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The Acupuncture and Oriental Medicine Society of Massachusetts (AOMSM, formerly the Acupuncture Society of Massachusetts, or ASM) recently sponsored a public seminar, "Ancient Medicine in a Modern World," in Brookline, Mass.
Under the direction of president Ra'ufa Clark, the AOMSM is re-invigorating professional activity across the state by providing educational programs and a state-of-the-art Web site (www.aomsm.org) to serve acupuncturists and the public.
Approximately 100 acupuncturists, students, other medical professionals and patients experienced a showcase of research on Oriental medicine by 10 Massachusetts-based scientists associated with the Osher Institute at Harvard University and the New England School of Acupuncture. Both institutions have received significant grants in recent years through the National Institute of Health's (NIH) National Center for Complementary and Alternative Medicine (NCCAM) to pursue clinical trials using acupuncture or related Oriental medicine modalities. Overviews of recent and current research were presented by Lisa Conboy, MA, ScD; Eric Jacobson, PhD; Kong Jian, MD, MS; Ted Kaptchuk, LAc; Catherine Kerr, PhD; Vitaly Napadow, PhD, LAc; Jongbae Park, KMD, PhD; Rosa Schnyer, LAc; Peter Wayne, PhD; and Gloria Yeh, MD, MPH. Most of these researchers also are clinicians in Western or Oriental healing arts.
Most of the studies were conducted at research hospitals in the greater Boston area. All of the researchers are affiliated with the Osher Institute's new program on Asian medicine and healing, which is guided by Ted Kaptchuk and Jongbae Park. The program represents a new approach in research, expanding its interpretative methodologies to include culture, history, linguistics and basic sciences, such as neuroimaging and genetics, as integral to the scientific endeavor in determining which modalities or protocols should be tested and how outcomes should be evaluated and interpreted. According to the directors, the multidisciplinary approach in the program provides a more reliable and efficient method of planning and executing meaningful studies.
Ted Kaptchuk is an assistant professor at the Harvard Medical School and associate director of the Division for Research and Education in Complementary and Integrative Medical Therapies at the Osher Institute. He currently serves on the NCCAM National Advisory Council. He began by pointing out that no longer is there a bridge to be sought between East and West in a world of interpenetrating influences, from tofu and yoga in the West to Calvin Klein jeans and personal stock portfolios in the East. According to Kaptchuk, Western medical researchers are desperately attempting to stay relevant in the midst of global shifts in epistemological assumptions. He continued with a critique of the difficulties encountered by modern medical research methods in seeking to isolate a "one size fits all" active ingredient from Asian treatments. His observation is that classically Asian medicine never asks about giving treatment to everyone in a group. Rather, it asks what treatment a particular patient needs. Western research commonly asks what treatment to give to all patients in a particular class, then measures the average of how they all do.
Kaptchuk also commented on flaws in the idea of the randomized control trial (RCT) in medical research, which is often termed the "gold standard" of scientific validity. Some of his recent research examines earlier published studies which demonstrated that the very fact of participation in experimental studies profoundly affects the apparent efficacy of drugs, as well as of the so-called placebo effect. This finding has implications for what criteria acupuncture research should have to meet in order to be respected by Western academics and policy-makers. He noted that the FDA only needs two positive clinical trials to approve a new drug. On the road to this criterion, pharmaceutical companies have been able to omit publishing unfavorable clinical trials. In contrast, acupuncture trials always are published, even if the findings are insignificant, because funding by government grants requires that the results be reported. Kaptchuk has a major study forthcoming in the British Medical Journal on the placebo effect of sham acupuncture versus oral pills. His team currently is midway into a study using acupuncture for irritable bowel syndrome. This reporter observes that Kaptchuk's career is itself a testament to the interpenetration of Eastern and Western modes of knowledge.
Jongbae Park, creator of a well-known sham needle, reported on a study he conducted for the National Health Service in England using acupuncture for subacute stroke rehabilitation, published in the Archives of Internal Medicine. The study used six points based on Korean diagnostic classifications and four points common to all patients. Using the standard measurement of the Barthel Index of Activities of Daily Living to evaluate 98 patients who completed the study, no significant improvement was found for those patients receiving authentic acupuncture treatment. However, there was greater improvement in leg functions for the more severely disabled patients. Park pointed out the weakness in the trial's design included a failure in the Barthels Index to provide a sufficiently sensitive outcome measure, as well as the relatively small number of patients available for the trial compared to typical multicenter drug trials funded by pharmaceutical companies. In the analysis of statistical significance of a measured change, an outcome that does not reach statistical significance in a test group of a certain size might be statistically significant had the test population been larger.
Peter Wayne is the founding director of the research faculty at the New England School of Acupuncture and a member of the Harvard program on Asian medicine and healing. He reported on just one of his recent studies, testing the effects of tai chi in vestibulopathic balance disorders, a syndrome of dizziness, unstable visual field, nausea and poor balance, which might affect as much as 2 percent of the American population at some point in their lives. The study, utilizing various measuring standards including activities of daily living (ADL), quality of life (QOL) and psychological well-being reports, also employed sophisticated technologies in the Massachusetts General Hospital biomotion lab to measure tai chi's ability to mitigate the dizziness and balance problems commonly troubling to these patients. The patients were given one session a week of simplified tai chi exercises that emphasized slow, mindful movements, and were instructed to practice daily at home. Computerized sensors were able to graph significant improvements in the "wobble" index, demonstrating the efficacy of tai chi exercises in improving anterior/posterior and medial/lateral stability.
Tai chi also was the therapeutic modality studied in a trial conducted by Gloria Yeh, Peter Wayne and others. According to Yeh, the trial evaluated simplified tai chi training as a rehabilitation treatment for the symptoms commonly found among the elderly following cardiac arrest (also known as heart failure): breathlessness, loss of exercise capacity and general fatigue. At the completion of the 12-week trial, patients experienced an improvement in exercise capacity as measured by a six-minute walk test and self-reported improved quality of life. A decrease in both measures was found among control patients. Yeh noted that the researchers conducted personal interviews with each patient and found that most described a very favorable reaction to the practice of tai chi. Yeh's study was published in the American Journal of Medicine. This trial has set the groundwork for a larger, current clinical trial of 150 patients sponsored by the NCCAM and conducted at Beth Israel Deaconess, Brigham and Women's and Massachusetts General Hospitals. This new study also will evaluate the cost-effectiveness of tai chi versus pharmaceutical treatment.
Analysis of brain activity through the use of fMRI was used by acupuncturist and neuroscientist Vitaly Napadow of the Martino Center for Neuroscience at M.I.T. in evaluating the effect of acupuncture in the treatment of carpal tunnel syndrome (CTS) patients for pain and paresthesia. Noteworthy differences in brain activity were found. Using digital mapping techniques of areas of the brain, these researchers found that sensory stimulation of the fingers in unaffected patients show activations contralaterally on the postcentral gyrus and deactivation ipsolaterally, whereas in patients suffering from CTS, there is more contralateral activity and less inhibition of the ipsolateral areas. After acupuncture treatment for five weeks, the CTS patients registered less contralateral activity. Patients exhibited improved grip strength and statistically important improvements in paresthesia, which correlated with fMRI changes.
Kong Jian reported his team's use of functional neuroimaging in evaluating acupuncture and placebo analgesia. The study's aim was to compare manual and electroacupuncture, and to assess if they both work according to the same neural mechanisms. LI 4 (hegu) was stimulated manually and with electrostimulation, and the brain response was recorded with digital mapping. They discovered that a region of the brain associated with pain was activated in common by both methods. However, there also were different regions involved, both in location and direction, when comparing manual acupuncture manipulation and electroacupuncture stimulation. Kong and his colleagues published this study in The Journal of Pain in 2005. It will provide the basis for a new randomized controlled trial to test further whether acupuncture is better than placebo, and whether manual needle stimulation is equal to electrostimulation in response to pain stimulated in the laboratory. To date, they have found that individuals respond differently depending on the mode of administration; that acupuncture, both manual and via electrical stimulation, is better than placebo; and that the effects of acupuncture analgesia are greater on the arm than on the leg due to the greater neural sensitivity (generally) of the arm. Kong noted that it could be inferred for the clinician that if one acupuncture modality fails, a patient might respond quite well to the other.
The final three presentations reflected wider issues related to research methodologies common to the program on Asian medicine and healing group. Rosa Schnyer, the author of Acupuncture in the Treatment of Depression: A Manual for Research and Clinical Practice and Curing Depression with Chinese Medicine, and a member of the board of the Society for Acupuncture Research, outlined a developing methodology of Chinese medicine research. While findings about the efficacy of treatment still are inconclusive eight years after the NIH Consensus Conference on Acupuncture, she said, we are building toward better research models. She emphasized several needs: to maintain fidelity to Chinese medicine as a medical system; to highlight diversity of styles in the profession; to allow both flexibility and standardization in trial design; and to use a clarified treatment implementation plan. She insists that a whole systems research framework, which is both contextual and individualized, is essential for research in defining and evaluating the therapeutic process of Chinese medicine, which includes a collaborative dimension between patient and practitioner, as well as a multiplicity of interventions (moxa, cupping, etc.). At the same time, reliable diagnosis and treatment methods require a degree of standardization and reliability in research, though this should not preclude both quantitative and qualitative measures for outcomes. Schnyer points out that if researchers assess efficacy merely by a few gross treatment outcomes, they might miss instances in which patients experience acupuncture effecting a meaningful change in something that was not measured, such as activities of daily living, adaptability, well-being or hope. In addition, a real challenge is in the development of appropriate controls in the design of trials in order to create control groups wherein the placebo or sham intervention does not, from the perspective of Chinese medical theory, affect the qi of the patient. Theoretically, in research design, an active intervention should be evaluated against an inert intervention. For example, a pill is manufactured that looks exactly like the drug under study, but has no active ingredients. But the designs of some studies on acupuncture seem to assume that if a skin location is not a textbook acupuncture point, a needle placed there would have no effect. Schnyer and her team currently are funded by the NIH to develop reliable and valid Chinese diagnostic research instruments.
Cathy Kerr asked whether there is a unique importance for subjective experience in research outcomes. Historically, only "objective measures" are statistically relevant in the RCT research, but does the experience of the therapeutic modality, especially associated with alternative therapies such as acupuncture, shiatsu, therapeutic touch and the like, change the ways our bodies feel? Working with early data from the Osher Institute's trial on irritable bowel syndrome, Kerr reported that there are interesting differences in the ways patients report the experience of sham acupuncture ("local," "pricking," "painful") and real acupuncture ("throbbing," "warm," "like stirring mud with a stick"). She has learned from fMRI studies that sham acupuncture elicits the surface areas of the brain in neuroimaging, while acupuncture proper activates deeper and wider areas of the brain. These deeper body perceptions are associated with the insula, a brain area that integrates bodily sensation with emotional feelings. Studies show that repeated stimulation of this region reorganizes the sensory mapping of the brain. Kerr believes that such discoveries based on the new technologies associated with neuroscience might provide unique ways to redefine the methodological priorities in complementary and alternative medicine research.
Lisa Conboy put the study of Chinese medicine and CAM into a sociological and epidemiological framework that has become increasingly important for researchers. Conboy, the chief methodologist for the program of Asian medicine and healing, reviewed how social forces affect health and noted the following factors: social integration, workplace stress and responsibility, social support and social determinants of health. She pointed out some of the current debates and battles in establishing meaningful measures of how social forces influence personal health. The need for more complex models was again echoed by Conboy, and she provided an example in the complex data collection mechanisms involved in the Osher Center's IBS trial, which includes the use of biomarkers, genetics, patient interviews on physiological and psychological symptomatology, as well as specific Chinese medicine measurements and social factors.
Tibetologist and psychiatric anthropologist Eric Jacobson finished the program by adding insights based upon his study of affective and anxiety disorders of Tibetan refugees living in India. He compared Tibetan medical models based upon ayurveda and Buddhist epistemology to the current Diagnostic and Statistical Manual of Mental Disorder. In an attempt to expand the methodological approaches in CAM research, Jacobson uses his anthropological training to include ethnography and qualitative research in interpreting psychophysical models of illness which, he believes, affect everyone at different levels. He elaborated on how the Tibetan model of diagnosis that integrates the ayurvedic tri-dosas and the Chinese five elements has important implications for understanding cross-cultural dimensions of psychiatry.
Kaptchuk TJ, Kerr C. Commentary: unbiased divination, unbiased evidence and the patulin clinical trial. J Clin Epid, 2004; 33:247-51.
Kaptchuk TJ. Effect of interpretation bias on research evidence. BMJ 2003; 326:1453-55.
Kaptchuk TJ. The placebo effect in alternative medicine: Can the performance of healing ritual have clinical significance? An Int Med 2002; 136:817-25.
Kaptchuk TJ. Acupuncture: theory, efficacy and practice. Ann Intern Med 2002; 136; 374-83.
Kaptchuk TJ. Varieties of Healing, 2: A taxonomy of unconventional healing practices. Ann Intern Med 2001; 135:196-204.
Kaptchuk TJ. The double-blind randomized controlled trial: Gold standard or golden calf? J Clin Epid 2001; 54-:541-49.
Kaptchuk TJ. The powerful placebo: the dark side of the randomised controlled trial. Lancet 1998; 351:1722-25.
Jongbae Park, KMD, PhD
Park J, White AR, James MA, Hemsley AG, Johnson P, Chambers J, Ernst E. Acupuncture for sub-acute stroke rehabilitation: A sham controlled, subject- and assessor - blind, randomised trial. Arch Intern Med. 2005, (September 26) 165:2026-2031.
Peter Wayne, PhD
Wayne PM, Krebs DE, Parker SW, McGibbon CA, Kaptchuk TJ, Scarborough DS, Gill-Body K, Wolf SL. Can Tai Chi Improve Vestibulopathic Whole Body Dynamic Postural Control? Arch Phys Med & Rehab. 2004; 85; 142-52.
Wayne PM, Scarborough DM, Krebs DE, Parker SW, Wolf SL, Asmundson L, McGibbon CA. Tai Chi as an Intervention for Vestibulopathy: A Case Study. Alt Ther Health Med, 2005;11:606.
McGibbon CA, Krebs DE, Parker S, Scarborough DM, Wayne PW, Wolf SL. Tai Chi and Vestibular Rehabilitation Improve Vestibulopathic Gait via Different Neuromuscular Mechanisms: Preliminary Report. BMC Neurology, 2005; 5:3-15.
McGibbon CA, Krebs DE, Parker S, Scarborough DM, Goldvasser D, Asmundson L, Wayne PW, Wolf SL. Effects of Tai Chi and Vestibular Rehabilitation on Gaze and Whole-Body Stability During a Repeated Stepping Task in Patients with Vestibulopathy. J. Vestib. Rehab, 2004;14:467-78.
Gloria Yeh, MD, MPH
Yeh GY, Lorell BH, Stevenson LW, Wood MJ, Eisenberg DM, Wayne PM, Goldberger AL, Davis RB, Phillips RS. Benefit of Tai Chi as an adjunct to standard care in patients with chronic heart failure. J Card Fail. 2003; 9(5): S1.
Yeh GY, Wood MJ, Lorell B,Â Stevenson LW,Â Eisenberg DM, Wayne P, Goldberger A, Davis RB, Phillip RS. Effect of tai chi mind-body movement therapy on functional status and exercise capacity in patients with chronic heart failure: a randomized controlled trial. Am J Med. 2004; 117:541-548.
Vitaly Napadow, PhD, Lic Ac
Napadow V, Kaptchuk TJ. Patient characteristics for outpatient acupuncture in Beijing, China. J Altern Complement Med. 2004 Jun;10(3):565-72.
Napadow V, Liu J, Kaptchuk TJ. A systematic study of acupuncture practice: acupoint usage in an outpatient setting in Beijing, China. Complement Ther Med. 2004 Dec;12(4):209-16.
Napadow V, Makris N, Liu J, Kettner NW, Kwong KK, Hui KK. Effects of electroacupuncture versus manual acupuncture on the human brain as measured by fMRI. Hum Brain Mapp. 2005 Mar;24(3):193-205.
Napadow V, Kettner N, Ryan A, Kwong KK, Audette J, Hui KKS. Somatosensory Cortical Plasticity in Carpal Tunnel Syndrome - a Cross-sectional fMRI Evaluation. in review.
Napadow V, Liu J, Li M, Kettner N, Ryan A, Kwong KK, Hui KKS, Audette J. Somatosensory Cortical Plasticity in Carpal Tunnel Syndrome - a Longitudinal fMRI Evaluation. In preparation.
Kong Jian, MD, MS
Kong J. A hypothesis on the corresponding brain centers of meridians.Journal of Acupuncture and Moxibustion. 1991;7: 11-13.
Kong J. A discussion on the phenomenon of sleeping induced bypropagated sensation along meridians. Journal of Yunnan College ofTraditional Chinese Medicine. 1991;14:23-25.
Kong J. A discussion on mechanism of the propagated sensation alongmeridians. Journal of Shandong College of Traditional Chinese Medicine.1992;16:67-68.
Kong J, Yang XZ, Wang Y, et al. Topographic observation onspatio-temporal character of SEP early component elicited by stimulatingdifferent acupoints. Acupuncture Research. 1997;22:283-286.
Kong J, Ding Z, Yang XZ, et al. Investigation of event-relatedpotential (P300) in Rujing (Relaxation) state. Chinese Journal ofBehavioral Medical Science. 1997;6:166-168.
Kong J, Ding Z, Yang XZ, et al. A study on the cerebral cortex statewith the appearance of PSM phenomena. Journal of Chinese Acupuncture.1998;18:41-43.
Wang YP, Tang XF, Kong J, Zhuang D and Li S. Different systems inhuman brain are involved in pre-semantic discrimination of pictures asrevealed by event-related potentials. Neuroscience Letters.1998;257:243-146.
Kong J, Wang YP, Wang HJ, Shan HY and Zhuang D. The effect ofelectro-stimulation of acupuncture points on the performance of"true/false" tests and reaction time. Chinese General Practice Medicine.1998;1:174-175.
Kong J, Wang YP, Shang HY, Wang Y, Yang X and Zhuang D. Brainpotentials during mental arithmetic--effect of problem difficulty on brainevent-related potentials. Neuroscience Letters. 1999;260:169-172.
Wei HF, Lawrence, CL. and Kong, J. The substance and properties ofMeridians: a review of modern research. Acupuncture in medicine.1999;17:134-139.
Kong, J, Wang YP, Zhang W, Wang H, Wei H, Shang H, Yang X, Zhuang D.Event-related brain potentials elicited by a number discrimination task.Neuroreport. 2000;11:1195-1197.
Wei HF, Kong, J, Zhuang, D, et al. Early-latency somatosensory evokedpotentials to electrical acupuncture in acupoint of LI-4. ClinicalElectroencephalography, 2000;31:160-164.
Cui LL, Wang Y, Wang HJ, Tian SJ, and Kong J Human brain sub-systemsfor discrimination of visual shapes, Neuroreport, 2000;11:2415-2418.
Wang YP, Kong J, Tang X, Zhuang D, Li S. Event-related potentialsproduced by an indirect matching task, Neuroscience Letters.2000;293:17-20
Wang H, Wang Y, Kong J, Cui L, Tian S, Enhancement of conflictprocessing activity in human brain under task relevant condition,Neuroscience Letters. 2001;298:155-158
Kong J, Ma L, Gollub RL, Wei J, Yang X, Li D, Weng X, Jia F, Wang C,Li F, Li R, Zhuang D, A Pilot Study of Functional Magnetic ResonanceImaging of the Brain During Manual and Electroacupuncture Stimulation ofAcupuncture Point (LI-4 Hegu) in Normal Subjects Reveals DifferentialBrain Activation Between Methods. J Altern Complement Med 2002;8:411-419
Kong J, Wang C, Kwong K, Vangel M, Chua E, Gollub R., The neuralsubstrates of arithmetic operations and procedure complexity, Brain ResCogn Brain Res, 2005; 22:397-405
Kong J, Fufa DT, Gerber AJ, Rosman IS, Vangel MG, Gracely RH, GollubRL, Psychophysical outcomes from a randomized double blind study ofacupuncture analgesia. Journal of Pain, 2005; 6: 55-64
Kong J, White N, Kwong K, Vangel, MG, Rosman IS, Gracely RH, GollubRL, using fMRI to dissociate sensory encoding from cognitive evaluation ofheat pain intensity, Human Brain Mapp. In press
Rosa N. Schnyer, LAc, Selected Peer Reviewed-Publications
Schnyer, RN. Chinese Medicine in the treatment of AIDS (1992). Journal of the Complementary Medicine Association. December.
Allen, J.J.B., Schnyer, R.N., & Hitt. S.K. (1998). The efficacy of acupuncture in the treatment of major depression in women. Psychological Science, 9, 397-401.
Allen, J.J.B., & Schnyer, R.N. (1998). The role of acupuncture in the treatment of Major Depression. E.A. Blechman, and K. Brownell (Eds.), Behavioral Medicine for Women: A Comprehensive Handbook. (pp.764-769). New York: Guilford Press
Schnyer, R.N. (2001). Depression in Women: Acupuncture as a Treatment. The Women's Studies Encyclopedia. Routledge International.
Schnyer, R.N., & Flaws, Bob. (1998). Curing Depression with Chinese Medicine. A lay person's guide. Blue Poppy Press: Boulder, Colorado.
Schnyer, R N., Allen J. B., Hitt, S.K., Manber R. (2001). Acupuncture in the Treatment of Major Depression: A Manual for Research and Practice. London. Churchill Livingston.
Schnyer, RN et al (2001) Evaluating Inter-rater reliability of the assessment of major depression from the perspective of Chinese medicine: rationale, challenges and preliminary conclusions. Alt Ther 2001; 7: 110.
Schnyer RN, Allen JJB (2001) Bridging the gap in acupuncture research: standardization vs. flexibility of treatment. Alt Ther 2001; 7:S29.
Schnyer, R. N. & Allen JJB (2002). Depression and Mental Illness. C. M. Cassidy (Ed.), Contemporary Practice of Acupuncture and Oriental Medicine, Churchill Livingston.
Schnyer R.N. & Allen J.J.B. Bridging the Gap in Complementary and Alternative Medicine Research: Manualization as a Means of Promoting Standardization and Flexibility of Treatment in Clinical Trials of Acupuncture. Compl and Alt Medicine, Vol8. No.5, October 2002.
Schnyer R.N, Manber R, Fitzcharlers A. Acupuncture Treatment for Depression during Pregnancy: Conceptual Framework and Two Case Reports (2003), Complementary Health Practice Review.
Manber R, Schnyer RN, Allen JJB, Rush J, Blasey C. Acupuncture: A Promising Treatment for Depression During Pregnancy (2004) Journal of Affective Disorders, 83, p.89-95.
Schnyer R, Wayne P, Kaptchuk T, Cheng X, Zhang Z, Stason, W. Acupuncture Protocols in Clinical Research: Development of Standardized, Individually-Tailored Treatments in a Randomized Control Trial of Acupuncture for Stroke Rehabilitation (in progress).
Wayne P, Krebs D, Macklin E, Schnyer R, Kaptchuk T, Parker S, Moxley Scarborough D, McGibbon C, Schaechter J, Stein J, Stason W. Acupuncture for Chronic Stroke: A Randomized Sham-Controlled Study. Submitted, February, 2005: Archives of Physical Medicine and Rehabilitation.
Nir Y, Schnyer R, Huang M, Chen B, manber R. Acupuncture for post-menopausal hot flashes. Submitted July, 2005: Obstetrics and Gynecology.
Duncan B, Davis M, Meaney FJ, McDonough-Means S, Worden KA, Schnyer R. The effectiveness of cranial sacral osteopathic manipulation or acupuncture as adjunctive therapy for children with spastic cerebral palsy. Submitted July, 2005: Pediatrics.
Schnyer R, Conboy L, Jacobson E, Mc Knight P, Goddard T, Moscatelli F, Legedza A, Kerr C, Kaptchuk T, Wayne P.Development of a Chinese Medicine Assessment Measure: An Interdisciplinary Approach using the Delphi Method. Accepted August 2005: Journal of Complementary and Alternative Medicine.
Huang M, Nir Y, Chen B, Shnyer R, Manber R. A randomized control pilot study of acupuncture for post-menopausal hot flashes: Effect on nocturnal hot flashes and sleep quality. Submitted; September 2005. Fertility and Sterility.
Catherine Kerr, PhD [none provided]
Lisa Conboy, MA, ScD [none provided]
Eric Jacobson, PhD, Publications on Tibetan medicine:
Panic Attack in a context of mixed anxiety and depression in a Tibetan refugee. Culture, Medicine and Psychiatry, 2002, 26:259-279.
'Life-wind illness' in Tibetan medicine: Depression, generalized anxiety and panic attack. In Proceedings of the 13th International Association for Tibetan Studies. Leiden: Brill. In press.
Panic Attack in Tibetan refugees. In Culture and Panic. Good BJ and Hinton D (eds). Rutgers University Press. Forthcoming.
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