Saturday, December 29, 2012

Revision of the Meridians of the Dorsal Aspect of the Body

In his article “Chinese Medicine Demystified1” Chris Kresser explained that the meridians of Chinese Medicine were an invention of Georges Soulie de Morant who translated the Huang Di Nei Jing into French. The meridians came about when de Morant studied Chinese anatomical diagrams that featured the acupuncture points, then drew lines connecting these points. According to Kresser, no such lines exist in the original text, though these points were known to have special physiological properties to the Chinese, as Kresser states:

“The original texts have drawings of major arteries going from the trunk into the legs. The points are arranged along these arterial routes.
The word De Morant translated as point is “jie”. Jie is more correctly translated as node, neurovascular node, or critical juncture. The Chinese knew that these nodes represent areas of fine vascular structures (arterioles, capillaries and venules – although they didn’t call them this at the time) and related nerves. Even 2,500 years ago, the superficial nodes were recognized to have afferent and efferent neural properties.
Modern research has demonstrated that neurovascular nodes (acupuncture points) contain a high concentration of sensory fibers, fine blood vessels, fine lymphatic vessels, and mast cells. These nodes are distributed along longitudinal pathways of the body where the collateral blood vessels supply the capillaries and fine vessels. The corneum stratum of the skin in these areas is slightly thinner with a lower electrical resistance. They also contain more sensory nerves, and have more fine vessels with sequestered mast cells than non nodes.”
Kresser also references the work of Donald Kendall2 in this assessment.

When one takes into account the background of de Morant, the picture for the meridians becomes clearer. He was a Dutch banker, living for a time in China, and had some exposure to Indian culture. There are quirks with how some of the meridians are put together, particularly the Bladder being the only 'double' meridian with two distinct external lines. When the point wei guan xia shu, is considered the problems are even greater. It is on the inner line of the Bladder meridian and functions as the back shu point for the pancreas. It is unusual that this point is regarded as an 'extra point', as it is clearly on the Bladder meridian and behaves like a back shu point, but is not part of the meridian by traditional texts. Did the translator forget to include it? Did it appear after people realized there was a pancreas (the Chinese, while they did have a good knowledge of anatomy, did not find the pancreas for a while)? Did someone just get lazy and not want to revise the system?

Morant was not a physician, he did have a background in Ayurveda and that appears to have informed his interpretation of the Huang Di Nei Jing. In the almost sixty years past his death the world of medicine, including the practice of Chinese Medicine, has progressed. We do ourselves and our patients an appalling disservice if we do not continue to refine our technique and make new discoveries.

That stated, the meridians still have their place. They are an excellent guideline to follow for the clinical anatomy that is relevant for Traditional Chinese Medical (TCM) Practitioners. Physical correlations have been found, particularly with the discovery of Bonghan ducts in 20043.

The meridians are a useful tool, but one that needs to be updated.

As stated in the title, I am principally concerned with the points on the back for this article. The current model of these points is as follows4:


Vertebrae
On vertebrae
0.5 cun lateral to the spine
1.3 cun
1.5 cun
2 cun
3 cun
3.5 cun
C1
Du 15
Jia jie (clinical), neck
Bl 10




C2

Jia jie (clinical), neck





C3

Jia jie (clinical), neck





C4

Jia jie (clinical), neck





C5

Jia jie (clinical), neck





C6

Jia jie (clinical), neck





C7
Du14
Jia jie (clinical), neck, and Ding Chuan


Si 15


T1
Du 13
Jia Jie, lung and upper limb

Bl 11 influential point of bones

Si 14

T2

Jia Jie, lung and upper limb

Bl 12

Bl 41

T3
Du 12
Jia Jie, lung and upper limb

Bl 13 bs lung

Bl 42

T4

Jia Jie, lung and upper limb, heart

Bl 14 bs pericardium

Bl 43

T5
Du 11
Jia Jie, heart

Bl 15 bs of heart (bl points are lower border of spinous process), Huan Men (level with the prominence of spinous process

Bl 44

T6
Du 10
Jia Jie, heart

Bl 16 bs du meridian

Bl 45

T7
Du 9
Jia Jie, heart, Liver and Gallbladder

Bl 17 bs diaphragm, influential point of blood

Bl 46

T8

Jia Jie, liver and gallbladder

Wei guan xia shu, bs of pancreas



T9
Du 8
Jia Jie, liver and gallbladder

Bl 18 bs of liver

Bl 47

T10
Du 7
Jia Jie, liver and gallbladder, spleen and stomach

Bl 19 bs of gallbladder

Bl 48

T11
Du 6
Jia Jie, spleen and Stomach

Bl 20 bs of spleen

Bl 49

T12

Jia JieJia Jie, spleen and Stomach

Bl 21 bs of stomach

Bl 50

L1
Du 5
Jia Jie, kidneys

Bl 22 bs of san jiao

Bl 51

L2
Du 4
Jia Jie, kidneys

Bl 23 bs of kidneys

Bl 52

L3

Jia Jie, bladder, large and small intestine, uterus, lower limbs

Bl 24



L4
Du 3
Jia Jie, bladder, large and small intestine, uterus, lower limbs

Bl 25 bs of large intestine


Yan Yao
L5
Shi Qi Zhui Xia
Jia Jie, bladder, large and small intestine, uterus, lower limbs

Bl 26



S1
Bl 31


Bl 27 bs of small intestine



S2
Bl 32


Bl 28 bs of bladder

Bl 53

S3
Bl 33


Bl 29



S4
Bl 34


Bl 30



Coccyx
Du 2
Bl 35



Bl 54


A few details one should keep in mind about this model.
  1. The points for the Du meridian are directly on the spine, the bladder points in the S1-4 region are in the sacral foremen and as such are not on the meridian of the Du.
  2. With the exception of the Huan Men point, all the points that are on the 1.5 cun line are 1.5 cun lateral to the lower border of the spinous process of the vertebrae that they are paired with.
  3. 'BS' is short for 'back shu'. 'Bl' is for 'bladder meridian', 'Du' is for 'Du meridian', 'Si' is for 'Small intestine meridian'.
  4. Named points, such as Jia jie, shi qi zhui xia, and some others, are not traditionally associated with any meridian.
  5. The jia jie points related with C1-7 are not traditionally taught points but are used clinically.
  6. The influential points of blood and bone are used to treat conditions relating to bone or blood issues.

While this model is remarkably done, especially considering the original sources did not have access to MRIs, and that our English translation and interpretation of it comes by way of a Dutch banker who translated an old Chinese dialect into French, there is some need for revision.

The current model in use by physicians today in treating conditions using points along the spine is as follows5:

Clearly, while there is similarity between the actual nerves and the related Chinese points, the correlation is not perfect.

As we now have access to research that was gained in the decades following De Morant's death, it is time that these points were revised. Tradition can guide us, but we need not be shackled to it. My proposal is:

  1. The extra points that are clearly on the lines of the Du or Bladder meridians should be incorporated into these meridians.
  2. The back shu points should be revised to reflect the actual spinal level where biological medicine treats the organ that the back shu point is related with.
  3. The Jia jie points should be considered as points that treat the internal meridian of the Du6
  4. The Jia jie points should clinically be considered for all vertebrae.

As such, the revised chart for the meridians on the spine is as follows:


Vertebrae
On vertebrae
0.5 cun lateral to the spine
1.3 cun
1.5 cun
2 cun
3 cun
3.5 cun
C1
Du 16
Jia jie head, brain, ears
Bl 10




C2

Jia jie ears, eyes, nose





C3

Jia jie ears, tooth ache





C4

Jia jie mouth





C5

Jia jie throat





C6

Jia jie neck





C7
Du15
Jia jie Thyroid


Si 15


T1
Du 14
Jia Jie, throat and upper limb

Bl 11 influential point of bones

Si 14

T2

Jia Jie, heart

Bl 12 bs of heart

Bl 43

T3
Du 13
Jia Jie, lung chest, throat

Bl 13 bs lung

Bl 44

T4

Jia Jie, gallbladder

Bl 14 bs gallbladder

Bl 45

T5



Bl 15 (originally Huan Men)
level with the prominence of spinous process, influential of blood





T5
Du 12
Jia Jie, liver, solar plexus

Bl 16 lower border of spinous process), bs of liver

Bl 46

T6
Du 11
Jia Jie, stomach

Bl 17 bs stomach

Bl 47

T7
Du 10
Jia Jie, heart, pancreas, duodenum

Bl 18 bs of pancrease

Bl 48

T8

Jia Jie,spleen

Bl 19 bs of spleen



T9
Du 9
Jia Jie, adrenal glands

Bl 20

Bl 49

T10
Du 8
Jia Jie, Kidneys

Bl 21

Bl 50

T11
Du 7
Jia Jie, kidneys, ureters

Bl 22 bs of kidneys

Bl 51

T12

Jia Jie small intestine, lymph

Bl 23 bs of small intestine

Bl 52

L1
Du 6
Jia Jie, large intestine, inguinal

Bl 24 bs large intestine

Bl 53

L2
Du 5
Jia Jie, appendix, abdomen, upper leg

Bl 25

Bl 54

L3

Jia Jie, bladder, sex organs, uterus, knees

Bl 26 bs of bladder



L4
Du 4
Jia Jie, prostate, lower back, sciatic nerve

Bl 27


Yan Yao
L5
Du 3
Jia Jie, lower leg

Bl 28



S1
Bl 33


Bl 29



S2
Bl 34


Bl 30

Bl 55

S3
Bl 35


Bl 31



S4
Bl 36


Bl 32



Coccyx
Du 2
Bl 37



Bl 56


This chart incorporates the extra points that are clearly on the path of a given meridian on the back, updates the clinical uses of these points to be compliant with current biomedical research, and updates the numbering system of the points. As one can see, the only extra point that was not incorporated is Yan Yao, which is clearly not on any of the meridians.

I anticipate that there will be further revisions made as more research occurs, I for one would like to make sure that this system correlates with what is known about dermatomes and myotomes as potentially revise the jia jie and outer bladder lines further, but for now I believe this is an adequate update to the meridians of the back which simplifies the matter of extra points and updates treatment guidelines to be complicit with modern research.


2Kendall, Donald. The Dao of Chinese Medicine. Oxford University Press, 2002

3Journal of Korean Physical Society, vol 45, no 5, November 2004 pp 1196-1198

4This chart is based off of the text by:
Deadman, Peter and Al-Khafaji Mazin, with Baker, Kevin, A Manual of Acupuncture, Journal of Chinese Medicine Publications, East Sussex England. 2007


6See Maciocia, Giovanni, The Foundations of Chinese Medicine Second Edition, Elsevier Churchill Livingstone, 2005, pg 840

Wednesday, August 1, 2012

Acid Reflux


It is summer, and in Texas that means barbeque, brisket, beer, tortillas, and a number of other grilled foods. With the temperature blazing away above 100 degrees, outdoor exercise is unlikely, but you still want to get together with your friends and neighbors. Then it hits, a painful burning sensation in your gut. You have just had a bout with acid reflux!

Acid Reflux is an irritation that is caused by a back flow of stomach acid into the esophagus. While occasional acid reflux, also called heartburn or gastroesophageal reflux disease (GERD), is nothing to worry about, a more chronic occurrence can be a serious problem.

What can Acupuncture do to help?
Acupuncture can help this condition by:
  • strengthening organ function to relieve symptoms
  • give dietary suggestions and herbal supplements
  • treat the cause(s)
Causes:
Acid reflux is caused by either too much food in the stomach (via overeating), or too much pressure on the stomach (usually from pregnancy or obesity). Issues that compound these factors are:
  • Stress
  • Lack of Sleep
  • Smoking
  • Excessive Alcohol intake
  • Hiatal hernia
  • Scleroderma
  • Cancer
  • Certain medications such as
      • Anticholinergics (e.g., for seasickness)
    • Beta-blockers for high blood pressure or heart disease
    • Bronchodilators for asthma
    • Calcium channel blockers for high blood pressure
    • Dopamine-active drugs for Parkinson's disease
    • Progestin for abnormal menstrual bleeding or birth control
    • Sedatives for insomnia or anxiety
    • Tricyclic antidepressants
Symptoms:
  • Feeling that food is stuck behind the breastbone
  • Heartburn or a burning pain in the chest (under the breastbone)
    • Increased by bending, stooping, lying down, or eating
    • More likely or worse at night
    • Relieved by antacids
  • Nausea after eating
Less common symptoms are:
  • Bringing food back up (regurgitation)
  • Cough or wheezing
  • Difficulty swallowing
  • Hiccups
  • Hoarseness or change in voice
  • Sore throat
What can I do?

1. If severe you may need to check with a gastroenterologist on some tests that can be done to secure a proper diagnosis.

2. If you suspect your medication is the culprit, speak with your doctor about it.

    3. You may wish to consider a dietary change. While I have been touting the Paleo diet, which is heavy on meats, it is not about greasy food. Pay attention to the oils you are using for cooking as well as what foods set you off. You may wish to consult with a nutritionist.
  1. Address any stress or insomnia issues in your life. Acupuncture can help with these factors as can a good psychologist, counselor, or hypnotherapist.


  1. Address any smoking or excessive alcohol intake. Like the fourth point, acupuncture and other modalities can help with these issues.
  2. If you suspect this is an issue from excessive weight, there are a number of fitness therapies, from my qigong articles (especially those dealing with the spleen and liver), to finding a trainer, or going to a gym.
7. If you suspect this is due to overeating, learn portion control. Your stomach is usually satiated about ten minutes before the 'full' feeling hits so slow down and allow the food to be processed a bit before you go all the way through a big meal.

I help people to go through their lives pain free and with greater energy, if you or someone you know someone would benefit from my services, please give me a call or e-mail. I look forward to working with you.

References:

Wednesday, July 25, 2012

Cancer


Cancer is the uncontrolled growth of abnormal cells in the body. Cancer occurs when normal cells multiply too quickly, or when natural cell death stops. Cancer can develop in almost any organ or tissue, such as the lungs, colon, breast, skin, bones, or nerve tissue.

What can Acupuncture do to help?
Acupuncture by and large is best used as a supplementary treatment for cancer, a preventative treatment, or to address the side effects of other cancer treatments. An acupuncturist can:
  • improve ones overall energy and immune system
  • prescribe herbal and dietary supplements to prevent cancer from occurring and treat the side effects of cancer fighting drugs
  • treat other effects of cancer, such as aches, pains, digestion issues, etc.

Causes:
Cancer is caused by
  • Benzene and other chemicals
  • Drinking excessive alcohol
  • Environmental toxins, particularly aflatoxins which are found in peanuts
  • Excessive sunlight exposure
  • Genetic problems
  • Obesity
  • Radiation
  • Viruses
However, the cause of many cancers remains unknown.

Types of Cancer:
Some of the many types of cancer are:


Symptoms:
The exact symptoms of a particular cancer will vary but there are a few symptoms that seem to be universal to any cancer. These are:

Stages of Cancer:
This is a broad and simplistic overview of the stages of cancer.

Stage 1 usually means a cancer is relatively small and contained within the organ it started in.



Stage 2 usually means the cancer has not started to spread into surrounding tissue, but the tumor is larger than in stage 1. Sometimes stage 2 means that cancer cells have spread into lymph nodes close to the tumor. This depends on the particular type of cancer.



Stage 3 usually means the cancer is larger. It may have started to spread into surrounding tissues and there are cancer cells in the lymph nodes in the area.



Stage 4 means the cancer has spread from where it started to another body organ. This is also called secondary or metastatic cancer.

What can I do?

  1. Make sure that you have done the proper tests and treatment.
  2. Become very informed and aware of your environment. Cancer can be linked to various chemicals and one will probably need to make life style choices to thoroughly treat this disease.
  3. Be aware of what you are ingesting through your diet, and air quality. Many chemicals break down into alcohol in the body. A proper diet can do wonders for your symptoms and is a great preventative. I recommend the Paleo Diet which you can find out more details about from: http://whole9life.com/2012/01/whole-30-v2012/
  4. Get environmental testing done on your living space and place of work if you suspect chemicals from there as being the cause. The Environmental Health Center can give you the name of some good testers and check you for any sensitivities you may have developed. http://www.ehcd.com/
  5. Qigong exercises can help with fatigue and other issues stemming from the cancer and are fairly gentle on the body. You can look over some of my previous articles:
    or contact me for specific information on your unique case.
  6. A more radical treatment approach, and one which I would recommend as either a preventative or in conjunction with a more standard treatment, is to take the Pan Alone Enzymatic Support for the immune system. This is best for people who have found they have bio-markers that predispose them to getting cancer within the next 10 years, but can help those who already have cancer. Please note: the research behind this treatment is not as fleshed out as it should be at this time and one needs to work with an entire protocol of sauna and coffee enemas to make this work. Failure to do so could result in severe, negative effects. Do not attempt this without consulting a medical practitioner who is knowledgeable about the process.
  7. Other alternative therapies, such as energy healing, reiki, naturopathy, radonics, and orgone therapies, etc. I am personally of the opinion that these make for useful supplemental therapies that some have had astounding results from. That said, I DO NOT endorse using these therapies exclusively and finding a good practitioner can be difficult. Cancer treatment needs to be integrative between standard and traditional approaches. A good energy healer would be Deborah at: https://www.ahealingplace.org/
  8. Develop a positive attitude. This one may be a very difficult task, however people with a better outlook on their health tend to have better responses to treatment.


Your health is in your hands and I can help you to improve your life. I look forward to assisting you on your journey.

References:
http://invigorating-acupuncture.blogspot.com/2011/12/five-organ-qigong.html
http://www.aehf.com/
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002267/

Tuesday, July 17, 2012

Blood Stasis

Blood Stasis

Blood Stasis is most classically defined as the bruising one develops after one's knees find locate a piece of furniture in a dark room. More broadly, blood stasis in Traditional Chinese Medicine (TCM) is any impairment of blood circulation, which can have a variety of causes.

What can Acupuncture do to help?
Acupuncture can help this conditions by:
  • improving one's sleep so one does not feel the need to explore a room in the dark
  • improve circulation
  • prescribe herbal medicine to supplement other treatments
  • treat underlying causes
Causes:
Blood stasis is caused by either some form of injury resulting in localized bruising, or by organ dysfunction, normally the Liver or the Spleen in TCM. The circulation of these organs can be impaired by:
  • insufficient nutrition
  • emotional stress
  • trauma
  • chemical stress
  • repetitive action (such is the case for carpal tunnel)

Symptoms:
  • sharp pain (usually aggravated by cold and pressure.)
  • numbness or tingling in the extremities
  • bruising
  • purple tongue
  • low energy
  • cold sensation in the hands or feet

What can I do?

1. If blood stasis is due to trauma, it will usually resolve on its own. Ice the area for the first 48 hours following the injury then start using heat. Start massaging the area gently to get the blood flow moving.

2. For more chronic blood stasis, especially if you suspect it is linked to emotional stress, check out my articles on Qigong, in particular pay attention to spleen, and liver patterns.

    3. If this is a chronic condition such as Multiple Sclerosis, or simply long term pain, consider a dietary change. Reduce or eliminate gluten (wheat), fruit intake, greasy food, spicy food and dairy as these tax your organs and can result in chronic inflammation which will impair your circulation. A paleo diet will help with this. Please note, while this will be a lifetime process, you don't have to skip out on tasty treats all the time.
  1. Drink some red wine. In moderation. This will help with your circulation.
  2. If your condition is due to repetitive motion on a computer, such as carpal tunnel, consider voice recognition software to assist you. There are also ergonomic keyboards. http://www.nuance.com/for-individuals/by-product/dragon-for-pc/index.htm
  3. A TENS unit can work wonders, as can a cupping set. I can treat you with either or show you how to use them yourself. http://invigorating-acupuncture.blogspot.com/2011/11/cupping.html
  4. Warm baths can help.
  5. Proper stretching and recovery time after workouts is important and will reduce your chances of developing shin splints and damaged muscles.
  6. Get at least 8 hours of sleep. Proper sleep will help your body recover from daily stresses and improve your ability to heal.
  7. If this has been a long term issue, without a clear cause, check out my article on the works of Dr. Shoemaker or consult with Dr. Rea.

Your health is in your hands and I can help you to improve your life. I look forward to assisting you on your journey.

References:

Tuesday, July 10, 2012

Adrenal Insufficiency and Adrenal Fatigue



Adrenal insufficiency is a condition, which can be diagnosed by blood tests, where the production of hormones by the adrenal glands has decreased. This can result in symptoms of chronic worsening fatigue, muscle weakness, and several others.

Adrenal fatigue is a set of non specific symptoms, such as fatigue, nervousness, body aches and others, which is often attributed to a mild form of Adrenal insufficiency brought on by chronic stress.


What can Acupuncture do to help?
Acupuncture can help both of these conditions by:
  • increasing one's energy
  • improving circulation
  • prescribing herbal medicine to supplement other treatments and address stress
  • assist you in planning an appropriate diet and exercise program
  • treat other symptoms


Causes:
Primary adrenal insufficiency is caused by damage to the adrenal glands resulting in decreased levels of cortisol and aldosterone. This is also called Addison's disease and it effects about 1 to 4 people per 100,000.

Secondary adrenal insufficiency is caused when the pituitary gland does not produce enough adrenocorticotropin (ACTH) which stimulates the adrenal glands to produce cortisol. Cortisol production drops with the decrease in ACTH and the adrenal glands shrink, which will eventually decrease aldosterone production as well. Secondary adrenal insufficiency is much more common than primary adrenal insufficiency.

Adrenal fatigue,being a rather vague set of symptoms, is not a well accepted medical diagnosis so the cause is not well known. That said it is possible that the symptoms of adrenal fatigue could be caused by chronic stress, depression, or fibromyalgia.

Full list of symptoms:
Adrenal insufficiency:

The symptoms of adrenal insufficiency usually have a gradual onset. The most common symptoms are:
  • chronic, worsening fatigue
  • muscle weakness
  • loss of appetite
  • weight loss
Other symptoms can include
  • nausea
  • vomiting
  • diarrhea
  • low blood pressure that falls further when standing, causing dizziness or fainting
  • irritability and depression
  • a craving for salty foods due to salt loss
  • hypoglycemia, or low blood glucose
  • headache
  • sweating
  • in women, irregular or absent menstrual periods
Hyperpigmentation, or darkening of the skin, can occur in Addison's disease but not in secondary adrenal insufficiency. This darkening is most visible on scars; skin folds; pressure points such as the elbows, knees, knuckles, and toes; lips; and mucous membranes such as the lining of the cheek.
Because the symptoms progress slowly, they are often ignored until a stressful event like an illness or accident causes them to worsen. Sudden, severe worsening of symptoms is called an Addisonian crisis, or acute adrenal insufficiency.
Symptoms of an Addisonian or "adrenal" crisis include
  • sudden, penetrating pain in the lower back, abdomen, or legs
  • severe vomiting and diarrhea
  • dehydration
  • low blood pressure
  • loss of consciousness
If not treated, an Addisonian crisis can be fatal

Adrenal Fatigue:
  • excessive fatigue and exhaustion
  • non-refreshing sleep (you get sufficient hours of sleep, but wake fatigued)
  • overwhelmed by or unable to cope with stressors
  • feeling rundown or overwhelmed
  • craving salty and sweet foods
  • you feel most energetic in the evening
  • a feeling of not being restored after a full night's sleep or having sleep disturbances
  • low stamina, slow to recover from exercise
  • slow to recover from injury, illness or stress
  • difficulty concentrating, brain fog
  • poor digestion
  • low immune function
  • food or environmental allergies
  • premenstrual syndrome or difficulties that develop during menopause
  • consistent low blood pressure
  • extreme sensitivity to cold

What can I do?

Adrenal insufficiency:
1. Check out my articles on Qigong, in particular pay attention to spleen, kidney, and liver patterns.

  1. Consult with a nutritionist about developing a proper diet with the correct amount of salt intake and sugar intake. Most likely a modification of a diet for Type II diabetes is in order.

  2. Be aware of any medications you are taking and what they interact with. Certain blood pressure medications, high or low, do not interact well with others. Be particularly aware of any hormone replacement medications you are taking as well as corticosteroids.

  3. Keep hydrated.

  4. Be careful about your use of stimulants as these further tax the adrenals.


Adrenal fatigue:

  1. Most of the steps mentioned for Adrenal insufficiency would be a good baseline for you.

  2. If you notice that symptoms consistently worsen after eating certain foods or you go to certain places, avoid those foods and areas. If the area is at your home or office consider having environmental and or mold testing done (see my review of Dr. Shoemaker's works: http://invigorating-acupuncture.blogspot.com/2012/04/review-of-works-of-dr-ritchie-shoemaker.html). You may find other information in there which is useful to you, feel free to call me if you need some interpretation.

  3. You may also wish to consider environmental testing. Consider: http://www.ehcd.com/

  4. Talk with a nutritionist about supplements to regain energy.


Your health is in your hands and I can help you to improve your life. I look forward to assisting you on your journey.

References:

Wednesday, April 4, 2012

Review of the Works of Dr. Ritchie Shoemaker


Executive Summary of the Works of Dr. Ritchie Shoemaker for Purposes of Establishing a Baseline

If one wished to determine if there was the potential for Chronic Inflammatory Response Syndrome (CIRS, no DX code mentioned, if one wished to use the code for SIRS that would be 995.90 ) in an individual as defined by Dr. Shoemaker’s terminology, one would test for:   Elevated TGFβ-1, C4-a, C3-a, and low levels of MSH and VIP.
In my opinion, the most important of these tests, if one was only going to take a few of them, would be the tests for MSH and VIP values.  While the other tests are important their readings could be misleading as they are both time and exposure sensitive.  If MSH and VIP are low then it would strongly imply that there is potential for some type of chronic inflammation and further investigation is recommended.  To conduct these tests Dr. Shoemaker recommends:
VCS aptitude test which can be done online for $15: http://www.survivingmold.com/store1/online-screening-test
However this should be backed up in the office with a second VCS test performed by an experienced healthcare professional.  Also:
Test: Melanocyte-stimulating hormone (MSH)
Lab:  Lab Corp
Spec: Lav freeze trasylol
ICD-9: 010421

Dx codes: 253.2 (Panhypopituitarism)

Normal Value:  35-81pg/mL* (please note this value is according to Dr. Shoemaker and is Lab Corp’s pre-2006 value for ‘normal’ Lab Corp’s current ‘normal’ is 0-40pg/mL)
AND
Test:  Vasoactive Intestinal Peptide (VIP)
Lab:  Lab Corp
Spec: Lav freeze trasylol
ICD-9: 010397

Dx codes: 279.8, 286.5, 710.0 (other specified disorders involving the immune system, Hemorrhagic disorder due to intrinsic circulating anticoagulants, Endocarditis in diseases classified elsewhere)

Normal Value:  23-63pg/mL

Review of the Works of Dr. Ritchie Shoemaker
By: Erik O. Jackson, L.Ac.
Disclaimer:  I was asked to review the works of Dr. Ritchie Shoemaker at the request of a patient.  I was paid for this research and for rendering my opinion as to if Dr. Shoemaker’s research is valid and worth pursuing for someone with Environmental Illness or Chemical Sensitivities (EI/CS).  I have a particular vested interest in both the health of this individual and in finding more tools to help some of my more difficult cases.  That stated I am also something of a disciple of Dr. William Rea, a specialist in treating EI/CS individuals, and use his work and opinion as a gold standard for assessing these cases.  If I were to render a positive opinion of Dr. Shoemaker’s work I may potentially send some of my patients to him or to those who are his disciples, which could potentially take business away from both myself and Dr. Rea.  However, if I were to render a negative opinion that is false or poorly judged, I would commit a serious ethical violation of trust to my patients.  I am therefore viewing Dr. Shoemaker’s work with the eyes of someone interested in EI/CS, and as such am trying to find useful information for this condition.
It should be noted that my biochemical background as a Licensed Acupuncturist is limited.  I do not have the training of a Medical Doctor (MD), nor a Biologist.  My review, therefore, is backed up by and large by my own clinical experience and what I can find in the works of others.  In this review I was specifically looking to see if the mechanisms described by Dr. Shoemaker are playing the part he claims they are, and therefore I was attempting to find supporting evidence, not counter evidence. It should also be noted that my license in the State of Texas precludes me from being able to prescribe pharmaceuticals which MDs have access to; I am also precluded from ordering any medical tests.  This makes me very keen, if I were to support Dr. Shoemaker’s claims, to find supplements, dietary plans, and treatment modalities that I could recommend.  Furthermore, any diagnostic tests mentioned in this presentation are mentioned for interested parties, be they patients or providers.  I am merely restating Dr. Shoemaker’s words, not prescribing these tests myself.  
Lastly, the time I have spent with the individual who requested this research, as well as my time with Dr. Rea, has lead me to be very skeptical about certain institutional standards, particularly how these standards are sometimes adjusted by agencies to account for readings which the agencies simply do not like.  This makes me more inclined to support Dr. Shoemaker’s assertion that the proper levels for Melanocyte-stimulating hormone (MSH) are 35-81pg/mL[1] as opposed to the current Lab Corp. standard, which was adjusted because of consistently low findings.  The relevance of this will be explained later.  In preparing this review I have assessed the following works of Dr. Shoemaker:
1.       Surviving Mold
3.      The Biotoxin Pathway
4.      IAQradio episodes 79, 80, 136, 181, and 235

With these facts in mind, let us begin.
From his own biography Dr. Shoemaker states that he is a Duke University medical school graduate of 1977.  He has developed a theory of, and a protocol for, treating people with what he defines as ‘Chronic Inflammatory Response Syndrome’ (CIRS) or ‘mold illness’ which is:
“…an acute and chronic, systemic inflammatory response syndrome acquired following exposure to the interior environment of a water damaged building (CIRS-WDB) with resident toxigenic organisms, including, but not limited to fungi, bacteria, actinomycetes, and mycobacteria as well as inflammagens such as endotoxins, beta glucans, hemolysins, proteinases, mannans, c-type lectins and possibly spirocyclic drimanes, plus volatile organic compounds (VOCs).[2]
This is a very broad definition and his term ‘mold illness’ is therefore rather misleading as the syndrome goes far beyond mold and can include a number of inflammatory conditions.  Indeed, it seems the only things which would not be covered by this definition are viral infections and other parasites.  For the sake of brevity we will be using CIRS as the term to describe the individuals he is concerned with for the duration of this paper. 
The diagnostic criteria which Dr. Shoemaker uses to diagnose CIRS, which he explains in IAQ radio episode 80 is:
-          VCS (Visual Contrast Sensativity) deficit
-          Low MSH
-          HLA susceptibility,
-          ADH/osmolality abnormalities
-          ACTH and Cortisol abnormalities 
-          Elevated MMP-9
One must meet three of these criteria before Dr. Shoemaker is willing to consider them as a CIRS case.
The definition of CIRS differs somewhat from Systemic Inflammatory Response Syndrome (SIRS) which is:
“a clinical response to a nonspecific insult of either infectious or noninfectious origin…. SIRS is nonspecific and can be caused by ischemia, inflammation, trauma, infection, or several insults combined. Thus, SIRS is not always related to infection.[3] 
The diagnostic criteria for SIRS are:
  • Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F)
  • Heart rate of more than 90 beats per minute
  • Respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension (PaCO2) of less than 32mm Hg
  • Abnormal white blood cell count (>12,000/µL or < 4,000/µL or >10% immature [band] forms)[4]
Only two of the symptoms need to be present for a diagnosis of SIRS.  SIRS is often, but not always, linked to sepsis. Dr. Shoemaker has at times made use of the term ‘chronic, systemic inflammatory response syndrome[5]’, which is likely for purposes of insurance billing.
  Please also compare Dr. Shoemaker’s definition of CIRS to the definition put out by the American Academy of Environmental Medicine (AAEM) on the contributing factors to individual susceptibility and total load in EI/CS:
“The "total load" concept postulates that multiple and chronic environmental exposures in a susceptible individual contribute to a breakdown of that person's homeostatic mechanisms. Rarely is there only one offending agent responsible for causing a diseased condition. Multiple factors co-exist, usually over a prolonged period of time in bringing about the disease process. Individual susceptibility to environmental agents occurs for a variety of reasons including genetic predisposition, gender, nutritional status, level of exposures to offending substances, infectious processes, and emotional and physical stress. Adaptation is defined as the ability of an organism to adjust to gradually changing sustained circumstances of its existence. Maladaptation would be a breakdown of the adaptive mechanism[6].”
The AAEM’s definition is not as specific as Dr. Shoemaker’s in defining what may cause these strange reactions in the body, and seems to take more of a toxin response approach to disease arguing that the dosage of the offending agent triggers the response of the body, at least initially.  Dr.  Shoemaker argues that it is an acquired innate immune response which causes these reactions and this response is simply, in the case of the individuals he treats, not suited for dealing with the toxins they face.  Seeing what I have of the work of the Environmental Health Center of Dallas (EHCD) I would say that the dose level of an offending agent can be an important factor ‘dose makes the poison’, but at other times the level is more or less irrelevant ‘host susceptibility makes the poison’.   
Dr. Shoemaker has found via Rosetta Stone testing for human leukocyte antigen (HLA) that there were 54 haplotypes, represented in a sample size of 6000 individuals, with 6 of these haplotypes having an innate immune response which renders them susceptible to CIRS[7].  HLA is found on chromosome six according to Dr. Shoemaker in IAQ radio episode 136.  Dr. Shoemaker explains in the second appendix of Surviving Mold how one reads the test results; however this is a very confusing process and one which I am not qualified to interpret.  Furthermore I have found no references detailing how this data was gathered.  
HLA allows the body to identify foreign substances from normal tissue.  Each individual will receive one HLA haplotype from each of their parents. If one or both of those haplotypes are among the six with a predisposition towards CIRS then there is an elevated risk for that individual.  Roughly a fourth of the population has this susceptibility[8]. 
While this percentage looks like a large portion of the population, Dr. Shoemaker claims from his own website (survivingmold.com) that CIRS is commonly misdiagnosed as one of the following conditions[9]:
  • Fibromyalgia
  • Chronic Fatigue Syndrome
  • Multiple Sclerosis
  • Depression
  • Stress
  • Allergy
  • Post Traumatic Stress Disorder
  • Somatization
  • Irritable Bowel Syndrome
  • Attention Deficit Disorder
From my own clinical experience, and having read more of his work in which he expands upon the previous statement, I believe that he may be on to something in the cases of:

-          Fibromyalgia
-          Chronic Fatigue Syndrome (potentially diagnosed as hypothyroidism or adrenal fatigue)
-          Generalized Anxiety Disorder (if not given adequate reasoning)
-          Panic Disorder (if not given adequate reasoning)
-          Attention Deficit Disorder
-          Autism
-          Irritable Bowel Syndrome and Chron’s Disease
-          Depression (if no other adequate reason is given)
-          Somatization
-          Lyme’s Disease (misdiagnosed)
-          Gluten sensitivity
-          Environmental Illness/Chemical Sensitivity
When these disorders are considered to be part of Dr. Shoemaker’s spectrum for either having CIRS or having a predisposition towards this syndrome, his statement of ‘one in four[10]’ starts to make more sense, at least for the American population.  However, this is still a large figure and many of these conditions are diagnosed hand in hand with each other.  That stated, these conditions are being diagnosed more and more often of late and many of them are poorly defined.  Furthermore there are times when these diagnoses are made that the criteria used to make such a diagnosis is sometimes disregarded.  Beyond that, individuals with these diagnoses are almost universally slow responders to treatment and some have hair trigger sensitivity to their environment.  I would point out though that some of the conditions have fairly well defined diagnostic criteria and should not, automatically, be assumed to be a misdiagnosis of CIRS.  For example Major Depression disorder may be a symptom of a CIRS, especially if there is no other cause for it, but it could very well be a real condition on its own (say, grief for a departed loved one, a legitimate hard time at work because one’s boss is sub par, etc.).  PTSD is specifically gained after living through very traumatic experiences and Lyme disease can come after a tick bite.  It is also possible that someone has Major Depression by diagnostic criteria, because one is reacting to a toxin.  To put it bluntly, CIRS may well be both quite prevalent and quite undiagnosed, even misdiagnosed, but one should not, in their haste to prove a CIRS condition, disregard other plausible explanations.  Sometimes the environment is fine and your boss really is a jerk.  Dr. Shoemaker states a similar view in the IAQ Radio Podcast episode 79[11], and I have made similar statements regarding some of Dr. William Rea’s work.  However, as Dr. Shoemaker would also point out, psychiatric illnesses do not have corresponding blood work, CIRS does[12].
Going back to the crux of this review, if the haplotype  of an individual makes them more susceptible to CIRS, then that means that the antibody creation process for working against mold, and presumably the other entities cited in Dr. Shoemaker’s definition of CIRS, does not function properly in this regard.  This will be explained in more detail with the following chart:


As seen in the graphic above[13], which Dr. Shoemaker has created, in most people a biotoxin that would be classified as an agent of CIRS is removed once it enters the body.  The normal process is as follows:
            A toxin/antigen invades the body.  This triggers the antigen recognition receptors along the Mannose Binding Lectin pathway (MBL) which releases inflammatory response agents including cytokines, Transforming Growth Factor (TGF-β1), and split products, the importance of which will be discussed later.  These inflammatory agents are continuously released until all antigens are engulfed by dendritic cells.  These cells coat the antigen with HLA and the antigen is processed further.  The antigen is then eaten by T lymphocytes which tell B lymphocytes to make specific antibodies to bind to the specific antigen[14].
            In CIRS individuals, the antibodies never get made.  This can result in improper immunities, as shown in the diagram, which can lead to effects on digestion, clotting, and T cells.   Gliadin antibodies in particular can result, in the presence of severe inflammation, in ‘leaky gut’ and presumably similar symptoms[15].  I suspect this may include Chron’s, IBS, Celiac disease (misdiagnosed), and gluten sensitivity.  The following process may also occur:
            Antigens stay in the body thus the process for releasing the inflammatory agents is never shut off.  The regulatory agents to prevent the inflammatory agents from attacking the body, Melanocyte-stimulating hormones (alpha-MSH), Vasoactive Intestinal Peptide (VIP) and  Arginine vasopressin/ Antidiuretic Hormone (AVP or ADH)  come in to play, but since the antigen is never removed these regulatory agents eventually are overwhelmed.  At this point the inflammation goes systemic[16].
To expand on the role of split products for a moment, we have C4a and C3a.  C4a is triggered along with TGF-β1 and cytokines, when an antigen invades the body.  The MBL pathway is engaged and releases certain enzymes called mannose-associated serine protease (MASP) which activates C4.  C4 splits into many active pieces which include C4a (alpha).  C4a starts the production of C3a which will start the rest of the complement cascade.  Once this cascade is activated the MASP enzymes will self regenerate which will in turn make more C4a.  C4a will, in CIRS individuals with von Willebrand’s Syndrome, a syndrome in which a certain blood sugar protein is either defective or deficient, interfere in clot formation leading to epistaxis (nosebleeds).  While I have encountered some individuals with severe nosebleeds at EHCD, they are not common, and this is supported by Dr. Shoemaker’s work in which he states that these patients make up about 1/40th of the CIRS population that he has treated.  However, without going in to the entire process of how these nosebleeds occur, it is safe to say that CIRS individuals with von Willebrand’s Syndrome may experience a nosebleed roughly 72 hours after exposure to an antigen[17].
            So what do all of these unregulated inflammatory agents in the body mean?  Well firstly, as stated in the graphic, high levels of cytokines lead to:
-          Flu like symptoms
-          Headaches
-          Muscle aches
-          Fatigue
-          Unstable temperature
-          Brain fog
All of these symptoms are commonly seen in Dr. Rea’s patients and those with the conditions Dr. Shoemaker mentioned.  I would note, however, that in regards to the statement of unstable temperature, most of Dr. Rea’s patients, in his experience, have a lower body temperature than normal.  This may be due to a lack of blood flow through the capillaries or some dysfunction of the hypothalamus, both of which I will go into shortly.  High cytokines also means elevated TGFβ-1 and increased levels of MMP-9, IL-1β and PAI-1.
MMP-9 or Matrix metallopeptidase 9 is an enzyme which is part of the Extracellular Matrix and is responsible for aspects of tissue remodeling; in particular it degrades certain collagens and may help in the formation of blood cells[18].   According to Shoemaker if MMP-9 is elevated it can deliver inflammatory agents from the blood to the brain and into the nerves, muscles, lungs, and joints.  As a further note, TGFβ-1, according to Dr. Shoemaker, can alter cells.  This, along with MMP-9, which also has a hand to play in tissue formation, are elevated in CIRS individual, and could potentially become cancerous if there were nutrients to support such growth, among other factors. 
IL-β or Interleukin-1 beta is a cytokine protein which, among other things, can introduce cyclooxygenase-2 into the Central Nervous System.  When this happens, perception of inflammatory pain increases[19].  This may contribute to some of the hair trigger responses of EI/CS patients, as well as their sensitivity to acupuncture needles, and may also explain the trigger point pain of Fibromyalgia.
Plasminogen activator inhibitor-1 or PAI-1 is a serine protease inhibitor which inhibits the breaking down of blood clots.  According to Shoemaker, if MMP-9 is elevated then it can combine with PAI-1 to increase blood clots and arterial blockages.  This may explain the rashes that many EI/CS patients have.
If cytokines enter the capillaries they will invite White Blood Cells into the area.  As the capillaries are small blood vessels they can only support so much traffic and the area will soon be clogged.  Cytokines regulate Hypoxia Inducible Factors (HIF) [20] which will result in constricted blood flow and a lack of oxygen to the cells, otherwise known as capillary hypoperfusion.  HIF stimulates TGFβ-1, which furthers the inflammation cycle and alters the cell structure, and Vascular Endothelial Growth Factor (VEGF).
VEGF normally restores oxygen to the cells by growing more blood vessels, however, according to Dr. Shoemaker, a CIRS individual whose body has been compromised by an anti-angiogensis agent (an agent which prevents the growth of new blood vessels), such as fumagillin, which cannot be removed will lower VEGF.  This results in fatigue, shortness of breath and muscle cramps.  Dr. Shoemaker references the works of Dr. Folkman[21] who founded the anti-antiogenesis movement which in essence states that, to treat cancer one must limit oxygen to the cancer cells.  This means that if a CIRS individual has a low VEGF they will likely have a reduced cancer rate because an anti-angiogensis agent may be preventing the development of new blood vessels.  A number of mycotoxins are known to be carcinogenic, but according to his clinical experience Dr. Shoemaker has seen a lower rate of breast, colon, and pancreatic cancer in his patient population, but does not state to what extent this is[22].
This lack of oxygen to the blood is where Chronic Fatigue Syndrome (CFS) sets in and also where I believe the symptoms of adrenal fatigue may be explained. 
By signaling the HIF, cytokines are preventing oxygen from getting to the cells.  If the cells do not have enough oxygen then only 5% of their available energy, in the form of glycogen, can be used.  The rest of the glycogen gets burned up in the form of lactic acid, hence the muscle cramps[23]. 
The body can overcome these limitations by burning fat for energy, however once the fat source runs out, and the people with the 6 haplotypes do have some genetic predispositions to be limber (many of these individuals according to Dr. Shoemaker have hyper mobile joints[24]) and athletic, then the body will find another fuel source to burn.  Since these individuals may not have a lot of stored fat to begin with, or simply run out of fat to burn, the body will start to burn the protein of the lean muscle mass.  Leptin is released after the fat stores are depleted and the body is signaled to start holding on to fatty acids.  Once the body starts to cannibalize itself and eat the lean muscle it figures it will pay the price for right now because the problem will resolve and then the normal stores of energy will be replenished.  This restoration never occurs in a CIRS individual, because the original problem of the foreign antigens was not resolved which means all the other processes are still in play.  It takes a minimum of two days of rest for the body to rebuild its glycogen stores[25] and most people with CFS, as soon as they get energy, burn it and do not pace themselves.  At the same time the body is gaining more fatty acids which become fat weight, and the Leptin release signal never shuts off[26]. 
Moving on, this release of Leptin will act on the hypothalamus[27].  According to Shoemaker, the increase of cytokines will eventually damage the Leptin receptors on the hypothalamus, which will inhibit the binding ability of Leptin.  Dr. Shoemaker amended this statement in IAQ radio episode 136 to state that the receptors for Leptin are not the only receptors which are damaged by this process.  Since this binding does not take place the hypothalamus does not produce enough MSH to regulate the inflammatory agents present in the body.  Even if Shoemaker is incorrect on this statement in regards to the cytokine effect on Leptin receptors, which I suspect he is not, the demand from Leptin for more MSH would eventually lead to reduced MSH if the antigens were not removed, simply because the MSH would be tapped out.
From my own clinical experience and what I have seen and heard working with Dr. Rea, I believe that Dr. Shoemaker has potentially come across an important piece of the puzzle.  While I am not sold on all that he says about Leptin, particularly trying to link it to obesity in CFS or EI/CS patients (as most of the ones I have seen have been, if anything, underweight) I do believe that he makes a good case for himself.  The lack of oxygen to the cells would cause the symptoms described and supports Dr. Rea’s use of oxygen therapy, and potentially supports the use of Tai Chi, and Qigong breathing exercises among other disciplines.  Leptin, while it may not result in weight gain in the patients described, may be the key to a number of other symptoms and the reason why some of Dr. Rea’s overweight patients, and others, have a hard time loosing weight.  Obesity is such a multifaceted issue that assuming there is a singular answer is, at this point, suspect at best.  It is also possible that his more recent discovery of more receptors being damaged could be the cause of some of the symptoms.
So what do low MSH, VIP and ADH mean?  Well as these are major hormones the deficiency of any of these could result in several symptoms.
MSH is a pigment hormone which is produced via the pituitary gland, which is part of the hypothalamus[28].  If MSH is overtaxed then the individual will likely become paler and presumably light sensitive; however this paleness could be attributed to the various blood and circulation issues mentioned elsewhere in this document.  The light sensitivity could also be explained by these circulation issues as such impairments could cause the blood vessels in the eyes to constrict.  MSH links to the libido so a decrease in MSH may cause a lack of sex drive, though this may also be accomplished by other effects going on in this chain of events which are lowering the body’s energy.  MSH also links to Adrenocorticotropic hormone (ACTH) which controls the production of cortisol.  ACTH also has a role in circadian rhythms[29] and in making cholesterol available to mitochondria.  This may explain some of the arguments I raised about Dr. Shoemaker’s assessment of Leptin.
            VIP is produced in the hypothalamus, among other places in the body.  It acts on the digestive system and helps to stimulate peristalsis, bile secretion, and inhibit gastric acid.  If it were low one could expect to see digestion issues and constipation, as well as acid reflux, which a number of Dr. Rea’s patients have.  Furthermore it is an important part of the make up for the body’s circadian rhythms, so insomnia or a sleeping schedule reset could arise if VIP was deficient.  Low VIP may also make recovery from jet lag more difficult in CIRS individuals.  VIP also acts on the heart to dilate the blood vessels.  Insufficient VIP could potentially lead to hypertension, among other issues[30].
            ADH controls water absorption in the kidneys and is stored in the posterior pituitary gland and synthesized in the hypothalamus.  If this hormone were deficient it could lead to edema and swelling.  Furthermore, because of the interplay between ADH and salt, the osmolality is disturbed[31] which may be what results in Dr. Shoemaker’s patients’ having a susceptibility towards experiencing a lot of shocks from ‘static electricity’ because of the presumed higher salt content in their blood.  A CIRS patient could potentially have a higher salt content in their sweat as well, which may lead to these ‘shocks’, though there are other processes which can affect the salt content in the body.  If one were to extrapolate from these observations, there could be a key here as to why some people are Electro-magnetically sensitive (EMF patients or EMS) and why Dr. Rea has stated that his EMF patients were usually only EI/CS patients before developing EMF sensitivity.  If an individual with CIRS had increased salt in their blood and was constantly receiving these ‘shocks’ along with potential light sensitivity from low MSH, it may be possible that they would be effected by electro magnetic fields. 
 ADH is also involved in short and long term memory function as well as reflexes.  All of these would be adversely affected if ADH were too low resulting in ‘brain fog’.  ADH links with bonding behavior in males so a deficiency would likely lead a man to be seen as less desirable and less emotionally competent to women.  It is interesting to note that ethanol will suppress ADH production[32].  ADH is also used to control for bleeding in von Wildebrand’s disease, which Dr. Shoemaker mentions when he speaks about nosebleeds, and in extreme cases of childhood bedwetting.  
All of these hormones are linked to the hypothalamus which could become overtaxed trying to fill their needs.  If this occurs the hypothalamus may not be able to regulate the internal body temperature resulting in Dr. Rea’s finding that most of his patients have lower body temperatures.
            The hypothalamus bears a little more mention.  Firstly, as the hypothalamus is part of the limbic system, cognitive and emotional dysfunctions that occur in CIRS patients could be explained by some malfunction of this structure[33].  Furthermore in one case study the individual has sudden drop attacks which happen nearly instantaneously, or with a build up which may take as long as an hour, and almost always after an exposure to some sort of scented product be that perfume or diesel fumes.  This individual has been able to adapt, build up resistances, and neutralize for some of the stimuli, but the drop attacks persist, though the combined use of coffee enemas and thermal light saunas have recently given this individual particularly remarkable results.  The hypothalamus is responsive to olfactory stimuli and is linked with the central nervous system (CNS). The olfactory nerve has a connection through the hypothalamus.  For more information on this please see references in the appendix.
It may be possible that damage to an olfactory receptor, or improper coding, could lead to these drop attacks by sending an improper signal to the CNS, though this is speculation.  The hypothalamus does respond to pheromones[34] which can certainly lead to involuntary responses in the body.  What is most interesting is that, while the individual is able to perceive everything going on around him while the attack is occurring, he is unable to respond or at times even breathe.  An expansion on my earlier hypothesis, proposed by a colleague and fellow acupuncturist, is that the sensory stimuli of sight, hearing, taste, and smell go directly into the brain without the use of the brain stem (illustrated in the links in the appendix).  However, subconscious or autonomic responses are relayed through the brain stem at an area near the occipital foramen.  If this individual has chronic swelling already near that anatomical region then an olfactory stimuli which, for whatever reason, causes further swelling could potentially inflame this region as the stimulus is travelling via the olfactory nerve and hypothalamus to the CNS.  If that swelling occurs then it could significantly decrease the individual’s blood pressure and cause a ‘traffic jam’ in the brain stem which would make breathing and other responses difficult but should not impair consciousness and perception, provided the effects are mitigated quickly.  This is not a perfect theory but may be a step in the right direction. 
            Further effects from the over taxation of these hormones is that the pituitary gland, which regulates MSH, may become over worked as well which can result in, poor temperature regulation, which was mentioned earlier, and endorphin production.  If endorphin production is low then pain perception can be elevated and the individual could experience depression.  This may be a key to treating Fibromyalgia, Myalgic Encephalomyelitis, Parkinson’s and Multiple Sclerosis.  Furthermore, testosterone levels may drop and, according to Dr. Shoemaker, androgen cream which is prescribed for individuals with low testosterone, further suppresses the body’s normal function to make testosterone[35].  If the patient has low VIP the enzyme aromatase comes in to play[36] which will convert testosterone into the hormones estrone and estradiol, in effect doing the opposite of what the treatment was supposed to accomplish.  These effects can be mitigated by Anastrozole, which is an aromatase inhibitor[37]. 
In a CIRS individual, since the antigens have not been removed, and these processes are still going on, then the body is more susceptible to ‘normal’ infections because all the immune responses are spread too thin, or are busy fighting each other.  If normal immune function is impaired and certain bacteria, Multiple Antibiotic Resistant Coag Neg Staph (MARCoNS), start to line the body’s biofilm and mucus membranes, then there could be further aggravation of symptoms as Dr. Shoemaker believes these bacteria could aggregate the cytokine levels and further diminish MSH.  These bacteria are probably the reason for some of the more serious infections in Dr. Rea’s clinic.  These bacteria also link to ones ability to get rid of Lyme’s disease as expanded upon in links in the appendix: 
So putting this all together, if one wished to go through Dr. Shoemaker’s treatment the steps are[38]:
1.  Differential Diagnosis begins with a compulsively obtained data base - answering questions like what could be wrong?  The labs needed to show inflammatory abnormalities are collected, and the labs that are always normal in biotoxin illness are also collected.
2.  Performing Environmental Relative Moldiness Index (ERMI) testing to ensure there is no exposure to a building with an ERMI greater than 2 if the patient's MSH is less than 35 and C4a is less than 20,000; or no exposure to ERMI greater than negative 1 if MSH is less than 35 and C4a is greater than 20,000.
3.  Removal from prior exposure (this means no more working, schooling, or living in a moldy environment for WDB illness patients)
4. Correcting toxin carriage in the body with CSM (Cholestyramine) or Welchol, using VCS monitoring to assess progress.  The function of CMS will be defined later in this document.
5.  Eradicating biofilm-forming MARCoNS.
6.  Eliminating gluten for those with anti-gliadin positivity as shown by a positive blood test, with celiac disease ruled out
7.  Correcting elevated MMP9
8.  Correcting ADH/osmolality.
9.  Correcting low VEGF, most likely with some artificial replacement.
10.  Correcting elevated C3a
11.  Correcting elevated C4a
12.  Reducing elevated TGF beta-1
13.  Replacing low VIP
14.  Final check to verify stability off meds
The fact that Dr. Shoemaker is taking the approach of establishing a comprehensive diagnosis and comparing it to other markers which would be used to establish other causes means that medically, he is making a very strong argument for his diagnosis.  He then proceeds, step-by-step, to reduce exposure so more inflammatory agents are not released, then correct the CIRS by going from the outermost manifestation of symptoms in.  Dr. Rea has a similar approach.  However, except with his use of CMS and artificial VIP, Dr. Shoemaker is rather unclear in the reviewed works as to how he is accomplishing these processes.  In episode 235 of IAQradio, Dr. Shoemaker explains some of the cautions regarding the use of artificial VIP.

When testing the building(s) one is exposed to, Dr. Shoemaker recommends the EMRI and the HERTSMI-2 (no definition found).  EMRI tests for 36 mold species that may be found in a WDB.  If the presence of any mold is detected the amount and species are then measured and given a score on the HERTSMI-2.  For more information on this please see the references in the appendix.  Naturally, if the cause of CIRS is not linked to mold in a particular individual, then this test would be worthless to that person.

Dr. Shoemaker makes use of Cholestyramine (CMS) which binds up bile acid in the body[39].  Once this happens the body starts to convert cholesterol into bile to make up for the loss.  If ACTH is low, there will likely be a fair amount of unutilized cholesterol in the body. According to Dr. Shoemaker CMS also binds with bile salts, and other toxins, and then allows these substances to be excreted from the body harmlessly.  Please see the appendix for more information on CMS.
The tests for all of these procedures are:
VCS aptitude test:
Can do an online version for $15, link mentioned in the appendix, but it should be backed up in the office with a second VCS test performed by an experienced healthcare professional.

MSH - Melanocyte Stimulating Hormone

Lab:                 Lab Corp.
Specimen:        LAV freeze trasylol
Code:                          010421
ICD-9:              253.2 (Panhypopituitarism)
Normal range: should 35-81pg/ml (CIRS diagnosis, this should be low, furthermore this standard is higher than Lab Corps and is in fact their standard pre 2006.)

 

VIP - Vasoactive Intestinal Polypeptide, this along with MSH, if low, are in my opinion the best evidence for a diagnosis of CIRS

Lab:                 Lab Corp.
Specimen:        LAV freeze trasylol
Code:                          010397

ICD-9:              279.8, 286.5, 710.0 (

-          Other specified disorders involving the immune system

-           Hemorrhagic disorder due to intrinsic circulating anticoagulants

-           Endocarditis in diseases classified elsewhere)


Normal range: should 23-63pg/ml (CIRS diagnosis, this should be low)

C4a: would be highest after exposure, Dr. Shoemaker states that this is the marker of greatest significance though I would state that the test would likely yield better results after an exposure.
C4a RIA (not Futhan)  
Lab:                 Quest
Specimen:        LAV freeze
Code:                          42658

ICD-9:             279.8, 286.5, 710.0, 780.79 

-          Other specified disorders involving the immune system

-           Hemorrhagic disorder due to intrinsic circulating anticoagulants

-          Endocarditis in diseases classified elsewhere

-           Other malaise and fatigue


Normal range: should be under 2380pg/ml (CIRS diagnosis, this should be elevated)

 

HLA DR: to check for your haplotype

            Lab:                 Lab Corp.

                Specimen:        Lavender, room temp
            Code:              012542

            ICD-9 code:    279.10, 377.34, 279.8

-          Immunodeficiency with predominant T-cell defect unspecified

-           Toxic optic neuropathy

-           Other specified disorders involving the immune system


 

MMP-9: probably more important for people with Fibromyalgia and similarly diagnosed individuals

            Lab:                 Lab Corp. or Quest

                Specimen:        SST freeze
            Code:              Lab Corp.: 503416  Quest: 41865 

            ICD-9 code:     340, 780.79

-          Multiple sclerosis

-          Endocarditis in diseases classified elsewhere


            Normal Range85-332 ng/mL (support for CIRS would have an elevated result)

VEGF: more important for people with Chronic Fatigue, do use serum.

Lab:                 Quest

                Specimen:        LAV freeze
            Code:              14512X

            ICD-9 code:     253.2, 416.9, 710.0

-           Panhypopituitarism

-           Chronic pulmonary heart disease unspecified

-           Endocarditis in diseases classified elsewhere

            Normal Range:  31-86 pg/mL (to support CIRS diagnosis, this will probably be low)


 

ADH/Osmolality:  more important for people with brain fog, ‘static shocks’, EMF sensitivity, and nosebleeds

            Lab:                 Quest

                Specimen:        LAV freeze
            Code:              252X

            ICD-9 code:     253.5 (Diabetes insipidus)

            Normal Range:  ADH - 1.0-13.3 pg/ml; Osmolality - 280-300 mosmol (to support a CIRS diagnosis, the ADH should be low while salt content was elevated)

 

TGF Beta-1 - Transforming Growth Factor Beta-1.  More exposure dependent.

Lab:                 Quest or Lab Corp
Specimen:        LAV freeze, platelet poor plasma
Code:                          Quest: 52112, Lab Corp: 905036
ICD-9:             279.8, 286.5, 710.0, 780.79
-          other specified disorders involving the immune system
-           Hemorrhagic disorder due to intrinsic circulating anticoagulants
-           Endocarditis in diseases classified elsewhere
-           Other malaise and fatigue
Normal range: should be under 2380pg/ml (CIRS diagnosis, this should be elevated)

 

The full physician’s lab orders are available in the appendix: 
            The works of Dr. Shoemaker appear to be consistent with findings from other sources and by and large my own experience working at EHCD.  That stated I believe that with just how multifaceted CIRS is that a correlation would be hard not to make, so some healthy skepticism is warranted.  Furthermore, Dr. Shoemaker’s approach makes me curious as to his explanation regarding individuals who develop CIRS after several exposures because, if their haplotype predisposes them to CIRS upon certain exposure, then I would imagine you would see younger people coming in, or at least people who have much longer case histories.  From my own experience, the EI patients that Dr. Rea sees, which by and large I think would fall into this CIRS category, seem to develop their condition in the later 20s at the earliest, though may have had chronic allergies of some variety beforehand.  Generally Dr. Rea’s patients are from about the mid 30s to mid 60s. 
Dr. Shoemaker, in episode 79 of IAQ radio, does explain that epigenetics (the interaction of the Environment and genetics) can play a role in altering the genetic expression of an individual, but does not emphasize this as much as Dr. Rea nor does he know, at this time, what the triggering event is that will cause this change in genetic expression.  In episode 136 Dr. Shoemaker explains that when he has pediatric cases they are more often having an autoimmune response to biotoxins as they simply do not have the hormone reservoir that adults do, and finally in episode 181, Dr. Shoemaker explains that most of his patients, within six months, will have a set pathway of responses.  In episode 235 Dr. Shoemaker explains some of his work with micro RNA and how he has started to track genomic signatures from various biotoxins.
I think that if a synthesis could be made between Dr. Shoemaker’s method and Dr. Rea’s ‘total load’ theory, then many people could benefit.  Both emphasize reduction of exposure as a very important part of their treatment protocols.  Dr. Shoemaker is more specialized for dealing with mold, genetics, and addressing various administrative issues that a CIRS individual is likely to face.  Dr. Rea is more flexible in his treatment, has more tools for removing toxins in an individual, uses fewer drugs, has more experience with a wider array of chemicals and other inciting agents, and is more versed with epigenetic presentation.  It is my opinion that if these two doctors could work together there would be some groundbreaking research, particularly if they could map the processes of the various chemicals, individually, in the body, correlating the findings with the biotoxin pathway and genomic signatures from Dr. Shoemaker with the breath test results that Dr. Rea uses.  It would also be very interesting to see what correlation was made with the VCS test versus the SPECT scan and if both improved with the use of Glutathione.
A hypothesis has been proposed by one of this paper’s editors that, if the appropriate data were gathered, one would suspect that there would be fewer CRIS cases in desert areas.  While I believe one would find few cases linking to mold in desert areas, as CIRS has a variety of causes it is possible that certain individuals could be susceptible to the products of natural gas fracking, which could cause CIRS symptoms to occur in individuals.  Still this would be an interesting analysis.  It should also be noted that Dr. Shoemaker stated, in episode 79 of IAQ radio, that mold in an indoor environment such as a WDB is substantially different than mold in an outdoor environment.  Furthermore, the use of fungicide in paints and other indoor chemicals has mutated certain strains of fungus which has lead to the development of different organisms that have different physiological effects on the human body which may partially explain the increased incidence of mold related illnesses.
            Dr. Shoemaker has put a lot of effort into developing his hypothesis and treatment plan, as well as figuring out ways to work the various legal, political, financial, administrative, and medical bureaucracies which his patients face, and has given some great information.  However, his book ‘Surviving Mold’, is poorly organized for conveying the biochemical education that practitioners need, nor is it well organized in dealing with the various bureaucratic issues his patients will face.  He rants, rambles, and well over half the book is laced with anecdotes, but there are a few gems in the first chapters if one is willing to look.  He has a number of keys that he can give but he’s buried them.  Dr. Shoemaker also is continuously focused on mold as opposed to chemicals, even though he acknowledges that mold is not the only player in this game.  Furthermore he is more concerned about genetic components as opposed to epigentics, while again recognizing that the latter plays a part as well.  Dr. Shoemaker still manages to make a good case for himself with 42 published papers, at least two of which were accepted in Environmental Health Perspectives, which has an impact factor of 6.09[40].  In 2002 he was the Family Practice Physician of the Year in Maryland and was the runner-up for the national counterpart of that award in the same year.  He has published three books on the topic of mold and its interaction with the body.  His research has been backed by the Copernicus Group Independent Review Board[41] and he explains this and some of his research methods with human models in greater detail in IAQ radio episode 136.   One can find more information via his website and radio talks he has given which are included in the appendix.
It is my opinion that, while there is still work to do, Dr. Shoemaker has laid out some remarkable insights into the inner workings of several conditions (or one big multifaceted one) which can take a variety of paths.  I believe that if further work was done along these lines all of us could see lives improved.  As far as any recommendations go, I would say that careful investigation would be a wise decision, but I am optimistic that there is some great potential here.  That stated, please remember what I said earlier in the disclaimer about my own bias and suitability in judging this work. 
Appendix:

References for Dr. Ritichie Shoemaker:
Web:

Books:
Life in the Era of Dangerous Buildings, 2010
Mold Warriors, 2005
Desperation Medicine 2001

DVDs:
9 hour DVD of a conference "Biotoxin Illness: the science behind accurate diagnosis and effective treatment" that includes talks  by Dr. Shoemaker and several other physicians and researchers that includes PPTs of the presentations, conference syllabus and pdfs is available for $130 

Radio:
Episodes:
            235
            181
            136
            80
            76
Episodes in italics are most pertinent for the purposes of this review.

Papers:
            Papers in Environmental Health Perspectives
            Miscellaneous paper

References for Dr. William Rea

References on the role of Leptin

References on the role of the Hypothalamus
(particularly pgs 1 and 2)

 References on Lyme disease
Please note Dr. Shoemaker is no longer using Actos as per: http://www.survivingmold.com/treatment/information-on-medications)         


References regarding mold testing for buildings

http://www.survivingmold.com/diagnosis/ermi-testing

http://www.survivingmold.com/diagnosis/hertsmi-2


References regarding the use of CMS

References for VCS testing

Reference for Diagnostic Codes

Full Physician’s Lab Order Sheet





[1] Shoemaker, Ritchie C, MD. Surviving Mold, Life in the Era of Dangerous Buildings, Otter Bay Books, Baltimore, MD, 2010 (Location 738 in Kindle)

[2] Shoemaker, Ritchie C, MD. Surviving Mold, Life in the Era of Dangerous Buildings, Otter Bay Books, Baltimore, MD, 2010 (Location 307 in Kindle)
[7] Shoemaker, Ritchie C, MD. Surviving Mold, Life in the Era of Dangerous Buildings, Otter Bay Books, Baltimore, MD, 2010  (Locations 413 and 419 in Kindle)
[8] Shoemaker, Ritchie C, MD. Surviving Mold, Life in the Era of Dangerous Buildings, Otter Bay Books, Baltimore, MD, 2010 (Locations 413 and 419 in Kindle)
[10] Shoemaker, Ritchie C, MD. Surviving Mold, Life in the Era of Dangerous Buildings, Otter Bay Books, Baltimore, MD, 2010 (Locations 413 and 419 in Kindle)
[12] Shoemaker, Ritchie C, MD. Surviving Mold, Life in the Era of Dangerous Buildings, Otter Bay Books, Baltimore, MD, 2010 (Location 1012 in Kindle)
[14] Shoemaker, Ritchie C, MD. Surviving Mold, Life in the Era of Dangerous Buildings, Otter Bay Books, Baltimore, MD, 2010 (Locations 408 and 413 in Kindle)
[15] http://lymebook.com/blog/the-recovery-process/mold-and-lyme-toxins/
[16] Shoemaker, Ritchie C, MD. Surviving Mold, Life in the Era of Dangerous Buildings, Otter Bay Books, Baltimore, MD, 2010 (Location 420 and 426 in Kindle)
[17] Shoemaker, Ritchie C, MD. Surviving Mold, Life in the Era of Dangerous Buildings, Otter Bay Books, Baltimore, MD, 2010 (Chapter 5)
[21] Shoemaker, Ritchie C, MD. Surviving Mold, Life in the Era of Dangerous Buildings, Otter Bay Books, Baltimore, MD, 2010 (location 1531 in Kindle)
[22] Shoemaker, Ritchie C, MD. Surviving Mold, Life in the Era of Dangerous Buildings, Otter Bay Books, Baltimore, MD, 2010 (location 1528 in Kindle)
[23] Shoemaker, Ritchie C, MD. Surviving Mold, Life in the Era of Dangerous Buildings, Otter Bay Books, Baltimore, MD, 2010 (Location 1940 in Kindle)
[24] Shoemaker, Ritchie C, MD. Surviving Mold, Life in the Era of Dangerous Buildings, Otter Bay Books, Baltimore, MD, 2010 (Location 1306 in Kindle)
[25] Shoemaker, Ritchie C, MD. Surviving Mold, Life in the Era of Dangerous Buildings, Otter Bay Books, Baltimore, MD, 2010 (Location 1940 in Kindle)
[26] Shoemaker, Ritchie C, MD. Surviving Mold, Life in the Era of Dangerous Buildings, Otter Bay Books, Baltimore, MD, 2010 (Location 731 in Kindle)
[27] Shoemaker, Ritchie C, MD. Surviving Mold, Life in the Era of Dangerous Buildings, Otter Bay Books, Baltimore, MD, 2010 (Location 736 in Kindle)
[32] "vasopressin." Encyclopædia Britannica. Encyclopædia Britannica Online. Encyclopædia Britannica Inc., 2012. Web. 31 Mar. 2012. <http://www.britannica.com/EBchecked/topic/623843/vasopressin>.
[35] Shoemaker, Ritchie C, MD. Surviving Mold, Life in the Era of Dangerous Buildings, Otter Bay Books, Baltimore, MD, 2010 (Location 1419 in Kindle)