, and that they have never seen women who had negative experiences. Yet, these moms who I have worked with and whose problems I have documented are often also the clients of those midwives and doulas. As such, I am concerned that the doulas and midwives are in fact not accurately assessing milk supply and infant weight gain and therefore do not see the picture I am seeing. In a normal situation, as long as the latch is comfortable, mom is nursing following baby’s cues, and you can hear swallowing, it is generally assumed that all is well with breastfeeding and that mom has plenty of milk. Nevertheless, infant weight gain is the most reliable indicator of milk supply, and weight checks at key points in the early days and weeks help to monitor for adequate growth and to identify red flags.

Marsden baby scale

Marsden baby scale

Often the baby’s slow weight gain goes unnoticed using the common “fish scale” that midwives use in their practice. The fish scale is easy to transport to the home and cradles the baby in a comfortable sling-like hold but measures in two- to four-ounce increments versus a digital scale that is calibrated to measure newborns in grams. Digital scales are much more accurate in assessing daily weight gain as well as breastmilk intake per feeding. Cases of low supply and slow weight gain can be too subtle and nearly impossible to detect with the fish scale, which may otherwise be adequate for its purposes in a normal breastfeeding situation. When I detect slow weight gain, sometimes the response from the midwives or doulas is that the mom has plenty of milk and that the baby is just following his or her own weight gain pattern. Babies have been brought into the clinic for the first time still significantly below birth weight by two or even four weeks of age, or are still gaining weight far below the expected range by the two-month visit. Such cases of failure to thrive are sometimes diagnosed in the clinic by looking at the growth curve in the baby’s growth chart, following the completion of the six-week midwifery care, so in many cases the midwife is not ever made aware of this finding. In so many of these low supply cases, the moms themselves report that they believed they had full milk supply. They commonly say that they believed breastfeeding had been going very well because baby nursed with a pain-free latch “every 45 minutes to an hour around the clock.” When nursing a baby, this is actually often a sign that there is not enough milk, not a sign that there is plenty. I am concerned that the assessment and reporting of milk supply remains a complex issue. As a lactation consultant, I have seen enough direct cases that I have serious concerns about the increasingly popular practice of having postpartum women consume their encapsulated placentas.

The claim made by placenta encapsulators that these pills will increase milk production is certainly not based on valid current research, nor does it make physiological sense. With that said, I have spoken with several moms who have told me that they had previously consumed their placenta and never had milk supply issues, and I have been able to verify that their babies had gained weight normally. I am sure this is a part of the picture as well, as we also know that some women’s milk supply can withstand hormonal suppression from birth control pills while others don’t. In any case, this remains a high-stakes gamble.

In my postpartum support group, I have seen women struggle with profound postpartum depression after taking their encapsulated placenta, especially as they are dealing with such heartbreaking milk supply issues. Tragically, most of these women had decided to take their placenta pills primarily to prevent postpartum depression. I wonder about the reasoning behind this idea. Is this accurate or even ethical to tell women? Isn’t your body meant to flush out the pregnancy hormones after the birth to allow the lactation hormones to come in? This is the big hormonal shift during the ‘baby blues’ that is happening with the natural hormonal cycling, and by clinical definition is not postpartum depression. I am concerned that the popularization of the “Happy Pill,” as many encapsulators refer to it, is not only potentially risky but is giving women the message that their body is naturally set up for depression and that they need a hormonal pill to “prevent” this process. What happened to the advice for women to trust their bodies? What is a “balanced hormonal state” for a lactating woman? I am concerned that there is a lack of understanding among some healthcare providers about the hormonal cycling from pregnancy to lactation. Continuing to give yourself pregnancy hormones for days and weeks and months once you’re done being pregnant doesn’t sound to me like a balanced hormonal state. I can appreciate the likelihood that ingesting estrogen and progesterone, which are steroid hormones, could certainly cause the dramatic energy surge moms so often report after consuming their placenta, but who can be certain that this is a natural and healthy state for postpartum women?

As the popularity of placenta encapsulation grows, we are seeing new situations and new potential risks that deserve a closer look. Ingesting the placental estrogens may increase a woman’s risk for thromboembolism (blood clots, stroke) as we know estrogen-containing birth control pills can (Hayes, 2016; Academy of Breastfeeding Medicine, Protocol #13, 2015). In yet another new development, many moms are now even advised by encapsulators to give their infants and toddlers the placenta in powder or tincture form as medicine for colic or temper tantrums. What are the health implications for babies ingesting these hormones? The GBS Case Report that the CDC released this year on an infant hospitalized from an infection coming from the same strain of GBS found in the mom’s placenta pills (Buser et al., 2017) illustrates that infection is yet another potential risk associated with this practice.

Given the recent valid research studies that clarify that no human culture ever had postpartum women routinely consume their placenta begs the question whether humans have evolved to not eat their placenta for a good reason?  We can continue to experiment on our new moms and babies and find out, but I believe this raises an ethical dilemma.

Painting taken from the supplement to Buyi Lei Gong’s Guide to the Preparation of Drugs (1591 edition), from Wellcome Images.

Painting taken from the supplement to Buyi Lei Gong’s Guide to the Preparation of Drugs (1591 edition), from Wellcome Images.

Lastly, my concerns about this fad of placenta encapsulation becoming the ‘new normal’ for postpartum care are not just for the implications to the moms and babies. My concern is also for the future and legacy of ancient wisdom in women’s health care. Midwifery is based on a long history of trusting a woman’s body and a tradition of providing safe, natural, and effective care. Aside from a brief exploration in the US in the 1970s of consuming whole cooked placenta, extensive research into world cultures shows us that it has clearly not historically been a part of standard midwifery practice to give women their placenta to eat. The covert social marketing that certain entrepreneurs have developed has in essence hijacked the knowledge and role of midwives and integrated a new practice into women’s health care. I see a similar disservice being done to Traditional Chinese Medicine (TCM). TCM is a highly complex system of medicine that has developed over thousands of years. Placenta encapsulation “specialists” are being trained online by business people, and after only watching a two-hour training video are told they will have “acquired experience in Traditional Chinese Medicine and placenta encapsulation.” Consequently, they are prescribing placenta pills under the name of TCM. Is there information included in the training that placenta consumption is actually in opposition to the medicinal properties indicated for postpartum women in TCM and that its use for postpartum care is actually not found in any of the traditional Chinese medicine texts? Will we allow a two-thousand-year-old system of medicine to get derailed this easily? There is much at stake in this new era of social media and cottage industries. Unfortunately, women’s bodies are the playing field.

unnamed (1).jpg

I have made a handout that I provide pregnant women with so they can research this topic by consulting more credible sources and at a more critical level than merely “googling” it or relying on the advertising of the placenta business marketing and websites, in order to make an informed decision on whether or not to ingest their placenta. The handout is attached here. Please take a look, and feel free to pass it along.

Update by Sarah: In my hundreds of interviews I have done with women on this topic, the need to honor the placenta definitely became clear to me. I buried my baby’s placenta and it was a wonderful tribute with deep meaning to me. It is an inherent need in every culture and a missing piece in our modern one. The encapsulation does meet that need in a way, I have realized. I actually have another handout I made about a year ago that I give to all pregnant women that lists burial customs from every culture, and the meaning behind them. My patients LOVE that handout, and get excited about the idea of creating their own meaningful burial ceremony with their placenta. That has been a way I can keep the conversation positive and support them in meeting their need to honor their placenta, while offering an alternative to encapsulation. That felt like to much to cover for the scope of this article, so I appreciate the artwork holding that part in the discussion in the current blog.

Original image by y0-y0, cited as Placenta burial art in Nurturing Our Wildness.

Original image by y0-y0, cited as Placenta burial art in Nurturing Our Wildness.

Update by Sabine: Here is the link to Sarah’s handout on “placenta burial rituals from around the world,”which she shares with her pregnant clients and just updated for this blog. She has added a bit of information on early Chinese customs based on my research for my Master’s Thesis decades ago on “Childbirth Customs in Early China” (University of Arizona, 1992). Both Sarah and I are concerned about the current popularity of placenta encapsulation and consumption as a postpartum tonic (In addition to the present blog, see also my previous one on classical Chinese medical attitudes toward human consumption of placenta “Placentophagy and Chinese Medicine.” At the same time, we recognize, support, celebrate the desire of many new mothers, doulas, and midwives to honor the placenta as a sacred and powerful substance, rather than disposing of it as medical waste. So it is in the spirit of presenting a positive and constructive alternative that Sarah created this handout. I will also write another blog on early Chinese placenta rituals in the next couple of weeks. The suggestions in Sarah’s handout are by no means intended as an authoritative statement on what YOU or anybody you know or work with should or should not do and are NOT the result of extensive scientific research. We simply want to provide a bit of inspiration to those of you who wonder what to do with your placentas or even how to think about them. We encourage you to let your imagination run free as you figure out whether and how to creatively express in your own ritual the sacred connection between baby, mother, family, community, and land that is by so many of us felt to be embodied in this substance, in the most meaningful and appropriate way for your cultural, social, religious, and personal beliefs and practices.In the meantime, I also buried my daughter’s placenta and planted a tree on top, and here we are now…

Momomom.jpg

Another update: Here’s a brief article from the American Journal of Obstetrics and Gynecology, published just last week, with a very strongly worded warning from the biomedical community:

“Placentophagy or placentophagia, the postpartum ingestion of the placenta-The evidence for positive effects of human placentophagy is anecdotal, and limited to self-reported surveys. Without any scientific evidence, individuals promoting placentophagy, especially in the form of placenta encapsulation, claim that it is associated with certain physical and psychosocial benefits. We found that there is NO scientific evidence of any clinical benefit of placentophagy among humans, and no placental nutrients and hormones are retained in sufficient amounts after placenta encapsulation to be potentially helpful to the mother, postpartum. In contrast to the belief of clinical benefits associated with placenta encapsulation, the Centers for Disease Control and Prevention recently issued a warning owing to a case where a newborn infant developed recurrent neonatal group B Streptococcus sepsis after the mother ingested contaminated placenta capsules containing Streptococcus agalactiae. The Centers for Disease Control and Prevention recommended that the intake of placenta capsules should be avoided owing to inadequate eradication of infectious pathogens during the encapsulation process.”

☝️Human placentophagy: a review

Alex Farr, MD, PhDcorrespondenceEmail the author MD, PhD Alex Farr, Frank A. Chervenak, MD, Laurence B. McCullough, PhD, Rebecca N. Baergen, MD, Amos Grünebaum, MD
Published Online: August 28, 2017

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]