Category Archives: Public, practitioners, students

Pathogens and Pathology

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The search for a vaccine to the corona virus while a worthy endeavour may take a long time, and may even turn out to be chasing the impossible. The guardian newspaper published an article on the 22nd of April implying that the vaccine if it arrives could indeed take a lot longer than we would like. The fastest developed vaccine was the mumps vaccine that took 4 years. In the meanwhile as I write this lockdown is easing off, schools are beginning to open, later this month we will also re open our clinic as everyone else, albeit with some extra precautions, will go back to work.

In the face of still high numbers of infections what can we do besides the sensible precautions of hand washing, wearing masks and [where possible] social distancing? This is good public health policy when considering the problem in terms of a pathogen i.e. the virus. When it comes to Traditional East Asian medicine the emphasis generally shifts from pathogen to pathology.

Although traditional medicine in many ways evolved as a response to epidemics, its approach to treatment focusses not on a causal pathogen such as a virus or bacteria, rather on how that pathology manifests in the patient. In this way we don’t think of treating an illness so much as a person who is ill. So in the case of Covid 19 there is no set formula or combination of points to needle, the treatment is determined by the collection of symptoms that the person is showing. Different combinations of fever, sweating, thirst, cough, sore throat, body aches, digestive issues, chest pain etc. together with specific pulse presentations, will determine what kind of herbal formula or acupuncture treatment will guide the body back to a healthy state. This approach takes the whole body’s systems into account to bring about a recovery irrespective of what has created the problem in the first place. As such it is applicable to Covid 19 or regular seasonal flu or any kind of deviation from a healthy state.

When the normal life promoting processes within us lose their way they can give rise to distressing symptoms, sometimes minor sometimes major. The aim of traditional medicine is to rectify pathology and reinstate physiology; actually this can be done at any time and ideally before pathology sets in. This is where traditional medicine has a role to play in prevention of illness, or at least minimising its risk. Because the focus of treatment is to optimise healthy functioning it can almost always be given as none of us are 100 % healthy. Herbal and acupuncture treatments are given based on pattern differentiation but there is a great deal of latitude in terms of severity of the pattern. Thus the same formula could be given to someone with almost no symptoms, just minor lack of appetite and some congestion under the ribs [not something they would remotely consider a medical problem] or to someone else with a severe sore throat and alternating fevers or migraines. The possibility of treating when things are mild or almost non existent is an opportunity to prevent or reduce the chance of  more serious health crisis.

At the beginning of the lockdown I read a translated blog from a county level hospital in Henan province in China written by traditional Chinese medical doctors describing the herbal medicine regime used at their hospital. In addition to the different formulas used for patients experiencing symptoms of Covid 19 they also had a regime of formulas for the admin staff and doctors and anyone who was healthy but might come into contact with infected people. At the time of writing none of the staff had become infected and this was seen in part due to the preventative treatment they were advocating. Although there is no Chinese medical magic bullet that will stop you getting ill, herbs and / or acupuncture treatments can help to keep your body functioning as well as it can and so minimise getting ill.

Some treatments like the application of direct moxa to an acupuncture point on the leg were specifically designed for the maintenance of health and immunity in later life. This is being utilised today in the treatment of drug resistant TB by the efforts of the group Moxafrica. It’s this approach of strengthening health that is a unique aspect of Chinese medicine and should be utilised as much as possible before we go into autumn and a possible second wave of the virus.

Skin deep

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One of the key features of my treatment style nowadays is the adoption of contact needling which forms a key part of the Toyohari style of acupuncture training. This a technique where the point is needled at the surface of the skin and the skin itself is not broken. It is carried out through slowly approaching the surface with a [usually] silver needle then after waiting for a short while the needle is removed. This seems counterintuitive to the commonly held image of acupuncture where one assumes [or at least I did at first] that a needle needs to penetrate the skin to have effect. Most of my treatments begin with this technique and in a few cases it is all I do; though I was sceptical my self in the beginning, after having used it for a number of years my confidence in the technique has grown through the results I’ve seen and also through feeling the body’s response as I use it.

It’s only relatively recently that I’ve come across the work of Dr. Denda a Japanese skin scientist through the journal of North American Oriental medicine [Nov 2013, Vol 20, #59, March 2013 Vol. 20 # 57]. Dr. Denda has discovered that the epidermis or outermost layer [0.06mm-0.2mm] of the skin doesn’t just act as a barrier to protect the interior, rather it is able to monitor the external environment, acting like a giant sense organ and processing this information much like an independent brain. He dubs it the “third brain” [I believe elsewhere people have dubbed the gastro intestinal system as a second brain]. According to Dr. Denda the skin cells can act like sensors picking up more detailed information that could be possible using just nerve receptors, rather the keratinocytes in every cells are able to pick up environmental information, process it and transmit it to the nervous system.

According to Dr Denda stimulating the skin can have a positive effect on the mind in times of stress. This is not really news to most of us, massage and touch have a calming effect in a general way but the emphasis on skin over muscle [as in a deep massage or deep needling] perhaps goes some way to explain the growth of skin level acupuncture techniques in japan such as contact needling. Both epidermis and the brain have a common developmental origin in the ectoderm, and it is known that the hormone oxytocin which promotes positive physical and mental states, is released from stimulation of the skin. But it doesn’t end with oxytocin, the epidermis has receptor also for dopamine, acetylcholine, adrenaline, melatonin, glucocorticoids and more. It is believed that the epidermis has a close relationship to the autonomic nervous system, research has shown stress levels of the pituitary gland showing as changes in the skin barrier function, and the adjustment of circadian rhythms can be achieved by shining light on the skin to affect the sleep centre in the hypothalamus. This relationship between the skin surface and the inner centres of the brain can explain the importance of palpation in diagnosing patterns in traditional acupuncture. It’s as if we can locate internal patterns of stress by feeling disturbances on the surface of the skin.

When it comes to needling, inserting a needle to a depth of around 4 mm will be detected by the brain as the local stimulation is transmitted to the somatosensory areas via unmyelinated and myelinated fibers. This way brain can identify the location of the stimulus, this is an effective means of relieving local pain, improving peripheral and therefore whole body circulation. With contact needling however there is no direct transmission through these nerve fibers, its as if the autonomic system is affected directly via the sensory organ aspect of the hypothalamus, namely the skin surface. This is not registered as a local stimulus but a skin initiated whole body effect. The autonomic system is the body’s autopilot, it governs the moment to moment functioning of the the organs either stimulating or dampening their function. It should ideally maintain optimum functioning of the body in differing situations of physical and emotional stress, when this becomes suboptimal it can begin to the the origin of illness and poor health. If this is not corrected then any symptomatic treatment whether western or Chinese will have limited effect so treating this level of imbalance is seen as a key to maintaining good health in traditional East Asian healthcare. This is what acupuncturists call a root treatment, something to create an overall global balance independent of any particular symptom. It manifests during treatment as a deeper sense of relaxation, changes in breathing and in the pulse. The nature of contact needling as a means of stimulation that does not register as coming from any one particular location makes it especially suitable for this aspect of treatment.

Freedom of Movement

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Sotai is a term that was invented by the Japanese physician Keizo Hashimoto, it uses the Chinese characters SO 操 meaning control and the character TAI 体 meaning body. Actually the characters are commonly used in reverse order TAISO meaning exercise but these exercises work as a kind of controlled movement that is used to help the body realign it self and improve its function.

Sotai is founded on the principle of always moving the body in the most comfortable direction. Many of us often have stiff joints or pain in our muscles and its tempting to think we just need to stretch out this stiffness and work against the restrictions head on. The Sotai method is different it directs you to move in the way that is most comfortable and feels nicest, the movements can be done solo for general maintenance but for therapeutical reasons would require a partner to offer mild resistance to the movement.

One example might be if you have backache you might try moving the knees from side to side to see if one direction is more difficult. If so then move from the difficult side towards the easy side and the parter puts light resistance at the end of the movement, then after a count to three the whole body relaxes. This can often be enough to realign the structure and your symptom is relieved.

This summer while in Japan I was lucky to meet the great grandson of Hashimoto sensei, Suzuki Kensuke, who practises and teaches sotai in Tokyo. We received treatment from him and were encouraged to look for more opportunities to study and practice. The simplicity of the ideas behind Sotai and its applicability to a wide range of physical constriction makes it easy to integrate in other kinds of treatment as well as to be adapted to self treatment. Actually there is something to the idea of the path of least resistance as a method of both therapeutic intervention as well as an approach to living that has much to recommend it. In keeping with the Daoist notion of effortless action it is not a call to capitulation but optimising ones outcomes by minimising unnecessary ‘effort’ that impedes as much as it moves. Whatever the situation there is probably a fulcrum around which we can glide into freer more unencumbered state of being.

Travels in Tokyo – study

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We got back this week from 2 1/2 weeks in Japan, part holiday part study work. While there I attended the Toyohari acupuncture society summer school, its a bi annual affair for both Japanese and foreign practitioners, this year was particularly special as it is the 60th anniversary of its founding. In the traditional chinese lunar solar colander 60 years marks the completion of a cycle, so it was a poignant moment to go back to the roots of the association and consider the cyclical nature of learning.

The association was founded by Kodo Fukushima and his close colleagues in 1959 after initially being encouraged to set up study groups for blind practitioners after the war by members of the acupuncture community. Fukushima was blind and there had always been a tradition of blind practitioners in Japan excelling in acupuncture and massage. The sense of touch being seen as paramount in this kind of work being developed to a degree that more than made up for the loss of visual experience. Even though today the association has probably almost as many sighted practitioners as visually impaired ones, the emphasis on touch as the medium for diagnosis and treatment is strong within Toyohari as well as being reflected in the Japanese acupuncture community. The primary modes of diagnosis in this system is palpation of the radial pulse, the abdomen and the meridians located in the limbs.

Another characteristic of study in this association is the need to study among peers. We cannot learn this on our own, we require the feedback of other practitioners to tell us when we have correctly located a point or when the technique is being applied correctly. This is not simply a matter of one more experience person enforcing their opinion but a consensus based feedback based on the real time changes of the person who is being practised on. To this end we try and meet up as often as we can, the Tokyo summer school might happen every two years but there are weekend seminars in Europe and informal study groups in each country.

This brings me to another aspect of this approach that can be described as a continual review of the basics. Perhaps its an aspect of Japanese culture that lends itself to people being willing to regularly turn up and practise what are more or less the same techniques month in month out seemingly without end. It runs counter to the prevailing trend of desiring continual novelty that exists in most aspects of life. We might not be chasing material stimulation but we still often look for a novelty of ideas or techniques to spice up our professional lives. In the UK practitioners graduate from basic colleges then drift around different weekend courses to create a mixed bag of theories and clinical applications. Of course we all like to keep an eye on what’s happening around us but the majority of our study time is really about refining our core skills.

Seeing some of these elderly acupuncturists in Tokyo it is inspiring for someone like me to consider the endless circular nature of study and practice, through repetition we are able to deepen our understanding and experience more novelty in the ordinary.

More about hair…and Spring time !!

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“The correlate of the kidneys are the bones; their splendor is the hair on the head” SuWen10

The “kidneys” in Chinese medicine symbolize the body’s capacity to store vitality, a bit like a savings account. They are the deep storage of resources, connected to bones, teeth etc. They represent the material aspects of our experience and their health can influence our aging process and our fertility. When our inner vitality is abundant it flows out to the extremities and the “blood of the kidneys” shows in the thickness and quality of our hair. Hence in the East Asia a woman [or man] with good lustrous hair was seen as having inner vitality and good fertility! As we get older our power retreats and so the extremities are less well nourished, the blood of the kidneys no longer nourishes the head hair, which turns white.

Spring time and fertility

“The three months of spring,
 they denote effusion and spreading.
In heaven and earth everything comes to life; the myriad beings prosper…Move through the courtyard with long strides. Dishevel the hair and relax the physical appearance, thereby cause the mind to come to life.
 SuWen2

If the energy of the kidneys is the stored potential for new life, then the liver supplies and distributes the blood to the organs of fertility. For the East Asian mind the region of the lower abdomen is seen as the gate of life; it is the source of vitality for the individual and it is where another life can appear [i.e. the uterus]. It is the focus of countless Yogic practices, meditation, Chi Kung, martial arts etc. If you can make this area strong you will live long and healthy life! In the context of fertility we can think of it as a cozy nest. It needs a good supply of blood to keep it warm and nourished. This is seen as one of the roles of the “liver”. Acupuncture treatments that nourish this aspect can promote the conditions for conception.

When it’s not functioning well, as well as fertility issues, it show up as irregular or painful periods, low libido, erectile dysfunction, PMT and general poor circulation.

Treatments!

We can’t reverse the aging process I’m afraid but we can try to help your body function a little closer to how it was designed to. I haven’t seen dramatic changes in hair colour through treatment [though sometimes the quality and quantity can improve if for example you have alopecia]. However when it comes to fertility management, acupuncture and Chinese medicine have a lot to offer. By helping to smooth out the functioning of the body and mind, its as if the distractions have been lifted and the body can relax and do what it was designed for.

 

 

Second solar term: Rain Water

Public, practitioners, students

Spring time is beginning!

Chinese new year is the seen as the birth of the year in the Chinese Lunar calendar. We can think of the year in two halves – the yin half in which the days get shorter and colder, and the yang half in which the days get longer and warmer. Though the yang half begins on December 22nd [after the solstice] its only really noticeable from now that nature is beginning to get ready to get out of bed.

In the Chinese solar calendar the year is marked by 24 solar periods of approximately 2 weeks. This was an agrarian calendar for farmers. The first is 4th of Feb which is called the beginning of spring, it doesn’t feel like it in terms of temperature but the increased light and signs of activity in the garden [you have to look close] give a clue or two.

February 19th marks the second solar period known as Rain Water. This suggests that along with the increase of yang there is damp and so one must still protect ourselves, particularly our digestive system and kidneys, so keep warm and eat well!

Traditional East Asian culture places strong emphasis on aligning ourselves with nature, so different seasons require different patterns of behaviour. A lot of this is straight forward; as the year gets going we should get up earlier and move about more, exercise more, eat what’s in season, initiate new plans and unlock creativity, start new projects etc.

There are also more specific actions that may appeal more to Chinese medicine nerds such as stimulating specific points, drinking particular herbs, performing particular exercises etc. One such exercise described in the 16th century Daoist work Tsun –Sheng- Pa- Chien that is suitable for practising during the first two solar terms is as follows:

Sitting cross legged, both hands crossed and pressing on the thighs. Turn the head left and right 15 times, knock the teeth together, breath and gargle the air in the mouth, swallow 3 times.

Knocking the teeth, gargling and swallowing etc. sounds a bit crazy to the uninitiated ! A simpler version that I tried is simply turning the head 15 times each way while pressing on the thighs cross legged then breathing deeply through the nose and out through the mouth [keeping the tongue touching the roof of the mouth behind the teeth]. You can also combine the turning of the head with the breath, just breathe in and turn outwards on the out breath and back to the centre on the in breath. Finish with a long relaxed out breath. Don’t push the air out let it leave you naturally. 

CHI GONG FOR HEALTH

Public, practitioners, students

Tuesday lunch time from 1-2 is now the new time for the chigong class. Beginners welcome, these are simple stretches and breathing exercises, and static postures to develop internal strength and restore vitality. Classes are £45 for 6 first class is free. Why not try it out!

The kika Facebook page had an interesting article uploaded about the history of chi gong within the medical community in China during the 50s and 60s where it was initially first introduced into hospitals. The article deals also with the problems they had in terms of the conflict of having to package it in terms that  were politically acceptable for the the ruling regime whilst still making it clinically effective. Though no doubt some of the claims at the time could be seen as questionable it is still a part of the medical establishment and can be offered to patients, with research continuing to this day in its appellation for specific illnesses.

Click here to get to the Facebook page which also has a post relating to taichi and heart disease.

kika

Public, practitioners, students

Why call it “kika”?  – kika is formed from two Chinese characters, or Kanji as they are known in Japanese. The ‘ki’  [ 喜 ] character means joy or happiness, the ‘ka’ [ 花 ] character means flower. Besides being taken from each of our daughters names the combination reflects a way of treatment. Traditional Chinese medicine is based on a “root and branch” approach. In order to get happy healthy flowers on your branches you need strong and balanced roots. The treatments on offer are to help strengthen your “roots” in order to maintain blossom on your branches!

So typically in acupuncture, treatment is structured in this way. Part is to strengthen the root or constitution and part is to address the symptom. Sometimes these parts of the treatment overlap.

The chi gong exercises can be seen as a kind of home therapy to strengthen one’s vital energy and improve health. Moving exercises co-ordinate the body’s muscle and nervous system and the standing exercises mimic the idea of a tree with strong roots, increasing stamina, circulation and lower body strength while relaxing the mind and lifting the spirit

Some reflections on studying Kampo

Public, practitioners, students

Some reflections on my studies in Kampo

Tony Todd

I got interested in Kampo around three years ago and decided to study it after having had treatment for a cough which hadn’t responded to other treatments. The formula prescribed to me was Polyporus combination for three days followed by min. Cinnamon and Peony for one week. The cough cleared before I’d finished the first packet and by the time I’d finished the second one I’d decided to sign up for the course. My reason for studying Kampo wasn’t simply that I thought it effective. I’d also had TCM herbs in the past with good results, though in the intervening period I’d moved away from TCM-style syndromes in favour of Japanese meridian therapy in my acupuncture practice. This approach to acupuncture is characterised by an emphasis on palpatory findings over other diagnostic information as well as forming diagnostic patterns around a Sho. Having come to acupuncture originally from Shiatsu, the twin aspects of palpation and Sho within Kampo made it seem like the most obvious choice for herbal study.

An overview of Kampo and its working methods

Much as in the case of acupuncture, traditional herbal medicine was in serious decline throughout the Meiji period (1868-1911) and modern Kampo owes much to figures like Otsuka Keisetsu who, with Yakuzu Domei in 1938, formed the East Asia Society for Medicine in order to unite traditional Doctors in Japan, China and Korea. If the Meiji era is seen as Kampo’s lowest point then its highest could be thought of as the Edo period (1600-1868) when the practice of fukushin abdominal palpation was developed as well as the emergence of the Koho-ha [Classical Medicine faction] school, founded by Geni Nagoya (1628-1696) and Yoshimisu Todo (1702-1773). Yoshimisu’s motto “Do not mention what is invisible” epitomised the contrast with the Gosei-ha [Later Generation faction] school by rejecting the more abstract and esoteric theories and promoting a return to the more simple and practical approach of early Chinese medicine as seen in the writings of Zhang Zhong Jing. Todo discarded the theories of Qi and flavour as well as the theory of channel affinities. His indications for herbs would be in terms of characteristic signs and symptoms derived from cross referencing the patterns they appeared in e.g. Gypsum would be indicated for severe thirst [1] rather than seen in terms as either its Qi or flavour. Though Gosei-ha did not entirely disappear (and in fact later objections to Koho-ha gave rise to an eclectic school, the Secchu-ha in the late Edo period), Kampo today has been influenced by this Koho-ha tendency to a simpler theoretical model grounded in more ‘tangible’ and tactile signs and less inclined to speculate on processes and pathophysiological mechanisms that are not directly experienced. Perhaps this is best expressed in the method of diagnosis by Sho.

Sho [sign/symptom package over syndrome]

The Sho or Akashi [証] is the constellation of signs and symptoms that point to a treatment method or formula. Whereas in other herbal styles one may move from:

signs/symptoms >> syndrome>> treatment

where the syndrome describes some kind of pathophysiological state of the body, and there maybe several treatments possibilities for a given syndrome (different herbs added to or subtracted from a formula, different formulas, different combinations of acupuncture points etc). The method of Sho on the other hand is simply:

signs/symptoms >> treatment

where a given formula (or acupuncture point protocol) will resolve a given a particular combination of signs and symptoms. Nigel Dawes has described this as “formula matching”:

..the practice of composing a formula based on the perceived individual actions of each herb was not discussed in the early classical texts. [2] Prescribing was done on the basis of ‘matching’ an existing formula to a patient conformation, called a SHO in Japanese. The SHO differs from the modern TCM concept of a pathological syndrome in that it includes not only a collection of identifiable signs and symptoms but also pays attention to the patient’s subjective complaints, the constitution, the state of the digestive function and diagnostic specialities such as Fukushin. In Kampo terms each formula is therefore said to have its own unique SHO and the practitioners job is to match the SHO with the patient. [3]

Rather than taking a formula and trying to bend it round to cover all the presenting symptoms, a practitioner will be looking for characteristic patterns within the patients symptoms that point to the use of a particular formula. The use of the formula may resolve the case entirely or in the case of a partial resolution will give rise to a new Sho that is treated with a new formula or possibly combination of formulas. The skill of the practitioner will be seeing the most appropriate Sho in an often confusing set of symptoms, and in knowing how long to prescribe for and what kind of combinations might be needed. In some respects there are similarities with homeopathy, both have a ‘key and lock approach’, matching the remedy to the person/condition. Arnaud Versluys has talked about a ‘Shen Nong’ lineage of practitioners, more concerned with the practicalities of medicine in the field rather than philosophical and theoretical speculation and though Zhang Zhong Jing was clearly a master of Nei Jing theory his book could be used by practitioners as a practical manual. The method of treatment by Sho fits this model; one may of course enquire into the pathophysiology that a Sho represents but it is not the primary object, that of course being to see the Sho and successfully treat the patient. This sensibility runs through Japanese meridian style acupuncture and Shiatsu too, giving rise to the motto ‘the diagnosis is the treatment’.

In practice one can organise Shos into groupings usually around the substances (qi, blood,water), around Shang Han Lun confirmations (tai yang, jue yin etc), or around weak digestion (ichokyojaku). Key signs/symptoms will lead one towards one group or another such as abdominal confirmations for some water or blood formulas, pulse and symptoms for tai yang or jue yin formulas etc. One then matches signs and symptoms with constitution eg a blood formula indication (such as pressure pain in the lower left quarter of the abdomen) could lead to a Persica and Rhubarb Sho for a more full type or Cinnamon and Hoelen for a more medium type constitution. Shos can also be grouped in terms of Outside/Inside [Hyo/Ri], Empty/Full [Kyo/Jitsu], Hot/Cold [Netsu/Kyo] where typically Outside/Surface Shos are treated by Shang Han Lun Yang confirmations and Inside Shos are treated by Shang Han Lun Yin confirmations or formulas from the Jing Gui Yao Lue or later texts, and are themselves typically grouped into qi, blood [Oketsu], water [Suidoku] types. Full and empty includes here the overall state of the patient as well as the nature of presenting symptoms and Hot and Cold to distinguish formulas that have a more heating or cooling effect.

Abdominal palpation

I don’t want to say much about abdominal palpation as it was covered in some detail in the last issue other than to point out that this too is largely derived from Zhang Zhong Jing [4] and exemplifies a sense of immediacy and practicality that runs through Japanese medicine. [5]

Formulas over ingredients

As formulas are seen as the basic building blocks of Kampo, in practice this means that addition or subtraction of ingredients is not common. A formula is given as a unit and then changed to another formula as the presenting pattern changes, similar to peeling layers of an onion. Sometimes more than one formula would be used simultaneously but again in general the formula would be seen as the basic unit. Of course this is not a black and white situation. Even when I first studied Kampo in the UK, modification was not seen as never occurring but simply bottom of the list of things to try, and after considerable experience of using the formula in its original form.[6] While I was in Japan I did see some modification but it was not often and tended to be more combinations of formulas or the addition or increasing of the amount of aconite to boost the warming properties of a formula.

Dosages and preference for classical formulas

The term Kampo could also be used to signify a preference for classical (Han dynasty) formulas. Though this is not exclusive, and there are examples of formulas from the fever schools and from Li Dong Yuan, as well as a few examples of more recent Japanese formulas, one can clearly say that there is a bias towards Zhang Zhong Jing formulas. Another feature is that dosages are smaller than are commonly used in modern Chinese formulas, typically 1/3 of the Chinese dose.

Formulas and the Japanese Health Service

In 1976 the Japanese Ministry of Health and Welfare listed 43 granulated extracts as being covered by the health insurance system. Today there are over 150 formulas, produced by pharmaceutical companies such as Sun Ten and Tsumura for the health system and available from any doctor or pharmacist. Formulas outside of these can also used but cost approximately three times as much for the patient.

My experience of two clinics

I spent time at two clinics in Tokyo in 2008 and 2007, with Dr Tarashi at the Genwado clinic in Ginza and with Dr Watanabe at Keio University. Both practice Kampo in the tradition of Dr Otsuka who’s material the UK course is based on, and this quickly became evident in the formulas they used and in the method of abdominal palpation which was more or less identical with what I studied at home. In both cases I was not the only student present, which in itself helped to shine light on the experience of studying in Japan. In both clinics students (mostly other doctors) would sit in with the doctor and simply observe the consultations and formulas given. Whenever doctors felt there was something especially interesting to point out they would do so in terms of symptom patterns or formulas, or sometimes taking the student over to feel the patient’s abdomen. Other than that there would be little if any formal teaching in the clinic. At Keio there were weekly discussions of new patients amongst the doctors, each discussing what they had prescribed and their assessment of the case. The time I was there this was followed by reading from one of Otsuka’s memoirs, on that occasion it was from a chapter on the action of Hoelen 5 combination and Tang Gui and Peony combination. The students would take it in turns to read and the senior doctors would comment on the text in the light of their experience.

The two clinics I visited were quite different in some ways. Tarashi’s clinic is a ‘family’ clinic that mostly specialises in fertility (though patients once having been

treated tend to also come back for other reasons too), while the Keio clinic is at a prestigious university hospital outpatients department which treats a wide variety of problems. Many of the patients are also simultaneously visiting other university departments, and patient information is kept on a database where formulas are noted alongside blood tests and other findings from other departments. It appears as a very modern integrated health system, with patients either self- referring or coming via other departments. In other ways what actually happens is similar in both clinics, both are very busy seeing around 50 patients in a morning. The importance of a large breakfast quickly became apparent as it could end up being a while before lunch.

The volume of patients is I believe an important factor as to how the art is learned. Unlike more modern western approaches to interactive learning the student is more of a sponge, seeing the patients come in, listening to their symptoms and (if the clinics not too busy) feeling their abdomen/pulse, and seeing the results of the prescription. It is an approach that cuts through intellectual analysis and gradually one begins to associate certain patterns with certain formulas.[7] The key of course is to see a sufficient volume of patients, in the absence of which it is helpful to have other methods of study to rely on.

Doctors in both clinics treated a lot of long term chronic problems, sometimes prescribing for a month or 6 weeks at a time, before checking the patient to either modify or continue with the prescription. At Keio especially, patients were often taking more than one prescription concurrently, in some cases alongside western pharmaceuticals. At Genwado I noted that formulas tended not to be changed according to the different stages of the menstrual cycle as is often taught in the UK (such as supplementing blood and yin before ovulation and warming and boosting yang post ovulation)[8] When I asked Tarashi about this he replied that this idea was introduced into Kampo circles some time ago but never really took root; he believed that formulas treating underlying imbalances take time to adjust the body’s core misalignments and that changing the formula at such regular intervals did not significantly improve results. At Keio, similarly, the changing of formulas though sometimes used is not popular. It would seem to highlight an interesting area of divergence between the use of Kampo and TCM formulas.

Another interesting comment that I heard was that though interest in Kampo amongst doctors has grown dramatically in recent years, actual understanding of Kampo is very poor. Many doctors prescribe quite symptomatically without an appreciation of traditional theory and working methods. The Doctors who were observing with me at Genwado seemed not to know very much traditional theory, though to their credit they were interested in learning Kampo as an alternative approach for their patients that was less likely to produce side effects. At Keio Dr. Nishimura told me that when he began to study Kampo there were very few departments in medical schools. Now over 80 medical schools teach Kampo as part of their core curriculum and there are three post graduate courses in Kampo at Keio, Chiba and Toyama Universities. The Keio course is a three-year course and he feels it is important for doctors interested in Kampo to study to this level.

At Genwado Terashi finds that a high percentage of his patients can be grouped according to the following (approximate) scheme:
FLOW CHARTS

Constitution

strong?

No

See below

Excess water type:

Stephania & Astragalus comb.

Yes

Yes

Yes

No

No

No

Yes

Average / normal constitution?

Large frame?

Kyokyokuman type

Maj. Buplerurum comb. with Cinnamon & Hoelen comb.

Condition worse before a period ?

Average build Oketsu type

Cinnamon & Hoelen comb.

Average build Gassy type:

Abdomen type

Cinnamon & Persica comb.

Constitution strong?

Yes

See above

No

Digestion strong ?

Weak digestion type [ichokyojaku]

Maj. Six comb.

Min. Cinnamon & Peony comb.

No Yes

No

Dizzy? Light headed on standing

Cold type Abdominal pain Dang Gui & Jujube comb.

Yes

Kyo type Blood type

Dang Gui & Peony comb.

These formulas don’t of course account for all the prescriptions though they would seem to form the base from which he would work. In some cases for example he might make use of Rehmannia 8 combination if in addition to the above there was also vacuity below the navel, or combine warming elements of the formula to Tang Gui and Peony for a Dang Gui and Peony Sho with more cold. In an addition to the abdominal patterns I’d previously learned he also saw tightness along both sides of the lower abdomen (superior to the anterior superior iliac spine) as relating to cold and an indication for Dang Gui & Jujube. Another feature of Genwado was the use of raw ingredients for most of the patients, though Keio made use of Tsumura produced granules which is typical of herbal medicine in Japan. The time I spent at the clinics was extremely interesting, it confirmed much of what I’d been taught about the Kampo approach and put it into a wider context, though it left me feeling that there are still too many formulas that I don’t know well enough!

After thoughts

Kampo in the UK is a small part of the Chinese herbal medicine sector. The Kampo society periodically runs introductory courses on a small group basis, with mornings covering theory and afternoons seeing patients. Despite a current lack of study/courses for practitioners who have completed the basic course, there is supervision available from existing practitioners and in some ways this is perhaps closer in spirit to how Kampo is often learned. Studying in Japan is always an option but does require a reasonable level of Japanese. Material is however increasingly becoming available in English. Otsuka’s book is soon to be published in English and there are books by Hong Yen Hsu, Robert Rister, Takahide Kuwaki, Yoshiharu Shibata, as well as several articles and cases published in the North American Journal of Oriental Medicine. Moving beyond what is ‘officially Kampo’, the recent series of lectures by Arnaud Versluys on the Shang Han Lun has for me been an inspiring and useful resource. The Shang Han Lun based working methods not surprisingly share a lot of common ground with Kampo, and though discussion of flavours may not be to Yoshimasu Todo’s liking, the presentation of family formulas I think would get a nod of approval. Of course books and lectures are no substitute for patients. My brief look at the clinics in Japan highlighted some differences in learning and teaching methods as well as clinical reality, since the situation in Japan is much more integrated with conventional healthcare, and driven by doctors with a full pharmacopoeia at their disposal and huge patient volumes. While at Keio I went to a presentation by a representative of Tsumura, the pharmaceutical company that manufacture the formulas used in the Japanese healthcare system. There I was told that the Japanese pharmacopoeia does not contain any aristolochic acid as they use varieties of Asarum and Stephania that are free of it. Perhaps this could be an answer to the restrictions faced by both TCM and Kampo practitioners in the UK?

NOTES

[1] ‘Stroll through Kampo History’, North American Journal of Oriental Medicine, November 2003 #20
[2] Though it has been shown that the architecture of Shang Han Lun formulas is founded on the flavour model of five phase therapeutics [Arnaud Versluys, ‘Shang Han Lun Seminars’, London, Spring 2008], applications of Kampo formulas are not discussed at this level but in terms of objective signs/symptoms (as they are described in Shang Han Lun)

[3] http://www.pacificcollege.edu/alumni/newsletters/summer2003/kampo [4] See The Lantern Vol 3 #2, Vol 3 #3 (articles by Michael Max and Steve Clavey)

[5] Though this trend is rooted in Classical Chinese medicine: see Elizabeth Hsu – Tactility and the Body in early Chinese Medicine. Science in Context 18 (1) 7-34 2005
[6] This was echoed in a recent lecture by Arnaud Versluys (November 2008) who stressed the importance of allowing classical formulas to demonstrate their efficacy before modifying and altering their effects. By not allowing this to happen one is never in a position to understand the effects of these formulas in their normal state and thus is in a even weaker position to be able to make decisions about how to modify

[7] Arnaud Versluys has painted similar descriptions of traditional study methods in the Chinese Shang Han Lun tradition
[8] Jane Littleton, The Treatment of Infertility with Chinese Medicine. Churchill Livingstone 2004

Treating back pain

Public, practitioners, students

Treatment of back pain with acupuncture

Effectiveness in treating back pain

“Affecting around 1 in 3 adults in the UK each year, low back pain is a very common According to NICE [National institute for clinical excellence] Lower back pain is a condition with an estimated 2.5 million people seeking help from their GP about their condition” 1. Recent recommendations from the guideline for health professionals include “ offering a course of acupuncture needling, up to a maximum of 10 sessions over a period of up to 12 weeks”2 While it is gratifying to have support from bodies such as NICE acupuncturists and their patients have long been aware of the benefits of acupuncture for back pain, which probably ranks as one of the more common complaints that people come to see us with.

So what can you expect if you come to see an acupuncturist for back pain. To some extent it depends who you go and see, what kind of training they’ve had, what style of acupuncture they practise etc. Part of the problem of trying to research acupuncture for a given condition is that there are a number of different approaches to treatment, and even within a given style practitioners adapt and evolve their own techniques. Thus research protocols that are based on standardized treatments actually tell us little about the efficacy of acupuncture in a realistic clinical setting.

From the perspective of a patient the most obvious differences will be whether they needle the area that hurts or whether they needle somewhere away from the pain, whether you feel the needles strongly or not at all, whether they leave the needles in or not, whether they use other techniques such as massage or cupping or moxa for example, how much importance they put on other aspects of your health/life, whether they rely on just asking you about the problem or whether they use traditional diagnostics such as pulse taking, inspection of the tongue, abdomen palpation etc.

Root and Branch

In traditional acupuncture there is the idea of ‘root’ and ‘branch’. Broadly speaking from a any problem such as a back ache has an aspect that is visible and tangible such as the pain it self and a more hidden aspect or origin out of which it has arisen and or to which it is still connected. In the same way as a tree has an aspect that is above ground and another that is below, the yang aspect is the branch or symptom and the yin aspect is the root which could be seen as the relative functioning of the body as a whole. This greater disharmony could have been what lead to the pain or in the case of a sudden acute trauma it could just be the way the body is responding to the pain; maybe with other muscles groups tightening, referred pain to other joints, affects on posture etc. Any treatment in traditional acupuncture consists of bringing a greater balance within yin and yang aspects of the person, that generally requires attending to the root and branch of the problem.

Often the difference in approach is characterised by the degree to which the acupuncturist focuses on the root or branch and the methods they use to treat one or the other. In this context the sort of ‘acupuncture’ [here on referred to as dry needling] that is done by GPs, physiotherapists, chiropractors etc can be thought of as one approach to treat the branch without consideration for

1 http://www.nice.org.uk/media/7D0/4D/2009031LowBackPainGuidelineRelease.pdf 2 http://www.nice.org.uk/media/7D0/4D/2009031LowBackPainGuidelineRelease.pdf

the root. Unless the pain is acute to the point that one has to control it before doing anything else, most traditionally trained acupuncturists will focus part of the treatment in resolving the symptom and part in resolving the root pattern. A smaller proportion of acupuncturists may focus simply on one or the other. This in turn leads to a broad diagnostic approach that goes beyond the specifics of the back pain and rather looks to see if there are any underlying patterns of disharmony whether in digestion, menstruation, sleep etc and is ascertained by questions as well as through traditional techniques such as palpation of the abdomen and pulse, and inspection of the tongue. These findings are in turn considered with reference to the main symptom eg back pain. Sometimes there is a clear connection, sometimes not. In either case traditional acupuncturists see balancing the big picture as a necessary step in treating any symptom, rather like laying firm foundations before building a house. Root treatment tends to relax the body’s nervous system which in turn helps in the release of spasm and improved postural alignment. Usually this is achieved through 2 or 3 points in the arms or legs which may or may not be left inserted [or in the case of some styles such as Toyohari which I practise, may not even be inserted at all].

Variation in Needling

In treating the main symptom some practitioners will tend to needle the place where you are feeling the pain, where as some will tend to needle away from the area, and of course a lot of us will do both to varying degrees. Alongside location differences exist between number of needles used (from just one or two to twenty or thirty), degree of stimulation (from none to very strong/painful) and also whether they use adjunct therapy like moxibustion, cupping, massage etc.

For me personally though I do often treat the affected directly I prefer to treat away from it as much as possible; the body is connected up in many interesting and mysterious ways that over many centuries have been documented in texts that became the basis for traditional East Asian medicine. [More on this in future article]. Often one has to release blocks in one part of the body which is stopping another part from repairing. Practically it means that stimulating a point on the outside of your wrist can help your lower back to get better! This is useful as sometimes when the back is in spasm trying to insert needles at that location can be quite uncomfortable and in some people can actually aggravate the condition. When this is suspected having a plan B or a selection of distal points can be very handy. So next time someone such as myself starts needling your foot for your headache, don’t assume that you have totally wasted your money on someone who doesn’t know his arse from his elbow, as there is in fact a point below the elbow that work rather well for haemorrhoids!

An extension of the use of distal points is the use of micro systems. You may have come across this idea in Reflexology treatments where the whole body is treated from the feet. This is also the case with ear acupuncture or Korean hand acupuncture, both of which use similar idea of treating the whole body from just a small part. In affect taking the body to be like a hologram. So sometimes one or two points in a specific part of the body can relieve your back pain or shoulder pain.

Another difference between approaches to treatment is the degree of stimulation and depth of insertion. Broadly speaking modern Chinese styles tend to needle more deeply and with more stimulation [including electric stimulation similar to TENS], needles are left in place for 20-30 mins or periodically stimulated. At the other end of the spectrum is shallow and contact needling used by

Japanese acupuncturists which is characterised by mild or no stimulation and without needles left in place [or for much shorter periods]. Both systems work well when practised correctly; personally I use a mix of the two but mostly rely on shallow insertions [often non insertions] and mild or no stimulation. Whatever the approach the final goal is for the nervous system and soft tissue to relax, alleviating spasm and allowing repair and re-alignment to take place.

What to expect from treatment

First a general consultation takes place to try to better understand the background to what may have caused the back pain as well as its nature and location. Then together with information about general health further diagnostic checks are made such as palpating the abdomen and the radial pulse, a few points will be chosen to either needle, or stimulate using heat or pressure, on the arms, legs and abdomen [not necessarily all at the same time]. This helps to relax the body as a whole and correct the big picture imbalances. As the body’s tissues are all interconnected this will begin the process of relaxing the area in pain. Then if you are able to turn over the back is now treated. Usually points are used in the lower legs and often the local area too is needled or treated with moxibustion [heat].

Traditional acupuncture is more than just insertion of needles. Originally acupuncturists used 9 kinds of needle; around half of these were not meant to be inserted, with rounded tips they were used to massage and press muscle tissue and joints. In addition moxibustion [heat from burning a herb] is used to warm the area or to dispel spasm and inflammation. There are many techniques for moxibustion that all revolve around the application of heat over a large or small area, either with a heat lamp or the pure dried herb. Other techniques include cupping and massage to move stuck blood and relax spasm.

Receiving treatment should feel relatively pleasant and relaxing. If it’s causing discomfort then its counter productive and alternative techniques need to be used. After treatment where possible try to relax and have an easy day, try to avoid vigorous exercise and alcohol. How many treatments are needed will depend on how long you have had the problem and you general state of health. Most muscular problems that present with reasonable healthy individuals respond fairly soon, with some noticeable improvement usually in the first two or three treatments. In some cases only one or two treatments are necessary, in more chronic cases it might take longer with the frequency of treatment decreasing as the condition improves. Usually I treat once a week though it sometimes it is better in the beginning to treat twice a week if the condition is severe. Acupuncture and moxibustion [as well as Chinese herbal medicine] often offer good cost effective solutions to back pain, joint pain and many muscular skeletal problems. If you are suffering from anything of this kind and would like to discuss it further please email me at info@croydonandpurleyacupuncture.co.uk or call me on 0781 585 1476.

Tony Todd