Chronic fatigue syndrome

Keywords: Chinese medicine, acupuncture, chronic fatigue syndrome (CFS), seven star needling, cupping, electro-acupuncture

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Chronic fatigue syndrome (CFS) refers to long-standing severe fatigue without substantial muscle weakness and without proven psychological or physical causes. This condition is also known as chronic fatigue immune deficiency syndrome (CFIDS). The prevalence of this condition is estimated to be somewhere between seven and 38 cases per 100,000, and women are 1.3-1.7 times more susceptible to it than men. Although chronic viral infection has been proposed as the etiology of this condition, this remains somewhat controversial. Other proposed but unproven etiologies include immunologic abnormalities, endocrine abnormalities, abnormal levels of neurotransmitters, inadequate cerebral circulation, and elevated levels of angiotensin-converting enzyme. Although this diagnostic category is a relatively recent one, a number of studies have been conducted on it in the People's Republic of China in terms of its treatment with acupuncture and its related adjunctive modalities. Four studies are included below.

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Study 1. For instance, Wang Wei-hong et al. published an article titled, "A Clinical Audit of the Treatment of Chronic Fatigue Syndrome with Acupuncture Combined with Cupping." This article appeared in issue #8, 2001 of Zhong Guo Zhen Jiu (Chinese Acupuncture & Moxibustion) on pages 481-482.

Cohort description: There were 50 patients altogether in this study, all of whom were seen as out-patients at the Ju County Chinese Medical Hospital in Shandong. These 50 patients were randomly divided into a treatment and a comparison group of 25 patients each. In the treatment group, there were 18 males and seven females aged 19-52 years. The shortest duration of illness was eight months and the longest was five years. In the comparison group, there were 16 males and nine females aged 23-55 years. These patients had been ill for from seven months to three years. The criteria for establishing a diagnosis of chronic fatigue syndrome in this study were those established by the US Centers for Disease Control in 1991. These consisted of main and secondary symptoms combined with physical signs. The main symptoms included fatigue continuing for over six months. The fatigue was severe enough to limit the amount of the patient's activity. Other fatigue-inducing diseases had been ruled out in all cases.

Secondary symptoms consisted of the following occurring simultaneously with or after the fatigue and continuing or occurring repeatedly for over six months: low-grade fever, sore throat, swollen lymph nodes, generalized muscular flaccidity and weakness, muscular pain and soreness, fatigue continuing 24 hours after activity, headache, wandering arthralgia, and neuropsychiatric symptoms such as depression and sleep disturbances. Physical signs included a body temperature of 37.5-38.5[degrees]C, local pharyngitis, and swelling of the cervical lymph nodes larger than 1cm in diameter. Exclusion criteria consisted of psychosis and drug dependency or abuse.

Treatment method: Patients in the treatment group were needled at Da Zhui (GV 14), Zhi Yang (GV 9), Xin Shu (Bl 15), Ge Shu (Bl 17), Ming Men (GV4), Shen Shu (Bl 23), and Chang Qiang (GV 1) with even supplementing-even draining technique and moderate stimulation. After obtaining the qi, the needles were retained for 40 minutes. After the needles were withdrawn, cupping therapy was applied on the governing vessel and the medial and lateral lines of the foot tai yang bladder channel. Using a large cup and an oil lubricant, sliding cupping was performed on the upper back until red or dark red spots or patches appeared on the skin and the patient felt a sensation of heat on the back. After the cupping, the local skin was cleaned with a sterilized cotton ball and the patient was advised to keep their body warm and not to bathe for one day after the treatment. This treatment was given once every six days, with 30 days equaling one course of therapy. Three days rest was allowed between successive courses.

The comparison group was treated with the following Chinese medicinals in liquid extract form: Radix Astragali Membranacei (Huang Qi), Radix Panacis Ginseng (Ren Shen), cooked Radix Rehmanniae (Shu Di), Fructus Corni Officinalis (Shan Zhu Yu), Cortex Eucommiae Ulmoidis (Du Zhong), Fructus Lycii Chinensis (Gou Qi Zi), Radix Angelicae Sinensis (Dang Gui), Carapax Amydae Sinensis (Bie Jia), Herba Epimedii (Xian Ling Pi), Sclerotium Poriae Cocos (Fu Ling), and Fructus Zizyphi Jujubae (Da Zao). Twenty-five milligrams of these medicinals were administered orally two times per day in a ready-made form manufactured by the Qingdao Third Pharmaceutical Factory.

Study outcomes: Cure was defined as complete disappearance of the clinical symptoms and resumption of normal work and life. Marked effect was defined as basic disappearance of clinical symptoms and resumption of normal work and life. Some effect was defined as marked improvement in clinical symptoms but the patient was still not able to resume normal work. No effect meant that there was no obvious improvement in symptoms and the patient could not resume normal work and life. Based on these criteria, after one month of treatment, the total amelioration rate in the treatment group was 92%, while it was only 64% in the comparison group. Therefore, there was a significant statistical differences in effectiveness between these two protocols (P < 0.05).

Discussion: Four out of seven of the points needled in the above protocol are located on the governing vessel. The governing vessel is the sea of yang, and fatigue is a failure of yang qi to be upborne and spread freely throughout the body. This failure may be due to either yang qi vacuity or blockage and obstruction to its free flow. By needling these governing vessel points, one can stimulate the yang qi of the body, leading it to rise upward and to flow outward. The other three points are those of the heart, blood, and the kidneys. The heart is the abode of the spirit which is the ruler of the entire body, while the kidneys are the former heaven root. The blood is that which nourishes and moistens the entire body and is the mother of the qi. Doing sliding cupping on the governing vessel and foot tai yang bladder channels on the back (the yang side of the body) can likewise, lead the qi into the yang tract so that it can ascend and spread throughout the body.

One of the key things about this protocol as a Western practitioner is that it was only done once per week. This is the same treatment frequency as is common in the West. Many other Chinese protocols are based on daily or every other day treatment, and it is reassuring to know that this protocol can be clinically effective even though it is done only once per week. In addition, many patients with CFS are abnormally sensitive to and shy of needles. Therefore, the fact that this protocol only uses a very few needles and relies more on cupping is also, I think, a plus.

Study 2. On pages 61-62 of issue #1, 2005 of Xin Zhong Yi (New Chinese Medicine), Li Yue-min et al. published an article titled, "Observations of the Therapeutic Effects of Treating 32 Cases of Chronic Fatigue Syndrome with Electro-acupuncture Combined with Ear Point Pressure."

Cohort description: Altogether, there were 64 patients enrolled in this study who suffered from chronic fatigue syndrome. All these patients were treated at the No. 1 Affiliated Hospital of the Guangzhou Chinese Medical University. These 64 patients were randomly divided into two groups, a treatment group and a comparison group. In the treatment group of 32, there were 19 males and 13 females aged 21-60 years, with an average age of 38. These patients had suffered from CFS for from eight months to 16 years, with an average disease duration of four years. In the comparison group of 32, there were 17 males and 15 females aged 20-62, with an average age of 37.5 years. These patients had suffered from CFS for from 1-15 years, with an average disease duration of four years. Therefore, in terms of age, sex, and disease duration, there was no significant statistical difference (P>0.05). In terms of the diagnostic criteria for CFS, patients had all suffered from serious continuous fatigue for six months or more. The authors further used the rating scale system of David S. Bell as found in his book, The Doctor's Guide to Chronic Fatigue Syndrome (NY, 1995, p. 122-123). This system subtracts points from a perfect score of 100. Then points are subtracted for the presence and severity of eight sets of symptoms: 1) impaired memory and/or decreased ability to think, 2) inflammation of the throat, 3) cervical lymphadenopathy with pressure pain, 4) muscle pain, 5) joint inflammation and pain in multiple joints, 6) recent onset of headaches, 7) sleep disturbances, and 8) extreme discomfort after exertion. Exclusion criteria included such causes of fatigue as hypothyroidism, insomnia, type B hepatitis, and reactions to medications. They also included serious obesity and a body mass index of more than 45.

Treatment method: Members of the treatment group received the following electro-acupuncture protocol. The main points consisted of the Hua Tuo paravertebral points from T1 to L 5. The auxiliary points consisted of Si Shen Cong (M-HN-1) if there was mainly mental exhaustion and fatigue and Zu San Li (St 36) and Qi Hai (CV 6) if there was mainly physical exhaustion and fatigue. Each time, 8-10 of the above points were chosen and needled with 1.5 inch 28 gauge needles. Points on the head were needled at 45 degree angle. Otherwise, the points were all needled perpendicularly. After insertion, the needles were stimulated using a 6805-G electro-acupuncture machine with a densely dispersing wave and as strong a stimulation as the patient could bear. This treatment lasted 30 minutes each time and was done once each day. After the electro-acupuncture, the following main ear points were chosen: Shen Men, Sympathetic, and Subcortex. Auxiliary points consisted of: Heart, Liver, Spleen, Lungs, and Kidneys. All the main points were used in combination with 2-3 of the auxiliary points. Seeds were taped over these points. Each day, these points were pressed three times, once in the morning, at noon, and at night, for five minutes each time. Ten days equaled one course of treatment. After each course, a three day rest was allowed, and a maximum of three courses were given.

Members of the comparison group were given hydrocortisone tablets once per day. Ten days also equaled one course of treatment for the members of this group, and three courses were given. During the first course, patients received 5mg per day of the hydrocortisone. This dose was decreased to 2.5mg per day during the second course, and the dose was reduced to 1.25mg per day during the third course.

Study outcomes: Clinical cure was defined as disappearance of symptoms at rest, with no or only very slight symptoms after exertion. Patients were able to resume their normal lifestyle and work. Their Bell score was 90 points or higher. Marked effect was defined as a marked improvement in clinical symptoms. At rest, the symptoms were nonexistent or very slight and only got slightly worse after exertion. Patients were able to function at 70-90% of normal, and had a Bell score of 60 points or higher. Some effect meant that there was some improvement in clinical symptoms. At rest times, symptoms were only moderate. However, after exertion, they became markedly more severe. Patients were able to function at only 50-60% of normal, and their Bell score was 40 points of more. No effect meant that there was no improvement in clinical symptoms which were moderate to severe in degree. Patients' function was less than 50% of normal, and their Bell score was 30 points or less. The following table shows the outcomes based on these criteria.

Discussion: According to the authors, CFS is most likely due to viral infection of the nervous system (and primarily the brain), which then affects the endocrine system, immune system, and motor system. In Chinese medicine, it is categorized as vacuity taxation. Its Chinese disease mechanisms are mainly a loss of normalcy of mental-emotional function and the qi transformation of the five viscera. Mostly it presents as a vacuity pattern. Therefore, electro-acupuncture was given mainly to the paravertebral points and the Si Shen Cong located over the brain. The Hua Tuo paravertebral points are located between the foot tai yang bladder channel and the governing vessel. The back transport points located on the foot tai yang bladder channel connect directly with the five viscera, while the governing vessel enters the brain. Located between these two channels, the Hua Tuo paravertebral points have a marked ability to both regulate the function of the five viscera and affect the central nervous system in general and the brain in particular. In addition, the combination of Zu San Li and Qi Hai supplements and boosts the source qi and regulates and harmonizes the five viscera. Modern research has also shown that the ear points have a pronounced ability to affect the central nervous system through various nerves that communicate with the ear. Thus the authors believe this protocol addresses both the modern Western and traditional Chinese disease mechanisms of this condition.

Study 3. On page 448 of issue #10, 2004 of the Zhe Jiang Zhong Yi Za Zhi (Zhejiang Journal of Chinese Medicine), Shi Yi-li and De Ru-hua of the Hebei Provincial Chinese Medical Hospital published an article titled, "The Treatment of 52 Cases of Chronic Fatigue Syndrome with Knocking Pricking of Brain Acuity Three Lines."

Cohort description: Altogether, there were 78 patients enrolled in this study, all of whom had CFS as defined by the 1991 U.S. CDC diagnostic criteria. Of the seven criteria for this diagnosis, each patient had to manifest at least four of them. These 78 patients were divided into a treatment group of 52 patients and a comparison group of 26. No further description of these patients was given by the Chinese authors in terms of sex, age, or disease duration. However, part of the definition of CFS is that symptoms must have lasted six months or more.

Treatment method: Treatment of the treatment group consisted of seven star needling three rows of points on the cranium. This was called "knocking and pricking" by the Chinese authors. Seven star needling is also called plum blossom needling and skin needling. The first row was along the governing vessel on the mid-line of the cranium from Hou Ding (GV 19) to

Shang Xing

(GV 23). The second two rows consisted of the right and left bladder channels from

Wu Chu

(Bl 5) to Luo Que (Bl 8, a.k.a. Nao Gai). These lines were knocked and pricked with weak to medium stimulation. Each row was "needled" for approximately 10-20 minutes. This was done once every other day.

The comparison group received fine needle acupuncture at the following points: Bai Hui (GV 20), Tai Yang (M-HN-9), Feng Chi (Gb 20), Qu Chi (LI 11), and Zu San Li (St36). Turning-twisting supplementing hand technique was used at all these points. After obtaining the qi, the needles were retained for 20 minutes. One treatment was performed per day, and eight treatments equaled one course of treatment. Two days rest were allowed between each two successive courses. Both groups were treated for a period of 60 days before outcomes were analyzed.

Study outcomes: Cure was defined as complete disappearance of symptoms with return to normal work and lifestyle. Marked effect was defined as basic disappearance of symptoms and return to normal work. Some effect was defined as marked improvement in symptoms. However, the patient was still not able to work. No effect meant that there was no obvious improvement in symptoms and still not able to return to one's normal lifestyle and work. The following table shows the outcomes of these two groups based on these criteria.

These outcomes show that the seven star needling of the three rows on the top of the head every other day was more effective than the daily fine needle acupuncture of a specific group of points.

Discussion: According to the two Chinese authors, CFS is categorized in Chinese medicine as vacuity taxation disorder. It is mostly due to loss of regulation in the function of the viscera and bowels resulting in insufficiency in the engenderment and transformation of qi and blood, yin and yang. According to Chinese medical theory: The head is the meeting of all yang [and] the mansion of clear yang. The efflorescence of the essence and blood of the five viscera and the clear yang qi of the six bowels all ascend and pour into the head.

The brain acuity three rows or lines are all located on the vertex of the head on the governing vessel and foot tai yang bladder channels. The governing vessel commands all the yang channels. Thus it is called the sea of yang vessels. The bladder channel and it connect with each other, and their channel qi mutually communicates of flows freely between the two. The back transport points situated on the bladder channel are where the essence qi of the five viscera is transported to and pours into. Therefore, the bladder channel can also be called the bridge between the brain and the channels and network vessels of the viscera and bowels. Thus knocking and pricking these three rows or lines is able to raise and vitalize the yang qi, to promote yang's engenderment and yin's growth, to regulate and supplement the five viscera, to supplement and boost both former and latter heavens, and to wash away and flush depression and stagnation.

Study 4. Huang Yong and Yu Qian published an interesting article on the treatment of chronic fatigue syndrome (CFS) using cupping on the back. Titled, "A Clinical Audit of the Treatment of 30 Cases of Chronic Fatigue Syndrome with Cupping on the Back," this article appeared in Si Chuan Zhong Yi (Sichuan Chinese Medicine), #6, 2001, on pages 70 & 71.

Cohort description: All 30 patients in this study were seen as out-patients. Nine were male and 21 were female, aged 28-54, with a median age of 37.89[+ or -]3.05 years. These patients had suffered from CFS from 6-18 months, with a median duration of 9.78[+ or -]0.55 months. All were diagnosed according to criteria published by the U.S. Center for Disease Control (CDC) as reported in Zhang and Zhang's Lin Chuang Xin Ji Bing Shou Ce (A Clinical Handbook of New Diseases), People's Army Medical Publishing Co., Beijing, 1998. Exclusion criteria included brain or organic visceral pathologies, depression, or other neurological or psychiatric disorders. All 30 cases suffered from fatigue, 21 from headache, 18 from dizziness, 12 from head distention, 17 from blurred vision, 22 from tinnitus, nine from vexatious heat in the five hearts, nine from spontaneous perspiration, six from night sweats, five from sore throat, five from chest opression, and 29 from muscle-joint, neck, shoulder, upper back aching and pain. Twelve suffered from low back and knee soreness and limpness, six from lymphadenopathy, 25 from insomnia, 13 from profuse dreams, 22 from impaired memory, 30 from poor intake, six from a bitter taste in the mouth, 21 from a bland taste in the mouth, 12 from abdominal distention, nine from diarrhea, six from alternating diarrhea and constipation, and seven cases of nocturia three or more times per night.

Treatment method: All the patients in this study were treated with sliding cupping on their backs. Hong Hua You (Carthamus Oil) was first applied to the back. Then the cups were applied and moved up and down the back until a large area of the back was flushed red and hyperemic. This was done two times per week for 12 treatments. Treatments were suspended in women during their menses

Outcomes criteria: Each of the above listed symptoms was measured before and after treatment using a 30 point rating scale. The most severe symptoms were scored 30, moderately severe symptoms were scored 20, relatively light symptoms were scored 10, and any symptom which was absent received a zero. These scores were then compared from before to after treatment.

Study outcomes: There was no marked mean reduction in the above-described scores in terms of head distention, vexatious heat in the five hearts, or a bitter taste in the mouth. Otherwise, there were marked mean reductions in all other symptoms (P+0.01-0.05). In particular, there were marked changes for the better in lassitude of the spirit and lack of strength, headache, spontaneous perspiration, sore throat, insomnia, profuse dreams, impaired memory, poor intake, a bland taste in the mouth, abdominal distention, diarrhea, and alternating diarrhea and constipation. For instance, fatigue and lack of strength went from a mean of 26.07[+ or -]3.44 to a mean of 5.33[+ or -]4.01, insomnia went from a mean of 22.39[+ or -]4.69 to a mean of 9.83[+ or -]3.64, and torpid intake went from a mean of 27.94[+ or -]4.08 to a mean of 5.35[+ or -]1.09.

Discussion: According to Huang and Yu, the symptoms of CFS mainly correspond to qi and yin, spleen and kidney vacuities. The back is traversed by the foot tai yang bladder channel and the governing vessel. On the inner or medial line of the bladder channel on the back, there are the back transport points of the five viscera and six bowels, such as Xin Shu (Bl 15), Shen Shu (Bl 23), and Pi Shu (Bl 20). Stimulation of these back transport points can regulate the function of the viscera and bowels. On the outer or lateral line of the bladder channel on the back, there are points such as Po Hu (Bl 42), Shen Tang (Bl 44), and Zhi Shi (Bl 52). Stimulation of these points can regulate and rectify the spirit qi of the five viscera and six bowels as well as course and rectify their qi mechanisms. In addition, stimulation of points on the back can vitalize and lift the yang qi, course the channels and quicken the network vessels, and eliminate the stasis, dampness, and/or cold which may result in stagnation and astringency. Use of Hong Hua You not only facilitates the sliding cupping mechanically but also has the effect of quickening the blood and transforming stasis. Therefore, this treatment technique is able to regulate and rectify the viscera and bowels of the entire organism, vitalize and lift the yang qi, transport and move the qi and blood, and dispel and eliminate disease evils. Huang and Yu say it can be seen as a combination of stimulation of channel and network vessel transport points, massage, and herbal medicine.

Copyright [c] Blue Poppy Press, 2005. All rights reserved.

abstracted & translated by Honora Lee Wolfe, Dipl. Ac., Lic. Ac., FNAAOM

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