CMHB221 Chinese Herbal Frmulae Sessin Seven Chinese herbal frmulae: English name; Pin yin name and Chinese name Cmpsitin; dsage and administratin Functins and indicatins Analysis and explanatin f the frmula Cautins and cntraindicatins Endeavur Cllege f Natural Health endeavur.edu.au 1
Sessin Aims Discuss the Chinese herbal frmulae s thrugh the investigatin f actins, dsage, preparatin/cking and cntraindicatins fr the fllwing medical actins: Clear heat Chinese herbal frmulae. Identify and grup the majr cmmn differentiating actins f the herbal cnstituents f each frmula; and Discuss sme f the cnventinal bimedical usages fr the each f Chinese herb frmulae s discussed and identify all ptential interactins. Endeavur Cllege f Natural Health endeavur.edu.au 2
Key Frmulae Clearing Heat Frmulae Bai Hu Tang Huang Lian Jie Du Tang Lng Dan Xie Gan Tang Da Chi San Wu Wei Xia Du Wan Endeavur Cllege f Natural Health endeavur.edu.au 3
What yu need t knw after this sessin The cmpsitin fr Bai Hu Tang, Huang Lian Jie Du Tang, Da Chi San and Wu wei Xia Du Wan The functins(actins) ; indicatins and cntraindicatins fr Bai Hu Tang, Huang Lian Jie Du Tang, Lng Dan Xie Gan Tang, Da Chi San and Wu wei Xia Du Wan The key clinic symptms/signs fr Bai Hu Tang, Huang Lian Jie Du Tang, Lng Dan Xie Gan Tang, Da Chi San and Wu wei Xia Du Wan All key clinic symptms fr Bai Hu Tang The significance f using Dang Gui & Sheng Di in Lng Dan Xie Gan Tang Endeavur Cllege f Natural Health endeavur.edu.au 4
Pin yin: Bai Hu Tang ( 白虎汤 ) English: White Tiger Decctin Pill Surce: Shang Han Lun Cmpsitin: Shi Ga; Zhi Mu; Gan Ca; Jing Mi Administratin: Decct the drugs in water until the rice is well-dne Functins: Clear away heat frm the lung and stmach, clear heat frm Yang Ming meridian r Qi level; prduce bdy fluid Indicatins: Yang Ming meridian syndrme Excessive heat f Qi phase Cautin: Cautin using lng-term (Shi Ga); Watch fr signs f ver cling, such as cld extremities and subjective feelings f cld. Bimedical Indicatins: Antipyretic Dsage: 8-12 r 16-24 pills 3 x / day away frm fd where pssible Endeavur Cllege f Natural Health endeavur.edu.au 5
Cardinal signs: Yang Ming Channel Pattern Irritability Frntal headache Bleeding gums, muth ulcers High fever Thirst Cpius sweating Cncentrated urine Tngue: Dry, yellw tngue cat Pulse: Rapid, big pulse Cmplexin: Red face and lips Endeavur Cllege f Natural Health endeavur.edu.au 6
Bright Yang Channel pattern Macicia, G 2015, The fundatins f Chinese medicine, 3rd edn, Churchill Livingstne, Edinburgh. Endeavur Cllege f Natural Health endeavur.edu.au 7 7
Grup discussin The difference between Yang Ming Channel and Yang Ming Organ pattern The representative frmula fr Yang Ming Channel and Yang Ming Organ pattern Endeavur Cllege f Natural Health endeavur.edu.au 8 8
Pin yin: Bai Hu Tang Wan (MacLean & Taylr 2003, p564) English: White Tiger Decctin Pill Herb Hierarchy Dsage Temp Taste Grup Actin Shi Ga Chief 30g Cld Pungent Sweet Clear Fire Zhi Mu Deputy 9g Cld Bitter Clear Fire Clears heat; Drain fire; Eczema, burns and ulceratin; Alleviates wheezing; Nurishes and tnifies the yin Clear heat; Clears damp-heat; Generates fluid, Tnifies and supprt the yin. Jing Mi Assistant 9g Neutral Sweat Tnifying Tnify the spleen Qi and prtect the stmach and spleen frm cld herbs Gan Ca Envy 3g Neutral Sweat Tnifying Harmnize/tnifies qi, spleen, stmach; Clears fire/misten dryness; Detxifies & disinfects; Calms/anchrs shen. Endeavur Cllege f Natural Health endeavur.edu.au 9
Herbal Identificatin Bai Hu Tang Shi Ga Drain Fire Zhi Mu Drain Fire Jing Mi Gan Ca Tnify Qi Balance Endeavur Cllege f Natural Health endeavur.edu.au 10
Analysis and explanatin f the frmula Shi Ga Gypsum fibrsum (calcium sulphate): Chief Herb Temperature: Very Cld;Taste: Pungent Sweet;Site f Actin: Lung; Interir Clear away excessive hear in Yangming Meridian Deputy herbs: Zhi Mu Anemarrhena asphelides rhizma Bitter in taste and sweet; cld in nature. Clear away heat, prduce bdy fluid and treat restlessness Endeavur Cllege f Natural Health endeavur.edu.au 11
Huang Lian Jie Du Tang Cptis Decctin t Relieve Txicity ( 黄连解毒汤 ) Surce: Wai Tai Mi Ya( Clandestine Essentials frm Imperial Library) Cmpsitin: Huang lian; Zhi Zi; Huang Qin; Huang Bai Administratin: All drugs decct in water fr ral administratin Functins: Reduce fire and remve txins Indicatins: Clear txic heat and damp heat frm the three jia; Purge fire used fr Excessive heat, fire and txin f three Jia Cautin: Cautin using lng-term fr Spleen and Stmach functin; Depletes yin; Over dsage can cause nausea and vmiting Bimedical Indicatins: Antipyretic; Antibitic; Anti-inflammatry Dsage: : 6-8 pills 3 x / day away frm fd where pssible Endeavur Cllege f Natural Health endeavur.edu.au 12
Cardinal Signs Damp heat, txic fire, fire: Fever Insmnia, restlessness and irritability Thirst, dry muth, vracius appetite Bleeding frm the upper bdy (eg. nse sclera, muth) Suppurative skin lesins Ful diarrhea r dysentry Cncentrated, smelly urine Tngue: Red with thick yellw cat Pulse: Rapid, slippery and strng pulse Cmplexin: Red face, eyes and ears Endeavur Cllege f Natural Health endeavur.edu.au 13
Herbal Identificatin Huang Lian Jie Du Tang Huang Lian Dry Damp Huang Qin Dry Damp Huang Bai Dry Damp Zhi Zi Drain Fire Endeavur Cllege f Natural Health endeavur.edu.au 14
Analysis and explanatin f the frmula Huang Lian Cptis chinensis rhizma): Chief Herb Temperature: Cld;Taste: Bitter;Site f Actin: Upper jia Middle jia Reducing the heart fire in the upper Jia and at the same time reducing the stmach fire in the middle JIa Deputy herbs: Huang Qin Scutellaria baicalensis radix Temperature: Cld;Taste: Bitter;Site f Actin: Upper jia Clear the lung fire in the upper Jia Endeavur Cllege f Natural Health endeavur.edu.au 15
Huang Bai Phelldendrn amurense crtex : Assistant Herb Temperature: Cld;Taste: Bitter;Site f Actin: Lwer jia Clear the fire in the lwer Jia Guide herb: Zhi Zi Gardenia jasminides fructus Temperature: Cld; Taste: Bitter; Site f Actin: Deep; Interir Reduce the fire in all the San Jia and cnduct the heat t descend Endeavur Cllege f Natural Health endeavur.edu.au 16
Chief Cmbinatin Mdificatins Huang Lian* (Hempen 2009, p.172) Actin CHM Grup Reference Fire txicity with high fever, irritability, dry muth and thrat, dark urine Insmnia and delerium when the ying level has been injured by heat and fire Huang Qin Dry Damp Hempen 2009, p.184 Zhi Zi Drain Fire Hempen 2009, p.126 Sheng Di Huang Cl Bld Hempen 2009, p.168 Dysenteric disrders due t heat r fire Mu Xiang Regulate Qi Hempen 2009, p.480 Ulceratins, septic lesins Zhi Zi Drain Fire Hempen 2009, p.126 Lian Qia Disinfect Hempen 2009, p.200 Pus filled sres Bai Sha Tnify Bld Hempen 2009, p.776 Mu Dan Pi Cl Bld Hempen 2009, p.164 Stmach Heat Tian Hua Fen Drain Fire Hempen 2009, p.142 Zhi Mu Drain Fire Hempen 2009, p.120 Sheng Di Huang Cl Bld Hempen 2009, p.168 Endeavur Cllege f Natural Health endeavur.edu.au 17
Pin yin: Lng Dan Xie Gan Tang ( 龙胆泻肝汤 ) English: Drain Liver Decctin Surce: Yi Fang Ji Jie (Cllectin f frmulas with ntes) Cmpsitin: lng Dan Ca, Chai hu, Ze xie, Che Qian Zi, Mu Tng, Huang Qin, Zhi Zi,Dang Gui, Sheng Di, Sheng Gan Ca Administratin: All drugs decct in water fr ral administratin Functins: Reduce excessive fire frm the liver and gallbladder and remve damp-heat frm the lwer Jia Clear damp-heat frm the Liver ;Cls liver fire Indicatins: Excessive fire flaming up syndrme f liver and gallbladder Dwnward flw f dampness and heat syndrme f liver and gallbladder Cautin: Cautin in pregnancy; Can weaken spleen and damage yin and yang when verused Bimedical Indicatins: Bitter tnic ; Depurative ;Anti-inflammatry; Detxicant ;Chlaggue Dsage: : 8-12 pills 3 x / day away frm fd where pssible Endeavur Cllege f Natural Health endeavur.edu.au 18
Cardinal signs: Redness, swelling, pain r yellw muc-purulent discharge in a ht, strng r therwise relatively rbust patient; Punding headache, migraine; Jaundice; Irritable / ht tempered; Bitter taste Sre eyes Hypchndriac pain Tngue: Red r red edges and tip; Yellw tngue cating Pulse: Wiry, slippery and strng pulse Cmplexin: Red cmplexin, Red Eyes Endeavur Cllege f Natural Health endeavur.edu.au 19
Herbal Identificatin Lng Dan Xie Gan Tang Lng Dan Ca Drain Fire Huang Qin Dry Damp Zhi Zi Drain Fire Ze Xie Drains Damp Mu Tng Drains Damp Che Qian Zi Drains Damp Dang Gui Tnify Bld Sheng Di Huang Cl Bld Chai Hu Release Exterir (Cling) Gan Ca Regulate Qi Balance Endeavur Cllege f Natural Health endeavur.edu.au 20
Analysis and explanatin f the frmula Chief Herb : Lng Dan Ca Gentiana manshurica radix Bitter in taste and cld in nature Reducing excessive fire in the liver and gallbladder and clearing away dampheat in the liver channel. Deputy herbs: Huang Qin; Zhi Zi Bitter in taste and cld in nature. Strengthening the effect f the chief herb t clear away the heat and reduce fire Endeavur Cllege f Natural Health endeavur.edu.au 21
Assistant Herbs: Ze Xie, MuTng and Chen Qian Zi Dang Gui and Sheng Di Ze Xie, MuTng and Chen Qian Zi : Helping the chief herb t clear away damp-heat frm liver and gallbladder Dang Gui and Sheng Di: Nurishing the bld and Yin t benefit the liver Guide herbs: Chai Hu and Gan Ca Chai Hu: Regulate Qi and guide ther drugs int the liver and gallbladder Gan Ca: crdinating the effect f varius ingredients in the frmula Endeavur Cllege f Natural Health endeavur.edu.au 22
Mu Tng in Lng Dan Xie Gan Tang NEVER cnfuse Mu Tng with Guan Mu Tng Eight different herbs have been called as Mu tng in the classic bks and literatures in the histry fr Chinese herbs and frmula. Three f them been frequently used: Guan mu tng (Caulis Aristlchiae manshuriensis), Chuan mu tng (Caulis Clematidis Armandii) and Mu tng (Akebia quinata). All cntain leanlic acid and hederagenin. Guan mu tng, an herb f Aristlchia genus, cntains aristlchic acid (AA) A, B, C and D, and aristlactam. The majr txicity f AA is t damage the kidney. There were reprts f Lng Dan Xie Gan Tang causing acute renal failure in China befre due t accidently using Guan Mu Tng in the frmula. In Chinese Pharmacpeia, the dsage f Mu tng (all three herbs mentined) nly 6-9g per ds In USA, FDA stated a prduct cntaining a small amunt f AA culd be used fr years with n apparent adverse effects until serius, irreversible effects, such as renal dammed, has ccurred (FDA 2000:8). Any herb prducts cntains Guan Mu Tng can NOT be used in Australia and lts f ther cuntries. http://www.victriaacupuncture.net/cnsult-herbtxin.htm 23 Endeavur Cllege f Natural Health endeavur.edu.au 23
Pin yin: Qing Wei San( 清胃散 ) English: Clear Stmach Pwder TCM Indicatins: Clear heat and cls the stmach Cls, nurishes and regulates bld Bimedical Indicatins: Anti-inflammatry Cntraindicatins: Refer t cautin Cautin: Oral disrders with deficient heat r withut excess heat Txiclgy: Nil nted Dsage: 8-12 pills 3 x / day away frm fd where pssible Cardinal signs: Frequent hunger Tendency t cnstipatin r dry stl Thirst, desire fr cld drinks Dry muth and lips Belching, heart burn, reflux Halitsis Tthache Burning epigastric pain Redness, swelling and ulceratin f the ral cavity Tngue: Red and redder t the centre tngue which is dry with a yellw cat Pulse: Large in the middle psitin, slippery and rapid pulse Endeavur Cllege f Natural Health endeavur.edu.au 24
Pin yin: Qing Wei San (MacLean & Taylr 2003, p392) English: Clear Stmach Pwder Herb Hierarchy Dsage Temp Taste Grup Actin Huang Lian Chief 3-6gm Cld Bitter Dry Damp Sheng Ma Deputy 3-6gm Cld Sweet Bitter Pungent Sheng Di Huang Assistant 6-12gm Cld Sweet Bitter Release Exterir (Cld) Cl Xue Mu Dan Pi Assistant 6-9gm Cld Cld Drain Fire Dang Gui Assistant 6-12gm Warm Pungent Sweet Tnify Bld Cls heat; Drain Fire; Clears damp-heat; Detxifies and disinfects; Stps bleeding; Eczema, burns and ulceratin; Descends yang. Release the exterir; Vents rash; Disinfects and detxifies; Raises qi; Clears heat; Expels wind/heat. Cls Heat Bld Fire; Tnifies Bld; Generates fluid; Clears deficient heat; Tnifies and nurishes yin. Prmte urinatin; Drains damp; Harmnize and strengthen the spleen; Calms and anchrs the spirit; Disldges the phlegm; Disperse swelling. Tnifies bld; Mves bld; Drains wind-dampness; Mistens dryness; Unblcks the bwels/laxative. Endeavur Cllege f Natural Health endeavur.edu.au 25
Pin yin: Da Chi San( 导赤散 ) English: Pwder fr treating dark urine surce: Xia Er Ya Zheng Zhi Jue (Key t therapeutics f Children s diseases) Cmpsitin: Sheng Di Huang, Mu Tng, Sheng Gan Ca, Zhu Ye Administratin: All drugs decct in water fr ral administratin Functins: Clears heat frm heart, inducing diuresis and nurishing yin Indicatins: Fire and heat syndrme f the heart channel Cautin: Cautin with spleen and stmach deficiency Dsage: : 8-12 pills 3 x / day away frm fd where pssible Endeavur Cllege f Natural Health endeavur.edu.au 26
Cardinal Signs: Feeling heat and agitatin in the chest and heart lcatin Redness and flushed face Thirsty with desire t drink cld water Sre muth and tngue When heart heat transmitted t small intestine; then shrt, frequent urinatin with dark urine Stabbing painful urinatin Tngue: Red tngue Pulse: Rapid pulse Endeavur Cllege f Natural Health endeavur.edu.au 27
Pin yin: Da Chi San English: Pwder fr treating dark urine Sheng Di Huang Herb Hierarchy Dsage Temp Taste Grup Actin Chief 6gm Cld Sweet and bitter Mu Tng Chief 6gm Cld Bitter Damp remving and prmting diuresis Zhu Ye Deputy 6gm Bland and cld Sheng Gan Ca Assistant/ envy Sweet, pungent Clear heat Clear heat, cl bld and nurish kidney yin Prmte diuresis t relieve stranguria; clear away heart-heat ; prmte menstruatin and lactatin Clear heat, relieve agitatin, generate fluids and prmte urinatin 6gm Neutral sweet Tnify Tnify spleen and replenish qi, clear heat and relieve txicity; harmnize all medicinal.. The frmula is the cmmn frmula f treating fire and heat syndrme f the heart meridian. Have effect f clearing heat frm clearing heat frm heart, nurishing yin and inducing diuresis. Endeavur Cllege f Natural Health endeavur.edu.au 28
Pin yin: Wu Wei Xia Du Yin ( 五味消毒饮 ) English: Five Ingredient Eliminate Txin Decctin surce: Yi Zng Jin Jian (The Glden Mirrr f Medicine) Cmpsitin: Jin Yin Hua, Di Ding, Tian Kui Zi, Pu Gng Ying, Ye Ju Hua Administratin: All drugs decct in water fr ral administratin Functins: Clear txic heat; Reduces txic swellings Indicatins: All types f bils and carbuncles caused by heat and txin Cautin: Yin type bils and swelling; Cautin with spleen xu Bimedical Indicatins: Brad spectrum anti-bacterial agent; Anti-inflammatry; Anti-pyretic; Disinfectant Dsage: : 8-12 pills 3 x / day away frm fd where pssible Endeavur Cllege f Natural Health endeavur.edu.au 29
Cardinal Signs: Lcalised suppurative infectins Redness, swelling, inflammatin, pain, pus Maybe fever and chills Deep rted bils and sres Tngue: Yellw tngue cat Pulse: Full slippery, rapid pulse Endeavur Cllege f Natural Health endeavur.edu.au 30
Pin yin: Wu Wei Xia Du Yin (MacLean & Taylr 2003, p.562) English: Five Ingredient Eliminate Txin Decctin Herb Hierarchy Dsage Temp Taste Grup Actin Jin Yin Hua Chief 9gm Cld Sweet Cls heat & bld; Clears damp heat; Dispels wind heat; Disinfects/detxifies; Eczema, burns, ulceratin; Drains fire; Mves/regulates qi. Pu Gng Yin Assistant 3.6gm Cld Bitter Sweet Zi Hua Di Ding Assistant 3.6gm Cld Bitter Pungent Ye Ju Hua Assistant 3.6gm Cld Bitter Sweet Tian Kui Zi Assistant 3.6gm Cld Sweet Bitter Disinfect Disinfect Disinfect Disinfect Cls heat; Disinfects and detxifies; Breaks up lumps; Disperse stagnatin; Clears damp-heat. Cls heat; Disinfects and detxifies; Eczema, burns and ulceratin; Breaks up lumps; Clears damp-heat; Cls bld. Drains fire; Detxifies and disinfects; Clears wind-heat; Eczema, burns and ulceratin. Cls heat; Detxifies and disinfects; Breaks up swelling; Dispels stagnatin; Reslves accumulatins. Endeavur Cllege f Natural Health endeavur.edu.au 31
Herbal Identificatin Wu Wei Xia Du Yin Jin Yin Hua Pu Gng Yin Disinfect Zi Hua Di Ding Disinfect Ye Ju Hua Disinfect Tian Kui Zi Disinfect Endeavur Cllege f Natural Health endeavur.edu.au 32
Chief Cmbinatin Mdificatins Jin Yin Hua* (Hempen 2009, p.216) Actin CHM Grup Reference Warm pathgen diseases, early stages f infectius diseases Lian Qia Disinfect Hempen 2009, p.200 Jing Jie Release Exterir (Cld) Hempen 2009, p.44 B He Release Exterir (Cld) Hempen 2009, p.60 Heat n the surface with wind heat Niu Bang Zi Release Exterir (Cld) Hempen 2009, p.48 Lian Qia Disinfect Hempen 2009, p.200 Jing Jie Release Exterir (Cld) Hempen 2009, p.44 B He Release Exterir (Cld) Hempen 2009, p.60 Heat in the nutritive level Sheng Di Huang Cl Bld Hempen 2009, p.168 Lian Qia Disinfect Hempen 2009, p.200 Xuan Shen Cl Bld Hempen 2009, p.170 Zhu Ru Stp vmiting Hempen 2009, p.78 Ulceratin Zi Hua Di Ding Disinfect Hempen 2009, p.254 Ju Hua Release Exterir (Cld) Hempen 2009, p.52 Pu Gng Ying Disinfect Hempen 2009, p.250 Endeavur Cllege f Natural Health endeavur.edu.au 33
Chief Cmbinatin Mdificatins Jin Yin Hua* (Hempen 2009, p.216) Actin CHM Grup Reference Internal sres, swelling Huang Qin Dry Damp Hempen 2009, p.184 Dang Gui Tnify Bld Hempen 2009, p.768 Gan Ca Tnify Qi Hempen 2009, p.716 Amebiasis Huang Qin Dry Damp Hempen 2009, p.184 Bai Sha Tnify Bld Hempen 2009, p.776 Gan Ca Tnify Qi Hempen 2009, p.716 Thrat: painful bstructin Jie Geng Transfrm Cld Phlegm Hempen 2009, p.636 Lian Qia Disinfect Hempen 2009, p.200 Niu Bang Zi Release Exterir (Cld) Hempen 2009, p.48 Suppurated ulcers, un-suppurated abscesses Huang Qin Dry Damp Hempen 2009, p.184 Lesins, bils Pu Gng Ying Disinfect Hempen 2009, p.250 Ju Hua Release Exterir (Cld) Hempen 2009, p.52 Zi Hua Di Ding Disinfect Hempen 2009, p.254 Endeavur Cllege f Natural Health endeavur.edu.au 34
Tutrial Activity Case Study 7.1 Patient 7.1 (Male 43 years) presents with burning pain in the epigastrium. Further questining identifies that the cnditin wrsens significantly with ht fd and that he has a distinct craving fr cling beverages. He als reprts t be suffering muth ulcers, sur regurgitatin and always feels hungry. Clinical Assessments: Other: Halitsis (Bad Breath) Pulse: Full, deep, rapid Tngue: Red thick yellw cat What is the TCM/CM Aetilgy and Pathgenesis f the abve cnditin? What is the TCM/CM diagnsis? What are the TCM/CM treatment principles required here? Which herbal frmula shuld be used here? What mdificatin shuld be further made here t enhance the utcmes achieved? Endeavur Cllege f Natural Health endeavur.edu.au 35
Tutrial Activity Case Study 7.2 Patient 7.2 (Female 36 years) presents fr mental restlessness which affects her sleep currently. Further questining als identifies that she als suffers frm excessive sweat and is cnstantly thirsty. She has n aversin t cld and has a regular bwel mvement (1x/day). She des hwever share that her partner currently cmplains that she has been mre angry/irritable f the past several mnths. Clinical Assessments: Other: Red face Pulse: Extra strng pulse Tngue: Red bdy with a thick yellw cating What is the TCM/CM Aetilgy and Pathgenesis f the abve cnditin? What is the TCM/CM diagnsis? What are the TCM/CM treatment principles required here? Which herbal frmula shuld be used here? What mdificatin shuld be further made here t enhance the utcmes achieved? Endeavur Cllege f Natural Health endeavur.edu.au 36
Tutrial Activity Case Study 7.3 Patient 7.3 (Male 48 years) presents with Hepatitis A. Further questining identifies that he als suffers frm fever, hypchndrium quadrant pain, abdminal distensin, nausea and vmiting. Yur questining als identifies that he has a pr appetite. Clinical Assessments: Other: Jaundice Pulse: Slippery and Rapid Tngue: Red bdy with a sticky yellw cat What is the TCM/CM Aetilgy and Pathgenesis f the abve cnditin? What is the TCM/CM diagnsis? What are the TCM/CM treatment principles required here? Which herbal frmula shuld be used here? What mdificatin shuld be further made here t enhance the utcmes achieved? Endeavur Cllege f Natural Health endeavur.edu.au 37
Tutrial Activity Case Study 7.4 Patient 7.4 (Male 14 years) presents with cystic acne and bils. He als cmments that he suffers frm diarrhea and blating. Further questining als identifies that he als suffers frm insmnia and restlessness, is cnstantly thirsty and vracius appetite. He is currently taking anti-bitics fr this cnditin. Clinical Assessments: Other: Red eyes and ears Pulse: Slippery and Rapid Tngue: Red with thick yellw cat What is the TCM/CM Aetilgy and Pathgenesis f the abve cnditin? What is the TCM/CM diagnsis? What are the TCM/CM treatment principles required here? Which herbal frmula shuld be used here? What mdificatin shuld be further made here t enhance the utcmes achieved? Endeavur Cllege f Natural Health endeavur.edu.au 38