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Traditional
Chinese Medicine |
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Introduction |
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Traditional Chinese Medicine (TCM) is an ancient medical system that has been
practiced for thousands of years and remains part of mainstream healthcare
delivery in many Asian countries today. TCM promotes a holistic approach to
health and aims to maintain physical, emotional, and spiritual balance in order
to prevent and treat disease (Parker 2000; Ergil 1996). TCM modalities include
acupuncture, moxibustion, herbal medicine, Chinese massage (known as tui
na), movement combined with breathing exercises (such as tai chi and
qi gong), nutrition, and lifestyle modification (Parker 2000). Cupping
and bleeding are also employed (Ergil 1996). |
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Historical Background |
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The first written documentation of TCM is recorded in the Pharmacopoeia of
the Heavenly Husbandman, a text dating back to 200 B.C. (Parker
2000). Herbal medicine and acupuncture, including theory, practice, diagnosis,
and treatment, were recorded in classical Chinese texts and refined over many
centuries (Ergil 1996).
Although TCM has been practiced in the United States since the mid-19th
century, it remained largely the province of immigrant Chinese communities until
the general public became exposed to the practice following former President
Nixon's trip to China in 1971. While covering Nixon's trip, New York
Times reporter James Reston received acupuncture for post-operative pain
following an emergency appendectomy. He published accounts of his experience
with TCM that fascinated the public and contributed to its mainstream emergence
as an alternative modality (Ergil 1996).
Today, TCM is practiced all over the world. A new term, Oriental medicine,
has been coined to encompass both traditional and contemporary interpretations
of TCM that are practiced throughout Asia (Ergil 1996). |
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Scientific
Principles |
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According to an expert in the field, Dr. Kevin Ergil, TCM is based on three
fundamental principles not easily understood from a Western cultural
perspective. The first is the idea that qi (pronounced "chee"), described
often in Western terminology as life energy, exists throughout the body and is
responsible for maintaining normal physiological, psychological, and spiritual
functions. There are five different types of qi with distinct associations:
support and nourishment (construction qi); protection and warmth (defensive qi);
flow of energy through channels, called meridians (channel qi); physiological
activity of organs (organ qi); and ancestral qi, which controls circulation and
respiration. Disease is caused by a disruption of qi and manifests as a unique
collection of signs and symptoms depending on the origin of the disturbance. In
an interesting analogy often used to explain its nature, qi is described as the
wind in a sail; we do not see the wind directly but we are aware of its presence
as it fills the sail (Ergil 1996).
Qi also maintains the balance of yin and yang, the principle of
complementary opposites that determines the world around us and is reflected
within each of us; together, yin and yang represent a state of dynamic
equilibrium that exists among all things in the universe. Thus, an individual
cannot be understood outside the context of his or her environment. As Ergil
writes,
"The external landscape, or human environment, is understood to be in profound and dynamic relationship with the internal landscape, or human organism"
(Ergil 1996).
The third principle influencing health and illness in Oriental medicine is
known as the five phases—earth, metal, water,
wood, and fire—which may be thought of as metaphoric
representations of the five patterns that characterize the dynamic interactions
of natural phenomena (Ergil 1996); the concept again reflects the inability to
separate the individual from the environment that is fundamental to the TCM
philosophy and belief system.
Two additional concepts are essential to the practice of TCM: mind and body
are not distinct from one another, and moderation is required to achieve balance
and health (Ergil 1996).
Finally, TCM reflects an understanding of human anatomy that is different
from that of conventional medicine. TCM views the internal organs not as
individual structures, but as complex networks (Ergil 1996). In parallel with
the five phases or elements mentioned above, there are five internal organs
regulating the human body. These five organs—liver,
heart, spleen, lung, and kidney—correspond to more than
a specific bodily part. The kidney, for example, represents not only the kidney
itself, but the entire urinary system and the adrenal glands as well. The heart
represents both the heart and the brain (Cheng 2000). According to TCM, there
are three major causes of disease: the external factors or environmental
influences known as wind, cold, fire, dampness, heat, and dryness; the internal
emotions of joy, anger, worry, sorrow, and fear (Ergil 1996; Cheng 2000); and
the constitutional factors relating to diet, sexual activity, lifestyle, work,
and exercise (Parker 2000). |
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Mechanism of Action |
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Through the use of its therapeutic modalities, TCM stimulates the body's own
healing mechanisms to regulate the flow of qi and the function of the organ
systems, bringing the body back into a state of balance (Parker 2000). The main
focus in TCM is to treat the underlying cause of disease as opposed to simply
managing symptoms (Ergil 1996).
The mechanistic action of acupuncture, in TCM terminology, is to access qi
with the needle. The practitioner knows that qi has been accessed when a gentle
grabbing of the needle is sensed in his or her hand and/or when the patient
reports a feeling of itching, numbness, soreness, or change in temperature at
the site of the needle (Ergil 1996).
With respect to the use of herbs, TCM practitioners formulate herbal
combinations to act synergistically in the body, and therefore typically
prescribe combinations of herbs rather than a single herbal remedy (Ergil
1996).
Moxibustion refers to burning the leaves of the herb Artemesia
vulgaris on or near the skin; although used separately as well, it is often
applied in conjunction with acupuncture to move qi appropriately. A safe and
common way to apply this technique is with a cigar-shaped stick known as pole
moxa held just above the skin to gently warm the acupuncture point (Ergil
1996).
Tui na literally means "pushing and pulling" and refers to a process of
massage that stimulates acupuncture points. Tui na can be used either as an
adjunct to or instead of acupuncture, particularly for people such as children
who may have a difficult time with needle insertion. The massage technique is
used for many neurological and orthopedic conditions to increase the range of
motion of joints; it can also be used for medical conditions not usually thought
of as treatable via massage, such as asthma, gastritis, and dysmenorrhea (Ergil
1996).
Cupping refers to a practice in which a cup with a vacuum seal is placed on
the surface of the skin; the theory is that the local application of a vacuum to
the skin increases lymph and blood circulation in the area under treatment. In
TCM terminology, the intention is to draw out cold or damp elements from the
patient that may be contributing to disease (Ergil 1996). |
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Clinical Evaluation |
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A clinical evaluation includes, in the following order: visual assessment of
the patient's skin, hair, posture, affect, tongue, complexion, and eyes (Parker
2000; Ergil 1996); listening to the quality of the patient's breathing and
speech; being aware of the patient's body odors; taking a medical history;
diagnosing the pulse; and palpating the body along acupuncture points or
meridian lines (Ergil 1996). Visualizing the overall appearance, complexion, and
eyes, as well as assessing the quality of the patient's voice, enables the
practitioner to observe the patient's shen (or spirit), which is critical
for determining prognosis. Shen is the radiant aspect of human existence that
encompasses consciousness and healthy mental and physical functioning (Ergil
1996).
Following this assessment, the TCM practitioner makes recommendations for the
modalities to be used (as described in the section on Mechanism of Action) and
the course of treatment; these decisions are based on "pattern identification"
as determined by the TCM practitioner. Pattern identification is, again, a
difficult concept to define in Western terminology; it is based on eight
principles of yin and yang and, unlike the situation in Western medicine, the
definition and particular diagnostic pattern does not depend solely on the
disease. Rather, it depends on a complex interaction of the illness or set of
signs and symptoms, the particular patient affected, and the environment at
large. Therefore, one disease can have many different appropriate treatment
approaches. Similarly, one treatment pattern can be appropriate for a wide
variety of illnesses (Ergil 1996). These facts illustrate some of the difficulty
in trying to understand TCM from the Western, biomedical perspective.
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Clinical Applications |
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Despite the difficulty of applying contemporary research methodologies to
evaluate outcomes of TCM, there have been some attempts with worthwhile results;
the following paragraphs provide a few examples of traditional herbal remedies
examined from the Western perspective. These examples are not meant to be an
exhaustive reflection of the breadth of appropriate applications of TCM, a
health system and approach that has been used for many diverse conditions for
thousands of years. The intent of the following examples is to give some sense
of the clinical benefits and limitations learned from studying aspects of TCM
from a biomedical point of view. (Please see the Acupuncture monograph for more
information on clinical applications of that modality specifically.)
In a report published in JAMA, a randomized, double-blind,
placebo-controlled trial of a Chinese herbal formulation was found to offer
significant improvements for some patients with Irritable Bowel Syndrome
(Bensoussan et al. 1998).
Qian ceng ta, a Chinese herb used to treat age-related memory
dysfunction and dementia, may show promise for possible adjunctive treatment of
Alzheimer's disease. Of 103 Alzheimer's patients from seven different hospitals
in Mainland China, 58% treated with huperzine A (the active ingredient of Qian
ceng ta) chemically linked to tacrine (a medication commonly used for
Alzheimer's) showed improvement in memory, cognition, and behavior (Carlier et
al. 1999). Another small study in the elderly suggests that Cs-4, a fermentation
product of Cordyceps sinesis (a popular supplement in China), increases
maximum oxygen uptake and anaerobic threshold compared to placebo, thus
improving exercise capacity and resistance to fatigue in this population (Xiao
et al. 1999). The study, presented at the 46th annual meeting of the American
College of Sports Medicine, included only 30 subjects, making it difficult to
draw conclusions; however, the information is intriguing since Cordyceps
sinesis has been used for similar purposes in TCM for many years.
A combination of Chinese herbs known as "Slimax" reduced weight, waist and
hip circumference, and body mass index significantly in an experimental group of
140 subjects participating in a randomized, placebo-controlled clinical trial
(Ignjatovic et al. 2000).
In TCM terms, diabetes and its complications are considered
"wasting and thirsting" disorders; a common treatment for diabetes nourishes yin
and tonifies qi (Luwen 2000). Patients with complications of diabetes, including
elevated cholesterol and triglycerides, poorly controlled blood sugar, and
metabolic disturbances, are frequently diagnosed by a TCM practitioner as having
"stagnant phlegm." According to researchers in China, Chinese herbs used to
treat phlegm stagnation, such as Wen dan tang, also tend to lower lipid
levels; there have been case reports of Wen dan tang improving additional
diabetic complications such as retinopathy (Luwen 2000).
Although a popular application in the lay community, the use of Chinese
herbal remedies for eczema remains controversial. There is a paucity of data in
the literature supporting the efficacy of oral Chinese herbs for this
application (Armstrong and Ernst 1999); in addition, one study addressing the
constituents of topical TCM remedies frequently used for eczema found that many
of them actually contained illegal, unlabeled steroids. One concern here is that
many patients taking such herbal preparations as an alternative to prescription
medications are under the impression that they do not contain steroids, which
may lead to excessive use, application to inappropriate sites, and unanticipated
risks (Keane et al. 1999).
All TCM modalities have traditionally been used for both male and female
infertility. TCM treatment of male infertility from sperm anomalies, for
example, generally involves replenishing kidney yin and/or kidney yang,
fortifying the spleen, and nourishing the liver (Becker 2000). TCM treatment for
infertility offers a viable opportunity for TCM to interface with Western
medicine, since sperm count and quality can be followed easily, as can other
contributing factors to male infertility such as chronic prostatitis and
hyperprolactinemia (Becker 2000). |
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Risks, Side Effects, Adverse
Events |
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Side effects from Chinese herbs are more likely to occur when a single agent
or active ingredient is used, rather than the customary combination of herbs
that are formulated to work harmoniously together and counterbalance side
effects (Parker 2000). As is the case with Western pharmaceuticals, there are
interactions among herbal medicines too numerous to mention here; trained and
certified TCM practitioners know which herbs can be safely and effectively
administered together (Parker 2000).
Chinese herbs containing aristolochic acid, a compound present in
plants of the family Aristolochiaceae, should be avoided, particularly in
patients with underlying kidney disorders; the active ingredient has been
identified as a carcinogen and nephrotoxin causing, by some reports, nearly 100
cases of kidney failure (Lewis and Alpert 2000) and even urothelial dysplasia
and carcinoma in patients with end-stage nephropathy (Nortier et al. 2000). In
addition, as mentioned above, some Chinese herbal creams used to treat skin
conditions such as eczema contain unlabeled steroids (Keane et al. 1999).
Although generally considered safe for autoimmune and rheumatological disorders,
patients prescribed a remedy prepared from Tripterygium wilfordii Hook F
(TwHF) occasionally report side effects of dry mouth, changes in skin
pigmentation, rash, and loss of appetite; nausea, vomiting, diarrhea, abdominal
pain, and secondary amenorrhea are even less common; leukopenia and
thrombocytopenia may occur with this herbal anti-inflammatory. The use of
properly prepared formulations of TwHF needs to be monitored, particularly for
patients with impaired renal function. Long-term treatment may also result in
reproductive tract damage (Tao and Lipsky 2000). These examples point to the
fact that all herbs need to be regulated for toxicity and monitored for side
effects (Keane et al. 1999). |
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Contraindications |
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Great caution and, at times, avoidance of some of the herbs mentioned in the
section entitled Risks, Side Effects, Adverse Events should be exercised;
otherwise, there are no specific conditions for which TCM is contraindicated in
its totality. There may be, however, specific conditions for which certain
Chinese herbs should not be used, such as during pregnancy and/or lactation
(Parker 2000). A trained and certified TCM practitioner knows under which
clinical circumstances particular herbal remedies are contraindicated.
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Additional Clinical
Outcomes |
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TCM may also be a useful adjunctive or alternative treatment for addictions,
allergies, sinusitis, asthma, respiratory infections, strep throat, amenorrhea,
premenstrual syndrome, childbirth, postpartum care, arthritis (including
rheumatoid arthritis), chronic or acute pain, bladder infection, candidal or
other vaginal infections, benign prostatic hypertrophy, prostatic cancer,
prostatitis, restless leg syndrome, sleep disorders, abdominal pain, stress, and
tinnitus (Parker 2000).
Although further research is needed, the Chinese herbal remedy
Tripterygium wilfordii Hook F shows considerable promise for
treating autoimmune and inflammatory diseases, including rheumatoid arthritis,
systemic lupus erythematosus, ankylosing spondylitis, psoriasis, Behcet's
disease, Henoch-Schönlein purpura, IgA nephropathy, chronic nephrotic syndrome,
nephritis, chronic lymphocytic thyroiditis, dermatitis, scleroderma,
polymyositis, and kidney transplant rejection (Tao and Lipsky
2000). |
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The Future |
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The Ohio University College of Osteopathic Medicine and nine Chinese medical
institutions recently formed the Sino-American Consortium to study applications
for TCM in Western medicine (OU-COM. 2000). In 2001, the Ohio University College
of Osteopathic Medicine plans to incorporate basic TCM principles into its
curriculum (OU-COM. 2000). In addition, the University of Pittsburgh recently
created the International TCM Center to coordinate research efforts with several
TCM institutes in China. The result will be a large-scale, systematic,
international effort to develop clinical standards for TCM (UPMC 2000).
Future research studies and clinical trials on TCM are required to establish
the efficacy, safety, cost-effectiveness, and mechanism of action of various TCM
treatments and overcome the limitations of existing research studies (Armstrong
and Ernst 1999). |
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Training, Certification, and
Licensing
Requirements |
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Currently, there are 35 Oriental medicine training programs in the United
States. Programs range in duration from two to four years and include the study
of herbs, acupuncture, and all other aspects of Oriental medicine (Parker 2000).
To be certified, students must graduate from accredited institutions and pass
the state board exam or the national certification commission exam. Licensure
requirements vary in each state (Parker 2000). |
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Resources |
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For more information, contact the American Association of Oriental Medicine
in Catasauqua, Pennsylvania at 888-500-7999 or on the web at www.aaom.org; the
National Acupuncture and Oriental Medicine Alliance in Olalla, Washington at
253-851-6896 or on the web at www.acuall.org; the Institute of Traditional
Medicine in Portland, Oregon at 503-233-4907 or on the web at www.itmonline.org;
or the National Certification Commission for Acupuncture and Oriental Medicine
in Alexandria, Virginia at 703-548-9004 or on the web at
www.nccaom.org. |
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References |
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Armstrong NC, Ernst E. The treatment of eczema with Chinese herbs: a
systematic review of randomized clinical trials. Br J Clin Pharmacol.
1999;48(2):262-264.
Becker SA. Treatment by Chinese medicine: semen anomalies. J Chin Med.
2000;62:46-51.
Bensoussan A, Talley NJ, Hing M, Menzies R, Guo A, Ngu M. Treatment of
irritable bowel syndrome with Chinese herbal medicine. JAMA.
1998;280(18):1585-1589.
Carlier PR, Du DM, Han Y, Liu J, Pang YP. Potent, easily synthesized
huperzine A-tacrine hybrid acetylcholinesterase inhibitors. Bioorg Med Chem
Lett. 1999;9(16):2335-2338.
Cheng JT. Review: drug therapy in Chinese traditional medicine. J Clin
Pharmacol. 2000;40(5):445-450.
Ergil KV. China's traditional medicine. In: Micozzi MS, ed. Fundamentals
of Complementary and Alternative Medicine. New York, NY: Churchill
Livingstone Inc.; 1996:185-223.
Ignjatovic V, Ogru E, Heffernan M, Libnaki R, Lim Y, Ng F. Studies on the use
of "Slimax," a Chinese herbal mixture, in the treatment of human obesity.
Pharm Biol. 2000;38(1):30-35.
Keane FM, Munn SE, du Vivier AW, Higgins EM. Analysis of Chinese herbal
creams prescribed for dermatological conditions. BMJ.
1999;318(7183):563-564.
Lewis CJ, Alpert S. Letter to Health Care Professionals on FDA Concerned
about Botanical Products, Including Dietary Supplements, Containing Aristolochic
Acid. Washington, DC: U.S. FDA Center for Food Safety and Applied Nutrition;
May 31, 2000.
Luwen G. Wen dan tang and diabetic retinal disease. J Chin Med.
2000;62:20-22.
Nortier JL, Martinez MC, Schmeiser HH, et al. Urothelial carcinoma associated
with the use of a Chinese herb. N Engl J Med. 2000;342(23):1686-1692.
OU-COM. OU medical school teams with Chinese universities [press release].
Athens: Ohio University College of Osteopathic Medicine; April 29,
2000.
Parker MJ. Traditional Chinese herbal medicine. In: Novey DW, ed.
Clinician's Complete Reference to Complementary and Alternative Medicine.
St. Louis, Mo: Mosby; 2000:203-218.
Tao X, Lipsky PE. The Chinese anti-inflammatory and immunosuppressive herbal
remedy Tripterygium wilfordii Hook F. Rheum Dis Clin North Am.
2000;26(1):29-50.
UPMC. Chinese government officials visit UPMC health system to establish ties
with International Traditional Chinese Medicine Center [press release].
Pittsburgh: University of Pittsburgh Medical Center Health System; January 20,
2000.
Xiao Y, Huang XZ, Chen G, Wang MB, Zhu JS, Cooper CB. Increased aerobic
capacity in healthy elderly humans given a fermentation product of
Cordyceps Cs-4. Paper presented at: Annual Meeting of the American
College of Sports Medicine; June 2-5, 1999; Seattle, Wash.
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |