Class 5: Fibromyalgia, Chronic Fatigue Syndrome (CFS), Multiple Sclerosis (MS)

1. Class 5: Fibromyalgia, Chronic Fatigue Syndrome (CFS), Multiple Sclerosis (MS) Xianhui Li

2. Fibromyalgia • Fibromyalgia is a clinical state of chronic, widespread musculoskeletal aches, pain and stiffness, soft tissues tenderness, general fatigue and sleep disturbances. • The most common sites of pain include the neck, back, shoulders, pelvic girdle and limbs, but any body part may be involved • It is estimated that approximately 3 to 6% of the population are suffering of Fibromyalgia. • It affect more woman than man.

3. Western Diagnosis of Fibromyalgia • Widespread pain in all four quadrants of the body for a minimum duration of 3 months • Tenderness or pain in at least 11 of 18 specified tender points when pressure is applied • American College of Rheumatology: • ----patient has experienced widespread aching for at least 3 months • A minimum 11 locations of pain that are abnormally tender under relatively mild,firm pressure • Widespread pain lasting at least 3months

4. Western Medical Treatment of Fibromyalgia • As with any other symptoms, there is not an accepted cure for Fibromaligia. Treatments involved the management of the symptoms. • The treatments include prescription medications (analgesic, antidepressant, non-steroidal anti-inflammatory medications), exercise and stretching, counseling, and dietary treatment. • Janet Travell’s Trigger points

5. Fibromyalgia in TCM • Etiology • ---- Invasion of external pathogenic factors (Dampness, Wind, Cold) • ---- Emotional stress • ---- Irregular diet • ---- Excessive physical work • Pathology • Full: • ---- Dampness • ---- Qi stagnation • ---- Blood stasis • Empty: • ---- Spleen-Qi or Spleen-Yang deficiency • ---- Spleen and Kidney Yang deficiency • ---- Liver-Blood deficiency • ---- Liver and Kidney Yin deficiency

6. Pattern Identifications • Acupuncture Today • Acupuncture and Traditional Chinese Medical Approaches for Fibromyalgia • By Douglas Yi Wang, LAc, Dipl. Ac., MD (China) • http://www.acupuncturetoday.com/archives2005/mar/03wang.html

7. Special Acupuncture Points • Ashi points: Use any tender points (18 tender point sites) • Headache (includes migraines): • For frontal/temple headache, GB 14, tai yang and yin tang or er zhong (above yin tang, in line with GB14). • For vertex headache: Du 20 and si shen cong. • Occipital headache: UB10, DU17 and GB20. • Neck pain: UB 11, GB 20 and bai lao. • Shoulder pain: LI 15, and two experienced points: point A, 2 cun anterior to LI 15 under the clavicle, and point B, 2 cun posterior to LI 15 on the back (half way between SJ 14 and LI 16). • Arm pain: LI 11, SJ 5 and LI 4. • Upper back pain: UB 11, UB 17, SI 12 • Lower back pain: UB 23, UB 25 and UB 52 • Leg pain: ST 36, SP 6, GB 30 • Thigh pain: SP 10, SP 11/ST 31 and ST 32

8. Common Patterns ---- Acupuncture Today • 1. Liver Qi Stagnation - anxiety, emotional upset, headaches (including migraine headache), being easily angered, muscle stiffness in neck and shoulders, insomnia, waking frequently and having difficulty falling back to sleep, irritable bowel syndrome. All symptoms may be triggered by emotional stress. • Tongue: slightly dusky or slightly puffy • Pulse: wiry/bowstring or slippery • Treatment plan: smooth liver, move qi and blood • Chinese medicine: modifications based on xiao yao wan or shu gan wan • Acupuncture points: yin tang, LI 4, LV 3, GB 34, an mian, ren 17, ren 12, ST 25, SP 6, UB 18, 19, and 20 • Ear points: shen men, liver, sympathetic

9. 2. Qi and Blood Deficiency - specifically spleen qi deficiency and heart blood/liver blood deficiency, with such symptoms as chronic fatigue, exhaustion, dull headache, muscle weakness and numbness, insomnia, dream-disturbed sleep and waking up tired, palpitations and depression. • Tongue: pale, with thin white fur • Pulse: thready, weak and deep. This pattern eventually creates pattern #3 below. • Treatment plan: tonify qi and blood, calm the spirit • Chinese medicine: modifications based on ba zhen tang or gui pi tang or gan mai da zao tang • Acupuncture points: LI 4, ST 36, ren 12, SP 6, 10, PC 6, HT 6, 7, Kid 3, and UB 17, 20 • Ear points: adrenal, endocrine, heart, spleen

10. 3. Qi Stagnation and Blood Stasis - aches and pains in the whole body, burning or gnawing pain with tingling sensations in extremities, headaches. • Tongue: purple, dusky • Pulse: wiry or irregular • Treatment plan: move the qi and blood, alleviate pain • Chinese medicine: modifications based on shen tong zhu yu tang or tao hong si wu tang • Acupuncture points: DU 20, LI 4, 10, ST 36, SP 9, 10, LV 3, PC 6, UB 17, 18 • Ear points: shen men, adrenal, subcortex.

11. 4. Kidney Deficiency (either Yin, Yang, Qi or Essence Deficiency) - there will be impotence or lack of libido for males and infertility issues for both males and females. Other symptoms: sore lower back with restless leg syndrome, irritable bladder, dysmenorrhea, amenorrhea, premenstrual syndrome, hot flashes and night sweats. • Tongue: pale or dry, with cracks • Pulse: thin, weak and deep • Treatment plan: tonify qi, tonify essence and yang, and nourish yin • Chinese medicine: modifications based on you /zuo gui yin (wan), jin gui sheng qi wan, jin suo gu jing wan • Acupuncture points: ren 3, 4, 6, LI 11, LV 2, GB 39, Kid 3, 6, 7, SP6, and UB 23, 31 • Ear points: adrenal, endocrine, kidney

12. Chronic Fatigue Syndrome (CFS) • Chronic fatigue, which used to be called ME (myalgic encephalomyelitis) is a relative new diseases, it might be caused by enterovirus. • Symptoms: • A clinic virus infection followed by: Severe Fatigue, Myalgia, Depression, Sleep disturbance, Irritability, Poor memory and concentration, fluctuation in body weight, intermittent low-grade fever, poor appetite, abdominal fullness and distention, alternation of constipation and loose stools, night sweating

13. Etiology and Pathogenesis in TCM • Etiology: • Overwork • Irregular diet • Excessive sexual activity • Emotional stress • Pathogenesis: • Residual pathogenic factors • Latent heat • Lesser yang patterns • Yin fire • deficiency

14. Pattern identification • Full patterns • Dampness in the muscles • Heat lurking in the interior • Lesser yang patterns • Yin fire • Empty patterns • Qi deficiency • Yang deficiency • Yin deficiency

15. Dampness in the muscles • Clinical manifestations: • Pronounce ache in the muscles, a feeling of heaviness of the limbs, body and head, muscle fatigue on slight exertion, tiredness and sleepiness, no appetite, feeling of fullness of the chest and epigastrium, poor memory, lack of concentration, a fuzzy feeling of the brain, headache, a sticky tongue coating, slippery pulse. • Treatment principle: • Resolve dampness • Acupuncture points: SP9, SP6, UB22, Ren12, Ren9, SP3, SP8, in cases of heat, LI11, DU14 • Herbal treatment: huo po xia ling tang or lian po yin

16. Heat lurking in the interior • Clinical manifestations: • Muscle fatigue without ache or with only a slight ache, thirst, insomnia, cough with scanty-yellow sputum, tiredness, breathlessness on exertion, loss of weight, dry throat, red tongue with yellow coating, rapid pulse. • Treatment principle: • Clear interior heat • Acupuncture points: LI11, DU14, SJ5, LU10, LU5, SP6 • Herbal treatment: Xie bai san

17. Lesser yang patterns • Clinical manifestations: • Alternative chills and fever, fullness of hypochondrial region, poor appetite, irritability, dry throat, nausea, bitter taste, blurred vision, white tongue coating, wiry pulse. • Treatment principle: • Harmonize lesser yang • Acupuncture points: SJ5, GB34, DU14 • Herbal treatment: Xiao chai hu tang

18. Yin fire • Clinical manifestations: • Feeling of heat in the face, red face, mouth ulcers, occasionally a low-grade fever, dizziness, weak voice, depression, muscle weakness, exhaustion, feeling cold in general, loose stools, cold feet, spontaneous sweating, shortness of breath, pale tongue, weak pulse. • Treatment principle: • Tonify the original qi (yuan qi), clear and subdue yin fire, raise qi, resolve dampness • Acupuncture points: Ren4, Ren12, Ren6, ST36, DU20, Ren15, HT5, PC8, SJ5, Ren9, SP6, SP9 and ST28 • Herbal treatment: Bu zhong yi qi tang

19. Lung and Spleen Qi deficiency • Clinical manifestations: • Tiredness that is worse in the mornings, slight ache in the muscles, muscle fatigue after slight exertion, shortness of breath, weak voice, spontaneous sweating, poor appetite, slight epigastric and abdominal distension, loose stool, pale tongue, weak pulse. • Treatment principle: • Tonify qi, expel any remaining pathogenic factor secondary • Acupuncture points: Ren12, ST36, SP6, UB20, UB21, Ren6, LU9, UB13, DU20, LI10 • Herbal treatment: Bu zhong yi qi tang, shen ling bai zhu san

20. Spleen and Kidney Yang Deficiency • Clinical manifestations: • Tiredness that is worse in the mornings, slight ache in the muscles, muscle fatigue after slight exertion, slight epigastric and abdominal distension, loose stools, lower backache, weak knees, frequent-pale urination, dizziness, tinnitus, feeling cold, cold feet, pale tongue, weak and deep pulse • Treatment principle: • Tonify the spleen and kidney yang, resolve dampness • Acupuncture points: Ren4, Ren12, Ren6, UB20, UB21, ST36, DU20, KI3, KI7 UB23, Ren9, SP6, SP9 • Herbal treatment: you gui wan and liu jun zi tang

21. Yin Deficiency • Clinical manifestations: • Lung yin deficiency: Dry throat, dry cough, exhaustion, breathlessness, hoarse voice, feeling of heat in the afternoon, night sweating • Stomach yin deficiency: dry mouth, no appetite, tiredness, dry stools, slight epigastric pain, malar flush, thirst with no desire to drink or a desire to drink only in small sips • Kidney yin deficiency: Soreness of the lower back, exhaustion, depression, lack of drive and will power, weak knee and legs, dizziness, tinnitus, deafness, night sweating • Treatment principle: • Nourish yin • Acupuncture points: • LU: LU9, Ren17, UB43, UB13, Ren12, ST36, SP6, Du20 • ST: ST36, SP6, Ren12, ST44, DU20 • KI: KI3, LU7, KI6, Ren4, SP6, UB23, UB52, DU20 • Herbal treatment: sha shen mai men dong tang, yi wei tang, zuo gui wan

22. Multiple Sclerosis (MS) • MS is an autoimmune disease in which the body's immune response attacks a person's central nervous system (brain and spinal cord), leading to demyelination • This disease is characterized by many different symptoms according to the location of the lesions in the myelin sheath: • Blurred vision, weakness and heaviness of one or both legs, jerking of the legs, double vision, vertigo, vomiting, forgetfulness, difficulty in concentration, incoordination, uncontrolled rapid eye movements, a feeling in arms and legs like suffering an electric shock, numbness or tingling of limbs, urgency or hesitancy of urination, impotence, slurred speech, incontinence

23. Etiology and Pathogenesis in TCM • Etiology: • Invasion of external dampness • Irregular diet • Excessive sexual activity • shock • Pathogenesis: • Stage 1: dampness/phlegm • Stage 2: stomach and spleen deficiency • Stage 3: liver and kidney deficiency • Stage 4: liver and kidney yin deficiency with liver wind • Stage 5: blood stasis

24. Pattern identification • Dampness in the channel • Damp phlegm with spleen deficiency • Stomach and spleen deficiency • Live and kidney deficiency • Liver and kidney yin deficiency with liver wind • Blood stasis

25. Dampness in the channel • Clinical manifestations: • Numbness of limbs, a feeling of heaviness of the limbs, blurred vision, sticky tongue coating slippery pulse. • Treatment principle: • Resolve dampness, invigorate the channel • Acupuncture points: Ren9, SP9, SP6, UB22, ST28, LI10, ST36 • Herbal treatment: er miao san

26. Damp phlegm with spleen deficiency • Clinical manifestations: • Numbness, feeling of heaviness of the legs, tingling, dizziness, tiredness, loose stools, poor appetite, swollen tongue with sticky tongue coating, soggy pulse. • Treatment principle: • Resolve dampness, tonify the spleen, invigorate the channel • Acupuncture points: Ren12, UB20, Ren9, SP9, SP6, UB22, ST40 • Herbal treatment: liu he tang

27. Stomach and spleen deficiency • Clinical manifestations: • Weakness of the legs, difficulty in walking, dragging of feet, tiredness, loose stools, poor appetite, pale tongue, weak pulse. • Treatment principle: • Tonify the spleen and stomach, invigorate the channel • Acupuncture points: Ren12, UB20, UB21, ST36, SP6, ST30, ST31 • Herbal treatment: liu jun zi tang

28. Live and kidney deficiency • Clinical manifestations: • Progressive weakness of the legs, weak back and knees, dizziness, poor memory, blurred vision, hesitancy or urgency of urination, pale tongue without coating, weak and deep pulse. • Treatment principle: • Tonify the kidney and liver, strengthen bones and tendons • Acupuncture points: Ren4, KI3, UB23, SP6, LV8, UB18, SI3, UB62, GB20 • Herbal treatment: du huo ji sheng tang

29. Liver and kidney yin deficiency with liver wind • Clinical manifestations: • Advanced stage of multiple sclerosis, great difficulty in walking, dragging of feet, spasms of legs, atrophy of muscles, dizziness, tinnitus, night sweating, red tongue without coating, thin rapid pulse. • Treatment principle: • Tonify the kidney and liver, extinguish wind • Acupuncture points: Ren4, KI3, UB23, SP6, LV8, UB18, SI3, UB62, GB20, LV3, DU16 • Herbal treatment: du huo ji sheng tang

30. Blood stasis • Clinical manifestations: • Chronic advanced stage of MS, great difficulty in walking, spasms of legs, rigidity of joints, pain in the legs, purple tongue, choppy or wiry pulse. • Treatment principle: • Invigorate blood and eliminate stasis • Acupuncture points: SP10, UB17, PC6, LV3 • Herbal treatment: huo luo xiao ling dan