Evidence-based Medicine (EBM) & Chinese medicine
Evidence-based Medicine (EBM) & Chinese medicine
Published on December 31st, 2008 @ 10:24:46 am , using 450 words, 1058 views
by Bob Flaws
Last night, Honora was telling me about how Tristate acupuncture college in New York had recently instituted some curriculum changes having to do with evidence-based medicine or EBM. I didn't get the particulars, but what Honora said started me thinking about EBM and Chinese medicine. Some readers may know that I have been an advocate of EBM within Chinese medicine and especially Chinese medical education for some time now. Any movement at any of our schools to incorporate the concepts of EBM is, I think, an important step in the right direction. In my opinion, as a profession all too often we say and do things based on tradition that are not truly evidence-based.
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For instance, I routinely hear Western Chinese medical practitioners say that ice for injuries and chronic somatic pain disorders is no good. As the logic goes, cold is constricting and contracting in nature and pain is due to lack of free flow. Therefore, the application of cold is not good for pain disorders as it will cause more lack of free flow. While this theory and logic are sound according to Chinese medical tradition, the conclusion is simply not true based on evidence. Anyone with any experience of physical therapy knows that the application of cold is very healing in most pain conditions, even chronic conditions where there are no signs and symptoms of heat according to Chinese medicine. In my experience as both a patient and a practitioner, this is an area where our theory is simply not backed up by the evidence. The evidence overwhelmingly supports the application of cold, and failure to recognize this is naive and potentially deleterious to our patients' health.
While Chinese medical theory is often quite brilliant and extremely useful in clinical practice, that theory needs to be supported by evidence. When the evidence is contrary to that theory, the evidence trumps the theory.
We Western practitioners of Chinese medicine are "converts," and it is well-known that converts tend to be more dogmatic than those who grow up within a system of belief. Sometimes that extra faith is good, but sometimes it is also what our Chinese friends would call guo fen, too much. Especially students and younger practitioners (younger in terms of years in practice) tend to be more doctrinaire. One of the important things about contemporary Chinese medicine in China is that a lot of attention is being paid to supporting theory and practice with evidence. The more we in the West follow suit, the better practitioner of medicine I think we will be.
So, if Honora got her story straight, kudos to Tristate on their efforts to incorporate more EBM into their curriculum.
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Bob,I don't know how clear-cut the evidence is on cold for treatment of pain. For example, "Worldviews on Evidence-Based Nursing" states the following in an article published in April, 2004:
"A simple and inexpensive therapy, cold application has been accepted for decades as an effective nonpharmacologic intervention for pain management. The purpose of this research synthesis is to explore the literature regarding the physiologic effects of cold, the effectiveness of cold, different modalities used for cold application, and the potential complications associated with the use of cold application. Several studies have shown ice to be effective in pain management associated with orthopedic procedures while other studies have shown contrary evidence. Studies have shown ice to be ineffective in pain associated with abdominal procedures. Studies involving pain associated with injections revealed significant positive findings with adults but not with children. Of the studies reviewed by this author, scientific rigor is often lacking which leaves the validity of the findings in question indicating a need for further investigation into the use of cold for relief of pain. As responsible caregivers, nurses must take the initiative to validate such interventions with a variety of pain experiences with controlled scientific investigations."
Having observed that both warm and cold applications have been observed to be useful in various pain conditions, we can apply Chinese medical theory to understand how and when cold applications might or might not be helpful.
Factors to consider include:
1) location of injury
2) intensity of cold application (ice, compress, temperature, size of application)
3) type of injury or pain
4) duration of treatment (time of application, repetition of application, 'proving' by over-treatment for too long a period)
To that we can add Chinese medical criteria, such as would cold applications on the lower back, governed by the kidneys, or the abdomen (interestingly mentioned in the above abstract) be more deleterious in the long term even if beneficial in the short term? (i.e. dosage concerns).
Then we could look at the nature of cold, being yin, slow, heavy, and how that would influence body reactions, or the doctrine of heteropathy from the Nei Jing (if cold, heat it, if heat, cool it).
On one hand, we can then be more flexible with applications for pain (such as in the use of camphor-based compresses or plasters), and still be in the realm of Chinese medical theories.
Z'ev Rosenberg
Dear Bob,I agree wholeheartedly with your appraisal of the need to integrate EBM into the teaching and practice of Chinese medicine. However, I disagree with the example of ice as a treatment with a history of efficacy, that is nonetheless routinely criticized within TCM circles.
I refer to a literary review of ice treatments by John McDonald in the Australian Journal of Acupuncture and Moxibustion, which finds that ice interventions are largely based on traditional physical therapies practices, rather than due to evidence found in research.
http://www.acupuncture.org.au/zone_files/Download_Icons/ajacm_2007_2(2)_fire_and_ice_(mcdonald).pdf
While Chinese medicine faces the greatest pressure from conventional medical authorities to base its practice on research outcomes, this article demonstrates that it is by no means the only modality that needs to implement such a culture.
It is of course a double standard that interventions which have a centuries old empirical history, are called upon to prove their worth in research conditions, while relatively new techniques such as ice therapy, or the use of many pharmaceuticals; do not.
But as the list of conditions that Chinese medicine is proven to effectively treat, widens; I suspect this counterproductive pressure from the medical establishment will quickly fade into oblivion.
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