MEDICAL ACUPUNCTURE

Volume 20, Number 3, 2008

© Mary Ann Liebert, Inc.
DOI: 10.1089/acu.2008.0587

Clinical Pearls
Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 02/06/15. For personal use only.

How Do You Treat Fibromyalgia in Your Practice?

Medical Acupuncture is pleased to continue this new regular feature, Clinical Pearls, which we trust will be useful to
the readership. All of us are confronted with clinical challenges, especially when dealing with therapeutic strategies. We
hope you will find this ongoing collection of Clinical Pearls at your fingertips, ready to put into action for the benefit of
our patients—and even ourselves. How often do we ask our colleagues, “How do you treat. . . ?” To continue this new
endeavor, we posed the question: “How do you treat fibromyalgia in your practice?” Here are the “Pearls” we received.
We trust that the readership will participate in this section by either asking the questions or supplying the “Pearls.” We
welcome your input. Please address your “Pearls” to our Managing Editor at RosalynR@aol.com.

Richard C. Niemtzow, MD, PhD, MPH

Editor-in-Chief
Medical Acupuncture 2008.20:141-145.

O VER THE PAST 25 YEARS, fibromyalgia has become a

common presenting symptom often associated with
chronic fatigue syndrome (CFS). From the beginning, I
Ziziphus Fruit
Panax
Panax (Korea)
da zao
ren shen
ren shen
5–20 g
9g
4.5 mg
found that the condition involves the nourishment of nerve Codonopsis dang shen 15 g
endings ordinarily supplied by Liver Blood that also nour- Aconitum fu zi 0.25 g
Cinnamomum rou gui 3g
ishes all peripheral nerves including the autonomic ner-
Salvia dan shen 6g
vous system as well as ligaments, tendons, and muscles.
Curcumae Tuber yu jin 6g
(I find that the Spleen controls the connective tissue Ligisticum chuan xiong 9 g (circulation
[hence, non-pitting edema], and not muscles as the liter- to the brain)
ature seems to indicate.) Notopterygli Qiang Ho 6g
This deficit in the supply of Blood to the peripheral nerves Corydalis Yan Hu So 6g
makes them more sensitive and irritable, and experienced as
pain when these nerves are stimulated by pressure. This formula treats Heart shock and offers several herbs
Most significant is that the supply of Blood to the surface specifically for Heart Qi (not all of which are needed, such
is more often due to a Heart-circulation deficiency. There may as ren shone, codonopsis and Korean ginseng; Fu Zi is also
be enough Blood stored by the Liver, but not a sufficient de- optional where there is Heart Yang deficiency). Other herbs
livery system to adequately supply this Blood to the superfi- take out Damp, generally, and phlegm blocking the Heart
cial nerves. The solution I found consistently effective is en- orifices.
hancing either Heart Qi and/or Liver Blood. This is effectively Acupuncture includes the points for Blood: BL 11, BL 17,
done with an herbal formula such as the following that also ST 37–39, GB 39, and for circulation of Blood and for the
includes surface releasing pain-reducing herbs: Heart, the extra channel, Chong Mai (especially useful with
the upper Kidney points and Heart-Kidney disharmony). The
Panax (American) xi yang shen 9 g Yin Wei and Yang Wei help when people feel stuck; the
Ophiopogon mai men dong 9 g latter is useful for exterior conditions. (For concomitant
Schizandra wu wei zi 6 g CFS, other treatments are indicated.)
Zizyphus Seed suan zao Ren 9 g Most important is to make a careful diagnosis before pro-
Biotae Seed bai zi ren 3 g ceeding with any management plan.
Polygonum ye jiao teng 6 g
Euphoria long yan rou 6 g
Albezzia he huan pi 9 g
Leon I. Hammer, MD
Poria Cocos fu shen 10 g 1000 NE 16 Street Building F
Craetegus Fruit shan zha 6 g Gainesville, FL 32601
Succinum hu po 1 g
Glycyrhiza gan cao 5 g E-mail: leonhammer@mac.com

141
 142 CLINICAL PEARLS

I MAKE THE DIAGNOSIS OF fibromyalgia using the 1990

American College of Rheumatology classification crite-
ria. I rule out comorbidities such as severe psychiatric dis-
avoids infection and wounds. Compared to other methods
(acupuncture and moxibustion), it also elevates the thresh-
old of pain and relieves the distress of the patient.
ease, neurological deficits, cardiac disease, or glaucoma, and
refer those patients for proper treatment. I routinely pre- Jun-Tao Feng, MD
scribe antidepressant medication in an analgesic dose (be- Cheng-Ping Hu, MD
tween 12.5 mg/d and 75 mg/d), oral instruction to walk for Department of Respiratory Medicine
Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 02/06/15. For personal use only.

30 minutes twice a week at the patient’s own pace, and to Xiangya Hospital
breathe deeply and perform mental relaxation exercises for Central South University
another 30 minutes. I also recommend to patients that he/she Changsha, 410008
perform twice-weekly stretching exercises involving the China
paraspinalis muscles, glutei, hamstrings, ankle plantar flex-
ors, and hip flexors. E-mail: jtfeng1976@hotmail.com
I also perform acupuncture: usually 20 sessions, twice
weekly for 20 minutes each. I use disposable, sterilized, flex-
ible stainless steel 0.25mm  40mm needles at these clas-
sical acupuncture points: Ex-HN-3, and bilateral LR 3,
F IBROMYALGIA IS A SYNDROME that could refer to a vari-
ety of Chinese Medicine (CM) energy states ranging
from Deficiency/Stagnation to excess Damp/Heat accumu-
LI 4, PC 6, GB 34, and SP 6 points. Needle penetration is lation. Assuming the more common scenario of a Blood and
10–30 mm with or without extra rotational or manual stim- Qi Deficiency with pain and fatigue, then one of the sim-
ulation after needle insertion. Depth of needle penetration is plest protocols I have found originated from the Shanghai
determined by the patient’s sensitivity until Qi is obtained. School of TCM and was adapted as a protocol for chronic
The inclination of the needle is 90° in all points except for
Medical Acupuncture 2008.20:141-145.

fatigue syndrome (CFS) by the Acupuncture Foundation of

Ex-HN-3, where it is 45°. Canada Institute.1
I inform all my patients about the disease, the poor prog- Though intended primarily for CFS, the protocol is
nosis, and teach them coping strategies to change pain be- equally applicable to fibromyalgia, being designed to boost
havior and improve quality of life. I recommend superficial the Qi and Blood, and enhance the immune system by toni-
heat, warm shower/bath, and gentle self-massage during fying the Kidney, Spleen, and Blood in a logical progres-
acute pain episodes and leisure activities, proper sleep, and sion. Ah Shi points can be added as desired.
diet. Beyond that, since many fibromyalgia patients are ener-
getically deficient, herbs and vitamin supplements can be an
Rosa Alves Targino, MD, PhD indispensable adjunct. Formulas such as Xiao Yao San and
University of São Paulo Bu Zhong Yi Qi Tang are often useful, while more complete
Avenue Doctor Amaldo, Number 455 herbal listings can be found elsewhere.2 And while any good
Department of Pathology multivitamin-mineral supplement is probably sufficient,
01246-903 there are always those who recommend much more exten-
Sãn Paulo SP, Brazil sive nutritional and antioxidant support.3

E-mail: targino@usp.br Week Points Action

1 GV 14, BL 23 Yang energy  Kid shu

2 GV 4, BL 20 energy  Spleen shu
A CCORDING TO THE THEORY of Traditional Chinese Med-
icine (TCM), fibromyalgia belongs to the category of
“bi syndrome.” In clinical practice, the Ah Shi point (living
3
4
CV 6, SP 10
BL 13, BL 17
energy  Blood
Lung shu  Blood
acupuncture point) is the effective point for relieving pain. Treatment frequency: 3 per week; Moxa, then needle
The acupuncture points near to the Ah Shi point are selected 10–15 min
to release spasm, analgesia, expelling Wind, dispersing
Cold, and promoting circulation of meridian and collateral. Finally, the therapeutic program needs be grounded in the
In addition to the acupuncture points mentioned, some context of uninterrupted sleep, and a regular exercise and
acupuncturists will select the points that are all situated on meditation routine.
2 sides of the midspinal line 0.5, 1.5, and 3 cun near to the
midspinal line. These points possess similar innervation,
physical function, and therapeutic effects; as a result, they REFERENCES
make up the functional area of Beishu. Usually, cupping
glass is suitable for the functional area of Beishu because 1. Chronic fatigue syndrome. Acupuncture Foundation of Canada
the manuduction of cupping glass is light and soft, and it Institute Newsletter. Spring 1997.
 CLINICAL PEARLS 143

2. Flaws B. Fibromyalgia syndrome and Chinese herbal medicine.
Townsend Letter for Doctors. Feb–Mar 2004. http://findarticles.
com/p/articles/mi_m0ISW/is_247-248/ai_113807047/pg_1.
Accessed April 19, 2008.
3. Wight A. Fibromyalgia; recommend USANA. http://news-
groups.derkeiler.com/Archive/Alt/alt.med.fibromyalgia/2005-
11/msg00200.html. Posted November 2005. Accessed April 19,
Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 02/06/15. For personal use only.
2. Martin DP, Sletten CD, Williams BA, Berger IH. Improvement
in fibromyalgia symptoms with acupuncture: results of a ran-
domised control trial. Mayo Clin Proc. 2006;81(6):749–757.
3. Wang ZY. Electroacupuncture. In: Qiu P-R, Cheng H-P, eds.
New Editorial Chinese Acupuncture and Moxibustion. Shang-
hai, China: Shanghai Science & Technology Publisher; 1992.
Edwin Yong Miao

2008.
M. Modern Traditional Chinese Medical Clinic
Michael T. Greenwood, MD, (MB), BCHIR,FCFP, 52 (Part 2) Pitt Street
CAFCI, FAAMA, FRSA Ringwood
Victoria Pain Clinic Victoria 3134
103-284 Helmcken Road Australia
Victoria, BC, V9B 1T2
Canada E-mail: edwinmiao2@optusnet.com.au

E-mail: michaeltgreenwood@shaw.ca
M Y PROTOCOL FOR TREATING
includes:
patients with fibromyalgia

ERNST1 concluded that there is insuffi-

M AYHEW AND
cient evidence for acupuncture in the treatment of fi-
bromyalgia, based on a systematic review of 5 randomized
• Check patient’s life stressors. What is going on with them?
They may be carrying the weight of the world. Do not for-
get past stress.
clinical trials (RCTs). However, in these 5 RCTs, there were
Medical Acupuncture 2008.20:141-145.

• Dietary measures. Off everything artificial; no dairy or

6 treatments in 4 trials and 24 treatments in 1 of the trials.
anything with cow’s milk protein. I would consider doing
These trials lacked details in methods used in 1 or more of
the Elisa/Act test for delayed food sensitivities. Basic daily
needling depth, angles, retention, and stimulations. There
diet: 3 to 4 fruits, 1 pound raw veggies, 1 pound of cooked
were variations in selecting acupoints. The common ones
veggies, 30 grams of fiber per day. These are goals—en-
selected were: LI 14 (Hegu) and ST 36 (Zusanli). Elec-
courage patients to do their best.
troacupuncture with 2–10 Hz was used only in 1 trial.2 Thus,
• Exercise. Depending on the patient, may want to start with
I concluded that these trials do not have clinical value be-
something gentle like Qi Gong. Consider yoga. Once feel-
cause of inadequate acupuncture knowledge.
ing better, patient can begin weightlifting program.
I treat fibromyalgia with acupuncture points LI 14
• Osteopathic evaluation.
(Hegu), LI 11 (Quchi); GB 34 (Yanglingquan), and ST 38
• Acupuncture. I use a PENS technique sometimes with
(Tiaokou). These 4 acupoints are selected in pairs for the
plum blossom and red tiger balm.
application of electroacupuncture. A standard acupuncture
• Possible physical therapy/massage (with someone who
treatment course constitutes 16 treatments with 20-minute
will give them personal attention).
sessions, 2 times per week. G6805-I, an original model of
• Magnesium load until patient has loose stools. Consider
the electroacupuncture stimulator (Shanghai Medical In-
referral to someone who does IV.
struments High-TECH Co) with 50 Hz, which is matched
• Discuss with patient not “becoming their disease.”
with data from the device inventor, is applied.3
• Check lab for vitamin D, ferritin, B12, and treat even if
Most patients have had long-lasting positive outcomes af-
low normal.
ter this acupuncture treatment course. However, some un-
• Some combination of anti-inflammatory supplements—
certainties remain; the precise percentage of satisfactory out-
Quercitin, Boswellia, Zyflamend, fish oils.
comes, the length of time the outcomes last, and the typical
type of patients suited for this kind of treatment. Thus, fur-
This would be a start. I think these are all multiple eti-
ther study is needed to increase the understanding of the
ologies of this condition. It takes time, but I believe that all
pathophysiology and etiology of fibromyalgia, and most im-
of these patients may be cured if the etiology is found. The
portantly, the degree of effectiveness of electroacupuncture
person who is angry is probably the hardest to treat.
treatment and its mechanisms.
Marie Steinmetz, MD
Steinmetz Medical Associates, PC
REFERENCES 1225 Martha Custis Drive, Suite C-1
Alexandria, VA 22302
1. Mayhew E, Ernst E. Fibromyalgia and Other Central Pain Syn-
dromes. Philadelphia, PA: Lippincott Williams & Wilkins; E-mail: info@caringdoc.com
2005. www.caringdoc.com
 144
I HAVE FOUND FIBROMYALGIA difficult to treat if one tries
to go after each individual trigger point or painful area. I
have had better luck addressing the central nervous system
as a whole and using sympathetic calming points such as:
• Shenmen, Point Zero, Sympathetic, and Tranquilizer on
the ear
Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 02/06/15. For personal use only.
• Ying Tang and GV 20 on the head
• MH 6, LR 2 and 3, LI 4 and 11, TH 5, HT 3 or 7, plus
CV 17 and 14, as well as Kidney tonification points, e.g.,
KI 3 or 7.
Moxa to the deficient points seems very soothing to pa-
tients. I tend to avoid electrical stimulation in these patients.
If a traumatic event preceded the onset, I also use the
Seven Dragons (Internal or External or both, at separate
treatments).
Linda J. Lemay, MD
3566 Pompey Hollow Road
Cazenovia, NY 13035
Medical Acupuncture 2008.20:141-145.
I N MY PRACTICE, FIBROMYALGIA therapy consists of
acupuncture point choices related to the FM tender point
map. The aim is to release the associated muscles: the oc-
cipital area, the sternocleidomastoid area, central pectoralis
area, lateral epicondyle areas, levator scapular areas, trapez-
ius areas, sacroiliac joint areas, the lateral gluteal areas, and
medial knee areas. I use intramuscular stimulation as per
C. Chan Gunn, MD (http://www.istop.org/index.html; The
Gunn Approach to the Treatment of Chronic Pain-ISBN
9780443054228). He also advises to release the masseter
and gastrocnemius muscles. Visits are 30–45 minutes
weekly for 6 weeks, then every 2 weeks for 6 weeks, then
6–12 visits per year. Patients should be weaned off narcotics,
slowly or with the aid of buprenorphine and naloxone (Sub-
oxone). I then prescribe trazodone and/or cyclobenzaprine
as sleep aids.
Magnesium is such an important component to therapy,
so I give intramuscular injections of magnesium sulfate, 2 g
(1 vial) added to 1–2 cc of 1%–2% lidocaine into the but-
tock at each visit (lidocaine takes the sting out of the injec-
tion). Valproic acid, phenytoin, or pregabalin are good
choices for neuropathic pain aids. The associated mood dis-
order should be treated with antidepressants. I am not ad-
verse to prescribing stimulants like methylphenidate or
modafinil.
Instructions for the patient:
• Soak regularly in a hot tub of Epsom salts, 2 cups per tub
for 15 minutes.
• Start a simple aerobic exercise program, i.e., walking,
house chores, gardening, using hand weights, or floor ex-
ercises.
CLINICAL PEARLS
• Stretch all of the major joint areas. Tai Chi or yoga Pi-
lates may help.
• Eat a low-carbohydrate diet.
• Have regular massages.
• Take a daily multivitamin (A–Z type). Take extra mag-
nesium glycinate (400 mg/d), vitamin D (1000 IU/d), ri-
boflavin (400 mg/d), fish oil, and flaxseed oil.
• Restrict caffeine, sugars, and alcohol.
Stephen S. Rodrigues, MD
5445 La Sierra Drive, Suite 102
Dallas, TX 75231
E-mail: drstephenrodrigues@msn.co
A CUPUNCTURE HAS BEEN SHOWN to be an efficient way to
treat fibromyalgia.1 Acupuncture is an increasingly ac-
cepted method used by physicians as a way to provide fi-
bromyalgia patients with a non-chemical antalgic. Symp-
toms such as a prolonged dull ache or sharp pain can be
resolved dramatically by inserting and manipulating a few
needles in several acupoints. While this might motivate clin-
icians to use acupuncture techniques, it also raises many
questions on how to achieve optimal results. A major con-
cern is which acupoints should one use? The following is
my general guidelines on acupoint selection in the treatment
of fibromyalgia:
Rule 1. Select points on involved channels. Fibromyalgia
pain can appear in any part of the body and affect 1 or more
channels. Determine which channels are involved based on
signs and symptoms, including visual inspection, then se-
lect acupoints on these channels. However, no matter how
many pain points are identified, it should be associated with
1 or more channels. Commonly, the 6 Yang channels are
used because this is where fibromyalgia pain is frequently
located. Among them, the Foot Tai Yang Urine Bladder
channel is one of the most important for muscular disorders.
There are 2 ways to select points after identifying the
channels involved:
• The first is called the “line-seating” method. Assume the
path of a channel is a straight line with a beginning and
an end, and pain is located on some point on the line. Di-
vide the line in half, with a superior part and an inferior
part. If pain is located on the superior part of the channel
line, select a corresponding acupoint on the inferior part
of line. An example is the Gallbladder channel that starts
from the outer cantus and ends at the little toe. If pain is
located on the outer canthus, a point should be used on
the same side of the body at GB 44 on the toe. If a pain
is at the top of the shoulder, then GB 39 on the ankle will
resolve it. For hypochondriac pain, GB 34 on the lateral
side of the knee joint would be a desirable point to use.
 CLINICAL PEARLS
Similarly, pain on the inferior portion of the line can be
treated with points on the superior portion, i.e., toe pain
could be relieved by an acupoint around the outer can-
thus; a shoulder acupoint will work on a pain around the
lateral ankle region, and so on. The key to this method is
that you have to seek a corresponding area of tenderness
and stiffness near the point you choose to needle. As a
Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 02/06/15. For personal use only.
rule of thumb, if the point is close to a regular acupoint,
choose the latter; if not, then use the point that is most
tender and reactive.
• The second method is called the “Neck Eight Points”
method. In Chinese pinyin, it is “Chi Zi Mai,” and these
points are similar to Sky-Window points. These 8 points
comprise a set of points on each of the 6 Yang channels,
Conceive Vessel (CV), and Governor Vessel (GV), re-
spectively. Structurally, all Yang channels will converge
to the head from the extremities and the neck is the ex-
clusive passgate. In addition, 6 neck points are where 12
divergent channels are converged. Those distinct struc-
tures endue the neck point’s expansive capabilities on pain
relief. It differs from the foregoing line-seat method
merely on antilogous channel regulating; furthermore,
Medical Acupuncture 2008.20:141-145.
neck points could treat a pain involving both exterior and
interior channels. In the clinic, neck points could be used
in suppressing various somatic pains, especially a dull
ache, fractious sore or strain, and pain. For example, if
pain is on the radial side of the forearm, sitting on the
Hand Taiyang compartment, LI 18 is the best acupoint to
puncture. If the pain or rigidity appears on the Foot
Taiyang region, like the groin or frontal thigh, ST 9 should
be used. Pain on the hip or lateral thigh could be stopped
by selecting SI 17. In most cases, a pain would disappear
without being noticed. It is not necessary to pursue a dis-
tinct needle reaction here because of possible injuries of
the carotid vessel or nervous trunks.
Rule 2. Select an acupoint on the pain point. This rule pro-
vides a geographic acupoint selecting method. It has 2 meth-
ods to it—situ point selecting and crossing point selecting.
Puncturing in situ is the most commonly used method in
acupuncture. One should puncture a needle at the irritated
point. Generally, it seems hard to locate a deep-seated pain
point distinctly, because pain points tend to sit deeply un-
der the skin, but one should at least try to get a rough idea
of its location. The position of pain refers not only to a bidi-
mentional landmark on the skin, but also to the depth un-
derneath the skin. The latter could determine how deep the
needles should go under the skin. A distinct needle reaction
should be sought because it will indicate whether the nee-
dle has touched the focus. Usually, it would cause an in-
creased but bearable tenderness around the pain point, but
145
would calm down soon after needle retaining. A desirable
relief will come after withdrawing the needles.
Crossing point selecting uses neither the point in situ nor
along the involving channel. The position of the selected
point is always on the opposite side of the original pain point,
and is corresponsive to the pain point locationally. It is ap-
plied for a pain that could not be punctured in situ because
of the pain point being extrasensitive. A good example is
pain and stiffness around the anus, which could be treated
by needling GV 20 on the vertex. This reflects a typical cor-
responding relation between top and bottom. Furthermore,
the point sitting on the lower lip, CV 24, could respond to
a rigid neck pain on the posterior middle line. It suggests a
corresponsive pair of front and back. Commonly, if a se-
lected point is close to a trigger point or a tender point, the
latter should be used.
Rule 3. Holistic regulation in pain. According to the idea of
holistic view, there is a mutual inductive relationship between
internal organs and exterior of the body. As a rule of treat-
ment, acupoint selection should reflect the relation between
the exterior and interior body as a whole. In practice, it is com-
mon to treat a pain in an internal organ with acupoints on ex-
tremes. Conversely, a pain on extremes could be alleviated by
points on the torso. For example, upper scapular rigidity might
couple with coldness on the lower abdomen, which can be as-
suaged by moxibustion on CV 3. For an ache around the un-
lar side olecranon, Hand Taiyang Small Intestine channel, one
might find the tender point around Heart Shu or Shen Dao
CV 11. It is clear that regulating internal organs could be a
desirable way to repress the pain on the exterior of body. Un-
der the guidance of traditional channel theory, one could find
more corresponsive connection between exterior pain and in-
ternal organs. Traditional Mu points might be useful in se-
lecting points for pain on relevant regions.
A typical prescription in acupoint selecting for fi-
bromyalgia should integrate all 3 point-selecting rules fore-
going. However, for some cases, not all 3 rules need to be
applied.
REFERENCE
1. Duncan B, Langhorst J, et al. Acupuncture in the treatment of
fibromyalgia in tertiary care—a case series. Acup Med.
2007;25(4):137–147.
He Chong, PhD
309 South Park Way, Lewis 205
Broomal, PA 19008
E-mail: hechongbox@gmail.com