Wednesday, May 23, 2012

Battlefield Acupuncture

Chief Warrant Officer James Brad Smith broke five ribs, punctured a lung and shattered bones in his hand and thigh after falling more than 20 feet from a Black Hawk helicopter in Baghdad last month.
While he was recovering at Walter Reed Army Medical Center in Washington, his doctor suggested he add acupuncture to his treatment to help with the pain.
On a recent morning, Col. Richard Niemtzow, an Air Force physician, carefully pushed a short needle into part of Smith's outer ear. The soldier flinched, saying it felt like he "got clipped by something." By the time three more of the tiny, gold alloy needles were arranged around the ear, though, the pain from his injuries began to ease.
"My ribs feel numb now and I feel it a little less in my hand," Smith said, raising his injured arm. "The pain isn't as sharp. It's maybe 50 percent better."
Acupuncture involves placing very thin needles at specific points on the body to try to control pain and reduce stress. There are only theories about how, why and even whether it might work.
Regardless, the ancient Chinese practice has been gradually catching on as a pain treatment for troops who come home wounded.
'Battlefield acupuncture'
Now the Air Force, which runs the military's only acupuncture clinic, is training doctors to take acupuncture to the war zones of Iraq and Afghanistan. A pilot program starting in March will prepare 44 Air Force, Navy and Army doctors to use acupuncture as part of emergency care in combat and in frontline hospitals, not just on bases back home.

They will learn "battlefield acupuncture," a method Niemtzow developed in 2001 that's derived from traditional ear acupuncture but uses the short needles to better fit under combat helmets so soldiers can continue their missions with the needles inserted to relieve pain. The needles are applied to five points on the outer ear. Niemtzow says most of his patients say their pain decreases within minutes.
The Navy has begun a similar pilot program to train its doctors at Camp Pendleton in California.
Niemtzow is chief of the acupuncture clinic at Andrews Air Force Base. He's leading the new program after training many of about 50 active duty military physicians who practice acupuncture.
The U.S. military encountered acupuncture during the Vietnam War, when an Army surgeon wrote in a 1967 edition of Military Medicine magazine about local physicians who were allowed to practice at a U.S. Army surgical hospital and administered acupuncture to Vietnamese patients.
Niemtzow started offering acupuncture in 1995 at McGuire Air Force Base in New Jersey. Several years later, he became the first full-time military medical acupuncturist for the Navy, which also provides health care for the Marines.
Later, he established the acupuncture clinic at the Malcolm Grow Medical Center at Andrews, and he continued to expand acupuncture by treating patients at Walter Reed and other Air Force bases in the country and in Germany. Niemtzow and his colleague Col. Stephen Burns administer about a dozen forms of acupuncture — including one type that uses lasers — to soldiers and their families every week.
Fewer narcotics means fewer side effects
Col. Arnyce Pock, medical director for the Air Force Medical Corps, said acupuncture comes without the side effects that are common after taking traditional painkillers. Acupuncture also quickly treats pain.
"It allows troops to reduce the number of narcotics they take for pain, and have a better assessment of any underlying brain injury they may have," Pock said. "When they're on narcotics, you can't do that because they're feeling the effects of the drugs."
Niemtzow cautions that while acupuncture can be effective, it's not a cure-all.
"In some instances it doesn't work," he said. "But it can be another tool in one's toolbox to be used in addition to painkillers to reduce the level of pain even further."
Smith says the throbbing pain in his leg didn't change with acupuncture treatment but that the pain levels in his arm and ribs were the lowest they've been since he was injured. He also said that he didn't feel groggy afterward, a side-effect he usually experiences from the low-level morphine he takes.
Ultimately, Niemtzow would like troops to learn acupuncture so they can treat each other while out on missions. For now, the Air Force program is limited to training physicians.
He says it's "remarkable" for the military, a "conservative institution," to incorporate acupuncture.
"The history of military medicine is rich in development," he said, "and a lot of people say that if the military is using it, then it must be good for the civilian world."

Wednesday, May 2, 2012

Traditional Chinese Medicine and Infertility

Written by Mike Berkley, L.Ac., FABORM
Although health and healing are the common goals of Traditional Chinese Medicine (TCM) and allopathic medicine, their ideas on the etiology of disease, disease itself and the process used to regain health are decidedly different. The allopathic physician learns that disease must be cured by prescribing medicine, which kills bacteria or renders a virus ineffective; at times surgical intervention is a necessity.

Though the goal of TCM is to cure a patient, the practitioner of TCM attempts to do this not by treating the disease but rather by treating the whole person, taking into account the various attributes of an individual which, when combined, account for an individual being sick or healthy. A person, according to the tenets of TCM is more than their pathology. While treating the pathology may yield impressive results, they are commonly temporary.
A person is not, according to TCM, represented solely by his or her illness, but by the accumulation of every human interaction engaged in from the moment of birth, including the values of and the culture from which the individual develops. The emotional experiences, eating habits, work habits, work and living environment, personal habits and the social milieu are factors that contribute to disease and are factors which, when modified appropriately may lead to regained health.

Though the Western scientific community has not, to date, arrived at a methodology to use in research of Chinese medicine, the veracity and efficaciousness of this medical modality is nonetheless proven by its long history of continued success. More than a quarter of the world's population regularly uses TCM as part of their health care regimen. Chinese medicine is the only form of classical medicine, which is regularly and continuously used outside of its country of origin.

The Four Examinations

The 'Four Examinations' is a method of diagnosis which dates back over three thousand years. Observing, Listening and Smelling (Listening and Smelling are counted as one of the Four Examinations), Questioning and Palpating make up the 'Four Examinations'. This method of diagnosis is far from simplistic, allowing the practitioner to arrive at a differential diagnosis.
Each of the "Four Examinations" can take years to master, and while these diagnostic tools are not replacements for that which Western medicine can provide in analyzing and treating disease, they have the ability to offer information which, when understood in the context of TCM, provides additional opportunities in mapping out patterns of disease and arriving at greater treatment success. The doctor of TCM must approach a patient with a clear and calm mind, without a preconceived diagnosis and etiology.
This mind-set will enable the practitioner to yield clinical gems which are clues about the individual who sits before us! This is the stuff of TCM.

The subjective, interpretive and objective evidence of an individual obtained via the 'Four Examinations' leads to the discovery of the etiology of disease while concomitantly opening a window to the 'Whole Person", thus revealing where in the individual's life the pathogenesis started and what initiated it. The practitioner of TCM must utilize his own interpretive skills, which takes into consideration what is verbalized by the patient and what is observed, while considering what the patient does not verbalize as well. Often, that which is not said can be as clinically enlightening as the information which is freely provided. The tone of the voice, the complexion, the condition of the eyes (in TCM, the Shen or spirt of an individual is said to be revealed through their eyes. Who can deny the clinical efficacy of this? Is there a different expression revealed through the eyes of a clinically depressed individual than from those of a happy, well adjusted one?), the facial expression, the overall demeanor, how one walks, sits, and stands are all observed and utilized by the doctor of Chinese medicine as part of the information required to arrive at a differential diagnosis. The doctor must be able to note and sense inconsistencies in an individual that are expressed by the patient even without the patient being cognizant of the chasms which exist between what they verbally express and what their spiritual presentation divulges. The sensitivity to and awareness of these human idiosyncrasies enables the TCM doctor to develop an understanding of who the patient is even before the 'main complaint' is discussed.

Proper treatment in TCM is more than the elimination of pathological processes. In addition to attacking a pathological factor(s), it is the responsibility of the TCM doctor to support the individual in his or her goal of achieving overall health which includes aspects of physical-psycho-emotional and spiritual health. This paradigmatic approach is an inexorable part of the process of healing. Without it, we are merely chasing the sickness and forgetting about the patient. With this approach, the patient is seen as a whole person, representing the sum of a lifetime of experiences if you will, not just an embodiment of pathology.

Pathologies are guests (and we hope temporary ones!) in a home which serves as a gracious host - our physical, emotional and spiritual selves. TCM first is concerned with strengthening the immune function which includes homeostasis of the physical, emotional and spiritual attributes of the patient, so as to be able to assist the patient in his or her endeavor to do battle and destroy the enemy at the gates (or inside them). When people are chronically exhausted from lack of sleep resulting from anxiety or depression, they can become chronically sick as a result of a lowered immune system.

In TCM the point of departure from Western medicine is not to view the acute presentation (called "the branch" in TCM) as primary, but to treat the etiology (called "the root" in TCM) which is the anxiety and depression which causes the insomnia then facilitating exhaustion and lowering the immune function which can lead to chronic illness.
So, rather than prescribing antibiotics repeatedly, we might address the patient's anxiety/depression syndrome or refer them out to a psychotherapist for appropriate intervention while simultaneously providing treatment.

Infertility and TCM - Mechanisms of Action

It was shown in a study done at Harvard that stress reduces the hypothalamic-anterior pituitary-ovarian axis function, thus being a factor to be considered in the infertility work-up. Acupuncture releases endorphins which mitigate ones response to stressful stimuli thus enhancing the possibility for conception.
"Historically, infertility, particularly "functional" infertility, was attributed to abnormal psychological functioning on the part of one or both members of the couple. Preliminary works in the 1940s and 1950s considered "psychogenic infertility" as the major cause of failure to conceive in as many as 50% of cases. As recently as the late 1960s, it was commonly believed that reproductive failure was the result of psychological and emotional factors. Psychogenic infertility was supposed to occur because of unconscious anxiety about sexual feelings, ambivalence toward motherhood, unresolved oedipal conflict, or conflicts of gender identity. Fortunately, advances in reproductive endocrinology and medical technology as well as in psychological research have de-emphasized the significance of psychopathology as the basis of infertility, and modern research shows that there is little evidence to support a role for personality factors or conflicts as a cause of infertility. This perspective unburdens the couple by relieving them of the additional guilt of thinking that it is their mental stress that may be responsible for their infertility.
Biologically, since the hypothalamus regulates both stress responses as well as the sex hormones, it's easy to see how stress could cause infertility in some women. Excessive stress may even lead to complete suppression of the menstrual cycle, and this is often seen in female marathon runners, who develop "runner's amenorrhea". In less severe cases, it could cause anovulation or irregular menstrual cycles. When activated by stress, the pituitary gland also produces increased amounts of prolactin, and elevated levels of prolactin could cause irregular ovulation. Since the female reproductive tract contains catecholamine receptors catecholamines produced in response to stress may potentially affect fertility, for example, by interfering with the transport of gametes through the Fallopian tube or by altering uterine blood flow. However, more complex mechanisms may be at play, and researchers still don't completely understand how stress interacts with the reproductive system. This is a story, which is still unfolding, and during the last 20 years, the new field of psychoneuroimmunology has emerged, which focuses on how your mind can affect your body.

Research has shown that the brain produces special molecules called neuropeptides, in response to emotions, and these peptides can interact with every cell of the body, including those of the immune system. In this view, the mind and the body are not only connected, but also inseparable, so that it is hardly surprising that stress can have a negative influence on fertility.

Stress can reduce sperm counts as well. Thus, testicular biopsies obtained from prisoners awaiting execution, who were obviously under extreme stress, revealed complete spermatogenetic arrest in all cases. Researchers have also showed significantly lower semen volume and sperm concentration in a group of chronically stressed marmoset monkey, and these changes were attributed to lower concentrations of LH and testosterone (which were reduced in the stressed group). However, how relevant these research findings are in clinical practice is still to be determined.(i) "

The stress factors that acupuncture addresses stems from both psycho-emotional factors as well as physical etiologies. For example, extremely painful pre-menstruum or mid cycle pain can be debilitating. This type of physical stress, no doubt produces emotional stress as a result of missed work, manifest pain and other life-style factors resulting from such extreme pain; all can mitigate the function of the reproductive system.
Aceto corticotropic hormone is released as a response to acupuncture needle stimuli. ACTH has an antiinflammatory mechanism which may for example, help with tubal factor based infertility as a response to pelvic inflammatory disease assuming that the tubes are not scarred.

The insertion of acupuncture needles has been shown to effectively increase blood circulation. Acupuncture is very effective in treating, for example, Reynaud's Syndrome. Enhanced microcirculatory patency to the uterine lining does, undoubtedly contribute to a healthier and more growth oriented endometrium, especially when utilizing electrical stimulation on inserted acupuncture needles on points known as zigongxue which reside superior to the ovaries. The points zigongxue are located 3 inches inferior to the umbilicus and three inches bilateral to the anterior midline.

"They reviewed existing evidence regarding the role of acupuncture in the treatment of infertility, and identified a number of studies indicating that acupuncture can be beneficial as an adjunct to other infertility treatments, including IVF. Only one randomized controlled study examined the independent effect of acupuncture on IVF outcomes, but this indicated a positive effect.

The reviewed authors also highlight evidence that shows the effects of acupuncture may be mediated through neuropeptides that influence gonadotropin secretion, which could in turn affect the menstrual cycle. The technique can also reduce stress, which is known to adversely affect fertility, and has been implicated in the regulation of uterine blood flow." (ii)

"Using acupuncture during assisted reproduction may improve pregnancy rates, say researchers. However, they acknowledge that the mechanism behind this effect is unclear, and the team plans to carry out further studies to confirm, and further investigate, their findings.

Noting that acupuncture has been shown to affect the autonomic nervous system, Dr. Wolfgang Paulus (Christian-Lauritzen-Institut, Ulm, Germany) and colleagues postulated that the therapy could increase endometrial receptivity via control of related muscles and glands.

The researchers randomly assigned 160 women receiving assisted reproductive therapy to undergo IVF with or without acupuncture, before and after embryo transfer. In acupuncture subjects, the needles were placed at points believed to influence reproductive factors, for example by improving blood flow to the uterus. Paulus et al report that the acupuncture group had a higher rate of pregnancy compared with those not given acupuncture (43 percent versus 26 percent). They conclude, therefore, that acupuncture could be "a useful tool" for improving pregnancy rates during certain infertility treatments." (iii)

A Diagnostic Window - East Meets West

One TCM diagnosis which exists and which may be etiologic for male or female infertility is called Liver qi stagnation. One of the key identifiers of an individual with the pattern differentiation of Liver qi stagnation is anger, rage, frustration, depression and anxiety.

"Symptoms of depression, anxiety, and anger may help in determining the nature of infertility experienced by some couples, and identify those who would benefit most from psychological counseling, suggest researchers.
Dr. Secondo Fassino (University School of Medicine, Turin, Italy) and colleagues recorded the personal characteristics of 156 infertile and 80 fertile couples, and measured their degree of psychopathology. When the researchers divided the couples according to the nature of the infertility-organic, functional, or undetermined-they found that the triad of anxiety, depression, and a tendency toward anger suppression successfully predicted the diagnosis of organic or functional infertility in women, with 97 percent accuracy.

For infertile men, anxiety was also an important independent predictor of functional infertility, increasing the likelihood of having this form of infertility five-fold, while depression was more predictive of organic infertility. However, with men - unlike women - anger did not appear to influence infertility in men.
The results suggest the possibility of identifying a subgroup of infertile subjects where, beyond the distress that is consequent to the failure of repeated attempts to conceive a baby, there is also a poorly adaptive psychological functioning, which is likely to play an important role in the onset and course of functional infertility," the team concludes."(iv)

It is becoming more and more prevalent that research conducted by Western scientists and physicians are highlighting the veracity and effectiveness of Traditional Chinese Medicine.

Herbal Medicine

The efficacy of herbal medicine in treating infertility is indisputable to the patient community although the mechanism of action is not completely understood at this time. Similarly the mechanism of action of tricyclic antidepressants is not fully understood in its effect on chronic pain (i.e., in the case of fibromyalgia), but its efficacy has been maintained.
Practitioners of Chinese herbal medicine rarely use a single herb in treatment. Chinese herbs are formula based; many herbs are mixed together to create the perfect 'decoction' specifically designed for the individual patient.
Some formulae contain two herbs and some thirty or more herbs. Each herb has many functions. Each herb has its own flavor, nature, temperature and trophism. Prescribing the correct herbal medicinals requires extensive training and clinical experience.

Self-medicating with herbal medicine presents a dual dilemma. At best the herbs will be useless, as the key to correct formula prescription is an accurate differential diagnosis which can only be rendered by a licensed, board certified, experienced practitioner. At the worst case, self-prescribing of herbal medicine may prove harmful or fatal.
A good example of this is Ma Huang/Ephedra. Ma Huang is an herb prescribed on a daily basis by hundreds of TCM practitioners to thousands of patients safely. That several people have died as a result of taking Ma Huang has nothing to do with the dangerous properties of the herb, rather with the fact that in all cases of fatalities the individuals were self-medicating, without directions from a doctor required for appropriate applications and contraindications. Aspirin can also prove fatal if taken by a hemophiliac. This is not an indication that aspirin should be banned or that it is a dangerous drug, but that it is unsafe if used inappropriately and safe if used appropriately.
Not only is herbal medicine safe, it is highly effective in treating much pathology without the concomitant adverse effects which often accompany pharmaceutical drugs. There are many hospitalizations and fatalities which occur yearly as a result of adverse reactions to biomedicine. The occurrence of adverse reactions to herbal medicine is far less.(v)

I have used herbal formulae repeatedly to lower elevated FSH levels, to regulate irregular menstrual cycles, to mitigate pain in the endometriosis patient; to mitigate pain in the patient who presents with ovulation and/or menstruation related migraines; to thicken an unresponsive endometrium; to treat the amenorrheic; the oligomenorrheic patient; and the patient who presents with idiopathic infertility. Additionally, I have successfully treated male factor infertility, which includes presentations such as low sperm count, poor motility and sperm DNA fragmentation.

Clearly, further research is needed to fully understand the mechanisms of action of acupuncture and herbal medicine in treating the infertile patient. Nevertheless, it is my opinion that the best-case scenario for most patients is to offer them every reasonable option which may serve to successfully address their presentation. Based upon the empirical evidence of my practice in which I specialize in the treatment of the infertility, the integration of acupuncture and herbal medicine into the treatment protocol from a clinical perspective makes sense.
i Domar, Alice (back) ii Fertility and Sterility 2002: 78: 1149-53 (back) iii Fertility and Sterility 2002: 77: 721-724 (back) iv Human Reproduction 2002; 17: 2986-94 (back)
v Adverse reactions to drugs are very common in everyday medical practice. A French study of 2067 adults aged 20-67 years attending a health centre for a check up reported that 14.7% gave reliable histories of systemic adverse reactions to one or more drugs. In a Swiss study of 5568 hospital inpatients, 17% had adverse reactions to drugs. Fatal drug reactions occur in 0.1% medical inpatients and 0.01% of surgical inpatients. The main drugs implicated are antibiotics and non-steroidal anti-inflammatory drugs. Adverse reactions to drugs occurring during anesthesia (muscle relaxants, general anesthetics, and opiates), although less common (1 in 6000 patients receiving anesthesia), are life threatening, with a mortality of about 6%. BMJ 1998;316:1511-1514 (16 May )(back)