revista 14

Revista de Medicina Tradicional ChinesaEscola Superior de Medicina Tradicional Chinesa

Número 14 Setembro 2008 Ano 4

Síndrome pré-menstrual (SPM) tratada com Medicina Herbal Chinesa

numa amostra de população portuguesa Manuel João Pinheiro

Research on acupuncture-antidiabetic combination treating T2DM (Activating blood and removing blood stasis method)

Eglantino Panóias Pereira

Effects of Traditional Chinese Medicine Shang Han Lun manufactured formulas in the treatment of ILI condition

Ana Varela

Investigação sobre o tratamento da Hérnia Discal Lombar (HDL) com moxa-acupunctura nos pontos Hua Tuo Jiaji

em combinação com massagem e manipulação Tuina Manuel Moreira

Differential Diagnosis of epistemological data of Flu Syndrome, in Lisbon, Portugal Lurdes de Carvalho

Revista de Medicina Tradicional Chinesa nº 14 Setembro 2008

2 Revista MTC, nº 14 Ano 4

Síndrome pré-menstrual (SPM) tratada com Medicina Herbal Chinesanuma amostra de população portuguesa

Manuel João Pinheiro(Mestre pela Universidade de Medicina Chinesa de Nanjing, com especialização em Fitoterapia)

Introdução

A apresentação de um estudo comparativo mostrando o efeito da medicina ocidental e da medicina herbal chinesa no tratamento da síndrome pré-menstrual em Portugal, foi a ideia inicial.

Para este efeito, era necessário um grupo de estudo tratado com a medicina ocidental e um outro tratado com medicina herbal chinesa.

Estávamos em 2005, e a relação medicina ocidental / medicina tradicional chinesa muito rapidamente fez perceber que o acesso a um grupo de estudo tratado com a medicina ocidental não seria viável.

Esta situação associada ao facto de todas as pacientes examinadas com síndrome pré-menstrual se mostrarem disponíveis para o tratamento com medicina herbal chinesa, proporcionou uma investigação com o objectivo de determinar até que ponto a medicina herbal chinesa poderia ter efeito no tratamento da síndrome pré-menstrual numa amostra de população portuguesa.

Porquê deste estudo?

Na prática clínica, encontrei muitas pacientes com os sintomas atribuídos à síndrome pré-menstrual, muitas delas sofrendo com estas queixas desde há muitos anos. Durante o tempo do estudo, foram observadas

204 pacientes, das quais 78 sofriam de síndrome pré-menstrual, o que corresponde a uma incidência de 38%. Quando questionadas sobre o tratamento que estavam a seguir, afirmaram que não estavam a seguirnenhum tratamento, ou tinham começado a tomar a pílula, mas sem resultados, ou tomavam analgésicos, nos dias críticos, para amenizar a situação. Na prática, apesar das dores e mal-estar, encaravam a situação como algo normal, até porque na maioria dos casos, as mães tinham passado pelo mesmo, e os tratamentos que tinham experimentado não tinham sido efectivos. A ideia desta “normalidade” era de tal ordem que, das 78 mulheres inseridas neste estudo, apenas 8 ( 10%) apresentaram a síndrome pré-menstrual como queixa principal. Todas as outras apresentaram diversas outras patologias como queixa principal. No decorrer do interrogatório, as queixas apresentadas eram conformes com o estipulado para síndrome pré-menstrual.

Apesar dos anteriores tratamentos não terem tido o efeito desejado, aceitaram “correr o risco” de um novo tratamento agora com medicina herbal chinesa, acreditando para além do seu conhecimento e compreensão.

Síndrome pré-menstrual - definição da OMS

SPM é uma desordem psiconeuroendócrina, com parâmetros físicos, psicológicos e sociais.



Para o conjunto destes sintomas serem considerados SPM são necessários alguns critérios:• Os sintomas físicos e psicológicos provocam mudanças de comportamento e sociais, devendo ocorrer ou agravar na segunda metade do ciclo menstrual, diminuir um pouco antes da menstruação, e cessam com a chegada do fluxo menstrual ou logoa seguir.• Os sintomas devem ocorrer, pelo menos, em 3 ciclos consecutivos.• Os sintomas devem ser suficientemente severospara requerer conselho ou intervenção médica.

As autoridades de saúde não estão todas de acordo no que concerne aos sintomas e aos critérios. De facto alguns sintomas são similares aos da depressão, pelo que muitas vezes a SPM é tratada como uma desordem mental. Os sintomas da SPM resultam da combinação do efei-to cíclico do estrogénio e da progesterona, podendo provocar uma deficiência central da serotonina.

Tensão emocional, alimentação desequilibrada, excesso de trabalho, e excesso de actividade sexual, são também consideradas causas da SPM.

Não há consenso quanto à definição e etiologia daSPM, pelo que o seu tratamento é muito controverso.

A supressão do ciclo menstrual com a administração de estrogénio, ingestão da pílula anticonceptiva, progesterona, diuréticos, vitaminas, minerais, alterações alimentares, exercício, antidepressivos, ansiolíticos e cirurgia são os tratamentos mais usados. No entanto, não têm um grande efeito, pelo que o tratamento deve ser adaptado de acordo com a condição do paciente. Terapia cirúrgica, como a ovarioctomia, devem ser usadas como último recurso.

SPM – ponto de vista da Medicina Chinesa

Relativamente aos sintomas e critérios a Medicina Chinesa, esta rege-se pelo estipulado pela OMS.

Etiologia e patogenia

Causas emocionais – obsessão, preocupação, pressão profissional, pressão na escola na altura dos exames,pressão monetária, divórcio, solidão, raiva, frustração e ressentimento podem provocar a estagnação do qi do fígado. Esta estagnação produz fogo e agita o espírito. A tensão emocional é a principal causa da SPM.Causas externas – vento, frio e humidade invadem o corpo humano e bloqueiam os meridianos e vasos, provocando a estagnação do qi e do sangue.

InchaçoDistensão abdominalDor no baixo abdómenTensão / dor mamáriaEnxaquecaRetenção de líquidosSuspiros frequentesAlteração do sonoAlteração do apetiteAlteração de concentraçãoAumento de pesoVómitosDiarreiaErupções cutâneasMialgiasFadiga

DepressãoAgitação

NervosismoAnsiedade

IrritabilidadeTristeza

Susceptibilidade para a raivaAgressãoGrosseria

Isolamento socialAlteração de libido

Alteração actividades diáriasChoro

Sintomas da SPM

Físicos Psicológicos Comportamentos/Sociais



Excesso de trabalho, excesso de estudo, excesso de actividade sexual, enfraquecem o yin do rim e fígado, podendo causar estagnação do qi do fígado. Nesta situação, o vazio de yin do rim e fígado, são a causa primária.

Desequilíbrios alimentares lesam a função de transformação e transporte do baço, provocando retenção de mucosidades e fluídos. Se uma estagnaçãodo qi do fígado produzir fogo, este combina-se com as mucosidades provocando fleuma-fogo que seacumula no peito, obstruindo os orifícios da mente.Outras causas – constituição fraca com debilidade constitucional do baço e rim, vazio yang do rim, reduzem o fogo no mingmen e inibe o aquecimento do baço. Hemorragias e pílula anticonceptiva podem lesar o qi e o sangue. Doenças crónicas bloqueiam e lesam o qi e o sangue.

A SPM é causada principalmente pela disfunção do fígado, mas o rim e o baço, também podem estar implicados.

Diferenciação de síndromes e tratamento

É necessário estabelecer se a SPM deriva de uma condição de vazio ou excesso.

• Se a estase do qi do fígado surge devido a situação emocional, é uma condição de excesso.• Se a estase do qi do fígado, tem por base um vazio de sangue do fígado, vazio de yin do fígado ou rim, é uma condição primária de vazio.• Se o yang do rim ou baço for deficiente, é umacondição de vazio.

Por vezes estão dois ou três órgãos envolvidos ao mesmo tempo, ou o desequilíbrio é de qi e sangue simultâneo. Sempre que os sintomas sejam complicados, a diferenciação de síndromes deve ser feita, tendo em conta o tempo, localização e natureza dos sintomas, bem como a condição da língua e pulso.

Síndrome de estagnação do fígado Sintomas principais: distensão e pressão hipocondríaca, dor e tensão mamária, depressão, suspiros frequentes, irritabilidade, susceptibilidade para a raiva, má educação, melancolia, dor no baixo

abdómen.Língua com capa fina e branca, pulso fino e tenso.Princípio de tratamento: acalmar o fígado para regular o qi e activar o sangue para drenar os vasos.

Prescrição: Xiao yao wan – fórmula patenteada Chai Hu - Radix Bupleuri Bo He - Herba Menthae hyplocalycis Dang Gui - Radix Angelicae sinensis Bai Shao - Radix Paeoniae lactiflorae Bai Zhu - Rhizoma Atractylodis macrocephalae Fu Ling - Sclerotium Poriae cocos Zhi Gan Cao - Radix Glycyrrhizae uralensis praeparata Sheng Jiang - Rhizoma Zingiberis officinalis recensEsta fórmula é específica para SPM derivada daestagnação do qi do fígado, com vazio de sangue do fígado. De facto, acalma o fígado, move o qi, elimina estagnação, nutre o sangue do fígado e tonifica obaço.

Síndrome de vazio de yin e hiperactividade do fígado

Sintomas principais: vertigens, cefaleia, nervosismo, febre ocasional, sensação de calor na palma das mãos, planta dos pés e peito, irritação ocular, zumbidos, boca e garganta seca, insónia, irritabilidade, alteração de memória, tensão mamária.Língua vermelha, pulso fino e rápido.Princípio de tratamento: nutrir o yin do fígado e rim, nutrir o sangue, acalmar o yang do fígado.

Prescrição: Qi Ju Di Huang Wan – fórmula patenteada Gou Qi Zi - Fructus Lycii chinensis Ju Hua Flos - Chrysanthemi morifolii

Shu Di Huang - Radix Rehmanniae glutinosae praeparata

Shan Yao - Radix Dioscoreae oppositae Shan Zhu Yu - Fructus Corni officinalis Ze Xie - Rhizoma Alismatis orientalis Fu Ling - Sclerotium Poriae cocos Mu Dan Pi - Cortex Moutan radicisEsta fórmula é usada em SPM com sintomas de hiperactividade do yang do fígado, com vazio yin do fígado. De facto, nutre o yin do fígado e rim e acalma



o yang do fígado.

Síndrome de vazio de yang do baço e rim

Sintomas principais: hidropisia facial, edema nos membros, fezes moles ou diarreia, anorexia, distensão epigástrica, sensação de dor e fraqueza na zona lombar e joelhos, lassitude, vertigens, náuseas, aversão ao frio, membros frios.Língua do capa branca e espessa, pulso profundo e fracoPrincípio de tratamento: tonificar e aquecer o yangdo rim, reforçar o baço e resolver as mucosidades.

Prescrição: You Gui Wan – fórmula patenteada Fu Zi - Radix Aconiti carmichaeli praeparata Rou Gui - Cortex Cinnamomi cassiae Du Zhong - Cortex Eucommiae ulmoidis Shan Zhu Yu - Fructus Corni officinalis Tu Si Zi - Sémen Cuscutae chinensis Lu Jiao Jiao - Colla Cornu Cervi

Shu Di Huang - Radix Rehmanniae glutinosae praeparata

Shan Yao - Radix Dioscoreae oppositae Gou Qi Zi - Fructus Lycii chinensis Dang Gui - Radix Angelicae sinensisEsta fórmula é usada em SPM com sintomas de vazio de yang do rim e baço, pois tonifica o yang e nutre osangue.

Pacientes e método

Objectivo: observação do efeito da medicina herbal chinesa (fórmulas patenteadas) no tratamento da SPM.

Universo de investigação: a investigação decorreu em Portugal, de Outubro de 2005 a Dezembro de 2007.

Foram seleccionadas 78 mulheres que neste período de tempo, apresentaram sintomas compatíveis com a SPM, de acordo com a OMS. Os sintomas agravavam na fase luteal do ciclo menstrual, e eram severas o suficiente para recorrer ao uso de qualquer tipo demedicação e obrigar a alteração das actividades diárias pelo menos durante um dia, e ocorreram pelo menos em três ciclos menstruais seguidos.A idade das pacientes variou entre os 15 e os 40 anos. Onze solteiras e 67 casadas com um número de filhosvariável. 60 mulheres tomavam a pílula como método anticonceptivo, pelo que não interromperam o seu uso durante o tratamento. 18 não tomaram pílula anticonceptiva.

Método

O tempo, natureza e periodicidade dos sintomas levou à classificação em três grupos:Cíclica – aparecia em determinadas circunstâncias, independentemente da época do ano. Neste grupo, pelas suas características, não se manifestava em 3 ciclos consecutivos.Sasonal – aparecia apenas em determinado período do ano, independentemente do seu primeiro aparecimento.Crónica – aparecia todos os meses, independentemente do seu primeiro aparecimento.

Para prevenir a privacidade das pacientes, foi atribuído um código a cada uma.Na primeira consulta, foi feito um cuidadoso historial clínico, aprofundando o interrogatório nos sintomas mais directamente relacionados com a SPM. Foram observados o pulso e a língua.Determinados a etiologia, patogenia, diferenciação de síndromes e princípio de tratamento, foi estabelecida a prescrição mais apropriada. (fórmulas patenteadas disponíveis em Portugal).A prescrição foi determinada de acordo com a diferenciação de síndromes e as quatro fases do ciclo menstrual.A cada paciente foi entregue uma check list diária com os sintomas mais frequentes. Para o preenchimento deste formulário, a intensidade dos sintomas foi graduada de 0 a 4:0 – sem sintoma, 1 – um pouco, 2 – moderada, 3



– bastante, 4 – severa.Para as pacientes com SPM crónica, foram estabelecidas mais cinco observações na fase luteal de cada ciclo menstrual. Nova observação 3 meses após a última e nova observação passados mais 3 meses. Para as pacientes com SPM sazonal, foram estipuladas mais duas observações no período crítico, mais quatro observações nos dois anos seguintes, a começar no mês anterior ao habitual agravamento dos sintomas.Para as pacientes com SPM cíclica, foram estabelecidas seis observações em cada um dos dois anos seguintes, repartidas pelo ciclo menstrual anterior ao normal agravamento dos sintomas e pelo ciclo menstrual com habitual agravamento dos sintomas.

Tratamento / Prescrição

O tratamento foi baseado na prescrição de fórmulas patenteadas disponíveis em Portugal.De Outubro de 2005 a Agosto de 2006, a prescrição foi de acordo com a diferenciação de síndromes.

Estagnação do qi do fígado – Dan Zhi Xiao Yao wan – 0,3 gr cada comprimido, 1,2 gr três vezes ao dia.

Vazio de yin do fígado e rim – Liu Wei Di Huang wan – 0,3 gr cada comprimido, 0,9 gr de manhã, 1,2 gr à tarde, 1,5 gr à noite Vazio de yang do baço e rim – Shen Qi wan – 0,3 gr cada comprimido, 1,5 gr de manhã, 1,2 gr à tarde, 0,6 gr à noite.Vazio de yin e sangue ( causas emocionais ) – Yang Xue An Shen wan – 0,3 grcada comprimido, 1,2 gr de manhã, 0,9 gr à tarde, 1,2 gr à noite.

Estagnação de qi e sangue ( frio ) – Dang Gui Si Ni wan – 0,3 gr cada comprimido, 1,5 gr de manhã, 1,2 gr à tarde, 0,9 gr à noite

De Outubro 2006 a Dezembro 2007, a prescrição foi de acordo com a diferenciação de síndromes e as quatro fases do ciclo menstrual.

Si Wu wan – 0,3 gr cada comprimido, 0,6 gr três vezes ao diaStrengthen the root – 0,6 gr cada comprimido, 18 gr de manhã, 1,2 gr à tarde.

Como complemento da prescrição, foram feitas alterações na alimentação e hábitos do dia a dia.

Resultados

SPM sasonal – Todos os sintomas reduziram de intensidade para valores suportáveis. O isolamento social desapareceu em todas as pacientes.

SPM cíclica – Todos os sintomas reduziram. O isolamento social desapareceu em todas as

pacientes.

SPM crónica - Houve evolução diferente da intensidade dos sintomas, conforme a prescrição foi de acordo com a diferenciação de síndromes ou de acordo com a diferenciação de síndromes e fase do ciclo menstrual. Os quadros mostram os resultados.

Típico ciclo menstrual de 28 dias



Diferença da intensidade dos sintomas entre o primeiro e o último tratamento

Alteração da actividade diária



Tensão mamária

Dor generalizada



Enxaqueca

Alterações de líbido



Dor no baixo abdómen

Isolamento social



Conclusão

O tratamento não foi efectivo em todos os sintomas, mas proporcionou uma grande melhoria na qualidade de vida de todas as pacientes.O tratamento de acordo com a diferenciação de síndromes mais a fase do ciclo menstrual, foi mais eficaz do que de acordo só com a diferenciaçãode síndromes.

Bibliografia

Bensky, Dan; Barolet, Randall. Formulas & strategies: Chinese herbal medicine. Eastland Press, Seatle; 1990

Decherney, Alan H; Pernoll, Martin L, eds. Current obstretic & gynecologic diagnosis & treatment. McGraw-Hill; 2000

Ling, Frank W; Duff ,Patrick. Obstetrics & Gynecology: Principles for practice. McGraw-Hill; 2001

Maciocia, Giovanni. Obstetrics and gynecology in chinese medicine. Churchill Livingstone, Edinburgh; 1998

Maciocia, Giovanni. The three treasures: classical formulas forthe modern world. East West Herbs Press; 1996

McCarthy, Andrew; Hunter, Bill. Obstetrics and gynaecology. Elsevier, Singapore; 2003

Nanjing University of Traditional Chinese Medicine. Gynecology of tradicional chinese medicine. Publishing House of Shanghai University of Traditional Chinese Medicine, Shanghai; 2000

Nanjing University of Traditional Chinese Medicine. Science of chinese material medica. Publishing House of Shanghai University of Traditional Chinese Medicine, Shanghai; 2000

Nanjing University of Traditional Chinese Medicine. Science of prescriptions. Publishing House of Shanghai University of Traditional Chinese Medicine, Shanghai; 2000Northrup, Christiane. Corpo de mulher, sabedoria de mulher: como criar saúde física e emocional e meios de cura. 2ª ed. Sinais de Fogo, Cascais; 2003



Purpose

This research elucidates the theoretical studyof acupuncture-antidiabetic combination with activating blood and removing blood stasis in treating T2DM. Based on the role of blood stasis during the occurrence and development of T2DM, as well as the action of activating blood and removing blood stasis method in the treatment, the research observed the therapeutic effect and discussed the mechanisms ofthe action. Through the study it objectively reflectsthe mechanisms of acupuncture-antidiabetic combination with activating blood and removing blood stasis in treating T2DM. Consequently provides the consultable clinical data and theory proof, so as to further improve acupuncture effect in treatingT2DM and broaden clinical ideas.

Methods

In order to observe the therapeutic effect ofacupuncture-antidiabetic combination with activating blood and removing blood stasis method in treating T2DM, and to explore the mechanism involved, this research is done from theories research and clinical research aspects.

The theories research reviews a vast data andinformation, both from TCM and modern medicine, to describe the etiology, pathology, diagnosis, treatment and current research on T2DM. On the other hand, it elucidates the role of blood stasis in pathogenesis of T2DM, and the action of activating blood and removing blood stasis method in the treatment, which provides the foundation for clinical research.

The clinic research observes 60 cases of T2DMpatients, randomly divided into acupuncture-drug combination group (30) and drug only group (30).

The 2 groups both use routine dosage of antidiabeticorally. It is applied in the acupuncture-drug combination group “activating blood and removing blood stasis”. The treatment is applied 2 times perweek. 12 weeks constitute a treatment cycle. Thetherapeutic effect, changes of symptom integral andglucose-relate items of both groups are respectively observed and objectively evaluated and compared before and after treatment.

Results

It was noticed through theory studies that blood stasis is an important pathogenic tache during the occurrence and development of T2DM. TCM treatment achieved satisfactory therapeutic effectby applying activating blood and removing blood stasis method. This method should be adequatelyconsidered when the acupuncture treatment plan is constituted.

It is found in the clinical research that2 after treatmentthe clinical therapeutic effect in combined group isobviously better than that in drug only group, and the difference shows the statistic significance (P<0.01);according to the comparison of the changes of symptoms and signs in 2 groups we notice that afterthe treatment, besides the symptoms of thirst and polyphagia, the improvements of other 7 symptoms such as lassitude, frequent night urine, heat in palm and sole, paresthesia in legs, insomnia, red tongue, thin, fast pulse are significantly different between 2 groups (P<0.01). This suggests that the improvementof the symptoms in treatment group is obviously better than control group. Meanwhile, acupuncture-antidiabetic combination with activating blood and removing blood stasis can effectively improveintegral total scores and glucose-relate items such as FPG, P2hPG and HbA1c. The action is obviouslybetter than drug only group (P<0.05).

Research on acupuncture-antidiabetic combination treating T2DM(Activating blood and removing blood stasis method)

Eglantino Panóias Pereira(Mestre pela Universidade de Medicina Chinesa de Nanjing,

com especialização em Acupunctura, Moxabustão e Massagem Tuina)



Conclusions

1. Activating blood and removing blood stasis method of acupuncture–antidiabetic combination has confirmed effect in treating T2DM;

2. Activating blood and removing blood stasis method of acupuncture–antidiabetic combination can effectively improve the therapeutic effect intreating T2DM.

3. In this research acupuncture treatment and antidiabetic have synergic action; such action may be related with the improvement of the status of blood stasis.

4. The advantage of activating blood and removingblood stasis method of acupuncture–antidiabetic combination in treating T2DM manifests as the treatment can effectively improve the clinicalsymptoms and symptom integral score of T2DM, can also improve FPG, P2hPG and HbA1c etc. glucose-relate items. The improvement in the treatment groupis significantly better than drug only group.



Abstract - Influenza is an acute respiratorycommunicable disease which, during epidemics, can cause high morbidity and mortality. Since 1949, WHO established an international network for the surveillance of influenza mainly based on sentinelphysician’s report of clinical cases of ILI (influenza-like illness) to a central registry. Traditional Chinese Medicine (TCM) considered this condition as an externally contracted disease caused by pathogenic factors and have developed from thousands years ago a rich system for its prevention and treatment expressed in the “Shang Han Lun”.

The purpose of this study was to assess the effectsof Chinese medicinal patent formulas according to TCM principles of “Shang Han Lun” in treating Portuguese people with established diagnosis of ILI condition by comparing it with western current treatment regimens.

Sixty patients from the Clinic of TCM College of Lisbon and from the clinical sets of Portuguese Association of Acupuncture and TCM in Lisbon region that have ILI condition were randomized allocated to Experimental (9 males of 48,00±21,66 years of age and 21 females of 42,19±16,76 years of age) and Control Group (8 males of 53,63±18,49 years of age and 22 females of 50,05±18,14 years of age). A diagnostic tool and professional follow-up sheets for externally diseases caused by Cold have been developed, validated and applied in the firstsession of treatment (24h maximum after the onset ofsymptoms) and after three and ten days. The follow-up registration sheet of the patient was answered every day during 10 days after the treatment. T-Student, Mann-Whitney U test and Chi squared tests were used to compare the quantitative and nominal variables, respectively, of the two independent samples. All the statistical analyses were done using SPSS.13.0. The significant level was settle to 5%(p≤0,05).

Since the two groups were not significantly differentin the beginning of treatment in relation to the

symptoms that define ILI condition it was possibleto verify that after the first three days the recoveryrate was significantly different in experimentalversus control group (p<0,000) with RR 2,95±2,61 to 8,57±3,59 respectively and that there was a marked improvement of clinical symptoms and signs in the experimental group versus a general improvement in the control one. In the experimental group it was also observed seven different types of syndromesrelated with ILI condition treated with seven different manufactured formulas. In this researchit has been possible to verify that manufactured classic prescriptions of Shang Han Lun can treat ILI conditions if used with the clinic decision though method that is implicit in this Classic monograph. Keywords – Traditional Chinese Medicine /Prescription / Shang Han Lun manufactured formulas

Preface

According to Western Medicine the flu (influenza),bird flu and common cold are respiratory infectiondiseases caused by a variety of viruses that present different main symptoms and mortality rate. Thecommon flu and cold were usually mild diseaseslasting 3 to 7 days when the patient could have enough rest, drink fluids and sweat. However in the lastyears, people have different life habits and the diseasespreads through communities creating an epidemic. The rapid diffusion of epidemics and pandemicsturns clear the need for clinical/epidemiological and virological surveillance, at local, regional and world level.

WHO established an international network for the surveillance of influenza since 1949 (WHO, 2000) .EISS project in Europe. This is done by the Integrationof virological information alone or with that obtained in patients diagnosed with ILI condition (influenza-like illness or flu like syndrome) (Fleming et al., 1995).EISS studies found a good match between the clinical data and laboratory reports of influenza collected by

Effects of Traditional Chinese Medicine Shang Han Lunmanufactured formulas in the treatment of ILI condition

Ana Varela(Mestre pela Universidade de Medicina Chinesa de Nanjing, com especialização em MTC)



physicians only during peak season levels of ILI (3 to 4 months) activity in a given country

Clearly, it has been difficult to establish commonrules for clinical definitions of influenza in differentcountries with different health systems andorganizations. However there have been a tendency of the European EISS members to define an ILI caseby its general criteria which are: sudden onset of fever > 38°C, with respiratory (i.e. cough, sore throat) and systemic symptoms (headache, muscular pain) or by the criteria for Acute Respiratory Infection (ARI) which are: sudden onset of respiratory symptoms, accompanied by fever and headache in the absence of other diagnosis.

Traditional Chinese Medicine (TCM) considered influenza as an externally contracted disease causedby pathogenic factors entering the body from out side and have developed from thousands years ago a complete and rich system for their treatment. In the prevention and in the treatment of this disease TCM has a very effective treatment according to thepattern of symptoms differentiated in each patient bythe TCM diagnose process. The clinical experiencein Portugal as in China also demonstrates that there is not a unique formula that can fit all the influenza-like TCM-patterns presented by the patients.

In the same way in more than 300 clinical trials of Chinese medicinal herbs for influenza systematicallyreviewed by Chen XY et al. (2005) showed that TCM has a treatment for influenza and that TCMdoctor’s have good results in treating this condition. However, the constituents of the prepared formulas are modified according to each patient TCM-patternsdiagnosed which make difficult to compare results orto know the more adjusted patent TCM formulas to treat ILI in other regions or in other patients.

So the purpose of this study is to assess the effectsof Chinese medicinal patent formulas according to TCM principles for treating people of all ages with established diagnosis of ILI defined by theInternational Classification of Health Problems inPrimary Care and standardized by the Portuguese Health Government.

It is also interest of this study to validate a diagnostic tool to characterize the main TCM syndromes corresponding to ILI syndrome according to Shang Han Lun differentiation system in the flu season of2007/2008.

In comparing groups intended for treatment with Chinese patented formulas and groups allocated to the treatment with western current treatment regimens, the following hypotheses are tested:1. Is there any difference in the number of peoplecured at the end of the third day?2. Is there any difference between Chinese patentedformulas and current treatment regimens in the clinical recovery and outcomes?

Theoretic Research

TCM characterization of external disease caused by cold damaged

In Chinese medicine, cold is a disease caused by exogenous factors, namely pathogenic wind-cold, invading the body. It manifests as blocked or runny nose, sneeze, cough, headache, aversion to cold, fever, general discomfort, superficial pulse.

Cold that presents symptoms of more serious nature, and that transmits more widely and rapidly, is known as influenza. Influenza appeared by thecombination of abnormal climates, pathogenic factor and individual reaction to that. It causes more severe illness and may deteriorate into heat syndrome or become complicated by diseases in other organs. Common symptoms include aversion to cold, chills, fever, body temperature up to 39°C - 40°C, general body ache and malaise, cough, sneeze, sore throat, nasal discharge and obstruction as have been seen (Nanjing, Internal Medicine, 2002 and Hong Kong Chinese Medicine Division, 2005).

Generally the main principle applied in the treatment of influenza is “to expel the pathogenic factor, relieving the exterior syndrome and resolve the interior condition”, following TCM diagnose. Chinese medicine practitioners differentiate syndromes andprescribe medicines according to the pathogenic



causes, characteristics of symptoms and strength of individual Zheng Qi, taking into account the seasonal prevalence of influenza and characteristicsof climates.

This study, instead of describing the commonsyndromes of influenza and the usual treatments asis presented in TCM internal medicine textbooks try to follow the thought and clinical experience transmitted by “Shang Han Lun” to analyse all the main possibilities of patterns of unbalanced related with ILI and the main prescriptions to treat this condition according.

In “Shang Han Lun” there is three main kind of differentiation: 1) the six syndrome differentiation;2) the eight principles; 3) the decoctions differentiation.

1. The six syndrome differentiation pointed out thestage and localization of the disease e.g. the channels and related organs (Tai Yang, Yang Ming, Shao Yang, Tai Yin, Shao Yin and Jue Yin). As a rule the pathogenic factor first affect the Tai Yang channel and end there.But the evil could progress through the various channels according to certain change patterns and rules if the patient’s Zheng Qi is not strong enough, or if the pathogenic factor is too strong, or if there is a wrong treatment. Disease in any of the six channels takes the form of different disease patterns that arereflected in various constellations of signs and pulseconditions.

2. The notion of the eight principles implicit in “Shang Han Lun” pattern identification was not formalizeduntil much later in history. The Eight Principlesgive the nature and character of the disease. Theseprinciples Exterior, Interior, Cold, Heat, Deficiency,Excess, Yin and Yang are closed linked and underlined to six channels differentiation.

3. The decoction selection is the latest stage of thedifferentiation process because at this moment weneed to combine or link the differentiation with thetreatment.

However all these three stages of the differentiationprocess are much closed related and directed to the

clinical treatment of these diseases. Differentiationis not only based in the strength or weakness of the pathogenic factor, but also in the patient’s constitution and Zheng Qi that will determine the progression of the disease. To differentiate the trends of developmentand the changes in disease the pulse and signs are the main criteria.

In the broad meaning of cold damage the influenzais differentiate into two types: wind-cold and wind-heat, however the pathogenic factor related with influenza, as is referred by literature transmits morewidely and rapidly and presents symptoms of more serious nature. This means that it is important toprofit the millenary clinical experience abstracted in“Shang Han Lun” to prevue, in advance, the possible changes of pathogenic factors when invading the human body.

Portugal has a temperate climate and the peak of influenza occurs in autumn and winter seasons whichmean that is usual that Cold, in the strict sense, may be involved in the initial phase of the ILI condition.

According with the Chinese clinical experience it’s common to observe cases of influenza beginningby a cold pathogenic factor rapidly changing to other Taiyang patterns concurrent or transferred, described in “Shang Han Lun” line’s. Table 1 shows a decision tree based on “Shang Han Lun” and Cheng Song Yu and Li Fei (1996) that allows us to visualize the main clinical decision thought present when we are deciding the best prescriptions that release the exterior condition as is the case of ILI.

The main divisions seen in this Table are based onTCM classics, the prescriptions are those that release exterior condition prescribed in accordance with the Six Channels or Four Levels patterns theory and in accordance with the possible observed associated conditions as are pointed out by Cheng Song Yu and Li Fei (1996).

Regarding Portuguese conditions and the objective of this study it was selected from this table the formulas (in bold) that could treat the main standard conditions related with ILI in Portugal. The selection was basedon 1) The Clinical Guide of Herbs and Formulas” by



Cheng Song Yu and Li Fei (1996); 2) “The Formulas& Srategies” by Bensky D. and Barolet R. (1990); 3) The translation and comments on “Shang Han Lun” written by Zhang Zhong-Jing (Zhang Zhong-Jing compiled and translated by Luo Xiwen, 1993; Zhang Zhong-Jing translation and commentaries by Craigh

Mitchell, Feng Ye & Nisel Wiseman (1999); 4) Thediscussion and orientation by the adviser Professor of Nanjing TCM University Professor Chunxiang Zhou about the Portuguese research conditions and available Chinese patent manufactured local formulas.

Formulas that release exteriorconditions

WindCold

WindHeat

Wind-cold

WindHeat

1.Exterior Excess

2.Exterior Vacuity

3. Wind-Cold Turning Heat

Pattern type

1.a) Excess – mild, early stage1. b) Excess – severe

2.a) Vacuity

Wei Qi level

Toxic heat

Interior Vacuity

Interior Vacuity

Associated conditions

Cold mild

Cold:• Wind-Cold-Damp • Qi Stagnation Torax Distension• Interior Heat• Water-Phlegm Retention

Wind• Stiffness neck and costal region• Cough and wheezing• Yang VacuityQi Vacuity

Concurrent and transferred patterns of Wind-Cold including: Taiyang Shaoyang Yangming CoughDeficient Ying Qi and Jin Ye

Early stage meales or rashesQi and Yang VacuityLesser Yin syndromeYin and Xue Vacuity

Prescriptions

Cong Chi Tang

Ma Huang TangJiu Wei Qiang Hu Tang

Xiang Su San

Da Qing Long Tang

Xiao Qing Long Tang

Gui Zhi TangGui Zhi Jia Ge Gen TangGui Zhi Jia Hou Po TangGui Zhi Fu Zi TangGui Zhi Jia Ren Shen TangDifferent prescriptionsaccording to the evolution of the pathogenic factor in each individual (see Table2)

Sang Ju Yin

Yin Qiao San

Sheng Ma Ge Gen Tang

Ma Huang Fu Zi Xi Xin Tang

Cong Bai Qi Wei Yin

Table 1 - Clinical decision tree based on the prescriptions that release the exterior of the “Clinical Guide of Herbs and Formulas” by Cheng Song Yu and Li Fei (1996)



Level/Transformation

patternCategory of disease

(Yin or Yang)

Exterior/Interior

(Depth of patho-logical changes)

Excess/Vacuity

(Status of confronta-tion of Zheng Qi

Xie Qi)

Patogenic factor(Initial Pathogenic

factor)

Heat/Cold(Nature of the

disease) Key symptoms

Prescriptions(Line - Song

version)

Tai Yang Exterior Excess Cold Cold Aversion to Cold, no perspiration

Ma Huang Tang (Line 35)

Hebing(Tai Yang concurrent pattern)

Exterior

Interior

Excess Cold Wind Cold

Heat

Aversion to cold, no perspiration. Restlessness

Da Qing Long Tang (Line 38)

Hebing(Tai Yang concurrent pattern)

Exterior

Interior

Excess Cold Cold

Retention of water-phlegm

Aversion to cold, nausea, cough, asthma, tight – tense pulse

Xiao Qing Long tang (Line 40)

Tai Yang Exterior Vacuity Wind Wind Perspiration and fever

Gui Zhi Tang (Line 12)

Hebing Tai Yang concurrent pattern

Exterior Vacuity Wind Wind Perspiration and fever and stiff neckand back

Gui Zhi Ge Gen Tang (Line 14)

HebingTai Yang concurrent pattern

Exterior Vacuity Wind Wind Perspiration and fever and dyspnea (asthma)

Gui Zhi Jia Hou Po Xing Zi Tang (Line 18)

HebingTai Yang concurrent pattern (Tai Yin)

Exterior

Interior

Vacuity Wind Wind turned heat

Vacuity cold

Perspiration and feverweek and floating pulse. Qi vacuity

Gui Zhi Ren Shen Tang (Line 163)

Shao Yang Pattern Half exterior

Half interior

Excess Cold Alternate cold and heat

Alternate chills and fever, opression sensation in chest and costal region, reluctant to eat, nausea/ vomiting

Xiao Chai Hu Tang (Line 37)

Hebing Tai Yang, Shaoyangconcurrent pattern

Half exterior

Half interior

Excess Cold Un resolved exterior pattern with mild cold in the exterior mild heat in the interior

Continuous fever, light chills, severe pain in the extremities and joints, slight náusea and fulness and distension of epigastrium. Both Shao Yang and Tai Yang are gentle.

Chai hu Gui Zhi Tang (Line 146)

BianzhengTransmuted pat-terns of Tai Yang

Exterior

Interior

Excess Cold Cold transfomed in Heat in the Lung

Excess heat obstructing lung, asthma, .cough, yellow phlegm, thirst for cold drinks. Perspiration du to excess heat

Ma Huang Xinren Gancao Shigao Tang (Line 63)

Yang Ming Interior Excess Cold Exuberant dryness Heat

High fever, great thirst, profuse perspiration(Fever without chills)

Bai Hu Tang (Line 176)

BianzhengTranmuted patterns of Tai Yang (Yang Ming)

Exterior

Interior

Excess Heat Cold transformed inInterior Heat

Acute Heat-type Watery diarrhea

Ge Gen Huangqin Huanglian Tang (Line 34)

Table 2 - Shang Han Lun differentiation process related with the possible patterns and formulas to treatthe ILI condition caused by Wind-Cold



As can be observed the most important exterior conditions related with ILI can be treated with “Shang Han Lun” formulas, except Wind-Heat conditions in the Wei Qi level, that are usually treated according to the Classic “Wei Bing Xue” – “Treatise of Warm Disease” . This could be a serious limitation of thestudy in a tropical country but not in the climatic conditions of Portugal as was described. However the occurrence of this pattern will be considered and notified in this study. Toxic Heat and Wind-Heat withsevere vacuity conditions are not commonly seen in ILI condition in Portugal and are not considered in this study. All the possible evolution conditions, namely the viscera patterns of Tai Yang will be reported, if observed, in clinical practice.

One of the most common formulas used to treat the common cold caused by Wind-Cold in Portugal is Jiu Wei Qiang Hu Tang. According to Bensky D. and Barolet R. (1990), this formula exclude the decision of Wind-Heat or Wind-Cold if the condition is at the first stage of the disease. However it can not treat allthe possible ILI conditions patterns and don’t have the some realizing effect as Ma Huang Tang.

So, after seeing the general approach to the possibleconditions of exterior contracted diseases it is possible to construct a decision table based on “Shang Han Lun” differentiation process as is presented in Table2. In this table are considered:

1. The level or pattern of the condition or it’slocalization which is defined by the channel orchannels involved in the disease; 2. The depth of pathologic changes which meansto observe if the condition is in the channels or in the Zangfu - Fu or Zang (usually the Lung in this disease);3. The status of Zheng Qi and Xie Qi confrontation which is related with the constitution of the patient and the strength of pathogenic factor and it’s relations;4. The initial nature of the pathogenic factor relatedwith the six pathogenic factors and its combinations;5. The nature of the condition and its transformationspresented by the patients;6. The key symptoms, between others, presented in theDiagnostic tool (Attachment 1) which determines all

the differential process that finishes with the choiceof the best formula to treat the patient condition.

Experimental Research

Case resource

Selection criteria

Patients were selected from the Clinic of TCM College of Lisbon and from the clinical sets of Professionals of the Portuguese Association of Traditional Chinese Medicine in Lisbon region that (1) have six of the eight symptoms of the influenza-like illness conditionas defined by the International Classification ofHealth Problems in Primary Care and adopted by the General Direction of Health in Portugal and (2) are in the first day (24hours) of complain.

Experimental Group – Group 1

Thirty (30) patients, 9 males (48,00±21,66 years ofage) and 21 females (42,19±16,76 years of age) from the Clinic of TCM College of Lisbon and one clinical set of Lisbon region. Control Group – Group 2

Thirty (30) patients, 8 males (53,63±18,49 years ofage) and 22 females (50,05±18,14 years of age) from the Clinic of TCM College of Lisbon and one clinical set of Lisbon region.

Randomized trials for Control and Experimental Groups

Each patient with influenza-like illness had a numberand a group distribution according to a computer generated allocation sequence from a random number table. The patients attributed to group1 (experimentalor MTC) were treated with patent traditional Chinese “Shang Han Lun” medicinal formulas. The patientsattributed to group 2 (control or western medicine) were treated with western current treatment regimen, self-medicated or prescribed by western doctor or pharmacist. In each center were used opaque sealed envelopes that were distributed by a non involved professional.



Experimental design

1. Development and validation of a diagnostic tool for externally contracted diseases caused by cold in the Lisbon region of Portugal according to “Shan Han Lun” differentiation process.2. Development of two types of follow-up sheet for patient and professional registration.3. Application of the diagnostic tool and the registration sheet at least to sixty patients with influenza-like illness syndrome during 1 to 10 days.4. Application of the TCM differential diagnose to 60 cases, prescription of the appropriated herbal patent traditional Chinese formulas to thirty of them and counseling the other thirty to utilize the western current treatment regimen or visit their western family doctor, according to the attributed number. 5. Study the case evolution by two process:a. By a personal registration done by patient.b. By the clinical assessment done by professionals.

In the following process have been observed as outcomes:

Rate of recovery (usually named clinical recovery)

Symptoms and clinical manifestations of influenza-like illness completely cleared and body temperature

returned to normal within one to three days after the administration (usually expressed in hours).

The effectiveness of the prescription or the treatment regimen:

Marked improvement – Most of clinical symptoms of influenza cleared and body temperature returned to normal within one to three days. General improvement – Partial symptoms or manifestations of influenza are not improved neither lightened nor deteriorated and body temperature falls within three days. No improvement – Symptoms or manifestations of influenza are not improved or may even have deteriorated (e.g. complications may occur) after three days.

The side effects – Any adverse events resulting from the treatment as: uncommon response and results causing discontinuation of treatment.

Marked, general or no improvement of the clinical signs and symptoms of TCM six channels differentiation



process related with influenza like illness wereobserved every day by each patient and in the firstday of treatment by a TCM doctor and between the third and tenth day by another TCM doctor in order to check and control the patient evolution and registration in both groups.

Treatment instruments The Diagnostic tool for external contracted diseasecaused by cold according to “Shang Han Lun” differentiation process and the follow-up registrationsheet (Attachment 1,2) were applied and corrected by Portuguese professional expert’s and validate by two experts of Shan Han Lun one from Nanjing TCM University other from Chengdu University.

Treatment Procedures

The diagnostic tools are applied in the first sessionof treatment and after three days to ten days in eachclinical timetable. The follow-up registration sheetanswered by the professionals is given and applied three to ten days after the first treatment. The follow-up and the registration sheet answered by the patient are given in the first day of treatment and is filled1-10 days after the first consultation done by TCMprofessionals.

The herbal prescription or western treatment is doneafter the first day of the diagnostic process and mustbe taken in the closest hour possible to that act. Thecompliance is assessed by the professionals and by the patients in the follow-up registration sheets.

Treatment Methods

Each diagnostic tool and registration sheet of the same patient is centralized and renumbered by a non-medical person and the data extracted by the same person. The following up treatment was notdone by the TCM specialist that has done the firstconsultation in both groups. The patients know whatkind of treatment they are doing but don’t know the research project objectives.

Descriptive statistical analysis is used to calculate

the mean, standard deviation of the quantitative variables presented or frequency, percent and valid percent of the nominal or ordinal variables. T-Student test is used to compare the quantitative variables of the two independent samples after verifying itsnormal distribution by Kolmogorov Smirnov test and homogeneity by Levene’s Test for Equality of Variation. If the variables don’t follow a Normal distribution, as happen frequently with new variables resulting by the sum of several different sources, itis used the Mann-Whitney U test for independent samples and the Wilcoxon matched pairs test for the same sample measured in two different conditions.

The Chi squared test is used to compare independentsamples in relation to proportions obtain in a qualitative variable or to measure the association of two qualitative variables with the correction of Exact Fisher test when more than 25% of expected frequencies are < 5. The P obtained by this test is alsoused, since the sample is small. ThePearsoncorrelationTest is used to verify the nature and strength of the association among the different variables. Thevariable plan and all the statistical analyses are done using the Statistical Tool SPSS.13.0. The significancelevel adopted for all the inference statistical test is 5% (p≤0,05).

Qualitative analysis

Thequalitativeanalysisdealswiththecharacterizationof the flu syndrome according to TCM and the datacollected by the diagnosis process. In this analysis was observed: The main syndromes of six channelsdifferentiation related with the influenza-like illnesscondition in the year 2007/2008 and the main patent Chinese formulas indicated to their treatment.

Experimental Results and Discussion

Almost all cases of this study have been diagnosed in the influenza peak period of 2007/2008, so theyhave an increased probability of representing this condition as can be observed when comparing the Figure 1 with the one published by Portuguese Health Observatory about Influenza activity in Portugal in2007/2008 (ONSA, 2008).



Figure 1 – Randomized allocation distribution of the two groups in the peak season of influenza 2007/2008.

Table 3 – Frequency, percent and valid percent of nominal variables related with influenza-like illness in experimental and control group.



The characterization variables of both groups that are related with the definition of ILI case are presented in Table 3. All subjects confirm the sudden onset of the disease and have, at least one episode of temperature above 38ºC.

As these nominal variables are used to select the ILI cases, it is important to know if there are significant differences in their proportions between the two groups, before the treatment regimens being applied.

The Chi square test and Fisher exact test shows no significant differences for these variables in the proportions of patient’s symptoms in group 1 and 2, except for Cough as can be seen in Table 4.

As age can, also, be a factor that can influence the results between the two groups, they are compared in relation to this variable. Student T test shows no differences in the means of the variable patient’s age of the two groups (Table 5). There are also no differences in the proportions of male and females (Table 6) and in the flu vaccination between the experimental and control groups (Table 7).

Table 4 – Observed and expected values for the nominal variables muscle aches/body generalized pain, stuffy nose, throat pain, cough and exposed to patients with flu.

Table 5 - Mean and standard deviation of the variable age in experimental and control group. Level of significance related with T-Student test



Since the two groups are not significantly different in the beginning of treatment in relation to the symptoms that define ILI and in relation to the variables Age, Sex and Vaccination, that could influence the results

Clinical recovery

The clinical recovery of symptoms, clinical manifestations of influenza-like illness completely cleared and body temperature returned to normal, in three days after the administration of the treatment regimens are presented and compared in Table 8 and

of treatment, it is possible to verify, now, if they differ significantly in the rate or clinical recovery expressed in days, the main objective of this research.

9.The variable rate of recovery distribution in experimental group is highly skewed showing no normal distribution so the Mann-Whitney Test is used for all clinical recovery analyses.

Table 6 – Observed and expected values for the nominal variable sex in experimental and control group

Table 7 – Observed and expected values for the nominal variable exposition to flu in experimental and control group

Table 8 - Mean and standard deviation of variable rate recovery (expressed in days), in experimental and control group.



As can be observed in Table 9 there are significant differences between the mean rank values of the two groups (p<0,001) which means that there is a significant tendency for the level values of the variable clinical rate of control group exceed the experimental

The effectiveness of the treatment regimen:

Although the two groups presented a normal distribution for the variable sum of symptoms and signs in the first day of treatment this doesn’t happen for the third ant tenth day, so the Mann-Whitney Test is used to analyse this variable in these three different considered moments. As can be observed in Table 10 there is a significant tendency (p<0,05) for the level values of the variable sum of symptoms and signs in the control group(14,03±3,44) exceed the

After 3 days, it was observed a marked improvement of the sum of clinical symptoms and signs in the experimental group (recovering of symptoms and signs from 368 to 123) and a general improvement in the control group (recovering of symptoms and signs from 421 to 357).

one. This also shows that the control group have a significantly slower (p<0,0001) recovery rate RR=8,57±3,59 when compared with the experimental one 2,95±2,61.

experimental one (12,27±3,93). However, after the first three days there was a more significant tendency (p<0,001) to the level values of the variable sum of symptoms and signs in the control group exceed the experimental one (11,90±4,99 to 4,10±3,62 for the control and experimental group respectively in the third day of treatment and 1,40±1,85 to 0,10±3,05 for the control and experimental group respectively in the tenth day of treatment).

Additionally the two groups showed significant differences before and after three and ten days of treatment by the two treatment regimens as can be observed in Table 11 by the Wilcoxon Signed Ranks Test following the natural course of the disease.

Table 9 - Mean and Sum of Rank values of the variable rate of recovery of experimental (group 1) and control (group 2) expressed in hours

Table 10 - Mean and Sum of Rank Mann-Whitney U value and significance level values for the variable sum of symptoms and signs of experimental (group 1) and control (group 2) before, after 3 and 10 days of treatment regimens



If we compare the rate of recovery between the experimental group and the group of 22 patients treated with western regimen that consulted their doctor, instead of using a western self-medication regimen, it is observed an even more significant difference in the treatment result (RR 5,05±4,90

versus RR 26,90±13,76 respectively, Mann-Whitney U Test =20,50 values and p<0,0001). This can mean or that the patients who went to their family doctor consultation are more severe cases, or that there is not an effective western treatment to control the virus of influenza complications.

Table 11 - Mean and standard deviation of variable sum of symptoms before and after 3 and 10 days of treatment regimen in experimental and in the control group. Level of significance related with T-pars and Levene Test

Figure 2 – Mean sum of symptoms before and after 3 and 10 days of treatment in TCM and Western Group



Side effects and secondary complications

There was no registration of any side effects in both groups. However eight patients of Control group and one patient of Experimental one presented secondary complications. The case of secondary complication in the Experimental group was related with an aggravation of a latent gastritis in a Xiao Chai Hu Wan case just in the first consult. The cases of the control group were related with self-wrong-medication or chronic diseases aggravated by ILI condition. Two patients of the control group stop the medication referring bad reaction to the treatment regimen.

The TCM diagnosis and the six channels differentiation process of the 60 cases determine

The vacuity and excess patterns of Tai Yang were observed in the very first days of the disease and were treated with the treatment method of expel wind and harmonize Wei Qi and Ying Qi with the classic formula Gui Zhi Tang in the first case, and by the treatment method of promote sweating and resolve the exterior and regulate the Lung functions with Ma Huang Tang, in the second case (Table 13). The two prescriptions are used for a very short period of time. Two patients that did not observe these indications showed clear signs of heat and worsening of some ILI the location, the nature and differentiation of the

trends of development and changes in disease. In the sample studied in the peak 2007/2008 influenza’s season were diagnosed 11 cases of Zhong feng and 17 cases of Shanghan, which means that almost half of the cases studied present a simple Tai Yang condition (Table 12). The presence of these two patterns is not different in both groups and presented a significant correlation with age (p±0,005). This indicate that the younger patients of both groups that have a simple Tai Yang case have the tendency to have an Excess pattern (Shanghan) and the older a Vacuity (Zhongfeng) Tai Yang pattern. However, the association of variables Age and differentiated patterns was not true for all the other channel’s patterns observed in the two groups.

related symptoms.

The Tai Yang cases that present interior heat were the most important challenges, since it is not correct to give Ma Huang or Gui Zhi Tang when there is interior heat. This can be easily controlled if the research uses decoctions instead of patent manufactured prescriptions bur this is not the case. So this few cases were excluded from this research but were treated by ethical reasons with a combination of Ma Huang or Gui Zhi Tang according the case, with Yin Qiao San in different hours of the day, with good results.

Table 12 – Frequency and Sum of the cases observed for the variable Differentiation Pattern diagnosed in Experimental and Control groups



The strength of the pathogenic factor and patient Zheng Qi have determined fourteen (14) cases of Tai Yang concurrent patterns (Hebing) with cases of exterior cold concurrent with internal heat pattern in the Lung and cases of exterior repletion complicated by interior rheum pattern. The first cases occurred mainly in young people with internal heat conditions. For the first condition was applied the treatment method of dissipate wind-cold externally, and internally to clear the depressed heat by the classic formula Da Qing Long Tang.

The two cases of water rheum observed in experimental group were patients that have the constitutional tendency to collect water rheum. This condition is aggravated by wind-cold blocking the exterior, damage of the lung functions and congestion of the fluids in its interior. The lung is unable to descend

From the two cases treated in the experimental group with acute heat watery diarrhea, one was an ILI condition of gastrointestinal type that happened in a Lisbon school and affected teachers and children; the other was a second ILI episode

and disperse, witch results in cough and painting breathing and copious white phlegm. The treatment method applied is, on the exterior to resolve wind-cold and in the interior to eliminate the water rheum with the classic prescription Xiao Qing Long Wan.

Eight (8) Tai Yang transferred patterns, were also observed, with cases of lung heat panting, cough patterns. The two cases of excess heat obstructing the lungs treated in experimental group are second episodes of ILI, one related with a wrong treatment regimen and the other with a second exposition to wind-cold before complete cure of anterior condition. In these cases there was yellow tongue fur, rapid pulse and perspiration. The method used to treat this condition has been to clear heat and regulate the Lung descendent function with the classic prescription Ma Huang Xinren Gancao Shigao Tang

with an incorrect self-medicated method. In the two cases was used the treatment method of clear heat and stop the diarrhea using the classic prescription Ge Gen Huang Qin Huang Liang Wan.

Table 13 – Frequency and Sum values for the variables Classic TCM Prescriptions and Western Medication in Experimental and Control groups.



In the present study were also observed eight conditions of Shao Yang pattern. Four were treated in the experimental group by the treatment method of harmonizing and resolving the exterior and interior condition with the governing formula Xiao Chai Hu Wan. It is interesting to note that one of the Shao Yang cases treated by a western doctor presents an ILI secondary complication, namely, an ear infection and loose of voice which were treated with antibiotic with no results. The gallbladder qi becomes depressedand bond. The depressed qi transformed into fire. Thenature of the fire is to flare upward and its rising driesthe orifices and can cause the condition observed.After the experimental period this condition wastreated with TCM.

The two cases of Tai Yang and Shao Yang concurrent patterns were caused by an untreated Tai Yang pattern that was aggravated by climate and daily life stress conditions. There was, in both cases, a severe pain inthe back, neck and members and distension in the costal region. The treatment method applied was toresolve the exterior, and harmonize with the classic formula Chai Hu Gui Zhi Wan.

In this study were also diagnosed two cases of Wind-heat type in group 2 of Wei Qi level, followed, with no secondary complications by Western treatment regimen. It was not observed any case of simple Yang Ming disease.

Conclusions In this study, the six channels principle of pattern identification discussed in the Shan Han Lun revealed to be a good method and guide for the pattern identification of externally contracted diseases, likeILI, in the Lisbon region of Portugal.

This study pointed out that Shan Han Lunmanufactured formulas can:

• Reduce the recovery period of the disease • Reduce the secondary infections • Avoid the self-medication abuse of antibiotics and anti-inflammatory substances.

This study also indicate that, for TCM intervention,it is doubtful the selection of cases based on ILI definition, since before the increase of temperaturehigher than 38ºC it is decisive to expel the pathogenic factor and prevent the wide and rapid spread of this Xie Qi.

The clinical knowledge present in this methoddoes not need the determination of the virus type but the development and maturation of clinical thought and observation analysis capacities by TCM professionals. It is also important the development of health consciousness of citizens to prevent the disease, be aware of primary manifestations and act appropriately.

According to that this study recommends, on one hand, the correct preparation of TCM professionals in Shan Han Lun clinical methodology and, on other hand, the development of preventive strategies, based on TCM principles and strategies, in order to increase the level of health consciousness and condition of Lisbon residents.

References

Chen Song Yu and Li Fei (1993) A Clinical Guide to Chinese Herbs and Formulas. Longman Group UK Lda.

Chen XY , Wu TX, Liu GJ, Wang Q, Zheng J , Wei J, Ni J , Zhou LK, Duan X , Qiao JQ (2007) Chinese medicinal herbs for influenza, Cochrane Database of Systematic Reviews.

Chinese Herbal Medicine (1992) Formulas and Strategies Compiled and Translated by Dan Bensky and Randal e Barolet. Eeastland Press Incorporated: Washington.

EISS publications - Fleming et al., 1995; Fleming & Cohen, 1996; Paget et al., 2003; Flahault et al.,1998..

European Influenza Surveillance Scheme. Available at: http://www.eiss.org/



Nanjing University of TCM (2002) Internal Chinese Medicine Compiled by Nanjing TCM University and Translate by Shangai TCM. Publishing House of Shanghai University of TCM.

Shang Han Lun - Traité des “coups de froid” Written by Zhang Zhong Jing and Translate by Catherine Despeux. Les classiques de la medicine chinoise : Paris

Shang Han Lun (1993) Treatise on febrile diseases caused by cold with 500 cases, Written by Zhang Zhong Jing and Compiled and translated by Luo Xiwen, Ph. D. New World Press, Beijing: China

Shang Han Lun (1999) On cold Damage, Written by Zhang Zhong Jing, Translation and Commentaries by Craig Mitch-ell, Feng Ye and Nigel Wiseman. Paradigm Publications:Mas-sachussets.

Shang Han Lun (2003) Tratado sobre enfermedades febriles Written by Zhang Zhong Jing and translate by Julio Garcia. JG Ediciones: Madrid

Shang Han Lun (2003) Maladies évolutives des 3 Yin et des 3 Yang selon Shang Han Lun. Written by Zhang Zhong Jing Com-ments by Nguyen Van Nghi. Pulsologie, nosologie, principes therapeuthiques - phytotherapie, acupuncture/moxibustion Edicions N.V.N. Christine Nguyen Recours: Marseille.

Shang Han Lun (2005) Introduction to Treatise on exogenous Fe-brile Disease compiled by Huang Hai: Shanghai University of TCM Press

The World Health Organization (2006) WHO guidelines on theuse of vaccines and antivirals during influenza pandemics. Ge-neva, Word Health Organization, 2004. Available at: www.who.int/csr/resources/publications/influenza/11_29_01_A.pdf. Ac-cessed March 23, 2006

World Health Organization (2000) Communicable diseases 2000/WHO/CDS 2000.1: 36-37.



A dor lombar é extremamente comum. Cerca de 80% da população em geral tem pelo menos 1 crise lombar durante a sua vida. Destas dores lombares, 13-40% estão associadas à ciática (com pressão do feixe nervoso designado “ciático”, que enerva os membros inferiores). E 90% da dor ciática é causada pela HDL, que é geralmente um agravamento da Protrusão Discal Lombar, muitas vezes após um esforço de pegar num objecto mais ou menos pesado, numa posição mais ou menos incorrecta. A dor lombar ocorre todos os anos em cerca de 25% da população activa, provocando um grau de incapacidade de 2-8%.É a 5.ª razão principal de consultas médicas nos EUA e é a causa principal de incapacidade para trabalhar, o que tem um enorme significado económico-financeiro nas sociedades modernas.

A patogenia da HDL está relacionada com a estrutura anatomofisiológica da coluna, considerando aposição ajustada ou desajustada das vértebras e das suas articulações.

Entre cada par de vértebras existe um disco composto por um tecido exterior bastante resistente e por um gel, como uma polpa, internamente. Estes discos protegem as diferentes vértebras, nas suas rotações, torções, deslizamentos ou compressões, como almofadas.

Muita degeneração por desgaste destes discos, pode conduzir a uma hérnia discal, na qual a protecção exterior está enfraquecida, ou por algum motivo é rasgada e nesse caso o suave tecido interior é expulso para fora do disco, provocando a hérnia discal. Se esta extrusão do disco pressionar o nervo (ou feixe nervoso) pode causar inflamação, dor eestrangulamento desse nervo, que são os típicos sintomas da ciática, sendo mais exarcebados e em maior extensão na hérnia discal.

Neste estudo foram usados os critérios de diagnóstico

segundo os Critérios de Diagnóstico e Efeitos na MTC elaborado pela Administração Nacional da Medicina Tradicional Chinesa:1 – Historial das lesões lombares, stress crónico laboral ou historial de obstipação. A maioria dos pacientes teve historial de dor lombar crónico antes de diagnosticada a hérnia discal;2 – Vulgarmente observada em pessoas de meia-idade;3 – A dor lombar que atinge as nádegas e se prolonga para a perna, aumenta durante o aumento da pressão abdominal (devida, por exemplo, a tosse ou espirros);4 – Escoliose, desaparecimento da curvatura lombar fisiológica,amolecimentopertodavértebraenvolvida,dor que poderá irradiar-se para o membro inferior, movimento lombar limitado;5 – Alta ou reduzida sensibilidade na zona dos nervos envolvidos, atrofiamento muscular, pode ocorrer empacientes de duração crónica, teste de Elevação da Perna Esticada positivo, reflexo rotuliano e reflexodo tendão de aquiles reduzido ou ausente, extensão do primeiro dedo do pé reduzida; 6 – Um exame de Raios X mostra escoliose ou desaparecimento da lordose lombar fisiológica, oespaço intervertebral do disco envolvido pode tornar-se estreito. A TAC mostra a localização e gravidade da hérnia discal.

Quanto aos critérios de diferenciação dos síndromes, eles foram também seleccionados de acordo com os Critérios de Diagnóstico e Efeitos das Doenças na MTC elaborado pela Administração Nacional da Medicina Tradicional Chinesa, que divide a HDL em quatro síndromes possíveis:1 – Síndrome de Estagnação de sangue: formigueiro fixo na zona lombar, limitação de movimentos emcasos ligeiros, incapacidade de movimentos em casos graves, área de dor impalpável, língua arroxeada com manchas arroxeadas, pulsação filiformeeadstringente,alguns pacientes têm historial de lesões;2 – Síndrome de Dormência: dor lombar fria com

Investigação sobre o tratamento da Hérnia Discal Lombar (HDL) com moxa-acupunctura nos pontos Hua Tuo Jiaji em combinação com massagem e manipulação Tuina

Manuel Moreira(Mestre pela Universidade de Medicina Chinesa de Nanjing,

com especialização em Acupunctura, Moxabustão e Massagem Tuina)



uma sensação de peso, limitação de movimentos, agravamento gradual, descanso na cama não liberta a dor nem a piora, a dor piora em dias chuvosos, camada acinzentada na língua, pulsação profunda e lenta;3 – Síndrome de Deficiência nos Rins e Fígado: dorligeira na região lombar e nos membros inferiores, dor obstinada aliviada pela pressão e agravada com esforço, dores e fraqueza nos joelhos, atrofiamentomuscular, língua pálida e pulsação fraca.4 – Síndrome de Dormência Quente: esta síndrome foi excluída desta pesquisa.

Ao nível da patogénese convém salientar o seguinte: Com a idade, as alterações degenerativas poderão ocorrer nos discos e destas poderão resultar necrose e sequestração do nucleus pulposus e amolecimento e enfraquecimento do annulus fribosus.

O factor de endogenia inclui degeneração, desgaste e lesão. O tecido fibroso (annulus fibrosus) ao restringir o material suave do disco (nucleus pulposus) poderá rasgar. Isto resulta numa protuberância do disco ou mesmo extrusão do material discal para o canal da espinal medula ou orifício neural. Isto tem sido chamado de hérnia discal, ruptura discal, hérnia do nucleus pulposus ou prolapso discal.

O factor de endogenia inclui as lesões agudas e crónicas, as quais aumentam a pressão na região posterior do disco, o que leva o annulus fibrosus a quebrar e o nucleus pulposus a exteriorizar-se postero-lateralmente. Em alguns casos a região lombar do paciente é afectada pelo frio, o que causa um aumento da tensão muscular local. Esta tensão muscular pode levar a que a pressão interna do disco aumente, o que pode causar o prolapso do disco degenerado.

Além das razões acima expostas, os seguintes factores são considerados relacionados com a ocorrência de HDL: 1 – Deformação da coluna espinal ou mudanças nas curvaturas fisiológicas: deslizamentos vertebraissimétricos ou assimétricos, escoliose, vértebras lombares deformadas podem ser factores indutores de HDL;2 – Punção lombar: o primeiro caso de estreitamento

do espaço intervertebral após punção lombar foi reportado por Pease em 1935. desde então, vários relatórios mencionaram o estreitamento de discos intervertebrais após punções lombares ou anestesia lombar;3 – Tremores profissionais crónicos: pessoascujo emprego as sujeita a tremores durante um longo período de tempo, tais como condutores profissionais;4 – Altura corporal: a morbilidade da HDL é superior em pessoas que são mais altas do que a média;5 – Factores genéticos: a morbilidade em familiares de pacientes com HDL é superior;6 – Gravidez: durante o estado de gravidez os ligamentos estão mais soltos;7 – Fumar: Batte avaliou a degeneração dos discos através de ressonâncias magnéticas, confirmandoque a média da degeneração dos discos lombares dos fumadores é 18% superior aos dos não-fumadores;8 -. Diabetes: na diabetes a estrutura da membrana arterial que faz a circulação sanguínea para os discos fica afectada. A diminuição da circulação sanguíneareduz o metabolismo dos tecidos discais o que provoca uma ruptura no tecido discal.

Ao nível da Medicina Ocidental Convencional (MOC), os tratamentos para a HDL constam geralmente de 3 tipos: 1 – Administração de medicamentos químicos anti-inflamatórios e analgésicos, para tratar a inflamaçãoe diminuir a dor;2 – Uso de algumas técnicas de manipulação, incluíndo fisioterapia, as quais não têm obtido até hoje, efeitocomprovado, segundo os estudos publicados, como os encontrados na pesquisa teórica que foi levada a efeito nesta investigação;3 – Cirurgia. A cirurgia, se bem que nalguns casos seja a melhor opção, tem diversas desvantagens, nomeadamente o enfraquecimento da própria coluna, ao nível da intervenção, para além de possíveis sequelas posteriores, pelo que, mesmo na MOC, pelo menos nos hospitais públicos, é encarada como a última opção.

Quando a Medicina Tradicional Chinesa (MTC) chegou a Portugal, os pacientes com HDL passaram assim a ter mais alternativas de tratamento.



A Acupunctura e Moxabustão e a Massagem e Manipulação Tuina provaram até hoje serem efectivas no tratamento da dor lombar, assim como nos casos de artrose, osteofitose, protrusão e também hérniadiscal.

De acordo com a teoria da MTC a etiologia e a patologia da HDL incluem síndromes de deficiênciana causa ou raíz da doença e simultaneamente síndromes de excesso na manifestação da mesma doença. É difícil, num único tratamento, resolver em simultâneo os dois aspectos.

Descobrir um tratamento prático combinado, com efeito confirmado, conveniente na prática, estávele com efeito rápido e ainda com um menor custo económico-financeiro possível, é a questão que nospropusemos resolver.

Esta pesquisa baseia-se nestas questões e está estruturada de forma a observar comparativamente o plano de tratamento que tem registado um bom efeito durante o nosso tratamento clínico em pacientes com HDL.

O objectivo desta investigação é o de explorar o mecanismo de agulhas aquecidas (moxa-acupunctura) inseridas nos pontos paravertebrais Hua Tuo Jiaji, em combinação com Massagem e Manipulação Tuina, no tratamento da HDL. E discutindo a vantagem do tratamento proposto, providenciando dados consolidados relativos ao tratamento de HDL, assim como para outras melhorias do efeito clínico e terapêutico no tratamento da HDL.

Esta investigação teve por objectivo também demonstrar a elevada eficácia da MTC emcomparação com a MOC que habitualmente utiliza a administração de anti-inflamatórios e analgésicospara os casos menos severos ou a cirurgia para os casos mais graves, que não respondem ao uso de anti-inflamatórios e analgésicos ou fisioterapia.

Esta pesquisa começou com investigação clínica, na clínica do investigador.

Foram seleccionados pacientes divididos aleatoriamente em 3 grupos:

- O Grupo de Tratamento (Moxa-Acupunctura + Massagem e Manipulação Tuina) foi tratado com Moxa-Acupunctura, basicamente nos pontos Hua Tuo Jiaji ao nível do disco herniado e proximidades, combinados com mais algum ponto, de acordo com a patologia focal individual, em combinação com massagem e manipulação Tuina;- O Grupo de Acupunctura foi tratado com Acupunctura (em vez de Moxa-Acupunctura), nos mesmos pontos que o grupo de tratamento; - O Grupo de Controlo foi tratado com anti-inflamatórios e analgésicos, de acordo com os padrõesda MOC.

Com base na MTC, foram estabelecidas as diferenciações de síndromes, a partir dos dados anatomofisiológicos, etiologia e patologia da HDL.

Com base nesta pesquisa, conclui-se que o efeito terapêutico, embora não sendo significativamentemuito diferente entre o Grupo de Tratamento e o Grupo de Acupunctura é, contudo, obviamente melhor do que o grupo da MOC.

Também após a finalização do tratamento se verificouque os resultados obtidos com o Grupo de Tratamento foram obviamente melhores do que com os Grupos de Acupunctura e o outro de MOC. Também a nível da redução da dor (considerando o questionário de dor de McGill), todos os itens foram obviamente melhores no Grupo de Tratamento.

Além disso, no Grupo de Tratamento obteve-se um melhor efeito analgésico não só em termos de maior rapidez de obtenção, mas também na maior duração do efeito e melhores efeitos analgésicos imediatos e tardios do que nos Grupos de Acupunctura e de Controlo.

Pelo que se pode concluir que:- A utilização de Moxa-Acupunctura (agulhas aquecidas com cilindros de moxa incandescente) combinada com Massagem e Manipulação Tuina, para tratar a HDL, pode alcançar um excelente efeito terapêutico desde que obviamente o praticante esteja devidamente preparado, ao nível da filosofia,da ciência e das técnicas dos métodos utilizados na MTC.



- Esta combinação terapêutica é efectivamente melhor do que os métodos utilizados nos Grupos de Acupunctura ou no Grupo de MOCl (químicos anti-inflamatórios e analgésicos), o que está reflectidonos melhores resultados obtidos quer ao nível da dor quer ao nível de sintomas clínicos em geral.- Outras das vantagens do método da Moxa-Acupunctura combinado com Massagem e Manipulação Tuina são também: - Um efeito analgésico mais imediato; - Um efeito analgésico com maior duração; - Um rápido resultado terapêutico e - Um melhor efeito duradouro do resultado terapêutico.



Differential Diagnosis of epistemological data of Flu Syndrome, in Lisbon, PortugalLurdes de Carvalho

(Mestre pela Universidade de Medicina Chinesa de Nanjing, com especialização em MTC)

Abstract - The present research has the broad purposeof being the first step to set up, put into practiceand improve the convenient TCM instruments for organized clinical intervention in situations of public epidemic external disease in Portugal.

The immediate objective is to experiment amethodology to describe and understand the general characteristics shown by each year epidemic influenzaoutbreak based on a standard case definition namedinfluenza –like-illness (ILI). An inquiry has beenprepared and applied to 100 individuals with ILI condition composed by 31 male and 67 female aged (50.11±16,6), assessed by TCM professionals of the Clinic of the Lisbon College of Traditional Chinese Medicine and by professionals of a Health Centre and Permanent Attendance Service of Lisbon Western Medicine Region.

In order to analyze the association or compare two qualitative variables were used the Chi Squared Test and to verify the relationships between dichotomous variables was used the Pearson correlation coefficientor the Kendall’s correlation. The linear regressionwas used to estimate relationships between the main distinctive symptoms of Shanghan Lun patterns.

The results suggest that the inquiry instrument canbe used to characterize the ILI syndrome accordingly to TCM diagnoses. It was also possible to defineand confirm the best representative symptoms foreach syndrome of the Tai Yang, Shao Yang and Yang Ming with significant (p<0,01) level of association.However the inquiry application by western doctors need to be improved as shown by the low coefficientregression (R>0,3 and < 0,6). Furthermore, these results reproduce with fidelity what could be expectedaccording with Shanghan Lun and the clinical experience of the TCM profession. They allow usto define the incidence of the Yang patterns and itscombinations in 2007/2008 peak influenza year. It isour conviction that a good clinical picture has been obtained of the analysed ILI outbreak. Anyway, some

questions remain about the epistemological status of this kind of “collective diagnosis” that needs further research.

Keywords: Traditional Chinese Medicine/ Shang Han Lun/ epidemiologic inquiry/ Influenza-like-illness

Introduction

One of the main concerns in present time public health politics is related to the prevention and treatment of flu, commonly designated in European countries asinfluenza. The incidence of influenza in Portugal is a national subject followed daily by the Portuguese Health Observatory. During last year (September 2006 to March 2007) the influenza incidence peakreached the maximum in February 2007 with a daily average of 10 people with influenza in 10.000.

Before and after the epidemic period only 2 in 10.000people catch influenza daily. The maximum weeklyincidence was 60 people in 10.000 and before and after the epidemic period 14 in 10.000 per weekapproximately. This was not high but sufficient to make thegovernment develop several measures to control its prevention and treatment.

Traditional Chinese Medicine holds that an attack of pathogenic wind is the predominant etiological factor in influenza, as well as in common colds. Itinvades the body surface and eventually the Lung when body resistance is low. It typically occurs when there is a sudden climatic change. The pathogenicwind combines with cold in winter, heat in spring and heat or damp-heat in summer, taking advantage of untimely climatic changes to attack the body.

The attack to the body is closely related to bodyresistance. So if one’s vital energy is low due to an irregular life style, drenching by rain, negligence regarding changes in temperature or over fatigue, the likelihood of invasion increases. The body’s



constitution also plays a role in the evolution of the affection. For instance, a person with a yang deficiencyis more susceptible to wind-cold, and one with a yin deficiency is more susceptible to wind-heat.However,Influenza is treated by Western Medicine in the sameway to every patient, without knowing what kind of symptoms and syndromes, according to TCM, are specific to each person and more common each year.Their relation to the climatic conditions, atmosphericpressure and the typical Qi of the year are also ignored. However, this information is necessary to select the traditional Chinese medicinal formulas more adapted to each patient and to the most commons syndromes of Influenza each year.

The present research has the broad purpose of beingthe first step to set up, put into practice and improvethe convenient TCM instruments for organized clinical intervention in situations of public epidemic external disease in Portugal.

As stated in the following chapter, the immediate objective is to experiment a methodology to describe and understand the general characteristics shown by each year epidemic influenza outbreak. An inquiryhas been prepared and applied and the discussion of its performance and results will follow.

But it is our hope that the meaning of this firststep may have in the future a much larger reach, considering the horizon of the actual conditions necessary for a successful intervention of TCM Portuguese practitioners in this clinical area.

The increasing rate of participation of TCM doctorsin public health care shows the importance it may assume. But in Western countries this is almost restricted to internal medicine. The public dangerrepresented by some forms of influenza illness andthe possibilities of TCM prevention and treatment of the disease, as recently shown in P.R. of China, turns into a duty the preparation to obtain the same level of effectiveness and success in externally acquireddisease.

At its onset, most cases of influenza syndromemanifest symptoms are not easily distinguishable from those of common cold as their pathogenesis has

many similarities. Their further differentiationdepends mostly on the condition of some of the factors present in both diseases. On the other hand, a quick evaluation and an early intervention may avoid the development of many serious symptoms of influenza.

Because of the above reasons we accepted the view of National Department of Health in considering 37 degrees fever as the minimum to be taken into consideration. So, both the inquiry instrument we used and the sample population we elected aimed all patients from that level of body heat upwards.

Case resource

Selection criterions

All the patients are from the Clinic of the Lisbon College of Traditional Chinese Medicine and one Health Centre and Permanent Attendance Service of Lisbon Western Medicine Region that present ILI syndrome as defined by the Portuguese NationalInfluenza Observatory (Annual Report, 2003/2004).

Sample

The sample is composed by 100 individuals withILI condition composed of 31 male and 67 female, with mean age of 50,11±16,6. Twenty six took flupreventive vaccination and all of them work in indoor working conditions.

Experimental design

The experimental design is based in the developmentand validation of a questionnaire about the clinical history and symptoms of people with ILI condition and according to standards of the Shang Han Lun.

Application of the questionnaire to, at least, one hundred patients, that presents, in the firstconsultation, an ILI condition.

Treatment instruments Questionnaire

Development of the Questionnaire



Development of a Questionnaire about the main symptoms of external contracted disease caused by cold, according to Shang Han Lun differentiationprocess.

Translation and presentation of the Questionnaire to Nanjing TCM University. Discussion and correction.

Preliminary Study of the questionnaire in Lisbon regionInformation and formation of Portuguese health professionals about the questionnaire tool and it’s application. Application of the questionnaire to 10 persons in order to verify the understanding, clarity and importance of the items included. Registration of the data observed and commentaries of health professionals.

Questionnaire reformulation Revision of the questionnaire by a group of experts after studying the results presented by the PortugueseProfessionals.

Treatment Procedures

Questionnaire sheets application proceduresThe questionnaires are applied when is madethe diagnoses of ILI in the western or TCM consultation.

Treatment Methods

Coding Each questionnaire is centralized and renumbered by a non-TCM specialist person and the data extracted by the same person.

Statistical methodsQuantitative analysesDescriptive statistical analyse is used to calculate the mean, standard deviation of all the variables presented.

In order to analyze the association or compare two qualitative variables is used the Chi Squared Test. In order to verify how close is the relationship between dichotomous variables are used the Pearson

correlation coefficient and the Kendall’s correlation.The linear regression is used to estimate thenumerical relationship between the m ain distinctive symptoms.

Conclusions

The significant statistical association between thecollected variable values shows that the inquiry instrument used in this research is a valid one, and the results it leads to reflect with good probabilitythe facts. Furthermore, these results reproduce with fidelity what could be expected according withShanghan Lun and the clinical experience of the TCM profession.

As a side effect, this research and its instrumentsrevealed to be a way to validate and update the real weight of the symptoms related with the syndromes under appreciation: the frequency of each symptom testifies its actual value for clinical TCM diagnosis,allowing a scientific re-appreciation of the traditionaldoctrines.

It is our conviction that a good clinical picture has been obtained of the analysed ILI outbreak. Anyway, some questions remain about the epistemological status of this kind of “collective diagnosis”. In fact, methods conceived to the individual patient have been applied to a large population sample, considered as a unique entity. Further research should be done to reveal the complete implications of this approach.

The exact time of each year ILI outbreak is neverknown in advance and can have important variations. For instance, the peak season in 2007/2008, in Portugal, happened mostly in January and February. This circumstance created, for instance, seriousdifficulties for the conclusion in due time of thisresearch.

In the following years this characteristic must be carefully taken in consideration to prepare the calendar of activities and to organize the availability of the professionals supposed to collaborate in the project.

The cooperation of western doctors in the recollection



of patient data is a pioneer experience and revealed to be extremely useful because they contact large amounts of ILI patients.

But their lack of preparation in TCM is a problem that created some difficulties. Namely, the impossibility, inthis research, to distinguish, in some cases, between Tai Yang excessive and deficient syndrome maybe related with their incapacity to recognize tight pulse and clearly differentiate aversion to cold fromaversion to wind.

Solutions must be found for further research: better to prepare western doctors for their cooperation in this field; and/or to have TCM doctors or advancedTCM students near them in their consultation places to analyse pulse, tongue and other difficult TCMsigns.

Has we have experienced, both TCM and Western doctors that helped to collect the data from the patients showed real interest in this activity. At the same time, their participation revealed to be a good way to deepen their understanding about influenza mechanisms and therapeutic. Learningthrough activity is in fact the best way to improve knowledge, and we found an instrument that in the following years can be extremely useful to show to the possibilities of TCM and how it works to health professionals in general. Concerning Portuguese TCM doctors, mainly experienced in TCM internal medicine, the participation in this research revealed itself to be a way of exchanging experiences and knowledge concerning external diseases as well as a stimulus for further organized study and research.

The bibliographical review and the contact withspecialists and researchers, national and from abroad, has shown some lines for the integration of Portuguese TCM doctors in international nets of specialized entities in this area, so that existing knowledge can be quickly exchanged and put into practice.

The timely definition of the characteristics of eachyear influenza outbreak is a result we can expect fromthis methodology and will allow to obtain in due time the convenient medicinal substances both in quality and quantity. These initial explorations have

shown that Portuguese and even European markets are not prepared to supply in quantity the required substances. If we consider the possible inclusion of TCM in public interventions in this field, the picturebecomes still more complex. Great supplies will be necessary, implying very accurate previsions, a good and powerful organization and a sound knowledge of the concerned markets. So the purpose of this observational/descriptive study is to observe and to describe the main Symptoms and Syndromes according to TCM related with ILI Syndrome as defined by Western Medicine, inPortugal, since September 2007 to March 2008.

The possibility of having an instrument that can beused by both physicians (West and TCM) and that can show the level of the disease according to the Six Channels Syndrome Differentiation (in spite of the fact that this study only research the Three Yang Channels-Taiyang, Yangming and Shaoyang) and that can help to know what patent traditional Chinese medicinal formulas we need here in our country to attack cold/influenza with more effectiveness.

References

Diagnosis in Chinese Medicine A Comprehensive guide (2004). Written by Giovanni Maciocia. For Churchill Livingstone.

European Influenza Surveillance Scheme. Available at: http://www.eiss.org/

Gripenet Portugal. Available at: http://www.gripenet.pt/

Practical Diagnosis in Traditional Chinese Medicine (2000). Written by Tietao Deng. For Churchill Livingstone.

Shang Han Lun - Traité des “coups de froid” Written by Zhang Zhong Jing and Translate by Catherine Despeux. Les classiques de la medicine chinoise: Paris

Shang Han Lun (2003) Maladies évolutives des 3 Yin et des 3 Yang selon Shang Han Lun. Written by Zhang

Zhong Jing Comments by Nguyen Van Nghi. Pulsologie, nosologie, principes therapeuthiques - phytotherapie, acupuncture/moxibustion Edicions N.V.N. Christine Nguyen Recours: Marseille.

Shang Han Lun (1999) On cold Damage, Written by Zhang Zhong Jing, Translation and Commentaries by Craig Mitchell, Feng Ye and Nigel Wiseman. Paradigm Publications:Massachussets.



Shang Han Lun (1993) Treatise on febrile diseases caused by cold with 500 cases, Written by Zhang Zhong Jing and Compiled and translated by Luo Xiwen, Ph. D. New World Press, Beijing: China.

Shang Han Lun (2003) Tratado sobre enfermedades febriles Written by Zhang Zhong Jing and translate by Julio Garcia. JG Ediciones: Madrid.

Shang Han Lun (2005) Introduction to Treatise on exogenous Febrile Disease compiled by Huang Hai: Shanghai University of TCM Press .

The Practice of Chinese Medicine (1994) The Treatment ofdiseases with Acupuncture and Chinese Herbs. Written by Giovanni Maciocia. For Churchill Livingstone.



FICHA TÉCNICA

Revista de Medicina Tradicional Chinesa, nº 14, Ano 4®Todos os direitos reservados

Propriedade e Administração: Escola Superior de Medicina Tradicional Chinesa

Direcção: Deolinda Fernandes, José Faro

Edição: Filomena Serrano

Design e Grafismo: Filomena Serrano, PascoalAmaral

Capa: Grupo de mestrados e doutorados da Universidade de Medicina Chinesa de Nanjing (2008)

Parcerias: Revista Medicina Holistica

Colaboram neste número: Ana Varela, Eglantino Panóias, Lurdes Carvalho, Manuel João Pinheiro, Manuel Moreira

Periodicidade: Trimestral

Sede: Escola Superior de Medicina Tradicional ChinesaRua das Portas de Santo Antão, 110 – 3º Esq. 150-269 Lisboa

Contactos: e-mail: [email protected]: 21 347 56 05 / 21 347 67 26Fax: 21 342 68 04

revista 14

Documents

Transcript of revista 14