In recent years auto immune disorders have become increasingly more common and fibromyalgia syndrome is no longer a rare diagnosis.
A diagnosis for fibromyalgia syndrome is usually arrived at by ruling out other rheumatoid disorders. In most cases the blood tests remain normal and many clients have spent years trying to find out what is wrong with them. Western medicine has not developed any treatments apart from pain medications and has no theories why the disorder develops.
An increasing number of fibromyalgia sufferers seek help from practitioners of Oriental medicine. The focus of this article is to discuss the stages the disease progresses through in TCM theory, to discuss the diagnostic differentiation and treatment approaches. The case histories are included to demonstrate the complexity the practitioner frequently encounters when dealing with autoimmune disorders.
The typical fibromyalgia patient is female usually older than 30 and presents with severe fatigue, joint pain especially in the shoulders, sensitivity to pressure and touch and frequently digestive symptoms. Some clients also report depression and sleep disorders. All symptoms might be of a coming and going nature.
In general we can say that deficiency underlies the development of fibromyalgia and it is often possible to elicit in the interview some of the etiology. Severe illness and childbirth late in life seem to be the most common causes. The patients often display psychological characteristics of being disillusioned and embittered by life and they often feel unable to make positive changes.
Usually the symptoms have existed for many years and clients have made a discouraging journey through numerous offices of specialists without receiving any help. Frequently clients have unrealistic expectation about the potential benefits of acupuncture and education is of principal importance. The acute phases of the disease will most likely continue for a period of time and only gradually lessen in intensity and frequency. Often clients fail to benefit from Oriental medicine since they tend to become discouraged as soon as the next flare-up occurs and they might chose to discontinue treatment.
Often the treatment course consists of a number of improvements followed by plateaus. Other healthcare modalities as well as changes in life-style might be needed to allow the client to take the next step up. Most clients benefit from dietary changes immediately. Abstaining from alcohol, sugar and coffee appears to be the most important aspect. In terms of food supplements, bovine collostrum, COQ 10 and NADH seem to be the most helpful.
Food allergy testing often helps to identify specific foods that might cause a worsening of the symptoms. Stool tests with specialized labs are usually indicated. Frequently these are the only tests that show any abnormality. Most commonly unusual bacteria and/or candida albicans overgrowth are found. A diet that is low in wheat and carbohydrates can result in dramatic changes.
Some clients respond well to the use of therapeutic lights especially if their fatigue and depression worsen in winter.
In Chinese therapeutics, herbs are often preferable to acupuncture because clients frequently require many months of treatment.
In TCM diagnosis we can say that firomyalgia progresses through three distinct phases that can be differentiated as follows.
1.Spleen and liver qi both deficient.
In this stage the client experiences the symptoms as coming and going and s/he is frequently in denial about the fact that any serious health problem exists. Clients often report having gone through a period of severe stress in the recent past, such as a divorce.
The symptoms usually include fatigue, depression, digestive problems, abdominal fullness, feeling spaced out and unable to concentrate. The deficiency of the spleen leads to the clear yang not rising, causing a variety of mental/psychological symptoms, such as feeling scattered and experiencing mild headaches.
This symptomology responds largely to what C. Chase calls Liver depression; the inability of wood to course earth. Depressive heat may develop, leading to night sweats, insomnia and irregular menstruation. This symptomology may lead to a deficiency of blood eventually and the client then progresses into the next stage of fibromyalgia.
The deficiency of both liver and spleen qi is optimally addressed by administering Xiao Yao San and choosing points such as Bl 18, Bl 20, SJ 5 and GB 41.
2.Cold entering the channels due to blood deficiency
The deficiency of the liver and spleen qi will result in an inability to produce blood wich in turn allows cold to enter the channels. Apart from the continuing fatigue clients experience pain and stiffness which is often aggrevated by cold exposure. The blood deficiency frequently leads to an inability to nourish the heart resulting in sleep disorders and depression.
At this stage the client has usually experienced symptoms for several years and they might benefit in winter from phototherapy.
The main complaint is now joint pain accompanied by severe lassitude. Depending on the severity of the disease the symptoms might be present now all the time or might still be in a coming and going pattern. All the symptoms mentioned in paragraph 1 might still be presenting. It is important to remember that fibromyalgia sufferers can present with vastly different symptom presentations.
At this stage most clients take prescription medication usually involving pain medications and sertonin reuptake inhibitors. Frequently, female clients report an early onset of menopause and are advised by their physicians to take hormone replacement therapy. From the viewpoint of Chinese medicine the liver is further stressed by the use of drugs making a recovery less likely.
The herbal therapy needs to be changed to Dang gui si ni san preferably 2 to 3 ji a week. The addition of evodia can be helpful. Clients benefit from moxabustion especially if they self administer it on a daily basis.( Ren 4, Ren 6, St 36)
While a client in the first stage will benefit substantially from regular exercise it is no longer of importance here because the deficiency now outweighs the stagnation.
3. Exhaustion of kidney yang and jing
As the disease progresses further, all vital substances become depleted especially the kidney yang leading to severe stasis of blood with significantly more severe pain. At this point the client is usually unable to continue with the ordinary demand of life and they are vastly incapacitated.
The tongue is usually pale and purple, the pulse faint and choppy.
Progress in treatment can be frustratingly slow for both clients and the practitioner. Patients benefit from strong warming tonics such as Lu Rong and aconite. Aconite moxa is often beneficial along with a warming diet including ginger tea and beef broth.
I have always noticed that case histories from China have a degree of simplicity and straight-forwardness that I rarely see in my own practice especially if the client has a long-standing chronic illness. I have chosen the following cases beause they demonstrate the complexity usually seen in a Western clinic.
I first saw this client, a 63 year old female in May of 97. Allison had lived in the Middle East for extensive periods of time and had experiences digestive problems. Two of her four children were born after she was forty years old.
At the time she came to see me she suffered from severe chestpain. She had already undergone three angioplasties and was considering a fourth. She had received a diagnosis for fibromyalgia, reporting chronic pain in her back, neck and shoulders and frequent headache that were affecting her eyes. She experienced nightsweats and severe insomnia and took two kinds of medication for it. She also was on hormone relacement therapy, thyroid medication and took antacids. Her digestive problems, especially bloating, reflux and a bad taste in the mouth were long-standing. Allison appeared thin and emaciated, her pulse was choppy and her tongue dark purpe.
The diagnosis was for liver qi and blood stagnation with deficiency of the vital substances. To decrease the likelihood odf her needing another angioplasty I administered 4ji of the following presciption and she consequently experienced a complete disappearance of all chest pain. Typhae pollen 15gr, trogopteri 15gr, salvia 15gr, ligusticum 10gr, Dang gui 10gr, red peony 10gr. I administered acupuncture once a week and the nightsweats stopped. After a month she reported no change in regard to the pain in her back, the dryness and sensitivity in her eyes and the bad taste in her mouth.
I changed the prescription to Qing pi 9gr, chen pi 7gr, Dang gui 12gr, red peony 6gr, atractylodes 7gr, magnolia hou po 7gr, corydalis 7gr.
After 8ji all digestive symptoms beside the bad taste in her mouth disappeared, the headaches stongly diminished and the pain in the back and legs improved. Shortly thereafter Allison upon the recommendation of her phycisan had epidural steroid injections done which alleviated the back pain completely and she chose to terminate therapy.
Sandra is a full-time mother, 37 years old. At age 18 she had a cancerous tumor removed from her neck but had not undergone chemotherapy or radiation. Since age 30 she had experienced severe back pain of a coming and going nature, headaches accompanied by light-headedness and forgethfulness. She felt fatigued a lot and had diverse digestive symptoms. The client had a nail fungus and ate a diet that was high in sugar.
I advised her to go on a sugar and yeast free diet and undergo stool testing. The client chose to see a rheumatologist now who offered her pain medication but did not encourage her to go forward with the stool tests. She reduced her sugar intake and noticed a definiet improvement from that. Sandra reported that her symptoms were aggrevated by exposure to cold but also reported waking up at night feeling hot.
The pulse was wiry and thin the tongue normal. My disgnosis was for liver and spleen both deficient and I administered Xiao yao san as a decoction and needled Liv 3, St 36, Bl 18. Bl 20.
The client experienced almost complete relieve from all digestive symptoms and an improvement in regard to the headaches and forgetfulness after even 1ji of the herbs. Although the fatigue was not as severe any more she felt tired most of the time and the back pain was unchanged. I continued to administer acupuncture once a week adding GV4, BL 31 and Bl 40. She continued to improve but would usually relaps the week following her menstruation. I concluded that the blood and liver needed to be nourished further and administered Si wu tang with the addition of eucomnia for an addition 6 weeks. The clients discontinued therapy having experienced an almost complete recovery. At a follow-up conversation after 18 months she reported being largely symptom free.
Sue, a female client, 46 years of age, first came to see me in October 96. She experienced severe fatigue with body aches both of which had a coming and going nature. Her digestion was fine. She had a child, her second at age 39 after having problems with infertility. Her symptoms started around age 42 when she was involved in a demanding post-graduate program. At that time she also started experiencing hot flashes and started hormone replacement therapy. She took presciption and over the counter pain medication, sleep medication and serotonin reuptake inhibitors. Both her mother and sister had received diagnosis for Hashimotos.
She experienced flare ups almost every week. She reported disliking heat and described the nature of the pain as burning. Winters were worse than summers. Her tongue was pale and her pulse thin.
The diagnosis was for deficiency of all vital substances with qi stagnation in the upper body. I administered acupuncture once a week emphasizing CV4, CV6, Sp6, St36 with moxa. I edvised the client to avoid raw foods, alcohol and sugar but she was non-compliant in regard to diet.
Angela H. Pfaffenberger, Dipl.Ac. & C.H. (NCCAOM) is a graduate of the New England School of Acupuncture (1985), Boston, MA. She is board-certified in Chinese Herbology and has taught at Southwest Acupuncture College, Boulder Campus. She currently is a member of an interdisciplinary medical practice in Loveland, Colorado and can be reached at: angelapf@EZLink.com