More on Complexity

Sorry for the long gap without posting! I guess I'll blame it on the holidays and getting back to work, though that certainly can't account for such a long window. I'm reworking my website, and will be giving a presentationm though that kind of activity is always going on.
But I wanted to continue a bit with the article by Andrew Ahn, discussed here. I will highlight the pertinent part, because it reflects my thinking about Heart Rate Variability and what it can tell us about the overall health of the patient. He even says that it may reflect a person's "adaptability" which is the conclusion I've come to over the years. Though effective acupuncture treatment most likely is a function of the correct acupoints, the overall state of the subjects system is probably an important factor too. Then the question becomes, how best to nurture that adaptability that will allow for self healing.

Because heart rate is dynamically balanced through many elements, including the autonomic nervous system, respiration, hormones, and other physiologic systems, the heart theoretically should be responsive to, and exhibit increased complexity across, multiple time scales in concert with fluctuations in these elements. The temporal changes of a variable therefore may contain hidden information that is useful for describing the overall system. This capacity to capture the global state of a system or an individual suggests these complexity-based measures may act as surrogates for concepts that were traditionally difficult to measure but considered important for CAM research (e.g., “health” and “adaptability”). Does a homeopathy prescription or massage treatment affect complexity measures of HRV?...
means to understand CAM better, CAM therapies themselves can be thought of as exemplars for how complexity theory can be applied to clinical medicine. Historically, conventional medicine has evolved and developed under a reductionist Cartesian framework. Complex problems such as chronic diseases were typically divided into smaller, simpler, and thus tractable, units. This approach has affected the way practitioners diagnose, treat, and prevent illnesses. Importantly, it has also shaped the practitioner's worldview and heuristic approach to medicine. To incorporate a distinct philosophical framework such as complexity theory to medicine may therefore challenge pervasive entrenched beliefs and perspectives....
In this regard, CAM is uniquely poised to provide the needed perspective and experience. Many CAM therapies are rooted in a worldview most consistent with complexity and systems theory. The human body is viewed holistically and considered dynamic and complex; the mind, body, and spirit are inextricably linked; and the interactions among the organs and individuals are as important as the components themselves... fractal patterns within the body (e.g., reflexology, auricular acupuncture), and the use of minimal interventions to affect the larger system (e.g., acupuncture and homeopathy).

I didn't realize that the traditional medical model was a "reductionist Cartesian model." I've always thought that the limiting perpective of traditional medicine, was that it was mainly developed after the industrial revolution, and so the body is seen as a machine rather than a living, adapting, organism.

More on my practice here.

Complexity Science and CAM: More Mental Models

I will divide this topic into two posts since this article touches on more than one meaty subjects.
Applying Principles from Complex Systems to Studying the Efficacy of CAM Therapies
This article was published over a year ago, but I missed it. The lead author, Andrew Ahn, is a fellow I had met at the SAR (Society for Acupuncture Research) meeting in North Carolina in 2010, discussed briefly here. The article is available in its entirety. I will point out a few points that are of interest to me in particular. My research has involved HRV (Heart Rate Variability) analysis in conjunction with acupuncture. It makes sense to do this if you recognize that acupuncture cannot be explained in a linear, mechanistic fashion. I discussed some of these dilemmas here and here. So Dr. Ahn grapples with ways to study these nonlinear phenomena in this article, describing a workshop he had attended. He says,

"This discusses possible benefits and challenges associated with applying complexity science to CAM research...
Complexity theory provides a theoretical framework for evaluating and analyzing complex systems. These systems are “complex,” because they exhibit global properties not made obvious from the properties of the individual components, and they are “systems,” because they are composed of interconnected parts. Historically, complexity theory borrows concepts and tools from a range of disciplines, including chaos theory (physics), control theory (engineering), cybernetics (mathematics), and General Systems Theory (biology). More broadly, these disciplines share a common theme of nonlinearity—a concept maintaining that the size of an output is not proportional to the size of an input.
Terms such as adaptability, robustness, or health were previously considered qualitative terms and thus were quantitatively intractable. Yet, complexity science has identified analytical methods that can help assess these features... Finally, complexity science offers a conceptual framework that reflects reality better. In the real world, small inputs can have large effects, processes are dynamic, interactive effects can span across many temporal and spatial scales, and transformations from one state to another can happen gradually or precipitously...

There is a lot here. As I discussed previously in my "argument" with Dr. Longhurst over whether I was actually giving continuous stimulation with manual acupuncture, clinical outcomes attest that I get results without continuous stimulation. This requires that one sees acupuncture as setting a cascade in motion of self healing or self regulation in response to the tiny injury incurred, rather than a nerve stimulation directly to the spinal canal, brain that needs continuous input.
He also echoes one of my favorite ways of describing acupuncture's effect on the body, that it makes it sturdier, more robust, more resilient (spoke about it in this interview.) As he says "these were qualitative terms and thus were quantitatively intractable." The search for biomarkers of health, or healthy response can be seen in the testing for telomere length, HRV, galvanic skin response, or electrical impedance at acupoints. My own interest is in HRV as a measure of health and stress level or ability to respond. I will discuss this more in the next post using Dr. Ahn's article
More on the practice here.

De Qi versus Psychological Factors and Acupuncture Efficacy

I have cut this description of the study. Please click on the title for the full abstract.

De-qi, not psychological factors, determines the therapeutic efficacy of acupuncture treatment for primary dysmenorrhea.
Xiong J, Liu F, Zhang MM, Wang W, Huang GY. Chin J Integr Med. 2011 Oct 12. [Epub ahead of print] Institute of Integrated Traditional and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
OBJECTIVE:
To study the impact of De-qi (, obtaining qi) and psychological factors on the efficacy of acupuncture treatment for primary dysmenorrhea, with an attempt to explore the relationship among De-qi, psychological factors, and clinical efficacy.
RESULTS:
Complete data were obtained from 120 patients, 60 patients in each group. There were statistically significant differences in pain intensity (W=2410.0, P<0.01) and pain duration (W=3181.0, P<0.01) between the two groups. The number of De-qi acupoints (W=1150.5, P<0.01) and the average intensity of De-qi (W=1141.0, P<0.01) were significantly higher in the manipulation group as compared with their non-manipulation counterparts. The correlation coefficients between De-qi and therapeutic efficacy of acupuncture were greater than those between psychological factors and therapeutic efficacy.
CONCLUSIONS:
Compared with the psychological factors, De-qi contributed more to the pain-relieving effect of acupuncture in subjects with primary dysmenorrhea. Moreover, manual manipulation is a prerequisite for eliciting and enhancing the De-qi sensations, and De-qi is critical for achieving therapeutic effects.

If we try to figure out why a De Qi sensation would be key to effectiveness (my teachers from Shanghai insisted that it wasn't, btw) maybe it's because acupuncture mimics an insect bite or some other insult encountered in nature that would start a healing cascade. Just thinking, thinking... Trying to come up with a mental model.
More on the practice here.

Max Planck and the Immutable Laws of Physics

Charlie Munger discusses Max Planck a number of times in the book, Poor Charlie's Almanack(1).
Max Planck was a physicist who developed Planck's constant, earned a doctorate at the age of 21, worked on energy emissions which lead to the "Quantum Theory," and received the Nobel Prize in 1918. He tried once to do economics and gave it up. So why would one of the smartest people to have ever lived give up economics? "It's to hard. The best solution you can get is messy and uncertain." It didn't have enough order to it so he gave it up.
What does this have to do with Health Matters? It made me think about the fact that medicine is a messy science too. Though our models are those of the hard sciences, physics, biochemisty, cellular biology, anatomy, results in medicine are not orderly. Outcomes are multifactorial. In my own career, I've gone from perhaps the only branch of medicine that has the most reliable outcomes, Anesthesiology, to one that has the least, Acupuncture (though I would say Psychiatry is on a par with Acupuncture.) But in contrast to Economics, where we're only talking about money (cough), the stakes in Medicine are so much higher. We need to convince people of Max Plancks' exceptional ability to wrestle with difficult, multifactorial, untidy outcomes because the need is so great. We need new and better models and methods.
Info on my practice here.

(1)Poor Charlie's Almanack: The Wit and Wisdom of Charles T. Munger, Peter Kaufman 2006

More on Munger's Mental Models and Acupuncture

My post yesterday was a riff on Charlie Munger and his use of mental models. Why is this of interest? I am searching for workable models to use for acupuncture and thereby improve its efficacy. I also think that the models for Western Medicine are breaking down in various ways and to varying degrees. They are still the best we have, but they are inadequate and have been corrupted by moneyed interests to boot.
Example:
At the ISAMS conference, I presented a poster on Heart Rate Variability and its correlation with clinical outcomes in my private practice clinic. Professor Longhurst was interested in the poster in so much as he came over a number of times to argue with me. He has done yeoman's work on hypertension and cardiac health and acupuncture. His argument was that since I used manual and not electroacupuncture, I was not getting a sustained stimulation so I couldn't draw any conclusions. His argument makes sense according to his mental model; i.e that acupuncture works by stimulating nerves under the meridian. My models say that that's part of it, but after reading a textbook on Immunology and the Skin describing what happens when one gets a sunburn, I would posit that there are cascades of immunological healing effects that happen with the tiny injury of placing of a needle. (This is the model that could account for the non-specific needling effects seen with acupuncture.) Also, as I've written about repeatedly on this blog and in my research I think that the decrease in the stress response can account for the variety of conditions treated by acupuncture from panic attacks to allergy to sciatica.
Models are extremely important, because without them how can we improve outcomes? When it comes to Longhurst's model it worked in this study on hypertension, but to use electroacupuncture routinely in the clinic, especially for musculoskeletal pain can lead to severe aggravation of symptoms, which, naturally enrages the patients. Not good clinically nor for business... Electroacupuncture is used on lab animals all the time and they don't seem to be enraged, but maybe they have a stronger placebo effect?? I kid.
The mental models used in Traditional Chinese Medicine, also do their best to make sense of health and healing in their own ingenious way and have structured their models completely differently than the models of Western Medicine. It is a struggle to use models that don't fit with our models, but on the other hand there is a constraint of thinking in only using the traditional models again and again if they are failing. For failing models you need look no further than Avastin, temporal artery surgery for stroke prevention, or stents to name a few.
More on my practice here.