Coursework: Research Study on Radix Bupleuri (Chai Hu)

Research Study on Radix Bupleuri (Chai Hu)

 Herbology I 

                                                                   AOMA Fall 2013        

           

            The Chinese herb known as Chai Hu is the root of Bupleurum Root Radix Bupleuri. It is part of the Umbelliferae family and is collected in the spring and autumn. Its preparation is to dry it in the sun, slice and use raw. It can also be bake-fried with wine or vinegar to produce different effects. It has aromatic qualities which disperse and lift, it is bitter for purgation and pungent for dispersion. These qualities release half-interior half-exterior pathogenetic heat, regulate the circulation of Qi, sooth the liver and elevate Yang to treat Qi sinking in the middle Jiao (Zhixian & Xingdong, 2004).

            Chai Hu is considered the key herb for treatment of a Shaoyang syndrome. When the pathogenic factor is halfway between interior and exterior the condition is rather complex since the patient can exhibit both interior related and exterior related symptoms (Zhixian & Xingdong, 2004). Of all the symptoms exhibited the most essential one for diagnosis of Shaoyang Syndrome is “alternating chills and fever.” In TCM diagnosis, Malaria is sometimes considered a shaoyang disorder due to patients often exhibiting alternating chills and fever. Chai Hu guides the trapped pathogenic factor outwards and harmonizes the interior and exterior (Chen & Chen, 2004).

            Chai Hu’s ascending and dispersing characteristics are also commonly used to spread Liver Qi and unblock Liver Qi stagnation. It can be combined with many different herbs to treat specific manifestations of Liver Qi stagnation such as emotional distress, hypochondriac fullness and pain, cold extremities, migraine, eye pain and swelling, irregular menstruation with cramps and jaundice (Chen & Chen, 2004).

            It’s ascending nature is also excellent for lifting Yang Qi. If there is a Qi or Yang deficiency causing prolapse of internal organs Chai Hu can be used to raise and tonify Qi, especially if paired with Sheng Ma and Huang Qi. Chai Hu treats prolapse of the rectum and uterus, hypermenorrhea, lingering diarrhea and polyuria caused by deficiency and sinking Qi in the middle Jiao (Chen & Chen, 2004).

            Chai Hu is part of a formula called Long Dan Xie Gan Tang which clears and drains damp-heat from the lower Jiao and drains excess fire from the liver and gallbladder. Due to Chai Hu’s dispersing quality it is added to the formula to dissipate the excess heat being retained. Having this function qualifies it to be the second deputy of the formula. Together Huang Qin and Zhi zi make up the first deputy because they not only clear heat but also drain damp, a quality Chai Hu doesn’t possess. Chai Hu is especially vital to the formula because it plays a second role as an envoy. One of the jobs of an envoy is to guide the effects of the other herbs to specific channels. Chai Hu enters the liver and gallbladder channels, so as an envoy in this formula it leads the other herbs to those channels (Kim, 2008).

            Chai Hu has been used in Chinese medicine to treat Liver Qi stagnation for thousands of years but in 2005 it’s chemical effects relating to Liver Qi stagnation were tested by doctors at the Beijing University of TCM (Chen, Ji, Lu, Hu, 2005). The study examined the effects of Xiao Yao San containing Chai Hu on patients with Liver Stagnation and Spleen Deficiency Syndrome (LSSDS). The study looked at 58 patients suffering from depression, hypochondriac pain, listlessness, flatulence and loose stools. They assessed changes in the plasma indices of norepinephrine(NE), epinephrine(E), dopamine(DA), beta-endorphin(beta-EP), adrenocorticotropin hormone(ACTH), estradiol(E2), testosterone(T), immunoglobulin A (Ig A) and G (Ig G) (Chen, Ji, Lu, Hu, 2005). After subjects in the experimental group had been taking Xiao Tao San containing Chai Hu for one month there was a significant decrease in their self-rated anxiety scale (Chen, Ji, Lu, Hu, 2005).  Blood samples of the experimental group showed their plasma beta-EP was enhanced and their E and DA were decreased. These finding suggests that Xiao Yao San containing Chai Hu treats patients with LSSDS by it’s regulation of beta-EP, E and DA (Chen, Ji, Lu, Hu, 2005). Beta-EP has a close relationship with emotional disorders and imbalance. One of Chai Hu’s actions in the Long Dan Xie Gan Tang formula has to do with it’s relationship to the liver and gallbladder. This study supports Chai Hu in this formula because all the studied plasma hormones have important biological connections to the liver and specifically deal with emotions which could be linked to Liver Stagnation.

            In 2012, two studies were published in which the effects of Chai Hu was investigated. The first one looked at how Vinegar-Baked Chai Hu (VBCH) treats obesity and hyperlipidemia. In previous studies it was shown that VBCH had a much stronger effect on migrating pain and bile secretion than with raw Chai Hu, but little was known about it’s effect on lipid regulation (Tzeng, Lu, Liou, Chang & Liu, 2012).  The 2012 study found that VBCH suppressed the growth of adipose tissue mass as well as bodyweight gain. These finding suggest that it may inhibit lipid accumulation in adipose tissues, most notably in the liver (Tzeng, Lu, Liou, Chang & Liu, 2012). This is an important finding because ectopic accumulation of lipids in the liver is associated with many diseases including metabolic syndrome and type 2 diabetes (Tzeng, Lu, Liou, Chang & Liu, 2012). Though Long Dan Xie Gan Tang wouldn’t specifically be used to treat obesity, type 2 diabetes and hyperlipidemia, many symptoms it treats could be secondary indications for those disorders; such as, glaucoma, uveitis, pyelonephritis, eczema, headaches, etc. (Kim, 2008).

            The second 2012 research paper is directly related to Long Dan Xie Gan Tang as it has to do with the treatment of hyperthyroidism. Hyperactivity of the thyroid promotes an accumulation of oxidatively damaging molecules and since the liver is a major target organ for thyroid hormone, this directly leads to liver damage (Kim, Kim, Chung, Cheon, Ku, 2012). Researchers induced hyperthyroidism in rats and administered Chai Hu to the experimental group. Chai Hu significantly inhibited histopathological changes in the thyroid by reducing the thickness of the follicular lining of the epithelium (Kim, Kim, Chung, Cheon, Ku, 2012). This shows that Chai Hu has direct control on hyperthyroid states. By decreasing epididymal fat, liver damage was inhibited and liver antioxidant defense were enhanced (Kim, Kim, Chung, Cheon, Ku, 2012). Long Dan Xie Gan Tang can be prescribed for hyperthyroidism already, so these findings further enforce its effectiveness in this pursuit. Chai Hu’s actions of dispersing heat and focusing the other herbs towards the liver and gallbladder are now even more significant.

            There are currently no herb-drug interactions for single Chai Hu, though their are a few for the formula which Chai Hu is a part,  Xiao Chai Hu Tang (Minor Bupleurum Decoction). It was shown that after administering Xiao Chai Hu Tang the bioavailability of Tolbutamide, a type 2 diabetes treatment, was reduced. It was also reported that Xiao Chai Hu Tang may cause an increased risk of acute pneumonitis. The formula did not directly produce any lung tissue damage but may be over stimulating the neutrophils which cause damage which is then repaired by fibroblasts leading to an increase in pulmonary fibrosis (Chen & Chen, 2004).

            Chai Hu’s functions are useful for overall health as well as treating more specific syndromes. The liver is an important organ for detoxing the body, so Chai Hu’s actions of both expelling pathogens and treating imbalance in the liver and spleen makes it an extremely functional herb.

Chen, J. K., & Chen, T. T. (2004). Chinese medical herbology and pharmacology. City of Industry, CA: Art of Medicine Press, Inc.

Chen, J., Ji, B., Lu, Z., Hu, L. (2005). Effects of Chai Hu (Radix Burpleuri) Containing Formulation on Plasma β-endorphin, Epinephrine and Dopamine in Patients. American Journal Of Chinese Medicine, 33(5), 737-745.

Kim, H. (2008). Handbook of Oriental Medicine. (4th ed). Anaheim, CA: QPuncture.

Kim, S., Kim, S., Chung, I., Cheon, W., Ku, S. (2012). Antioxidant and Protective Effects of Bupleurum falcatum on the l-Thyroxine-Induced Hyperthyroidism in Rats. Evidence-Based Complementary & Alternative Medicine (Ecam), 1-12.     

Tzeng, T., Lu, H., Liou, S., Chang, C., Liu, I. (2012). Vinegar-Baked Radix Bupleuri Regulates Lipid Disorders via a Pathway Dependent on Peroxisome-Proliferator-Activated Receptor-α in High-Fat-Diet-Induced Obese Rats. Evidence-Based Complementary & Alternative Medicine (Ecam), 1-12.         

  

Zhixian, L., & Xingdong, H. (2004). The chinese materia medica. (2nd ed.). Beijing: Academy Press (Xue Yuan).

Case Study: The Use of Auricular Acupuncture for Low Back Pain

                                   The Use of Auricular Acupuncture for Low Back Pain

                          Advanced Needling Techniques 1: Auricular Acupuncture Module

                                                            AOMA Spring 2014

 

       Patient, G.G. first came into the clinic for a flare up of her chronic low back pain

in January 2014. G.G. is a 69-year- old female who has worked as a massage therapist 5

days a week for the past 20 years. She’s returned for continuing treatment approximately

3 times a month since her first visit. Though her lumbago has improved by at least 50%,

due to the physical stress of her work it seems that her treatments have reached a plato.

She has received needling, tuina, cupping, guasha and e.stem, which all work temporarily

until her next shift at work. She has yet to have been offered any auricular treatment,

which according to multiple articles, can be very effective for this type of pain.

         According to an article published in 2013 titled, A Randomized Clinical Trial of

Auricular Point Acupressure for Chronic Low Back Pain: A Feasibility Study, pain

was statistically reduced in patients who were administered auricular ear seeds in the

correct locations versus those that were given sham points. The correct points used were

shen men, sympathetic and ashi in the low back area. The sham points selected were

simply located away from areas where the patient was experiencing pain (Yeh et al.

2013). In another article published in 2003, the effectiveness of e.stem on ear points for

chronic low back was investigated. In this study they used both shen men and low back

with or without e.stem. Patients who received e.stem were able to return to work full-time

earlier than patients treated with manual auricular acupuncture. The frequency of low

back pain decreased in 82% of patients who received e.stem while it decreased by 54% in

patients without it, which is still a significant amount (Sator-Katzenschlager et al. 2004).

           While these two studies found shen men and the low back points to have clear

analgesic effects there remain other auricular points which could be used as well. It’s

important to understand what underlying factors are involved in the low back pain. For

example, it could be more stress related, caused by muscle tension, bone spurs,

subluxation, or nerve impingement. In the case of G.G., she had undergone

decompression surgery 30 years previously and had lots of scar tissue in the L3-L4 area.

She also suffered from sciatic and some thoracic pain aggravated by overuse. For G.G. it

would be beneficial to start off with points such as, lumbo-scaral, sciatic and thoracic. It

could also be useful to use shen men for general pain, tension, inflammation and to assist

with auxiliary symptoms caused by the chronic pain such as insomnia and depression.

The Thalamus point could also be used for it’s ability in reducing chronic pain (Shores).

It will be interesting to see how including these auricular points will effect the length of

analgesia provided by acupuncture for G.G..

 

Chao Hsing YehLung Chang ChienBalaban, D. (2013). A Randomized Clinical Trial of

Auricular Point Acupressure for Chronic Low Back Pain: A Feasibility Study. Evidence-

Based Complementary & Alternative Medicine (Ecam), 1-9.

 

Sator-Katzenschlager, S., Scharbert, G., Kozek-Langenecker, S., Szeles, J., Finster, G.,

Schiesser, A., et al. The Short- and Long-Term Benifits in Chronic Low Back Pain

Through Adjuvant Electrical Versus Manual Auricular Acupuncture. Anesthesia &

Analgesia, 98, 1359-1364. Retrieved June 28, 2014, from

http://journals.lww.com/anesthesia-analgesia/Fulltext/2004/05000/The_Short__and_Long_Term_Benefit_in_Chronic_Low.3

 

Shores, J. Auriculotherapy: Evaluation Survey : Protocols : the Ultimate for Pain

Management. Tulsa, OK: Electro Therapy Association.

Coursework: Biomedical and TCM Study of Osterarthritis

Biomedical and TCM Study of Osterarthritis

                                                                            ATD I

AOMA Fall 2013

    One out of every three Americans suffer from some type of joint pain (J. Wu & F. Yip, 2004). According to The Global Burden of Disease: 2004, Osteoarthritis (OA) causes moderate to severe disability for 43.4 million people globally (WHO, 2004). In 2011 the US saw close to a million hospitalizations for OA (A. Pfuntner et al, 2011). Currently there are no measures being taken to control OA prevalence, lifestyle modifications are shown to provide some slowing in degeneration, but there are no known cures.

    There are many different types and causes for arthritis ranging from auto-immune to overwork. Osteoarthritis is one of the most common types of arthritis, it is also known as degenerative arthritis or wear-and-tear arthritis. OA differers from other types of arthritis because it is affects specific joints that are repetitively damaged from mechanical stress with insufficient self repair (J. Wu & F. Yip, 2004 ). Primary OA is found to have a genetic component, though a single factor has not be shown to be a sufficient cause. Primary OA is also correlated to a history of joint injury, obesity and change in the sex-hormones of post-menopausal women. Secondary OA is caused by other factors but the resulting pathology remains the same as primary (WHO, 2004).

    In TCM Osteoarthritis and Rheumatoid arthritis are both categorized as simply arthritis. The etiology of arthritis in TCM involves the invasion of the external pathogens: wind, cold and dampness. The combination of all three external pathogenetic factors is what makes arthritis more complex to treat. It can also be caused by irregular diet, specifically food allergies leading to damp-heat. Lastly, it can be caused by repetitive physical work and strain throughout life. The TCM mechanism of arthritis is local Qi and blood stagnation with general weakness. In the case of OA, it is considered to be in the Qi stage because it has a more functional etiology (J. WU & F. Yip, 2004).

    The signs and symptoms of osteoarthritis are mainly pain, loss of ability and often stiffness. Pain is usually described as sharp, aching and burning (J. Wu & F. Yip, 2004). OA usually affects the hands, feet, spine and large weight bearing joints like the knees and hips (J. Ezzo et al, 2001). Sometimes crackling noises called crepitus can be heard when the affected joint is touched or moved. Hard boney enlargements may form on the smaller joints, called Heberden’s nodes when on the distal interphalangeal joints and/or Bouchard’s nodes when on the proximal interphalangeal joints. The biomedical method for diagnosis involves clinical examinations and can be made with reasonable certainty based on patient history. X-rays can confirms the diagnosis if needed. The X-ray will show joint space narrowing, osteophytes, increased bone formation around the joint and subchondral cyst formation.

    In TCM the etiology of OA is the combination of wind, cold and dampness, so in order to diagnosis and treat the patients their other symptoms must be looked at to learn if there is more cold, damp or wind involved. If it is more due to a wind invasion the pain will be wandering and will be located more of the upper part of the body. There will be other common wind invasion symptoms like aversion to wind and a slight fever. If the OA is more due to a cold invasion the pain will be more sever and stabbing and can be alleviated by warmth. There will also be general cold symptoms like cold extremities, aversion to cold, profuse clear urine and a superficial & tight or deep & slow pulse. If there is more dampness involved the arthritis will mainly be on the lower limbs due to damp sinking. The pain will be dull with a sensation of heaviness. In the local area there will be swelling and there may be edema and numbness. There will also be general damp symptoms including general heaviness, nausea, decreased appetite, vomiting, profuse vaginal discharge, loose stools with sticky pieces, gas and bloating. The tongue will show dampness with swelling and teeth marks (J. Wu & F. Yip, 2004).

    Biomedical treatments are limited and more about management. Weight lose is important for obese patients, and a prescription for acetaminophen is very common (J. Flood, 2004). Moderate exercise is recommended for reduction of pain and increase in function (J. Wu & F.Yip, 2004). If these management options are ineffective and disability is significant, joint replacement surgery can be performed. For TCM treatments, a combination of acupuncture and Tui-na is considered the most effective (J. Wu & F. Yip, 2004). Though research has shown that acupuncture can provide pain relief, because OA is a disorder of the tendo-muscular meridians, massage and Tui-na address the type of pain much better (J. Ezzo et al, 2001). Warming therapies and exercise are also recommended (J. Wu & F. Yip, 2004).

    Acupuncture points should be chosen based on the differentiation: if more wind, use common wind points like BL12 and 13, GB20 and SJ17, if more cold, use common cold points like GB20, LU7, LI4 with moxa. If there is more dampness, use common damp points like SJ5, Sp9, St40, Sp6. It is important to pair cold, wind and/or damp points with local points according to the location of the arthritis (J. Wu & F. Yip, 2004). There are some herbal formulas which can be used in conjunction with Tui-na and acupuncture. If cold is prominent use Chuan Wu Tang (J. Wu & F. Yip, 2004). In a 2004 study on the effectiveness of Duhuo Jisheng Wan compared to the commonly used Diclofenac it was found that they have clinically comparable effects after four weeks of treatment (S. Teekachunhatean et al, 2004).

    Osteoarthritis is a complex, multi-layered disease and it’s management can be difficult whether it’s being treated by biomedical or TCM techniques.

Arthritis/bi syndrome (guan jie yan). In (2004). J. Wu & F. Yip (Eds.), Acupuncture treatment of disease: Student study guide

Ezzo, J., Hadhazy, V., Birch, S., Lao, L., Kaplan, G., Hochberg, M., & Berman, B. (2001). Acupuncture for osteoarthritis of the knee: A systematic review.Arthritis & Rheumatism, 44(4), 819-825. doi: 10.1002/1529-0131(200104)44:4<819::AID-ANR138>3.0.CO;2-P

Flood, J. (2010). The role of acetaminophen in the treatment of osteoarthritis. The American journal of managed care, 48-54. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20297877

Pfuntner A., Wier L.M., Stocks C. Most Frequent Conditions in U.S. Hospitals, 2011. HCUP Statistical Brief #162. September 2013. Agency for Healthcare Research and Quality, Rockville, MD.

Teekachunhatean, S., Kunanusorn, P., Rojanasthien, N., Sananpanich, K., Pojchamarnwiputh, S., Lhieochaiphunt, S., & Pruksakorn, S. (2004). Chinese herbal recipe versus diclofenac in symptomatic treatment of osteoarthritis of the knee: a randomized controlled trial . BMC Complementary and Alternative Medicine, 4(19), doi: 10.1186/1472-6882-4-19

World Health Organization. (2004). The global burden of disease:2004 update . Geneva, Switzerland: World Health Organization Press. Retrieved from http://books.google.com/books?id=xrYYZ6Jcfv0C&pg=PA35

Intern Reflection 3: J.S. 8/19/15

                 

J.S. was a male in his mid-60s. His wife and he came in together weekly but I only treated him this one time. They had just returned from vacation to find their AC and fridge were both broken. He had felt stressed about this but was now reporting it was much less. He mainly wanted to work on his tight shoulders and upper back. I could tell that he seemed worn out and somewhat tense. I got the sense that he had transferred his stress into his upper back and shoulders and had not realized it. His differentiation was “Qi and Xue Yu, Qi and Yin Xu and LV Qi Yu.” I felt that Tuina was best primary modality for this patient but I also incorporated  some local points, GB 20 and 21, 4 gates, SP6 and Ren4, 6, 17. While I was treating him I felt a little disappointed in myself for not having “done more.” I was thinking that maybe the treatment wasn’t going far enough, or that it was too simple. At the end of the session as he was walking out he stopped me and hugged me, telling me, “Thank you so much! I’ve never felt so good after a treatment.” I was surprised and humbled by this. Though I never got to treat him again, that interaction has stuck with me. It made me see how sometimes a simple treatment is the best and also how powerful touch can be. After that treatment I started using Tuina in almost all my treatments.

Set of 3 Intern Reflection 2: E.M. 3/26/15, 4/2/15, 5/14/15

           

E.M. was a woman in her mid to late 80s. She had been coming in to the AOMA clinic once a week for many years. When I first saw her she was suffering from fatigue, low back pain and a recently torn rotator cuff. She was the sole caregiver for her adult paraplegic son and this was one of the only times during the week she was able to focus on herself. My initial assessment was “Local Qi and Xue Yu in the GB channel and LV and KD yin Xu.” She had about 30 degrees range of motion on her left arm with pain ranging from 7-8/10. I first treated her in Mandy Marrows clinic so we started with a Japanese style Hara treatment as well as tuina on the low back and some local points around her left arm. I continued to see her every week and we formed a positive bond. Despite all her hard work taking care of her son alone E.M. had an inspiring attitude and was always smiling and excited to see me. We got to a point a few months into treating where I realized the treatments for her energy were not working and in fact her energy level was worse. I encouraged her to get some bloodwork done and she was compliant. E.M. was the perfect example of a good compliant patient. Even when it seemed nothing was helping, she continued to return with the same positive outlook. She was flexible and open to trying new things but was also honest when something hadn’t worked.

            On the April 2^nd treatment I reported to Mandy that I was concerned the treatments for her fatigue were not working and asked what else we could do. Mandy showed me a technique where you do direct rice moxa on Du20 and Ren6. I told E.M. about the technique and knew because of the amount of time she had been coming and her willingness to try new things that she would be open to the idea, and indeed she was. She next time I saw her she reported her fatigue to be almost completely resolved. After that it would dip down here and there but as long as I kept doing that moxa technique her fatigue never dropped back down so low.

            At this point we had moved into the next term and I was treating under Dr. Luo. While her fatigue was well managed her should pain was unrelenting. We had had small successes with e.stem but ultimately the benefits only lasted a few days. I was in the same opposition as before with her fatigue, not knowing what to do next. I mentioned to Dr. Luo my success with the moxa on Du20 and that gave him the idea to try warm needling pai-ci on her shoulder. He felt that because she had responded so well to the direct moxa it meant that she was the type of person who can see great success with moxa. I did the warm needle pai-ci and within 3 treatments the pain was completely gone. Though she would never regain her range of motion, as the cuff was torn and she had turned down surgery, our treatment was a success.

            Over the months of knowing E.M. and treating her I became quite fond of her and felt very much like a care-taker to her. I had never felt that way about a patient before. I would think about her outside of clinic and even though I haven’t seen her in many months I still think fondly of her and wonder how she’s doing. Having this experience with such a compliant patient who is undergoing recurring symptoms helped me to remember never to give up or just keep doing the same thing over and over if it’s not working. It also taught me that learning what type of techniques work best for specific patients can lead to more success with them in the future.