Chinesische Medizin
- ein traditionelles Modell der Systembiologie? -
Johannes GretenProfessor der Universität PortoPräsident der Dt. Ges. f. TCM
Director, Heidelberg School of Chinese Medicine
Informationen im Internet
• SWR: Teleakademie
• SWR: Odysso
• www.dgtcm.de
Kontrollierte Integration derTCM
I. Rationale Theoriebildung
II. Nachweis der Wirkung und Sicherheit
III. Qualitätskontrolle
Versorgungsrealität
10
5
0
Tho
raci
cal p
ain
Fat
igue
Diz
zine
ss
Hea
dach
e
Ede
ma
Bac
kpai
n
Dys
pnoe
Inso
mni
a
Abd
omin
al p
ain
Num
bnes
s
The „unmeasurable“ is reality
Kroenke and Mangelsdorff, AM J Med 89white: complaints with no measurable correlate blue: probable „organic“ origin of complaints
Komplementäre Verfahren• 60-80 % der chronisch Erkrankten nutzen
Komplementärmedizin (Ernst 99, Ernst and Cassileth 98, Ernst and Cassileth 99, Richardson et. al. 2000, Bernstein and Grasso 2001, Ashikaga et al 2002)
• Meist Nutzung als Zusatzangebot („on top of it“), in der Mehrzahl ohne Wissen der Ärzte
(Zimmerman and Thompson 2002)
• Risiken! (Ernst 99, Müller 2000, Werneke et al 2004, (www.acupuncture.com , Stockinger, G, „Kidney-Killers from Asia“ in „Der Spiegel“, 6, 2000, available via www.spiegel.de, Perharic-Walton L, Murray V, Toxicity of Chinese Herbal Remedies, Lancet 340, 674, 1992, Eisenbrand G, Tang W, „Mutagenic and cancerogenic Substances in Chinese Medical Herbs“, Ztschr. f. Phytotherapie, 1998, 19:39-42
)
Versorgungsrealität Deutschland 2005
• Asiaphilie:
Gebildete,
WohlhabendeKonservative (Greten 2005, Gesundheitswirtschafts-kongress Hamburg, Erhebung im Daomed Network)
Oberschicht/Obere
Mittelschicht
MittlereMittelschicht
UntereMittelschicht /Unterschicht
SozialeLage
Grund-orientierung
Traditionelle WertePflichterfüllung,
Ordnung
Modernisierung IIPatchworking
Virtualisierung
Modernisierung IKonsum-Hedonismus
und Postmaterialismus
DDR- Nostal- gische unter 1%
Konsum-Materialisten
Postmaterielle
Etablierte
Hedonisten
Experimentalisten
Moderne Performer
Konservative
Traditions-verwurzelte
Bürgerliche Mitte
Integration auf dem Schleichweg ?
• Umsatz: 3,2 Mrd. Euro (Greten 2003; Gutachten f. d. Hamburger Senat)
• Wachstumsrate: 10-22% (Greten 2003 dto. ; The Economist 5.1.98)
• Sozio-ökonomischer Gradient: Inanspruchnahme durch Gebildete, Wohlhabende, Konservative (Greten 2005, Gesundheitswirtschaftskongress Hamburg, Erhebung im Daomed Network)
I. Rationale Theoriebildung ?
Wood
Water Metal
Fire
EarthYin/yang +
= Chinesische Medizin ?
Asia Philosophie als therapeutische Grundlage ?
10
Konfuzius (551-479)
762 Wang Bing enlarges Huangdi Neijing Suwen
1078 public health office with college of physicians and publishing house
Hua Tuo (141-203) Surgery on the intestines
6-stages of the „Shang Han Lun“Zhang Zhongjing (150-219)
Li Shizhen (1518-1593) – „Bencao Gangmu“
12.-14. century decay of CM and the public health office
five phases (wu xing)Yellow emperors classic on internal disease„Huangdi Neijing“
I Ging (Yin/Yang) (1000-700)Laotse
Buddhism to China
Printing of books, mechanical clock
Chinese Wall
Manual on arithmetics in 9 parts: circular functions
„Unity of the three teachings“ Confucianism, Daoism, Buddhism
Prohibition of Chin. Medicine 1927„TCM“: pragmatic reconstruction
Heidelberg Model
0
1000
2000
Zho
uH
anN
orth/South
Song,Jin,Y
uanT
angM
ingQ
ing
PRC
Hippokrates (470-360)
Sokrates (470-399)
Jesus is born 6-4
New testamony 100-150
Printing 1450
1543 KopernikusGalileo Galilei (1564-1642)
Bach (1685-1750)Homepathy by Hahnemann (1755-1832)
Fall of the iron curtain 1989
Pythagoras (570-500)
Platon (428-348)
Mohammed (570-632)
Marco Polo (1254-1324)
Hildegard von Bingen (1098-1136)
Walther von der Vogelweide (1177-1230)
Luther (1483-1530)
Galenus (129-199)
Leibniz (1646-1716)
Mohists, mathem. space-time concept(ju chow) (479-381)
Normans conquer England 1066
500
- 500
1500
Limes
Anglons und Saxons invade England
Battle of Poitiers 732
„Cellular Pathology“ by Virchow (1821-1902)
Heidelberger Modell der TCM
constitution path. factor„organ
pattern“ orbs
„What is the patients „inner
nature“
„What affected the patient?“
„Which signs and symptoms appear
now?“
4x2guiding criteria
„snapshot of the actual functional
state“
+ + +
repletio/depletio„fullness“/
„emptiness“
calor/ algor„heat“/„cold“
extima/intima„exterior“/„interior“
yin/ yang
?
neurovegetative signs humoro-veget. signs neuro-immunolog. stages structural deficiency vs.
regulatory deficiency
repl
etio
depl
etio
cal
or a
lgor
repl
eti
ode
plet
io
cal
or a
lgor I II III IV V VI
F
W
H
M
EF
W
H
M
EF
W
H
M
EF
W
H
M
E
Chinesische Diagnose = vegetativer Status
14
SummerS
Fire
WaterN
Winter
Autum
n W
Spri
ng E
Woo
d Metal
Yin and Yang as binary Numbers
SommerS
Feuer
WasserN
Winter
Herbs t W
Früh
ling
OH
olz
Metal l
Entmystifizierung der Chinesischen Medizin
16
thermostatelectric heater
water basin
yin (depletion)
yang (repletion)
time
analogies of western regulation and Chinese technical terms
WATERMETALFIRE WOOD
17
postulated nervous and hormonal mechanisms of the phases
Hyper-dynamic
sympathetic parasympathetic
Cortisol
Adrenaline
Endorphines
enteric NS active
Hyper-tone
T3, T4
Hypo-tone Hypo-dynamic
enteric NS inactive enteric NS inactive
37°Ctime
38°C
36°C
Wood Metal WaterFire
Vegetative Regulation in Western terms (below) and Phases (up)
Vier Arten von Rückenschmerz
Eine Therapie?
Vier Arten „Energiestatus“
vier „Selbstkonzepte“
20
Dopamin
Serotonin
Adrenalin(Ocytocine)
Therapieformen • Arzneitherapie • Akupunktur• Tuina (manuelle Therapie), • Diätetik• Taiji und Qigong• PTTCM (Psychotherapie der TCM)• Betriebsmedizin
Heidelberger Modell der TCM
constitution path. factor„organ
pattern“ orbs
„What is the patients „inner
nature“
„What affected the patient?“
„Which signs and symptoms appear
now?“
4x2guiding criteria
„snapshot of the actual functional
state“
+ + +
repletio/depletio„fullness“/
„emptiness“
calor/ algor„heat“/„cold“
extima/intima„exterior“/„interior“
yin/ yang
?
neurovegetative signs humoro-veget. signs neuro-immunolog. stages structural deficiency vs.
regulatory deficiency
repl
etio
depl
etio
cal
or a
lgor
repl
eti
ode
plet
io
cal
or a
lgor I II III IV V VI
F
W
H
M
EF
W
H
M
EF
W
H
M
EF
W
H
M
E
Chinesische Diagnose = vegetativer Status
II. Wirknachweis ?
Specific and non-specific effects of acupuncture:A double-blinded, randomized, controlled trial in
patients with osteoarthritis of the knee
M. Karner1*, , F. Brazkiewicz4, A. Remppis1,6*, J. Fischer2, O. Gerlach3, W. Stremmel1, S.V. Subramanian5, J. Greten1,6
1 Department of Internal Medicine, University Hospital Heidelberg, Heidelberg, Germany; 2 Institute of Public Health, Mannheim Medical Faculty, Heidelberg University, Germany;
3 Shen-Centre for Traditional Chinese Medicine, Erlangen, Germany;4 Centre for Chinese Medicine, Bremen, Germany;
5 Department of Society, Human Development and Health, Harvard School of Public Health, Boston, MA; 6 German Society for Traditional Chinese Medicine (DGTCM), Heidelberg, Germany
ECAM 2013, IF = 4,773
Schritt 1
Diagnostiker
TCM Diagnose
Markierung der Punkte A, B, C
mit dreirandomisierten
Farbstiften
Schritt 1
Diagnostiker
TCM Diagnose
Markierung der Punkte A, B, C
mit dreirandomisierten
Farbstiften
Schritt 2
Therapeut Unausgebildeter
„Therapeut“ sticht jeweils einmalig (!)
3 markierte
Punktekonzepte
Randomisierte Reihenfolge, z.B.ABC, BAC, CAB
Schritt 2
Therapeut Unausgebildeter
„Therapeut“ sticht jeweils einmalig (!)
3 markierte
Punktekonzepte
Randomisierte Reihenfolge, z.B.ABC, BAC, CAB
Ablauf der Knie-Akupunkturstudie
Schritt 3
Untersucher
bestimmt Endpunkt, Nachunter-
suchungTag 7
Schritt 3
Untersucher
bestimmt Endpunkt, Nachunter-
suchungTag 7
Verblindung Patient
Verblindung Therapeut
Verblindung Untersucher
Beweglichkeit (Neutral Null Methode)
110
112
114
116
118
120
122
124
126
128
130
beforetreatment
immediatelyafter treatment
7-days
Classical Ac, HM
Schematic Ac
Control Ac-
Kn
ee
flexi
on
, d
eg
ree
s
0
27
Evaluating acupuncture effects according to the Heidelberg Model (case study)
Pain image (before acupuncture):
Note: parietal sensory and motor cortex, sensory region highly active
Acup 4 tif
28
“No-pain” image (after acupuncture)
Note: cingulum, sensory and motor cortex inactive, amygdala inactive
Acup 5 tif
Evaluating acupuncture effects according to the Heidelberg Model
29
Proofs of EfficacyIs such a model useful?
• Sternotomy induced pain: 78 % vs. 16,3% pain reduction (p< 0,001)
lung function (IVC): + 360 ml vs. + 33ml (N=100, p <0,001) (Kick A et al. AMSTCAR, Shanghai 2006)
• Walking distance in pAOD : 86,5 % vs. 40% (N= 34, p< 0,001) (Buhlmann E et al. AMSTCAR, Shanghai 2006)
• Capillary bloodflow (O2) in pAOD: 2-6 fold enhancement,
Effects reversible by „counter acupuncture“ (Greten J, Krug A, Kick A, Remppis A, Diehm C, in preparation )
• Polyneuropathy: 76% of the patients show enhanced nerve conductivitySchröder S et. al. European Journal of Neurology)
• Pain after Tonsillectomy: HM beats standard aupuncture by 3xSertel et al., Archives of Otorhinolaryngology, in 2009
• Congestive Heart failure: HM better than standard points
Journal of Acupunture and Tuina Sciences, 2008
• Congestion of the nose: classical point beat ordinary facial pointsSertel et al. , American Journal of Rhinology, 2009
Evaluating Chinese Pharmacology Background: NF-kappa B as transcription factor e.g. in cancer
NfkappaB locatedwithin the cytosol
TNFalpha inducestranslocation
TCM extract preventsNFkB translocaton
AP1
NFλB
LPS Ø + + + + +Coptisextrakt
Fluvastatin
10µmol
Telmisartan
10µmol
Kalte
Kompetition
pos. Kontrolle
neg.Kontrolle
Rhizoma coptidis
Suppression der LPS induzierten AP1 und NFΚB DNA-Bindungs Aktivität in RAW-264.7 Macrophagen
Inkubationszeiten
Coptis
Telmisartan
Fluvastatin
LPS
6h
30min
…und Emotionen ?
• Angst
• Burn out• Emotionale Erschöpfung
• Depersonalisierung
• Wahrnehung der Leistungsfähigkeit
I.1 Symptoms of Anxiety
ANXIETY
(Watson et al, 1995)
Decreased performance
ME disorders
Absenteeism
Loss of QL
in Flutists
ANXIETY
I.1 Symptoms of Anxiety
I.2 What can conventional Medicine do about anxiety?
• Pharmacology• Benzodiazepines, • Buspirone, • Antidepressives, • Beta-blocking agents, • Antipsychotics,
• Psychotherapy(Andreatini, Lacerda and Filho, 2001)
1 out of 3 patients shows
insufficient response to
standardized western treatment
Loss of memory
Dependancy
Sleep disruption
Weight gain
Headache
Proband ohne spezifische Übung, keine Veränderung der Funktionen
Proband mit funktionsspezifischer Übung, Steiger-ung des Stoffwechsel in Zielregion nach 2 min
Figure 2 - Mean change of heart rate (1/s)
Qigong group
Mean =11 ± 7
Control Group
Mean = 5 ± 9
Senkung der angstbedingten Herzfrequenz
Qigong Therapy in Physiotherapists in Burnout – A preliminary StudySaganha JP. Doenitz C. Greten T. Efferth T. Greten HJ(submitted to JCIM 2012)
Emotional ExhaustionDecrease of the mean from 38 to 31.4 in the intervention group (- 17.4%) and increase of the mean from 33.9 to 37.9 (+11,8%) in the control group . The difference between the two groups was statistically significant (p < 0.05).
Depersonalization (D) subscale: The results showed a decrease of the mean from 10.8 to 6.8 (- 37.0 %) in the intervention group and an increase of the mean from 7.3 to 10.6 (+45.2) in the control group see Figure 2. The difference between the two groups was statistically significant (p < 0.05).
Personal Accomplishment (PA) subscale: Decrease of the mean from 35.4 to 33.9 (- 4.2 %) in the intervention group and decrease of the mean from 37.5 to 37.1(- 1.1 %) in the control group. The difference between the two groups was not statistically significant
State Administration of Trad. Chinese Medicine,Beijing, PRCProf. Shen Yulong über das Heidelberger Modell :
„…the future model to integrate Chinese Medicine in Western health care systems“
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