Acupuncture and Neuroplasticity in Stroke

A recent study from the journal Frontiers in Human Neuroscience looked at the effect of acupuncture and the functional connectivity of the bilateral primary motor cortices in individuals that had ischemic stroke.  A group of normal (i.e. no stroke) subjects was used as a control.  Both groups had brain scans done before and after acupuncture stimulation.  Not surprisingly the stroke group showed a decreased value of functional connectivity between the motor cortices compared to the control group in the baseline scans.   Acupuncture stimulation increased the functional connectivity in the stroke group, but had no effect in the control group.

This is another study that provides evidence that acupuncture achieves clinical results by increasing what is known as neuroplasticity – the ability of the brain to establish new physical and/or functional connections.  The way different brain areas communicate with each other is critically important to our ability to function normally and maintain optimal health.  Therefore treatment methods which can stimulate the communication between brain areas are very important.  For stroke patients in particular it is vital for recovery to restore the communication between brain areas and this study is evidence acupuncture can do exactly that.

The study used only a single acupuncture point, GB 34.  This point is very commonly used clinically to treat tendon, connective tissue, and skeletal-muscle related disorders.  Earlier studies have shown GB 34 to have a modulatory effect on the motor cortex, which in combination with its clinical usage was the reason this point was selected.

This study also provides evidence for one of the fundamental components of TCM theory – that acupuncture treatment is auto-regulatory.  As would be expected, the control group showed no changes in the functional connectivity as there was nothing wrong with that communication in the first place.  The stroke group, whose connectivity was impaired, did show improvement as expected.  In other words this study have provided evidence that acupuncture does not create changes in neural plasticity if there is nothing wrong with the communication between brain areas in the first place.  These results are exactly what is expected from an auto-regulatory mechanism.

Research Shows Acupuncture Can Benefit Both Cognitive Performance and Neural Plasticity

As a former brain scientist I’m well aware of the importance of brain functions and inter-brain connectivity and how that relates to overall physical and mental health.  While the function of individual brain areas is important, the way different areas of the brain communicate with each other is equally, if not more important.  Neural plasticity refers to the ability of the brain to establish new connections, both physical and functional, between brain areas.  As we age neural plasticity is thought to be less, well elastic, and therefore our brains are less responsive to making adaptations and changes that are necessary to maintain optimal mental and physical health.  

Many diseases and disorders result from different areas of the brain failing to communicate properly.  Aging related disorders such as cognitive impairment, dementia, and memory loss, often have no structural component (no brain damage, no interruption of neurotransmitter creation, etc.) and are instead the result of a breakdown of the communication between different brain areas.  This is the result of a breakdown of our neural plasticity.  Therefore to treat these types of disorders we need to be able to restore the communication between the affected brain areas, or in effect restore our neural plasticity.  

A recent study from the Journal of Neural Regeneration Research found that acupuncture treatment resulted in an improvement of cognitive function and furthermore fMRI brain imaging showed corresponding increases in the communication of brain areas associated with higher level cognitive functioning and memory.  The study split patients into a sham acupuncture and a real acupuncture groups.  It is important to note the sham acupuncture was done by needling non acupuncture points – often sham acupuncture uses the same acupuncture points but doesn’t insert the needle which is basically acupressure and therefore not an effective control.  Brain scans and cognitive assessment tests were taken before the study began and again after 4 weeks of treatment.  Those in the true acupuncture group showed both a significant increase in their cognitive testing as well as increases the communication between areas of the brain involved in higher level cognition.  Those in the sham acupuncture group showed no significant performance increase and no changes in the communication between areas of the brain.

There is an important difference between showing acupuncture can influence brain activity (for example this study) while the needles are in versus establishing that acupuncture can have a longer lasting influence on the way the brain functions.  Showing that acupuncture treatment can influence the communication between brain areas both helps to establish that acupuncture does in fact have a lasting effect and the mechanism by which that effect is established – by restoring neural plasticity.  

Basic Guidelines For Choosing An Appropriate Herbal Formula

One of the most common questions we get is what Chinese herbal formula is used to treat “insert any condition/symptom/western diagnosis”.  There is a common assumption that herbal formulas are chosen and then used in the same way Western pharmaceuticals are.  That is largely misleading.  Herbal formulas are chosen based on what the underlying pattern or patterns are, not based on a specific symptom or a specific western medicine diagnosis (for a discussion of tcm patterns see “Treating the Cause and Not the Symptoms“).  So in effect, the answer to what formula treats condition “x” is that there is no single formula that would universally apply.  The selection of herbal formulas is necessarily customized to each individual based on their overall health.  Incidentally this same principle applies to how we select acupuncture points.

So for example take a specific condition like insomnia.  We have over a dozen formulas listed on our store site that are used to treat insomnia.  The reason we have so many is that insomnia can be caused by a somewhat broad variety of underlying patterns.  In one case the insomnia could be due to what in TCM (Traditional Chinese Medicine) is a diagnosis of heart yin deficiency.  Usually in that case other symptoms might include palpitations, anxiety, restlessness, and vivid dreaming.  A formula like Tian Wan Bu Xin Dan would be appropriate for insomnia in that case.  Insomnia could also be the result of liver fire.  In that case other symptoms could include frequent outbursts of anger, bloodshot eyes or other manifestations of red coloring in the face, extreme irritability, dizziness, and constipation.  You would need to use a very different formula than Tian Wa Bu Xin Dan for someone with insomnia in this case (for example something like Long Dan Xie Gan Wan).

In Western medicine insomnia can be diagnosed as a stand alone disorder.  In TCM insomnia is never considered a stand alone disorder but rather as a symptom that is being manifest by an underlying disorder in the working of the body.  And according to the principles and theories of TCM there are several possible patterns that could present with insomnia as one of the symptoms.  So in the context of TCM, we are not treating the symptom of insomnia, we are looking to treat what underlying patterns are causing it.  This is why there is no one specific formula you can universally use for insomnia (or any other condition or western diagnosis).

To further complicate the selection of the appropriate formula, most people present with more than one underlying condition.  It takes a deep understanding of the principles and theories of Chinese and Oriental medicine to establish a proper diagnosis.  Once a diagnosis is established, appropriate herbal formula choices can be made from there.  And a diagnosis within the framework of oriental medicine does not (for the most part) have a corresponding diagnosis in the context of Western medicine.  For this reason we do not recommend that people take TCM formulas on their own based on information available online.  You will get better and safer results by consulting with a local acupuncturist or herbalist.

Types of Formula

It is common practice that the last character of each formula reflects the form it comes in.  Some herbal companies do not follow this which can be somewhat confusing.  But if the last part of a formula is slightly different or even missing it is very likely the same formula.  For example Bi Yan Wan is the same formula as Bi Yan Tang/Pian or even just Bi Yan.  

Tang is usually used to refer to the preparation of raw herbs and is also commonly used for capsules containing powder.  Pian are compressed herbal tablets without any coating.  Wan are small, usually black, balls of compressed herbs with a coating.  The wan form are also known as tea pills.  There are also some companies that offer herbal formulas in liquid drop form (usually alcohol based).  As far as I know there isn’t a separate name or designation for this.

I have a personal preference for formula in powdered or capsule format that I can make a tea from.  However from a clinical perspective there is very little, if any, clinical difference between the different formats.  My herbal teachers in school did say that the raw herb decoctions had a slightly faster absorption rate, but in most cases that doesn’t translate into a noticeable clinical effect.  Due to the smell, taste, and preparation time required the raw herbs are not commonly used.  Some of the capsules (tang) are larger and for some people may be more difficult to swallow than wan, which are usually smaller.  Other than simple practical considerations (like young children being unable to swallow large pills) the form the formula comes in doesn’t, except in rare cases, have any significant impact on the clinical effectiveness.

Dosage

Unlike Western pharmaceuticals the dosage of TCM herbal formulas is not as strict.  For example if you have the wan version of a formula taking 4 instead of 3 will not likely have any noticeable effect.  Young children usually require lower dosages.  Larger or heavy set people usually require a slightly larger dose.  In our clinical practice we tend to prescribe dosages that are less than what are printed on the bottle.  The different types of formula will also dictate dosage.  For example you’ll generally take more pills in wan form versus capsule form for the same formula.  Your local practitioner will be the best source for the proper dosage of any herbal formula for you to take. 

Contraindications

If you develop acute cold or flu there are some formulas you should stop taking.  If you have liver or kidney disease you should only take herbal formula with the guidance of a licensed/trained practitioner.  There are also some formulas that should not be taken when pregnant or breastfeeding. There are also a very few formulas that cannot be taken with certain Western pharmaceuticals.  Your practitioner should be able to provide you with any possible contraindications.  

Side Effects

If you’re taking herbal formulas with the guidance of a licensed practitioner there are extremely low risks of any negative side effects.  This doesn’t mean that herbal formulas are 100% safe for everyone.  It is possible that taking a formula that does not match the pattern(s) you are presenting could make some of your symptoms worse.  This is yet another reason why you should not take herbal formulas without the guidance of a licensed/trained practitioner.

Chinese Medicine and Weight Loss

Chinese medicine, including acupuncture, herbal, and food therapy, can help with several aspects that are important to successful weight loss.  Acupuncture will not melt off fat and in many cases will have little to no effect if other factors, particularly stress and diet, are not also addressed.  Any acupuncturist, or really anyone else for that matter, that tells you can eat your fast food and lose weight is terribly misinformed.  

There are, at least in my own personal experience and clinical way of thinking, four broad types of weight loss patients.  The first type are stress eaters- who eat reasonable well but then splurge too often in response to stress.  The second group are those who eat poorly.  The third are the type of people with either neurological or hormonal disorders that make it difficult, if not impossible to lose weight even if the diet is spot on perfect.  I also consider people with weak stomach and/or spleen function (in the context of TCM) part of this group.  And the fourth type is some combination of the first three.

For stress eaters acupuncture can help reduce stress and to specifically reduce the cravings to eat when stressed.  The focus of treatment is explicitly not on weight loss but rather on helping the brain and the body chemistry to change so that the automatic response to stress is not to crave food.  In my clinical experience cravings can be reduced pretty quickly and ultimately eliminated all together for most people.  It is important to recognize that the patient plays a role as well.  The more strict they are with themselves initially the quicker the behavioral changes will become easier to implement and the quicker the cravings will become less frequent and/or intense.

For patients who simply eat poorly, acupuncture alone is pretty much useless for helping with weight loss.  Without making sometimes significant dietary changes, [natural] weight loss is pretty much going to be impossible.  Acupuncture can’t superboost your metabolism or drastically improve your body’s ability to burn through fats or carbs or sugars.  Or somehow convince your body that donut you just ate was actually just a funny looking vegetable.  Most of the time people in this group have some various other digestive issues, whether it is bloating, cramping, constipation, excess gas, reflux etc.  And most of the time these symptoms are directly caused by the foods they eat.  Acupuncture can help improve digestive functioning, improve the bowels, and help with pretty much any other digestive related symptoms.  This helps to prime the body to be able to lose weight in the first place but again is not by itself a strong enough result that the diet can be ignored.  So in my own practice my focus is on explaining appropriate dietary choices and using acupuncture to help alleviate what are mostly side effects of nutritionally poor food choices.   

For people with disorders such as PCOS or hypothyroidism, weight loss can be significantly harder, if not almost impossible, to achieve by dietary changes alone.  For these types of patients weight loss itself is really not the focus.  The focus is using acupuncture to help balance and restore the hormones and biochemistry of the body.  This in turn helps the body to be able to lose weight again.  Diet is still important, but until the body is rebalanced a good diet in these cases is mostly a non factor because even if they are eating as good as the possibly can the weight won’t come off.  Diet is important however to prevent more weight gain in the first place of course.

Most people end up in the fourth category – a combination of poor diet and weakness or inability of the body to lose weight effectively.  Each treatment is customized to each patient each time they are seen.  Even many of the dietary recommendations I make are customized and specific for each patient.  There really is no cookie cutter approach to weight loss (or any other condition for that matter).  

There are no magic Chinese herbs or formulas that burn off fat.  Chinese herbal therapy can be helpful for treating the various underlying causes of weight gain but do not specifically create weight loss by themselves.  Some formulas help strengthen the function of the spleen/stomach with the intent to help minimize the amount of damp that is generated.  Some formulas might help the liver to more effectively metabolize fats.  Some can help if water retention is part of the weight they might focus on aspects of the kidney system.  Some formulas can help reduce stress and anxiety which in turn helps reduce stress eating.  But no formula by itself will actually force the body to lose weight by burning off fat.

While exercise has basically no role in weight loss (according to multiple studies and my own personal and clinical experience) I still recommend people engage in regular activity as it does help to improve mental and emotional health as well as improving other aspects such as blood pressure, heart rate, sugar levels, etc.  If patients ask me what kind of exercise they should be doing I always recommend either yoga or tai chi as they both offer health benefits above and beyond what you can achieve from going to a gym.  

In summary, Chinese medicine can be a very powerful tool in helping people to achieve weight loss.  Most people will need to be willing to make some dietary changes as well.  

Understanding and Treating Fibromyalgia From An Acupuncture Perspective

Fibromyalgia can be a difficult disease both to identify and to treat from the western medical perspective.  Literally every single fibromyalgia patient I’ve ever seen had gone for months, sometimes years before being diagnosed.  It is sadly not too uncommon that more than a few have even been told by their respective MD’s that ‘it’s all in their heads’.  Many of them were put on medications that did nothing for their pain and more often than not had mild to moderate unpleasant side effects.  Most of the time my patients with fibromyalgia have already tried every western treatment with little to no positive benefit and we’re basically their last resort.  Which is really unfortunate as acupuncture is particularly effective at treating fibromyalgia.

There are a few different underlying TCM (Traditional Chinese Medicine) patterns that are usually involved with fibromyalgia.  From a TCM perspective the most commonly seen are qi and blood deficiency and/or stagnation and liver qi stagnation (0), others are listed on our acupuncture for fibromyalgia page).  In my own clinical experience I almost always see some issues with the heart system as well, which is just a more specific description of where the qi/blood stagnation and deficiency is manifesting.  In a nutshell, what all that means is the natural flow of the qi (energy) and blood is impaired, often due to a weakening of the energy to keep everything moving in the first place.  Pain is the result of stagnation (of energy/blood/fluids) and therefore when there is both qi and blood stagnation there is almost certainly going to be pain.  An underlying deficiency of the qi/blood is usually seen in chronic cases and simply reflects a weakened state that results from chronic imbalance.  The liver qi stagnation often translates symptomatically into stress, depression and anxiety that are exacerbated by chronic pain and discomfort.  It is important to note though that with fibromyalgia, like all western diseases, the underlying TCM patterns that give rise to the symptoms may be very different across individuals.

Acupuncture is a safe, natural, and most importantly effective method for treating fibromyalgia and there are clinical studies that confirm that (1,2,3).  In my clinical experience most patients are able to notice at least a moderate and often more significant reduction of the pain and discomfort within a few treatments.  Perhaps more importantly the vast majority of patients notice a significant improvement in overall quality of life.  Much of the emotional turmoil that they experience due to the constant pain, difficulty diagnosing and treating the disease, etc. can be significantly resolved with acupuncture (4,5).

In Chinese medicine the emotions are considered an integral part of the body’s energetic physiology.  In a nutshell, emotions can directly influence the physical body, and vice-versa.  That concept has yet to gain full traction in the practice of western medicine, particularly in a clinical setting where there is evidence that the empathy of doctors is actually declining (6).  There is however a growing body of western research regarding the relationship between the emotions and various physiological markers which essentially confirms there is direct link between the emotions and the physical body (for example 7,8).

In diseases like fibromyalgia there is almost always a very strong emotional aspect of the disease, most often depression but also anxiety, restlessness, irritability and low affect are commonly experienced.  It is, from a TCM perspective, essential for the overall effectiveness of the treatment to consider and address the various emotional components involved with fibromyalgia.  Much of the time Western oriented treatments either ignore outright the emotional component of fibromyalgia or prescribe some sort of psychotropics i.e. antidepressants, which are generally not effective (9).

Another issue many patients face from a western perspective is that fibromyalgia often presents with multiple symptoms and doctors tend to focus on only a few.  For example gastrointestinal troubles are a common symptom, and many general practitioners will do nothing to address GI issues, referring to Gastro-intestinal (GI) specialists instead.  The GI, in return, may largely ignore the pain and emotional aspects  and just focus on treating the GI symptoms.  Or perhaps the GI then refers to a psychiatrist for the anxiety/depression, and so on.  In worst case scenarios doctors don’t even look at the meds other doctors have prescribed, which is among the reasons drug interactions are a leading cause of death in this country (10).

For complex diseases like fibromyalgia, what often seems like a hopeless tangle of various symptoms is often relatively straightforward from a TCM perspective.  The hallmark of TCM is that we are able to treat the patient as a whole, in effect addressing all symptoms all at once by identifying the underlying imbalances that generate those symptoms.  Now this doesn’t mean everything will get better all at once, generally the symptoms that are mildest or have been around for the shortest duration improve first, but again everyone is different.  However pretty much across the board the various symptoms fibromyalgia patients should start to improve after several acupuncture treatments.

Acupuncture is not a placebo effect

As acupuncture and alternative medicine in general continue to be utilized by a growing number of people, more skepticism and criticism naturally emerge as well.  There are a number of western oriented sites and blogs that claim acupuncture, if it works at all, is nothing more than a placebo effect.

There is a whole discussion to be had with regards to the inherent bias against acupuncture that many Western doctors and researchers have.  It is virtually impossible to do the gold standard double blind type studies with acupuncture.  A very brief summary is that 1) a holistic system does not match well to reductionist methods 2) sham acupuncture is a very poor control 3) many studies are designed and performed by people with no experience whatsoever with acupuncture or eastern medicine and in effect are almost guaranteed to produce a negative result.  I’ll get more into that in another post.  The emphasis here is to demonstrate that acupuncture is not in fact merely an elaborate ritual to evoke the placebo effect.

I’ll start off with my own clinical experience.  It goes without saying that I do not believe that positive clinical outcomes from using acupuncture is nothing more than placebo effect.  The vast majority of the patients I’ve seen had experienced at least some improvement in their condition, more often than not significant improvement.  This doesn’t necessarily show that acupuncture is more than placebo however so let me talk a bit about some more specific instances that very strongly suggest it is not.

It is not terribly uncommon for some new patients to be highly skeptical that acupuncture can do anything to help them.  Their doubt essentially creates the potential for the nocebo effect (the opposite of placebo).  The vast majority of these patients return with improved symptoms and often profess near astonishment at the difference they felt given that they didn’t believe acupuncture would do anything in the first place.  In fact, somewhat ironically, my clinical experience has shown that many of the most skeptical patients actually get slightly better relief than some of the most believing patients.  Logically, if acupuncture is nothing more than a placebo effect than the results would scale to some degree with patient belief and those patients that had no belief or expectation of acupuncture working should not show any improvement.  My clinical experience shows otherwise, specifically that even when patients have no expectation of any positive outcome they still experience a clinical benefit.

There is another trend I’ve noticed in my clinical practice that further supports acupuncture is not just placebo.  The placebo is relatively specific, i.e. this treatment is for this specific condition and the greater belief that the treatment will help the condition the greater the effect.  It is not uncommon for patients to focus on only one or two main complaints and not mention other health issues they are having.  I see this most often with pain.  It is quite common for patients who come in primarily for pain relief to later mention, hey my sleep has been much better lately…or my appetite is much better…my libido has returned to normal… etc.  If acupuncture were only a placebo effect it would be difficult to explain how patients, without disclosing these other conditions and without having any expectation of improvement of these conditions, show a positive clinical result.

Of course any critic will point out clinical experience doesn’t have the same validity as well controlled scientific studies which are published in peer reviewed magazines.  To that end, the scientific evidence comes from various studies involving animals.  It is widely accepted that animals are not susceptible to the placebo effect.   There are a number of studies using rats or mice that have conclusively demonstrated that acupuncture can induce very specific physiological effects that are effectively impossible to explain as the result of placebo (for example 1,2,3,4).  A review from the veterinary world concludes acupuncture is both safe and effect for pain and “should be strongly considered” (5).  Acupuncture has even been reviewed in zoological settings and has been found to be highly beneficial (6,7). It is in fact difficult to find any animal studies involving acupuncture that do not show a positive result.  The overwhelming scientific results showing acupuncture on animals induces both physiological effects and clinical benefits very strongly indicate that acupuncture is not, in fact, merely a placebo effect.