As an increasing number of individuals in society seek alternatives to traditional western medicine, the important question raised is: “are these alternatives truly effective – and more importantly are they safe?”
Traditional Chinese Medicine (TCM) has been practiced in Australia since the 19th century when the Australian gold rush brought many Chinese migrants. The WHO survey of Australia in 2000 described over 1100 practitioners of Chinese Medicine graduating in that year and that there were also over 23 professional associations present that represented different aspects of Chinese Medicine. One can only assume that in 2017 these figures are now higher.
TCM is increasingly mainstream, here and overseas. In a National Health Survey in the USA in 2007, over 3 million people confirmed that they had used acupuncture in the previous year, 2.3 million practiced Tai Chi and 600,000 practiced Qi Gong.
Despite these numbers, up to now scientific analysis on the effectiveness of these therapies has been fraught with complexity: due to many factors including the differing ideologies of Traditional Chinese Medicine and Western Medicine, and the lack of prior engagement between the differing practitioner groups.
Traditional Chinese Medicine dates back 2500 years and it is based on the philosophy of Taoism. It is based on the Qi, the Yin and Yang. The Qi is the vital energy that pervades the body. The forces of Yin (negative energy) and Yang (positive energy) are balanced but when that balance becomes altered so is the Qi and an individual becomes sick. According to TCM teaching, one’s organs are part of a system called Zang Fu. Zang organs manufacture and store while Fu organs transmit and digest. The imbalance between Zang and Fu then makes the individual sick. Unlike western medicine, TCM is customised to the individual and hence additional ingredients can be included dependent on the individual’s Yin-Yang. As a result, formulations differ from patient to patient, making it challenging to study.
TCM tries to avoid invasive methods and uses external techniques or herbal medications to help the balance Yin and Yang and allow the Qi to flow again.It encompasses many different practices: acupuncture, Chinese Herbal Medicine, Tui Na (Chinese Therapeutic Massage), Tai Chi and Qi Gong (movement and posture therapy that help with mental focus and coordinated breathing), Moxibustion (burning a herb and hence heat therapy above acupuncture point) and Cupping therapy.
Furthermore additional traditional systems of medicine exist in other Asian countries such as Kampo in Japan which was originally based on the Chinese Medicine. The Japanese Ministry of Health formally recognised the practice of Kampo and hence it is covered by National Health Insurance. Similarly throughout Asia traditional Chinese Medicine is practiced alongside Western Medicine and funded through public health insurance.
What is the evidence for Chinese Medicine?
Western Medicine has set rigorous methods by which to assess the safety and efficacy of treatments. The best accepted mode of analysis in medicine is a randomised controlled trial. This is where individuals are allocated a treatment at random and therefore by chance receive one of several clinical interventions. One of these interventions will be the new treatment under study, one may be the standard of current treatment and/or one may involve no intervention at all (what is called a placebo eg a ‘sugar pill’). Consequently in Western Medicine when a new drug is made available, it has been assessed by a randomised control trial in a large population to demonstrate its benefit over current therapy and doses and formulations are fixed. The problem with applying this to Chinese medicine is that the treatments are often individualised to align the yin and yang. Even trying to assess the benefits of something as standardised as acupuncture is difficult: how do you organise a ‘placebo arm’ to the trial? Needling an individual as an obvious treatment that is hard to sham.
As a result, there are few randomised control trials with traditional chinese medicine.
Furthermore studies in Chinese are not widely available to western doctors with our limited access to translated texts. Over the last 15 years a number of studies have been performed and published in Western societies but have not involved full collaboration with Traditional Chinese Medical practitioners. Collaboration between western societies and Chinese medical practitioners needs to be encouraged if validity of treatment is to be sought.
So what does the evidence say?
Systematic reviews of acupuncture cannot reach a definitive conclusion regarding its benefits, due to the problems mentioned above. Some studies have shown that Tai Chi has benefits with respect to improving balance and stability in people with Parkinson’s disease, and improves pain management in those with arthritis of the knee and fibromyalgia.
The US government and WHO recommended that if an individual is planning to use TCM, they should alert their usual medical practitioner and check the experience of the TCM practitioner, the evidence for the therapy being offered and also not substitute it for conventional therapy.
When can Chinese Medicine help Western Medicine?
While straight comparison of TCM and Western medicine is still challenging, it is important to review how TCM can support Western medicine.
Oral and topical medications in TCM have been used for eczema/ atopic dermatitis for many years but unfortunately the randomised control trials using the formulations have been flawed. However Xiao-Feng-San (XFS), a 13-herb formula, was studied in a randomized trial in Taiwan. 47 Patients with severe intractable Atopic Dermatitis were treated for eight weeks with oral XFS or given placebo (n = 24). There was a significantly greater improvement in the the area of skin involvement and symptoms associated in the XFS group compared with placebo. These differences, except for the redness score, were still significant four weeks after the completion of treatment. Preliminary observational studies suggest that the combination of Chinese herbal therapy and acupuncture may be more effective than herbal therapy alone. Further controlled clinical studies are needed.
There is increasing scientific evidence to support the use of Traditional Chinese medicine (TCM) herbal therapy for asthma with a number of differing therapies being used including anti-asthma herbal medicine intervention (ASHMI), which has received new drug approval for investigation in the US. 14 herbs make up ASHMI but a modified form of just three is also available that contains Ling-Zhi (Ganoderma lucidum), Ku-Shen (Sophorae flavescentis), and Gan-Cao (Glycyrrhiza uralensis). Preliminary data suggest that ASHMI is safe and effective for mild to moderate asthma. One trial compared ASHMI against steroid treatment which is commonly used in moderate asthma flares and found there was nearly equivalence in ASHMI to steroids. The advantage of ASHMI is that its side effect profile is not as great as steroids. Furthermore it did not appear to interact with other drugs and hence could be used along with other therapies. However while this is enticing larger trials are required to remove any effects by chance.
Low Back Pain and Arthitis
Well-designed clinical trials have found that both acupuncture and sham acupuncture are more effective than control interventions for low back pain. Similarly in over 1000 patients with knee arthritis allocated acupuncture, sham acupuncture versus physiotherapy and pain killers, the rates of success were similar for acupuncture and sham acupuncture but greater than standard therapy. The concern with these results is that the recruits for this trial may have had preconceived ideas about the benefits of acupuncture and this may have affected the results. The study demonstrated that acupuncture was safe providing clean sterile needle practices were followed.
In the 1960s after many attempts to eradicate malaria, the number of cases rebounded and increased pressure existed to find treatment. In Beijing a national project was set up by the Chinese government and over 240 herbal preparations were studies with Qinghaosu (artemesinin) the most promising. In 2005 the World Health Organisation embraced this drug in a combination therapy that is now used widely in Africa.
Other trials in drugs for Alzheimer’s disease, Leukaemia, and heart disease are all currently being explored.
The downside: Side Effects of TCM
The difficulty with Traditional Chinese Medicine is trying to ensure that each component of the herbal medicine is known, what are are its side effects and how does it interact with other conventional medication. Cases that highlight the risks include the development of sudden kidney failure in a number of individuals in the UK, Spain, Belgium and Japan who had taken a TCM weight loss therapy. This was confirmed to be due to the presence of toxic agents (fenfluramine and diethylpropion) which reduced the blood supply to kidneys. It appeared that therapists had not appreciated that some species of the Mu Tong plant contained these kidney toxins.
Consequently it is important that patients know the compounds they use. In China and places like Taiwan often Western and traditional chinese medicines are used concurrently and side effects understood in an Asian population. In Western countries the interactions are not fully documented or known.
Consequently there is still a lot to be done to align the science and balance of TCM with Western Medicine. With increased collaboration, there is potential for great benefit.