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Contents lists available at ScienceDirect
Journal of Ethnopharmacology
journal homepage: www.elsevier.com/locate/jethpharm
Graphical Abstract
An integrative approach of linking traditional Chinese medicine pattern
classification and biomedicine diagnosis
Journal of Ethnopharmacology xx (2011) xxx–xxx
Paern Classificaon in TCM
Disease diagnosis in biomedicine
Aiping Lu∗ , Miao Jiang, Chi Zhang, Kelvin Chan∗∗
Linkage between
TCM paern classificaon and diagnosis in
biomedicine
Historical evoluon on the integraon of the TCM paern
classificaon and disease diagnosis in biomedicine
Methodology of paern classificaon for diseases
Efficacy when integrang TCM paern classificaon and biomedical
disease diagnosis
Biological basis of TCM paern
TCM paern classificaon could lead new findings in biomedicine
JEP 6989 1
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JEP 6989 1–8
Journal of Ethnopharmacology xxx (2011) xxx–xxx
Contents lists available at SciVerse ScienceDirect
Journal of Ethnopharmacology
journal homepage: www.elsevier.com/locate/jethpharm
An integrative approach of linking traditional Chinese medicine pattern
classification and biomedicine diagnosis
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Q1
Aiping Lu a,∗ , Miao Jiang a , Chi Zhang a , Kelvin Chan b,∗∗
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b
China Academy of Chinese Medical Sciences, Beijing 100700, China
The University of Sydney, NSW 2006 and CompleMED University of Western Sydney, NSW 2560, Sydney, Australia
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a r t i c l e
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a b s t r a c t
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Q2 Article history:
Received 22 March 2011
Received in revised form 11 August 2011
Accepted 21 August 2011
Available online xxx
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Keywords:
Pattern classification
Traditional Chinese medicine
Integrative medicine
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1. Introduction
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Traditional Chinese medicine (TCM) is a medical system with over 3000 years of continuous practice
experience and refinement through treatment observations. The TCM pattern classification (also defined
as Syndrome or Zheng differentiation) and treatment of ill health is the basis and the key concept of
the TCM theory. All diagnostic and therapeutic methods in TCM are based on the differentiation of TCM
pattern. TCM pattern can be considered as the TCM theoretical interpretation of the symptom profiles.
Pattern classification is often used as a guideline in disease classification in TCM practice and has been
recently incorporated with biomedical diagnosis, resulting in the increasing research interest of TCM
pattern among various disciplines of integrative medicine. This paper describes the historical evolution on
the integration of the TCM pattern classification and disease diagnosis in biomedicine, the methodology of
pattern classification for diseases, efficacy of TCM practice with integration of TCM pattern classification
and biomedical disease diagnosis, and the biological basis of TCM pattern. TCM pattern classification,
which may lead to new findings in biological sciences, was also discussed.
© 2011 Published by Elsevier Ireland Ltd.
Traditional Chinese medicine (TCM) is a healthcare-focused
medical system with its rich experience over 3000 years of continuous practice and refinement through observations, testing and
critical thinking in treating ill-health. TCM management of health
can be characterized as holistic with the emphasis on regulating the
integrity of the human body functions and the interaction between
human individuals and their environments. TCM applies multiple
therapeutic methods for patient management such as, life-style
adjustment of diet, treatments with prescribed herbal formulas
apart from the application of acupuncture and other nonchemical
interventions such as tuina (medical massage) and taichi.
TCM pattern classification (also called as Syndrome or Zheng differentiation) is the basic unit and the key concept in TCM theory.
All diagnostic and therapeutic methods in TCM are based on the
differentiation of TCM pattern, and this concept has been used for
thousands of years in China (Chen and Xu, 2003; Ma et al., 2010).
TCM pattern can be considered as the TCM theoretical interpretation of the symptom profiles of a disease but not only an assemblage
of disease symptoms. It is also used as a guideline in disease clas-
∗ Corresponding author. Tel.: +86 10 64067611; fax: +86 10 84032881.
∗ ∗ Corresponding author. Tel.: +61 2 91141485; fax: +61 2 46203291.
E-mail addresses: [email protected] (A. Lu), [email protected]
(K. Chan).
sification in TCM practice. For example, patients suffering from
the same disease may be categorized into different TCM patterns,
whereas different diseases may be categorized as the same TCM
pattern.
As one of the main items of complementary and alternative medicine, the practice of TCM has increased dramatically in
recent decades (Eisenberg et al., 1998). However, the study of
TCM still encounters serious challenges due to the almost irreconcilable differences from the conventional orthodox medicine
(OM) (Fontanarosa and Lundberg, 1998). There are at least two
major differences between TCM and OM: patient classification and
intervention methodology. In patient classification, TCM uses pattern classification based on TCM information (obtained from direct
observation of patients’ external features, auscultation & olfaction,
interrogation or questioning and pulse detection and palpation)
while OM uses disease diagnosis based on pathological examinations of individual organ functions and receptors malfunctions. As
to the intervention: In TCM, establishing the therapeutic principles and general rules is of initial importance; this is followed
by the formulation of prescriptions containing Chinese material
medica (CMM) and other therapeutic measures because the latter
depends on the former for guidance. The outcome of a treatment
will indicate whether or not the diagnosed pattern and the CMM
prescription therapy are correct. The basic steps of the four TCM
examination techniques help to confirm the signs and symptoms
that, in turn, serve as means to work out the CMM prescriptions. Finally, the therapy directs the formulation of a specific
0378-8741/$ – see front matter © 2011 Published by Elsevier Ireland Ltd.
doi:10.1016/j.jep.2011.08.045
Please cite this article in press as: Lu, A., et al., An integrative approach of linking traditional Chinese medicine pattern classification and
biomedicine diagnosis. J. Ethnopharmacol. (2011), doi:10.1016/j.jep.2011.08.045
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Without Pattern
classification
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With Pattern
classification
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Before
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20002001
20022003
20042005
20062007
20082009
Fig. 2. The publications in Chinese about clinical trials on Dan Shen Di Wan (a TCM
product). The data were obtained from CBM database.
Fig. 1. The published papers in Chinese about TCM pattern classification. The data
were obtained from CBM database (till February 17 of 2011).
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prescription. These essential steps are interlinked, interconnected
and indispensable in TCM practice.
In OM practice symptomatic treatments mainly aim at relieving patients’ complaints or main symptoms with pharmaceutical
drugs and surgery in severe cases, based on disease diagnosis to
provide specific chemical components acting on targeted receptors
or enzyme components at molecular levels. This paper attempts
to illustrate that the appropriate linking of TCM pattern classification with OM disease diagnosis can provide a better understanding
of the incorporation of TCM pattern classification into OM disease
diagnosis.
2. History of integration of TCM pattern classification and
disease diagnosis in biomedicine
In China, the integration of TCM pattern classification with disease diagnosis in biomedicine was proposed in the early 1960s by
Zhu (1962). In 1980s, the Chinese Association of Integration of TCM
and Western medicine was setup with the objectives of improving the integration of TCM with OM, in which the incorporation
of the TCM pattern classification into disease diagnosis in OM is
one of the tasks. The integration of the TCM pattern classification
and biomedical disease diagnosis has then been reported in the
English journals. Table 1 shows that there is a tendency in the TCM
pattern classification research, from the TCM concept to the biological basis, from clinical trial to innovation in biomedicine, from
clinical trial on herbal medicine to on biomedicine therapy, from
general biological basis exploration to the exploration with systems
biology approach. The clinical trial with the TCM pattern classification will help to provide improvement with more innovation in
biomedicine.
Since the 1980s we witnessed the changing situation of clinical studies with the TCM pattern classification in diseases in China.
TCM practitioners or integrative medicine practitioners in China
focused on clinical observations with TCM pattern classification
in diseases. From CMB (Chinese BioMedical Literature Database
at http://sinomed.imicams.ac.cn/index.jsp), there were more than
50,000 papers published on clinical observations with TCM pattern classification in different diseases. Fig. 1 shows the papers an
increase in the number of publications annually. Of these papers,
429 types of diseases linked with 190 categories of TCM pattern
have been treated with TCM interventions integrated with the TCM
pattern classification. Top 50 diseases treated in this manner and
top 50 TCM patterns classified in the 429 diseases are summarized
in Tables 2 and 3.
From Tables 2 and 3, it can be concluded that TCM pattern classification has been widely incorporated into the treatment of many
types of diseases know in biomedicine identified in OM practice.
Because of the complexity in RCTs with TCM pattern classification; there were few RCT publications in the Chinese language
journals. However, in recent years the observation detects an
increase of publications in RCTs with inclusion of TCM pattern classification. For example, a total of 171 RCT publications in Chinese
language journal on Dan Shen Di Wan (a TCM proprietary product for treatment of angina pectoris) was observed and more RCTs
were reported after 2006 (Fig. 2). A total of 381 papers on clinical
study were found in the Pubmed-cited journals with pattern classification (or syndrome differentiation) (till July 31 of 2010). Most
of them were published in Chinese language journals with English
abstracts, and only 44 published in English with full papers. Of these
33 were published after 2005, and 11 from 1983 to 2004. About 10
types of diseases with the TCM pattern differentiation were studied in the 12 RCTs from 2002 to 2009 (Jiang et al., 2010a). A total
of 11 RCTs showed that TCM was effective in the treatment of the
diseases or in the alleviation of symptoms, with one study failing
to confirm the efficacy. No study reported negative results.
Presently in China, governmental authorities only strongly fund
high quality clinical studies with strict regulations and guidelines
on TCM clinical trials. Researchers are required to pay more attention to the quality of clinical trials with proper protocols. It has
been estimated that there are more than 50 TCM clinical trials
ongoing that are sponsored by the National Key Technology R&D
Program in China [http://www.most.gov.cn/eng/programmes1/
200610/t20061009 36224.htm]. Among them, more than half
includes interventions based on the TCM pattern classification. We
believe that more evidence-based clinical trials will confirm and
support the role of the TCM pattern classification in future clinical
studies on the efficacy assessment of TCM practice.
3. Method for TCM pattern classification for diseases
TCM pattern identification had been used as a basis for
developing treatment protocols in clinical trials. TCM syndromes
differentiate biomedical diseases into different patterns, and each
pattern comprises of symptom/signs that have their own unique
treatment protocol. The TCM pattern classification is mainly based
on symptoms (including self-reported signs), tongue and pulse
diagnosis, and it is difficult to interpret in OM terminology. This
could be the main reason why TCM pattern classification was not
incorporated into the biomedical disease diagnosis. For this reason
Please cite this article in press as: Lu, A., et al., An integrative approach of linking traditional Chinese medicine pattern classification and
biomedicine diagnosis. J. Ethnopharmacol. (2011), doi:10.1016/j.jep.2011.08.045
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Table 1
Important events in TCM pattern research published at first time in Medline or SCI indexed journals.
Key event
Journal
Author
Years
Integration of TCM and Western medicine
Double blinded clinical trial in coronary heart disease with TCM intervention
Basic concept on TCM pattern classification
Review on TCM pattern of blood stasis
Biological basis focusing on TCM pattern of kidney deficiency
Biological basis focusing on TCM pattern
Linkage between TCM symptoms and biological parameters in gastritis
Integration of TCM pattern classification into disease diagnosis
TCM pattern and innovation in biomedicine
Clinical efficacy and TCM pattern classification in biomedical disease with RCT
Role of TCM pattern classification in biomedical sciences
TCM pattern help biomedicine for improvement of efficacy for biomedical disease
Omics based TCM pattern classification in biomedical disease
Safety evaluation based on TCM pattern classification in a biomedical disease
Medline, Chinese
Medline, Chinese
Medline, English
Medline, Chinese
Medline, English
SCI, English
SCI, English
SCI, English
SCI, English
SCI, English
SCI, English
SCI, English
SCI, English
SCI, English
Chen KJ
Chen KJ
No author listed
Chen KJ
Zhang Q
Chen ZQ
Li S
Jiang WY
Zha Q
Lu A
He Y
Lu C
van Wietmarschen H
Jiang M
1979 (Chen, 1979)
1982 (Chen, 1982)
1983 (No author listed, 1983)
1983 (Chen, 1983)
1990 (Zhang et al., 1990)
1999 (Chen et al., 1999)
2003 (Li et al., 2003)
2005 (Jiang, 2005)
2006 (Zha et al., 2006)
2009 (Lu and Chen, 2009)
2007 (He et al., 2007a)
2009 (Lu et al., 2009)
2009 (van Wietmarschen et al., 2009)
2010 (Jiang et al., 2010b)
Table 2
Top 50 TCM patterns in Chinese publications about TCM clinical studies.
Patterns (Zheng)
Qi deficiency
Blood stasis
Deficiency of the kidney
Damp-heat
Spleen deficiency
Blood deficiency
Yin deficiency of liver and kidney
Wind-cold
Yin deficiency
Cold-dampness
Qi stagnation
Hemoptysis
Qi depression to blood stasis
Wind heat
Blood heat
Pyrexia
Hematochezia
Cough
Asthenia of qi and blood
Yang deficiency
Bleeding Syndrome
Arthralgia syndrome
Spleen-kidney Yang deficiency
Asthenia syndrome
Bellyache
Total papers
20,286
19,065
12,600
9856
9088
3488
2016
1916
1876
1680
1620
1599
1452
1088
792
710
606
605
560
448
386
375
354
329
276
Patterns (Zheng)
Paper No.
Kidney-yang deficiency kidney-yang deficiency
Heat syndrome
Haematemesis
Deficiency-cold
Kidney-Yin deficiency
Constipation
Spleen Qi deficiency
Phlegm accumulation
Common influenza
Deficient cold of spleen and stomach
Night Sweats
Apoplexia
Liver heat
Liver-stomach disharmony
Edema
Xiaoke
Dysmenorrheal
Dyspnea
Jaundice
Vomit
Headache
Dyspepsia caused by improper diet
Phlegm syndrome
Cervical spondylosis
Dizziness
272
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238
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218
209
191
172
163
162
156
146
140
128
126
119
113
106
101
95
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89
86
84
Table 3
Top 50 diseases published in Chinese about the clinical studies in TCM.
Diseases
Total number of paper
Diseases
Paper No.
Hemoptysis
Hematochezia
Hematuria
Hypertension
Diabetes
Pneumonia
Stenocardia
Abdominalgia
Albuminuria
Respiratory tract infection
Haematemesis
Hyperlipidaemia
Cerebral infarction
Constipation
Diarrhea
Blood hyperviscosity
Dyspnea
Cardiac failure
Asthma
Influenza
Infection
Aging
Nephrosis
Edema
Gastritis
1599
606
575
421
360
352
294
276
264
249
238
229
214
209
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201
186
175
163
161
130
126
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124
Dysmenorrheal
Prostatitis
Jaundice
Vomit
Cephalalgia (encephalalgia)
Nephrotic syndrome
Bronchitis
Vertigo
Osteoporosis
Arteriosclerosis
Myocardial infarction
Coma
Urinary tract infection
Anaphylaxis
Irritable bowel syndrome
Facial paralysisfacial paralysis
Migraine
Encephalorrhagia
Prostate hyperplasia
Hepatic tumor
Kidney failure
Depression
Arthralgia (arthrodynia)
Coronary heart disease
Dyspepsia
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101
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88
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TCM pattern classification becomes the most important factor to
be included in the incorporation process.
There is a wide variation of the differentiation of symptoms,
tongue and pulse diagnosis. Some of these are not closely related
to the disease diagnostic parameters, and are less focused upon
by biomedicine, such as thirst and turbid urine and yellow tongue
fur in some diseases (Lu et al., 2004). The quantification of TCM
patterns usually is based on the textbook or expert consensus. On
the other hand, statistical evaluation of the TCM pattern or pattern change can be obtained (Lu et al., 2008; Berle et al., 2010).
Although the symptoms, which are the key information for the
TCM pattern classification, are diversified in a disease, they can
be clustered into specific groups using bio-statistical approaches,
even though traditionally they are classified into groups based
on the TCM theory and clinical experiences. A multi-center RCT
study had shown that among 13 common symptoms of rheumatoid arthritis (RA), 5 are related to the joint, 8 are not related to
the joint. Symptoms clusters in 396 patients could be classified
into four factors (symptom combinations) with factor analysis. The
symptom combinations are very similar to the patterns differentiated by the TCM theory in RA patients, which divides the RA into
three basic patterns: cold, heat and deficiency patterns (He et al.,
2007a).
More instruments are being developed in the diagnosis of
tongue appearance and pulse feeling (Lu et al., 2008; Yan et al.,
2009; Berle et al., 2010; Xu et al., 2010). It is encouraging that
integration of TCM information in symptoms, signs, tongue appearance and pulse feeling will be the focus in the near future, and
TCM pattern classification would be based on objective examinations, which can further lead to more understanding with
biomedical aspects and the concepts can be used by other OM
scientists.
4. Efficacy of TCM practice with integration of TCM pattern
classification and biomedical disease diagnosis
Increasing numbers of medical researchers recognized that the
combination of disease diagnosis in biomedicine and pattern classification in TCM is essential for the clinical practice when TCM
is included as part of the treatment along side with the OM diagnostic approaches, and it has been a common practice model in
China since it focuses on a better assessment of clinical effect
(Manheimer et al., 2009). Over the past 50 years, clinical practice in TCM hospitals in China has applied both principles of
biomedical disease diagnosis and TCM pattern classification for
intervention/treatment of patients. A clinical investigation indicated that a more effective treatment rate could be achieved from
the RA patients with specific symptoms and co-diagnosed and
treated based on their TCM pattern classification (He et al., 2007a).
While clinical research on TCM has been conducted in China and the
West, much of this research was inadequate in delivering reliable
data. In 2008, a review of a total of 70 Cochrane systematic reviews
regarding TCM clinical research found most of the studies to be
inconclusive (Manheimer et al., 2009). Several reasons could be
identified: Most of trial protocols employed randomized controlled
trial (RCT) designs that were not suitable for TCM research, and
most of the investigations had not involved collaboration between
OM and TCM scientists. There was a failure to consider fundamental
concepts of TCM in terms of diagnosis. It is important to incorporate
the concepts of both OM and TCM into research protocols, necessitating collaboration between OM and TCM practitioners (Tsang,
2007).
Many meta-analyses on TCM clinical studies focused on the specific diseases, showed no evidence to prove the efficacy of TCM in
the treatment of the diseases because of lower quality of clinical
design (Chen and Hu, 2006; Zhu et al., 2008; Tu et al., 2009). Anecdotally, increasing number of patients were seeking help from TCM
for its better clinical outcomes. This suggests that TCM could have
a clinical effect; and it is necessary to assess the TCM clinical efficacy with better and innovative approaches. The RCT is considered
to be the methodology offering the highest level of evidence. However, different types of research approaches are needed to assess
different types of clinical problems. Observational studies and case
reports often are the only research method suitable for assessment
of TCM efficacy. TCM, being holistic in approach, it identifies and
treats syndromes rather than diseases. Recent RCTs on TCM have
been conducted and showed clinical efficacy in the treatment of
arthritis based on TCM pattern differentiation (Goldbach-Mansky
et al., 2009; Min et al., 2010; Tsang et al., 2010; Wang and He, 2010).
It is believed that the incorporation of TCM pattern classification
into disease diagnosis would greatly improve the efficacy of TCM
interventions.
Evaluation of TCM treatment efficacy should focus on a specific subgroup of patients with a specific disease, or a specific
herbal preparation with clinically proven effectiveness. Many system reviews currently on TCM efficacy showed that there were
no evidence to support the TCM intervention efficacy, and more
quality clinical trials of TCM were needed for collecting evidence
to support the TCM clinical application without focusing on the
TCM pattern classification. Based on our search on CMB (Chinese
BioMedical) Literature Database (in Chinese) and Pubmed database
(in English), there were 180 RCT about Danhong Injection (consisting of safflower and Salvia miltiorrhiza), which is commonly used
in the clinical practice in China for the activation of blood stasis
(based on TCM theory), and only two of them were based on TCM
pattern classification.
As TCM pattern classification focuses on further classification
of the patients into treatment sub-group, the treatment efficacy
would be improved if the responsive cases can be clarified from
non-responsive cases with the their TCM patterns. It has been
reported that the TCM pattern differentiation can specify the indications for the combination biomedical therapy in the treatment
of existing RA patients (Lu et al., 2009). A RCT was performed to
compare the symptomatic effects on patients with benign prostatic
hyperplasia (BPH) treated by two therapeutic approaches, the OM
and TCM, and the results showed that TCM is a potentially effective
treatment in improving the Quality of Life (QOL), prostate volumes
and maximum UFR for a subgroup of patients with BPH, and the
non-urethra related symptoms experienced by BPH patients could
be one of the parameters for further distinguishing the effects of
TCM and OM therapies (Li et al., 2010). The results suggest that it
may also be useful in defining specific indications for biomedical
therapies used to treat other diseases.
TCM psychotherapy is a special intervention and more clinical
experience proved that it could be used alone or in combination
to treat many diseases. TCM psychotherapy was recorded in many
ancient TCM books and has been applied in many mental diseases or
diseases with mental symptoms successfully for thousands of years.
Distinguished from modern psychotherapy, it integrated TCM theory basis with several therapeutic approaches such psychological
counseling and cognitive-behavioral techniques together, aiming
at the harmony of human body, mental and social status. Since
according to TCM theory, the human is regarded as a holistic system, there exist inner correlations between Zang-fu viscera and
various emotions, the regulation of one aspect will have effect
to the other aspect, and TCM psychotherapy focuses on not only
mental diseases, but also physical disorders during treatment. This
feature determines the high applicability of TCM psychotherapy
to the psychosomatic diseases, one good representative is female
menopausal syndrome. Modern clinical study, especially for the
randomized controlled trials (RCTs) conducting, usually ignores
Please cite this article in press as: Lu, A., et al., An integrative approach of linking traditional Chinese medicine pattern classification and
biomedicine diagnosis. J. Ethnopharmacol. (2011), doi:10.1016/j.jep.2011.08.045
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TCM psychotherapy due to the highly personalized therapeutic regimen and the difficulties in the fulfilling of the treatment, though
TCM based psychotherapy is an essential part of TCM therapeutics, and it has been widely used in many diseases and achieved
favorable outcomes, especially in those diseases signed with psychological symptoms (Wang et al., 2011). Therefore more clinical
trials should be focused on the effectiveness of TCM based psychotherapy.
5. Biological basis of TCM pattern
To illustrate the importance of TCM pattern in both the theory
and the practice of TCM, much effort has been paid to investigate its
biomedical basis. Previous study explored the biological basis of the
TCM pattern by applying general biological approaches. The results
included the linkage between sex hormones and Kidney deficiency
pattern in chronic nephritis (Zhang et al., 1990), linkage between
C-reactive protein and cold/hot pattern in RA (Zhao et al., 2006),
linkage between homeo-rheology and blood stasis pattern in cardiovascular diseases (Jia, 1989; Lin and Liao, 1990; Takeichi and
Sato, 1997), and linkage between gastric mucosal immune reactions and the TCM pattern in chronic gastritis (Lu et al., 2005).
It is still far from reaching a full understanding of the inherent
mechanism of the TCM pattern, as it is known that the scientific
evaluation of TCM into OM disease terminology is very difficult
using existing conventional methods (Lu et al., 2007; Wu et al.,
2008). In the exploration on the biological basis of TCM patterns,
Li et al. explored the molecular basis of TCM pattern within the
context of neuro-endocrine-immune (NEI) system (Li et al., 2006,
2007). Patients suffering from RA are found to experience an alteration of the NEI system (He et al., 2007a; Lu and Chen, 2009). Our
previous studies showed that there were some the distinct molecular signatures in discriminating the RA patients with traditional
Chinese medicine (TCM) cold pattern and heat pattern (Lu et al., in
press). These results suggest that a better knowledge of the main
biological processes involved at a given pattern in TCM could help
to choose the most appropriate treatment.
The advances of “Omics” revolution and methodology in modern life science, bioinformatics and systems biology have offered
an opportunity to integrate multi-dimensional and various types
of data, in the new era of the medical and biological sciences (Lu
et al., in press; Zheng et al., 2011). Capturing these unprecedented
opportunities and challenges, bioinformatics and systems biology
approaches are expected to open the way to a new convergence of
TCM and OM in both concept and methodology. Such observations
can be interpreted as follows: Prescribing Chinese herbal medicine
(often referred to as Chinese material medica, CMM) in the form
of composite formulae based on TCM pattern classification is the
key disease prevention/treatment regimen in TCM practice. The
human body is a complex and hugely interconnected system, which
is dynamically regulated within boundaries of cells, tissues and
organs to achieve homeostasis. The treatment strategy of prescribing TCM composite formulae is based on supporting the balancing
capabilities of the body (salutogenesis) to recover from an imbalanced state. In the formula, each CMM contains many compounds
that possess concerted actions (Chan and Lee, 2000; Chan, 2005). A
successful formula organizes these concerted actions derived from
different CMMs to create holistic, multi-target, multi-dimensional
pharmacological actions, which could be expressed by technology
derived from “omics’ and systems biology, to achieve personalized
therapy. Thus the advance of pharmcogenomics and systems biology has created the building blocks to measure the mechanisms of
composite CMM formulae by modern pharmacology methodology
(Wang et al., 2009).
5
6. TCM pattern classification could lead new findings in
biomedicine
TCM pattern classification would lead to new findings when
linked with biomedicine diagnosis since there should have some
differences between different TCM patterns in the same diseases as
diagnosis in OM. For example, the treatment of RA with TCM intervention in the later stage of the disease usually focuses on the blood
stasis and deficiency TCM pattern (Zhou et al., 2000; Wang et al.,
2010). While TCM blood stasis pattern shows some linkage with
platelet activity (Ma et al., 2009), the TCM deficiency pattern shows
some linkage with immune response (Yuan et al., 2010). Thus it is
reasonable to make the hypothesis that there is a positive correlation among IgA (reflecting immune response), platelet and cartilage
erosion (severe in late stage) in RA. The changes in peripheral IgA
level and platelet number positively correlated with the grade of
cartilage damage in active RA patients, thus supporting the hypothesis (Zha et al., 2006; He et al., 2007b). In the clinical practice, the
CMMs with activating blood stasis pattern, and those reinforcing
deficiency pattern and containing polysacharides or animal proteins were used for the treatment (Yang et al., 2003; Zhang et al.,
2010).
On the other hand, biomedical sciences not only help identify
the scientific basis for TCM pattern, it can also improve further
clarification of TCM pattern. For example, Kangxin capsule and
Tongxinluo capsule are two TCM products exist in the China market
for years, are used to target TCM Qi deficiency and blood stasis pattern in the treatment of angina pectoris. Our previous study found
that biomedical parameters such as LDL and blood pressure can be
used as indicators showing the efficacy of Tongxinluo capsule and
Kangxin capsule respectively in the treatment of angina pectoris
even though there are targeting same TCM pattern (Yan et al., in
press).
Another important concept in TCM is named as “Treating Different Diseases with the Same Therapy” (TDDST) has been applied
in TCM practice. Some patients with Rheumatoid Arthritis (RA) and
other with Coronary Heart Disease (CHD) can be treated with similar therapies. (For example, activation of blood stasis for RA patients
with TCM pattern of blood stasis.) This suggests that there could
be something commonly existing between RA and CHD conditions
according to TCM diagnosis within the context of imbalance in the
body functions biological networks or biological basis. In order to
substantiate such concepts, there exists a need to search for these
interlinking data from reliable databases. Presently in our leading research database the amount of biomedical data is growing
rapidly, it is possible to get relevant and meaningful information
through the techniques developed in the fields of data mining.
Our previous study proposed an hierarchical analysis algorithm
called discrete derivatives which is based on the frequencies of coconcurrent MeSH (The Medical Subject Headings) terms, we have
found some significant results which can support the concept of
TDDST, and also that the biological basis and biological networks
commonly existing in RA and CHD. These networks can be affected
by the basic CMMs, which are widely used in the TCM therapies on
both RA and CHD (Figs. 3 and 4).
Therefore TCM pattern classification, as a new approach to
identify the relevant diseases among patients into different TCM
categories will certainly contribute important concepts in the
innovation of integrative treatment of diseases with supporting
biomedical sciences.
7. Future perspectives
The principles of TCM pattern classification (obtained from
direct observation of patients’ external features, auscultation &
Please cite this article in press as: Lu, A., et al., An integrative approach of linking traditional Chinese medicine pattern classification and
biomedicine diagnosis. J. Ethnopharmacol. (2011), doi:10.1016/j.jep.2011.08.045
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Fig. 3. The con-concurrent MeSH terms between RA and coronary heart disease were obtained from PubMed (till July 30 of 2010). Here is a small part focusing on apoptosis,
inflammation and genotype and their con-concurrent MeSH terms. The results indicate that there might be a similarity on apoptosis, inflammation and genotype and their
networks between the pathogenesis of RA and coronary heart disease.
Fig. 4. Radix Notoginseng (NG, San Qi in Chinese) and Radix Salivae Miltiorrhizae (SM, Dan Sheng in Chinese) are an herbal combination and commonly used for activation of
blood stasis in TCM practice. The con-concurrent MeSH terms on NG and SM were obtained from PubMed (till July 30 of 2010), which then incorporated into the con-concurrent
MeSH terms between RA and coronary heart disease to find out the overlapped con-concurrent MeSH term network. Here is a small part focusing on apoptosis, superoxide
dismutase and intercellular adhesion molecule-1 and their con-concurrent MeSH terms, which NG and SM have been reported to target on (Triangle: SM; Diamond: NG;
Hexagon: combined two herbs). The results indicate that NG and SM have shown their activity in the similar MeSH terms (targets) about apoptosis, superoxide dismutase,
intercellular adhesion molecule-1 and their con-concurrent MeSH terms, which are co-shared by both in RA and coronary heart disease.
Please cite this article in press as: Lu, A., et al., An integrative approach of linking traditional Chinese medicine pattern classification and
biomedicine diagnosis. J. Ethnopharmacol. (2011), doi:10.1016/j.jep.2011.08.045
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olfaction, interrogation or questioning and pulse detection and
palpation) provide a firm basis to classify patients into subtypes
for selection of specific therapy even though the subjective measurements such as tongue appearance and pulse diagnosis through
direct observation require standardization.
The development of objective measurements such as quality of life instruments to monitor patients reported outcomes
(Zhao and Chan, 2005) and systems biology technology that provide biomarker measurement during treatment intervention will
substantiate the subjective assessment of TCM pattern classification of diseases. These two aspects should be considered in the
development of integrative medicine including OM and TCM. Furthermore, investigations based on systems biology approaches on
mechanisms of actions of CMM formulae can be applied as holistic approach in analyzing the complexity of CMM formulae. This
approach has become an important direction for the elucidation of
mechanism of TCM herbal mixtures used in clinical management of
patients treated by both OM and TCM (Lu and Li, 2010). Therefore
systems biology and bioinformatics are useful tools to clarify the
molecular basis for the TCM pattern. Likewise, TCM pattern classification could provide innovation approaches to examine if holistic
nature provided by OM using modern biomedical sciences.
In summary, the incorporation of TCM pattern classification into
biomedical disease diagnosis will lead to a new era in the development of medical sciences to provide improving treatment efficacy
with specific indications of integrative therapy. Further classifying
patients suffering from diseases into TCM pattern categories before
therapy selection will lead to innovation of biomedicine based concepts for TCM pattern assessment.
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Acknowledgements
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This research is partly sponsored by the projects from the
National Science Foundation of China (Project Nos. 30825047 and
90709007) and National Eleventh Five Year Support Plan (Project
No. 2006BAI04A10).
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