Fibromyalgia is a term given to a disorder which may have other, equally
applicable designations. In a recent study, patients who had been diagnosed
as having fibromyalgia, chronic fatigue syndrome, or environmental sensitivities
(multiple chemical sensitivities) were questioned about their symptom patterns;
the patterns were found to strongly overlap. That is, these disease designations
may be different names for the same condition, each given according to
the dominant manifestation or dominant concern: muscle aching, fatigue,
reactions to various chemicals. In an article by Giovanni Maciocia on myalgic
encephalomyelitis, a disorder frequently diagnosed in England, he says
that it is variously called such things as post viral syndrome, chronic
fatigue syndrome, chronic Epstein Barr virus disease, and epidemic neuromyasthenia.
In short, there are symptoms for which no definitive etiology has been
determined, and numerous names have been assigned, often based on assumptions
about the causative factor. Not a few physicians believe that the proper
designation for the disorder suffered by most of the patients is depression
combined with hypochondriac tendency, pushed ahead by mass hysteria (thanks
to overly
enthusiastic alternative health practitioners and the press).
In an article describing symptoms of fibromyalgia, aside from the muscular problems indicated by the term myalgia, there was listed sleep disturbance, chronic fatigue, anxiety, depression, gastro intestinal disturbances, and dizziness. The characteristic symptoms that lead to a diagnosis of fibromyalgia, as opposed to one of the other designations, are tenderness at specific points (18 points are typically mentioned: eight of these are on the back, two at the elbows, two at the knees, two in the upper chest (in front) and two at the sides of the neck), and muscular aching and pain. This syndrome might correspond to an earlier designation of "muscular rheumatism," a term which still appears in some modern books about Chinese medicine.
According to the fundamental theories of Chinese medicine, when treatment (including acupuncture, herbs, diet, and exercise) is prescribed appropriately to address imbalances of yin and yang, qi and blood, etc., the outcome will be a normalization of physiological processes. Therefore, in selecting treatment for a disease categorized by Western medicine--such as "Fibromyalgia"--it is vital to consider the Oriental medical diagnosis. Otherwise one may fail to obtain the desired effects or even obtain a negative outcome.
Therfore, the essence of effective treatment from the Traditional Chinese Medicine perspective becomes a reevaluation of the "disease" in terms of Oriental Medical Principles. For example, if fatigue, weakness, a tendency to chilliness, weak pulse, poor muscle tone, a pale or yellowish complexion, possible poor digestion/assimulation (gas/bloating), weight loss, a low voice, etc, are predominat, then a basic Qi and Yang defficiency pattern would be diagnosed and treatment would aim at warming and tonification principles.
This basic Qi Defficiency pattern is further confirmed by a summary
from Doctor DANIEL J. CLAUW, M.D,
assistant professor of medicine at Georgetown university School of
Medicine, Washington, D.C.
"Fibromyalgia is a common condition. Although the syndrome is defined by its musculoskeletal features, virtually any area of the body may be affected. This disease causes decreased pain tolerance throughout the body, rather than only at tender points, and patients with fibromyalgia display a higher incidence of a number of other symptoms and syndromes than normal persons. Most of these allied conditions are characterized by dysmotility of abnormal tone in skeletal or smooth muscle and by increased peripheral or visceral nociception."
This underlying defficiency pattern is in keeping with the Nutritional model that employs suplementation with minerals, amiono acids, and transfatty acids (Omegs's),and myer's cocktails.
The predominace of painful, fixed, points possibly along with a choppy
pulse, a purle hue to the toungue, and patchy skin
disorder, would imply a "blood stagnation" pattern. However since this
is usually a fixed "stabbing" pain, this Blood
stagnation is of a defficient nature, i.e. blood not nourishing the
channels (Muscles), then mild nourishing blood regualting
treatments would be appropriate.
Besides the straight Symptomology aspect of the Oriental Diagnosis, is the all pervasive "Shen" aspect. This is the correlation of the emotional aspects associated with the various networks in question.For more on emotional balancing and Tradotional Chinese Medicine using the 5 element theory, please see my newsletter, July Issue. Generally a defficiency condition is secondary to exhaustion of the Qi, Blood, Yin, and Yang from extreme activity stress. The old axiom is exteme Yang (activity, albeit physical or mental), will eventually transform into it's opposite, Yin or "collapse". This is better exemplified by a stroke condition, but the case of lifestyle burnout is applicable to chronic degenerative disorders.
In refference to the etiology of Fibromyalgia, as well as Chronic fatigue syndrone, there are currently four factors that are considered potential triggers, along with exposure--or unique susceptibility--to one or mroe infectious agents:
1) Severe emotional stress or chronic depression, which appears to affect
50% or more of those with CFS/FIBROMYALGIA. It is difficult to distinguish
whether the psychological conditions are initiating factors, contributors
to exacerbations, or simply a symptom of the disease, since depression,
anxiety disorder, and panic disorder are among the neruopsychological symptoms.
It is well-established that emotional stress has a negative response on
the immune system. In a study on breast cancer patients, the natural
killer cell activity decreased in response to the increase in the amount
of depression and the withdrawal of social support. By contrast,
participation
in support groups reduced depression and also decreased symptoms and increased
survival time. It is expected that depression and emotional stressors
can lead to viral activation or worsen the immune disorder. When
cell mediated immune responses were compared in those with CFS, and those
with major depression but without CFS, the prevalence and magnitude of
the disturbance was found to be greater in those with CFS than
without. Thus, while depression may be a contributor, it cannot
itself be responsible for the full range of immune
dysfunctions.
2) Chronic stress of the digestive system. For a large portion of the population, digestive stress begins early in life and persists for many years. Lack of breast-feeding or early weaning is typically followed by eating disorders involving diets too high in fats and simple sugars leading to an extraordinarily high obesity rate amongst young people that was particularly noted in the 1960's (President Kennedy strongly promoted fitness programs at the time) and which has been steadily worsening. Obesity and anorexia nervosa usually develop as overwhelming problems during the late teens and early twenties, though incidence of obesity at younger ages is increasing rapidly, as is the less frequent but equally serious problem of anorexia nervosa. The constant stress associated with characteristic American diets, combined with erratic eating patterns and nervous tension, often leads to the development of food sensitivities or allergies, and chronic bowel disorders (including "leaky gut syndrome"). Food sensitivities can affect any organ system in the board, resulting in many signs and symptoms that resemble FIBROMYALGIA, including lethargy, aching joints, headaches, and lymphatic swelling. Numerous laboratory and clinical studies have shown that improper diet leads to immunosuppression.
3) Environmental derangement of the immune system. Some individuals believe that their experience of CFS, can be traced back to an episode of exposure to a toxic chemical. Some industrial, research, and farm workers have been repeatedly exposed to chemicals that accumulate to produce a toxic syndrome. It is known that many drugs, such as corticosteroids, antihistamines, and chemotherapeutic agents for cancer cause severe fatigue and immune suppression as a side-effect, and this also applies to a number of environmental pollutants. Some chemicals may alter DNA, activate viruses, or interfere with normal metabolism. Problems of environmental contamination by heavy metals, pesticides, and chemicals used for cleaning are among those that could trigger immune dysfunctions. Lead poisoning, which affects the central nervous system, became such a serious urban problem in the 1960's and 1970's that legislative restrictions on lead in numerous products had to be instituted; the neurological effects of lead poisoning are thought to persist for a long time, especially when there are high blood levels early in life.
Exposure to ultra violet light (especially UVB) is known to depress immune functions and to activate latent viruses (which may be the reason that autoimmune flare-ups occur with exposure to UVB). A mechanism of viral activation by oxidant chemicals and UV light has been elucidated: the nuclear factor NF-kappa B is first activated by these environmental factors and then this factor moves to the nucleus and initiates DNA processes, including promotion of latent virus and oncogene replication cycles. UV light (and several chemical pollutants) also acts directly on DNA, leading to an activation of latent viruses and oncogenes. During the years just prior to initial reports of chronic fatigue syndrome, and continuing until very recently, there was a strong emphasis among the light skinned population to develop a sun tan. In fact, the "yuppie" population may have frequently indulged in use of tanning booths and tropical vacations, leading to excessive UV exposure. The development of CFS is paralleled by a rapid increase in the incidence of skin cancer.
Another environmental factor of concern is the rapid rise in use of estrogens and total body exposure to estrogen (delays in childbearing and reduction in total number of children born lead to high total estrogen exposure), which has been suggested to be associated with the continuing rise in rates of breast cancer. Additionally, during the 1970's, in response to an "energy crisis" (restricted crude oil supplies), homes and office building were sealed to reduce heating/cooling expenses; indoor pollution levels quickly rose, often exceeding those in city air. Such pollutants could help activate latent viruses, depress cellular immunity, and worsen allergies.
4) Overwork coupled with under-exercise. Overwork in the modern
context often refers to excessive mental activity (as opposed to physical
labor) under deadlines; this may put substantial stress on the adrenal
gland. At first one experiences a surge of energy, as the adrenal
cortex releases increased amounts of cortisol, so it is easy to do too
much. But if a person continually overworks, the adrenal output begins
to fail, and both the precursor of steroid hormones---DHEA (dehydroepiandrosterone),
and cortisol levels begin to fall. Decreased levels of cortisol are
associated with lethargy and fatigue (cortisol prevents overstimulation
of the immune system) as well as experience of peripheral aching.
Patients with CFS often end up having a decreased output of corticotropin
releasing hormone (CRH). This hormone is released in response to
stress and helps to stimulate the body's "fight or flight" response via
norepinephrine, and it has a general impact on all adrenal corticol hormones.
A decrease in this hormone thus leads to a decrease in exercise.
This lower level of exercise contributes to a lower metabolic rate and
poor circulation, resulting in fatigue. The fatigue associated with
the syndrome further inhibits physical
activity, in a vicious cycle that eventually has a nearly paralyzing
effect. It is thought that the condition called "fibromyalgia", which
sometimes accompanies CFS, is due to poor microcirculation in the muscles,
which is usually relieved by exercise; however, too much exercise will
exacerbate this condition, probably because of the disturbed microcirculation
which can not respond to the demands of exercise. A small amount
of necrotic tissue is detected in muscle biopsy of those with CFS.
From what has been learned thus far, it is likely that a virus is a necessary precondition to experience CFS and that environmental influences, behavioral patterns, and/or adrenal exhaustion are necessary to trigger the full-blown immune dysfunction syndrome that is difficult to cure, while dietary stress, emotional disorders, and lack of exercise may be contributing factors to CFS and other cases of chronic fatigue. Additional syndromes may arise from the same types of factors, and may occur in association with CFS, including fibromyalgia, post-viral infection syndrome, and multiple chemical sensitivities. The appearance of CFS (or the increase in its frequency, making it a medical concern) comes at a time when there are increases in the incidence rates of early and late onset diabetes, childhood asthma, Parkinson's disease, testicular cancer, vulvar vestibulitis, and several other diseases for which similar factors may be responsible.
LABORATORY FINDINGS AND DIFFERENTIAL DIAGNOSIS
Although specific medical treatment for CFIDS has not yet been developed, it is considered very important to determine whether other diseases that may be the cause of teh sumptoms are present, and then to treat them specifically, if possible. The following tests should be conducted.
COMPLETE BLOOD COUNT (CBC): it is expected that there will be a decreased white blood cell count, increased lymphs or atypical lymphs on a peripheral smear. There may also be increased eosinophils if there is a major allergic condition. A CBC may reveal other abnormalities that would suggest a number of other possible diseases.
CHEMISTRY SCREEN: An examiniation of enzyme and chemical levels can be used to rule out hepatitis and other organic diseases which may cause fatigue and other symptoms characteristic of CFIDS.
THYROID PANEL (T4 AND TSH): This information can determine if hypothyroidism is present, which produces chronic fatigue, and which can be treated with supplemental thyroid hormone.
ADRENAL FUNCTION TEST: A saliva test can be conducted which is best for tracking the daily variation in cortisol levels. Levels of cortisol may be elevated or depressed in the AM or PM. This panel also measures DHEA, an adrenal hormone that may be lowered in CFIDS. The adrenal test will not necessarily indicate any particular disease, but it may suggest an appropriate treatment to rectify adrenal dysfunction.
MONONUCLEOSIS PANEL: IgG and IgM for EBV (CMV and toxoplasmosis
can be tested by the same methodology). Viral capsid antigen (VCA,
an antigen found in infected cells) is the test for EBV. VCA-IgG
titers remain detectable for life, thus a good marker for past mononucleosis.
VCA-IgM antibodies, on the other hand, decline to undectable levels 2-3
months after infection by EBV, and are a good marker for acute infection.
Early antigen (EA; early antigens are produced in the infected cell within
24-48 hours) antibodies arise at about 5 weeks after infection and peak
at 7-0 weeks. By 7-8 months, levels should be normal, though titers
have been known to remain high for up to 4 years.), and nuclear antigen
(NA; found in the nucleus of the cells. NA antibodies appear late
in the illness, around 6-10 weeks, peaking at 10 months; they may remain
persent for life.). Chronic infection by EBV, CMV, or toxoplasmosis can
be treated by drug therapy, and possibly by herbal
compounds.
ANTI-NUCLEAR ANTIBODY (ANA): This measure is used to rule out autoimmune diseases. Note some individuals with CFIDS, will have a lisghtly positive ANA, and all other factors associated with known autoimmune disorders will be negative. Autoimmune disorders are often treated with anti-inflammatory and immunosuppressive drugs; there are also many natural treatment strategies that can be applied.
STOOL TEST: A person with CFIDS may have parasites and/or candida, but these conditions may yield symptoms of digestive disturbance and fatigue in those without CFIDS, which are alleviated by reducing the levels of these organisms in the intestines. A stool test can reveal occult bleeding that may suggest the presence of a tumor.
HIV TEST: Rule out HIV infection, which presents similar symptoms. HIV infection may persist for ten years before causing obvious sumptoms; therefore, a person may consider themselves not at risk, yet they may have been at risk a decade ago.
CA-125 OR CEA: Rule out tumor growth. These blood tests are not as definitive as a CT scan for cancer, but may be used as an additional test for potential CFIDS patients to suggest that the reported symptomsa re not secondary to cancer development.
The following is further delineation from both Western and Oriental observation.
Pathology studies of the muscles of people with fibromyalgia suggests that there is a disruption of microcirculation, only limited (if any) inflammation, and possible metabolic disturbance of the muscle fibers. This correlates with the blood stagnation of a deficient nature (lack of inflammation). It has been reported that cardiovascular fitness training can be of benefit, though exercise capabilities and requirements vary considerably among those affected by the disorder. Exercise training improves the circulation to the muscles and also regulates the metabolism.
It has been suggested that energy metabolism in the muscles is reduced in the painful areas. An amino acid, L carnitine, may prove helpful, as it helps convey lipids to the mitochondria for metabolism into usable energy. It has been shown, for example, that ingestion of 1.5 to 2.0 grams of L carnitine prior to vigorous physical exercise increases the power output of the muscles, even in healthy individuals. If there is a carnitine deficiency or a lower carnitine utilization potential, then supplementing with it may have major effects.
Coenzyme Q 10 is important in oxygen metabolism and may be valuable in improving muscle metabolism. It is an important component in heart muscle function. Coenzyme Q10 in doses as low as 30 mg per day has been shown to improve cardiovascular function; doses up to 180 mg per day have been used in treating some disease conditions.
Microcirculation is promoted by the use of herbs; examples are salvia, red peony, crateegus, and moutan (also, the red pepper, capsicum, has this effect). Nutrients, especially magnesium (which can be given orally or by injection) and manganese, have been proposed as treatments for muscular pain. Vitamin B1 is often administered to relieve aching in the legs.
It is likely that the disease or diseases involved with fibromyalgia
have a viral etiology and this is suggested in disease names mentioning
an epidemic nature, post viral syndrome, and chronic Epstein Barr syndrome.
Human herpes viruses 6 and 7 (HHV 6 and HHV 7), as well as herpes simplex,
cytomegalovirus, and Epstein Barr virus may each contribute to dysfunctions
which transform a non viral functional problem (due to lack of exercise,
poor diet, depression, nervous stress) into a persisting disease. Antiviral
therapies may prove helpful. Typical antiviral herbs include garlic, echinacia,
isatis, hu-chang, lonicera, and licorice. Viruses can cause an abnormal
pattern of cytokines, resulting in several of the symptoms. Even after
the virus is inhibited, the may remain abnormal for some time, and therefore,
after a reasonable course of antiviral therapy (e.g. two to four weeks),
one may need to continue treatment of the secondary effects, by regulating
microcirculation, resolving moisture
accumulation, and harmonizing the internal organs.
In the analysis of myalgic encephalomyelitis by Maciocia (Journal of Chinese Medicine 35; 1991 ) it was suggested that some cases may be due to damp heat affecting the muscles as a secondary effect of a pathogen. Some traditional Chinese formulas recommended for this syndrome include Coptis and Magnolia Combination (which also contains gardenia, soja, acorus, pinellia, and phragmites), Chih shih Pills (which also contains rhubarb, coptis, scute, hoelen, alisma, atractylodes, and shen chu), and Agastache and Magnolia Combination (which also contains cardamom, hoelen, polyporus, coix, alisma, pinellia, soja, and apricot seed). The presence of such a damp heat syndrome will often be readily detectable in the feeling of the pulse (e.g. slippery) and the tongue (e.g. thick and/or greasy coating).
Based on these considerations, a suggested herbal/supplement protocol for treatmentof fibromyalgia would include:
Diet rich in Vegetables and fruits, as a bioavailable source of these, see Juice Plus information.
L-Carnitine combination, such as Cartaequin: four to six tablets per day (contains L carnitine, coenzyme Q10, and crataegus). For high dose L carnitine, a bulk powder of L carnitine tartrate can be used at the dose of one teaspoon (3 grams) three times daily. ( to address the "local deficiency pattern", as necessary according to differentiation)
Microcirculation Herbs, such as Gincofolin: two to four tablets per day (contains salvia and ginkgo extracts ).(to address "Blood Stagnation" syndrome as necessary according to differentiation)
Specific Minerals, such as Fibroplex (or another Magnesium & Malic Acid), Mg/K Asperate BID, B Complex BID, Calmagnium: two tablets daily (contains magnesium, manganese, and other minerals, also has B1 and other vitamins).
Antivirals, such as Katsu Garlic: eight to ten tablets per day (contains deodorized garlic, B1, and coix). Alternatively, use an antiviral combination such as Isatis 6, Ilex 15, Bidens 6, Isatis Gold (9 -15 tablets per day for any of these)(as according to viral etiology)
Formulas to address "Damp Heat", as according to differentiation, such as Shen chu 16 or Alisma 16 can be used. These would be taken in a dosage of 6 12 tablets per day. Alternatively, the traditional formulas mentioned above can be made as decoctions, or made from dried decoctions of the individual herb ingredients.
Optional: Compound GL (complex formula designed for persons with chronic
fatigue, digestive disorders, insomnia, etc.). 6- 15 tablets per day. It
has been suggested by one practitioner working with many "chronic fatigue"
patients that aching associated with this syndrome would respond to the
ingestion of single herbs such as cnidium or ginger when used on an as
needed basis for flare ups. The dosage of the herbs is one level teaspoon
of extract granules, taken in the morning. Kampo (Japanese Powders) practitioners
recommend Coix Combination (also contains ma huang, tang kuei, peony, licorice,
cinnamon twig, and atractylodes) as a treatment for muscular rheumatism,
and claim a high rate of success (typical dosage is 7.5 to 12.0 grams per
day).This group of remedies may seem a lot, but the duration of therapy
should not be very long, and not all these
supplements need be taken simultaneously (use the highest dosage of
herb tablets that is acceptable to the patient; the nutritional supplement
dosage does not need to exceed the amounts suggested here). If effective,
some improvement should be seen within two to three weeks, and the total
duration of therapy should be about three months (for the muscular disorders)
assuming that appropriate exercise is undertaken.
Again, according to the fundamental theories of Chinese medicine, when treatment (including acupuncture, herbs, diet, and exercise) is prescribed appropriately to address imbalances of yin and yang, qi and blood, etc., the outcome will be a normalization of physiological processes. Therefore, in selecting treatment for a disease categorized by Western medicine--such as "Fibromyalgia"--it is vital to consider the Oriental medical diagnosis. Otherwise one may fail to obtain the desired effects or even obtain a negative outcome.
For obtaining formulas, contact Dr Kelley at alohadoc@gte.net
UNDERSTANDING CFIDS FROM A CHINESE PERSPECTIVE
Traditional Chinese doctors make frequent reference to symptoms of fatigue and exhaustion. While none of the traditional disease categories quite fits CFIDS, there are some parallels that can be explored.
Based on the experience of one of the current authors (E.V.) with CIFDS
patients over a 6-year period, the typical presentation of CFIDS, is deficiency
of spleen qi with some dampness, and kidney exhaustion. Spleen qi
deficiency can lead to accumulation of dampnesss which may initially present
only minor symptoms. Both the spleen qi deficiency and the dampness
may be caused by, or worsened by, dietary factors. Because of its
heaviness, dampness tends to descend and its accumulation will most often
be found in teh lower abdomen. For women, the group most often affected
by CFIDS, the manifestations may include persistent vaginal or urinary
tract infections (or irritable conditions without infection), as wel as
bowel disorders. The stagnated dampness will block the normal circulation
of qi, and this may be complicated by pre-existing problems of qi irculation
or the impact of emotionally stressful situations. The stagnated
qi and moisture can give rise to pathological heat and phlegm. Because
heat tends to rise, the secondary manifestation of such a disorder may
include respiratory system congestion (with or without obvious infection).
Sinus disorders associated with this pattern will often worsen with ingestion
of certain foods (e.g. fatty foods), and will be unresponsive to antibiotic
therapies (indeed, the antibiotic therapy is thought to weaken the spleen
qi and thus will worsen the disease pattern). The hot phlegm can
also obstruct the orifices of the heart (and the channel connecting kidney
and heart), producing insomnia and mental disorders. The phlegm-damp
may produce masses (lymph node swelling, thyroid swelling, breast lumps).
In some cases, the stagnation of qi will elad to blood stasis, with the
formation of firm masses or with sumptoms of pain, dry skin, and numerous
other conditions. The stagnation in the lower abdomen has a
weakening effect on the kidney system, which may already be weakened
as a pre-existing condition that makes the manifestation of CFIDS possible.
Both spleen qi deficiency and kidney exhaustion are associated with low
production of blood cells, lowered immune responses, poor memory, aching,
and reduced libido and energy.
According to the report of an acupuncturist treating chronic fatigue syndrome (the report did not make it clear how strictly CFIDS was diagnosed, of 75 cases, damp-heat syndrome, dampness without heat, and spleen qi deficiency accounted for 59 of the cases (79%), of which three out of four were said to be successfully treated by Chinese herbs and acupuncture. These diagnostic patterns are consistent with the description presented here. The other 16 cases were reported to have yin deficiency or heat syndrome.
Formulas that tonify the spleen and/or clear dampness should be considered as a first line of treatment, since kidney tonification requires adequate spleen function. Among the classical formulas, Six Major Herb Combination (Liu Jun Qi Tang: ginseng, licorice, hoelen, atractylodes, fresh ginger, pinellia, citrus), Saussurea and Cardamon Combination (Hsaing Sha Liu Junqi Tang: ginseng, licorice, atractylodes, hoelen, pinellia, citrus, cardamon, saussurea), or Atractylodes and Hoelen Combination (Ling Gui Qhu Gan Tang: hoelen, atractylodes, cinnamon twig, licorice) may be used as base formulas.
All of the above formulas were designed to address the general treatment
principles of tonifying the spleen, aiding digestion, and clearing dampness.
Their common indications for use include weak digestion, poor appetite,
fatigue, pallor, and intestinal irregularity. All three formulas
also benefit the immune system with herbs such as ginseng, licorice, and
atractylodes. These formulas do not address heat that might be generated
from stagnated qi and accumulated fluid. In the event that heat symptoms
are a significant manifestation, the formulas may be modified by adding
scute, cpotis, phellodendron, or bupleurum (or some combination of these
hersb). Pinellia Combination (Banxia Xiexin Tang or several related traditional
formulas, may be suitable, especially if diarrhea is present; Minor Bupleurum
Combination (Xiao Chaihu Tang) may be used instead if constipation and
diarrhea are both experienced. Additional examples of spleen-tonifying
formulas are Ginseng and Longan Combination (Gui Pi Tang: zizyphus,
longan, polygala, ginseng, astragalus, hoelen, tang-kuei, saussurea, jujube,
locirice), which tonifies qi and blood affecting primarily teh spleen and
heart, and Ginseng and Astragalus Combination (Bu Zhong Yi Qi Tang:
ginseng, atractylodes, astragalus, bupleurum, cimicifuga, tang-kuei, citrus,
ginger, jujube, licorice), which tonifies spleen and lung qi, conteracts
prolpase, and normalizes digestion. The main indications for these
formulas are fatigue, pallor and weak digestion. Ginseng and Longan
Combination is selected when there also poor memory and insomnia; Ginseng
and Astragalus Combination is selected when there is frequent illness.
These formulas, however, are not recommended when there are pronounced
symptoms of dampness, such as greasy tongue coat.
Persons who suffer form symptoms of leukorrhea, diarrhea, or frequent urination may benefit by additionally consuming soups or herbal formulas that include dioscorea, euryale and lotus seed.
Once the digestive system seems able to absorb and transform food and
distribute the moisture, one may introduce more tonics, especially for
the kidney. It must be determined whether a yin or yang deficiency
dominates. Classical formulas emphasizing kindey yin include Rehmannia
Six Formula (Liu Wei Di Huang Wan: rehmannia, alisma, cornus, moutan, hoelen,
dioscorea,), Cnidium and Moutan Combination (Qingre Bu Xue Tang:
phellodendron, ophiopogon, anemarrhena, scrophularia, rehmannia, tang=kuei,
peony, cnidium, moutan, schizandra, bupleurum), Generate the Pulse Powder
(Shengmai San: ginseng, phiopogon, schizandra), and Majore Restoration
Pill (Da Zao Wan: rehmannia, ginseng, astragalus, ophiopogon, achyranthes,
eucommia, phellodendron, tortoise shell, placenta, cardamon). The
main treatment principles for all of these formulas are nourishing the
yin and blood and clearing heat. The common indications for use include
thirst, weakness, dry
cough, and feverish feeling. Heat encountered in a person with
CFIDS is usually due to deficiency of yin or blood giving rise to deficiency
heat, or locaized heat due to phlegm or blood stasis. One must e
careful when clearing heat, so that overcooling does not occur. Otherwise
additional injury will be inflicted on the spleen. In case kidney yang
deficiency dominates, one should consider the following formulas to warm
or tonify kidney yang: Aconite and G. L. Combination (Si Ni Tang
: aconite, dried ginger, honey baked licorice), Kidney Nourishing
Pills (Ge Jie Bu Shen Wan: gecko, deer antler, ginseng, astragalus,
eucommia, cordyceps, lycium, hoelen, white atractylodes), and Cuscuta Seed
Pills ( Tu Si Zi Wan: cuscuta, deer antler, cistanche, dioscorea,
aconite, lindera, schizandra, mantis egg, alpinia, oyster shell, cornus).
The main treatment principles for these formulas include tonification of
kidney yang and warming the center. Indications for use include exhaustion,
coolness of the extremities, and weakness in the back. The spleen
qi deficiency observed in many cases of CFIDS may have its basis in kidney
yang deficiency.
For the problem of kidney and heart not communicating, one may consider Ginseng and Zizyphus Formula (Tian Wang, Bu Xin Dan: zizyphus, asparagus, scrophularia, biota, ophiopogon, raw rehmannia, salvia, tang-kuie, acorus, polygala, cinnabar, coptis, ginseng, hoelen, schizandra, platycodon). The treatment principle is to nourish the yin of the heart and kidney, build blood, clear deficiency heat, and calm the spirit. Signs and symptoms to be treated by this formula include insomnia, vivid dreaming, anxiety, nervousness, flushed feeling, weakness in the lower extremities, heart palpitations, poor memory, and fatigue. If the kidney, spleen and heart suffer from yang deficiency, then Hui Yang Jiu Ji Tang (ginger, cinnamon, ginseng, atractylodes, hoelen, pinellia, citrus, licorice, and schizandra) may be used. It is intended to treat lethargic state with a constant desire to sleep, chilliness, digestive distress and cold extremities. Both these formulas rely on ginseng, schizandra, and hoelen to tonify the kidney, spleen and heart, remove damp obstruction, and calm agitation.
If blood stasis is present, one may have to first tonify the spleen and kidney and then move blood stagnation or visa versa, depending on the level of deficiency syndrome present, Primary formulas to be considered when moving blood stagnation in a deficient individual are Tang-kuei and Jujube Combination (Danggui Si Ni Tang: tang-kuei, akebia, licorice, cinnamon twig, jujube, peony, asarum), Rhubarb and Eupolyphaga Formula (Da Huang Zhe Chong Wan: rhubarb, apricot seed, peony, raw rehmannia, lacquer, gadfly, leech, holotrichia, eupolyphaga), and Cinnamon and Bulrush Combination (Shao Fu Zhy Yu Tang: fennel, dry ginger, corydalis, tang-kuei, cnidium, myrrh, cinnamon bark, re peony, bulrush, pteropus). The treatment principles for these formulas include increasing blood circulation, regulating temperature and stopping pain.
There is a disorder defined in the ancient and modern Chinese literature
as Taxation Syndrome (xulao). This term is applied to any kind of
chronic debilitating disease, such as tuberculosis and aplastic anemia,
which will involve severe fatigue as a symptom and may lead to weight loss
(due to loss of appetite, sweating and internal degereration). In
classical sources, Xulao is described as an exhaustion of all organ networks,
and a deficiency of qi, blood yin and yang. In general, xulao refers
to a chronic state of exhaustion that does not go away when simply resting.
Simple fatigue, on the other hand, disappears when one takes time out for
rest and relaxation. Although xulao implies a deficiency condition, it
may arise from an excess condition. Thus, there may be deficiency
(spleen or kidney qi deficiency being the probable) or a combination of
deficiency and excess (liver qi stagnation resulting in spleen qi weakness)
or an excess condition (stagnation of qi and blood, accumulation of
dampness).
In the Jingui Yaolue (Essentials from the Golden Cabinet), Rhubarb and
Eupolyphaga Formula (Da Huang Zhe Chong Wan) is presented as a primary
remedy for the treatment of xulao diseases. The formula is said to
treat the complete exhaustion of all organ networks caused by chronic blood
stasis. Patients afflicted by this condition can exhibit a variety
of symptoms originally described by Zhang Zhongjing as follows: "they
appear severely injured by the noxious influences of food, drink, depression,
sex, hunger, exhaustion, as well as meridian obstruction and imbalance
of nutritive and protective qi. Inside this patient lodges dry blood,
the skin and the flesh are rough, and the eyes appear dark. In such
a case, we must harmonize the center and tonify deficiency with Rhubarb
and Eupolyphaga Formula." Later commentators remark that Rhubarb
and Eupolyphaga Formula
is the classical remedy for internal blood stasis of a chronic nature,
in contrast to Cinnamon and Hoelen Formula (Gui Zhi Fu Ling Wan) and Persica
and Rhubarb Combination (Tao He Chengi Tang) are the standard treatment
for freshly developed blood stasis.
The blood stasis syndrome may appear in prolonged CFIDS. An extended experience of CFIDS is what is commonly presented to practitioners of Chinese medicine after numerous other practitioners have been consulted with unsatisfactory therapeutic results. Blood stasis is recognized as a common feature of chronic hepatitis B infeciton, many autoimmune disorders, as well as other chronic diseases.
Herbal treatment of CFIDS can be very successful. However, one must watch the progress of the patient to be able to change the formula when patterns shift. Treatment time to resolve major CFIDS symptoms is typically six months, but one must then continue to treat the patient even though they appear well, as their fundamental qi is weak; otherwise there may be a relapse.
A strategy that has been used by the Institute for Traditional Medicine to deal with viral activation is to vigorously treat, and threefore stop, any suspected early viral infection with herbs that have well-established antiviral properties in hopes of preventing secondary effects of the full immune response that develops over a period of several days. Hence, for influenza or herpes eruption (which may activate other latent viruses), a high dose of certain herbs are given, replacing other long-term regimens, usually for only 24-48 hours. Most people with CFIDS are well-aware of prodromal symptoms of an emerging disease. If they have the herbal materials on hand, they can avoid delay in treatment. Lonicera and Forsythia Formula (Yin Qiao San) is a typical combination used for influenza; Gentiana Combination (Long Dan Xie Gan Tang) is used for herpes simplex and herpes zoster. There are numerous antiviral herbs, of which isatis, hu-chang, lonicera, gentiana, chrysanthemum, bidens, viola, and licorice are especially powerful.
There are several experimental herbal combinations in convenient tablet
form that may be used as substitutes for the traditional decoctions and
pills mentioned above for the treatment of CFIDS. These include the
spleen tonic formulas Ginseng 18 and Lotus 9, the qi and moisture stagnation-
relieving formulas Bupleurum 12 and Cyperus 18, the kidney tonic formulas
Restorative Tablets and Gecko-A, the heart-kidney formulas Zizyphus 18
and Dry Ginger Tablets, the blood-stasis formulas Euppolyphaga Tablets
and Myrrh Tablets, and the antiviral formulas Ilex 15, Gentiana 12, Isatis
6, and Bidens 6. Further, apreparation devised specfically for long-term
management of CFIDS, called Compound GL, contains herbs for enhancing
immune function, tonifying the spleen and kidney, calming agiation,
vitalizing blood circulation, and clearing deficiency heat. It has
been used often for CFIDS by practitioners of Chinese medicine during the
past three years.See Pharmacy for listing and
prices.
Acupuncture points to be used in treating CFIDS vary as the treatment
progresses over a duration of many
months. One usually starts with tonifying the spleen and promoting
digestion, and then the kidney and heart, and
later to treatment of static blood. Specific treatment plans
for acute illness, insomnia, depression and pain may
be interspersed throughout the treatment plan, applied as needed.
Acupuncture points to be considered include:
Spleen deficiency and dampness: ST 36 (zusanli), CV 12 (zhongwan),
SP 9 (yinlingquan), and UB 20 (pishu).
The treatment method used should be tonification, or warm needling
with only a few points chosen each time.
For very weak or debilitated patients there should be only mild or
no stimulation. For moxibustion, one might
conisder CV 8 (shenque), CV 4 (guanyuan) or UB 20 (pishu).
Kidney deficiency: KI3 (taixi), KI7 (fuliu), CV 4 (guanyuan),
UB 23 (shenshu), and KI 27 (shufu). Use
reinforcing technique and moxibustion on all points, with direct moxibustion
to UB 23 (shenshu).
Heart and kidney not communicating: HT 7 (shenmen), HT 6 (yinxi),
PC 5 (daling), aCV 14 (juque), KI 6
(zhaohai), and KI 3 (taixi). All points should be treated with
reinforcing technique, but no moxibustion.
Blood stasis: LV 3 (taichong), SP 6 (sanyinjiao), SP 10 (xuehai),
ST 29 (guilao), UB 17 (geshu), UB 19
(danshu) and UB 20 (pishu).
Acute illness: LI 4 (hegu), LV 3 (taichong), ST 36 (zusanli) and GV 14 (dazhui).
Insomnia: ST 36 (zusanli), SP 6 (sanyinjiao), HT 7 (shenmen),
PC 6 (neiguan), and anmian. Direct moxibustion
should be applied to the center of the bottom of the heel (special
point for insomnia).
Depression: LV 3(taichong), LI 4 (hegu), GB 34 (yanglingquan),
ST 40 (fenglong), HT 7 (shenmen), and KI 3
(taixi). The points ned to be inserted in the order given.
This treatment should be done two times a week for
three weeks, and then on a weekly basis for at least 4 more weeks.
Acupuncture for CFIDS usually produces substantial symptom relief on
the day of treatment and for up to two
days after, but to obtain continued relief during the first months
of treatment, the individual must make daily use
of herbs and other therapy.
DHEA
DHEA decreases when cortisol levels are high, probably due to increased
adrenal output of cortisol. However
when there is a true deficiency of DHEA, supplementation is recommended.
Normal DHEA output of the
adrenals is 20-30 mg/day. Because DHEA is only partly absorbed
when taken orally, the dosage needs to be
somewhat higher than the deficit in adrenal output. Dosage also
depends on sex of the patient, because DHEA is
an androgen; males 25 mg., twoce daily, upt to 100 mg twoce daily,
females 5 mg twice daily, up to 20 mg twice
daily. Supplementation with either cortisol or DHEA shows marked
improvement in energy, sleep and flu-like
symptoms.
Glandulars:
The of glandulars, or "protomorphogens", has a long history, although
few scientific studies have been done.
Thymus extract has been shown to reverse some of the age related defects
in cell-mediated immunity and to
enhance immune funciton. The typical dosage of a glandular produce
is 2 capsules, 3 times per day; see label
instructions for actual recommendations.''
Anti-candida regimen:
Candida overgrowth is a frequently reported to occur in people with
CFIDS. At one time, it was speculated to
be the cause of chronic fatigue syndrome, candida is now recognized
as a secondary disease. Treatments include
a yeast-free, sugar-free, mold-free diet (medicinal mushrooms are acceptable),
and usually supplementation with
several of the following: caprylic acid (450-750 mg daily; coenzyme
Q10 will counter energy-inhibiting effects
of chronic caprylic acid administration), glutamine (500 mg daily),
grapefruit seed extract (10-15 drops daily;
dilute with water), omega-3 and omega-6 fatty acids (1.0-1.5 gms daily;
excessive fatty acid levels can inhibit
immune functions), pau d'arco (1,500 mg daily). Supplementation
with Lactobacillus acidophilus, often
combined with other beneficial strains to insure stability during storage,
is also highly recommended. It is
important to check for hydrochloric acid deficiency, as Candida albicans
requires a pH of 7.4 for optimal growth
and is less likely to survive in an acid environment. Acid levels
can be increased by administering hydrochloric
acid, or by using herbs that increase secretion of hydrochloric acid.
Chinese herbs that inhibit candida growth
include phellodendron, mume, and capillarls.
OTHER CONSIDERATIONS
Food Sensitivities: A common response to foods for which a person is
sensitive is fatigue (36). The most
common food sensitivities are dairy (especially lactose), wheat and
corn (though other grains may be
problematic), eggs (especially the whites), and tomatoes. However,
any food eaten with enough repetition may
cause a reaction. Food sensitivities may have effects any part
of the body, and not just the digestive organs.
Although it Is unlikely that food sensitivities directly cause CFIDS,
they can play a role in suppressing the
immune system and aiding the perpetual exhaustion a person feels.
To test for food sensitivities, the RAST test
and the ELISA test (IgG, IgM) are considered reliable methods.
If food allergies are found, a six week
avoidance diet followed by a rotation diet is typical practice among
naturopathic physicians. The rotation diet
should be continued for several months.
Elimination of dietary components: In general, elimination or reduction
of caffeine (which decreases
lymphocytic response), alcohol (impairs cell-mediated immunity), and
refined sugar and flour (rapid absorption of
simple sugars causes insulin stress and secondary reactions) is beneficial
for persons with CFIDS (37).
Exercise: It is important to do moderate exercise, when possible.
This strengthens the body, increases the
blood flow, and decreases stress and fatigue. A regular routine
is best, concentrating on strengthening and
cardiovascular work-out.
Counseling: Emotional response to having any chronic illness may include
disorientation, depression, anxiety,
and sense of hopeless at times; with CFI DS, the pathophysiology of
the disease further reinforces these
responses. One needs to gain perspective that it is a disease
process that may require prolonged therapy, but it is
not a permanent condition. Counseling is an excellent way to
relieve the chronic stress of a long term illness. It
is a place to help one gather the tools necessary to deal with CFIDS,
to build a stress reduction plan, and to "let
out" the worries, fears, and anger about being chronically !II.
According to the principles of Chinese medicine, it
is believed that for the qi to spread evenly and nourish the body,
the emotions must also flow smoothly.
Bodywork: For many patients, regular acupuncture therapy beyond six
months is not appropriate, as a
physical therapy. Massage techniques such as shiatsu, jinshindo,
and lymphatic drainage are alternatives to
explore. Bodywork increases the blood circulation and helps move
the qi.
DIFFICULTIES IN EVALUATING TREATMENT RESULTS
There are a number of problems encountered in determining the impact
of the therapeutic interventions, such as
those described here. The difficulties fall into three categories:
1) Course of the disease. Because CFIDS usually resolves over
a period of a few years (a period which is
highly variable among the population observed thus far), it is difficult
to know whether the therapies applied are
responsible for any shortening of the disease period in a patient who
improves. Further, the manifestation of the
disease is highly variable over its course, with good days and bad
days (and good weeks and bad weeks), making
it difficult to know whether the change was due to the therapy applied,
a dietary or other factor that entered into
the picture at the time, or some variable inherent in the disease that
was relatively independent of intended or
unintended actions.
2) Compliance problems. CFIDS frequently involves problems with
memory, cognition, and emotional
stability. As a result, it may be difficult for persons with
CFIDS to comply with suggested protocols (including
use of herbs, nutritional supplements, dietary inclusion and restrictions,
etc.); even the reporting of compliance
may be Inaccurate. Further, many persons with CFIDS have visited
numerous practitioners and tried numerous
remedies previously in an unsuccessful attempt to quickly resolve the
symptoms experienced; in the expectation
of quick and reliable response from a skillful practitioner, long-term
compliance with a protocol may be
interupted by set-backs, even if the progress is otherwise deemed positive
by the practitioner. Additionally,
because the financial resources of the patient may have been squandered
on previous attempts at therapy or on
simultaneous self-medication (in hopes of guaranteeing success), the
individual may not be able to pursue the
recommended therapies for lack of funds.
3) Monitoring problems. CFIDS involves many symptoms that are
not easily monitored by objective means.
Fatigue, depression, pain, and sleep quality are all self-reported,
and even accepted surveys for these factors have
limited reliability unless applied to a large number of patients for
the purposes of statistical analysis. Practitioners
of Chinese medicine or naturopathic medicine are not trained in objective
clinical evaluation of responses to
therapies, which promotes the tendency to remember successes and dismiss
failures, or to attribute success or
failure to a particular intervention with no objective proof (as a
result, the literature commonly read by
practitioners of these medical arts is often filled with unsubstantiated
claims that can divert attention from the
needs of the patients). Monitoring by medical doctors may be
flawed by presumptions that a disease such as
CFIDS is not a real disease (38), because of the lack of a logical
causative factor and mechanism of pathology,
thus causing important data to be ignored. This problem is worsened
by the tendency of alternative medicine
practitioners to ascribe the symptoms to currently unrecognized causative
factors and mechanisms.
To minimize these difficulties, practitioners should obtain a thorough
history of the disease development plus
current laboratory reports, develop means of tracking compliance (e.g.
pill counts and diet diaries), use accepted
instruments for measuring disease status, and take care not to jump
to conclusions about the impact of medical
interventions or behaviors of the patient. While future medical
research will undoubtedly yield information about
the cause and pathological mechanisms behind CFIDS, such progress often
only serves to calm the agitation of
patients and practitioners about the course to follow, but with complicated
diseases like this, it rarely provides a
sudden solution. Therefore, a calm, reasoned, and directed approach
to this disease might just as well be
undertaken now.