The Natural Therapist - ANTA Journal - Jan 2016 by ANTA

The official journal of the Australian Natural Therapists Association (ANTA)

NaturalTherapist

The

november 2015 vol 30 no 3

FEMALE INFERTILITy WESTERN AND TRADITIONAL CHINESE OPTIONS Tony Reid literature review of the use of calcium & magnesium during chemo therapy for colorectal cancer Rosemary King THE AMAZING CLINICAL VERSATILITY OF sT mARY’S MILK THISTLE Kerry Bone sPECIAL TREATMENT OF ACHILLES TENDONITIS

www.anta.com.au

Bing Wu

THE NATURAL THERAPIST Volume 30 No.3

ISSN 1031 6965

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THE NATURAL THERAPIST Volume 30 No.3

Advanced natural, nutritional and herbal formulations recommended by Professionals

NOVEMBER 2015 Volume 30 No.3

CONTENTS

32 ANTA News Updates

Features 9

Special Treatment Of Achilles Tendonitis Achilles Tendonitis is a term that commonly refers to an inflammation of the Achilles tendon or its covering. It is a type of injury caused by overuse.

24 The Important information and tips for Professional Indemnity Insurance As a ANTA member you need to be aware policies are specific in regard to the cover provided.

Bing Wu

12 Literature Review Of The Use Of Calcium and Magnesium During Chemotherapy For Colorectal Cancer This literature review aims to assess the safety and efficacy of intravenous CaMg infusions. Rosemary King

18 Treating Joint Pain Natural and natural-derived supplements can provide safe and effective long-term management of joint and musculoskeletal pain.

Natural

Therapist

Volume 30 Number 3 - November 2015 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.

Executive Officers Report - November 2015

ANTA Awards $100,000 to natural therapy students

ANTA Attends AHPRA Meeting New Laws Regarding ‘Child Safe Environments’ in SA

Jaclyn Lees

ANTA Representatives meet with advisor to the Australian Minister for Health

26 The Amazing Clinical Versatility Of St Mary’s Milk Thistle

A Guide to Working With Minors

St Mary’s thistle (Silybum marianum, also called milk thistle) is probably the bestproven herb for protecting the liver from chemical and inflammatory damage.

ANTA Again calls on State & Federal Governments to register Naturopaths, Herbalists, Nutritionists & Homeopaths

Kerry Bone

Women’s Health Survey: Identifying gaps in women’s health

32 Female Infertility Western and TCM Options The likelihood of success using the WM approach has been well researched and TCM has not, it appears that, based on the best available evidence, the TCM approach may be just as effective as well as more economical.

David Cannata

The

Free Legal Advice For ANTA Members

ANTA Continuing Professional Education (Cpe) Hours Guidelines

National Code of Conduct for All Unregistered Health Care Workers

Tony Reid

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

Kevin McLean 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 30 No.3

Executive Officers

Report - nOVEMBER 2015

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) & Unqualified Practitioners ANTA continues to push for the inclusion of Naturopaths, Homoeopaths, Herbalists (Western), Nutritionists, Musculoskeletal Therapists, Myotherapists, Remedial Therapists, Shiatsu Therapists, Aromatherapists and Ayurvedic Medicine Practitioners under the NRAS. In August 2015 ANTA participated on the AHPRA Professions Reference Group meeting and utilised this opportunity to continue the pursuit of statutory registration for natural therapy practitioners under the NRAS. Attendees at the meeting included representatives from registered professions and senior AHPRA management. The meeting was chaired by AHPRA CEO Martin Fletcher and discussed a wide range of topics including: Health Minister’s response to final report of the review of the National Registration and Accreditation Scheme (NRAS) • improving the notifications process • risk-based approach to regulation • raising public awareness of registration • improvements to processes ANTA is pursuing registration for natural therapists and attendance at these meetings is essential to keep the issue of registration at the forefront and to develop ongoing working relationships. ANTA will be attending further AHPRA meetings and will continue to engage in dialogue with AHPRA management, Ministers and government departments to achieve our goal of registration for natural therapists. ANTA representatives recently had a meeting with the advisor to the Australian Minister for Health (Hon. Sussan Ley MP) to discuss statutory registration of Natural Therapists and inclusion in the National Registration and Accreditation Scheme. The advisor was briefed and updated by ANTA on the quality of courses, representation of the natural therapy profession and the public interest. Information regarding ANTA and copies of ANTA submissions for inclusion of natural therapists in the NRAS were provided and reviewed. The recent review of the NRAS was also discussed at some length together with the response and recommendations of the Australian Health Workforce Ministerial Council (AHWMC) (these documents were recently circulated to ANTA members and posted on the ANTA website). It appears from the AHWMC response a commitment to registering natural therapists and inclusion in the NRAS has not been made, however, our discussions did include how protection of title and standards for natural therapists could be legislated. Although it is early stages, ANTA representatives were encouraged that further discussions to explore how this might be implemented will continue. As discussions and developments occur on the push for registration, we will keep ANTA members informed. It is alarming that some associations allow members to join online without appropriate qualifications or without even identifying the person applying to join. These types of associations should not be allowed to exist and pose a serious risk to the public. ANTA believes the only way to bring about an end to these associations and unqualified practitioners is to register natural therapists under

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the NRAS. Advanced Diploma’s Naturopathy, Western Herbal Medicine, Nutritional Medicine & Homeopathy We continue to remind members of the decision by ASQA to cease delivery of the above qualifications. Just to reiterate, from December 2015 colleges will not be able to enrol further students in these programs. Colleges have also been given an extension of time until 2018 in which to teach out these courses and award qualifications. ANTA has been in contact with colleges to advise Advanced Diploma graduates will be eligible to join ANTA. ANTA members who joined with Advanced Diploma qualifications are not affected by the ASQA decision to cease delivery of Advanced Diploma’s. Members with Advanced Diploma qualifications are not required to upgrade to bachelor degree level qualifications. As long as members 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 As we move into 2016 health funds will again be conducting 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-to-date. 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 practitioners receipting profiles shows any abnormalities the practitioner will be required to provide additional information and meet with Medibank 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 The response by members to the Free ANTA seminars held in Brisbane, Perth, Sydney and Melbourne have been outstanding. We are working on our 2016 series of free seminars which will be bigger and better. We will contact members by email to advise them to register for the next seminar is being held in their state. All ANTA members including students can register to attend ANTA seminars free of charge.

2016

I NT E

NA L C O N

T IO NA

URAL MED

Saturday 11th - Monday 13th June | Sofitel Brisbane Central

CONGRESS IS ALWAYS A SELL OUT - DON’T MISS YOUR SEAT IN BRISBANE

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 Brisbane in 2016. This gives us the chance to come together as an industry with likeminded people for an enthusiastic and insightful long-weekend.

The Event - Neurology and Psychiatry Metagenics International Congress on Natural Medicine for 2016 will address one of the most important areas of health care – neurology and psychiatry. Although Descartes philosophy split the mind from the body in the 1600s, we will be reuniting matter and function and exploring the impact of neural physiology on mood, learning and cognition. Functional psychiatry has taken substantial steps forward over the last few years with increasing understanding of the role of oxidative stress, inflammation, mitochondrial function and the blood brain barrier on conditions once thought to be purely psychological. We will also explore the role of the milieu that the brain finds itself in on neurological function, including nutrition, gut function, systemic infection and toxicity.

Don’t miss the most significant event on the Natural Medicine calendar in 2016. 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

Early Bird price of $695.00 incl. GST (normal price $795.00 incl. GST) per person. (Same price applies in New Zealand). Early Bird ends Friday 29th January 2016.

For full details of Congress go to metagenics.com.au

THE NATURAL THERAPIST Volume 30 No.3

Call 1800 777 648 to book today.

Executive Officers

Report - november 2015

FREE ANTA Webinars We are continually adding outstanding webinars to this collection and I recommend members who are unable to attend the FREE ANTA National Seminars to log on and check them out. Viewing of the webinars is a great way to keep up with the latest developments and earn CPE points. Stay informed and up-to-date To stay in touch with the latest information make sure you visit the ANTA website, members centre and ANTA facebook. Updates containing a wealth of information are also sent to member by ANTA e-News regularly.

ANTA Annual Report 2015 I am pleased to announce that ANTA has again posted another successful financial result in 2015. The ANTA Annual Report for 2015 is available on the members section of the ANTA website. The results ANTA has continued to achieve over many years don’t happen by chance and It is assuring for ANTA members to know the governance of ANTA is in good hands.

During 2015 funds were deployed for: • Federal Government submissions • State Government submissions • Meetings with Federal and State government departments/ministers • Registration/Regulation meetings with Australian Minister for Health. • Further Upgrades to the ANTA website www.anta.com.au • Providing members with free access to the latest online scientific information eMIMS • Providing members with free access to the latest online scientific information IMGateway • Providing members with free access to the world’s most comprehensive resource - EBSCO • Meetings with Health Funds and Workcover authorities • Providing members with free seminars • Providing members with access to free ANTA webinars • Development of systems to manage the new Health Fund Rules • Protecting and safeguarding members interests in relation to the new Health Fund rules • College and University course review meetings • Supporting College and University graduation programs • ANTA Bursary Awards program • Obtaining cheaper professional indemnity insurance for members • Collaborating and networking with other associations • Complementary Medicine Practitioner Associations Council (CMPAC) • Australian National Register of Accredited Natural Therapists (ANRANT) • Health Training package reviews • Upgrading the ANTA e-Learning Centre

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for member CPE activities • National Advertising program in major health publications • Review and upgrading of the ANTA journal The natural Therapist • Developing the ANTA Natural Therapies App with practitioner search for members • Maximizing the public’s use of the ANTA practitioner referral free call number service • Updating the practitioner referral section on the ANTA website • Updating the practitioner referral section on the CMPAC website • Updating the practitioners referral section on the ANRANT website • Upgrading the free members web pages on the ANTA website • Enhancements to the ANTA e-News service to members • Upgrading the membership data base Advertising and Promotion of ANTA Members in national magazines 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.

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 We are finalising our Business Plan for 2016 and looking to make it another successful year for ANTA members. Any members requiring advice, assistance or has feedback on ways in which we can improve our member services please feel free contact either myself or the team in the ANTA National Office at anytime on 1800 817 577 or info@anta.com.au In closing and behalf of the Directors and Staff at ANTA, to all ANTA members and their families, we wish you a wonderful holiday season and a New Year filled with peace, good health and happiness. The ANTA National Administration Office is closed over the following period: Friday 18th December 2015 - Friday 1st January 2016 The office reopens on Monday 4th January 2016 Regards Brian Coleman Executive Officer

ANTA Awards $100,000 to natural therapy students 2015 marks a significant milestone in the ANTA National Bursary Awards program. ANTA is proud to announce that $100,000 has now been awarded to students enrolled in natural therapy courses. This is truly a magnificent achievement and to mark this special occasion and to add to the support and assistance ANTA is committed to providing students, the ANTA National Bursary Awards in 2015 were increased to $12,000. The submissions received for the ANTA National Bursary Awards in 2015 were outstanding which made the task of selecting the 12 recipients very difficult. ANTA is very pleased to announce the following 12 students as the recipients of $1,000 each for 2015: Gary Capstick

NSW

Eleanor Eastwood

NSW

Stephanie Malouf

NSW

Samantha Moorman

QLD

Ann Burns-Hutchinson

QLD

Alexandra Martin

QLD

Isabella Walton

QLD

Brooke Donnelly

QLD

Meghann Hayes

VIC

Samantha Bake

VIC

Rosemary King

VIC

Sonia Gulwadi

VIC

ANTA congratulates the above recipients on their excellent submissions and thanks all students who lodged a submission. ANTA is now looking forward to reaching the next milestone of delivering $200,000 to students.

HICAPS - Payment Processing for Health Fund Claims We have become aware of some instances where errors have occurred when processing patient payments through HICAPS.

The errors occurred whereby incorrectly authorised patient payments processed through HICAPS to include herbal medicines, supplements etc. To avoid any issues or problems arising with health funds, we recommend that practioners check to ensure that only consultation fees for patients are processed through HICAPS where the patient does not have cover for herbal remedies, supplements etc.

ANTA Attends AHPRA Meeting ANTA attended the Professions Reference Group (PRG) meeting at the AHPRA National Office in August 2015. Attendees at the meeting included representatives from registered professions and senior AHPRA management. The meeting was chaired by AHPRA CEO Martin Fletcher and discussed a wide range of topics including: Health Minister’s response to final report of the review of the National Registration and Accreditation Scheme (NRAS) Improving the notifications process Risk-based approach to regulation Raising public awareness of registration Improvements to processes ANTA is pursuing registration for natural therapists and attendance at these meetings is essential to keep the issue of registration at the forefront and to develop ongoing working relationships. ANTA will be attending further AHPRA meetings and will continue to engage in dialogue with AHPRA management, Ministers and government departments to achieve our goal of registration for natural therapists.

A Guide to Working With Minors Clearance checks and requirements relating to Natural Therapists and other health professionals in relation to treating patients who are minors varies considerably across Australia.

Consent to treating a minor (children) must also be obtained from a parent or guardian. Failure to obtain valid consent from a parent or guardian prior to treating a minor may make a practitioner liable to civil and criminal sanctions Minors (Children): The rights and protection of children are governed by both Federal, State and Territory laws. Persons below the age of 18 are generally considered children, although this can vary in some states. The above mentioned Fact Sheet can also be downloaded from the members centre of the ANTA website.

ANTA Representatives meet with advisor to the Australian Minister for Health ANTA representatives recently had a meeting with the advisor to the Australian Minister for Health (Hon. Sussan Ley MP) to discuss statutory registration of Natural Therapists and inclusion in the National Registration and Accreditation Scheme.

As a result of police arresting a Sydney self proclaimed Naturopath and Registered Nurse, ANTA strongly recommends State and Federal Governments consider registration of Naturopaths, Herbalists, Nutritionists and Homeopaths under the National Registration and Accreditation Scheme (NRAS).

The recent review of the NRAS was also discussed at some length together with the response and recommendations of the Australian Health Workforce Ministerial Council (these documents were recently circulated to ANTA members and posted on the ANTA website). It appears from the AHWMC response a commitment to registering natural therapists and inclusion in the NRAS has not been made, however, our discussions did include how protection of title and standards for natural therapists could be legislated. Although it is early stages, ANTA representatives were encouraged that further discussions to explore how this might be implemented will continue.

ANTA is very pleased to announce that all members now have 30min of FREE legal advice

Practitioners should check with the relevant authorities in their state regarding clearance checks and treating patients who are minors (children).

ANTA again calls on State & Federal Governments to register Naturopaths, Herbalists, Nutritionists & Homeopaths

The advisor was briefed and updated on the quality of courses, representation of the natural therapy profession and the public interest. Information regarding ANTA and copies of ANTA submissions for inclusion of natural therapists in the NRAS were also reviewed and discussed.

News

The NRAS has been established by State and Territory Governments through the introduction of consistent legislation in all jurisdictions. The NRAS protects the public by ensuring that only suitably trained and qualified practitioners are registered to practice. Whilst ANTA has stringent requirements for qualifications, training and ethical practice it is a concern that some associations still accept practitioners without the necessary training or qualifications. Registration of natural therapists under the NRAS would greatly reduce the risk of the public being exposed to untrained practitioners.

Free Legal Advice for ANTA members We are very pleased to announce that ANTA members who are insured through our preferred supplier of professional indemnity insurance Arthur J Gallagher (incorporating OAMPS), can now obtain 30 minutes of free legal advice.

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

Women’s Health Survey: Identifying gaps in women’s health Jean Hailes releases Australia’s most comprehensive study of women’s fears and needs. Below is the link to the Jean Hails Women Health Survey Report 2015. The reports identifies some interesting results particularly in relation to Natural Therapies. Download the Report on ANTA’s website under ”Latest News”

As discussions and developments occur we will keep ANTA members informed.

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News 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-to-date 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 your 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

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• researching scientific information on EBSCO - free access for members on www.anta.com.au • researching scientific information on eMIMS Cloud – free access for members on www. anta.com.au • viewing seminar video’s 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 • first aid qualification renewal • contributing an article to the ANTA journal “The Natural Therapist” and ANTA website • contributing an article to other relevant journals, magazines & 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 & 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 video’s 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: 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.

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Update ANTA UPDATES - ANTA ADVICE, UPDATES AND RECOMMEDATIONS . IMPORTANT - Health Fund Qualifications Information Health Funds are continuously qualification requirements for registration

updating provider

ANTA’s focus is to assist members to maintain current provider registration with health funds. ANTA members who maintain current membership, professional indemnity insurance (PI), and first aid (FA) qualifications at all times and complete 20 hours of CPE/CPD annually will continue as registered providers with health funds when health funds update qualification requirements. Private Health Insurance (Accreditation) Rules 2011 (Private Health Insurance Act 2007) Under the above rules/act, health funds will not re-register practitioners as providers when qualification requirements for provider registration are updated and members allow ANTA membership, PI or FA to lapse or do not complete 20 hours of CPE/CPD annually. In the future (at a date to be determined), health funds will be updating qualifications requirements for provider registration in naturopathy, nutrition, homoeopathy and western herbal medicine to bachelor degree level (a result of the delivery of Advanced Diploma qualifications ceasing). Members who do not have qualifications at bachelor degree level and are currently registered as providers with health funds will not be required to upgrade their qualifications provided they:

• Maintain current membership with ANTA at all times • Have current PI at all times • Have current FA at all times • Complete and lodge 20 hours of CPE/ CPD at the end of each year • Maintain current registration with the CMBA/AHPRA if accredited in acupuncture and/or chinese herbal medicine ANTA regularly reminds members of the above requirements using the following methods: ANTA e-News

• ANTA membership renewal notices and subsequent follow up reminders • Quarterly ANTA journal “The Natural Therapist” • ANTA website www.anta.com.au • I, FA and CPE/CPD reminder emails • PI, FA and CPE/CPD reminder letters • Telephone calls to members

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These methods are successful in reminding members if members keep us updated with their current email address, postal/clinic address and telephone numbers. Members relying on email reminders should check the spam settings on computers as emails can be overlooked/missed if they end up in the member’s junk email folders. Members are also encouraged to record/ use their own reminders of expiry dates for membership, PI, FA and CPE/CPD in their diaries and/or outlook tasks and/or mobile phones (there are numerous free apps available to manage reminders) or use any other reminder method that works. Reminders are useful tools, however the key is to act in a timely manner and complete the task required on time (e.g. renew ANTA membership PI, FA on time and lodge CPE/CPD).

Advice to all Members – Health Fund Provider Registration Health Funds are continuously analysing practitioner receipting practices to identify any irregularities and problems. Health Funds are also conducting regular audits to ensure practitioners maintain, detailed and up-to-date patient records. Any practitioner identified by health funds as not complying with health fund provider terms and conditions, not complying with receipting practices or patient record requirements are being de-registered as providers with health funds instantly and permanently. Over servicing of patients by practitioners has also been identified as a major problem by health funds. We are aware of instances where practitioners have been caught issuing more than 40 receipts per day over several months. As a result of the surveillance and auditing by health funds, significant numbers of practitioners continue to be de-registered by health funds and expelled from associations for non compliance. The opportunity to reapply for or regain provider registration and association membership is no longer available to these practitioners.

ANTA recommends members to review and ensure: • all receipts issued are correct in all aspects, and are for genuine and valid treatments • other practitioners are not using your provider numbers or receipts • all patient records are detailed, accurate and kept up-to-date Information and guidelines regarding health funds, provider registration and patient records is on the members section of the ANTA website

ANTA Policy & Guidelines for Remedial Massage Therapy, Myotherapy Musculoskeletal Therapy, Shiatsu, An-Mo-Tuina and other massage therapy techniques used by ANTA members This document sets out relevant professional considerations, behaviour and conduct expected of ANTA members using various massage techniques in which they are trained. This document should be read in conjunction with the ANTA Code of Professional Ethics, ANTA Constitution, Federal, State & Local Govt laws and regulations( including the Code of Conduct in NSW & SA), Health Fund & Work Cover Authority requirements. When a client is present for assessment and treatment the professional and legal duty of care in relation to the client is established. Members have a responsibility to ensure the therapeutic intervention is intended to be of benefit to the client, is appropriate and in accordance with their training. Members should be aware any breach of care may give rise to a claim for damages for negligence by the client. The full document is on the members section of the ANTA website and members should ensure they are familiar with its contents. Visit ANTA website for more updates on www.anta.com.au

National Code of Conduct for All Unregistered Health Care Workers The Qld Minister for Health has announced the National Code of Conduct for Unregistered Health Care Workers will apply to health care workers delivering a health care service in Queensland from the 1st October 2015. The National Code for Health Care Workers (Qld) will apply to all natural therapists and all other unregistered practitioners providing a health care service in Qld. All health care workers in Qld, unless exempt must display or make available at all premises or locations where they practice a copy of the National Code for Health Care Workers (Qld). Complaints under the National Code for Health Care Workers (Qld) are reported to and resolved by the Office of the Health Ombudsman. The above mentioned Fact Sheet can also be downloaded from the members centre of the ANTA website.

Special Treatment of Achilles Tendonitis Bing Wu

Achilles Tendonitis The Achilles tendon is a large tendon joining the calf muscle to the heel bone. The function of the Achilles tendon is to point the foot, downwards at the ankle joint. As the cross-section of the Achilles tendon is much smaller than the calf muscle, therefore the Achilles tendon bears much higher unit area tension and is vulnerable to the injury. Achilles Tendonitis is a term that commonly refers to an inflammation of the Achilles tendon or its covering. It is a type of injury caused by overuse. Achilles tendonitis may be felt as a burning pain at the beginning of an activity, which gets less during the activity and then worsens following the activity. The tendon may feel stiffness and pain first thing in the morning or at the beginning of any exercise. Treatment includes rest, non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and orthotics. In some cases the injury may need steroid injections. For most people, the symptoms of Achilles tendinopathy usually clear within 3-6 months of commencing treatmentÂš. In my clinical practice, I know that Gua Sha is very useful in the treatment of Achilles Tendonitis.

Gua Sha is a traditional Chinese medical treatment in which the skin is scraped to produce light bruising. Modern research shows Gua Sha produces an anti-inflammatory and immune protective effect that persists for days following a single Gua Sha treatmentÂ˛.

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Special Treatment of Achilles Tendonitis

Bing Wu Some Western practitioners may know of and use the Graston Technique. This is a modification of traditional hands-on soft tissue mobilization. This technique uses specifically designed instruments to allow the therapist to introduce a controlled amount of microtrauma into an area of excessive scarring and/or soft tissue fibrosis, hoping that this will invoke an inflammatory response that will augment the healing process³.

In my clinical practice, I use this process to treat Achilles Tendonitis. For a majority of patients, (if they come once a week), after three treatments, they can see a significant improvement with their symptoms and after five treatments, the symptoms have almost disappeared. This indicates the treatment achieves a satisfactory result.

According to the Graston technique and principles, I use Gua Sha tools as an instrument combined with theoretical, traditional Chinese medicine to treat Achilles Tendonitis.

Treatment goal • • •

Breakdown the scar tissue Reduce swelling and pain Recovery of normal function

Treatment process Put oil around the calf and the Achilles tendon to reduce the friction on the skin’s surface, • Following the Bladder • Meridian of Foot-Taiyang, scrape from the top of the calf muscle to the bottom of the heel in one direction for about 5-7 minutes • On both sides of the Achilles tendon, scrape with added pressure for another 5 minutes from the proximal to the distal • Put pressure on the points of Kunlun (BL 60) and Taixi (KI 3) for about a minute each

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References

1. http://patient.info/health/achilles-tendinopathy 2. http://guasha.com/ 3. http://www.grastontechnique.com

AUSTRALIAN OWNED & MANUFACTURED

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Literature review of the use of calcium and magnesium during chemotherapy for colorectal cancer Southern School of Natural Therapies Advanced Nutritional Medicine Rosemary King

In Australia colorectal cancer is the second most commonly diagnosed form of cancer with the estimated incidence rising from 12,844 cases in 2001 to 15,840 in 2012 (ABS, 2006; AIHW, 2013). Oxaliplatin combination therapy is now the standard treatment in advanced metastatic colorectal cancer, however neurotoxicity is a well-足known dose limiting side effect

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literature Review of the use of calcium and magnesium during chemotherapy for colorectal cancer

Rosemary King Introduction In Australia colorectal cancer is the second most commonly diagnosed form of cancer with the estimated incidence rising from 12,844 cases in 2001 to 15,840 in 2012 (ABS, 2006; AIHW, 2013). Oxaliplatin combination therapy is now the standard treatment in advanced metastatic colorectal cancer, however neurotoxicity is a well-known dose limiting side effect (Grothey, Nikcevich, Sloan, Kugler, Silberstein, Dentchev, Wender, Novotny, Chitley, Alberts, & Loprinzi, 2011; Knijn, Tol, Koopman, Werter, Imholz, Valster, Mol, Vincent, Teerenstra, & Punt, 2011; Loprinzi, Qin, Dakhil, Fehrenbacher, Flynn, Atherton, Seisler, Qamar, Lewis, & Grothey, 2014). There are two forms of peripheral neuropathy (PN) observed in patients receiving oxaliplatin, which are categorized as acute and chronic. The acute form is generally transient beginning during administration of oxaliplatin or shortly afterwards leading to cold-‐ triggered distal and perioral paraesthesia’s including lock jaw, muscle cramps as well as pharyngolaryngeal dysthesias which may last for hours or a few days (Argyriou, Polychronopoulos, Iconomou, Chroni, & Kalofonos, 2008; Schloss, Colosimo, Airey, Masci, Linnane, & Vitetta, 2013). Chronic PN is a pure sensory, axonal neuropathy presenting in a glove-and-stocking distribution with loss of deep tendon reflexes and proprioception and results from the cumulative effect of oxaliplatin. Chronic PN is persistent between treatments and for some patients has continued years after initial treatment (Han, Khwaounjoo, Kilfoyle, Hill, & McKeage, 2013; Mols, Lemmens, van den Hurk, Vreugdenhil, van de Poll- Franse, 2013; Park, Lin, Krishnan, Goldstein, Friedlanders, & Kiernan, 2011; Schloss et al., 2013). The ability to augment these undesirable adverse effects could provide a unique opportunity for intervention by complementary and alternative medical practitioners. It has been hypothesized that the oxaliplantin metabolite oxalate rapidly chelates calcium thereby disrupting the voltage-gated sodium channels leading to hyperexcitability of neurons (Gamelin, Boisdron-Celle, Delva, Guerin-Meyer, Ifrah, Morel, & Gamelin, 2004; Knijn et al., 2011). Alterations to these pathways may subsequently initiate acute PN and there may be a role for adjuvant intravenous (i.v.) calcium and magnesium (CaMg) infusions in reducing or preventing the damage caused oxalipltain-based therapy (Gamelin et al., 2004; Knijn et al., 2011). Additionally, prolonged initiation of these voltage-gated channels may exacerbate cellular stress and the nerve damage attributed to chronic PN (Argyriou, Cavaletti, Antonacopoulou, Genazzani, Briani, Bruna, Terrazzino, Velasco, Alberti, Campagnolo, Lonardi, Cortinoris, Cazzaniga, Santos, Psaromyalou, Angelopoulou, & Kalofonos 2013). Ameliorating these adverse effects may not only increase treatment efficacy through improving compliance without dose reduction but may significantly improve the quality of life for those undergoing treatment for advanced colorectal cancer.

Aim This literature review aims to assess the safety and efficacy of intravenous CaMg infusions for the prevention or reduction of PN in patients undergoing treatment with oxaliplatin-based therapy for advanced colorectal cancer. Evaluation of the clinical significance and potential application of this adjuvant therapy may prove beneficial during treatment as well as for long-term colorectal cancer survivors.

Methods

‘oxaliplatin’, ‘neurotoxicity’, ‘neuropathy’, ‘prevention’, ‘randomised placebo-controlled trials’, ‘clinical trials’, ‘case study’, ‘English language’. Boolean phrases used for the search included Oxaliplatin induced neuropathy AND advanced colorectal cancer NOT ovarian cancer; Calcium magnesium infusions AND chemotherapy AND colorectal cancer; Calcium magnesium AND neurotoxicity OR neuropathy; Platinum-containing compounds OR oxaliplatin AND neurotoxicity. For the purposes of this paper eight studies were included for critical evaluation.

Effect of CaMg on oxaliplantin-induced neurotoxicity Retrospective studies

There have been considerable conflicting reports in regard to the safety and efficacy of CaMg infusions for the prevention or reduction of oxaliplatin induced PN over the past 10 years (Chay, Tan, Lo, Ong, Ng, Gao, Koo, & Choo, 2010; Gamelin et al., 2004; Grothey et al., 2011; Han et al., 2013; Ishibashi, Okada, Miyazaki, Sano, & Ishida, 2010; Knijin et al., 2011; Loprinizi et al., 2014). Positive results in favour of i.v. CaMg were found in two retrospective studies which evaluated a total of 893 patients receiving oxalipltain-based chemotherapy (Gamelin et al., 2004; Knijn et al., 2011). Gamelin et al. (2004, p.4056) had initially given several patients with manifestations of acute PN i.v. CaMg infusions and noted an immediate improvement in symptoms. As reported in the retrospective cohort study (Gamelin et al., 2004, p.4056) there were significant differences in the occurrence of acute and chronic PN between patients receiving CaMg (1g of each) compared to controls. The files of 161 patients receiving oxaliplatin plus leucovorin and 5-fluorouracil (FOLFOX) with colorectal cancer were retrieved and analysed, 96 of which had been given CaMg pre and post oxaliplatin administration while the remaining 65 formed the control group (Gamelin et al., 2004, p.4056) Significant improvement in the occurrence of neuropathy according to the National Cancer Institute Common Terminology Criteria scale (NCI-CTC) was seen in the CaMg group with less frequent grade 3 PN at any point during treatment compared to the control group (7% verses 26%) and significantly fewer patients withdraw from treatment due to neurotoxicity (4% verses 31%) (Gamelin et al., 2004, p.4058). More modest results were noted in the Knijn et al. (2011, p.371) retrospective study with the reduced prevalence of NCI-CTC all grade sensory neurotoxicity in the CaMg group (85%) compared to control (92%) as well as all grade early neurotoxicity during the first six cycles of treatment (CaMg 81%; control 91%), however no differences were noticed for late neurotoxicity grade ≥2 between each group. Conversely, Gamelin et al. (2004, p.4060) reported that chronic grade 3 neurotoxicity was less severe and frequent in those administered CaMg and seemed to be most effective with lower doses of oxaliplatin (85mg/m2 compared to 130mg/m2). Although the studies showed that CaMg reduced the frequency of neurotoxicity, due to the retrospective nature there may have been selection bias and the data is subject to reporting bias from the nurses and physicians as no person was blinded during these studies. Additionally, some of the data evaluated in the Gamelin et al study (2004, p.4058) was taken from as little as three treatment cycles therefore limiting the information regarding the efficacy of CaMg for prolonged oxaliplatin therapy. Interestingly, the prevention of early toxicity in the Knijn et al. study (2011, p.371) and the increased efficacy of CaMg to reduce the prevalence neuropathy with the lower doses of FOLFOX treatment (oxaliplatin 85mg/m2) (Gamelin et al., 2004, p.4060) indicates that perhaps the cumulative effect of oxaliplatin requires dose modification of CaMg that should be investigated in prospective randomized controlled trials.

A literature search was conducted through Web of Science, PubMed, Cochrane Collaboration, Medline and EBSCO databases in June 2014. The key words used for the search included; ‘colorectal cancer’, ‘calcium’, ‘magnesium’,

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literature Review of the use of calcium and magnesium during chemotherapy for colorectal cancer

Rosemary King THE TRADITIONAL Despite the positive results from the two retrospective studies, more

recent randomized controlled trials (RCT’s) have had varying results partly due to the early termination of some studies following interim reports that CaMg infusions reduced the tumour response rate (Chay, Tan, Lo, Ong, Ng, Gao, Koo, & Choo, 2010; Grothey et al., 2011; Ishibashi, Okada, Miyazaki, Sano, & Ishida, 2010). Chay et al. (2010, p.274) concluded from a blinded, RCT (n=27) that CaMg (1g each) was not effective in preventing acute neuropathy (CaMg 77% and placebo 85%), however the trial was terminated early and planned long-term evaluation was not conducted due to concerns from findings in the CONcePT trial of a reduction in tumour response rate. Although, an independent response evaluation criteria in solid tumours review of the CONcePT trial concluded that there was no interference with tumour response with CaMg treatment (Chay et al., 2010, p.275). Overall grade 3 neuropathy (NCI-CTC) was higher in the treatment group compared to placebo (11% verses 0%) while grade 1 and 2 were higher in the placebo group (70% verses 40%) (Chay et al., 2010, p.274). This could be explained by the lack of homogeneity of chemotherapy treatment because of differences in oxaliplatin administration as the majority of patients (n=22) received XELOX (oxaliplatin 130mg/m2 plus capecitabine) while the remainder (n=5) received FOLFOX-4 (oxaliplatin 85mg/m2) and previous reports suggest that CaMg is more affective at lower oxaliplatin doses (Chay et al., 2010, p.272). Despite the results not being statically significant it is interesting to note that the median oxaliplatin dose reached before developing acute neuropathy was slightly higher in the CaMg group (480mg/m2 verses 400mg/m2) and no patients terminated chemotherapy prematurely due to grade 3 neurotoxicity compared with three in the control group suggesting a potential for increased treatment duration (Chay et al., 2010, p.274). Han et al. (2013, p.496) performed a similar study with almost identical chemotherapy regimes (XELOX n=16; FOLFOX-6 n=4) in a crossover double-blind RCT and found that there was no difference in occurrence of acute neurotoxicity between each group (CaMg 1g each verses placebo). Patient reported cold-induced paraesthesia’s (84% both groups), jaw tightness (placebo 68%; CaMg 74%) and muscle cramps (placebo 42%; CaMg 47%) were not significantly different between groups, however the study alternated between placebo and CaMg at each cycle, no standardized neurotoxicity scale were used along with a small sample size may have skewed the results (Han et al., 2013, p.499.) Objective data were only obtained from two studies (Chay et al., 2010; Han et al., 2013). One trial using nerve conduction studies indicated that the treatment group had worse scores at the end of six cycles, however only 16 people were tested (CaMg n=7 and placebo n=9) with significant differences only evident at the end of treatment when the cumulative doses of oxaliplatin were higher without any increase in the frequency or amount of CaMg infusions (Chay et al., 2010, p.275). In contrast, Han et al. (2013, p.499) noted abnormal spontaneous high frequency motor unit activity measured by electromyography in the first two cycles of treatment with no difference between those receiving 130mg/m2 or 85mg/m2 of oxaliplatin, however a small sample size may limit the analysis. Another small (n=33) double-blind, RCT (Ishibashi et al., 2010) showed no significant difference in the prevalence of all grade neurotoxicity between the CaMg group and placebo after six treatment cycles (Ishibashi et al., 2010, p.84). Although all the patients received the same modified FOLFOX-6 regime (85mg/m2) the amount of CaMg differed to other studies (i.v.; 850mg and 720mg respectively) (Ishibashi et al., 2010, p.83). This decrease in the dose of CaMg compared to other studies (Chay et al., 2010; Gamelin et al., 2004; Grothey et al., 2011; Knijn et al., 2011; Loprinzi et al., 2014) along with the small sample size and early termination may confound the results.

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One study investigated secondary outcomes by measuring the plasma levels of platinum and interestingly there were no significant differences in platinum concentrations with those patients that developed grade ≥2 neurotoxicity than those with no symptoms (Ishibashi et al., 2010, p.85), suggesting there may be other mechanisms involved in neuronal damage. Platinum compounds are known to accumulate in the dorsal root ganglion cells causing cytotoxicity, mitochondrial damage and impaired cellular oxygen consumption due to an increase in reactive oxygen species, which is believed to be partly responsible for the chronic manifestations of oxaliplatin-induced PN. Additionally, prolonged activation of voltage- gated sodium channels may increase cellular stress further damaging sensory nerve cells. This may be compounded by voltage-gated sodium channel polymorphisms in some individuals and may explain the varying outcomes between the literature and why CaMg alone may not attenuate all of the adverse effects (Argyriou et al., 2013, 2008). Furthermore, there is no information in the literature regarding the nutritional status of patients during treatments and given the role of intracellular antioxidant systems such as glutathione in preventing cellular and mitochondrial damage, investigating nutritional status particularly protein to determine amino acid intake may prove beneficial (Wu, Fang, Yang, Lupton, & Turner, 2004, In contrast to the findings of Chay et al. (2010), Han et al. (2013) and Ishihashi et al. (2010), the double blind, RCT (n=104) performed by Grothey et al. (2011, p.423) showed positive results in favour of the use of CaMg (i.v.; 1g each) for the prevention of chronic PN. A reduction of grade ≥2 neurotoxicity was observed on both NCI-CTC (22% verses 41%) and the oxaliplatin-‐specific scale (28% verses 51%) with the onset of chronic PN being significantly delayed in the CaMg group (Grothey et al., 2011, p.424). Patient reported outcomes also followed a similar pattern with patients receiving CaMg experiencing less frequent sensory neuropathy than placebo. There appeared to be no significant evidence that CaMg reduced acute neurotoxicity, however there were some differences in the occurrence of symptoms particularly relating to muscle cramping in the first cycle (Grothey et al., 2011 p.424). Conversely, the most recent double blind, RCT (n=353) showed no difference in acute

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literature Review of the use of calcium and magnesium during chemotherapy for colorectal cancer

Rosemary King muscle cramping, however there were indications for decreases in throat discomfort (raw P=0.036) (Loprinzi et al., 2014, p.1001) highlighting the potential variances in interpreting clinical aspects through subjective reporting. The only two RCT’s that were not terminated early include those performed by Loprinizi et al. (2014) and Han et al. (2013). Both of these studies showed that CaMg had no effect on acute or chronic sensory neuropathy (Han et al., 2013; Loprinzi et al., 2014). The largest (n=353) and most comprehensive three arm RCT was performed by Loprinzi et al. (2014) and used three different measures to evaluate the prevalence of neurotoxicity including NCI-CTC, oxaliplatin-specific scale and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Chemotherapy-Induced Peripheral Neuropathy 20 (EORTC QLQ-CIPN20). No significant differences were noted between any of the three arms (CaMg before/CaMg after; CaMg/placebo; placebo/placebo) with regard to the development of acute or chronic sensory neuropathy as well as no differences in FOLFOX dose administration between groups over the 12 cycles (Loprinzi et al., 2014, p.1002), however no long-term evaluation on the potential reduction in recovery time from chronic PN was performed. In fact, of all of the RCT’s in this literature review none have completed any long-term follow ups to assess the rate of recovery of PN after the end of treatment and whether CaMg aids in the return to normal functioning or an improved quality of life. It was estimated in an Australian study that up 79.2% of colorectal cancer patients who received oxaliplatin-based chemotherapy were still experiencing some form of PN and that nerve damage was not resolved at long-term follow up, therefore evaluating the long-term benefit of CaMg could provide further insight in to its role as a neuroprotective agent (Park et al., 2011, p.715).

Case Study One case study was included to evaluate the efficacy of oral calcium on the prevention of oxaliplatin-based PN in a colorectal cancer patient. A 62 year old male was being treated with FOLFOX-4 and experienced grade 1 neurotoxicity in the lower extremities, however after he changed to a capecitabine/oxaliplatin regime the PN worsened and he was given an undefined dose of i.v. CaMg (Saif, 2004, p.577). After developing a severe itch after the infusion he ceased the CaMg and was given a “new pill” to help with the numbness and lack of sensation in the feet and tips of his fingers, which he said was significantly improving his symptoms (Saif, 2004, p.578). The over-the-counter oral calcium (Rolaids, undefined dose) was continued throughout the remainder of his treatment while magnesium oxide was added to his prescription and he reported a continued improvement in both acute and chronic presentation of PN. He received a cumulative dose of 2500mg/m2 of oxaliplatin during the course of treatment and had no evidence of subjective or objective PN after treatment had stopped (Saif, 2004, p.579). This case study shows the individualistic nature of response to treatment and could indicate a convenient, cost effect and potentially clinically significant way to reduce oxaplitain-induced PN.

CaMg toxicity and impact on the efficacy oxaliplatin-based chemotherapy After initial reports that CaMg infusions interfered with oxaliplatins antitumor activity subsequent investigations have proven that there is no impact on survival rates of patients or altered pharmacokinetics of the chemotherapeutic agent (Chay et al., 2010; Gamelin et al., 2004; Grothey et al., 2011; Han et al., 2013; Ishibashi et al., 2010; Knijn et al., 2011; Loprinzi et al., 2014). Secondary outcomes in one study were to measure the plasma levels of platinum during the first and fifth treatment cycle and while the concentrations tended to be higher in the placebo group at three hours in the first cycle, there were no significant differences at any other point during treatment (Ishibashi et al., 2010, p.85). The pharmacokinetics of oxaliplatin were investigated by Han et al. (2013, p.499) and plasma concentrations verses time profiles for free platinum and intact oxaliplatin were not altered by CaMg infusions

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literature Review of the use of calcium and magnesium during chemotherapy for colorectal cancer

Rosemary King There were no differences in progression free survival between CaMg (10.1 months) and control (10.7 months) nor overall survival (CaMg 19.8 months verses control 20.7 months), tumour response rate was comparable (43% verses 50% respectively) (Knijn et al., 2011, p.371) and Chay et al. (2010, p.276) proposed there were no differences in the recurrence of cancer. There have also been no reports of CaMg toxicity and it appears to be well tolerated, except for one case study involving a 62 year old male who developed severe itching after the CaMg infusions (Grothey et al., 2011; Ishibashi et al., 2010; Loprinzi et al., 2014; Saif, 2004).

Conclusion The literature in relation to the efficacy of CaMg infusions in the prevention or reduction of oxaliplatin-induced PN is still relatively inconclusive particularly with regard to its use for acute verses chronic manifestations. While some studies suggest there is a role for its use to reduce acute onset, others have determined that it slows progression of chronic neurotoxicity, however most studies have a small sample size, were terminated early or were retrospective in nature. There is only one large scale RCT to date and although the results were against the prophylactic use of CaMg additional research into the long-term residual effects of chronic PN may be able to give insight into whether there is any potential as a neuroprotective agent. As all of the studies, except for one case study, have investigated the i.v. use of CaMg the effect of oral administration is relatively unknown. Given the cumulative nature of oxaliplatin it stands to reason that further investigations into the effect of an increased dose or frequency of CaMg for the prevention of PN may prove to be beneficial. The neuronal damage caused by oxaliplatin-based chemotherapy is complex and additional studies into the effects other nutriceutical therapies may be required to attenuate all of the cellular stress and adverse outcomes. Due to the potentially debilitating consequences of chemotherapy, the individualistic subjectivity of PN and the lack of evidence of CaMg toxicity, reductions in tumour response rate or altered pharmacokinetics it is possible that the use of CaMg as an adjuvant therapy could be at the discretion of the patient and practitioner; however studies with regard to the safety of orally administered CaMg are lacking and a defined dose is not known. Until further studies are performed in this area it may be prudent to avoid the use of orally administered CaMg in patients with colorectal cancer undergoing oxaliplatin-based chemotherapy.

References: 1. Argyriou, A. a, Cavaletti, G., Antonacopoulou, A., Genazzani, A. A, Briani, C., Bruna, J., Terrazzino, S., Velasco, R., Alberti, P., Campagnolo, M., Lonardi, S., Cortinoris, D., Cazzaniga, M., Santos, C., Psaromyalou, A., Angelopoulou, A., & Kalofonos, H. P. (2013). Voltage-‐gated sodium channel polymorphisms play a pivotal role in the development of oxaliplatin-‐induced peripheral neurotoxicity: results from a prospective multicenter study. Cancer, 119(19), 3570–7. doi:10.1002/cncr.28234. 2. Argyriou, A. a, Polychronopoulos, P., Iconomou, G., Chroni, E., & Kalofonos, H. P. (2008). A review on oxaliplatin-‐induced peripheral nerve damage. Cancer Treatment Reviews, 34(4), 368–77. doi:10.1016/j.ctrv.2008.01.003. 3. Australian Bureau of Statistics (2006). Cancer in Australia: A Snapshot, 2004-‐05. Retrieved from http://www.abs.gov.au/ Ausstats/abs@.nsf/0e5fa1cc95cd093c4a2568110007852b/8ddd 5aed085834daca256f010077be4a!OpenDocument. 4. Australian Institue of Health and Welfare (2013). Bowel cancer. Retrieved from http://www.aihw.gov.au/cancer/cancer-in-australia/

5. Chay, W.-Y., Tan, S.-H., Lo, Y.-L., Ong, S. Y.-K., Ng, H.-C., Gao, F., Koo, W.-H., & Choo, S.-P. (2010) 6. Use of calcium and magnesium infusions in prevention of oxaliplatin induced sensory neuropathy. 7. Asia-Pacific Journal of Clinical Oncology, 6(4), 270–7.

doi:10.1111/j.1743-7563.2010.01344.x 8. Gamelin, L., Boisdron-Celle, M., Delva, R., Guerin-Meyer, V., Ifrah, N., Morel, A., & Gamelin, E. (2004). Prevention of Oxaliplatin-Related Neurotoxicity by Calcium and Magnesium Infusions : A Retrospective Study of 161 Patients Receiving Oxaliplatin Combined with 5-Fluorouracil and Leucovorin for Advanced Colorectal Cancer. Clinical Cancer Research, 10, 4055–4061. Retrieved from http://clincancerres.aacrjournals. org.ezp.lib.unimelb.edu.au/content/10/12/4055. 9. Grothey, A., Nikcevich, D. A., Sloan, J. A., Kugler, J. W., Silberstein, P. T., Dentchev, T., Wender, D. B., Novotny, P. J., Chitaley, U., Alberts, S. R., & Loprinzi, C. L. (2011). Intravenous calcium and magnesium for oxaliplatin-induced sensory neurotoxicity in adjuvant colon cancer: NCCTG N04C7. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology, 29(4), 421–7. doi:10.1200/ JCO.2010.31.5911 10. Han, C. H., Khwaounjoo, P., Kilfoyle, D. H., Hill, A., & McKeage, M. J. (2013). Phase I drug-interaction study of effects of calcium and magnesium infusions on oxaliplatin pharmacokinetics and acute neurotoxicity in colorectal cancer patients. BMC Cancer, 13(1), 495. doi:10.1186/1471-2407- 13-495. 11. Ishibashi, K., Okada, N., Miyazaki, T., Sano, M., & Ishida, H. (2010). Effect of calcium and magnesium on neurotoxicity and blood platinum concentrations in patients receiving mFOLFOX6 therapy: a prospective randomized study. International Journal of Clinical Oncology, 15(1), 82–7. doi:10.1007/s10147-009- 0015-3. 12. Knijn, N., Tol, J., Koopman, M., Werter, M. J. B. P., Imholz, A. L. T., Valster, F. A. A., Mol, L., Vincent, A. D., Teerenstra, S., & Punt, C. J. A. (2011). The effect of prophylactic calcium and magnesium infusions on the incidence of neurotoxicity and clinical outcome of oxaliplatin-based systemic treatment in advanced colorectal cancer patients. European Journal of Cancer (Oxford, England : 1990), 47(3), 369–74. doi:10.1016/j. ejca.2010.10.006. 13. Loprinzi, C. L., Qin, R., Dakhil, S. R., Fehrenbacher, L., Flynn, K. A., Atherton, P., Selisler, D., Qamar, R., Lewis, G. C., & Grothey, A. (2014). Phase III randomized, placebo-controlled, double-blind study of intravenous calcium and magnesium to prevent oxaliplatin-induced sensory neurotoxicity (N08CB/ Alliance). Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology, 32(10), 997–1005. doi:10.1200/JCO.2013.52.0536. 14. Mols, F., Beijers, T., Lemmens, V., van den Hurk, C. J., Vreugdenhil, G., & van de Poll-Franse, L. V. (2013). Chemotherapy-induced neuropathy and its association with quality of life among 2-to 11-year colorectal cancer survivors: results from the population-based PROFILES registry. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology, 31(21), 2699–707. doi:10.1200/ JCO.2013.49.1514. 15. Park, S. B., Lin, C. S. Y., Krishnan, A. V, Goldstein, D., Friedlander, M. L., & Kiernan, M. C. (2011) Long-term neuropathy after oxaliplatin treatment: challenging the dictum of reversibility. The Oncologist, 16(5), 708–16. doi:10.1634/ theoncologist.2010-0248. 16. Saif, M. W. (2004). Oral Calcium Ameliorating Oxaliplatin- Induced Peripheral Neuropathy. The Journal of Applied Research, 4(4), 576–582. Retrieved from http://www. pubmedcentral.nih.gov/articlerender.fcgi?artid=2758795&tool= pmcentrez &rendertype=abstract. 17. Schloss, J. M., Colosimo, M., Airey, C., Masci, P. P., Linnane, A. W., & Vitetta, L. (2013) Nutraceuticals and chemotherapy induced peripheral neuropathy (CIPN): a systematic review.

THE NATURAL THERAPIST Volume 30 No.3

Treating Joint Pain David Cannata

Natural and natural-derived supplements can provide safe and effective long-term management of joint and musculoskeletal pain. Today, they compete with fast-acting pharmaceutical drugs, which while no one can doubt their short-term effectiveness, their safety and ability to stem disease progression long-term remain a concern. Below we take a look at some of the most effective natural supplements; the new and promising SAMe, herbs traditionally used for articular pain, the reliability of glucosamine and fish oil as well the importance of additional physical therapy. THE NEW S-Adenosylmethionine (SAMe) In the early 1950’s, SAMe was discovered in Europe and used to treat depression. Decades later during a clinical study for depression, patients reported a marked improvement in their osteoarthritis symptoms with SAMe use. Since then, it has been employed in a number of clinical studies for arthritis and commonly prescribed for osteoarthritis treatment in Europe, the UK and more recently, the USA. SAMe is formed naturally in the body, from methionine and adenosine triphosphate (ATP). It is found in every cell and has a central position in cell metabolism, involved in three different catabolic pathways; methylation, transsulfuration and aminopropylation. Whilst it can be synthesized in the body, SAMe can be depleted by low levels of methionine, folate and vitamin B12 as well as reduced activity or polymorphism of methyltetrahydrofolate reductase (MTHFR). Without any appreciable dietary sources, supplementation becomes important. The role of SAMe in transsulfuration is important for glutathione production, in methylation it helps support protein synthesis and modification, maintaining cellular integrity and assisting cellular repair [1]. It also has monoamine stimulatory effects, including support for serotogenic activity. In aminopropylation, it supports the production of polyamines (eg. spermine and spermidine) that have antioxidant, anti-inflammatory and analgesic effects ( Figure 1) [1]. These mechanisms are all important for supporting joint health and providing relief from degenerative joint conditions. Specifically in joint tissues, SAMe can stimulate collagen and proteoglycan production in chondrocytes, protect against proteolysis and support cartilage repair. It can restore basal conditions after cytokine-induced damage and protects against TNF-α chronic inflammation. It’s interaction with serotonin is believed to alter pain perception to provide additional analgesic relief. Figure 1: The central role of SAMe in catabolic pathways In 1987, a review of 12 clinical studies involving around 22,000 patients concluded that SAMe was an effective treatment for osteoarthritis, similar to NSAIDS but with better tolerability and safety [2]. In 2002, a meta-analysis of 11 high-quality studies comparing SAMe with either placebo or NSAIDs was published and concluded SAMe was more effective than placebo and equal to NSAIDs but with less risk (58%) of side effects [3]. In 2009, a Cochrane review of 4 placebo-controlled trials could not make definitive conclusions as the trials were deemed to be low quality; however meta-analysis did reveal a reduction in pain with SAMe compared to placebo [4]. SUMMARY: Clinical evidence supports SAMe supplementation as a safe and effective long-term treatment option for osteoarthritis providing functional improvements and pain relief by supporting its natural role in the body.

THE NATURAL THERAPIST Volume 30 No.3

Treating Joint Pain: The new, the traditional & the reliable

David Cannata

THE TRADITIONAL Devil’s Claw (Harpagophytum procumbens) Native to the Kalahari Desert in Africa, the tuber and root of Devil’s Claw has traditionally been used as an analgesic and for relief of inflammatory conditions and articular pain. The most recognizable and standardized active constituent is the iridoid glycoside harpagoside. It also contains other iridoids, triterpenoids, phytosterols, flavonoids and aromatic acids. They all contribute to reducing chronic inflammation and pain by inhibiting AP-1, NF-κB and COX-2 pathways, targeting TNF-α, IL-6, IL-1β and PGE2. Whilst Devil’s Claw may not be the most versatile herb, it is one of the best at what it does, treating inflammation and providing pain relief. In 2000, a double-blind, multicenter study observed that Devil’s Claw was as effective as diacerhein (NSAID) for reducing pain, functional disability and Lequesne score in knee and hip osteoarthritis sufferers (n = 122) [5]. However, subjects taking Devil’s Claw had a greater reduction in the use of rescue medication (analgesics) and a lower rate of adverse effects. The global tolerance assessment by patients favoured Devil’s Claw [6]. In 2006, a review identified 14 clinical studies that assessed Devil’s Claw in the treatment of osteoarthritis [7]. Whilst the quality of studies varied, results from the four high quality studies showed Devil’s Claw to be effective in pain reduction. In 2007, an open study (n = 259) revealed that Devil’s Claw was well tolerated and made significant improvements in arthritic and rheumatic disorder patient’s assessments of pain, stiffness and function in a variety of joints [8]. Quality of life improved and a reduction and cessation of concomitant pain medication was seen in 60% of patients.

SUMMARY: Evidence supports Devil’s Claw as an effective treatment for osteoarthritis and rheumatic conditions, particularly for the reduction in pain. It appears to be as effective as NSAIDs but with greater tolerance and safety. Willow bark (Salix alba) The bark of the white willow tree has been used in traditional herbal medicine for pain relief and more recently for inflammatory conditions. It is well known for the active constituent salicin, which is converted to salicylic acid in the body. Salicylic acid has analgesic properties (inhibiting prostaglandins in nerves) and anti-inflammatory mechanisms (inhibiting cytokines).

acetylation. The advantage of natural salicin is the body controls its conversion and it has no acetylation properties, meaning it is slower-acting but does not carry the same toxicity and safety concerns. Furthermore, willow bark also contains flavonoids and polyphenols which also contribute to the analgesic, antiinflammatory and antioxidant mechanisms. In 2009, a systematic review of 3 studies provided moderate evidence of willow bark effectiveness in terms of relief from musculoskeletal pain [9]. Two studies showed willow bark was effective for lower back pain relief, one greater than placebo the other equal to a NSAID [10, 11]. In 2013, 436 patients with rheumatic pain (mainly osteoarthritis and back pain) found pain intensity reduced by almost half after only three weeks of use [12]. A recent Cochrane’s review (2014) concluded that willow bark as well as devil’s claw reduced lower back pain greater than placebo, though also highlighted larger, well-designed studies were still needed [13].

SUMMARY: Whilst there is a small amount of clinical evidence for willow bark, studies so far have suggested it to be effective for rheumatic and lower back pain relief. Many studies use the same standardized dose of 240mg/d of salicin, making the combined evidence easier to support. It appears to be safe and well tolerated compared to NSAIDs. THE RELIABLE

Glucosamine Around the world, glucosamine is synonymous with the treatment of osteoarthritis. Whilst there is still debate on how effective it is, there are few other treatment options that have withstood the relative test of time and undergone the level of scrutiny from the number of clinical studies. Glucosamine is a natural amino sugar and a precursor for the synthesis of many glycosylated proteins

The discovery of salicin led to the development of Aspirin (acetylsalicylic acid). Whilst Aspirin has proven to be an effective analgesic, it has significant toxicity concerns and side effects, most notable gastric bleeding due to the inhibition of COX-I via

THE NATURAL THERAPIST Volume 30 No.3

Treating Joint Pain: The new, the traditional & the reliable

David Cannata and lipids, which include proteoglycans, glycosaminoglycans and collagen. This makes it an essential building block for cartilage but also tendons, ligaments, synovial fluid and tissues. Glucosamine production in the body declines with age thus is a large contributing factor to the degeneration of joint tissue. Glucosamine supplementation is important for repairing joint tissue but has also demonstrated the ability to inhibit inflammatory pathways that lead to cartilage degradation. In 2005, a meta-analytical review of 20 randomized controlled studies investigated the effect of glucosamine in osteoarthritis patients (n = 2,570) [14]. The analysis concluded that glucosamine significantly reduced pain by 28% and improved functionality by 21%. A systematic review investigated the longterm effectiveness of glucosamine in osteoarthritis patients (n = 412) [15]. Results demonstrated that glucosamine significantly reduced disease progression by 54% and made improvements in pain reduction (59%) and physical function (54%) in the knee. In addition, cessation of joint space narrowing and improvement in WOMAC and Lequesne Algofunctional Index scores for pain, stiffness and function were also demonstrated [16, 17].

SUMMARY: Regardless of what some people might suggest, glucosamine is still one of the most reliable treatments for osteoarthritis. It has significantly more clinical evidence behind it than other treatments and with good safety, long-term use; it should form the base of osteoarthritis management. Fish Oil (Omega-3 fatty acids) Fish oil has long been used for arthritis management (both rheumatoid and osteoarthritis) and is recommended by most arthritis organizations around the world. Recently, other omega-3 fatty acid sources have entered the market, krill oil being the most notable. Studies suggest the efficacy of a smaller dose of krill oil is comparable to a larger dose of fish oil. But the main problem is, that small dose of krill oil is a lot more expensive than the larger fish oil dose. So the cost to efficacy ratio doesn’t add up. Furthermore, the ‘clinically proven’ claims of krill oil come from only one small, 30 day trial [18]. Thus omega-3 fatty acids from fish oil still remain the most reliable and effective, long-term source. Eicosapentaenoic acid (EPA) and Docosahexaenoic acid (DHA) are the two main omega-3 fatty acids which support the natural anti-inflammatory mechanisms in the body. By using the desaturase, COX and LOX enzymes they competitively inhibit the inflammatory pathway of the omega-6 fatty acid, arachidonic acid. Not only do they reduce the production and release of inflammatory prostanoids (eg. PGE2), leukotrienes (eg. LTB4) and cytokines (eg. TNF-α, IL-1, IL-6, IL-12), they promote the production of anti-inflammatory prostanoids (eg. PGE3), leukotrienes (eg. LTB5), protectins and resolvins. Omega-3 insufficiency and/or excess omega-6 intake is believed to be responsible for many chronic inflammatory conditions, including arthritis. A meta-analysis review of 16 randomized controlled trials investigated the effectiveness of fish oil supplementation in patients (n = 753) suffering from rheumatoid arthritis over a 3-4 month period [19]. The analysis showed that fish oil significantly reduced pain intensity, duration of morning stiffness, number of painful and tender joints and NSAID use. In addition to the results of the meta-analysis, several clinical studies have shown that fish oil and omega-3 can reduce the number of swollen joints and improve; grip strength, global assessment scores of pain and activity (patient and physician) and the Ritchie articular index of joint pain [20-26]. Combining the two reliable treatments of omega-3 fatty acids and glucosamine significantly reduced morning stiffness as well as pain in the hip and knee joints of osteoarthritis sufferers (n = 177) [27].

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SUMMARY: Fish oil is beneficial in the management of both rheumatoid arthritis and osteoarthritis. It is the most reliable source of omega-3 and has been clinically proven to be safe and effective over the long-term. THE ADDITIONAL

The management of joint and muscular pain can’t be solely reliant on supplements and/or pharmaceutical drugs. Acupuncture, has been shown to be most effective for osteoarthritis, fibromyalgia and back pain. Tai Chi is effective for osteoarthritis and fibromyalgia, whilst yoga and Pilates is effective for lower back pain. Transcutaneous- and neuromuscular- electrical stimulation (TES & NMES, respectively) may be effective for knee osteoarthritis, whilst weight loss is a common factor that can help ease general pain and stress on the joints. In terms of pain management, aromatherapy and hot treatments (or cold for acute pain) are still the most simple and effective. REFERENCES 1.Bottiglieri, T., (2002) ‘S-Adenosyl-L-methionine (SAMe): from the bench to the bedside--molecular basis of a pleiotrophic molecule.’ Am J Clin Nutr. 76(5): p. 1151S-7S. 2.di Padova, C., (1987) ‘S-adenosylmethionine in the treatment of osteoarthritis. Review of the clinical studies.’ Am J Med. 83(5A): p. 60-5. 3.Soeken, K.L. et al., (2002) ‘Safety and efficacy of S-adenosylmethionine (SAMe) for osteoarthritis.’ J Fam Pract. 51(5): p. 425-30. 4.Rutjes, A.W. et al., (2009) ‘S-Adenosylmethionine for osteoarthritis of the knee or hip.’ Cochrane Database Syst Rev. (4): p. CD007321. 5.Leblan, D. et al., (2000) ‘Harpagophytum procumbens in the treatment of knee and hip osteoarthritis. Four-month results of a prospective, multicenter, double-blind trial versus diacerhein.’ Joint Bone Spine. 67(5): p. 462-7. 6.Chantre, P. et al., (2000) ‘Efficacy and tolerance of Harpagophytum procumbens versus diacerhein in treatment of osteoarthritis.’ Phytomedicine. 7(3): p. 177-83. 7.Brien, S. et al., (2006) ‘Devil’s Claw (Harpagophytum procumbens) as a treatment for osteoarthritis: a review of efficacy and safety.’ J Altern Complement Med. 12(10): p. 981-93. 8.Warnock, M. et al., (2007) ‘Effectiveness and safety of Devil’s Claw tablets in patients with general rheumatic disorders.’ Phytother Res. 21(12): p. 1228-33. 9.Vlachojannis, J.E. et al., (2009) ‘A systematic review on the effectiveness of willow bark for musculoskeletal pain.’ Phytother Res. 23(7): p. 897-900. 10.Chrubasik, S. et al., (2000) ‘Treatment of low back pain exacerbations with willow bark extract: a randomized double-blind study.’ Am J Med. 109(1): p. 9-14. 11.Chrubasik, S. et al., (2001) ‘Treatment of low back pain with a herbal or synthetic anti-rheumatic: a randomized controlled study. Willow bark extract for low back pain.’ Rheumatology (Oxford). 40(12): p. 1388-93. 12.Uehleke, B. et al., (2013) ‘Willow bark extract STW 33-I in the long-term treatment of outpatients with rheumatic pain mainly osteoarthritis or back pain.’ Phytomedicine. 20(11): p. 980-4. 13.Oltean, H. et al., (2014) ‘Herbal medicine for low-back pain.’ Cochrane Database Syst Rev. 12: p. CD004504. 14.Towheed, T.E. et al., (2005) ‘Glucosamine therapy for treating osteoarthritis.’ Cochrane Database Syst Rev. (2): p. CD002946. 15.Poolsup, N. et al., (2005) ‘Glucosamine long-term treatment and the progression of knee osteoarthritis: systematic review of randomized controlled trials.’ Ann Pharmacother. 39(6): p. 1080-7. 16.Coulson, S. et al., (2012) ‘Green-lipped mussel extract (Perna canaliculus) and glucosamine sulphate in patients with knee osteoarthritis: therapeutic efficacy and effects on gastrointestinal microbiota profiles.’ Inflammopharmacology.

THE NATURAL THERAPIST Volume 30 No.3

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Important Information And Tips for Professional Indemnity

Jaclyn Lees, Team Leader at Arthur J. Gallagher

As a Natural Therapist, if you were to source your own cover for public liability and professional indemnity the prices would start at $1000+ per year. So being a member of the Australian Natural Therapists Association that sets high qualification standards entitles you to access to a scheme for your profession that not everyone else is entitled to however, by taking advantage of special pricing for ANTA members there are things you should be aware of. You need to be aware policies are specific in regard to the cover provided. I’m bringing this to your attention because this is not something you go to bed thinking about, but I do. I want to help you understand your policy so should a claim arise you will be confident you’re protected.

Are all of your modalities covered? You will find that most scheme based insurance products are very specific in the sense that if it’s not specified on the policy you’re probably not covered for it. Check to ensure your policy covers you for all of the modalities you practice. If it doesn’t contact us immediately to update your policy. A perfect example is if you practice Acupuncture and Massage, you look at your documents and noticed you’re only listed for Acupuncture on your insurance schedule. Would you be covered if a claim was to arise from a massage? You may not be covered in the event of a claim against you.

Is my Pty Ltd Company covered? Companies can be treated differently depending on your insurer, here are a couple of tips to help you identify if your policy is set up correctly. You’re trading and invoicing your clients as a Pty Ltd company however, you only have an individual policy. It’s important to ensure that all your interests are protected, what if a client decided to sue your company, will your individual policy be enough? You might be left holding the ball! Contact us if you have any doubts about this. What about your employees? check to see if employees are insured under your policy, you should make sure your employees are in the event a claim is made by a patient It’s also important to note that subcontractors are all required to hold their own insurance policy, you should request to sight a certificate of currency to ensure they have adequate cover should a claim be made against you for work they have done while working for you.

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Sharing a space with another therapist? If you are a sole trader and you share a space with another sole trader did you know that you should both hold your own policy? Each business is required to have their own insurance cover. Make sure they’re all covered!

So what do you do now? Review your insurance documents year on year, make sure your paper work is correct and up to date and that the policy will respond to your needs. Change is a fact of life so there is a good chance that things you were doing 12 months ago are different to now.

We are here to help you If you have questions do not hesitate to contact the Specialty Risks Team P.1800 222 012 E.specialtyrisks@ajg.com.au. W. www.ajg.com.au/industries/natural-therapies-insurance

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The Amazing Clinical Versatility Of St Mary’s Thistle Kerry Bone

THE NATURAL THERAPIST Volume 30 No.3

“

tHe amazing Clinical versatality of st mary’s thistle

Kerry Bone

Most of us know that the standardised extract from the seeds of St Mary’s thistle (Silybum marianum, also called milk thistle) is probably the best-proven herb for protecting the liver from chemical and inflammatory damage. Benefits have also been shown in a wide range of liver disorders, including hepatitis and cirrhosis. But this extract, which is typically (and perhaps inaccurately) referred to as silymarin or silymarin extract, has also revealed some intriguing outcomes in other clinical studies: surprising results that indicate a wide clinical versatility. So it is important not to think of this herbal extract as only good for the liver.

Clinically proven for allergies and inflammation In a double blind trial, 94 patients suffering the signs and symptoms of allergic rhinitis (hay fever) and exhibiting positive skin prick tests to common aeroallergens randomly received either silymarin extract (420 mg/ day) or placebo for one month. Routine antihistamine treatment was also allowed. Based on the Sino-Nasal Outcome Test (SNOT-20!), an improvement in clinical symptom severity was observed in both groups, but the improvement was significantly greater in the herbal group (9.2 for the silymarin group versus only 2.2 for the placebo group). In a 2009-published double blind clinical trial, 220 patients with painful knee osteoarthritis (OA) were randomized into 5 groups, receiving either silymarin (300 mg/day), piroxicam (20 mg/day), meloxicam (15 mg/ day) or a combination of silymarin with each of the anti-inflammatory drugs. There was no placebo group in the study design and treatment was over 8 weeks. Treatment with silymarin significantly reduced serum levels of the inflammatory cytokines interleukin (IL)-1alpha (by 56%) and IL-8 (by 58%) (p < 0.02 compared with baseline), and the complement proteins C3 (by 81%) and C4 (by 45%). Adjunct use of silymarin with the drugs gave mixed results for these measures of inflammation (no effect with meloxicam and a significant lowering with piroxicam). The drugs on their own generally exhibited minimal beneficial or even adverse effects. Unfortunately, the trial did not provide data for clinical OA symptoms. An earlier study also demonstrated that co-administered silymarin decreased the renal and hepatic toxicities of these drugs in OA patients.

outcomes for herbal treatments, so the above clinical findings do add significant credibility to the use of silymarin for allergic rhinitis (and perhaps other allergies) and OA. More studies are needed, however, especially one assessing clinical outcomes in OA.

Making mothers’ milk flow better One surprising new role for the silymarin extract is the enhancement of milk production in healthy breastfeeding mothers, verified by a clinical trial. Following an agricultural trial demonstrating that silymarin promoted milk production in dairy cows, a group of Italian scientists investigated its galactagogue (enhancing milk flow) value in humans. The trial enrolled 50 healthy lactating women who received a daily dose of 420 mg of micronized (very fine) silymarin or an identical placebo for 63 days. At both days 30 and 63 of the trial there was a clear and significant difference over placebo in favour of the silymarin group in terms of total milk production (p < 0.01). There also appeared to be a cumulative treatment effect, with a 64.4% increase above baseline at day 30 for the silymarin group (versus 22.5% for placebo), which increased to 86.0% by day 63 (versus 32.1% for placebo). Analysis of the nutritional value (water, fats, carbohydrates and proteins) of the milk confirmed no difference between the active and placebo groups. Testing of the milk from a smaller group of women who received 1800 mg/day silymarin for 5 days found no detectable levels of silymarin actives, indicating no issue for the baby.

authors of another paper on the topic claim that the book of Newall and co-workers carries a reference to galactagogue use. However, that text was found to contain no such information on the pages cited or anywhere else. Perhaps this confusion serendipitously led to its discovery, or maybe this is a previously unrecognised example of the doctrine of signatures (in which the appearance of a herb suggests its therapeutic activity). The well-known book A Modern Herbal by Maude Grieve does talk about this herb enhancing milk flow, but she is clearly referring to the use of the leaves, not an extract of the seeds. A lab study has provided a possible mechanism behind the galactagogue activity of silymarin. A dose-dependent increase in prolactin levels was observed in female rats after the administration of 25 to 200 mg/kg orally for 14 days. Prolactin levels remained elevated even after the herbal extract had been discontinued for 66 days. The prolactininducing activity of silymarin extract was antagonised by the drug bromocriptine, suggesting that dopamine D2 receptors are involved. Such hormonal effects need to be investigated in lactating women.

Just the thing for too much iron Evidence is growing that the silymarin complex of flavonolignans from milk thistle, can impact serum ferritin and iron overload in various clinical circumstances. There are three recent clinical trials of this extract in

Given the common name of “milk thistle”, why is it surprising to learn of its galactagogue effects? The answer is that the most likely source of this common name is the appearance of the plant, not any traditional galactagogue usage. Specifically the white stripes on the leaves were said to represent the milk of the Virgin Mary. , There is no reference to any galactagogue action in texts reflecting traditional use, such as the British Herbal Compendium. The

Although these uses might seem novel for silymarin, they are consistent with several lab studies demonstrating various antiinflammatory, antiallergic and immunemodulating outcomes for the herbal extract. However, results from experimental models do not necessarily reflect on clinical

THE NATURAL THERAPIST Volume 30 No.3

tHe amazing Clinical versatality of st mary’s thistle

Kerry Bone patients with -thalassaemia, mainly used in conjunction with the drug desferrioxamine. Beta-thalassaemia is a relatively common genetic haemoglobin disorder that leads to severe chronic anaemia and requires regular blood transfusions, resulting in iron overload and very high serum ferritin levels. When the iron-binding capacities of transferrin and ferritin are exceeded, the excess iron also generates harmful free radicals and causes tissue and multi-organ damage. Chelation therapy with the drug desferrioxamine is standard therapy for these iron-induced complications. A key drawback, however, is about one third of patients find it difficult to comply with the almost daily subcutaneous infusions of this drug that are required.11 In the first trial, patients were treated with the combination of desferrioxamine and 420 mg/day silymarin (n=49) or desferrioxamine and placebo (n=48) for 9 months using a randomised, double blind design.11 Serum ferritin levels decreased significantly from the beginning to the end of silymarin treatment (3028.8 ± 2002.6 versus 1972.2 ± 1250.6 ng/ mL); however, no significant change in serum ferritin was observed in the patients receiving placebo (2249.0 ± 1304.2 versus 2015.6 ± 1146.8 ng/mL). Patients on silymarin therapy also had a significant decrease in serum levels of hepcidin and soluble transferrin receptor after the 9-month treatment period. (Hepcidin is a peptide hormone produced by the liver and involved in iron homeostasis.) A significant improvement in serum transaminases (liver function test) was also observed in the silymarin-treated group. Measurements of soluble transferrin receptor (sTfR) are helpful in monitoring the erythropoietic (red blood cell production) response to various forms of therapy, in particular when changes in haemoglobin are not yet apparent. Increased values of sTfR are detectable in thalassaemia syndromes due to ineffective erythropoiesis. The

THE NATURAL THERAPIST Volume 30 No.3

study revealed that combination therapy of silymarin and desferrioxamine significantly reduced levels of sTfR after the 9-month treatment compared with baseline values. To the best of the study authors’ knowledge, this was the first evidence to show the effect of iron chelation therapy (via silymarin and the drug) on sTfR levels in β-thalassaemia major. The second trial was conducted over 6 months in 40 children (average age about 5 years) with  thalassaemia major and a serum ferritin level of more than 1000 ng/mL. Patients included in the study (group I) were divided into two subgroups (group IA and group IB) by simple random allocation. Group IA received combination of oral desferrioxamine 20 to 40 mg/kg/ day (supplied in orally dispersible tablets dissolved in water or juice and administered on an empty stomach) together with oral silymarin in the form of 140 mg tablets, one hour before each meal (in other words 3 times daily). Group IB received oral desferrioxamine 20 to 40 mg/kg/day and placebo. Group II included 20 healthy children matched in age and sex and served as a control group. Serum ferritin levels markedly decreased from baseline by around 67% in group IA compared with 43% for group IB (p = 0.001). However, levels were still well above those measured in the healthy control children. Serum iron was also reduced.

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tHe amazing Clinical versatality of st mary’s thistle

Kerry Bone In the third study, the immunomodulatory effects of silymarin were investigated in an open-label 12-week clinical trial in two groups of patients. In the combined therapy group (n=25), patients continued subcutaneous desferrioxamine at a dose of 40 mg/kg/day and silymarin tablets (420 mg daily) were added. In the silymarin only group (n=5), patients who were unable or unwilling to use desferrioxamine received just silymarin. Immunological tests were assessed at the beginning and the end of the trial. Serum tumour necrosis factor (TNF-α) levels were significantly decreased in both groups. The analysis of cell culture supernatants of activated T cells showed increased production of interferon gamma (IFNγ) and interleukin (IL)-4 after silymarin treatment in both groups. The authors concluded that silymarin stimulated cell-mediated immune responses in β-thalassaemia major, possibly through a direct action on cytokine-producing mononuclear cells. The reduction in TNF-also suggested an anti-inflammatory effect. Silymarin’s hepatoprotective and ironbonding capacities suggest a role in iron overload disorders such as -thalassaemia and haemochromatosis, and now there is a reasonable body of clinical evidence supporting its value in the former and preliminary evidence for the latter (see below). While the trial designs were not strong, the substantial ferritin reductions observed suggest a clinically relevant effect. In terms of hereditary haemochromatosis, one small study found that a single dose of silymarin (140 mg) with food reduced subsequent iron absorption in patients with this disorder. Also, silymarin did reduce serum ferritin in chronic hepatitis C patients. Iron from damaged liver cells could contribute to the inflammatory pathology of this disorder. In a randomised, open-label, dose-finding study, the impact of silymarin (360, 720 or 1080 mg/day) as the phosphatidylcholine (lecithin) complex was assessed in 37 patients with chronic hepatitis C and liver fibrosis. There was a highly significant 12% decrease in mean serum ferritin from baseline to the end of treatment 12 weeks

THE NATURAL THERAPIST Volume 30 No.3

later (p = 0.0005). In all, 78% of patients responded with a decrease in this factor. The potential clinical value of silymarin’s impact on iron overload extends well beyond the above disorders. One good example is type 2 diabetes. There is now a strong link between this common disorder and serum ferritin and tissue iron stores, and the relationship is thought to be causal. In fact, type 2 diabetes (T2D) has reversed with a reduction in iron status. Based on a recent meta-analysis there is a 1% increased risk of T2D for every 5 ng/mL ferritin increment, and 224% for every 5 mg/day intake of dietary haem iron. However, supplemental iron is not implicated. In addition, silymarin also can help manage blood glucose levels. In two clinical trials in T2D patients, silymarin improved glycaemic control. , It also improved BMI,8 hepatic transaminases,9 and reduced urinary albumin in T2D patients with nephropathy. References 1. Bone KM, Mills SY. Principles and Practice of Phytotherapy: Modern Herbal Medicine, 2nd Edition, Elsevier, UK, 2013, pp 861-884 2. Bakhshaee M, Jabbari F, Hoseini S et al. Otolaryngol Head Neck Surg 2011; 145(6): 904-909 3. Hussain SA, Jassim NA, Numan IT et al. Saudi Med J 2009; 30(1): 98-103 4. Hussain SA, Numan IT, Khalaf BH et al. Iraqi J Pharm Sci 2007; 16(1): 34-38 5. Di Pierro F, Callegari A, Carotenuto D et al. Acta Biomed 2008; 79(3): 205-210 6. Madaus G. Lehrbuch der biologischen Heilmettel, Band I. Hildesheim: Georg Olms Verlag, 1976, p 830. 7. Zeylstra H, Materia Medica Lectures, School of Herbal Medicine, UK, 1982. 8. British Herbal Medicine Association. British Herbal Compendium, Volume 2. BHMA, Bournemouth, 2006, p 282. 9. Capasso R, Aviello G, Capasso F et al. Phytomed 2009; 16(9): 839-844 10. Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health-Care Professionals.

Pharmaceutical Press, London, 1996, pp 46-47. 11. Capasso R, Aviello G, Capasso F et al. Phytomed 2009; 16(9): 839-844 12. Moayedi B, Gharagozloo M, Esmaeil N et al. Eur J Haematol 2013; 90(3): 202-209 13. Hagag AA, Elfrargy MS, Gazar RA, et al. Mediterr J Hematol Infect Dis 2013; 5(1): e2013065 14. Gharagozloo M, Karimi M, Amirghofran Z. Int Immunopharmacol 2013; 16(2): 243-247 15. Bares JM, Berger J, Nelson JE et al. J Clin Gastroenterol 2008; 42(8): 937-944 16. Simcox JA, McClain DA. Cell Metab 2013: 17(3): 329-341 17. Kunutsor SK, Apekey TA, Walley J et al. Diabetes Metab Res Rev 2013; 29(4): 308-318 18. Bao W, Rong Y, Rong S, et al. BMC Med 2012; 10: 119. 19. Hussain SA. J Med Food 2007; 10(3): 543-547 20. Huseini HF, Larijani B, Heshmat R et al. Phytother Res 2006; 20(12): 1036-1039 21. Fallahzadeh MK, Dormanesh B, Sagheb MM et al. Am J Kidney Dis 2012; 60(6): 896-903

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THE NATURAL THERAPIST Volume 30 No.3

FEMALE INFERTILITY Western and Traditional Chinese Options Tony Reid Abstract This paper explores and contrasts the western medical (WM) and the traditional Chinese medical (TCM) approaches to fertility management. Although the likelihood of success using the WM approach has been well researched and TCM has not, it appears that, based on the best available evidence, the TCM approach may be just as effective as well as more economical. Moreover, the combination of WM and TCM may provide the best outcome for some couples. Treatment protocols using prepared Chinese herbal medicines are provided in Appendix 1. Additional information on IVF is provided in Appendix 2

THE NATURAL THERAPIST Volume 30 No.3

FEMALE INFERTILITY Treatment options: Western and traditional Chinese

Tony Reid Introduction As more couples in western countries delay having a family until the woman is in her early to mid 30’s, there is an increasing demand for assistance with conception, due to the age related decease in fecundity. This situation is exacerbated by contemporary cultural expectations, leading to an increasing number of couples seeking help after only six to eight months of unwanted non-conception. Under increasing pressure from their patients, WM practitioners tend to investigate female infertility too early, with the danger of false positive test results, leading to unnecessary overtreatment, which may expose women to unnecessary medical complications and unnecessary expense. (Brosens, et al., 2004; Gnoth et al, 2005) While WM may have superior diagnostic capabilities, it has limited tools available to assist the subfertile couple. On the other hand, TCM appears to be much better equipped, with its emphasis on supporting normal healthy bodily and mental functioning. Owing to the difficulty in establishing whether a woman is truly infertile or only sub-fertile, this article uses the term ‘infertility’ to cover both clinical scenarios. It is also unfortunate that the currently accepted medical definition of ‘infertility’, does, in fact include both. I say ‘unfortunate’ because many women are encouraged to seek expensive and possibly risky treatments for ‘infertility’, when the majority would become pregnant in due course, without any outside assistance. These matters are the subject of an ongoing debate within the medical profession. (Gnoth et al., 2005) Iinfertility in Western Medicine Up until recently infertility was defined as the inability to conceive after 2 years of unprotected sexual intercourse. (European Society for Human Reproduction and Embryology, 1996) More recently the time limit has been truncated, (Hall, 2007, Jairo, Nelson & Wallach, 2006; Al-Inany, 2005) most likely due to the tendency in developed countries to delay procreation. In these populations 80–90% of couples attempting to conceive are successful after 1 year and 95% after 2 years. (Brosens, et al., 2004; Gnoth et al, 2005) This trend towards a delay in child-bearing has important implications because of an agerelated decrease in fecundability, which begins at age 35 and is exacerbated after age 40. Currently, about 17% of couples in developed countries seek medical advice for infertility. (Cahill & Wardle, 2002). The implications of the above statistics for a couple seeking assistance with pregnancy after less than one year of trying are as follows:

THE NATURAL THERAPIST Volume 30 No.3

• They are likely to be part of the 20% who do not achieve pregnancy within this time (assuming that 80% of couples will be successful after six months of fertility timed intercourse) • Of these couples, around 25% (5% out of 20%) will be truly infertile and in most of these a cause will be found. • The remaining 75% of these couples will eventually achieve a pregnancy, and will be found, retrospectively (and only retrospectively) to have been subfertile but not truly infertile. Causes if infertility Various authors give slightly different figures for the allocation of causes in infertility:

• ‘‘10 - 20% of infertility cases are unexplained; the rest are caused by ovulatory failure (27%), tubal damage (14%), endometriosis (5%), low sperm count or quality (19%), and other causes (5%)’. (Al-Inany, 2005)

• ‘Female factors account for 32% of infertility; male factors account for 18.8% of infertility; male and female factors combined cause 18.5% of fertility; and the etiology is unknown in 11.1%, and other causes are identified in 5.6%’. (Jairo, Nelson & Wallach, 2006) • ‘infertility can be attributed primarily to male factors in 25%, female factors in 58%, and is unexplained in about 17%.’ (Hall, 2007) • Ovulatory failure (27%); tubal damage (14%); endometriosis (5%); low sperm count (10%); other causes (5%); unexplained (20%) (Bhattacharya et. al, 2010) • Ovulatory disorders (25%); tubal damage (20%); male factors (30%); uterine or peritoneal disorders (10%); unexplained (no identified male or female cause (25%). Disorders are found in both the man and the woman in about 40% of cases. (NICE, 2013)

It should be noted that the acknowledgement of male factors has gained an increased prominence in recent years. Normal fertility depends upon the following factors: • The integrity of the female and male reproductive tracts • The release of a normal preovulatory oocyte • The production of adequate spermatozoa • The normal transport of the gametes to the ampullary portion of the fallopian tubes for fertilization • The subsequent transport of the cleaving embryo up to the endometrial cavity for its normal implantation and further • development. Disruption at any of these levels will lead to the inability of a couple to conceive or have a normal pregnancy. The three major known mechanisms underlying female infertility are ovulatory failure, tubal damage and endometriosis. In addition various drugs, such as, non-steroidal anti-inflammatory drugs (CSM, 2006; Aronson, 2006) can reduce fertility. The main etiologic factors associated with an increased risk of infertility include pelvic inflammatory disease (PID); endometriosis; environmental and occupational factors; toxic effects related to tobacco, marijuana, or other drugs; excessive exercise; inadequate diet associated with extreme weight loss or gain; and advanced age. (Jairo, Nelson & Wallach, 2006) Initial Evaluation of Infertile Couples In all couples presenting with infertility, the initial evaluation includes discussion of the appropriate timing of intercourse and discussion of modifiable risk factors such as ‘recreational’ drug use (e.g. tobacco, cannabis and alcohol), caffeine intake and obesity. A description of the range of investigations that may be required and

FEMALE INFERTILITY Treatment options: Western and traditional Chinese

Tony Reid a brief description of infertility treatment options, including adoption, should be reviewed. Initial investigations are focused on determining whether the primary cause of the infertility is male, female, or both. These investigations include a semen analysis in the male, confirmation of ovulation in the female (measurement of mid-luteal phase progesterone), and, in the majority of situations, documentation of tubal patency in the female. Although frequently used in the past, recent studies have not supported the efficacy of postcoital testing of sperm interaction with cervical mucus as a routine component of initial testing. In some cases, after an extensive evaluation has excluded identifiable male or female causes of infertility, the disorder is classified as unexplained infertility. (Hall, 2007) Ovulatory Failure Ovulation may be inhibited due to various factors, e.g. PCOS, adenoma in the anterior pituitary, thyroid disorders and adrenal disorders (NICE, 2007). Treatments for women in whom this has been detected include the following: 1. 2. 3. 4. 5.

Clomifene. Tamoxifen Metformin. Cyclofenil. Gonadotrophins (human menopausal gonadotrophin, recombinant folliclestimulating hormone) 6. Gonadotrophin releasing hormone (gnrh) agonists plus gonadotrophins. 7. Gonadotrophin releasing hormone (gnrh) antagonists. 8. Ovarian wedge biopsy. . 9. Laparoscopic ovarian drilling. 10. Pulsatile gonadotrophin releasing hormone. . 11. In vitro fertilization (IVF) 12. Intrauterine insemination (IUI) plus controlled ovarian stimulation. 13. Gonadotrophin priming of oocytes before in vitro maturation.

Of the above treatments, in IVF has been shown to be beneficial, while tubal flushing with oil soluble media and tubal surgery before IVF are likely to be beneficial. Selective salpingography plus tubal catheterization and tubal flushing with water soluble media are of unknown benefit. (AlInany, 2005; Bhattacharya et. al, 2010) Endometriosis Endometriosis may be suspected from the case history and physical examination, and it is confirmed by laparoscopic examination. (Kapoor & Davila, 2007). Treatments for women in whom this has been detected include the following: • • • • •

Drug-induced ovarian suppression. IUI plus gonadotrophins. Laparoscopic ablation IVF Tubal flushing

years this is increased to 25.1%. After five attempts, approximately 50% of women under 34 years will have conceived. (NICE, 2007). • Tubal surgery: 5% - 50% depending on the initial extent of tubal damage. (NICE, 2007). • Clomiphene citrate: With the achievement of 3 consecutive ovulatory cycles, 40-50% of women will become pregnant. However, endometrial thinning, which is associated

with a lowered pregnancy rate in IVF • cycles, is a possible adverse event. (Petrozza & Styer, 2006).

Treatment outcomes for cases with unexplained infertility (from Petrozza & Styer, 2006) Protocol

No treatment

Pregnancy Rate, %

1.3-4.1

IUI alone

3.8

Clomiphene with timed coitus

5.6

Of the above treatments, IVF, intrauterine insemination plus gonadotrophins, laparoscopic ablation of endometrial deposits and tubal flushing are likely to be beneficial. Drug-induced ovarian suppression is likely to be ineffective or harmful. (Al-Inany, 2005; Bhattacharya et. al, 2010)

Clomiphene with IUI

Gonadotropins with timed coitus

7.7

Outcomes of Western treatments for Infertility with known cause

Gonadotropins with IUI

17.1

IVF

35-50

• IVF: 21.8% live birth rate per treatment cycle. If the woman’s age is less than 38

Thus, IVF is the treatment of choice in these cases.

Out of these Clomifene, IVF and Metformin are likely to be beneficial. Gonadotrophins are likely to cause adverse events such as multiple pregnancies or ovarian cancer. The efficacy of the other treatments is at present unknown. (Al-Inany, 2005; Bhattacharya et. al, 2010) Tubal Damage Tubal damage is primarily due to previous pelvic surgery or endometriosis. (NICE, 2007). Treatments for women in whom this has been detected include the following: • Selective salpingography plus tubal catheterisation. • Tubal flushing with oil soluble media. • Tubal flushing with water soluble media. • Tubal surgery. • IVF

THE NATURAL THERAPIST Volume 30 No.3

FEMALE INFERTILITY Treatment options: Western and traditional Chinese

Tony Reid In Vitro Fertilisation (IVF) IVF is also known as assisted reproduction technology (see Appendix 2). It is extremely difficult to get an idea of potential outcomes in IVF as different authors used different end points (i.e. some used pregnancy, and others live births). Moreover, the figures quoted were sometimes per cycle and sometimes per couple (presumably over several cycles until a pregnancy was achieved or, in the cases that were unsuccessful, until the couple gave up) and sometimes it was not specified. The most recent NICE guidelines avoid giving any estimates for outcomes and simply provide some relatively meaningless charts that reveal the fact that after age 36 the live birth rates for IVF decline sharply. The outcomes of IVF treatment, in terms of live deliveries per embryo transfer cycle, vary considerably depending on age. • 30 - 34 years: 32.8% • 35-39 years: 23.1% • 40 - 44 years: 9.2% (Macaldowie, Lee, Chambers, 2015)

The overall success rate for a course of IVF treatment in 2010 was 35.4%, with the average number of cycles of IVF needed to achieve a live birth, being 1.3 cycles (in the UK). (The Human Fertilisation and Embryology Authority, 2010) Although some couples may continue for up to nine cycles if they have been unsuccessful, the generally accepted number of IVF cycles is three to five. By the third cycle around 70 – 90% will result in a live birth, and after the fifth there is minimal increase in successful outcomes. (Macaldowie, Lee, Chambers, 2015; Luke et al., 2012)

INFERTILITY IN TCM Female fertility depends upon several factors. Firstly the arrival of the tian gui, which is related to the 7 year cyclical development (and orderly decline) of the

THE NATURAL THERAPIST Volume 30 No.3

Kidney Qi in a woman’s body. This has been an essential part of TCM perspective on a woman’s ability to conceive since the time of the Huang Di Nei Jing in the early Han dynastic period. ‘In general the reproductive physiology of woman is such that at seven years of age her Kidney energy becomes full, her permanent teeth come in and her hair grows long. At fourteen years the tian gui, or fertility essence, matures and the ren and the chong channels responsible for conception open, menstruation begins and conception is possible…..At forty nine years the Chong and the Ren channels are completely empty, and the tian gui has dried up. Hence the flow of the menses ceases and the woman is no longer able to conceive’. (Ni, 1995, p. 2) Other factors which have a strong influence on fertility include an abundant supply of Qi and Blood, absence of pathogenic factors (which may obstruct the chong-ren channels and the uterus), and normal movement of the Qi and Blood, particularly in the lower Jiao. Thus, any disruption to these processes may lead to infertility. (Ye, 2001, p.2; 45-46; Xuan & Li, 1990, p. 260; Maciocia, 1998, pp. 15-18, 25-26) Early methods of classification for causes of female infertility were based on deficiency and excess syndrome patterns in accordance with the three basic causes of disease (i.e. External, Internal and neither External nor Internal). (Yang 1993, p.391; Ye, 2001, pp.2-4) Contemporary authorities further elaborate on this to distinguish three deficiency and four or five excess types of pathodynamics underlying female infertility. (Maciocia, 1993, pp.695-696; Xuan & Li, 1990, p. 260-268) Other authorities focus on the Western diseases that may cause infertility, classifying each of these according to TCM syndrome pattern identification. (Yu, 1998, pp.55-69; 73-77, 171-177; Yin & Liu, 2000, pp.438-443, 443-447, 454-457; Blue Poppy Enterprises, 2008)

Taking a purely traditional perspective we can describe the following pathodynamics that underlie female infertility: • Kidney Essence deficiency: predominantly Kidney Yin deficiency or Kidney Yang deficiency. Having sufficient Kidney Essence is crucial, as it underlies every aspect of a woman’s ability to conceive and to nurture the growing fetus. • Blood deficiency: including Liver Blood deficiency, and Qi-Blood dual deficiency. The uterus and the chong-ren channels lack the nourishment required to nurture the fertilized ovum. • Liver Qi constraint: leading to Qi stagnation and/or Blood stasis which affect the chongren channels and the uterus. • Internally generated pathogens, which obstruct the uterus and the chong-ren: Phlegm-Damp, Damp-Heat, Cold due to Yang deficiency. • Exogenous pathogens, which obstruct the uterus and the chong-ren: Cold (the most common one), summer-Heat, Damp-Heat.

Acupuncture and IVF Considering that IVF is the major treatment option for all types of female infertility, (as discussed above) it would be advantageous if acupuncture were to improve the outcome of this procedure. The results of trials so far are mixed: some positive (e.g. Dieterle et al., 2006; Westergaard et al., 2006) and some negative. (e.g. Smith et al, 2006; Wang et al, 2007) Thus, a recent review concluded that that ‘Limited but supportive evidence from clinical trials and case series suggests that acupuncture may improve the success rate of IVF and the quality of life of patients undergoing IVF and that it is a safe adjunct therapy.’ (Anderson et al., 2007)

Chinese Herbal Medicine Dharmananda provides a review of Chinese studies conducted up to 1996: ‘clinical studies conducted in China indicate that about 70% of all cases of infertility (male and female) treated by Chinese herbs resulted

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THE NATURAL THERAPIST Volume 30 No.3

FEMALE INFERTILITY Treatment options: Western and traditional Chinese

Tony Reid in pregnancy or restored fertility. Depending on the particular study and the types of infertility treated, success rates ranged from about 50% up to more than 90%. Included in these statistics are cases of infertility involving obstruction of the fallopian tubes, amenorrhea, absent ovulation, endometriosis, uterine fibroids, low sperm count, non-liquefaction of semen, and other causes. In China, due to the greater experience with using herbs, the ability to directly integrate traditional and modern methods of therapy, and the willingness of individuals to consume relatively large doses of herbs, the success rates are probably somewhat higher than can be achieved in the U.S. at the present time. Nonetheless, U.S. practitioners have had many experiences of success in treating infertility…… In the Chinese clinical studies, daily or periodic use of herbs usually resulted in restored fertility within three to six months. Many Chinese doctors feel that if pregnancy is not achieved within about eight to nine months, then it is unlikely that the treatment will be successful with continued attempts. In Japan, where doctors give lower dosages of herbs and are restricted to using a smaller range of herbs, treatment time is usually longer: from six to fifteen months. In the U.S., nearly the full range of Chinese herb materials are accessible, but the dosage to be used is usually lower than in China; as a result, it is estimated that pregnancy can be achieved within six to twelve months. It must be remembered, however, that approximately one-third of infertility cases may fail to respond to all reasonable attempts.’ (Dharmananda, 1996) It would also be reasonable to assume that these observations apply equally in an Australian clinical setting. Recent studies on Chinese herbal treatments coming out of China, although lacking the

THE NATURAL THERAPIST Volume 30 No.3

methodological rigor of Western trials, may in fact provide a model that more realistically represents the clinical scenarios and treatment strategies of Western TCM practitioners (some examples are given below).

Integration of WM and TCM Given the high costs of the common Western treatments (e.g. IVF, tubal surgery) it would be advantageous if results could be improved through combining with TCM therapies. There is a burgeoning body of research in China based on WM diagnostic categories of female infertility. Many of such reports involve the comparison of standard WM treatments with the same treatment augmented by CHM or acupuncture. Although most of these trials do not meet Western standards, there is some indication that a combined TCM and WM approach may produce superior results. While the magnitude of such results is uncertain, the following examples of recent research lend support to this idea. • Chinese herbal medicines that tonify the Kidney and activate Blood circulation together with tubal surgery. (Jiang et al., 2006) • Acupuncture on the point Shenque (CV8) with tubal surgery. (Huang, 2005) • Chinese herbal medicine with clomiphene in cases of PCOS that are resistant to clomiphene. (Yang & Zhang, 2005). • Chinese herbal medicine with clomiphene. (Ma et al., 2005) • Chinese herbal medicine that tonify the Kidney and activate the Blood circulation with clomiphene in Stein-Leventhal syndrome. (Shao et al, 2004) • Chinese herbal medicine with IUI. (Lian et al, 2002)

In addition, some Chinese studies highlight the possibility that Chinese herbal treatment may provide at least

as good a result as some Western therapies, e.g. Chinese herbal medicine for nourishing the Blood and tonifying the Kidney compared with clomiphene (Xia et al., 2004); Chinese herbal medicine to tonify the Kidney and resolve Blood stasis for infertility due to endometriosis (Liu et al, 1998) Considerably more and better research is needed in the future to confirm the above findings, following which we may see an increased co-operation between Western obstetricians and TCM practitioners. At present it is the decision of the woman (possibly informed by her TCM practitioner) whether or not to opt for TCM, Western or combined therapies. In comparison to the high cost of Western treatments for infertility and the uncertain outcomes (e.g. for IVF: a five months course can cost in the region of $20,000 and still only offers around 50% chance of pregnancy) a preliminary course of TCM treatment over the same time period is a safe and much less expensive option (i.e. the cost would be less than $1800, counting $30 per week for herbs and $60 consultation fee over 20 weeks). Thus, in accordance with the present state of our knowledge, if the initial TCM treatment is not successful, say over 6-12 months, it may be advantageous for the woman to try combined Western and TCM therapy.

APPENDIX 1 A generalised TCM approach to treatment using prepared herbal formulas As discussed above, one or more of the following pathodynamic factors may underlie female infertility: • Kidney Essence deficiency: either Kidney Yin deficiency or Kidney Yang deficiency • Blood deficiency: including Liver Blood deficiency, and Qi-Blood dual deficiency • Liver Qi constraint: leading to Qi stagnation and/or Blood stasis

FEMALE INFERTILITY Treatment options: Western and traditional Chinese

Tony Reid

• Internally generated pathogens: PhlegmDamp, Damp-Heat, Cold due to Yang deficiency. • Exogenous pathogens: Cold (most commonly), summer-Heat, Damp-Heat. In general, women with a mild to moderate degree of Qi-Blood deficiency or Liver constraint, are more likely to be subfertile. On the other hand women with pronounced features of Blood stasis and/or Kidney Essence deficiency are more likely to be truly infertile – and hence require a longer treatment course as well as a realistic prognosis i.e. she should be prepared to accept that the outcome may not be favorable. Kidney Essence deficiency (Yang deficiency type) Long menstrual cycle, cold signs (intolerance of cold, cold extremities and lower abdomen), urination is copious and clear, tongue is pale swollen and moist pulse is deep, weak and slow; general signs of Kidney Yang deficiency, e.g. sexual hypofunction (low libido, lack of vaginal secretions), low back pain with a cold sensation, cold knees, weakness of the legs and knees, severe fatigue.

P/T: Warm-tonify the Kidney Yang and enrich the Kidney Essence to nourish the Chong and Ren Channels. Select one or more of the following: Ba Ji Yin Yang Wan (Morinda Combination) You Gui Wan (Right Returning Formula) MOTHERHOOD FORMULA (Nuan Gong Cheng Yun Fang) MOTHERHOOD 2 FORMULA (Yang Shen Cheng Yun Fang)

Kidney Essence deficiency (Yin deficiency type) Early menstruation (i.e. short cycle), dry mouth, night sweating, red tongue with little or no coat, thread-rapid pulse. General signs of Kidney Yin deficiency (e.g. dry vagina, dizziness, tinnitus, pain and weakness of the low back and knees, night sweating, heat in the five centres, malar flush, afternoon fever, dry mouth).

P/T: Nourish the Kidney Yin and enrich the Kidney Essence. Zuo Gui Wan (Left Returning Formula) Plus Si Wu Wan (Dang-gui Four Combination) a.k.a. NOURISH THE BLOOD FORMULA (Si Wu Tang)

Qi-Blood dual deficiency

Scanty menstrual flow, which is pale in colour, pale or sallow complexion, fatigue, muscular weakness, poor appetite, loose stools and other signs of general Qi-Blood deficiency (e.g. pale tongue with a thin white coat, thread-weak pulse). P/T: Tonify the Qi and nourish the Blood Shi Quan Da Bu Wan (Ginseng & Danggui Ten Formula) OR QI & BLOOD TONIC FORMULA (Ren Shen Yang Rong Tang)

Variation: • With history or prior miscarriage or with threatened miscarriage.MOTHERHOOD FT-2 FORMULA (An Gong Gu Tai Fang) • With stress and emotional strain+ Xiao Yao San (Bupleurum & Danggui Formula) a.k.a. STRESS RELIEF 2 FORMULA (Xiao Yao San)

Liver constraint, Qi stagnation Irregular menstruation, lower abdominal pain before and during menstruation, breast distension and pain before the period (i.e. PMS), depressed mood, irritability, stress and emotional strain, discomfort in the hypochondria and/or chest, wiry pulse.

Plus Chai Hu Shu Gan Wan (Bupleurum & Cyperus Combination) a.k.a. QI MOVER FORMULA (Chai Hu Shu Gan Wan)

Qi stagnation and Blood stasis Irregular or infrequent periods, dark menstrual flow with clots, dysmenorrhea, premenstrual syndrome, low back pain, fatigue, pale complexion, tongue is dark or purple or may have dark spots, pulse is choppy or wiry and may also be thready and deep. There may also be a long menstrual cycle.

P/T: Activate the Blood and dispel stasis, regulate menstruation. MOTHERHOOD FT-I FORMULA (Cu Luan Cheng Yun Fang)

Cold in the Uterus Long menstrual cycle with scanty bleeding and small clots, dysmenorrhea that is alleviated by the application of heat, sensations of cold, pallor, low back pain, tongue is pale with a thick white coat, pulse is weak-taut or choppy. There may also be hot flushes (in spite of feeling cold).

P/T: Warm –tonify the Kidney Yang and warm the Uterus to dispel Cold

P/T: Soothe the Liver and relieve constraint, regulate menstruation (by regulating the Qi and Blood).

Wen Jing Tang (Danggui & Evodia Formula)

Xiao Yao San (Bupleurum & Danggui Formula ) a.k.a. STRESS RELIEF 2 FORMULA (Xiao Yao San) Plus Tao Hong Si Wu Wan (Persica, Carthamus & Dang-gui Combination) a.k.a. BLOOD MOVING 2 FORMULA (Tao Hong Si Wu Wan)

Based on reports from practitioners, the treated woman generally falls pregnant within three to nine months, and the establishment of a normal, regular menstrual cycle is usually the first indication that there will be a positive outcome. Once there is evidence of a pregnancy the treatment protocol should be reviewed. In cases with ‘morning’ sickness, treatment should be directed primarily towards promoting normal digestion, and tonifying formulas should be minimized or avoided as they may aggravate this condition.

Phlegm-Damp retention Overweight or obesity, prolonged menstrual cycle with scanty flow, greasy tongue coat, slippery pulse. There may also be prolonged menstrual cycle with scanty flow or amenorrhea, excessive vaginal discharge.

P/T: Resolve Phlegm and dry Damp, regulate the Qi to readjust menstruation Wen Dan Tang (Bamboo & Hoelen Formula) a.k.a. CLEAR THE PHLEGM FORMULA (Wen Dan Tang)

How long to continue treatment

Practitioners who have been taught that all Blood-moving herbs should be avoided in pregnancy may fear that even formulas that contain relatively mild Blood-moving ingredients, such as Angelica polymorpha (dang gi) and Ligusticum wallichii (chuan xiong), risk harming the embryo or fetus if taken for too long, especially during the time that conception has actually occurred and the time that the woman discovers that she is pregnant. However, in clinical practice this is not the case. In the gynecology departments of Chinese hospitals, the use of these herbs is common, both before pregnancy and in the early stages.

THE NATURAL THERAPIST Volume 30 No.3

FEMALE INFERTILITY Treatment options: Western and traditional Chinese

Tony Reid Moreover, there is no clinical evidence that the commonly used Blood-moving herbs (as used in the above formulas) cause any harm when taken during pregnancy. APPENDIX 2 Assisted Reproductive Technologies (ART) (From: Assisted Reproductive Technology in Australia and New Zealand, 2013) ‘Assisted reproductive technology (ART) is a group of procedures that involve the in vitro (outside of body) handling of human oocytes (eggs) and sperm or embryos for the purposes of establishing a pregnancy. Each ART treatment involves a number of stages and is generally referred to as an ART treatment cycle. The embryos transferred to a women can either originate from the cycle in which they were created (fresh cycle) or be frozen and thawed before transfer (thaw cycle).’ ‘A typical fresh in vitro fertilisation (IVF) cycle involves the following five steps: • Controlled ovarian stimulation during which an ovarian stimulation regimen, typically using follicle stimulating hormone (FSH), is administered to a woman over a number of days to induce the maturation of multiple oocytes • Oocyte pick-up (OPU) where mature oocytes are aspirated from ovarian follicles • Fertilisation of the collected oocytes using the woman’s partner or donor sperm • Embryo maturation during which a fertilised oocyte is cultured for 2–3 days to form a cleavage stage embryo (6–8 cells) or 5–6 days to create a blastocyst (60–100 cells). • Transfer of one or more fresh embryos into the uterus in order to achieve pregnancy.’ ‘Over the last three decades, ART has evolved to encompass complex ovarian hyperstimulation protocols and numerous variations to the typical fresh IVF treatment cycle described above. Some of these variations include: • Intracytoplasmic sperm injection (ICSI), when a single sperm is injected directly into the oocyte • Assisted hatching, when the outer layer of the embryo, the zona pellucida, is either thinned or perforated in the laboratory to aid ‘hatching’ of the embryo • Gamete intrafallopian transfer (GIFT), when mature oocytes and sperm are placed directly into a woman’s fallopian tubes so that fertilisation may take place in vivo (inside the body). While once popular, this procedure now accounts for only a very small percentage of ART cycles • Preimplantation genetic diagnosis

THE NATURAL THERAPIST Volume 30 No.3

• • •

• •

(PGD), when one or more cells are removed from the embryo and analysed for chromosomal disorders or genetic diseases Oocyte donation, when a woman donates her oocytes to others Oocyte/embryo recipient, when a woman receives oocytes or embryos from another woman Cryopreservation and storage of embryos that are not transferred in the initial fresh treatment cycle. Once thawed or warmed, the embryos can be transferred in subsequent treatment cycles. Cryopreservation techniques include both the traditional slow freezing method and a newer technique called ‘vitrification’. Vitrification can be used to cryopreserve gametes and embryos, and uses an ultra-rapid temperature change with exposure to higher concentrations of cryoprotectants Cryopreservation and storage of oocytes and embryos for fertility preservation Surrogacy arrangements, where a woman, known as the ‘gestational carrier’, agrees to carry a child for another person or couple, known as the ‘intended parent(s)’, with the intention that the child will be raised by the intended parent(s).

Along with ART, a number of other fertility treatments are undertaken in Australia and New Zealand. Artificial insemination is one such treatment by which sperm are placed into the female genital tract (for example, intracervical or intrauterine), and can be used with controlled ovarian hyperstimulation or in natural cycles. Artificial insemination can be undertaken using a partner’s sperm, or donated sperm, also known as ‘donor sperm insemination’ (DI).’ (Macaldowie, Lee, Chambers, 2015)

for all ages. Rates were higher with blastocyst embryos (day of transfer, 5 or 6) than with cleavage embryos (day of transfer, 2 or 3). At the third cycle, the conservative and optimal estimates of cumulative live-birth rates were, respectively, 42.7% and 65.3% for transfer of cleavage embryos and 52.4% and 80.7% for transfer of blastocyst embryos when fresh autologous oocytes were used.’ ‘Conservative estimates assumed that women who did not return for treatment would not have a live birth; optimal estimates assumed that these women would have live-birth rates similar to those for women continuing treatment.’ (Luke et al., 2012) REFERENCES

14. Al-Inany, H. (2005). Female Infertility, in BMJ Clinical Evidence. Retreived 13th May, 2008 from: http:// clinicalevidence.bmj.com/ceweb/ conditions/woh/0819/0819_I1.jsp 15. Anderson, B., Haimovici, F., Ginsburg, E., Schust, D., Wayne, P. (2007). In vitro fertilization and acupuncture: clinical efficacy and mechanistic basis. Altern Ther Health Med; 13(3):38-48. 16. Aronson, J. (Ed.) (2006) Meyler’s side effects of drugs. The international

How many cycles?

(From: Cumulative Birth Rates with Linked Assisted Reproductive Technology Cycles, 2012) Data collected for the period from 2004 through 2009 from the Society for Assisted Reproductive Technology (SART) Clinic Outcome Reporting System (CORS) database, from clinics providing assisted reproductive technology in the United States. ‘The data were from 246,740 women, with 471,208 cycles and 140,859 live births. Live-birth rates declined with increasing maternal age and increasing cycle number with autologous, but not donor, oocytes. By the third cycle, the conservative and optimal estimates of live-birth rates with autologous oocytes had declined from 63.3% and 74.6%, respectively, for women younger than 31 years of age to 18.6% and 27.8% for those 41 or 42 years of age and to 6.6% and 11.3% for those 43 years of age or older. When donor oocytes were used, the rates were higher than 60% and 80%, respectively,

encyclopedia of adverse drug reactions and interactions. Volume 4: J-O. 15th edn. Amsterdam: Elsevier. 17. Bhattacharya, S., Johnson, N., Tijani, H., Hart, R., Pandey, S., Gibreel, A. (2010). Female infertility. Systematic review 819. BMJ Clinical Evidence. Accessed, 22 October, 2015, from: http://clinicalevidence.bmj.com/x/ systematic-review/0819/overview.html. Blue Poppy Enterprises (2008) Website, article search, keyword ‘Infertility”. Retreived, May 15, 2008 from: http://www. bluepoppy.com/

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FEMALE INFERTILITY Treatment options: Western and traditional Chinese

Tony Reid

cfwebstorefb/index.cfm?fuseaction=page.Search%20Results 18. Brosens, I., Gordts, S., Valkenburg, M., Puttemans, P., Campo, R. & Gordts, S. (2004). Investigation of the infertile couple: when is the appropriate time to explore female infertility? Hum Reprod; 19:1689 –1692. 19. Cahill, D., Wardle, P. (2002). Management of infertility. BMJ; 325:28–32. 20. CSM (2006) NSAIDs and infertility. Current Problems in Pharmacovigilance 31(May), 11. 21. Dharmananda, S. (1996). Chinese Herbs And Fertility. From ITM Online, Articles. Retreived 15 May 2008, from: http://www. itmonline.org/arts/fertility.htm 22. Dieterle, S., Ying, G., Hatzmann, W., Neuer, A. (2006). Effect of acupuncture on the outcome of in vitro fertilization and intracytoplasmic sperm injection: a randomized, prospective, controlled clinical study. Fertil Steril; 85(5):1347-51. 23. European Society for Human Reproduction and Embryology (1996). Guidelines to the prevalence, diagnosis, treatment and management of infertility. Hum Reprod; 11:1775–1807. 24. Gnoth, C., Godehardt, E., Frank-Herrmann, P., Friol, K., Tigges, J., Freundl, G., (2005). Definition and prevalence of subfertility and infertility Hum Reprod; 20(5):1144-1147. 25. Hall, J. (2007). Infertility and Fertility Control in Harrisons Internal Medicine. Retrieved March 16, 2008 from: http://www. accessmedicine.com.ezproxy.uws.edu.au/content.aspx?aID=5649 6&searchStr=infertility#56496 26. Huang, J. (2005). External application of chinese drugs on acupoint Shenque combined with salpingostomy for treatment of sterility caused by obstruction of the fallopian tube--a clinical report of 45 cases. J Tradit Chin Med. 25(3):174-6. 27. Ioannidis, J., (2005). Why Most Published Research Findings Are False. PLoS Med. 2(8): e124. 28. Jairo, E., Nelson, L, Wallach, E. (2006). Infertility. From eMedicine Specialties: Obstertrics & Gynecology, Reproductive Endocrinology and Infertility. Retrieved March 16, from: http://www.emedicine. com/med/topic3535.htm 29. Jiang, Y., Liang, R., Liu, R. (2006). Effects of combined therapy of salpingostomy and Bushen Huoxue drugs on fallopian tube obstructive infertility. Zhongguo Zhong Xi Yi Jie He Za Zhi; 26(4):325-8 30. Kapoor, D., Davila, W. (2007). Endometriosis. From e-Medicine website. Retrieved Jun 30 from: http://www.emedicine.com/med/ TOPIC3419.HTM 31. Lian, F., Zhang, N., Zhang, J. (2002). Clinical observation on effect of zhenqi zhuanyin decoction combined with intrauterine insemination in treating spleen-kidney deficiency type patients of sterility with positive anti-sperm antibody. Zhongguo Zhong Xi Yi Jie He Za Zhi. 22(2):95-7. 32. Liu, J., Li, X., Hu, X. (1998). Clinical observations on treatment of endometriosis by tonifying kidney and removing blood stasis. Zhongguo Zhong Xi Yi Jie He Za Zhi. 18(3):145-7 33. Luke, B., Brown, M., Wantman, E., Lederman, A., Gibbons, W., Schattman, G., Lobo, R., Leach, R., Stern, J., (2012). Cumulative Birth Rates with Linked Assisted Reproductive Technology Cycles. N Engl J Med; 366:2483-2491 34. Ma, S., Yin, D., Zhu, Y. (2005). Clinical observation on effect of Chinese herbs in adjusting hypoestrogenemia status by clomiphene to promote ovulation. Zhongguo Zhong Xi Yi Jie He Za Zhi. 25(4):360-2. 35. Macaldowie, A., Lee, E., Chambers, G. (2015). Assisted Reproductive Technology in Australia and New Zealand, 2013 36. Maciocia, G. (1998). Obstetrics and Gynecology in Chinese Medicine. Edinburgh: Churchill Livingstone 37. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline Fertility (2007): Assessment and Treatment for People

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with Fertility Problems. From CKS website, Retreived June 302008 from: http://www.cks.library.nhs.uk/infertility/view_ whole_ topic#288126001 38. Ni, M., (Transl.) (1995). The Yellow Emperor’s Classic of Medicine. A new Translation of the Neijing Suwen with Commentary. Boston: Shambala Publications Inc. 39. Petrozza, J., Styer, A. (2006). Assisted Reproduction Technology. . From eMedicine Specialties: Obstertrics & Gynecology. Retrieved July 1, 2008 from: http://www. emedicine.com/med/TOPIC3288.HTM 40. Shao, R., lang, F, Cai, J. (2004). Clinical observation on treatment of Stein-Leventhal syndrome caused sterility by combined use of clomiphene and Chinese nourishing shen and activating blood circulation drugs. Zhongguo Zhong Xi Yi Jie He Za Zhi. 24(1):41-3 41. Smith, C., Coyle, M., Norman, R. (2006). Influence of acupuncture stimulation on pregnancy rates for women undergoing embryo transfer. Fertil Steril; 85(5): 1352-8. 42. The Human Fertilisation and Embryology Authority website. Facts and Figures (for 2010): Latest UK IVF figures: 2010 and 2011. Retrieved 23 October, 2015 from: http://www.hfea.gov.uk/ ivf-figures-2006.html 43. Wang, W., Check, J., Liss, J., Choe, J. (2007). A matched controlled study to evaluate the efficacy of acupuncture for improving pregnancy rates following in vitro fertilization-embryo transfer. Clin Exp Obstet Gynecol; 34(3):137-8. 44. Westergaard, L., Mao, Q., Krogslund, M., Sandrini, S., Lenz, S., Grinsted, J. (2006). Acupuncture on the day of embryo transfer significantly improves the reproductive outcome in infertile women: a prospective, randomized trial. Fertil Steril; 85(5):1341-6 45. Xia, Y., Cai, L., Zhang, S. (2004). Therapeutic effect of Chinese herbal medicines for nourishing blood and reinforcing shen in treating patients with anovulatory sterility of shen-deficiency type and its influence on the hemodynamics in ovarian and uterine arteries. Zhongguo Zhong Xi Yi Jie He Za Zhi. 24(4):299-302. 46. Xuan, J., Li, Z (Chief Eds.) (1990) The Chinese-English Encyclopedia of Practical Traditional Chinese Medicine. Vol. 12: Gynegology. Beijing: Higher Education Press. 47. Yang, S. (transl.) (1993). The Heart and Essence of Dan-xi’s Methods of Treatment. A Treanslation of Zhu Dan-xi’s Dan Xi Zhi Fa Xin Yao. Boulder, CO: Blue Poppy Press.

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