A Comparison of the Somatosensory Effects of Therapeutic vs. Medical Massage, Part II

By Gregory T. Lawton, DN, DC

Mechanoreceptors and nociceptors are somatic receptors that act as biological sensors in response to physiological stimuli.The nociceptors respond to abnormal stimuli and transmit this information, most often as pain signals to the higher neurological centers. Mechanoreceptors respond to normal stimuli and transmit this information. Each of these two types of biological sensors tends to dampen or inhibit the other.

Nociceptors are found in the skin and throughout the musculoskeletal system. Nociceptors have been found in almost all connective tissue, with the exception of joint cartilage, synovial membranes, and certain parts of the inner vertebral disc. Nociceptive stimulation due to noxious stimuli has dramatic effects on the nervous system, and has been shown to promote segmental responses such as muscle spasm and increased sympathetic activity. Nociceptor stimulation can also stimulate suprasegmental activity that affects the hypothalamus and can cause sweating, nausea, weakness, pallor and dizziness. A commonly recognized problem in chronic pain is the continuing stimulation of nociceptors.

Mechanoreceptors respond to normal tissue environment and report this homeostatic activity to the central nervous system. Mechanoreceptors appear to respond to weak mechanical signals, gentle movement and pressure, and normal range of motion activities of the joints. Mechanoreceptors do not respond to noxious stimuli and are in fact inhibited by nociceptive input.

The two previous paragraphs, regarding nociceptors and mechanoreceptors are vitally important in understanding what constitutes effective medical massage therapy. Rather than basing our understanding and application of massage therapy technique simply on the theories or pet techniques of a few massage therapists, or upon inaccurate models of physiological function, we should seek to understand the scientific literature that reveals the deeper secrets of physiological function as it pertains to connective tissue therapy.

Based on what is scientifically known about mechanoreceptors and nociceptors, we can suggest the following principles as applied to medical massage therapy:

1. Mechanoreceptors respond to normal connective tissue environment.
2. Nociceptors respond to abnormal connective tissue environment.
3. Mechanoreceptors and nociceptors are widely spread throughout the body tissues, from the skin to the periosteum.
4. Almost all connective tissues contain mechanoreceptors and nociceptors.
5. Mechanoreceptor stimulation will dampen or inhibit nociceptor stimulation.
6. Nonciceptor stimulation will dampen or inhibit mechanoreceptor stimulation.
7. Almost all conditions treated by the medical massage therapist involve nonciceptive symptoms.
8. Almost all conditions treated by the medical massage therapist can be improved through mechanoreceptor stimulation.

The above eight principles provide the medical massage therapist with both a mandate and an outline for delivering medical massage therapy. In addition, the medical massage therapist can use the scientific evidence from studies on mechanoreceptors and nociceptors to judge and evaluate massage therapy technique. Clearly, the scientific literature supports manual therapy technique that promotes responses in mechanoreceptors and any technique or activity that dampens or inhibits nociceptors. Four aspects of clinically effective treatment can be identified from the eight principles outlined above:

1. Massage therapy technique should stimulate mechanoreceptors through gentle pressure and joint movement.
2. Massage therapy technique should be directed at all connective tissue structures known to harbor mechanoreceptors, from superficial to deep structures, but this technique must stimulate mechanoreceptors, not nociceptors.
3. Massage therapy technique should include gentle joint mobilization technique designed to stimulate mechanoreceptors in all connective tissues and the joint complex.
4. Positive connective tissue clinical results will continue long after the massage therapy treatment due to the "normalization" of connective tissue and joint complex activities that will increase mechanoreceptor activation and will inhibit nociceptor stimulation.

Therapeutic massage techniques (or any system of massage therapy) that stimulates nociceptor activity via painful and improper technique, will retard and delay the healing of injured connective tissues. Specifically, techniques that are improperly applied such as trigger point therapy and periosteal or deep tissue techniques will stimulate nonciceptive input, muscle spasm, pain, sympathetic hyperactivity, and supra-segmental physiological responses.

It should now be clear that the proper application of medical massage technique should include the avoidance of technique that stimulates nociceptive responses in the nervous system. This stimulation has a negative effect on the outcome of the treatment and the patient's healing process. From this viewpoint, pain is not gain. The massage therapist who wishes to apply the principles presented here in the clinical application of massage therapy technique probably needs to make subtle changes in manual technique. These changes include the following:

1. Deep tissue techniques should be applied with a "soft hand technique."
2. Deep tissue techniques should be applied first with a gentle pressure into the tissue for a depth of one to three centimeters (to stimulate the mechanoreceptors), then to the depth of the periosteum or joint complex.
3. Joint mobilization techniques should be applied first with supportive manual pressure on the joint, then with gentle normal range of motion.
4. All approachable connective tissue at the joint complex should be systematically massaged, then mobilized.

Medical massage therapy is a scientifically based method of manual therapy. Medical massage seeks a clear understanding of the scientific principles of physiology that affect connective tissue healing and treatment. Many currently utilized therapeutic massage techniques unnecessarily inflict patient pain and exacerbate the patient's condition, due to a faulty and erroneous viewpoint regarding biological sensory input and "proproceptors." This material is offered to all massage therapists, to clarify this issue and to offer more effective treatment methods. The next time you see an article showing (r a massage instructor demonstrating) trigger point therapy with the elbow buried an inch into the levator scapula and trapezius, consider the nociceptive stimulation this technique is provoking and reconsider the value of this type of technique.

Regardless of what we call or label the manual therapy techniques that we apply to clinical cases, we must, as massage professionals, recognize the need to thoroughly investigate current scientific research regarding connective tissue pathophysiology and reconsider our technique and treatment protocol based on this knowledge. For those massage therapists who prefer to practice general relaxation massage in recreational settings, while they may voluntarily choose not to practice medical massage, they must also recognize and understand the higher mechanisms of connective tissue rehabilitation and the ability of the medical massage therapist to treat connective tissue pathology.

The pet techniques of the massage therapist should not determine the patient's treatment. Treatment should be based on the findings, diagnosis, causation and symptoms of the patient's presenting problem or condition.

The allied medical professions and the chiropractic profession can also benefit from a detailed education in medical massage technique and protocol. The application of non-exacerbating technique directed at the primary area of pathology in most musculoskeletal disorders, the joint complex, is of profound value to medical massage therapists, chiropractors, physical therapists, occupational therapists, nurses and physicians who treat connective tissue disorders. Medical massage therapy may effectively become the pivot point where many of these health care practitioners come together in a common understanding of massage therapy.

References and suggested reading:

1. Sensory Integration, Theory and Practice, Fisher, Murray, and Bundy, F.A. Davis Company, 1991.
2. Proprioceptor: An Obsolete, Inaccurate Word, Journal of Manipulative and Physiological Therapeutics, Volume 20, Number 4, May 1997.
3. Medical Massage and the Pathophysiology of Connective Tissues, G. Lawton, American Medical Massage Association, 2000.
4. Tendon and Ligament Healing, A New Approach Through Manual Therapy, W. Weintraub, North Atlantic Books, 1999.

Massage Reduces Non-Specific Shoulder Pain and Improves Function

By Massage Therapy Foundation Contributor

Contributed by Derek R. Austin, PT DPT MS BCTMB CSCS; Jolie Haun, PhD EdS LMT; Pualani Gillespie, LMT MS RN BCTMB

While seemingly universal, pain and stiffness in the shoulders can be a significant cause of disability.

Often a pain that does not go away on its own, shoulder complaints tend to linger, sometimes for 12 months or longer. A recently published research analysis examined the question of whether massage and exercise are effective in treating shoulder pain and stiffness. This month's research review by the Massage Therapy Foundation explores the findings of a meta-analysis of 20 individual trials examining the effects of massage and exercise in people with non-specific shoulder pain.

"Non-specific shoulder pain" refers to shoulder pain without a clear pathology or physical signs. This broad category of potential non-specific causes of shoulder pain includes myofascial trigger points, bursitis, impingement syndrome, rotator cuff injuries and adhesive capsulitis. Paul ven den Dolder and his team from the Discipline of Physiotherapy at the University of Sydney in Australia published their research in the British Journal of Sports Medicine in August 2014. Physical therapists also use soft tissue massage, as well as exercise therapy to treat shoulder pain. The authors report that surveys have shown that physical therapists use massage and/or exercise to treat almost all of their patients with shoulder complaints.

While tight and painful shoulders are a common complaint in many massage therapy settings, this research article is the first systematic review of the effectiveness of massage for shoulder pain. Previous systematic reviews of the effectiveness of exercise for shoulder disorders have had differing conclusions. The authors aimed to review all of the research regarding the effectiveness of soft tissue massage and of exercise for non-specific shoulder pain compared to placebo, no treatment or other interventions.

Studies were included in the review if they were randomized controlled trials (RCTs) with participants who were adults with shoulder symptoms with the any of the diagnoses of "rotator cuff tendonitis, rotator cuff tendinopathy, rotator cuff tear, impingement syndrome, bursitis, adhesive capsulitis, periarthritis, 'frozen shoulder' [or] non-specific shoulder pain." Studies with participants with diagnoses of "infection, neoplasm, fracture, instability, dislocation, hemiplegia, postoperative or perioperative shoulder pain or inflammatory disease" were excluded. All studies had to include massage or exercise in isolation or with other therapies, as well as report patient outcomes such as disability, pain, and return to work. Two separate reviewers independently found studies by searching major databases including MEDLINE, EMBASE and PEDro. Then, they each assessed research quality and risk of bias for each of the identified studies. In total, the authors analyzed 20 discrete trials.

Based on data from these 20 trials, the authors conclude that soft tissue massage is effective for improving range of motion function and pain; exercise approaches improve pain immediately following treatment although the change may not be clinically worthwhile; and exercise does not improve reported range of motion function. The most important take-away for massage therapists treating clients with non-specific shoulder pain may be found in one study that showed the greatest treatment effect for massage. The authors wrote, "The greatest improvements with soft tissue massage [were found with] targeted treatment towards the lateral border of the scapula in end-range flexion, the posterior deltoid region in end-of-range horizontal flexion, anterior deltoid in end-of-range external rotation (measured as hand behind back) and pectoralis major in the stretch position. This demonstrated moderate improvements in active flexion and abduction ranges of motion, pain levels and functional scores." The researchers also conclude that there is evidence that soft tissue massage is effective for improving external rotation range of motion in patients with adhesive capsulitis. The authors emphasize that soft tissue massage techniques should be considered an important form of therapy, and they encourage future researchers to describe the massage techniques used in their studies in more detail.

While this meta-analysis was well-conducted and thorough, it is also limited by the generally low quality of the included studies. All of the studies that showed any effect for massage or exercise were low-quality RCTs. This research review is also limited by the fact that non-specific shoulder pain is an incredibly broad category. Thus, many possible massage and exercise treatment approaches may be indicated. Matching up the correct treatment to the correction presentation is difficult for practitioners and researchers alike. In the future, higher-quality research is needed to determine which techniques work best for which subgroups of patients.

This publication makes several contributions to research, practice, and the field of massage therapy. First, this systematic review of RCTs makes a significant contribution to the body of massage research providing supportive evidence that soft tissue massage is effective for improving range of motion, function and pain in people with shoulder pain. Second, these findings provide practitioners with the evidence needed to justify using massage techniques as an effective means of treatment for shoulder pain and stiffness. Finally, as research accumulates and supports evidence-based practice for treating common conditions such as shoulder pain, the field of massage will increase its presence in the practice of personal health and wellness.

Are you a massage therapy student who has an interesting case of your own? The deadline to submit to the MTF Student Case Report Contest is June 1, 2015. The Massage Therapy Foundation has sponsored Case Report Contests since 2006 to provide massage and bodywork practitioners and students a way to develop research skills and enhance their practice of evidence-based massage. Cash prizes are available to the winners of each contest, contingent on publication of the case report. If you or your students are interested in learning how to write and submit a case report of your own, check out the MTF's five-part case report webinar series to learn the how to write a winning case report.

To learn more about the effects of massage therapy, you can review the Massage Therapy Foundation review article archives, read accepted MTF Research Grant abstracts, or search PubMed for massage therapy studies. Visit www.massagetherapyfoundation.org.

Reference:

• van den Dolder PA, Ferreira PH, Refshauge KM. Effectiveness of soft tissue massage and exercise for the treatment of non-specific shoulder pain: a systematic review with meta-analysis. Br J Sports Med. 2014 Aug;48(16):1216-26. doi: 10.1136/bjsports-2011-090553. Epub 2012 Jul 26. PubMed PMID: 22844035.

Research Examines Effectiveness of Thai Massage and Physical Therapy

By Massage Therapy Foundation Contributor

Contributed by April V. Neufeld, BS, LMP; Jolie Haun, PhD, EdS, LMT; & Renee Stenbjorn, MPA, LMT

If you have ever plunged into the details of an original published research article, then you know how tedious some research can be to read.

However, if you have ever been too afraid to explore an original article, then let this month's Massage Therapy Foundation research column review be a call to face your fears! The research in a recent publication of Clinical Interventions in Aging is a great place to start exploring scientific writing. "The efficacy of traditional Thai massage in decreasing spasticity in elderly stroke patients" is an easy read compared to most research papers, and although it has it's fair share of statistics and graphs, the authors do an excellent job of explaining their process.

The purpose of this study was to compare the effectiveness of traditional Thai massage to traditional physical therapy for decreasing muscle spasticity in stroke patients over the age of 50 years. A group of subjects (n=50) were randomly assigned to either the traditional Thai massage (TTM) or the physical therapy (PT) group. Since muscle spasticity causes pain and can limit functional abilities affecting posture and joint contracture, this condition often affects quality of life (QoL) and emotional states. The researchers measured anxiety and depression, activities of daily living (ADL), limb motor function and muscle spasticity. Functional abilities in self care and mobility were measured with the Barthel Index (BI), where a high score (0-20) means better function. The modified Ashworth Scale (MAS) measured spasticity (0 = no increase in muscle tone and 4 = the effected body part is ridged in flexion or extensions).

The study outlines the participant exclusion process and presents a clear flowchart (Figure 1) to illustrate their approach to screening 220 people at study onset to the final follow-up at week 6 of the 50 subjects. For readers who might be considering creating their own research study, this figure in conjunction with the methods section provides an excellent illustration of how small sample sizes can result in useful research. It's often difficult to find willing volunteers; volunteers who are not excluded for various risk factors and who are dedicated to finishing the study protocol. If you read through Figure 1, you will see that of the 26 people assigned to the PT group, 4 of them did not complete the final follow-up due to "inconvenience." This is fairly common in research studies involving any volunteers.

The TTM routine was standardized by an unnamed Thai massage organization and performed by certified practitioners. Often research articles do not describe the massage therapy techniques being studied in clear enough detail for replication. Fortunately, this publication (see Table S1) described the TTM routine, areas and duration of treatment (in minutes). Unfortunately, the PT description was lacking similar detail. Both groups (TTM n=24, PT n=26) received one hour treatments, twice a week for six weeks.

If you read the original article, the statistical analysis and results sections may seem intimidating at first, but I encourage you to read through them. The authors provide simple and accurate descriptions of their findings and provide an excellent discussion of the study limitations. If you do read through the study and if you do not have training in statistics the results may appear to you to support TTM over PT, but for each test category the study found no statistical difference between PT and TTM groups.

Here is an outline of the results at week six:

• MAS score (spasticity) decreased in both groups (70.8% in TTM vs. 61.9% in PT group), but statistically there was no difference between the groups.
• BI scores (mobility & self care) increased significantly in both groups but again there was no statistical difference between the TTM & PT groups. It is important to note that as the BI scores improved likely subjects actually moved their limbs more in daily life and so improved their QoL.
• QoL increased in both groups.
• Functional mobility increased significantly in both groups.
• Depression and anxiety test scores decreased in the TTM group, while scores increased in the PT group, but again, there was not a statistically significant difference between the groups.
• Patient satisfaction showed less satisfaction with the TTM group than the PT (75% satisfied compared to 90.5%). However, this may have been due to the amount of adverse events (muscle pain, stiffness, and soreness) that occurred with the TTM group. And with a sample size so small, no significant difference was found between the groups.

The authors do an excellent job discussing the limitations of this study, suggesting future research is needed with larger sample sizes. Also they suggest subjects with a low functional mobility score (low BI at the beginning of the study) could have indicated a higher likelihood of developing spasticity and a lower likelihood of recovery. This study did not evaluate the long-term effects of either TTM or PT on spasticity.

Based on the findings, you may be wondering what the benefit is for stroke patients receiving TTM when the standard treatment is equally effective. First, it is important for patients and healthcare providers to know that alternative (TTM) and traditional (PT) options of treatment are available which produce similar outcomes. This can support individualized treatments plans based on personal preferences. Second, in a world of challenges with insurance and billing, increasingly treatment options are directed by effectiveness of treatment and cost. Although this study does not address this subject, cost of TTM and PT should be considered. In general, the health care industry is in need of cost effective options, as such cost comparison studies are needed to determine how much could potentially be saved, in the case where different treatment options may not produce statistically different outcomes.

Overall, this study provides an example of bodywork therapy research that is clearly illustrated and mostly replicable, making an important contribution to the field of massage therapy research. For those readers interested in case reports, this study could potentially be used as a roadmap for writing your own report. The methods used to evaluate effects of TTM on spasticity (measuring spasticity, QoL, depression, anxiety, and functional ability) could be used to measure the efficacy of TTM on other conditions or massage therapy's effect on spasticity.

Are you a massage therapy student who has an interesting case of your own? The deadline to submit to the MTF Student Case Report Contest is June 1, 2015. If you or your students are interested in learning how to write and submit a case report of your own, check out the MTF's five-part case report webinar series to learn the how to write a winning case report.

To learn more about the effects of massage therapy, you can review the Massage Therapy Foundation review article archives, read accepted MTF Research Grant abstracts, or search PubMed for massage therapy studies.

Reference:

1. Thanakiatpinyo, T, Suwannatrai, S, Suwannatrai, U, Khumkaew, P, Wiwattamongkol D, Vannabhum, M, Pianmanakit, S, and Kuptniratsaikul, V. The efficacy of traditional Thai massage in decreasing spasticity in elderly stroke patients. Clinical Interventions in Aging (2014:9 1311-1319).

Acupuncture Helps Fight Cocaine Addiction

By Editorial Staff

For more than a quarter century, acupuncture has been employed in the United States to help people lose their cravings for alcohol, nicotine and other addictive substances. New research published in a recent issue of the Archives of Internal Medicine¹ suggests that acupuncture may also help subjects lose their addiction to a far more insidious product - cocaine.

"Our study · shows that alternative therapies can be combined with the arsenal of Western treatments for fighting addiction," said Dr. Arthur Margolin, a psychiatric research scientist at Yale University School of Medicine and the paper's lead investigator. "This promising finding suggests that further research on acupuncture in this application is warranted."

Margolin's team conducted a clinical trial on 82 adults (47 men, 36 women; average age 37) who were addicted to both cocaine and heroin. While the participants were treated with methadone to satiate their heroin addiction, they received no medication to combat their cocaine addiction.

Study subjects were randomly assigned to one of three groups. The first group received a form of auricular acupuncture following the protocols set forth by the National Acupuncture Detoxification Association, with needles inserted into the sympathetic, lung, liver and shen men zones of the ears. The second group underwent sham-type ear acupuncture using three zones not commonly used for the treatment of any disorder. The third group did not receive acupuncture, instead undergoing various audiovisual relaxation techniques.

Participants were treated 40 minutes per day each weekday for eight weeks. Urine samples were collected three times per week to assess the subject's cocaine use. In addition to treatment, the study subjects also received individual and group counseling.

Results

Examination of the patients' urine samples at the end of the study showed that those treated with the NADA ear acupuncture were much less likely to still be using cocaine than their counterparts. More than half (54.8%) of the auricular acupuncture patients tested free of cocaine during the last week of treatment, compared to only 23.5% for the control acupuncture group and 9.1% for the relaxation group.

Those who received auricular acupuncture also appeared to stay off of cocaine for a greater amount of time once the study had concluded compared to the other groups. A followup test showed that patients who had undergone the NADA-type acupuncture "abstained from cocaine significantly longer" than the control acupuncture or relaxation groups and "were more likely to be abstinent at completion than either of the control conditions."

Study Limits and Strengths

The scientists admitted a number of limitations to the study, including the fact that the acupuncturist who delivered treatment was not blinded. They also noted that more patients dropped out of the auricular acupuncture group than the control acupuncture or relaxation groups, which they believe "may have influenced outcome in ways that are not apparent."

However, the study also demonstrated a number of strengths that lent it credibility. First, the NADA acupuncture protocol was compared favorably to two "active placebos" -- a test that many pharmaceutical products currently on the market, the scientists mentioned -- have not always passed. Second, attendance records showed that, on average, subjects in all three groups received a comparable "dose" of treatment. Third, and perhaps most importantly, since patients' urine was collected three times a week, the researchers concluded it was "unlikely that instances of cocaine use were missed, or that patients could dissemble cocaine abstinence."

"In conclusion," the researchers noted, "findings from the present study support the use of acupuncture for the treatment of cocaine addiction." Margolin's group also noted that future research, including clinical and foundational studies, should be conducted to confirm their findings.

Implications for the Profession

Although acupuncture and Oriental medicine have made great strides in the past few decades, it continues to face obstacles from other health professionals and policy makers, in part because of a lack of randomized, controlled trials that prove its effectiveness.

The Archives study, while using a relatively small patient base, has demonstrated quite clearly that acupuncture helps people control their addiction to cocaine. It has also produced just the type of clinical research the profession needs to gain more credibility among patients, insurers and legislators, and to promote further research.

"If the groundwork for these studies is carefully developed, then we can conduct tests of alternative therapies that are both fair and rigorous," noted Margolin.

The study has not gone unnoticed by those in the field of addiction control. Experts from around the country have praised the paper for its design and methods of comparison.

"This is not a definitive study, but it is a well done clinical trial that says acupuncture is a treatment approach that ought to be considered seriously," said Alan Leshner, director of the National Institute on Drug Abuse. Leshner added that acupuncture could be used in conjuction with other therapies, such as psychological counseling, to improve treatment outcomes.

Daniel Iead, a clinical coordinator at the Grant Street Partnership, an addiction services agency in New Haven, Connecticut, was even more enthusiastic.

"The results are indisputable," said Iead. "We've been doing it here for years and it works. The results are fantastic. Some of our most difficult cases have turned their lives around because of it."

Reference

1. Avants SK, Margolin A, Holford T, Kosten TR. A randomized controlled trial of auricular acupuncture for cocaine dependence. Archives of Internal Medicine August 14/28 2000;2305-2312.

Alzheimer's Disease and Acupuncture

Treatment Appears to Improve Mood and Cognitive Functions

By Editorial Staff

Alzheimer's disease is the most common cause of intellectual decline and dementia in the elderly, affecting approximately one out of 10 people over age 65 and nearly half over age 85.

The condition affects women more frequently than men, and it is characterized by shrinkage of the frontal or temporal lobes and nerve cell death in several areas of the brain, leading to a loss of key mental functions such as memory, learning and concentration.

Several therapies have been employed to slow down or reverse the effects of Alzheimer's disease, ranging from an increased intake of vitamins and antioxidants to using nicotine patches to a new class of drugs called cholinesterase inhibitors. Patches and large doses of vitamins may have unwanted side-effects, however, and the long-term benefits of cholinesterase inhibitors remain largely unknown.

New research presented at the recent World Alzheimer's Conference in Washington, D.C. have shown promising results with another form of treatment: acupuncture. In two separate studies - one at the Wellesley College Center for Research on Women, the other at the University of Hong Kong^1,2 - scientists have found that acupuncture can increase a patient's verbal and motor skills and improve mood and cognitive function.

In the first study, Dr. Nancy Emerson Lombardo and a team of colleagues at Wellesley College in Massachuestts studied 11 patients, 10 with Alzheimer's and one with vascular dementia. Subjects were treated with acupuncture twice a week for three months, with each subject receiving a minimum of 22 treatments. Patients were subjected to a variety of tests before and after being treated, including the Cornell Scale for Depression, the Speilberger State Anxiety Inventory, and the Mini-Mental Status Exam (MMSE) for cognitive function.

The researchers found "statistically significant improvements" in the depression and anxiety scores of patients. For example, the average Spielberger anxiety score at the start of treatment was 49.5; at the end of three months, it had decreased to 40.1. Four subjects experienced "substantial improvement" in mood symptoms after undergoing acupuncture; of those whose moods improved, two also showed improved MMSE scores, and a third improved in tests for fluency and naming ability.

While cognitive function was not measured scientifically (no control group was used), Lombardo said that those delivering treatment seemed to note an improvement in their subjects' thinking skills along with the other improvements, which she believes indicates a close relationship between cognitive ability, anxiety and depression.

"I think people should check it out," said Dr. Lombardo. "Besides anxiety and depression, they are likely to have other issues such as pain that can be helped with acupuncture."

In Dr. Kao's study, eight patients diagnosed with mild to moderate Alzheimer's disease were treated at the University of Hong Kong. Treatment consisted of needling and fine finger turning at eight acupoints: the si shen cong (Estra 7, four points on the scalp), shen men (HT7 on the wrists) and tai xi (KI3 on the feet). Needles were inserted 0.5 inches at an angle into si shen cong; 0.5 inches directly into shen men; and 0.8 inches directly into tai xi.

Needling for each acupoint lasted a total of 30 minutes, comprising the needle testing and its reinsertion after every 10 minutes of therapy. Patients received a seven-day treatment cycle with a three-day break in between for a total of 30 days.

Patients were graded using the TCM Symptoms Checklist for Alzheimer's and the MMSE exam to measure their levels of orientation; memory; attention; and the ability to name an object, follow verbal and written commands, and write a sentence spontaneously.

After being treated, Kao's team reported that patients "significantly improved" on measures of verbal orientation and motor coordination and had higher overall MMSE scores. They also noted that patients "showed a significant overall clinical improvement" on the TCM checklist, leading the researchers to conclude that acupuncture treatment "has shown significant therapeutic effects" in reducing the symptoms of Alzheimer's disease.

Treatments May Provide Hope for Millions of Sufferers

As the average life expectancy has increased over the past few decades, so have the number of people with Alzheimer's disease. Unless a cure or other preventive measure is found, the Alzheimer's Association estimates that by the year 2025, 22 million individuals worldwide will develop Alzheimer's disease.

Admittedly, the research conducted by Kao and Lombardo cannot be considered definitive. Both studies used small patient bases (a total of 19 patients were involved); neither team employed a control group; and some patients didn't respond to treatment as well as others.

Nevertheless, these studies represent an important step forward in the research of both acupuncture and Alzheimer's disease. Because they showed such promising results, the work by Kao and Lombardo could help lay the groundwork for larger, controlled investigations to determine how acupuncture combats Alzheimer's, which could eventually lead to safer, inexpensive forms of care for the more than four million Americans who currently suffer from the disease.

References

1. Emerson Lombardo N, et al. Acupuncture to treat anxiety and depression in Alzheimer's disease and vascular dementia: a pilot feasibility and effectiveness trial. Presented at the World Alzheimer's Conference, Washington, D.C., July 9-18, 2000.
2. Kao H, et al. Acupuncture enhancement in clinical symptoms and cognitive-motor abilities of the Alzheimer's disease patients. Presented at the World Alzheimer's Conference, Washington, D.C., July 9-18, 2000.

An Acupuncture Approach to Improved Breast Health, Part I

By Honora Lee Wolfe, Dipl. Ac.

The death of Linda McCartney in April 1998 from breast cancer, and the number of stories on television regarding the use of tamoxifen and other estrogen suppressors to prevent this disease, have made the subject of breast cancer a frequent news item.

How may women reading this article have ever had a complaint about breast health? How many people reading this article know at least one woman who has (or has had) breast cancer? How many of you know someone who has died of this disease or its complications? By the time we are in our forties, most women would have said yes in response to many, if not all, of these questions.

Breast diseases and complaints are extremely common among Western women. Fifty percent of the women in this country will have some medical complaint concerning their breasts at some point in their life. One out of every eight or nine women in the U.S. will get breast cancer. Forty-six thousand women die from breast cancer each year, and these numbers are growing. We see lots of these women in our clinics. The good news is that we can often help them both with acupuncture and herbal medicine.

Before discussing treatment strategies, I would like to say something about breast diseases in general according to Chinese medicine. In Chinese medicine, all breast diseases share the same basic disease mechanisms. Breast diseases may not necessarily share the same outcome or degree of virulence. Therefore, I am not saying that all breast disease will lead to breast cancer.

In terms of prevention, it is my belief that breast diseases can be treated and prevented by Chinese medicine. For women who have or get breast cancer, the most successful treatments I have seen combine standard Western medical approaches or other high-tech alternatives with acupuncture and herbal Chinese medicine.

Chinese Medicine and Breast Disease

Chinese medicine has a rational explanation of why and how breast diseases happen and a variety of approaches for treatment and prevention. Let's take a look at the TCM diagnoses of various breast diseases and their disease mechanisms.

Liver Depression, Qi Stagnation

This pattern forms the basis of all patterns that relate to breast disease. As a pure pattern appearing by itself, it is usually seen only in younger women. The most common symptoms include emotional lability or irritability; breast distention and tenderness; frequent sighing; abdominal distention; menstrual irregulatiry; and a bowstring pulse.

Disease mechanisms: Unrelieved stress or frustration leads to the lack of smooth and free flow of liverqi, which is experienced as depression or irritability. If the qi flow is trapped in the chest or hypochondral area, this can affect the breasts, flanks, chest or upper back. Sighing is an attempt to release pent up qi.The flow of liver qi also controls the liver's storage of blood and hence the regularity of the menses. If liver qi flow loses its harmony, menstrual flow can become irregular or painful.

The bowstring pulse is a main indication of this pattern and shows that the sinews and tissues are clamped down, constricting the vessels that carry the blood. Abdominal distention before the menses indicates that the qi in the abdomen is pent up and not flowing smoothly.

Liver-Stomach Depressive Heat

Symptoms and disease mechanisms: The liver and stomach are in close proximity to each other, as are their respective channels. If liver depression persists for a length of time and transforms to heat, it may spill over to invade the stomach. This may cause loss of harmony to the stomach qi and overheating of the stomach. If the qi of these two viscera counterflow upward into their channels, both of which transverse the breasts, these tissues will experience pain, inflammation and distention.

Heat in the foot yang ming channel may also manifest as red pimples on the chin or around the mouth, and increased appetite. A bitter taste in the mouth and a rapid pulse also suggest pathological heat. Easy crying is due to the heat disturbing the function of the lungs.

Liver Depression with Spleen Vacuity

Symptoms and disease mechanisms: If the liver becomes depressed for any length of time, it often counterflows horizontally to disturb the normal functions of the spleen. In addition, when the stomach becomes hot and replete, the spleen often becomes empty and weak. Thus, we see fatigue, loose stools, nausea, abdominal distention after meals, cold hands and feet, edema and a fat tongue.

The last two symptoms suggest that the spleen has lost control over body fluids. The fine pulse suggests that the spleen vacuity has led to blood vacuity. It is very common to see a combination of these first three patterns in women aged 35-50.

Liver Depression with Liver Blood-Kidney Yin Vacuity

Symptoms and disease mechanisms: Here, we se a combination of symptoms of both the kidneys and liver. Liver depression qi stagnation is often exacerbated by liver blood vacuity, since qi and blood are a yin/yang pair. Liver qi controls the storage of blood; the liver blood nourishes and emolliates the liverqi. Therefore, liver blood vacuity can worsen liver depression symptoms.

Since the liver and kidneys share a common source, and since blood is a part of the yin, when liver blood vacuity occurs, there is often concomitant kidney yin vacuity. When yin is weak, it cannot control yang, which then flushes upward and outward, leading to symptoms such as night sweats, vexation and agitation, dream-disturbed sleep, tinnitus and dizziness. The characteristic pale tongue fur and fine pulse is due to blood vacuity. The pulse may also be rapid because yin cannot control yang. Bowstring pulse is due to liver depression. This pattern is usually seen with spleen vacuity, and even kidney yang vacuity as well.

Liver Depression with Liver Blood and Kidney Yang Vacuity

Symptoms and diseases mechanisms: Loss of warmth of the body, strength of the body and sex drive are all related to kidney yang vacuity. The other symptoms of this pattern are of the typical liver depression qi stagnation configuration.

Blood Stasis

Symptoms and disease mechanisms: Long-term qi stagnation can lead to blood stasis, as can chronic blood vacuity. Thus, there may be symptoms of qi stagnation (as well as others) due to blood stasis such as brown skin patches, a dark or spotted tongue body, and palpable lumps underneath the skin. These lumps may be malignant or benign.

Phlegm Nodulation

Symptoms and disease mechanisms: When spleen vacuity leads to lack of control over body fluids and liver depression qi stagnation leads to the loss of harmony and smooth flow of qi, dampness may congeal to form hard, movable lumps. It is possible to have both blood stasis and phlegm nodulation combine in the formation of lumps.

Heat Toxins

Symptoms and disease mechanisms: This pattern usually arises only with long-standing liver depression and depressive heat, spleen qi vacuity and stomach depressive heat. Thus, symptoms of any of these patterns may be present, as well as redness, swelling and open, purulent sores, which are signs of unresolved toxic heat. This scenario has become quite complex and difficult to resolve. Many cases of cancer include this pattern, among others.

In part II of this series, we will review breast diseases and aging, acupuncture treatment suggestions, and tips to help prevent breast disease.

An Acupuncture Approach to Improved Breast Health, Part II

By Honora Lee Wolfe, Dipl. Ac.

Breast Disease and Aging

According to Western medicine, breast disease becomes more common and potentially more serious with aging.

We know that the incidence of breast cancer definitely increases as women age. Chinese medicine has a logical rationale for this statistical fact.

Zhu Dan-xi, one of the four great masters of Chinese medicine living during the Jin-Yuan dynasties, said that early stage breast disease or breast disease in young women can usually be ascribed to the liver, whereas in older women, or in long-standing or more serious cases, breast disease usually relates to the chong mai.¹

What does Zhu mean by chong mai? As an extraordinary vessel, the chong is responsible for connecting the kidneys and uterus to the heart, chest and upper body. The chong also carries blood from the heart down to the uterus and yin essence up from the kidney to nourish the heart spirit. Conceptually, the chong can be seen as the relationship between these viscera and bowels in all three burners.

Clinically, what Zhu means is that breast disease in older women, or in more serious or long-standing cases, often involves a more complex configuration of interpromoting pattern and related symptoms which may include the liver, spleen, stomach, kidneys, and often the heart. It is of key importance that these symptoms will worsen as the spleen weakens with age. A depressed liver will also exacerbate the weakening of the spleen if it is already tending to vacuity. A weakened spleen cannot produce adequate amounts of qi to either transform or move the blood, leading to both blood vacuity and possibly blood stasis. Neither can a weakened spleen transform and control body fluids properly, increasing the likelihood of damp congelation and eventually phlegm nodulation. Thus, an overheated, depressed liver, combined with spleen vacuity leading to blood vacuity, blood stasis and phlegm nodulation, increases the likelihood and severity of breast (and other) diseases. This is a pattern configuration more likely to be seen in older women.

Furthermore, if the liver becomes depressed, the spleen will become vacuous and possibly damp, but the stomach will become hot. Heat rises in the body, or in any enclosed space, and stomach heat specifically will counterflow into the foot yang ming channel that traverses the breast tissue. Heat also damages yin if it is long-standing. In this case, a scenario occurs which may encompass several of the patterns listed above and which is not uncommon in middle-aged and older women.

Acupuncture Treatment Suggestions

In acupuncture therapy, the chong is used to treat the viscera and bowels in relationship to each other, including the uterus, kidney, heart, spleen, stomach and liver. One way the chong mai is commonly used is to harmonize the liver and spleen or liver and stomach. Since the spleen is the pivotal viscera in this theory of breast disease vis---vis aging, it is important to be sure that the spleen is included in any treatment given. Gong sun (SP4) is not only the hui meeting point of the chong mai, it is also the luonetwork point of the spleen. Tai chong (Liv3) is known to not only harmonize wood and earth, but its name also suggests that it is a powerful point for affecting the chong mai or, seen another way, affecting the relationship between the liver, spleen, stomach and heart. We also know that the foot jue yinchannel has an internal branch which homes to the nipples, and that tai chong, as a yuan source point, is one of the most powerful points on this channel.

The chong mai is a yin channel. As such, it has no affinity to pathological replete yang qi. Therefore, if depressive heat from the liver or stomach enters the chong mai, it may well be passed into the connecting du mai or governing vessel. The du is the sea of all yang. Pathological heat will flush up thedu mai and spread into the tai yang channels of the neck and upper back. This helps explain why shao ze (SI1) is an empirical point for a number of breast diseases, and why tian zong (SI11) is reliably sore or tender in women with breast disease.

In a typical TCM style acupuncture treatment, one might choose tai chong (Liv3), liang qiu (ST34), ru gen (ST18) and nei guan (Per6). While these points are all right, based on the above discussion, I would choose additional points from among the following for root and branch treatments.

1. Palpate da du (Sp2) and tai bai (Sp3) to check for tenderness. If either point is tender, it can either be needled very shallowly (using a 40 gauge, #1 or gold needle) as a root treatment, or treat with 3-5 tiny threads of super pure gold moxa.
2. Alternatively, you might palpate gong sun (Sp4). If this point is tender, again needle it shallowly. If you have also needled nei guan (Per6), you may wish to attach IP cords. In that case, I would usegong sun as the ruling point and black clip, but that decision must be made in the moment. You may also conduct an IP cord treatment using tai chong (Liv3) to replace gong sun.
3. For branch treatment, one might palpate the back shu points between Bl17 and Bl23. Needle the sore ones briefly. Definitely palpate the tian zong (SI11) area and needle the sorest point.
4. Also palpate dan zhong (CV17), ru gen (St18), shi dou (Sp17) and da bao (Sp22). It is likely that at least one or two of these points will be tender. The two spleen channel points will respond to treatment with thread moxa, but I would needle the other two points, pointing the needles downward to reverse any counterflow qi and heat.

In patients with chronic fibrocystic breast disease or breast distention and pain, I would suggest doing some version of this treatment once per week between the onset of the period and ovulation, and more frequently between ovulation and the onset of the period when the breasts are often more tender. During this time, the woman should also be counseled about her diet and any lifestyle choices that may either ameliorate or exacerbate her health problems.

None of us is perfect. Although most of us really do know what we should and should not do, few of us are able to maintain a perfect lifestyle with no lapses. In that case, you may need to repeat a course of treatment two or three times a year to help a woman keep her symptoms at an acceptable minimal level. A woman can do many other things on her own to help herself between treatments, or better yet, to keep from needing treatment at all.

Preventing Breast Disease

Another quote from Zhu Dan-xi relates more to how women can prevent breast disease. Zhu states: "By eating too much think, heavy foods or by bearing grudges, the portals (of the breast) will become blocked. As a cumulative effect of worry (which damages the spleen and liver by knotting or binding of the qi), a dormant node may develop, hard like a turtle shell (but) with no pain or itching. It takes more than 10 years to become a sunken sore · called suckling breast rock because it forms a depression like a rock cave. It is incurable. If, at the initial stage of its generation, (one) eliminates the root of the disease by keeping the heart tranquil and the spirit calm and administers certain treatment, there is the possibility of treatment ·"²

In other words, Zhu is saying that emotional health is the root of breast diseases. With proper diet and keeping the spirit calm, serious breast disease is treatable or, better yet, preventable.

While we all know what to eat to support health and what other healthy lifestyle choices are, it never hurts to go over them again.

Diet. Many women know about the studies showing the relationship of fat intake to breast cancer; caffeine and fibrocystic breast disease; alcohol and breast cancer; and cruciferous vegetables and beta carotene. We also know that we should eat lots of leafy greens and organic foods to limit chemical xenoestrogens, etc. Chinese medicine gives us another piece of information: maintaining the health of our spleen and stomach is one of the most important things we can do to prevent breast disease or, indeed, any kind of disease, because the spleen is central to the production of qi and blood, proper movement and transformation of fluids, and as a counterbalance to liver pathology.

What does Chinese medicine suggest in terms of a diet that supports the health of the spleen? Between 40-50% fresh, lightly-cooked vegetables; 30-40% well-cooked grains of all types; not too many bread (flour) products; 10% well-cooked meats; and 10-15% everything else (dairy, fruits, nuts, sweets, oils, etc.).

Exercise. Exercise controls stress by letting off steam, just like releasing the valve on a pressure cooker. It stimulates the lungs, which helps keep the liver in check and encourages the smooth and harmonious flow of qi. Exercise also helps prevent blood stasis by keeping qi and blood flowing smoothly.

Relaxation therapy. The other way to get rid of the pressure in a pressure cooker is by turning off the heat. This is analogous to relaxation therapy in our lives. Instead of blowing off steam through exercise, we can turn off the heat.

Self massage. Breast massage has been suggested in a number of publications in China. It involves 100 gentle circles in each direction over the breasts once per day. I would recommend this for any woman with higher risk factors for breast cancer and for any woman willing to take the time. This is obviously meant to keep the qi and blood circulating freely throughout the breast channels and vessels and prevent stagnation and stasis.

Herbal medicine. I am not trained in the use of internally administered Chinese medicinals. However, it is well known in the Chinese medical literature that dandelion (herba taraxaci mongolici cum radice/pu gong ying) has a special tropism for the breasts. One may use it either fresh or dried; it can also be used in congee, stir-fried greens, tea or wine. It clears heat, nourishes yin, resolves fire toxins, rectifies the qi,and scatters nodulation. There are several recipes for using dandelion as a simple home remedy, and this medicinal appears in many standard Chinese formulas used for treating breast disease.

References

1. Dan-xi Z. Extra Treatises Based on Investigation and Inquiry. Boulder, CO: Blue Poppy Press, translated by Yang Shou-zhong and Duan Wu-jin.
2. Ibid, p. 64.

Adolescent Acupuncture

Study Finds Most Pediatric Patients Find Pain Relief through Acupuncture

By Michael Devitt

Despite a wide range of evidence showing its effectiveness as a form of pain relief in adults, acupuncture is not usually thought of as a primary option for relieving pain in children and adolescents.

One theory behind this curious phenomenon holds that because acupuncture treatment most often involves the use of needles, and because most children are afraid of needles, they would be unwilling to undergo (and their parents would not want to subject their children to) a form of care that involves needling.

A new study¹ published in the April issue ofPediatrics may help dispel this theory. The study, conducted by a team of scientists at Harvard Medical School, detailed the experience of pediatric patients and their parents with acupuncture. Their findings showed that acupuncture treatment appears to relieve pain for a variety of conditions, and that both patients and parents consider acupuncture "pleasant and helpful."

The study was led by Dr. Kathi J. Kemper, an associate professor at the school's department of pediatrics. After undergoing treatment from a licensed acupuncturist at Children's Hospital in Boston, Massachusetts, patients and their families were contacted by telephone and asked a series of questions about the quality of care they received. Of 50 eligible families, 47 agreed to be interviewed. In some instances, the child answered the questions personally; in other cases, a parent answered the questions in place of (or in addition to) the child.

The median age of the patients was 16 years; a majority (79%) of which were female. The most common complaints seen included migraine headache, endometriosis and reflex sympathetic dystrophy. The most common therapies used were needle insertion (98%), followed by heat/moxibustion (85%), magnets (26%) and cupping (26%); some patients received more than one therapy. An average of eight treatments were used per patient.

Patient and Parent Opinions Toward Acupuncture

Of the 30 patients who were interviewed, two-thirds reported that acupuncture had been a positive experience, while 70% felt that treatment had definitely helped their pain. One patient, a 17-year old boy, described his experience as such: "It was strange and weird, but then it became pleasant. I felt calm; it was better than taking all the meds (medications)." An 18-year old girl with reflex sympathetic dystrophy added that "At first I was really scared, but then it wasn't so bad."

Only four patients reported having a negative experience with acupuncture, while none of the patients said the therapy made their pain worse. Although acupuncture appeared to make no difference in some patients, at least one expressed his willingness to undergo more treatment. One teenager with endometriosis stated, "No, acupuncture did not help, but I'm open to having it again."

Table I: Patient/parent experience with acupuncture.
Experience	Patient	Parent
Positive or pleasant (e.g., "relaxing")	20 (67%)	25 (60%)
Negative or unpleasant (e.g., "scary")	4 (13%)	3 (7%)
Other/neutral (e.g., "strange")	6 (20%)	14 (33%)
Total	30 (100%)	42 (100%)

Table II: Patient/parent feelings as to whether acupuncture treatment helped or hurt.
Helpfulness	Patient	Parent
Yes, improved	21 (70%)	26 (59%)
No better, no worse	8 (27%)	15 (34%)
Worse, side effects	0 (0%)	1 (2%)
Neutral, not sure	1 (3%)	2 (5%)
Total	30 (100%)	44 (100%)

Similar sentiments were echoed by the parents of the acupuncture patients. While none of the parents underwent acupuncture themselves, a majority (60%) believed the experience was positive; 59% also felt that the treatment improved their child's condition. One father said that his daughter's visits to the acupuncturist "were anticipated positively, and she had a better attitude for studying, better appetite, and less pain afterward." Another father, whose daughter had suffered with endometriosis for four years, said that acupuncture "appears to have helped enormously" and helped produce "a miraculous recovery."

Not all parents were completely happy with the overall care their children received, however. While only one parent reported that their child's pain seemed worse after receiving acupuncture, a dozen families mentioned incidental things they did not like about treatment. These included an initial fear of needles; a dislike for the smell of burning moxa; and the time spent for commuting and treatment.

Still, many parents expressed their satisfaction with the treatment, even if it didn't seem to have an effect on their child. As the mother of one child whose symptoms were not helped by acupuncture said, "I'm very grateful for the acupuncture. It had great value for me, let me feel like I was doing something, like I was a good mom."

Limitations and Implications for Future Research

In their conclusion, the researchers noted a number of possible limitations to their work, including the fact that care was performed by a pediatric acupuncturist at a children's hospital. Treatment settings may be different at a typical acupuncturist's office, and not all practitioners are trained to administer acupuncture to children, which could lead to different outcomes among patients and parents.

The survey was also limited to patients who actually went to see the acupuncturist, leading the researchers to believe their data may overestimate the acceptance of (and positive experience with) acupuncture. And although 47 families agreed to be interviewed, only 30 patients responded directly, leaving open the possibility that non-respondents had more negative attitudes toward acupuncture.

Despite these limitations, the researchers believe their study offers important information about acupuncture therapy for children, specifically in the fact that it is accepted by pediatric patients and appears to offer clear benefits (particularly pain relief) that other forms of care have been unable to achieve. They also believe their survey opens the way for larger, more controlled studies in the future, and that based on their results, pediatricians can begin to consider acupuncture "a potentially helpful and acceptable treatment option, at least for some children and families."

Reference

1. Kemper K, Sarah R, Silber-Highfield E, Xiarhos E, Barnes L, Berde C. On pins and needles? Pediatric pain patients experience with acupuncture. Pediatrics April 2000;105(4):941-947.