Dr. John Amaro, a columnist for Dynamic Chiropractic and a chiropractor/acupuncturist, and David Molony, LAc, paired off in a "point-counterpoint" in the March issue of Acupuncture Today (www.acupuncturetoday.com/archives2001/mar/03point.html). I am proud to state that I am a graduate of Dr. Amaro's acupuncture course. I also completed three additional courses in acupuncture in the 1980s while in chiropractic school. However, I intend to look at the issues to be addressed in this two-part series primarily from my perspective as a lawyer.
I will first look briefly at the gist of the respective positions of Dr. Amaro and Mr. Molony as presented in the Acupuncture Today, and then add a perspective based upon neurology and functional medicine. Mr. Molony comes at the issue from the perspective of a "traditional Chinese medicine" (TCM) practitioner. Dr. Amaro wrote from his extensive background in Chinese acupuncture, and other forms of oriental acupuncture. I will add a German perspective.
Patient Welfare
Mr. Molony has declared war on the medical and chiropractic communities by stating that when it comes to acupuncture, these groups, and especially chiropractors, are "hobbyists." As a lawyer, I am inclined to fire back when somebody makes such a remark. However, first let's see if the rest of the acupuncturists join the battle started by Mr. Molony. I will, for now, assume that most participants on both sides will be more inclined to open dialog. Or, more importantly, that all parties will be guided by the evidence.
Mr. Molony claimed to be defending the patient's welfare when he made the "hobbyist" remark. His position may be simply summarized: Acupuncture, as practiced by the medical and chiropractic communities, is not traditional Chinese medicine (TCM). That, in a general sense, is true. Three questions arise: Is there more to the use of needles (acupuncture, hypodermic) than is addressed in TCM? Who is, or should be, authorized by law to practice within this potentially alternative (broader) frame of reference? How is the patient's best interest to be served?
I will return to these questions. Traditional Chinese medicine is, in part, based upon a metaphysical position that has been stated, in part, as: "At the basis of all is qi: all the other vital substances are but manifestations of qi in varying degrees of materiality, ranging from the completely material, such as body fluids, to the totally immaterial, such as the mind (shen)." It is also an empirically developed system. Personally, and as an attorney, I defend the TCM practitioner's right to their metaphysical and empirical position. But, other metaphysical positions must not be excluded from the marketplace of ideas or in the practice of medicine. I will not enlarge upon that point here.
A quotation from a Chinese medical text will further demonstrate the TCM system: "A fund manager from London suffers from anxiety and insomnia. He works long hours and under considerable pressure, as he is responsible for the management of several million-pound funds. A colleague at work had tried acupuncture to stop smoking and recommends him to his acupuncturist who diagnoses a case of liver-qi stagnation from the pressure at work. He inserts a few needles to remove the stagnation of liver-qi and calm the mind. After a few weekly treatments there is considerable improvement."
Can acupuncture be used effectively without this kind of diagnosis? The neurological, electronic meridian imaging and functional medicine perspective addressed below clearly demonstrate than it can. (Of course, a legitimate question arises as to whether use of the acupuncture needle pursuant to non-traditional practice should be called by some other name. I will not address that issue further here.)
The acupuncturist treating the London fund manager could have also used some traditional Chinese (single) herb to treat this man. Many options are available in TCM: herbs that "drain fire;" "cool the blood;" "drain dampness;" "regulate qi;" and "herbs that tonify the yin or the yang," etc.
TCM is a complete, comprehensive, coherent health care system, which happens to, among other things, use dry needles. These self-same needles can, however, be used effectively apart from the TCM perspective. The patient welfare for which Mr. Molony presumes to speak is best served when all available approaches to health care are fully developed, funded and made available to the patient population. Patients should have the "right" to make fully informed decisions about their own health care without any group of practitioners being granted a monopoly. All practice monopolies serve more the interest of the practitioners than the patients as argued by Dr. Amaro in his portion of the article written along with Mr. Maloney. Dr. Amaro called it the way it is: "a turf war."
Turf Wars
Dr. Amaro, in the article in Acupuncture Today, stated: "Yes, there's no question. It's all about turf. It's all about money. The real issue at hand is who owns acupuncture and who is going to be able to practice it." I would like to add some points to those made by Dr. Amaro.
First, the issue is not only acupuncture. It is also:
- Who will lead or control the "alternative medicine" (nonallopathic "primary care") parade?
- Who will dominate the musculoskeletal (personal injury, workers' compensation) market?
- Who will dominate the worldwide, multibillion-dollar sales of herbal medicines? (the pharmaceutical/academic-medicine/governmental complex)
- Who will sell seminars?
- Who will dominate the schooling for non-allopathic practitioners?
- Who will gain recognition, prestige and power?
The "patient welfare" offensive taken by Mr. Molony is a worn-out song. It did not work for the medical establishment when they tried it in the chiropractic case where the medical establishment was successfully sued for anti-trust activities against chiropractors (Wilk, et al. vs. AMA, et al.)
The prestigious CATO Institute came to the conclusion, in a 1995 article, that the medical monopoly was more about limiting competition than protecting consumers. The interest of patients is in fully informed decision-making. They should, however, know what it is they are getting when they seek health care. To repeat, some sort of "labeling" is needed.
Maybe the practitioner's degree should be a sufficient label, but maybe not. I recently looked at some courses being listed for continuing education credit for California acupuncturists: "Hypertension and TCM"; "Breast Cancer and TCM"; "Gout and TCM"; "Kidney Stone and TCM"; "Acupuncture Orthopedics"; and Peripheral Nervous and Thoracolumbar Anatomy." Do acupuncture students learn how to properly diagnose any of these conditions? No! Hypertension, cancer, gout, etc., are not diagnostic categories within TCM.
My position as a lawyer is simple: I am opposed to the medical establishment discrimination against chiropractors, acupuncturists, naturopaths, and others. If acupuncturists discriminate against chiropractors, I am on the side of the chiropractors, or visa versa. I have made my point, but I will stretch it: If "mixer" chiropractors choose to discriminate against "straights," I am on the side of the straights; and if the straights discriminate, as they have in California, I am on the side of the mixers. Why? The patient's right to choose (and have choices available) is always foremost.
Of course, patients cannot choose unless there are some biologically plausible options. There are!
Enlarging the View
Space limitations here only permit a very limited review of some of the developments of nontraditional acupuncture, so I will focus on those developments that most closely track with the history, principles and theories of chiropractic.
Neurological Models
The implication of the above picture of segmental acupuncture for chiropractors is obvious. Chiropractors have been saying exactly what is depicted in this picture for over 100 years: There is an interconnection between neural dysfunction and disease that is mediated, in part, by the muscular and vertebral components. Chiropractors would add the inflammatory and connective tissue (see regulatory matrix below) components to this picture.
In treating the factors depicted in the segmental acupuncture picture, the practitioner "needles" the neuro-anatomically related structures. According to the text, the points to be needled "are situated in the dermatome, myotome or sclerotome of the disturbed segment." That is, rather, than at traditional acupuncture points. Obviously, this is a concept with which chiropractors can readily relate.
Dr. Gunn is an MD acupuncturist whose primary theory is that contracted (paraspinal and other) muscles impinge on nerves as they exit the IVF (or elsewhere), causing radicular pain. It is her position that spinal manipulation will not always resolve the problems with the paraspinal muscle contractures. The contractures will, however, often release with dry needling. She would choose to use acupuncture needles. One could also use a dry hypodermic needle. But, the hypodermic treatment would be needlessly painful to the patient. Dr. Gunn states that the purpose of the needling "is not to produce analgesia, but to desensitize supersensitive structures and restore motion and function." You cannot get more "chiropractic" than that.
A subject of great importance to me as a P.I. attorney is pain. The medical literature is clear; until the late 1980s and early 1990s, almost all of our knowledge of pain came from studies of cutaneous pain. Chiropractors have been saying for over 100 years that deep tissue pain is different. It is!
Cutaneous pain, along with mechanoreceptor discharge, is transmitted to the dorsal horn of the spinal cord over primarily A
(fast, myelinated) fibers, whereas deep tissue pain is transmitted over primarily C (slow, unmyelinated) fibers. Most chronic, musculoskeletal, pain involves C-fiber input. When a chiropractor performs an "adjustment," a huge barrage of sensory, mechanoreceptor, information is sent into the dorsal horn of the spinal cord over A
fibers. This A
input blocks the C-fiber input, breaking the pain cycle. (The "gate" mechanism.)
"Needling," through acupuncture, hypodermic, cactus - whatever - also stimulates the A
fibers with a similar result to that just described for the chiropractic adjustment. The Medical Acupuncture text is the clearest delineation of the dorsal horn, mid-brain, hypothalamic and anterior cortical aspects of these neurological phenomena that I have personally seen. If the chiropractic adjustment and the needling involve the same mechanisms, why should the chiropractor not be using both approaches to patient care? Obviously, he or she should be, and should also be permitted by law to do so. Again, this is not TCM, but extremely important for the patient population. Let's go further still and look at certain Japanese (as presented by Dr. Amaro in his courses) and German developments.
"Electronic Meridian Imaging" and/or Functional Medicine Models
In "Point-Counterpoint," Dr. Amaro refers to "electronic meridian imaging" and ryodaraku. I have been privileged to study under Dr. Amaro and will enlarge slightly on this subject. All living matter gives off a resonance signal (electronic) that can be measured at certain (perhaps all) acupuncture points. One can, therefore, use this phenomenon to detect imbalance within the "meridian system." Dr. Amaro teaches how to do this and howto use needles and the five-element theory from TCM to bring the system back into balance. Dr. Amaro teaches an advanced form of five-element theory that is derived, in part, from the Japanese acupuncture tradition. TCM practitioners can, therefore, hardly be said to have a monopoly over this type of practice.
The preceding is a model developed by German naturopaths based, primarily, upon the work of A. Pischinger,MD, from the University of Vienna Medical School. This type of practice can be, and often is, termed functional medicine. Notice the arrows showing this system as one complex - they point in both directions between the depicted components. Evidence is accumulating that the meridian system is, at least in part, a component of this matrix. Or is the term "meridian" just another name for the whole complex? I will leave that to others, and to future scientific developments, to resolve.
Using similar principles to those taught by Dr. Amaro, the Germans have developed electronic technologies with which to measure changes in the regulatory matrix and in its functional capacity. Needling (acupuncture or otherwise) will cause measurable changes. Equally important, so will homeopathic, allopathic or herbal medicines. This opens new vistas for scientific study and an advanced form of preventive and early intervention medicine. These matters demand to be explored on equal footing with allopathic concepts and those from TCM.
The Germans have not focused on the needling aspects taught by Dr. Amaro, but more on using the "imaging" technology to assess the body's response to homeopathic, herbal and allopathic medicines. They have also developed electronic technologies for treating this regulatory matrix. Each of these approaches has great merit and has its place in the medical market place. I am not, however, suggesting we should turn our back on the 3,000+ years of medical history called TCM. That too, has been clinically shown to have great merit.
In the second part of this article, I will continue to trace the relationship between the history of chiropractors in this country and the theories referenced here. The road ahead for alternative practitioners is clouded by selfish interests and struggles for dominance. It is time to focus on the rights of patients to choose, and the practitioners' rights to enable patients to make meaningful decisions. As a lawyer for over 30 years, I do not expect that to occur without a fight. As always, we'll fight if we must, but first, all licensed health care practitioners should attempt to find common ground and be called upon to act with restraint and mutual respect for all biologically plausible traditions, theories and practices.
References
- "At the basis of all is Qi." G. Maciocia. The Foundations of Chinese Medicine, Churchill Livingstone, 1989, p. 35.
- "... other metaphysical positions must not be excluded..." W. Harman & J. Clark, Ed., New Metaphysical Foundations of Modern Science, Institute of Noetic Sciences, 1994.
- "A quotation from a Chinese medical text will further demonstrate the TCM system." J. Filshie & A. White, Medical Acupuncture, a Western Scientific Approach, Churchill Livingstone, 1998.
- CATO Institute: Policy Analysis, The Medical Monopoly, Protecting Consumers or Limiting Competition? Dec. 15, 1995, #246.
- "Segmental Acupuncture" picture - See Reference # 3, p. 118.
- "Aim for transverse process." C. Chan Gunn, Treatment of Chronic Pain, Intramuscular Stimulation for Myofascial Pain of Radiculopathic Origin, Churchill Livingstone, 1997, p. 57.
- "Matrix and Matrix Regulation" picture. H. Heine, Ed., Matrix and Matrix Regulation, Basis for a Holistic Theory in Medicine, Haug Intl. 1991 (English Ed.), p. 21.
David Prescott,DC,MA,JD,FIAMA
Silverado, California