Treatment approaches for autonomic nervous system dysbalances

Transcription

Advanced Clinical Practice, Self Directed Research
Module code: 3TCM7A3
Project title:
Review and comparative literature analysis on treatment approaches for autonomic nervous system dysbalances with Chinese herbal medicine July 2015
Word count: 7648
This report is submitted in partial fulfilment of the requirements of the University of
Westminster for the award of Master of Science Chinese Herbal Medicine.
The project is the property of Brigitte Elisabeth Scheffold but may be available to the public
for borrowing, photocopying or consultation, with the prior consent of the author.
Abstract
II
Abstract
Newly emerging diseases like dysautonomia, chronic fatigue syndrome, fibromyalgia,
adrenal fatigue syndrome and burnout seem to share an underlying cluster of autonomic
nervous system pathologies, which can not be treated sufficiently so far.
This paper aims to provide an overview of the terminology, definition and diagnosis of
autonomic nervous system dysbalances in Western and traditional Chinese medicine. A
review and a comparative literature analysis were performed to identify possible Chinese
herbal medicine treatment approaches for patterns related with diseases of the autonomic
nervous system.
Chinese herbal medicine treatment approaches for dysautonomia were identified by
performing an online research including studies of the PubMed database in English language
until 8/7/2015. Additionally, a comparative literature analysis was performed by screening
seven TCM reference books for 14 search terms related to autonomic nervous system
disorders.
The review included 9 trials with 11 different formulas, a combination of 2 single herbs and 1
single herb, and the comparative literature analysis found 88 formulas of 39 different
categories with a total of 204 single herbs. Analysis revealed that formulas of the categories
to regulate qi, harmonize, calm the spirit, dispel phlegm and tonify qi were most frequently
used. The 5 most frequently prescribed formulas included Ban Xia Hou Po Tang, Gui Pi
Tang, Wen Dan Tang, Chai Hu jia Long Gu Mu Li Tang and Gan Mai Da Zao Tang. A list of
frequently occuring herbs was also provided.
The findings of this research offer several treatment options for patterns related to
dysbalances of the ANS and could serve as a guideline for TCM practitioners to treat the
multiple symptoms of ANS diseases with Chinese herbal medicine.
Table of Contents
III
Table of Contents Abstract ...................................................................................................................... II Table of Contents ..................................................................................................... III Glossary ..................................................................................................................... 4 A Introduction ............................................................................................................ 1 B Background ............................................................................................................ 3 1. Dysautonomia in Western Medicine .................................................................... 3 1.1 Definition of Dysautonomia in Western Medicine........................................... 3 1.2 Dysautonomia and Neurasthenia in the West ................................................ 5 1.3 Dysautonomia and Neurasthenia in China..................................................... 6 1.4 Dysautonomia and other differential diagnoses ............................................. 8 1.5 Etiology and Pathomechanisms of Dysautonomia in Western medicine ..... 11 1.6 Western Medicine treatment ........................................................................ 13 2. Dysautonomia in Traditional Chinese Medicine ................................................. 15 2.1 (Autonomic) Nervous System in TCM .......................................................... 15 2.2 Patterns of Dysautonomia or Neurasthenia in TCM..................................... 16 2.3 Etiology and Pathomechanisms of Dysautonomia in TCM .......................... 18 C Research Methods ............................................................................................... 21 1. Comparative Literature Analysis of Dysautonomia Treatment in TCM .............. 21 1.1 Search methods for comparative literature analysis .................................... 21 1.2 Comparative Literature Analysis Results ..................................................... 22 2. Online Database Research of Dysautonomia Treatment in TCM ...................... 27 2.1 Search methods for online database research ............................................ 27 2.2 Online Database Research Results ............................................................. 29 D Discussion............................................................................................................ 32 E Conclusion ........................................................................................................... 37 References ............................................................................................................... 38 Appendix .................................................................................................................. 46 Glossary
IV
Glossary
ACTH
Adrenocorticotropic Hormone
AF
Adrenal Fatigue
ANS
Autonomic Nervous System
CCMD
Chinese Classification of Mental Disorders
CFS
Chronic Fatigue Syndrom
CNS
Central Nervous System
CRF
Corticotropin Releasing Factor
DSM
Diagnostic and Statistical Manual of Mental Disorders
FM
Fibromyalgia
HPA
Hypothalamic–pituitary–adrenal axis
ICD 10
International Classification of Diseases
PAF
Pure Autonomic Failure
TCM
Traditional Chinese Medicine
WHO
World Health Organisation
WM
Western Medicine
A Introduction
1
A Introduction
In recent years, several new conditions like autonomic nervous system dysbalance or
dysautonomia, chronic fatigue syndrome (CF), fibromyalgia (FM), adrenal fatigue
syndrome (AF) and burnout appeared. Researchers suggest, that these diseases
share a common underlying cluster of autonomic nervous system (ANS) pathologies
caused by periods of acute or chronic stress of either mental or physical nature
(Rowe et al., 1995; Bou-Holaigah et al., 1995; LaManca et al., 1999; Schondorf et al.,
1999). All of these syndromes include a broad and vaguely defined range of patterns
and symptoms, which cannot be sufficiently treated by Western medicine yet
(NINDS, 2013).
However, in contrary to Western medicine (WM) an important principle of traditional
Chinese medicine (TCM) says 'one disease, many patterns - one pattern, many
diseases' (Maciocia, 2015, p441). This individually adaptable treatment approach of
TCM might therefore offer suitable treatment options for conditions with various
patterns of underlying ANS dysbalances.
This paper aims to first provide an overview of the definition and diagnosis of various
ANS diseases and will also try to explain their etiology and underlying
pathomechanisms from both a Western medicine and traditional Chinese medicine
point of view. Furthermore, former terminology of these conditions and of similar
syndromes will be discussed, as part of it is still used in modern psychosomatic
medicine in China and still plays an important role in the nomenclature of these
diseases in traditional Chinese medicine books.
A Introduction
2
The resulting findings will then be applied as search terms for a short online
database research and for a broader comparative literature research to define
possible treatment approaches with Chinese herbal medicine (CHM).
Results will be discussed to provide an overview of frequently used formula
categories, herbal formulas and frequently used single herbs for the treatment of
dysbalances of the autonomic nervous system.
B Background
3
B Background
As the term dysautonomia is not yet defined properly in Western and Chinese
medicine, it is necessary to dedicate the first part of this research to a thorough
review of the relevant terminology, diagnosis, symptoms, differential diagnoses,
etiology, pathomechanisms and treatment approaches in Western medicine. Only by
doing so, it will be possible to create an equal TCM model for this disease, its related
patterns and for an appropriate Chinese herbal medicine treatment approach.
1. Dysautonomia in Western Medicine
1.1 Definition of Dysautonomia in Western Medicine
The terms 'autonomic neuropathy', 'autonomic dysbalance' or 'dysautonomia'
describe medical conditions that cause a malfunction of the autonomic nervous
system (Dysautonomia International, 2012a) with a predominance of either
parasympathetic or sympathetic systems at various times. (Fogoros, 2015).
Dysautonomia can be local or generalized, acute and reversible or chronic and
progressive. (Goldstein et al., 2002). It can either appear as a primary disturbance of
the ANS or as a secondary effect of an underlying systemic disease (Dysautonomia
International, 2012a).
Primary disturbances with ANS pathologies dominating the clinical picture without a
detectable pathophysiological cause are called primary chronic autonomic failure
(Goldstein et al., 2002) or pure autonomic failure (PAF). This term was first
introduced by Roger Bannister to describe ANS pathologies that do not affect the
central nervous system. Symptoms of PAF might develop slowly in adolescence, or
more acute after immunological challenges like febrile diseases (Gurme et al., 2014)
B Background
4
Primary syndromes of autonomic failure:
!
Idiopathic orthostatic hypotension and other forms of pure autonomic failure
(PAF)
!
Postural orthostatic tachycardia syndrome (POTS)
!
Autoimmune autonomic neuropathy (AAN)
!
Multiple system atrophy (MSA)
This review will only focus on pure autonomic failure with idiopathic orthostatic
hypotension and on postural orthostatic tachycardia syndrome. Severe diseases like
AAN and MSA, as well as secondary syndromes of autonomic failure due to
underlying systemic diseases will not be discussed in this paper. For a list of these
diseases refer to appendix I.
Symptoms of dysautonomia:
!
Patients can experience all of the following symptoms or just a few of them.
(Gurme et al., 2014; Mayo Clinic, 2015):
Symptoms of decreased sympathetic function:
!
Cardiovascular manifestations like orthostatic hypotension with dizziness and
fainting due to sudden drop in bloodpressure with standing
!
Decreased sweating with heat or exercise intolerance, very warm and/or dry
skin
!
Ejaculatory dysfunction, low libido, vaginal dryness
!
Blurry vision due to ptosis, anisocoria, Horner syndrome, or tonic pupils
Symptoms of decreased parasympathetic function:
!
Gastroparesis, nausea, constipation or diarrhea, bloating, heartburn
!
Urinary retention, incomplete emptying of the bladder or incontinence
!
Erectile dysfunction
B Background
5
Prognosis of ANS dysbalance:
ANS abnormalities can improve over the course of several years or progress.
Persisting dysautonomia has been associated with greater mortality, mostly from
cardiovascular causes (Tsuji et al., 1996), as acute mental stress responses of the
sympathetic nervous system preferentially target the heart. (Esler et al., 1990)
1.2 Dysautonomia and Neurasthenia in the West
As the terms dysautonomia or ANS dysbalance are still relatively new, they cannot
be found in older medical textbooks, although similar conditions were already
defined. About a century ago imbalances of the ANS were often called neurasthenia
(Fogoros, 2015).
The term neurasthenia was first defined in 1869 as "a functional disease of the
nervous system without structural organic changes but distinct from mental illness"
(Kleinman, 1986), caused by emotional or physical overtaxation of the nervous
system (Reid, 2009). Nowadays, the term is rarely used any more, but it is still
included in the ICD-10 system of the World Health Organization, where it is
categorized under "other neurotic disorders" (WHO, 2007).
The ICD-10 (WHO, 2010) system defines neurasthenia as a syndrome with core
symptoms of:
!
mental and physical fatigue for more than six month
accompanied by at least two of the following symptoms:
!
dizziness
!
dyspepsia
!
muscular aches or pains
B Background
!
tension headaches
!
inability to relax
!
irritability
!
sleep disturbance
6
Neurasthenia ≈ Neurosis
Since early 1900 neurasthenia was grouped under the broader term 'neurosis'. The
term neurosis itself was divided into anxiety and somatoform disorders. (The
Committee on Nomenclature and Statistics of the American Psychiatric Association.,
1968, p39), the latter including conversion disorders / hysteria and hypochondriasis.
For a more detailed explanation of all the terms, please refer to appendix II.
Because of the resemblance between symptoms under the terms of autonomic
dysbalance and neurasthenia, neurosis or it's subgroup of somatoform disorders
(including conversion disorders / hysteria and hypochondriasis, later: somatic
symptom disorders), all terms along this line will be included in the comparative
literature research.
1.3 Dysautonomia and Neurasthenia in China
Due to the cultural and historical differences in the evolution of Eastern and Western
medical systems, diagnosis and treatment of the above psychosomatic and
psychiatric diseases still differs significantly in WM hospitals in Asia.
In the 1920-30s the first systems of neuropsychiatry were introduced to WM doctors
in China. One of the more frequently used terms for psychosomatic diseases at that
time, neurasthenia, was introduced to China via Japan and was translated as
'shenjing shuairuo' (神經衰弱): weakness or asthenia of the nervs (Kleinman, 1986,
p25-29).
B Background
7
While the diagnosis of neurasthenia slowly established in China, it was already falling
out of use in Europe and was eventually eliminated of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-III) in 1980 (Kleinman, 1986, p21).
However, neurasthenia is still listed in the Chinese ICD-10 as a condition
“characterized by physical and mental fatigue, dizziness, headaches, other pains,
concentration difficulties, sleep disturbance, and memory loss' (American Psychiatric
Association, 1994, p48).
Slightly different to this, the Chinese Classification of Mental Disorders (CCMD)
defines neurasthenia as a disorder of at least 3 months duration with significantly
decreased work or social functioning, causing mental distress. For diagnosis, at least
3 of the following symptoms have to be present (Chinese Medical Association and
Nanjing Medical University, 1995 cited in Schwartz, 2002):
!
Mental or physical weakness
!
Dysphoria or irritability
!
Increased excitability
!
Nervous muscular pain
!
Sleep disturbances
The main difference between the two diagnostic systems is that according to the
CCMD neurasthenia can also be diagnosed without any fatigue, weakness or
exhaustion.
Such differences for the diagnosis of neurasthenia in Asia not only exist among
different diagnostic systems, but also among different countries.
B Background
8
While in China and Hong Kong the most frequent symptoms of neurasthenia were
headache, insomnia, dizziness, and chronic pain (Kleinman, 1982; Lee, 1994)
symptoms in Taiwan differed significantly with main complaints of insomnia, difficulty
concentrating, tension, and anxiety (Rin and Huang, 1989).
Despite these differences and vague diagnostic criteria, neurasthenia is still
frequently used throughout Asia. Schwartz (2002) and Kleinman (1986, p115)
suggest, that the condition might persist as a culturally acceptable diagnosis for
somatization, distress and psychosocial coping that 'avoids the social stigma of a
diagnosis of mental disorder'.
1.4 Dysautonomia and other differential diagnoses
The previous paragraphs already present a broad range of symptoms included under
the old term of neurasthenia or the newer term of autonomic nervous system
dysbalance / dysautonomia.
However, in recent years more terms with similar symptoms appeared. Although
many of these terms are not yet defined by medical literature or by official clinical
guidelines, they shall still be considered in this research to guarantuee a
comprehensive overview on any possible relation with ANS dysbalances.
As several researchers consider the symptom complex of chronic fatigue (Ware and
Kleinman, 1992) (Abbey and Garfinkel, 1991), or burn-out (Johannisson, 2006) to be
a contemporary revival of neurasthenia, it is necessary to define and differentiate
these syndromes and similar diseases in this category, such as fibromyalgia and
adrenal fatigue.
B Background
9
Dysautonomia / neurasthenia and chronic fatigue
Due to contradictory definitions for the two conditions, a differentiation seems difficult.
While Starcevic (1999) emphasizes that both syndromes overlap in their focus on
physical symptoms, Lee states that neurasthenia has a broader scope of symptoms
than chronic fatigue (Lee, 1998).
In contrast to Lee's (1998) statement, Zheng et al. (1992) claims that a diagnosis of
chronic fatigue requires more symptoms and is associated with more specific
physical signs and impairment of social functioning. Zheng et al. supports his
statement with a referral to the 1994 Centers for Disease Control criteria for CFS
(Zheng et al., 1992).
However, a review of these criteria only allows a conclusion on the congruent
symptoms of both diseases: fatigue, muscle pain, headaches, inability to
concentrate, irritability, and sleep disturbances (Centers for Disease Control and
Prevention., 2012). Several other studies undermine these congruences by pointing
out the underlying common pathologies of the autonomic nervous system (Rowe et
al., 1995; Bou-Holaigah et al., 1995; LaManca et al., 1999; Schondorf et al., 1999).
Chronic fatigue and fibromyalgia
Warrell et al. (2003), provide a differentiation between chronic fatigue and
fibromyalgia by defining chronic fatigue as 'a post-infectious fatigue syndrome with
duration of at least six months' (although the infectious theory was never proven
(Mawle at al., 1995)), characterized by fatigue, cognitive dysfunction, sleeping
problems, and muscle aches. Fibromyalgia on the contrary was defined with less
cognitive symptoms but more muscular pains.
B Background
10
Adrenal fatigue and burn-out
A differentiation of the terms adrenal fatigue and burnout seems to be more difficult,
as no scientific or clinical guidelines exist. So far, only one study (Bianchi et al.,
2013) provides a list of symptoms for burnout syndrome, including a depressed
mood, anhedonia, change of appetite and weight, sleeping problems, psychomotor
disturbance, fatigue, and cognitive impairment.
For adrenal fatigue a definition is only provided by Wilson (2001). It includes fatigue,
insomnia, salt cravings, lightheadedness, decreased libido, depression, premenstrual
syndrome, memory decline and decreased resistance to stress. However, Pranjic
(2012) postulates that the two syndromes might be similar or equal due to their
underlying chronic stress condition. So far it even appears to be impossible to
differentiate between these diseases and a general exhaustion as a normal reaction
to stress. (Informed Health Online, 2013).
In conclusion, all of the above diseases show a common underlying condition of
chronic stress. The definitions of neurasthenia, chronic fatigue and fibromyalgia
undermine their emphasis on physical symptoms, with fibromyalgia differing because
of its focus on pain. The definitions of adrenal fatigue and burnout syndrome however
seem to be less rigid and rather mimic an exhaustion after chronic stress with less
severe physical symptoms.
According to this, the review will discuss dysautonomia, neurasthenia and chronic
fatigue because of their closely related physical symptoms, which include responses
of the ANS to chronic stress. This assumption is supported by a study, which
proposes dysautonomia as common clustering underlying pathogenesis of chronic
stress diseases (Luyten et al., 2011).
B Background
11
1.5 Etiology and Pathomechanisms of Dysautonomia in Western medicine
Physiological stress response
A short introduction to the mechanisms of stress response in Western medicine
seems to be neccessary, as many papers about the effects of CHM on chronic stress
rely on biomedical measurements of blood and immune markers to prove efficacy.
After a stressful event, the body enters the so-called “fight or flight” state, where an
interaction of nervous and endocrine systems occurs, which results in an adaptive
response to stress (Kelly, 1999). This response increases awareness, improves
cognition and enhances analgesia (Chrousos and Gold, 1992; Charmandari et al.,
2005). Physiological adaptations include an increased cardiovascular tone, a higher
respiratory rate, increased metabolism and inhibition of vegetative functions such as
digestion, reproduction, and immunity (Sapolsky et al., 2000; Habib et al., 2001).
These stress responses are mediated by structures in the central nervous system
and peripheral tissues. The principal effectors are localized in parts of the
hypothalamus, the pituitary gland and the adrenal gland. Together, these structures
are called the hypo-thalamic-pituitary-adrenal (HPA) axis. (Munck et al., 1984)
As a first response to stress, CRF is released and consequently induces pituitary
corticotropes, which in turn induce the release of adrenocorticotropic hormone
(ACTH) into the circulation. ACTH primarily targets the adrenal cortex, where it
stimulates glucocorticoid secretion. Glucocorticoids then initiate physiological stress
responses throughout the whole body (Bamberger et al, 1996).
B Background
12
Regulation and inhibition of ANS response to stress
Usually, the adaptive response to stress is well regulated and balanced by
endocrines via a negative feedback mechanism on the HPA axis (Habib et al., 2001;
Chrousos, 1992; Whitnall, 1993). These regulatory mechanisms are called resilience
to stress and describe the body's ability to maintain normal physiology, development
and behavior in the face of pronounced stress and adversity (Pfau and Russo, 2015).
Causes of ANS dysbalance
If the adaption of the stress response results in excessive activation of the HPA axis,
autonomic nervous system imbalances may occur (Munck et al., 1984; McEwen and
Stellar,
1993)
and
cause
inappropriate
predominating
parasympathetic
or
sympathetic systems (Fogoros, 2015). Such autonomic imbalances can be facilitated
by an inherited predisposition, by long-term stress, viral infections or can occur
secondary to other medical conditions like diabetes or Parkinson's (Fogoros, 2015).
For a comprehensive list of underlying diseases, which will not be considered in this
review, please refer to appendix I.
What kind of stress causes ANS dysbalance?
Koolhaas et al. (2011, p1296) suggested that the term stress 'should be restricted to
conditions where an environmental demand exceeds the natural regulatory capacity
of an organism either frequently, in a high intensity or in particular situations that
include unpredictability and uncontrollability'. Such situations might either be caused
by long-term effects of emotional trauma, trauma causing post-traumatic stress
disorder, chronic dysthymic disorders and chronic anxiety disorders (Corrigan et al.,
2011) or by chronic inflammations with high oxidative stress (Romano et al., 2015).
B Background
13
1.6 Western Medicine treatment
So far no cure for dysautonomia exists, but single symptoms of the secondary forms
can be treated (NINDS, (2013). In appendix III Western medicine symptomatic
treatment approaches for the symptoms of ANS dysbalance will be outlined
according to Holtorf (2007) and Gurme et al. (2014).
After reviewing WM treatment options, it becomes obvious that even patients with a
range of only mild symptoms would still have to take strong medication. In addition,
most of the treatments listed here are “off label” (Grubb, 2008, p2816) prespcriptions
with not sufficient scientific evidence for their use in dysautonomic conditions.
To avoid the risks of too many medications, research is currently trying to treat the
body's reaction to chronic stress itself rather than just treating the negative effects of
stress on the organs.
However,
supporting
the
body's
stress
resilience
with
biomarkers
like
dehydroepiandrosterone (DHEA) and neuropeptide Y (NPY) would also require
application of cortisol (Yehuda et al., 2006; Kearns et al., 2012). Although Holtorf
(2007) reported that physiologic replacement of cortisol at 5-15 mg per day was
shown to be safe, many patients are still reluctant to take it.
An alternative treatment option includes the use of Western herbal medicine, which
offers a wide range of well researched single herbs for the treatment of chronic stress
on the nervous system. A study by Panossian and Wikman (2009) investigated
scientific evidence for the use of these so called adaptogen herbs.
B Background
14
They found strong evidence that several herbs can improve attention, cognitive
function, and endurance in fatigued patients. The mechanism of adaptogens, which
increase tolerance to mental exhaustion and enhance attention and mental
endurance is related to a regulation of homeostasis via the hypothalamic-pituitaryadrenal axis (Panossian and Wikman, 2009).
While Western herbal medicine offers the category of adaptogen herbs, no
equivalent system can be found in TCM. As a treatment with TCM always requires an
individual treatment approach for each patient, the following discussion shall
introduce diagnostic criteria and underlying pathomechanisms of dysautonomia and
neurasthenia in TCM and provide an overview on treatment approaches for several
possible patterns related with these diseases.
B Background
15
2. Dysautonomia in Traditional Chinese Medicine
2.1 (Autonomic) Nervous System in TCM
In Chinese medicine liver is roughly analogous to the nervous system and as all
emotions have a close relationship with the nervous system, many practitioners
relate neuropsychiatric and psychosomatic conditions such as neurasthenia to the
liver, too (Hammer, 2005, p51).
A definition of specific 'psychosomatic' conditions however, is more difficult than in
Western medicine, as mosts texts divide the etiology of all diseases into internal
(psychological) and external (somatic) factors (Hammer, 2005, p53).
The link between neurologic or neuropsychiatric diseases and psychological factors
can be found in 'constraint'. Constraint can be caused by emotional factors or the
seven sentiments (Scheid, 2013) if in excess. Joy injures the heart, anger the liver,
overthinking the spleen, sadness the lungs and fear injures the kidneys. If no
rebalance can be achieved, constraint will result (Hammer, 2005, p53).
Lu Yuanlei argues that the resulting constraint is mainly located in the liver, as in
classic texts all emotions of the brain are referenced to the liver (Lu, 2008, p77). He
supports this assumption with a reinterpretation of a passage of the Synopsis of the
Golden Casket (Lu, 2008, p2), where the virtue of liver is said to be 'joy and
openness - and with joy, the nerves are relaxed, with anxiety and anger, the nerves
are excited.' Karchmer (Karchmer, 2013) further supports the idea of the liver as a
general of all emotions, by citing Yun Tieqiao (2008, p48) who states that
melancholy, anxiety and hatred could activate the nerves and cause tension in the
arteries, causing a wiry pulse, which is usually associated with Liver pathologies.
B Background
16
Additionally, Karchmer (2013) reports a possible differentiation between the voluntary
and the ANS after Zhu Weiju, (1931, cited in Karchmer, 2013), who suggested that
heart qi refers to functions of the voluntary nervous system, whereas liver qi refers to
the functions of the autonomic nervous system (Zhu W., 2008, p14, cited in
Karchmer, 2013).
2.2 Patterns of Dysautonomia or Neurasthenia in TCM
Lu Yuanlei (2008, p2) states that the fight or flight function of the autonomic
sympathetic nervous system has changed over the time as humankind evolved and
stimuli like fear gradually diminished while desires grew. However, in modern life
many desires cannot be fulfilled, leading to emotional imbalances.
Such imbalanced emotions can cause stress and stimulate sympathetic reflexes. If
these reflexes cannot be relieved by flight or fight, excess energy in muscles,
meridians and blood vessels will result in problems like sleeping difficulties and
palpitations, which were called Liver disease by the ancients (Lu, Y., 2008, p3).
Disease progression of ANS dysbalance and organ pathologies
Hammer (2005, p310) states that the nervous system belongs to Tai Yang, the
outmost layer of the body, which is first affected by physical or emotional stress.
When the pathogenic factor of stress moves to deeper levels in the body, it first
affects the innervation of the circulatory system, then the digestive system and at last
the organ systems. If one these systems is weakend, stress will intrude there first.
This process could provide an explanation why different ANS pathologies appear in
stressed individuals.
B Background
17
Inside the body, constraint liver qi can attack the spleen and stomach, disrupt the
heart qi and insult the lungs (Shanghai College of Chinese Medicine, 1964, p336
cited in Karchmer, 2013). In the following, some of the resulting patterns are
displayed, grouped by the affected organ(s).
Liver overacting on spleen/stomach
If the liver overacts on spleen and stomach, it might lead to stomach pain, poor
digestion or constipation or dry heaves (Lu, 2008, p3).
Kidney yang deficiency
Long term stress resulting in kidney yang deficiency might cause bad circulation with
a pale facial complexion and cold extremities, low spirit, dizziness and tinnitus as well
as nocturia or urinary difficulties, urinary block and edema. (Wiseman and Ellis, 1996,
p179).
Kidney-heart imbalances
More serious cases of kidney yang deficiency can also damage the heart, causing
palpitations, panting and rapid breathing at the slightest exertion. (Wiseman and Ellis,
1996, p179).
Heart and lung yin deficiency
Extreme kidney yang deficiency resulting in heart and lung yin deficiency causes the
socalled lilly disease (bai he bing), nowadays translated with hysteria. (Qiao and
Stone, 2008, p16). Patients might suffer from manic symptoms 'as if the spirit is
enclosed' (Deng, 1999, p349). In modern medicine, these patterns could also be
called neurosis (Wiseman and Ellis, 1996, p154).
B Background
18
2.3 Etiology and Pathomechanisms of Dysautonomia in TCM
While in Western medicine genetics might be able to explain the predisposition of
(autonomic) nervous system imbalances, in traditional Chinese medicine the system
of constitutional types offers some explanations.
Hammer (2005, p315) postulates that from a TCM point of view, genetics can cause
imbalances of mostly the nervous system and sometimes the organ system
(especially heart and kidneys). Besides this, he explains that for the development
and maintenance of a healthy nervous system, for will power and drive, the kidney is
of utmost importance. While the mental level is controlled by liver blood and the
conscious mind by the heart, the pericardium is ultimately responsable for all mentalemotional processes, the defence and adaptability of the nervous system (Hammer,
2005, p335).
The tables below display possible emotional causes of some organ pathologies as
etiology for diseases of the nervous system (Hammer, 2005, p337-347):
Liver Liver fire rising Frustration, severe suppression or repression of emotion leading to qi stagnation Liver yin deficiency Restorative strategies or lack of release for the musculoskeletal system after stress Uprising of liver yang Severe liver yin deficiency due to stress / tension Liver wind Strokes, infectious diseases with delirium and coma Liver yang deficiency Overwork, alcohol, infections, drug abuse B Background
19
Heart Very mild heart yin deficiency Mild emotional shock Severe heart qi-‐yang deficiency Shock, guilt, fear Heart fire flaring up Heart balances excess heat from liver, gallbladder and stomach, worry, shock, stimulating drugs Heart qi agitation with mild yin deficiency Shock and physical trauma in utero or during birth Mild heart yin deficiency Obsessive, incessant thinking Heart qi stagnation Personal loss, disappointment Stagnation of heart blood Prolonged fear, unexpressed anger Heart blood deficiency Prolonged nervousness, secondary deficiency due to kidney essence deficiency, spleen qi deficiency or gradual blood loss Trapped qi in the heart Profound unexpressed anger Kidney Kidney yang deficiency Consitutional weakness, depression, grief Kidney yin deficiency Overuse of the mind (thinking, rumination, worry) Stomach / Spleen Stomach yin deficiency Eating bad food, eating too fast, overwork Spleen yang deficiency Obsessive thinking (ruminating) while eating Lung Lung yang deficiency Persistent sadness and pessimism Lung yin deficiency Self-‐indulgance, attention seeking, jealousy B Background
20
In the modern world all the above emotional pathogenic processes seem to change
towards a more chronic type of stress, thus affecting the autonomic nervous system.
In clinic, the early resulting ANS effects of emotional stress present as pathologies of
the smooth muscles in the intestines, the eyes, blood vessels and skin and are often
diagnosed as psychosomatic disorders like IBS, cardiac neurosis, idiopathic
headaches, hyperhidriasis and microcirculatory changes. (Hammer, 2005, p362).
For the treatment of these diseases, not all of the organ pathologies (mentioned in
the lists above) play an equally important role. Scheid (Scheid et al., 2009, p105)
states that contemporary Chinese medicine attributes many of the psychosomatic
diseases to liver, gallbladder, or liver-spleen disharmony and according to this, treats
most problems, which were caused by stress with harmonizing shao yang formulas.
Another important role of formulas treating the heart and liver can also be seen in a
different chapter about formulas that calm the spirit, as this chapter addresses
modern pathologies like neurasthenia or nervous exhaustion, too.
C Results
21
C Research Methods
As the terms 'autonomic nervous system dysbalance, autonomic dysbalance or
dysautonomia' have not been used in classical TCM textbooks so far, no clear
treatment instructions can be found. A comparative literature analysis might provide
an overview of possible treatment approaches for the symptoms and disease
patterns related with this condition.
1. Comparative Literature Analysis of Dysautonomia Treatment in TCM
This literature analysis screened several comprehensive reference books of TCM
formulas with a wide range of search terms to identify all suitable TCM patterns,
disease entities and their corresponding Chinese herbal formulas to define individual
treatments based on the symptoms and on the constitution of different patients.
1.1 Search methods for comparative literature analysis
For a list of the included books and the search terms (resulting from the WM
definition of dysautonomia and related diseases) refer to appendix IV.
Data collection of Formulas
Formulas of all books were identified for each disease and transferred to Excel.
The first data set grouped the retrieved formulas according to their categories under
each disease. Most frequently used formula categories overall and for each disease
were calculated in Excel.
The second data set grouped the retrieved formulas under each disease and the
most frequently used formulas overall and for each disease were calculated in Excel.
C Results
22
Data collection of single herbs
All single herbs of the formulas above were transferred to Excel.
This data set grouped all herbs of one formula under each disease and most
frequently used single herbs for each disease were calculated in Excel.
In contrary to the formula analysis, no calculation of most frequently used herbal
categories was performed. As each herb changes its function in combination with
different herbs within various formulas, results about herbal categories would be of
little significance.
1.2 Comparative Literature Analysis Results
Only the most important findings will be discussed in the following chapters. For a
complete list of all results of the comparative literature analysis refer to appendix V.
Data collection of Formulas
A total of 39 different formula categories was found for the treatment of all diseases
related to dysautonomia. The five most frequently used formulas will be displayed for
each result.
Formula categories: most frequently used formula categories overall
In the list below, the number of entries and the names of the 5 most frequently
(number of entries found in books) used formula categories are displayed.
Entries Formulas 15 Formulas that regulate the qi 14 Formulas that harmonize 10 Formulas that calm the spirit 10 Formulas that dispel phlegm 9 Formulas that tonify C Results
23
Formula categories: most frequently used formula categories for each disease
For the search term 'Autonomic Disorder', 5 different formula categories were found.
In the list below, all 5 categories are displayed.
Autonomic Disorder Entries Formulas 5 Formulas that harmonize 2 Formulas that calm the spirit 2 Formulas that dispel phlegm 2 Formulas that release the exterior 2 Formulas that warm interior cold For the term 'Chronic Fatigue', 6 different categories were used, of which the most
frequently used 5 categories can be seen below.
Entries 5 3 2 3 3 4 Categories -‐ Chronic Fatigue Formulas Formulas that tonify Formulas that harmonize Formulas that dispel phlegm Formulas that expel dampness Formulas that release the exterior Formulas that tonify For 'Hysteria', all 5 formula categories found are displayed below.
Entries 3 2 2 2 2 Categories -‐ Hysteria Formulas Formulas that harmonize Formulas that open the sensory orifices Formulas that calm the spirit Formulas that regulate the qi Formulas that stabilize and bind For the term 'Neurasthenia' the 5 most frequently out of 12 categories can be found
in the following list.
C Results
24
Categories -‐ Neurasthenia Entries Formulas 6 Formulas that tonify 4 Formulas that calm the spirit 3 Formulas that calm the spirit 3 Formulas that harmonize 3 Formulas that tonify For the term 'Neurosis' the 5 most frequently used out of 9 formula categories are
displayed below.
Categories -‐ Neurosis Entries Formulas 8 Formulas that regulate the qi 4 Formulas that regulate the blood 4 Formulas that Dispel Phlegm 3 Formulas that Harmonize 3 Formulas that tonify For 'Somatoform Disorders' only 1 formula category was used.
Categories -‐ Somatoform Disorders Entries Formulas 2 Formulas that regulate the qi C Results
25
Herbal formulas: most frequently used formulas overall
In total, 88 different herbal formulas were found for the treatment of diseases related
to dysautonomia. In the following all formulas, which were used more than twice will
be displayed (this equals the concept of displaying the five most frequently used
ones from above, as some of them had the same amount of entries).
Entries 9 7 6 4 4 4 4 4 4 3 3 3 3 3 Total Formulas ban xia hou po tang gui pi tang wen dan tang chai hu jia long gu mu li tang gan mai da zao tang jia wei xiao yao san sang piao xiao san xiao yao san yi gan san bai he di huang tang gui zhi jia long gu mu li tang xiao chai hu tang xue fu zhu yu tang zhi zi chi tang Herbal formulas: most frequently used formulas for each disease
In the following a list for each disease will present formulas, which were mentioned
more than once throughout the different books of the comparative literature analysis.
Formulas -‐ Autonomic Disorder Entries Formulas 2 jia wei xiao yao san 2 si ni san 2 wen dan tang C Results
Entries 3 3 2 2 Formulas -‐ Cronic Fatigue Formulas gui pi tang xiao chai hu tang san ren tang shen su yin Entries 2 2 2 2 Formulas -‐ Hysteria Formulas ban xia hou po tang gan mai da zao tang gui zhi jia long gu mu li tang yi gan san Entries 3 2 Formulas -‐ Neurasthenia Formulas gui pi tang sang piao xiao san Entries 3 3 2 2 2 Formulas -‐ Neurosis Formulas ban xia hou po tang wen dan tang chai hu jia long gu mu li tang xue fu zhu yu tang yue ju wan 26
Data collection of single herbs
In total, 204 single herbs were included in all studies, which were retrieved in the
comparative literature search. The list differenciates the number of entries for herbs
with different preparation methods (zhi, chao). If different herb preparations were not
considered, the number of single herbs included in all books would be reduced to
189. For a complete list of the single herbs included, refer to appendix IV.
C Results
27
2. Online Database Research of Dysautonomia Treatment in TCM
To support and complete the comparative literature research findings, an additional
online database research was performed.
2.1 Search methods for online database research
Inclusion criteria
For the online literature research the following eligibility criteria were set:
Types of studies:
The review included all published randomized and non-randomized controlled clinical
studies as well as observational studies (cohort and case studies) with or without
control groups, no blinding required.
Types of participants:
Due to the lack of studies, all human and animal studies with no restriction to the
number of participants were included.
Types of interventions:
Studies reporting treatment with single herbs, herbal combinations and treatment
with classic herbal formulas were accepted.
Exclusion Criteria:
Only those studies were accepted, where at least one person or one group was
treated with Chinese herbal medicine.
C Results
28
Search methods for identification of studies:
The PubMed Database was searched until 8/7/2015 for studies according to the
above inclusion criteria. The detailed strategy for the PubMed search and the MeSH
terms are listed in appendix VII.
Study selection:
Title and abstract of all results in the literature search list were examined and full
texts were retrieved if possible.
During the first screening duplicates, reviews and studies with unrelevant topics were
removed as well as any studies, where full text was not available.
In the second step full texts of potential studies were evaluated according to predefined inclusion and exclusion criteria. For an overview of the detailed study
screening process, refer to appendix VIII.
Data collection:
Data of all included studies were extracted and study characteristics and outcomes
were transferred to Excel (refer to appendix IX).
C Results
29
2.2 Online Database Research Results
Study selection
The study selection process is illustrated in the flowchart below.
124 records identified through database searching (Pubmed) Records excluded: 111 First screening 12 full-‐text articles not available 50 language restriction 39 not Chinese herbal medicine 10 duplicates 13 full-‐text articles assessed for eligibility Second screening Full-‐text articles excluded: 4 not relevant full-‐text articles 9 studies included Figure 1: Flowchart study selection (own illustration)
Studies considered in this review
In total, the database search resulted in 124 studies, from which 9 studies were
included. For a list of excluded studies, please refer to appendix X.
The included studies are introduced shortly in the following (for details and critique,
see appendix IX):
C Results
!
30
Two human studies focused explicitly on the vascular aspect of autonomic
nervous system diseases, called orthostatic hypotension:
A case report study by Wang and Zhang (2013) reported stabilization of one
patient's blood pressure after 4 weeks of treatment with Tian Ma Gou Teng
Yin.
Contrary to this, a larger RCT on the same symptom by Gao et al. (2008) did
not find any difference in resting cardiovascular variables and orthostatic
capacity in 5 humans after treatment with Huang Qi, compared to a placebo
control group of the same size.
!
Two lager human studies were dedicated to treating fatigue in general and
investigated the use of herbal medicine for chronic fatigue in controlled trials:
Lijue (2005) used a unique approach and matched several TCM disease
patterns with corresponding formulas (Xiao Yao San, Xiang Sha Liu Jun Zi
Wan, Gui Pi Wan, Liu Wei Di Huang Wan and Si Shen Wan). He found
significant improvement for 78 % of the 42 patients after treatment for 4
weeks.
A RCT by Cho et al. (2009) not only investigated improvement of chronic
fatigue symptoms after treating 24 humans with Huang Qi and Dan Shen for 4
weeks, but also examined cytokine levels in the blood. However, even though
chronic fatigue improved, no changes in cytokine expression could be found.
!
Three animal studies showed a similar approach like Cho et al. and analyzed
several immune markers in the blood after treating chronic fatigue with
traditional herbal formulas:
Similar to Cho et al. (2009), the first study by Chen et al. (2008) did not find
any changes of blood markers, although their mice, which were treated with
Bu Zhong Yi Qi Tang for chronic fatigue showed an overall increase in activity
and body weight.
C Results
31
Another mouse study by Cao et al. (2012) however, was able to proof
changes in biomedical parameters in accordance with improved reaction to
electric shocks in mice with CF syndrome after 4 weeks of Kai Xin San.
The last animal study by Liu et al. (2011) also found increased levels of
immune markers as well as increased body weight and endurance after
treatment of chronic fatigued rats with Dang Gui Bu Xue Tang for 4 weeks.
!
The more general search for somatoform disorders resulted in another case
study on a patient with fatigue, insomnia, headache and tinnitus. Okamoto et
al. (2005) found significant improvement of the condition after 2 weeks
treatment with Yi Gan San.
!
The last study within this research by Bo et al. (2010) bears only little relation
to the topics of the above studies, as it focused on conversion disorders with
globus hystericus. However, 3 weeks of treatment with Ban Xia Hou Po Tang
did not only treat the globus hystericus but also improved the overall energy
levels and the psychological condition of 46 patients.
Due to the heterogenity of these studies, further comparison of their methodological
quality and their data reporting is not useful. However, their results will be considered
in relation to the findings of the comparative literature research in the discussion of all
findings.
D Discussion
32
D Discussion
Each part of this research yielded different results, which might be useful for different
aspects of treating autonomic nervous system disorders with Chinese herbal
medicine. For students or practitioners of TCM, the most interesting results can be
found in the evaluation of the 39 formula categories of the comparative literature
analysis.
Frequently used formula categories
In the first part, the discussion of most frequently used formula categories for the
treatment of autonomic dysbalances provides a ranking of important patterns that
usually will be present in such diseases. The five most frequently used formula
categories (to regulate qi, harmonize, calm the spirit, dispel phlegm and tonify)
thereby undermine the patterns, which were earlier identified in the general
background literature review.
Formulas to regulate qi are said to treat stagnation of (liver) qi, which manifests as
constraint, clumping, or rebellion caused by emotional disturbances, trauma or
longterm qi deficiency. In clinic, qi stagnation and liver constraint often manifest as
pain and distention (Scheid et al., 2009, p505).
Harmonizing formulas point towards conditions of liver/gallbladder or disharmony of
liver and spleen due to emotional problems. It treats these psychosomatic disorders,
caused by stress in 'coping with the rigors of modern life' with formulas of this
category (Scheid et al., 2009, p104).
D Discussion
33
Formulas that calm the mind treat diseases caused by the five spirits, which clinically
manifest as anxiety, forgetfulness, disorientation, and insomnia or on the contrary as
a stressed feeling, manic behavior, bad temper, and agitation. Therefore they are
said to treat conditions, such as neurasthenia or nervous exhaustion (Scheid et al.,
2009, p458).
The contribution of phlegm dispelling formulas to the treatment of dysautonomia can
be found in their secondary ability to smooth the flow of qi and relieving constraint.
They are useful for conditions, which present with dizziness, palpitations, insomnia or
headache (Scheid et al., 2009, p774).
Tonifying formulas might be helpful for deficient patients with reduced vitality due to
constitutional factors, bad diet, overwork, emotional stress, trauma and chronic
illnesses (Scheid et al., 2009, p307).
Formula categories for each disease
Even more useful for the clinical application of formulas is the second section about
the most frequently used formula categories for various diseases related with ANS
dysbalance. The results of this section might serve as a guideline for the treatment of
TCM disease patterns, which belong to the respective disease category.
Although these Western medical disease names do not automatically relate to a
certain pattern, herbal practitioners might simply look up the symptoms listed for the
respective disease and connect the most suitable formula for the condition of their
patient out of a range of suggested formula categories.
D Discussion
34
Frequently used formulas
In this section, the results of the 88 most frequently applied herbal formulas overall
are not particularly useful as a clinical guideline but rather as an orientation for future
studies. As more research on this topic is needed, it would be reasonable to choose
formulas for randomized controlled trials from a such a pool of frequently used
formulas to produce data with high clinical relevance.
Formulas for each disease
The results of this calculation are not representative for the treatment of certain
autonomic nervous system conditions. Due to different popularity of the search terms
for the diseases, the number of suggested formulas for each disease group differs
significantly (autonomic disorders 5, chronic fatigue 6, hysteria 5, neurasthenia 12,
neurosis 9, somatoform disorders 1). The resulting formula suggestions can therefore
not be considered to be a representative sample.
Single herbs
In addition to the analysis of herbal formulas and their categories, the 204 single
herbs included in these formulas were also retrieved and listed according to their
prevalence. Like mentioned above, a further analysis of the herbal categories was
not performed, as the actions of each herb vary according to its function in
combination with other herbs within one formula. An analysis of the herbs with regard
to each of these functions would go beyond the scope of this research.
D Discussion
35
Despite this, it is still interesting to identify possible reasons for a more frequent use
of some of the single herbs. So far, not much literature exists on the pharmacological
effects of herbs on the ANS.
However, one paper by Wang et al., (2014) presents a review of several so-called
adaptogenic herbs, which possess various positive regulatory effects on hormones
related to the hypothalamus-pitutary-adrenal (HPA) axix and might therefore be
useful for the treatment of stress.
Herbs that were mentioned in the review by Wang et al. (2014) as well as in this
research included: Gan Cao, Sheng Jiang, Ren Shen, Ban Xia, Yuan Zhi, Ge Gen, Yi
Yi Ren, Zhi Mu, Bai Zhi, and Lian Qiao (listed in this order from more frequently to
less frequently used in this study).
Online database research
The second part of this research comprised a short online database research in
addition to the comparative literature research findings.
In contrary to the literature research, two of the included research papers reported
the application of a single herb (Huang Qi) and a herbal combination (Huang Qi and
Dan Shen) and were therefore not able to be interrelated with other research results.
Furthermore, a pharmacological effect on the ANS was not reported for the two herbs
either (Wang et al., 2014).
D Discussion
36
All other included studies found proof of efficacy for formulas, which were also
mentioned in the comparative literature analysis. These formulas included Tian Ma
Gou Teng Yin for orthostatic hypotension, Yi Gan San for somatoform disorders, Ban
Xia Hou Po Tang for conversion disorders with a globus hystericus and for the
treatment of chronic fatigue syndrome Dang Gui Bu Xue Tang, Xiao Yao San, Xiang
Sha Liu Jun Zi Wan, Gui Pi Wan, Liu Wei Di Huang Wan, Si Shen Wan, Bu Zhong Yi
Qi Tang and Kai Xin San.
Nevertheless, due to the limited amount of studies in the online database research
and due to the insufficient quality of those studies, no further conclusions or
recommondations can be drawn from these results.
The results of this study have several limitations. For a sufficient online research
more databases than Pubmed, Medline and Embase should have been searched.
Also, the comparative literature search strategy was not extensive enough, as
screeing of additional books could have increased the significance of all findings.
However, overall the results of the comparative literature analysis seem to provide
better advice for herbal practicioners for the treatment of autonomic dysbalances.
E Conclusion
37
E Conclusion
The background literature research of this paper provides an overview on etiology,
pathomechanisms and possible underlying TCM patterns of diseases with an
underlying autonomic nervous system dysbalance.
The detailed pattern differentiation for these diseases, ranging from psychosomatic to
emotional or physical stress conditions, might help students and practitioners to
choose a suitable formula from the results section for the individual needs of the
patient. However, the formulas found in the online database research and in the
comparative iterature analysis just provide a basic treatment approach according to
TCM principles.
Further research is needed to provide scientific evidence for the efficacy of these
formulas in larger human randomized trials. Animal research however, might provide
promising research findings by analyzing the pharmacological effects on the HPA
axis of more adaptogenic TCM herbs.
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Appendix
46
Appendix
Appendix I: Exclusion list of underlying systemic diseases of ANS
dysbalance
This review will not discuss any kinds of severe dysautonomia, which appears due to
the following underlying diseases (Dysautonomia International., 2012b; Gurme et al.,
2014):
Acute Inflammatory Demyelinating Polyradiculoneuropathy
Acute and Chronic Inflammatory Demyelinating Polyneuropathy in HIV
Alcohol (Ethanol) Related Neuropathy
Amyloidosis
Anisocoria
Antiphospholipid Syndrome
Assessment of Neuromuscular Transmission
Autonomic Neuropathy
Celiac Disease
Charcot-Marie-Tooth and Other Hereditary Motor and Sensory Neuropathies
Chiari Malformation
Chronic Inflammatory Demyelinating Polyradiculoneuropathy
Crohn's Disease and Ulcerative Colitis
Delta Storage Pool Deficiency
Diabetes and Pre-Diabetes
Dizziness, Vertigo, and Imbalance
Eclampsia
Appendix
Ehlers-Danlos Syndrome
Emergent Management of Myasthenia Gravis
Hereditary Neuropathies of the Charcot-Marie-Tooth Disease Type
Lambert-Eaton Myasthenic Syndrome (LEMS)
Mast Cell Disorders
Metabolic Neuropathy
Mitchochondrial Diseases
Multiple System Atrophy
Organophosphates
Paraneoplastic Autonomic Neuropathy
Parkinson Disease
Parkinson-Plus Syndromes
Pediatric Guillain-Barre Syndrome
Physical Trauma, Surgery and Pregnancy
Sarcoidosis
Sjogren's Syndrome
Toxic Neuropathy
Urologic Management in Neurologic Disease
Vitamin Deficiencies
47
Appendix
48
Appendix II: Explanation of terms related to neurosis/neurasthenia
Somatoform Disorders
Conversion disorders / Hysteria
The old term of hysteria was known to describe psychosomatic diseases in women.
Later, characteristic symptoms like shortness of breath, heaviness in the abdomen,
muscular spasms, fainting, anxiety and irritability were attributed to the term
conversion disorders (Science Museum, n.d.).
Hypochondriasis
The second subgroup of somatoform disorders was defined as a 'preoccupation with
fears of having a serious disease'. Hypochondriasis was diagnosed, if this fear
persisted despite medical evaluation and caused clinically significant distress or
impairment in social life. Symptoms had to be present for at least 6 months, but
should not be of delusional intensity (American Psychiatric Association, 1994). In a
later version of the Diagnostic and Statistical Manual of Mental Disorders
hypochondriasis has been replaced by somatic symptom disorders.
Somatic Symptom Disorders
Somatic symptom disorders are vaguely defined as physical symptoms that persist
for at least 6 months and cannot be explained by a medical condition, but are not
attributable to a mental disorder (American Psychiatric Association, 1994, p485).
Complaints involve chronic pain, problems with the digestive, nervous and
reproductive system (Rogge, 2014). The condition results in disruption of functioning
due to excessive thoughts and behaviors (American Psychiatric Association, 2013).
Appendix
49
Appendix III: WM treatment approaches for ANS dysbalance
Nonpharmacologic measures:
!
Increased fluid and salt intake
!
Tight support stockings or abdominal binders for hypotension
!
Bladder catheterization for urinary retention
!
Dietary fiber and enemas for bowel motility
!
No large meals
!
Slow positional changes
Good results were found for relaxation techniques, breathing exercises, water-based
exercises, tai-chi, and cognitive-behavioral therapy (Hasset and Gevirtz, 2009).
However, all exercises should be introduced gradually, working toward 20 to 30
minutes of aerobic activity three times a week (Grubb, 2008).
Antocholinergics to increases bladder capacity and decrease stress incontinence:
!
Parasympathomimetics to initiate micturition to empty the bladder
!
Viagra to treat erectile dysfunction
Pharmacologic treatment options for symptomatic relieve:
!
Cortidosteroids to increase standing blood pressure
!
Alpha-adrenergic agonists to increase standing blood pressure
!
Norepinephrine derivates to increase blood pressure via vasoconstriction
!
Beta blockers to augment coronary and cerebral blood flow
!
Desmopressin to ameliorate nocturia
!
Epoetin to increase intravascular volume
!
Dopamine agonists to relieve gastrointestinal paresis
!
Parasympathomimetics to increase salivation and gastric motility
!
Psyllium to relieve constipation
Immunmodulatory pharmacologic treatments for shortening the duration in acute or
very severe cases:
!
Corticosteroids to decrease autoantibody production
!
Immune globulins intravenous to reduce immune complexes
Appendix
50
Appendix IV: Books included in the comparative literature research
!
Chinese Herbal Formulas and Applications (Chen and Chen, 2008)
!
Chinese Herbal Medicine: Formulas & Strategies (Scheid et al., 2009)
!
Clinical Handbook of Internal Medicine: The Treatment of Disease with
Traditional Chinese Medicine, Volume 1 (Maclean and Lyttleton, 2008)
!
!
!
Qin Bo-Weis 56 Treatment Methods: Writing Precise Prescriptions (Wu and
Qin, 2011)
!
The Treatise on the Spleen and Stomach: A Translation of the Pi Wei Lun (Li,
1993)
Search terms applied in the comparative literature research:
!
Autonomic Nervous System Disease
!
Autonomic Dysbalance
!
Autonomic Disorder
!
Chronic Fatigue (syndrome)
!
Conversion Disorder
!
Hypochondriasis
!
Hysteric Disorder
!
Neurasthenia
!
Neurotic Disorder
!
Neurosis
!
Orthostatic Hypotension
!
Postural orthostatic tachycardia (syndrome)
!
POTS
!
Somatoform Disorder
Appendix
51
Appendix V: Comparative literature analysis: data collection of formulas
Totals of formula categories:
Amount
15
14
10
10
9
7
7
6
6
6
5
5
5
4
4
3
3
3
3
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
Formulas
Formulas that regulate the qi (promote the movement of qi)
Formulas that harmonize (regulate and harmonize the liver and s pleen)
Formulas that calm the s pirit (nourish the heart (blood and yin) and calm the s pirit)
Formulas that Dispel Phlegm (dry dampness and transform phlegm)
Formulas that tonify (Tonify the Qi)
Formulas that s tabilize and bind (Secure the essence and s top enuresis)
Formulas that tonify (Nourish and tonify the Yin)
Formulas that expel dampness (warm and transform water and dampness)
Formulas that regulate the blood (invigorate the blood and dispel blood s tasis)
Formulas that tonify (Tonify the Qi and Blood)
Formulas that calm the s pirit (sedate and calm the s pirit)
Formulas that Harmonize (Lesser Yang-‐Warp Disorders
Formulas that warm interior cold (warm the middle and dispel cold)
Formulas that release the exterior (release exterior disorders with interior deficiency)
Formulas that tonify (Tonify the Qi and the blood)
Formulas that clear heat (Heat from Deficiency)
Formulas that clear heat (qi-‐level Heat)
Formulas that expel dampness (clear heat and expel dampness)
Formulas that harmonize (harmonize lesser yang-‐warp disorders)
Formulas that clear heat (clear heat and resolve toxicity)
Formulas that Dispel Phlegm (clear heat and transform phlegm)
Formulas that expel parasites Formulas that expel wind (pacify and extinguish internal wind)
Formulas that open the s ensory orifices (warm and open the s ensory orifices)
Formulas that release the exterior (release exterior wind-‐cold)
Formulas that tonify (Tonify the blood)
Formulas that tonify (warm and tonify the yang)
Formulas that harmonize (treat malarial disorders and vent pathogens from the membrane s ource)
Formulas that clear heat (clear heat from the organs)
Formulas that clear heat (clear qi-‐level heat)
Formulas that dispel phlegm (induce vomiting)
Formulas that Dispel Phlegm (transform phlegm and extinguish wind))
Formulas that dispel s ummerheat (dispel s ummerheat and augment the qi)
Formulas that expel dampness (transform dampness and harmonize the s tomach)
Formulas that harmonize (harmonize the s tomach and intestins)
Formulas that Harmonize (Liver and Spleen)
Formulas that regulate the qi (direct rebellious qi downward)
Formulas that s tabilize and Bind (Stabilize the exterior and s top s weating)
Formulas that warm interior cold (warm the channels and disperse cold)
Appendix
52
Formula categories for each disease:
Autonomic Disorder -‐ per Categorie
Amount
5
2
2
2
2
Formulas
Formulas that release the exterior (release exterior wind-‐cold)
Chronic Fatigue -‐ per Categorie
Amount
5
3
2
3
3
4
Formulas
Formulas that harmonize (harmonize lesser yang-‐warp disorders)
Formulas that dispel phlegm (dry dampness and transform phlegm)
Formulas that expel dampness (clear heat and expel dampness)
Formulas that release the exterior (release exterior disorders with interior deficiency)
Formulas that tonify (Tonify the Qi and the blood)
Hysteria -‐ per Categorie
Amount
3
2
2
2
2
Formulas
Formulas that open the s ensory orifices (warm and open the s ensory orifices)
Formulas that s tabilize and bind (Secure the essence and s top enuresis)
Neurasthenia -‐ per Categorie
Amount
6
4
3
3
3
3
2
2
2
2
2
2
Formulas
Formulas that tonify (Nourish and tonify the Yin)
Formulas that calm the s pirit (sedate and calm the s pirit)
Formulas that s tabilize and Bind (Secure the essence and s top enuresis)
Appendix
53
Neurosis -‐ per Categorie
Amount
8
4
4
3
3
3
3
2
2
Formulas
Formulas that regulate the blood (invigorate the blood and dispel blood s tasis)
Formulas that Harmonize (Lesser Yang-‐Warp Disorders)
Formulas that s tabilize and Bind (Secure the essence and s top enuresis)
Somatoform Disorders -‐ per Categorie
Amount Formulas
2
Appendix
Total Formulas
Amount
9
7
6
4
4
4
4
4
4
3
3
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
Formulas
ban xia hou po tang
gui pi tang
wen dan tang
chai hu jia long gu mu li tang
gan mai da zao tang
jia wei xiao yao s an
sang piao xiao s an
xiao yao s an
yi gan s an
bai he di huang tang
gui zhi jia long gu mu li tang
xiao chai hu tang
xue fu zhu yu tang
zhi zi chi tang
bu zhong yi qi tang
chai hu gui jiang tang
dao tan tang
huang qi jian zhong tang
ling gui zhu gan tang
liu wei di huang wan
ma huang xi xin fu zi tang
nü s hen s an
san huang xie xin tang
san ren tang
shen s u yin
si ni s an
suan zao ren tang
tian ma gou teng yin
wu mei wan
xiao jian zhong tang
yue ju wan
zhu s han an s hen wan
ban xia xie xin tang
bei xie fen qing yin
bu gan tang
bu yang huan wu tang
chai hu gui zhi tang
chai hu qing gan tang
chai hu s hu gan s an
ci zhu wan
da bu yin wan
da bu yuan jian
da zao wan
dang gui bu xue tang
54
Appendix
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
di tan tang
ding zhi wan
er chen tang
er zhi wan
fu ling gui zhi gan cao da zao tang
fu zi li zhong wan
gou teng s an
gua di s an
gui zhi fu ling wan
gui zhi jia fu zi tang
gui zhi tang
gun tan wan
huang lian e jiao tang
huang qi gui zhi wu wu tang
huo po xia ling tang
ji s heng s hen qi wan
jin gui s hen qi wan
liu jun zi tang
mu li s an
ping wei s an
qing s hu yi qi tang
ren s hen yang rong tang
shao fu zhu yu tang
shen ling bai zhu s an
sheng mai s an
sheng xian tang
shi pi yin
shi quan da bu tang
si jun zi tang
su he xiang wan
tian wang bu xin dan
tong guan s an
xiang s ha liu jun zi tang
xiao xian xiong tang
xuan fu dai zhe zhi tang
yang xin tang
yu ping feng s an
zhen wu tang
zhen zhu mu wan
zhi gan cao tang
zhu ru wen dan tang
zhu s ha an s hen wan
zhu ye s hi gao tang
zuo gui wan
55
Appendix
56
Formulas for each disease
Formulas -‐ Autonomic Disorder
Amount Formulas
2
jia wei xiao yao s an
2
si ni s an
2
wen dan tang
Formula -‐ Cronic Fatigue
Amount
3
3
2
2
Formulas
gui pi tang
xiao chai hu tang
san ren tang
shen s u yin
Amount
2
2
2
2
Formula -‐ Hysteria
Formulas
ban xia hou po tang
gan mai da zao tang
gui zhi jia long gu mu li tang
yi gan s an
Formula -‐ Neurasthenia
Amount Formulas
3
gui pi tang
2
sang piao xiao s an
Formula -‐ Neurosis
Amount
3
3
2
2
2
Formulas
ban xia hou po tang
wen dan tang
chai hu jia long gu mu li tang
xue fu zhu yu tang
yue ju wan
Appendix
57
Appendix VI: Comparative literature analysis: data collection of single
herbs
Amount 70 53 44 43 40 37 32 31 30 29 28 21 20 19 18 16 15 14 14 12 10 10 10 10 9 9 9 9 9 9 8 8 8 8 7 7 7 7 7 7 Single Herbs fu ling zhi gan cao dang gui sheng jiang ren shen gan cao chai hu da zao bai zhu zhi ban xia gui zhi bai shao chen pi chuan xiong huang qin huang lian hou po huang qi long gu ban xia yuan zhi zhi fu zi zhi shi zi su ye dang shen fu shen mu dan pi mu li mu xiang shi chang pu bo he da huang suan zao ren zhu ru gan jiang gou teng jie geng shao yao shu di xiang fu Appendix
7 6 6 5 5 5 5 5 5 5 5 5 5 5 5 5 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 3 3 3 3 3 3 3 3 58
zhi zi shan yao sheng di huang cang zhu chi shao chi shao gua lou mai dong mu xiang rou gui shan zhi zi shan zhu yu tao ren ze xie zhi gui ban zhi ke chao bai zhu chao huang qi chao suan zao ren dan dou chi du zhong ge gen hong hua huang bai long yan rou niu xi qian dan sang piao xiao shu di huang wei jiang wu wie zi xi xin xiao mai yi tang yu jin zhi yuan zhi bai dou kou bai he bai zi ren chen xiang chuan niu xi dan nan xing dan zhu ye ding xiang Appendix
3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 59
ju hong shen qu xian di huang xiao hui xiang xing ren yi ren zhi mu zhu sha bai zhi bing lang chao zhi shi che qian zi chuan lian zi dan zhu po di huang e jiao fang feng gou qi zi haung qin hua jiao hua shi huo xiang jie geng lang yan rou ma huang mai men dong mu gua mu hu die qian hu sang ji sheng sha ren shao yao sheng ma shi gao shi jue ming shui fei zhu sha tian ma wu mei ye jiao teng yi mu cao zhi huang qi zi su yu an xi xiang bai fu ling Appendix
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 60
ban xia qu bei xie bi ba bin lan bing pian cao guo chao bian dou chao shan yao chao wu ling zhi chao yi ren chi xiao dou chuan xiaong ci shi da fu pi da zao tang dan shen deng xin cao di long duan meng shi duan mu li fu xiao mai geng mi gua di gui ban jiao gui xin he geng he zi hu po huai niu xi huang pin huo ma ren ji zi huang jing mi jiu xi da huang jiu xi huang qin ju hua lian qiao lian zi lian zi xin long chi lu jiao jiao ma huang gen mo han lian mo yao Appendix
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 61
nu zhen zi pao jiang ru xiang sang bai pi she xiang sheng di sheng pu huang shi hu shi wei shui niu jiao su gui ban su he xiang tan xiang tian dong tian men dong tu si zi wu wei zi xi gua cui pi xi jiao xi yang shen xuan fu hua xuan shen yan hu suo yan huang bai yan zhi mu zhe shi zhen zhu mu zhi qiao zhu ling zhu ya zao zhu ye zi he che Appendix
62
Appendix VII: Search terms Pubmed
To guarantee a broad range of findings, the Mesh terms of all disease categories
were matched with not only the Mesh search term for Chinese herbal medicine, but
also the more general Mesh search term for traditional Chinese medicine.
!
"Autonomic Nervous System Diseases"[Mesh] AND (("Drugs, Chinese
Herbal"[Mesh]) OR ("Medicine, Chinese Traditional"[Mesh]))
!
"Fatigue Syndrome, Chronic"[Mesh] AND (("Drugs, Chinese Herbal"[Mesh])
OR ("Medicine, Chinese Traditional"[Mesh]))
!
"Conversion Disorder"[Mesh] AND (("Drugs, Chinese Herbal"[Mesh]) OR
("Medicine, Chinese Traditional"[Mesh]))
!
"Hypochondriasis"[Mesh] AND (("Drugs, Chinese Herbal"[Mesh]) OR
!
"Hypotension, Orthostatic"[Mesh] AND (("Drugs, Chinese Herbal"[Mesh]) OR
!
"Hysteria"[Mesh] AND (("Drugs, Chinese Herbal"[Mesh]) OR ("Medicine,
Chinese Traditional"[Mesh]))
!
"Neurasthenia"[Mesh] AND (("Drugs, Chinese Herbal"[Mesh]) OR ("Medicine,
Chinese Traditional"[Mesh]))
!
"Neurocirculatory Asthenia"[Mesh] AND (("Drugs, Chinese Herbal"[Mesh]) OR
!
"Neurotic Disorders"[Mesh] AND (("Drugs, Chinese Herbal"[Mesh]) OR
!
POTS AND (("Drugs, Chinese Herbal"[Mesh]) OR ("Medicine, Chinese
Traditional"[Mesh]))
!
"Somatoform Disorders"[Mesh] AND (("Drugs, Chinese Herbal"[Mesh]) OR
Appendix
Appendix VIII: Inclusion/ Exclusion process
63
Appendix
Appendix IX:
Inclusion List
64
Appendix
Appendix X: Excluded studies
65
Appendix
66
Appendix
67

Treatment approaches for autonomic nervous system dysbalances

Transcription

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