TCM and Western Approaches to RA
Professors CS Lau and U. Chau Leung reviewed the philosophical orientation of users of TCM in Hong Kong and in the United States. They noted that users of TCM are generally not dissatisfied with conventional "Western" medicine, but find alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life. Much of this sentiment is based on a "paradigm shift" of thinking, leading to an increased interest in preventing illness, limiting dependence upon physicians, and focusing attention on fitness and stress management. The recent widespread interest in TCM in the United States also represents a dramatic reconfiguration of the physician-patient relationship -- from historical "physician knows all" to what might arguably be described as "patient empowerment" with use of tools such as the Internet. This recent shift may have less to do with acknowledging "new" evidence-based clinical data than with representing shifts in medicine's institutional authority in a consumer-driven healthcare environment.
Robert Fox, MD, of San Diego, United States reviewed the use of evidence-based western medications for RA in the United States, such as gold, methotrexate, leflunomide, and tumor necrosis factor (TNF) inhibitors. Of note, the most recent and effective agents for RA, namely the TNF inhibitors, were not rationally developed for RA but were initially designed for treatment of septic shock. The success of TNF inhibitors led to increased recognition of the important role of the innate immune system in RA. The innate immune system is based on the expression of Toll receptors by dendritic cells. The family of Toll receptors responds to repetitive motifs such as lipopolysaccharide (endotoxin) or mannose binding lectins.[28,29,30,31,32] These Toll receptors may be targets for certain herbal components which also possess mannose lectin receptor like properties.
Dr. Fox also reviewed the increasing use of herbal supplements and alternative care for RA in the United States. According to recent publications, physicians are recommending alternative therapies to their patients and are using these forms of treatment themselves. However, the vast majority of western practicing clinicians have little if any substantive knowledge regarding herbal treatments, their therapeutic properties, possible drug interactions, or side effects. Thus, most patients obtain information on herbal products from other sources, including the Internet, family, friends, and media advertising. Some patients feel uneasy discussing the issue with their physician for fear of a negative response. However, patients using nutriceuticals are generally well educated and likely to be strong allies for the constructive use of information available to them.
Until recently, the US medical community has sought to ignore or suppress nutriceuticals. Recently, it seems, a new dialogue is emerging due to publication of data concerning the public's use of alternative medicine. Rather, the new biomedical discussion is probably substantially due to changes in the internal orientation of the biomedical community.
It is important to recognize that the apparent chasm between western medicine and the use of nutriceuticals can only be bridged when validated, standardized agents are available. Some therapies can transcend across that border; for example, nitroglycerin and digitalis began as alternative drugs, just as corn flakes and graham crackers began as unconventional health foods.
Additional sessions of the meeting were devoted to acupuncture. This is a source of frustration to the western rheumatologist, who does not recognize an anatomic basis for use of acupuncture that is intended to "unblock channels where energy is trapped." Thus, we have a paradox. Many western physicians have patients (or family members) who enthusiastically embrace acupuncture for pain relief. However, they have little in the way of positive randomized, double-blind control trials. This has led western physicians to suggest that the entire response is a "placebo" effect. Prof. Wolfgang Weidenhammer of the University of Koblenz (Germany) reported that acupuncture using traditionally targeted points was not superior to minimal acupuncture that scrupulously avoided the traditional points. However, outcomes derived by both "true" acupuncture and "sham" acupuncture appeared to be markedly better than doing nothing (placebo). This failure of acupuncture in "double" blind trials has been previously reviewed in the US literature by Kaptchuk. Nevertheless, the use of acupuncture has a persuasive appeal as judged by the number of patients who pay "out of pocket" for these treatments and thus express their satisfaction.
Part of the schism between western physicians and their patients involves the concept that herbs are natural, while western medications are "drugs" and thereby less safe and less natural. Acupuncture is an example of this schism where randomized trials do not show efficacy but the practice of acupuncture is becoming increasingly popular. Most western rheumatologists feel "why not give acupuncture a try, it is a safe placebo." Indeed, the perception of "wellness" in the brain resulting from acupuncture may lead to beneficial changes in endogenous transmitters of pain. The interest in acupuncture has led to recent studies using functional MRI of the brain and the abolition of acupuncture effect with opioid antagonists suggests that humility toward these methods is still warranted. Before we dismiss the value of acupuncture as a placebo, it is certainly worth looking at the placebo curve in virtually all drugs approved for RA by the FDA. The key may be the qi of the acupuncturist, the quality of the physician-patient relationship in terms of trust, or simply the act of the physician being a "witness" or "facilitator" to help the patient cope with the illness. All of these "interventions" may be at least as important as the medications we prescribe to ultimately help the patient function more optimally. Perhaps, it is timely to re-visit the history of western medicine, that we come from a 200-year-old tradition of use of heavy metals (arsenic), herbs, and blood letting.
Professor Ian Tsang (Clinical Professor Emeritus, University of British Columbia, Canada) and Dean Liu Liang, Hong Kong Baptist University) emphasized that studies need to be funded by the Government Authority to obtain reliable results. As an observer, I was impressed with the parallel of TCM with the role of "prayer" or religion in healing. Certainly, the role of coping with illness has played a key role in the western Judeo-Christian society. At a minimum, the doctor- patient relationship has an inherent therapeutic value and this certainly plays a role in both western and TCM. However, the therapeutic value of prayer is difficult to validate in a randomized control trial, but it remains a very important response to the illness of a relative. Thus, it seems that TCM has a kindred philosophical system of Confucianism and Taoism. The diagnosis in TCM is based on the precept that sensory perceptions and ordinary appearances are sufficient to understand the human condition, including health and illness.
This assertion is fundamentally different from the western biomedical viewpoint, which gives privileged status to objective technology and quantitative measurement. TCM is full of peculiar concepts to western-trained physicians that can act as formidable barriers (or attractions) to many patients. For example, in TCM, "yin," "yang," dampness, wind, fire, dryness, cold, and earth reflect a person's state of being and behavior. To westerners, perhaps it is easiest to consider these factors as a personal health weather report. They represent conditions that are sometimes pathologic and disruptive and sometimes necessary and healthy. They are the fundamental patterns for detecting and synthesizing clinical information.
Yin.Yin is associated with cold, darkness, being stationary, passiveness, receptivity, tranquility, and quiescence.
Yang.Yang is associated with heat, light, stimulation, excess, assertiveness, dominance, movement, arousal, and dynamic potential.
In TCM, these complementary opposites are successively intertwined for additional levels of descriptive refinement. A simple example is dampness. It has the yin qualities of cold, wet, soft, and lingering and also the yang qualities of excessiveness, dominance, heaviness, and "inexhaustible abundance." TCM suggests that dampness is easy to recognize and that it applies to "psychological, ecological, and even moral as well as corporeal phenomena." Some damp signs point to imbalance, or "bad weather," for example, weeping eczema, edema, "slippery" pulse, heaviness in digestion, indecision, clinging, or being helpful to others at the expense of oneself. Some dampness is an essential component of a healthy state of being, for example, smooth skin, normal secretions and excretions, being imperturbable when threatened, generosity, and patience.
In addition to a general synthesis, yin and yang and their climatic subcategories are used to interpret specific "subregions" of a person's health. These subregions can be different from a person's general meteorological pattern and can create overlapping domains of yin and yang (for example, yins within yangs) that are as complex as multiple, intersecting circles. Both for the overview pattern and for the subregions, no single sign is conclusive; the overall context defines the parts. Heaviness in digestion or generosity might be "wind" if it appeared in a different configuration of signs. Unlike western medicine, in which signs and symptoms are used analytically to isolate an underlying mechanism, East Asian medicine seeks to discern a qualitative image in the overall gestalt or regions of a person's signs and behaviors. Whereas biomedicine aspires toward the scientific and dimensionally measurable quantitative, East Asian medicine emphasizes a human-centered approach of artistic impressions and sensitivities. If TCM resembles anything in the West, it would be the pre-scientific but rational Greek humoral medical system, which also perceived health status in such images of weather as phlegmatic (cold-moist) and choleric (hot-dry).
Qi. In TCM, Qi is the "life force" that is similar to the ancient Greek notion of pneuma, and takes on a myriad of forms. The concept of qi for the Chinese provides a rationale for explaining positive healing energy. Whether qi is some kind of "real" quantitative energy in the western sense (akin to 19th century vitalist life-force) or an internal "energy pathway" is assumed in classic Asian thought. In addition, the target of treatment in TCM is the state of the body's "disharmony," any imbalance in yin-yang and its connecting qi. There has been increasing recognition of benefit in chronic disease by non-medicinal methods such as tai chi and yoga.
Medscape Rheumatology. 2005;7(2) © 2005 Medscape
Cite this: Highlights of the International Conference and Exhibition of the Modernization of Traditional Chinese Medicine and Health Products - Medscape - Sep 15, 2005.