The Somatic Arts and Sciences Institute www.sasionline.net

3-Hours Continuing Education

SASI Course: ABS001

Fundamentals of Traditional Chinese

Medicine (TCM) For Massage Therapists

The Somatic Arts and Sciences Institute P.O. Box 3181 Merced, CA 95344 (209) 777-6305 www.sasionline.net

NCBTMB Approved

Provider #450872-08

Image courtesy of: Jomphong / FreeDigitalPhotos.net

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Table of Contents Instructions…………………………………………………………………………………………………..……… 3 Educational Objectives……………………………………………………………………….………………….… 3 Chapter 1: Introduction to TCM for Massage Therapists..………………………………………..…………….4 Chapter 2: The TCM Primer (Basic Terms and Vocabulary)……..………………………………………..….10 Chapter 3:Traditional Chinese Medicine Concepts……………………………………………………………..29 Chapter 4: Different Modalities of Traditional Chinese Medicine ……..……………………………………...54 Chapter 5: A History of TCM …………………………………………………………………………………….148 Summary of Fundamentals of TCM for Massage Therapists………………………………………………...153 Course Completion: Certificate of Completion and Transcript…………………………………………….…154 Course Evaluation and Errata.………………………………………………………………….……….………155 Help and Technical Support Line……………………………………………………………………….….……155 Bibliography (Sources)…………………………………………………………………………………………...156

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Fundamentals of Traditional Chinese Medicine

Instructions Thanks for downloading this Somatic Arts and Sciences continuing education course. You are looking at the text version of the course, which can be printed out if you like, or you can click the link below and read the course entirely online.

Target Audience This continuing education course has been designed to meet the educational needs of massage therapists. Degree of Difficulty Beginner/Entry Level

Course Description This course is designed to offer a detailed introduction to the fundamental concepts of Traditional Chinese Medicine (TCM) as they apply to massage therapists. It covers the basic theory and history of Traditional Chinese Medicine and takes an unbiased evidenced based look at the efficacy of TCM based somatic therapies. It introduces the foundational concepts and theories upon which all forms of Asian bodywork are based on. Educational Objectives Upon completion of this home study continuing education course, the massage practitioner should be able to: � Define the terms Meridian, and Chi � List the Five Elements of Traditional Chinese Medicine. � Explain the connection between Acupuncture and Acupressure. � Explain how the traditional practice of Moxibustion is similar to the

use of Hot Stones in western massage therapy.

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Chapter 1: Introduction to TCM for Massage Therapists This course is presented for educational purposes only. It was developed and marketed specifically for massage therapists that are required to obtain continuing education hours for licensing purposes. The author is not giving medical, legal or other professional advice. This course is classified as “Cognitive” learning, meaning that there is no hands on portion. The Somatic Arts and Sciences Institute strives to provide the most up to date and accurate material possible, however research and new discoveries continue daily and we assume no responsibility for errors or omissions due to the rapid advancement of science. A brief introduction to Traditional Chinese medicine Traditional Chinese medicine (TCM) originated in ancient China and has evolved over thousands of years. TCM practitioners use herbal medicines and various mind and body practices, such as acupuncture and tai chi, to treat or prevent health problems. In the United States, people use TCM primarily as a complementary health approach. This fact sheet provides a general overview of TCM and suggests sources for additional information. Acupuncture is generally considered safe when performed by an experienced practitioner using sterile needles. Improperly performed acupuncture can cause potentially serious side effects. Tai chi and qi gong, two mind and body practices used in TCM, are generally safe. There have been reports of Chinese herbal products being contaminated with drugs, toxins, or heavy metals or not containing the listed ingredients. Some of the herbs used in Chinese medicine can interact with drugs, have serious side effects, or be unsafe for people with certain medical conditions. Efficacy For most conditions, there is not enough rigorous scientific evidence to know whether TCM methods work for the conditions for which they are used. In an attempt to present an unbiased and evidenced based

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argument about it’s merits we have included some clinical research and studies that have been conducted on Shiatsu and other forms of TCM. Scope of Practice Traditional Chinese Medicine is more than just a system of somatic therapies, it is, as the name implies, an entire system of medicine and like all systems of medicine it includes a diagnostic component. As massage therapists we are not allowed to diagnose conditions; that is outside of our scope of practice. As you read through this course you will find numerous references to TCM diagnostic elements, such as Qi deficiency, for example. When a condition is presented it will be presented with symptoms, much in the same way a condition is presented in western medicine. This information is not included for you to make a diagnosis for your client, rather it is included so that you will have an indication of the proper theoretical application of traditional Chinese medicine in reference to somatic therapies (massage and bodywork). We are in no way advocating that massage practitioners diagnose their clients using the material presented in this course, or any of the other courses in our Asian Bodywork Series. Background TCM encompasses many different practices, including acupuncture, moxibustion (burning an herb above the skin to apply heat to acupuncture points), Chinese herbal medicine, tui na (Chinese therapeutic massage), dietary therapy, and tai chi and qi gong (practices that combine specific movements or postures, coordinated breathing, and mental focus). TCM is rooted in the ancient philosophy of Taoism and dates back more than 2,500 years. Traditional systems of medicine also exist in other East and South Asian countries, including Japan (where the traditional herbal medicine is called Kampo) and Korea. Some of these systems have been influenced by TCM and are similar to it in some ways, but each has developed distinctive features of its own.

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Although the exact number of people who use TCM in the United States is unknown, it was estimated in 1997 that some 10,000 practitioners served more than 1 million patients each year. According to the 2007 National Health Interview Survey (NHIS), which included a comprehensive survey on the use of complementary health approaches by Americans, an estimated 3.1 million U.S. adults had used acupuncture in the previous year. The number of visits to acupuncturists tripled between 1997 and 2007. According to the 2007 NHIS, about 2.3 million Americans practiced tai chi and 600,000 practiced qi gong in the previous year. Herbal medicines Practitioners of TCM make frequent use of herbal medicine, it is an integral part of the medicinal system. Herbal medicines used in TCM are sometimes marketed in the United States as dietary supplements. The U.S. Food and Drug Administration (FDA) regulations for dietary supplements are not the same as those for prescription or over-the-counter drugs; in general, the regulations for dietary supplements are less stringent. For example, manufacturers don’t have to prove to the FDA that most claims made for dietary supplements are valid; if the product were a drug, they would have to provide proof. Some Chinese herbal products may be safe, but others may not be. There have been reports of products being contaminated with drugs, toxins, or heavy metals or not containing the listed ingredients. Some of the herbs used in Chinese medicine can interact with drugs, can have serious side effects, or may be unsafe for people with certain medical conditions. For example, the Chinese herb ephedra (ma huang) has been linked to serious health complications, including heart attack and stroke. In 2004, the FDA banned the sale of ephedra-containing dietary supplements, but the ban does not apply to TCM remedies. As massage therapists the prescribing of any medications is outside of our scope of practice, so references to herbal medicines in this course is strictly for educational purposes-we do not advocate you employing herbal remedies.

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The one exception would be in the area of moxibustion, which we will discuss later in this course, which falls in the arena of Aromatherapy. There are some reported complications of moxibustion which include allergic reactions, burns, and infections, but how often these events occur is not known. It is safe to assume that the occurrences are about as common as the incidents of the same type in regards to common Aromatherapy. Both moxibustion and cupping (applying a heated cup to the skin to create a slight suction) may mark the skin, usually temporarily. The origin of these marks should be explained to health care providers so that they will not be mistaken for signs of disease or physical abuse. Underlying Concepts When thinking about ancient medical systems such as TCM, it is important to separate questions about traditional theories and concepts of health and wellness from questions about whether specific interventions might be helpful in the context of modern science-based medicine and health promotion practices. The ancient beliefs on which TCM is based include the following: The human body is a miniature version of the larger, surrounding universe. Harmony between two opposing yet complementary forces, called yin and yang, supports health, and disease results from an imbalance between these forces. Five elements—fire, earth, wood, metal, and water—symbolically represent all phenomena, including the stages of human life, and explain the functioning of the body and how it changes during disease. Qi, a vital energy that flows through the body, performs multiple functions in maintaining health. Concepts such as these are of interest In understanding the history of TCM. However, NCCAM-supported research on TCM does not focus on these ideas. Instead, it examines specific TCM practices from a scientific perspective, looking at their effects in the body and whether the practices are helpful in symptom management.

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TCM practitioners use a variety of techniques in an effort to promote health and treat disease. In the United States, the most commonly used approaches include Chinese herbal medicine, acupuncture, and tai chi. The Chinese Materia Medica (a pharmacological reference book used by TCM practitioners) describes thousands of medicinal substances—primarily plants, but also some minerals and animal products. Different parts of plants, such as the leaves, roots, stems, flowers, and seeds, are used. In TCM, herbs are often combined in formulas and given as teas, capsules, liquid extracts, granules, or powders. Acupuncture is a family of procedures involving the stimulation of specific points on the body using a variety of techniques. The acupuncture technique that has been most often studied scientifically involves penetrating the skin with thin, solid, metal needles that are manipulated by the hands or by electrical stimulation. Tai chi is a centuries-old mind and body practice. It involves gentle, dance-like body movements with mental focus, breathing, and relaxation. The Status of TCM Research In spite of the widespread use of TCM in China and its use in the West, rigorous scientific evidence of its effectiveness is limited. TCM can be difficult for researchers to study because its treatments are often complex and are based on ideas very different from those of modern Western medicine. Most research studies on TCM have focused on specific techniques, primarily acupuncture and Chinese herbal remedies, and there have been many systematic reviews of studies of TCM approaches for various conditions. An assessment of the research found that 41 of 70 systematic reviews of the scientific evidence (including 19 of 26 reviews on acupuncture for a variety of conditions and 22 of 42 reviews on Chinese herbal medicine) were unable to reach conclusions about whether the technique worked for the condition under investigation because there was not enough good-quality evidence. The other 29 systematic reviews (including 7 of 26 reviews on acupuncture and 20 of 42 reviews on Chinese herbal medicine)

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suggested possible benefits but could not reach definite conclusions because of the small quantity or poor quality of the studies. In a 2012 analysis that combined data on individual participants in 29 studies of acupuncture for pain, patients who received acupuncture for back or neck pain, osteoarthritis, or chronic headache had better pain relief than those who did not receive acupuncture. However, in the same analysis, when actual acupuncture was compared with simulated acupuncture (a sham procedure that resembles acupuncture but in which the needles do not penetrate the skin or penetrate it only slightly), the difference in pain relief between the two treatments was much smaller—so small that it may not have been meaningful to patients. Tai chi has not been investigated as extensively as acupuncture or Chinese herbal medicine, but recent studies, including some supported by NCCAM, suggest that practicing tai chi may help to improve balance and stability in people with Parkinson’s disease; reduce pain from knee osteoarthritis and fibromyalgia; and promote quality of life and mood in people with heart failure.

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Chapter 2: The TCM Primer (Basic Terms and Vocabulary) A-shi Point We massage therapists know that it is instinctive for people to rub or press on an area that hurts, we do it without even thinking about it. For example, when one has a headache, one usually puts their hand up to the forehead. Or if one has sinus problems, one usually puts two thumbs pressing up against the inside of the eyebrows to bring relief. More than 5,000 years ago the Chinese observed this phenomenon and deduced a way to relieve some pain and discomfort through formalizing this instinctive touching. What was once man’s instinctive nature to relieve his own pain eventually developed into local acupressure “ashi” points. Ashi points are the points of pain or tenderness on the body, they are not “magic spots” that make pain go away if you press on them or put a needle in them, they are just areas on the skin that are sensitive to bioelectrical impulses in the body. Stimulating these sensitive points stimulates the release of endorphins or neurochemicals and inhibits pain signals sent to the brain. Acupuncture and acupressure both operate under this concept, that by stimulating these points you can reduce tension, enabling the body to relax deeply, and strengthen the body’s resistance to disease and promotes wellness. It is also believed to help circulation by enabling the muscle fibers to elongate and relax which helps the blood flow freely and the toxins to be released and eliminated. This brings more oxygen and other nutrients to the affected areas. This is an area that is not necessarily based on the meridians of the qi but is instead the location or site of the symptom, in other words, where it actually hurts. Acupoint Injection Or “water needling”, this is a procedure that involves introduction of a herbal solution directly into an acupuncture point. This is injected with the use of the needle. Obviously this is outside of the scope of practice for massage therapists, I have included the definition only so you can be familiar with it, should you find yourself working in a facility that practice the full spectrum of TCM.

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Acupoint According to traditional Chinese medicine there are about 361 important pressure points or acupoints along the meridians. These are the sites through which the vital energy of organs and meridians normally flow through the body. Stimulating these points, as is done in a Acupressure massage, is believed to have therapeutic effects. Acupressure Acupressure is a type of somatic therapy where the practitioner applies pressure with the fingers to specific acupoints on the body. It is generally believed to provide therapeutic benefits and used for relaxation and wellness. This is the basic form of massage therapy in TCM and we will be exploring the basic concepts in this course. It is explored in much more detail in my course Tenets of Zen Shiatsu. Acupuncture I’m sure you already know that Acupuncture is the practice of inserting extremely thin needles into strategic locations in the body to balance of flow of qi or life force. Acupuncture is believed to stimulate nerves, muscles and connective tissues hence boosting the body’s immune system. Obviously this is outside of the scope of practice for massage therapists, I have included the definition only so you can be familiar with it, should you find yourself working in a facility that practice the full spectrum of TCM. Aromatic stomacic These are herbs that are aromatic and promote digestion by moving dampness. Assistant Herbs In the traditional practice of Chinese herbology, assistant herbs are used in different herbal combinations to help the primary herb (called the monarch) and to mitigate it’s toxicity. This course doesn’t focus much on the role of herbology since it is, other than Aromatherapy applications, beyond our scope of practice, but it is important for you to know the process of how they work. Bi Syndrome In acupuncture this is a term used to refer to a blockage or obstruction in the meridians, organs or extremities. The result of these blockages are

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usually manifested as pain, swelling of the tendons and joints, numbness and heaviness of muscles or limitation of movements of the joints. Bladder In TCM the bladder is not just an organ, it is also an important meridian, or energy channel. It is responsible for storing and excreting urine. It is said that an imbalance in the bladder can lead to urinary problems. Blood In TCM, blood is a broadly used term. Blood nourishes the body: complements the nourishing action of Ying qi. As a denser form of qi, it flows with the (Ying) qi in the vessels and channels all over the body. It moistens the muscles, tissues, skin and hair, as well as nourishing the cells and organs and it is also seen as the fluid inside the blood vessels that provide nutrition for the cells and organs and keeping the body moist. Blood deficiency In TCM this a lack of blood with signs of anemia, dizziness, dry skin or hair, scant or absent menstruation, fatigue, pale skin and poor memory. Calmative Has a sedative or calming effect on the mind and the nerves Chinese Medicinal Diet One of the elements of TCM is diet; and this in particular refers to a specially prepared meal plan made from Chinese herbs, food and condiments for the symptoms of the disease that was diagnosed. A Chinese medicinal diet is a functional diet that is used to prevent and treat diseases, improve fitness, and can also slow down the aging process. Cold In TCM this is a descriptive term that refers to a decreased functioning of an organ system and is usually manifested in symptoms like: body aches, chills, poor circulation, fatigue, lack of appetite, loose stools or diarrhea, poor digestion, pain in the joints, slow movements and speech, aversion to cold and craving for heat. In western medicine you would assign all "hypo" conditions such as hypoadrenalism, hypoglycemia and hypothyroidism to this category.

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Cupping This is a practice of applying a series of bell or cup-shaped vessels upside down over strategic points on the skin to create a vacuum and create a stimulating effect. They can also be “dragged” once the vacuum has been established to create a lifting stretch of the tissues. Damp, dampness In TCM this is a descriptive term for conditions that create a build up of excessive fluids in the body with symptoms like abdominal bloating, loss of appetite, nausea, vomiting, lack of thirst, feeling of heaviness or being sluggish, and stiff, aching or sore joints Dampness Evil When you see the word “Evil” in TCM it is usually referring to a pathogen. In this case, it is a pathogen affecting the yin. Symptoms of having the dampness evil in the body include sluggishness, tiredness, heavy limbs, sticky and turbid bodily discharges and a sticky coat on the tongue. Damp Heat This refers to a condition of dampness and heat combined with symptoms of thick yellow secretions and phlegm such as jaundice, hepatitis, urinary problems, or eczema Decoction This is the act of combining and cooking medicinal herbs to create a brew or a soup for a specific illness or condition. It also refers to the combination of herbs, which is cooked or brewed to make a soup or medicinal tea. While this is very interesting I am not going to be covering it in this course because it is not massage related, but it is part of TCM so you should know what it is. Deficiency This is a generic term for any weakness or insufficiency of qi, blood, yin, yang or essence. Deficiency heat This is heat due to yin deficiency. It results in weakness and emaciation because of the lack of moistening fluids (yin) in the body.

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Diuretic This is a substance that rids the body of excess fluid Dry / Dryness This is a descriptive term in TCM used to refer to symptoms like dry hair, lips, mouth, nose, skin and throat, extreme thirst and constipation. Eight Principles These are four sets of factors used by TCM practitioners to assess a person's health. Represented by internal/external, cold/heat, excess/deficiency, and yin/yang (they should all be in balance with their counterpart). We will be discussing those in more detail later. Eight Therapies These are the common therapeutic methods performed by trained TCM practitioners. The methods are: diaphoretic (dispersion of pathogens from the body’s surface); Emetic (expelling toxic substances via the mouth); Purgative (relieving the bowels); Regulating (building the body’s resistance to pathogens by controlling body functions); Warming (eliminating cold and boosting yang); Heat-Removing (diminishing fever and quenching bodily thirst); Tonifying (nourishing and boosting qi or life energy); and Resolving (elimination of accumulated and stagnated qi, blood, phlegm, retained food and fluids that have hardened into lumps). Empty Heat This is a deficiency of yin energy resulting in symptoms such as hot flashes, mood swings, night sweats and other changes in hormonal levels. Also known as empty fire Essence This is a fluid substance that provides the basis of reproduction, growth, sexual power, conception and preganancy. It is the material foundation of qi and is stored in the kidney. Also referred to as Jing Excess In TCM this generally refers to too much heat, cold, damp, yin or yang Excess yang This is similar to excess heat with symptoms of rapid pulse, hypertension, aggressive actions, loud voice, high fever, red complexion or restlessness

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Excess yin This is an imbalance of excessive fluids in the body with symptoms of fluid retention, a plump or swollen appearance, lethargy and overall signs of dampness - although those with excess yin may still have adequate energy levels External This refers to the location of illnesses such as fevers and skin lesions or sores on the surface of the body Energy Tonic Or known as “qi tonic,” they influence the spleen functions and help the body increase its vitality for the body to function optimally. Not to be confused with stimulants, the energy tonic is believed to enhance the absorption of nutrients in the gastrointestinal system so that energy and blood circulates freely within the body. Enuresis Commonly referred to as “bed wetting,” in Chinese medicine, this is attributed to kidney-qi failure, or a primordial energy deficiency. Epimedium This is a common herb used in Chinese medicine to relieve stress and fatigue. It has been used by Chinese folk healers to strengthen the yang element in the body and boost qi. The leaves are believed to be potent aphrodisiac and are also used for the alcoholic beverage “Spring Wine.” The western scientific name for it is Epimedium brevicornum Maxim; Exogenous Evils Called “Lao Shang” in Chinese, this refers to the six natural weather factors that are not harmful under normal conditions but become toxic to the human body when in excess or there is an imbalance in the yin and yang elements inside the body. The six climates involved are: wind, cold, summer-heat, dampness, dryness and fire. Fire and Heat Evils These refer to the pathogenic effect to the yang element in the body, producing heat-related symptoms such as fevers, inflammation, skin eruptions, dry skin, brittle hair and constipation.

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Fire Fire is one of the five elements, and we will be discussing it in detail later. It results from malfunction of the internal organs or from extreme mood swings. Symptoms include fever, red or bloodshot eyes, swelling, sore throat and flushed face. May also include dry mouth, bleeding or inflammed gums, and a desire for cold drinks Five Elements The five energies of wood, earth, metal, water and fire which exist in nature. Each transforms and controls one another to maintain a harmonious balance. Five Elements theory is integral part of TCM-see below. Five Elements Theory A fundamental principle used by Chinese medicine practitioners to explain the relationship between the natural world and the body. The basis of Traditional Chinese medicine as known in the modern world, this theory asserts that all substance and matter in the universe are correlated and interact naturally to one another. The five essential elements of Wood, Fire, Earth, Metal and Water have corresponding effects on climatic seasons of Spring, Summer, Late Summer, Autumn and Winter, as well as body parts and organs such as the Liver, Heart, Lungs, Kidney, Stomach, Intestines, Bladder and so on. There is an organized relationship in all the elements in nature and the body, and the practice of TCM is to restore and maintain the harmony among all the five elements. We will be discussing it in more detail later in this course. Five Zang Organs Also referred to as the “yin” organs, these are the liver, heart, spleen, lung and kidneys. Their primary roles are to produce, regulate and store essential qi, blood and other bodily fluids. Flush Channel Or the “thoroughfare vessel,” this is an acupuncture point that is where the 12 normal meridians in the body converge.

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Gall Bladder Meridian The Leg Shao Yang Gall Bladder Meridian starts out from the outer corner of the eye. Afterwards it splits into two paths – one runs at the exterior, weaving back and forth at the back of the head and then curves by the ear to trail down the top of the shoulder, the lateral side of the rib cage and abdomen and ends at the side of the hip. Another path goes into the cheek and trails down internally – down to the neck, chest, gall bladder – and then comes out to the lower abdomen to connect with the other trail at the hip before it snakes down to the lateral side of the thigh, the lower leg, crossing over the ankle and lands on the tip of the fourth toe. This meridian is used in acupuncture for conditions of the eyes, ear, throat, as well as mental illnesses. Gecko Used in Chinese herbology, the Gecko lizard is widely found in southern China. It is believed that the tail and the backbone of the Gecko are good ingredients for a warming Yang tonic. It is also said to boost the strength and endurance among athletes and is said to provide sexual energy. Don’t worry, I won’t be recommending you do anything with lizard parts in this course, it just makes a nice bit of cultural flavor. Ginseng Also known as the “king of herbs” it is one of the most valued and most commonly used Chinese herbs. It is believed to help strengthen the immune system, regulate metabolism and help combat stress and fatigue. Glossy Pivet Fruit A sweet and bitter fruit found in several provinces in China that is believed to have therapeutic actions on the liver and kidney meridians. The western scientific name is Fructus Ligustri Lucidi. Governor Vessel Meridian Running along the end of the spinal column up until the head, this is referred to as the “Sea of the Yang Meridians” because this is where all the Yang meridians meet and it controls the qi flow in all the Yang meridian points in the body.We discuss Meridians in exhaustive detail in Introduction to Meridians and Acupoints, the second course in the Asian bodywork series.

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Guide Herbs In an herbal combination, the guide herbs act to direct the herb’s active ingredient to reach the target meridian. It also provides a buffer effect on the other herbs in the mixture. Healthy Energy Also referred to as “genuine qi”, “vital energy,” “vital essence” or “vitality qi”. This refers to the proper and natural functioning of all the elements of the body according to the climate and seasons. Heart Energy In TCM, the heart organ is not only related to cardiovascular functions but also to mental and “spirit” activities. Deficiency in heart energy leads to palpitations, shortness of breath, pale face, fatigue and general weakness. Heart Meridian Also known as the Arm Shao Yin Heart Meridian and is one of the twelve major meridians of the body. The Heart Meridian actually starts from the heart and then splits of into three branches. The first goes down to the small intestine. The second one travels up along the throat to the eyes. And the third goes under the arm and runs along the inner side of the forearm, elbow and upper arm, crossing to the inner side of the wrist and palm. It ends at the inside tip of the little finger where it connects with the Small Intestine Meridian. The acupoints in this meridian are used for heart, chest and nervous system disorders. Inspection Part of the diagnosis process in TCM, inspection entails the practitioner or physician to make use of his visual senses to ascertain the condition of the patient. By observing the changes in the patient’s appearance, secretions, excretions and vitality, he or she can determine which body part is affected. Generally the following parts are inspected: Tongue, Movement and Posture, Body Shape, Skin Colour and Spirit (or outward manifestation of vital qi). Of course as massage therapists we do not diagnose our clients, but we can and should be doing an assessment where they tell us how they feel-it accomplishes the same purpose for us.

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Internal When this word is used in TCM it refers to the location of illnesses such as those that affect qi, blood, and organs inside the body. Jing In TCM, Jing is considered an essential fluid-like substance for life. It is needed for reproduction, growth, development and maturation. As one grows older, Jing normally decreases. The Jing can be found in the kidneys. Kidney Meridian This Meridian starts from the bottom of the small toe then crosses the middle part of the sole and the arch of the foot, goes behind the inner ankle upwards along the inner lower leg and thigh and enters the body to connect with the kidney. The path continues over the abdomen running externally until the upper chest. Another branch begins from the kidney and moves internally upward through the liver, diaphragm, lungs, throat to land at the root of the tongue. Still yet another branch connects with the heart and the pericardium. This meridian is used from gynecological, genital, kidney, lung and throat conditions. Kidney Qi An important body organ, the kidneys regulate the urinary and excretory system and also has influence over the reproductive, endocrine and nervous systems. TCM teaches that if there is some kind of imbalance in the kidney qi, it shows as spiritual fatigue, frequent urination, soreness and weakness in the lower back and knees, menstrual problems for women, prostate disorders in men and sexual dysfunction in both genders. Large Intestine Meridian The Large Intestine Meridian starts from the tip of the index finger then runs between the thumb and the index finger. It travels along the back of the forearm and the front side of the upper arm until the highest point at the shoulder. From this tip it branches off into two paths: an internal one travels to the lungs, diaphragm and large intestine, the other trails externally upwards to the neck, cheek, entering through the gums and lower teeth then curves around the upper lip and to the opposite side of the nose. Imbalance in the Large Intestine Meridian can cause diarrhea, constipation dysentery or oral problems such as toothache.

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Liver Meridian The Liver Meridian, it starts from the top of the big toe and across the top of the foot then crosses around to the inner ankle to trail upward along the inner side of the lower leg and thigh. The path then goes around the external genitalia to the lower abdomen, up to the lower chest, the liver, the gall bladder then further upwards to the throat, eyes and then emerges from the top of the head. Imbalance in the Liver Meridian presents itself as pain in the groin area, incontinence, hernia, difficulty in urinating and chest fullness. Lung Meridian The Lung Meridian begins in the middle area of the body and runs down to the large intestine. From there it passes through the diaphragm to connect with the lungs. As with the other meridians, it branches out: one travels from the armpit and runs down the upper arms to the elbow crease. It then continues until the tip of the thumb, passing along the major artery of the wrist. The other branch appears from the back of the wrist and ends at the inner tip of the index finger connecting with the Large Intestine Meridian. This meridian is used for conditions of the throat, chest and lungs. Lung Qi The lungs connect with the throat and nose and they regulate respiration as well as water flow in the body. An imbalance in the lung energy results to feeble cough, asthma, shortness of breath fatigue and lusterless complexion. Meridian In TCM there are 12 major pathways through which the qi flows. These are called Meridians and they correspond to the yin and yang organs and the pericardium. We will be discussing these a little in this course, but in greater detail in our introductions to Meridians and Acupoints course. These are also interrelated and which are used for treating ailments and correcting imbalances in the qi. The Chinese word for meridian is “Jing Luo.” “Jing” refers to the vertical channels, while “Luo” refers to the networks that branch off from the vertical channels.

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Minister Herbs TCM practitioners use herbal combinations in healing, much like the way arromatherapists do today. In an herbal combination a minister herb is an herb that supports the monarch herb in performing its major action on the body. It also helps treat the accompanying symptoms of the ailment. Monarch Herbs This is the principle herb in a combination, the major “active ingredient” if you prefer to think of it that way. A potent herbal combination may have more than one monarch herb. Moxibustion A method of TCM therapy whereby a burning moxa wool (made of mugwort leaves), or moxa wool occasionally mixed with herbs, is applied on a patient’s acupoints to facilitate healing. The heat from the moxa wool is said to penetrate deep into the affected location without damaging the skin. This technique is used to warm the meridians, boost the flow of qi and blood and eliminate the pathogens from the body. Nutrient Essence In TCM a health diet can be designed to treat certain conditions with select foods, a “food therapy” if you want to think of it that way. The nutrient essence is acquired from the food and is considered a necessity for the body to maintain its health and optimum performance. When a nutrient essence is absorbed by the body it can be converted into Jing, which is stored in the kidneys. Organs In TCM there are five major organs that cover a wide range of systems and functions in the body: the heart, the liver, the spleen, the lung and the kidney. Each of these organs possesses their own qi or energy and an imbalance leads to chronic ailments. Orifices In TCM the term orfices refers to the openings of the five major organs on the body’s surface: the eyes for the liver; the tongue for the heart; the spleen opens into the mouth; the nose to the lungs; and the kidneys open into the ears. It is said that when an orifice is closed, there is blockage, or worse, unconsciousness.

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Overstrain In TCM, overstrain refers to the external factors result lead to chronic conditions. Examples would be stress, toil, improper diet or emotional troubles. Overstrain is believed to damage the spleen and kidney energies such that the patient can suffer from restlessness, palpitations and vexing heat. Palpation Just like in western massage therapy, palpation in TCM is an inquisitive skill that feels the clients body to identify factors in treatment. In TCM the practitioner takes the patient’s pulse and feels the skin, hands, feet, chest, abdomen and other areas of the body for abnormalities and changes. In TCM, pulse-taking is an important method to determine the location and the nature of the patient’s condition. Pericardium In TCM the pericardium is viewed as an attachment to the heart – of course we know it as the membrane that surrounds the heart. When exogenous pathogens invade the heart, the pericardium is the first to be attacked. Pericardium Meridian The Pericardium Meridian starts from the chest from the pericardium and runs down along the diaphragm to connect with the Triple Burner Meridian. It has two branches: one from the chest travels to the armpit and along the middle part of the upper arm, down between the lung and heart channels to the elbow crease. It continues down the forearm and enters the palm where it ends at the tip of the middle finger. A second branch emerges from the palm and connects with the Triple Burner Meridian at the end of the ring finger. Imbalance in the Pericardium Meridian presents itself as symptoms of heart pain, palpitations, chest discomfort and “shen” disorders such as manias. Pestilential Evil This poetically biblical sounding name refers to droughts, floods, extreme heat, pollution and unsanitary environmental conditions. This pathogenic factor affects not only one, but a significant number of people with epidemics and highly contagious diseases.

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Phlegm A good indicator of a pathogenic substance or a disorder in the body. Phlegm can either be external and visible, or internal and invisible. Qi Commonly translated as “energy flow”, or the “breath of life”, qi is an essential and fundamental concept in TCM that pertains to the vital energy that flows throughout and around the body. It is believed to be found in all living things and is formed from the harmonious interaction of yin and yang energies. Qi flows through the body’s meridians and the practice of TCM is hinged on regulating and maintaining the proper flow of Qi throughout the body. Qi deficiency As the name implies, this is a lack of qi which manifests as symptoms of lethargy, weakness, shortness of breath, slow metabolism, frequent colds and flu with slow recovery, low or soft voice, palpitations and/or frequent urination Qi-Gong A system of physical and mental training exercises for physical, emotional and spiritual health. There are four types of training in Qi-Gong: dynamic, static, meditative and training activities requiring external aids. Also considered as part of TCM, the practice of Qi-Gong is meant to control the flow of qi. We will be discussing it in more detail later. Questioning TCM practitioners perform an assessment with their clients the same way we massage therapists do, by asking questions. Usually they ask about the client’s immediate complaint, symptoms, medical history and background and more. Reverse Flow of Qi This usually refers to an adverse or negative state of qi in the body, resulting to dysfunctions in certain internal organs. Signs of a reverse flow of qi present itself in shortness of breath, vomiting or hiccups. Scraping Therapy This is a variation of acupressure or TCM massage, it is a therapeutic method practiced by old Chinese healers whereby rim tools that have been

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lubricated with oil or warm water is scraped down the patient’s shoulder, back or neck. This is believed to promote blood and qi circulation in the body, activate meridians and regulate functions of the organs. It has been used for treatment or relief of motion sickness, stomach distention and flu. We will be discussing it in more detail later. Seven Emotions These refer to the human emotional responses to environmental conditions and changes. They are believed to be potential causes of illnesses. The Seven emotions are: sadness, fright, fear, grief, anger, extreme joy, and restlessness or pensiveness. Shen The spirit and mental faculties of a person which include the zest for life, charisma, the ability to exhibit self control, be responsible, speak coherently, think and form ideas and live a happy, spiritually fulfilled life Six External Evils The six external evils, like the seven emotions, are causes of illness and disease. Also known as the six climatic factors, the six excesses and the six evil qi. The six external evils are terms from nature that are used to describe the condition. These include wind, cold, summer heat, dampness, dryness and fire. Terms are also used metaphorically to indicate the behaviour of a particular ailment or condition Stagnation An important concept in TCM, stagnation refers to blockage or buildup of qi or blood that prevents it from flowing freely. Is a precursor of illness and disease and is frequently accompanied by pain or tingling Stomach heat In TCM too much heat in the stomach is represented by bad breath, bleeding or swollen gums, burning sensation in the stomach, extreme thirst, frontal headaches and/or mouth ulcers Summer Heat Overactive functioning of an organ system resulting in symptoms of thirst, aversion to heat and craving for cold, infection, inflammation, dryness, red face, sweating, irritability, dark yellow urine, restlessness, constipation and "hyper" conditions such as hypertension

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Shen This is a TCM word for life force, or vitality, it represents the spiritual abilities of a person such as his passion and enthusiasm for life, to think and form ideas and speak coherently and to live a happy life. Shanghan The term refers to severe diseases caused by exogenous cold evils. Manifestations of shanghan vary from chills, aching of muscles and bones, belching, and may present itself with or without fever. Small Intestine Meridian This is a major meridian that connects with the Bladder Meridian through a short branch in the cheek that travels upward to the inner corner of the eye. It connects to the small intestine along a branch that moves internally through the heart and stomach. Imbalances in the Small Intestine Meridian are said to result to stiff neck, sore throat, hearing problems, and pain along the shoulder, upper arm, elbow and forearm. Spleen Meridian The Spleen Meridian starts at the big toe, running along the inside of the foot and crosses to the inner ankle. It then travels upward along the inner lower leg and thigh, entering into the abdominal cavity to connect with the spleen and upwards to the Heart Meridian. Disharmony in the Spleen Meridian can cause loose bowel movement, flatulence, indigestion or gastric pains. Stagnation of Qi In contrast to reverse flow of qi, this condition depicts the impairment of the normal flow of qi in the body. Stagnant qi in the meridians may result in pain and aches in the body. Stomach Meridian The Stomach Meridian begins from the end of the Large Intestine Meridian (side of the nose), and travels along the inner corner of the eye then emerging from the lower part of the eye. It then travels downwards entering the upper gum, lips and lower jaw. When it reaches the corner of the forehead through the front of the ear, it splits into an internal and external branch. The Stomach Meridian connects with the Spleen Meridian at the

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end of the bid toe. This meridian is used for several gastro enteric diseases as well as toothaches and mental illnesses. Tai Chi Also known as Tai Chi Chuan, this is a form of health benefits exercise and is similar in many respects Qigong. It is a system of routines with therapeutic benefits as well as recognized as a martial art. The objective of Tai Chi is to promote a balance between the yin and yang energies in the body and the smooth flow of qi along the meridians. It is a set of smooth, flowing exercises used to improve or maintain health, create a sense of relaxation and keep qi flowing Tao The ancient philosophy of oneness in all creation TCM The acronym for Traditional Chinese Medicine, an alternative medical system and practice originating from ancient China. Tonification This is a term in TCM that refers to the nourishment and replenishment of the qi and the blood when they are deficient in the body, as well as the balance of yin and yang is restored. There are different methods of tonifying: through diet; tonifying by herbs; by acupuncture and moxibustion; or by massage therapy. Toxicity Applies to any inflammation, infection or severe heat disease Triple Burner Meridian In TCM the Triple Burner is a Meridian that is an essential element in digestion. It consists of three parts: the Upper Burner (Mouth to Stomach); the Middle Burner (Stomach to Large Intestine) and the Lower Burner (Small Intestine to Rectum). The Triple Burner Meridian connects with the Gall Bladder Meridian through an external branch that runs up the side of the neck, the ear and ends at the outer end of the eyebrow. An internal branch connects with the Triple Burner sections. This meridian is used for ailments involving the ears, eyes, chest and throat.

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Tui Na Also known as Naprapathy, it is a form of Traditional Chinese massage that focuses on meridians and acupoints to bring balance to the body’s energies. We will be discussing it in more detail later. Wei Qi This is the TCM equivalent of the body’s immune system as known in mainstream medicine. Weifen (or Wei) Syndrome If a patient is diagnosed with the Wei Syndrome, there is weakness and eventual wasting of the muscles particularly in the lower extremities of the body. Wind Causes the sudden movement of a condition. Examples are a rash that is spreading, onset of colds, fever, chills, vertigo, spasms or twitches Wind Evil An influential pathogen that causes cold ailments such as chills, vertigo, spasms or twitches. Yang Represents heat and the body's ability to generate and maintain warmth and circulation Yang Deficiency Inadequate yang energy in the body manifests itself in general swelling, pale complexion, lethargy, lower back pain, a deep and slow pulse and bland taste in the mouth. This denotes that the body cannot sustain functions of warmth and motivation. It is a cold condition due to lack of the heating quality of yang. Symptoms include lethargy, poor digestion, cold, lower back pain and decreased sexual drive Yin Represents cool and the substance of the body, including blood and bodily fluids that nurture and moisten the organs and tissues

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Yin Deficiency Lack of yin energy in the body results to symptoms of night sweats, fever, dizziness, insomnia, blurry vision, dry mouth, scanty and yellow urine and afternoon fevers. This denotes that there is excess heat in the body. It is a heat condition that results in symptoms of night sweats, fever, nervous exhaustion, dry eyes and throat, dizziness, blurred vision, insomnia and a burning sensation in the palms of the hands, soles of the feet and the chest Yin-Yang In Chinese philosophy, Yin and Yang are mutually interdependent properties or elements that represent the duality of everything. The two polar factors constantly interact in either a complementary or opposing way, and the result of their interaction produces Qi. In TCM, Yin stands for coolness and bodily fluid that moisten and nourish the organs and tissues, while Yang represents heat and the body’s ability to generate and maintain warmth and circulation in the body. Zang Fu In TCM, it denotes the functions of the major organs of the body and their interaction to each other. There are twelve zang fu organs: the yin organs of the heart, liver, spleen, lung, kidney, pericardium; and the yang organs of small intestine, large intestine, gall bladder, urinary bladder, stomach and the triple burner. The easy way to remember it is that it describes the solid organs (zang) that store vital substances and the hollow organs (fu) which are responsible for transportation.

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Chapter 3:Traditional Chinese Medicine Concepts Traditional Chinese Medicine (TCM) has a long and rich history and is one of the oldest forms of medicine. The fact that TCM has existed for thousands of years, and is still used today is a testament to its value as a form of healthcare. The physical isolation of China throughout its long history plays a role in TCM's lack of development in other world civilizations. However, with the opening of China to the west in 1972 it has been spreading to the USA and European countries. TCM's practice has been molded over time by many factors including culture, philosophy, politics, religion, and science. Today, we think of China as one very large country, but this is only a recent development. Throughout most of its long history China was composed of many sovereign states. These small states were ruled by dynasties and were feudalistic societies. They frequently warred with each other on both the field of battle as well as in the academic world of ideas, which is why you will encounter frequent disagreements and contradictions in your study of Traditional Chinese Medicine. It is important to understand that Western Medicine developed in a straight chronological line, each culture built upon the knowledge of the previous one (Babylonians-Greeks-Romans-Europeans-Americans, etc) Development of TCM, however, was often occurring side by side with different states and overlapping dynasties. How the individual TCM practitioner exercised his art was influenced greatly by his teacher's views. This is true even today. You will find many modern TCM manuals that disagree on the exact location of Acupoints or that prescribe a person with the same symptoms different herbal remedies. Each herbal remedy will cure the symptoms even though they have different ingredients. The success of the treatment is measured through observation and how the patient feels. Understanding TCM through a historical context gives insight to this ancient form of medicine and establishes its validity as a healthcare system.

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An Ancient Healing Philosophy A great deal of the foundational concepts of TCM originate in the phisiophical roots of Taoist and Buddhist beliefs in the creation of the Universe and mankinds intimate relationship with all there is. The earliest practitioners of TCM were Taoist Masters1 who had developed a keen insight into the body and its workings through countless hours of meditation and rigourous academic pursuit. The Taoist influence can be seen in the view of the body as a microcosm, or a smaller version of the entire universe. Meaning that what is true for the universe at large is also true for the human body. Balance and harmony are seen as the progenitors of good health, an idea now embraced by western science on the biological level as homeostasis and the holistic level as the wellness model. Traditional Chinese Medicine incorporates the use of Massage, Acupuncture, Herbal remedies and diet modification to produce results so well documented that they have managed to remain well into modern time and are regarded as a primary mode of treatment in China and an Alternative form of medicine in the United States as well accepted as Chiropractic practice and physical therapy. The Fundamental Concepts

Yin Yang Theory The theory of Yin and Yang originated in the study of relationships and patterns that occurred in the natural world. Instead of studying isolated things, the scholars of Ancient China viewed the world as a harmonious and holistic entity. In their eyes, no single being or form could exist unless it was seen in relation to its surrounding environment. By simplifying these relationships, they tried to explain complicated phenomena in the universe. The Yin yang theory is a kind of logic, which views things in relation to its whole. It is kind of like the binary code of computer programming, everything is either 1 or 0.

1 Inner Canon of Huangdi or Yellow Emperor's Inner Canon; an ancient Chinese medical text that has been treated as the fundamental doctrinal source for Chinese medicine for more than two millennia

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You could be running an incredibly complex and sophisticated computer program. It is performing a thousand actions per minute, affecting dozens of different parts of a network, but it is still a code of just 1s and 0s. So the Yin Yang theory is based on two basic components: yin and yang, which are neither materials nor energy. They combine in a complementary manner and form a method for explaining relationships between objects. Gradually, this logic was developed into a system of thought that was applied to other areas. Traditional Chinese Medicine (TCM) is an example of one area where the yin yang theory is used to understand complicated relationships in the body. The Origin of the Theory As stated above the original concept of yin and yang came from the observation of nature and the environment. "Yin" originally referred to the shady side of a mountain while "yang" referred to the sunny side. Later this concept was expanded to encompass a dualistic, 2-sided nature to nearly everything. Some examples include: sky and earth, day and night, water and fire, active and passive, male and female and so on. Working with this basic concept the ancient Chinese Scholars developed a truly binary view of existence. Nearly all things could have yin and yang properties. Yin and yang can describe two aspects of the same phenomena such as the example of the slope, or they can describe two different objects like sky and earth. Generally, yang is associated with energetic qualities such as movement, outward and upward direction, heat, brightness, stimulation, activity and excitement. Consequently Yin is associated with the physical form of an object and has less energetic qualities such as rest, inward and downward direction, cold, darkness, condensation, inhibition, and nourishment.

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Properties of Yin and Yang By describing how things work in relation to the universe and to each other, the yin yang theory establishes a dynamic thought process that can be applied to everyday life. 1. Yin and Yang are in opposition to each other. Yin yang theory postulates that everything has an opposing yin and yang aspect. These aspects are both controlled and inhibited by each other, which results in a continuous state of dynamic balance. While this may seem complicated it can be illustrated simply with temperature: Heat can dispel cold and cold can reduce heat. If there is not enough heat, it will become cold and if there is not enough cold it will become hot. The perfect example of the Yin Yang relationship, both opposing forces that are related to one another. Another good example is the physiological functions in your own body. Both the exciting (yang) and the inhibiting (yin) aspects are in mutual balance. If the sensitive balance is disturbed, one side could become excessive causing a variety of health problems. 2. Yin and Yang mutually create and depend on each other. Neither Yin nor Yang can exist independent of the other. They are dependent upon each other for definition and can only be measured by comparing themselves to the other. For example, if you were to try and describe something that is hard you would inevitably say that it was not soft. If there was no such thing as soft it would be impossible to describe something as hard, the word would be without meaning. These mutual dualities abound in nature; we can say that heat ceases to exist (yang aspect) when there is no such thing as cold (yin aspect). Height (yang aspect) cannot be measured except when compared to a low reference (yin aspect).

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Our own body shape can be said to be closely connected to it’s physiological functions. The activity (yang) of our body is powered by its physical form (yin), and the physical form is sculpted and maintained by the activity. They are both required to achieve a balanced state of health. Take the body builder, for example. His work out (activity-yang) is fueled by his body (yin). His body in turn is shaped and empowered by the activity. 3. Yin and Yang will change and grow in a cyclic manner. In a healthy person Yin and yang are in a state of balance by mutual control and inhibition. The balance is constantly shifting, each side giving and taking in turn, within a normal parameter. Another good example of this is the natural change of the seasons. From winter through spring and summer, the weather goes from cold to hot. This is a process where yang (heat) grows and yin (cold) diminishes. The opposite happens when the weather changes from hot to cold from summer through autumn and winter. This is a process wherein yin grows and yang shrinks. Over time, the balance of hot (yang) and cold (yin) will change and be balanced in harmony. 4. Yin and Yang transform into each other. When either Yin or Yang reaches an extreme point, it will undergo a reverse transformation into its opposite! As strange as that sounds it is very logical and simiple. If you are climbing a mountain you go up until your reach the peak (most extreme point), at which time the only option is to go down. On the hottest day of the summer (most extreme point) the next day will naturally be cooler. This transformation is the source of all changes, which allow both yin and yang to create each other. In the body, the pattern of yin yang transformation happens when exciting and inhibiting functions morph into one another.

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Yin and Yang in human body structures In Yin and Yang theory the body's organs and tissues are classified according their functions and locations. The upper body belongs to yang while the lower body belongs to yin. Other yin yang pairs in the body include the interior (yin) and the exterior (yang), the front (yin) and the back (yang), the inside (yin) and the outside (yang) of the limbs and the five yin organs and the six yang organs. Each organ can additionally be divided into yin and yang facets such as heart yin and heart yang and kidney yin and kidney yang. Physiological application In TCM health and wellness is the result of yin and yang harmony. As mentioned earlier with the body builder example, the physical body belongs to yin while the activities or functions belong to yang. Because both the physical body and its functions are dynamically balanced, they mutually restrict and depend on one another. The body cannot function if it doesn't have a corporeal nature in which to act in. Physiological actions consume food and metabolizes it to obtain energy. Pathological application If TCM believes health and wellness is the result of yin and yang harmony it follows that disharmony is the cause of disease and physiological disorders. This disharmony means the amount of yin and yang are not proportional, or are unbalanced. One aspect is deficient, resulting in the other being in excess. The cause of this disharmony can be many things, but they are always related in some way to the "evils" (outside influences that cause disease) and the flow of qi throughout the body. When a person has a normal and healthy flow of qi their body works the way it is supposed to, including their immune system. Recovery time is shorter and illness when they occur are less severe. Normal qi consists of yang qi (used for both physiological functions and energy) and yin fluids (physical form and the physiological fluid of body) while the "pernicious evils" are composed of six evils.

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The yin evils include cold and dampness while wind, dryness, summer heat, and fire belong to the yang evils. In TCM disease is a result of either a deficiency of normal qi (a deficiency of yin fluid or a deficiency of yang qi) or an excess of the "pernicious evils" (an excess of yin or yang evils). Diagnostic application In TCM the practitioner diagnoses the client according to their pattern of qi disharmony. There is a pattern classification system that is useful for categorizing these disharmonies. This is called the "eight principal patterns." The "eight principal patterns" contain four pairs: interior and exterior, cold and heat, deficiency and excess, and yin and yang. Naturally, yin and yang are the most basic and fundamental essential pair. Yang signs are usually associated with excitatory, active, hot, progressing externally and developing upward and improving manifestations. Naturally yin signs are associated with inhibitory, resting, passive, cold, progressing internally and developing downward and worsening manifestations. The Eight Principles of Disharmony The Eight Principles is an important basic concept in TCM, as it shows the general location and nature of the imbalance in the body. Using the Eight Principles we learn the basic characteristics of the imbalance. The Eight Principles of disharmony form a system in which illnesses can be categorized. In traditional Chinese medicine, illness is seen as an imbalance, a disruption in the body’s harmony, and knowledge of the eight principles allows the practitioner to perceive the location, severity, and nature of the disease process. The practitioner of TCM can then use the information gleaned from the Eight Principles to make a treatment strategy. It tells him or her which meridians or organ systems to focus on, and what treatment might work best.

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This thinking relies heavily on the idea Taoist attitude of flexibility while perceiving the symptoms of the body. Any pattern of symptoms is a considered to be temporary subject to change. An experienced TCM practitioner recognizes this and is always prepared to adjust the diagnosis and treatment plan to accommodate these changes. External/Internal The terms external (or exterior) and internal (or interior) do not refer to where the pathogen comes from; rather, they specify the location of the disease process in the body. The exterior of the body is considered the skin and muscles, while the interior is defined as the internal organs and bones. In an external pattern, the pathogen fights with the body's defensive qi, or wei qi, which circulates under the skin. Symptoms of this struggle are chills, fever, sensitivity to wind or cold, body aches, sore throat, nasal congestion, and a floating pulse. If the cause of disease, known in traditional Chinese medicine as the pernicious influence, is not expelled, typically it penetrates the interior. An interior, or internal, condition has more organ-related symptoms, such as diarrhea, stomachache, intestinal cramps, lung pain, bladder pain, constipation, and changes in the color of the tongue. A pathogen trapped between the interior and exterior exhibits such symptoms as alternating chills and fever, a bitter taste in the mouth, and a wiry pulse. Heat/Cold The possible causes of heat conditions are an external heat pernicious influence (for example, a virus that produces heat symptoms, such as a high fever), internal hyperactivity of yang functions (for example, drinking too much alcohol can cause a red face and headache), or insufficient yin. The yin aspect of the body includes the "lubricating and cooling" systems. When these systems are depleted, the body tends to overheat due to the deficiency of yin. In general, heat signs include redness in the face; feeling hot; thirst; colored secretions (such as yellow mucus or other discharges or dark urine); constipation; burning sensations; irritability; red tongue body with a

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yellow coating; and a rapid pulse. Conversely, cold arises from external cold pernicious influences (for example, a virus that produces the cold symptoms of chills and a runny nose), an internal yang deficiency, or internal excess cold pathogenic factors. An internal yang deficiency produces such symptoms as always feeling cold, a low sex drive, and low energy. A person who has acute symptoms of loose stools and abdominal pains from eating too much ice cream likely has an internal excess cold condition. General signs of cold are a pale face, feelings of cold, lack of thirst, clear secretions (pale urine, clear mucus or discharges), loose stools, muscle tightness, fatigue, pale tongue with a white coating, and a slow pulse. Excess/Deficiency A disease is classified as an excess condition or a deficient condition. Excess conditions occur when an external pernicious influence attacks the body and creates over-activity (for example, a high fever that is caused by infection with a virus); a body function becomes overactive (for example, redness and swelling that are caused by an infection); or an obstruction of qi or blood causes pain. Acute conditions tend to be conditions of excess. Deficient conditions arise due to an inherent weakness in the body or a weakness in the body's vital energy (qi), blood, yin, or yang. Symptoms of deficiency include weak movement, pale face, pale tongue, and weak pulse. Chronic conditions tend to be conditions of deficiency. Yin/Yang The most general of all the diagnostic categories, it can be considered a summary of all the others. Heat, excess, and external conditions are yang conditions, while cold, deficiency, and internal conditions are yin conditions. Most conditions include a mixture of yin and yang imbalances. In addition, each internal organ has its yin and yang aspects that must be balanced. For example, if heart yin is deficient, a person may experience insomnia, poor memory, and palpitations. If heart yang is depleted, poor circulation, pale face, purple lips, edema, and cold extremities can result.

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When yin, with its cooling function, is low, heat signs occur. When yang, with its heating function, is low, cold signs occur. Restoring the optimum yin/yang balance of each internal organ is the most important secret of maintaining health and vitality in traditional Chinese medicine. Therapeutic application of yin yang theory The universal goal of all TCM procedures (including Shiatsu and Tui Na Massage) is to restore yin yang harmony. The approach to treatment is to formulate a strategy to replenish the deficient element and reduce the excess. When one of the aspects is excessive and the other aspect remains normal, the treatment naturally should seek to clear away the excess. As one would expect, when one aspect is deficient and the other remains normal, the treatment strategy aims to replenish the deficient aspect. If both excess and deficiency take place at the same time (sounds strange, but totally possible), removing the excess and replenishing the deficiency are both necessary. 1. Excess of Yang Disharmony occurs when the yang aspect is in excess and the yin aspect is normal. A persons that is diagnosed with pneumonia may exhibit a high fever, a red face, and a rapid pulse. The physiological signs like fever and a strong pulse are considered to be an excess of "heat." Since the yin aspect is still normal, the heat symptoms are an excessive type. The TCM based healing strategy for treating pneumonia would utilyze herbs with “cooling” properties to remove "excessive heat". As soon as the heat aspect is diminished, yin yang balance and health are restored. 2. Deficiency of Yin In a normal healthy person yin and yang control and balance each other out. If the yin suddenly diminishes, a proportionate excess of yang will develop due to a relative excess of heat. We refer to this type of heat as "virtual heat" because it is caused by a deficiency of yin and not an excess of yang. In hyperthyroidism, for example, a condition of deficient yin, people can show symptoms like insomnia, irritability, and have a fluttering, rapid pulse. This is different from the "excessive heat" condition described with excessive yang, "deficiency or virtual heat" cannot be treated with "cooling herbs”. Instead it must be treated using yin nourishing herbs.

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In TCM, yin deficiency can also refer to a deficiency of the yin fluids in the body like blood and lymph. If they do not have enough nourishment the excitatory functions can become stagnant, which causes symptoms like afternoon fevers or night sweats to emerge. 3. Importance of distinguishing disharmony pattern It should be obvious that identifying the pattern of disharmony is vitally important to the practitioner of TCM. You can see that both types of heat, "virtual" and "excessive", have similar heat symptoms but they have subtle differences in the overall presentations. A good example would be that "excessive heat" can cause a high fever whereas "a virtual heat” caused by yin deficiency may lead to a night fever or a low-grade fever. A person with "excessive heat" will show a pulse that is fast and powerful, while a person with "virtual heat” from yin deficiency has a fast and weak pulse. Herbs and their Yin and Yang Properties Herb lore is an important part of Traditional Chinese Medicine. The use of herbs to naturally affect qi is based upon a system of classification of the herbs by their "nature" and their "taste". Cold and cooling nature herbs belong to yin while hot and warming ones belong to yang. Yin herbs may taste sour, bitter or salty, and yang herbs can taste sweet or pungent. The yin yang theory also presents a description of the effects of medicinal herbs. Herbs with properties that can be described as “floating” are considered yang while herbs that sink to the bottom are considered to have properties of yin. When choosing the correct medicinal herbs for treatment using TCM, you must first identify the nature of the disharmony pattern and then select herbs with the appropriate aspect, taste and effect. By following these simple procedures, Traditional Chinese Medicine can use herbs to help maintain the body's balance and health.

Review of Yin and Yang In Traditional Chinese Medicine the concept of Yin Yang is used to demonstrate the concept of seemingly opposing forces that are interdependent in the natural world, giving rise to each other in turn. The concept is rooted in many intellectual disciplines in china, from religion to medicine and even the physical sciences. Many forms of martial arts,

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such as qi-gong and thai-chi, rely heavily on the belief that a constant interplay of energy is taking place in combat, such as the idea that brute force can be countered with a gentle, passive movement. Many natural dualities - e.g. dark and light, female and male, low and high, hot and cold- are cited as manifestation of yin yang in Chinese thought. All forces in nature can be seen as having yin and yang states, and the two are in constant movement rather than held in absolute stasis. The bottom line of yin-Yang is the belief that the universe is run by a single force, the Tao, or Great Ultimate. This force is divided into two opposite sub-forces, or two energies which oppose one another in their actions, yin and yang. All the opposites one perceives in the universe can be reduced to one of the opposite forces. The Five Elements The five elements theory presents wood, fire, earth, metal, and water as the basic elements of the material world. In other words, everything that exists in the universe is composed of one or more of these five elements. These elements are in constant motion and flux. The complex connections between material objects are believed to be explained through the relationship of interdependence and mutual restraint that governs the five elements. In TCM five elements theory is used to interpret the relationship between the human body and the natural environment. The ancient physicians studied the relationships between the physiology

The yin and yang accomplish changes in the universe through the five material agents, or Elements , which both produce one another and overcome one another. All change in the universe can be explained by the workings of yin and yang and the progress of the five material agents as they either produce one another or overcome one another.

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and pathology of the body, specifically its organs and tissues, and the environment. By using a methodology of "comparing similarity to expose phenomenon," these ancient scientists categorized different phenomena into five classifications, which they then called the five elements. 2

The five-element model helps us understand how natural changes within our body and outside environment affect our health. To predict and understand these changes, ancient practitioners studied the world around them to determine what universal principles existed that could be applied to health and well-being.

The Relationship between the Five Elements The five elements of wood, fire, earth, metal, and water do not exist in a vacuum, but rather they are closely connected and have their own internal orders and rhythms. The system that governs the five elements includes a cycle of mutual generation and a cycle of mutual restriction. The Mutual generation cycle This cycle can demonstrate how the elements can create each another. As you know, wood easily burns to make fire. Fire then produces ash, considered part of earth (it is often used as fertilizer). The earth is mined for metal. When metal is heated and cooled in the forging process, water droplets will condense on the metal, thereby making water. Water is used to nourish trees, which are wood. The mutual generation cycle is constant and gives rise to change and transformation all the time.

Mutual restriction cycle The opposite of the mutual generation cycle, the mutual restriction cycle it refers to the manner in which the elements restrict and check each other. As a tree grows the roots break up the soil and drain the earth's minerals, thus controlling earth. The earth can be seen to contain water in many places, like the banks of a river, the earth controls the water. The water extinguishes fire and controls its spread. Fire exhibits control over metal during the forging process, only heat can tame the metal. The metal can then be shaped into an axe or saw, which can then be used to cut down the tree, thus controlling the wood. The cycle of control repeats endlessly in nature and in the human body, keeping the five elements in check, preventing over-functioning.

2 Peter Deadman and Mazin Al-Khafaji with Kevin Baker. "A Manuel of Acupuncture" Journal of Chinese Mediceine, 2007.

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Correlations within the Five Elements All phenomena occurring in the natural world can be grouped into one of the five elements according to their properties, functions and appearance, but other correlations can be made among them. Wood is a great example of this in nature and the body. In the season of spring when the climate is both windy and warm the tree germinates and begins to grow. Everything is green. We see the microcosm in the body. The Liver, which is tied to the element of wood, is responsible for spreading qi through the body the way the wind spreads pollen in the spring time. In the Chinese language the act is described as "sprinkling". The healthy liver is soft and light, like the grass of spring. The liver is also connected to the eyes and the gall bladder. When a person is suffering from a liver or gall bladder condition you can sometimes see it in their eyes and the color of their skin, they will yellow (jaundice) much like grass that will turn yellow when it is in distress. Applying the model to bodywork

The relevance of five-element theory to modern massage therapy lies in the association of the elements to internal organs, external parts and personality traits. The model on the following page demonstrates how each element is related to an organ, external body part and mental faculty. When illness is manifested in the organ, external body part or personality traits are overbearing or faculties diminished, it means that the element representing it is out of balance, either deficient or excessive.

The important thing to keep in mind with the TCM application of the five elements is that it is only a representative model, it is not literal.

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Five Element Model in Bodywork

Element Organ Bowel External Part

Opening Personality Trait

Faculty Taste

Water Kidneys Bladder

Bones Ears Fear Will Power Salty

Wood Liver Gall Bladder Nerves Eyes Anger Mental Activity Sour

Fire Heart & Sexual Glands

Small Intestine

Blood vessels

Tongue Arrogance and Impatience

Intuition, Joy, Peace

Bitter

Earth Spleen & Pancreas

Stomach Muscles Mouth Worry Pondering Sweet

Metal Lungs Large Intestine

Skin Nose & Sinuses

Sadness Orderliness and Rightness

Spicy

The yin-yang and five elements models represent the world outlook and methodology of the ancient Chinese for their understanding and explanation of nature. The application of these two theories to Chinese medicine consists of viewing the phenomena of nature and applying it to the study of the activities of the human body. Yin-Yang theory and the five element model can best be described in western language as the need for homeostasis, which western medicine defines as the property of a living organism to regulate the processes of the body in order to maintain a stable, healthy condition.

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Meridians Thus far we have been introduced to the Yin-Yang, the belief that the natural world (including us) is comprised of opposing yet complimentary forces in constant motion. We have also seen that this dynamic force is further broken down into five key categories, or elements, based on their manifestation in the physical world. The next step in our journey through TCM is to learn about the Meridians. The Meridians are a series of channels, or energy pathways, that traverse the human body. TCM seeks to identify patterns of disharmony (such as illness or emotional distress). It is believed that disharmony (and therefore, disease) are caused by a disruption in the body’s energy flow along one or more of the meridians. To correct these disruptions specific points on the meridians are stimulated. These points are called tsubo, or acupoints. They can be stimulated by a variety of means, including Acupuncture and Massage. The meridian network can be compared to a system of highways, roads and streets that link major cities. The highways (meridians) and the cities (organs) make up an entire map (the body). It is through this system of energy highways that qi runs. For example, if a city's internal streets are congested with traffic, eventually this situation will cause a traffic jam with the freeway leading into the city. If the traffic condition continues to deteriorate, even the cities connected by the major highways will experience a issues. If the traffic to these cities is blocked, one or more of the cities will suffer. This analogy offers a powerful visual tool for understanding how energy blockages in meridians can cause problems in organs, manifested as disease. In addition to moving qi, meridians also transmit information in manner similar to nerves. It is through the meridians and the flow of qi that the various parts of the body communicate with each other and coordinate the needs of the body with its resources.

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"As long as qi flows freely through the meridians and the Organs work in harmony, the body can avoid disease."

The Primary Meridians and Acupoints The specific areas on the Meridians that can be stimulated to correct the flow of energy in these meridians are referred to as Acupoints. These are the places that are targeted during an acupuncture or acupressure massage session. Our qi begins its flow in the lungs, then travels to the large intestine. From there it goes to the stomach, then to the spleen. Next it travels to the heart, then to the small intestine. Next it goes to the urinary bladder and the kidneys. After this it heads toward the pericardium and the sanjiau (also known as the triple burner). Finally it goes to the gall bladder, then the liver, then back to the lungs where it starts its circular journey again.

Primary meridians are those that pass through our internal organs, while the secondary meridians do not. There are twelve pairs of primary meridians flowing in a never-ending circle. These twelve primary meridians are symmetrical on the right and left sides of the body, and they all interconnected with each other: Lung Meridian Colon Meridian Stomach Meridian Spleen Meridian Heart Meridian Small Intestine Meridian Urinary Bladder Meridian Kidney Meridian Pericardium Meridian Triple Burner Meridian Gall Bladder Meridian Liver Meridian

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For a healthy person, the qi travels smoothly through each of the organs at a specific time of the day:

Lungs 3 A.M. - 5 A.M.

Large Intestine 5 A.M. - 7 A.M.

Stomach 7 A.M. - 9 A.M.

Spleen 9 A.M. - 11 A.M.

Heart 11 A.M. - l P.M.

Small Intestine 1 P.M. - 3 P.M.

Urinary Bladder 3 P.M. - 5 P.M.

Kidneys 5 P.M. - 7 P.M.

Pericardium 7 P.M. - 9 P.M.

Triple Burner 9 P.M. - 11 P.M.

Gall Bladder 11 P.M. - l A.M.

Liver 1 A.M. - 3 A.M.

The meridian clock is a multidimensional energetic model used in the practice of Chinese medicine, it is an incredibly complex system that we will attempt to present in the simplest terms.

The meridian clock was first represented in the classic Taoist texts I Ching and Nei Jing. It is a way of viewing the flow of qi energy through the body along its timetable.

More than just a map of energy as it travels the body, the Meridian Clock also presents the complex interactions and relationships of the different meridians to each other.

The illustration below is one example of the Meridian Clock. Many other forms of this representation can be found in use in acupuncture and acupressure practices in China and the United States.

The individual Meridians and their unique natures are discussed in much more detail in: ABS002: Introduction to Meridians and Acupoints. The application of this in Massage is demonstrated in ABS003: Tenets of Zen Shiatsu.

An ancient Taoist scroll depicting the flow of qi energy through a meridian. Similar charts are still in common use in acupuncture and shiatsu practices around the world.

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The Six Evils The six climatic evils are Wind Cold Summer Heat Dampness Dryness and Fire. They have the following attributes: They are related to the seasons or working environment. Generally there are wind diseases in spring, summer-heat diseases in summer, damp diseases in late summer and early autumn, dry diseases in autumn, and cold diseases in winter. People that work or live in a damp environment tend to be easily attacked by the damp evil, and those who work long in an environment of relatively high temperatures can be easily attacked by the dry-heat evil or fire evil. All evils can work alone or together in attacking the body Sometimes medical problems can result from a combination of evils. A good example of this is the common cold of wind-cold type, damp-heat diarrhea, and wind-cold-damp blockage. In the course of causing disease, any one of the six evils can influence the others and can also morph into a different kind of evil under the right conditions. Here is an example: The cold evil that enters the body's can morph into the heat evil, and the long-persisting summer-heat with dampness can change into dryness evil. The six climate related evils enter the body through the spaces located between skin and muscle, or the openings like nose and mouth and this is why we refer to them as the "six exogenous or outside evils". Special Conditions The form the six evils take is different for each person. A person in good health may not even be affected by them at all. The evils will only be able to mount an attack on a body in an area that is weak and under defended, like when the protective qi is deficient. The preventative nature of TCM is aimed at helping the body to resist such attacks. The kinds of diseases caused by the six evils are most likely to be brought on by exposure to inclement weather. This is most often the case when the

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change is sudden, and the body is unprepared for the change. This is why people that travel from one climate zone to another are more likely become ill. Plague was a major problem in ancient China, therefore TCM learned about epidemic diseases early on. They blamed the plague on pestilential evils. This idea of pestilential evil is basically a pathogenic factor with an intensified communicability rate. Outbreaks of pestilential evils are usually related to unusual climates such as droughts, floods, extreme heat as well as pollution. Wind Wind is of the element wood and is dominant in the springtime. Suwen (The Book of Plain Questions) says, " The wind evil can hide in the skin. It causes cold symptoms and sweating when the subcutaneous tissue is loosened, it causes heat symptoms but no sweating when the subcutaneous (means beneath the skin) space is closed." In the spring, the body is unaccustomed to the warm temperatures and the pores dilate easily, making it easier for evil-wind excess to enter the body. Wind injuries are commonly seen as coughing, head ache, runny nose and sneezing. The Wind evil often combines with heat or cold (producing “Wind-heat or Wind-cold”) and can produce symptoms of both heat and cold excess. There is also the internal wind which has nothing to do with the climate, it stems from the heart, liver or kidneys and is due to energy imbalance. Injuries caused by this “Inner-wind” include fainting, weakness, nervousness and achy sore muscles and joints. Characteristics of the Wind Evil: � The wind is the leading evil of all diseases. � The wind evil possesses a penetrating ability. � Wind is characterized by constant movement, moveable and

changeable. � Upward and outgoing dispersion is a yang pathogenic factor.

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The symptoms of wind-injury can mimic the nature of wind itself in that it can come about in “gusts”. Things like migraines, rheumatic joint issues and skin rashes that come and go. Cold Cold is closely associated with water and is most prevalent in winter. Cold is described as a “yin evil” and it enters the body’s yang qi. When cold has entered the exterior surface of the body it can make symptoms like fever, headache or general body pain. If it penetrates into he meridians it can make muscle cramps and pains in the joints. If it gets as deep as the internal organs you could expect to see diarrhea, vomiting and abdominal pain. The presence of “inner-cold” is caused by a deficiency of yang-energy and this can be seen in coldness of the limbs and a pallid complexion. Eating large amounts of cold foods (energy cold, not temperature cold) can cause inner cold. Common examples of “energy cold” foods are green tea, eggplant, tomato, celery, and barley. Characteristics of the Cold Evil: � Being a yin-evil, cold tends to impair yang-qi. � It is the nature of cold to congeal and stagnate. � It is the nature of cold to contract and shrink.

Summer-heat Summer-heat is of the element fire and is dominant during the season of summer. Some of the common symptoms of summer-heat are excess body temperature, parched throat, constipation and heart palpitations. Summer-heat combined with dampness produces abdominal pains, vomiting and other intestinal discomforts. Characteristics of the Summer Heat Evil: � Summer-heat belongs to the yang evils; it is hot in nature. � The summer-heat evil is characterized by ascension and dispersal; it

can consume qi (vital energy) and impair body fluid. � The summer-heat evil often mingles with pathogenic dampness.

Dampness Dampness is generally related to the earth element and is the most active in the late summer months. The symptoms related to excessive dampness can be triggered by exposure to fog, immersion in water or rain and living in

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damp climates. The symptoms can include aching joints, lethargy, and heaviness in the chest. And of course there is also "Inner-dampness", which is caused by over consuming greasy foods, sweets and liquors. These all impede the functions of the spleen and cause symptoms of abdominal swelling, vomiting and diarrhea. Characteristics of the Damp Evil: � The damp evil is related to heaviness and turbidness. � The damp evil belongs to the yin evil, and it tends to disturb the

functional activities of qi (vital energy) and injure the yang-qi. � Dampness is characterized by stickiness and stagnation. � Dampness tends to descend and attack the yin sites of the body.

Dryness Dryness is of the Metal element and is the dominant evil autumn. There are two types of dryness, "cold-dryness" and "hot-dryness". Too much dryness can cause injures of the lungs, with symptoms of heavy coughing, blood in the sputum, dry nose and throat, and pains in the chest. The dryness evil can also interfere with the bodies natural balance of fluids, leading to dehydration. "Inner-dryness" is caused by an excessive loss of fluids due to too sweating profusely, vomiting, bleeding, and diarrhea. The use of certain herbal medicines which can induce sweating, vomiting, or purging of the bowels, can also induce inner-dryness, as can certain diets that offer “cleansing properties”. The usual symptoms are dry, wrinkled, skin, dry hair and scalp, dry mouth and cracked lips, dry stomach and hard, dry stools. Characteristics of the Dry Evil: � Dryness has a drying and puckering nature, and tends to impair the

body. � Dryness tends to impair the lungs.

Fire When any of the five evils become too extreme, they combine to become fire-evil. The symptoms are y more intense forms of those associated with the original evil, plus symptoms of extreme heat.

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"Inner-fire" can also be caused by excessive emotional activity or by over-indulgence in food, drink, and sex. Violent anger, for example, often causes a sensation of heat rising from the upper abdomen, where liver-fire is raging. Too much strong food and drink causes fire to collect in the stomach; while deep grief or passion will often cause it to rise to the lungs. Characteristics of the Fire Evil: � Pathogenic fire-heat is one of the yang evils and it flames upwards in

the body. � Fire is likely to consume qi (vital energy) and impair the body fluid. � Fire may produce wind and stir up the blood.

Fire is likely to cause sores and ulcers. Qi (Bioforce) Qi, pronounced "chee", refers to the natural energy of life. You may see it spelled "Chi" or even "Ki" in Japanese, it is that which animates the forms of the world. It is the vibratory nature of phenomena -- the flow and tremoring that is happening continuously at molecular, atomic and sub-atomic levels. The literal translation is “breaths”. There is no single word in English that adequately conveys the meaning of Qi, but the term Bioforce or Bioenergy are perhaps the closest. The concept of Qi is based on the ancient Chinese understanding of the natural world. Qi is seen as the most basic substance of which the world is comprised. Everything in the universe is composed of it and is formed by its movement. In TCM Qi in the human body is categorized in two ways, Congenital Qi and Acquired Qi. Congenital Qi is inherited from our parents; it is what we are born with. Acquired Qi is derived from out lifestyle, the food we eat and our exercise habits. Qi serves several vital functions within the body. Some of these functions are presented here:

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Catalyzing Processes

• Qi assists in transformations within the body, for example the transformation of food new cellular material.

Protective Functions

• Qi defends the body from external pathogens, such as bacteria and viruses.

Stabilizing the body

• Qi holds organs in their place, keeps Blood in the vessels, governs the removal of fluids.

Transporting material

• Qi is the foundation of all movement and growth in the body. Warming the body

• Qi helps to regulate temperature and provides warmth for the body. It is a fundamental belief in TCM that disease is caused by a deficiency or stagnation of Qi flow in the body. Qi stagnation and deficiency is treated in TCM by several means.

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Chapter 4: Different Modalities of Traditional Chinese Medicine The following portion of the course presents different modalities practiced by Traditional Chinese Medicine practitioners. Some of these are appropriate for massage therapists; others are definitely outside of our scope of practice. I will be sure to point out which ones are within our scope of practice and which ones are not. Acupuncture Acupuncture is a technique where by skilled practitioners apply different types of needle or instruments to stimulate certain points; through using various techniques to activate the circulation / propagation of meridian Qi to regulate the physical functions of the human body. 3 Acupuncture is among the oldest healing practices in the world. In the United States, where practitioners incorporate healing traditions from China, Japan, Korea, and other countries, acupuncture is considered part of complementary and alternative medicine (CAM). Acupuncture has been practiced in China and other Asian countries for thousands of years. Scientists are studying the efficacy of acupuncture for a wide range of conditions. Relatively few complications have been reported from the use of acupuncture. However, acupuncture can cause potentially serious side effects if not delivered properly by a qualified practitioner. The term “acupuncture” describes a family of procedures involving the stimulation of anatomical points on the body using a variety of techniques. The acupuncture technique that has been most often studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation. Practiced in China and other Asian countries for thousands of years, acupuncture is one of the key components of traditional Chinese medicine. Acupuncture became better known in the United States in 1971, when New York Times reporter James Reston wrote about how doctors in China used needles to ease his pain after surgery. American practices of acupuncture

3 O’Conner J and Bensky D (translators), Acupuncture: A Comprehensive Text, 1981 Eastland Press, Seattle, WA.

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incorporate medical traditions from China, Japan, Korea, and other countries. Acupuncture Use in the United States The report from a Consensus Development Conference on Acupuncture held at the National Institutes of Health (NIH) in 1997 stated that acupuncture is being “widely” practiced—by thousands of physicians, dentists, acupuncturists, and other practitioners—for relief or prevention of pain and for various other health conditions. According to the 2007 National Health Interview Survey, which included a comprehensive survey of CAM use by Americans, an estimated 3.1 million U.S. adults and 150,000 children had used acupuncture in the previous year. Between the 2002 and 2007 NHIS, acupuncture use among adults increased by approximately 1 million people. Acupuncture Side Effects and Risks The U.S. Food and Drug Administration (FDA) regulates acupuncture needles for use by licensed practitioners, requiring that needles be manufactured and labeled according to certain standards. For example, the FDA requires that needles be sterile, nontoxic, and labeled for single use by qualified practitioners only. Relatively few complications from the use of acupuncture have been reported to the FDA, in light of the millions of people treated each year and the number of acupuncture needles used. Still, complications have resulted from inadequate sterilization of needles and from improper delivery of treatments. Practitioners should use a new set of disposable needles taken from a sealed package for each patient and should swab treatment sites with alcohol or another disinfectant before inserting needles. When not delivered properly, acupuncture can cause serious adverse effects, including infections and punctured organs. Status of Acupuncture Research Although millions of Americans use acupuncture each year, often for chronic pain, there has been considerable controversy surrounding its value as a therapy and whether it is anything more than placebo. Research exploring a number of possible mechanisms for acupuncture’s pain-relieving effects is ongoing. Some recent NCCAM-supported studies have looked at:

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� Whether acupuncture works for specific health conditions such as chronic low-back pain, headache, and osteoarthritis of the knee.

� How acupuncture might work, such as what happens in the brain

during acupuncture treatment � Ways to better identify and understand the potential neurological

properties of meridians and acupuncture points Methods and instruments for improving the quality of acupuncture research

Acupuncture has been the subject of active scientific research both in regard to its basis and therapeutic effectiveness since the late 20th century. Any evidence on the effectiveness of acupuncture is variable and inconsistent for all conditions. An overview of high-quality Cochrane reviews suggested that acupuncture is effective for some but not all kinds of pain4. An overview of systematic reviews found little evidence that acupuncture is an effective treatment for reducing pain. It is generally safe when administered using Clean Needle Technique (CNT) but there is a low risk of adverse effects, which can be serious, including death in rare cases. An editorial in Nature found TCM to be largely pseudoscience, with no valid mechanism of action for the majority of its treatments. Although minimally invasive, the puncturing of the skin with acupuncture needles poses problems when designing trials that adequately control for placebo effects. Publication bias is listed as a concern in the reviews of randomized controlled trials of acupuncture. Since most trials found "sham" acupuncture may be as efficacious as "real" acupuncture, the validity of traditional acupuncture theories including acupuncture point locations has been questioned. Some research results are encouraging but others suggest acupuncture's effects are mainly due to placebo. It remains unclear whether acupuncture reduces pain independent of a psychological impact of the needling ritual. Scientific investigation has not found any histological or physiological correlates for traditional Chinese concepts such as qi, meridians, and acupuncture points, and some contemporary practitioners use acupuncture

4 "Acupuncture for pain: An overview of Cochrane reviews". Chinese Journal of Integrative Medicine

This study has been included with this course as part of our objective evidenced based research.

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without following the traditional Chinese approach and have abandoned the concepts of qi and meridians as pseudoscientific5. Acupuncture is currently used widely throughout China and many other countries, including the U.S.. It is uncertain exactly when acupuncture was generally thought to have originated in ancient China and how it evolved. Traditional Chinese religion attributes the introduction of acupuncture to the god Shennong. Hieroglyphs and pictographs have been found dating from the Shang Dynasty (1600–1100 BCE) which suggests that acupuncture was practiced along with moxibustion. However, the tattoo marks identified on the Ice Man who died around 3300 BCE suggested that a form of stimulatory treatment resembling acupuncture developed independent of China. Acupuncture is the stimulation of precisely defined, specific acupoints along the skin of the body involving various methods such as the application of heat, pressure, or laser, or penetration of thin needles. In a modern acupuncture session, an initial consultation is followed by taking the pulse on both arms, and an inspection of the tongue. Classically, in clinical practice, acupuncture is highly individualized and based on philosophy and intuition, and not on controlled scientific research. The number and frequency of acupuncture sessions vary but most practitioners don't think one session is sufficient. In the United States, acupuncture typically lasts from 10 to 60 minutes, with diagnosis and treatment for a single session ranging from $25 to $80 in 2011. Sometimes needles are left in the ear for up to 3 days. Clinical practice varies depending on the country. A comparison of the average number of patients treated per hour found significant differences between China (10) and the United States (1.2). Traditional acupuncture involves needle insertion, moxibustion, and cupping therapy. Acupuncturists generally practice acupuncture as an overall system of care, which includes using traditional diagnostic techniques, acupuncture needling, and other adjunctive treatments. Chinese herbs are also often used.

5 Singh, S; Ernst, E (2008). Trick or Treatment: Alternative Medicine on Trial. London: Bantam. ISBN

9780593061299.

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Acupuncture needles are typically made of stainless steel, making them flexible and preventing them from rusting or breaking. Once needles have been used they are thrown away to prevent contamination. They are usually disposable, but reusable needles are sometimes used as well, though they must be sterilized between uses. Needles vary in length between 13 to 130 millimetres (0.51 to 5.12 in), with shorter needles used near the face and eyes, and longer needles in more fleshy areas; needle diameters vary from 0.16 mm (0.006 in) to 0.46 mm (0.018 in), with thicker needles used on more robust patients. Thinner needles may be flexible and require tubes for insertion. The tip of the needle should not be made too sharp to prevent breakage, although blunt needles cause more pain. Apart from the usual filiform needle, there are also other needle types which can be utilized, such as three-edged needles and the Nine Ancient Needles. Japanese acupuncturists use extremely thin needles that are used superficially, sometimes without penetrating the skin, and surrounded by a guide tube (a technique adopted in China and the West). Korean acupuncture uses copper needles and has a greater focus on the hand. Insertion of Needles The skin is sterilized, e.g. with alcohol, and the needles are inserted, frequently with a plastic guide tube. Needles may be manipulated in various ways, e.g. spun, flicked, or moved up and down relative to the skin. Since most pain is felt in the superficial layers of the skin, a quick insertion of the needle is recommended. Acupuncture can be painful. The skill level of the acupuncturist may influence how painful the needle insertion is, and a sufficiently skilled practitioner may be able to insert the needles without causing any pain. Obviously Acupuncture is outside of the scope of practice of massage therapists. However, Acupressure is a non-invasive somatic therapy that is well within our scope of practice and uses much of the same theory as acupuncture. Acupressure uses physical pressure applied to acupressure points by the hand, elbow, or with various devices. Acupressure Acupressure is an alternative medicine technique similar in principle to Acupuncture. It is based on the concept of life energy which flows through

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"meridians" in the body. In treatment, physical pressure is applied to acupuncture points with the aim of clearing blockages in these meridians. Pressure may be applied by hand, by elbow, or with various devices. Some medical studies have suggested that acupressure may be effective at helping manage nausea and vomiting, for helping lower back pain, tension headaches, stomach ache, among other things. It may probably not be as effective as acupuncture, but some claim it provides temporary relief. Acupoints used in treatment may or may not be in the same area of the body as the targeted symptom. The traditional Chinese medicine (TCM) theory for the selection of such points and their effectiveness is that they work by stimulating the meridian system to bring about relief by rebalancing yin, yang and qi. This theory is based on the paradigm of TCM. Many East Asian martial arts also make extensive study and use of acupressure for self-defense and health purposes. The points or combinations of points are said to be used to manipulate or incapacitate an opponent. Also, martial artists regularly massage their own acupressure points in routines to remove blockages from their own meridians, claiming to thereby enhance their circulation and flexibility and keeping the points "soft" or less vulnerable to an attack. A 2011 systematic review of acupressure's effectiveness at treating symptoms reported that 16 out of 23 studies had concluded that acupressure was effective, but that that the evaluation also "indicated a significant likelihood of bias" in the studies. A 2011 Cochrane review of trials using acupuncture and acupressure to control pain in childbirth concluded that "acupuncture or acupressure may help relieve pain during labour, but more research is needed". An acupressure wristband that is claimed to relieve the symptoms of motion sickness and other forms of nausea provides pressure to the P6 acupuncture point, a point that has been extensively investigated. The Cochrane Collaboration, a group of evidence-based medicine (EBM) reviewers, reviewed the use of P6 for nausea and vomiting, and found it to be effective for reducing post-operative nausea, but not vomiting. The Cochrane review included various means of stimulating P6, including acupuncture, electro-acupuncture, transcutaneous nerve stimulation, laser

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stimulation, acustimulation device and acupressure; it did not comment on whether one or more forms of stimulation were more effective. EBM reviewer Bandolier said that P6 in two studies showed 52% of patients with control having a success, compared with 75% with P6. One author of an article published in the Scientific Review of Alternative Medicine disagreed. A Cochrane Collaboration review found that massage provided some long-term benefit for low back pain, and said: It seems that acupressure or pressure point massage techniques provide more relief than classic (Swedish) massage, although more research is needed to confirm this. A variant system known as two point acupressure attempts to bypass a blockage of vital flow by using one acupoint to create a link with one of the collateral meridians, and then using one additional acupoint to stimulate or reduce the flow around the obstruction. Clinical use of acupressure frequently relies on the conceptual framework of Traditional Chinese Medicine (TCM). There is no physically verifiable anatomical or histological basis for the existence of acupuncture points or meridians. Proponents reply that TCM is a prescientific system that continues to have practical relevance. Acupuncturists tend to perceive TCM concepts in functional rather than structural terms (e.g., as being useful in guiding evaluation and care of patients). The most popular form of Acupressure is the Japanese massage modality known as Shiatsu. Shiatsu Shiatsu in Japanese means "finger pressure"; it is a type of alternative medicine consisting of finger and palm pressure, stretches, and other massage techniques. Shiatsu practitioners believe in a purported type of vital energy called qi that flows through the body, and that their manual manipulations can help to unblock it and so help the body heal itself. Tokujiro Namikoshi (1905-2000) invented shiatsu and founded the first shiatsu college in 1940. Acupressure and Shiatsu are legitimate forms of bodywork and are definitely appropriate for massage therapists and are worth further study.

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Both of which are discussed in much more detail and with video demonstrations in our course ABS:003 Tenets of Zen Shiatsu. In an effort to present as much unbiased information as possible we have included two articles entitled “The evidence for Shiatsu: a systematic review of Shiatsu and acupressure” and “The role of acupoint stimulation as an adjunct therapy for lung cancer: a systematic review and meta-analysis” Both articles are Open Access articles distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Please note that the Creative Commons License extends only to the article on pages 59-106, the rest of this course is covered by standard Copyright licensure. The evidence for Shiatsu: a systematic review of Shiatsu and acupressure Nicola Robinson, Ava Lorenc and Xing Liao © 2011 Robinson et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution Abstract Background Shiatsu, similar to acupressure, uses finger pressure, manipulations and stretches, along Traditional Chinese Medicine meridians. Shiatsu is popular in Europe, but lacks reviews on its evidence-base. Methods Acupressure and Shiatsu clinical trials were identified using the MeSH term 'acupressure' in: EBM reviews; AMED; BNI; CINAHL; EMBASE; MEDLINE; PsycARTICLES; Science Direct; Blackwell Synergy; Ingenta Select; Wiley Interscience; Index to Theses and ZETOC. References of articles were checked. Inclusion criteria were Shiatsu or acupressure administered

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manually/bodily, published after January 1990. Two reviewers performed independent study selection and evaluation of study design and reporting, using standardised checklists (CONSORT, TREND, CASP and STRICTA). Results Searches identified 1714 publications. Final inclusions were 9 Shiatsu and 71 acupressure studies. A quarter were graded A (highest quality). Shiatsu studies comprised 1 RCT, three controlled non-randomised, one within-subjects, one observational and 3 uncontrolled studies investigating mental and physical health issues. Evidence was of insufficient quantity and quality. Acupressure studies included 2 meta-analyses, 6 systematic reviews and 39 RCTs. Strongest evidence was for pain (particularly dysmenorrhoea, lower back and labour), post-operative nausea and vomiting. Additionally quality evidence found improvements in sleep in institutionalised elderly. Variable/poor quality evidence existed for renal disease symptoms, dementia, stress, anxiety and respiratory conditions. Appraisal tools may be inappropriate for some study designs. Potential biases included focus on UK/USA databases, limited grey literature, and exclusion of qualitative and pre-1989 studies. Conclusions Evidence is improving in quantity, quality and reporting, but more research is needed, particularly for Shiatsu, where evidence is poor. Acupressure may be beneficial for pain, nausea and vomiting and sleep. Background Shiatsu is a form of complementary and alternative medicine (CAM) which primarily developed in Japan [1]. Both Shiatsu and acupressure have roots in Chinese medicine and embrace the philosophy of Yin and Yang, the energy meridians, the five elements and the concept of Ki, or energy. This concept of affecting the balance of energy through acupoints on the meridians is similar to acupuncture where needles or heat is applied to acupoints [2]. 'Shiatsu' literally means "finger pressure", but uses gentle manipulations, stretches and pressure using fingers, thumbs, elbows, knees and feet. Shiatsu incorporates acupressure, which is similar but applies pressure for longer on specific pressure points on meridians, following Traditional Chinese Medicine (TCM) theory. Shiatsu tends to cover the whole body[3]. Shiatsu diagnosis is primarily through touch, rather than TCM which primarily uses the pulse diagnosis and inspection of the tongue. Shiatsu practitioners are trained in the anatomical location,

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functions and uses over 150 pressure points on the body. Evidence for the efficacy of acupressure may therefore potentially support claims about the efficacy of Shiatsu [4]. Shiatsu is practiced in many European countries but varies in styles, philosophical approaches and theoretical bases. The approaches most commonly found in Britain are Zen Shiatsu, Macrobiotic Shiatsu, Healing Shiatsu, Tao Shiatsu, Seiki, Namikoshi Shiatsu and Hara Shiatsu) [3,5]. Shiatsu aims to balance, restore and maintain the body's energy balance and prevent the build up of stress in the UK. The most common conditions presenting for treatment are musculo-skeletal and psychological problems[6]. Health problems which may be amenable to treatment by Shiatsu include: headaches, migraine, stiff necks and shoulders, backaches, coughs, colds, menstrual problems, respiratory illnesses including asthma and bronchitis, sinus trouble and catarrh, insomnia, tension, anxiety and depression, fatigue and weakness, digestive disorders and bowel trouble, circulatory problems, rheumatic and arthritic complaints, sciatica and conditions following sprains and injuries [3]. Shiatsu is, however, a holistic therapy and often also impacts a patient's well-being, lifestyle, diet, body/mind awareness [7]. Shiatsu is commonly used by older (median age of 50 in the UK) females [7]. This review aimed to identify the evidence base informing the practice of Shiatsu. Due to the lack of Shiatsu specific literature and overlap in practice and theory, acupressure studies were also included. Although there are a number of systematic reviews for acupressure, they were mostly confined to a single (Western) condition such as nausea and vomiting [8] or dysmenorrhoea [9]. Objectives To systematically review all papers using Shiatsu or acupressure for any health condition for any population, using either a systematic review/meta-analysis, RCT, quasi-experimental, or uncontrolled design. Methods Eligibility criteria Inclusion criteria were: • Shiatsu or acupressure administered manually/bodily

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• Meta-analysis, systematic review or clinical trial • Published after January 1990 Exclusions were: • Guidelines for treatment, reports of possible adverse events, surveys, case reports/series, non systematic reviews, qualitative studies, conference abstracts/posters • Newspaper articles, book reviews, 'popular' health publications, general comments or letters. • Papers included in systematic reviews included in this review • Papers in a language other than English • Use of plasters, devices, or wristbands • Acupressure on auricular or Korean points/meridians Information sources Databases searched were: EBM reviews (includes all Cochrane Library resources); Allied and Complementary Medicine (AMED);British Nursing Index (BNI);Cumulative Index to Nursing & Allied Health Literature (CINAHL); EMBASE; MEDLINE; PsycINFO/PsycARTICLES; Science Direct; Blackwell Synergy; Ingenta Select; Wiley Interscience; Index to Theses and ZETOC (British Library electronic table of contents). In addition the references of retrieved articles were checked to identify any further studies. Search The MeSH term tree 'acupressure' was used which incorporates Shiatsu. For databases not using MeSH terms, 'shiatsu' or 'acupressure' were used. Study selection Study selection was independently performed by two reviewers using the inclusion/exclusion criteria given above, followed by discussion and

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consensus within the research team. The first stage of selection used the abstracts, the second stage the full text of the papers. Data collection process For each study the following data was extracted independently by two reviewers using a standardised extraction form. Any disagreements were moderated by a third reviewer. • Authors • Date • Study design (meta analysis, systematic review, randomized controlled trial, case control trial or uncontrolled study) • Health condition • Setting • Sample • Intervention • Outcome measures • Results • Conclusion Quality assessment The contribution made to the evidence base by each study, based on the study design, rigour of methods and reporting, was evaluated independently by two reviewers, with an independent adjudicator. Studies were evaluated on the following quality indicators to determine its contribution to the evidence base: • The rigour of the study conducted was determined using a critical appraisal checklist [10]

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• Adapted STRICTA score for quality of reporting of the intervention (acupressure only, not Shiatsu) for each study [11] (reported as a score out of 16 relevant items - item 2 g on STRICTA, needle type was not relevant) • Quality of reporting, assessed using established checklists: CONSORT guidelines for RCTs[12]; CASP guidelines for systematic reviews [13]; and TREND statement for non-randomised studies [14]. • Study design (according to the hierarchy meta-analysis > systematic review > RCT > controlled trial > uncontrolled trial), as discussed in the NICE guidelines manual, section 6 [15]. Studies were graded A (good), B (fair/moderate) or C (poor) depending on these indicators. Results of this evaluation are given for each study in Additional file 1. Additional file 1. Table 1. This table contains details of each of the included studies Synthesis of results Studies were grouped into either Shiatsu or acupressure and within these categories according to health condition treated. For each health condition evidence was categorised according to criteria from Waddell [16]. Category 1: Generally consistent finding in a range of evidence from well-designed experimental studies Category 2: Either based on a single acceptable study, or a weak or inconsistent finding in some multiple acceptable studies. Category 3: Limited scientific evidence, which does not meet all the criteria of acceptable studies, or an absence of directly applicable studies of good quality. This includes published and unpublished expert opinion. This review has been reported according to the principles in the PRISMA statement [17] and acupoints are reported using the WHO system [18]

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Results Study selection After carrying out the database searches, a total of 1714 publications were identified (Figure 1). After duplicate items, newspaper articles and commentaries were removed 1285 items remained. From screening the abstracts 933 articles were excluded. Two reviewers screened the full texts of the remaining 351 articles using exclusion criteria and quality assessment and excluded 206. Of those remaining, 56 were used for background information only, leaving 89 studies. A further 9 were excluded as they were already included in systematic reviews included in this review. The total included studies were 9 Shiatsu and 71 acupressure publications. Figure 1. Flowchart of study selection. Details of included studies are presented in Additional file 1, grouped by health condition. Just under one third (27.5%) were graded A (highest quality), 42.5% graded B and 26.3% C (lowest quality) (3 studies were

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ungraded); this grading refers to the contribution the study made to the evidence, which took into account study design, rigour and reporting. Shiatsu Only 9 Shiatsu studies were of sufficient quality to be included in the review. These comprised 1 randomised controlled trial (RCT), three controlled non-randomised, one within-subjects trial, one observational study and 3 uncontrolled studies. These studies investigated quite separate health issues, did not use comparable methodology and data could not be pooled due to their heterogeneity. Subjects were chronic stress, schizophrenia, promoting well-being and critical health literacy, angina, low back and shoulder pain, fibromyalgia, chemotherapy side effects/anxiety and inducing labour. They are grouped by methodology and discussed below. One RCT was identified (integrated care, which included Shiatsu), for back and neck pain [19]. No significant effects, compared to standard care were identified. The study used a fairly large sample (n = 80) but was underpowered to detect any statistically significant effects. Three studies compared two or more treatments with non-random group allocation, rather by preference [20], participants in another study [21] or staff on duty [22]. Lucini et al [20] evaluated Shiatsu for chronic stress; 70 volunteer patients chose either active (relaxation and breathing training), passive (Shiatsu) or sham treatment (stress management information). Small sample, limited the validity of results. Although the design accounted for patient preference, results were confounded by more stressed patients choosing sham. Ingram [22] compared Shiatsu to no intervention for post-term pregnancy in 142 women. The Shiatsu group was significantly more likely to labour spontaneously than the control (p = 0.038) and had a longer labour (p = 0.03), but groups were allocated according to which midwife was on duty (although groups were homogenous for maternal age, parity and delivery details). Ballegaard et al [21] conducted a study of cost-effectiveness and efficacy of Shiatsu for angina pectoris. Sixty-nine consecutive patients were treated and compared with those from a separate trial of two invasive treatments for angina[23]. Incidence of death/myocardial infarction (MI) was 7% in this sample, compared to 21% and 15% in the comparison group with no significant difference in pain relief. Additionally a cost-saving of $12000 per patient was estimated. The groups were from different countries (USA and Denmark), additionally 56%

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of the participants would have been excluded from the one of the comparison groups. It also used a convenience and unpowered sample and no blinding. One study used a within-subjects repeated measures design, comparing Watsu (water Shiatsu) with Aix massage for fibromyalgia syndrome [24]. A significant improvement was seen after treatment with Watsu (p = 0.01) for SF-36 subscales of physical function, bodily pain, vitality and social function, but not for Aix. The repeated measures design with counterbalancing should reduce carryover effects although order effects may have occurred due to high dropout. In addition it used a volunteer sample. Three studies had no separate control group, using a single group pretest-posttest design[25-27], limiting the validity of results. Lichtenberg et al's [27] pilot study of Shiatsu for schizophrenia showed significant improvements on scales relating to illness, psychopathy, anxiety, depression and others (p values ranged from 0.0015 to 0.0192). Brady et al [26] tested Shiatsu for lower back pain in 66 volunteers. Pain and anxiety significantly decreased after treatment (p < 0.001), which did not change when demographic variables were controlled for. Iida et al [25] investigated the relaxation effects of Shiatsu on anxiety and other side effects in 9 patients receiving cancer chemotherapy. The small and self-selected samples and lack of control group in these studies limits the quality and generalisablity of the results. In addition 13 of Brady et al's [26] participants had previously received Shiatsu Long (2008) conducted a prospective observational study of 948 patients of Shiatsu practitioners in 3 different countries[7]. Significant improvement in symptoms, especially for tension or stress and structural problems (effect size 0.66 to 0.77) were demonstrated. This study is of greater quality than other Shiatsu studies as the sample size was powered and it used a longitudinal and pragmatic study design. For a longitudinal observational design, this study had a good response rate (67% of patients on average returned all questionnaires). Recruitment of patients was through practitioners, who received a rigorous training and kept a recruitment log. Confounding factors are reported and outcomes were accurately measured. However, data on non-respondents or those who refused to participate were not reported so evaluation of response bias is problematic.

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Sundberg et al [19] and Ballegaard [21] used a pragmatic design - Shiatsu as part of an integrated model of healthcare or with other interventions (acupuncture and lifestyle adjustment). This reflects normal practice but specific effects of Shiatsu cannot be isolated. There was insufficient evidence both in quantity and quality on Shiatsu in order to provide consensus for any specific health condition or symptom. Acupressure Of a total of 71 included studies described as giving acupressure as an intervention, 2 were meta-analyses, 6 systematic reviews, 39 RCTs, five crossover trials, 5 within-subjects trials, 5 controlled non-randomised, 7 uncontrolled trials and 1 prospective study. These are summarised by health condition below. Pain Pain was the most common issue addressed by acupressure studies and covered a range of topics. This included a systematic review, six RCTs with control groups and random assignment; 2 with non-randomised control groups or within-subject controls, and the remainder either did not have a control or random assignment. Overall, the evidence for the efficacy of acupressure for pain is fairly strong and can be graded as category 1 evidence. Although some studies had methodological flaws, studies consistently show that acupressure is more effective than control for reducing pain, namely dysmenorrhoea (acupressure at SP6) [9,28-30], lower back pain [31-33] and labour pain [34,35]. The evidence for minor trauma [36,37] and injection pain [38,39] is less conclusive and the evidence for headache is insufficient [40]. Each pain condition is discussed below. Dysmenorrhoea Of 4 papers for dysmenorrhoea, 1 was a systematic review 2 were RCTs, and one non equivalent control group. All studied school or university students, with sample sizes ranging from 30 to 216. Two used acupressure on SP6, The other used a combination of points. Both of the RCTs [28,30] compared acupressure to rest, which does not control for the placebo effect. Jun et al [29] compared acupressure to light touch, potentially controlling for non-specific effects but used sequential allocation which may create bias, although groups were homogenous in baseline demographics and dysmenorrhoea factors. All studies found a significant reduction in

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pain. Studies were generally good quality, with low attrition rates and validated measures (usually VAS). Only including students may limit generalisability and create Hawthorne bias. Acupressure procedure was generally well-reported; all studies reported 12 or 13 STRICTA items. Labour pain Two of the three studies of acupressure for labour pain were RCTs [34,35]. They both compared acupressure to touch, thus controlling for the effect of human touch; Chung et al [34] additionally had a conversation only control group. The third was a one group uncontrolled study [41]. Two studies usedLI4 [34,41]; Chung et al [34] additionally used BL67; Lee et al used SP6 [35]. All studies found acupressure significantly reduced pain, Back and neck pain Four studies on back or neck pain were identified, all RCTs and conducted by two groups of researchers, Hsieh et al [31,32] and Yip and Tse [33,42]. Hsieh et al unusually used a pragmatic design of four weeks of individualised acupressure compared to physical therapy. They also used powered samples, blinding where possible, valid outcome measures and intention to treat analysis to protect against attrition bias. A no treatment group was not included, limiting assessment of specific effects. Yip and Tse also compared acupressure to usual care, although an acupressure protocol was used. They also had powered sample sizes but no blinding. Comparison groups of aromatherapy and electroacupuncture, limit specific effects of acupressure. All four studies showed a significant reduction in pain. Minor trauma Two double-blind RCTs evaluated acupressure for minor trauma pain during ambulance transport [36,37]. Both used sham acupressure as a control, with Kober et al [36] additionally comparing to no treatment. Both studies showed significant reductions in pain, anxiety and heart rate. Limitations include fairly small sample and lack of no-treatment control. Injection pain Two studies evaluated acupressure for pain of injection [38,39]. Both studies showed reduction in pain but both were subject to limitations - Arai et al [39] only included 22 subjects although it was powered and randomised, with a sham treatment; Alavi et al's [38] trial was larger and

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randomised, but used a within-subjects crossover design which can create practice bias. Headache Only one study investigated headache [40], comparing a course of 8 sessions of acupressure to medication, which reduced pain. Although this used an RCT design, power calculation, intention-to-treat analysis, blinding and long follow up, there is very little detail on intervention (only 7 STRICTA items), randomisation, recruitment or limitations. Dental pain One RCT for dental pain [43] compared acupressure at LI4 to medication or sham acupressure, showing reduction in pain 4 and 24 hours after the first orthodontic treatment but not after second treatment. Although an RCT and well reported, only 23 patients completed the study, despite a power calculation specifying a sample of 156. Nausea & vomiting Nausea and vomiting (N&V) was the second most commonly investigated health issue. The evidence was somewhat inconsistent and varied with type of nausea investigated. Post-operative nausea had strongest evidence, graded as Category 1 evidence mainly due to a Cochrane systematic review and update [8,44] and a meta-analysis [45]. The two systematic reviews [46,47] of chemotherapy-induced N&V give additional quality evidence, although little is true acupressure. Little reliable evidence is added by the RCT [48]. The three studies of acupressure for nausea in pregnancy are of variable quality. Although one has a small sample and uncontrolled study design [49], a well conducted RCT [50]and meta analysis [51] provide Category 2 evidence for nausea in pregnancy. Post-operative A Cochrane review [44] (update of a previous review [8]) and meta-analysis [45] indicate the extensive evidence for acupressure in treating postoperative N&V. All the studies in the review and the majority in the meta-analysis used acupoint PC6. The review concluded that acupressure reduced the risk of both N&V compared to sham, and reduced the risk of nausea but not vomiting compared to antiemetic medication. The meta-analysis concluded that all modalities of acupoint stimulation reduced postoperative N&V compared to control, and were as effective as

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medication. Both reviews were very high quality with comprehensive search terms and pooling of data. Chemotherapy Acustimulation, including acupressure, for nausea as a side-effect of chemotherapy also has been reported in a Cochrane review [46], as well as an RCT published subsequently [48] and a non-randomised trial [52]. Chao et al [47] also covered N&V as part of their review of adverse effects of breast cancer treatment. The Cochrane review identified 11 trials and pooled data demonstrated significantly reduced vomiting but not nausea [46]. It was very good quality, with intention-to-treat analysis of pooled data and controlling for duplicate and language bias. The RCT (n = 160)[48] was based on a pilot [53] included in the Cochrane review. It found significant reductions in delayed N&V but not acute N&V, results facilitated by the unusually long follow-up period. The main limitations are the lack of sample size calculation (despite conducting a pilot study) and patients breaking the blind. The non randomised study [52] of self-acupressure on PC6 compared to anti-emesis medication found significant reductions in severity of N&V, duration of nausea and frequency of vomiting compared to control. However, these results are limited by a small and convenience sample. Pregnancy Three studies investigated N&V in pregnancy: one RCT [50]; one uncontrolled study [49] and one meta-analysis [51]. All used acupressure on PC6 (neiguan). As concluded by the meta-analysis [51], the RCT found improvements compared to sham or control. Shin et al's RCT [50] is excellent quality with double-blinding, powered sample size, objective and subjective outcomes and good reporting. Markose et al [49] also found improvements in nausea, vomiting and retching, but due to lack of control group, small sample, high attrition and poor reporting the evidence is limited.

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The meta-analysis included studies on all forms of acustimulation and was generally well conducted, although it did not attempt to find unpublished material and only 3 databases were used. Renal disease Five papers (based on four RCTs) investigated the use of acupressure for symptoms of renal disease. Due to limitations, repeated in all studies due to the common research team, evidence is category 2. Three compared acupressure to sham points/electrical stimulation and to usual care [54-56], the fourth to usual care only [57]. The studies used different points for different symptoms, including fatigue [55,57], depression [56,57] and sleep [54,56]. All studies showed improvements compared to control but also found improvements in the sham/electrical stimulation group compared to control, suggesting that the effects of acupressure on these symptoms are non-specific. Sample sizes were between 62 (powered) and 106 and had low attrition rates. One study used blinding [54], the others may have been subject to placebo or observer bias. Between 9 and 15 STRICTA items were reported and interventions and outcome measures were validated. Sleep and alertness Five studies investigated acupressure for sleep in elderly long term care facilities [58-62], and one investigated alertness in the classroom [63]. Evidence for improving sleep quality in institutionalised elderly is consistent from a number of high quality studies and is category 1. Four of the sleep studies were RCTs [59-62], an additional single-group pilot study of only 13 people contributes little to the evidence base [29]. The four RCTs all used different acupoints. Two compared acupressure to sham points and control (conversation [62]or routine care [60]) but only one found significant improvements in sleep for acupressure compared to sham [62], giving limited evidence for specific effects. Three of the studies had powered and randomly selected samples (between 44 and 246) [60,62], validated procedure [62], intention-to-treat analysis or triple blinding [60]. The one study on alertness in the classroom [63]was a crossover study, randomly assigning 39 students to either stimulation-relaxation-relaxation or relaxation-stimulation-stimulation. Compared to relaxation, stimulation acupressure improved alertness. Although students were blinded, the majority correctly discerned the treatment. This did not significantly affect the results, although it raised p to 0.0484. Potential Hawthorne effect, small sample size (39) and low generalizability reduce the quality. Crossover

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design should reduce effects of retesting, carryover or time-related effects, although practise effect may be present (especially with self-report). Mental health Five studies investigated mental health, specifically dementia [64,65] and stress or anxiety [66-68]. The quality was very variable, with two pilot studies with sample sizes of 12 and 31 [64,68], a small one group study of 25 women [67] and two larger RCTs [65,69]. Category 2 evidence was present for anxiety related to surgery, although this was compared to sham only[69]. Fairly good evidence existed for agitation in dementia compared to control, although generalisability was limited by small sample size, lack of control and high attrition[65]. Evidence for reducing stress, anxiety and heart rate and thus enhancing spontaneous labour is promising, but limited by lack of control and a small, volunteer sample [67]. Chronic respiratory conditions Six studies on respiratory conditions were identified, chronic obstructive pulmonary disease (COPD)[70-73], chronic obstructive asthma [74] and bronchiectasis [75]. Overall, the evidence is Category 2, as studies were well designed but had a number of methodological flaws. Study designs included two controlled trials using randomised blocking design, matching groups for demographic and clinical factors [71,72]; one crossover design [70]; two pilot RCTs [74,75] and an RCT [73]. Results showed improvements in dyspnoea and decathexis compared to sham, although limited by high attrition, poor blinding and a small sample [70]. The pilot studies (with the same authors) showed improved quality of life for asthma patients [74] and sputum and respiratory scores for bronchiectasis compared to control [75], but are limited by small sample sizes, high dropout and lack of blinding. The matched studies [71,72] provided high quality evidence for improvements in dyspnoea and related outcomes, with valid and reliable interventions and outcome measures, and blocking design giving more powerful treatment effects for small samples. Anaesthesia/consciousness Three studies investigated the effects of acupressure on levels of anaesthesia or consciousness. These levels include the acoustic evoked potential (AEP), changes in which reflect the depth of anaesthesia and transition from awake to anaesthetised [76]; bispectral index (BIS) and spectral edge frequency (SEF) which are measures of the level of consciousness during anaesthesia/sedation [77,78]. Overall, the evidence

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is Category 3 as only three studies were identified, all had repeated measures designs and small sample sizes (between 15 and 25), although one was powered [68,76-78]. Patients acting as their own controls in these studies can cause practice and carryover effects, although reduced by counterbalancing/randomising of treatment order. However, lack of control group and lack of details on sample selection limit the evidence. Stroke Three studies investigated acupressure for stroke [79-81]. All three were RCTs; Shin and Lee [80] used a blocked randomised design comparing acupressure to acupressure plus aromatherapy, Kang et al [81] randomised to acupressure or control groups; McFadden and Hernandez [79] used a crossover design comparing acupressure to control. Although studies used good designs and results suggested significant improvements in pain[80], motor power [80], limb function [81], daily living[81], depression [81], and heart rate [79], all findings were limited by small unpowered samples and poor reporting, so evidence is rated at Category 2. Body weight Two randomised studies investigated the effect of acupressure on body weight, although for very different conditions - weight loss [82] and weight gain in premature babies[83]. Elder et al's [82] RCT compared 'Tapas Acupressure Technique'® (TAT)1, qi gong and control (self directed support). TAT resulted in greater weight loss than both qi gong and control. Chen et al's[83] RCT compared acupressure and meridian massage to routine care, resulting in significantly more weight gain. The weight-loss study was high quality with a large sample, design-adaptive group allocation (equivalent to randomisation, but balanced for demographic and clinical factors). The weight gain study was randomised and matched for weight and gestation age and used blinding (although details are not clear), but had a small sample size and lack of information on randomisation, allocation, drop outs, harms and ethics. The evidence for weight loss/gain is Category 2 as more studies are needed. Visual impairment Two non-randomised studies from China and Taiwan evaluated acupressure for schoolchildren with visual impairment [84,85]. Both found improvements compared to control but were limited in reporting of study design and findings and did not randomise. With only 2 studies, both with

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significant limitations, the evidence for acupressure for improving eyesight is Category 3. Other conditions The remaining 11 articles on acupressure investigated distinct health conditions which could not be grouped. A systematic review evaluated the effect of acupoint stimulation for side effects of breast cancer treatment[47]. 26 studies were identified, concluding that evidence is high quality for nausea and vomiting but weak for all other adverse effects. It was well conducted with appropriate inclusion criteria, Jadad scale for rating and two independent raters. Ballegaard et al [86,87] studied acupressure for angina. The 1999 study [86] was a cost benefit analysis and used non-equivalent control groups, a volunteer and convenience sample and used co-interventions of acupuncture and the self-care program. The 2004 study [87] had a good sample size although subjects were not randomised, the follow-up period was long, but no equivalent control group or blinding. Again, it was difficult to isolate the effects of acupressure from co-interventions. At baseline the sample did not significantly differ to Scandinavian heart patients. This 'quality control review', is subject to selection, expectation and social biases. Gastrointestinal motility was studied by Chen et al [88,89], with significant improvements demonstrated. In [88], although the intervention was well reported, randomisation is not described (although groups were homogenous for a range of variables). In [89] the sample was small and not powered and the study was single-blind, although groups were homogenous. Significant effects were observed. A poorly reported study observed that acupressure on PC6 significantly reduced gagging in 109 dental patients [90]. The study was described as double-blind although blinding procedures were not described. Details of the sampling were not available. In a comparison of acupressure with oxybutinin for nocturnal enuresis in children[91], the main flaw was the very small sample size, with no details of sampling, comparison of groups or randomisation, potential selection bias and no placebo/sham group.

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A controlled trial of acupressure for 30 patients with peripheral arterial occlusive diseases (PAOD) reported a significant reduction in transcutaneous oximetry[92]. This is a poor quality study with an apparent lack of randomisation and non-equivalent control group, poor reporting and no comparison of groups, although outcomes are objective and intervention is well reported. A high quality RCT of acupressure for symptoms of diabetes found improvement in Hyperlipidemia, hypertrophy and kidney function [93] Acupressure was given regularly for 3 years, an unusually long follow up period and showed improvements in hyperlipidemia, ventricular hypertrophy, kidney function and neuropathy. The sample size was appropriate (although fairly high attrition) and group allocation was random. Very good description of treatment was provided (14 STRICTA items reported) although discussion is limited. Yao et al [94] conducted a single group study of massage combined with acupressure for 85 patients with chronic fatigue syndrome. Treatment was effective in 91.8% of cases. This study did not use any clear outcome measures, had no control, and only reported 7 STRICTA items, and given its poor reporting it is low quality. An uncontrolled pilot study was conducted of vaginal acupressure for sexual problems[95]. This showed significant improvements in symptoms, physical health, mental health, sexual ability and quality of life. This study is severely limited by small sample, lack of control, no details of recruitment, unvalidated and subjective outcome measures and poor reporting of acupressure. In addition the intervention did not appear to be based on meridian theory. Sugiura et al [96] conducted an uncontrolled study with 22 healthy volunteers of the effects of acupressure on yu-sen, souk-shin and shitsu-min on heart rate and brain activity. Heart rates decreased. This study investigated mechanisms rather than effectiveness. Analysis/Summary of quality Twenty-two of the 80 included studies were graded C (the lowest quality grading). All five of the studies in Chinese language were graded C (or ungraded), and most of the Shiatsu studies were graded C. Analysis of

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results over time suggests some improvement in the evidence base. Figure 2 shows an improvement in the average number of STRICTA items reported by studies, shown by the line of best fit. Figure 3 indicates a reduction in the percentage of C graded papers over time, and an increase in those graded B. Figure 4 shows the numbers of studies and numbers of studies for each A/B/C grading for the different countries. This shows no obvious trend, although countries publishing more studies (Taiwan, USA and Korea) seem to have better quality studies, compared to countries with only one or two publications. Regarding quality appraisal, in a third of papers, a third reviewer was need to reach agreement on quality grading. Figure 2. STRICTA scores over time.

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Figure 3. Chart of study quality over time. Figure 4. Country of study.

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Discussion Summary of evidence These findings provide an important addition to the existing knowledge base on Shiatsu but are very limited in providing any evidence of efficacy for Shiatsu. To our knowledge this is the first systematic literature review for shiatsu. The strongest evidence for acupressure was for pain, post-operative nausea and vomiting, and sleep. Study design & quality While much of the research is of insufficient quality to provide consensus on Shiatsu or acupressure use, some high quality clinical research (particularly around pain) does exist. The methodological limitations of the studies reported in this systematic literature review included small sample sizes, non-reporting of follow up, insufficient details on sampling, high drop-out rates, uncontrolled design and lack of blinding. Many studies were also underpowered. Although most studies were RCTs, many studies used a controlled design but controls were non-randomised (8), crossover (5) or within-subjects (6) or they were uncontrolled (10), or observational (1). Lack of randomisation, allocation concealment and comparable treatments can create bias as non-randomised controlled trials can be subject to confounding factors such as time-related or seasonal bias. Evidence for Shiatsu is thus severely limited as only 3 of the 9 studies used a control group, one of which was non-random, with two pilot studies. Crossover designs may be subject to practice effect, especially for self-administered acupressure. Within subjects repeated measure designs can also be subject to learning, and are only useful for stable populations such as those with a chronic disease or healthy volunteers (as used by studies on anxiety, dementia and consciousness in this review). One-group uncontrolled studies are of limited value due to a range of potential confounding variables. Longitudinal designs such as [7] are useful to evaluate effects of a treatment, but again causality cannot be implied, and there is increased risk of Hawthorne effect or conditioning. Well-conducted randomised trials are therefore more likely to have internal validity and thus accurately estimate the causal effects of interventions than non-randomised studies [15]. However, certain study designs are more appropriate for certain interventions and populations[97] and contention is emerging about how complementary medicine should be

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evaluated[98-103]. The complexity of interventions such as Shiatsu, including their patient-centred and individualised nature, practitioner and non-specific effects, the influence of patient choice, and potential synergistic effects require innovative evaluative approaches. Most studies used a small number of acupoints for a specific condition or symptom in a protocol approach, which facilitates replicability[104]. MacPherson et al [105] identify three levels of individualisation in acupuncture: "explanatory" trials which use the protocol approach; partially individualised treatments using some fixed points plus some flexible point choice; and "pragmatic" trials which use fully individualised treatment unique for each patient, as used in Shiatsu/TCM treatment[105]. Pragmatic trials can be highly valuable, for example the trial of acupuncture for back pain which informed NICE clinical guidance in the UK[106]. There was an improvement in the quality/reporting of papers over the time period searched. This may have been due to a greater appreciation of research amongst practitioners, advances in research methods in acupressure/shiatsu and the recent publication of a number of guidelines on presenting research such as the CONSORT, STRICTA and TREND statements used in this review [11,12,14]. The reporting of studies was very limited for many papers, with items most commonly missing from the CONSORT checklist including: 1a (identification as RCT in title); 16 (numbers of participants included in each analysis); 6b (changes to trial outcomes); 8,9 and 10 (details of randomisation procedure); 14b (why the trial was ended); and 23 and 24 (registration number and full protocol access) [12]. The average of 10.09 (63%) of applicable STRICTA items reported is similar to a previous review (53.4%) [107]. The increase in the number of STRICTA items reported over time is likely due to the gradual adoption of the STRICTA guidelines published in 2001 [11,107]. In common with this previous review the items most commonly missing were details of practitioner background, setting/context and explanations to patients, as well as amount of pressure used (equivalent to depth of insertion of needle), style of acupressure, de qi or the extent treatment was varied, perhaps less relevant to acupressure than acupuncture. Awareness of STRICTA guidelines is likely to be the key factor[107].

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Implications for practice For conventional practitioners Many of the conditions with the strongest evidence (pain, post-operative nausea and vomiting, and sleep) are side effects of or challenging symptoms for conventional medicine suggesting that an integrated treatment approach may be of benefit. Conventional healthcare practitioners may therefore consider acupressure, in particular: SP6 for dysmenorrhoea; PC6 for N&V postoperatively, in chemotherapy and pregnancy; combinations of ST36, SP6, KI1, KI3, HT17, KI11 and GB34 for renal symptoms; a range of points for COPD; HT7 and other points for sleep in elderly residents; and perhaps GB20, GV20, HT7, PC6 and SP6 for agitation in dementia. The evidence for protocol-based treatment supports suggestions that nurses incorporate acupressure and Shiatsu into their practice, in particular for pain relief, fatigue in cancer, augmenting effects of medication, providing comfort and improving breathing [108-110]. Shiatsu could be effectively delivered in general practice but further research in clinical and cost effectiveness is warranted [111]. For shiatsu/CAM practitioners While much of the research carried out with Shiatsu or acupressure as an intervention is of insufficient quality to inform practice, the high quality evidence for pain, post-operative nausea and vomiting, and sleep may be of use to Shiatsu and acupressure practitioners. These symptoms highlight the value of acupressure/Shiatsu as a complementary approach to conventional treatment. The findings relating to protocol-based acupressure may not directly inform the evidence base for more individualised and holistic treatments. However, the evidence for a specific acupoint for a specific symptom/condition can be integrated into an individualised treatment by combining with points suited for the individual. Hsieh et al provide pragmatic evidence for individualised treatment for low back pain and headache [31,32,40]. Some studies also supported the long-term effects of acupressure/Shiatsu, for example for headache [40], low back pain [31,32], and nausea and vomiting [48]. This review has highlighted the contention around the specificity of CAM treatments. Acupressure was often effective compared to control but not sham or medication, suggesting that effects are non-specific. Examples include labour pain [34], dysmenorrhoea [112], renal symptoms of fatigue,

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depression and sleep [54-56,59] and nausea and vomiting [8]. However, other studies found effects compared to sham treatment for similar conditions [8,35-37,47,62], and patient's belief in treatment may not affect results [63], suggesting specific effects. This review therefore provides little clarity on specificity of effects. Shiatsu is an inherently safe treatment [113]. Four single case reports of adverse events occurring following Shiatsu massage were identified (not included in review)[114-117] as this review focussed on efficacy rather than safety these findings were incidental and there are likely to be more reports on safety. This is an important area for the profession regarding safety issues and possible causal links between Shiatsu and adverse events. Professional bodies for Shiatsu may need to consider the development and piloting of an adverse event reporting system for Shiatsu. Work by Andrew Long provides a useful typology of adverse effects [118]. These are: Type 1: Responses unconnected to the CAM modality; Type 2: Transitional effect (client-perceived and theory-consistent); Type 3: Transitional effect (theory and experientially consistent); Type 4: Undesired, but not unsafe event or effect; Type 5: Potentially adverse event or effect and possible risk to client safety. This typology could be utilised in future studies. Implications for research The research base for Shiatsu is still very much in its infancy and the profession will need to work closely with practitioners and researchers in order to build up a larger body of evidence. Given the prevalence of Shiatsu used in the UK (820 registered practitioners/teachers/trainee teachers2), the need for high quality research is imperative. Shiatsu practitioners should be encouraged to engage in research using well designed and reported studies, in particular with large samples and controlled designs. Results have highlighted that alternative RCT designs may be necessary, such as: • Whole systems research, which includes qualitative and quantitative methods to include the broader aspects of treatment, not just the intervention[119,120]

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• Mixed-methods research, as qualitative data can provide additional information on patients' and/or practitioners' views on the effectiveness of treatment. Many studies are including such qualitative data as part of their design to provide a broader picture of patient outcomes [119]. • Preference trials, which include patient choice of treatment, often important in CAM, producing more generalisable results, such as in the study by Lucini [20], • Early phase research or pilot studies to generate hypotheses, identify the most appropriate health conditions, patient groups and treatments to test in full clinical studies[121], given the limited evidence base for Shiatsu. • A pragmatic design as used by some studies in this review. Pragmatic trial design overcomes some of the barriers of conducting RCTs in CAM, including improved recruitment and providing patient-centred treatment as usual. Only six studies used a pragmatic design; three for shiatsu [7,19,86] and three for acupressure [31,32,87]. Examples of pragmatic trials are the cohort multiple randomised controlled trial [122] and health services research [101]. There is promising research using both a pragmatic approach to evaluate Shiatsu as part of an integrated or massage intervention [19,21,123]. A flexible protocol approach could be used to improve replicability[104]. • One of the main issues in RCTs of complementary approaches is the control treatment, for example the limitations of blinding and sham acupressure. The included studies have confirmed that "sham" acupressure including light touch at acupoints does have an effect. The highest quality evidence was from three armed trials which use sham treatment and an inert control, as advocated in acupuncture research[124]. Shiatsu (as distinct from acupressure) presents further complexities as treatments are based on Hara diagnosis and rarely if ever "standardised". This needs to be adequately reported in papers, following guidelines such as CONSORT or TREND. Although excluded from this review due to resource constraints, qualitative studies provide additional information on patients' and/or practitioners' views on the effectiveness of treatment [125-127]. Many studies now include such qualitative data as part of their design to provide a broader picture of patient outcomes.

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Particular areas to focus research, commonly treated with Shiatsu/acupressure include psychological and musculoskeletal conditions, in particular neck/shoulder, lower back problems, arthritis, depression, stress and anxiety[6]. There is also good evidence for sleep and symptoms of renal disease, but studies to increase the generalisability of these findings is necessary. Taiwanese researchers appear to have been most prolific in this area, as well as Korea and the USA. Given the increasing use of CAM in Europe more research based in European countries may be needed. Given the prevalence of Shiatsu used in the UK, the need for research is imperative. Use of quality guidelines such as STRICTA and CONSORT is advised to improve the reporting of studies, especially details of interventions, to provide replicability as well as to inform practice [11]. Strengths and limitations A wide range of databases was used to maximise the number of articles captured. This review used recognised quality checklists to evaluate studies and each was independently assessed by 2 reviewers, with fairly high inter-rater agreement, and with a third reviewer for adjudication. The checklists used to calculate the quality of the reporting of studies (CONSORT, TREND etc) were useful but do have limitations. In particular with such a broad range of study designs other than RCTs, the appropriateness of checklists for specific study designs is limited. For example the TREND checklist for nonrandomised study designs may require additional specific criteria for specific types of nonrandomised designs [14]. Searches were restricted to UK/USA databases due to resource constraints; including Asian databases may have added to the evidence. Language bias may also have been present, although some Chinese language studies were included. There was no attempt to find grey literature except searching for UK postgraduate theses; no contact was made with individual authors due to the large numbers of authors.

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As this review was not limited by health condition, the breadth of the included studies necessitated limiting inclusion by excluding studies prior to 1990. This may have created bias. As the quality assessment in a systematic review depends on contextual and pragmatic considerations, it was necessary to limit the number of articles reviewed due to time and resource constraints [97]. In particular, purely qualitative studies were excluded, which may have limited results given the now recognised value given to qualitative outcome measures, particularly in complex interventions such as Shiatsu. Conclusions This review identified very little Shiatsu research, suggesting well designed studies are needed. The evidence for acupressure and pain is generally consistent and positive. There is also evidence for acupressure improving sleep in institutionalised elderly. Acupressure studies for nausea and vomiting have been somewhat inconsistent, with strongest evidence for post-operative nausea, and may merit further research. Evidence for pain, nausea and vomiting and sleep support an integrated approach using acupressure for conditions problematic to conventional medicine. There is limited evidence for chronic respiratory conditions, especially COPD, and psycho-social aspects of health, anaesthesia and other health conditions. Evidence on specific vs non-specific effects is inconclusive. This review highlighted the challenges of conducting rigorous research into CAM, which are complex, individualised and patient-centred, but illustrates useful study designs such as pragmatic/flexible protocol, 3 armed with sham and no treatment, longitudinal and preference trials. Evidence appears to be improving in quantity, quality and comprehensive reporting, but there is still much room for improvement. Competing interests The authors declare that they have no competing interests. Authors' contributions XL conducted the searches and retrieved the articles. XL and AL reviewed the articles and NR was the adjudicator. XL and AL compiled the evidence tables. AL and NR wrote the introduction and discussion section. AL created the tables and graphs in the main text. All authors read and approved the final manuscript.

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Lancet 1993, 341:447. PubMed Abstract OpenURL Tsuboi K, Tsuboi K: Retinal and cerebral artery embolism after "shiatsu" on the neck. Stroke 2001, 32:2441. PubMed Abstract OpenURL Wada Y, Yanagihara C, Nishimura Y: Internal jugular vein thrombosis associated with shiatsu massage of the neck. J Neurol Neurosurg Psychiatry 2005, 76:142-143. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL Long AF, Esmonde L, Connolly S: A typology of negative responses: a case study of shiatsu. Complement Ther Med 2009, 17:168-175. PubMed Abstract | Publisher Full Text OpenURL Verhoef MJ, Lewith G, Ritenbaugh C, Boon H, Fleishman S, Leis A: Complementary and alternative medicine whole systems research: beyond identification of inadequacies of the RCT. Complement Ther Med 2005, 13:206-212. PubMed Abstract | Publisher Full Text OpenURL Giordano J, Garcia MK, Strickland G: Integrating Chinese traditional medicine into a U.S. public health paradigm. J Altern Complement Med 2004, 10:706-710. PubMed Abstract | Publisher Full Text OpenURL Aickin M: The importance of early phase research. J Altern Complement Med 2007, 13:447-450. PubMed Abstract | Publisher Full Text OpenURL Relton C, Torgerson D, O'Cathain A, Nicholl J: Rethinking pragmatic randomised controlled trials: introducing the "cohort multiple randomised controlled trial" design. BMJ 2010, 340:c1066. PubMed Abstract | Publisher Full Text OpenURL Wahner-Roedler DL, Vincent A, Elkin PL, Loehrer LL, Cha SS, Bauer BA: Physicians' Attitudes Toward Complementary and Alternative Medicine and Their Knowledge of Specific Therapies: A Survey at an Academic Medical Center. eCAM 2006, 3:495-501. PubMed Abstract | PubMed Central Full Text OpenURL Leibovici L: Alternative (complementary) medicine: a cuckoo in the nest of empiricist reed warblers. BMJ 1999, 319:1629-1632. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL Cheesman S, Christian R, Cresswell J: Exploring the value of shiatsu in palliative care day services. Int J Palliat Nurs 2001, 7:234-239. PubMed Abstract | Publisher Full Text OpenURL Chevalier D: The Role of Shiatsu in the Treatment of the Side-Effects of Chemotherapy. Shiatsu Society News 2007, 103:14-16. OpenURL Long AF, Mackay HC: The effects of shiatsu: findings from a two-country exploratory study. J Altern Complement Med 2003, 9:539-547. PubMed Abstract | Publisher Full Text OpenURL End of Article 1 Article 2 begins on the following page.

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The role of acupoint stimulation as an adjunct therapy for lung cancer: a systematic review and meta-analysis Hai-Yong Chen, Shi-Guang Li, William CS Cho and Zhang-Jin Zhang Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background Lung cancer is the leading cause of death in cancer patients. Clinical studies showed that a variety of acupoint stimulations have been extensively used for lung cancer patients, including needle insertion, injection with herbal extraction, plaster application, and moxibustion. However, the role of acupoint stimulation in lung cancer treatment was not fully reviewed. Methods In the present study, we conducted a systematic review and meta-analysis on the role of acupoint stimulation in lung cancer treatment by electronic and manual searching in seven databases, including Ovid (Ovid MEDLINE, AMED, CAB Abstracts, EMBASE), EBSCOhost research databases (Academic Search premier, MEDLINE, CIHAHL Plus), PreQuest (British Nursing Index, ProQuest Medical Library, ProQuest Dissertations & Theses A&I, PsycINFO), and ISI web of knowledge (Web of Science, BIOSIS Citation Index, Biological Abstracts, Chinese Science Citation Database), CNKI, Wanfang Data, and CQVIP. Results Our study showed that acupoint stimulation has strong immunomodulatory effect for lung cancer patients as demonstrated by the significant increase of IL-2, T cell subtypes (CD3+ and CD4+, but not CD8+ cells), and natural killer cells. Further analysis revealed that acupoint stimulation remarkably alleviates the conventional therapy-induced bone marrow suppression (hemoglobin, platelet, and WBC reduction) in lung cancer patients, as well as decreases nausea and vomiting. The pooled studies also showed that acupoint stimulation can improve Karnofsky performance status, immediate tumor response, quality of life (EORCT-QLQ-C30), and pain control of cancer patients.

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Conclusions Acupoint stimulation is found to be effective in lung cancer treatment, further confirmatory evaluation via large scale randomized trials is warranted. Background Acupuncture has been widely used for more than three thousand years in China. It is one of the key treatment modalities in traditional Chinese medicine (TCM), which is also based on the Yin-Yang, Channel and Collateral Theories. Accordingly to TCM theories, Yin-Yang imbalance is the basis of diseases and stimulation of certain acupoints along the collaterals can nurture the qi (or vital energy) and rebalance Yin-Yang in the body. Recently, acupuncture has been widely developed into a variety form of acupoint stimulation, including needle insertion, injection with herbal extract, plaster application, and moxibustion, etc. [1]. Previous studies have shown that acupoint stimulation can be used to treat a variety of diseases and symptoms, e.g. insomnia [2], depression [3], and pain [4]. In recent decades, TCM is regarded as a complementary therapy to cancer patients worldwide [5-7]. A number of literatures have reported that acupoint stimulation may be effective on symptom management [8,9], reduction of chemotherapy-induced side effects [10-12], and quality of life improvement [13] in cancer patients. Lung cancer is a leading cause of cancer mortality with 1.37 million deaths in 2008 worldwide. It is the most prevalent cancer in male and the fourth prevalent cancer in female. Conventional therapies for lung cancer include surgery, radiotherapy, chemotherapy, and targeted therapies (e.g. erlotinib and bevacizumab). Recently, the use of alternative and complementary therapies is increasingly widespread [14,15]. We have previously found that Chinese herbal medicine, as an adjunct therapy, has advantage in the reduction of side effects and improvement of symptoms in patients with non-small cell lung carcinoma [16]. Some clinical studies have also reported the use of acupoint stimulation as a treatment for lung cancer [17,18]. However, the role of acupoint stimulation in treating lung cancer is not thoroughly evaluated. Thus, we conducted a systematic review and meta-analysis on the efficacy of acupoint stimulation for lung cancer patients in the present study. Methods

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Selection criteria Included studies have to meet all of the following criteria: 1. Studies claimed as random allocation or showed the baseline data without significant difference (age, gender, and severity) among the intervention and control groups. 2. Studies had to use acupoint stimulation as the adjunct intervention, or had to use acupoint stimulation as the primary studying objective or evaluating purpose. 3. Studies had at least one control group with conventional therapies, placebo, or other appropriate controls. 4. Studies investigated at least one of the outcomes of interest listed below: i) Immunomodulation: changes in CD3, CD4, CD8 levels of T cell, natural killer (NK) cells, and IL-2 levels. ii) Bone marrow suppression: changes in hemoglobin, platelets, and white blood cells (WBCs). iii) Conventional therapy-induced side effect: nausea and vomiting. Judgment of vomiting grade was based on WHO toxicity reaction: grade 0: no nausea and vomiting; grade I: nausea; grade II: casual vomiting, not requiring medication; grade III: frequent vomiting, requiring medication; grade IV: serious vomiting, uncontrolled with medication. iv) Immediate tumor response: number of patients with complete response (CR) or partial response (PR) evaluated with the WHO scale. v) Performance status: the changes of Karnofsky performance status (KPS) scores. vi) Other quality of life assessments, e.g. EORTC-QLQ-C30. Databases Four major search engines were retrieved, including:

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1. OVID® (Ovid MEDLINE 1946 to January 2013, AMED 1985 to 2013, CAB Abstracts 1910 to January 2013, EMBASE 1996 to February 2013). 2. EBSCOhost research databases (Academic Search premier, MEDLINE, CIHAHL Plus, all to January 2013). 3. PreQuest (British Nursing Index 1994 to January 2013, ProQuest Medical Library from starts to January 2013, ProQuest Dissertations & Theses A&I from starts to January 2013, PsycINFO 1806 to January 2013). 4. ISI web of knowledge (Web of Science® 1956 to January 2013, BIOSIS Citation Index 2006 to January 2013, Biological Abstracts® 1980 to 2012, Chinese Science Citation Database 1989 to January 2013). The Chinese electronic databases were as the follows: 1. CNKI (China Academic Journals Full-text Database 1979 to January 2013, China Doctoral Dissertations Full-text Database 1984 to January 2013, China Masters’ Theses Full-text Database 1984 to January 2013, China Proceedings of Conference Full-text Database 1953 to January 2013). 2. Wanfang Data (1990 to January 2013). 3. CQVIP (1989 to January 2013). Search strategy Electronic databases were searched using the following strategy: Searching terms: (acupuncture OR acupressure OR acupoint OR massage OR meridian OR moxibustion OR moxa) AND (pulmonary cancer OR pulmonary carcinoma OR pulmonary adenocarcinoma OR pulmonary squamous cell carcinomas OR pulmonary neoplasms OR pulmonary nodules OR pulmonary tumor OR lung cancer OR lung carcinoma OR lung adenocarcinoma OR lung squamous cell carcinoma OR lung neoplasms OR lung nodules OR lung tumor OR non-small-cell lung carcinoma OR non-small-cell-lung carcinoma OR NSCLC OR small-cell lung carcinoma OR small-cell-lung carcinoma OR SCLC). Chinese language database was retrieved with similar search strategy. “AND” and “OR” are Boolean operators.

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Risk bias assessment Risk bias of studies was assessed using the Cochrane Risk of Bias Assessment Tool (http://handbook.cochrane.org/ webcite, part 2, chapter 8). All trials were reviewed by at least two reviewers (HYC and SGL) and any disagreement was resolved through the involvement of a third reviewer in consensus conferences. Data synthesis All analyses were performed with RevMan version 5.2 to quantify and compare the efficacy outcomes of the treatment versus the control groups. Dichotomous data were reported as relative ratio (RR) whereas continuous data were reported as standardized mean difference (SMD) ± standard deviation (SD). The random-effect model was employed when the study of heterogeneity (I2) was large than 50%, otherwise a fix-effect model was used when the I2 was less than 50%. To test the heterogeneity, subgroup analysis was performed according to the types of acupoint stimulation (needle insertion, acupuncture injection with herbs, acupoint plaster application, and moxibustion). The Z-test was used to compare the overall effects of the treatment groups and the control groups, differences were considered to be statistically significant when P < 0.05. Results and discussion 993 abstracts were retrieved with 155 duplications. 154 studies in full text were further examined. A total of 31 studies satisfied the selection criteria and were analyzed in the present study (Figure 1) and their characteristics are listed in Table 1. Acupoint stimulation varies from needle insertion, pressure, plaster application, and moxibustion to herbal extraction injection on the acupoints. The most commonly used acupoints were listed in Table 2. The risk of bias in the included studies was assessed as shown in Figure 2. The risk of bias in each study was shown in (Additional file 1: Table S1).

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Figure 1. Flow chart of study selection. Figure 2. Risk of bias assessment among included studies.

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Immunomodulation A remarkable increase in CD3+ T cell level was reported in patients treated with acupoint stimulation (SMD, 0.41 [95% CI, 0.20 to 0.62], P = 1E-4, 9 studies, 370 patients) (Figure 3A), and the heterogeneity test indicated no significant difference among those studies [20,21,27,29,36,39,42,46],[47]. Subgroup analysis showed that acupoint needle insertion (SMD, 0.35 [95% CI, 0.04 to 0.66], P = 0.03, 4 studies) and acupoint injection with herbs (SMD, 0.59 [95% CI, 0.12 to 1.07], P = 0.01, 2 studies) had advantage in improving CD3+ while acupoint plaster application (SMD, 0.22 [95% CI, -0.19 to 0.64], P = 0.29, 2 studies) had no significant advantage in CD3+ improvement.

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Figure 3. Immunomodulation of acupuncture in lung cancer patients.

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(A) CD3+ T cells; (B) CD4+ T cells. We also observed an improvement in the CD4+ T cell level (SMD, 0.61 [95% CI, 0.42 to 0.80], P < 1E-5, 10 studies, 459 patients) (Figure 3B) [20,21,27,36,37,39,42,44],[46,47]. Subgroup analysis showed that acupoint needle insertion (SMD, 0.50 [95% CI, 0.19 to 0.82], P = 0.002, 4 studies) and acupoint injection with herbs (SMD, 0.72 [95% CI, 0.17 to 0.83], P = 0.003, 2 studies) had advantage in improving CD4+ while acupoint plaster application (SMD, 0.50 [95% CI, 0.17 to 0.83], P = 0.003, 3 studies) had no significant advantage in CD4+ improvement. The CD8+ T cell level in patients treated with acupuncture has shown no significant difference compared with the control group (SMD, 0.0 [95% CI, -0.19 to 0.19], P = 1.0, 10 studies, 459 patients) (Additional file 2: Figure S1A) [20,21,27,36,37,39,42,44],[46,47]. Subgroup analysis showed that acupoint injection with herbs (SMD = −0.67, 95% CI = -1.15 to -0.20, p = 0.006, 2 studies) had advantage in lowing CD8+, acupoint plaster application (SMD, 0.21 [95% CI, -0.18 to 0.61], P = 0.29, 2 studies) had advantage in upregulating CD8+, and acupoint needle insertion (SMD, 0.0 [95% CI, -0.31 to 0.31], P = 0.99, 4 studies) had no significant advantage. Heterogeneity test indicated a significant difference among the acupoint needle insertion subgroup. After further removing any study among them, the acupoint needle insertion group still showed no significant alternation compared with the control groups. Additional file 2: Figure S1. CD8+, NK cells, and IL-2 in acupuncture treatment and control group. (A) CD8+, (B) NK cells, and (C) IL-2. Figure S2: Bone marrow suppression in acupuncture treatment and control group. (A) Hemoglobin, (B) Platelet, and (C) White blood cell (WBC). Figure S3: Effective response of nausea and vomiting in treatment and control group. Among them, two studies used needle insertion and the left used acupoint injection with herb extraction. Four studies used IL-2 as the outcome measurement to assess the efficacy of acupoint stimulation as an adjunct therapy for lung cancer [27,41,42,45]. The acupoint stimulation group showed a slightly better outcome than the control (SMD, 0.28 [95% CI, 0.01 to 0.55], P = 0.04, 4 studies, 220 patients).

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There was no significant difference in the baseline of CD3+, CD4+, CD8+ T cells, NK cells, and IL-2 between the acupoint stimulation and control groups as shown in Table 3. Bone marrow suppression The pooled study showed that the prevention against hemoglobin reduction was significantly in favor of the acupoint stimulation group (SMD, 0.40 [95% CI, 0.17 to 0.63], P = 7E-4, 5 studies, 296 patients) (Additional file 2: Figure S2A) [24,42,43,45,49]. There was no significant heterogeneity among these studies (P = 0. 64). The number of patients with decreased platelets was significantly reduced in the acupoint stimulation group (SMD, 0.28 [95% CI, 0.05 to 0.51], P = 0.02, 5 studies, 296 patients) [24,42,43,45,49]. The inhibition of WBCs in lung cancer patients with acupoint stimulation was significant reduced (SMD, 0.93 [95% CI, 0.44 to 1.42], P < 2E-4, 8 studies, 519 patients) [22,24,33,34,42,43,45,49], but there was a prominent heterogeneity among these studies (P = 1E-5) (Additional file 2: Figure S2C). Sensitivity test showed that removing any of the studies did not alter the patterns, however, there is still heterogeneity among the studies (data not shown). As shown in Table 3, there was no significant difference in the baseline of hemoglobin, platelets, and WBCs between the acupoint stimulation and control groups. Nausea and vomiting As shown in Figure 4, the occurrence of chemotherapy-induced nausea and vomiting at Grade II-IV was remarkably reduced in the acupoint stimulation group compared to the control group (RR, 0.46 [95% CI, 0.37-0.51], P = 1E-5, 8 studies, 501 patients) [19,20,25,26,28,41,42,45]. Subgroup analysis showed that acupoint needle insertion, acupoint injection with herbs, and moxibustion significantly attenuated the grade of nausea and vomiting (P = 0.02, P = 0.005, and P = 0.01, respectively).

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Figure 4. Effective responses of nausea and vomiting (vomiting grade II to IV). Clinical efficacy The immediate tumor response indicated that acupoint stimulation had a significant advantage compared to the control group (RR, 1.54 [95% CI, 1.15 to 2.07], P = 0.004, 3 studies, 148 patients) (Figure 5A) [20,38,49]. Two studies used acupoint injection with herb extraction and one used microwave treatment in the assessed studies.

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Figure 5. Clinical efficacy. (A) Tumor response; (B) KPS. The pooled KPS Scale showed a significant increase of clinical performance in the acupoint stimulation group compared to the control group (SMD, 0.76 [95% CI, 0.42 to 1.10], P < 1E-4, 9 studies, 508 patients) as shown in Figure 5B [25,33,38,41,42,44,45,48],[49]. However, the heterogeneity study showed a significant difference among these studies. Sensitivity test indicated a significant increase of KPS in the acupoint stimulation group with removal of anyone study in the nine studies. Subgroup analysis showed that acupoint injection with herb extraction, plaster application, and moxibustion had significant advantage in KPS

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without heterogeneity in studies (P = 0.0002, P = 0.001, and P < 0.0001 respectively). Acupoint needle insertion also had no advantage in KPS, but Zhou et al.’s study in the needle insertion group showed a high heterogeneity (P = 0.51, I2 = 79%) compared to the other two studies [48]. The baseline of KPS showed no significant difference between the acupoint stimulation group and the control group (Table 3). EORTC-QLQ-C30 also showed a total favorable score in the acupoint stimulation group compared to the control group (SMD, 0.47 [95% CI, 0.04 to 0.90], P = 0.03, 2 studies, 85 patients) as shown in Figure 6A [31,48]. In addition, the Visual Analog Scale had a significant improvement in the acupoint stimulation group compared to the control group (SMD, -1.13 [95% CI, -1.58 to −0.69], P < 1E-5, 2 studies, 92 patients) [20,32] (Figure 6). Figure 6. Quality of life assessments. QLQ-C30 total score. Discussion In the present study, we systematically reviewed the role of acupoint stimulation in lung cancer management. Our results showed that acupoint stimulation has immunomodulatory effect for lung cancer patients, which was demonstrated by a significant increase of IL-2, CD3+ and CD4+ T cells, NK cells, but not CD8+ T cells. Further analysis also revealed that acupoint stimulation remarkably reduces the conventional therapy-induced bone marrow suppression, enhances hemoglobin and platelets in lung cancer patients, and decreases the chemotherapy-induced nausea and vomiting. In addition, the pooled studies also showed that acupoint stimulation has an advantage in the improvement of performance status, immediate tumor response, and quality of life (EORCT-QLQ-C30). We found that acupoint stimulation enhances T cell subtype CD3+ and CD4+ cells, but not CD8+ cells. Subgroup analysis indicated that acupoint

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insertion and injection with herb extraction are able to elevate the total T cells (CD3+) and T helper cells (CD4+) in lung cancer patients. Acupoint plaster application enhances CD4+ T cells, but not CD3+ T cells. CD8+ is cytotoxic T cells which are one of the most effective immune cells to kill tumor cells [50]. Interestingly, our study showed that acupoint stimulation has no significant effect on the increase of CD8+ T cells compared to the control group. Subgroup analysis showed that acupoint needle insertion has no significant effect, while acupoint injection with herbs decreases CD8+ T cells and plaster application increases CD8+ T cells in lung cancer patients. Although some studies have shown that acupuncture may upregulate CD8+ expression in patients [51,52], there may be various mechanisms for the immunomodulatory effects of acupoint stimulation lung cancer patients. T helper cells (CD4+) have four subtypes, including Th1, Th2, Treg, and Th-17 cells. IL-23 is a newly identified cytokine that has close association with Th17. On the other hand, IL-23 has been shown to impair antitumor CD8+ T cells and dendritic cells transduced with IL-23 have the ability to trigger strong antitumor activity [50]. More importantly, our findings have indicated that acupoint stimulation upregulates IL-2 in lung cancer patients. It is in line with another study that acupuncture can enhance IL-2 expression by stimulation of acupoint ST36 in rats [53]. As shown in Table 2, ST36 is the most common acupoint used for lung cancer patients. Previous study has shown that IL-2 is necessary for the growth, proliferation, and differentiation of T cells [54]. A recent study has also demonstrated that IL-2 controls the balance between Th-17 and Treg cells in the tumor microenvironment [55]. It has been hypothesized that acupuncture may also upregulate NK cells in lung cancer patients. A number of studies have demonstrated that acupuncture is a strong immunomodulator of NK cells in animals and human [56-60]. Upregulation of NK cells may contribute to the antitumor effect in cancer patients [61]. Anemia, thrombocytopenia, and pancytopenia are the most common symptoms of bone marrow suppression during chemotherapy or radiotherapy. Our findings indicated that acupuncture reduces conventional therapy-induced bone marrow suppression, e.g. increase of WBCs, hemoglobin, and platelets, which is in accordance with other findings that acupuncture can improve bone marrow suppression during chemotherapy [62]. Although the mechanism remains largely unknown, previous studies have provided some possible mechanisms, for examples, acupuncture

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induces the erythropoietin expression [63] and bone marrow megakaryocytes [62]. Moreover, upregulation of IL-2 by acupuncture promotes the mature of T cells [54]. Subgroup analysis showed that acupoint needle insertion, injection with herb extraction, and moxibustion may play different roles in modulating WBCs, hemoglobin, and platelets. Reduction of side effects (SEs) is the main goal for using commentary therapies during conventional cancer treatments. Our previous studies have shown that Chinese herbal medicine has the advantage of minimizing chemotherapy-induced SEs in colon cancer [7], nasopharyngeal carcinoma [6], hepatocellular carcinoma [5], and non-small cell lung cancer [16]. These studies showed an alleviation of nausea and vomiting during TCM treatment, which is in line with our present findings that acupoint stimulation may reduce nausea and vomiting during lung cancer treatment. As acupoint stimulation has a neuromodulatory effect on GI motility and the mechanism involving endogenous opiates, it may be effective in treating chemotherapy-induced nausea and vomiting [64,65]. On the other hand, pain, cough, constipation, hair and weight loss are also common SEs during lung cancer treatment. However, no pooled data was analyzed due to the lack of relevant clinical studies. Therefore, whether acupoint stimulation can reduce these SEs during lung cancer treatment needs to be further explored. Our finding also showed the enhancement of immediate tumor response, suggesting that acupoint stimulation may improve clinical symptoms and performance status. KPS analysis showed that acupoint stimulation (acupoint injection, plaster application, and moxibustion) can enhance performance status during lung cancer treatment. EORTC-QLQ-C30 is a questionnaire developed to assess the quality of life of cancer patients. The analysis of EORTC-QLQ-C30 showed that acupoint stimulation has an advantage in the improvement of quality of life. However, the supplemented questionnaire QLQ-C13 for lung cancer was not analyzed in this meta-analysis as there was only one study reporting the results of QLQ-C13. Although the current evidence indicates that acupoint stimulation plays a positive role in lung cancer treatment. However, the different forms of acupoint stimulations may play different role in immunomodulation, bone marrow suppression, reduction of SEs, and improvement of performance status as demonstrated in our studies. Nevertheless, it is no doubt that using acupoint stimulation as an adjunct therapy not only can reduce the

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SEs of chemotherapy and radiotherapy, but also can enhance immunomodulation, attenuate bone marrow suppression, as well as improve clinical efficacy and quality of life. Even with these promising results, there are some limitations for the present study. The frequency and duration of treatment varied in the included studies from several days to weeks, which may lead to heterogeneity in the analyzed studies. Moreover, we did not analyze the herbs used in acupoint injection and plaster application as the main purpose of this study is to evaluate the effect of acupoint stimulation as an adjunct therapy for lung cancer. But we can’t exclude the herb effects in acupoint stimulation (acupoint injection and plaster application). In addition, there were a variety of control interventions that may also increase heterogeneity of the included studies. Besides, the efficacy of acupoint stimulation on the prolongation of survival rate for lung cancer patients remains unexplored. Risk bias study showed that a number of studies are unclear with high risks in allocation concealment, blinding of participants and personnel, as well as outcome assessments. The unclear and high risk of bias in the included studies weakens the conclusion and well-designed randomized clinical trials are warranted to confirm the efficacy of acupoint stimulation in lung cancer. In the present study, we also conducted the sensitivity test, excluding studies with less than three of seven items marked as low risk from the risk bias assessment table. The sensitivity test (data not shown) is in line with the results from the analysis of all the included studies. Although the included literatures indicate that acupuncture is effective for symptom management, reducing SEs, and improving immune response in cancer patients, the underlining mechanism on the efficacy of acupuncture is mostly unknown and this deserves further exploration by mechanistic studies. This systematic review also arouses the need for better designed randomized trials of acupuncture for lung cancer patients to support the meaningful findings of the included studies. Conclusion Acupoint stimulation is found to be effective in lung cancer treatment, further confirmatory evaluation via large scale randomized trials is warranted.

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Competing interests The authors declare that they have no competing interests. Authors’ contributions WCSC and ZJZ initiated and supervised the project. SGL and HYC retrieved the databases, extracted, analyzed data, and wrote the manuscript. SGL, HYC, WCSC, and ZJZ all involved in the conception, design, interpretation of data, as well as revision and final approval of the article. All authors read and approved the final manuscript. References Cao HJ, Yang GY, Wang YY, Liu JP: Acupoint stimulation for acne: a systematic review of randomized controlled trials. Acupunct Med 2013, 25:173-194. Publisher Full Text OpenURL Chen HY, Shi Y, Ng CS, Chan SM, Yung KK, Zhang QL: Auricular acupuncture treatment for insomnia: a systematic review. J Altern Complement Med 2007, 13:669-676. PubMed Abstract | Publisher Full Text OpenURL Zhang ZJ, Chen HY, Yip KC, Ng R, Wong VT: The effectiveness and safety of acupuncture therapy in depressive disorders: systematic review and meta-analysis. 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Jiang Y, Liu LS, Li CJ, Tian JH, Shen LP, Li HG: Effect of Chinese medicine comprehensive regimen as the maintenance therapy on time to progression and quality of life of patients with advanced non-small-cell lung cancer. Chin J Integr Tradit Western Med 2011, 31:1311-1316. OpenURL Li X: Clinical Observation of Acupoint Sticking Therapy for Lung Cancer Patients with Dyspnea Symptoms. Beijing, China: Beijing University of Chinese Medicine; 2010. [Master Thesis] OpenURL Lin GH, Li LX, Lin LZ, Chen CY, Li QL, Guo YQ, Zhang QF: Clinical Observation on electro-acupoints’ Prevention and Treatment on Chemotherapy-Induced Side Effects in Lung Cancer Patients. In International Symposium of Acupuncture and Meridian Research Review and Prospect. Beijing: China Association of Acupuncture-Moxibustion; 2010:301-304. OpenURL Lin GH, Li LX, Zhang QF, Lin LZ: The Effect of Direct Moxibustion on Bone Marrow Suppression Induced by Lung Cancer Chemotherapy. Guangzhou, China: Acupuncture Association of Guangdong Province Twelfth Symposium on National Stroke and Spinal Disease; 2011:30-33. OpenURL Liu HY, Wang JH: 30 cases of dingdi of pinellia acupoint sticking Zhongwan (RN12) prevention and treatment on lung cancer patients with chemotherapy induced vomiting. Chin J Inf on TCM 2012, 19:79-80. OpenURL Lou T: Impact of magnetic point on the immune function of patients with non-small cell lung cancer chemotherapy. Chin J of Tradit Med Sci Technol 2012, 6:516-517. OpenURL Ouyang J, Cao ML: Observation of 69 cases of strong moxibustion treatment on lung cancer immune function. Acupunct Res 1992, 17:241-243. OpenURL Qiao ZB, Yin T, Li Z, Hu KW, Cao Y, He XL, Zuo HM, Zhou EF, Chen XY: Millimeter wave treatment with the Gu Chong Granules on the lung cancer patients quality of life. J of Beijing Univ of TCM (Clin Med) 2004, 11:1-4. OpenURL Shi LL, Zhou H, Tong WP: Acupuncture regulation on the T lymphocytes immune function of lung cancer patients with surgery. Shanghai J Acupunct Moxibustion 2003, 22:27-27. OpenURL Tao YZ, Long J, Wen J, He ZL: Acupoint application therapy on the chemotherapy- induced gastrointestinal reactions of lung cancer patients. Mod J Integr Tradit Chin, West Med 2012, 21:2961-2962. OpenURL Wang T: The Effect of Direct Moxibustion Sihua Acupoints for Lung Cancer Chemotoxicity. Guangzhou, China: Guangzhou University of Chinese Medicine; 2010. [Master Thesis] OpenURL Xu YL: Influence on IL-2 TNF-a and T Lymphocyte Subsets Level with Fire Needle on Si Hua Acupoint in Chemotherapy Patients with Lung Cancer. Guangzhou, China: Master thesis, Guangzhou University of Chinese Medicine; 2012. OpenURL Xu TS LIM, Zhao H, Liu YL, Wang YJ: Clinical research on the wheat-grain size cone moxibustion for improving life quality of elderly NSCLC patients. J Nanjing TCM Univ 2011, 27:418-420. OpenURL Xuan LH, Liu LM, Xu F, Xu YG, Ling SY: Clinical and experimental studies of WenJing acupoint application treatment for non-small cell lung cancer. Master thesis Zhejiang J Tradit Chin Med 2003, 38:223-224. OpenURL Zhang QF: Influence on CSF TNF and IL-2 Level with Direct Moxibustion on Si Hua Acupoint in Chemotherapy Patients with Lung Cancer. Guangzhou, China: Guangzhou University of Chinese Medicine,; 2010. OpenURL Zhang Q, Cheng J: Clinical observations of chuankezhi injection treatment on 20 cases of advanced lung cancer with COPD. Chin Gen Pract 2010, 13:2397-2399. OpenURL Zhou H, Tong WP, Shi LL: Influence of acupuncture on cellular immunity of T lymphocyte in patients with lung cancer operation. Shanghai J Acupunct Moxibustion 2003, 22:34-35. OpenURL Zhou K, Wu WY, Xie MD: Abdominal acupuncture combined with external high frequency thermotherapy in advanced lung cancer patients. Guangdong Med J 2011, 32:2124-2126. OpenURL Lin Q: The Clinical Study of Chuankezhi Injection to the Acupoint to Treat Kidney Yang Deficiency Type of Advanced Lung Cancer of Asthma. Guangzhou, China: Guangzhou University of Traditional Chinese Medicine; 2011. [Master Thesis] OpenURL Bronte V: Th17 and cancer: friends or foes? Blood 2008, 112:214. OpenURL Kou W, Bell JD, Gareus I, Pacheco-Lopez G, Goebel MU, Spahn G, Stratmann M, Janssen OE, Schedlowski M, Dobos GJ: Repeated acupuncture treatment affects leukocyte circulation in healthy young male subjects: a randomized single-blind two-period crossover study. Brain Behav Immun 2005, 19:318-324. PubMed Abstract | Publisher Full Text OpenURL Yamaguchi N, Takahashi T, Sakuma M, Sugita T, Uchikawa K, Sakaihara S, Kanda T, Arai M, Kawakita K: Acupuncture regulates leukocyte subpopulations in human peripheral blood. Evid Based Complement Alternat Med 2007, 4:447-453. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL Yu Y, Kasahara T, Sato T, Asano K, Yu G, Fang J, Guo S, Sahara M, Hisamitsu T: Role of endogenous interferon-gamma on the enhancement of splenic NK cell activity by electroacupuncture stimulation in mice. J Neuroimmunol 1998, 90:176-186. PubMed Abstract | Publisher Full Text OpenURL Cantrell DA, Smith KA: The interleukin-2 T-cell system: a new cell growth model. Science 1984, 224:1312-1316. PubMed Abstract | Publisher Full Text OpenURL Kryczek I, Wei S, Zou L, Altuwaijri S, Szeliga W, Kolls J, Chang A, Zou W: Cutting edge: Th17 and regulatory T cell dynamics and the regulation by IL-2 in the tumor microenvironment. J Immunol 2007, 178:6730-6733. PubMed Abstract | Publisher Full Text OpenURL Johnston MF, Ortiz Sanchez E, Vujanovic NL, Li W: Acupuncture may stimulate anticancer immunity via activation of natural killer cells. Evid Based Complement Altern Med 2011, 2011:481625. OpenURL Ye F, Liu D, Wang S, Xu L: Effects of electro-acupuncture on T cell subpopulations, NK activity, humoral immunity and leukocyte count in patients undergoing chemotherapy. J Tradit Chin Med 2007, 27:19-21. PubMed Abstract OpenURL Kim CK, Choi GS, Oh SD, Han JB, Kim SK, Ahn HJ, Bae H, Min BI: Electroacupuncture up-regulates natural killer cell activity Identification of genes altering their expressions in electroacupuncture induced up-regulation of natural killer cell activity. J Neuroimmunol 2005, 168:144-153. PubMed Abstract | Publisher Full Text OpenURL Zhang R, Lao L: Acupuncture and Moxibustion in Animal Models of Cancer. In Acupuncture and Moxibustion as an Evidence-Based Therapy for Cancer. Volume 3. Edited by Cho WC, Cho WC. Heidelberg, Germany: Springer; 2012:291-311. OpenURL Yu Y, Kasahara T, Sato T, Guo SY, Liu YQ, Asano K, Hisamitsu T: Enhancement of splenic interferon-gamma, interleukin-2, and NK cytotoxicity by S36 acupoint acupuncture in F344 rats. 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Tui Na Massage The words Tui Na translate into "push-grasp" or "poke-pinch" in Chinese. Tui Na is a Chinese form of massage therapy that has been used in China for 2,000 years. Tui Na uses the traditional Chinese medical theory of the flow of Qi through the meridians as its basic therapeutic orientation. Through the application of massage and manipulation techniques the practitioner of Tui Na seeks to establish a more harmonious flow of Qi through the system of channels and collaterals, allowing the body the naturally heal itself. Tui Na dates back to the Shang Dynasty of China, 1700 B.C.E. By 600 C.E. Tui Na was included in the Imperial Medical College as a separate department. Tui Na flourished throughout China until the Qing Dynasty where it was suppressed along with other Chinese cultural arts. Tui Na was eventually restored along with other traditional medical arts and was included in the creation of the current system of Traditional Medicine Colleges. Tui Na methods include the use of hand techniques to massage the soft tissues of the body as well as acupressure manipulation of points to directly affect the flow of Qi , and some more aggressive manual manipulation techniques to realign the musculoskeletal and ligamentous relationships. Most Tui Na practitioners also use TCM herbology in the form of herbal poultices, compresses, liniments, and salves are also used to enhance the other therapeutic methods. The main schools in China include the rolling method school which emphasizes soft tissue techniques and specializes in joint injuries and muscle sprains, the one finger pushing method school which emphasizes techniques for acupressure and the treatment of internal diseases, and Nei Gung method school which emphasizes the use of Nei Gong Qi energy generation exercises and specific massage methods for revitalizing depleted energy systems, and the bone setting method school which emphasizes manipulation methods to realign the musculoskeletal and ligamentous relationships and specializes in joint injuries and nerve pain. In a typical Tui Na massage session the client wears loose fitting clothes and no shoes. They lay on a table or floor mat, much like the ones used in a Shiatsu massage. The major focus of application is upon specific pain

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sites, acupressure points, energy meridians, and muscles and joints. Sessions last from 30 minutes to 1 hour. Depending on the specific problems of the client, they may return for additional treatments. The client usually feels relaxed but energized by the treatment. Tui Na is best suited for rectifying chronic pain, musculoskeletal conditions and stress-related disorders that affect the digestive and/or respiratory systems. Among the ailments Tui Natreats best are neck pain, shoulder pain, back pain, sciatica and tennis elbow. However, because Tui Na is designed to improve and restore the flow of qi, treatment often ends up causing improvements to the whole body, not just a specific area. There is anecdotal evidence that headaches, constipation, premenstrual symptoms and some emotional problems may also be effectively treated through tuina. Because it tends to be more specific and intense than other types of bodywork, Tui Na may not necessarily be used to sedate or relax a patient. The type of massage delivered by a Tui Na practitioner can be quite vigorous; in fact, some people may feel sore after their first session. Some patients may also experience feelings of sleepiness or euphoria. As with all forms of care, there are certain instances in which Tui Na should not be performed. Patients with osteoporosis or conditions involving fractures, for instance, should not receive Tui Na. Neither should patients with infectious diseases, skin problems or open wounds. Tui Na is well suited for the treatment of specific musculoskeletal disorders and chronic stress-related disorders of the digestive, respiratory and reproductive systems. Effective treatment protocols have been tested in a practical setting. Tui Nais not especially useful for those seeking a mild, sedating and relaxing massage since it tends to be more task focused than other types of bodywork. Contraindications include conditions involving fractures, phlebitis, infectious conditions, open wounds, and lesions. Tui Na is a system of massage and as such is definitely appropriate for massage therapists to learn and incorporate into their practice. Unfortunately the school I attended focused on the teaching Shiatsu and that is what I teach in my other Asian Bodywork courses, but if you are interested in learning more about it is definitely worth pursuing.

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Qigong Qigong is a practice of aligning body, breath, and mind for health, meditation, and martial arts training. With roots in Chinese medicine, philosophy, and martial arts, qigong is traditionally viewed as a practice to cultivate and balance qi. According to Taoist, Buddhist, and Confucian philosophy, respectively, qigong allows access to higher realms of awareness, awakens one's "true nature", and helps develop human potential. Qigong practice typically involves moving meditation, coordinating slow flowing movement, deep rhythmic breathing, and calm meditative state of mind. Qigong is now practiced throughout China and worldwide for recreation, exercise and relaxation, preventive medicine and self-healing, complementary and alternative medicine, meditation and self-cultivation, and training for martial arts. Over the centuries, a diverse spectrum of qigong forms developed in different segments of Chinese society. Traditionally, qigong training has been esoteric and secretive, with knowledge passed from adept master to student in lineages that maintain their own unique interpretations and methods. Research concerning qigong has been conducted for a wide range of medical conditions, including hypertension, pain, and cancer treatment. Most systematic reviews of clinical trials have not been conclusive, and all have been based on poor quality clinical studies, such that no firm conclusions about the health effects of qigong can be drawn at this stage. You already know that Qi is the central underlying principle in traditional Chinese medicine, but it was also an important concept of the martial arts. Gong (or kung) is often translated as cultivation or work, and definitions include practice, skill, mastery, merit, achievement, service, result, or accomplishment, and is often used to mean gongfu (kung fu) in the traditional sense of achievement through great effort. The two words are combined to describe systems to cultivate and balance life energy, especially for health.

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Although the term qigong has been traced back to the early Tang Dynasty (618-907 AD), the term qigong as currently used was promoted in the late 1940s through the 1950s to refer to a broad range of Chinese self-cultivation exercises, and to emphasize health and scientific approaches, while de-emphasizing spiritual practices, mysticism, and elite lineages. With roots in ancient Chinese culture dating back more than 4,000 years, a wide variety of qigong forms have developed within different segments of Chinese society: in traditional Chinese medicine for preventive and curative functions, in Confucianism to promote longevity and improve moral character in Taoism and Buddhism as part of meditative practice, and in Chinese martial arts to enhance fighting abilities. Starting in the late 1940s and the 1950s, the mainland Chinese government tried to integrate disparate qigong approaches into one coherent system, with the intention of establishing a firm scientific basis for qigong practice. In 1949, Liu Guizhen established the name "Qigong" to refer to the system of life preserving practices that he and his associates developed based on Dao yin and other philosophical traditions. This attempt is considered by some sinologists as the start of the modern or scientific interpretation of qigong. During the Great Leap Forward (1958–1963) and the Cultural Revolution (1966–1976), qigong, along with other traditional Chinese medicine, was under tight control with limited access among the general public, but was encouraged in state-run rehabilitation centers and spread to universities and hospitals. After the Cultural Revolution, qigong, along with Tai Chi, was popularized as daily morning exercise practiced en masse throughout China. Qigong comprises a diverse set of practices that coordinate body, breath, and mind based on Chinese philosophy. Practices include moving and still meditation, massage, chanting, sound meditation, and non-contact treatments, performed in a broad array of body postures. Qigong is commonly classified into two foundational categories: 1) dynamic or active qigong (dong gong), with slow flowing movement; and 2) meditative or passive qigong (jing gong), with still positions and inner movement of the breath. From a therapeutic perspective, qigong can be classified into two systems: 1) internal qigong, which focuses on self-care and self-cultivation, and 2) external qigong, which involves treatment by a therapist who directs or

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transmits qi. As moving meditation, qigong practice typically coordinates slow stylized movement, deep diaphragmatic breathing, and calm mental focus, with visualization of guiding qi through the body. While implementation details vary, generally qigong forms can be characterized as a mix of four types of practice: dynamic, static, meditative, and activities requiring external aids. Dynamic practice involves fluid movement, usually carefully choreographed, coordinated with breath and awareness. Examples include the slow stylized movements of Tai chi, Baguazhang, and Xing yi. Other examples include graceful movement that mimics the motion of animals in Five Animals (Wu Qin Xi qigong), White Crane, and Wild Goose (Dayan) Qigong. As a form of gentle exercise, qigong is composed of movements that are typically repeated, strengthening and stretching the body, increasing fluid movement (blood, synovial, and lymph), enhancing balance and proprioception, and improving the awareness of how the body moves through space. Static practice involves holding postures for sustained periods of time. In some cases this bears resemblance to the practice of Yoga and its continuation in the Buddhist tradition. For example Yiquan, a Chinese martial art derived from xingyiquan, emphasizes static stance training. In another example, the healing form Eight Pieces of Brocade (Baduanjin qigong) is based on a series of static postures. Meditative practice utilizes breath awareness, visualization, mantra, chanting, sound, and focus on philosophical concepts such as qi circulation, aesthetics, or moral values. In traditional Chinese medicine and Daoist practice, the meditative focus is commonly on cultivating qi in dantian energy centers and balancing qi flow in meridian and other pathways. In various Buddhist traditions, the aim is to still the mind, either through outward focus, for example on a place, or through inward focus on the breath, a mantra, a koan, emptiness, or the idea of the eternal. In the Confucius scholar tradition, meditation is focused on humanity and virtue, with the aim of self-enlightenment. Many systems of qigong practice include the use of external agents such as ingestion of herbs, massage, physical manipulation, or interaction with other living organisms. For example, specialized food and drinks are used

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in some medical and Taoist forms, whereas massage and body manipulation are sometimes used in martial arts forms. In some medical systems a qigong master uses non-contact treatment, purportedly guiding qi through his or her own body into the body of another person. Tai Chi Tai chi is a TCM “Health Benefiting Exercise” that looks very similar to qigong. Like qigong it is an internal Chinese martial art practised for both its defense training and its health benefits. It is also typically practised for a variety of other personal reasons: its hard and soft martial art technique, demonstration competitions, and longevity. As a result, a multitude of training forms exist, both traditional and modern, which correspond to those aims. Some of Tai Chi ch'uan's training forms are especially known for being practised with what most people would categorise as slow movement. Today, Tai Chi has spread worldwide. Medical research has found evidence that Tai Chi is helpful for improving balance and for general psychological health, and that it is associated with general health benefits in older people. To most people Tai Chi and qigong look the same, and they are closely related, but so are Sports Massage and Swedish Massage, and you know they have differences too. Tai Chi and qigong are both ancient Chinese traditions that relieve stress and increase energy. Here's a brief overview of their main differences: Tai Chi is generally more complex and involve a series of many moves. One Tai Chi form can take months to learn and a lifetime to master. Qigong is often one single move repeated over and over, and sometimes does not involve movement at all, but will focus only on breathing. For this reason, Tai Chi may be effective for anti-aging, since it is a mental workout as well as a physical one. Tai Chi focuses more on form and requires much discipline. The position of your knees, feet and spine are all crucial to the proper execution of form. Qigong is less rigid; it is a free-form practice.

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Qigong is more adaptive and is better suited as an exercise, especially for the elderly, because some of the and moves required by Tai Chi may be difficult for some to achieve. Athletes who have suffered serious injuries or participants with certain disabilities may find Tai Chi forms more challenging. Because qigong is free-form, it is also very adaptive. Anyone in any condition may participate in its breathing exercises, and may adapt its simple moves to their own level of physical ability. Qigong's roots go back thousands of years and are deeply intertwined with the Chinese way of life. Tai Chi was developed more recently by Shaolin monks and Chinese military leaders. They originally intended their "Tai Chi Chuan," or "Grand Ultimate Fist," for self-defense and combat. The founders of Tai Chi were also well-versed in the practices of Qigong, and interwove elements of it throughout their system of self-defense. However, qigong is considered a health system, and Tai Chi is truly a martial art. Qigong is a widespread institution in China and Tai Chi has gained more notoriety than qigong here in the West, but in its native land, qigong is an element of daily living. Qigong is part of the Chinese National Health Plan and is practiced in schools, universities and hospitals. While Tai Chi is popular in China as well, qigong is an everyday practice for even more Chinese citizens. The following article is entitled “Complementary and alternative medicine for patients with chronic fatigue syndrome: A systematic review” is presented to give you an example of clinical study of Tui Na and Tai Chi, and Qigong. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Please note that the Creative Commons License is limited to the article in question, which appears on pages 117- 126 and the rest of this course is covered by standard copyright laws.

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Complementary and alternative medicine for patients with chronic fatigue syndrome: A systematic review Terje Alraek, Myeong Soo Lee, Tae-Young Choi, Huijuan Cao and Jianping Liu Author Affiliations National Research Center for Complementary and Alternative Medicine, University of Tromsø, Norway Brain Disease Research Center, Korea Institute of Oriental Medicine, Daejeon, South Korea Center for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China BMC Complementary and Alternative Medicine 2011, 11:87 doi:10.1186/1472-6882-11-87 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background Throughout the world, patients with chronic diseases/illnesses use complementary and alternative medicines (CAM). The use of CAM is also substantial among patients with diseases/illnesses of unknown aetiology. Chronic fatigue syndrome (CFS), also termed myalgic encephalomyelitis (ME), is no exception. Hence, a systematic review of randomised controlled trials of CAM treatments in patients with CFS/ME was undertaken to summarise the existing evidence from RCTs of CAM treatments in this patient population. Methods Seventeen data sources were searched up to 13th August 2011. All randomised controlled trials (RCTs) of any type of CAM therapy used for treating CFS were included, with the exception of acupuncture and

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complex herbal medicines; studies were included regardless of blinding. Controlled clinical trials, uncontrolled observational studies, and case studies were excluded. Results A total of 26 RCTs, which included 3,273 participants, met our inclusion criteria. The CAM therapy from the RCTs included the following: mind-body medicine, distant healing, massage, tuina and tai chi, homeopathy, ginseng, and dietary supplementation. Studies of qigong, massage and tuina were demonstrated to have positive effects, whereas distant healing failed to do so. Compared with placebo, homeopathy also had insufficient evidence of symptom improvement in CFS. Seventeen studies tested supplements for CFS. Most of the supplements failed to show beneficial effects for CFS, with the exception of NADH and magnesium. Conclusions The results of our systematic review provide limited evidence for the effectiveness of CAM therapy in relieving symptoms of CFS. However, we are not able to draw firm conclusions concerning CAM therapy for CFS due to the limited number of RCTs for each therapy, the small sample size of each study and the high risk of bias in these trials. Further rigorous RCTs that focus on promising CAM therapies are warranted. Background Throughout the world, patients with chronic diseases tend to be high utilisers of health care resources and/or the health care system. Such patients are also frequent users of Complementary and Alternative Medicine (CAM) services, which are present either within or outside the National Health Service. The reasons for using CAM are diverse; however, hope, engagement in one's own health and positive expectations of treatment efficacy are nearly always present. Patients with chronic fatigue syndrome (CFS) are no exception. CFS is a challenging illness for patients, as well as those close to them, health care providers and society in general. Western medicine usually has potent treatments readily available for diseases with a single cause and a well-described pathophysiology. However, as of yet, no single cause of CFS has been discovered, although potential factors, which are still questionable, have been identified [1-3]. Several treatments for this condition have been explored; however, none has shown persistent or consistently significant outcomes in this patient population [4-6]. Although several CAM treatments for CFS patients were

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described in a previous review, the review only included literature up to April 2007 [7]. Furthermore, a new quality assessment tool (the Cochrane risk of bias tool) has since been proposed to enhance the validity of systematic reviews [8]. Therefore, the aim of our review was to systematically summarise and critically evaluate the data from RCTs of CAM treatment for patients with CFS. Methods Data sources We searched the following electronic databases up to 13th August 2011: Medline, PsycInfo, Alternative Medicine (AMED), the Cumulative Index to Nursing & Allied Health Literature (CINAHL), EMBASE, and the Cochrane Library 2011 (Issue 5). We also searched the Chinese databases (China Network Knowledge Infrastructure (CNKI; 1979-2010), the Chinese Scientific Journal Database VIP (1989-2010), the Wan Fang Database (1985-2010), and the Chinese Biomedicine (CBM) database (1978-2010); the Korean medical databases (including Korean Studies Information, DBPIA, Korea Institute of Science and Technology Information, Research Information Service System, KoreaMed, and National Assembly Library); and Japanese databases (Japan Science and Technology Information Aggregator, Electronic). The search strategy is listed in Additional file 1. In addition, we manually searched our own files, Focus on Alternative and Complementary Therapies and Forschende Komplementärmedizin. The references in all located articles were also searched. Selection Criteria All randomised controlled trials (RCTs) of any type of CAM therapy, with the exception of acupuncture and complex Chinese herbal medicines, for the treatment of CFS were included, regardless of blinding or the published language. Cochrane reviews of trials testing acupuncture type therapies [9] are ongoing, and as a result, this topic was excluded. We included RCTs that tested a single herb for CFS. RCTs testing complex herbal medicines for CFS were excluded, as it is not possible to isolate the effects of single herbs. Trials were included if they used CAM as either the sole treatment or as an adjunct to other treatments, which occurred in cases where the control group also received the same concomitant treatments as the CAM group. Studies comparing two different forms of CAM and those in which no clinical data were reported were also excluded. Cognitive behavioural interventions were not considered to be a part of CAM and were therefore excluded. If cognitive behavioural intervention was used as a control, the

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trial was included. Trials that employed CAM as the sole treatment or as an adjunct to other treatments were included. Dissertations and abstracts were included if they contained sufficient detail for critical evaluation. Hard copies of all articles were obtained. Data Extraction, Quality, and Risk of Bias Assessment All articles were read, and data were extracted from the articles based on predefined selection criteria by two independent reviewers (MSL and TYC). To evaluate the methodological quality of the RCTs, the risk of bias was determined using the Cochrane classification for eight criteria: random sequence generation, allocation concealment, patient blinding, assessor blinding, reporting of dropout or withdrawal, intention-to-treat analysis, selective outcome reporting and other potential biases [8]. Results Study description We screened 647 relevant articles, and 592 were excluded, leaving us with 55 full-text eligible articles. Of these, 29 more were excluded. The remaining 26 RCTs met our inclusion criteria (Figure 1). Figure 1.

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Flow diagram of literature search. CCT: controlled clinical trial; NCT: not clinical trial; UOS: uncontrolled observational study; CAM: complementary and alternative medicine; CFS: chronic fatigue syndrome Key data from these studies are summarised in Tables 1 and 2[10-35]. The RCTs included in the table employed the following treatments: mind-body medicine (4) [10-13], massage (2) [14,15], tuina and tai chi (1) [16], homeopathy (2) [17,18], ginseng (1) [19], nicotinamide adenine dinucleotide (NADH) (2) [20,21], and dietary supplements (14) [22-35]. A placebo procedure was employed in 16 trials [17-20,22-27,29-34]. Twenty of the included trials adopted a two-arm parallel group design [10-12,14,15,17-27,29,30,33,35], three adopted a three-arm parallel group design [16,28,34], and one used a four-arm parallel group design [13], while two trials employed a cross-over design [31,32]. Nine trials adopted the CDC criteria for the diagnosis of CFS [11,20,22,24,25,27,28,31,32], five studies diagnosed CFS according to the criteria published by Fukuda [10,15,16,19,21], five used the Oxford criteria [12,17,18,30,35], two combined with Fukuda and Oxford criteria [13,23], and one used a different classification system [33]. The risk of bias in the studies was variable. Eleven RCTs had an adequate method for random sequence generation [10,11,13,15,17,19,24,25,28,29,33], whereas the remaining 15 RCTs did not [12,14,16,18,20-23,26,27,30-32,34,35]. Allocation concealments were adequately performed in 13 RCTs [10,11,13,17,19,24,25,29-33]. Patient and assessor blinding was reported in 16 of the RCTs [17-20,22-27,29-34], whereas two RCTs employed assessor blinding only [10,11]. Reasons for dropouts and withdrawals were fully described in 17 trials [10,11,13,17,19,22-26,28-30,32-35]. With respect to the intention-to-treat (ITT) analysis, 11 RCTs did not report the basis of the analysis [11,12,14-16,28,30-32,34,35], and 9 were analysed on a per-protocol basis [10,13,18,20,21,23,25-27]. The remaining 6 studies employed the ITT method [17,19,22,24,29,33]. Eleven RCTs had a low risk of bias in selective outcome reporting [11,13,14,17-19,21,23,25,29,33], and the others had a high risk of such bias. Mind-body and energy medicine Two RCTs compared qigong plus meditation with no treatment [10,11]. Both studies reported beneficial effects of qigong with meditation on fatigue. One RCT tested Mindfulness Based Stress Reduction (MBSR) as compared with a wait-list control and found significant effects of the

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treatment on anxiety [12]. The other RCT compared distant healing with a four-armed partial blinding, placebo-controlled design and did not show a significant effect on mental or physical components of quality of life [13]. Massage Two RCTs tested massage compared with Sham TENS or another type of massage [14,15]. One RCT demonstrated the beneficial effects of massage on several symptoms of CFS, including depression, fatigue, pain and insomnia [14]. The other RCT compared a special type of massage (Intelligent-turtle) with general massage and reported some effect of this type of massage on physical symptoms [15]. Tuina and tai chi One RCT tested tuina and tai chi as compared to fluoxetine [16]. The tuina group had more symptom reduction than the fluoxetine group fluoxetine, but there were no significant differences between tuina and tai chi or tai chi and fluoxetine after 1 month of treatment. The effective rate was decided by the practitioner and was based on symptom improvement, which was not described in detail. Homeopathy Two RCTs compared homeopathy with placebo [17,18]. One RCT showed that homeopathy improved fatigue and function [17]. The other RCT reported the beneficial effects of homeopathy on symptom improvement [18]. Ginseng One RCT tested Siberian ginseng and failed to show the effectiveness of ginseng on the Rand Vitality Index [19]. Supplements Two RCTs compared NADH with placebo or psychological therapy [20,21]. One RCT showed statistically significant effects of NADH (10 mg) on symptom scores when compared with placebo after 1 month of treatment [20]. The other RCT also reported the positive effects of NADH (from 5 to 10 mg) when compared with psychological therapy (not reported in details) after 3 months [21]. Six RCTs compared several types of general food supplements with a placebo control [22-27]. Five of these RCTs failed to show significant

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effects of dietary supplements on symptoms of CFS when compared with placebo. One RCT compared acclydine with placebo and showed the beneficial effects of acclydine on clinical improvement at weeks 4 and 8 [23]. One RCT tested Acetyl-L-carnitine as compared with Propionyl-carnitine and combined both therapies [28]. The results showed the beneficial effects of each therapy on fatigue, pain and attention/concentration. Two RCTs compared essential fatty acids (Efamol Marine-evening primrose oil) with placebo [29,30]. One RCT showed the possible efficacy of essential fatty acids on symptoms and general heath [29], whereas the other RCT failed to show an impact of this therapy on physical symptoms and depression when compared to placebo [30]. One RCT compared liver extract-folic acid-cyanocobalamin with placebo and failed to show an effect for the treatment [31]. The second RCT compared antioxidant treatment with placebo and reported beneficial effects in the treatment group; however, there were no reports on intergroup differences [32]. The third RCT compared a magnesium supplement with placebo and found beneficial effects of magnesium on patients' symptom profiles [33]. A large, double-blind RCT of patients with CFS investigated the effect of isobutyryl-thiamine disulphide. No improvements were observed when compared with placebo [34]. When melatonin was compared in an RCT with phototherapy, neither intervention generated beneficial effects [34]. Adverse events Five of the 26 included studies reported no adverse events or a slight occurrence of them [16,20,24,31,34], whereas the remaining 20 studies lacked descriptions regarding the occurrence of adverse events. Discussion Our analysis shows that a range of CAM studies have been conducted to determine which therapies might ameliorate CFS symptoms. There is insufficient evidence to conclusively determine efficacy. Studies of qigong, massage and tuina have demonstrated positive effects; however, the nature of the control group and the quality of the studies prevent us from concluding that those CAM therapies are effective for CFS. Compared with placebo, homeopathy also had insufficient evidence of symptom

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improvement in CFS. Seventeen studies tested supplements for CFS. Most of the supplements failed to show favourable effects for CFS, with the exception of NADH and magnesium. However, the total number of RCTs and the total sample size were too small to draw firm conclusions. Our review aimed to update and complete the evidence of CAM treatments for symptom relief in patients with CFS. Compared to a previous review [7], we identified 3 new types of CAM and 9 new RCTs and successfully updated the evidence for these therapies in CFS. The results of our review are similar to that of the previous review [7], which also expressed concern regarding the poor methodological quality of the included primary studies [7]. Another two published reviews concerning traditional Chinese medicine and herbal medicines were unable to find appropriate studies to review [36,37]. Most of the included trials had a high risk of bias in many domains. Low quality trials are more likely to overestimate effect size [38]. This is also true for trials with inadequate blinding and inadequate allocation concealment, as such trials are more subject to selection bias and are likely to generate exaggerated treatment effects [38,39]. Several trials used an inadequate method for sequence generation. Because inadequate sequence generation in randomisation studies also tends to yield a larger estimate of treatment effects, this is another source of potential bias. One argument for using CAM for the management of CFS might be that it causes fewer adverse effects than drug treatment. Only five RCTs [16,20,24,31,34] assessed the adverse effects of CAM treatment, while 21 RCTs did not. No severe adverse effects of CAM were noted. However, adverse effects should be assessed in future CAM trials. This is an important factor for patients, as CAM treatments are generally offered outside of the official health care system. Our review has a number of important limitations. Although strong efforts were made to retrieve all RCTs on the subject, we cannot be absolutely certain that we succeeded. Moreover, selective publishing and reporting are other major causes for bias, which must be considered [40,41]. It is conceivable that several negative RCTs remain unpublished, thus distorting the overall picture [40,42]. Further limitations include the paucity and often suboptimal methodological quality of the primary data. Together, these factors limit the conclusiveness of this systematic review considerably.

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Conclusions The results of our systematic review provide limited evidence for the effectiveness of CAM in treating patients with CFS. However, the total number of RCTs included in the analysis, the total sample size and their risk of bias were quite high in several domains; thus, drawing firm conclusions concerning the effectiveness of CAM therapies remains difficult. Further rigorous RCTs that can overcome the many limitations of the current literature are warranted. Competing interests The authors declare that they have no competing interests. Authors' contributions TA obtained funding for the study, conceived and participated in its design and coordination and helped to draft the manuscript. MSL conceived and participated in its design. MSL and TYC searched databases, extracted and assessed studies. They also helped to draft the manuscript. HC participated in the study design and helped to draft the manuscript. JL conceived the study, and participated in its design and helped to draft the manuscript. All authors read and approved the final manuscript. Acknowledgements This study was supported with a grant from the Norwegian Directorate of Health. References Jason LA, Evans M, Brown M, Porter N: What is fatigue? Pathological and nonpathological fatigue. PM R 2010, 2(5):327-331. PubMed Abstract | Publisher Full Text OpenURL Rusmevichientong A, Chow SA: Biology and pathophysiology of the new human retrovirus XMRV and its association with human disease. Immunol Res 2010, 48(1-3):27-39. PubMed Abstract | Publisher Full Text OpenURL Van Houdenhove B, Kempke S, Luyten P: Psychiatric aspects of chronic fatigue syndrome and fibromyalgia. Curr Psychiatry Rep 2010, 12(3):208-214. PubMed Abstract | Publisher Full Text OpenURL Bagnall AM, Whiting P, Richardson R, Sowden AJ: Interventions for the treatment and management of chronic fatigue syndrome/myalgic encephalomyelitis. Qual Saf Health Care 2002, 11(3):284-288. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL Chambers D, Bagnall AM, Hempel S, Forbes C: Interventions for the treatment, management and rehabilitation of patients with chronic fatigue syndrome/myalgic encephalomyelitis: an updated systematic review. J R Soc Med 2006, 99(10):506-520. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL Whiting P, Bagnall AM, Sowden AJ, Cornell JE, Mulrow CD, Ramirez G: Interventions for the treatment and management of chronic fatigue syndrome: a systematic review. JAMA: the journal of the American Medical Association 2001, 286(11):1360-1368. Publisher Full Text OpenURL Porter NS, Jason LA, Boulton A, Bothne N, Coleman B: Alternative medical interventions used in the treatment and management of myalgic encephalomyelitis/chronic fatigue syndrome and fibromyalgia. J Altern Complement Med 2010, 16(3):235-249. PubMed Abstract | Publisher Full Text OpenURL Higgins JPT, Altman DG, Sterne JAC: Chapter 8: Assessing risk of bias in included studies. [http://www.cochrane-handbook.org] webcite In Cochrane Handbook for Systematic Reviews of Interventions Version 510 (updated March 2011) Edited by Higgins JPT, Green S. The Cochrane Collaboration; 2011. OpenURL Zhang W, Liu Z, Wu T, Peng W: Acupuncture for chronic fatigue syndrome. Cochrane DB Syst Rev 2006, CD006010. OpenURL Collinge W, Yarnold PR, Raskin E: Use of mind-body selfhealing practice predicts positive health transition in chronic fatigue syndrome: a controlled study. Subtle Energies Energy 1998, 9:171-190. OpenURL Dybwad MH, Frøslie KF, Stanghelle JK: Work capacity, fatigue and health related quality of life in patients with myalgic encephalopathy or chronic fatigue syndrome, before and after qigong Therapy, a randomized controlled study. [http://old.sunnaas.no/stream_file.asp?iEntityId=7623] webcite Nesoddtangen, Norway: Sunnaas Rehabilitation Hospital 2007. OpenURL Surawy C, Roberts J, Silver A: The effect of mindfulness training on mood and measures of fatigue, activity, and quality of life in patients with chronic fatigue syndrome on a hospital waiting list: a series of exploratory studies. Behav Cogn Psychother 2005, 33:103-109. Publisher Full Text OpenURL Walach H, Bosch H, Lewith G, Naumann J, Schwarzer B, Falk S, Kohls N, Haraldsson E, Wiesendanger H, Nordmann A, et al.: Effectiveness of distant healing for patients with chronic fatigue syndrome: a randomised controlled partially blinded trial (EUHEALS). Psychother Psychosom 2008, 77(3):158-166. PubMed Abstract | Publisher Full Text OpenURL

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Cupping Cupping therapy is an ancient Chinese form of alternative medicine in which a local suction is created on the skin; practitioners believe this mobilizes blood flow in order to promote healing. Suction is created using heat (fire) or mechanical devices (hand or electrical pumps). Like many other forms of TCM modern science has difficulty proving the efficacy of cupping, but those who practice it and their clients believe it does them some good. I do not practice it myself but I have had fire cupping (described below) done to me and while I felt no benefit from the cups being left on me, the practitioner did “drag” at one point, (moving cupping) which as a practitioner trained in both eastern and western methods I can tell you that did have an effect on the muscles of my back-I could feel the soft tissues lifting and stretching in a way that is hard to describe. The basic practice of cupping involves creating a vacuum in a cup, either by heat or mechanical means, and placing the cup on the skin so that the skin is gently drawn upwards into the cup. Generally the cup stays in place for five to fifteen minutes. The belief in TCM is that cupping can help treat pain, deep scar tissues in the muscles and connective tissue, muscle knots, and swelling. There is some archeological evidence that the practice dates back as far as 3000 B.C.; the earliest record of cupping is in the Ebers Papyrus, one of the oldest medical textbooks in the world, describes in 1550 B.C. Egyptians used cupping. Archaeologists have found evidence in China of cupping dating back to 1000 B.C. In ancient Greece, Hippocrates (c. 400 B.C.) used cupping for internal disease and structural problems. This method in multiple forms spread into medicine throughout Asian and European civilizations The cups can be various shapes including balls or bells, and may range in size from 1 to 3 inches (25 to 76 mm) across the opening. Plastic and glass are the most common materials used today, replacing the horn, pottery, bronze and bamboo cups used in earlier times. The low air pressure required may be created by heating the cup or the air inside it with an open flame or a bath in hot scented oils, then placing it against the skin. As the air inside the cup cools, it contracts and draws the skin slightly inside. More recently, vacuum can be created with a mechanical suction pump acting through a valve located at the top of the cup. Rubber cups are

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also available that squeeze the air out and adapt to uneven or bony surfaces. In practice, cups are normally used only on softer tissue that can form a good seal with the edge of the cup. They may be used singly or with many to cover a larger area. They may be used by themselves or placed over an acupuncture needle. Skin may be lubricated, allowing the cup to move across the skin slowly. Depending on the specific treatment, skin marking is common after the cups are removed. This may be a simple red ring that disappears quickly, the discoloration left by the cups is normally from bruising especially if dragging the cups while suctioned from one place to another to break down muscle fiber. Usually treatments are not painful. Fire cupping involves soaking a cotton ball in 70% alcohol. The cotton is then clamped by a pair of forceps and lit via match or lighter. The flaming cotton ball is then, in one fluid motion, placed into the cup, quickly removed, and placed on the skin. By adding fire to the inside of the cup, oxygen is removed (which is of course replaced with an equal volume of carbon dioxide) and a small amount of suction is created by the air cooling down again. Massage oil may be applied to create a better seal as well as allow the cups to glide over muscle groups (e.g. trapezius, erectors, latisimus dorsi, etc.) in an act called "moving cupping". Dark circles may appear where the cups were placed due to rupture of the capillaries just under the skin, but are not the same as a bruise caused by blunt-force trauma. According to traditional Chinese medicine (TCM) cupping is a method of creating a vacuum on the patient's skin to dispel stagnation or stagnant blood and lymph, thereby improving qi flow to treat respiratory diseases such as the common cold, pneumonia and bronchitis. Cupping also is used on back, neck, shoulder and other musculoskeletal conditions. Its advocates say it has other applications, as well. Cupping is not advised over skin ulcers or to the abdominal or sacral regions of pregnant women. New silicone cupping therapy massage cups are available, an innovation for cupping therapy and its wider acceptance. "Medical silicone" cups are claimed to alleviate deep bruising associated with traditional cupping. The cups allow for added new massage techniques because they are simple to

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use and are pliable, unlike glass or plastic. It is also highly recommended to drink plenty of water after cupping to help move the blood and other fluids through the area affected; general massage can help reduce the blood bruising immediately after the cupping. Cupping is claimed to treat a broad range of medical conditions such as blood disorders (anaemia, haemophilia), rheumatic diseases (arthritic joint and muscular conditions), fertility and gynaecological disorders, and skin problems (eczema, acne and is claimed by proponents to help general physical and psychological well-being. An article was published that detailed a study of cupping as a means of treating Carpal Tunnel Syndrome6. They investigated the effectiveness of cupping in patients with carpal tunnel syndrome (CTS) in an open randomized trial. The primary outcome, severity of CTS symptoms (VAS), was reduced from 61.5 ± 20.5 to 24.6 ± 22.7mm at day 7 in the cupping group and from 67.1 ± 20.2 to 51.7 ± 23.9mm in the control group [group difference –24.5mm (95%CI –36.1; –2.9, P < .001)]. The authors conclude that cupping therapy may be effective in relieving the pain and other symptoms related to CTS. The efficacy of cupping in the long-term management of CTS and related mechanisms remains to be clarified. A similar study was conducted in India. In this study, they attempted to evaluate the efficacy of cupping in patients of arthritis7. 30 patients were randomly selected, of which 20 patients were kept in the test group i.e. these patients were given the cupping therapy, while the rest 10 patients were in the control group and were not receiving the cupping therapy. At the end of the study, it was concluded that cupping is an effective therapy for the patients of arthritis. Moxibustion Many massage therapists use Aromatherapy products in their massage practices. They blend potent and volatile essential oils into their massage lotions, or place them in effuse them in their treatment rooms with all manner of burners and steamers, believing (and rightfully so) that the

6 Effects of Traditional Cupping Therapy in Patients With Carpal Tunnel Syndrome: A Randomized Controlled Trial published in The Journal of

Pain Volume 10, Issue 6, June 2009, Pages 601–608 7 Clinical Efficacy of Hijamat (Cupping) in Waja-ul-Mafasil (Arthritis) Indian Journal of Traditional Knowledge Vol.04 October 2005

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molecules of the essential oil will be picked up by the olfactory bulbs of the client while they are on the table, and thus enter the blood stream where they will trigger the desired chemical reactions. In TCM there is a similar practice called Moxibustion. It is a traditional Chinese medicine therapy using moxa made from dried mugwort (Artemisia argyi). It plays an important role in the traditional medical systems of China (including Tibet), Japan, Korea, Vietnam, and Mongolia. Suppliers usually age the mugwort and grind it up to a fluff; practitioners burn the fluff or process it further into a cigar-shaped stick. They can use it indirectly, with acupuncture needles, or burn it on the patient's skin. Practitioners use moxa to warm regions and acupuncture points with the intention of stimulating circulation through the points and inducing a smoother flow of blood and qi. Some believe it can treat conditions associated with the "cold" or "yang deficiencies" in Chinese Medicine. It is claimed that moxibustion militates against cold and dampness in the body, and can serve to turn breech babies. Practitioners claim moxibustion to be especially effective in the treatment of chronic problems, "deficient conditions" (weakness), and gerontology. Bian Que (fl. circa 500 BCE), one of the most famous semi-legendary doctors of Chinese antiquity and the first specialist in moxibustion, discussed the benefits of moxa over acupuncture in his classic work. He asserted that moxa could add new energy to the body and could treat both excess and deficient conditions. On the other hand, he advised against the use of acupuncture in an already deficient (weak) patient, on the grounds that needle manipulation would leak too much energy. Practitioners may use acupuncture needles made of various materials in combination with moxa, depending on the direction of qi flow they wish to stimulate. There are several methods of moxibustion. Three of them are direct scarring, direct non-scarring, and indirect moxibustion. Direct scarring moxibustion places a small cone of mugwort on the skin at an acupuncture point and burns it until the skin blisters, which then scars after it heals. Direct non-scarring moxibustion removes the burning mugwort before the skin burns enough to scar, unless the burning mugwort is left on the skin too long. Indirect moxibustion holds a cigar made of mugwort near the

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acupuncture point to heat the skin, or holds it on an acupuncture needle inserted in the skin to heat the needle. Scarring and non-scarring methods are both inappropriate for a massage practice, but indirect moxibustion is no more dangerous than a hot stone massage-in fact it is less dangerous because unlike the hot stone, the burning Moxa never touches the skin in the indirect method. The techniques explained There are about 50 techniques that have been elaborated in the ancient medical books of China, obviously far more detail than I can present here. But I can endeavor to give you a short description of the different types. Please remember this is for educational purposes only, so that you will know and understand the practices, we do not intend for you to try these yourself unless you have been properly trained. 1. Non-Scarring Moxibustion with Moxa Cones A moxa cone is placed on a point and ignited. This looks just like an “incense cone” you may have seen in stores or even burned in your massage room if you are in to that sort of thing. When about 2/3 of it is burnt or the patient feels a burning discomfort, the cone is removed and replaced another one. Three to seventeen cones are continuously burnt to cause flush in the local site, but no blister should be formed. This method is used widely, often for cold and deficiency disorders such as asthma, chronic diarrhea, and indigestion. 2. Indirect Moxibustion (Interposed Moxibustion) The ignited moxa cone does not contact the skin directly, but is insulated from the skin by a layer of ginseng, salt, garlic, or aconite cake. Depending on the technique used, this kind of moxa may induce blistering, but it is often used for non-scarring moxibustion.

A Moxa cone on a back of a client.

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3. Moxibustion with Moxa Stick Mild-warm moxa: Ignite a moxa stick and place it 2-3 centimeters away over the site to bring mild warmth to the local place, but not burning, for some 15 minutes until the skin becomes slightly red. It is suitable for all the syndromes indicated for moxibustion. Sparrow-pecking moxibustion: In this method, the ignited moxa stick is moved up and down over the point like a bird pecking, or moving left and right, or circularly. It is indicated for numbness and pain in the limbs. 4. Warming Needle Moxibustion Moxibustion with warming needle is an integration of acupuncture and moxibustion, and is used for conditions in which both retention of the needle and moxibustion are needed. It is applied as follows: after the arrival of qi and with the needle retained in the point, get a small section of a moxa stick (about 2 cm long) and put on the handle of the needle; ignite the moxa stick from its bottom and let it burn out. This method has the function of warming the meridians and promoting the flow of qi and blood so as to treat bi-syndrome caused by cold-damp and paralysis. Application to cold-damp syndrome was the subject of a clinical evaluation involving patients with rheumatoid arthritis (46). Acupuncture was performed by deep needling of the shu (stream) points, and then moxa was applied to the needles for 30 minutes, performed daily (with short breaks) during a two month course of therapy. The original technique described in the classics is different and was called the fire needle. This involved holding the needle in a lamp flame until very hot, and then inserting to the appropriate depth in the body quickly and removing it (34). Warming needle, as now used, allows longer

A rolled Moxa “cigar” being held over the acupoints to be treated.

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retention and gentler heating. Obviously since this involves needles and acupuncture it is out of the scope of practice for massage therapists. Why it is used TCM teaches that Moxibustion therapy is effective in treatment of simple diarrhea, chronic gastroenteritis, peptic ulcer, bronchial asthma, rheumatism of muscles and joints, neurasthenia, hypertension, menstrual disorders, chronic pelvic inflammation, and climacteric menopause. Definite effect was obtained in the treatment of pulmonary tuberculosis, and thromboangitis obliterans. One clinical study in China looked at a report of 182 cases of asthma treated with scarring moxibustion at acupoints selected on the basis of differential diagnosis resulted in a shot-term effective rate of 76.9%, with 70% long-term effective rate on follow-up examination for three years. Other reports claim that scarring moxibustion may markedly lower blood pressure, reduce blood viscosity, and dilate various vessels. These reports indicate that scarring moxibustion decreases the incidence of fulminant apoplexy by lowering blood pressure. Observation over 17 years of 54 cases of high blood pressure revealed that only 5 suffered from fulminant apoplexy after receiving scarring moxibustion, while 4 out of 12 in the control group did. These results of the therapy are obvious. Experimental and clinical studies have pointed to further health benefits of scarring moxibustion. An example is 299 cases of asthma treated by purulent moxibustion in which 70.6% were effective and 29.1% markedly effective. Abnormal WBC count in 20 cases before treatment were corrected in 19 cases8. Like western Aromatherapy, relatively few diseases are treated by moxa alone as the primary therapy. Academic articles on moxibustion as the primary technique tend to be short, and little is said about the point selection or method of applying the moxa. The Acupoints for Moxibustion There are certain points mentioned repeatedly in the literature on moxibustion; the accumulated experience with using these points suggests that they might be uniquely effective. Aside from zusanli (ST-36), which is

8 Wang Kenliang, Several diseases treated by suppurative moxibustion therapy, 2000 International Congress on Traditional Medicine, April 22-

24, Beijing.

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also the most frequently mentioned of all the points used for needling, the primary moxibustion points are located on the governing and conception vessels. On the conception vessel, points 4, 6, 8, 12, and 17 are mainly utilized. On the governing vessel, points 4, 14, and 20 are mainly used. One of the important moxa points is dazhui (GV-14), which is the meeting point of the governing vessel with the six yang channels of the hand and foot. An article reviewing the many uses of moxibustion at this point (31) listed the following examples of applications for moxa at this point: � Expelling wind, clearing heat, and dispersing the lung to relieve the

exterior (for acute feverish diseases); � Dispersing the lung, eliminating cold, and activating yang to relieve

asthma; � Restoring consciousness, tranquilizing the mind, and calming internal

wind to relieve epilepsy; � Removing obstruction in the governing channel to relieve spasm and

dispersing yang to eliminate pathogenic factors (for cervical spondylopathy and other disorders of the spinal column);

Warming the channels, restoring yang, and replenishing qi to consolidate resistance (protecting from recurrent common cold and influenza). Dazhui was also described separately as the acupoint suitable for treating herpes zoster by moxibustion9. Reflecting the common usage of the points, the students of Wang Leting noted that the points he used for moxibustion were relatively few. They included conception vessel points 4, 6, 8, and 12, and governing vessel points GV-4 and 20 (he also used the back shu points fenshu, BL-13, and shenshu, BL-23). A harmonizing treatment for the yin and yang is moxibustion at guanyuan (CV-4) and dazhui (GV-14). Robert Johns, in his book The Art of Acupuncture Techniques (32), mentions that this ancient formula is well suited to helping cancer patients recover from the adverse effects of modern cancer therapies. Other moxibustion therapies for helping patients with leucopenia mentioned in Chinese texts include dazhui with zusanli, usually along with one or two other points. One other point frequently mentioned is yongquan (KI-1), a point relied upon for treatment of collapse of yang, for which moxibustion

9 Li Huailin, 34 cases of herpes zoster treated by moxibustion at dazhui (GV-14), Journal of Traditional Chinese Medicine 1992; 12 (1): 71.

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seems appropriate. It might also be used, with slow heating, to help tonify yin. How can this actually Work? While it might seem like pseudoscientific hokum there are some pretty sound theories as to why Moxibustion might work, and it is closely related to Hot Stone Massage, a favorite practice western massage therapists. One theory is that the application of heat to the local tissues initiates a non-specific healing reaction that can have effects throughout the body. This healing reaction is stimulated by production of immunological mediators and neurotransmitters. The impact of the local heat stimulus was studied in the laboratory to follow-up on the suggestion that the production of inflammation mediators, mainly histamine, at the site of burning skin were important to the impact of moxibustion therapy. After burning a single cone of moxa, the authors reported that: The maximum temperature of the treated spot was about 130° C at the outer skin, and about 56° C at the inner skin. Therefore, moxibustion treatments are naturally considered heat stimulation with inflammatory response. In general, inflammatory response induces vascular changes. Our results of moxibustion as a heat stimulation induced vasoconstriction at the site under the moxibustion spot and vasodilation around the moxibustion spot. Our results indicate that moxibustion induces an increase in capillary permeability mediated by histamine; additionally, this enhancement of permeability can be correlated with the degree of mast cell degranulation [release of inflammation mediators by the cells], which relates to the weights of moxa cone used. This is essentially the same vasodialation effect that the application of hot stones to the body can produce, so it’s not as far out there as you might think. Moxibustion and the Immune system One of the frequently investigated functions of moxibustion mentioned in modern Chinese clinical literature is boosting the immune system. It remains unclear whether moxibustion differs in its effects from acupuncture in this regard. In elderly patients, both acupuncture and warm needle

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acupuncture (with moxa applied to the needles for 20 minutes, using daily treatment for 10 days) applied to zusanli (ST-36) enhanced production of IL-2 (45). In a review article on research examining immunological effects of acupuncture and moxibustion (18), no distinction was made regarding the two techniques, only the points treated and the outcomes were noted for each method interchangeably. The author of the review article concluded that the effect of the techniques on the immune system might be a secondary result of their effects on the whole body, rather than a specific action. This interpretation does not necessarily contradict the results of animal studies on mechanism of moxibustion: the technique might have an initial effect on the immune system that then produces, via the action of various mediators, a systemic effect that goes beyond the initial immune response, eventually causing a greater immunological improvement. In the report on moxibustion treatment of coronary heart disease, some immune parameters of the patients were measured (including lymphocyte conversion rates and levels of immunoglobulins), showing an enhanced immunological response. The authors had concluded that "moxibustion treats coronary heart disease through regulating the internal environment of the organism and reinforcing its ability to fight disease." This interpretation of results is consistent with the idea that the techniques produce non-specific improvements in the entire body that manifest in better immune function as well as better function of all the internal organs. In the TCM system, spleen deficiency (a subcategory of qi deficiency) syndrome is often associated with weak immune functions. Clinical studies have been conducted to test whether application of Moxibustion can have any immunological effects10 and the results did show an elevation in immune functioning and an alleviation of symptoms. Another study on the treatment of chronic diarrhea associated with ulcerative colitis or simple chronic colitis with moxibustion focused on immunologic mechanisms11. Herb-interposed moxibustion was used with two sets of points alternated daily: zhongwan (CV-12), qihai (CV-6), and zusanli (ST-36) made up one set; dachangshu (BL-25), tianshu (ST-25), and shangjuxu (ST-37) made up

10 Shi Huaisheng, et al., Ginger-partitioned moxibustion on sifeng point (extra-29) in treating children's asthenia and its effects on cellular

immune functions, Chinese Acupuncture and Moxibustion 1995; (6): 9-10.

Xhou Jianwei, et al., Impact of medicated mugwort moxibustion on serum gastrin, d-xylose excretion rate, and T-cell subgroup in patients with

spleen deficiency syndrome, Chinese Acupuncture and Moxibustion 1998; (1): 15-16. 11 Wu Huangan, et al., Clinical therapeutic effect of drug-separated moxibustion on chronic diarrhea and its immunological mechanisms, Journal

of Traditional Chinese Medicine 1997; 17(4): 253-258.

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the second set. The number of moxa cones used would vary by site and syndrome, but ranged from 2 to 7 cones. Daily treatment was provided for 12 days, followed by an interval of 3 days, and then another course of 12 days, for a total of 60 treatments. It was claimed that along with resolution of the diarrhea there was a reduction in the excess IgM and complement that were present at the beginning of treatment for those with ulcerative colitis, and an improvement in the T-lymphocyte subgroup of suppressor cells that inhibit autoimmune reactions. An improvement in an autoimmune disorder was also noted for Hoshimoto's thyroditis12. Immune parameters that were normal at the beginning of the studies did not change. In an outline summary of laboratory and clinical studies of the immunological effects of moxibustion, it was reported that moxibustion could reduce the level of rheumatoid factor in rheumatoid arthritis and improve symptoms of allergic rhinitis13. These studies all seem to suggest that the immune system seems to react to the burning of moxa near the skin, although it is impossible to say if this is due to the herbal concoctions, the nearness of the heat and corresponding vasodilatation or simply a placebo effect. Contraindications for Moxibustion Like Aromatherapy there are some conditions that could be worsened by the use of Moxibustion. TCM recognizes any heat disorder as a contraindication for Moxibustion based on the idea that moxa increases the bodies heat and does so effectively, and thus the treatment method fails to meet the criteria of balancing a hot condition with a cooling therapy. Theoretically, it could cause the disease to worsen by increasing the imbalance. Other contraindications for moxibustion involve the sensitive areas of the body, such as the face (where one especially avoids the scarring therapy, but also avoids getting smoke directly into the eyes or nose). It is difficult to know, based on the literature review, whether moxibustion is more effective than acupuncture or other stimulus methods administered for the same condition. In the absence of more detailed studies, moxa is 12 Hu Guosheng, et al., Clinical observations on Hashimoto's thyroiditis treated by indirect moxibustion with various Chinese medicines, Journal

of Traditional Chinese Medicine 1996; 16(1): 27-32. 13 Tang Youwei and Chen Shuhong, Acupuncture, moxibustion, and the immune system, International Journal of Oriental Medicine, 1999; 24(4):

192-198.

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applied primarily on the basis of the Chinese traditional medical descriptions, such as treating syndromes associated with cold, retention of food, spasms, immune deficiency, and local stagnation of fluids with formation masses. Moxa may be utilized in some cases of heat syndromes. Herbology

Herbal knowledge has long been one of the most dominant branches

of Chinese medicine. Using both indigenous herbs and those brought

by traders and merchants from all over the continent, its theories and

uses comprise a large percentage of Chinese medical publications

throughout the ages. One of the earliest of these books, known in

English as The Yellow Emperor's Classic on Internal Medicine, advises

the TCM practitioner to use the herbs as a general would use soldiers

in battle. One must use strategies and tactics that make the most of

individual herbs and take into account their synergistic effects when

combined together to defeat the illness and return the body to balance.

The focus is very holistic: it takes into account the nature of the

pathogen; the age and sex of the patient; and overall physical

condition of the patient.

Each herbal medicine prescription is a cocktail of many herbs tailored to the individual patient. One batch of herbs is typically decocted twice over the course of one hour. The practitioner usually designs a remedy using one or two main ingredients that target the illness. Then the practitioner adds many other ingredients to adjust the formula to the patient's yin/yang conditions.

Sometimes, ingredients are needed to cancel out toxicity or side-effects of the main ingredients. In China today, herbal medicine is used alongside conventional pharmaceutical treatment. Considerable attempts have been made to subject herbal medicine to scientific evaluation; however, most of the published Chinese studies on the subject fall far short of current scientific standards (they generally lack a placebo group.) In neighboring Japan, a variation of the herbal medicine system known as Kampo has become popular, and the Japanese Health Ministry has

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approved many Kampo remedies for common medical use. The scientific basis for these remedies remains incomplete, but several studies of minimally acceptable quality have been reported. Many massage practitioners are big believers in herbal remedies and use them personally, but the prescribing of any kind of herbal medicine is not allowed under our scope of practice. Many therapists do sell “herbal supplements” in their massage businesses and this is not specifically outside of our scope of practice, anymore than selling orthopedic equipment would be, it is simply that we cannot diagnose a need for orthopedic equipment or herbal supplements and prescribe them. Simply having them for sale in your business is perfectly ethical and legal. That being said, there is an ethical responsibility to sell products that are safe, and most herbal supplements sold in the United States are generally speaking, safe for the public to consume. Herbal supplements here are generally considered to be, at best “folk medicine” and at worst “snake oil.” However in China herbal remedies are an important part of the TCM model. In western herbal remedies we typically see one herb being used to treat one condition or deficiency, for example, they say take Gingko biloba to help with memory, or Hypericum perforatum (St. John's Wort) for depression. This is not the case with TCM, their herbal remedies consist of four categories of herbs: ministerial, deputy, assistant, and envoy. The ministerial herb addresses the principal pattern of the disease. Deputy herbs assist the ministerial herb or address coexisting conditions. Assistant herbs are designed to reduce the side effects of the first two classes of herbs, and envoy herbs direct the therapy to a particular part of the body. For example, in the case of “dryness in the liver and ascending Qi” described above, an herbalist might employ a ministerial herb to reverse ascending Qi, a deputy herb to exert a moistening effect, an assistant herb to prevent the stagnation of Qi (Qi stagnation is said to be a side effect of moistening herbs), and an envoy to carry these effects to the liver.

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So it’s not simply a matter of picking which herb goes with which condition, it’s a chemistry that requires each concoction to be brewed specifically for the individual. Types of Chinese Herbal Remedies Usually in TCM a person would visit an herbalist’s shop where a highly trained professional herbalist would prepare the herbal concoction for you and you would take it home and prepare it according to the instructions, which typically involve adding water, boiling for several hours in a ceramic pot, pouring off the liquid, adding more water, and repeating the process twice more. Certain herbs are supposed to be added right at the end, while others require extra-long preparation. Of course even TCM has modernized somewhat, and today you can prepackaged herbal formulas in powder, capsule, or tablet form that can be used much more conveniently than fully traditional herbs. Many Kampo combinations are licensed in Japan and are manufactured there on a large scale by reputable manufacturers. Herbs most commonly used in this manner include astragalus , dong quai , ginger , kudzu ( Pueraria lobata ), licorice , lycium , Panax ginseng , and schizandra. In addition to herbs, substances that we might consider supplements are utilized in TCM. These include extract of human placenta, 76 glandular extracts, and a variety of minerals. In the traditional system of Chinese herbal medicine, herbal formulas can be used to treat virtually any condition. Some of the most common uses in China include liver disease ( hepatitis and cirrhosis ), sexual dysfunction in men , infertility in women , insomnia , colds and flus , menstrual pain , irregular menstruation, menopause , and cancer treatment support . The efficacy of TCM-Herbalism The standard for establishing effectiveness in western sciences is to us a double-blind, placebo-controlled trial. Like all other practices of Traditional Chinese Medicine we have looked at in this course is difficult to fit herbalism into those categories. The problem with these methods of evaluating TCM is that each practice is based on the individual-so doing a clinical trial is very difficult because no two individuals have the exact same diagnosis in TCM.

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In TCM herbalism, for example, there is no one herb for depression. In the western medical model you can test the efficacy of St. John's Wort with a group of people diagnosed with clinical depression and give some of them a placebo and some of them the actual herb and then measure the results, but this just can’t be done with the TCM model. As described above, there is no such thing as a TCHM remedy for depression, for example. Each person with depression would have a different diagnosis based on their assessment with the TCM practitioner, as each individuals would have different degrees of Qi deficiency or excess and each would receives individualized treatment. The closest they can come to a western style test for the efficacy of TCM herbalism is to chose people to participate in a study based on a Western diagnosis. Then all of the participants are diagnosed by a practitioner of TCM and prescribed an herbal formula specific to their individual constitutions according to the principles of TCM. Finally, another party steps in and provides participants with either the real formula or a placebo formula, under conditions whereby neither practitioners nor participants know which is which. Some studies utilize a fixed remedy for all participants, in hopes that it will still prove effective on average. Such an approach cannot be said to truly test the effectiveness of TCM since that is not the way it is practiced, but at least it gives the western-minded scientist something they can look at in their own frame of reference. Another problem is cultural. It’s not racist to point out that most of the clinical studies that prove the efficacy of TCM originate in China and those that show it has no practical use generally come out of Europe or the United States. There may be an element of cultural pride or prejudice coloring these studies, but the pattern is definitely there. That being said, let’s look at some of the studies that were done with TCM herbal remedies. Chronic Hepatitis Hepatitis B is endemic in China. Of the 350 million individuals worldwide infected with the hepatitis B virus (HBV), one-third reside in China. As of

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2006 China has immunized 11.1 million children in its poorest provinces as part of several programs initiated by the Chinese government and as part of the Global Alliance for Vaccines and Immunization (GAVI). However, the effects of these programs have yet to reach levels of immunization that would limit the spread of hepatitis B effectively, so herbal remedies are widely used. The herbal concoction Shosaiko-to (Minor Bupleurum) has been approved as a treatment for chronic hepatitis by the Japanese Health Ministry, and it enjoys wide use in that country and in China. A search of the literature uncovered only one large-scale, double-blind, placebo-controlled study supporting its effectiveness14. This was conducted in a 24-week trial where the efficacy of Shosaiko-to was tested in 222 people with chronic active hepatitis using a double-blind, placebo-controlled crossover design. The results showed that use of Shosaiko-to significantly improved liver function measurements compared to placebo. Other Chinese herbal formulas that have shown promise for the treatment of chronic hepatitis include Bing Gan Tang, Yi Zhu decoction, Fuzheng Jiedu Tang, and Jianpi Wenshen recipe. However, the quality of most of these studies are not up to western standards and are too weak to establish a firm report. Liver Cirrhosis In another study, this one a double-blind, placebo-controlled study, 260 people with cirrhosis were randomly assigned to take Shosaiko-to or a placebo, along with conventional treatment15. This study was much longer, taking place over 5 years, and the people taking the herb appeared to be less likely to develop cancer or die, but the results were again too short for statistical significance. For the subgroup of participants without hepatitis B infection, the benefits were statistically significant at the usual cutoff point. Irritable Bowel Syndrome In another double-blind, placebo-controlled trial, 116 people suffering from irritable bowel syndrome (IBS) were randomly assigned to receive individualized Chinese herbal formulations, a “one-size-fits-all” Chinese herbal formulation, or placebo. 11 Treatment consisted of 5 capsules 3 14 Japanese Health Ministry confirms effectiveness of Tsumura's top-selling kampo herbal prescription. Kampo Today [serial online]. 1995;1.

Available at: http://www.tsumura.co.jp/english/ . Accessed November 4, 2002. 15 Oka H, Yamamoto S, Kuroki T, et al. Prospective study of chemoprevention of hepatocellular carcinoma with sho-saiko-to (TJ-9). Cancer.

1995;76:743-749.

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times daily, taken for 16 weeks. The results were very interesting. They showed that both forms of active treatment were superior to the placebo, significantly reducing IBS symptoms. The interesting thing was that the positive results for the individualzed treatment and the “one-size-fits-all” Chinese herbal formulation were roughly the same16. Constipation The popular Japanese Kampo formula called Daio-kanzo-to is a mixture of rhubarb and licorice. In a 2-week, double-blind, placebo-controlled trial, 132 people suffering from constipation were randomly assigned to one of three groups: placebo, low-dose Daio-kanzo-to, or high-dose Daio-kanzo-to. The results indicate that the higher-dose group, but not the lower-dose group, experienced statistically significant improvements in constipation compared to placebo17. Allergic rhinitis Two herbal remedies, Sho-seiryu-to and Biminne were subjected to western style scrutiny. Sho-seiryu-to was tested in a double-blind, placebo-controlled trial consisting of 220 people with allergic rhinitis given either placebo or the Kampo remedy for a period of 2 weeks. The results showed a significal reduction in the symptoms of rhinitis compared to that of the placebo. Following that success an 11-herb combination remedy called Biminne was tested in a 12-week, double-blind, placebo-controlled trial. In this test 58 people with allergic rhinitis were given either placebo or Biminne. This one was not as successful, some of the subjects taking Biminne showed improvement, but it was not statistically conclusive. Osteoarthritis Duhuo Jisheng Wan is perhaps the best known and most widely used Chinese herbal recipe for arthralgia, but the clinical study to verify its efficacy is lacking. The purpose of this study was to compare the efficacy of DJW versus diclofenac in symptomatic treatment of osteoarthritis of the knee.

16 Leung WK, Wu JC, Liang SM, et al. Treatment of diarrhea-predominant irritable bowel syndrome with traditional Chinese herbal medicine: a

randomized placebo-controlled trial. Am J Gastroenterol. 2006;101:1574-1580. 17 A double-blind study is used to reevaluate constipation formula. Kampo Today [serial online]. 2000:4. Available at:

http://www.tsumura.co.jp/english/ . Accessed November 4, 2002.

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This study was a randomized, double-blind, double-dummy, controlled trial. The 200 patients suffering from osteoarthritis of the knee, were randomized into the DJW and diclofenac group. The patients were evaluated after a run-in period of one week (week 0) and then weekly during 4 weeks of treatment. The clinical assessments included visual analog scale (VAS) score that assessed pain and stiffness, Lequesne's functional index, time for climbing up 10 steps, as well as physician's and patients' overall opinions on improvement. Ninety four patients in each group completed the study. In the first few weeks of treatment, the mean changes in some variables (VAS, which assessed walking pain, standing pain and stiffness, as well as Lequesne's functional index) of the DJW group were significantly lower than those of the diclofenac group. Afterwards, these mean changes became no different throughout the study. Most of the physician's and patients' overall opinions on improvement at each time point did not significantly differ between the two groups. Approximately 30% of patients in both groups experienced mild adverse events. DJW demonstrates clinically comparable efficacy to diclofenac after 4 weeks of treatment. However, the slow onset of action as well as approximately equal rate of adverse events to diclofenac might limit its alternative role in treatment of osteoarthritis of the knee18. Muscle Cramps Muscle cramps are one of the most common complications of hemodialysis (HD), and often are a source of great pain in spite of various clinical measures. The traditional herbal medicine, Shao-Yao-Gan-Cao-Tang (Japanese name: Shakuyaku-kanzo-to), consists of equal amounts of paeony and licorice roots, and has been used in Japan and China for muscle pain or skeletal muscle tremors. To determine whether this medicine is able to prevent frequent and unendurable muscle cramps in patients undergoing HD, Shakuyaku-kanzo-to at 6 g per day was prospectively administered for 4 weeks to five patients on HD who were suffering from frequent muscle cramps. The frequency and severity of cramping before and after the treatment were carefully observed and compared. Skeletal muscle cramps completely disappeared in two of the

18 Chinese herbal recipe versus diclofenac in symptomatic treatment of osteoarthritis of the knee: a randomized controlled trial

[ISRCTN70292892] Supanimit Teekachunhatean1, Puongtip Kunanusorn1, Noppamas Rojanasthien1, Kanit Sananpanich2, Suwalee

Pojchamarnwiputh3, Sorasak Lhieochaiphunt4 and Sumalee Pruksakorn5

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treated patients after the start of oral administration of Shakuyaku-kanzo-to. Moreover, the frequency of cramping was significantly decreased in two of the remaining three patients after persistent administration. The severity of muscle cramps was also decreased by this treatment in the responsive patients. No serious side effects were detected during the treatment period. The inhibitory effect of Shakuyaku-kanzo-to on muscle contraction was also experimentally examined by using phrenic nerve-diaphragm preparations from male Wistar rats. Differences between the twitch responses were determined when the diaphragms and the nerves were stimulated in the presence and absence of the extract of Shakuyaku-kanzo-to. The results demonstrated that extracts of paeony and licorice roots inhibit contraction of skeletal muscles in rats. Taken together, we suggest that administration of Shakuyaku-kanzo-to is a safe, effective treatment for preventing muscle cramps in patients undergoing HD19. Menstrual Pain Dysmenorrhoea refers to the occurrence of painful menstrual cramps. The efficacy of conventional treatments such as nonsteroidals is considerable, however the failure rate is still often 20-25%. Many consumers are now seeking alternatives means to deal with this pain and one of them is Herbal and dietary therapies. To determine the efficacy and safety of herbal and dietary therapies for the treatment of primary and secondary dysmenorrhoea when compared to each other, placebo, no treatment or other conventional treatments (e.g. NSAIDS). Seven trials were included in the review. Quality assessment and data extraction were performed independently by two reviewers. The main outcomes were pain intensity or pain relief and the number of adverse effects. Data on absence from work and the use of additional medication was also collected if available. Data was combined for meta-analysis using Peto odds ratios for dichotomous data or weighted mean difference for continuous data. A fixed effects statistical model was used. If data suitable for meta-analysis could not be extracted, any available data from the trial was extracted and presented as descriptive data. 19 Am. J. Chin. Med. 31, 445 (2003). DOI: 10.1142/S0192415X03001144

Effect of Orally Administered Shao-Yao-Gan-Cao-Tang (Shakuyaku-kanzo-to) on Muscle Cramps in Maintenance Hemodialysis Patients: A

Preliminary Study

Fumihiko Hinoshita

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The trial showed the Japanese Kampo formula Toki-shakuyaku-saherbal combination to be more effective for pain relief than placebo, and less additional pain medication was taken by the treatment group20. Diabetes Another study was conducted using 200 people that suffer from Diabetes. The study was aimed at determining the efficacy of Coptis Formula, a TCM herbal remedy compared to the drug glibenclamide, which is commonly prescribed for diabetes. Coptis Formula appeared to significantly enhance the effectiveness of the drug; however, the herbs produced marginal benefits at best when taken alone. Eczema In paired double-blind, placebo-controlled trials carried out by one research group, the Chinese herbal mixture known as Zemaphyte produced significantly better effects than placebo for both adults and children21. Each included approximately 40 people and used a crossover design in which all participants received the real treatment and placebo for 8 weeks each. Use of the herb significantly reduced eczema symptoms compared to placebo. In a superannuate 12-week, double-blind study, a different traditional Chinese herbal formula also failed to prove more effective than placebo for treatment of eczema. Headache A double-blind study enrolling 57 people with acute tension headache compared the application of Tiger Balm (a topical ointment composed of camphor, menthol, cajaput, and clove oil) to the forehead against placebo ointment, as well as against the drug Tylenol. The placebo ointment contained mint essence to make it smell similar to Tiger Balm. Real Tiger Balm proved more effective than placebo, and just as effective and more rapid-acting than acetaminophen22. HIV Chinese herbal therapies have been investigated for the treatment of HIV, but the results have not been very promising. In a 12-week, double-blind,

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21 Sheehan MP, Rustin MH, Atherton DJ, et al. Efficacy of traditional Chinese herbal therapy in adult atopic dermatitis. Lancet. 1992;340:13-17. 22 Schattner P, Randerson D. Tiger Balm as a treatment of tension headache. A clinical trial in general practice. Aust Fam Physician.

1996;25:216,218,22

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placebo-controlled trial, 30 HIV-infected adults with CD4 counts of 200 to 500 were given a Chinese herbal formula containing 31 herbs. Intervention and placebo groups were equivalent at baseline regarding, respectively, previous antiretroviral therapy (74% versus 79%), median CD4 cell counts (0.20 x 109/L versus 0.25 x 109/L), and median HIV-1 plasma viral loads (35,612 copies/ml versus 52,027 copies/ml). At enrollment, none of the study subjects was seriously ill or depressed, and average coping and quality of life scores were in the normal range. In all, 53 (78%) participants completed the study. Patients taking Chinese herbs reported significantly more gastrointestinal disturbances (79% versus 38%; p = .003) than those receiving placebo. No therapy-related toxicities were observed. At completion of the study, no significant differences between the intervention and placebo groups were found regarding plasma viral loads, CD4 cell counts, symptoms, and psychometric parameters. HIV-1 RNA level was unchanged at study end. Among participants who were not on concomitant antiretroviral therapy, median CD4 cell counts declined by 0.05 x 109/L in both the intervention and placebo groups. This standardized formulation of Chinese herbs for HIV-infected individuals did not improve quality of life, clinical manifestations, plasma virus loads, or CD4 cell counts. The data suggest that this formulation of Chinese herbs is not effective when administered in a Western medicine setting23. Chemotherapy A double-blind study performed in Hong Kong evaluated the potential benefits in cancer chemotherapy of personalized herbal formulas designed according to the principles of Traditional Chinese herbal medicine. Fifteen trials involving 862 participants met the inclusion criteria. All trials were of poor quality with a considerable risk of bias. There was a significant improvement in quality of life when CHM is combined with chemotherapy compared to chemotherapy alone. There was no significant difference in short term effectiveness and limited inconclusive data concerning long term survival. Five promising herbs have been identified that might improve quality of life in patients with non-small cell lung cancer undergoing chemotherapy24.

23 Randomized, Placebo-Controlled Trial of Chinese Herb Therapy for HIV-1-Infected Individuals.

Weber, Rainer; Christen, Lisanne; Loy, Monika; Schaller, Silvio; Christen, Stephan; Joyce, Charles R. B.; Ledermann, Ueli; Ledergerber, Bruno;

Cone, Richard; Lüthy, Ruedi; Cohen, Misha R. 24Chen S, Flower A, Ritchie A, et al. Oral Chinese herbal medicine (CHM) as an adjuvant treatment during chemotherapy for non-small cell lung

cancer: A systematic review. Lung Cancer. 2010 May;68(2):137.

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Chapter 5: A History of TCM25 Antiquity: It is believed that the origins of Traditional Chinese Medicine goes back more than 5,000 years to at least the 3rd millennium BC. The practice of acupuncture probably dates back to the Stone Age, as suggested by findings of ancient stone needles. Also, hieroglyphs and pictographs documenting acupuncture and moxibustion have been found, dating back to the Shang Dynasty (1600-1100 BC). 3rd millennium BC: During the golden age of his reign from 2698 to 2596 BC, the Yellow Emperor is supposed by Chinese tradition to have composed his Huang Di Nei Jing ("The Yellow Emperor's Canon of Medicine" or simply, "The Canon of Medicine"), as a result of a dialogue with his minister Ch'i Pai. "The Canon of Medicine", the earliest and most comprehensive medical classic from both theoretical and clinical point of view, covers a variety of subjects, including human and nature; human anatomy and physiology; causes of diseases; pathology, the study and diagnosis of disease; differentiation of symptoms and signs; disease prevention and treatment; and health preservation. The theories of Yin-Yang, visceral organs and meridians have since become the foundation of Traditional Chinese Medicine. 13th century BC: Records of various diseases, including tooth decay and parasitic diseases, had been inscribed on tortoise shells and bones found near Anyang in Henan Province, China. 12th century BC: The Shi Jing (Book of Poems) was compiled, containing a collection of verses on the use of herbs such as fritillaries, motherwort, and asiatic plantain. 8th - 3rd century BC: Medical writings were found among the books made of silk discovered in Tomb No. 3, excavated in 1973 near Mawangdui Village in Changsha, Hunan Province, China. They include: methods of pulse feeling; 11 meridians for moxibustion of the arms and feet; and prescription for 52 diseases. 5th century BC: The celebrated physician Bian Que successfully employed diagnostic pulse feeling and acupuncture treatment to cure the crown

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CC http://health.jbdirectory.com/Chronology:Traditional_Chinese_Medicine

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prince of the State of Guo who was in shock and proclaimed by the court to have just died. 3rd century BC: Under the influence of the prevailing materialistic outlook and simple dialectics, particularly the philosophical concepts of Yin-Yang and the Five Elements, traditional Chinese medicine was integrated into a unique system of medical theories. 2nd century BC: China's first pharmacological work, Shen Nong Ben Cao Jing ("The Divine Peasant's Herbal" or simply, "The Herbal") was written. 365 kinds of drugs were divided, according to their toxicity, into 3 categories: (1) superior; (2) common; and (3) inferior. Hua Tuo (c. 145-208), the most famous doctor in ancient China, performed laporotomy (abdomen surgery) under drug anesthesia. He was the first person in the world to use narcotic drugs and his skill in this field was ahead of the West by at least 1,600 years. He also developed the Five Animal Play, exercises that mimics the movements and postures of five animals, i.e. tiger, deer, bear, ape, and bird. According to Hua Tuo, the movements are fundamentally important to health and by mimicking the movements of these animals, all parts of the body are exercised and stretched, thereby activating the flow of fluid and energy in the body. 3rd century AD: Beginning of the century: Zhang Zhongjing (150-219 AD) wrote Treatise on Febrile and Miscellaneous Diseases, a book on diagnosis and treatment of fevers and other miscellaneous diseases. Outlining a system of diagnosis and treatment of diseases based on analyses and differentiation of syndromes with tested prescriptions, the work laid the foundation for clinical practice in traditional Chinese medicine. Later divided into 2 books, Shang Han Lun ("Treatise of Febrile Diseases") and Jin Kui Yao Lue Fang Lun ("Synopsis of Prescriptions of the Golden Chamber"), the Treatise, together with Canon of Medicine and The Herbal have become the most influential works in the field. Mai Jing ("Classic on the Pulse") was compiled, with 24 different patterns and their diagnostic significance described in detail. Zhen Jiu Jia Yi Jing ("A Classic of Acupuncture and Moxibustion") was compiled. This work gave comprehensive information on the location and

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therapeutic effects of the acupuncture points and detailed the experiences gained in these treatments. 5th century AD: Couching of cataracts with needles was developed. 6th century AD: Ben Cao Jing Ji Zhu ("Commentaries on Materia Medica") was compiled, after Shen Nong Ben Cao Jing ("The Herbal") fell behind clinical needs. It classified 730 medicines, according to their sources and therapeutic applications. 7th century AD: Creating false teeth with amalgam was developed. Mai Jing ("Classic on the Pulse") and Zhen Jiu Jia Yi Jing ("A Classic of Acupuncture and Moxibustion") were taken to Japan, with both being listed as textbooks by the Japanese government for a medical degree. 8th century AD: 752 AD: Wang Tao (c. 702-772 AD), a well-known scholar of Chinese medicine, wrote a book called Waitai Miyao ("The Medical Secrets of An Official"). This book, which consisted of 40 volumes and 1,104 categories, discusses over 6,000 herbal prescriptions. 11th century AD: 1025: Pulse feeling, introduced to the Arabs, was reflected in the voluminous work, The Canon of Medicine by the celebrated physician, Avicenna. 12th century AD: Treatment of vertebra fracture by suspension, reduction, and other means, was developed. 13th century AD: 13 medical specialities were established, including internal medicine, pediatrics, obstetrics and gynaecology, ophthalmology, stomatology and dentistry, pharyngo-laryngology, bone-setting, and traumatology, as well as acupuncture and moxibustion. 15th century AD: 1478: The celebrated physician and naturalist Li Shizhen compiled Ben Cao Gang Mu ("Compendium of Materia Medica"), a 52-volume

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encyclopedia of 1,892 medicines, with illustrations and 11,000 prescriptions. Having been translated in whole or in part into Japanese, English, German, French, Latin, and Russian, it has become a masterpiece known throughout the world. 16th century AD: Innoculation to prevent smallpox was widely used in China. It was only after vaccination was initiated by Edward Jenner in 1796 that innoculation was abandoned. 17th century AD: Mid of the century: Epidemics in China arose outside the range of previous Chinese medical experience and a school of thought in the field of febrile diseases (any disease associated with or characterized by fever) forwarded the theory that respiratory and digestive infections were the cause of these epidemics. 1659: Xin Xiu Ben Cao ("Revised Materia Medica") was compiled, listing 844 medical substances. This pharmacopoeia, sponsored by the Manchu imperial court, was the first officially issued in China, as well as the first in the world. 1669: Tongrentang, a Chinese pharmaceutical company, was founded and is today the largest producer of traditional Chinese medicine (TCM). The company, headquartered in Beijing, is engaged in both manufacture and retail sales, operating drug stores predominantly in Northeast China. Russia sent doctors to China to learn innoculation for smallpox. 18th century AD: Books on epidemic febrile diseases began to catalogue experiences of diagnosing and treating such diseases. Some of the treatments, such as for diptheria and epidemic encephalitis, have been proven effective today. 19th - 1st half of 20th century: Traditional Chinese medicine developed more slowly than Western medicine, due to various historical reasons. 20th century: 1911: The Xinhai Revolution saw the overthrow of the Manchu dynasty. During this time, China developed a desire to modernize, and the new

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government, proposing the abolition of traditional Chinese medicine, took measures to stop its development and use. 1941: The classic Handbook of Traditional Drugs listed 517 drugs, 45 of which were animal parts and 30 were minerals. 1966 - 1976: Traditional Chinese medicine doctors were purged from the schools, hospitals and clinics under Mao Zedong's Cultural Revolution, with many of the old practitioners jailed or killed. 1979: The National Association for Chinese Medicine was established, and many of the traditional texts were edited and republished. 1980: The World Health Organization released a list of 43 types of diseases which can be effectively treated with acupuncture. 1997: Some 10,000 Traditional Chinese Medicine (TCM) practitioners in the United States served more than 1 million patients each year.

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Summary of Fundamentals of TCM for Massage Therapists Traditional Chinese Medicine looks at the human body as a microcosm, a model of the entire universe,or “all that is”. In the body we find the Yin Yang in constant motion and the Qi energy manifested in the Five Elemental forms. This Qi energy moves through the body along a network of pathways known as Meridians, along wich are highly esensitive areas that can be manipulated to influence this flow. Practitioners of TCM have learned over centuries of study that this Qi energy, which is the pregenitor of good health, can be influenced by diet, exercise and the application of specific therapies, including Acupuncture, Acupressure, Shiatsu, Tui Na, Moxibustion and Cupping. Although the methods differ slightly, they all share the common goal of removing blockage and stagnation of Qi in the body and thereby enhancing health. Of all of the courses in our Asian Bodywork series this one has the least amount of material directly related to hands on work, since it covers the basic theories of Traditional Chinese Medicine and gives you an introductory look at several different facets of healing, specifically herbalism, Moxibustion and the Health benefiting exercises of Tai Chi and Qigong. As a massage therapist I understand that you are most interested in the hands on bodywork, but unfortunately the majority of that is described in our course ABS003: Tenants of Zen Shiatsu. This courses was needed to lay the foundation, the other two build upon it. Traditional Chinese Medicine sees the universe as being connected, and so their practice of medicine is also made up of several practices that are intricately connected, including hands on massage, exercise, and proper diet. This course has been an introduction to the Fundamentals of Traditional Chinese Medicine. If you have enjoyed learning about this ancient healing philosophy we encourage you to continue on the journey with ABS002: Introduction to Meridians and Acupoints.

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Certificate of Completion and Transcript In order to receive your certificate of completion and an updated transcript for this course you must complete and pass the quiz. Once we have received your quiz we will generate your certificate and transcript and both will be emailed to you. If you completed the last quiz during our business hours (Monday-Friday 8:00 am-5:00 pm Pacific Standard Time) it should be emailed to you within a few minutes. If you complete the last quiz after business hours, or on a weekened it will still be emailed to you as quickly as possible. We check the system every hour until midnight most days so it should go out within an hour of you taking it. If you take the last quiz after midnight you will probably have to wait until the next morning, we do sleep. Please give us a full 24 hours before you call us if you have not received your certificate and transcript. We pride ourselves on being very fast, but if there is a condition beyond our control (the Internet Service Provider is down, etc) it may take us longer than usual. Also please be aware that many people wait until the last minute to do their courses. For this reason, the last few days of the month (28th, 29th, 30th, etc) are usually very, very busy times for us so our turn around time may be a little slower-but it should still be within 24 hours. If it has been more than 24 hours and you still have not received your emailed certificate, by all means call us! The number is (209) 777-6305. Lost Certificates and Transcripts If you need another copy of your documents emailed to you we will gladly do that for free at any time, just go to the contact page on our website and ask for it.

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Course Evaluation We would like to hear some feedback form you. You can complete the evaluation online by clicking this link: http://www.sasionline.com/courseevaluation.html If you are using the “embedded” version of this course you will not be able to click the link above but there should be one you can access on the webpage itself. Thanks for taking our course; we really appreciate your business and we hope you come back to us next time you need continuing education hours. We would also love it if you would “Like us” on facebook, you can find us at www.facebook.com/beyondmassageschool. Errata If you found a typo PLEASE LET US KNOW what page it is on and the paragraph and we will fix it ASAP. This book has 45,000 words in the course content alone. Some of those are going to be misspelled. We’re not perfect, but we strive to be- so help us out. Help and Technical Support We have worked hard to make this course as easy to use as possible, but it does rely on technology and sometimes there are factors that are out of our control (like your local internet provider, your computer, your browser version, the device you are using etc). If for some reason you are not able to access the quiz you can call us and let us know, and we will problem solve it for you. We have office hours, Monday-Friday 8:00 am-5:00 pm PST but you can call or email for help at any time after hours, I monitor the system every hour until I go to sleep, so call if you need to and I will do my best to help you. The number is (209) 777-6305.

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Bibliography

The Medical Classic of the Yellow Emperor, translated by Zhu Ming, Foreign Language Press, Beijing, China, 2001, 302 pages.

Peter Deadman and Mazin Al-Khafaji with Kevin Baker. "A Manuel of Acupuncture" Journal of Chinese Mediceine, 2007. O’Conner J and Bensky D (translators), Acupuncture: A Comprehensive Text, 1981 Eastland Press, Seattle, WA. Wiseman, Nigel and Andy Ellis (1995). Fundamentals of Chinese Medicine: Zhong Yi Xue Ji Chu. Revised edition. Brookline, Mass.: Paradigm Publications. BIBLIOGRAPHY-JOURNALS Sivin, Nathan (1988). "Science and Medicine in Imperial China—The State of the Field." The Journal of Asian Studies (Vol. 47, number 1): 41–90.

Yu Lubin How To Learn Chinese Herbs 1-6 The Journal of Chinese Medicine vol 24-75

Haosheng Zhang The Art of Applying Chinese Herbs The Journal of Chinese Medicine vol 79-34 Zhu Ming (June 2007) On the natural medical features of Traditional Chinese Medicine The Journal of Chinese Medicine Peter Deadman and Mazin Al-Khafaji with Kevin Baker. "A Manuel of Acupuncture" Journal of Chinese Mediceine, 2007. Effects of Traditional Cupping Therapy in Patients With Carpal Tunnel Syndrome: A Randomized Controlled Trial published in The Journal of Pain Volume 10, Issue 6, June 2009, Pages 601–608 Clinical Efficacy of Hijamat (Cupping) in Waja-ul-Mafasil (Arthritis) Indian Journal of Traditional Knowledge Vol.04 October 2005

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Wang Kenliang, Several diseases treated by suppurative moxibustion therapy, 2000 International Congress on Traditional Medicine, April 22-24, Beijing. Li Huailin, 34 cases of herpes zoster treated by moxibustion at dazhui (GV-14), Journal of Traditional Chinese Medicine 1992; 12 (1): 71. Shi Huaisheng, et al., Ginger-partitioned moxibustion on sifeng point (extra-29) in treating children's asthenia and its effects on cellular immune functions, Chinese Acupuncture and Moxibustion 1995; (6): 9-10. Xhou Jianwei, et al., Impact of medicated mugwort moxibustion on serum gastrin, d-xylose excretion rate, and T-cell subgroup in patients with spleen deficiency syndrome, Chinese Acupuncture and Moxibustion 1998; (1): 15-16. Wu Huangan, et al., Clinical therapeutic effect of drug-separated moxibustion on chronic diarrhea and its immunological mechanisms, Journal of Traditional Chinese Medicine 1997; 17(4): 253-258. Hu Guosheng, et al., Clinical observations on Hashimoto's thyroiditis treated by indirect moxibustion with various Chinese medicines, Journal of Traditional Chinese Medicine 1996; 16(1): 27-32. Tang Youwei and Chen Shuhong, Acupuncture, moxibustion, and the immune system, International Journal of Oriental Medicine, 1999; 24(4): 192-198. Japanese Health Ministry confirms effectiveness of Tsumura's top-selling kampo herbal prescription. Kampo Today [serial online]. 1995;1. Available at: http://www.tsumura.co.jp/english/ . Accessed November 4, 2002. Oka H, Yamamoto S, Kuroki T, et al. Prospective study of chemoprevention of hepatocellular carcinoma with sho-saiko-to (TJ-9). Cancer. 1995;76:743-749. Leung WK, Wu JC, Liang SM, et al. Treatment of diarrhea-predominant irritable bowel syndrome with traditional Chinese herbal medicine: a randomized placebo-controlled trial. Am J Gastroenterol. 2006;101:1574-1580.

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A double-blind study is used to reevaluate constipation formula. Kampo Today [serial online]. 2000:4. Available at: http://www.tsumura.co.jp/english/ . Accessed November 4, 2002. Chinese herbal recipe versus diclofenac in symptomatic treatment of osteoarthritis of the knee: a randomized controlled trial [ISRCTN70292892] Supanimit Teekachunhatean1, Puongtip Kunanusorn1, Noppamas Rojanasthien1, Kanit Sananpanich2, Suwalee Pojchamarnwiputh3, Sorasak Lhieochaiphunt4 and Sumalee Pruksakorn5 Am. J. Chin. Med. 31, 445 (2003). DOI: 10.1142/S0192415X03001144 Effect of Orally Administered Shao-Yao-Gan-Cao-Tang (Shakuyaku-kanzo-to) on Muscle Cramps in Maintenance Hemodialysis Patients: A Preliminary Study Fumihiko Hinoshita Sheehan MP, Rustin MH, Atherton DJ, et al. Efficacy of traditional Chinese herbal therapy in adult atopic dermatitis. Lancet. 1992;340:13-17. Schattner P, Randerson D. Tiger Balm as a treatment of tension headache. A clinical trial in general practice. Aust Fam Physician. 1996;25:216,218,22 Randomized, Placebo-Controlled Trial of Chinese Herb Therapy for HIV-1-Infected Individuals. Weber, Rainer; Christen, Lisanne; Loy, Monika; Schaller, Silvio; Christen, Stephan; Joyce, Charles R. B.; Ledermann, Ueli; Ledergerber, Bruno; Cone, Richard; Lüthy, Ruedi; Cohen, Misha R. Chen S, Flower A, Ritchie A, et al. Oral Chinese herbal medicine (CHM) as an adjuvant treatment during chemotherapy for non-small cell lung cancer: A systematic review. Lung Cancer. 2010 May;68(2):137.