How to use Chinese herbal medicine to prevent and treat restenosis after coronary stent implantation

Tiejun Tang

Coronary in-stent is the most common treatment in coronary heart disease (CHD).  It can improve myocardial ischemiaand release angina immediately. About 800,000 Americans receive stents each year. Although coronary artery stent is very effective on CHD, but the ischaemic heart disease still is the world’s biggest killer according to WHO’s report (2012). Statistical data showed 73,000 people died from CHD every year in the UK. (200 died per day). The biggest problem in the treatment of CHD is restenosis or re-narrowing of the coronary artery. 

Restenosis usually occurs 6-9 months after stent placement, as a result of neointimal hyperplasia due to the proliferation and migration of vascular smooth muscle cells. A recent research report showed that from 2006 to 2014, 65,443 patients underwent percutaneous coronary intervention (PCI) and 6,872 patients (10.5%) with 8,921 lesions were treated for in-stent restenosis (ISR). The proportion of patients undergoing revascularization for restenosis increased 0.28% per year^[1].

The small scaffold stent props open the diseased artery to prevent heart attacks, but because

the body treats stents as foreign, the risk of blood clots is ever present. That is why its short term effects are good, but long term effects are not satisfactory.  Dr Aseem Malhotra said to Daily Mail: ‘There is no evidence that coronary angioplasty reduces risk of heart attack or death in patients with uncomplicated stable angina’

In traditional Chinese medicine (TCM) angina is known as Xin Tong or Xiong Bi. The common pathological mechanisms of this disease were due to heart blood stagnation, heart yang deficiency, cold stagnation or phlegm obstruction. Chinese medicine usually selects different herb formula to treat different individual cases. Some formulas have been used for thousands of years. Every prescription was modified according to the symptoms of the individual patients.

 

In China, Chinese herbal medicines are widely used for preventing restenosis after stent placement. A Meta-analysis on 52 trials (4905 patients),  the result showed at the end of at least 3 months' follow up, Chinese herb medicine could significantly reduce restenosis rate, cardiac mortality, recurrence rate of angina, acute myocardial infarction, numbers of repeat PCI, and numbers of coronary artery bypass graft^[2]. Chinese herb treatment includes extracts from mixtures of herbs, single herbs, or a compound of herb decoction.  The most commonly used single herb is Dan Shen (Salvia miltiorrhiza). More than 230 randomized controlled trials (RCTs) of Danshen dripping pillin treating angina pectoris. Among the included 109 RCTs with 11,973 participants, the efficacy of Danshen was better than isosorbide dinitrate in treating angina pectoris^[3]. Dan Shen also showed a good effect on preventing restenosis after coronary stent^[4].  Xiong Shao capsule is an herbal remedy which was composed by Chuanxiong（Ligusticum chuanxiong）and Chishao (red paeony root). Clinical study showed it can effectively prevent restenosis after PCI in combination with conventional western medical treatment.^[5]

If you have time to read all of reference below this article, you will understand coronary stent and by-pass operation are not only option in CHD treatment. TCM as an alternative option is the right choice, because it can reduce the mortality rate and save lives. 

Reference:

1. Waldo SW. Incidence, procedural management, and clinical outcomes of coronary in-stent restenosis: Insights from the National VA CART Program.Catheter Cardiovasc Interv. 2017 Jun 28. doi: 10.1002/ccd.27161. 

2. Zheng GH.Systematic Review of Chinese Herbal Medicines for Preventing in-Stent Coronary Restenosis after Percutaneous Coronary Intervention. Evid Based Complement Alternat Med. 2012;2012:253409.

3. Jia Y. How Efficacious is Danshen (Salvia miltiorrhiza) Dripping Pill in Treating Angina Pectoris? Evidence Assessment for Meta-Analysis of Randomized Controlled Trials. J Altern Complement Med. 2017 Jun 26. doi: 10.1089/acm.2017.0069

4. Fu GS. Clinical observation of compound Danshen drop pill preventing restenosis of patients with coronary heart disease after stenting operation (Part 1) China Medical Herald. 2009; 6:68–69.

5. Lu XY. Clinical study on effect of Xiong Shao capsule on restenosis after percutaneous coronary intervention. Chinese Journal of Integrated Traditional and Western Medicine. 2006;26(1):13–17.

How to treat IBS with Chinese herbal medicine and acupuncture?

Tiejun Tang 

Irritable bowel syndrome (IBS) is a common, chronic disease. IBS occurs in 10-20% of the population in the UK, but prevalence is thought to be higher than this as many people with the disorder do not seek medical advice.^[1] If you often have unexplained diarrhoea and /or constipation accompanied by abdominal pain and stressed mood,  you may suffer from IBS, and should contact your GP. IBS diagnosis can be confirmed by exclusion using stools test, blood test and colonoscopy results.

Western medicine usually focuses on the symptoms for IBS patients. Antispasmodics can relieve abdominal pain and cramping and antimotility agents can relieve diarrhoea. Laxatives can relieve constipation and anti-depressants can relieve stressed moods. All of these medicines only can release symptoms temporarily. It is difficult to cure the IBS from the root. Many patients have to live with IBS for many years.

According to the philosophy of traditional Chinese medicine depression and stressed mood was due to liver qi stagnation, and diarrhoea and constipation were due to spleen deficiency. If the diarrhoea were triggered by emotional stimulation, the Chinese medicine diagnosis should be “liver restrict spleen” or “disharmonious between liver and spleen”. The treatment principle for this condition must be dispersing the depressed liver and benefiting the spleen. The basic classic formula is Sini San, a prescription which has more than 1700 years history for diarrhoea treatment. Alternatively we also can use modified Senling Baizhu San and Tongxie YaoFang according to patient’s symptoms for individual cases.

In a pharmacological research to investigate the effects of Sini San and fluoxetine on the levels of central and peripheral 5-HT in a rat model of depression, the result showed that after eight weeks Sini San treatment  appeared at least as effective as fluoxetine. It suggested Sini San can replace fluoxetine in the later stages of depression treatment to minimize side effects of this anti-depressant^[2].  In another  report from my ex colleague’s research team, it showed Shenling Baizhu San suppresses colitis associated colorectal cancer through inhibition of epithelial-mesenchymal transition and myeloid-derived suppressor infiltration^[3]. Baishaoyao (Paeonia lactiflora Pall) is a common ingredient of these three formulas. In in-vitro and in-vivo studies showed it has a beneficial effect of Anti-inflammatory and immunomodulation^[4]. With regard to the pathophysiology of IBS a recent report indicated that low-grade mucosal inflammation and immune activation were involved^.[5] Based on thousand years clinical experience of Chinese medicine and modern scientific research, we have enough reasons to try Chinese medicine in IBS treatment.

Acupuncture and moxibustion also have good effect on IBS if a good protocol is selected. Although there is much evidence indicating that acupuncture works well on IBS^,[6] unfortunately NICE did not recommend acupuncture in their clinical guidance. Maybe their decision based on different treatment protocols.

The advantage of TCM is to combine herbs and needles. The treatment effect of herbs and acupuncture can enhance each other. Chinese medicines tend to cure the disease from the root and not just control the symptoms.

References:

1.   Guidelines on the Irritable Bowel Syndrome: Mechanisms and Practical Management; British Society of Gastroenterology (May 2007)

2. Li Y. Effects of Sini San used alone and in combination with fluoxetine on central and peripheral 5-HT levels in a rat model of depression. J Tradit Chin Med. 2013 Oct;33(5):674-81.

3. Lin X. Shenling Baizhu San supresses colitis associated colorectal cancer through inhibition of epithelial-mesenchymal transition and myeloid-derived suppressor infiltration.BMC Complement Altern Med. 2015 Apr 22;15:126.

4. He DY. Anti-inflammatory and immunomodulatory effects of paeonia lactiflora pall, a traditional Chinese herbal medicine. Front Pharmacol. 2011 Feb 25;2:10

5.  Holtmann GJ . Pathophysiology of irritable bowel syndrome.Lancet Gastroenterol Hepatol. 2016 Oct;1(2):133-146.

6.  Xiao-Peng Ma. Acupuncture-moxibustion in treating irritable bowel syndrome: How does it work? World J Gastroenterol. 2014 May 28; 20(20): 6044–6054.

A new acupuncture technique for dance injuries

Tiejun Tang

Dance injuries are very common in professional dancers. A recent systematic review study showed the period prevalence of musculoskeletal injuries in ballet dancers is 280%. The most prevalent musculoskeletal disorders included: hamstring strain (51%), ankle tendinopathy (19%) and general lower back pain (14%)^[1].Typical treatments for dance injuries are usually physiotherapy, massage and pain killers, with some dancers trying traditional acupuncture. Although these therapies can temporarily release pain to varying degrees,the effect comes slowly and tends to be of limited duration.  Dance injuries have a considerable impact upon the lives and careers of the dancers impairing their training and performance and potentially resulting in long term chronic pain or even disablement.

As an acupuncturist I used to work in the pain clinic at Whittington hospital for many years, where we used acupuncture to help a lot of patients who suffer from a broad range of pain types. Many of the patients had been taking pain killers for a long time with limited effect.We applied acupuncture in every patient, plus cupping in some severe cases. Most of patients saw note worthy improvement after 5-10 sessions. In some cases, very significant improvement was noted.

Dance injuries may not have been common in ancient China, but injuries arising from martial arts and acrobatics training were. The ancient doctors believing that life energy (Qi) stagnation and blood stasis were the main pathological changes arising from trauma injuries, this caused pain and that acupuncture stimulated the energy flow and consequently relieved the pain. The treatment outcomes remain valid today, but we now have a new technique called Fu's SubcutaneousNeedle (FSN)^[2] which has an almost magical effect without the need to fully penetrate the skin. It is my experience that this relatively new acupuncture technique can obtain immediate pain release effects. This treatment differs from traditional acupuncture in that it applies a special patent needle to the sub-cutaneous layer, the innermost layer of skin, where there are no nerves and therefore minimal sensation of pinprick for the patient. After about 30-40 minutes about 80% of patients feel the pain much better or totally disappeared right after the treatment finish.

As well as releasing the local pain of dance injury, acupuncture also can relieve anxiety, benefit sleep and boost energy levels in dancers. A good health condition is a guarantee of good dance. Acupuncture can help you to become a great dancer!

Reference

1. Smith TO. Prevalence and profile of musculoskeletal injuries in ballet dancers: A systematic review and meta-analysis.Phys Ther Sport. 2016;19:50-6.
2. Tiejun Tang. FSN – A Magical Acupuncture for Pain Release. http://chinesemedicinesalon.blogspot.co.uk/2016/09/fsn-magical-acupuncture-for-pain-release.html

Research evidence shows cosmetic acupuncture works

Tiejun Tang

Cosmetic acupuncture has gained popularity worldwide in recent years. MailOnline published “Cosmetic acupuncture is the newest weapon in the anti-ageing war”. Many public figures have tried cosmetic acupuncture. From Kim Kardashian to many Hollywood stars they all like facial acupuncture for cosmetic purposes.Can facial acupuncture really make you look younger and keep you beautiful? Some clinical reports have shown positive results.
 

A research team from a Korea university selected 50 female participants of aged from 40 to 59 years. The participants received five treatment sessions over a three week period. All the participants were measured by the Moire topography criteria before and after facial acupuncture. The secondary outcome was a patient-oriented self-assessment scale of facial elasticity. Results showed, among 50 women screened, 28 were eligible and 27 completed the five treatment sessions. A significant improvement after treatment was evident according to mean change in Moire topography criteria^[1].

Moisturising of the skin is recognised as the first anti-ageing skin care. Research from Korea use scientific methodology to explore whether acupuncture can modulate the water and oil content of the skin. The results suggest that cosmetic acupuncture increased the water and oil content of facial skin in a female participant whose water content and oil content were lower before receiving acupuncture than those of the mean values of women of the same age. Acupuncture might contribute to enhancing the appearance of the skin^[2].

To investigate the effect of the De-Qi sensationsof acupuncture stimulation, a research group from Taiwan selected fifty-two healthy medical student volunteers, acupuncture at Hegu (LI-4) acupoint as they were resting. During a test that lasted 30 minutes, their skin blood flow was measured.The results indicated that acupuncture increased blood flow when the De-Qi sensation occurred^[3].Blood delivers oxygen and nutrients to the cells while it removes waste products. Good circulation is important not only for working muscles, but for healthy skin. Facial acupuncture can significant improve facial skin blood circulation. That is why it can have anti aging and cosmetic effects. 

Cosmetic acupuncture doesn’t mean facial acupuncture, because not only points on the face are selected, but also use some distant points. These distant points vary in different cases and different stages of the same case. The acupoints selection must match the TCM diagnosis of each case. Distant points can regulate the Qi and blood circulation of the whole body and regulate the functions of internal organs. Sometimes they are more important than local facial points. A few minutesof facial massage after acupuncture can enhance the effect of the treatment.

The first cosmetic acupuncture recording can be traced back to Western Jin Dynasty. Acupuncture grandmaster Huangfu Mi (AD215-282) mentioned puncture Quchi (LI11) can treat facial dryness in his book “A-B Classic of Acupuncture and Moxibustion”. A lot of written records about cosmetic acupuncture can be found in TCM classics.

On the basis of historical ancient Chinese acupuncture points selection in combination with the use of hi-technology facial dermatological needles it has become the most effective and safe new cosmetic technique.

References

1. Yun Y. Effect of facial cosmetic acupuncture on facial elasticity: an open-label, single-arm pilot study.Evid Based Complement Alternat Med. 2013;424313. doi: 10.1155/2013/424313. Epub 2013 Jul 28.
2. Nozomi Donoyama. Cosmetic acupuncture to enhance facial skin appearance: a preliminary studyAcupunct Med 2012;30:152-153 
3. Kuo TC . The soreness and numbness effect of acupuncture on skin blood flow. Am J Chin Med. 2004;32(1):117-29.

Cosmetic Acupuncture

How to treat Vitamin D deficiency with Chinese medicine?

Tiejun Tang 

Many of my patients report of being clinically diagnosed with vitamin D deficiency. Many of which have dismissed this as a “minor” condition, due to symptoms being mild or non-life threatening. However, I believe we should pay due attention to the early onset of signs and symptoms because if left untreated it can lead to chronic health issues.

Below are some questions I have been asked by my clients and my answers as follows:

 Q: Do I have vitamin D deficiency?      

 A: If you often feel lethargic, tired, experience non specific aches and pains, with a general sense of being unwell, this could be a sign of vitamin D deficiency. 

In addition, if you are in a job, i.e. office worker, with minimal exposure to natural sunlight; or that your current health condition / constitution (i.e. women of menopause age or above) you maybe at increased risk of developing VD. It is advised that you book an appointment with your General practitioner to have your blood VD level checked.

Statistic shows that 90% of the obese population, in the UK, has VD deficiency ^[1]. The South Asian community in the UK have a higher prevalence of VD deficiency compared to the White English population, due to different lifestyle^[2].

Q: Do I need any treatment?

A: The early stage of VD deficiency can present with non to mild symptoms, which can be easily overlooked as a “minor” problem.

The main function of VD is regulating the calcium and phosphorus metabolism and  plays a key role in osteoporosis in adults and rickets in children. A recent study from Cambridge, found that VD is a custodian of cell signaling stability in health and disease. It contributes to many human diseases, such as Alzheimer's disease (AD), Parkinson's disease (PD), multiple sclerosis (MS), hypertension and cardiovascular diseases ^[3].  If you have VD deficiency, this can increase your risk of developing serious illness (listed above).If you are experiencing mild signs and symptoms, it is advised that you check your VD level and if necessary to start early treatment, in order to re-balance your calcium and phosphate levels.

Q: How to treat VD insufficiency？

A: Vitamin D deficiency in Western medicine is usually treated in the form of artificially manufactured oral supplements (solutions or capsules), which are available for purchase over the counter. Unfortunately, the general public often self administer vitamin D, without knowing the recommended intake and this can result in high to toxic 25-hydroxyvitamin D levels ^[4]. A randomised, placebo controlled clinical trial report showed calcium supplementation in healthy postmenopausal women is associated with upward trends in cardiovascular event rates. This is potentially detrimental to health and should be carefully weighed against the likely benefits of calcium on bone health^[5]. It is in my opinion, based upon my extensive clinical experience, the safest treatment for VD deficiency, should be naturally derived e.g. regulate diet, lifestyle and the use of natural herbal medicine and acupuncture.

 Q: What is Chinese medicine’s opinion on VD deficiency?

 A: According to Traditional Chinese Medicine theory, the Kidneys dominate bone, growth and regeneration. Bone health (strength and density) depends on the quality of Kidney Essence. Vitamin D is first absorbed via the skin (from sunlight) and transported and metabolized in the Liver. However, hyrdroxylation (the first step of degradation of organic compounds) in the liver is only capable of producing 25 hydro vitamin D3, which is almost inactive. Compared with the kidneys ability to activate 25-hydroxycholecalcifero into 1,25-dihydroxycholecalciferol, it is endogenous vitamin D3 (1000x higher than its almost inactive form in the liver).The aetiology behind vitamin D deficiency is due to Kidney deficiency, from a TCM perspective.

For further reading on “Kidney dominate bone theory,” please reference my previous publication..   

 Q: How to treat VD deficiency in Chinese medicine?

 A: Any kidney tonification method can benefit VD. These include the use of acupuncture treatment, focusing on the following key kidney meridian points, eg. KI 3, KI 6, BL23, DU4, applying reinforce manipulation. Kidney tonifying herbs can be selected according to the principle of syndrome differentiation diagnosis. For example, for Kidney Yin deficiency, use modified Liuwei Dihuang Wan. For Kidney Yang disharmony, use modified Jingui Shenqi Wan.

To conclude, Chinese medicine has a ‘two way regulation effect.’ The use of Chinese herbal medicine and acupuncture can effectively balance the kidney yin/yang, which governs and stimulates the body's natural production of vitamin D and calcium. The use of artificially manufactured Vitamin D and calcium supplements can, therefore, be avoided, preventing VD toxicity.

Kidney tonifying herbs contain active ingredients and compounds used for maintaining health and preventing premature aging for millennia. In ancient China, from Emperors to ordinary civilians, regardless of social rank, everybody enjoyed reaping the benefits of consuming kidney tonifying pills and decoctions.

Reference:

1. Grace C. High prevalence of vitamin D insufficiency in a United Kingdom urban morbidly obese population: implications for testing and treatment.  SurgObesRelat Dis. 2014;10(2):355-60.

2. Kift R. Lifestyle factors including less cutaneous sun exposure contribute to starkly lower vitamin D levels in U.K. South Asians compared with the white population. Br J Dermatol. 2013;169(6):1272-8.

3. Berridge MJ^. Vitamin D: a custodian of cell signalling stability in health and disease. BiochemSoc Trans. 201; 43(3):349-58.

4.   Shea R. ANNALS EXPRESS: Self-administration of Vitamin D supplements in the general public can result in high to toxic 25-hydroxyvitamin D levels. Ann ClinBiochem. 2016; 15.

5. Mark J Bolland. Vascular events in healthy older women receiving calcium supplementation: randomised controlled trial.BMJ. 2008; 336(7638): 262–266.

FSN – A Magical Acupuncture for Pain Release

Tiejun Tang

FSN is an abbreviation of Fu's Subcutaneous Needle. It is a relatively new acupuncture technique invented by Dr.Zhonghua Fu in 1996. In the past 20 years this new technique has had a rapid development in China and is gradually getting more and more popular around the world.  

Originating from Traditional Chinese Medicine (TCM), FSN does not follow the rules and principles of TCM, and the chosen insertion points do not coincide with traditional acupuncture points. Although both needles are manipulated and act on soft connective tissue, FSN involves the insertion of a special patent needle horizontally in and around the affected area, rather than perpendicularly in way of meridians.

Although FSN’s clinical indications include the treatment of many diseases and their symptoms, the treatment of pain related diseases are most effective in my practice. It has shown much better effect compared to ordinary acupuncture. In acute conditions, FSN usually can release the pain immediately after the first session, whilst in chronic conditions it also showed a significant improvement after a few sessions. I have found that many pain cases which failed in ordinary acupuncture could be relieved by FSN. The reasons for the pain could be due to different diagnosis including: sciatica, lumbar muscle over strain, tennis elbow, golf elbow, cervical spondylosis, carpal tunnel syndrome, frozen shoulder, fibromyalgia, migraine, stomachache and dysmenorrhea.

FSN is an innovation for the treatment of myofascial pain and trigger points based on the research and clinical findings of Dr. D. Simons and Dr. Janet G. Travell. The effects that FSN have on the body are by means of mechanotransduction as the swinging of the needle triggers a response on the connective tissue, specifically the collagen fibres, by stimulating signal transduction and gene expression in fibroblasts of the subcutaneous tissue.^[1] A drawing or magnetic effect on connective tissue has been observed upon needle manipulation as the contraction and shape changes of fibroblasts cause pulling of collagen fibres and secondary alignment of fibroblasts and collagen fibres.^[2] During manipulation of the needle, collagen fibres would wind and tighten around the needle shaft,and dispersing of nociceptive substances and PH balance has also been observed in skeletal muscles^[3] . The mechanisms of FSN still need further investigation.

The inventor of FSN Mr. Zhonghua Fu is a long term friend and colleague of mine. We used to work in the same University hospital 20 years ago. He was a very clever and diligent young man when I met him and he has dedicated himself to the invention and developmentof FSN since then.

I had serious concerns when I first encountered FSN, even doubting its effect, because it is so different from traditional acupuncture. In the past 20 years Zhonghua gradually changed my opinion on FSN by his excellent work. After I applied FSN on my patients, the magical results convinced me of its effectiveness. The use of FSN gives greater confidence that successful pain mitigation will be achieved.

Reference :

1. Langevin, H.M. "Subcutaneous tissue fibroblasts cytoskeletal remodeling induced by acupuncture: evidence for a mechanotransduction-based mechanism". J Cell Physiol 2006; (3) 207
2. Langevin, H.M..  "Mechanical signalling through connective tissue: A mechanism for the therapeutic effect of acupuncture". 2001; FASEB J (1) 15.
3.  Anderson, G.B.  "Epidemiological features of chronic low back pain". 1999; The Lancet (1) 354

Why NICE is wrong?

Tiejun Tang

On 24 March, the National Institute for Health and Clinical Excellence (NICE) released a draft of its updated guideline. Acupuncture, recommended in the previous version was no longer being recommended for the treatment of non-specific low back pain and sciatica.

Acupuncturist across the UK have expressed serious concerns regarding the correctness of the findings expressed in this revised guideline, and formal responses have been made by primary stakeholders such as ATCM and BAcC. Research evidence, clinical case records and statistical analysis have all been collated and provided to NICE, electronically, in hard copy, and verbally at the NICE Public Board Meeting on 18^th May, by representatives of the above professional bodies

Why NICE is wrong in this case?    

Firstly, measures applied to the assessment of effectiveness of a pain killer are not appropriate for the assessment of a therapy such as acupuncture.

Pain killer is a fixed production, each tablet has the exactly same chemical component, the same doses, of course it will produce the same effect on human whom suffer from the same disease. Acupuncture is not a production, it is a therapy. Although all acupuncture treatment looks similar, practitioners just simply insert needles into skin, but the acupoints selection is different, the depth, angles and manipulation are much different. Acupuncture is a therapy which depends on the technique and knowledge of individual practitioner. The effects of acupuncture are varied. How can we evaluate acupuncture effect just based on few clinical trial reports?

The comparison of a pharmaceutical intervention against a placebo can give a representative and absolute analysis of the effectiveness of that pharmaceutical, but the efficacy of a therapy cannot be confirmed in such a manner, as the therapeutic results are entirely dependent on the case by case treatment administered by the practitioner. The so called placebo or ‘sham’ treatment is effectively an attempt at consistent malpractice on the part of the practitioner. Appendectomy is recommended by NICE for acute appendicitis treatment, but if the operator is a physician or an acupuncturist nobody will recommend this operation.

Secondly, side effects should be taken in to account when assessing the effectiveness of a treatment.

Pain killers usually have very good effect after taken or injection. But its side effect shouldn’t be ignored. In clinical we often found some pain killers released joint pain or headache but it cause stomachache or liver function damage. From paracetamol to tramadol and morphine, their side effect is proportional to their function. Better effect always along with stronger side effects. Long term use pain killer will lead another problem – addiction. Acupuncture can reduce the doses of pain killers and even can replace the pain killer that is why it was widely accepted by patients all over the world. If NICE stop recommend acupuncture for treat low back pain, more patient will suffer from the side effects of pain killers.

Thirdly, there is the cost dimension.

The cost of direct health care for back pain in the UK in 1998 was estimated to be £1,632 million^[1]. The management of chronic back pain amounting to 4.6 million appointments per year or 793 full time GPs at a cost of £69 million^[2]. This is on the basis of the current shared workload between General Practitioners and Acupuncturists. If NICE stop recommend acupuncture in low back pain treatment this number will be definitely higher in the future.

NCEI had made a lot right direction to the public health in the past 17 years, but this time I have to say they are completely wrong. They should reconsider their conclusions in respect of acupuncture for low back pain and sciatica. Otherwise it will mislead public to the wrong direction of their treatment.

Reference

1.      Maniadakis, N. The economic burden of back pain in the UK. Pain. 2000; 84(1): 95–103.

2.      Belsey, J. Primary care workload in the management of chronic pain. A retrospective cohort study using a GP database to identify resource implications for UK primary care. Journal of Medical Economics.2002; 5, 39-50.