中匿 TRADITIONAL CHINESE MEDICINEFibromyalgia (FMS) - A Chinese Medicine Perspective

B\ Dagmar Riley Dip. TCM

Fibromyalgia is a chronic conditioncharacterised by fatigue , pain in themuscles, ligaments and tendons, andmultiple tender points on the body. Whilethe exact cause remains unknown , thereis 巴vidence that people with fibromyalgiamay be mor巴 sensitive to pain because ofa malfunction with the body's usual painperception processes. More women than

men havefibromyalgia. Fibromyalg悶， whiledifferent for everyone who has it , tends tocome and go throughout life. Althoughit can be debilitating for some peop悟， itis not degenerative or life-threatening ,

and symptoms can be managed withprofessional and self care

Signs and Symptoms• Widespread pain and sti仟ness

. Tender points throughout the body

• Fatigue or trouble sleeping• Paraesthesia (tingling)

2

Western Drug TherapiesYour Patients presenting with fibromyalgia(FMS) may already be taking some of thefollowing drugs

. Low doses of tricyclics or SSRI's.

• Analgesics e.g. non-steroidal ant卜

inflammatory drugs (NSAIDs)

• Muscle relaxants.

• Pain in specific spots in muscles maybe treated with lidocaine or procaine(injected into points where pain isgreatest) or with capsaicin (usedtopically).

Pattern DifferentiationsFibromyalgia is not recorded in traditionalTCM literature. Although modern TCMliterature tends to classify fibromyalgiaas a type of bi syndrome (impedimentsyndrome) , FMS has its own unusualcharacteristics , such as a complicatedand varied symptom pictur巴 and theinvolvement of a wide range of organs andlocations in the body. Hence, treatmentapproaches di仟er considerably. Mostpattern differentiations, however, stressthe involvement of the liver as shown inthis pattern differentiation by Or Liu YingChun of the TCM department, Xian CityNumber Five Hospital' (refer to the casestudies belowfor examples of how patientswith these patterns may present)

• Liver depression and spleen vacuity.Formu旬 : Xiao 冶o San [Bupleurum&. Dang Gui Formula] adding YuanZhi [Polygal 訓， Long Yan Rou [Arilluslongan] and Ye Jiao Teng [Polygonum

stem] to nourish the heart and calmthe spirit , and Xiang Fu [Cyperus] tocourse depressed liver qi

.Liver depression transforming into fire ,

phlegm heat. Formula: Wen Dan Tang

[Bamboo &. Hoelen Combination] ,

adding Wu Zhu Yu [Evodia] as it entersthe liver and spleen channel , coursesthe liver and downbears qi , and alsodries dampness and transformsdampness, Chuan Xiong [Cnidium]quickens blood , and Shi Chang Pu[Acorus] opens the orifices, diffuses qiand eliminates phlegm

• Enduring liver qi depression damagingyin , liver kidney yin deficiency.Formula: Liu Wei Di Huang Tang

[Rehmannia Six Combination] addingXuan Shen [Scrophularia] , Mai MenDong [Ophiopogon] , Tian Men Dong[Asparagus] to supplement yin andclear vacuity heat , Dang Gui [Angelicasinensis] to nourish yin and bodyfluids , benefit qi and engender blood ,

Wu Wei Zi [SchizandraJ. Zhen Zhu Mu[Concha Margaratiferae] and Zhu Sha[Cinnabar] to strongly calm the spiri t,clear liver heat and subdue liver yang ,

Suan Zao Ren [Zizyphus] , He HuanPi [Albizzia] to nourish the heart andcalm the spirit

. Liver depression qi stagnation, bloodstagnation. Formu怡 Chai Hu Shu

GCi n Tang [Bupleurum & CyperusCombination] and Tao Hong Si Wu

Tang [Persica , Carthamus & DangGui Combination] with additionsφ 泊。

HangSiW，υ 芯ng consists of Si Wu Tang[Dang Gui Four Combination] plusTao Ren [Persica] a鬥 d Hong HuarCa吋hamus]. Additions are Bai He[Lily] and Bai Zi Ren [Biota] to nourishthe heart calm the spirit and improvesleep

Although Flaws and Sio門 neau provide adifferent pattern differentiation2 in theirbook 'The Treatment of Modern W巴stern

Medical Diseases with Chinese Medicine'(Blue Poppy Press) , they agree that liverspleen disharmony is the core pattern

of FMS, although rarely the only diseasemechanism , The authors also note that'damp heat complicates most if not allcases of FMS' ,3 and that in the treatmentof FMS 'pri mary attention shou Id be givento insomnia , Much of the body pain tendsto disappear on its own if the patient'ssleep can be improved , '3

Spirit calming medicinals often added tobase formulas to treat insomnia are:

• Mu Li [Oyst 巴 r Shell]: Calms the spiri t,boosts yin and subdues yang , but alsotransforms phlegm and is also used tosoften hardness and dissipate binds

. Long Gu [Dragon Bone]: Calms thespiri t. Calms the liver and subduesyang

• Suan Zao Ren [Zizyphus]: Calms thespi ri t. Su pplements hea吋 and liverblood , constrains sweat

• Bai Zi Ren [Biota]: Calms the spiritSupplements heart qi , nourishes heartblood , Also moistens the intestin巴S

• Ye Jiao Teng [Polygonum Stem]: Calmsthe spiri t. R巴gulates yin and yang of thebody and is suitable for liver-kidney yindeficiency with exuberant yang , Alsodispels wind and frees the networkvessels , and is used in impedim 巴 nt

pain

• Yuan Zhi [Polygala]: Calms the spiritpromotes hea吋-kidney interactionAlso dispels phlegm and op巴ns theorifices

Clinical Studies on (J ia Wei) Xiao Yao Sanin the treatment of FibromyalgiaIn a recent study, Xiaa 冶a San Jia Jian[Bupleurum &Dang Gui Formula Modified]was used in 56 cases of fibromyalgia toobserve the clinical therapeutic effectof the treatment strategy ‘ sooth巴 the

Iiver and strength巴 n the spleen' onfibromyalgia , Subjects were divided intogroup A (prima門， FMS n=38) and group B(complicated by rheumatism , n=18) andtreated with modified Xiao Yao San for 12weeks:

Formula (all quantities referring to raw

herbs): Dang Gui [Angelica sinensis]

10 g, Bai Shao [Peony] 20 g, Chai Hu

[Bupleurum] 10 g, Gan Cao [Li corice]10 g, Fu Li ng [Hoelen] 15 g, Bai Zhu

[Atractylodes , white] 10 g, Huang Oi

[Atractylodes] 20 g, Gui Zhi [Cinnamon

twigs] 10 g,Xiang Fu [Cyperus] 10 g, Chuan

Shan Jia [sq manthis pentadactylis] 10 g

Additional modifications

Red tongue and strong vexation and

ag itation: Mu Dan Pi [Moutan] 10 g, Huang

Oin [Scute] 10 g

Insomnia, palpitations and dream

disturbed sleep: Suan Zao Ren [Zizyphus]

15 g , Ye Jiao Teng [Polygonum stem] 15 g

Resul t: The effective rate was 92 , 11% in

group A and 72 , 22% in group B (pain ,

pressing pain , rigidity, fatigue and

insomnia improv巴d significantly)

In another trial , Jia Wei Xiaa Yaa San[Bupleurum & Peony Formula] with

modifications was used in 27 cases offibromyalgia , 5

Formula (all quantities referring to raw

herbs): Dang Gui [Angelica sinensis] 10 g ,

Bai Shao [Peony] 10 g, Bo He [Mentha]

9 g , Chai Hu [Bupleurum] 10 g, Sheng

Jiang [Ginger] 5 slices , Gan Cao [Li corice]

10 g, Fu Ling [Hoelen] 15 g, Bai Zhu

[Atractylodes] 10 g, Shan Zhi Zi [Gardenia]

10 g , Mu Dan Pi [Moutan] 10 g , Added

Xiang Fu [Cyperus] 10 g, Chuan Xiong[Cyperus] 10 g

Additional modifications

Scurrying pain throughout the body

(wanderi ng pai n, due to eitherq i stag nationor wind evil): Oiang Huo [Notopterygium] ,

Fang Feng [Siler] , Oin Jiao [G巴 ntiana

macroph]

Symptoms of dampness: Yi Yi Ren [Coix] ,

Cang Zhu [Atractylodes]

Resul t: Out of 27 cases , 16 were cured

(59 , 3%) , 6 experienced a significantimprovement (222%) , 3 improved (11 , 1%)and 2 experienced no resu It (7 .4%),

Case Studies6

liver depression and spleen vacuity

Mrs Sun , 39 years old , Symptoms: Sincethree years she experiences breast rib­side and stomach duct oppression andpain that repeatedly changes location , Thisis accompanied by muscle and joint pain

at multiple locations over the whole body,

all of which repeatedly change locationThe above symptoms are aggravated byemotional stress , Abdominal pain anddiarrhoea upon consumption of evensmall quantities of greasy food , The patient

is easily angered , rash and impatient

She was diagnosed with FMS and givenpainkillers that worked at first , butthen thecondition worsened again and she soughtTCM treatment. At the first appointment

she also complained of insomnia andprofuse dreaming , diarrhoea, a string-like

and slippery pulse , a red tongue with teethmarks and a thin greasy coating

TCM diagnosis: Li ver depression and qivacuity

Treatment strategy: Course the liver,strengthen the spleen and harmonise thestomach

Formula (all quantities referring to raw

herbs): Chai Hu [Bupleurum] 10 g, Bai

Shao [White Peony] 15 g , Zhi Gan Cao[baked Licorice] 5 g , Fu Ling [Hoelen]15 g, Bai Zhu [Atractylodes, white] 10 g,

Zhi Ke [Citrus , ripe] 6 g, Bai Bian Dou

[Dolichos Seed] 15 g , Xiang Fu [Cyperus]

10 g, Fo Shou Pian [Citrii Sarcodactylis] 6 g,

Yi Yi Ren [Coix] 30 g, Tai Zi Shen [RadixPseudostellariae] 15 g, Mei Gui Hua [FlosRosae Rugosae] 3 g, LLi Mei Hua [Prunus

mume] 10 g, Bai Ji Li [Tribulus] 15 g, JiangCan [Silkworm] 10 g, Si Gua Luo [Luffa]

15 g , Fu Xiao Mai [Wheat] 30 g

After seven doses her diarrhoea and sleephad improved , Shan Yao [Dioscor 巴a] 30 gand Tal Zi Shen [Radix Pseudostellariae]

40 g were added to above prescriptionand the patient advised to take another 21

doses, after which she reported that thepain had almost completely gone , and thather spirits , appetite and sleep were normalShe was asked to take the prescription for

another month to stabilise the result , afterwhich all symptoms had gone , At a check­

up six months later she was feeling welland her condition had not relapsed

Sun Ten Newsletter SUIηmer 2008 3

Enduring liver qi depression damagingyin, liver kidney yin deficiencyMrs Ye , 50 years old , Symptoms: For sixyears she has had muscle pain alloverthe body，的r the last two years this painbecame severe and was accompaniedby insomnia , Other symptoms: Dizzinessand flowery vision , tinnitus , forgetfulness ,

pain and weak們ess ofthe lumbar area and

knees , lack of strength , irritability, heatin the palms and soles , dry thro訓， nightsweats, constipation , normal appetite, redtongue with little coating , thin rapid pulseHistory of diabetes and hypertension

TCM diagnosis: liv巴 r-kidney yin vacuityTreatment strategy: Supplement liver andkidney yin , harmonise the liver,

Formula (all quantities referri 門g to raw

herbs): Tian Ma [Rhizoma Gastrodiae] 6 g,

Gou Qi Zi [lycium fruit] 30 g, Gou Teng[Gambir] 15 g, Bai Shao [White Peony]15 g, Zhi Gan Cao [baked licorice] 5 g,

Shi Hu [herba dendrobii] 15 g, Huang Lian[Coptis] 3 g, Suan Zao Ren [Zizyphus] 30 g,

Sha Shen [Glehnia] 30 g, Mai Dong[Ophiopogon] 10 g, Jiang Can [Silkworm]10 g, Si Gua luo flu仟a] 15 g, Ye JiaoTeng [Polygonum Stem] 30 g, Fu XiaoMai [Wheat] 30 g, Tai Zi Shen [RadixPseudostellariae] 30 g, Fo Shou Pian [CitriiSarcodactylis] 6 g, lu Mei Hua [Prunusmume] 10 g

After taking this prescription for onemonth , the muscle pain was significantly

reduced , Th巴 patient continued taking theprescription unaltered for another twomonths, after which all her symptoms haddisappeared ,

Liver depression qi stagnation, bloodstagnationMrs Chen , 32 years old , Symptoms:Distending pain in the hypochondrium,

breasts and abdomen , Pain and numbnessin the neck, back and extr巴 mities ， includingmuscles and joints , After several tests sheis diagnosed with FMS , Despite WesternMedicine tr巴atment， the symptoms getwors巴 and she now also suffers fromdepression , at which point she seeks helpin the TCM department.

Additional symptoms: Prolonged menstrualcycle , scanty flow, dysmenorrhoeaConstipation , insomn 悶， string-like pulse,

thin coating ,

TCM diagnosis: Bi syndrome, liverdepression qi stagnation , impaired flow ofqi and blood ,

Treatment strategy: Course the liver andresolv巴 depression ， rectify qi and alleviatepain , harmonise the stomach

Formula (all quantities referring to rawherbs): Chai Hu [Bupleurum] 10 g, BaiShao [White Peony] 15 g, Zhi Gan Cao[baked licorice] 5 g, Xiang Fu [Cyperus]10 g, Fo Shou Pian [Citri i Sarcodactyl is]6 g, Bai Ji li [Tribulus] 15 g, Jiang Can

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after which her abdomin訓， chest and rib­side pain is alleviated , and her joint andmuscle pain is slightly alleviated , She isstill constipated and her sleep is dream­

disturbed , Bai Zi Ren [Biota] 15 g andYe Jiao TI巴 ng [Polygonum stem] 30 g ar巴

added to the above prescription and shetakes it for one month , after which herpain is almost gone, and her sleep andstool are normal , Her p巴 riod is now pain­free , She is then put on ready-made Xiao冶o Wan [Bupleurum &Dang Gui Formula]to stabilise th巴 result. At a follow-upconsultation after six months she is stillhealthy with no r巴 lapses ，

ConclusionThe above CI inical studies and case studiesare good examples of how a base formulamay be modified in the treatm巴 nt of FMSThe high flexibility of TCM theory and itsabi Iity to deal with disorders and sym ptom

pictures without clinical precedent makeit suitable to treat the varied symptompicture of FMS with good results andwithout side- effects

References available on request.