Research Commentary [22] August 2018

Aug 20, 2018

This review focuses on the use of Traditional Chinese Medicine (TCM). 

There has been a worldwide increase in the use of complementary and alternative medicine (CAM) including the use of traditional Chinese medicine (TCM). This is the second of four in a series on complementary and alternative healthcare in New Zealand. 

In China, TCM has been practised for over 2,000 years. TCM encompasses a number of treatment modalities, which include: acupuncture, acupressure, Chinese herbal medicine, moxibustion, cupping, tuina, qigong and tai chi. This commentary will feature research on the safety and efficacy or otherwise of acupuncture, acupressure, Chinese herbal medicine, and qigong. Acupuncture and Chinese herbal medicine are two of the most well known TCM treatment modalities in many Western countries (Patel & Toosi, 2016).  Traditional Chinese Medicine is currently being considered by the Ministry of Health for regulation under the Health Practitioners Competence Assurance Act 2003.

References: 

Ministry of Health (2017). Regulating a new profession. Wellington: Ministry of Health. Retrieved from:  https://www.health.govt.nz/our-work/regulation-health-and-disability-system/health-practitioners-competence-assurance-act/regulating-new-profession

Patel, A. & Toossi, V. (2016). Traditional Chinese medicine practitioners in New Zealand: differences associated with being a practitioner in New Zealand compared to China. NZMJ, 129 (1444), 48-55. Retrieved from: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no-1444-28-october-2016/7045

Commentary provided by Dr Annette Mortensen, eCALD® Services Project Manager: Research and Development 

The following articles are reviewed:

Article 1: Traditional Chinese medicine practitioners in New Zealand: differences associated with being a practitioner in New Zealand compared to China.

In 1950, alongside Western medicine (WM), TCM became officially part of the healthcare system in China. Western medicine and TCM are the two mainstream medical practices used in China, where it is now common practice to combine WM and TCM. Research indicates that Chinese herbal medicine represents between 30 to 50% of all medicines prescribed in China (Xue et al., 2006). 

This New Zealand-based article is illuminating and explains the growth of TCM centres throughout Auckland and elsewhere. The authors explain the role of TCM practitioners as part of the mainstream health system in China. In China, TCM treatment is integrated with Western medicine and TCM practitioners can treat a range of conditions, including internal conditions (eg, cardiovascular conditions, stroke recovery, diabetes and cancer). TCM practitioners can also prescribe certain Western medicine drug treatments for a number of conditions. One main reason for this is that biomedicine is part of the TCM degree structure in China. A TCM practitioner is part of the mainstream healthcare system. TCM practitioners work in a number of medical settings, including hospitals and clinics. By comparison, TCM practitioners in New Zealand are viewed as alternative healthcare practitioners

TCM-based acupuncture is one of the most recognised and utilised CAM treatments. In New Zealand, there has been an increase in the use of TCM-based acupuncture, as well as an increase in the number of practitioners graduating with formal qualifications in acupuncture and Chinese herbal medicine. Interestingly, a recent New Zealand study found that an almost equal proportion of clients identifying as Chinese or New Zealand European received acupuncture and other TCM treatment during a four-month period at a TCM clinic in Auckland. This may be associated with the fact that since the 1990s in New Zealand, the Accident Compensation Corporation (ACC) has funded acupuncture treatment for injury-related conditions based on the efficacy of acupuncture in the management of musculoskeletal pain.

Reference: 

Citation: Patel, A. & Standen, C. (2014). An Auckland-based student acupuncture clinic patient profile and utilisation study. NZ Med J, 127 (1398), 134–37.

Publication: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2014/vol-127-no.-1398/6215

Authors: Patel, A. & Toossi, V.

Citation: Patel, A. & Toossi, V. (2016). Traditional Chinese medicine practitioners in New Zealand: differences associated with being a practitioner in New Zealand compared to China. NZMJ, 129 (1444), 48-55. 

Publication

Article 2: The effect of ginseng (genus Panax) on blood pressure: a systematic review and meta-analysis of randomized controlled clinical trials.

Pre-clinical evidence indicates the potential for ginseng to reduce cardiovascular disease risk and acutely aid in blood pressure (BP) control. This study sought to find clinical evidence to support these findings. This systematic review and meta-analysis revealed an overall non-significant and neutral effect of ginseng (genus Panax) on systolic (SBP), diastolic (DBP) and mean arterial (MAP) BPs, relative to control. Stratified analyses although not significant, suggest that ginseng may have a more favourable effect on SBP in individuals with diabetes, metabolic syndrome or obesity. This may have important clinical implications, as BP control remains elusive in the global population and hypertension (HTN) continues to be a significant risk factor for cardiovascular disease risk and mortality. Subgroup analyses suggest that ginseng may be more beneficial particularly for SBP, in individuals with higher baseline BP. 

The findings from this study also contribute to the present understanding of ginseng safety. Notably, ginseng had no significant adverse effect on BP, as was previously reported in early research. Although subject to limitations, findings suggest ginseng should not be avoided for concern of increased BP and may be explored safely in individuals with or at risk of HTN for its other associated health benefits, including diabetes control. 

Authors: Komishon, A. M.,  Shishtar, E.,  Ha, V. et al.

Citation: Komishon, A. M.,  Shishtar, E.,  Ha, V. et al. (2016). The effect of ginseng (genus Panax) on blood pressure: a systematic review and meta-analysis of randomized controlled clinical trials. J Hum Hypertens, 30 (10), 619-26. 

Publication

Article 3: The effect of ginseng (the genus panax) on glycemic control: a systematic review and meta-analysis of randomized controlled clinical trials.

This study reviewed randomised controlled trials of more than 30 days which assessed the glycaemic effects of ginseng in people with and without diabetes. The review found that ginseng modestly yet significantly improved fasting blood glucose in people with and without diabetes. Although ginseng did show advantages for HbA1c in parallel trials, the overall lack of an effect on HbA1c and persistent unexplained heterogeneity among the effect estimates from the available trials creates some uncertainty as to the long-term benefits of ginseng supplementation on glycaemic control. The author’s conclude that in order to provide better assessments of ginseng’s anti-diabetic efficacy, larger and longer randomised controlled trials using standardized ginseng preparations are warranted

Authors: Shishtar, E. et al.

Citation: Shishtar, E. et al. (2014). The effect of ginseng (the genus panax) on glycemic control: a systematic review and meta-analysis of randomized controlled clinical trials. PLoS One, 9 (9), e107391. 

Publication

Article 4:  Effectiveness and Cost-Effectiveness of Tuina for Chronic Neck Pain: A Randomized Controlled Trial Comparing Tuina with a No-Intervention Waiting List.

Tuina therapy is also known as Chinese massage and is often used by Chinese patients with neck pain. It is also increasingly popular in the West. As a part of Traditional Chinese Medicine, tuina combines a manual therapeutic approach and anatomical and physiological principles, and emphasises the meridians and acupoints. Tuina therapy uses mainly two components: soft tissue manipulation and backbone manipulation. The soft tissue techniques include stroking, kneading, and drumming, which are also found in some western massage techniques. The backbone manipulation techniques use manual operation procedures. 

The aim of this study was to evaluate whether tuina is more effective and cost-effective in reducing pain compared to no intervention in patients with chronic neck pain. The authors observed that six sessions of tuina led to a clinically relevant reduction in mean neck pain intensity and an improved function and physical quality of life compared to the no-intervention control group. Tuina treatment was a safe and relatively cost-effective for patients with chronic neck pain. 

Authors: Pach, D., Piper, M., Lotz, F. et al.

Citation: Pach, D., Piper, M., Lotz, F. et al. (2018). Effectiveness and Cost-Effectiveness of Tuina for Chronic Neck Pain: A Randomized Controlled Trial Comparing Tuina with a No-Intervention Waiting List. The Journal of Alternative and Complementary Medicine (JACM), 24 (3), 231–237

Publication

Article 5: Does Acupressure Hit the Mark? A Three-Arm Randomized Placebo-Controlled Trial of Acupressure for Pain and Anxiety Relief in Athletes With Acute Musculoskeletal Sports Injuries.

This New Zealand-based study was conducted to investigate whether acupressure could decrease pain and anxiety in athletes with acute musculoskeletal injuries. This is the first study to assess acupressure’s effectiveness in musculoskeletal sports injuries. The study found that three minutes of acupressure was effective in decreasing pain intensity in athletes who sustained an acute musculoskeletal sports injury when measured on the Visual Analog Scale (VAS), but did not change anxiety levels

The use of complementary and alternative medicine is gaining momentum in sports and exercise medicine research. Along with well-established therapies such as massage, acupuncture, and manipulation, new therapies such as acupressure are receiving more attention. Acupressure is an intervention derived from Traditional Chinese Medicine and is similar to acupuncture, but instead of using needles on specific points on the body (acupoints), it generally involves pressure applied by the thumb or index finger. Acupressure has been successfully used to manage pain in a range of conditions, including headaches, dysmenorrhea, cancer, during labour/child delivery, and in chronic musculoskeletal conditions such as chronic low back pain. 

The acupressure procedure used in this study is simple/uncomplicated and time efficient, making it available to a wide range of sports personnel. In addition, the immediate effect of the acupressure application is encouraging given that traditional treatments, such as ice and analgesics, take some time to bring about change in pain. Moreover, the application used in this study is performed using thumb pressure and does not require any equipment or special setting/environment, thus suggesting its applicability in the wider sports community. Considering the simplicity and high acceptance of this procedure and lack of adverse effects, it presents as a viable pain management intervention in a sports medicine setting.

Authors: Macznik, A.K., Schneiders, A.G., Athens, J. Sullivan, S.J.

Citation: Macznik, A.K., Schneiders, A.G., Athens, J. Sullivan, S.J. (2017). Does Acupressure Hit the Mark? A Three-Arm Randomized Placebo-Controlled Trial of Acupressure for Pain and Anxiety Relief in Athletes With Acute Musculoskeletal Sports Injuries. Clin J Sport Med, 27 (4), 338-43. 

Publication

Article 6:  Pharmacological and non-pharmacological treatments for major depressive disorder: review of systematic reviews.

This study aims to summarise the evidence on more than 140 pharmacological and non-pharmacological treatment options for major depressive disorder (MDD) and to evaluate the confidence that patients and clinicians can have in the underlying science about their effect in contrast to pharmacological treatments. The majority of non-pharmacological interventions for treating patients with MDD are not evidence based. The authors advise that for patients with strong preferences against pharmacological treatments, clinicians should focus on therapies that have been compared directly with antidepressants.

Only cognitive behavioural therapy is supported by reliable evidence to produce responses to treatment similar to those of second-generation antidepressants. All remaining comparisons of non-pharmacological treatments including Chinese herbal formulations and acupuncture, with second-generation antidepressants either led to inconclusive results or had substantial methodological shortcomings.

Authors: Gartlehner, G., Wagner, G., Matyas, N., et al.

Citation: Gartlehner, G., Wagner, G., Matyas, N., et al. (2017). Pharmacological and non-pharmacological treatments for major depressive disorder: review of systematic reviews. BMJ Open 2017;7:e014912. doi:10.1136/ bmjopen-2016-014912.  

Publication

Article 7:  The Treatment of Depressed Chinese Americans Using Qigong in a Health Care Setting: A Pilot Study.

This pilot study examined the feasibility and efficacy of providing Qigong treatment in a health centre to Chinese Americans with major depressive disorder (MDD). The Qigong intervention provided at a health care setting for the treatment of primary care patients with MDD is feasible. Qigong is a form of exercise that incorporates orchestrated body postures, breath practices, and meditation to attain deeply focused and relaxed states. The Qigong practices are thought to activate naturally occurring physiological and psychological mechanisms of self-repair and health recovery. Most Qigong forms involve slow gentle movements that can be easily adapted and are thus appropriate for people of all ages, fitness levels, and physical conditions. 

The health effects of this  pilot study provides preliminary information on the potential impact of a Chinese traditional healing practice to treat MDD in underserved Chinese Americans, who historically underutilise conventional psychiatric treatments. The Chinese community responded positively to the idea of using Qigong as an intervention for depression. At baseline evaluation, all participants had positive expectations of Qigong. 71% of participants in the Qigong group completed the intervention (>62.5% attendance) demonstrating satisfactory compliance to treatment. The completers reported that they practiced Qigong four times a week at home in addition to going to the class twice weekly. The response and remission rates after the Qigong intervention were satisfactory. 

The results of the study show that Qigong as a stress reduction intervention in a health care setting is safe, feasible, and well received. A 12-week Qigong intervention may be effective for improving symptoms and inducing remission in Chinese Americans with MDD. Future studies with larger sample sizes randomized to the intervention and control groups and the inclusion of biological outcome measures will be needed to provide more definitive outcomes.

Authors: Yeung, A. et al.

Citation: Yeung, A. et al., (2013). The Treatment of Depressed Chinese Americans Using Qigong in a Health Care Setting: A Pilot Study. Evidence-Based Complementary and Alternative Medicine, 2013, Article ID 168784: http://dx.doi.org/10.1155/2013/168784

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