2007 Summer Broadening Program Faculty of Medicine, HKU

TCM Nursing Care of Common Diseases (2)Lixing Lao ()

Director and ProfessorSchool of Chinese MedicineThe University of Hong Kong

November 18, 2014BCHM3701&3801 Introduction to Chinese Medicine and NursingOverviewTCM for common diseases/conditions (Cont.):Postpartum Care , Persistent flow of the lochia (), Oligogalactia (), Pain management (cancer care (

TCM emotion-improving therapies

TCM exercise therapy

Fumigating and bathing therapy

Clinical Evidence of TCM therapies

8. Postpartum Care Postpartum period: 6-week period after the birth

Sweating and bleeding during delivery

Yin-blood depleted suddenly, Yang Qi floating easily (, )

Immune function decrease

Life style During postpartum period, exterior is deficient and insecure, the body can be easily invaded by pathogenic wind

should not face the wind when sitting or sleeping, keep away from the wind and cold,

Adequate rest and sleep to prevent persistent flow of the lochia and uterine prolapse

Avoid raw/ cold/ indulgence () in a richly fatty and sweet diet () to prevent spleen-stomach from damage. Digestive function is important for the transformation of milk.

Regulate the emotions and will () to prevent abdominal pain and oligogalactia () due to stagnation of Qi and blood ()

9. Persistent flow of the lochia()abnormally prolonged virginal discharge for more than 3 weeks after childbirth

ClassificationExcessive types () Blood stasis syndrome ()Blood heat syndrome ()Deficient types ()Qi deficiency syndrome ()6Persistent flow of the lochia ():Chinese herbal medicineTonify Yin to clear heat, cool the blood to stop bleeding ()Formula: Bao Yin Jian ()Herbs: Sheng Di Huang (), Shu Di Huang (), Bai Shao () , Shan Yao () , Xu Duan (), Huang Qin () , Huang Bo (), Gan Cao ()

Tonify Qi and blood, control blood to stop bleeding () Formula: Bu Zhong Yi Qi Tang ()Herbs: Ren Shen (), Huang Qi (), Bai Zhu (), Dang Gui (), Chen Pi (), Gan Cao (), Chai Hu (), Sheng Ma ()

Promote blood circulation and remove blood stasis()Formula: Sheng Hua Tang ()Herbs: Dang Gui (), Chuan Xiong (), Tao Ren (), Gan Cao (), Pao Jiang ()10. Oligogalactia ()deficiency of milk secretion during lactation

TCM DifferentiationExcessive types () Liver Qi depression and Qi stagnation syndrome ()Deficient types ()Qi and blood deficiency ()Oligogalactia ()Chinese herbal medicineTonify Qi and blood to promote lactation ()FormulaTong Ru Dan ()Herbs: Ren Shen (), Huang Qi (), Dang Gui (), Mai Dong (), Tong Cao (), Jie Geng (), Pigs feet ()

Soothe the liver to solve the Qi stagnation, free the collateral vessels to promote lactation () FormulaXia Ru Yong Quan San ()Herbs: Dang Gui (), Bai Shao () , Chuan Xiong () , Sheng Di Huang (), Chai Hu (), Qing Pi (), Tian Hua Fen () , Lou Lu (), Mu Tong (), Jie Geng () , Bai Zhi (), Chuan Shan Jia () , Wang Bu Liu Xing (), Gan Cao ()Other treatmentsAcupuncture: Tangzhong (CV-17) , Ru Gen (ST-18) .

Point combination (): Shaoze (SI-1), TianZong (SI-11) , Hegu (LI-4) Blood deficiency syndrome: addition of Ganshu (BL-18) , Geshu (BL-17) , Qi stagnation syndrome : addition of Neiguan (PC-6) , Qimen (LR-14) Tangzhong (CV-17)

Shaoze (SI-1)

10. TCM Pain Management (Bi- Syndrome Pain in the joints of the limbs

Image courtesy of stockimages at FreeDigitalPhotos.netOther SymptomsOther Symptom ()Soreness ,numbness, heaviness ()

Sign()Limited motion ()

Location ()Muscles, tendons and joints ()

Severe case ()Redness, swellings and a burning sensation in the joints ()Introduction of Bi- Syndrome Common pathogenic factorWind ()Cold ()Damp ()Heat ()

TCM classification of Bi- Syndrome Excessive types () Wandering Bi-syndrome ()Painful Bi-syndrome ()Fixed Bi-syndrome ()Heat Bi-syndrome ()

Excessive and Deficient types ()Wang Bi-syndrome ()

Deficient types ()Syndrome of deficiencies of Qi and blood ()

Bi- Syndrome :Chinese herbal medicineRemoving obstruction from the collaterals plus eliminating wind(): Fangfeng Tang ()

Warming up the channels to disperse cold plus harmonizing the nutrient (): Wenjing Tongbi Tang ()Bi- Syndrome :Chinese herbal medicineOozing dampness to remove obstructions from the channels and collaterals plus strengthening the spleen (): Coix Seed Decoction ()

Dispersing heat to relieve toxins , removing obstructions from the collaterals, plus eliminating wind(): Baihu Jia Guizhi Tang().

Bi- Syndrome :Chinese herbal medicineTonifying the kidneys to disperse cold plus activating blood circulation and freeing the collaterals(): Bushen Quhan Zhiwang Tang ()

Invigorating Qi to nourish blood, freeing the collaterals to smooth the tendons (): Qixue Bingbu Rongjin Tang ()Bi- Syndrome : AcupuncturePrincipal points: A shi points ()Additional points:Wandering Bi-syndrome (): Geshu (BL17,), Xuehai (SP10, )

Painful Bi-syndrome (): Shenshu (BL23,) , Yaoyangguan (DU3, )

Fixed Bi-syndrome (): Yinlingquan (SP9, ), Zhusanli (ST36, )

Heat Bi-syndrome (): Dazhui(DU14,), Quchi (LI11, )Bi- Syndrome : Food therapiesCoix Seed congee(): Coix Seed()50g, Rice ()50g

Wu Jia Pi wine(): Wu Jia Pi ()60g, Glutinous rice()100gBrewers yeast() someEpigastric pain ()Disease of spleen, stomach and intestines~ Epigastric pain Epigastric pain ()Abdominal pain ()Vomiting ()Dysphagia ()Diarrhea ()Constipation ()Introduction of Epigastric pain-Core symptomPain in the epigastrium, or upper abdomen of the region close to ensiform process

Image courtesy of marin at FreeDigitalPhotos.netIntroduction of Epigastric pain -others Other Symptom ()NauseaEpigastric fullnessBelchingAbnormal defecation

TCM classification of Epigastric pain Excessive types () Attach of the stomach by pathogenic cold ()Retention of food ()Attach of the stomach by stagnant liver Qi()Retention of heat in the liver and stomach ()Retention of blood stasis ()Blocking the middle by dampness-heat ()

TCM classification of Epigastric pain Deficient types ()Yin deficiency of the stomach ()

Deficient cold of the spleen and stomach ()Epigastric pain :Chinese herbal medicineWarming up the stomach to disperse cold, regulating Qi to relieve pain(): Liangfu Wan ()

Promoting digestion to eliminate stagnation, harmonizing the stomach to relieve pain (): Baohe Wan ()Epigastric pain :AcupuncturePrincipal points: Zhongwan (RN12,)Neiguan (PC6,) Zhusanli (ST36, )

Dysmenorrhea()Introduction of Dysmenorrhea -Core symptomPeriodic pain in the abdomen before, during or after menstruation

Image courtesy of Ohmega1982 at FreeDigitalPhotos.netTCM classification of Dysmenorrhea Excessive types () Qi Stagnation and Blood Stasis()Cold evil congeals blood()Damp, heat and blood Stasis()

Deficient types ()Syndrome of deficiencies of Qi and blood ()Deficiency of Kidney-Qi()

Dysmenorrhea :Chinese herbal medicineRegulating Qi and removing blood stasis to relieve pain (): Geixia Zhuyu Tang ()

Warming up the collaterals to disperse cold, removing blood stasis to relieve pain (): Wen Jing Tang ()Shaofu Zhuyu Tang ()

Dysmenorrhea : AcupuncturePrincipal points: Zhongji (RN3, )Chilao (BL32, )Sanyinjiao (SP6, )

Dysmenorrhea : Food therapiesCinnamon hawthorn decoction(): Hawthorn()10g, Cinnamon()7g, Brown sugar()50gDrink before menstruation

Jiucai juice(): Fresh Jiucai juice()50g, Brown sugar() some11. TCM Cancer Palliative carePalliative care is comfort care given to a patient who has a serious or life-threatening disease, such as cancer, from the time of diagnosis and throughout the course of illness.

http://www.cancer.gov/cancertopics/factsheet/Support/palliative-care38Goal:Prevent or treat, as early as possible, the symptoms and side effects of the disease and its treatment, in addition to the related psychological, social, and spiritual problems.

The goal is not to cure.

Palliative care is also called comfort care, supportive care, and symptom management.TCM Cancer Palliative care39Role of Chinese MedicineMost cancer patients use CAM with the hope of boosting the immune system, relieving pain, and controlling side effects related to disease or treatment.

CM can help you to cope with your cancer treatment by:Improving your quality of life. Improving your general health and well-being.Giving you a sense of control during your cancer experience.Helping control anxiety, stress, insomnia, and depression.Helping reduce symptoms of cancer and side-effects of chemotherapy or radiation treatment, for example, pain, nausea, loss of appetite, breathlessness, constipation, diarrhoea, or fatigue.Patrick J. Mansky, Dawn B. Wallerstedt. Complementary Medicine in Palliative Care and Cancer Symptom Management Cancer Journal:2006;12(5):42543140Common classification of CM syndromeDifferentiated by symptoms and side effects related to cancer treatment (radiotherapy, chemotherapy and surgery)

Deficiency of Qi and Yin () Deficiency of Qi and blood ()Qi deficiency and blood stasis ()retained dampness and heat toxin ()

Deficiency of Qi and Yin () Commonly seen in radiotherapy and chemotherapyShengmai San ()

Deficiency of Qi and blood ()Commonly seen in cancer surgeryShi Quan Da Bu Wan ()

Qi deficiency and blood stasis ()Commonly seen in cancer post operationBuyang Huanwu Tang ()

Retained dampness and heat toxin ()Commonly seen in cancer post operationHuanglian Jiedu Tang () and Shenling Baizhu San ()

Chinese Herbal FormulasDiarrheaShangjuxu (ST37, )

Nausea and vomitingNeiguan (PC6, )

HeadacheHegu (LI4, )

FeverDazui (GV14) and Hegu (LI4)

Stomach acheZhusanli (ST36) and Zhongwan (Ren12)

Acupuncture for Cancer CareMonkey-head Mushroom, American Ginseng and Pork Soup ()

Symptoms: Weakness, fatigue, insomnia due to cancer treatment/operation

Therapeutic Effects: Clear heat and toxins, prevent and treat cancer.

Ingredients: Monkey-head mushroom-100gmPork-240gmAmerican ginseng 30gmDried lungan fruit (long yan rou)-10gmDietary therapyAcupuncture/TCM and Pain Management Current Evidence

45What is Evidence-based Medicine? Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isnt. BMJ 1996;312:71-2.46Read slideIt requires that clinicians combine their best clinical wisdom and experience with the best available evidenceIn essence, by applying their best clinical experience while keeping abreast of new research, clinicians have always strived to practice evidence based medicine which is why some have called it an old wine with a new label

Strong evidence EvidenceOpinionType and Strength of Efficacy EvidenceH J McQuay, R A Moore Evidence-based Research for Pain ReliefRCT----Randomized Clinical Trial RCT RCTOther non-randomized, trial designsWell-designed, non-experimental studiesSystematic Review of RCTsOpinions of respected authoritiesReports of expert committees47I. Strong Evidence from at least one systematic review of multiple well-designed randomized controlled trials

II. Strong evidence from at least one properly designed randomized controlled trial of appropriate size

III. Evidence from well designed trials without randomization,single group pre post,cohort, time series or matched case controlled studies

IV. Evidence from well designed non experimental studies from more than one center or research group.

V. Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees.

Systematic Reviews and Meta-AnalysisSystematic review takes all the available evidence, categorizes it by how scientifically sound it is, and then makes summary statements Meta-analysis may be, but is not necessarily, used as part of the process48Large Acupuncture Clinical Trials Published in Recent Years

Effectiveness of Acupuncture as Adjunctive Therapy in Osteoarthritis of the Knee: A Randomized Trial Berman, Lao, et al. Ann Intern Med. 2004;141(12):901-10Study Objective

To determine whether traditional Chinese acupuncture (TCA) provides greater pain relief and improvement in function than sham acupuncture (SA) or education for patients with osteoarthritis of the knee.50O/A Impact most common cause of arthritis ~21 million Americans suffer from this

Assoc. with significant reduction in quality of life because of pain and functional limitationStudy Design Three arm parallel design: (N = 570) N=570) Real acupuncture Sham acupuncture control Attention / education control group Multi-sites Patients randomized by computer Outcomes assessor blinded to group assignment

Five local points:Yanglinquan GB34, Yinlinquan SP9, Zhusanli ST36. Dubi ST35, and Xiyan5Four distal points: Kunlun UB60, Xuanzhong GB39, Sanyinjiao SP6 and Taixi Kid3452

Acupuncture Treatment 53Outcome Measures Primary WOMAC Osteoarthritis Index WOMAC Pain and Function subscales Secondary Patient global assessment MOS SF-36 SF-36Six-minute walk distance 6 Adverse events 54Results

* *P=.003 vs SA

***P=.009 vs SAResults German Randomized Acupuncture Trial for Chronic Shoulder Pain (GRASP) A pragmatic, controlled, patient-blinded, multi-centre trial in an outpatient care environment

Molsberger, Schneideret al. Pain. 2010;151(1):146-54. Study Objective

To determine whether traditional Chinese acupuncture (TCA) is an effective alternative to conventional orthopaedic treatment for chronic shoulder pain Study Design Three arm parallel design: (N = 424) Real acupuncture (n=154) 154Insertion Sham Acupuncture control (n=135) 1353Conventional orthopaedic therapy group (n=135) 135Multi-center Patients randomized by computer Patients were blinded to the type of acupuncture Intervention Acupuncture group 15 treatments of Chinese acupuncture 15 (one to three per week, 6 weeks, each lasting for 20 min)local and distal points according to the channel and the individual location of the pain Sham group 15 treatments of sham acupuncture 15 (one to three per week, 6 weeks, each lasting for 20 min)non-acupuncture points, shallow puncture COT group 50 mg diclofenac daily50mgselected from physiotherapy, physical exercise, heat or cold therapy, ultra-sonic treatment and TENS. Selecting of acupoint in Acup group One to three locus dolendi (Ahshi) points

Local and distal points according to the channel and the individual location of the pain: ventral Lung 1, 2; ventrolateral Large Intestine 4, 11, 14, 15;lateral Sanjiao 5, 13, 14; dorsal Small Intestine 3, 9

Additionally distal points on the homolateral leg could be selectedfrom Stomach 38, Gallbladder 34, Bladder 58

Hegu ( LI 4 )Waiguan ( SJ 5 )Quchi ( LI 11 )Binao ( LI 14 )Jianzhen ( SI 9 )Jianliao ( SJ 14 )Jianyu ( LI 15 )Yunmen ( LU 2) Naohui ( SJ 13 )Sham-pointAcupointsSham points60

Results: primary and secondary endpoints* P< 0.001 as compared to sham and COT**VAS50%3Acupuncture for depression during pregnancy: a randomized controlled trial Manber, Schnyer, et al. Obstetrics & Gynecology. 2010; 115(3): 511-520Design: Sample size: N = 150

Interventions: 1) acupuncture specific for depression (8 wks) 2) acupuncture not specific for depression (control) 3) prenatal massage

Outcome measures: Hamilton Rating Scale for Depression

Randomization: Blocked randomization

Blinding: Patients, treating acupuncturists and raters were blinded to the type of acupuncture

Results P>>>>>>>>>>>Tai Chip-value24 weeksControlFIQ score28.6 10.2>>>>>>>=>>>>Conclusion:

Tai chi may be a useful treatment for fibromyalgia and merits long-term study in larger study populationsFurther readingGuo-Shiou Liao, Maria Karmella Apaya, and Lie-Fen Shyur. Herbal Medicine and Acupuncture for Breast Cancer Palliative Care and Adjuvant Therapy.eCAM, Volume 2013 (2013), Article ID 437948, http://dx.doi.org/10.1155/2013/437948

References(2004). Traditional Chinese internal medicine. Beijing, Beijing : China Press of Traditional Chinese medicine.(2004). Zhong yi shi liao xue. Beijing Shi, Beijing Shi : Zhongguo Zhong yi yao chu ban she : .(2006). Zhong yi yao shan xue. Beijing Shi, Beijing Shi : Ren min wei sheng chu ban she : .(2009). Essentials of Chinese medicine. Z. Liu and L. Liu. London, London : Springer.(2009). Zhong yi ying yang zhi liao xue. Beijing, Beijing : Ren min wei sheng chu ban she : .Xie, Z. (2010). Contemporary introduction to Chinese medicine : in comparison with Western medicine. Beijing, Beijing : Foreign Languages Press.

_1177464974.xlsChart1

3.123.022.970.07548881470.08757605390.07831560080.07548881470.0875760539

3.233.193.050.06785511440.09695920250.07405931820.06785511440.0969592025

3.33.313.110.07633700370.08757605390.07235680510.07633700370.0875760539

3.413.343.160.07379243690.0896611980.07491057470.07379243690.089661198

3.33.513.20.07803338150.0886186260.08597690960.07803338150.088618626

Sham

True

Education

Time

Patient Global Assessment Score

Figure 1. Patient Global Assessment

Chart2

8.98.929.010.38162586110.28548950120.2880159570.28548950120.2880159570.3816258611

6.886.648.030.38162586110.27369937430.26359355130.27369937430.26359355130.3816258611

6.25.727.590.4146313410.27369937430.28885810890.27369937430.28885810890.414631341

6.115.187.120.43629118720.31833342620.28885810890.31833342620.28885810890.4362911872

6.044.856.890.4146313410.32675494540.29559532430.32675494540.29559532430.414631341

0 4 8 14 26

0 4 8 14 26

Sham

True

Education

Weeks

WOMAC Pain Score

WOMAC Pain Score

Chart3

31.2931.3132.481.21810849181.007017631.01563521681.21810849181.007017631.0156352168

25.1823.8527.581.32640772270.94743575350.93815724011.32640772270.94743575350.9381572401

23.2620.6426.791.33156482891.01373108080.93057787281.33156482891.01373108080.9305778728

21.4319.2425.941.38932441871.07666968270.9389993921.38932441871.07666968270.938999392

21.2518.0324.081.32228203771.06659950640.96847470921.32228203771.06659950640.9684747092

0 4 8 14 26

Sham

True

Education

Weeks

WOMAC Function Score

Figure 2 (Panel 2). WOMAC Function Score

Sheet1

SDSE

Global AssessmnetGroupBase.4-Wks8-Wks14-Wks26-WksBase.4-Wks8-Wks14-Wks26-WksBase.4-Wks8-Wks14-Wks26-Wks

Sham3.123.233.33.413.30.890.80.90.870.9213911.790.080.070.080.070.08

True3.023.193.313.343.510.920.870.850.881.0113811.750.080.070.070.070.09

Education2.973.053.113.163.20.840.930.840.860.85929.590.090.100.090.090.09

Group04814260481426Base.4-Wks8-Wks14-Wks26-Wks

Womac PainSham8.96.886.26.116.043.393.253.253.783.8814111.870.290.270.270.320.33

True8.926.645.725.184.853.423.133.433.433.5114111.870.290.260.290.290.30

Education9.018.037.597.126.893.73.74.024.234.02949.700.380.380.410.440.41

Group04814260481426Base.4-Wks8-Wks14-Wks26-Wks

Womac FunctionSham31.2925.1823.2621.4321.251211.2912.0812.8312.7114211.921.010.951.011.081.07

True31.3123.8520.6419.2418.0312.0611.1411.0511.1511.514111.871.020.940.930.940.97

Education32.4827.5826.7925.9424.0811.8112.8612.9113.4712.82949.701.221.331.331.391.32

_1177465087.xlsChart1

3.123.022.970.07548881470.08757605390.07831560080.07548881470.0875760539

3.233.193.050.06785511440.09695920250.07405931820.06785511440.0969592025

3.33.313.110.07633700370.08757605390.07235680510.07633700370.0875760539

3.413.343.160.07379243690.0896611980.07491057470.07379243690.089661198

3.33.513.20.07803338150.0886186260.08597690960.07803338150.088618626

Sham

True

Education

Time

Patient Global Assessment Score

Figure 1. Patient Global Assessment

Chart2

8.98.929.010.38162586110.28548950120.2880159570.28548950120.2880159570.3816258611

6.886.648.030.38162586110.27369937430.26359355130.27369937430.26359355130.3816258611

6.25.727.590.4146313410.27369937430.28885810890.27369937430.28885810890.414631341

6.115.187.120.43629118720.31833342620.28885810890.31833342620.28885810890.4362911872

6.044.856.890.4146313410.32675494540.29559532430.32675494540.29559532430.414631341

0 4 8 14 26

Sham

True

Education

Weeks

WOMAC Pain Score

Figure 2 (Panel 1). WOMAC Pain Score

Chart3

31.2931.3132.481.21810849181.007017631.01563521681.21810849181.007017631.0156352168

25.1823.8527.581.32640772270.94743575350.93815724011.32640772270.94743575350.9381572401

23.2620.6426.791.33156482891.01373108080.93057787281.33156482891.01373108080.9305778728

21.4319.2425.941.38932441871.07666968270.9389993921.38932441871.07666968270.938999392

21.2518.0324.081.32228203771.06659950640.96847470921.32228203771.06659950640.9684747092

0 4 8 14 26

Sham

True

Education

Weeks

WOMAC Function Score

WOMAC Function Score

Sheet1

SDSE

Global AssessmnetGroupBase.4-Wks8-Wks14-Wks26-WksBase.4-Wks8-Wks14-Wks26-WksBase.4-Wks8-Wks14-Wks26-Wks

Sham3.123.233.33.413.30.890.80.90.870.9213911.790.080.070.080.070.08

True3.023.193.313.343.510.920.870.850.881.0113811.750.080.070.070.070.09

Education2.973.053.113.163.20.840.930.840.860.85929.590.090.100.090.090.09

Group04814260481426Base.4-Wks8-Wks14-Wks26-Wks

Womac PainSham8.96.886.26.116.043.393.253.253.783.8814111.870.290.270.270.320.33

True8.926.645.725.184.853.423.133.433.433.5114111.870.290.260.290.290.30

Education9.018.037.597.126.893.73.74.024.234.02949.700.380.380.410.440.41

Group04814260481426Base.4-Wks8-Wks14-Wks26-Wks

Womac FunctionSham31.2925.1823.2621.4321.251211.2912.0812.8312.7114211.921.010.951.011.081.07

True31.3123.8520.6419.2418.0312.0611.1411.0511.1511.514111.871.020.940.930.940.97

Education32.4827.5826.7925.9424.0811.8112.8612.9113.4712.82949.701.221.331.331.391.32