The Natural Therapist Winter 2022

The

Natural

EDITION 37 NO. 2 | WINTER 2022

Therapist ISSN 1031 6965

Winter 2022 Inside now!

• A cross-modality approach on Thoracic Outlet Syndrome • Three useful trauma therapies: A practical perspective • Harnessing the power of nutritional compounding

plus more!

The Official Journal of THE AUSTRALIAN NATURAL THERAPISTS ASSOCIATION

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Contents Edition 37 No. 2

|

Winter 2022

From the Chair

5 Executive Officer Report 6 A NTA News 8 2021 Bursary Award Winners 9 2021 Round 2 Graduate Award Winners 30 Healthy Recipes by Rachel Knight

10

15

Case Study Analysis: Central Serous Chorioretinopathy

Dermatlogical Effects of a Herbal Menopause Formula

Samantha Gladstone, ANTA Member, provides

George Thouas, highlights the second series

Bacopa Monnieri - New Validation and Insights for This Important BrainBoosting Herb

a case study analysis about Central Serous

of outcomes of a clinical trial of a combination

Kerry Bone, explores the herb Bacopa

Chorioretinopathy and explains how Bilberry

herbal extract, produced in Australia, involving

Monnieri and how it can help in a range

and Ginkgo help with this condition.

a sample of Thai post-menoapusal women.

of conditions including Attention Deficit

23

Hyperactivity Disorder and Alzhiemer’s Disease.

32

39

43

48

Thoracic Outlet Syndrome: A CrossModality Approach

Three Useful Trauma Therapies: A Practical Perspective

Harnessing the Power of Nutritional Compounding Warren Maginn, ANTA Nutrition Branch Chair,

Homeopathy Materia Medica: Small Stinging Nettle (Urtica Urens)

Tino D’Angelo, ANTA Chinese Herbal Medicine

Mark Shoring, ANTA Multi-Modality Branch

explains what nutritional compounding is and

Emma Ahearn, ANTA Member, explores the

Branch Chair, explains Thoracic Outlet

Chair, writes how he uses Dit Da Jiao, Tao

how this can be used in clinic.

Small Stinging Nettle (Urtica Urens).

Syndrome and explains how this condition can

Hong Si Wu Tang and White Flower Oil in

be treated across Chinese Herbal Medicine and

clinic.

manual therapy.

The

Natural Therapist

The Natural Therapist is published by the Australian Natural Therapists Association (ANTA) for natural therapy practitioners. The opinions and views expressed by the contributors and advertisers are not necessarily the opinions and views of ANTA. Every effort is taken to ensure accuracy and ANTA accepts no responsibility for omissions, errors or inaccuracies. ANTA relies on contributors and advertisers to make sure material provided for The Natural Therapist complies with the Australian Consumer Law under the Competition and Consumer Act 2010. ANTA accepts no responsibility for breaches of the Australian Consumer Law by contributors or advertisers.

Material in The Natural Therapist is subject to copyright and may not be reproduced in any form without the permission of ANTA and its contributors.

EDITION 37 NUMBER 2 – WINTER 2022

ISSN 1031 6965

ANTA BRANCH CHAIRPERSONS Shaun Brewster • National President • Director of ANTA • National Myotherapy Branch Chair • ANTAB Chair • ANRANT Committee Member • Health Fund Chair Warren Maginn • National Vice-President • Director of ANTA • National Nutrition Branch Chair • TGA Chair • Ethics Panel Chair • ANTAB Committee Member • ANRANT Committee Member Ananda Mahony • National Treasurer • Director of ANTA • National Naturopathy Branch Chair Kaitlin Edin • Director of ANTA • National Acupuncture Branch Chair • ANTAB Committee Member • ANRANT Committee Member

Isaac Enbom • Director of ANTA • National Remedial Therapy Branch Chair • ANTAB Committee Member • ANRANT Committee Member Mark Shoring • Director of ANTA • National Multi-Modality Branch Chair • ANTAB Committee Member • ANRANT Committee Member Tino D’Angelo • Director of ANTA • National Chinese Herbal Medicine Branch Chair Neerja Ahuja • Director of ANTA • National Ayurvedic Branch Chair Jim Olds • Executive Officer • Company Secretary • Business Plan Chair • ANRANT Chair

The

Natural Therapist

Marketing & Production Tasha Kemsley Circulation Enquiries 1800 817 577 Editorial & Advertising Enquiries thenaturaltherapist@anta.com.au Membership Enquiries info@anta.com.au

ANTA NATIONAL ADMINISTRATION OFFICE T: 1800 817 577 | F: (07) 5409 8200 E: info@anta.com.au P: PO BOX 657 MAROOCHYDORE QLD 4558 W: www.anta.com.au

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ANTA Executive Welcome Winter 2022

From the Chair ANTA has applied a refreshed approach to the format of the ANTA Continuing Professional Education (CPE) Training Days. These are always associated with the ANTA National Council Board Meetings that are conducted the day prior to the training seminars.

We changed the Board Meetings to a full day meeting on Saturday to allow full and frank discussion of all ANTA Business and a more focussed review of the ANTA Business Plan for the ensuing year.

The ANTA Board of Directors are pleased to report that these changes resulted in ANTA Board Meeting processes being more fluid, and comprehensive outcomes were achieved with all matters through a more efficient approach across a full day on Saturday.

This new format allows an energised team to host the ANTA Member Continuing Professional Education Seminar, now held on Sundays through a fully focussed approach beginning at 10.00am and concluding at 3.00pm.

ANTA has included a welcome addition of a onehour lunch break at 12.00pm to allow audience members, presenters, partners, and industry supporters to mingle and replenish ahead of the afternoon session.

ANTA Members in attendance reached record levels in a return to in person attendance at ANTA seminars. This occurred despite the recent floods affecting Brisbane and surrounding regions within the two weeks prior to the meeting and seminar.

Winter 2022

latter target has been achieved through ANTA’s professional approach to understanding the difficulties faced by educational institutions and training organisations resulting from the layers of pandemic conditions and restrictions.

ANTA has been able to support and strengthen relationships and assist educators to achieve timely graduation rates. The flexibility ANTA adopted, provides assurance to students who continue toward clinical practice. This also allows ANTA to maintain its standards for clinical excellence through supporting student members.

ANTA is aware of the stressful and frustrating experiences students have endured over the last two years. ANTA has supported education providers with few choices within Pandemic restrictions, to deliver the best options achievable for all students approaching graduation deadlines.

We will continue to normalise the clinical practice environment for all branches through our National Council’s stewardship and innovation.

Regards

Jim Olds

ANTA Fellow ANTA Executive Officer & Company Secretary BHSc MST, BHSc Comp Med, GC Higher Ed, MSC, Dip Nut, Dip RM, Dip TCMRM

In other positive outcomes, ANTA has achieved its goals in the retention of existing members and the acquisition of new members joining the Association during the past twelve months. This THE NATURAL THERAPIST VOL 37 NO. 2 | WINTER 2022 | PAGE 5

ANTA News Winter 2022

ANTA News

Winter 2022

Health Fund Compliance ANTA staff have currently been experiencing an increase in Health Fund Audits and wanted to remined Members of their obligations as a Health Fund Provider. Health Fund Fraud is a criminal offence and should a Member be caught carrying out fradulent activities, they could lose their Health Fund recognition, their ANTA Membership and may not be eligible to join other Associations or be recognised as a Health Fund provider again; as well as possible criminal prosecution.

Health Fund Fraud is defined as ‘receiving a benefit payment where there is no legitimate entitlement, submitting deliberately misleading or false information, or withholding relevant information’ (Private Healthcare Australia, n.d.). This can be in the following forms, by a healthcare provider or the Health Fund member: • Charging for treatment/s that have not been provided • Creating false documents • Altering accounts to increase financial benefits • Claiming for additional services without the healthcare providers’ Health Fund members’ knowledge.

Located in the ANTA Member Portal is a video explaining the requirements of Health Funds for compliance and audit purposes. As an Association, we are audited yearly on the compliance of our Members, but when a Health Fund suspects a Practitioner/Member to possibly be committing some form of fraud, they will conduct a ‘triangulation’ audit. For AHPRA registered members, it is important that any questions you have in relation to compliance is directed to AHPRA. If you have any further questions around Health Funds and their auditing processes, please contact ANTA on 1800 817 577 or info@anta.com.au.

Member Portal ‘How To’ Videos We have created a series of ‘How To’ videos for Members to view to assist in using the new Member Portal. Whilst the new Member Portal is not ready to go live yet, we welcome you to take a look at the videos to get an understanding of the system in advance.

Click here to view the ‘How To’ videos!

PAGE 6 | WINTER 2022 | THE NATURAL THERAPIST VOL 37 NO. 2

ANTA News Winter 2022

New Member Portal Launching Soon Over the past eight months, ANTA has been working in the background on updating our Member Portal to make it more user-friendly and functional. We are now nearing completion. During the change over, the current Member Centre will be closed to ensure all data remains current. Members will be notified via email of the shutdown date.

When the new system has gone live, you will be asked to create new login details. These details will have the username as the current registered email address in our system, and you will need to set a new password.

The new Member Portal will be more user-friendly, clearer and easier to navigate both on the desktop/

laptop and iPad/Tablet. The uploading of compliance requirements, such as Insurance Certificate of Currency, First Aid Certificate, Police Check or Working with Children Check, and Continuing Professional Educations points will be much simpler.

Clinic addresses will be easier to add by using Google Maps to validate addresses to avoid mistakes. You also have the option to choose whether you want the address to show on the new Practitioner Directory.

We have built this new Practitioner Directory to promote and highlight ANTA members through online search engines to drive more clients your way!

THE NATURAL THERAPIST VOL 37 NO. 2 | WINTER 2022 | PAGE 7

ANTA News Winter 2022

ANTA 2021 Bursary Award Winners

Christine Yen

Samantha Gladstone

Jamie Bradbury

Madelaine Brown

Kevin Chen

Jazzmyn McKenzie

Matilda Wardale

Matthew Parker

Muhamad Aizat Ahmad

Jalena Martin

Nicole Ward

Peter Spanoudakis

PAGE 8 | WINTER 2022 | THE NATURAL THERAPIST VOL 37 NO. 2

ANTA News Winter 2022

ANTA 2021 Round 2 Graduate Award Winners Samantha Buckley

Monika Papiernik

Catherine Clarke

Tanya Mikheal

Lydie Carret

Li-Yeh Chou

Congratulations also too: Yoshiko Yamawaki

Olfa Hafsa

Sebastian Visona Bradley Banks Sunday Lual

THE NATURAL THERAPIST VOL 37 NO. 2 | WINTER 2022 | PAGE 9

ANTA Member Article Winter 2022

Samantha Gladstone ANTA Member BHSc (Naturopathy)

Case Study Analysis: Central Serous Chorioretinopathy Summary of Central Serous Chorioretinopathy:

The aetiology of Central Serous Chorioretinopathy (CSC) is poorly understood, and has been hypothesised to have multiple origins, including psychosocial, immunological, neuronal, circulatory and hormonal1.

Increased expression of mineralocorticoid receptors and circulating cortisol2 can influence electrolyte balance and sub-retinal fluid volume3,4. Changes to choroidal thickness, permeability and vascularity impair absorption sub-retinally, leading to an increase in hydrostatic pressure5,6. The resulting accumulation of fluid can cause retinal detachment5, and clinical manifestations including pain, visual changes, such as partial or full loss, and distortion of lines, colours and contrasts7. Prostaglandins are also associated with vasodilation and hyperpermeability of the bloodretinal barrier, and progressive inflammation8 so it can be hypothesised that the ongoing presence of pain conditions in a patient could be linked to pathogenesis of CSC. Acute CSC is generally self-limiting with no significant lasting damage and resolves within three months whereas chronic CSC may lead to visual dysfunction1.

Medical treatment options include various laser treatments to seal areas of fluid leakage9,10, however some laser treatment types may be no more effective than not treating at all11. Photodynamic therapy is also used to reduce choroidal permeability and prevent accumulation of fluid12, however, there is a risk of damage, including neovascularisation13 with some of these methods.

Pharmacological treatments include oral aldosterone and mineralocorticoid receptor antagonists, such as spironolactone and eplerenone, however, spironolactone can cause hyperkalaemia, and influence liver function14,15. Anti-vascular endothelial growth factor (anti-VEGF) agents are also used to combat choroidal hyper-permeability with mixed results16. There are studies suggesting the beneficial use of melatonin, salicylic acid and lutein1.

Risk factors including male gender, single status, increased cortisol, A-type personality, higher levels of education and income, high alcohol consumption, smoking, use of non-steroidal anti-inflammatory drugs (NSAIDs), hypertension, and stress, have all been associated with CSC17.

PAGE 10 | WINTER 2022 | THE NATURAL THERAPIST VOL 37 NO. 2

ANTA Member Article Winter 2022

Assessment:

Regarding the patient, many of the above risk factors for developing CSC are evident in the case history and clinical presentation. The male client is currently 48 years old, which is the mean age for incidence of CSC in a recent study by Chatziralli et al. (2017)17. It is likely that he has an A-type personality, with an increased tendency towards experiencing psychological stress, with ongoing exposure, the sympathetic nervous and the hypothalamic-pituitary-adrenal axis balance has dysregulated, increasing the release of catecholamines and corticosteroids17. Mineralocorticoid receptor activity in the eye increases as a result of this release2 and subsequently, the aetiological events outlined above have occurred. Due to CSC being undiagnosed for some time, the right eye has been untreated, and the condition has become chronic. The left eye situation is recurrent acute.

Anthocyanidins found in Vaccinium myrtillus inhibit xanthine oxidase, reducing reactive oxygen species and free radicals19,20.

Bilberry increases ocular blood flow, and reduces vascular permeability and intraocular pressure21,22.

Due to the ability of Vaccinium myrtillus to reduce angiogenesis in vivo18,23, it is a good choice of herb for conditions such as CSC, where neovascularisation rapidly progresses the disease.

Vaccinium myrtillus has been shown to improve rhodopsin recovery, which is beneficial in restoration of visual acuity24.

Bone (2007)25 recommends Vaccinium myrtillus for hypertensive retinopathy in a fresh weight tablet dose up to 2400mg per day, which is the dose selected for this client, given the urgency of halting progression of his retinopathy.

Treatment Strategy: Table 1: Treatment Strategy for Central Serous Chorioretinopathy Treatment Objective

Time Frame

Herbal Action

Restore visual acuity, and prevent further neovascularisation, retinal thickening, and detachment

3 months

Anti-inflammatory, antioxidant, tissue perfusion enhancer, vascular endothelial growth factor expression inhibitor, anti-platelet, vasoprotective

Reduced blood pressure to 120/80 to regress CSC

2 months

Hypotensive

Reduced anxiety to reduce risk of progression and recurrence of CSC

2 months

Anxiolytic

Improve energy levels

4 weeks

Adaptogen

Balance cortisol production

2 weeks

Adrenal restorative, adaptogen

Herbal Prescription: Table 2: Herbal Prescription for Central Serous Chorioretinopathy Herb

Part Used

Preparation Form

Specifications

Dosage and Instructions

Vaccinium myrtillus

Fruit, dried

Tablet

Fresh weight tablet

1 x 2400mg to be taken per day 1 x 1200mg tablet in the morning and 1 x 1200mg tablet in the evening, with food

Ginkgo biloba

Leaf, dried

Tablet

Standardised to contain 6% sesquiterpene lactones

1 x 1200mg to be taken per day 1 x 600mg tablet in the morning and 1 x 600mg table in the evening, with food

Rationale for Herbal Prescription: Vaccinium myrtillus, Bilberry

Vaccinium myrtillus contains anthocyanidins, flavonoids and procyanidins, accounting for its vasoprotective, anti-oedema, antioxidant and antiinflammatory actions18.

THE NATURAL THERAPIST VOL 37 NO. 2 | WINTER 2022 | PAGE 11

ANTA Member Article Winter 2022

Ginkgo biloba, Ginkgo

Ginkgo biloba contains flavone glycosides, and ginkgolide and bilobalide sesquiterpernes26.

Ginkgo biloba has been seen to have a protective effect against oxidative stress through inhibition of reactive oxygen species production27.

Age related macular degeneration (ARMD) is caused by choroidal neovascularisation28,29 and related to death of retinal pigment epithelium30 as is CSC31. As Ginkgo biloba has been found effective in slowing retinal pigment epithelium death in ARMD30, it is likely the same effect may be seen in CSC. In one study, Ginkgo biloba significantly increased ocular blood flow velocity with no impact on arterial blood pressure or heart rate27, which is important for the client.

Free radical reduction, increased vasodilation, reduced blood viscosity26, all contribute to an improvement in visual acuity in macular degeneration32, which, theoretically, may be of use in CSC33.

Vascular endothelial growth factor (VEGF) overexpression caused by local cell inflammation hypoxia is thought to induce choroidal neovascularisation31, and Ginkgo biloba has been shown to reduce VEGF expression in vitro30.

1200mg per day is at the higher end of the suggested dosage range25. Due to the seriousness of the client’s situation, and the potential to lose his sight, a rapid improvement is required.

Safety Considerations and Interactions: Vaccinium myrtillus

Earlier studies have shown large quantities of Vaccinium myrtillus as potentially toxic due to the risk of hydroquinone poisoning21, however, more recent studies have shown safety of dosages of up to 480mg per day21,34. 80mg to 160mg of Vaccinium myrtillus is considered a safe dose for humans, and no toxic effects were observed in a rat study where 400mg was administered per kilogram of body weight21,35.

Adulteration with colourants and other Vaccinium species has been found so care should be taken to find a reputable source25,36.

No safety issues or drug interactions are to be expected within recommended dosages25, however, care and monitoring should be exercised if the client begins taking Mifepristone.

Ginkgo biloba

Due to the popularity of Ginkgo biloba, adulteration with Styphnolobium japonicum and flavonoid aglycones has been found in the marketplace, through the presence of genistein, which is not present in Ginkgo biloba37.

Care must be taken to ensure reputable standardised sources of product are found, which contain not less than six percent total sesquiterpene lactones, being ginkgolides and bilobalide37. Due to this adulteration, care should be taken when evaluating studies where genistein is found as a constituents of Ginkgo biloba.

One study shows an intake of 120mg of Ginkgo biloba per day has no serious adverse effects, or drug interactions with common medications, including NSAIDs38, another shows safety and no drug interactions in doses of up to 210mg per day39. In other studies, the risk of bleeding has been highlighted as a serious risk, although there has been debate over dosages used being much higher than the average consumer dose of 60mg per day, and therefore validity has been questioned40. As there is uncertainty in this area, care should be taken to cease taking Ginkgo biloba two weeks before and after surgery, or if there is any other risk of excessive bleeding.

Mifepristone, a competitive glucocorticoid receptor agonist, may have been prescribed to reduce cortisol, improve sleep41, and therefore halt the progression of Central Serous Retinopathy (CSR). Cytochrome PA503A is involved in metabolism of Mifepristone, which is used in management of Cushing’s disease, improving glycaemic control, and reduce diastolic blood pressure, although adverse events reported include hypertension42. It is recommended that NSAIDs should be taken concurrently in only the smallest possible dose and monitored closely, so it would be recommended to cease taking NSAIDs if Mifepristone is commenced42.

No studies were found demonstrating the specific safety of taking Mifepristone and Gingko biloba concurrently, and some studies suggest no adverse effects would be expected38,39, however, it would be wise to monitor the patient closely if any new drug is commenced.

For references log into your ANTA Member Centre > The Natural Therapist > Journal Articles

PAGE 12 | WINTER 2022 | THE NATURAL THERAPIST VOL 37 NO. 2

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ANTA Member Article Winter 2022

George Thouas, PhD

Head of Research and Development Max Biocare Pty Ltd.

Dermatological Effects of a Herbal Menopause Formula

Introduction:

Menopause is defined by the naturally occurring decline of menstrual cycles in women in their early 50’s. Although many women experience a variety of symptoms, such as hot flushes and mood swings, the process itself is a natural part of the aging process.

It is associated with a decrease in the production of the reproductive hormones, most notably estradiol.

This hormone controls not only ovulation and endometrial receptivity, but has a growth regulatory role in many other tissues, including skin, hair, bone and connective tissue where the estrogen receptor is

expressed1. Formulations that contain herbal sources of phytoestrogens have provided a valuable tool in the natural therapy toolbox for menopausal symptoms2.

This article highlights the second series of outcomes of a clinical trial of a combination herbal extract, produced in Australia, involving a sample of Thai postmenopausal women.

Study Design:

The study, published in the Journal of Cosmetic Dermatology by Tamsutti et al. (2021)3, presents the outcomes of a randomised, placebo-controlled

THE NATURAL THERAPIST VOL 37 NO. 2 | WINTER 2022 | PAGE 15

ANTA Member Article Winter 2022

clinical trial of a commercially available combination of dry extracts of soy isoflavones, black cohosh, chasteberry and evening primrose oil. The trial itself was conducted at the Women’s Center and VitalLife Scientific Wellness Center, Bumrungrad International Hospital and the Department of Dermatology, Siriraj Hospital, Mahidol University, in Bangkok, Thailand.

The women involved (n=110, aged 45-60 years), who showed post-menopausal symptoms and exhibited type II and III fine lines and wrinkles, were randomly given the intervention tablet product, or a placebo (soybean oil) tablet once daily for 12 weeks.

Uniquely, the study measured a range of facial dermatology parameters, together with blood testing for antioxidant status. Dermatologists measured a range of skin parameters at baseline, weeks 6 and 12, including wrinkles, texture, moisture level and melanin levels in facial skin areas on the sides of both eyes.

Blood samples were also taken to determine the level of glutathione (GSH) as an indicator of antioxidant production, and malonyldialdehyde (MDA), a marker of lipid-based oxidative stress. The work represents the second publication emanating from the trial following from the first publication by Rattanatantikul and colleagues (2020)4, highlighted in the Autumn 2021 issue of The Natural Therapist.

Outcomes:

After six weeks, the subjects who took the test formula showed significant improvements in skin roughness compared to placebo. At the 12-week mark, the test group showed further significant improvements in skin elasticity, roughness,

smoothness, scaliness and wrinkle density. In addition, the blood levels of malondialdehyde (MDA) in test group subjects were significantly lower, while their glutathione (GSH) levels were elevated, indicating systemic improvement in oxidative stress status, compared to placebo subjects. There were no changes in trans-epithelial water loss (TEWL), melanin, skin gloss level or hydration levels between the two groups. When questioned about their skin outcomes, significantly more test participants perceived an improvement in the smoothness, moisture, elasticity and wrinkles, from six weeks after test product usage, compared to placebo users.

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ANTA Member Article Winter 2022

THE NATURAL THERAPIST VOL 37 NO. 2 | WINTER 2022 | PAGE 17

ANTA Member Article Winter 2022

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ANTA Member Article Winter 2022

THE NATURAL THERAPIST VOL 37 NO. 2 | WINTER 2022 | PAGE 19

ANTA Member Article Winter 2022

Implications of the Study:

The study is unique because it shows that herbal formulas containing phytoestrogens can elicit measurable, progressive improvements in skin integrity and antioxidant status in aging women, alongside improvements in menopause symptoms.

These effects are specifically relevant to postmenopausal women, who no longer produce estradiol, an important regulator of skin turnover and integrity.

Some of the underlying mechanisms by which the herbal ingredients in the test product may have induced these effects are through a combination of the estrogen receptor (ER) modulating and antioxidant effects of soy isoflavones, the barrier promoting effects of evening primrose oil fatty acids, and the mixed antioxidant and cytoprotective effects of polyphenol compounds in chasteberry and black cohosh. The researchers suggested that the activation of ER-beta by soy isoflavones may have stimulated collagen and elastin content, which was responsible for the observed improvements in mechanical integrity of the skin. Additional actions that may have had a secondary benefit include the anti-microbial and anti-inflammatory properties of some of these herbs, which relates to clinical uses such as alleviation of

Soy Isoflavones

acne vulgaris and dermatitis.

The antioxidant effects observed here are particularly relevant to natural aging processes because oxidative stress is intimately involved in degenerative changes not only in skin, but in most other tissues. These include heart and skeletal muscle, blood vessels, liver and joint tissues. Oxidative damage is also a contributing factor in inflammation, as we know from slower rates of repair and regeneration in ageing tissues.

Conclusion:

In summary, the outcomes described in the publication

by Tamsutti et al (2021)3 suggest that the investigated herbal formula can help to protect skin health and oxidative stress status in post-menopausal women. These findings are complementary to the improvements in menopause symptoms, as well as the reductions in cardiovascular risk and inflammatory status described by Rattanatantikul et al. (2020)4 for the same product.

For references log into your ANTA Member Centre > The Natural Therapist > Journal Articles

Evening Primrose Oil

PAGE 20 | WINTER 2022 | THE NATURAL THERAPIST VOL 37 NO. 2

Chasteberry

Black Cohosh

Belle Dame Supporting Women's Health

Each soft capsule contains: Isoflavones (calc. as daidzin/ein, genistin/ein, glycitin/ein) from Glycine max (Soya bean) seed germ ext. dry conc. stand. equiv. to fresh Actaea racemosa (Black cohosh) root & rhizome ext. dry conc. stand. equiv. to dry equiv. triterpene glycosides calc. as 27-desoxyactein (of Actaea racemosa)

100mg 7.5g 264mg 2mg

Vitex agnus-castus (Chasteberry) fruit ext. dry conc. equiv. to dry

400mg

Evening Primrose Oil equiv. gamma-Linolenic acid equiv. Linoleic acid

500mg 50mg 325mg

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Maxucosa®

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Each hard capsule contains: Fucoidan (Maritech®*) from Undaria pinnatifida whole plant extract dry conc. stand. equiv. to dry

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PAGE 22 | WINTER 2022 | THE NATURAL THERAPIST VOL 37 NO. 2

ANTA Member Article Winter 2022

Kerry Bone

Founder and Director of Research at MediHerb Principal of Australian College of Phytotherapy Adjunct Professor of New York Chiropractic College

Bacopa Monnieri - New Validation and Insights for This Important Brain-Boosting Herb

Introduction:

The herb Bacopa monnieri (family formerly Scrophulariaceae, now Plantaginaceae) is an annual, succulent, creeping plant found throughout India in wet, damp and marshy areas. Often confused with gotu kola (Centella asiatica) which is also known as Brahmi, Bacopa is the foremost nervine tonic of the Ayurvedic tradition. The aerial parts or whole plant are used for epilepsy, insanity and to improve memory and mental capacities. It is also native to Australia.

Research interest in Bacopa has accelerated this century and there are now more than 30 clinical trials across a range of applications, mostly related to memory and cognitive function. Cumulatively, the trial data suggest that Bacopa is now an important herb in the modern materia medica for boosting mental function and cognitive capacity. Even more exciting is the suggestion from recent clinical research that Bacopa might be able to increase brain neuroplasticity.

Some key findings from the recent clinical research that provide new validation and insights for this important brain-boosting herb are summarised below.

Bacopa Monnieri for Attention Deficit Hyperactivity Disorder:

An Australian study investigated the efficacy of an extract of Bacopa in reducing the levels of inattention and hyperactivity in young children with Attention Deficit Hyperactivity Disorder (ADHD) symptoms.

Bacopa has demonstrated improvements in cognitive outcomes in adults, yet little research is available on its effects in younger populations, apart from uncontrolled trials mainly from India in ADHD and related diagnoses.

A 14-week randomised, double-blind, placebocontrolled clinical trial (n=112), with placebo run-in and run-out phases, investigated the effects of Bacopa on behavioural, cognitive, mood and sleep effects in male children aged 6 to 14 years with a Diagnostic

THE NATURAL THERAPIST VOL 37 NO. 2 | WINTER 2022 | PAGE 23

ANTA Member Article Winter 2022

and Statistical Manual of Mental Disorders 5 (DSMIV) ADHD rating score above 15 against a placebo.

By the end of the trial, no significant behavioural differences were noted between treatment groups.

However, cognitive function outcomes showed decreased error-making in children taking Bacopa (p=0.04) and increased speed of reaction time in those taking placebo (p=0.04) at the study end. This trade-off between accuracy and speed has also been noted in another clinical trial of Bacopa in adults (see below). Improvements in cognitive flexibility (p=0.01), executive functioning (p=0.04), interpersonal problems (p=0.02), and sleep routine (p=0.04) were noted in those taking Bacopa compared with placebo.

The authors concluded while Bacopa did not improve behavioural outcomes, it may have cognitive, mood and sleep benefits in children aged 6 to 14 years showing signs and symptoms of ADHD1.

Bacopa Monnieri Might Be An Adaptogen:

Despite the fact that Bacopa is not typically used to improve sleep in adults, 89 healthy men and women aged 18 to 70 years with self-reported sleep problems were enrolled into a 28-day, randomised, double blind, placebo-controlled trial. Researchers examined the administration of 150mg of Bacopa extract (twice daily) and its impact on quality of life (QOL) measures, including emotional wellbeing, alertness, and quality of sleep2.

Perhaps not surprisingly, Bacopa did not improve sleep patterns more than placebo (based on the Bergen Insomnia Scale). However, the trial did reveal some interesting findings. Bacopa was associated with

greater improvements in emotional wellbeing, general health, and pain-related symptoms. Specifically, the data revealed positive improvements in salivary biomarkers with Bacopa when compared to placebo, indicating reduced stress, including positive changes in morning cortisol levels.

Does Bacopa Monnieri Exert Neuroplastic Effects?

Neuroplasticity, also known as neural plasticity, or brain plasticity, is the ability of neural networks in the brain to change through growth and reorganisation.

These changes might range from individual neuron pathways making new connections, to systematic adjustments like cortical remapping (every part of the body is connected to a corresponding area in the brain, which creates a cortical map). Neuroplasticity allows the neurons in the brain to compensate for injury and disease and to adjust their activities in response to new situations or changes in their environment. It is being actively researched as a therapeutic strategy for areas as diverse as stroke recovery, pain management, Autism and Alzheimer’s Disease (AD).

A randomised, double blind, placebo-controlled trial asked 28 healthy adults aged over 55 years to complete cognitive training (CT) three hours weekly for 12 weeks while taking Bacopa or a placebo.

Compared with placebo, mean accuracy was higher in the Bacopa group for the tested tasks, but speed was slower, suggesting a change in the speed-accuracy trade-off3.

PAGE 24 | WINTER 2022 | THE NATURAL THERAPIST VOL 37 NO. 2

ANTA Member Article Winter 2022

Exploratory imaging of the participants’ brains revealed some new and novel findings. Results showed increased white matter (WM), mean diffusivity (MD), and grey matter (GM) dispersion of neurites (orientation dispersion index (ODI)) with Bacopa intake. Also, there were decreased WM, fractional anisotropy (FA), and GM neurite density (ND) in the Bacopa group. The increase in ODI with a decrease in MD and ND for the Bacopa group may indicate an increase in network complexity (through higher dendritic branching) accompanied by dendritic pruning to enhance network efficiency.

Simplifying the technical and complex nature of these neuroimaging findings, the results suggest that Bacopa might exert a favourable neuroplastic effect while learning new tasks. The authors noted that the neuroimaging outcomes curiously conflicted with the behavioural results, which showed poorer reaction times in the Bacopa group.

Progress in the Evidence for Alzheimer’s Disease:

While there are several clinical trials demonstrating how Bacopa can improve memory and cognitive functioning, most of these trials have been in healthy people of all ages. There was one open-label trial published in 2011 that found a Bacopa extract given over six months to 39 patients with recently diagnosed AD resulted in significant improvements in cognition measures compared to baseline for orientation of time/place/person, attention, reading, writing and comprehension measured with the MiniMental State Examination (MMSE)4.

Just recently, a small study (n=34) was published comparing the efficacy and safety of Bacopa extract versus the drug donepezil (10mg/day) for 12 months in patients with AD and mild cognitive impairment (MCI). While the trial was probably underpowered, it did find no difference between the efficacy of Bacopa and donepezil5.

For references log into your ANTA Member Centre > The Natural Therapist > Journal Articles

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Healthy Recipes Winter 2022

Healthy Recipes Rachel Knight is a Chef and Nutritionist in Melbourne. Her passion for seasonal and locally sourced produce has led her to a career in recipe development aimed at optimal health. Rachel currently works for Lamanna Supermarket as a Nutritionist and Product Developer.

Spiced Pumpkin Bread with Chai Butter

Categories:

• Gluten-Free

• Breakfast

• Low-Carbohydrate High-Fat

• Low Carbohydrates

• Keto

• Diabetic Friendly

• Kids Treat

• Lunch Box Treats

Recipe Data: Serves:

9

Preparation:

15 minutes

Cook / Chill:

1.5 hours

Nutrition: Carbohydrates

Protein

Fats

Energy (KJ)

Calories

Serving Size

6g

11.8g

38.7g

1770 KJ

423

125g

Ingredients: • • • • • • • • •

450g Pumpkin, grated 1 tsp Cinnamon ⅛ tsp Nutmeg 4 Eggs 60ml Olive Oil 300g Almond Meal 2 tsp Baking Powder Pinch of Salt Pepitas and Sunflower Seeds (optional)

Chai Butter

• • • • • • •

125g Butter, softened 1 tsp Ground Cinnamon 1 tsp Ground Ginger ⅛ tsp Ground Nutmeg Pinch of Ground Cloves 1 tsp Honey ⅛ tsp Ground Cardamom

Method: 1. Preheat oven to 160°C (fan-forced). Grease

2.

3.

4.

5.

6.

7.

8.

and line a loaf tin with baking powder.

Combine the pumpkin, spices, eggs and oil in a bowl. Mix well to combine.

Add the almond meal, salt and baking powder and mix again.

Spoon the mixture into the prepared loaf tin and sprinkle with pepitas and sunflower seeds (optional).

Place into the oven for 1 ½ hours or until a skewer inserted comes out clean.

To make the chai butter, combine all of the ingredients in a bowl and mix well until smooth and creamy.

Remove from the oven and allow to cool in the tin for 15 minutes before transferring to a wire rack to cool completely.

Serve warm with chai butter.

Nutritional Information Tips/Tricks: • Nutritional information is per piece with 2 teaspoons of butter.

PAGE 30 | WINTER 2022 | THE NATURAL THERAPIST VOL 37 NO. 2

Healthy Recipes Winter 2022

Palak Tofu Categories: • Dairy-free

• Gluten-free

• Low-Carbohydrate High-Fat

• Keto

• Low Carbohydrates

• Diabetic Friendly

• Vegan

• Dinner

Recipe Data: Serves:

4

Preparation:

35 minutes

Cook / Chill:

35 minutes

Nutrition: Carbohydrates

Protein

Fats

Energy (KJ)

Calories

Serving Size

6.6g

17.9g

22g

1350 KJ

323

260g

Ingredients:

Spiced Tofu • 450g Firm Tofu, cut into cubes • 2 tsp Nutritional Yeast • ½ tsp Salt • 1 tsp Ground Cumin • 1 tsp Garam Masala • 1 tsp Cayenne Pepper

3.

4.

Spinach Curry • 120g Baby Spinach • 1 tbsp Coconut Oil • 1 Brown Onion, diced • 60ml Water (¼ cup) • 180ml Coconut Milk (¾ cup) • 2 Tomatoes, roughly chopped • 8 Garlic Cloves, minced • 2 tbsp Ginger, minced • 1 tsp Garam Masala • 1 tsp Salt

5.

6.

7.

8.

9.

To serve (optional) • Coconut Milk • Fresh Coriander • Slivered Almonds • Rice

Method: 1. Preheat the oven to 200°C. 2. Place all of the ingredients for the spiced tofu

in a bowl and toss to combine ensuring the tofu is coated. Place onto a baking tray and bake for 15 minutes.

For the spinach curry, heat the oil in a large frying pan over a medium heat. Add the onion, ginger and garam masala, and cook until the onion is soft and translucent.

Add the tomatoes, salt and garlic and cook until the tomatoes have softened (3-4 minutes).

Add the spinach, water and coconut milk and cook until the spinach has wilted (around 30 seconds).

Place into a food processor or high-speed blender and blitz until smooth.

Pour the mixture back into the frying pan over a medium heat and cook for 3-4 minutes.

Add the tofu to the pan and cook for a further 2-3 minutes.

Adjust the seasoning to taste and serve with a drizzle of coconut milk. Top with fresh corriander, slivered almonds and a side of rice.

Nutritional Information Tips/Tricks: • Nutritional Information is calculated per serve without rice.

• The flavours will develop over the next few hours so be careful not to over season the dish if you are not serving it straight away.

THE NATURAL THERAPIST VOL 37 NO. 2 | WINTER 2022 | PAGE 31

ANTA Member Article Winter 2022

Tino D’Angelo

MAppSc (Chinese Medicine) BHSc (Acupuncture) BHSc (Musculoskeletal Therapy) ANTA Chinese Herbal Medicine Branch Chair

Thoracic Outlet Syndrome: A CrossModality Approach Thoracic Outlet Syndrome (TOS) is a neurogenic syndrome that may affect the neck, chest, shoulder and upper limb1, however, it is most frequently experienced in the medial aspect of the upper extremity along the C8 and T1 dermatomes2. Patients may experience symptoms that are quite debilitating, and mostly include pain, numbness and tingling2,3, and paraesthesia1,3. The symptoms of TOS are caused by entrapment of the neurovascular bundle that passes through the thoracic outlet, which is how the syndrome was first termed in 1958 by Rob and Standeven4. The ‘neurovascular bundle’ is comprised of the brachial plexus, subclavian artery and subclavian vein2; and the ‘thoracic outlet’ may be defined as the anatomical space bordered by the anterior and middle scalene muscles, the clavicle, and the first rib1,2,3,4.

The patient with TOS often presents a challenge for the clinician, as the diagnosis and treatment are

rarely straightforward1,5,6. Firstly, the presenting symptoms can vary because of the various structures that may be compressed. As such, there are three subgroups of TOS consisting of neurogenic (nTOS), venous (vTOS), and arterial (aTOS)1,2,3. However, the most frequent cause of TOS tends to be neurogenic (brachial plexus compression)4. The second dilemma is to establish the site of compression within the thoracic outlet. Generally, compression may occur in one (or more) of three regions within the thoracic outlet: between the anterior and middle scalenes (scalene triangle), between the clavicle and first rib (costoclavicular space), and between the coracoid process and pectoralis minor (retro-coracopectoral space)1,2,3,4,5. Other structural anomalies such as cervical ribs and extended transverses process could also be responsible for compression of the neurovascular bundle4. Often, these anomalies may require surgery for correction.

PAGE 32 | WINTER 2022 | THE NATURAL THERAPIST VOL 37 NO. 2

ANTA Member Article Winter 2022

In order to determine the site of obstruction, specific orthopaedic tests must be employed. When the neurovascular bundle is compressed within the scalene triangle, the condition is referred to as ‘Scalene Syndrome’. There are two tests that can assist the clinician to ascertain impingement within the scalene triangle, the Adson’s Test2,3,4,6,15 and Halstead’s Test16. Both tests monitor the radial pulse while the arm is extended and abducted to around 30°. In the Adson’s Test, the patient is instructed to rotate their head to the side being tested, slightly extend the neck, and hold in their breath. For the Halstead’s Test, rotation of the head is to the opposite side whilst holding their breath. If the pulse is diminished or absent, it will indicate Scalene Syndrome15,16. Compression between the clavicle and the first rib (Costoclavicular Syndrome) can be determined by a positive Costoclavicular Test. The positioning is the same as the Adson’s Test without head or neck movement, however the clinician is required to press down on the affected shoulder girdle. The finding will also be a diminished or absent pulse15,16. A Wright’s Test is used to determine when the obstruction is caused through impingement at the retro-coracopectoral space (Pectoralis Minor Syndrome)15,16. The way the neurovascular bundle passes through this space lends itself to impingement in two ways. Firstly, by compression from the coracoid process which lies directly superior, and secondly from a hypertonic pectoralis minor muscle pressing against it anteriorly. It is for this reason that the Wright’s Test has two variations. In the first variation, the patient’s arm is flexed to a full 180°, which puts excessive tension on the bundle if the coracoid process is inferiorly displaced. The second variation involves horizontally abducting the arm until resistance is met.

A significantly diminished or occluded pulse in both variations will indicate Pectoralis Minor Syndrome15,16.

Other orthopaedic tests that are commonly mentioned are the Elevated Arm Stress Test (EAST) also called the Roo’s Test2,3,4,6,15, and the Upper Limb Tension Test (ULTT)2,3,4,6. These tests may lack specificity, as in, positive findings will indicate impingement of the neurovascular bundle, however the tests will not aid in pinpointing the location of the obstruction. More significance could be placed on the orthopaedic tests discussed above, as diagnostic accuracy is imperative for the most appropriate treatment to be applied4.

the main symptoms of TOS (numbness and tingling), they are classified in Chinese Medicine as Má Mù9,10,21.

The aetiology and pathogenesis of numbness and tingling can be attributed to some form of obstruction restricting the nourishment of Qi and Blood to muscles or limb supplied. In some cases, the source of the obstruction is an external pathogen, mainly cold and/or phlegm. In other cases, Qi stagnation and/or Blood stasis may be responsible for the obstruction, which may correlate to a postural dysfunction from the aspect of Western Medicine. In each case, the numbness and tingling are a direct result of the malnourishment of Qi and Blood10,11. It is interesting to note that even from a Western Medicine perspective, stress5,12 (Liver Qi stagnation), and cold are known aggravators of the symptoms of TOS12.

Bäcker and Hammes7 support the above aetiology of neuropathic pain, stating that acute scenarios are often associated with a Bi Syndrome, whereas the later stages fall under the category of Wei Syndrome. In addition, Bäcker and Hammes7 state that Spleen involvement should also be considered.

Furthermore, they reinforce that treatment in Traditional Chinese Medicine (TCM) must typically follow a phenomenologically oriented approach, as the nervous system does not exist as an independent entity7, and thus pattern differentiation is essential for correct treatment.

Example herbal formulae that address the patterns discussed are presented in Table 1 below13. The formulae are the same as those used in the treatment of periarthritis of the shoulder, as they follow very similar treatment principles and are guided to the same area. An important factor worth noting when building an appropriate formula is the inclusion of guiding herbs. Qiang Huo is used to guide the action of the other herbs in a formula to the upper body; Jiang Huang to the shoulder; and Gui Zhi to the extremities14. The formulae suggested below are only examples and could therefore be modified and expanded on by the experienced herbalist.

With regard to treatment, it has been suggested that a multimodal approach is often required to ensure the best outcomes7. TOS has been widely documented in manual therapies literature, however, from a Chinese Medicine perspective TOS is seldomly discussed, especially in English8. When analysing THE NATURAL THERAPIST VOL 37 NO. 2 | WINTER 2022 | PAGE 33

ANTA Member Article Winter 2022

Table 1: Herbal Formulae for Thoracic Outlet Syndrome Formula

Ingredients

Treatment Principle

Wu Tou Tang Jia Jian (modified)

Bai Shao (Radix Paeoniae Albae) Huang Qi (Radix Astragali) Gui Zhi (Ramulus Cinnamomi) Jiang Huang (Rhizoma Curcumae Longae) Processed Chuan Wu (Radix Aconiti Carmichaeli) Qiang Huo (Radix Et Rhizoma Notopterygii) Gan Cao (Radix Glycyrrhizae)

Dispel wind, scatter cold, and free the flow of the network vessels.

Qiang Huo Sheng Shi Tang Jia Wei (modified)

Qiang Huo (Radix Et Rhizoma Notopterygii) Du Huo (Radix Angelicae Pubescentis) Goa Ben (Rhizoma Ligustici) Fang Feng (Radix Saposhnikoviae) Chuan Xiong (Rhizoma Chuanxiong) Man Jing Zi (Fructus Viticis) Jiang Huang (Rhizoma Curcumae Longae) Gan Cao (Radix Glycyrrhizae)

Dispel wind, overcome dampness, and free the flow of the network vessels.

Shen Tong Zhu Yu Tang Jia Jian (modified)

Qin Jiao (Radix Gentianae Macrophyllae) Tao Ren (Semen Persicae) Hong Hua (Flos Carthami) Qiang Huo (Radix Et Rhizoma Notopterygii) Ru Xiang (Olibanum) Dang Gui (Radix Angelicae Sinensis) Chuan Niu Xi (Radix Cyathulae) Di Long (Pheretima) Jiang Huang (Rhizoma Curcumae Longae) Chuan Xiong (Rhizoma Chuanxiong) Xiang Fu (Rhizoma Cyperi) Gan Cao (Radix Glycyrrhizae)

Quicken the blood, transform stasis, and stop pain.

Ban Xia Fu Ling Wan Jia Wei (modified)

Ban Xia (Rhizoma Pinelliae) Fu Ling (Poria) Ze Xie (Rhizoma Alismatis) Han Fang Ji (Radix Stephaniae) Luo Shi Teng (Caulis Trachelospermi) Zhi Ke (Fructus Aurantii) Bai Zhu (Rhizoma Atractylodis Macrocephalae) Jiang Huang (Rhizoma Curcumae Longae)

Fortify the spleen and dispel wind dampness, transform phelgm and free the flow of the network vessels.

Huang Qi Gui Zhi Wu Wu Tang Jia Jian (modified)

Huang Qi (Radix Astragali) Sheng Jiang (uncooked Rhizoma Zingiberis) Dan Shen (Radix Salviae Miltiorrhizae) Ji Xue Teng (Caulis Spatholobi) Bai Shao (Radix Paeoniae Albae) Da Zao (Fructus Jujubae)

Supplement the qi and nourish the blood, harmonise the constructive and stop pain.

From an acupuncture standpoint, and according to the trajectory of the symptoms, the main dysfunctional meridians are the Small Intestine and Heart from a Channel perspective. This could also extend to the Pericardium and San Jiao meridians. One could further expand on the acupuncture prescription by considering the Sinew Channels. According to Dr Kendall17, the anterior scalene is encompassed by the Gall Bladder Sinew Channel, whilst the middle scalene belongs to the Large Intestine. The posterior scalene, which is governed by the San Jiao17, could also be considered since the whole group of muscles

may be hypertonic in Scalene Syndrome. Whilst not mentioned by Dr Kendall, the subclavius muscle is likely encompassed by the Lung Sinew Channel18, as is the pectoralis minor17. The upper portion of pectoralis major is governed by the Pericardium17, which along with the subclavius muscle may be, in part, responsible for Costoclavicular Syndrome. As one would expect from the nomenclature, the pectoralis minor muscle is mainly responsible for Pectoralis Minor Syndrome28. This muscle is also bound by the Lung Sinew Channel17.

PAGE 34 | WINTER 2022 | THE NATURAL THERAPIST VOL 37 NO. 2

ANTA Member Article Winter 2022

As we map the pathway of pain and numbness inferiorly along the upper limb, affected muscles and their respective Sinew Channels are as follows. The short head of the biceps belongs to the Lung; the medial head of the triceps and hypothenar muscles to the Heart; flexor carpi ulnaris and abductor digiti minimi belong to the Small Intestine Sinew Channel; and extensor carpi ulnaris and extensor digiti minimi belong to the San Jiao.

This opens up the treatment enormously, bringing in more possibilities for effective results. With all the above in mind, example local points to help disperse stagnation in the obstructed region for the diagnosis of Scalene Syndrome, could include GB-12 Wangu8, GB-21 Jianjing8, SJ-16 Tianyou, SI-16 Yuanchuang, LI-17 Tianding, LI-18 Futu, ST-12 Quepen, and any Ahshi points found in or around the scalene muscles. ST13 Qihu, ST-14 Kufang and KID-27 Shufu are worthy options for Costoclavicular Syndrome. Pectoralis Minor Syndrome can be treated with ST-16 Yingchuang, LU-1 Zhongfu and LU-2 Yunmen. Useful adjacent points could include LI-15 Jianyu5, LI-16 Jugu8, SJ-14 Jianliao5, HT-1 Jiquan, HT-2 Qingling and P-2 Tianquan. Possible distal points that could be chosen from are numerous when considering treating the Sinew Channels.

Examples would include LI-11 Quchi5, LI-4 Hegu5,8, LU-5 Chize, P-3 Quzi, HE-3 Shaohai, SJ-6 Zhigou (also for numbness of the hand)19, SI-3 Houxi, SI-6 Yanglao, ST-38 Tiaokou5,19 and GB-41 Zulinqi. In addition, Wang and Robertson20 recommend the use of Jing Well points when there is numbness and tingling in the limbs. They advise that the Jing Well points be bled for excess conditions and needled for deficiency syndromes20.

Heart Meridian

As stated earlier, it is advantageous to balance the pattern/s of disharmony and treat from the aspect of pattern differentiation7 as opposed to merely just treating the condition from a Channel and/or Sinew Channel perspective, which will lead to more synergistic results. Some example points for the pattern of Wind Cold are (but obviously not limited to): LU-7 Lieque and LI-4 Hegu; LU-7 Lieque and SP-9 Yinlingquan for wind dampness; LI-4 Hegu, SP-10 Xuehai and BL-17 Geshu for Blood stasis; LIV-3 Taichong, BL-18 Ganshu and LI-4 Hegu for Qi stagnation; and ST-36 Zusanli, SP-4 Gongsun and SP-6 Sanyinjiao to tonify Qi and Blood21,22. Again, these points are used as an example, and may be manipulated and expanded upon by the experienced acupuncturist.

This article on TOS would not be complete without discussion of the manual therapy treatment aimed at the dysfunctional muscles, as addressing the mechanical component is crucial in aiding to resolve the condition effectively7. Treatment should be aimed at relaxation of tight muscles and correction of faulty posture since most cases of TOS involve shoulder stooping22.

The first of the three subgroups of TOS identified above, Scalene Syndrome, is essentially due to hypertonic scalene muscles, which then entrap the neurovascular bundle between the anterior and middle scalenes. Posturally, this is represented with a ‘head forward’ presentation. Manual therapy techniques (including Tuina) that aim at lengthening the scalene muscles and deactivating trigger points should be employed. Example methods of treatment include longitudinal stripping, cross fibre frictions,

Small Instestine Meridian

THE NATURAL THERAPIST VOL 37 NO. 2 | WINTER 2022 | PAGE 35

ANTA Member Article Winter 2022

deep compressions, muscle energy technique (MET), and self-stretching. Myofascial release techniques are equally as important, as facial adhesions and shortening develop over time in hypertonic muscles due to faulty postures23. Needling Ahshi points and/ or trigger points in the scalene group would also have a beneficial effect in lengthening the muscles25.

However, care should be taken not to needle into the neuromuscular bundle, and even greater care taken when approaching the inferior aspect of the muscles because of the proximity to the apex of the lung. Chin tuck exercises are a valuable addition to the treatment procedure, as they will help strengthen the deep cervical flexors, which are generally weakened in patients with a head forward posture23.

Similar procedures should be taken to resolve Costoclavicular Syndrome. This commonly presents with a stooping posture23, where the shoulders are rolled forward. The mechanism of entrapment may potentially arise because the clavicle rolls forward onto the first rib and compresses the neurovascular bundle26. Another possible mechanism is that the first rib may be slightly elevated due to hypertonic anterior and middle scalene muscles23,26, and thus the neurovascular bundle is compressed in the opposite to the previously stated manner. In this scenario, the treatment involves lengthening the scalene muscles as discussed earlier. Careful assessment of the posture in conjunction to orthopaedic tests is very helpful in ascertaining exactly where the dysfunction lies. To address the clavicle rolling forward against the first rib, there are two components that need to be considered. Firstly, tightness of pectoralis minor, subclavius and possibly the clavicular fibres of pectoralis major will have to be addressed using

the same techniques listed for hypertonic scalenes.

Secondly, the rhomboids and middle trapezius (shoulder retractors) are usually fatigued and weak, thus allowing the hypertonic muscles to be rolling the shoulders forward. These muscles will therefore require strengthening. Simple rowing exercises whilst squeezing the shoulder blades together would be beneficial to begin with.

The third subgroup of TOS, Pectoralis Minor Syndrome, is likely caused the depression or ‘ptosis’ of the scapula23,26, which may also be referred to as a droopy shoulder. This is generally caused by a weakened upper trapezius and/or levator scapulae muscle, which is generally seen in the middle or older age group23. It may also be accompanied by a hypertonic pectoralis minor which traps the neurovascular bundle, and along with the depressed position of the scapula, it allows the coracoid process to compress and place traction on the bundle.

Treatment is accordingly aimed at strengthening the scapular elevators (upper trapezius and levator scapulae) and releasing tension in the pectoralis minor with methods suggested earlier. Strengthening the shoulder elevators can be accomplished with simple shoulder shrug exercises27.

Having analysed the anatomy, presentation of symptoms, pathomechanism of the condition and the various treatment methods based on each subcategory of TOS, it is hoped that the complexity of this challenging condition has been made somewhat clearer. Having a good understanding of these concepts, the patterns of disharmony, dysfunctional sinew channels and meridians, along with carefully conducted assessment procedures will ensure optimum treatment is applied.

For references log into your ANTA Member Centre > The Natural Therapist > Journal Articles

PAGE 36 | WINTER 2022 | THE NATURAL THERAPIST VOL 37 NO. 2

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ANTA Member Article Winter 2022

Mark Shoring

ANTA Multi-Modality Branch Chair

Three Useful Trauma Therapies: A Practical Perspective There are many therapies that can be commonly used with trauma related injuries. The purpose of the following editorial is to explore some of the more unusual therapies that I commonly employ in clinical practice. These therapies include Dit Da Jiao; Tao Hong Si Wu Tang, and White Flower Oil. It is my sincere hope that by the editorials conclusion other practitioners will consider the use of these therapies within their practice.

‘Dit Da Jiao’ also known as ‘Die Da Jiu’ is a topical therapy that I initially encountered through Chinese martial arts practice. It is commonly employed as both a conditioning and trauma remedy, however, through clinical application I have also found it useful in rehabilitation. I would characterise its use in the management and conditioning of bruising and tissue trauma of soft and hard tissues where the surface skin

of the effected region is relatively intact. Therefore, a practitioner would consider this for soft tissue and bone bruising and hairline fractures to aid in recovery.

Application of Dit Da Jiao requires the topical application of this therapy to the effected region 1-2 x/day. From an herbalist’s perspective, the formulae typically contain strong blood moving herbs, so I recommend all practitioners exercise caution when applying this to patients with blood thinning medications. Further, it is contraindicated in patients with haemophilia or similar blood type disorders.

Unfortunately, there is no set generic formulae for this remedy with many different versions available on the market. The easiest to use version of this remedy in the Australian marketplace is a ‘Die Da Jiu’. This version comes in a spray bottle for easy application.

THE NATURAL THERAPIST VOL 37 NO. 2 | WINTER 2022 | PAGE 39

ANTA Member Article Winter 2022 Herb

Latin Name

Temperature

Taste

Group

Tao Ren

Prunus persica semen

Neutral

Bitter, Sweet

Invigorate the Blood

Hong Hua

Carthamus tinctorius flos

Warm

Pungent

Invigorate the Blood

Shu Di Huang

Rehmanniae glutinosa radix praepararta

Warm

Sweet

Tonify the Blood

Bai Shao

Paeonia lactiflora radix

Neutral

Bitter, Sour

Tonify the Blood

Dang Gui

Angelica sinensis radix

Warm

Pungent, Sweet

Tonify the Blood

Chuan Xiong

Ligusticum chuanxiong rhizoma

Warm

Pungent

Invigorate the Blood

Tao Ren

Hong Hua

Shu Di Huang

Bai Shao

Dang Gui

Chuan Xiong

Tao Hong Si Wu Tang or Hong Si Wu Wan is a patent Chinese Herbal Medicine remedy for pain and trauma.

Like Dit Da Jiao, practitioners should apply caution when using this with patients on blood thinning medications. Further, it is contraindicated in patients with haemophilia or similar blood type disorders.

That said, I have commonly employed this remedy in the management of trauma where soft and/or hard tissue damage has occurred. Orally administered, a practitioner needs to refer to the directions outlined on the bottle as a starting point. See the table above for a herbalist’s perspective, the formula consists of the certain agents and associated properties.

tolerated. When applied it gives a hot/cold sensation on the applied region. I advise caution with sensitive areas and do not apply it to the eyes. It has also been my experience that young children often find the application of this remedy too uncomfortable to tolerate. Further, I strongly discourage the use of White Flower Oil over recently sun burnt regions.

The final remedy for discussion is White Flower Oil or Pak Fah Yeow. Manufactured in Hong Kong this topical remedy is excellent in managing soft tissue injury. It is a clear liquid that, to my experience, does not discolour clothing or linen when applied. It has a strong eucalyptus smell which is generally well

In conclusion, it is my hope that the following editorial has provided an insight into alternative methods for practitioners to consider when rehabilitating a range of stabilised trauma-based pathologies encountered in clinical practice.

Eucalyptus Oil

Camphor

Application of White Flower Oil requires the topical application of this therapy to the effected region 1-2 x/ day or as required. From a Herbalist’s perspective, the formula includes Eucalyptus Oil, Camphor, Lavender Oil, Methyl Salicylate, and Menthol Crystal.

Lavender Oil

Methyl Salicylate

Menthol Crystal

For references log into your ANTA Member Centre > The Natural Therapist > Journal Articles

PAGE 40 | WINTER 2022 | THE NATURAL THERAPIST VOL 37 NO. 2

THE NATURAL THERAPIST VOL 37 NO. 2 | WINTER 2022 | PAGE 41

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ANTA Member Article Winter 2022

Warren Maginn

ANTA Nutrition Branch Chair

Harnessing the Power of Nutritional Compounding Introduction:

Most natural medicine healthcare practitioners have heard the term ‘compounding’, however a surprisingly large number of practitioners still remain relatively unfamiliar with its true nature, how it can be (and/ or should be) performed, and ultimately its power to transform their practice.

Some reasons for this may include uncertainties around what is allowed under current Australian regulations, how best to navigate some of the technical complexities involved, and the currently relatively limited level of training available (including within various natural medicine college courses).

It therefore continues to be of benefit, to both experienced practitioners as well as new students alike, to revisit and explore the topic of compounding.

The following overview is intended to serve as a summary of the key concepts involved, as well as some of the main requirements, techniques and tools available, to assist more practitioners to build their confidence with this powerful and important aspect of personalised medicine.

What is Compounding?

Quite simply the act of ‘compounding’ simply refers to the making of ‘custom’ medicines (as opposed to those that are mass manufactured for commercial sale in stores).

Even though the term ‘compounding’ does imply the combining of ingredients, it is important to note that this is not compulsory (i.e. the dispensing of a single ingredient as a medicine on its own still constitutes a form of compounding).

Therefore, a compounded medicine may be comprised of multiple ingredients, or a single ingredient, and may come in any number of ‘dosage forms’ e.g. liquids, creams, and of course… powders.

Some of the benefits of choosing powders as the primary dosage form to use (especially in the case of Nutritional Compounding) include: • They are stable (when free from moisture) • They avoid the need for many additives (stabilisers, preservatives, antioxidants, etc.)

• They are easy to blend (create an even mixture) • They are easy to dose (deliver predictable quantities) • Most nutrient/nutraceutical ingredients are produced in powder form • They can free us from the mortar and pestle!

Despite the above benefits of using pre-powdered ingredients, the somewhat cliché imagery of a mortar and pestle often continues to be used when illustrating the practice of compounding. This is primarily a nod to past medical traditions that involved

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ANTA Member Article Winter 2022

manually breaking down raw ingredients into powder form prior to use for ease of mixing, rather than a literal representation of what is actually involved in the practice of modern compounding.

Historically, it could be said that compounding has been performed since the dawn of medicine. It can also be said that modern pharmaceutical medicine derives much of its origins from related ancient herbal medicine practices. Due to this strong historical heritage, modern Western Herbal Medicine has continued the tradition of custom compounded medicines, most typically in Australia in the form of liquid tinctures.

The reasons perhaps why custom Nutritional Compounding has been somewhat less familiar to some practitioners relates to the relatively more historically recent discovery and synthesis of isolated pure nutrients and nutraceuticals, their clinical benefits, and how to use them.

In this sense, natural medicine practitioners who are able to update their understanding of Nutritional Medicine to include the production of custom nutritional medicines (through Nutritional Compounding) as a fundamental practice, follow in much the same heritage as the Herbal Medicine practitioners of yesteryear who contributed to the currently ubiquitous understanding and practice of personalised herbal medicines.

Who Can Compound In Australia?

The dispensing of pharmaceutical (S3 and S4) ingredients are restricted to medical doctors and pharmacists (e.g. Compounding Pharmacies) in Australia, for obvious reasons related to their specialist qualifications and areas of training and expertise.

The dispensing of natural medicine ingredients (such as amino acids, vitamins, minerals, botanicals, nutraceuticals, etc.) are restricted to healthcare practitioners that are sufficiently trained and qualified in an ingestive modality (such as Clinical Nutritionists, Herbalists and Naturopaths), as accredited by a professional

association (such as those recognised by Australia’s Therapeutic Goods Administration (TGA), including ANTA).

This means that the practice of compounding is restricted to qualified healthcare professionals only, and the ingredients allowed to be used are limited by qualifications, scope of practice, and various other regulatory controls.

However, this also means that numerous (non-TGA) ingredients which are not currently available to be used in mass-produced commercial supplement products in Australia, can in fact be used by Australian natural medicine practitioners when making their own custom medicines. Which may, therefore, present an opportunity to access powerful therapeutic ingredients that would otherwise be unobtainable to a given patient who could benefit from them.

Regulatory Requirements:

Some of the regulatory requirements of this exclusive practitioner privilege include that a compounded medicine must be: • Made for an individual person (not mass-produced) • After private consultation with the patient (at the time it will be dispensed) • Made on the premises (they will be dispensed from) • By a suitably qualified professional (using their own knowledge and judgement) • Appropriately sourced, assembled, documented, and labelled.

Ingredient Sourcing:

The appropriate ‘sourcing’ of ingredients to use within compounding requires that: • For products/ingredients that are not registered with the TGA: Only use pure single ingredients (no premixes, no excipients – otherwise they would need to be listed with the TGA) • When using ‘pre-mixed’ commercial formulas: Only use TGA registered products (otherwise they would breach the on-premises provisions) • Only use ingredients permitted by all national regulations (e.g. TGA, agricultural, etc.)

• Within scope of practice (according to training and qualifications) • Accurately identified (knowing precisely what is being sourced).

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ANTA Member Article Winter 2022

Assembling Compounded Medicines:

The process usually begins with the initial clinical evaluation of a patient’s needs, e.g. via a thorough case history and investigations. Which may sometimes include laboratory testing to gain insights into unique metabolic processes (such as hormone levels, nutrient levels, toxin levels, etc.).

After considering which substances and nutrients may be most beneficial to the patient in their current circumstances, some specific ingredient forms and their quantities need to be decided.

Once these desirable ingredients and their quantities have been decided, the process of assembling the medicine can begin (usually immediately after the consultation).

Note: The responsibility for any decisions related to doses and quantities remains exclusively with the prescribing practitioner (this key responsibility should not be delegated to staff or external resources without confirmation by the responsible practitioner).

The ‘appropriate assembly’ of a compounded medicine includes a number of requirements that should be kept in mind, practiced, and planned for, whenever carrying out compounding in clinical practice.

The following sequence outlines the key steps involved: Note: All key stages of the assembly of a compounded medicine should be carried out by the suitably qualified/trained practitioner/s in a clinic. Any unqualified staff (such as reception staff) need to be supervised by a practitioner in order for them to participate in assembly steps.

Step 1: Calculate the amounts of ingredient needed to deliver the desired daily dose, divided by the number of doses per day, for the number of days the prescription should be taken (which will help determine the total amount of ingredient required).

Step 2: Each intended ingredient should be correctly identified and gathered (e.g. via clear bulk container labelling) and checks for expiry dates (to the end of the intended prescription).

Step 3: The intended total quantity of each ingredient required to achieve the overall formula should be accurately measured (using well-calibrated highprecision scales).

Step 4: If using more than one ingredient, all

measured ingredient quantities need to be blended (through the thorough rotation/shaking of a sufficiently spacious container to create an even mixture).

Step 5: The ingredient/mixture then needs to be poured into a suitable container and sealed, to be dispensed to the patient (along with a suitably sized scoop and some instructions to assist accurate dosing).

Documentation Requirements:

Maintaining ‘appropriate documentation’ i.e. for giving to the patient as well as for keeping on file within practitioner clinical records, is particularly important when dispensing medicines and should include at least the following: • Full patient details (especially Name, Date of Birth, contact details) • Full formula details (all substances and input quantities used) • Full dosing instructions (when, how much, how often, for how long) • Other advice and rationale (why, what for).

Labelling Requirements:

Ensuring that ‘appropriate labelling’ is provided with all medicines being dispensed is one of the most important requirements of all, and given the overlap with many of the same items of information described in the above documentation requirements, it may be most efficient for practitioners to simply provide their patient prescription information on the label at the same time.

Practitioners should ensure their medicine labels include: • Secure attachment to the dispensed container • Patient Identifiers (at least Name and Date of Birth) • Prescriber/Dispenser Identifiers (Name, Contact details, Modality/Qualifications) • The names and quantities of all active ingredients (e.g. mg per dose) • The Dosing Unit (e.g. scoop size) • How many of the dosing units to take (to achieve a Single Dose) • The Dosing Frequency (e.g. how many doses per day) • Instructions for Use (e.g. with/without food, at certain times of day, etc.)

• Expiry/Duration of Supply (how long to take before renewal is required)

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ANTA Member Article Winter 2022

• The Total Quantity of medicine being supplied.

The Benefits of Compounding: Personalisation

It is one of the most fundamental tenets of natural and holistic medicine to ‘treat the individual rather than the disease’. Compounding therefore provides one of the most profoundly individualistic ways to approach clinical treatment.

Better Results

Getting access to certain powerful active ingredients that would be highly beneficial but otherwise unavailable to use in a prescription for a given patient, as well as ensuring that a medicine delivers all that it should and nothing it shouldn’t (e.g. avoiding unnecessary ingredients and even potentially obstructive excipients), often yields better compliance and better clinical outcomes.

Increased Value

The value of a medicine can be gauged in a number of ways, not least of which its potential to yield potent improvements to the clinical outcomes described above. However compounded medicines are often able to achieve this whilst also being more cost effective (through reduced overall cost and/or higher delivery of key ingredients).

Furthermore, the value to practitioners can include creating some exclusivity for their patient, which can in turn build their rapport and engagement with their treatment. This, along with compliance, are often critical to achieving long term clinical success, and long-term success is particularly important within natural medicine practice, given how many natural medicine goals seek to address long term chronic health risks and processes.

It could therefore be said that compounding may be key to the success of certain modalities, and overcome some of the over commercialisation of industry prescribing practices.

Putting It Into Practice:

The next steps for any practitioner who has not yet tried making custom formulas, is simply to begin. Thankfully there are now numerous ranges of compounding ingredients in Australia that are specifically provided for natural medicine practitioners to use in their practice, along with some of the further equipment and guidance required.

For an example formula sheet, practitioners may wish to view a manual compounding template online here: wmed.link/manualsheet Once the basics have been mastered (for example the dispensing of a single ingredient, and establishing accurate in-clinic compounding processes), practitioners may then wish to seek out further tools and resources to make the process easier and more efficient (e.g. through automation), as well as potentially more advanced and complex (e.g. for those particularly difficult cases that require a practitioner with the care and attention to detail to go the extra mile).

For more tools and resources intended to help practitioners to implement compounding and personalised medicines into their practice go to warrenmaginn.com.

Happy Compounding.

For references log into your ANTA Member Centre > The Natural Therapist > Journal Articles

PAGE 46 | WINTER 2022 | THE NATURAL THERAPIST VOL 37 NO. 2

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THE NATURAL THERAPIST VOL 37 NO. 2 | WINTER 2022 | PAGE 47

ANTA Member Article Winter 2022

Emma Ahearn

ANTA Member BHSc (Naturopathy)

Homeopathy Materia Medica: Small Stinging Nettle (Urtica Urens) Taxonomic Rank: • • • • • • • • •

Domain: Eukaryota Kingdom: Plantae Phylum: Spermatophyta Subphylum: Angiospermae Class: Dicotyledonae Order: Urticales Family: Urticaceae Genus: Urtica Species: Urtica urens1.

Major Constituents:

Contains: • Hydroxycinnamic acid derivatives • Flavonoids and flavones • Antioxidants

• Flavonol type glycosides • Silica.

The major constituents of Urtica urens consists of its active components, such as: • Acetylcholine • Histamine • Formic acid • Serotonin2.

The major constituents of formic acid, acetylcholine, histamine3 and serotonin leads to the inflammatory response and perceived pain. These constituents also act as irritants on the integumentary system2.

These constituents may also have possible synergistic effects, prolonging the inflammatory response4.

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ANTA Member Article Winter 2022

Parts Used:

Tissue/Organ Affinity:

Fresh plant in flower.

Method for Homeopathic Preparation:

Urtica urens is prepared as a mother tincture5, which eliminates formic acid from the plant. This allows for safe internal consumption2. The whole plant is chopped into fine pieces and soaked in alcohol, which is then strained and diluted to a low potency5.

Pathogenic Trials:

There are no modern human pathogenetic trails on Urtica urens. Therefore, there is no significant current data to inform clinical reasoning in homeopathic treatment.

Toxicology/Poisonings:

No known poisonings or toxicology reports. However, when the skin comes into contact with this plant it exhibits a red, itchy and burning rash that might swell1. These symptoms may last for up to 36 hours in sensitive individuals6. This is supported by the European Medicines Agency (2010)7.

Major Clinical Contributors:

James Compton Burnett utilised Urtica urens for spleen affections, gout, headaches, rush of blood to the head, a painful abdomen, dysentery, burning and itching of the anus, oedema, urticaria, rheumatic complaints and fevers8. Burnett gave this remedy to a middle-aged women, who passed large amounts of gravel, and aided in decreasing abdominal pain over a few days. The urine was noticeably more plentiful, dark and loaded with uric acid8. This affinity for the urinary system is supported by Boericke (1999)5, as he utilised this remedy for gout and uric acid diathesis, as the plant favours elimination9.

Additionally, the symptoms tend to return every year at the same time9.

This remedy has an affinity for the skin, kidneys and bladder, joints and cartilage. It also has an affinity for the breasts, in particular with suppressed breast milk10. Symptoms usually occur on the right side of the body8.

Characteristic Symptoms:

Urticaria-like eruptions, rheumatism, spleen affections, neuritis, agalactia and lithiasis9.

Mental Generals:

Vertigo, headache with spleen pains9, sensation of a fullness in the head all day with giddiness, sensation of blood rushing to the head and headaches over the eyes8. Anger, aversion to company, confusion, wandering thoughts and a fear of survival11.

Physical Generals:

Allergic reactions after eating shellfish, complaints come yearly/periodically, ailments from supressed nettle rash, suppressed breast milk, urticaria alternating with rheumatism and symptoms are aggravated for cold bathing or cool damp air10. Also, aggravated for touch9.

Physical Particulars:

• Chest: Disturbances in lactation, excessive swelling of breasts with burning and stinging pains10.

• Extremities: Acute gout, rheumatism associated with urticaria-like eruptions, pain in right deltoid, which is aggravated by rotating the arm inwards10, and pain in ankles and wrists9.

• Skin: Urticaria-like eruptions, urticaria, burning and stinging, red blotches, sensitive to touch, aggravated by over-heating, burns and scalds of first and second degree, insect bites and stings and chicken pox10. Also indicated in itching swellings over fingers and hands resembling ‘bold hives’, lumps and red spots on hands, and fever blisters on lips. Feeling of heat in the skin of the face, arms, shoulders and chest with formication, numbness and itching. Intense burning on skin after sleep8.

Usage in Other Medicinal Systems:

Urtica urens is utilised as a valid treatment for various allergies, arthritis, bladder infections, skin complaints, neurological disorders, cancer treatment, respiratory diseases, and gum inflammation12. This is due to the plant’s high antioxidant and antiinflammatory activity12, as well as its antimicrobial actions2. Furthermore, it also contains various

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ANTA Member Article Winter 2022

phytochemicals that enables a hostile environment for gram positive and negative bacteria2.

Urtica urens is considered safe for internal consumption, as it was found that in a bioactive extract it didn’t create a cytotoxic environment to macrophages and hepatocytes13. This is supported by the European Food Safety Authority, concluding that Urtica urens is a safe plant to consume with no immediate or delayed harmful effects2. This allows the plant to be utilised as medicinal food.

Major Homeopathic Medicinal Relationships:

Clarke (2000)8 states that Urtica urens is similar to Natrium Muriaticum and Urinum for skin conditions, such as urticaria. Clarke (2000)8 also compares the similarities of Urtica urens with Apis for genitourinary organs, as well as Pulsatilla for female reproductive issues associated with pain8. Furthermore, it is similar to Medusa, Lac Caninum, Ricinus for diminished mammary secretions and Lycopodium Clavatum and Hedeoma for uric acid conditions5.

Compare and Contrast Action of Urtica urens and Urtica diocia:

Compared to other nettles, Urtica urens has a higher affinity for inflammation, thus is indicative in inflammatory conditions13. This is due to higher amounts of acetylcholine and histamine giving it a greater therapeutic affect3 compared to Urtica diocia.

It also demonstrates chemoprotective, anxiolytic and anti-bacterial properties, alongside its antioxidant, antimicrobial and anti-arthritis actions, which is also

seen in Urtica dioica14. Furthermore, Urtica urens is a specific remedy chosen for its actions on uric acid and the suppression of breast milk9.

Medicine Posology:

Urtica urens is utilised at low doses of 1x potency. For acute conditions, take one pilule or five drops of the remedy every 15 minutes (for intense symptoms) to 4 hours (for mild symptoms). Once an improvement is noticed, cease remedy and repeat if symptoms return. If there is no improvement within three doses, consider another remedy15.

Published Research:

• Its antioxidant property protects against imidacloprid intoxication, which aids in bone health16. Also, the antioxidant action prevents against ovarian injury accompanied with disturbances of oxidant status induced by imidacloprid17.

• The leaves contain saponin glycosides which has the capability to inhibit pancreatic lipase enzyme.

This remedy may be suitable in the treatment of obesity18.

• Urtica urens reduces CYP1A1 and CYP1A2 expression levels and associated activities by modulating CYP1A enzymes, thus having a chemoprotective action. It also prevents CCI4induced hepatotoxicity by boosting the antioxidant defence system in animal studies19.

For references log into your ANTA Member Centre > The Natural Therapist > Journal Articles

PAGE 50 | WINTER 2022 | THE NATURAL THERAPIST VOL 37 NO. 2