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Resources and Links

Official Opinions Regarding Acupuncture

http://consensus.nih.gov/1997/1997Acupuncture107html.htm
National Institute of Health’s Consensus Statement on Acupuncture

http://www.who.int/topics/acupuncture/en/
The World Health Organization Viewpoint on Acupuncture

Related Articles

Can TCM help hypertension?

Traditional Chinese Medicine Treatment for Hypertension
Dr. Zhuoling Ren, T.C.M.D., The Edge/June 2001
Friday, June 01, 2001

John is a retired social worker who has suffered from hypertension for the past few years. His blood pressure is in the range of between 140/90 to 180/100. In western medicine, his hypertension was diagnosed between stage I and stage II. When beta-blockers and diuretics didn't work for him, John turned to Traditional Chinese Medicine for treatment.

To help with his blood pressure, I first needed to do a Traditional Chinese Medicine diagnosis, which is also called differentiation. John's blood pressure is unstable and it rises when he is stressed or nervous. He has headaches whenever his pressure is high and he suffers anxiety attacks, as well. He also becomes angry, irritable and has disturbed sleep. In addition, there is a history of overstress and strong emotional issues. John also has a red tongue with a yellowish thick coating and a rapid and taut pulse. If you are someone who has studied Traditional Chinese Medicine you should be able to tell the obvious: hypertension. John's hypertension is differentiated into excess of liver yang.

After Three Months
The treatment for hypertension is to reduce the liver heat and to calm liver Qi. After three months of treatment, John's treatment is down to 130/84 and stable. He no longer takes any medication and his emotions are also significantly improved.
Hypertension is a common disease. It may develop and cause dysfunction and organic changes of the brain, heart, and kidneys. Up to now, favorable and radical treatment has not been found in Western medicine.

Hypertension in Traditional Chinese Medicine is usually listed under vertigo and headache. Traditional Chinese Medicine's treatment has a gentle and stable effect. It may improve the symptoms, reduce the complications, reverse the impairment of target organs, and improve the prognosis. However, in many cases, the combination of Western medicine and Traditional Chinese Medicine treatment can help reduce the drug dosage in-take and also work to eliminate the side-effects of the drugs.

Far More Complex
Traditional Chinese Medicine believes the pathogen of hypertension is mainly related with the heart, liver, and kidney. Clinically, most of the cases are far more complex than John's condition, but commonly, five categories of differentiation are typical: heart yin deficiency, liver yang excess, kidney yin deficiency, Qi and blood stasis, and internal dampness and heat.

Nourishing yin, clearing the heart, removing stagnation, and expelling the dampness are common treatment principles. In addition to regular exercise and reducing stress, some suggestions about diet from Traditional Chinese Medicine are also helpful and practical: Light food with low salt, celery, radishes, corn, watermelon, bananas, persimmon, kelp, jellyfish, mussels, and honey are recommended. Avoid alcohol, because it lowers the systolic function of the heart but enhances the systole of the blood vessels, causing a rise of the blood pressure.

Again, for many severe conditions of hypertension, Western medicine treatment is necessary. Integrated Traditional Chinese Medicine and Western medicine could be the most beneficial way to treat hypertension and its complications.

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Does acupuncture help with weight loss?

Overweight and Obesity Treated by Traditional Chinese Medicine
Dr. Zhuoling Ren, T.C.M.D. , The Edge/June 2000
Thursday, June 01, 2000

More than 50% of the adult American population is affected by an overweight problem. Excess weight and obesity are related to many illnesses, such as diabetes, hypertension, dyslipidemia, coronary heart disease, stroke, osteoarthritis, sleep opnea, respiratory problems and more. Obesity is a chronic disease. It is associated with increased morbidity and mortality.

How does traditional Chinese medicine see an overweight problem and obesity? What can traditional Chinese medicine do for these conditions? Such questions have been brought up to me very often. Today, I would like to address this subject.

1. The Theory of the Cause
Like western medicine, traditional Chinese medicine also believes that eating disorder, physical activity, life style, depression, and stress, as well as heredity and some types of disease can all contribute to overweight conditions and obesity. Overweight and obesity can be classified into mainly three types by traditional Chinese medicine.

Type A: Excessive Internal Phlegm
Phlegm is an important concept in traditional Chinese medicine. It indicates not only mucus from cough or nose discharge. It also refers to stagnant body fluids. The excessive internal phlegm manifests itself as overweight accompanied by tiredness, body heaviness, chest and, or, stomach distention, and in some cases, poor appetite, etc.
This type of obesity is generally due to an eating disorder or secondarily by some other illness.

Type B: Stagnation of Qi and Blood
An overweight condition and obesity when accompanied by the following symptoms are considered a condition of Qi and blood stagnation: emotional disorder, irritability or low motivation, hopelessness, chest or breast fullness or insomnia, a dreamy state, menstrual disorder or skipping menstruation, and infertility. Some patients might also complain about headaches.

This type of obesity is due to stress, depression or an hormone disorder. Stagnation of Qi and blood usually slows down the metabolism. In this situation, the emotional condition and the physical condition often affect each other. Over eating to comfort one's emotion, or lack of exercise, also contribute to weight gain.

Type C: Deficiency of Spleen and Kidney Energy
Overweigh and obesity patients in this type often feel exhausted or fatigued, have lower back and knee weakness, shortness of breath or impotence, lost sexual interest, etc. Genetic factors can be one of the main reasons for this type. It can also be the result of other illnesses, overstress, or an unhealthy life style, etc.

2. Method of Treatment
Acupuncture
Acupuncture treatment can be used on all of the above types. The stimulating points and methods selected are determined by the diagnosis. Each type of patient needs a different focus. Each individual patient needs a specific treatment because some patients can have more than one type or a mixed type of disorder.
Auricular acupuncture can also be applied to weight control treatment. Needling or ear pressure can usually be used.

Chinese Herbs
There are several herbal formulas suitable for each type of overweight and obesity condition. However, I suggest individualized formulas for each patient. There are hundreds of herbs that can function in controlling weight. But for each patient, which herbs are most needed depends upon which treatment principle we want to treat; for example: to release Qi stagnation, to disperse phlegm, to remove blood stagnation or tonify spleen, or to nourish the kidney, etc.

Tuina Massage
This is a special massage for reducing local fat or promoting circulation or for relaxation. It is also designed for different conditions. Sometimes, external herbs can also be applied along with tuina massage.

Dietary Therapy
We all know that diet is essential for weight issues. The theory of traditional Chinese medicine dietary therapy considers several factors about one's diet. What to eat is most important: light, easy to digest food for those who have a spleen deficiency; foods that have a worm property and promoting movements of the stomach and intestine are recommended for those suffering from internal phlegm, etc. Traditional Chinese medicine dietary therapy not only suggests eating proper foods, it is also important to pay attention to an eating schedule, eating environment , herbs used in diet and more.

Exercise
Exercise can be difficult for some obese patients. Different types of exercise and different amounts of exercise are applied on an individual to individual basis. Many types of Qi Gong exercises are also helpful.

All of the treatment methods I have mentioned above can be used differently or combined. A comprehensive treatment and individualized treatment plan are strongly recommended. Our clinic recently design a program for treating overweight and obesity and is available to the public. Dr. Weixing Zhao, nutritionist Yuen Tsai and myself are working together to make this program beneficial to each of you. For more information you can contact our clinic at 651.222.1200.

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Does acupuncture work for allergies and asthma?

More Solutions Than an Antihistamine:
How Traditional Chinese Medicine Views Allergy
Dr. Zhuoling Ren, T.C.M.D., The Edge/October 1998
Saturday, August 01, 1998

The seasons are changing, the weather is changing, and so are you. For many people, though, this transition is miserable. Seasonal allergies afflict millions of people, causing them to suffer symptoms such as sneezing, running noses, itching eyes, headaches, skin problems, fatigue, and more. At times this reaction can be so severe as to affect personal lives and even job performance.

Is this a lifelong problem, only temporarily relieved by remedies from the drugstore shelf? Or can there be a permanent solution? Traditional Chinese medicine looks at seasonal allergies in a holistic manner, the same as all other ailments.

Why We Have Allergies
Traditional Chinese medicine views a person as a small universe, living within and interacting with nature, the large universe. Allergic reactions are triggered by the environment, an external cause; or by one's own body, an internal cause; or by a combination of both.

Traditional Chinese medicine sees the external factors being wind, cold, heat, dryness, and dampness. These come from nature, according to the seasons. Spring brings more wind, summer more heat and dampness, autumn more dryness and winter more cold. These factors can invade and affect one's body. People have ability to adjust to a changing environment. However, if the body's balance is damaged and we lose the ability to adjust, we cannot follow change. The small universe becomes unbalanced, is not in harmony with the large universe, and disease occurs.

Two seasons - spring with wind, and autumn with dryness - are the major allergy seasons. With some people, when winter gives way to spring, their bodies cannot adjust, and they are affected by the wind. The symptoms of allergic reaction follow. The autumn's change from the heat of summer to more coldness and dryness affects others. Sometimes the body hasn't cleared out the summer's heat, which combined with dryness, can bring on symptoms of allergy.

But why do some people have allergies, and others don't? The same external attack does not affect everyone the same. Some people have stronger immune systems, and are more resistant to outside imbalance (what traditional Chinese medicine calls devil energy, or devil Qi). Others have a weakness in the body and are more affected.

I have noticed in my practice in the U.S. that more Americans suffer from allergies, with more severe symptoms. They also tend to look at this as a normal condition. The seasons change and their allergies kick in. Perhaps this has evolved from the overuse and misuse of medicines and antibiotics, especially as children.

Children are more susceptible to seasonal changes. Their bodies are weaker, and their immune systems are not that strong. The solution is to get the body stronger. Children don't have to be given drugs if the symptoms are not that severe. Let their bodies fight and build up their own immune system. Western medicine too often intercedes and uses antibodies to do the work the immune system is supposed to do. If this is done repeatedly, it leaves the body's immune system weakened, and external factors relatively even stronger.

Treatment for Allergies
Traditional Chinese medicine treats allergies by helping the body clean out the problem and balance the internal environment. The patient must be examined to determine how much the symptoms are caused by internal conditions, and how much by external conditions. Then we must decide what we should do according to the patient's reaction.

Sometimes symptoms indicate dryness or coldness. For example, in autumn when the season is dry, people with a Yin deficiency tend to suffer allergic reactions. The internal universe has a lack of body fluids while the external has more dryness. The treatment is to help the patient regain Yin balance - create more body fluid - to help deal with the outside environment. This is achieved with acupuncture and Chinese herbs.

Other times, patients have conditions that complicate their allergies. They may have a digestive disorder, or be under stress, or be depressed. This should all be diagnosed, and the treatment should be all-inclusive, as traditional Chinese medicine is holistic and all systems are interrelated.

Prevention of Allergies
Sometimes people think prevention is taking an antihistamine or getting a shot in the early stages of an allergic reaction. This is not prevention; this is treating the symptoms. While it is possible to quickly relieve allergy symptoms, the problem remains and persistently returns. The best prevention is to bring the body back into balance and eliminate the allergy. This process can take time, and it is good to begin before the season starts. Whenever you begin, though, the goal is to permanently free you from allergic reactions.

The upcoming season, autumn, tends to attack the respiratory system. Allergic reactions common now involve the lungs and nasal passage. To help protect the lungs' energy, your diet should involve eating more warm foods, avoiding spicy food, and consuming enough fluids.

Here is a simple exercise you can do to help your lungs. Sit straight, staying relaxed, breathing evenly. Now crossing your legs, bend foward at the waist as much as possible. Using your hands to support yourself, raise your body upright, holding your breath. Repeat this action five times. This exercise not only regulates the qi of the lungs, but helps promote and reinforce the function of the lungs. Try to get outdoor exercise frequently. We react to the external conditions, so give your body a chance to get used to the change of seasons. The seasons change gradually, so being outdoors every day gives your body time to adjust.

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Does acupuncture work for arthritis?

A Better Answer for Arthritis: Acupuncture and More
Dr. Zhuoling Ren, T.C.M.D. , The Edge/December 2000
Friday, December 01, 2000

A few months ago, it was just before the Olympic Games . One evening I turned on the TV to "Larry King Live". That evening he was interviewing olympic athletes who were suffering from arthritis and a rheumatologist. I watched for a few minutes. There were questions about arthritis such as "Is it related to the weather or geographic environment?" The answer from the doctor was "No, there is no relationship between the weather, the geographic environment and arthritis." Another question was "Does diet help?"Again the answer form the doctor was "No." I was a little disappointed by those answers.

The biggest disappointment for me was that western medicine tells arthritis patients to: 1. Learn to live with it. And 2, you will have to rely on drugs forever. From my knowledge and experience, there are better answers to arthritis.

There are better solutions than resorting to drugs for arthritis. In this month's article I would like to introduce how Traditional Chinese Medicine sees arthritis and how acupuncture and Traditional Chinese Medicine can help.

In Traditional Chinese Medicine there is one syndrome called the Bi-syndrome. "Bi" literally means obstruction, stiffness, numbness. The main symptoms of Bi-syndrome are pain, soreness, stiffness and numbness of the tendons, muscles and joints. Sometimes there can be redness, swelling ,or a burning sensation or pain in the joints, limited motion, or paralysis of the limbs.

From the above symptoms description many kinds of arthritis can fit into the Bi-syndrome category: rheumatic arthritis, hypertrophic arthritis, rheumatoid arthritis, and rheumatic fever.

The Cause
Traditional Chinese Medicine describes the cause of Bi-syndrome in this way: "Bi-syndrome is produced by weak resistance and deficiencies of the nutrient and defensive Qi, complicated by the invasion of pathogenic wind, cold and dampness."
Prolonged residence in damp and/or cold environments, wading through water, abnormal weather conditions, and other factors can result in an invasion of the muscles, joints and meridians by wind, cold and dampness.

As a common disease, Bi-syndrome may occur in people of either sex and at any age and is more common in damp and cold geographic environments. But today, people change residences so frequently and so dramatically (for example: I'm here in Minnesota.) as to weaken the significance of geographic factor on the etiology of many diseases. But, for each individual, the geographic factor is still important.

Mild cases of Bi-syndrome may only show soreness and pain in a certain part of the body or in certain joints, which become aggravated when the weather changes. In severe cases, marked pain, soreness and swelling are recurring. This may lead to deformities of the joints, effecting the flexibility of limbs.

The Treatment
The treatment for Bi-syndrome was developed two thousand years ago. The principles of treatment are: To disperse cold, relieve pain, eliminate wind, and remove dampness. Acupuncture, moxibustion and Chinese herbal medicine formulas are the main methods. Since arthritis is so common, China has performed a great deal of arthritis research. Those herbs which have the function of dispersing cold and dampness, which have the function to eliminate wind and relieve pain, have been tested again and again. Which ingredients are the functional ingredients? How do they affect the body's immune system? How do they affect the rheumatic factor? Which are the powerful herbs? These are some of the subjects that have been researched in the last few decades.

There is ongoing clinical research on arthritis and acupuncture treatment, combined acupuncture and herbal medicine treatment, Traditional Chinese Medicine treatment combined with Western Medicine treatment. I cannot begin to list all of the achievements of research, but I can give a general impression. Introducing acupuncture and Chinese herbal medicine into arthritis treatment will increase the clinical results and eliminate the using of drugs and their side effects. For many cases, only using acupuncture and Chinese herbal medicine can control the symptoms and achieve the clinical cure for some arthritis.

In China, in terms of public knowledge about arthritis treatment, I'd say at least 85% of the arthritis patients know or have been informed about the effectiveness of acupuncture and Chinese herbal medicine. When I worked in the Acupuncture Department at Xiyuan Hospital, among my daily patients, there were about 10%, or more, who suffered from some kind of arthritis or Bi-syndrome.

Diet and the amount of exercise are also important matters. But again, each individual has a different condition. Each can be treated differently.

The Case
Andrea, female, aged 31. Andrea came to the China Institute of Traditional Chinese Medicine in August of 1999. She was suffering from severe joint pain, mainly in her fingers, shoulders, and knees. She was currently on prednisone and acetominaphin. She had a two month old baby and she was breast feeding. The pain was limiting Andrea from holding her baby, walking up stairs, and the pain waking her up at night. She had been diagnosed with rheumatoid arthritis ten years ago. Her rheumatologist suggested that she should be on stronger drugs but the drug could affect her milk. She wanted to continue breast feeding and, therefore, was looking for an alternative to drugs.

I prescribed a Chinese herbal formula and did acupuncture for her twice a week. After two treatments, the pain was relieved by 60%. Three weeks (six treatments) later, she could walk up and down stairs without pain. Two and half months later, the joint pain, redness and swelling were all gone. After discussion with her rheumatologist, Andrea stopped taking prednisone and acetominaphin.

In December, She had a blood test. The result came back normal. She continued acupuncture and Chinese herbal medicine treatment with me for about a year and during and after treatment her condition was under control. In other words, there are no significant symptoms recurring.

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Does acupuncture work for depression?

Acupuncture, Depression and Fatigue
Dr. Zhuoling Ren, T.C.M.D., The Edge/October 99
Friday, October 01, 1999

Depression and fatigue are two rather all too common conditions. When we consider mild depression, common symptoms can occur as mild sadness, anxiety, irritability, worry, lack of concentration and discouragement. In the case of severe depression, a loss of interest and pleasure (known as anhedonia), withdrawal from activities, and feelings of guilt can be found. Inability to concentrate, some cognitive dysfunction, anxiety, chronic fatigue, feelings of worthlessness, and loss of sexual drive will also manifest themselves.

Fatigue or lassitude is generally manifested as weakness, tiredness and overexertion, often accompanied by poor physical conditions, and inadequate quantity or quality of sleep. Undernutrition, stress, or emotional problems also cause fatigue.

From my clinic experience at least 50 percent of depression patients also experience fatigue and, vice versa, almost 50 percent of fatigue patients experience differing degrees of depression. But, certain illnesses can also cause both depression and fatigue, such as common diseases of the endocrine disorder (for example hyperthyroidism, hypo-thyroidism, and postmenopausal syndrome), cardiac diseases, cancer, etc. Alcoholism and drug side effects can also be a cause of depression and fatigue.

Since depression is a psychiatric condition and fatigue is a physical symptom in Western medicine, the relationship between these two conditions is not usually considered. There are no physical findings or laboratory tests that can be used to confirm the diagnosis of depression or fatigue. A person suffering from depression frequently will seek out help from a psychologist or psychiatrist, while going to their family practitioner for relief from fatigue. But from the view of traditional Chinese medicine there is a definite connection between them. Evidence of their connection can be found through the use of such traditional Chinese medicine diagnostic tools as pulse reading and tongue diagnosis, etc.

Early records show that traditional Chinese medicine had already diagnosed manic-depressive syndrome and developed a treatment plan two thousand years ago. In the Inner Canon of the Yellow Emperor, for instance, there is systematic description of the etiology, pathogenesis and treatment of manic-depressive syndrome . There is a section in which various kinds of irritability and insanity are said to belong to fire. The book also tells the story of the Yellow Emperor, who one day asked his physician, "What causes insanity?" Qi Bo, the physician, replied that it was a syndrome caused by disorders of Yang. The Yellow Emperor then asked how it might be treated, and Qi Bo told him that first, the patient should be made to stop eating. Once this was begun, a decoction of iron scale was to be administered.

Today, in traditional Chinese medicine, treatment for depression is not as simple as described in this ancient story. Traditional Chinese medicine sees the human body as a complex, whole universe of interconnections and relationships, one in which emotional conditions and physical states are connected.

In traditional Chinese medicine emotional balance is a major consideration for health. Emotional factors are very important and can never be ignored in diagnosis. Emotional and physical health can very significantly affect each other. Because emotional activities originate from Qi and blood in relationship with the internal organs, emotional stress can impair the flow and function of Qi and blood. The reverse is also important to note. The functional activities of Qi, blood and the internal organs can bring about relevant changes in the emotions.

Liver Qi stagnation and spleen Qi deficiency are typical diagnoses for depression and fatigue. Liver Qi stagnation refers to the inability of the liver to disperse Qi. Its clinical manifestations are depression, irritability, stuffiness in the chest, wandering pain with distension in the chest and lower abdomen, hypochondria, and frequent sighing, etc. Liver Qi stagnation usually results from emotional drama, abrupt mental irritation, long- term stress, or an invasion by other pathogens.

Spleen Qi deficiency shows up as an inability of the spleen to transport nutrients. Major symptoms are fatigue, lassitude of the limbs, low motivation, disinclination to talk. These symptoms are accompanied by digestive disorders: poor appetite, abdominal distension, diarrhea or loose stool, etc. Spleen deficiency is usually caused by improper diet, or other acute or chronic disorders and, emotionwise, is often caused by liver Qi stagnation.

Many patients wonder, "Was the depression caused by fatigue? Or, was the physical condition a result of depression?" As we briefly illustrated above, either can cause the occurrence of the other since the relationship between emotions, Qi, blood, and internal organs are so closely interrelated. Long-term stress, for instance, can cause an over-taxing of the function of one of the internal organs, which over time leads to a fatigue syndrome. And the reverse is equally true. This can be explained in traditional Chinese medicine theory. In the next issue, I will continue my discussion of acupuncture, depression and fatigue.

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Back Pain and Sciatica

Acupuncture Provides Long-Term Relief of Low Back Pain
By Michael Devitt, Managing Editor

Back pain is one of the most common reasons people see a health care provider. It has been estimated that up to 80% of the world's population will suffer from back pain at some point in their lives, with the lower back as the most common location of pain. Although most episodes of low back pain last less than two weeks, research has shown that recurrence rates for low back pain can reach as high as 50% in the first few months following an initial episode.1,2

While there is no definitive way to resolve lower back pain, the use of acupuncture to treat this condition has increased dramatically in the past few decades, based in a large extent to placebo-controlled studies that have validated it as a reliable method of pain relief. The results of a recent study published in the Clinical Journal of Pain3 provide further proof that acupuncture is a safe and effective procedure for low-back pain, and that it can maintain positive outcomes for periods of six months or longer without producing the negative side-effects that often accompany more traditional pain remedies.

Drs. Christer Carlsson and Bengt Sj˜lund of the Lund University Hospital in Sweden recruited 50 patients (33 women, 17 main) from a tertiary level pain clinic for their study. The median age of the participants was 49.8; each patient had been suffering chronic low back pain for a minimum of six months and had tried a variety of other therapies (such as corsets, nerve blocks, drugs and physiotherapy) to treat their condition, but to no avail.

Subjects were randomly assigned to a manual acupuncture group, an electroacupuncture group or a placebo group. Treatment sessions lasted a total of 20 minutes each and were delivered once per week for eight weeks, with the same amount of time and care given to all patients in each group. A followup treatment was given after two months, and a tenth and final treatment was given after an additional two months.

In the manual group, local points on the lower back and distal points on the lower limbs, forearms and hands were used. The number of needles used per patient increased from an average of eight during the first session to as many as 18 during the third or fourth session. Needles were stimulated three times during each session to attain de qi.
A slightly different protocol was used on patients receiving electroacupuncture. Patients in this group received manual stimulation only during the first few sessions, followed by electrical stimulation of four needles in the low back in subsequent sessions. A similar number of needles as used in the manual acupuncture group were inserted and activated by hand.

The placebo group was given mock stimulation using what the researchers termed an "impressive" -- but disconnected - stimulator attached to two large electrodes. The electrodes were placed on the skin over the most painful areas in the lower back. During mock stimulation, flashing lamps from the machine were displayed and made visible to the patient to give the illusion that treatment was being delivered.

Throughout the study, patients recorded pain levels and other measurements in small booklets called pain diaries. Among the variables measured were pain intensity (recorded twice daily on a visual analog scale from 0 to 100, 100 being severe as possible); intake of analgesics (recorded daily); sleep quality (scored on a scale of "good," "slightly disturbed by pain" or "badly disturbed by pain"); and activity level. These diaries were compiled and their results analyzed by a nurse practitioner at the end of the study.

In addition, assessments were performed by an independent observer who did not know which type of acupuncture each patient received. These assessments were taken at four intervals: baseline, one month, three months and six months after the treatment period. These assessments consisted of a clinical interview and physical examination, after which the observer classified the patient's pain as improved, unchanged, or worse.

"Significant" Changes Observed in Acupuncture Patients
Analysis of the pain diaries revealed "significant" differences between acupuncture and placebo patients at the one-, three- and six-month intervals following treatment, all of which favored acupuncture as a more effective form of pain relief. For example, in the acupuncture group, both morning and evening pain scores were lower than baseline measurements and continued to decrease for the duration of treatment. In the placebo group, however, pain scores were several points higher after one month than they were at baseline, and continued to remain higher than the baseline scores throughout the study.

Activity levels were also markedly improved in the acupuncture group. Fourteen acupuncture patients and seven placebo patients had been on sick leave (either part-time or full-time) prior to the start of the study. By the time the tenth acupuncture treatment was delivered, six of the acupuncture patients on sick leave had returned to part-time or full-time work; another six were retired but still reported improved activity levels. In comparison, only one patient in the placebo group showed an improvement in activity; another patient actually regressed to being put on full sick leave.

Furthermore, acupuncture patients experienced less episodes of sleep disturbance than their placebo-treated counterparts. Before the study, 30 acupuncture patients and 12 placebo patients reported sleep disturbances due to pain. The researchers reported that the sleep pattern was "significantly less disturbed after the treatment period" in the acupuncture group, but that there was "no significant difference in sleep disturbance" in the placebo patients.

Finally, total intake of analgesics dropped dramatically in the acupuncture group, but not the placebo group. At the start of the study, patients in the acupuncture group consumed an average of 31 pills per week; those in the placebo group consumed an average of 23 pills. At the six-month follow-up, the number of pills taken by placebo patients remained almost identical (21.5 per person per week), but had dropped more than 28% to 21.4 pills per week in acupuncture patients.

Independent examination by the blinded observer appeared to corroborate the patients' pain estimates. One month after the initial treatment period, 16 acupuncture patients (but only two placebo patients) were judged to be improved. After six months, 14 acupuncture patients (and only two placebo patients) were still improved. Both types of acupuncture worked effectively; of the 14 patients who showed improvement after six months, eight received manual acupuncture and six received electrical stimulation.

One interesting result of the study was that acupuncture appeared to be most effective in women. Of the 16 acupuncture patients judged to be "improved" at the one-month follow-up, 15 were women. At the six-month follow-up, all 14 patients who were still improved were women. The researchers were at a loss to explain this phenomenon, but hypothesized that it may be linked to estrogen receptors in the central nervous system.

Treatment Works Best with Specific Types of Pain
In their discussion, Carlsson and Sj˜lund stated that the trial "demonstrated a long-term pain-relieving effect of needle acupuncture compared with true placebo in some patients with chronic low back pain." To substantiate this claim, they highlighted several components that had been built into the study to help validate its results. Among them:
· Only acupuncture na€ve patients (those who had never received acupuncture before) were selected for inclusion;
· Patients were informed at the start of the study that the treatment might not be felt;
· An equal amount of time and care was spent on each patient from every treatment group;
· The placebo treatment used in the trial (mock stimulation) was preferred because, unlike sham acupuncture, needles were not inserted, which might have inadvertently skewed the results from the placebo group; and
· The independent observer who performed assessments was never made aware of which group each subject was in and specifically avoided asking any questions about the type of treatment subjects received.

Taken together, the researchers concluded that these factors "seem sufficient to establish a true placebo treatment in the current study." They added that based on their latest study, in conjunction with the results of acupuncture trials on other disorders, "there is now reasonable evidence that acupuncture has a clinically relevant pain-relieving effect on certain forms of chronic pain."

Carlsson and Sj˜lund also advised practitioners that just because acupuncture works on certain types of back pain, it may not produce the same results on every type. "It would be as correct to assess the effect of acupuncture on all types of pain," they observed, "as it would be to study the effect of common penicillin on all types of bacterial infections and calculate some form of 'average.'"

As to the specific type of pain, the researchers believe that based on previously published papers, acupuncture may be most effective for low back pain that is nociceptive (caused by an injury or disease outside the nervous system) in origin. Determining the cause of pain, they feel, is paramount to using a particular therapy for relief. As the scientists stated in their conclusion:

"Acupuncture does not seem to be a suitable treatment modality for neuropathic pain. However, the clinical use of acupuncture is sometimes indicated for the treatment of chronic nociceptive pain. Our study is the first to show that acupuncture may have a long-term effect on chronic low back pain superior to that of placebo · Therefore, it is vital that before acupuncture is applied, a thorough analysis of the pain condition is performed to preclude the indiscriminate, unnecessary, and costly use of this treatment technique."

References
1. Moffett JK, Torgerson D, Bell-Syer S, et al. Randomised controlled trial of exercise for low back pain: clinical outcomes, cost and preferences. British Medical Journal July 31, 1999;319(7205):279-283.
2. Nyiendo J, Haas M, Goodwin P. Patient characteristics, practice activities, and one-month outcomes for chronic, recurrent low-back pain treated by chiropractors and family medical physicians: a practice-based feasibility study. Journal of Manipulative and Physiological Therapeutics May 2000; 23(4):239-45.
3. Carlsson C, Sj˜lund B. Acupuncture for chronic low back pain: a randomized placebo-controlled study with long-term follow-up. Clinical Journal of Pain 2001;17(4):296-305.

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Knee Pain

Acupuncture Today
/ap, /200, Volume 0-1999, Issue
Acupuncture Relieves Knee Pain
Study Finds "Clear, Durable Effect" in Reducing Pain and Improving Function
By Michael Devitt, Managing Editor

According to the National Institutes of Health, more than four million people seek medical care for a knee problem each year.1 A leading cause of chronic knee pain, particularly in young adults, is patellofemoral pain syndrome (PFPS). The condition occurs most frequently in adolescents who participate in sports, and is one of the most common diagnoses given at orthopedic centers and sports medicine clinics worldwide.

Despite its prevalence, the contributing factors to patellofemoral pain syndrome are unclear. Although several studies have linked knee pain to certain physical activities, there seems to be no direct correlation between the level of pain and the degree of cartilage damage to one's knee, or to the amount of flexion or extension a person's knee experiences.2,3

To date, no single therapy has been shown to be completely effective in treating PFPS. However, acupuncture has shown promise in treating similar conditions such as gonarthrosis and osteoarthritis of the knee.4 In an effort to evaluate its effectiveness on PFPS, a team of researchers from Jensen Fysikalske Institutt in Bergen, Norway performed acupuncture on a group of 70 patients aged 18-45. Their results, which appear in the December 1999 issue of the Journal of Alternative and Complementary Medicine, show that acupuncture "may be an alternative treatment" for patients suffering from patellofemoral pain syndrome.5

The study's patients were randomly assigned into an acupuncture group or a control group. The acupuncture group consisted of 36 patients (20 female) with an average age of 29; the control group contained 34 patients (21 female) with an average age of 33.4.

All patients in the acupuncture group received treatment at the ST-34 and SP-10 points. Other points used included LE-5 and ST-35; SP-9 and ST-36; BL-17; BL-18; BL-20; BL-23; LI-4; and CV-4, depending on each patient's diagnosis. Treatment was administered by a licensed acupuncturist twice weekly for four weeks, with each session lasting between 20-25 minutes.

Patients were evaluated both before and after treatment using the Cincinnati Knee Rating System (CRS). The CRS measures symptoms of pain, swelling, giving way and function on a scale of 1-100, with a higher score meaning fewer signs of injury or pain symptoms. A variety of physical tests were also employed, including the Stairs-Hopple test, a quadriceps atrophy exam, and a visual analogue scale for evaluating pain.

Based on the researchers' findings, acupuncture appeared to have a dramatic effect on reducing knee pain and symptoms and improving function. Within six weeks, the CRS scores for patients in the acupuncture group improved between 4.2 and 11.9 points per category (see Table I).

Improvement in the acupuncture group continued far beyond the initial six weeks, the scientists noted. "The score continued to increase more in this group than in the control group for all scales during the 12-month observation time," they said, "and is significantly different from the results in the control group at 12 months after inclusion."

Table I: Patient knee results using the Cincinnati Rating System. The control group was not evaluated for CRS scores at six weeks after the start of the study.

The CRS scores were further analyzed for the clinical implications of each category. At the start of the study, two patients in the acupuncture group and one patient in the control group experienced no pain, or only occasional pain during rigorous physical activity. Twelve months after treatment, that number had increased to 14 patients in the acupuncture group, versus only three patients in the control group.

Similar results were found for improved knee function. Five acupuncture patients and four control patients reported no or only slight limitation to activity at the start of the study; those figures increased to 17 and seven, respectively, one year after treatment.

The researchers acknowledged that no placebo group was used in the study, reasoning that there is "no fully satisfying way" of designing an acupuncture placebo group. Because almost any needling of the skin may raise the body's endorphin levels or trigger other response systems, it was decided to use an untreated group as controls. As a result, the effect of acupuncture itself could not be evaluated, but rather "the effect for the patient of going to acupuncture treatment."

Nevertheless, the effect did appear to produce the desired results both patients and researchers were looking for - namely, decreased knee pain and increased knee function. While no definitive studies have shown a specific treatment for patellofemoral pain, the scientists concluded that "our study is one of the largest treatment studies on the syndrome, and it shows a clear, durable effect of acupuncture treatment in reducing pain and improving function for the patient."

References
1. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Questions and answers about knee problems. Available at www.nih.gov/niams.
2. Galanty HL, Matthews C, Hergenroeder AC. Anterior knee pain in adolescents. Clin J Sports Med 1994;4:176-181.
3. Karlsson J, et al. Eleven year followup of patellofemoral pain syndrome. Clin J Sports Med 1996;6:22-26.
4. Christensen BV, Iuhl IU, Vilbaek H, Bulow HH, Dreijer NC, Rasmussesn HF. Acupuncture treatment of severe knee osteoarthrosis. A long-term study. Acta Anesthesiol Scand 1992;36:519-525.
5. Jensen R, Gothesen O, Liseth K, Baerheim A. Acupuncture treatment of patellofemoral pain syndrome. J Altern Complement Med Dec 1999;5(6):521-7.

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Tension Headaches

Dr. Katz's Corner
Alejandro J. Katz, MD, OMD, LAc, QME
Tensional Headaches

Pain treatment is what acupuncture is used for most frequently. Within the different pain syndromes, headaches are the number one complaint that patients will have, either alone or in combination with other symptoms. Tensional headaches are the most common type, followed by migraines and sinusitis (9:1 ratio). The main symptoms the patient will complain of will be pain, tingling and/or burning of the occipital area (nape), top of the head, temporal area, forehead and/or face.

The usual treatment MDs will recommend is NSAIDs (non steroidal anti-inflammatory drugs), which often produce secondary effects (upper GI disorders) such as nausea, vomiting, heartburn and diarrhea. Another approach is physical therapy (massage and stretching exercises).

Some cases are resolved with the previously mentioned modalities, but some of the patients' symptoms will continue with little or no improvement, passing from the acute phase to the chronic phase (3+ months).

Compression of the greater occipital nerve (C2) by the trapezius and the lesser occipital nerve (C2-3) by the sternocleidomastoideus muscles is very common in neck injuries. Both nerves are superficial; that is why direct trauma or microtrauma (over time, repetitive motion) will cause muscle spasm (tightening) that in turn will irritate the nerve.

Exam of the area involved: The examination of the area is performed with the head flexed forward; the points are palpated with mild-moderate pressure in order to reproduce the patient's complaints (pain/numbness/burning or tingling, radiated from the neck toward the ear/skull/vertex/eye, following a GB or UB channel pattern).

The recommended points to be used are GB20, C2-C3-C4, bilaterally (when they are tender). C2-3-4 are extra points found on the upper trapezius muscle border, under GB20 at one inch intervals.

Technique used: Chinese acupuncture needles (#38 gauge).

Micro-current device: Acutron Mentor, biphasic, 150-200 microamps. The clips are attached directly to the needles.

Point combination: GB20, C2-3-4 (bilaterally, depending on the active points).
Secondary point combination: GB21 and TW15 to relax the upper trapezius muscle. The Acutron Mentor pads are located on top of the needles; the current used is 75 microamps, biphasic, for 25 minutes, at interferential #2, crossing the pads from GB21 to the contralateral TW15.

The treatment frequency is three times a week for 4-6 weeks. The acupuncture needles are inserted perpendicularly, with the microcurrent clips attached to the needles.

The Acutron Mentor clips (biphasic, with an output of 150-200 microamps for 20 minutes) are applied directly to the needles (GB20, C2-3-4). The use of microcurrent is in some cases subsensational (the patient does not feel the electric stimulation). In some cases, the sensation is a background tingling. In any event, the sensation should be comfortable, or there should be no sensation at all.

Within 6-8 treatments, the patient will able to feel the improvement: the frequency and/or intensity of the pain is reduced, and the pain medication is reduced or discontinued.

As I usually recommend in muscles disorders, the indication of the appropriate stretching exercises for the muscles involved will assist in a speedy recovery. In this case, the chin-chest and over-the-shoulder stretch will be performed three times a day, five times every series for 5-10 seconds, within a comfortable pull.

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Insomnia

Medical Acupuncture
A Journal For Physicians By Physicians
Volume 13 / Number 3
"Aurum Nostrum Non Est Aurum Vulgi"
Acupuncture and the Treatment of Insomnia
Judith R. Peterson, MD

ABSTRACT
Insomnia is commonly encountered in clinical practice; reportedly, with a prevalence of nearly 40% in certain populations. Although not commonly used for this condition, acupuncture may be helpful in the treatment of insomnia and has an excellent tolerability and safety profile. Increased awareness of the potential utility of acupuncture for the treatment of sleep impairment may result in improved patient care.

KEY WORDS
Sleep Disorders, Acupuncture, Insomnia

INTRODUCTION
Insomnia and sleep disturbances are commonly-encountered clinical problems in the outpatient setting. Insomnia may represent impaired sleep induction, the presence of sleep fragmentation, or non-restorative sleep.1 In a study of 218 patients in general outpatient facilities, nearly 40% complained of insomnia.2 Prevalence rates were higher among women and those 35-54 years old.2 Insomnia is commonly reported in patients older than 65 years. Approximately 13,000 such individuals older than 65 were surveyed by use of a clinical questionnaire,3 and more than a third of respondents reported insomnia.

PHARMACOLOGICAL TREATMENT
Sleep disruption complaints are often managed by the use of medications such as benzodiazepines and tricyclic antidepressants. Sedatives and oral hypnotics have high abuse potential and can be addicting. Tricyclic antidepressants may have intolerable adverse effects, including dry mouth, orthostatic hypotension, urinary retention, and cardiac conduction effects.

Many patients self-medicate. Melatonin is widely available and may be used in an attempt to normalize the sleep-wake cycle. However, there is a paucity of data on the long-term safety of melatonin. The pharmacodynamics and pharmacokinetics are not completely understood, and medication interactions with melatonin are not known. Theorized potential adverse effects, based on animal data, for the long-term use of melatonin include inhibition of reproductive function and delay of puberty.4,5

Other Modalities
Non-pharmacological interventions may attempt to change sleep hygiene, habits, or expectations. One study used cognitive behavioral therapy to improve sleep in a randomized, placebo-controlled trial achieving a 55.6% response rate with such interventions.6

Additional non-pharmacological interventions include "light therapy," a commonly used modality for seasonal affective disorder and sleep disruption. In an analysis of 83 patients with seasonal affective disorder treated with bright light therapy, Terman and Terman noted significant adverse effects: nausea was reported in approximately 16% of patients, and headache and shakiness were reported in more than 8%.7

ACUPUNCTURE TREATMENT
Acupuncture may be uniquely beneficial in the treatment of this common clinical problem. In a study by Lee,8 all patients reported severe insomnia as a chief complaint; no patient slept more than 3-4 hours per night. Seven auricular points were used in this study: Heart, Kidney, Adrenal, Sub-Cortex, Endocrine, San Chiao, and Shen Men. In addition to these standard 7 auricular points, Sympathetic, Occiput, and Gallbladder auricular points were added if reactive or tender. Treatment was 3 times per week with a typical duration of 10-12 initial treatments, followed by a 2- to 4-week observational period; 15 of 16 patients had regimens of 15 treatments or fewer; 1 patient received 28 treatments total. Lee reported that lidocaine injections into exclusively auricular points improved symptoms of sleep disorder in 15 of 16 patients treated. Therapeutic effects were still present 3 months following the conclusion of treatment.8

In a study of outpatients in his department, Fischer9 reported similarly encouraging results: 100% of patients treated for insomnia obtained benefit without recurrences within 18 months of follow-up. Montakab and Langel10 diagnosed 40 patients using Chinese traditional diagnosis and performed polysomnographic analyses of true acupuncture vs control needled patients. Objective change was noted and found statistically significant in the true acupuncture group.

Acupuncture has been found to be an effective therapeutic tool in the treatment of HIV-infected patients with sleep disruption syndromes. Sleep architecture is disrupted in all stages of HIV disease. In a study by Phillips and Skelton,11 sleep quality significantly improved with acupuncture treatment after 5 weeks. Participants in the study were screened with a self-report questionnaire for sleep disruption; only those with severe to moderate disruption were eligible. Wrist actigraph analysis (which detects motion and sleep monitoring at home), current sleep quality index as a self-report score, and a visual analog scale of pain rating were used to assess patient responses to treatment. Acupuncture was performed 2 times weekly for 5 weeks. Acupuncture treatment was individualized based on Traditional Chinese Medicine (TCM), and was reassessed during treatment. Auricular and body points were used. Statistically significant pre- and post-treatment values were noted for amount of sleep, time awake, and sleep quality.

DISCUSSION
Acupuncture prescriptions for insomnia will vary with the clinical scenario and the style of acupuncture practiced by the physician. Each patient must be assessed for clinical syndromes contributing to sleep disturbance that may require specific medical or surgical interventions, e.g., hypercaffeinism, hyperthyroidism, pheochromocytoma.1 Some general suggestions are found in the medical literature for acupuncture approaches in the treatment of insomnia. One author suggests Shen Men (HT 7) and An Mien (extra point) for an acupuncture prescription.12

Comparison studies of varying acupuncture styles for the treatment of insomnia represent an interesting research path yet to be vigorously pursued in peer-reviewed medical literature. Additionally, comparison studies of acupuncture and medication for the treatment of insomnia have not yet been published in peer-reviewed literature.

CONCLUSION
Acupuncture appears to be a useful treatment approach for a common clinical problem. In China, acupuncture is used most commonly in the treatment of pain disorders, similar to the use of acupuncture in North America. Acupuncture is also commonly used to treat insomnia in China, which is not true in North America.13 This is an area in patient care where acupuncture could be a beneficial addition to standard allopathic treatments. Clinicians should be aware that acupuncture is a potentially valuable adjunct in the treatment of this common clinical problem.

REFERENCES
1. Professional Guide to Signs and Symptoms. 3rd ed. Springhouse, Pa: Springhouse Corp; 2001:422-426.
2. Blais FC, Morin CM, Boisclair A, Grenier V, Guay B. Insomnia: prevalence and treatment of patients in general practice [in French]. Can Fam Physician. 2001;47:759-767.
3. Ohayon MM, Zulley J, Guilleminault C, Smirne S, Priest RG. How age and daytime activities are related to insomnia in the general population: consequences for older people. J Am Geriatr Soc. 2001;49:360-366.
4. Arendt J. Safety of melatonin in long-term use. J Biol Rhythms. 1997;12: 673-681.
5. Arendt J. Melatonin, circadian rhythms, and sleep [editorial]. N Engl J Med. 2000;343:1114-1116.
6. Morin CM, Colecchi C, Stone J, Sood R, Brink D. Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. JAMA. 1999;281:991-999.
7. Terman M, Terman JS. Bright light therapy: side effects and benefits across the symptom spectrum. J Clin Psychiatry. 1999;60:799-808.
8. Lee TN. Lidocaine injection of auricular points in the treatment of insomnia. Am J Chin Med. 1977;5:71-77.
9. Fischer MV. Acupuncture therapy in the outpatients-department of the University Clinic Heidelberg [in German]. Anaesthesist. 1982;31:25-32.
10. Montakab H, Langel G. The effect of acupuncture in the treatment of insomnia: clinical study of subjective and objective evaluation [in French]. Schweiz Med Wochenschr Suppl. 1994;62:49-54.
11. Phillips KD, Skelton WD. Effects of individualized acupuncture on sleep quality in HIV disease. J Assoc Nurses AIDS Care. 2001;12:27-39.
12. Lin Y. Acupuncture for insomnia and acupuncture analgesia. Psychiatry Clin Neurosci. 1995;49:119-120.
13. Xu X. Acupuncture in an outpatient clinic in China: a comparison with the use of acupuncture in North America. South Med J. 2001;94:813-816.

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Chronic fatigue
Acupuncture Today
March, 2002, Volume 03, Issue 03
Clinical Practice Issues
Bob Flaws, Dipl. Ac., CH, FNAAOM, FRCHM
Chronic Fatigue Syndrome

The disease category of chronic fatigue syndrome (also called chronic fatigue immune deficiency syndrome or CFIDS) has only recently entered the Chinese medical literature, where it has begun, in a number of patients, to replace the previously popular disease category of neurasthenia (shen jing shuai rou). Because chronic fatigue syndrome is such a recent entry into the Chinese medical literature, there is not much on this condition. However, it is a not uncommon diagnosis of patients coming to Western acupuncturists and practitioners of Chinese medicine given that we tend to be caregivers of last resort. Therefore, I am keen to collect anything I can find on chronic fatigue syndrome coming from the People's Republic of China.

In the November 2000 issue of the Zhe Jiang Zhong Yi Za Zhi (Zhejiang Journal of Chinese Medicine), there is an interesting article titled "Self-Composed Bu Gan Yi Qi Tang (supplement the liver & boost the qi decoction) in the Treatment of 46 Cases of Chronic Fatigue Syndrome" by Zhu Guang-wen.1 A summary of what I find to be the salient features of that article is given below.

Cohort Description
Among the 46 patients in this study, 31 were male and 15 were female. These patients ranged in age from 19-44. Their clinical symptoms included a long period of extreme fatigue; a wan effect; emotional depression; insomnia; impaired memory; occasional sighing; scanty qi and a disinclination to talk or faint voice; no thought for food and drink or indigestion; flabby muscles; lack of strength; possible muscle-joint soreness and pain; heart palpitations; shortness of breath; and an inability to recuperate. After various sorts of examination, organic disease had been ruled out.

Treatment Method
Self-composed bu gan yi qi tang consisted of 30g each of radix astragali membranacei (huang qi); herba agrimoniae pilosae (xian he cao); and bulbus lilii (bai he); 10g each of radix rubrus panacis ginseng (hong shen); fructus corni officinalis (shan zhu yu); radix bupleuri (chai hu); fructus citri aurantii (zhi ke); pericarpium citri reticulatae (chen pi); and radix angelicae sinensis (dang gui); and 12g each of rhizoma actractylodis macrocephalae (bai zhu) and radix albus paeoniae lactiflorae (bai shao). If there was a tendency toward heat, rhizoma coptidis chinensis (huang lian) and radix scutellariae baicalensis (huang qin) were added. If there was yang vacuity, herba epimedii (xian ling pi) and rhizoma curculiginis orchiodis (xian mao) were added. If there was torpid intake, massa medica fermentata (shen qu), fructus crataegi (shan zha) and fructus germinatus horedi vulgaris (mai ya) were added. If there was insomnia and heart palpitations, radix sophorae flavescentis (ku shen) and stir-fried semen zizyphi spinosae (suan zao ren) were added. Ten ji equaled one course of treatment. Treatment consisted of 1-3 courses.

Treatment Outcomes
Thirty-five (76.09%) out of 46 patients were judged cured, which meant that their symptoms completely disappeared. Eleven patients (23.91%) improved, meaning that their clinical symptoms lessened. Thus, the total effectiveness rate was 100% using this protocol.

Discussion
In his discussion, Zhu Guang-wen presents an argument for the diagnosis of liver qi vacuity as the main Chinese medical disease mechanism of this disease. Personally, I find Zhu's use of this pattern an unnecessary terminological obfuscation. In my reading of the Chinese medical literature, the overwhelming majority of Chinese medical textbooks on pattern discrimination do not even mention a liver qi vacuity pattern. Because it is a statement of fact in Chinese medicine that "the liver commonly has a surplus," typically, the term "liver qi" is used as a contraction for liver depression qi stagnation. If one looks at the above formula as well as the patients' signs and symptoms, it is clear that they suffered from a liver-spleen disharmony. This means a combination of liver depression and spleen vacuity. Spleen vacuity symptoms included fatigue; lack of strength; disinclination to speak or faint, weak voice; shortness of breath; no thought for eating or drinking, or indigestion (after meals); and flabby, atonic muscles and flesh. The symptoms of liver depression were emotional depression and periodic sighing. Because the spleen is the latter heaven root of qi and blood engenderment and transformation, spleen vacuity has led to a heart qi and blood vacuity as evidenced by symptoms of heart spirit nonconstruction and malnourishment, including insomnia and impaired memory. Liver blood vacuity resulted in muscle-joint soreness and pain due to malnourishment of the sinews.2

This reading of the signs and symptoms given by Zhu as characteristic of his chronic fatigue patients is borne out by an analysis of his formula. Huang qi, xian he cao, hong shen and bai zhu all supplment the spleen and boost the qi. Contemporary Chinese materia medica, such as Bensky and Gamble's Chinese Herbal Medicine: Materia Medica, do not list any Chinese medicinals that specifically supplement the liver qi. Together, chai hu, zhi ke and chen pi course the liver and rectify the qi. Dang gui and bai shao supplement the blood, thus nourishing the heart spirit above and harmonizing and emolliating the liver below. Bai he nourishes heart blood and yin and thus quiets the spirit. Shan zhu yu is an astringing medicinal, but it also supplements liver blood and kidney qi. Hence, it is sometimes also said to fill the essence and invigorate yang. Since the former and latter heavens are mutually rooted, its inclusion in this formula helps make the formula more harmonious and holistic.

Virtually all the patients with CFIDS I have treated over the last 20 years have had a liver-spleen disharmony sitting squarely in the middle of their Chinese disease mechanisms. As Zhu's protocol shows via its various additions, this central disease mechanism may then be complicated by any of a number of other related disease mechanisms. Zhu lists (depressive or damp) heat, food stagnation and yang vacuity as commonly seen complications. From my own clinical experience, I would add phlegm dampness, yin vacuity, vacuity heat and blood stasis, and other commonly seen complications. Because there is often a defensive qi vacuity ultimately due to spleen vacuity, there may also be lingering external evils in the exterior, or deep-lying evils in the blood aspect or division.

If there is concomitant dampness, I would add sclerotium poriae cocos (fu ling) and rhizoma pinelliae ternatae (ban xia), at least as a being, to Zhu's formula. If there is yin vacuity, I would probably choose between fructus lycii chinensis (gou qi zi), fructus ligustri lucidi (nu zhen zi), fructus schisandrae chinensis (wu wei zi), cooked radix rehmanniae (shu di) and processed radix polygoni multiflori (he shou wu). If there is vacuity heat, I would probably add rhizoma anemarrhenae aspheloidis (zhi mu) and cortex phellodendri (huang bai). If there is blood stasis, I might choose between radix rubrus paeoniae lactiflorae (chi shao), radix salviae miltiorrhizae (dan shen), cortex radicis moutan (dan pi) or herba leonuri heterophylli (yi mu cao). If there were lingering wind evils in the exterior, I would probably first think of adding radix ledebouriellae divaricatae (fang feng), while for warm evils hidden or deeply lying in the blood, I would probably consider radix lithospermi seu arnebiae (zi cao), flos lonicerae japonicae (jin yin hua), fructus forsythiae suspensae (lian qiao), herba taraxaci mongolici cum radice (pu gong ying) and/or radix isatidis seu baphicancanthi (ban lan gen).

In closing, I would like to comment on the fact that I find two medicinals chosen by Zhu quite interesting in the context of CFIDS. They are bai he and xian he cao. Bai he is Zhang Zhong-jing's flagship medicinal for lily disease. The symptoms of lily disease are a restless or disquieted spirit; taciturnity and little speech; a desire (but inability) to eat; a desire (but inability) to move; a desire to sleep but inability to eat; and a tendency to vomit up Chinese medicinals that otherwise appear appropriate for the patterns at hand. Patients with lily disease appear to have a normal body and do not look obviously diseased. Bai he is one of the spirit-quieting medicinals favored by the gu worm school of Chinese medicine, and many patients with CFIDS have been told by other practitioners that they have intestinal dysbiosis, candidasis, parasites or leaky guy syndrome. Along these same lines, it is interesting to note that xian he cao also kills worms or parasites at the same time it stops diarrhea.3 At least four other medicinals in this formula were favored by gu worm practitioners: chai hu, dang gui, bai shao and chen pi. According to Heiner Fruehauf, gu worm conditions are characterized by a combination of mental-emotional disorders, musculoskeletal disorders (e.g., chronic soreness and pain and wilting) and digestive disorders4 -- just the sort of combination of symptoms Zhu describes in his article on chronic fatigue syndrome.

References
1. Zhu Guang-wen. Self-composed bu gan yi qi tang in the treatment of 46 cases of chronic fatigue syndrome. Zhe Jiang Zhong Yi Za Zhi (Zhejiang Journal of Chinese Medicine) 2000;11:476.
2. I have seen one other article on liver qi vacuity in the Chinese medical journal literature. In that case as well, the signs and symptoms of liver qi vacuity were really only a combination of liver depression plus spleen vacuity.
3. Here we are talking about the Chinese medical concept of worms or parasites (chong), not their Western medical counterpart.
4. Fruehauf H. Driving out demons and snakes: gu syndrome and a forgotten clinical approach to chronic parasitism. Journal of Chinese Medicine 1998;5:10-17.

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