Introduction to Traditional Chinese Medicine (TCM) therapies
For more than 5000 years, TCM therapies have been popular as methods of preventing and treating diseases in China. These treatment modalities have been increasingly accepted by the world, as conventional medicines have been considered toxic since most had been derived from chemicals, especially when used for chronic and non-life-threatening diseases.(Jonas 1998; Wong, Jue et al. 1998)
TCM therapies mainly consisted of two streams: Chinese herbal medicine and acupuncture /moxibustion. These, together with other TCM therapies, like Tui-na and cupping, are a form of medicine unique from Western medicine. These TCM therapies are based on the same fundamental principles, but vary in treatment methods and knowledge. Using Chinese herbal medicine required in-depth knowledge of the specific characteristics of herbs and prescription, while acupuncture and moxibustion requires an understanding of the pathological relationship in the theory of meridians and collaterals.
The general contents of TCM and its fundamental principles are presented below.
Basic Principles of Traditional Chinese Medicine (TCM)
Yin-yang theory (陰陽學說)
The Yin-Yang theory was originally a philosophical concept of the ancient Chinese and deals with two opposite aspects of nature that are interrelated with each other. The Chinese believe that the universe is governed by two opposing forces. All matters in nature can be categorized by Yin and Yang. The characteristics of Yin in Chinese philosophy describes the feminine, latent and passive principle; while the characteristics of Yang describe the masculine, active and positive principle of the two opposing cosmic forces into which creative energy divides and whose fusion in physical matter brings the phenomenal world into being.
Table 1 - Characteristic of Yin and Yang
|Yin (陰)||Yang (陽)|
|TCM four examination||Inspection (望診)||Dim||Bright|
|Listening and Smelling (聞診)||Low and weak voice, silent and reticent||High and strong voice, talkative and agitated|
|Inquiry (問診)||Cold , not thirst, diarrhea||Hot, thirst, constipation|
|Palpation (切診)||Deep and slow, thread, forceless pulse||Floating, full, slippery, forceful pulse|
Five Phases Theory (五行學說)
Five phases theory (also known as Five Elements Theory) is another central philosophical theory in TCM. Based on observations, the ancient Chinese classified material things or phenomena into five categories by comparing their structures, properties and actions. The Five Phases theory posits wood, fire, earth, metal and water as the basic elements of the material world and these elements are in constant movement and change in relation to each other.
Table 2 - Structure and properties of the Five Phases
|Five Phases||Structures and properties|
|Wood (木)||Growing, ascending, flourishing and harmonious|
|Fire (火)||Warm and hot, evaporating and flaring-up|
|Earth (土)||Reproducible, change and receiving|
|Metal (金)||Dispersing and descending, firm and solid, astringent|
|Water (水)||Cold and cool, moistening and running downwards|
Table 3- Classification according to the Five Phases Theory
|Wood (木)||Fire (火)||Earth (土)||Metal (金)||Water (水)|
|Color||Blue / Green||Red||Yellow||White||Black|
|Human body||Zang Organ||Liver||Heart||Spleen||Lung||Kidney|
|Fu Organ||Gallbladder||Small intestine||Stomach||Large intestine||Urinary bladder|
|Tissue||Tendon||Vessel||Muscle||Skin and hair||Bone|
|Secretion||Tear||Sweat||Serous saliva||Nasal discharge||Mucous saliva|
Theory of Qi (氣), Blood (血), Fluid and Humor (津液)
The theory of Qi, Blood, Fluid and Humor in TCM is used to understand the development, transportation, distribution, physiological function, pathological change and mutual relations of Qi, Blood, Fluids and Humors in the human body. In TCM, Qi refers to the refined nutritive substance that flows within the human body as well as to its functional activities. Blood is a kind of red liquid rich in nutrition, circulating within the blood vessels, which has the functions of nourishing and moistening the whole body. Fluid and Humor refer to all kinds of normal fluid in the body, except the blood, also known as Body Fluids. Qi, Blood and Body fluids are all derived from Essence. They are the basic materials comprising the human body and maintaining life activities. Although the three have different properties, forms and functions, they are physiologically dependent on each other and influence each other in pathology.
Visceral Manifestation Theory (臟象學說)
The internal organs and associated terminologies in TCM are very different from those in Western medicine. The organs are divided into "Zang" or "viscera" (i.e., heart, liver, spleen, lung and kidney), where Essence and Qi are formed and stored, and "Fu" or 'bowel' (i.e., gallbladder, stomach, large intestine, small intestine, urinary bladder and triple energizers) where food is received, transported and digested.
Meridian (經), Collateral (絡) and acupoint (穴位)
Meridian and collateral systems act as conduits that allow the circulation of qi and blood, connection of the bowels, viscera, extremities, superficial organs and tissues, making the body an organic whole. It mainly consists of the 12 meridians (or channels), the 8 extra meridians and the 15 collateral vessels (the small braches of the meridians, serving as a network linking the various aspects of the body). The 12 regular meridians, together with the governor vessel and conception vessel of the eight extra meridians, form the 14 meridians. There are acupoints for applying acupuncture and moxibustion along each meridian. Acupoints are classified into 3 categories:
- Acupoints of 14 meridians total 361 acupoints which make up the majority of all the points on the human body. Those of the 12 meridians exist in pairs distributed symmetrically on the left and the right side of the body, while those of the governor vessel and conception vessel are single, aligning on the anterior and the posterior midline respectively.
- Extra point (Non-meridian point) acupoints that are useful in therapy, though discovered in the course of practice. They have definite locations but are not located on the 14 meridians.
- Ouch point (Ashi point)the site of which is determined by tenderness, sensitivity or other pathological responses in certain disease. They have neither definite locations nor specific name, which is "where there is painful spot, there is an acupuncture point".
Chinese herbal medicine (中藥治療)
In the Han dynasty (206 B.C.-220 A.D.), the ancient Materia Medica book "Shennongbencaojing" (神農本草經) recorded 365 herbs and categorized herbs into "warmth (溫) , hot (熱), coolness (寒), cold (涼) "according to four qi (四氣) and "pungency (辛), sweetness (甘), sourness (酸), bitterness (苦), saltiness (醎)" according to five flavors (五味) principles by their therapeutic characteristics from clinical observation.
For a TCM practitioner, after a comprehensive consideration of the clinical data obtained from the four examination approach (i.e. inspection, listening and smelling, enquiry and palpation), TCM practitioners analyze the data to determine the location, cause, nature of the patient disease and achieving a diagnosis of syndrome, that is called syndrome differentiation (辨証). TCM herbal prescriptions with a number of various herbals for producing the desired therapeutic effect and reducing toxic or side effects will then be used according to the specific condition of the patient. Therefore there is no unique prescription for the same disease or the same patient. This method of thinking is relatively macroscopic, wide-ranged, highly inductive and systemic, in contrast to the methods of western medicine.
Acupuncture and moxibustion therapy (針灸治療)
Acupuncture(針法) treats disease by puncturing certain acupoints on the human body with filiform needles, while moxibustion(灸法) is the application of heat produced by ignited material (usually moxa floss or moxa-stick made from dry moxa leaves) over the acupoints of the skin surface or certain locations on the body surface. Although the equipments and materials used in the two methods are different, the therapeutic and preventive results in both cases are similarly achieved, thus achieving the aim of prevention and treatment of diseases. Clinically, acupuncture and moxibustion methods are frequently used in combination and are therefore known as acupuncture and moxibustion therapy.(Lao 1996)
Types of acupuncture
Categorized by Location
- Body acupuncture conventional acupuncture using the acupoints on 14 meridians, extra points and ouch points.
- Scalp acupuncture This is a new therapy based on the theory of TCM, acupuncture techniques, clinical experience, holographic theory, and a modern knowledge of representative areas of the cerebral cortex. It is widely used among Chinese for neurological and psychological disorders. There is anecdotal evidence of restoration of speech following cerebrovascular accidents after scalp acupuncture. (Ellis 1994) It is used clinically to treat central nervous system disorders, such as sequelae of cerebral disease, mal-development of the nervous system, and sequelae of brain damage, especially for paralysis due to stroke, as well as internal medicine, gynecology, and pediatric. Scalp acupuncture was claimed able to teat more than 100 different diseases. (Wang 2009)
- Auditory acupuncture auditory acupuncture, also named as ear acupuncture, is used in the treatment and prevention of disease by stimulating certain points on the auricle with needles or other devices. Such a method of treatment was recorded as early as in the book Neijing (500-300BC). This therapeutic method has been used by the people of China for thousands of years. The "NeiJing" (內經) recorded the close relationship of the ear with the meridians. From the cyclical flow of the 12 regular meridians, the 6 Yang meridians either enter through the ear or distribute to areas surrounding the ear. Filiform needles, embedded needles, acupressure and electro-acupuncture are the common manipulation methods of auditory acupuncture. Auditory acupuncture therapy treats disease by stimulating certain points of the auricle with needles.
- Tongue acupuncture it stimulates points on the tongue in order to treat disease. TCM believes that the tongue is an organ that is connected with other Zang-fu through meridians; the tongue can reflect the function of the Zang-fu and Qi. It is the part of the body that is an external reflection of the Zang-fu physiology and pathology related to internal conditions, especially the function of the heart and spleen. Therefore, there can be a direct effect on the organs of the whole body by stimulating points on the tongue. In the past ten years, it was increasingly used for treating neurological diseases (Wong, Sun et al. 2001; Sun, Ko et al. 2004; Li, Wang et al. 2005; Wong, Sun et al. 2006; Wong, Sun et al. 2006)
Categorized by Stimulation methods
- Electro-acupuncture a new acupuncture modality in which stimulating acupuncture needles with electrical impulses are used to supplement the action of the needles. It is claimed that it reduces the time needed to achieve the required effect of acupuncture treatment. Studies show that differences in frequency and intensity of the stimulation affects the degree of pain relief(Mao, Ghia et al. 1980).
- Subcutaneous electro-needling- a stimulation method which inserting acupuncture needles into subcutaneous tissue and applying electrodes on the needles, thereby allowing electrical current to pass through needles.
- Laser acupuncture using laser irradiation on the acupoints, this technique has been clinically applied since 1970s. The indications for treatment are mainly the same as for conventional acupuncture (Whittaker 2004)
- Acupoint injection it is a combination of acupuncture and medication by which liquid medicine is injected into the acupuncture.
Different types of needles
- Filiform needle (亳針) a type of fine needle of varying length most commonly used in performing acupuncture for body acupuncture, scalp acupuncture and tongue acupuncture. (WHO 2007)
- Dermal needle (皮膚針) a needling instrument (such as Plum blossom needle (梅花針) and seven-star needle (七星針)) composed of several short needles used for tapping the point.
- Three-edged needle (三棱針) - a thick sharp needle which used to perform fast piercing method to let out a small amount of blood.(WHO 2007)
- Intradermal needle (皮內針) a small needling instrument which used to embed at a certain point for extended periods.
Mechanism of acupuncture
Up to now the mechanism of acupuncture has not been not clearly explained. To our knowledge, the theory of acupuncture is based on meridians. Modern scientists and acupuncturists hypothesize that the basis of meridian is the nervous system. It also includes the muscle, vascular and lymphatic system, but is another independent system that is apart from these three systems. Although we have not undercovered the secret of meridians, we cannot deny the existence of meridians.
By investigating the neuronal specificity of an acupoint with electro-acupuncture stimulation using functional magnetic resonance imaging, Na and his colleagues (Na, Jahng et al. 2009) reported that there is neurobiological evidence for the existence of acupoint specificity.
Cabyoglu, Ergene et al. (2006) reported that acupuncture has been shown to increase the levels of endomorphin-1, beta endorphin, encephalin, and serotonin in plasma and brain tissue with cause analgesia, sedation and recovery in motor functions.
The effectiveness of acupuncture on brain activation by fMRI and PET has been reviewed recently by Lewith (Lewith, White et al. 2005).
Evidence based medicine
We identified 26 reviews in the Cochrane Collaboration concerning the efficacy of acupuncture:
|Title||Latest updated||No. of RCTs||Results|
|1||Acupuncture for peripheral joint osteoarthritis (Manheimer, Cheng et al. 2010)||2010||16||Sham-controlled trials show statistically significant benefits.|
|2||Acupuncture for migraine prophylaxis (Linde, Allais et al. 2009)||2009||22||Acupuncture provides additional benefit to treatment of acute migraine attacks only or to routine care. No evidence for an effect of 'true' acupuncture over sham intervention|
|3||Acupuncture for tension-type headache (Linde, Allais et al. 2009)||2009||11||Acupuncture could be a valuable non-pharmacological tool in patients with frequent episodic or chronic tension-type headaches|
|4||Acupuncture for depression (Smith, Hay et al. 2010)||2010||30||Insufficient evidence|
|5||Acupuncture for shoulder pain (Green, Buchbinder et al. 2005)||2008||9||Insufficient evidence|
|6||Acupuncture for neck disorders (Trinh, Graham et al. 2006)||2010||10||moderate evidence that acupuncture was more effective than a wait-list control at short-term follow-up|
|7||Acupuncture for insomnia (Cheuk, Yeung et al. 2007)||2009||7||Insufficient evidence|
|8||Acupuncture for schizophrenia (Rathbone and Xia 2005)||2009||5||Insufficient evidence|
|9||Acupuncture for treatment of irritable bowel syndrome (Lim, Manheimer et al. 2006)||2008||6||Insufficient evidence|
|10||Acupuncture and electroacupuncture for the treatment of rheumatoid arthritis (Casimiro, Brosseau et al. 2002)||2009||2||Insufficient evidence|
|11||Acupuncture for acute stroke (Zhang, Liu et al. 2005)||2008||14||Insufficient evidence|
|12||Auricular acupuncture for cocaine dependence (Gates, Smith et al. 2006)||2008||7||Insufficient evidence|
|13||Acupuncture and related interventions for smoking cessation (White, Rampes et al. 2006)||2008||24||Insufficient evidence|
|14||Acupuncture for restless legs syndrome (Cui, Wang et al. 2008)||2008||2||Insufficient evidence|
|15||Acupuncture for Bell's palsy (He, Zhou et al. 2007)||2009||6||Insufficient evidence|
|16||Acupuncture for chronic asthma (McCarney, Brinkhaus et al. 2004)||2009||12||Insufficient evidence|
|17||Acupuncture and dry-needling for low back pain (Furlan, van Tulder et al. 2005)||2008||35||For chronic low-back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and "alternative" treatments. The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low-back pain.|
|18||Acupuncture for dysphagia in acute stroke (Xie, Wang et al. 2008)||2008||1||Insufficient evidence|
|19||Acupuncture for stroke rehabilitation (Wu, Tang et al. 2006)||2009||5||Insufficient evidence|
|20||Acupuncture for lateral elbow pain (Green, Buchbinder et al. 2002)||2008||4||Insufficient evidence|
|21||Acupuncture for uterine fibroids (Zhang, Peng et al. 2010)||2010||0||Uncertain|
|22||Acupuncture for vascular dementia (Peng, Zhao et al. 2007)||2009||0||Uncertain|
|23||Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting (Ezzo, Richardson et al. 2006)||2010||11||Electro-acupuncture reduced first-day vomiting, but manual acupuncture did not. Acupressure reduced first-day nausea, but was not effective on later days. Acupressure showed no benefit for vomiting. Electrical stimulation on the skin showed no benefit.|
|24||Acupuncture for epilepsy (Cheuk and Wong 2006)||2009||11||Insufficient evidence|
|25||Acupuncture for glaucoma (Law and Li 2007)||2009||0||Uncertain|
|26||Acupuncture for induction of labour (Smith and Crowther 2001)||2009||3||Insufficient evidence|
Undoubtedly, using the gold standards of evidence based medicine, most RCT studies show no evidence or even evidence of inefficacy in alternative medicine including acupuncture. As a scientific and professional medical practitioner, we should continue to be skeptical of the therapeutic efficacy of CAM due to the deficiencies in the clinical trials such as poorly designed studies or publication bias. (Critchley, Zhang et al. 2000; KORETZ 2002)
Bloom did a systematic review in 2000 to identify RCTs of Complementary and Alternative Medicine (CAM) from 1966 to 1998 and assessed the methodological quality of these trials. Two reviewers identified 258 RCTs out of 5000 and scored each study independently. The mean score across 95 diagnosis/intervention categories was relatively low (44.7/100). However, when this same process was applied to RCTs from the standard biomedical literature, the mean score was 45/100. Thus, most services are provided without good evidence of benefit. (Bloom, Retbi et al. 2000)
Moxibustion treats and prevents diseases by applying heat onto acupoints or certain locations of the human body. The material used is mainly moxa floss in the form of a large cigarette or a small cone. Moxa floss is made of moxa (mugwort leaves) with the coarse stems removed. It has the function of warming and removing obstruction of the meridians, eliminating cold and damp, thus promoting normal functioning of the organs.
Advantage of acupuncture and moxibustion
Safe and reliable- reports show that if the acupuncture procedure is under sterilization and operation, the risk and side effects is minimal. (Jonas 1998)
Simple and economic- acupuncture and moxibustion may save on the costs of medicine and lighten the patient's economical burden by means of the simple equipment and convenient usage.
Side Effects and Adverse events
Acupuncture is a relatively safe procedure with very few side effects or adverse events. A cumulative review indicated the risk of serious events occurring in association with acupuncture is very low while the range of adverse events reported is wide, 715 significant or serious adverse events out of 1107270 treatments have been reported including hepatitis and pneumothorax. The cumulative world-wide incidence for serious adverse events with acupuncture is estimated to be 0.05 per 10 000 treatments, and the incidence is 0.55 per 10 000 individual patients (White 2004). A large scale survey in 2004 also concluded that "acupuncture is a relatively safe intervention when practiced by regulated practitioners" (Macpherson, Scullion et al. 2004).
Other TCM therapies
Cupping is the treatment of disease by suction onto the affected or any part of the body surface by attaching cup or jar in which a vacuum is created by introducing heat in the form of an ignited alcohol-soaked cotton ball. This therapeutic method is widely used in patients with rheumatism, painful joints, sprains, facial paralysis, asthma etc. (Tian 2007; Awad 2008; Wu and Hu 2009) However, it is not advisable to apply cupping to patients with high fever, convulsions, allergic skin diseases, edema, hemorrhagic tendencies, or to the abdominal area of women during pregnancy. The local area will show blood congestion after cupping. The bruise on the skin surface gradually disappeared within a few days.
There is a dire need to use current evidence based medicine approach to address the efficacy of TCM with the long historical use for chronic diseases. Integration of management strategies with western medicine for acute diseases and TCM for subacute and chronic diseases is the way forward. For human diseases, individual variation in response to treatment and in natural course may occur, thus, different diseases should be treated at various stages with multimodal treatment modalities which might be too complex to be proven by randomized controlled trials.