Friday, 19 February 2016

Chinese medicine / Acupuncture and Ashtanga: A study

Before coming to Japan I closed up the house in the UK, sold 700 odd books (kept only around twenty to ship/bring over), boxing them up and shipping them all off (straining my back in the process) and went to Crete for three months while waiting for my Japanese visa to come through.
I practiced Ashtanga each morning at Kristina Karitinou Rethymno Shala and attended Manju's Teacher training for a second year running. I say I practiced Ashtanga each morning but there were some morning's when my back was playing up so much (from packing up all those books) that I stayed in my room and practiced a lighter Vinyasa Krama sequence instead. One morning sticks out in my memory actually. I had begun my Surya namaskaras but it was clear my back wasn't up to it so I, discreetly I thought, rolled up my mat and headed to the back of the shala to slip out and go and do my lighter practice at home. Kristina Asked me where I was going, I explained and she said, "This is Chikitsa, Healing, go back and do your krama" and so I did, practicing my Vinyasa Krama in that room full of hot sweaty Ashtangi's.

One of these Hot Sweaty Ashtangi's ( intermediate series I  believe)was a student of Kristina's Dr. Ioannis P. Dimitriou, A regular doctor as well as a  Chinese medicine practitioner. Kristina sent me along to him to get some treatment. I'd never been for acupuncture before, I'm a skeptical guy, skeptical concerning all alternative medicines and therapies (and that includes the benefits claimed for yoga), veins and arteries I can see, meridians?

I remember mentioning to Dr Dimitriou that my back was particularly painful when putting my leg behind my head in Eka pada Sirsasana, the obvious response would be to say well DON'T do it then. Dr Dimitriou gave me treatment put some pins in my ear and then mentioned if I felt any pain in my back while my leg was behind my head just worry the little pin under the plaster on my ear until the pain passed. I have to say it worked. I felt less pain in my back after treatment and if I did feel a twinge during practice the worrying the pin in the ear trick seemed to work.



I'm still skeptical, perhaps it's all psychological but have to say that in my own personal experience I received relief from the pain i was experiencing. Thank you again Dr Dimitriou.

Kristina recently sent me this paper by  Dr.Dimitriou, a study of Acupuncture and Ashtanga, it's a small study group but interesting , an area to be explored further perhaps in a larger study. the full paper can be found on my google docs page, here I've included the Abstract, Discussion and conclusion


*

A Study on the Relationship Between Health Issues and Advanced Ashtanga Yoga Practice. Report on the Effectiveness of a Combined “Fire Needling” and “Distant Needling” Acupuncture Treatment Method for Pain in Ashtanga Yoga Practitioners
Ioannis P. Dimitriou MD MSc. PhD  

Abstract

Background
Yoga is frequently recommended by healthcare practitioners for the improvement of physical and mental, or emotional wellbeing. However there is limited published data on potential risks. Furthermore, there is an absence of published data on the treatment of musculoskeletal problems with the use of protocols that include “fire needling” and “distant needling” acupuncture.

Aim
Investigate the correlation between knee, cervical and hamstring pain, sleep problems and advanced Ashtanga Yoga practice. Report the effectiveness of Traditional Chinese Medicine (TCM) acupuncture treatment protocols that includes both fire needling and distal needling methods.

Method
A group of Advanced Yoga practitioners (N=28) was clinically examined, those with knee, cervical, and hamstring pain (N=23) were treated by “fire needling” and “distal needling”.  The control group (N=28) was recruited by email and responded to a survey or interview. The Mc Nemar test was used for data analysis. 

Results
Hamstring pain: yoga vs control p-value=0.070; knee pain: yoga vs control p-value=0.388; cervical pain yoga vs control p-value=0.791; Sleep problems: yoga vs control p-value=0.180

Conclusions 
There is no association between cervical, knee, hamstring pain and sleep problems with AY practice in the population of interest. However, in the population with hamstring pain vs control group with p-value=0.070 it is possible that with a larger sample size there would be a statistically significant correlation between the two variables of interest. The combined treatment method, brought positive results short term, however, it is important to investigate long-term outcomes.

Keywords: Traditional Chinese Medicine, Ashtanga Yoga, Acupuncture, Pain 
Table of Contents


Background
Yoga is an ancient Hindu philosophy that literally means "union". This union is described as the union of the self with the universal spirit. This philosophy includes systems of movement to attain physical, mental control and well-being and amongst its suggested benefits is that it can lead to an improved quality of life (Leslie Kaminoff, 2007). Yoga has different systems of practice one of which is Ashtanga Yoga (AY). The roots of AY are in Yoga Korunta, a manuscript discovered in the 1930’s by Sri Tirumalai Krishnamacharya and his disciple K. Pattabhi Jois, at one of Calcutta’s university libraries. This manuscript dates back to 500 to 1,500 AD (Larry Schultz, 2000)
Ashtanga practitioners practice a series of postures (asanas). These can be simple to do or very demanding physically. Postures are formed through continuous transitional movement and are synchronized with the breath. At the same time, there is a focus on the contraction (bandha) of specific muscle groups to direct energy; this also protects practitioners from injury by redistributing mechanical stress.  The main physical benefits of AY are an increased range of movement of most of the joints, increased flexibility of the soft tissues of the musculoskeletal system and increased muscle strength. Though these benefits can be achieved through other forms of physical exercise such as gymnastics, there is a key element that distinguishes yoga practice. This is the intentional integration of breath, posture, movement and the basic principle that practice should promote a healthy mind-body. Yoga theory stipulates that the integration of all of the above is fundamental to wellbeing as it seeks to benefit holistically, by assisting the development of mind, body and spirit. There is significant support (Lee M, Moon W, Kim J, 2014) with concerns to the benefits of yoga for both physical and other ailments. However, researchers (Uebelacker LA, Weinstock LM, Kraines MA, 2014) report that the most common side effect of yoga is physical injury and pain. For this reason, it is important to establish potential risks, in order for general practitioners to give sound advice to their patients with concerns to the practice of AY, as well as raise practitioner and tutor awareness in ensuring safe practice.
This study took place in Crete, Greece, during a six day AY workshop designed for AY teachers and advanced students. The purpose of the workshop was for practitioners to improve familiar poses and to learn new ones. The organizers facilitated this process with hands on adjustments, passive movements of specific anatomical regions, and by reminding practitioners to breathe consciously and to stay focused in their practice. 

Twenty eight practitioners were examined. Clinical examination by means of conventional and Chinese medicine (CM) revealed an increased ratio of practitioners suffering from knee pain, cervical pain and hamstring regional pain in comparison to the control group. It identified two pain categories; one group reported pain present only when in particular AY postures not common to daily life and extreme joint positions. For example, one of the practitioners complained of right side lower back pain that occurred only when in a posture that involves placing both lower limbs behind the head. Another example of this category involved knee pain that was not present during daily activities such as walking, or going up and down stairs, but only during yoga postures such as in lotus, where the knee is in flexion and passive internal rotation. The second pain category involves the presence of pain and discomfort throughout most of the day, during ordinary physical movement or while resting. For example this group of practitioners reported that thigh, hamstring pain was often present when walking and during other daily life movements, this was aggravated when the hamstrings were stretched during AY practice. Cervical pain is also included in this category; felt throughout most of the day, it was either partially or fully alleviated during AY practice. 

The respective correlation between alleviation, or aggravation of hamstring and cervical pain and the practice of AY is mainly related to the cause of the pain and the postures practiced. Studies on exercise such as intense isometric, aerobic, or dynamic resistance report that they can reduce pain perception in experimentally induced pain in healthy individuals, with effects ranging from small to large depending on pain induction method and exercise protocol (Kelly M. Naugle, Roger B. Fillingim, Joseph L. Riley,2012). The same studies report that exercise has a reductive perception effect on chronic pain, even though the effect varies between aerobic and isometric exercise. AY is a combination of isometric and isotonic exercise.  Studies report that yoga reduces pain such as lower back pain, migraine, knee osteoarthritis etc.( Lee M, Moon W, Kim J, 2014). The above support the experience of AY practitioners which says that during AY there is a amelioration of cervical pain and an initial amelioration hamstring pain, which then decreases if the hamstrings are stretched.

Conventional medicine defines pain as the sensation resulting from a stimulus which is intense enough to threaten injury. The stimulus can be thermal, chemical, mechanical or a combination of these. This stimulus excites nociceptors, which transmit the pain signal to the central nervous system (CNS) through either myelinated Aδ fibers or unmyelinated C fibers. Myelinated Aδ fibers are responsible for perception of fast pain which is well localized and unmyelinated C fibers for slow pain which is not easily defined and localized. Studies support that Aδ and C fibers play an important role in acupuncture pain relief (Christopher M. Norris, 2001), when it isn’t due to healing; according to these, acupuncture stimuli trigger mechanoreceptors, which transmit their signal through Aδ fibers to the CNS where opioids are released that inhibit the transmission of C fibers. In addition acupuncture stimuli travels through Aα fibers to the cerebral cortex and facilitates the release of endorphins which will cause pain reduction through opioid release into the dorsal horn of the spinal cord (Christopher M. Norris, 2001).  

Pain in CM is a symptom that may be categorized into an excess and deficient type. Excess pain (e.g. sharp, acute or burning) can be caused due to obstruction, stagnation, climatic influence (e.g. cold), or through the influence of a pathogen which will lead to interruption of the flow of the qi, Blood or both.  Deficient pain (such as dull chronic ache) may be due to qi, Blood, Fluids, yin or yang deficiency that may also lead to stagnation and so forth. Commonly pain in the musculoskeletal system is related to injury but could also be related to emotional, pathogenic invasion, any kind of deficiency and organic dysfunction. From the Chinese medical examination of the practitioners, the most common reason that practitioners of AY suffered from pain in the cervical, knee or hamstring area, was injury that led to Blood and qi stagnation. Although, in CM, the reason for the particular weakness that lead to injuries in the particular region in the individual is also examined, such as constitutional, or lifestyle patterns (e.g. anatomical structure, impatience/overachieving tendencies leading to overexertion). CM reports that exercise such as AY moves Blood and qi, thus movement results in pain reduction, especially in cases where pain is due to stagnation and obstruction as the oxygen and nutrient stagnated area becomes nourished by xue Blood) and qi.

Acupuncture therapy has different application methods. Fire needling is one of them. During this procedure a purpose designed needle is warmed by an ignited cotton ball and rapidly inserted into soft tissue (Liu En Ming, 2011). Distal needling is the method in which acupuncture points are selected based on CM diagnosis and used distally to the site of pathology. For example if there is pain in the wrist joint, meridians and points may be used that are located at the ankle joint.  This is based either on balancing regions and meridian pathway relationships, as well as an understanding of the cause of weakness and type of condition and which zang-fu can help adjust the movement of qi (upward, downward, free-flow etc.), or creation of qi and xue, reminding the body how to heal itself and move. Pain may be a symptom of the body’s attempt to establish balance, homeostasis when it has been affected by the aforementioned pathophysiological changes.


Aim
The aim of this paper is dual, firstly, to investigate whether there is a correlation between musculoskeletal pain, sleeping problems and the practice of AY. Secondly, to report the effectiveness of two acupuncture treatment methods, “fire needling and “distant needling” on these particular musculoskeletal issues on advanced AY practitioners. 
Currently, there is no reference that compare the effect of “fire needling” and “distant needling” on musculoskeletal pain of yoga practitioners. Furthermore, there are no known studies on musculoskeletal complications associated to advanced AY practitioners and as AY is quite popular in the West, this study wished to contribute to this field. 
   

For the main body of the paper containing...

Methodology.
Results.
    Posterior Thigh Pain.
    Knee Pain..
    Cervical Pain.
     Sleeping Problems.
References

Follow this link to dview the full paper on my google docs page
https://drive.google.com/file/d/0B7JXC_g3qGlWRXZnYnVyY0pWdUE/view?usp=sharing



Discussion

It is important to highlight that within the AY group 64% reported pain. Of those, those who reported hamstring pain (25%) may correlate to AY practice, especially within a larger group however, it is possible that yoga merely brings it to their attention during warm up as those muscles engage more. For those who report pain in poses that require significant joint extension as there is no pain at other times, it may only be attributed to yoga. 
From the medical history it is evident that these forms of pain began while an AY practitioner and in particular in the years that their practice became more advanced, suggesting a potential correlation, although other lifestyle factors may be the cause, the statistical findings suggest no correlation. Yoga, is a practice that aims towards the development of a person at every level. One of the constant challenges and by extension lessons, is to become conscious in such a way to recognize when the ego obstructs the practice, a fundamental aspect of yoga is to learn to have patience with the body, to give space mentally and physically for change to happen and to accept physical limitations. This is different to remaining present in a challenging posture to create ‘openess’, part of the learning requires understanding limitations and knowing how much one’s body can achieve without leading to injury before moving to the next level of a posture. As aforementioned, from the AY group 64% reported pain, so when it comes to healthcare advice it seems advisable that healthcare workers should advise their patients of potential risks, the importance of choosing instructors that are registered and have trained with well-established schools of practice and the importance of listening to the body.
Although there was no significant correlation between those who reported cervical, or knee pain that occurred only when in specific poses that hyper extend the joints, the fact that they do report pain on those occasions cannot be dismissed, as pain is a signal of an aggravation/ distress at the joint. This study did not evaluate whether these practitioners, avoid this postures, or use variations, how they respond to that pain, or whether they ignore the discomfort and maintain the posture through it.



Conclusion
For the hamstring pain yoga vs control group the resulting p-value=0,070 is not statistically significant, nevertheless it is indicative of a potential correlation.  A future study with a larger sample size may result in a statistically significant association between the above two variables of interest. There is no association between the variables knee pain and advanced yoga practice in the population of interest. There is no association between the variables cervical pain and advanced yoga practice in the population of interest. There is no association between the variables sleeping disorders and advanced yoga practice in the population of interest. A further area of interest would be to evaluate the frequency of dull pain vs acute (sharp) pain.
From the study, although overall there is no association between AY practice and injury, it nevertheless seems important to raise awareness with concerns to how people approach yoga, to understand that it can cause injury without appropriate guidance and when spirituality and breath is separated from movement.
The acupuncture protocol that combines “fire needling” and “distal needling” is effective short term. However, it will be of importance in a future study to compare this treatment method against other treatments, such as massage, tissue manipulation, herbs, pharmaceutical medication, though such a study removes an aspect of the holistic approach of Chinese Medicine. Furthermore, long term follow up is necessary in order to find out if it is clinically effective long term signifying healing, rather than pain relief.


Acknowledgements
I would like to thank Ashtanga yoga teacher Kristina Karitinou for her permission to attend the “Ashtanga Teacher Training Workshop” and Christina Maniavou Msc. for the data collection. Finally, I would like to express my gratitude to Alexandros Griparis for the conduction of the statistical analysis. 



CV 

Websites (in greek) www.yinyang.gr. and Www.hccm.gr.

Dr. Ioannis Dimitriou MD PT CCH MSc PhD in TCM, has graduated from Medical Schools in Athens Greece, Tianjin China, Prague Czech Republic. He is the president of the Hellenic Association of Chinese Medicine, the Hellenic Corporation of Chinese Medicine, the International Chinese Medicine Congress in Athens and a founding member of the Filiform Fire Needle Medical Company in Hong Kong. He has more than 16 years of clinical experience in Chinese Medicine, Physiotherapy, Homeopathy and Conventional Medicine and has spent the better part of the past 13 years in China pursuing the mastery and refinement of Chinese Medicine. Furthermore he has been a well-sought after lecturer and tutor since 2005 and is presently giving various Chinese Medicine lectures internationally and manages his own clinic in Athens. Most recently he is participating in the well-esteemed Doctor of Osteopathy Program for Medical Doctors in London.


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A Reminder

from Kalama sutra, translation from the Pali by Bhikkhu Bodhi This blog included.

"So, as I said, Kalamas: 'Don't go by reports, by legends, by traditions, by scripture, by logical conjecture, by inference, by analogies, by agreement through pondering views, by probability, or by the thought, "This contemplative is our teacher." When you know for yourselves that, "These qualities are unskillful; these qualities are blameworthy; these qualities are criticized by the wise; these qualities, when adopted & carried out, lead to harm & to suffering" — then you should abandon them.' Thus was it said. And in reference to this was it said.

"Now, Kalamas, don't go by reports, by legends, by traditions, by scripture, by logical conjecture, by inference, by analogies, by agreement through pondering views, by probability, or by the thought, 'This contemplative is our teacher.' When you know for yourselves that, 'These qualities are skillful; these qualities are blameless; these qualities are praised by the wise; these qualities, when adopted & carried out, lead to welfare & to happiness' — then you should enter & remain in them. Buddha - Kalama Sutta
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