The Natural Therapist - ANTA Journal - December 2016 by ANTA

The Official Journal of the Australian Natural Therapists Association (ANTA) R EM E D I AL MASSAG E WELLNESS DE P RE S S ION

GREAT ARTICLE

For Osteoarthritis

Constructive Interventions

Herbs For Depression

The Natural Therapist Herbs for Depression: Recent Developments Nutrients beneficial to liver health

Dietary therapy and nutritional medicine management of multiple sclerosis

+ ANTA NEWS, BURSARY AWARDS, ANTA HISTORY, ARTICLES AND MORE IN THIS ISSUE

www.anta.com.au

Digestive health

Part 2 - Gastroesophageal Reflux Disease (GERD)

NOVEMBER 2016 VOL 31 NO 3

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CO N T E N T S TNT JOURNAL 5 Executive Officer’s Report A warm welcome to all ANTA practicing and student members

7 ANTA News & Awards ANTA announce Bursary Award winners for 2016

11 New Health Fund Providers New Health Funds recognise ANTA members as providers

13 Nutrients Beneficial To Liver Health Nutrients for effective liver health

15 Herbs For Depression Recent developments on herbs

17 Foot and Ankle Osteoarthritis Remedial massage techniques for practitioners

23 Gastrointestinal Disorders Part 2 of Functional Gastrointestinal Disorders

36 Dietary Therapy Nutritional medicine management for multiple sclerosis

36 Constructive Interventions Applied Wellness: Building a good day for a good life

Natural

The

Therapist

VOLUME 31 NUMBER 3 - NOVEMBER 2016 ISSN 1031 6965 The Natural Therapist is published by the Australian Natural Therapists Association (ANTA) for natural therapy practitioners. The opinions and views expressed by the contributors and advertisers are not necessarily the opinions and views of ANTA. Every effort is taken to ensure accuracy and ANTA accepts no responsibility for omissions, errors or inaccuracies. ANTA relies on contributors and advertisers to make sure material provided for The Natural Therapist complies with Australian Laws. ANTA accepts no responsibility for breaches of Australian Law by contributors or advertisers. Material in The Natural Therapist is subject to copyright and may not be reproduced in any form without the permission of ANTA and authors.

ANTA BRANCH CHAIR PERSONS Jim Olds - President National Multi-Modality Branch Chair Director of ANTA Director of CMPAC ANTAB/ANTAC Chair Ethics Panel Chair

Warren Maginn National Nutrition Branch Chair Director of ANTA TGA Chair ANTAB/ANTAC Committee Member ANRANT Committee Member

Justin Lovelock National Herbal Medicine Branch Chair Director of ANTA Director of CMPAC Constitution & Policy Chair ANTAB/ANTAC Committee Member ANRANT Committee Member

Kevin McLean – Treasurer National Musculoskeletal Therapy & Myotherapy Branch Chair Director of ANTA CPE/Seminar Chair ANTAB/ANTAC Committee Member ANRANT Committee Member

Tanya Morris National Naturopathy Branch Chair Director of ANTA Media/Web Chair ANTAB/ANTAC Committee Member ANRANT Committee Member

Brian Coleman Company Secretary Executive Officer Director of CMPAC ANRANT Chair Business Plan Chair

Jeanetta Gogol - Vice President National Remedial Massage Branch Chair Director of ANTA ANTAB/ANTAC Committee Member

ANTA NATIONAL ADMINISTRATION OFFICE T: 1800 817 577 F: (07) 5409 8200 E: info@anta.com.au P: PO BOX 657 MAROOCHYDORE QLD 4558 australiannaturaltherapistsassociation.com.au

THE NATURAL THERAPIST Executive Officer Brian Coleman Marketing/Production Steven Venter Circulation Enquiries 1800 817 577 Editorial & Advertising Enquiries steven@anta.com.au Membership Enquiries info@anta.com.au General Enquiries info@anta.com.au THE NATURAL THERAPIST Volume 31 No.3

THE 2017 INTERNATIONAL CONGRESS ON

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YOUR INVITATION The Metagenics International Congress on Natural Medicine has earned the privilege of being recognised as the most significant educational event in our industry. We are pleased to invite you to join us in the Hunter Valley in 2017. This gives us the chance to come together as an industry with likeminded people for an enthusiastic and insightful long-weekend. By taking advantage of this early invitation you can secure your place in the Hunter Valley before the detailed invitation is released. We encourage you to book in and pay in full now to secure your seat and avoid disappointment.

MASTERING THE MICROBIOME – A CONTEMPORARY TARGET FOR ALLERGY, PSYCHOPATHOLOGY, METABOLIC DISEASE AND BEYOND... In 2017, The Metagenics Congress on International Medicine will share the latest updates in this fast-paced field, explaining how the trillions of microorganisms living on us and inside of us are connected with everyday clinical presentations such as allergies, immune dysfunction, digestive disorders and chronic health issues such as cardiometabolic disease, obesity and psychological disorders. The rapid development of sequencing methods and analytical techniques which have allowed us to ‘map’ the microbial genome are enhancing our ability to define the characteristics of a healthy microbiome, and understand how it can be manipulated to trigger changes in human cellular activities to ultimately reduce susceptibility to disease or its progression... Unite with leading global researchers and expert clinicians to unravel the complexity of the microbe-human relationship and the molecular mechanisms that govern pathological processes, gain deeper insight into evidence-based strategies for intervention and identify the areas where the science is still in its infancy. There are still many questions to be answered, however, by the time we come together in June 2017, we will undoubtedly know much more than we even do today...

PRESENTERS INCLUDE Dr Jeffrey Bland – Founder and President of the Personalized Lifestyle Medicine Institute, CEO – Kindex Therapeutics Dr Michael Ruscio – Functional Medicine Practitioner Prof Mimi Tang – Leading Allergy Researcher Dr Ritchie Shoemaker – Medical Practitioner Registration Includes: • Full Congress manual • Congress gift pack • Morning tea and refreshments upon arrival • Healthy and delicious full buffet lunch • Afternoon tea • Coffee, tea and purified water • A light dinner on Saturday night

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THE NATURAL THERAPIST Volume 31 No.3

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E xec u t i ve O ff i cer ’sR epo r t - N ovem ber 2016

Executive Officer’s Report – November 2016 A warm welcome to all new ANTA practicing members and ANTA student members. If you require any information, advice or assistance please feel free to contact the team in the ANTA National Administration Office on 1800 817 577 or info@anta.com.au Statutory Registration - National Regulation & Accreditation Scheme (NRAS) ANTA continues to push for the inclusion of natural therapy practitioners under the NRAS. ANTA has provided Ministers, government departments, government advisors, registration boards, health funds and colleges with a detailed submission on the statutory registration of Naturopathy, Western Herbal Medicine and Nutritional Medicine. The ANTA submission is the first detailed submission for Naturopathy, Western Herbal Medicine developed by the profession and presents evidence for the statutory regulation of Naturopathy, Western Herbal Medicine and Nutritional Medicine (Nat/WHM/NM) in Australia under the National Registration and Accreditation Scheme for the Health Professions (NRASHP). The submission applies the process outlined in Attachment B of The Intergovernmental Agreement for a National Registration and Accreditation Scheme for the Health Professions (IGA), which outlines six criteria to be met before registration of any health profession is considered. The IGA states ‘it was envisaged that other health professions would be added over time. The submission focus is on all of these criteria with a special focus on Criterion 2 which requires that the occupations’ practice presents a serious risk to public health and safety which could be minimised by regulation. The submission seeks to demonstrate that registration of these three health professions is justified and will provide evidence of the risk to public health and safety and the reasons why current regulatory mechanisms are insufficient in minimising this risk. In achieving that goal, the submission is cognisant of the COAG Best Practice Regulation Guidelines (COAG guidelines) which requires any regulatory response to first find a case for action, any decisions made should consider self-regulation, co-regulation and non-regulatory options and it should provide the greatest net benefit for the community which is proportional to the issue being addressed. ANTA is continuing to discuss with Ministers, government departments, government advisors and AHPRA the submission prepared by ANTA and the benefits of registering Naturopathy, Western Herbal Medicine and Nutritional Medicine under the NRAS. As discussions and developments occur on the push for registration, we will keep ANTA members informed. Advanced Diplomas - Naturopathy, Western Herbal Medicine, Nutritional Medicine & Homeopathy

members with Advanced Diploma qualifications maintain continuous ANTA membership and abide by health fund provider register requirements they will continue to be ANTA members and registered as providers with health funds. Health Funds Audits Health funds are conducting regular audits of associations. Completion of 20 hours of CPE is one of the areas health funds focus on and we are very pleased to see the positive response by members to ensure their CPE records are up-todate. It is encouraging to see members have taken full advantage of the CPE facilities ANTA provides such as the ANTA e-Learning Centre, free ANTA webinars, free ANTA seminars, free access to IMGateway scientific and e-learning resources, EBSCO Host research database and eMIMS Cloud to name but a few. It is also satisfying to see the new processes we introduced to ensure members renew their professional indemnity insurance and first aid qualifications on time has paid dividends and this process has been instrumental in ensuring ANTA members are audit compliant. We have received notification from health funds they will be continuing their ongoing program of detailed analysis of receipts issued by members of all associations to ensure compliance with health funds provider terms and conditions. We have also received advice from Medibank that it is continuing to monitor claim and receipting profiles of all providers to identify any variations when compared with profiles of their peers. If a practitioner’s receipting profile shows any abnormalities the practitioner will be required to provide additional information and meet with Medibank management to explain the variations in receipting practices. Important information regarding Medibank reviews of providers is outlined on the ANTA website and detailed in the previous edition of The Natural Therapist. We recommend members read this information and contact us if you require further clarification. FREE ANTA National Seminars We have completed our 2016 national seminar series. All of the seminars have been an outstanding success and planning for our 2017 national seminar series is well under way. We will contact members by email to advise them when the next seminar is being held in their State. All ANTA members including students can register to attend ANTA seminars free of charge. FREE ANTA Webinars

We continue to remind members of the decision by ASQA to cease delivery of these programs. Colleges have also been given an extension of time until 2018 in which to teach out these courses and award graduates with their qualifications. ANTA has been in contact with colleges to advise graduates who have completed accredited HLT Advanced Diploma courses will be eligible to join ANTA.

We are continually adding outstanding webinars to this collection and I recommend members to log on the members section of the ANTA website and check them out. Viewing of the webinars is a great way to keep up with the latest developments and earn CPE points.

ANTA members who joined with Advanced Diploma qualifications are not affected by the ASQA decision to cease delivery of Advanced Diplomas.

To stay in touch with the latest information make sure you visit the ANTA website, members centre and ANTA Facebook page. Updates containing a wealth of information are also sent to member by ANTA e-News regularly.

Members with Advanced Diploma qualifications are not required to upgrade to Bachelor degree level qualifications. As long as

Stay informed and up-to-date

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Changing your contact details or clinic address

Advertising and Promotion of ANTA Members in national magazines

Don’t forget to let us know asap if you change your email address, postal address, telephone or clinic addresses. This information is essential for us to contact you, keep you updated and to ensure your clinic addresses are registered with health funds.

Due to the success of our advertising and promotion of ANTA members in national lifestyle magazines, we have expanded our promotion to include banner advertisements on magazine e-News and newsletters. This program has been successful in raising public awareness on the benefits of consulting with an ANTA accredited practitioner.

ANTA National Student Bursary Awards for 2016 The submissions received from students for the ANTA National Student Bursary Awards for 2016 were outstanding and clearly shows the future of natural therapies is in excellent hands. Due to the high quality of submissions the task of determining the 12 recipients to each receive $1000 was very difficult. After many hours of reviewing the submissions the 12 recipients were determined and details of the recipients including photos are included in this edition. ANTA will again be providing another 12 $1000 Student Bursary Awards in 2017. ANTA Financial Performance

Natural Therapies App ANTA is the only association with an App that promotes natural therapies and ANTA members to the public. The App is free and the public can complete instant searches for an ANTA member on their phone and at the same time set up an appointment with an ANTA member in a matter of seconds. Members details are updated on the App regularly. For more information go to www. naturaltherapiesapp.com.au Upgrade of Member Engagement Management software

I am pleased to advise that ANTA again posted another successful financial result in 2016. The results ANTA has continued to achieve over many years don’t happen by chance and it is reassuring for ANTA members to know the governance of ANTA is in good hands. The ANTA 2016 Financial Report is available on the members section of the ANTA website.

ANTA is in the process of upgrading software to provide members with a range of real time services and facilities including online communities, updating of members profiles, streamlined communications across all devices, automation of processes, real time updating of information, searchable online directories, interfacing with social media Free Legal Advice for ANTA members and much more. This is an exciting project which will provide members with a range The facility provided to ANTA members through of benefits not seen before in the natural our supplier of professional indemnity insurance therapy profession and we look forward to Arthur J Gallagher (incorporating OAMPS) has introducing these benefits to members in been a huge success with numerous members the new year as we progressively roll out taking advantage of this free service. this project. 30 minutes of free legal advice is available for: • • •

ANTA members who have a professional indemnity policy with Arthur J Gallagher Issues regarding professional indemnity policies and/or claims Any other issues regarding your practice such as employment contracts, employment disputes, tenant agreements, leases, ownership of client records, restraint of trade etc

To obtain 30 minutes of free legal advice contact the Arthur J Gallagher Specialty Risks team on: • •

free call - 1800 222 012 email - specialtyrisks@ajg.com.au

This offer is provided to ANTA members by Arthur J Gallagher in conjunction with White & Mason Lawyers.

THE NATURAL THERAPIST Volume 31 No.3

Contact us if you require any advice, support or assistance – we value your feedback Any members requiring advice, support, assistance or has feedback on ways in which we can improve our member services please feel free to contact either myself or the team in the ANTA National Office anytime on 1800 817 577 or info@anta. com.au Our Administration team is ready to assist you. Regards Brian Coleman Executive Officer

ANTA President’s Report Since 1955 ANTA is an association that has supported the highest levels of public health and safety. To this end the idea of statutory legislation to underpin any registration model and provide the level of accountability, integrity, quality and safety of therapy our members strive to achieve is uppermost in our minds. It is with some pride and satisfaction after serving ANTA National Council and the broader membership for more than fifteen years that I can say one of our most important goals has moved a step closer in 2016. Professor Michael Weir, Faculty of Law Bond University accepted ANTA’s commission to prepare a submission consistent with the process outlined in Attachment B of the Intergovernmental Agreement for Statutory Registration of Naturopathy, Western Herbal Medicine and Nutrition Medicine within the National Registration and Accreditation Scheme for the Health Professions. This submission has now been distributed to our members, Federal and State Health Ministers across Australia in addition to direct industry stakeholders including health funds and educational institutions. As the National Multi-modality Branch Chair I also want to reassure our members from the manual therapies disciplines that a submission specific to their field of practice has also been commissioned with Professor Weir. Progress on this submission will be updated through the ANTA website and eNews as it comes to hand. It is known Naturopathic, Herbal and Nutritional Medicine all require the oral consumption of remedies and in specific cases changes to dietary intake. These procedures may present an element of risk to some consumers and it is fitting for any professional association to have in place robust measures for reporting adverse events and impartial processes for investigation and reporting when a consumer believes they may have suffered at the hands of a practitioner. Current procedures for dealing with adverse outcomes and consumer complaints Certain questions about the nature, severity and extent of any risk to the public have been considered within the ANTA Code Of Ethics and the ANTA Constitution. These measures rely to some extent on the prompt selfreporting by members or their clients about any matter they are aware of that might have caused harm or pose a danger to the public generally or to any individual specifically. It can be said the ANTA National Council has established an exemplary reputation for dealing with members in a responsible, accountable, transparent and equitable manner when dealing with consumer complaints.

AN TA - N E W S N ews - N ovem ber 2016

Registered professions

Under legislation, registration boards have carriage over receiving reports from and responding to consumer complaints relevant to registered practitioners. This removes the onus to occasionally administer punitive measures on members by an association in some cases and provides an impartial, external group decision about any matters reported to the board by consumers. ANTA milestone The submission stating the case for statutory registration from ANTA to government is an ANTA milestone. It is an action that will lead us to greater clarity and recognition of ANTA’s aims and objectives. Continuing Education Seminars ANTA National Council members Kevin McLean, Warren Maginn and Jim Olds continue to present topics alongside respected educators such as Kerry Bone, Rob Santich, Tony Reid, Elizabeth Greenwood, Professor Michael Weir, Berris Burgoyne, Dan Roytas, Dianne Bowman and Shaun Brewster to name some of the leaders in our profession appearing at the National Seminars delivered across Australia each year. These seminars have proved popular to ANTA practitioner and student members as well as members of other associations and the general public. We will continue delivering this service as part of ANTA’s open door policy and inclusion of interested parties looking for more involvement and information about the benefits of using natural and traditional therapies.

ANTA Bursary Award Winners

The ANTA National Bursary Awards have been established to encourage students to maximize the opportunities provided in their education and to assist students to achieve their aims and goals in natural therapies. Since introducing the ANTA National Bursary Awards in 2006, ANTA has awarded more than $120,000 to students. ANTA has reviewed and assessed all Bursary Award submissions received for 2016 and are delighted to announce 12 recipients have been selected to receive an ANTA Bursary Award of $1,000. The 12 recipients of ANTA National Student Bursary Awards for 2016 are: Judith Ruggeri Jean Martain Melissa Gianatti Emma Pendlebury Tristen Van Der Kley Joshua Weymouth

NSW NSW QLD VIC VIC WA

Candice Berghan Hannah Gilbard Edileuza Kyne Sharon Abel Alison Felton Carrie Reedy

NSW NSW QLD VIC SA WA

Congratulations go to each of the 12 recipients on their outstanding submissions and selection as a recipient of an ANTA Bursary Award of $1,000. Congratulations also go to all of the students who lodged submissions. The quality of submissions was exceptionally high and made the task of selecting 12 recipients very difficult. ANTA National Student Bursary Awards will be available again in 2017 and we are excited to work towards achieving our next target of providing $200,000 in bursary awards to students. Below some of the Students being presented with their awards. Melissa Gianatti / ANTA Director Tanya Morris

Arthur J. Gallagher CEO Andrew Godden / Hannah Gilbard

Membership The goals National Council set for growing the membership of ANTA have been surpassed and we believe the leadership model within the administration team and National Council are largely responsible for this positive growth. We trust the members will continue to support and participate in the excellent reputation ANTA practitioners continue to establish and maintain within their communities. Appreciation On behalf of the ANTA members I thank Brian Coleman and his staff for their positive management of our profession, their dedication to the service provided to members and their continuing energy in looking after our interests. This appreciation is extended to my colleagues on National Council who have worked tirelessly for yet another year, our industry is a safer place for their efforts.

Bronwyn Spencer / Carrie Reedy

ANTA Director Warren Maginn / Edileuza Kyne

I look forward to meeting up with members as we travel around the country as we stay in touch with your needs and aspirations. Jim Olds ANTA National President THE NATURAL THERAPIST Volume 31 No.3

ANTA - N E W S N ews - N ovem ber 2016

ANTA Continuing Professional Education (CPE) Hours Guidelines What is CPE: Continuing Professional Education is the upgrading or acquisition of knowledge and skills in the accredited modalities that will aid the practitioner in providing the patient with a high standard of health care. Why is CPE Necessary: CPE is an important part of providing professional healthcare services to patients and ensures practitioners regularly update their clinical skills and professional knowledge. ANTA requires members to complete 20 CPE hours annually (Jan – Dec). Completion of 20 CPE hours annually is a requirement for ongoing provider recognition with all Health Funds and WorkCover Authorities. Note: If you do not complete 20 hours of CPE annually, Health Funds and WorkCover Authorities can terminate your provider recognition. Each year Health Funds carry out audits of members records to ensure 20 hours of CPE are completed by all members annually.

• • • • • • • • • • • • • •

Make sure you lodge online or send to ANTA, details of 20 hours of CPE you have completed by the end of each year.

• • •

CPE reinforces ANTA’s natural health philosophy.

•

Other Benefits of CPE: • members are kept informed and up-todate with the latest developments • facilitates communication and networking • encourages further study • enhances professional standing within the community Required CPE Hours: ANTA members must accumulate a minimum of 20 CPE Hours per annum (Jan – Dec). At least 50 % of CPE hours undertaken must be related to the modalities you are accredited in by ANTA. Note: Hours in excess of 20 completed in the current year are not able to be carried over to subsequent years. Members registered with CMBA/AHPRA must abide by CMBA CPD/CPE Guidelines (http:// www.ahpra.gov.au/chinese-medicine.aspx) for the modalities of acupuncture and chinese herbal medicine and also submit their CPE to ANTA. CPE Activities: Members can undertake CPE hours in many ways including the following: • • •

attending ANTA free seminars – details of seminars are regularly posted on www. anta.com.au researching scientific information on IMGateway - free access for members on www.anta.com.au researching scientific information on EBSCO - free access for members on

THE NATURAL THERAPIST Volume 31 No.3

•

www.anta.com.au researching scientific information on eMIMS Cloud – free access for members on www.anta.com.au participating in research projects involving or related to natural therapies viewing seminar videos and seminar presentations - free access for members on www.anta.com.au completing courses on ANTA e-Learning Centre -free access for members on www.anta.com.au giving lectures/tutorials giving CPE seminar presentations undertaking further study completing short courses contributing an article to the ANTA journal “The Natural Therapist” and ANTA website contributing an article to other relevant journals, magazines and publications reading articles in the quarterly ANTA journal “The Natural Therapist” subscribing to and reading other professional publications and journals attending webinars viewing online, DVD’s or videos on relevant topics listening to recordings on relevant topics radio/tv broadcasting on relevant topics reading and researching information on topics relevant to your practice attending local practitioner groups/ workshops volunteer work with community groups involving natural therapies

CPE Seminars: ANTA National CPE seminars are held in each state annually and are free for all ANTA members ANTA and other CPE seminars are communicated to members via the ANTA website, ANTA e-News and in “The Natural Therapist”. Members should regularly check the ANTA website for details of seminars. Maintaining your own personal online CPE Record: ANTA provides members with simple easy to use online facilities to complete and lodge their CPE hours in their own personal and permanent CPE online record fully maintained on the Members section of the ANTA website (Note: your CPE history is retained for future reference and you should not delete any of your online CPE records). ANTA members can as an example, undertake research on EBSCO, IMGateway scientific resources, view videos of ANTA seminars etc and then record those CPE hours on their personal CPE record all in the one session via the ANTA website. To submit/view your CPE hours online with ANTA: • • •

Log onto the “Members Login” section of www.anta.com.au using your username & password click on “Your Profile” then click on “Submit CPE Hours”

• •

key in your CPE activity (date, description, hours) you can view your CPE hours recorded online at any time by clicking on “View CPE Hours”

Maintaining your own manual CPE Record: Members not wishing to take advantage of the ANTA online CPE record can keep their own manual CPE Hours record which should include the following minimum information shown in the example below: Maintaining your own manual CPE Record: Members not wishing to take advantage of the ANTA online CPE record can keep their own manual CPE record which should include the following minimum information shown in the example below: CPE Hours Record Year: (insert year) Name of Member: ANTA Member Number: Date of CPE

Description of CPE Activity Completed

C P E Hours

(Note: the following CPE activities are provided as examples) 22nd March

Attended ANTA Free Seminar

3rd April

Remedial Therapy research on EBSCO

4th May

Naturopathy e-learning module IMGateway

30th June

Read ANTA Journal – The Natural Therapist June edition

5th September

Completed short course Stress & Wellness

TOTAL CPE HOURS

Members who do not record and maintain their CPE hours in their own personal online file via the ANTA website, can maintain their own manual record as shown in the example above and submit their CPE Hours Record to ANTA prior to the end of each year in the following ways: • by email to info@anta.com.au • by fax to (07) 5409 8200 • by post to ANTA PO Box 657 Maroochydore Qld 4558 (Note: members should keep a copy of their manual CPE Activity for their own records and for any audits of their practice undertaken by ANTA, Health Funds or WorkCover). Make sure you lodge online or forward to ANTA details of 20 hours of CPE you have completed by the end of each year. Health Funds carry out annual audits of members records and if you have not submitted 20 hours of CPE activity to ANTA, Health Funds will de-register you as a provider.

AN TA - N E W S N ews - N ovem ber 2016

MEDIA RELEASE

Quality Control and Accreditation of Massage and Myotherapy There have recently been some discussions in social media regarding Quality Control and Accreditation of Massage Therapists and Myotherapists. To correct some of the misinformation that has been circulating, ANTA has prepared the following: Quality Control and Accreditation of Massage therapists and myotherapists is not a new concept. ANTA has been leading the profession in quality assurance and accreditation and has had in place for more than 40 years a fully developed transparent national accreditation (certification) program that ensures/delivers a high level of quality control/assurance, maintains high levels of standards for all ANTA members and modalities including massage and myotherapy that safeguards public health and safety. The ANTA national accreditation/ certification program is part of the ANTA membership package and members are not charged any additional fees to be accredited/certified by ANTA. In addition to receiving an ANTA membership certificate, all ANTA members receive an ANTA accreditation certificate and are entered in the Australian National Register of Accredited Natural Therapists (ANRANT) www.anrant.com.au. ANTA members and ANTA accreditation is recognised by all health stakeholders. We believe an important first step in any quality assurance program is to acknowledge failures and it is pleasing to see AAMT has identified shortcomings to their members in this area. The cornerstone of any quality assurance program is the setting of high education standards and for more than 40 years ANTA has had in place high educational standards for membership and accreditation for all modalities/disciplines including massage and myotherapy. Unlike many other associations representing the massage and myotherapy professions, ANTA has demonstrated over many years it has the skills, resources, systems and infrastructure to successfully manage and operate world class quality control processes. ANTA has set one national educational standard across the board for membership and accreditation based on ANTA and Medibank educational requirements. Many associations lacking the necessary skills, resources, systems and infrastructure to manage quality control processes have adopted a two-tiered system of educational standards and course recognition for massage that involves recognising courses that meet Medibank requirements and also recognising sub-standard courses that do not meet Medibank requirements. The two-tiered course recognition employed by massage associations is not focused on achieving quality but is solely focused on achieving quantity (i.e. more members). The two-tiered course recognition process used by many massage associations continues to damage the profession and places the health and safety of the public at considerable risk. Unlike many other associations representing the massage profession, ANTA does not operate a two-tiered massage course recognition system and has always set one minimum educational standard across the board for course assessment and recognition based on ANTA, Medibank and HCF educational requirements. The two-tiered massage course recognition system has created serious problems, is not in the interests of the profession, poses a considerable risk to the public and cannot be part of any legitimate quality assurance program. The two-tiered course recognition system employed by many massage associations encouraged course providers to deliver sub-standard courses and also enabled graduates of sub-standard courses to be welcomed as members of many massage associations and registered as providers with health funds.

minimum educational standard based on ANTA, Medibank and HCF educational requirements. We note that AAMT have indicated it will be implementing the best education standards as part of its quality assurance program. We also note AAMT has not publicly made available on its website details of educational standards or course assessment requirements for membership and details of courses recognised by AAMT. In the interests of transparency we encourage AAMT to rectify this as soon as practicable. Each state government is in the process of adopting the National Code of Conduct (the code) for unregistered health service providers and that the code will apply to all natural therapy practitioners including massage therapists. NSW, QLD, SA and VIC have in place codes of conduct that apply to massage therapists and other states are working to introduce the code. This initiative by State and Federal Governments also sets in place another level of quality assurance and a formal complaints system supported by robust legislation. We are encouraged AAMT has decided to pursue the establishment of higher education standards and we look forward to seeing some positive outcomes. ANTA ceased recognition of certificate IV massage qualifications more than 10 years ago and if fully committed to quality assurance, AAMT must recognise that certificate IV qualifications cannot be part of a modern quality assurance program for AAMT members. We recommend that AAMT follow ANTA’s lead and cease recognition of certificate IV massage qualifications without delay. In summary, ANTA as part of its national quality control process: • Maintains a robust single-tiered course assessment and recognition process • Maintains a robust code of professional ethics and scope of practice • Maintains a robust Constitution • Maintains a robust accreditation and certification quality system • Maintains a robust Continuing Professional Education system • Maintains a range of robust policies and procedures • Maintains a robust complaints system • Maintains consistent good governance committed to high education standards and quality control • Provides all members with free national seminars/webinars • Provides all members with free access to the latest world class scientific reports and information including. EBSCO, eMIMS, IMGateway and iTherapeutics • Conducts regular onsite audits of members • Ceased recognition of certificate IV qualifications more than 10 years ago • Participates on Course Advisory Committees • Participates on AHPRA Professions Reference Group • Is supported by the Australian Qualifications Framework regulatory and quality assurance requirements • Is supported by the Australian Natural Therapists Accreditation Board • Is supported by the Australian National Register of Accredited Natural Therapists • Is supported by the Complementary Medicine Practitioner Associations Council (established with Dept Health & Ageing funding) • Is supported by Health Fund Agreements • Is supported by the Goverment National Code of Conduct and complaints process • Is supported by Memorandum of Understanding with ASQA • Is supported by the Private Health Insurance (Accreditation) Rules 2011 • Is a Schedule 1 association listed in the Therapeutic Goods Act 1989 as part of the TGA national quality control systemIs recognised by the Australian Taxation Office as a Professional Association that has uniform national registration requirements for practitioners.

We encourage massage associations to follow ANTA’s lead and abandon the two-tiered course recognition system and to set one

THE NATURAL THERAPIST Volume 31 No.3

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AN TA - N E W S N ews - N ovem ber 2016

• Participates on the Complementary & Alternative Health Industry Reference Committee administered by Skills IQ under the Australian Industry & Skills Committee established by COAG ANTA has been leading the profession in accreditation and has in place a fully developed high level national quality assurance program fully supported by government departments and regulations as outlined above and we look forward to AAMT setting similar standards in place. On the 9th October 2012 massage associations were invited by Medibank to attend a meeting to discuss quality control issues including: • issues surrounding RTO’s • graduates of sub-standard courses joining massage associations and being sent to Medibank to be registered as providers • ongoing recognition of remedial massage providers by Medibank Associations were encouraged at that meeting to work together to put in place quality assurance systems to ensure that only graduates of quality courses were accepted as members by associations. It is worth reflecting on outcomes and discussions resulting from that meeting including the following documents: •

Rock and a Hard Place discussion paper 29/11/2013 – AAMT

•

Letter from ANTA in response to above discussion paper

The ANTA letter in response to the AAMT Rock and a Hard Place paper highlighted that it was the massage associations responsibility to put in place robust educational standards and quality control systems and that ANTA did not support the AAMT notion the profession was between a rock and hard place. Associations that did not have in place adequate and robust quality control systems in 2012 had a clear choice and could have implemented quality controls at the time if they were committed to high education standards and quality. The massage associations had an opportunity in 2012 to put in place quality assurance systems and unfortunately very few associations accepted the challenge and continued to accept graduates who had completed sub-standard courses. As a result of many associations failing to put in place any quality control measures, Medibank and HCF decided to implement their own educational standards and quality control measures to ensure only appropriately trained massage therapists were registered as providers. We are pleased to advise ANTA quality control systems and processes exceed Medibank and HCF requirements. Several years ago we were invited to participate in a similar quality program being developed by AAMT in collaboration with some other associations. The program involved the establishment of the Natural Medicine Register (NMR) and associated complaints system. Communications released by the NMR advised the NMR will promote high practitioner and educational standards across the natural therapy industry including massage and myotherapy. We have not received any recent communications from the NMR, however we have been made aware that the NMR notified ASIC it had ceased on the 18th May 2016 and that the NMR President (also AAMT President) resigned as a director and president of the NMR on the 3rd March 2016. We have not received any advice on the demise of the NMR, however as it has ceased as an organisation we can only conclude the establishment of the NMR by AAMT to provide quality assurance and educational standards was a failure. It is now more than 5 years since the issue of quality control systems for massage and myotherapy were discussed and the NMR was established and closed down. ANTA remains hopeful other massage and myotherapy associations take up the challenge and adopt the quality assurance and accreditation systems implemented by ANTA. Further misleading information has also recently been circulated promoting and stating an association (AAMT) intends to trademark

commonly used terms to describe modalities. Legal advice received on this issue from Trademark Lawyers is that it is not possible to trademark commonly used terms to describe modalities and any attempt by any association to trademark commonly used massage terms or titles will not be successful. Titles of practice can only be protected under government legislation in accordance with the National Registration and Accreditation Scheme statutory registration administered by AHPRA. Another piece of false information circulating is that it will be mandatory to be accredited under the quality assurance program proposed by AAMT and to pay them annual fees. ANTA has had in place for more than 40 years a high level accreditation program free of charge for all members to participate in when they choose to join ANTA. Under Australian Consumer Laws it is illegal to force anyone to join or pay to join an association or accreditation scheme. It is ludicrous for any association to suggest it will be mandatory to join their association or accreditation scheme. ANTA members are already accredited by ANTA under a quality assurance program at no cost and there is no need for members to pay any fees to be part of any other proposed accreditation schemes. Please feel free to contact the ANTA Administration Office at anytime for advice if you have any concerns regarding the massage and myotherapy professions.

New Health Funds recognise ANTA Members as providers ANTA is pleased to advise three new players have entered the private health Insurance arena and the three new health funds recognise ANTA members as providers. The details of the funds and ANTA recognition are as follows: APIA Health Insurance http://www.apia.com.au/health-insurance ANTA members are automatically recognised as providers by this health fund (no need to apply to the health fund). Use your ANTA membership number as your provider number on patient receipts relating to APIA Health Insurance. Modalities recognised by this fund: Acupuncture, Chinese Herbal Medicine, Western Herbal Medicine, Myotherapy, Naturopathy, Remedial Massage & Shiatsu Budget Direct Health Insurance http://www.budgetdirect.com.au/private-health-insurance.html ANTA members are automatically recognised as providers by this health fund (no need to apply to the health fund). Use your ANTA membership number as your provider number on patient receipts relating to Budget Direct Health Insurance. Modalities recognised by this fund: Acupuncture, Naturopathy, Remedial Massage & Homeopathy Qantas Health Insurance https://www.qantasassure.com/ ANTA members are automatically recognised as providers by this health fund (no need to apply to the health fund). Use your ANTA membership number as your provider number on patient receipts relating to Qantas Health Insurance Modalities recognised by this fund: Acupuncture, Chinese Herbal Medicine, Western Herbal Medicine, Myotherapy, Naturopathy, Remedial Massage & Shiatsu

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ANTA - N E W S N ews - N ovem ber 2016

ANTA UPDATES - ANTA ADVICE, UPDATES AND RECOMMEDATIONS ANTA Submission September 2016

ANTA History

Registration of Naturopathy, Western Herbal Medicine and Nutritional Medicine

ANTA Members are eligible to participate in My Health - National Digital Health Records

The Australian Natural Therapists Association (ANTA) has been working with the Health Workforce Principal Committee (HWPC) and Professor Michael Weir to develop a submission for the registration of Naturopathy, Western Herbal Medicine and Nutritional Medicine under the National Registration and Accreditation Scheme (NRAS).

Members may be aware the Australian Government Department of Human Services has launched digital health records for patients. Digital health records allows practitioners including ANTA members to access patients records on a national online system.

The Intergovernmental Agreement for a National Registration and Accreditation Scheme for the health professions (IGA) signed by the Council of Australian Governments (COAG) in March 2008 has provision for cover to be extended to additional health professions if all state, territory and Commonwealth Health Ministers agree to amend the Health Practitioner National Law as it applies in each state and territory. Attachment B of the IGA advises the Australian Health Ministers’ Advisory Council established a process for determining whether to regulate any current unregulated health profession, involving assessment against six criteria. Attachment B of the IGA also advises that it has been determined that the six criteria are appropriate for assessing the inclusion of unregulated health professions in the NRAS. The ANTA submission addresses the six criteria in detail as well as the principles of best practice regulation including establishing a sound case for action, cost and benefits of regulatory options and benefits to the community with clearly identifiable outcomes. Copies of the ANTA submission have been provided to Federal, State and Territory Ministers for Health and we look forward to further discussions with ministers, HWPC and government departments to achieve registration of Naturopathy, Western Herbal Medicine and Nutritional Medicine under the NRAS. A copy of the ANTA submission for Registration of Naturopathy, Western Herbal Medicine and Nutritional Medicine is available on the ANTA website for your information and distribution to colleagues and interested parties. Regards ANTA National Council

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The Department of Human Services has advised the system provides practitioners with a way to accurately match the records to the person you are treating, improve accuracy when communicating information with other healthcare providers and enables a much more reliable way of referencing information. We have confirmed with the Department of Human Services that ANTA members are eligible to participate in the national online digital system. There is a considerable amount of information available on the digital health record and how to participate in the system. If you are interested in participating in the national digital health records system there are two main steps involved as follows: •

If you are not registered with the Department of Human Services you must provide a number of documents (certified copies) including birth certificates, passport, drivers license etc (full list of documents detailed on application) plus a copy of your ANTA Membership and ANTA Accreditation certificates. •

Follow the links below for further details and information on how to register, obtain your HPI-I and participate in My Health Record. https://www.digitalhealth.gov.au/get-startedwith-digital-health/registration https://myhealthrecord.gov.au/internet/mhr/ publishing.nsf/Content/healthcare-providers

ANTA was formed and incorporated under the Companies Act 1936 on the 31st August 1955 under the name of The Australian Naturopathic Physicians Association (ANPA) The names of the persons who formed ANTA on the 31st August 1955 (known as ANPA at that time) were: Leslie Bailey Francis Gunter Francis James John Jones William Pruss Francis Singer Henry Woodward We owe a huge debt of gratitude to the foresight and acumen of our founders. ANTA has grown significantly over more than 60 years to become the leader of the profession and representing the interests of more than 10,000 members nationally. Below is the Memorandum of Association printed in 1955.

he liver is a vital organ and the largest organ in the human body, serving basically as a very high throughput “processing plant” for metabolic and cellular waste and dietary toxins (eg. alcohol) and biological pathogens. It is also a “manufacturing plant and storage depot”, synthesizing bile salts that assist in the absorption, breakdown and transport of cholesterol and fatty acids from dietary fats, lipid-soluble vitamins (eg A, D, E and K) and trace elements (eg. iron and selenium). In addition, the liver manufactures precursors of hormones and maintains serum glucose levels. Liver disease covers a broad spectrum of dysfunction, ranging from mild to moderate loss of metabolic function, particularly progressive fat accumulation (fatty liver) to more severe damage involving fibrosis and scarring. Incredibly, the liver is endowed with an extraordinary ability to regenerate itself, able to regrow by up to 50%, and remain functional after as much as about 2/3 of it has been removed or damaged. Thankfully, there has been a 47% decrease in the incidence of premature mortality due to liver disease, from 19862012, although it remained the 11th leading cause of mortality in Australia in 2012.

form of metabolic dysfunction, such as deficiency or loss of activity of an array of specific liver enzymes, and indicates cellular stress or toxicity, but not necessarily hepatocyte damage or necrosis yet. As a result, a slowing of bile secretion (cholestasis) may occur, which decreases the ability of the liver to process absorbed fats, causing elevated circulating triglycerides, higher cholersterol levels and excessive fat storage within the hepatocytes (simple hepatic steatosis); this is exacerbated by high dietary lipids and cholesterol. If left unchecked, a pro-inflammatory state (steatohepatitis) can ensue in about 30% of cases, resulting in hepatocyte necrosis and collagen deposition (fibrosis), which greatly reduces liver efficiency and can ultimately progress to liver failure.

Maintaining liver health Since it is progressive, liver disease and the risks of secondary complications, such as hepatitis and liver cancer, are preventable by slowing down the progression. This entails minimizing or eliminating many of the key risk factors shared with cardiovascular disease:

While steatohepatitis has classically been attributed to alcohol induced hepatoxicity, non-alcoholic fatty liver disease (NAFLD) has now become the most common cause of liver disease worldwide, mainly due to the obesity epidemic. Indeed, NAFLD is now an independent risk factor in cardiovascular disease. Phosphatidylcholine - fighting fat with fat

Diet and nutrition management: • •

Minimizing intake of saturated fat, refined sugar, protein and sodium (lowers risk of obesity and associated consequences such as insulin intolerance, type II diabetes and hypertension) include more natural food sources (eating more fruit, vegetables, nuts, seeds, priobiotics etc)

Managing alcohol, smoking and intake of toxins: • •

Drinking less or reducing the frequency of alcohol intake Avoid smoking and intake of toxic chemicals (e.g. environmental or drug related compounds)

While these changes can be easier said than implemented, and are usually recommended by healthcare professionals on a case-by-case basis, opting for a more natural approach to diet and lifestyle can be very beneficial for general health and well-being. Key mechanisms Liver dysfunction generally occurs at the cellular and molecular level, especially at the earlier stages of progression. This can be in the

While it may seem counter-intuitive that a fatty acid would have beneficial effects on liver function, there has been much press about the benefits of this unassuming member of the long chain phospholipid family. Phosphatidylcholine (PC) is considered as an essential liver phospholipid that is critical for hepatocyte differentiation, proliferation, regeneration and transport of lipids and cholesterol. In the liver, PC (along with other phospholipids) contributes to maintaining the fluidity of the cell membranes of the ~300 billion hepatocytes, as well as the stability of membrane bound enzymes, receptors and intracellular membrane-dependent organelles. PC is also heavily involved in lipoprotein synthesis, and high rates of PC and free fatty acid trafficking between hepatocytes and circulating LDL/HDL occur under normal physiological condition. In diseased liver, injured or apoptotic hepatocytes, macrophages and Kuppfner cells tend to exhibit higher concentrations of oxidized PC (oxPC), especially in intracellular structures. It has been speculated only recently that compromised PC activity may also contribute a reduced fatty acid turnover via 1-carbon metabolism. There is emerging evidence that PC supplementation can mitigate liver damage, most likely via the disease related changes in PC. A small, open-label clinical trial (n = 71) was conducted on patients with histologically verified steatosis related to chronic alcoholism (AFLD) to establish the beneficial effects of a multivitamin supplement containing a proprietary blend of essential phospholipids, including phosphatidylcholine. After 3 months of treatment, patients with AFLD exhibited significant reductions in the activity of liver enzymes,

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Nu t r i e nt s -

B enef ic ia l To Liver H ea l th

Figure 1. Treatment with a phosphatidylcholine blend was improved after 3 months, as indicated by correction of the catalytic activity of specific liver enzymes in patients with AFLD (mean ± SEM. *P < 0.05 and #P < 0.01 before vs after. ALT: alanine aminotransferase, AST: aspartate aminotransferase, GMT: gamma glutamyltransferase).

relative to baseline (Fig. 1), suggesting an improvement in hepatocyte integrity and overall liver function. In another smaller interventional study from Japan, a sample

of six patients with severe liver disease, including cirrhosis and complications such as hepatitis B and C, were administered a phosphatidylcholine-rich extract of salmon roe. After treatment, patients showed a significant increase in HDL and apolipoprotein levels, which are usually severely decreased in the diseased state, indicating a partial resumption of hepatocyte activity. The improved HDL may also have a protective benefit on general cardiovascular function. Liver protective botanicals Schisandra Chinenesis: Used extensively in TCM, S. chinensis fruit is rich in lignins such as schisandrins, which have hepatoprotective effects via their combined anti-inflammatory, immunomodulatory and antioxidant properties. Schisandrin B is specifically regulates the activity of hepatocyte glutathione and heat-shock proteins, as well as inhibiting pro-fibrotic and pro-inflammatory pathways, and promoting fatty acid oxidation. In a laboratory models of liver disease, S. chinensis extract has only recently shown significant promise in halting the progress of NAFLD, by significantly lowering fat accumulation, hepatocyte stress due to defective protein synthesis and the expression of some inflammatory responses genes. In a randomised, placebo-controlled clinical trial (n = 40), patients with borderline liver dysfunction treated with S. chinensis for 5 months displayed a significant reduction in serum ALT and AST, increased a range of blood and serum antioxidants and improved ultrasound indicators of liver damage.

taurine exhibited significantly reduced AST and ALT levels (P < 0.05), significantly reduced serum cholesterol and triglyceride levels (both P < 0.05), and decreased levels of blood oxidative stress biomarkers relative to baseline values. Furthermore, taurine supplementation (in powder form) significantly reduced the prevalence of fatty liver in obese children, normalizing ALT levels even when weight management had not been achieved. The general health benefits of B-vitamins are generally well described. However, in regard to 1-carbon metabolism, folic acid, pyridoxine (vitamin B6) and cyanocobalamin (vitamin B12) often appear as a specific sub-group because of synergistic effects in this pathway. It is critical for regulating DNA synthesis and chromatin methylation, hence playing a central role in supporting cell division in large cell populations, such as the greater hepatocyte pool of the liver, especially when working as a single, high throughput functional unit. Elevated homocysteine levels have been associated with the pathogenic events of steatohepatitis, including fibrosis, oxidative stress and hepatic lipid accumulation. Compared to healthy individuals, some studies have reported that patients with NAFLD exhibit increased homocysteine levels and decreased B12 levels, compared to healthy individuals, hence there is good basis for including these vitamins in combinatorial therapies. Protective effects are also offered by the antioxidant properties of vitamin E, and potentially for selenium, based on deficits in selenium and glutathione, and general pro-oxidant states in association with advanced liver disease. Further benefits appear to be offered by vitamin D, as an antioxidant and anti-inflammatory mediator for which the liver has known metabolic processing functions. Summary There is significant hope on the nutraceutical horizon for sufferers of liver conditions, and for general maintenance of liver health, especially in the age of high stress and dietary challenges. Provided liver toxicity has been ruled out, it is more than likely that the implementation of mixed paradigm formulas using traditional herbs with chemically defined micronutrients, will continue to gain momentum. As the efficacy of such approaches as demonstrated in laboratory and preclinical studies continues to filter through to clinical trials, general awareness of naturally occurring hepatoprotective substances will hopefully shed new light on established CAM techniques. REFERENCES • • • • • • •

Cynara scolymus (Globe artichoke): Globe artichoke has a more extensive history of usage in European herbal medicine. Its leaves contain phenolic acids that include quinic acid, chlorogenic acid, caffeic acid and cynarin. These have the collective effects of stimulating the flow of bile [16], lowering blood levels of lipids, LDL and oxidized LDL and regulating cholesterol levels . A randomised, double-blind, placebo-controlled clinical trial investigated the effects a standardised globe artichoke leaf extract on serum lipid profiles in patients (n = 73) with mild hypercholesterolaemia. It was shown that administering the broad-spectrum aqueous extract for 12 weeks moderately but significantly (P = 0.025) reduced plasma total cholesterol by 6.1% when compared to the placebo group.

• • • • •

Other supportive micronutrients

• •

There are several vitamins and trace elements that support liver health, with a range of specific targets. Two basic areas include: (i) protecting liver cellular and molecular function, and (ii) regulating cholesterol and lipid balance. Regarding the latter, the amino acid taurine has been proposed to reduce apolipoprotein and vLDL secretion, increase cholesterol clearance and stimulate its turnover via the CYP7A1 enzyme. In a small group of Taiwanese patients with chronic hepatitis C (n = 24), patients treated with

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G eo rge Th o ua s

• • • •

http://www.aihw.gov.au/WorkArea/DownloadAsset. aspx?id=60129552763 Ozer J et al. 2008 Toxicology. Mar 20;245(3):194-205. Cohen, JC et al 2011. Science, 332(6037):1519-1523. Gundermann, KJ et al. 2016. Clin Exp Gastroenterol 9:10517. Vance DE 2008 Curr Opin Lipidol. Jun;19(3):229-34. Ikura Y et al., 2006. Hepatology. Mar;43(3):506-14. Walker AK, 2016. Trends Endocrinol Metab. 2016 Oct 24. pii: S1043-2760(16)30129-1. Turecky, L., et al., 2003. Bratisl Lek Listy,. 104(7-8):227-31. Hayashi H., et al. 1999. Curr Med Res Opin. 15(3):177-84. Wang, R., et al., 2007. Chin Med, 2: p5. Chiu, P.Y., et al., 2003. Free Rad. Biol. Chem. 35(4):368-380. Chu J et al., 2011 World J Gastroenterol. May 21;17(19):237988. Jang MK et al., 2016 Ethnopharmacol. Jun 5;185:96-104. Chiu, H.-F., et al., , 2013 Phytotherapy Research. 27(3):368373. Salem, M.B., et al., 2015. Plant Foods for Human Nutrition. 70(4):441-453. Rondanelli, M., et al., 2013. Monaldi Arch Chest Dis 80(1):1726. Kraft, K., 1997. Phytomedicine, 4(4):369-378 Gebhardt, R., 1998. J Pharmacol Exper Therap 286(3):11221128. Bundy, R., et al., 2008. Phytomedicine,15(9): p. 668-675. Chen, W., J.-X. Guo, and P. Chang, 2012. Molecular Nutrition & Food Research,. 56(5):681-690. Hu, H.Y., et al., 2008. Amino Acids, 35(2): p. 469-473. Obinata, K., et al., 1996. Adv Exp Med Biol, 403: p. 607-13.

* More References available from ANTA on request.

Herbs for

Depression

Recent Developments By Kerry Bone

Herbs with antidepressant activity form part of the herbal category known as the nervine tonics (or nervous system trophorestoratives). The best known example is St Johnâ&#x20AC;&#x2122;s wort (Hypericum perforatum), which unfortunately has acquired the reputation of interacting adversely with antidepressant drugs. In addition, there is some encouraging research that has highlighted some unlikely herbal candidates for antidepressant activity, namely Bupleurum (Bupleurum falcatum) and saffron (Crocus sativus). Also, perhaps not unexpectedly, the tonic herb Rhodiola now has some reasonable evidence for a supporting role in depression. This article reviews some of the recent developments for these herbs in depression, with an emphasis on the results from clinical trials. Saffron and mood: now a significant player There have been several controlled clinical trials investigating the impact of a saffron extract on mood in depressed patients (including the diagnosis of major depressive disorder, MDD). Now a group from the United States has subjected the results of those clinical trials of saffron in MDD to a meta-analysis. Based on the authors specified selection criteria, five randomised, controlled trials (RCTs) (two placebo controlled trials and three antidepressant-controlled trials) were included in the review. A large effect size was found for saffron supplementation versus placebo in treating depressive symptoms (p < 0.001), revealing that saffron significantly reduced depression symptoms compared to the placebo control. A null effect size was seen between saffron supplementation and the antidepressant drugs, suggesting that both treatments were similarly effective in reducing depression symptoms. The mean Jadad score was 5, indicating a high quality for the trials. The authors concluded that the findings from clinical trials published to date indicate saffron supplementation can improve symptoms of depression in adults with MDD. They suggested larger and longer clinical trials conducted by international research teams are needed before firm conclusions

can be made. Since that meta-analysis, there has been an additional trial in a special cohort. A significant correlation exists between coronary artery disease and depression, hence the aim of the trial was to compare the efficacy and safety of saffron versus fluoxetine in improving symptoms in patients who were suffering from depression after receiving percutaneous coronary intervention (PCI, coronary angioplasty). In this small randomised, double blind, parallel-group study, 40 patients with a diagnosis of mild to moderate depression who had undergone PCI in the last six months were randomised to receive either fluoxetine (40 mg/day) or saffron extract (30 mg/day) for six weeks. Participants were evaluated by Hamilton depression rating scale (HDRS) at weeks 3 and 6 and any adverse events were recorded. By the study endpoint, no significant difference was detected between two groups in terms of reduction of HDRS scores (p = 0.62). Remission and response rates were not significantly different as well (p = 1.00 and p = 0.67; respectively). Also there was no significant difference between the two groups in frequency of adverse events during the trial. As some indication of what might be active in saffron, the carotenoid compound crocin (a major component that contributes to its intense yellow/orange colour) has also been investigated as an adjunctive treatment in MDD. This study was a placebocontrolled, pilot RCT over 4 weeks in 40 MDD patients. The crocin group (n = 20) was given one selective serotonin reuptake inhibitor (SSRI) drug (fluoxetine 20 mg/day or sertraline 50 mg/day or citalopram 20 mg/day) plus crocin tablets (30 mg/day). The placebo group (n = 20) was administered one SSRI (fluoxetine 20 mg/day or sertraline 50 mg/day or citalopram 20 mg/day) plus placebo (two placebo tablets per day). Both groups completed Beck depression inventory (BDI), Beck anxiety inventory (BAI), a general health questionnaire (GHQ), the mood disorder questionnaire (MDQ), a side effect evaluation questionnaire, and a demographic questionnaire before and after one month of intervention. The crocin plus SSRI drug group showed significantly improved scores on BDI, BAI and GHQ compared to the placebo plus SSRI drug group (p < 0.0001). THE NATURAL THERAPIST Volume 31 No.3

H er b s Fo r D e p re s s i o n

Ker r y B o n e

The mean decreases in BDI, BAI and GHQ scores in the SSRI plus placebo group were 6.15, 2.6 and 10.3 respectively; whereas corresponding values in the SSRI plus crocin group were 17.6, 12.7 and 17.2 by the end of the 4-week trial. The study was hampered by poor patient compliance with medications and a short trial period. Although the trial immediately above was using crocin and not saffron, it does suggest the herb is safe with conventional SSRIs. Such a conclusion is also backed up by trials of saffron in men and women with sexual dysfunction while taking SSRIs. This is further supported by experimental data that saffron’s neurotransmitter impact is more likely to be at NMDA (N-methyl-D-aspartate) and Sigma-1 receptors in the brain, rather than serotonin receptors. There are other possible mechanisms of action for saffron in depression. These were recently reviewed by an Australian team, who first conducted a systematic review of clinical trials. From this 2014 review, the authors concluded the clinical trials conducted so far provide initial support for the use of saffron in mild to moderate MDD. In terms of mechanisms, they highlighted saffron’s antidepressant effects are potentially due to its antioxidant, antiinflammatory, neuroendocrine and neuroprotective effects. The authors also suggest a possible serotonergic effect, but concede the evidence here is very limited (confined to one rodent study not using a depression model). Consistent with these proposed mechanisms for saffron, two other key hypotheses (besides the neurotransmitter hypothesis) of what possibly underlies depressive illness are receiving increasing research attention: neuroinflammation (with associated increased oxidative stress, decreased neuronal plasticity and mitochondrial dysfunction) and dysregulation of hypothalamuspituitary-adrenal (HPA) axis function.As noted briefly above, the Australian review suggests that saffron could be acting to correct these pathophysiologies, rather than having any direct impact on serotonin neurotransmitter function (or perhaps in conjunction with a mild effect on serotonin neurotransmission that would not create any interactive risk with SSRIs). Rhodiola: active and less side effects than sertraline The first clinical study of Rhodiola in depression was a 6-week RCT (n=99), published in 2007. Two doses of the herbal extract (340 or 680 mg/day) were compared against a matched placebo. Results revealed that depression, insomnia and emotional instability all improved in both Rhodiola groups. More recently there has been a 12-week RCT (n=57), where Rhodiola extract (340 mg/day) was compared with the drug sertraline (50 mg/day) or a placebo. The Rhodiola extract was active compared to the placebo, but less so than drug. However, the herb did show fewer side effects. The postulated mechanism for Rhodiola in depression via animal models is improved sensitivity of the glucocorticoid receptor (GR) via a downregulation of stress-activated protein kinases (SAPK). SAPK, also known as JNK, are released in response to stress and pro-inflammatory cytokines. They are thought to play a key role in in the links between HPA axis overactivity, neuroinflammation and depression.

A surprising result for Bupleurum Chinese herb Bupleurum has been regarded in China as effective to improve depression, but the mechanism of action remains unknown. Low levels of nerve growth factor (NGF) and brainderived neurotrophic factor (BDNF) increase the likelihood of developing the depression, although their role is controversial. Recently a group of Chinese researchers investigated whether Bupleurum could help depression in a clinical trial setting, and whether it did so by increasing these factors. A total 160 haemodialysis patients diagnosed with depression were randomly assigned to two groups: Bupleurum (1 g root power in a capsule daily) and a control group (placebo). After a three-month follow-up the patients who received Bupleurum were found to have an improvement in depression symptoms, anxiety symptoms and general functioning, versus the control group (p < 0.05). Serum NGF levels were significantly higher in the patients taking Bupleurum (178.64 ± 52.18 pg/ mL) when compared to control patients (103.54 ± 31.23 pg/mL) (p < 0.01). Similarly, serum BDNF levels were significantly higher for Bupleurum (1635.26 ± 121.66 pg/mL) versus the control group (516.38 ± 44.89 pg/mL) (p < 0.01). These serum levels of NGF and BDNF were negatively related with the Montgomery-Asberg Depression Rating Scale (MADRS) and positively related to a score of quality of life (p < 0.01). The authors concluded that the herb ameliorates depression by increasing serum levels of NGF and BDNF. The surprising finding here was the huge increase in serum BDNF induced by Bupleurum; it was about triple the average in the control group. Although this clinical study was in a special cohort (haemodialysis patients), the remarkable boost in BDNF suggests Bupleurum might have potential in other situations associated with reduced neuroplasticity, such as traumatic brain injury and brain ageing. References: • • • • • • • • •

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Hausenblas HA, Saha D, Dubyak PJ et al. J Integr Med 2013; 11(6): 377-83 Shahmansouri N, Farokhnia M, Abbasi SH et al. J Affect Disord 2014; 155: 216-222 Talaei A, Hassanpour Moghadam M, Sajadi Tabassi SA et al. J Affect Disord 2015; 174: 51-56 Hausenblas HA, Heekin K, Mutchie HL et al. J Integr Med 2015; 13(4): 231-240 Lopresti AL, Drummond PD. Hum Psychopharmacol 2014; 29(6): 517-527. Darbinyan V, Aslanyan G, Amroyan E et al. Nord J Psychiatry 2007; 61(5): 343-348. Mao JJ, Xie SX, Zee et al. J Phytomedicine 2015; 22(3): 394399 Bone K Mediherb e-Monitor no. 19, 2007, p1 Wang X, Feng Q, Xiao Y, Li P. Int J Clin Exp Med 2015; 8(6): 9205-9217.

Remedial massage for foot and ankle osteoarthritis George Wu

Because of this concentrated stress, the foot and ankle are often involved in static deformities not ordinarily affecting other parts of the body. Overview: Arthritis is inflammation of one or more of joints. It can cause pain and stiffness in any joint in the body, and is common in the small joints of the foot and ankle. There are over 100 types of arthritis. The most common forms are osteoarthritis (degenerative joint disease) and rheumatoid arthritis. Osteoarthritis is a disease that affects the whole joint including bone, cartilage, ligaments and muscles. It may include: • • •

inflammation of the tissue around a joint damage to joint cartilage bony spurs growing around the edge of a joint

Osteoarthritis is a progressive disease; signs and symptoms gradually worsen over time. There is no cure. Anatomy of foot and ankle osteoarthritis: Three bones make up the ankle joint, primarily enabling up and down movement. There are 28 bones in the foot and more than 30 joints that allow for a wide range of movement. The foot and ankle are the focal points to which the total body weight is transmitted in ambulation, and they are well tailored to that function. The thick heel and toe pads perform as shock absorbers in the acts of walking and running and the joints are capable of the adjustments necessary for fine balance on a variety of terrain.

Cause of foot and ankle osteoarthritis: Osteoarthritis also known as degenerative or “wear-andtear” arthritis, it is more common among females than males, especially after the age of 50 years. Younger people may also be affected; usually after an injury or as a result of another joint condition. Symptoms of foot and ankle osteoarthritis: • • •

Tenderness or pain (when walk, or bear weight) Stiffness (especial in the morning) Swelling in the joint

Benefit of massage for foot and ankle osteoarthritis: • • • • •

Improving circulation Reduce swelling Relax and soften injured, tired, and overused muscles Increase joint flexibility Reduce pain

Massage techniques: Effleurage A Effleurage each digit firmly from phalanges to tarsus. B Effleurage from phalanges to tarsus cover all dorsal surfaces. C Effleurage along Achilles tendon with finger.

(A)

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R em e d i a l M as s ag e - Os teo a r th r itis G eo rge Wu

(B)

Knuckling

Kneading Thenar eminences together on dorsum; fingers on plantar surface, gently separate each metatarsal using a scissoring action. Work medial to lateral.

Circular and rectilinear frictions to plantar surface, using knuckles and fists

Passive movements to foot •

• • • • Friction

•

Thumb friction cross fiber, backwards and forwards, on both sides of the ankle ligaments

• • • • • •

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Rotation of phalanges: Grasp proximal phalange with one hand, support proximal to MTP joint with other hand. Rotate each phalange slowly and gently in both (clockwise and anticlockwise) directions. Traction of phalanges: Support at above. Apply tension gently to separate joint. (Use a hand towel if a better grip is needed.) Extension of phalanges: Support proximal to MTP joints with one hand. Grasp phalanges with other hand and gently extend Flexion of phalanges: Support as above. Grasp phalanges with other hand and gently traction and flex. Rotation of talo-tibial joint: Support calcaneus with one hand; other hand proximal to MTP joint. Rotate talo-tibial joint clockwise/anti-clockwise/figure of 8. Dorsiflexion of talo-tibial joint: Support calcaneus with one hand and lift slightly; other hand on plantar surface. Move foot into dorsiflexion, using body weight. Plantar flexion of talo-tibial joint: Support calcaneus with one hand and lift slightly; other hand on dorsum. Move foot into plantar flexion. Inversion: Thumbs together on dorsum, proximal to MTP joints, turn plantar surface medially. Eversion: Thumbs together on dorsum, proximal to MTP joints, turn plantar surface laterally foot into dorsiflexion, using body weight. Plantar flexion of talo-tibial joint: Support calcaneus with one hand and lift slightly; other hand on dorsum. Move foot into plantar flexion. Inversion: Thumbs together on dorsum, proximal to MTP joints, turn plantar surface medially. Eversion: Thumbs together on dorsum, proximal to MTP joints, turn plantar surface laterally.

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Use it – so you don’t lose it By Natasha Burr, Senior Account Executive, Arthur J. Gallagher Insurance Brokers

Several thousand members of ANTA are insured through Arthur J. Gallagher. Fingers crossed, this involves little more than a quick check-in with their broker each year and a straightforward renewal process. That’s the way you like it, and that’s the way we like it because it tells us that all is going smoothly with your business. Things become a bit more complicated in the event of a claim. Luckily, claims incidences in the natural therapies space are few and far between. However, they do happen and when they do they can be extremely stressful for the individual, as well as damaging to their business. That’s when the insurance process really proves its value and makes good on its promises to policyholders. However, you’d be surprised at how often policyholders overlook this vital aspect of insurance in the event of a claim being made against them. Here at Arthur J. Gallagher, we have more than 15,000 natural therapist clients across Australia, so a fair few claims cross our desks every year. The most alarming examples, from our perspective, are when we are informed of an insured event (i.e. any incident that would cause an insurer to pay a claim) weeks, or even months after they have occurred. This is troubling, because not declaring these events can invalidate your insurance policy in the result of a claim being made against you. Don’t suffer in silence When it comes to insurance, the golden rule is to make sure you are absolutely transparent with your insurer or broker. This means you should contact them immediately if any of the following incidents occur:• A client is injured on your premises • A client makes a complaint against your services or advice you have provided – even if this seems a minor complaint • You have branched out into new lines of business or modalities – or in fact made any changes whatsoever to your business, including your activities/modalities or location Even if the event doesn’t lead to a claim being made against you, providing as much information is vital. If nothing else it could help provide peace of mind knowing that your insurance will protect you and that you have someone on your side. That’s where brokers are particularly useful. They work for you, not the insurer, and in the event of a claim they are able to manage that whole process and negotiate the best outcome for you. A good analogy for this is a parachute. If you had a parachute on your back and you were plummeting towards the earth at high speed, you’d pull the cord to avoid a messy end. Insurance acts in a similar way, protecting you and your business from financial and reputational harm in the event of a claim. That’s why you pay for insurance, so make sure you use it to the maximum benefit. Arthur J. Gallagher is the endorsed insurance broker of the ANTA. For more information on how we can help you, call 1800 222 012 or visit www.ajg.com.au/anta/

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Traditional Chinese Medicine and Functional Gastrointestinal Disorders Tony Reid

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TRADItiONAL CHINESE MEDICINE and FUNCTIONAL GASTROINTESTINAL DISORDERS Part 2 Gastroesophageal Reflux Disease (GERD) ‘I go to a famous physician, I sleep in the local hotel. From what I can see Of the people like me We get better But we never get well.’ (Paul Simon, 1983) INTRODUCTION I was intrigued by a statement in David Healey’s recent book, which implied that the vested interests of industry had influenced the diagnosis and treatment of gastric reflux in a similar way to that in which normal human sadness had been transformed into a multibillion dollars’ a year business through the marketing of ‘depressive disorders’ and their treatment with the SSRI class of drugs.(Healey, 2012, pp. 53-54). I have discussed the latter issue at some length previously (Reid, 2010; Reid, 2015), and in light of these efforts I began to gather together various papers from the mid 1980’s onwards in support of this idea. It soon became apparent that the gradual morphing of the functional disorder known as gastric reflux (GR) into the clinical entity of gastroesophageal reflux disease (GERD) corresponded in timing with the rediscovery of Helicobacter pylori by Marshall and Warren, and their research linking it with gastric and duodenal ulcers.(Marshall, Warren, 1894) With the acceptance of a bacterial cause for peptic ulcer disease, the primary treatment now became antibiotics, which displaced drugs such as Zantac (ranitidine) and Prilosec (omeprazole). The former drug is an histamine 2 (H2) blocker, the latter a proton pump inhibitor (PPI), and both classes of drugs work to reduce gastric acid production. As research had already demonstrated that there is a correllation between severe and persistent GR and oesophageal carcinoma, it was relatively easy to give disease status to GR, and by association link all cases of troublesome reflux, including relatively mild ones, with some degree of cancer risk. Another interesting thing I found was that the early guidelines stipulated various tests to determine how frequently the contents of the stomach entered the esophagus and how much acid was involved. Endoscopy was often used in order to assess the degree of esophageal inflammation and whether or not there was dysplasia.(Kahrilasa, Shaheenb & Vaezic, 2008; Fisichella & Patti, 2008). In this way a cut-off point was established below which patients simply had troubling GR and above which they had GERD – an actual disease, which mandated serious treatment by means of acid reduction with histamine 2 blockers or, more commonly with PPI’s. However, the current clinical guidelines for GERD assert that doctors do not need to carry out any of the elaborate, time consuming and

costly tests; that all people complaining of heartburn most likely have GERD; and that all should be given PPI’s as the treatment of choice. (Katz, Gerson, Vela, 2013; NICE, 2014, Patti, 2016). While treatment with PPI’s does provide relief from the troublesome symptoms caused by the erosive and irritating effects of gastric acid, helping to stop the inflammation and prevent morbidity, it does not stop the mechanism that caused the reflux in the first place, and this continues unabated. Thus, PPI’s must be given long term or the problem returns. However, as discussed in part one of this paper, there are serious health concerns with the long term use of PPI’s, namely an increased risk for the following: • Nutritional deficiencies (e.g. B12) • Food poisoning • Dysbiosis • Pneumonia • Bone loss • Hip fractures • Infection with Clostridium difficile • Dementia • Renal disease • Heart disease (Reid, 2016) The most important issue that is left unanswered by this approach is that gastric acid is not the real culprit here. Gastric acid secretion is vital to digestion and hence to health. In fact, there is emerging evidence that the lower esophageal sphincter (LES), which is responsible for stopping the stomach contents from entering the esophagus, is directly controlled by gastric acid levels, the rise of which causes it to contract.(Stiennon, 1995; Wright, 2009; Wright & Lenard, 2001). It has been estimated that 25 - 40% of healthy adult Americans experience symptomatic ‘GERD’, most commonly manifested clinically by pyrosis (heartburn), at least once a month. Furthermore, approximately 7 - 10% of the adult population in the United States experiences such symptoms on a daily basis. Since the condition is closely linked to Western lifestyle and dietary habits (one might even say ‘caused by’ such factors), we can expect to see similar prevalence throughout the Western world.(Richter, 1992; Herbella et al., 2007; Patti, 2016) It is likely, moreover, that these figures are actually much higher, as many of these people do not seek medical help.(Harmon & Peura, 2010; Talley & Ford, 2015).Thus, gastric reflux is a very common problem in the community, one that is very poorly understood and even more poorly treated by conventional medicine. Importantly, the research agenda for the diagnosis and treatment of this condition has been hijacked by vested interests, and therefore it is highly unlikely that any paradigm shift or significant development will occur in the near future. Such a deplorable state has only one redeeming feature: the early detection of cancer in those patients at high risk. However, since the vast majority of people who experience reflux are not at significant THE NATURAL THERAPIST Volume 31 No.3

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short term risk and since this condition may readily be corrected by lifestyle changes (principally the intelligent management of the diet) and herbal medicines, I have chosen not to discuss the orthodox Western approach in detail. Instead, without further ado, let us examine how this health issue is dealt with in TCM. The TCM Approach to GR: the Stomach and the middle Jiao In TCM the internal organs and their functions are paired according to Yin-Yang: Liver-Gallbladder; Heart-Small Intestines; SpleenStomach; Lung-Large Intestine; Kidney-Bladder. Of these pairs, the Spleen and Stomach have the closest relationship and may be considered as a single unit, often referred to by their location within the body: the middle Jiao (which they share with the Liver Yang). The Chinese word Jiao is understood in this context to signify a body cavity (although in other contexts it may mean ‘roasted’ or ‘burnt’). The upper Jiao contains the Heart and Lung, while the lower Jiao contains the Kidney, Bladder and Liver Yin. The Stomach works closely with the Spleen to digest and absorb nutrients. The Qi of the Stomach, which is the yang organ of this pair, has a descending (i.e. yin type) movement, i.e. it sends the partially digested matter down to the Small Intestine for further processing. This is part of the general trend for ‘turbid Yin’ (i.e. waste) substances to be sent downward for excretion. The Qi of the Spleen, which is the yin organ, has an upwards and outwards (i.e. yang quality) direction of activity. This ensures that the ‘clear Yang’ products of digestion (i.e. vital nutrients) are distributed throughout the body from the middle Jiao. Thus, according to the traditional theory, the middle Jiao is responsible for normal assimilation of nutrients as well as normal elimination of waste material. Both the Stomach and Spleen are involved in the various aspects or stages of these two processes. If digestion is strong, elimination will also be complete and effective; if digestion is disturbed, elimination will also be affected. Moreover, if the functions of only one member of this pair are disrupted in some way, there will be a reflex disruption of function in the other organ. If the Stomach Qi becomes injured due to dietary factors or pathogens, not only will this have an effect on appetite and digestion; it will also impair the processes that control the elimination of waste materials. The major physiological functions of the Stomach are to receive and digest solid and liquid foods. This activity depends upon the Spleen’s ‘transformation’ (i.e. digestion) and ‘transportation’ (i.e. distribution of nutrients) functions . If the Stomach Qi becomes disturbed, due to the effects of various pathogenic factors, it may counterflow upward, resulting in reflux, belching, hiccup, nausea or vomiting. When the Stomach Qi loses its normal direction of movement, the Spleen Qi will be affected in a similar way. This may cause the stools to become loose or sloppy (or even diarrhea), with poor absorption of nutrients. In addition, waste materials are no longer effectively processed and internally generated pathogens, such as Damp, Heat and Phlegm may develop. TCM emphasises the crucial role of the middle Jiao in health maintenance and recovery from illness. Often, the critical first step in the journey through which one takes full responsibility for one’s state of health is to restore the normal healthy functioning of the digestive system – as so eloquently described by the author, Upton Sinclair.(Sinclair, 1911). Clearly, if a treatment is given that only masks the symptoms of digestive disorder without correcting the underlying condition, patients are condemned to a poor state of health for the rest of their lives. Gastric Reflux in TCM In the 14th century, Zhu Dan-xi described gastric reflux, noting that in some cases, which are more severe, esophageal constriction was a likely consequence. Zhu was also the first to describe the formula Zuo Jin Wan, which has a strong anti-reflux and anti-

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emetic action. (Yang, 1993, pp.25-30, 206-208). Zuo Jin Wan is frequently used today as a base formula, to which other herbal ingredients are generally added, in the treatment of this disorder (Maclean & Lyttleton, 2002, pp. 110-133). Aetiology Gastric reflux (fan suan) is generally discussed as an appendix to the heading of Epigastric Pain (wei wan tong) in traditional Chinese Internal Medicine (nei ke). The causes are primarily inappropriate dietary habits and emotional strain. The former affects the Stomach and Spleen; while the latter affects the Liver. Although either of these two factors alone may lead to GR, commonly both are involved to some extent. Inappropriate diet includes: consumption of too many Heating foods (e.g. chillies, alcohol, coffee); specific foods to which an individual has a specific sensitivity (e.g. citrus fruits, radishes, garlic); irregular timing of meals, including eating soon before retiring at night, eating when feeling stressed or while walking or rushing around; eating excessive quantities of food; consuming too many Cold and cooling foods; inappropriate fasting or strict dieting. As noted above, Western dietary habits appear to have a lot to do with the high incidence of gastric reflux throughout the postindustrial, globalised, free market economies. In particular, obese patients are more prone to developing this condition.(Patti, 2016). These facts tie in very neatly with the TCM perspective. The effects of stress and emotional strain are also common causes, as these may affect the Liver leading to Liver constraint and Qi stagnation. Emotional suppression, (e.g. of socially unacceptable emotions such as anger), prolonged frustration, disappointments, unfulfilled desires (often provoked by consumer advertising), amongst other things, disrupt the Liver’s function of ensuring the smooth and even flow of the Qi throughout the body. The Spleen may be injured by inordinate worrying, obsessive thinking and prolonged concentration, predisposing to invasion of the Spleen by the Liver Qi. Moreover, Spleen Qi deficiency may manifest in the failure of the Spleen Qi to ascend. This leads to failure of the Stomach Qi to descend with subsequent counterflow ascent of the Stomach Qi. (Maclean & Lyttleton, 2002, pp.104106; Flaws & Sionneau, 2001, p.455; Shi, 2003, p.70). Another very important factor in our particular cultural setting is the lack of exercise associated with our sedentary lifestyle. This has a profound influence on both the Liver Qi as well as the Spleen. If we compare the activity levels of people in preindustrialized and so-called primitive societies with those of our contemporaries, we can infer that normal activity levels for humans must be several orders of magnitude greater than those practiced by most of the present population. Even allowing for human adaptability, a healthy level of physical activity may only be achieved by very few people. In TCM terms, physical activity is necessary to support the Liver’s function of ensuring that the Qi flows smoothly and evenly; it is also necessary to maintain muscle tone and strength, which supports Spleen function. Thus, prolonged and persistent lack of exercise may lead to stagnation of the Qi and Liver constraint together with Spleen Qi deficiency (Maclean & Lyttleton, 2002, pp. xx,xxi). Pathogenesis The various factors described above set in train a series of pathological changes that ultimately result in disordered movement of the Stomach Qi. As described previously, the normal directional movement of the Stomach Qi is downwards, propelling the contents of the stomach into the duodenum and small intestines and from there to large intestine. As a result of the above pathological changes, instead of sending the stomach contents downwards, the Stomach Qi now sends the stomach

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contents upwards and this is referred to as counterflow (qi ni) of the Stomach Qi, also referred to as ‘rebellious Qi’. Excess and Deficiency Patterns According to the science of Yin-Yang, the same effect may be produced by causes, which are opposite in nature. In TCM these causes are broadly classified into excess and deficiency types. In the former, there are pathogenic factors present that need to be eliminated; while in the latter, various aspects of functional activity are lacking. A pathogenic factor (a.k.a. ‘pathogen’) may have several effects, e.g. sensations of heat, sensations of cold, sensations of heaviness, pain or swelling. However, the one constant is that pathogens create stagnation. This is envisaged as an obstructive influence on the free movement of the Qi, Blood and body fluids. In the digestive tract stagnation of the Qi and stagnation of the fluid metabolism pathways and stagnation of the movement of the GIT contents are the critical factors, as will be seen in the next section, below.

Phlegm may develop in the Stomach and Spleen in three main ways: Spleen deficiency, Damp-Heat and Liver constraint. Thus, Phlegm is usually seen clinically as a complication of these other conditions. In essence, disorders due to Phlegm may be regarded as a further development, or more severe form of disorders due to Damp (above). Generally, they are long term conditions and the underlying disorders that lead to the development of Phlegm are more pronounced. As this pathogen has a very strong tendency to cause stagnation, it obstructs the normal Qi movements of the middle Jiao (i.e. the Stomach and Spleen), leading to counterflow of the Stomach Qi and GR. Key clinical features include a sticky feeling in the mouth, sense of dryness in the mouth but no desire to drink, a greasy tongue coat and a slippery pulse.

4. Spleen-Stomach Qi (or Yang) deficiency: The Spleen-Stomach may become deficient due to the effects of ageing, chronic illness, malnutrition (including prolonged or inappropriate fasting), constitutional weakness or a combination of these factors. In addition, the excessive consumption of Cold natured foods (such as raw foods, refrigerated items, iced drinks and fruit juices) may weaken the Yang Qi of the Spleen and Stomach, leading In contrast to the effects of pathogens, which create stagnation by to a more severe state of deficiency that is characterised by signs of obstruction, deficiency patterns lead to stagnation due to a lack of Cold (e.g. cold hands and feet, sensitivity to the cold), as well as fluid motive force to move the contents of the stomach and intestines as retention. This state of deficiency means that the functional potential well as to drive the pathways of fluid metabolism. These processes of the digestive system has become considerably reduced, leading lead to the pathological accumulation of partially digested food to reduction, or failure, of the various digestive functions. It manifests material as well as partially metabolised fluids, generating pathogens in poor appetite, feeling full after only eating a small amount of food, in a vicious cycle that worsens the stagnation and places an even loose stools, muscular weakness, generalised wasting and also GR. greater burden on an already weak system. The reason GR occurs is that one of the normal functions of the middle Jiao is to maintain the proper directional flow of the Qi. When One of the main effects of stagnation, particularly in the Stomachthis function starts to fail the Spleen Qi begins to go downwards Spleen system is that it disrupts the normal movements of the Qi (resulting in loose stools) and the Stomach Qi begins to counterflow in the middle Jiao, causing a reversal of direction leading to Qi upwards (resulting in GR). counterflow. Clinical Syndrome-Patterns Clinically, there are seven commonly seen syndrome patterns underlying this phenomenon, all deriving in various ways from the two primary factors mentioned in the previous section:

5. Liver constraint, Qi stagnation: As a result of stress and emotional strain, the Liver fails to adequately maintain the smooth and even flow of Qi throughout the body and the Qi begins to stagnate. In particular, the Qi of the Liver becomes obstructed and builds up tension such that the Liver Qi moves erratically, referred to as ‘Liver constraint, Qi stagnation’. This may manifest on an emotional level as emotional volatility with sudden outbursts. It may also manifest physically, with disordered function of the Stomach and Spleen. In health, the Liver provides support and direction for the normal movements of the Spleen Qi and the Stomach Qi. However, with Liver constraint, the Liver Qi now ‘invades’ the Spleen-Stomach and disrupts their functions. Thus, under the influence of a malfunctioning Liver, the Stomach Qi now moves upwards (giving rise to reflux) and the Spleen Qi may now move downwards (giving rise to loose stools or diarrhea). The characteristic feature of this pattern is that the GR is brought on or worsened by stress and emotional strain.

1. Food stagnation: When the quantity of food eaten exceeds the capacity of the Stomach and Spleen to process it, a residue of partially digested material remains in the Stomach. This residue is referred to as ‘stagnant food’ and gives rise to the syndrome pattern referred to as ‘food stagnation’. This means that the residual undigested food mass has become pathogenic and causes the Qi of both Stomach and Spleen to become stagnant. The major consequence of stagnation of the Stomach Qi is that the Stomach Qi loses its normal direction of movement and tends to either fail to move at all or it begins to move in the opposite direction, resulting in counterflow upward movement, which underlies the mechanism of GR. In younger and middle aged patients, this is a very common cause for GR. 6. Stomach and Liver Heat: Excessive consumption of Heating foods (such as chillies, alcoholic 2. Retained Damp (either Cold-Damp and Damp-Heat): beverages (specifically spirits), coffee, chocolate and deep fried In chronic GR these pathogens are internally generated, generally as items) may eventually have the opposite effect on the Stomach a result of inappropriate food choices, which over time weaken the to that produced by the excessive consumption of Cold natured Spleen. The Spleen’s ability to process fluids becomes impaired and food (as discussed in point 4, above), i.e. the Stomach may pathological fluid accumulates and stagnates. This scenario leads become over-heated. This is conceptualized in TCM as a type of to the development of Damp, which may be accompanied by either pathogenic Qi (i.e. Heat), which produces characteristic signs and Cold or Heat. The stagnating effect of these pathogens causes the symptoms (dry mouth and lips, epigastric burning sensation, red Stomach Qi to counterflow upwards. Some key clinical features are tongue with a yellow coat). The Heat pathogen disrupts the normal bloating (especially after eating), increased respiratory secretions, directional flow within the middle Jiao, and the tendency of Heat to sensation of bodily heaviness, mental dullness (with an increased rise upwards causes the Stomach Qi to follow suit. This condition desire for caffeinated beverages), a thick tongue coat, loose stools or may be aggravated by long term Liver constraint, Qi stagnation (as diarrhea. discussed in point 5, above), which has a tendency to develop Heat, which may be transferred to the Stomach as the Liver Qi invades the 3. Phlegm: Stomach. We usually think of phlegm in terms of respiratory system pathology. However, TCM regards pathological changes in the digestive 7. Stomach and Liver Yin deficiency: system as one of the principal sources of Phlegm (the pathogen). This condition may arise due to the effects of ageing, in the aftermath THE NATURAL THERAPIST Volume 31 No.3

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of a febrile illness or as a further development of the Stomach and Liver Heat (described above). The Yin and fluids become depleted within the Stomach and Liver, generating deficiency Heat within these organ systems. As Heat tends to rise upwards in the body, the Stomach Qi will counterflow upwards, and the disordered Liver Qi will also contribute to this process by ‘invading’ the Stomach (Maclean & Lyttleton, 2002, pp. 110-133; Flaws & Sionneau, 2001, pp. 455-458).

normal or pale tongue with a thin white coat, wiry pulse.

Treatment

Bitter taste in the mouth, dry throat, distending pain in the hypochondria, irritability, red tongue with a yellow coat, wiry-rapid pulse.

Treatment should be primarily directed to lifestyle changes – appropriate adjustments to the diet, daily exercise and stress management. While herbal and other natural medicines are highly effective in providing symptom relief and correcting the underlying imbalances, unless the causative factors are addressed, the condition is bound to recur. As mentioned in Part 1 (Functional Dyspepsia), recent studies have shown that simply by reducing food intake, the majority of patients will experience remission of GR. (Randhawa, Gillessen, 2013; Randhawa, Mahfouz, Selim, Yar, Gillessen, 2015) The key point in dealing with GR is intelligent management of the diet. The patient must learn to only eat when truly hungry; the stomach must be permitted to empty before more food is taken in. This is a very simple principle, that is rarely fully understood nor followed, particularly in Western countries where food is abundant all year around. The other aspect to this concept of food stagnation is to avoid overfilling the stomach at each meal. Again, this is a very simple principle, that is generally overlooked. Commonly used classical herbal formulas: • •

• • • •

Food stagnation: Bao He Wan Liver constraint, Qi stagnation (with or without stagnant heat); Liver Qi invasion of the Stomach: Si Ni San, Chai Hu Shu Gan San, Dan Zhi Xiao Yao San (a.k.a. Jia Wei Xiao Yao San) Stomach and Liver Heat: Hua Gan Jian, Zuo Jin Wan Retained Phlegm-Damp: Ping Wei San, Er Chen Wan, Wen Dan Tang Spleen-Stomach Qi (or Yang) deficiency: Xiang Sha Lui Jun Zi Tang, Fu Zi Li Zhong Wan Stomach and Liver Yin deficiency: Yi Guan Jian (Maclean & Lyttleton, 2002, pp. 110-133; Flaws & Sionneau, 2001, pp. 456-458; Shi, 2003, pp.70-71)

TREATMENT PROTOCOLS WITH PREPARED CHINESE HERBAL FORMULAS Food stagnation Dull epigastric pain or discomfort with a sensation of fullness and distention, malodorous belching, nausea or vomiting, discomfort is alleviated by belching or vomiting or passing flatus, alternating loose stools and constipation, thick and greasy tongue coat, slippery or wiry-slippery pulse. P/T: Resolve food stagnation and promote digestion, redirect the Stomach Qi downwards. Bao He Wan (Citrus & Crataegus Formula BP004) a.k.a. DIGEST-AID FORMULA (Bao He Xiao Shi Fang) CM102 Variations: • Severe reflux + Ban Xia Hou Po Tang – Jia Wei (Pinellia & Magnolia Combination BP067) Liver constraint, Qi stagnation Sensation of distention in epigastrium and/or hypochondria, symptoms brought on by stress and emotional strain, sighing,

THE NATURAL THERAPIST Volume 31 No.3

P/T: Soothe the Liver to relieve constraint, regulate the Qi and harmonise the middle Jiao. REFLUX & DYSPEPSIA FORMULA (He Wei Li Qi Fang) CM137 Liver Fire invading the Stomach

P/T: Clear Heat from the Liver and harmonize the Stomach. Zuo Jin Wan (Coptis & Evodia Formula BP093) + Chai Hu Shu Gan Wan (Bupleurum & Cyperus Combination BP006) a.k.a. QI MOVER FORMULA (Chai Hu Shu Gan Wan) CM193. Spleen-Stomach Qi or Yang deficiency Poor appetite, bloated sensation in the epigastrium, feels better with application of warmth and pressure, loose stools, pale tongue with a white and moist coat, wiry-thready pulse. P/T: Warm-tonify the middle Jiao, strengthen the Spleen and harmonize the Stomach. Xiang Sha Liu Jun Zi Wan (Saussurea & Cardamon Formula BP028) a.k.a. DIGESTIVE TONIC FORMULA (Xiang Sha Liu Jun Zi Tang) CM155. Variation: a) Food stagnation (reflux occurs after eating or worsened by eating, thick tongue coat) + Bao He Wan (Citrus & Crataegus Formula BP004) a.k.a. DIGEST-AID FORMULA (Bao He Xiao Shi Fang) CM102 b) Marked Yang deficiency (cold intolerance, cold extremities, deep-slow pulse) Fu Zi Li Zhong Wan – Jia Wei (Dangshen & Ginger Formula M* BP070) Turbid Damp or Phlegm-Damp retention Fullness and distention in the epigastrium, sensation of bodily heaviness and fatigue that is better with exercise, loose stools, possibly excessive mucous production (nose or lungs), thick and greasy tongue coat, moderate or slippery pulse. P/T: Dry damp and resolve Phlegm, promote Spleen function, move the Qi and harmonize the Stomach. Ping Wei San (Magnolia & Ginger Combination BP088) – more Damp Or Ban Xia Hou Po Tang – Jia Wei (Pinellia & Magnolia Combination BP067) – more Phlegm Variations: c) Severe condition + Wen Dan Tang (Bamboo & Hoelen Formula BP050) a.k.a. CLEAR THE PHLEGM FORMULA (Wen Dan Tang) CM180 Yin deficiency of the Spleen-Stomach Post febrile illness, elderly patient or Yin deficiency constitution (body tends to overheat and there are signs of Dryness, such as constant thirst, dry skin, dry eyes, etc.), normal or dry stools, experiences gastric discomfort when eats or drinks quickly (i.e. feels more comfortable when eating slowly and drinking small sips of liquid), red tongue with scanty coat, thread pulse that may also be rapid.

Digesti ve H e al t h

To ny R eid

P/T: Nourish the Yin and harmonise the middle Jiao. Zhi Yin Gan Lu Yin (Rehmannia & Asparagus Formula BP052) Variation: a) With constipation: + Run Chang Wan (Linum & Rhubarb Formula BP019 b) With Spleen Qi deficiency (normal or loose stools): + Shen Ling Bai Zhu San (Ginseng & Atractylodes Formula BP020)

National Institute for Health and Care Excellence (NICE), (2014). Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. Retrieved, July 25, 2016 from: https://www.nice.org.uk/guidance/cg184 Patti, M. (2016). Gastroesophageal Reflux Disease. From eMedicine, Gastroenterology. Retrieved July 22, 2016 from: http:// emedicine.medscape.com/article/176595-overview Reid, T., (2010). Depression – A Multifaceted Problem. EJOM. 6(5):32-47

REFERENCES Dickman, R., Schiff, E., Holland, A., Wright, C., Sarela, S., Han, B., Fass, R. (2007). Clinical trial: acupuncture vs. doubling the proton pump inhibitor dose in refractory heartburn. Aliment Pharmacol Ther. 26(10):1333-44

Reid, T., (2015). The Limitations and Misuses of Evidence-Based Medicine: A Critical Evaluation. JCM. 108:15-30

El-Seraq, H. (2008). The association between obesity and GERD: a review of the epidemiological evidence. Dig Dis Sci.; 53(9):2307-12.

Richter, J., (1992). Surgery for reflux disease: reflections of a gastroenterologist. N Engl J Med. 326(12):825-7

Fisichella, P., Patti, M. (2008). Gastroesophageal Reflux Disease. From eMedicine Specialties: Gastroenterology: Esophagus. Retrieved 14th March, 2009 from: http://emedicine.medscape. com/article/176595-overview Flaws, B. & Sionneau, P. (2001). The Treatment of Modern Western Diseases With Chinese Medicine: A Textbook & Clinical Manual. Boulder, CO: Blue Poppy Press Ghen, J., Qiu, J., Pan, F. (2004). Clinical observation on treatment of gastro-esophageal reflux with modified zhizhu pill. . Zhongguo Zhong Xi Yi Jie He Za Zhi. 24(1):25-7 Hao, Y., Sun, X., Zhang, J. (1998). Effects of Yunqitang on both esophageal mucosal morphology and esophageal motility in reflux esophagitis patients. Zhongguo Zhong Xi Yi Jie He Za Zhi. 18(6):345-7 Healy, D. (2012). Pharmageddon. University of California Press: Berkeley & Los Angeles Herbella, F., Sweet, M., Tedesco, P., Nipomnick, I., Patti, M., (2007). Gastroesophageal reflux disease and obesity. Pathophysiology and implications for treatment. J Gastrointest Surg. 11(3):286-90. Kahrilasa, P., Shaheenb, N., Vaezic, M. (2008). American Gastroenterological Association Medical Position Statement on the Management of Gastroesophageal Reflux Disease. Gastroent.; 135(4):1383-91 Katz, P., Gerson, L., Vela, M. (2013). Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol.108:308 – 328 Maclean, W., Lyttleton, J. (2002). Clinical Handbook of Internal Medicine, Vol. 2 Spleen and Stomach. Sydney: University of Western Sydney Marshall, B., Warren, J. (1894). Unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration. Lancet. 1(8390):1311–1315. Moayyedi, P., Axon, A. (2005). Review article: gastro-oesophageal reflux disease--the extent of the problem. Aliment Pharmacol Ther. Suppl 1:11-9

Reid, T. (2016). Traditional Chinese Medicine and Functional Gastrointestinal Disorders: Part 1 Functional Dyspepsia. The Natural Therapist. 31(2):

Shi, A. (2003). Essentials of Chinese Medicine: Internal Medicine. Walnut California: Bridge Publishing Group Sinclair, U. (1911). The Fasting Cure. New York: Mitchell Kennerley. Retrieved August 10, 20916 from: http://soilandhealth. org/wp-content/uploads/02/0201hyglibcat/020106/02010600fra me.html Stiennon, O.A. (1995). The Longitudinal Muscle in Esophageal Disease. Retrieved 15th August, 2016 from: http://www. esophagushoncho.com/ Takahashi, T. (2006). Acupuncture for functional gastrointestinal disorders. J Gastroenterol. 41(5):408-17 Tran T., Lowry A., El-Serag H. (2007). Meta-analysis: the efficacy of over-the-counter gastro-oesophageal reflux disease therapies. Aliment Pharmacol Ther.; 25(2):143-53 Wang, C., Zhou, D., Shuai, X., Liu, J., Xie, P. (2007). Effects and mechanisms of electroacupuncture at PC6 on frequency of transient lower esophageal sphincter relaxation in cats. World J Gastroenterol. 13(36):4873-80 Wu, J., Chan, F., Ching, J., Leung, W., Hui, Y, Leong, R., Chung, S., Sung, J. (2004). Effect of Helicobacter pylori eradication on treatment of gastro-oesophageal reflux disease: a double blind, placebo controlled, randomised trial. Gut. 53(2):174-9 Wright, J. (2009). Your Stomach: What is Really Making You Miserable and What to Do About It. Mount Jackson VA: Praktikos Books. Wright, J, Lenard, L. (2001). Why Stomach Acid is Good for You. Natural Relief from Heartburn, Indigestion, Reflux and GERD. Lanham, Maryland: M. Evans Xie, S., Liang, J., Yan, C. (2007). Therapeutic effects of acupoint drug-finger pressing on gastroesophageal reflux. Zhongguo Zhong Xi Yi Jie He Za Zhi. (4):355-8 Xu, H., Bo, P., Yuan, Y. (2007). Study on integrated Chinese and Western therapy and criterion for efficacy evaluation of gastroesophageal reflux disease--a clinical observation on 116 cases. Zhongguo Zhong Xi Yi Jie He Za Zhi. 27(3):204-7 Yang, S. (1993). The Heart & Essence of Dan-xi’s Methods of Treatment. A Translation of Zhu Dan-xi’s Dan Xi Zhi Fa Xin Yao. Boulder, CO: Blue Poppy Press THE NATURAL THERAPIST Volume 31 No.3

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Dietary therapy and nutritional medicine management of multiple sclerosis a systematic literature review

Ms. S a l ly Len n ox B.A . 1 D r S im on A Ciche llo Ph.D. R. Nu t r. Gra d. Dip. H.S c. ( Her b. M e d. ) 1.N ut r it io n Care Ph ar maceutic al s, K eys bo ro u g h, Vic to r ia, Au s tral ia 2 . Fac u lt y of Ve ter in ar y an d Agr icult ural S c iences, The Univer s it y o f M el bo u r ne, Au s t ra l i a

THE NATURAL THERAPIST Volume 31 No.3

Die t a r y Th e rapy S Le n n ox / Dr S A Cic h el l o

Abstract:

Objective: The purpose of this review is to investigate CAM (Complementary, Alternative Medicine) use in MS (Multiple Sclerosis) to determine efficacy, and preferred choice of CAM use by MS sufferers and the types of treatments used. Methods: The Pubmed and EBSCO databases were searched using the search terms ‘multiple sclerosis’, ‘diet’, ‘vitamin’, ‘clinical trials’, ‘free full text’, ‘humans’ in combination and published between 2004-2014, and isolated to English only publications. Results: There were 630 articles found, 10 were chosen to be included in the review. Anti-oxidant supplements, Cannabis (Cannabis sativa), Evening Primrose (Oenothera biennis), fish oil, polyunsaturated fatty acids, low fat diet and a hot-natured diet from Traditional Iranian Medicine were shown to reduce inflammation in MS patients. Calcitrol, vitamin D, fish oil, a Traditional Iranian Medicine hot-natured diet and other dietary changes were shown to reduce inflammation and reduce EDSS (expanded disability status scale). Conclusion: Multiple sclerosis is a multi-factorial condition that requires comprehensive treatment. Singular approaches to reduce inflammation have not translated into reduced symptoms or relapses. Comprehensive interventions encompassing diet, increased polyunsaturated fatty acids (PUFA) though fish oil or Cannabis sativa oil and vitamin D or multivitamin supplementation have shown the most efficacy in terms of reduction of symptoms, EDSS and disease progression.

organic solvents have been correlated with MS occurrence (Namaka et. al. 2008). Low vitamin D levels, low sunlight exposure and infection with the Epstein Barr virus have also been correlated with MS (Allen et. al. 2010). Improved vitamin D status, increased exercise and decreased cigarette smoking have been associated with reduced EDSS (Inusah et. al. 2010). Moreover, in an Iranian study of 150 individuals it was revealed that a lacto-vegetarian and vegetarian diet reduced the odds ratio of multiple sclerosis by 5-fold when compared to a diet consuming red meat (Jahromi et. al. 2012), which contains vitamin B12, a necessary nutrient for myelin formation and repair. This paradox maybe related to the oil composition of different foods and their relationship to inflammation as immune modulation appears to be one key to controlling symptoms. There is no known cure for MS, however pharmaceutical agents are used to manage the symptoms. Corticosteroids are used to decrease the inflammation during the inflammatory periods. Immune modulators and suppressors are used to decrease the relapse rate (Allen et. al. 2010). Up to 70% of patients with MS reported CAM usage in a survey and most reported a perceived benefit. The most commonly used treatments were omega-3 fatty acids, anti-oxidants and dietary modification. These patients chose to use CAM to improve general health and to relieve physical and psychological symptoms. Most patients used CAM concurrently with conventional pharmaceuticals and perceived benefits in both treatment types (Yadav et. al. 2010).

Introduction:

Methodology:

Multiple sclerosis is an auto-immune disease of unknown etiology, but considered to be an auto-immune disease which affects the myelin sheath surrounding the central nervous system (CNS). Thus symptoms display both nervous system/ co-ordination related dysfunction, but also systematic inflammatory response. There are 3 types of MS categorised; 85% of patients have the ‘relapsing-remitting type’ in which there are periods of symptoms and inflammation followed by remission. Further, 10% of patients have the primary-progressive type in which there is no remission of symptoms and lastly, 5% of patients have the progressiverelapsing type. Around 50% of patients with the relapsing-remitting type will stop remising after 10 years and get progressively worse (Horowitz, 2011). During the inflammatory stage, activated T lymphocytes cross the blood brain barrier (BBB) and recognise myelin-derived antigens on the antigen presenting cells of the CNS. The T lymphocytes then undergo clonal proliferation which initiates the inflammatory cascade. Cytokines are released and macrophages attack the myelin sheath resulting in demyelination, oxidative damage and scarring of the CNS (Allen et. al. 2010). The degradation of the myelin sheath interferes with impulse transmission in the CNS and results in symptoms such as muscle spasticity, ataxia, dysaesthesia, urinary urgency, fatigue and impotence. As the disease progresses the inflammatory periods increase and the remission periods decrease. Fifteen years after diagnosis around 50% of patients cannot walk unaided. Cognitive and memory impairment are common in the late stages of the disease (Allen et. al. 2010). Further, nutrition status, or the balance of certain minerals such as iron is thought to be implicated in both oxidative damage as well as the regeneration of the myelin sheath, both poison and panacea (Stephenson et. al. 2014). The expanded disability status scale (EDSS) is used as a measurement of MS disease progression in clinical trials. The EDSS is a scale from 0-10; 0 indicates no neurological abnormality and 10 indicates death from MS. Steps 1-4.5 are used to describe patients who can walk without an aid but experience weakness, ataxia, numbness in the limbs and decreased intellectual capacity. Steps 5-9 are used to indicate the severity of walking disability (MS Australia 2013).

Four searches were performed on EBSCOhost including the databases Alt HealthWatch, AMED, MEDLINE and Academic Search Premier. Limiters were set on ‘full text’ and published between 20042014. The first search terms used were ‘multiple sclerosis’, ‘diet’, ‘English’ and ‘all adults 19+’. There were 19 results, 3 were used in the review. The second search terms were ‘multiple sclerosis’, ‘diet therapy’, ‘English’, and ‘all adults 19+’. There were 32 results, 1 was chosen to be included in the review. The third search terms were ‘multiple sclerosis’, ‘fish oil’, ‘English’, and ‘all adults 19+’, there were 10 results, 1 was used in the review. The fourth search terms were ‘multiple sclerosis’, ‘vitamin D’ and ‘human’, there were 555 results, 1 was chosen to be included in the review.

There are over 2 million people living with MS globally. People are most commonly diagnosed between the ages of 20-50 and women are affected twice as often as men (Horowitz 2011). The prevalence of MS is significantly decreased in countries close to the equator however the risk remains high for people from temperate climates who relocate to countries closer to the equator indicating that there are relevant contributing environmental factors during childhood (Allen et. al. 2010). Although the etiology is unknown there are several factors associated with an increased prevalence of MS. The risk of children developing MS is doubled if one parent has MS. Exposure to heavy metals and

Pubmed was searched with the same search terms ‘multiple sclerosis’, ‘vitamin’ and the limiters ‘clinical trials’, ‘free full text’, ‘humans’ and published between 2004-2014. There were 11 results, 2 were used in the review. The second search terms ‘multiple sclerosis’, ‘fish oil’ and the limiters ‘clinical trials’, ‘free full text’, ‘humans’ and published between 2004-2014. There were 2 results, 1 was included in the review. The third search terms ‘multiple sclerosis’, ‘inosine’ and the limiters ‘clinical trials’, ‘free full text’, ‘humans’ and published between 2004-2014. There was one result which was included in the review. The articles not included were reviews, not directly related to the use of CAM in MS, were already included or were not clinical trials. Results: A total of 10 studies were selected for the systematic review based on the selection criteria as shown in the methodology section. There were 630 articles found, 10 were chosen to be included in the review. Table 1. Dissemination of clinical studies chosen for systematic review Abbreviations: 25-hydroxy-vitamin-D (25-OH-D), 8-Iso Prostaglandin F2alpha (8-isoPGF2a), C reactive protein (CRP), Cannabis sativa (CS), cyclic adenosine monophosphate (cAMP), decrease (↓), docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA), expanded disability status scale (EDSS), gadolinium enhanced lesions (GEL), increase (↑), interferon gamma (IFN-γ), interleukin 1 beta (IL-1β), interleukin 17 (IL-17), interleukin 4 (IL-4), interleukin 6 (IL-6), matrix metalloproteinase-9 (MMP-9), nanomole per litre (nmol/l), natural killer cells (NK), nitric oxide metabolites (NO met),

THE NATURAL THERAPIST Volume 31 No.3

Dieta r y Th e rapy S Len n ox / Dr S A Cic h el l o

ntervention & route of administration I

Author, Year

Type of study

Trial Duration

Outcome

Adverse effects

Randomised prospective placebo controlled trial

Low fat diet & antioxidant supplements, OP

42 days

↓CRP, ↓IL-6, ↓8-iso-PGF2a

None reported

Rezapour-Firouzi Et. Al. 2013

Clinical trial (no placebo)

Hot-natured diet, 18-21g/day of CS & OB oil (9:1 ratio), OT

6 months

↓IFN-y, ↓IL-6, ↑IL4,↓EDSS

None reported

Steffensen Et. Al. 2013

Randomised placebo controlled trial

20,000IU vitamin D3/ week, OT

96 weeks

↑serum vit D from 68nmol/L to 123nmol/L

None reported

Pilot clinical trial (no placebo)

100IU oral calcitrol/day, dietary calcium restricted to 800mg/day, OT

48 weeks

Hypercalcaemia, headache, Median change in constipation, EDSS:0 dizziness, paresthesia

Mauriz Et. Al. 2013

Wingerchuk Et. Al. 2005

Golan Et. Al. 2013

Randomised, double blind trial

800IU/day of vit D VS 4,370IU/day 1 year vit D, OT

↑25-OH-D, ↓PTH in ↑dose group, ↑IL-17 in ↓dose group, no change in EDSS

None reported

4g fish oil/ day, OT

1 year

↓TNFα, ↓IL-1β, ↓IL-6, ↓NO met

<5% reported nausea, stomach pain, diarrhoea

Ramirez-Ramirez Et. Al. 2013

Randomised, double blind, placebo controlled

Salinthone Et. Al. 2010

Clinical trial

1200mg lipoic acid, OT

4 hours

cAMP ↑ by 43%

None reported

Open label, randomised, prospective, controlled trial

40,000IU vit D/ day for 28 weeks then 10,000IU/ day & 1200mg calcium/day, OL

1 year

↓T cell proliferation, ↓EDSS

None reported

Markowitz Et. Al. 2009

Randomised, double blind, pilot, placebo controlled, crossover trial

2-3g inosine/day to maintain ↑UA level, OT

1 year

↑SU, ↓GEL

Kidney stone formation in 4/16 PT

Shinto Et. Al. 2009

Open label study

9.6g fish oil/day, OT

6 months

↓58% MMP-9, ↑EPA & DHA in RBC

Fatigue in 3/10 PT

Burton Et. Al. 2010

Table 2. Dissemination of clinical studies chosen for systematic review

Author, Year

Comments regarding quality of publication

Mauriz et. al. 2013

Small number of participants (n = 9) Low fat diet; may or may not control for the type of fatty acids consumed Low fat diet & antioxidant acting independently or synergistically Short term reduction in inflammatory hormone i.e. 42 days, ;longer term study is required to confirm results after 1-2 years and the possibility of relapse.

Rezapour-Firouzi et. al. 2013

Small number of participants (n = 23) There was no placebo for comparison. There were three concurrent interventions the Traditional Iranian hot-natured diet, the CS & OB oil therefore making it hard to determine which intervention is responsible for the result. The trial took place for 6 months in which there was a reduction in inflammation (↓IFN-y, ↓IL-6, ↑IL-4), and a reduction in EDSS, a longer term study would be beneficial to see whether EDSS could be reduced further and maintained.

Steffensen et. al. 2013

Adequate number of participants (n = 68) Randomised placebo controlled trial. 96 weeks adequate time to measure varying blood D3 levels throughout the seasons.

Wingerchuk et. al. 2005

Small number of participants (n = 15) Pilot clinical trial (no placebo). The purpose of the study was to evaluate the tolerability and safety of calcitrol. The efficacy of the treatment could be evaluated in further studies.

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Die t a r y Th e rapy

Author, Year

S Len n ox / Dr S A Cic h el l o Comments regarding quality of publication

Golan et. al. 2013

Adequate number of participants (n = 45) Low dose group versus high dose group, no placebo group due to ethics, harder to evaluate full potential of treatment. Benefits: 1 year an adequate amount of time to measure effects, the groups were double blinded and randomised, large difference between high and low dose groups which revealed the dose dependant differences in biomarkers.

Ramirez-Ramirez et. al. 2013

Adequate number of participants (n = 50) Thorough statistical analysis, many types of inflammatory mediators tested.

Salinthone et. al. 2010

Adequate number of participants (n = 49) The study design lacked statistical precision to adequately measure differences in EDSS

Markowitz et. al. 2009

Small number of participants (n = 16) Thorough methodology (Randomised, double blind, pilot, placebo controlled, crossover trial) and time frame (1 year) Thorough evaluations (EDSS, MRI and serum nitrotyrosine were measured)

Shinto et. al. 2009

Small number of participants (n = 10) Short treatment time (3 months) No control group, some participants were using glatiramer acetate (immunomodulator drug) and interferon-β concurrently which may have influenced results.

Discussion: In total 10 clinical studies were selected for this review and a number of commonalities were identified. In particular, the studies by Mauriz et. al. (2009), Rezapour-Firouzi et. al. (2013), Golan et. al. (2013), Ramirez-Ramirez et. al. (2013), Salinthone et. al. (2010), Burton et. al. (2010) and Shinto et. al. (2009) reported a reduction in the inflammatory mediators i.e. interleukin 5 (IL-5), 8-Iso Prostaglandin F2alpha (8-iso-PGF2a), C reactive protein (CRP), interferon gamma (IFN-γ), interleukin 17 (IL-17), tumour necrosis factor alpha (TNFα), interleukin 1 beta (IL1b), interleukin 6 (IL-6), Nitric oxide metabolites, cyclic adenosine monophosphate (cAMP) and T cell proliferation. These inflammatory mediators are implicated in MS pathogenesis and severity. Rezapour-Firouzi et. al. (2013) and Shinto et. al. (2009) reported an increase in the anti-inflammatory mediators interleukin 4 (IL-4) and docosahexaenoic acid (DHA)/ eicosapentaenoic acid (EPA) respectively. However reduced inflammation rarely coincided with reduced severity of EDSS. Burton et. al. (2010), Golan et. al. (2013), Steffensen et. al. (2013) and Wingerchuk et. al. (2005) utilised vitamin D. Hypovitaminosis D occurs with a lack of sunlight exposure and is strongly associated with occurrence of MS (Sainaghi et. al. 2011). The anti-inflammatory effects of Vitamin D that are beneficial in autoimmunity include decreased proliferation of T helper cells, decreased production of IFN-γ, IL-6 and IL-5 and increased production of IL-4 (Mahon et. al. 2003). Interleukins are cytokines; a type of signalling molecule in the immune system implicated in the process of inflammation. The calcium RDI for adult men and women is 1,000mg/day and 1,300mg/day respectively (National Health & Medical Research Council, 2014). Wingerchuk et. al. (2005) restricted the patient’s dietary calcium to 800mg/day and used the calcitrol form of vitamin D. Vitamin D3 becomes the active form of calcitrol through liver metabolism (Preston, 2014). Two patients withdrew from the trial due to hypercalcaemia due to noncompliance with the dietary calcium restrictions. Two compliant patients experienced mild hypercalcaemia and had their calcitrol doses adjusted. Calcitrol is the metabolically active form of D3 and potentially has an effect on the immune system. Calcitrol has been shown to reduce disease expression and prolong survival in mice with allergic encephalomyelitis. During the study the exacerbation of MS symptoms was less than baseline but at the end of the study the median change in EDSS was 0. Wingerchuk et. al. concluded that vitamin D supplementation may be beneficial to aid in the prevention of MS in high risk individuals or in the very early treatment of the disease. They also stated that the dose of calcitrol may not be sustainable and that the use of other vitamin D analogues may be useful to avoid hypercalcaemia.

The main aim of the trial by Golan et. al. was to examine whether vitamin D3 supplementation would decrease cytokines and ameliorate flu like symptoms in patients with MS after being treated with interferon beta. Flu like symptoms are a common adverse effect during treatment with interferon beta. The high dose group received 4370 IU 25-hydroxy-vitamin-D (25-OH-D) per day for one year, at the end of the study the median serum vitamin D level was 122.6 nmol/l and parathyroid hormone (PTH) had decreased from a median of 30.4 pg/ml at the start of the trial to 25.0 pg/ml at 3 months, there was no data on PTH after that. Increased PTH has been associated with decreased osteocalcin and increased bone resorption markers in patients with MS, decreased bone mineral density is prevalent in MS (Moen et. al. 2012). The low dose group received 800IU 25-OH-D per day; the median serum level was 68nmol/l, there was no significant change in PTH and IL-17 was increased from 4.01 to 9.14 pg/ml in serum. IL-17 is a pro-inflammatory cytokine which has been implicated in MS pathogenesis. An observational study has suggested that treatment with 25-OH-D is associated with decreased EDSS in patients who are being treated with interferon beta. Golan et. al. reported no change in EDSS or the occurrence of flu like symptoms in either treatment group. The main aim of the trial by Steffensen et. al. (2013) was to increase serum vitamin D levels to 50 nmol/l or above in order to help maintain bone mineral density. Levels of 50 nmol/l to 75nmol/l are considered sufficient to maintain bone health. However previous studies by Steffensen et. al. have shown that 20,000IU of vitamin D weekly was not sufficient to prevent bone loss. 91% of participants had serum levels of 75nmol/l or above at the end of the 96 weeks. Burton et. al. (2010) administered 40,000IU of vitamin D3 per day for 28 weeks to raise 25-OH-D serum levels then 10,000IU per day for 12 weeks then 0IU per day for 12 weeks. 1200mg of calcium per day was administered throughout the entire trial to maintain adequate levels. Although all variables were not accounted for the treatment group appeared to have a reduction in EDSS and T-cell proliferation. EDSS was decreased by 0.5-1 point. T-cell proliferation is increased in MS; there are T-cells which specifically target myelin auto-antigens and are involved in MS pathogenesis (Varrin-Doyer et al, 2014). There was no significant change in cytokine levels in either group. Nitrotyrosine is an indicator of cell damage and inflammation; inosine (amino acid-like precursor to adenosine) can be used to increase serum urate levels and therefore decrease nitrotyrosine. Markowitz et. al. (2009) reported a decrease in MS associated lesions and decreased EDSS. THE NATURAL THERAPIST Volume 31 No.3

Dieta r y Th e rapy

S Lenn ox / Dr S A Cic h el l o methylation cycle to convert homocysteine to methionine. Homocysteine has a neurotoxic effect and increases cell death (Moghaddasi et. al. 2013). There have been conflicting results on B12 supplementation in MS. However 1000µg B12 administered intramuscularly has shown increased neurological function in some cases (Gaby, 2013). Occurrence of MS is strongly associated with diets high in saturated fat and dairy milk while diets higher in omega-3 (a PUFA) have been observed to have a preventative effect (Schwarz & Leweling, 2005). The immune cells in patients with MS have been observed to target cow’s milk proteins; this causes lymphocyte apoptosis to be upregulated (Jelinek & Hassed, 2009). Mauriz et. al. (2013) utilized a low fat diet (<30%) and antioxidant supplements. No details of the foods were listed except that processed meats and triturated foods were used. There were decreased levels of inflammatory markers (CRP, IL-6 and 8-iso-PGF2a) reported but no reduction in EDSS. Rezapour-Firouzi et. al. (2013) used a hot-natured diet in addition to CS oil which is 80% is PUFA. ‘Hot-natured diet’ is a concept of traditional Iranian medicine. Cholesterol, trans fats, saturated fat, sugar, additives, artificial sweeteners, alcohol and refined starch are reduced or removed from the diet. Consumption of dairy products is minimal. Olive oil, grape oil, fruit, vegetables, nuts, seeds, seafood, unrefined carbohydrates and water are increased. There was a reduction in the inflammatory cytokines IL-4, IFN-γ and IL-17 which correlated with a decrease in EDSS. Nordvik et. al. (2000) employed a comprehensive protocol for newly diagnosed patients. Saturated fat, alcohol and dairy were reduced; smoking was ceased. Vegetables and fish intake were increased. Tea and coffee was kept to a maximum of 2 cups per day (unspecified type/strength). The patients were advised to take 5ml of fish oil daily containing 0.4g of EPA, 0.5g of DHA, 1.0mg of vitamin A, 10mg of vitamin D and 5.5mg of vitamin E. They also took a B-complex containing 2.25 mg of thiamin, 2.6 mg of riboflavin, 30 mg of niacin,7 mg of pantothenic acid, 3 mg of pyridoxine,150 mg of biotin, 100 mg of folic acid, 6 mg of cobalamin) and 200 mg of vitamin C (acid neutral). Up to 69% of patients experienced a reduction in EDSS. Lastly, herbs regularly eaten in the diet such as cinnamon (Cinnamomum verum) have shown promise to reduce inflammation in animal models. In particular, a model of C57/ BL6 mice with induced experimental allergic encephalomyelitis, cinnamon powder fed orally at a dosage of 50mg/ kg live body weight, normalized the mRNA expression of myelin genes and further inhibited demyelination within the central nervous system. Moreover, the treatment up-regulated T-regulatory cells via the reduction of nitric oxide production (Mondal and Pahan 2015), however clinical trials are necessary to demonstrate these findings in humans. Figure 1. Proposed physiological mechanisms by which diet

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may influence inflammatory cytokines and thus reduce the symptoms of multiple sclerosisConclusions Multiple sclerosis is a multi-factorial condition and requires comprehensive treatment. Singular approaches to reduce inflammation have not translated into reduced EDSS. Comprehensive interventions that included diet, increased PUFA though fish oil or CS oil and vitamin D or multivitamin supplementation have shown the best results in terms of reduction of EDSS and disease progression.

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Allen, C.M.C, Lueck, C.J. & Dennis, M, 2010, ‘Neurological disease’, in Colledge, N, Walker, B & Ralston, S (eds), Davidson’s principles and practice of medicine, 21st edn, Churchill Livingstone Elsevier, Edinburgh, pp.1131-1236. Gaby, A. (2013). Multiple sclerosis. Global Advances in Health and Medicine : Improving Healthcare Outcomes Worldwide, 2(1), 50–6. doi:10.7453/gahmj.2013.2.1.009 Golan, D, Halhal, B, Glass-Marmor, L, Staun-Ram, E, Rozenberg, O, Lavi, I, Dishon, S, Barak, M, Ish-Shalom, S, & Miller, A 2013, ‘Vitamin D supplementation for patients with multiple sclerosis treated with interferon-beta: a randomized controlled trial assessing the effect on flu-like symptoms and immunomodulatory properties’, BMC Neurology, 13, 1, pp. 1-10, Academic Search Premier, EBSCOhost, viewed 5 October 2014. Horowitz, S 2011, ‘CAM Interventions for Multiple Sclerosis: Part 1-Diet and Supplements for Relieving Symptoms’, Alternative & Complementary Therapies, 17(3), 156-161 Inusah, S, Sormani, M, Cofield, S, Aban, I, Musani, S, Srinivasasainagendra, V, & Cutter, G 2010, ‘Assessing changes in relapse rates in multiple sclerosis’, Multiple Sclerosis (13524585), 16, 12, pp. 1414-1421, Academic Search Premier, EBSCOhost, viewed 5 October 2014. Jahromi SR, Toghae M, Jahromi MJ, Aloosh M. (2012). Dietary pattern and risk of multiple sclerosis. Iran J Neurol. 11(2), 47-53. Jelinek, G, & Hassed, C 2009, ‘Managing multiple sclerosis in primary care: are we forgetting something?’, Quality In Primary Care, 17, 1, pp. 55-61, Academic Search Premier, EBSCOhost, viewed 8 October 2014. Mahon, B. D., Wittke, A., Weaver, V., & Cantorna, M. T. (2003). The targets of vitamin D depend on the differentiation and activation status of CD4 positive T cells. Journal of Cellular Biochemistry, 89(5), 922–32. doi:10.1002/jcb.10580 Markowitz, C. E., Spitsin, S., Zimmerman, V., Jacobs, D., Udupa, J. K., Hooper, D. C., & Koprowski, H. (2009). The treatment of multiple sclerosis with inosine. Journal of Alternative and Complementary Medicine (New York, N.Y.), 15(6), 619–25. doi:10.1089/acm.2008.0513. Mauriz, E, Laliena, A, Vallejo, D, Tuñón, M, Rodríguez-López, J, Rodríguez-Pérez, R, & García-Fernández, M 2013, ‘Effects of a low-fat diet with antioxidant supplementation on biochemical markers of multiple sclerosis long-term care residents’, Nutricion Hospitalaria, 28, 6, pp. 2229-2235, Academic Search Premier, EBSCOhost, viewed 4 October 2014. Moen SM, Celius EG, Sandvik L, et al. Bone Turnover and Metabolism in Patients with Early Multiple Sclerosis and Prevalent Bone Mass Deficit: A Population-Based Case-Control Study. Oreja-Guevara C, ed. PLoS ONE 2012;7(9):e45703. doi:10.1371/journal.pone.0045703. Moghaddasi, M, Mamarabadi, M, Mohebi, N, Razjouyan, H, & Aghaei, M 2013, ‘Homocysteine, vitamin B12 and folate levels in Iranian patients with Multiple Sclerosis: a case control study’, Clinical Neurology And Neurosurgery, 115, 9, pp. 1802-1805, MEDLINE Complete, EBSCOhost, viewed 8 October 2014. Mondal S, Pahan K. (2015). Cinnamon Ameliorates Experimental Allergic Encephalomyelitis in Mice via Regulatory T Cells: Implications for Multiple Sclerosis Therapy. PLoS One 10(1), e0116566. Moore AR, Willoughby DA. The role of cAMP regulation

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in controlling inflammation. Clinical and Experimental Immunology 1995;101(3):387-389. MS Australa, 2013, ‘Making sense of MS research’ http:// www.makingsenseofmsresearch.org.au/about-the-research/ glossary.php Namaka, M, Crook, A, Doupe, A, Kler, K, Vasconcelos, M, Klowak, M, Gong, Y, Wojewnik-Smith, A, & Melanson, M 2008, ‘Examining the evidence: complementary adjunctive therapies for multiple sclerosis’, Neurological Research, 30, 7, pp. 710-719, MEDLINE Complete, EBSCOhost, viewed 4 October 2014. National Health & Medical Research Council, 2014, ‘Nutrient reference values for Australia & New Zealand: Calcium’, viewed 7 October 2012, http://www.nrv.gov.au/nutrients/ calcium. Nordvik, I., Myhr, K.-M., Nyland, H., & Bjerve, K. S. (2000). Effect of dietary advice and n-3 supplementation in newly diagnosed MS patients. Acta Neurologica Scandinavica, 102(3), 143–149. doi:10.1034/j.1600-0404.2000.102003143.x Preston, A, 2014, Nutritional biochemistry explained, published by Alexandra Preston, distributed by lulu.com. Ramirez-Ramirez, V, Macias-Islas, M, Ortiz, G, PachecoMoises, F, Torres-Sanchez, E, Sorto-Gomez, T, Cruz-Ramos, J, Orozco-Aviña, G, & Celis de la Rosa, A 2013, ‘Efficacy of fish oil on serum of TNF α , IL-1 β , and IL-6 oxidative stress markers in multiple sclerosis treated with interferon beta-1b’, Oxidative Medicine And Cellular Longevity, 2013, p. 709493, MEDLINE Complete, EBSCOhost, viewed 5 October 2014. Rezapour-Firouzi, S, Arefhosseini, S, Farhoudi, M, EbrahimiMamaghani, M, Rashidi, M, Torbati, M, & Baradaran, B 2013, ‘Association of Expanded Disability Status Scale and Cytokines after Intervention with Co-supplemented Hemp Seed, Evening Primrose Oils and Hot-natured Diet in Multiple Sclerosis Patients’, Bioimpacts, 3, 1, pp. 43-47, Academic Search Premier, EBSCOhost, viewed 4 October 2014. Sainaghi, P, Bellan, M, Carda, S, Cerutti, C, Sola, D, Nerviani, A, Molinari, R, Cisari, C, & Avanzi, G 2011, ‘Hypovitaminosis D and response to cholecalciferol supplementation in patients with autoimmune and non-autoimmune rheumatic diseases’, Rheumatology International, 32, 11, pp. 3365-3372, MEDLINE Complete, EBSCOhost, viewed 5 October 2014. Salinthone, S., Yadav, V., Schillace, R. V, Bourdette, D. N., & Carr, D. W. (2010). Lipoic acid attenuates inflammation via cAMP and protein kinase A signaling. PloS One, 5(9). doi:10.1371/journal.pone.0013058 Schwarz, S, & Leweling, H 2005, ‘Multiple sclerosis and nutrition’, Multiple Sclerosis (Houndmills, Basingstoke, England), 11, 1, pp. 24-32, MEDLINE Complete, EBSCOhost, viewed 4 October 2014. Shinto, L., Marracci, G., Baldauf-Wagner, S., Strehlow, A., Yadav, V., Stuber, L., & Bourdette, D. (n.d.). Omega-3 fatty acid supplementation decreases matrix metalloproteinase-9 production in relapsing-remitting multiple sclerosis. Prostaglandins, Leukotrienes, and Essential Fatty Acids, 80(23), 131–6. doi:10.1016/j.plefa.2008.12.001 Steffensen, L, Brustad, M, & Kampman, M 2013, ‘What is needed to keep persons with multiple sclerosis vitamin D-sufficient throughout the year?’, Journal Of Neurology, 260, 1, pp. 182-188, MEDLINE Complete, EBSCOhost, viewed 4 October 2014. More references available from ANTA

THE NATURAL THERAPIST Volume 31 No.3

Constructive interventions for applied wellness: Building a good day for a good life

Mark D. Payne – BHsc (Nat), GCert (Wellness), MEd (CPEP)

Const r uc t ive I nte r venti o n s M a r k D. Pay n e

Abstract:

With the increasing complexity of clinical practice it is little wonder that practitioners are becoming treatment focussed at the expense of addressing the holistic wellbeing of the client. Whilst historically complementary medicine (CM) practices have been built on a philosophical foundation of vitalism, contemporary clinical practice is focussed on the perspective-monism of evidence based medicine (EBM). This perspective disregards the evidence for strategies that address the holistic wellbeing of the client, likely because they are not perceived as being directly relevant to the treatment of the condition for which the client has presented. The model of this article is descriptive; it is not intended to reinvent the wheel, only to present some of the well-regarded theories of wellness for consideration, along with a practical approach, through applied constructive interventions, to scaffold wellbeing for clients within the scope of the standard clinical consultation. Introduction: Whilst the basic sciences are typically engaged in discovery, applied sciences are commonly involved in the innovative and practical application of existing knowledge. For this purpose, applied sciences are highly relevant to the scientific investigation and validation of wellness and wellbeing. Indeed any review of the literature will quickly demonstrate that the vast body of research into human wellbeing is essentially applied in nature, and justifiably so. One could hardly argue with the fact that sufficient evidence already exists that a balanced whole food diet, adequate hydration, and an active lifestyle are compatible not only with health, but also an overall improved level of wellbeing, but despite this common knowledge, how do we improve compliance with these basic lifestyle measures at an individual and societal level? Questions like this cannot be answered by pursuing further research to prove the value of healthy diet and lifestyle choices, and can only be answered through the application of practical strategies for behavior change, the core strength of the applied sciences. In clinical practice, CM practitioners are well aware of the difficulties often encountered in effecting positive changes in the lifestyle factors and behaviors that are believed to be having a negative influence on a client’s overall wellbeing, and even when change is achieved “poor adherence to prescribed changes or recommended behaviours over time” continue to undermine the therapeutic intention (Ryan, Patrick, Deci, & Williams, 2008). Zeff, Snider, Myers & DeGrandpre (2013) in The Textbook of Natural Medicine (2013) describes a Unifying Theory of Natural Medicine, complicit within, is the Hierarchy of Healing, which posits that the foundational step involves establishing the foundation for health. Re-establishment of the foundation for health and wellbeing is the primary outcome targeted through wellness interventions, and forms the premise of the proceeding discussion on constructive interventions for wellness based on the principles of applied science.

(Fig. 1) continuum ranging from premature death to high level wellness. Here the treatment paradigm progresses the person to the neutral point, whereas the wellness paradigm runs parallel to treatment, and then extends beyond the neutral point in a dynamic process of growth directed towards high level wellness. The implication here is that any person, or even group of people, can be positioned on the continuum at any point appropriate to their presenting circumstances, what’s important in the first instance is the orientation of the person. Negative affect behaviours will orientate the person towards illness and premature death, whereas positive affect behaviours orientate the person towards high level wellness. This doesn’t propose that premature death or high level wellness will necessarily be the outcome, as orientation is only one aspect of the continuum theory. The role of the CM practitioner in this scenario is to facilitate positive affect change, by engaging the person in a process of growth over time, leading the person to their fullest potential for wellness as an active participant in their own wellbeing. Several wellness models of varying complexity have been developed as conceptual frameworks for scaffolding wellness interventions from the individual to the organisational, to the societal level. Travis and Ryan (2004) present one such model compromised of twelve dimensions encompassing the physical, mental and spiritual aspects of wellness as shown in Figure 2. Individuals can assess themselves in each of the twelve dimensions by completing the extensive 434 item wellness index and plotting their results in the wellness wheel, an example of which is shown in Figure 3. (Albrecht, 2011).

Key aspects of wellness theory: The principle purpose of wellness practices is to increase the total wellbeing of the client. From a wellness perspective the absence of disease is not a pre-requisite, and even less important is the need for diagnosis of disease. This is not meant to imply that diagnosis and treatment of disease is not important, of course it certainly is, but diagnostic and therapeutic interventions are targeted at the identification and treatment of disease, whereas wellness is targeted at total, or holistic, wellbeing. Thus, the clinical approach and the wellness approach are complementary, with the wellness approach scaffolding a shift towards high level wellness, and supporting the therapeutic intervention, both during treatment and beyond it (Chang & Myers, 2003). This perspective was described by Travis in the Wellness Workbook (2004) where the illness/wellness continuum (Fig. 1) places both the wellness paradigm and the treatment paradigm on a conceptual (Fig.

Once the person has completed the Wellness Index and plotted their results in the wellness wheel, they have a conceptual map of their strengths and weaknesses within the twelve dimensions, the intention being that they will continue to embrace and develop their strengths, while focussing on addressing their weaknesses. The CM practitioner serves great purpose in fulfilling this role through educating and mediating the clients process of developing high level wellness. The National Wellness Institute (NWI) have adopted an interdependent six dimension model of wellness developed by Dr Bill Hettler in 1976, and defines wellness as “an active process through which people become aware of, and make choices towards, a more successful existence.

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Dimension-by-dimension approach:

Both the Travis and Ryan (2004), and Hettler (1976) models of wellness depict the multi-dimensional nature of wellness common to all such conceptual

models. These multi-dimensional constructs are representative of the interconnectedness of the physical, mental, emotional, social and spiritual aspects implicit within any attempt to describe holistic wellbeing, and serve as a conceptual map which CM practitioners can use to scaffold a process of change that re-orientates the individual, and sets in motion a process of growth towards high level wellness. Seligman (2011) in his book Flourish: A Visionary New Understanding of Happiness and Well-being, presents his new Well-being Theory, often referred to as PERMA theory, which is comprised of the five elements of “positive emotion, engagement, meaning, positive relationships, and accomplishment” (Seligman, 2011). Whilst this model is less explicit in its presentation of the physical dimension, with a principle focus on positive psychology approaches to wellbeing, the multi-dimensional, interdependent nature of wellbeing governs that physical benefits are derived from mental, social, emotional and spiritual interventions. Cardiovascular disease has been shown to be favourably influenced by positive psychological approaches (Boehm & Kubzansky, 2012), as have neuroendocrine, immune and inflammatory conditions (Kiecolt-Glaser, McGuire, Robles, & Glaser, 2002; Ryff, Singer, & Dienberg Love, 2004; Steptoe, Wardle, & Marmot, 2005). Whilst models of wellness that explicitly incorporate physical dimensions such as diet and exercise are likely to be more conducive to CM practice, especially if the practitioner feels under-skilled in facilitating a purely psychological approach, as is often the case, the predominant emphasis is on the need for multi-dimensional approaches to facilitate positive change in health behaviour. Whichever model is adopted, application remains the key to unlocking wellbeing. Facilitating change in health behaviour: Most CM practitioners will attest to the difficulty in affecting lasting, positive change in the health behaviours of many clients. Even comparatively simple changes like reducing coffee intake, and increasing water intake, can prove an arduous task. Affecting complex changes such as smoking cessation, substance withdrawal, emotional regulation, or complete lifestyle change for risk reduction of chronic degenerative disease can seem overwhelmingly perplexing.

Self-regulation of health behaviour declares that; “Individuals continuously preside over their own health behaviour…in the development and successful maintenance of health promotive habits” (Bandura, 2005). The challenge for CM practitioners is how to affect lasting change? An incremental approach based on goal setting facilitated by the CM practitioner has been shown to be effective in achieving health and wellness outcomes (Maes & Karoly, 2005). Underlying such change is the need for goal oriented, incremental change. Humans are capable of health behaviour change at the physical, personal, mental, emotional and social level, when approached from an intentional and motivational perspective (Sniehotta, 2009). In relation to the multi-dimensional approach to wellness, such a perspective calls for consideration of the dimension-by-dimension approach versus the day-by-day approach to facilitating incremental change in health behaviours that reorientate the individual towards high level health and wellbeing.

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Dimension-by dimension change suggests an approach to health and wellness that sequentially addresses subordinate fractions of wellness, which might see a singular dimension of wellness, such as physical wellbeing, being subdivided into multiple sub-dimensions such as diet, exercise, hydration, detoxification, and sleep. This could be seen as a de-constructive approach, essentially involved in breaking old bad habits and replacing them with new good habits. Whilst explicit change is inarguably important, application of change behaviour remains quintessential to effecting lasting positive change for the affective change that is required for health and wellbeing. The Health Beliefs Model describes that an individual’s willingness to undertake positive change to improve their health and wellbeing is informed by a number of variables including the perceived threat to health, individual modifying factors, perceived ability to change in terms of both self-efficacy and barriers to change, and the perceived benefit of the outcome (Jones et al., 2015). Thus any approach for successfully affecting positive change needs to involve a process of educating the client on the benefits of change as well as the consequences of not changing, negotiating an effective change strategy, moderating the strategy over time to ensure that the person is continuously engaged in the process, and must result in a perceived benefit from the perspective of the individual. The dimension-by-dimension approach is useful when an individual need only make a small number of changes before they perceive the benefit, but for people who need to make significant changes to their lifestyle, the dimension-by dimension approach may present a lengthy transition period, consisting of multiple challenges, which may be conceived as being too great a task to be undertaken, thus undermining the individuals motivation to persist with the change strategy. Day-by-day approach: The day-by-day approach is a constructive intervention whereby multiple dimensions of wellness can be addressed simultaneously through the construction of a good day. In this approach the CM practitioner engages the client in a process of education, negotiation, and moderation to construct a health promoting lifestyle for a day. The client’s task is to live the day intentionally, being attentive to how they feel. The good day can simultaneously address the physical, mental, emotional, social and spiritual aspects of a person’s lifestyle through diet, exercise, sleep, family time, social time, and self-time, or any other dimensions appropriate to the needs of the individual. From a single good day, the client progressively works with the CM practitioner to construct more good days which are progressively implemented across multiple domains. A single good day on the weekend is developed to incorporate both days on the weekend within the individual’s personal, family and social domains. Then a good day incorporating the individuals work domain is constructed for during the working week, progressively incorporating more and more days, until the individual is essentially living a wellness promoting lifestyle every day, across all the domains of their life. The CM practitioner serves in the coaching role, facilitating change and increasing the individual’s independence in undertaking the process of building a wellness orientated lifestyle. The process improves the individual’s self-efficacy through an applied approach that is both practical and deeply personal, improving the perception of benefit in a shorter timeframe, and helping to sustain motivation to change. Self-determination theory (SDT) has been extensively applied to health interventions, and has shown that increasing autonomy is directly correlated with successful health behaviour change in individuals (Deci & Ryan, 2012), thus self-determination and selfefficacy should always form the foundation of the CM practitioners intention when working with individuals to develop a health promoting lifestyle.

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Conclusion:

With the rapid expansion, and increasing complexity of human health and complementary medicine practice, the importance of addressing the health needs of the client through evidence-based practice needs to be complemented by the holistic philosophy of re-establishing the foundation of health (Zeff et al., 2013) in order to reorientate the individual towards high level wellness, and engage them in a dynamic process of change and growth to achieve this end. For some decades now, many validated models of wellness have been proposed; all expectedly have their strengths and weaknesses, whilst simultaneously sharing some common attributes. Firstly, that wellness is multi-dimensional incorporating various strategies for addressing the mind, body and spirit, across multiple domains including the personal, family, social, professional, societal, and even global aspects of an individual’s lifestyle (National Wellness Institute, 2016; Seligman, 2011; Travis & Ryan, 2004). Secondly, that wellness is not dependent on the absence of disease and can be achieved in conjunction with health focussed outcomes. Thirdly, that autonomy is a reliable predictor of successful, self-regulated, health behaviour change (Deci & Ryan, 2012). For the CM practitioner the challenge is to facilitate health behaviour change in clients in an effective and efficient manner, scaffolding the client’s autonomous self-efficacy to sustain motivation to change, that meets the clients expectations in terms of perceived benefit. Whilst there are many different ways to achieve this outcome, this paper has presented the concept of constructive interventions, applied through a day-by-day approach, across multiple domains, with a principle focus on increasing the individual’s autonomy in reorientating themselves towards high level wellness and undertaking the process of growth that successfully delivers them into a wellness promoting lifestyle. The intention is to inform complementary medicine practice so that practitioners can feel empowered to support their clients alongside, and beyond, the immediacy of the illness-disease presentation, to achieve life-long wellness. Conflict of interest:

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and intervention in physical health and illness: a review. Appl Psychol Int Rev., 54(2), 267–299. http://doi.org/10.1111/j.14640597.2005.00210.x National Wellness Institute. (n.d.). About Wellness. Retrieved from http://www.nationalwellness.org/?page=AboutWellness National Wellness Institute. (2016). The six dimensions of wellness. Retrieved July 17, 2016, from http://www. nationalwellness.org/?page=Six_Dimensions Pizzorno, J., & Murray, M. (2013). Textbook of Natural Medicine (4th edn). Missouri: Churchill Livingstone Elsevier. Ryan, R. M., Patrick, H., Deci, E. L., & Williams, G. C. (2008). Facilitating health behaviour change and its maintenance : Interventions based on Self-Determination Theory. The European Health Psychologist, 10, 2–5. Ryff, C. D., Singer, B. H., & Dienberg Love, G. (2004). Positive health: connecting well-being with biology. Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences, 359(1449), 1383–94. http://doi.org/10.1098/ rstb.2004.1521 Seligman, M. (2011). Flourish: A Visionary New Understanding of Happiness and Well-being. Sydney: Random House. Sniehotta, F. F. (2009). Towards a theory of intentional behaviour change: Plans, planning, and self-regulation. British Journal of Health Psychology, 14(2), 261–273. http://doi. org/10.1348/135910708X389042 Steptoe, A., Wardle, J., & Marmot, M. (2005). Positive affect and health-related neuroendocrine, cardiovascular, and inflammatory processes. Proceedings of the National Academy of Sciences of the United States of America, 102(18), 6508–12. http://doi. org/10.1073/pnas.0409174102 Travis, J., & Ryan, R. (2004). Wellness Workbook: How to achieve enduring health and vitality. New York: Celestial Arts. Wellness Associates Inc. (2016). The Wellspring. Retrieved July 23, 2016, from http://www.thewellspring.com/ Zeff, J. L., Snider, P., & Myers, S. P. (2013). A Hierarchy of Healing : The Therapeutic Order A Unifying Theory of Naturopathic Medicine. In Textbook of Natural Medicine (4th edn, pp. 18–33). http://doi.org/10.1016/B978-1-4377-2333-5.00003-1

Mark Payne is a Naturopath and Senior Lecturer of Biosciences at Endeavour College of Natural Health (Melbourne). No conflict of interest exists. References: •

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Albrecht, N. J. (2011). Does meditation play an integral role in achieving high-level wellness as defined by Travis and Ryan (2004)? J Complement Integr Med, 8(2004). http://doi. org/10.2202/1553-3840.1373 Bandura, A. (2005). The primacy of self-regulation in health promotion. Applied Psychology, 54(2), 245–254. http://doi. org/10.1111/j.1464-0597.2005.00208.x Boehm, J. K., & Kubzansky, L. D. (2012). The heart’s content: The association between positive psychological well-being and cardiovascular health. Psychological Bulletin, 138(4), 655–691. http://doi.org/10.1037/a0027448 Chang, C., & Myers, J. (2003). Cultural adaptation of the Wellness Evaluation of Lifestyle (WEL): An assessment challenge. Measurement in Counseling and Development, 34(4), 239–250. Deci, E. L., & Ryan, R. M. (2012). Self-determination theory in health care and its relations to motivational interviewing: a few comments. International Journal of Behavioral Nutrition and Physical Activity, 9(1), 24. http://doi.org/10.1186/1479-5868-9-24 Jones, C., Jensen, J., Scherr, C., Brown, N., Christy, K., & Weaver, J. (2015). The Health Belief Model as an Explanatory Framework in Communication Research: Exploring Parallel, Serial, and Moderation Mediation. Health Commun, 30(6), 566–576. http://doi. org/10.1007/s12671-013-0269-8.Moving Kiecolt-Glaser, J. K., McGuire, L., Robles, T. F., & Glaser, R. (2002). Psychoneuroimmunology: psychological influences on immune function and health. Journal of Consulting and Clinical Psychology, 70(3), 537–547. http://doi.org/10.1037/0022006X.70.3.537 Maes, S., & Karoly, P. (2005). Self-regulation assessment THE NATURAL THERAPIST Volume 31 No.3

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