On pages 101–102 of issue 12, 2009, of Xin Zhong Yi (New Chinese Medicine), Zhou Yi-chen and Wang Bi published an article titled “Treating Fibromyalgia Syndrome Via the Liver.” A summary of this article is presented below.

Introduction

The main symptom of fibromyalgia syndrome is generalized body pain.

Most sufferers of FMS are female. In addition to specific sites of pressure pain, other accompanying symptoms include insomnia, vexation and agitation, fatigue, lassitude of the spirit, low-grade fever, and menstrual irregularities. Based on the experience of the Chinese authors of this article, they believe that this condition should mainly be treated via the liver. This is also my own clinical experience. I have never been able to substantiate the presence of externally contracted evils in the case of FMS.

Disease Causes and Mechanisms
According to some Chinese doctors, this condition is due to external contraction of wind, cold, dampness, and/or heat evils which lodge in the body. These evils block and obstruct the channels and network vessels. Hence the flow of the qi and blood is not smooth. According to this point of view, it is mainly this that leads to soreness and pain in the muscles and flesh, sinews and bones, and joints as well as heaviness, numbness, inability to flex and extend, and, if severe, joint swelling and burning heat. Such doctors categorize this condition as the sinew impediment subtype of impediment condition. However, the authors’ experience is that treatment for FMS based on impediment condition either gets no or only slight effect. In fact, after finely searching, they have not found evidence of the lodging of external evils in the body. Instead, most patients with this condition also present with frustration, chest oppression, and depression. Even during its initial stage, they commonly see rib-side discomfort, vexation and agitation, insomnia, and bodily fatigue. Only gradually later does generalized muscle pain develop and get worse. Further, due to the enduring nature of this suffering and failure to heal, the psyche becomes tense and the disease condition gets worse. Therefore, Drs. Zhou and Wang believe that FMS should be categorized as depression condition in Chinese medicine, not impediment condition.

If depression and anger are left unsoothed, the liver loses its spreading and extending and the qi loses its coursing and discharge.

Thus the liver becomes depressed and the qi becomes bound. The qi is the commander of the blood. If there is qi stagnation, this leads to blood stasis not moving, and blood stasis leads to lack of free flow, lack of construction, and ultimately to pain. If qi depression transforms fire, fire;s nature is to flame upward. This then can give rise to vexation and agitation and easy anger. If anxiety and depression are not resolved, heart yin may be consumed and damaged. In that case, heart yin is unable to provide supplies for and nourish the heart spirit. The heart spirit loses its calm and there is insomnia. If liver yin becomes insufficient, yin vacuity may engender heat. If vacuity heat harasses the spirit, then there may be heart palpitations and dizziness. Further, because “the liver is the root of resistance to fatigue,” enduring depression damaging the liver can also give rise to fatigue and lack of strength. If depression damages the heart spirit and the constructive and blood are exhausted and consumed, visceral yin becomes insufficient and vacuity yang may ascend. This may give rise to afternoon low-grade fever. If the liver and kidneys lose their nourishment, the chong and ren become dysregulated, and this may give rise to menstrual irregularity.

Treatment Based on Pattern Discrimination
Based on the foregoing, Drs. Zhou and Wang believe that FMS should be treated by coursing the liver and resolving depression, moving the qi and quickening the blood, freeing the flow of the network vessels and stabilizing pain. For this, they use Chai Hu Shu Gan San (Bupleurum Course the Liver Powder) plus Xue Fu Zhu Yu Tang (Blood Mansion Dispel Stasis Decoction) with additions and subtractions:

Dang Gui (Radix Angelicae Sinensis)
Sheng Di Huang (uncooked Radix Rehmanniae)
Tao Ren (Semen Persicae)
Hong Hua (Flos Carthami)
Mu Dan Pi (Cortex Moutan)
Chuan Xiong (Rhizoma Chuanxiong)
Chai Hu (Radix Bupleuri)
Xiang Fu (Rhizoma Cyperi)
Bai Shao (Radix Alba Paeoniae)
Zhi Qiao (Fructus Aurantii)
Yan Hu Suo (Rhizoma Corydalis)
Dan Shen (Radix Salviae Miltiorrhizae)
Ge Gen (Radix Puerariae)
Gan Cao (Radix Glycyrrhizae)

Within this formula, Dang Gui, Dan Shen, and Sheng Di Huang nourish the blood and emolliate the liver. Tao Ren, Hong Hua, Chuan Xiong, Yan Hu Suo, and Mu Dan Pi quicken and harmonize the blood. Xiang Fu, Chai Hu, and Zhi Qiao course the liver and rectify the qi. Ge Gen, Bai Shao, and Gan Cao relax cramping and stop pain. Using the combination of Chai Hu and Bai Shao, one medicinal scatters while the other restrains. Hence one is able to course the liver and resolve depression at the same time as harmonizing the constructive and restraining or constraining yin. The combination of Bai Shao and Gan Cao makes up the famous formula Shao Yao Gan Cao Tang (Peony and Licorice Decoction), which relaxes cramping and stops pain. When Xiang Fu and Chuan Xiong are used together, they are capable of pushing the depressed qi of the liver-gallbladder, which then obtain stirring (or movement).

If fatigue is severe, they add Huang Qi (Radix Astragali).

If there is insomnia and vexation and agitation, they add Suan Zao Ren (Semen Zizyphi Spinosae), Lian Zi Xin (Plumula Nelumbinis), and Shi Chang Pu (Rhizoma Acori Tatarinowii).

If there is chest oppression, they add Gua Lou (Fructus Trichosanthis) and Yu Jin (Tuber Curcumae).

If pain in the four limbs is severe, they add Jiang Huang (Rhizoma Curcumae Longae), Niu Xi (Radix Achyranthis Bidentatae), and Sang Zhi (Ramulus Mori).

If appetite is poor, they add scorched Bai Zhu (Rhizoma Atractylodis Macrocephalae), Fu Ling (Poria), and scorched Shan Zha (Fructus Crataegi).

If dampness is severe with thick, slimy tongue fur, they add Yi Yi Ren (Semen Coicis), Hou Po (Cortex Magnoliae Officinalis), Bai Bian Dou (Semen Dolichoris), and Can Sha (Excrementum Bombycis).

If the stools are dry and bound, they add Da Huang (Radix Et Rhizoma Rhei).

Also, depending on the symptoms, they may add Qin Jiao (Radix Gentianae Macrophyllae), Qiang Huo (Radix Et Rhizoma Notopterygii), Du Huo (Radix Angelicae Pubescentis), Ren Dong Teng (Caulis Lonicerae), Luo Shi Teng (Caulis Trachelospermi), and/or Shen Jin Cao (Herba Lycopodii) to soothe the sinews and free the flow of the network vessels. (Note: although Qiang Huo and Du Huo are wind-treating medicinals, Drs. Zhou and Wang use them in FMS based on the principles of soothing the sinews and freeing the flow of the network vessels, not resolving the exterior and coursing wind.)

In a representative case history, Drs. Zhou and Wang report that the patient was cured in three months of treatment with variations of the above protocol using one packet of medicinals per day.

Copyright © Blue Poppy Press, 2009. All rights reserved.

Uptown Acupuncture San Diego can make this formula for you, modify it to your personal presentations and provide acupucture to enhance it’s effects.

Acupuncture and Stress

• This is a special chapter which could need a whole lesson.

• Briefly: it’s impossible to have an emotion without a reflex response of muscles and the Autonomous nervous system.

• In the opposite direction, you can not act on muscles or the autonomous nervous system without having an emotional modification.

The cholinergic anti-inflammatory system:

• Reflex loop mediated by the vagus nerve.

• Inflammation releases cytokines; cytokines activate vagus nerve afferents, and the vagus nerve will respond by the

release of acetylcholine ,which will act on the nicotinic receptors of the inflammatory cells, inhibiting the release

of cytokines.

• The response can be global or local.

• Acupuncture has a cholinergic effect.

Activation of the cholinergic anti-inflammatory system.

Aspirin and ibuprofen found to substantially increases vagus nerve activity.

Acupuncture, meditation, hypnosis, and relaxation therapies can stimulate vagus nerve.

Exercise raises vagus nerve activity and decreases cytokine levels.

Fish oil, soy oil, olive oil increases vagus nerve activity through cholecystokinin. ^[2]

Kevin J. Tracey (b. 10 December 1957, Fort Wayne, IN, USA) is Director of The Feinstein Institute for Medical Research and Professor and President of the Elmezzi Graduate School of Molecular Medicine in Manhasset, NY. Although trained as a neurosurgeon, he is an immunologist known for his physiological and molecular studies of inflammation and disease and, in particular, for investigating how the nervous system controls the responses of the immune system to threat.

G. Baden / Zefa / Corbis

Parents who suspect that artificial ingredients in food are affecting their children’s behavior can now point to some cold, hard proof.

A carefully designed study released Thursday in The Lancet, a leading British medical journal, shows that a variety of common food dyes and the preservative sodium benzoate — an ingredient in many soft drinks, fruit juices, salad dressings and other foods — causes some children to become more hyperactive and distractible than usual.

“In terms of a question that’s been raging for years, it’s the best study to date — an extremely good study,” says Dr. Philip Shaw, a research psychiatrist in the Child Psychiatry branch of the National Institute of Mental Health. 

The study prompted Britain’s Food Standards Agency to issue an immediate advisory to parents to limit their children’s intake of additives if they notice an effect on behavior. In the U.S., there’s been no such official response, but doctors say it makes sense for parents to be on the alert.

Meanwhile, the food industry is awaiting further research. “We take our responsibility to consumers seriously and will study the research finding in great detail,” says Cathy Cook, spokesperson for the International Association of Color Manufacturers.

The research, led by Jim Stevenson, a professor of psychology at England’s University of Southampton, involved about 300 children in two age groups: 3-year-olds and 8- and 9-year-olds. Over three one-week periods, the children were randomly assigned to consume one of three fruit drinks daily: one contained the amount of dye and sodium benzoate typically found in a British child’s diet, a second drink had a lower concentration of the additives, and a third was additive-free. All the children spent a week drinking each of the three mixtures, which looked and tasted alike. During each weeklong period, teachers and parents, who did not know which drink the kids were getting, used a variety of standardized behavior-evaluation tools — some observational and one computer-based — to size up such qualities as restlessness, lack of concentration, fidgeting, and talking or interrupting too much. 

Stevenson found that children in both age groups were significantly more hyperactive when drinking the stuff containing additives.

Three-year-olds had a bigger response than the older kids to the lower dose of additives — roughly the same amount of food coloring as in two 2-oz. bags of candy. And, there were big individual differences in sensitivity. While the effects were not nearly so great as to cause full-blown ADHD, Stevenson nonetheless warns that “these adverse effects could affect the child’s ability to benefit from the experience of school.”

He notes that a separate pilot study found that kids can become more hyperactive within one hour of consuming food additives.

The Lancet study is the first to nail down a link between artificial ingredients and hyperactivity, though the connection has long been suspected and was the basis for the Feingold Diet, which eliminates all artificial colors, flavors, sweeteners and preservatives and was popularized in the 1970s as a treatment for ADHD. Though such a diet alone is not a proven treatment for ADHD, some clinicians routinely advise parents of kids with ADHD to stick with a more natural diet.” I’m not maniacal about it, but I tell parents that your kid will do better if they are on a diet that is free of additives and junk food,” says psychiatrist Edward Hallowell, author a several books on ADHD. “I urge them to eat whole foods; they’ll be healthier anyway.”

Now that a link has been found, researchers will be looking to confirm the British study and build upon it. “My guess is that if we do similarly systematic work with other additives, we’d learn they, too, have implications for behavior,” says Dr. James Perrin, professor of pediatrics at Harvard. “My friends who study the food industry say we have about 70,000 new products a year, so children are facing tremendous numbers of new opportunities for things that may not be good for them.” The study, he says, is one more reason to cheer the movement toward organic and natural foods.

Can Sugar Substitutes Make You Fat?

By Alice Park Sunday, Feb. 10, 2008

When it comes to dieting, most of us are willing to resort to a trick or two to help us curb our appetite and eat less

— drinking water to fill up when we’re hungry, for example, or opting for artificial sweeteners instead of sugar to get the same satisfying sweetness without the offending calories.

But new research suggests that the body is not so easily fooled, and that sugar substitutes are no key to weight loss —

perhaps helping to explain why, despite a plethora of low-calorie food and drink, Americans are heavier than ever.

In a series of experiments, scientists at Purdue University compared weight gain and eating habits in rats whose diets were supplemented with sweetened food containing either zero-calorie saccharin or sugar. The report, published in Behavioral Neuroscience, presents some counterintuitive findings: Animals fed with artificially sweetened yogurt over a two-week period consumed more calories and gained more weight — mostly in the form of fat — than animals eating yogurt flavored with glucose, a natural, high-calorie sweetener. It’s a continuation of work the Purdue group began in 2004, when they reported that animals consuming saccharin-sweetened liquids and snacks tended to eat more than animals fed high-calorie, sweetened foods. The new study, say the scientists, offers stronger evidence that how we eat may depend on automatic, conditioned responses to food that are beyond our control. (See a special report on the science of appetite.)

What they mean is that like Pavlov’s dog, trained to salivate at the sound of a bell, animals are similarly trained to anticipate lots of calories when they taste something sweet — in nature, sweet foods are usually loaded with calories. When an animal eats a saccharin-flavored food with no calories, however — disrupting the sweetness and calorie link — the animal tends to eat more and gain more weight, the new study shows. The study was even able to document at the physiological level that animals given artificial sweeteners responded differently to their food than those eating high-calorie sweetened foods. The sugar-fed rats, for example, showed the expected uptick in core body temperature at mealtime, corresponding to their anticipation of a bolus of calories that they would need to start burning off — a sort of metabolic revving of the energy engines. The saccharin-fed animals, on the other hand, showed no such rise in temperature. “The animals that had the artificial sweetener appear to have a different anticipatory response,” says Susan Swithers, a professor of psychological sciences at Purdue University and a co-author of the study. “They don’t anticipate as many calories arriving.” The net result is a more sluggish metabolism that stores, rather than burns, incoming excess calories.

Swithers stops short of saying that the animals in her study were compelled to overeat to compensate for phantom calories. But she says that the study does suggest artificial sweeteners somehow disrupt the body’s ability to regulate incoming calories. “It’s still a bit of a mystery why they are overeating, but we definitely have evidence that the animals getting artificially sweetened yogurt end up eating more calories than the ones getting calorically sweetened yogurt.” 

Though it’s premature to generalize based on animal results that the same phenomena would hold true in people, Swithers says, she notes that other human studies have already shown a similar effect. A University of Texas Health Science Center survey in 2005 found that people who drink diet soft drinks may actually gain weight; in that study, for every can of diet soda people consumed each day, there was a 41% increased risk of being overweight. So even though her findings were in animals, says Swithers, they could lead to a better understanding of how the human body responds to food, and explain why eating low-calorie foods doesn’t always lead to weight loss. “There is lots of evidence that we learn about the consequences about eating food,” she says. “And we have physiological responses to food that are conditioned.”

So does that mean you should ditch the artificial sweeteners and welcome sugar back into your life?

Not exactly. Excess sugar in the diet can lead to diabetes and heart disease, even independent of its effect on weight. But it’s worth remembering that when it comes to counting calories, it’s not just the ones you eat that you have to worry about. The calories you give up matter too, and they may very well reappear in that extra helping of pasta or dessert that your body demands. Your body may actually be keeping better count than you are.

The Neuroimmune Basis of Anti-inflammatory Acupuncture

Ben Kavoussi, MS

Southern California University of Health Sciences, College of Acupuncture and Oriental Medicine, Whittier, CA, kavoussi@ucla.edu

B. Evan Ross, DOM, LAc

Cedars-Sinai Medical Center, Department of Medicine, Los Angeles, CA

This review article presents the evidence that the anti-inflammatory actions of acupuncture are mediated via the reflexive central inhibition of the innate immune system.

Both laboratory and clinical evidence have recently shown the existence of a negative feedback loop between the autonomic nervous system and the innate immunity.

There is also experimental evidence that the electrical stimulation of the vagus nerve inhibits macrophage activation and the production of TNF, IL-1ß , IL-6, IL-18, and other proinflammatory cytokines.

It is therefore conceivable that along with hypnosis, meditation, prayer, guided imagery, biofeedback, and the placebo effect, the systemic anti-inflammatory actions of traditional and electro-acupuncture are directly or indirectly mediated by the efferent vagus nerve activation and inflammatory macrophage deactivation.

In view of this common physiological mediation, assessing the clinical efficacy of a specific acupuncture regimen using conventional double-blind placebo-controlled trials inherently lacks objectivity due to (1) the uncertainty of ancient rules for needle placement, (2) the diffuse noxious inhibitory control triggered by control-needling at irrelevant points, (3) the possibility of a dose-response relationship between stimulation and effects, and (4) the possibility of inadequate blinding using an inert sham procedure. A more objective assessment of its efficacy could perhaps consist of measuring its effects on the surrogate markers of autonomic tone and inflammation.

The use of acupuncture as an adjunct therapy to conventional medical treatment for a number of chronic inflammatory and autoimmune diseases seems plausible and should be validated by confirming its cholinergicity.

Sick but at work? Study finds it’s worse in the long-run

Thu Jun 11, 1:03 am ET

SYDNEY (Reuters Life!) – Sick but still going to work?

You’ll probably end up taking more sick days in the future than colleagues who stay at home when unwell,

according to a Swedish study.

Researchers at the Karolinska Institutet of Stockholm found that employees who often go to work feeling sick — termed “sickness presenteeism” – have higher rates of future work absences due to illness.

Gunnar Bergstrom, who led the study, said these findings suggest that measures attempting to decrease work absences could inadvertently have the opposite effect and show that taking sick-leave when appropriate benefited the workplace.

“Discouraging workers from staying home when they are sick could lead to increased sickness presenteeism, and thus inadvertently increase sick leave,” Bergstrom said in a statement.

“This underscores the importance of sickness presenteeism in the evaluations of such interventions and considering the effects from a long-term perspective.”

The study, published in the June issue of the Journal of Occupational and Environmental Medicine, was based on research involving two groups of workers — about 3,750 public sector employees who were mainly female, and 2,500 private-sector employees who were mainly male. In the first year of the study, 19 percent of public sector workers and 13 percent of private sector workers had more than five “sickness presenteeism” days.

For these workers, the risk of having more than 30 days of sickness absenteeism the following year was 40 to 50 percent higher that for employees who had less days sick in the office, after adjustment for other factors.

Bergstrom said recent studies have shown that sickness presenteeism is common, with most employees saying they go to work sick at least sometimes.

Poor health is one likely risk factor for sickness presenteeism, but other job-related and personal factors could also play a role, according to the researchers.

(Writing by Belinda Goldsmith, Editing by Miral Fahmy)

Psychological Stress Impairs Early Wound Repair Following Surgery

Elizabeth Broadbent, MSc, Keith J. Petrie, PhD, Patrick G. Alley, MBChB, FRACS and Roger J. Booth, PhD

From the Departments of Health Psychology (E.B., K.J.P.) and Molecular Medicine and Pathology (R.J.B.), Faculty of Medical and Health Sciences, University of Auckland; and the Department of Surgery (P.G.A.), Waitemata Health, Auckland, New Zealand.

OBJECTIVE: Laboratory studies have demonstrated that psychological stress is associated with slower healing of small superficial wounds. The application of this finding to the clinical environment has not yet been undertaken. In order to do this, we investigated the relationship between psychological stress and wound repair in patients following routine surgery.

METHODS: Forty-seven adults with an inguinal hernia were given a standardized questionnaire assessing psychological stress and worry about the operation before undergoing open incision repair. Wound fluid was collected from 36 participants over the first 20-hour postoperative period. Wound healing was assessed by levels of interleukin-1, interleukin-6, and matrix metalloproteinase-9 in the fluid. Other outcome measures included patient self-reports of recovery, as well as cytokine response to lipopolysaccharide stimulation of peripheral blood.

RESULTS: Greater preoperative perceived stress significantly predicted lower levels of interleukin-1 in the wound fluid (ß = -0.44, p = 0.03). Greater worry about the operation predicted lower levels of matrix metalloproteinase-9 in the wound fluid (ß = -0.38, p = 0.03) as well as a more painful (ß = 0.51, p = 0.002), poorer (ß = -0.36, p = 0.04), and slower recovery (ß = 0.43, p = 0.01).

CONCLUSIONS: Psychological stress impairs the inflammatory response and matrix degradation processes in the wound immediately following surgery. This finding generalizes previous laboratory research to surgical patients and expands the known influence of stress to connective tissue matrix remodelling processes. These results suggest that in clinical practice, interventions to reduce the patient’s psychological stress level may improve wound repair and recovery following surgery.

Key Words: stress, • surgery, • wound healing, • interleukin-1, • smoking, • metalloproteinases.

Abbreviations: ELISA = enzyme linked immunosorbent assay;; IL-1 = interleukin-1;; IL-6 = interleukin-6;; LPS = lipopolysaccharide;; MMP-9 = matrix metalloproteinase-9.

Previous laboratory work with both animal and human subjects has shown that stress decreases the speed of wound healing.

Stressed mice produce higher levels of glucocorticoids and display less inflammation in the first 3 days after wounding, impaired bacterial clearance, and slower healing than their nonstressed counterparts (1, 2). Laboratory studies have also shown that psychological stress impairs the healing of small puncture wounds in humans. Women caring for relatives with Alzheimer’s disease reported greater stress and demonstrated 24% slower healing of dermal punch biopsy wounds than did matched control subjects (3). Similarly, punch biopsy wounds in the hard palates of students healed on average 40% more slowly during an examination period than in the same students during vacation time (4). Both of these studies found that higher stress was associated with a poorer IL-1 response to LPS-stimulated peripheral blood. This is consistent with the hypothesis that stress impairs wound healing via immune processes.

Wound repair involves a number of progressing stages.

In the initial stages the pro-inflammatory cytokines, including IL-1 and IL-6, attract phagocytes to the wound which remove infectious agents and prepare the site for the growth of new tissue (5). The cytokines also regulate the production and activation of matrix metalloproteinase enzymes, which are involved in the degradation of collagen. MMP-9 facilitates cellular invasion and migration in the wound by degrading basement membranes (6). This is necessary to allow the recruitment of cells involved in tissue regeneration. Measuring cytokine and metalloproteinase concentrations in the wound provides an effective way to monitor repair processes. Previous research has found that women who report higher psychological stress have lower levels of IL-1 and IL-8 in laboratory-induced blister wounds than do other women (7), suggesting that stress impairs the inflammatory stage of wound repair.

Wound healing is a critical outcome in surgery. Poor healing can result in wound infections or complications, as well as prolong hospital stays, increase patient discomfort, and delay return to activity. While previous research has established the deleterious effects of stress in laboratory settings, there has previously been no work examining the effect of stress on wound healing in clinical settings. The aim of this study was to investigate the effects of stress on wound repair in patients following surgery. Based on previous research, we hypothesized that higher levels of stress would be associated with reduced inflammatory and matrix degradation processes in the early stages of repair.

Participants
Participants were inguinal hernia patients booked for elective open surgery at North Shore Hospital, Auckland, New Zealand. Excluded from the study were those whose hernia was bilateral or recurrent because larger operations and those performed on previous operation sites could adversely affect healing. Also excluded were those who were on any form of medication that affected their immune status and patients who had any illnesses known to influence immune function or impair cognitive ability. Consecutive sampling of patients older than 16 years referred to the preoperative clinic was used. Fifty-five patients who met the inclusion and exclusion criteria were invited to participate in the study. Four patients declined to take part in the research (93% participation rate). Refusers did not differ from participants on any demographic variables. Four patients who were enrolled in the study had their operation postponed beyond the completion date of the study. The participants receiving surgery comprised 41 males and 6 females, aged between 16 and 86 years (mean = 63.36 years, SD = 16.42 years). They were predominantly European and two were from other racial groups. Twelve of the participants were smokers.

Of the 47 patients who received surgery, wound fluid data were not available from eight participants because wound drains were inadvertently not inserted by the surgeon. Three patients’ wound fluids were excluded from the analysis: two due to blockage in wound drains and one due to a myocardial infarction while recovering in hospital, which has been shown to affect cytokine levels (8). These patients did not differ from other participants on any variables. The final sample size used in wound fluid analyses was therefore 36. Forty-two participants attended their scheduled follow-up visit and returned their postoperative questionnaires (89%).

The study was granted ethics approval by the Ministry of Health Ethics Committee. Recruitment began in mid-April and continued until mid-October 2001.

Procedures
Patients with inguinal hernia were admitted through the surgical unit by a standard protocol of preadmission and anesthetic assessment. At the preadmission clinic 1 week before surgery, participants completed a preoperative questionnaire and gave a blood sample. The surgical procedure followed a standard protocol in which the groin was exposed through a skin crease incision measuring approximately 6 cm. The external oblique muscle was divided, and the ilioinguinal and iliohypogastric nerves were preserved. The hernial sac was excised and a nontension mesh repair using prolene mesh was carried out. The mesh was sutured to the conjoint tendon and the deep aspect of the inguinal ligament with prolene. The muscles were repaired with nonabsorbable suture and the skin closed with subcuticular absorbable suture. Before closure, a manovac drain (Medinorm, French gauge 6, 40 ml) was inserted above the outer muscle layer to drain the wound. No significant local or general complications occurred in study participants. Pain was controlled by a standard range of narcotic and nonnarcotic analgesics. In the first 6 hours intravenous morphine by patient-controlled pump (dosage range 1–3 mg/ml) was used. Thereafter until discharge, nonsteroidal anti-inflammatory agents and paracetamol were used. Thirty-seven of the operations were performed under general anesthetic and 10 were performed using spinal anesthetic.

Patients stayed overnight in the ward where the drains were removed 20 hours following surgery. Patients attended an outpatient clinic 1 week after surgery. At this clinic, the research surgeon took a blood sample and gave the participants a postoperative questionnaire to return by mail.

Preoperative Questionnaire
The 10-item Perceived Stress Scale (9) was used to assess the degree to which participants found their daily lives over the past 4 weeks to be unpredictable, uncontrollable, and overloading. Subjects rated their responses from “never” (0) to “very often” (4). Cronbach’s alpha for the scale was 0.87 (mean = 13.14, SD = 6.66).

Respondents rated how worried they were currently feeling about their operation on a 100-mm visual analogue scale ranging from “not at all worried” (0) to “extremely worried” (100), (mean = 28.45, SD = 28.24).

The Mental Health Index (10) was used as an indicator of negative affect. Five items asked how frequently participants experienced depression, anxiety, behavioral/emotional control, and positive mood states over the past month on a six-point Likert scale from “none of the time” to “all of the time.” Higher scores indicate lower levels of negative affect. Cronbach’s alpha for the scale was 0.86 (mean = 74.65, SD = 21.29).

Data were also collected on whether participants smoked, their alcohol consumption in the past 3 months, the amount of strenuous exercise they did in an average week, and the amount of sleep they obtained in the past week because these variables all have the potential to influence immune parameters (11). Age, gender, and ethnicity were recorded from medical records.

Postoperative Questionnaire
Outcome variables included two 100-mm visual analogue scales for pain experienced since the operation (ranging from “no pain” to “extreme pain”) and self-assessed surgical recovery (ranging from “poor” to “excellent”). Patients were also asked to estimate how many days it would take them from that day forward to feel like they were back to normal.

Peripheral Blood Analysis
Blood samples were collected in 4-ml heparinized tubes. The blood was divided into ten 250-µl aliquots and each was added to a 20-µl aliquot of 13.5 mg/l LPS in a 96-well microtiter tray (Nunclon brand, cat. no. 163320, batch no. 057743) and incubated for 24 hours at 37°C (3% CO₂ and 96% humidity). Culture supernatants were collected, pooled, and frozen at -20°C until the end of data collection when they were analyzed for their IL-1ß and IL-6 content using a standard sandwich ELISA technique using monoclonal capture antibodies and polyclonal detection antibodies (R&D Systems, Minneapolis, MN).

Wound Fluid Analysis
Wound drain fluid was transferred to 10-ml plastic tubes, centrifuged at 2000 rpm for 5 minutes, and the plasma recovered and stored frozen at -20°C. When all the samples had been collected, they were assayed for MMP-9 using an ELISA system (Amersham Pharmacia Biotech UK Ltd, code RPN 2614, batch no. 185867) and for their IL-1ß and IL-6 content using a standard sandwich ELISA technique.

Statistical Analysis
The data were analyzed using SPSS version 10 software. Means and reliabilities of scales were calculated and data checked for normal distributions. The relationships between variables were investigated using Pearson correlation coefficients, and scatter plots were run to check for linearity of relationships. Hierarchical multiple linear regression analyses were run to assess how stress and worry affected wound repair and self-rated surgical outcomes, after first controlling for possible confounding factors.

Within the distributions of the cytokine data, five cases were identified as outliers. Each outlier was on a different cytokine variable, and each was a different participant. Thus cytokine data were log-transformed to create normal distributions (12).

Hierarchical multiple regression analyses were conducted to predict the immune markers of wound repair from perceived stress and worry about surgery after controlling for age, gender, exercise, alcohol intake, sleep, smoking, and type of anesthetic . These control variables did not significantly predict any variance in IL-1 concentration in the wound fluid. Perceived stress significantly accounted for 17% of the variance in IL-1 in the wound fluid over and above the control variables. Higher stress predicted lower IL-1 in the wound fluid as shown in figure 1.

The concentration of MMP-9 in the wound fluid increased in a linear relationship with IL-6 (r = 0.59, p < 0.01), indicating that matrix remodelling was linked to inflammatory processes. The hierarchical multiple regression analysis showed that after entering the control variables and perceived stress, worry about surgery significantly predicted 12% of the variance in MMP-9 concentration over and above the previous steps. As shown in Table 2, nonsmoking patients and those with greater worry about surgery had a significantly lower concentration of MMP-9 in their wound fluid.

A hierarchical regression analysis to predict IL-6 in the wound fluid from control variables, perceived stress, and worry about surgery was not significant (all p values >0.05). Similar regression analyses conducted to predict the concentrations of IL-1 and IL-6 in LPS-stimulated blood samples were also not significant (all p values >0.05).

Three hierarchical multiple regression analyses were run to predict self-rated postsurgical pain, recovery, and time to return to normal from perceived stress and worry about surgery, after controlling for age, gender, type of anesthetic, and negative affect. The regression analyses showed that none of the control variables nor perceived stress were significantly related to self-report outcomes. However, worry about surgery significantly predicted 23% of the variance in postsurgical pain [R² change = 0.23, F change (1,33) = 11.97, p = 0.002], 12% of the variance in quality of recovery [R² change = 0.12, F change (1,33) = 4.60, p = 0.04], and 16% of the variance in recovery time [R² change = 0.16, F change (1,33) = 7.00, p = 0.01], over and above the control variables. Greater worry predicted greater pain (ß = 0.51, p = 0.002), poorer self-rated recovery (ß = -0.36, p = 0.04), and longer recovery time (ß = 0.43, p = 0.01). The correlations between the physiological outcome variables and the self-reported outcome variables were not statistically significant.

This study found that higher reported psychological stress before surgery predicted lower cellular wound repair processes in the early postoperative period. Patients who reported greater perceived stress for the month before surgery had lower levels of IL-1 in their surgical wounds. Furthermore, patients reporting greater worry about their upcoming surgery had lower levels of MMP-9 in the wound site. These findings are consistent with earlier laboratory research that has shown stress to impair inflammatory processes in the wound (7) and extend the influence of stress to the matrix degradation stage of wound repair.

Consistent with earlier research (6), this study found a positive correlation between MMP-9 and IL-6 in the wound fluid. This link with the inflammatory response provides theoretical support for the association between worry about the operation and lower MMP-9 levels. Stress-induced glucocorticoid secretion may nonspecifically impair the inflammatory response, which in turn may impair MMP-9 production, although this argument is weakened by the lack of relationship between IL-1 and IL-6, and between IL-1 and MMP-9. It is also possible that glucocorticoids may directly influence the production of MMP-9, although there is currently little literature on this proposed relationship. Some evidence suggests that norepinephrine and cortisol can modulate levels of another metalloproteinase involved in wound healing, MMP-2 (13). There may be different effects on immune function from acute worry (about the operation) and more longer-term stress.

The finding that worry was associated with lower levels of MMP-9 is further evidence for the ability of psychological processes to impair wound healing because MMP-9 is an enzyme critical to tissue reconstruction. However, the implications of this finding may extend to tissue remodelling in other processes not associated with wound healing, such as airway remodelling (14). The impact of worry on MMP-9 may therefore affect medical conditions outside of surgical wound healing.

The finding that MMP-9 concentration was higher among smokers is also consistent with earlier work. Airway macrophages in smokers have been found to produce more MMP-9 at baseline and in response to IL-1ß and LPS than those of nonsmokers (14). Smoking may be associated with higher baseline levels of MMP-9 in a number of body tissues and therefore prolonged high levels of MMP-9 in the wound. Prolonged elevation of MMP-9 levels has been associated with chronic nonhealing of wounds (15, 16). Slower wound repair has been well recognized in smokers on a clinical level for many years, and studies have found that smokers have an increased incidence of skin sloughing after face-lift surgery, a higher rate of skin-flap and breast surgery complications, and worse scarring after surgery than nonsmokers (17). The mechanisms remain largely unknown, but nicotine is known to increase catecholamine release, which causes vasoconstriction and reduces oxygen flow to the wound, and to reduce fibroblast and macrophage production. Recent work in this area has found smokers to have significantly higher levels of MMP-8 and lower collagen synthesis in blister wounds than nonsmokers (18).

It is important to recognize that levels of cytokines from LPS-stimulated blood cultures may not necessarily reflect what is happening at a local wound site. This is borne out by the stronger relationship of stress to wound fluid markers than with blood-derived measures. However, the small sample size may have limited the ability of the study to detect significant effects in blood-derived measures. In previous work, higher preoperative stress has been associated with a lower lymphocyte response and lower lymphocyte counts in the blood following surgery (19).

In addition to lower wound remodelling processes, presurgical worry was also associated with greater postoperative pain, poorer self-rating of recovery, and a longer recovery time. The finding that worry about the procedure predicted these self-reported recovery outcomes while general stress and negative affect did not do so suggests that it is not stress per se that causes people to experience greater pain and distress after surgery but more specifically it is concern about the operation. This may be related to previous work that suggests a mediating role for self-focused attention in symptom reporting (20). Patients who are more worried may pay more attention to their wounds and notice signs of pain and discomfort more than their less worried counterparts.

A limitation of this study is that participants’ use of pain medication was not recorded and controlled for in the analyses. It is possible that the more stressed individuals used more pain medication, which could have influenced immune responses. However, we consider this unlikely as reported postsurgical pain was not significantly related to either perceived stress or to any of the immune variables.

This study extends earlier laboratory wound healing research to an everyday clinical surgical setting. By examining IL-1, IL-6, and MMP-9 (an enzyme not previously studied in stress research), the data provide further support for the influence of stress on wound healing at the cellular wound repair level. This current study suggests that interventions designed to reduce presurgical stress, which have previously been found to shorten length of hospital stay, and to reduce postoperative complications, pain, and distress (21), may also improve wound repair.

Received for publication September 30, 2002.

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Prenatal Stress and Outlook Affects Birth Outcomes in High-Risk Pregnancies

Lobel M, DeVincent CJ, Kaminer A, Meyer BA. The impact of prenatal maternal stress and optimistic disposition on birth outcomes in medically high-risk women. Health Psychology. 2000;19:544-553.

Evidence suggests that prenatal maternal stress adversely affects birth outcomes. Nurse researchers followed 129 high-risk pregnant women, aged 20-43 years, to study the effect of chronic stress and life disposition on the rate of premature delivery. Participants completed a series of questionnaires at 3 points during their pregnancy to assess perceived stress, anxiety level, pregnancy-specific distress, prenatal life events, health behaviors, and disposition. Medical risk factors and birth outcomes were derived from patient chart data. The results showed that women with a pessimistic disposition experienced more stress during their pregnancy and delivered infants of lower birth weight. While stress level alone did not seem to affect the outcomes, it may contribute to a pessimistic outlook. Optimism, on the opposite end of the outlook scale, involves positive thinking and planning. Optimistic women reported more regular exercise and other health behaviors linked to more positive birth outcomes. The researchers conclude that disposition may affect maternal and fetal health as much as ethnicity or medical risk.

Acupuncture can help relieve stress and improve mental outlook!

Acupuncture for nausea in early pregnancy: a discussion and case.(Medical condition overview)

Abstract

Nausea and vomiting is very common in pregnancy. A patient presented with nausea at the 10th week of gestation and was treated with acupuncture, reporting a total elimination of her symptoms within five minutes. This article investigates the aetiology, physiology and pathology of morning sickness and is illustrated via a case study from the author’s own practice.

Keywords: Nausea, vomiting, pregnancy, acupuncture, case study, morning sickness.

Introduction

Nausea and vomiting in pregnancy (commonly known as morning sickness) is estimated to be experienced by 75-80% of pregnant women (Jewell et al, 2003; Gadsby, 1993). It varies significantly in intensity, usually occurring between the fourth and sixteenth week of gestation and peaking around eight to twelve weeks. The aetiology of morning sickness is complex with many influencing factors, both intrinsic and extrinsic. Women suffering from morning sickness may experience nausea and vomiting at any time of the day, and symptoms may continue throughout their entire pregnancy. Excess vomiting (hyperemesis gravidarum) occurs in 1-2% of all pregnancies and can lead to severe dehydration requiring hospitalisation (Carlsson et al, 2000).

Physiology of emesis

The mechanics and physiology of nausea and vomiting are complex as they can be caused by a range of possible stimuli from different parts of the body. The part of the brain that controls vomiting is known as the vomiting centre, a collection of neurones located in the medulla oblongata. The vomiting centre receives afferent signals from the gastrointestinal tract (via the vagus nerve), vestibular system (as in Meniere’s disease), higher cortical centres within the brain (from unpleasant smells/ sights /memories/ feelings), intracranial pressure receptors (as in meningitis), spinoreticular system (with physical injury) and the chemoreceptor zone (from hormones, toxins, infections and drugs).

There is a wide variety of neurotransmitters and receptors involved in these afferent nerve pathways, and it is these neurotransmitters and receptors that are targeted by many anti-emetic drugs (Tate et al, 1996). A significant amount of research has focused on the neuropharmacology of different emetic receptors in post-operative or chemotherapy-induced emesis, although many fewer studies have looked at the treatment of nausea and vomiting associated with pregnancy (due to the obvious ethical issues (1)). This research has led to a number of evidence-based pharmacological options to manage post-operative or chemotherapy-induced emesis (anticholingerics, phenothiazines, antihistamines, benzamines and serotonin receptor antagonists), but it is not known how effectively or safely these anti-emetic drugs might be applied to the pregnant population (Kovac, 2000; Habib et al, 2004; Vayrat-Follet et a1,1997).

Aetiology and pathophysiology

The exact cause of nausea and vomiting in pregnancy is unknown, but is thought to be intrinsically and extrinsically multi-factorial. The wide spectrum of symptoms experienced suggest that a combination of various factors probably affects individual women differently.

The following factors have been found to be associated with an increased risk of nausea and vomiting in pregnancy (2):

* Non-white ethnic status

* Unemployment

* Housewife status

* Low socio-economic status

* Low maternal age

* An increased number of prior pregnancies (full-term or otherwise)

* Multiple pregnancies

* Increased fatigue and stress levels

* Depression and anxiety

* High maternal body weight

Diet is thought to play a contributing role in morning sickness. A review of 56 studies of the average diet of women in 21 different countries showed nausea and vomiting to be associated with diets high in sugars, alcohol, stimulants, meat, milk and eggs. Diets that were low in cereals and pulses were also associated with nausea and vomiting (Pepper et al, 2006). Helicobacter pylori infection in the gut has also been associated with both nausea and vomiting in pregnancy and hyperemesis gravidarum (Frigo et al, 1998).

Hormonal changes during pregnancy are thought to influence nausea and vomiting. Levels of human chorionicgonadotropin hormone (hCG) rise in the first weeks of pregnancy, reaching peak levels between eight and eleven weeks gestation (the time when most women experience morning sickness), and then begin to plateau or diminish for the remainder of the pregnancy (Furneaux et al, 2001). Despite this coincidental timing, hCG levels vary hugely between women, and it has been difficult to draw a definite conclusion as to their role in morning sickness. Some studies have found higher levels of hCG to be associated with nausea and vomiting (Kauppila et al, 1984; Masson et al, 1985) while others have found no association (Soules et a1,1980). Increased levels of oestradiol have also been found to be associated with nausea in pregnancy and hyperemesis gravidarum, whilst estriol and progesterone have not (Depue et al, 1987; Lagiou et al, 2003). Progesterone can affect gastrointestinal function by decreasing smooth muscle contractility, resulting in gastric arrhythmias and delaying gastric emptying (Kosh et al, 1990). Non-pregnant women given first trimester levels of oestrogen and progesterone experienced similar gastric smooth muscle disruptions as those experienced by pregnant women with morning sickness. The presence of the pregnancy hormones may alter the digestive muscle function, giving rise to the sensation of nausea (Walsh et a1,1996).

It is worth pointing out here a positive association with morning sickness. A meta-analytical review of 11 studies found that nausea or vomiting in pregnancy is associated with a decreased risk of miscarriage or perinatal mortality (Weigel et al, 1989), although a later prospective cohort study found that this association was not significant (Weigel et al, 2006).

Acupuncture and pregnancy hormones

There has been limited research on acupuncture and hormone levels in pregnant women. Ying et al (1985) found no change in hCG levels with acupuncture for first trimester abortion. Dong et al (2001) found no change with acupuncture in follicle-stimulating hormone, luteinising hormone, oestradiol, progesterone, or prolactin in 11 menopausal women with climacteric symptoms. It is not known if these results can be extrapolated to pregnancy.

Basic TCM theory

The main structures, substances, vessels and organs involved in pregnancy and morning sickness are as follows (3):

* The uterus

* Nourishes the foetus and governs the birthing process; closely related to the Kidneys and the Penetrating (Chong) and Conception (Ren) vessels..

* The Extraordinary Vessels

* The Penetrating and Conception vessels are particularly important in menstruation and pregnancy. Both originate between the Kidneys and flow through the uterus.

* The Penetrating vessel (the “sea of blood”) governs the supply and circulation of blood in the uterus; the main pathway by which the Stomach and uterus are linked in morning sickness.

* The Conception vessel (the “sea of yin”) regulates the uterus and menstruation and governs yin and fluids.

* Kidney qi

* The foetus is nourished by the mother’s Kidney qi, which must be sufficient to sustain both mother and foetus.

* If a woman is deficient in Kidney qi prior to conception this is likely to be accentuated once pregnant, possibly compromising the development of the foetus and causing symptoms of fatigue and weakness in the mother.

* Essence

* Formed at conception and stored in the Kidneys; governs birth, growth, development and reproduction.

* The mother’s essence is used to nourish the developing foetus; if essence is weak, it may adversely affect foetal development and miscarriage may result.

* Kidney yin

* The source of fluids throughout the body; nourishes the organs and tissues of both mother and foetus.

* Yin deficiency leads to depletion of moisture and nourishment and results in the body being unable to regulate the increase in yang that occurs naturally during pregnancy (see below).

* Blood

* Nourishes the foetus via the uterus.

* Liver qi

* The Liver stores blood for menstruation and is responsible for the smooth flow of qi throughout the body; Liver qi is responsible for assisting proper digestion and helps the Stomach qi to descend; the Liver is particularly affected by stress and emotional problems.

* If Liver qi becomes stagnant, it will disrupt the descending of Stomach qi as well as generating pathological heat.

* Stomach qi:

* With the Spleen, the Stomach is the root of post-heaven qi and blood production.

* Stomach qi should descend; disruption to this downwards movement results in Stomach qi rebelling upwards, causing nausea and vomiting; if food stagnates in the Stomach this will create heat which further disrupts the descending of Stomach qi.

* Spleen qi:

* With the Stomach, the Spleen is the root of post-heaven qi and blood production; both Spleen and Stomach are adversely affected by worry and overthinking.

* Deficiency of Spleen gi will typically cause symptoms of tiredness, poor appetite and loose stools alongside the nausea and vomiting in morning sickness.

* Heart qi

* Like Stomach qi, the qi of the Heart should descend. Heart qi is easily affected by emotional stress causing palpitations, anxiety and insomnia.

TCM pathology of morning sickness

Morning sickness is, by definition, caused by Stomach qi rebelling upwards, causing the characteristic sensation of nausea and the urge to vomit. This disharmony of Stomach qi is itself usually caused by other organ pathologies, which should be clearly differentiated in clinic in order to treat the condition successfully.

During the first months of pregnancy, the qi and blood of the mother begins to flourish and increases significantly in volume in order to nourish the developing foetus (4). It is the function of the Penetrating vessel to distribute this blood downwards to the uterus. One proposed explanation of morning sickness is that either because the foetus is “blocking” the uterus (now menstruation has stopped), or else because the foetus is unable to make use of the increased qi and blood, the excess is “backwashed” upwards along the Penetrating vessel towards the Stomach, causing its qi to rebel upwards. The qi of the Penetrating vessel will also rebel upwards if the essence and qi of the lower jiao is deficient and unable to “anchor” it, causing it to escape upwards.

One of the common patterns seen in morning sickness is a deficiency of Stomach and Spleen qi. If Stomach qi is deficient, it is easily affected by small changes in the Penetrating vessel and its qi counterflows upwards. In addition, if food stagnates in the Stomach it easily develops heat, the upward movement of which will further disrupt the natural descending of its qi.

Another typical cause of morning sickness is stagnation of Liver qi, which disrupts digestion and can invade the Stomach and Spleen, especially if their qi is deficient. Prolonged Liver qi stagnation will create heat, the ascending nature of which will further prevent Stomach qi from descending.

Heart qi may also play a role in morning sickness. Heart qi, like Stomach qi, should have a descending action. A deficiency in the flow of Heart qi can adversely affect the descending flow of Stomach qi.

Case Study

Mrs B was a fit and healthy 42 year old in full-time work when she first attended the clinic. She had undergone two terminations in her early twenties for unplanned pregnancies with previous partners. Mr and Mrs B had been trying for a family for more than eight years and had been through two unsuccessful rounds of IVF in the past two years. Mr B was also fit and healthy, although tests had shown decreased sperm motility and morphology, thought to be due to a previous hepatitis A infection. Mrs B received weekly acupuncture at my clinic for six weeks prior to the IVF procedure, and both pre- and post-embryo transfer using the Paulus protocol (Paulus et al, 2002).

The IVF treatment was successful, and a happy Mrs B contacted me at 10 weeks gestation, reporting a progressive onset of nausea over the previous three weeks which was making it difficult to function at work. Her nausea occurred at various times throughout the day, ranging from zero to eight out of ten in intensity on a visual analogue scale (VAS). She reported rushing to the bathroom several times in anticipation of vomiting, but was not actually sick. Clearly this was disruptive to her day, and had prompted her to seek treatment.

At the time of her first treatment Mrs B rated her nausea at six out of ten in intensity. She reported having no appetite, although she did report some relief for a short time after eating. She had tried eliminating all dairy and wheat from her diet, without any noticeable effect. She disliked the smell of perfumes, tea, coffee and fruit, all of which caused her nausea to increase. Her stools were regular, if slightly loose, but she reported no tiredness or lethargy. Although her face was slightly flushed, she reported that her sleep was good, and she appeared calm and in good spirits. Her tongue was slightly pale without tooth-marks, and her pulse was weak.

Treatment

My diagnosis was Stomach qi deficiency because of her weak pulse, lack of appetite and relief of symptoms after eating. During treatment Mrs B lay supine on a couch with needles (0.3 x 25mm) in place for 20 minutes. Deqi was obtained after insertion, and the needles manipulated using reinforcing technique. The needles were stimulated once or twice more during the 20 minutes, depending on how quickly her nausea decreased. The points (5) used with the aim of strengthening and harmonising Stomach qi are shown in order of placement in Table 1.

Results

Mrs B reported complete elimination of nausea within five minutes of needle placement. This lasted for several days, and she presented for treatment twice more with a similar elimination of symptoms within five minutes.

At 14 weeks gestation Mrs B reported a slight change in her nausea. She now experienced nausea after eating, accompanied by a bloated sensation. Her tongue was redder and her pulse remained weak but was more rapid. She was still not experiencing any vomiting. I repeated the same points as used in the previous three treatments and she reported a reduction, but not a complete elimination of her nausea. I therefore decided to add Neiting ST 44 to eliminate heat from the Stomach and promote the flow of Stomach qi, which resulted in a complete disappearance of her nausea.

Mrs B periodically called into the clinic over the next few months to say hello and keep me updated on her progress. She did not experience any further nausea and gave birth to a healthy boy by normal delivery.

Incidentally, Mrs B told me that she had a fifth acupuncture treatment for nausea with another acupuncturist ten days after her fourth treatment at our clinic (I was away on holiday). This acupuncturist chose to needle Youmen KID-21 and Shufu KID-27 bilaterally (6). This treatment did not cause any reduction in her symptoms. By the time I had returned from holiday she was no longer experiencing any nausea.

Relevant research

There have been mixed results in studies investigating the use of acupuncture in the treatment of nausea and vomiting in pregnancy. Systematic reviews assessing the effectiveness of stimulation of acupoint Neiguan P-6 show more favourable results for post-operative and chemotherapy-induced nausea than for nausea during pregnancy (7). Six trials investigating nausea and vomiting in pregnancy across 1150 patients showed mixed results, with some favourable and some showing no difference (Ezzo et al, 2006).

A single-blind randomised controlled trial studied 593 women at less than 14 weeks gestation divided into four treatment groups: TCM acupuncture (maximum of six needles), acupuncture using Neiguan P-6 only, sham acupuncture (maximum of six needles) and a control non-acupuncture group. The women received two treatments in the first week, and then weekly treatments over for three weeks, with symptoms assessed once a week. The TCM group, Neiguan P-6 group and sham acupuncture group all experienced a reduction in symptoms, with the TCM group more quickly than the Neiguan P-6 or sham groups (Smith et al, 2002).

Another trial compared acupuncture at Neiguan P-6 with superficial acupuncture elsewhere on the arm for 33 women hospitalised with hyperemesis gravidarum. This single-blind cross-over study showed a more favourable effect for the Neiguan P-6 group. The two groups had differing levels of baseline nausea (on VAS) however, which makes definite conclusions harder to draw (Carlsson et al, 2000).

Discussion

Evidence for the efficacy of acupuncture in reducing nausea and vomiting in pregnancy is inconclusive. The role of acupuncture in the case of Mrs B can also be questioned for various reasons. Psychological components may, of course, have played a significant role in the improvement of her symptoms. Mrs B already held me as a therapist in high regard prior to commencing acupuncture treatment, due to my previous successful treatment of her husband’s shoulder problem. My enthusiastic presentation of acupuncture would also have positively influenced Mrs B’s perception of treatment. This might provide a powerful placebo effect–she was expecting the treatment to help her and it did. Mrs B was also of older maternal age, white, financially stable, working full-time, and was without a history of depression or anxiety. The pregnancy had been planned and very much wanted, and Mrs B had a positive attitude towards her situation. All of these factors are linked with lower incidence of morning sickness.

It is therefore impossible to say how much Mrs B’s positive and rapid response to treatment was indicative of a placebo effect, or whether it was due to successful harmonising her Penetrating vessel and strengthening her Stomach qi.

Conclusion

Neiguan P-6, combined with other points according to TCM patterns, appears to be very effective at reducing pregnancy-induced nausea. Mrs B achieved rapid elimination of her symptoms without pharmacological intervention. Acupuncture at the points used for Mrs B has been found to be safe, with no evidence of spontaneous miscarriage or tetragenetic effects (Smith et al, 2002). Although there is limited research regarding the efficacy of acupuncture for morning sickness, there is plenty of evidence testifying to acupuncture’s effectiveness in reducing post-operative and chemotherapy-induced nausea and vomiting. If extrapolated to pregnancy, this supports the use of acupuncture as a safe, non-pharmacological treatment of significant benefit to pregnant women. In addition, acupuncture may reduce the risk of dehydration and hyperemesis gravidarum (Streitberger et al, 2006). Nausea and vomiting during pregnancy can have a profound effect on a woman’s personal and professional life, affecting her ability to work and subsequent financial status. Severe vomiting can lead to dehydration and hospitalisation, with a consequent drain on healthcare resources (Arsenault et al, 2002). If symptoms of nausea and vomiting in pregnancy can be reduced without pharmacological intervention, then this must surely be better for both mother and foetus.

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Footnotes

(1) For example, the devastating tetragenetic effects of thalidomide.

(2) Weigel et al, 1998; Depue et al, 1987; Kallen et al, 2003; Louik et al, 2006; Buckwalter et al, 2002; Betts, 2003.

(3) A comprehensive analysis of TCM obstetric theory is beyond the scope of this article; readers are referred to the excellent texts by Maciocia (1998) and West (2001) for a full description of the relevant TCM theory.

(4) An increase in blood, heat, dampness and Liver gi(along with a decrease in Kidney qi) can usually be observed as a normal part of early pregnancy; these changes can put significant pressure on the balanced functioning of the qi mechanism in a pregnant woman.

(5) Choice of points and functions are based on Stux and Pomeranz, 1995; Mao-liang 199; Personal notes, 2002.

(6) These points are recommended by Betts (2006) to treat morning sickness by harmonizing the Chong Mai.

(7) Invasive and non-invasive stimulation of P-6 for postoperative nausea and vomiting was found to be consistently effective in 26 trials with over 3000 patients, with minimal side effects (Lee et al, 2004). Electroacupuncture (but not manual acupuncture) was found to be effective for first day vomiting for chemotherapy-induced nausea and vomiting for 1200 patients over 11 trials.

Julie Gear is a physiotherapist working in private practice in the UK. Her initial training in acupuncture was a foundation course with the Acupuncture Association for Chartered Physiotherapists (AACP) in 2002. She completed further studies of TCM acupuncture in Beijing. Julie can be contacted at Julie_gear@hotmail.com

Table 1: Points used to strengthen and harmonise Stomach qi.

 Point   Special information   Traditional uses

  Neiguan P-6Luo-connecting point  Regulates Heart qi and

 Confluent point of   blood, Yin Linking

Vessel

 Zusanli ST-36  He-sea pointTonifies Stomach qi,

strengthens defensive

   qi, promotes nourishment

  of internal organs

Fenglong ST-40   Luo-connecting point  Clears dampness, clears

shen, eliminates heat

  from the Stomach,

regulates Stomach qi,

   resolves phlegm

Zhongwan REN-12   Front-mu point of Stomach Harmonises Spleen and

   Hui-meeting point of the   Stomach, resolves

  fu   dampness

 4th Treatment (in addition to points

above)

 Neiting ST-44Ying-spring Point  Eliminates heat and

 pathological

influences, promotes

  flow of Stomach qi

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Gear, Julie. “Acupuncture for nausea in early pregnancy: a discussion and case.(Medical condition overview).” The Journal of Chinese Medicine. The Journal of Chinese Medicine. 2008. HighBeam Research. 18 Jun. 2009 <http://www.highbeam.com>.

Gear, Julie. “Acupuncture for nausea in early pregnancy: a discussion and case.(Medical condition overview).” The Journal of Chinese Medicine. 2008. HighBeam Research. (June 18, 2009). http://www.highbeam.com/doc/1G1-177719247.html

Gear, Julie. “Acupuncture for nausea in early pregnancy: a discussion and case.(Medical condition overview).” The Journal of Chinese Medicine. The Journal of Chinese Medicine. 2008. Retrieved June 18, 2009 from HighBeam Research: http://www.highbeam.com/doc/1G1-177719247.html