Australian Traditional Medicine Society

Volume 19 | Number 4 | December 2013 Australian Traditional To Flex Journal of the Medicine or Extend? Society The Lumbar Spine An anatomical evaluation of skin scar tissue

Long-term use of supplemental Lysine - is it safe?

Burns and their management using homoeopathy

Nutraceuticals for Chronic Inflammatory Diseases Lindsay Brown discusses inflammation suppression

ISSN 1326-3390

Health Fund News | New Research | Book Reviews The Australian Traditional-Medicine Society Limited (ATMS) was incorporated in 1984 as a company limited by guarantee ABN 46 002 844 233. LIFE MEMBERS Dorothy Hall* - bestowed 11/08/1989 ATMS HAS THREE CATEGORIES OF MEMBERSHIP Simon Schot* - bestowed 11/08/1989 Accredited member Alan Jones* - bestowed 21/09/1990 Associate member Catherine McEwan - bestowed 09/12/1994 Student membership is free Garnet Skinner - bestowed 09/12/1994 Phillip Turner - bestowed 16/06/1995 MEMBERSHIP AND GENERAL ENQUIRIES Nancy Evelyn - bestowed 20/09/1997 ATMS, PO Box 1027 Leonie Cains - bestowed 20/09/1997 Meadowbank NSW 2114 Peter Derig* - bestowed 09/04/1999 Tel: 1800 456 855 Sandi Rogers - bestowed 09/04/1999 Fax: (02) 9809 7570 Maggie Sands - bestowed 09/04/1999 [email protected] Freida Bielik - bestowed 09/04/1999 www.atms.com.au Marie Fawcett - bestowed 09/04/1999 Roma Turner - bestowed 18/09/19999 PRESIDENT Raymond Khoury - bestowed 21/09/2002 Maggie Sands | [email protected] Bill Pearson - bestowed 07/08/2009 * deceased VICE PRESIDENT David Stelfox | [email protected] HALL OF FAME Dorothy Hall - inducted 17/09/2011 VICE PRESIDENT Marcus Blackmore - inducted 17/09/2011 Stephen Eddey | [email protected] Peter Derig - inducted 17/09/2011 Denis Stewart - inducted 23/09/2012 CEO Garnet Skinner - inducted 22/09/2013 Trevor Le Breton | [email protected] Copyright 2013. All rights reserved. The opinions TREASURER expressed in this journal are those of each author. Antoinette Balnave | [email protected] Advertisements are solely for general information and not necessarily endorsed by ATMS. DIRECTORS Peter Berryman | [email protected] Raymond Khoury | [email protected] Bill Pearson | [email protected] Daniel Zhang | [email protected]

Tribute to Alan Jones

It is with much sadness that I write these words in regards to the passing of Alan was a professional Homoeopath who brought his Alan Jones. passion, experience and expertise to his much loved modality. May I take this opportunity to send my sincere Alan was a founding member of ATMS - his membership number was 03. Alan condolences to Alan’s family on behalf of the ATMS Board, was one of the five original signatory’s to the ATMS Constitution signed on the past and present ATMS staff, the ATMS membership, and 4/9/1984 with Dorothy Hall, Roy Hand, Christine Berle and Garnet Skinner. The the Australian Homoeopathic community. signing was witnessed by Marie Fawcett, ATMS’s original and long standing Company Secretary. Thank you Alan for being one of my teachers, may you rest in peace. Without the wisdom, insight, dedication and strength of pioneers such as Alan, ATMS may not have been created three decades ago. In 1988 when I initially Yours faithfully commenced my ATMS directorship, Alan was the ATMS president. I learnt a great Maggie Sands deal from Alan. The inaugural president was Dorothy Hall and after Dorothy stepped down, Alan took on this important role as President from 1988 to 1992. ATMS President | Life member number 28 Journal of the Australian Traditional Medicine Society

Volume 19 | Number 4 Contents DECEMBER

196 PRESIDENT’S MESSAGE | M. SANDS 226 245 200 CRANIOSACRAL THERAPY: A CASE MEDIA WATCH CEO’S REPORT | T. LE BRETON STUDY TEALE, C. 246 ARTICLES RECENT RESEARCH 228 LONG-TERM USE OF SUPPLEMENTAL LYSINE - IS IT SAFE? BUMPSTEAD, L.

204 TO FLEX OR EXTEND? 252 MUSCOLINO, J. BOOK REVIEWS

232 NEWS BURNS AND THEIR MANAGEMENT USING HOMOEOPATHY MEDHURST, R. 254 HEALTH FUND NEWS 236 AN ANATOMICAL EVALUATION OF SKIN SCAR TISSUE 257 214 DE PERMENTIER, P. HEALTH FUND UPDATE NEUTRACEUTICALS FOR CHRONIC INFLAMMATORY DISEASES REPORTS 258 BROWN, L. CONTINUING PROFESSIONAL 242 EDUCATION LAW REPORT 222 HOMOEOPATHY, HUMANITARIAN AID AND 259 HOMOEOPROPHYLAXIS: PART 1 244 CONTINUING EDUCATION WOLLUMBIN, J. REGULATORY WATCH CALENDAR 2014

JATMS | December 2013 | 195 “It’s great for all of us as practitioners to reflect on why we do what we do and where our passion lies as we work in a truly amazing industry. An industry that often challenges the norm and an industry that is being embraced more and more by the general public.” Message President’sMaggieSands | ATMS President Life member number 28

ear Colleagues, those present if they believe in what your clients and contacts to join the they do. The answer was unanimously ’Friends of ATMS’ site on our homepage DAs 2013 draws to a close it is a yes! I then asked, ‘How much do you www.atms.com.au. We need members’ good time to reflect on the past believe in natural medicine?’ I pose this support to grow the ‘Friends of ATMS’ year but also to reflect on the journey question to you as you read this now, as site to add strength and spread the word we take to become a natural medicine it truly is a time to strengthen our belief of natural medicine. practitioner. I am sure you will agree in ourselves as practitioners, our industry, the journey of the natural medicine our practices and the benefits of natural Hall of Fame award recipient practitioner is in totality, on a road less medicine that we share with our clients, 2013 travelled and less understood by many. family and friends. It was a great honour to award Garnet Although our practitioner numbers have Skinner the Hall of Fame award at held strong for decades, our practices One of my favourite sayings is ‘The only the AGM. For those who may not are challenged more than ever in these way to do great work is to love what you know Garnet, he was one of the current times. With this in mind it is do’ by Steve Jobs (now sadly deceased). original driving force members who important that we stay committed and It’s great for all of us as practitioners to remain a strong community, striving to reflect on why we do what we do and assist fellow humans, many with serious where our passion lies as we work in and challenging health and quality of a truly amazing industry. An industry life issues. that often challenges the norm and an industry that is being embraced more At the ATMS AGM at Tweed Heads and more by the general public. I suggest recently I spoke about who we are, this is an actual reflection of so many what we do and why we do what we people gaining good health outcomes do. I am sure we all have our own from our services. It is essential that natural medicine practitioner journey through ongoing challenges we story as many of us are drawn to personally reflect on our intent, ignite assist others from our own personal our passion and unite as like-minded life challenges which may have been people. I strongly believe that the work physical, emotional, mental and or we do and the services we provide will spiritual. Most practitioners I know have override the challenges presented to us a personal story that has led them to if we collectively focus on our combined take this journey and as a community intent to assist humanity. There is always this assists to bind us in our common strength in numbers. To assist us grow Garnet Skinner intent and purpose. At the AGM I asked the strength, thanks again for asking

196 | vol19 no4 | JATMS was signatory to the inaugural ATMS 2. the value of naturopathic medicine outstanding 12,000. Truly amazing - that’s constitution on 7th September, 1984 in providing safe, effective and 12,000 like-minded people! A special along with Dorothy Hand (Hall), affordable health care be recognized, thank you to all the ATMS office staff and founding president and Hall of Fame Trevor CEO who do their best to serve recipient, Roy Hand (Dorothy’s 3. the people of the US be encouraged all the membership. The office is made husband), Alan Jones (past president) to learn about naturopathic up of a remarkable high spirited team. and Christine Berle. The document medicine and the role that With 30 modalities, 12,000 members was witnessed by Marie Fawcett (past naturopathic physicians play in and 30 colleges there is a lot going on all company secretary for 24 years). Garnet preventing chronic and debilitating the time. With the new-look refurbished is a very special human being and a illnesses and conditions. office and new staff uniforms the office deeply knowledgeable man. Now in his is looking more professional than ever. 80’s, he has been a pioneer in natural Amazing news! Simply inspiring, so let’s medicine and taught many natural spread this news with clients, family, I take this opportunity to offer a medicine practitioners throughout friends and politicians. If you would like heartfelt farewell to Cherie Walkerden. Australia. Garnet’s ATMS membership a copy of the resolution send a request Cherie has been a driving force at the number is 004. We sincerely thank to [email protected] or it’s easy to office for some 14 years. Many members Garnet for his contribution to ATMS find on the Internet. will know Cherie for her can-do and his passion for the advancement personal approach to members. The of natural medicine in Australia. Garnet, Board innovation Board offer Cherie enormous thanks for you will be remembered for all you have The Board, with renewed spirit her dedication and the spirit she has given to so many. and focus, have been working hard bought to her position as office manager. in numerous areas and projects You will be missed, Cherie and we wish Community spirit to assist to advance the practices of ATMS you happiness and fulfillment for the fellow members affected by members and natural medicine. Several next part of your journey. recent fires new committees are well under During October many areas of NSW way, including the new Regulatory Along with the Continuing Education were severely affected by fires. An appeal Committee chaired by Director Committee chaired by Stephen Eddey, for assistance was launched on both the Raymond Khoury and the Media Watch the CEO and I are looking at ways to ATMS facebook page and via direct email Committee chaired by Director Stephen reinvent the ATMS Continuing Education on Wise and Well. The response from Eddey. Please note inaugural articles program, offering a wider variety of ATMS members to assist other fellow from both committee chairs are in this events with greater national coverage to members who suffered in the fires was journal. Much has been happening in allow all members greater opportunity heart-warming. As president and on the area of regulation and ATMS is proud to be involved in professional education behalf of the ATMS Board of Directors, to demonstrate industry leadership in a development and to accrue the annual the CEO and office staff we sincerely variety of current challenges. 20 mandatory CE points. thank those members who have donated a treatment to a fellow practitioner who The CEO Trevor Le Breton and myself In November ATMS hosted a special may need a helping hand to deal with have been meeting with stakeholders free seminar targeted at Asian massage the trauma that can arise from such in various states to further develop and practitioners at the Sydney Institute a potentially devastating experience. enhance relationships. Now that ATMS of Traditional Chinese Medicine in This is a real community effort and a has accredited its 30th modality Polarity Sydney’s Chinatown regarding health reflection of unity of spirit amongst Therapy, we are focused on working funds. The seminar was facilitated by like-minded people and ATMS members. with smaller associations who support myself with the assistance of the CEO Thank you again to all who have rallied single therapy modalities and assisting and two members, who are graduates to assist others in need. them with various matters that can arise, from the college and who translated in particular association governance. The the presentation into both Chinese and United States Senate ATMS Board has an inclusive policy to Korean to assist those in attendance Resolution regarding assist all natural medicine stakeholders to have a full understanding of health Naturopathic Medicine when and where possible and to fund regulations. Special guest for the On 10/9/13 the senate on the US develop mutually beneficial relationships evening was Peter Dunn, the Medibank considered and resolved that: to assist the advancement of natural National Manager. ATMS is endeavouring medicine in Australia. to educate Asian practitioners in regard 1. there would be an annual to aspects of what is required for health Naturopathic Medicine week Recently ATMS was proud to announce fund status and to advise Asian members 7-13 October, that its membership number had hit an that all associations have a zero tolerance

JATMS | December 2013 | 197 PRESIDENT’S MESSAGE

policy to health fund compliance by the full Board at the December Board issues. A special thank you to ATMS meeting. Each committee has a very director Daniel Zhang for his invaluable different focus and intent, however all assistance in working with the Chinese are essential areas that provide service to practitioner community. the membership, move our association forward and show leadership to the Also in November a meeting of current natural medicine industry. ATMS committee chairs was called. Current chairs include David Stelfox, The Marketing Committee consisting of Chair of Academic Review Committee, CEO Trevor Le Breton, Alanna Hinds from Antoinette Balnave, Chair of Finance Hindsight Marketing and myself meet President Maggie Sands meeting with former Audit and Compliance Committee, on a regular basis to move the branding Director Kevin Watkins on recent trip to Adelaide Raymond Khoury, Chair of both of ATMS forward. There is much ground Complaints Committee and Regulation to cover but projects are well underway Committee, and Stephen Eddey, Chair of with the new fresher, healthier ATMS look. Continuing Education and Media Watch Wishing you and your loved ones a Committees. The purpose of the meeting Before finishing my report for this relaxing and joy-filled break and a time was to focus on each Committee’s plan journal a personal thank you for being to renew and refresh spirits. Family and for 2014 and how it aligns with the a part of the ATMS community. We have community are essential components of overall ATMS Strategic Plan. The Board members in every corner far and wide our own health as ‘Individually we are a of ATMS predominantly moves projects of this great nation and together we are drop but together we are an ocean’. forward via its committee work. This part of the health solution and health important meeting sets the focus for the revolution. Believe in what you do, focus My very best regards, year ahead. After the committee plans on the intent of your work and together were created they were then voted on we are a sizeable force. Maggie Sands | ATMS President

elcome to the December 2013 to attend would agree that the day was associations would agree to administer edition of JATMS. a mixture of celebrating the past, but members to ensure their access to W importantly gaining a greater appreciation advertising remains as they presently A time to reflect of where we are heading in the future. enjoy. More information will be available This edition marks twelve months since Congratulations to foundation member on this via our newsletter and website as the Board appointed me as your CEO. Garnet Skinner on being inducted into the discussions continue. During that time we have seen many Hall of Fame, a fitting reward for a lifetime changes both at Board and in recent of dedicated service to our industry. Association of Remedial times some staff changes. However, Masseurs (ARM) one thing that has not changed is the Therapeutic Goods For some time ATMS has been in commitment from our President Maggie Administration (TGA) discussion with representatives from Sands, the management team and the As reported previously the TGA proposed ARM about how members may apply to remainder of the Board to continue to changes to the advertising requirements join other associations and continue to work on all aspects of ATMS so that we for practitioner-only products, potentially operate in practice in the event that ARM remain the leaders of natural medicine. impacting the ongoing livelihood of ceased to continue to operate. ARM have our ingestive members (naturopaths, invited your President and I to a meeting We currently have ten, very active homoeopaths, herbalists and nutrionists). of members on Sunday 3rd November, and committees, working through On 25th August ATMS hosted a forum by the time you receive this Journal it is reviewing standards, refining processes on the issue attended by National our expectation that many former ARM for members and developing our Manager for TGA, Professor John members will have joined the other 7700 brand and what it stands for. We are Skerritt. A transcript of the forum can Remedial Massage members which ATMS also working closely with external be located on the ATMS website or by presently represents. stakeholders so that ATMS and its contacting the office. Since then our members have a strong, passionate Regulatory Committee and I have met The cost of operating for many voice in a variety of discussions which with Professor Skerritt and his team to associations is becoming an ever presently face our industry. understand their requirements for the increasing concern, as too the ageing future. In keeping with our leadership demographic for many groups putting AGM role in industry ATMS hosted a meeting financial pressure on their future Sunday 22nd September at the Twin of ingestive stakeholders on Friday viability. Your President and I have been Towns Resort Tweed Heads marked 25th October. From this meeting a draft in discussion with several other groups the day and venue for our 29th AGM. It discussion model has been developed providing advice and support as they was a privilege to meet with so many which outlines the minimum educational work through these troubled times. members, and those who made the effort requirements and the manner in which Should they find that they can no longer

200 | vol19 no4 | JATMS provide relevant ongoing services to OUR MANAGEMENT AND BOARD HAVE SET OURSELVES AN their members, we have offered to them AMBITIOUS TARGET OF 95% RETENTION AND TO THE END OF that ATMS is available as a solution to their members’ future needs. OCTOBER I AM PLEASED TO ANNOUNCE THAT WE SIT AT 95.8% Facebook AND HAVE OVERALL MEMBERSHIP GROWTH OF 2.1%, WITH OUR ATMS is fast becoming one of the STUDENT MEMBER NUMBERS ALMOST DOUBLE THE SAME TIME most followed sites for people seeking AS LAST YEAR. information on natural medicine. In the past twelve months our ‘follower’ numbers have swollen by almost double to just below 4000. We know that not all a few changes have been made over of topics including education levels, members are followers, but encourage the years, it is essentially the same behaviour and ethics within the you to sign up for free, and receive Constitution. Organisational structures massage sector with Medibank, HCF regular information about our industry, and corporate governance best practice and representatives from the Industry ATMS specifically, and regular information have changed considerably in the last 29 Skills Council. It has become apparent on the 30 modalities that ATMS is now years. In order to bring the Constitution that the funds have expectations responsible for. Many people external to in line with best practice, the review of associations that in some cases ATMS are regularly monitoring what we is necessary. The draft Constitution outweigh the ability of some to comply have to offer them and we encourage will be released for member comment with the requirements. I am pleased to you, our members, to have your clients in early 2014. There will be a 30 day say that what is being asked of ATMS is sign up to the Friends of ATMS site to consultative period for members to offer in the main what we have done for the get regular Facebook and email news suggestions and changes. The draft will past 29 years and will continue to do. on developments in our industry. As we be posted on the ATMS website and engage further with Government the sent via Wise-n-Well. At the end of the As a further step to ensure our members reforms we seek will require ‘people consultative period, members’ comments fully understand what is expected of power’ weight of numbers. The more will be considered and changes adopted them an event has been organised for late passionate support we have about the accordingly. An Extraordinary General November to address requirements for services you provide on a day to day Meeting of members will be held on 26 recording clinical records, issuing receipts basis, the more likely our message will be March 2014. All members are encouraged and processing of member payments. heard – sign up today. It’s FREE! to participate in the review process. The Constitution belongs to the members, As members have often stated it is a ARE you really accredited? and the new Constitution should reflect shame that a few make it so difficult for This is a gentle reminder to all accredited the members’ views. the rest, and to that end the Board have members that in order for you to be adopted a ZERO TOLERANCE policy to eligible to retain your status and have Health funds and Associations behaviour of members who blatantly are your details forwarded to Health Funds You will recall that in September in breach of our CODE OF CONDUCT. you must be FINANCIAL, you must have Medibank removed 55 practitioners Make sure you have a copy and a CERTIFICATE OF CURRENCY for across 250 locations nationwide. Since understand how it appplies to you. both Public Liability and Professional that time ATMS has conducted a number Indemnity Insurance and a current First of seminars on recording clinical Members should be reminded that your Aid Certificate. If any one of these three records and been in discussion with provider number is for your exclusive key pieces of information is missing you Medibank about future requirements. use, not to be shared and should be are NOT accredited and ATMS will be A further meeting was held on 8 kept safely so others cannot access. removing members from funds during November, where Medibank and ATMS Additionally this number cannot be used December who do not meet these work through a list of requirements at multiple locations simultaneously. If requirements. If in doubt, please check expected of the fund from associations you require further information on these with our office immediately. in the administration of members. I points contact our offices immediately. remain confident that these issues Constitution will be resolved in the favour of our Membership For many months the management members before Christmas. During October we introduced our team and the ATMS Board of Directors 12,000th member to the Society – have been reviewing the Society’s During October a meeting of key welcome Jessica Bateman #27911 from Constitution. The present Constitution massage associations was organised Tasmania who is accredited with ATMS was compiled in 1984, and although by ATMS and AMT to discuss a range for kinesiology.

JATMS | December 2013 | 201 CEO’S REPORT

On the financial front Director decided to stand down from the announce that Cherie Walkerden had position. Nominations for the forthcoming decided that after thirteen years that our goal is to increase Board elections to be held in August 2014 this will be her last with ATMS. Cherie will be called for in the new year. will finish up on our last day of the revenue by some 12% year. Cherie has seen many changes Financials in her time at ATMS and has at all over the 2013/14 On the financial front our goal is to times operated in a professional way. increase revenue by some 12% over Personally I want to extend my gratitude financial year; and I the 2013/14 financial year; and I am to Cherie for her assistance as I settled delighted to advise that we are well on into my new role. Thank you just doesn’t am delighted to advise track to achieving this KPI. Our overall say enough. goal is to ensure financial sustainability that we are well on for the Society, and with high member I am delighted to advise that internally retention, new member growth and Karen Fan has been promoted to the track to achieving consistent income from our other role of Health Funds and after a little revenue streams this has been the negotiating Charlotte Kennedy will this KPI cornerstone of our ongoing success. be returning to take on the role of Assistant Registrar, building us a strong One of the key measures of our success Representatives update membership-focussed team for the future. is our membership retention rate. Most The Board continue to work on a new associations can attract new members model for representatives, taking on As always for further information please with offers; however it is far more board the feedback that each of the do not hesitate to contact me directly. expensive to attract a new member than former State Representatives provided. A to keep those who are already on our workshop of representatives will be held On behalf of all the team at Meadowbank, list. Our Management and Board have once the final requirements have been we thank you for your ongoing support set ourselves an ambitious target of 95% agreed. However it is highly likely that and we value your membership. Please retention and to the end of October I am a far greater number of people will be have a very safe, peaceful and Merry pleased to announce that we sit at 95.8% required to cover the broad geographic Christmas and may the New Year deliver and have overall membership growth of area that our membership extends. you everything you wish. 2.1%, with our student member numbers almost double the same time as last year. Office administration/Staff Take Care. For those who were at the AGM you Board Matters would have been saddened, as I was, to Trevor Le Breton | CEO As is required under our present Constitution, an election took place at the September Board meeting prior to our AGM. It is my pleasure to announce that the existing Executive were returned unopposed. This is an endorsement of the renewed energy that the Executive have brought to ATMS since the commencement of the new Financial Year. Your Executive comprises Maggie Sands (President) and to support her, David Stelfox has been appointed Senior Vice-President and Stephen Eddey has stepped up to be our other Vice- President. Antoinette Balnave remains as Treasurer and Chair of the Finance Audit and Compliance Committee.

I would also like to acknowledge long standing Director and Life Member Staff at the ATMS office in Meadowbank. L-R: Cass Zogbee, Xiao Ling Wu, Nicole Crowley, Sandi Rogers who has after two stints Andrew Crowley, Heidi Drieschner, Adi Chettiar, Jackie Kassab, Sylvie Kassab, Trevor Le Breton, as President and several decades as a Jennie Hyde, Sue Dryden, Karen Fan

202 | vol19 no4 | JATMS JATMS | December 2013 | 203 ARTICLE

To Flex or Extend? Joseph Muscolino, DC

This article originally appeared in Massage Therapy Journal Fall 2013. It is reprinted with permission from the author.

204 | vol19 no4 | JATMS hen a client presents with a same time by a massage therapist. A pathologic lumbar disc, there client with a pathologic disc condition Wis a divide in the world of can be under the supervision of a manual and movement therapy: Do we physician and also benefit from massage treat the client with flexion or do we and other manual therapies. avoid flexion and instead treat the client with extension? There are proponents The Lumbar Spine for each method, and unfortunately these The lumbar spine is composed of five proponents often divide along rigid vertebrae that sit on the base of the ideological lines, each one believing that sacrum. Because in anatomic position their approach is the superior one. As is the pelvis/sacrum is anteriorly tilted often the case, whenever two differing approximately 30 degrees, there is a treatment approaches exist, usually both natural lordotic curve to the lumbar spine. are valid. So how do we decide which The healthy lordotic curve varies from method to use with the next client who individual to individual, but on average is presents with a pathologic disc? approximately 40-50 degrees (Figure 1).

As with all clinical orthopedic work, Lumbar Spinal Joints the answer lies in choosing the correct At each segmental level of the treatment approach based on the lumbar spine, there are three joints: specific pathomechanics of the client’s an intervertebral disc joint located condition and the needs of the client anteriorly, and paired left and right at that moment. Not all pathologic disc facet joints located posteriorly. The FIGURE 1 conditions are the same, and therefore not disc joint is composed of three major THE LUMBAR SPINE HAS A NORMAL all clients with a pathologic disc condition parts: cartilaginous vertebral endplates LORDOTIC CURVE OF APPROXIMATELY will respond the same. Making the best that cap the bodies of the vertebrae, a 40-50 DEGREES decision requires a clear understanding fibrous annulus fibrosus that is located of biomechanics, which ultimately rests circumferentially between the vertebral on a fundamental understanding of bodies, and a thick gel-like nucleus musculoskeletal anatomy and physiology, pulposus in the center bounded by in other words, kinesiology. the fibers of the annulus fibrosus. The facet joints are synovial joints, located Also located between each two adjacent Note: Because a pathologic disc is between the inferior articular processes vertebrae are two intervertebral foramina potentially a very serious condition, of the superior vertebra and the (IVFs), through which the spinal nerves with possible permanent effects, it superiorarticular processes of the inferior from the spinal cord pass. An IVF is is important to refer any client who vertebra. Each facet joint is bounded by a formed by a notch in each of the two presents with this condition to a fibrous joint capsule containing synovial adjacent vertebrae, that when placed physician. Referral does not mean that fluid; and the joint surfaces are capped together form the foramen for the entry/ the client cannot also be treated at the with articular cartilage. exit of the spinal nerve (Figure 2).

FIGURE 2 DISC AND FACET JOINTS OF THE SPINE. INTERVERTEBRAL FORAMEN, IVF.

JATMS | December 2013 | 205 ARTICLE

THE MORE SERIOUS CONSEQUENCES OF A PATHOLOGIC DISC compression upon the nucleus can cause ARE USUALLY DUE TO COMPRESSION OF NEURAL TISSUES. it to bulge the annular fibers outward, creating what is known as a bulging BECAUSE OF HOW STRESS FORCES ARE USUALLY PLACED ON THE disc. If the annular fibers are sufficiently INTERVERTEBRAL DISCS, BULGING AND HERNIATION MOST OFTEN stressed, they can rupture, allowing the nuclear material to extrude through the OCCUR POSTEROLATERALLY. annulus; this is called a ruptured disc prolapsed disc or herniated disc. Lumbar pathologic discs most often occur in the lower lumbar region, at the L4-L5 or L5- Lumbar Joint Function spine is a weight-bearing structure; the S1 joint levels (Figure 3). The degree of motion that exists in lumbar spine must bear the weight of any region of the spine is primarily the entire body above it. The disc joints Pain from a pathologic disc can determined by the thickness of the discs, bear approximately 80% of the weight; occur due to the irritation of local whereas the direction of motion best the facet joints bear the remaining 20%. structures, such as the annular fibers allowed is determined by the orientation It is important to note that as weight themselves or the posterior longitudinal of the facet joints. In the lumbar spine, bears through the disc joint, the nucleus ligament. However, the more serious the facet joints are oriented in the sagittal pulposus is compressed, pushing it consequences of a pathologic disc are plane. For this reason, sagittal plane outward away from the center and usually due to compression of neural motions of flexion and extension occur against the fibers of the annulus. Weight tissues. Because of how stress forces freely in this region. From anatomic bearing also affects the facet joints by are usually placed on the intervertebral position, the lumbar spine allows compressing their joint surfaces. discs, bulging and herniation most approximately 50 degrees of flexion and often occur posterolaterally. When approximately 15 degrees of extension. Pathologic Disc this occurs, the disc protrudes into This totals 65 degrees of sagittal plane When the intervertebral disc is healthy, the IVF and can compress the nerve motion; quite impressive given that this the nucleus is confined within the fibers root, causing symptoms into the motion occurs across only five segmental of the annulus fibrosus. However, the lower extremity on that side (midline joint levels. In addition to motion, the accumulation of physical stresses to the posterior bulges/herniations occur less disc can weaken the annular fibers. These frequently because the annulus fibrosus stresses can be macrotraumas such as a is reinforced in the midline by the car accident or a fall; and/or they can be posterior longitudinal ligament). Because repetitive stress microtraumas that occur the nerve roots of the lower lumbar due to such things as poor postures or spine contribute to the sciatic nerve, the ongoing compression force of weight pathologic lumbar discs usually cause bearing. Regardless of the cause, if the symptoms of sciatica referring down annulus is weakened, weight-bearing into the lower extremity.

It is important to point out that the IVF can also be narrowed due to calcium FIGURE 3 deposition (bone spurs) PATHOLOGIC DISCS COMPRESSING SPINAL NERVES. A BULGING DISC at the joint margins; this IS SEEN AT THE L%-S1 DISC AND A HERNIATED DISC IS SEEN AT THE condition is known as L4-L5 DISC. OSTEOARTHRITIC (DEGENERATIVE JOINT DISEASE) osteoarthritis or degenerative BONE SPURS ARE SEEN ON THE BODY OR L3. joint disease.

206 | vol19 no4 | JATMS Degenerated Disc In addition to bulging and herniated discs, there is a third pathologic condition of the intervertebral disc known as degenerative disc disease (DDD). DDD involves breakdown/degeneration of the annular fibers and desiccation of the nucleus pulposus. This results in thinning of the disc, which can be seen on X-ray; the space that the disc occupies between the adjacent vertebral bodies will be decreased in height. DDD is a normal part of aging and is usually asymptomatic. But if it is advanced in degree, it can potentially cause symptoms. Thinning causes approximation of the vertebral bodes, which decreases the size of the IVFs, increasing the likelihood of nerve compression within the IVF (compare the healthy disc in Figure A with the degenerated disc in Figure B). Because DDD involves degeneration of the annulus, it also increases the chance that the annular fibers will weaken and bulge, or perhaps herniate. Interestingly, if the nucleus pulposus is sufficiently desiccated, it exerts less pressure against the annular fibers and the likelihood of a bulging or herniated disc actually goes down. This is why the incidence of nerve compression from pathologic disc conditions decreases in senior citizens.

Figures courtesy of Joseph E. Muscolino.

Therefore, there are two major responsible for the nerve compression factors at play when a client has a and resulting symptoms. It is important Positive (+) and Negative (-) bulging/herniated disc. One is the to point out that the IVF can also be Effects of Flexion and disc lesion itself, in other words, narrowed due to calcium deposition Extension Upon the the weakened or ruptured fibers of (bone spurs) at the joint margins; this Lumbar Spine the annulus fibrosis. The second is condition is known as osteoarthritis the encroachment within the IVF or degenerative joint disease. When Flexion of the annulus or nucleus pressing the size of the IVF narrows, it is also (-) Drives the nucleus posteriorly on the nerve. Once the pathologic described as foraminal stenosis. against posterior annular disc is present, a third factor occurs. fibers Because of the irritation caused by Flexion versus Extension the compression upon the nerve The question now becomes: What (-) Places tensile force upon root, it usually becomes inflamed. are the mechanical forces of flexion the posterior annular fibers, Given that the IVF is a narrow closed and extension upon the lumbar spine, pulling them taut space, there is little chance for the and how do these forces affect the swelling to escape, so it remains in pathologic disc and nerve compression? (+) Increases size of IVFs the IVF, further compressing the nerve It turns out that each movement has root. It is often the size of the bulge/ positive and negative effects upon the (+) Unloads the facets herniation plus the swelling that is lumbar spine. (-) Loads the discs

(+) Stretches the paraspinal musculature

Extension (+) Relieves pressure on posterior annular fibers

(+) Relieves tensile force upon the posterior annular fibers

(-) Loads the facets

(+) Unloads the discs

(+) Strengthens the paraspinal FIGURE 4A EFFECTS OF SPINAL FLEXION

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Tight paraspinal musculature is often of the facets can lead to osteoarthritic (also known as degenerative joint responsible for directly causing low back pain. disease) bone spurs, which can further narrow the size of the IVF, increasing the More importantly for a pathologic disc, if the likelihood that a bulging or herniated disc will cause compression of a nerve paraspinal musculature is tight, it pulls in toward root there (See Figure 3). its center, thereby creating a compression force Of course, if the facets are unloaded, the compressive load that is removed from upon the discs of the spine the facets must be placed somewhere. Given that flexion is an anterior motion, the load is shifted anteriorly onto the discs. In typical anatomic position, the The Effects of Flexion However, flexion also has positive effects discs normally bear 80% of the weight- The worst effect of flexion upon the upon the lumbar spine. As the lumbar bearing load and the facets normally lumbar spine is that it compresses spine flexes, the IVFs increase in size bear the remaining 20%. So not only the anterior disc. This has two approximately 19%. This can be very does flexion preferentially load the consequences. First, it drives the helpful if there is compression of the anterior discs, it also increases the overall nucleus pulposus posteriorly against the nerve root within the IVF, which usually compressive load on the discs. posterior annular fibers. is a major aspect of a pathologic disc condition. Another positive effect that Flexion has another positive effect: Second, it pulls the posterior annular flexion has upon the lumbar spine is not It stretches all posterior tissues of fibers taut (Figure 4A). The combination directly disc-related, but important none- the spine, including the paraspinal of the tensile force pulling these fibers the-less. Flexion unloads compression (erector spinae and transversospinalis) taut as the pressure from the nucleus force from the facets. This can be musculature. Tight paraspinal is exerted against them can lead to important if the client has irritation or musculature is often responsible for their degeneration. The fibers begin inflammation of the facets, common directly causing low back pain. More to fray; and cracks form within them. in people who have the typical lower- importantly for a pathologic disc, if the This can lead to weakening of the crossed syndrome marked by excessive paraspinal musculature is tight, it pulls posterior annulus and eventual bulging anterior pelvic tilt and hyperlordosis in toward its center, thereby creating a and/or herniation. Unfortunately, most of the lumbar spine. However, it is compression force upon the discs of the activities of life are performed down in important to note that the presence spine. Increasing compression of the front of us, requiring repetitive flexion of compression force upon the facets discs can then increase nucleus pressure movements of the lumbar spine. For this can indirectly affect the client with upon the annulus, thereby increasing the reason, proponents of extension decry pathologic disc. Via Wolff’s Law, which size of the bulge or herniation. Therefore, the use of further flexion as part of the states that calcium is laid down on bone loosening tight paraspinal muscles can treatment program for a client with a in response to physical forces placed benefit a client’s pathologic disc. pathologic disc. upon the bone, compression loading The Effects of Extension The position of lumbar extension places compression upon the posterior disc instead of the anterior disc. This has two important sequelae. First, the annulus is driven anteriorly instead of posteriorly, removing its pressure from the posterior annular fibers. Second, the tensile force upon the posterior annular fibers is removed, so that it is no longer pulled taut. The combination of these two factors can have the direct effect of lessening the degree of a posterolateral bulge or herniation, thereby decreasing FIGURE 4B compression of the spinal nerve roots EFFECTS OF SPINAL EXTENSION within the IVFs.

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FIGURE 5A FIGURE 5C FLEXION TECHNIQUES FLEXION TECHNIQUES Therapist-assisted double knee Self-care double knee to chest stretch to chest stretch

FIGURE 5B FLEXION TECHNIQUES Table that allows for flexicon of the spine

Note: Extension will cause the same paraspinal musculature is also better of the discs. So not only does extension negative effects upon the anterior able to meet the demands placed upon remove loading of the anterior aspect annular fibers that flexion causes it, lessening the likelihood that it will be of the disc, by shifting weight-bearing upon the posterior annular fibers. overburdened and strained. to the facets, it decreases the overall However, because of the relative lack load upon the discs. of extension postures during our life, However, extension can also have there is less accumulated physical negative effects upon the lumbar spine. Flexion and Extension stress to the anterior annular fibers, and Extension decreases the size of the Treatment Techniques therefore less likelihood of bulging/ IVF by approximately 11% (Figure 4B). If we choose to use flexion as our herniated discs anteriorly. Further, Given that the greatest consequences treatment approach for a client with the anterior disc is reinforced by the of a bulging/herniated disc are due a pathologic disc, it is typically done anterior longitudinal ligament, which is to the neural compression of the disc by performing double knee to chest very strong. And even if there were an upon the spinal nerve within the IVF, stretching. By bringing the knees to anterior disc bulge or herniation, there decreasing the size of the IVF could the chest, the client’s pelvis posteriorly are no neural tissues located anteriorly potentially increase compression of tilts, thereby moving their spine into that would be compressed. the nerve, further inflaming it and flexion (Figure 5A). Flexion distraction worsening the condition. technique is another flexion-based If the extension position is created treatment option that is available by the client actively engaging The position of extension also for those therapists with tables that their extensor musculature to move compression loads the facet joints; as allow for the caudal (foot) and/or their trunk against gravity up into stated previously, via Wolff’s Law, this cephalad (head) end of the table to extension, there is the added benefit of could increase bone spur formation drop. Regarding self-care directions for strengthening paraspinal musculature. at the facets, which could further the client, either double knee to chest This can help to stabilize the spine decrease the size of the IVF. The and/or a sitting trunk flexion stretch and protect the discs (and facet joints) upside of this is that loading the facets (Figures 5 BC) can be recommended. from excessive physical stress. Strong commensurately results in unloading The benefits derived from flexion are

210 | vol19 no4 | JATMS Flexion and Extension Treatment Techniques

FIGURE 6A EXTENSION SELF-CARE EXERCISES Passive extension of the spine supported by the forearms

FIGURE 6B EXTENSION SELF-CARE EXERCISES Active extension created by contraction of the paraspinal extension musculature.

The benefits derived from extension are based extension exercises for their low back? Looking at the biomechanics on relieving stress on the posterior annular of a pathologic disc with nerve compression within the IVF, it would fibers and strengthening the paraspinal seem that the answer lies in which aspect of a pathologic disc is more extensor musculature. problematic for the client when they present: The bulge/herniation of the annulus or the compression of the opening up the IVFs and stretching the McKenzie exercises. The benefits nerve root within the IVF? This might paraspinal extensor musculature, as well derived from extension are based on be a difficult question to answer as decompressing the facets. relieving stress on the posterior annular because neural compression due to a fibers and strengthening the paraspinal pathologic disc involves both factors, If we choose to instead treat the extensor musculature. which is why each approach works pathologic disc client with extension, with some clients, and not with others. although it is possible to stretch the To Flex or To Extend? client’s trunk into extension, it is If both flexion and extension positions A clue might lie in whether the size of not logistically easy to do so. For this can be beneficial for the low back, and the IVF is decreased for other reasons reason, extension oriented treatment specifically for a pathologic lumbar such as osteoarthritic bone spurs or the strategy is often based on directing the disc condition, it brings us back to presence of inflammation/swelling. Bone client to perform self-care stretching our original question: When a client spurs can be seen on X-Ray as well as and strengthening extension exercises presents with a pathologic lumbar on CT scan or MRI. If IVF narrowing is (Figure 6). This approach has been disc, do we utilize flexion-based occurring largely due to osteoarthritic made popular by the physical therapist, treatment techniques or do we avoid bony hypertrophy, flexion might be the Robin McKenzie; for this reason, flexion-based postures and instead better course. The more information extension exercises are often called recommend that the client perform you have from radiographic findings,

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Decompression and movement Flexion is problematic because it compresses the anterior spine; and extension is problematic because it compresses the intervertebral foraminal spaces and the facet joints. Therefore, whether flexion or extension is performed, spinal compression occurs. It might be argued that what is most important is not necessarily whether the therapist employs flexion or extension, but rather to avoid compression of the spine. Therefore, with either approach, many therapists recommend that the client focuses on elongating the spine so that it is decompressed. A helpful cue for the client is to ask them to imagine that there is a string that is pulling their head straight up.

It should also be emphasized that movement in most every direction is of paramount importance. No posture is necessarily bad, as long as the client doesn’t get stuck in it. The human body is meant to move. Movement works our muscles and joints, stretches and strengthens soft tissues, facilitates neural patterning, and promotes the circulation of body fluids, including a pumping action of the nucleus pulposus so that nutrient supply to the disc tissue of clients with pathologic disc conditions is improved. Ultimately, the goal of all manual and movement therapy is graceful and pain-free functional motion.

the better able you might be to decide choose one approach and follow it for whether to use flexion or not. For this a number of sessions: a period of two reason, it is important to request that to four weeks would be a fair length of the client either give you a copy of the time to see if the approach is working. If radiographic reports, or you consult the client responds favorably and begins directly with their physician. The to clearly improve, continue with this presence of swelling is more challenging approach. If the client does not improve, to determine, but as a rule, the more or if the client’s condition worsens, then acute and aggravated the condition, the the alternative approach can be tried. greater the likelihood that swelling is present. Therefore, acute disc episodes What is most important is to might favor a flexion approach. understand the pathomechanics of a pathologic disc condition as well Conversely, if the client is experiencing as the (bio)mechanics of flexion and a pathologic disc episode that is chronic, extension as treatment approaches. an extension approach is more likely Working from a fundamental indicated. Given that inflammation understanding of the kinesiology of usually subsides with chronicity, the body allows for critical reasoning extension would seem to be the wiser and therefore creative application of choice in the long term because it assessment and treatment techniques, unloads the posterior annular fibers, which ultimately results in a more decreasing the bulge or herniation. successful clinical orthopedic practice! Whichever approach is used to relieve the client’s episode in the short run, an understanding of lumbar disc mechanics Joe Muscolino is a Doctor of Chiropractic. seems to indicate that extension is the He has been an instructor in the world of best approach for the long run. massage therapy for over 25 years. Joe will travel to Australia and teach a In the absence of detailed radiographic series of clinical orthopedic manual therapy findings and/or other information that workshops from 8-23 February, 2014. would help us make this decision, a For more information, visit default guideline might be to simply www.learnmuscles.com.

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Nutraceuticals for Chronic Inflammatory Diseases

Lindsay Brown | BPharm PhD, Professor of Biomedical Science,

University of Southern Queensland, Toowoomba, Australia

214 | vol19 no4 | JATMS as infectious agents and damaged cells. Abstract The signs of acute inflammation are well- Inflammation is clearly involved in the initial cellular changes that initiate chronic known as pain, heat, swelling and loss of diseases such as cardiovascular disease, cancer, obesity, diabetes and central function. These signs may not be obvious nervous system disorders. Inflammation increases with normal ageing, and in non-communicable diseases, as these increases further in disease states. Suppression of inflammation can delay the onset diseases are considered as chronic of these chronic diseases, and possibly reduce the symptoms. This suppression low-grade inflammation and usually can occur with selective synthetic chemicals and also with natural products, some occur in the internal organs of the derived from foods and so defined as nutraceuticals, to reduce disease symptoms. body. Continuation of the inflammatory Pre-clinical testing of nutraceuticals has been undertaken by my research process, even at a low rate, may damage group using rats fed a high carbohydrate, high fat diet to initiate inflammation, some of the body’s own cells. Disease is obesity, hypertension, fatty liver and glucose intolerance. This research has unlikely to develop immediately, but may produced options derived from foods that may be useful for chronic treatment of take decades before clinical symptoms inflammatory diseases in patients, especially in an ageing population. are evident, as in atherosclerosis.

The important regulator of cellular hronic inflammation is a major Glance 2007 (www.aihw.gov.au/ responses to inflammation is the protein cause of non-communicable publication-detail/?id=6442468045). NFkB (nuclear factor kappa-light-chain- Cdiseases, especially in the ageing In 2009, cardiovascular disease caused enhancer of activated B cells). This population. This article will review about 33% of all deaths in Australia, and protein induces hundreds of genes the extent of the problem, and then cancer about 29% of all deaths. Australia’s with critical roles in many physiological discuss whether nutraceuticals, defined Health 2012 details that both cancer and pathological processes.1 NFkB is as medicines from foods, could help in and cardiovascular disease are more critical to the protection of integrity in the prevention or treatment of chronic common in the elderly; for example, 62% multicellular organisms by controlling inflammatory diseases. of Australians aged 75 and over have a cytokine production, for example, cardiovascular condition compared with during infections. As such, it is usually The World Health Organisation (WHO) 5% in Australians aged under 45 years. chronically activated during long-term collects data on the incidence of chronic inflammatory disorders,1 including diseases, accessible at https://apps.who. cancer.2 After the threat to the organism’s int/infobase/, including an informative integrity has passed, the NFkB activation map library of this data (http:// The role of the gut needs to be down-regulated to prevent gamapserver.who.int/mapLibrary/ continuous inflammation.3 Inflammatory app/searchResults.aspx). The WHO bacteria in obesity is mediators include the eicosanoids, estimates that, of 57 million global deaths biologically active lipids formed from in 2008, 63% or 36 million were due to now beginning to receive arachidonic acid by cyclo-oxygenases, non-communicable diseases (www.who. lipoxygenases or epoxygenases. int/gho/ncd/mortality_morbidity/ attention, as these The cyclo-oxygenases produce the en/). The WHO includes four main different prostaglandins that have been diseases in this category - cardiovascular bacteria may change extensively studied for their role in diseases, cancers, diabetes and chronic human diseases including inflammation, lung diseases. The non-communicable energy extraction from cancer, arthritis and cardiovascular risk disease profile for Australia is diseases.4,5 The role of the gut bacteria available from either WHO data (https:// the diet, and also the in obesity is now beginning to receive apps.who.int/infobase/CountryProfiles. attention, as these bacteria may change aspx) or the Australian Institute of host metabolism of energy extraction from the diet, and Health and Welfare (www.aihw.gov.au/ also the host metabolism of absorbed publications/), especially their biennial absorbed calories calories.6 Could the gut bacteria also be reports on the health of Australians, with the source of the initiators of the low- the latest being Australia’s Health 2012 grade inflammation that defines obesity? (www.aihw.gov.au/publication- Inflammation is likely to be the cause detail/?id=10737422172). Like that of of the initial cellular changes that The concept that the tissue damage many developed countries, Australia’s eventually result in non-communicable leading to chronic diseases is initiated by population is ageing; this has been diseases. The complex processes of inflammation leads to questions that may documented in Australia’s Health 2012 inflammation start as a repair response of help us understand the therapeutic role as well as in Older Australians at a the body to remove harmful stimuli such of nutraceuticals.

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OBESITY INCREASES THE RISK OF A SURPRISING RANGE OF abnormal metabolism, altered hormonal DISEASES. THE MOST OBVIOUS ONES ARE CARDIOVASCULAR signaling and increased inflammation that promote damage to the brain. DISEASE, DIABETES AND FATTY LIVER. Neurologic disorders as varied as complex neurodevelopmental disorders such as Prader-Willi syndrome to chronic neuropathologic disorders IF INFLAMMATION INITIATES DISEASES IF AN INCREASED INFLAMMATION IS such as epilepsy, multiple sclerosis and THAT ARE MORE COMMON IN THE ASSOCIATED WITH VASCULAR AGEING, Alzheimer’s disease have all been linked AGEING POPULATION, DOES THIS MEAN CAN SUPPRESSION OF INFLAMMATION to obesity.13 THAT INFLAMMATION IS INCREASED PREVENT THE ONSET OF AGEING- EVEN IN HEALTHY AGEING? RELATED VASCULAR DYSFUNCTION? DOES REDUCTION OF INFLAMMATION The answer is probably yes. One The answer to this question is also a REDUCE DISEASE SYMPTOMS? example is the ageing of the probable yes. Interventions such as There is widespread evidence for vasculature, independent of the onset of caloric restriction and exercise are this concept. The non-steroidal anti- cardiovascular disease, where decreased effective in reversing the increased inflammatory drugs (NSAIDs) are used ageing-related endothelial function oxidative stress and inflammation of throughout the world to relieve pain is related to oxidative stress and vascular ageing, and also decrease from minor tissue damage. Another inflammation.7 Vascular ageing includes the risk of cardiovascular disease.7 clear example is the improvement structural and functional changes in Recent studies have emphasised that in joint pain and swelling in patients both the endothelial cells that line an increased release of interleukin-6 with rheumatoid arthritis treated with the blood vessels and in the smooth from skeletal muscle suppresses pro- etanercept, a soluble TNFα receptor muscle cells that allow contraction of inflammatory factors and also increases that decreases the ability of TNFα to the vessels.7 Characteristics of ageing the release of interleukin-10, a potent induce inflammation.14 Intakes of fruits, vessels include an impaired endothelial anti-inflammatory molecule.8 vegetables, cereals, legumes and spices control of vascular tone by release of have been linked to age-associated the endogenous dilator nitric oxide DOES SUSTAINED LOW-GRADE chronic diseases all having inflammation (NO). Ageing vessels lose elasticity by a INFLAMMATION, ABOVE THAT IN as a major activator; however, this loss of elastin between the cells and an AGEING, CAUSE DISEASE? association does not prove that increase in collagen within the vessel There is now a wide consensus that interventions with these products will wall. This then increases the stiffness obesity can be accurately described reduce these chronic diseases.15 of the vessel wall, compromising as a chronic low-grade inflammation.9 adaptation to the blood pressure Obesity increases the risk of a changes in the normal cycle of the surprising range of diseases. The heart. There is also a reduced capacity most obvious ones are cardiovascular Peroxisome to repair blood vessels even in the disease, diabetes and fatty liver. Obesity healthy ageing patient. The endothelial induces systemic inflammation, proliferator-activated progenitor cells that are critical for release of adipokines such as leptin endothelial cell regeneration are fewer and adiponectin, and endothelial receptors play in the ageing patient and show a dysfunction.10 Obesity increases the decreased ability to function. Further, risk of cancers, especially endometrial, important roles in the oxidative stress is increased in the colorectal, postmenopausal breast, vascular wall as there is an increased prostate and renal cancers, with two of many biological physiological production of superoxide the key pathogenic links being chronic and other reactive oxygen species. inflammation and oxidative stress.11 The pathways, including Low concentrations of superoxide are estimate is that 20% of all cancers are important for cellular signaling, but caused by obesity, increasing to 50% in lipid, protein and higher concentrations may damage postmenopausal women. Inflammatory essential cellular machinery. This processes play a key role in colorectal glucose metabolism, increase in damaged cells may activate cancers with adipose tissue the inflammatory pathways in these macrophages secreting tumor necrosis and are also cells. In addition, superoxide reacts factor-α, monocyte chemoattractant very quickly with NO, the endogenous protein-1, and interleukin-6, all linked prominent players in vasodilator, and so decreases the local to colorectal cancer.12 The brain is also control of the vascular tone.7 a target of obesity as this promotes inflammation control

216 | vol19 no4 | JATMS WHAT IS THE EVIDENCE THAT and herbs and spices, although Western These compounds show potential NUTRACEUTICALS CAN REDUCE dietary sources may be insufficient to in experimental studies of obesity, INFLAMMATION? prevent diseases.16 but development of their potential Modern treatment of inflammation in the effective and safe treatment of relies on compounds such as the WHAT IS THE EVIDENCE THAT human obesity requires clinical trials.18 glucocorticoids and aspirin, both NUTRACEUTICALS CAN REDUCE OBESITY The same comment applies to the natural products, as well as synthetic AND HYPERTENSION BY REDUCING chronic treatment of hypertension compounds including ibuprofen INFLAMMATION? with nutraceuticals. Oxidative stress and naproxen. The gold standard Peroxisome proliferator-activated and inflammation can initiate and anti-inflammatory compounds receptors (PPARs) play important roles propagate hypertension, but many trials are the glucocorticoids such as in many biological pathways, including of nutraceuticals for hypertension are dexamethasone, semisynthetic lipid, protein and glucose metabolism, small and do not have long-term follow- derivatives of hydrocortisone and are also prominent players in up for efficacy and adverse effects.19,20 produced by the adrenal cortex. The inflammation control.9,17 Since these However, these studies indicate that a use of salicylate-rich preparations for receptors are important in control of combination of lifestyle changes and treatment of inflammation dates from adipose tissue and liver inflammation, pharmacological treatments will best the third millennium BC, including a they could play a role in control of reduce cardiovascular risk. later description by Hippocrates of obesity and fatty liver. PPARs may also the use of the bark and leaves of the up-regulate anti-inflammatory genes. WHAT IS THE EVIDENCE THAT willow, so long before the development Natural products that may modulate NUTRACEUTICALS CAN REDUCE of acetylsalicylic acid (aspirin) by PPARy and therefore improve obesity CANCERS BY REDUCING Bayer in 1897. Salicylates are present include the tocopherols and tocotrienols, INFLAMMATION? in many foods, including tomato-based omega3 fatty acids, curcumin, resveratrol The role of inflammation suppression in sauces, fruit and fruit juice, tea, wine, and flavonoids such as genistein.18 the treatment of cancers is now a major

FIGURE 1 FOODS WITH COMPONENTS THAT REDUCED OBESITY IN RATS FED A HIGH CARBOHYDRATE FAT DIET (L TO R). Purple carrots and anthocyanins27; onions and rutin28; grapefruit and naringin29; strawberries and ellagic acid30; peanuts and L-arginine31; chia seeds and alpha-linolenic acid.32

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research topic. One example is chronic There is now increasing recognition that dietary lymphocytic leukaemia (CLL) where pro-inflammatory pathway inhibitors saturated fats may change the intestinal bacteria, such as the tyrosine kinase inhibitors including ibrutinib induced impressive increasing the Firmicutes to Bacteroidetes ratio, clinical responses in CLL patients with relapsed or refractory disease.21 and therefore increasing the local inflammatory Aspirin is an effective chemopreventive agent for colorectal cancer, reducing responses in the intestine both incidence and mortality.22 Cyclo- oxygenase-dependent effects are important, but independent effects concentrated forms of products from in drinking water.23 Rats showed such as an increased degradation of foods. These definitions will overlap, progressive increases in body weight, IkBα, the inhibitor protein that usually with differences being subjective rather energy intake, abdominal fat deposition maintains NFαB in the cytoplasm, as well than objective. and abdominal circumference along as acetylation of biomolecules, have also with impaired glucose tolerance, been implicated.22 WHAT PRECLINICAL STUDIES ARE dyslipidaemia and increased plasma NECESSARY TO DEFINE THE POTENTIAL insulin, leptin and malondialdehyde SHOULD PATIENTS BE ASKED TO TAKE OF NUTRACEUTICALS IN OBESITY? concentrations. Cardiovascular signs NUTRACEUTICALS AS FUNCTIONAL Since obesity has been defined as a included increased systolic blood FOODS OR DIETARY SUPPLEMENTS? chronic low-grade inflammation, we pressure and endothelial dysfunction The answer will depend on the situation. hypothesised that treatment with anti- together with inflammation, fibrosis, Nutraceuticals, as a combination from inflammatory compounds would reverse hypertrophy and increased stiffness food for nutrition and pharmaceuticals obesity. We developed a rat model of in the left ventricle. The liver showed for disease, defines compounds from diet-induced metabolic, cardiovascular increased wet weight, fat deposition, food sources that provide health and liver changes by feeding male rats inflammation and fibrosis with increased benefits in addition to basic nutrition. for 16 weeks with a high carbohydrate, plasma activity of liver enzymes. This Functional foods are considered to be high fat diet containing condensed diet-induced model closely mimics the enriched foods eaten in forms similar to milk (39.5%), beef tallow (20%), changes observed in human metabolic the natural state to provide physiological fructose (17.5%), salt mixture (2.5%), syndrome. We then determined the benefits or reduce the risk of chronic rat food (15.5%) and water (5%), and importance of inflammation by showing disease. Dietary supplements are supplementing with fructose (25%) that these diet-induced changes could be reversed by novel compounds including KH064 (secretory phospholipase A2 inhibitor),24 3D53 and SB290157 (complement receptor antagonists)25 and GB88 (PAR2 antagonist)26 that selectively target inflammatory mechanisms. We further showed that dietary supplementation with foods or their components including purple carrots,27 rutin,28 grapefruit,29 ellagic acid,30 L-arginine31 and n-3 polyunsaturated fatty acids32 (Figure 1) reversed the diet-induced metabolic, cardiovascular and liver changes. The key mechanism is the prevention of inflammatory cell infiltration into the heart, liver and fat pads by these interventions, despite continuing the high carbohydrate, high fat diet. This will lead to prevention of the tissue damage Members of the research laboratory (L to R): Dr Sunil Panchal, Dr Mark Lynch, Maharshi Bhaswant, caused by these excess inflammatory Prof Lindsay Brown, Sharyn Canrahan, Dr Kate Kauter, Senthil Arun Kumar, Siti Raihanah Shafie and Dr cells, and so possibly prevent or delay Hemant Poudyal chronic disease. These results strongly

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suggest that certain foods contain non- References mechanisms. Curr Opin Clin Nutr Metab Care nutritive components that can reverse 1. Baltimore D. NF-kB is 25. Nature Immunol 2013;16:595–600. the chronic low-grade inflammatory 2011;12:683-5. changes in heart, liver and fat pads in 13. Lee EB, Mattson MP. The neuropathology diet-induced obesity, without toxicity. 2. Ben-Neriah Y, Karin M. Inflammation meets of obesity: insights from human disease. These rat studies indicate that human cancer, with NF-α B as the matchmaker. Acta Neuropathol doi 10.1007/s00401-013- studies could be successful and so need Nature Immunol 2011;12:715-23. 1190-x. to be undertaken. 3. Ruland J. Return to homeostasis: 14. Lethaby A, Lopez-Olivo MA, Maxwell L, There is now increasing recognition Burls A, Tugwell P, Wells GA. Etanercept that dietary saturated fats may change downregulation of NF-α B responses. 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Further controlled studies will supplements for the treatment of be welcomed. 10 Diaz-Melean CM, Somers VK, Rodriguez- hypertension. Part 1. J Clin Hypertens Escudero JP, Singh P, Sochor O, Llano EM, (Greenwich) 2013;15:752-7. Natural products are clearly a part of our Lopez-Jimenez F. Mechanisms of adverse diet; the development of nutraceuticals is cardiometabolic consequences of obesity. 20. Houston MC. The role of nutrition, a logical extension. Separating anecdote Curr Atheroscler Rep 2013;15:364. nutraceuticals, vitamins, antioxidants, and from evidence that the intake of minerals in the prevention and treatment nutraceuticals improves health remains 11. De Pergola G, Silvestris F. Obesity as of hypertension. Altern Ther Health Med a priority. The increasing understanding a major risk factor for cancer. J Obes 2013;19 Suppl 1:32-49. of the role of chronic inflammation 2013; Article ID 291546, http://dx.doi. in noncommunicable diseases gives org/10.1155/2013/291546. 21. Rozovski U, Keating MJ, Estrov Z. a solid foundation for further studies Targeting inflammatory pathways in on the anti-inflammatory properties of 12. Guffey CR, anF D, Singh UP, Murphy EA. chronic lymphocytic leukemia. Crit Rev nutraceuticals. Linking obesity to colorectal cancer: Oncol Hematol. 2013 doi: 10.1016/j. recent insights into plausible biological critrevonc.2013.07.011.

220 | vol19 no4 | JATMS 22. Ferrández A, Piazuelo E, Castells A. Aspirin 26. Lim J, Iyer A, Liu L, Suen JY, Lohman R-J, Seow 30. Panchal SK, Ward L, Brown L. Ellagic acid and the prevention of colorectal cancer. Best V, Yau M-K, Brown L, Fairlie DP. Diet-induced attenuates high-carbohydrate, high-fat Pract Res Clin Gastroenterol 2012;26:185-95. obesity, adipose inflammation and metabolic diet-induced metabolic syndrome in rats. Eur dysfunction correlating with PAR2 expression J Nutr 2012;52:559-68. 23. Panchal S, Poudyal H, Iyer A, Nazer R, Alam are attenuated by PAR2 antagonism. FASEB J; MA, Diwan V, Kauter K, Sernia C, Campbell doi: 10.1096/fj.13-232702. 31. Alam MA, Kauter K, Withers K, Sernia C, F, Ward L, Gobe G, Fenning A, Brown L. Brown L. Chronic L-arginine treatment High carbohydrate-high fat diet-induced 27. Poudyal H, Panchal S, Brown L. Comparison improves metabolic, cardiovascular and liver metabolic syndrome and cardiovascular of purple carrot juice and β-carotene in complications in diet-induced obesity in rats. remodeling in rats. J Cardiovasc Pharmacol high carbohydrate, high fat diet-fed rat Food Funct 2013;4:83-91. 2011;57:611-24. model of metabolic syndrome. Br J Nutr 2010:104;1322-32. 32. Poudyal H, Panchal SK, Ward LC, Brown 24. Iyer A, Lim J, Poudyal H, Reid RC, Suen JY, L. Effects of ALA, EPA and DHA in high- Webster J, Prins JB, Whitehead JP, Fairlie DP, 28. Panchal SK, Poudyal H, Arumugam TV, Brown carbohydrate, high-fat diet-induced Brown L. An inhibitor of phospholipase A2 L. Rutin attenuates metabolic changes, non- metabolic syndrome in rats. J Nutr Biochem group IIa modulates adipocyte signaling alcoholic steatohepatitis, and cardiovascular 2013;24:1041-52. and protects against diet-induced metabolic remodeling in high carbohydrate-, high syndrome in rats. Diabetes, 2012;61:2320-9. fat-fed rats. J Nutr 2011;141:1062-9. 33. Kuo S-M. The interplay between fiber and the intestinal microbiome in the inflammatory 25. Lim J, Iyer A, Suen JY, Seow V, Reid RC, Brown 29. Alam MA, Kauter K, Brown L. Naringin response. Adv Nutr 2013;4:16-28. L, Fairlie DP. C3aR and C5aR antagonists improves diet-induced cardiovascular each inhibit diet-induced obesity, metabolic dysfunction and obesity in high 34. Slavin J. Fiber and prebiotics: mechanisms dysfunction, adipocyte, and macrophage carbohydrate, high fat diet-fed rats. Nutrients and health benefits. Nutrients 2013;5: signalling. FASEB J 2013;27:822–831. 2013;5:637-50. 1417-35.

JATMS | December 2013 | 221 ARTICLE

Homoeopathy, Humanitarian Aid and Homoeoprophylaxis: Part 1 Jimi Wollumbin

Abstract Homoeopathy has a 200 year history of use in epidemic diseases and arose during a period of history when Europe’s sanitation and nutritional levels were comparable to those of many developing countries today. This has resulted in a significant body of information around the treatment and prevention of many of the diseases encountered in international relief efforts and community development today. In 2012 One Health Organisation (OHO) conducted a pilot project in India with its collaborative partner Traditional Healthcare to assess the viability of using homoeopathy to increase host resistance to malaria. This article documents OHO’s experience, together with some of the relevant classical literature and more recent studies in order to better disseminate knowledge that has clear applications for modern humanitarian aid seeking to include holistic approaches.

222 | vol19 no4 | JATMS Dr Jimi Wollumbin, CEO, One Health Organisation, with a 9 year-old client suffering from malarial encephalitis-induced brain damage. This photo was taken shortly after the clients very first unassisted walk following 3 weeks of treatment with acupuncture.

Project Background too many’.3 With some commentators Homoeoprophylaxis’ The rural communities of Datom and suggesting that the death rate could Historical Uses surrounding localities in the Ranchi double in the next twenty years,1 holistic The history of the use of homoeopathic district of Jharkhand, North-East India, medical practices should continue to be medicines in epidemics, both curatively lack any semblance of an accessible evaluated for the contributions they may and preventatively, dates back to the public healthcare facility. Community make to this global epidemic. founder of homoeopathy, Samuel members requiring urgent and/or Hahnneman, when in 1801 he published specialised medical treatment are Pathology an article titled ‘The Prevention and Cure required to make a train journey (often Malaria is a disease caused by four of Scarlet Fever’:2 preceded by a lengthy walk) of up to parasites, all of which are transmitted by five hours to one of the two hospitals female mosquitoes. General symptoms ‘Who can deny that perfect prevention in Ranchi where healthcare is available are intermittent fever, headache, general of infection from this devastating – a trip that is both unaffordable and malaise, and bone and waist pain. scourge, the discovery of a means infeasible for the severely ill or infirm. The diagnosis is confirmed by clinical whereby this divine aim may be surely Frequently, individuals and families who presentation and a thick blood smear. attained, would offer infinite advantages do manage to make this trip are forced over any mode of treatment, be it of to curtail their hospital treatment early the most incomparable kind soever? due to financial constraints. The most … The remedy capable of maintaining prevalent infectious disease in the area is the healthy uninfectable by the miasm malaria, which afflicts a large percentage IN 1813 AN EPIDEMIC of scarletina, I was so fortunate as to 3 of the population. In response to FOLLOWED THE DEVASTATION discover.’ this urgent need, the team from the Traditional Healthcare project, with the OF NAPOLEON’S ARMY Hahnemann also wrote on his 4 support of One Health Organisation, MARCHING THROUGH experiences with typhus epidemics. have created open air clinics since In 1813 an epidemic followed the 2005 while constructing sustainable GERMANY TO ATTACK RUSSIA. devastation of Napoleon’s army healthcare facilities. WHEN THE EPIDEMIC CAME marching through Germany to attack Russia. When the epidemic came through Epidemiology THROUGH LEIPZIG AS THE Leipzig as the army pulled back from Malaria is presently endemic in a broad ARMY PULLED BACK FROM the east, Hahnemann was able to treat band around the equator, in areas of 180 cases of typhus and documented the Americas, many parts of Asia, and THE EAST, HAHNEMANN WAS a 1.5% mortality rate as opposed to 5 much of Africa. Based on documented ABLE TO TREAT 180 CASES OF the conventional figures of 30%. As a cases, the WHO estimates that there result of experiences such as this and were 216 million cases of malaria in TYPHUS AND DOCUMENTED the reported success in preventing 1 2010 resulting in 655,000 deaths. The A 1.5% MORTALITY RATE and curing cholera that Hahnemann majority of cases occur in children under himself documented,6 homoeopathy’s five years, with 65% of cases occurring AS OPPOSED TO THE professional acceptance bloomed, and 2 in children under fifteen. Raymond CONVENTIONAL FIGURES within a single generation had expanded Chambers, the UN Secretary General’s into most European countries and some Special Envoy for Malaria, states that ‘one OF 30% American states. By the time of the 1831 child still dies every minute from malaria pan-European cholera epidemic official - and that is one child and one minute mortality statistics were available from

JATMS | December 2013 | 223 ARTICLE

By the time of the 1854 London cholera epidemic the success of homoeopathic medicine in epidemics had come to be seen as a threat by practitioners of the conventional medicine of the day

a wide range of sources that compared and preventing nineteenth century that under allopathic care mortality was the results of conventional care and epidemics.8 The allopathic editor of 59.2% while under homoeopathic care it homoeopathic treatment.7 A well the Dublin Quarterly Medical Journal was only 9%.10 regarded textbook of the time, Osler’s wrote in response to the documented ‘Principles and Practice of Medicine’, results in Austria that ‘On account of this Results in the new world were no less reported a cholera mortality rate of a extraordinary result, the law interdicting dramatic, with the infamous 1850’s terrifying 80% under normal treatment, the practice of homoeopathy in Austria yellow fever epidemics that swept whereas the Imperial Council of Russia was repealed.’ These results were not through the southern states of the USA listed 40% and the Austrian government anomalous,9 and were repeated in the claiming mortality rates of up to 85%, figures were 66%. The homoeopathic 1849 French cholera epidemic, where according to official Osler’s statistics, mortality rates from the same epidemic a single homoeopathic doctor treated whereas the mortality figures gathered at however were as follows: 1662 cases, with a mere 49 deaths homoeopathic hospitals were between resulting in a 2.9% mortality rate, as 5% and 6%.11 The New York diphtheria • Average mortality in the ten London opposed to the conventional rate of over epidemics of 1862-1864 yielded a similar homoeopathic hospitals examined: 9% 10%. In recognition of this, Napoleon III disparity, with Bradford recording the bestowed a Legion of Honour and Pope mortality rate under conventional care as • King of Bavaria’s report on Pius IX awarded an Order of St Gregory 83.6%, whereas the mortality rate among homoeopathy: 7% to the doctor.8 By the time of the 1854 patients treated homoeopathically was London cholera epidemic the success of only 16.4%. Based on figures such as • Imperial Russian Council’s report: 10% homoeopathic medicine in epidemics this the Homoeopathic Mutual Life had come to be seen as a threat by Insurance Company was formed, and • Austrian homoeopathic mortality: 33% practitioners of the conventional offered lowered premiums for clients medicine of the day, with the records under homoeopathic care. In 1878 they This is a good example of what of the many homoeopathic hospitals recorded 7927 policies for clients under public health historian Dana Ullman being omitted from the report to the homoeopathic medical care and 84 summarised as ‘the astounding House of Lords so they didn’t ‘skew the deaths, making a mortality rate of 1.06%, success’ of homoeopathy in treating results’. The suppressed report revealed whereas among 2258 clients under

224 | vol19 no4 | JATMS allopathic medical care there were 66 deaths, a 2.92% mortality fever similarly succumbed to advances in town planning and rate. A non- homoeopathic client was therefore almost three public health, as fleas and mosquitoes were more effective times more likely to die, which explains the higher premiums managed. Finally, significant increases in nutrition had reduced they were forced to pay for life insurance policies.8 the previously high mortality rates of otherwise mild diseases (measles, mumps, rubella, scarlet fever, rheumatic fever and The Experience of the 20th Century whooping cough) to their current low levels. However, the By the beginning of the twentieth century.12 The American rising epidemic of the era was poliomyelitis, which in 1950 Institute of Homoeopathy’s 1916 report documented that was confirmed by the UK Ministry of Health to be associated patronage of homoeopathy had grown to rival conventional with conventional inoculations.15 A series of homoeopathic medicine, with 35.5% of the population seeking homoeopathic trials was conducted throughout this period but due to the care. They listed the following figures for the previous year: closure of the previously established medical infrastructure they were smaller ones.16 The largest of these, which involved • 101 accredited institutes representing 20,092 beds for up to 40 000 patients, was conducted in Brazil, which had been in-patient treatment unaffected by the Flexner Report.17

• 109,527 hospital patients treated during the previous fiscal year The second part of this article will be published in the March 2014 issue of JATMS. A full list of references will be published along with • The dispensary departments of these institutions treated Part 2. 287,887 out-patients

• An average mortality rate of only 4.1%

When the Spanish flu pandemic struck two years later in 1918 it killed an estimated 4%, or 675000 Americans, and infected around 500 million people worldwide, with somewhere between 30-50 million lives lost.8 Fortunately for us, significant figures were able to be documented by the established hospitals practising homoeopathic medicine due to the above-mentioned healthcare infrastructure. The Journal of the American Institute for Homoeopathy reported in May 1921 that of 24000 cases treated conventionally the mortality rate was 28.2%, meaning almost one in three contracting the illness died from it. By comparison, of the 26000 cases treated homoeopathically in accredited homoeopathic institutes the mortality rate was only 1.05%. This figure was further supported by Dean W.A. Pearson of Philadelphia who collected 26,795 cases of flu treated with homoeopathy with the above result.10

By the 1930’s, following the controversial closure of most non- conventional medical institutes due to the Flexner Report’s recommendation on uniformity in medical education and practice, the focus of homoeopathy and infectious disease had shifted from the field into the laboratory. In 1938 a French researcher, Dr Chavanon, conducted trials on diphtheria which suggested that lasting immunity was conferred by preventative homoeopathic treatment with the nosode, using the recently invented Schick test.13 These results were then reproduced by British researchers in 194114 and 19438 indicating possible protection for up to five years after a single dose.

At this point in history advances in public sanitation had largely removed the occurrence of cholera, typhus and diphtheria, as water supplies contaminated with effluent had been the root cause of these diseases. Typhus and yellow ARTICLE

Craniosacral Therapy: A Case Study Chris Teale | Physiotherapist and Certified CranioSacral Therapist

saw baby Ali* who was six weeks temporal bones. There was an associated her father to allow her to suck on his old for attachment issues and the decrease in normal craniosacral little finger. This was a practice they Itendency to hold her head to the right expansion of the cranial base. Her used at home to comfort her and as side. Her mother was referred to me by sacrum had a right lateral torsion she relaxed her hyoid bone posterior a visiting community midwife. Ali’s birth and fascial tension radiated from her cervical tension released. I then used was an uncomplicated 17 hours, with respiratory diaphragm anteriorly into a gloved finger to palpate her vomer, final stage lasting 15 minutes. Her mum her neck, with her hyoid bone deviated a small bone that articulates with the felt that Ali had some signs of colic and to the right. Associated with this was an soft palate and sphenoid, which was was a bit whiney but her main problem increase in tension of the deep posterior restricted and which released while Ali was attachment, with mum resorting to cervical muscles. sucked on my finger. a nipple shield due to discomfort and stress caused by feeding. She also had a In the initial treatment I released the She was now quite settled and on re- tendency to short sleeps in the day, being sacral torsion and fascial tension of the evaluation of her cranial system there unable to sleep past one sleep cycle. respiratory diaphragm which radiated was increased craniosacral rhythm anteriorly into her neck. This was of her right temporal and occipital The visiting midwife thought it was achieved by applying less than 5gms bones. I finished her session with a related to the baby’s high palate and of pressure to the tissues, allowing Ali’s decompression of her sphenoid. This suggested that Ali try CranioSacral body to release in its own time. The bone along with occiput and temporal Therapy. On evaluation, she was a happy release was confirmed when heat was bones forms the cranial base, one of the and settled baby but she tended to released from the tissues. My fingers most vulnerable areas during childbirth. lie with her head to the right, which settled on Ali’s hyoid while I cupped corresponded with some obvious her posterior cervical muscles. As she On her follow up-session, Mum had flattening of the right occipital and became slightly agitated I encourage reduced using her nipple shield to 2-3

Some pictures of babies not from case study

Sphenoid decompression Tentorium cerebellum release - horizontal membrane system

226 | vol19 no4 | JATMS times per day rather than with every time to feed and the symptoms that they feed. This was more precautionary than thought were colic had now disappeared. necessary, as her Mum had felt quite She still had a slight tendency to favour stressed by the pain that had occurred the right although it was now hard to during feeding and wasn’t keen to distinguish the flattening of the occiput re-experience it. Ali had also changed and temporal bones that was initially her sleep pattern and was now having present. On evaluation there was still at least one long sleep in the day. On some restriction of the cranial and spinal palpation the sacral, diaphragm and membrane system and right trapezius hyoid releases were maintained, but muscle. The final treatment included there was still some restriction of the gentle dural releases, and stretches to posterior cervical muscles, right occiput the right trapezius muscle, which her and temporal bones. Treatment focused parents could do at home. They phoned on releasing her cranial base, including a week later to say that she was now the occiput and temporal bones, and the comfortably sleeping with her head horizontal membrane system, particularly resting spontaneously on either side. on the right. Frontal bone release On her third visit Ali’s Mum had stopped *baby’s name changed for confidentiality using her nipple shield altogether and was very happy. Ali was taking a lot less NEED CPE POINTS! • Positional release therapy • Craniosacral Therapy • Acupressure Increase your skill set with light Touch therapies!

Call 0438 584 123 or visit our website for times and dates www.craniosacraltherapy.com.au

JATMS | December 2013 | 227 ARTICLE

Long-term Use of Supplemental Lysine – Is it Safe? Lea Bumpstead | BHSc (Nut Med), Prof Ext Dip Herb Med, MEAA Safety Cons. Lea is currently working as a nutritionist in the Geelong area. Email: [email protected]

Abstract The amino acids lysine and arginine have been shown to respectively inhibit and stimulate herpes simplex virus (HSV) replication. Lysine supplements have been used over the last three decades to inhibit viral replication, shorten the duration of herpetic blisters and help prevent recurrence. However arginine has many physiological roles in the body and as it uses the same intracellular transport routes as lysine there is the potential for adverse effects due to a relative arginine deficiency. There is also the potential for adverse effects on renal function due to increased amino acid intake.

Background Clinical and anecdotal evidence suggests In 1977 Griffith, Norins and Kagan1,2 that the benefits of lysine supplements discovered that if arginine was added are obtained with doses from 394mg to isolated HSV in a petri dish, the virus to 3000mg, and ranging up to 9000mg. would multiply. However, when lysine In one double blind study using a dose was added the virus’s ability to multiply of 1000mg t.d.s, after six months lysine was inhibited. In 1983 they ran a small was rated as effective or very effective study on 45 human subjects by 74% as opposed to 28% on placebo, which supported their with the conclusion that L-lysine is an hypothesis that lysine effective agent for reduced occurrence, would inhibit the HSV severity and healing time for recurrent in vivo. A subsequent HSV infection.3 study in 1983 expanded the research to 1543 participants which Studies have yielded mixed results; For again supported the therapeutic example, a 1984 study by DiGiovanna application of lysine. and Harvey found no benefit.4 But this may have been due to factors such as the dose tested being too low for therapeutic benefit, the severity of the outbreak, the large number of dropouts in the placebo group and whether the supplement was used prophylactically or post-outbreak. Some studies have also used synthetic non-biologically active d-lysine.

The most common side effects reported from acute usage are nausea, diarrhoea and weakness. Side effects appear to be minimised if doses are divided into Ball-and-stick model of the L-lysine cation, (S)-2,6-diammoniohexanoate, [C6H15N2O2]+, smaller ones and ingested with foods from the crystal structure of L-lysine monohydrochloride dihydrate containing protein.

228 | vol19 no4 | JATMS Arginine anti-atherosclerotic.6,7,8 Endothelial Arginine is a conditionally essential dysfunction is associated with amino acid as it can be obtained atherosclerosis and cardiovascular from the diet and is synthesised disease. Arginine administration has endogenously from the amino acid been shown to improve endothelial citrulline and sourced from the function in animals and humans breakdown of proteins in the body. with hypercholesterolemia and Arginine synthesis from citrulline atherosclerosis.12 occurs primarily in the small intestine and the renal tubules in the kidney.5,6,8 Defective gallbladder motility is implicated in cholesterol gallbladder Infants and people with kidney disease. Nitric oxide plays an important or small intestine damage require role in gallbladder motility by exogenous sources due to the reduced triggering relaxation of the gallbladder ability to synthesise arginine. Arginine and allowing emptying, thereby becomes essential in pathological reducing the build-up of gallstones.13,14 states such as sepsis, burns, trauma or Supplemental lysine has been linked surgery.6,8 Low plasma arginine levels to hypercholesterolemia and gallstone are a hallmark of sepsis.8 Arginine formation in animal studies.15,16 deficiency is also a feature of sickle Skeletal formula of the L-lysine monocation cell disease.9 Nitric oxide is also important for male reproduction due to effects on sperm Arginine is important for the production and for achieving and an intact gut lining and weakened by transport, storage and removal of maintaining erections.7,8 Nitric oxide intestinal permeability. excess nitrogen and ammonia.7 In triggers the synthesis of cyclic GMP one patient with small intestine and which causes calcium uptake leading to kidney damage an arginine deficiency muscle cell relaxation, vasodilation and LYSINE IS AN ESSENTIAL led to hyperammonemia and resultant increased blood flow to the penis. As AMINO ACID; IT IS NOT disturbed consciousness, which were an example of the importance of this corrected with supplemental arginine.10 pathway for achieving and maintaining SYNTHESISED IN THE BODY erections, the drug Sildenafil (Viagra) AND MUST BE OBTAINED Arginine is converted to ornithine by works by binding the enzyme PDE5 arginase. Ornithine is converted to that degrades cyclic GMP.17 FROM THE DIET. LYSINE polyamines necessary for cell growth EXCESS CAN INHIBIT NITRIC and differentiation and to proline Asthma sufferers have been found to which is important for collagen have lower circulating arginine levels OXIDE PRODUCTION VIA ITS 5,7,8 synthesis and wound healing. than controls. The relative nitric oxide COMPETITION WITH ARGININE Supplementation with arginine has deficiency induces hyper-reactive been shown to directly support airways which contributes to asthma FOR SHARED INTRACELLULAR 11 9,18 collagen synthesis and wound healing. symptoms. TRANSPORT Arginine is an important amino acid Arginine is important for the thymus and which is an essential precursor for lymphocyte count and nitric oxide is the synthesis of molecules with wide generated by phagocytes as part of the ranging metabolic roles, including nitric immune response. Nitric oxide is utilised Lysine oxide.5,6,7 by macrophages, neutrophils, mast Lysine is an essential amino acid; it cells, fibroblasts, hepatocytes, vascular is not synthesised in the body and Nitric oxide endothelial cells, smooth muscles cells must be obtained from the diet. Nitric oxide has many physiological and cardiac myocytes.7 Lysine excess can inhibit nitric oxide roles in the body, including production via its competition with vasodilation which affects Nitric oxide has an indirect but arginine for shared intracellular cardiovascular health, free radical important role in the repair and transport. Long term use of lysine scavenging and neurotransmission. integrity of gastric mucosa.7,19 This therefore has the potential to hinder Nitric oxide released by vascular in turn has an indirect effect on the nitric oxide production with possible endothelium is vasoprotective and immune system, which is supported by effects on immunity, collagen synthesis,

JATMS | December 2013 | 229 ARTICLE

TABLE A A SELECTION OF LYSINE SUPPLEMENTS, RECOMMENDED DOSE AND ADVICE

BRAND LYSINE DOSE ADVICE/CONTRADICTIONS/CAUTIONS

Supermarket Brand A Adults 500mg b.d Or as professionally prescribed (contains other 1000mg b.d during outbreak Advice given on other ingredients ingredients) Children 6-12, 500mg q.d

Supermarket Brand B 500mg b.d with food Or as recommended by a healthcare practitioner

Health Store Brand C Adults prevention 1000mg q.d Or as directed by a healthcare practitioner (contains other Acute 1000mg t..d.s ingredients) Children <12 1000mg q.d

Health store Brand D 500mg b.d Consult a healthcare practitioner if you have kidney or liver 1000mg b.d or t.d.s acute disease or during pregnancy and breastfeeding

Practitioner Brand E 1 x 800mg q.d Not all contradictions and cautions are listed on the bottle. (contains other 2 x 800mg b.d A phone number is provided for further information then: ingredients) Not recommended for persons with hypercalcaemia, kidney disease, existing high blood levels of lysine, pregnancy and lactation, plus other advice related to other ingredients

wound healing, male sexual health and Lysine aids calcium absorption and Abbreviations 8,20 cardiovascular health. therefore may be beneficial for those q.d = once a day; suffering from effects of calcium b.d = twice a day; Lysine may have a nephrotoxic deficiency such as osteoporosis or t.d.s = three times a day effect and should not be taken with osteopenia 24,25 but may not be advisable aminoglycoside antibiotics due to the for people with hypercalcaemia. increased risk of nephrotoxicity.21,22 There is however, the potential for lysine The kidney has an important role in the There is a potential for a rebound to be counterproductive long term metabolism of amino acids. Excess amino effect when ceasing lysine intake after due to competition with arginine for acid intake causes greater amounts chronic use. Anecdotal reports suggest shared transport and a proposed relative of waste such as urea that must be HSV sufferers report lesion recurrence arginine deficiency. eliminated. This can overload kidney if they stop taking lysine. In an early function leading to progressive kidney small double cross-over study those Arginine is the precursor for many impairment, particularly in people with allocated to six months on lysine who important molecules with influence existing kidney disease, hypertension, were then changed to the placebo group in many pathways, but of particular diabetes or aged over 65 years. experienced an increase in herpetic concern in relation to HSV are the lesion frequency.26 roles in the immune system, gut A case report from 1996 linked a daily integrity and wound healing. Given intake of 3000mg lysine over five years Table A shows that in the sample lysine the possibility of a rebound effect to Fanconi syndrome which progressed supplements a prophylactic dose from when ceasing supplementation, there to end stage renal failure.23 The 44-year- 800 to 1000mg is recommended on is the possibility that people with old female presented to a nephrology an ongoing daily basis with various HSV, especially chronic sufferers, will clinic with polyuria, polydipsia and increases recommended during continue to take lysine in order to fatigue. Tests revealed proteinuria and outbreaks. The safety advice varies prevent HSV outbreaks. In fact most abnormal creatinine clearance. After but there doesn’t appear to be any lysine supplements recommend an four months a biopsy showed long -term information relating to duration of use. ongoing prophylactic daily intake vascular injury with interstitial fibrosis of 1000mg. and tubular atrophy. At this stage, the Discussion patient revealed she had been taking Supplementation with lysine has shown Without appropriate safety advice, 3000mg of lysine a day for five years. benefit in the acute treatment of HSV. people may also take a larger

230 | vol19 no4 | JATMS prophylactic dose than recommended, 4. DiGiovanna JJ, Blank H. Failure of Lysine Sciences & Business Media LLC. Totowa as demonstrated by the case study in Frequently Recurrent Herpes Simplex USA:Humana Press; 2008. linked to Fanconi syndrome. Excess Infection Treatment and Prophylaxis. Arch protein or amino acid intake can lead to Dermatol. 1984:120(1):48-51 17. Pfizer Canada. Product monograph kidney damage. It is possible there are Viagra. Quebec Canada. Last reviewed other cases where adverse effects have 5. Morris S. Arginine Metabolism in Vascular August 2013. Available from www. occurred due to excess or long term Biology and Disease. Vasc Med. 2005; 10:S83 pfizer.ca/en/our_products/products/ lysine ingestion without the cause being monograph/132 identified. 6. Flynn NE et al. The Metabolic Basis of Arginine Nutrition and Pharmacotherapy. Biomed 18. Morris, CR et al. Decreased Arginine Conclusion Pharmacotherapy. 2002; 56(9):427-38 Bioavailability and Increased Serum Short term use of lysine appears to be Arginase Activity in Asthma. Amer Jnl safe for the symptomatic treatment 7. Duggan C, Gannon J, Walker WA. Protective Resp & Crit Care Med. 2004; 170(2) of HSV in the general population, Nutrients and Functional Foods for the especially if taken in divided doses Gastrointestinal Tract. Am J Clin Nutr. 2002; 19. Kochar NI, Chandewal AV, Bakal and ingested with meals containing 75(5): 789-808 RL, Kochar PN. Nitric Oxide and the protein. The available evidence on the Gastrointestinal Tract. Int Jnl Pharm. safety of long term and/or high dose 8. Luiking YC, Deutz NEP. Biomarkers of 2011; 7(1): 31-39 lysine supplementation for the general Arginine and Lysine Excess. J. Nutr. 2007; population is inconclusive; however 137(6): 1662S-1668S 20.Tong BC, Barbul A. Cellular & Physiological doses at or above 3000mg should not be Effect of Arginine. Mini Reviews in Medical recommended for long term use due to 9. Morris CR et al. Elevated Arginase and Limited Chemistry. 2004; 4(8): 823-832 the potential for kidney damage. Arginine Availability: a Common Feature in Asthma and Sickle Cell Disease. Nitric Oxide. 21. L-Lysine (Internet) NYU Langone Medical Lysine should not be recommended for 2004;11:112 Centre: Dept Otolaryngology [reviewed infants or young children or for persons Aug 2013 EBSCO CAM Review board] at risk of harm from a relative arginine 10. Yokoyam K et al. Hyperamnonemia in a Patient Available from http://ent.med.nyu.edu/ deficiency such as, but not limited to, with Short Bowel Syndrome and Chronic Renal content?ChunkIID=21791 people suffering from asthma, sickle cell Failure. Nephron. 1996; 72(4):693-5 disease, kidney disease or small intestine 22. Ehrlich, SD. Lysine University of Maryland complications such as short bowel 11. Barbul A. Proline Precursors to Sustain Medical Centre. Updated 2011. Available syndrome, without appropriate medical Mammalian Collagen Synthesis. J Nutr. 2008; from: http://umm.edu/health/medical/ advice. In addition, caution is warranted 138(10): 2021S-2024S altmed/supplement/lysine in relation to males with reproductive health concerns such as low sperm 12. Gornik HL, Creager MA. Arginine and 23. Lo JC, Chertow GM, Rennke H, Seifter JL. count or erectile dysfunction as well as Endothelial and Vascular Health. J Nutr. Fanconi’s Syndrome and Tubulointerstitial persons with hypercalcemia, gallbladder 2004;134(10 suppl):2880S-2887S Nephritis in Association with L-lysine disease or cardiovascular disease and Ingestion. Am J Kidney Dis, 1996; also during pregnancy and breastfeeding. 13. van Berge-Henegouwen GP et al. Drugs 28(4):614-7 Affecting Biliary Secretion andGallbladder References Motility: Their Potential Role in Gallstone 24. Tanner LM, Nanto-Salonen K, Niinikoski H. 1. Griffith RS, Norins AL, Kagan C. A Treatment and Prevention. Current Drug Long-term Oral Lysine Supplementation in Multicentered Study of Lysine Therapy in Target – Imm, Endocr & Metab Disorders. Lysinuric Protein Intolerance. Metabolism. Herpes simplex infection. Dermatology. 2005; 5(2):185-191 2007; 56(2): 185-189 1978;156(5): 257-267 14. Poso MJ, Camello PJ, Mawe GM. Chemical 25. Civitelli R et al. Dietary L-lysine and 2. Griffith RS,alsh W DE, Behforooz A. Subjective Mediators of Gallbladder Dysmotility. Current Calcium Metabolism in Humans. Response to Lysine in the Therapy of Herpes Med Chem. 2004: 11(13):1801-1812 Nutrition. 1992; 8 (6):400-5 Simplex. Oxford, Jnl of Antimicrobial Chemo. 1983; 12(16): 489-496 15. Klurfeld DM, Weber MM, Kritchevsky 26. Thein DJ, Hurt WC. Lysine as a Prophylactic D. Dietary Protein Effects on Gallstone Agent in the Treatment of Recurrent 3. Griffiths RS et .al Success of L-lysine therapy in Formation. 1987; 64(8): 1193-1195 Herpes Simplex Labialis. Oral Surg Oral frequently recurrent herpes simplex infection. Med Oral Path, 1984; 58(6):659-66 Treatment and prophylaxis. Dermatologica. 16. Antonio, J PhD et al. Essentials of Sports 1987;175(4):183-90 Nutrition and Supplements. Spring

JATMS | December 2013 | 231 ARTICLE

Burns and their Management Using Homoeopathy

Robert Medhurst | BNat DHom t some stage or other, just about present. Second degree burns, sometimes everyone will experience burns, known as partial thickness burns, involve Asome minor and some severe. damage to the epidermis and dermis. Burns are generally classified into three The pain here is severe. There is peeling, types, depending on the severity of blistering and swelling and a clear or the burn. yellow-coloured exudate is produced at the site. Infection may occur and First degree burns, sometimes known spread down to the third layer of the as superficial burns, involve damage to skin. Skin grafts may be required and the epidermis. The burn site is painful there is a risk of scarring. In the case of and erythematous, and blistering is not third degree or full thickness burns, the epidermis, dermis and subcutaneous tissue are often destroyed. There may be shock from fluid loss. The burn site may be painless because of damage to nerve tissue, but pain will be felt in the area surrounding the site. Underlying tissue such as muscle, tendon and bone can be damaged or destroyed, and the burn site appears white or charred. Extensive scarring may arise and skin grafts are often necessary. In cases of second or third degree burns, anything other than emergency medical management should only be used as first aid while such management is sought.

The first aid management for burns usually involves the removal of the person from the source of the burn, gentle but copious washing of the burn site, and covering the area to reduce the risk of infection. The faster that treatment is started, the lower the risk of sequelae. It should be remembered that any external materials used in the treatment

232 | vol19 no4 | JATMS of burns must be sterile because of the Urtica urens CAUSTICUM HAS A HISTORY very high risk of infection, and for the Traditionally used in first or second OF USE IN THIRD DEGREE same reason, care must be taken to avoid degree burns, Stinging Nettle may be breaking blisters. used internally and/or externally as a BURNS, PAIN RELIEF FROM dilute tincture. It has been found to be BURNS, POOR RESOLUTION Homoeopathic treatment of minor useful for relieving pain and promoting burns, or its use as first aid together with healing. The indications here include OF OLD BURNS AND THE orthodox medical first aid while waiting redness, intense burning heat, stinging, PATHOLOGICAL EFFECTS for emergency medical treatment, intense itching and agonising pain. has some significant advantages. One There may be burning heat in the skin OF BURNS of the most impressive things about with formication. Symptoms are worse homoeopathic medicines is the speed from cold, water, cold applications, cool with which they work - particularly moist air or touch. in acute conditions. The medicines Aconite themselves are relatively easy to Causticum Aconite’s primary role in this situation prescribe, they will not interact with Causticum has a history of use in is the relief of shock. It is best used pharmaceutical therapy, the remedies third degree burns, pain relief from in the early stages and discontinued are eminently transportable, and the burns, poor resolution of old burns as tissue changes occur. Some of the selection of the appropriate remedy is and the pathological effects of burns. pointers to its suitability include panic, relatively easy. The remedy picture is characterised fear of death, alternating bodily cold by tearing, drawing or burning pain, and heat, chills, fever, thirst, physical Following is a short list of tried and true restlessness, tremor, blistering, loss of and mental restlessness, fright, anxiety, homoeopathic remedies for burns and muscular strength, obscured vision, as a sudden sinking of strength and a their associated conditions that have if a film were over the eyes, hoarseness fear of being touched. Hyperaemia, been minimising pain and suffering and cough with a raw pan in the chest tachycardia, a hot, bursting headache, for many generations. Please note that and drowsiness. Symptoms are worse intolerable pains, redness of the face these are intended as a guide, and are from thinking about the ailment, worse and eyes and redness and swelling for educational purposes only. They are from dry cold or a cold wind and of the skin with a burning heat may not meant to replace the services of a are better from heat or damp or also be noted, as may oppressed suitably qualified person. rainy weather. breathing, a hoarse, dry cough, tracheal constriction, laryngeal sensitivity, and Cantharis Arsenicum album sensitivity to inspired air. Symptoms This is often the first choice in Restlessness and depression are are worse in a warm room, at night, homoeopathic medicines for burns of common pointers to Arsenicum. The or in dry, cold wind, and better from all kinds, and it may be used internally sufferer may seem exhausted, even after open air. in potency, or externally as a dilution of the slightest exertion, will often desire the 1X potency or tincture. Used early, it company, expresses fears of death Hepar Sulph often helps to prevent blister formation. or being alone, thinks it is useless to This is often called for in the later The symptoms indicating its selection take medicine and may be irritated by stages of burns and is particularly include a red face, hypersensitivity, disorder or confusion. There may be useful in cases where suppurating blistering, particularly where small fever with a cold sweat, deep burns wounds or glandular swellings are blisters combine to form larger ones, with vesicles, oedema, swelling and evident, and the skin is cracked and an intolerable and constant urge burning of the skin, infected flesh, and itchy. Small papules may also to urinate. There may be feelings of and inflammatory swelling, burning spread around the sides of the old being alternately hot or cold, delirium, or lancinating pain and the body may lesion. The sufferer may be chilly, and burn pain that feels burning, seem icy cold. Thirst, burning pains, a want to be wrapped in blankets cutting, biting or smarting. There may cold sweat, a burning in the throat and and yet be sweating. There may also be convulsions, a sudden loss of chest and constriction of the airways be hypersensitivity, irritability and consciousness, restlessness, anxiety or and also often present. Colic or septic nocturnal depression as well as a renal complications. A burning or scalded infections may develop here. Symptoms craving for sour or strongly flavoured feeling may be present in the mouth and are worse at night, particularly after things. Symptoms are worse from throat with burning pains in the chest. midnight, from cold, cold drink or cold touch, lying on the painful side, dry Symptoms are often worse from touch, food, and symptoms may be improved cold wind, or cool air, and are better from being approached, and better from by heat, warm drinks and having the from damp weather and warmth. rest or cold applications. head elevated. ARTICLE

Arnica dilute tincture) or both. Its action often Aloe vera is certainly Mental and physical shock, trauma or makes it more applicable to the later fainting and other issues arising after stages of serious burns, particularly where popular as a topical severe burns are often relieved by decomposition of fluids has occurred. the use of Arnica. It has a history of Burning pains, irritability, loss of memory, treatment for minor use in the prevention of septicaemia, a burning throat with hoarseness, a cough tissue inflammation or abscesses that with copious purulent expectoration and burns, accelerating fail to mature. There’s often extreme a burning pain in the chest, may also be sensitiveness and pain. The sufferer present. Symptoms are worse from open healing and reducing feels bruised and beaten, fears being air, cold, when lying down, and better approached or touched, wants to be from warmth, motion and warm food the itch from burns left alone, and tells everyone they’re and drink. okay. There may be delirium, shivering, diplopia, a feeling as if the head Rhus tox fearful, and experience hyperaesthesia were hot and the body cold, and the Rhus tox is a homoeopathic remedy of all of the senses, neuralgic pains that whole body may feel hypersensitive, made from Poison Ivy (Rhus come and go, dryness of mouth and throat Symptoms here are worse from touch toxicodendron). Anyone who’s and an aversion to water. There may also or motion, rest or damp cold, and are experienced physical contact with be convulsions, a loss of consciousness, better from lying down or having the this plant will have a clear idea why diplopia, swollen eyelids, cold extremities, a head held low. it’s used homeopathically for burns. Its painless hoarseness, a short dry cough and symptoms include superficial blistering, oppressed breathing. Symptoms are usually Carbo Veg vesicles, and burning. Intense itching worse from touch, noise, draught and lying Colloquially known as the ‘corpse is characteristic here, as is restlessness, down, and are better from sitting up. reviver’, Carbo veg may be of use in delirium, photophobia, a dry cough states of shock or collapse. and oppression of breathing. There may Carbolic acid It’s noted for supporting the circulation be tearing pain and stiffness on first This remedy is often used for the and respiration, and preventing shock motion that’s improved by continued sequelae of burns, notably burns that from developing into collapse. The motion, as well as mental dimness and ulcerate and don’t heal, particularly guiding signs and symptoms here disturbed sleep. Symptoms are worse where the skin itches and exudes a include a blue and icy cold body with from cold, at night, from rest, and putrid discharge. The sufferer may appear a hot head, exhaustion, tachypnoea, a better from warmth, motion, and a languid and may exhibit a feeble pulse, faint pulse, gasping for air, cool breath, change of position. depressed breathing and have very acute an aversion to darkness, hoarseness sense of smell. The symptoms here are and cough with a burning in the chest. Apis usually aggravated by cold. Symptoms are worse at night, from Often useful in the early stages of heat or open air and better from burns. The indications for Apis include Topical Preparations being fanned. pink, stinging and swollen skin that’s Aloe vera is certainly popular as a topical very sensitive to touch, oedema, and treatment for minor burns, accelerating Hypericum acute inflammation. Other pointers healing and reducing the itch from This may be used internally in potency, to the remedy are intolerance to burns. Calendula is also popular as a and/or externally as a dilution of the heat, stupor, listlessness, prostration, topical application, reducing the risk tincture. Its main roles in situations photophobia, a sensation of stiffness, of infection, accelerating healing and where a person has been burnt include red and swollen eyelids with hot reducing the risk of scars. The only shock, nerve pain or injuries to nerves. lachrymation, a feeling of suffocation, caution here is that Calendula is best The pain experienced here is often very a short dry cough, hoarseness and used around the edges of the wound. severe and the sufferer may appear to be dyspnoea. Symptoms are worse from This is because the healing action of quite drowsy. The symptoms experienced heat, touch, or pressure, and better from Calendula can be quite rapid, and any by the person who may benefit from open air or cold bathing. potentially pathogenic material not Hypericum are usually worse from cold, cleaned from the wound before its use from touch, from damp or exposure, and Belladonna may well be quickly encased within are better from bending the head back. Belladonna is noted for a rapid onset of the healed wound, setting the scene for symptoms, thirstlessness and dilated pupils. the formation of an abscess. As a final Kreosote The skin may radiate heat and may be hot, reminder, it’s essential to ensure that Like Hypericum, Kreosote may be used bright red, throbbing, swollen and sensitive. any topical preparations used in the either internally, externally (as a very The sufferer may be delirious, anxious, management of burns are be sterile.

234 | vol19 no4 | JATMS All programs are approved for continuing education points. Chris O’Brien’s programs are widely respected & sell out fast. Programs for every skill level

JATMS | December 2013 | 235 ARTICLE

An Anatomical Evaluation of Skin Scar Tissue Patrick de Permentier | BSc (Hons), MSc (Research),Grad Cert HEd, Diploma Remedial Massage, Cert IV in TAE. Lecturer and Head of Histology, Anatomy Department, School of Medical Sciences, Faculty of Medicine, UNSW. Lecturer in Anatomy and Physiology, NSW School of Massage, Sydney. ATMS NSW Representative, Council member ANZACA (Australian and New Zealand Association of Clinical Anatomists).

scar is defined in the Oxford collagen, a fibrous connective tissue Dictionary as ‘a mark left on produced by fibroblasts. This is the most Athe skin or within body tissue common tissue in the body, existing in where a wound, burn, or sore has not components such as bone, cartilage, healed completely and fibrous tissue ligaments, tendons, around muscle and has developed’. Scarring in many nerves and in the dermis of skin. instances is a mechanism by the body to repair itself after injury in a rapid Minimisation or absence manner. Unfortunately, the scar repair of scar formation after a is not the original tissue (e.g., epithelial minor skin lesion involving or muscle tissue) and this leads to epidermal tissue functional deficiencies such as the In a small skin lesion it is better to muscle being unable to fully contract. allow a scab to develop after a blood The predominant tissue in a scar is clot has developed during the wound

236 | vol19 no4 | JATMS healing phase. This usually occurs three to four days post-injury and detaches Keloid scars could actually be categorised as a naturally with time. The irritability that some people experience when the benign type of tumour, and often grow bigger than scab is present could be attributed to the increased tension developed in the the area of the original injury. The time course of dermal region, resulting in heightened sensory stimulation of the variety of keloids is generally an onset of three months sensory receptors which reside in the region, including Meisner’s corpuscles (fine and discriminative touch), Paccinian a collagenous matrix in order to close Main types of abnormal skin corpuscles (coarse touch and pressure), the wound as rapidly as possible. scar tissue Ruffini endings (subcutaneous stretch) This cellular activity is supported Principally, these can be categorised into: and others. If the scab is removed by the formation of an increased prematurely, then the body will replace capillary network, which occurs for • Atrophic scars, which are the re-opened lesion with collagenous a couple of weeks. The resultant scar depressions in the skin created by scar tissue which restricts normal tissue formation at this stage is usually very inflammatory conditions such as acne (epithelial) regeneration causing a fine erythematous. During the next four or chicken pox. Collagen production white line to develop on the skin surface. weeks the scar accommodates more does not proceed normally, leading to Allowing the natural process of scab collagen formation and increases in poor regeneration of the skin surface. formation and detachment to occur density. The fibroblast proliferation and According to Fife,1 ‘The will invariably lead to normal epithelial abundance of collagen also increases pathogenesis of atrophic acne regeneration underneath the scab, the stiffness of the tissue. As the matrix scarring is not completely avoiding the need to rapidly replace further develops the fibroblasts re- understood, but is most likely related the lesion with collagen to minimize organize the collagen fibres, pulling to inflammatory mediators and bacterial and antigenic invasion. the edges of the wound together. This enzymatic degradation of collagen thickening of the collagen then affects fibres and subcutaneous fat’. Scar formation resulting from the vascular supply to the scar, leading a dermal injury to the development of a paler region. As • Hypertrophic scars, which are When a skin lesion involving dermal a result, a scar is usually thicker, denser, due to an overproduction of collagen. tissue occurs the body’s initial response and paler than surrounding tissues, and They are usually red or purple and are is to close off the wound by creating a the poor elasticity of scar tissue can slightly raised above the surrounding blood clot. The tissue disruption initiates limit movement in areas of the body skin. They tend to fade and become flat an acute inflammatory process within that were extensively damaged, such as over time. According to Gauglitz et al.2 a few hours, with the occurrence of around a joint. A major element of scar hypertrophic scarring has the highest vasodilation and localized oedema. This tissue is that collagen cross-links and incidence related to surgery (40% to allows leucocytes (white blood cells) forms an alignment in a single direction 70%) and around 90% following burns, and macrophages to phagocytose the rather than the irregular basketweave with the most common sites being area of cell debris and pathogens. Within pattern in normal tissue. The collagenous the shoulders, neck, knees and ankles. a timeframe of 72 hours fibroblasts start fibres bind to the damaged tissue and The time for developing these types to produce collagen and manufacture this has a tendency to deform and of scars is usually within four to eight shorten the surrounding soft tissues, weeks after the wound, followed by resulting in loss of flexibility. This further scar growth (up to six months) A MAJOR ELEMENT OF SCAR weakness in a soft tissue like muscle and then gradual regression over a TISSUE IS THAT COLLAGEN predisposes it to further damage and few years. An important feature of this leads to loss of power and strength. In type of scar is that it does not extend CROSS-LINKS AND FORMS addition, a complete stretch and normal beyond the initial injury site and AN ALIGNMENT IN A SINGLE contraction is unable to occur. Scars recurrence following excision is rare. can also lead to nerve impingement DIRECTION RATHER THAN THE and tissue hypoxia, as the blood supply • Keloid scars, which are very IRREGULAR BASKETWEAVE can be restricted by newly formed elevated, red or dark scars that form collagenous tissue. Another feature to when the body produces a lot of PATTERN IN NORMAL TISSUE. take into account is that skin scar tissue extra collagen in a scar. Keloid scars does not contain dermal structures such could actually be categorised as a as sweat glands and hair follicles. benign type of tumour, and often grow

JATMS | December 2013 | 237 ARTICLE

bigger than the area of the original From a medical point of view there are a number injury. The time course of keloids is generally an onset of three months. of highly variable treatments, ranging from According to Meenakshi et al.,3 keloids can occur following trauma, prescription creams, ointments (silicone-based), gels, inflammation, surgery and burns, and occasionally spontaneously. The excess steroid injections, collagen induction therapy, laser deposition of collagen occurs in the dermis and subcutaneous tissues. This surgery, cryotherapy and other forms of surgical scar overproduction of collagen can lead to disfigurement, contractures and pain. removal such as skin grafts and scar revision Guaglitz et al.2 state that the primary sites of this type of scarring are usually on the anterior chest, shoulders, earlobes, upper arms and cheeks.

Meenakshi et al.,3 claim a familial ointments (silicone-based), gels, steroid lymphatic flow. In conclusion, although connection among darker skin people injections, collagen induction therapy, treatments (medical and natural such as African and Hispanics. The laser surgery, cryotherapy and other therapy) are aimed at reducing scar main features differentiating keloid forms of surgical scar removal such as tissue formation and thereby attempt scars from hypertrophic scars are skin grafts and scar revision. These are to restore a high degree of functional that keloid scars enlarge and extend applied in order to reduce or eliminate normality, it should be acknowledged beyond the original injury site, there the scar, or reduce the inflammatory that the literature reveals different is no spontaneous regression and response. From a natural therapy point opinions about their effectiveness. following excision there is a high of view, there are also many treatments recurrence rate. in the healing process of scar tissue. For References instance, Nima Shei4 mentions Vitamin E, 1. Fife D. Practical evaluation and management • Contracture scars, which often which stimulates collagen formation to of atrophic acne scars. J Clin Aesthet happen with burns, and end up pulling improve skin texture, and aloe vera juice Dermatol. 2011; 4(8): 50–57. the skin in towards the site of the to regenerate skin tissue. Interestingly, injury. This can make the skin appear a study by Shih et al.,5 when reviewing 2. Gauglitz GG, Korting HC, Pavicic T, Ruzicka, puckered around the wound. These some topical scar treatments, claimed T, Jeschke, MG. Hypertrophic Scarring and scars are mainly fixed, thick and rigid. that Vitamin E alone did not improve Keloids: Pathomechanisms and Current and Contracture scars may also venture scars but that some evidence existed Emerging Treatment Strategies. Molecular deeper, affecting muscles and nerves. that it may when combined with Medicine 2011; 17 (1-2): 113–125. If the scar occurs around a joint, it may silicone gel sheets. Nicole Cutler6 cause restrictions in movement. mentions massage techniques such 3. Meenakshi J, Jayaraman V, Ramakrishnan as manual lymphatic drainage to KM, Babu M. Keloids and hypertrophic scars: • Stretch (striae) marks, which improve the lymph circulation around a review. Indian J Plast Surg 2005; 38: (2): are caused by the skin, especially the area, myofascial release to help 175–179. the dermis, being stretched rapidly, affected tissue constriction, and heat often during pregnancy, during rapid application to aid with the pliability 4. Shei N. Healing scars naturally [Internet]. growth phases in adolescence and in of the scar. She cautions that these Accessed 2013 April 9. Available from: obesity. The tissue is often sunken a should be performed within the scope http://positivemed.com/2013/04/09/healing- little into the skin, and tends to fade of a massage therapist’s training and scars-naturally/ with time. The most common areas knowledge and if doubt exists a medical are the abdomen, breasts, upper arms, practitioner’s permission should be 5. Shih R., Waltzman JM, Evans GR. Review underarms, back, thighs, hips and sought. Scars increase in collagenous of over the counter topical scar treatment gluteal regions. density from three months to more products. Plastic and Reconstructive Surgery than one year, so as a general rule scars 2007; 119 (3): 1091-1095. Various forms of treatment for need to be addressed before they reducing skin scars become excessively fibrous, otherwise 6. Cutler N. Six massage techniques to remove From a medical point of view there are there can be complications such as scar tissue. [Internet]. Updated 2007 July 20. a number of highly variable treatments, nerve compression, further discomfort, Availabe from: ranging from prescription creams, and markedly reduced blood and www.integrativehealthcare.org/

238 | vol19 no4 | JATMS JATMS | December 2013 | 239 READERS’ SURVEY

JATMS Readers’ Survey Dr Sandra Grace | Editor JATMS

TMS conducted an online survey • To keep members up to date with would like to see in the journal. Many of members to collect feedback current research that may affect members requested a greater focus on Aabout their journal. The email their practices (88.5% agreed or their own modalities. Other suggestions was sent to 9116 emails. A total of 1185 strongly agreed) included interviews with practitioners, responses were received (13% response articles on building a practice and rate). Of those who responded, 23.4% • To be a showpiece for ATMS (75.9% integrating natural and mainstream had been in practice for less than 5 years, agreed or strongly agreed). medicine, and case studies. Several 48% had been in practice for between members requested a classified section. 6 and 20 years, and 12.6% had been in Almost all respondents reported that Some members preferred shorter articles: practice for more than 20 years. Only they read or looked through the journal: 0.8% of respondents were under 25 years 51.6% said always, 27.5% said often and “I FEEL THE ARTICLES ARE TOO of age; 6.6% were under 35 years. Most 17.5% said sometimes. The most useful LONG MOST OF THE TIME. (77.8%) of respondents were female. sections of the journal were reported THERE IS SO MUCH TO READ to be the updates on health fund issues FROM SO MANY SOURCES, I There was very strong support for the (96.8%), the research sections (original OFTEN GET OVERWHELMED aims of the journal: research articles 96.2%, recent research BY THE LENGTH OF THEM.” summaries 96.3%), opportunities for CPE • To provide important association (95.4%) and the Law Report (91.3%) Some members also suggested a news, government legislation and (Table 1). questions and answers section (e.g. a policies that affect natural medicine forum for members to put question to practice, and CPE opportunities (95.3% Forty-four percent of respondents made the ATMS Board). Others requested more agreed or strongly agreed) suggestions for additional features they opportunities to gain CPE points.

TABLE 1 USEFULNESS OF JOURNAL CONTENT TO ATMS MEMBERS

Very useful quite useful not useful rating count

President’s Report 16.4% (183) 63.4% (708) 20.2% (226) 1 117

Chief Executive Officer’s Report 12.0% (132) 61.3% (675) 26.7% (294) 1 101

State News 26.4% (294) 58.2% (647) 15.6% (174) 1 112

Law Report 36.4% (403) 54.9% (608) 8.8% (97) 1 107

Policy Report 35.0% (380) 54.8% (596) 10.6% (115) 1 087

Original Research Articles 60.7% (682) 35.5% (399) 3.9% (44) 1 124

Summary of Recent Research 60.8% (682) 35.5% (398) 3.8% (43) 1 122

Book Reviews 38.2% (428) 54.1% (606) 7.9% (89) 1 120

Health Fund News & Update 64.9% (733) 31.9% (360) 3.5% (39) 1 130

Continuing Professional Education 64.5% (730) 30.9% (350) 4.7% (53) 1 131 Opportunities

Minutes of the AGM 10.0% (108) 59.1% (639) 31.3% (339) 1 082

Answered 1 144

Skipped 50

240 | vol19 no4 | JATMS Quarterly publications were JOURNAL WITH FACTUAL AND additional cost for the journal, and of considered about right by 91.4% COMPREHENSIVE ARTICLES, those 66.5% said they would be prepared (1,045) respondents and 70.5% (807) OR OPEN IT UP TO INCLUDE to pay an additional $10 per year. preferred to receive a hard copy of MORE RELAXED, ENJOYABLE the journal; 12.2% (139) preferred to TO READ PIECES. I DON’T Editor’s response receive an electronic version and 17.3% THINK THE BLEND IS QUITE I thank all those members who (198) preferred both; 81.5% (928) of RIGHT YET.” responded to our survey with many respondents preferred to read the insightful and constructive suggestions journal in hard copy. A number of respondents (27.3%) said and expressions of approval for the they would consider writing an article that journal’s present content and format. With regard to layout and design of the would be of interest to ATMS members. Wherever it is practicable, I will try to journal, including colour, font, front cover implement your suggestions. Those that image, 93% (1051) of respondents were Most (93.6%) thought that the name of require ATMS Board approval have been happy with the current format. Seven the journal was appropriate. presented to the CEO. I will certainly percent of respondents (79) offered be following up on the suggestion that suggestions, including the use of a Sixty-three percent of respondents members have greater input to the larger font size and recycled matt paper. retained their past issues of the journal journal in the form of articles, letters They were divided over the need for a for more than a year; a further 14.5% for and forums. I have always felt that more scientific look or a more contemporary up to a year; 38.2% displayed the journal contributions from members would magazine style journal. in the waiting room of their clinic. strengthen the journal and I look forward eagerly to receiving them. Send your “EITHER SHOOT FOR BEING Just over a quarter (25.5%) of articles and letters to me at A PROFESSIONAL STIFF respondents were prepared to pay an [email protected].

JATMS | December 2013 | 241 LAW REPORT

Therapists’ Obligations under Consumer Law Ingrid Pagura | BA, LLB

to disclose relevant facts to a customer. person is satisfied with the goods or Under the Competition and Silence can be misleading or deceptive services and encourage them to buy Consumer Act 2010 which came when important details a person should something to their detriment, based on into force on 1 January 2011, all know are not told to them or there is belief in the testimonial. Testimonials complementary health therapists a change in information already given must be real, not ones that you’ve have obligations. Two of the major to them that makes it incorrect. This written yourself! obligations relate to behaviour and also depends on the circumstances of goods and services. each case. For example, silence could Finally do not mislead clients about be seen as misleading when a massage your qualifications, skills or experience. therapist is selling their clinic and For example, if I call myself a surgeon, herapists are required not to doesn’t mention to the buyer that it is patients would assume that I have a undertake any misleading or because another massage therapist is certain level of knowledge and skill. Tdeceptive conduct. ‘Conduct’ moving in nearby. Again, silence could be an issue here includes actions and statements, such where you don’t correct a person who as advertisements, promotions or Promises, opinions and predictions incorrectly assumes your qualifications. quotations made by a person. If the can be misleading or deceptive if the statement creates a misleading overall person making them knew they were Your business can’t rely on disclaimers impression about the price, value or false, did not care whether they were and small print as an excuse for quality of consumer goods or services true or not and had no reasonable misleading or deceptive conduct. it is likely to break the law. It doesn’t grounds for making them. For example, matter that you didn’t intend to mislead a therapist assures a client that a health The ACCC gives the following advice on or deceive. What matters is how your fund will give them a full rebate even if presenting information to customers. statements and actions, that is business they don’t know for sure. conduct, could affect the thoughts and Be sure to: beliefs of a consumer. This area also relates to promises • give current and correct information a therapist makes, in particular • use simple language Slightly exaggerated comments may those about treatments or products. • check that the overall impression is be acceptable but ‘puffery’ may not Therapists must never make accurate be. ‘Puffery’ is wildly exaggerated, statements about curing or improving • back up claims with facts and fanciful or vague claims that no certain conditions unless they have documented evidence where reasonable person could possibly treat evidence to prove it. Testimonials appropriate as serious. Examples of puffery could from other clients are not seen to • note important limitations or be a massage therapist claiming to give be evidence for this type of claim. A exemptions the best massage in the world or a therapist must always be very careful • correct any misunderstandings naturopath selling herbs that will melt when explaining potential benefits and • be prepared to substantiate. fat away. There is no legal distinction outcomes to clients. between puffery and misleading or The other obligation relates to the deceptive conduct and it will depend Testimonials are statements from provision of goods and services. As a on the circumstances in each case. previous customers about their supplier or manufacturer you guarantee Whether a court considers puffery as experience with a product or service that goods or services are of acceptable misleading or deceptive depends on the and it is unlawful to present false quality when sold to a consumer. circumstances of each case. or misleading ones. These can give consumers confidence in a product This means you guarantee the goods will A therapist can break the law by failing or service on the basis that another be safe, durable and free from defects,

242 | vol19 no4 | JATMS acceptable in appearance and finish, and do the job that that • using a friend or relative of the customer to influence the type of thing is usually used for. The test for goods is whether a customer’s decision reasonable consumer would find the goods: • inducing a person to sign a blank or one-sided contract • fit orf all the purposes for which goods of that kind are commonly supplied (e.g., massage oil able to be used • taking advantage of a low-income consumer by making false on clients) statements about the real cost of a loan

• acceptable in appearance and finish (e.g., a massage table • failing to disclose key contractual terms should be free from scratches to the upholstery) • using high pressure tactics, such as refusing to take ‘no’ for • free from defects (e.g., the clinic printer will only print every an answer. second page) Note: these are examples and not a complete list of • durable (e.g., the towels must last in good shape for a unconscionable conduct and sometimes these instances will not reasonable time after purchase, without fraying after be unconscionable – it depends on the circumstances. one wash).

When looking at these elements there are a number of things For further information please see ACCC website at www.accc.gov.au to take into account, such as the nature of the goods, the or NSW Department of Fair Trading at www.fairtrading.nsw.gov.au. price paid, any statements on any packaging or label on the goods and any representation you made about the goods.

The acceptable quality guarantee may not apply if defects have been pointed out to the consumer or if they have examined the goods and didn’t find any defects they should have noticed. Finally any abnormal use of the goods may also mean that the guarantee doesn’t apply.

All goods carry with them certain guarantees. These terms are implied in every consumer transaction. They must:

• be of acceptable quality – they will be safe, durable and free from defects and do the job that that type of thing is usually used for

• match any description given to the consumer

• match the sample or demonstration model

• be fit orf any disclosed purpose (i.e., the goods will do the job the consumer was told they would)

One of the most important aspects of consumer law is that all suppliers of goods and services act in a conscionable manner. Generally, ‘unconscionable conduct’ is a statement or action so unreasonable it defies good conscience. The Department of Fair Trading highlights the following examples of unconscionable conduct by a trader:

• not properly explaining the conditions of a contract to a person they know does not speak English or has a learning disability

• not allowing sufficient time to read an agreement, ask questions or get advice

JATMS | December 2013 | 243 REGULATORY WATCH

Proposed Reforms to Advertising of Therapeutic Goods Raymond Khoury | BA, DBM, PhD, ATMS Director

n May 2013 the Therapeutic Goods Code of Conduct for unregistered References Administration (TGA) commenced health practitioners.(2) It is possible 1. Khoury R. Therapeutic Goods Ia consultative process on its that the model of the NSW Health Administration proposes reforms that will proposed reforms to the advertising of Care Complaints Commission could restrict access to our medicines. Journal of therapeutic goods.(1) If the proposal be adopted nationally. A public the Australian Traditional-Medicine Society for advertisements to healthcare consultative process to further inform 2013, 19(3), 160-163. professionals is adopted, herbalists, the ministers is expected. naturopaths, homoeopaths and 2. Standing Council on Health. Communique: nutritionists will be removed from USA Senate Regulation of Unregistered Health Schedule 1 of the Therapeutic Goods The United States Senate has passed a Practitioners. 1 August 2013. Australian Regulations 1990 (Cth). Additionally, resolution designating 7 to 13 October Health Ministers’ Advisory Council, Canberra. these practitioners will no longer 2013 as Naturopathic Medicine Week. be able to receive therapeutic The purpose of this designation is to goods advertisements for healthcare recognise the value of naturopathic professionals from suppliers. medicine ‘in providing safe, effective and affordable health care’. On 25 August 2013 a seminar was sponsored by ATMS to inform members. Invitation to join submission The guest speaker was Professor John writers’ group Skerritt, National Manager of the TGA. The ATMS Regulatory Committee is Professor Skerritt told participants that inviting members to join a group of 22,000 petitions had been received. submission writers. This voluntary At the end of the seminar participants position is to compile submissions were invited to ask questions. The to various government agencies and general mood was one of hostility other stakeholders. Any member who towards the reform. has experience in submission writing, or members who wish to develop On 25 October 2013 ATMS hosted a submission writing skills, please meeting of the affected associations send your details to to discuss a unified strategy to halt the [email protected]. reform’s introduction. Representatives of six associations attended the meeting. Some of the associations agreed to participate with ATMS to develop an alternative approach to the TGA reform. This model is expected to be presented to the TGA in late 2013.

Code of Conduct The Australian Health Ministers’ Standing Council on Health has agreed in principle on a single national

244 | vol19 no4 | JATMS MEDIA WATCH

ATMS Media Watch Stephen Eddey | Vice President of ATMS

he aim of the ATMS Media Another aim is to respond to negative We need your help! If you come across Watch service is to look at the press and put forward a positive negative or positive information about Tscientific evidence and develop alternative. For example, a hypothetical natural medicine, please submit the good news stories supporting the Dr Smith publishes an article stating information to natural medicine industry and ATMS there is no evidence for the use of [email protected] members. For example, if a new study acupuncture. The ATMS Media Watch team and we will respond in a prompt comes out finding that massage could then collates a raft of studies supporting manner to ‘nullify the negative’ and help relieve migraines, it would then the use of acupuncture and showing ‘promote the positive’ information. be distributed to all of our members its effectiveness in many situations. We who have listed their e-mail address will also comment on medical drugs and With your help, we will endeavour with ATMS. ATMS members would be suggest alternative treatment methods to promote natural medicine across encouraged to re-post the article for conditions that require these medical Australia and across the world, while and so assist to increase exposure to drugs. We will, of course, not recommend supporting ATMS members’ practices. the story. that anybody stop taking any medications.

TGA Reforms TGA Certificate In May 2013, the Therapeutic Goods Administration (TGA) Since 1991, ATMS has issued the Certificate of Advertising commenced a consultative process on reforms to the Exemption, commonly known as the ‘TGA Certificate’, to advertising of therapeutic goods. Details of the reforms were enable members to receive practitioner only products. published in the September 2013 issue of the Journal of the Australian Tradiional–Medicine Society. The TGA reforms will mean that a new system to identify properly qualified herbalists, naturopaths, homoeopaths, On 25 August 2013, a seminar was sponsored by ATMS and nutritionists will be introduced. In our discussion with on the reforms, and the guest speaker was Professor John the TGA it was understood that the TGA Certificate was not Skerritt, National Manager of the TGA. On 2 October, ATMS required to be issued in this transitional period. Therefore, we representatives met with Professor Skerritt and Dr Larry Kelly will not be issuing you with a TGA Certificate this year. of the TGA to further discuss the impact of the reforms on herbalists, naturopaths, homeopaths and nutritionists. On 25 This will not affect your access to purchase practitioner-only October, ATMS hosted a meeting of the associations to discuss products. In the improbable event that you experience a a unified strategy to the reforms. difficulty with a distributor, please let us know and we will rectify it. ATMS’s main concern is the proposed removal of Schedule 1 from the Therapeutic Goods Regulations 1990 (Cth), If members need more information, please contact Raymond and whether members will lose their status as healthcare Khoury, Chair of the ATMS Regulatory committee, via email professionals in Therapeutic Goods Law. ATMS representatives [email protected]. are negotiating with the TGA, and other stakeholders, to attain a solution which is in our best interests.

JATMS | December 2013 | 245 RECENT RESEARCH

Acupuncture and TCM Aromatherapy Aim This systematic review was aimed Fang L, Fang M. Varney E, Buckle J. at critically evaluating the evidence regarding the adverse effects associated Research progress on the standardization Effect of inhaled essential oils on mental with aromatherapy. of Chinese Tuina therapy: a short review. exhaustion and moderate burnout: a [Review] Chinese Journal of Integrative small pilot study. Journal of Alternative & Method Medicine. 2013; 19(1):68-72. Complementary Medicine. 2013; 19(1):69-71. Five electronic databases were searched to identify all relevant case reports and The standardization of Chinese Tuina Objectives case series. therapy is one of the most popular The objective of this pilot study was research topics in Chinese medicine. By to determine the effectiveness of a Results reviewing the literatures contributed mixture of essential oils (peppermint, Forty-two primary reports met our by Chinese investigators between 1982 basil, and helichrysum) on mental inclusion criteria. In total, 71 patients and 2010, the authors summarized the exhaustion, or moderate burnout (ME/ experienced adverse effects of progress on Chinese Tuina manipulation MB) using a personal inhaler. aromatherapy. Adverse effects ranged techniques, in particular, focusing on from mild to severe and included one the data on several key parameters Design fatality. The most common adverse (i.e., frequency, duration, and force). This was a randomized, controlled, double- effect was dermatitis. Lavender, This summarization will benefit the blind pilot study. Data were collected 3 peppermint, tea tree oil and ylang-ylang standardization of Chinese Tuina. times a day for 3 weeks (Monday-Friday). were the most common essential oils The first week was baseline for both responsible for adverse effects. groups, the second week was intervention Li T, Peng T. (aromatherapy or placebo), and the third Conclusion week was washout. Aromatherapy has the potential Traditional Chinese herbal medicine as a to cause adverse effects some of source of molecules with antiviral activity. Settings which are serious. Their frequency [Review] Antiviral Research. 2013; 97(1):1-9. Participants used a personal inhaler at remains unknown. Lack of sufficiently home or at work. The outcome measures convincing evidence regarding Traditional Chinese herbal medicine were a 0-10 scale with 10=worst feeling the effectiveness of aromatherapy (TCHM) is widely used in the of burnout, 0=no feeling of burnout. combined with its potential to cause prevention and treatment of viral There was a qualitative questionnaire adverse effects questions the usefulness infectious diseases. However, the rating aroma and a questionnaire of this modality in any condition. operative mechanisms of TCHM listing perceived stressors comprised a remain largely obscure, mainly convenience sample of 13 women and 1 because of its complicated nature man who each had self-assessed ME/MB. HERBAL MEDICINE and the fragmented nature of research. In recent years, systematic Results Braun LA, Spitzer O, Tiralongo E, methodologies have been developed While both groups had a reduction in Wilkinson JM, Bailey M, Poole to discover the active compounds in perception of ME/MB, the aromatherapy SG, Dooley M. Naturopaths and TCHM and to elucidate its underlying group had a much greater reduction. Western herbalists’ attitudes to mechanisms. In this review, we evidence, regulation, information summarize recent progress in TCHM- Conclusions sources and knowledge about based antiviral research in China and The results suggest that inhaling popular complementary medicines. other Asian countries. In particular, essential oils may reduce the perceived Complementary Therapies in Medicine. this review focuses on progress level of mental fatigue/burnout. Further 2013; 21(1):58-64 in targeting key steps in the viral research is warranted. replication cycle and key cellular Background components of the host defence The practice of naturopathy and system. Recent developments in Posadzki P, Alotaibi A, Ernst E. Western herbal medicine (WHM) centralized and standardized TCHM was built on traditional evidence but screening and databases are Adverse effects of aromatherapy: a may be undergoing change with the also summarized. systematic review of case reports and case advent of scientific evidence. The aims series. [Review] International Journal of Risk of this research were to provide a & Safety in Medicine. 201; 24(3):147-61. better understanding of practitioners’

246 | vol19 no4 | JATMS attitudes towards evidence, information Niwa Y, Matsuura H, Murakami M, Sato J, Initial treatment was with 2.6 +/- 0.8 sources, professional regulation and Hirai K, Sumi H. agents (range 2-4). Overall, patients were their knowledge about the evidence treated with 3.7 +/- 1.2 agents (range of commonly used complementary Evidence that naturopathic therapy 2-7). There was a significant correlation medicines (CMs). including Cordyceps sinensis prolongs, between number of agents administered survival of patients with hepatocellular and survival (P < .0001). Patients treated Method carcinoma. Integrative Cancer Therapies. with >/= 4 agents survived significantly Naturopaths and WHM practitioners 2013; 12(1):50-68. longer than patients treated with /= 4 agents prepared from Significantly more recent graduates Pugh scoring was used to assess liver natural products was associated with (less than 5 years) rated randomised disease. Patients were treated with prolonged survival in a substantial trials as essential compared to orally administered combinations of portion of patients. The data provide others. Most (82%) respondents want 12 naturopathic agents. Patients were level II evidence for the efficacy of information sources containing both monitored clinically and by CT tumor naturopathic therapy in HCC. traditional and scientific evidence. imaging, serial tumor markers, and liver They currently use several resources; function tests. 74% CM textbooks, 67% conferences/ Homoeopathy seminars, 57% CM journals, 48% Results databases and 40% manufacturers’ Patient characteristics: 101 patients Roll S, Reinhold T, Pach D, Brinkhaus B, Icke information. The mean knowledge with HCC (67 men and 34 women, K, Staab D, Jackel T, Wegscheider K, Willich score was 61.5% with no significant age 67.2 +/- 8.8 years) were treated SN, Witt CM. differences between respondents with for a median of 13.4 months (range diploma or degree level education or by 0.8-100.8). Of these 84% had cirrhosis, Comparative effectiveness of graduating year. Eighty-five percent of 63% had hepatitis C virus, 18% had homoeopathic vs. conventional therapy in practitioners strongly agreed or agreed hepatitis B virus, 1% had both, and usual care of atopic eczema in children: long- that practitioners should be formally 9% had metastatic disease. Median term medical and economic outcomes. PLoS registered to safeguard the public, modified Childs-Pugh score was 6 ONE. 2013; 8(1):e54973. 8% were unsure and 8% disagreed or (range 3-13). Barcelona Clinic Liver strongly disagreed. Cancer tumor stages of 0, A, B, C, Background and D were found in 36%, 25%, 20%, One in five children visiting a Conclusion 14%, and 6%, respectively. Median homeopathic physician suffers from Naturopaths and WHM practitioners AFP was 40 (range 0-311,000). atopic eczema. accept the importance of scientific Median PIVKA II was 59 (0-378,000). evidence whilst maintaining the Previous treatment was included none Objectives importance and use of traditional (27%), resection with relapse (20%), We aimed to examine the long- evidence. The majority are in favour of transarterial chemoembolization term effectiveness, safety and costs professional registration. (50%), radiofrequency ablation (28%), of homoeopathic vs. conventional percutaneous ethanol injection therapy treatment in usual medical care of (15%), chemotherapy (14%). Outcomes: children with atopic eczema.

JATMS | December 2013 | 247 RECENT RESEARCH

Methods Danno K, Colas A, Terzan L & Bordet MF. Conclusions In this prospective multi-centre Homeopathic treatment was well comparative observational non- Homeopathic treatment of premenstrual tolerated and seemed to have a positive randomized rater-blinded study, syndrome: a case series. Homeopathy: the impact on PMS symptoms. Folliculinum 135 children (48 homoeopathy, 87 Journal of the Faculty of Homeopathy. 2013; was the most frequent homeopathic conventional) with mild to moderate 102(1):59-65. medicine prescribed. There appears atopic eczema were included by their to be scope for a properly designed, respective physicians. Depending on Objective randomized, placebo-controlled trial the specialisation of the physician, Observational, prospective study to to investigate the efficacy of individual the primary treatment was either describe the homeopathic management homeopathic medicines in PMS. standard conventional treatment of premenstrual syndrome (PMS) by a or individualized homeopathy as group of French physicians. delivered in routine medical care. Integrative medicine The main outcome was the SCORAD Method (SCORing Atopic Dermatitis) at 36 Women with PMS for >3 months Coulter ID, Herman PM, Nataraj S. months by a blinded rater. Further were prescribed individualized Economic analysis of complementary, outcomes included quality of life, homeopathic treatment. The intensity alternative, and integrative medicine: conventional medicine consumption, of 10 clinical symptoms of PMS was considerations raised by an expert safety and disease related costs at scored individually at inclusion and at panel. BMC Complementary and six, 12 and 36 months after baseline. a 3-6 month follow-up visit: absent=0, Alternative Medicine. 2013; 13:191 A multilevel ANCOVA was used, with mild=1, moderate=2, severe=3. Total doi:10.1186/1472-6882-13-191 physician as random effect and the symptom score (range: 0-30) was following fixed effects: age, gender, calculated and compared for each Background baseline value, severity score, social patient at inclusion and at follow-up. An international panel of experts was class and parents’ expectation. PMS impact on daily activities (quality convened to examine the challenges of life, QoL) was compared at inclusion faced in conducting economic analyses Results and follow-up as: none, mild, moderate, of Complementary, Alternative and The adjusted mean SCORAD showed severe, very severe. Integrative Medicine (CAIM). no significant differences between the groups at 36 months (13.7 95% Results Methods CI [7.9-19.5] vs. 14.9 [10.4-19.4], Twenty-three women were prescribed A one and a half-day panel of experts p=0.741). The SCORAD response rates homeopathic treatment only (mean was convened in early 2011 to discuss at 36 months were similar in both age: 39.7 years). Folliculinum (87%) what was needed to bring about robust groups (33% response: homoeopathic was the most frequently prescribed economic analysis of CAIM. The goals 63.9% vs. conventional 64.5%, p=0.94; homeopathic medicine followed by of the expert panel were to review 50% response: 52.0% vs. 52.3%, Lachesis mutus (52.2%). The most the current state of the science of p=0.974). Total costs were higher common PMS symptoms (moderate or economic evaluations in health, and to in the homoeopathic versus the severe) at inclusion were: irritability, discuss the issues involved in applying conventional group (months 31-36 aggression and tension (87%), these methods to CAIM, recognizing 200.54 Euro [132.33-268.76] vs. 68.86 mastodynia (78.2%) and weight gain its unique characteristics. The panel Euro [9.13-128.58], p=0.005). and abdominal bloating (73.9%); proceedings were audiotaped and and the most common symptoms at a thematic analysis was conducted Conclusions follow-up were: irritability, aggression independently by two researchers. Taking patient preferences into and tension (39.1%), weight gain The results were then discussed and account, while being unable to rule and abdominal bloating (26.1%) and differences resolved. This manuscript out residual confounding, in this mastodynia (17.4%). Mean global summarizes the discussions held by the long-term observational study, the score for symptom intensity was 13.7 panel members on each theme. effects of homoeopathic treatment at inclusion and 6.3 at follow-up. The were not superior to conventional mean decrease in score (7.4) was Results treatment for children with mild to statistically significant (p<0.0001). The panel identified seven major themes moderate atopic eczema, but involved Twenty-one women reported that regarding economic evaluation that are higher costs. their QoL also improved significantly particularly salient to determining the (91.3%; p<0.0001). economics of CAIM: standardization (in order to compare CAIM with conventional therapies, the same basic

248 | vol19 no4 | JATMS economic evaluation methods and Materials and Methods Myburgh C, Hartvigsen J, Aagaard P & framework must be used); identifying A randomized controlled trial of 10 Holsgaard-Larsen A. the question being asked, the audience scheduled treatments of myofascial targeted for the results and whose physical therapy vs global therapeutic Skeletal muscle contractility, self-reported perspective is being used (e.g., the patient massage was performed at 11 clinical pain and tissue sensitivity in females with perspective is especially relevant to CAIM centers in North America. We recruited neck/shoulder pain and upper trapezius because of the high level of self-referral women with interstitial cystitis/painful myofascial trigger points– a randomized and out-of-pocket payment); the analytic bladder syndrome with demonstrable intervention study. Chiropractic & Manual methods to be used (e.g., the importance pelvic floor tenderness on physical Therapies. 2012; 20:36 doi:10.1186/2045- of treatment description and fidelity); examination and a limitation of no more 709X-20-36 the outcomes to be measured (e.g., it is than 3 years’ symptom duration. The important to consider a broad range of primary outcome was the proportion Background outcomes, particularly for CAIM therapies, of responders defined as moderately In relation to Myofascial Triggerpoints which often treat the whole person rather improved or markedly improved in (MFTrPs) of the upper trapezius, this than a specific symptom or disease); costs overall symptoms compared to baseline study explored muscle contractility (e.g., again because of treating the whole on a 7-point global response assessment characteristics, the occurrence of person, the impact of CAIM on overall scale. Secondary outcomes included post-intervention muscle soreness healthcare costs, rather than only disease- ratings for pain, urgency and frequency, and the effect of dry needling on specific costs, should be measured); the O’Leary-Sant IC Symptom and muscle contractile characteristics and implementation (e.g., highlighting studies Problem Index, and reports of adverse clinical outcomes. where CAIM allows cost savings may help events. We compared response rates offset its image as an “add on” cost); and between treatment arms using the Methods generalizability (e.g., proper reporting can exact conditional version of the Mantel- Seventy-seven female office workers enable study results to be useful beyond Haenszel test to control for clustering (25-46yrs) with and without neck/ the study sample). by clinical center. For secondary shoulder pain were observed with efficacy outcomes cross-sectional respect to self-reported pain (NRS- Conclusions descriptive statistics and changes from 101), pressure-pain threshold (PPT), The business case for CAIM depends baseline were calculated. maximum voluntary contraction on economic analysis and standard (Fmax) and rate of force development methods for conducting such economic Results (RFD) at baseline (pre-intervention), evaluations exist. The challenge for A total of 81 women randomized to the 2 immediately post-intervention and 48 CAIM lies in appropriately applying treatment groups had similar symptoms hours post-intervention. Symptomatic these methods. The deliberations of at baseline. The global response and asymptomatic participant groups this panel provide a list of factors to be assessment response rate was 26% in the were each randomized into two considered in meeting that challenge. global therapeutic massage group and treatment sub-groups (superficial (SDN) 59% in the myofascial physical therapy and deep dry needling (DDN)) after group (p=0.0012). Pain, urgency and baseline testing. At 48 hours post- MASSAGE frequency ratings, and O’Leary-Sant IC intervention participants were asked Symptom and Problem Index decreased whether delayed onset muscle soreness FitzGerald MP, Payne CK, Lukacz ES, Yang in both groups during followup, and (DOMS) and/or post-needling soreness CC, Peters KM et al. were not significantly different between had developed. the groups. Pain was the most common Randomized multicenter clinical trial of adverse event, occurring at similar rates Results myofascial physical therapy in women in both groups. No serious adverse Muscle contractile characteristics with interstitial cystitis/painful bladder events were reported. did not differ between groups syndrome and pelvic floor tenderness. at baseline. Forty-six individuals Journal of Urology. 2012; 187(6):2113-8. Conclusions developed muscle soreness (39 from A significantly higher proportion mechanical testing and seven from Purpose of women with interstitial cystitis/ needling). No inter-group differences We determined the efficacy and safety painful bladder syndrome responded were observed post-intervention of pelvic floor myofascial physical to treatment with myofascial physical for Fmax or RFD for the four sub- therapy compared to global therapeutic therapy than to global therapeutic groups. Over the observation period, massage in women with newly massage. Myofascial physical therapy symptomatic participants reported symptomatic interstitial cystitis/painful may be a beneficial therapy in women less pain from both SDN (p= 0.003) bladder syndrome. with this syndrome. and DDN (p=0.011). However, PPT

JATMS | December 2013 | 249 RECENT RESEARCH

levels were reduced for all participants administered by intragastric gavage dysregulated in states of under- and (p=0.029). Those reporting DOMS twice a day for 30 days prior to MCAO. over-nutrition, its serum concentrations experienced significant decreases in At different time points, the expression falling in malnutrition and responding PPT, irrespective of symptom state or of claudin-5, occludin, ZO-1, and PKCα promptly to refeeding. This has led to intervention (p=0.001). signaling pathway in microvessel interest in its utility as a nutritional fragments of cerebral ischemic tissue biomarker. A considerable evidence Conclusions were evaluated. base supports utility for measurement In selected female neck/shoulder of IGF-I in nutritional contexts. Its pain sufferers, maximum voluntary Results concentration may be valuable in contraction and rapid force generation GTPs reduced BBB permeability at providing information on nutritional of the upper Trapezius was not 60 min and 120 min after ischemia status, prognosis and in monitoring influenced by clinically relevant as compared with the vehicle group. nutritional support. However, it is self-reported pain or the presence of Transmission electron microscopy also insufficiently specific for use as a diagnostically relevant MFTrPs. Dry revealed that GTPs could reverse the screening test for under nutrition as needling, deep or superficial, did not opening of tight junction (TJ) barrier its serum concentration is influenced affect measured functional outcomes at 60 min and 120 min after MACO. by many factors other than nutritional over the 48-hour observation period. The decreased mRNA and protein status, notably the APR (acute-phase DOMS affected participants uniformly expression levels of claudin-5, occludin, response) and endocrine conditions. irrespective of pain, MFTrP status or and ZO-1 in microvessel fragments Concentrations should be interpreted intervention type and therefore is like of cerebral ischemic tissue were along with clinical findings and the to act as a modifier. significantly prevented by treatment results of other investigations such as with GTPs at the same time points after CRP (C-reactive protein). More recently, ischemia in rats. Furthermore, GTPs there has been interest in free IGF-I Nutrition could attenuate the increase in the which holds promise as a nutritional expression levels of PKCα mRNA and marker. The present review covers Liu X, Wang Z, Wan P, Yu B, Liu Y, Xue Y. protein caused by cerebral ischemia. nutritional regulation of IGF-I and its dysregulation in disease, then goes on Green tea polyphenols alleviate early Conclusions to review recent studies supporting its blood brain barrier damage during These results demonstrate that GTPs utility as a nutritional marker in clinical experimental focal cerebral ischemia may act as a potential neuroprotective contexts. Although not currently through regulating tight junctions and agent against BBB damage at the early recommended by clinical guidelines, PKCalpha signalling. BMC Complementary stage of focal cerebral ischemia through it is likely that, in time, measurement and Alternative Medicine. 2013; 13:187 the regulation of TJ and PKCαsignaling. of IGF-I will become a routine part of doi:10.1186/1472-6882-13-187 nutritional assessment in a number of these contexts. Background Livingstone C. It has been supposed that green tea polyphenols (GTPs) have Insulin-like growth factor-I (IGF-I) and neuroprotective effects on brain clinical nutrition. [Review] Clinical Science. damage after brain ischemia in 2013; (6):265-80, 2013. animal experiments. Little is known regarding GTPs’ protective effects IGF-I (insulin-like growth factor-I) against the blood-brain barrier (BBB) is a peptide hormone, produced disruption after ischemic stroke. We predominantly by the liver in response investigated the effects of GTPs on the to pituitary GH (growth hormone), expression of claudin-5, occludin, and which is involved in a wide variety ZO-1, and the corresponding cellular of physiological processes. It acts mechanisms involved in the early stage in an endocrine, paracrine and of cerebral ischemia. autocrine manner to promote growth. The production of IGF-I signals the Methods availability of nutrients needed for its Male Wistar rats were subjected to anabolic actions. Recently, there has a middle cerebral artery occlusion been growing interest in its role in (MCAO) for 0, 30, 60, and 120 min. health and disease. IGF-I has long been GTPs (400 mg/kg/day) or vehicle was known to be regulated by nutrition and

250 | vol19 no4 | JATMS JATMS | December 2013 | 251 BOOK REVIEWS

Alkymia’s Child

Reviewed by: Bill Pearson

For members of ATMS, Mariangela is offering her book at a 20% discount. Contact Mariangela on 0411 389 811 or visit her website at www.alkymia.com.au. The book is usually $24.95 in paperback or $9.99 as an EBook. Discount applies to both.

Too often it is a nightmare story as Mariangela takes us with her family along the circuitous pathway of finding answers to things which were capable of tearing her family apart. With that in mind it is also a love story. A profoundly deep and moving love Perhaps there is no greater journey in I am an avid reader. So much so that I story primarily between a mother, this thing we call life than that journey believe there is a difference (well there father, initially one child and then which involves family as that surely is in my mind) between a writer and an children but with a supporting cast engages us in our own search for identity. author. A writer can spin a good yarn. of hundreds. Some in the physical For our position. And like all journeys An author creates something which is world and many beyond. It is a book it is often circuitous and challenging. I spellbinding and leaves us with huge which will tear you apart as it tears at suggest that this book by Mariangela is impressions. I have no hesitation in Mariangela and her family. an outstanding example of that genre. saying that Mariangela Parodi is On every page is a moving example of an author. It demonstrates in wonderful and search but little or temporary discovery, often confronting detail how special of questions but few resulting in the family is and even though satisfying answers and consequently a Findlay because of his special needs search begins which understandably comes under fire there is obviously a challenges Mariangela and her family but special soul emerging. But there are eventually leads them all to what I feel also many sections of the book where Mariangela knew anyway. She just had to he is just like any other kid, terribly have it confirmed. And this is probably aware that he is in public with why this all happened. Had to happen. his parents. Two of my favourite maxims came to This book will challenge many a reader. mind while reading this book: And why not? What Mariangela shares with us challenged her, her family and • Life is what happens when we have the many practitioners covering all made other plans branches of medicine and healing as they all strove for answers. I believe • Sometimes we stumble over the truth Mariangela found hers. but pick ourselves up and walk away as though nothing had happened This book also transports us to La Paz, Buenos Aires, Machu Picchu, Santiago Well Mariangela and her family certainly and other exotic locations where we had a slice of life thrust upon them tango, salsa, join a cattle ranch but of which they hadn’t planned, the result course wherever we are taken healing, being that they couldn’t walk away as ATMS member and Author Mariangela growth, learning etc is the foundation though nothing had happened. What had Parodi and ATMS Director and Life which travels with us and the very happened would challenge them, stretch Member Bill Pearson following the underpinning of why pen first them and in many ways push them to launch of her book in Hobart on touched paper. the brink of what families endure. September 8th 2013.

252 | vol19 no4 | JATMS Heal with Food - of value to both informed and interested Food Farmocopoeia members of the public and practitioners who want a ready reference to be used Reviewed by: Stephen Clarke in its own right or as a starting point for further research. Hard copy can be purchased by contacting the author Debbie at www.healwithfood.com.au The format consists of an alphabetical for $27.50 plus postage and handling. An list of ailments and foods recommended e-book format can be purchased by following for their treatment and management and the links on that website. those to avoid. Where relevant, healthy lifestyle practices are presented along Debbie Pannowitz is an accredited with nutritional advice. For example, specialist in both kinesiology and maintaining normal body weight and nutritional medicine. She has drawn on using hot compresses of essential oils The book is an A4 spiral bound format. her long career in scientific research, the are recommended to treat arthritis along It also contains 14 appendices dealing food pharmacology and health industries, with ten dietary recommendations. with a wide range of important subjects teaching and clinical practice to compile such as serving sizes, foods high in this A to Z of nutritional approaches to Although the book is intended for use phytoestrogens, acid-forming and over a hundred common ailments. by health professionals and the general alkali-forming foods, and foods with public, the author clearly makes the a low GI. The final pages of the book Perhaps its major strength is the point that it is not intended to replace comprise a glossary of nutritional simplicity and clarity with which the advice of qualified practitioners and terms which further contribute to the a wealth of expert information is further warns of the dangers inherent in book’s functionality as an accessible and provided. Its clear layout would make it self-medicating with supplements. comprehensive reference.

JATMS | December 2013 | 253 HEALTH FUND NEWS

Health Funds funds on their next available list. Please It is of note that the health funds ATMS is a ‘professional organisation’ note that the health funds can take up require practitioners to be in private within the meaning of section 10 of the to one month to process new providers practice. Rebates are only claimable for Private Health Insurance Accreditation and change of details as we are only one the consultation (not the medicines or Rules 2008. This potentially allows of many health professions that they remedies); however this does not extend ATMS accredited members to be deal with. to mobile work including markets, recognised as approved providers corporate or hotels. Home visits are by the various private health funds. Lapsed membership, insurance or eligible for rebates. Approved health fund provider status first aid will result in a member being is, however, subject to each individual removed from the health funds list. Australian Health health fund’s requirements. As health funds change their provider Management (AHM) eligibility requirements from time to Names of eligible ATMS members will be Consequently membership of ATMS does time, upgrading qualifications may be automatically sent to AHM each month. not automatically guarantee provider necessary to be re-instated with some AHM’s eligibility requirements are listed status with all health funds. Please also health funds. on the ATMS website www.atms.com. note that several health funds do not au. ATMS members can check their recognise courses done substantially Terms and Conditions of eligibility by checking the ATMS website by distance education, or qualifications Provider Status or by contacting the ATMS Office on obtained overseas. Many of the Terms and Conditions of 1800 456 855. Your ATMS Number will Provider Status for the individual health be your provider number, unless you Additional requirements for recognition funds are located on the ATMS website. wish to have online claiming. You will as a provider by health funds include: For the Terms and Conditions for the then need to contact AHM directly for other health funds, it will be necessary to the new provider number. • Clinic Address (Full Street Address contact the health fund directly. must be provided – Please note that Australian Regional Health some health funds may list your clinic Please note that whilst there is no law or Group (ARHG) address on their public websites) regulation requiring patient clinical notes This group consists of the following to be taken in English, many of the major health funds: • Current Senior First Aid health funds do require patient clinical notes to be taken in English. Failure to do • ACA Health Benefits Fund Ltd • Current Professional Indemnity this will be a breach of the Health Funds • Cessnock District Health Benefits Fund Insurance (some health funds require Terms and Conditions and may result • CUA Health Limited specific minimum cover amounts) in the practitioner being removed as a • Defence Health Limited provider for that health fund. • GMHBA (Including Frank Health Fund) • Compliance with the ATMS Continuing • GMF Health Education Policy For health funds to rebate on the • Health.com.au Pty Ltd services of Accredited members, it is • Health Care Insurance Limited • Compliance with the Terms and important that a proper invoice be • HIF WA Conditions of Provider Status with the issued to patients. The information • Latrobe Health Services (Federation individual health funds. which must be included on an invoice Health) is also listed on the ATMS website. It • Mildura District Hospital Fund ATMS must have current evidence of is ATMS policy that only Accredited • Navy Health Fund your first aid and insurance on file at members issue their own invoice. An • Onemedifund all times. Accredited member must never allow • Peoplecare Health Insurance another practitioner, student or staff • Phoenix Health Fund When you join or rejoin ATMS, or when member to use their provider details, • Police Health Fund you upgrade your qualifications, details as this constitutes health fund fraud. • Queensland Country Health Fund Ltd of eligible members are automatically Misrepresenting the service(s) provided • Railway and Transport Fund Ltd sent to the applicable health funds on the invoice also constitutes health • Reserve Bank Health Society Limited (provided you have given ATMS fund fraud. Health fund fraud is a • St Luke’s Health permission to send your details to the criminal offence which may involve a • Teachers Federation Health health funds) on their next available police investigation and expulsion from • Teachers Union Health listing. The ATMS office will also forward the ATMS Register of Members. • Transport Health your change of details, including clinic • Westfund address details to your approved health

254 | vol19 no4 | JATMS Details of eligible members, including Members who are accredited for requirements include an IELTS test member updates are automatically sent Remedial Massage, will need to use the result of an overall Band 6 or higher to ARHG by ATMS monthly. The details following letters. for TCM qualifications completed in sent to ARHG are your name, address, a language other than English. BUPA telephone and accredited discipline(s). M Massage Therapy will generate a Provider Number These details will appear on the AHHG R Remedial Therapy after receiving the list of eligible websites. If you do not wish your details practitioners. BUPA advises ATMS of to be sent to ARHG, please advise the The letter at the end of your provider your Provider Number and ATMS will ATMS office on 1800 456 855. number will depend on your then advise those members directly. qualification, not the modality in which The ARHG provider number is based you hold accreditation. All members who CBHS Health Fund Limited on your ATMS number with additional hold a Diploma of Remedial HLT50302 Names and details of eligible ATMS lettering. To work out your ARHG or HLT50307 will be able to use both members will be automatically sent to provider number please follow these the ‘M’ and ‘R’ letters. It is recommended CBHS each month. The details sent to steps: to use the ‘R’ as often as possible, but CBHS are your name, address, telephone as not all health funds under ARHG and accredited discipline(s). These details 1 Add the letters AT to the front of your cover ‘Remedial Therapy’, it will be will appear on the CBHS website. If you do ATMS member number necessary to use the ‘M’ at the end of not want your details to be sent to CBHS, the provider number for those funds please advise the ATMS office on 1800 456 2 If your ATMS number has five digits only. All other eligible Remedial Massage 855. The provider eligibility requirements go to step 3. If it has two, three or four Therapists who do not hold the Diploma for CBHS are located on the ATMS website digits, you need to add enough zeros to of Remedial Massage HLT50302 or www.atms.com.au. Your ATMS number the front to make it a five digit number HLT50307 are required to use the ‘M’ at will be your Provider Number. (e.g. 123 becomes 00123). the end of their provider number. Doctors Health Fund 3 Add the letter that corresponds to Australian Unity Names and details of eligible ATMS your accredited modality at the end of Names and details of eligible ATMS members will be automatically sent to the provider number; members will be automatically sent Doctors Health Fund each fortnight. to Australian Unity each month. ATMS Please note that Doctors Health Fund only A Acupuncture, members will need to contact Australian covers Remedial Massage. The provider C Chinese Herbal Medicine, Unity on 1800 035 360 to register as a eligibility requirements for Doctors Health H Homoeopathy, provider, after filling out the Australian Fund are located on the ATMS website N Naturopathy, Unity Application Form located on the www.atms.com.au. Your ATMS number O Aromatherapy, ATMS website to activate their provider will be your Provider Number. W Western Herbal Medicine. status. This only needs to happen the first time. The provider eligibility Grand United Corporate If ATMS member 123 is accredited in requirements for Australian Unity are To register with Grand United Corporate, Western herbal medicine, the ARHG located on the ATMS website please apply directly to Grand United on provider number will be AT00123W. www.atms.com.au. Your ATMS 1800 249 966. number can be used as your Provider 4 If you are accredited in several Number, or you can contact Australian HBF modalities, you will need a different Unity for your Australian Unity Names and details of eligible ATMS provider number for each modality generated Provider Number. members will be automatically sent to (e.g. if ATMS member 123 is accredited HBF each month. The provider eligibility for Western Herbal Medicine and BUPA (including MBF, HBA, Health Cover requirements for HBF are located on Aromatherapy, the ARHG provider Direct, AXA, NRMA, SGIO, SGIC, the ATMS website www.atms.com.au. numbers are AT00123W and St Georges Health, ANZ Health and HBF generates provider numbers after AT00123O. Mutual Community) they receive the first claim from first HBF client. ARHG and Remedial Massage Names and details of eligible ATMS Remedial massage therapists who members will be automatically sent to HCF (including Manchester graduated after March 2002 must hold a BUPA on a weekly basis. The provider Unity) Certificate IV or higher from a registered eligibility requirements for BUPA are Names and details of eligible ATMS training organisation. located on the ATMS website www. members will be automatically sent atms.com.au. The Provider eligibility to HCF each fortnight. The provider

JATMS | December 2013 | 255 HEALTH FUND NEWS

eligibility requirements for HCF are located on the ATMS Please go to www.hicaps.com.au or call 1800 805 780 for website www.atms.com.au. Your ATMS number will be your further information. Provider Number.

Health Partners Names and details of eligible ATMS members will be Erratum automatically sent to Health Partners each month. The provider My sincere thanks to Dr Ghaith Al Badri for pointing out eligibility requirements for Health Partners are located on the an error in the article I published on Galenic Medicine in ATMS website www.atms.com.au. Your ATMS number will be JATMS June 2013 which mistakenly referred to an image your Provider Number. of a book as a ‘Persian Galenic text’. Dr Badri assures me that the text featured is actually the Koran. The tour Medibank Private guide showing me the rare books collection of the CCRUM Names and details of eligible ATMS members will be library was in fact a student, and either I misunderstood automatically sent to Medibank Private on a weekly basis. The his explanation of the display case in question or he was provider eligibility requirements for Medibank Private are himself mistaken in thinking this particular text to be a located on the ATMS website www.atms.com.au. Medibank Galenic medical work. Ultimately the fault lies entirely Private requires Clinical Records to be taken in English. with me as the author of the article and I can only Medibank Private generates Provider Numbers after receiving offer my sincere thanks for correcting the error, and my the list of eligible practitioners from ATMS. Medibank Private similarly sincere apologies for the misunderstanding. sends these provider numbers directly to your clinic address/es. Kind Regards, NIB Names and details of eligible ATMS members will be Dr Jimi Wollumbin (TCM) automatically sent to NIB on a weekly basis. The provider eligibility requirements for NIB are located on the ATMS website www.atms.com.au. NIB does accept overseas Acupuncture and Chinese Herbal Medicine qualifications which have been assessed as equivalent to the required Australian qualification by Vetassess. Your ATMS Number will be your provider number, unless your client wishes to claim online. Your client will need to contact NIB directly or search by your surname and postcode on the NIB website www.nib.com.au for your provider number for online claiming purposes.

HICAPS ATMS members who wish to activate these facilities need to register directly with HICAPS. Please note that you must have a Medibank Private Provider number to be able to use these facilities. HICAPS do not cover all health funds and modalities.

Database of medical cases Billions of patients are treated around the world every year and the potential learning from each patient interaction or ‘case’ is enormous. Most cases go unreported. A new database of medical cases has recently been set up by BioMed Central providing an opportunity to capture much of the potential learning that has previously been unrecorded and unshared.

Cases Database is available at www.casesdatabase.com. Searching and access to case summaries is free. Access to the full text of non-open access case reports may require a subscription to the journal.

256 | vol19 no4 | JATMS HEALTH FUND UPDATE

Traditional Chinese  Massage 3 

Sports Massage u  or contactour office

3 3 3 3 Shiatsu u

Rolfing 

www.atms.com.au

Remedial Therapies (No longer ATMS Accredited) 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

Remedial Massage 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 ay changeay without prior notice. m  3 3 3 3 3 Reflexology u 

Nutrition 3 3 3 

Naturopathy 3 3 3 3 3 3 33 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 33 3 3 3 3 3 3 33 3 3 3 3 3 3 3 3

Lymphatic Drainage  3 3 3 3 3 Kinesiology u



Iridology 

Hypnotherapy 

Homoeopathy 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Herbal Medicine u

Deep Tissue Massage 

Counselling  

Chinese Herbal Medicine 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

Bowen Therapy 3 3

3 3 3 3 3 3 3 3 3 3 3 3 3 Aromatherapy u

Alexander Technique 3 3 3 Rebates do not usually cover medicines, only consultations. For further rebate terms and conditions, patients should contact their health fund. Policies

Acupuncture 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 ian Unityian recognised Naturopath. note that this table is only a guide to show what funds ATMS cover accredited modalities. If the modality that are you accred ited for is not listed,this means that no health fund covers the modality. The only exceptions are

Austral

n Please Chiropractic and Osteopathy. ATMS accreditation a modality in does not guarantee provider status funds as all their have individual set of strict eligibility requirements. Please see our website for current requirements.

(Goldfields Medical Fund)

(Credicare)

(Geelong Medical)

Health Fund e Health Services (Health Insurance Fund ofWA) Partners

Frank Health Fund A Health Benefits Fund

Iridology can only be claimed when provided a by HEALTH HEALTH FUND UPDATE AC Health District Cessnock CUA Health Defence Health Partners GMF Health GMHBA InsuranceHealth Care Limited Health.com.au HIF Latrob MDHF (Mildura District Hospital Fund) Navy Health Fund Onemedifund Peoplecare Health Insurance Phoenix Police Health Fund Queensland Country Health Railway and Transport Reserve Bank Health Society St Lukes Teachers Federation Teachers Union Health Transport Health Westfund Only openOnly to existing recognised Manchester Unity Providers. HCF are not accepting new practitioners under these modalities. Therapy covered by Fund Therapy covered by Fund

Need to Apply directly to Fund

Health Fund Health Australian Health Management Australian RegionalGroup Health Australian Unity BUPA CBHS Health Fund Doctors Health Fund GU Health (Grand United)* Health HBF HCF Medibank Private NIB 3 *  u

JATMS | December 2013 | 257 EDUCATION AND TRAINING

Continuing Professional Education

Continuing professional education • Applicable to not only clinical practice, (5) CPE points can be gained from (CPE) is a structured program of further but also to all activities associated with each issue of this journal. To gain five education for practitioners in their managing a small business (e.g. book- CPE points from this issue, select any professional occupations. keeping, advertising) three of the following articles, read them carefully and critically reflect The ATMS CPE policy is designed to • Seminars, workshops and conferences how the information in the article ensure its practitioners regularly update that qualify for CPE points must be may influence your own practice and/ their clinical skills and professional of a high standard and encompass or understanding of complementary knowledge. One of the main aims of CPE both broad based topics as well as medicine practice: is to keep members abreast of current discipline-specific topics research and new developments which • Muscolino J. To flex or extend? inform contemporary clinical practice. • Financially viable, so that costs will not inhibit participation by members, • Brown L. Neutraceuticals for chronic The ATMS CPE Policy is based on the especially those in remote areas inflammatory diseases following principles: • Relevant to the learning needs of • Wollumbin J. Homoeopathy, • Easily accessible to all members, practitioners, taking into account humanitarian aid and regardless of geographic location different learning styles and needs homoeoprophylaxis: Part 1

• Members should not be given broad • Collaborative processes between • Bumpstead L. Long term use of latitude in the selection and design of professional complementary medicine supplemental lysine - is it safe? their individual learning programs associations, teaching institutions, suppliers of therapeutic goods and • Medhurst R. Burns and their • Applicable to not only the disciplines devices and government agencies to management using homoeopathy in which a member has ATMS offer members the widest possible accreditation, but also to other choice in CPE activities As part of your critical reflection and practices that are relevant to clinical analysis, answer in approximately 100 practice which ATMS does not accredit • Emphasis on consultation and co- words the following questions for each (e.g. Ayurveda, yoga) operation with ATMS members in the of the three articles: development and implementation of the CPE program 1 What new information did I learn from this article? ATMS members can gain CPE points through a wide range of professional 2 In what ways will this information IT IS A MANDATORY activities in accordance with the ATMS affect my clinical prescribing/ REQUIREMENT OF ATMS CPE policy. CPE activities are described techniques and/or my understanding in the CPE policy document as well of complementary medicine practice? MEMBERSHIP THAT MEMBERS as the CPE Record. These documents ACCUMULATE 20 CPE POINTS can be obtained from the ATMS office 3 In what ways has my attitude to this (telephone 1800 456 855, fax (02) 9809 topic changed? PER FINANCIAL YEAR. FIVE (5) 7570, or email [email protected]) or CPE POINTS CAN BE GAINED downloaded from the ATMS website at Record your answers clearly on paper www.atms.com.au. for each article. Date and sign the sheets FROM EACH ISSUE OF THIS and attach to your ATMS CPE Record. JOURNAL It is a mandatory requirement of ATMS As a condition of membership, the CPE membership that members accumulate Record must be kept in a safe place, and 20 CPE points per financial year. Five be produced on request from ATMS.

258 | vol19 no4 | JATMS EDUCATION AND TRAINING

Continuing Education Calendar 2014

MONTH EVENT TOPIC REGION

January 2014 Webinar Communication Skills in TCM Practice -

February 2014 Seminar Paediatric Nutrition and Health Melbourne

Webinar Website & Social Media -

Seminar Advanced Remedial Massage Techniques Sydney

Seminar Lymphatic Drainage Coffs Harbour

Webinar Principles of Integrative Oncology -

Seminar Anti-Ageing Medicine: Add years to your life and life to your years - the Telomere Brisbane Story

March 2014 Webinar Self Care: Practitioner Health & Wellbeing -

Seminar Nutrition Deficiencies, Body Signs, Clinical Signs and Complex Conditions in Sydney Clinical Practice

Webinar Nutrition Support for Autoimmune Diseases? -

Seminar Lower Back Pain Tasmania

Seminar Ayurvedic approaches to rejuvenation and ageing well Central Coast

April 2014 Webinar Paediatric Nutrition and Health -

Seminar Acupressure Adelaide

Seminar Advanced Remedial Massage Techniques Canberra

Webinar Communication & Counselling in Clinical Practice -

May 2014 Seminar Intro to Kinesiology Sydney

Webinar Optimizing Hormones -

Seminar ATMS & Natural Medicine: a Natural Choice Perth

Webinar Generic Clinical Records -

Seminar Exercise Therapy & Sports Nutrition Newcastle

June 2014 Seminar Acupuncture Treatment of Tension Headaches Sydney

Webinar Skin Deep: Nutrition for Better Skin -

Seminar Cupping Melbourne

Webinar Treating Complex Sensitive Patients -

Seminar Manual Lymphatic Drainage North Queensland

Seminar Advanced Remedial Massage Techniques Newcastle

JATMS | December 2013 | 259