Irritable Bowel Syndrome: How Chinese Medicine can help
This is a research paper I wrote in 2006. It has a lot of information but if you are interested in the cause and treatment of IBS you may find this article to be invaluable. I encourage you to scroll through and just read the sections that you are interested in. Enjoy! - Rebecca
Epidemiology and Basic Pathology of IBS
The Merck Manual categorizes IBS as a functional bowel disorder and
describes IBS as “a motility disorder involving the entire GI tract, causing
recurring upper and lower GI symptoms, including variable degrees of
abdominal pain, constipation and/or diarrhea, and abdominal bloating.”
This means that IBS, unlike Crohn’s or Ulcerative Colitis say, is a problem
with the movement of the smooth muscle of the intestines rather than
some sort of inflammation along the GI tract. Normally, the smooth
muscle of the intestines moves in smooth rolling waves of contraction
called peristalsis but in IBS, we experience what’s called “spastic colon”
where different portions of the intestines contract at the same time
instead of in waves often causing cramping pain and discomfort. The
exact cause of IBS is unknown, but emotional stress and dietary factors in
particular are known to aggravate symptoms. (Merck 312, 1999)
According to UpToDate Patient Information, an official educational
program produced in cooperation with the American
Gastroenterological Association, IBS is the most commonly diagnosed
gastrointestinal condition and is second only to the common cold as a
cause of absence from work. An estimated 10 to 20 percent of people in
the general population experience symptoms of IBS, that’s over 2 million
people in the US, but only about 15 percent of affected people actually
seek medical help (UpToDate, 2004; NDDIC, 2004). The National Women’s
Health Info Center, a division of the U.S. Department of Health and Human
Services, maintains that the majority of people diagnosed with IBS are
women, possibly as high as 75% (Nat’l Women’s Health Info Ctr, 2005).
Bowel function, Western biomedical diagnosis and treatment
The most common site for IBS irritation is the sigmoid colon but it’s
important to understand the basic structure and function of the entire
Large Intestine before we move on (Merck 313, 1999). The large intestine,
or colon, consists of the cecum and ascending colon, the transverse
colon, the descending colon, and the sigmoid colon, making a large
question-mark shape in the abdomen. (use hands to outline the ? on my
own abdomen) The sigmoid colon in turn is connected to the rectum and
anus. The cecum, which is at the beginning of the ascending colon, is the
point at which the small intestine joins the large intestine and projecting
from the cecum is the appendix, which is a small finger-shaped tube that
serves no known function but is often removed due to infection, known
more commonly as appendicitis. Intestinal contents are liquid when they
reach the large intestine but are normally solid by the time they reach the
rectum as stool. Therefore the large intestine is largely responsible for the
absorption of water along with certain vitamins and nutrients from the
stool and is also responsible for the excretion of fecal matter. In addition
to the smooth waves of peristalsis we discussed earlier, the large intestine
also secretes mucus to help the movement of stool through the bowel.
There are also many bacteria in the large intestine that can further digest
some intestinal contents and create important substances for the body
such as vitamin K, which plays an important role in blood clotting. Healthy
gut bacteria or flora and a proper balance of these bacteria are also
essential to proper large intestine function. (Merck Manuals Online, 2003)
Keeping this in mind, there are three recognized types of Irritable Bowel
Syndrome: Constipation type, diarrhea type and alternating between
constipation and diarrhea type. Each of these types can be combined in
any way (Merck 313, 1999; NDDIC, 2004). There is no test for Irritable Bowel
Syndrome, IBS is diagnosed based on clinical symptoms including how
often you have abdominal pain, when the pain starts and stops relative to
bowel function and how your stool consistency and frequency are altered
(NDDIC, 2004).
More specifically, IBS is diagnosed using the ROME criteria. The ROME
criteria were first published 1990 after a special committee was set up at
the 1988 International Congress of Gastroenterology held in Rome, Italy to
develop the first classification system for functional gastrointestinal
disorders. The ROME criteria were revisited and revised in 2000 by a larger
number of committees addressing psychosocial and pediatric issues in
addition to the original ROME criteria considerations resulting in what we
consider ROME criteria today. A third revision is currently underway that
will be released sometime in 2006. (ROME II, 2006)
The ROME criteria states that IBS is characterized by at least 12 weeks of
abdominal discomfort or pain in the prior year that need not be
consecutive and has two of three features:
(1) Relieved with defecation; and/or
(2) Onset associated with a change in frequency of stool; and/or
(3) Onset associated with a change in form (appearance) of stool
(ROME II, 2006)
Cumulatively, presence of any of these nine additional symptoms are said
to support the diagnosis of IBS:
• Fewer than three bowel movements a week
• More than three bowel movements a day
• Hard or lumpy stool
• Loose, mushy or watery stool
• Straining during a bowel movement
• Urgency – having to rush to have a bowel movement
• Feeling of incomplete bowel movement
• Passing mucus (white material) during a bowel movement
• Abdominal fullness, bloating or swelling (ROME II, 2006)
In turn, these additional symptoms are used to diagnose diarrhea versus
constipation or alternating type IBS. Namely, more hard and lumpy stool
with decreased frequency equals constipation type while more loose and
watery stool with increased frequency equals diarrhea type and an
alternating combination of the two is equivalent with alternating type.
(ROME II, 2006)
Western biomedical treatment includes dietary therapy and
pharmaceutical administration. Common dietary advice is to increase
fiber for constipation type IBS, decrease or eliminate dairy for those who
show lactose intolerance and decrease or eliminate gluten containing
products such as wheat, barley and rye for those with low grade celiac
disease, also known as gluten intolerance. (Merck 315, 1999; UpToDate,
2004; IBS Self Help, 2004)
There is also a wide range of pharmaceutical approaches to treating IBS
and I will briefly summarize them here. At the top of the list are the
antispasmodic drugs that are anticholinergic agents that inhibit
gastrointestinal propulsive motility, or peristalsis, and decrease gastric acid
secretion. They are used to treat diarrhea predominant IBS. Next are the
antidiarrheals, also used to manage the symptoms of diarrhea
predominant IBS. These include medications such as Immodium AD that
you can get both by prescription and over the counter. Antidiarrheals,
like antispasmodics, decrease gastrointestinal propulsive motility, inhibiting
peristalsis and also affect water and electrolyte movement through the
bowel. Moving on, we have fiber supplements to help increase bulk and
promote bowel movement for constipation type IBS. (IBS Self Help, 2004;
Merck 314-315, 1999; Rx List, 2004)
More recently, tricyclic antidepressants and newer SSRI, or selective
seratonin reuptake inhibitor-type antidepressants have been used to treat
IBS. The exact mechanism of action for tricyclic antidepressants is not
known though they show some anticholinergic effects in the body and,
like SSRI’s, provide some relief of the stress associated with IBS and
decrease spastic colon pain. (IBS Self Help, 2004; Merck 315, 1999; Rx List,
2004)
The newest class of IBS pharmaceuticals are the 5-HT4 antagonists such as
Tegaserod. These most recently developed drugs focus on constipation
type IBS and act on seratonin receptors in the gut to stimulate GI peristalsis
and decrease visceral sensitivity. (IBS Self Help, 2004; Rx List, 2004; NDDIC,
2004)
As a student and soon to be practitioner of Chinese medicine, I have no
experience-based knowledge to share with you about the efficacy of
Western pharmaceutical treatments so I must rely on the experience of
others. Therefore, I would like to discuss a couple of Randomized
Controlled Trials of some of these afore mentioned Western drugs to give
you an idea of Western IBS treatment outcomes.
Review of biomedical Randomized Controlled Trial’s
The first study I would like to share with you was published in 2004 in the
Scandinavian Journal of Gastroenterology. Entitled “A double-blind,
placebo-controlled, randomized study to evaluate the efficacy, safety
and tolerability of tegaserod in patients with irritable bowel syndrome,”
this study was completed by a group of eight Scandinavian doctors
treating 647 patients who were randomized to 86 different
gastroenterological centers spanning Denmark, Finland, Iceland, Norway
and Sweden. The treatment group consisted of 327 patients who
received 6 mg of tegaserod two times a day while the placebo group
consisted of 320 patients receiving two daily doses of a placebo tablet.
Patients received treatment for 12 weeks and then were monitored for 4
weeks post treatment. (Nyhlin Bang Elsborg 119-126, 2004)
Patients were diagnosed with IBS using the ROME criteria and exclusion
criteria included an abdominal pain score equal to or less than one,
diarrhea type IBS, as tegaserod is indicated for constipation type IBS only.
Exclusion criteria also included severe laxative dependence, other
relevant GI conditions, and use of other medications affecting GI motility.
To assess efficacy of treatment, patients kept a daily diary for the 12
weeks of treatment and for four weeks beyond treatment recording stool
frequency, abdominal pain/discomfort, bloating, loose/watery stool, hard
stool, urgency, straining and sense of incomplete evacuation. Patients
were also asked weekly to answer yes or no to the question, “Over the
past week, do you consider that you have had satisfactory relief of your
symptoms of IBS?” Patients were instructed that ‘satisfactory’ meant that
in comparison to their typical experience with IBS in the past, the patient
felt that their symptoms had been alleviated during that week to the
extent that they would take medication to maintain that state. (Nyhlin
Bang Elsborg 119-126, 2004)
There were no clinically significant differences between the treatment
groups in any key demographic areas so the patients were randomized
well. Of the 647 randomized patients, 564 completed the treatment
period and 544 completed both the treatment and the four-week
withdrawal period. There was also no significant difference between the
treatment groups with respect to their daily symptoms. Eighty-five percent
of the treatment group participants were female. (Nyhlin Bang Elsborg
119-126, 2004)
Patients who received tegaserod experienced a significant improvement
in satisfactory relief of their IBS symptoms. At four weeks, 26% of the
tegaserod group experienced satisfactory relief versus 19% for the
placebo group, and by week 12, 34% of the tegaserod group reported
satisfactory relief versus only 23% for the placebo group. Over the four-
week withdrawal period, the number of patients experiencing satisfactory
relief decreased greatly, but the patients who had been in the tegaserod
group at 16% still experienced more satisfactory relief than those who had
been in the placebo group at only10% during withdrawal. (Nyhlin Bang
Elsborg 119-126, 2004)
Patients who received tegaserod also experienced no bowel movements
or hard stools an average of 3.3 days less than before compared to the
placebo group and experienced straining or a feeling of incomplete
evacuation of the bowel 3.8 days less than before compared to the
placebo group. The decrease in abdominal pain and discomfort,
however, was the same in both groups and therefore was not statistically
significant. Approximately 55% of the patients in the tegaserod group
experienced some adverse event during the course of treatment while
50% of patients in the placebo group experienced the same. The most
common adverse event was headache. Just over 9% of the patients in
the tegaserod group experienced diarrhea as a side effect of
medication, however, while only 1% experienced diarrhea in the placebo
group. Overall, the site investigator determined that 23% of the of the
patients in the tegaserod group experienced adverse events that were
directly related to the study medication versus 13% in the placebo group,
but as the frequency and type of adverse events experienced were
similar in number and frequency overall, this was considered to be
statistically insignificant. In conclusion, this study recommended the use of
6mg of tegaserod twice daily as a safe well-tolerated treatment for
constipation type IBS. (Nyhlin Bang Elsborg 119-126, 2004)
This next study was published in 2005 in Gut magazine. A study by
researchers V. Morgan, D. Pickens, S. Gautam, R. Kessler and H. Mertz, it
was entitled “Amitriptyline reduces rectal pain related activation of the
anterior cingulate cortex in patients with irritable bowel syndrome.”
Building on previous studies showing that the anterior cingulate cortex
region of the brain is activated during the experience of irritable bowel
syndrome symptoms, the purpose of this study was to observe whether
Amitriptyline, a tricyclic antidepressant, is effective in reducing anterior
cingulate cortex activation during painful rectal distension in IBS.
(Morgan. 601-607, 2005)
Nineteen women with painful IBS were enrolled in the study after satisfying
the ROME criteria for IBS and being screened and excluded for any other
health conditions that could be affecting their IBS symptoms. The women
were randomized to receive either 50mg of Amitriptyline once per day or
placebo for one month and then, after a three-week washout period,
were crossed over to the other treatment. (Morgan. 601-607, 2005)
They measured the effects of painful IBS distension of the rectum in the
brain by performing functional MRI scans of the brain to measure anterior
cingulate cortex activation while inserting a small balloon into the rectum
which was inflated to alternating pressures of 4 mm Hg, 15 mm Hg, 30 mm
Hg and 50 mm Hg in a random order to decrease the anticipation of
painful distension that occurred at the highest pressure. A series of nine
distensions were administered for 40 seconds each, followed by a 30
second baseline. While in the MRI, the patients wore headphones to
mask the MRI sound that played either the stressful sounds of babies
crying or relaxing music. The order of stressful or relaxing conditions was
determined randomly and distensions were repeated with the alternate
stress condition. (Morgan. 601-607, 2005)
At the end of each set of nine distensions, the patients were asked to
verbally rate the stimuli on a scale of 0-10 where 0 was non-painful an 10
was the worst pain imaginable. They were also asked to rate their overall
experience with the Amitriptyline versus placebo. In addition, blood
pressure and heart rate were taken and the functional MRI images were
recorded. Distention tests were performed at the end of each one-month
treatment period comparing placebo to Amitriptyline treatment.
(Morgan. 601-607, 2005)
At the conclusion of the study, 13 out of the 19 patients reported that
overall their IBS symptoms were better on Amitriptyline, five reported that
their IBS symptoms were better on placebo and one reported no change.
During rectal distension at 50 mm Hg with the auditory stress of babies
crying, pain level was reported as 4.2 on Amitriptyline versus 5.3 on
placebo. During relaxing music, pain from 50 mm Hg of distension was
reported at 5.7 on Amitriptyline versus 6.0 on placebo. Blood pressure and
heart rate were similar during Amitriptyline and placebo with stimuli and at
baseline. Activity in the anterior cingulate cortex was decreased by 4.5%
during rectal pain from 50 mm Hg distention with auditory stress. In the
absence of auditory stress, i.e. during the sound of relaxing music versus
babies crying, no decrease in brain activity was observed. (Morgan. 601-
607, 2005)
In conclusion, this study reported that Amitriptyline 50mg versus placebo is
effective in reducing brain activation and IBS pain during stressful events
triggering IBS symptoms. IBS symptoms during non-stressful instances were
unchanged. A daily dose of 50mg of Amitriptyline is recommended as a
safe and effective dose for stress related IBS pain. (Morgan. 601-607, 2005)
All of these treatments are viable and effective but for some people, at
20%-50%, the instances of adverse events are still too high. These
medications also treat IBS symptom by symptom. Alternative treatment
treats the person as a whole taking into account not only the individual
symptoms but also the underlying cause. TCM in particular offers little to
no adverse events or side effects to treatment and is a complete system
of health care including acupuncture, herbs, dietary and lifestyle advise.
With centuries of experienced based practice behind it, it is a viable and
successful treatment for IBS.
TCM history and approach to medicine. (Maciocia Foundations1-68, 1989;
Maciocia Practice 431-492, 1994; Cheng 1-59, 1987)
Chinese medicine has a history of over 2,000 years. A holistic form of
medicine believing that the body is an organic whole, Chinese medicine
maintains that the body must be harmonized and balanced with itself
and with nature around it. At the heart of Chinese medicine is Yin-Yang
theory, the balance and mutual dependence of light and dark, fullness
and vacuity, day and night. They are the greatest of opposites but
without one you cannot have the other. As the sun rises, the moon sets
but without both crops would fail and the ocean’s tides would be in
disarray. The same is true of the body. In Chinese medicine everything
can be described by Yin and Yang, organs are even paired in yin-yang,
also called zang-fu, pairs such as the Kidney and Bladder, the Spleen and
the Stomach, and the Liver and Gallbladder. The substantive or solid
organ is Yin in nature, serving primarily to store energy, while the hollow
organ is Yang and primarily moves or transports energy. The proper
function of these organs and the proper movement of Qi, Blood and Body
Fluids through them is essential to health.
The concept of Qi is one of the more challenging ideas for those of us in
the Western world to grasp, but it too is essential to Chinese medicine. It is
important to note here, that without the benefit of detailed internal
anatomical knowledge, the Chinese medicine doctors of 2,000 years ago
nonetheless gained very accurate knowledge of the body’s workings and
how to positively affect the body with acupuncture and herbs. They
gained this knowledge through meditation, observation, and trial and
error. And what they discovered and specifically learned to manipulate
was Qi.
Qi is an unseen non-physical energy that courses through the body in
channels like rivers that traverse the surface of the body and plunge deep
to the internal organs. The internal organs create, store and maintain the
flow of Qi throughout these channels that keep the mind and body both
healthy and animated. Acupuncture in particular is the stimulation of
certain points along these channels on the surface of the body with very
fine needles in order to affect and balance the internal organs. The
Stomach channel, for instance, begins internally at the Stomach organ,
connects to its zang-fu or yin-yang paired organ the Spleen, and emerges
on the surface of the body here (point to St-1 on self). It then flows down
the head and neck, down the chest and abdomen, and along the lateral
aspect of the leg to end at the lateral corner of the nail of the second
toe. Points along this channel can affect any pathology that physically
manifests along the channel pathway on the exterior of the body and
can also affect the energy of the Stomach and Spleen organs
harmonizing digestive functions, treating gastric pain and more. There are
twelve main channels that traverse the body in this way connecting to
twelve main organs. Acupuncture itself is an extension of this channel
system. It functions on the premise that by accessing certain
acupuncture points along various channels, one can rectify the flow of Qi
in those channels as well as rectify the Qi within the organs themselves. By
rectifying the Qi within the channels and organs we can work to correct
function and imbalance.
Acupuncture by itself, however, is not always enough. Herbs are
therefore an essential part of Chinese medicine and they too seek to
balance the energy of the different organs. Chinese herbs have been
part of Chinese medicine for as long as acupuncture, and Chinese herbs
have very specific properties to balance the body. Different herbs enter
different energetic organs and build or disperse Yin, Yang, Qi, blood, and
body fluids. Herbs are mixed together into formulas and while there are
traditional formulas that are designed to treat common energetic
imbalances, the beauty of Chinese herbal formulas are that they can be
modified and individualized for specific people’s individual health
concerns.
Chinese herbs consist of a wide range of plants – roots, barks, leaves and
flowers – as well as some minerals, insects and animal products. In their
leaf/twig/root/branch form they are called bulk herbs, and they can be
cooked into medicinal teas. In modern times, cooking bulk tea has
become cumbersome and often too impractical and while bulk teas are
the strongest and sometimes the most affordable form of Chinese herbs,
you can also get herbs in a powdered form called granules or pre-formed
into pills. The pill or patent form is the weakest and, as the herbs have
been made into pills in a factory, the least customizable for the individual
patient, but they can still be very effective. Chinese herbal teas, be they
bulk or granule, can also be very bitter tasting to the Western palate and
basically taste very bad. Sometimes very bad taste makes compliance a
problem in the West as we aren’t used to “eating our bitters” as they say
in China, but for many people once they try it and really gain relief from
their ailments, they can get past the taste to enjoy the benefits.
Chinese herbs work in tandem with acupuncture to affect both the
physicality of an ailment as well as the energetics of the body. Beyond
affecting Yin, Yang and Qi there is also Blood, Body Fluids and the five
elements to take into consideration that are additional key features in the
Chinese medicine understanding of the body. Blood and body fluids are
easier to understand than Qi and the strange workings of Chinese herbs
as in Chinese medicine they are still the same substantive fluids we think of
in the West. Blood courses through blood vessels and body fluids moisten
the skin and lubricate the bowels among other commonly understood
functions. In Chinese medicine, however, blood and body fluids also
have an energetic component that is maintained by the proper
energetic function of certain internal organs. More important for our
discussion of IBS, however, is a basic understanding of the five elements,
their relation to each other and to certain internal organs. When I talk
about organs, however, please remember that I am speaking of the
energetic functioning of the organ, not the physicality of the organ. The
basis behind Chinese medicine is that affecting the energetics of the
body affects the physicality of the body, so Licensed Acupuncturists
approach the body from an energetic balance perspective. As I
continue I hope this concept will become more clear, but if you have any
questions, please feel free to ask as I go along.
To continue, the five elements are wood, fire, earth, metal and water.
Like Yin and Yang, they too generate and control one another. Wood
can come alight to create fire, Fire burns to ash to create earth, earth can
be mined for ore creating metal, metal can be shaped into containers to
hold water and water can feed the roots of trees giving birth to wood.
Each of the five elements corresponds with different seasons, colors,
emotions and organs. Wood represents the Liver and Gallbladder, Fire
the Heart, Pericardium, Small Intestine and Triple Burner which is a
completely non-physical organ responsible for creating an addition
connection between the upper middle and lower parts of the body, earth
represents the Spleen and Stomach, metal represents the Lungs and the
Large Intestine, and water represents the Kidneys and the Bladder.
For our discussions of IBS, the most important elements and associated
organs to understand are those of Earth and Wood, especially the Spleen
and the Liver. Physically, IBS affects the Large Intestine – the metal
element – whose job both physically and energetically is eliminating what
is no longer needed. IBS, however, has to do with much more than simply
elimination. From a Chinese medicine perspective, it has to do with
problems transforming and transporting food and drink, a function of the
Spleen, and it has to do with stress and emotions, the smooth flow of
which is governed energetically by the Liver. You can imagine the Spleen
like an industrial factory oven in a production line. It likes to be warm and
dry and moving so foods come in, get properly cooked or transformed,
and then transported away to be packaged and sent to their various
destinations and used accordingly. But imagine if the oven didn’t have
enough power, or was frozen by a cold ice storm, or the conveyer belt
broke. What would happen? The food would stagnate, it would rot, gunk
up the system with damp wet yuk and create problems with distribution
and if distribution is disrupted or even if the food goes out but it isn’t
properly cooked, everything down the line suffers. You have idle workers
who can’t do their jobs and begin smoking and slacking, you have
people in the community getting sick and suing the company for food
poisoning and a large mess ensues. What we call a Spleen Qi deficiency
would be like the power getting cut off or the conveyer belt not moving,
what we call cold invading the spleen would be the ice storm, and
exactly what happens to the oven is what happens to the body. Without
clear differentiation between good food and bad, the Large Intestine
doesn’t know when to eliminate and when to hold on creating spasm,
pain, constipation and diarrhea.
The Liver and the Spleen also have a special relationship. As I mentioned
earlier, the five elements and their associated organs have a generating
relationship, which I outlined for you, but they also have a controlling
relationship. Water controls fire, keeps it from getting out of hand, and
wood controls earth the way the roots of trees and grasses bind the soil of
a steep hill, keeping the earth from sliding away. Energetically, three of
the Liver organ’s main responsibilities are to ensure the smooth flow of
energy through the body, to ensure the smooth flow of the emotions and
to assist the Spleen and Stomach in digestion, transformation and
transportation of Qi and nutrients. It is easy to understand, therefore, that
emotional upset can easily disrupt the smooth flow of Qi. When stress in
particular affects the mind and body, the smooth flow of Qi in the Liver is
disrupted and stagnates. Due to the controlling relationship between
wood and earth, representing the Liver and the Spleen, along with the
function of the Liver to assist in digestion and move Qi, when emotional
upset causes the Liver Qi to stagnate it can build up to a boiling point and
overact on the Spleen, essentially controlling it too much. It would be like
the foreman at the factory micromanaging the workers who keep the
ovens and the conveyer belt going. His constant concern and worry,
questions and extra tasks to the workers makes them unable to properly
complete their normal jobs and the oven and conveyers can’t function
properly and just like in the Spleen Qi deficiency, everything down the line
will suffer. We call this Liver overacting Spleen or Wood invading Earth.
While the cause for the disruption of the production line is different the
result when the disruption goes down the line, i.e. the results in the large
intestine, are the same.
This brings me to another important concept, that of pattern or syndrome
differentiation. Along with the holistic nature of Chinese medicine, we
also believe that everyone and every health concern is individual. Each
of the three patterns I mentioned above – Spleen Qi Deficiency, Cold
invading the Spleen, and Liver Overacting Spleen – can result in IBS
symptoms, perhaps even in the same IBS symptoms as far as rectal pain,
gas and bloating are concerned, but each of them would be treated in a
completely different way by a Chinese medicine practitioner. Which
pattern presented would be differentiated by a number of symptoms
beyond stool pattern such as one’s subjective sense of body temperature,
someone’s energy level, their sleep patterns, as well as other seemingly
unrelated questions. Each of these gives the Chinese medicine
practitioner valuable information about the individuality of the patient,
about the energetic play of the different organs together in the body,
and the sum of the whole creates a pattern that gives the same
complaint a thousand different treatments tailored to a thousand
different individuals. Also essential to this pattern differentiation are
tongue and pulse assessment. The pulse is felt in three positions on each
wrist, each position corresponding to a different yin-yang or zang-fu organ
pair. The tongue is assessed for color, size, shape and coating, which
show a snapshot of one’s body constitution.
So, if you go see a Chinese medicine practitioner you can expect that he
or she will want to feel your pulse, look at your tongue and ask you a lot of
questions that may not seem related to the problem you are seeking help
with, but they will be invaluable to proper diagnosis and treatment. You
can also expect that he or she will put needles in places that can be
physically near or physically distant from your area of complaint but you
can rest assured that they have a channel connection to whatever is
being treated. You can expect that the needles used will be sterile and
one-time use only and that while you may feel a pin prick when they go
in, there’s a better chance that you will not because the needles are so
small they’re often not felt and they rarely hurt. Now that we have a
reasonable basic understanding of Chinese medicine theory, let us
continue by discussing some research on the treatment of IBS with
Chinese medicine.
The treatment of IBS with TCM – Review of TCM random controlled trials.
Before I get into the details of research proven Chinese medicine IBS
treatment, let me first speak a little about the challenge of double-blind
placebo when it comes to this medicine. As I mentioned above, the gold
standard of Chinese medicine is pattern differentiation and individually
tailored treatment where no two people are treated alike, even for the
same disease. The gold-standard of Western research, however, is
double-blind placebo, where everyone gets the same treatment which is
compared to a placebo equivalent to no treatment and herein lies the
dilemma. First, how do we treat individuals with stock randomized herbs if
their pattern differentiations are different for the same Western medical
disease and second, how do we placebo-double blind the act of sticking
needles into people? These are big questions and important concerns
and some researchers have come up with very elegant solutions that I will
share with you as I tell you about the following research studies. I also
want to tell you this because it’s important to understand that there is a
wide range of Chinese medicine research out there, some which is very
good and some which is very bad because people didn’t fully
understand these challenges and tried to force the round peg of Chinese
medicine into the square hole of placebo-double-blind study and I will
share one of these studies with you as well.
I urge you, therefore, to read
Chinese medicine research carefully and if you are unclear or concerned
about whether a new study is good, bad or indifferent ask a Chinese
medicine practitioner that you trust to review it with you to help you
understand if they have represented our medicine accurately.
With that said, first on our list is a very well designed study that was
published in the November 1998 issue of the Journal of the American
Medical Association, or JAMA, entitled “Treatment of Irritable Bowel
Syndrome with Chinese Herbal Medicine: A Randomized Controlled Trial”
by an Australian research group headed by Alan Bensoussan. To address
the issue of reconciling individualized treatment with the format of double-
blind placebo research, a total of 116 patients enrolled in the study were
randomized to three different groups. A placebo group, a standard
herbal formula group and an individualized herbal treatment group. The
standard herbal formula was designed by a group of several Chinese
herbalists to address the major Chinese medical pattern differentiations
for IBS in a balanced manner. Those patients in the individualized herbal
formula group were treated by individual Chinese medicine practitioners.
All participants were made to wait 30 minutes to receive their herbal
prescriptions, which were powdered and encapsulated, after each
consultation to ensure proper blinding. (Bensoussan 1585-1589, 1998)
Patients enrolled satisfied the ROME criteria for IBS and were excluded for
food allergies, celiac disease, gastric ulcers, and for any other symptoms
or current medications that could affect their IBS symptoms. They were
not excluded or included for any specific type of IBS – i.e. constipation,
diarrhea or alternating predominant. Patients received 5 capsules three
times a day. They consulted with a Chinese herbalist every two weeks for
one month and every month thereafter for a four-month treatment
period. They were assessed by completing questionnaires while they
waited for their herbs to be prepared at their Chinese herbal consultations
as well as by a follow up questionnaire 14 weeks post treatment. They
were also assessed using the Bowel Symptom Scale (BSS) and were each
evaluated by a gastroenterologist who was blinded as to which treatment
group the patient was randomized to before entering the study, at 8
weeks of treatment, at 16 weeks of treatment, which marked the end of
the treatment period, and at a follow up 14 weeks after the completion of
the study. (Bensoussan 1585-1589, 1998)
Two patients withdrew from the trial because of discomfort associated
with treatment. One experienced upper gastrointestinal discomfort from
the standard Chinese herbal formulation and a second patient
developed headaches from the same but no other major adverse effects
were noted by any patients. Liver function tests were also performed
regularly on all patients to ensure safety and no Liver tests showed any
abnormal values. At the end of the trial, only 33% of the patients on
placebo reported that they felt improvement compared to 76% of
patients receiving the standard herbal formulation and 64% of patients
receiving individualized treatment. As rated by the gastroenterologist,
30% of patients receiving placebo showed improvement on evaluation as
compared to 78% of patients on the standard herbal formulation and 50%
of patients on the individualized herbal formula. The outcome of this study
was very positive, showing clear benefits to Chinese herbal treatment for
IBS versus placebo with little to no side effects. Interesting, however, were
the statistics for standardized herbal treatment compared to
individualized treatment. Individualized treatment is the hallmark of
Chinese medicine but in this study, patients who received the standard
formulation showed a higher rate of improvement during the treatment
period. The interesting part is that after the follow up period, the patients
who received the individualized herbal formulas maintained the results of
their treatment while those that received the standard herbal formula did
not maintain the same rate of symptom improvement. This suggests that
while the standard herbal formula may provide more short-term relief, the
individualized formulas may have a more long-term effect. (Bensoussan et
al. 1585-1589, 1998)
The next study I would like to share was published in July 2005 in the World
Journal of Gastroenterology and is the most recent study on IBS treatment
with Chinese medicine. Entitled “Acupuncture for Irritable Bowel
Syndrome: A blinded placebo-controlled trial,” it was completed at St.
Mark’s Hospital in the United Kingdom by a group of six researchers. Sixty
patients were recruited to participate in the study and were required to
have IBS diagnosed by ROME criteria, have no other conditions and use
no drugs that would affect their digestion or gastric motility, and also have
tried and not responded to conventional Western treatment for IBS.
(Forbes et al. 4040-4044, 1998)
Two acupuncturists were recruited to treat patients. The first was
designated as the “Diagnosing Acupuncturist” or DA who diagnosed and
wrote prescriptions for all patients. Patients would meet with the DA
before and after treatment when the DA would take case history
information, perform tongue and pulse assessment and give patients
dietary and lifestyle advice depending on their syndrome differentiation.
The second “Treating Acupuncturist” or TA would open a randomization
envelope that designated whether the patient was to receive the
acupuncture treatment prescribed by the DA or a sham acupuncture
treatment and carry out the treatment as prescribed. The TA was the only
treater/evaluator who was not blinded. “Real” acupuncture consisted of
inserting eight to sixteen needles at 4-8 acupuncture sites bilaterally that
were left in place momentarily or retained for up to 25 minutes depending
on the patients syndrome differentiation by the DA. “Sham” acupuncture
consisted of inserting an unmentioned number of needles in three
different areas of the body, namely the anterior thigh, posterior thigh and
lateral aspect of the low back, which do not correspond to recognized
acupuncture points. Needle technique and length of retention were
varied as in genuine treatment though how they were varied was not
published in the study. (Forbes et al. 4040-4044, 1998)
Outcomes were measured by having the patients complete weekly
symptom diaries based on the Bristol scale and by being assessed by a
physician at entry and prior to exit. The primary outcome measure was a
change in symptom score. Of the sixty enrolled study participants, 59
completed the study and no adverse events were recorded. Overall, the
patients receiving true acupuncture showed a 40% improvement in
symptom score while the patients receiving sham acupuncture showed a
30% improvement in symptom score. This is not considered to be a
statistically significant improvement over placebo treatment and
therefore, this study did not recommend acupuncture as a worthwhile
treatment for IBS in a European hospital setting. (Forbes et al. 4040-4044,
1998)
This, however, is an example of a relatively poor Chinese medicine study
but, as the most recently published randomized controlled trial of Chinese
medicine treatment for IBS, it warrants reviewing. The most basic criticism
is that this study is not reproducible – a requirement of any randomized
controlled trial Western or Eastern in nature. It is admirable that they
decided to treat patients individually the way Chinese medicine was
meant to be practiced, but this is no reason not to explain what points
were used, why they were used, what diagnoses were given and how
long needles were retained or how the needles were manipulated to elicit
what kind of effect. Furthermore, the method of sham acupuncture used
still involved inserting needles into the body rather than more accepted
placebo versions of sham acupuncture where patients are first of all
required never to have experienced acupuncture before so they enter
with no expectations, and second, are draped in such a way as to not be
able to see where the needles will be (or will not be) inserted. In this way,
patients receiving sham acupuncture can have a sharp object such as a
pin or toothpick tapped against the skin without puncturing it to mimic the
insertion of a needle without ever actually stimulating any sort of
acupuncture response anywhere in the body. A third criticism of this
study, is that only a single acupuncturist was responsible for diagnosing
and prescribing treatment for the entire study rather than having a panel
of Chinese medicine practitioners at least choose points, such as in the
herbal study discussed earlier. A panel of practitioners rules out, or at least
decreases, the possibility of personal error in diagnosis and prescription.
Positive and well-derived randomized controlled trials of acupuncture do
exist, however, though I could not find any other randomized controlled
trials concerning IBS and Chinese medicine in particular. While the exact
cause of IBS from a Western medical perspective is poorly understood, as I
mentioned at the beginning of this discussion, it is accepted that stress
plays a major role in aggravating IBS symptoms. I would like, therefore, to
mention another randomized controlled trial entitled “Acupuncture
Inhibits Sympathetic Activation During Mental Stress in Advanced Heart
Failure Patients,” which was published in the Journal of Cardiac Failure in
December 2002. (Middlekauff et al. 399-406, 2002)
Mental stress induces a sympathetic nervous response in the body, also
knows as a “fight or flight” response. This study measured muscle
sympathetic nerve activity, or MSNA, in fifteen advanced heart failure
patients during acute mental stress testing before and during real
acupuncture, non-acupoint acupuncture and a no-needle acupuncture
control. (Middlekauff et al. 399-406, 2002)
Fourteen of the fifteen patients were acupuncture naïve. The points
chosen for treatment were listed in the study and the specific points were
chosen because they were either associated with stress reduction or had
been used in previous studies treating heart failure. The same points and
stimulation methods were used on each patient receiving real
acupuncture. Non-acupoint acupuncture was performed bilaterally in a
non-acupuncture point in the anterior deltoid muscle, and no-
acupuncture was performed by placing and tapping an empty guide-
tube on the skin in an area out of view of the patient. All acupuncture
was performed by the same licensed acupuncturist and no adverse
affects were reported as a result of acupuncture treatment. (Middlekauff
et al. 399-406, 2002)
Mental stress testing was performed for 4 minutes by either the Stoop color
word test or mental arithmetic. Each patient was asked to assess task
difficulty on completion of each task on a scale of 0 to 4 where 0 is not
stressful at all and 4 is very, very stressful. Blood pressure and heart rate
were also monitored with an automatic blood pressure cuff and an
electrocardiogram. (Middlekauff et al. 399-406, 2002)
The major finding of this study was that sympathetic activation during
mental stress “is virtually eliminated” after acupuncture at the acupoints
LI-4, Pc-6 and LR-3 and that this is not a placebo effect because during
non-acupoint and no needle acupuncture, sympathetic activation as
measured by MSNA was not decreased compared to baseline.
(Middlekauff et al. 399-406, 2002)
While this study was not directly on Irritable Bowel Syndrome, it does prove
that acupuncture is effective in treating stress and decreasing
sympathetic fight or flight response. As this is recognized as a major
aggravator of IBS symptoms in all types of IBS – constipation, diarrhea and
alternating – it stands to reason that acupuncture can be a reasonable
treatment to relieve stress associated IBS symptoms.
Additional TCM studies/articles
While Western randomized controlled trials dealing with the treatment of
IBS with Chinese medicine are few and far between, more and more
articles about and case study examples of IBS treatment with Chinese
medicine are appearing in Chinese medicine journals. This indicates that
more IBS patients are seeking out Chinese medical treatment irregardless
of how much, or more accurately how little, Western research on IBS
treatment efficacy has been done.
While none of the Western randomized controlled trials featured a
combination of acupuncture and herbal treatment, this is most often the
type of treatment prescribed and discussed in the Chinese medicine
journal articles that I surveyed when preparing for this discussion. (Lade 10-
16, 1998; Li 16-18, 2004; Lewis 9-12, 1992; Mauer 53-57, 1998; Pagon 28-31,
2002; Yu 27-30, 2005) I have a printed list of these Chinese medicine
journal articles available for anyone who is interested in reading more
specifics about Chinese medicine treatment of IBS that I will hand out at
the end of this discussion. Rather than discuss each of these articles,
however, I will just share the highlights of one of them with you because
truth to tell, the essence of these articles are all the same – it works. And
not only does it work, but the combination of herbs, acupuncture and
dietary change can work well enough to be curative in some cases.
In an article by Dr. Zhenbo Li, a professor at OCOM with a Ph.D. from
Guangzhou University of Traditional Chinese Medicine, that was published
in the 2004 issue of The Journal of Chinese Medicine, Dr. Li discusses two
main pattern differentiations for IBS. Namely, these are two of the same
patterns I mentioned earlier – Spleen Qi Deficiency and Liver Overacting
Spleen. For each of these patterns she gives a point prescription and
needling protocol along with a basic herbal formula prescription and a
series of possible modifications to better tailor the herbal formula to an
individual’s personal symptomology. In the end, she discusses three cases
from her clinical experience. One patient received a series of eight
acupuncture treatments, one a series of fifteen, and one a treatment
course lasting two months. Each were also given dietary advice based on
their individual constitutional picture and daily Chinese herbs. By the end
of each treatment period, each patient was fully recovered and had no
more IBS symptoms. (Li 16-18, 2004)
Conclusion
In conclusion, I feel confident in suggesting that Chinese medicine is a
worthwhile adjunctive and or alternative therapy to Western biomedical
treatment for irritable bowel syndrome of any type. Both Western
pharmaceutical and Traditional Chinese Medicine treatments for irritable
bowel have been proven effective in randomized controlled trials. I
personally believe that if you had to choose one treatment over the
other, Traditional Chinese Medicine treatment has an edge over current
Western medical treatment for this disease. Chinese medicine has the
benefit of over 2,000 years of experience in treating internal medicine
disorders with little to no side effects. While Western medicine does not
have a clear understanding of the underlying cause of irritable bowel
syndrome, Chinese medicine is able to specifically diagnose IBS using its
holistic and energetic understanding of the body and then directly treat
both the symptoms and the underlying energetic imbalance.
From personal experience and the cases presented in a number of
Chinese medicine journals spanning the past ten years, I can say that
Chinese medicine can be curative for this condition, but I can’t say that it
will cure everyone. If there is one thing Chinese medicine teaches above
all, it is that everyone is an individual and that means that not only should
everyone be treated specifically and individually, but also that everyone
has the potential to respond differently to treatment. I can tell you
Chinese medicine cured me, I can tell you that I am confident that it can
be an effective alternative and certainly a worthwhile adjunctive therapy
to Western medical treatment, but I can’t tell you that Chinese medicine
will cure you because I don’t know. We are different and unique, but you
will never know unless you try and in light of the information I have shared
with you today, I hope that you will at least feel comfortable to try
Chinese medicine for the treatment of your own IBS if you suffer from this
disorder or recommend it to an affected friend or family member.
If you have any questions, please feel free to email me at allwayswell@mac.com or call at (503)445-8888.
LINKS
All Ways Well Patient Resources Store - my new Amazon store full of hand picked books, music and more for learning to be well and stay that way.
Web MD - a great starting point for reliable western medical information
Acufinder.com Learning Center- a great source of general articles about Chinese Medicine
Livestrong - a great source for health and fitness information, overviews of different dieting techniques (Atkins vs. Blood Type Diet vs. the Zone etc.) as well as free online calorie tracking program called The Daily Plate.
WellPDX - a new local resource for finding qualified alternative health practitioners and basic overviews of different natural healing modalities
BNI Portland Community Professionals Directory - a listing of qualified practitioners across different disciplines that I know and trust to refer you to
You can also find great health tips on my BLOG including archives of my monthly email newsletter and monthly QiMail newsletter. You can also find links to some of my favorite local practitioners on my BIO page
Bibliography
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bowel syndrome with Chinese herbal medicine: a
randomized controlled trial.” JAMA 280.18 11 Nov. 1998: 1585-
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irritable bowel syndrome: A blinded placebo-controlled trial.”
World Journal of Gastroenterology 11.26 14 July 2005: 4040-
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21 Oct. 2005. Irritable Bowel Syndrome Association, The IBS
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d. Li, Zhenbo. “The Treatment of IBS by Acupuncture.” The
Journal of Chinese Medicine 74. 2004: 16-18.
e. Merck & Co., Inc.. Merck Manual 17th Edition. Ed. Mark H.
Beers, M.D., Robert Berkow, M.D., Robert M. Bogin, M.D., et al.
Whitehouse Station, N.J.: Merck Research Laboratories, 1999.
f. Middlekauff, Holly R, Hui Kakit, Jun L. Yu, et al. “Acupuncture
Inhibits Sympathetic Activation During Mental Stress in
Rebecca Hurwood IBS and Chinese Medicine page 20 of 24
Advanced Heart Failure Patients.” Journal of Cardiac Failure
8.6 Dec. 2002: 399-406.
g. Morgan, V, D Pickens, S Gautam, et al. “Amitriptyline reduces
rectal pain related activation of the anterior cingulate cortex
in patients with irritable bowel syndrome.” Gut 54. 2005: 601-
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<http://www.romecriteria.org/history.html>. The official
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m. Lewis, Peter J. “Irritable Bowel Syndrome: Emotional Factors
and Acupuncture Treatment.” The Journal of Chinese
Medicine n40. 1992: 9-12.
n. Maciocia, Giovanni. Foundations of Chinese Medicine.
Edinburgh: Churchill Livingstone, 1989.
o. Maciocia, Giovanni. Practice of Chinese Medicine.
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p. Mauer, Charles F. “Acupuncture & Irritable Bowel Syndrome.”
Oriental Medicine Journal 7.1 1998: 53-57.
q. Pagon, Andrew. “Treatment by Traditional Oriental Medicine:
Irritable Bowel Syndrome.” The Journal of Chinese Medicine
n58. 2002: 28-31.
r. Yu, Su-Ping, Hui Ye, Nan-Lin Ha, et al. “Effect of Modified
Sinisan on Anorectal Manometry of the Constipation
Predominant Type of Irritable Bowel Syndrome.” Chinese
Journal of Integrative Medicine 11.1 Mar. 2005: 27-30.
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Rebecca Hurwood IBS and Chinese Medicine page 21 of 24
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A list of Chinese Medicine Journal Articles about Irritable Bowel Syndrome
Lade, Heiko. “Irritable Bowel Syndrome.” Pacific Journal of Oriental
Medicine n15. 1998: 10-16.
Lewis, Peter J. “Irritable Bowel Syndrome: Emotional Factors and
Acupuncture Treatment.” The Journal of Chinese Medicine n40.
1992: 9-12.
Li, Zhenbo. “The Treatment of IBS by Acupuncture.” The Journal of Chinese
Medicine 74. 2004: 16-18.
Mauer, Charles F. “Acupuncture & Irritable Bowel Syndrome.” Oriental
Medicine Journal 7.1 1998: 53-57.
Pagon, Andrew. “Treatment by Traditional Oriental Medicine: Irritable
Bowel Syndrome.” The Journal of Chinese Medicine n58. 2002: 28-
31.
Yu, Su-Ping, Hui Ye, Nan-Lin Ha, et al. “Effect of Modified Sinisan on
Anorectal Manometry of the Constipation Predominant Type of
Irritable Bowel Syndrome.” Chinese Journal of Integrative Medicine
11.1 Mar. 2005: 27-30.
