Access to the PPM Journal and newsletters is FREE for clinicians.
11 Articles in Volume 10, Issue #7
Selecting an Antidepressant for Pain Patients
Use of Opioids in Pain Patients with Psychiatric Disorders
Osteopathic Medicine Approach to Pain Management
Cannabis as Medicine
Pain Management in Patients with Pyoderma Gangrenosum
Occipito-Atlanto (C0-C1) Joints as a Source of Spinal Pain
Treat the Pain First—Worry about Psyche Problems Later
Traditional Chinese Medicine for Fibromyalgia
TMJ Condylar Pain From Parapharyngeal Space Tumor
Contraindications for Use of Therapeutic Laser
Platelet-Rich Plasma Prolotherapy for Low Back Pain Caused by Sacroiliac Joint Laxity

Traditional Chinese Medicine for Fibromyalgia

Traditional Chinese medicine has a number of modalities that may help treat primary and secondary symptoms in the fibromyalgia population.

Traditional Chinese Medicine as a treatment for fibromyalgia appears to hold some favorable possibilities. Dr. Mist gives an excellent overview of the specific Chinese Medicine modalities that are used for this group of patients and offers suggestions for interested healthcare professionals regarding how to find qualified practitioners for patients interested in pursuing this treatment alternative. Acupuncture is more commonly used in the United States to treat pain patients, but the addition of herbs and tuina offer interesting options that are not currently utilized by American physicians.

Over 15 million people live with fibromyalgia (FM), a disorder with an estimated annual direct cost that exceeds $20 billion. FM is associated with a multiplicity of symptoms such as pain,1,2 work limitations,3 poor quality of life,4 poor coping,1 poor physical functioning,5 and multiple chronic comorbidities that make it particularly challenging to treat. Rational evidence-based treatment paradigms are emerging, but there remains a research-to-practice gap, leaving patients to seek out their own treatment options. Alternatively, patients may seek guidance from their provider about adding complementary therapies to their existing treatment plan. Therefore, patients are increasingly seeking out Traditional Chinese medicine (TCM) for answers concerning FM. Evidence-based clinical studies suggest that there are both Eastern and Western interventions that treat FM symptoms, provide maximization of function and enhance quality of life. However, Western-educated health care providers may be uncertain as to the scope, efficacy or safety of TCM therapies. The purpose of this paper is to describe the components of TCM, overview the state of the science in regards to safety and efficacy and, when appropriate, help patients find the best trained TCM practitioners.

Traditional Chinese Medicine

Traditional Chinese Medicine is a full medical system that has been practiced in Asia for over 3,000 years. TCM includes several modalities including acupuncture, herbal medicine, tai chi, qi gong, and tuina.

Acupuncture is the most commonly known and practiced modality in the U.S. While there is a wide variety of techniques used in acupuncture, it is commonly defined as the penetration of the skin with thin, solid needles at specific anatomical points. Generally, acupuncture delivered by a licensed acupuncturist is extremely safe. The major risk of acupuncture is pneumothorax from puncturing the lungs. Witt6 indicates that is a very rare occurrence, with an estimated frequency of 0.001% in an observational study of patients receiving acupuncture. The most common side effects are hematoma or bleeding (6.7%) and pain (2.0%).6 A frequent concern is of disease transmission but this has been virtually eliminated with the standardization of disposable, single use needles.

Herbal medicine is the second most common TCM modality practiced in the U.S. In China, this is the primary modality of TCM and is used for a wider range of ailments than acupuncture. In Nanjing University Hospital, fibromyalgia is treated primarily with herbal medicine and only secondarily with acupuncture. Herbal medicine includes over 2,000 different medicinal substances, with 80 to 100 of them commonly used for the treatment of fibromyalgia. As practiced in the U.S., herbal formulas are generally given in decoction, powdered or pill form. The formulas tend to consist of 6-12 herbs with a balanced approach that include a focus on ameliorating the side effects that one has from single herbs. For example, it is very common that formulas have a small amount of ginger added to make the formulas easier on the digestion. It is commonly thought that decoction or granulated formulas are superior to pill form as they can easily be modified to address different symptom profiles. However, it is often easier to get patients to take the formulas in pill form as they have little or no taste—unlike the decoctions (and, to a lesser extent, granules) which can be very bitter or pungent.

Tai Chi and Qigong are two common movement-based therapies that are considered modalities of TCM. Tai Chi is a martial arts form that is often considered moving meditation. It has been used as an adjunctive therapy for many ailments as well as general wellbeing. Qigong is a movement and breathing system developed specifically for medical purposes.

Tuina is a form of manual therapy that includes specific types of massage, acupressure, and chiropractic adjustments. Tuina is often a subspecialty of the TCM practitioner but can be used in conjunction with any of the other modalities of TCM. In the U.S., those trained in tuina generally do not practice adjustments as they are not in their scope of practice.

Each of these modalities includes the same medical theoretical underpinnings and indications. This allows the practitioner to make informed decisions, based on TCM theory, about which modalities are likely to be more effective.

State of Research

While there are many modalities in TCM, the vast amount of research has been focused on acupuncture. Just in the last three years, there have been several different systematic reviews. The two most recent reviews of acupuncture have shown that acupuncture significantly improves VAS pain scores compared to sham acupuncture (p=0.00001).7,8 When compared to first generation pharmaceuticals (meloxicam, oryzanol, mirtazapine, or amitriptyline), acupuncture was found to be significantly better at reducing pain and number of tender points.8 There was further evidence that the relapse rate of pain was better with acupuncture than amitriptyline.

The most recent review, done by Cao et al,8 includes both acupuncture and herbs. This review found that the active components of the various trials could not be grouped due to widely differing active components used in the studies. Of the six studies, five reported improvement compared to pharmaceuticals on measures including depression, VAS, symptoms and quality of life. Herbal decoctions tend to focus on reducing stress with formulas such as jiawei xiaoyao san or reducing blood stagnation and cold with formulas such as shugan jieyu huoxue tongluo wan. The only single herb studied for the treatment of fibromyalgia was rhizome drynariae, which showed no significant effect on VAS.9 It should be noted that there are a plethora of Chinese herbs that fibromyalgia patients might be taking to treat the symptoms of fibromyalgia such as hypericum (guan ye lian qiao) for depression, American ginseng (xi yang shen) for lethargy, and valerian root (xie cao) for insomnia.

While there is limited research on tai chi and qigong for fibromyalgia, clinically one would expect that these would be a good match for fibromyalgia patients. One study of tai chi10 reported improvements in the Fibromyalgia Impact Questionnaire11 and the SF36. A systematic review of qigong for pain indicated that the study quality was low and called for additional research into this area of pain management.12

Currently there are no studies in Pubmed that address the treatment of fibromyalgia with tuina. A more general review of massage for fibromyalgia indicated that there is evidence supporting the use of massage for the reduction of pain but that the evidence was not conclusive.13 This review indicates that there is evidence of reduction of anxiety, improved sleep, and lowered depression.

Treatment of Fibromyalgia Patients in China and Taiwan

Health care providers using Chinese medicine embrace the overall concepts of syndrome differentiation, dehumidification collaterals, and regulation liver qi to blood and kidneys. In general, the term “fibromyalgia” is not recognized by pro-viders in China or Taiwan. Instead, low back pain is a more common diagnosis. Patients are seen in a variety of clinics such as orthopedics, neurology, rheumatology, psychiatry, or Chinese medicine—depending on the patients’ symptoms or preference. As in the U.S., providers first rule out other causes of widespread pain such as cancer, thyroid disorders and autoimmune diseases.

A key word search of “fibromyalgia” in an academic Chinese website14 from 1990 to 2010 returns 51 articles regarding fibromyalgia. The three major treatments referenced for fibromyalgia patients in these articles are: acupuncture treatment (eight articles) using acupoints selected by TCM theory; Chinese herbal medicine (nine articles) from the liver, rheumatism and pain point of view; or a combination of acupuncture and herbs.15 Other treatments such as tuina,16 scraping17 and ginger moxibustion18 are seen in the research as well. Most patients in these trials were diagnosed by a rheumatologist according to the 1990 ACR criteria. There are no reliable data in mainland China or Taiwan regarding the prevalence of FM.

How to Refer Patients

If your patients express interest in TCM for their FM symptoms, referral should be based on professional credentials. TCM providers should be licensed in the state and, ideally, graduated from an accredited program of study. Additionally, the practitioner should be board certified in either acupuncture or Oriental medicine. The exam is administered by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). At their website, www.nccaom.org, the public can access names and contact information of practitioners who have met the board certification standards. Alternatively, one may meet with area practitioners and experience a treatment or two. Another avenue to find local practitioners, as well as discover professional misconduct and regulations within your state, can be found online at www.acupuncture .com/statelaws/statelaw.htm.

Herb–drug Interactions

Herb-drug interactions are a serious con-cern of which TCM practitioners are acutely aware. The most important consideration is to make sure that the patient is communicating with both medical and complementary practitioners about what they are taking or any unexpected reactions.

Course of Treatment

The course of treatment will vary depending on the condition treated. For chronic pain conditions there is not likely to be a complete remission. With this in mind, the patient should adjust their expectations and be prepared for frequent treatments early on, followed by weekly or monthly treatments for maintenance.


Expense is probably the biggest barrier to TCM for most patients. Some states mandate that insurance companies cover a specified number of treatments and some insurance companies offer alternative therapy riders. However, most insurance do not cover TCM modalities and the patient is expected to pay out of pocket. If patients live in larger cities where Chinese medical schools exist, such schools often offer a very cost-effective means for treatment. Some cities have acupuncturists who practice a model of business called Community Acupuncture where, instead of individual treatment rooms and hour-long sessions, groups of patients are treated in reclining chairs or on gurneys at a substantially reduced price. Depending on location, private practitioners may charge anywhere from $35-$150 per acupuncture treatment, with a recommendation of at least 10 treatments to determine effectiveness. Herbs are usually an additional charge of $10-$65 for a seven-day supply. Comparatively, the three FDA-approved agents for fibromyalgia (pregabalin, duloxetine and milnaciprin) are approximately $130/ month at full price without insurance.


Current research, while preliminary, suggests that Traditional Chinese medicine has a number of modalities that could help treat primary and secondary symptoms in the fibromyalgia population. It is likely that this response is not due to placebo or expectation.14


This work was funded by National Center for Complementary and Alternative Medicine (AT002688), National Institute of Nursing Research (NR0007061), and made possible by the contributions of the National Fibromyalgia Research Association and the Fibromyalgia Information Foundation.

Last updated on: January 5, 2012
close X