Acupuncture and Moxibustion, College of Korean Medicine Kyung Hee University

Current Practice of Korean Medicine

Sponsored by Ministry of Health and Welfare, and Korea Institute of Oriental Medicine (Project for International Promotion of Korean Medicine 2016)

Approved by Society of Korean Medicine

Published in December 2016 by Pusan National University School of Korean Medicine 49 Pusandaehak-ro, Yangsan-si, Gyeongnam 50612, Korea Tel.+82-51-510-8408 Fax.+82-51-510-8446 http://kmed.pusan.ac.kr E-mail: [email protected]

English Translated by Jeong-min Ko, KMD, CEO Dr. Jeongmin Ko's Korean Medicine Clinic (Inc.) All that Korean Medicine Ye-Sle Emilie Shin, KMD Jaseng Medical Foundation

Proofread by Hyunmi Jung Division of Humanities and Social Medicine, School of Korean Medicine Pusan National University Me-riong Kim, KMD (proofread Part 1, Chapter 4 Chuna Manual Medicine) Jaseng Medical Foundation

Designed and printed by Shinjin Communications 2F, 74-21, Taejeon-ro, Dong-gu, Daejeon, Korea Tel.+82-42-638-7887 Fax.+82-42-638-7889

Reprinted in December 2017 with support of National Development Institute of Korean Medicine

ISBN 979-11-88027-01-9 Contributors

Byungmook Lim, KMD, MPH, PhD Professor Division of Humanities and Social Medicine, School of Korean Medicine Pusan National University

Yongsuk Kim, KMD, PhD Professor Department of Acupuncture and Moxibustion, College of Korean Medicine Kyung Hee University

Dongwoo Nam, KMD, PhD Assistant Professor Department of Acupuncture and Moxibustion, College of Korean Medicine Kyung Hee University

Byunghee Koh, KMD, PhD Professor Department of Sasang Constitutional Medicine, College of Korean Medicine Kyung Hee University

Byung-Cheul Shin, KMD, MPH, PhD Professor Department of Rehabilitation Medicine of Korean Medicine, School of Korean Medicine Pusan National University

Woo Sang Jung, KMD, PhD Professor Department of Cerebrovascular & Neurologic diseases(Stroke Center), College of Korean Medicine Kyung Hee University

Jinsung Kim, M.D.(KMD), Ph.D Professor Department of Digestive Diseases & Oral Diseases Clinic, Kyung Hee University Korean Medicine Hospital

Deok-Sang Hwang, KMD, PhD Professor Department of Korean Medicine Obstetrics & Gynecology, College of Korean Medicine Kyung Hee University

Kibong Kim, KMD, PhD Associate Professor Department of Pediatrics, School of Korean Medicine Pusan National University

Jongwoo Kim, KMD, Ph.D Professor Deptment of Neuropsychiatry, College of Korean Medicine Kyung Hee University

Hojun Kim, KMD, PhD Professor Department of Rehabilitation Medicine of Korean Medicine, College of Korean Medicine Dongguk University

Mi-Rim Jung, KMD Chief Director Dongbaekmiz Korean Medicine Clinic

Sungjin Lee, KMD, PhD Director Dongbaekmiz Korean Medicine Clinic

Kim Dong il, KMD, Ph.D Professor Department of Korean Medicine Obstetrics & Gynecology, College of Korean Medicine Dongguk University Foreword

There are many types of traditional medicine worldwide, and some are considered ‘complementary medicine’ in the Western countries. With Western Medicine becoming the mainstream of a medical treatment method, traditional medicine has lost its former status in most countries. In many Asian countries, such as Korea, China, India, and Vietnam, however, traditional medicine is officially recognized and has played an important role in the country’s health care system.

In Korea, Korean Medicine doctors have made continuous efforts to modernize traditional medicine, and it comes with the government’s policies to promote Korean Medicine, which has made it the most developed traditional medical system in the world. Legal status of Korean Medicine is almost equivalent to that of Western medicine, and qualified education system for Korean Medicine exists. Bureau of Korean Medicine under the Ministry of Health and Welfare supports policy development for Korean Medicine, and National Health Insurance covers most procedures of Korean Medicine.

As a part of the mainstream health care system, Korean Medicine is currently providing qualified medical services and is widely used in Korea, but international awareness is still not high enough. To support Korean Medicine’s contribution to the people’s health around the world, the Korean government declared the ‘International promotion of Korean Medicine’ as one of the national tasks in 2014. With this background, this book was designed to introduce the outstanding clinical practice of Korean Medicine to traditional medicine professions, medical doctors, health related experts, and medical students all over the world. I hope this book provides an opportunity to understand the true value of Korean Medicine for those who are interested in learning about the Korean Medicine system.

2016. 12. Director for Korean Medicine Policy Ministry of Health and Welfare, Republic of Korea

Hyunghoon Lee Preface

Although traditional medicine such as acupuncture, herbal therapy, and massage has been popularized in Western countries, most are still at the level of ‘complementary medicine’. Howev- er, Korean traditional Medicine has been a kind of medical system that is more than complementary. Through the historical stages of ‘colonization’ and the ‘advent of scientific medicine’, Korean Medicine has maintained its fundamental basis and played a great role in the Korean health care system since the liberation.

In the eyes of Westerners, it may be surprising that traditional medicine is based on theories from thousands of years ago and has been existed as an important part of a health care system that was chosen by the public, even in this modern era, which has been flooded with the development of new medical techniques and knowledge. There are three main reasons that Korean Medicine has maintained an official status and been widely utilized. First, from a cultural viewpoint, Koreans have confidence and preference for Korean Medicine. Second, from a political viewpoint, Korean Medicine doctors have made an effort to maintain and develop Korean Med- icine as a part of the national medical system. Lastly, techniques of Korean Medicine have been shown to be efficient.

This book is designed to promote an understanding of the structure and function of clinical Ko- rean Medicine; how it is clinically used and how specific diseases can be approached according to Korean Medicine perspective. Although Korean Medicine is considered traditional medicine, modernized Korean Medicine has made it different from its practice of hundreds years ago. It has been changed technically and even theoretically over time. Korean Medicine, as described in this book, is the most modernized Korean Medicine that is currently utilized in Korea.

This book is composed of two parts. Part I. Understanding the Clinical System of Korean Med- icine is about how Korean Medicine is integrated into the health care system in Korea, and it discusses the uniqueness of Korean Medicine compared to other traditional medicines of East- ern Asia. Part Ⅱ. Korean Medicine Treatments for Various Medical Conditions discusses major diseases along with the diagnosis and treatment methods of Korean Medicine and promotes the understanding of clinical techniques.

The first chapter of Part I is Korean Medicine in the Modern Health Care System. This chapter examines the systematic development and use of Korean Medicine, showing the current status of modern Korean Medicine in the legal system, educational system, and health care system. This will facilitate understanding of the systemic basis that supports Korean Medicine to function as a significant part of the health care system.

The second chapter, Therapeutic technologies of Korean Medicine, introduces basic techniques that are used in clinical Korean Medicine. The main tools of Korean Medicine are acupuncture, moxibustion, cupping, and herbal medicine. These are described with their uses, and unique Korean acupuncture methods, such as Taekeuk acupuncture, Saam acupuncture, and Embed- ding acupuncture.

The third chapter addresses Sasang Constitutional Medicine. It is a medical theory created at the end of the 1800s stating that people can be categorized into four typologies; Taeyangin, Taeeumin, Soyangin, Soeumin, according to their inborn constitution. Each constitution has different physiological, pathological, and psychological characteristics. Also, suitable and un- suitable herbs are introduced for each constitution. Sasang constitutional medicine is the main theory of Korean Medicine different from other Eastern traditional Medicine systems.

The fourth chapter introduces Chuna Manual Medicine. Chuna is a modified method of a traditional manual technique combined with a modern technique. It has been shed new light on since the 1980s. Due to the preference of the public, as of 2017, a pilot program for Chuna manual medicine for the coverage of National Health Insurance will be implemented.

Part Ⅱ describes Korean Medicine diagnosis and treatment methods for nine different types of diseases and health problems. The first chapter of part Ⅱ is muscular skeletal diseases, which are the most frequent disorders treated by Korean Medicine in Korea. In both outpatient and inpatient care, the top ten common disorders mostly consist of musculoskeletal disorders. Treat- ments for these disorders that are covered by the National Health Insurance include acupuncture and cupping therapy, which have shown high efficacy in treating musculoskeletal disorders.

The second chapter is cerebrovascular diseases, which comprise many of the inpatient cases in Korean Medicine hospitals because the public has a preference for treatment with Korean Med- icine after cerebrovascular attacks. Electronic and radiographic devices are used for diagnosis, and these diseases are therefore most commonly treated cooperatively with Western Medicine.

The third chapter is digestive disorders. Diseases such as Burning Mouth Syndrome (BMS), Gastroesophageal Reflux Disease (GERD), Functional Dyspepsia (FD), and Irritable Bowel Syndrome (IBS) are managed with Korean Medicine based on current clinical evidence.

The fourth chapter is women‘s diseases, which include the diagnosis and treatment of menstrual pain, uterine myoma, and menopausal syndrome. Many young females are under stress, have unhealthy habits, and are obsessed with weight loss that may cause various health problems. From the Korean Medicine point of view, warming the lower energizer and releasing obstructions may be of help in these diseases.

The fifth chapter is pediatric diseases. Diseases such as the common cold, anorexia, constipation, and nocturnal enuresis are treated with Korean Medicine. Pediatrics of Korean Medicine has been popularized since the 1990s, with the introduction of clinics specializing in pediatrics. This has also led to other areas of Korean Medicine being developed as specialties in certain clinics.

The sixth chapter is psychiatric diseases. Depression, anxiety disorder, Hwa-byung, and sleep disorders are discussed along with approaches and guidelines for clinical treatment based on evidence from current researches. To date, psychiatric therapy on Korean Medicine is covered by the National Health Insurance when administered by a specialized Korean Medicine doctor of Neuropsychiatry. Lastly, obesity treatment, cosmetic treatment, and infertility treatment are introduced in from the seventh to ninth chapter. These areas are in which Korean Medicine is showing advantages and has been developing since the 2000s. Obesity treatment in Korean Medicine includes control of the diet and an increase in metabolic function for weight loss, which have been shown in evidence-based research studies. Cosmetic treatment, with cosmetic acupuncture (needle embedding) as the main treatment, is an area where Korea pioneered new therapies, and the spotlight on Korea has spread knowledge of these new therapies worldwide. Infertility treatment with Korean Medicine has been shown to have an effect on patients for whom Western Medicine treatment has failed. Many related studies are on-going. To meet the needs of the low fertility community, many local governments have provided funding for Korean Medicine infertility treatment.

This book will help readers understand the general outline and the structure of clinical Korean Medicine. For medical professions in either Western Medicine or complementary medicine, however, more information will be needed to apply Korean Medicine actually in their clinical field. To fulfill the needs, it is slated to publish English textbooks on specific clinical areas of Korean Medicine in a serial form.

I sincerely thank the Ministry of Health and Welfare for providing funding for the publication of this book and the Society of Korean Medicine for proofreading and approving. I also thank co-authors and staffs for sharing their time and efforts to make this book more valuable.

2016. 12. On behalf of the authors

Byungmook Lim CONTENTS

● Current Practice of Korean Medicine 2016 Foreword 004 Preface 006 Glossary 012

PART 1 Understanding the Clinical System of Korean Medicine

CHAPTER 1 Korean Medicine in the Modern 017 Health Care System

CHAPTER 2 Therapeutic Techniques of 035 Korean Medicine

CHAPTER 3 Clinical Applications of Sasang 069 Constitutional Medicine

CHAPTER 4 Chuna Manual Medicine 099 PART 2 Korean Medicine Treatments for Various Medical Conditions

CHAPTER 1 CHAPTER 7 Musculoskeletal Diseases 121 Obesity 275

CHAPTER 2 CHAPTER 8 Cardiovascular and 151 Korean Medicine Cosmetic 303 Neurological Diseases Procedures

CHAPTER 3 CHAPTER 9 Digestive Diseases 175 Infertility 323

CHAPTER 4 Women’s Diseases 199

CHAPTER 5 Pediatric Diseases 225 Appendix 342 CHAPTER 6 Psychiatric Diseases 251 Index 350 Glossary ACQ Agoraphobic Cognitions Questionnaire AMH Anti-Mullerian Hormone AMI Acute Myocardial Infarction AMTS Auto-Microneedle Therapy System ART Assisted Reproduction Techniques ASRM American Society of Reproductive Medicine AST Aspartate amino Transferase BADL Basic Activities of Daily Living BDI-II Beck Depression Inventory II BIA Bioelectric Impedance Analysis BMD Bone Mineral Density BMI Body Mass Index BMS Burning Mouth Syndrome BPSD Behavioral and Psychological Symptoms in Dementia BUN Blood Urea Nitrogen CBC Complete Blood Count CDR Clinical Dementia Rating CES-D Center for Epidemiological Studies-Depression Scale CMM Chuna Manual Medicine CMT Chuna Manual Therapy COPD Chronic Obstructive Pulmonary Disease CPR Clinical Pregnancy Rate CPX Clinical Performance Examinations CRP C-Reactive Protein CSF Cerebrospinal Fluid CST Combining craniosacral Therapy CT Computed Tomography DITI Digital Infrared Thermal Imaging DLBP Discogenic Lower Back Pain DXA Dual energy X-ray Absorptiometry ECG Electrocardiography EFT Emotion Freedom Technique EMG Electromyography ENoG Early-performed Electroneurography ESRs Erythrocyte Sedimentation Rates FD Functional Dyspepsia FSH Follicle Stimulating Hormone GDS Geriatric Depression Scale GERD Gastroesophageal Reflux Disease GI Glycemic Index HAM-A Hamilton Anxiety Rating Scale HBDIS Hwa-Byung Diagnositic Interview Schedule HDL High-Density Lipoprotein HDRS Hamilton Depression Rating Scale NPI Neuropsychiatric Inventory HIV Human Immunodeficiency Virus NRS Numeric Rating Score HPA Hypothalamic-Pituitary-Adrenal axis OECD Organization for Economic Co-operation and HPO-axis Hypothalamus-Pituitary gland-Ovary axis Development HRmax maximal Heart Rate OHSS Ovarian Hyperstimulation Syndrome HRT Hormone Therapy OPR Ongoing Pregnancy Rate HRV Heart Rate Variability OSCE Objective Structured Clinical Examinations HVLA High-Velocity Low-Amplitude PBL Problem-Based Learning IBS Irritable Bowel Syndrome PDO Polydioxanone IBS-C IBS with Constipation PDS Postprandial Distress Syndrome IBS-D IBS with Diarrhea PHQ-9 Patient Health Questionnaire IBS-M Mixed IBS PID Pelvic Inflammatory Disease IBS-U Un-subtyped IBS PMR Progressive Muscle Relaxation ICT Interference Current Therapy PPI Proton Pump Inhibitors IKMEE Institute of Korean Medicine Education Evaluation PPP Point by Point INR International Normalized Ratio PSS Perceived Stress Scale IUD Intrauterine Device PSWQ Penn State Worry Questionnaire K-DRS Kingston Dementia Rating Scale RCTs Randomized Controlled clinical Trials KIOM Korean Institute of Oriental Medicine SCID-I The Structured Clinical Interview for DSM-IV Axis I Disorders KM Korean Medicine SFT Skin-Fold Thickness KMDs Korean Medicine Doctors SLR Straight Leg Raising K-MoCA Korean Montreal Cognitive Assessment SMAS Superficial Musculo-Aponeurotic System KSCMM The Korean Society of Chuna Manual Medicine for Spine & Nerves SNPs Single Nucleotide Polymorphisms LBP Lower Back Pain SR Systematic Review LBR Live Birth Rate STAI State-Trait Anxiety Inventory LCD Low-Carlorie Diet STAXI State-Trait Anger Expression Inventory LDH Lactate Dehydrogenase TCD Transcranial Doppler sonography LDL Low-Density Lipoprotein TNS Transcutaneous Electrical Nerve Stimulator LFT Liver Function Tests TMD Temporomandibular joint Dysfunction LH Luteinizing Hormone TMJ Temporomandibular joint dysfunction MAOIs Mono-Amine Oxidase Inhibitors TSH Thyroid-Stimulating Hormone MBCT Mindfulness-Based Cognitive Therapy VLCD Very Low-Calorie Diet MBI Modified Barthel Index VO2 max maximal Oxygen Uptake MBSR Mindfulness Based Stress Reduction program WBC White Blood Cell MFR Monthly Fecundity Rate WC Waist Circumference MMSE Mini-Mental State Examination WHO World Health Organization MMSE-K Korean Mini-Mental State Examination WHOQoL World Health Organization Quality of Life MOCI Maudsley Obsessive-Compulsive Inventory WHR Waist-Hip Ratio MPH Mid-Parental Height WM Western Medicine MRI Magnetic Resonance Imaging WURSS-21 Wisconsin Upper Respiratory Symptom Survey-21 NERD Non-Erosive Reflux Disease NIHSS National Institutes of Health Stroke Scale 1 PART

● Current Practice of Korean Medicine 2016 Understanding the Clinical System of Korean Medicine

CHAPTER 1 Korean Medicine in the Modern Health Care System

CHAPTER 2 Therapeutic Techniques of Korean Medicine

CHAPTER 3 Clinical Applications of Sasang Constitutional Medicine

CHAPTER 4 Chuna Manual Medicine 2016 Korean Medicine Current Practiceof CHAPTER 1

Korean Medicine in the Modern Health Care System

▼ Byungmook Lim PART 1 Understanding the clinical system of Korean Medicine

chapter 1

Korean Medicine in the Modern Health Care System

Introduction

Korea has “the most advanced policy regime for traditional medicine” in the world (Holliday, 2003). In Korea, traditional Korean Medicine doctors occupy a legal position equivalent to that of Western Medicine doctors under the Medical Medical Service Act, and the Bureau for Korean Medicine within the Ministry of Health and Welfare controls and develops Korean Medicine-related policies. As of 2014, 800 Korean Medicine doctors graduated from twelve academic institutions (colleges and school), and 234 hospitals and over 13,000 clinics of Korean Medicine provided high-quality medical services to the Korean population. Korea is the only country in the world where there is a specialist system for traditional medicine, including eight specialized departments. With the exception of raw herbal medicines, most Korean Medicine procedures and herbal preparations are covered by the National Health Insurance. (Pusan National University, 2015; Ministry of Health and Welfare, 2015)

High frequency in using Korean Medicine by the public has been stably maintained. A national survey (Korea Health Industry Development Institute, 2014) revealed that 92% of Koreans had received Korean Medicine services in their lifetime and that 27.1% had received Korean Med- icine care within the past three months of the survey. Korean Medicine is the most successful example of traditional medicine being integrated into the modern health care system while maintaining its essential characteristics. In this chapter, the status and role of Korean Medicine in the Korean health care system will be introduced.

18 Korean Medicine in the Modern Health Care System chapter 1

Brief History of Korean Medicine

Providing a background of the history of Korean Medicine will improve understanding of its modern clinical practice. The oldest record of traditional medicine dates back to the Gojoseon Dynasty, approximately 4,000 years ago, on the Korean peninsula (WHO, 2001). Korean Medicine was formed under the influence of ancient Chinese medicine, and these two systems have affected each other. During the Goryo Dynasty (AD 10C–14C), awareness of indigenous herbal medicines, called Hyangyak (鄕藥), grew and the search for and use of local herbs was encouraged.

During the Joseon Dynasty (1392–1897), a national project compiling Korean and Chinese medical texts was initiated under King Sejong (世宗; reigned 1418–1450). In 1445, the Euib- angyoochui (醫方類聚) was published; this text was a compilation of various formulas developed for disease conditions. The knowledge gained through this publication contributed significantly to the birth of the symbol of Korean Medicine in 1679, the Donguibogam (東醫寶鑑). This book is a medical masterpiece compiled by Hŏ Jun (許浚, 1539–1615) that offers a faithful and systematic arrangement of contemporary medical achievements in an easy-to-use format (Seonsam Na, 2012). It is still widely utilized clinically among Korean Medicine doctors.

In the later period of the Joseon Dynasty, a significant medical theory was introduced: Sasang constitutional medicine, which was proposed by Dr. Lee Jema (李濟馬, 1837–1899). This theory states that people can be categorized into four typologies and that each typology differs in terms of physiology and pathology; thus, people’s medical treatment should also be different. According to Sasang constitutional medicine, suitable medicinal herbs and foods exist for each typology, and when an inappropriate herb or food is consumed, a person will not recover and may even experience adverse effects. Sasang constitutional medicine is widely utilized to date, and differentiation of Sasang typology and regimen by constitution in daily life are very popular among the public (Lee, 2014).

In the early twentieth century, when Japanese imperialists colonized the Korean peninsula, the Korean health care system was reformed to conform to the Japanese system, and traditional medicine subsequently lost its status as mainstream medicine. Korean Medicine doctors were

19 PART 1 Understanding the clinical system of Korean Medicine

expelled from public hospitals and armed forces hospitals, and Dongje medical school, the first modern school for Korean Medicine that was supported by Emperor Gojong, closed within three years. Korean Medicine doctors were degraded to medical apprentices (醫生, Uisaeng), and education in Korean Medicine was shifted to small private institutions (Lee, 1977).

Liberation from colonialization in 1945 provided Korean Medicine the opportunity for revival. During the Korean War, a new National Medical Service Act declaring the legitimacy of Kore- an Medicine doctors and Korean Medicine education was enacted in September 1951 through an intense pro-con debate. Korea has subsequently maintained a dual health care system in which Western Medicine doctors and Korean Medicine doctors coexist. Based on the new Act, a 4-year regular medical education system for Korean Medicine started and the education period was expanded to 6 years in 1965.

Since 1987, the utilization of Korean Medicine by the public increased rapidly with the Nation- al Health Insurance’s coverage of acupuncture, moxibustion, and herbal medicine treatment. Although the number of Korean Medicine doctors and the utilization of Korean Medicine services was also increased, Korean Medicine doctors were dissatisfied that the institutional status of Korean Medicine remained unequal to that of Western Medicine.

In 1993, a conflict regarding the preparation of herbal medicines occurred between Korean Medicine doctors and (Western) pharmacists (BH Cho, 2000; HJ Cho, 2000). Pharmacists in- sisted that herbal medicine was also medicine and that pharmacists could thus prepare it, whereas Korean Medicine doctors asserted that the prescription and preparation of herbal medicines were the responsibility of Korean Medicine doctors. This yearlong conflict was resolved by creating new health personnel, the herbal pharmacist, and by allowing pharmacists to prepare herbal medicines if they passed an additional licensing examination.

During the conflict, Korean Medicine doctors strongly demanded the government to foster Korean Medicine. As a result, the office for Korean Medicine in the Ministry of Health and Welfare was enlarged, a national research institute for Korean Medicine was built, and grant programs for Korean Medicine studies were introduced. After 2000, Korean Medicine doctors could work at public health centers as public health doctors and could participate in the army as

20 Korean Medicine in the Modern Health Care System chapter 1

medical officers. The medical specialist system for Korean Medicine was implemented for the first time. In 2004, the Korean Medicine and Pharmaceutics Promotion Act, which was the legal basis for the systematic development of Korean Medicine, was enacted. In accordance with this law, the Ministry of Health and Welfare establishes promotion plans for Korean Medicine every five years (Lim, 2015).

Utilization of Korean Medicine Services 1)

As of 2014, Korean Medicine services were provided in 234 Korean Medicine hospitals and 13,135 local Korean Medicine clinics. Additionally, 204 public health centers and 672 public health center branches provided Korean Medicine health promotion programs as well as medical services. The number of licensed Korean Medicine doctors had been reached 22,074 (Ministry of Health and Welfare, 2014; 2015).

In a recent nation-wide survey of 5,000 Koreans over 20 years old (Korea Health Industry De- velopment Institute, 2014), 92% of respondents had received Korean Medicine services in their lifetime, 27.1% had used in the past three months, and 0.8% had been hospitalized in Korean Medicine hospitals in the past year.

Korean Medicine was used more often by females than by males, with the largest age group represented by those aged 50 to 59 years. High school graduates used Korean Medicine services the least among the education groups, and usage was positively correlated with income. The use of inpatient hospitalization was similar to that of outpatient visits, with a greater preference by females, people in their fifties, and people with higher incomes.

Regarding the perception of the effectiveness of Korean Medicine services, 67.7% responded positively regarding its effectiveness. In contrast, 26.6% said that the effect was mediocre, and

1) The text of this sub-chapter is an excerpt from Byungmook Lim. Chapter 4; “Policy and Management of Korean Medicine” in Korean Medicine: Current Status and Future Prospects. 2015.

21 PART 1 Understanding the clinical system of Korean Medicine

only 5.6% answered that Korean Medicine was not effective. In response to a similar question regarding their intention to use Korean Medicine in the future, 68.8% responded positively, whereas 21.6% responded negatively.

When asked about points for improvement in Korean Medicine services, 40.9% noted the ‘ex- pensive fees,’ 27.6% chose ‘safety issues with medicinal plants,’ 15.5% stated ‘uncertainty of effectiveness,’ and 9.2% chose the ‘need for increased expertise.’

Table 1. Trend in national medical expenses and Korean Medicine expenses (2005–2012) Annual Classification 2005 2006 2007 2008 2009 2010 2011 2012 Increase Rate

Korean Medicine 2,367.2 2,647.0 2,686.0 2,865.2 3,273.0 4,006.1 4,127.0 4,327.6 9.0 Expenses (A)

National Medical 48,941.6 55,528.9 62,478.4 68,112.0 76,565.0 86,052.0 91,687.5 97,187.5 10.3 Expenses (B)

A/B (%) 4.8 4.8 4.3 4.2 4.3 4.7 4.5 4.5 -

Korean Medicine Expenses per 49 55 55 59 67 81 83 87 8.5 Person (USD)

National Medical Expenses per 1,017 1,148 1,286 1,391 1,557 1,742 1,842 1,943 9.7 Person (USD)

* Source: Korea Health Industry Development Institute. The report on the use of Korean Medicine services and the consumption of herbal medicines. 2014.

The medical expenses paid to Korean Medicine hospitals and clinics in 2012 amounted to $4,327.6 million, which included public assets, such as health insurance (37.8%), and private assets, such as out-of-pocket payments (62.2%). The average annual increase rate was 9.0%, which was similar to the trend in overall national medical costs.

Although the use of Korean Medicine service has been increasing, the category of diseases that Korean Medicine doctors manage is focused on musculoskeletal disorders. The following table lists the ten most common disorders in Korean Medicine hospitals and clinics according to charges submitted to the National Health Insurance. Other than indigestion, most of the con-

22 Korean Medicine in the Modern Health Care System chapter 1

ditions are musculoskeletal disorders, such as sprains and joint strains. These results arise from the coverage of the National Health Insurance for Korean Medicine, enacted in 1987, which was designed mainly for acupuncture and moxibustion, techniques that yield fast improvements in musculoskeletal disorders.

Table 2. Ten most common disorders of Korean Medicine outpatient visits in the National Health Insurance

KCD2) Code and Name No. of Visits No. of Patients

M54 Back pain 25,099,389 4,260,471

M79 Other soft tissue disorders 8,438,618 1,839,349

S33 Dislocation, sprain and strain of joints and ligaments of lumbar 7,276,667 1,796,795 spine and pelvis

M75 Shoulder lesions 5,154,741 1,106,939

M17 Arthrosis of knee 4,627,825 701,488

S93 Dislocation, sprain and strain of joints and ligaments at ankle 4,259,325 1,179,996 and foot level

M62 Other disorders of muscle 4,006,278 959,908

K30 Indigestion 2,662,733 822,717

S13 Dislocation, sprain and strain of joints and ligaments at neck level 2,212,989 670,866

S63 Dislocation, sprain and strain of joints and ligaments at wrist 1,943,167 570,783 and hand level

* Source : Health insurance review and assessment agency. 2014 Medical expense statistics. 2015.

2) Korean standard Classification of Diseases

23 PART 1 Understanding the clinical system of Korean Medicine

Education in Korean Medicine 3)

Modern education in Korean Medicine has been developing since the six-year system was introduced in 1965. Eleven colleges of Korean Medicine and one school of Korean Med- icine now exist. Each Korean Medicine college comprises two years of pre-medicine and four years of medicine. The Korean Medicine school provides a four-year course for students with education higher than or equal to a bachelor’s degree. The annual number of students enrolling in the eleven Korean Medicine colleges and the one Korean Medicine school is 750. The Korean Medicine colleges and school are as popular as medical and dental schools in Korea, with less than the top 1% of students applying to them.

A curriculum of Korean Medicine colleges is provided below. In the two years of pre-medicine, courses in liberal arts, an introduction to Korean Medicine, Medical Chinese, and Basic West- ern Medicine are provided. In the four years after pre-medicine, basic and clinical courses are taken, with clinical training pursued afterwards. Kyung Hee University, for example, provides a six-year course with 244 credits, comprising 20% liberal arts, 50% Korean Medicine and 30% Western Medicine. Because clinical education in Korean Medicine also addresses West- ern Medicine, the total portion of Western Medicine taught in Korean Medicine colleges may exceed 40%.

Table 3. Curriculum for Korean Medicine

Pre-medicine Medicine (Requisites) Pathology and lab, Herbology and lab, medical classics, Shanghanlun, Famous theories in Korean Medical classics, Introduction to medicine, Studies on warm diseases, Korean medicine, Medical English, Meridianology and lab, Preventive Required Basic Medical Chinese, Medical history, medicine and lab, Prescriptionology subjects subjects Physiology and lab, Medial Qigong, and lab, Medical ethics, Public health Herbology, Biochemistry and lab (WM), regulations, Anatomy and lab (WM), Embryology (WM) Physiology (WM), Pathology (WM), Histology (WM), Pharmacology and lab, Preventive medicine (WM), Microbiology and lab (WM)

3) This sub-chapter is an excerpt from Byungmook Lim. Chapter 5; “Contemporary Education in Korean Medicine” in Korean Medicine: Current Status and Future Prospects. 2015 by permission of the author and the publisher.

24 Korean Medicine in the Modern Health Care System chapter 1

Pre-medicine Medicine (Requisites)

Sasang constitutional medicine, Internal medicine, Acupuncture and moxibustion, Diagnostics, Gynecology, Dermatology and surgery, Ophthalmology and Clinical Otorhinolaryngology, Neuropsychiatry, subjects Pediatrics, Rehabilitation medicine, Manipulation, Diagnostics (WM), Radiology (WM), Laboratory medicine (WM), Emergency medicine (WM), Forensic science (WM)

Classics reading, Psychology, Medical management, Medical informatics, Writing, English conversation, Chinese Clinical psychology, Alternative medicine, conversation, Molecular biology, Electives Integrative medicine, Clinical dietetics, Eastern philosophy, Philosophy of science, Medical statistics Special lectures (electives run differently according to school policy)

To improve the quality of education, an accreditation system has been applied to the Korean Medicine educational institutions. Led by the Institute of Korean Medicine Education Evalua- tion (IKMEE), regular evaluation and accreditation of educational facilities, infrastructure, educational content, faculty, and student welfare are performed. When an evaluation identifies insuf- ficiencies in the education provided, the institution may be banned from enrolling new students.

In 2000, Herbal pharmacists began receiving licenses specifically for herbal medicines. Three colleges with four-year courses for herbal pharmacists now exist. The number of students en- rolled each year is 120. The educational course requires 160 credits, and the table below lists the major subjects covered.

Table 4. Curriculum for department of herbal pharmacy

Requisite Courses Major Electives

Medicinal botany, Introduction to herbal medicine, Classics General chemistry, Medical terminology, Bioscience, of herbal medicine, Herbology and lab, Pharmaceutical Korean Medicine terminology, Natural products, organic chemistry, Physiology and lab, Pathology, Anatomy, Physical pharmacy, Bioinorganic chemistry, Pharmaceutical analysis, Pharmaceutical biochemistry pharmaceutical statistics, Introduction of Meridianology, and lab, Pharmacognosy, Physiology (WM), Natural Instrumental analysis, Pharmaceutical organic chemistry, product chemistry and lab, Microbiology, Pharmacopoeia, Pharmaceutical biochemistry, Advanced instrumental Herbal processing and lab, Prescriptionology and analysis, Shanghanlun, Herbal medicine, Medical lab, Pharmacology, Pharmaceutics and lab, Herbal microbiology, Industrial property rights, bioinformatics, pharmacology and lab, Clinical herbology, Pharmacy Immunology, Public health, Pharmacotherapy, Sasang regulations, Pharmaceutical distribution and storage, pharmacology, Health functional foods, Clinical herbal Identification of herbal medicine and lab, Preventive pharmacy and public health medicine, Herbal pharmacy management, Quality control

25 PART 1 Understanding the clinical system of Korean Medicine

Korea has a unique specialist system for Korean Medicine doctors. This system was first introduced in 2000 to provide better medical services and to develop each clinical department. Eight departments exist in which graduates of Korean Medicine colleges and school can train to receive specialized board certification: Korean internal medicine; Korean Medicine gynecology; Korean Medicine pediatrics; Korean Medicine neuropsychiatry; acupuncture and moxibustion; Korean ophthalmology, otolaryngology, and dermatology; Korean Medicine rehabilitation medicine; and Sasang constitutional medicine. A Korean Medicine doctor has to complete one year of internship and three years of residency after earning a license to qualify. After the four-year course, a qualification examination must be passed to be approved by the specialization board. The certificate of specialization of Korean Medicine is awarded by the Minister of Health and Welfare. As of 2014, 37 Korean Medicine hospitals were eligible to train Korean Medicine doctors for specialization, and there were 2,472 specialized doctors, approximately 11.2% of registered licensed Korean Medicine doctors.

As described thus far, Korean Medicine education fosters qualified Korean Medicine human resources with a curriculum system equivalent to that of Western medical schools, a unique specialization system for Korean Medicine doctors, an educational evaluation system, and a license awarded by the Minister of Health and Welfare. The annual OECD Health Data treat Korean Medicine doctors as physicians.

Recently, the School of Korean Medicine at Pusan National University implemented Prob- lem-Based Learning (PBL), Objective Structured Clinical Examinations (OSCE), and Clinical Performance Examinations (CPX), all of which are advanced medical education methodologies.

Korean Medicine Service Policies

Korean Medicine services are provided within an official health care system. This chapter will address the legal status of these services, their function in the public sector, and collaboration with Western Medicine. Please refer to Byungmook Lim, Chapter 4; “Policy and

26 Korean Medicine in the Modern Health Care System chapter 1

Management of Korean Medicine” in Korean Medicine: Current Status and Future Prospects 2015 for more details.

1. Legal Status of and National Promotion Plan for Korean Medicine

The licensing and responsibilities of Korean Medicine doctors and the opening of Korean Medicine institutions are regulated by the Medical Service Act, and the distribution and preparation of herbal medicines are regulated by the Pharmaceutical Affairs Act. In addition to these two acts, the ‘Korean Medicine and Pharmaceutics Promotion Act’ was enacted in 2004 to support the systemic development of Korean Medicine. This act outlines the policies for establishing Korean Medicine promotion plans, supporting research and development, controlling the quality of herbal medicines, and promoting the herbal medicine industry.

According to the Korean Medicine and Pharmaceutics Promotion Act, medium- and long-term promotion plans for Korean Medicine are established every five years. This process is led by the Ministry of Health and Welfare with the participation of the Ministry of Science and Technology; the Ministry of Trade, Industry, and Energy; and the Ministry of Food and Drug Safety. The first plan was established in 2006; this plan provided policies for improving public health through Korean Medicine and enhancing the international competitiveness of the Korean Medicine industry. Recently, in 2016, the third medium- and long-term plan was established. In the third plan, three major goals were determined; enhancing the scientific evidence of Korean Medicine and raising its public credibility, enhancing accessibility of Korean Medicine, and promoting the Korean Medicinal industry.

2. Korean Medicine in the Public Health Sector

Korean Medicine services are widely utilized in public health. As of 2010, one Ko- rean Medicine national hospital existed, and fifteen national and public hospitals had Korean Medicine departments (Lim, 2011). In addition, as public health doctors, Korean Medicine doctors are assigned to 206 public health centers and 588 public health center branches in re-

27 PART 1 Understanding the clinical system of Korean Medicine

mote areas; public health Korean Medicine doctors numbered 1,005 in 2014 (Pusan National University, 2015) . In public health centers, Korean Medicine doctors provide medical services, such as acupuncture, moxibustion, and cupping, and visiting care services for senile patients who have ambula- tory difficulties. Korean public health centers also provide treatment services, as other private medical institutions do, but the proportion of these services is rather small compared with those of other health promotion programs. Local public health centers also provide health promotion services using Korean Medicine in addition to Korean Medicine treatment services. Ten-week health promotion programs based on Korean Medicine are typically provided to communities, and the table below lists examples of programs frequently provided. Most of the programs are conducted by staff within the public health centers, but other Korean Medicine doctors and staff from other institutions also occasionally participate.

Table 5. Example of health promotion programs provided to the community

•Qigong program •Korean Medicine Stroke prevention program •Korean Medicine infant care program •Sasang Constitutional Medicine based health promotion •Korean Medicine health promotion program for school-age children •Smoking cessation program, etc

Korean Medicine is considered a military medicine. Korean Medicine doctors were first employed as medical officers in Korea in 1989. Approximately fifty Korean Medicine officers are selected annually among the newly certified Korean Medicine specialist board holders.

3. Korean Medicine-Western Medicine Collaboration

Since 1951, when the dual health care system was first established in Korea, Korean Medicine doctors and Western Medicine doctors have maintained a conflicting relationship, especially in the 1970s and 1980s, when Western medicine doctors continuously tried to abolish the Korean Medicine system. Although conflict between Korean Medicine doctors and Western Medicine doctors has con-

28 Korean Medicine in the Modern Health Care System chapter 1

tinued, combined treatments from both Korean and Western Medicine have been provided ex- pediently to inpatients in Korean Medicine hospitals. For example, when a cerebrovascular infarction patient is treated in a Korean Medicine hospital, he or she receives acupuncture and herbal medicine treatment while simultaneously undergoing radiographic examination with an- tihypertensive and thrombolytic medicine. To provide radiographic examinations and Western medications, most Korean Medicine hospitals have had to establish separate Western Medicine clinics or form partnerships with Western Medicine hospitals.

Since the 1990s, with the rapid growth in utilization of Korean Medicine, social consensus to enhance the collaboration between these two medical groups has increased in the health policy field. In 1991, the Division of Korean Medicine was established at the National Medical Center. This division was the first Korean Medicine department in a national public hospital, represent- ing a first step toward collaboration between Korean and Western Medicine in the public health care arena. Since then, Korean Medicine departments have been established in some public hospitals as separate institutions, although in the same buildings as Western Medicine hospitals.

The revision of the Medical Service Act in 2010 is considered a great advance towards improvement in promoting collaboration between Korean Medicine and Western Medicine doctors. This revision made it legally possible for a Western Medicine hospital to establish a Korean Medicine department and to hire Korean Medicine doctors and for a Korean Medicine hospital to hire Western Medicine doctors and establish a Western medical department. In accordance with this revision, most Western Medicine-based long-term care hospitals currently hire Korean Medicine doctors.

Finally, to facilitate communication between the two medical groups, the government has encouraged the development of dual license holders. Most medical colleges and schools provide special favor for entrance to licensed Korean Medicine doctors, and the school of Korean Med- icine provides this exception to medical doctors and dental doctors as well.

29 PART 1 Understanding the clinical system of Korean Medicine

Korean Medicine in the Health Security System

1. National Health Insurance and Korean Medicine

After a two-year pilot program, the National Health Insurance system began covering Korean Medicine services in 1987. This improved the accessibility of Korean Medicine services to the public. In 1990, claims for Korean Medicine services numbered 1,559 thousand, which was only 1.1% of the total number of claims. This number increased to 104.5 million in 2014, accounting for 7.1% of the total number of claims. In the same period, medical expenses increased from 7 million USD to 2.2 billion USD (Lim, 2015). The table below lists the procedures covered by the National Health Insurance system in Korea.

Table 6. KM services covered by National Health Insurance

Outpatient (per visit) Basic Consultation Inpatient (per day) Pattern identification Yangdorak (Ryodoraku) Pulse diagnosis Diagnostic Test Meridian function test Dizziness test Personality test Dementia test

Acupuncture - General acupuncture - Special acupuncture - Laser acupuncture

Moxibustion Procedures - Direct type - Indirect type

Cupping - Cupping only - Cupping with bloodletting

Electrical stimulation for acupuncture needle

* Source: Association of Korean Oriental Medicine. Benefit expense of Korean Medicine health insurance [HanbangGŏn- gangbohŏmYoy angGeupyŏBiyong]. 2016

30 Korean Medicine in the Modern Health Care System chapter 1

Dispensing of 56 formulae from 68 herbal medicines herbal preparations Individual psychotherapy Psychotherapy Psychiatric personal history taking Family psychotherapy Hot pack Physical Therapy Ice pack Infra-red irradiation

Of these, the most frequently utilized procedures are acupuncture, moxibustion, and cupping. Acupuncture treatment can be provided alone, but it is more often accompanied by cupping or moxibustion treatment in Korea. Because the reimbursement system for Korean Medicine in the National Health Insurance follows the fee-for-service model, Korean Medicine doctors tend to provide as many treatment procedures within the limit as possible.

Herbal medicine is also a frequently used modality in Korean Medicine; however, within the National Health Insurance, herbal medicine accounted for only 1.5% of the total expenses to the Korean Medicine service as of 2014 (Pusan National University, 2015). This imbalance in herbal medicine use results from the fact that the National Health Insurance covers only herbal preparations, not herbal decoctions4), and that the number of insured herbal preparations is insufficient (Lim, 2013).

With the increase in use of Korean Medicine services, management tools for quality and cost are also being applied to these services. The Health Insurance Review and Assessment Agency (HIRA) manages Korean Medicine hospitals via costliness index and lengthiness index. In addition, an outpatient classification system (KOPG-KM) and an inpatient classification system (KDRG-KM) for traditional medicine were developed and applied for the first time in the world.

2. Other Health Security Schemes and Korean Medicine

In addition to the National Health Insurance, other health security schemes also cover Korean Medicine services. Firstly, Medical Care Assistance, the medical aid system for low-in-

4) Herbal decoction is boiled liquid of raw medicinal plants according to formulae; this is the type of herbal medicine preferred by most Koreans. 31 PART 1 Understanding the clinical system of Korean Medicine

come households, covers Korean Medicine services. The range of coverage is equivalent to that of the National Health Insurance. Medical Care Assistance differs only in having a no-cost- sharing program for the covered services. In 2014, Korean Medicine services accounted for 6.7% of the claims submitted to Medical Care Assistance and 2.2% of its total expenses (Pusan National University, 2015).

The Industrial Accident Compensation Insurance scheme also covers Korean Medicine services for patients experiencing industrial accidents and occupational diseases. In addition to coverage from the National Health Insurance, the fees for various physical therapies and medicinal herb decoctions are reimbursed. Korean Medicine services represented 0.5% of the claims submitted and 0.2% of the total expenses in the Industrial Accident Compensation Insurance (Pusan National University, 2015).

Since 1999, the Car Insurance Medical Coverage for traffic accident patients has also paid for Korean Medicine services. The range of coverage in this program includes Chuna Therapy (Tuina), Pharmacopuncture, Digital Infrared Thermal Imaging (DITI), Transcutaneous Electri- cal Nerve Stimulator (TENS), Interference Current Therapy (ICT), and Meridian laser therapy in addition to the treatments covered by National Health Insurance. Korean Medicine services for traffic accident patients complements Western Medicine treatments by relieving pain and promoting recovery of function, which explains the increasing use of Korean Medicine. Korean Medicine services account for 34% of the claims for the Car Insurance Medical Coverage and 19% of the total expenses (Pusan National University, 2015).

Conclusions

Korean Medicine has been successfully integrated into the modern health care system and is widely utilized in Korea with a secured legal status and public health insurance coverage. Qualified Korean Medicine doctors from advanced education systems provide credible and high-quality health care services. However, given the insufficient coverage of herbal medicines

32 Korean Medicine in the Modern Health Care System chapter 1

by the National Health Insurance, Korean Medicine treatments are overly concentrated on musculoskeletal disorders, a situation that should be improved.

Recently, the Korean government has established policies to promote the use of Korean Medi- cine, including the following; enhancing the National Health Insurance link to the development of clinical practice guidelines, developing health promotion programs for children and adolescents, and piloting a project for infertility treatment using Korean Medicine. These efforts are expected to enable further contributions of Korean Medicine to public health.

Reference

•Byong-Hee Cho. The politics of herbal drugs in Korea. Social Science & Medicine 51 (2000) 505-509 •Byungmook Lim, et al. Korean Medicine: Current Status and Future Prospects. 2015 •Hyo-Je Cho. Traditional medicine, professional monopoly and structural interests: a Korean case. Social Science & Medicine 50 (2000) 123-135 •Ian Holliday. Traditional Medicines in Modern Societies: An Exploration of Integration- ist Options through East Asian Experience. Journal of Medicine and Philosophy. 2003 Jun;28(3):373-89. •Jonghyeong Lee. Hanguk Donguihaksa (History of Eastern Medicine in Korea) in Hanguk uihakmunhwasa daegye Ⅲ (Encyclopedia of history of medical culture Ⅲ) (Seoul: Research Institute of Korean Studies, Korea University) 1977. •Korea Health Industry Development Institute. The report on the use of Korean Medicine services and the consumption of herbal medicines. 2014. •Eui-Ju Lee, et al. Sasang Constitutional Typology A Beginner’s Guide to Sasang Constitu- tional Medicine. (Seoul: Jimoondang) 2014. •Ministry of Health and Welfare. Statistical Year Book. 2015. •Ministry of Health and Welfare. 2014 Reference book for health and welfare affairs. 2014. •Pusan National University, et al. 2014 Year book of traditional Korean Medicine. 2015. •Seonsam Na. East Asian Medicine in South Korea. HARVARD ASIA QUARTERLY 14.4 (2012) •Sungsoo Kim. “Chosŏnjŏng’i Gukgajungshim Ŭhakjŏnglip” (The Establishment of State-Centred Medicine in the Early Chosŏn Period), in Hangukŭhaksa (The History of Med- icine in Korea) (Seoul: KMA Health Policy Institute, n.d.), 108-13. •World Health Organization (WHO). (2001). Legal status of traditional medicine and complementary/alternative medicine: A worldwide review. Geneva: World Health Organization.

33 2016 Korean Medicine Current Practiceof CHAPTER 2

Therapeutic Techniques of Korean Medicine

▼ Yongsuk Kim & Dongwoo Nam PART 1 Understanding the clinical system of Korean Medicine

chapter 2

Therapeutic Techniques of Korean Medicine1)

Acupuncture

1. Introduction

Acupuncture treatment, which is based on the basic theories of Korean Medicine, is a preventive, alleviative, or therapeutic act against disease in which a needle is inserted into one of many specific points on the exterior of the body known as an acupoint. Practiced in East Asian regions for 2,500 years, acupuncture is a remedial method representative of Korean Medicine. Acupuncture treatment is believed to have originated from early human experiences in which disease was ameliorated after instinctively stimulating particular regions of the skin with sharp stones or other simple implements. After centuries of practical experience and the development of the East Asian system of thought, methods of acupuncture based on the principles and theories of Korean Medicine.

The principle of traditional acupuncture treatment is founded on theories such as Qi and Blood (氣血), Yin-Yang and the Five Elements (陰陽五行), Meridians and Collaterals (經絡), and the Viscera and Bowels (臟腑). According to Korean Medicine, the activities of life take place in response to the flow of qi and blood which follows the structure of the viscera and bowels (臟腑), and the meridian and collateral (經絡). Disease is a manifestation of an imbalance between yin and yang (陰陽) arising from an abnormality in qi and blood flow. Qi (氣) circulates throughout the body following the meridians and collaterals (經絡) or other pathways, and hence, acupunc-

1) This chapter has been revised according to Chapter 3; “Therapeutic Technologies in Korean Medicine” in Korean Medicine : Current Status and Future Prospects permitted by an author and publisher.

36 Therapeutic Techniques of Korean Medicine chapter 2

ture treatment aims to recover the circulation of qi and yin-yang imbalance and cure disease by stimulating the meridian or acupoint (經穴) related to the diseased part (體表) or viscera and bowels. An acupoint is a reactive point and diagnostic point that reflects the pathological state of the body surface and internal organs, and a treatment point into which the acupuncture needle is inserted based on its relationship with the viscera and meridians. Methods for combining and stimulating the acupoints vary depending on the disease and the condition of the patient. Sometimes unconventional acupoints located to the local areas such as the head, ears, hands, fingers or feet are used for treatment. This strategy is based on the the condition of a specific area reflects the condition of the body reflects the condition of the body as a whole.

In this chapter, we will examine general acupuncture treatment processes, indications and contraindications, and then address the acupuncture methods that best represent Korean Medicine, Sa-am acupuncture therapy and constitutional acupuncture (Taegeuk acupuncture).

2. Procedures

(1) Treatment Tools

The instrument that is most often used in the practice of acupuncture is the filiform needle(毫鍼). The filiform needle structurally consists of five parts: the needle tip (鍼尖), the needle shaft (鍼體), the needle root (鍼根), the needle handle (鍼柄), and the needle tail (鍼尾). The practitioner holds the needle handle and penetrates the skin with the sharp needle tip while being careful to avoid touching the needle shaft below the needle root. This prevents infection during procedure. The needle standard is determined based on the length and diameter of the needle shaft. At present, stainless steel is popularly used to manufacture filiform needles because it is protected against rust and heat while possessing the appropriate intensity and elasticity. Most needles are disposable, and they are sterilized, individually packaged and disposed of after a single use.

(2) Patient Posture

Patients should be positioned such that the Korean Medicine doctor can precisely locate acupoints, easily manipulate the needle, and such that he or she may maintain posture com-

37 PART 1 Understanding the clinical system of Korean Medicine

fortably during needling and needle retention. If the patient is weak or very nervous, he or she may easily faint during acupuncture treatment while sitting down. In circumstances in which the patient moves during needle retention due to discomfort, the needle shaft may bend. The patient may feel local pain, reducing the treatment effect except when the movement is intended by physicians.

(3) Insertion

The practitioner checks that the therapeutic instruments are sterilized, washes his or her hands and disinfects the needling site with an alcohol swab. After locating the acupoint by palpating with one hand, the other hand is used to insert the needle into the acupoint.

(4) Angle and Depth

Needling the identical acupoint may result in different types of tissue stimulation, patient sensation and treatment effects, depending on the needling angle, direction and depth.

Acupuncture methods may be classified as perpendicular insertion (直刺), oblique insertion (斜刺), and transverse insertion (橫刺) according to the angle of the needle insertion.

The depth of the needle insertion varies according to the location of the acupoint, patient condition or nature of disease. Typically, deep needling (深刺) is performed when the insertion site is large with profuse muscle. It can also be applied for strong stimulation or in the case of chronic disease.

(5) Stimulation Method

Needle manipulation is the core of acupuncture treatment and includes various methods such as twirling, lifting-thrusting, and respiration control during needling.

For example, in the supplementation method (補法) the needle is inserted in the direction of the meridian course and twirled clockwise nine times after insertion. The patient exhales during needle insertion and inhales during needle extraction, and the acupoint is pressed with the hand right after needle extraction.

The needle is directed against the meridian course in the draining method (寫法), twirled

38 Therapeutic Techniques of Korean Medicine chapter 2

counterclockwise six times after insertion, the patient inhales while needle is inserted and exhales while needle is extracted, and the acupoint is left without pressing after needle extraction.

(6) Needle Sensation

Needle sensation (鍼感) is also known as obtaining qi (得氣), and includes the sensation of sinking (沈), heaviness (重), tenseness (緊) and roughness (澁) felt below the needle by the practitioner, as well as the sensation of soreness (酸), numbness (麻), distension (脹) and heaviness (重) felt by the patient. The patient sometimes feels linear conduction-diffusion around one point, which is called movement of qi (行氣).

(7) Needle Retention

Needle retention is the term for allowing the needle shaft to remain at the acupoint after inserting and stimulating the needle through manipulation. The needle retention time varies depending on the literature and intention of the practitioner and patient̓s condition. Based on the experimental study demonstrating that it took approximately 20 minutes to reach the highest Cerebrospinal Fluid (CSF) endorphin level after acupuncture stimulation, the needle may be retained for 20 minutes. In addition, the needle may be retained for 28-30 minutes, which is the time given in Huangdi’s Internal Classic for defensive qi to arise. The needle may be extracted without retention following a short, strong stimulation or may be retained for a prolonged duration such as 1-2 hours in a person with obesity or acute pulse according to the practitioner.

(8) Treatment Frequency and Duration

The treatment frequency and duration differ with the condition of the patient and severity of the disease. Considering that the therapeutic effect of acupuncture progresses with the accumulation of treatments, acupuncture should be performed at least twice a week or daily in the case of hospital admission and concentrated care. Recent occurrences such as acute indigestion or acute lumbago may require only one to four sessions, but persistent diseases such as stroke sequela, requiring prolonged care may demand more than several months of treatment.

39 PART 1 Understanding the clinical system of Korean Medicine

3. Indication

Acupuncture is an accredited medical procedure that is performed by a licensed Kore- an Medicine doctor under the national medical system in Korea. Therefore, there is no need for the distinct labelling of acupuncture treatment indications. However, outside of East Asia and mostly in the West, acupuncture has been only been introduced recently and is outside of the official medical system with research considering its efficacy still ongoing. To date, acupuncture has been shown to be effective for diseases such as chronic pain, postoperative nausea and vomiting, radiotherapy-induced nausea, acute pain including dental pain, headache, hypertension, Chronic Obstructive Pulmonary Disease (COPD), and seasonal allergic rhinitis. The study of the efficacy of acupuncture for stroke, depression, fibromyalgia, functional dyspepsia, schizophrenia and smoking is underway.

4. Contraindications and Side Effects

(1) Contraindications

For safe and effective treatment, it is important to identify when to avoid acupuncture. In the Huangdi’s Internal Classic, the 12 cases in which acupuncture should be avoided are mentioned. When the patient has just arrived for treatment, before or after coitus, extremely drunk or angry, extremely hungry or overfull, the qi and blood are disorderly and acupuncture should not be performed. In short, the time sequence, climate change and patient condition should be considered when determining whether to perform acupuncture treatment. In an emergency situation or when there is a need for surgery, emergency measures should be considered first. The use of acupuncture for cancer may be considered to treat the side effects of chemotherapy or radiotherapy, but direct needling of the tumor site should be avoided. If the patient is receiving an anticoagulant for a blood coagulation disorder, acupuncture is not contraindicated, but deep needling should be applied carefully in patients who bruise easily or have a high risk of hemorrhage.

Additionally, the site of acupuncture should be considered. Direct needling at sites of edema may worsen the condition, and acupuncture in the abdominal region or at particular acupoints may affect pregnancy. LI04, SP06, CV05, CV04, LU11, BL67, and the Gollyun

40 Therapeutic Techniques of Korean Medicine chapter 2

(BL60) are some of the needling points that are prohibited during pregnancy in the literature on acupuncture. However, unless one performs a strong stimulation such as electro-acupuncture or manipulation, acupuncture is an option during the entire pregnancy period. In the first trimester of pregnancy, acupuncture in the lower abdomen or lumbosacral area is undesirable, and after more than three months, the needling of regions with a strong stimulus, such as the upper abdomen or lumbosacral area, should be performed with caution.

If the patient has a phobia of acupuncture, other modes of treatment should be considered.

(2) Adverse Effects

Adverse effects or complications rarely occur from acupuncture, but indiscretions of the practitioner, such as the violation of sanitary procedures or excessively strong stimulation, may be problematic. Adverse effects and complications resulting from acupuncture treatment are described below.

• Internal Organ Damage: Excessively deep needling may cause injury of the spleen, liver, spinal cord or other internal organs. Needling acupoints such as the GB21 should be cautioned due to the possibility of a pneumothorax if the patient is thin. • Infection: There are reports of hepatitis B and Human Immunodeficiency Virus (HIV) after using unsterilized needles. Bacterial infection rarely occurs but may arise from in- tradermal acupuncture on addiction therapy when the needle is retained for a few days. • Dizziness: The patient should be treated in the supine position, minimally when receiving treatment for the first time. • Hemorrhage: Microhemmorhage is frequently observed but causes very little adversity because it tends to be stanched after disinfection and the application of pressure for a period. Arterial hemorrhage is uncommon.

Other possible adverse effects include abortion, convulsion, dermatitis from metal allergy and needle breakage.

41 PART 1 Understanding the clinical system of Korean Medicine

5. Acupuncture Therapy Indigenous to Korea

(1) Sa-am Acupuncture Therapy

Sa-am acupuncture therapy is an original acupuncture technique that is widely used in clinical practice in Korean Medicine. Founded by the ascetic Sa-am, a monk who lived four centuries ago, Sa-am acupuncture has a theoretical background in the Five Elements theory and the supplementation-draining method of acupuncture. The five transport points (well point, brook point, stream point, river point, sea point) in the 12 meridians at the end of limbs such as hands and feet are arranged into five phases in the order of wood, fire, earth, metal, and water for yin meridians and in the order of metal, water, wood, fire, and earth for yang meridians. Combinations of these 60 acupoints result in a maximum efficacy with minimum needling.

Table1. Five transport points in 12 Meridians

Yin Meridian (陰經) Well (wood) Brook (fire) Stream (earth) River (metal) Sea (water)

Lung Meridian LU11 LU10 LU09 LU08 LU05

Spleen Meridian SP01 SP02 SP03 SP05 SP09

Heart Meridian HT09 HT08 HT07 HT04 HT03

Kidney Meridian KI01 KI02 KI03 KI07 KI10

Pericardium Meridian PC09 PC08 PC07 PC05 PC03

Liver Meridian LR01 LR02 LR03 LR04 LR08

Yang Meridian (陽經) Well (metal) Brook (water) Stream (wood) River (fire) Sea (earth)

Large Intestine Meridian LI01 LI02 LI03 LI05 LI11

Stomach Meridian ST45 ST44 ST43 ST41 ST36

Small Intestine Meridian SI01 SI02 SI03 SI05 SI08

Bladder Meridian BL67 BL66 BL65 BL60 BL40

Triple Energizers TE01 TE02 TE03 TE06 TE10 Meridian

Gallbladder Meridian GB44 GB43 GB41 GB38 GB34

42 Therapeutic Techniques of Korean Medicine chapter 2

After pattern identification of the state of the patient by the viscera-bowels, the meridians and five elements and deficiency-excess and cold-heat, the acupoints are selected under the principle of “Supplement the mother if deficient and drain the child if excessive” for self-meridian supplementation-draining and other-meridian supplementation-draining. The mother-child is determined by the engendering and restraining the five elements. (Figure 1)

[ Figure 1 ] Engendering and restraining The deficiency excess supplementation drain- of the Five Elements ing method is as follows. In the deficiency syndrome of yin-wood, water, which is the mother of wood, should be reinforced, and metal, which restrains wood, should be reduced. Thus, LR08 of the liver meridian, the water point of the relevant meridian, and the KI10 of the kidney meridian, the water point of the water meridian, should be supplemented. The LR04 in the liver meridian, the metal point of the pertinent channel, and the LU08 in the lung meridian, the metal point of the metal meridian, should be drained. In the excess syndrome of yin wood, fire, which is the child of wood, should be drained, and the metal point of the metal meridian that restrains wood should be supplemented. This indicates that the LR02 in the liver meridian, the fire point of the pertinent meridian, and HT08 in the heart meridian, the fire point of the fire meridian, are drained. LR04 in the liver meridian, which is the metal point of the self-meridian, and the LU08 in the lung meridian, which is the metal point of the metal meridian, are supplemented.

The following is a chart of acupoints stimulated for the Jung-gyeuk (replenishing deficiencies) and Seung-gyeuk (draining excesses) methods.

In the cold-heat supplementation-draining method, fire is reinforced, and water is reduced in the cold pattern. In addition, water is reinforced and fire is reduced in the heat pattern. For example, in the lung cold pattern, LU10 in the lung meridian and HT08 in the heart

43 PART 1 Understanding the clinical system of Korean Medicine

Table 2. Acupoints stimulated for the Jung-gyeuk and Seung-gyeuk methods

Deficient Syndrome :Jung-gyeuk Excess Syndrome: Seung-gyeuk Twelve Meridians Tonification Discharge Tonification Discharge

Lung SP03 LU09 HT08 LU10 HT08 LU19 KI10 LU05 Large intestine ST36 LI11 SI5 LI5 SI5 LI5 BL66 LI12 Stomach SI05 ST41 GB41 ST43 GB41 ST43 LI01 ST45 Spleen HT08 ST41 LR01 SP01 LR01 SP01 LU08 SP05 Heart LR01 HT09 KI19 HT03 KI19 HT03 SP03 H17 Small intestine GB41 SI03 BL66 SI02 BL22 SI02 ST36 SI08 Bladder LI01 BL67 ST36 BL54 ST36 BL54 GB411 BL65 Kidney LU08 KI07 SP03 KI03 SP03 KI03 LR01 KI01 Pericardium LR01 PC09 KI10 PC03 KI10 PC03 SP03 PC07 Triple energizer GB41 TE03 BL66 TE02 BL66 TE02 ST36 TE10 Gall bladder BL66 GB43 LI01 GB44 LI01 GB44 SI05 GB38 Liver KI10 LR08 LU08 LR04 LU08 LR04 HT08 LR02

meridian are supplemented, and LU08 in the lung meridian and KI10 in the kidney meridian are drained.

The above-mentioned formula are the most basic acupoint combinations for deficiency, excess, cold, and heat syndrome. In clinical practice, acupoint selections are not limited to combinations of eight acupoints but are modified diversely.

(2) Taegeuk Acupuncture(Constitutional Acupuncture Therapy)

Constitution is first mentioned in Huangdi’s Internal Classic, while Lee Jema developed the concept into Sasang constitutional medicine, which is a system original to Korea. There is a distinctive physiology and pathology for each constitution, and people are categorized as Taeyangin (greater yang person), a Taeeumin (greater yin person), a Soyangin ( lesser yang person), or a Soeumin (lesser yin person).

More details on Sasang Constitutional Medicine refer to Chapter 3 “Clinical Applications of Sasang Constitutional Medicine.”

Taegeuk Acupuncture (Constitutional Acupuncture Therapy) is an acupuncture therapy that complies with the theory of the Visceral Five Elements created by Lee Byeonghaeng based

44 Therapeutic Techniques of Korean Medicine chapter 2

on Lee Jema’s Sasang constitutional medicine. This form of acupuncture is also called Tae- geuk acupuncture, with Taegeuk refering to the heart. Among the five viscera, the heart is excluded from the four constitutions and governs the other viscera and bowels. The heart is the basis for the differentiation of constitution. Table 3 The Diagnosis of constitution by Taegeuk acupuncture Constitution Basis for Constitution Organ Functionality Excessive Diagnosis Diagnosis Greater Lung Supplement Fire restrains Taeyangin Metal Lesser Liver HT08 Metal

Greater Liver Supplement Metal restrains Taeeumin Wood Lesser Lung HT04 Wood

Greater Spleen Supplement Water Soyangin Fire Lesser Kidney HT03 restrains Fire

Greater Kidney Supplement Earth Soeumin Water Lesser Spleen HT07 restrains Water

Constitution is differentiated by acupoints of the heart meridian based on the differences in excessive qi in each constitution. For example, a Taeyangin exhibits greater lung and less liver, and it has an excessive metal qi. Following the principle that fire restrains metal, which supplements HT08, the fire point of the heart meridian controls the excessive metal qi, and this instantaneous effect aids in identifying the patient as Taeyangin.

After the diagnosis of constitution, constitution-appropriate acupoints from the source points of the 12 meridians are selected for treatment. For example, if the patient is diagnosed as a Taeyangin, to reinforce the recessive qi and reduce the dominant qi, LR03, the source point of the liver meridian, is supplemented, and LU09, the source point of the lung meridian, is drained.

Taekuk acupuncture method is intended to reinforce organs or viscera with dysfunctions by replenishing the source point of the meridian of the weak viscera. To suppress hypertoned functions, the source point of the meridian that is hypertoned is drained. However, in the case of Soeumin, under the principle that “the kidney should not be reduced” the source point of the kidney meridian) is not stimulated; rather, the source point of the large intestine meridian is stimulated.

45 PART 1 Understanding the clinical system of Korean Medicine

Another point to note is that Soyangin, with a large spleen and small kidney, is not assigned to earth as one would expect; rather, it is assigned to fire.

Table 4 Constitutional differentiation and treatment based on Taekuk Acupuncture

Wood Fire Earth Metal Water

Heart Meridian HT9 HT8 HT7 HT4 HT3

Identifying Reinforcing Reducing Organ Five Elements Point Point Point Character Classification Large Lung Taeyangin HT8 LV3 LU9 Small Liver Metal Large Liver Taeeumin HT4 LU9 LV3 Small Lung Wood Large Spleen Soyangin HT3 KD3 SP3 Small Kidney Fire Large Kidney Soeumin HT7 SP3 LI4 Small Spleen Water

The treatment points for each constitution type are as follows.

Table 5 Acupoints for each Constitution type

Lung Area Spleen Area Liver Area Kidney Area

Taeyangin Drain LU9 Drain Replenish HT7 Replenish

Taeeumin Replenish LU9 Replenish Drain HT7 Drain LI4

Soyangin Drain LU9 Drain Replenish HT7 Replenish

Soeumin Replenish LU9 Replenish Drain HT7 Drain LI4

The application of Taekeuk acupuncture is as follows.

• To identify a patient’s Sasang constitution. • Apply pressure to the area immediately below the sternum and rate the Numeric Rating Score(NRS). • Apply acupuncture on the heart meridian acupoint relevant to the patient’s constitution. • Apply further pressure to the area below the sternum, and evaluate changes in the NRS score. • If the diagnosed constitution is correct, the patient will express an average decrease in pain

46 Therapeutic Techniques of Korean Medicine chapter 2

of approximately 60~70%. If the diagnosed constitution is incorrect, the patient will only express an average decrease in pain of approximately 20~30% or no change at all. • Select the replenishing and draining acupuncture points for the patient. After inserting the needle, twist the acupuncture needle clockwise in a multiple of 9 to replenish energy. To drain energy, twist the acupuncture needle counter-clockwise in a multiple of six.

Taegeuk acupuncture is most effective for psychological diseases, particularly anxiety, palpitations, chronic gastrointestinal disorders, tension-type headache, insomnia, and chronic fatigue syndrome.

Moxibustion

1. Introduction

Moxibustion therapy is a preventive, remedial, and curative technique that is based on acupuncture theory and uses moxa, which are various medicinal items or instruments that target specific areas on the body surface to exert burning, scorching, fuming, ironing, and stimulation. Using fire, the experience of disease alleviation after receiving a thermostimulus, such as the warming or searing of particular body parts, seems to aid in the establishment of moxibustion therapy.

Moxibustion shares its roots with acupuncture, but whereas the acupoint is physically stimulated by needle insertion in acupuncture therapy, thermostimuli are applied at acupoints in moxibustion therapy. According to the Introduction to Medicine (醫學入門) in Ming Dynasty, moxibustion will boost the source qi through the addition of fire qi in a deficiency syndrome, disperse excessive pathogens along with the excessive fire qi, recover warmth in centralized heat syndromes, and centralize and disperse the amassed heat in heat syndrome. Ancient moxibustion typically involves direct moxibustion in which the moxa cone is directly burnt over the acupoint on the skin. In later generations, indirect moxibustion was developed utilizing medicinals or instruments between the acupoint of the skin and moxa cone. We shall examine procedures, indications and adverse effects regarding direct and indirect moxibustion.

47 PART 1 Understanding the clinical system of Korean Medicine

2. Procedure

(1) Instruments

Moxa is the most frequently used material in moxibustion therapy. Moxa is appropriate for clinical practice because it can be easily shaped into a moxa cone and applied in treatment. Combustion of moxa provides aromatic therapy and moderate heat therapy while burning and transferring heat into the deeper layers of the skin. Moxa is made of the leaf or caulicle of Artemisia argyi Lev. et Sav., Atemisia princeps pamp. or Artemisia montana pampan., a perennial herb in the chrysanthemum family. It is easy to find in Korea and very cheap. Older leaf is preferred because fresh Artemisia Folium contains a large amount of volatile oil and is not easily extinguished following combustion, potentially aggravating pain.

After collecting and drying the Artemisiaeargyi Folium, soft moxa floss is generated from the repeated process of grinding and sifting to remove stems or soil. When moxa floss is hand- rubbed and firmly kneaded into a cone-shaped mass that can be neatly positioned on the skin, it is called a moxa cone.

(2) Patient Posture and Pre-procedure Preparation

The patient should assume a position that he or she may feel comfortable in for a long time and in which the moxa can be placed stably. The posture used for acupoint selection and moxibustion therapy must be identical. After disinfecting the acupoint, the moxa cone is positioned. One may apply Vaseline or another ointment to fix the moxa cone and prevent burns. The choice of the appropriate acupoint method for the procedure and stimuli level should take the age and constitution of the patient into consideration, based on the diagnosis and identification of patterns.

(3) Direct Moxibustion

The direct application of the moxa cone on the acupoint can be divided into scarring moxibustion and non-scarring moxibustion based on whether suppuration occurs. Scarring moxibustion positions the moxa directly on the acupoint and allows skin blisters and suppurate from moxa combustion. A moxa cone the size of a bean or jujube seed is placed on the acupoint and ignited with incense. After approximately half of the cone’s height burns, it is

48 Therapeutic Techniques of Korean Medicine chapter 2

extinguished by pressing it into the skin. On the second time, the cone is doused when half of it has combusted and the patient experiences a sensation of heat. In the third time, the cone is extinguished immediately after almost complete burning and the experience of pain in the patient. A few days later, the treatment site will show aseptic suppuration, and one should perform sanitation to prevent secondary infection. The pus is clear white and does not cause problems during normal aseptic suppuration. After a month, the crust falls off, and only a local scar remains.

Non-scarring moxibustion does not cause blisters. After placing a small moxa cone on the acupoint, the cone is ignited and is removed with a pincette when the patient feels heat and before the moxa fire burns the skin. Three to seven consecutive time are performed, and the procedure is terminated when the skin exhibits a local flare.

(4) Indirect Moxibustion

Ginger, garlic, salt, aconiti radix or piper nigrum paste, and yellow terra, among others, can be applied between the moxa cone and skin. In addition, various moxibustion instruments can be used to transmit the thermostimulus through the moxa-burnt smoke and resin. The characteristics and healing properties of the applied medium are dependent on the therapeutic effects of moxibustion therapy and thus must be chosen accordingly.

(5) Stimulation Intensity

The level of stimulation is determined by the size and number of moxa cones. As the size of the cone increases so does maximum temperature and the length of heating time and heat retention. As the number of moxibustion increases so does the amount of stimulus propor- tionally to the calories that penetrate the skin of the patient.

3. Indications

Moxibustion is mostly used for syndromes of cold, chronic disease, and diseases caused by prolonged yang-deficiency and may also be used in some syndromes of excess heat under the principles mentioned in Introduction to medicine. A warm nurturing property is fun-

49 PART 1 Understanding the clinical system of Korean Medicine

damental for the efficacy of moxibustion, and thus, moxibustion may also be indicated for yang collapse-yin collapse, cold reversal in the extremities, hidden pulse, stupor and skin diseases such as abscesses, carbuncles and pruritus.

Scarring moxibustion is applied for chronic and prolonged diseases as well as gynecologic diseases such as wheezing and dyspnea, chronic stomach disease, innate weakness, underde- velopment, hypertension, arteriosclerosis, chronic bronchitis, tuberculosis, impotence, seminal emission, menstrual irregularities, vaginal discharge, and fetal instability. Non-scarring moxibustion is utilized for light-deficient cold syndromes. Moxibustion is applicable for pain, paralysis and various diseases.

4. Contraindications and Adverse Effects

(1) Contraindications

Moxibustion is not advisable for senile people or for children who do not respond well to moxa stimulation, or in cases of faint-rapid pulse, high fever with a floating pulse, and excess heat syndrome.

Caution must be taken when performing moxibustion in patients with diminished consciousness, sensory disorders, mental disorders, diabetes, purulent dermatitis, or circulatory disorders. Burns may occur after moxibustion if the patient is insensitive to heat stimuli, and idiosyncratic necrosis or decreased recovery of injury at the time of moxibustion treatment may occur.

One should avoid applying direct moxibustion to facial areas, ligaments, and areas containing large blood vessels. Suppuration near joints may heal slowly due to the joint motion.

(2) Adverse Effects

Inflammation and scarring due to burn injury are the most common adverse effects of moxibustion. The resin and smoke caused by moxa combustion may induce allergic dermatitis or respiratory diseases. If adequate care is not given upon the worsening of burn injuries that may caused by moxibustion being administered by a non-practitioner, the patient may suffer sepsis.

50 Therapeutic Techniques of Korean Medicine chapter 2

Cupping Therapy

1. Introduction

Cupping therapy uses negative pressure from suction by a vacuumized cup or jar on the skin surface to various internal elements. The origin of the therapy is unclear, but use of the term ‘horn’ (角) in the literature has been conjectured to be the equivalent of cupping.

The fundamental principle of the therapeutic effect in cupping is to relax the sinews and activate collaterals. Cupping removes stagnated bodily wastes from the skin to expedite systemic or local circulation, diffuse and communicate qi-blood by congestion from negative areas, and is useful for various paralytic syndromes and muscular diseases. In addition to applying suction, pus drainage and bloodletting are performed to cleanse the bodily fluid around the lesion to achieve an anti-inflammatory analgesic effect and thus become beneficial to arthropathy. In addition, internal injuries, stomach disorders, hypertension and cough can be treated by cupping through the regulation of qi-blood circulation.

Cupping therapy is classified as flash cupping, retained cupping, and bloodletting cupping according to the method employed. The cup material varies from an artificial synthetic cup to a glass cup, bamboo cup, conduit jar or copper cup.

2. Procedure

(1) Instrument

The plastic cup that is typically used in clinical practice is composed of a vent valve and body. The vent valve is pulled with an absorber to create a vacuum that attaches the cup, and the valve is pulled again after the procedure to detach the cup by allowing the entry of air. There is no separate vent valve in glass cups. The cup is attached as the air combusts and is detached by lightly pressing the skin around the cup opening to allow air to enter.

51 PART 1 Understanding the clinical system of Korean Medicine

(2) Classification by Method

One can attach the cup through the pumping vent method or the fire cupping method. The pumping vent method uses a pump to create a vacuum and attach the cup. This method is used mostly with plastic cups. Fire cupping is performed through the combustion of the air within the cup to create a vacuum and attach the cup. The ignition method takes various forms, and the practitioner must always take cautions against burn injuries.

The procedural method may be categorized as flash cupping, retained cupping, slide cupping or pricking-cupping. The flash cupping method attaches and detaches the cup instant- ly, and the procedure is repeated until the skin flushes. Flash cupping is used for local numbness or deficiency syndrome. The cup is attached and retained for 5~15 minutes using the retained cupping method. The retention time depends on the season, treatment site and presence of lesions. The slide cupping method lubricates body areas with a broad surface and abundant muscles, attaches the cup and allows it to slide up and down repeatedly. The items mentioned above are dry cupping method. Wet cupping, which is also known as pricking-cupping or bloodletting cupping, is a procedure in which the small blood vessels are pricked with small needles before cup suction begins for the purpose of exsanguination.

In addition, medicated cupping occurs when a cup containing medicine is attached, and acupuncture cupping consists of cup attachment while a needle is inserted.

(3) Treatment Precautions and Normal Reactions

The acupoint or response point related to the lesion or organ is identified to select the treatment area. Unevenness of the skin and muscles is assessed to select the adequate cup and patient position so that the cup remains in place. The cup is ordinarily retained for 5 to 15 minutes, but the practitioner should detach the cup if the patient complains of severe pain.

The bloodletting volume during pricking-cupping varies according to the state of the lesion but should not exceed 10ml. A sterilized cup is used to prevent infection. A sterilized disposable cup and three-pronged needle must be used for pricking-cupping.

Tenderness due to pressure during the procedure, or pigmentation, purpura or blistering after the procedure may normally occur. Resting for 2-3 days is important for patients who are

52 Therapeutic Techniques of Korean Medicine chapter 2

very fatigued following the treatment.

3. Indications

Cupping may be applied to treat various conditions including excess syndrome, stasis, blood stasis, the common cold, wind-dampness, pain in the limbs, back pain, headache, cough- ing, red swollen pain in the eyes, hypertension, poisonous snake bite and early sores and ulcers.

4. Contraindications and Adverse Effects

The procedure is prohibited during high fever, convulsion, fracture or on the lower abdomen during pregnancy. Skin hypersensitivity, infection, bruising or skin ulcers should inspire caution. Discretion should be used when the patient has severe coagulopathy, heart disease or systemic edema. Excessive and repetitive wet cupping may cause anemia. If a blister forms after cupping, the exudate is drained with a sterilized three-edge needle and disinfection, ointment, dressing or other appropriate care is applied.

Herbal Therapy

1. Introduction

Herbal medicine is defined as that is processed and prepared from a raw medicine under the principles of Korean Medicine. Herbal medicine is prescribed under the principle of the sovereign, minister, assistant and courier, and it is based on Qi and Flavor theory as well a meridian tropism of the raw herbs that make up the materia medica. Herbal medicine therapy is a medical practice performed by Korean Medicine doctors and officially sanctioned by the Korean Medicine system, and its indications are not limited to predetermination.

Herbal medicine prescriptions are highly diverse, and it is impossible to mention all of them.

53 PART 1 Understanding the clinical system of Korean Medicine

Therefore, in this chapter, we will provide a brief overview of the four categories of prescriptions that are frequently used in Korean clinical practice and classify them according to the era and school. Subsequently, we shall elucidate the general contraindications and adverse effects of herbal medicine.

2. History of Herbal Medicines Therapy

There are largely four types of frequently used clinical prescriptions that are categorized by the classic textbooks to form the theoretical basis of Korean Medicine. There are antiquity prescriptions (Koho prescription) founded by Zhang Zhongjing ̓s Treatise on Cold 傷寒論金要 Damage Diseases ( ) and Synopsis of Prescriptions of the Golden Chamber ( 匱略), latter-day prescription based on the Korean developed the Treasured Mirror of Eastern Medicine, Donguibogam (東醫寶鑑) and Compilation of Formulas and Medicinals (方藥合編), constitutional prescription based on Sasang constitutional medicine, and warm disease prescriptions that have been developed since the Qing Dynasty.

(1) The Prescriptions of Antiquity: Based on the Treatise on Cold Damage Diseases> and Syn- opsis of Prescriptions of the Golden Chamber

The treatise on Cold Damage Diseases is the first specialized book regarding clinical practice and was written by Zhang Zhongjing, who published the book based on the clinical experience of the previous eras as well as his own experiences with references from Internal Classic and Classic of Difficult Issues. The treatise covers the general outbreak of exopathic diseases, transfer mutations, pattern identification and treatment while classifying the post-external contraction symptoms and deficiency-excess of healthy qi based on yin-yang, cold-heat, deficiency-excess, and the six meridians of three yin and three yang. The treatise is useful for not only diseases of external contraction but also overall internal diseases. Be- low is a brief overview of the differentiation of the Six-Meridian syndromes.

• Greater Yang Syndrome (太陽病): This syndrome represents the early stage of exopathic febrile disease. The symptoms of greater yang syndrome are the expression of healthy qi fighting the external contracted pathogenic qi and include a floating pulse, stiffness

54 Therapeutic Techniques of Korean Medicine chapter 2

of the head and neck, and chills. Release of the exterior method is often used, and major prescriptions are for decoctions of ‘Cinnamon Twig Decoction’ (桂枝湯) and ‘Ephedra Decoction’ (麻黃湯). • Yang Brightness Syndrome (陽明病): Pathogenic heat is at its height during this stage, and the symptoms are fever and spontaneous sweating, lack of chills, aversion to heat, and a high pulse. The patient is differentiated as heat syndrome or excess syndrome depending on whether he has only intangible pathogenic heat or tangible dry stool inside the intestines. In heat syndrome, the patient presents symptoms of high fever, sweating, thirst, and a surging pulse. Patients with excess syndrome form dry stools inside the intestines. One must clear and release interior heat and purge exopathogens. Representative prescriptions are for decoctions of ‘White Tiger Decoction’ (白虎湯) and ‘Order the Qi Decoction’ (承氣湯). • Lesser Yang Syndrome (少陽病): This syndrome is the stage at which a struggle between the healthy qi and pathogenic qi takes place between the exterior and interior of the body. The major symptoms are fullness and a choking feeling in the chest and hypochondriac region, bitter taste in the mouth, dry throat, dizzy vision and string-like pulse. Instead of diaphoresis or purgation, a harmonizing method is recommended. The most common prescription is for a decoction of Soshiho, also known as the Minor Bupuleurum ‘Minor Bupuleurum Decoction’ (少柴胡湯). • Greater Yin Syndrome (太陰病): A pattern of interior cold caused by a deficiency in the middle energizer and cold dampness. The major symptoms are abdominal distention and vomiting, indigestion, spontaneous diarrhea, lack of thirst, and occasional abdominal pain. Therapeutic methods such as warming the interior along with cold removal are used. The prescriptions mainly used to treat this are the Four-Counter Decoction (四逆湯) and the ‘Regulate the middle Decoction’ (理中湯). • Lesser Yin Syndrome (少陰病): Yin syndrome or cold syndrome occurs after exopathogen invasion due to a deficiency in yang qi. Symptoms caused by cold syndrome are aversion to cold without fever, a faint pulse, and a desire to sleep. This stage should be treated by tonifying the healthy qi while promoting sweating to release the exterior. • Reverting Yin Syndrome (厥陰病): This syndrome involves the last stage of the disease in which the cold-heat complex appears in place of extreme cold or extreme heat. A reversal

55 PART 1 Understanding the clinical system of Korean Medicine

of the cold in the limbs and fever coexist, the warm yang harmonizes and release methods should be used.

(2) Latter-day Prescriptions Based on the Treasured Mirror of Eastern Medicine and the Com- pilation of Formulas and Medicinals

The Treasured Mirror of Eastern Medicine, Donguibogam, a medical textbook that was published in mid-Joseon Dynasty 1613, is a classic in Korean Medicine that integrated and organized the previous medical theories into a new medical system to optimize its clinical utility. The treatise is composed of five volumes: “Internal Bodily Elements” (內景編), “External Bodily Elements (外形編)”, “Miscellaneous Disorders (雜病編)”, “Herbal Med- ications (湯液編)”, and “Acupuncture and Moxibustion (鍼灸編)”. Each volume is divided into chapters and subchapters. Divisions such as essence, qi, spirit, viscera and bowels (under the volume regarding “Internal Bodily Elements”) and head, face, tendon, pulse, bone and flesh (under the volume of “External Bodily Elements”) are classified by the original perspective on the human body. These chapters generalize the various physical functions and diseases. Other sections such as the five circuits and six qi, four manifestations, three methods, internal damage and external contraction occur subsequently (under the volume of “Miscellaneous Disorders”), and the book closes with the treatment method (under the volume concerning “Herbal Medication and Acupuncture and Moxibustion”).

This composition reflects the perspective that the clear comprehension of normal bodily functions must precede the treatment of diseases. Physiology, pathology, treatment principles and methods and the use of medication and acupuncture are neatly organized in each section so that practitioners may conveniently select pertinent treatment methods for various conditions.

Essential materials from diverse textbooks were collected and rearranged in a unique structure that was unprecedented in previous Chinese textbooks. Component capacities in the quoted prescriptions were altered to match the contemporary Korean environment, and the prescriptions with the same title differed according to the amounts or compositions of the medicine. Flexible attitudes towards the application of prescriptions by period and region can be observed herein.

To be well informed regarding many prescriptions, one must read numerous textbooks, but

56 Therapeutic Techniques of Korean Medicine chapter 2

it is not possible to carry all of the books to the bedside of the patient. The Treasured Mirror of Eastern Medicine, Donguibogam is a useful book for clinical practice, but because it is a sort of medical encyclopedia, its portability is limited. The Compilation of Formulas and Medicinals enables the doctor to identify the most adequate and practical prescription for each disease pattern in such situations. The compilation is a kind of clinical handbook that was written by Hwang Doyeon in late Joseon Dynasty year of 1885 that referenced his clinical experience and 106 medical textbooks including the Treasured Mirror of Eastern Med- icine, Donguibogam. The book contains a selection of prescriptions that are frequently used in practice. Therefore, it is difficult for a novice to fully understand the content, but the book is a good reference for practitioners who already possess knowledge of Korean Medicine. Comprising mainly the upper division, middle division and lower division, the prescriptions in the book are classified by those that tonify, those that harmonize, and those that purge.

(3) Constitutional Prescription: Based on the Sasang Constitutional Medicine Established in Longevity and Life Preservation in Eastern Medicine

The Longevity & Life Preservation In Eastern Medicine, Dongui Suse Bowon (東醫壽世保元) was published in 1894, in the late Joseon Dynasty (revised in 1901), by Lee Jema. Lee Jema’s original theory of Sasang constitutions (a Taeyangin, a Taeeumin, a Soyangin, and a Soeumin) on the establishment of visceral power according to the constitution-inherent healthy qi, its pathology and treatment is established in this book. Sasang constitutional medicine is discussed in Chapter 3, and further explanations will be omitted herein.

(4) Warm Disease Prescription Based on the Study of Warm Disease

The study of warm disease is a study of acute epidemic febrile diseases that were found in China during the Qing Dynasty. This study reflects a more advanced perception of exopathic diseases compared to the treatise on Cold Damage Diseases. Rather than focusing on pathogenic cold in cold damage, the pathology of heat damage such as fever caused by warm pathogens in warm disease or dryness that consumes bodily fluid is emphasized. Pattern identification methods such as defense, qi, nutrients, blood pattern identification and the patterns of triple energizers, as well as new treatment methods and prescriptions are presented accordingly. Invention of the release of the exterior with pungent-cool, clear heat and

57 PART 1 Understanding the clinical system of Korean Medicine

detoxification, clear nutrients and cool blood, and nurturing of the yin and increasing humor methods aided in the rediscovery of medicinal herbs with such properties, such as Gypsum Fibrosum, Rehmanniae Radix Crudus, Scrophulariae Radix, Lonicerae Flos, Phyllostachys Folium, and Liriopis Tuber. Approximately 130 prescriptions were created, including the ‘Mori Chrisanthemi Drink’ (桑菊飮) and the ‘Lonicerae Forsythiae Powder’ (銀翹散), the ‘To Increase Humor Decoction’ (增液湯) and the ‘Clear the Nutrient Decoction’ (淸營湯). Below is a summary of defense, qi, nutrients, and blood pattern identification.

• Defense Aspect Pattern (衛分證) : This is an initial stage of warm disease that is marked by aversion to cold with fever wherein the diffusion capacity of the lung and defense qi are affected. • Qi Aspect Pattern (氣分證): The pathogenic qi invades and affects the internal organs, and symptoms occur during the conflict between the healthy qi and pathogenic qi. The patient presents fever without chills, sweats, thirst and dryness of the mouth. • Nutrient Aspect Pattern (營分證): The invasion of the pathogenic qi progresses to the heart and pericardium, consuming fluid and humor and disturbing the heart spirit. The patient exhibits a scorching fever pattern in which the skin is feverish and dry, the fever worsens at night, and the patient cannot sleep due to heart vexation and is delirious. Thirst is miti- gated during this stage. • Blood Aspect Pattern (血分證): This is the most fatal stage of warm disease in which the fluid and humor is consumed, blood collaterals are damaged, and bleeding occurs as a result of exuberant heat toxins. Low fever continues while worsening during the afternoon and night, and heat in the palms and soles may be noticeable.

3. Contraindications and Adverse Effects

Herbal medicine, unlike Western Medicine, shows pharmaceutical activities through the activation of multiple sites of action by diverse components. Each prescription may have contraindication or precautions according to the qi and taste of ingredients and patient conditions. In this chapter, we shall cover the material medica and situations that require special attention.

58 Therapeutic Techniques of Korean Medicine chapter 2

(1) Herbal Medicinals that Require Precautions

• Herba Ephedrae (麻黃): Urine retention, sleep disorders, palpitations and nausea may occur if this medicine is used inappropriately. The medicine should not be used with medicine for myocardial excitatory such as digoxine or antidepressants such as Mono-Amine Oxidase Inhibitors(MAOIs). The dosage of Herba Ephedrae should be decreased when it is administered with medicines for bronchial asthma and increased when it is administered with medicines for tannin-containing. The medicine is usually prescribed at dosages of 16g per day and no more than 12g per day in patients suffering from kidney conditions. • Aconiti Lateralis Radix (附子): When inadequately prescribed, ordinary toxic symptoms are nausea and vomiting, palpitations and convulsions around the mouth, which are mostly relieved in one day. If severe, the patient may suffer ventricular fibrillation, general paralysis, hypotension, dyspnea or even death. Therefore, the medicinal should be boiled 1-2 hours prior to decoction, and the patient should not drink alcohol. Adverse effects may easily occur if the patient is strong, susceptible to heat, or if the disease exhibits a heat pattern and yang syndrome. • Glycyrrhizae Radix (甘草): If inappropriately prescribed, edema, weakening of the limbs, or changes in blood pressure and electrolytes may occur. The medicine’s use should be cautioned when coadministered with steroids or diuretics, when prescribed excessively for 4-6 weeks consecutively, or when prescribed in patients older than 60 years.

(2) Precautions

• Coadministration with Warfarin: Warfarin is a major anticoagulant that may be reinforced or inhibited due to its anticoagulative effect when coadministered with an herbal medicine. For example, research has shown that the International Normalized Ratio (INR) is prolonged following coadministration with activated blood and the removal of stasis medicinals such as Salviae Miltiorrhizae Radix, Persicae Semen, Carthami Flos, Sparganii Rhizoma, Angelica Gigantis Radix and Cnidii Rhizoma and that it is decreased following the coadministration with Ginseng Radix. • Coadministration with antibiotics: Antibiotics that are preferentially administered during suspicion of bacterial infection in acute inflammatory disease may have enhanced or inhibited antibacterial activity following coadministration with herbal medicines. Labo-

59 PART 1 Understanding the clinical system of Korean Medicine

ratory research has shown that ‘Lonicerae Forsythiae Powder’ (銀翹散) and ‘Ephedrae Moisten the Lung Decoction’ (麻黃潤肺湯) enhance the effect of antibiotics while Cratae- gi Fructus-containing prescriptions inhibit it. • In pregnancy: Most of the internal organs are formed by the 14th week of pregnancy, and limitations of medicine administration are recommended during this period. Rhei Radix et Rhizoma and Natrii Sulfas with oxytocic action or other compounds that activate the blood and result in the removal of stasis medicinals with a risk of premature birth and miscarriage, such as Carthami Flos, Persicae Semen and Moutan Cortex, should be used with extreme caution. The medicine transmission rate is less than 1% during breastfeeding, but Rhei Radix et Rhizoma may cause infantile diarrhea, and Hordei Fructus Germinatus, Oryzae Fructus Germinatus, Herba Menthae and Glycine Semen Preparatum may inhibit lactation and thus should be prescribed with caution.

Herbal Acupuncture (Pharmacopuncture) Therapy

1. Introduction

Herbal acupuncture therapy, or pharmacopuncture, is a combination of acupuncture and herbal medicine. The pharmacopuncture is a unique therapeutic techniques in Korean Med- icine that permits the treatment of disease by injecting a medicine that has been refined and extracted from herbal medicine into an acupoint, the response point on the body surface, after pattern identification of the patient’s constitution and disease. Pharmacopuncture applies physical stimulation through the meridian and an acupoint associated with the pathogenic organ or region, and it also applies chemical stimulation via the selection of an herbal medicine according to the Qi and Flavor theory of herbal medicine therapy. In contrast to conventional injection therapy during which the doctor injects 1ml~tens of milliliters allopathically or according to the test results, in pharmacopuncture therapy, 0.1ml~a few milliliters of herbal extraction are injected into an acupoint or relevant region based on the pattern of identification. Korean herbal acupuncture therapy shares its context with Chinese hand acupuncture therapy or European ho- meopathy, but while the latter is founded on somewhat mechanical compounds of acupuncture

60 Therapeutic Techniques of Korean Medicine chapter 2

and the study of herbal medicine, the basis of the former lies in the unique Korean medicinal system of diagnosis and treatment.

Currently, various therapies such as bee venom acupuncture, Hominis Placenta acupuncture, Cervi Cornu Parvum acupuncture, Ginseng acupuncture and distilled herbal medicines are used in practice.

2. Procedures

(1) Herbal Acupuncture Medicine Preparation and Storage

The preferred extraction method for each medicine, such as immersion, distillation, low temperature extraction, expression and dilution, is used for pharmacopuncture medicine manu- facturing purposes. The powdered medicine used as an herbal acupuncture ingredient should be stored at -20°C in the freezer, while all of the herbal acupuncture medicines are stored in the refrigerator. Exposure to sunlight or a high temperature may spoil the components. Con- sidering that the study results displayed a reduction of the active component melittine to 50% in sweet bee venom stored at room temperature for six months, herbal acupuncture older than six months past the manufacture date should be discarded. Even if they are not old, one must check for signs of transmutation such as clots, flotage and precipitate.

(2) Pre-procedure Precautions The patient’s past history including medicine allergies and present medicine history should be checked prior to performing bee venom acupuncture. Questions regarding skin reactions during the past history of bee stings or mosquito bites may be useful. When receiving bee venom acupuncture for the first time, a minimal amount of 0.05cc should be injected intra- dermally to check for allergic reactions.

An adequate injection site should be selected through diagnosis and syndrome identification, and disinfection processes for the area of the procedure, injections and syringes should be used carefully to prevent infection.

61 PART 1 Understanding the clinical system of Korean Medicine

(3) Herbal Acupuncture (Pharmacopuncture) Injection

The injection of cold solutions may cause pain, and therefore, the medicine temperature must be appropriate. The muscles must be relaxed at the injection site, and air bubbles inside the sy- ringe must be removed and the needle held in a steady direction during injection and retraction to avoid incurring pain to the patient. Blood vessels should be avoided during the injection.

The injection volume differs according to the point of injection and type of medicine. Acu- points in areas with little flesh, such as the extremities, head and face or neck, may be injected with approximately 0.02-0.05ml, and areas with abundant flesh, such as the limbs, chest, abdomen or back, may be injected with approximately 0.05-0.2ml. The total injection volume in one session varies from 2.0ml to 5.0ml depending on the medicine properties.

(4) Response to the Procedure

It is recommended that the condition of the patient be assessed for at least 20 minutes after the procedure. Fomentation is advised during the post-procedure induration and pain, and an ice-pack may be applied temporarily for edema or pruritus. One should wait for at least a few days until the symptoms diminish or avoid the previous treatment site to resume the procedure if the patient complains of discomfort. Symptoms will generally disappear in a few hours or days.

Flare, pruritus or heat sensation and other normal local responses may be apparent around the treatment site in the case of bee venom acupuncture. The patient may apply an ice-pack or ointment for insect bites in the presence of itching.

3. Indications

The indications for herbal acupuncture are very diverse. Examples of indications for herbal acupuncture injections are presented below.

(1) Bee Venom

This venom is frequently used for various types of inflammation, pain or paralysis.

62 Therapeutic Techniques of Korean Medicine chapter 2

(2) Musk Musk promotes diaphoresis and diuresis, stimulates the central nervous system, respiratory, and circulatory functions, and is considered to have anti-inflammatory effects during the initial to middle stage, blood circulation and anticancer activity. Musk is used as a compound medicine.

(3) Cervi Cornu Parvum

This medicine reinforces the deficiency in the qi, blood, yin and yang, and therefore, it may be used for kidney deficient lumbago, vertigo, trigeminal neuralgia, otolaryngology and ophthalmic disorders, as well as musculoskeletal pain. Exposure to air causes the medicine to fiberize and induce aching pain, and therefore, the medicine must be carefully stored.

(4) Hominis Placenta

Infant placenta is washed and dried after removal of the blood vessels, and then, is hydro- lyzed and extracted after high pressure sterilization and filtering. Processes associated with growth facilitation, tissue regeneration, immune enhancement, hormone production and an- tiphlogistic activity may be used for xerophthalmia, allergies, dermal conditions, frequent contusions and neurasthesia.

Additionally, there are ‘Coptis Decoction to Relieve Toxicity’ (黃連解毒湯), neutral stasis acupuncture (Jungsongouhyul pharmacoacupuncture) composed of Gardeniae Fructus, Corydalis Tuber, Olibanum, Myrrha, Persicae Semen, Paeoniae Radix Rubrum, Salviae Miltiorrhizae Radix and Sappan Lignum, and sciatica no. 5 pharmacopuncture composed of Dipsaci Radix, Cibotii Rhizoma, Drynariae Rhizoma, Kalopanacis Cortex, Osterici Radix, Araliae Continentalis Radix, Gentianae Macrophyllae Radix, Cinnamomi Ramulus, Achy- ranthis Radix, Eucommiae Cortex, Corydalis Tuber, Olibanum and Myrrha. Depending on the Qi and Flavor of its ingredients, each injection is selected for headache, neck stiffness, insomnia, heat symptoms such as febrile dermatopathy, pain due to qi stagnation and blood stasis or lower back pain and neuralgia. For more details on needle embedding refer to Chapter 8; “Korean Medicine Cosmetic Procedures.”

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4. Contraindications and Adverse Effects

(1) Contraindications As in acupuncture therapy, strong stimulation in children, elders, feeble or fatigued patients or excessive injections should be avoided. Injections in the lower abdomen or lumbosacral area are prohibited during pregnancy. Caution should be exercised in the case of dermal infection, edema, cuts, blood-related diseases, such as severe coagulopathy, and medicine hypersensitivity. Bee venom acupuncture is normally advised against in cardiovasculopathy, kidney disease, asthma and infectious diseases such as tuberculosis. Caution should also be exercised in pregnancy, diabetes, allergic dermopathy, and epimenorrhea.

(2) Adverse Effects One to ten people in every hundred-thousand may present systemic immediate reactions within 15 minutes after bee venom acupuncture. Systemic reactions include chills, fever, aches, skin rubor, urticaria and nausea. In severe cases, dyspnea or shock may occur. Pa- tients may require epinephrine or antihistamine treatment.

Embedding Acupuncture

1. Introduction

Needle embedding is an evolved form of the acupuncture method. Needles are embedded into acupoints, meridian sinews, percutaneous, meridian, or other sites of pain to continuously stimulate soft tissues and treat disorders. These stimuli are applied using thread-like substances inserted into the tissues to initiate physical and chemical responses to restore normal function and form to the tissues.

2. What is Needle Embedding?

Needle embedding is a technique using specifically devised needle, digestible threads are embedded in affected areas. Treatment effects are retained as this thread continues to provide stimuli.

64 Therapeutic Techniques of Korean Medicine chapter 2

3. Mechanism of Needle Embedding

(1) Physical Stimulus

The thread inserted attracts immune substances to help reinforce the soft tissues around it.

(2) Chemical Stimulus

Inserted threads are recognized by the body as an alien substance. Therefore, acupoints are continuously stimulated, and biochemical reactions are triggered to help tissue regeneration.

(3) Maximum Acupoint Stimulation

The prolonged physical and chemical stimulation (over the course of 1~6 months) may cause both structural and functional changes in the body to treat chronic conditions. Needle embedding may also be used to stimulate meridian, meridian sinews, and percutaneous as stimulated in traditional Korean Medicine to treat a wide range of disorders.

4. Indications

Needle embedding is a form of acupuncture. Therefore, it may be applied to a wide range of conditions. The history of needle embedding is such that, until the 1970s, needle embedding was most frequently used for internal diseases, musculoskeletal problems, and diseases of otorhinolaryngologic conditions. Since the 1980s, needle embedding has been used more for cosmetic improvement, as indicated by the increasing volumes of research on needle embedding for cosmetic purposes. In Korea, needle embedding is a popular treatment for wrinkles, facial lifting, and other cosmetic issues, as well as musculoskeletal problems, such as facial nerve palsy. For more details on needle embedding refer to Chapter 8; “Korean Medicine Cosmetic Procedures.”

Supports the muscles and ligaments and helps improve circulation. Effective for pain control and cosmetic improvements.

Lumbar disc herniation, cervical disc herniation, facial nerve palsy, and other indications are treated with needle embedding.

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5. Treatment Procedures

Specially devised needles are used to assist ‘thread’ implantation into the affected areas. These needles continuously stimulate meridians and collaterals, which thereby boosts the self-healing abilities of the body. Anesthesia is not necessary, and the entire procedure is completed within several minutes. Treatment session [ Figure 2 ] Example of embedding therapy treatment setting is 1 or 2 week interval.

Needle embedding is an invasive technique, and the embedded needles will be retained until they are digested. Thus, it is important to maintain an antiseptic condition and thoroughly cleanse the patient’s affected area and the practitioner’s hands before treatment to prevent infection.

The sanitization procedures are as follows: Hand sanitization → skin sanitization → hand sanitization → wear glove → needle embedding → glove removal → hand sanitization. Treatment sites should be sanitized using 70% alcohol swabs (disposable, individually packaged swab- sticks are recommended).

Needles should be used immediately after opening the package, and the insertion methods vary depending on the site of treatment and treatment plans. For example, subcutaneous regions are stimulated to fill wrinkles, and sub-Superficial Musculo-Aponeurotic System (SMAS) areas are stimulated to help collagen regenerate and resolve dermal adhesion. For lipid digestion or muscle reinforcement, adjust the depth of the needle so that it correctly reaches the target area. It is very uncommon to insert needles into the intracutaneous area.

If the patient has severe pain, bleeding, or signs of nerve damage, do not force the needles in. Identify the cause of the problem and address it or remove the needle. When inserting needles into curved surfaces or areas that encompass blood vessels or nerves, use thin, short needles. When inserting the needles, position the needle approximately 15 degrees away from the skin surface. Once the needle has penetrated the skin, change the direction of the needle so that it is parallel to the skin surface. Continue to insert the remaining portion of the needle.

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(1) Effects of Needle Embedding

• Provides a continuous stimulus to the tissues, which provides long-term, powerful treatment effects • A safe form of treatment as certified by the Korea Ministry of Food and Medicine Safety; non-toxic materials that are digested naturally are used. Limited adverse effects have been reported to date • Supports the muscles and ligaments to help prevent the recurrence of problems. Is also highly effective for pain control. • Do not leave scars. Patients may return to their normal daily activities immediately after treatment.

Reference

•Adrian White, Mike Cummings, Jacqueline Filshie. Acupunctue and meridian research center of Korean institute of oriental medicine(translator). An introduction to western medicla acupuncture. Elsevere Korea. 2010. •Byeong-haeng Lee. Chimdowonlyujungma. Haeng lim seo weon. 1974. •Dal-Ho Kim. Illustration of Saam acupuncture. Sogang. 2001. •Gwan-woo Kim. Saam acupuncture susanglog. chorakdang. 2007. •Gwan-woo Kim. Saam acupuncture pathology. chorakdang. 2009. •In-Gy Jung, Sung-Keel Kang, Chang-Hwan Kim. A comparative study on acupuncture using five su points, The journal of Korean acupuncture and moxibustion society. 2001; 18(2): 186-99. •Kim Jae-kyu. Clinical Opinion of Taegeuk Acupuncture Treatment by Sasang Constitutional Medicine. The Journal of Korean Acupuncture & Moxibustion Society. 2011;28(2):69-73. •Korean Acupuncture & Moxibustion Medicine Society textbook compilation committee. Ac- upuncture & Moxibustion medicine. Seoul. Jipmoondang. 2012. •Korean Acupuncture & Moxibustion Medicine Society textbook compilation committee. Ac- upuncture & Moxibustion medicine clinical practice guideline. Seoul. Jipmoondang. 2014. •Korean Medicine educational evaluation institute. A medical handbook for resident of department of acupuncture and moxibustion. 2013. •Kyunghee University Korean Medicine Hospital Department of Acupuncture and Moxibus- tion. Kyunghee University Korean Medicine Hospital Department of Acupuncture and Mox- ibustion FIX teacing material. 2014. •Se-Hyeong Jo. Systematic study of Saam acupuncture. Seongbosa. 1986.

67 2016 Korean Medicine Current Practiceof CHAPTER 3

Clinical Applications of Sasang Constitutional Medicine

▼ Byunghee Koh PART 1 Understanding the clinical system of Korean Medicine

chapter 3

Clinical Applications of Sasang Constitutional Medicine

Constitution Differentiation

While there are many different methods for classifying Sasang types, the three most important aspects are appearance, mind/nature, and illness.

Appearance refers to body type and facial appearance. This includes a simple observation of the face and its’ overall configuration, as well as the atmosphere that can be detected based on the movement and speech pattern. Each type has a set of distinct physical traits, which may provide clues for differentiation. Although the overall size of the body is subject to change, the frame does not. However, observing body type and appearance alone does not provide enough information to differentiate the constitutions.

Mind/nature is reflected in one’s personality, capacity (ability to take care of matters), determination (thoughts that one carries in their heart), and covetous desires. There are very distinct personality features for each type, and these features are very important. However, these features cannot be used as the primary evaluation tool, as there are individuals who do not show their true personality. In these cases, the patient is put in an urgent situation to examine their true intention.

Differentiation based on illness is possible based on healthy states and symptoms of disease; these states and symptoms are significantly different for each Sasang type. However, some Sasang types only display symptoms when conditions are severe. Therefore, Sasang differentiation that is based on illness alone is not a complete method.

70 Clinical Applications of Sasang Constitutional Medicine chapter 3

For accurate differentiation, it is recommended that all three aspects, appearance, mind/nature, and illness, are reviewed before reaching a conclusion.

1. Sasang Type Differentiations based on Appearance

(1) Taeyangin

In appearance, Taeyangin have large upper chests, thick necks, and large head, which are all areas that pertain to the lungs. They have an overall image that makes them appear as though the qi is surging upwards. As such, Taeyangin resemble “lions”; [ Figure 1 ] Face by Sasang constitution types however, they are weak below the waist * Source: Korea Institute of Oriental Medicine in areas that pertain to the liver. They have small, lean legs, and they may appear unstable when standing. Taeyangin tend to have very prominent facial features and rarely become overweight. Taeyangin are the least common of the four Sasang types and are difficult to find.

(2) Soyangin

Soyangin have a large chest, which is related to the spleen. They have very broad shoulder that results in an “eagle”-like appearance. In contrast, the kidneys, which relate to the rear, are very small, which results in an unstable appearance when sitting. Many Soyangin have small, round head that protrudes anteriorly and posteriorly. Their eyes look sharp, and the mouth [ Figure 2 ] Taeyangin Taeeumin

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is small with thin lips. The chin tends to be pointy, and the skin is fair yet dry. Soyangin do not perspire, and they have clear and high-pitched voices. They do not give much thought to what they say. Soyangin may appear hasty because their speech and movements are abrupt.

(3) Taeeumin

The low back area is strong, which gives Taeeumin a stout and stable posture when standing. However, they have a relatively thin neck. Many Taeeumin have a very large frame. Their hands and feet are large in size and easily become dry and chapped during the winter. They are often sweaty, and even the smallest movements may cause them to perspire. Taeeumin tend to have prominent facial features. They have a stable gait, but their upper torso gravitates anteriorly as they walk. Taeeumin’s waist and abdominal areas appear to be oversized, and they may look arrogant.

[ Figure 3 ] Soyangin Soeumin (4) Soeumin

The buttocks are developed, which provides stability in the sitting position. However, they have small chest that makes them appear as though they are hunched forward. They usually have stronger lower body than upper body. When they walk, they hunch forward and flop their body. Because Soeumin tend to have a stronger lower body compared to their upper body, they look petite, thin, and often weak. Their facial features are not prominent but are harmonious. Soeumin appear modest, and have petite facial features. Their skin is soft, and perspiration is sparse. They tend to smile with their eyes during conversations.

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2. Constitution Determinations based on Mind and Nature

Mind and nature refer to proclivity and capacity (talent, special ability, and strength), covetous determination (thoughts that are always in their heart), and desires (greed that surfaces when mind and nature are not properly controlled).

(1) Taeyangin

Taeyangin are very talented at socializing. They are not intimidated by the presence of others and are very active. They make friends very easily. Taeyangin tend to only move forward, and do not move backwards. They rarely look at their surroundings and only face forward. They may develop an urgent mind (a state of being hasty). When mind and nature are not controlled, they develop self-indulgence and become self-righteous or arrogant.

(2) Soyangin

Soyangin are active and swift in their movements. They are outspoken and are good at gen- erating and pursuing ideas. However, they do not often see matters through to their conclusion. They tend to focus more on matters outside the home and neglect what occurs inside (the mind and the home). This results in an anxious mind. When Soyangin are confronted with serious problems, anxiety may develop into fear, which may in turn cause memory impairments. This is a dangerous state.

When they only focus on matters outside the home and neglect matters inside the home, they may develop an irrational mind (the tendency to only focus on personal things).

(3) Taeeumin

Taeeumin are calm and determined. They successfully complete things that they have started or have been assigned. However, because they prefer to remain still without moving, they are aware of their mind and home, but do not know much about the outside world. This causes a cowardly mind (the tendency to be careful). When this anxiety becomes severe, they may develop palpitations.

When the tendency to protect the inside becomes too strong, they may develop a materialis- tic mind. It is good to focus on personal achievements and protect personal possessions, but

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when this tendency becomes too strong and love becomes an obsession, greed can develop.

(4) Soeumin

Soeumin are gentle, calm and meticulous. They are detail-oriented, and precisely plan matters to attract other people’s minds. However, they always prefer to stay in without coming forth. In other words, they are more introverted than extroverted. They are not very ambi- tious because they have such introverted characteristics. Soeumin have a tendency to be anxious all the time.

When these traits of Soeumin become too strong, they may become complacent. Even in matters that can bring great success, they are reluctant to try new things because of their introverted nature. When they face hardship, rather than trying to overcome difficulties, Soeumin tend to sit back and wait. This complacent nature is be a negative characteristic of the Soeumin type.

3. Constitution Differentiations Based on Illness

Each Sasang constitution is susceptible to a distinct set of illnesses. These illnesses are called “Constitutional Illnesses” and are caused by a lack of control of daily habit. There are very distinct definitions of health, unhealthy states, and severe diseases for each Sasang type.

A healthy condition refers to the state of health that is unique to each Sasang type. Unhealthy state is not serious illness but is transitory phase between health and pathology. Severe disease refers to a condition in which the person is at his or her weakest.

(1) Taeyangin

Taeyangin are healthy when they urinate well and have clear urine. When there is saliva or foam reflux in the mouth, they are in an unhealthy state. When the body is not adequately nurtured, more severe condition may develop. Regurgitation can occur when Taeyangin cannot swallow food, or when they swallow food that does not successfully reach the stomach. When these symptoms occur, the entire body feels heavy and the legs feel weak, and the patient does not want to move or speak, which is called paraparesis. Both regurgitation and

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paraparesis are severe conditions in which there is an upsurge in qi, that causes deficiency in the lower body and excess in the upper body. These are Taeyangin’s illnesses.

(2) Soyangin

Soyangin are healthy when they adequately defecate. When a person adequately defecates but becomes constipated when unwell, it is likely that he or she is Soyangin. If constipation is observed in a Soyangin, they are in an unhealthy state that may develop into more serious problems. If a Soyangin feels stuffy in chest and is unable to defecate for 2-3 days, they may have a severe disease. Soyangin’s illnesses are internal heat due to fire and heat.

(3) Taeeumin

Taeeumin are healthy when they adequately perspire. When the skin is so dense and tight that it interferes with proper perspiration, they are in a state of severe disease that may cause further problems. When Taeeumin have diarrhea and feel heavy and full in the lower abdomen, they may have a severe disease. Dryness-heat disease that is due to improper perspiration, urination, and defecation is a state of illness that is observed in Taeeumin.

(4) Soeumin

Soeumin are considered healthy if they can properly digest food. When they are not able to properly digest food or when they excessively perspire, they are in an unhealthy state. When diarrhea does not stop and the lower abdomen feels cold, they are in a state of severe illness. Soeumin illnesses can be divided into two conditions, the cold stomach syndrome, which is a condition of coldness in the digestive system, or the yang deficiency syndrome, which is due to excessive sweating.

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Constitution and Illnesses

1. Common Illnesses of Taeyangin

Taeyangin have a strong tendency to expel energy outwards due to their large (strong) lungs, but they lack the ability to take qi inward, due to a small (weak) liver. The upper body is large, which pertains to the lungs, while the lower body is smaller. The neck is especially thick and strong. Taeyangin have a large head but a weak lower body with small buttocks and thin legs. They appear somewhat unstable in a standing position. Taeyangin find it hard to stand or walk for long periods of time.

In their structure and function, Taeyangin have a tendency to upsurge and expel but lack an ability to accumulate. This may cause illness. Illnesses that are commonly found in Taeyangin are paraparesis and regurgitation.

Paraparesis is a condition in which an excessive upsurge of qi has led to excess in the upper areas and deficiency in the lower areas. The legs are weak. There is no swelling, pain, or numbness, but the legs do not receive the qi that is needed to walk properly.

Regurgitation is a condition in which energy is expelled outwards, but less energy is consumed by the middle and lower energy. When food passes through the esophagus to enter the stomach, there is a sense of obstruction or actual vomiting.

To treat this condition, it is important to eliminate qi upsurge in the upper body. To achieve this goal, it is important not to become angry. Before prescribing medication, it is important to find peace of mind, stay away from anger, remain calm, and avoid greasy food.

2. Common Illnesses of Soyangin

Soyangin have a weak urogenital system and therefore often have bladder or kidney disease. Soyangin may have edema due to dysfunctions in urination.

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When Soyangin illnesses are mostly hot in nature, they lack the yin and qi that can yield an excess of heat and fire and causes heat-type disease. Types of diseases that are prevalent in Soy- angin are edema due to insufficient urination and heat pattern in the chest that is accompanied by constipation. When the chest heat pattern remains unresolved for an extended period of time, it becomes a chronic condition that is called yin deficiency afternoon heat syndrome.

Soyangin illnesses can either be of an excessive heat or a deficient heat-type. The excessive heat-type syndrome is the Hyunggyeok-yeol symptomatic pattern. In this syndrome, an inability to defecate causes fire heat to upsurge. Symptoms include a red face, an increase in thirst, vexation in the chest, and insomnia. Diabetes yang toxin skin spots (skin rashes with itchiness) can develop when Soyangin are prescribed with heat-type medication that is contraindicated. Children may develop convulsions. Parts of the head that are affected include the eyes, nose, ears, lips, teeth, larynx, and other parts, which become inflammatory and bloodshot. In these cases, constipation aggravates the condition. Herbal medicine can clear the heat inside, treat constipation, clear the urine, resolve thirst, and clear the vexing heat in the chest.

When these symptoms are not properly treated, a Eumheo-yeol symptomatic pattern develops. This is a state of repeated episodes of tidal fever in the afternoon. These result from heat that is produced under deficient circumstances. This is a state of yin deficiency and yang exuberance, which occurs when the Soyangin have lost control of their lifestyle and have not appropriately treated their illnesses. In this case, it is important to replenish yin to compensate for constitutional shortcomings.

3. Common Illnesses of Taeeumin

Taeeumin are subtyped into two categories for discussing illnesses: Cold-type Taeeumin and heat-type Taeeumin.

Cold-type Taeeumin are very similar to Soeumin. They are sensitive to cold climate and easily catch cold. They frequently have diarrhea. In contrast, heat-type Taeeumin easily develop constipation, obesity, thirst, and irritation in the chest. By observing their usual conditions, it

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is possible to differentiate between cold-type and heat-type Taeeumin. Heat-type often present with problems in the circulatory system due to constipation and obesity. Cold-type Taeeumin perspire well and thus may not have circulatory issues but may suffer from frequent diarrhea and/or common cold.

Taeeumin can easily become obese. For children, sibling rivalry or peer pressure may cause anxiety. As a way to address these issues, Taeeumin develop a strong appetite because they are not confident about their activities outside the home. They do not like to socialize and prefer to stay at home. They do not like to move and avoid exercise. Constipation and obesity are common in Taeeumin.

For adults, an undisciplined diet and a lack of exercise may cause obesity, circulatory problems, diabetes, and stroke, which are prevalent conditions in Taeeumin. Additionally, nervousness due to accumulating stress may cause arteriosclerosis, hypertension, cardiovascular diseases, diabetes, and stroke. Obesity and constipation may interfere with proper digestion and cause an accumulation in phlegm (abnormally accumulated bodily fluid), which in turn can cause arthritis, allergies, psychological problems, and skin problems.

Taeeumin should be aware of the following recommendations.

First, it is possible to enhance circulation by sweating through proper exercise and bathing. Taeeumin are healthy when they adequately perspire. Soeumin are healthy when they do not sweat, but Taeeumin are ill when they do not sweat.

Second, to aid in proper digestion, Taeeumin must maintain a healthy weight and eat meals with sufficient amount of fiber-rich food to ensure proper defecation. Third, emotional anxiety and stress should be minimized. Actively participating in experiences outside of the home can help the inner self related to the external world. These experiences help broaden Taeeumin’s perceptions, purify their mind and nature and contribute to improvement in their constitution.

78 Clinical Applications of Sasang Constitutional Medicine chapter 3

4. Common Illnesses of Soeumin

Soeumin have large kidneys and small spleen. Because the spleen and stomach are small, Soeumin tend to have gastrointestinal problems.

They cannot digest food as well as others types, even when they do not eat much. They have pain under the sternum, feel uneasy and stuffy in the abdominal region, and have trouble digest- ing food. In Soeumin, the end of the sternum feels painful, the stomach feels bloated, there are frequent complaints of stomach pain, and they have diarrhea after eating cold food or drinking beer. This type of diarrhea is not due to intestinal problems but manifests from problems in the stomach. Because they are born with a weak and cold digestive system, they cannot properly digest food. Exposure to cold food may trigger diarrhea. Therefore, dyspepsia, gastritis, gas- troptosis, habitual abdominal pain, and other acute or chronic illnesses of the gastrointestinal system are common conditions in Soeumin.

Soeumin do not have a large body mass, and their body is cold. Therefore, they should avoid sweating. Sweating will cause deficiency in qi, thereby causing the body to become frail. When Soeumin habitually sweat, it is a sign that they are not well. In contrast, Taeeumin tend to have a very large body. They should frequently perspire to ensure proper circulation. However, Soeumin are the opposite because they are well when their skin is tight and they do not perspire. When Soeumin become very tired or participate in aggressive sporting activities, they may sweat too much, lose their qi, become cold and develop illnesses.

Soeumin have a weak digestive system, which may lead to several problems. Even when there are other symptoms, when there are no gastrointestinal symptoms, there are no serious problems. Soeumin are timid and introverted. They can easily become anxious about the small things, which may cause dyspepsia or neurosis and insomnia. Therefore, anxiety should be controlled, and Soeumin should attempt to be more adventurous to prevent psychological problems. Soeumin are weak and frail because their body is cold, they should refrain from participating in aggressive sporting activities or being overworked. Soeumin must keep the body warm at all times and avoid overeating and cold food to maintain a healthy state in the gastrointestinal system.

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Acupuncture based on Sasang Constitutions

Table 1. Taekuk acupuncture method

Acupoints stimulated Treatment Acupuncture Points Constitution Replenish Tonify Sedate according to Diseases

Lungs>Spleen>Kidneys>Liver. Taeyangin HT08 少府(火) LR03 太衝 LU09 太淵 SpleenLungs=Drain KidneysLiver=Replenish

Liver>Kidneys>Spleen>Lungs. Taeeumin HT04 靈道(金) LU09 太淵 LR03 太衝 KidneysLiver=Drain Lungs-太淵 LungsSpleen=Replenish Spleen-太白 -太衝 Spleen>Lungs>Liver>Kidneys. Liver Soyangin HT03 少海(水) KI03 太谿 SP03 太白 SpleenLungs=Drain Kidneys-太谿 LiverKidneys=Replenish

Kidneys>Liver>Lungs>Spleen. Soeumin HT07 神門(土) SP03 太白 LI04 合谷 KidneysLiver=Drain LungsSpleen=Replenish

Table 2. Fundamental formulas of 8 Constitutions

Name of Symbol of Formula / Name of Symbol of Formula / Constitutions Therapeutical Process Constitutions Therapeutical Process

X′ 10c VIII′ 10c IV′ 4p Hespero I AC I′ 7c IX′ 9p I′ 9p Hespera VIII RP VIII′ 4p V′ 5c IX′ 5 VII′ 7p Saturno IX AM Saturna VI RP VI′ 8c II′ 2p VI′ 2p IX ′7p VIII′ 7p I′ 7p III′ VI′ 6p VIII′ 6p IV ′4c Jupito I RC Jupita VIII AP 3c I′ 3c VIII′ 4c V′ 5p IX′ 5p I′ 1c Mercurio IX RM Mercuria VI AP IV′ 4p VI′ 4p II′ 2c VI′ 2c IX′ 1c

Legend: Symbols of FU system Symbols of ZANG system II Gall bladder I Liver IV Small intestine III Heart VI Stomach V Pancreas VIII Large intestine VII Lung IX Kidney X Urinary bladder III Simpo (Pericardium) IV Samcho (Triple warmer)

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Table 3. 24 Constitutions: The root of the disease replenishes and eliminates the origin and then the symptom

Treatment Method Treatment Method Type Type Tonification Discharge Tonification Discharge

IR-Gall Bladder I A-Gall Bladder Excessive-type Deficient-type UB66 GB43 LI01 GB44 GB44 UB66 SI05 GB38 (Gall bladder (Gall bladder jung-gyuk) seung-gyuk)

II A-Liver IIR- Liver Deficient-type K10 LIV08 L08 LIV04 Excessive-type L08 LIV08 H08 LIV02 (Live jung-gyuk) (Liver seung-gyuk)

III A-Small Intestine III R-small Intestine Deficient-type Excessive-type GB41 SI03 UB66 SI02 UB66 SI02 ST36 SI08 (Small intestine jung- (Small intestine seung- gyuk) gyuk)

III A-Triple Energizer III R-Triple Energizer Deficient-type Excessive-type GB41 T03 UB66 T02 UB66 T02 ST36 T10 (Triple energizer jung- (Triple energizer seung- gyuk) gyuk)

IV A-Heart IV R-Heart Deficient-type LIV01 H09 K10 H03 Excessive-type K10 H03 SP03 H07 (Heart jung-gyuk) (Heart seung-gyuk)

IV R-pericardium IV A-Pericardium Excessive-type Deficient-type LIV01 P09 K10 P03 K10 P03 SP03 P07 (Pericardium seung- (Pericardium jung-gyuk) gyuk)

V A-Stomach VR-Stomach Deficient- type SI05 ST41 GB41 ST43 Excessive-type GB41 ST43 LI01 ST45 (Stomach jung-gyuk) (Stomach seung-gyuk)

VI A- Spleen VI R-Spleen Deficient-type H08 SP02 LIV01 SP01 Excessive-type LIV01 SP01 L08 SP05 (Spleen jung-gyuk) (Spleen seung-gyuk)

VII A-Large Intestine VII R-large Intestine Deficient-type Excessive-type ST36 LI11 SI05 SI05 SI05 LI05 UB66 LI02 (Large intestine jung- (Large intestine seung- gyuk) gyuk)

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Treatment Method Treatment Method Type Type Tonification Discharge Tonification Discharge

VIII A-Lung VIII R-Lung Deficient-type SP03 L09 H08 L10 Excessive-type H08 L10 K10 L05 (Lung jung-gyuk) (Lung seung-gyuk)

XI A-Mladder XI R-bladder Deficient-type LI01 UB67 ST36 UB54 Excessive-type ST36 UB54 GB41 UB65 (Bladder jung-gyuk) (Bladder seung-gyuk)

X A- Kidney XR-Kidney Deficient-type L08 K07 SP03 K03 Excessive-type SP03 K03 LIV01 K01 (Kidney jung-gyuk) (Kidney seung-gyuk)

Regimen for each Sasang Type

Dr. Lee Jema recommended regimens for each Sasang type in addition to treatment with herbal medicine. The plans include management of the mind and body, diet, and social life.

1. Healthy Condition for each Sasang Type

In Sasang medicine, people are perceived as spiritually and physically (心身) inadequate at birth. Such incompleteness cannot be naturally resolved. A state of balance can only be acquired through effort. Although external pathogens may directly cause a specific illness, internal self-regulation can help heal or prevent illness before it causes problems. Therefore, nurturing the mind and body is based on the theory that controlling the mind can help control qi and thereby prevent illness. Careful observation of one’s general well-being can help maintain a heathy state in the body.

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(1) Taeyangin

In Taeyangin, qi can easily rise upwards. Therefore, they should take care not to become angry, as this will cause an upsurge in qi. They should always try to control their irrational habits. They should also be careful to not become aggressive.

It is important to examine the amount of urination. Foam or saliva that frequently well up in the mouth or hard tender points that form at the tip of the sternum are signs of unhealthiness. When Taeyangin feel weakness in the legs or cannot swallow food, they should be treated immediately as this condition is fatal.

(2) Taeeumin

In Taeeumin, qi can quite easily move downwards. Taeeumin should take care not to be overjoyed, as joy will make the qi sink inwards. They should also attempt to take an interest in the outside world and try to become more adventurous. Taeeumin are healthy when they adequately perspire. When they do not or when they only perspire in certain areas, such as the upper back or neck without sweat on the face or soles and palms, they are unhealthy.

(3) Soyangin

Soyangin are emotionally sensitive, tend to easily develop heat and should be careful not to become excessively sad. Additionally, it is important to refrain from overestimating oneself and belittling others. In addition, they should take more interest in matters inside the home than matters outside the home. Soyangin should not have unresolved duties. Soyangin are health only when they regularly defecate every day. If not, they will feel uncomfortable and stuffy in the chest.

When Soyangin present with constipation or a headache, caution should be paid. When they present with even a small amount of nasal bleeding, it should be viewed as a state of vomiting blood. When cool saliva is secreted in the mouth, it should be treated as vomiting, even when there is no actual vomit. Stroke and edema may progress quite quickly in Soyangin. These conditions should be treated immediately.

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(4) Soeumin

It is important that Soeumin take precaution not to be overly happy, as it may cause the qi to sink downwards. They should try to be one step ahead and more adventurous, without settling. Anxiety and jealousy should also be kept under the control.

Soeumin should be able to adequately digest their food, and heavy perspiration is not a good sign. A fever that is accompanied by heavy sweating and continuous diarrhea with a very cold sensation in the lower abdomen is a critical condition.

2. Nutrition for each Sasang Type

In Korean Medicine, food is as important as medicinal herbs. This concept is described by the famous phrase “medicine and food share origins.” Food, in Korean Medicine, is not perceived as nutrients and calories, but as qi and substances with characteristics that trigger changes in the body.

Because food is often more neutral than medicinal herbs, it is difficult to recognize harms that can be inflicted by food in a healthy state. However, in an unhealthy state, when the immune system and resistance to disease is weak, food has a larger effect on the body.

In Sasang medicine, the four Sasang types are very distinct in nature and visceral characteristics. Therefore, qi is biased in a certain direction. In Taeyangin and Soyangin, qi is biased upwards and outwards, while in Soeumin and Taeeumin, qi is biased downwards and inwards. In a healthy state, the human body can regulate such imbalances. However, states of emotional distress or irregular habits and diets disrupt the harmony of the qi and cause illnesse. A full understanding of the nature and visceral characteristics for each Sasang type, knowledge of qi and the flavor of food can help a practitioner plan an appropriate diet for each Sasang type.

(1) Taeyangin

Qi in Taeyangin tends to surge upwards. It is recommended that they consume food that has pure qi and/or a bland taste that are easily digested and absorbed, such as seafood, which has a low-fat food, or vegetables. These help the qi flow downwards.

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Fagopyrum esculentum, Vitis coignetiae , gooseberry, grapes, persimmon, Beneficial Food cherry ,quince, Brasenia schreber pine pollen, sea cucumber, carp, clams, crab, etc

Harmful Food Spicy food that are heavily spiced or foods that are greasy

Recommended Herbs Acanthopanacis Cortex, quince , gooseberry , pine needles, goldfish, etc

(2) Taeeumin

Taeeumin are quite large and have good gastrointestinal functioning. They have a tendency to overeat, and obesity, hypertension, and constipation are common problems for Taeeumin. They should avoid spicy food or high-fat food and refrain from overeating.

Wheat, beans, sweet potato, pearl barley , corn, peanut, unpolished rice, beef, milk and diary products, chestnut, pine nut, Beneficial Food walnut, gingko, white radish, bellflower roots, carrot, deodeok, bracken, seaweed, dried seaweed, yam, etc

Harmful Food Chicken, dog meat, pork, garlic, ginger, pepper, honey, ginseng, coffee, etc

Dioscoreae Rhizoma, Schisandrae Fructus, Puerariae Radix, Cervi Parvum Recommended Herbs Cornu, Ursi Fel, Moschus, Liriopis Tuber

(3) Soyangin

Soyangin have heat in their digestive system and are impulsive. They should consume cold food, vegetables, and seafood to help remove the heat and restore peace of mind.

Barley, red bean, mung beans, cabbage, cucumber, lettuce, burdock, pumpkin, eggplant, watermelon, oriental melon, strawberries, banana, Beneficial Food pineapple, oyster, sea cucumber, sea squirt, abalones, shrimp, lobster, carp, pork, beer, iced products, etc

Welsh onion, garlic, pepper, ginger, chicken, dog meat, deer meat, goat Harmful Food meet, honey, ginseng, etc

Recommended Rehmanniae Radix Preparata, Corni Fructus, Lycii Fructus, Rehmanniae Herbs Radix Crudus

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(4) Soeumin

Soeumin have a weak digestive system and must eat small portions at a time. They should always remember to eat food that has warm properties or is slightly spiced. Greasy or cold food may adversely affect the digestive system and cause diarrhea and dyspepsia.

Food that is suitable for each type should be understood as a way to help the body return to a balanced state. Eating only one or two types of beneficial food for each constitutional type for an extended period of time can impact one’s health.

Glutinous rice, potatoes, honey, chicken, dog meat, deer meat, goat meat, sheep milk, pollack, sea bream, croaker Beneficial Food anchovy, croaker, apples, tomatoes, peaches, jujubes, spinach, Welsh onion, garlic, ginger, pepper, mustard, etc

Cold noodles, oriental melon, watermelon, cold milk, ice products, beer, Harmful Food barley rice, pork, flour, etc

Recommended Ginseng, Eleocharitis Dulcis Rhizoma, Astragali Radix, Angelica Gigantis Herbs Radix, Cnidii Rhizoma, Cinnamomi Cortex

3. Social life Management for each Sasang Type

(1) Taeyangin

Taeyangin are very active and adventurous. They are sociable and can make friends easily. However, they are self-righteous. They have no goals and are aggressive. When things go as planned, they may become arrogant and lazy. Taeyangin also tend to be idealists who dream of “paradise”. When their reality is different from their ideal, they are often discouraged, become lazy and resort to drinking alcohol for comfort. Therefore, Taeyangin should always cultivate their diligent and incorrupt and avoid alcohol and disinclination. This does mean avoiding all types of alcohol, but when alcohol is consumed, it is important for Taeyangin to drink with good friends who understand them so that they can reach a state of moderation.

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(2) Soyangin

Soyangin are active and passionate but hasty and careless. Soyangin have warm heart. They are not calculative and tend to help others in need. They have a strong sense of justice. They are active in their social lives and love to stand out in the presence of others. However, Soyangin have a tendency to neglect themselves and their family. They have a tendency to exaggerate themselves in the presence of others. They like to stand out from all the others, and they have strong sexual desire, which may result in neglecting their family. Sexual desire is not confined to enjoying sexual intercourse, but more broadly refer to an extravagant lifestyle that is not appropriate for one’s income. To avoid these problems, Soyangin should simplify and minimize their lives to stop extravagant overspending.

(3) Taeeumin

Taeeumin are honest and reserved. They are trustworthy and are hardworking with strong perseverance. They are generally very conservative and skeptical about change. They are always in doubt and conceal their true feelings. In other people’s eyes, they may appear cun- ning and arrogant. Taeeumin are greedy. They prioritize family matters over matters outside the home. They are not active and are somewhat lazy. If they have strong desire for possessions, it can develop into greed, and they may obsess over money or material possessions. Such greed can be overcome through listening and seeing. Listening and seeing refers to reading books, listening to lectures, traveling, and focusing on things other than themselves.

(4) Soeumin

Soeumin are kind, calm and sociable, meticulous and good planners. They attend to small details and understand other people’s feelings. Introverted in nature, Soeumin are generally very shy and do not express themselves. They are somewhat passive, so they do not actively pursue matters. Soeumin do not tolerate unsolicited advice and can become easily jealous. When they are emotionally hurt, they keep it inside for a long time. They are perceived as timid by others. They are quite calculative and like to group together people who they favor. Soeumin pursue authority and power. They do not extend their love to everyone, but are very selective of their peers. They enjoy power, whether it is little or big, and they do not like to be controlled by others. They like to be in charge. Soeumin who are focused on authority and

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power dislike being told what to do and are always jealous of others who have prominent abilities. They should keep this jealousy under the control.

In common practice, when discussing the different constitutions, beneficial or harmful food and herbal medication are usually referenced without considering other factors. True Sasang medicine extends beyond the food and medicine.

Sasang constitutional medicine perceives humans as physically and spiritually imperfect. Because humans are born imperfect, problems arise, and life can be perceived as a long process of solving these problems and pondering how to overcome these issues. Humans need to maintain a healthy lifestyle, both physically and spiritually. They need to be a part of society and have peers. This is related to how one adapts nature to reality. The phrase “humans are born unwhole” suggests that, in physical terms, humans have constitutional differences in the size of the viscera. In mental terms, there are individual differences in states of real purpose (thoughts that are kept in the mind) and the inclination of the mind (greed that surfaces when the mind and nature are not properly controlled).

Dr. Lee Jema wrote, “The size (function) of the viscera in saints are no different from those of common people, but the size of their greed cause differences between common people and saints.” In other words, humans have four natures, humanity, justice, propriety, and wisdom. They also have four types of greed; rudeness, shallowness, greed, and indolence. Those who have more nature are saints, and those who have more greed are common people. Therefore, depending on how well the inclination of mind is controlled and how well thoughts and actions are cultivated, one can become a saint or a commoner. When people can overcome their weaknesses and construct stronger thoughts and actions, they can become saints.

Lee Jema definition of self-regulation does not end with cultivating one’s mind, as is recommended by Daoism and Buddhism. It is based on Confucianist ideas that suggest, “Cultivate oneself. Bring order to the family. Govern the country. Bring peace to all.” He emphasized that one should take care of oneself and family, as well as the entire society.

Lee Jema emphasized the importance of abstinence from alcohol, sex, wealth and power but also established guidelines for self-control.

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Finally, Lee Jema wrote, “The worst thing to do in the world is to envy kind people and to be jealous of others’ talents. The best thing to do in the world is to honor kind people and to enjoy doing kind things.” Envying kind people and being jealous of others’ talents is a severe illness, while honoring kind people and enjoying doing kind things is a very effective medicine, which emphasizes the importance of mind control.

Therefore, Sasang medicine is not only a form of medicine, but a form of anthropology in that it focuses on “What humans are and what they should pursue.”

By controlling and nurturing based on these principles, the mind and body can both become healthy. It is important to know one’s Sasang constitution and the advantages and setbacks for each type. Changing lifestyle to better suit the constitutional type will lead to a healthy and happy life.

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Appendix: Sasang Constitution Questionnaire

This questionnaire was developed to help determine your Sasang consitutional type. Select the answer choices you consider best describes you. After you are done, find the diagnosis table at the back of the packet and check the appropriate boxes to find out what your Sasang type is.

▣ Example Check(✓) the items of the survey and circle (○) the respective item on the table

1. Which of the following statements describe your body frame? Questionnaire ① I have a large frame. ② Average. ③ I have a small frame.

Table

① Taeeumin

1 ②

③ Taeyangin○ Soeumin○

☞ If none describe you, omit the question. If one item describes you circle one item. If multiple items describe you, circle all that applies

▣ Check the number for the item that applies to you.

1. Which of the following statements describes your body frame? ① I have a large frame. ② Average. ③ I have a small frame.

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2. Which of the following statements describes your body form? ① I am large. ② I am about average. ③ I am small.

3. Which of the following statements describes your body proportion? ① The upper body is larger than the lower body. ② The lower body is larger than the upper body. ③ The upper body and the lower body are about the same proportion.

4. Which of the following statements describes your body? ① I have a well-developed neck area and a rather weak low back area. ② I have a well-developed chest area and rather weak buttocks area. ③ I have a well-developed low back area and a rather weak neck area. ④ I have well-developed buttocks and a rather weak chest area.

5. Which of the following statements describes your bone structure and overall features? ① Large bone structure and overweight ② Small bone structure and skinny ③ Average bone structure with a well-developed physique

6. Which of the following statements describes your chest? ① Broad and well-developed. (obesity type) ② Very thin and hunched. (slender) ③ Broad and strong. (muscular type) ④ Broad and sturdy.

7. What food temperature do you prefer? ① Warm food ② Cold food

8. Which of the following statements describe you? ① I have cold hands and feet. ② I have warm hands and feet.

9. Which of the following statements describe your walking habits? ① I walk slowly with dignity. ② I walk naturally and gently. ③ I walk briskly and swing my body back and forth. ④ I walk stiffly.

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10. Which of the following statements describes you? ① I usually sweat a lot. I feel refreshed after I sweat. ② I do not usually sweat a lot. I feel tired after sweating. ③ I am not very tired after I sweat.

11. Which of the following statements describes you? ① Outspoken and decisive ② Active and courageous ③ Dignified and formal ④ Docile and sincere

12. Which of the following statements describes you? (in work or daily activities) ① I do not withdraw no matter what. I move forward. ② I start projects but cannot finish them. ③ I prefer to work alone as opposed to moving around. ④ I tend to stay in one place and do not like to go out.

▣ Read the following statements carefully, and check only the ones that you feel describe your usual thoughts or actions.

13. I take care of all matters very energetically.

14. I am very active and have strong will power.

15. I am not very calculating before I take action.

16. I can stay in a fixed place for a long time.

17. I am meticulous and careful.

18. I restrict my social activities to those with close friends.

19. I befriend others quite easily, without thinking much about it.

20. I am more focused on personal matters than social matters.

21. I think that a physical appearance is more important than inner beauty.

22. I cannot befriend others easily because I am reserved in my thoughts.

23. I am neat and careful.

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24. I am outspoken.

25. I am very sweet. I can comfort others well.

26. I am happy to participate in social events.

27. When I look at someone, I can tell whether or not he or she is diligent.

28. I am always in a hurry.

29. I am not comfortable speaking to strangers.

30. I am timid and always anxious.

31. I am usually quite sensitive.

32. I am patient.

33. I am quite careless.

34. I am swift and courageous.

35. I am more masculine than feminine.

36. I am bothered by small things.

37. I find it difficult to speak or present in front of others.

38. I am usually cheerful but have mood swings.

39. I pretend to be okay even when I am hurt.

40. When someone looks down on me, I cannot control myself.

41. I do not speak until I am sure that I am right.

42. I often pretend to know or show off my intelligence.

43. I tend to neglect myself but am very polite to others.

44. I cannot take action in the presence of others.

45. I am not generous when returning favors to others.

46. I am often timid and anxious.

47. I am more feminine than masculine.

48. I’m not satisfied, even after I have achieved a considerable goal.

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49. Sometimes I have vomited food or have not been able to swallow food for no specific reason.

50. When I am not well, sweating makes me feel better.

51. When I am not well, I have bad digestion.

52. I am usually very low in energy. I sigh a lot.

53. I have experienced several episodes of not being able to move my body, especially my legs, because I felt so low in energy.

54. I frequently feel uneasy in the chest and stomach after eating.

▣ Table

① Taeeumin 1 ② ③ Taeyangin Soeumin ① Taeeumin 2 ② Taeyangin Soyangin ③ ① Taeeumin 3 ② Soeumin ③ Soyangin ① 4 ② Soyangin ③ ④ Soeumin ① Taeeumin 5 ② Soeumin ③ Soyangin ① Taeeumin ② Soeumin 6 ③ Soyangin ④

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① Soeumin 7 ② ① Soeumin 8 ② Taeeumin ① Taeeumin ② Soeumin 9 ③ Soyangin ④ ① Taeeumin 10 ② Soeumin ③ ① Taeyangin ② Taeeumin 11 ③ Soyangin ④ Soeumin ① Taeyangin ② Soyangin 12 ③ Soeumin ④ 13 Soyangin 14 Soyangin Taeeumin 15 Soyangin 16 Taeeumin Soeumin 17 Soeumin 18 Soeumin 19 Soyangin 20 Soeumin 21 Taeyangin 22 Taeeumin 23 Soeumin 24 Taeyangin Soyangin

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25 Soeumin 26 Taeeumin 27 Taeeumin 28 Soyangin 29 Soeumin 30 Soeumin 31 Soeumin 32 Taeeumin Soeumin 33 Soyangin 34 Taeyangin 35 Soyangin Taeeumin 36 Soeumin 37 Soeumin 38 Soyangin 39 Soyangin Taeeumin 40 Soyangin 41 Taeeumin Soeumin 42 Soeumin 43 Soeumin 44 Soyangin 45 Soeumin 46 Taeyangin 47 Taeeumin 48 Soeumin 49 Taeyangin Soyangin 50 Soeumin 51 Taeeumin 51 Taeeumin 52 Taeeumin 53 Soyangin 54 Soeumin total( )questions total( )questions total( )questions total( )questions results ( /11= %) ( /19= %) ( /17= %) ( /33= %)

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How to Evaluate the Results

Of the 54 questions on this survey, 11 reflect Taeyangin traits, 19 for Soyangin, 17 for Taeeumin, and 33 for Soeumin traits. None of the questions refer to any two types. Some questions do not indicate a specific type.

One checked response counts as 1 point. Add up the scores for each constitution type and divide the number of answers you responded “yes” to by the number of questions to obtain a percent (%). This value will be used to determine your Sasang type. The type that has the highest percentage value is your Sasang type, but only when the percentage score for that type is at least 10% higher than those for the other types. If not, the result is not significant. The one exception is Taeyangin. To be a Taeyangin, the percentage score should be above 60%, and the difference between scores, as opposed to other types, should be at least 20%.

This test alone is not sufficient for identifying your Sasang type. If the results are ambiguous or if you want more information, visit a Korean Medicine doctor for consultation.

Example1) If you chose 1 Taeyangin item, 4 Soyangin items, 4 Taeeumin items, and 17 Soeumin items, Your percentage scores are 5% for Taeyangin (1/11), 20% for Soyangin (4/19), 25% for Taeeumin (4/17), and 50% for Soeumin (17/33). This means that you are a Soeumin-constitutional person. Your score for Soeumin is at least 25% higher than scores for other Sasang types. So you can be considered a Soeumin.

Constitution Sasang Types Taeyangin Soyangin Taeeumin Soeumin

total total total total ( 1 )questions ( 4 )questions ( 4 )questions ( 17 )questions Results 1/11=5% 4/19=20% 4/17=25% 17/33=50%

Example2) If your results indicate 70% Taeyangin, 40% Soyangin, 10% Taeeumin, and 30% Soeumin, you are a Taeyangin. However, if you are 60% Taeyangin, 50% Soyangin, 10% Taeeumin, and 20% Soeumin 20%, you cannot be considered a Taeyangin because the difference is not significant. (should be at least 20% difference)

97 2016 Korean Medicine Current Practiceof CHAPTER 4

Chuna Manual Medicine

▼ Byung-Cheul Shin PART 1 Understanding the clinical system of Korean Medicine

chapter 4

Chuna Manual Medicine

What is Chuna Manual Medicine?

Chuna Manual Medicine (CMM, 推拿療法) is a division of Korean Medicine (KM) that combines medical knowledge of anatomy and physiology with biomechanics and sports biomechanics. Chuna Manual Therapy (CMT) is a scientific art of palpating and treating medical conditions manually.

Chuna Manual Therapy is performed by Korean Medicine Doctors (KMDs) using hands or other body parts as necessary with of medical devices or tools such as Chuna tables. Physical stimuli are applied to the patient’s body to restore balance of structural and/or functional problems. People have been using their hands to treat various diseases since ancient times. It is one of the oldest known forms of medicine.

Chuna treatment (also referred to as Chuna Manipulative Treatment) encompasses a wide range of ideas and concepts spanning biomechanics and sports biomechanics to functional anatomy. Neuromusculoskeletal structures, the craniosacral system, and viscera are all subjects of Chuna manual treatment. Some examples of Chuna manipulation include: ❶ Joint Mobilization Chuna, [ Figure 1 ] Chuna Manual Therapy

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❷ Joint Distraction Chuna (including distraction using Chuna devices/machines), ❸ Joint Ma- nipulation Chuna, ❹ Fascia Chuna (meridian muscle) Chuna, ❺ Visceral Chuna, ❻ Craniosa- cral Chuna, ❼ Dislocation Manipulation Chuna.

History of Chuna Manual Medicine

Using the hands as a treatment method is a long-standing tradition all over the world. Historians studying the field of manual medicine have confirmed that various manual therapies were developed in a parallel manner in many civilizations.

The root of East Asian manual medicine can be traced back to Huangdi’s Internal Classic (黃帝內經), a book written by Chinese medical professionals in the Warring States Period (BC475 ~ BC221). Huangdi’s Internal Classic was the basic textbook commonly referred to by practitioners in many East Asian countries until the publication of Donguibogam in Joseon Dynasty in Korea.

Chuna originates from Do-in (導引) and massage (按) therapies introduced in Huangdi’s In- ternal Classic. Chuna at the time referred to massage (按摩; what has today developed into meridian muscle (經筋) Chuna or acupoint Chuna), Do-in (導引; conduction exercise therapy), Qigong exercise therapy, Tae-keuk-kwon, and Moo-gong Chuna), and Chuna (correlating to osteopathic manipulation Chuna). The term Chuna is believed to have been used since the Ming or Chung Dynasty of China.

The first records containing the term Chuna (推拿) were such pediatric medicine classics of the Ming Dynasty as Encyclopedia of pediatric Chuna, formulas, pulse and rescuing (小兒推拿方脈活秘旨全書) and Secret tips in pediatric Chuna (小兒推拿秘訣). Massage and Chuna were considered very similar until quite recently. However, modern Chuna (focusing more on joints) and massage (focusing more on muscles/meridians) are now recognized as very distinct treatments that have evolved into specific, individual forms of healthcare.

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[ Figure 2 ] Wie’s hanging method (危氏懸弔法) applied to [ Figure 3 ] Wie’s hanging method (危氏懸弔法) applied vertebral fracture (1337) to vertebral fracture (1337)

The history of Korean Medicine dates back approximately 400 years ago, during the Joseon Dynasty in Korea. A royal doctor, Hŏ Jun (the Father of Korean Medicine), published Dongui- bogam(Treasured Mirror of Eastern Medicine), a modified and abridged version of traditional Chinese medicine to better accommodate the health needs of the Korean population. “Dongui” means “Medicine of the East”; Joseon is located east of China, thus explaining the title Dongui- bogam. As a significant historical document written in Chinese characters, Donguibogam was added to the UNESCO world cultural heritage list in July 2009. However, Chuna is rarely discussed in this important medical record, possibly because physical contact was considered taboo during the Joseon Dynasty.

Modern Korean Medicine manual therapy was officially recognized beginning with the 1988 Seoul Olympics. The Korean Society of Chuna Manual Medicine for Spine & Nerves (KSCMM) was founded in 1992 as a member of the Society of Korean Medicine. Today, KSCMM is comprised of 1,057 regular active members (total of 3,500 active and non-active members), about 100 instructors, and 32 board members. Since its founding, the society has contributed exten- sively to the development of Chuna manual medicine.

Manual medicine is a comprehensive term commonly used to refer to all manipulation therapy. In Korea, manual medicine is usually referred to as “Chuna”. Massage, Chinese manipulation

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or Chinese Orthopedics of Traditional Chinese Medicine; Osteopathic Medicine, Chiropractic, Physical Manipulation, Exercise Therapy, Applied Kinesiology, Myofascial Release Technique, and Podiatric Medicine of the United States and Europe; Japanese style Manual Medicine (整體療法. 操體術), and acupressure are unique with respect to their history, treatment rationale, and technique, but are similar in that they all make use of the hands. Korean Chuna manual medicine has been developed further by incorporating modern techniques in traditional Chuna to develop a comprehensive treatment discipline covering practical, unique, and effective manual treatment techniques.

In Korea, the term “Chuna” was first used upon the establishment of KSCMM. The founding members recognized the similarities between traditional Chuna and modern manual medicine and decided to use the term “Chuna” as an umbrella term.

Mechanism of Action

According to the basic principles of Korean Medicine, humans are part of nature, consisting of body and spirit as a unit, and are “small universes”.

Chuna Manual Medicine is a division of Korean Medicine with an extensive history and potent treatment effects. Chuna is used not only as a treatment method but also preventive means. Through years of clinical experience, Chuna has been honed and developed to its present unique and distinguished form of Korean Medicine.

The basic principle of Chuna is that all phenomena of the human body are a result of interactions between function and structure. In fact, all changes are perceived to be a result of interactions between structure (體) and function (用), body (形) and spirit (神), and yin (陰) and yang (陽). Any disharmony of these factors may cause disease. To resolve such disharmony, the body is perceived and evaluated as an integral whole. This holistic approach does not focus simply on the disease, lesion or dysfunctional area but on the entire body. Diagnosis in Chuna manual

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medicine is comparable to other subdivisions of Korean Medicine in that the Four Diagnosis (四診), Meridians and Collaterals (經絡) theory and Viscera and Bowels (臟腑) theory are taken into consideration. However, Chuna manual medicine is also based on the basic principles of structural anatomy, functional anatomy, sports biomechanics, physiology, pathology, neurology, radiology, and basic sciences. Such ideas are applied not only to diagnosis and evaluation but also treatment.

Chuna manual treatment aims to restore balance between yin and yang, to stimulate normal circulation of the meridians and collaterals, and resolve any structural and functional dysfunctions of the spine and other regions. All Chuna manual treatment should be performed based on the examination results of static and motion palpation, range of motion tests and other forms of diagnostic tests providing information on normal, increased or decreased movement of structures. A dysfunctional joint may display signs of hypomobility, hypermobility, instability, or a combination. Manual treatment is especially effective when applied to hypomobile joints. In other words, manual treatment is best suited for joint fixation where joints show impaired movement. Treatment can help restore full range of healthy movement to these areas.

Chuna Manual Medicine and Clinical Evidence

Randomized Controlled clinical Trials (RCTs) provide the highest level of evidence. A Systematic Review (SR) of the literature on the use of Chuna manual treatment funded by the Korean Ministry of Health & Welfare reported that, as of 2016, a total number of 778 RCTs on the effects of Chuna had been studied. Conditions reported to be treated with Chuna included musculoskeletal disorders (n=419), pediatric conditions (n=121), neuropsychiatric disorders (n=95), gastrointestinal diseases (n=36), obstetric or gynecological disorders (n=47), and cardiovascular diseases (n=28). Research on Chuna was most frequently conducted for musculoskeletal disorders, pediatric conditions, and neuropsychiatric disorders (Table 1).

Literature searches were conducted for articles published in English (PubMed, Embase, Med- line, Cochrane CENTRAL), Chinese (CAJ), and Korean (a total 7 databases). 288 systematic

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reviews and 778 RCTs were analyzed in total. The goal was to establish an evidence-based rationale for Chuna manual treatment using the best available evidence.

Table 1. Categories of medical conditions and number of Randomized Controlled trials (RCTs) and Systematic Reviews (SRs) in the literature (up to 2016)

Publication Field Number of SRs Number of RCTs

Musculoskeletal 18 419

Neuropsychiatric 1 95

Pediatric 3 121

Gastric 2 36

Endocrine 0 3

Obstetric 0 47

Cardiovascular 2 28

Respiratory 0 3

Ophthalmologic 0 1

Kidney 0 7

Dental 0 3

Healthy subjects 2 12

Otolaryngological 0 1

Surgery 0 2

Total 28 778

In a search (2013) for RCTs conducted in Korea testing the effect of Chuna compared to that of control groups, 14 RCTs on musculoskeletal conditions and 3 on neurological disorders have been investigated.

The cost-effectiveness of Chuna manual treatment is considered similar to that of other manual therapies. Chuna has been reported to be highly cost-effective for musculoskeletal disorders and especially low back pain.

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Indications of Chuna Therapy and Safety of Chuna Manual Medicine

Chuna therapy can be applied to a wide range of conditions. It is most frequently used to treat musculoskeletal disorders and neurological disorders (Table 2, Figure 4).

Table 2. Indications of Chuna therapy

Division Indications

Muscle pain, disc herniation (cervical spine, lumbar spine), spinal stenosis (cervical spine, lumbar spine), arthritis, scoliosis, Musculoskeletal kyphoscoliosis, Spondylosis, thoracic outlet syndrome, myofascial pain syndrome, postoperative pain

Neuropsychiatric Headache, vertigo, stroke, carpal tunnel syndrome, insomnia

Pediatric Scoliosis, postural imbalance, nocturnal crying in infants

Gastric Dyspepsia, constipation, abdominal pain

Dysmenorrhea, postpartum low back pain, Obstetric postpartum arthritis

Cardiovascular Circulation problems, edema

Respiratory Asthma, dyspnea

Tinnitus, hearing impairment, sinusitis, Otolaryngological decreased visual acuity

Dental Toothache, tempromandibular joint disorder

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Percentage of patients treated

30%

25%

20%

15%

10%

0% Post traumatic Low back Lumbar Muscle Arthritis pain sprain injuries symptoms (traffic accident)

[ Figure 4 ] Top 5 common diseases treated by Chuna manual therapy

Regarding the safety of Chuna manual treatment, few severe adverse events have been reported. Most adverse events reported were reversible injuries that resolved naturally without additional treatment. However, to prevent adverse events, physicians should be well trained at universities and/or certified institutions such as KSCMM. Regular courses covering systematic course material should be completed for the specified number of hours (for example, KSCMM conducts a 126-hour program covering basic principles, clinical application, and ethical and legal issues). It is recommended that only physicians with extensive training perform Chuna manual therapy.

Relative contraindications are conditions in which special attention is required because complications may occur after treatment, and absolute contraindications are conditions in which Chuna treatment should be avoided altogether and be substituted with alternatives (Table 3, 4).

It is necessary that the physician carefully assess the patient prior to treatment and consider the indications and contraindications of Chuna manipulation. Differential diagnosis for relevant comorbidities is also of critical importance.

The practitioner should always consider the benefits and harms of Chuna manipulation before commencing treatment and re-evaluate the patient to identify any adverse events following treatment.

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Table 3. Contraindications of manual treatment applied to vertebrae

1. Malformation of odontoid dens, os odontoideum 2. Acute fracture 3. Spinal cord tumor 4. Osteomyelitis, septic discitis, spinal tuberculosis and other acute infections 5. Tumor of the meninges 6. Hematoma at the spinal cord or vertebral foramen 7. Malignant tumor of the vertebrae 8. Disc herniation with neurologic deficit 9. Sub basilar invasion of the upper cervical spine 10. Arnold-Chiari malformation of the upper cervical spine 11. Vertebrae dislocation 12. Aneurysmal bone cyst, large cell tumor, osteoblastoma, osteoid osteoma and other benign tumors 13. Spinal fusion or other implanted equipment 14. Neoplasm of the muscle or other soft tissue 15. Positive Kernig’s sign or Lhermitte's sign 16. Congenital hypermobility 17. Instability 18. Syringohydromyelia 19. Hydrocephalus of no known cause 20. Diastematomyelia 21. Cauda equine syndrome

Table 4. Contraindications of manual treatment applied to joints

Absolute Contraindications Relative Contraindications Caution

- Inflammation (RA) - Hypermobile joints, joints - Degenerative joint - Serum test negative that are not confirmed to be conditions, osteoarthritis, vertebral joint diseases stable inflammation stages of - Malalignment and/ - Post-operative joints facet joint syndrome or ligament injuries - Spondylitis, Joint accompanied by spondylolisthesis Conditions subluxation or dislocation (depending on severity) - Fracture, dislocation, - Acute joint and soft tissue ligament injuries and/or injuries healed fractures with - Trauma visible instability - Instability of C1-C2

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Absolute Contraindications Relative Contraindications Caution

- Active ischemic necrosis - Ossifluence due to - L ong-term exposure to of weight-bearing joints metabolic disorders steroids, osteoporosis, - Benign bone tumor - Benign tumor of osseous postmenopausal women Bone - Malignant spinal tumor, structures Conditions infections of the spine and - Discitis with severe pain, joints disc herniation - Infections of the bone and joints

- Vasobasilar dysfunction - Exposure to anti-platelet Cardiovascular - Past history of stroke agents and Blood - Cerebral aneurysm - Diseases that may cause Conditions problems with blood coagulation

- Acute spinal cord diseases - Increased intracranial pressure Neurologic Deficits - Encephalomeningitis - Acute cauda equine syndrome

Emotional Fake illness, hysteria, Factors hypochondriasis

Different Types of Chuna Manual Therapy

The most frequently applied forms of Chuna manual therapy are as follows. Also, in addition to Chuna, another commonly used Korean Medicine manipulation technique is Do-in (conduction exercise) therapy. The seven Chuna techniques described below can be applied to vertebral and/or other joints.

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CLASSIFICATION OF MANUAL THERAPIES

Joint manipulation Soft tissue manipulation procedures procedures

Mobilization Adjustments Point pressure Visceral techniques manipulation Manual traction distraction Massage Therapeutic muscle stretching

[ Figure 5 ] Classification of manipulative procedures (This illustration is not intended to cover all possible manual therapies)

* Source: Thomas F. Bergmann, David H. Peterson: Chiropractic technique: principles and procedures 3rd. ed., Mosby. 85p. 2011.

1. Fascia (meridian muscle) Chuna Therapy

Fascia Chuna therapy is applicable to soft tissues (e.g., muscle, fascia, tendon, ligaments) that are tight and tense or those that are loose and weak. Upon taking up the optimal position, the practitioner applies gradually increasing pressure to the tissues or induces isometric or isotonic contraction. The patient is often required to push against the resistance provided by the practitioner to restore normal length and tension to the soft tissue. This technique is known to help resolve pain and dysfunction in the joints and muscles as well as [ Figure 6 ] Fascia Chuna Therapy – Applied to the other malalignments of the body. scalenes

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2. Chuna Joint Mobilization Therapy

When malalignment of the joints causes functional dysfunction and decreased range of motion, joint mobilization techniques may be used to help restore range of motion.

[ Figure 7 ] Joint mobilization therapy – Applied to the 2nd rib

3. Chuna Joint Distraction Therapy

Joint distraction is a technique applied to the cervical or lumbar spine to decrease the pressure load on intervertebral discs.

[ Figure 8 ] Chuna joint distraction therapy – Applied to the lumbar spine

4. Chuna Spine & Joint Manipulation Therapy

Spine and joint manipulation refers to High-Velocity Low-Amplitude (HVLA) techniques applied to joints to correct spine or joint displacement and/or dysfunctions.

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[ Figure 9 ] Joint manipulation therapy – Applied to the thoracic spine

5. Chnuna Manipulation of Joint Dislocation

Joint dislocation Chuna is a subdivision of Chuna usually applied to the temporomandibular, shoulder, elbow or hip joints with the aim of restoring proper alignment to dislocated joints.

[ Figure 10 ] Chnuna manipulation of joint dislocation - Applied to the shoulder joint

6. Chuna Visceral Manipulation

Visceral manipulation employs gentle corrective force to aid visceral mobility and motility, fluid circulation, and secretion of bodily fluids, and to alleviate muscle spasms arising from visceral problems.

[ Figure 11 ] Chuna visceral manipulation

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7. Chuna Craniosacral Therapy

Craniosacral therapy applies techniques to the cranial bones and sutures to regulate Cerebrospinal Fluid (CSF) flow. Any abnormalities in the inherent motion of the craniosacral system are detected by palpation and restored.

[ Figure 12 ] Chuna craniosacral therapy

Chuna Manual Therapy Procedures

Procedures of Chuna treatment comprise of diagnosis -> treatment -> re-evaluation. Diagnosis should be based on Korean Medicine diagnosis (the Four Diagnosis: Inspection, listening, and smelling, inquiry, and palpation), and conventional diagnosis (history taking, physical examination, palpation, radiological tests (X-ray, CT, MRI).

A comprehensive evaluation is needed, and treatment plans should be established accordingly. Treatment can be complete only after re-evaluation confirms that the treatment was successful.

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Diagnosis Treatment

[Four Diagnosis ( )] [Before Treatment] 四診 Inspection Short term / Long term Plans Listening and Smelling Determine Area, Inquiry Technique, Palpation Duration, and Frequency [Physical Tests] [Treatment] [Palpation] Soft Tissue Chuna Screening Tests Joint Distraction Chuna Scanning Tests Joint Mobilization Chuna [Radiological findings] Joint Manipulation Chuna Cranial Chuna, Visceral Chuna Diagnostic Imaging [After Treatment] [Lab tests] Re-evaluation Clinical Laboratory Tests Teaching

[ Figure 13 ] Evaluation of Form and Posture

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Combination of Korean Medicine and Chuna

1. Holistic Approach

Korean Medicine and Chuna manual medicine are similar in that they focus on restoring healthy balance of both structure and function. Korean Medicine has traditionally treated such imbalances using acupuncture, moxibustion, and herbal medicine. KMDs trained in Chuna manipulation have the added option of restoring alignment to asymmetric structures and normal body function using a manual holistic approach. Chuna manual medicine does not focus on a single joint or a single displacement because the goal of treatment is to restore proper function and structure to the entire system.

2. Combination of Acupuncture and Manual Medicine

Acupuncture is a traditional form of treatment approved and supported by the World Health Organization (WHO). KMDs have long treated musculoskeletal disorders with acupuncture. The combined knowledge and application of acupuncture and manual medicine have been reported to yield favorable outcomes through synergistic effects. Acupuncture helps resolve localized pain and circulation problems, while Chuna manual medicine targets both local and general structural issues.

3. Combination of Herbal Medicine and Manual Medicine

Many herbal medicine prescriptions include active substances that help regenerate and heal joints. While Chuna manipulation directly affects muscles and joints to restore normal functional movement, herbal medicine helps strengthen joints. Combinations of both therapies have also been shown to be effective.

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Future Prospects of Chuna Manual Medicine

Some Korean Medicine treatment interventions are covered by the Korean National Health Insurance (public insurance for all Korean citizens). For example, acupuncture treatment has the broadest coverage and is reimbursed by the National Health Insurance Service, automobile insurance, workers’ compensation insurance, and various fee-for-service health insurances.

In Korea, National Health Insurance coverage qualification for Chuna manual medicine is underway. Chuna is currently reimbursed by automobile insurance, workers’ compensation insurance, and fee-for-service health insurances. After a 2-year (2016-2017) pilot health promotion program, Chuna is expected to be reimbursed by the National Health Insurance Service as of 2018. This change indicates that Chuna manual medicine is considered as an essential and basic component of Korean healthcare services and in an evidence-based Korean Medicine approach.

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Reference

•Jean-Pierre Barral, D.O., MRO(F) http://www.barralinstitute.com/about/jean-pierre-barral.php

•John E. Upledger,(1932-2012) http://www.upledger.com/about/john-upledger.php

•Park TY et al. An introduction to Chuna manual medicine in Korea: History, insurance coverage, education, and clinical research in Korean literature. Integrative medicine research. 2014:3:49-59.

•School of Korean Medicine, Pusan National University. Policy proposal research services for ‘educational standards of Korean Medicine manual therapy’. Korea Institute of Oriental Medicine. 2015.

•The Korean Society of Chuna Manual Medicine.『Chuna Manual Medicine』 2nd Edition. Seoul:The Korean Society of Chna Manual Medicine. 2014. p.4,10-11,47-50.

117 2 PART

● Current Practice of Korean Medicine 2016 Korean Medicine Treatments for Various Medical Conditions

CHAPTER 1 Musculoskeletal Diseases CHAPTER 2 Cardiovascular and Neurological Diseases CHAPTER 3 Digestive Diseases CHAPTER 4 Women’s Diseases CHAPTER 5 Pediatric Diseases CHAPTER 6 Psychiatric Diseases CHAPTER 7 Obesity CHAPTER 8 Korean Medicine Cosmetic Procedures CHAPTER 9 Infertility 2016 Korean Medicine Current Practiceof CHAPTER 1

Musculoskeletal Diseases

▼ Dongwoo Nam PART 2 Korean Medicine Treatments for Various Medical Conditions

chapter 1

Musculoskeletal Diseases

Introduction

Musculoskeletal diseases are one of the most strong points of Korean Medicine. The effectiveness of acupuncture and herbal medicine treatment for pain control has already been acknowledged world wide.

Along with an increased interest in non-surgical treatments for spine & joint diseases, the demand for Korean Medicine treatment has also been growing.

Many local clinics specialize as spine & joint clinics focusing on intervertebral herniations and degenerative joint diseases. Many hospitals have also arranged specific outpatient and inpatient treatment programs that focus on spine & joint diseases and some manage specialized centers as well.

In this chapter we will study the conditions most frequently treated with Korean Medicine.

Disorder of the Cervical Area

1. Diagnosis

Diagnosis should commence the moment the patient walks into the office. Evalu- ations should start with an evaluation of the overall posture, followed by the Four Diagnosis.

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Basic evaluations should be thorough, should be able to determine prognosis, and should minimize the possibility of overlooking conditions that require emergency care.

Be careful not to diagnose based solely on patient complaints. Always re-examine the circumstances of onset, and remember that symptoms of cervical conditions may not always be present in the specific area. Evaluate and record the circumstances of the first visit in detail.

Examine even the areas that the patient does not actively mention. Perform basic physical examinations and determine any correlations with radiological findings and other neurological tests.

Cervical nerve root compressions, degenerative cervical spondylosis, and neck stiffness are common conditions in clinical settings. However, do not underestimate the possibility of others, unusual and rare medical conditions conditions, such as spinal cord lesions, tumors, and other space-occupying lesions. Determine the prognosis and diagnose the patient in Korean Medicine terms to make a treatment plan.

• Injury Onset • Acute/chronic

• Acute pain/chronic pain • Radiations, if any Pain • Patterns of pain • Progression of pain

• Radiation, sensory abnormalities, weakness Neurological Signs • Vertebral artery compression sign

• Examine areas of pain Examination/Palpation • ROM Physical Examinations • Physical examinations

Korean Medicine • Wind/Cold/Dampness Diagnosis • Liver-Kidney-deficiency/Phlegm fire/Food damage

Comparison with Radiological Findings

[ Figure1 ] Flow chart of Korean Medicine diagnosis process of cervical pain patients.

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2. Tests

(1) ROM

• Flexion: Patient should be able to touch his or her chin to the chest. • Extension: Patient should be able to look at the ceiling. • Rotation: 70 degrees, bilaterally / Side-bending: 50-60 degrees. • Active motion testing, passive motion testing, and resistance motion testing.

(2) Spurling test and Compression test

• Space-occupying lesions that compress nerve roots. Do not imply disc herniation. • Testing may aggravate pain. Take caution and refrain from overuse.

(3) Grip & release test, Hoffman sign, L’hermitte sign.

• Suspect compression, injury and degeneration of the spinal cord.

(4) Neck stiffness

• Nonspecific neck stiffness should be ruled out. Take caution as neck stiffness may be a sign of meninge irritation. * Atypical muscle weakness, sensory abnormalities, and other suspicious symptoms Central nervous system-cerebral abnormalities/below the spinal cord, vertebral nerve root, and peripheral nerve system-single branch/multi-branch conditions

(5) Radiological tests

• X-ray: Problems of the osseous structure and biomechanics • CT(Computed Tomography): Further evaluation of osseous structures • MRI (Magnetic Resonance Imaging): Soft tissue (e.g., disc, nerve), ENoG (Early-performed Electroneurography) and EMG (Electromyography) are used to diagnose motor nerve injuries and the degree of damage.

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3. Treatment

Symptoms and the causes should be determined, and priority should be determined with respect to the two factors. If there are signs of inflammation or pain at rest or if pain is elicited by a specific movement, treatment should initially focus on the local areas.

(1) Nakchim (Neck stiffness) symptom: Neck stiffness is a form of muscle spasm. Palpate relevant muscles and select acupoints for use. Examples include Hyeopcheok (Jiaji, Extra point) point, GB21, GB20, SI14, SI13. Distant points such as SI03, BL62 may also be stimulated. Gyunjung pharmacopuncture and bee venom are both frequently used. Regarding herbal medication, ‘Invigorate the Channels Decoction’ , ‘Peony and Licorice Decoction’, and ‘Re- turn to Being in Charge Powder’ are frequently prescribed. If the condition is a result of wind dampness, prescribe ‘Notopterygium Decoction to Overcome Dampness’ . Motion style acupuncture treatment may induce a dramatic, immediate increase in the range of motion of the joint. However, the patient should be informed that treatment effects may not be persistent, and the symptoms may appear to temporarily deteriorate at a specific point. (2) Nerve root compression (discogenic): Both physical compression of the nerves and chemical and inflammatory responses elicited at the site of the compression may be present. Treatments that focus on the local symptoms should be prioritized. Hyeopcheok (Jiaji) point is typically stimulated. It is particularly effective with use of bee venom. Gunchilg- wanjul-dan (Lacca Sinica Exsiccata, Cinnamomi Cortex, Saposhnikoviae Radix) is frequently prescribed. Approximately 1-3 months of treatment is needed.

4. Prevention and Management

It is critical to educate the patient on appropriate habits.

(1) Daily advices to avoid aggravation in symptoms

- When driving or working at a desk, occasionally stretch out the neck. - Refrain from activities that involve lifting objects above eye level. - Refrain from activities that involve rapid rotation of the torso, such as golf or tennis.

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(2) Other maintenance tips - Hot packs: Help alleviate muscle spasm. - Ice packs may be applied in cases of acute sprains. - Exercise: Stretching and self-resistance isometric exercises are recommended. Simple exercises help to increase compliance therefore light exercise is also recommended.

Disorders of Shoulder Joint

1. Diagnosis

Anatomical structures, functions, and dysfunctions of the shoulder joint should be considered prior to the diagnosis of a shoulder joint problem.

When examining shoulder joint pain, a differential diagnosis is needed to determine whether pain is related to the cervical spine or the shoulder joint. Shoulder joint conditions typically elicit pain in the deltoid area, whereas pain is present in the trapezius area of the affected side in the case of cervical intervertebral disc herniation or cervical arthritis. A detailed history

Function Dysfunction Common conditions

Adhesive capsulitis Mobility Stiffness (e.g., post-injury, post-operation)

Rotator cuff injuries Strength Weakness Impingement syndromes

Smoothness Roughness e.g., OA, RA

Instability (anterior/posterior/ Stability Instability multidirectional) SLAP lesions

[ Figure 2 ] Reference for diagnosis of shoulder pain patients

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should include items regarding stiffness, weakness, clicking, and instability. The exact areas of these symptoms should be determined for a preliminary diagnosis. Then, proceed to perform appropriate physical examinations to gain credibility to the diagnosis and refer to radiological tests if needed.

Rotator cuff disorders, adhesive joint capsulitis (frozen shoulder), calcific tendinitis, and thoracic outlet syndromes are the most common shoulder joint diseases. Each condition has a different prognosis; thus, treatment goals should be also different.

• Diffuse/localized/radiation (differential diagnosis to rule Evaluate Pain out problems that arise from the cervical vertebra)

• Deltoid vs Trapezius Locate the Site of Pain • Anterior portion of acromion/posterior joint capsule/ infraspinatus fossa

1. Stiffness 2. Weakness Obtain History 3. Clicking 4. Instability-preliminary diagnosis

• Observe structures Observation/Palpation/Physical • Identify pressure points Examination • ROM evaluation (active/passive) • Impingement signs, weakness/instability evaluation

• Determine relevant meridian Korean Medicine Diagnosis • Phlegm/wind cold dampness/qi and blood stagnation

Refer to Radiology if necessary

[ Figure 3 ] Flow chart of Korean Medicine diagnosis process of shoulder pain patients.

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2. Tests

(1) ROM • Clinically important ROM: forward flexion 180 degrees, external rotation to the sides (at neutral) 90 degrees, and internal rotation (to the back) beyond T7. Compare with the unaffected side. * It is important to determine which part of the joint capsule is causing the limited ROM.

(2) Impingement tests (Neer sign and Hawkin’s sign) Check for injuries of the rotator cuff and bursa of the subscapular region.

(3) Muscle strength tests (empty can test, drop arm sign, and dropping sign) Induce isometric contraction of the supraspinatus, infraspinatus, and other relevant muscles. Determine which muscles cause pain upon movement and whether weaknesses are present.

(4) Instability tests If the patient complains that “the shoulder feel as if it has fallen off ” evaluate for instability, and record the position in which the instability is induced.

(5) Radiological tests • X-ray : Evaluation of acute injury in shoulder joint, diagnosis of calcific tendinitis • CT: Ultrasonography of sternoclavicular lesions and shoulder joint. Most structure of the shoulder joint are superficial;thus sonographs may be used for differential diagnosis. • MRI : Diagnosis of soft tissues

3. Treatment

It is important to consider both symptoms and causes in the treatment of shoulder joint disease. In the initial stages, when pain and inflammation are the chief complaints, and if it is a superficial or excessive-type condition, treat the symptoms first.

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(1) Rotator Cuff Injuries: Sites of pain and areas of suspected lesions should be identified with physical examinations. Select acupoints based on the meridians relevant to the symptoms for stimulation. Bee venom, as well as other pharmacopuncture injections, may be used. Herbal medications, such as ‘Invigorate the Channels Decoction’, may be prescribed to help reduce pain, reinforce soft tissues, and improve circulation. (2) Adhesive Capsulitis (frozen shoulder): Treatment goals should be to help reduce pain and increase the range of motion. Bee venom and local acupuncture are effective for pain control. If prominent tender points are palpated, cupping is also an effective treatment option. If swelling and/or tender points are identified on the SI11, LI15, or TE14 sites, apply dry or wet cupping on these areas. If symptoms of blood stagnation are persistent, wet cupping every 2-3 days is effective. It is critical that active and passive exercises are performed as early as possible. Always consider that the natural prognosis of adhesive capsulitis is as follows. A freezing stage in which night pain is severe (4-6 months), a frozen stage in which there is a severe loss of motion with particularly severe pain during external rotation (4-12 months), and a thawing stage in which the pain decreases and motor function is restored (4-6 months). (3) Calcific Tendinitis: In the acute stages, severe pain accompanied by severe swelling may be identified. Prominent tender points may be palpated; thus, it is effective to inject bee venom on these areas. However, if the pain persists after extensive conventional and/or Korean Medicine treatment or the condition relapses often, treatment may be prolonged. Explain the condition to the patient, and subsequently initiate treatment. (4) Thoracic Outlet Syndrome: Local acupuncture applied to the site that appears to be compressing the nerve and more distal acupuncture on the relevant meridians are effective. Bee venom pharmacopuncture is also very effective. Stretching, hot packs, and other conservative care help alleviate pain. Even after clinical symptoms have been resolved, patients should be aware of maintaining a correct posture. If the superficial symptoms have been treated or there are prominent problems of the viscera and bowel functions, treat the cause of the problem. Local acupuncture and bee venom may be effective treatments for symptom, whereas Sa-Am acupuncture and other acupuncture methods that regulate viscera and bowel functions as well as herbal medicines may treat the causes.

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(5) If it is evident that the cause of the condition is external pathogens, such as wind, cold, and/or dampness, prescribe herbal medicine. Prescribe ‘Five Accumulations Powder’ for conditions that result from cold pathogens, ‘Lindera Smooth Qi Powder’ for conditions that result from wind pathogens, and ‘Relieve Painful Obstruction Decoction’ for conditions that result from dampness pathogens. (6) If there is phlegm, blood stagnation, food damage, or other pathogens that may cause shoulder joint conditions, ‘Pinellia, Scutellaria and Atractylodes Decoction’ or ‘Angelicae Gigantis Radix Powder’ may be prescribed even in the initial stages of treatment. If the patient is obese, prescribe ‘Decoction of Two Aged Drugs’ or other medicines that remove dampness phlegm. (7) Spleen-stomach yang qi deficiency and yin deficiency are typically caused by dysfunction of fire in upper energizer. Prescribe medicines, such as ‘Pinellia, Atractylodes Macroceph- ala and Gastrodia Decoction’ and ‘Auckandia and Amomum Decoction for Nuturing Stom- ach’, which tonify and help qi movement and thereby resolve dysfunctions of spleen and stomach. ‘Rehmannia Decoction with Schizonopeta and Ledebouriellia’, ‘Guide out the Red and suppress the qi decoction’, and other medicines replenish kidney yin and help fire of upper energizer to descend properly.

4. Prevention and Management

The management of shoulder joint diseases should consist of the avoidance of motions that aggravate the condition. Appropriate exercises are mandatory.

(1) Positions and Motions to avoid - Lifting heavy objects - Carrying a bag on the affected shoulder - Extending the head back for an extended period of time - Rigorous cardio exercises - Sleeping on the affected shoulder (2) Exercise: Rotator cuff injuries are predominately a result of weakness of the rotator cuff muscles; thus, reinforcement of these muscles is important. In the case of frozen shoulder,

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active and passive exercises of flexion, external rotation, and posterior external rotation are recommended for treatment. For calcific tendinitis, initiate an exercise once the pain is alleviated to prevent atrophy of the muscles around the area.

Disorders of Elbow Joint

1. Diagnosis

The elbow joint is a hinge joint supported by osseous structures. The elbow joint is a stable joint that consists of the humeroradial joint, humeroulnar joint, and proximal radioulnar joint. Therefore, when examining the elbow joint, all three joints and the peripheral soft tissues should be closely assessed.

If the chief complaint of a patient is elbow joint pain, take note of injury episodes, the patient’s

Identify the Cause of the • Previous injuries, occupation, medical history Problem

• Acute/chronic Observe Pain Pattern • Persistent/intermittent

• Carrying angle Observation/Palpation • Swelling, tender points • Osseous structures and soft tissues

• ROM (active/passive) compared with the unaffected side Physical Examination/ • Relevant physical examinations Neurological testing • Neurological testing

• Identify relevant meridians • Phlegm/Wind cold dampness/qi deficiency Korean Medicine Diagnosis • Five viscera heat/heart deficiency/lung heat/spleen deficiency

Refer to Radiology

[ Figure 4 ] Flow chart of Korean Medicine diagnosis process of elbow joint pain patients

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occupation, and the history of relevant conditions to determine the cause of the problem. Acute pain of the lateral/medial elbow is highly correlated with exercises, such as golf or tennis. Chronic pain is associated with repetitive use. Occupational environment in which the wrist joint is frequently used is a risk factor. When inspecting and palpating the area, check for swellings or pressure pain points. If pressure triggers pain, re-evaluate the area to determine the cause of the pain. Perform appropriate physical examinations or neurological tests for diagnosis. If necessary, refer the patient to radiological test. Rotator Cuff Disease, frozen shoulder, calcific tendinitis, thoracic outlet syndrome are the most frequent disease of elbow joint, therefore it is important for practitioners to be knowledgeable regarding the common symptoms, diagnosis, treatment, and prognosis of elbow conditions.

2. Tests

(1) Carrying Angle • A normal carrying angle is 5 degrees in males and 10-15 degrees in females. Women have larger carrying angles.

(2) ROM • Flexion: 135 degrees/Extension: 0 degrees in males and 5 degrees in females. Females often present with hyperextension. • Measure with the elbow joint flexed at 90 degree angle and the elbow held against the torso. The normal range of motion is 90 degrees.

(3) Muscle Strength Test and Neurological Tests • Flexion (muscles of the humeroradial articulation, biceps brachii), extension (triceps brachii), supination (supinators), and pronation (pronators) • Deep tendon reflex (biceps brachii: C5, tendons of the humeroradial articulation muscles: C6, triceps brachii: C7)

(4) Wrist extension test and Finger extension test • Inversion and eversion stress tests: Tinel sign, Egawa sign • Inversion and eversion stress tests: Used to determine instability of the medial and lateral

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collateral ligaments. • Tinel sign-positive: Cubital tunnel syndrome/Egawa sign-positive: Ulnar nerve palsy * Points to consider when swelling is identified • Local swelling of the subcutaneous layer: Typically bursitis • Overall swelling of the entire joint: Typically fractures of the humerus or compression injuries of the elbow joint.

3. Treatment

Acute pain in the elbow joint is typically a result of inflammation. Treat the symptoms first. For Korean Medicine treatment, diagnose the patient as one would for shoulder joint problems, and use similar prescriptions. Modified ‘Soothe the Channels Decoction’ is effective.

(1) Medial/lateral epicondylitis: Lateral epicondylitis responds well to bee venom injections at the site of the pain and relevant acupoints. Additional acupuncture to the affected area, as well as relevant meridians, may contribute to treatment outcomes. If treatment outcomes are not favorable, re-examine to identify aggravating factors that may prevent the joint from recovery. Remind the patient to refrain from such activities aggravating recovery. For the treatment of persistent cases, high-dosage bee venom and acupuncture applied to relevant meridians are more effective than local acupuncture alone. Treatment for medial epicondylitis is predominately the same as lateral epicondylitis treatment; however, the prognosis is less favorable. The patient should be informed of these differences. (2) Bursitis: If no special causes are identified, the prognosis is favorable for the condition to disappear naturally. Of the treatments available in conventional medicine, steroid injections are effective. For Korean Medicine treatment, bee venom should be considered first, as well as herbal medicines prescribed according to each constitution. Pain control and the prevention of recurrence are important for patients after a treatment. In these cases, bee venom treatment and herbal medicines that treat blood stagnation are helpful. However, note that redness and fevers during the acute stages may be a sign of infection. In this case, refer to conventional diagnosis in advance. In the case of chronic bursitis, if the synovial fluid is thick and the prognosis is unfavorable, surgery should be considered as an option.

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(3) Cubital tunnel syndrome: Painkillers, avoidance of aggravating activities, fixation of the joint during sleep, and other conservative treatment are effective for more than 50% of cases. If no weakness is identified, acupuncture and bee venom treatment may be applied. If there are motor function problems, a conventional diagnosis to determine the need for operative care is needed. If the initial pain in a medial and lateral epicondylitis patient has subsided, active exercises aimed at reinforcing muscles are important. At this time, ‘Surrounding Celestial Bodies Elixir’, ‘Muscle and Bone Pill’, and other medicines that fortify the liver and kidney and reinforce muscles and bones facilitate tissue healing, which provides a treatment for the cause.

4. Prevention and Management

All elbow conditions, particularly lateral and medial epicondylitis, should be subject to rest in the early stages. All activities that aggravate the symptoms and therefore interfere with proper treatment should be avoided. Computer tasks, cooking, knitting, and other activities that require repetitive motions of the wrists and hands should be strictly prohibited. After pain has been alleviated to some extent, exercises to reinforce wrist extension muscles should be performed.

Disorders of the Lumbar Spine

1. Diagnosis

Evaluate the postural balance with the patient in a supine position with the Four Di- agnosis, including observation and palpation. If sensory or motor deficits are present or symptoms appear to reflect specific conditions, perform physical examinations and/or refer to further tests. Radiological tests are recommended if conservative care appears to be ineffective or there are red flags or yellow flags that are unusual, such as neurological symptoms. These tests are frequently false positives; thus, an assessment of patient history and physical examinations are important.

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• Onset (time, situation) Evaluate Condition • Gait and posture

• Pain patterns, aggravating/alleviating factors Observe Patterns of Pain and • Radiations, if any Relevant Symptoms • Other relevant symptoms (fever, chills)

• Weakness, numbness, sensory abnormalities Neurological Signs • Loss of bladder or rectum control

• Bony landmarks (shoulder, scapula, lower back) • Protrusions of the rib cage and lower back in flexion Observation/Palpation • Motion of intervertebral joints, spinous process movements • Ligaments, muscles, vertebral foramina, nerve roots

• ROM Physical Examinations • Physical examination/neurological testing

• Kidney-deficiency/phlegm/food stagnation/blood stagnation Korean Medicine Diagnosis • Wind Cold Dampness/Heat/qi

Radiological Testing

[ Figure 5 ] Flow chart of Korean Medicine diagnosis process of lumbar pain patients

The primary point of consideration when approaching Lower Back Pain (LBP) is to treat the cause of the problem. For all types of lower back pain, including nonspecific lower back pain, it is important to reinforce the paraspinal muscles.

2. Tests

(1) ROM • Flexion: In a standing position, fully extend the knee joints, flex the lumbar spine, and measure the distance from the finger tips to the floor. • Extension: If radiation is aggravated in extension, suspect lumbar spinal stenosis. • Side bending: Compare the maximum side flexion angles of both sides. Record the rotation angles.

(2) Other tests • Spinous process tap test: If pain is elicited on tapping the spinous process, fracture and

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inflammation of the spinous process fracture should be suspected. If pain is elicited on tapping the paravertebral muscles, strains should be suspected. • Nerve root injury tests: Straight leg raise tests, femoral stretch tests, and heel walk. • Testing for sciatica: Lasegue’s Test, Bragard’s test. • Testing for space-occupying lesions: Valsalva’s maneuver, Milgram’s test. • Ankylosing spondylitis tests: Schöber test.

As is true for disorders of the cervical spine, a history assessment is the most important part of the diagnosis. Subjective symptoms described by patients and objective signs should be combined for a differential diagnosis. Radiological findings and electromyograms should be interpreted with consideration of the patient’s history and physical examination results.

3. Treatment

(1) Treatment of the symptoms and the causes

When treating patients with lower back pain, it is most important to determine the chronicity of the condition and whether there are underlying problems compared with nonspecific lower back pain. Determine the symptoms and causes using a Korean Medicine diagnosis. Acute nonspecific lower back pain occurs as a result of injuries such as the impaired the muscles and ligaments, incorrect posture, or overexercise. Chronic nonspecific LBP is a result of prolonged exposure to various factors, including occupational factors, lack of exercise, unhealthy habits, and emotional stress.

❶ Acute nonspecific lower back pain: Prognosis is favorable, and 80% of patients recover within 6 weeks regardless of the type of treatment. For the first 2 days of severe pain and decreased mobility, absolute bed rest (only restroom use allowed) is helpful. In the early stages of treatment, bee venom and subcutaneous acupuncture on tender points, wet cupping, and local and distal acupuncture have dramatic effects. For Korean Medicine treatment, identify the causes of the problem, such as distortion, blood stagnation, cold, and dampness. Prescribe appropriate acupuncture and herbal medicine. Distortion-type LBP responds well to ‘Angelica Pubescentis Decoction’, blood stagnation LBP responds to ‘Five Accumulations Powder’, ‘Peach Pit Order the Qi Decoction’, ‘Four-Substances

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Decoction’ with Persicae Semen, Sappan Lignum, and Carthami Flos, and cold dampness-type LBP responds to modified ‘Five Accumulations Powder’. ❷ Chronic, nonspecific lower back pain: The ultimate goal of treatment is to strengthen the muscles that support the lumbar vertebrae. Core exercise, swimming, walking, and hik- ing help strengthen the muscles around the spine. To restore motor function, continuous bee venom and Chuna treatment are necessary. If there are underlying conditions that may affect the lower back, such as kidney deficiency, prescribe appropriate medications to relieve this condition. ❸ Discogenic Lower Back Pain (DLBP): If injuries or degenerative changes of the intervertebral discs trigger chronic pain in the lower back, it is considered discogenic pain. The pain is typically affected by movement (aggravated when sitting, alleviated when lean- ing). In contrast to pain in the central lower back, the pain is similar to the pain of nerve root problems. In some cases, radiations are identified behind the thighs. If no symptoms are present, treatment is not needed. Absolute bed rest is recommended in the early stages. Treatment is similar to the previously described treatment for lower back pain. ❹ Lumbar disc herniation: Symptoms include lower back pain and radiating pain observed along the affected nerve root. Lower back pain and radiating pain can be alleviated naturally over time, regardless of the type of treatment received. Therefore, if there is not an absolute indication for surgery, conservative care should initially be implemented. In general, for acute pain, 2 days of rest is helpful. When pain is reduced, initiate an appropriate exercise that helps stabilize muscles and increase flexibility. In the early stages of treatment, local acupuncture, electroacupuncture, herbal medicine, and distal acupuncture on relevant meridians may be considered. Bee venom and acupuncture are particularly effective when used on appropriate acupoints and Hyeopcheok (Jiaji). Stimulation of distal points, such as ST36, ST37, ST39, and SI3, is also effective. If tender points are identified in the hip, thigh, or shin areas, blood-letting is recommended; ‘Five Accumu- lations Powder’, ‘Great Nutrition Decoction’, or ‘Six-Ingredients Pill with Rehmannia’ may be prescribed. ❺ Lumbar spinal stenosis: When the spinal nerve canal is narrowed, physical stress is exerted on nerves. Hindered blood circulation as a result of the compression causes pain, radiating pain, motor deficits, and other problems related to gait. It is preferable to begin with

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conservative care; however, if the prognosis appears unfavorable or an operation may be needed, refer the patient to further diagnosis and evaluation for physical examinations, neurological tests, and treatments received prior to this visit for review. The treatment goal should be to improve gait. Appropriate treatments should be selected. ❻ In Korean Medicine, the primary cause of lower back pain is kidney deficiency. There- fore, prescriptions based on ‘Six-Ingredient Pill with Rehmannia’ are used. ❼ In the case of phlegm-type lower back pain, which is distinguishable by the slippery pulse (脈滑), and dark circles under the eyes, prescribe ‘Decoction of Two Aged Drugs’, or ‘Chuanxiong and Pinellia Decoction’. Patients with food damage should be prescribed a combination of ‘Four-substances Decoction’ and ‘Decoction of Two Aged Drugs’. Patients who have dampness heat or stomach heat should be prescribed ‘Two Marvels Atractylodes and Phellodendron Powder’ for the excessive-type and ‘Angelica Pain Re- lief Decoction’ for the yin deficient-type. If qi stagnation as a result of emotional stress is causing the pain, prescribe ‘Aquilaria Decoction for Directing Qi Downward’. ❽ If the causes by each constitution are obvious, consider these issues when prescribing herbal medicine. Soyangin responds favorably to Hyungbangjihwang-tang (‘Rehman- nia Decoction with Schizonopeta and Ledebouriellia’, 荊防地黃湯) and Dokhwal- jihwang-tang (‘Decoction of Rehmannia with Angelica Pubescentis’, 獨活地黃湯). Soeumin responds better to Hyangsayangwi-tang (‘Auckandia and Amomum Decoction for Nuturing Stomach’, 香砂養胃湯), Bojoongikqi-tang (‘Tonify the Middle and Aug- ment the Qi Decoction’, 補中益氣湯) or Gwangyebujaijoong-tang (‘Decoction for Regu- lating the Middle with Cortex Cinnamomi and Radix Aconiti Lateralis Praeparata’, 官桂附子理中湯). Taeeumin may be treated with Jowiseungcheong-tang (‘Decoction for El- evating the Clean Yang through Regulating Stomach’, 調胃升淸湯) or Yeoldahanso-tang (Decoction for greater heat and lesser cold, 熱多寒少湯).

(2) Conservative care for pain alleviation Eighty percent of acute lower back pain improves within 1-2 months. Before natural healing occurs, many methods are used to help alleviate the pain. This includes conservative care or non-surgical treatment.

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• Effective for the first 2-4 days; however, prolonged bed rest does not help. Bed Rest • The best resting position is that in which the patient feels most comfortable.

• Non-Steroidal Anti-Inflammatory Drug (NSAIDS) are the most frequently prescribed. Medication • Effects of muscle relaxants have not been proved yet by evidence. • Steroids may be effective for short-term pain control; however, the use of steroids is not recommended due to adverse events.

• Cold packs help reduce swelling and control muscle spasms; effective for acute pain. Physical Therapy • Hot packs help circulation and increase flexibility, effective in chronic pain. • Traction may help acute pain; however, it is not recommended for chronic pain.

• Back Brace should only be worn for a short period of time. Back Brace Prolonged use may cause the muscles around the spine to weaken.

• Injections of anti-inflammatory agents (steroids) to the nerve root area. Pain • Pain is reduced as inflammation is controlled. • Steroids may develop side effects. Long-term use is not recommended.

Exercise * Refer to the management section below.

[ Figure 6 ] Flow treatment of low back pain patients

4. Prevention and Management

To prevent disorders of the lumbar region, treat pre-existing problems, or prevent recurrence, inform the patient of the habits they should refrain from. To treat the cause of the disease, exercise is important. The patient should understand this importance. The lumbar spine is supported by the vertebral pillar (vertebrae, discs, and ligaments) and supporting tissues (muscle). The goal of exercise treatment is to reduce the strain on the pillar by reinforcing the muscles. Exercise should begin as soon as pain is alleviated. For optimal results, 1-2 hours of daily exercise is recommended for at least 6 months.

139 PART 2 Korean Medicine Treatments for Various Medical Conditions

Disorders of Knee Joint

1. Diagnosis

Patients who present to a Korean Medicine clinic for a knee problem typically do so because of pain. A history assessment is the most important component for the diagnosis and treatment of knee conditions. Injuries inflicted to the area, occupation, hobbies, family history, and other causes that may cause symptoms of the joints should be determined. The exact site of the pain, conditions that aggravate the pain, characteristics of the pain, and onset should be part of the history assessment. Information regarding the causes, conditions, and suitable treatment methods may be collected. It is important to note the chief complaints and the patient’s needs prior to commencing the treatment procedures. The goals of the treatment should be to treat the chief complaints for a satisfying treatment result. Pay an attention to the symptoms described by

• Previous injuries History Assessment • History of stress exerted on joint • Onset

• Onset (time and place) Pain Patterns • Activities that aggravate pain • Factors that aggravate pain

• Gait, lower limb alignment Observation • Swelling, edema, muscle atrophy • Swelling/edema of the lower extremities

• Knee joint (clicking) Palpation • Tender points around the joint • Ligaments, muscles, nerves

Physical Examinations/ • ROM of both joints Neurological Tests • Physical examination/neurological testing

• Liver/Kidney deficiency/Frustration/Food accumulation/ Wind Cold Dampness Korean Medicine Diagnosis • Beriberi Flaccidity of lower limbs/Wi Syndrome/Gwol Syndrome/Crane’s Knee

Refer to radiology

[ Figure 7 ] Flow chart of Korean Medicine diagnosis process of knee joint pain patients

140 Musculoskeletal Diseases chapter 1

the patient, and then use the Four Diagnosis and appropriate physical examination or neurological tests for a thorough diagnosis. It is also important to refer to radiological findings for a differential diagnosis and to determine prognosis.

2. Tests

• Lower limb alignment tests: O-shaped legs, X-shaped legs • Range of motion (bilateral) * Observe differences of maximum extension (bilateral) * Maximum flexion (bilateral) (If patient can kneel on the floor, the patient may be considered to have full range of flexion) • Patella tests: Grinding test • Knee stability tests * Anterior cruciate ligament injury (Lachman test, Anterior drawer test, Pivot-shift test) * Posterior cruciate ligament injury (Posterior drawer test, Posterior sagging) * Medial/lateral ligament injury (Varus stress test, Valgus stress test) • Meniscus injury tests * McMurray test, Apley test • Red Flags * Neurovascular injury (high-velocity injuries, loss of pulse, foot drop, and weaknesses of varying severities) * Extensor injuries: Unable to perform Straight Leg Raising (SLR), gapping of tissue, changes in patellar levels * Infection (severe pain accompanied by severe fevers, previous history of medicine abuse) * Internal bleeding and tumors (previous history of tumors, persistent severe pain, nocturnal pain) • If any of these signs are observed, precise diagnosis and evaluation are necessary.

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3. Treatment

When treating knee joint conditions, once the acute symptoms of pain and inflammation have subsided, the five viscera and six bowels should be treated because they are perceived to be the “root of all extremities”. Soft tissues that support the joint, such as muscles, tendons, and ligaments, as well as bony structures and cartilages should be reinforced for a complete treatment. Prior to treatment initiation, the meridian that is relevant to the condition should be determined. Knee pain is typically relevant to the stomach meridian, and medial pain is associated with spleen, liver, and kidney meridians, whereas lateral pain is associated with the gallbladder meridian. These meridians may be stimulated with acupuncture. Moreover, in Korean Medicine, diseases of the knee joints are affected by direct injuries of the joint and surrounding soft tissue as well as by external factors, such as wind, cold, and dampness; food and other internal factors; and emotional factors. It is therefore important to thoroughly diagnose the condition. When diagnosing the patient, the the Four Diagnosis, as well as physical examination or neurological/radiological tests should be conducted.

(1) Degenerative Arthritis: Degenerative arthritis is a condition of the joint where the cartilages are degenerated, and bone spurs have formed. Calcification of the subchondral bone also occurs. Conditions described in Korean Medicine similar to degenerative arthritis of the knee are the Crane’s knee wind, impediment syndrome, joint wind, and Beriberi Flaccidity of lower limbs. Disorders of the knee, injuries, and mechanical stress exerted on the knees may cause degenerative arthritis. The main symptoms are pain and impaired motor function. If the chief complaint is pain, carefully observe the area of the pain and subsequently treat the patient with bee venom and/or acupuncture. It is also effective to stimulate acupoints on the meridian that are relevant to the area of the pain. For herbal medicine, ‘Great Notopterygium Decoction’ is recommended for the pain in the early stage and inflammation. For more chronic conditions, prescribe modified ‘Three Qi Drink’, ‘Great Ledebouri- ella Decoction’, ‘Notopterygium Meritorious Life Decoction’. Moxibustion may be applied to dentures around the knee joint. If there are prominent deficiencies or excesses of the viscera and bowels or constitutional problems, combine Sa-Am or constitutional acupuncture. Herbal medicines should be prescribed to reinforce viscera and bowel functions and compensate for constitutional shortcomings.

142 Musculoskeletal Diseases chapter 1

(2) Knee Joint Bursitis: A condition in which inflammation of the bursa around the knee joint causes pain and swelling. Acute injuries and chronic repetitive use are the most common causes; however, the possibility of infections should be also considered. Bursitis is a subtype based on the area and characteristics of the symptoms. Several prevalent types include anterior knee joint bursitis, pes anserine bursitis, and medial ligament bursitis. Convention- al care consists of suction of the exudates or steroid injections if it is a result of injuries. If there are infections, administer antibiotics after sufficient lab tests and antituberculous agents if tuberculosis is diagnosed. In some cases, incisions and other operations may be needed. If infection is suspected, it is important to refer to appropriate tests as soon as possible. Bursitis as a result of injuries responds well to bee venom injected into pressure points and the bursa. Regarding herbal medicine, prescribe medicines that clear heat and detoxify, dispel dampness heat, tonify qi and tonify water.

4. Prevention and Management

In the acute stages, rest is needed. Overall activity and weight bearing should be avoided. Crutches or canes may be used if needed. During the recovery period, exercises to strengthen the quadriceps femoris and hamstrings are recommended. Leg exercises that involve raising the leg without weights are helpful for arthritis patients because these exercises minimize the weight burden. Weight bearing exercises are recommended for rehabilitation from sports injuries. Swimming and cycling are recommended because these activities strengthen muscles around the knee joints without an excessive impact. Knee-orthosis may be used accordingly; however, they are not substantially effective for arthritis and are more for chondro- malacia of the patella or mild ligament injuries.

143 PART 2 Korean Medicine Treatments for Various Medical Conditions

Disorders of Foot Joint

1. Diagnosis

The foot joint consists of the talocrural articulation (joint with a joint capsule) and inferior tibiofibular joints (joints without joint capsules), as well as the subtalar joint, which consists of 3 joints. Anatomical structures of the foot as well as prevalent conditions of the foot joint should be fully understood prior to the initiation of treatment.

Patients who present to Korean Medicine clinic mostly do so for foot joint sprains, plantar fasciitis, and calcaneal bursitis. The patient may present with a wide range of symptoms; however, the chief complaint is likely to be pain. It is important to record the exact characteristics of the pain. For diagnosis, consider the phases of gait, and observe the gait of the patients from the moment they walk into the office. It helps to observe differences in symptoms when walking with and without shoes. The first step of treatment should involve palpating for tender points.

• Previous injures, site of pain History Assessment • Previous treatments (e.g., medications, operations) • Shoes

• Acute/chronic • Aggravating/alleviating factors Evaluate Symptoms • Local/radiating pain • Pain intensity

• Gait and appearance of feet • Swellings/tender points Observation/Palpation • Tarsal tunnel • Ligaments

Physical Examinations/ • ROM (active/passive) compared with the unaffected side Neurological Testing • Physical examinations

• Liver kidney-deficiency/Wind, Cold, Dampness/Blood Korean Medicine Diagnosis stagnation • Food damage/five viscera heat/stomach heat

Refer to Radiology

[ Figure 8 ] Flow chart of Korean Medicine diagnosis process of foot joint pain patients

144 Musculoskeletal Diseases chapter 1

Then, evaluate movements, muscle strengths, and stability to determine the severity of the condition, which is followed by the initiation of treatment. Patients with repeated injuries should be prescribed with medications to help strengthen the tissues around the joint after symptoms have alleviated. Adequate exercise is necessary to prevent recurrence.

2. Tests

(1) Walking Initial contact, mid-stance, and heel lift

(2) ROM Comparison of flexion, extension angles with the unaffected side/inversion, eversion (5 degrees)/adduction, abduction/ big toe flexion (30-40 degrees)

(3) Muscle strength tests Plantarflexion (gastrocnemius, soleus), dorsiflexion (tibialis anterior), inversion (tibialis posterior), and abduction (peroneus longus/brevis)

(4) Stability tests Protrusion tests, retrusion tests, medial instability tests, and lateral instability tests

(5) Special tests Tinel’s sign, Thompson’s Tests, Achilles tendon tap tests, and Morton’s syndrome tests

3. Treatment

The most common condition of the foot joint is foot joint sprain and plantar fasciitis. In the earlier stages, when pain and inflammation are the chief complaints, treat the symptoms. In the more chronic stages or when recurrence is frequent, treat both the symptoms and the causes by reinforcing the soft tissues around the joint.

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(1) Ankle Joint Sprains: As the most common injury of the foot joint, ankle joint sprains are injuries to the lateral ligaments (anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament) caused by varus stress. If the medial ligaments are injured, fractures of the lateral foot joint are common. Single injury is rare, and most injuries are accompanied by instability of muscles around the joint. The symptoms include pain, pressure pain, and edema. If fracture is suspected (Ottawa ankle rule), refer to X-ray. For treatment, comply with RICE (the Rest, Ice, Compression and Elevation) criteria. For degree 1 sprains, observation and simple compression bands are recommended. For degree 2 sprains, 3-4 weeks of splints and simple compression bands and early commitment to exercise are recommended. For degree 3 sprains, 4-6 weeks of a cast is recommended. Degree 1 and 2 sprains respond well to bee venom and acupuncture on the tender points and acupoints around the injured area. ‘Angelicae Gigantis Root Powder’ and ‘Invigorate the Channels Decoction’ may be prescribed to facilitate pain control and dissipate blood stagnation. Blood-letting is more effective for more chronic cases in which edema or tenderness has not subsided even after treatment in the acute stages. For degree 3 sprains, residual pain/ muscle spasms after cast splints are subject to acupuncture treatment. (2) Plantar Fasciitis: When the plantar fascia is repetitively injured, the collagens that constitute the fascia are degenerated and inflamed. In Korean Medicine, this state is perceived to be a state of spleen and kidney yin deficiency. The main symptoms include progressive pain at the heel region of the sole, where the plantar fascia attaches. The pain is aggravated in the morning or after walking. The pain is also aggravated when walking upstairs or extending the toes. For treatment, the fascia at the region of pressure pain should be treated with bee venom, local acupuncture, and electroacupuncture. The spleen, kidney, and bladder meridians are associated with plantar fasciitis. Stimulate the transport points of these meridians for better effects. Herbal medicines may be prescribed to help alleviate symptoms; however, it is more effective to prescribe medicines that treat the cause of the pain, as diagnosed by Korean Medicine principles. Jaeumganghwa-tang (‘Decoction to Tonify Yin and Direct Fire Downward’, 滋陰降火湯), Jibaekjihwang-tang (‘Rehmannia Decoction with Anemar- rhena and Phellodendron’, 知栢地黃湯), or Yookmijihwang-tang (‘Six-Ingredient Pill with Rehmannia’, 六味地黃湯) may be considered for use. Because stomach heat and kidney yin deficiency may cause plantar fasciitis in Soyangin. Yanggyuksanhwa-tang (‘Decoc- tion for Cooling the Diaphragm and Dispersing Fire’, 凉膈散火湯), Hyungbangsabaek-san

146 Musculoskeletal Diseases chapter 1

(‘Powder for Expelling Lung-Heat with Schizonopeta and Ledebouriellia’, 荊防瀉白散) or Hyungbangjihwang-tang (‘Rehmannia Decoction with Schizonopeta and Ledebouriellia’, 荊防地黃湯) may be prescribed depending on the relative severity of stomach heat and kidney yin deficiency.

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149 2016 Korean Medicine: Korean Medicine Current Practiceof 2016 Korean Medicine Current Practiceof

CHAPTER 2

Cardiovascular and Neurological Diseases

▼ Woo Sang Jung PART 2 Korean Medicine Treatments for Various Medical Conditions

chapter 2

Cardiovascular and Neurological Diseases

Introduction

In Korean Medicine, the five viscera (五臟) do not refer to just the anatomical organs but to physiologically interrelated units. Therefore, cardiac internal medicine not only focuses on the heart itself, but the heart as a functional unit that is part of a five phase system. In other words, cardiac internal medicine focuses on the characteristics and roles of viscera and bowels and other organs that pertain to fire. Any pathogens, disease mechanism, diagnosis, and treatment for relevant diseases are points of interest.

The function of the heart is explained by two famous quotes, “the heart controls the blood vessels” and “the heart controls the spirit and will”. The former refers to the cardiovascular aspect of the heart, whereas the latter refers to the neurological aspect of the heart. Cardiac internal medicine encompasses disorders and diseases of the heart and the overall cardiovascular system, including blood pressure abnormality, stroke, and other neurological diseases.

Stroke

1. Diagnosis

If there are any of the following premonitory symptoms, stroke should be suspected.

152 Cardiovascular and Neurological Diseases chapter 2

(1) Main Symptoms

• Symptoms of impaired consciousness: Fainting, stuporous mentality, semi-coma, coma, and loss of vitality • Symptoms of motor disorder: Hemiplegia, hemi-wasting, facial nerve palsy, and limb spasticity • Symptoms of verbal disorder: Acute aphasia, dysarthria, tongue palsy, dysphasia, loss of voice, stiffness of the tongue and dysarthria • Symptoms of sensory disorder: Hemi-paresthesia and limb paresthesia

(2) Accessory Symptoms

• Headache, dizziness, facial flushing and hyperemia, chest discomfort and anxiety, hema- turia and dry stool, constipation, abdominal bloating, nausea, vomiting, sputum, general weakness, sweating, palpitation, loose stool, limb edema, insomnia, dizziness and tinnitus, hot sensations in the palms and soles, neck stiffness and fever, restlessness, limb coldness, sweating of the palms and soles and incontinence.

2. Diagnosis

• Chest X-ray • Electrocardiography (ECG) • Blood test • Urinalysis • Vascular examination - Transcranial Doppler sonography (TCD) • Brain imaging: CT or MRI [ Figure 1 ] cerebral hemorrhage cerebral infarction

3. Treatment

(1) Fire Heat Pattern

• Symptoms: Hemiplegia or an inability to speak properly due to facial nerve palsy. Symp-

153 PART 2 Korean Medicine Treatments for Various Medical Conditions

toms worsen when the patient becomes angry. Headache and vertigo may also be present. The patient experiences chest discomfort such that the chest feels as if it is full. Fever may be present. The patient experiences difficulty in sleeping, and the mouth feels dry with or without aphthous ulcers. The patient’s hands and feet may feel hot or they may become thirsty for cold water. Constipation may be present and their urine becomes darker. The patient’s tongue appears red with yellowish black tongue fur and the pulse feels surging and fast. • Treatment Method: Clear heat and purge fire • Herbal Medicine: ‘Ledebouriella Powder that Sagely Unblocks’ (防風通聖散), ‘Clear Heat and Guide Out Phelgm Decoction’ (淸熱導痰湯), ‘Clear the Lung and Drain the Liver Decoction’ (淸肺瀉肝湯), ‘Augmented Heart Clearing Decoction’ (加味淸心湯), and ‘Decoction for Cooling the Diaphragm and Dispersing Fire’ (凉膈散火湯)

(2) Dampness Phlegm-Type

• Symptoms: Hemiplegia or an inability to speak properly due to facial nerve palsy. Sputum interferes with normal breathing. The patient often complains of a heavy sensation in the head and is often lethargic. Tongue fur is thick and the pulse is slippery. • Treatment Method: Dispel dampness and eliminate phlegm • Herbal Medicine: ‘Dispel Wind and Eliminate Dampness Decoction’ (祛風除濕湯), ‘Guide Out Phlegm Decoction’ (導痰湯), ‘Pinellia, Atractylodes Macrocephala and Gastrodia Decoction’ (半夏白朮天麻湯), and ‘Augmented Decoction for Facilitating Speech’ (加味解語湯)

(3) Blood Stagnation Pattern

• Symptoms: Hemiplegia or an inability to speak properly due to facial nerve palsy. Certain areas of the head are constantly painful and hot. The patient’s under-eye regions become dark, the complexion seems dark, and the lips may appear bluish black. These types of patients do not drink water even when they are thirsty. Chest pain may be severe. The pulse feels rough. • Treatment Method: Activate blood and resolve stasis

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• Herbal Medicine: ‘Decoction for removing blood stasis in the blood mansion’ (血府逐瘀湯), ‘Guide Out Phlegm and Invigorate Blood Decoction’ (導痰活血湯), and ‘Eliminate Wind and Invigorate Blood Decoction’ (疏風活血湯)

(4) Qi Deficiency Pattern

• Symptoms: Hemiplegia or an inability to speak properly due to facial nerve palsy. The patients experience a subtle, persistent headache that worsens when they are tired. Vertigo and tinnitus are common symptoms and the patient’s complexion seems somewhat pale. Cold sweat may be present. These types of patients feel lethargic and want to lie down. They have little or no appetite. The tongue is bland and the pulse feels somewhat weak. • Treatment Method: Tonify qi and activate blood; tonify and replenish spleen • Herbal Medicine: ‘Tonify the Middle and Augment the Qi Decoction’ (補中益氣湯), ‘Ton- ify the Yang to Restore Five Decoction’ (補陽還五湯), ‘Tonify Qi and Invigorate blood Decoction’ (益氣活血湯), and ‘Tonify Qi and Guide Out Phlegm Decoction’ (益氣導痰湯)

(5) Yin Deficiency Pattern

• Symptoms: Hemiplegia or an inability to speak properly due to facial nerve palsy. The patient’s eyes are bloodshot and the mouth feels dry. Although these patients are hungry, they do not have an appetite. Fever occurs in the afternoon and heat in the palms and soles. Stuffiness in the chest keeps the patient from sleeping. Cold sweat may break out during the night. The tongue is thin, red, and dry, the surface of the tongue is like a mirror, and the pulse is thin and fast. • Treatment Method: Tonify yin and clear heat; nourish yin and extinguish wind • Herbal Medicine: ‘Rehmannia Drink’ (地黃飮子), ‘Great Tonify the Yin Pill’ (大補陰丸)

4. Recent findings

Treatment methods for stroke have been discussed as far back as Han Dynasty. Pre- scriptions of the Golden Chamber (金匱要略), the book by Zhang Zhongjing (張仲景), discusses treatment and herbal medicine for stroke. Stroke has been discussed in all Korean Medicine

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literature since that time. Therefore, stroke has been a point of interest in Korean Medicine for generations. Herbal medicine has been created and used for generations. Researches have supported the use of Korean Medicine to treat stroke.

In the early stages of stroke, herbal medicine is prescribed to prevent cerebral edema by stimulating qi and blood circulation. ‘Clear the Lung and Drain the Liver Decoction’, and ‘Decoc- tion for Cooling the Diaphragm and Dispersing Fire’ are prescribed, all of which had significant effects on patients with acute cerebral infarction (onset within 7 days). Outcomes were measured using the NIHSS (National Institutes of Health Stroke Scale), a scale used to assess the severity of stroke, and the MBI (Modified Barthel Index), a scale used to measure motor disturbance (Jung et al., 2003; Noh et al., 1999; Ko et al., 2002). ‘Cattle Gallstone Clear Heart Pill’ was validated to have vasodilation effects that help minimize ischemic damage during acute ischemic stroke (Park et al., 1997; Kim et al., 1999). Recent findings have supported the use of herbal medicine for stroke comorbidities, including ‘Peony and Licorice Decoction’ for numbness in the extremities (Jung et al., 2004), ‘Major Construct the Middle Decoction’ for enteroplegia after stroke (Lee et al., 1998), ‘Eight Ingredient Rectify Powder’ for cystitis (Jung et al., 1998; Noh et al., 1999), and ‘Bupleurum, Balloon Flower Root, and Pinellia Decoction’ for pneumonia (Leet et al., 1999).

5. Prevention

Cerebral infarction is a refractory condition with a 10-15% of 1-year recurrence rate and a 25-30% of 5-year recurrence rate. The preventive measures provided by conventional medicine are usually prescriptions of antiplatelet agents such as aspirin and Plavix. The mechanism of action of these antiplatelet agents is to hinder hemostasis and prevent blood vessel blockage. However, these approaches have only been shown to be successful in 15-20% of patients. Antiplatelet agents may interfere with normal hemostasis and cause adverse events, such as bleeding, dyspepsia, hepatic failure, and rashes. ‘Clear the Blood Pill’ (淸血丹) is used to clear or purify the blood. Previous studies have validated the anti-cholesterol effects and anti-inflammatory effects of ‘Clear the Blood Pill’ (Park et al., 2005; Ko et al., 2013; Jung et al., 2010; Nam et al., 2009). In recent clinical studies, a 2-year recurrence rate of stroke was report-

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ed to be 2.0% in patients treated with ‘Clear the Blood Pill’. This rate was 8.2% less than the control group (antiplatelet agent) (Cho et al., 2008). These effects of ‘Clear the Blood Pill’ may be attributed to the antioxidant and anti-atherosclerotic effects of Radix Scutellariae (黃芩), Coptidis Rhizoma (黃連), and Phellodendri Cortex (黃柏), herbs included in the prescription. The neuroprotective effects of Berberine ((included in Radix Scutellariae (黃芩)) and Crocin/ Genipin ((included in Fructus Gardeniae (梔子)) have been validated to be the key ingredients that are responsible for these effects.

Parkinson’s Disease (Syndrome)

1. Diagnosis

Parkinson’s disease is a progressive degenerative condition of the nervous system. Symptoms include tremor, rigidity, slowed movement, and postural abnormality. Tremor usually begins at the extremities and sometimes the chin, tongue, or lips. These tremors are also called “resting tremors” as they are observed when the patient is at rest. Parkinson’s disease is considered a cause of a deficiency in the neurotransmitter dopamine. However, most cases of Parkinson’s disease are idiopathic. The causes of secondary Parkinson’s disease include medicines (phenothiazine, reserpine, and haloperidol), head injury, exposure to carbon monoxide, and encephalitis. Tremor, rigidity, and bradykinesia are the main symptoms. Phonological disorder and dysphagia are also common symptoms. The movement of the facial muscles is also hindered, causing masked face.

2. Treatment

(1) Liver and Kidney

• Symptoms: Vertigo and tinnitus are common symptoms. The patient have many dreams. Low back pain and sensory loss in the extremities are common symptoms. Dementia and amnesia are often present. The tongue is red with little tongue fur. The pulse feels thin and string-like, or sunken, thin, and string-like.

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• Treatment Method: Nourish and replenish the liver and kidneys; nurture yang and extinguish wind • Herbal Medicine: ‘Great Tonify the Yin Pill’ added to ‘Six-Ingredients Pill with Rehman- nia’ (大補陰丸合六味地黃湯), and ‘Major Arrest Wind Pearl’ (大定風珠)

(2) Qi and Blood Deficiency

• Symptoms: The complexion appears unhealthy, patient feels lethargic and dizzy. The tongue is swollen, and teeth marks are visible or appear dark and pale. The pulse is thin and weak. • Treatment Method: Tonify qi and nourish blood, extinguish wind and activate collaterals • Herbal Medicine: ‘Eight Treasure Decoction added with Gastrodia and Uncaria Decoc- tion’ (八珍湯合天麻鉤藤飮), ‘Ginseng Decoction to Nourish the Nutritive Qi’ (人蔘養榮湯), and ‘Augmented Great Tonifying Decoction’ (加味大補湯)

(3) Phlegm Heat Engendering Wind

• Symptoms: The patient’s chest feels stuffy and uneasy. Vertigo is often present. The patient’s mouth feels dry and yellow sputum is observed. The patient perspires more than normal. The tongue fur is yellow and the pulse is string-like, slippery and fast. • Treatment Method: Clear fire phlegm and heat and extinguish wind • Herbal Medicine: ‘Restrain Liver Pill’ (抑肝丸) and ‘Guide Out Phlegm Decoction added with Gastrodia and Uncaria Decoction’ (導痰湯合天麻鉤藤飮)

(4) Acupuncture and Moxibustion

• GV20, GB20, LI04, BL67, LR02, LR03, GB34, GB39, GB41, ST36, TE03, etc.

3. Recent findings

The results of clinical studies on Parkinson’s disease have confirmed that acupuncture is an effective treatment for motor function problems, including tremor. Acupuncture was also shown to complement of levodopa and therefore helped reduce the dosage and the risks of side effects associated with levodopa. (Jiang et al., 2006; Shin et al., 2011; Lee et al., 2008).

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Acupuncture and bee venom pharmacopuncture have been reported to be significantly helpful in controlling Parkinson’s symptoms, including tremor (Cho et al., 2012). As validated in double-blinded randomized controlled trials, granulated ‘Tonify Kidney and Invigorate Blood Decoction’ (補腎活血湯) is effective for the treatment of dyskinesia, including tremor (Yang et al., 2010). In a study comparing a group treated with head acupuncture and herbal medicine with a control group (dopamine group), both the amplitude and frequency of tremor were significantly improved in both groups (Lee et al., 2013). Case reports of patients treated with ‘Gin- seng Decoction to Nourish the Nutritive Qi’ (人蔘養營湯), ‘Tonify Spleen Decoction’ (補脾湯), and ‘White Tiger Decoction with Rehmannia’ combined with acupuncture have also reported favorable outcomes for the control of tremor and other symptoms (Huang et al., 2009; Lee et al., 2002; Gok et al., 2007).

Dementia

1. Diagnosis

Dementia is defined as a state of impaired recollection, cognition, orientation, comprehension, computation, learning or linguistic abilities. Dementia may be subcategorized as Alzheimer’s dementia, a condition resulting from the degeneration of the brain, or vascular dementia that occur secondary to stroke. The impairment of cognitive skills that do not interfere with daily activities is diagnosed as a mild cognitive impairment. Symptoms include cognitive impairment, a failure to recollect, impaired judgement, a sudden loss of calculation ability, emotional incontinence, and personality change. In the case of vascular dementia, symptoms due to neurological deficits may include motor or language impairments and sensory loss. Dementia is diagnosed by evaluating the patient’s cognitive skill. Brain wave tests are only positive in progressed dementia. CT or MRI images show enlarged cerebral ventricles and/or subarachnoid areas.

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2. Treatment

(1) Sea of Marrow Deficiency

• Symptoms: Impairment of cognitive skills and the ability to recollect. The patient feels lethargic and wants to lie down. The head feels unclear and tinnitus may be present. The teeth become dry and hair is falling out. The low back feels painful and cold. Tongue fur appears bland and white. The pulse feels sunken, thin and weak. • Treatment Method: Replenish and tonify liver and kidneys; tonify the sea of marrow to improve cognition. • Herbal Medicine: ‘Great Tonify the Primal Decoction’ (大補元煎), ‘Hidden Tiger Pill’ (虎潛丸), and ‘Six-Ingredient Pill with Rehmannia’ (六味地黃丸).

(2) Spleen and Kidney Yang Deficiency

• Symptoms: Impairment of cognitive skills and the ability to recollect. The patient becomes very quiet and drools. Loss of bladder control and coldness in the extremities may be present. In some cases, the intestines may produce sound. Diarrhea is also a possible symptom. The tongue is bland and white. The pulse is sunken, thin, and weak. • Treatment Method: Replenish and tonify the liver and kidneys; replenish and tonify the spleen and kidney engender the essence to improve cognition. • Herbal Medicine: ‘Eight-Ingredient Pill with Rehmannia’ (八味地黃丸) and ‘Restore the Spleen Decoction’ (歸脾湯)

(3) Stagnated Blood

• Symptoms: Impairment of cognitive skills and the ability to recollect. The patient is easily startled or afraid and may even show abnormal behavior and cognition. Although the patient is thirsty, he or she does not drink water. The patient’s under-eye region is dark. The tongue appears burgundy in color or is spotted. The pulse is thin and rough. • Treatment Method: Activate blood and resolve stasis; open the orifices to awaken the brain. • Herbal Medicine: ‘Unblock Orifices and Invigorate Blood Decoction’ (通竅活血湯), ‘Four-Substance Decoction wih Peach Seed and Carthami Flos’ (桃紅四物湯), and ‘Cin-

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namon and Poria Pill’ (桂枝茯苓丸)

(4) Phlegm Turbidity Obstructing the Orifices

• Symptoms: Impairment of cognitive skills and the ability to recollect. Intelligence seems to be affected. The patient speaks to oneself or does not speak at all. Patients with these types of dementia do not want to eat and they cannot digest food. The tongue is bland and white and the pulse feels thin and slippery. • Treatment Method: Fortify the spleen to dissipate phlegm; clear phlegm and expel impurities to open the orifices. • Herbal Medicine: ‘Six Gentlemen Decoction’ (六君子湯), ‘Warm Gallbladder Decoction’ (溫膽湯), and ‘Pinellia, Atractylodes Macrocephala and Gastrodia Decoction’ (半夏白朮天麻湯)

(5) Heart-Liver Fire Exuberance

• Symptoms: Impairment of cognitive skills and the ability to recollect. The patient becomes hot-tempered and anxious. The patient experiences difficulty in falling asleep, as chest discomfort is present. These types of patients often quarrel with their peers. The patient’s mouth feels dry and the urine seems red. The tongue fur appears yellow and the pulse is string-like and fast. • Treatment Method: Clear heat and purge fire; tranquilize and calm the mind. • Herbal Medicine: ‘Coptis Decoction to Relieve Toxicity’ (黃連解毒湯), ‘Precious Treasure Elixir’ (至寶丹), and ‘Cattle Gallstone Clear Heart Pill’ (牛黃淸心元)

(6) Acupuncture and Moxibustion Treatment

• Main acupoints: GV14, ST36, PC6, Anmian (安眠, Extra point) • Additional acupoints ❶ Deficiency (虛證): KI03 and SP06 ❷ Blood stagnation (血瘀): ST36 and LI11 ❸ Phlegm Turbidity (痰濁): ST40 and SP6 ❹ Fire Exuberance (火盛): ST44 and LR02

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• Auricular acupuncture: Shenmen (神門), Sub-cortex (皮質下), kidney (腎), brain (腦點), occiput (枕) • Blood-letting: PC09, KI01, PC08

3. Recent findings

A systematic review and meta-analysis of studies investigating the effects of Uk- gan-san (Restrain the Liver Powder) as a treatment for the Behavioral and Psychological Symptoms in Dementia (BPSD) reported better outcomes in the ‘Restrain the Liver Powder’ experimental groups than in the control groups treated with usual care. The outcomes were measured using the Neuropsychiatric Inventory (NPI) scores. A significant improvement in symptoms (delusion, hallucination, agitation or aggression and other aspects of daily life) was observed (Matsuda et al., 2013). A systemic review of Randomized Controlled Trials (RCTs) has confirmed the effects of acupuncture on Alzheimer’s disease (Lee et al., 2009). Herbal medicines prescribed for Alzheimer’s disease were safer and more effective than single herb or cholinesterase inhibitors (Man et al., 2008). According to a systemic review of natural products used for Alzheimer’s disease, ‘Six-Ingredient Rehmannia Pill’ is effective for the control of mild to moderate symptoms (Dos et al., 2006). Patients with vascular dementia were administered ‘Uncaria Powder (Choto-san)’ (Tsumura, TJ-47, 2.5 g) 2 hours after meals 3 times per day for 4 weeks. Significant changes in Mini-Mental State Examination (MMSE) and Basic Activities of Daily Living (BADL) scores were observed and the Geriatric Depression Scale (GDS) scores improved in 50% of the patients (Min et al., 2007). Based on case reports, Ga- mibohyul-tang (Augmented Tonify the Blood Decoction) successfully improved the symptoms of cognitive impairment resulting from subarachnoid hemorrhage and the MMSE scores were improved (Kim et al., 2012). Another investigation of vascular dementia secondary to subarachnoid hemorrhage reported that modified ‘Samoolahnshin-tang (Four-Substances Calm Spirit Decoction)’ helped improve the MMSE and Kingston Dementia Rating Scale (K-DRS) scores (Kwon et al., 2011). Patients with vascular dementia and constipation were administered ‘Chunghyulgangqi-tang (Decoction to Clear the Blood and Direct Qi downward)’, ‘Chungpes- agan-tang (Clear the Lung and Drain the Liver Decoction)’, ‘Daeshiho-tang (Great Bupleu- rum Decoction)’ and other prescriptions including Rhei Radix et Rhizoma (大黃). Favorable

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outcomes were observed in Korean MMSE (MMSE-K) and Clinical Dementia Rating (CDR) scores. ‘Jihwangbaekho-tang (White Tiger Decoction with Rehmannia), Jeoryungchajun- ja-tang (Polyporus and Plantain Decoction)’, ‘Yanggyuksanhwa-tang (Decoction for Cooling the Diaphragm and Dispersing Fire)’, and ‘Hyulboochookuh-tang (Drive Out Stasis in the Mansion of Blood Decoction)’ were also reported to be effective (Kwon et al., 2010; Lee et al., 2010; Yun et al., 2003).

A systemic review of acupuncture trials for mild cognitive impairment suggested that although no adverse events were reported, acupuncture was insufficient as a single intervention, but the MMSE scores were improved when acupuncture was combined with other treatments (Cao et al., 2013). Herbal medicines that have been prescribed for mild cognitive impairment include Hwannoeikchoong (还脑益冲) or Noeryukbo-hwan (脑力宝丸) capsules, which had better effects on the patients’ cognitive ability than were seen in the control group (Han et al., 2011; May et al., 2009). Short-term administration of herbal medicines to patients with mild cognitive impairment was equally or slightly more effective than Ginkgo biloba at improving recollection (Wang et al., 2010). A case report reported improved Korean Montreal Cognitive Assessment (K-MoCA) scores in a patient with mild cognitive impairment due to hemorrhage who was treated with ‘Boyanghwanoh-tang (Tonify the Yang to Restore Five Decoction)’ (Oh et al., 2015).

Ischemic Heart Disease

1. Diagnosis

Ischemic heart disease is a condition in which cardiac problems arise due to decreased blood input through the coronary arteries. Angina pectoris, myocardial infarction, sudden death, and cardiac failure are common clinical presentations of ischemic heart disease. Angina pectoris is a reversible condition that results from a temporary blood supply deficiency. The duration of chest pain is relatively short, and physical activity and emotional change may contribute to its onset. Rest and sublingual administration of appropriate medications (nitroglyc- erin) alleviate symptoms. Myocardial infarction is a condition resulting from obstructions of the

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coronary artery that lead to irreversible changes called myocardial necrosis and are accompanied by severe chest pain and eventually death. Ischemic heart disease is diagnosed when clinical symptoms (chest pain) are present, changes in ECG are observed (detection of pathologic Q waves and ST elevations), and elevations in the levels of myocardial enzymes (troponin I, Cre- atine Kinase MB isozyme (CK-MB)) , Lactate Dehydrogenase (LDH), and Aspartate Amino Transferase (AST) are observed. Coronary angiography is used to observe the coronary arteries.

2. Treatment

(1) Heart Blood Stagnation-Type

• Symptoms: The patient experiences localized chest pain that worsens during the night. The tongue is dark burgundy and the pulse is sunken and rough. • Treatment Method: Activate blood and resolve stasis; free the collateral vessels to stop pain. • Herbal Medicine: ‘Drive Out Stasis in the Mansion of Blood Decoction’ (血府逐瘀湯) and ‘Salvia Drink’ (丹參飮)

(2) Phlegm Turbidity Obstruction

• Symptoms: Chest pain radiates to the shoulder or to the back. The patient is short of breath. In many cases, these types of patients tend to be overweight and avoid physical activities. The tongue fur seems turbid and the pulse feels slippery. • Treatment Method: Free yang and turbidities, eliminate phlegm and release mass • Herbal Medicine: ‘Trichosanthes, Chives and Pinellia Decoction’ (括蔞薤白半夏湯)

(3) Yin-Cold Coagulation

• Symptoms: The chest pain spreads to the back. Exposure to cold environment aggravates the condition. Physical activities trigger shortness of breath. The patient is unable to lie down comfortably. The patient’s complexion appears pale and the hands and feet feel cold. The tongue fur is white and the pulse feels sunken and thin. • Treatment Method: Warm to free yang, open any stagnancies and dissipate cold.

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• Herbal Medicine: ‘White Wine Decoction with Trichosanthes, Chives’ (括蔞薤白白酒湯), ‘Liquid Styrax Pill’ (蘇合香丸).

(4) Heart and Kidney Yin Deficiency

• Symptoms: The patient experiences discomfort and pain in the chest. Palpations are frequent and cold sweat is observed during the night. Tinnitus and/or vertigo may be present as well. The tongue is red or spotted. The pulse is thin and fast or thin and rough. • Treatment Method: Enrich Yin and tonify kidneys; nourish and tranquilize heart. • Herbal Medicine: ‘Restore the Left (Kidney) Pill’ (左歸飮)

(5) Qi and Yin Deficiency

• Symptoms: Subtle chest pain is intermittent. The patient feels shortness of breath and cannot even speak because they are lethargic. Physical activities aggravate symptoms. The tongue is hemi-laterally red or has bite marks. The pulse is thin and weak or intermittent. • Treatment Method: Tonify qi and nourish yin; activate the blood and free the collateral vessels. • Herbal Medicine: Combination of ‘Generate the Pulse powder’ added to ‘Ginseng Decoc- tion to Nourish the Nutritive Qi’ (生脈散合人蔘養榮湯)

(6) Yang Qi Deficiency

• Symptoms: The chest pain spreads to the back. The patient breaks out in cold sweat and dislikes exposure to cold. The patient’s extremities feel cold, their complexion appears pale, and their nails become blue. The tongue is bland and white or burgundy in color. The pulse is sunken and thick or sunken and faint as if to break. • Treatment Method: Tonify qi and warm yang; activate blood and free the collateral vessels. • Herbal Medicine: ‘Ginseng and Aconite Decoction’ added to ‘Restore the Right (Kidney) Pill’ (蔘附湯合右歸飮) and ‘True Warrior Decoction’ (眞武湯)

(7) Acupuncture and Moxibustion

• Main acupoints (主穴): BL15, BL14, PC6, to HT5, PC5, ST36

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Additional acupoints (配穴): Heart yin deficiency (心陰虛) SP6, HT7 Heart yang deficiency (心陽虛氣海關元) Phlegm (痰濁) (on ST40) • Auricular acupuncture (耳鍼): Heart (心), spleen (脾), sub-cortex (皮質下), sympathetic (交感), endocrine (內分泌), kidney (腎), and stomach (胃)

3. Recent findings

In a meta-analysis of RCTs conducted in populations with myocardial infarction, a significantly lower death rate was reported in groups that received a combination of herbal and conventional medicine (Chung et al., 2013). Acute Myocardial Infarction (Acute MI, AMI) was better controlled with Radix Salviae Miltiorrhizae extracts than with conventional treatment used to prevent heart failure and cardiac death (Luo et al., 2013). Moreover, a combination of the conventional treatment with Saengmaek-san pharmacopuncture was more effective at preventing death, heart failure, shock, and re-infarction than conventional treatment alone (Hu et al., 2012).

A meta-analysis of RCTs on patients with myocardial infarction and angina pectoris reported that Radix Salviae Miltiorrhizae and Cnidii Rhizoma pharmacopuncture were significantly more effective than conventional treatment at controlling symptoms and improving ECGs (Nie et al., 2012; Jia et al., 2013). The administration of herbal medicines in combination with conventional medicine was significantly more effective than conventional medicine alone at controlling the symptoms of angina pectoris and ECG (Glenton et al., 2010; Li et al., 2013; Shang et al., 2013; Jia et al., 2012; Junhua et al., 2008). Patients with angina pectoris who received a combination of conventional treatment and acupuncture exhibited a significantly greater improvement than patients who received conventional treatment alone.

The occurrence rates of Acute Myocardial Infarction (AMI) decreased, the symptoms of angina pectoris were alleviated, the time required for alleviation was shortened, and more improvement in ECG was observed (Richter et al., 1991; Chen et al., 2012). As shown in a study comparing the effects of cardiotonic pills with placebo medication, the cardiotonic pill (心適丸) was significantly more effective at treating chest pain and discomfort due to cardiovascular causes and other diseases (Radix M et al., 2005).

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Hyperlipidemia

1. Diagnosis

A state of a higher than normal blood lipid content, hyperlipidemia is either primary or secondary (due to diabetes, hypothyroidism, nephrotic syndrome, uremia, obstructive hepatic disease, or Cushing’s syndrome). Oral contraceptives, steroids, alcohol, and saturated fats may also lead to hyperlipidemia. Hyperlipidemia is diagnosed based on the total cholesterol, High-Density Lipoprotein (HDL) cholesterol, Low-Density Lipoprotein (LDL) cholesterol, neutral lipid, and Apolipoprotein levels. A high blood cholesterol content is a very strong cause of coronary artery diseases. HDL cholesterol helps prevent atherosclerosis. In contrast, LDL cholesterol is a risk factor that may contribute to atherosclerosis, coronary artery diseases, and stroke.

2. Treatment

(1) Cold-type Blood Stagnation

• Symptoms: In addition to the typical symptoms of hyperlipidemia, the patient feels chest discomfort, and may even experience localized pain in a certain area of the chest. Expo- sure to warmth alleviates the pain. The tongue is burgundy in color or is spotted. The pulse feels rough. • Treatment Method: Warm the meridians and stimulate blood circulation. • Herbal Medicine: ‘Warm up Channels Decoction’ (溫經湯), ‘Drive Out Stasis Decoction’ (身痛逐瘀湯), and ‘Myrrh Remove Pain Decoction’ (沒藥除痛湯)

(2) Heat-type Blood Stagnation

• Symptoms: In addition to the typical symptoms of hyperlipidemia, the patient presents with fever, thirst, and in severe cases, deranged speech. The patient may vomit or defecate blood. The tongue fur appears yellow and the pulse is slippery and fast. • Treatment Method: Cool the blood and dissipate stagnations; detoxify and stimulate blood circulation.

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• Herbal Medicine: ‘Immortals’ Formula for Sustaining Life’ (仙方活命飮), ‘Clear epidemic and overcome toxin drink’ (淸瘟敗毒飮), ‘Peach Seed Decoction to Order the Qi’ (桃仁承氣湯), and ‘Rhinoceros Horn and Rehmannia Decoction’ (犀角地黃湯)

(3) Excessive-type Blood Stagnation

• Symptoms: In addition to the typical symptoms of hyperlipidemia, the patient presents with headache, vertigo, forgetfulness or tremors that resemble epilepsy. The stool is dark and the patient often complains of abdominal pain. The tongue appears to be spotted or is burgundy in color. The pulse feels string-like and rough. • Treatment Method: Tonify qi and activate blood; purge stagnations. • Herbal Medicine: ‘Drive Out Stasis in the Mansion of Blood Decoction’ (血府逐瘀湯), ‘Unblock Orifices and Invigorate Blood Decoction’ (通竅活血湯), ‘Peach Seed Decoction to Order the Qi’ (桃仁承氣湯), and ‘Drive Out Stasis Decoction in Small Abdomen’ (少腹逐瘀湯)

(4) Deficient-type Blood Stagnation

• Symptoms: In addition to the typical symptoms of hyperlipidemia, lethargy and shortness of breath are present. Headache, amnesia, and/or insomnia are possible accompanying symptoms. The patient’s complexion may appear somewhat yellow. The patient may even present with heat in the palms and soles. The tongue appears bland and the pulse feels thin and rough. • Treatment Method: Tonify qi and activate the blood, tonify and activate the blood, tonify Yin and activate the blood, and warm yang and activate the blood. • Herbal Medicine: ‘Tonify the Yang to Restore Five Decoction’ (補陽還五湯), ‘Four-Sub- stance Decoction wih Peach Seed and Carthami Flos’ (桃紅四物湯), ‘Unblock Hidden Decoction’ (通幽湯), and ‘Emergent Restoration of Yang Decoction’ (急救回陽湯)

3. Recent findings

A systematic review of the effects and safety of herbal medicine and 22 natural

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products on hyperlipidemia has validated that the following treatments are significantly effective at regulating the total cholesterol and LDL cholesterol levels: Daming capsule, ‘Chun- ghyul-dan (Clear the Blood Pill)’, Radix Glycyrrhizae (甘草), powdered garlic (Allicor), black tea, green tea, soy bean milk, Satureja khuzestanica, Monascus purpureus Went rice, Trigonel- lae Semen (葫蘆巴), Myrrha (沒藥), Achillea wilhelmsii C. Koch, Ningzhi1 capsule, cherry, composite salviae dropping pill, Shanzha Xiaozhi capsule, ‘Eight-Ingredient Rehmannia Pill’, Rhei Radix et Rhizoma (大黃), milk thistle, Rheum ribes, and Jingmingdan granule (primrose oil) (Hasani-Ranjbar et al., 2010). Other herbal medicines that were shown to be effective are ‘Chunghyul-dan (Clear the Blood Pill)’, modified Pyungjingunbi-tang, and modified Ohjuk- san (Five Accumulations Powder, 五積散) (Chung et al., 2003; Kim et al., 2003; Park et al., 2006). A He-Ne laser treatment was reported to be effective at resolving phlegm and eliminat- ing stasis, resulting in a decrease in the lipid content (Ryu et al., 2004).

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Reference

•Cao H, et al. Acupuncture for vascular mild cognitive impairment : a systematic review of randomized controlled trials. Acupuncture in Medicine. 2013;31(4):368-374.

•Cardiology and Neurology of Korean Medicine. National union of departments of Cardiology and Neurology of Korean Medicine. KOONJA publishing INC. 2010. p69-77, p99-106, p331-342, p365-368, p375,378

•Chen J, et al. Acupuncture therapy for angina pectoris: a systematic review. Journal of Tradi- tional Chinese Medicine. 2012;32(4):494-501.

•Cho KH, et al. A preliminary study on the inhibitory effect of Chunghyul-dan on stroke recurrence in patients with small vessel disease. Neurological Research. 2008;30(6):655-658.

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173 2016 Korean Medicine Current Practiceof CHAPTER 3

Digestive Diseases

▼ Jinsung Kim PART 2 Korean Medicine Treatments for Various Medical Conditions

chapter 3

Digestive Diseases

Introduction

The digestive system consists of the gastrointestinal tract (a continuous, tubular system that starts at the mouth and esophagus and connects the stomach, small intestine, large intestine) and the digestive glands (liver, gallbladder, and pancreas) that secrete the substances that digest food.

In Korean Medicine, the viscera and bowel that represent these digestive functions are the

Mouth Salivary glands

Esophagus

Gallbladder Stomach

Liver Small intestine

Pancreas Large intestine

Rectum Anus

[ Figure 1 ] Schematic diagram of human digestive system

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spleen and stomach. The spleen and stomach system is responsible for the ingestion, digestion, absorption, excretion, redistribution of nutrients. Digestive diseases are very common in clinical settings. Restoring proper function of the spleen and stomach is the fundamental basis of replenishment and nourishment using herbal medicines. In this chapter, some clinically prevalent conditions in the oral cavity, esophagus, stomach, and intestines will be discussed along with Korean Medicine approaches.

Burning Mouth Syndrome (BMS) is characterized by a burning sensation in the tongue or other oral sites, usually in the absence of clinical and laboratory findings. Affected patients often present with multiple oral complaints, including burning, dryness and taste alterations. The prevalence rate of BMS is approximately 0.7% to 4.6%, and the syndrome is mainly observed in women after menopause. However, women in their 20’s to 40’s or men can also have BMS. Approximately 2/3 of the patients present with dryness of the mouth, changes in taste perception, and in many cases, sleeping disorders, anxiety, depression, and fear of oral cavity carcinoma. The conventional treatment for BMS consists of pain relievers for neurologic pain, but this approach does not seem effective. In Korean Medicine, excess heart fire and a deficiency in kidney water are main causes of BMS. Therefore, the condition is treated with herbal medicine that decreases heart fire and replenishes kidney water. Acupuncture that takes into consideration the meridians and collateral system and pharmacopuncture that takes into consideration the pain intensity are also recommended.

Gastroesophageal Reflux Disease (GERD) is a condition in which the stomach contents reflux into the esophagus to cause symptoms and other complications. The prevalence of GERD in developed countries ranges from 10 to 20%. A 2006 multi-center study reported 12% prevalence rate in Korea. GERD has an unfavorable prognosis in many cases, with frequent relapse. How- ever, refractory GERD responds well to Korean Medicine treatment. Treatment goals include not only a relief of symptoms but also a restoration of normal function to the entire body system. Proton Pump Inhibitors (PPI) and acupuncture may be used in addition to herbal medicine.

Functional Dyspepsia (FD) is a condition in which mild pain or discomfort in the upper abdominal region was first observed in the previous 6 months and has persisted for at least 3 months. The prevalence rate of FD ranges from 9% to 22% globally and approximately 8-15% in Korea.

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Korean Medicine treatment that helps improve stomach and intestinal motility and decrease intestinal sensitivity are prescribed according to the patients’ individual characteristics and patterns. Electroacupuncture is also known to be helpful.

Irritable Bowel Syndrome (IBS) is defined as chronic abdominal pain or discomfort accompanied by changes in defecation patterns and stool types. There are no underlying structural problems. IBS is one of the most common refractory gastrointestinal disorder. The global prevalence of IBS is approximately 7-10%, and similar prevalence rates have been reported in Ko- rea (8-9.6%). The prevalence of IBS is approximately 1.6 times higher in females (14%) than in males (8.9%). Females usually present with abdominal pain and constipation, whereas males present with diarrhea. In Korean Medicine, IBS is caused by a combination of different factors, including a spleen-stomach qi deficiency, emotional stress, kidney deficiency, and dampness phlegm. Physicians must devise an appropriate treatment plan that considers the patient’s general condition.

Burning Mouth Syndrome

1. Diagnosis

Burning Mouth Syndrome (BMS), as described by the name, is a condition in which the patient presents with a burning sensation in the oral cavity and other accompanying symptoms. The pain is described as “burning” or “stinging” at the edge or margins of the tongue. Symptoms may also be present in the gums, lips, cheeks, palates, and other mucosa in the oral cavity.

BMS is either primary or secondary. Secondary BMS is diagnosed when other illnesses are the cause of the symptoms. Local Candida infections and other local diseases should be ruled out. A blood test is recommended to exclude other conditions that may cause a burning sensation in the mouth such as anemia, vitamin deficiency, uncontrolled diabetes, and hypothyroidism. In other words, a diagnosis of BMS should be based on a basic oral examination and an evaluation of other factors that may cause or aggravate symptoms. Histological changes in the oral mucosa

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are observed under appropriate lighting without any special devices. The tongue, cheeks, lips, gums and palates should be investigated. Tongue diagnosis, a basic form of diagnosis used in Korean Medicine, may also be performed.

A tool used to evaluate sensitivity is tenderness at the CV17 acupoint .

• CV 17

[ Figure 2 ] Location of acupoint CV17 and pressure algometer used to measure intensity of tenderness

* Source: https://wagner.isecuresites.com/products/show.php?id=12183&sub=&type=923

Stagnation of qi and blood may cause tender points to form at certain areas of the body. Emo- tional factors may cause qi stagnation. If qi stagnation is not treated for long periods, the stagnation becomes Fire-like in nature. Therefore, tender points form around the CV17 area (Kang et al., 2012). CV17 is the alarm point (募穴) of the pericardium vessel (心包經) and is also called “qi hae (氣海, sea of qi)” or “qi hoe (氣會穴, the place where qi come together)”. It is known to be an acupoint that is very sensitive to emotional stress. Approximately 70% of patients with Hwa-byung (火病) have reported tenderness at CV17 (Kim et al., 1998).

2. Treatment

As various factors are associated with BMS, a wide spectrum of symptoms can be present. Thus, pain intensity and duration and aggravating factors must be evaluated. The patient’s history and a detailed record of any changes in symptoms are important. A comprehen-

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sive care plan, including a saliva examination, modifications to the diet, relief from psychological stress, and modifications of other administered medicines, is necessary.

Pain relievers prescribed in conventional medicine, such as clonazepam, have limited effect. Patients who have received conventional treatment are dissatisfied. For a more effective Ko- rean Medicine treatment, it is important to select effective acupuncture, herbal medicine, and other treatment techniques to consider the general physical and psychological condition of the patient. The causes of both local and general symptoms should be analyzed appropriately. An analysis of the psychological factors from a Korean Medicine perspective is also needed. Patients and their family members should be notified of the characteristics of the condition and the overall treatment plan. The physician must establish a strong rapport so that the patient can follow through the treatment plan; the physician must also provide thorough explanations of the anticipated changes.

One must remember that the prognosis of BMS is not favorable in most cases. At least 6 weeks of treatment should be allowed to establish a specific treatment plan. The physician should record the pain intensity using a visual analogue scale, salivary flow rate, intensity of tenderness at CV17 and other quantitative indicators during the first visit (Son et al., 2013).

Acupuncture, acupuncture is a preferred method of treatment for pain relief. In a systematic review of 9 clinical trials including 547 BMS patients, acupuncture and pharmacopuncture (acupoint injection) were reported to be effective for the sedation of BMS symptoms, including pain (Zhimin Y et al., 2012). Acupuncture, electroacupuncture, pharmacopuncture, and laser acupuncture are applied to many acupoints. CV23 and TE17 are the main acupoints; proximal acupoints such as SI17, ST06, ST5 and distal acupoints such as LI04, KI04, SP10, and SP06 may be added. For CV23, an acupoint located on the conception vessel, the needle should be inserted 2cm deep towards the root of the tongue and then ask the patient is swallowing. Apply a left-right twirling movement to the needle while the patient swallows. The treatment is even more effective when an Ashi point 1 chon above RN23 called Sangyeomchun (上廉泉; Ashi point) is stimulated together with electroacupuncture. Electroacupuncture should be performed using a low frequency rate of 1-4Hz, which is a sufficient stimulus for the patient to feel twitching or mild pain at the treatment area.

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Sphenoidal sinus Atresia of pharyngeal opening of eustachiuan tubes Soft palate Genioglossus muscle Geniohyoid muscle Mylohyoid muscle Horacic cavity Hyoid bone Epiglottis Upper CV-23 Cricoid lamina CV-23 Thyroid cartilage

[ Figure 3 ] Electoacupuncture applied to CV23 andSangyumchun (上廉泉) * Source: Clinical Anatomy Diagram for Acupuncture

When stimulating TE17, aim the acupuncture needle toward the root of the tongue instead of the apex of the head. For a proper treatment, the patient should open his or her mouth when the needles are being inserted. Gently apply a left to right twirling movement to the needles.

Herbal injections used for pharmacopuncture are usually ‘Coptis Decoction to Relieve Toxic- ity’ (黃連解毒湯) or ‘Six-Ingredient Pill with Rehmannia’ (六味地黃湯). Acupoints stimulated are decided based on the characteristic of the injections. Acupoints such as EX-HN12,13, GB21, CV17and CV6 are frequently stimulated. Tongue acupuncture, a method in which the tongue is divided into three sections that correspond to the upper, middle, and lower energizers and then stimulated according to the organ from which the problem originates, is a commonly used technique.

Lung Branch meridian Heart Forehead Eye Upper energizer Nose Arm Ear

Sea river Throat Nervous stream Sublingual Stomach Jade liquid Golden effort Middle energizer Spleen Gall Liquid bladder Tongue pillar Small intestine Helper of stream Urinary bladder Kidney Lower energizer Liver Spirit base Large intestine Middle torch Yin Leg

[ Figure 4 ] Acupoints located on the surface of the tongue (left) and base of the tongue (right) stimulated for tongue acupuncture * Source: Literature review of tongue acupuncture

181 PART 2 Korean Medicine Treatments for Various Medical Conditions

When stimulating acupoints located in the mouth, suppress the tongue with a depressor so that the acupoints are easily approached. Inject 0.1-0.3ml at the margin between the root and body of the tongue. Consider the pain intensity and duration when deciding on a dose.

The basic principles of Korean Medicine treatments are to decrease heart fire (心火) and replenish kidney water (腎水). When the patient presents with dryness of the mouth accompanied by vexing heat and reddish urine, prescribe ‘Clear Heart Lotus Seed Drink’ (淸心蓮子飮), a formula known to be effective for reducing heart fire that consists of 8g of Nelumbinis Semen (蓮子肉), 4g each of Radix Ginseng (人蔘) and Radix Astragali (黃芪), and 3g each of Poria Sclerotium Rubra (赤茯苓), Radix Scutellariae (黃芩), Plantaginis Semen (車前子), Liriopis Tuber (麥門冬), Lycii Cortex (地骨皮), and Radix Glycyrrhizae (甘草). If the dryness of the mouth is severe, add 16g of Rehmanniae Radix Crudus (生地黃) and 8g each of Radix Scro- phulariae (玄蔘) and Liriopis Tuber (麥門冬), and if the face feels hot, increase the amount of Radix Scutellariae (黃芩) to 6g. If anxiety and insomnia are present, add 6g each of Zizyphi Semen (酸棗仁), Hoelen cum Radix (白茯神), and Longan Arillus (龍眼肉). In cases in which kidney water (腎水) must be replenished to restore proper function to the water uprise and fire downflow (水升火降) mechanism, prescribe ‘Rehmannia Decoction with Anemarrhena and Phellodendron’ (知柏地黃湯), which consists of 16g of Rehmanniae Radix Preparata (熟地黃), 8g each of Dioscoreae Rhizoma (山藥) and Corni fructus (山茱萸), 6g each of Poria Sclerotium (白茯苓), Cortex Moutan (牧丹皮), and Alismatis Rhizoma (澤瀉), and 4g each of Rhizoma Anemarrhenae (知母) and Phellodendri Cortex (黃柏). Add Rehmanniae Radix Crudus (生地黃), Radix Scrophulariae (玄蔘), Liriopis Tuber (麥門冬), Gypsum Fibrosum (石膏), and Radix Curcumae (鬱金) accordingly.

BMS responds relatively well to Korean Medicine treatment; 2/3 of BMS patients who had received 6-12 weeks of acupuncture treatment and herbal medicine reported a partial or complete improvement of symptoms, including the burning sensation in the mouth. Taking into account that these patients had not recovered after receiving conventional treatment, this result is a significant improvement (Son J et al., 2013).

182 Digestive Diseases chapter 3

Gastroesophageal Reflux Disease

1. Diagnosis

Gastroesophageal Reflux Disease (GERD) occurs when the stomach contents reflux into the esophagus. When the esophageal epithelium is damaged, GERD is known as reflux esophagitis. Many patients actually present symptoms but do not have any structural problems in the esophagus. GERD patients who have reflux without any observable structural changes in the esophageal mucosa are classified as having Non-Erosive Reflux Disease (NERD).

A typical symptom of GERD is short, repetitive episodes of heartburn behind the sternum. The pain sometimes feels similar to angina pectoris. Korean patients often present with non-typical symptoms, including wringing, constriction, stiffness, globus pharyngis, chronic cough, and hoarse voice.

The cardinal symptoms of GERD include heartburn and reflux. Many tests are used to support the diagnosis, including upper GI tract endoscopy and 24-hour impedance pH monitoring. However, if heartburn is present, treatment can commence without further testing. Even when patients present with typical symptoms, GERD is only visible in less than 50% of all cases using an upper GI tract endoscopy. Approximately 20% of patients with typical heartburn symptoms of GERD appear normal when diagnosed with GI tract endoscopy and 24-hour impedance pH monitoring (Katz et al., 2013). In the Korean Medicine literature, patterns of disease that is similar to GERD are acid regurgitation, acid vomiting, chest discomfort, and dysphagia-occlusion. The patterns of the disease must be identified, as mandated in Korean Medicine. The most common types of GERD patterns are the liver-spleen disharmony pattern, dampness and heat in the spleen and stomach, a spleen-stomach qi deficiency, and a stomach yin deficiency (Han et al., 2015) (Table 1). The different characteristics of each subtype must be differentiated to identify the GERD patterns. First, the liver-spleen disharmony pattern subtypes are usually triggered by emotional stress. Symptoms include anxiety, depression, bitterness in the mouth, and fullness in the chest. Second, dampness and heat in the spleen and stomach is a typical excess type pattern that presents with the common symptoms of reflux of gastric juice, nausea, and an inability to swallow properly. Third, spleen-stomach qi deficiency-types are caused by

183 PART 2 Korean Medicine Treatments for Various Medical Conditions

weak spleen and stomach function. This type is usually a chronic condition in which significant weight loss is observed. The area below the sternum is soft and succession sound is heard upon tapping. Finally, the stomach yin deficiency-type shows deficient-type fever that is often visible in very underweight individuals. Dryness in the mouth, constipation, and a burning sensation in the chest are common symptoms.

Table 1. Identification of GERD Patterns

Pattern Definition

A pattern characterized by dizziness, hypochondriac pain, irritability, Liver-Stomach epigastric distension and pain, anorexia, belching, nausea, vomiting Disharmony pattern and string-like pulse. It may be due to stress or metabolic states 肝胃不和型 associated with stagnation of liver qi that flows upwards to invade the stomach. The normal downward flow of stomachqi is hindered, leading to symptoms in the stomach.

A pattern characterized by epigastric or abdominal distention, Dampness and Heat in anorexia, nausea, vomiting, lethargy, heavy sensation of the body, and the Spleen-Stomach a bright yellow discoloration of the skin and the whites of the eyes. The pattern tongue fur seems yellow, dense and slimy, which may be caused by the 脾胃濕熱型 accumulation of dampness and heat in the spleen and stomach that affects digestive function.

A pattern characterized by reduced appetite, impaired digestion, Spleen-Stomach Qi- abdominal distension, loose stool, lethargy, a pale tongue or a weak deficiency pattern pulse. When there is deficiency in spleenqi , digestion is impaired and 脾胃虛弱型 proper blood production is hindered, causing problems with circulation. The water regulation mechanism of the body is abnormal.

A pattern characterized by dry mouth and throat, vague burning pain in Stomach Yin- the stomach and epigastrium, dry vomiting, hiccup, constipation, and deficiency pattern a reddish tongue with scanty fluid. The pulse feels thin and rapid. A 胃陰不足型 deficiency of fluid in the stomach and impaired function are caused by intense stomach fire or exuberant heat.

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2. Treatment

Basic care for GERD consists of changes in health behaviors and the use of Proton Pump Inhibitors (PPIs). For obese patients or those with a rapid weight gain in a short period of time, weight loss is recommended. Abdominal obesity exerts physical pressure on the internal organs and therefore increases the possibility of reflux. For patients whose GERD symptoms worsen during the night, head-of-bed elevation and limiting the intake of high-fat food 2-3 hours prior to sleep is recommended. Patients are generally recommended to refrain from consuming alcoholic beverages, cigarettes, coffee (caffeine), soft drinks, and spicy or greasy food. An appropriate diet should be planned based on the patient’s experience with different food. PPIs is used as a primary treatment for GERD. Once-daily doses should be administered for at least 4-8 weeks. If the patient is not responsive to PPI, or if the symptoms relapse, Korean Medicine treatments can be helpful. In a study of GERD patients, 40-50% of GERD patients did not respond well to PPI treatment (Fass et al., 2006).

GERD

Non-erosive Erosive Barrett's reflux disease esophangitis esophagus 60-70% 20-30% 6-10%

Failure on PPI qd Failure on PPI qd Failure on PPI qd 40-50% 6-15% 20%

PPI failure patients

[ Figure 5 ] The proportion of patients who failed symptomatically Proton Pump Inhibitor (PPI) once daily in each of Gastroesophageal Reflux Disease (GERD) group * Source: http://www.nature.com/gimo/contents/pt1/fig_tab/gimo42_F5.html

GERD is a refractory condition. Therefore complementing conventional treatment with Korean Medicine is effective. In a clinical trial including patients with refractory heartburn who did not respond to conventional PPI treatment, the group in which acupuncture administered to PC06,

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ST36, CV12, CV17, LR03, and SP09 in combination with PPI treatment reported significantly better effects than those in the double-dosage PPI group (Dickman et al., 2007). ST36 is an acupoint that helps regulate stomach and intestinal motility. The lower esophageal sphincter pressure is also affected. PC06 is known to help reduce lower esophageal sphincter relaxation rates by approximately 40%. ST36 and PC06 are frequently used together (Wu et al., 2014). Both acupuncture and electroacupuncture are effective. If the patient has a globus sense, RN 23 and TE17 are also recommended in addition to the acupoints mentioned above, and they are stimulated in the same way as for BMS.

Herbal medicine prescriptions differ according to the pattern the patient presents. In other words, GERD must be approached differently depending on the chronicity; if it is an acute problem or a recurrent, chronic problem. In the acute stage, emotional stress may be the cause of a liver-spleen disharmony pattern, an excessive type pattern. For dampness and heat in the spleen and stomach, where pain and acid regurgitation are the most prominent symptoms, prescribe ‘Clear Depression Powder’ (淸鬱散) and ‘Supplemented Decoction of Two Aged Drugs’ (增味二陳湯), which are introduced in “stomach heart pain (胃心痛) and acid regurgitation” (呑酸) chapters of Donguibogam (東醫寶鑑). These two prescriptions are very similar and share 10 herbs. They are effective treatments for acute GERD. ‘Supplemented Decoction of Two Aged Drugs’ consists of 13 herbs; 4g each of Pinelliae Tuber (半夏), Citrus Unshius Pericarpium (陳皮), Poria Sclerotium Rubra (赤茯苓), Fructus Gardeniae (梔子), Rhizoma Coptidis (黃連), Rhizoma Cyperi (香附子), Poncirus Fructus Immaturus (枳實), Cnidii Rhizoma (川芎), Rhi- zoma Atractylodis (蒼朮), and Paeoniae Radix Alba (白芍藥), and 3g each of stir-baked Massa Medicata Fermentata (神麯炒), Radix Glycyrrhizae (甘草), and Zingiberis Rhizoma Crudus (生薑). Spleen-stomach qi deficiency-type and stomach yin deficiency-type are the most common types of chronic GERD. The differences of chronic and deficient type patterns are that the spleen-stomach qi deficiency-types present with more ‘cold’ symptoms, whereas stomach yin deficiency-types have more ‘warm’ symptoms. Spleen-stomach qi deficiency-types should be prescribed with ‘Six Gentlemen Decoction’ (六君子湯), which consists of 6g each of Pinelliae Tuber (半夏) and Atractylodis Rhizoma Alba (白朮), 4g each of Citrus Unshius Pericarpium (陳皮), Poria Sclerotium (白茯苓), and Radix Ginseng (人參), 2g of stir-baked Radix Glycyrrhizae (炙甘草), and 4g each of Zingiberis Rhizoma Crudus (生薑) and Zizyphi Fructus (大棗). If the patient presents with discomfort and fullness under the sternum and frequent eructation, add

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4g each of Poncirus Fructus Immaturus (枳實), Rhizoma Atractylodis (蒼朮), Fructus Hordei Germinatus (麥芽). If water-like sound is heard in the upper abdominal region, increase the amount of Poria Sclerotium (白茯苓) to 8g. If emotional stress is associated with dryness of the mouth, vertigo, and fullness in the chest (胸脇苦滿), add 6g of Radix Paeoniae Alba (白芍藥) and 4g of Radix Bupleuri (柴胡). If irritation in the throat is present, add 6g of Magnoliae Cortex (厚朴) and 4g of Perilla frutescens (蘇葉). Stomach yin deficiency-type should be prescribed Ikwi-tang (益胃湯), which is a combination of 15g of Rehmanniae Radix Crudus (生地黃), 12g of Radix Adenophorae (沙蔘), 9g of Liriopis Tuber (麥門冬), and 9g of Polygonatum odoratum (玉竹). Add other medicines that aid in digestion (消導之劑) as needed. Many studies have validated the effects of ‘Six Gentlemen Decoction’ as a treatment for GERD. ‘Six Gentle- men Decoction’ has been shown to improve esophageal clearance rates, shorten the esophageal acid exposure time, and control esophageal hypersensitivity. Furthermore, in a clinical trial of refractory GERD patients who did not respond favorably to conventional PPI treatment, a combination of ‘Six Gentlemen Decoction’ and normal dose of rabeprazole was equally effective as a double-dose PPI treatment (Tominaga et al., 2013).

A meta-analysis of 26 clinical trials comparing the effects of conventional and Korean Med- icine treatment for GERD (acupuncture, as well as acupuncture with herbal or conventional medicine) reported better outcomes in the Korean Medicine groups. Over the 4-8 weeks of treatment, the effectiveness rate in the control group (conventional treatment group) was 40.0 to 90.0%, whereas the effectiveness rate of the acupuncture group was higher at 66.7 - 97.9% (Kang., 2015).

Functional Dyspepsia

1. Diagnosis

Dyspepsia is defined as a state of abdominal pain or discomfort in the upper abdominal area, regardless of food intake. Pain and discomfort should be treated differently. Discom- fort is defined as a state of uncomfortableness that is not described as “pain”. Early satiety, full-

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ness, bloating, nausea are all symptoms of discomfort. Functional Dyspepsia (FD) is diagnosed when other possible causes of the symptoms, such as peptic ulcers, malignant carcinoma, and pancreato-biliary diseases, have been ruled out. FD is diagnosed when symptoms have been present for at least 3 months without any structural problems. Onset should be at least 6 months prior to diagnosis. Symptoms include postprandial fullness, early satiety, epigastric pain, and epigastric burning. When abdominal discomfort is the chief complaint, the overall condition is called Postprandial Distress Syndrome (PDS); if pain is the chief complaint, the condition is called epigastric pain syndrome. FD is a very common disorder observed in primary healthcare facilities. FD accounts for 70-92% of all dyspepsia cases and FD is prevalent in 25% of the entire population.

In Korean Medicine, FD is caused by internal damage inflicted by food. Stuffiness below the heart, acid regurgitation, stomach distress, stomach pain and nausea are all patterns with symptoms similar to FD. According to 3,406 clinical cases of 30 articles published on pattern identification in FD published between 2005 and 2010, the liver-stomach disharmony pattern was the most prevalent (18.96%), followed by spleen-stomach qi deficiency (17.32%), dampness and heat in the spleen and stomach (12.71%), liver depression and qi stagnation (11.00%), liver depression and spleen deficiency (8.74%), food accumulation (5.34%), cold-heat complex (4.75%), and spleen-stomach deficiency cold (4.55%) (Cui et al., 2011). In a study conducted in Korea to develop an instrument for diagnosing the patterns in functional dyspepsia, FD was subtyped as a liver-stomach disharmony pattern, food stagnation, dampness and heat in the spleen and stomach, cold-heat complex, spleen-stomach deficiency cold, and stomach yin deficiency-types (Kim et al., 2010). Food accumulation, qi stagnation, phlegm-retained fluid and other symptoms relevant to symptom onset should be differentiated as excessive or deficient types. Cases in which the cause is a deficiency but the symptoms seem to be due to excess should be approached with caution.

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Clinical Aspects of Clinical Aspects of Dyspepsia Functional Dyspepsia Does it correspond to the RomeⅢ criteria Organic Disorders • Stomach symptoms on the upper abdomen ・Gastric ulcer • Continuous for more than three months in the past six ・Reflux esophagitis months NO ・Pancreatobiliary diseases • Rule out organic disorder that has an evident cause ・Cancer YES Functional Dyspepsia

・Hospitalization ・Cooperative treatment with History of Western Medicine Treatment and Western Medication Evaluation of Severity ・Fluid therapy for improvement of nutritional state Mild and moderate Dyspepsia Pattern Identification Types Moderate Dyspepsia Suitable for sub-type ・Liver stagnation andqi blockage Moderate Malnutrition categorization? NO ・Liver stagnation and Spleen YES deficiency ・Spleen deficiency and phlegm dampness Postprandial Distress Syndrome Epigastric Pain Syndrome ・Accumulation and stagnation of ・Unpleasant Postprandial fullness food ・Epigastric pain or soreness ・Early satiation ・Tangled cold and heat

Moderate Dyspepsia Distention and Fullness Stomach Pain Moderate Malnutrition Epigastric Upset/ Acid Reflux ・Cold distention ・Deficiency, excess, cold, heat ・・Heat distention ・Food accumulation Heat pattern ・・Deficient distention ・Phlegm fluid Cold pattern ・Excess distention ・Stagnated blood

Herbal Medicine Moxibustion /Cupping Acupuncture/Electro- Lifestyle Control and acupuncture Qigong ・Immediate and continuous relief ・Continuous relief of symptom of symptoms ・Immediate relief of ・Prevention of relapse ・Mid and long-term treatment symptom ・Prevention of relapse

Maintenance or aggravation Improvement of symptoms of symptom Consideration of other treatment Continuous care and prevention of relapse

Maintenance or aggravation Improvement of symptoms of symptom Re-evaluation of Continuous care and prevention of relapse conditions

[ Figure 6 ] Critical pathway of Korean Medicine treatment of functional dyspepsia

2. Treatment

For treatment, physicians must maintain a strong rapport with the patient. In conventional medicine, PPI and prokinetics are prescribed. If the patient does not respond favorably, antidepressants or antianxiety agents are prescribed. Eradication of H. pylori infections and

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modifications to the diet can also help with symptoms. However, in many cases, FD does not respond favorably to these treatments. Korean Medicine treatment is very effective alternative. The basic treatment for FD relieves stress and anxiety. As this condition is associated with the stomach, proper diet is particularly important. Specific recommendations are listed below (Shin , 2016). First, any food that causes unfavorable symptoms should be avoided. Second, poor eating habits, such as overeating, eating too fast, and other irregular eating habits, may further aggravate dyspepsia. Third, patients should avoid high-fat food. Fourth, beans, onions, soft drinks, and chocolate may further aggravate dyspepsia. Fifth, dairy products (milk, cheese, and yogurt) may also trigger symptoms. Sixth, rice should be chosen over flour products. Seventh, tea is better than coffee. Eighth, Zingiberis Rhizoma Crudus can help reduce discomfort. Ninth, spicy food can aggravate heartburn and dyspepsia.

Korean Medicine treatment for FD consists of herbal medicine, acupuncture, moxibustion, thermotherapy, and Qigong treatment. When prescribing herbal medicine, the physician must consider that FD is usually chronic and in some cases, the cause may be a deficiency but the symptoms seem to be due to excess. Symptoms should be analyzed appropriately. Any distinctive pathogens, such as food accumulation, phlegm-retained fluid, and qi stagnation, must be identified. If there is discomfort under the sternum accompanied by sudden swelling or discomfort in the abdomen, and if the pain feels as if the abdomen is being twisted, prescribe ‘Decoction to Eliminate internal Accumulation and Harmonize’ (內消和中湯), 8g each of Fruc- tus Crataegi (山楂) and Fructus Hordei Germinatus (麥芽), 6g each of Magnoliae Cortex (厚朴), Citrus Unshius Pericarpium (陳皮), and Alismatis Rhizoma (澤瀉), 4g each of Atractylodis Rhizoma (蒼朮), Cyperi Rhizoma (香附子), Poncirus Fructus Immaturus (枳實), Pinelliae Tu- ber (半夏), Poria Sclerotium (白茯苓), stir-baked Massa Medicata Fermentata Amomi Fructus (砂仁), Rhizoma Sparganii (三稜), Curcumae Rhizoma (蓬朮), and Rhizoma Zingiberis (乾薑), 3g each of Agastachis Herba (藿香), Radix Aucklandiae (木香), and Radix Glycyrrhizae (甘草), and 4g of Zingiberis Rhizoma Crudus (生薑). A combination of ‘Powder to Eliminate internal Accumulation’ and ‘Great Harmonization Drink’, both of which promote digestion (消食導滯), named ‘Decoction to Eliminate internal Accumulation and Harmonize’ has been confirmed to effectively improve gastric dysmotility. If symptoms of qi deficiency (氣虛) are present, add ‘Four Gentlemen Decoction’ (四君子湯), 4g each of Radix Ginseng (人參), Atractylodis Rhi- zoma Alba (白朮), Poria Sclerotium (白茯苓), and Radix Glycyrrhizae (甘草).

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Phlegm (痰飮) is an abnormal accumulation of body fluids that may cause discomfort below the sternum, nausea, vertigo and/or headache, and dyspepsia. In such cases, prescribe Pyung- jin-tang (平陳湯), 8g each of Rhizoma Atractylodis (蒼朮) and Pinelliae Tuber (半夏), 5g each of Magnoliae Cortex (厚朴) Citrus Unshius Pericarpium (陳皮) Poria Sclerotium Rubra (赤茯苓), 3g of Radix Glycyrrhizae (甘草), and 6g each of Zingiberis Rhizoma Crudus (生薑) and Zizyphi Fructus (大棗), a combination of Pyungwi-san (平胃散) and ‘Decoction of Two Aged Drugs’ (二陳湯). If strong qi deficiency symptoms are present, add ‘Four Gentlemen Decoc- tion’, and if vertigo or headache is present, add Gastrodiae Rhizoma (天麻) or Saposhnikoviae Radix (防風). For patients who are exposed to psychologically stressful environment, consider the characteristics of qi stagnation (氣鬱) and add Radix Paeoniae Alba (白芍藥) or Radix Bu- pleuri (柴胡).

The effects of Korean Medicine on FD have been validated by many studies. ‘Six Gentlemen Decoction’ (六君子湯) has been reported to improve dyspepsia, upper abdominal pain, postprandial discomfort and other symptoms of the upper digestive system. There is also evidence to support the hypothesis that ‘Six Gentlemen Decoction’ helps increase ghrelin levels to improve gastric dysmotility and treat anorexia (Saegusa et al., 2015). Ten studies investigating the effects of ‘Pinellia Decoction to Drain the Epigastrium’ on FD (972 patients) suggest that ‘Pinellia Decoction to Drain the Epigastrium’ exhibits better performance than conventional medicine (Gan et al., 2014).

Acupuncture treatment consists of a 15-20 min- ute stimulation of ST36, PC06, LI4, LR03, SP04, and CV12. To stimulate ST36 with electroacupuncture, insert the needle 1cm away from the actual acupoint. Connect the needles to the electroacupuncture device and apply a low-frequency stimulus of approximately 1-4Hz. This stimulus is the lowest frequency at which the patient can feel twitching or mild pain in the muscles .

Electroacupuncture stimulation of ST36 appears to [ Figure 7 ] Electric stimulation added to ST36 for be effective at reducing the gastric emptying time the treatment of functional dyspepsia

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in patients with FD (Xu et al., 2006). The basic treatment consists of 2-3 sessions of acupuncture treatment per week for 4 weeks. The treatment outcomes should be evaluated and the treatment should be modified as necessary. According to the results of a recent randomized controlled trial including 76 patients with FD, the outcomes of dyspepsia were significantly improved in patients who were treated with 9 basic acupoints used for FD and approximately 10 additional acupoints, depending on the individual symptoms (15 minutes of needle retention time per session, two sessions per week for 4 weeks) (Kim et al., 2015). A systematic review of 7 randomized controlled trials including 542 patients with FD who were treated with acupuncture or electroacupuncture and conventional medicine (cisapride, domperidone, and itopride) showed that there were no significant differences in outcome measures. In a comparison of acupuncture with sham acupuncture, significant improvements in the FD symptom scores and other outcome measures were observed in the acupuncture group (Lan et al., 2014).

Irritable Bowel Syndrome

1. Diagnosis

Irritable Bowel Syndrome (IBS) can be subcategorized into IBS with Diarrhea (IBS-D), IBS with Constipation (IBS-C), and Mixed IBS (IBS-M) and Un-subtyped IBS (IBS-U), based on the consistency of the stool. Patients usually present with a combination of multiple types rather than one distinctive type. The Rome III Criteria, which was revised in 2006, is commonly used to diagnose IBS. The onset of symptoms should date to more than 6 months prior to diagnosis, and symptoms should have been present at least 3 days a month for the last [ Figure 8 ] Bristol stool form scal 3 months. Discomfort and/or pain in the abdominal * Source: http://www.rapidcme.com/Bristol- region should be present with ❶ an alleviation of Stool-Form-Scale.html

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symptoms after defecation, ❷ changes in the bowel pattern, and ❸ changes in stool form and consistency. IBS is diagnosed if two or more of these symptoms are present. Stool form and consistency are measured with Bristol stool form scale.

However, re-evaluate the patient for any structural problems even if the symptoms fit the diagnostic criteria of IBS; if the patient is over 50 years old, if the duration of onset is short, if the patient exhibits significant weight loss, rectal bleeding, anemia, nocturnal symptoms, a family history of other underlying problems of the large intestine or rectum, inflammatory conditions of the intestines, non-tropical sprue, or celiac sprue, recent exposure to antibiotics, ulcers in the abdomen or rectum, severe fevers, and other signs of inflammation.

IBS is similar to the symptoms of abdominal pain, constipation, and diarrhea described in Ko- rean Medicine. The most prominent causes are excessive psychological stress and other emotional factors that remain unresolved for an extended period of time to cause liver depression and qi stagnation. Liver-spleen disharmony patterns affect intestinal motility. An inappropriate diet, physical and mental overstrain, and cold and damp living conditions are factors that may further aggravate the condition. Although the symptoms are present in the intestines, this condition results from a loss of the normal function of the liver, spleen, and kidneys. Therefore, when treating such conditions, the physician must also consider the liver, spleen, and kidneys for a pattern identification.

2. Treatment

Conventional treatments for IBS include sedatives, anti-diarrheals, antibiotics, anti-depressants and other medications, modifications to the diet and other habits, as well as therapies to relieve psychological stress. Diet control is becoming increasingly important for IBS as well as other gastrointestinal conditions. The basic principle of treatment is to avoid food that triggers symptoms. These types of food are usually fried food, pork, flour products such as bread and noodles, and cold food such as ice cream and cold noodles. For diarrhea type, patients should limit their intake of dietary fibers, as they may stimulate intestinal motility. Patients with IBS-C should consume more dietary fiber. Patients should limit their consumption of alcoholic beverages and soft drinks. Patients should limit the number of caffeinated drinks consumed to

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no more than 3 cups per day and substitute caffeinated drinks with water or herbal tea. Whole wheat, flour, cereal with high bran content, and unpolished rice may help alleviate symptoms, but starch (carbohydrates that remain in the small intestines for an extended period of time) is not recommended. Patients should limit raw vegetable and fruit intake and instead boiled or cooked. Patients should limit their intake of artificial additives such as sorbitol if diarrhea is a symptom. Milk and other dairy products should be limited. If needed, dairy products may be substituted with low-fat or fat-free alternatives (Hookway et al., 2015).

Korean Medicine treatments for IBS begin with an identification of the patterns of the symptoms, including diarrhea, constipation, and abdominal pain. Patients usually present with abdominal pain or discomfort along with diarrhea. When a patient presents with symptoms of diarrhea and abdominal pain under emotional stress situations, this person may be a liver depression and spleen deficiency-type patient. Patients with this subtype complain of a sudden, urgent need to defecate, and abdominal pain is alleviated after defection. Patients with this type complain of frequent dyspepsia and often complain of lethargy. Possible herbal medicines include the ‘Augmented Important Formula for Painful Diarrhea’ (痛瀉要方加味) : 8g each of stir-baked Atractylodis Rhizoma Alba (白朮) and stir-baked Radix Paeoniae Alba (白芍藥), 6g each of Radix Ginseng (人參), Poria Sclerotium (白茯苓), Coicis Semen (薏苡仁), and stir- baked Radix Saposhnikoviae (防風) and 4g of Radix Glycyrrhizae (甘草). The second subtype is the spleen-kidney yang deficiency (脾腎陽虛)-type. Diarrhea is generally mucous-like and the patients experience subtle abdominal pain. Diarrhea usually occurs early in the morning and the body responds very sensitively to cold food. Prescribe a combination of ‘Four-Miracle Pill’ (四神丸) : Psoraleae Semen (破故紙), Myristicae Semen (肉豆蔲), Fructus Schisandrae (五味子), Fructus Evodiae (吳茱萸), Zingiberis Rhizoma Crudus (生薑), Fructus Zizyphi (大棗) and ‘Regulate the Middle Decoction’ (理中湯) : 4g of Radix Ginseng (人參), Atractylodis Rhizoma Alba (白朮), Zingiberis Rhizoma (乾薑) and Radix Glycyrrhizae (甘草) for use. If the patient also has dyspepsia, add stir-baked Fructus Amomi (砂仁) and Fructus Hordei Germina- tus (麥芽). The third type is the dampness heat obstruction-type (濕熱阻滯), which presents as twisting pain in the abdomen. Diarrhea does not help alleviate the symptoms thus the patient makes frequent visits to the restroom. The body feels heavy and the mouth feels dry. In this case, prescribe ‘Pinellia Decoction to Drain the Epigastrium’ (半夏瀉心湯) : 8g each of Pinelli- ae Tuber (半夏), 6g each of Radix Scutellariae (黃芩), Radix Ginseng Radix (人參) and Radix

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Glycyrrhizae (甘草), 4g of Zingiberis Rhizoma (乾薑), 2g of Coptidis Rhizoma (黃連), and 4g each of Zingiberis Rhizoma Crudus (生薑) and Fructus Zizyphi (大棗). Modify the treatment accordingly. The last type is the intestinal fluid depletion (腸道津虧)-type. The main symptom is constipation. The stool is very dry and very small and round, like the feces of a goat. The abdomen feels bloated and painful. The patient feels as if they are experiencing a fever, and the mouth feels dry. For these types, prescribe modified versions of ‘Linking Decoction’ (一貫煎), a prescription consisting of 16g of Rehmanniae Radix Crudus (生地黃), 12g each of Radix Adenophorae Radix (沙參) and Cassiae Semen (決明子), and 8g each of Liriopis Tuber (麥門冬), Angelica Gigantis Radix (當歸), Lycii Fructus and Meliae Fructus. If there are signs of constipation, add Rhei Radix et Rhizoma and Aruantii Fructus Immaturus. In a review of 279 publications from 1985 to 2015 discussing the treatment of IBS-D, the liver depression and spleen deficiency (肝鬱脾虛)-types were the most prevalent (81.47%), followed by the spleen-kidney yang deficiency (脾腎陽虛)-type (11.2%), dampness turbidity stagnation (濕濁瘀阻)-type (4.25%), and heart spirit deficiency (心神不定)-type (3.09%). An analysis of the herbal medicines prescribed showed that medicines that replenish deficiencies (補虛藥) were prescribed most often (29.26%), followed by medicines that help qi flow (理氣藥) (12.07%), and medicines that release the exterior (11.27%). The single herbs, Atractylodis Rhizoma Alba (白朮), Paeoniae Radix Alba (白芍藥), Poria Sclerotium (茯苓), Radix Glycyrrhizae (甘草), Citrus Unshius Pericarpium (陳皮), and Radix Saposhnikoviae (防風) were most frequently prescribed (Wei et al., 2016).

Acupuncture treatment is usually applied to CV10, ST25, LI03, SP04, PC06 , ST36, and ST37. Needles should be inserted perpendicularly to ST36 and ST37, then stimulated with twisting movements to left and right. Then, connect the needles to the electroacupuncture instrument and apply a low frequency stimulus of approximately 1-4Hz, which is just strong enough for the patient to feel muscle twitching or mild pain. The treatment time should be approximately 20 minutes. Minimum treatment should consist of three sessions per week for 6 weeks.

3. Care and Maintenance

Korean Medicine emphasizes the management of psychological stress and appropriate food consumption for the prevention of problems in the digestive system, and states that

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“The Heart is an organ of the King. It is where bright spirit arises”. All emotional changes (joy, fury, sadness, worries, and fear) arise from the heart. If emotional stress is severe, sudden, or chronic, it interferes with the healthy state of the body and causes disease. Excessive emotional stress may affect gastrointestinal activity. Therefore, it is also important for patients to establish a lifestyle that controls emotional stress. Food is a factor that greatly affects overall health. It is a critical component that promotes normal physiological processes. Immunity to diseases, normal growth and recovery are all based on appropriate nutrition. Korean Medicine literature specifies that “the basis of maintaining the body in a healthy state is food, and the fundamental component of disease treatment is medicine”. The four main principles of food regimen are as follows: ❶ maintain a balanced diet and refrain from consuming greasy or provocative food, ❸ eat meals at a pre-designated time, ❷ prepare foods soft and warm, chew the food thoroughly and slowly, ❹ be selective with the food you eat, and eat clean and fresh food.

Reference

•American College of Gastroenterology Task Force on Irritable Bowel Syndrome et al. An evidence-based position statement on the management of irritable bowel syndrome. Am J Gas- troenterol 2009;104(Suppl1):S1-35. •Bredenoord AJ et al. Gastro-oesophageal reflux disease. Lancet. 2013;381(9881):1933-42. •Cui SS et al. Progression of TCM Typing Regular in Functional Dyspesia. Journal of Liaoning university of TCM. 2011;13(3):83-5. •Dickman R et al. Clinical trial: acupuncture vs. doubling the proton pump inhibitor dose in refractory heartburn. Aliment Pharmacol Ther. 2007;26(10):1333-44. •Fass R, Dickman R. Nonerosive reflux disease. GI Motility online (2006) doi:10.1038/gimo42 •Gan Y et al. Effect of banxiaxiexin tang on treatment of functional dyspepsia: a meta-analysis of randomized controlled trials. J Tradit Chin Med. 2014;34(2):140-4. •Halder SL et al. Functional dyspepsia: a new Rome III paradigm. Curr Treat Options Gstroen- terol. 2007;10(4):259-72. •Han GJ et al. Development of a Standard Tool for Pattern Identification of Gastroesophageal Reflux Disease. J Kor Orient Int Med. 2015;36(2):122-52. •Hookway C et al. Irritable bowel syndrome in adults in primary care: summary of updated NICE guidance. BMJ. 2015;350:h701.

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•Kang K et al. Correlation between qi-stagnation and pressure pain threshold on CV17 in burning mouth syndrome patients-In the perspective of Quantification of pressure pain threshold on CV17 by using algometer. J Int Kor Med. 2012;33(4):498-510. •Kang SY. A review on clinical studies of the acupuncture and moxibustion therapy for gastroesophageal reflux disease in china by searching CAJ. Kor J Acupuncture. 2015;32(1):1-12. •Katz PO et al. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108:308-28. •Kim J et al. Development of Instrument of Pattern Identification for Functional Dyspepsia. J Physiol Pathol Kor Med. 2010;24(6):1094-8. •Kim JW et al. A clinical study on treatments of Hwabyung with oriental medicine. J Kor Med. 1998;19(2):5-16. •Kim SK et al. Does Realistic Clinical Acupuncture Treatment Have an Effect on Functional Dyspepsia? Gastroenterology. 2015;148(4):S-820-1. •Lan L et al. Acupuncture for functional dyspepsia. Cochrane Database Syst Rev 2014;(10):CD008487. •Lovell RM et al. Global prevalence of and risk factors for irritable bowel syndrome: a meta-analysis. Clin Gastroenterol Hepatol. 2012;10:712-21. •Park DW et al. The differences in prevalence and sociodemographic characteristics of irritable bowel syndrome according to Rome II and Rome III. J Neurogastroenterol Motil. 2010;16:186-93. •Saegusa Y et al. A new strategy using Rikkunshito to treat aAnorexia and gastrointestinal dysfunction. Evid Based Complement Alternat Med 2015;2015:364260. •Shin CM. Diet and nutritional management in functional gastrointestinal disorder:functional dyspepsia. Kor J Med. 2016;90(2):98-104. •SLS Halder et al, NJ Talley. Functional dyspepsia: a new Rome III paradigm. Current treatment options in gastroenterology, 2007, 10.4: 259-272. •Son J et al. Effects of korean medicine therapies on oral pain in patients with burning mouth syndrome: a before and after study. J Kor Orient Int Med. 2013;34(2):122-33. •Sun A et al. Burning mouth syndrome: a review and update. J Oral Pathol Med. 2013;42(9):649-55. •Tominaga K et al. Kampo medicines for gastrointestinal tract disorders: a review of basic science and clinical evidence and their future application. J Gastroenterol. 2013;48:452-62. •Wei B et al. Analysis on principles of herbal medicine utilized to treat irritable bowel syndrome with diarrhea during the past 30 years. Journal of Emergency in Traditional Chinese Medicine. 2016;25(4):658-60. •Wu LL et al. Recent advanced in treatment of gastgroesophageal reflux disease by acupuncture. World Chinese journal of Digestology. 2014;22(36):195-218. •Xu S et al. Electroacupuncture accelerates solid gastric emptying and improves dyspeptic symptoms in patients with functional dyspepsia. Dig Dis Sci. 2006;51(12):2154-9. •Zhimin Y et al. A systematic review of acupuncture or acupoint injection for management of burning mouth syndrome. Quintessence International. 2012;43(8):695-701.

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Women’s Diseases

▼ Deok-Sang Hwang PART 2 Korean Medicine Treatments for Various Medical Conditions

chapter 4

Women’s Diseases

Introduction

Korean Medicine obstetrics and gynecology is a branch of clinical science that in- vestigates diseases unique to women based on anatomy, physiology, and pathology, also taking Korean Medicine theories into consideration. Both the local and general causes of disease are carefully observed from a holistic perspective. Korean Medicine has traditionally emphasized the differences between men and women, which include not only anatomical structures but also physiological functions, psychological differences, and sociocultural roles. The female reproductive system is distinct from the male reproductive system and therefore has different physiological functions, such as menstruation, pregnancy, childbirth, and breastfeeding. Because of these structural and functional factors, problems such as dysmenorrhea, vaginal discharge, pregnancy-related conditions, complications during childbirth, postpartum conditions, breast problems, external genitalia issues and other illnesses relevant to the genital system arise. All such problems are subject to treatment at the Korean Medicine Obstetrics and Gynecology clinic. Korean Medicine also emphasizes the importance of mind and body.

In Korean Medicine, psychological causes were importantly recognized for an approach that has been proven to be highly effective.

A treatment of women’s diseases should always be based on a structural diagnosis. With conventional diagnostics, the practitioner should accurately diagnose the problem and provide treatment for both structural and functional problems. This chapter introduces several prevalent conditions treated with Korean Medicine.

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Cyclic Pelvic Pain

Pain in the lower abdominals and upper pubic area during or before and after menstruation is called dysmenorrhea. Dysmenorrhea is also referred to as “pain during menstruation”, “abdominal pain while menstruation occurs”, or “menstruation period abdominal pain”. Prima- ry dysmenorrhea is dysmenorrhea that occurs without any structural lesions of the intrapelvic organs. Secondary dysmenorrhea is caused by a disorder in the reproductive system. Primary dysmenorrhea usually begins within 1 to 2 years of the first menstruation. While more prevalent in younger women, primary dysmenorrhea may affect women in their 40s as well. Secondary dysmenorrhea usually begins several years after the first menstruation. Endometriosis, uterine myoma, intrauterine devices, adenomyosis, polyps, and inflammation may be underlying causes of secondary dysmenorrhea.

1. Primary Dysmenorrhea

Primary dysmenorrhea usually begins several hours prior to or after menstruation. The pain lasts for approximately 48~72 hours. Cramping pain occurs above the pubis and is similar to pain before labor. Low back pain, referred pain to the anterior surface of the thigh, nausea, vomiting, and diarrhea may also be present. In some rare cases, the patient may lose consciousness. Vital signs are normal, and tender points can be found in the pubic region. Bow- el sounds are normal, and there is neither pain in the upper abdominals nor rebound tenderness. Tender points can be found during a dysmenorrhea episode, but tenderness aggravated with movement and/or tenderness of adnexa are not common. All diagnostic testing of the intrapelvic organs is negative.

(1) Cause of Disease / Mechanism of Disease

Women undergo many changes before, during, and after menstruation. Due to this, women are vulnerable to vulnerable to pathogens. Psychological factors, congenital weakness, and the six excesses greatly affect menstruation. These three factors also contribute greatly to the onset of dysmenorrhea. The mechanism of dysmenorrhea causes pain due to hindered circulation (excessive type condition) and pain due to insufficient nurturing (deficiency type

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condition). Pain due to hindered circulation can be further subtyped as qi and blood stagnation, cold congealed in the uterus, dampness heat flowing downwards, and pain due to insufficient nurturing can be subtyped as qi and blood deficiency (氣血虛弱) or liver-kidney deficiency.

❶ Qi stagnation and Blood Stagnation - Liver qi is not able to disperse, causing obstruction of the qi mechanism and further causing stagnation of the blood, which cannot flow into the thoroughfare and conception vessels. Therefore, the blood of the meridians cannot leave the uterus, causing the state of dysmenorrhea.

❷ Cold Coagulated in Uterine - Women who are born with a cold-type constitution, have lived in a damp, cold area for a long time, were exposed to cold environment during menstruation, or have consumed excessive amounts of cold food have damaged their lower energizer. The uterus, therefore, is also cold. Blood of the meridians is coagulated, resulting in dysmenorrhea.

❸ Qi Deficiency - If the qi or blood becomes deficient or is damaged due to severe diseases or chronic illnesses, the blood becomes even more deficient by the end of the menstruation cycle. The uterine vessels are not nurtured sufficiently, which may be a cause of dysmenorrhea. In some cases, qi stagnation is due to blood deficiency.

❹ Liver-Kidney Deficiency - If born with a deficient liver and kidney or the liver and kidney are damaged due to repeated childbirth and/or sexual incontinence, essence blood becomes deficient. During menstruation, yin blood becomes even more deficient, and the uterine vessels are not properly nurtured, resulting in dysmenorrhea.

(2) Diagnosis

To diagnose primary dysmenorrhea, it is critical to rule out any structural lesions of the pelvic region and to identify pain patterns. The size, shape, and motility of the uterus and relevant organs should be checked. Tenderness and any nodules or tumors in the pelvic region should be identified. For differential diagnosis from subacute salpingo-oophoritis, culture tests for

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Patient with Dysmenorrhea

History taking : Pain patterns (periodicity, referred pain) Infection Use of IUD

Correlation to menstruation

Yes No

Physical Tests for abdominal pain : tests/Observation X-ray, ultrasonography internal/external medicine

Abnormal Normal Findings

Secondary Primary Dysmenorrhea

Ultrasonography Endometriosis Hysterosalpingography Adenomyosis, uterine myoma, polyps Laparosoopy uterine deformities(hymen, vaginal Hysteroscopy diaphragm) endometrial adhesion, Biopsy Chronic pelvic inflammation disease

[ Figure 1 ] Diagnosis of dysmenorrhea

gonococcuse and Chlamydia trachomatis, blood lab tests, and erythrocyte sedimentation rate tests should be performed. When no findings are confirmed, it can be diagnosed as primary dysmenorrhea.

(3) Treatment

The fundamental rule of dysmenorrhea treatment is restoring balance to the qi and blood of the thoroughfare and conception vessels. Methods to move the qi, activate the blood, dissipate cold, clear heat, replenish deficiencies, and drain excesses should be used accordingly. During menstruation, symptoms should be treated with methods that regulate blood to stop pain. At other times, consider the patient’s constitution type and determine the cause of the

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condition to treat the cause. Regulate the liver, tonify the kidney, and/or reinforce the spleen.

Donguibogam recommends diagnosis of dysmenorrhea using the excess-deficient model. Herbal medicines recommended for use include ‘Augmented Eight-Substances Decoction’ (四物湯加味) and ‘Augmented Four-Substances Decoction’ (八物湯加味), or ‘Clear Heat and Regulate the Blood Decoction’ (淸熱調血湯). Later, publications such as Cheongkangeuigam have supported the use of Hyunbooyikyung-tang (玄附理經湯) for qi stagnation.

❶ Qi stagnation and Blood stagnation - Clinical symptoms: One to two days prior to each menstruation cycle or during the menstruation period, the lower abdominals feel swollen and painful, with prominent tender points. The breasts also feel swollen and painful before menstruation, with similar symptoms on the sides. Menstruation cycles may be irregular, and the amount of menstrual fluid is decreased substantially. Menstrual fluid is blackish red with membrane-like lumps. Pain is alleviated after lumps are secreted. These types of patients are usually under intense emotional stress and are always tense and anxious. In severe cases, nausea and vomiting are present. The tongue is dark or spotted, and the pulse feels string-like or and rough. - Treatment strategy: Activate blood and resolve stasis, regulate qi, and move stagnations to stop pain. - Herbal medicine: Hyunbookyikyung-tang (玄附理經湯), ‘Drive out Stasis under Dia- phragm Decoction’ (膈下逐瘀湯).

❷ Cold and Dampness Congealed and Stagnant. - Clinical symptoms: The lower abdominal region feels cold and painful before or during menstruation. The pain even extends to the low back. Warming the areas of pain can help alleviate the condition. Menstrual fluid is occasionally decreased in volume and is dark with lumps; menstruation may also be delayed. The face appears pale, and warmth cannot be detected in the extremities; the patient avoids cold items and feels pain all over. The tongue appears bland yet dark, the tongue fur is white and slippery, and the pulse feels sunken and tense. - Treatment strategy: Warm cold and dissipate dampness, activate the blood and resolve stasis, and regulate the qi to stop pain. - Herbal medicine: ‘Drive Out Stasis Decoction in Small Abdomen’ (少腹逐瘀湯), ‘Painful

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Menstruation Decoction’ (痛經湯).

❸ Qi and Blood Deficiency - Clinical symptoms: There is subtle pain in the lower abdominals during or after menstruation. The patient will sometimes complain of an “emptiness” in the lower abdominals. Compressing the abdomen will be relaxing, and rubbing it will alleviate the pain. The amount of menstrual fluid may either be too little or too much. Menstruation itself is either early or delayed. If more a qi deficiency-type, menstruation occurs early. If more a blood deficiency-type, menstruation is delayed, and the amount of fluid is increased. The face appears pale, and the mind is unclear. Vertigo or palpation may be accompanied. The tongue appears bland and red, tongue fur is white and thin and the pulse feels thin and weak. - Treatment strategy: Replenish blood and boost qi, regulate meridians to stop pain. - Herbal medicine: ‘Ten significant Great Tonifying Decoction’ (十全大補湯), ‘Sagely Heal Decoction’ (聖愈湯).

❹ Liver-Kidney Depletion - Clinical symptoms: There is subtle pain in the lower abdomen after menstruation. Either an increase or a decrease in the amount of menstruation fluids is observed. The color of the fluid is bland, and the texture is thin. There is soreness in the low back, vertigo, and/or tinnitus. Urine is clear and frequent. If it tends to be more a liver-kidney yin deficiency-type, tidal fevers, dryness of the mouth, and insomnia will be present due to heat in the chest. The tongue appears pale and dark or slightly red. There is not much tongue fur, the pulse feels sunken, thin, and weak, and both cubital pulses are weak. - Treatment strategy: Replenish the kidney and nourish the blood; regulate the liver to alleviate pain. - Herbal medicine: ‘Great Nutrition Decoction’ (大營煎), ‘Small Nutrition Decoction’ (小營煎), ‘Regulate the Liver Decoction’ (調肝湯). - Acupuncture and moxibustion treatment ・ Acupuncture: CV4, CV04, SR06, LR03 is the crossing point (交會穴) of the three yin meridians of the foot (足三陰經) and the conception vessel (任脈). SP6 is the crossing point (交會穴) of the three yin meridians of the foot (足三陰經). LR3 is the transport

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point (輸穴) of the liver meridian. Pallyo(Eight Influential) acupoints (八髎穴) refer to the BL31, BL32 , and BL34. ・ Stimulate: CV3, CV6, BL67, CV4, SP6, LI04, LR3, and Pallyo acupoints (八髎穴). ・ Sa-Am acupuncture: Small intestine Junggyuk + SP06, liver Junggyuk ・ Auricular acupuncture: Uterus, Endocrine, Sympathetic, Shenmun - Moxibustion

(4) Recent findings

‘Seven Refined Ingredients Cyperus Pill’ has been proven effective for warming the abdomen to help reduce symptoms of dysmenorrhea. Qi-blood stagnation-type patients administered with modified Hyunburikyung-tang for 20 days, reported a significant improvement in pain scores. Hyunburikyung-tang was effective for both secondary and primary conditions. Treatment outcomes were maintained 6 months after completion of treatment in 44.68% of patients. In 19.1% of patients, pain relapsed between 3 months to 6 months after completion of treatment.

(5) Prevention

To prevent dysmenorrhea, recommend an exercise which relax the muscles around the pelvic area, and reinforce relevant muscles. It is important to refrain from high-sugar foods. Eat and sleep at regular times. Dysmenorrhea can be prevented when yin and yang are in harmony.

2. Secondary Dysmenorrhea

Secondary dysmenorrhea can occur several years following menarche. The presence of structural lesions in the intrapelvic region is more important rather than the age of the patient. Symptoms of dysmenorrhea begin 1–2 weeks prior to menstruation and continue until several days after menstruation. Little is known about the mechanism of secondary dysmenorrhea. It is considered that excessive prostaglandin, obstruction of the cervical canal, intrauterine tumors, and foreign bodies cause excessive contraction of the uterus. Analgesics and oral contraceptives are less effective for such conditions than for primary dysmenorrhea.

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Causes of secondary dysmenorrhea include endometriosis, Intrauterine Device (IUD), Pelvic Inflammatory Disease (PID) and infections, adenomyosis, uterine myoma, uterine polyps, uterine adhesions, bicornuate and septate uterus, transverse vaginal septum, blind uterine horn, cervical strictures or stenosis, ovarian cyst, and pelvic congestion syndrome.

Korean Medicine diagnosis and treatment for primary and secondary dysmenorrhea are largely the same. However, secondary dysmenorrhea usually requires a longer treatment period, and conventional treatment may also be needed.

Climacteric Syndrome

Women begin menopause between the ages of 40 and 50. The exact age of menopause varies depending on geographic region, ethnicity, age at menarche, and any prior birth. Cultural and financial factors also affect the condition. Korean women generally begin menopause at approximately 50 years of age. The life expectancy at birth of Koreans born in 2011 is estimated to be approximately 81.2 years. This means that, on average, Korean women will spend 1/3 of their lives after menopause. Therefore, it is critical to overcome climacteric symptoms.

Climacteric syndrome refers to a condition with a wide range of symptoms during the time when reproductive ability gradually decreases, in other words, during the menopausal transition.

Menopause is a natural phenomenon of the human body. While symptoms that is present during this time may cause substantial discomfort and be subject to treatment, menopause itself should be understood as only a part of the natural aging process of the body. Menopause is a natural change in a woman’s life and should not be considered a state of disease. If this change is recognized as the permanent nature, it causes anxiety and agony. Decreased hormone level is not considered as a disease. Even Novak & Berek Gynecology does not find the deficiency of estrogen to be the cause of hot flashes, which are instead due to sudden, abrupt changes in hormone level. In fact, patients with Turner syndrome, which is similar to climacteric syndrome in that

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Follicle Stimulating Hormone (FSH) levels are increased while estrogen levels are decreased, do not have hot flashes. If patients cease hormone treatment, hot flashes occur. The conventional treatment for climacteric syndrome usually includes hormone therapies. Recent publications in obstetrics and gynecology recommend the lowest effective dose of Hormone Therapy (HRT) for the shortest amount of time possible. Precaution is needed when treating with hormone therapy. Korean Medicine treatment helps alleviate symptoms and facilitate the menopausal transition without hormone therapy. Vasomotor symptoms usually last for 1–2 years after menopause in most women but may last for 10 years or more in severe cases. Hormone replacement therapy using the lowest dosage for the shortest period of time can be used in combination with Korean Medicine.

1. Cause and Mechanism of Disease

During menopause, kidney qi becomes increasingly deficient. Heavenly tenth (天癸) becomes deficient, and the thoroughfare and conception vessels become deficient as well, and the woman loses her reproductive ability. Viscera and bowel function are also affected, causing disharmony in yin and yang, therefore it becomes a disease. Symptoms of climacteric syndromes vary depending on the cause of the ovarian dysfunction, sociocultural factors, and psychological factors. A wide variety of different symptoms is present over an extended period of time. The causes of the condition include liver stagnation, heart-liver fire exuberance, disharmony of heart and kidney, spleen-heart deficiency, and blood stagnation.

2. Diagnosis

(1) Symptom Analysis

Climacteric symptoms include those stated in the climacteric syndrome classification table. Hot flashes and a sense of upsurging qi and other vasomotor symptoms are the most typical climacteric symptoms. Other common symptoms include low back pain, shoulder pain, and fatigue.

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Table. The classification of climactic syndrome

Hot flashes, signs of upsurging qi, cold A group hands and feet Vasomotor symptoms B group Shortness of breath, palpitations Acute Neurological/muscular Shoulder pain, headache, low back pain, C group symptoms joint pain

Neuropsychological Restlessness, anxiety, insomnia, D group symptoms helplessness,

Dry skin, itching, numbness of the hands Skin sensory symptom E group and feet

Vaginal atrophy Vaginal dryness, dyspareunia, loss of Subacute F group symptom interest in sex

Bladder/ureter atrophy G group Urinary frequency, urinary incontinence symptom

Neuropsychological Restlessness, anxiety, insomnia, Acute D group symptoms helplessnes

Hyperlipidemia

Chronic Osteoporosis

Increased risk of cardiovascular diseases

(2) Diagnosis

• Clinical symptoms • Lab tests Estradiol and gonadotropins are analyzed. The average blood contents of these hormones in women after menopause are as follows. ・ Estradiol (E2): Below ND~14 pg/mL ・ FSH > 40 mIU/mL ・ LH > 25 mIU/mL ・ AMH < 0.08

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However, the analysis of hormone levels should be considered upon the clinical symptoms. Comparison of different hormone levels is also recommended.

3. Treatment

(1) Kidney Yin Deficiency

• Clinical symptoms: Hot flashes, sweating, nausea, fever, vertigo, and tinnitus. There is also memory loss and itchiness that feels as if bugs are crawling. The genitals are dry, rough, and itchy. Urine appears yellow, and stool is dry and hard. In some cases, menstruation occurs early, and the amount of menstrual fluid is decreased. In some cases, menstruation is irregular or similar to flooding and spotting. The tongue is red, tongue fur is scarce, and the pulse feels thin and rapid or sunken, string-like or thin. • Treatment strategy: Nourish and nurture the liver and kidney, cultivate yin and nourish yang • Herbal medicine: ‘Restore the Left (Kidney) Drink’ (左歸飮), ‘Rehmannia Decoction with Anemarrhena and Phellodendron’ (知柏地黃丸)

(2) Kidney Yang Deficiency

• Clinical symptoms: The hands and feet feel cold, and edema is common. Stool is soft, and urination is frequent; occasionally, urinary incontinence is also present. Menstruation is irregular or flooding, and spotting occurs. The tongue appears pale, the tongue fur is white, and the pulse feels sunken, delayed and weak. • Treatment strategy: Warm the kidneys and invigorate yang • Herbal medicine: ‘Restore the Right (Kidney) Pill’ (右歸丸)

(3) Kidney Yin and Yang Deficiency

• Clinical symptoms: Vertigo, tinnitus, weakness and soreness in the low back, and hands and feet are cold. Hot flashes are present, accompanied by spontaneous sweating and night sweating. The tongue appears pale, the tongue fur is thin and white, and the pulse feels sunken, string-like and thin.

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• Treatment strategy: Warm the yang, cultivate water, and boost yang and thoroughfare and conception • Herbal medicine: ‘Restore the Left (Kidney) Pill’ (左歸丸) combined with ‘Two Immortals Decoction’ (二仙湯)

(4) Disharmony of Heart and Kidney

• Clinical symptoms: Heart palpations are common, and the patient is startled easily. The chest feels vexing and uncomfortable. Patients sleep less but dream more. The knees and low back feel sore and weak. Concentration and memory ability are impaired. Menstrua- tion is irregular. The tongue appears red, tongue fur is scarce, and the pulse feels sunken, string-like and thin or thin and rapid. • Treatment strategy: Nourish yin to control fire, and replenish the kidney to calm the heart. • Herbal medicine: ‘Water and Fire Instant Relief Decoction’ (坎离旣濟丸), ‘Licorice Wheat and Jujube Decoction’ (甘麥大棗湯) combined with ‘Cinnamon Twig Decoction with Dragon Bone and Oyster Shell’ (桂枝加龍骨牡蠣湯).

(5) Liver Stagnation

• Clinical symptoms: The patient is mentally stressed, depressed, and stuffy in the chest. The chest and abdominals feel swollen. The patient is easily enraged, cannot sleep well, dreams a lot, has hot flashes, and sweats heavily. The patient is sad without any specific reason. In severe cases, the patient may lose self-control or become disoriented. Menstruation is irregular. There are alternating episodes of constipation and loose stool. The tongue appears red, and the tongue fur is thin, thin and yellow, or yellow and slimy. The pulse feels sunken and string-like or string-like and rapid. • Treatment strategy: Soothe the liver to release stagnation. • Herbal medicine: ‘Rambling powder’ (逍遙散).

(6) Heart Spleen Deficiency

• Clinical symptoms: Palpitations, shortness of breath, and insomnia are observed. Hot flashes are present with heavy sweating on the face. The face is frequently swollen, appetite is

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lost, and the patient feels lethargic. Stool is soft, and bloody discharge is occasionally observed. The tongue appears pale, the tongue fur is thin, and the pulse feels thin or slippery. • Treatment strategy: Replenish the heart and fortify the spleen. • Herbal medicine: ‘Restore the Spleen Decoction’ (歸脾湯). • Acupuncture Treatment - Recent researches proved acupuncture treatment for climacteric symptoms is very effective with strong evidence. Hot flashes respond well to acupuncture not only in climacteric patients but also patients who have the condition due to hormonal therapies for carcinoma. The mechanism of action appears to be only peripheral nerve stimulation but also changes in serotonin or beta endorphin levels induced by acupuncture. - Treatment acupoints: PC06, HT08, HT07, LI04, ST36, SP06, and CV04

4. Prevention

Climacteric syndrome is highly prevalent in overweight patients. The intensity and duration of hot flashes and perspiration are both significantly more intense in overweight patients. Kupperman’s Index is also reported to be significantly higher in patients who do not exercise regularly. Therefore, to prevent or overcome climacteric syndrome, it is important to maintain a healthy weight and regular exercise.

Vaginal Discharge

1. Introduction

It is important to figure out the condition of vaginal discharge. The vaginal discharge is considered normal if it is transparent with no color and somewhat mucous-like with no other accompanying symptoms. However, if there is an increase in the total volume of discharge, inflammation of the cervix can be suspected. Some women have large volumes of white or light yellow discharges during pregnancy. Light yellow vaginal discharge is a common symptom of

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bacterial infection. A reddish vaginal discharge may be due to bleeding. This should be treated differently from menstrual problems. For accurate diagnosis, cultures of the discharge should be performed. If the vaginal discharge is due to bacterial infection, antibiotics should be administered as part of a Korean Medicine-conventional integrative treatment. However, if the condition is chronic, Korean Medicine treatment or integrative treatment can be both recommended.

2. Cause and Mechanism of Disease

In Korean Medicine, vaginal discharge is believed to be affected by dysfunctions of all viscera and bowels. In other words, if kidney qi is deficient or if spleen function is hindered, the conception vessel becomes weak, and the belt vessel is unable to function properly. Then, the body fluids flow into the genitalia to be discharged in the form of vaginal discharge. Therefore, dampness is considered to be an important cause of disease. Spleen deficiency, kidney deficiency, dampness heat, and dampness toxins are the most common causes of vaginal discharge.

3. Diagnosis

(1) History taking The morphology of the discharge should be determined, and any odors or pain and the duration of discharge should be noted. Any previous history of sexually transmitted diseases, use of tampons, use of antibiotics, infection, and allergies should be included as well.

(2) Tests Smear method and biopsy

(3) Differential Diagnosis • White Turbidity Upon discharge from the ureter, the urine appears white and muggy. This is usually due to problems of the urinary system. • White Flooding

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Discharge from the vagina similar to white vaginal discharge. Large volumes of discharge are secreted very abruptly. In such a case, suspect tumors of the reproductive system. • Vaginal Bleeding Bleeding that occurs regularly between menstrual cycles and persists for 2–3 days at a time. The bleeding is different from red vaginal discharge in that red vaginal discharge occurs irregularly, does not stop, and the discharge looks similar to blood but is not actual blood.

• Spotting A small amount of blood is present irregularly and continue to flow without stopping. The discharge does not have a distinctive odor. It should be differentiated from the red vaginal discharge after menstruation, which is thick, milky, and has a foul odor.

4. Treatment

(1) Spleen Deficiency

• Clinical symptoms: A large amount of vaginal discharge is secreted that is sticky or watery and white or light yellow in color. The discharge is secreted continuously but with no distinctive odor. The face appears yellow, and the patient appears tired. The hands and feet feel cold, and the patient has no appetite. Stool is soft, and edema is observed in the legs. The tongue appears pale and tongue fur is white or slippery. The pulse feels thin and weak. • Treatment strategy: Fortify the spleen, boost qi, and promote yang to eliminate dampness • Herbal medicine: Wandae-tang (完帶湯), ‘Ginseng, Poria, and Atractylodes Macroceph- ala Powder’ (蔘苓白朮散)

(2) Kidney Deficiency

1. Kidney Yang Deficiency • Clinical symptoms A large amount of vaginal discharge is secreted for a long period of time. The discharge is watery and white in color. There is no distinctive odor. The patient’s face appears dark in color, the low back feels sore, and the lower abdominals feel cold. Urination is frequent,

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and the urine is clear. This symptom worsens during the night. Stool is soft, and the patient is sensitive to cold. The tongue is pale, tongue fur is white, and the pulse feels sunken and delayed. • Treatment ❶ Treatment strategy: Warm and replenish kidney yang, make rough, stop discharge. ❷ Herbal medicine: ‘Tonify the Inside Pill’ (內補丸), ‘Cervi Cornu and Cnidii Pill’ (鹿角菟絲子丸).

2. Kidney Yin Deficiency • Clinical symptoms A small amount of vaginal discharge is present. The color is pale red or a mixture of white and red. The discharge is very sticky, but with no distinctive odor. The vagina feels dry and rough, or a burning sensation or discomfort may be present. There is tidal fever on the face. Vertigo, soreness of the low back, and tinnitus are common symptoms. These patients cannot sleep well and dream frequently. The mouth is dry, and stool is hard. Urine is also yellow. The tongue appears red with very little fur, and the pulse feels thin and rapid. • Treatment ❶ Treatment strategy: Boost kidney, nourish yin, clear heat • Herbal medicine: ‘Rehmannia Decoction with Anemarrhena and Phellodendron’ (知栢地黃湯)

(3) Dampness heat • Clinical symptoms A large amount of vaginal discharge is secreted. The discharge is yellow and sticky. The color may be white and appear cheesy. Occasionally threads of blood are mixed with the white vaginal discharge. The odor may be foul. The chest, sides and breasts feel uncomfortable or swollen and painful. The mouth tastes bitter, and the throat feels dry. Pain is present in the lower abdominals, accompanied by a burning sensation in the vagina. Urine is yellow, and diarrhea is often present. The tongue appears red, tongue fur is yellow and slippery, and the pulse feels string-like and slippery. • Treatment ❶ Treatment strategy: Clear heat and release dampness to stop discharge. ❷ Herbal medicine: Jidae-bang (止帶方), ‘Scutellaria, Atractylodes, and Ailanthi Radicis

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Cortex Pill’ (芩朮樗皮丸), ‘Scutellaria, Phellodendron, and Ailanthi Radicis Cortex Pill’ (芩栢樗皮丸), ‘Gentian Drain Liver Decoction’ (龍膽瀉肝湯).

(4) Dampness Toxins

• Clinical symptoms A large amount of yellow and sticky vaginal discharge is secreted. The discharge may even appear mucous-like with blood mixed in or may be milky. In severe cases, pyemia is observed, and the discharge has a foul odor. The lower abdominal region feels as if it is going to fall off. Significant, actual, detectable fever is present with pain/burning sensation of the genitalia. The chest feels stuffy and uneasy, and the lips become dry. Urine volume is decreased and is yellowish-red color. Stool becomes hard. The tongue appears red, tongue fur is yellow and dry and the pulse feels slippery and fast. • Treatment ❶ Treatment strategy: Clear heat, detoxify, eliminate dampness. ❷ Herbal medicine: modified Ohmisodok-eum (五味消毒飮).

Aggregation-Accumulation (Women’s Tumors)

1. Introduction

Aggregation-accumulation (癥瘕) refers to all tumors that form in the female genitalia. Similar conditions are described in Korean Medicine; paraumbilical and hypochondriac aggregation, and stuffiness mass. However, these conditions differ in their location, morphology, and other characteristics. Korean Medicine treatment of tumors should be based on conventional diagnosis. Surgical procedures and/or hormone treatments should be considered according to the patient’s condition. It is important to determine whether Korean Medicine should be the only form of treatment or whether referrals are needed. 2. Cause and Mechanism of Disease

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(1) Qi Stagnation Women tend to be more vulnerable to stress. Qi stagnation is usually a result of seven emotions causing internal damage. Rage and fury harms the liver, and anxiety and thought damage the spleen. If qi stagnation remains unresolved for an extended period of time, it develops into stagnation, and when exposed to phlegm, accumulations may form.

(2) Blood Stagnation

Hindered blood circulation in women can cause many problems. Blood stagnation can not only be caused by qi stagnation but also by exposure to cold wind after menstruation or immediately after childbirth, when healthy qi is deficient and the blood chamber is vulnerable. If sexual incontinence causes the formation of residual blood and foul essence, blood stagnation may result.

(3) Dampness Phlegm

Dampness phlegm form due to dysfunction of the liver, spleen, and kidneys. The liver has free coursing properties, which helps circulation. The spleen helps digestion and the movement of water and dampness, and the kidney is an important part of water circulation as it affects bladder function.

Aggregation-accumulation is caused by a variety of different factors, but the greatest con- tributor is qi stagnation and blood stagnation. Dampness phlegm, dampness heat, and food stagnation may all be causes of qi stagnation and/or blood stagnation. In the acute stages, the disease is more likely to be an excessive type, but when the condition becomes chronic, the symptoms are a mixture of deficient and excess symptoms.

3. Diagnosis

The results of history taking, physical examinations, X-ray, sonography and laparoscopy are all considered for diagnosis.

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4. Treatment

(1) Qi stagnation

• Clinical symptoms: The mass is not hard and shifts positions. Because the site of the mass is inconsistent, the areas of the pain are also subject to change. Occasionally menstruation is delayed, or the amount of menstrual fluid is decreased. Dysmenorrhea or an increase in the amount of vaginal discharge is observed. The lower abdominal region feels swollen and painful, with discomfort in the chest area and belching; the patient always feels suppressed. Tongue fur is thin and glossy, and the pulse feels sunken and string-like. • Treatment strategy: Move qi to dissipate stagnation, break stasis and eliminate mass. • Herbal medicine: ‘Great Seven Qi Decoction’ (大七氣湯).

(2) Blood stagnation • Clinical symptoms: The mass in the uterus is hard, firm, and fixed, therefore it does not move. The pain is severe, and the patient avoids any contact to the area. The amount of menstrual fluid is increased, or the menstruation period is extended. The menstrual blood is dark burgundy, and lumps of blood can be found. The face appears dark and dry; the mouth feels dry, but the patient does not want to drink water. The margins of the tongue are spotted. The pulse feels sunken and rough. • Treatment strategy: Activate blood and resolve stasis; break stagnation to dissipate accumulation. • Herbal medicine: ‘Cinnamon and Poria Pill’ (桂枝茯苓丸).

(3) Dampness phlegm • Clinical symptoms: The mass is soft and causes intermittent pain. Vaginal discharge is secreted in large volumes and is white, slippery and thick. The chest feels stuffy and uncomfortable, but urine volume is decreased. Tongue fur is white and slippery, the tongue is dark burgundy, and the pulse feels thin and relaxed or sunken and slippery. • Treatment strategy: Regulate qi, resolve phlegm, break stasis and eliminate the mass. • Herbal medicine: ‘Decoction of Two Aged Drugs to Relieve Depression’ (開鬱二陳湯).

218 Women’s Diseases chapter 4

Uterine Myoma

1. Introduction

Uterine myoma is the most common condition in women, with 4–11% of all women; 20% of uterine myomas are diagnosed in women in their child bearing years. Uterine myoma is actually more prevalent when ovarian function is active. Little is known of uterine myoma after menopause. Myomas are estrogen-dependent tumors, as existing myomas decease in size after menopause.

Korean Medicine treatment of uterine myoma is highly effective for symptom alleviation. Treatment aimed at reducing the size of the actual uterine myoma may not be very effective.

2. Clinical Symptoms and Signs

Clinical symptoms vary depending on the affected areas, morphology, and size of the myoma. Uterine myoma may be asymptomatic. Even patients with large myomas may present with no symptoms at all.

(1) Mass If the mass is large, it can be palpated in the lower abdomen or cause distension.

(2) Bleeding Hypermenorrhea is common and is more severe if the myoma is submucosal. Blood can be running out due to the increased surface area of the endometrium and blood congestion. Curettage can be performed for the differential diagnosis of adenocarcinoma, polyp, endometrial hyperplasia, and other functional factors.

(3) Pain Although pain is a very common symptom of uterine myoma, it is non-specific. Other underlying diseases of the urogenital/gastrointestinal systems, intrapelvic inflammation, and

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endometriosis should be ruled out. Large tumors can cause dull tension in the lower abdominal area and cyclic pelvic pain.

(4) Pressure

Large myomas can compress the bladder, causing symptoms such as urinary frequency, or the rectum, causing constipation.

3. Diagnosis

History taking, palpation, physical examination, endometrial curettage, X-ray, ultrasonography, hysterography, hysteroscopy, laparoscopy, and MRI are effective methods for diagnosing uterine myoma.

(1) Palpation

In some cases, hard and irregular masses can be palpated at the abdominal wall.

(2) Physical examination

In most cases, diagnosis of uterine myoma is possible with a very simple process. Nodules or enlargements of the uterus can be palpated.

(3) Ultrasonography

The most frequently used test for tumor diagnosis. Although ultrasonography is helpful for finding tumors, its sensitivity is low. Tumors of the uterus and the ovaries cannot be differentiated.

(4) Special tests

Hysteroscopy can help locate submucosal myomas. Laparoscopy is not usually used for the diagnosis of intrapelvic tumors but may be helpful in determining the origin of the tumor. MRI is an effective tool to differentiate uterine myoma from adenomyosis.

220 Women’s Diseases chapter 4

4. Treatment

(1) Pre-menstruation phases

• Qi stagnation and Blood Stagnation - Clinical symptoms: Patient usually is under considerable mental stress. The breasts feel swollen and painful before menstruation, the chest and the sides feel swollen and uncomfortable, or the chest may feel stuffy. Such types of patients are easily enraged. Tongue fur is thin, and spots can be found at the margins. The pulse feels thin and string-like. - Treatment strategy: Soothe the liver and regulate qi, activate blood and resolve stasis, soften hardness and dissipate binds. - Herbal medicine: ‘Drive out Stasis under Diaphragm Decoction (膈下逐瘀湯), ‘Dissolve Stasis and Aggregation Decoction’ (化瘀消癥湯), Gami-saenghwa-tang (加味生化湯). • Cold Dampness Congealing Stagnation-Type - Clinical symptoms: Aggregation-accumulation can be palpated in the abdomen. Vaginal discharge is continuous. The patient is sensitive to cold and feels cold in the extremities, and the pain in the lower abdominals worsens when exposed to cold. The tongue appears dark, and the margins of the tongue are spotted. Tongue fur is thin and white, and the pulse feels string-like and tense. - Treatment strategy: Warm yang and dissipate cold, activate blood and resolve stasis, and soften hardness and dissipate binds. - Herbal medicine: ‘Cinnamon and Poria Pill’ (桂枝茯苓丸), ‘Dry Dampness, Dissolve Phlegm and Soften Tension Decoction’ (燥濕化痰軟堅湯).

(2) Menstruation period

• Qi Stagnation and Blood Stagnation - Clinical symptoms: The amount of menstrual fluid is excessive only in the case of flooding and spotting. The color is red at first but becomes lighter later in the cycle. Lumps are often found, and the menstrual fluid is red but becomes more clear later in the cycle. Lumps are frequently found, and the menstrual fluid continues to flow without stopping. Vertigo, fatigue, palpitations and shortness of qi are observed, and the face appears to be bright white. The tongue appears pale and large, or the margins of the tongue have spots, and the pulse

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feels string-like, thin, and weak. - Treatment strategy: Boost qi, tonify yin and expel stagnation to stop bleeding. - Herbal medicine: ‘Decoction to Stabilize the Root and Stop Blood Flooding’ (固本止崩湯), ‘Raise the Basis Decoction’ (擧元煎). • Stagnation and Heat Inter Obstruction Type - Clinical symptoms: A large amount of menstrual fluid is secreted, and the fluid is red and thick with lumps. The fluid occasionally continues to flow without stopping. The lower abdominal region is swollen and painful, vertigo is present, and the eyes are bloodshot. The mouth and lips are dry, and vexing heat in the heart causes insomnia. The tongue is red, and the margins of the tongue are spotted. Tongue fur is thin and yellow and the pulse feels thin, string-like, and rapid. - Treatment strategy: Clear heat to resolve stasis, and cool the blood to stop bleeding . - Herbal medicine: ‘Drive Out Stasis and Stop Bleeding Decoction’ (逐瘀止血湯). • Yin Deficiency Internal Heat-Type - Clinical symptoms: Although the bleeding does not occur in excessive amounts, there are intermittent rushes of bleeding. The menstrual fluid appears dark red. Vertigo and heart palpations occur, the low back feels sore, mouth and throat feel dry, and stool is dry and firm. The tongue is red, the tongue fur is thin, and the pulse feels thin and fast. - Treatment strategy: Tonify yin, clear heat, and cool the blood to stop bleeding. - Herbal medicine: ‘Clean Ocean Pill’ (淸海丸), ‘Stabilize the Menstruation Pill’ (固經丸).

5. Recent Findings

There have been no large-scale clinical studies of the Korean Medicine treatment of uterine myoma. Most publications are case reports or lab findings. Further research on Korean Medicine treatment is needed. In conclusion, myoma should be treated with activating blood, resolving stasis and helping spleen and stomach function. Korean Medicine treatment of uterine myoma is highly effective for symptom alleviation. Treatment aimed at reducing the size of the actual uterine myoma may not be very effective. The primary goal of Korean Medicine treatment should be to help control symptoms. Treatment outcomes should be followed up with ultrasonography and careful observation of symptoms.

222 Women’s Diseases chapter 4

Reference

•Baek YJ, Kim MD. The Study on the Treatment of Leiomyoma - Focusing on the Papers Pub- lished in 2010 within China. The Journal of oriental obstetrics & gynecology. 2011;24(1):109 – 131. •Berek & Novak’s Gynecology, 15th edition, Jonathan S. Berek, •Borud, Einar, White, Adrian. A review of acupuncture for menopausal problems, Maturitas, v.66 no.2, pp.131 - 134, 2010 •Dong-il Kim, A review of Dysmenorrhea Related Articles in Literature of Oriental Medicine, The Journal of Oriental Obstetrics & Gynecology. 2008;21(1):134-149 •Gynecology, 4th edition, Korea Medical Book Publishing Company. 2007. •In Sun Lee, Hyoun Min Youn, Kyoung Keun Jung, Soo Min Kim, Young Kwang Min, Cheol Hong Kim, Sung Hwan Park, Ji Eun Park, Sun Mi Choi. Effect of Sa-am Acupuncture Treatment on the Dysmenorrhea(Pillot Study, Single Blind, Randomized, Sham Acupuncture, Controlled Clinical Trial). The Journal of Korean Acupuncture & Moxibustion Society. 2007;24(3):63-79 •Jun Bock Jang, Yon Hui Choi, Young Jin Yoon, Jung Hoon Cho, Kyung Sub Lee. Clinical Study on the Efficacy and Safety of Chiljehyangbuhwan in the Treatment of Dysmenorrhea. The Journal of Oriental Obstetrics & Gynecology. 2005;18(1):156-168 •Kim, Kun Hyung, et al. “Effects of acupuncture on hot flashes in perimenopausal and postmenopausal women-a multicenter randomized clinical trial.” Menopause 17.2 (2010): 269-280. •Kim Dong IL, Acupuncture for hot flushes in perimenopausal and postmenopausal women: a randomised, sham-controlled trial, Acupuncture in Medicine 2011;29(4): 249-56. •Korean Medicine Obstetrics & Gynecology. The society of Korean Medicine Obstetrics & Gy- necology, the 3rd edition. Euiseongdang Publising Company. 2016. •Sung Won Ryu, In Hwan Youn, Young Eun Kim, Seoung Geun Lee, Key Sang Lee, Han Baek Cho. Systematic Review on Complementary and Alternative Medicine for Dysmenorrhea. The Journal of Oriental Obstetrics & Gynecology. 2009;22(1):279-302 •Seong Hee Cho, The Clinical Study of 21 Menopausal Disorder Patients Treated by kamiku- bi-hwan. The Journal of Oriental Obstetrics & Gynecology. 2014;27(4) •Seo et al. Uterine Myoma 41 Case series. The Journal of oriental obstetrics & gynecology. 2006;19(1):272-285. •Uterine Myoma 41 Case Series ) •Yoon et al. A Study on Relations among General Characteristics, Lifestyle Habits, and Men- opausal Symptoms Measurement Indicators during Treatment for Hot Flush in Menopausal Women. The Journal of oriental obstetrics & gynecology. 2011;24(4): 114-125.

223 2016 Korean Medicine Current Practiceof CHAPTER 5

Pediatric Diseases

▼ Kibong Kim PART 2 Korean Medicine Treatments for Various Medical Conditions

chapter 5

Pediatric Diseases

Introduction

Children undergo many stages of growth before they reach adulthood. This growth not only refers to quantitative growth but also to qualitative changes in overall form and organ function. Therefore, children are physiologically and pathologically different from adults. This fact is important for clinicians to remember when they are diagnosing, treating, and preventing diseases in children.

1. Physiological Features

Children are still developing; both their form and function are not yet fully developed. The younger the child, the faster the growth and more active of their metabolic processes. Thus, children require comparatively more nutrients, calories, and fluids than are required by adults.

2. Pathological Features

Children are more vulnerable to external pathogens. As their physiological development is incomplete, diseases are transferred and altered easily in children. Because children are easily affected, six excesses and food pathogens are the most common problems of the spleen and the lungs.

226 Pediatric Diseases chapter 5

Diseases have a tendency to shift phases quickly in children. When a child is ill, pathogenic qi easily becomes excessive and healthy qi easily becomes deficient, causing excessive types to quickly become a deficient type disease. Both deficient and excessive types can co-exist.

Children are lively, and their development processes are vigorous and fast. They recover from illness rather quickly. If the diagnosis is correct and treatment is appropriate, children respond well to treatment.

3. Precautions for Treating Pediatric Patients

Accurate pattern identification should precede any treatment. The physician must determine the mechanism of the disease and target it without damaging healthy qi, as well as replenishing deficient factors while being careful to avoid stagnation. As children respond more quickly and more sensitively to medicine than do adults, physicians must prescribe the best suited medicine that replenishes any weaknesses and fights against any pathogens.

The growth process of a child is often explained by an analogy with the growth processes of grass and trees. The child’s qi must be boosted for recovery. Caution is needed when physicians are prescribing medicines with heat properties, medicines that are too bitter or too cold, or medicines that have very strong properties. When trying to replenish frail children, physicians must be careful to avoid stagnation in the process, as stagnation may cause problems with the function of the spleen and stomach.

Common Cold

The occurrence rate of the common cold is directly proportional to the rates of the common cold of exposure to relevant pathogens. Children who are undernourished are more likely to catch the common cold and are more likely to have other comorbidities. Common cold occurs year round, but is particularly evident in April and September, when

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school starts. This observation suggests that involvement in group activities may be a contributing factor. This trend may also be related to the finding that rhinoviruses are particularly prevalent during April-May and August-October. The prevalence rates are directly proportional to the rates of exposure to pathogens, but immunity affects the actual occurrence rate. Children catch the common cold an average of 6-7 times a year; 10-15% of children are affected at least 12 times a year. The common cold is particularly prevalent in infants 3 years old or less, but the prevalence rates show a decrease as the child becomes older. Gastrointestinal symptoms or febrile seizures may also be present. The largest factor contributing to the common cold is harsh climates and an inability to sufficiently adapt to these climates.

1. Diagnosis

The latency period is between 1 and 3 days, and nasal symptoms are present in all patients. Nasal discharge and nasal obstruction are the main symptoms, which may be accompanied by sneezing. Because the nasal obstruction causes post-nasal drip or mouth breathing, the patient may experience irritation or pain in the trachea. The nasal discharge may become more thick and yellow as the cold progresses, but these symptoms do not imply that the cause is bacterial. Symptoms are more intense in younger children, and may include fever, vomiting, and diarrhea. General symptoms, such as fevers, improve within 4 to 5 days. Nasal symptoms tend to persist for one more week. When otitis media is comorbidity, fevers may be more persistent. In older children, symptoms such as dryness in the nose, discomfort in the pharynx and headache are present in the first few hours, followed by a thin nasal discharge, cough, and sneezing. General symptoms, such as headaches, general weakness, loss of appetite, muscle pain and chills, are frequently present. Fever, if present, is not severe.

2. Tests

(1) Child Pneumonia : Mostly lobular, bronchopneumonia

• Increased White Blood Cell (WBC) counts, Erythrocyte Sedimentation Rates (ESRs), and C-Reactive Protein (CRP) levels indicate acute bacterial pneumonia. • Normal or decreased WBC levels, increased lymphocyte levels indicate viral pneumonia.

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• The differential diagnosis of pneumonia is based on a chest X-ray.

a. Bronchopneumonia b. Lobar Pneumonia

[ Figure 1 ] Chest X-Ray

(2) Sinusitis

• Sinus X-ray (Water’s view) • Sinus computed tomography (CT) scan

3. Treatment

(1) Herbal Medicine Treatment

• Wind cold (風寒)-type cold is treated with ‘Apricot Kernel and Perilla Leaf Decoction’ (杏蘇湯) or ‘Minor Blue-green Dragon Decoction’ (小靑龍湯). • Wind heat (風熱)-type cold is treated with ‘Toxin-Vanquishing Powder with Forsythia’ (連翹敗毒散) or ‘Schizonopeta and Forsythia Decoction’ (荊芥連翹湯). • When a child with the common cold also has food stagnation, prescribe ‘Agastache Pow- der to Rectify the Qi’ (藿香正氣散) or ‘Worth More Than Gold Rectify Qi Powder’ (不換金正氣散). • When infantile convulsions are present, prescribe ‘Embracing Dragon Pill’ (抱龍丸) or ‘Warm Gallbladder Decoction’ (溫膽湯).

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(2) Acupuncture and Moxibustion Treatment

• If nasal obstruction is present, apply acupuncture to EXHN3, CV23, and LI04 + LR03. • If headaches are present, apply acupuncture to GV20, BL10, and GB20. • If cough is present, apply acupuncture to LU09, LU05, and CV22. • If nasal discharge is present, apply acupuncture to LI20. • If there is pain in the trachea, apply acupuncture to LU11, SI01, LI01, and TE01 or LI04 and LU05.

(3) Aroma Therapy

• Bathing: Thyme 2 drops, tea tree 2 drops, eucalyptus 1 drop, lemon 3 pieces . Mix and add to bath water for use. • Inhalation Methods ❶ Thyme, tea tree, lavender, and peppermint: Mix equal amounts and inhale steam from the mixture. ❷ Thyme, peppermint, eucalyptus, and clove buds: Mix equal amounts of each, spray on a gauze and inhale. ❸ Massage: Mix equal amounts of lemon, eucalyptus, and lavender in 30ml of carrier oil. Mix thoroughly and apply to the chest, neck, forehead, nose, and chin. Massage.

4. Prevention

• Take sufficient time to rest. Maintain humidity at approximately 60-90%. • Keep the body warm while sleeping and when going outdoors. • Be sure to provide sufficient nutrients. • Soothe a crying baby. • Keep the baby in a prone position so that any discharges can exit the body freely. • When it comes with seizures, remove the child’s clothing and lay him or her in a comfortable position. Confirm that there are no obstructions in the airway and then perform a tepid massage. Do not provide any food or drinks, which may cause inhalation pneumonia.

230 Pediatric Diseases chapter 5

5. Recent Findings

Recent findings suggest favorable outcomes of the common cold treated with Korean Medicine. Chronic cough (cough that persists for more than 3 weeks) responded very well to Korean Medicine, with 80% of patients reporting complete alleviation of the symptoms within 4 weeks of treatment. Patients were allocated to 3 groups; group A was administered placebo medications, group B was administered ‘Minor Blue-green Dragon Decoction’, a commonly prescribed herbal medicine, and group C received ‘Toxin-Vanquishing Powder with Forsythia’. The treatment groups (group B and C) recovered at least 1 day faster than the control group (group A). To date, treatment for common cold has primarily been limited to antibiotics, with a prescription rate of over 50%. However, studies have reported the efficacy of herbal medications as treatments for the common cold. In another study in which 27 patients with chronic cough were treated with ‘Tonify Lung and Reduce Cough Decoction’, acupuncture and an herbal medicine steam bathing treatment, coughs were cured in patients with asthma (100%), post-infection cough (100%), and upper respiratory cough syndrome (69%). Within 4 weeks, 81% of all patients reported a complete alleviation of symptoms. This period is more than 2 weeks shorter than the average 6-week treatment for chronic coughs. Because the common

WURSS

Translation & back-translation Translation committee by two blinded bilingual physicians

• English linguist • Korean linguist Cognitive debriefing process • Internal medical doctor • Statistician WUREDD-K

IRB Approval Common cold patients (n=107

Analysis

[ Figure 2 ] Wisconsin Upper Respiratory Symptom Survey (WURSS-K), Korean version

231 PART 2 Korean Medicine Treatments for Various Medical Conditions

cold is caused by a variety of different viruses, it is difficult to prevent. Although the common cold is usually treated with antibiotics, recent findings indicate that other treatment options may help reduce the socio-economic costs and antibiotic use (Byun, et al., 2011).

Recent studies have validated the official Korean version (WURSS-21-K) of the Wisconsin Upper Respiratory Symptom Survey-21 (WURSS-21), a tool commonly used to assess upper respiratory conditions. This tool has greatly contributed to the standardization of clinical studies on the common cold (Yang, et al., 2011).

Child Constipation

1. Diagnosis

Infants under the age of 1 defecate 0 to 9 times a day, depending on the age and form of nutrition they receive. Only when they reach the age of 3 or 4, they defecate 1-2 times per 1-2 days, similar to adults. Generally, a child is expected to defecate at least once a day, but if the child defecates once every 2-3 days and does not feel any discomfort, the child is not constipated. However, constipation is diagnosed if the child defecates less than 2 times a week, if the feces is dry enough to cause pain and/or bleeding while defecating, or if the patient has “feeling of incomplete defection”.

Situations in which defecation is difficult and the feces remain in the intestines for longer than normal or when the stool is too much hard are also considered as constipation. Bladder or ureter reflux, hydronephrosis, enuresis, urinary tract infection and other urogenital problems are often present in patients with constipation. Abdominal pain, loss of appetite, and vomiting may also be present. Only rarely could growth disorders be delayed due to constipation.

2. Causes

Overeating spicy, dry, or strong food; overuse of medicines with hot properties that may

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cause tidal fevers; consumption of stagnated milk or food; psychological conditions such as depression or anxiety; and a lack of physical activity are all factors contributing to constipation.

If a child is chronically ill and frail, if the qi, blood, and fluids are depleted, or if a weak child eats too much cold food, constipation may occur.

Constipation may occur if the child is weak and colon function is affected. A blood deficiency can also cause constipation, as the colon is not lubricated properly. Idiopathic or functional constipation accounts for 90-95% of all child constipation.

3. Treatment

(1) Herbal Medicine Treatment

• If tidal fevers are observed, prescribe ‘Hemp Seed Pill’ (麻子仁丸) or ‘Chuanxiong and Angelica Gigantis Decoction’ (芎歸湯). • If constipation is due to psychological causes, prescribe ‘Six Milled Ingredients Decoc- tion’ (六磨湯). • If constipation is due to food stagnation, prescribe ‘Unripe Bitter Orange Pill to Guide out Stagnation’ (枳實導滯丸) or ‘Calm the Stomach Powder’ (平胃散). • If there is a blood deficiency, add Majain (麻子仁), Polygoni Multiflori Radix (何首烏), and Ponciri Fructus Pericarpium (地殼) to ‘Four-Substances Decoction’ (四物湯) or Ma- jain (麻子仁), Radix Scrophulariae (玄蔘), Polygonatum Odoratum (玉竹), and honey (蜂蜜) to ‘Six-Ingredient Decoction with Rehmannia’ (六味地黃湯). • If there is a deficiency in qi, prescribe ‘Astragalus Decoction’ (黃芪湯).

(2) Acupuncture and Moxibustion Treatment

• Apply acupuncture to BL25, ST25, and TE06. • If tidal fevers are observed, apply acupuncture to LI04 and LI11 as well. • If constipation is due to psychological causes, apply acupuncture to CV12 and LR02 as well. • If the child cannot digest food well, apply acupuncture to BL20 and BL21 as well.

233 PART 2 Korean Medicine Treatments for Various Medical Conditions

• If the child seems to have weak qi, apply moxibustion to CV08 and CV06 for 15 minutes.

4. Prevention and Management

• Sufficient nursing is needed. • Normal bowel habits must be established. An enema is recommended in the early stages of treatment. After a few days, train the child to go to the bathroom at a certain time of the day. • Stimulate colon activity with regular exercise. • Add a sufficient amount of fiber-rich vegetables and fruits to the child’s daily diet. • If the cause of the constipation is anorexia, pain during defecation may cause the child to avoid defecating, which leads to a further aggravation of anorexia. In this case, enhance the child’s appetite in advance of treating the constipation.

Anorexia

1. Diagnosis

Anorexia is often overlooked in clinical settings and therefore is neglected. When anorexia is caused by other disorders of the gastrointestinal system, early diagnosis is possible. However, for children, visiting hospital is usually delayed. In such cases, the patient is likely to be underweight and frail, which may further aggravate anorexia.

Patients have no interest in food and refuse food. Other accompanying symptoms may include abdominal pain, diarrhea, vertigo, headache, nausea, and vomiting.

2. Cause

Causes of anorexia include imbalanced diets, overeating, irregular eating habit, eating food that does not digest well, improper nurturing of newborns, chronic illnesses that have

234 Pediatric Diseases chapter 5

affected normal function of the spleen and stomach, congenital problems with spleen and stomach function, malnutrition, family issues, forced food intake, neglect, overprotection, and other environmental and/or psychological problems.

3. Treatment

(1) Herbal Medicine Treatment

• If the spleen and stomach are damaged by food, prescribe ‘Eliminate the Undigested Food Pill’ (消食丸) or ‘Preserve Harmony Pill’ (保和丸). • If the function of the spleen and stomach is abnormal, prescribe ‘Auckandia and Amomum Calm the Stomach Powder’ (香砂平胃散), ‘Ginseng Decoction to Nourish the Stomach’ (人蔘養胃湯), or ‘Eliminate the Inside Powder’ (內消散). • When stomach yin is deficient, prescribe ‘Ginseng Decoction to Nourish the Stomach’ (人蔘養胃湯), or ‘Comparative Harmonization Drink’ (比和飮). • When the cause is a qi deficiency, prescribe ‘Ginseng, Poria, and Atractylodes Macro- cephala Powder’ (蔘笭白朮散), ‘Tonify the Middle and Augment the Qi Decoction’ (補中益氣湯), ‘Ginseng and White Atractylodes Strengthen Spleen Decoction’ (蔘朮健脾湯), ‘Auckandia and Amomum Decoction for Nuturing Stomach’ (香砂養胃湯), or ‘Six Gentle- men Decoction with Auckandia and Amomum’ (香砂六君子湯). • Due to psychological causes, prescribe ‘Resolve Depression and Strengthen Spleen De- coction’ (解鬱健脾湯).

(2) Acupuncture and Moxibustion Treatment

• Apply acupuncture to CV-12, LI-4, and ST-36. • Apply moxibustion to CV-12 and CV-13 for 15 minutes.

4. Management

• Figure out the causes in advance of the treatment. • Prevention is very important for psychogenic anorexia.

235 PART 2 Korean Medicine Treatments for Various Medical Conditions

• Notify parents that individual differences determine body weight, appetite, and the amount of food consumed. • Refrain from forcing the child to eat. • Explain that much time and effort is needed to treat anorexia. • Evaluate breastfeeding, recipe and the menu and correct any unsatisfactory findings.

5. Recent findings

According to recent studies, anorexia during infancy and childhood affect the overall health state of the child and causes a non-organic failure to thrive. Anorexia is a factor that contributes to conditions such as short stature, behavioral disorders, and developmental re- tardation. It is known to negatively affect long-term growth and development (Ruldolf et al., 2005). Conventional treatment does not provide a treatment for patients with anorexia who do not have underlying diseases. According to previous studies, anorexic patients frequently have severe alexithymia (Nandrino et al., 2012). Based on the assumption that the failure emotional processing or emotional control are a main cause of patients with eating disorders (Oldershaw et al., 2011), some researchers have attempted to resolve anorexia using a psychiatric approach (Manikam et al., 2000). In contrast, a recent study of Korean Medicine treatment for anorexic children reported that anorexic children were successfully treated with an eating sensitivity approach (Lee et al., 2012).

Enuresis

Enuresis is diagnosed when a child who has reached an age where complete control of urination is expected (5 years of age) continues to involuntarily wet the bed at least twice a week for at least 3 consecutive months. Enuresis significantly affects the child’s quality of life. Approx- imately 10-15% of children cannot fully control their urination even when they reach 5 years of age. These children usually develop the ability to control their urination as they become older, but approximately 1% remains enuretic at age 15. Enuresis is more common in boys than girls.

236 Pediatric Diseases chapter 5

1. Diagnosis

Enuresis is either primary or secondary. Primary enuresis refers to a condition in which the child has never been able to control their urination due to congenital problems, sleep disorders, antidiuretic hormone deficiencies, psychological issues, or delayed brain development. Secondary enuresis is defined as the inability to control urination even they had been able to control the urination for about 6 months or 1 year. This condition may be due to physical changes including urinary tract infections or malformations, diabetes insipidus, diabetes, chronic renal problems, or emotional stress resulting from a move, the birth of a younger sibling, or the death of a family member.

Physicians should exclude other possible problems such as dysuria or urinary tract infections. The patient’s history, including the amount of water consumed and total amount of urine, is needed for a differential diagnosis of diabetes insipidus, diabetes, and other chronic renal problems.

2. Tests

• Urinalysis and urine culture test • Urinalysis and osmosis test after limiting fluid intake • Blood antidiuretic hormone analysis • Ultrasonography, renal function test, urography, and cystoscopy

3. Treatment

(1) Herbal Medicine Treatment

• When the lower energizer is weak and the kidney qi (腎氣) is deficient, prescribe ‘Mantis Egg-Case powder’ (桑螵帩散) or ‘Cuscutae Seed Pill’ (兎絲子丸). • When the spleen and lung qi are weak, prescribe ‘Tonify the Middle and Augment the Qi Decoction’ (補中益氣湯) or ‘Restrain Stream Pill’ (縮泉丸). • When liver qi is stagnant, prescribe ‘Gentian Drain Liver Decoction’ (龍膽瀉肝湯). • ‘Six-Ingredients Decoction with Rehmannia’ (六味地黃湯), ‘Kidney Qi Pill of the Golden

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Cabinet’ (腎氣丸), ‘Astragalus Decoction’ (黃耆湯), and ‘Restrain Stream Pill’ (縮泉丸) are frequently prescribed to treat enuresis.

(2) Acupuncture and Moxibustion Treatment

• When there is deficiency in kidney yang, apply acupuncture to BL23, BL28, CV04, CV03, and KI03. • If the respiratory and metabolic systems are weak, apply acupuncture to CV06, LU09, ST36, CV03, and BL28. • Apply moxibustion to GV20, GV04, CV04, BL33, and LR01. • Head acupuncture: Apply bilateral acupuncture to leg motor and sensory area (足運動感覺區) and reproduction area (生殖區). • Auricular acupuncture (耳鍼): Stimulate kidney (腎), bladder (膀胱), sub-cortex (皮質下), occiput (枕), bladder (尿道區).

(3) Enuresis Alarm

• When a child wets the bed, a buzzer rings to wake the child. The child turns the alarm off and is instructed to go to the bathroom. Because the alarm disrupts sleep, it is only recommended for very persistent cases. The relapse rate has been reported to be approximately 30%.

4. Management

• The child must be an active participant. Reassure the child that this condition is treatable. • Keep a log of enuresis events to monitor treatment outcomes. • Do not provide drinks after dinner and have the child go to the toilet before going to bed. • The child should not be punished. Ask the child for his or her cooperation instead. • Train the child to refrain from urinating during the day to increase the mechanical volume of the bladder. • Recurrence is common after short-term treatment. Sufficient treatment is needed.

238 Pediatric Diseases chapter 5

5. Recent findings

Researches on Korean Medicine treatment for enuresis conducted to date has largely focused on the effects of acupuncture treatment. According to the results of these investiga- tions, significant improvement has been observed in patients who were treated with acupuncture for monosymptomatic enuresis and primary enuresis. Acupuncture, electricity, and laser stimuli applied to acupoints affect noradrenaline secretion that, along with vasopressin, affects bladder activity. These results support the use of alternative medicine for treating enuresis (Oh et al., 2005).

Infantile Colic

1. Introduction

Colic refers to a condition in which the patient presents with tightness and pain in the abdominal region that feels as if there is an upward and downward tension. The testis feels swollen and painful and tension is present in the lower abdomen. Infants who are congenitally weak are vulnerable to colic when they are exposed to cold wind externally or cold food internally. Colic is subclassified into inflammation of the genitalia, tumors, edema (testis, epididymis, scrotum, etc.), chest cavity problems, and if there is abdominal pain, hernia. The most prevalent types of colic in children are water colic and qi colic.

2. Diagnosis

(1) Cold-type Colic (Painful Colic)

• Children who have the habit of eating cold food or sitting in cold and damp areas are affected by cold pathogens that interfere with qi flow. When the child is exposed to wind cold or water dampness under these conditions, cold-type colic develops.

Exposure to cold temperatures aggravates the pain. The affected area becomes very hard, and the scrotum feels tense and painful. In severe cases, tension is present in the lower

239 PART 2 Korean Medicine Treatments for Various Medical Conditions

abdominal area and the legs and arms feel cold.

(2) Fetal Colic

• If the mother experiences severe mood swings in her pregnancy or feels excessive emotion, qi becomes stagnant and affects the fetus. Symptoms are observed after birth including tension, pain, and coagulation in the lower abdomen.

(3) Yin Edema (Water Colic)

• Yin edema is also called scrotum edema. The scrotum is swollen and either itchy or painful.

[ Figure 3 ] Ultrasonography of scrotum edema (T:testicle)

(4) Qi Colic (Fox hernia)

• Qi colic is usually due to qi deficiency that induces an overall downward movement of qi. Qi colic may be diagnosed if an infant suddenly cries, vomits milk, or shows an abnormal flush; the upper thighs or the scrotum are swollen and hard; and touching the area elicits strong pain. In the early stages, the pain is localized. However, as the disease progresses, the pain spreads to the entire abdominal area and the affected area swells.

3. Treatment

(1) Cold-type Colic (Pain Colic)

• Warm the middle area and dissipate the cold. Prescribe ‘Coiled Shallots Powder’ (蟠蔥散), ‘Five Accumulations Powder’ (五積散), ‘Angelica Decoction for Frigid Extremities’ (當歸

240 Pediatric Diseases chapter 5

四逆湯), or ‘Prepared Aconite and Cinnamomum Decoction’ (烏頭桂枝湯).

(2) Fetal Colic

• Prescribe ‘Ten Ingredients Atractylodes and Phellodendron Powder’ (十味蒼栢散), ‘Toosendan Powder’ (金鈴散).

(3) Yin Edema (Water Colic)

• Wind dampness affects the lower energizer and causes the scrotum to swell and itch. Pre- scribe ‘Five-Ingredient Formula with Poria for Dredge Wind’ (疏風五苓散). If the pain is due to heart fire, prescribe ‘Guide Out the Red powder’ (導赤散).

(3) Qi Colic (Fox hernia)

• Tonify qi and boost an upward motion of any sunken qi. ‘Tonify the Middle and Augment the Qi Decoction’ (補中益氣湯) is prescribed.

Growth Disorder

Growth disorders are either primary or secondary. Primary growth disorder refers to a state in which children are not able to reach a normal height due to endogenous causes. In primary growth disorder, the child’s skeletal age is not delayed compared to the chronological age and the growth disorder begins in the fetal stages and continues after birth. The leading cause of growth disorders is hereditary dwarfism. However, dwarfism is not considered a disorder.

Secondary growth disorder is a type of growth disorder caused by environmental factors. This type of growth disorder is acquired and may be treated if the cause is efficiently treated. In contrast to primary growth disorders, skeletal age is significantly delayed compared to chronological age. The most common form of secondary growth disorder is a constitutional growth delay (growth disorder due to body constitution type). Although the growth rate is normal, total growth is consistently below the 3rd percentile. Generally, adolescence is delayed and skeletal

241 PART 2 Korean Medicine Treatments for Various Medical Conditions

age is decreased. Most cases of secondary growth disorders have a genetic correlate. The most common cause of secondary growth disorder worldwide is malnutrition.

1. Diagnosis

Growth disorder is diagnosed if the child’s height falls below the 3rd percentile or above the 97th percentile, if the growth rate surpasses or falls short of the normal growth rate, if the final estimated height is 5 cm shorter or taller than the Mid-Parental Height (MPH), if the skeletal age is 2 standard deviations away from the average skeletal age, or if other deformities of facial features and body proportions are present.

2. Tests

(1) Blood analysis

• Complete Blood Count (CBC), Erythrocyte Sedimentation Rate (ESR), and blood thyrox- ine (T4), triiodothyronine (T3), Thyroid-Stimulating Hormone (TSH), Blood Urea Nitro- gen (BUN), creatinine levels • Liver function, anemia, hepatic function, anemia, diabetes, and other basic disease diagnosis

(2) Thyroid hormone analysis

• Urinalysis: Diabetes and renal problems • Examination of the feces: Parasites • Electrocardiogram: Heart problems • X-ray: Physeal plate (used to predict growth, left hand for children under the age of 10 and left arm for children 10 years and older). • Growth hormone provocative test • Chromosome examination • Computed Tomography (CT), Magnetic Resonance Imaging (MRI) • Bone Mineral Density (BMD) • Body composition analysis

242 Pediatric Diseases chapter 5

0pen Physeal Plates Closing Physeal Plates Closed Physeal Plates

Tivia

Phalange

Calcaneus

[ Figure 4 ] Physeal plate test (X-ray)

Adult height

Growth curve Physeal reached Pubic hair plates close develops

Puberty begins Growth Spurt

12 Years 14 Years 16 Years 20 Years

[ Figure 5 ] Growth curve (Male)

243 PART 2 Korean Medicine Treatments for Various Medical Conditions

In males, puberty begins at approximately the age of 12. After a 2-year growth spurt period, they develop pubic hair at age 14. After 2 years of slow growth, the physeal plates close at approximately age 16. Males reach their adult height at approximately age 20.

Adult height Physeal plates close reached Growth curve completely First Menstruation

Breast growth Growth Spurt

10 Years 12 Years 14 Years 16 Years

[ Figure 6 ] Growth curve (Female)

In females, puberty begins at approximately the age of 10. After a 2-year growth spurt period, they begin their first menstruation at age 12. After 2 year of slow growth, the physeal plates close at approximately age 14. Females reach their adult height at approximately age 16.

3. Treatment

(1) Warming Yang Method

• Replenish kidney yang to help the child grow and replenish blood essence. • Help boost growth and activate intelligence. • Indications: Delayed growth, edema, intelligence decline, hypothyroidism, hypoparathy- roidism, rickets, and delayed growth due to chronic diseases. • Prescribe ‘Kidney Qi Pill of the Golden Cabinet’ (金匱腎氣丸).

(2) Nourish Yin Method

• Help blood essence and replenish marrow essence to treat yin deficiency and promote growth.

244 Pediatric Diseases chapter 5

• Indications: Cerebral growth impairment, premature birth, rickets, chronic malnutrition, chronic wearing diseases, a yin deficiency-type of aplastic anemia, a yin deficiency-type of leukopenia, a yin deficiency-type of leukemia, a yin deficiency-type of thrombocyto- penia, etc. • Prescribe ‘Six-Ingredients Decoction with Rehmannia’ (六味地黃湯).

(3) Tonify Qi and Replenish Spleen

• Focus on the treatment of acquired growth disorders. • Indications: Frequent common cold, qi deficiency due to chronic illness, rickets, malnutrition, etc. • Prescribe ‘Four Gentlemen Decoction’ (四君子湯) to tonify spleen qi. • If the inside feels cold due to a deficiency in spleen yang, prescribe ‘Regulate the Middle Decoction’ (理中湯). • Prescribe ‘Tonify the Middle and Augment the Qi Decoction’ (補中益氣湯) to replenish the spleen and tonify qi or ‘Ginseng and White Atractylodes Strengthen Spleen Decoction’ (蔘朮健脾湯) to nourish the spleen and stomach. • Prescribe ‘Six-Ingredients Decoction with Rehmannia’ (六味地黃湯) to nourish yin and replenish the kidneys and blood. • Add herbs that replenish kidney yang (Cynomorium songaricum (鎖陽), Gynochthodes officinalis (巴戟天), Psoralea corylifolia (補骨脂), Fructus Alpiniae Oxyphyllae (益智仁), Placenta Hominis (紫河車), etc.), dissipate wind dampness and fortify muscles and bones (强筋骨) (Cortex Acanthopanacis (五加皮), Rhizoma Drynariae (骨碎補), Fructus Chae- nomelis (木瓜), etc.), and activate the blood (Carthamus tinctorius seed (紅花子), Achy- ranthes bidentata (牛膝), etc.).

245 PART 2 Korean Medicine Treatments for Various Medical Conditions

GB34 SP9 SP10 ST34

KI3 BL60 BL57

[ Figure 7 ] Acupressure points that help the child to grow

4. Management

• Keep the back warm. This protects the lungs from external pathogens. • Keep the abdomen warm. Exposing the abdomen to cold may cause digestive problems such as diarrhea. • Keep the feet warm. • Keep the head cool. As the head is the area where all yang meet, it should be kept cool. • Limit exposure to strangers or strange objects, as they may cause trauma that leads to other symptoms. • Do not feed the baby when he/she cries. The food may obstruct the airway. • Do not abuse Calomelas and Cinnabar. Do not prescribe herbs that have strong properties. • Refrain from bathing child frequently. Children have very weak skin and are vulnerable to infection.

246 Pediatric Diseases chapter 5

• If a child frequently catches common cold, train the child with cold water baths or dry tow- eling. • Regular exercise is recommended. Have the child take regular bath to help circulation.

Herbal Medicine Instructions

1. Number of administrations

• Infants: 6-8 times a day • 3-7 years old: 3-4 times day • 7-8 years old: 3 times a day

2 . Time of Administration

• Children 7-8 years of age should take their medication 2 hours after meal. • Medicines for replenishment should be taken before meal, and medicines that aid in digestion should be taken immediately after meal. Medicines for psychological problems should be taken before bed. • For acute or severe condition, take the medication any time it is needed. • Regarding the time of administration, the child should take the medication after meal if the site of the problem is located above the chest, before meals if it is located under the chest, early in the morning before eating if it is located in the limb, and at night after eating if it is located in the bone marrow. • Medications that are generally not digested well should be administered 30 minutes after meal. Other medications should be administered between meals, allowing approximately 2 hours after a meal to increase the absorption rate.

247 PART 2 Korean Medicine Treatments for Various Medical Conditions

3. Doses (The recommended dose for adults is 1)

• Newborns (birth – 1 month old): 1/5 - 1/6 • Infants (1 month old – 1 year old): 1/3 - 1/5 • Toddlers (1 year old – 6-7 years old): 1/2 - 2/3 • Children (7 years old – 14 years old): 3/4(2/3) - 1 (same dose as adults)

248 Pediatric Diseases chapter 5

Reference

•Byun JS, Yang SY, Jeong IC, Hong KE, Kang W, Yeo Y, Park YC. Effects of So-cheong-ryong- tang and Yeon-gyo-pae-dok-san on the common cold: randomized, double blind, placebo controlled trial. J Ethnopharmacol. 2011;133(2):642-6.

•Lee SH, Kim CY, Chang GT. Assessment of Herbal Treatment in Appetite Improvement of Anorexia Children Using Korean Children’s Eating Behaviour Questionnaire (K-CEBQ). J Korean Orient Pediatr. 2012;26(1):60-69

•Manikam R, Perman J. Pediatric Feeding Disorders. J Clin Gastroenterol. 2000;30(1):34-46.

•Nandrino JL, Berna G, Hot P, Dodin V, Latrée J, Decharles S, Sequeira H. Cognitive and physiological dissociations in response to emotional pictures in patients with anorexia. J Psychosom Res. 2012;72(1):58-64.

•Oh JY, Chang GT, Kim JH. Three cases report about enuretic children treated with electro-acupuncture on Zhongji (CV3), Guanyuan (CV4). J Korean Orient Pediatr. 2005;19(1):103-15

•Oldershaw A, Hambrook D, Stahl D, Tchanturia K, Treasure J, Schmidt U. The socio-emotional processing stream in Anorexia Nervosa. Neurosci Biobehav Rev. 2011;35:970-88.

•Ruldolf MC, Logan S. What is the long-term outcome for children who fail to thrive? A systemic review. Arch Dis Child. 2005;90:925-31.

•Yang SY, Kang W, Yeo Y, Park YC. Reliability and validity of Wisconsin Upper Respiratory Symptom Survey, Korean version. J Epidemiol. 2011;21(5):313-8

249 2016 Korean Medicine Current Practiceof CHAPTER 6

Psychiatric Diseases

▼ Jongwoo Kim PART 2 Korean Medicine Treatments for Various Medical Conditions

chapter 6

Psychiatric Diseases

Introduction

Korean Neuropsychiatry Medicine is a clinical field based on Korean Medicine and encompasses anatomy, physiology, etiology, pathology, diagnosis, treatment, prevention, and public health. It is one of the eight subfields within Korean Medicine with specialized internship and residency training.

The Korean Medicine approach to the mind and psychiatric disorders differs from that of West- ern Medicine; it sees the body and mind as one, from an integrative point of view. This is due to the influence of Donguibogam and Sasang constitutional medicine, in which a patient’s suffering and symptoms are approached by considering the patient’s tendency, constitution, and self-healing power and through humanistic and philosophical consultations.

This viewpoint is also applied in clinical practice. The approach to mental illness in Korean Medicine is sometimes based on a trans-diagnostic approach that believed the entire mental illness from a single point of view, and sometimes approaches it by each disease

252 Psychiatric Diseases chapter 6

Depression

Depression, which has the highest prevalence rate among psychiatric disorders, is characterized by low spirits. It is considered a part of a stagnation pattern in Korean Medicine. The stagnation is divided into six types: qi, blood, fire, food, dampness, and phlegm. Because depression is related to problems of the mind, it is closely related to qi stagnation.

1. Diagnosis and Examination

The diagnosis is based on clinical symptoms and an additional questionnaire, structured clinical interview, and pattern identification tools for depression in Korean Medicine.

2. Treatment

In Korean Medicine, depression is treated with herbal medicine based on the identified pattern.

(1) Liver Qi Stagnation

Patients experiencing this type of stagnation complain of discomfort in the mind, which results from the liver qi’s failure to smooth the flow of qi and regulate emotion.

(2) Qi Stagnation becoming Fire

The patient has dryness of the mouth, constipation, or anger, which results from a prolonged state of qi obstruction that leads to symptoms of fire or heat.

(3) Stagnation of the Blood Circulation

The patient has local pain, stagnated blood, insomnia, and forgetfulness, blood efficiency; the blood is blocked because the qi that accompanies blood is blocked.

253 PART 2 Korean Medicine Treatments for Various Medical Conditions

(4) Stagnation of the Phlegm Qi

The patient has palpitations, dizziness, heaviness of the head or body, indigestion, nausea, and chest discomfort from irregular meals or malfunctioning of the digestive system (from stress or a constitutional basis). This occurs because of qi stagnation.

(5) Collapse and Deficiency of the Heart Yin

The patient has palpitations, forgetfulness, insomnia, many dreams, heat on the palms and soles, flushing, stealthy sweat, and dryness of the mouth resulting from a heart yin deficiency. This occurs because too many thoughts deprive the blood.

(6) Bilateral Deficiency of the Heart-Spleen

The patient complains of palpitations, frightfulness, insomnia, forgetfulness, loss of appetite, dizziness, tiredness, and a pale complexion that results from deprivation of the qi and blood.

(7) Collapse and Deficiency of the Liver Yin

The patient has dizziness, tinnitus, dryness or congestion of the eye, headache, flushing, and restlessness resulting from a liver yin deficiency.

(8) Heart Spirit in Confusion

The heart, which controls the mind, is diseased, resulting in mental disorder, doubtfulness, frightfulness, an inability to control one’s emotions, and psychosis.

3. Algorithm of Depression

The algorithm for the treatment of depression includes the diagnosis, differentiation, evaluation of severity, treatment with Korean Medicine, and treatment with Western Medicine. For the diagnosis, differentiation, and evaluation of severity, diagnostic criteria and assessment tools in psychiatry and psychology are utilized. Treatment with Korean Medicine uses the pattern identification of stagnation patterns in combination with a Western Medicine treatment.

254 Psychiatric Diseases chapter 6

Clinical Aspects of Depression

No Differential Diagnosis correspondence Diagnosis ・Bipolar affective disorder Standards for depressive disorder (SCID- I1), (F31) PHQ-92)) ・Adjustive disorder (F43.2) correspondence ・Anxiety disorder (F40, F41) ・Schizoaffective disorder Diagnosis (F25) ・Hwa-byung (U22.2) Depressive disorder (F32, F33, F38)

Evaluation of Severity ・Is there any past history of suicide ideation, attemped suicide, or suicide? ・Is there any psychologic signs of hallucination (auditory or visual) or delusion? ・Is the depressive symptom severe as to affect everyday life activities? ・Is any physical disorder or medication suspicious of for showing depressive symptoms? ・Questionnaire: BDI-II3), HDRS4), or CES-D5) is selectively utilized

BDI-II≥20 Moderate to severe Mild BDI-II≥14~19 HDRS≥17 HDRS≥11~16 Treatment Treatment Specialized treatment in Reference of pattern identification department of Korean Medicine and treatment for stagnation neuropsychiatry or admission syndrome

Maintenance or Improvement of aggravation of symptoms symptoms Combined treatment with Western Medicine ・Danger to self or others ・Accompanied by psychologic Continuous management symptoms Consideration of and prevention ・Maintenance or aggravation of other treatment of relapse symptoms

Maintenance or aggravation of symptoms Improvement of symptoms

Re-evaluation of Maintenance of treatment and symptoms and signs continuous management

[ Figure 1 ] Treatment algorithm of depression

1) The Structured Clinical Interview for DSM-IV Axis I Disorders 2) Patient Health Questionnaire 3) Beck Depression Inventory II 4) Hamilton Depression Rating Scale 5) Center for Epidemiological Studies-Depression Scale 255 PART 2 Korean Medicine Treatments for Various Medical Conditions

4. Recent findings

(1) Clinical Guidelines for Depression

The Korean Society of Oriental Neuropsychiatry and the Korean Institution of Oriental Med- icine developed and published a clinical guideline for depression in 2016. Utilizing an evidence-based method, it includes evidence levels and recommendation grade for herbal medicine, acupuncture, electro-acupuncture, meditation, and the relaxation method.

(2) Tools for Pattern Identification in Depression

The committee for the development of pattern identification for depression is comprised of professors of Korean Medicine neuropsychiatry. Each item included in the pattern identification is scored and put in an Excel file and is then automatically categorized into one of the six types of pattern identification: liver qi stagnation, bilateral deficiency of the heart-spleen, stagnation of the phlegm qi, stagnation from qi deficiency, qi stagnation becoming fire, and a yin deficiency leading to exuberant fire (Lee et al, 2013; Lee et al, 2015; KIOM, 2016).

(3) Clinical Trials on Depression

A systemic review and meta-analysis for depression shows that the administration of ‘Rambling Powder with Salvia and Gardenia’ (丹梔逍遙散) significantly decreased the symptoms of depression (Dou, 2012; Wang, 2001; Tian et al, 2011). In addition, compared to the administration of anti-depressant medication alone, combined treatment with ‘Rambling Powder with Salvia and Gardenia’ (丹梔逍遙散) and ‘Augmented Rambling Powder’ (加味逍遙散) significantly decreased the symptoms of depression (Zhang, 2012; Liu, 2013; Lao, 2012; Xia, 2011 Wei et al., 1999).

Although there were no well-designed controlled clinical trials conducted in Korea, the relaxation method (the muscle relaxation method, mindfulness meditation, abdominal breathing, exercise, and breathing) and the exercise method (yoga and tai chi) were shown to significantly decrease the symptoms of depression (Hwang et al, 2011).

256 Psychiatric Diseases chapter 6

Anxiety Disorders

In Korean Medicine, anxiety disorders are characterized by fright palpitations and shaking in fear. Many classic texts include these overall bodily symptoms in combination with mental symptoms. Treatment methods and specific medicinal herbs are recommended for certain conditions. In Korean Medicine, we classify the physical symptoms accompanying with anxiety and recommend appropriate herbal medicine. It has strengths over the Western Medi- cine treatment, which is limited to the anti-anxiety and sedative medicines.

1. Diagnosis and Examination

Based on clinical features, the diagnosis is made according to the diagnosis criteria of anxiety disorder. It can be supplemented by psychological and psychiatric questionnaires. Pattern identification is also performed for anxiety disorders.

2. Treatment

(1) Heart-Gall Bladder Deficiency and Timidity

The patient has an anxious mind, sensitivity, palpitations, restlessness, loss of appetite, and abhorrence to sound resulting from a constitutional tendency or after being frightened.

(2) Bilateral Deficiency of the Heart-Spleen

The qi and blood become scarce, thereby inducing palpitations, shortness of breath, dizziness, a pale complexion, tiredness, a loss of appetite, and abdominal distention.

(3) Collapse and Deficiency of the Heart Yin

257 PART 2 Korean Medicine Treatments for Various Medical Conditions

(4) Yin Deficiency of the Liver-Kidney

Deficiency of the liver yin accompanies deficiency of the kidney yin to induce palpitations, insomnia, heat on the palms and soles, dizziness, restlessness, lower back pain, and the involuntary discharge of semen.

(5) Obstruction of Turbid Phlegm

Blocked qi leads to palpitations, short breath, chest discomfort, phlegm, the loss of appetite, abdominal distention, and nausea.

(6) Stagnation of the Blood Flow

Blocked qi blocks the flow of blood, leading to local pain (stagnated blood), insomnia, and forgetfulness (blood deficiency).

3. Algorithm for Treatment

This process includes the diagnosis, differentiation, evaluation for severity, treatment with Korean Medicine, and referral to specialists. For the diagnosis, differentiation, and evaluation of severity, diagnostic criteria and assessment tools in psychiatry and psychology are utilized. Treatment with Korean Medicine uses pattern identification for palpitations and shaking in fear, with recommendations of cooperative treatment with Western Medicine upon severity.

4. Recent findings

There is a case report on the improvement of anxiety with Insuksan (仁熟散) (Kwon et al., 2005; Lee et al., 2005) and a case report showing that acupuncture treatment leads to significant improvement on bio functional examinations, such as Heart Rate Variability (HRV), which is related to anxious stimuli and subjective anxiety (Choi et al., 2004; Jeong et al., 2009; Kang et al., 2009).

258 Psychiatric Diseases chapter 6

Clinical Aspects of Anxiety

No Differential Diagnosis correspondence Diagnosis ・Hwa byung Anxiety-related disorder, diagnostic ・Chest pain standards, tool for pattern identification ・Running piglet Correspondence ・Depressive disorder ・Adaptive disorder Diagnosis ・Sleep disorder Anxiety-related disorder ・Thyroid disorder (F40, F41, F42, F43)

Evaluation of Severity

・Is the score higher than moderate in evaluation tool for anxiety? (HAM-A6), STAI7), ACQ8), Phobia Questionnaire, MOCI9), PSWQ10)) ・Is daily activities impossible from severity of anxiety, panic, or obsession? ・Is there high risk degree for complication of depressive symptoms or suicide? ・Is isolation needed from stressful environment? ・Did the patient take western medication for a long time?

moderate to severe mild

Treatment Treatment

Specialized treatment in Reference of pattern identification department of Korean Medicine and treatment of fright palpitation and neuropsychiatry or admission shaking in fear

Maintenance or Improvement of aggravation of symptoms symptoms

Consideration of other Continued management treatments and prevention of relapse

Maintenance or aggravation of symptoms Improvement of symptoms

Re-evaluation of Maintenance of treatment symptoms and signs

[ Figure 2 ] Treatment algorithm for anxiety

6) Hamilton Anxiety Rating Scale 7) State-Trait Anxiety Inventory 8) Agoraphobic Cognitions Questionnaire 9) Maudsley Obsessive-Compulsive Inventory 10) Penn State Worry Questionnaire 259 PART 2 Korean Medicine Treatments for Various Medical Conditions

Hwa-byung

It is a mental disorder that reflects the concept of Korean Medicine. Hwa-byung is an anger-related disorder. As increasing social problems, this disease is currently relevant to anger significantly.

1. Diagnosis and Examination

The diagnosis is based on characterizing the somatic and psychological symptoms of Hwa-byung using a Hwa-Byung Diagnositic Interview Schedule (HBDIS) and Hwa-byung scale. For the treatment of Hwa-byung, pattern identification and the Hwa-byung evaluation tool are used.

2. Treatment

(1) Liver Qi Stagnation

The lack of liver function, required to smooth the flow and moderate the emotions, leads to qi blockage, which manifests as discomfort.

(2) Liver Yang Ascension

A chronic state of qi blockage causes suppressed energy to upsurge, which induces symptoms such as feelings of heat, dryness of the mouth, headaches, and anger.

(3) Heart-Kidney Disharmony

Disharmony between the heart and kidney, which control water and fire, leads to palpitations, feelings of heat, insomnia, and the involuntary discharge of semen.

(4) Bilateral Deficiency of the Qi and Blood

Shortages in both the qi and blood lead to palpitations, frightfulness, forgetfulness, loss of appetite, dizziness, and a pale complexion.

260 Psychiatric Diseases chapter 6

(5) Stagnated Gall Bladder-Phlegm Disturbance

Hindrance in the qi flow irritates mental function, leading to an inability to control one’s emotion, chest discomfort, and psychosis.

3. Algorithm for Treatment

The treatment algorithm for Hwa-byung includes diagnosis, differentiation, and treatment. For the diagnosis and differentiation, Hwa-Byung Diagnositic Interview Schedule (HBDIS) is conducted. For treatments, prescriptions are presented by pattern identification and by symptoms.

4. Recent findings

(1) Clinical Guidelines for Hwa-byung

Clinical guidelines for Hwa-byung were developed in 2013 and are based on clinical researches.

(2) Pattern Identification and Evaluation Tools for Hwa-byung

• Instrument on Pattern Identifications for Hwa-Byung: This tool was developed by a com- mitee composed of Korean Medicine neuropsychiatry professors in 2008. It is a questionnaire with an interviewer-evaluation format composed of 38 questions. The results of the questionnaire are categorized into five types of patterns (Lim et al., 2008). • Instrument of Korean Medicine Evaluation for Hwa-Byung: This tool was developed in 2010 and is composed of five types of questionnaires used to evaluate the severity of symptoms according to each pattern identification type. It can be also utilized for evaluating the treatment for Hwa-byung (Cheong et al., 2010).

(3) Clinical Trials on Hwa-byung

A randomized controlled trial was performed on a representative prescription for Hwa- byung, Bunsimgi-eum (分心氣飮; heart qi parting drink), and Sihogayonggolmyryo-tang

261 PART 2 Korean Medicine Treatments for Various Medical Conditions

Clinical Aspects of Hwa-byung

Differential Diagnosis None Examination

・Menopausal disorder Relationship with stress ・Thyroid disease Yes Differential Diagnosis No Diagnosis correspondence ・Depression (F32) ・Anxiety disorder (F40) Confrontation test for Hwa-byung ・Psycho-somatic disorder (F45) Correspondence Diagnosis

Hwa-byung (U22.2)

Prescriptions upon Pattern Identification Prescriptions upon Symptoms

・Liver qi stagnation: Bupleurum liver ・Anger: Modified peripatetic powder, liver suppressing powder dispersing decoction, modified peripatetic ・Stuffy chest: Heart qi parting drink, six stagnation decoction powder ・Flushing: modified peripatetic powder,yin moistening and ・Liver yang ascending: Modified peripatetic fire suppressing decoction powder, gastrodia and uncaria drink ・Plum-pit sensation: Pinellia and magnolia bark decoction, modified four seven decoction ・Heart and kidney disharmony: Heavenly ・Feeling of colliding: Modified peripatetic powder, king’s heart tonifying pill, four material ‘Cinnamomum and Poria Decoction’ spirit-calming decoction ・Anxiety/fright palpitation, shaking in fear: modified gall ・Bilateral-deficiency of qi and blood:Yin bladder-warming decoction, ‘Bupleurum and Poria Decoction’ nourishing and spleen nurturing decoction, ・Depression: Six stagnation decoction, modified heartqi middle tonifying and qi augmenting dividing drink decoction ・Insomnia: Heavenly king’s heart tonifying pill, modified ・Stagnated gall bladder and phlegm return to the spleen decoction disturbance: Spirit clearing and phlegm ・Headache: Clear the upper and clear the pain decoction, guiding out decoction, phlegm removing clear the upper and extinguish the fire decoction and spirit clearing decoction ・Dizziness: Clear the dizziness and remove the phlegm ・Widely used prescription: Heart qi parting decoction, pinellia, atractylodis mcrocephalae, and drink ・Bodily pain: Aucklandia qi smoothing powder, storax pill

Maintenance or aggravation of symptoms Improvement of symptoms

Continuous management and Consideration of other treatment prevention of relapse Maintenance or aggravation of symptoms Improvement of symptoms

Consideration of combination Maintenance of treatment and treatment with western medicine continuous management

[ Figure 3 ] Treatment algorithm for Hwa-byung

262 Psychiatric Diseases chapter 6

(柴胡加龍骨牡蠣湯). There was also a clinical trial on Yeoldahanso-tang (熱多寒少湯; more heat and less cold decoction), a Sasang constitutional prescription (Kim et al., 2012; Choi et al., 2012; Bae, 2006).

There was a clinical study on Saam acupuncture, including heart Jung Gyeok (心政格) and pericardium Jung Gyeok (心包政格), for the regulation of organs related to Hwa-byung. There were also randomized controlled trials including Hwa-byung patients with insomnia who were treated with scalp acupuncture on the vision area and the comfortable sleep point, which showed significant results (Jung et al, 2008., Choi et al., 2011, Lee et al., 2012).

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Sleep Disorders

Sleep disorders are frequently observed in patients with neuropsychiatric disorders. Such disorders are approached from the perspective of balance and harmony in Korean Medicine.

1. Diagnosis and Examination

The diagnosis is based on clinical symptoms. For the treatment, the causes of the sleep disorder and the distinguishing symptoms are taken into account and the treatment is performed based on these pattern identification.

2. Treatment

(1) Insomnia due to too many Thoughts Too many thoughts lead to insomnia with a loss in appetite, indigestion, and weakness of the limbs.

(2) Shortage in Nutritious Blood Overworking physically or mentally and experiencing serious diseases all cause shortages of the blood and qi that lead to anxiety, palpitations, and dizziness.

(3) Internal Heat from Yin Deficiency The chronic shortage of essence and blood gives rise to deficient fire. Feeling of heat, sweating, bitter or dry mouth, and dizziness may accompany this condition.

(4) Heart and Gall Bladder Deficiency and Timidity Becoming anxious, sensitive, fearful, frightful, and sleepless after being frightened or due to one’s constitution.

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(5) Phlegm Stagnation

The flow of the qi obstructed by an irregular diet, stress, or constitutionally may lead to indigestion. This may cause palpitations, dizziness, heaviness of the head and body, nausea, chest discomfort, and insomnia.

(6) Disharmony within the Stomach

A problem in digestion causes abdominal distention, tiredness, burping, nausea, vomiting, loss of appetite, and insomnia.

3. Algorithm for Treatment

This algorithm divides sleep disorders into primary and secondary insomnia according to clinical aspects. In particular, it specifies the conditions for secondary insomnia. Treat- ment follows the pattern identification of sleep-related symptoms. (Figure 4)

4. Recent findings

Several clinical studies have been conducted. One study examined the effects of Sanjoin-tang (‘Sour Jujube Decoction’, 酸棗仁湯) on insomnia (Hong, 2005). One depressed patient showed improvements following combination treatment with Western medication and Samhwangsasim-tang (‘Three Yellows Drain Heart Decoction’, 三黃瀉心湯) (Seok et al., 2006). One study reported three cases of insomnia patients treated with modified Yookgunja-tang (‘Six Gentlemen Decoction’, 六君子湯) (Kim et al., 2010). Another clinical study evaluated the effects of Sanjoin-tang (酸棗仁湯) on insomnia in patients with cerebral artery disorders (Hong et al., 2004). The effectiveness of sour jujube on insomnia in cerebrovascular attack patients was also evaluated (Chung et al., 2010). A study of the effectiveness of acupuncture treatment on Hwa-byung patients was performed (Lee et al.,2012), and combination treatment with ear acupuncture and acupuncture on HT07 was examined (So et al., 2003). Another clinical study examined the effects of pharmacopuncture on insomnia and tiredness (Lee et al., 2012) (Lee et al., 2012; Park et al., 2013).

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Clinical Aspects of Insomnia

No Insufficient sleep provoked Sufficient opportunity and environment for by behavior sleep was provided

yes

Occurrence of symptoms like tiredness, No Short sleeper: lethargy, attention deficit, memory deficit, Genetic short mood change, psycho-somatic change, and sleeper somatic change

yes Secondary Insomnia RLS, periodic limb movement Insomnia from Insomnia from Circadian rhythm disorder, drug, addictive Insomnia from neuropsychiatric sleep disorder dyspnea related material, or disorders disorders to sleep, alcohol parasomnia

No No No No No

Mismatch between Learning of Behavior does Acute change subjective and conditioned Not early onset not match good in environment, objective sleep, awakening nor acute conditions for physical or social extreme sleep and sleep sleep stress symptom disturbance Primary Insomnia

Insomnia from Temporary Psycho- Idiopathic Paradoxic sleep inadequate sleep insomnia from physiologic insomnia hygiene stress insomnia

Treatment

Reference of sleep-related symptoms and pattern identification of dreams

[ Figure 4 ] Treatment algorithm for sleep disorders

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Psychotherapy in Korean Medicine

Consultation and psychotherapy are important for the treatment of neuropsychiatric disorders. These therapies not only improve symptoms but also help alter patients emotion, thought patterns, and behavior. In Korean Medicine, consultation, medication, Qigong, and Emotion Freedom Technique (EFT) are utilized, in addition to traditional methods for psychotherapy.

1. Psychotherapy in Korean Medicine

Many methods within Korean Medicine for treating the mind and neuropsychiatric problems are related to the practices of supportive therapy and dynamic therapy in current neuropsychiatry or psychology (College of Korean Medicine Neuropsychiatry Textbook Com- mittee, 2016).

(1) Therapy for Moving Emotions and Changing Qi

In this type of psychotherapy, the doctor utilizes various methods to alter the patient’s mental state and regulate the pathologic condition to promote recovery from the disorder. Spe- cific methods can be categorized as ‘moving the problem within the thinking’ and ‘inducing the emotion in other ways.’

(2) Conversation Therapy

This is an education method in which the doctor performs psychotherapy on the patient with care and sympathy to make the patient feel relieved. Conversation therapy is the primary psychotherapy method because it is simple and easy. The doctor must have high levels of sympathy and patience throughout the therapy in addition to comprehensive knowledge.

(3) Desensitization Therapy

This method entails stimulating the patient with weak stimulants to stronger stimulants to desensitize the patient to the stimulus and resolve the symptoms. It is similar to “systemic desensitization”. It is utilized for frights, phobias, and anger.

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(4) Therapy for the Mutual Conquest of Five Emotions

This type of psychotherapy is based on the theory of Five Phases and the mutual conquest of emotion. It removes the pathologic emotion that inhibits other emotions to treat specific psycho-somatic disorders due to an excess of a certain emotion. It can be categorized as the “regulation of thinking through anger”, the “regulation of sadness through joy”, the “regulation of anxiety through thinking”, the “regulation of anger through sadness”, and the “regulation of excessive joy through fear”.

2. Consultation

Consultation is performed to help the patient practice methods of life nurturing and to increase the patient’s ability to cure him or herself. First of all, personal traits, characteristics, weaknesses, and strong points are determined. During the consultation, patients often report being disappointed with Western Medicine treatment and look forward to treatment with Korean Medicine, which is holistic. This holistic approach allows the doctor to identify the strengths of each patient, which can be utilized to help the patient recover his or her ability for self-healing (Kim et al., 2016).

3. Meditation and Qigong

With evidence from clinical trials, meditation methods based on mindfulness, meditation and Qigong are utilized. In Korean Medicine, Qigong enhances the effects of meditation.

In clinical practice, not only breathing medication and relaxation but also methods that combine feeling and utilizing qi to maximize curative properties, have been attempted (Kim et al., 2011).

One study of Mindfulness Based Stress Reduction program (MBSR), a meditation program based on MBSR that utilizes the qi, was performed on patients who had shown high levels of stress and showed that the scores on the World Health Organization Quality of Life (WHO- QoL), the scale for Hwa-byung, the Perceived Stress Scale (PSS), and the State-Trait Anxiety Inventory (STAI) all significantly decreased; furthermore, it was more effective for people who

268 Psychiatric Diseases chapter 6

tend to avoid high risk or with low autonomy (Hwang et al., 2010; Hwang et al., 2013).

Mindfulness-Based Cognitive Therapy (MBCT) is based on mindfulness and is combined with cognitive therapy. It is widely utilized to prevent the recurrence of depression. The recurrence rates were decreased in the patients who received MBCT simultaneously with tapering off antidepressant than those who did not received MBCT simultaneously with tapering off antidepressant. The effect size of MBCT was similar to the result of antidepressant maintenance therapy (Segal et al., 2010).

4. Emotion Freedom Technique (EFT)

Emotion Freedom Technique (EFT) is a meridian-based psychotherapy that combines the method of treating trauma in psychology with tapping acupoints. It is an evidence-based method widely used for a variety of neuropsychiatric disorders. EFT assumes that a past memory that has become a scar is related to negative emotions (fear, anxiety, frustration, depression, etc.). When this negative emotion is removed, the past memory itself will be faded. EFT functions to remove negative emotions and destroy negative beliefs that accumulate from negative memories. It is therefore directly utilized not only for trauma and phobias but also for anxiety disorders, depression, and various cases of psycho-somatic disorders (Choi et al, 2008).

The performance of EFT on Hwa-byung patients resulted in significant reductions in the Hwa- byung scale, The State-Trait Anxiety Inventory (STAI), and State-Trait Anger Expression In- ventory (STAXI), but produced no significant differences compared to a group that underwent Progressive Muscle Relaxation (PMR). In addition, this effect was maintained, or even resulted in further reductions, after 4 weeks of treatment cessation (Suh et al., 2015) and Hwa- byung symptoms and involuntarily memory recall was reduced. In addition to coping ability and positive thinking were increased and self-image was recovered. Negative emotions were also decreased and positive emotions were increased. Sensitivity in personal relationships were decreasesed, leading to fewer troubles with others and in turn to better understanding others (Song et al., 2014).

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A complementary and Preventive Approach to Neuropsychiatric Disorders

Neuropsychiatric disorders require a treatment as well as management. This management is necessary in the clinic and daily life. Life nurturing methods in Korean Medicine suggest various methods in which complementary approaches can be implemented.

1. Method of Life Nurturing for Neuropsychiatric Health

This is suggested for training the mind.

2. Tracking

This is a method used to overcome neuropsychiatric disorders by walking exercise. In Korea, there is forest therapy program or tracking program.

The Roles of Korean Medicine in Neuropsychiatry

The prevalence of neuropsychiatric disorders is increasing each year. Particularly in Korea, more patients have psycho-somatic disorders than typical mood disorders. Korean Medicine approaches such disorders from a holistic perspective.

Korean Medicine is able to give a remedy to patients who misusing and abusing neuropsychiatric medication.

Korean Medicine has a profound understanding of the human being. With integrative interpre- tations of the body and mind, Korean Medicine offers solutions for people living in modern society. In addition to alleviating symptoms, it can help recover self-healing and facilitate development into a mature human being.

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Reference

•Bae EJ. The Clinical Study of Effectiveness of Yuldahansotang in Hwabyung Patient. Kyung Hee University. Master’ Thesis. 2006. •Cheong MH, Lee SR, Kang WC, et al. Preliminary Study to Develop the Instrument of Oriental Medical Evaluation for Hwa-Byung. Journal of Oriental Neuropsychiatry. 2010;21(2):141-55. •Choi WC, Park DM, Kang WC, et al. Interim Report about the Effect of Sihogayonggolmoryeo-tang on the Anxiety of Hwa-byung. Journal of Oriental Neuropsychiatry. 2012;23(4):133-52. •Choi WJ, Lee SG, Son IB, et al. The Effects of Sa-am Acupuncture Simpojeongkyeok Treat- ment on Hwa-byung: Randomized, Patient-assessor Blind, Placebo-controlled Acupunc- ture, Pilot Clinical Trial. Journal of Oriental Neuropsychiatry. 2011;22(2):1-13. •Chung KH, Roh GH, Lee DS, Moon SK, Cho KH. Effectiveness of Zizyphus seed (ANsim-san) for Insomnia in Stroke Patients. Journal of Korean Oriental Medical Society. 2001;22:101-6. •Choi WJ, Lee SG, Park KM. A study on the relationship with acupuncture stimulation and stress using heart rate variability. Journal of Oriental Neuropsychiatry. 2004;15(1):197-209. •College of Korean Medicine Neuropsychiatry Textbook Committee. Korean Neuropsychiatry 3rd Edition. Seoul, Republic of Korea: Jipmoon Publications. 2016. pp.715-720. •Dou NJ. Clinical research of 50 cases using Danzhisoyosan for depression[丹栀逍遥散治疗抑郁症50 例临床观察]. China Medical Engineering 2012;20(9):89, 91. •Eun-Young Hwang, Sun-Yong Chung, Jae-Heung Cho, Mi-Yeon Song, Sehyun Kim and Jong-Woo Kim. Effects of a Brief Qigong-based Stress Reduction Program (BQSRP) in a distressed Korean population: a randomized trial. BMC Complementary and Alternative Medicine 2013;13:113. •EH Lee, WC Choi, IC Jung. Preliminary Study to Develop the Instrument on Pattern Identifi- cations for Depression. J of Oriental Neuropsychiatry 2013;24(4):435-50. •EY Hwang, SY Chung, WW Hwang, JW Kim. The Correlation between the Effectiveness of Brief Qigong-based Stress Reduction Program(BQSRP) and Personality. J of Oriental Neu- ropsychiatry 2010;21(2):45-60. •Gao X. Xiaoyao powder combined with escitalopram oxalate tablets in the treatment of depression. China Modern Doctor 2012:50(1):66-7, 70 •HJ Park, JH Yoo, JH Kwon, SW Lee. Literature Review of Randomized Clinical Trials Re- garding Insomina. J of Oriental Neuropsychiatry 2013;24(3):201-210. •Hong HW. A Clinical Study of Sanjoin-Tang on Insomnia Patients. Dept of Oriental Medicine Graduate School Dong-Eui University. 2005. •Hong HW, Lee SD, Gam CW, Park DI. Clinical Study of Sanjoin-Tang on Insomnia Pa- tients with Cerebrovascular Accident. Korean Journal of Oriental Physiology & Pathology. 2004;18:1927-32.

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•HS Lee, WC Kang, IC Jung. Reliability and Validity Analysis of the Instrument on Pattern Identifications for Depression. J of Oriental Neuropsychiatry 2015;26(4):407-16. •Jeong MS, Choi WJ, Lee KW, Lee SG, Kim JE, Lee JC, et al. The effects of acupuncture stimulation on skin conductance response of anxiety patients and normal subjects. Journal of Oriental Neuropsy- chiatry. 2009;20(2): 101-10. •Jung IC, Lee SR, Park YC, et al. The Effect of Sa-am Acupuncture Simjeongkyeok Treatment for Major Symptom of Hwa-byung. Journal of Oriental Neuropsychiatry. 2008;19(1):1-18. •JW Kim, SY Song. Counseling Korean Medicine. Seoul, Republic of Korea: Jipmoon Publi- cations. 2016. •JW Kim. Fifteen Minutes Meditation with Qi. Seoul, Republic of Korea: Jipmoon Publications. 2011. •JW Suh, SY Chung, SY Kim, JH Lee, JW Kim. Anxiety and Anger Symptoms in Hwabyung Patients Improved More following 4 Weeks of the Emotional Freedom Technique Program Compared to the Progressive Muscle Relaxation Program: A Randomized Controlled Trial. Evidence-Based Complementary and Alternative Medicine 2015. •JY Hwang, IC Jung, SR Lee. The Review for Studies of Aromatherapy, Relaxation Therapy and Exercise Therapy on Depression. J of Oriental Neuropsychiatry 2011;22(4):1-10. •Kang HC, Lee SG. The trends in clinical trials about effects of acupuncture on anxiety, depression and mental stress. Journal of Oriental Neuropsychiatry. 2009;20(4):137-148. •Kim SH, Lee JI, Gu JH, Chung DK. Three Case Report of Modified Yukgunja-tang Main Treat- ment Effect on Imprevement of Insomnia Caused by Wibulhwa. Korean Journal of Oriental Physiology & Pathology. 2010;24:892-7. •Kim SH, Park YC, Hong KE, Kang WC, et al. The effect of Bunsimgi-eum on Hwa-byung: Randomized, double blind, placebo controlled trial. J Ethnopharmacol. 2012;144(2):402-7. •Korean Institute of Oriental Medicine, The Korean Society Of Oriental Neuropsychiatry. Ko- rean Medicine Clinical Practice Guideline for Depression. Seoul, Republic of Korea: Elsevier Korea. 2016. •Kwon JJ, Kim TH, Kang HW, Lyu YS. A bibliographic study of anxiety and anxiety disorder in oriental medicine. Journal of Oriental Neuropsychiatrγ. 2005;16(1):159-69. •Lee EK, Lee JI, Kwon SJ, Chung DK. A clinical report on anxiety improved by Insooksan. Journal of Oriental Neuropsy- chiatry. 2005;16(2): 309-15. •Lee GE, Kim NK, Kim HY, Kang HW. The Effects of Acupuncture Treatment on Hwa-byung Patient’s Insomnia-Patient Assessor Blind, Randomized, Placebo-controlled Clinical Trial. Journal of Oriental Neuropsychiatry. 2012;23:31-48. •Lee GE, Kim NK, Kim HY, et al. The Effects of Acupuncture Treatment on Hwa-byung Pa- tient’s Insomnia: Patient-assessor Blind, Randomized, Placebo-controlled Clinical Trial.

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Journal of Oriental Neuropsychiatry. 2012;23(1):31-48. •Lee YH, Kwon GS, Lee SH, Lee ES, Kim CH, Jang KJ, Song CH, Kim YG, Kim WI, Yoon HM. The Clinical Review of Samgj-Halleak Pharmacopuncture Effects for Insomnia & Fatigue. The Joumal of Korean Acupuncture & Moxibustion Medicine Society. 2012;29:101-13. •Lim HJ, Kim SH, Lee SR, et al. Study to Develop the Instrument of Pattern Identification for Hwa-byung. Korean Journal of Oriental Physiology & Pathology. 2008;22(5):1071-7. •Liu GC. Clinical research of 60 cases using Soyosan and Paroxetine for depression 逍遥散联合帕罗[ 西汀治疗抑郁症60例疗效观察]. Nei Mongol Journal of Traditional Chinese Medicine. 2013(3):56-7 •Seok SH, Kim JH, Kin GW, Koo BS. A Case of Insomnia Incuralble by Neuropsychiatric Med- ication Alone but Made Possible with Sam-HwangSa-Sim-Tang. Journal of Oriental Neu- ropsychiatry. 2006;17:117-29. •So WR, Park WT, Lee SH, Sin KH, Roh JD, Choi SW, Kim JG. Clinical Stury on Effect of Auricular Acupuncture Theraphy and Auricular Acupuncture Theraphy with Common Acu- puncture Theraphy on Insomnia in Stroke Patients. The Journal of Korean Acupuncture & Moxibustion Society. 2003;20:38-49 •Segal ZV, Bieling P, Young T, MacQueen G, Cooke R, Martin L, et al. Antidepressant mon- otherapy vs sequential pharmacotherapy and mindfulnessbased cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression. Archives of General Psychiatry 2010;12:1256–64. •SY Song, JH Lee, JW Suh, CY Kwon, JW Kim. Qualitative Analysis for the Influences of Emo- tion Freedom Techniques (EFT) Group Treatment Program for Hwa-Byung Patients. J of Oriental Neuropsychiatry. 2014; 25(1): 29-37 •Tian Q, Li BH. Clinical research of 48 cases using Gamidanzhisoyo-tang for depression [加味丹栀逍遥汤治疗抑郁症48例]. Modern Traditional Chinese Medicine, 2011;31(6):10-1. •Wang TY. Clinical research of 34 cases using Danzhisoyo-tang-gagam for depression [丹栀逍遥汤加减治疗抑郁症34例]. Chinese Journal of Scientific and Technical Periodicals. 2001;21(9):710-1 •Wei P, Li Y, Li YC. Clinical research of 30 cases using Soyosan-gami for depression[逍遥散加味治疗抑郁症30 例]. Traditional Chinese Medicinal Research. 1999;12(5):54-5. •WY Choi, WY Kim, YJ. Miracle in 5 minutes. Seoul, Republic of Korea: Jeong-sin-se-gye Publications. 2008. •Xia X, Tan X, Wang D, Meng Q. The efficacy observation of Xiaoyaosan combined with Escit- alopram in the treatment of depression. China Medical Herald. 2011;8(24):71-2 •Zhang JZ. Clinical efficiency of paroxetine combined with Xiaoyaosan in the treatment of 68 patients with depression. Guide of China Medicine. 2012;10(12):415-6

273 2016 Korean Medicine Current Practiceof CHAPTER 7

Obesity

▼ Hojun Kim PART 2 Korean Medicine Treatments for Various Medical Conditions

chapter 7

Obesity

Introduction

Obesity is considered to be a state of an energy imbalance either of excessive calories or of insufficient physical activity. Hormonal factors, genetics, psychological, and socioec- onomic factors are associated with obesity. Because of the high correlation with other adult diseases, obesity is an impending issue in the global health community. While obesity was only recognized as a disease by the WHO 50 years ago, it has now become an epidemic. Obesity is the leading cause of death and disorder. The prevalence rate of obesity has rapidly risen in Korea, especially in child and adolescent population. While this calls for a special attention, obesity is not yet accepted as a serious disease in our society.

Aside from genetic factors and endocrine system malfunctions, obesity is affected by behavioral factors, such as exercise, excessive calories, and inappropriate eating habits, as well as psychological factors.

Acupuncture and moxibustion, medication, and surgical procedures are recommended for obesity treatment, but when these strategies are not supported with a proper diet, exercise, and behavior modifications, there are limited long-term effects. Therefore, even in cases in which there are no comorbidities, treating overweight or obese patients or preventing obesity in children and adolescents requires a long-term plan that includes an appropriate diet, exercise, and behavior modification to establish self-management skills.

276 Obesity chapter 7

Definition of Obesity: Causes and Pathogenesis

Obesity is not just a state of being overweight. It should be perceived as an over-accumulation of body fat due to a metabolic disorder. In other words, excessive calorie intake that surpasses the amount of the required energy for a body function leads to a calorie imbalance; residual energy has been deposited in the body in the form of excessive amounts of fat. This is the definition of obesity.

In Korean Medicine, obesity was first recognized in the Huangdi’s Internal Classic, Plain Questions, Chapter of “A general discussion of deficiency and excess”, in which “obesity is a disorder caused by eating too much”.

1. Energy Imbalance

The mechanism through which obesity occurs can be explained by excessive calorie intake and insufficient energy consumption theories. When there is more energy taken in than is spent, or when less energy is spent than is taken in, the residual energy is accumulated in the form of fats in the body, which causes a metabolic disorder.

2. Genetic Factors

Genetic factors largely contribute to obesity, therefore family history should be considered prior to diagnosis. Researches that observes the prevalence of obesity in identical twins and adopted children also show a correlation between obesity and genetics. At least one parent of 60~80% of obese children is also obese. Single Nucleotide Polymorphisms (SNPs) is also known to affect the prevalence of obesity and treatment reactions.

3. Neuroendocrinological Factors

In most cases, problems in the endocrine system do not directly cause obesity. How-

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ever, imbalances in the endocrine system affect the clinical symptoms that are displayed by obesity patients. Insulin plays an important role in the biosynthesis and storage of fat. Therefore, insulin over- production and the resulting resistance in peripheral tissues are one of the most important pathophysiologic factors for obesity and metabolic syndromes. The higher the blood insulin concentration, the less heat is produced, which interferes with proper metabolism.

Hypersensitivity in the Hypothalamic-Pituitary-Adrenal axis (HPA axis) can explain hormonal imbalances. Decrease in growth hormones that help to burn fat tissue, increase in cortisol that contributes to abdominal obesity, and altered levels of sex hormones are caused by HPA axis dysfunction.

Leptin, which is secreted from adipocytes, suppresses appetite by stimulating neurotransmitters that inhibit and block the neurotransmitters that stimulate appetite. Although effective in animal models, human applications are disappointing except for in cases of leptin deficiency.

Thyroid hormones are the most important hormones for energy metabolism. They stimulate heat production. Therefore, in patients with hypothyroidism, obesity is common. Extreme low-calorie diets can cause temporary hypothyroidism. Serotonin is associated with many psychological problems, such as depression, bulimia, nocturnal eating syndrome, and anorexia.

4. Environmental Factors

Rapid economic growth and industrial structure has led to an increased prevalence of obesity due to over-nutrition and a lack of exercise. Therefore, obesity is perceived as a social disease. Concerns about obesity are rising, as it imposes threat on overall health.

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Korean Medicine Approaches to Obesity

1. Different Types of Obesity

In Miraculous Pivot, Chapter on “Abnormal Defense Qi”, (衛氣失常篇) categorized obesity patients as Bi-in (a fat-type person), Go-in (an adipose person), and Yook-in (a flesh- type person). According to the book, the overall characteristics of the fat layer differ depending on the constitution of the person. The development of specific layer is determined by the robust- ness of the defense qi at each layer. The morphology of Bi, Go, Yook determines the size of the person and their levels of blood and qi. Bi-in and Go-in are similar to obesity in patients today. When there is excessive blood and deficient qi, the patient is a Bi-in; when there is excessive qi and deficient blood, the patient is a Soo-in (a thin-type person). Bi-in can be characterized as qi deficient, cold, and damp. Soo-in can be characterized as blood deficient, hot and dry.

2. Causes of Obesity and Illnesses in Obesity Patients

Phlegm, dampness, cold dampness, and qi deficiencies are considered the causes of obesity. Stroke, phlegm, white vaginal discharge, red and white turbid urines, and diabetes are complications that are prevalent in obese individuals. Delicious food can cause the body to become fat, and frequently consuming sweet food can cause obesity.

3. Mechanisms of Obesity

The mechanisms of obesity are described as follows; food qi overriding innate qi, spleen-stomach exuberance, deficiencies in the spleen-stomach, spleen dysfunction, phlegm, qi deficiencies, excessive blood with qi deficiencies, delicious food, the frequent consumption of sweet food and calorie-rich food.

• Obesity is said to occur when food qi overrides innate qi. When stomach qi is congenitally weak, food and drinks multiply on their own to cause the condition. Another possible cause

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is damage that is inflicted by seven emotions. According to Donguibogam: Body, Shape and Qi determines the lifespan, “When grain qi wins over original qi, the person will become fat and live short, and when original qi wins over grain qi, the person will become skinny and live long”. • Disharmony in the five viscera and six bowel functions may result in an over-accumulation of spleen dampness. Dysfunctions in the spleen, lung and kidney may cause over-accumulations of dampness phlegm. Of the three viscera, the spleen and stomach are the most important. Both excesses and deficiencies in the spleen and stomach can be a cause. “If the spleen and stomach are both exuberant, the patient can eat and is not diseased, but is obese. These types do not feel hungry even after meal times”, “If the spleen and stomach are both deficient, and the spleen is overridden by pathogens, the patient eats little and the extremities are weak”. Zhang Jiebin’s Complete book of Jingyue said (張介賓・景岳全書) “If the stomach qi is weak in the first place, food and drinks will multiply on their own and will damage the spleen and stomach and therefore innate qi cannot become strong.” “If anger harms the liver, liver qi will surely interfere with the spleen, and the stomach will also be affected and thereby, it causes food stagnation” • If there is phlegm in the intestines and stomach that makes gurgling sounds, a sudden weight gain is possible. A qi deficiency refers to deficiencies in the spleen-stomach, and these types suddenly gain weight after fasting for a while and resuming food consumption. People who appear fit but actually have weak qi are often obese because excessive blood and deficiencies in qi can cause obesity.

• Food factors that are relevant to obesity are consuming calorie-rich food and sweets.

4. Pattern Identifications for Obesity

Although there are many pattern identification models for diagnosing obesity in Ko- rean Medicine, the most popular one is suggested by the Korean Institute of Oriental Medicine (KIOM). Six types of obesity; liver congestion, food accumulation, yang deficiency, spleen deficiency, phlegm, and blood stagnation are the most common clinical presentations among patients.

280 Obesity chapter 7

(1) Spleen Deficiency-Type

Patients have edema, are tired, feel heavy, and are stiff all over the body. Uneasiness in the stomach prevents them from eating well, and the patient feels relief from pain when pressure is applied to the stomach. The patient loses his appetite and does not eat much. Diarrhea is a common symptom. Tongue fur is white and slippery, the tongue is bland, and the pulse is thin or thin and slippery.

(2) Phlegm-Type

The skin is pale and dry. This type of person favors greasy and sweet food. The patient has vertigo, feels as though their head is swollen, feels as though the stomach is full, and has severe headaches and an unclear mind. These types becomes tired easily and feel as though the body is about to sink. The hands and feet feel stiff. The patient coughs and vomits phlegm, the tongue fur is white and slippery, and the pulse feels slippery.

(3) Yang Deficiency-Type

Yang deficiency-type patients feel cold and tired and are low in energy. They do not like being exposed to cold environment. Lower back pain and knee pain are common, and the patient feels as though the wind is penetrating the joints. The extremities and the body are swollen, the stomach cannot take in food, the stool is very soft, and fragments of food are excreted undigested. Urination is hindered. The tongue is bland, and the fur is thin and white. The pulse feels sunken and thin or weak.

(4) Food Stagnation-Type

These patients are compulsive in overeating and binge eating. Digestion is hindered, gas accumulates in the intestines, and the stomach feels bloated.

(5) Liver Congestion-Type

The chest and flanks are uneasy and full. The patient is easily enraged, and the stomach area feels stuffy. Applying pressure to the abdomen aggravates these symptoms. There is a bitter taste in the mouth, and the tongue feels dry, but the patient does not want to drink water.

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The stomach feels bloated and cannot take in food. Women may have irregular menstruation with more menstrual fluid secreted. The tongue fur appears slippery, and the pulse feels string-like.

(6) Blood Stagnation-Type

This type includes symptoms such as palpitations, fatigue, stabbing pains in the chest and the flanks, and irregular menstruation. There is ambiguous pain. Female patients may also present with dysmenorrhea with dark menstrual fluid. The tongue fur is thin, and the tongue is dark or spotted. The pulse is thin and string-like or rough.

5. Four Constitutional Approaches

When a person engages in physical activity, the heart rate increases, the respiration rate increases, perspiration occurs, and energy is consumed. Uric acid and other impurities that are synthesized during this process are excreted with urine. To produce energy, consumed food is digested and metabolized in the gastrointestinal system and is then processed by the liver. Some energy that is produced in the liver is consumed, and the remainder is saved as fat.

In Korean Medicine, the heart, lung and kidney are viewed as energy-consuming and excreting organs, while the spleen and liver are energy-accumulating and absorbing organs. According to their constitutions and dominant organs, people have different energy metabolism patterns.

Taeyangin, who have strong lungs and a weak liver, and Soeumin, who have strong kidneys and a weak spleen, are rarely obese. Taeeumin, who have a strong liver and weak lungs, and Soyangin, who have a strong spleen and weak kidneys, are vulnerable to obesity.

Taeeumin are gluttonous in nature and therefore are mostly obese due to overeating. Soyangin are very emotionally sensitive and therefore have a tendency to binge when exposed to stress.

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Diagnosing Obesity

1. Body Mass Index (BMI)

Body Mass Index (BMI) is calculated by dividing the weight (kg) by the height (m) squared. It is a simple, cost-effective and accurate way to diagnose obesity. In most populations, BMI is highly correlated with fat mass. BMI can be used to predict relative risk rates for disease and death. A higher BMI indicates that a patient is more likely to have cardiovascular disease and cancer. Patients with high BMI scores may also be more likely to have a higher risk of early death. According to the guidelines for obesity of the Asia Pacific region, BMI of 18.5 to 22.9 is considered healthy. BMI of over 23 is considered overweight. BMI of 25-30 is considered first degree obese, BMI of 30 or higher is considered second degree obese.

2. Body Composition Analysis

(1) Indirect methods

• Bioelectric Impedance Analysis (BIA) When human tissues are exposed to low electrical currents, there is a certain resistance that depends on the frequency. Impedance that occurs in this process is correlated with body composition. At low frequencies, currents flow through extracellular fluids, while at high frequencies, currents can travel through all types of body fluids. Impendence that is produced by these differences is measured. Generally, week electric currents applies to legs and arms. Although it is cost effective and easy to use, this method may be prone to errors in calculating total body water and converting it to the total fat volume. There may be differences across ethnicities, and readings may differ depending on the time of the day and the amount of the total body water.

(2) Skin-Fold Thickness (SFT) A caliper is used to measure the width of skinfold in on the biceps brachii, triceps brachii, lower scapula, and suprailiac crest areas. The readings can be used on regression models to calculate body mass. However, these readings are vulnerable to errors, and it may be difficult to obtain measurements from patients who have too much subcutaneous fat.

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(3) Dual energy X-ray Absorptiometry (DXA) Dual energy X-ray Absorptiometry (DXA) was originally devised as a tool for measuring bone density, which can also be used to measure body composition. The body is simultaneously exposed to two different low energy radiations to estimate the amount of body fat and bone mineral density. DXA can be used with all patients, even those who are over 150kg. It is an easy and relatively accurate method for diagnosis. Drawbacks include the high cost of the appliance and the need for regular calibration. Radition exposure is less than that for a chest X-ray.

3. Body fat Distribution Measurement

(1) Abdominal Obesity According to the 2007 National Survey, 36.6% of males and 27.9% of females over the age of 19 were obese (BMIs over 25). The prevalence rate for abdominal obesity (a cut-off value of 90cm for males and 85cm for females in Korea) is approximately 26.1% and 26.8% for males and females, respectively.

Abdominal obesity is a cause of hypertension, hyperinsulinemia, hyperlipidemia, and other metabolic disorders as well as cardiovascular issues. Abdominal obesity is a critical diagnostic criteria for metabolic disorders.

• Visceral/abdominal fat evaluations MRI, CT, and DXA can be used for diagnosis. These tools estimate the surface areas of visceral fat at the L3/L4 level. This method is suitable to monitor small changes in body fat. • Clinically useful method for diagnosing abdominal obesity ❶ Waist Circumference (WC) WC is a simple yet effective way to evaluate the risk of visceral fat and cardiovascular disease. Even individuals who have a normal BMI have a higher risk of cardiovascular disease when they have high WC. Waist-Hip Ratio (WHR) has been used more frequently in the past, but recent findings suggest that WC better reflects abdominal obesity. As such, it has become more commonly used. The WHO cut-off values for the Asian Pacific region are 90cm for males and 85cm for

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females. Guidelines for other areas suggest 94cm for males and 80cm for females. ❷ Waist-Hip Ratio (WHR) WHO sets the guideline at >0.85 for males and >0.80 for females.

(2) Local Fat Deposits

Local deposits of fat depend on sex, individual lipase activity, cortisol level, and smoking habit. The most vulnerable areas of the body for fat deposits are the chest, abdomen, flank, buttock, thigh, and underarm. Localized fat, which is also known as cellulite, may be an aesthetic problem that is differentially mobilized with fat oxidation. Free fatty acid that is produced by lipolysis may re-deposit into other areas when there is no increase in energy consumption through physical activity.

Localized fat accumulation causes circulation problem in the lymph and microcirculation; this problem causes deformation in fat. This results in an orange-peel-like condition of the skin, which is called cellulite. A total of 85~98% of females after adolescence have at least some degree of cellulite. Because this is one of the main causes of body shape changes, cellulite should be considered when treating obesity.

Treatment of Obesity

The goal of treating obesity is to help reduce body fat without affecting the fat-free mass and to further help maintain a normal weight after treatment. By suggesting an appropriate treatment plan based on the health risk, it is important to help for patients comply with the plan that consists of diet, exercise, and long-term behavior modification.

1. Diet

The most fundamental aspect of obesity treatment is diet. For more than 150 years, countless methods of weight loss have been proposed for treating and preventing obesity. The

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effects of diet during weight gain are distinctively different from the effects of diet during weight loss. However, professionals have stressed the importance of consuming fewer calories than are expected. However, little is known about the effects of the nutrient composition of food.

Diets that are recommended for obesity include a Low-Carlorie Diet (LCD), a diet of 1200 calories, and a Very Low-Calorie Diet (VLCD), which is a diet of approximately 400 to 800 calories. However, these extreme methods of weight loss can cause a protein loss and other side effects, such as cardiovascular problem. Physician monitoring and consultations to nutri- tionist are needed. Another aggressive approach to treat obesity is fasting. For several weeks to months, the patient is only allowed to take water, minerals, and vitamins. Although very time-effective, prolonged fasting may cause serious side effects, such as cardiovascular condition, hepatic failure, and arthritis. Monitoring by a specialist is necessary.

• Diet treatments that are clinically recommended for weight loss Calorie-based approaches (without consideration of food quality), which have been used for the last few decades, have been rejected by recent researches. Newer nutrition guidelines are being suggested, but there is not yet an effective and scientifically validated diet with sufficient evidence. The following are some diet treatments frequently prescribed in clinical settings today.

(1) Very low-Carbohydrate Diet

The Atkins’ and South Beach Diets, which are commonly known in Korea as the “Emperor diet,” are the most well-known forms of very low-carbohydrate diet. Only a very small amount of carbohydrates from green vegetables and other starch-free vegetables are allowed for approximately 6 months, depending on the intended goal. The diet consists of 50-60% fat, 30-35% protein, and less than 10% carbohydrates. Possible side effects include ketosis and cardiovascular disease due to the high fat diet.

(2) Low-Carbohydrate Diet

Low-carbohydrate diet limits the total calories consumed to less than 45% of the recommended daily calories. The Zone diet is a common form of low-carbohydrate diet. The ratio of carbohydrates, protein, and fats is maintained at approximately 4:3:3. That is the propor-

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tion that helps maintain balance between the pro-inflammatory and anti-inflammatory cy- tokines. Several studies have suggested that low-carbohydrate diet could help decrease the risks for cardiovascular problems, but long-term compliance rates to this diet are very low.

(3) High-Carbohydrate Diet

The most popular high-carbohydrate diet is the Ornish and Pritikin diets, which consist of 80% carbohydrates and less than 10% fat. High-carbohydrate diet was originally recommended for heart disease prevention but has been extended to weight loss. This diet consists of 6-7 satisfying meals that consist of complex carbohydrates and high-fiber food such as vegetables, whole grains, fruits, beans. However, this diet decreases LDL and HDL cholesterol level.

(4) The low-Glycemic Index (GI) Diet

The glycemic index is defined by quantifying the rate of carbohydrate absorption. The Gly- cemic Index (GI) is determined by dividing the incremental area under the blood glucose curve after consuming 50g of specific carbohydrates by the incremental area under the blood glucose curve after consuming white bread or glucose. Research has shown that high-fiber foods such as whole grains are effective for weight loss and blood sugar control. Low-GI foods give more satiety and use more fat than carbohydrates.

2. Exercise

The 3 elements of exercise for obesity patients are the intensity, duration, and frequency. Therefore, it is important to include these elements when designing an appropriate exercise program.

(1) Intensity

It is important to set an appropriate intensity. The most commonly used method is to measure maximal Oxygen Uptake (VO2max), but more indirect methods are used in clinical settings. The simplest and most practical method is to assess the heart rate.

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In most cases, the difference between the heart rate at rest and the maximal heart rate, or the HRmax reserve, is used to set the optimal exercise intensity. The heart rate at rest is measured immediately after getting out of bed in the morning and then calculate the maximal heart rate. Generally, this value roughly equals the age subtracted from 220.

(2) Duration

For general exercise regimens, the most important factor to consider is the intensity of the workout. However, for weight loss, the most important factor is duration.

Because more energy from fat is consumed during low-intensity training, it is preferable to exercise for a longer period of time at a lower intensity. In other words, if the goal of the exercise is weight loss, commit to an exercise program that consists of long blocks of exercise that are frequently performed to maximize the amount of energy that is expended.

(3) Frequency

The frequency of the exercise compensates for the effects of intensity and duration. The frequency is the number of times an individual engages in physical activity per week. More frequent workout results in more energy being expended. Assuming that the intensity and duration are set to an appropriate level, 3~4 times workout is recommended per week. How- ever, because 6~7 times workout per week will expend twice as many calories, daily exercise is recommended if the goal is to lose weight.

3. Behavior Modification Method

(1) Setting Realistic Goals

The practitioner should inform the patient that obesity is not only an aesthetic issue, but a leading cause of other diseases. Patients should be noticed that normalizing both weight and fat percentages is the treatment goal. However, some patients want to lose weight even when their weight is normal, and others desire body weights that are below the recommended weight. In this case, it is important to acknowledge the medical definition of weight control and to help the patient set appropriate goals that will not cause health problems.

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(2) Keeping Oneself Motivated and Re-evaluating Ones’ lifestyle

For a successful treatment of obesity, the practitioner’s role in diagnosing and treating obesity is important, but it is more important that the patient has the will and motivation for treatment. Therefore, the practitioner should re-educate the patient about the reasons for active weight loss and continuously provide support so that the patient can maintain the motivation. The patient should be well aware of the reasons of the treatment and realistic goals. Goals should be written down so that they are a constant reminder to commit treatment.

(3) Cognitive-Behavioral Therapy

Decreased metabolism, dampness phlegm and blood stagnation, qi deficiency, and yang qi deficiency are all factors that affect obesity. However, it is more common to find cases of obesity due to unhealthy habit and environmental factors. Examples of these factors include habitual binge eating, a lack of exercise, and emotional stress. Obese patients who have habitual binge eating have distorted body images and have lost control over their appetite. Cognitive-behavioral therapy is critical for treating these factors. Cognitive-behavioral therapy includes autosuggestion, stimulus regulation, cognition restructuring, stress management, and social support.

4. Korean Medicine Treatment

(1) Disharmony of the Viscera and Bowels and its Correlation with Obesity

Obesity is an excess of body mass that is primarily due to constitutionally overactive function of the liver or spleen, which are both used to digest, absorb, and store, or due to overex- citement of the two viscera due to changes in interactions among the heart, kidney, and lung systems. In contrast to the function of the heart, lung and kidney, viscera that are involved in respiration, blood circulation, energy consumption, and excretion, promote obesity when their function is suppressed. This state may lead to spleen dampness, or, in other words, obesity. Treating obesity should focus on restoring balance to these viscera and bowels.

(2) Subtyping based on Cause Treatment method should be chosen according to the cause of obesity; qi deficiency-type, qi

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stagnation-type, qi laxity-type, phlegm-type, spleen excessive-type, spleen deficiency and dampness-type, and liver overriding spleen-type, which is obesity due to a lack of exercise.

(3) Subtyping based on Time of Onset Subtype the condition as congenital obesity, stress-type obesity, adolescent obesity, edema-type obesity, postpartum obesity, or geriatric obesity. Select treatment that is appropriate for the diagnosed condition.

(4) Herbal Medicine • Spleen Deficiency Type ❶ Treatment method: Fortify the spleen to drain dampness ❷ Prescription: ‘Poria, Cinnamon Twig, Atractylodes, and Licorice Decoction’ (笭桂朮甘湯)

• Stomach-Heat Type ❶ Treatment method: Clear heat to drain dampness ❷ Prescription: Modified ‘Ledebouriella Powder that Sagely Unblocks’ (防風通聖散)

• Liver Congestion Type ❶ Treatment method: Soothe the liver to drain qi ❷ Prescription: ‘Major Bupleurum Decoction’ (大柴胡湯)

• Stagnated Blood Type ❶ Treatment method: Tonify qi to activate blood ❷ Prescription: Modified ‘Four-Substance Decoction wih Peach Seed and Carthami Flos’ (桃紅四物湯)

• Phlegm Type ❶ Treatment method: Fortify the spleen to dissipate phlegm ❷ Prescription: Modified ‘Warm Gallbladder Decoction’ (溫膽湯)

• Yang Deficiency Type ❶ Treatment method: Warm the kidneys and fortify the spleen ❷ Prescription: ‘True Warrior Decoction’ (眞武湯)

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5. Acupuncture Treatment

(1) Auricular Acupuncture

• Acupoints: The most frequently stimulated are the shenmen, spleen, kidney, hunger, stomach, mouth, and endocrine areas. The small intestine, abdomen, brain, subcortex, large intestine, trienergy, esophagus, and thyroid glands can also be stimulated. Alternating sides (right/left) every other week is recommended. • Effect: This is a popular treatment method in clinical settings, in which 5~7 small acupuncture needles are used to stimulate acupoints. The ear on which the acupuncture is performed is alternated every few days. There are no special precaution, and the stimulation does not interfere with daily life. Auricular acupuncture can effectively control appetite, relieve anxiety, and help with urination. It also helps the patient consume fewer calories, excrete sodium, and delay digestion by affecting gastric motility. Treatment is usually performed twice per week. • Evidence: Auricular acupuncture stimulates the vagus nerve to maximize satiety, increase serotonin level, and improve gastric motility for controlling appetite. • The effects of individual acupoints - Shenmen (神門): Regulate excitement in the cerebral cortex. Keeps the appetite under control. - Endocrine (內分泌): Help respiration, excretion, and energy metabolism. - Brain (腦點): Regulate excitation of the cerebral cortex. Keep the appetite under the control and stimulate the energy consumption by stimulating the endocrine hormones. - Brain stem (腦幹): Improve cerebral blood circulation to help memory and anemia. - Hunger (饑點): Help control appetite and stimulate nerves to assist in fat digestion. - Large intestine (大腸): Stimulate large intestine motility to prevent constipation. - Bladder (膀胱): Help with normal urination.

(2) Acupuncture

A meta-analysis of 31 clinical trials found that the groups undergoing acupuncture had a significantly greater weight loss of approximately 1.72kg more than the lifestyle modification-only group (control group) and 1.56kg more than the sham control group.

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Although acupuncture is rarely the only intervention that is used for treating obesity, the stomach meridian, the spleen meridian and the governor vessel are the most frequently stimulated. LI04, LI11; SP05, SP06, SP09, SP10, SP14, SP15; BL20, BL21, BL22; ST06, ST25, ST26, ST28, ST34, ST36, ST40, ST44; and GV04, GV06, GV10, GV12 are the acupoints that have been stimulated in recent studies. Electrical stimulation that is applied to acupuncture needles can assist in appetite control.

(3) Percutaneous Electric Stimulation using Acupuncture Needles

To treat localized obesity, such as abdominal obesity, acupuncture needles are inserted directly into the site of the fat deposits and are connected to low frequency electric currents to stimulate the metabolism of fat.

The low frequency currents produce heat. As a result, neutral fat is broken down into glycer- ol, and fatty acids are removed through microcirculation. The sympathetic nervous system, which is closely related to lipolysis, is also stimulated to induce an endocrine response. This stimulates adipocyte lysis, and the electrical stimulus causes potential differences in the cell membranes to help metabolic activity and lipolysis.

• Introduction: Percutaneous electric stimulation using acupuncture needles is a method in which electrical currents are applied to acupuncture needles to help break down adipocytes. 1 to 3 sessions per week is recommended, for total of 6~10 sessions. This method is highly effective for treating localized obesity. • Clinical study: There is a report of an 8~12cm decrease in the circumference of the buttock and abdomen, 4cm decrease in thigh. However, these effects were observed when acupuncture was performed in addition to other treatments. There are clinical reports that suggest that significant changes have been induced by acupuncture as a single intervention. • Mechanism of Action: The flow of electric currents increases body temperature and thereby help to improve local circulation to aid lipolysis. The low frequency currents that are delivered by the acupuncture needles stimulate catecholamine secretion from the peripheral sympathetic nerves on the adipocyte wall. This helps lipolysis and the transport of free fats, but to excrete the free fat, aerobic exercise is needed.

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(4) Pharmacopuncture

Pharmacopuncture is a method of inserting herbal preparations directly into acupoints or areas of high fat displacement, which is similar to PPP (Point by Point) and nappage in mesotherapy. It is frequently used simultaneously with other treatments. It has been reported that pharmacopuncture is effective for reducing thigh circumference.

(5) Embedding Therapy

For embedding therapy, specially designed tools are used to insert catgut into the acupoints. Catgut continuously stimulates acupoints for treatment. Similar methods of embedding catgut date back to the Song Dynasty. Records of embedding threads soaked in medicine can be found in Prescriptions from the bureau of peaceful benevolence (太平惠民方), which was published in 982.

In China, the inserted catgut is usually sheep intestine threads. In Korea, surgical threads made of chrome are being used. Both substances go through the process of 3 steps; malaxation, colli- quation and absorption, therefore it stimulates continuously. Embedding catgut may be used for a wide range of treatments. This technique is popular for treating aesthetic procedures, wrinkles, striae distensae, and obesity.

Embedding catgut in the body usually helps with local lipolysis and maintaining elasticity. Studies in Korea have investigated the effects of catgut embedding. Approximately 6~9cm of catgut was inserted into the arms, abdomen, and thigh, for a total of 10~15 pieces of catgut each. The purpose of this treatment was to help reduce the circumference of these areas and to help lipolysis.

The results indicated that the patients were satisfied and that there were positive outcomes. However, the frequency, repetition, and appropriate interval of the treatment has yet to be determined because there is a lack of evidence to support the effects and effective retention time. For adverse events, all patients reported bruises and pain. 78% of the patients reported discomfort in the treated areas. However, these symptoms usually disappeared within 1~2 weeks.

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6. Other Korean Medicine Treatment

(1) Cupping

Cupping can be used to stimulate blood circulation in specific areas and may also be applied at transport points to help general circulation.

(2) Chuna Manipulation

An ideal skeletal alignment is a state of the least possible stress and tension that allows the body to fully engage in the most efficient and stress-free biomechanical movement. It is also important for obesity patients to be able to efficiently expend their energy. Abnormal muscle tension and joint dysfunctions may interfere with a motion and may thus affect an overall energy consumption rate.

Therefore, chuna manipulation that is applied to the pelvis and other joints should be included in the first stage of treatment if one goal is to correct posture and body shape.

(3) Others

Hot packs, low-(mid) frequency treatment, and ultrasonography are recommended as additional treatment methods.

7. Sa-sang (four constitution) Approach to Obesity Treatment

The description of the viscera and bowels in Korean Medicine do not only refer to the anatomical structures but also to their respective function. The terms “large” or “small” viscera do not refer to the size of the actual organs but rather the strength of their function. Such strengths and weaknesses of functions are considered to differ across different constitution types. Some types of people have a strong tendency for consuming energy (strong heart, lung, or kidney function). These types tend to expend all their energy before it is deposited as fat. In contrast, some types have strong tendency for accumulating energy (strong spleen or liver function) and may be more vulnerable to weight gain. Taeyangin, who have strong lungs and weak livers, and Soeumin, who have strong kidneys and weak spleens, are rarely obese. Taeeumin, who have a strong liver and weak lungs, and Soyangin, who have a strong spleen and weak

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kidneys, are vulnerable to obesity.

(1) Taeeumin

Taeeumin are likely to be obese because they are greedy (likely to ingest excessive amounts of food) and are conservative and somewhat lazy (likely to expend less energy). Food that helps release energy should be included in their daily diet. Activities that can help increase the total amount of physical activity are recommended.

• Adequate exercises: Taeeumin have a very strong build and a highly competitive mind. However, they lack judgement skills, agility, and reactivity to change. Swimming, cycling, mountain climbing, and marathon, which are endurance sports that require strength, are best suited for Taeeumin. When participating in team sports, it is best that they are positioned in roles that require strength. For example, in baseball, they should be the catcher, outfielder, or pitcher. • Herbal medicine: If heat-type symptom is dominant, prescribe Chungpaesagan-tang (‘Clear the Lung and Drain the Liver Decoction’, 淸肺瀉肝湯) or Galgeunhaegi-tang (‘Decoction to Relieve Muscles with Kudzu’, 葛根解肌湯). If cold-type symptom is dominant, use Taeeumjowi-tang (‘Decoction to Regulate the Stomach for Taeeumin’, 太陰調胃湯). Cervi Parvum Cornu is helpful for weight loss.

(2) Soyangin Soyangin are the second-most likely constitution to become obese. They are usually hot tempered and rush through their meal, which results in overeating. Soyangin are emotionally sensitive. To cope with stress, they tend to overeat. Because they have a strong digestive system, what they eat will easily accumulate in the body. Therefore, it is important to eat more slowly and find other ways to resolve emotional stress (i.e., exercise and other hobbies), rather than eating.

• Adequate exercises: While highly adaptive and quick in making decisions, Soyangin become tired easily and have low endurance level. It is preferable to choose a short-duration excercise. Short distance sprints, skiing, tennis, and taekwondo are recommended. When participating in team sports, the position of striker best suits Soyangin.

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• Herbal medicine: Dokhwaljihwang-tang (‘Decoction of Rehmannia with Angelica Pu- bescentis’, 獨活地黃湯) and Yookmijihwang-tang (‘Six-Ingredients Decoction with Reh- mannia’, 六味地黃湯) are effective. Those with stomach fever should be given Yanggyuk- sanhwa-tang (‘Decoction for Cooling the Diaphragm and Dispersing Fire’, 凉膈散火湯). Those with very stiff muscles respond well to Hyungbangjihwang-tang (‘Rehmannia Decoction with Schizonopeta and Ledebouriellia’, 荊防地黃湯). Observe stools and give adequate amounts of Gypsum as needed.

(3) Soeumin Soeumin have a weak digestive system and therefore do not eat much. They are rarely obese. However, irregular eating habit, high-calorie snacks and a lack of exercise due to their introverted nature may contribute to be obesity. Therefore, it is important that they establish regular eating habit, reduce snacks, and exercise regularly.

• Adequate exercises: Soeumin are good at making decisions and are sophisticated. They have a high sense of responsibility and are careful thinkers. However, they have relatively weak stamina. Therefore, exercise that requires more attention to detail than strength is recommended. Examples include table tennis, badminton, horse riding, shooting, and gymnastics. When participating in team sports, such as soccer, volleyball, basketball, and handball, it is better to be on the defense in a role that requires accurate decision-making and less strength. • Herbal medicine: Gwanjoong-tang (‘Penetrate the Middle Decoction’, 寬中湯) can help improve metabolism. Yangwi-tang (‘Decoction for Nuturing Stomach’, 養胃湯) is also highly effective for patients who have gastrointestinal dysfunction or edema. For patients with severe heat on the surface, Gwakhyangjungqi-san (‘Agastache Powder to Rectify the Qi’, 藿香正氣散) is effective. Palmool-tang (‘Eight Substances Decoction’, 八物湯) or Bojoongikqi-tang (‘Tonify the Middle and Augment the Qi Decoction’, 補中益氣湯) are less frequently used.

(4) Taeyangin Taeyangin are usually very slim. They are rarely obese. Taeyangin have a tendency to be tormented by all worldly matters as if these issues are their own problems. When entrapped

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in their own thoughts, especially fury, they go on binge drinking. Such emotional stress may cause obesity in some cases. Therefore, it is important to abstain from alcoholic beverages, meditate, and commit to a regular exercise.

• Adequate exercise: Taeyangin have a strong drive, are quick to make decisions and have very good judgement. However, they have weak lower limbs compared to the other Sasang types, which makes it difficult for them to excel in exercise. Taeyangin are better at team sports than individual sports. They are especially skilled at establishing strategies.

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•Korean Society for The Study of Obesity. Contemporary diagnosis and management of obesity. Seoul : Korean Society for The Study of Obesity. 2003:93-100. •Kyung-Won Kang, Jin-Seok Moon, Byung-Gab Kang, Bo-Young Kim, Sun-Mi Choi. The Com- parision of Pattern Identification Diagnosis According to Symptom Scale Based on Obesity Pattern Identification Questionnaire •Matsuzawa Y. Pathophysiology and Molecular mechanism of visceral fat syndrome: The Jap- anese Experience. Ann NY Aca Sci. 1987;676:270-8. •Mi ja Hwang, Hyun Dae Shin, Mi Yeon Song. Literature Review of Herbal Medicines on Treat- ment of Obesity Since 2000;Mainly about Ephedra Herba. Journal of Society of Korean Medi- cine For Obesity Research. 2007;7(1):39-54. •Mi Sook Shin. A Case Series: The Effects of Cultivated Wild Ginseng Pharmacopuncture and Thread Implantation Therapy on Abdominal Obesity. The Society of Korean Medicine for Obe- sity Research. 2013;13(1):46-50. •Mi-Young Song, Ji-Hun Park, Jung-Ho Lee, Ho-Jun Kim, Myeong-Jong Lee . The Efficacy and Safety of Ephedra and Green Tea Mesotherapy on Localized Fat. The Society of Korean Medicine for Obesity Research. 2007;7(1):71-85. •Mi-Yong Song, Ho-Jun Kim, Myung-Jong Lee, Jung-Mi Park, Jin-Ah Kim, Byeong-Pyo Ko. Methodological Comparison between Measured and Predicted Resting Energy Expendi- ture in Korea Obese Women. Journal of Korean Oriental Association for Study of Obesity. 2005;5(1):57-66. •Mi-Young Song, Ho-Jun Kim, Myeong-Jong Lee. The Review on the Evidence : Effects of Non-surgical Localized Fat Treatment. Journal of Korean Oriental Association for Study of Obesity. 2006;6(1):1-10. •Mi-Young Song, Ho-Jun Kim. Review on Clinical Trials of Catgut Embedding for Obesity Treatment. The Journal of Society of Korean Medicine for Obesity Research. 2012;12(2):1-7. •Moon se-Hee, Sin Soo-Hwan, Kim Hui-jun, Kim Jeong-Yun. A Relationship of the Obesity and Body composition Analysis by Sasang Constitution. Journal of oriental rehabilitation medicine. 2002;12(4):1-10. •Na JC. Excercise Prescription. DKBOOKS. 2004. •National Institute of Health, National Heart, Lung, and Blood Institute. North American Association for the Study of Obesity. The practical guide: identification, evaluation, and treatment of overweight and obesity in adults. NIH Publication. 00-4084. 2000. •Park HS. Epidemiolgy of Metabolic Syndrome in Korea. Korean Journal of Obesity. 2002;22: 203-11. •Park YE. Medicine yarn for Acupuncture. Seoul: HLseowon. 2003:23,27-8.

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•Park YW. Body Shape menagement Clinic. Korean Society for Health Promotion and Diseas- es Prevention. 2003. •Park YW. Body Shape menagement Clinic. Korean Society for Health Promotion and Diseas- es Prevention. 2003. •Park YW et al. Guide for Nutrition treatment. Hanmibook. Seoul. 2003. •Song et al. Anatomy Trains, myofascial meridians for manual and movement therapists. Seoul: Hyunmoon. 2005. •Sung-Soon Jin, Yun-Kyung Song, Hyun-Ho Lim. Study on Mechanical Stability and Safety of Electroacupuncture fo Localized Fat Deposit. Journal of Oriental Rehabilitation Medicine. 2009;19(1):169-186. •Su-Min Ryu, Seung-Woo Shin, Kil-soo Kim, Jin-Seok Moon, Yoo-Sik Yoon. A case Report on Types of Identification of Symptom in Obese Patients. Journal of Korean Oriental Association for Study of Obesity. 2005;5(1):21-29. •Sung-Min Song, Yun-Kyung Song, Hyun-Ho Lim. The Effect of Elctroacupuncture on Abdom- inal Fat Deposit and Parameters for Obesity. Journal of Oriental Rehabilitation Medicine. 2010;20(2):113-127. •Seung-Uoo Shin, Young-Min Choi, Woo-Jin Shim, Hyung-Chul Lee, Kil-Soo Kim. Effects of High Frequency Therapy on Localized Obesity. The Society of Korean Medicine for Obesity Research. 2006;6(2):75-83. •The Korean Academy of Family Medicine. 2005 Office Management of Obesity. Seoul: Han- mibook. 2005:12, 21-22. •The Society of Korean Medicine Rehabilitation. Korea Rehabilitation Medicine 4th. Seoul: Koonja 2014 •Wi et al. Fox’s Exercise Physiology. Daehanmedia. 2002. •Yeo E. The management of Obesity Clinic. Korean Society for Health Promotion and Diseases Prevention. 2003. •Young-Joon Eun, Seung-Peom Choi, Mun-Gie Soh, Yun-Kyung Song, Hyung-Ho Lim. A Com- parative Study of Body Image, Eating Attitudes and Obesity Degree in Incheon University Stu- dents. Journal of Society of Korean Medicine for Obesity Research. 2006;6(1):93-105. •Yun-Kyung Song, Hyung-Ho Lim. A Study on Obesity Management by Body Shape Correction Program. Journal of Korean Oriental Association for Study of Obesity. 2005;5(1):133-140. •Yun Kyung Song, Hyung Ho Lim. The study of Myofascial Meridian Clinical Application for Functional Exercise and Manual Therapy. The Journal of Korea CHUNA Manual Medicine.

301 2016 Korean Medicine Current Practiceof CHAPTER 8

Korean Medicine Cosmetic Procedures

▼ Mi-Rim Jung & Sungjin Lee PART 2 Korean Medicine Treatments for Various Medical Conditions

chapter 8

Korean Medicine Cosmetic Procedures

Introduction

Appearance is an important factor in social life, especially in peer relations. It also contributes to the self-identity that sets one apart from the others (Lee et al., 2010). Therefore, dissatisfaction or a sense of inferiority due to appearance can be more devastating for patients than actual diseases. As a way to resolve such issues, people may seek plastic surgery and other ways to improve their appearance (Hwang et al., 2003). According to an investigation, 93% of Korean college students believed that appearance is important and indicated that they would consider plastic surgery (Won et al., 2004). Recent trends are shifting from surgery to less invasive treatments. There are now lasers, Botox, fillers, and other treatment methods. However, because these approaches are associated with adverse events, there is increasing interest in Korean Medicine treatment.

Treatment methods that are used in Korean Medicine for cosmetic purposes include needle embedding therapy (埋線療法) and acupuncture. An anatomical structure important for both needle embedding therapy and acupuncture for cosmetic purposes is the Superficial Muscu- loaponeurotic System (SMAS). SMAS is a three-dimensional structure that consists of the inner dermis, subcutaneous adipose tissue, fibrous membranes, and fascia. It connects the dermis to the fascia (Macchi et al., 2007), delivers contractions of facial muscles to the skin and may contribute to the formation of wrinkles when the facial muscles are overused or tight. There- fore, SMAS is stimulated (Cho., 2013).

Needle embedding therapy is a method of inserting disposable threads into the skin or other

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soft tissues. During the 1990s, needle embedding therapy in Korea was performed using pituitary gland tissues from rabbits. Currently, Polydioxanone (PDO) is used instead (Park, 2003). Depending on the length and thickness of the needle, PDO is digested and absorbed completely within 7 months (Lerwick E, 1983). PDO is recognized as a foreign body that induces an axenic inflammatory response. This stimulates the synthesis of collagen and restores elasticity in soft tissues (Liu, 2011). Needle embedding therapy is based on such findings. Acupoints, meridians/ collaterals, muscles, and skin are continuously stimulated to achieve the treatment goals. In the “Origin and Termination” chapter of Huangdi’s Internal Classic (黃帝內經), Miraculous Pivot, it is said “Patients who were sick for a long time, pathogens have penetrated deep. When pricking (stimulating with acupuncture) such patients, insert the needle deep as the old pathogen are in the deeper layers. Repeatedly stimulate them every other day.” “In the Different conditions can be all perceived as imbalances of the true and pathogenic qi” chapter of Plain Questions , it is said “The reason (pathogen) is quiet and yet persistent, is because qi has reached (far enough) it is like awaiting for a precious guest not knowing that the day is drawing to an end. the qi has already reached (deep), one should be able to protect oneself.”

This suggests that more chronic states should be subject to deeper and longer acupuncture stimulations. The earliest forms of using a thread for treatment can be found in Prescriptions from the bureau of peaceful benevolence (太平惠民方), which was published during the Song Dynasty. There are records of threads that were soaked in medicine and inserted into the acupoints. Needle embedding therapy was originally used to alleviate pain, but after confirming the collagen formation effects, it started to be used for cosmetic procedures (Lee et al., 2008). The PDOs are embedded in the SMAS layer. If they are inserted deeper than the fascia, then it is not likely that it will be effective as a cosmetic procedure. If it is inserted too superficially, in either the epidermal or dermal layers, there are higher risks of inflammation. Granulomas may also form (Jung et al., 2014). It is important to insert the needle precisely where it is needed.

Acupuncture for cosmetic purposes is usually Jung-an acupuncture (整顔鍼) or Miso facial rejuvenation acupuncture. Jung-an acupuncture helps the fascia and SMAS to relax, thereby helping blood and lymph circulation. To stimulate the fascia and SMAS, stimulation should be low-intensity, the needle should be almost parallel to the surface, and the needles should be removed immediately, without any retention time (Lee et al., 2008). Miso facial rejuvenation

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acupuncture stimulates acupoints around the facial muscles to lift lax muscles and smooth wrinkles. The goal is to make the face more firm, especially along the margins to enhance contour (Lee et al., 2010). The mechanism operates such that abnormally tense muscles are relaxed and abnormally relaxed muscles are stimulated to smooth wrinkles. The sternocleidomastoid muscle, temporal muscle, frontal muscle, auricular muscle, pterygoid muscle lateral, and masseter muscle are stimulated. The stimulation intensity is relatively strong, and needles are sometimes repeatedly inserted and retracted to provide a stronger stimulus (Kwon et al., 2009).

Wrinkles and Acne Scars

1. Wrinkles

Causes of skin aging are intrinsic, which reflects the natural aging process of the human body, photoaging, which is due to radiation exposure, thermal aging, which is due to heat exposure, or climacteric aging, which results from decreased estrogen levels (Korean Derma- tological Association, 2014). Skin dehydration causes the tissue to lose elasticity. Degeneration of the collagen and elastic fibers of the dermis cause the skin to fold and wrinkle. One of the most commonly recognized risk factors is exposure to sunlight (Fauci et al., 2010). Prolonged exposure to sunlight causes degeneration of the collagen and elastic fibers and causes deep wrinkles. Dehydration of the skin due to aging also contributes to the formation of wrinkles, and these wrinkles are usually fine lines. Facial expressions also affect wrinkle formation. The continuous contractions of muscles can cause deeper lines than those that are formed due to other causes.

It is most important to prevent wrinkles before they form. Sunscreen should be regularly applied to prevent the degeneration of collagen and elastic fibers. Cosmetics should be appropriately applied to keep the skin from drying. It is also effective to massage the skin in a direction that is opposite to the gravitational force.

The most popular method for wrinkle treatment is subcision. Subcision, which is short for “subcutaneous incisionless surgery,” is a method in which needles are inserted below the adipose

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tissue to make incisions to fibrous membranes to induce bleeding and initiate a self-healing process (Orentreich et al., 1995). Because a sufficient amount of bleeding is needed to properly recover the injured fibrous membranes, it is critical to monitor the amount of bleeding.

Needle embedding therapy can also be used during subcision treatments. Because the needles enter the subcutaneous area, subcision occurs, and the inserted PDO stimulates collagen formation. This method is more effective than subcisions that are performed with regular needles. Nasolabial folds and marionette wrinkles, which are conditions that are caused by a laxity in adipose fats, can be treated more effectively with combined subcision and needle embedding therapy, as the subcision helps the fibrous membrane heal, while at the same time, PDOs keep the adipose pad from slipping.

2. Acne Scars

Acne scars are scars that form due to acne comedonica, acne papulosa, and other dermatological conditions. The four types of acne scars are the icepick (deep, sharp scars that appear as icicles), boxcar (small, square scars), rolling (round), and hypertrophic scars (protruded scars) (Tosti et al., 2010).

The Auto-Microneedle Therapy System (AMTS) and subcision are used to treat acne scars (JE et al., 2013). Rolling, icepick, and boxcar type scars are depressed acne scars. They can be treated with AMTS or subcision. However, hypertrophic scars respond better to steroids injection. Consider transferring the patient. Rolling types that have affected the epidermis are easier to treat than deeper, ice pick or boxcar types that have affected the dermis. When scars that are due to nodules are dispersed over a large area, taking herbal medications can assist in recovery.

3. Precautions

The depth of the subcision is important. Needles that are inserted too superficially may trigger hyperplasticity in the skin. Needles that are inserted too deeply may be less effective (Aalami et al., 2011). Sunscreen should be worn to prevent hyperpigmentation in the

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treated areas. Use caution not to injure the facial nerves.

To ensure that there is no injury to the great auricular nerve, refrain from embedding needles deeper than the platysma level. Because the zygomatic and buccal nerves are covered by the parotid gland, they are less exposed to the risks for injury. In contrast, the mandibular nerve is vulnerable to injuries, so it is important to be cautious. The supraorbital nerve and the supratrochlear nerve at risk of injury as they both pass the foramina of the cranium. The mental nerve should be kept in mind when inserting needles into the marionette folds or the mandibular areas.

Table 1. Facial nerves

Nerve Location Symptoms of Injury

A 3 cm wide circular area that Numbness of the lower 2/3 of the Great auricular nerve is 6.5 cm below the external external ear, sides of the face, auditory meatus and neck

The triangular area between the line that connects the point 0.5 cm below the tragus and the Temporal nerve point 2 cm above the lateral end Paralysis of the frontal area of the eyebrow and the line that connects the zygoma with the outer corner of the orbit

A 2-cm wide circular area that is around the central mandible Mandibular nerve Paralysis of the lower lip area and is 2 cm posterior to the mandibular angle

The triangular area between the Zygomatic nerve, zygomatic process, the posterior Paralysis of the upper lip area Buccal nerve margin of the mandibular angle, and the buccal areas and the corners of the lips

Numbness of the frontal, Supraorbital nerve, The circular area around the supraorbital, nasal ridge, and Supratrochlear nerve supraorbital fossa, 1.5 cm wide scalp areas

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Nerve Location Symptoms of Injury

A circular area that is 1.5 cm wide Numbness of the lateral areas of Infraorbital nerve and is located below the pupil and the nose, sides of the face, upper the lower margin of the orbit lip area and lower eyelid

The central mandibular area Numbness of the lower lip area Mental nerve below the second maxillary and the lower half of the chin premolar

Cell division rates for the epidermis cells of aging skin are slower than those for young skin. Skin regeneration rates substantially decrease after the age of 50. (Korean Dermatological As- sociation, 2014). If the patient is over the age of 50, scars may develop after treatment.

Facial lifts

There are some patients present with reduced of elasticity in the skin. Such aging of the skin is a part of the body’s natural aging process. UV radiation, wind, heat, and other external factors may further cause progression. The collagen layers sink inward, which causes the skin to lose elasticity. Nasolabial folds and marionette wrinkles become more prominent. Conventional care usually consists of Botulinum injections, peeling, and laser therapies. Re- covery time is needed for these treatments. Redness, discoloration, infections, and scarring are frequently reported adverse effects. Because they are relatively safe, Korean Medicine treatment is an attractive option for many people.

In Korean Medicine, needle embedding therapy has been used to reinforce elasticity in the skin. Regular needles are used as well as mono and spine needles that have small bumps. Evidence supports the effects of needle embedding therapy for skin elasticity. A single treatment session was enough to induce favorable outcomes. After the second session, there were additional improvements (Lee et al., 2011).

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1. Procedures for the forehead

[ Figure 1 ] Treatment of facial asymmetry * Source: Lee JC, Park SH, Yoon JH, Kim JW, Lim CG. Preliminary Standard Procedure for Face Lift and Correction of Nasolabial Fold using Thread-Embedding (Maeseon) of Korean Medicine. J Korean Med Ophthalmol Otolaryngol Dermatol.

As mentioned above, skin laxity occurs when the collagen layer gives in. Facial lifts are not merely a procedure that lifts the lax skin tissues. This procedure stimulates collagen formation. Mono PDOs are embedded in the form of a grid. The tension that is provided by PDOs keeps the skin from sagging. Collagen formation is stimulated to help the skin become more firm. When the patient’s skin is not too thin, spine needles can be used. These spine needles have small bumps. There are spine needles of several lengths, thicknesses, and bumps (unilateral/bilateral). Select the appropriate needle given the patient’s condition. Approximately 3~8 spine needles are used per session, depending on the patient’s condition.

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The most common complaint is usually skin laxity along the mandible and corners of the lips. When laxity is the most common complaint, do not stop needling the area that is lax, which is usually the skin around the mandible. Embed PDOs to the frontal, temporal, and zygomatic areas for better outcomes. Embed 4cm, 27G (thinner needles may suffice) mono PDOs to the SMAS layer. Monitor the facial muscles with the left hand and insert the PDOs into the fascia. The frontal, zygomatic, levator anguli oris, masseter, and orbicularis oculi muscles are stimulated along the direction of the muscle fibers. The facial muscles are stimulated to help the facial expressions appear more relaxed, the complexion to appear more vibrant, and the patient to feel an overall improvement. Spine PDOs (with unilateral or bilateral small bumps) can be embedded in the SMAS layer for immediate effects. Thicker spine PDOs can be used for more dramatic outcomes. However, caution is needed.

2. Precautions

When embedding spine PDOs, it is important not to penetrate the maxilla and mandible. If the mandible and maxilla are laced together, there may be considerable discomfort. Chewing hard food or opening the jaw too much can cause pain for 2~3 days. Because they are thicker than regular PDOs, there may be swelling. If swelling occurs during treatment, use a handheld cooler for relief. Treating the area with appropriate measures to help it heal is also recommended. If the patient’s skin is too thin, the skin may appear uneven due to the embedded PDO. Therefore, people with thin skin should not receive this treatment. If the skin appears uneven, soften the embedded PDOs with radio frequency treatment to even out the surface.

Facial Asymmetry

Facial asymmetry is defined as a condition where the right and left sides of the face are uneven in length and/or surface area and the lip is not level on both sides. Facial asymmetry is diagnosed when the eyes and ears are uneven, the midline through the glabella and apex of the chin is distorted, one end of the mouth droops more than the other when smiling, and when

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the zygoma are uneven. Asymmetry due to the asymmetry of skeletal structures is sometime due to congenital conditions, such as hemifacial microsomia, but in most cases it is due to abnormal development in the mandibular area. Facial asymmetry may be caused by soft tissue problems, such as the asymmetric development of facial muscles and Temporomandibular joint Dysfunction (TMD). It is important to identify the cause of the problem.

Facial asymmetry is treated differently depending on whether the cause is due to a problem in the maxilla or the mandible. Clinically, problems of the mandible are much more prevalent. If the problem is with the mandible, it is usually caused by a TMD. A three knuckle test (positive if the jaw cannot fit 3 fingers) should be performed to confirm dysfunction. Check for asymmetry of movement when opening the mouth (in most cases, a Temporomandibular Joint dysfunction (TMJ) will move in a zig-zag pattern, away from the midline). If there is clicking of the joint or pain, TMD can be diagnosed.

1. Treatment Methods

Structures above the maxilla do not respond favorably to treatment when there is a problem with the cranial structures. Acupuncture can help relieve tension in the muscles, thereby helping reduce pressure that is exerted on the skull. Jung-an acupuncture and Miso facial rejuvenation acupuncture can be performed to relieve tension in the facial muscles. The galea aponeurotica and suboccipitals should be stimulated. Combining Craniosacral Therapy (CST) with acupuncture is also effective.

If problems are detected in the mandible, check for a forward head posture. If cervical hypolor- dosis is present, tension develops in the suprahyoid, sternohyoid, and omohyoid muscles. The patient tends to pull the chin posteriorly. This causes the lateral pterygoid muscle to contract. Therefore, before treating TMD, diagnose and treat the forward head posture. Accurate diagnosis is needed because overall problems may arise in the cervical, thoracic, lumbar vertebrae, and pelvic regions.

According to a systematic review (Gesch et al., 2004), dental braces are not helpful for treating TMD or for alleviating clicking in the joint. (Manfredini et al., 2014). Although dental braces

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[ Figure 2 ] Forward head posture 2)

* Source: Donald A. NEUMANN, KINESIOLOGY of the MUSCULOSKELET AL SYSTEM Foundation for Physical Rehabilitation. 1sted. Seoul:Jeongdam. 2004:395. are helpful for TMD to some extent due to malocclusion, treating TMD should include other treatments besides dental braces. However, splints to help maintain the normal 3~5mm gap in the joint may be effective.

Aside from cases due to injuries, those who have had bad habits such as chewing consistently on the same side or chewing hard food, for a long time are vulnerable to TMD. Therefore, not only treatments at the clinic but also exercise prescription should be included. The Chuna As- sociation of Spine and Nerves developed “6X6 exercise” modified from Rocabado’s exercise which is devised by Rocabado, expert in the physiotherapy.

• Stimulation points: Sternocleidomastoid, digastric, temporal, masseter, medial/lateral pterygoid, suboccipital, and facial muscles.

• Chuna manipulation: Apply a gentle movement caudad anteriorly to distract the joint. When tender points are detected on the masticatory muscle or the medial/lateral pterygoid muscles, forcing the jaw open may cause muscle spasms. Treat the tender points first with acupuncture and then proceed to the Chuna treatment.

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• Rocabado’s 6X6 exercise - Step 1: Alignment of the head, neck, and scapula. Position the patient so that the zygoma and the sternum are perpendicular. Flex the neck approximately 15 degrees and hold for 6 seconds. Repeat 6 times.

- Step 2: Vertical Traction [ Figure 3 ] Rocabado's step 1 Hold the inner molar with the thumb and the mandible with the other fingers. Apply a gentle caudad/ anterior pressure. Hold for 6 seconds and repeat 6 times. Palpate the lateral condylar head to ensure that the joint is not displaced more than 1mm.

- Step 3: Rotation of the bilateral condylar head. Monitor the lateral condylar head with the index [ Figure 4 ] Rocabado's step 2 finger and place the tongue on the palate. Keep the tongue on the palate, open the mouth and say “Now.” Hold for 6 seconds. Repeat 6 times.

- Step 4: Exercise to place the condylar head at the center of the joint fossa. Place the index finger on the canine of the maxilla. Place this canine above the canine on the mandi- [ Figure 5 ] Rocabado's step 3 ble. Have the patient place the tongue on the palate, and then open and close the mouth, with the finger inducing a sideways movement. With the helping hand, monitor the movement of the lateral condylar head. Repeat 6 times.

- Step 5: Isotonic resistance exercises for the deep masseter.

Place the index finger on the upper canine and place [ Figure 6 ] Rocabado's step 4 it above the canine of the mandible. With the mouth open, induce an isotonic resistance movement with the index finger from the helping hand.

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Perform 6 repetitions of 6 second sessions.

- Step 6: 3-dimensional rhythmic mandible stabili- zation exercise. Place the tongue on the palate and pull the upper and lower teeth apart. Hold the mandible with the thumb and index fingers from both hands, and apply pressure to the antagonistic muscle of the man- [ Figure 7 ] Rocabado's step 5 dible. Pull the mandible down, left, right, and up to induce an isotonic resistance movement.

[ Figure 8 ] Rocabado's step 6 * Source: Korea Chuna Manual Medicine for Spine & Nerves. Chuna manual medicine.Seoul: Korea Society of Chuna Manual Medicine for Spine & Nerves. 2014:401~403.

2. Precautions

Use caution to avoid applying excessive force to the TMJ during the Chuna manipulation. Palpate the joint with the practitioner’s non-correcting hand to ensure that the joint is not displaced more than 1mm. Severe cases of TMD may not respond favorably to strong stimuli.

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Procedures for Breast Enlargement

For generations, the breasts have been considered an icon of womanhood (Marilyn., 1998), and since the 1990s, fuller breasts have been considered beautiful (Kim et al., 2001). Due to a cultural preference, there has been an increased demand for breast implants. However, these procedures have caused complications and are often subject to re-operation; thus, there is an increased demand for safer methods. Many Korean women are currently being treated with Korean Medicine (MR et al., 2013).

1. Treatment Methods

Korean Medicine breast enlargement procedures involve needle embedding therapy and acupuncture. Needles are inserted from eight directions, which is consistent with the eight-direction acupuncture (八方鍼) method. Eight needles are inserted per layer, for a total of 3 layers. A total of 24 needles are inserted into each breast. The needles should be inserted toward the center of the breast, approximately 30 degrees away from the surface. Acupuncture needles stimulate qi and blood circulation around the mammary gland to simulate the tissues around the area. However, this approach is less effective in age groups that have lower levels of female hormones. Even relatively young patients may find this approach less effective when there are problems with hormone levels. In this case, prescribe herbal medications that help to restore normal hormone functions to enhance the effects. The overall shapes of the breasts are determined by the mammary gland. Treatment outcomes may not be favorable in patients who have very small breasts. Additionally, because breast sizes are affected by changes in weight, it is recommended that one maintain healthy weight. Stimulating blood circulation with acupuncture treatment can help the breasts become fuller to an extent that is commonly observed prior to menstruation or during pregnancy. 1 to 2 or even 3 sessions are recommended per week.

To reduce the number of treatment sessions, treatment also includes needle embedding therapy. Less intense and less frequent treatment is needed in smaller and thinner patients. Needle embedding therapy is especially effective for the treatment of breast ptosis. These effects can be attributed to an increase in the number of collagen fibers. If the pectoralis muscles are underdevel-

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[ Figure 9 ] Breast oped, stimulate the pectoralis muscles and the muscles around them to help the breasts maintain their ideal shape. Needle embedding theraphy alone is effective for significant changes in the breast chest circumference (Han, 2008).

2. Precautions

The most important adverse event to avoid is pneumothorax. If the patient is thin, insert the needle nearly parallel to the surface of the skin. If the patient is curvy, insert the needle

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30~40 degrees away from the surface. With the non-needling hand, hold the breasts as far away from the torso as possible to decrease the risks for adverse events. 1 to 3 sessions per week for 3-6 months can help the patient move up a half or whole cup size. Depending on the patient’s condition, there may be a need for additional treatment. However, treatment effects are limited in underweight individuals who have a BMI of less than 17 or who have already experienced menopause. These conditions should be assessed during the first visit. Explain to the patient before commencing treatment that if treatment goals are too unrealistic, expectations may not be met.

Post-Treatment Care

Symptoms that patients usually complain after acupuncture or needle embedding therapy are pain, swelling, bruising, and inflammation. Pain is usually elicited when the needles penetrate nerves or blood vessels. Therefore, it is very important to use caution when inserting the needle. If pain is elicited during treatment, use a handheld cooler to apply strong pressure to the site of the pain. The immediate drop in temperature helps alleviate pain. Handheld cooler is effective for pain [ Figure 10 ] Handheld cooler as well as swelling and bruising. * Source: Derma cooler. TradeKorea.com. 2016 Oct 5. Available from: URL:HYPERLINK “http// www.esmediglobal.com/#!derma-cooler/ Because needle embedding therapy is a strong aegjz” stimulus, maintenance is important. For 1~2 days after the treatment, it is recommended to minimize swelling and bruising using ice or handheld coolers or ice. Avoid rubbing, as rubbing the area may cause PDOs to shift and injure the surrounding tissues. By day 3, as the swelling decreases, bruises may surface. Hot packs should be applied at this time to improve blood circulation. Herbal medicines, such as ‘Angelicae Gigantis Root Powder’ (當歸鬚散), are also good methods for controlling swelling and bruises.

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It is also important to limit facial movements. Laughing, singing, and other activities that require extensive movement of the facial muscles may cause the embedded PDOs to shift positions, which may damage the surrounding tissues and cause bruising, inflammation, and other complications. Using a sauna, alcohol consumption and other activities that may stimulate blood circulation to the face may aggravate bleeding in cases in which injuries were inflicted to the capillaries during treatment. In some cases, the PDOs may cause irritation. Touching these areas with the hands may cause inflammation. Instruct the patient to avoid any direct contact with the area. For herbal medicine, ‘Coptis Decoction to Relieve Toxicity’ (黃連解毒湯), which is known for its anti-inflammatory effects, should be kept in the clinic at all times. Because it is available in dry form, it is easy to purchase and ingest.

Reference

•Aalami Harandi S, Balighi K, Lajevardi V, Akbari E. Subcision-suction method: a new successful combination therapy in treatment of atrophic acne scars and other depressed scars. J Eur Acad Dermatol Venereol. 2011 Jan;25(1):92-9.

•Bak JW, Sim BY, Kim DH. The effects of Danggwisusan on restoration ability in wound induced animal models. Kor. J. Herbology. 2014;29(5):55-63.

•Cho SP. Maeseonseonghyeongsisulmanual. Seoul:SHmedscience. 2013:29.

•Cho SP. Maeseonseonghyeongsisulmanual. Seoul:SHmedscience. 2013:36.

•Derma cooler. TradeKorea.com. 2016 Oct 5. Available from: URL:http://web.tradekorea.com/ editor/2015/10/20151001182638905/20151001182638905

•Donald A. NEUMANN, KINESIOLOGY of the MUSCULOSKELET AL SYSTEM Foundation for Physical Rehabilitation. 1st ed. Seoul:Jeongdam. 2004:395.

•Fauci, Braunwald, Kasper, Hauser, Longo, Jameson, Loscalzo. Harrison`s Principles of In- ternal Medicine 17th ed. 2010:421.

•Frank H Netter. Atlas of Human Anatomy 4th ed. Seoul:Jeongdam. 2007:25.

•Frank H Netter. Atlas of Human Anatomy 4th ed. Seoul:Jeongdam. 2007:182.

•Gesch D, Bernhardt O, Kocher T, John U, Hensel E, Alte D. Association of malocclusion and functional occlusion with signs of temporomandibular disorders in adults: results of the population-based study of health in Pomerania. Angle Orthod. 2004;74(4):512-20.

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•Lee JC, Kim YR. The Effect of Beauty Therapy on the Self-esteem. Journal of Investigative Cosmetology. 2010;6(1):57-62. •Han JW, Kim SJ, Oh MS. A Clinical Study of Breast Augmentation Effect of Jahyungchim to 20’s Female Patients. The Journal of Korean Acupuncture & Moxibustion Society. 2008;25(6):117-23. •Heo JE, Yun JM, Shin SH. Case Study of Treating Acne Scars Using Reconstruction of Skin Scars and Auto Microneedle Therapy System. J Korean Med Ophthalmol Otolaryngol Derma- tol. 2013;26(4):127-34. •Hwang YJ, Jo KY, Yoo TS. The Study on Cosmetic Surgery Behavior according to Appearance Concern, Body Cathexis, and Self-esteem. Journal of Fashion Business. 2003; 7(4):17-25. •Jung IH, Yun YH. Miyongchim and Maeseonchim. Seoul:Hansol. 2014:192-4. •Jung MR, Kim SJ, Jeong JJ. The Breast Augmentation Effect of Breast Needle-embedding Therapy on 85 Females and its Correlation Analysis with Body Fatness. The Journal of Kore- an Acupuncture & Moxibustion Society. 2013;30(4):79-85. •Kim MY, Han MS. A Study on the Culural Meanings of Underclothes Advertisements on •Korea Chuna Manual Medicine for Spine & Nerves. Chuna manual medicine. Seoul:Korea Society of Chuna Manual Medicine for Spine & Nerves. 2014:401. •Korea Chuna Manual Medicine for Spine & Nerves. Chuna manual medicine. Seoul:Korea Society of Chuna Manual Medicine for Spine & Nerves. 2014:401. •Korea Chuna Manual Medicine for Spine & Nerves. Chuna manual medicine. Seoul:Korea Society of Chuna Manual Medicine for Spine & Nerves. 2014:401. •Korea Chuna Manual Medicine for Spine & Nerves. Chuna manual medicine. Seoul:Korea Society of Chuna Manual Medicine for Spine & Nerves. 2014:402. •Korea Chuna Manual Medicine for Spine & Nerves. Chuna manual medicine. Seoul:Korea Society of Chuna Manual Medicine for Spine & Nerves. 2014:402. •Korea Chuna Manual Medicine for Spine & Nerves. Chuna manual medicine. Seoul:Korea Society of Chuna Manual Medicine for Spine & Nerves. 2014:403. •Korean Dermatological Association. Textbook of Dermatology 6th ed. 2014:699. •Korean Dermatological Association. Textbook of Dermatology 6th ed. 2014:701. •Kwon NH, Kim CY, Shin YJ, Seo S, Song JH, Baek HY, Woo HS, Park DS. Clinical Study on Facial Skin Furrow Measurement Changes after Miso Facial Rejuvenation Acupuncture. J Korean Acupuncture & Moxibustion Society. 2009;26(6):133-40. •Lee EM, Park DS, Kim DH, Kim HW, Jo EH, Ahn MS, Lee GM. A Literature Study and Recent Tendency on Oriental Correction of Deformities and ‘Needle-embedding Therapy’. J Korean Acupuncture & Moxibustion Society. 2008;25(3):229-36.

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•Lee KM, Lim SC, Kim JS, Lee BH. A Clinical Study on Facial Wrinkles Treated with Miso Facial Acupuncture -Measured by The Facial Skin Photographing System-. J Korean Acupuncture & Moxibustion Society. 2010;27(1):101-7. •Lee KS, Ko MK, Lee JH, Kim MJ, Hong KE. The effect of facial embedding therapy on skin elasticity and moisture content. J Korean Acupuncture & Moxibustion Society. 2011;28(5):111-9. •Lee HM, Kim SK, Kim CH, Kim YS. A Literuture Study on the Effect of Jung-an Acupunc- ture Meridian Point and Needling Method. J Korean Acupuncture & Moxibustion Society. 2008;25(1):179-86. •Lee JC, Park SH, Yoon JH, Kim JW, Lim CG. Preliminary Standard Procedure for Face Lift and Correction of Nasolabial Fold using Thread-Embedding(Maeseon) of Korean Medicine. J Korean Med Ophthalmol Otolaryngol Dermatol. 2013;26(4):46. •Lerwick E. Studies on the efficacy and safety of polydioxanone monofilament absorbable su- ture. Surg Gynecol Obstet. 1983 Jan;156(1):51-5. •Liu Jie, Jiang Zhaozhong, Zhang Shengmin, Liu Chen, Gross Richard A, Kyriakides Themis R, Saltzman W. Mark. Biodegradation, biocompatibility, and drug deLivery in poly(ω-pentadeca- lactone-co-p-dioxanone) copolyesters. Biomaterials. 2011;32(27):6646-54. •Macchi V, Tiengo C, Porzionato A, Stecco C, Galli S, Vigato E, Azzena B, Parenti A, De Caro R. Anatomo-radiological study of the superficial musculo-aponeurotic system of the face. Ital J Anat Embryol. 2007:112(4):247-53 •Manfredini D, Perinetti G, Guarda-Nardini L. Dental malocclusion is not related to temporomandibular joint clicking: a logistic regression analysis in a patient population. Angle Orthod. 2014;84(2):310-5. •Marilyn Yalom. History of the breast. New York:Ballantine Books. 1998. •Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol Surg. 1995 Jun;21(6):543-9. •Park YY. Yaksiljaipyobeop. Seoul:Haenglim. 2003:19. •Tosti A, Padova MD, Beer K. Acne Scar Classification and treatment. Seoul:Gabon Medical Book, Inc. 2010:1,8,22-7. •Women`s Magazines. The Research Journal of the Costume Culture. 2001;9(5):783-97. •Won CH, Kang DH, Koo SH, Park SH. A survey of Korean college students’ cognition of cosmetic operation. J Korean Soc Aesthetic Plast Surg. 2004;10:51-8. •Yang HJ, Joo HA, Baek SC, Park JS, Hong SH. Anti-inflammatory effects of Hwangnyeonhae- dok-tang and Fermented Hwangnyeonhaedok-tang. J Korean Med Ophthalmol Otolaryngol Dermatol. 2011;24(2):1-15.

321 2016 Korean Medicine Current Practiceof CHAPTER 9

Infertility

▼ Kim Dong il PART 2 Korean Medicine Treatments for Various Medical Conditions

chapter 9

Infertility

Introduction

All physiological processes of the human body are products of interactions among the five viscera, six bowels, essence, qi, spirit, and blood. In Korean Medicine, the kidney plays an important role in the reproduction. Only after Heavenly tenth (天癸, a substance that controls the overall reproductive system) is activated does a woman become able to conceive. This theory is analogous to the Hypothalamus-Pituitary gland-Ovary axis (HPO-axis) in that harmonious function of the different components of a system contributes to the proper functioning of the body.

In Korean Medicine, improving fertility and treating infertility are referred to as “Jokyung (調經; restore normal menstruation and ovulation)” and “Gusa (求嗣; treat fertility to facilitate conception)”.

Infertility is defined as the inability to conceive a child despite one year of unprotected sexual intercourse. In 2008, the American Society of Reproductive Medicine (ASRM) recommended earlier attempts to diagnose and treat women 35 years old or older or those with a relevant history or diagnostic results who have been unable to successfully conceive after 6 months (Gurunath et al., 2011).

Therefore, infertility treatment should consider the patient’s overall health, the length of time that conception has been attempted, and the natural decline in fertility as the patient’s age. Con- ditions to consider include uterine myoma, endometriosis, and adenomyosis.

324 Infertility chapter 9

The prevalence of infertility varies geographically. A maximum of 1 of 4 couples is infertile; a prevalence of 3.5-16.7% has been reported in developed countries, whereas reported infertility rates are 6.9-9.3% in less developed nations, yielding a total average of 9%. A reported 56% of infertile couples have received a treatment (Jacky et al., 2007).

It has been reported that 15% of couples in Korea are infertile. Social problems such as delayed marriage, an occupational environment and a financial reason are known to affect the infertility rate.

In Korean Medicine, pattern identification subtyping a particular set of symptoms to be kidney deficiency, liver stagnation, dampness phlegm, qi and blood deficiency, blood stagnation, dampness heat, or cohesive cold is critical for an effective treatment plan. However, conventional diagnosis of underlying factors, such as decreased ovarian reserve, ovulatory factor, tubal factor, uterine factor, and pelvic factor, should precede any treatment. kidney deficiency, liver stagnation, dampness phlegm, cold cohesion, qi and blood deficiency-types are considered highly relevant to problems related to ovulatory factor, cervical factor, nutrition, and metabolic condition. Blood stagnation and dampness heat-types are more closely correlated with oviduct, peritoneum, and uterine factor (Kim et al., 2016).

The Korean Medicine approach to infertility is a natural method of restoring stress-free. Risks of Ovarian Hyperstimulation Syndrome (OHSS) or multiple pregnancy, a common complication of Assisted Reproduction Techniques (ART), are substantially lower in patients treated with Korean Medicine.

Unexplained Infertility

1. Diagnosis

Unexplained Infertility can be diagnosed when there is no identifiable cause. There may be underlying problems that lead to condition such as luteinized unruptured follicle syndrome, immunologic dysfunction, decreased endometrial perfusion, infection, undiagnosed pelvic pathologies, or occult male or oocyte factors. All possible causes should be ruled out

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before diagnosis [Figure 1].

For accurate diagnosis, history taking, hormone analysis, and ultrasonography are needed to examine sexual activity and ovulation pattern; ovarian reserve test should be performed to rule out very low fertility condition. On the 3rd day of the menstruation cycle, Follicle Stimulating Hormone (FSH) levels are measured; a level higher than 10-15 IU/ml is considered abnormal. Anti-Müllerian Hormone (AMH) is frequently used to evaluate ovarian reserve. Because AMH is less sensitive to ovulatory factors, it is clinically valuable. Abnormally high (＞3.5 ng/mL) or low (＜1 ng/mL) level of AMH is known to affect fertility (Tremellen, Kolo 2010).

Hysterosalpingography can rule out uterine and oviduct factors such as uterine synechia or submucosal fibroids.

Diagnostic laparoscopy or CT scan is necessary to rule out suspected endometriosis or other abnormal condition.

After preliminary testing, the Four Diagnosis is performed for pattern diagnosis.

Infertile couple • History taking • Testing

Ovulation and Ovarian ReserveEvaluation (female) • Basal body temperature Semen Analysis (male) • Blood progesterone levels during luteal phase • FSH, LH/AMH (if needed) • Ultrasonograph • Endometrium biopsy

• Sperm penetrating assay • Post-intercourse testing • Immunology tests • Cell culture

Referral to Urology or Hysterosalpingography Endocrinology Laparoscopy

[ Figure1] Diagnosis of infertility

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2. Treatment

(1) Pattern Identification Treatment (Kim 2010)

• Kidney Deficiency Type ❶ Treatment plan: Tonify the kidneys and nourish the essence. Because patients with this type are likely to refrain from sexual activity, emotional support is necessary. ❷ Herbal medicine: ‘Unicorn-Rearing Pill’ (毓麟珠) ❸ Acupuncture/Moxibustion: CV03, CV04, SP06, EX-CA1, GV04, BL23, and SP09; add electro-acupuncture to CV3–CV4 and SP06-SP09. Apply moxibustion on KI13 for kidney yin deficiency and on CV04.

• Qi and Blood Deficiency Type ❶ Treatment plan: Tonify the qi and nourish the blood. Because malnutrition and overwork are associated with this condition, a healthy lifestyle should be emphasized. ❷ Herbal medicine: ‘Warm Soil Unicorn-Rearing Decoction’ and ‘Restore the Spleen De- coction’ (溫土毓麟湯合歸脾湯). If symptom of kidney deficiency is also present, add Psoraleae Semen (補骨脂) and Cuscutae Semen (菟絲子). ❸ Acupuncture/Moxibustion: CV03, CV04, SP06, EX-CA1, ST36, BL20, and SP10. Add electro-acupuncture to CV03-CV04 and SP06-ST36.

• Liver Stagnation Type ❶ Treatment plan: Soothe the liver and relieve qi stasis. Because the primary cause is emotional stress, stress management and emotional support are critical for this type. Reduced frequency of sexual activity and functional problems of the reproductive system are common. ❷ Herbal medicine: ‘Regulate Channels and Pregnancy Decoction’ (調經種玉湯). If symptom of kidney deficiency is also present, add Cervi Parvum Cornu (鹿茸) or Cervi Cornu (鹿角). ❸ Acupuncture/Moxibustion: CV03, CV04, SP06, EX-CA1, BL18, LR03, and SP9. Add electro-acupuncture to CV3-CV4 and SP6-SP9.

• Dampness Phlegm Type ❶ Treatment plan: Eliminate dampness and dispel phlegm. If obese, add a diet/exercise plan to treat obesity. ❷ Herbal medicine: ‘Guide Out Phlegm Decoction with Atractylodes and Aconite’ (蒼附導痰

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湯). If patient also presents with a symptom of stagnated blood, add Herba Leonuri (益母草), Herba Lycopi (澤蘭), Crataegi Fructus (山査肉), and Carthami Flos (紅花). If edema is observed, omit Glycyrrhizae Radix et Rhizoma (甘草). ❸ Acupuncture/Moxibustion: CV03, CV04, SP06, EX-CA1, SP09, ST40, ST36, and BL20 . Add electro-acupuncture to CV03-CV04, SP06-SP09, and ST40-ST36.

• Blood Stagnation Type ❶ Treatment plan: Activate blood circulation to eliminate blood stasis (activate blood). Even if direct correlations cannot be found between the condition, uterine myoma, adenomyosis, endometriosis and other underlying problems may be present. ❷ Herbal medicine: ‘Drive Out Stasis in the Mansion of Blood Decoction’ (血府逐瘀湯). ❸ Acupuncture/Moxibustion: CV03, CV04, SP06, EX-CA1, SP09, BL17, SP10, and BL32. Add electro-acupuncture to CV03-CV04 and SP06-SP09.

• Dampness Heat Type ❶ Treatment plan: Remove evil heat and remove dampness. ❷ Herbal medicine: ‘Four Substances Decoction for Relieving Toxicity’ (解毒四物湯). ❸ Acupuncture/Moxibustion: CV03, CV04, SP06, EX-CA1, SP09, PC3, LI04, and SP10. Add electro-acupuncture to CV03-CV04 and SP06-SP09.

• Cold Cohesion Type ❶ Treatment plan: To treat cold cohesion-type infertility, warm the reproductive system and dispel coldness. Manage food and other habits to limit exposure to cold pathogens and remove internal coldness. ❷ Herbal medicine: ‘Warm Channels Decoction’ (溫經湯). ❸ Acupuncture/Moxibustion: CV01, CV04, SP06, EX-CA1, GV04, BL23, and KI07. Add electro-acupuncture to CV01-CV04. Apply moxibustion on CV04.

(2) Treatment Effects and Prognosis

The prognosis of unexplained infertility treated with Korean Medicine depends on the patient’s age, duration of infertility, age of the partner, treatment duration, and treatment intervention. Recently, 7 local government projects for the treatment of infertility using Korean Medicine were launched, with a variety of age limit (38, 40, and 44 years). Interventions included both herbal medicine and acupuncture. Herbal medicine was provided for 3 months

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and 6 months. Acupuncture was provided for 3 months, 6 months, 3-6 months, and 3-9 months, depending on the patient’s condition and the physician’s discretion.

The demographic characteristics of the patients included in the study were as follows; total Live Birth Rate (LBR) of 21.1% (19/90, three studies), Ongoing Pregnancy Rate (OPR) of 18.6% (44/236, five studies), and Clinical Pregnancy Rate (CPR) of 24.9% (69/277, six studies) after Korean Medicine (KM) treatment for three to six months. KM treatment is generally safe in terms of Liver Function Tests (LFT) in infertile women (J. et al. 2016).

According to the results of a study investigating the effects of a 6-month treatment consisting of herbal medicine, acupuncture, and moxibustion on unidentified and ovulatory infertility patients (recruited regardless of the number of Assisted Reproduction Techniques attempts prior to inclusion) under the age of 38 (Jeong et al 2015), 5 of 25 patients conceived during the 6-month treatment period and 1 additional pregnancy was reported during the 1-month follow-up period, yielding a 24% success rate. All 6 patients who conceived gave a birth to a healthy baby.

The herbal medicine regimen included modified ‘Augmented Decoction for Regulating Channels and Pregnancy’ (調經種玉湯加味方) and ‘Ovulation and Implantation Formula’ (排卵着床方). Acupuncture treatment was applied to GV20, CV04, EX-CA1, EX-CA09, ST36, SP06, and SP09, and moxibustion was applied on CV04 . The needle retention time was 20 minutes. Electro-acupuncture (4Hz) was applied to EX-CA1 – EX-CA9, and SP06- SP09.

Acupuncture was provided 3 times during the follicular phase followed by administration of modified ‘Augmented Decoction for Regulating Channels and Pregnancy’ (調經種玉湯加味方) during the follicular phase, followed by ‘Ovulation and Implantation Formula’ ( 排卵着床方) during the period between ovulation and menstruation. After pregnancy was confirmed, ‘Ovulation and Implantation Formula’ was administered for 10 more days to stabilize the fetus.

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Infertility due to Polycystic Ovarian Syndrome and other Ovulatory Factors

1. Diagnosis

(1) Evaluation of Ovulatory Factors with History Taking

If the patient presents with irregular menstrual cycle, oligomenorrhea or amenorrhea, anovulation should be diagnosed. Polycystic ovarian syndrome refers to the state of hyperan- drogenism confirmed by clinical or biochemical diagnosis accompanied by anovulation or oligo-ovulation. If polycystic ovary is confirmed by ultrasonography, other similar disorders can be ruled out.

(2) Diagnosis of Anovulation

• Anovulation can be diagnosed as follows: - Blood progesterone level: Begin analysis 1 week prior to menstruation; progesterone level under 3mg/ml imply anovulation. - Urine Luteinizing Hormone (LH) level: LH diagnosis kits are used. - Endometrium biopsy and luteal phase defect: Rule out endometrial hyperplasia due to prolonged anovulation and other luteal phase defect. - Indirect diagnosis of anovulation with ultrasonography, based on diagnosis of polycystic ovary and other problems [Figure 2].

2. Treatment

(1) Polycystic Ovarian Syndrome

• Treatment plan: To treat polycystic ovarian syndrome, devise a treatment that incudes methods that normalize menstrual physiology and treat metabolic disorders. Keep in mind that the fundamental (本, true cause) of the pathologic mechanism is kidney deficiency and dampness phlegm. [ Figure 2] Polycystic ovary

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The incidental symptoms (標證, superficial symptoms) may be liver stagnation. If the patient is obese, treat the obesity as well. The minimum treatment duration is 3 months; in many cases, 6 months of treatment or longer is required. It is important to provide a thorough explanation during the patient’s first visit (Kim, 2010). • Herbal medicine: Refer to the diagnosis pattern of unexplained infertility. ‘Augmented Gentian Drain Liver Decoction’ (龍膽瀉肝湯加味方) can be prescribed. • Acupuncture/Moxibustion: Refer to the acupuncture/moxibustion methods described for unexplained infertility.

(2) Other Ovulatory Problems

Refer to the diagnosis pattern of unexplained infertility. The first herbal medicines used should be ‘Regulate Channels and Pregnancy Decoction’ (調經種玉湯) and ‘Unicorn-Rear- ing Pill’ (毓麟珠). One treatment unit is 3 months. Acupuncture should be applied to CV04, EX-CA1, ST29, ST36, SP06, and SP09. 1-2 times a week for the same duration as herbal medicine.

Infertility due to Endometriosis

1. Diagnosis

Endometriosis affects fertility in many different ways, including hypomotility or structure of the oviduct, localized inflammation, fertilization and/or implantation problems due to negatively affected chemotaxis of the sperm and fertilized egg, anovulation, and reduction of sexual activity due to pain. Therefore, it is important to diagnose endometriosis and evaluate the extent to which this condition affects the oviduct and peritoneum. Diagnosis is possible when the patient presents with sharp and severe dysmenorrhea, pelvic pain, dyspareunia, and pain during defecation. Ultrasonography [Figure 3] and abdominal CT scans are used for added reliability.

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2. Treatment

(1) Treatment Principles

The incidental symptom of the pathologic mechanism of endometriosis is blood stagnation. The fundamental problem is deficiency, including kidney deficiency and qi deficiency. When focusing on the localized lesion itself, devise a treatment plan that focuses on resolving the blood stagnation. However, if general symptoms are promi- [ Figure 3] Endometriosis of right ovary nent, further analyze the pattern to devise a (Endomentrioma) treatment plan for the general symptoms as well (Kim, Lee. 2001). The treatment duration should be approximately 6 months. Further treatment can be recommended according to the treatment outcomes and changes in general symptoms as well as the patient’s age (Kim, 2010).

(2) Herbal Medicine

‘Drive Out Stasis Decoction in Small Abdomen’ (少腹逐瘀湯) and modified ‘Cinnamon and Poria Pill’ (桂枝茯苓丸加味方).

(3) Acupuncture and Moxibustion

CV0, CV04, SP06, EX-CA1, EX-CA9, SP09, BL17, SP10, and BL32. Apply electro-acupuncture (4Hz) to CV03-CV04, EX-CA1 – EX-CA9, and SP06-SP09)

(4) Treatment Outcomes and Prognosis

Unfavorable prognosis is possibly considered when endometriosis has caused adhesions in the oviduct that affect tubo-ovarian motility and/or ovum pickup or if chemotaxis of the sperm has been negatively affected by lesions of the abdominal organs.

The Monthly Fecundity Rate (MFR) is approximately 25% for normal couples engaging in unprotected intercourse but is only 5-11% in women with endometriosis (Haney, 1993). The

332 Infertility chapter 9

spontaneous abortion rate is approximately 15-25% in normal women, compared with 40% for patients with endometriosis (Groll, 1984). Hence, even if pregnancy is successful, there is a high possibility of miscarriage.

There have been no prospective studies on the treatment of infertility due to endometriosis to date; only case reports of successful conception have been published. According to a case report (Kim et al., 2002), 2 months of ‘Drive Out Stasis Decoction in Small Abdomen’ (少腹逐瘀湯) and ‘Unicorn-Rearing Pill’ (毓麟珠) administration resulted in a successful pregnancy.

Korean Medicine Treatment and Assisted Reproduction Techniques (ART)

The goal of Korean Medicine treatment for women attempting Assisted Reproduc- tion Techniques (ART) is to increase reactivity to induced ovulation (number of follicles 14 mm or larger, ova collected, fertilization rate) and to help increase the thickness of the endometrium and improve circulation for better implantation rate (Kim et al., 2002). The ultimate goal is to improve the live birth rate, which is currently only 25%.

Korean Medicine treatment can be applied before, during, and after induced ovulation and during pregnancy after failure of an attempt as preparatory conditioning for the next attempt.

Acupuncture treatment and herbal medicine can be applied effective for each stage of the treatment. A variety of treatment approaches can be possible, such as replenishing the kidneys, boosting qi, nourishing the blood, activating and nourishing the blood, or dispelling phlegm.

Further studies of the effects of Korean Medicine treatment, including pharmacopuncture, acupuncture, and herbal medicine, combined with ART are expected.

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1. Treatment

A wide range of acupuncture treatment can be applied during this stage. Acupuncture should be applied as indicated for general patterns. Taking into account the mentally stressful nature of ART, acupoints effective for soothing the spirit may be added. Herbal medicine may also be prescribed for 2-3 months to restore balance to yin and yang, qi and blood, and the viscera and bowels (Kim, 2010).

2. Korean Medicine during ART

Acupuncture treatment is applied during the ovum collection phase and before and after embryo transfer. Patients show well response. Continuing acupuncture after embryo transfer is not recommended.

There is controversy regarding the administration of herbal medicine during induced ovulation. During controlled ovarian stimulation, essence and blood are consumed in large amount. Tonify the kidney to tonify the essence and to nourish and activate blood (Kim, 2010).

Such treatments may contribute to increased pregnancy and implantation rate by improving ovarian reserve or endometrium formation (Lee et al., 2010; Park and Baek, 2011).

Yookrin-ju (‘Unicorn-Rearing Pill’, 毓麟珠), Jokyungjongok-tang (‘Regulate Channels and Pregnancy Decoction’, 調經種玉湯), and Samool-tang (‘Four Substances Decoction’, 四物湯) have been reported to be effective (Kim, 2010).

3. Korean Medicine Care after Failure of ART

After the failure of an ART attempt, a resting phase is needed before the next controlled ovarian stimulation. Detoxify and replenish the body with Korean Medicine treatment during this period. Decreased response to induced ovulation and malformation of the endometrium should be treated differently. Use treatment methods that replenish the kidneys, boost qi, and activate the blood for 1-3 menstrual cycles or 1-3 months prior to another ART attempt (Kim, 2010).

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If the ovum did not respond favorably to induced ovulation, replenish the kidneys and activate the blood to increase sensitivity to hormones and increase local blood circulation. Furthermore, methods that replenish the kidneys can help improve ovarian reserve. Induced ovulation after such treatments can help increase sensitivity to hormones and improve the quantity and quality of the ova collected, thereby increasing successful pregnancy rate (Kim, 2010).

Factors that affect the success of ART include patient’s age, response to induced ovulation, and the condition of the endometrium. Therefore, patient age, the results of previous induced ovulation (quantity and quality of ovary), and the thickness of the endometrium should be considered before treatment. Women older than 35, women who did not respond favorably to induced ovulation, and women with an endometrium thinner than 7.5mm are all subject to treatment. There is no recommended standard endometrial thickness, but previous research (Abdalla et al. 1994) reported an average thickness of approximately 10.24mm ± 2.63 SD. The average thickness of the endometrium in 40 women who did not successfully conceive was approximately 8.62 mm ± 3.49 SD. Only 2 of 15 patients with an endometrial thickness of less than 7.5 mm were successful. In a study conducted in Korea (Ko and Cho, 2001), the endometrium of women with successful pregnancy was approximately 9± 2mm thick.

If the endometrial thickness is not ideal, replenish the kidneys and boost qi or activate the blood to facilitate endometrial development and fertilized egg implantation (Kim, 2010).

When treating ovarian hyperstimulation syndrome, boost the kidneys, fortify the spleen, and drain water to remove dampness. Modify herbal prescription based on the symptoms displayed (nausea, vomiting, shortness of breath, decreased urination), BMI, and the amount of abdominal fat. Clinically, Yookmijihwang-tang (‘Six-Ingredients Decoction with Rehmannia’, 六味地黃湯), Samchoolgunbi-tang ‘Ginseng and White Atractylodes Strengthen Spleen Decoction’, 蔘朮健脾湯), Boonshimqi-eum (‘Heart Qi Parting Drink’, 分心氣飮) and Gwakhyangjungqi-san (‘Agastache Powder to Rectify the Qi’, 藿香正氣散) are prescribed as a single prescription or in combination (Kim, 2010).

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Health Maintenance

To prevent infertility, it is important to attempt pregnancy at a recommended age. For healthy childbirth, sexual activity, food, items of personal preference, exercise, and weight should all be monitored.

1. Sexual Intercourse

For natural conception, sexual intercourse is recommended every 2-3 days. Maintain an appropriate frequency between menstruation cycle (Kim, 2010). “Trying” on or around ovulation date is not recommended as it is stressful for both the woman and her partner. In addition, slight changes in ovulation patterns may affect outcomes.

The “fertile window” refers to the 6 days prior to ovulation; in other words, the time period during which pregnancy is possible. However, the fertile window does not include the days after ovulation (Berek et al., 2007). Assuming favorable estrogen exposures in the cervical mucosa, sperm can survive for up to 6 days. Clear, transparent, slippery, and “spinnbarkeit” (i.e., stretch- able) cervical mucous is most abundant 2-3 days before ovulation. This is the most preferable condition for conception.

2. Nutrition

A regular and balanced diet is recommended for natural conception. A “fertility diet” includes food rich in monounsaturated fat with limited trans fats. Protein from animal sources is not recommended, but vegetables are encouraged. Low glycemic index carbohydrate, unpro- cessed dairy products, vitamin supplement, estrogen supplement from herbal sources, and iron supplement is recommended. Such a diet is known to help prevent infertility due to ovulatory factors (Kim, 2010).

336 Infertility chapter 9

3. Items of Personal Preference

Refrain from overdrinking. Each dose of alcoholic beverages should not exceed 1 or 2 glasses. The frequency of alcohol consumption should not exceed 1-2 times a week.

Smoking and secondhand smoke are likely to affect pregnancy rate. Therefore, any couple seeking to conceive a child should refrain from smoking.

No correlation between caffeinated drinks (tea, coffee, coke) and infertility has been confirmed to date. However, high doses may interfere with general health, which may contribute to an increased possibility of spontaneous abortion. Therefore, excessive consumption of caffeinated drinks is not recommended (Kim, 2010). There is no specific guideline for a safe caffeine level, but it is considered to be approximately 100-200mg per day, which corresponds to 1 to 2 cups of coffee per day.

4. Exercise

Exercise helps improve quality of life in most women, with considerable benefits. However, excessive exercise may negatively affect reproductive ability. Such problems include abnormal menstruation, oligo-ovulation and oocyte problems. Women who participate in extreme sports activities have a 2.3-fold higher risk of infertility than those who participate in less challenging sports. Therefore, plan an exercise routine that considers the patient’s individual abilities, obesity, and other individual factors. Light regular exercise is recommended.

5. Weight Control

Overweight or obese patients should aim to maintain a healthy weight to prevent ovulation problems.

337 PART 2 Korean Medicine Treatments for Various Medical Conditions

6. Health Maintenance for the Partner

Abstinence from alcohol and smoking, maintaining a healthy weight, preventing temperature extremes of the testes (obesity, exposure to high temperature), and wearing loose garments is recommended. It is also important to engage in regular sexual intercourse.

Reference

•Abdalla HI et al. Endometrial thickness: a predictor of implantation in ovum recipients? Hu- man Reproduction. 1994; 9(2):363-365.

•Berek JS et al. Berek & Novak’s Gynecology. 14th rev. ed. Philadelphia:Lippincott Williams & Wilkins. 2007:1245.

•Dong-Il Kim, Dong-Kyu Lee, Tae-Kyun Lee. A study of Traditional Korean Medicine treatment in Endometriosis. THE JOURNAL OF ORIENTAL OBSTETRICS & GYNECOLOGY VOL.15 NO.2 : 126-143. (2002)

•Dong-Il Kim. Oriental Medical Treatment as Supplementary Treatment Method in ART : clinical review. THE JOURNAL OF ORIENTAL OBSTETRICS & GYNECOLOGY VOL.23 NO.4 : 67-79. (2010)

•Dong-Il Kim, Tae-Kyun Lee. A study of the clinical management for women’s organic infertility. THE JOURNAL OF ORIENTAL GYNECOLOGY VOL.14 NO.1 : 196-208. (2001)

338 Infertility chapter 9

•Groll M. endometriosis and spontaneous abortion. Fertile Steril 1984;44:933-5.

•Gurunath S, Pandian Z, Anderson RA, et al. Defining infertility-a systematic review of prevalence studies. Hum Reprod Update. 2011;17(5):575-588.

•Haney AF. Endometriosis-associated infertility. Baillieres Clin Obstet Gynaecol. 1993;7:791- 812.

•International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care. Jacky Boivin, Laura Bunting, John A. Collins, Karl G. Nygren. Hum. Reprod. (2007) 22 (6): 1506-1512.

•Jae-Cheol Jeong, Min-Sun Choi, Sang-Ho Yoon, Dong-Il Kim. Analysis of the Result of Ko- rean Medicine Treatment for Female Subfertility Using Herbal Medicine, Acupuncture and Moxibustion Treatment. J Korean Med. 2015;36(2): 1-7.

•Junyoung Jo, Tae-Hun Kim, Min Kyung Hyun, Hyunho Kim, Dong Il Kim, Traditional Korean Medicine for female infertility: A review of results from infertility support programs in Korea. European Journal of Integrative Medicine. 8(2016) : 847-853.

•Kim Dong-il. Infertility Korean Medicine Clinical Practice Guidelines. Association of Korean Medicine. 2010.

•Kim et al. The Society of Korean Medicine Ob&Gy. Korean Medicine Ob&Gy 3rd ed. Seoul; 2016;167.

•Tremellen K, Kolo M. Serum Anti-Müllerian Hormone is a useful measure of quantitative ovarian reserve but does not predict the chances of live-birth pregnancy. Obstet Gynaecol. 2010;50(6):568-572.

•Young-Sun Park, Jung-Han Baek. Influence of Herbal Medicine and Acupuncture Treatment on the Pregnancy Rate in Infertile Women before In Vitro Fertilization-Embryo Transfer. J Ko- rean Oriental Med 2011;32(5):25-40.

•Yu-Mi Ko, Jung-Hoon Cho. A Study on the effect of Yukmijihwangtang for IVF. The Journal of Oriental Gynecology. 2001;14(1):146-56.

339 ● Current Practice of Korean Medicine 2016 APPENDIX INDEX APPENDIX

List of Acupuncture Points

Meridian Code Chinese Name Korean Pronunciation

LU01 中府 Jungbu LU02 雲門 Unmun LU03 天府 Cheonbu LU04 俠白 Hyeopbaek LU05 尺澤 Cheoktaek Lung Meridian (LU) LU06 孔最 Gongchoe (手太陰肺經) LU07 列缺 Yeolgyeol LU08 經渠 Gyeonggeo LU09 太淵 Taeyeon LU10 魚際 Eoje LU11 少商 Sosang LI01 商陽 Sangyang LI02 二間 Igan LI03 三間 Samgan LI04 合谷 Hapgok LI05 陽谿 Yanggye LI06 偏歷 Pyeollyeok LI07 溫溜 Ollyu LI08 下廉 Haryeom LI09 上廉 Sangnyeom Large Intestine Meridian (LI) LI10 手三里 Susamni (手陽明大腸經) LI11 曲池 Gokji LI12 肘髎 Juryo LI13 手五里 Suori LI14 臂臑 Bino LI15 肩髃 Gyeonu LI16 巨骨 Geogol LI17 天鼎 Cheonjeong LI18 扶突 Budol LI19 禾髎 Hwaryo LI20 迎香 Yeonghyang ST01 承泣 Seungeup ST02 四白 Sabaek ST03 巨髎 Georyo ST04 地倉 Jichang Stomach Meridian (ST) ST05 大迎 Daeyeong (足陽明胃經) ST06 頰車 Hyeopgeo ST07 下關 Hagwan ST08 頭維 Duyu ST09 人迎 Inyeong ST10 水突 Sudol

342 Current Practice of Korean Medicine

Meridian Code Chinese Name Korean Pronunciation ST11 氣舍 Gisa ST12 缺盆 Gyeolbun ST13 氣戶 Giho ST14 庫房 Gobang ST15 屋翳 Ogye ST16 膺窓 Eungchang ST17 乳中 Yujung ST18 乳根 Yugeun ST19 不容 Buryong ST20 承滿 Seungman ST21 梁門 Yangmun ST22 關門 Gwanmun ST23 太乙 Taeeul ST24 滑肉門 Hwaryungmun ST25 天樞 Cheonchu ST26 外陵 Oereung Stomach Meridian (ST) ST27 大巨 Daegeo ST28 水道 Sudo (足陽明胃經) ST29 歸來 Gwirae ST30 氣衝 Gichung ST31 髀關 Bigwan ST32 伏兎 Bokto ST33 陰市 Eumsi ST34 梁丘 Yanggu ST35 犢鼻 Dokbi ST36 足三里 Joksamni ST37 上巨虛 Sanggeoheo ST38 條口 Jogu ST39 下巨虛 Hageohe ST40 豊隆 Pungnyung ST41 解谿 Haegye ST42 衝陽 Chungyang ST43 陷谷 Hamgok ST44 內庭 Naejeong ST45 厲兌 Yeotae SP01 隱白 Eunbaek SP02 大都 Daedo SP03 太白 Taebaek SP04 公孫 Gongson Spleen Meridian (SP) SP05 商丘 Sanggu (足太陰脾經) SP06 三陰交 Sameumgyo SP07 漏谷 Nugok SP08 地機 Jigi SP09 陰陵泉 Eumneungcheon

343 APPENDIX

Meridian Code Chinese Name Korean Pronunciation

SP10 血海 Hyeolhae SP11 箕門 Gimun SP12 衝門 Chungmun SP13 府舍 Busa SP14 腹結 Bokgyeol Spleen Meridian (SP) SP15 大橫 Daehoeng (足太陰脾經) SP16 腹哀 Bogae SP17 食竇 Sikdu SP18 天谿 Cheongye SP19 胸鄕 Hyunghyang SP20 周榮 Juyeong SP21 大包 Daepo

HT01 極泉 Geukcheon HT02 靑靈 Cheongnyeong HT03 少海 Sohae HT04 靈道 Yeongdo Heart Meridian (HT) HT05 通里 Tong-Ri (手少陰心經) HT06 陰郄 Eumgeuk HT07 神門 Sinmun HT08 少府 Sobu HT09 少衝 Sochung

SI01 少澤 Sotaek SI02 前谷 Jeongok SI03 後谿 Hugye SI04 腕骨 Wangol SI05 陽谷 Yanggok SI06 養老 Yangno SI07 支正 Jijeong SI08 小海 Sohae SI09 肩貞 Gyeonjeong Small Intestine Meridian (SI) SI10 臑兪 Nosu (手太陽小腸經) SI11 天宗 Cheonjong SI12 秉風 Byeongpung SI13 曲垣 Gogwon SI14 肩外兪 Gyeonoesu SI15 肩中兪 Gyeonjungsu SI16 天窓 Cheonchang SI17 天容 Cheonyong SI18 顴髎 Gwollyo SI19 聽宮 Cheonggung

344 Current Practice of Korean Medicine

Meridian Code Chinese Name Korean Pronunciation BL01 睛明 Jeongmyeong BL02 攢竹 Chanjuk BL03 眉衝 Michung BL04 曲差 Gokcha BL05 五處 Ocheo BL06 承光 Seunggwang BL07 通天 Tongcheon BL08 絡却 Nakgak BL09 玉枕 Okchim BL10 天柱 Cheonju BL11 大杼 Daejeo BL12 風門 Pungmun BL13 肺兪 Pyesu BL14 厥陰兪 Gworeumsu BL15 心兪 Simsu BL16 督兪 Doksu BL17 膈兪 Gyeoksu BL18 肝兪 Gansu BL19 膽兪 Damsu BL20 脾兪 Bisu BL21 胃兪 Wisu 三焦 Bladder Meridian (BL) BL22 兪 Samchosu BL23 腎兪 Sinsu (足太陽膀胱經) BL24 氣海兪 Gihaesu BL25 大腸兪 Daejangsu BL26 關元兪 Gwanwonsu BL27 小腸兪 Sojangsu BL28 膀胱兪 Banggwangsu BL29 中膂兪 Jungnyeosu BL30 白環兪 Baekwansu BL31 上髎 Sangnyo BL32 次髎 Charyo BL33 中髎 Jungnyo BL34 下髎 Haryo BL35 會陽 Hoeyang BL36 承扶 Seungbu BL37 殷門 Eunmun BL38 浮郄 Bugeuk BL39 委陽 Wiyang BL40 委中 Wijung BL41 附分 Bubun BL42 癿戶 Baekho BL43 膏肓 Gohwang BL44 神堂 Sindang BL45 譩譆 Uihui

345 APPENDIX

Meridian Code Chinese Name Korean Pronunciation BL46 膈關 Gyeokgwan BL47 魂門 Honmun BL48 陽綱 Yanggang BL49 意舍 Uisa BL50 胃倉 Wichang BL51 肓門 Hwangmun BL52 志室 Jisil BL53 胞肓 Pohwang BL54 秩邊 Jilbyeon BL55 合陽 Habyang Bladder Meridian (BL) BL56 承筋 Seunggeun (足太陽膀胱經) BL57 承山 Seungsan BL58 飛揚 Biyang BL59 跗陽 Buyang BL60 崑崙 Gollyun BL61 僕參 Boksam BL62 申脈 Sinmaek BL63 金門 Geummun BL64 京骨 Gyeonggol BL65 束骨 Sokgol BL66 足通谷 Joktonggok BL67 至陰 Jieum

KI01 湧泉 Yongcheon KI02 然谷 Yeongok KI03 太谿 Taegye KI04 大鐘 Daejong KI05 水泉 Sucheon KI06 照海 Johae KI07 復溜 Buryu KI08 交信 Gyosin KI09 築賓 Chukbin KI10 陰谷 umgok KI11 橫骨 Hoenggol KI12 大赫 Daehyeok Kidney Meridian (KI) KI13 氣穴 Gihyeol KI14 四滿 Saman (足少陰腎經) KI15 中注 Jungju KI16 肓兪 Hwangsu KI17 商曲 Sanggok KI18 石關 Seokgwan KI19 陰都 Eumdo KI20 腹通谷 Boktonggok KI21 幽門 Yumun KI22 步廊 Borang KI23 神封 Sinbong KI24 靈墟 Yeongheo KI25 神藏 Sinjang KI26 彧中 Ukjung KI27 兪府 Subu

346 Current Practice of Korean Medicine

Meridian Code Chinese Name Korean Pronunciation

PC01 天池 Cheonji PC02 天泉 Cheoncheon PC03 曲澤 Goktaek Pericardium Meridian (PC) PC04 郄門 Geungmun PC05 間使 Gansa (手厥陰心包經) PC06 内關 Naegwan PC07 大陵 Daereung PC08 勞宮 Nogung PC09 中衝 Jungchung

TE01 關衝 Gwanchung TE02 液門 Aengmun TE03 中渚 Jungjeo TE04 陽池 Yangji TE05 外關 Oegwan TE06 支溝 Jigu TE07 會宗 Hoejong TE08 三陽絡 Samyangnak TE09 四瀆 Sadok TE10 天井 Cheonjeong Triple Energizer Meridian (TE) TE11 淸冷淵 Cheongnaengyeon TE12 消濼 Sorak (手少陽三焦經) TE13 臑會 Nohoe TE14 肩髎 Gyeollyo TE15 天髎 Cheollyo TE16 天牖 Cheonyu TE17 翳風 Yepung TE18 瘈脈 Gyemaek TE19 顱息 Nosik TE20 角孫 Gakson TE21 耳門 Imun TE22 和髎 Hwaryo TE23 絲竹空 Sajukgong

GB01 瞳子髎 Dongjaryo GB02 聽會 Cheonghoe GB03 上關 Sanggwan GB04 頷厭 Hamyeom GB05 懸顱 Hyeollo Gall Bladder Meridian (GB) GB06 懸釐 Hyeolli GB07 曲鬢 Gokbin (足少陽膽經) GB08 率谷 Solgok GB09 天衝 Cheonchung GB10 浮白 Bubaek GB11 頭竅陰 Dugyueum GB12 完骨 Wangol GB13 本神 Bonsin

347 APPENDIX

Meridian Code Chinese Name Korean Pronunciation

GB14 陽白 Yangbaek GB15 頭臨泣 Duimeup GB16 目窓 Mokchang GB17 正營 Jeongyeong GB18 承靈 Seungnyeong GB19 腦空 Noegong GB20 風池 Pungji GB21 肩井 Gyeonjeong GB22 淵腋 Yeonaek GB23 輒筋 Cheopgeun GB24 日月 Irwol GB25 京門 Gyeongmun GB26 帶脈 Daema GB27 五樞 Ochu Gall Bladder Meridian (GB) GB28 維道 Yudo GB29 居髎 Georyo (足少陽膽經) GB30 環跳 Hwando GB31 風市 Pungsi GB32 中瀆 Jungdok GB33 膝陽關 Seuryanggwan GB34 陽陵泉 Yangneungcheon GB35 陽交 Yanggyo GB36 外丘 Oegu GB37 光明 Gwangmyeong GB38 陽輔 Yangbo GB39 懸鐘 Hyeonjong GB40 丘墟 Guheo GB41 足臨泣 Jogimeup GB42 地五會 Jiohoe GB43 俠谿 Hyeopgye GB44 足竅陰 Jokgyueum

LR01 大敦 Daedon LR02 行間 Haenggan LR03 太衝 Taechung LR04 中封 Jungbong LR05 蠡溝 Yeogu LR06 中都 Jungdo Liver Meridian (LR) LR07 膝關 Seulgwan (足厥陰肝經) LR08 曲泉 Gokcheon LR09 陰包 Eumpo LR10 足五里 Jogori LR11 陰廉 Eumnyeom LR12 急脈 Geummaek LR13 章門 Jangmun LR14 期門 Gimun

348 Current Practice of Korean Medicine

Meridian Code Chinese Name Korean Pronunciation CV01 會陰 Hoeeum CV02 曲骨 Gokgol CV03 中極 Junggeuk CV04 關元 Gwanwon CV05 石門 Seongmun CV06 氣海 Gihae CV07 陰交 Eumgyo CV08 神闕 Singwol CV09 水分 Subun CV10 下脘 Hawan CV11 建里 Geolli Conception Vessel (CV) CV12 中脘 Jungwan (任脈) CV13 上脘 Sangwan CV14 巨闕 Geogwol CV15 鳩尾 Gumi CV16 中庭 Jungjeong CV17 膻中 Danjung CV18 玉堂 Okdang CV19 紫宮 Jagung CV20 華蓋 Hwagae CV21 璇璣 Seon-gi CV22 天突 Cheondol CV23 廉泉 Yeomcheon CV24 承漿 Seungjang

GV01 長强 Janggang GV02 腰兪 Yosu GV03 腰陽關 Yoyanggwan GV04 命門 Myeongmun GV05 懸樞 Hyeonchu GV06 脊中 Cheokjung GV07 中樞 Jungchu GV08 筋縮 Geunchuk GV09 至陽 Jiyang GV10 靈臺 Yeongdae GV11 神道 Sindo GV12 身柱 Sinju GV13 陶道 Dodo Governor Vessel (GV) GV14 大椎 Daechu (督脈) GV15 瘂門 Amun GV16 風府 Pungbu GV17 腦戶 Noeho GV18 强間 Ganggan GV19 後頂 Hujeong GV20 百會 Baekhoe GV21 前頂 Jeonjeong GV22 顖會 Sinhoe GV23 上星 Sangseong GV24 神庭 Sinjeong GV25 素髎 Soryo GV26 水溝 Sugu GV27 兌端 Taedan GV28 齦交 Eungyo

349 INDEX

Index

A Augmented Rambling Powder 256 Augmented Tonify the Blood Decoction 162 Achilles tendon tap tests 145 Auricular Acupuncture 162, 166, 206, 238, 291 Acne Scars 306, 307 Acute aphasia 153 Acute pain 40, 123, 132, 133, 137, 139 B Adhesive Capsulitis (frozen shoulder) 126,129 Bee venom acupuncture 61, 62, 64 Agastache Powder to Rectify the Qi 229, 296, 335 Bioelectric Impedance Analysis (BIA) 283 Aggregation-Accumulation 216, 217, 221 Blood Stagnation 127, 129, 130, 133, 135, 136, 144, 146, Allergic rhinitis 40 161, 164,167,168, 202, 204, 206, 208, 217, 218, 221, 280, Anesthesia 66 282, 289, 325, 328, 332 Angelica Decoction for Frigid Extremities 240 Blood Stagnation Pattern 154 Angelica Pubescentis Decoction 136 Bloodletting 30, 51, 52 Angelicae Gigantis Radix Powder 130 Body Mass Index (BMI) 283 Angelicae Gigantis Root Powder 146, 318 Bojoongikqi-tang 138, 296 Ankylosing spondylitis 136 Boonshimqi-eum 335 Bragard’s test 136 Anorexia 8, 184, 191, 234, 235, 236, 278 Bupleurum, Balloon Flower Root, and Pinellia Decoction 156 Anterior drawer test 141 Burning Mouth Syndrome(BMS) 177, 178 Anti-Müllerian Hormone (AMH) 326 Bursitis 133, 143, 144 Anxiety Disorders 257, 269 Apley test 141 Apricot Kernel and Perilla Leaf Decoction 229 C Aroma Therapy 230 Calcific Tendinitis 127~129, 131, 132 Arteriosclerosis 50,78 Calm the Stomach Powder 233, 235 Assisted Reproduction Techniques (ART) 325, 329, 333 Car Insurance Medical Coverage 32 Astragalus Decoction 233, 238 Cattle Gallstone Clear Heart Pill 156, 161 Auckandia and Amomum Calm the Stomach Powder 235 Central nervous system 63, 124 Auckandia and Amomum Decoction for Nuturing Cerebral infarction 153, 156 Stomach 130, 138, 235 Augmented Decoction for Facilitating Speech 154 Cerebrovascular infarction 29 Augmented Decoction for Regulating Channels and Cervi Cornu and Cnidii Pill 215 Pregnancy 329 Cervical nerve root compressions 123 Augmented Eight-Substances Decoction 204 Chronic bronchitis 50 Augmented Four-Substances Decoction 204 Chronic pain 40, 123, 132, 137, 139 Augmented Great Tonifying Decoction 158 Chronic Obstructive Pulmonary Disease (COPD) 40 Augmented Heart Clearing Decoction 154 Chuanxiong and Angelica Gigantis Decoction 233 Augmented Important Formula for Painful Diarrhea 194 Chuna Manual Medicine 100~106,115,116

350 Current Practice of Korean Medicine

Manual Therapy 100, 107, 109, 113 D Therapy 32, 106, 110 Dampness phlegm Chungpaesagan-tang 295 130, 154, 178, 217, 218, 280, 289, 325, 327, 330 Cinnamon and Poria Pill 218, 221, 332 Decoction for Cooling the Diaphragm and Dispersing Cinnamon Twig Decoction 55 Fire 146,154,156,163, 296 Cinnamon Twig Decoction with Dragon Bone and Oyster Decoction for Nuturing Stomach 130, 138, 235, 296 Shell 211 Decoction of Rehmannia with Angelica Pubescentis Circulatory functions 63 138, 296 Clean Ocean Pill 222 Decoction of Two Aged Drugs 130, 138, 186, 191 Clear Depression Powder 186 Decoction of Two Aged Drugs to Relieve Depression 218 Clear Heart Lotus Seed Drink 182 Decoction to Clear the Blood and Direct Qi downward 162 Clear Heat and Guide Out Phelgm Decoction 154 Decoction to Eliminate internal Accumulation and Clear Heat and Regulate the Blood Decoction 204 Harmonize 190 Clear the Blood Pill 156, 157, 169 Decoction to Regulate the Stomach for Taeeumin 295 Clear the Lung and Drain the Liver Decoction Decoction to Relieve Muscles with Kudzu 295 154, 156, 162, 295 Decoction to Stabilize the Root and Stop Blood Flooding 222 Clear the Nutrient Decoction 58 Decoction to Tonify Yin and Direct Fire Downward 146 Clear epidemic and overcome toxin drink 168 Deficiency-excess 43, 54 Climacteric Syndrome 207, 208, 212 Degenerative cervical spondylosis 123 Cognitive-Behavioral Therapy 289 Dementia 30, 157, 159, 161, 162 Coiled Shallots Powder 240 Dental pain 40 Cold Damage Diseases 54, 57 Depression 40, 177, 183, 233, 253~256, 262, 269, 278 Cold-heat supplementation-draining method 43 Diabetes 50, 64, 77, 78, 167, 178, 237, 242, 279 Colleges of Korean Medicine 24 Diarrhea 55, 60, 75, 77~79, 84, 86, 160, 178, 192~194, 201, 215, 228, 234, 246, 281 Combining Craniosacral Therapy (CST) 312 Digestive Diseases 176, 177 Common cold 53, 78, 227~229, 231, 232, 245, 247 Digital Infrared Thermal Imaging (DITI) 32 Comparative Harmonization Drink 235 Discogenic Lower Back Pain(DLBP) 137 Constipation 75, 77, 78, 83, 85, 106, 153, 154, 162, 178, 184, Dispel Wind and Eliminate Dampness Decoction 154 192~195, 211, 220, 232~234, 253, 291 Dissolve Stasis and Aggregation Decoction 221 Constitutional acupuncture (Taegeuk acupuncture) Dizziness 30, 41,153,184, 254, 257, 258, 260, 262, 264, 265 37, 44, 142 Dokhwaljihwang-tang 138, 296 Coptis Decoction to Relieve Toxicity 63, 161, 181, 319 Dongje medical school 20 Cubital tunnel syndrome 133, 134 Donguibogam 19, 54, 56, 57, 101, 102, 186, 204, 252, 280 Cupping Therapy 51 Draining method 38, 42, 43 Cuscutae Seed Pill 237 Drive Out Stasis and Stop Bleeding Decoction 222 Cyclic Pelvic Pain 201, 220 Drive Out Stasis Decoction 167

351 INDEX

Drive Out Stasis Decoction in Small Abdomen Facial nerve palsy 65, 153, 154, 155 168, 204, 332, 333 Fascia Chuna therapy 110 Drive out Stasis under Diaphragm Decoction 204, 221 Fibromyalgia 40 Drive Out Stasis in the Mansion of Blood Decoction Five Accumulations Powder 130, 136, 137, 169, 240 163, 164, 168, 328 Five Element 36, 42, 43, 44, 46 Dry Dampness, Dissolve Phlegm and Soften Tension Five-Ingredient Formula with Poria for Dredge Wind 241 Decoction 221 Follicle Stimulating Hormone (FSH) 208, 326 Dual energy X-ray Absorptiometry (DXA) 284 Foot joint sprains 144 Dysarthria 153 Dysmenorrhea 106, 200~204, 206, 207, 218, 282, 331 Four Gentlemen Decoction 190, 191, 245 Dyspepsia 40, 79, 86,106,156, 177, 187~192,194 Four Substances Decoction 138, 204, 233, 334 Dysphasia 153 Four Substances Decoction for Relieving Toxicity 328 Four-Counter Decoction 55 Four-Miracle Pill 194 E Four-Substance Decoction wih Peach Seed and Carthami Flos 160, 168, 290 Eight Ingredient Rectify Powder 156 Four-Substances Calm Spirit Decoction 162 Eight Substances Decoction 204, 296 Functional Dyspepsia (FD) 40, 177, 187, 188, 189, 191 Eight Treasure Decoction 158 Eight-Ingredient Pill with Rehmannia 160 Eliminate the Inside Powder 235 G Eliminate the Undigested Food Pill 235 Galgeunhaegi-tang 295 Eliminate Wind and Invigorate Blood Decoction 155 Gami-saenghwa-tang 221 Embedding Acupuncture 64 Gastritis 79 Embedding Therapy 293, 304, 305, 307, 309, 316, 318 Gastrodia and Uncaria Decoction 158 Embracing Dragon Pill 229 Gastroesophageal Reflux Disease(GERD) 177, 183, 185 Emergent Restoration of Yang Decoction 168 Generate the Pulse powder 165 Emotion Freedom Technique (EFT) 267, 269 Gentian Drain Liver Decoction 216, 237, 331 Enuresis 232, 236~239 Ginseng and Aconite Decoction 165 Ephedra Decoction 55 Ginseng and White Atractylodes Strengthen Spleen Ephedrae Moisten the Lung Decoction 60 Decoction 235, 245, 335 Epicondylitis 133, 134 Ginseng Decoction to Nourish the Nutritive Qi Euibangyoochui 19 158, 159, 165 Ginseng Decoction to Nourish the Stomach 235 F Ginseng, Poria, and Atractylodes Macrocephala Powder 214, 235 Facial Asymmetry 311, 312 Glycemic Index (GI) 287, 336 Facial lifting 65 Great Bupleurum Decoction 162

352 Current Practice of Korean Medicine

Great Nutrition Decoction 137, 205 Hwa-Byung Diagnositic Interview Schedule (HBDIS) Great Ledebouriella Decoction 142 260, 261 Great Notopterygium Decoction 142 Hyperlipidemia 167~69, 209, 284 Great Seven Qi Decoction 218 Hypertension 40, 50, 51, 53, 78, 85, 284 Great Tonify the Primal Decoction 160 Hypothalamus-Pituitary gland-Ovary axis (HPO-axis) 324 Great Tonify the Yin Pill 155, 158 Hysteroscopy 203, 220 Grinding test 141 Hyungbangjihwang-tang 138, 147, 296 Growth Disorder 232, 241, 242, 245 Guide Out Phlegm and Invigorate Blood Decoction 155 I Guide Out Phlegm Decoction 154, 155, 158 Guide Out Phlegm Decoction with Atractylodes and Ikwi-tang 187 Aconite 327 Immortals’ Formula for Sustaining Life 168 Guide out the red and Suppress the Qi Decoction 130 Impotence 50 Guide Out the Red powder 241 Industrial Accident Compensation Insurance 32 Gunchilgwanjul-dan 125 Infantile Colic 239 Gwakhyangjungqi-san 296, 335 Infertility 324~326, 328~331, 333, 336, 337 Gwanjoong-tang 296 Interference Current Therapy (ICT) 32 International Normalized Ratio (INR) 59 Introduction to Medicine 47, 49 H Invigorate the Channels Decoction 125, 129, 146

Headache 40, 47, 53, 63, 83, 106, 153~155, 168, 191, Irritable Bowel Syndrome (IBS) 178, 192 209, 228, 230, 234, 254, 260, 262, 281 Ischemic Heart Disease 163, 164 Health Insurance Review and Assessment Agency(HIRA) 31 Jung-an acupuncture 305, 312 Heart Qi Parting Drink 261, 262, 335 Hemi-paresthesia 153 J Hemiplegia 153, 154, 155 Hemorrhage 40, 41, 153, 162, 163 Jung-gyeuk 43, 44 Hemp Seed Pill 233 Kidney Qi Pill of the Golden Cabinet 237, 244 Herbal acupuncture therapy 60 Herbal pharmacists 25 K Herbal Therapy 53 Hidden Tiger Pill 160 Knee Joint Bursitis 143 High-Carbohydrate Diet 287 Knee stability tests 141 Hŏ Jun 19, 102 Korean Institution of Oriental Medicine 256 Huangdi’s Internal Classic 39, 40, 44, 101, 277, 305 Korean Medicine and Pharmaceutics Promotion Act 21, 27 Human Immunodeficiency Virus (HIV) 41 Korean Medicine doctors 18~22, 26~29, 31, 32, 53, 100 Hwa-byung 179, 255, 259, 260, 261, 262, 263, 265, 268, 269 Korean Medicine Education Evaluation(IKMEE) 25

353 INDEX

Korean Society of Chuna Manual Medicine for Spine & Mid-Parental Height (MPH) 242 Nerves (KSCMM) 102 Milgram’s test 136 Korean Society of Oriental Neuropsychiatry 256 Mindfulness Based Stress Reduction program (MBSR) 268 Mindfulness-Based Cognitive Therapy (MBCT) 269 L Ministry of Health and Welfare 18, 20, 21, 27, 104 Minor Blue-green Dragon Decoction 229, 231 Lachman test 141 Minor Bupuleurum Decoction 55 Lasegue’s Test 136 Mori Chrisanthemi Drink 58, 104 lateral instability tests 145 Morton’s syndrome tests 145 Ledebouriella Powder that Sagely Unblocks 154, 290 Moxibustion 20, 23, 25, 26, 28, 30, 31, 47~50, 56, 115, Lee Jema 19, 44, 45, 57, 82, 88, 89 142, 158, 161, 165, 189, 190, 205, 206, 230, 233~235, 238, Licorice Wheat and Jujube Decoction 211 276, 327~329, 331, 332 Limb paresthesia 153 Muscle and Bone Pill 134 Limb spasticity 153 Musculoskeletal disorders 22, 23, 33, 104~106, 115 Lindera Smooth Qi Powder 130 Musk 63 Linking Decoction 195 Myrrh Remove Pain Decoction 61 Liquid Styrax Pill 165 Lonicerae Forsythia Powder 58, 60 N Low-Carlorie Diet (LCD) 286 Lower limb alignment tests 141 National Health Insurance 18, 20, 22, 23, 30~33, 116 Low-Glycemic Index (GI) Diet 287 Neck stiffness 63, 123~125, 153 Lumbar disc herniation 65, 137 Needle embedding 63~67, 304, 305, 307, 309, 316, 317, 318 Lumbar spinal stenosis 135, 137 Needle insertion 38, 47 Major Arrest Wind Pearl 158 Needle sensation 39 Nerve Stimulator (TENS) 32 M Neurological disorders 105, 106 NIHSS (National Institutes of Health Stroke Scale) 156 Major Bupleurum Decoction 290 Non-Steroidal Anti-Inflammatory Drug (NSAIDS) 139 Major Construct the Middle Decoction 156 Notopterygium Decoction to Overcome Dampness 125 Mantis Egg-Case powder 237 Notopterygium Meritorious Life Decoction 142 McMurray test 141 Numeric Rating Score(NRS) 46 Medial instability tests 145 Medical Care Assistance 31, 32 Medical Service Act 18, 20, 27, 29 O Meridian function test 30 Obesity 39, 77, 78, 85, 91, 185, 276~280, 331, 337, 338 Meridian laser therapy 32 Order the Qi Decoction 55, 136 Meridians and Collaterals 36, 66, 104

354 Current Practice of Korean Medicine

Ovulation and Implantation Formula 329 Prepared Aconite and Cinnamomum Decoction 241 Prescriptions from the bureau of peaceful benevolence 293, 305 P Preserve Harmony Pill 235

Painful Menstruation Decoction 204, 205 Progressive Muscle Relaxation (PMR) 269 Parkinson’s Disease 157, 158, 159 Protrusion tests 145 Pattern identification 30, 43, 54, 57, 58, 60, 188, 189, Psychiatric Diseases 251~273 193, 227, 253~262, 264~266, 280, 325, 327 Psychotherapy 31, 267, 268, 269 Peach Pit Order the Qi Decoction 136 Pump Inhibitors (PPIs) 177, 185 Peach Seed Decoction to Order the Qi 168 Pediatric Diseases 226~248 Q Penetrate the Middle Decoction 296 Peony and Licorice Decoction 125, 156 Qi and Blood 36, 40, 156, 179, 203, 254, 257, 260, 262, Perceived Stress Scale (PSS) 268 316, 334 Perpendicular insertion 38 Qi and Blood Deficiency 158, 202, 205, 325, 327 Pharmaceutical Affairs Act 27 Qi and Flavor theory 53, 60 Pharmacopuncture 32, 60~63, 125, 129, 159, 166, 177, Qi and Blood Stagnation 127, 202 180, 181, 265, 293, 333 Qi Colic 239, 240, 241 Physical Therapy 31, 139 Qi stagnation 63, 138, 179, 188, 190, 191, 193, 202, 204, Pinellia Decoction to Drain the Epigastrium 191, 194 217, 218, 221, 253, 254, 256, 260, 262 Pinellia, Atractylodes Macrocephala and Gastrodia Qigong 24, 28, 101, 189, 190, 267, 268 Decoction 130, 154, 161 Pinellia, Scutellaria and Atractylodes Decoction 130 Pivot-shift test 141 R Plantar fasciitis 144~146 Raise the Basis Decoction 222 Polycystic Ovarian Syndrome 330 Polydioxanone (PDO) 305 Rambling powder 211, 256 Polyporus and Plantain Decoction 163 Rambling Powder with Salvia and Gardenia 256 Poria, Cinnamon Twig, Atractylodes, and Licorice Regulate Channels and Pregnancy Decoction 327, 331, 334 Decoction 290 Regulate the Liver Decoction 205 Posterior drawer test 141 Regulate the Middle Decoction 55, 194, 245 Posterior sagging 141 Rehmannia Decoction with Anemarrhena and Postoperative nausea 40 Phellodendron 182, 210, 215 Powder for Expelling Lung-Heat with Schizonopeta and Rehmannia Decoction with Schizonopeta and Ledebouriellia 147 Ledebouriellia 130, 138,147, 296 Precious Treasure Elixir 161 Rehmannia Drink 155 Pregnancy 40, 41, 53, 60, 64, 200, 212, 240, 316, 325, Relieve Painful Obstruction Decoction 130 329, 333,~337 Resolve Depression and Strengthen Spleen Decoction 235

355 INDEX

Restore the Left (Kidney) Drink 210 Six-Ingredients Pill with Rehmannia 137, 158 Restore the Left (Kidney) Pill 165, 211 Skin-Fold Thickness (SFT) 283 Restore the Right (Kidney) Pill 165, 210 Sleep Disorders 59, 237, 264, 265, 266 Restore the Spleen Decoction 160, 212, 327 Small Nutrition Decoction 205 Restrain Liver Pill 158 Society of Korean Medicine 102 Restrain Stream Pill 237, 238 Soeumin 44~46, 57, 72, 74, 75, 77~80, 84, 86, 87, 90, Restrain the Liver Powder 162 94, 97, 138, 282, 294, 296 Retrusion tests 145 Soothe the Channels Decoction 133 Return to Being in Charge Powder 125 Sour Jujube Decoction 265 Rhinoceros Horn and Rehmannia Decoction 168 Soyangin 44~46, 57, 71~73, 75~77, 80, 83~85, 87, Risks of Ovarian Hyperstimulation Syndrome (OHSS) 325 94~97, 138, 282, 294, 295 Rotator Cuff Injuries 126, 129, 130 Stabilize the Menstruation Pill 222 State-Trait Anger Expression Inventory (STAXI) 269 State-Trait Anxiety Inventory (STAI) 259, 268, 269 S Stroke 28, 39, 40, 78, 83, 106, 109, 152, 155, 156, 159, 167, 279 Sa-am acupuncture 37, 42, 129, 206, 263 Supplementation method 38 Sagely Heal Decoction 205 Supplementation-draining 42, 43 Salvia Drink 164 Supplemented Decoction of Two Aged Drugs 186 Samchoolgunbi-tang 335 Surrounding Celestial Bodies Elixir 134 Sasang constitutional medicine 19, 25, 26, 28, 44, 45, 54, 57, 70, 69~97, 252 Synopsis of Prescriptions of the Golden Chamber 54 Schizonopeta and Forsythia Decoction 229 Taeeumjowi-tang 295 Schizophrenia 40 Taeeumin 44~46,57, 71~73, 75, 77~80, 83~85, 87, 90, Schöber test 136 School of Korean Medicine 24, 26, 29 T Scutellaria, Atractylodes, and Ailanthi Radicis Cortex Pill 94~97, 138, 282, 294, 295 215, 216 Taeyangin 44~46, 57, 71, 73~76, 80, 83, 84, 86, 90, Scutellaria, Phellodendron, and Ailanthi Radicis Cortex 94~97, 282, 294, 296, 297 Pill 216 Temporomandibular joint Dysfunction (TMD) 312 Seminal emission 50 Ten Ingredients Atractylodes and Phellodendron Powder 241 Seung-gyeuk 43, 44 Ten Significant Great Tonifying Decoction 205 Shoulder joint problem 126, 133 The Longevity & Life Preservation In Eastern Medicine, Six Gentlemen Decoction 161, 186, 187, 191, 235, 265 Dongui Suse Bowon 57 Six Gentlemen Decoction with Auckandia and Amomum 235 the Superficial Musculoaponeurotic System (SMAS) Six Milled Ingredients Decoction 233 304 Six-Ingredients Decoction with Rehmannia Thompson’s Tests 145 237, 245, 296, 335 Thoracic Outlet Syndrome 106, 127, 129, 132

356 Current Practice of Korean Medicine

Three Qi Drink 142 V Three Yellows Drain Heart Decoction 265 Vaginal discharge 50, 200, 212~216, 218, 221, 279 Tinel’s sign 145 Valgus stress test 141 Tinnitus 106, 153, 155, 157, 160, 165, 205, 210, 215, 254 Valsalva’s maneuver 136 To Increase Humor Decoction 58 Varus stress test 141, 146 Tongue palsy 153 Very Low-Calorie Diet (VLCD) 286 Tonify Kidney and Invigorate Blood Decoction 159 Viscera and Bowels Tonify Lung and Reduce Cough Decoction 231 36, 37, 45, 56, 104, 142, 152, 213, 289, 294, 334 Tonify Qi and Guide Out Phlegm Decoction 155 Tonify Qi and Invigorate blood Decoction 155 Tonify Spleen Decoction 159 W Tonify the Inside Pill 215 Waist Circumference (WC) 284 Tonify the Middle and Augment the Qi Decoction Waist-Hip Ratio (WHR) 284, 285 138, 155, 235, 237, 241, 245, 296 Warm Channels Decoction 328 Tonify the Yang to Restore Five Decoction 155, 163, 168 Warm disease 24, 54, 57, 58 Toosendan Powder 241 Warm Gallbladder Decoction 161, 229, 290 Toxin-Vanquishing Powder with Forsythia 229, 231 Warm Soil Unicorn-Rearing Decoction 327 Traditional medicine 18, 19, 31 Warm up Channels Decoction 167 Transcutaneous Electrical Nerve Stimulator (TENS) 32 Water and Fire Instant Relief Decoction 211 Transverse insertion 38 Western Medicine doctors 18, 20, 28, 29 Trichosanthes, Chives and Pinellia Decoction 164 White Tiger Decoction 55 True Warrior Decoction 165, 290 White Tiger Decoction with Rehmannia 159, 163 Tuberculosis 50, 64, 108, 143, World Health Organization(WHO) 115 Two Immortals Decoction 211 World Health Organization Quality of Life (WHOQoL) 268 Worth More Than Gold Rectify Qi Powder 229 U

Ultrasonography Y 128, 203, 220, 222, 237, 240, 294, 326, 330, 331 Yanggyuksanhwa-tang 146, 163, 296 Unblock Hidden Decoction 168 Yangwi-tang 296 Unblock Orifices and Invigorate Blood Decoction 160, 168 Yin Deficiency Pattern 155, 184 Uncaria Powder 162 Yin Edema 240, 241 Unicorn-Rearing Pill 327, 331, 333, 334 Yin-Yang 36, 37, 54 Unripe Bitter Orange Pill to Guide out Stagnation 233 Yookmijihwang-tang 146, 296, 335 Upper Respiratory Symptom Survey-21(WURSS-21) 231, 232 Uterine Myoma 201, 203, 207, 219~222, 324, 328

357