KAIM
T
Thhee JJoouurrnnaall ooffK
Kaammppoo,, A
Accuuppuunnccttuurree aanndd IInntteeggrraattiivvee M
Meeddiicciinnee
INTERNATIONAL INSTITUTE OF HEALTH AND HUMAN SERVICES,
BERKELEY
Volume 8, Number 3 ･ Fall 2013

Editorial

Application of European Herbal Medicine to Kampo Medicine
Hiromichi Yasui

Japanese Acupuncture - Current Research
Japanese Traditional Medicine Text (9) –Obstetrics
Hiroaki Suzuki

Kampo Medicine - Current Research

Kampo Medicine and Concept of Weak Constitution- Frailty, Locomotive Syndrome, and Sarcopenia
Kazunari Ozaki

Clinical Report 1 (Acupuncture)

Rubbing Acupuncture Method: A Case Report for Dementia
Haruo Yoshimura

Clinical Report 2 (Kampo Medicine)

A Case in Which the Administration of Multiple Kampo Drugs Improved the Symptoms of ASD and ADHD in a 15-year-old Boy
Hideaki Yamaguchi

ISSN:1559-033X

College Logos
We believe it is necessary to create a new way of thinking
for the total understanding of "Life, Survival, and Health".
We decided to coin the world "Lifence" to express this.
Lifence means the combination of life sceince and medicine
as well as other disciplines such as health science, psychology,
ethics, etc.
Our college logos symbolizes the above.
The ripple effect represents the ocean and the birth of life.
The rainbow colored sphere represents a safe environment
and a barrier to protect us from negative influences.
The picture by Leonardo da Vinch represents a balanced
body and health.
Completing our logos is a ring which represents the unity ofspace fulfilling the total meanings of lifence.

―

The Journal of
Kampo, Acupuncture andIntegrative Medicine(KAIM)
Research on Theory, Practice and Integration

Volume 8, Number 3 ･ Fall 2013

EXECUTIVE EDITOR

Shuji Goto
Chairman, GOTO College ofMedical Arts & Sciences

TA B L E O F C O N T E N T S

Tokyo, JapanASSOCIATE EDITORS
Shuichi Katai

1 Editorial
Application of European Herbal Medicine to Kampo Medicine
Hiromichi Yasui

Ibaraki-ken, Japan

Hiromichi Yasui
Tokyo, JapanEDITORIAL STAFF

Akihiro Souma
Hiromi Sasaki
Hiroshi Tsukayama
Hitoshi Yamashita
Junko Okubo
Kazunari Ozaki
Kengo Nakata
Masayuki Kashima
Naoya Ono
Noboru Mitsuhata
Sayaka Toda
Takao Namiki
Toshiaki Makino
Toshihiro Togo

PUBLISHER

Shuji Goto
International Institute of Health andHuman Services, Berkeley

2 Japanese Acupuncture - Current Research
Japanese Traditional Medicine Text (9) – Obstetrics
Hiroaki Suzuki

8 Kampo Medicine - Current Research
Kampo Medicine and Concept of Weak Constitution– Frailty, Locomotive Syndrome, and Sarcopenia
Kazunari Ozaki

15 Clinical Report 1 (Acupunture)
Rubbing Acupuncture Method: A Case Report for Dementia
Haruo Yoshimura

2550 Shattuck Avenue, Berkeley
California 94704-2724, U.S.A.

22 Clinical Report 2 (Kampo Medicine)
A Case in which the Administration of Multiple Kampo Drugs Improved the Symptoms of
ASD and ADHD in a 15-year-old Boy
Hideaki Yamaguchi

MISSIONTo disseminate peer-reviewed information on the use of acupuncture and herbs, and integration with western
medicine, based on research from an international perspective; thereby stimulating further research, applicationof documented therapeutic measures; and facilitating dialogue among health care practitioners worldwide.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)KOTARO PHARMACEUTICAL introduced in 1957 the world's first Kampo extract
preparations on the market. Later, in 1967, six of our preparations could be covered in Japanfor the first time by the health insurance and after 1976 more than 100 of our preparations
were used in hospitals and clinics. Now it is half a century since we put our Kampo extract
preparations on the market and believe, we made a major contribution to this industry.
In the future we intend to continue working in accordance with our company motto: "Still better
Kampo for still more people" and provide pharmaceutical products of still higher quality.

Origin of the company's name
The company was named "KOTARO" by its
founder Taro Ueda with reference to his birthplace. Close to the ancient city of Nara. Kotaro
is the name of an enormous sheer cliff, 700 m
wide and about 200 m high. Mr. Ueda felt anaffection rising to the heavens for this cliff andthus made it the company's name.

KOTARO PHARMACEUTICAL CO., LTD.
5-23 Nakatsu 2-Chome, Kita-ku, Osaka 531-0071, JAPANURL: http://www.kotaro.co.jp

Volume 8, Number 3 | Fall 2013

Editorial
Application of European Herbal Medicine to Kampo Medicine
Europe has a long history of herbal studies. In ancient Greece, Theophrastus (371–287 BC) wrote
Enquiry into Plants, and built the foundation of pharmaceutical botany. In ancient Rome, Dioscorides (40?
– 90 AD) wrote Materia Medica, which contains descriptions of some 600 species of medicinal plants andtheir effects, and laid the foundation of pharmaceutical botany in Europe thereafter. In the 16th century,
O. Brunfels, L. Fuchs, C. de Clusius, J.D. Tabernaemontanus and others published content-rich books thatwidely spread the knowledge of pharmaceutical botany in society.
Among the medicinal plants described in these books, more than a few share the same origin as
medicinal plants in China. For example, peony exists not only in Japan and China, but also in Europe andNorth America, although the species that exist in Europe is Paeoniaofficinalis, and that in Japan isPaeonialactiflora. With regard to licorice, Glycyrrhizauralensis is commonly used in Japan, while
Glycyrrhizaglabra is mainly used in Europe.
Ginseng (Panax ginseng) is a plant that grows wild in China and the Korean Peninsula (and is also
cultivated in Japan today), but an extremely similar plant (American ginseng, or Panaxquinquefolius) isalso found in North America, and was exported in large amounts to China in the 19th to 20th centuries.
Called Huāqí ginseng, American ginseng, and Cantonese ginseng, it is highly valued in China as acomplementary drugthat has cooling properties.
Herbs that are similar to medicinal plants used in kampo medicine are also found in Europe andNorth America. The above are simply a few examples; there are many other closely related plants thatoffer not exactly the same but similar medicinal effects.
There are two methods for applying European herbal medicine to kampo medicine. One is to use
European herbs that are botanically similar to their kampo versions and that provide similar effects as
defined in books, as substitutes for the original herbs in kampo medicine. The other is to use herbs that
display completely different effects tocreate prescriptions that provide completely new medicinal effects.
In China, from around the beginning of the first century, herbs from the West were included in thepharmacological collection of drugs in the country and were actually clinically applied to establish their
medicinal effects. This is clearly apparent by looking at the content of successive pharmacological books
in China, beginning with the Shennong Ben Cao Jing. When medicine not only of Europe, but also theAmerican continent, African continent and Oceania could be incorporated into the system of kampo
medicine will kampo medicine become a worldwide medicine in the true sense of the word.

Hiromichi Yasui
Japan Institute of TCM Research

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 8, Number 3 | Fall 2013

Japanese Acupuncture - Current Research
Japanese Traditional Medicine Text (9) – Obstetrics
Hiroaki Suzuki

alleviation of pain at delivery, as well as acupuncture
anesthesia for caesarean section, and subsequentcase reports but no RCTs, so it is difficult to say that
there are any papers with a high evidence level at[Chapter 4 Clinical Acupuncture and Moxibustion p217]

the moment. Among that research is a comparative

1. Introduction

study by Yasuda et al. on alleviation of pain at

A search of MEDLINE for research literature on

delivery using acupuncture anesthesia claiming thatclinical acupuncture and moxibustion in obstetrics

electro-needling at Zusanli and Sanyinjiao achieved

overseasandpain alleviation in all 18 primipara and 83% of the‘acupuncture’ obtained 195 results. Some researchpara (12)2). While it has drawbacks, including theinto acupuncture anesthesia in obstetric surgery wasfact that the effects of acupuncture anesthesia varycarried out in the 1970s, then from the 1980s a few

among individuals and that movement is limited forstudies examined analgesia for contractions andthe pregnant women, it does demonstrate alleviationdelivery, correction of fetal breech presentation andof anxiety in pregnant women owing to alleviation ofanalgesia for caesarian section. There are also

pain, shortening of the course of labor, and some

papers on treatment of morning sickness andreduction in the amount of bleeding. It is also safe

dysmenorrhea. Much clinical research has examinedand simple, making it a method of alleviating pain

acupuncturewithat delivery with no complications. Additionally,

assisted reproductive technology (ART), typically in-

Tsujiuchi has published a comparative study on

vitro

acupuncture

using

the

and

fertilization,

terms

moxibustion
with‘obstetrics’

associatedpapersaddressing

improvement of uterine blood flow, alleviation ofandmoxibustionforbreechpresentation3).

pain associated with ovum collection, as well as
improvement of pregnancy rates. While infertility[Chapter 4 Clinical Acupuncture and Moxibustion p218]

and breech position are addressed in detail below,

Mizumoto et al. reviewed 10 papers on low back pain

three quarters of the 195 papers were publishedand pelvic pain in pregnant women in a meta-

after 2000, suggesting acupuncture and moxibustion

analysis of the safety of acupuncture and its

have attracted much attention in obstetrics over the

analgesic effects, finding in all papers significant

last 10 years. Focusing on randomized controlleddecreases in low back pain and pelvic pain during

trials (RCTs), the results include 39 papers on

pregnancy compared to the control group, andobstetrics (12 on contractions and delivery, 6 on ART,

finding no adverse event in either mother or

6 on morning sickness and hyperemesis, and 5 on

newborn.

peripelvic pain, 4 on breech presentation, 2 on

The topic will now turn to obstetric acupuncture

mastitis, and 4 on other topics including failure ofandmoxibustion

lactation, caesarian section, climacterium, andpresentation.

forinfertility

andbreechpremenstrual tension). Most of the papers are from
Europe, which accounted for 60% of the total,

2. Acupuncture and moxibustion for infertility -including 11 papers from Sweden. A meta-analysis1)

Overseasof contractions suggests that acupuncture may beOverseas researchers have published a number of

useful for alleviating labor pain, however, the sample

studies into the question of whether acupunctureis small, therefore further research is required.

improves the rate of pregnancy by ART, including an

Clinical obstetrical research in Japan includes a

RCT by Paulus (2002), as well as studies by Smith

paper by Kakizaki et al. in 1973 on labor induction,(2006), Dieterle (2006) and Westergaard (2006). As

2

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 8, Number 3 | Fall 2013of 2010, the results of 3 meta-analyses had been(3) Stress alleviation: While it has been reported thatpublished. According to Manheimer et al. (2008), 7

stress has an impact on infertility, acupuncture can

RCTs showed that the odds ratio of clinical gestation

be expected to ease stress by stimulating thein women who received acupuncture was 1.65, theproduction of endogenous opioids.

rate of ongoing pregnancy (more than 12 weeks) in 5of them was 1.87, and the live birth rate in 4 was

Before acupuncture and moxibustion

1.91, thereby finding significant improvement in thegroups receiving acupuncture and moxibustion ineach of the RCTs5). Further, Cheong et al. (2008)
found in 13 well-designed studies that the live birthrate odds ratio for women who received acupunctureon the day of embryo transfer was 1.89, suggesting
it is effective6). However, El-Toukhy et al. (2008)
found that in 5 studies in which acupuncture was
performed around the time of ovum collection the

3-layer structure

5 mmThree months after acupuncture and moxibustion

clinical gestation risk rate was 1.06; the clinicalgestation risk rate was 1.23 in 8 studies in which
acupuncture was performed around the time ofembryo transfer; and the live birth risk rate was 1.34
in 5 of the 8 studies, thereby finding no significant
difference

attributabletoacupunctureandmoxibustion in any of the studies7). Thus, while
researchers

have

found

that

acupunctureisbeneficial, some studies found no effectiveness, so
further research is required.

1-layer structure

9 mm

Six months after acupuncture and moxibustion

Acupuncture’s mechanisms of effect
The following are some possible mechanisms ofeffect in acupuncture for the female reproductive
system.
(1) Effects on the endocrine system: Acupuncture canbe expected to affect the menstrual cycle,
ovulationandgestationbyregulating

the

3-layer structure

discharge of neurotransmitters and stimulating
GnRH excretion.

8 mm

Figure 1: Typical transvaginal ultrasound images of a(2) Improvement of uterine blood flow: StenerVictorin found that electro-needling improved

case of endometrial improvement
Beforeacupunctureandmoxibustion

endometrial

vascular resistance in uterine arteries between

thickness is thin (5 mm), making embryo transfer impossible,

in-vitro fertilization and embryo transfer. This

however, 6 months after acupuncture and moxibustion, theeffect is thought to be attributable to theendometrium has grown to a 3-layer structure and 8 mm,

suppression of sympathetic nerve activity.

which meets the criteria for embryo transfer thereby allowing
embryo transfer.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 8, Number 3 | Fall 2013

After endometrial improvement, gestation was

3. Acupuncture for infertility - Japan
Although no RCTs have yet been published inachieved in 14 (45.1%) of the 31 patients who

Japan, Shimizu et al. published a comparative study

received freeze-thaw embryo transfer. Furthermore,on the “effects of acupuncture on the menstrual cycle

repeating ART cycles achieved high rates ofand glycometabolism in women with ovulatory

endometrial condition improvement (2nd cycle: 75%,

disorder”8). The following are some of the effects of

3rd cycle: 60%) and gestation (2nd cycle: 44.4%, 3rd

acupuncture and moxibustion for infertility we havecycle: 66.7%). These results suggest acupuncture

published.

and(a) Acupuncture and moxibustion combined withendometrial condition and contribute to an increase

freeze-thaw embryo transfer in 57 patients within gestation rates.

moxibustionareeffectivein

improving

endometrial misshaping and replication study(51st & 52nd Congresses of the Japan Society of

Uterine artery RI

Uterine radial artery RI

Before acupuncture After acupuncture

Before acupuncture After acupuncture

and moxibustion

and moxibustion

Acupuncture and Moxibustion).
Acupuncture and moxibustion were performed fora defined period on 57 patients with intractable
infertility, after failing to achieve gestation with atleast 3 attempts at ART, and the endometrium
failing to meet the defined criteria for formation
thereby precluding freeze-thaw embryo transfer
despite at least two attempts at endometrial
preparation with hormone replacement therapy.
Patients’ patterns ( 証 ) were determined by pulse
location and quality diagnosis ( 脉 位 脉 状 診 ),abdominal examination (腹診), and interview, andthe casual or essential treatment ( 本 治 法 ) were
performed in addition to local or symptomatic
treatment ( 標 治 法 ) at Guanyuan, Zhongji, Dahe,
Xuehai, Sanyinjiao, Shenshu, Ciliao and symptombased selection of other acupuncture points. An
electro-moxa device was used on the abdomen andindirect moxibustion was performed at the low to
mid back and legs (low back: Shenshu, baliaoxue,legs:

Sanyinjiao,

Yongquan,

Shimian,etc.).

Endometrial preparation with a repeated cycle ofhormonereplacement

acupuncture

and

was

performed

moxibustion

,

after

resultinginendometrial condition improving to the defined
criteria (3-layer structure of at least 6 mm) in 31(54.4%) of the 57 patients (see Figure 1).

and moxibustion

Figure 2: Change in uterine and uterine radial artery RI
before and after Zhongliao needlingTransvaginal color Doppler was used to measure vascular
resistance on the 3rd-7th day of menses and acupuncture was
performed once a week for an average between 7 and 15 times(mean: 9.4). Measurements were repeated on the 3rd-7th dayof the second menses after acupuncture commenced. Uterine
artery RI decreased in 8 out of nine cases, while the mean also
decreased significantly from 0.87 to 0.80 (p=0.011). Utene
radial artery RI decreased in at least half, demonstrating adownward trend in the mean from 0.81 to 0.77, however, thiswas not statistically significant.

4

and moxibustion

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 8, Number 3 | Fall 2013

[Chapter 4 Clinical Acupuncture and Moxibustion p219]

and 1 meta-analysis. In 1998, Cardini conducted an(b) Impact of needling Zhongliao on uterine

RCT in China on the “effects of moxibustion forarterial circulation in infertile patients (51stcorrection

Annual Meeting of the Japan Society for

primipara in the 33rd week of pregnancy and a

Reproductive Medicine)

control group of 130. The method involved theFaced with the need to attempt new therapies for

pregnant women themselves applying stick moxa at

cases in which our usual therapies have not resulted

Zhiyin, resulting in cephalic version in 75.4% of thein gestation, we turned our attention to the bladder,treatment group and 47.4% in the control group,

another organ within the pelvis along with thewhich was a significantly high rate of version in theuterus and ovaries. Because needling Zhongliao istreatment group. However, the study was criticized

effective in urology for lower urinal tract symptoms

for a lack of randomization and placebo. In 2004,

such as overactive bladder and prostate enlargement,

Neri published the results of an RCT with 226

nocturnal enuresis, as well as chronic pelvic pain

pregnant women showing breech presentation in the

syndrome with venal stasis in the pelvis9), we trialed

33th to 35th week of pregnancy, achieving significant

Zhongliao

of itsresults with needle retention and stick moxibustion.

effectiveness on the pelvic organs, for infertility

More recently, in November 2009, Guittier et al.

patients.

published an RCT with 212 pregnant womenneedling,

with

the

promiseofbreechpresentation”

with

130

Our method of needling Zhongliao involved

showing breech presentation in the 34th to 36th weekretaining stainless disposable needles (0.3 mm inof pregnancy. Their method involved performing

diameter, 60 mm long) at about 60 mm depth, thenmoxibustion at Zhiyin and the patients themselves

manual stimulation at left and right for a total of 10

applying moxa at home, which achieved nominutes, with the patient in prone position. Aftersignificant result. The numerous studies to date

performing acupuncture at Zhongliao only for ashow the rate of version is low if initial consultation

definedis in the 34th week or later.

periodon9infertility

patients,

measurements of vascular resistance using color

In September 2009, Vas et al. published a meta-

Doppler showed a significant decrease in the uterine

analysis of 6 studies up to June 200710). It covered

artery resistance index (RI) from 0.87 to 0.80, and a

1,087 pregnant women showing breech presentation

decrease in the RI for the uterine radial arteries inand compared groups in which moxibustion was

at least half, although the decrease from 0.81 to 0.77

performed and control groups in which treatment

was

2).

other than moxibustion was performed. The results

Furthermore, gestation was achieved in 4 of the 8

showed that while the rate of version was 72.5% forpatients who received freeze-thaw embryo transfergroups in which moxibustion was performed, theafter acupuncture.

rate was 53.2% in control groups (relative risk: 1.36,

notstatisticallysignificant(Figureconfidence interval: 1.17-1.58). Vas et al. concluded
4. Acupuncture and moxibustion for breech
presentation - Overseas
In the 1980s, after Yoshiro Hayashida performedthat moxibustion performed at Zhiyin (BL67) was

moxa needling at Sanyinjiao and moxibustion at

5. Acupuncture andpresentation - Japan

Zhiyin to treat breech presentation and showed its

effective.
moxibustionforbreechconducted RCTs of acupuncture and moxibustion for

Sakago no Shinkyu Chiryo (Acupuncture andMoxibustion for Breech Presentation), written andbreech presentation. Searching MEDLINE using theedited by Shuichi Katai11), reports 14 of the Japaneseterms “acupuncture” and “breech” results in 10 RCTs

publications on acupuncture and moxibustion for

great

benefits,

variousoverseas

researchers

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

5

Volume 8, Number 3 | Fall 2013breech presentation since World War II in Japan,

6. Issues in clinical obstetric research

however, not one of them was a randomized study. Of

From an ethical perspective, making comparisons

the total 1,663 cases covered, correction waswith no-treatment groups in a clinical acupuncture

achieved in 1,382. So, while the rate of correction

and moxibustion scenario is difficult and shamwas 83.1% across all type of the cases, the rate ofneedling has not yet been clearly defined, whichcorrection in each type varied between 11.7 andsuggests that further good-quality studies, not just

92.3%. Of the total 210 cases in which treatment

RCTs, must be undertaken. The issue for the future

started during weeks 32 to 35, when it becomes moreis how to go on disseminating truly useful clinicaldifficult for the fetus to change position naturally,

research from Japan.

correction was achieved in 136 (64.76%). In regard totreatment methods, while many of the publications

Referenceused Zhiyin and Sanyinjiao, they varied in terms of

1)

Smith CA: Complementary and alternative

their methods, types and frequencies. Other than 4

therapies for pain management in labour.

cases of nausea and blistering or pigmentation

Cochrane Database Syst Rev Oct 18; (4),caused by moxa, no serious symptoms were observed

Australia, 2006

that could be attributed to acupuncture and2)

Kenta Akira: Experiences of Pain Relief

moxibustion stimulation in the 1,363 cases that did

duringmention adverse events.

Anesthesia.

[Chapter 4 Clinical Acupuncture and Moxibustion p220]

The first to use moxibustion at Zhiyin for breech

3)

4)pregnancy:Abirth among women undergoing in vitro
fertilization: systematic review and meta ─analysis. BMJ 336(7643): 545-549, 2008
6)

Cheong YC, Hung Yu Ng E, Ledger WL:
Acupunctureandassisted

conception.

Cochrane Database Syst Rev Oct 8; (4):CD006920, 2008

been, for example, a case control study. The author
andduringof acupuncture on rates of pregnancy and live

possible if it finds benefit for patients, even if it had
acupuncturePain5) Manheimer E, Zhang G, Udoff L, et al.: Effects

high level as an RCT, it makes the practice of EBM

that

PelvicSchool of Therapeutics 33: 198-202, 2010

evidence, it is not equivalent to an RCT or meta-suggests

BreechLiterature Study. Journal of the Oriental

The author says that while in terms of its level oftherefore

for

Ayako Mizumoto, Minami Kazunari, Satoko
andmedical concepts.”

rather than insisting that the evidence must be as

Acupuncture

Nakagomi et al. Acupuncture for Low Backthe history of acupuncture and moxibustion to use

analysis, if you take EBM as the starting point,

gynecology

9(1): 65-70, 200920 patients. … This paper appears to be the first inpresentation, which is defined according to Western

andPresentation. Modern Acupuncture Studies

treat breech presentation was effective in 16 out ofacupuncture and moxibustion to treat breech

Obstetrics

Acupuncture

Keiko Tsujiuchi: Treatment for Women`s
Conditions:delivery was the obstetrician and gynecologist Ishino
findings in 1950 that moxibustion at Sanyinjiao tousingtreatment 91(2) 227-230, 2005

presentation during pregnancy rather than at
Nobuyasu. It is said that “Ishino published his

Delivery7)

El - Toukhy T, Sunkara SK, Khairy M, et al.:moxibustion for breech position is an effective, safe,

A systematic review and meta ─ analysis ofand comfortable treatment that should be widely

acupuncture in in vitro fertilisation. BJOG

used.

115(10): 1203-1213, 2008

6

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 8, Number 3 | Fall 2013

8)

Yoji

Shimizu,

KuniakiNiwa,

KazamiNakazawa et al.: Effect of Acupuncture for
Irregular

Menstrual

Cycle

and

GlucoseMetabolism in Women with Anovulation. The
Japanese Society of Balneology, Climatology
and Physical Medicine 73(3)292-211, 2010
9)

Hisasi H, Kamoi K, Naya Y, et al.: Effect ofacupuncture for chronic pelvic pain syndromewithintrapelvic

venouscongestion:

preliminary result. Int J Urol 11: 607─ 612,
2004
10) Vas J, Aranda JM, Nishishinya B, et al.:Correction of nonvertex presentation withmoxibusiton:asystematic

reviewandmetaanalysis. Am j Obstet Gynecol 201(3):241─ 259, 200911) Shuichi

Katai(editor):Acupuncture

Treatment of Breech Presentation: Studyingin Illustrations and Photographs. Ishiyaku
Publishers, Tokyo, 2009

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 8, Number 3 | Fall 2013

Kampo Medicine - Current Research
Kampo Medicine and Concept of Weak Constitution– Frailty, Locomotive Syndrome, and Sarcopenia
Kazunari Ozaki1)2)3)
1) Department of Clinical Gene Therapy,
Osaka University Graduate School of Medicine,
Osaka, Japan
2) Department of Geriatric Medicine and Nephrology,
Osaka University Graduate School of Medicine,
Osaka, Japan
3) Department of Geriatric Medicine, Itami City Hospital,
Itami, Hyogo, Japan

Key words: weak constitution, frailty, locomotive
syndrome,
sarcopenia,
asthenic,
traditional
medicine, Kampo medicine, Arthralgia Due toStagnation of Blood and Consumptive Diseases (Xue
Bi Xu Lao, 血痺虚労), Quantification in traditional
medicine, globalization of traditional medicine,International Organization for Standard (ISO)Introduction
In recent years, terms such as frailty, locomotive
syndrome, and sarcopenia have been proposed toembody the concept of “weak constitution.” Theauthor has long been occupied with the question: “Isthere any concept equivalent to frailty, locomotive
syndrome, or sarcopenia in traditional medicine,
particularly in Kampo medicine?” In practice,concepts quite akin to these terms have been used in
Kampo medicine, and treatments for such conditions
are also found in Kampo medicine. In this paper,
frailty, locomotive syndrome, and sarcopenia will
first be briefly described. The Kampo medicine terms(or candidate terms) corresponding to these concepts
will then be introduced and compared. We will thus
discuss correlations and differences between Kampo
medicine and Western medicine. Due to limited
space, only representative examples will be cited.
After these discussions, the author will point out
unaddressed issues associated with Kampo medicine
research in order to provide hints that may stimulate
future advances in Kampo medicine research. At theunaddressed issues related to Kampo medicine
research, we will first discuss issues related to8quantification in traditional medicine and thenconsider issues related to the globalization of
traditional medicine.
1. Summarization of the terms frailty, locomotive
syndrome, and sarcopenia
The concepts of frailty, locomotive syndrome, andsarcopenia will first be briefly described. The term“frailty” is used in the field of geriatric medicine.
This term indicates weak constitution, senile decay,
and weakening or vulnerability. In short, it is used
to describe aging-associated irreversible weakness.
Frailty may also be used to describe the state in thesenile period (a period of discrepancy between
healthy life expectancy and mean life expectancy),
which is characterized by reduced physiologicalreserve resulting in the outcomes such as
vulnerability to stress, disturbance in activities ofdaily living, requirement of assistance with dailyliving, and likelihood of death.
The term “locomotive syndrome” is used in thefield of orthopedics. Unlike the term “frailty,” which
is a broad concept encompassing physical,
mental/psychological, and social aspects, the term
“locomotive syndrome” is a narrower term confinedto the fields of orthopedics and rehabilitation. It is
used to indicate “a condition of restricted daily living
due to reduction in mobility (walking, standing andsitting, etc.) arising from locomotor organ
dysfunction, leading to need or imminent need ofassistance with daily living.” Locomotive syndrome
was proposed as a new concept at the meeting of theJapanese Orthopaedic Association in 20071). Since
this condition may show recovery in response toappropriate treatment, early diagnosis is considered
to be of high value.
Moreover, the concept of “sarcopenia” was recently
proposed to indicate aging-associated reduction in
muscular mass and muscular strength2). Sarcopenia is
one of underlying diseases of locomotive syndrome,
focusing on reduction in muscular mass and muscularstrength. The term was coined based on the Greek
words sarx (flesh) and penia (loss). Disturbed

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 8, Number 3 | Fall 2013

walking/balance associated with sarcopenia can lead to
aggravation of frailty.
Now that the differences among frailty,
locomotive syndrome, and sarcopenia have beenbriefly described, we will begin a more detailed
discussion of frailty, locomotive syndrome, andsarcopenia. According to Fried et al., frailty isdefined as “A physiologic syndrome characterized bydecreased reserve and resistance to stressors,
resulting from cumulative decline across multiple
physiologic systems, and causing vulnerability toadverse outcomes”3). The concept of “frailty” is easy
to understand for clinical practitioners, but isdifficult to define strictly. For this reason, the fivephenotypes of frailty proposed by Fried in 2001 seemto be used frequently during clinical practice. The
five phenotypes comprise (1) weight loss, (2) fatigue(subjective sensation of fatigue), (3) low energy
expenditure (reduction in activity of daily living), (4)slow gait (weakening of physical capability [walking
speed]), and (5) weak grip (reduction in muscularstrength [grip strength]). Patients with at least threeof these phenotypes are considered to have “frailty”
and those with one or two phenotypes are considered“intermediate” or “pre-frail”4). Frailty is in essence areversible condition in which normalcy may berestored if the appropriate intervention is used. For
this reason, early detection of frailty in elderly
individuals
andsubsequent
appropriate
intervention is expected to enable the maintenanceand improvement of functions of daily living.
Although the Japanese term “Kyojaku (虚弱) or weak
constitution” may be used as a translation for“frailty,” it cannot sufficiently express the diverse
elements of frailty (i.e., weakness in the physical,
mental/psychological, and social aspects). The Japan
Geriatrics Society is thus exploring a more
appropriate Japanese term as a translation forfrailty to lead to widespread recognition of frailty
and dissemination of the importance of its
prevention. “Frailty” may be caused by a variety offactors, including not only locomotor organ disease
and aging, but also disturbed cognitive function,
nutrition, mental state, and socioenvironmental

factors. Epidemiological studies have demonstrated
a close association between frailty and cognitive
dysfunction. Although the exact mechanism is
unknown, it has been epidemiologically shown thatearly detection of cognitive dysfunction is importantto prevent frailty. In order to avoid frailty, maintainand improve functions of daily living, appropriate
interventions
based
on
more
accurate
epidemiological data are desirable. An important
issue for the future is the execution of appropriate
screening tests at early stages of the condition.
Frailty is a broad concept encompassing physical,
mental/psychological, and social aspects. Locomotive
syndrome, on the other hand, is a concept used inorthopedics and indicates a condition of restricteddaily living due to reduction in mobility (walking,standing and sitting, etc.) arising from locomotororgans dysfunction, leading to need or imminent
need of assistance with daily living. Since thiscondition may show recovery in response totreatment, early diagnosis is considered to be of highvalue.
Sarcopenia is attributable to reduction in
muscular mass, muscular strength, and physicalcapabilities, and is a condition that may underlie
locomotive syndrome. It is a term that has beencoined relatively recently by Rosenberg andindicates the “aging-associated reduction in
muscularstrengthorsenescence-associateddecrease in muscular mass”5). The decrease inskeletal muscle mass is assessed using the skeletal
muscle index (SMI), which is calculated by dividing
the limb skeletal muscle mass (kg) by the square ofheight (m), i.e., limb fat-free soft tissue quantity(kg)/height (m2). A SMI of 2 standard deviations(SDs) below the mean SMI of healthy individuals
aged 18-40 years is often considered to reflectsignificant decreases in skeletal muscle mass6). In
2010, the European Union Geriatric Medicine
Society and 4 European and international societies
related to nutrition jointly established the European
Working Group on Sarcopenia in Older People(EWGSOP), which proposed a definition forsarcopenia7). Based on this definition, a diagnosis of

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

9Volume 8, Number 3 | Fall 2013

sarcopenia can be made if there is decreased skeletal
muscle mass (essential) and either reduction in
muscular strength or locomotor function, or both, arepresent. The parameters assessed to diagnose frailty
include attenuation of physical function andreduction in muscular strength. This indicates thatsarcopenia is closely associated with frailty. The
presence of sarcopenia is associated with dizziness,
fall/fracture, and frailty in elderly individuals, andcorrelates closely with physical dysfunction andconditions requiring assistance with daily living8).
2. The term “asthenic” was seemingly used in theearly 20th century.
Concepts such as frailty, locomotive syndrome,and sarcopenia, which correspond to the Japaneseterm “Kyojaku” or “weak constitution” were alreadyin use at the beginning of the 20th century in Westerncountries. In 1908, a publication in the journal
Lancet used the term “asthenic constitution” toindicate the group of diseases causing “atonic habitof body” in the broader sense of the term. These
conditions included floating kidney, gastroptosis,
enteroptosis, nervous dyspepsia, and neurasthenia9).
The term “asthenic” seems to have been a word thatwas prevalent in those days. This term was also usedin the famous paper on body build and physicalconstitution typing by Kretschmer. Kretschmer
described three types of body build: pyknic (stocky
and rounded), athletic (with strong development ofmuscles and bones), and asthenic or leptosomatic(lean and narrow)10).
3. What is the traditional medicine term
corresponding to frailty, locomotive syndrome, andsarcopenia?
Before discussing Kampo medicine terms
corresponding to frailty, locomotive syndrome, andsarcopenia, we will focus only on the physical aspectsoffrailty
without
consideringthemental/psychological and social aspects mentioned
in its definition to simplify the discussion. We willthus treat locomotive syndrome and frailty as the10same concept and explore Kampo medicine terms
corresponding to this concept.
The Kampo medicine or traditional Chinese
medicine terms corresponding to locomotive
syndrome and frailty seem to be “legweakening/adynamia” and “weakening/adynamia,”
which were used in “Dokkatsukiseito, or PubescentAngelica and Taxillus Decoction (Du Huo Ji Sheng
Tang, 獨活寄生湯)” in the monograph “Important
Formulas Worth a Thousand Gold Pieces (Bei Ji
Qian Jin Yao Fang, 備急千金要方)”11). “PubescentAngelica and Taxillus Decoction” is an EightTreasure Decoction (Ba Zhen Tang, 八珍湯) made ofa Four-Substance Decoction (Si Wu Tang, 四君子湯)with blood-replenishing activity and a FourGentlemen Decoction (Si Jun Zi Tang) with Qireplenishing ( 補 気 ) activity. This herbal mix has
been used to treat (1) conditions characterized byphysical senescence (kidney deficiency according totraditional Chinese medicine); and (2) thosecondition involving shortages of Qi and bloodaccompanied by cold sensation and pain in the lower
back and knees due to moisture or water retention,and by fear of coldness, pleasure with warmness,
weak/powerless legs, and paralysis/neuralgia/swelling
attributable to external factors (invasion by
disturbing factors, such as wind, coldness, andmoisture). In Japan, Pubescent Angelica andTaxillus Decoction is often replaced with an herbal
extract called “Relax the Channels and Invigorate
the Blood Decoction (Hu Jing Huo Xue Tang, 疎経活血 湯 ),” which is covered by the national healthinsurance system.
The term corresponding to sarcopenia seems to be“Arthralgia Due to Stagnation of Blood andConsumptive Diseases (Xue Bi Xu Lao, 血痺虚労),”which is found in the Astragalus Decoction toConstruct the Middle (Ogikenchuto, Huang Qi Jian
Zhong Tang, 黄耆建中湯) or Minor Construct the
Middle Decoction (Shokenchuto, Xiao Jian Zhong
Tang, 小建中湯) in the monograph “Kinkiyoryaku(Essential Prescriptions from the Golden Cabinet,
Jin Gui Yao Lue, 金匱要略)”12). This expression isfound in the chapter “On Pulse, Symptom Complex

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Volume 8, Number 3 | Fall 2013

and Treatment of Arthralgia Due to Stagnation of
Blood and Consumptive Diseases (血痺虚労病脈証幷
治)” in the same monograph. Both the Astragalus
Decoction to Construct the Middle and the Minor
Construct the Middle Decoction are herbal
preparations used to treat consumptive disease (虚労 ). In traditional Chinese medicine, they areclassified as Onrikyokanzai (agents used to reverse
warmth and control coldness, 温 裏 袪 寒 剤 ). The
concept of “decrease of skeletal muscle mass,” which
is used in the current definition of sarcopenia, wasundoubtedly absent in the age of “Kinkiyoryaku(Essential Prescriptions from the Golden Cabinet).”However, patients with conditions corresponding tosarcopenia, i.e. patients with frailty presenting withdecreased skeletal muscle mass, reduced muscularstrength, or reduced locomotor function, are likely tohave chronic disease or senescence as a background.
The presence of chronic disease or senescence is
probably accompanied by asthenia cold (Yangdeficiency,陽虚). Therefore, the use of Onrikyokanzai(agents used to reverse warmth and control coldness),which is indicated for asthenia cold (Yang deficiency)
is expected to be effective in patients with sarcopenia.

脾(気)虚＋血虚?
(Spleen (Qi)deficiency andBlooddeficiency)

The author believes that aging corresponds to“kidney deficiency of both Ying and Yang nature (腎陰陽両虚)” (a concept of traditional Chinese medicine andJapanese Kampo medicine), while long-term
malnutrition corresponds to the concept of “spleen (Qi)deficiency (脾(気)虚)” or “blood deficiency (血虚).” Theauthor has compared these concepts using an
illustration of the vicious cycle of frailty, locomotive
syndrome, and sarcopenia, as proposed in the field of
geriatric medicine in Western medicine13) (Figure).
This illustrative comparison includes some indefinite
points. For example, reduced walking speed is aconcept that began to be used when accurate
measurements of time became possible and was absent
in the age of “Kinkiyoryaku (Essential Prescriptions
from the Golden Cabinet).” However, if “Symptom
Complex of Arthralgia (痺証)” is present, a reduction in
mobility should be present, and a reduction in walking
speed is a plausible consequence. However, the author
cannot rule out the possibility that newliterature/documents will be found later indicatingthat a concept corresponding to reduced walking speed
was used already in those days. This illustration is only
the author’s proposal and may require correction,
improvement, and review in the future.

腎陰陽両虛?
(Kidney deficiency
of both Ying and ≒Yang nature)

脾(気)虚?
(Spleen(Qi)≒
deficiency)≒ 外邪(邪気)?
(External
pathogen)(血痺) 虚労?
(Arthralgia
due to≒Stagnation of
Blood andConsumptive
Diseases)
Locomotive
syndrome≒ 下肢軟弱無力?
and Frailty(Leg weakening/
Adynamia)

Adapted from Linda P. Fried et al. J Gerontol A Biol Sci Med Sci 2001;56:M146-M157

Figure: Cycle of frailty with Kampo terms: Under-nutrition, Aging, andDisease will lead elderly people to sarcopenia. And sarcopenia lead toloss of walking-speed, which is one of the frailty sign.

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Volume 8, Number 3 | Fall 2013

4. Existing issues essential to advancement of

quantitative approach to diagnostic imaging andtraditional medicine researchmolecular biology.
In the future, it would be desirable to conduct

4-1 Quantification in traditional medicine
A striking difference in the diagnostic methods

comparisons and analyses of the correlations

between Kampo medicine and modern medicine is

between quantitative data obtained in traditionalthat Kampo medicine basically attempts diagnosis

medicine and data obtained in modern medicine

andregardingtreatment

throughthecomprehensive

clinicalindicators

andbiochemicalinterpretation of subjective symptoms and objective

markers. It would also be desirable to conduct

findings or through holistic assessment of individual

pharmacological and molecular biological studies topatients. One problem in Kampo medicine researchenable the detailed visualization of biologicalthat arises from this feature is difficulty inactivity and drug delivery at the molecular level sonumerical or quantitative analysis when comparedthat further advances in traditional medicine

to Western medicine. However, quantitative analysis

research can be linked to life science research.

of parameters serving as criteria for diagnosis in

Eventually, the development of diagnosis/treatment

traditional medicine will also be indispensable in themethods through the integration of modern medicine

future. Surprisingly, there was little difference(Westernbetween Kampo medicine and Western medicine in(Kampo medicine) beyond the borders of these two

the level of diagnosis/treatment until about 100

fields may contribute to further advances inyears ago, and the outcome of treatment for Spanish

medicine.

medicine)

andtraditional

medicine

flu was better with Kampo medicine than withFor example, we have introduced "New clinicalWestern medicine. However, due to advances inassessment in diastolic heart failure: The correlation

science during the past 100 years, the predominancebetween a combination of clinical findings andof modern medicine/Western medicine has been

indices with echocardiography"15)16). We studied

established. Following recent advances in technology

more than 30 outpatients at the hemodyalysis unit

used for measurements for medical use and inwithmedicalandechocardiographical indices with echocardiography.

diagnostic imaging data have frequently been used

They measured and compared Kampo-scores andfor diagnosis in modern/Western medicine. In

echo-cardiographical indices by linear regression.

contrast, in traditional medicine/Kampo medicine,

According to our study, some of the Kampo-scores

the quantitative approach is seldom used, except for(Suitai-score (or water stagnation score)) had strong

some sporadic cases wherein information regarding

positive correlation to E/Ea (or E/e’: transmitral

subjective

interviews,

early diastolic velocity / mitral annular earlyquestionnaires, etc., and physical findings (such as

diastolic velocity ratio), which were suggested tofindings from abdominal investigations) is processed

have strong relation to pulmonary capillary wedge

numerically. The methods used for quantitative

pressure (PCWP). They suggested that Kampo-

analysis vary greatly among the different schools ofscores especially Suitai-score could be used to define

traditional/Kampo medicine. In the latter half of theclinical assessment of congestion in hemodialysis

1980s, Terasawa et al. made several attempts to

outpatients with diastolic heart failure.

imagingtechnology,

symptoms

biochemical

obtainedinquantitatively analyze diagnostic scores for Qi-

simultaneous

Kampo-scoresandIn order to address sarcopenia and the evidence

However,in “Arthralgia Due to Stagnation of Blood andtraditional/Kampo medicine is far behind theConsumptive Diseases” presented in the author’s

advancedprevious and present papers, we plan to collect not

Blood-Fluid14)

12

level

and
of

similarmoderntests.
medicine

inthe

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 8, Number 3 | Fall 2013

patients

preparations may have to be modified to match thesatisfying the diagnostic criteria for sarcopenia, but

Chinese domestic standards. Needless to say, aalso data on biomarkers (e.g., inflammatory markers

similar influence will also be seen in Korea, the U.S.,

such as tumor necrosis factor-α and interleukin-6)17)

and other countries in addition to Japan. At present,

andtomography,

there is little international understanding of themagnetic resonance imaging, etc.). We will thendifferences between Kampo medicine in Japan andstudy the correlations among these data. In addition,

Chinese medicine. In addition, many individuals intreatment of sarcopenia and “Arthralgia Due toJapan (other than healthcare professionals) believe

Stagnation of Blood and Consumptive Diseases”

that Kampo medicine in Japan is identical tousing modern medicine will be compared to that

Chinese medicine. However, the differences between

using traditional medicine through randomized

Kampo medicine and Chinese medicine are as large

controlled trials (RCTs) if possible, or by means ofas the differences between baseball and softball, andcross-over trials if RCTs are not possible. We believe

it would be impossible to apply the same rules tothatboth these types of medicine. Kampo medicine in

only

traditional

imaging

medicine

findings

medicinefrom(computed

diagnosis/treatment

moderndata

methods(Western

combining

medicine)

withJapan is far behind Chinese medicine in terms of

traditional medicine (Kampo medicine) can be

globalization effort. In addition, the education forestablished through these incessant studies. It is

non-experts in Japan is insufficient.

desirable that such a scientific and objective versionof traditional medicine be established as soon asConclusions
This paper briefly described frailty, locomotive

possible.

syndrome, and sarcopenia, which are important
4-2 Trends of globalization of traditional medicine
Differences in traditional medicine from different

problems in ultra-aging societies. The author thenpresented terms (or candidate terms) in Kampo

countries have been discussed at international

medicine

conferences, such as meeting of the Internationalcorresponding to these concepts. This was followed

Organization for Standardization (ISO; in particular

by a comparison among these concepts and theTC249, which is discussed later) and the World

description of some herbal preparations used for

Health Organization (International Classification of

their treatment. The author also addressed existing

Diseases 11, etc.). However, smooth arguments haveissues essential to the advancement of traditional

been hampered by conflicts of political and economic

medicine research, focusing on the issues ofinterest, honor/prestige of each country, and so on.

quantification in traditional medicine and theandtraditional

Chinesemedicine

In 2009, China submitted an application for the

globalization of traditional medicine. The author

establishment of the organization of an expert

hopes to make some contribution to the stimulationcommittee on traditional Chinese medicine (TC249)

of progress in traditional medicine research in theto the ISO in an attempt to facilitate the adoption of

future.

Chinesepharmacopeia

and

other

domestic

standards directly as global standards. If thestandards proposed by China are adopted as global
standards, Japanese pharmacopeia (now securing
the quality of herbal medicines used in Japan fromthe viewpoint of Western medicine) and otherstandards related to herbal mixtures and Kampo

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Volume 8, Number 3 | Fall 2013

Reference
1 Nakamura K: A “super-aged” society and the “locomotive
syndrome”. J Orthop Sci 2008; 13: 1-2.
2 Rosenberg IH: Sarcopenia: origins and clinical relevance. J Nutr
1997; 127: 990S-991S.
3 Fried, L.P. and Walston, J. (2003) Frailty and Failure to Thrive. In:
Hazzard, W., Blass, J.P., Halter, J.B., et al., Eds., Principles ofGeriatric Medicine and Gerontology, 5th Edition, McGraw-Hill,
New York, 1487-1502.
4 Fried LP, Tangen CM, Walston J, et al. Frailty in older adults:
evidence for a phenotype. J Gerontol Biol Sci Med Sci.
2001;56A:M146-M156.
5 Rosenberg IH. Summary comments. Am J Clin Nutr 1989 ; 50:
1231-3.
6 Baumgartner RN, Koehler KM, Gallagher D, et al. Epidemiologyof sarcopenia among the elderly in New Mexico. Am J Epidemiol
1998 ; 147: 755-63.
7 Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. European Working
Group on Sarcopenia in Older People. Sarcopenia : European
consensus on definition and diagnosis : Report of the European
Working Group on Sarcopenia in Older People. Age Aging 2010;
39: 412-23.
8 Fried LP, Tangen CM, Walston J, et al. Cardiovascular Health Study
Collaborative Research Group. Frailty in older adults : evidence fora phenotype. J Gerontol A Biol Sci Med Sci 2001; 56 : M146-56.
9 The Asthenic Constitution. The Lancet 1908; Vol 172, No. 4436,
p745–746.
10 Kretschmer E. Physique and character. Transl. by Sprott WJ. Kegal
Paul Trench Trubner & Co, London UK, 1936.
11 Scheid
V, Bensky D, et al. (2009) Chinese Herbal
Medicine :Formulas & Strategies, (2nd Edition). Eastland Press,
Seattle, 758-759.
12 Compiled by Zhang Zhong Jing: Synopsis of Prescriptions of the Golden
Chamber (Jin-Gui-Yao-Lue), Beijing, New World Press, 2007, 70-84.
13 Linda P. Fried et al. J Gerontol A Biol Sci Med Sci 2001;56:M146M157.
14 Distinctive features of Kampo Medicine: Kampo, Acupuncture andIntegrative Medicine 2005; 1, Special Edition: 10-12
15 Ozaki K, et al.: New clinical assessment in diastolic heart failure:
The correlation between a combination of clinical findings andindices with echocardiography, The Lancet/JACC 1st Asia Pacific
Cardiovascular Summit – Breakthroughs and Controversies, 8-10
July, 2011 (Hong Kong, China)
16 Ozaki K, et al.: A Clinical Assessment In Diastolic Heart Failure:
The Correlation Between a Combination of Clinical Findings andIndices with Echocardiography in Hemodialysis Outpatients,
American Heart Association, 5 Nov, 2012 (Los Angeles, CA, USA)
17 Visser M, Pahor M, Taaffe DR, Goodpaster BH, Simonsick EM,
Newman AB, et al.: Relationship of interleukin-6 and tumor
necrosis factor-alpha with muscle mass and muscle strength inelderly men and women: the Health ABC Study. J Gerontol A Biol
Sci Med Sci 2002; 57: M326-332

14

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 8, Number 3 | Fall 2013

Clinical Report 1 (Acupuncture)
Rubbing Acupuncture Method: A Case Reportfor Dementia

reassurance to those receiving the treatment as anextremelysafe

method,

but

can

be

appliedconveniently, and has high reproducibility.

Haruo Yoshimura

The rubbing acupuncture method has alreadyCare Prevention Committee, Japan Acupuncture &Moxibustion Association
Yoshimura Acupuncture & Moxibustion Clinic

been applied to a total of some 6,400 elderly people

The Ministry of Health, Labour and Welfare
estimates that the number of elderly persons withdementia at a degree of independence level II or
higher totaled 2.2 million as of 2010, and willcontinue to increase hereafter to 4.7 million in 2025.
People of the baby-boom generation will all becomeage 75 or older in 2025. It is a reasonable figure when
considering today’s rate of increase of elderly people
with dementia, and requires urgent measures to betaken hereafter.
Under this situation, focusing on the peripheralofover a period of nine years. The following is a reportthat focuses on one of those cases.

1. Introduction

symptoms

with dementia living in group homes in Osaka City,

peoplewithdementia

reveals

symptoms that are thought to occur from emotional
stress, such as anxiety, restlessness and loss ofconfidence, and symptoms that occur from an
imbalance of the autonomic nerve system. This issimilar to autonomic nerve imbalance and stressthat are triggered by a baby crying at night or baby
colic. In simple terms, it was thought that if thecause is the same, the same treatment method might
apply, and thus pediatric acupuncture came to mind.
Pediatric acupuncture involves rubbing the skin asa procedure for treating night-crying and colic inbabies, and has been popularly practiced in Osaka
since ancient times. It was thought that theprocedure could regulate the autonomic nerves andmitigate the peripheral symptoms of dementia.
Based on this thinking, this writer developed an
original rubbing acupuncture tool for adults called
SAKKA (the term ‘sakka’ means rubbing inJapanese), and launched a procedure that uses
SAKKA, Enrishin round-head needles and roller
needles to rub the skin. Because it does not harm thebody in any way, SAKKA not only provides

2. CaseThe subject is an 88-year-old widow who lived
alone, as her son and daughter had already gone out
on their own. Two years ago, she lost her balance andslowly collapsed on a bicycle that was parked in theyard in front of her house. She suffered a simple
fracture of the femur. She had an operation to set herbone using a metal plate, but became unable to walk.
Her dementia advanced sharply after the operation,
to the point that she became unable to comprehend
where she is. Her children could not live with her
because of their jobs and families, and the difficultyofproviding

at-homenursing

care

made

it

impossible for her to live alone. Upon being
discharged from the hospital, she was admitted to agroup home. Unable to walk on her own, shedepended on a wheelchair to move around. Her
upper limbs were fine, she could eat, wash her face,and get dressed on her own. She required someassistance to defecate and bathe. She was able toturn over in her sleep by herself, but required someassistance to get up and transfer to her wheelchair.
She spent a long time lying down. She used
eyeglasses, but her vision was normal. So were her
senses of hearing and smelling. When she was first
admitted to the nursing home, she was certified as
requiring a nursing care level of 4, and had a degreeof independence level of IIIb. She displayed an
extremely strong desire to go home, and would
repeatedly and with frustration ask the staff to let
her go home, whenever she spotted any staff member.
She had a strong tendency to refuse nursing care,stemming from her helplessness in having things

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 8, Number 3 | Fall 2013

her way. She was diagnosed with mixed dementia,

The procedure was completed when thewith characteristics of both Alzheimer’s disease andpatient’s skin became moist and a general

cerebrovascular dementia. She suffered depression,

reddening appeared.

insomnia, anxiety and restlessness. She displayed a* With the progress of treatment, the patientlevel 8 on the face scale, and had a sad expression.

became able to walk, but nighttime pains

She has no past medical history, and took no

occurred from a circulatory deficit in her lower

medicine

limbs, so rubbing was also performed on her

for

her

dementia.

She

had

never

experienced acupuncture and moxibustion, and had
a sense of fear of being pricked by a needle.

lower legs using a roller needle.
* Observations were made of changes in the
degree of peripheral symptoms, changes in
expression according to the face scale (Figure-1) Method of treatment
A KN petit roller, Enrishin needle and SAKKA2), changes in expression according to the(rubbing acupuncture tool) were used to rub the skin.

staff ’s response a question, and changes in

Each procedure consisted of the following routine

care burden, as evaluation criteria.

from (1) to (9) as the basic procedure. (Figure-1)(1) Rub the anterior surface of the forearm along
the meridian flow from the elbow to thefingertips with a KN petit roller(2) Rub the posterior surface of the forearmalong the meridian flow from the fingertips tothe elbow with a KN petit roller(3) Trace the eyebrows from the inner to outerside of the face with a KN petit roller(4) Trace the eyebrows from the inner to outerside of the face with an Enrishin needle(5) Rub the temporal muscles on both sides of thehead in a fan-like manner with an Enrishinneedle, toward the Kakuson acupoint as
though to stretch the muscle(6) Rub from the top of the head to the forehead
with an Enrishin needle(7) Rub from the top of the head to the nape ofthe neck with an Enrishin needle(8) Rub both sides of the dorsal spine diagonally
downward from top to bottom, with a KN
petit roller(9) Rub both sides of the dorsal spine diagonally
downward from top to bottom, with a SAKKA* In all cases, the procedure was applied with

2) Result
The procedure was applied once a week 26 times
from June 5 to November 27, 2013.
1st treatment (6/5): The patient had no experience
with acupuncture and moxibustion, so she had aworried expression when she heard the term
acupuncture. The treatment was applied with thepatient sitting in a wheelchair escorted by anursing staff. After the treatment, the patient’s
expression improved from a level 8 to level 3 on
the face scale (Table -1), and a smile appeared onher face, although it was still somewhat stiff. She
voiced that she felt good. Basic treatment.
2nd treatment (6/12): The treatment was appliedwith the patient sitting in a wheelchair. She
remembered the previous treatment, andexpressed her opinion that it had felt good. Her
unhappy feelings disappeared even before thetreatment, and her depression also abated. She
was smiling from before the treatment, without
any stiffness. She said the area where she had
surgery for her right femur fracture hurt, and she
also had lower back pain. She spoke actively.
Expression level 2 on the face scale. Basictreatment.

careful attention to rubbing intensity, in
consideration of the patient’s skin condition,state of perspiration, and reddening of the skin.

16

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 8, Number 3 | Fall 2013

NK petit Roller

ENRISHIN

SAKKA(Figure 1)(Figure 2 Face scale)

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Volume 8, Number 3 | Fall 2013

(Table 1)

Changes seen in the face scale
9
8
7
6
5

フェイススケール
Face
scale

4
3
2
1
0

1

2 3

4 5 6

7 8 9

10 11 12 13 14 15 16 17 18 19 20 21 22 23(week)

3rd treatment (6/26): The patient voiced her feelingand repeatedly asked to be taken home. She camethat the treatment felt good. However, sheto her treatment with a full smile on her face. She

seemed slightly out of sorts, and her smile washad been refusing to bathe, but with some

somewhat stiff. She talked much about her family,

prompting, she took a bath immediately after her

and desired to go home. She had been refusing totreatment. Expression level of 1 on the face scale.

bathe, but with some prompting, she took a bath

Basic treatment.

immediately after the treatment. Expression
level 3 on the face scale. Basic treatment.

8th treatment (7/31): The patient was tired fromgoing to the hospital the previous day, and seemed

4th treatment (7/3): The patient came to theslightly out of sorts. However, she said her bodytreatment room not on a wheelchair, but using afelt lighter, and she felt good. Expression level ofwalker. She said she had been doing walking

1 on the face scale after treatment. Basic

exercises since she came to the nursing home, but

treatment.

she found it difficult to walk. After the treatment,

13th treatment (8/28): She said her surgery site hurt,

she noted that she felt good. Her smile seemedand she found it difficult to sleep at night. Her

stiff, perhaps because she was tired due to hersmile seemed to be stiff, perhaps due to lack ofwalking exercise. Expression level 3 on the face

sleep. She had been refusing to bathe, but withscale. Basic treatment.
7th treatment (7/24): The patient was using her
walker. Her post-operative progress was good.
She volunteered that she has begun to feel good,
and that she had been looking forward to the day’s
treatment. She talked about her house and herfamily without any sense of anxiety or
restlessness, and her desire to go home seemed tohave weakened. She no longer called on the staff

some prompting, she took a bath immediately
after the treatment. Expression level of 3 on theface scale. Basic treatment.
17th treatment (9/25): The patient had caught a cold,and coughed up blood in her sputum. She had nofever or chills, but her throat and back of her nose
were swollen. She was administered a cold
medicine. Her smile seemed stiff, perhaps due toher cold. Expression level of 3 on the face scale.
Basic treatment.

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The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 8, Number 3 | Fall 2013

18th treatment (10/2): The patient’s cold had abated.

Ten nursing staff members were asked whether

She seemed more energized, and the stiffness had

the patient’s expression changed immediately after

disappeared from her smile. Expression level of 2

treatment,on the face scale. Basic treatment.

significantly,”

19th treatment (10/9): The patient said her body felt

accordingto“Changed

5levels:somewhat,”“Changed“Did

notchange,” “Worsened somewhat,” and “Worsened

heavy, and she felt strong pain in her surgical site.

significantly.”

Her smile was stiff, perhaps due to the pain. She

significantly,” four responded “Changed somewhat,”

did not refuse to bathe, but she asked if sheshould. She took a bath when prompted, andrepeated this thereafter. Expression level of 4 on
the face scale. Basic treatment.
20th treatment (10/16): The patient said her cold
was completely gone, and she was beginning tofeel much better. The pain in her surgical site had
improved, and a smile returned to her face.
Expression level of 1 on the face scale. Basictreatment.
22nd treatment (10/30): The patient began to talk alot, and said she felt much better. She said her
body felt lighter after the treatment, and she felt
good. She came to her treatment with a full smileon her face. Expression level of 1 on the face scale.
Basic treatment.
25th treatment (11/20): The patient experienced areddening of her feet below the ankle in theFive

responded“Changedand one responded “Did not change.”
When combining “Changed significantly” and“Changed somewhat,” 90% of respondents said thepatient’s expression “changed.” No respondents gave
“Worsened somewhat” or “Worsened significantly” astheir answer.
The respondents were also asked to rate thechanges in nursing case burden immediately after
the treatment, according to the 5 levels of “Decreased
significantly,” “Decreased somewhat,” “No change,”“Increased somewhat,” and “Increased significantly.”Two

responded

responded“Decreased“Decreased

significantly,”

somewhat,”

and

five
three

responded “No change.”
When combining “Decreased significantly” and“Decreased somewhat,” 70% of respondents said
nursing care burden “decreased.” No respondents

middle of the night, and woke up in pain agave“Increased

somewhat”

number of times. The symptom did not appear

significantly” as their answer.

or“Increased

during the daytime, however, and she came to her

Another question asked the respondents to rate

treatment with a full smile on her face.

how the patient’s expression changed from before theExpression level of 1 on the face scale. Basictreatment compared to today, also according to 5

treatment + roller acupuncture of the lower limbs.

levels. Four responded “Changed significantly,” five

26th treatment (11/27): The patient was in good

responded “Changed somewhat,” and one responded

physical condition, and her legs had come to feel

“No change.”light. She began walking using a rollator

When combining “Changed significantly” andbeginning from this day. She came to her“Changed somewhat,” 90% of respondents said thetreatment with a full smile on her face.

patient’s expression “changed.” No respondents said

Expression level of 1 on the face scale. Basicher expression “Worsened somewhat” or “Worsened

treatment + roller acupuncture.

significantly.”
Yet another question asked the respondents to

Thereafter until today, the patient has beenrate how their nursing care burden changed fromstable, with no recurrence of psychological /before the treatment compared to today, similarly

behavioral disorders, and is showing good progress.

according to 5 levels. One responded “Decreased

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

19

Volume 8, Number 3 | Fall 2013

significantly,” six responded “Decreased somewhat,”

indicating the continuous effect of the treatment. By

and three responded “No change.”

continuing the treatment, the patient’s anxiety,

When combining “Decreased significantly” andrestlessness, and depression coming from these“Decreased somewhat,” 70% of respondents said

feelings disappeared, she became more motivated,

nursing care burden “decreased.” No respondents

she stopped refusing nursing care, and became able

said

to communicate better with the nursing staff andtheirburden“Increased

somewhat”

orother residents. These improvements also helped“Increased significantly.”

decreased the staff ’s nursing burden.
Kurosawa et al.1) reports that non-invasive

3. Observation
The patient’s expression level of 8 on the facemechanical stimulation on the skin promotes

scale before the first treatment improved to level 3

dopamine secretion from the nucleus accumbens.

immediately after the treatment. In a question that

Dopamine is said to be a “pleasure” hormone. Whenwas put to the nursing staff, 90% responded that theconsidering the fact that the patient’s expression

patient’s expression “changed” immediately after

rapidly loosened after the treatment and she begantreatment. The patient constantly smiled thereafter,

to smile more often, that her anxiety, restlessness

and the unhappy feelings she had before treatment

and depression disappeared and remained gone, thatdisappeared. Her anxiety and restlessness abated,

she constantly noted that her body felt lighter, andand her sense of depression also disappeared. In athat she remembered her previous treatment andquestion that was put to the nursing staff, 70%

said she had been looking forward to the next

responded that their nursing burden “decreased”

treatment whenever she came in for her treatment,

immediately after treatment. The patient’s desire to

the writer thinks a dopamine activation system wasgo home and her refusal to bathe also dissipated, andinvolved as a reward system.

she began to not only look forward to the treatment,

Depending on the severity of dementia, rubbing

but to also voice her feeling that she had been

acupuncture treatment may have an even greater

looking forward to it. The nursing staff became able

effect by applying it not only once but two to three

to eliminate the time and effort to cajole the patient

times a week.

to doing something she refused to do, and their
nursing burden decreased.

4. Conclusion

The patient had never experienced acupunctureThis case indicates that rubbing acupuncture, bytreatment, and had a sense of fear of being pricked

its method of rubbing the skin without harm to theby a needle, but her first treatment dissipated her

body in any way, may be safely applied within

worries, and the treatment was able to be continued.

around seven minutes, causes no fear of being

In a question put to the nursing staff, 90% responded

pricked by a needle, and has hardly no side effects.

that the patient’s expression “changed” when

It can be applied with the patient sitting or lying

comparing her expression before the treatment anddown, and is thus a simple procedure that anyone

today, and 70% responded that their nursing burden

can receive, including people who are confined to the“decreased” when comparing the burden before

bed or who cannot maintain a sitting position. The

treatment and today. The patient’s expression

side effects of taking multiple drugs have become aimproved significantly and the staff ’s nursing

problem today, but rubbing acupuncture causes

burden decreased immediately after the treatment,

hardly any side effects, as stimulation is applied toand these aspects remained stable thereafter,

the skin by rubbing. Its immediate effect is strong,

20

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 8, Number 3 | Fall 2013its effect lasts, and the amount of drugs taken can be
reduced.
The rubbing acupuncture method is thought to bea procedure that is capable of improving such
psychological symptoms as anxiety, restlessness,depression and low motivation, as well as ofdelivering the joy of living, realizing the lifestyle thatis actively desired by the patient, and increasing
QOL.
Reference
1 Maruyama K, Shimoju R, Ohkubo M, Maruyama
H,

Kurosawa

M.

Tactileskinstimulation

increases dopamine release in the nucleus
accumbens in rats. J Physiol Sci. 2012; 62(3): 259266.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

21

Volume 8, Number 3 | Fall 2013

Clinical Report 2 (Kampo Medicine)
A Case in which the Administration of Multiple Kampo
Drugs Improved the Symptoms of ASD and ADHD in a
15-year-ole Boy

Hideaki Yamaguchi
Tosei General Hospital

Tsumura Kanbakudaisoto extract 5g (single use at times ofanxiety)
The patient clearly began to calm down after taking theprescription, and his respiratory symptoms also abated. The
single-use drug for times of anxiety was also effective.
In March, the patient took the entrance examination and got
into his first-choice school. At his request, he continued toIntroduction
Children encounter various issues and environmental
changes at each stage of their growth. Most children
overcome these issues and changes as they grow up, butsome are unable to fully cope with them, and may fall into astate of mental disorientation. Kampo therapy is effective asa pharmacotherapy for such cases.

take the above prescription in addition to Concerta even after
entering high school, but the Kampo drugs were terminatedafter a month.
Observation:
Children with ASD lack sufficient reality processing
capacity, so their symptoms may be exacerbated byenvironmental changes. In this case, the patient had beenCase: 15-year-old boy with an autistic spectrum disorder(AHD) and attention deficit hyperactivity disorder (ADHD)
Chief complaint: Agitation and panic about taking theentrance examination
History of present illness: At the age of six, the patient wasdiagnosed with Asperger’s syndrome at a specialized
institution. From around the age of ten, he began to exhibit
marked impulsiveness and inattentiveness, so he was put on
methylphenidate. Thereafter, the patient adapted to regularclasses for general students, and did well. However, fromaround November in his third year in junior high school,
before the entrance examination season, he began to become
agitated and restless, and would frequently clear his throat.
In December, he had episodes of panic about taking trial
examinations, to the point that his daily life was disrupted.
As it was unpreferable to increase the dosage ofmethylphenidate, Kampo therapy was attempted.
Interview and findings: The patient was agitated by worries
about the entrance examination, and complained of feelingthat something was caught in his throat. Tip of tongue: red.
Pulse: sunken and thin. Abdomen: nothing in particular.
Treatment and course:
Category 1 (heart and liver blood deficiency), category 2 (qiaccumulation and counterflow), and category 3 (upwardflaming of heart fire) were thought to apply, so the following
prescription was administered.

nervous about the coming examination, so the mostappropriate prescription was selected from among category
1, 2 and 3 drugs, to allow the patient to cope with theexamination.
Reference:
Categories of states of the heart in traditional medicine
and corresponding prescriptions
Category 1 (mainly weakness of the heart, heart blood
deficiency, liver qi deficiency)
Anxiousness, insecurity, sadness, fear (timidity), etc.
In particular, depressive and passive feelings continue
for a prolonged period.
Pre s cription: kanbakutaisoto , kamikihito ,keishikaryukotsuboreito, etc.
Category 2 (mainly liver depression qi stagnation)
Depression, insecurity, anxiousness, hysterics, etc.
Physical tension is strong, and moods tend to readilychange.
Prescription: shigyakusan, saibokuto, etc.
Category 3 (mainly hyperactivity of heart fire, upwardflaming of liver fire, gallbladder stagnation with
disturbance from phlegm)
Anxiousness, short temper, restlessness, impatience, etc.
In particular, agitated symptoms tend to continue for a
prolonged period.
Prescription: yokukansan, yokukansankachinpihange,
orengedokuto, daisaikotokyodaio, etc.

Tsumura orengedokuto extract 5g (twice/day)
Tsumura hangekobokuto extract 5g (twice/day)22

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Make the most of Kampo in modern medicine

Foundation: 1905
A century of tradition ――――We are a manufacturer consistently controlling the entire process fromthe import of crude herbs to the manufacture of Kampo extracts and assuch have contributed to the development of Japanese Kampo.
We sincerely hope to continue in the future with our contribution tomodern medicine through "Kampo".

OHSUGI Pharmaceutical Co., Ltd.

1-1-2 Tennojicho, Minami, Abeno-Ku, Osaka, Japan
Phone: +81-6-6693-3301

The crude drugs like many other creatures on earth areraised by bountiful NATURE.
Humankind earns as well grace from Mother Natureand is blessed as a member of natural world.
PROFILE of

TOCHIMOTO

Since Tochimoto was appointed as aJapan-China friendship trading firm in
1963, we have expanded our businessoverseas, mainly with China.
We import a variety of quality-controlled
natural resources from all over the world
for maintaining wellness.

TOCHIMOTO TENKAIDO CO., LTD.
3-21 Suehiro-cho, Kita-ku, Osaka 530-0053, JAPANwww.tochimoto.co.jp