Traditional Chinese Medicine for Fibromyalgia
Over 15 million people live with fibromyalgia (FM), a disorder with an estimated annual direct cost that exceeds $20 billion. FM is associated with a multiplicity of symptoms such as pain,1,2 work limitations,3 poor quality of life,4 poor coping,1 poor physical functioning,5 and multiple chronic comorbidities that make it particularly challenging to treat. Rational evidence-based treatment paradigms are emerging, but there remains a research-to-practice gap, leaving patients to seek out their own treatment options. Alternatively, patients may seek guidance from their provider about adding complementary therapies to their existing treatment plan. Therefore, patients are increasingly seeking out Traditional Chinese medicine (TCM) for answers concerning FM. Evidence-based clinical studies suggest that there are both Eastern and Western interventions that treat FM symptoms, provide maximization of function and enhance quality of life. However, Western-educated health care providers may be uncertain as to the scope, efficacy or safety of TCM therapies. The purpose of this paper is to describe the components of TCM, overview the state of the science in regards to safety and efficacy and, when appropriate, help patients find the best trained TCM practitioners.
Traditional Chinese Medicine
Traditional Chinese Medicine is a full medical system that has been practiced in Asia for over 3,000 years. TCM includes several modalities including acupuncture, herbal medicine, tai chi, qi gong, and tuina.
Acupuncture is the most commonly known and practiced modality in the U.S. While there is a wide variety of techniques used in acupuncture, it is commonly defined as the penetration of the skin with thin, solid needles at specific anatomical points. Generally, acupuncture delivered by a licensed acupuncturist is extremely safe. The major risk of acupuncture is pneumothorax from puncturing the lungs. Witt6 indicates that is a very rare occurrence, with an estimated frequency of 0.001% in an observational study of patients receiving acupuncture. The most common side effects are hematoma or bleeding (6.7%) and pain (2.0%).6 A frequent concern is of disease transmission but this has been virtually eliminated with the standardization of disposable, single use needles.
Herbal medicine is the second most common TCM modality practiced in the U.S. In China, this is the primary modality of TCM and is used for a wider range of ailments than acupuncture. In Nanjing University Hospital, fibromyalgia is treated primarily with herbal medicine and only secondarily with acupuncture. Herbal medicine includes over 2,000 different medicinal substances, with 80 to 100 of them commonly used for the treatment of fibromyalgia. As practiced in the U.S., herbal formulas are generally given in decoction, powdered or pill form. The formulas tend to consist of 6-12 herbs with a balanced approach that include a focus on ameliorating the side effects that one has from single herbs. For example, it is very common that formulas have a small amount of ginger added to make the formulas easier on the digestion. It is commonly thought that decoction or granulated formulas are superior to pill form as they can easily be modified to address different symptom profiles. However, it is often easier to get patients to take the formulas in pill form as they have little or no taste—unlike the decoctions (and, to a lesser extent, granules) which can be very bitter or pungent.
Tai Chi and Qigong are two common movement-based therapies that are considered modalities of TCM. Tai Chi is a martial arts form that is often considered moving meditation. It has been used as an adjunctive therapy for many ailments as well as general wellbeing. Qigong is a movement and breathing system developed specifically for medical purposes.
Tuina is a form of manual therapy that includes specific types of massage, acupressure, and chiropractic adjustments. Tuina is often a subspecialty of the TCM practitioner but can be used in conjunction with any of the other modalities of TCM. In the U.S., those trained in tuina generally do not practice adjustments as they are not in their scope of practice.
Each of these modalities includes the same medical theoretical underpinnings and indications. This allows the practitioner to make informed decisions, based on TCM theory, about which modalities are likely to be more effective.
State of Research
While there are many modalities in TCM, the vast amount of research has been focused on acupuncture. Just in the last three years, there have been several different systematic reviews. The two most recent reviews of acupuncture have shown that acupuncture significantly improves VAS pain scores compared to sham acupuncture (p=0.00001).7,8 When compared to first generation pharmaceuticals (meloxicam, oryzanol, mirtazapine, or amitriptyline), acupuncture was found to be significantly better at reducing pain and number of tender points.8 There was further evidence that the relapse rate of pain was better with acupuncture than amitriptyline.
The most recent review, done by Cao et al,8 includes both acupuncture and herbs. This review found that the active components of the various trials could not be grouped due to widely differing active components used in the studies. Of the six studies, five reported improvement compared to pharmaceuticals on measures including depression, VAS, symptoms and quality of life. Herbal decoctions tend to focus on reducing stress with formulas such as jiawei xiaoyao san or reducing blood stagnation and cold with formulas such as shugan jieyu huoxue tongluo wan. The only single herb studied for the treatment of fibromyalgia was rhizome drynariae, which showed no significant effect on VAS.9 It should be noted that there are a plethora of Chinese herbs that fibromyalgia patients might be taking to treat the symptoms of fibromyalgia such as hypericum (guan ye lian qiao) for depression, American ginseng (xi yang shen) for lethargy, and valerian root (xie cao) for insomnia.
While there is limited research on tai chi and qigong for fibromyalgia, clinically one would expect that these would be a good match for fibromyalgia patients. One study of tai chi10 reported improvements in the Fibromyalgia Impact Questionnaire11 and the SF36. A systematic review of qigong for pain indicated that the study quality was low and called for additional research into this area of pain management.12
Currently there are no studies in Pubmed that address the treatment of fibromyalgia with tuina. A more general review of massage for fibromyalgia indicated that there is evidence supporting the use of massage for the reduction of pain but that the evidence was not conclusive.13 This review indicates that there is evidence of reduction of anxiety, improved sleep, and lowered depression.