Deep Water Medicine

Acupuncture & Chinese Medicine

Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a chronic condition affecting between 10-15% of the population (Grundmann & Yoon, 2010) with multifaceted possible causes in both western medicine (WM) and traditional Chinese medicine (TCM). It is not considered life threatening yet, as it is chronic and episodic, it impacts on health-related quality of life (Holloway, 2010; Ruepert et al., 2011).

IBS is characterised by abdominal pain, bloating and altered bowel dysfunction resulting in diarrhoea or constipation (Snyder, 2012) and in significant impairments of functional status, higher levels of disability and increased frequency of physician visits (Zijdenbos, de Wit Niek, van der Heijden Geert, Rubin, & Quartero, 2011).

Acupuncture was considered significantly more competent than pharmacological therapy and no specific treatment (Manheimer et al., 2012). Herbal medicine treatment of IBS is looking promising for the treatment of IBS yet it is too premature to make recommendations (Liu, M, Liu, ML, & Grimsgaard, 2011).

A recent trial involving 233 participants with IBS looked at the use of 10 weekly individualised acupuncture sessions plus usual care or usual care alone (Macpherson et al., 2012). Usual care referred to treatment with their medical doctor and the use of prescription medication and outcome data was collected for up to 12 months. There was a statistically significant difference between the groups IBS symptom severity score (IBS-SSS) favouring acupuncture and usual care which suggests that acupuncture could be considered as a treatment option alongside primary care (Macpherson et al., 2012).

In a systematic review of 75 trials investigating herbal medicine including TCM, Tibetan, and  Ayurvedic medicine, they are assessed as being ‘promising for the treatment of irritable bowel syndrome’ (Liu et al., 2011).

Polycystic Ovarian Syndrome

Polycystic Ovary Syndrome (PCOS) is considered to be the most common endocrine abnormality in women of reproductive age (Azziz, Woods, Reyna, Key, Knochenhauer, & Yildiz, 2004; Costello, Shrestha, Eden, Johnson, & Moran, 2010).

Normal ovulation relies upon selection of a follicle that becomes ‘dominant’ and ovulates (Balen, 2000). In women with PCOS there are multiple small cysts which contain potentially viable oocytes yet with dysfunctional follicles.The current recommended definition (ESHRE/ASRM, 2003) diagnose PCOS when a woman has two of the following; oligo- or anovulation, clinical or biochemical hyperandrogenism, and/or polycystic ovaries (with the exclusion of other aetiologies). Clinically the presentation can include infrequent or light menstruation, infertility, hirsutism and acne (Costello, Shrestha, Eden, Johnson, & Moran, 2010).

In Australia NHMRC says PCOS affects 12-21% of reproductive-aged women depending on the population studied and the diagnostic criteria used and is considered a “major public health concern”. The current WM treatment options are lifestyle changes, prescription medication including the oral contraceptive pill (OCP), clomiphene, metformin, gonadotrophins and surgery. The National Health and Medical Research Council [NHMRC] (2011) considered lifestyle management to be the first-line of therapy to improve reproductive, metabolic and psychological features. This includes reduced dietary energy intake and exercise. The suggestion is that this is used for 3-6months to determine if ovulation is induced before trying pharmaceutical ovulation.

PCOS & Acupuncture – Literature Review

Acupuncture may have a role in treating the pathology of PCOS with a focus on regulating ovulation and menstruation.

Lim et al. (2011) and Lim and Wong (2010) reviewed acupuncture and PCOS and suggest that acupuncture has a low adverse event rate, no risk of multiple pregnancies and is relatively inexpensive.

Takeshi (1976), found acupuncture could control the ovulation mechanism and may provide an approach for fertility regulation. Gerhard and Postneel (1992) observed that acupuncture induced regular menstrual cycles over using hormone therapy. Mo et al. (1993) claimed an 82.35% effective rate for inducing ovulation. The fourth trial (Stener-Victorin et al., 2000) evaluated patients with electro-acupuncture (EA) and its effect on PCOS anovulation and other endocrine features. The results showed that EA caused regular ovulation in one third participants.

Jin’s (2002) study of ovulation induction concluded that adequate oestrogen levels were closely related to ovulation induction with acupuncture. Biphasic basal body temperature charts occured after acupuncture .

Pastore, Williams, Jenkins and Patrie’s (2011) study of 84 women showed similar improvement in LH/FSH ratios in both the true and sham acupuncture groups. Wang, Zhang, Wu, and Lu (2007) described 26 cases of PCOS. Results showed 6 (23.1%) cured, meaning they had a regular cycle for more than 3 months post treatment or became pregnant. 15 (57.7%) cases improved where their menstrual cycle and volume was normal for less than three months and ultrasound confirmed a reduction in follicles, 5 (19.2%) failed with no change. Stern (1999) illustrates three cases of women diagnosed with PCOS, each with varying diagnoses and presentations. All three cases showed improvement over time.

Osteoarthritis

Osteoarthritis (OA) is the tenth most common problem in general practise and is self-reported in 7.3% of the Australian population. Due to the proportional increase in the older population, this figure is set to rise increasing the burden on the individual and the community (National Health and Medical Research Council, 2009).

Due to limited OA studies for the hip, some studies looking at OA of the knee have been included. Berman, Lao, Greene, Anderson, Wong, Langenberg, et al. (1995)  looked knee OA and patients had significant reductions in both WOMAN score [see appendix 2] and Lequesne index (Osteoarthritis Research Society International, 2012).  7 patients responded so well, they did not want an operation. Witt, Brinkhaus, Jena, Linde, Streng, Wagenpfeil, et al. (2005) studied knee OA in a well-conducted trial concluded that pain and joint function improved with acupuncture after 8 weeks of treatment over minimal or no acupuncture. Witt, Jena, Brinkhaus, Liecker, Wegscheider, and Willich (2006) also showed that acupuncture along with routine care was associated with a clinical improvement for chronic OA associated pain of the knee or hip. Ahsin, Saleem, Manzoor Bhatti, Iles, and Aslam (2009) showed an improvement to knee OA using electro-acupuncture (EA).

The review by Manheimer, Cheng, Linde, Lao, Yoo, Wieland, et al. (2010) looked at a study by Stener-Victorin, Kruse-Smidje, and Jung (2002) covering 3 types of treatment; EA, hydrotherapy and a patient education group which had low follow up numbers. Overall conclusion was that “EA and hydrotherapy, both in combination with patient education, offer clear advantages for patients with hip pain caused by…as shown by reduced pain, increased function, and increased quality of life.”

Kwon, Pittler, and Ernst (2006) also conducted a systematic review of the treatment of OA with acupuncture and concluded that it was considered favourable due to its safety profile and is worth considering. Linde, Weidenhammer, Streng, Hoppe, and  Melchart (2006) did a large uncontrolled observational study of acupuncture treatment for OA for the knee and hip.  Of the 70 patients suffering from OA of the hip, it was found that stiffness and function in the hip improved. The German statutory sickness fund has included acupuncture as a routine medical option in the treatment of pain for OA of the knee.

The conservative treatments presented do not reliably inform us of their efficacy from current research, yet may play a role in the reduction of pain and the improvement of function and mobility in patients with OA. Interestingly, Zhang, Moskowitz, Nuki, Abramson, Altman, Arden, et al. (2008) notes that in their systematic review to develop clear clinical guidelines, there was no significant difference in outcomes for the use of non-pharmacological therapies or pharmacological therapies.

Aquatic Exercise has “gold level evidence that for OA of the hip or knee…slightly reduced pain and improves function over 3 months” (Bartels, LundHagen Kåre, Dagfinrud, Christensen, & Danneskiold-Samsøe, 2009). Bennell & Hinman (2011) mentioned aquatic exercise as improving pain and function in people with OA. Some research suggests Tai Chi may offer a small improvement in pain and disability for arthritis (Hall,  Maher, Latimer, Ferreira, 2009).

Heel pain

Podiatric conditions involve dysfunction of the musculature, joints, and fascia of the legs and feet. Achilles tendinopathy is one of the most common injuries in sport (National Health Service (NHS) Clinical Knowledge Summary, 2012). It accounts for 6-17% of all running injuries, estimated to effect up to 50% of elite athletes and is predominant in men, especially athletes. Plantar fasciitis is the most common type of pain in the inferior heel, and is amongst 11-15% of all foot symptoms requiring professional care amongst adults (Buchbinder, 2004).

A literature review undertaken in 2016 shows that acupuncture can assist in treating achilles tendinopathy and plantar fasciitis. Outcomes for both these conditions when treated with acupuncture are improved with stretching/eccentric exercises and treatment frequency should ideally be higher within the first 1-2 weeks of a treatment course (2-3x/weekly), reducing to 1x/week frequency in the second or third week depending on the patients response.

Results from a trial by Takaoka, Ohta, Ito, Takamatsu, Sugano, Funakoshi, et al. (2007) suggest that EA may induce cell proliferation in skeletal muscle. A study by Kim, Wang, Lee, Kim, Chung, & Chung, (2009) showed that EA selectively inhibits centrally mediated pain by suppressing central sensitization. One trial by Kubo, K., Yajima, H., Takayama, M., Ikebukuro, T., Mizoguchi, H., & Takakura, N. (2010) assessed acupuncture and heating on the blood volume and oxygen saturation of the Achilles. Kubo et al. (2010) concluded that “acupuncture and heating treatments could contribute to tendon repair”. Foell, (2010) published a case study of a 68 year old male with AT used EA and attention to muscle function and gait. The patient improved immediately and after 3 sessions he was able to walk and jog.

Biomedicine options can be physiotherapy, (including eccentric exercises, motor improvement, biomechanical improvement, orthotics) paracetamol and local injections.

There is growing interest in using an integrative East-West health approach, such as that of Marcus (2004), who is proposing that “the ability to accurately diagnose and treat musculoskeletal and soft tissue disease is…dependent on the ability to move fluently amongst medical paradigms” which could strengthen communication between biomedicine medicine and Chinese Medicine (CM) practitioners.

Period Pain (Dysmenorrhea)

Dysmenorrhea can be debilitating and is considered the most common gynaecological condition in women regardless of age and nationality (Proctor & Farquhar, 2006).

Dysmenorrhea is classified as ‘primary dysmenorrhea’ where the symptoms cannot be explained by structural gynaecological disorders and ‘secondary dysmenorrhea’ where the symptoms are due to pelvic abnormalities (The Merck Manual, 2011). Symptoms can include cramping pain in the lower abdomen with pain radiating to the lower back, nausea, vomiting, diarrhea, headache and fatigue (Hillen, Grbavac, Johnston, Straton, & Keogh, 1999). It was first noted by Pickles in 1965 (Hillen et al., 1999) that the pain of dysmenorrhea is thought to be from uterine contractions and ischemia in the myometrium caused by prostaglandins produced in secretory endometrium (The Merck Manual, 2011).

Four systematic reviews on acupuncture for dysmenorrhea have been completed (Smith, Zhu, He, & Song, 2011, Yang et al., 2008, Cho & Hwang 2010, Chung, Chen, Yeh 2012). There is a combined opinion that the potential for dysmenorrhea to be treated with acupuncture is promising yet there are methodological research flaws. A unanimous call amongst the four reviews was given for further quality research using randomised controlled trials. The reviews all had different eligibility criteria and investigated different Chinese medicine techniques including acupuncture, acupressure, electro-acupuncture, Chinese herbs, auricular ear points and moxibustion.

Within the above reviews there is improvement to dysmenorrhea pain symptoms (Witt 2008, Helms 1987 and Li 2008 as cited in Smith et al. 2011, Yan-qing Bu 2011). Smith et al., (2011)’s completed a ‘low risk’ (Smith et al. 2011) trial on dysmenorrhea which showed improved menstrual mood symptoms. And Witt (2008) showed improvements in pain intensity and quality of life compared to those receiving standard care only.

Biomedical treatment has some options with the possibility of adverse effects and 20-25% of women do not improve (Proctor, Latthe, Farquhar, Khan, & Johnson, 2011). The main treatment options available from a western perspective are non-steroid anti-inflammatory drugs (NSAIDs) or the oral contraceptive pill (OCP). NSAIDs inhibit prostaglandins production which reduces the pain. NSAIDs are significantly more effective for pain reduction than paracetamol or placebo yet are associated with adverse effects including indigestion, headaches and drowsiness (Marjoribanks, Proctor, Farquhar, & Derks, 2010). The synthetic hormones in combined OCPs suppress ovulation. They too have adverse effects of nausea, headache and weight gain and there is limited evidence to suggest pain improvement from its use (Wong, Farquhar, Roberts, & Proctor, 2009).