Traditional Chinese Medicine

Introduction
Traditional Chinese Medicine (TCM) is an ancient medical system that has been practiced for thousands of years and remains part of mainstream healthcare delivery in many Asian countries today. TCM promotes a holistic approach to health and aims to maintain physical, emotional, and spiritual balance in order to prevent and treat disease (Parker 2000; Ergil 1996). TCM modalities include acupuncture, moxibustion, herbal medicine, Chinese massage (known as tui na), movement combined with breathing exercises (such as tai chi and qi gong), nutrition, and lifestyle modification (Parker 2000). Cupping and bleeding are also employed (Ergil 1996).
Historical Background
The first written documentation of TCM is recorded in the Pharmacopoeia of the Heavenly Husbandman, a text dating back to 200 B.C. (Parker 2000). Herbal medicine and acupuncture, including theory, practice, diagnosis, and treatment, were recorded in classical Chinese texts and refined over many centuries (Ergil 1996).
Although TCM has been practiced in the United States since the mid-19th century, it remained largely the province of immigrant Chinese communities until the general public became exposed to the practice following former President Nixon's trip to China in 1971. While covering Nixon's trip, New York Times reporter James Reston received acupuncture for post-operative pain following an emergency appendectomy. He published accounts of his experience with TCM that fascinated the public and contributed to its mainstream emergence as an alternative modality (Ergil 1996).
Today, TCM is practiced all over the world. A new term, Oriental medicine, has been coined to encompass both traditional and contemporary interpretations of TCM that are practiced throughout Asia (Ergil 1996).
Scientific Principles
According to an expert in the field, Dr. Kevin Ergil, TCM is based on three fundamental principles not easily understood from a Western cultural perspective. The first is the idea that qi (pronounced "chee"), described often in Western terminology as life energy, exists throughout the body and is responsible for maintaining normal physiological, psychological, and spiritual functions. There are five different types of qi with distinct associations: support and nourishment (construction qi); protection and warmth (defensive qi); flow of energy through channels, called meridians (channel qi); physiological activity of organs (organ qi); and ancestral qi, which controls circulation and respiration. Disease is caused by a disruption of qi and manifests as a unique collection of signs and symptoms depending on the origin of the disturbance. In an interesting analogy often used to explain its nature, qi is described as the wind in a sail; we do not see the wind directly but we are aware of its presence as it fills the sail (Ergil 1996).
Qi also maintains the balance of yin and yang, the principle of complementary opposites that determines the world around us and is reflected within each of us; together, yin and yang represent a state of dynamic equilibrium that exists among all things in the universe. Thus, an individual cannot be understood outside the context of his or her environment. As Ergil writes, "The external landscape, or human environment, is understood to be in profound and dynamic relationship with the internal landscape, or human organism" (Ergil 1996).
The third principle influencing health and illness in Oriental medicine is known as the five phases-earth, metal, water, wood, and fire-which may be thought of as metaphoric representations of the five patterns that characterize the dynamic interactions of natural phenomena (Ergil 1996); the concept again reflects the inability to separate the individual from the environment that is fundamental to the TCM philosophy and belief system.
Two additional concepts are essential to the practice of TCM: mind and body are not distinct from one another, and moderation is required to achieve balance and health (Ergil 1996).
Finally, TCM reflects an understanding of human anatomy that is different from that of conventional medicine. TCM views the internal organs not as individual structures, but as complex networks (Ergil 1996). In parallel with the five phases or elements mentioned above, there are five internal organs regulating the human body. These five organs-liver, heart, spleen, lung, and kidney-correspond to more than a specific bodily part. The kidney, for example, represents not only the kidney itself, but the entire urinary system and the adrenal glands as well. The heart represents both the heart and the brain (Cheng 2000). According to TCM, there are three major causes of disease: the external factors or environmental influences known as wind, cold, fire, dampness, heat, and dryness; the internal emotions of joy, anger, worry, sorrow, and fear (Ergil 1996; Cheng 2000); and the constitutional factors relating to diet, sexual activity, lifestyle, work, and exercise (Parker 2000).
Mechanism of Action
Through the use of its therapeutic modalities, TCM stimulates the body's own healing mechanisms to regulate the flow of qi and the function of the organ systems, bringing the body back into a state of balance (Parker 2000). The main focus in TCM is to treat the underlying cause of disease as opposed to simply managing symptoms (Ergil 1996).
The mechanistic action of acupuncture, in TCM terminology, is to access qi with the needle. The practitioner knows that qi has been accessed when a gentle grabbing of the needle is sensed in his or her hand and/or when the patient reports a feeling of itching, numbness, soreness, or change in temperature at the site of the needle (Ergil 1996).
With respect to the use of herbs, TCM practitioners formulate herbal combinations to act synergistically in the body, and therefore typically prescribe combinations of herbs rather than a single herbal remedy (Ergil 1996).
Moxibustion refers to burning the leaves of the herb Artemesia vulgaris on or near the skin; although used separately as well, it is often applied in conjunction with acupuncture to move qi appropriately. A safe and common way to apply this technique is with a cigar-shaped stick known as pole moxa held just above the skin to gently warm the acupuncture point (Ergil 1996).
Tui na literally means "pushing and pulling" and refers to a process of massage that stimulates acupuncture points. Tui na can be used either as an adjunct to or instead of acupuncture, particularly for people such as children who may have a difficult time with needle insertion. The massage technique is used for many neurological and orthopedic conditions to increase the range of motion of joints; it can also be used for medical conditions not usually thought of as treatable via massage, such as asthma, gastritis, and dysmenorrhea (Ergil 1996).
Cupping refers to a practice in which a cup with a vacuum seal is placed on the surface of the skin; the theory is that the local application of a vacuum to the skin increases lymph and blood circulation in the area under treatment. In TCM terminology, the intention is to draw out cold or damp elements from the patient that may be contributing to disease (Ergil 1996).
Clinical Evaluation
A clinical evaluation includes, in the following order: visual assessment of the patient's skin, hair, posture, affect, tongue, complexion, and eyes (Parker 2000; Ergil 1996); listening to the quality of the patient's breathing and speech; being aware of the patient's body odors; taking a medical history; diagnosing the pulse; and palpating the body along acupuncture points or meridian lines (Ergil 1996). Visualizing the overall appearance, complexion, and eyes, as well as assessing the quality of the patient's voice, enables the practitioner to observe the patient's shen (or spirit), which is critical for determining prognosis. Shen is the radiant aspect of human existence that encompasses consciousness and healthy mental and physical functioning (Ergil 1996).
Following this assessment, the TCM practitioner makes recommendations for the modalities to be used (as described in the section on Mechanism of Action) and the course of treatment; these decisions are based on "pattern identification" as determined by the TCM practitioner. Pattern identification is, again, a difficult concept to define in Western terminology; it is based on eight principles of yin and yang and, unlike the situation in Western medicine, the definition and particular diagnostic pattern does not depend solely on the disease. Rather, it depends on a complex interaction of the illness or set of signs and symptoms, the particular patient affected, and the environment at large. Therefore, one disease can have many different appropriate treatment approaches. Similarly, one treatment pattern can be appropriate for a wide variety of illnesses (Ergil 1996). These facts illustrate some of the difficulty in trying to understand TCM from the Western, biomedical perspective.
Clinical Applications
Despite the difficulty of applying contemporary research methodologies to evaluate outcomes of TCM, there have been some attempts with worthwhile results; the following paragraphs provide a few examples of traditional herbal remedies examined from the Western perspective. These examples are not meant to be an exhaustive reflection of the breadth of appropriate applications of TCM, a health system and approach that has been used for many diverse conditions for thousands of years. The intent of the following examples is to give some sense of the clinical benefits and limitations learned from studying aspects of TCM from a biomedical point of view. (Please see the Acupuncture monograph for more information on clinical applications of that modality specifically.)
In a report published in JAMA, a randomized, double-blind, placebo-controlled trial of a Chinese herbal formulation was found to offer significant improvements for some patients with Irritable Bowel Syndrome (Bensoussan et al. 1998).
Qian ceng ta, a Chinese herb used to treat age-related memory dysfunction and dementia, may show promise for possible adjunctive treatment of Alzheimer's disease. Of 103 Alzheimer's patients from seven different hospitals in Mainland China, 58% treated with huperzine A (the active ingredient of Qian ceng ta) chemically linked to tacrine (a medication commonly used for Alzheimer's) showed improvement in memory, cognition, and behavior (Carlier et al. 1999). Another small study in the elderly suggests that Cs-4, a fermentation product of Cordyceps sinesis (a popular supplement in China), increases maximum oxygen uptake and anaerobic threshold compared to placebo, thus improving exercise capacity and resistance to fatigue in this population (Xiao et al. 1999). The study, presented at the 46th annual meeting of the American College of Sports Medicine, included only 30 subjects, making it difficult to draw conclusions; however, the information is intriguing since Cordyceps sinesis has been used for similar purposes in TCM for many years.
A combination of Chinese herbs known as "Slimax" reduced weight, waist and hip circumference, and body mass index significantly in an experimental group of 140 subjects participating in a randomized, placebo-controlled clinical trial (Ignjatovic et al. 2000).
In TCM terms, diabetes and its complications are considered "wasting and thirsting" disorders; a common treatment for diabetes nourishes yin and tonifies qi (Luwen 2000). Patients with complications of diabetes, including elevated cholesterol and triglycerides, poorly controlled blood sugar, and metabolic disturbances, are frequently diagnosed by a TCM practitioner as having "stagnant phlegm." According to researchers in China, Chinese herbs used to treat phlegm stagnation, such as Wen dan tang, also tend to lower lipid levels; there have been case reports of Wen dan tang improving additional diabetic complications such as retinopathy (Luwen 2000).
Although a popular application in the lay community, the use of Chinese herbal remedies for eczema remains controversial. There is a paucity of data in the literature supporting the efficacy of oral Chinese herbs for this application (Armstrong and Ernst 1999); in addition, one study addressing the constituents of topical TCM remedies frequently used for eczema found that many of them actually contained illegal, unlabeled steroids. One concern here is that many patients taking such herbal preparations as an alternative to prescription medications are under the impression that they do not contain steroids, which may lead to excessive use, application to inappropriate sites, and unanticipated risks (Keane et al. 1999).
All TCM modalities have traditionally been used for both male and female infertility. TCM treatment of male infertility from sperm anomalies, for example, generally involves replenishing kidney yin and/or kidney yang, fortifying the spleen, and nourishing the liver (Becker 2000). TCM treatment for infertility offers a viable opportunity for TCM to interface with Western medicine, since sperm count and quality can be followed easily, as can other contributing factors to male infertility such as chronic prostatitis and hyperprolactinemia (Becker 2000).
Risks, Side Effects, Adverse Events
Side effects from Chinese herbs are more likely to occur when a single agent or active ingredient is used, rather than the customary combination of herbs that are formulated to work harmoniously together and counterbalance side effects (Parker 2000). As is the case with Western pharmaceuticals, there are interactions among herbal medicines too numerous to mention here; trained and certified TCM practitioners know which herbs can be safely and effectively administered together (Parker 2000).
Chinese herbs containing aristolochic acid, a compound present in plants of the family Aristolochiaceae, should be avoided, particularly in patients with underlying kidney disorders; the active ingredient has been identified as a carcinogen and nephrotoxin causing, by some reports, nearly 100 cases of kidney failure (Lewis and Alpert 2000) and even urothelial dysplasia and carcinoma in patients with end-stage nephropathy (Nortier et al. 2000). In addition, as mentioned above, some Chinese herbal creams used to treat skin conditions such as eczema contain unlabeled steroids (Keane et al. 1999). Although generally considered safe for autoimmune and rheumatological disorders, patients prescribed a remedy prepared from Tripterygium wilfordii Hook F (TwHF) occasionally report side effects of dry mouth, changes in skin pigmentation, rash, and loss of appetite; nausea, vomiting, diarrhea, abdominal pain, and secondary amenorrhea are even less common; leukopenia and thrombocytopenia may occur with this herbal anti-inflammatory. The use of properly prepared formulations of TwHF needs to be monitored, particularly for patients with impaired renal function. Long-term treatment may also result in reproductive tract damage (Tao and Lipsky 2000). These examples point to the fact that all herbs need to be regulated for toxicity and monitored for side effects (Keane et al. 1999).
Contraindications
Great caution and, at times, avoidance of some of the herbs mentioned in the section entitled Risks, Side Effects, Adverse Events should be exercised; otherwise, there are no specific conditions for which TCM is contraindicated in its totality. There may be, however, specific conditions for which certain Chinese herbs should not be used, such as during pregnancy and/or lactation (Parker 2000). A trained and certified TCM practitioner knows under which clinical circumstances particular herbal remedies are contraindicated.
Additional Clinical Outcomes
TCM may also be a useful adjunctive or alternative treatment for addictions, allergies, sinusitis, asthma, respiratory infections, strep throat, amenorrhea, premenstrual syndrome, childbirth, postpartum care, arthritis (including rheumatoid arthritis), chronic or acute pain, bladder infection, candidal or other vaginal infections, benign prostatic hypertrophy, prostatic cancer, prostatitis, restless leg syndrome, sleep disorders, abdominal pain, stress, and tinnitus (Parker 2000).
Although further research is needed, the Chinese herbal remedy Tripterygium wilfordii Hook F shows considerable promise for treating autoimmune and inflammatory diseases, including rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylitis, psoriasis, Behcet's disease, Henoch-Schnlein purpura, IgA nephropathy, chronic nephrotic syndrome, nephritis, chronic lymphocytic thyroiditis, dermatitis, scleroderma, polymyositis, and kidney transplant rejection (Tao and Lipsky 2000).
The Future
The Ohio University College of Osteopathic Medicine and nine Chinese medical institutions recently formed the Sino-American Consortium to study applications for TCM in Western medicine (OU-COM. 2000). In 2001, the Ohio University College of Osteopathic Medicine plans to incorporate basic TCM principles into its curriculum (OU-COM. 2000). In addition, the University of Pittsburgh recently created the International TCM Center to coordinate research efforts with several TCM institutes in China. The result will be a large-scale, systematic, international effort to develop clinical standards for TCM (UPMC 2000).
Future research studies and clinical trials on TCM are required to establish the efficacy, safety, cost-effectiveness, and mechanism of action of various TCM treatments and overcome the limitations of existing research studies (Armstrong and Ernst 1999).
Training, Certification, and Licensing Requirements
Currently, there are 35 Oriental medicine training programs in the United States. Programs range in duration from two to four years and include the study of herbs, acupuncture, and all other aspects of Oriental medicine (Parker 2000). To be certified, students must graduate from accredited institutions and pass the state board exam or the national certification commission exam. Licensure requirements vary in each state (Parker 2000).
Resources
For more information, contact the American Association of Oriental Medicine in Catasauqua, Pennsylvania at 888-500-7999 or on the web at www.aaom.org; the National Acupuncture and Oriental Medicine Alliance in Olalla, Washington at 253-851-6896 or on the web at www.acuall.org; the Institute of Traditional Medicine in Portland, Oregon at 503-233-4907 or on the web at www.itmonline.org; or the National Certification Commission for Acupuncture and Oriental Medicine in Alexandria, Virginia at 703-548-9004 or on the web at www.nccaom.org.
References
Armstrong NC, Ernst E. The treatment of eczema with Chinese herbs: a systematic review of randomized clinical trials. Br J Clin Pharmacol. 1999;48(2):262-264.
Becker SA. Treatment by Chinese medicine: semen anomalies. J Chin Med. 2000;62:46-51.
Bensoussan A, Talley NJ, Hing M, Menzies R, Guo A, Ngu M. Treatment of irritable bowel syndrome with Chinese herbal medicine. JAMA. 1998;280(18):1585-1589.
Carlier PR, Du DM, Han Y, Liu J, Pang YP. Potent, easily synthesized huperzine A-tacrine hybrid acetylcholinesterase inhibitors. Bioorg Med Chem Lett. 1999;9(16):2335-2338.
Cheng JT. Review: drug therapy in Chinese traditional medicine. J Clin Pharmacol. 2000;40(5):445-450.
Ergil KV. China's traditional medicine. In: Micozzi MS, ed. Fundamentals of Complementary and Alternative Medicine. New York, NY: Churchill Livingstone Inc.; 1996:185-223.
Ignjatovic V, Ogru E, Heffernan M, Libnaki R, Lim Y, Ng F. Studies on the use of "Slimax," a Chinese herbal mixture, in the treatment of human obesity. Pharm Biol. 2000;38(1):30-35.
Keane FM, Munn SE, du Vivier AW, Higgins EM. Analysis of Chinese herbal creams prescribed for dermatological conditions. BMJ. 1999;318(7183):563-564.
Lewis CJ, Alpert S. Letter to Health Care Professionals on FDA Concerned about Botanical Products, Including Dietary Supplements, Containing Aristolochic Acid. Washington, DC: U.S. FDA Center for Food Safety and Applied Nutrition; May 31, 2000.
Luwen G. Wen dan tang and diabetic retinal disease. J Chin Med. 2000;62:20-22.
Nortier JL, Martinez MC, Schmeiser HH, et al. Urothelial carcinoma associated with the use of a Chinese herb. N Engl J Med. 2000;342(23):1686-1692.
OU-COM. OU medical school teams with Chinese universities [press release]. Athens: Ohio University College of Osteopathic Medicine; April 29, 2000.
Parker MJ. Traditional Chinese herbal medicine. In: Novey DW, ed. Clinician's Complete Reference to Complementary and Alternative Medicine. St. Louis, Mo: Mosby; 2000:203-218.
Tao X, Lipsky PE. The Chinese anti-inflammatory and immunosuppressive herbal remedy Tripterygium wilfordii Hook F. Rheum Dis Clin North Am. 2000;26(1):29-50.
UPMC. Chinese government officials visit UPMC health system to establish ties with International Traditional Chinese Medicine Center [press release]. Pittsburgh: University of Pittsburgh Medical Center Health System; January 20, 2000.
Xiao Y, Huang XZ, Chen G, Wang MB, Zhu JS, Cooper CB. Increased aerobic capacity in healthy elderly humans given a fermentation product of Cordyceps Cs-4. Paper presented at: Annual Meeting of the American College of Sports Medicine; June 2-5, 1999; Seattle, Wash.

Integrative Medicine Communications, Access 2.0; 2000.

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