Qi Spot

I’m a bit tired so I’ll just quote this article and comment on it:

Outrage over Acupuncture Evidence Attacks NIH (http://www.healthcmi.com/index.php/acupuncturist-news-online/291-outrageacupunctureproofnih)

Doctors from the University of Maryland School of Medicine, Baltimore and the University of Vermont College of Medicine, Burlington published a case vignette in the New England Journal of Medicine recommending acupuncture for the treatment of lower back pain. The article cites that patients with lower back pain account for over $90 billion in annual health care expenses in the US. The doctors conclude that acupuncture is an effective means for treating lower back pain based partly on a recent study of 6,359 patients published in Spine1. For the lower back pain patient in the case study presented, 10-12 acupuncture treatments over an 8 week period are recommended.

Hmmm, why do these names sound familiar?  Oh I recall!  I had cited the University of Maryland Medical Center for it’s excellent website resource on astragalus root (Huang qi) research.  (http://qi-spot.com/2009/10/20/astragalus-root-for-swine-flu/).   Apparently, those guys are quite open minded.

So anyway, what this means is that some doctors published their opinions that acupuncture should be recommended.  Fair enough.  Everyone’s entitled to an opinion, right?  If it’s wrong, let it be proven wrong through tact and reasoning.

NOT.

The pro-acu docs cite extensive evidence:

The doctors cite physiological phenomena that measure the effects of acupuncture. Local anesthesia at needle insertion sites block the the analgesic effects of acupuncture showing that acupuncture is dependent upon neural innervation2. Acupuncture has been proven to cause the release of endogenous opioids in brain-stem, subcortical, and limbic structures3,4. Acupuncture has also been proven to induce the secretion of adrenocorticotropic hormone and cortisol from the pituitary gland thereby creating a systemic anti-inflammatory response5. Functional MRI studies in humans reveal that acupuncture stimulates limbic and basal forebrain areas involved in pain processing6. PET scan MRIs (positron-emission tomography) show that acupuncture increases opioid binding potential in the brain for several days7. Acupuncture has also been proven to mechanically stimulate connective tissues8, release adenosine at the site of needle stimulation9, and increase local blood blow10. The doctors then cite clinical trials showing the efficaciousness of acupuncture in the treatment of thousands of patients10-15.

So what do some skeptics do?  Do they try to base their argument on refuting the evidence?

Despite this overwhelming evidence proving the mechanisms of action and efficaciousness of acupuncture, skeptics were outraged at the publication of an article supportive of acupuncture in the venerable New England Journal of Medicine. An article recently posted in the Forbes “science business” section stated that the article is “embarrassing” and that acupuncture “infiltrates” the University of Maryland Medical School. In the article, the author calls acupuncture “pseudoscience” and states that it is based on “magical thinking of non-existent life-force.” The skeptic author’s only proof of his theory is that one of the many studies cited in the article found that acupuncture was only 47.6% effective for the treatment of lower back pain and that sham acupuncture was 44.2% effective. Therefore, the author concludes that using “toothpicks” randomly on the human body will have the same pain relieving effects as acupuncture. What the author fails to mention in the Forbes attack article is that conventional western medicine therapy (a combination of drugs, physical therapy, and exercise) was only 27.4% effective in that very same study. Should we therefore abolish western medicine by MDs and call it pseudoscience? Acupuncturists have noted that the success of sham acupuncture noted in that particular study of 1,162 patients in Germany reveals that poorly placed acupuncture needles also derive benefit for the patient.

I have already blogged at length on the physiologic differences between sham and real acupuncture (http://qi-spot.com/2010/04/30/definite-proof-acupuncture-more-than-placebo/) and why it SEEMS that acupuncture is hard to validate using holy grail of western medicine studies – the double blind study (http://qi-spot.com/2010/03/30/how-to-research-acupuncture/).

What I also find interesting is the insistence of skeptics that acupuncture works by balancing Qi or something.  That is the lynchpin of their argument.  I can hear it now:

Skeptic: “They believe in some quasi mystical energy flow!  That means acupuncture MUST be quackery!”

Acupuncturist:  ”There are modern, scientifically proven phenomena that explains what we mean by qi flow.  The “needling sensation” is a result of stimulation of nerve fibers, and can be inhibited by certain drugs.  Qi can also be used to mean function, so when “qi” is deficient, one can say there may be decreased circulation to a certain area, or decreased organ function.  An excess of qi can mean a muscle is too tense… (cites more examples)”

Skeptic: (oblivious) “They believe in some quasi mystical energy flow!  That means acupuncture MUST be quackery!”

Acupuncturist:  ”Never mind.”

Seriously, I feel that way sometimes, talking to skeptics.  What’s the point?  You can treat pain in these people and they’ll assign all sorts of reasons EXCEPT the obvious – acupuncture works.

The use of the word “toothpick” also indicates a lack of even a basic awareness of how acupuncture is performed.  You don’t just “prick” people, you insert the needle and manipulate it.

Oh well…

And lastly, a list of references cited by the link I cited…

References

1. Yuan J, Purepong N, Kerr DP, Park J, Bradbury I, McDonough S. Effectiveness of acupuncture for low back pain: a systematic review. Spine 2008;33:E887-E900.

2. Wang SM, Kain ZN, White P. Acupuncture analgesia: I. The scientific basis. Anesth Analg 2008;106:602-10.

3. Han JS. Acupuncture: neuropeptide release produced by electrical stimulation of different frequencies. Trends Neurosci 2003;26:17-22.

4. Pomeranz B. Scientific research into acupuncture for the relief of pain. J Altern Complement Med 1996;2:53-60.

5. Li A, Lao L, Wang Y, et al. Electroacupuncture activates corticotrophin-releasing hormone-containing neurons in the paraventricular nucleus of the hypothalamus to alleviate edema in a rat model of inflammation. BMC Complement Altern Med 2008;8:20.

6. Dhond RP, Kettner N, Napadow V. Neuroimaging acupuncture effects in the human brain. J Altern Complement Med 2007;13:603-16.

7. Harris RE, Zubieta JK, Scott DJ, Napa- dow V, Gracely RH, Clauw DJ. Traditional Chinese acupuncture and placebo (sham) acupuncture are differentiated by their effects on mu-opioid receptors (MORs). Neuroimage 2009;47:1077-85.

8. Langevin HM, Churchill DL, Wu J, et al. Evidence of connective tissue involvement in acupuncture. FASEB J 2002;16:872-4.

9. Goldman N, Chen M, Fujita T, et al. Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture. Nat Neurosci 2010 May 30 (Epub ahead of print).

10. Sandberg M, Lundeberg T, Lindberg LG, Gerdle B. Effects of acupuncture on skin and muscle blood flow in healthy subjects. Eur J Appl Physiol 2003;90:114-9.

11. Brinkhaus B, Witt CM, Jena S, et al. Acupuncture in patients with chronic low back pain: a randomized controlled trial. Arch Intern Med 2006;166:450-7.

12. Haake M, Muller HH, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, paralel-group trial with 3 groups. Arch Intern Med 2007;167:1892-8. [Erratum, Arch In- tern Med 2007;167:2072.]

13. Cherkin DC, Sherman KJ, Avins AL, et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch In- tern Med 2009;169:858-66.

14. Thomas KJ, MacPherson H, Thorpe L, et al. Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain. BMJ 2006; 333:623. 15. Witt CM, Jena S, Selim D, et al. Prag- matic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain. Am J Epidemiol 2006;164:487-96.

Last time, I talked about Suan Zao Ren Tang and mentioned some things about the main ingredient, Suan Zao Ren (Sour Date Seed).  I now present to the reader some excerpts from a 2002 study:

Chen, et al.  Prescriptions of Chinese Herbal Medicines for Insomnia in Taiwan in 2002. eCAM Advance Access published online on April 1, 2009.
eCAM, doi:10.1093/ecam/nep018 (http://ecam.oxfordjournals.org/cgi/content/full/nep018)

Let’s go specifically into the part on Suan Zao Ren.

The second most commonly used Chinese herb for subjects with insomnia in our study was Suan-zao-ren (Z. spinosa). It is the chief ingredient in the formula of Suan-zao-ren-tang. In an animal model, Peng et al. (29) reported that Suan-zao-ren had a sedative effect at higher doses and an anxiolytic effect at lower doses. In addition, Zhang et al. (30) indicated that Jujuboside A, one of the components of Suan-zao-ren, produced its sedative–hypnotic effects through effecting the actions of anti-calcium-binding proteins and it inhibited the glutamate-mediated excitatorysignaling pathway in the hippocampus. Jiang et al. (31) also reported that saponins, the main bioactive components of Suan-zao-ren, could prolong the sleeping time induced by barbiturates. In addition, Ma et al. (32) revealed that sanjoinine A, an alkaloid compound of Suan-zao-ren, might regulate GABAergic neurons and further increase the sleeping time and decrease the sleep latency induced by pentobarbital. Notably, there was a case report indicating that Suan-zao-ren could interact with the antidepressant, venlafaxine (Efexor), thereby leading to an acute serotonin reaction (33).

So nice to see that traditional Chinese Medicine is being STUDIED and PROVEN to work.  Here are the research papers cited by Chen et al:

1. Peng WH, Hsieh MT, Lee YS, Lin YC, Liao J. Anxiolytic effect of seed of Ziziphus jujuba in mouse models of anxiety. J Ethnopharmacol ( 2000;) 72:: 435–41. 
2. Zhang M, Ning G, Shou C, Lu Y, Hong D, Zheng X. Inhibitory effect of jujuboside A on glutamate-mediated excitatory signal pathway in hippocampus. Planta Med ( 2003;) 69:: 692–5. 
3. Jiang JG, Huang XJ, Chen J. Separation and purification of saponins from Semen Ziziphus jujuba and their sedative and hypnotic effects. J Pharm Pharmacol ( 2007;) 59:: 1175–80. 
4. Ma Y, Han H, Eun JS, Kim HC, Hong JT, Oh KW. Sanjoinine A isolated from Zizyphi Spinosi Semen augments pentobarbital-induced sleeping behaviors through the modification of GABA-ergic systems. Biol Pharm Bull ( 2007;) 30:: 1748–53. 
5. Stewart DE. Venlafaxine and sour date nut. Am J Psychiatry ( 2004;) 161:: 1129–30.

The other herbs in the formula include Chuanxiong, Fuling, Zhimu and Gancao.  The effects of each material seems obvious at first.  From a Chinese pharmacologic point of view, Chuanxiong regulates liver blood and clears blood stasis, Zhu Mu clears deficiency heat and nourishes yin, Gan Cao harmonizes, but what about Fu Ling?  Fu Ling is known for draining dampness, but it should be noted that it enters the Heart meridian as well and thus, has an effect of tranquilizing the mind and calming the spirit.

I had read somewhere that the formula as a whole lowers epinephrine levels, but have yet to find the actual research stating such.

This formula was first noted in Zhang Zhongjing’s “Essentials from the Golden Cabinet”, around 208 AD.  Truly a brilliant man.

I am a big fan of sleep.  I believe that good sleep is the best medicine, not just laughter.  I would like to write about a patient of mine, a fifty-something male, with complaints of hypertension and insomnia.

I was not the first TCM physician who the patient saw.  He had been given herbs before but his hypertension was still unabated.  When I saw him for the first time, history revealed that he had severe insomnia.  Logic dictates that his hypertension could be due to the lack of sleep.

Acupuncture, however, did not work at all.  I tried the patent remedy Zao Ren An Shen Ye, which helped a bit, but not so much.  Also, his blood pressure was still in the 180/100 range.  Not acceptable to me.

I brought out the heavy artillery.  I decided to use Suan Zao Ren Tang (Sour Jujube decoction).

After three days of taking the formula, the patient followed up.  He is sleeping better and his blood pressure is down to 140/90.  Talk about treating the branch by treating the root!

So what’s so special about Sour Jujube?

Wild Chinese Jujube, courtesy foodsnherbs.com

A lot of people know about Da Zao (jujube or red dates) but what about Suan Zao Ren or sour jujube seeds?

Suan Zao Ren is sweet and sour in flavor, meaning it tonifies and preserves yin and fluids.  It’s nature is neutral so it will neither promote nor modulate physiology and inflammation.  It enters the Heart and Liver meridians so it affects the Mind through the Heart and the Qi through the Liver.  Great Chief herb.

Anyway that’s enough for now.  In a few days we will present an analysis of Suan Zao Ren Tang – the formula itself!

A buzz topic now is the translation of the government label “No Approved Therapeutic Claims” into Filipino.  The term “No Approved Therapeutic Claims” was used for “food supplements” – a blanket term for non-big pharma produced products, usually “natural” or “herbal” medicine.

“No Approved Therapeutic Claims” thus means – “the claims of these products are not validated by the BFAD/FDA (Bureau of Food and Drugs, now renamed Food and Drug Administration).  What happens then is I can market a “natural” product as a “food supplement” and not as a medicine and it doesn’t have to go through same research as big pharma products.

The problem on this end is that there is a myriad of lousy products out there.  I am an advocate of Chinese herbal medicine but I am also the first to caution against lousy products that only end up harming the patient and the reputation of Chinese medicine.  in China, you see news about companies being penalized for putting out lousy products.  What about us?

Health Secretary Esperanza Cabral has good intentions.  We should be protected from bogus products.  I however, do not agree with the new translation for food supplement “warnings”.  I shan’t print the Filipino version here, but I can tell you it means “this product is not medicine and cannot cure any disease.”

This is obviously where I have a beef.

As a Chinese medicine doctor, I cannot agree that just because something is not produced by Big Pharma, it cannot be considered, “medicine.”  The American Heritage Dictionary defines medicine as “An agent, such as a drug, used to treat disease or injury.”  Note, it says an agent, SUCH AS a drug.  This means that there are other agents, while NOT drugs, that can be used to treat disease or injury.

To the Chinese, one of the most important agents are not just food “supplements”, but food itself.

Sun Simiao is known as the “Yao Wang” or “King of Medicinals”.  He is famous for a book entitled “Prescriptions Worth a Thousand Gold”.  Yet here is this important quote from him:

“Doctors should first understand the cause of disease, then treat it with diet. (Herbal) Medicine should only be used if diet fails” – Sun Simiao

Wow, the “King of Medicinals”, famous for life saving herbal prescriptions… recommends DIETARY therapy?!!  Good luck hearing that from Big Pharma.

Unfortunately this applies to "herbal medicine" product hawkers also. Image by Mike Adams. http://www.naturalnews.com/021638_conventional_medicine_quackery.html

Anyway my final thoughts are these:

1) We should not put down the idea of “food as medicine” as it is actually more effective for a lot of common, everyday problems.

2) The Chinese have this down to a science and I’ll be darned  - the stuff works.  Click http://www.meridianpress.net/intro.html for more info.

3) At the same time, a lot of food supplement products out there are just bunk.  Better not to rely on products made by people who just want your money.  Do your homework.  Pick a tradition of diet therapy (western, Chinese, whatever) and stick to it.

4) Don’t think that one herb or one fruit or one vegetable will solve all your ills.  Make lifestyle adjustments as well.

Now I’m off to get a nice porridge breakfast.  Be well!

Enough with answering back at mudslingers.  I get more than enough of that in the local media, with the Philippine elections just around the corner.  Let’s move on to being proactive instead of being defensive.

A common “debunking” technique of anti-acupuncture bigots is to come up with “evidence” that acupuncture is clinical similar to placebo and then “conclude” that acupuncture is therefore useless or irrelevant.  This plays the assumption that placebo = no effect, when in actuality placebo  = the doc does nothing but the patient feels an effect. (http://qi-spot.com/2010/04/28/the-smear-campaign-continues-acupuncture-does-not-relieve-childbirth-pain/)

Of course, even if both acupuncture and sham acupuncture have clinical effects that seem similar (and studies have shown that the real thing beats the fake stuff, even if not by much), the argument the skeptics pose is that if acupuncture is no different than placebo, then what’s the point of doing real acupuncture at all?

Well, a while back, I posted about a study I was looking forward to. (http://qi-spot.com/2010/04/04/a-study-to-look-forward-to-acupuncture-more-than-just-placebo/).  Thanks to Chris, I now have the whole article.   I would like to start by quoting thus:

As long as acupuncture and sham acupuncture treatments produce similar clinical improvements, the results of respective trials can only be taken as evidence against the efficacy of acupuncture. (I don’t think so… – Philip) Only when it can be shown that acupuncture and sham acupuncture effects are mediated differently, this can be taken as evidence that acupuncture effects are different from placebo effects, although both may still be equally effective.

I still can’t help but detect a bit of bias.  When something can be interpreted negatively, it “can only be taken as evidence against…” meaning there is no other way to interpret it, supposedly.

Similar clinical effect, different mechanism of action

Still the point is valid.  If we can show that the real deal triggers physiologic reactions distinct from sham, then that should construe evidence that acupuncture is not only valid, but should be encouraged.

According to the article “Acupuncture, Psyche and the Placebo Response” (the article mentioned above) they HAVE found such physiologic differences.  Why does this matter?  It matters because a) skeptics can’t say it’s like placebo anymore and b) we now have an increased knowledge of acupuncture mechanism of action, which is more than what we can say for such western drugs as lithium.

Take two of these and call me in the morning, even if we don't know how they work

So how does the real thing differ from the fake stuff?  Let’s count the ways as enumerated by Enck et al:

a) “Acupuncture but not sham acupuncture was found to induce both cerebellar as well as limbic cortex activation indicating both motor as well as affective component modulation of the pain matrix.  Acupuncture resp. electroacupuncture at non-acupuncture points and tactile stimulation alone served as controls in early fMRI studies (Wu et al., 2002; Yoo et al.m 2004)

b) Verum (true) acupuncture in contrast to non-penetrating placebo nedles activated cortical centers involved in affective pain modulation (Chae et al., 2009)

c) Greater activation of sensorimotor areas by sham procedure (superficial manipulation at acupuncture points) than by true acupuncture (Napadow et al 2009) – (note that stimulation of true acupuncture points by non-needling methods was considered sham by the authors, whereas in chinese medicine it is a valid method of stimulation)

d) Variances of time of central activation between verum and sham acupuncture, attributed to stronger peripheral actions of true acupuncture

e) PET scans on fibromyalgia patients show that needling at true points elicited significant activation of mu opoid receptor binding capacity in the cingulate, caudate, thalamus and amygdala both after one session and after four weeks, while with sham (insertion into non acupuncture points), small DEactivations were noted, an effect that is seen with placebo analgesia. (Zubieta et al., 2005)

There are more, but these should suffice to prove the point.

All in all I believe this evidence validates my personal belief that real acupuncture has longer lasting effects than sham acupuncture.  This is shown by the fact that real acupuncture has more central (meaning up in the brain, as opposed to just local pain mediation) effects.

Another thing worth noting is that different people have different definitions of sham.  For some, it’s using real points but not inserting.  For others, it’s inserting into non-acupoints.  Logic dictates that both have different effects.  Controls used in acupuncture studies should be standardized!

The crazy thing is that all this has been known by Stux, Berman and others since I was in grammar school in the early 80s!  Jeez!

_________________________

Enck, P., et al., Acupuncture, psyche and the placebo response.  Auton. Neurosci. (2010), http://www.ncbi.nlm.nih.gov/pubmed/20359961

Harris, Zubieta et al. ” Traditional Chinese Acupuncture and placebo (sham) acupuncture are differentiated by their effects on Mu-Opioid Receptors (MORS)” Neuroimage.  2009 Sep; 47(3):1077-85. Epub 2009 Jun 6. http://www.ncbi.nlm.nih.gov/pubmed/19501658