Saturday, 29 July 2017

New clinic. Same space

I have some exciting, if a little overdue news. I have officially taken over the clinic I have been working in as of the start of July. Lovisa decided she was going to move Joy of Change to a new location and this provided me with the opportunity to take over the current clinic space. Since I was already so busy (booked out weeks ahead), and it is such a great location, I jumped at the chance and here we are. Joy of Change has moved to Aschebergsgatan 21 and the clinic at Kjellbergsgatan 2 (where I have been practising for over a year now) is now officially called Jimi Windmills Akupunktur och Traditionell Kinesisk Medicin. It's now the end of July and things are going really well. I couldn't be happier.

To celebrate this new adventure I have decided to run a little promotion. The details are on the Jimi Windmills Akupunktur facebook page. Those of you who are previous or current patients should also have received an email

Thanks again to Lovisa 

Saturday, 23 May 2015

Dampness, Diet and Chinese Medicine

When I enquire about a patients diet in my practise at Joy of Change, my patients are often quick to reply that they have a healthy diet. On further inspection however, this is not always the case. A banana, or yoghurt with fruit, coffee or a protein shake. Perhaps skipping breakfast altogether. Salads and green smoothies for lunch, and rich creamy sauces with dinner.
Let's have a look at the Chinese concept of Dampness.
Note - In this article I will capitalise words like Spleen, Cold, and Damp when they refer to Chinese medicine concepts. I will Italicise key Chinese medicine phrases like Qi or Transform and Transport. 

The Qi Mechanism - We will keep this brief 
Since Chinese medicine physiology is different to western medicine physiology we will have a brief look at how the food we eat is processed by the body
In Chinese medicine we consider the Stomach and the Spleen to be the organs primarily involved in digesting food. Together, they extract the nutrients and essences to be refined into Qi, blood and body fluids, which energise, nourish and lubricate our bodies. The Spleen and Stomach are a Yin and Yang pair and belong to the Earth element.
The Stomachs job is to receive food and to rot and ripen it. The Spleens job is to transform that food which the stomach has processed into Gu (nutritive) Qi. This Gu Qi which has been extracted from the food is then Transported to the Upper Jiao, a term which denotes the thoracic cavity, the heart and lungs, or simply the chest. Here, Gu Qi is combined with air and is further refined into the various vital substances in the body. The Spleen is also responsible for transforming and transporting body fluids. Qi is distributed around the body by the action of the lungs. Blood, the other main product of the Qi differentiation that happens in the Upper Jiao, is pumped around the body by the heart. It is this physiological mechanism that generates all of our Qi, blood and various body fluids, which nourish our bodies and minds. This earns the earth element organs the generous title of the "root of post-heaven Qi".


The Spleen and Stomach.
  • The Stomach ReceivesRots and Ripens.
  • The Spleen Transforms the food into Gu Qi and Transports the Qi upward. It also transforms and transports body fluids.



What is Dampness?
The concept of "Dampness" in Chinese medicine can be a little tricky to get your head around at first. Damp is one of the six external evils along with Cold, Heat, Dryness, Wind and Fire. Each of these external evils can be found in the environment around us. With prolonged exposure, they can invade our bodies and cause illness. However, these pathogenic factors can also be generated internally as a product of lifestyle, diet, and our habitual emotional responses. 
Dampness is the condition or substance that occurs or accumulates when the Spleen isn't able to transform and transport body fluids and Qi effectively. Ironically, along with Cold, Damp in our environments and in our diets is one of the primary causes of impaired spleen function. Dampness can be both the cause and the outcome!
The Spleen and Stomach are delicate organs which can easily be thrown out of balance. The Stomach is said to be vulnerable to Heat and Fire. Similarly, Cold and Damp are considered to be the two pathogenic factors that most affect the SpleenWhile Cold and Damp can often be found in the environment around us (especially here in Sweden), it is probably more common that they enter the body as a part of our diets.


Other things that damage the spleen are over-eating, over-thinking or “heavy” conversation while eating, eating irregularly, eating late at night, stress and anxiety, excessive exercise over-working yourself and shift work, especially especially working overnight for extended periods.


When the Spleen is affected by Cold and Damp it fails to properly perform its role to transform food into Qi and to transport Qi upwards to the chest. When food is not transformed properly it tends to stagnate in the Stomach causing you to feel bloated. This food stagnation can become a blockage that stops the normal flow of Qi in the digestive system. Qi that is obstructed and isn't moving freely, stagnates and stops the Spleen from properly transforming and transporting body fluids allowing them to accumulate and transform into Dampness. When the spleen isn't functioning properly, it can't transport Gu Qi upwards to the chest. The Qi begins to sink downwards. This sinking Qi is not properly transformed, and is considered turbid, dirty or impure. This turbid Qi causes loose, poorly formed and sometimes frequent stools and also abdominal bloating or pain.

Damp conditions
Sinus congestion and chronic infections. Allergies. Respiratory problems. Digestive problems. Skin conditions. Lethargy or heaviness of the body. Edema. Yeast infections. Cysts. Arthritic conditions. Headaches or absence of mental clarity. 


How do we avoid dampness?
As stated previously, Cold (which injures the spleen and leads to dampness) and Dampness come from two primary sources; Externally in our environment and from internal sources. Examples of external sources might be damp in the home or workplace (basements, bathrooms, working outdoors in winter etc.) or even wearing improperly dried damp laundry. Internally generated Dampness is most often a product of lifestyle and diet. The main culprits are refined sugars and high carbohydrate foods like white bread and pasta. Rich and greasy foods like peanut butter, pizza and burgers are also very Damp forming. Raw, Cold foods such as fruit (especially bananas, avocado and mango) fruit juice, green smoothies and salads all contribute to poor digestive function due to their Cold energy injuring the Spleen. Perhaps most common, especially in Sweden, are dairy foods. Milk, cheese, yoghurt, cream, filmjölk and especially ice-cream, contribute to Dampness because they are often both Cold and Damp in nature. This isn't to say that dairy is always bad. However, a traditional Chinese medicine diet incorporates dairy very sparingly. It was used mostly to treat very under nourished people. Those of us that are well fed will typically find dairy to be Damp-forming and a hindrance to our digestion.
Dampness can be expressed in many ways in the body. Tiredness and fatigue, feeling bloated or tired after eating, a poor appetite and a feeling of heaviness in the body, especially the arms and legs. Having muddled unclear thinking or a poor memory. Cloudy urine. Loose stools that might be sticky, greasy and poorly formed or contains mucus. Woman may have excessive thick, sticky white vaginal discharge. As more and more Dampness accumulates in the body it tends to become more "solid". Examples of this are swollen joints, fluid collecting at the ankles or waist, thighs and buttocks, and conditions such as gout or rheumatoid arthritis.
The best way to avoid accumulation of Damp (other than drying out your basement) is to avoid Damp-forming foods and to strengthen the Spleen and Stomach. The Spleen likes warmth and dryness. It loves regular meal times, so try to eat at the same time each day. Eat in a calm environment and don't rush through your meals. Try not to have heavy conversations during meals, remember, over-thinking damages the spleen. Regular light exercise is important but remember not to over do it, too much exercise can also damage the Spleen.
If you suspect you already have some Damp accumulating, switch out some of the 'bad' foods (no food in Chinese medicine is ever really considered to be bad) for foods that support and strengthen the Spleen and Stomach and drain Dampness. While it might seem contradictory, a healthy intake of water is important. Drinking water promotes urination, which lets your body get rid of the dirty or “turbid” fluids and replaces them with clean fluids. Just make sure the water isn't cold. Let your tap water come to room temperature before you drink it. 7:00 - 9:00 in the morning is considered the Stomachs time. This is the best time to eat breakfast. 9:00 - 11:00 is the Spleens time. This is the best time for clear thinking, working and being active.


Foods that fight Damp
Here are some suggested foods to incorporate into your diet to help drain the Damp.
  • Grains: corn, barley, basmati rice, oats
  • Vegetables: alfalfa sprout, mushroom, caper, pumpkin, radish, turnip, parsley, lettuce, celery, asparagus, white fungus, onion, mustard leaf, spring onion and leek, dandelion leaf.
  • Fruit: papaya, lemon
  • Beans: adzuki, lentils, kidney
  • Fish: eel, tuna, mackerel, anchovy
  • Herbs, spices: aniseed, garlic, ginger, cloves, cardamom, cinnamon, nettle, parsley, basil, turmeric, white and black pepper
  • Drinks: green tea, raspberry leaf tea, jasmine tea, licorice tea, water (room temperature or warm).
There are a lot of good Chinese medicine food blogs online. Sarah George, The Wellness Ninja, an old Lecturer of mine is particularly good.


Here is a simple recipe for a rice porridge (congee or jook) that will help to expel dampness and strengthen the Stomach and Spleen function. It makes an excellent breakfast, especially when followed by green tea or licorice tea

  • 6 cups water
  • 1 cup long-grain white rice
  • 4 cups chicken broth
  • 1 1/2 pounds bone-in chicken legs or thighs, skin removed and trimmed of excess fat
  • 1-inch fresh ginger with skin on, sliced into 4 pieces
  • 1/2 cup adzuki beans
  • 2 teaspoons salt (river/pink/Himalaya)
  • Pinch freshly ground white pepper.
  • Coarsely chopped fresh coriander, for garnish
  • Thinly sliced spring onion, for garnish
Place all ingredients except the coriander and spring onions in a large saucepan. Bring to a boil over medium-high heat. Reduce the heat to medium low and cook at a brisk simmer, stirring occasionally, until the rice has broken down and turned creamy, about 1 hour.
Turn off the heat and remove the chicken to a cutting board. When it’s cool enough to handle, shred the chicken into bite-sized pieces, discarding the cartilage and bones. Return the chicken pieces to the congee. Taste, and season with additional salt and pepper as needed. Garnish with coriander and spring onions.


Thursday, 16 April 2015

Försöker du sluta röka?

NADA-protokollet är en metod för behandling med fem akupunkturpunkter som utvecklats under 70-talet och 80-talet för att behandla olika typer av missbruk. Protokollet används ofta för att hjälpa människor att sluta röka, men även andra typer av beroenden och missbruk kan behandlas framgångsrikt.

Akupunkturpunkterna som används vid NADA är belägna på ytterdelen av örat.
När de här punkterna stimuleras med nålar samtidigt ger de en bred systemisk effekt, som bidrar till att minska suget och lindra andra abstinensbesvär. Akupunkturen i sig kommer inte att hindra dig från att röka. Du måste vara redo och villig att göra det hårda arbetet. Vad det däremot kan göra är att minska suget och abstinensbesvären och därmed hjälpa dig genom processen. Om du kämpar med några av följande symtom kan det vara dags att prova akupunktur:

  • Sug efter nikotin (eller andra droger)
  • Irritabilitet
  • Huvudvärk
  • Ångest eller depression
  • Koncentrationssvårigheter
  • Ökad hunger och sug efter sötsaker
  • Illamående
  • Förstoppning eller diarré
  • Minskad hjärtfrekvens eller lågt blodtryck
  • Trötthet, dåsighet eller sömnlöshet

Under mitten av 1970-talet var det en läkare vid namn Michael Smith på Lincoln Hospital i New York som modifierade ett befintligt system av öronakupunktur till en enkel teknik för att behandla många vanliga beroenden som ett alternativ till metadon. De punkter som valdes visade sig vara extremt effektiva vid behandling av missbruk, och fick namnet "NADA-protokollet."

NADA är en förkortning av National Acupuncture Detoxification Association, och det är också spanska för "ingenting". NADA grundades 1985 av Dr Smith och en grupp som var intresserade av att använda protokollet med behandling av missbruk.

Ursprungligen bestod NADA-protokollet av elektrisk stimulering på en enda punkt (Lung punkten) på patientens ytteröra. Man fann dock att manuell stimulering av nålen på denna punkt gav en mer långvarig effekt. Protokollet utökades så småningom till att inkludera Shen Men, en punkt som är välkänd för att leda till avslappning och även flera andra punkter. Idag består NADA-protokollet av att små akupunkturnålar sätts på fem punkter i ytterörat på patienten. Dessa punkter kallas Shen Men, Sympatikus, Njure, Lever, Lunga.

Vanligtvis sätts nålar i båda öronen samtidigt, och de får sitta i mellan 30 till 45 minuter. NADA-protokollet utövas ofta i grupp för att hjälpa till att bygga stöd och att bryta ner känslor av isolering som kan upplevas av patienten. Patienter behandlas i ett lugnt, bekvämt rum, som tillåter dem att slappna av ordentligt. Alla patienter behandlas lika, med samma uppsättning punkter. Detta för att patienterna skall känna att de delar en gemensam upplevelse och det möjliggör även för utövaren att behandla flera patienter samtidigt.

Patienter som behandlats med NADA-protokollet beskriver ofta en känsla av välbefinnande efteråt, och det är vanligt att man får mer energi och känner sig lättare och mer avslappnad. Gruppbehandlingen är i sig ett icke-verbalt verktyg som möjliggör för patienten att känna trygghet och stöttning och som kan hjälpa dem framåt i avgiftningsprocessen.

Det finns många dokumenterade studier som visar på effektiviteten av NADA-protokollet. De fördelar som rapporterats av patienter och utövare är: förbättrad förmåga att hålla sig till missbruksbehandlingsprogram, en mer positiv inställning till avgiftning och återhämtning, minskat sug, minskad och ångest, bättre sömnkvalitet, och minskat behov av läkemedel.

NADA-protokollet kan vara en viktig komponent i avgiftningsprocessen, men det är inte den enda komponenten. Patienternas attityd och beteende, hur de identifierar sig med sitt missbruk, samt deras uppfattning av utövaren av behandlingen är också viktiga aspekter för en framgångsrik behandling. NADA-protokollet används ofta i kombination med andra behandlingsformer, såsom rådgivning, stödgrupper och självhjälpsprogram, för att på så sätt öka effektiviteten.

Monday, 27 October 2014

Cold and Flu


At this time of the year it is common for people to find themselves feeling a little stuffy in the head, maybe a little cough, some sneezing or a runny nose. It may be a minor irritation or perhaps a downright crippling flu. With this in mind I would like to relate an often told story that highlights the different attitude toward cold and flu and its treatment in China.

Some years ago, a group of esteemed scientists from the People's Republic of China were invited to visit the United States by the American scientific community. This event ushered in an exchange of ideas and an opportunity for two great nations to be able to corroborate on a number of issues vital to the health and welfare of the world.

Over a period of two months, the Chinese scientists visited virtually every major research facility in the nation, followed closely by their American hosts, who were furiously taking notes and promoting discussion on matters from nuclear physics to aerospace, medical research and treatment approaches. The visit culminated in a banquet at Princeton University in honor of the Chinese scientists, which was attended by a virtual "who's who" of the North American scientific world.

During the banquet, the moderator of the event posed the question to the chief Chinese scientist as to what he felt was one of the most significant things he had learned in America; what had impressed him the most about the United States that he would return to China and share it with his colleagues who were not present on this historic visit? The scientist rose from his chair, strode to the microphone, gazed over the crowd and stated in understandable English: "The number one thing that has impressed me the most about America is the common belief by the common person that there is no cure for the common cold." The American scientists were totally caught off guard with this statement, as it was perhaps the farthest thing from anyone's mind. It was not what they had expected to hear (Acupuncture Today).

As the most common sickness experienced by people the world over, it is no surprise that Chinese medicine with its long history is well regarded in China as a cure for cold and flu. This knowledge is slowly spreading to the rest of the world with more and more people every year seeking treatment from their local acupuncturist or Chinese herbalist for cold and flu. The beauty of Chinese medicine is that when caught and treated in the early stages (before the pathogen has had a chance to penetrate more deeply and is still in the most superficial channels), cold and flu can be stopped dead in its tracks, completely preventing or dramatically reducing the symptoms. For someone who is already suffering the unpleasant effects of cold and flu, acupuncture can do a lot to reduce symptoms and speed along the recovery process.

The best approach, as always, is prevention. Stay healthy by maintaining a regular routine of light exercise. Don't let the cold and dark of winter convince you that you should be hibernating. Eat warm nourishing food in the cold months from autumn to spring, this will give your body the energy it need to fight off the bugs. Stay out of the wind as much as possible. Remember, the wind is the spearhead of a thousand illnesses, so make sure you wear a scarf when you are out, and keep your lower back well covered. When you feel the first signs of cold and flu, a bit of a sniffle or a scratchy throat, make an appointment to see your local acupuncturist and get on top of it before it gets on top of you! 

Monday, 13 October 2014

Hälsosjälen

For the last few months I have been working with an amazing team of practitioners at a beautiful clinic in Mölndal called Hälsosjälen.

I am really enjoying treating a broad spectrum of conditions at the moment, including uterine fibroids, migraine, chemotherapy sequelae, and bells palsy to mention a few of the more interesting cases. It is wonderful to see people finding an acupuncturist for such diverse conditions here in Sweden where acupuncture is still relatively unknown as a treatment except for musculo-skeletal conditions.

Saturday, 27 July 2013

Asthma

An Evaluation of Current Research 
Jimi Windmills

Epidemiology

Asthma is characterised by airway hypersensitivity to a variety of stimuli leading to chronic airway inflammation and obstruction. It is considered to be partially reversible, with treatment or by spontaneous resolution (Tortora and Derrickson 2009: 913). Asthma affects 3-5% of the US population and 300 million worldwide, with a steadily increasing prevalence, particularly in westernised countries. Asthma is more common in children, especially boys. However, after puberty, it more commonly affects females (Tortora and Derrickson 2009: 913; Boon et al. 2006: 670).

Aetiology and Pathogenesis

The Aetiology of asthma is complicated, and involves various environmental and genetic determinants (Boon et al, 2006: 670). People with asthma often react to triggering stimuli in concentrations too low to cause problems for people without asthma. Common triggers include allergens such as pollen, moulds, dust mites, and aspirin. Asthma attacks can also be provoked by exercise, emotional upset and breathing cold air or cigarette smoke. The resulting airway obstruction in the early (acute) phase response is due to smooth muscle spasms in the smaller bronchi and bronchioles, and may be contributed to by increased mucous secretion, oedema of the mucosa of the airways, or damage to the epithelium of the airway (Tortora and Derrickson 2009: 913). In the late phase (chronic) response we generally see inflammation, oedema, fibrosis, and necrosis of bronchial epithelial cells. These responses are mediated by leukotrienes, prostoglandins, thromboxane, platelet-activating factor, and histamine (Tortora and Derrickson 2009: 913).
Symptoms include coughing, wheezing, difficult breathing, fatigue, moist skin, chest tightness, tachycardia, and anxiety. In severe chronic cases, remodelling of the airway can occur, which may progress further to fibrosis of the wall of the airway, fixed narrowing of the airway, and a reduced response to inhaled medication (Boom et al, 2006: 671).

Diagnosis and Treatment

Asthma is diagnosed on the basis of a comparable clinical history, and demonstrated airflow obstruction. Diurnal (measured first thing in the morning and before bed) variation of more than 20% in peak expiratory flow (PEF) is diagnostic of asthma, and the degree of variability is an indication of the severity of the condition (Boon et al. 2006: 673). Treatment of asthma most commonly utilises inhaled B2-adrenoceptor agonists, and corticosteroids
Treatment of asthma in western medicine generally follows an established, five-tier system, where treatment becomes more intense until the condition stabilises, and then is gradually reduced, as the patients symptoms become less severe, and less frequent.
Acute attacks are treated with inhaled B2-adrenoceptor agonists (albuterol) which help relax the smooth muscles in the bronchioles and dilate the airways. Long-term treatment of asthma attempts to suppress the underlying inflammation. Anti-inflammatory drugs are used most often, especially inhaled corticosteroids (glucocorticoids), cromolyn sodium, and leukotriene blockers.
Patient education and avoidance of aggravating factors play a key part of the management of asthma. Patients should be advised not to smoke, and encouraged to identify other triggers, and remove them from the home environment (Boon et al 2006: 675-6).

TCM Background Asthma

Asthma, in Traditional Chinese Medicine (TCM), is called Xiao Chuan. Xiao refers to patterns of rapid shallow breathing, with wheezing, while Chuan refers to breathing which is laboured, through the mouth, with elevated shoulders and flared nostrils, breathing is so difficult that patients are unable to breath when lying flat (Wu and Fischer 2009: 28). According to Wu and Fischer, it is often difficult in practise to differentiate which pattern is predominant during an acute asthma attack, so the patterns of Xiao Zheng (Wheezing) and Chuan Zheng (Breathlessness) are often considered together (2009: 28).

Aetiology and Pathogenesis

The aetiology of asthma, according to Wu and Fischer include the six external influences, disruption of the seven emotions, improper diet and eating habits, stress and over-strain and extended illness where the physical condition is frail. However, it is noted that in Xiao conditions, the primary factor is chronic phlegm in the lung, with external pathogens and internal disharmony playing a lesser, although still important role (2009: 28).
According to Anshen Shi, asthma is considered to be a disease of latent phlegm in the lung, which is triggered by an external pathogenic influence (Shi 2003: 336). The primary aetiology of asthma in this view is phlegm. This phlegm is the result of the bodies inability to properly distribute and process fluids in an appropriate manner.
[Phlegm] results from failure of the lungs to distribute and disseminate fluids adequately, or from failure of the spleen to transform and transport fluids, or from failure of the kidneys to steam and transform fluids. Phlegm forms, accumulates and lies in the lung; latent phlegm can be stirred by weather changes (exterior wind carrying allergens), improper diet, emotional stress, and exertion (Shi 2003: 336).
This latent phlegm obstructs the airways, and impairs the lungs dispersing and descending of lung qi, which causes wheezing, breathlessness, chest congestion and a productive cough.

Patterns of Asthma

There seems to be a general consensus on the patterns of asthma. Most authors split the patterns into excess type, and deficient type asthma. Excess patterns of asthma are usually invasion of wind-cold/heat, and accumulation of phlegm/phlegm-heat in the lung. Deficient patterns are most often vacuity of the lung, and vacuity of the kidney.
A notable exception to the two excess and two deficient pattern trend comes from Cheng, who lists four deficient patterns; Asthma combined with lung qi deficiency, asthma combined with spleen qi deficiency, asthma combined with kidney deficiency, and asthma combined with heart qi and yang deficiency.
Shi, unique amongst all other authors, treats the conditions of Xiao and Chuan separately. Xiao Zheng (wheezing) has excess and deficient patterns, which Shi correlates with acute attack and remission phase asthma. In the acute phase, he gives us cold pattern and heat pattern, and in the remission phase, he lists lung deficiency, spleen deficiency, and kidney deficiency (Shi 2003: 21). Shi lists five excess patterns of Chuan Zheng (breathlessness); Wind cold invading the lung, turbid phlegm accumulation in the lung, phlegm-heat accumulation in the lung, stagnant qi obstructing the lung, and exterior cold with lung heat. The deficient patterns are lung deficiency and kidney deficiency (Shi 3002: 27). See appendix 1 for a full table of patterns.

Critical Analysis

In this section, after a brief report of the setting and methods of each study, I will critique aspects of each clinical trial against the consort check list and STRICTA guidelines, and score the study on the JADAD scale.

Databases and Journals

Search terms employed to identify relevant studies; Acupuncture, Asthma, Randomised Controlled Trial (RCT), Xiao Chuan, Childhood, Paediatric, Breathlessness, and Wheezing.
The following databases were searched; The Cochrane Library, PubMed/Medline, ScienceDirect, EBSCOhost, and Google Scholar.
This resulted in 24 articles of interest from 1996 - 2012, relating to the topic of asthma and acupuncture. Some of these were systematic reviews or meta analysis, some related to laser acupuncture, and some considered other modalities alongside acupuncture.

Paper 1.

Joos S, Schott C, Zho H, Daniel V, Martin E 2000. 'Immunomodulatory Effects of Acupuncture in the Treatment of Allergic Asthma: A Randomized Controlled Study', The Journal of Alternative and Complementary Medicine, vol. 6, no. 6, pp. 519-525.

Objectives and Methods

The authors stated objective was to investigate the immunological effects of Chinese acupuncture on patients with allergic asthma.
Setting
Department of Anaesthetics of the University of Heidelberg

Recruitment and Inclusion /Exclusion

Patients were recruited from two pulmonologic practises and via newspaper advertisements. Patients were included with mild to moderately severe bronchial allergic asthma, with at least one positive reaction to a prick test, perennial symptoms and regular use of anti-asthmatic medication. Other inclusion criteria was a disease duration of minimum 1 year and maximum of 20 years.
Patients were excluded if they had any other serious disease, or were undergoing any other type of therapy, including psychotherapy. Patients were also excluded if they were using oral steroids in doses larger than 7.5mg of Prednisone a day.

Power calculation

There was no power calculation performed to determine the number needed to treat. There was no other rationale reported as to how the number of participants needed was determined. In the discussion the author acknowledges that the study was most likely underpowered to be able to demonstrate a broader improvement in immune response.

Randomisation and Blinding

This study was a single blinded, randomised controlled trial. Patients were stratified according to their age and duration of disease. Randomisation was performed in groups of 6 to 10 patients using numbered envelopes.

Dropouts

There were no drop-outs in this study. All patients completed the study, however there were two exclusions that occurred along the way. One of the control patients was excluded since she became pregnant during the study. One of the TCM treatment group patients was excluded because of missing immunologic data.

Practitioner

Dr. H. Zho, an experienced acupuncturist from China, who works in the Department of Anaesthetics at the Heidelberg University, where the study was conducted.

Pattern Differentiation, Point Prescription, and Treatment

Dr. Zho performed a TCM differential diagnosis, and a set of fixed points were used, these being; BL 13, BL 17, LI 4 and LU 7. To these points Dr. Zho added others, based on his diagnosis, including; LU 5, LU 6, ST 36, ST 40, KI 3, KI 7, SP 6, SP 9, CV 6, CV 12, and HT 7.
Needles used were Asia-Med brand needles manufactured in Germany. All points were needled to a depth of 0.3 – 3cm, and de qi sensation was elicited from each point upon insertion of the needles, and again before they were removed. Treatments were conducted for 30 minutes, 12 times during the 4 weeks of the trial.

Control Group

This was not a placebo controlled trial, the treatment group was compared to a control group who received points that were selected by Dr. Zho, deemed to be non-specific to the treatment of acupuncture. The control group, like the treatment group received a fixed set of points; TE 3, TE 19, GB 8, and GB 34, and additional points randomly chosen from the following set; BL 38, BL 55, ST 4, ST 6, ST 32, TE 14, TE 25, and SI 5. These points were needled superficially, less then 1cm depth, and given no stimulation.

Outcome Measurements and Results

The authors report a statistically significant improvement in the general well being of the treatment group over the control group. However, the most interesting results of this study are the immunologic changes that were measured. In the TCM treatment group CD3+ lymphocytes increased by 16%, and CD4+ cells by 14%. CD8+, and CD25+ cells had non-significant increases. There were also significant changes in cytokine levels, IL-6 and IL-10 concentrations decreased, while IL-8 increased. The in vitro lymphocyte proliferation rate in the treatment group increased by 83%, and the eosinophil count decreased by 25%. In the control group on only the CD4+ lymphocytes showed a change (22% increase), and there were no significant changes to cytokine concentrations or in vitro lymphocyte proliferation rates. It was not reported that the data collation and statistical analysis was performed by an external competent blinded assessor.

Exit Questionnaire

There was no reported exit questionnaire to determine the success of the blinding

Criticisms

Practitioner

The diagnosis and point prescription was described as being made by an experienced practitioner, Dr H. Zho. We are not actually provided with his credentials except that he is from China, which is not necessarily an indication of skill or experience, and that he works in the Anaesthetics department at the University of Heidelberg, again not an indication of experience or skill as an acupuncturist. All we have to go on, to determine his skill as an acupuncturist, is that we are told he was able to perform a TCM differential diagnosis, including tongue and pulse, which would require at least some knowledge of TCM, and that his point prescription seems reasonable as a treatment for asthma.
The actual treatment of patients was performed by medical students, not Dr. Zho, and not acupuncture students or qualified practitioners. These medical students had six months training from Dr. Zho to 'achieve a comparable qualification' (Joos et al. 2000: 521). I'm not exactly sure what is intended by this statement. If it means that in six months, they had achieved a comparable level of skill and TCM knowledge to their mentor, then perhaps Dr. Zho was a “medical acupuncturist” who himself had had just six months of training. Then again he may have been a 70 year old master acupuncturist with 50 years of experience, and this is just some obscure remark by the author. Without his qualifications being reported we just do not know.

Treatment

We are to assume that all point locations are standard locations. However this is troublesome, since it depends upon whose standards you are treating in accordance with. The author makes no mention of which standard they are basing their location on, and in lieu of a reported standard, gives no anatomical description of the locations of any points.
We are told exactly which points were used as fixed points in every patient in the TCM treatment groups point prescription. However Dr. Zho's pattern specific points are not thoroughly documented. The author states that Dr Zho prescribed 'flexible points, which were variable added in accordance to the Chinese diagnosis (e.g., LU 5, LU6 […]' (2000: 521) etc. as I have listed in the above section on treatment. This is terrible reporting, in this statement, the only such listing of points in the study we are given an “e.g.”, an example of other points employed in the treatment. From this I can only conclude that we have not been provided with an exhaustive list of the points employed throughout the study. Neither were we given any information about the needles used other than their brand, or whether points were needled bilaterally or unilaterally.
This treatment would have benefited greatly from a justification for the point selection, and a demonstration of the historic usage of these specific points for asthma. In the interests of consistent treatment within the groups, a fixed point prescription would have lent greater cohesion to the study. Also, reassessing a patient and changing a point prescription after a course of treatment in a private acupuncture clinic, is a well established and acceptable practise. However, doing so during the course of a clinical trial is akin to running a pharmaceutical trial and changing dosages or even switching medications entirely in the middle of the trial based on how the patient is responding to the treatment. In the end, we do not know which set of points are responsible for the measured immunologic changes at the end of the study.

Control Treatment

The authors acknowledge the fundamental problem of using acupuncture of any kind as a control. They themselves state;
'On the one hand, the control procedure should be indistinguishable from the real treatment, which means penetration of the skin is necessary to produce pain sensation. On the other hand, the placebo has to be physically inert otherwise it is called sham control [...]. However, any needling or manipulation of the skin is believed to produce a physiologic response. Keeping these much discussed considerations in mind, it can be concluded that there is no acceptable placebo for acupuncture research' (Joos et al. 2000: 524).
The point selection for the control is interesting then, since all the fixed points have some action that affects the areas of the chest and/or throat. According to Deadman et al. the following points have these actions;
  • TE 3 – throat painful obstruction (2007: 394).
  • TE 19 – indicated for fright, pain of the chest and lateral costal region, and dyspnoea (2007: 409).
  • GB 8 – eliminates wind, and harmonises the diaphragm and stomach (2007: 427)
  • GB – 34 – spreads liver qi and benefits the lateral costal region, treats all disorders of the lateral costal region, expels pathogens from the shaoyang [which runs over the lungs in the costal region and over the top of the lungs, on the upper back and shoulders] (2011: GB-34).
Now these might not be the first points you would pick to treat asthma, but they obviously have a general, if not a specific effect on the lungs and throat. Without looking at the specific actions and indications of the variable points in the control treatment, I would note that the channels on which they are located (bladder, stomach, triple energiser [San Jiao] and small intestine), all travel over the area of the lungs/throat.

Outcomes and Conclusions

This study is interesting in that, unlike others studies, the effects of acupuncture as a treatment for asthma are not measured by lung function, but rather by measuring immunologic blood parameters. This is a stated goal of the study and they certainly achieved some interesting results. I find it interesting that while pulmonary function tests were performed at the beginning of the study (FEV1 - forced expiratory volume in 1 second), the only actual measurement of improvement in the patient’s condition taken at the end of the study, is their subjectively reported general wellbeing. On top of this, there is no explanation of how general wellbeing was measured except that patients were asked at the end of the study if they thought their general wellbeing had improved, and the answers were recorded by their practitioners. This seems very sloppy, as there is no baseline being measured at the beginning of the study, and there is no particular scale, or specific wellbeing questionnaire used to make any sort of accurate or objective measurement. In this study, given the sloppy measurement and reporting of wellbeing, and given that no pulmonary function tests were taken after the course of treatment, I do not think that the authors conclusion that acupuncture is an effective treatment for patients with allergic asthma is at all valid. Rather, as the authors have stated, acupuncture does seem to have a strong immunomodulatory effect in patients suffering allergic asthma, but without pulmonary function tests it is not a valid conclusion to say that this correlates to an improvement in the severity of frequency of the patient’s condition.

JADAD

Jadad Calculation

Score
Was the study randomised
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1
Was the randomisation method appropriate
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Double Blinded
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Blinding described and appropriate
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Description of withdrawals and dropouts
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Randomisation described but inappropriate
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Described as double blind but blinding inappropriate
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Total Jadad Score

4

Paper 2.


Schween S, Vogt L, Minakawa S, Eichmann D, Welle S, Stachow R, Banzer W 2011. 'Acupuncture in Children and Adolescents with Bronchial Asthma: A Randomised Controlled Study', Complementary Therapies in Medicine, vol. 19, pp. 239-246.

Objectives and Methods

The objective of this clinical trial was to collect data in the field of paediatric pulmonology and acupuncture on the basis of a randomised clinical trial. The study aimed to evaluate the immediate effects of acupuncture as an adjunctive treatment in children and adolescents with mild to severe bronchial asthma.

Setting

This study was set in an inpatient rehabilitation centre, It does not report the location of the centre nor does it report exactly what type of rehabilitation typically occurs there. We can only assume that it is an inpatient rehabilitation centre for those with chronic respiratory conditions.

Recruitment and Inclusion / Exclusion

The inclusion criteria for the study was children between 12 and 17 years of age with bronchial asthma who were currently being treated with chronic use of inhaled corticosteroids. These patients were assigned randomly to either the acupuncture or control group. Patients with diseases which might have affected the development of asthma, for example, obesity, were excluded. As was any patients who had been assigned to the non-acupuncture group who expressed a desire to be included in the acupuncture group.
Power Calculation
Power calculation was performed using specific software, and taking into consideration previous research. The total sample size needed was 47 in each group, a total of 94 patients. Taking into account a 30% dropout rate 130 patients were recruited for the study.
Randomisation and Blinding
The study was randomised, but there is no mention of the method of randomisation. There was no blinding attempted in this study. Since there were only two groups, one who underwent the normal rehabilitation programme, and the other who participated in the same program, but also received acupuncture, it was quite obvious who was, and who was not in the acupuncture group. In their discussion, the authors point out the fundamental flaws in placebo and sham acupuncture as control methods, and deliberately avoided using them.
Dropouts
Full data was collected for 93 subjects, 46 in the acupuncture group, and 47 in the control group. There was an overall dropout rate of 27%. Reasons reported for exiting the study were life events, health issues and lack of personal motivation.
Practitioner
The authors report that the acupuncture was performed by three acupuncturists, belonging to the German Medical Acupuncture Association. These medical acupuncturists had many years of experience in practical acupuncture.
Pattern Differentiation, Point Prescription, and Treatment
Acupuncture treatment happened three times per week for each participant in the acupuncture treatment group. The treatment consisted of 3 fixed points; BL 13, CV 17, and LU 7, and then a number of individual points between 2 and 6, that were specific to the patients TCM diagnosis. Examples of these variable points are ST 40, KI 6, LI 11, ST 41, and BL 42. de qi was attained at each point, and needles were retained for 30 minutes. The needles used were uncoated steel acupuncture needles, 0.18 x 13mm, and 0.3 x 30mm.
Control Group
The control group in this study, instead of receiving acupuncture, attended a group discussion to clarify questions on the topic of the study, to explain their role as reference patients and to motivate them to continue in the study.
Outcome Measurements and Results
This study found comparable results between both groups. There were no improvement differences between the groups in lung function, provocation testing and quality of life scores. At the end of the study, 50% of patients had reduced medication use but there was no significant difference between the groups.
In the discussion the authors report that there was a significant therapeutic effect of acupuncture in regard to bronchial hyper-reactivity (PEF measurement), which indicates better asthma control since it points to a reduction of inflammatory cytokines, and processes in the bronchial mucosa. The authors also report a significant decrease in anxiety sensation in the acupuncture group.
Exit Questionnaire
Since there was no blinding, there was no exit questionnaire to determine its success. The patients were asked four months after the study to rate their quality of life, and the majority reported a continued improvement of the subjective quality of life. The authors do not attribute this to acupuncture, as the change was the same in both groups.

Criticisms

Practitioner
The authors of the study reported that the 'acupuncture was carried out by three acupuncture physicians with many years continuous experience of practical acupuncture' (2011: 240), who were members of the 'German Medical Acupuncture Association' (2011: 240). The authors fail to report the actual qualifications of these “medical acupuncturists”.
My main contention here is the distinction that is often present between a real TCM acupuncturist, and these so called “medical acupuncturists”. Citing a number of years of experience of practical acupuncture means nothing. If I, having attended a few weekend seminars on “medical acupuncture”, go off and for the next 25 years stick needles in people I can say I have many years experience of physically needling people and yet have absolutely no understanding of TCM theory. The term the authors use is practical acupuncture. This is a far cry from being a true TCM acupuncturist who has completed a degree or perhaps even post graduate studies in TCM, and has a thorough understanding of complex TCM theory to back up their many years of clinical and theoretical experience.
To be fair, the practitioners in this study may well have been physicians who have also extensively studied TCM. The problem here is that the authors failed to make this distinction bringing the practitioners qualifications, and skill into question.
Treatment
The authors reporting of the acupuncture intervention was actually very good, with a few exceptions that I will cover first. The locations of the points were not specified as belonging to any particular standard, nor were the anatomical location described. This is a shortcoming that is shared with Joos et al, and of most of the research that I read. Also in common with Joos et al., is a failure to give a complete list of points that were used. Again we are treated to an example of other points that were used, leading to the conclusion that this is by no means a definitive list.
To the authors credit, They included the length and gauge of needles, as well as the angle and depth of insertion. However, angle of insertion is only included for the fixed points that were used. Additional points that made the list, were given needle depth, as well as the indication for choosing each point, e.g. 'mucous symptoms: St (stomach) 40; 10 – 15mm, kidney Qi deficiency: Ki (kidney) 6; 2 – 3mm' (2011: 240).
Control Treatment
The control group was a simple non-acupuncture treatment group.
Outcomes and Conclusions
This study in somewhat conflicting. On the one hand they report that acupuncture was completely ineffective in improving pulmonary function, based on a range of function tests, and that it did not improve the patients reported quality of life, as measured by an asthma specific quality of life questionnaire. On the other hand, in the discussion, they tell us that acupuncture had an immunomodulating effect which reduced inflammatory cytokines and processes in the bronchial mucosa, and had a marked impact on asthma related anxiety.
I find it somewhat perplexing to expect patients who are dependant on anti-asthma medication and have a history of chronic use of broncho-dilating inhaled corticosteroids, to show significant improvement in pulmonary function in one month. I find it even more difficult to understand the idea that if you take away someone’s medication, upon which they have been dependant for a long time and which specifically dilates the airways, for an entire day, then make them run for 6 minutes as a provocation test, that you would expect anything other than broncho-constriction to occur.
With these methods, it is hardly surprising that no significant improvement of pulmonary function occurred in the acupuncture group over the control group.
The author’s statement that acupuncture had an effect on reducing inflammatory cytokines, and inflammatory processes in the bronchial mucosa is completely unfounded based on this study. While this statement agrees with previous studies such as Joos et al., it is still not a valid conclusion of the study. No inflammatory markers were measured in this study, therefore no statement should be made about presumed changes in inflammatory cytokine levels, leading to better control of asthma.
A nice outcome of this study is that in measuring with a questionnaire, the patients change in anxiety related to asthma, the authors have confirmed this finding from Joos et al, who only had subjective patient reports as a measurement. While the authors state that acupuncture provided no improvement to quality of life for the patients in the treatment group, I would say that reduced anxiety and fear related to asthma, is probably an improvement.
JADAD
Jadad Calculation

Score
Was the study randomised
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1
Was the randomisation method appropriate
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Double Blinded
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0
Blinding described and appropriate
0/1
1
Description of withdrawals and dropouts
0/1
1
Randomisation described but inappropriate
0/-1
0
Described as double blind but blinding inappropriate
0/-1
0
Total Jadad Score

3

General Remarks


There does not appear to be much in the way of recent, well performed, research into the efficacy of acupuncture as a treatment for asthma. Certainly the material reviewed here leaves a lot to be desired in terms of quality methodology in the clinical trial and the quality of the reporting. This especially seems to be the case when it comes to reporting the treating acupuncturists credentials, what point location standards were utilised, using a fixed treatment protocol so as to provide a specific set of points to which any significant change can be attributed and when using a variable point prescription actually providing an exhaustive list of every point that was needled during the course of the study. Without these fundamental issues being addressed it is my opinion that the research cannot be considered to be thorough.
Criticisms aside, it is very encouraging to see the results obtained by Joos et al, pointing to the immunomodulating effects of acupuncture in patients with asthma. It would be especially interesting to see more studies along similar lines that aim to measure both immune markers and changes in pulmonary function in patients with a new diagnosis of asthma who have not yet started on conventional treatment. I would say the future looks strong for research into acupuncture and asthma, and hopefully the effect of acupuncture on immune responses.

Appendix 1

Patterns of asthma according to various authors

Deficient patterns of asthma


Shi
Wu and Fischer
Cheng
Patel
Lung Xu
Spontaneous sweating, aversion to wind, slight wheezing sound in the throat, induced by changes in weather. In the aura stage there will be sneezing and nasal congestion with clear, watery discharge. Shortness of breath, low voice, pale complexion, and clear white sputum. Pale tongue with thin white coat, Weak and thready pulse.
Shortness of breath, feeble voice, weak forceless coughing and wheezing, spontaneous perspiration, sensitivity to draughts, expectoration of thin runny phlegm. Tongue: pale. Pulse: weak

Pale complexion, spontaneous sweating, aversion to cold, shortness of breath, tiredness, sneezing, stuffy nose. Tongue: Pale with thin white coat. Pulse: Thin fast and weak.
Short and quick breathing, weak and low voice, hydrosis, weak pulse.
Spleen Xu
Poor appetite, epigastric and abdominal distension, loose stools and wheezing elicited by excessive consumption of cold, raw, sweet, and greasy food. Shortness of breath, low weak voice and fatigue. Tongue with thin greasy or white moist coating. Pulse thready weak and soft.
No pattern
Pale complexion, poor appetite associated with phlegm, lassitude, loose stool, or diarrhoea. Tongue: Swollen, thick greasy coating. Pulse: slow and slippery.
No pattern
Kidney Xu
Shortness of breath, shallow rapid breathing aggravated by exertion, more difficulty inhaling than exhaling, wheezing triggered by exertion and fatigue, soreness and weakness of the lower back and knees.


Kidney Yang Xu – cold intolerance, cold limbs , pale complexion and spontaneous complexion. Swollen tongue with white coating, Deep thready pulse.


Kidney Yin Xu – Red cheeks, irritability, sensation of heat and night sweating. Red tongue with scanty coating. Thready rapid pulse.
Persistent wheezing aggravated by physical exertion, shallow inspiration, shortness of breath, difficulty in maintaining regular rhythm of respiration, fatigue, lassitude, physical cold, cold extremities and greenish complexion, Tongue: Pale. Pulse: Deep, weak, and thready.
Dark complexion, shortness of breath and becoming quite severe after activities, associated with heart palpitations, dizziness, ringing ears, soreness, weakness, and cold lower back and knees. Tongue: Pale with a thin white coat. Pulse: Thin and weak.
Dyspnoea upon exertion, chilliness with cold extremities, deep thready feeble pulse.
Heart Qi and Yang Xu
No pattern
No pattern
Heart palpitations, sweating, restlessness, green or purple colour on the lips, nails and tongue. There may be a cold or freezing sensation in the extremities. Tongue: Dark with a white coat. Pulse: Tiny, weak and irregular.
No pattern


Excess patterns of asthma


Shi
Wu and Fischer
Cheng
Patel
Wind-cold invading the lung
Xiao Zheng pattern – Rapid breathing with wheezing sound in the throat, stifling sensation in the chest and diaphragm, scanty sputum that is difficult to expectorate, and wheezing aggravated by cold weather. Dull complexion, no thirst, aversion to cold and cold limbs. Tongue White moist coat. Pulse: wiry tight or floating tight.


Chuan Zheng pattern – Audible signing dyspnea with coughing and gasping, rapid breathing, stifling sensation in the chest, and abundant thin white sputum. Aversion to cold, fever, headache, absence of sweating and no thirst. Tongue: Thin white slippery coating. Pulse: Floating and tight
Rapid, laboured breathing, oppression in the chest, coughing and expectoration of this white and sometimes foamy phlegm. Aversion to cold, fever, headache, lack of perspiration without apparent thirst and aching joints. Tongue: Thin white coat. Pulse: Tight and floating.
Fullness and distress in the chest, and dyspnea that are associated with wheezing sound in the throat, cough with thin sputum, headache, frequent attacks during the cold seasons or caused by cold. Tongue: Pale with moist or greasy coating. Pulse: Floating and tight.
Cough with thin sputum, shortness of breath. Usually there are accompanying symptoms of fever, chills, anhydrosis, white coating on tongue, superficial pulse.
Turbid phlegm accumulation in the lung
Audible sighing Dyspnea, stifling sensation in the chest, cough, copious sticky white sputum that is difficult to expectorate. Poor appetite, sticky sensation in the mouth, no thirst, nausea and vomiting. Tongue: Thick white greasy coating. Pulse: Slippery
No Pattern
No Pattern
No Pattern
Phlegm-heat accumulation in the lung
Xiao Zheng pattern - Heavy breathing sound with high-pitched wheezing choking cough, and thick sticky yellow sputum that is difficult to expectorate. Anxiety, sweating, red face, thirst with desire to drink, headache, fever and aversion to wind. Tongue: Red with yellow greasy coating. Pulse: Slippery rapid or slippery wiry.


Chuan Zheng pattern – Audible sighing with dyspnea, heat sensation in the chest with distension and pain, coughing up copious thick yellow sputum that might be blood tinged. Thirst with desire to drink cold beverages, irritability, red face, dry throat, dark urine, and constipation. Tongue: Yellow greasy coating. Pulse: Slippery and rapid.
Short rapid respiration, loud husky voice, wheezing, coughing, oppression in the chest, expectoration of thick yellow phlegm, fever, perspiration, thirst with preference for cool drinks, constipation and dark urine. Tongue: yellow slimy coating. Pulse: rapid and slippery.
Dyspnea with wheezing, irritability, oppressed sensation in the chest, gasping for breath, cough with yellowish thick sputum, red complexion, fever, sweating, thirst, and onset closely associated with the warmer seasons. Tongue: Red with yellow greasy coating. Pulse: Slippery and rapid.
Rapid and coarse breathing, stifling sensation in chest, thick purulent sputum, thick yellowish coating on tongue, rapid rolling and forceful pulse.
Stagnant qi obstructing the lung
Sudden attacks of breathlessness elicited by emotional stress, rapid short breathing with a suffocating sensation or constriction in the throat, chest oppression and pain. Insomnia, palpitations, stuffiness and pain in the hypochondriac and chest regions. Tongue: Thin white coating. Pulse: Wiry


No Pattern
Exterior cold with lung heat
Audible sighing dyspnea, rapid breathing, chest distension or pain, dilated nostrils, and stick yellow sputum that is difficult to expectorate. Slight aversion to cold, fever with or without sweating, thirst, irritability, and headache. Tongue:Thin white or yellow coating. Pulse: Floating or slippery and rapid.


No Pattern


Bibliography

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Deadman P, Al-Khafaji M, Baker K 2007. A Manual of acupuncture, Journal of Chinese Medicine Publications, United Stated of America.
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