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Rhinitis and Chinese Medicine 

Rhinitis involves inflammation of the mucous membranes of the nose, eyes, eustachian tubes, middle ear, sinuses, and pharynx. The nose invariably is involved, and the other organs are affected in certain individuals. Characteristic symptoms include repetitive sneezing; runny nose; post-nasal drip; nasal congestion; itchy eyes, ears, nose or throat; and generalized fatigue. Symptoms can also include wheezing, eye tearing, sore throat, and impaired smell. A chronic cough may be secondary to postnasal drip, and sinus headaches and ear plugging are also common.  

Causes

It is caused by acute or chronic inflammation of the mucous membrane of the nose due to viruses, bacteria, irritants, or allergens. The inflammation results in the generating of excessive amounts of mucus, commonly producing the aforementioned runny nose, as well as nasal congestion and post-nasal drip.  

Rhinitis is categorized into three types:

• Infective rhinitis: It is commonly caused by a viral or bacterial infection.
• Non allergic (vasomotor) rhinitis: It includes autonomic, hormonal, drug-induced, atrophic, and gustatory rhinitis, as well as rhinitis medicamentosa. Those non-allergic triggers cause dilation of the blood vessels in the lining of the nose, which results in swelling and drainage. Vasomotor rhinitis can coexist with allergic rhinitis, which is called "mixed rhinitis”.
• Allergic rhinitis: It is often caused by seasonal pollens (tree, grass or ragweed pollens), outdoor allergens (cockroaches, rodents, or molds); indoor allergens (house dust, mites, pets).
  

Conventional treatment

In cases of allergic rhinitis, the most effective way to decrease allergic symptoms is to completely avoid the allergen. Vasomotor rhinitis can be brought under a measure of control through avoidance of irritants, though many irritants, such as weather changes, are uncontrollable. The goal of rhinitis treatment is to reduce the symptoms caused by the inflammation of affected tissues. Oral antihistamines or decongestants, and sprays such as antihistamine, anti-drip anticholinergic, corticosteroid, and decongestant nasal sprays, are helpful for reducing the symptoms. Immunotherapy (Allergy Shots) may be useful for allergic rhinitis.  

Chinese medicine

In recent years, intensive studies have been carried out to explain the underlying mechanisms of the efficacy of acupuncture. Various studies have shown that acupuncture inhibits inflammatory reactions and regulates immune reactions in different diseases, including rhinitis.   

Chinese medicine considers a human body as a whole and healthy body is maintained by a balance of yin and yang, as well as qi and blood. When yin and yang are balanced and qi and blood flow freely through the meridians, the body is in good health and can perform at its optimum. However, if a particular energy pathway is obstructed, its corresponding organ's function will also be affected and the body's yin and yang will become unbalanced. This imbalance will ultimately affect the functioning of the body as a whole.

In Chinese medicine, rhinitis is due to an invasion of external pathogens (such as wind cold or wind-heat), and internal factors, including the deficiency of qi or yin in lung, kidney and spleen, general qi deficiency or blood stasis.   

Classification

Rhinitis is categorized into different kind of types and the following are commonly observed in clinic practice.  

Acute rhinitis

• Wind-cold invading nose
• Wind-heat invading nose 

Chronic rhinitis

• Heat stagnation of lung-stomach
• qi deficiency of lung-spleen
• qi stagnation and blood stasis
• Lung qi stagnation and phlegm-stasis

Dry rhinitis

• Dry injuring nose
• yin deficiency leading to lack of nose nourishing
• qi deficiency leading to loss of tonifying nose
• Heat stagnation of lung and stomach

Atrophic rhinitis

• General yin deficiency leading to lung dry
• yin deficiency of lung and kidney
• yin deficiency and damp-heat invading nose
• Heat stagnation of lung and stomach
• qi and yin deficiency

Allergic rhinitis

• Lung qi deficiency: It leads to wind-cold, which eventually invades nose
• qi deficiency of lung and spleen: It  leads to water-damp that eventually invades nose
• Kidney qi deficiency: It results in the nose to lose the balance
• Heat stagnation in lung
• qi deficiency and blood stasis
• Superficial coldness and internal heat
  

Clinical studies of acupuncture for allergic rhinitis

Impact of acupuncture on vasomotor rhinitis: a randomized placebo-controlled pilot study. Fleckenstein J, et al. J Altern Complement Med. 2009;15(4):391-8. OBJECTIVES: Chronic rhinitis without an allergic or infectious etiology (vasomotor rhinitis) is a common disease for which there are only few and not very effective therapeutic treatment options. The current placebo-controlled, partially double-blinded pilot study evaluated the effects of acupuncture on the symptoms of vasomotor rhinitis. DESIGN: A total of 24 patients with confirmed diagnosis of vasomotor rhinitis were randomly allocated to either acupuncture or sham laser acupuncture treatment. The sham laser was a deactivated laser pen beaming normal red light. The main outcome measure was the alteration of the nasal sickness score (NSS; score(max) 27 points). Secondary outcome measures were the evaluation of a subjective symptoms score by patients' diaries and of their quality of life (SF-12 health survey). A credibility assessment regarding the respective treatment was performed. The study is registered as an International Standard Randomised Controlled Trial, number NCT00682162. RESULTS: NSS of patients treated by acupuncture was significantly reduced from 9.3 +/- 3.89 to 4.1 +/- 3.20 points (p < 0.001), whereas NSS declined from 5.6 +/- 2.74 to 3.7 +/- 2.61 points after sham treatment (p < 0.05). Comparison between the groups revealed a significant change of NSS (Mann-Whitney, p < 0.01), an analysis that also considers the significant difference between the baseline values of both groups (p < 0.05). Secondary outcome measures did not show significant differences between both groups. The credibility assessment was comparable for both treatments. CONCLUSIONS: This pilot study showed significant effects of acupuncture compared to a sham treatment in the NSS on symptoms of vasomotor rhinitis. These results may justify the performance of a large randomized trial to strengthen our understanding of the therapeutic value of acupuncture in the treatment of vasomotor rhinitis. 

Status of the autonomic nervous system and reflexotherapy in children with vasomotor rhinitis. Shevrygin BV et al.  Pediatriia. 1989;(9):46-9. Different variants of vegetative nervous system dysfunction were identified during the examination of 86 children with vasomotor rhinitis. Based on the findings of the examination a pathogenetically-based method of acupuncture was proposed for the management of this patients' group. Acupuncture with regard to vegetative dysfunction attenuated the latter's manifestations and corrected associated psychoemotional disorders. As a result the clinical manifestations of vasomotor rhinitis were eliminated. 

Application of acureflexotherapy to the treatment of seasonal allergic rhinitis. Kudaibergenova SF et al. Vestn Otorinolaringol. 2009;(6):71-3. The objective of this study was to evaluate efficiency of acureflexotherapy for the prevention of exacerbations of seasonal allergic rhinitis. Up to seven needles were used per session depending on the acupuncture point. A set of auricular and remote (corporal) points were chosen on either side of the patient's body. Efficiency of the treatment was evaluated from changes in the clinical picture of the disease, results of rhinoscopy and laboratory analyses during the period of plant pollination. A total of 24 patients with seasonal allergic rhinitis were given this treatment of whom 18 (75%) reported marked improvement of health conditions. It manifested itself as the disappearance of clinical symptoms of the disease and a substantial decrease in the number and severity of pathological changes in nasal mucosa revealed by rhinoscopy. 

Clinical experience in acupuncture treatment of allergic rhinitis. Zhang YQ. Journal of Traditional Chinese Medicine. 2009;29(3):186-9. OBJECTIVE: To observe the clinical effects of acupuncture for allergic rhinitis. METHODS: The body acupuncture, auricular seed-embedding and microwave irradiation were adopted for treatment of allergic rhinitis due to various causative factors, such as cold and insufficiency of the lung-qi weakening the body resistance, insufficiency of the spleen-qi with lucid yang failing to rise, insufficiency of the kidney-yang failing to warm the body surface, and the heat accumulated in the lung channels giving invading the nose. RESULTS: After treatment, the symptoms and signs disappeared in all illustrative cases, with no recurrence found after a one-year follow-up. CONCLUSION: Acupuncture may help to improve the blood theology indexes with an increased volume of blood flow, and regulate the immunological function of the human body, thus giving therapeutic effects for allergic rhinitis. 

Acupuncture for persistent allergic rhinitis: a multi-centre, randomised, controlled trial protocol. Kim JI et al.  Trials [Electronic Resource]. 2009:10:54. BACKGROUND: Allergic rhinitis is one of the most common health complaints worldwide. Complementary and alternative medical approaches have been employed to relieve allergic rhinitis symptoms and to avoid the side effects of conventional medication. Acupuncture has been widely used to treat patients with allergic rhinitis, but the available evidence of its effectiveness is insufficient. Our objective is to evaluate the effectiveness of acupuncture in patients in Korea and China with persistent allergic rhinitis compared to sham acupuncture treatment or waitlist control. METHODS: This study consists of a multi-centre (two centres in Korea and two centres in China), randomised, controlled trial with three parallel arms (active acupuncture, sham acupuncture, and waitlist group). The active acupuncture and sham acupuncture groups will receive real or sham acupuncture treatment, respectively, three times per week for a total of 12 sessions over four weeks. Post-treatment follow-up will be performed a month later to complement these 12 acupuncture sessions. Participants in the waitlist group will not receive real or sham acupuncture treatments during this period but will only be required to keep recording their symptoms in a daily diary. After four weeks, the same treatment given to the active acupuncture group will be provided to the waitlist group. DISCUSSION: This trial will provide evidence for the effectiveness of acupuncture as a treatment for persistent allergic rhinitis. The primary outcome between groups is a change in the self-reported total nasal symptom score (i.e., nasal obstruction, rhinorrhea, sneezing, and itching) from baseline at the fourth week. Secondary outcome measures include the Rhinitis Quality of Life Questionnaire score and total non-nasal symptom score (i.e., headache, itching, pain, eye-dropping). The quantity of conventional relief medication used during the follow-up period is another secondary outcome measure.  

DNA microarray analysis of the effect on inflammation in patients treated with acupuncture for allergic rhinitis. Shiue HS et al. Journal of Alternative & Complementary Medicine. 2008;14(6):689-98. BACKGROUND: Allergic rhinitis affects approximately 30% of adults and up to 40% of children in industrialized societies. Medicines available for relief of allergic rhinitis symptoms include antihistamines, decongestants, leukotriene inhibitors, topical hormones, and corticosteroids. However, the negative side-effects of antiallergic medicines cause many patients with allergic rhinitis to choose traditional Chinese medical treatments, such as taking Chinese herbs or treatment with acupuncture. OBJECTIVES: This study assessed the effect of acupuncture for treatment of allergic rhinitis. METHODS: Eighteen (18) patients with allergic rhinitis were treated with acupuncture 8 times over a 4-week period, and peripheral blood of these patients was collected at each visit for analysis of gene expression via cDNA microarray. To estimate the therapeutic effect of acupuncture objectively, patients completed the rhinoconjunctivitis quality of life questionnaire (RQLQ) before and after acupuncture therapy. RESULTS: Based upon patients' response to the RQLQ, acupuncture therapy significantly reduced allergic rhinitis symptoms, including nasal symptoms, non-hay fever symptoms, and sleep and practical problems (associated with daily activities). In addition, expression of interleukin-1 receptor-alpha (IL1R1) in peripheral blood was significantly decreased at 2 hours, 24 hours, and 4 weeks after acupuncture treatment in these patients. CONCLUSIONS: To our knowledge, this is the first report of cDNA microarray analysis of differential gene expression in the peripheral blood of patients with allergic rhinitis before and after acupuncture treatment. Our data suggest that the balance between T-helper 1 and T-helper 2 cell-derived proinflammatory versus anti-inflammatory cytokines might be improved by acupuncture treatment. 

External application of herbal medicine to acupoints. Yang J et al. Journal of Traditional Chinese Medicine. 2008;28(1):21-3. Application of herbal medicine to acupoints is to regulate the meridians, yin-yang, and qi and blood for preventing and treating diseases through the pharmacological action of herbal medicines and with their stimulation to the acupoints. This article explains how to apply herbal medicines and gave the examples for the treatment of hypertension, asthma, chronic bronchitis and allergic rhinitis. Application of herbal medicines to acupoints is one of the important components of TCM, which shows satisfactory effects in treatment of some chronic diseases. 

Acupuncture for persistent allergic rhinitis: a randomised, sham-controlled trial. Xue CC et al. Med J Aust. 2008;188(1):64. OBJECTIVE: To investigate the effectiveness and safety of acupuncture in persistent allergic rhinitis (PAR). DESIGN: Randomised, single-blind, sham-controlled trial conducted from May 2004 to February 2005. PARTICIPANTS AND INTERVENTION: 80 patients with PAR (age, 16-70 years) were randomly assigned to receive real or sham acupuncture. After a 1-week baseline period, participants were treated twice weekly for 8 weeks and followed up for another 12 weeks. MAIN OUTCOME MEASURES: Nasal obstruction, sneezing, rhinorrhoea and nasal itch were each self-assessed daily on a 5-point scale, and scores were aggregated weekly. The sum of the symptom scores (total nasal symptom score, TNSS) was also determined. A secondary outcome was use of PAR relief medication. RESULTS: After 8 weeks' treatment, the weekly mean difference in TNSS from baseline was greater with real (-17.2; 95% CI, -24.6 to -9.8) than with sham acupuncture (-4.2; 95% CI, -11.0 to 2.7) (P = 0.01). The decrease in individual symptom score was also greater with real acupuncture for rhinorrhoea (P < 0.01) but not the other symptoms. At the end of follow-up, the greater difference in TNSS from baseline in the real acupuncture group was still apparent: real, -21.0 (95% CI, -29.1 to -12.9) versus sham, - 2.3 (95% CI, -10.2 to 5.6) (P = 0.001). Moreover, the differences from baseline in all four individual symptom scores were greater for the real than for the sham group (P < 0.05). Real and sham acupuncture were both well tolerated. CONCLUSION: Our findings suggest that acupuncture is effective in the symptomatic treatment of PAR. 

Clinical observation on acupuncture for treatment of allergic rhinitis. Chen ZX et al. Zhongguo Zhenjiu. 2007;27(8):578-80. OBJECTIVE: To find out an effective acupuncture and moxibustion therapy for allergic rhinitis. METHODS: One hundred and thirty-five cases were randomly divided into a treatment group, a control group I , and a control group II , 45 cases in each group. The treatment group were treated with acupuncture at Yingxiang (LI 20), Shangyingxiang (EX-HN 8), Yintang (EX-HN 3), Hegu (LI 4), Fengchi (GB 20), Dazhui (GV 14), Feishu (BL 13); the control group I with Yingxiang (LI 20), Shangyingxiang (EX-HN 8), Yintang (EX-HN 3), Hegu (LI 4), and the control group II with oral administration of Biyankang tablets, 4 tablets each time, thrice each day. Acupuncture was given one session daily, 10 sessions constituting one course. Their therapeutic effects were compared after treatment of 2 courses and were followed up a half year later. RESULTS: The total effective rate was 91.1% in the treatment group, 71.1% in the control group I and 46.7% in the control group II, with a significant difference among the 3 groups (P<0.05), and with a significant difference in the recurrence rate one year later among the cured cases of the 3 groups (P<0.05). CONCLUSION: Acupuncture has a definite therapeutic effect on allergic rhinitis, with a better result by acupuncture with the anterior and posterior acupoint association method. 

Effect of acupuncture in the treatment of seasonal allergic rhinitis: a randomized controlled clinical trial. Xue CC et al.  Am J Chin Med. 2002;30(1):1-11. The clinical efficacy and safety of acupuncture in the treatment of Seasonal Allergic Rhinitis (SAR) was evaluated by employing a two-phase crossover single-blind clinical trial. Thirty subjects were randomly assigned to two groups with 17 and 13 subjects respectively and treated with real or sham acupuncture (three times per week) for four consecutive weeks and then a crossover for treatments for a further four weeks without a washout period. The administration of real acupuncture treatment was guided by a syndrome differentiation according to Chinese Medicine Theory. Subjects were assessed by various criteria before, during and after the treatments. Outcome measures included subjective symptom scores using a five-point scale (FPS), relief medication scores (RMS) and adverse effect records. Twenty-six (26) subjects completed the study. There was a significant improvement in FPS (nasal and non-nasal symptoms) between the two types of acupuncture treatments. No significant differences were shown in RMS between the real acupuncture treatment group and the sham acupuncture treatment group. No side effects were observed for both groups. The results indicate that acupuncture is an effective and safe alternative treatment for the management of SAR. 

A double-blind, randomized, placebo-controlled trial of acupuncture for the treatment of childhood persistent allergic rhinitis. Ng DK et al. Pediatrics. 2004;114(5):1242-7. OBJECTIVE: To compare active acupuncture with sham acupuncture for the treatment of persistent allergic rhinitis among children. METHODS: Subjects with persistent allergic rhinitis were recruited from the pediatric outpatient clinic. They were randomized to receive either active acupuncture or sham acupuncture. Main outcome measures included daily rhinitis scores, symptom-free days, visual analog scale scores for immediate effects of acupuncture, daily relief medication scores, blood eosinophil counts, serum IgE levels, nasal eosinophil counts, patients' and parents' preferences for treatment modalities, and adverse effects. RESULTS: Eighty-five patients were recruited from the pediatric outpatient clinic at Kwong Wah Hospital, in Hong Kong. Thirteen patients withdrew before randomization; 35 patients (mean age: 11.7 +/- 3.2 years) were randomized to receive active acupuncture for 8 weeks, and 37 patients (mean age: 11 +/- 3.8 years) were randomized to receive sham acupuncture for 8 weeks. Acupuncture was performed twice per week for both groups. Both the assessing pediatricians and the patients were blinded. There were significantly lower daily rhinitis scores and more symptom-free days for the group receiving active acupuncture, during both the treatment and follow-up periods. The visual analog scale scores for immediate improvement after acupuncture were also significantly better for the active acupuncture group. There was no significant difference in the following outcome measures between the active and sham acupuncture groups: daily relief medication scores, blood eosinophil counts, serum IgE levels, and nasal eosinophil counts, except for the IgE levels before and 2 months after acupuncture in the sham acupuncture group. No severe adverse effects were encountered. Numbness, headache, and dizziness were found in both the active and sham acupuncture groups, with no difference in incidence, and the effects were self-limiting. CONCLUSIONS: This study showed that active acupuncture was more effective than sham acupuncture in decreasing the symptom scores for persistent allergic rhinitis and increasing the symptom-free days. No serious adverse effect was identified. A large-scale study is required to confirm the safety of acupuncture for children. 

Acupuncture and Chinese herbal medicine in the treatment of patients with seasonal allergic rhinitis: a randomized-controlled clinical trial. Brinkhaus B et al. Allergy. 2004;59(9):953-60. BACKGROUND: Patients with allergic rhinitis (AR) increasingly use complementary medicine. The aim of this study was to determine whether traditional Chinese therapy is efficacious in patients suffering from seasonal AR. METHODS: Fifty-two patients between the ages of 20 and 58 who had typical symptoms of seasonal AR were assigned randomly and in a blinded fashion to (i) an active treatment group which received a semi-standardized treatment of acupuncture and Chinese herbal medicine, and (ii) a control group which received acupuncture applied to non-acupuncture points in addition to a non-specific Chinese herbal formula. All patients received acupuncture treatment once per week and the respective Chinese herbal formula as a decoction three times daily for a total of 6 weeks. Assessments were performed before, during, and 1 week after treatment. The change in severity of hay fever symptoms was the primary outcome measured on a visual analogue scale (VAS). RESULTS: Compared with patients in the control group, patients in the active treatment group showed a significant after-treatment improvement on the VAS (P = 0.006) and Rhinitis Quality of Life Questionnaire (P = 0.015). Improvement on the Global Assessment of Change Scale was noted in 85% of active treatment group participants vs 40% in the control group (P = 0.048). No differences between the two groups could be detected with the Allergic Rhinitis Symptom Questionnaire. Both treatments were well-tolerated. CONCLUSIONS: The results of this study suggest that traditional Chinese therapy may be an efficacious and safe treatment option for patients with seasonal AR. 

Acupuncture and Chinese herbal medicine in the treatment of patients with seasonal allergic rhinitis: a randomized-controlled clinical trial. Brinkhaus B et al. Allergy. 2004;59(9):953-60. BACKGROUND: Patients with allergic rhinitis (AR) increasingly use complementary medicine. The aim of this study was to determine whether traditional Chinese therapy is efficacious in patients suffering from seasonal AR. METHODS: Fifty-two patients between the ages of 20 and 58 who had typical symptoms of seasonal AR were assigned randomly and in a blinded fashion to (i) an active treatment group which received a semi-standardized treatment of acupuncture and Chinese herbal medicine, and (ii) a control group which received acupuncture applied to non-acupuncture points in addition to a non-specific Chinese herbal formula. All patients received acupuncture treatment once per week and the respective Chinese herbal formula as a decoction three times daily for a total of 6 weeks. Assessments were performed before, during, and 1 week after treatment. The change in severity of hay fever symptoms was the primary outcome measured on a visual analogue scale (VAS). RESULTS: Compared with patients in the control group, patients in the active treatment group showed a significant after-treatment improvement on the VAS (P = 0.006) and Rhinitis Quality of Life Questionnaire (P = 0.015). Improvement on the Global Assessment of Change Scale was noted in 85% of active treatment group participants vs 40% in the control group (P = 0.048). No differences between the two groups could be detected with the Allergic Rhinitis Symptom Questionnaire. Both treatments were well-tolerated. CONCLUSIONS: The results of this study suggest that traditional Chinese therapy may be an efficacious and safe treatment option for patients with seasonal AR.  

Sinusitis and Chinese Medicine 

Sinusitis is an inflammation of the sinuses and nasal passages. A sinus infection can cause a headache or pressure in the eyes, nose, cheek area, or on one side of the head. A person with a sinus infection may also have a cough, a fever, bad breath, and nasal congestion with thick nasal secretions. Sinusitis is categorized as acute or chronic. 

Since anatomical location of sinuses, if sinusitis is left undiagnosed and untreated, the complications of sinusitis can occur that may lead to severe medical problems and possibly death. The complications may include: Infection of the frontal bone; Infection of the eye socket from ethmoid sinusitis; Formation of a blood clot in the sinus area around the front and top of the face; Infection of brain.  

Causes

Acute sinusitis usually follows a viral infection in the upper respiratory tract, but allergy-causing substances or pollutants may also trigger acute sinusitis. Bacteria can cause acute sinusitis and chronic sinusitis. Fungi are also becoming an increasing cause of chronic sinusitis, especially in people with diseases that weaken the immune system, such as AIDS, leukemia, and diabetes. 

Conventional treatment

Medications most often used to treat sinusitis include:

• Antibiotics: Kill bacteria or fungi
• Antiallergic medicine: Improve the allergy
• Decongestants: Reduce the swelling of the mucous membranes in the nose
• Analgesics: Relieve pain
• Mucolytics: Thin the mucus
• Corticosteroids: Reduce inflammation in the nasal passages
• Sinus surgery is generally a last line of defense for medical doctors

Chinese medicine

Acupuncture or/and herbal formula work very well on sinusitis. They can be used alone or combined with each other. There are several kinds of sinusitis and the following are commonly observed in clinical practice. 

Wind-heat

• Symptoms: Stuffy nose, nasal discharge (yellow/green, thick), headache, inability to smell, aversion to cold, or fever
• Tongue:  Red on tip or sides
• Pulse:  Floating and rapid
• Treatment principle:

• Expel wind-heat
• Induce diaphoresis
• Restore the descending and dispersing functions of the lung qi

Liver/gallbladder heat

• Symptoms: Yellow discharge, red face, headaches at frontal or temporal, irritability, and bitter taste in the mouth
• Tongue:  Red on the sides, greasy yellow tongue coating
• Pulse:  Wiry, slippery and fast
• Treatment principle:
  • Clear liver and gallbladder fire
  • Restore the descending and dispersing functions of the lung qi

Heat in the lung

• Symptoms: Thick nasal discharge, tender sinus area, heat signs - flushed face, thirst, and feelings of heat
• Tongue:  Red with sticky yellow coating
• Pulse:  Slippery, full
• Treatment principle:
  • Clear lung-heat
  • Restore the descending and dispersing functions of the lung qi 

Spleen deficiency – Stomach/spleen damp-heat

• Symptoms: Heavy/foggy feeling in the head, sticky /yellow discharge, red cheeks, thirst, dry lips, frontal headache, chest/epigastrium oppression.
• Tongue:  Sticky yellow coating in the stomach or spleen area
• Pulse:  Slippery
• Treatment principle:
  • Clear heat
  • Resolve dampness
  • Tonify  stomach and spleen

Studies of Chinese medicine for sinusitis

The root and development of otorhinolaryngology in traditional Chinese medicine. Yap L ea al. European Archives of Oto-Rhino-Laryngology. 2009;266(9):1353-9. There is an increasing trend in society to look beyond conventional medicine to find answers to problems in health. Traditional Chinese medicine (TCM) is one of the most popular alternative, complementary therapies worldwide. It is becoming a popular alternative in otorhinolaryngology where its use in the treatment of sinusitis, tinnitus, deafness and Meniere's disease is growing. Despite the general awareness of TCM, the literature relating specifically to otorhinolaryngology is relatively scarce. In this review, we have traced the origin and development of otorhinolaryngology with respect to TCM and have provided a few interesting insights into otorhinolaryngology, as it used to be practised. Archaeological sources have shown that diseases affecting the ear, nose and throat were of medical concern as early as the 18th century BC. The first practising otorhinolaryngologist can be traced back to the 5th century BC. Acupuncture, moxibustion, herbal therapy and massage were amongst his treatments. Otorhinolaryngology was recognised as a major specialty when formal medical education began in the 7th century AD. Therapeutic measures since then expanded to include exercise, food therapy and surgery. References to using oesophageal speech as a substitute voice generator, the use of copper wire to excise nasal polyps, procedures for removal of sharp foreign bodies in the oropharynx, repair of lacerated trachea and treatment of cancer of lips can be found in historical notes. In conclusion, from its primitive roots, TCM has developed into a distinct branch of health care system in China today that works alongside Western medicine. 

Treatment of acute rhinosinusitis with the preparation from Pelargonium sidoides EPs 7630: a randomized, double-blind, placebo-controlled trial. Bachert C ea al. Rhinology. 2009;47(1):51-8. OBJECTIVE: To evaluate the efficacy and safety of the herbal drug preparation from the roots of Pelargonium sidoides (EPs 7630) compared to placebo. DESIGN: Double-blind, randomized, placebo-controlled, parallel-group, multicenter trial with a group-sequential adaptive design. SUBJECTS: Patients with sinonasal symptoms of at least 7 days duration, and radiographically and clinically confirmed acute rhinosinusitis of presumably bacterial origin with a Sinusitis Severity Score (SSS) of at least 12 out of 24 points at inclusion. INTERVENTIONS: EPs 7630, a herbal drug preparation from the roots of Pelargonium sidoides (1: 8-10; extraction solvent: ethanol 11% (w/w)), or matching placebo at a dose of 60 drops three times daily for maximum 22 days. MAIN OUTCOME MEASURES: Change in the SSS after 7 days. RESULTS: 103 patients were recruited until the planned interim analysis. The mean decrease in the SSS was 5.5 points in the EPs 7630 group compared to 2.5 points in the placebo group, a difference of 3.0 points (95% confidence interval 2.0 to 3.9, p < 0.00001). This result was confirmed by all secondary parameters indicating a more favourable course of the disease and a faster recovery in the EPs 7630 group. According to the pre-specified decision rule, the study was stopped after obtaining proof of efficacy for EPs 7630. CONCLUSIONS: EPs 7630 was well tolerated and superior in efficacy compared to placebo in the treatment of acute rhinosinusitis of presumably bacterial origin. 

Treatment of perennial allergic rhinitis using Shi-Bi-Lin, a Chinese herbal formula. Zhao Y et al. Journal of Ethnopharmacology. 122(1):100-5, 2009 Feb 25. AIM OF THE STUDY: Shi-Bi-Lin (SBL) is modified from the classic formula Cang-Er-Zi-San which has been used to treat chronic rhinitis, paranasal sinusitis and allergic rhinitis by herbal practitioners. The present study aimed at patients with moderate to severe perennial allergic rhinitis. SBL which has been shown effective in treating a guinea-pig model of allergic rhinitis, was evaluated for its efficacy and safety. MATERIALS AND METHODS: 126 allergic rhinitis patients were recruited in a double-blind randomized control trial. Half of the patients received SBL capsules and the others half received placebo for 4 weeks. Symptoms scores, physician's evaluation, nose examination, quality of life, adverse effects, serum cytokines were evaluated before and after treatment. RESULTS: SBL was found to be safe and effective in relieving some symptoms of perennial allergic rhinitis, improving the nose condition, and enhancing some domains of quality of life when compare to placebo, (p<0.05). In the 2 weeks follow up after treatment completion, the SBL enjoyed a prolongation of symptom control (p=0.05). CONCLUSION: SBL relieved symptoms of nose blockage among patients with perennial allergic rhinitis, and some aspects of the quality of life were also improved. The improvement was sustained for at least 2 weeks after treatment. No serious adverse events were encountered. 

The value of herbal medicines in the treatment of acute non-purulent rhinosinusitis. Results of a double-blind, randomised, controlled trial. Tesche S et al. European Archives of Oto-Rhino-Laryngology. 2008;265(11):1355-9.  In a prospective, randomised, double-blinded controlled study, we compared the efficacy and safety of two different treatment options with the herbal medicines cineole and a combination of five different components for acute viral rhinosinusitis. One hundred and fifty patients with acute and viral rhinosinusitis (75 patients in each treatment group) were enrolled. The diagnosis rhinosinusitis was made according to a defined symptoms-sum-score which was based on rhinoscopic and clinical signs which are characteristic for rhinosinusitis. The primary endpoint was the amelioration of the symptoms-sum-score, which includes all relevant characteristics for rhinosinusitis as headache on bending, frontal headache, sensitivity of pressure points of trigeminal nerve, impairment of general condition, nasal obstruction, rhino-secretion, secretion quantity, secretion viscosity and fever in a treatment period of 7 days. The mean reduction of the symptoms-sum-score after 4 days was 6.7 (+/-3.4) and after 7 days 11.0 (+/-3.3) in the cineole group and 3.6 (+/-2.8) after 4 days and 8.0 (+/-3.0) after 7 days in the control group. The differences between both groups were clinically relevant and statistically significant after 4 and 7 days (P < 0.0001). This result is validated by the amelioration of the secondary endpoints headache on bending, frontal headache, sensitivity of pressure points of trigeminal nerve, impairment of general condition, nasal obstruction and rhino-secretion. These findings correlate with the statistically significant difference of the estimation of B-scan ultrasonography. It is safe to use both medications for 7 days in patients with acute viral rhinosinusitis. Treatment with cineole is clinically relevant and statistically significant, more effective in comparison to the alternative herbal preparation with five different components. 

Chemistry and bioactivity of Flos Magnoliae, a Chinese herb for rhinitis and sinusitis. Shen Y et al. Current Medicinal Chemistry. 2008;15(16):1616-27. Flos Magnoliae (FM, Chinese name: Xin-yi) is one of the most commonly used Chinese medicinal herbs. It has a long history of clinical use for managing rhinitis, sinusitis and headache. More than 20 different FM species have been used clinically, which makes species identification and evaluation of pharmacological effects of individual chemical ingredients difficult. In this review, we have summarized the current knowledge on FM phytochemistry and its bioactivity activities. The bioactive compounds in FM include both lipid and water-soluble components. More than 90% of the essential components of FM species are terpenoids, including monoterpenes and sesquiterpenes. Lignans and neolignans including tetrahydrofurofuran, tetrahydrofuran and aryltetralin are also present in FM species. A small number of water-soluble compounds have been isolated from Magnolia flower buds, including a benzylisoquinoline alkaloid magnoflorine, an ester ethyl-E-p-hydroxyl-cinnamate and a flavonoid biondnoid. A wide range of pharmacological actions of FM have been reported, including anti-allergy, anti-inflammation and anti-microbial activity. The structure-activity relationship analysis revealed the influence of methylation at position 5 on the 3,7-dioxabicyclo-(3,3,0)-octane backbone of six lignans in antagonistic activities against platelet-activating factor. In addition, the trans stereoisomer fargesin had a much lower bioactivity than the cis stereoisomer demethoxyaschantin. Recent studies have been directed towards the isolation of other bioactive compounds. Further studies on FM may help to develop new anti-inflammatory and anti-allergic drugs. 

Electroacupuncture in combination with surgical intervention in the treatment of patients with polypous rhinosinusitis. Mikhireva MM et al.  Vestnik Otorinolaringologii. 1990;2:40-2. In 36 patients with polypous rhinosinusitis the olfactory function, mucociliary transport, humoral and local immunity were investigated before and after treatment that combined surgical intervention and electric acupuncture. The points were selected on an individual basis using diagnostic data, i.e. measurement of electric conductivity of representative points. In most cases the combined treatment led to improvement of the olfactory function, mucociliary transport and local immunity. During two-year follow-up recurrent polyps were detected in 4 patients whose general health condition remained good. These observations indicate the electric acupuncture can be recommended for the combined therapy of polypous rhinosinusitis. 

Acupuncture therapy in the outpatients-department of the University Clinic Heidelberg. Fischer MV. Anaesthesist.1982;31(1):25-32. Encouraged by the good results obtained using acupuncture anaesthesia, we started therapeutic acupuncture in our institute of anaesthesiology four years ago. In the meantime acupuncture is as important a therapeutic method in our out-patients department as are therapeutic local anaesthesia, transcutaneous electrical nerve stimulation and biofeedback. The results in 520 patients who have been treated with acupuncture for different diseases are reported. The success of treatment, the number of sessions and the recurrence-rate within one and a half years are discussed for the different diseases. Acupuncture treatment was regarded successful when 1, the patient had no complaints at all without medication, and 2, when there was significant improvement (no long term medication, only mild complaints with unusual strain, which were responsive to minimal medication). Thus treatment in cephalgia was successful in 83% with no recurrences (NR) in 84%. In cervical pain syndromes the respective percentages were 80% (NR = 74%) in constipation 80% (NR = 72%), sinusitis 86% (NR = 100%), insomnia 100% (NR = 100%). Good results, albeit with high recurrence rate were achieved in cases of trigeminal neuralgia in 90% (NR = 23%), colitis ulcerosa in 100% (NR = 0%), in bronchial asthma 70% (NR = 50%) and in tumour pain 61% (NR = 0%). Treatment in patients suffering from parathymic conditions were unsatisfactory and results in cases of tinnitus were negative. 

Electro-acupuncture in otolaryngology. Heimann H. HNO. 1978;26(8):278-81. As an introduction to electro-acupuncture, the author discusses the basic theory of classical acupuncture as well as the therapeutic applications of low frequency positive or negative half-waves. Electro-therapy using specific points of acupuncture which refer to selected organs can now be carried out with a compact apparatus called ELBION. This instrument had originally been designed by the author for reliable and uncomplicated applications in oto-rhino-laryngology. ELBION thus permits the realization of a complete electro-acupuncture (EAP). Typical indications for EAP, as confirmed by the author, include influenzal anosmia, Bell's paralysis and central equilibrium disturbances of the neurovascular type. EAP serves as a most helpful additional treatment in cases of frontal sinusitis, various kinds of neuralgia, cervical otalgia, as well as sialoses of obscure or chronic genesis. 

Urinary Incontinence and Chinese Medicine 

Urinary incontinence is any involuntary leakage of urine or loss of bladder control. It can happen to anyone, but is very common in older people. Symptoms can range from mild leaking to uncontrollable wetting. Women are more likely than men to have incontinence.  

Causes

Urinary incontinence can result from anatomic, physiologic or pathologic factors, causing weak bladder muscles, overactive bladder muscles, blockage of urinary tract, damage to nerves that control the bladder.

   Temporary urinary incontinence

• Alcohol
• Overhydration
• Caffeine
• Bladder irritation
• Constipation
• Medications
• Urinary tract infection

   Persistent urinary incontinence

• Pregnancy and childbirth
• Changes with aging
• Hysterectomy
• Painful bladder syndrome
• Prostatitis
• Enlarged prostate
• Prostate cancer
• Chronic urinary tract infection
• Bladder cancer or bladder stones
• Neurological disorders: multiple sclerosis, Parkinson’s disease, stroke, a brain tumor or a spinal injury
• Obstruction: tumor or stone in urinary stones and vaginal prolapse
  

Types

• Stress urinary incontinence is due essentially to insufficient strength of the pelvic floor muscles.
• Urge incontinence is involuntary loss of urine occurring for no apparent reason while suddenly feeling the need or urge to urinate.
• Overflow incontinence occurs when the patient's bladder is always full so that it frequently leaks urine.
• Structural incontinence caused by structural problems such as an ectopic ureter or vaginal fistulas.
• Functional incontinence happens in many older people who have normal bladder control. They just have a hard time getting to the toilet in time because of other disorders that make moving quickly difficult.
• Mixed urinary incontinence involves two or more types of incontinence.
  

Conventional treatment

Weight loss in overweight women reduced stress incontinence; Exercises to the muscles of the pelvis to strengthen or retrain pelvic floor muscles and sphincter muscles can reduce stress leakage; Absorbent products such as shields, undergarments, briefs, diapers and underpads can be used to protect underwear; Electrical stimulation can strengthen muscles in the lower pelvis; Biofeedback can be used to help the patient become aware of his or her body's functioning; Medications can reduce some types of leakage; Pessaries can be used to the patients who have urinary incontinence caused by vaginal prolapse; A variety of materials can be used to add bulk to the urethra and thereby increase outlet resistance;  Catheterization to the bladder can be used for the patients due to overflow incontinence to drain urine; Surgery procedures are often used to alleviate incontinence after other treatments have been tried, including bladder repositioning, retropubic suspension or bladder neck suspension surgery, various sling procedures, bladder augmentation or artificial urinary sphincter. 

Chinese Medicine

Since the complexity of herbal medicine, acupuncture is often chosen for clinical studies. However, in clinical practice, acupuncture is often combined with herbal medicine or some other modalities of Chinese medicine.  The following types of urinary incontinence are often observed in clinical practice. 

Deficiency and coldness of kidney qi

• Symptoms: frequently urine leaking, long and thin flow of clear urine, low spirit, aversion to coldness, tiredness, pale complexion, sore waist and knees with no strength, dizzy and tinnitus, cold extremities, spermatorrhea, premature ejaculation or impotence
• Tongue: light-colored, fat with teeth marker, and thin and white coat
• Pulse: thin, weak and no strength

qi deficiency of lung and spleen

• Symptoms: urinary incontinence with urgency after the birth or after the disease, occasional urine leak, exacerbating when coughing, standing up, sneezing, talking or laughing, accompanied by cough, asthma and tiredness, poor appetite or abdominal bloating
• Tongue: light-colored with thin, white coat
• Pulse: weak and no strength

Hot dominancy of bladder

• Symptoms: urine dripping frequently, urgent and painful urination, yellow urine, burning feeling when urinate, heavy and uncomfortable feeling in low abdomen, bitter and dry month
• Tongue: red with yellow coat
• Pulse: stringy, slippery and fast

Yin deficiency of liver and kidney

• Symptoms: urinary incontinence, short and slow flow of yellow urine, burning feeling in urinary tract, often accompanied by dizzy and tinnitus, red cheeks, thirsty and forgetful, sore waist and no strength in the legs, night sweating or constipation
• Tongue: red with scanty coat
• Pulse: stringy, thin and fast

Stagnation of Xia-Jao:

• Symptoms: can not control urination, bloating, pain in low abdominal area with sometime detectable mass
• Tongue: dark, or petechiae with thin coat
• Pulse: stringy, weak and uneven
  

Clinical studies of acupuncture on urinary incontinence

Various clinical studies have been performed and show that acupuncture is effective in the treatment of urinary incontinence. The following are some of studies. 

Observation on therapeutic effect of dog-day acupuncture and moxibustion combined with pelvic floor muscle exercises for treatment of female stress urinary incontinence. Tang CLet al. Zhongguo Zhen Jiu. 2009; 29(11):879-83. Seventy one cases were randomly divided into two groups. Thirty six cases in the observation group were treated with acupuncture on Zhongji (CV 3), Zigong (EX-CA 1), Chize (LU 5) etc. and tortoise-shell moxibustion on Shenque (CV 8) combined with pelvic floor muscle exercises; while thirty five cases in the control group were treated with only pelvic floor muscle exercises. The scores of the International Consultation Committee on Incontinence Questionnaire Short Form (ICI-Q-SF) and the Medical Outcomes Survey Short Form-36 (SF-36) were evaluated before and after treatment, and the scores of SF-36 were also compared with 35 cases in normal group. RESULTS: The total effective rate of 91.7% in the observation group was higher than that of 77.1% in the control group (P < 0.05). The dimensions of SF-36 of stress urinary incontinence patients were remarkably lower than those of normal group (all P < 0.05). The scores of ICI-Q-SF were decreased while the scores of SF-36 were increased obviously after treatment in both the observation group and the control group, there were pronounced improvements on physiological function, pain, physical activity, social function and affection function in the observation group (all P < 0.05). CONCLUSION: the dog-day acupuncture and tortoise-shell moxibustion combined with pelvic floor muscle exercises can improve the symptoms of urinary incontinence and increase the quality of life of patients.  

The efficacy of acupuncture in treating urge and mixed incontinence in women: a pilot study.  Engberg S et al. J Wound Ostomy Continence Nurs. 2009;36(6):661-70. This study consisted of 9 women between the ages of 44 and 66 years with urge or mixed urge and stress UI at least twice a week for a minimum of 3 months. MEASURES: Subjects completed a 1-week bladder diary at baseline and at 1 and 4 weeks postacupuncture to assess the impact of acupuncture on incontinence episodes. Quality of life was measured at baseline and at 1 and 4 weeks postacupuncture using the Medical Outcomes Short-Form (general health- related quality of life) and the Incontinence Impact Questionnaire and Urogenital Distress Inventory (incontinence-specific quality of life). RESULTS: It was feasible to recruit subjects and perform the planned study procedures. Subjects randomized to the true acupuncture group had a mean 63.30% (median = 65.99%) reduction in daytime accidents/day at 1 week postacupuncture and 67.47% reduction (median = 75.76%) at 4 weeks postacupuncture. In contrast, the mean reduction in daytime accidents was 18.88% (median = 19.64%) at 1 week and 16.67% (median = 0%) at 4 weeks post-sham acupuncture. There were no significant group differences in changes in the scores on the quality-of-life measures. Subjects' perceptions about whether they had received the true or sham acupuncture were not significantly better than one would expect by chance. CONCLUSIONS: The findings of this pilot study support the need for additional research examining the efficacy of acupuncture in the treatment of UI in women, the feasibility of performing study procedures, and the use of a sham needle as placebo in acupuncture studies.  

Acupuncture in the treatment of diabetic bladder dysfunction. Tong Y et al. J Altern Complement Med. 2009;15(8):905-9. This study compared 30 cases in the acupuncture group with 15 cases in the sham acupuncture group (n = 45 total). The effects of acupuncture were observed on urodynamic measurements, as well as a variety of symptoms associated with DBD. RESULTS: In the acupuncture group, five of the six urodynamic measures (maximal detrusor pressure, bladder compliance, maximal bladder capacity, bladder volume at desire to void and urge to void) demonstrated significant improvement (p < 0.05, 0.01) over the 15-day treatment period. Only one measure (bladder volume at urge to void) was significantly improved (p < 0.05) in the sham acupuncture group. There were significant differences after therapy in four measures (bladder compliance, maximal bladder capacity, bladder volume at desire to void, and urge to void) between the groups (p < 0.05, 0.01). A significant difference of the changes in symptoms compared with pretreatment in the acupuncture group was observed (p < 0.05, 0.01). In 25 subjects in the acupuncture group, incontinence improved from 2.4 to 1.4. In the sham acupuncture group, incontinence deteriorated from 2.2 to 2.3. CONCLUSIONS: Our pilot study has provided evidence that acupuncture may be clinically useful for the radical treatment of DBD.  

Effects of electroacupuncture on urinary bladder function after radical hysterectomy.  Yi WM et al. Zhongguo Zhen Jiu. 2008;28(9):653-5.

One hundred and ten cases were randomly divided into an electroacupuncture (EA) group and a control group, 55 cases in each group. In the control group, the urinary tube was placed and kept with routine method and the urinary bladder was rinsed, and from the eighth day the abdomen was radiated with TDP, 30 min each day, for 5 days. In the EA group, on the basis of treatment in the control group EA was given at Sanyinjiao (SP 6), Zusanli (ST 36), Waiguan (TE 5), Shuidao (ST 28), Guilai (ST 29), etc. from the eighth day to twelfth day after operation. The recovery time of urinary bladder function after radical hysterectomy, urine dynamic indexes and hospitalization days were compared between the two groups. RESULTS: The cases of the bladder function recovery, retention of urine, urinary incontinence were 51(51/55), 4(4/55), 0 on the 14 th day after operation and 53(53/55), 2(2/55), 0 on the 28 th day in the EA group, and 27(27/55), 25(25/55), 3(3/55) on the 14 th day and 43(43/55), 11(11/55), 1(1/55) on the 28th day in the control group, respectively, with a very significant difference between the two groups (P < 0.01); the EA group in residual urine volume, bladder volume, mean urinary flowing rate was better than the control group on the 14 th day after operation (P < 0.01 or P < 0.05); the hospitalization days after operation was (21.1 +/- 3.3) days in the EA group and (25.5 +/- 3.5) days in the control group, the former being shorter than the later (P < 0.01). CONCLUSION: EA can promote recovery of bladder function, shorten the keeping time of urinary tube after radical hysterectomy, which is benefit to decreasing incidence rate of urinary system infection and shortening hospitalization days.  

Acupuncture for overactive bladder: a randomized controlled trial. Emmons SL and Otto L. Obstet Gynecol. 2005;106(1):138-43. Eighty-five women were enrolled in this randomized, placebo-controlled trial. Women were randomly assigned to either receive an acupuncture treatment expected to improve their bladder symptoms, or a placebo acupuncture treatment designed to promote relaxation. They underwent cystometric testing, completed a 3-day voiding diary, and completed the urinary distress inventory and incontinence impact questionnaire, validated quality-of-life inventories, before and after 4 weekly acupuncture treatments. The primary endpoint was number of incontinent episodes over 3 days. Secondary endpoints included voiding frequency and urgency, cystometric bladder capacity, maximum voided volume, and the urinary distress inventory and incontinence impact questionnaire symptom scores. RESULTS: Seventy-four women completed all aspects of the study. Women in both treatment and placebo groups had significant decreases in number of incontinent episodes (59% for treatment, 40% for placebo) without a significant difference in the change between the groups. Women in the treatment group had a 14% reduction in urinary frequency (P = .013), a 30% reduction in the proportion of voids associated with urgency (P = .016), and a 13% increase in both maximum voided volume and maximum cystometric capacity (P = .01). Both groups also had an improvement in the urinary distress inventory and incontinence impact questionnaire scores (54% decrease for treatment, 30% decrease for placebo, P < .001 for the difference in change between the groups). CONCLUSION: Women who received 4 weekly bladder-specific acupuncture treatments had significant improvements in bladder capacity, urgency, frequency, and quality-of-life scores as compared with women who received placebo acupuncture treatments.  

Acupuncture on clinical symptoms and urodynamic measurements in spinal-cord-injured patients with detrusor hyperreflexia. Honjo H et al. Urol Int. 2000;65(4):190-5. A total of 13 patients (11 males, 2 females) suffering from urinary incontinence due to spinal cord injuries were treated by acupuncture, which was carried out with disposable stainless steel needles inserted into the bilateral BL-33 (Zhongliao) points on the skin of the third posterior sacral foramina. Urodynamic studies were also performed before acupuncture, immediately after the 1st acupuncture and 1 week after the 4th acupuncture. In 6 patients, these urodynamic studies were performed again 1 month after the 4th acupuncture. RESULTS: No side effects were recognized throughout the treatment period. Of the 13 patients, incontinence disappeared in 2 (15%) and decreased to 50% or less compared to baseline in a further 6 (46%). Maximum cystometric bladder capacity increased significantly from 76.2 +/- 62.3 to 148.1 +/- 81.5 ml 1 week after the 4th acupuncture (p < 0.01). In the 6 patients in whom cystometry was repeated 1 month after the 4th acupuncture, bladder capacity decreased from 187.5 +/- 90.4 ml 1 week after the 4th acupuncture to 128.3 +/- 93.4 ml. CONCLUSION: In spinal cord injury patients acupuncture could represent another valuable therapeutic alternative to the treatment of urinary incontinence caused by detrusor hyperreflexia.  

Improvement of urge- and mixed-type incontinence after acupuncture treatment among elderly women - a pilot study. Bergström K, et al. J Auton Nerv Syst. 2000;79(2-3):173-80. The aim of this study was to investigate if sensory stimulation in the form of manual acupuncture could influence urge- or mixed-type incontinence among elderly women who were not satisfactorily relieved by standard pharmacological and non-pharmacological treatments given at a specialized incontinence unit. The study is an open clinical follow-up study. The study included 15 elderly women who were treated with manual acupuncture 12 times. Both subjective scorings and objective measurements in the form of leakage in grams (48 h Inco-test) were used. Evaluations were performed at discharge and 1 and 3 months thereafter. Almost all outcome measurements were significantly improved even at follow-up 3 months after the last treatment. Global scorings showed that 12 of the 15 women considered themselves improved even at the follow-up 3 month after treatments were completed. The possible mechanisms of action are discussed, as is the way to perform more studies in this field.  

Acupuncture for urinary incontinence in patients with chronic spinal cord injury. A preliminary report.  Honjo H et al. Nippon Hinyokika Gakkai Zasshi. 1998;89(7):665-9. A total of 8 male chronic spinal cord injured patients with urinary incontinence were treated by acupuncture. Their ages ranged from 20 to 33 years (mean 27). The level of lesion was cervical in 4 and thoracic in 4. Detrusor hyperreflexia with uninhibited bladder contraction was confirmed by urodynamic studies in all of them. Acupuncture was performed using a disposable stainless needle (0.3 mm in diameter, 60 mm in length), which was inserted into bilateral BL-33 (Zhongliao) points and was rotated manually for 10 minutes. The treatment was conducted every week for 4 weeks. Urodynamic studies were repeated, immediately after the beginning of and a week after the completion of the treatment. Urinary symptoms were also checked before and after the treatment. RESULTS: No side effects were recognized throughout the treatment period. Among 8 patients, incontinence was controlled completely in 3 (38%) and partially in 3 (38%). The average maximum cystometric bladder capacity increased significantly, from 42.3 +/- 37.9 ml to 148.1 +/- 101.2 ml by the treatment (p < 0.05), while the average maximum bladder pressure was not changed. CONCLUSIONS: These data suggest that acupuncture could be a promising alternative for conventional therapies for urinary incontinence caused by detrusor hyperreflexia in patients with chronic spinal cord injuries. 

Post Traumatic Stress Disorder and Chinese Medicine 

Post Traumatic Stress Disorder (PTSD) is a prevalent anxiety disorder, which develops following the experience of a traumatic event and may result in multiple disabling symptoms.  About 70% of people will experience a traumatic event in their life, but not all will develop PTSD. According to a report published in 2004, PTSD has affected 18% of Operation Iraqi Freedom veterans. The median time to care for most veterans is 12 years. Therefore, getting treatment as soon as possible after PTSD symptoms develop may prevent PTSD from becoming a long-term condition.  

Symptoms

Through years of research, 17 PTSD symptoms have been identified.

Re-experiencing Symptoms

• Frequently having upsetting thoughts or memories about a traumatic event. Having recurrent nightmares.
• Acting or feeling as though the traumatic event were happening again, sometimes called a "flashback."
• Having strong feelings of distress when reminded of the traumatic event.
• Being physically responsive, such as experiencing a surge in your heart rate or sweating, to reminders of the traumatic event.

Avoidance Symptoms

• Making an effort to avoid thoughts, feelings, or conversations about the traumatic event.
• Making an effort to avoid places or people that remind of the traumatic event.
• Having a difficult time remembering important parts of the traumatic event.
• A loss of interest in important, once positive, activities.
• Feeling distant from others.
• Experiencing difficulties having positive feelings, such as happiness or love.
• Feeling as though your life may be cut short.

Hyperarousal Symptoms

• Having a difficult time falling or staying asleep.
• Feeling more irritable or having outbursts of anger.
• Having difficulty concentrating.
• Feeling constantly "on guard" or like danger is lurking around every corner.
• Being "jumpy" or easily startled.
  

Causes 

Traumatic events that can lead to post-traumatic stress disorder (PTSD) include:

• Combat or military exposure
• Child sexual or physical abuse
• Terrorist attacks
• Catastrophic accident (e.g., auto, airplane, mining)
• Violent asexual or physical assault
• Kidnapping
• Medical procedures (especially in kids)
• Natural disasters (fire, tornado, hurricane, flood, or earthquake)
• There is evidence that susceptibility to PTSD is hereditary
  

Conventional treatment

Treatment for PTSD is more complex and clinicians often utilize both cognitive-behavioral therapy and medication. Psychological treatment strategies are often aimed at disarming avoidance behaviors via focusing on the experience of the traumatic event as well as employing practices that help the patient to overcome demoralization and fear of recurrence; Sertraline (Zoloft) and paroxetine (Paxil) are selective serotonin reuptake inhibitors (SSRI) that are the first medications to have received FDA approval as indicated treatments for PTSD. While some of these therapies appear promising, there is no definitive treatment and no cure for the condition.  

Chinese medicine

Acupuncture is very effective in the treatment of persons who have been traumatized as a result of emotional and/or physical damage. Multiple studies have shown that acupuncture can relieve pain; Improve sleeping quality; Eliminate anxiety; Reduce stress and worry; Improve emotional fluctuations; Improve depression; Improve memory; Improve tachycardia; Reduce cravings for alcohol and other substances; Attenuate inflammation and regulate immune function. To date, research supports using acupuncture for treating PTSD symptoms, including insomnia, anxiety and depression, in addition to some pain disorders.  

PTSD is a complex disorder, which is a combination of emotional, cognitive, behavioral abnormalities. Clinical symptoms and manifestations are various from person to person. In my clinical practice, the following types of PTSD are commonly observed. 

Classifications of PTSD by Chinese medicine 

• Liver qi stagnation
• Yin deficiency and fire domination
• Deficiency of kidney essence
• Dominant damp restraining spleen
• Phlegm fire disturbing interiors
• Deficiency of both heart and spleen
• Disharmony of heart and kidney
• qi deficiency of both heart and gallbladder
  

Chinese medicine is individualized medicine. Experienced Chinese medicine practitioners will make accurate diagnosis according individual’s symptoms, signs, pulse, tongue, as well as individual’s life style and individual’s constitution. The choice of accupoints, herbal components, as well as some other modalities of Chinese medicine such as TuiNa, Gwasha, or electric stimulation, is highly individualized and there is no one who has exactly same accupoints or herbal formula. Acupuncture is often given to PTSD patients twice per week, total 10-12 times per one course. The courses to be given depend on individual’s situation or response to acupuncture. Often, after one course, the patients get dramatic improvement. Acupuncture can be combined with herbal formula or some other modalities of Chinese medicine, which can get better results. 

Scientific evidence of acupuncture

Scientific evidence of acupuncture for PTSD: Various studies have approached the mechanisms of acupuncture to improve PTSD symptoms. It seems that acupuncture and/or Chinese herbal medicine could regulate the most abnormalities involved in the mechanisms of PTSD.  

Amygdala

Amygdala, a structure in the brain, is involved in the expression of emotion, especially fear, autonomic reactions (e.g., increased heart rate and blood pressure, the startle response), and emotional memory. Dysfunction in this structure may produce symptoms of PTSD. Studies have shown that acupuncture can regulate this region of brain.

• Acupuncture produced extensive deactivation of the limbic-paralimbic-neocortical system in the medial prefrontal cortex, the temporal lobe (amygdala, hippocampus, and parahippocampus) and the posterior medial cortex and activates sensorimotor cortices, thalamus and occasional paralimbic structures1.
• Acupuncture evoked short-term and long-term increases in MOR binding potential and sensory processing regions including amygdala2.
• Acupuncture changes amygdala-specific brain network into a functional state that underlies pain perception and pain modulation, including anti-nociceptive, memory, and affective brain regions3,4.
  

Hypothalamic-Pituitary-Adrenocortical (HPA) axis

Reactions to stress are regulated primarily via the HPA axis. When a healthy person is faced with a stressor, the activation of the hypothalamus results in the secretion of corticotropin-releasing hormone (CRH) and arginine vasopressin. These hormones quickly trigger pituitary release of adrenocorticotropin-releasing hormone (ACTH), which acts on the adrenal glands to prompt release

of glucocorticoids into the bloodstream. Glucocorticoids (along with norepinephrine and epinephrine, released by the sympathetic nervous system) are primarily responsible for changes that occur in the body during a stressful situation to maximize one’s ability to deal with the stressor at hand. While glucocorticoids (notably, cortisol) are the main output of the human stress response, they are also critical for the termination of that response. Recognition of adequate glucocorticoid release results in a negative feedback loop whereby the hippocampus signals the hypothalamus to halt glucocorticoid release, thus ending the cascade.

• HPA axis: Studies have demonstrated that PTSD is associated with functional abnormalities of HPA axis and acupuncture regulates HPA axis5.
• CRH and cortisol: PTSD patients have baseline high levels of corticotrophin releasing hormone (CRH) in CSF and low levels of cortisol in plasma and 24 h urine6.  Acupuncture decreases CRH23 and increases cortisol level7.
• Norepinephrine and epinephrine: PTSD patients have elevated plasma norepinephrine and 24-hour urinary norepinephrine 8,9, which may be related to increased heart rate, increased startle reaction, and increased blood pressure as responses to traumatic slides, sounds and scripts. Studies demonstrate that acupuncture reduces plasma norepinephrine and epinephrine contents 10,11,12.
  

Serotonin (5-HT) system: connection of amygdala and HPA axis

Studies show that PTSD is associated with HPA axis dysfunctions and other brain-related structures, including amygdale. The amygdala is known to modulate the function of the HPA axis but the mechanism of this effect is still not clear. The studies suggest a mechanism by which the amygdala may modulate the function of the HPA axis via the serotonin (5-HT) system13.

The brain 5-HT system is involved in the regulation of stress and anxiety and has been linked to the neurobiology of PTSD. Serotonin depletion may result from repeated exposure to severe stress and trauma, which may be a factor in the development of irritability and violent or angry outbursts in people with PTSD. Studies have shown that acupuncture increases plasma serotonin14 and stimulates the release of serotonin of brain15. 

Inflammation and dysfunction of immune function

PTSD is associated with inflammatory-related medical conditions. Studies suggest an excess of inflammatory actions of the immune system in individuals with chronic PTSD. High levels of inflammatory cytokines have also been linked to PTSD vulnerability in traumatized individuals. There is also evidence that excessive inflammation is in part due to insufficient regulation by cortisol. Following a trauma, the HPA axis is activated. In PTSD, the HPA axis is often dysregulated, resulting in altered cortisol activity and levels. A dysregulated HPA axis may result in excessive inflammation through insufficient regulation of immune function16. Multiple studies have demonstrated that:

• Acupuncture reduces or eliminates inflammation 17
• Acupuncture regulates dysfunction of immune system18.
  

Hypothalamus-Pituitary-Thyroid (HPT) axis

HPT axis is stress-responsive, especially to traumatic stress. Studies show that PTSD patients have low level of plasma thyrotropin (TSH)19 and elevated total and the free fractions of triiodothyronine (T3) and thyroxine (T4)20, 21, indicating HPT axis might be dysregulated in PTSD patients. Studies demonstrate that Chinese herbal formula, Ahnjeonbaekho-tang, reduces the levels of serum T3 and T4 and increase TSH level22.  Acupuncture or/and moxibustion can decrease prominently serum value of thyroxine21.   

Clinical studies of acupuncture and herbal medicine on PTSD

Acupuncture Improves Symptoms of PTSD. Wendling P.  Family Practice News. 2009;39(4):17. Brief exposure to acupuncture significantly improved the symptoms of PTSD when this treatment was compared with usual care, in a randomized controlled trial in 55 veterans. 55 active-duty personnel with PTSD were randomized to usual care (medication or psychosocial therapy) or eight 90-minute of acupuncture sessions delivered twice weekly for 4 weeks, plus usual care. The acupuncture sessions, which included needling and patient-practitioner interaction, were standardized for the first four sessions and individualized for the second four sessions.  

Compared with usual care, acupuncture was associated with significantly greater decreases in PTSD symptoms on Clinician-Administered PTSD Scale (CAPS) and PTSD Checklist-Civilian Version (PCL-C), and these improvements were maintained through the 12-week follow-up. The mean PCL-C decreases were 19.4 at the end of treatment and 19.8 at the 12-week follow-up in the acupuncture group, compared with 4.0 and 9.7 in the usual care group. Symptoms of depression and pain also significantly improved in the acupuncture group, compared with the usual care group. The 36-Item Short Form Health Survey (SF-36) scores for mental functioning improved significantly with acupuncture. There was a trend toward improvement in physical functioning on the SF-36, but it likely didn't reach significance because the sample was fairly healthy physically and didn't have much room to improve.  

Acupuncture for posttraumatic stress disorder: a randomized controlled pilot trial. Hollifield M et al.  Journal of Nervous & Mental Disease. 2007;95(6):504-13. The purpose of the study was to evaluate the potential efficacy and acceptability of acupuncture for posttraumatic stress disorder (PTSD). People diagnosed with PTSD were randomized to either an empirically developed acupuncture treatment (ACU), a group cognitive-behavioral therapy (CBT), or a wait-list control (WLC). The primary outcome measure was self-reported PTSD symptoms at baseline, end treatment, and 3-month follow-up. Repeated measures MANOVA was used to detect predicted Group X Time effects in both intent-to-treat (ITT) and treatment completion models. Compared with the WLC condition in the ITT model, acupuncture provided large treatment effects for PTSD (F [1, 46] = 12.60; p < 0.01; Cohen's d = 1.29), similar in magnitude to group CBT (F [1, 47] = 12.45; p < 0.01; d = 1.42) (ACU vs. CBT, d = 0.29). Symptom reductions at end treatment were maintained at 3-month follow-up for both interventions. Acupuncture may be an efficacious and acceptable nonexposure treatment option for PTSD. Larger trials with additional controls and methods are warranted to replicate and extend these findings. 

Developing a traditional Chinese medicine diagnostic structure for post-traumatic stress disorder. Sinclair-Lian N et al.  Journal of Alternative & Complementary Medicine. 2006;12(1):45-57. BACKGROUND: Post-traumatic stress disorder (PTSD) is a common, disabling condition with many diverse symptoms including anxiety, depression, insomnia, and body pain. These symptoms are likely to be helped by treatment with Traditional Chinese Medicine (TCM); however, PTSD is not yet a recognized disorder (bing ming) in Chinese medicine. In preparation for a phase II clinical trial comparing TCM and cognitive behavioral therapy (CBT) treatment of PTSD symptoms, a TCM diagnostic pattern framework for persons who meet the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) definition of PTSD was sought. METHODS: Three approaches were used to identify the most likely TCM pattern differentiations for PTSD: an English-language TCM textbook review on the conditions "depression," "anxiety," and "insomnia"; a survey of 20 experienced practitioners of TCM; and TCM assessments of 21 individuals affected by PTSD. Two TCM practitioners synthesized the information into a list of pattern differentiations. RESULTS: The most likely pattern differentiations for PTSD were Heart Shen disturbance caused by Heat, Fire, or a constitutional deficiency; Liver Qi stagnation; and Kidney deficiency. Secondary patterns identified were outcomes of long-term Liver Qi stagnation-Liver overacting on Spleen/Stomach, Liver Fire, Phlegm Fire, Phlegm-Damp, and Heart Fire-and constitutional deficiencies in the Heart, Kidney, and Spleen organ systems. CONCLUSIONS: The use of extant literature, expert knowledge, and clinical TCM diagnoses contributed to the development of a TCM diagnostic structure for PTSD. The results can inform the clinical practice of TCM. The method can be used to guide research design involving different diagnostic systems.  

Integrating complementary therapies into community mental health practice: an exploration. Collinge W et al.  Journal of Alternative & Complementary Medicine. 2005;11(3):569-74. OBJECTIVES: To (1) describe the integration of massage and energy-based therapies with psychotherapy in a community mental health center, (2) to present qualitative feedback on the service, and (3) to present pilot data from a sample of long-term clients with persistent mental health concerns. DESIGN: A noncontrolled pilot study was conducted using interview data before and self-report instruments after completing a brief program of complementary therapy accompanying ongoing psychotherapy. SETTINGS/LOCATION: The program took place at a comprehensive community mental health center in southern Maine and in the private offices of massage therapists and energy healing practitioners who contracted with the program. SUBJECTS: Subjects were 20 women and 5 men, with mean age of 42 years and a mean history of 7.4 years of mental health treatment. All had histories that included trauma, 10 of which involved sexual abuse. The Diagnostic and Statistical Manual of Mental Disorders IV Axis I diagnoses were PTSD (10), major depression (nine), anxiety disorder (three), and dual diagnosis (three). INTERVENTIONS: Clients receiving ongoing psychotherapy were assigned to one modality of complementary therapy based on clinical judgment, availability of practitioners, and client interest. Modalities used were massage, acupuncture, Reiki, and Healing Touch. The mean number of sessions was five. OUTCOME MEASURES: Clients completed an investigator-generated instrument with Likert-scaled ratings of satisfaction and perceived changes in four dimensions of trauma recovery: perceived interpersonal safety, interpersonal boundary setting, bodily sensation, and bodily shame. RESULTS: Clients reported high levels of satisfaction with the service and significant levels of perceived (self-rated) change on each outcome measure. Qualitative results included enhanced psychotherapeutic outcomes reported by mental health clinicians. CONCLUSIONS: The integration of complementary therapies into community mental health practice may hold promise of enhancing mental health outcomes and improving quality of life for long-term users of mental health services. 

Free and Easy Wanderer Plus (FEWP), a polyherbal preparation, ameliorates PTSD-like behavior and cognitive impairments in stressed rats.  Wang HN et al. Progress in Neuro-Psychopharmacology & Biological Psychiatry. 2009;33(8):1458-63. Free and Easy Wanderer Plus (FEWP) is a well-known traditional Chinese medicine that has been shown to be effective in treating various mood disorders. The purpose of the present study was to determine whether FEWP could ameliorate stress-associated behavior in rats. Following the exposure to enhanced single prolonged stress (ESPS) paradigm, consisting of 2-hr constraint, 20-min forced swimming, ether-induced loss of consciousness, and an electric foot shock, animals were administered orally with FEWP (2.5, 5, or 10mg/kg daily) or vehicle for 2 weeks. Animals were then tested in the open field, elevated plus-maze, and Morris water maze. ESPS exposure resulted in pronounced anxiety-like behavior, without impairing locomotor activity, as indicated by significant decreases of time spent and number of entries into open arms in the elevated plus-maze test, and unaltered distance traveled in the open field test compared to unexposed animals. ESPS-exposed animals also displayed marked cognitive impairments, with significant increases of distance traveled and the escape latency to the underwater platform, and a striking decrease of time spent in the target quadrant with and without the removal of the platform in the water maze test. However, repeated treatment with FEWP, particularly at higher doses, reversed the aforementioned behavioral values in the elevated plus-maze and water maze tests to the levels similar to unexposed animals. These results indicate that FEWP possesses anxiolytic and cognition-improving effects and may be an effective herbal preparation for the treatment of stress-associated conditions, such as posttraumatic stress disorder (PTSD). 

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