Vol. 16, #1

Acupuncture In The Management Of Chronic Fatigue Syndrome In Adolescents: A Pilot Study
Yuan-Chi Lin, MD
Helen Ly, BS
Aimee B. Bioteau, BS

ABSTRACT
Background Chronic fatigue syndrome consists of disabling fatigue accompanied by a combination of musculoskeletal symptoms and sleep disorders. There is currently no specific diagnostic test or therapy for patients with chronic fatigue syndrome.
Objective To evaluate the effectiveness of integrating acupuncture as a complementary therapy for patients with chronic fatigue syndrome.
Design, Setting, and Patients All patients (7 females, 1 male; age range, 11-18 years) studied were referred by the Chronic Fatigue Syndrome Clinic at the Children's Hospital Boston and had the diagnosis of chronic fatigue syndrome. Symptoms were recorded at the beginning of the round of treatments and again at each follow-up visit by an assistant (not an acupuncture provider).
Intervention Each pediatric patient received acupuncture once a week for 6 weeks at points including Hua Tuo Jia Ji, BL 18, BL 20, BL 23, and SP 6.
Main Outcome MeasuresVisual analog scale (VAS) scores for pain (0-10) and functional level (0-10). Patients also reported changes in sleep, ability to return to school and any adverse effects.
Results The mean (SD) VAS score for pain was 6.5 (1.9) at the initial evaluation and 5.8 (1.9) after the 6th treatment (P>.50). The functional level was improved from 4.5 (1.4) to 7.0 (1.5) (P<.01). The patients reported that initially they felt tired and relaxed. They reported falling asleep quicker the 1st night after treatment and feeling more energetic following treatment. All patients were able to return to school after their initial series of 6 acupuncture treatments. There were no reported cases of orthostatic hypotension during the study periods. All the patients and their families were satisfied with the results of the acupuncture treatments. No side effects or complications related to the acupuncture services were reported.
Conclusions Though the baseline pain score for patients with chronic fatigue syndrome did not change significantly, the functional level of the patients improved. Patients displayed improvement in energy levels and sleep. The duration of the reported effectiveness of the acupuncture treatments was lengthened as the treatments progressed.  Thus, acupuncture can be a useful tool for the management of chronic fatigue syndrome.
KEY WORDS
     Chronic Fatigue Syndrome, Acupuncture, Pediatric, Visual Analog Scale (VAS)

INTRODUCTION
Chronic fatigue syndrome is characterized by severe disabling fatigue accompanied by a combination of symptoms, including musculoskeletal pain, sleep disturbances, difficulties with concentration and headache. Chronic fatigue syndrome is a common health condition, particularly in women, and occurs across various ethnic groups.1 It has been reported that the current prevalence of chronic fatigue syndrome is 0.2%-2.6%, depending on the determining criteria.2

The cause of chronic fatigue syndrome is poorly understood. Children diagnosed with the syndrome seem to have a better outcome than do adults. The goals of therapy include reducing the levels of fatigue-associated symptoms, increasing the levels of activity and school participation, and improving the psychosocial and physiological symptoms. We report our experience of integrating acupuncture as a complementary therapy for pediatric patients with chronic fatigue syndrome.

METHODS
This study was approved by our hospital's institutional review board. Written informed consent was obtained from the patients and/or legal guardian prior to the 1st session of therapy. The patients were referred from the Chronic Fatigue Syndrome Clinic at the Children's Hospital Boston with the diagnosis of chronic fatigue syndrome. After initial evaluation, the patients received acupuncture treatment 1 time weekly for 6 weeks. The treatment style was according to Traditional Chinese Medicine. (The acupuncture treatment was performed by the 1st author, Dr Yuan-Chi Lin, who trained in TCM in Taiwan. Dr Lin is the Director of Medical Acupuncture Service at Children's Hospital Boston, Harvard Medical School.)

Symptoms and signs of chronic fatigue syndrome were recorded at the beginning of the treatment and on each follow-up visit by a research assistant (who was not an acupuncture provider). Pain scores were recorded using a visual analog scale (VAS) from 0 (no pain) to 10 (worst pain) by the patients and the research associate at each visit. The activity level was also recorded from 0 (no activity at all) to 10 (maximum activity). Supine and orthostatic blood pressures were recorded during each visit. Results are reported as mean (SD) unless noted otherwise.

Treatment
Acupuncture was performed with patients in a prone position. The major acupuncture points included Hua Tuo Jia Ji, BL 18 (Gan Shu), BL 20 (Pi Shu), BL 23 (Sheen Shu), and SP 6 (San Yin Jiao). Needles were inserted through the skin about 3-5 mm, and manual stimulation produced De Qi. Serin No. 3 J type (0.20 x 30 mm) needles were used. The patients were seen once a week for an acupuncture course of 6 weeks.

Hua Tuo Jia Ji (M-BW-35) is a group of 34 points on both sides of the spinal column. Hua Tuo Jia Ji is 0.5 cun lateral to the lower border of each spinal process from the 1st thoracic vertebrae to the 5th lumbar vertebrae. (It is unnecessary to needle all 34 points.) We palpated all the Hua Tuo Jia Ji points and needled the tender Hua Tuo Jia Ji points. The needles were inserted perpendicularly 0.5-1 inch in the chest region, and 1-1.5 inch in the lumbar region. During needling, we attempted to bring out the distension and soreness. 

BL 18 (Gan Shu) is 1.5 cun lateral to the lower border of the spinous process of the 9th thoracic vertebrae; we punctured obliquely 0.5 inch and used moxibustion. BL 20 (Pi Shu) is 1.5 cun lateral to the lower border of the spinous process of the 11th thoracic vertebrae; we punctured obliquely 0.5 inch with moxibustion. BL 23 (Sheen Shu) is 1.5 cun lateral to the lower border of the spinous process of the 2nd lumbar vertebrae; we punctured obliquely 0.5 inch with moxibustion. SP 6 (San Yin Jiao) is 3 cun directly above the tip of the medial malleous, on the posterior border of the tibia.

RESULTS
Eight patients were referred from the Chronic Fatigue Clinic for acupuncture treatments: 7 females and 1 male, aged mean (SD) of 15.4 (2.4) years (range, 11-18 years). The patients reported chronic fatigue syndrome symptoms an average of 5.4 (3.3) years. Upon the initial consultation, all patients presented with the following symptoms: fatigue, limited activity level, inability to participate in regular exercise, decreased energy level, pain in the limbs, and muscle pain. The majority of patients complained of loss of concentration (75%), low school attendance (75%), unrefreshing sleep (75%), pain in the back (75%), joint pain (75%), neck pain (75%), headache (75%), dizziness (50%), depression (50%), bowel dysfunction (50%), abdominal pain 50%), orthostatic hypotension (50%), and mood disorder (38%).

The overall VAS pain score was 6.5 (1.9) at the initial evaluation and decreased to 5.8 (1.9) after the 6th treatment (P>.50). The functional level improved from 4.5 (1.4) to 7.0 (1.5) (P<.01). The patients reported that initially after the treatments, they felt tired and relaxed.

They were able to fall asleep faster the 1st night after treatment and reported feeling more refreshed and energetic afterward. They reported feeling less fatigued with more energy and all were able to return school. Regarding improvement in the level of fatigue, the overall effect of acupuncture lasted on average 2.4 (1.5) days. Increased energy lasted for 1.2 (1.0) and 3.7 (2.1) days after the 1st and 5th treatments, respectively. There was no reported orthostatic hypotension during the study periods.

All the patients and their families reported satisfaction with the acupuncture treatments. No side effects or complications related to the acupuncture services were stated. Following the initial 6-week sessions of acupuncture, the patients were offered twice-monthly treatments for continuing acupuncture therapy. 

DISCUSSION
Chronic fatigue syndrome is a disorder of no proven cause, manifesting in extended periods of extreme debilitating fatigue. It can be associated with considerable morbidity.3 Myalgias, tender lymph nodes, arthralgias, chills, feverish feelings, and postexertional malaise are common symptoms. The diagnosis of chronic fatigue syndrome is achieved primarily by exclusion, with no definitive laboratory test or physical findings.4 The US Centers for Disease Control and Prevention (CDC) offers a conservative estimate of 4 to 10 cases per 100,000 US adults. More women than men experience chronic fatigue syndrome.5 Children with chronic fatigue syndrome present with symptoms that are similar to those of adults. In the adolescent population, chronic fatigue syndrome is commonly related to orthostatic hypotension,6 as seen in our patient group. In the literature, chronic fatigue syndrome is often referred to as myalgic encephalomyelitis and post-viral fatigue syndrome.

The CDC criteria for the diagnosis of chronic fatigue syndrome include a broad symptom spectrum: new, unexplained, persistent, or relapsing chronic debilitating fatigue that is not a consequence of exertion, not resolved by bed rest, and severe enough to significantly reduce daily activities for at least 6 months. Other symptoms of chronic fatigue syndrome include unexplained new headaches, short-term memory or concentration impairment, muscle pain, pain in multiple joints unaccompanied by redness or swelling, unrefreshing sleep, postexertion malaise that lasts up to 24 hours or longer, sore throat, and tender lymph nodes in the neck or armpit, along with fatigue and impairments not caused by any other identifiable clinical condition.7

Despite substantial efforts in the research of chronic fatigue syndrome, the etiology is still not clear. Various hypotheses have been suggested, including immunological, virological, neuroendocrinological, psychological, environmental, or socioeconomical causes. Abnormal cerebral perfusion patterns in chronic fatigue syndrome patients who are not depressed are similar but not identical to those in patients with depressive illness.8 In 1 study, half of the patients with chronic fatigue syndrome showed abnormalities in cerebral glucose metabolism on positron emission tomography.9

No single medical test detects chronic fatigue syndrome. Its diagnosis depends on the history of illness, physical examination, and ruling out all other conditions that present with similar symptoms. The differential diagnosis includes chronic viral illnesses, systemic lupus erythematosus, rheumatoid arthritis, multiple sclerosis, hepatitis, sleep disorder, medication adverse effects, severe obesity, and psychiatric illnesses. There is no standard treatment, although antidepressant therapy is commonly prescribed.

Complementary and alternative medical therapies have also been used in the treatment of chronic fatigue syndrome. Graded exercise programs can produce improvements in the measures of fatigue level and functional capacity.10 Herbal medicine has also been used,11 as have homeopathic remedies,12 massage therapy,13 osteopathic manipulation,14 and cognitive behavioral therapies.15 

The major acupuncture points utilized in this report include the Hua Tuo Jia Ji points, whose actions are similar to the corresponding Shu points; BL 18 (Gan Shu), the Shu points of the Liver. They regulate the Liver-Qi to remove Qi stagnation in the Liver. BL 20 (Pi Shu), Shu points of the spleen, tonifies the Qi of the spleen. BL 23 (Sheen Shu), Shu points of the kidney, tonifies the Qi of the Kidney. SP 6 (San Yin Jiao), the crossing point of the Spleen, Kidney, and Liver channels, regulates the circulation of Qi and can remove Liver-Qi stagnation.

CONCLUSION
This report demonstrates that acupuncture was well-tolerated in pediatric patients diagnosed with chronic fatigue syndrome. Patients with chronic fatigue syndrome may display the symptoms of spleen Qi deficiency, kidney Qi lack of firmness, and/or deficiency of the state of the liver-blood. This can be due to the invasion of external Wind-Cold or Wind-Damp. These conditions may cause fatigue, muscle weakness, dizziness, insomnia, muscle cramps, weakness of limbs and back, abdominal discomfort, and/or urogenital problems. The tongue is usually pale and the pulse is commonly empty.

This study is one of the first to study the integration of acupuncture into the management of patients with chronic fatigue syndrome. A major limitation was the small study population. Acupuncture was used as a complementary therapy and thus we did not control other medications the patients were taking for their symptoms. Further prospective randomized controlled studies in patients with chronic fatigue syndrome are needed to evaluate the short- and long-term effects of acupuncture for this condition.

ACKNOWLEDGEMENT
We wish to thank Ms Margaret Munro Lyons for her assistance in editing this article.

REFERENCES

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AUTHORS' INFORMATION
Dr Yuan-Chi Lin is Director of the Medical Acupuncture Service at Children's Hospital Boston, Harvard Medical School, and Assistant Professor of Anesthesia at Harvard Medical School in Boston, Mass. Dr Lin is a member of the AAMA Board of Directors.

Yuan-Chi Lin, MD, MPH, DABMA, FAAMA*
Dept of Anesthesia, Children's Hospital Boston
300 Longwood Ave
Boston, MA 02115
Phone: 617- 355-4158 • Fax: 617- 739-2599 • E-mail: yuan-hi.lin@tch.harvard.edu
Helen Ly, BS, and Aimee B. Bioteau, BS, are Research Assistants in the Medical Acupuncture Service, Children's Hospital Boston, Harvard Medical School.
*Correspondence and reprint requests

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