Acupuncture and Traditional Chinese Medical Approaches for Fibromyalgia
Douglas Yi Wang, LAc, Dipl. Ac., MD (China)
Fibromyalgia is a commonly encountered disorder characterized by widespread musculoskeletal pain, stiffness, paresthesia, nonrestorative sleep, and easy fatigability, along with multiple tender points that are widely and symmetrically distributed. Fibromyalgia affects predominantly women in a ratio of 8:1 or 9:1 compared to men. This disorder is found in most countries, in most ethnic groups, and in all types of climates. The prevalence of fibromyalgia in the general population of a community in the United States using the 1990 American College of Rheumatology (ACR) classification criteria was reported to be 3.4 percent in women and 0.5 percent in men. Contrary to some previous reports, fibromyalgia was not found to be present mainly in young women, but rather was most prevalent in women aged 50 years and above. The prevalence increased with age, being 7.4 percent in women between the ages of 70 and 79.
Clinical Manifestations
Symptoms include generalized aching and stiffness of the trunk, hip, and shoulder girdles. Other patients complain of generalized muscle aching and weakness. Patients may complain of low back pain, which may radiate into buttock and legs. Others complain of pain and tightness in the neck and across the upper posterior shoulders. Some patients complain of muscle pain after even mild exertion. Some degree of pain is always present. The pain has been described as burning or gnawing, or as soreness, stiffness or aching. While pain may begin in one region, such as the shoulders, neck, or lower back, it eventually becomes widespread. Patients may complain of joint pain and perceive that their joints are swollen; however, joint examination yields normal findings. Stiffness is usually present upon waking in the morning; usually it improves during the day, but in some patients, it lasts all day. Patients may complain of numbness of the hands and feet. They may also feel colder overall than others in the home, and some may experience Raynaud's-like phenomena or actual Raynaud's phenomenon. Patients complain of feeling fatigued and exhausted, and wake up tired. They also awaken frequently at night and have trouble falling back to sleep. Symptoms are made worse by stress, anxiety, cold, damp weather, and overexertion. Patients often feel better during warmer weather and vacations.
The characteristic feature on physical examination is the demonstration of specific tender points, which are exclusively more tender or painful than adjacent areas. The ACR criteria for fibromyalgia defines 18 tender points (see Figure 1). These points of tenderness are remarkably constant in location. A moderate degree of pressure should be used in digital palpation of these tender points. Some sources recommend that the tender site be palpated using a rolling motion, which may be more effective in eliciting the tenderness. Digital palpation appears to be as effective and accurate for the diagnosis of fibromyalgia as dolorimetry. The amount of pressure applied by the examiner introduces variability in interpretation, however. If too much pressure is applied, the pain will be produced even in normal subjects. Likewise, tenderness will not be appreciated if too little pressure is applied or the site is missed on palpation. Some patients are tender all over and not just at the specific tender point sites. These patients are still more tender over the specific tender point sites; however, sites where there is usually no tenderness and which can be used as controls are the dorsum of the third digit between the proximal interphalangeal and distal interphalangeal joints, the medial third of the clavicle, the medial malleolus, and the forehead.
Skinfold tenderness may be present, particularly over the upper scapular region. Subcutaneous nodules may be felt at sites of tenderness.
Fibromyalgia may be triggered by emotional stress, medical illness, surgery, hypothyroidism, and trauma. It has appeared in some patients with HIV infection, parvovirus B19 infection, or Lyme disease. Disorders commonly associated with fibromyalgia include irritable bowel syndrome, irritable bladder, headaches (including migraine headaches), dysmenorrhea, premenstrual syndrome, restless leg syndrome, temporomandibular joint pain, and Sicca syndrome.
Diagnosis
Fibromyalgia is diagnosed by a history of widespread pain and the demonstration of at least 11 of the 18 tender point sites on digital palpation. However, not all patients with fibromyalgia meet these criteria. Some patients have fewer tender sites and more regional pain, and may be considered to have probable fibromyalgia.
Results of joint and muscle examination are normal in fibromyalgia patients, and there are no laboratory abnormalities.
Common Typical TCM Patterns for Fibromyalgia
There are four common typical TCM patterns for fibromyalgia. However, one person may exhibit more than one pattern. The patterns are:
1. Liver Qi Stagnation - anxiety, emotional upset, headaches (including migraine headache), being easily angered, muscle stiffness in neck and shoulders, insomnia, waking frequently and having difficulty falling back to sleep, irritable bowel syndrome. All symptoms may be triggered by emotional stress.
Tongue: slightly dusky or slightly puffy
Pulse: wiry/bowstring or slippery
Treatment plan: smooth liver, move qi and blood
Chinese medicine: modifications based on xiao yao wan or shu gan wan
Acupuncture points: yin tang, LI 4, LV 3, GB 34, an mian, ren 17, ren 12, ST 25, SP 6, UB 18, 19, and 20
Ear points: shen men, liver, sympathetic
2. Qi and Blood Deficiency - specifically spleen qi deficiency and heart blood/liver blood deficiency, with such symptoms as chronic fatigue, exhaustion, dull headache, muscle weakness and numbness, insomnia, dream-disturbed sleep and waking up tired, palpitations and depression.
Tongue: pale, with thin white fur
Pulse: thready, weak and deep. This pattern eventually creates pattern #3 below.
Treatment plan: tonify qi and blood, calm the spirit
Chinese medicine: modifications based on ba zhen tang or gui pi tang or gan mai da zao tang
Acupuncture points: LI 4, ST 36, ren 12, SP 6, 10, PC 6, HT 6, 7, Kid 3, and UB 17, 20
Ear points: adrenal, endocrine, heart, spleen
3. Qi Stagnation and Blood Stasis - aches and pains in the whole body, burning or gnawing pain with tingling sensations in extremities, headaches.
Tongue: purple, dusky
Pulse: wiry or irregular
Treatment plan: move the qi and blood, alleviate pain
Chinese medicine: modifications based on shen tong zhu yu tang or tao hong si wu tang
Acupuncture points: DU 20, LI 4, 10, ST 36, SP 9, 10, LV 3, PC 6, UB 17, 18
Ear points: shen men, adrenal, subcortex.
4. Kidney Deficiency (either Yin, Yang, Qi or Essence Deficiency) - there will be impotence or lack of libido for males and infertility issues for both males and females. Other symptoms: sore lower back with restless leg syndrome, irritable bladder, dysmenorrhea, amenorrhea, premenstrual syndrome, hot flashes and night sweats.
Tongue: pale or dry, with cracks
Pulse: thin, weak and deep
Treatment plan: tonify qi, tonify essence and yang, and nourish yin
Chinese medicine: modifications based on you /zuo gui yin (wan), jin gui sheng qi wan, jin suo gu jing wan
Fibromyalgia doesn't seem to affect the lung so often, as there are few lung symptoms associated with fibromyalgia such as chest tightness, or shortness of breath in a few cases.
Special Points for Fibromyalgia Pain
Integrative medicine, in terms of acupuncture and Chinese medicine combined with Western medicine and other therapies, is very helpful in treating all kinds of pain related to fibromyalgia. As a neuropsychiatrist, I have been continuously working and studying at hospitals in China, as well as at my clinic in United States, for over 20 years. Based on my experiences, I now have a personal conclusion about some special acupuncture points, which are very useful and applicable in fibromyalgia.
Special Acupuncture Points
Ashi points: Use any tender points that the patient has along with any of the following points listed below. There are a total of 18 tender point sites that may present in fibromyalgia, which are located in Figure 1. Note that the points are in groups of three, so they are referred to as "three points" along with the body area's name (for example, "the three arm points").
Headache (includes migraines): For frontal/temple headache, GB 14, tai yang and yin tang or er zhong (above yin tang, in line with GB14). For vertex headache: Du 20 and si shen cong. You can do a variation of si shen cong by putting the needles 1.5 cun out from Du 20 (si shen cong is 1 cun out from DU 20). Occipital headache: UB10, DU17 and GB20.
Neck pain: UB 11, GB 20 and bai lao.
Shoulder pain: LI 15, and two experienced points: point A, 2 cun anterior to LI 15 under the clavicle, and point B, 2 cun posterior to LI 15 on the back (half way between SJ 14 and LI 16).
Arm pain: LI 11, SJ 5 and LI 4.
Upper back pain: UB 11, UB 17, SI 12
Lower back pain: UB 23, UB 25 and UB 52
Leg pain: ST 36, SP 6, GB 30
Thigh pain: SP 10, SP 11/ST 31 and ST 32
For any tight muscle: release the muscle with three needles - one at each insertion and one in the middle of the muscle.
Acupuncture and Chinese medicine provide relief of symptoms by balancing yin and yang, and adjusting the circulation of qi and the blood. Local measures such as heat, therapeutic massage, cupping, moxibustion and gua sha in specific regions also help to reduce the pain. A regular plan, with long-term, consistent integrative treatment is necessary in patients with fibromyalgia.
Reference
Harrison's Principles of Internal Medicine, 16th edition.
Pelvic pain has a prevalence of >25% in women and >15% in men, and up to 50% of cases are undiagnosed, demonstrating that there is a definite need for pelvic care awareness among health care practitioners. As holistic practitioners, acupuncturists offer a safe space for clients and are often the practitioners clients seek out when nothing else has worked. Thus, acupuncturists are presented with an opportunity to serve an underserved population.
Though the creation of a financially sustainable, health-promoting model feels far away today, we are casting a vision for a full return on health, believing that this compels us to keep one foot firmly rooted in caring for the sick and the other foot firmly founded in maintaining health. Shifting from a fee-for-service model to value-based care using a phased approach is paramount.
Traditional Chinese medicine and the Vedic traditions both offer rich frameworks for understanding human health, emphasizing the balance of physical, mental, and spiritual aspects. The concept of "souls" or spiritual components in TCM, namely Hun, Po, Shen, Yi, and Zhi, bears significant similarities to the yogic concept of koshas. Their similarities and differences provide insights into how these systems contribute to holistic health practices.
