Richard G. Petty, MD

Acupuncture for Hay Fever

A study from Melbourne, Australia has found that acupuncture can significantly reduce the symptoms of persistent allergic rhinitis (PAR), a.k.a. hay fever. This was a randomized, single-blind, sham-controlled trial included 80 patients with PAR aged 16-70 years, who were randomly assigned to real or sham acupuncture. Three key acupuncture points, Yingxiang L.I.-20, Yintang M-HN-3 and Fengchi GB-20, plus one supplementary point (determined individually on the basis of traditional Chinese Medicine pattern differentiation) were used for each participant. After a one-week baseline period, participants were treated twice weekly for eight weeks and followed up for another 12 weeks. Nasal obstruction, sneezing, rhinorrhea and nasal itch were each self-assessed daily on a 5-point scale, and individual symptom scores were added to give a sum of the symptom scores: total nasal symptom score (TNSS). A secondary outcome was use of PAR relief medication. At the end of eight weeks' treatment, the weekly mean difference in TNSS from baseline was significantly greater with real (-17.2) than with sham acupuncture (-4.2) and these benefits persisted three months after the end of treatment. Comparisons of relief medication scores revealed a significant decline in the use of medication in the real acupuncture group between baseline and Week 8 of treatment, the reduction being still apparent at the end of follow-up.

This research is convincing. The effect size is not enormous, and we do not know how long the effect will last, but it does suggest another approach for people who have chronic symptoms and for whom medications are ineffective, or who do not want to take medications, or have side effects from them.

It may be relevant that some years ago it was shown that needling the Fengchi point - which lies at the base of the skull at the back of the head - increases some components of cerebral blood flow. That may give us a mechanism of action of the acupuncture in this trial.

“I am pretty sure that, if you will be quite honest, you will admit that a good rousing sneeze, one that tears open your collar and throws your hair into your eyes, is really one of life's sensational pleasures.”
--Robert Charles Benchley (American Humorist, Critic and Parodist, 1889-1945)

“The nose is for breathing, the mouth is for eating.”
--English Proverb

“Warmth, moisture, food-these are the causes that activate latent germs and arouse them to activity. They exist, all except the food, in the mouth, nose and throat at all times. The food is thrown out into these, as excretions, in disease. The germs feed on the excretions. They are scavengers. They were never anything else and will never be anything else. They break up and consume the discharge from the tissues. This is the function ascribed to germs everywhere in nature outside the body and is their real and only function in disease. They are purifying and beneficial agents. The medical profession has worked itself into hysteria over the germ theory and is using it to exploit an all too credulous public. Germs are ubiquitous. They are in the air we breathe, the food we eat, the water we drink. We cannot escape them. We can destroy them only to a limited extent. It is folly to attempt to escape disease by attempting to destroy or escape germs. Once they are in the body, the physician has no means of destroying them that will not, at the same time, destroy the patient. We cannot avoid germs. We must be proof against them. We have to accept them as one of the joys of life.”
--Herbert Shelton (English Evolutionary Philosopher, 1820-1903)

National Acupuncture Detoxification Association

I had the pleasure and privilege of being on Scott Cluthe’s show on Lime Radio this evening. It’s on Sirius Satellite Channel 114, and if you are interested in the new holistic worldview that is emerging all over the planet, I highly recommend Scott’s show and, in fact, all the shows that I have heard on Lime. I have also had a link to Lime website for some time now, and it always has a great deal of excellent material.

There were some excellent questions from listeners, and one caused me to do some research. The question was about the National Acupuncture Detoxification Association (NADA). The Association is a nonprofit that conducts training and provides public education about the use of acupuncture as an adjunctive treatment for addictions and mental disorders.

There is a substantial body of research literature on the topic of using acupuncture as part of a package of measures for treating substance abuse, and although it is still considered controversial in some quarters, it is being used in over 1,500 places around the world, and that does not include China and Japan, where I have seen acupuncture used a great deal in addictive disorders.

My own experience has been mixed. I have had little success I treating smoking addiction with acupuncture, though I have many colleagues who say that it is extremely helpful. I have had more success in using thought field therapy and homeopathy for treating smoking addiction, even though there is so far no good research data on the use of either for smoking.

If you are interested in the use of acupuncture as an adjunctive treatment for substance abuse, the NADA website if a good place to start.

Acupuncture for Hypertension

In China and Japan I have seen acupuncture used to treat just about everything, with varying degrees of success.

Researchers from Erlangen in Germany have published a randomized single blind trial comparing acupuncture with sham needling in the journal Circulation. The results suggest that acupuncture may decrease blood pressure in hypertensive patients by a similar amount to that achieved using medication.

The investigators randomized 160 outpatients (mean age 58) with uncomplicated, mild to moderate hypertension to six weeks of acupuncture performed by Chinese medicine practitioners (trained in China), or to a sham procedure. Those on hypertensive medication continued taking it.

Patients were assigned to one of four patterns of hypertension, based on TCM diagnosis. Those in both trial arms underwent 22, 30-minute treatment sessions over a six-week period. During each session, three acupuncture points were needled bilaterally for 20 minutes. In the active treatment group, the points were chosen according to traditional Chinese medical diagnosis. Sham treatment consisted of needling points that according to Chinese medical theory would have no effect on blood pressure

Twenty-four hour ambulatory systolic and diastolic blood pressures were significantly reduced from baseline in the acupuncture-treated patients (by 5.4 mmHg and 3.0 mmHg, respectively). No significant decrease was seen in the sham-treated patients. The extent of blood pressure reduction observed was comparable to that seen with ACE-inhibitor monotherapy or aggressive lifestyle changes. However, blood pressure returned to pretreatment levels within 12 weeks of treatment cessation, leading investigators to conclude that ongoing acupuncture treatments would be required to maintain the beneficial effects.

This in an interesting study, but I agree entirely with some of the comments made in an accompanying editorial by Fiona Turnbull and Anushka Patel from the George Institute for International Health in Sydney, Australia.

Randomized trials of acupuncture have been conducted since the 1970s, but many were of poor quality, and did not even include control groups. In 1995 the World Health Organization published clear guidelines for clinical research on acupuncture, which included detailed information relating to the nature of control groups and blinding in randomized controlled trials. More recently, a National Institutes of Health Consensus Development Panel stated that the acceptance of acupuncture as a reliable therapeutic choice would depend on its evaluation using study designs that could withstand careful scientific scrutiny.

The whole issue of “sham” acupuncture remains problematic. Not only are we doing something physical. But the people administering the acupuncture know whether or not they are needling an “active” point, an even if they say nothing, they may well communicate what they are doing. There is also a more subtle point that is not raised in the editorial. A good acupuncturist does not just stick in a needle. He or she waits for the appearance of a characteristic and subjective needle sensation that tells him or her whether the needle is in the correct position.

Acupuncture studies are, simply for logistical reasons, usually fairly small and this one was no exception. And that brings us to the other point. Most forms of alternative and complementary treatment are very time consuming, and need a lot from a patient who has to show up for multiple treatments, for which he may be paying himself.

If a course of acupuncture treatment can bring about some long-term change or re-balancing in a person that might be worthwhile, but in this study the blood pressure went back up once the treatment was discontinued.

Ear Acupuncture and Knee Surgery

There is growing interest, particularly in Europe, about the use of acupuncture and acupressure in combination with conventional Western Medicine.

Researchers from Ernst Moritz Arndt University in Greifswald in Germany have reported the results of a study to see whether acupuncture would help 120 people undergoing surgery of the knee.

Their main measurement was the patients' need for postoperative pain medication.

The patients were randomly received true auricular (ear) acupuncture at the main points that Chinese medicine says are important in treatment: the Lung, Shenmen and Knee points.

The control group had a sham procedure: they were “treated” at three non-acupuncture points on the outside of the ear: the auricular helix. The “real” and the “sham” treatments were given on the ear on the same side as the knee, before ambulatory knee arthroscopy. Permanent press needles were left in place for one day after surgery and post-operative pain was treated with ibuprofen. Pain intensity was similar in both groups at all time points, but those in the acupuncture group required significantly less post-operative ibuprofen than controls.

This fits with clinical experience and is a good first study.

Not only may this provide personal benefit for the patients, but if acupuncture can reduce post-operative costs, you can be sure that insurance companies are going to get very interested very quickly.

Acupuncture and Anxiety During Medical Procedures

Over the years I have become impressed with the increasing research on something close to my own heart: how to use the best of scientific medicine in conjunction with less orthodox approaches. And, for that matter, when each is best left on its own.

I have mentioned that a few years ago I had to have surgery for a potentially serious problem. The surgeon – widely regarded as one of the best in this neck of the woods - was stunned by the speed of my recovery.

“I have seen it with my own eyes, “ He said, “But how did you do it?”

“Well,” I said, “You are an excellent surgeon. But I also some outside help: acupressure, homeopathic remedies, qigong and three prayer groups. We call it Integrated Medicine. You may think that it’s odd, but that’s what I did.”

“Oh no,” he said, “I have been in practice for over 35 years:  I trust my senses far more than I trust some graph with p values on it!”

Although anxiety has never been one of my problems, I was pleased to see two new publications on the use of acupuncture to reduce anxiety during medical procedures.

A randomized controlled study was carried out to determine whether a combination of auricular and body acupuncture is effective as an adjunctive treatment for pre-procedural anxiety and pain, in 56 patients undergoing lithotripsy (ultrasonic destruction of kidney stones). In the acupuncture group, pre-procedural auricular acupuncture was combined with intra-procedural electro-acupuncture stimulation, while in the control group both treatments were sham. Patients in the acupuncture group were less anxious pre-procedure than those in the sham group and they also used a significantly smaller amount of analgesic during the procedure than those in the sham control group. Patients in the acupuncture group also reported significantly lower pain scores on admission to the recovery room.

Meanwhile an Italian study has found that patients undergoing cataract removal are less anxious after receiving acupuncture. People underwent phacoemulsification, in which the cloudy eye lens is emulsified with an ultrasound probe, before being aspirated and replaced by an artificial lens. The procedure is carried out under topical anesthesia while the patient is awake and can therefore provoke significant anxiety. In this prospective randomized double-blind controlled trial, anxiety levels were assessed before and after surgery in three groups (no acupuncture, true acupuncture and sham acupuncture) of 25 patients. Preoperative anxiety levels were significantly lower only in the true acupuncture group. The difference in postoperative anxiety levels between the real acupuncture and no acupuncture groups was also significant.

These studies are particularly interesting in the light of a recent analysis of the published research on acupuncture and anxiety, that did not include these studies. There is not much research out there, but what we have suggests that it may perhaps help with generalized anxiety disorder. The best evidence is indeed in using it to allay anxiety before, during or after surgery, though we still need a lot more research to be sure.

I have heard people say that using acupuncture like this somehow belittles it: that an ancient and self-contained system should not become the handmaiden of Western medicine.

That is only half true. First, traditional Chinese medicine was developed at a time and placed very different from today. Human beings have changed radically in the intervening centuries. That is why acupuncturists in modern China are discovering and developing new way to treat people that do not always conform to the precepts laid down hundreds of years ago.

Second, many of us have failed to recognize the treasures in our midst. Acupuncture and acupressure are two of them. If using them together with conventional medicine is the best way for people to come to know of them, that is all to the good.

There are several other similar studies that will be coming out in the next few months, and I shall keep you informed.

Acupuncture and Peripheral Neuropathy

Neuropathic pain is one of the toughest problems to deal with.

I have had more relative failures in trying to help this problem than any other.

So I was very interested to see a pilot study that has evaluated the therapeutic effect of acupuncture on peripheral neuropathy (PN) as measured by changes in nerve conduction and assessment of subjective symptoms.

One hundred and ninety-two consecutive patients with PN as diagnosed by nerve conduction studies (NCS) were evaluated over a period of 1 year. Of 47 patients who met the criteria for PN of undefined etiology, 21 received traditional Chinese acupuncture, while 26 received medical care but no specific treatment for PN. 76% of the acupuncture group improved symptomatically and objectively as measured by NCS, while only 15% of the control group did so. 14% of the acupuncture group showed no change and 10% showed an aggravation, whereas in the control group 27% showed no change and 58% an aggravation. Subjective improvement was fully correlated with improvement in NCS in both groups.

These numbers are stunning. I might have some small quibbles about the way that the study was dne, but the results are impressive.

A second study compared Chinese and Japanese acupuncture for treating painful diabetic neuropathy. Both treatments improved pain, but only the Chinese style produced an objective improvement in the ability to feel in the affected areas.

These findings are remarkable: peripheral neuropathy can be a bear to treat, and according to the received wisdom, neither the pain nor the sensation should be able to get better. In the second study the patients were only treated once a week for ten weeks. In China such patients get daily treatments, and people in the West who treat neuropathy with acupuncture normally recommend treatments at least two or three times a week.

Both of these studies were small, but they are very encouraging.

If they are confirmed, we may to re-think another one of those, "Everyone knows that.." statements. This one about neuropathy: That is supposed to be untreatable and irreversible.

That is why the next set of studies will be super-rigorous,

They need to be.

If confirmed, we are going to be re-writing the textbooks.

Non-pharmacological and Lifestyle Approaches to Attention-Deficit/Hyperactivity Disorder: 10. Traditional Chinese Medicine

One of the problems when looking at research using traditional Chinese medicine (TCM) is that the Chinese medical system does not easily map onto the Western system of medicine. So while we might talk about attention-deficit hyperactivity disorder (ADHD), a Chinese medicine expert would be more interested in disturbances of qi, shen and jing in the whole person.

Most people who have done much acupuncture have seen people with attentional problems and tried to help them with acupuncture or acupressure. In traditional Chinese medicine, hyperactivity is thought to be the result of disturbance of the Shen (Mind or Spirit) that resides in the Heart. If the Shen is healthy then the mind and body of the child will be calm.

According to traditional Chinese medical pathology, there are three things that can disturb the Shen residing in the Heart:

• Heat
• Phlegm and/or
• Xu (Deficiency)

In the poetic language of the Chinese:

“If the Shen is not nourished sufficiently the child will not feel grounded and their Shen will flutter around nervously, like an agitated flame; this will be made worse if further Heat develops and rises, or if excessive Phlegm develops and obstructs the portals or orifices of the Heart to cause confusion and poor judgment.”

You see why Western doctors often have a hard time learning about Chinese medicine, and few ever comprehend its beauty and subtlety. And I say that after 26 years of acupuncture practice under my belt!

Despite the popularity of Chinese medicine, which includes acupuncture, herbs, nutrition and qigong, there are very few studies.

There have been some done in China, but often the structure of trials is different in China, where it is often considered unethical to withhold treatment, so studies rarely have a placebo arm.

A number of experts in Chinese medicine have written articles on their experience in treating ADHD.

Since there are so many people claiming success using Chinese medicine, there is an urgent need for controlled studies so that we can see how acupuncture and Chinese herbal medicine might fit in with other forms of treatment, and when to use what. As we have said when examining all the different forms of unorthodox medicine, we always have to balance the natural desire to do without medications against the havoc that can be caused by untreated or inadequately treated ADHD.

Having seen acupuncture and acupressure help some people with ADHD myself, I shall continue to monitor and report on any research reports that come out in the future.

Acupuncture and the Gag Reflex

A pronounced gag reflex can be a severe limitation to a person’s ability to accept dental care and for a clinician's ability to provide it. It can compromise all aspects of dental care from diagnostic procedures to treatment and can be distressing for all concerned. Many things have been tried to reduce it, most without much success.

So I was very interested to see a new study showing that a skinny acupuncture needle inserted at a point that the Chinese call Chengjiang (Ren or Conception Vessel 24) which lies just below the middle of the bottom lip, is an effective method of controlling the gag reflex. Members of the British Dental Acupuncture Society took part in a patient audit. The patients had two upper dental alginate impressions taken (or attempted), one before and one after acupuncture at that point. Before the acupuncture, none of the 37 patients was able to tolerate the procedure, however after acupuncture there was a mean improvement of 53% in measures of gag severity at all stages of the impression taking process. 81% of patients were able to accept the impression taking after acupuncture.

This research will need to be confirmed in a controlled study, but this initial result does not surprise me: I have seen how effective this simple treatment can be.

And as we have said before, good dental care is not just about protecting your pearly whites. Sick teeth and gums can give you a very sick body.

Acupuncture for Temporomandibular Joint Pain

I was pleased to see that a group of researchers from Manchester in England (that's its skyline, above!) did a double-bind randomized controlled study of twenty seven people suffering from temporomandibular joint myofascial pain (TMJ/MP), to see if acupuncture would help them.

The people in the trial either had acupuncture or something called "sham" acupuncture, using a device that was created to create a "placebo control." The piece of equipment is called the Park Sham Device, and there has been a lot of discussion about whether it is really feasible to do "pretend" acupuncture. This study showed that it is.

The acupuncture was shown to have a greater influence on pain and movement than the "sham" treatment.

This is important: TMJ can be very difficult to treat. Last year there was a report, also from the UK, that acupuncture seemed to be effective, based on an audit of dental practices, and this study just adds to the evidence that we are accumulating.

Acupuncture for Itch

Acupuncture has been used for every conceivable type of problem, and I have often been surprised how well it can help some skin problems. I was particularly impressed by its effectiveness in treating shingles, but I have sometimes also found that it can be very helpful in treating chronic itching.

So I was interested to see a study from Bochum in Germany in which 32 healthy volunteers had histamine applied to both forearms. Histamine is the chemical that normally causes a red wheal and a flare after being bitten by a mosquito or other bug.

Then, five minutes later, they had electroacupuncture of either the right or left ear. There are specific points on the ear that are said to be good for treating itching. They then re-tested the volunteers four weeks later, but this time without the acupuncture.

Acupuncture was found to significantly reduce  - and in some cases completely prevent – the areas of itchy redness, but only on the same side that had the acupuncture. So if the right ear was treated, the itch and redness was less on the right side, but not of the left.

This is an impressive demonstration of something that we have seen in clinical practice, but until now have never proven.

Acupuncture and Acupressure for Morning Sickness

Although I am most definitely of the male persuasion, I know that morning sickness can be an awful problem, though there is some evidence that it is an attempt by the body to rid itself of toxins that could otherwise harm the baby.

I have had a longstanding interest in the use of acupuncture and acupressure for the treatment of nausea and vomiting, whether pregnancy related or caused by infections, anesthesia or chemotherapy. Over twenty years ago my committee at the Research Council for Complementary Medicine helped fund research on the topic at the University of Belfast, and I have used both acupuncture and acupressure to treat many hundreds of people with nausea and vomiting. Before I left England, we were planning to do a clinical trial of acupuncture on morning sickness at Queen Charlotte’s hospital in London.

So I was delighted to see a meta-analysis published in the journal Explore.

The authors identified 14 eligible trials that had been completed over the last sixteen years, involving a total of 1615 women who had been treated with either acupressure, acupuncture or electrical stimulation at acupuncture points.

The conclusions were that these methods may reduce nausea by more than 50% compared with controls and vomiting by around 40%. These figures look about right, though acupuncture and acupuncture are very “operator-dependent:” some therapists get better results than others. What was interesting was that the effect was all due to acupressure: acupuncture was not shown to be effective, but acupressure was.

The analysis also points out a potential weakness in other meta-analyses. It is not wise to lump all acupuncture and acupressure together, since each may work somewhat differently.

As a sidebar, when we use acupuncture or acupressure, we always tailor the treatment to the individual, but the most commonly used points are Liver-3 on the top of the foot between the big toe and second toe, and Pericardium-6, which lies on the inside of the forearm, about two inches above the wrist.

Back Pain, The Brain and Pain Cycles

A German research team using a specialized imaging technique called diffusion tensor imaging (DTI) to look at the differences between back pain sufferers' and healthy volunteers' brains found that individuals suffering from chronic low back pain also had micro-structural changes in their brains. The findings were presented at the annual meeting of the Radiological Society of North America in Chicago by the lead researcher Dr Jurgen Lutz, a radiologist at Ludwig-Maximilians University in Munich, Germany.

DTI tracks the movement of water molecules in the brain's gray and white matter. Individual water molecules are constantly in motion, colliding with each other and other nearby molecules, causing them to spread out, or diffuse. DTI allows us to analyze water diffusion in the tissues of the brain. In normal white matter, water diffuses in only one direction. So if they are moving in the “wrong” direction, we can use this as an indication that there are changes in the fiber pathways.

The investigators studied 20 patients who were experiencing chronic back pain with no precisely identifiable cause and 20 age- and gender-matched healthy volunteers. DTI was performed to measure the diffusion in several areas of each patient's brain. 
 



They discovered the brains of patients with chronic back pain had a more complex and active microstructure compared with the healthy volunteers' brains.

The changes were found in regions of the brain associated with pain-processing, emotion and stress response, including the cingulate gyrus, postcentral gyrus and superior frontal gyrus.

Although it is possible that theses structural disturbances are a cause of chronic pain, it is more likely to be the other way round.

This leads us to a very important concept that is not talked about as much as it should be: it is the idea of pain cycles. Pain cycles can have a physical or psychological origin and are thought to be maintained by some of the centers in the brain that process pain and emotional distress. The two are often mixed together: pain is extremely common in both depression and in bipolar disorder, and pain can, of course, make you feel depressed.

Theses pain cycles will often persist for long periods after the original cause of the pain has gone. So we may continue to feel pain long after a broken bone has healed, or we may continue to suffer emotionally long after a bad relationship should have been dead and buried. Many interventions like acupuncture or injecting steroids or anesthetics into trigger points can interfere with the pain cycle. Similarly there are many therapies, including some of the tapping therapies, that seem to “re-set” some of the systems in the nervous and subtle systems of the body.

In my forthcoming book Sacred Cycles, I talk a lo about these vicious pain cycles and how to interrupt them.

“Pain is part of being alive and we need to learn that. Pain does not last forever, nor is it necessarily unbeatable, and we need to be taught that.”
--Rabbi Harold S. Kushner (American Rabbi Aligned with the Progressive Wing of Conservative Judaism and Writer, 1935-)

“Softness is a dream in every ache to become a better soul.”
--John Kells (Irish-born British Grand Master of T’ai Chi Ch’uan, 1940-)

Acupuncture and Parkinson's Disease

Over the last 25 years I have used acupuncture to try and help a great many people with Parkinson's disease. It has certainly helped a lot of the symptoms, but in my experience has not often done much to change the course of the illness. That being said, I have seen a few people who had remarkable improvements that were sustained for months and even years. The best results have usually come when we have used a combination of acupuncture, diet and homeopathy, in addition to regular medications.

So I was very interested to see a study in the journal Brain Research, even though the work used animals, and I've had a longstanding aversion to animal experiments.

There is a chemical called MPTP (1-methyl 4-phenyl 1,2,3,6-tetrahydropyridine) that damages and kills some types of dopaminergic neurons in the brain, so it can produce Parkinsonian symptoms in humans and in some animals.

Mice were injected with MPTP and then some of them received acupuncture every two days in two spots, one behind the knee and one on top of the foot. In humans, these are two of the points that are traditionally considered to be involved in muscle movement. Another group of mice received acupuncture in two spots on the hips that are not believed to be effective for acupuncture. A third group had no acupuncture at all.

By the end of seven days, the MPTP injections had decreased dopamine levels both in the mice that had not received acupuncture, and in the mice that received fake acupuncture, to about half the normal amount. But in the acupuncture-treated group, dopamine levels declined much less steeply, and nearly 80% of the dopamine remained.

The mechanism for such an effect remains unknown. The most likely mechanism is that it is reducing the inflammation in the brain often accompanies and worsens other symptoms of Parkinson's disease. So acupuncture might maintain dopamine levels by preventing this inflammation. The same team of researchers from South Korea has already reported that acupuncture also prevents loss of dopamine neurons in rats.

The clinical studies in humans have been less encouraging, and more closely reflect my clinical experience. The problem is that by the time most people get to see an acupuncturist, they have already lost huge numbers of dopamine neurons and it is difficult to do very much. If acupuncture is to be helpful, we would probably need to be able to identify someone with Parkinson's disease extremely early, perhaps even before clinical signs have appeared, and so far we have no reliable way of doing that.

Acupuncture and Depression

I have been using acupuncture for over 25 years and one of the reasons for doing my advanced training in China was to examine its use in neurological and psychiatric disorders.

It was interesting to discover that even in hospitals specializing in traditional Chinese medicine, the doctors usually used conventional antidepressants and antipsychotics rather than acupuncture, although I had seen many Western acupuncturists claim that they could treat depression.

My own experience with treating acupuncture has been disappointing. By contrast, it is often very good indeed for anxiety, and I have shown many people how to follow up with simple acupressure if they experience anxiety or panic.

There is new research that seems to endorse my lack of success in treating depression and why the Chinese doctors used Western medicine. There had been a number of small studies (e.g. 1. 2. 3. 4. 5. 6.) of acupuncture in depression that had shown promise, as well as some huge Chinese studies that had claimed good results.

One of the problems with much of the Chinese research is that it is normally done without control groups and with very broad criteria. Many only rate whether someone is “cured,” “much better” or “no better.”

Despite the promise of the early studies, three recent reviews (1. 2. 3.) suggested that the evidence for acupuncture in depression was inconclusive.

This new study was published in the Journal of Clinical Psychiatry in November of this year and involved 151 patients with Major Depressive Disorder. The study ran for four years. This was a well-conducted clinical trial by researchers who had originally found some promising results in a pilot study (Allen JBJ, Schnyer RN, Hitt SK. The efficacy of acupuncture in the treatment of major depression in women. Psychological Science 1998; 9: 397-401). Although well tolerated, the research failed to support the use of acupuncture as a single therapy for depression.

This is important: depression carries an appreciable mortality and morbidity and there are real ethical problems about withholding treatments that have been shown to work.

It also does not mean that acupuncture has no place in the treatment of depression: it may be a useful adjunctive treatment - particularly if the individual has comorbid anxiety - and it may help with treating the side effects of conventional medicines. There is also another important point: we need to be sure that we are measuring the right thing when doing studies on acupuncture: the Western doctor may want to see if depression gets better. The acupuncturist may be more interested in improving the overall well being of the individual as well as helping an individual’s search for meaning. 

Regular readers will remember that last month I commented on some promising research on the use of qigong in depression. Why the different results from the different studies? There are many schools of acupuncture, t’ai chi ch’uan and qigong, as there are many different medicines for depression. One of the difficulties in the critical evaluation of these forms of treatment is that we have to assess the effectiveness not just of acupuncture, but of different schools of acupuncture and sometimes of different practitioners: a daunting but not impossible task. Not only are there many school in China, there are also Japanese, Korean and Vietnamese variants of traditional acupuncture, Western acupuncture and electro- and laser acupuncture. We use clinical observations to guide us to research the most promising types of intervention, whether they are forms of acupuncture, herbal remedies, homeopathy or anything else.

My "job" is to bring you the best and most rigorous research so that you can make decisions about what is most likely to help you.

Acupuncture, Qigong and Fibromyalgia

As we have discussed before fibromyalgia can be difficult to treat, so any decent research indicating a new approach is always welcome.

Two recent studies have indicated that acupuncture may be helpful in the treatment of fibromyalgia. In the first, published in Alternative Therapies in Health and Medicine, 21 patients completed the study, which consisted of 16 treatments in eight weeks. The patients all know that they were getting acupuncture, and there was no attempt to “blind” the study. The investigators used something called the Fibromyalgia Impact Questionnaire, and found an improvement. One of the problems with the study was that there were so many measurements done in so few people that there’s always a worry that something positive will turn up by chance. This may explain an odd observation: sicker people did better and it didn’t matter how long they had been in treatment.

The second study was a partially blinded, controlled, randomized clinical trial of 25 patients and 25 controls done at the Mayo Clinic. Acupuncture seemed to be more effective in improving pain, fatigue and anxiety, than putting needles at ineffective points.

One of the biggest practical problems is that some people with fibromyalgia are so sensitive that they cannot tolerate even the mild discomfort of acupuncture, which is usually all but painless if done by an expert.

So I was interested to see a small pilot study from the Department of Psychiatry in the University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School in Piscataway, New Jersey, of the use of external qigong in fibromyalgia. A qigong practitioner worked to stimulate the flow of Qi in people with fibromyalgia, on the principle that in traditional Chinese medicine, pain is usually conceived as a blockage of the free flow of Qi. The results were very strongly positive, thought the trial only involved ten people.

Clearly more research is needed, but these preliminary results are all very encouraging.

Cluster Headache: A New Approach

By a strange "coincidence", just a couple of days after posting about cluster headaches, the BBC is carrying an article about a woman with cluster headache who was successfully treated by a neurosurgeon who implanted a nerve stimulator attached to the greater occipital nerve at the back of the skull.

It has been known for some time that there is a type of atypical cluster headache that can be treated by blocking these nerves. Some experts feel that since cluster headache is usually driven by the hypothalamus, headaches that can be stopped by nerve blockade or nerve stimulation are not cluster headaches at all.

That is something for us to sort out at scientific conferences.

But for now, there is at least one person - who was featured in the BBC's article - who has been cured after everything else failed.

But here's the strange thing: none of the neurologists or neurosurgeons has a clue how the treatment works.

Yet anyone versed in Traditional Chinese Medicine would tell you immediately the nerve runs directly above a key acupuncture point - Fengchi, or Gallbladder 20 - that is often used in treating severe headaches. Because disturbances in the subtle systems of the liver and gallbladder are common in many types of headache.

In other words, knowledge of the subtle anatomy of the body can explain how the nerve stimulator is working, but the best of current Western neurological science cannot.

A beautiful example of how the combined approaches of Integrated Medicine can help and inform everyone involved.

And it is the patient who gets all the benefits.

Multiple Sclerosis and Integrated Medicine

Although there are some fairly effective conventional therapies for multiple sclerosis (MS), many people with MS explore complementary and alternative medicine (CAM) therapies for their symptoms. The most effective strategies are to combine conventional and unorthodox treatments that address the physical, psychological, social, subtle and spiritual aspects of the illness. This combined approach also avoids the problem of people taking herbs or supplements that may either interact with each other or with conventional treatments.

It is also essential for us to get over the idea that MS is just something to be conquered. That may seem like an odd comment, but the language and the mindset of fighting, battles and warfare can be problematic. Let me explain something that I discuss at length in Healing, Meaning and Purpose.

There have been two distinct approaches to health in the Western medical tradition. The first is that the role of a physician is to treat diseases. That is the way that all my colleagues and I were trained. The second approach is to consider that health is the natural order of things. So in the first case we constantly hear the use of military metaphors: People speak of  “a war on cancer,” “killer cells,” “magic bullets,” and the need to adopt a “fighting spirit.” Sadly this aggressive attitude by the medical profession may be at odds with the wishes and needs of an individual, the family and the other people in a person’s life. We have to try to strike a balance between the whole instinct to fight and expressions of healing and acceptance.

In the second case, the philosophy is grounded in the idea that we need to work in harmony with nature. The maintenance of health and well being comes from reestablishing balance and harmony not just in ourselves but also in our relationships with each other, with society and with the entire environment around us.

Some of the most commonly CAM therapies include dietary modification, nutritional and herbal supplementation, and mind-body therapies. There has been a revival of interest among MS researchers about the therapeutic potential of low-fat diet and essential fatty acid supplementation in MS. The research on CAM therapies in MS is still exploratory, but considering peoples' interest and common use of these therapies, further research in this area is clearly warranted. Many sufferers show “spontaneous” recoveries, so reports of cures with unorthodox remedies are often treated with skepticism.

Diet, Vitamins and Supplements: There have been scattered reports of symptoms improving after the removal of dental amalgam, but there is scant evidence that this is really worthwhile. There is some evidence 1. 2. 3. 4. that polyunsaturated fatty acid (PUFA) supplementation may help MS. There used to be a lot of support for something called the “Swank diet,” but over the years the evidence has not been very good. In a small number of people with MS certain foods can make them worse. This is to expected if there is an autoimmune component to the illness. It is always a good idea to see if there is something that makes a person feel worse. The other important qestion is whether food additives may be causing symptoms. Although this must be uncommon, I have written elsewhere about occasional cases of MS symptoms with all the classical neurological, biochemical, radiological and electrical signs that have improved or become completely better after removing aspartame from the diet.

Physical exercise: Exercise is highly recommended for people with MS, though it is best to avoid it during an attack. There is evidence that over-exertion can actually bring on an attack. There is some literature about the use of Feldenkrais bodywork in MS, but a study from the University of North Carolina failed to find any benefit. T’ai Chi Ch’uan, qigong, yoga and graduated exercise have all been helpful to some people with MS, but it is essential to discuss it with a healthcare provider to see how any one of these fits in to an package of care. There is no published data on the use of Pilates in MS. At least not in any of the languages that I can read. But since it has been shown to improve posture and flexibility, it is logical to think that Pilates might be helpful, and it would be very valuable to see some research on it.

Acupuncture: Although widely used, the research on acupuncture in MS is not yet convincing. Like most acupuncturists I’ve had some good results in treating pain, muscle stiffness and fatigue. I’ve also seen people achieve some remarkable recoveries, but there are two issues: MS is a relapsing and remitting illness. And second, many of the people who did well only did so because they shifted their thinking: acupuncture became the vehicle for their personal transformation rather than a device for removing nasty symptoms.

Homeopathic remedies: Even the most enthusiastic homeopaths have fairly limited expectations of what homeopathy can achieve in MS.

From the point of view of homeopathy there is little point in making the diagnosis on multiple sclerosis because the disease has such a variable course with highly variable symptoms. To a homeopath the diagnosis is not useful: it is the symptoms that are all important. The homeopathic treatment of MS is highly individualized: one of the key items is the timing of symptoms and associated features. Some of the most common remedies for people with MS are:

• Agaricus
• Alumina
• Argentum Nitricum
• Arsenicum
• Aurum Metallicum
• Causticum
• Cocculus
• Conium Maculatum
• Ignatia
• Lachesis
• Nux Vomica
• Natrum Muriaticum
• Phosphorus
• Plumbum

This is not the whole list of homeopathic remedies that we have sometimes found helpful, but it highlights some of the more commonly used ones in people with the symptoms of MS.

Herbal remedies: Many herbal remedies have been tried in MS, and many experts have told me that they have had some good results. There is an important issue in MS called “apitherapy,” a.k.a. bee venom therapy (BVT). Several reports suggest that bee venom may be an effective treatment for patients with MS. But formal trials suggest that although the treatment appears relatively safe apart from itching and swelling of the skin, it does not seem to be helpful. 

The best approach is to embrace the best of what conventional medicine has to offer, combine unorthodox approaches and to realize that management of a chronic illness is not about dominating it but learning from it and learning strategies for peacefully co-existing with it.

Qigong Therapy at a Distance

I just had a very nice question from someone who had seen my article in which I commented on the way in which I had seen qigong masters treat patients without touching them.

Dear Dr. Petty,
That’s really interesting, and if it’s true, it would be very important for the future of therapy. Is that actually any scientific evidence to support what you said?

Good question, and yes, there is. But not very much of it.

A recent study from South Korea examined the effects of Qi therapy, also known as external qigong. During the study they looked at the effects – if any – of touching the patient. The researchers examined the impact of treatment on anxiety, mood, several hormones and cellular immune function. Whether or not they were touched, the patients showed improvements in anxiety, alertness, depression, fatigue, tension and cortisol levels. Treatment at a distance was just as good as hands-on treatment with one interesting exception: treatment at a distance caused the white blood count to rise slightly, while the effect wasn’t seen in people who were touched.

There is also another type of research in which qigong practitioners have tried to influence either animals or cells in culture. In one recent study practitioners directed their intention toward cultured brain cells for 20 minutes from a minimum distance of 10 centimeters. The first study seemed to show an effect on the proliferation of the cultured cells, but the second did not, showing the difficulty of doing experiments like these.

More experiments like these are underway in centers throughout the world, and I shall continue to report on both the positive and negative studies.

Acupuncture Points

The Pacific College of Oriental Medicine publishes a newspaper entitled Oriental Medicine, that carries a great many interesting articles mainly written by practicing acupuncturists. In the current issue there is a nice article entitled “What are Meridians and Points?” by Iona Marsaa Teeguarden a therapist who has developed some very interesting acupressure techniques for dealing with an array of problems. This is a very interesting topic to me: you may have seen some of those pictures of acupuncture points that look like tramlines traversing the body.

Over the last few years I’ve read everything about the acupuncture points that I could get my hands on. If it’s in one of the ten or twelve languages that I can read, then I’ve probably got a reprint of the paper, and people have been kind enough to send me translations of at least parts of papers in Chinese, Japanese and Korean. Some of the research has been excellent, and some less so.

The first point (ha ha…), often controversial when I am talking to classically trained acupuncturists, is that although some of the large well-known acupuncture points are usually in the same place in different individuals, many of the lesser known points are not. Of the 361 main named acupuncture points only a couple of dozen seem to be fixed on the body. Most of the rest can be some way off from the pictures in books. I learned that first when I was an apprentice in London, and then during my studies in China. The top Chinese acupuncturists search for the right points to use. It’s one of the reasons why modern Chinese acupuncturists have identified over a thousand “extra points.”

Although people usually talk about “meridians” joining the acupuncture points together, the Chinese usually refer to them as “channels and collaterals.”

There does not seem to be any neurological or vascular structure at the site of an acupuncture point. Taken together with he fact that acupuncture points tend to be tender and to have characteristic electrical properties, both of which get better with treatment, suggests that they are functional rather than structural entities. Most experienced acupuncturists have noticed that the points vary not just with treatment, but also with mood, the weather and in women, during the menstrual cycle.

In the late 1930s, a French physician named Niboyet was probably the first to find indications that the main acupuncture points have lowered electrical resistance compared with surrounding skin. Some other studies (1, 2, 3, 4, 5.)have provided some support for these findings, although it is difficult to known precisely what to make of the finding that these areas of reduced electrical resistance can also be located on fresh but not dried cadavers. Some people have invoked some mechanism involving electrolytic fluxes along connective tissue or fascial planes of the body. But that’s all just speculation backed by some research correlating acupuncture points and fascial planes.

An additional problem for simple electrical models is that some of the acupuncture points also respond to polarized light, which would be odd if the primary mechanisms of acupuncture points were electrical.

Another set of experiments sought to exploit the phenomenon of “propagated needle sensation.” If acupuncture is done well, then this happens very frequently. It is a subjective sensation of warmth, heaviness, numbness or bursting, that moves at between 1 and 10 centimeters per second, which is much slower than a nerve impulse. This sensation moves along the proposed channels along which the Qi is supposed to flow. But this is the interesting bit: the sensations are not related to any known neurological pathways. The precise nature of this propagated needle sensation remains elusive, with reports of it being interrupted by chilling, local anesthetics and mechanical pressure, whilst it has also been shown to travel to phantom limbs in amputees.

Attempts have been made to trace out acupuncture points and their associated channels by the use of radioactive tracers and by measuring electrical propagation along the channels. 99-Technetium has been the most widely used, and it has been claimed that the tracers diffuse from acupuncture points along the classical acupuncture channels, whilst tracer injected at non acupuncture points diffuses without showing any such linear pattern. The speed of the linear migration of the tracer injected into acupuncture points was accelerated by the use stimulation of appropriate acupuncture points.

If we cannot find anything anatomical at acupuncture points, and they clearly change place and character as the person changes. Then what do the Chinese have to say about the points and the channels?

They say that the channels are there to distribute Qi, and that the acupuncture points are the control points of the channels. The traditional theory is that Qi flows in response to thoughts and emotions. Perhaps thoughts and emotions have effects on muscle contraction and that pushes the Qi along, but I thin that we have to step away from the physical body. I can well remember one of the first people whom I ever treated. I gently needled a “Liver point” on her foot, and she felt the sensation in her eye on the same side of the body. There is no known neurological connection between the foot and the eye on the same side. But in Chinese medicine, the Liver channel terminates in the eye on the same side of the body. The theory of fascial planes can also not explain that. Neither can the observation that many of us have made in the clinic. In some people, acupuncture reveals their entire acupuncture system: the channels become red.

Even when acupressure is used in the subtle systems around the body. I have seen a Chinese Qigong Master demonstrate this phenomenon in a paraplegic patient.

While the Master’s hands were three feet away for the body.

And that will be the topic of yet another research study.

Shock Waves and Diabetes

A psychiatrist friend once called me to say that he knew that he had to change his job. He was in the second year of his Freudian training analysis, and as he was driving to work he experienced a severe pain in the back. He told me that it felt as if someone had put a knife in his back. This, he told me, was a psychosomatic reflection of the mean back stabbing environment in which he was working. “Tell me more about the pain,” I said. “Just like a knife,” he said, “it’s the most obvious example of my body telling me what’s going on here.” I suggested that he should come over for me to give him a physical check up, but he was having none of it.

The following day he passed a large kidney stone.

It’s important to listen to your body, and to try and understand its message. It’s also important to respect every aspect of your being: physical, psychological, social, subtle and spiritual. A physical pain may be telling you about something in your environment or it may just be telling you that there’s something wrong with your body. Sigmund Freud once famously remarked that “Sometimes a cigar is just a cigar.”

I was reminded of this story as I was reviewing a new report about an association between the use of sound waves – lithotripsy - to shatter kidney stones and the eventual development of diabetes. Approximately 10 percent of men and 5 percent of women under the age of 70 will experience a kidney stone.

Surgery for kidney stones used to be horribly traumatic. As a very young student and junior doctor I assisted in more than one operation to remove them. The invention of the lithotripter – a device that uses ultrasound to break up stones, so that they can be passed out of the body – was a big advance. Though the treatment itself is far from being painless, it is much better than major surgery, It is a shame to learn that the treatment is not as innocuous as we thought. This is important, because about 1 million people in the United States have had shock wave lithotripsy (SWL).

In a study published in the May issue of the Journal of Urology, researchers at the Mayo Clinic followed up on a group of 630 patients who had been treated with SWL in 1985. The Mayo was one of the first centers to use the technique, the hospital keeps wonderful records, and so it was one of the few places in the world where it was possible to follow people 19 years after treatment.

Almost 60 percent of the patients responded to a questionnaire and were matched to an equal number of patients whose kidney stones had been treated by some other method. Among the SWL group, 16.8 percent had developed diabetes, compared with 6.7 percent of the control group, and 36.4 percent had high blood pressure compared with 27.9 percent of the control group. According to the study, the development of hypertension was related to the treatment of stones in both kidneys, while the onset of diabetes bore a relationship to the number of shocks administered and the intensity of the treatment.

This makes sense: the kidneys are key controllers of blood pressure, and it has long been known that stones, inflammation, infection or vascular disease in the kidneys can cause elevated blood pressure. Perhaps the treatment scars the kidneys. And it is not surprising that sound waves powerful enough to shatter a stone might also cause damage to the tissues through which they are passing; which include the pancreas.

These findings will need to be replicated, particularly with newer model lithotripters. But even before that, I’m sure that the criteria for gets the treatment will be modified, and it will also be necessary to re-think how the treatment is done. As an example, instead of shooting one powerful burst of sound waves at the stone, it may be necessary to fire several low intensity burst from different directions that all crisscross in the vicinity of the stone.

For now, if you are one of the unlucky ones who gets a kidney stone, discuss this new research with your doctor before having lithotripsy. And if you have access to a good acupuncturist, naturopath or homeopath, ask them if they have had any success in treating kidney stones, and if “Yes,” whether they would be prepared to work with your physician to help you.

Peripheral Neuropathy and Integrated Medicine

We have already discussed some of the causes and conventional treatments for peripheral neuropathy.

Unfortunately many people are not much helped, and it is good to know what else may assist them. And also what may not: sadly people suffering from chronic illnesses often become the victims of people selling treatments that may have scant chance of success.

There is not much research to support most of these approaches, which we use in tandem with conventional medicine. However, I’ve used all of these approaches and found that each has helped some people. The problem, as with most of conventional medicine, is in knowing who will respond to what. Often the key is to use several approaches in combination. That is where you need a specialist in Integrated Medicine who can put together the right “package” of treatment for the individual. What we don’t want to do is use a kind of “blunderbuss approach,” where we hit people with everything at once.

1. Diet and exercise may help, particularly in diabetic neuropathy, where improved metabolic control will reduce – but not abolish - the risk of neuropathy, and may improve pre-existing neuropathic pain.
2. Some naturopaths in Europe recommend using parsley, celery and carrot juices. Not something that I’ve seen work, but some people tell me that they’ve found them helpful.
3. There has been a lot of research on the use of alpha lipoic acid and vitamins B and E, particularly in diabetic neuropathy: some positive and some negative. Each has sometimes helped in clinical practice, though you have to be a little careful with vitamin E: it can impair the clotting system, and cause diarrhea and transient elevations in blood pressure.
4. Acupuncture – traditional Chinese, “Western Medical,” and electro-acupuncture - have been used a lot in peripheral neuropathy. There have been some positive studies in painful diabetic,  HIV-associated and chemotherapy-induced neuropathy. None of the studies has been perfect, but they tend to support the clinical impression that man people are helped – some greatly - but few are cured with acupuncture. There have also been negative studies. There are also some positive studies from China, but only a few have been translated in their entirety. There are often two big problems with research done in China: many Chinese investigators feel that it’s unethical to include a control group, and their studies tend to use endpoints like “cured” or “partially cured,” rather than objective rating scales. I have used it in peripheral neuropathy, but it’s extremely important to use scrupulous technique, since people with neuropathy are at increased risk of getting skin breakdown and ulcers, especially if they also have any vascular compromise. Many of us have also found that it can be helpful in compression neuropathies, like carpal tunnel syndrome. There’s recently been some fascinating research using brain imaging in acupuncture treated carpal tunnel syndrome.
5. Herbal remedies are used by about a fifth of people with neuropathy, but I’ve never had much luck with them. Some herbalists tell me that they have good results with an array of different herbs, though there is little objective evidence that they work.
6. There have been clinical reports and at least one research study on the use of magnet therapy in neuropathy. Earlier this year there was an article in the British Medical Journal that was critical about magnet therapy in general. The article provoked one of the most vigorous debates that I've seen in  along time. I’ve not seen it help, but there are some people who swear by it. And other who swear at it!
7. There have been many attempts to use electrical fields to help neuropathy, from the conventional transcutaneous electrical nerve stimulation (TENS) boxes, to yet more variations on electro-acupuncture. Some people are helped, and these are good extra tools.
8. Many homeopathic remedies have been used in neuropathy. Homeopathy is a highly individualized form of therapy: no two patients will get the same remedies. But some of the most commonly used remedies are Agaricus, Alumina, Arsenicum album, Natrum muriaticum, Phosphorus and Plumbum. If you live somewhere that there are good homeopaths, homeopathy is an option to consider, despite the dearth of good research into its use in neuropathy.
9. It is important not to neglect the psychological aspects of neuropathy: people can become profoundly depressed by the intractable pain, and sometimes psychotherapy and antidepressants can be a helpful.


10. Finally, ask yourself what the neuropathy is trying to teach you. There is no problem that comes out of a clear blue sky, and it is always valuable to look beyond the physical problem itself to its meaning and purpose. 



If you are not having success from conventional medicine alone, or if you don’t care for conventional medicine, then discuss these options with a professional, use your intuition to guide you, and let us know if you have success.

Restless Legs Syndrome and Integrated Medicine

In the last entry we looked at RLS: what it is, and some of the conventional approaches to treating it. I now want to spend a moment talking about some of the other approaches that we have tried. For most of these there is very little evidence, so we use them in conjunction with conventional medicine.

If you want to try any of them, discuss them with your health care provider, so that he or she can guide you toward the best ways of putting treatments together.

1. Diet: A low sugar diet helps some people, and it is always worth keeping a food diary for a week to see if there’s any association between something that you’ve eaten and a worsening of your symptoms.
2. If you like juicing, there have been a number of anecdotal reports of the use of carrot, celery and spinach juices helping some people. (I am writing this while we are still in the middle of the spinach/E. coli scare, so leave this one out until the FDA has given us the all clear.
3. There have been publications about the use of vitamins E and B and folic acid in RLS. Vitamin E can cause a GI upset in some people and if used in too high a dose (above 800IU/day) may elevate blood pressure; folic acid has to be used with caution in people on anticonvulsants. If you try these options, bear in mind that no supplement is likely to work unless it is taken for at least a month.
4. Acupuncture sometimes helps: there are three acupuncture points in the legs that come up in the prescription: Urinary bladder 57, Spleen 6 and Stomach 36.
5. Homeopathic remedies have been reported to help, and I’ve had some success. The precise remedy always depends on the precise characteristics of the individual, but the most common ones have been Rhus Toxicodendron, Causticum, Tarentula Hispanica and Zincum Metallicum. If you live in a place in which there are good homeopaths available for consultation, it’s another option.
6. Several herbal remedies have been reported to help: Passion Flower, Cimicifuga, Valerian, Black Cohosh and Piper Methysticum. Just remember that some of the herbs sold in health food stores don’t contain what they should, and Valerian and Black Cohosh have recently been associated with liver toxicity in some people.
7. Here is an old trick from China: take a one inch piece of fresh ginger root and grate it into a bowl of warm water. Then soak your feet in the water for about ten minutes. I’ve never seen that one work myself, by some people whom I respect have.

I also think it important not to neglect the psychological aspects of this problem, and sometimes some psychotherapy can be a helpful adjunct.

Finally, ask yourself what the RLS is trying to teach you.

These are all options that have been tried and have helped some people. If you are not having success from conventional medicine alone, or if you don’t care for conventional medicine, then discuss these options with a professional, use your intuition, and let us know if you have success.

Integrated Medicine and Cancer

There's a very interesting and important piece of research from the School of Social Work at the University of South Florida in Tampa.

The title of the paper is “Patient-physician communication regarding use of complementary therapies during cancer treatment,” and it discusses something with which I’ve been very involved for many years.

The paper uses the terms “complementary and alternative medicine,” though the same principles apply to the far more sophisticated and comprehensive approaches of Integrated Medicine.

Studies from the United Kingdom, Germany, Holland, France and the United States have estimated that as many as 80% of adult cancer patients use at least one form of Complementary and Alternative Medicine (CAM) during or after conventional treatment. I’ve discussed before the pitfalls of trying to use unorthodox medicine in place of conventional medicine. In Europe some of the practices of Integrated Medicine, particularly acupuncture, homeopathy and massage, are used to help people cope with the rigors of chemotherapy and radiation therapy, rather than to treat the tumors themselves. Many people claim that they can use homeopathy or some herbal remedies as the sole treatment for different types of cancer. But I won’t endorse them unless they can show me some data.

We already know that patients frequently do not tell their oncologists about their use of unorthodox medicines and physicians consistently underestimate the numbers of their patients using them. The purpose of this study was to assess newly diagnosed cancer patients' and oncologists' communications with regard to unorthodox medicines. They looked at people with two types of cancer: 106 had breast cancer and 82 had prostate cancer. All the patients in the study were receiving regular conventional medical treatment.

In line with previous research, 84% reported that they were using at least one unorthodox therapy. The most popular were exercise, vitamins, prayer, and nutritional supplements.

But here was the surprise for the investigators: The oncologists surveyed were generally enthusiastic and supportive of patients' use of these therapies. In addition to those therapies popular with patients, at least half the physicians supported massage, journal writing, support groups, acupuncture, biofeedback, and art therapy.

This was no surprise to me at all. I spent most of my clinical career in tertiary referral centers, and I’ve worked with the best of the best. The vast majority was extremely supportive of anything that would help. Every one of them was a skeptic who would say, “show me.” But once they had been shown, they would be very helpful. After all, who doesn’t want to help people get better?

It has always been so noticeable that the biggest critics, not skeptics, but critics, have been people who were less secure. Often not the “Best of the best,” they would carp and complain that “we don’t do things that way,” and “I don’t see how it could work, so I’m sure that it doesn’t.”

What this new piece of research showed was that discussions the use of unorthodox medicine were relatively rare and were most likely to be initiated by the patients. When the topic was discussed, both patients and doctors said that it usually enhanced their relationship.

What do I take away from this study?

If you, a friend or loved one has cancer, or any other type of illness for that matter, consider using something else in addition to your regular medical care. Not as a replacement, but in addition. The regular treatment will be helping the physical side of the illness, but you also need help with the psychological, social, subtle and spiritual aspects of what is going on in your life.

And guess what? Chances are that if you have a good oncologist, or any other type of conventional clinician working with you, he or she will probably be very supportive of anything that you do.

I once said at a very large meeting that if I needed to put a bone through my nose and do a dance to get someone better, I’d do it.

And I’m not the only one.

What Integrated Medicine does is to put all the cards on the table from the very beginning. We tell people that we are going to be helping guide them toward physical, psychological, social, subtle and spiritual health. They need to be able to derive meaning and purpose from what’s happened to them, rather than just cussing at their misfortune.

And then using the experience to grow as individuals and to help others.

The Integrated Practitioner will also be working with the way in which this person’s challenge is changing them. If a practitioner is not changed by the person in front of him or her, they are working only as a technician and not as a healer.

There’s nothing wrong with that, but everyone needs to be clear about what the practitioner is bringing to the table, and what their expectation is for the person who has come to see them with a problem.

For now, if you are not working with an Integrated Practitioner, do tell your health care provider if your are doing something else to help yourself.

Chances are that he or she will be very supportive.

The Ethics of Complementary, Alternative and Integrated Medicine

In my recent item about ethics I mentioned that Paul Root Wolpe from the University of Pennsylvania is interested in the ethics of Complementary and Alternative Medicine (CAM), and, by extension, its offspring, Integrated Medicine. This caused some raised eyebrows, but it shouldn’t.

Using unorthodox therapies carries a number of ethical and moral responsibilities.

When I was still on faculty at the University of Pennsylvania, on one occasion I caused outrage amongst many friends using natural medicine, when I pointed out on a TV show that just because something’s natural doesn’t mean it’s safe. Think arsenic, deadly nightshade and hurricanes! But there is more to the ethics of CAM than just the safety of the treatments involved.

Just a few months ago I was asked to look at a study by someone claiming to debunk one of the tapping therapies. Neither the investigator nor the practitioners and patients inveigled into the “research,” understood the principles of informed consent. This is important: one of the many consequences of the Holocaust was a re-consideration of what to do with medical “data” collected by Nazi doctors in the most unprincipled ways imaginable. Should the data be kept, so that people would not have died in vain? Or should it be destroyed, because information from unethical experiments was tainted. After a great deal of heart searching, it was decided that any information obtained under those circumstances was likely to be junk. This is one of the reasons for the absolute insistence on informed consent. I shall say something else about consent in just a moment. Let’s have a look at the ethical issues involved in CAM, because much of the criticism of the emerging models of healthcare has come from people genuinely concerned about patient welfare.

1. If we do anything with or for an individual, there has to be informed consent. Informed consent includes full disclosure not just of the chances of efficacy, but also of the possible toxicity of a treatment and an agreement of what we hope to achieve. A therapist may want to balance your Qi and stop you getting sick in the future. You may just want to be rid of your headaches. When we ask about the chances of efficacy, we all run into the problem of positive bias. I was once planning some research with a very well known practitioner in the UK, who told me that he cured every single person he saw, whether they had cancer, schizophrenia, heart disease or anything else. I was astonished, and asked him for something to backup what he said. He flew into a rage! “How dare I question him?” he said.It soon turned out that although he probably was a genuine healer who got a lot of people better, he had no evidence at all. It was like a study in the medical arena in which the investigators decided that anyone who did not come back for treatment was cured! Not a common reaction if someone fails to turn up for an appointment!
2. People often say to me that there can be no harm in giving someone a homeopathic remedy. And of course, from a purely physical and psychological perspective, that’s probably true. Though I once participated in an experiment in which I took the homeopathic remedy Pulsatilla, that is prepared from the Passion Flower. I had what is known as an exacerbation, and was unable to function for several hours. But we also need to think about some of the other things that can follow from using treatments that work at the level of the subtle systems. One of our biggest objections to people who believe that they can do acupuncture after a weekend course, is that acupuncture, homeopathy and the rest are powerful medicines. Putting a needle into the wrong part of a person’s anatomy may not just cause physical harm, but can do extraordinary things to a person’s subtle systems. A fact that is exploited in some martial arts. In the Jet Li movie Kiss of the Dragon, Jet uses acupuncture needles to do some extraordinary things. The filmmakers used little artistic license: with one exception I have personally seen all of the things demonstrated in the movie.
3. I mentioned that informed consent includes full disclosure about the chances of efficacy and toxicity of a treatment and agreement on therapeutic goals. We can find ourselves in a real ethical dilemma when patients have unrealistic expectations for an untested remedy. Sometimes people don’t inform their patients realistically, and they rationalize it as either choosing not to remove hope or as providing support. But we have to be sure that we are not supporting potentially dangerous or harmful decisions. The problem is not necessarily the treatment itself. Using an untested treatment in place of something that we know can be effective can also lead us into difficult ethical waters. Regular readers will remember a sad case that I highlighted a few months ago.

I’m all for holistic therapy: the less invasive the better. I've spent the last 35 years helping develop new and better ways of integrating treatments.

But it’s really important to be realistic, to use what we know works and if we don’t know if a thing works, then to be totally honest with the individual, and keep meticulous records of why we want to use an untested remedy in combination with the conventional.

In the 1980s, the Research Council for Complementary Medicine began to train complementary practitioners in the basics of research, so that they could be better at obtaining informed consent and monitoring the effectiveness of treatments that they were using. We had some success, and it is high time that we helped practitioners in other parts of the world do the same thing.

Rheumatoid Arthritis: A Neurological Disease?

For more than a century, there’s has been a puzzle in rheumatology. Why is it that so many people with inflammatory arthritis get symmetrical involvement of their joints? It is very common for people to get exactly the same joints involved in both hands or in both feet.

Sometimes joints get affected by arthritis because they have already been subjected to a lot of wear and tear: that’s thought to be one of the reasons why gout most often affects the big toe. But the symmetrical pattern of arthritis is far more difficult to understand. There has been speculation for at least 30 years that this symmetry indicates neurological involvement in the disease, and there was a stimulating paper on the topic seventeen years ago, and it has been known for some time that artificially induced arthritis in one joint produces inflammatory changes in the same joint on the other side of the body.

Now investigators from the University of California at San Diego School of Medicine have published an important discovery. Rheumatoid arthritis drugs work better, at least in arthritic rats, when delivered into the central nervous system. Rheumatoid arthritis (RA) is a disease in which there is chronic inflammation, leading to joint pain and destruction. Pain and inflammation in the joints are constantly monitored by the central nervous system, and we have known for many years that the nervous system can regulate inflammation and immune responses. It was demonstrated in the 1960s that damage to certain regions in the hypothalamus of the brain could impair the work of the immune system. The scientists from San Diego focused on a protein called p38, which is involved in a number of cellular processes critical to the development of RA. Several substances that block the action of p38 are effective in animal models of arthritis and are currently being tested in clinical trials in patients with RA.

Pain and inflammation activate p38 in the brain and spinal cord, and blocking it by introducing medicines directly into the central nervous system reduces inflammation in joints.

This is important research, because it opens up new possibilities for treating an illness that can often be very difficult to treat. It may also help explain another observation. Some patients with rheumatoid arthritis who are treated with acupuncture get a reduction in joint symptoms and sometimes even repair of some of the damage to the cartilage in their joints. Experienced acupuncturists see this in about a third of patients whom they treat, so it was a surprise to see a review claiming that acupuncture did not help RA. If we see a disconnect between clinical observation and a research study, there are two options: either clinicians are deluding themselves or there’s something wrong with the research method. Interestingly, there’s recently been a great deal of discussion about the kind of research methodology that produced this negative result, prompted by a very interesting and challenging paper.

My conclusion? Acupuncture may indeed be a valuable adjunctive treatment for RA. But whether it will work on its own remains less certain.

And the best approach of all is to address the physical, psychological, social, subtle and spiritual dimensions of a person with RA. In other words, the new form of Integrated Medicine that I describe in Healing, Meaning and Purpose.

Acupuncture and Acupressure for Chemotherapy Induced Nausea and Vomiting

During the years that I served on the Research Council for Complementary Medicine, one of the most successful pieces of research that we funded was an investigation by the late Professor John Dundee into the use of acupuncture to treat and to prevent post-operative nausea, and chemotherapy-induced nausea and vomiting.

Those early trials helped us learn a lot about how to do trials in acupuncture, and over the years this work has progressed in a number of enters around the world. The Cochrane Collaboration in Oxford has just published a systematic review of the use of acupuncture and acupressure for the treatment of chemotherapy induced nausea and vomiting. Acupuncture was shown to reduce vomiting on the first day after chemotherapy compared with those who did not receive acupuncture: 22% compared with 33%. Acupuncture did not help with nausea but acupressure did. Though acupressure did not help with vomiting.

This shows once again that acupuncture and acupressure almost certainly work by different mechanisms.

For many years, the department of oncology at the Royal Postgraduate Medical School in London used an array of complementary practices. Not to treat the cancers, but to make it possible for people to tolerate the chemotherapy and radiation therapy.

I recently spoke to a woman who had an illness that would only respond to a certain antibiotic. She was very involved with natural medicine, and did not like taking it. But treatment by world-class homeopaths, naturopaths and acupuncturists had not helped her. My solution was to use the antibiotic, but to also use acupressure, homeopathy, a precisely designed diet and some qigong. With that combination she sailed through the conventional treatment, the organism that was causing her problems has gone, and she has re-built her resilience. That is integrated medicine in action.

Technorati tags: Acupuncture Acupressure Chemotherapy Nausea Vomiting Integrated medicine

Temporomandibular Joint Dysfunction

The temporomandibular joint (TMJ) is the hinge joint that connects your mandible or lower jaw to the temporal bone at the side of the skull.

The joint can be affected by many disease processes including osteoarthritis, rheumatoid arthritis, the arthritis associated with psoriasis and infectious arthritis. There’s a whole ragbag of other illnesses and injuries that can affect the joint. But it is more commonly affected by muscular tension, problems with the bite, or tooth grinding (bruxism). I’ve been interested in TMJ problems ever since my days working in the Princess Margaret Migraine Clinic in London, where I saw a great many people with chronic headaches due to problems at the joint. A dental colleague helped many of them. Once I had been trained in acupuncture, I found that this is one condition in which I’ve always had good rates of success, both in humans and in horses.

So I was pleased to see an audit of 60 patients with TMJ dysfunction was compiled from the practices of 15 dental practitioners in the United Kingdom who were applying to become members of the thriving British Dental Acupuncture Society. Simple acupuncture was used at local points around the joint, on the neck, and on a point on the hand that is linked up with the joint, and tends to relax muscles and improve blood flow. This was a simple study, and in hindsight, it could have been improved. But the conclusions were encouraging: 85% of patients benefited, and the intensity of the pain was reduced by an average of 75%. This is remarkable since the patients were only receiving acupuncture and not any of the “extras” that I normally recommend as a matter of course.

Technorati tags: Temporomandibular joint Arthritis Acupuncture Migraine

Acupuncture for Obesity

I was recently astonished to realize that it is now 25 years since I began my training in acupuncture.

It is an extraordinary system of prevention and treatment, yet one of my biggest disappointments has been the lack of effect in smoking and obesity. I have plenty of friends and collegues who have had great results, but I just have not. In fact I find that the "tapping therapies" seem to be a lot more helpful.

So I was interested to see a note about a report from Germany, that claimed modest success in treating the weight gain that can accompany treatment with some prescription medications. It will be interesting to see if anyone else is able to replicate the study. If they do, I shall report it immediately.

In the meantime, we have enjoyed considerable success with an integrated weight management strategy that addresses the physical, psychological, social, subtle and spiritual aspects of the issue. If you try only to diet and/or exercise, the long term results are usually disappointing.

Address everything at once in a very carefully coordinated manner, and the results can be spectacular. Remember the adage: Combinations are Key.

I outline our strategy in the last chapter and CD of Healing, Meaning and Purpose. Later this year we shall be publishing the entire program, and inviting researchers to examine our approach objectively.

Technorati tags: Obesity Weight management Acupuncture Integrated medicine The Atlanta Approach

Presence and Charisma

I was reading a heart-warming story reported by the BBC of a unique case of a young woman who had a heart transplant at the age of two, and when, ten years later, her adolescent body began to reject the heart, the transplant was removed, and her original heart, which had been resting for ten years, was able to take over. A medical first, but that was not what attracted my attention. Neither was it the lymphoma that she developed several years ago, perhaps because of the original illness that damaged her heart, or perhaps because of the anti-rejection medicines that she has had to take all these years.

It was instead the smiling face of Professor Sir Magdi Yacoub (I just love the pictures of him here.) who did the original operation and who consulted on this new operation. He recently turned 70 and no longer operates himself. I cast my mind back almost 25 years, when I was working at the National Heart Hospital in London and first met him. There are two things that I remember about him. The first is that he was the person who allowed me to show the successful use of acupuncture to treat people who had gone through open-heart surgery, and still had pain in their chests. And the second is the reason for today’s item: Magdi had the most extraordinary personal “Presence.” When he walked in a room, everyone would notice him. Most had no idea who he was, or his extraordinary achievements; they were just drawn to him.

I have met many people who have this “presence” or “aura.” In the Eastern world it is often thought of as another manifestation of “Qi.” Closely related to “presence” is charisma: a compelling attractiveness or charm that can inspire devotion in others. In the ancient world charisma was thought to be a divine power or talent, and the word comes from the Greek word kharis meaning “grace” or “favor.” There is a small scientific literature on this phenomenon of charisma, which often flows from having a strong presence. Some of the research is summarized here.

There are clearly many types of charisma: Political, sports, performance, business, spiritual, literary. scientific and so on. The only two people whom I’ve met who knew Einstein told me that people would usually all stand up when he entered the room. Charisma is more than just a personal characteristic; it can also be conceptualized as the way in which certain groups interact with each other. There is a fascinating book entitled Charisma and Social Structure by Raymond Trevor Bradley, that has a fascinating discussion of the transformative and transcendent power of charisma. It must also not be forgotten that there are those who have used charisma for evil ends: three of the most wicked people of the last century were also possessed of extraordinary personal charisma.

Clearly some people have presence and charisma. The question is whether theses characteristics can also be developed. The answer is yes, they can be. Presence is created by an overall impression constituted of posture, eye contact, stillness, silence, self-confidence, competence and serenity. People with a strong presence are often a little mysterious, in the sense that they tend not to reveal much about themselves or their accomplishments. I have also felt if very strongly in people who have worked to develop the subtle systems of their bodies. One of the most potent examples was a Korean Ki-Master who spoke not a word of English, but whose presence could be felt the moment he entered a packed room. Work on your subtle systems will likely cause you to be more still and serene and to have a better posture and that's a great start.

There are a number of things that you can do to improve your own charisma:

1. Create a strong first impression by developing your presence
2. Develop a good impression when you speak
3. Be a good active empathic listener who connects with other people and asks pertinent questions
4. Be supportive of other people and their aspirations
5. Be persuasive
6. Be resilient and adaptable
7. Expand your vision of what is possible
8. Practice thinking creatively
9. Use humor
10. Be committed and courageous
11. Initiate persistent action
12. Instill hope in the people around you

Technorati tags: Sir Magdi Yacoub, Charisma, presence, empathy, acupuncture

Acupuncture for Migraine

It was frustration at being unable to help so many people with migraine, that first lead me to begin my training in acupuncture. At the time I was working as a young research fellow in the main migraine clinic in London and I quickly discovered that acupuncture could be a wonderful treatment for many people suffering from this illness. I did my advanced training in acupuncture in China and even there – working with some of the best practitioners in the world - I confirmed my observation that acupuncture is no panacea. But it is a very helpful addition to our therapeutic toolbox.

There is a most interesting article in this week’s Lancet Neurology, that was also picked up by the BBC. The study came from Germany, and involved 960 patients who were randomly assigned to normal migraine medication treatment, traditional acupuncture, and sham – or fake – acupuncture. People in all three groups got better, and there was nothing to choose between the treatments in terms of efficacy.

So what does that mean? That acupuncture was in this trial as good as medications. But it adds to the growing literature that indicates that the precise placement of needles is not always as important as we used to think. But we also need to know exactly where the “sham” needling was done. During my years with the Research Council for Complementary Medicine and Prince Charles’ Foundation for Integrated Medicine, I saw a great many studies and proposals for studies in which the “sham” needles had actually been placed in highly active acupunctures points.

When I was training in China, most of my fellow students had trained in classical acupuncture in Europe, and some were outraged when they heard Chinese professors of acupuncture say that only some acupuncture points were always in the same place, and that it was not necessary to follow all the classical teachings. Some of the Europeans felt that the Chinese were destroying an ancient legacy. The Chinese simply responded by saying that the practice of acupuncture was being evolved on the basis of clinical observations and empirical research. It looks as if they were correct!

Technorati tag: acupuncture, migraine

Acupuncture Without Needles

There are, in the United States, over 7 million people who are partially or completely disabled by back pain and another 40-50 million people who suffer from chronic recurrent headaches. Frustrated with my inability to help all my patients with conventional treatments, I have been using acupuncture since 1981. But about ten years ago I started using more acupressure, particularly since I could teach a lot of people to continue treating themselves.

Last month we saw evidence from a study using magnetoencephelography (MEG) scanning equipment that acupuncture reduces the activity of regions of the limbic system of the brain. MEG is a relatively new technology that measures the very faint magnetic fields that emanate from the head because of brain activity, instead of measuring electrical activity itself, which is a fairly blunt instrument. This reduced activity only occurred with deep needling, and when the patient experienced what is known as de qi. In Chinese medicine it is normally considered that the needle has not been correctly positioned until the patient and the practitioner both get the sensation of de qi. By contrast, superficial needling just caused activation of sensory areas of the cortex. Many doctors trained in needling techniques ignore the de qi experience, which is, I think, a mistake. When you are able to elicit it, the efficacy of acupuncture increases enormously.

Keep in mind what I have said before: just because acupuncture is associated with neurological changes, does not mean that they are responsible for the effects of acupuncture.

In this week’s British Medical Journal is an article from Taiwan, showing the effectiveness of acupressure in 129 patients with chronic low back pain. Like every study ever done, it is possible to pick some holes in this one, but overall it appears to be sound.

Now I am interested to see a press release about a form of needle-less therapy. I have written before about Thought Field Therapy (TFT), and the subject of the press release is a development of it called Emotional Freedom Technique, or EFT. While TFT uses tapping at specific points, together with humming, counting and eye movements, EFT is much simpler. It combines gentle fingertip tapping on key acupuncture points with focused thought. It is claimed to effectively reduce – and often permanently eliminating – chronic pain. According to its practitioners, EFT is more than 80-percent effective in treating headaches, back pain, cancer pain, arthritis, and pain from other conditions.

There is the rub: I could find no published research when I did a Medline search. That being said, I have reported elsewhere that I went to California to debunk TFT and became a convert after being treated by its inventor, Roger Callahan. There is a small amount of research on TFT that appears to confirm its effectiveness in some conditions, and I have certainly found it to be very helpful for many people.

Whether the claims of EFT will be born out remains to be seen. I have seen the techniques work, and I have to give credit where it is due. In exchange for your email address Gary Craig, who developed EFT, allows you to download a EFT manual from his website. You may also purchase DVDs from his site to learn more about this treatment modality. As always, I do not suggest using EFT or any other method in place of tried and tested treatments, but it may be a good adjunctive treatment for mild conditions.

In future message and in my newsletter I shall share some of the precise techniques that I have found useful, as well as ones that did not work out for me.

Technorati tags: Emotional Freedom Technique, headaches, acupuncture, acupressure, chronic pain

Some New Research on Acupuncture

Acupuncture has been in use for at least three thousand years and some evidence that our ancestors were first exploring this amazing form of healing seven thousand years ago. We now have several forms of acupuncture being practiced: Traditional Chinese, that operates on a system of yin and yang, of five elements, of Qi and channels along which it flows. It was this system that I studied in China almost fifteen years ago. There are many schools and styles of traditional acupuncture, and distinct forms of treatment have grown up in many parts of the Far East, including Japan, Korea and Vietnam. There is also something called "medical acupuncture," that ignores the principles and precepts of traditional Chinese medicine, and instead focuses on stimulating tender spots and using simple "recipes" for treating people. This stimulation might be with needles, lasers of electricity. Both types of acupuncture have been subjected to a great deal of research.

It may be that medical acupuncture works simply by stimulating the release of endorphins, or modulating some other chemical transmitters in the brain and spine. But the situation with traditional acupuncture is more complex. Every competent practitioner has seen clinical responses that cannot be explained on that basis alone. I have personally treated people paralyzed by strokes, and have seen them recover far more than we would ever expect in Western medicine. Other odd things too, like the cartilage being restored in people with arthritis. The frustrating thing is that none of the treatments works every time. But when it does, it can be amazing.

Recent studies that have been published in major journals have extended the list of conditions that may improve with acupuncture to include:

• Fibromyalgia
• The side effects of HIV medicines
• Arthritis of the knee
• Overactive bladder in women
• Itching associated with dialysis

On the other hand, I was surprised to see a large study of people with migraine, who failed to obtain much benefit. More than 20 years ago I reported good results using acupuncture for migraine at a conference in London. An esteemed colleague from Chicago immediately disagreed, saying that he had tried acupuncture and it had not worked for him. I think the message here is that it is not just the therapy, but also who is doing it.

Technorati tags:  acupuncture Energy medicine Qi