By: Alex McDonald, MD
Acupuncture has it’s origins in ancient China. For thousands of years practitioners of Eastern medicine have developed acupuncture skills and techniques that have been refined and re-refined into a very effective and precise medical art. However, it is still in many ways an art and can differ greatly from one practitioner to another. Within recent decades acupuncture has gain broad acceptance within Western medicine and has been scientifically show to have great benefit in many different medical and health circumstances. One of many specific uses for acupuncture that has been closely examined is it’s effect on athletic performance. Athlete’s have been shown to be more willing to engage in Complementary and Alternative Medicine (CAM), 56%, as compared to the general population, 36%. So is there an actual benefit to acupuncture on athletics? After a brief literature review, the answer is a resounding yes. Keep in mind, that there are many additional benefits of acupuncture, which are beyond the scope of this article.
It should be noted that there are several different methods of “acupuncture” all of which utilize a complex map of meridians and points on the body. Some of the more common types of treatment include; Needling, where a tiny needle is inserted into/thru the skin; Acupressure, where the skin is not penetrated; Transcutaneous electrical acupoint stimulation (TEAS), where an electrical stimulus is applied at specific acupuncture points by an electrode placed on the skin; Lastly, when an electrical stimulus is applied through a needle inserted into/thru the skin. All of these various modalities have been show to be beneficial to athletic performance.
There have been several studies, which point toward improved athletic performance with the use of acupuncture. Although there are certainly several different pathways involved, the major factors are most likely, reduced tension in the muscle, increased blood flow, increased oxygen utilization, and psychological effects.
Endurance athletics is particularly attuned to the effect of oxygen consumption and utilization and acupuncture has been shown to increase VO2 max. In one study by Lin et al. 3 groups of athlete’s were run to exhaustion. The control group had no treatment, the acupuncture group had auricular acupuncture treatment, and the third group had auricular acupressure treatment (no needle). The group that had received acupuncture treatment had a statistically significant higher measured VO2 max at exhaustion.
Muscular force production and recovery has also been shown to improve with acupuncture . In one study by So et al., participants completed 3 successive days of isokinetic knee exercises. The treatment group received TEAS right after exercise for 15min, where electrodes and current was applied to specific acupuncture points. A second, control group received pseudo-TEAS for 15min right after exercise, where electrodes where placed on points which were not established acupuncture points. Maximal muscular force was measured before and after exercise, as well as at 5min increments during the 15 minutes of TEAS or pseudo-TEAS treatment. The results showed that the group treated with TEAS had significantly improved recovery time and were able to generate greater maximal force and create it sooner than the pseudo-TEAS group. There have been additional studies, which demonstrate improved recovery after endurance exercise with acupuncture treatment, showing lower heart rate and lactic acid levels (lin).
In addition to allowing for higher muscle force production after acupuncture, studies have also demonstrated reduced muscle tension (de Sousa). Muscle fibers have an optimal length at which state they function best. If the muscle is stretched to long then contraction will be sub maximal, additionally, if the muscle is pre-contracted and too short then, again, contraction will be sub maximal. Part of the theory behind why muscular forces are greater after acupuncture is that the muscle is better able to relax to it’s optimal length. Acupuncture likely achieves this through two methods. First, it functions to relax the muscle itself. Secondly, it release tension in the fascia surrounding the muscle. Connective tissue, known as fascia is continuous and contiguous throughout the entire body form the bottom of the feet to the top of the head. This is one reason why treatment to one specific area, such as the leg can positively impact distance structure such as the shoulder. In one anecdotal, albeit uncommon situation, a woman with knee pain experienced symptom relief after acupuncture releasing tight fascia in her jaw.
Acupuncture has been shown to increased blood supply throughout the body, particularly to the muscle during and after acupuncture treatment (Ohkubo). This is one probable reason for why VO2 max has been shown to increase with acupuncture treatment. The act of microtrauma to muscle seems to create a healing response form the body without actually cause notable trauma. When an injury occurs there is a highly sophisticated response of hormonal, neural and metabolic intermediates that stimulate the healing response. Most notably in this situation, increased blood flow and resultant increased oxygen flow. Although slightly out of the scope of this article, acupuncture has been show to be beneficial during injury rehabilitation for many of the same reasons. Injured structures require blood flow to provide nutrients and metabolites to repair damaged tissue, as well as carry away waste products. Acupuncture has been show to be particularly helpful to increase blood flow to tendon injuries which typically have a very low blood flow, such as the achilles (Kubo).
Lastly, acupuncture has been show to decrease pain. The application of acupuncture has been show to have potential analgesic effect through the activation of endogenous opioid system within the body (Ma). That is to say, that acupuncture causes the release of substances naturally found in the body, known as endorphins, which act on the same neural pathways where medicines such as morphine and codeine. We have all experienced this sense of invincibility, or “no pain” during moments of emergency.
The Placebo Effect:
There have been some case studies, which describe immediate and significant improvement in athletic performance after commencing a regular acupuncture program. . For example, Kaada reported a mean improvement of 2.3 s in 800 m track racing and 4.3 s in 1000m road racing (Usichenco). The points for acupuncture were based on specific complaints by the athlete, for example, stomach pain, arm fatigue, stiffness of the shoulder and excitement and tremor of specific muscles. It is very difficult to explain these benefits based solely on physiology. As a result other causes of the benefits have been proposed, especially the placebo effect. The placebo effect being the benefits are psychological and due to the athlete’s belief that a treatment is helping and it becomes a self fulfilling prophecy. Some researchers argue that placebo, in addition to physiological effects, may constitute 30–50% of the entire clinical effect of acupuncture (Lundenburg) although, this cannot be confirmed. However, the placebo effect alone has been shown to produce the same performance improvement in trained athletes, as could be achieved using various pharmacological agents—caffeine and sodium bicarbonate in cyclists and anabolic steroids in weight lifting, thus even challenging the specific effect of these drugs (Usichenco). As a result, if a treatment helps an athlete believe that they will perform better, regardless of any physiologic base, than so be it!
There is a significant about information that indicates acupuncture can and does improve athletic performance. These benefits are mediated thru numerous physiologic and psycho logic pathways. There are certainly other benefits to acupuncture which have not been touched upon in this article. As a result it may be something that an athlete might utilize to take their training and racing to the next level.
Alex M. McDonald, MD is a professional triathlete, First Endurance Research Board Member, and endurance coach at Fast Forward Triathlon. Alex’s professional interests lie in coaching endurance athletes, sports medicine and exercise physiology. He obtained his MD degree from the University of Vermont. Prior to medical school, Alex graduated from Connecticut College with an emphasis on both the biological and social sciences. He currently trains and lives, with is wife and daughter, in Durham, NC.
Contact information:
Alex M. McDonald, MD
Professional Triathlete
www.alexmmtri.com
alexmmtri@gmail.com
919.699.6593
References:
Improved performance in endurance sports through acupuncture].
Benner S, Benner K. Sportverletz Sportschaden. 2010 Sep;24(3):140-3. Epub 2010 Sep 15. German.
Local increase in trapezius muscle oxygenation during and after acupuncture.
Ohkubo M, Hamaoka T, Niwayama M, Murase N, Osada T, Kime R, Kurosawa Y, Sakamoto A, Katsumura T. Dyn Med. 2009 Mar 16;8:2.
Immediate effects of acupuncture on strength performance: a randomized, controlled crossover trial. Hübscher M, Vogt L, Ziebart T, Banzer W.
Eur J Appl Physiol. 2010 Sep;110(2):353-8. Epub 2010 May 25.
Ergogenic effect of acupuncture in sport and exercise: a brief review.
Ahmedov S. J Strength Cond Res. 2010 May;24(5):1421-7. Review.
Effects of acupuncture and heating on blood volume and oxygen saturation of human Achilles tendon in vivo. Kubo K, Yajima H, Takayama M, Ikebukuro T, Mizoguchi H, Takakura N. Eur J Appl Physiol. 2010 Jun;109(3):545-50. Epub 2010 Feb 6.
Lundeberg T, Lund I, Sing A, Näslund J. Is placebo acupuncture what it is intended to be? eCAM ( 2009;) doi:10.1093/ecam/nep049.
Goal-directed Acupuncture in Sports--Placebo or Doping?
Usichenko TI, Gizhko V, Wendt M. Evid Based Complement Alternat Med. . [Epub ahead of print]
So RC, Ng JK, Ng GY. Effect of transcutaneous electrical acupoint stimulation on fatigue recovery of the quadriceps. Eur J Appl Physiol ( 2007;) 100:: 693–700.
Nichols AW, Harrigan R. Complementary and alternative medicine usage by intercollegiate athletes. Clin J Sport Med ( 2006;) 16:: 232–237.
Ma SX. Neurobiology of acupuncture: toward CAM. eCAM ( 2004;) 1:: 41–47
Lin ZP, Wang CY, Jang TR, Ma TC, Chia F, Lin JG, et al. Effect of auricular acupuncture on oxygen consumption of boxing athletes. Chin Med J ( 2009;) 122:: 1587–1590.
Effects of acupuncture stimulation on recovery ability of male elite basketball athletes. Lin ZP, Lan LW, He TY, Lin SP, Lin JG, Jang TR, Ho TJ. Am J Chin Med. 2009;37(3):471-81.
Electromyographic evaluation of the masseter and temporal muscles activity in volunteers submitted to acupuncture. de Sousa RA, Semprini M, Vitti M, Borsatto MC, Hallak Regalo SC. Electromyogr Clin Neurophysiol. 2007 Jul;47(4-5):243-50.
The Science of Cholesterol
Acupuncture Today
December, 2010, Vol. 11, Issue 12
Big Fat Lies
By Marlene Merritt, DOM, LAc, ACN
One of the most important aspects about being a good practitioner/citizen/general person is to not believe everything you read or hear. It's not so much being skeptical as questioning the source of your information, wondering about the agenda behind the information, and just generally checking up on the facts.
And one of the biggest lies perpetrated on people today is the paradigm of low fat -- that eating low fat is healthy for you and will prevent heart attacks and lengthen your life. Nothing could be further from the truth.
Heart Studies
Did you know that high cholesterol levels in women of all ages and in the elderly is associated with a longer lifespan? In fact, for women and the elderly, no appreciable difference in cardiovascular heart disease (CHD) rate is seen for ANY level of cholesterol. The scientific publication Circulation (Circulation 1992 86:3) in 1992 said, "Many studies have shown that all-cause deaths, especially deaths from cancer, are higher for individuals with cholesterol levels lower than 180." How about this one? "Those individuals with a low serum cholesterol maintained over a 20-year period will have the worst outlook for all-cause mortality." (Lancet, 2001 358:351-55.) You probably hadn't heard that, had you? What about the French? They have the highest saturated fat intake of the entire European Union, but have the lowest rates of heart disease (European CVD statistics, 2005). How did we end up with a national stance that is so anathema to what is actually healthy?
Between 1930 and 1960, the number of deaths from heart attacks went from 3,000 to 500,000. Today, 650,000 to 700,000 people die from a myocardial infarction every year. Researchers started looking into this and saw some trends. They pointed out that they were using a lot more vegetable oils and fewer animal fats. We were especially consuming liquid oils hardened by a process called partial hydrogenation such as margarine and shortening in baked goods. These researchers suggested the solution to the new health problem was to return to traditional foods and stop using these vegetable oils -- a very logical suggestion.
However, other scientists proposed a different theory -- the "diet/heart theory" or the "lipid hypothesis." This hypothesis was based on experiments with vegetarian rats who were fed huge amounts of purified, oxidized cholesterol, which caused them to develop what seemed like atherogenic plaque in their arteries leading to blockages and heart disease.
According to the diet/heart theory, the cause of heart disease was a "bad diet," containing too much cholesterol and saturated fat, which led to us having elevated levels of cholesterol in the blood, which in turn, led to the build-up of plaque in the arteries. The overall conclusion was that this bad, indulgent diet of butter and bacon was the cause of heart disease.
So, the first of many studies was done. In 1957, the Anti-Coronary Club was a study done with men eating a "Prudent Diet," substituting corn oil and margarine for butter, cold breakfast cereal for eggs and chicken and fish for beef. Nine years later, the "Prudent Dieters" had cholesterol levels 30 points less than the control (220 vs. 250), but had had eight deaths in their group versus none in the control.
Studies were done comparing countries around the world (Ancel Keys' Six Country Study is one of the most famous) but again and again, when looking at the full data, it cannot be seen that reducing saturated fat improves your health. The Six Country study is quoted repeatedly as one of the basic studies showing high fat intake equals high CHD, but in actuality, it's a 22-country study. And when you see the graph for all 22 countries absolutely no correlation between saturated fat intake and heart disease occurs. This is a great example of cherry-picked statistics.
The majority of your patients (and probably yourself) have heard again and again, in advertising, in headlines, in everyday conversation, that it's advisable to lower their cholesterol, reduce their intake of saturated fats and eat "healthy" vegetable oils. If you're interested in your own health, as well as the health of your patients, you might consider challenging those long-standing notions you think are correct.
The Skinny on Fats
There are books written on this topic (try Mary Enig's book, Know Your Fats) but the basics are this: all fats, saturated and unsaturated, are actually a combination of both. You need the characteristics and attributes of both. You NEED both saturated and unsaturated fats. And, like other processed foods, the more processed a fat is, the more dangerous it is to the body.
Without going into the chemical structure of fats (I could, but who wants to read that?), unsaturated fats include polyunsaturated and monounsaturated. A example of a polyunsaturated fat is flax oil or fish oil -- those are very unstable oils and go rancid very easily, which is why they have to be in containers that are dark and stored in refrigerators and packed with nitrogen because light, heat and oxygen all damage those fragile oils. You've heard you should have a lot of Omega 3's versus Omega 6's, right? The ratio is supposed to be 1:2 or up to 1:4, but for most people, the ratio is a very unhealthy 1:25 because they're eating so many oils that have Omega 6's. Where are they getting those oils?
Vegetable oils, that's where - there are healthy sources of Omega 6's like Black Currant Seed Oil, or Evening Primrose, but that's not what people are typically ingesting. We've heard we should be eating vegetable oils like corn, soy, safflower, canola, etc. and yes, they're technically polyunsaturated fats, but they're heavily processed. They are NOT fresh oils. Basically, to produce them, they have to heat the ingredients to such a high temperature it causes the oil to go rancid. You'd smell that rancidity, so then they undergo a chemical process to deodorize them and when you ingest those oils, an enormous amount of free radicals are introduced into your system, causing huge amounts of damage. It's distinctly possible the vegetable oil industry has had an influence on the U.S. food policy -- corn IS our biggest crop, after all, with soy running a close second.
Monounsaturated fats are like olive oil or avocados. Lard is actually a monounsaturated fat as well. Olive oil is best if it's cold-pressed, obviously (when it's fresh, since it will otherwise be damaged by heat) and there are schools of thought that think it's not healthy to cook with it -- hence the reason it's so often used on salads.
But for being all-around healthy, it's not enough to live only on olive oil. The types of fats you eat are what are used in cell membranes -- if you eat a lot of unstable, damaged oils like vegetable oils, your cells are more prone to damage and faster aging. People think that saturated fats are unhealthy, but if this was true, why are the plaques found in arteries 74 percent unsaturated fats? What about life expectancy? A study already back in 1965 showed this conclusively: patients who already had had a heart attack were divided into three groups, and after two years, the corn oil group had 30 percent lower cholesterol, but only 52 percent of them were still alive. The olive oil group had 57 percent still alive and the animal fat group had 75 percent still alive (British Medical Journal, 1965 1:1531-33).
Yes, the quality of fat is very important. You DEFINITELY don't want to be eating animal fats filled with pesticides or hormones (farmers markets often have the cleanest sources). That being said, your body desperately needs nutrients found in animal fats. Have you noticed the uproar about vitamin D in the news? The food sources of vitamin D are cod liver oil and lard - that's how people kept from getting vitamin D deficient in the winter. Vitamins A, D, K, and K2 are all found in animal fats -- even your vegetarian patients could gain an advantage by ingesting coconut oil, butter, eggs, whole milk and cheese. Studies show that choline from egg yolks and liver help the brain make critical connections and protect against neurotoxins; animal studies suggest that if choline is abundant during developmental years, the individual is protected for life from developmental decline. The best way to get that is 4-5 egg yolks per day, but with our incorrect information, people get freaked out about the cholesterol in eggs, which is, as I pointed out earlier completely unfounded.
It's a challenge to find studies discussing the nutritional benefits of fats (government health policy dictates to a large degree where the research funds are allotted), but they are there. "In studies conducted over 20 years, the Harvard School of Public Health showed that total fat intake bore no significant relation to Coronary Artery Disease risk. . . Four epidemiological studies have shown no evidence that men who eat less fat live longer or have fewer myocardial infarctions (MIs)" (Circulation 2003; 107:10). As acupuncturists, you challenge the conventional wisdom regarding the body's ability to heal itself; as nutritionists, continuing to learn and reading critically and between the lines, you will have a huge health impact on your patients and on yourself.
you can view the origional article here:
http://www.acupuncturetoday.com/mpacms/at/article.php?id=32321
December, 2010, Vol. 11, Issue 12
Big Fat Lies
By Marlene Merritt, DOM, LAc, ACN
One of the most important aspects about being a good practitioner/citizen/general person is to not believe everything you read or hear. It's not so much being skeptical as questioning the source of your information, wondering about the agenda behind the information, and just generally checking up on the facts.
And one of the biggest lies perpetrated on people today is the paradigm of low fat -- that eating low fat is healthy for you and will prevent heart attacks and lengthen your life. Nothing could be further from the truth.
Heart Studies
Did you know that high cholesterol levels in women of all ages and in the elderly is associated with a longer lifespan? In fact, for women and the elderly, no appreciable difference in cardiovascular heart disease (CHD) rate is seen for ANY level of cholesterol. The scientific publication Circulation (Circulation 1992 86:3) in 1992 said, "Many studies have shown that all-cause deaths, especially deaths from cancer, are higher for individuals with cholesterol levels lower than 180." How about this one? "Those individuals with a low serum cholesterol maintained over a 20-year period will have the worst outlook for all-cause mortality." (Lancet, 2001 358:351-55.) You probably hadn't heard that, had you? What about the French? They have the highest saturated fat intake of the entire European Union, but have the lowest rates of heart disease (European CVD statistics, 2005). How did we end up with a national stance that is so anathema to what is actually healthy?
Between 1930 and 1960, the number of deaths from heart attacks went from 3,000 to 500,000. Today, 650,000 to 700,000 people die from a myocardial infarction every year. Researchers started looking into this and saw some trends. They pointed out that they were using a lot more vegetable oils and fewer animal fats. We were especially consuming liquid oils hardened by a process called partial hydrogenation such as margarine and shortening in baked goods. These researchers suggested the solution to the new health problem was to return to traditional foods and stop using these vegetable oils -- a very logical suggestion.
However, other scientists proposed a different theory -- the "diet/heart theory" or the "lipid hypothesis." This hypothesis was based on experiments with vegetarian rats who were fed huge amounts of purified, oxidized cholesterol, which caused them to develop what seemed like atherogenic plaque in their arteries leading to blockages and heart disease.
According to the diet/heart theory, the cause of heart disease was a "bad diet," containing too much cholesterol and saturated fat, which led to us having elevated levels of cholesterol in the blood, which in turn, led to the build-up of plaque in the arteries. The overall conclusion was that this bad, indulgent diet of butter and bacon was the cause of heart disease.
So, the first of many studies was done. In 1957, the Anti-Coronary Club was a study done with men eating a "Prudent Diet," substituting corn oil and margarine for butter, cold breakfast cereal for eggs and chicken and fish for beef. Nine years later, the "Prudent Dieters" had cholesterol levels 30 points less than the control (220 vs. 250), but had had eight deaths in their group versus none in the control.
Studies were done comparing countries around the world (Ancel Keys' Six Country Study is one of the most famous) but again and again, when looking at the full data, it cannot be seen that reducing saturated fat improves your health. The Six Country study is quoted repeatedly as one of the basic studies showing high fat intake equals high CHD, but in actuality, it's a 22-country study. And when you see the graph for all 22 countries absolutely no correlation between saturated fat intake and heart disease occurs. This is a great example of cherry-picked statistics.
The majority of your patients (and probably yourself) have heard again and again, in advertising, in headlines, in everyday conversation, that it's advisable to lower their cholesterol, reduce their intake of saturated fats and eat "healthy" vegetable oils. If you're interested in your own health, as well as the health of your patients, you might consider challenging those long-standing notions you think are correct.
The Skinny on Fats
There are books written on this topic (try Mary Enig's book, Know Your Fats) but the basics are this: all fats, saturated and unsaturated, are actually a combination of both. You need the characteristics and attributes of both. You NEED both saturated and unsaturated fats. And, like other processed foods, the more processed a fat is, the more dangerous it is to the body.
Without going into the chemical structure of fats (I could, but who wants to read that?), unsaturated fats include polyunsaturated and monounsaturated. A example of a polyunsaturated fat is flax oil or fish oil -- those are very unstable oils and go rancid very easily, which is why they have to be in containers that are dark and stored in refrigerators and packed with nitrogen because light, heat and oxygen all damage those fragile oils. You've heard you should have a lot of Omega 3's versus Omega 6's, right? The ratio is supposed to be 1:2 or up to 1:4, but for most people, the ratio is a very unhealthy 1:25 because they're eating so many oils that have Omega 6's. Where are they getting those oils?
Vegetable oils, that's where - there are healthy sources of Omega 6's like Black Currant Seed Oil, or Evening Primrose, but that's not what people are typically ingesting. We've heard we should be eating vegetable oils like corn, soy, safflower, canola, etc. and yes, they're technically polyunsaturated fats, but they're heavily processed. They are NOT fresh oils. Basically, to produce them, they have to heat the ingredients to such a high temperature it causes the oil to go rancid. You'd smell that rancidity, so then they undergo a chemical process to deodorize them and when you ingest those oils, an enormous amount of free radicals are introduced into your system, causing huge amounts of damage. It's distinctly possible the vegetable oil industry has had an influence on the U.S. food policy -- corn IS our biggest crop, after all, with soy running a close second.
Monounsaturated fats are like olive oil or avocados. Lard is actually a monounsaturated fat as well. Olive oil is best if it's cold-pressed, obviously (when it's fresh, since it will otherwise be damaged by heat) and there are schools of thought that think it's not healthy to cook with it -- hence the reason it's so often used on salads.
But for being all-around healthy, it's not enough to live only on olive oil. The types of fats you eat are what are used in cell membranes -- if you eat a lot of unstable, damaged oils like vegetable oils, your cells are more prone to damage and faster aging. People think that saturated fats are unhealthy, but if this was true, why are the plaques found in arteries 74 percent unsaturated fats? What about life expectancy? A study already back in 1965 showed this conclusively: patients who already had had a heart attack were divided into three groups, and after two years, the corn oil group had 30 percent lower cholesterol, but only 52 percent of them were still alive. The olive oil group had 57 percent still alive and the animal fat group had 75 percent still alive (British Medical Journal, 1965 1:1531-33).
Yes, the quality of fat is very important. You DEFINITELY don't want to be eating animal fats filled with pesticides or hormones (farmers markets often have the cleanest sources). That being said, your body desperately needs nutrients found in animal fats. Have you noticed the uproar about vitamin D in the news? The food sources of vitamin D are cod liver oil and lard - that's how people kept from getting vitamin D deficient in the winter. Vitamins A, D, K, and K2 are all found in animal fats -- even your vegetarian patients could gain an advantage by ingesting coconut oil, butter, eggs, whole milk and cheese. Studies show that choline from egg yolks and liver help the brain make critical connections and protect against neurotoxins; animal studies suggest that if choline is abundant during developmental years, the individual is protected for life from developmental decline. The best way to get that is 4-5 egg yolks per day, but with our incorrect information, people get freaked out about the cholesterol in eggs, which is, as I pointed out earlier completely unfounded.
It's a challenge to find studies discussing the nutritional benefits of fats (government health policy dictates to a large degree where the research funds are allotted), but they are there. "In studies conducted over 20 years, the Harvard School of Public Health showed that total fat intake bore no significant relation to Coronary Artery Disease risk. . . Four epidemiological studies have shown no evidence that men who eat less fat live longer or have fewer myocardial infarctions (MIs)" (Circulation 2003; 107:10). As acupuncturists, you challenge the conventional wisdom regarding the body's ability to heal itself; as nutritionists, continuing to learn and reading critically and between the lines, you will have a huge health impact on your patients and on yourself.
you can view the origional article here:
http://www.acupuncturetoday.com/mpacms/at/article.php?id=32321
IRS Allows Flex Spending for Herbal Formulas
The following is a copy of a letter from the IRS regarding the use of Healthcare Flexible Spending Accounts for the payment of Herbal Medicines.
CHIEF COUNSEL
DEPARTMENT OF THE TREASURY
INTERNAL REVENUE SERVICE
WASHINGTON, D.C. 20224
March 31, 2010
Number: INFO 2010-0080
Release Date: 6/25/2010
CONEX-110127-10
UIL: 213.00-00
The Honorable Charles E. Schumer
United States Senator
757 Third Avenue, Suite 17-02
New York, NY 10017
Attention: Senator Schumer:
I am responding to your letter, dated March 3, 2010, on behalf of your constituent, -asked whether the cost of an herb prescribed by her doctor to treat migraine headaches qualifies as a medical care expense for purposes of her health care flexible spending account.
In general, individuals must use funds from a flexible spending account for medical care. Medical care is for the diagnosis, cure, mitigation, treatment or prevention of disease, or for the purpose of affecting a structure or function of the body (section 213(d) of the Internal Revenue Code).
Deductions for medical care are limited to expenses paid primarily for the alleviation or prevention of a physical or mental defect or illness (section 1.213-1(e)(1)(ii) of the Income Tax Regulations).
A taxpayer claiming a deduction must establish that the expense is primarily for medical care. Among the objective factors indicating that an otherwise personal expense is for medical care are the taxpayer’s motive or purpose, recommendation by a physician, linkage between the treatment and the illness, treatment effectiveness, and proximity in time to the onset or recurrence of a disease.
Havey v. Commissioner, 12 T.C. 409
(1949). The taxpayer must also establish that the expenses would not have been incurred “but for” the disease or illness.
Commissioner v. Jacobs, 62 T.C. 813, 818 (1974); Altman v. Commissioner, 53 T.C. 487 (1969).
CONEX-110127-10 2
Naturopathic care, including herbs, can qualify as medical care. Dickie v. Commissioner, T.C. Memo. 1999-138; Crain v. Commissioner, T.C. Memo. 1986-138; Tso v. Commissioner, T.C. Memo. 1980-399.
The cost of an herb may be an expense for medical care if the taxpayer can substantiate that he or she:
- Has a medical condition (disease, illness or injury);
- Is purchasing the herb to treat or alleviate the medical condition;
- And would not have purchased the herb “but for” the medical condition;
(They) may wish to review the letter of medical necessity form that her doctor filled out to determine if it clearly and fully describes her circumstances.
I hope this information is helpful. If you have additional questions, please contact me.
Sincerely,
George J. Blaine
Associate Chief Counsel
(Income Tax and Accounting)
CHIEF COUNSEL
DEPARTMENT OF THE TREASURY
INTERNAL REVENUE SERVICE
WASHINGTON, D.C. 20224
March 31, 2010
Number: INFO 2010-0080
Release Date: 6/25/2010
CONEX-110127-10
UIL: 213.00-00
The Honorable Charles E. Schumer
United States Senator
757 Third Avenue, Suite 17-02
New York, NY 10017
Attention: Senator Schumer:
I am responding to your letter, dated March 3, 2010, on behalf of your constituent, -asked whether the cost of an herb prescribed by her doctor to treat migraine headaches qualifies as a medical care expense for purposes of her health care flexible spending account.
In general, individuals must use funds from a flexible spending account for medical care. Medical care is for the diagnosis, cure, mitigation, treatment or prevention of disease, or for the purpose of affecting a structure or function of the body (section 213(d) of the Internal Revenue Code).
Deductions for medical care are limited to expenses paid primarily for the alleviation or prevention of a physical or mental defect or illness (section 1.213-1(e)(1)(ii) of the Income Tax Regulations).
A taxpayer claiming a deduction must establish that the expense is primarily for medical care. Among the objective factors indicating that an otherwise personal expense is for medical care are the taxpayer’s motive or purpose, recommendation by a physician, linkage between the treatment and the illness, treatment effectiveness, and proximity in time to the onset or recurrence of a disease.
Havey v. Commissioner, 12 T.C. 409
(1949). The taxpayer must also establish that the expenses would not have been incurred “but for” the disease or illness.
Commissioner v. Jacobs, 62 T.C. 813, 818 (1974); Altman v. Commissioner, 53 T.C. 487 (1969).
CONEX-110127-10 2
Naturopathic care, including herbs, can qualify as medical care. Dickie v. Commissioner, T.C. Memo. 1999-138; Crain v. Commissioner, T.C. Memo. 1986-138; Tso v. Commissioner, T.C. Memo. 1980-399.
The cost of an herb may be an expense for medical care if the taxpayer can substantiate that he or she:
- Has a medical condition (disease, illness or injury);
- Is purchasing the herb to treat or alleviate the medical condition;
- And would not have purchased the herb “but for” the medical condition;
(They) may wish to review the letter of medical necessity form that her doctor filled out to determine if it clearly and fully describes her circumstances.
I hope this information is helpful. If you have additional questions, please contact me.
Sincerely,
George J. Blaine
Associate Chief Counsel
(Income Tax and Accounting)
National Foundation For Women Legislators Endorsement
see the official site at:
http://www.aaaomonline.info/Inclusion_of_Acupuncturists_Access_to_Care_Resolution_passed_Sept_2009.pdf
National Policy Committee on Healthcare and Empowerment
Resolution in Support of Ensuring that any Congressional Effort to Expand Healthcare
Access through Medicare and Other Government Funded Programs Include Professional
Acupuncturists and Doctors of Oriental Medicine
(Ratified September 2009)
WHEREAS, the United States faces a $36 trillion deficit in the coming decades in part due to
unfunded healthcare liabilities related to the Medicare and Medicaid programs; and
WHEREAS, the United States spends 17 % of its Gross Domestic Product on health care versus
an average of only 9% for the 30 other members of the Organization for Economic Co-operation
and Development and 4.5% for China; and
WHEREAS, China has 362,600 Doctors of Traditional Chinese Medicine working in concert
with 836,360 Western trained M.D.s; and
WHEREAS, there are 5,500 designated Health Profession Shortage Areas (HPSA) in the US,
and 6941 more primary care providers are needed to reduce HPSA’s; and
WHEREAS, there are 6,525 Medically Underserved Areas (MUA’s) at the county and local
levels nationwide (as determined by the number of primary care providers in an area and the
distance to a primary care provider); and
WHEREAS, there are 58 nationally accredited colleges of Acupuncture and Oriental Medicine
in the U.S. with approximately 8,100 students in attendance; and
WHEREAS, there are over 26,000 duly qualified practitioners of acupuncture and Oriental
medicine licensed in 44 states who may serve as primary care professionals; and
WHEREAS, acupuncture has been determined to be a drug-free, safe, and effective form of
primary care by the World Health Organization and has been approved by the 1997 National
Institutes of Health Consensus study; and
WHEREAS, based upon studies that showed acupuncture to be among the most cost-effective
modalities for the treatment of low back pain, the countries of Great Britain and Germany cover
acupuncture in their national health systems; and
WHEREAS, a 2003 survey found that nearly 1 in 10 Americans over age 18 have tried
acupuncture with 82 % of those surveyed satisfied with their treatment and 65% of physicians
surveyed in 2005 found acupuncture to be an effective complementary therapy; and
WHEREAS, a National Health Survey conducted by the National Institutes of Health and the
Centers for Disease Control and Prevention reported in 2009 that while visits to all
complementary and alternative medicine providers (CAM) appears to have decreased in the past decade, visits to acupuncturists tripled; and
WHEREAS, a 2005 survey found that employer provided insurance increasingly provides
coverage for acupuncture. (52% of POS plans, 47 percent of PPO plans, 44% of conventional
plans and 41% of HMOs); and
WHEREAS, the availability of acupuncture provides a valuable option for millions of
Americans and its inclusion in Medicare and other insurance programs will increase its
availability to seniors and others who could not otherwise access this safe and effective
treatment;
NOW THEREFORE BE IT RESOLVED, by NFWL’s National Policy Committee on
Healthcare & Empowerment, that Congress should ensure that licensed acupuncture practitioners
are eligible to be included as providers in government insurance programs and health delivery
programs; and
BE IT FURTHER RESOLVED, by NFWL’s National Policy Committee on Healthcare &
Empowerment, that all 50 states’ governments, territories, and tribal communities are urged to
license the practice of acupuncture and Oriental herbal medicine or improve their licensure
guidelines to encourage a broader scope of practice.
THE POWER TO MAKE THE DIFFERENCE FOR YOU
WWW.WOMENLEGISLATORS.ORG
ROBIN READ, PRESIDENT & CEO
NFWL@WOMENLEGISLATORS.ORG
910 16TH STREET, NW, SUITE 100 WASHINGTON, DC 20006
202-293-3040 FAX 202-293-5430
http://www.aaaomonline.info/Inclusion_of_Acupuncturists_Access_to_Care_Resolution_passed_Sept_2009.pdf
National Policy Committee on Healthcare and Empowerment
Resolution in Support of Ensuring that any Congressional Effort to Expand Healthcare
Access through Medicare and Other Government Funded Programs Include Professional
Acupuncturists and Doctors of Oriental Medicine
(Ratified September 2009)
WHEREAS, the United States faces a $36 trillion deficit in the coming decades in part due to
unfunded healthcare liabilities related to the Medicare and Medicaid programs; and
WHEREAS, the United States spends 17 % of its Gross Domestic Product on health care versus
an average of only 9% for the 30 other members of the Organization for Economic Co-operation
and Development and 4.5% for China; and
WHEREAS, China has 362,600 Doctors of Traditional Chinese Medicine working in concert
with 836,360 Western trained M.D.s; and
WHEREAS, there are 5,500 designated Health Profession Shortage Areas (HPSA) in the US,
and 6941 more primary care providers are needed to reduce HPSA’s; and
WHEREAS, there are 6,525 Medically Underserved Areas (MUA’s) at the county and local
levels nationwide (as determined by the number of primary care providers in an area and the
distance to a primary care provider); and
WHEREAS, there are 58 nationally accredited colleges of Acupuncture and Oriental Medicine
in the U.S. with approximately 8,100 students in attendance; and
WHEREAS, there are over 26,000 duly qualified practitioners of acupuncture and Oriental
medicine licensed in 44 states who may serve as primary care professionals; and
WHEREAS, acupuncture has been determined to be a drug-free, safe, and effective form of
primary care by the World Health Organization and has been approved by the 1997 National
Institutes of Health Consensus study; and
WHEREAS, based upon studies that showed acupuncture to be among the most cost-effective
modalities for the treatment of low back pain, the countries of Great Britain and Germany cover
acupuncture in their national health systems; and
WHEREAS, a 2003 survey found that nearly 1 in 10 Americans over age 18 have tried
acupuncture with 82 % of those surveyed satisfied with their treatment and 65% of physicians
surveyed in 2005 found acupuncture to be an effective complementary therapy; and
WHEREAS, a National Health Survey conducted by the National Institutes of Health and the
Centers for Disease Control and Prevention reported in 2009 that while visits to all
complementary and alternative medicine providers (CAM) appears to have decreased in the past decade, visits to acupuncturists tripled; and
WHEREAS, a 2005 survey found that employer provided insurance increasingly provides
coverage for acupuncture. (52% of POS plans, 47 percent of PPO plans, 44% of conventional
plans and 41% of HMOs); and
WHEREAS, the availability of acupuncture provides a valuable option for millions of
Americans and its inclusion in Medicare and other insurance programs will increase its
availability to seniors and others who could not otherwise access this safe and effective
treatment;
NOW THEREFORE BE IT RESOLVED, by NFWL’s National Policy Committee on
Healthcare & Empowerment, that Congress should ensure that licensed acupuncture practitioners
are eligible to be included as providers in government insurance programs and health delivery
programs; and
BE IT FURTHER RESOLVED, by NFWL’s National Policy Committee on Healthcare &
Empowerment, that all 50 states’ governments, territories, and tribal communities are urged to
license the practice of acupuncture and Oriental herbal medicine or improve their licensure
guidelines to encourage a broader scope of practice.
THE POWER TO MAKE THE DIFFERENCE FOR YOU
WWW.WOMENLEGISLATORS.ORG
ROBIN READ, PRESIDENT & CEO
NFWL@WOMENLEGISLATORS.ORG
910 16TH STREET, NW, SUITE 100 WASHINGTON, DC 20006
202-293-3040 FAX 202-293-5430
An Historic Political Step Achieved for Oriental Medicine at the 72nd National Foundation for Women Legislators Conference
Every year, women legislators meet to discuss important issues facing our country and enjoy a relaxing weekend together beyond the partisanship of politics. This year, at the 72nd National Foundation for Women Legislators (NFWL) conference held at the Hyatt Regency Tamaya Resort on the Santa Ana Pueblo in New Mexico over Labor Day weekend, the American Association of Acupuncture and Oriental Medicine (AAAOM) showed a strong presence when 25 Doctors of Oriental Medicine and Licensed Acupuncturists gave over 100 treatments to our elected officials, demonstrating firsthand the effectiveness of acupuncture and Tui Na.
AAAOM members attended the entire weekend’s events to educate these leaders about this medicine. The women legislators were very open to what Acupuncture and Oriental Medicine (AOM) have to offer the healthcare system in our country. Even though some had very little prior awareness of, or direct contact with, AOM, all of them were appreciative of the treatments they received and many, if not most, experienced dramatic and positive results.
AOM got a big boost from keynote speeches by two of AAAOM’s most dynamic speakers, educating the audience about how AOM can help solve America’s health care crisis. AAAOM Public Member/Counsel Michael Taromina spoke passionately about the economic benefits of including Acupuncture and Oriental Medicine in mainstream health care, and AAAOM President Emeritus Claudette Baker spoke eloquently from a clinical perspective, outlining what conditions Acupuncture and Oriental Medicine can treat and illustrating how AOM can alleviate the burden of chronic and acute primary care in the U.S.
Robin Reed, president of the NFWL, stated "I am so pleased NFWL's National Policy Committee on Healthcare & Empowerment has decided to partner with the AAAOM. Our elected women have come to realize that the acupuncturists' addition to the health care delivery system is critical to ensuring the wellness of our country as a whole. After having the opportunity to interact with practitioners from across the nation, our legislators understand how important it is for acupuncturists to be included on the list of cost-saving solutions to meet the needs of their constituents."
As a result of bringing this medicine and message directly to the legislators, a resolution has been passed declaring parity for acupuncture as a health care profession:
Inclusion of Acupuncturists Access to Care Resolution,
http://www.aaaomonline.info/Inclusion_of_Acupuncturists_Access_to_Care_Resolution_passed_Sept_2009.pdf
thereby paving the way for future growth, recognition, and legislative acceptance of AOM in the U.S.
This weekend was the first time that a cross-section of elected state and federal government officials from every part of the country experienced this medicine and heard this message firsthand. As a result of this effort, the AOM profession now has their support, solidarity and vote in favor of expanding AOM’s role in American health care.
AAAOM members attended the entire weekend’s events to educate these leaders about this medicine. The women legislators were very open to what Acupuncture and Oriental Medicine (AOM) have to offer the healthcare system in our country. Even though some had very little prior awareness of, or direct contact with, AOM, all of them were appreciative of the treatments they received and many, if not most, experienced dramatic and positive results.
AOM got a big boost from keynote speeches by two of AAAOM’s most dynamic speakers, educating the audience about how AOM can help solve America’s health care crisis. AAAOM Public Member/Counsel Michael Taromina spoke passionately about the economic benefits of including Acupuncture and Oriental Medicine in mainstream health care, and AAAOM President Emeritus Claudette Baker spoke eloquently from a clinical perspective, outlining what conditions Acupuncture and Oriental Medicine can treat and illustrating how AOM can alleviate the burden of chronic and acute primary care in the U.S.
Robin Reed, president of the NFWL, stated "I am so pleased NFWL's National Policy Committee on Healthcare & Empowerment has decided to partner with the AAAOM. Our elected women have come to realize that the acupuncturists' addition to the health care delivery system is critical to ensuring the wellness of our country as a whole. After having the opportunity to interact with practitioners from across the nation, our legislators understand how important it is for acupuncturists to be included on the list of cost-saving solutions to meet the needs of their constituents."
As a result of bringing this medicine and message directly to the legislators, a resolution has been passed declaring parity for acupuncture as a health care profession:
Inclusion of Acupuncturists Access to Care Resolution,
http://www.aaaomonline.info/Inclusion_of_Acupuncturists_Access_to_Care_Resolution_passed_Sept_2009.pdf
thereby paving the way for future growth, recognition, and legislative acceptance of AOM in the U.S.
This weekend was the first time that a cross-section of elected state and federal government officials from every part of the country experienced this medicine and heard this message firsthand. As a result of this effort, the AOM profession now has their support, solidarity and vote in favor of expanding AOM’s role in American health care.
Wall Street Journal Article on Chinese Medicine
By LAURA JOHANNES
Stuffed up and miserable from allergies? A traditional Chinese mix of 11 herbs called Biyan Pian can relieve congestion and help you breathe easier, according to companies that sell it. Western scientific evidence for the formula is scant, though one recent preliminary study found it effective.
iii
Biyan Pian literally means “nose inflammation pill.” In the U.S., it is sold in supermarkets and natural-food stores and through acupuncturists either as tablets or as a strongly flavored tea. Its ingredients include Xanthium fruit, magnolia flower, wild chrysanthemum and Chinese licorice root. It is marketed to allergy sufferers and to people with inflamed nasal passages from a cold or the flu.
There is little published Western evidence for Biyan Pian. Natural Standard Research Collaboration, a Cambridge, Mass., scientist-owned group that evaluates natural therapies, says it didn’t find enough evidence to even grade it. One of the few Western studies was published earlier this year. In a January study in the Journal of Alternative and Complementary Medicine, a tea containing Biyan Pian was found to be effective in treating symptoms of chronic rhinosinusitis, a long-lasting and often miserable inflammation of the nasal passages.
In the study, researchers at Morehouse School of Medicine in Atlanta found that the 27 study patients who drank four cups a day of tea enjoyed a better quality of life, including fewer headaches, relief from nasal congestion and less trouble falling asleep. The study didn’t have a placebo group for comparison, generally considered necessary for a conclusive result. The study was funded in part by Traditional Medicinals Inc., the Sebastopol, Calif., company that sells the tea.
Terry Courtney, dean of Bastyr University’s School of Acupuncture and Oriental Medicine in Seattle, says she has found in her patients that Biyan Pian tablets work well as a mild herbal decongestant. It is appropriate for “dry” congestion, a condition in which phlegm and mucus seems stuck and the person may feel headachy or hot, she adds. “Within 20 minutes of ingesting it, people begin to blow their nose. Inflamed and swollen passages start to calm down,” Ms. Courtney says. If you see no effect, Biyan Pian may not be the best treatment for you, she adds. The treatment isn’t best suited for people with runny noses and sneezing, she says.
The herb mix is considered fairly safe, though one of its components, licorice root, has been linked to high blood pressure in large amounts. In the traditional formula sold in most tablets, licorice is present in only small quantities and shouldn’t be a problem, clinicians say. Traditional Medicinals’ Breathe Easy tea, in which additional licorice root has been added to the Biyan Pian formula, carries a warning that it shouldn’t be used in patients with high blood pressure.
In some people, says Roger Batchelor, an assistant professor at the National College of Natural Medicine in Portland, Ore., the herb mix can create excessive sinus drying and should be discontinued.
—Email aches@wsj.com Printed in The Wall Street Journal, page D4http://online.wsj.com/article/SB20001424052970204900904574300363502923136.html
An Appeal for Complementary, Integrated Health Care Modalities to Be a Part of Any Future American Health Care Plan
The following petition was created by leaders in the alternative health care field. To sign the petition, go to: http://www.petitiononline.com/cihc8888/petition.html
To: President-Elect Barack H. Obama
Dear President-Elect Barack Obama, I respectfully ask that you incorporate Integrative Medicine modalities into any new U.S. health care policy once you take office in January 2009. The 1979 oft-cited resolution by the World Health Organization[i] called on countries to promote the role of traditional practitioners in the health care systems of the world and also encouraged more financial support for the development of traditional systems. It further recommended that the medical profession should not undervalue the role played by the traditional medical system in providing important health care in developing countries and even specifically advocated the use of medicinal plants and remedies used by traditional practitioners to effectively treat their patients. With the popularity of these traditional healing systems, we are at the place in time where at least a third of the people of America have recognized the value of these traditional systems not only for developing countries but as being of great benefit for certain conditions in our own country. Because they provide relatively safe and effective approaches for treating many conditions, evidence-based, complementary, alternative medicine (CAM) health care modalities should be integrated into the U.S. health care system. There are many reasons why one would choose such alternative health care methods but one of the most obvious is described in published research revealing that over 150,000 Americans die annually from FDA-approved pharmaceuticals that have been prescribed and utilized according to their indications. Shockingly, these iatrogenic (medically induced) deaths account for the fifth major cause of mortality in the U.S. I am one of the millions of Americans who have found complementary, natural health methods to be an invaluable part of my health care requirements and needs. These systems, including acupuncture, herbal medicine, naturopathy, chiropractic, homeopathy and Traditional Chinese and Ayurvedic medicine offer aspects of health care that are not provided by conventional Western medicine. A recent study based on 1162 patients found acupuncture to be more effective for treating lower back pain, from which 85% of all people will suffer at some point in their life, than conventional treatments.[ii] This is only one of many conditions that are better treated with traditional alternative medicine but the fact remains that these time honored methods represent relatively non-invasive treatments that continues to be the legacy of all traditional peoples throughout the world. The reasons that these methods continue to be resorted to is because conventional Western medicine based on expensive technological procedures and synthetic drugs, for various reasons is not always the best approach for all conditions, in much the same ways that exclusive reliance on fossil fuels is unsatisfactory for all of our energy needs. Happily, there are other approaches from which to choose and utilize. These are some of the reasons why Harvard studies conducted by David Eisenberg, M.D. et al.,[iii] in 1990 and again in 1997 revealed that a significantly large percentage of Americans are already using these integrate, alternative, complementary therapeutic approaches and that they are even willing to spend more out-of-pocket money for such care than for all allopathic primary care and hospital care combined. As recent as December, 2008, a National Health Statistics Report, entitled Complementary and Alternative Health (CAM) Care Use Among Children and Adults: United States 2007 by Barnes' et al. revealed that 38% of adults and 12% of children used CAM therapies over the previous 12 months.[iv] I stand ready to be of assistance to you and Secretary of Health, Tom Daschle in any way that I can. Thank you for your kind attention and I look forward to your expedient response.
To: President-Elect Barack H. Obama
Dear President-Elect Barack Obama, I respectfully ask that you incorporate Integrative Medicine modalities into any new U.S. health care policy once you take office in January 2009. The 1979 oft-cited resolution by the World Health Organization[i] called on countries to promote the role of traditional practitioners in the health care systems of the world and also encouraged more financial support for the development of traditional systems. It further recommended that the medical profession should not undervalue the role played by the traditional medical system in providing important health care in developing countries and even specifically advocated the use of medicinal plants and remedies used by traditional practitioners to effectively treat their patients. With the popularity of these traditional healing systems, we are at the place in time where at least a third of the people of America have recognized the value of these traditional systems not only for developing countries but as being of great benefit for certain conditions in our own country. Because they provide relatively safe and effective approaches for treating many conditions, evidence-based, complementary, alternative medicine (CAM) health care modalities should be integrated into the U.S. health care system. There are many reasons why one would choose such alternative health care methods but one of the most obvious is described in published research revealing that over 150,000 Americans die annually from FDA-approved pharmaceuticals that have been prescribed and utilized according to their indications. Shockingly, these iatrogenic (medically induced) deaths account for the fifth major cause of mortality in the U.S. I am one of the millions of Americans who have found complementary, natural health methods to be an invaluable part of my health care requirements and needs. These systems, including acupuncture, herbal medicine, naturopathy, chiropractic, homeopathy and Traditional Chinese and Ayurvedic medicine offer aspects of health care that are not provided by conventional Western medicine. A recent study based on 1162 patients found acupuncture to be more effective for treating lower back pain, from which 85% of all people will suffer at some point in their life, than conventional treatments.[ii] This is only one of many conditions that are better treated with traditional alternative medicine but the fact remains that these time honored methods represent relatively non-invasive treatments that continues to be the legacy of all traditional peoples throughout the world. The reasons that these methods continue to be resorted to is because conventional Western medicine based on expensive technological procedures and synthetic drugs, for various reasons is not always the best approach for all conditions, in much the same ways that exclusive reliance on fossil fuels is unsatisfactory for all of our energy needs. Happily, there are other approaches from which to choose and utilize. These are some of the reasons why Harvard studies conducted by David Eisenberg, M.D. et al.,[iii] in 1990 and again in 1997 revealed that a significantly large percentage of Americans are already using these integrate, alternative, complementary therapeutic approaches and that they are even willing to spend more out-of-pocket money for such care than for all allopathic primary care and hospital care combined. As recent as December, 2008, a National Health Statistics Report, entitled Complementary and Alternative Health (CAM) Care Use Among Children and Adults: United States 2007 by Barnes' et al. revealed that 38% of adults and 12% of children used CAM therapies over the previous 12 months.[iv] I stand ready to be of assistance to you and Secretary of Health, Tom Daschle in any way that I can. Thank you for your kind attention and I look forward to your expedient response.
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