All posts by drmorris

JAMA Publishes Shoddy Acupuncture Research – Responds to Professionals

Letters to JAMA Exposing Acupuncture Research Flaws Applauded by TCMAAA TCMAAA calls for stricter adherence to research ethics and well-designed acupuncture studies among the integrative medicine community

February 19, 2015 08:00 AM Eastern Standard Time

TAMPA, Fla.–(BUSINESS WIRE http://www.businesswire.com/)--In five letters to the editor published in the latest issue of JAMA, the Journal of the American Medical Association, acupuncture clinicians and researchers around the world point to key flaws that call into question the validity and research methods used in a randomized clinical trial published in JAMA in October of 2014. The Australian study, Acupuncture for chronic knee pain: a randomized clinical trial, by Hinman, et al., concluded, “In patients older than 50 years with moderate or severe chronic knee pain, neither laser nor needle acupuncture conferred benefit over sham for pain or function. Our findings do not support acupuncture for these patients.” Many American acupuncturists were outraged when the October 2014 article was published in JAMA and have called for a review of the study’s design and protocols.
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“This collection of letters represents a merging of licensed acupuncturists and integrative medicine practitioners who demand the same gold standards of ethics and design quality for clinical acupuncture research as conventional medical studies”

Yong Ming Li, MD, Ph.D., of New Jersey challenges that the researchers altered the aims and hypotheses of the study after the data was collected and the trial was closed. According to the original aims and hypotheses submitted to the official clinical trials registry in 2009 the objective of the study was not to evaluate the effectiveness of traditional needle acupuncture against sham laser acupuncture, but to evaluate laser acupuncture against sham laser acupuncture with needle acupuncture serving as a positive control for laser acupuncture. Protocols originally filed with the registry as well as the authors’ baseline publication do not describe sham laser acupuncture as being a control for needle acupuncture. Dr. Li’s letter furthermore debates the validity of using sham laser acupuncture as a control for needle acupuncture, as it is not generally accepted as a valid control for needle acupuncture.

Hongjian He, AP, Ph.D., of Florida also questions design choices: she specifically points to the use of non-standardized point selection for chronic knee pain. Also some patients received treatments once a week, while others got treated twice a week. This lack of consistency throws into question the validity of the statistics extrapolated from the data collected during the study.
David Baxter, TD, DPhil, MBA, and Steve Tumilty, Ph.D., questioned in their letters why the researchers chose to use laser dosages below the threshold necessary to have a therapeutic effect and why they failed to specify wavelength used in the study and why those levels were chosen.

Lixing Lao, Ph.D., MB, and Dr. Wing-Fai Yeung, BCM, Ph.D., point out in their letter that patients were assessed after 12 weeks and then again after one year, but that without treatment for chronic knee pain after one year, the condition naturally will deteriorate, so that the findings after a year are irrelevant. With these key flaws revealed the conclusion of this randomized clinical trial is clearly undermined.
No group has been more involved in this issue than the Traditional Chinese Medicine American Alumni Association (TCMAAA). Through its broad social media in the USA and around the world, TCMAAA has orchestrated a series of professional forums and discussions on research ethics and design for acupuncture studies after the Australian study was published in JAMA.

“This collection of letters represents a merging of licensed acupuncturists and integrative medicine practitioners who demand the same gold standards of ethics and design quality for clinical acupuncture research as conventional medical studies,” stated Haihe Tian, Ph.D., AP., the President of TCMAAA.

Even with the challenges acupuncture poses in gold-standard randomized clinical trials this valuable treatment method should not be overlooked. With properly designed and well-thought-out studies acupuncture can be evaluated fairly and thoroughly, with conclusions founded upon careful reasoning, accepted controls, and irrefutable evidence.

About TCMAAA:
Registered in Florida, TCMAAA (website: www.tcmaaa.org http://cts.businesswire.com/ct/CT?id=smartlink&url=http%3A%2F%2Fwww.tcmaaa.org&esheet=51043049&newsitemid=20150219005222&lan=en-US&anchor=www.tcmaaa.org&index=1&md5=1a9f12e9da09de10aab91b1f3898cb3f) is a nonprofit organization with one thousand members of licensed acupuncture practitioners formally trained in accredited medical education institutions in China. As a leading organization among Chinese Medicine practitioners, TCMAAA continues to support its members’ professional growth across the United States.

Contacts For TCMAAA
Selene Hausman, L.Ac., 480-510-2259
seleneph@… mailto:seleneph@

Astrology and Medicine – the charts

There are three primary methods of medical charting in astrology. The first is the natal chart which is used to discern patterns and constitution. The second is the decumbiture which is the chart calculated for the moment a person develops a condition. The last is the medical horary, which is calculated at the moment the physician understands the inquiry. The horary was often conducted at the time the urine was inspected. Culpeper had very low regard for this method, emphasizing the Decumbiture as the appropriate method for medical practice.

One factor that drives chart selection is the availability of accurate data. It was uncommon for the average person to possess their birth data in premodern times. This fact predisposed the medical astrologer towards available data in the form of either the decumbiture or the medical horary.

In decumbiture – the 1st house is the patient, the 6th is the disease, the 7th is the physician, the 10th is the treatment. The placement of the moon can be compared with the natal chart if available.

In medical horary, the 1st house is the physician, 10th is the patient and the 7th is the condition. The moon is a vital consideration. Planets that it has close association with at the time of inquiry speak to the condition. Further, the moon may be checked at 10 and 40 degrees from the moment of inquiry to understand its status at that time.

Shen Harmony: The Normal Mental Condition in Chinese Medicine, Part 1

Acupuncture Today
September, 2008, Vol. 09, Issue 09

By Joseph Changqing Yang, PhD, LAc and William Morris, DAOM, PhD, LAc

Psychiatric and psychological conditions are a common experience in the daily clinical process. In this paper, we will discuss the normal shen as a method of understanding conditions such as depression, anxiety, bipolar disorders and addictions.

We have been interested in the importance of shen harmony for some time and consider shen to be the capstone of human experience.

While the wisdom of working with human shen has been lost for some time, there is a new movement in contemporary times to recover the art of the shen. There are increasing publications and courses on shen as renewed interest and inquiry emerges. However, the  complexities are limited to the conception of shen. The practical use of this discipline is far from clinical, in part because of the impact of a Newtonian physical conception of reality that has impacted the development of scientific approaches to medicine in the East and West. Further, the needs for physical pattern diagnosis, reports and other demands of contemporary practice limit the attention of the practitioner. There are other factors that have impacted the development of shen concepts in clinical practice, including superstitions and beliefs that can become confusing or easily dismissed on conventional cultural settings.

The ideal shen presents with a healthy, harmonious spiritedness. The loss of shen presents with spiritlessness and mental illness. This is the Chinese medical condition described as “shen disturbance” and includes mental and spiritual pathological conditions. The patient’s spiritedness may be evaluated by using the four examination methods of Chinese medical diagnosis: observation, olfaction, inquiry and palpation.   Ever since the Chinese medical classic the Nei Jing emerged, many early practitioners have worked on the shen for various mental disorders, providing a clear view about healthy shen and shen harmony. Following Nei Jing theory and early practitioners, we know the practices of shen harmony and spiritedness include concepts such as shen unity, shen awareness, shen clarity, shen flexibility, shen stability, shen balancing, shen power, shen reactivity, shen initiation and shen processing. These discussions may be found in the Nei Jing Su Wen, chapters 1, 2, 13 and 25. The Ling Shu discussions of shen are in chapters 8 and 72.

A healthy mental state may be described as a harmonized shen. Similarly, the Su Wen (Shang Gu Tian Zhen Lun, chapter 1) states: “The Yellow Emperor of ancient times was bright and clever when he was born.” This description suggests that the Yellow Emperor had a harmonized shen. Since it was from birth, it implies that pre-heaven essence is involved. The Chinese medical conception of shen, however, is not assessed based only upon factors of spirit or mind. Observations may include hand or eye movements as expressions of shen . Further, observe the hair and nails for a deeper knowledge of the shen during clinical diagnosis. This provides a better understanding of the yin essence and blood which provide a root for the shen. We will now discuss the shen concepts individually.

Shen Unity

Shen resides at the interior and fills the physical form. When shen is harmonized with the physical body, the physique and shen are harmonizing in oneness. The shen located in the heart is a singular concept called heart shen. The shen is also a plural concept and may reside in various organs. For example, the shen residing in the liver is called the hun; the shen residing in the lung is po; the shen residing in the spleen is yi; and the shen residing in the kidney is zhi. In a healthy state, these shen are united in a cooperative state. When the shen are harmonized together, creating the big shen, there is harmony throughout mind and body. Correspondingly, each organ system has its own shen pattern and activities, and must function cooperatively with other organ systems in order to perform the activities of the shen. Shen unity is an important component of healthy mental function so people move through life in contact with and using wisdom. Shen unity is an integral state of being that demonstrates congruency between the subpersonalities and can be observed by the practitioner via clinical signs.

If a single shen is hyper- or hypofunctioning, it also can affect other shen or systems. For example, heart fire may lead to heart shen irritability; the person who suffers from this condition may be easily startled or experience anxiety and insomnia. If the heart qi is weak, this may lead to a weakness of the heart shen and the patient may feel sad or have sluggish mental powers. A happy and enjoyable life requires attention not just to heart shen; there also must be cooperation from the hun, po, yi and zhi in a harmonious state.

Shen Awareness

Shen awareness extends from self into an individual’s social context. At the level of self, consciousness involves awareness of being, actions and location. Further, there is knowledge and awareness of orientation with complex social and life situations. For example, the patients know their family members, co-workers and relevant details about their lives. When the patients have good shen awareness, their shen situation will generally improve while they work with their doctor cooperatively and have good compliance.

When treating shen disturbance, it is necessary to assist patients in the recovery of their shen awareness. The general status of shen harmony is an indicator for progress in the treatment of mental disorders. For example, some severe shen disharmony patients have significantly reduced or no shen awareness; they may refuse to see a doctor or deny their unbalanced behaviors. Consciousness is shen awareness; mild shen awareness troubles may be related to the reorganization of current situations, while severe shen awareness disorders may involve a complete loss of consciousness.

Shen Clarity

Shen clarity involves an aspect of consciousness that remains clear and unclouded. With shen clarity, the individual has clear thought processes and stable shen activities. The mind develops breadth and depth of consciousness. Thus, we can understand that great thinkers have developed shen clarity. The development of shen clarity usually requires a harmonized shen. The Su Wen (Mai Yao Jing Wei Lun, chapter 17) mentions, “The head is where the spirit located.” Here, “spirit” is translated into English from the Chinese word jing ming, where the head houses the jing essence and the ming is the clarity property of consciousness.

Many patients with mental disorders have disturbances of shen clarity. They complain of mental cloudiness and a lack of ability to maintain focus. Disturbed shen clarity may be described as a foggy feeling with poor thinking ability and loss of memory.

Shen Balancing

Shen activity is working in a balanced condition. According to the Ling Shu ( Tong Tian , chapter 72), a yin/yang constitution is the most balanced personality and is ideal. There are four additional forms with relative differences in the balance of yin and yang. The tai yin type has more yin and almost no yang, while the shao yin type has less yin and some yang. Tai yang is predominantly yang with very little yin, and shao yang is mostly yang with some yin. Here, we are using the yin/yang principle to explain the five types of personalities. When the person is more of a yin type, the shen energy is directed inward, similar to Jung’s concept of the introvert. The tai yang and shao yang types are outgoing personalities and the shen energy acts differently, extending outward.

The ideal type of shen is expressed in a yin and yang balanced manner. For example, we may have natural emotional responses to external stimuli or endogenously generated feelings and thoughts. In these situations, it is the shen harmony power that provides the capacity to control and recover relatively normal states. Thus, when crying or angry for some reason, we feel relief afterward. However, this recovery occurs when the emotions are within a tolerable range. The shen knows that to avoid the further damage from extreme emotional reactions, it must keep these extremes in balance, or a proper harmonious condition. Thus, if someone feels angry much of the time, experiences chronic sadness and depression, or otherwise has a flat affect with little emotional response range, we can call this situation a loss of shen balance. This situation is discussed in detail in the Ling Shu (Ben Shen, chapter 8), which mentions, “When liver qi is deficient, it feels fear, excess is anger; when heart qi is deficient, it feels sad, excess is over-joy.”

Shen Power

Shen energy expresses differently according to different types of personality and constitution. The qi transformation theory provides an opportunity and method for evaluating the shen power and clinical progress. Shen qi can be strong or weak, depending on the clinical condition.

Normal daily cycles require shen power and physical vitality, and are balanced with physical and mental rest at night. There are also social, economic and family needs that require the expression of shen. Such efforts require both mental and physical power. Some patients may be fatigued both mentally and physically; they tend to feel their energy leave quickly. Some patients feel mental exhaustion more than the physical. Clinical depression is a typical diagnosis associated with the pattern of shen qi weakness. Many forms of mental disorder have shen lassitude and sluggishness in the early stages that also correlate with weak physical energy. This is a type of shen disharmony. Conversely, the shen qi may be too strong and active, so patients feel more joyful and have an optimistic mood all the time, need little or no sleep, and have abundant mental and physical energy. This is the manic yang pattern of the shen disharmony condition. Such mood disorders may present either subtly or in the extreme, which could lead to a conventional diagnosis of a bipolar disorder. In either regard, there is a disturbance in the harmony range.

The shen and xing should harmonize. This is commonly known in Chinese medicine as “physique and shen harmonizing in oneness.” Thus, the shen power affects the physique, leading to a zang fu (viscera and bowel) system disharmony condition. This concept is discussed in the Ling Shu (Ben Shen, chapter 8): “I was told the human body is different in character: some are firm and some are soft in the personality; some are strong and some are weak in constitution.”

Proving East Asian Medicine: Research Methods

Acupuncture Today
September, 2010, Vol. 11, Issue 09

By William Morris, DAOM, PhD, LAc

East Asian medical research focuses on quantitative means of proof. This affects the information obtained, thus what become considered best practices. I maintain that the world of East Asian medicine might also be understood through qualitative means.

In this article, I address the thinking behind these forms of research and to provide some examples of, and resources for, qualitative methods.

Quantitative Research

The traditional scientific approach to research has its underpinnings in what is called positivist philosophy. As a paradigm, positivists consider that true knowledge is scientific and measurable. The methods of positivism are informed by a set of principles including:

Value-freedom. Human beliefs and interests should not influence the choice of what and how to study a problem. Rather, it should be determined by objective criteria.

Causality. Research should identify causal explanations and fundamental laws.

Operationalization. The methods should enable facts to be measured quantitatively.

Independence. The researcher is independent of the subject.

Reductionism. Problems are better understood if they are reduced to the simplest possible elements.

Qualitative Research

Qualitative researchers consider that human beliefs and interest form the bedrock of decisions about what should be researched. The focus upon fundamental laws creates general information, and causes may change when applied to the individual human being. Qualitative methods of capturing information can often provide rich depth compared to quantitative. Regarding independence, qualitative research represents the researchers’ participation in, and influence upon, research and its outcomes. For Chinese medicine, which is a model of care that embraces complex systems and conditions, reductionism might miss the point.

In the hierarchical scheme of knowledge for evidence-based medicine, the randomized controlled trial sits at the top of the pyramid. This comes from a positivist point of view and does have value. The application of pharmaceutical treatments and population studies for risk-benefit assessment make the randomized controlled trial vital.

The extension of the resulting assumptions into social systems and individual lives poses a problem, however. Speaking about the world of human experience requires an extensive commitment in terms of time and dedication to process. However, this world is often dismissed as subjective and regarded with suspicion. Small qualitative studies are not generalizable in the traditional sense, yet have redeeming qualities that set them above that requirement.

Qualitative research investigates the why, not the how. Often, data is unstructured and can involve interview transcripts, e-mails, notes, feedback forms, photos and videos. Qualitative data can be used to gain insight into people’s attitudes, behaviors, value systems, concerns, motivations, aspirations, culture or lifestyles. Here, I will present six methods of qualitative research including case study, grounded theory, phenomenology, ethnography, narrative methods and historical research. Last, I will briefly present models for mixing qualitative and quantitative methods.

Case-study research is a form of qualitative descriptive research that looks intensely at an individual or small participant pool, drawing conclusions only about that participant or group and only in that specific context. Researchers do not focus on the discovery of a universal, generalizable truth, nor do they typically look for cause-effect relationships. Instead, emphasis is placed on exploration and description. Developing a case study involves gathering all the data, organizing it into an approach to highlight the focus of the study. Then, a case study narrative is developed. The narrative might be validated by review from program participants. Further, a case study series might be cross-compared to isolate any themes or patterns. The writings of Robert Stake and Robert Yin should be seriously considered by anyone wishing to employ case studies and case series in their graduate work.1-4

Grounded theory is a systematic generation of theory from data. Rather than beginning with a hypothesis, the first step is to collect data via qualitative or quantitative means. Key points are identified in the data and marked with codes and grouped into categories which become the basis for the development of theories and reverse-engineered hypotheses. Grounded theory is gaining strength in the area of medical research and there are medical research projects receiving funds from the NIH.5,6

Phenomenology involves describing the structures of experience as they present themselves to consciousness, without recourse to theory, deduction, or assumptions from other disciplines. Phenomenology studies the structures of consciousness as experienced from the first-person point of view. The central structure of an experience is its intentionality, being directed toward something, as it is an experience of or about some object. An experience is directed toward an object by virtue of its content or meaning (which represents the object) together with appropriate enabling conditions.7-9

Ethnography is a form of research focusing on creating meaning through close field observation of sociocultural phenomena. Typically, the ethnographer focuses on a community that may occur geographically or in cyberspace, They may be practitioner groups, patient groups and provider networks. From these groups, informants are selected who are known to have an overview of the activities of the community. Such informants are asked to identify other informants representative of the community, using chain sampling to obtain a saturation of informants in all empirical areas of investigation. Informants are interviewed multiple times, using information from previous informants to elicit clarification and deeper responses upon re-interview. This process is intended to reveal common cultural understandings related to the phenomena under study.10-12

Historical research involves the systematic collection and objective evaluation of data related to past occurrences in order to test hypotheses concerning causes, effects or trends of these events that may help to explain present events and anticipate future events.13 Historical research involves developing an understanding of the past through the examination and interpretation of artifacts such as texts, physical remains of historic sites, recorded data, pictures, maps recordings and other forms of evidence. The historian’s job is to find evidence, analyze its content and biases, corroborate it with other evidence, and use the evidence to develop an interpretation of past events that has some importance for the present. Historians use libraries to locate primary sources (firsthand information such as diaries, letters and original documents) for evidence find secondary sources, historians’ interpretations and analyses of historical evidence verify factual material as inconsistencies arise.

Narrative research methods involve the researchers collecting and telling stories about people’s lives, and writing narratives of individual experiences. As a distinct form of qualitative research, a narrative typically focuses on studying a single person, gathering data through the collection of stories, reporting individual experiences, and discussing the meaning of those experiences for the individual.

Mixed-methods research provides for quantitative and qualitative points of view to be used simultaneously. Mixed methods research refers to methods, design and philosophical assumptions. There is a good deal of discussion about philosophical assumptions that guide the direction of the collection and analysis of data.14

There are other forms of qualitative inquiry. The ones I presented here are representative of more common methods and applications. I hope that the tools presented here can further the dialog.

References

  1. Yin R. Applications of Case Study Research. Thousand Oaks, Calif.: Sage, 2003.
  2. Yin R. Case Study Research: Design and Methods. Thousand Oaks, Calif: Sage, 2002.
  3. Stake R. The Art of Case Study Research. Thousand Oaks, Calif.: Sage, 1995.
  4. Stake R. Multiple Case Study Analysis. New York: Guilford Press, 2006.
  5. Glaser BG, Strauss A. Discovery of Grounded Theory. Strategies for Qualitative Research. Edison, N.J.: Aldine Transaction, 1967.
  6. Bryant A, Charmaz K, eds. The Sage Handbook of Grounded Theory. In: The SAGE Handbook of Qualitative Research. Thousand Oaks, Calif: Sage Publications, 2007.
  7. Merleau-Ponty M. Phenomenology of Perception. New York: Routledge, 1962.
  8. Husserl E. Ideas Pertaining to a Pure Phenomenology and to a Phenomenological Philosophy. Boston: Kluwer Academic Publishers, 1991.
  9. Moustakas C. Phenomenological Research Methods. Thousand Oaks, Calif.: Sage Publications, 1994.
  10. Denzin NK. Interpretive Ethnography: Ethnographic Practices for the 21st Century. Thousand Oaks, Calif.: Sage Publications, Inc, 1996.
  11. Denzin NK. Interpretive ethnography for the next century. J Contemp Ethnography Oct 1, 1999;28(5):510-9.
  12. Heivilin D, MacColl G, Jackson E, Edwards T. Federal Programs: Ethnographic Studies Can Inform Agencies’ Actions. www.gao.gov/cgi-bin/getrpt?GAO-03-455.
  13. Gay LR. Educational Research. Competencies For Analysis and Application. Prentice-Hall, Inc., 1996.
  14. Clark VLP, Creswell JW. The Mixed Methods Reader. Thousand Oaks, Calif.: Sage Publications, 2008.

Post-paradox: Room for View

By William Morris, DAOM, PhD, LAc

Do we mix our ways of thought in collaboration? Closely guarded views can lead to isolation. This piece explores the notion of post-paradox as an inclusive worldview across disciplines. Essential to critical thinking, worldview influences all levels of research, education and practice in general but also acupuncture and Chinese medicine.

Not a recommendation of method, I consider worldview related to how we think, create and present knowledge. Neither do I bias against quantitative proof, nor the hard ‘proofiness’ of randomized controlled trials. I seek a third, inclusive point of view that unifies qualitative and quantitative, subjective and objective, specific and general, calling it post-paradox.

Skills in research methods do not assure awareness of worldview, which operates in the background, forming knowledge and informing decisions.

There are research methods that could employ a worldview of post-paradox including Mixed Methods, Action Research and Grounded Theory1,2.

Or, take for example this rant from viewpoint of Critical Theory3: Science has pursued a belief in the primacy of the objective for too long. A researcher’s choice of topic, method, analysis and presentation are embedded within the subjective. Further, the cultural frame in which the researcher operates influences these features. It is time to reveal self from behind the impersonal 3rd person writing of science4. When the researcher articulates their subjective stance, it allows for a more genuine presentation of research. We must fully own our biases and communicate them in the spirit of transparency. Introducing complexity and uncertainty: I could be wrong.

Post-paradox

Post-paradoxic has affinity with and roots within the ideas of transdiscipline. The prefix “trans” in transdiscipline suggests that which is at once between, across, and beyond disciplines. I adopt post-paradox as a direct statement of the view, with the goal of understanding the present world as a unity of knowledge5. Resolving dualities, a post-paradoxical view brings a perspective that transcends the objective and the subjective, embracing both from a third place6. The keystone of post-paradox lays within the unification of the meanings that traverse and lay beyond different disciplines7.

Post-paradoxical thought includes levels of reality, logic of an included middle (the center of paradox), and complexity. Shifting logic can bring a change in perspective7. New knowledge emerges when disciplines encounter each other, inviting a new vision of nature and reality, posing a framework for what we believe to be true. Tools of knowledge include the admitted involvement of the researcher in the process of inquiry, and an awareness of the degree to which knowledge is constructed6.

The post-paradox view allows the practitioner and society to better meet the needs of building an inclusive body of evidence, one that might include a history of medical case studies, experience based knowledge and the rich data field of the qualitative domain in addition to the quantitative proofs. New possibilities and an open-minded rationale are achieved by re-examining the concepts of subjectivity and objectivity.

Try it. We can explore assumptions about objective and subjective data during clinical intake. A physician’s observations (biomedical, naturopathic or AOM) are considered to be objective and the patient report of symptoms subjective. This does not take into account the culturally bound beliefs that inform a physician’s inquiry, a subjective process. As a physician, analyze your SOAP notes (subjective, objective, assessment, plan), and take that feature assigned to ‘objective’ and break it down. Just how much of your subjective state influences what you record as objective? The information relayed upon your neo-cortex of sight, sound, smell and touch were constructed into impressions. You had to decide which of those impressions were valuable and which were not… this is what then gained primacy in the record of the ‘objective’ in your SOAP notes.

Language and Logic

Logics form many assumptions that take place in communication and correspondingly, in practice. AOM profession binds itself into a monoculture of mind through unconscious adherence to logics of Aristotle, which has three postulates:

  • axiom of identity: that which is A is A.
  • axiom of non-contradiction: that which is not A cannot be A.
  • axiom of the non-included middle: there exists no third term, T which is at the same time A and non-A. In other words, there is no paradox.

Many who practice classical forms of Chinese medicine approach the problem from an Aristotelian view.

It is reasonable to consider that contemporary Chinese medicine developed in alignment with Cartesian philosophical dictums, rooted in Aristotelian thought. The extent of the Silk Road and its influences on medical thought were not isolated events. Examples of such influences are located in slogans used by Chairman Mao’s government in state developed forms of TCM:

  • The Cooperation of Chinese and Western Medicine: 1945-50
  • The Unification of Chinese and Western Medicine: 1950-58
  • Chinese Medicine Studies Western Medicine: 1950-53
  • Western Medicine Studies Chinese Medicine: from 1954–58
  • Integration of Chinese and Western Medicine: 1958 – Present (8, pp. 23-28).

Net result of these campaigns: a synthesized practice of Chinese and Western medicine, currently taught in the major university medical systems throughout China. Chinese medicine, as practiced today and no matter where on this great globe, has an integral composition of thought threads forming it.

Reflection

We return to discussion of the Aristotelian-Cartesian worldview. Descartes provided rules for thinking that involved reduction, simplification and clarity in Discourse on Method9. This reductionism may be located in the gold standard of quantitative research, the randomized, double blinded, placebo controlled trial, where environmental complexities are limited with the intent of control that simplifies and clarifies the inquiry. These rules for directing the mind, coupled with Aristotelian logic, have become the foundation for good thinking, which in turn has become institutionalized in the university systems10. This view is now the rigor in University systems of China conducting research on Chinese medicine. But, is it possible the gold standard is losing its sheen?

Vitalism and scientism are both ensconced in the beliefs of the practitioner. From a third, post-paradoxical view, the applications of vitality in harmony with science can be achieved12. The post-paradoxical view entertains mechanism and vitalism from a newly created and inclusive space. In a lower level of reality, opposites are not compatible. When restricting worldviews to a single discipline, higher levels of reality are unattained because the incompatibility of truths between disciplines maintains the space between them. However, when viewing the universe through accessing new levels of reality by merging opposite truths a more sophisticated universe is realized. Through the complimentary pairings of perception and level of reality a merging of the two is possible. After paradox, what is there? The space operates as if potential opposites are both true.

References

  1. Reason P, Bradbury H. Handbook of action research. Thousand Oaks: Sage Publications; 2006.
  2. The Sage Handbook of Grounded Theory. 3 ed. Bryant A, Charmaz K, editors. Thousand Oaks, CA: Sage Publications; 2007.
  3. Horkheimer M. Traditional and Critical Theory1937: Available from: www.sfu.ca/~andrewf/hork.doc.
  4. Morris W. Standards for Reporting Acupuncture Research. American Acupuncturist. 2011;Summer 2011(56).
  5. Nicolescu B. Manifesto of Transdisciplinarity. Albany: SUNY Press; 2002.
  6. Morin E. On Complexity. Montuori A, editor. Cresskill, New Jersey: Hampton Press; 2008.
  7. Charter of Transdisciplinarity. 1994; Available from: http://nicol.club.fr/ciret/english/charten.htm.
  8. Taylor K. Chinese Medicine in Early Communist China, 1945-63, A Medicine of Revolution. New York: RoutledgeCurzon 2005.
  9. Descartes R. A Discourse on Method: Project Gutenberg; 2008. Available from: http://www.gutenberg.org/files/59/59-h/59-h.htm.
  10. Montuori A. Forward. In: Montuori A, editor. On Complexity. Cresskill, New Jersey: Hampton Press; 2008.
  11. Ames RT, Hall DL. Dao De Jing (Making this Life Significant): A Philosophical Translation New York: Ballentine Publishing Group; 2003.
  12. Morris W. Vitalistic Philosophy Acupuncture/TCM Vis Medicatrix Naturae: Stewardship of the Source of Healing: The LifeSource Octagon, A Center for Infinite Thinking; 2009.

Transdisciplinary Approaches to Patient Care: Lymph and Ground Substance

William Morris, PhD

(Matrix Regulation, Pulse Diagnosis, Lymph Function, Endocrine Function, and Chinese Medicine)

Transdisciplinarity can be distinguished from interdisciplinarity which is information systems that travel between disciplines. Whereas multidisciplinarity is a grouping of disciplines in an effort towards a common purpose, transdisciplinarity is information systems that move between, across and beyond all disciplines. Transdisciplinarity aims to realize that which disciplines share and to connect to that which lies beyond them. In comparison with interdisciplinarity and multidisciplinarity, transdisciplinarity is multireferential and multidimensional. It creates the possibility of the emergence of new data and new interactions from the encounter between disciplines. This in turn allows for a potentially new vision of nature and reality. (Nicolescu, 2002)

Collaboration between Eastern and Western medicine occurs in many strata from the socio-political environment of the public policy makers to various forms of institutional involvement to the efforts between practitioners. In addition to these sociological collaborations, synthesis can occur between Eastern and Western epistemologies in terms of clinical practices. This paper examines a transdisciplinary approach to pulse diagnosis at the clinical level through a synthesis of Eastern and Western medical thinking. To accomplish the synthesis there will be an exploration of the relationship between immunology, fluid metabolism, lymph drainage, endocrine function, and Chinese medicine with attention to pulse diagnosis.

Pulse Diagnosis and the Interstices

Both Western and Eastern medical thought may be elucidated by the pulse diagnostic methods of Chinese medicine. Pulse qualities that suggest collection of fluid in the interstices such as the ‘cotton’ pulse of the Shen-Hammer system suggest impeded flow of protective qi which, in turn, suggests poor local perfusion resulting in the production of interstitial fluid accumulation and diminished lymph return. Table 1 correlates Chinese and Western concepts and common pulse diagnostic findings.

Table 1: Pulse diagnostic findings common to Chinese and Western medicine

Western Concepts related to the phenomena Chinese concepts related to the condition Pulse finding

 

Lymph

Protein

Thyroid

Exercise

Immune

Spleen Depletion

Kidney Yang Depletion

Heart Qi and Yang Depletion

 

Cotton pulse

Weak pulse

Deep pulse

Floating pulse

Slow pulse

Changing qualities

Changing rate at rest

Arrhythmias

 

The following is an explanation of each of the pulses and the ways in which they can contribute to interstitial fluid accumulation and correspondingly poor lymph return. These phenomena are considered by the author to be synonymous with the Chinese medicine pathogen ‘damp.’

Cotton Pulse

The cotton pulse is conflated with the soft pulse by some practitioners. However the soft pulse is described as the sensation of a thread floating on water while the cotton pulse is a “spongy, amorphous, formless resistence that is without structure and wave form.” (Hammer, 2001, pp237) The pathophysiological findings are similar: dampness, or interstitial fluid accumulation.

Weak Pulse

The weak pulse lacks force and is very soft, deep, and thin. It can only be felt in the deep level. This can be indicative of low cardiac output and a likely low circulating blood volume resulting in poor perfusion and interstitial fluid accumulation known as ‘damp.’

Deep Pulse

The deep pulse is found only at the organ depth. It can be compounded by deficiency patterns which can also suggest poor perfusion and accumulation of interstitial fluid.

 

Floating Pulse

The floating pulse occurs when there is a depletion of qi or when there is an external pathogen. When due to deficiencies, yin and yang lose intimate contact. The warming and moving functions of qi allow for local metabolic functions to become impaired with a corresponding collection of damp.

Slow Pulse

The slow pulse may often be associated with poor circulation and local perfusion, resulting in the accumulation of interstitial fluids. A chief exception is in the case of highly efficient cardiac ejection fraction as with an athlete.

Changing Qualities (Hammer, 2001)

When the pulse changes qualities, there are two primary reasons. First is that the physiology and structure of the vascular system cannot express all the processes that are occurring in complex patterns of disharmony at once, so they happen over time. The other is that the qi is deficient and cannot maintain the shape of the vessels over time so that they change. In the latter situation, the qi is deficient such that damp easily accumulates.

Changing Rate at Rest (Hammer, 2001) and Arrhythmias

When the pulse rate changes at rest, this can be due to sinus node inefficiencies and cardiac conductivity inefficiencies. It can also occur due to rapidly changing humoral influences with respect to the psycho-neuro-endocrinological loop – this usually occurs concomitantly with labile emotional tonus. Under these circumstances, the local perfusion is impacted and damp can accumulate. The same is true for the arrhythmias.

Lymph as a Portal to Integral Medicine

It has been argued that the lymph return system has features common to the flow of the protective qi. (Kendall, 2002) If a patient presents with a ‘cotton’ pulse, (Hammer, 2001) then there is an accumulation of interstitial fluid occurring that is consistent with poor lymph return. Hammer describes this as a ‘sad’ pulse wherein people live lives of quiet desperation; however, this may not be the only reason for such a pulse. Other causes may include spleen qi or yang depletion leading to damp accumulation; other causes include impaired cardiac function or kidney yang depletion. From a Western perspective, this scenario can be induced through sedentary behaviors or reduced metabolism related to an impaired pancreatic function or hypothyroidism. (Gretz et al., 2000)

Before 1983, editions of Guyton’s Physiology (Guyton, 1982) describe lymph function in substantial detail, yet later editions of the book have much of the lymph conversation deleted. This was to the author’s chagrin since he continues to consider lymph a critical piece of a normal physiological state. There are specialists who call themselves ‘lymphologists.’ This specialty refers to tissues states such as ‘dry’ or ‘wet.’ When the state of the cell and interstitial spaces is ‘dry,’ it tends to be richly oxygenated and nourished resulting in healthier and pain-free with longer living, while the patient in the ‘wet’ state tends to have fatigue, malaise, and patterns related to spleen qi depletion.  These concepts are also directly applicable to cell wall tone and function. The strategy is to bring tissue and cellular integrity back to a ‘dry’ state in order to achieve health and longevity. In Chinese medical concepts, we are boosting qi and draining damp through the use of medicinals such as bai zhu (Rhizoma Atractylodes alba) or fu ling (Poria cocos). Other treatments strategies may be helpful such as harmonizing the protective and nutritive qi with gui zhi (Ramulua Cinnamomi) and bai shao (Rhizoma Zingiberis), and supplementing yang or supplementing, harmonizing and moving blood, Blood supplementation occurs with improved protein intake and correspondingly, the blood proteins are increased. The hydrophilic nature of the protein in the blood stream attracts the fluids back into the vessels. These proteins such as albumin can also enhance the movement of fluids through tissues and across cell membranes. There is a net improvement the osmolarity of the tissues due to the increase of protein mass within the circulating serum.

The issues of poor lymph return are rooted in lifestyle, especially exercise. However, depression and worry can overwork the spleen and cause dampness to accumulate as the pure yang qi of the spleen is depressed. If this state of affairs continues, the yang of the kidney and heart (shao yin) axis can be affected as the disease progresses towards a chronic debilitative and poorly compensated state.

The ability of cells to communicate with each other through electrical conductivity and energy movement within and between the cells is moderated through the ‘sodium-potassium pump’ which is the most important part of the mineral electrolyte conduction system since it is the only one that is ubiquitous.  The inner cellular mineral electrolyte mix becomes more potassium dominant closer to the nucleus, whereas it is sodium dominant near the cell membrane. The cell membrane is where the sodium-potassium pumping mechanism resides. If the inner-cellular fluid matrix becomes loaded with sodium, the highly structured fluid state within the cell breaks down and degenerative disease, especially cancer, sets in. This is due to impaired nucleus communication with the other parts of the cell as the intracellular matrix is less conductive. (Pischinger, 1991; Tso et al., 1986)

Perfusion through tissues with oxygen requires a functional sodium/potassium pump and this requires that the tissue spaces be in a ‘dry’ state For the ‘dry’ state to occur there must be adequate perfusion with nutrient supply and adequate waste removal. Under these circumstances, lymph congestion can lead to inflammatory compound buildup. (Gretz et al., 2000) This is another route to a toxic physiological environment wherein many chronic a diffuse functional disorders may occur. This set of problems is addressed by using medicinals that are ‘aromatic’ and ‘dry damp’ such as those medicinals that contain the term ‘xiang’ or fragrance in the name like mu xiang (Radix Sausurrea) or tan xiang (Lignum Santali albi), These are combined with medicinals that clear heat toxins such as lian qiao (Fructus Forsythia) and jin yin hua (Flos Lonicera). Perfusion and effective regulation of the intracellular matrix also requires activities that improve circulation and move energy include qi gung, breathing exercises, moderate cardiovascular exercise, (Convertino, 1991) and clean drinking water. Moderate stair-step type exercise induces deep breathing and the muscle movement helps propel lymph through the body and back to the thoracic duct and then back through the subclavian vein into the blood system. (Albert et al., 2004)

Overeating impairs circulation through the mesenteric tract and subsequently the whole body. Undigested foods builds up metabolic toxins that can be absorbed into the blood stream causing the capillaries to dilate and flood the interstitial spaces with excess fluids and blood proteins, which tends to congest the lymph system. This process will cause an accumulation of peptides within the blood stream and can be felt as a widening of the vessel and blood stream as one lifts the fingers from the organ depth through the blood depth, and a subsequent narrowing of the vessel as one lifts further to the qi depth. Hammer calls this pulse ‘blood unclear.’

Toxic influences due to improper diet, environmental factors, drugs, and chemicals have the effect of dilating blood capillaries and flooding the tissues with excess fluids and blood proteins that cause histamine reactions as well as a series of inflammatory cascades involving kinins. This leads to chronic health problems and degenerative conditions. The pulse that indicates that this process gets even wider when lifting through the blood depth. It is wider than the ‘blood unclear’ pulse and is called ‘blood heat.’ This situation tends to respond well when mu dan pi (Cortex Mutan radicis) is added to the formula.

Emotional stability is an important part of the equation, so much so that the primary pulse of this condition–the ‘cotton’ pulse–is also called the ‘sad pulse’ by Hammer.  Emotional stresses can cause a spillage of blood proteins and excess fluids into the interstitial spaces.  Here aromatic open orifice herbs are helpful in respect to opening the mind. It is important to cultivate non-attachment and a moderate response to life events for those who tend to overreact. This is easier said than done, and meditation is a key to cultivating a moderated response to difficult life situations.

Summary and Closure

Diffuse complex and clinical scenarios often involve several systems and the multifactorial events of life. The functional disorders that result from this set of circumstances often occur subclinically. However, Chinese medicine has a great deal to offer for this range of maladies. Impaired fluid metabolism, endocrinological concerns, and poor lymph return are often present with the ‘cotton’ pulse that demonstrates a stagnation of ‘wei qi’ or interstitial fluid and lymph. When this occurs, it is important to explore thyroid function. Here we are considering the fluid metabolism lymph return and the impact of thyroid function on metabolic capacity to supply nutrients. When the lymph and metabolic function are slower than necessary, then the extra cellular and interstitial matrices are congested with fluid and toxins. This scenario predisposes a significant range of complex clinical scenarios that are both replete and delete, hot and cold, but in this case the cold is due to the metabolic insufficiency of thyroid deficiency or–yang depletion.

In closing, the malaise and fatigued state of the walking wounded are often bound with clinical scenarios involving hypothyroidism, depression, and a ‘wet’ cellular state. These conditions have clear diagnoses in Chinese medicine when they remain undiagnosed due to the subclinical nature of the disorders from a Western medical perspective. There are tremendous advantages with respect to the TCM approach to these concerns. Lastly – the crossover in terms of the related pathophysiology for these conditions makes for fertile ground as a model of integration at the biological level.

References

Albert, N. M., Eastwood, C. A., & Edwards, M. L. (2004). Evidence-based practice for acute decompensated heart failure. Crit Care Nurse, 24(6), 14-29.

Convertino, V. (1991). Blood volume: Its adaptation to endurance training. Med Sci Sports Exerc., 23(12), 1338-1348.

Gretz, J. E., Norbury, C. C., Anderson, A. O., Proudfoot, A. E. I., & Shaw, S. (2000). Lymph-borne chemokines and other low molecular weight molecules reach high endothelial venules via specialized conduits while a functional barrier limits access to the lymphocyte microenvironments in lymph node cortex. J. Exp. Med., 192(10), 1425-1440.

Guyton, A. C. (1982). Human physiology and mechanisms of disease (3rd ed.). Philadelphia: Saunders.

Hammer, L. (2001). Chinese pulse diagnosis a contemporary approach. Seattle: Eastland Press.

Kendall, D. (2002). Dao of chinese medicine: Understanding an ancient healing art.

Nicolescu, B. (2002). Manifesto of transdisciplinarity. Albany: SUNY Press.

Pischinger, A. (1991). Matrix and matrix regulation, basis for a holistic theory in medicine. Brussels: Haug International.

Tso, P., Barrowman, J. A., & Granger, D. N. (1986). Importance of interstitial matrix hydration in intestinal chylomicron transport. Am J Physiol Gastrointest Liver Physiol, 250(4), G497-500.