Journal of the
Australian Traditional Medicine Society
Volume 20 | Number 1 | March 2014
Pilates 101 for Massage Therapists Examining current evidence for the association between diet and cancer prevention
The Massage Paradox: When Touch Causes Fear An Update on Recent Research in Homoeopathy
Can Spices Modify the Cancer Cell Signaling Pathway? Manuela Malaguti-Boyle
ISSN 1326-3390
Health Fund News | New Research | Book Reviews
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Journal of the
Australian Traditional Medicine Society Volume 20 | Number 1
Contents MARCH
6
........................................
54
REGULATORY WATCH
PRESIDENTS MESSAGE | M.SANDS
8
57
CEO’S REPORT | T. LE BRETON
MEDIA WATCH
ARTICLES
RECENT RESEARCH ........................................
58
32
CAN SPICES MODIFY THE CANCER CELL SIGNALING PATHWAY? MANUELA MALAGUTI-BOYLE
38
12
TREATMENT USING FAR-INFRARED
HUI-CHUAN CHU & CHI-FENG LIU
20
PILATES 101 FOR MASSAGE THERAPISTS SIMONA CIPRIANI
40
SILYBUM MARIANUM MONOGRAPH JOHN POWER ........................................
HOMOEOPATHY, HUMANITARIAN AID AND HOMOEOPROPHYLAXIS: PART 2 JIMI WOLLUMBIN ........................................
62
BOOK REVIEWS
65
LETTER TO THE EDITOR DR JIMI WOLLUMBIN
NEWS
66
46
24
EXAMINING CURRENT EVIDENCE FOR THE ASSOCIATION BETWEEN DIET AND CANCER PREVENTION
28
69
AN UPDATE ON RECENT RESEARCH IN HOMOEOPATHY ROBERT MEDHURST
HEALTH FUND UPDATE
50
PRODUCTS & SERVICES GUIDE
PRACTITIONER PROFILE MIM BEIM
75 82
CONTINUING PROFESSIONAL EDUCATION
ANNALIES CORSE
THE MASSAGE PARADOX: WHEN TOUCH CAUSES FEAR GREG MORLING
HEALTH FUND NEWS
REPORTS
52
LAW REPORT
83
CONTINUING EDUCATION CALENDAR 2014
JATMS | March 2014 | 3
The Australian Traditional-Medicine Society Limited (ATMS) was incorporated in 1984 as a company limited by guarantee ABN 46 002 844 233. ATMS HAS THREE CATEGORIES OF MEMBERSHIP
Accredited member Associate member Student membership is free MEMBERSHIP AND GENERAL ENQUIRIES
ATMS, PO Box 1027 Meadowbank NSW 2114 Tel: 1800 456 855 Fax: (02) 9809 7570 info@atms.com.au www.atms.com.au
LIFE MEMBERS
Dorothy Hall* - bestowed 11/08/1989 Simon Schot* - bestowed 11/08/1989 Alan Jones* - bestowed 21/09/1990 Catherine McEwan - bestowed 09/12/1994 Garnet Skinner - bestowed 09/12/1994 Phillip Turner - bestowed 16/06/1995 Nancy Evelyn - bestowed 20/09/1997 Leonie Cains - bestowed 20/09/1997 Peter Derig* - bestowed 09/04/1999 Sandi Rogers - bestowed 09/04/1999 Maggie Sands - bestowed 09/04/1999 Freida Bielik - bestowed 09/04/1999 Marie Fawcett - bestowed 09/04/1999 Roma Turner - bestowed 18/09/19999 Raymond Khoury - bestowed 21/09/2002 Bill Pearson - bestowed 07/08/2009
PRESIDENT
Maggie Sands | maggie.sands@atms.com.au
* deceased
VICE PRESIDENT
HALL OF FAME
David Stelfox | david.stelfox@atms.com.au
Dorothy Hall - inducted 17/09/2011 Marcus Blackmore - inducted 17/09/2011 Peter Derig - inducted 17/09/2011 Denis Stewart - inducted 23/09/2012 Garnet Skinner - inducted 22/09/2013
VICE PRESIDENT
Stephen Eddey | stephen.eddey@atms.com.au CEO
Trevor Le Breton | trevor@atms.com.au TREASURER
Antoinette Balnave | antoinette.balnave@atms.com.au DIRECTORS
Peter Berryman | peter.berryman@atms.com.au Raymond Khoury | raymond.khoury@atms.com.au Bill Pearson | bill.pearson@atms.com.au Daniel Zhang | daniel.zhang@atms.com.au
Copyright 2014. All rights reserved. The opinions expressed in this journal are those of each author. Advertisements are solely for general information and not necessarily endorsed by ATMS.
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“What you each do in your practices has the potential to not only alter and improve a person’s health but also their attitude about their world and how they exist in it.”
President’s Message MaggieSands | ATMS President
D
Life member number 28
ear Colleagues and Friends,
We are well into 2014 and as usual there is much going on in our profession. I hope this year is good for you personally and that many positive opportunities come your way. At a time when our profession not only has significant challenges but is also steering its way through considerable change it is important for us to reflect on how our various natural medicine modalities and practices support healing, wellbeing and/ or recovery for our clients.The ATMS Board of Directors maintains a ‘for the better good of all’ attitude and will continue to assist and liaise with other natural medicine organisations to achieve this intent.The Board, our CEO and office staff have volumes of work to navigate through and prioritise. I take this opportunity to thank our hard working office team, led by our CEO Trevor Le Breton, and welcome two new staff members to our staff community. I also thank and appreciate the support of my fellow directors who come from a variety of modalities including naturopathy, acupuncture and TCM, massage and other bodywork modalities, homoeopathy, herbal medicine and naturopathic nutrition. Your Board has vast collective knowledge and wisdom about natural medicine. Several directors teach and are also in clinical practice. I would
6 | vol20 no1 | JATMS
estimate the Board’s collective experience in the profession at over 250 years. I recently read the following words by William F. Bengston that I share with you now:‘Your body’s ability to heal is greater than anyone has permitted you to believe’. What you each do in your practices has the potential to not only alter and improve a person’s health but also their attitude about their world and how they exist in it.We have an amazing vehicle for life, our body. As practitioners in our various natural medicine fields we offer health support for another’s life vehicle or body. It is truly amazing just how intelligent our bodies are and how the body’s self healing mechanisms have the potential to repair itself and maintain homeostasis when provided with therapeutic support and/or a healing environment. I have no doubt our life force wants to win, so to speak. It is designed to assist us strive and maintain health but how do our collective therapies actually assist this intrinsic drive? The body’s physiological responses to our therapies can and have been tested.They support and give strength to the body’s own ability to fight dis-ease. Let’s consider the energetic nature of our individual therapies and how they resonate with the body’s healing capacity and life force. Our modalities either contain energetic constituents such as in nutrients, herbs,
essential oils and homoeopathics, or stimulate healing energy flow via acupuncture, chiropractic or by massage and other forms of bodywork. Let’s not forget the healing power of nature, being in a garden or forest and by the sea or a river has an effect energetically on us, even if maybe unfelt at the time. Plants and water are vibrational, just as our bodies are. In our busy and often stressful lives it is easy to forget the true essence of our work and that our own body also needs support, not only for our own health and wellbeing, but to enable us to work with clients who may not be well and may have considerable health or emotional needs. As a practitioner feeling drained, on edge and/or tired can be an indication that it’s time to turn the focus to our own healing and support our own life force to repair and mend. My own observation over several decades is that many natural medicine practitioners often give to their clients beyond their own personal limits. I believe this may be the nature of who we are as practitioners, however it is essential to remember that unless we give to ourselves equally we may invite our own imbalance or dis-ease.The old saying ‘practise what we preach’ is certainly worth striving for. Perhaps now is a good time to assess your personal commitment to your own health and wellbeing.
At this time of significant challenges for our natural medicine profession it is gratifying to see a shift in thinking in some areas of orthodox medicine that are willing to support, promote and acknowledge our practices. Such organisations as Chris O’Brien’s Lighthouse Sydney Cancer Clinic provide advanced medical and complementary therapy support, offering patients a very different experience including emotional counselling and an holistic patient-centred model. Another such centre in Melbourne is the Olivia Newton-John Cancer and Wellness Centre in the Austin hospital that also combine orthodox cancer treatment and natural medicine practices.These pioneer medical organisations clearly understand the curative value of what our practices offer and it is refreshing to see patients in need being offered numerous natural medicine options in a medical setting.
Tribute to Association of Remedial Masseurs’(ARM) ARM was formally established as a national massage association in 1976 and for many years had offices in Strathfield, Sydney. Sadly after supporting the massage industry development in Australia for over 37 years ARM has officially closed. I wish to give thanks to two early pioneer ARM presidents, Roma Turner and Reg Warren (now deceased). During the 1980’s and early 1990’s ARM and ATMS worked closely together and their offices were housed in the same building in Top Ryde, Sydney. At that time ARM held a director position on the ATMS Board. I was fortunate during those earlier years to work with both Roma and Reg on several projects while they served as ATMS directors. In 1990 Roma was one of the original five members on one of ATMS’s inaugural committees, the Modality, Standard and Structure Committee, along with myself, Catherine McEwan (then President), Marie Fawcett (ATMS Company Secretary for 24 years) and Frieda Bielik (Co-founder of ACNT Surry Hills). I would like to formally thank Veronica Watson, retiring ARM President, and the ARM board as the decisions that were made to wind up ARM were not easy. ATMS has received many applications from ARM members and we
are endeavouring to assist these members, as many are long-standing members of the profession and of ARM.We welcome the ARM members into the ATMS community. The year 2014 will certainly be an enormous year for ATMS as we have the revised constitution ready for members’ input and vote in March, the second democratic election of directors to the Board later in the year and the ATMS 30th anniversary on 7/9/2014.We are planning a fabulous 30th celebration in Sydney and I hope many members will be able to attend this exciting event.The event will be advertised soon. Looking back over the last 30 years, natural medicine has travelled an enormous distance. During the 80’s and 90’s natural therapies (as they were often called during those years) did not reflect the confidence that the general public give natural medicine in current times. In fact our younger members may not be aware that there was a time that spanned decades when no health fund in Australia paid a rebate to a client for our services.The ATMS board and staff fought many battles for years and years to achieve the health fund status we have today. In the early 80’s when I was a student studying massage it was not unusual to attract suggestive and inappropriate comments as to what massage was about. Times have radically shifted and we now know that billions of dollars are spent annually on our modalities.The general public appear to have gone past the fork in the road.What we offer is popular and sought after.This trend of support for our practices is seen internationally as well as in Australia and I have no doubt this interest will continue to expand as more people receive the benefits from our work and gain confidence in what we offer. It is interesting to note that in years to come we may not have sufficient natural medicine practitioners to meet the needs of an ageing population.The government has already identified serious concerns that there will not be sufficient aged care workers or nurses to meet the demand and there are reliable signs that the number of natural medicine practitioners will reduce as our current members age and retire.
The Relationship between Diet and Dis-ease It would seem orthodox medicine is proclaiming at long last what we have been saying for decades. In 1983 when I was studying naturopathic nutrition, I organised a seminar for the public titled ‘The relationship between diet and disease’ with special guest presenter and ATMS Hall of Fame recipient Denis Stewart, my mentor and teacher at that time, well known in Australia and internationally as a pioneer in western herbal medicine. Well, the seminar was packed with standing room only. In the audience were disbelievers, several proclaiming that we were misleading the public. In 1983, some 30 years ago, the majority of Australians and medical practitioners did not associate diet with dis-ease, in fact many at the seminar were irate and upset that such a suggestion could be implied.That was not that long ago but now our long-standing beliefs in dis-ease creation are understood by most in a western culture. As your President my focus is on a future vision and in forward thinking. Having been in the natural medicine profession working full time for over 33 years, I clearly remember the past, where we have been and where we have come from.The knowledge I have gained from these years of experience ignite and fuel my enthusiasm today. I believe in natural medicine and I believe in what you do in your practices.There is much to do to progress natural medicine in Australia. This is my intent and commitment. I am grateful for this opportunity and have as much passion now as when I first became a director many years ago. The saying below has been a personal mantra of mine for some years. I hope you like it and find it useful as I do. “All that we are is a result of what we have thought. The mind is everything. What we think we become.” Buddha My very best regards, Maggie Sands/ ATMS President
JATMS | March 2014 | 7
“The availability and acceptance of alternative health therapies are increasing, with revenue forecast to total $3.8 billion in 2013-14 after growing by an annualised 4.1% over the past five years.”
CEO’s Report Trevor Le Breton | Chief Executive Officer
Key Statistic Snapshots Revenue
$3.8bn Annual Growth 09-14
4.1%
W
elcome to the March Edition of JATMS for 2014.
With so many external forces impacting on our industry, it is interesting to sit back and review where we are placed and where we are headed into the future.This month with the assistance of a new planning tool, ATMS takes a look into our industry. I welcome you to provide your experience by way of feedback to the information contained in the report which is published on average twice a year; ATMS will be a significant contributor to future reports.
The availability and acceptance of alternative health therapies are increasing, with revenue forecast to total $3.8 billion in 2013-14 after growing by an annualised 4.1% over the past five years. Industry revenue has also grown due to the ageing population and surging private health fund membership. The amount of revenue is likely to remain constant with employment numbers as the employment in our industry drops away percentage wise in the coming years, meaning slightly more per practitioner.
Annual Growth 14-19
3.4% Businesses
28,741 Wages
$41.4bn Profit
$269.6m
Major market segmentation (2013-14)
7%
65.7%
People aged 17 years and younger
27.3%
People aged 65 years and older
Graph A
People aged 18 to 64 years
Total $3.8bn
Source: www.ibisworld.com.au
8 | vol20 no1 | JATMS
Graph B, C, D
Revenue vs. employment growth
Total health expenditure
66.5
240
16
66.0
12
8
4
160
Percentage
200 $ billion
% change
Health consciousness
65.5 65.0 64.5
120
0
64.0 80
-4
Year 06 08 10 12 14 16 18 20 Revenue
Year 06 08 10 12 14 16 18 20
Employment
Over the next five years, a greater spotlight is likely to be shone on the efficacy of alternative health therapies. Further research will be undertaken to strengthen the arguments on the legitimacy of alternative health theories. However, with key external trends persisting, industry revenue is expected to continue rising. These trends include increases in total health expenditure, some of which will be met by alternative health therapies, and the ageing of the population.With greater regulation and increasing educational qualifications of practitioners, competition is likely to intensify over the next five years. High demand is forecast to drive strong revenue growth of an annualised 3.4% over the next five years, to $4.5 billion in 2018-19. Graphs C & D show that as total health consciousness amongst our clients grows total expenditure increases by some $40billion over the next 5-7 years The number of establishments and where they are located is not of any great surprise to ATMS, in fact this distribution is relatively consistent with our coverage across the entire industry. NSW leads the way followed by Victoria and then Queensland. What is of interest is the number of establishments compared to the actual population, with more establishments in NSW, ACT and Victoria than population (i.e. over serviced). Where the growth opportunities exist are in SA, NT and to a lesser extent Tasmania,
63.5
Year 05 07 09 11 13 15 17 19
Source: www.ibisworld.com.au
where there are fewer establishments able to service the existing population. Graph E shows the break-up of some of the modalities studied as part of this report. In future reports we will be seeking a wider break-up of the some 30 modalities which ATMS is presently representing.
Constitution The Board of ATMS have voted to adopt a new Constitution. The process to have this new Constitution adopted by the members will commence with an Extraordinary General Meeting of members being held on 26 March 2014 commencing 6.30pm at the New South Wales Teachers Federation Conference Centre, 37 Reservoir Street, Surry Hills NSW. All members are encouraged to participate in the review process, and a face-to-face meeting in Sydney will be held to assist in addressing any concerns with the proposed new Constitution in the lead-up to the meeting on the 26th. The Constitution belongs to the members, and the new Constitution should reflect the members’ views.
Health Funds and Associations After many months of discussions with Medibank, the ATMS Board has resolved to sign the addendum. It should be noted that these changes only affect remedial massage and therapies members, other modalities are not affected by the proposed changes.
Primarily our decision to sign is to protect the business interests of existing remedial massage members. As a result of signing the document, members who are currently recognised practitioners with Medibank are able to: • Select up to three (3) locations at which to practice • Move premises from one location to another – provided the number of locations does not exceed three (3). These new Medibank conditions are different from those with which RTOs are expected to comply under the ASQA guidelines by which all RTOs are audited and with which they must comply. It is of note, that if a Remedial Massage Provider has Provider status with Medibank for other modalities (ie. Acupuncture, Naturopathy, Shiatsu, etc.) that all clinics the member has listed with ATMS will continue to be recognised for those other modalities only. Medibank claim to have 30% of the available Private Health Fund market in Australia. The changes proposed for Remedial Massage do not impact on existing providers, however it is strongly recommended that that you do not lapse your ATMS Accredited Membership. It is also very important to maintain current first aid and insurance and complete the ATMS CPE requirements to ensure your eligibility to stay on the Medibank List. ATMS cannot guarantee that if a member inadvertently comes off the
JATMS | March 2014 | 9
CEO’S REPORT Graph E, F
Products and services segmentation (2013-14)
Establishments 1.8% TAS
9%
Source: www.ibisworld.com.au
0.6% NT
2% ACT
Traditional Chinese medicine
9.9%
25.4%
Other therapies
Chiropractic and osteopathy
Total $3.8bn
10.5%
Therapeutic massage and reflexology
17.2%
12.9%
6.5% SA 9.7% WA 18.3% QLD
Naturopathy and homeopathy
Acupuncture
26.4% VIC
15.1%
Dietary supplements and herbal medicines
Medibank Provider listing, that they will be reinstated without having to meet the current requirements for Remedial Massage. Provider status. For Remedial Massage providers interested in Medibank Provider status, ATMS will continue to work with colleges, other associations and Medibank to ensure that they are able to meet the conditions set down by Medibank, these are: • That the duration of a Diploma course is to be 12 months – for the purposes of this addendum that can be interpreted as Late
Distribution of establishments vs. population 40
Graph G
Percentage
30
20
10
WA
VIC
TAS
SA
QLD
NT
NSW
ACT
0
Establishments Population
10 | vol20 no1 | JATMS
34.7% NSW
Source: www.ibisworld.com.au
January/Early February to late October/early December • It does not mean an academic year, as some RTO’s are delivering their course in six or twelve weeks • Additionally, a minimum of 20% of the Diploma course is to contain clinical training to be conducted ON campus SUPERVISED by a trainer with qualifications – therefore if the course is of 1000 hours duration, a minimum of 200 hours supervised clinic must be achieved • Only where the units of competency are identical from a Certificate IV to Diploma, will they be permissible as Recognition of Prior Learning • Certificate IV training and clinic DO NOT form part of the duration of the course • It should be noted that should a new member not meet the above conditions it only impacts on their ability to be recognised by Medibank, they are still eligible to be recognised by other Private Health Fund Providers. ATMS will continue to work with practitioners to ensure that they: • Take and maintain treatment plans and clinical notes to the standard expected by Medibank • Conduct random audits of treatment plans and clinic notes by both ATMS and Medibank • Ensure that RTOs are delivering the
training courses as they were intended • Ensure that only one service is claimed where multiple services are performed at the same time by the same provider during the same appointment • Monitor how ATMS members advertise their services • Encourage members to report fraudulent activities, ie. misuse of provider numbers, billing for services not performed, treatment by an unrecognised therapist using another’s provider number, treatments conducted at one clinic with the receipt indicating it took place elsewhere.
TGA Update ATMS has continued to work with the TGA throughout the summer on the issue of the proposed advertising reforms. The new Coalition government are presently considering a number of reviews for health reform, but no decisions have been reached nor is it expected that an outcome will be delivered in the near future. Therefore, the status quo remains and members will continue to receive advertising material and not be restricted from this information or the purchase of products.
Complaints Committee I recently emailed that we had a ‘surge’ in the number of complaints received
from Health Funds and members of the public. I remind each and every member that your provider number is for your exclusive use, is not to be shared and should be kept safely so others cannot access it. Additionally this number cannot be used at multiple locations simultaneously. If you require further information on these points contact our offices immediately. As members have often stated it is a shame that a few make it so difficult for the rest, and to that end the Board have adopted a zero tolerance policy to behaviour of members who are blatantly in breach of our Code of Conduct. Make sure you have a copy, and understand how it applies to you. Don’t have one? Contact the office on 1800 456 855 to obtain a copy.
CPE Audit The achievement of 20 CPE points in a financial year is a mandatory requirement for accredited membership. It is also a condition which enables the Society to forward practitioners’ details to a health fund. On renewal of their membership each year, members are asked to tick a box stating that they will comply with this requirement. In 2014 ATMS will be increasing the level of audit to ensure members are in fact compliant. Members found not to have achieved the necessary requirements will have their membership downgraded and also be withdrawn from access to the funds.
points you visit our website and plan for upcoming events. These events are provided not only by ATMS but a range of other recognised providers. Members are not obliged to undertake programs delivered by ATMS; however in doing so the money invested in your development is reinvested into the future of the Society. As always for further information on any issue call me on 1800 456 855 or send an email to trevor@atms.com.au. On behalf of all the team at Meadowbank, we thank you for your ongoing support and we value your membership. Take Care.
We strongly suggest that if you have not yet completed your annual CPE
Trevor Le Breton | CEO
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JATMS | March 2014 | 11
ARTICLE
Treatment using far-infrared meridian heat pad covering six acupuncture points on the hand for patients at high risk of diabetes mellitus Hui-Chuan Chu | Ph.D, Wenshan District Health Center, Taipei City, Taiwan Chi-Feng Liu | Ph.D, Graduate Institute of Integration of Traditional Chinese Medicine
Abstract
with Western Nursing, National Taipei University
The aim of this study was to compare effects of farinfrared (FIR) meridian heat pad therapy and health education in subjects at high risk of developing diabetes mellitus. A total of 103 participants with at least one high-risk factor for type 2 diabetes mellitus were enrolled in either an experimental group (n =50) receiving FIR meridian heat pad therapy or an untreated group (n = 53) receiving a diabetes mellitusrelated health education program combining traditional and Western medicine (TMWM).The experimental group was treated with FIR heat pads covering an area consisting of six acupuncture points on the hand:Yangxi,Yanggu,Yangchi, Shenmen, Daling, and Taiyuan. Waist circumference, body mass index, fasting blood glucose, total serum cholesterol and blood pressure were measured at baseline and 10 weeks post-intervention.The Chinese version of the SF-36 Health Survey for quality of life was completed postintervention. Significant changes in waist circumference were shown between baseline and post-intervention in the TMWM group (P=0.003) and FIR group (P=0.002), with greater mean reduction in the TMWM group than the FIR group. Mean fasting blood glucose levels increased significantly in the TMWM group after intervention (P<0.05) but showed no significant increase in the FIR group. General health scores significantly decreased after intervention (P=0.015), while physical functioning scores increased (P=0.027) in the TMWM group but not in the FIR group postintervention. FIR meridian heat pad therapy may reduce chances of elevating fasting blood glucose levels and a diabetes mellitus-related TMWM health education program may modulate quality of life in patients at high risk of diabetes mellitus.
of Nursing and Health Sciences, Taipei, Taiwan
12 | vol20 no1 | JATMS
Introduction Far-infrared (FIR) rays originate in sunlight as electromagnetic waves that radiate energy. Infrared rays with wavelengths of 0.75-1000µm are part of the light spectrum below red, which is the colour of the longest wavelengths of visible light.1 FIR rays of 8 to 14µm can directly heat the human body.This radiation has low skin permeability and is mostly absorbed in superficial skin layers stimulating the corium, blood capillaries and sweat glands.This type of FIR ray raises skin temperature and blood flow at a relatively low temperature (40–60°C) without causing apnoea, blood rushing to the head, damaged hair or heart stress.2 FIR sauna is a relatively new type of treatment that is helpful in chronic diseases, including cardiovascular disease, depression and insomnia.1 Treatment with a 60˚C FIR-ray dry sauna bath for 15 minutes followed by keeping warm in a bed covered with blankets for 30 minutes once a day for two weeks improves endothelial function in patients with coronary risk factors such as hypercholesterolemia, hypertension, diabetes mellitus and smoking.3 However, no study has reported outcomes of FIR therapy for individuals at high risk of diabetes mellitus. Acupuncture is another non-traditional approach to insulin resistance. Previous studies have demonstrated that acupuncture can correct various metabolic disorders, including hyperglycemia, being overweight, hyperphagia, hyperlipidemia, inflammation, altered sympathetic nervous system activity and insulin signal defect, which all contribute to developing insulin resistance.4 In addition, acupuncture has the potential to improve insulin sensitivity. This study combined FIR therapy with specific acupuncture points as an alternative therapy to treat individuals at high risk of diabetes mellitus. We hypothesized that this alternative therapy may have a beneficial effect on
controlling risk factors of type 2 diabetes mellitus and improve quality of life in high-risk patients.
Materials and Methods Participants:Two hundred and thirteen volunteers were recruited from the community in Wenshan District,Taipei, Taiwan by advertisements between September 2009 and January 2010 and were screened for factors associated with high risk of developing diabetes mellitus according to established criteria.5,6 The inclusion criteria were individuals with at least one of the following high-risk factors for type 2 diabetes mellitus: (1) family history of diabetes mellitus, especially in firstdegree relatives; (2) being overweight; body mass index (BMI) > 24 kg/m2 [BMI = weight ÷ height2 (in metres)]; (3) gestational diabetes in female subjects; and (4) impaired fasting blood glucose levels and glucose tolerance. Exclusion criteria were: (1) receiving far-infrared heat pad therapy during the previous month; (2) subjects with a history of one or more of the following: drugrelated hypersensitivity, hypertension, cardiovascular disease, cardiac arrhythmias, bronchitis, asthma, or anemia.The project was supported and approved by the Department of Health, Taipei City. All participants provided signed informed consent.
Study design We compared the effects of FIR meridian heat pad therapy (FIR group) with a health education approach among subjects at high risk of developing diabetes mellitus. Quasi-experimental design was applied since random assignment of participants was not possible. Each volunteer decided independently whether to receive FIR therapy or health education. Major outcome measures were well-defined risk factors associated with developing diabetes mellitus, including selective diagnostic criteria of metabolic syndrome (MetS),7, 8 BMI,9, 10 and serum total cholesterol.11 The secondary outcome measure was subjects’ quality of life (Chinese version of SF-36 questionnaire).
A total of 103 volunteers who met the inclusion criteria participated in either an FIR group (n=50) receiving FIR therapy using FIR heat pads or a health education group (n=53) receiving a health education program based on both Chinese traditional medicine and Western medicine (TMWM) viewpoints concerning self-management of diabetes mellitus.The interventions were given once a week for 10 weeks, after which patients in both groups were evaluated for diabetes mellitus risk factors and quality of life.
FIR group Fifty subjects in the experimental group received FIR meridian heat pad therapy once a week for 10 weeks. Participants were treated with FIR heat pads applied to cover the area on the hand consisting of six acupuncture points: Yangxi (LI5), Yanggu (SI5), Yangchi (TE4), Shenmen (HT7), Daling (PC7), and Taiyuan (LU9). The heating pads (EverShine Far-Infrared Heating Pad, Arm-Wrist Wrap (ES-HP805), EverShine Medical Company, Taipei, Taiwan) were placed on subjects’ right hands. FIR of 4 to 20µm was applied, which raised the skin temperature to approximately 45°C. Therapy was administered twice a week for 30 minutes each time. The entire therapeutic protocol lasted for 5 weeks during which no side effects were documented.
Health education group The health education group was enrolled in a ten-week TMWM education program that included three-hour sessions once a week. Instructors were physicians or experts recruited from the Department of Oriental-Western Integrated Medicine, the Nursing Department and the Nutrition Department of National Taipei University of Nursing and Health Science. Patients had sessions on diabetes and its course, effects of exercise, Chinese herbal cuisine, aerobic exercise, medications and selection of foods, among other topics. A list of topics in the ten-week course is presented in Appendix A.
JATMS | March 2014 | 13
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Table 1. Demographic characteristics, lab data and quality of life in 76 subjects TMWM group (n=44)
FIR group (n=32)
P
58.52 ± 6.36
52.88 ± 8.74
0.002*
2 (4.55)
8 (25.00)
0.014*
42 (92.45)
24 (75.00)
30 (68.18)
25 (75.13)
0.339
≤ 90 cm (men); ≤80 cm (women)
14 (31.8)
16 (50.0)
0.109
> 90 cm (men); > 80 cm (women)
30 (68.2)
16 (50.0)
≤ 24 kg/ m2
9 (20.5)
12 (37.5)
> 24 kg/ m2
35 (79.5)
20 (62.5)
< 130 mmHg
26 (59.1)
17 (53.1)
≥ 130 mmHg
18 (40.9)
15 (46.9)
31 (70.5)
23 (71.9)
13 (29.5)
9 (28.1)
Age (years)
1
Gender, n (%)
2
Male Female Marriage, n (%)
3
WC, n (%) 3
BMI, n (%) 3 0.101
SBP, n (%) 3
DBP, n (%)
0.604
3
< 85 mmHg ≥ 85 mmHg Total cholesterol, n (%)
0.893
Measuring quality of life
3
≤ 200 mg/dL
35 (79.5)
23 (71.9)
9 (20.5)
9 (28.1)
< 110 mg/dl
43 (97.7)
27 (84.4)
≥ 110 mg/dl
1 (2.3)
5 (15.6)
Physical Functioning
24.00 (20.50, 26.00)
24.00 (23.00, 27.00)
0.160
Role-Physical
8.00 (6.00, 8.00)
8.00 (6.00, 8.00)
0.609
Bodily Pain
4.00 (3.00, 5.00)
4.00 (3.00, 5.00)
0.396
General Health
15.50 (13.25, 17.00)
15.00 (14.00, 16.00)
0.305
Vitality
15.00 (13.00, 16.00)
15.00 (14.00, 16.00)
0.749
Social Function
6.00 (4.25, 6.00)
6.00 (4.00, 6.00)
0.450
Role-Emotional
5.00 (5.00, 6.00)
5.00 (5.00, 6.00)
0.167
Mental Health
18.50 (17.00, 20.00)
19.00 (18.00, 20.00)
0.602
> 200 mg/dL Fasting blood glucose, n (%)
0.437
2
0.077
SF-36 score3
Continuous data were presented as mean ± standard deviation; categorical variables are expressed as numbers (%). P-values were calculated by 1independent two-sample t-test, 2Fisher’s exact test, and 3chi-square test * Significant difference between the two groups (P <0.05) Key: TMWM= traditional medicine combined with western medicine; FIR= far-infrared therapy; WC= waist circumference; BMI= body mass index; SBP= systolic blood pressure; DBP= diastolic blood pressure
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Measuring risk factors of developing diabetes mellitus: MetS was defined from the modified Third Report of the National Cholesterol Education Program’s Adult Treatment Panel (ATP).8 The ATP II defined MetS as the presence of three or more of fasting plasma glucose ≥ 110 mg/dl, serum triglycerides ≥ 150 mg/dl, serum HDL-cholesterol <40 mg/dl in men and <50 mg/dl in women, blood pressure ≥ 130/85 mmHg, or waist circumference >90 cm in men and >80 cm in women.13 Participants’ fasting plasma glucose, blood pressure and waist circumference were measured. Based on Taiwan Department of Health criteria, BMI [BMI = weight ÷ height2 (in metres)] was divided into three subgroups: obese (BMI ³27), overweight (24 £BMI < 27), and normal (BMI < 24)14 with BMI=24 as the cut-off point. Individuals with normal glucose tolerance have a total cholesterol level of about 200 mg/dL.15 Therefore, a total cholesterol of 200mg/dL was used as the cut-off point.
The previously validated Chinese version of the SF-36 Health Survey was used to measure patients’ quality of life after treatment, including overall health status and self-reported physical functioning level.16 The Chinese SF-36 Survey is a generic measure that contains 36 items in 8 scales and two components. Subjects evaluated their own health status and filled out the questionnaires themselves. Results were used to compare health and lifestyle effects between the intervention and the control group.
Statistical analysis Continuous and categorical variables were compared by independent twosample t-test and chi-square/Fisher’s exact test, respectively. Non-parametric data were compared using the MannWhitney-U test. Differences between baseline and post-intervention were evaluated using paired t-tests/ Wilcoxon signed-rank tests in both FIR and TMWM groups. Continuous variables are presented as mean ± standard deviation, while categorical data are represented by number and percentage. Non-parametric
data are presented as median values (interquartile range, IQR). Analysis of covariance (ANCOVA) was performed to examine post-intervention differences between groups after controlling for effects of age and gender due to imbalance of these variables between the two groups. A linear mixed model was also performed to account for differences in serum glucose levels at baseline and post-intervention. All statistical assessments were two-sided, and a P-level of 0.05 was determined to be statistically significant. Statistical analyses were performed using SPSS 15.0 statistics software (SPSS Inc, Chicago, IL, USA).
Results Two hundred and thirteen volunteers were screened between September 2009 and January 2010. In all, 103 volunteers who met at least one high-risk criterion for type 2 diabetes mellitus were assigned to either an experimental group receiving FIR therapy (n=50) or a TMWM education group (n=53). Among 10 male and 93 female subjects in the two groups, 27 (26.2%) did not complete the study. In the TMWM group, 44 of 53 patients (83%) completed the study and nine withdrew early; ten subjects missed one class, six subjects missed two classes and seven subjects missed three classes. In the FIR group, 32 of 50 patients (64%) completed the study and 18 withdrew, including three who left the country during the intervention period, one who was hospitalized and 14 who withdrew for personal reasons. Baseline characteristics of the 76 remaining subjects (44 in the TMWM group; 32 in the FIR group) are shown in Table 1. Marital status, distribution of normal and abnormal levels of waist circumference, BMI, blood pressure, total plasma cholesterol and fasting blood glucose were similar between the two groups (all: P > 0.05). Both groups also had similar quality of life (P > 0.05). FIR group subjects were younger than TMWM subjects (52.8± 8.748 years
vs. 58.52± 6.36 years, respectively; P=0.002), and the FIR group had a higher percentage of males than the TMWM group (25.00% vs. 4.55%, respectively; P=0.014). Results of interventions in the two groups are listed in Table 2. Both TMWM and FIR groups had significant changes in waist circumference between baseline and post-intervention measurements: TMWM group 85.05 ± 9.56 cm vs 81.51 ± 6.12 cm (P=0.003); and FIR group 83.16 ± 9.17 cm vs 82.94 ± 9.24 cm (P=0.002). Although the TMWM group had a greater mean reduction in waist circumference than the FIR group, the difference was not statistically significant. Mean fasting blood glucose levels of the TMWM group were significantly increased (74.5 ± 19.32 mg/dL vs. 82.95 ± 21.36 mg/dL; P<0.05) and also increased in the FIR group after intervention, but without significant difference from baseline. The degree of increase in fasting blood glucose levels was significantly lower in the FIR group than in the TMWM group (P=0.032). No side effects were reported in either group.
The Chinese SF-36 scores for both groups after therapy are shown in Table 3. No significant differences were found in scores between the two groups (P >0.05). In the TMWM group, the self-reported scores of general health (15.50 vs. 15.00; P=0.015) decreased significantly after the intervention, while scores of physical functioning significantly increased compared to baseline scores (P=0.027). In the FIR group, no significant differences were found in any subscale of SF-36 scores between pre- and post-intervention.
Discussion This study demonstrated that fasting blood glucose levels in the TMWM group increased significantly after intervention and also increased in the FIR group but not significantly. The degree of increase in fasting blood glucose levels in the FIR group was significantly lower than that in the TMWM group. Accordingly, FIR therapy may be helpful for alleviating the increase in fasting blood glucose levels among individuals at high risk of diabetes mellitus, while the TMWM health education intervention failed to control increases in fasting blood glucose levels.
Table 2. Change in parameters before and after intervention (n=76). TMWM group (n=44)
FIR group (n=32)
Adjusted p^
WC (cm) 1 BMI (kg/m2)1
-3.43 ± 7.02†
-0.39 ± 2.15†
0.00 (-0.41, 0.33)
0.00 (-0.25, 0.21)
0.065 0.566
SBP (mmHg) 1 DBP (mmHg) 1 Total cholesterol (mg/dL)1 Fasting blood glucose (mg/dL) 2
1.98 ± 12.26 1.98 ± 8.97 -1.00 (-12.00, 11.00) 8.45 ± 22.10†
-3.72 ± 11.65 -3.44 ± 10.47 -7.50 (-28.00, 12,00) 4.34 ± 18.41
0.200 0.067 0.216 0.032*
Key: TMWM= traditional medicine combined with western medicine; FIR =far-infrared therapy; WC= waist circumference; BMI= body mass index; SBP= systolic blood pressure; DBP= diastolic blood pressure Data were presented as mean ± standard deviation for waist circumference, blood pressure and fasting blood glucose, and median (interquartile range) for other measures. † Indicates a significant change before and after intervention according to paired t-test / Wilcoxon signedrank tests, P <0.05 ^ Age and gender were adjusted because of imbalanced age and gender between the 2 groups.. P-values were calculated by 1 analysis of covariance and 2linear mixed model. * Significant difference between the two groups (P<0.05)
JATMS | March 2014 | 15
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Table 3. Quality of life (SF-36 score) post-intervention between the 2 groups
Physical Functioning Role-Physical Bodily Pain General Health Vitality Social Function Role-Emotional Mental Health
TMWM group (n=44)
FIR group (n=32)
adjusted P^
24.00(22.00, 26.00) † 8.00 (6.00, 8.00) 4.00 (3.00, 5.00) 15.00 (13.25, 16.00) † 14.00 (13.00, 16.00) 6.00 (4.00, 6.00) 5.00 (5.00, 6.00) 19.00 (16.00, 20.00)
25.00(24.00, 26.00) 8.00 (6.00, 8.00) 4.00 (3.00, 5.00) 15.00 (14.00, 17.00) 14.00 (13.00, 16.00) 6.00 (4.00, 6.00) 5.00 (4.25, 6.00) 19.00 (18.00, 20.00)
0.478 0.561 0.679 0.168 0.633 0.359 0.325 0.685
Subjects in both intervention groups (FIR therapy and TMWM education) had significantly reduced waist circumference post-intervention compared to baseline, but without significant difference between the two groups. Waist circumference is an indicator of obesity among criteria for clinical diagnosis of MetS.8 Since MetS is the risk factor associated with developing diabetes mellitus,7,8 reductions in participants’ waist circumference after receiving either FIR therapy or TMWM education indicated a positive effect on diabetes mellitus prevention among the highrisk population. Little is known about the effects of FIR therapy on diabetes mellitus patients’ clinical symptoms and physiological condition. Chang et al.17 applied FIR heating to three acupuncture points, Nei-Kuan (PC6), Shenmen (HT7) and Sanyinjiao (SP6), for depressed patients with insomnia. Based on the study results, the authors suggested that FIR therapy applied at acupuncture points may help to strengthen serotonergic function. An evaluation of several serotonergic compounds in clinical use in the treatment of obesity and type 2 diabetes mellitus indicated that serotonergic pathways may also directly affect glucose homeostasis by regulating autonomic efferents and/or acting on peripheral tissues.18 Therefore, FIR therapy applied at acupuncture points may affect glucose homeostasis by strengthening serotonergic function.The detailed mechanism linking FIR therapy
16 | vol20 no1 | JATMS
and serum glucose levels warrants further investigation. In the present study, effects of TMWM health education were consistent with reported outcomes of similar interventions. A systematic review conducted by Duke et al.19 suggested that significant differences between individual education and usual care are not apparent. However, results of that study suggested that individual education about glycemic control was beneficial compared to usual care in a subgroup of those with a baseline HbA1c greater than 8%. Chen et al.20 reported that a diabetes education program did not show better efficacy than a special educational reminder pamphlet about maintaining glycemic control during the holiday season. No significant differences were found between FIR and TWMW groups in postintervention quality of life (SF-36) scores in the present study. However, general health scores decreased significantly in TMWM subjects while physical functioning scores increased significantly post-intervention. Rubin and Peyrot21 proposed that intensive blood glucose control and prevention of comorbidities are important determinants for quality of life in diabetes patients, and that improving patients’ health status and perceived ability to control their disease results in improved quality of life, consistent with results of other studies of clinical and educational interventions.22 It has been suggested that type 2 diabetes mellitus can be prevented
Key: TMWM = traditional medicine combined with western medicine; FIR = far-infrared therapy. Data were presented as median (interquartile range) † Indicates a significant difference between before and after therapy in TMWM groups with Wilcoxon signed-rank tests, P<0.05 ^ Age and gender were adjusted. Adjusted P-values were calculated by analysis of covariance.
by lifestyle changes among high-risk persons,23,24 which may be achieved in part by participating in a healthcare education program. In the present study, quality of life was not significantly different for the FIR group before and after the treatment. However, a recent study indicated that FIR sauna use may be associated with improved quality of life in people with type 2 diabetes mellitus.25 In that study, indices of the SF-36v2, including physical health, general health, and social functioning improved after patients received 20-minute infrared sauna sessions three times weekly for three months. Differences between these findings and ours may be due to different ways of applying FIR thermal therapy. The present study has several limitations. First, enrolment was restricted to residents from the Wenshan District, which may not represent the general population in Taiwan. Secondly, the study could not be conducted as a randomized control trial (RCT) since not all participants were willing to accept FIR meridian heat pad therapy. In addition, placebo was not appropriate for this type of therapy. Finally, gender bias was a factor since most participants were women. Study results are thus limited to effective comparison of reported cases.
Conclusion FIR meridian heat pad therapy may reduce risk of elevating fasting blood glucose levels in patients at high risk of diabetes mellitus, while education alone
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Appendix A. Curriculum of the education program combining Traditional Medicine with Western Medicine (TMWM program) for diabetes mellitus
I. II. III. IV. V. VI. VII. VIII. IX X. XI. XII.
Objective 1. Definition of Diabetes 2. Factors and dangers of diabetes Knowing Diabetes 1. Facts and Management of calories in Food 2. Diet Skills for Diabetic Patients The Properties and Flavors of Diabetic Food Ingredients 1. The Influence of Exercise on Diabetes 2. Exercise Skills and Practices for Diabetic Patients Meridian Circulation and Exercise 1. Food Selection and Precautions when Eating Out 2. Simple Diabetic Recipes Simple Diabetic Recipes Take Your Diabetic Medicine in Correct Ways Knowledge and Application of Herbal Cuisine 1. Outdoor Aerobic Exercise with Deep Breathing 2. The Importance of Continuing Exercise Increase in Quality Of Life by Combining Traditional Medicine with Western Medicine
may not. In contrast, diabetes mellitusrelated TMWM health education program alone may modulate quality of life.
References 1 Beever R. Far-infrared saunas for treatment of cardiovascular risk factors: summary of published evidence. Can Fam Physician 2009;55:691-6. 2 Masuda A, Kihara T, Fukudome T, et al. The effects of repeated thermal therapy for two patients with chronic fatigue syndrome. J Psychosom Res 2005;58:383-7. 3 Imamura M, Biro S, Kihara T, et al. Repeated thermal therapy improves impaired vascular endothelial function in patients with coronary risk factors. J Am Coll Cardiol 2001;38:1083-8. 4 Liang F, Koya D. Acupuncture: is it effective for treatment of insulin resistance? Diabetes Obes Metab 2010;12:555-69. 5 Bennett WL, Bolen S, Wilson LM, et al. Performance characteristics of postpartum screening tests for type 2 diabetes mellitus in women with a
18 | vol20 no1 | JATMS
Notes Lecture course on prevention of diabetes – by physicians Lecture course on prevention of diabetes – by physicians Lecture course on diabetic diet – by dietitians (design individual diabetic diet plan) Dietitians in Chinese Medicine Demonstrations and instructions in proper exercise - dance teachers (design individual exercise plan) Exercise specialists in Chinese Medicine Lecture course on diabetic diet – by dietitians Dietitians in Chinese Medicine Lecture course on diabetic medicine - by pharmacists Pharmacists in Chinese Medicine Outdoor activities
history of gestational diabetes mellitus: a systematic review. J Womens Health (Larchmt) 2009;18:979-87. 6 Valdez R. Detecting undiagnosed type 2 diabetes: family history as a risk factor and screening tool. J Diabetes Sci Technol 2009;3:722-6. 7 Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: Diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med 1998;15:539-53. 8 Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement: Executive Summary. Cirt Pathw Cardiol 2005;4:198-203. 9 Njølstad I, Arnesen E, Lund-Larsen PG. Sex differences in risk factors for clinical diabetes mellitus in a general population: a 12-year follow-up of the Finnmark Study. Am J Epidemiol 1998;147:49-58.
10 Decoda Study Group, Nyamdorj R, Qiao Q, et al. BMI compared with central obesity indicators in relation to diabetes and hypertension in Asians. Obesity (Silver Spring) 2008;16:1622-35. 11 Koga H, Sugiyama S, Kugiyama K, et al. Elevated levels of remnant lipoproteins are associated with plasma platelet microparticles in patients with type-2 diabetes mellitus without obstructive coronary artery disease. Eur Heart J 2006;27:817-23. 12 Okazaki K, Sadove MS, Kim SI, et al. Ryodoraku therapy for migraine headache. Am J Chin Med (Gard City N Y) 1975;3:61-70. 13 Lin CC, Liu CS, Lai MM, et al. Metabolic syndrome in a Taiwanese metropolitan adult population. BMC Public Health 2007;7:239. 14 Department of Health. Definition and treatment of obesity in adults. Available at http://www.doh.gov.tw/ CHT2006/DM/DM2_p01.aspx?class_ no=25&now_fod_list_no=3942&level_ no=2&doc_no=32. Accessed May 25, 2008. (in Chinese).
15 Lim SC, Tai ES, Tan BY, et al. Cardiovascular risk profile in individuals with borderline glycemia: the effect of the 1997 American Diabetes Association diagnostic criteria and the 1998 World Health Organization Provisional Report. Diabetes Care 2000;23:278-82. 16 Li L, Wang HM, Shen Y. Chinese SF-36 Health Survey: translation, cultural adaptation, validation, and normalization. J Epidemiol Community Health 2003;57:259-63. 17 Chang Y, Liu YP, Liu CF. The effect on serotonin and MDA levels in depressed patients with insomnia when farinfrared rays are applied to acupoints. Am J Chin Med 2009;37:837-42.
Citylife_A5.pdf
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18 Lam DD, Heisler LK. Serotonin and energy balance: molecular mechanisms and implications for type 2 diabetes. Expert Rev Mol Med 2007;9:1-24. 19 Duke SA, Colagiuri S, Colagiuri R. Individual patient education for people with type 2 diabetes mellitus. Cochrane Database Syst Rev 2009;21:CD005268. 20 Chen HS, Wu TE, Jap TS, et al. Effects of health education on glycemic control during holiday time in patients with type 2 diabetes mellitus. Am J Manag Care 2008;14:45-51. 21 Rubin RR, Peyrot M. Quality of life and diabetes. Diabetes Metab Res Rev 1999;15:205-18.
22 Tuomilehto J, Lindstrรถm J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001;344:1343-50. 23 Hu FB, Manson JE, Stampfer MJ, et al. Diet, lifestyle and the risk of type 2 diabetes mellitus in women. N Engl J Med 2001;345:790-7. 24 Edelman SV. Type II diabetes mellitus. Adv Intern Med 1998;43:449-500 25 Beever R. The effects of repeated thermal therapy on quality of life in patients with type II diabetes mellitus. J Altern Complement Med 2010;16:677-81.