Background
Aim
Methods
Uncovering the Underlying Theory
Developing the Analytical Framework
TA | Component | MA |
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Approach is orientated to the whole person based on an understanding that mind, body and spirit are integral |
Theory
| Approach is focused on the symptom |
Aetiology of the main complaint: a detailed history of the main complaint is integral to the diagnosis |
Theory (Aetiology)
| Aetiology of the symptom is prognostic only and does not affect process of treatment. |
▪ Differential Diagnosis: summary of the core curriculum theory of TCM encompassed by Bian Zheng or pattern differentiation |
Theory (Diagnosis)
| ▪ Symptom based diagnosis |
▪ Diagnostic Methods: principles of looking, listening, asking, touching (tongue and pulse) are part of differential diagnosis | ▪ Diagnostic Methods: concerned with nature and location of symptom | |
▪ Treatment Principles: understanding of main complaint in terms of context, nature and location including concepts of xu and shi, and ben and biao (specific CM terminology) |
Theory (Treatment)
| ▪ Treatment Principles: the symptom and its underlying biomedical mechanism have a linear path |
▪ Responsiveness: diagnosis and treatment change in response to patient reported changes | ▪ Constant: treatment approach stays focussed on the principle of affecting change in the biomedical mechanism of the symptom | |
▪ Mechanism of change is dependent on affecting the balance of Qi, Yin and Yang and other defined substances of the person as decided by the differential diagnosis |
Rationale
| ▪ Mechanism of change is based in biomedical science and is linked to a direct expected action of acupuncture |
▪ Acupuncture works by affecting change in the balance of Qi, Yin and Yang and other imbalances as defined by the differential diagnosis. | ▪ Biomedical mechanism of acupuncture whether hypothesised or tested is t linked to the symptom | |
An iterative, individualistic and interactive approach - At each session the practitioner uses the principles of looking, listening, asking, touching (tongue and pulse) to make a differential diagnosis and to formulate a new treatment. |
Practice
| At each session, the selection for the formulae of points remains fixed on the biomedical mechanism of the symptom. |
Non-linear, with degrees of uncertainty at each stage of treatment |
Possible Causal Pathway
| Linear, from acupuncture needling to symptom |
Desired changes in the balance of Qi, Yin and Yang and other imbalances as defined by the differential diagnosis which will manifest in various aspects of the person in mind and body, in addition to any specific symptom changes |
Outcome
| A change in dimensions of the symptom, for example, hot flushes, a change in the intensity and frequency. |
Methods for Applying the Framework
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Study type: randomised and non-randomised studies, with a comparison/control group; uncontrolled studies published in key journals and/or cited by subsequent studies;
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Outcome measures: validated measures for either fatigue or vasomotor symptoms;
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Acupuncture: to include needling;
Results
Applying the Framework
Adherence to a Theoretical Model
Authors | Outcome Measure | Authors' description of acupuncture treatment | N | Rationale for classification (how the acupuncture points were selected) |
---|---|---|---|---|
TRADITIONAL ACUPUNCTURE
| ||||
Dong H, Ludicke F et al (2001) | Vasomotor | 'Classic manual acupuncture (based on the principles of TCM)' | 11 | Diagnosis and treatment was given based on the interpretation of symptoms and signs of based on TCM; treatment was individualised. |
Huang MI, Nir Y et al (2006) | Vasomotor | Based on 'the principles of TCM' | 29 | Points were selected from a group that were selected according to TCM patterns but the authors mention elsewhere 'based on their ability to target hot flashes'. There was a degree of interpretation, and an individualised approach on the part of the practitioner. |
MEDICAL ACUPUNCTURE
| ||||
Wyon Y, Lindgren R et al (1995) | Vasomotor | 'classical acupuncture' | 24 | No rationale given as to why choosing points for a different syndrome/disease (dysmenorrhoea) except that they didn't know what else to do. As the rationale for treatment is based on matching the mechanism of disease with the mechanism of acupuncture - this group have rationalised that beta-endorphins are the key link. |
Hammer M, Frisk J et al (1999) | Vasomotor | - | 9 | These were male participants given a fixed-point prescription chosen for dysmenorrhoea because the mechanism of vasomotor symptoms is hypothesised to be linked to the production of beta-endorphins. |
Cohen SM, Rousseau ME, Carey BL (2003) | Vasomotor | 'Within Eastern thought, acupuncture is viewed as a holistic approach grounded in Chinese medical philosophy.' | 18 | Much TCM language is used in the paper but the points were the same fixed prescription as the other MA vasomotor papers, the rationale for treatment is based on matching the mechanism of disease with the mechanism of acupuncture - this group have rationalised that beta-endorphins are the key link. |
Wyon Y, Wigma K et al (2004) | Vasomotor | - | 45 | As the rationale for treatment is based on matching the mechanism of disease with the mechanism of acupuncture - this group have rationalised that beta-endorphins are the key link and have used the same fixed-point prescription as the other vasomotor studies. |
Nedstrand E, Wikma K et al (2005) | Vasomotor | - | 38 | As the rationale for treatment is based on matching the mechanism of disease with the mechanism of acupuncture - this group have rationalised that beta-endorphins are the key link and have used the same fixed-point prescription as the other vasomotor studies. |
UNCLASSIFIABLE
| ||||
Deng G, Vickers AJ, et al. (2007) | Vasomotor | - | 72 | The fixed point 'prescription was derived from previous reports and from expert opinion, as found in standard acupuncture textbooks.' It was also changed mid-way through when a change of acupuncturists who wanted to use different points meant the study had to be started again. The is no explanation offered as to why these points might have a certain effect. |
Frisk J, Carlhall S et al (2008) | Vasomotor | - | 45 | Insufficient detail is provided on the acupuncture intervention. Reference is only made to the Wyon Y, Lindgren R et al (1995) study. No other rationale or detail about the treatment is provided. |
Harris RE, Tian XM et al (2005) | Fatigue | 'The active point formula was chosen based on the points' ability to relieve fibromyalgia symptoms in TCM.' | 114 | Although the authors describe the study being based on TCM with the knowledge of two acupuncturists, a fixed-point prescription was used according to its effect on symptoms. It is difficult to make further judgement as no rationale was offered as to why these points were chosen or how they might be expected to work. |
Kho HG, Eijk RJR et al (1991) | Fatigue | - | 29 | A fixed-point prescription was used. No information was given regarding rationale for treatment, or mechanism of acupuncture and how it might work in this circumstance. |
Malassiotis A, Sylt P, Diggins H. 2006 | Fatigue | Point selection was '...based on the Traditional Chinese medicine style, although individualisation was not part of the study.' | 47 | The points selected are chosen because they have been 'traditionally used for 'energy' over the past 2000 years'. The authors hypothesised why the acupuncture may have worked but this did not drive the fixed-point prescription, which was selected after consultation with two acupuncturists with no rationale offered other than the above or references given. |
Martin DP, Sletten CD et al (2006) | Fatigue | - | 60 | The authors chosen points that 'commonly recur in the acupuncture literature'. No rationale was offered as to why these points might have an effect. A fixed-point prescription was used. |
Vickers AJ, Strauss DJ et al (2004) | Fatigue | 'Traditional Chinese acupuncture' | 37 | The authors chose a selection of points that they say are traditionally used to treat fatigue referring to a textbook. There is no index by symptom in this (point-location) textbook thus all points have to be looked up individually and made use of according to TCM theory. A fixed-point prescription is used but is changed during the study with no explanation. |
Exploration by Symptom
Vasomotor Symptoms
Fatigue
Discussion
Does the Framework Help to Identify the Explanatory Model?
Notions of Causality
What are the Gaps in the Knowledge?
Implications
Key Questions | Guiding Prompts |
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1. What is the underlying theory of healing and rationale? | • Derived or based within a TA model? |
• Bio-medically based? | |
• Symptom based? | |
• Pattern differentiation (based on the approach of looking, listening, asking, touching)? | |
2. What form does the diagnosis of the patient take? | • Symptom based? |
• Pattern differentiation (based on the approach of looking, listening, asking, touching)? | |
• Aetiology of the main complaint (detail and depth of exploration)? | |
3. What is the nature of the treatment process? | • Fixed set of acu-points selected according to the main symptom(s)? |
• Is the treatment individualised? | |
• Treatment is characterised according to the diagnosis of the whole person using pattern differentiation? | |
4. How is treatment modified at subsequent treatment sessions? | • Treatment modified in response to patient-reported change? |
• Treatment staying constant focussing only on the (main) symptom(s)? | |
5. What is the implied mechanism of change for how the acupuncture might work? | • Biomedical mechanism of the acu-points are linked directly to the symptom? |
• Change is dependent on affecting the balance of Qi, Yin and Yang and other imbalances as defined by the differential diagnosis? | |
6. What outcomes are explored and what is the underlying rationale? | • Resolution of symptoms? |
• Broader benefits on health and well-being? |