Depression and the Five Elements, Part II

By Barbra Esher, AOBTA CI. Dipl. ABT & Ac. (NCCAOM), LAc

Last month in Massage Today, we started exploring the Western diagnosis of depression through the Five Elements. The five-element paradigm is particularly useful in looking beyond the physical manifestation, at our client's emotional and spiritual climate.

Even though we always focus on treating the whole person on all levels - not just the symptoms - sometimes it is helpful to give clients "homework" for symptomatic relief.

It may not deal with the underlying cause of their problem as effective treatments would, but it could help them cope between sessions.

One type of homework you can give your clients to help ease their depression is self-moxa, if moxa use was included in your training. First, make sure the client doesn't have any obvious symptoms of heat invasion or empty heat, e.g., a red tongue and face, feeling of being too warm, or a rapid pulse. In those instances, moxa is contraindicated. Demonstrate on the client how to use moxa on bafeng/eight winds, located between the webbing of each toe, proximal to the margins of the webs (see illustration below). You can use a moxa pole, but a tiger warmer is better. It should take only about 5-10 minutes. Tell the client to use the moxa every morning, warming each point until just before it is too hot, then moving onto the next point, repeating two-to-three times. By the way, I have been advised by people knowledgeable in legal matters not to give my clients moxa because if they burn themselves, they can sue. It's best to have them purchase their own sticks at an Asian medical supply store.

Another caution that I need to repeat is that shiatsu or any other form of bodywork should not be used in lieu of professional medical treatment or psychotherapy. It works very well in conjunction with other therapies, but be very clear on what you can and cannot treat within your scope of practice.

In my last column, I gave a detailed case study of a client with a typical wood element depression. She was angry, frustrated and suffered with temporal headaches. I can't spend a whole article on each kind of depression but I can give you a basic idea of what to look for in each type so you know where to start working. Keep in mind that usually people will manifest as a combination of a few elements.

The meridians associated with the fire element are primarily the heart and small intestine. A person who has a fire element depression usually attributes "funks" to a broken heart or to relationship problems. This person invests a lot into relationships, losing the importance of the sense of self. When two hearts beat as one, usually it means one of the two people is dead! The "dead one" usually ends up being a woman. I have seen all of the other four types of depression in my male clients, but never a fire element depression. There must be a certain amount of acculturation that supports a woman who "sacrifices" -- whether she is involved with a man or in a same-sex relationship.

The season of the fire element is Summer, and the climate of this person is hot, passionate and joyful - when she is up! This person is optimistic and bubbly when she is in love. She has a lot of energy and focuses much of it on her partner. Every thought and dream is about being with the one she loves. She lives in her heart, finding pleasure in sublimating her own desires to make the one she loves "happy."

Unfortunately, the cost of this temporary bliss is dear. When she wakes up from the dream and finds herself alone, she is devastated, and often falls into a deep depression, until the next relationship that lifts her up again. She needs to eventually find herself worthy of the love that she lavishes on others.

The climate of an earth element depression is characterized by a sticky, cloying dampness. You can feel it in the muscles, which are weak and sometimes puffy filled with a soggy, muddy quality. When earth is weak, the water element backs up along the ko cycle, causing a debilitating swamp in the spleen and stomach meridians. This person obviously is going to have trouble moving through this kind of environment! Such a person may complain of being often tired with a heavy feeling in the limbs.

An earth element person will also have issues involving food, including binging and purging. This person will sometimes have uncontrollable sweet cravings, which are easily controlled by working spleen points. I had a client who would eat candy bars before her sessions because she knew she wouldn't feel like eating them afterward!

This illustrates the challenge of treating an earth element-type of person. Earth-element types are often stuck and are uncomfortable with transition and change. They sometimes have many excuses why they are depressed, and feel little gratitude for the blessings in their lives.

Reprinted with permission from the Acu-Coloring Book by Loren Nelson, lorenhere@iexpress.com.The metal element meridians are lung and large intestine. These meridians not only help us to let go of waste that we don't need anymore on a physical level; they also assist in that process on an emotional level. The climate that you see in a metal element depression is one of long-term grief and sadness. There is a deep and desperate inability to let go, causing disabling depression.

The physical symptoms that may accompany a metal element depression are asthma and allergies. You may notice, many children develop asthma after their parents divorce.

The last and most dangerous form of depression relates to the water element: the bladder and kidney meridians. Not only does the water element house our deep-seated fears -- it is also responsible for our genetic makeup. Therefore, often these are the types of depressions that run in the family.

This is the deepest and darkest of all depressions, and the one for which medication is most helpful (and often essential). People suffering with this type of depression are sometimes suicidal. One client of mine describes shiatsu as helping her "keep her head above water" through difficult times, juggling suicide attempts, ECT (shock) treatments, and ineffective medications with many side effects. Any off-the-cuff mention of "checking out" must be noted in your client's chart and reported to her/his therapist.

So you can see, depression is not something you want to work with without experienced professional support and a considerable amount of training yourself. Although it may be difficult at times, there is nothing more satisfying than helping people make significant and lasting changes in their lives!

For a list of schools that offers programs in ABT, go to www.aobta.org.

The Five Elements of Depression, Part I

By Barbra Esher, AOBTA CI. Dipl. ABT & Ac. (NCCAOM), LAc

In the last two issues of Massage Today, I have talked about headaches and other physical complaints. Pain relief may be the most common reason clients seek shiatsu and other Asian bodywork therapies, but it certainly is not the only benefit they can receive.

A physical problem will bring a client in, like the woman's headaches in the example I use later on in this article. But we need to look beyond the physical manifestation at our client's emotional and spiritual climate, to explore and treat the person, not just the symptoms.

When we do any form of Asian bodywork therapy (ABT), we are working with Qi -- the vital force that moves us through the dance of life. Qi is not only involved in every emotional and physiological process of our bodies; it also binds us together as individuals and connects us spiritually, reverberating through every being on this earth. This awareness of the interconnectedness of all, along being present and compassionate, are more essential than ego-based, "clever" techniques.

Keeping this in mind, we are looking beyond any Western diagnosis our clients may have come to us with, to see the energetic relationships within themselves and to the world. An excellent paradigm for doing this is the Five Elements. The five elements are a poetic but scientific way of using natural phenomenon, like the changing of the seasons, to explore and treat our psyche, spiritual state, anatomy, physiology, and the dynamics of the disease process as a whole.

Often, clients come to us with the Western diagnosis of depression. A major depressive episode implies a prominent and relatively persistent (nearly every day for at least two weeks) depressed or dysphoric mood that usually interferes with daily functioning, and includes at least five of the following nine symptoms:

• depressed mood;
• loss of interest in usual activities;
• significant change in weight and/or appetite;
• insomnia or hypersomnia;
• psychomotor agitation or retardation;
• increased fatigue;
• feelings of guilt or worthlessness;
• slowed thinking or impaired concentration; and
• suicide attempt or suicide ideation.

So what do we do with a diagnosis of depression? Is there a magic point that cures depression? Wouldn't that make it easy! The beauty of shiatsu and Asian bodywork therapy is that we have the tools to see people as a vortex of natural forces, as great works of art, with their life force as an integral part of that picture. We have to see the symptom of depression as part of a whole being, manifesting differently in everyone. The five elements allow us to look at the person's individual "climate." Depression could lie in any of the five elements; often, it's a combination of the dynamic relationship between two or more elements.

Reprinted with permission from the Acu-Coloring Book by Loren Nelson, lorenhere@iexpress.com.The Wood Element closely relates to the season of spring. The energy of the flowers pushing through the still frozen ground upward resembles the force of wood. It's a powerful, yang force within our bodies, responsible for moving the Qi upward. It has an energy that can flare up quickly and move rapidly, often like wind.

The wood organs, Liver and Gall Bladder, are related to the ease and flow of Qi and the emotions, particularly anger. Wood also gives us the ability to make decisions. Wood gives us flexibility in our tendons and sinews, which manifests on an emotional level as well. Someone who is very "woody" may be rigid, inflexible and have issues about being in control. Their anger will flare upward easily; they will hold themselves and others to a high standard of perfection. The eyes relate to the wood element -- not just physically, but in having a life vision and plan. When thwarted, their energy can get stuck or stagnate, causing resentment, repressed anger and, over a long period of time, depression.

Let me give you an example of a typical dark, moody, wood-type of depression. I had a client who was a single mother in her 40's. For years, she worked in a job that she didn't like, with a demanding boss. She got angry, but she always stifled it because she was afraid to lose her job. Her kids had a lot of behavior problems that caused her even more stress. She often spoke of how frustrated she was and how she felt like she had no control in her life. She felt as if she had no options. She would ineffectually explode at her kids and then get mad at herself for doing so. Her physical symptoms included menstrual cramps, PMS and temporal migraines. (Do you remember shaoyang headaches?) Her pulse was wiry and the sides of her tongue were red. Her doctor diagnosed her with mild depression and suggested that she try Prozac, but she wanted to wait a bit longer, trying shiatsu as a last resort recommendation from a friend.

Don't you hate it when you are a last resort? I'd much rather have seen her years before she got into such a desperate state! Luckily, she responded very quickly to shiatsu. Not only was that due to the wood element's easily changeable nature, she also realized that she was spiraling downward and she was committed to making changes in her life.

I focused treatments on the wood meridians, Lv and GB, and the shaoyang meridians, which are Gall Bladder and Triple Heater. I also supplemented the treatments with the Water or Earth meridians intermittently as a precaution. Point combinations that I used were Lv 3 and GB 34. I also held both GB 20s with one hand as I thumb pressed down the TH meridian, stopping and holding TH 6, then TH 5 on one side with Pc 6 on the other. I worked on the TH and GB meridians on the temples, around the ears, occiput and shoulders. In the side position, I worked on the ribs, hips, the outside and the inside of the legs, ending with work on the feet including GB 41 and Lv 3. I also included many meridian stretches.

I recommended that she take a yoga class, which she did. Stretching literally "cools you out" by opening up the meridians, allowing heat to be released. A wood depression due to stagnant liver Qi often starts to generate heat, which can cause irritability, restlessness and insomnia. The stretching not only helped her become calmer, but also more flexible at all levels.

I suggested that she cut out fatty, greasy and spicy foods. Due to her schedule, she relied far too heavily on fast food. She also cut back on coffee and alcohol, which previously had just added fuel to her fire.

She didn't quit her job, but she got better at not letting her boss get to her. She started communicating with her kids more effectively, and they responded by acting out less. Her moods improved, and her headaches and PMS symptoms became less frequent.

This woman's particular case was a straightforward, classic wood case with little complications from other elements. This is unusual. More often than not two or more elements are involved. Deficient water can cause a wood imbalance in the shen-growth cycle. Wood can overact in the ko-control cycle, causing the earth element to be affected and dampness to accumulate.

In future articles, I will give examples of how depression manifests in the other elements. I am hoping that this series will spark your interest in further study. Are you getting tired of hearing this yet? This is just a taste - it in no way takes the place of actual training!

For a list of schools that offers programs in ABT, go to www.aobta.org. For information on the national ABT exam, go to www.nccaom.org.

Herbal Alternatives to Drugs in Pain Management, Part II

By John Chen, PhD, PharmD, OMD, LAc

Traditional Chinese Medicine

According to traditional Chinese medicine (TCM), the fundamental etiology of pain is qi stagnation, blood stagnation, or both.It is often said that where there is pain, there is stagnation; where there is stagnation, there is pain. Therefore, effective pain relief most often requires the use of herbs that activate qi and blood, removing stagnation and thus resolving the cause of pain. As is true in all treatment involving Chinese medicinal herbs, they are most commonly prescribed in carefully-combined formulas (rather than singly) that directly address the causes and/or symptoms of the imbalance and treat without creating unwanted side-effects or complications.

In addition to treating qi and blood stagnation, successful treatment of pain also requires careful differential diagnosis of pain. The three main diagnostic keys are the location of the discomfort, the type of pain and the cause of pain. Locationrefers to the exact part of the body that is affected: upper body, lower body, external musculoskeletal muscle, internal smooth muscle and so on. The type of pain refers to the characteristics of the patient's pain, such as a sharp, stabbing pain or dull aching, pain at a fixed location as opposed to migratory pain, pain helped by cold or by heat, and other distinguishing characteristics. Lastly, identifying the cause of pain helps the practitioner differentiate soft tissue injuries from structural damage. For example, leg spasms and cramps often involve only soft tissue, while an acute sprained ankle is often accompanied by structural damage. Accurate evaluation of these three criteria is crucial for greatly enhanced diagnostic accuracy and successful relief for the patient.

Herbal Treatment for Headache

Headache pain may arise from internal or external causes such as invasion of wind, cold, heat, dampness, dryness, summer heat, accumulation of phlegm, and other pathogens in addition to qi and blood stagnation. Headache pain may represent excess or deficient conditions and may affect the occiput, vertex, sinuses and orbital region. It may also present with a complex of locations/symptoms, such as in migraine.

Corydalis (yan hu suo) is one of the strongest herbs available to relieve pain and reduce inflammation. Research studies have shown it to work directly on the central nervous system with analgesic effects comparable to those of morphine and codeine.^1,2 Another herb, pueraria root (ge gen), has demonstrated remarkable effectiveness in relieving headache pain.^3,4,5 Other herbs have proved effective in relieving various types of headaches, including (but not limited to) migraine, vertex, sinus and orbital headache.^6,7,8

Many classical Chinese herbal formulas are also commonly used to treat headache. Cnidium & tea formula (chuan xiong cha tiao san) treats headaches due to wind cold. Evodia combination (wu zhu yu tang) relieves vertex headache due to cold and is also used to treat migraine. Coptis, phellodendron & mint formula (huang lian shang qing wan) addresses headache caused by heat. Notopterygium & tuhuo combination (qiang huo sheng shi tang) treats headache due to wind and dampness. Gastrodia & gambir combination (tian ma gou teng yin) relieves headache secondary to liver yang rising. Eucommia & rehmannia formula (you gui wan) tonifies kidney deficiency to relieve headache. Tangkuei & ginseng eight combination (ba zhen tang) tonifies qi and blood deficiency to relieve headache. Pinellia & gastrodia combination (ban xia bai zhu tian ma tang) relieves headache due to phlegm stagnation.

Herbal Treatment for Neck and Shoulder Pain

Neck and shoulder injuries can be divided into two major categories: acute and chronic. Acute injuries are generally characterized by redness, swelling, inflammation and sharp pain. Chronic injuries are generally characterized by stiffness, numbness, discomfort and dull pain.

Acute neck and shoulder problems are often caused by accidents, whiplash, improper sleeping or reading postures, and similar traumas. In addition to pain, redness, swelling and/or inflammation are sometimes present. Treatment consists of reducing pain, swelling and muscle spasms. Herbal formulas are designed to dispel painful symptoms while supporting the healing process. Strong analgesic herbs like corydalis (yan hu suo) are combined with anti-spasmodic herbs and blood-invigorating herbs to alleviate pain, promote blood circulation and open the meridian channels.

Chronic neck and shoulder problems are characterized by pain, numbness, stiffness, discomfort, limited mobility, slow recovery or continuing deterioration. Effective treatment must focus on activating qi and blood circulation, opening the channels and collaterals, and nourishing the muscles and tendons.

Corydalis is a main herb in the treatment of both acute and chronic neck and shoulder problems. In addition to having strong analgesic properties, it also has a distinctive facility for treating both acute and chronic cases of inflammation.⁹ Corydalis also protects against NSAID-induced gastric and duodenal ulcers by reducing gastric acid secretion.¹⁰

Classical formulas that treat neck and shoulder pain include the following specific applications. Lindera formula (wu yao shun qi san) is formulated for shoulder pain, while pueraria combination (ge gen tang) is more specific for stiff neck due to cold. Atractylodes & arisaema combination (er zhu tang) relieves deficient-type neck and shoulder disorders but may not have strong analgesic effects.

Herbal Treatment for Back Pain

Similar to neck and shoulder pain, back pain can be divided into two major categories: acute and chronic, with many of the key symptoms described in the categories above.

Many classic formulas tonify the kidney to relieve back pain and weakness. Tuhuo & loranthus combination (du huo ji sheng tang) eliminates wind and dampness and has a rapid onset to relieve acute back pain. Herbal formulas that tonify the kidney tend to be slower in action and are more suitable for chronic back pain. Cyathula & rehmannia formula (zuo gui wan) is more specific to address kidney yin deficiency; eucommia & rehmannia formula (you gui wan) focuses more specifically on kidney yang deficiency; and rehmannia eight formula (ba wei di huang wan) tonifies both kidney yin and yang.

Herbal Treatment for Musculoskeletal Pain and Painful Obstruction (Bi) Syndrome

Musculoskeletal pain is often classified as painful obstruction (bi) syndrome. Though there are many causes of this syndrome, cold and heat are the most common etiologies. Cold-type musculoskeletal pain is characterized by stiffness, pain and limited range of motion of the joints. In Western terms, cold conditions are associated with chronic arthritis and arthralgias such as osteoarthritis and fibromyalgia.

Heat-type musculoskeletal pain is characterized by redness, swelling, pain and/or inflammation of the muscles and joints. Patients typically present with muscle cramping and spasms. From a Western perspective, these patients have acute musculoskeletal disorders, typically involving inflammation of the muscles, bursae, tendons and ligaments.

Gentiana macrophylla root (qin jiao), a popular ingredient in some remedies, has been shown to have anti-inflammatory activities comparable to those of aspirin (salicylic acid).⁴ Aconite tsao wu (cao wu) and aconite wu tou (chuan wu) Other herbs have demonstrated exceptional anti-rheumatic, anti-inflammatory, analgesic and anti-pyretic functions.^13,14

White peony (bai shao) and licorice (gan cao) have demonstrated remarkable properties in relieving spasms, cramps and pain of skeletal and smooth muscles. Clinical applications include dysmenorrhea,³musculoskeletal disorders,¹⁵ trigeminal pain,¹⁶ muscle spasms and twitching in the facial region,¹⁷ pain in the lower back and legs,¹⁸ abdominal pain and cramps due to intestinal parasites,¹⁹ and epigastric and abdominal pain.²⁰

If there are complications to the musculoskeletal disorders described above, classical formulas offer treatment options for the patients. Cinnamon & anemarrhena combination (gui zhi shao yao zhi mu tang) treats musculoskeletal and joint pain due to wind heat. Cyathula & plantago formula (ji sheng shen qi wan) treats musculoskeletal and joint pain arising from cold. Coix combination (yi yi ren tang) treats musculoskeletal and joint pain caused by dampness. Tuhuo & astragalus combination (san bi tang) treats musculoskeletal and joint pain due to deficiency of qi and blood and weakness of the liver and kidney. If the etiology is unclear, notopterygium & turmeric combination (juan bi tang) may be used for relief of general musculoskeletal and joint pain.

Herbal Treatment for Traumatic Injury

Traumatic injury is characterized by severe qi and blood stagnation. Types of injuries include bruises, contusions, sprains, broken bones, surgical incisions and related internal trauma, and other physical traumas.

For complications of traumatic injury, cinnamon & hoelen formula (gui zhi fu ling wan) is used to treat internal bleeding after traumatic or sports injuries; persica & rhubarb combination (tao ren cheng qi tang) is used to treat subcutaneous bleeding with severe swelling and pain.

Conclusion

Pain is universally understood as a signal of disease and is the most common symptom that brings a patient to a physician.²¹ Western clinical medicine and traditional Oriental medicine share common goals of alleviating pain and eliminating the causes of pain; however, the philosophy and clinical approach to pain management in the two disciplines is very different. Generally speaking, Western drugs have immediate and reliable analgesic effects. Unfortunately, Western pharmaceuticals often cause serious short- and long-term side-effects. In addition, the chronic use of drugs, especially opioid analgesics, is strongly associated with addiction and negative social consequences and connotations. As a result, more and more patients are turning to herbal medicine as their primary, complementary or alternative treatment for pain.

Herbal medicines definitely have outstanding analgesic, anti-inflammatory and anti-spasmodic functions and benefits. However, even though herbs and pharmaceutical drugs have many overlapping functions, they are not directly interchangeable or analogs of each other. The therapeutic effectiveness of herbal formulas is dependent on accurate diagnosis and careful prescription. When used properly, herbs are powerful alternatives to drugs for pain management.

References

1. Pharmacology and Applications of Chinese Herbs 1983; 447.
2. Zhu XZ. Development of natural products as drugs acting on central nervous system. Memorias do Instituto Oswaldo Cruz 86 (2):173-5, 191.
3. Bensky D, et al. Chinese Herbal Medicine Materia Medica. Eastland Press 1993.
4. Yeung HC. Handbook of Chinese Herbs. Institute of Chinese Medicine, 1983.
5. Gao XX, et al. Effectiveness of pueraria root (ge gen) in treating migraine headache: a case report of 53 patients. Journal of TCM Internal Medicine (Zhong Hua Nei Ke Za Zi) 1977;6:326.
6. Effectiveness of angelica (bai zhi) in treating occipital headache: a report of 73 cases. Air Force hospital in Hengyang, China. Modern Medical Journal (Xin Zhong Yi) 1976;3:128.
7. Effectiveness of angelica (bai zhi) in treating chronic headache: a report of 62 cases. National Defense Hospital. Journal of Modern Medicine (Xin Yi Xue Yao Za Zi) 1976;8:35.
8. Wang LS. Treatment of headache using xiong zhi shi gao tang: 50 cases. Shanxi Journal of Traditional Chinese Medicine 1985;10:447.
9. Kubo M, et al. Anti-inflammatory activities of methanolic extract and alkaloidal components from corydalis tuber. Biol Pharm Bull February 1994;17(2):262-5.
10. Study of Chinese Herbal Medicine 1976; p. 340.
11. Military Hospital Unit #64. Effectiveness of aconite wu tou (chuan wu) in treating low back pain, a report with 225 patients. New Journal of Medicine and Pharmacology 1975;4:45.
12. Zhang HT, et al. Treatment of frozen shoulders with aconite wu tou (chuan wu) and camphor (zhang nao). Shanghai Journal of Medicine and Pharmacology 1987;1:29.
13. Liao JF. Evaluation with receptor binding assay on the water extracts of ten CNS-active Chinese herbal drugs. Proceedings of the National Science Council, Republic of China. Part B, Life Sciences. July 1995;19(3):151-8.
14. Sun DH. Treatment of heat type of painful obstruction (Bi) syndrome with stephania (fang ji) in 120 patients. Shangdong Journal of Traditional Chinese Medicine 1987;6:21.
15. Tan H, et al. Chemical components of decoction of radix paeoniae and radix glycyrrhizae. China Journal of Chinese Materia Medica Sep 1995;20(9):550-1, 576.
16. Huang DD. Journal of Traditional Chinese Medicine 1983;11:9.
17. Luo DP. Hunan Journal of Traditional Chinese Medicine 1989;2:7.
18. Chen H. Yunnan Journal of Traditional Chinese Medicine 1990;4:15.
19. Zhang RB. Jiangxu Journal of Traditional Chinese Medicine 1966;5:38-39.
20. You JH. Guanxi Journal of Chinese Herbology 1987;5:5-6.
21. Harrison TR, et al. Harrison's Principles of Internal Medicine, 14th edition, 1998.

Herbs for Boosting the Immune System

By John Chen, PhD, PharmD, OMD, LAc

Q: I have a four year-old daughter who has just started attending preschool. She has not been very healthy, and I am afraid that she is going to get sick every time there is a flu.What can I do to boost her immune system?

A: One of the most important emphases of Chinese medicine is prevention. Herbs are commonly prescribed during a change of season to help a person adapt to the changing weather. By planning ahead and taking herbs accordingly, one can drastically reduce the frequency and severity of catching the common cold or the flu.

According to traditional Chinese medicine, defense (wei) qi is located at the exterior surface of the body and offers initial protection against foreign or pathogenic factors. When wei qi is strong, pathogenic factors cannot penetrate the body. When it is weak, a variety of infections can occur.

Prevention of infections relies on normal function of wei qi. From the Western perspective, many herbs that tonify qi enhance the immune system. Herbs that perform such functions include astragalus (huang qi), ganoderma (ling zhi) and cordyceps (dong chong xia cao).

Astragalus (huang qi) is one of the most frequently used Chinese herbs and has historically been used to tonify wei qi. It fortifies the lungs, strengthens the wei qi and indirectly protects against external pathogenic factors.

In terms of Western medicine, modern research has confirmed repeatedly that astragalus increases both specific and non-specific immunity.^1,2,3 In a clinical trial of 115 leucopenic patients, astragalus was found to be associated with an "obvious rise of the white blood cell (WBC) count" with a dose-dependent relationship.⁴ In addition, astragalus works well with concurrent drug therapy in enhancing the overall effectiveness of the treatment. It also potentiates the anti-tumor effect of chemotherapy drugs⁵ while reversing drug-induced immune suppression.⁶ Lastly, astragalus demonstrates anti-cancer activity by increasing the content of camp and inhibiting the growth of tumor cells.⁷

Ganoderma (ling zhi) has been traditionally used to tonify blood and vital energy. It is thus essential in rebuilding a patient's constitution.

Ganoderma increases the number of white blood cells and inhibits the growth of various viruses and bacteria associated with the flu. It has been demonstrated to enhance the immune system in various clinical studies. The specific effects of ganoderma include an increase in monocytes, macrophages and T-lymphocytes.^8-11 There is also an increased production of cytokine, interleukin, tumor necrosis factor and interferon. Furthermore, ganoderma has a broad spectrum of antibacterial activities, inhibiting the growth of pneumocci, streptocci (type A), staphylococci, e. coli, b. dysentarie and pseudomonas, among others.⁷

Cordyceps (dong chong xia cao) has traditionally been used in chronic debilitated patients. It is an excellent herb to tonify the kidney yin and yang and improve overall bodily constitution. Cordyceps is another herb which has marked immunomodulatory functions. It enhances overall immunity by increasing lymphocytes and natural killer cells and the production of interleukin, interferon and tumor necrosis factor.^12-16 Cordyceps was also found to significantly inhibit the proliferation of cancer cells;¹⁷ in some instances, the growth inhibition rate of the cancer cells reached between 78-83%.¹⁸

Keep in mind that while these herbs are effective individually, they should be prescribed in the content of an herbal formula to enhance synergistic action and minimize possible side-effects.

Q: Are there any contraindications for these herbs?

A: Astragalus, ganoderma, cordyceps and herbs that boost the immune system are contraindicated for patients taking immunosuppressants such as imuran (azathioprine) or sandimmune (cyclosporin). These drugs are commonly prescribed following organ transplant surgery to suppress the immune system and prevent tissue rejection. Because these herbs have potent immune enhancing effects, they should not be prescribed for patients taking immunosuppresants following organ transplant surgery. Despite their weak constitution, use of some immune enhancing herbs can increase the risk of rejection and severely compromise the patient's health.

References

1. Chu DT, et al. Immunotherapy with Chinese medicinal herbs. I. Immune restoration of local xenogenetic graft-versus-host reaction in cancer patients by fractionated astragalus membranaceus in vitro. Journal of Clinical & Laboratory Immunology Mar 1988;25(3):119-23.
2. Sun Y, et al. Immune restoration and/or augmentation of local graft versus host reaction by traditional Chinese medicinal herbs. Cancer July 1, 1983;52(1):70-3.
3. Sun Y, et al. Preliminary observations on the effects of the Chinese medicinal herbs astragalus membranaceus and ganoderma lucidum on lymphocyte blastogenic responses. Journal of Biological Response Modifiers 1983;2(3):227-37.
4. Weng XS. Chung Juo Chung Hsia I Chieh Ho Tsa Chih August 1995.
5. Chu DT, et al. Fractionated extract of astragalus membranaceus, a Chinese medicinal herb, potentiates LAK cell cytotoxicity generated by a low dose of recombinant interleukin-2. Journal of Clinical & Laboratory Immunology Aug 1988;26(4):183-7.
6. Chu DT, et al. Immunotherapy with Chinese medicinal herbs. II. Reversal of cyclophosphamide-induced immune suppression by administration of fractionated astragalus membranaceus in vivo.Journal of Clinical & Laboratory Immunology Mar 1988;25(3):125-9.
7. Yeung HC. Handbook of Chinese Herbs. Institute of Chinese Medicine, 1996.
8. Wang SY, et al. The anti-tumor effect of ganoderma lucidum is mediated by cytokines released from activated macrophages and T-lymphocytes. International Journal of Cancer Mar 17, 1997;70(6):699-705.
9. Van der Hem LG, et al. Ling zhi-8: studies of a new immunomodulating agent. Transplantation Sep 15, 1995;60(5):438-43.
10. Haak-Frendscho M, et al. Ling zhi-8: a novel T-cell mitogen induces cytokine production and up-regulation of ICAM-1 expression. Cellular Immunology Aug 1993;150(1):101-13.
11. Tanaka S, et al. Complete amino acid sequence of a novel immunomodulatory protein, ling zhi-9. An immuno-modulator from a fungus, ganoderma lucidum, having similar effect to immunoglobulin variable regions. Journal of Biological Chemistry Oct 5, 1989;264(28):16372-7.
12. Kuo YC, et al. Cordyceps sinensis as an immunomodulatory agent. American Journal of Chinese Medicine 1996;24(2):111-25.
13. Guan YJ, et al. Effect of cordyceps sinensis on T-lymphocyte subsets in chronic renal failure. Chung-Kuo Chung His I Chieh Ho Tsa Chih Jun 1992;12(6):323,338-9.
14. Liu C, et al. Effects of cordyceps sinensis (CS) on in vitro natural killer cells. Chung-Kuo Chung His I Chieh Ho Tsa Chih May 1992;12(5):259,267-9.
15. Xu RH, et al. Effects of cordyceps sinensis on natural killer activity and colony formation of B16 melanoma. Chinese Medical Journal Feb 1992;105(2):97-101.
16. Liu P, et al. Influence of cordyceps sinensis (berk. sacc.) and rat serum containing same medicine on IL-1, IFN and TNF produced by rat Kupffer's cells. Chung Kuo Chung Yao Tsa Chih Jun 1996;21(6):367-9,384.
17. Kuo YC, et al. Growth inhibitors against tumor cells in cordyceps sinensis other than cordycepin and polysaccharides. Cancer Investigation 1994;12(6):611-5.
18. Chen YJ, et al. Effect of cordyceps sinensis on the proliferation and differentiation of human leukemic U-937 cells. Life Sciences 1997;60(25):2349-59.

The End of Fibromyalgia? A View from the Defense

The End of Fibromyalgia? A View from the Defense

By Della Welch

The term fibromyalgia was coined by the American Rheumatology Association in 1990. However, there have been many changes in the criteria since that time. Currently, Dr. Frederick Wolfe, the chair of the American Rheumatological Committee, has stated that he no longer thinks of fibromyalgia as a disease, but only as a "clinical term" (Wolfe 1997, pp.1247-49). The following are some reasons a defense may use to question the validity of a fibromyalgia diagnosis:

1. The cat is out of the bag. The American Rheumatology Association's criteria of 11 out of 18 tender points has been published so that everyone can see where the tender points are and what symptoms one must have in order to have a "positive examination."
2. Fibromyalgia relies on self-reporting. The diagnosis is based on the applicant's self-reporting of symptoms. In other words, "I touch, you hurt." Applicants may tend to be very self-serving during the examination.
3. Fibromyalgia cannot occur as a result of trauma. The recommendation of the 1996 revision of the American Rheumatology Association excluded "reactive" and "posttraumatic fibromyalgia" as a cause of fibromyalgia (Wolfe 1996, p. 537). Based on the association's criteria, this would appear to exclude car accidents, falls and other traumatic incidents as acceptable causes of fibromyalgia.
4. Fibromyalgia treatment should not continue forever. Assuming that a judge would decide that there is a diagnosis of fibromyalgia, treatment should not go on forever and should be limited to item two of the 1996 Vancouver consensus report. This section states: "Therapies should not be continuous or indefinite. The goal of therapy is to make the patient independent." Accordingly, there should not be long periods of temporary disability or extensive future medical treatments for fibromyalgia patients.
5. Fibromyalgia is not disabling. Dr. Frederick Wolfe makes a clear statement that "people with fibromyalgia should not be considered disabled" (Wolfe 1997). Accordingly, people with fibromyalgia can work. In the 1996 case of Yeager v. Reliance Standard Life Insurance Company (88 F 3rd 376 [6th circuit]), the plaintiff with fibromyalgia was found by the doctor to be capable of performing 95% of his work functions and was not disabled (p. 382). The Yeager case is not a worker's compensation case, but is well-reasoned.
6. Fibromyalgia is resistant to treatment, and it is unknown exactly what the best treatment is. The treatment for fibromyalgia is unclear. Thus, applicants might not be able to address all issues in order to prove their case or to establish a need for continuing medical treatment for fibromyalgia.
7. Fibromyalgia has three elements. Experts often forget to describe all three elements in their diagnosis. The three elements are: (1) Pain in eleven out of 18 tender points; (2) widespread pain in three of four quadrants; and (3) pain for a minimum of three months. It is difficult to see how a doctor on one examination could diagnose widespread pain for three months. Further, when tender points "wax and wane," it is hard to know whether the tender points are waxing or waning on the date of the patient's examination. The skills of the examiner in applying pressure to the tender points often differ as well.
8. Fibromyalgia has a sleeping component. Often, the practitioner does not explore the sleeping conditions of the applicant. A practitioner may note that the applicant drinks six cups of coffee a day, then wonder why the applicant stays awake.
9. New case law may make fibromyalgia more difficult to prove. A major development from the United States Supreme Court may make it difficult for applicants with controversial conditions such as fibromyalgia to recover. The most recent U.S. Supreme Court case on the issue of expert testimony was Kumho Tire Co. v. Carmichael (March 23, 1999; 119 5 ct. 1167 [199]).

A man was injured when one of the company's tires failed. The plaintiff, Patrick Carmichael, had as an expert Dennis Carlson, a mechanical engineer, who testified that the failure could have been caused by a design or manufacturing defect, which he could neither specify nor identify. Kumho moved to exclude the evidence of this expert. As a result of this case, the court held that the trial judge is now the gatekeeper and determines the reliability and admissibility of expert evidence. The judge must make sure that the expert's opinions are based on "scientific principles."

The bottom line from the Kumho case is that "intellectual rigor" must be used in evaluating expert testimony. The defense may argue that Kumho means the following for factors should be cited in evaluating expert testimony (Kumho referred to a previously decided 1993 case, Daubert v. Merrill Dow, Inc.). The four factors are:

1. whether the expert's methodology can be tested;
2. whether it has been subjected to peer review and publications;
3. its potential rate of error; and
4. whether it has gained general acceptance in the relevant scientific community.

In conclusion, with all of the conflicts going on in the scientific community over whether fibromyalgia exists, it might appear that fibromyalgia cannot pass the rigors of the Kumho case. Furthermore, broader issues are created for the acupuncture community in reviewing Kumho and applying it to acupuncture in general. Much of acupuncture methodology has not been tested in peer review articles. Since Kumho is so new, we can only wait and see how this case will ultimately be applied in acupuncture cases.

As a defense attorney, the following might be a good recommended checklist for fibromyalgia cases:

1. Contend that the applicant does not have fibromyalgia and may have something else.
2. Contend that fibromyalgia was not caused, aggravated or exacerbated by work. If work did "light up fibromyalgia," for how long? Causation is difficult to establish due to Dr. Wolfe's denouncing the criteria, the differences among professionals on the tender points checked, and the conflicts on what causes or aggravates fibromyalgia.
3. Contend hat if the applicant does have fibromyalgia, it was a pre-existing condition and request apportionment.
4. Look to see if histories and current activity levels are accurate.

References

• Wolfe F. Vancouver Fibromyalgia Consensus Group. The fibromyalgia syndrome: a consensus report on fibromyalgia and disability. Journal of Rheumatology 1996;23:534-9.
• Wolfe F. The fibromyalgia problem. Journal of Rheumato

Acupuncture for Rheumatism and Asthma

By Julian Scott and Teresa Barlow

This month's question: What can acupuncture do for children? I know it can help some adult problems like pain, but why should I bring my child to acupuncture?

These questions are asked so frequently that we must have replied hundreds of times.For most people, acupuncture is still strange and new: the thought of bringing your child is extraordinary, even to many acupuncturists! Our answer is simple: acupuncture can do a lot for your child. It is a very effective medicine and can be used to treat virtually anything for which you might go to your regular pediatrician. Furthermore, acupuncture works incredibly quickly in children. In fact, it works so well that we can actually cure many children of their disease.

This is an inflammatory statement and often provokes a heated response. "Cure" is a difficult word, so perhaps we should explain what we mean by a cure.

Can You Really Say "Cure"?

When we are controlling the symptoms and are in the process of strengthening a child, we call it treating. When the root cause of a child's illness is removed, we call it a cure. When we talk of curing asthma (a condition which we see frequently), we mean that the underlying cause of the problem is cleared, and the child does not get any more asthma attacks. Obviously this may not be possible for all children that we see. If a child is born very weak, it may always have weak lungs, but for many children it is possible to take away the root cause of their disease. When this happens, the symptoms that describe the disease no longer occur. We call this a cure.

Let us give an example of what we mean by the word cure by using the examples of rheumatism and asthma.

Treating Rheumatism

When I was in England, a large part of my practice was treating people over 60 who had rheumatic pain: aches in the muscles and joints. Usually they were worse in wet weather and in damp places. In England the weather outside is damp, except when it is raining! Many people live in old houses which are over 100 years old; they too are damp. That meant that they had rheumatism much of the time. When they came for treatment, it would normally take a just a few weekly treatments to perk them up so that they felt more cheerful. It would take only a few more to take away the pain, but after that, they would have to come for treatment fairly regularly. If they stopped coming, the pain would creep back. I would typically treat them about once a month for maintenance.

This could not really be called a cure. Although giving acupuncture is fundamentally different from giving a painkiller (a painkiller is deadening, while acupuncture is enlivening), the net result is that they still have the condition, and it takes ongoing treatments to alleviate the symptoms.

In contrast, let us look at a disease which we do often cure: asthma.

Curing Asthma in Children

To understand why we say we can cure asthma, one needs to understand why children get asthma in the first place. In our experience, asthma is a deep diseases, one in which there is always a lingering pathogenic factor (LPF). The LPF is the root cause of the child's getting asthma. It is not the only cause, but if the child did not have an LPF, the child probably would not have asthma.

LPFs are strange beasts. The idea behind them is quite simple: you get an illness, and you are never quite well after. In practice, however, it is quite complex. The LPF affects not just the physical body, but the emotions and spirit as well. In some way or other the child will be more agitated or more repressed than before. There is always something in the child's behavior which is not quite right. (We will discuss lingering pathogenic factors in another issue).

Without treatment, as a child gets stronger, the child gradually "grows out" of the asthma. We also notice that although the symptoms of asthma have gradually subsided as the child has gotten older and stronger, the pattern of LPF stays unchanged. This deep distortion of the child's emotions stays and, if anything, gets deeper. Over time the attitudes harden. What started as just a physical imbalance affecting a child's mood becomes an attitude problem, then a character problem. This is an important part of the disease of asthma. In order to effect a cure, you need to help get the child back on its feet, not just physically, but emotionally and spiritually as well. If you do not change this, the symptoms of asthma may return.

Now, when a child is treated using Western drugs, the physical part of the disease can be kept under control. By contrast, if a child is treated by acupuncture, there is a good chance that it will completely eliminate the LPF. Not only can you relieve the symptoms of asthma, you can really root out the underlying insidious LPF which is upsetting the child. This means that the illness will never come back. The child is cured.

Of course, it does not always happen this way. No one cures every patient who walks in through the door, but it happens more often than not. Let me give an example of a boy who really was cured, at least from my point of view!

A Child Who Got Better

Little Eric (the name has been changed) was just under one year old when he came in for treatment. The mother was at her wits end, for Eric was on quite large doses of inhaled steroids and albuterol. In addition, he kept on getting colds which quickly turned into coughs and brought on an asthma attack. These attacks were invariably treated by heavy courses of antibiotics. By the time he came in, he had received 10 courses of antibiotics during the previous six months. Not only that, but the antibiotics had stopped working. Not surprisingly, his mother was worried to the point of being terrified.

Treating him was really quite difficult, for it took quite some time before he was strong enough to cope with even the mildest infection. Typically I would give him eight or ten treatments. He would then get another cold which would precipitate an asthma attack, and so it was off to the ER.

Fortunately the mother stuck with treatments, because she noticed that although he had to keep on going to the ER, each time the attack was less severe than the time before. She noticed how he was gradually getting stronger and more able to fight off an illness.

This went on for quite a long time -- about 18 months. During the last six months, he was still coming weekly and still getting asthma attacks, but they were quite mild and could easily be managed by the family.

Throwing Out the LPF

When Eric was two and a half, he finally managed to throw out the LPF once and for all. He caught the flu. He did not have any sort of problem with breathing, which was rather unusual, but he did have a fever of 104^o, which nothing would bring down. They tried Tylenol, which brought the fever down to 102^o for two hours, but then the temperature shot up again. Surprisingly, he was quite cheerful during this time, and wanted his food as normal! This went on for five days uninterrupted. This was his final battle with the LPF. Since then, he has been one of the healthiest children I see. He never needs treatment, and when the family gets a cough, he is the one who does not get it!

There are many diseases like asthma in which acupuncture can remove the root cause. This is one of the most beautiful things about this medicine; being able to see deep beyond the symptoms to the root of the disease, and more importantly, having the means to treat the root.

To be fair, we are at an advantage treating children and babies. For most of them the condition has not been ingrained by years of conditioning and bad habits as it has in most adults! We all know it is easier to treat something of fairly recent origin rather than one that has manifested for 30 years. This is one of the reasons why we love treating children so much: acupuncture is so successful for so many of their problems. Furthermore, once the condition is cured, the child is freed from a potential of struggling through life one sickness after another and a bathroom cabinet full of medications. The child is given a new chance to really enjoy a life full of love and laughter.

If you have any questions about acupuncture, we would be glad to try and answer them. You may send them by mail or e-mail to us in care of Acupuncture Today. All questions will be treated confidentially if you so wish.

Diabetic Peripheral Neuropathy

Chinese Medicine and Diabetic Peripheral Neuropathy

By Bob Flaws, LAc, FNAAOM (USA), FRCHM (UK)

Peripheral neuropathy, also known as polyneuropathy or peripheral neuritis, is a disease usually secondary to collagen vascular diseases such as systemic lupus erythmatosus (SLE), scleroderma and rheumatoid arthritis (RA).It is also secondary to metabolic diseases such as diabetes, or to infectious agents such as Lyme disease.

In diabetes, symptoms of neuropathy may precede other symptoms of carbohydrate and vascular abnormalities. As many as 60-90% of patients with diabetes suffer from peripheral neuropathy; however, modern Western medicine does not have any truly effective treatment for this condition.

One of the most common treatments of PN is the prescription of amitriptyline, frequently sold under the brand name Elavil. Amitriptyline is an antidepressant. Some of its side-effects include skin rashes; headache; dizziness; weakness; hepatitis; agitation; nightmares; nausea; fluctuations in blood sugar levels; heart palpitations; and even peripheral neuritis.¹

Peripheral neuropathy is also commonly encountered in AIDS cases. Recent research published in theJournal of the American Medical Association suggests that amitriptyline is definitely not effective for that type of peripheral neuropathy.² However, the Chinese medical descriptions of the pathophysiology of diabetes and AIDS are essentially the same, especially the Chinese description of peripheral neuropathy in both diseases. This description also accounts for PN associated with SLE and Lyme disease and often (though not always) covers PN associated with rheumatoid arthritis and scleroderma.

The following is a report on a recently published study on the treatment of diabetic peripheral neuropathy with Chinese medicinals. In composing his protocol, the author assumes that most patients with diabetic PN present the Chinese medical pattern of qi and yin vacuity with vacuity heat complicated by blood stasis in the network vessels. The title of the article (in English) is "The Use of Yi Qi Zhu Yu Tong Mai Tang (boost the qi, dispel stasis and free the flow of the vessels decoction) in the Treamtnet of Diabetic Peripheral Neuropathy." It was authored by Xu Sheng-sheng and published in Jiang Su Zhong Yi (Jiangsu Chinese Medicine) 1999, issue 3, p. 23.

Cohort Description

The study consisted of 118 patients, all of whom met the WHO's criteria for diabetes mellitus. Each patient also displayed varying symptoms of diabetic peripheral neuropathy, which included lower extremity tingling and numbness, formication, vague pain, piercing pain, burning pain and muscular loss of strength. In addition, patellar and Achilles reflexes were either weakened or absent.

Patients were divided into similar treatment and comparison groups. The treatment group consisted of 86 patients, 45 male and 41 female, and ranged in age from 31-76, with a median age of 50.6. Eighty-four patients were diagnosed with non-insulin dependent diabetes mellitus (NIDDM); two were diagnosed with insulin dependent diabetes mellitus (IDDM).

Of the 32 patients in the comparison group, 18 were male and 14 female. The patients ranged in age from 29-74 with a median age of 52.8. Thirty-one patients were diagnosed with NIDDM; one had IDDM.

Treatment Method

In addition to dietary restrictions and sugar lowering medications (i.e., insulin), patients in the treatment group were given the following basic formula orally: uncooked radix astragali membranacei (huang qui), 30g; radix dioscoreae oppositae (shan yao), 10g; radix scrophuariae ningpoensis (xuan shen), 10g;rhizoma atractylodis (cang zhu), 10g; radix angelicae sinensis (dang gui), 12g; radix rubrus paeoniae lactiflorae (chi shao), 12g; flos carthami tinctorii (hong hua), 12g; cortex radicis moutan (dan pi), 12g;semen pruni persicae (tao ren), 12g; caulis milletiae seu spatholobi (ji xue teng), 8g; dry lumbricus (di long), 5g; lignum sappan (su mu), 6g; radix achyranthis bidentatae (huai nui xi), 9g; radix dipsaci(chuan duan), 10g; fructus chaenomelis lagenariae (mu gua), 10g; radix gentianae macricphyllae (qin jiao), 10g; radix pseudoginseng (san qi), 6g; and hirudo (shui zhi), 3g. All except the final ingredient were decocted in water once per day and administered orally. The hirudo was powdered and taken orally in gelatin capsules. Twenty days of this regimen equaled one course of therapy.

The comparison group was administered 25mg of dipyridamole, 10mg of vitamin B₁ and 20mg of vitamin B₆ three times a day. Twenty days of this regimen likewise equaled one course of treatment.

Treatment Outcomes

Marked effect was defined as a marked improvement in, or disappearance of, self-conscious symptoms and either normal or markedly improved patellar and Achilles reflexes. Some effect meant reflected some improvement in both self-conscious symptoms and patellar and Achilles reflexes. No effect meant no improvement in self-conscious symptoms and no improvement in patellar and Achilles reflexes.

Based on these criteria, 41 patients in the treatment group (47.7%) were judged to have a marked effect; 38 patients (44.2%) received some effect; only seven patients (8/1%) failed to register an effect. The total amelioration rate in the treatment group was 91.9%.

In the comparison group, only two patients (6.3%) were judged to have experienced a marked effect. Nine patients (28.1%) received some effect; 21 patients (65.6%) did not register an effect. The total amelioration rate in the comparison group was only 34.4%; hence, there was a very marked difference in statistical outcomes between the two groups (P<0.005).

Author's Discussion

According to the study's author, diabetic peripheral neuropathy should be categorized as xue bi or blood impediment in Chinese medicine. While yin vacuity and dry heat are the basic disease mechanisms in diabetes, these do not just damage yin but also consume the qi. According to Chinese medical theory, if the qi becomes vacuous and weak, there will be no power to move the blood. Likewise, if there is yin vacuity, blood movement will also become difficult and choppy or astringent. In addition, because enduring diseases enter the network vessels (i.e., the smallest vessels in the body), this results in static blood in the network vessels. Because the movement and transportation of qi and blood is not smooth and easy, static blood obstructs and stagnates. The muscles and flesh of the limbs lose their nourishment, resulting in numbness and insensitivity. If the stasis obstruction is marked, then lack of free flow leads to pain.

Based on the above ideas of Chinese pathophysiology, the author then states that the requisite treatment principles for remedying this situation are to boost the qi and nourish yin, dispel stasis and free the flow of the network vessels. Within self-composed yi qi zhu yu tong mai tang, astragalus, dioscorea, scrophularia, atractylodis (a.k.a. atractylis) and dipsacus nourish yin, boost the qi, and supplement and boost the spleen and kidneys. Chaenomeles and gentiana soothe the sinews and free the flow of the network vessels. Achyranthes guides the other medicinals to move downward to the lower half of the body. Dang gui, red peony, moutan, persica, carthamus, pseudoginseng, lumbricus and hirudo are all strongly blood-quickening, stasis-dispelling medicinals, while lumbricus and hirudo in particular transform stasis and free the flow of the network vessels.

Hirudo's flavor is salty and its nature is cold. It enters the blood division and strongly dispels stasis. However, its nature is slow and relaxed (i.e., moderate); thus, it does not damage the righteous qi. It is used in this formula to eliminate deeply recalcitrant stasis accumulation.

Another medicinal the author singles out is pseudoginseng (a.k.a. notoginseng). According to the author, pseudoginseng has the ability to supplement vacuity. It is also able to quicken the blood and dispel stasis.

The author ends the article by saying that the patients in the study were treated with these medicinals for a long period of time and that no hemorrhagic symptoms or other adverse side-effects were seen during that time. Based on this formula's reported clinical efficacy and its freedom from side-effects, I think it is good to try for all PN patients whose Chinese medical pattern is (spleen) qi and (liver-kidney) yin vacuity complicated by blood stasis in the network vessels. However, if the patient's pattern is not the one stated above, one should not use this formula as a generic treatment for PN. As I have stated previously, professional Chinese medicine bases its treatment on each patient's personal pattern, not on their disease diagnosis.

References

1. Long JW. The Essential Guide to Prescription Drugs 1990. New York: Harper and Row, 1990, p. 193.
2. Shlay JC, et al. Acupuncture and amitriptyline for pain due to HIV-related peripheral neuropathy.JAMA Nov. 11 1998, pp. 1590-1600.