Ruan Jin Zhao

Abstract: Chemotherapy-induced peripheral neuropathy (CIPN) is a frequent adverse effect observed in clinical oncology following chemotherapy treatments. Both acupuncture and Chinese herbal medicine have been shown to independently mitigate the symptoms of neuropathy. The outcome has not been immediate and still has room for improvement. According to Traditional Chinese medical theory, combining diagnosis based on clinical symptoms in modern medicine and differentiating syndromes in Traditional Chinese Medicine, CIPN should be treated as Jue syndrome and Feng syndrome. Its core pathology is classified as a complex mixed syndrome of Cold and Heat. Combining acupuncture with Chinese herbal medicine has significant advantages, as they enhance each other’s effectiveness. Jue syndrome, characterized by limb pain, results from disrupted Yin and Yang energy flow. Treatment should focus on unblocking obstructed Yang and reconnecting Yin-Yang channels.   Numbness and a sensation of electricity characterize Feng Syndrome, which is caused by interior wind. Treatment involves opening the collaterals and calming the wind. By adhering to the same principles of herbal formulae and acupoint selection, acupuncture can effectively enhance the regulation of energy flow. Herbal medicine may act more rapidly when supported by acupuncture. The combination of acupuncture and herbal medicine is more efficacious in the treatment of Chemotherapy-Induced Peripheral Neuropathy (CIPN).

Key Words: Chemotherapy, Peripheral Neuropathy, CIPN, Acupuncture and Chinese herbal medicine, Jue syndrome, Feng syndrome.

Chemotherapy-induced peripheral neuropathy is a prevalent side effect observed in clinical oncology. It presents significant challenges due to the absence of effective treatments, potentially affecting chemotherapy treatment plans and adversely impacting patient prognosis. Chemotherapy can affect the sensory nerve, motor nerve, and autonomic nerve. However, the most common peripheral neuropathy resulting from chemotherapy impacts the sensory nerve, potentially causing hypersensitivity. The patient presents symptoms of limb sensor injury, including pain, burning sensation, numbness, needle-like sensation, prickling, electricity-shock burning, or cold sensation. In some cases, there may be skin lesions on the patient’s palms and the soles of their feet. The patient is also highly sensitive to needling and cold.

A minor group of patients may experience involvement of motor nerves and autonomic nerves. Numerous research articles have reported that acupuncture can alleviate chemotherapy-induced peripheral neuropathy (CIPN). Positive results for CIPN have also been reported with moxibustion and electroacupuncture (EA). Chinese herbal medicine aimed at warming and tonifying Qi and blood has been shown to have benefits, as well as herbal medicine designed to unblock collaterals and promote blood circulation. Food supplements such as Vitamin E may help alleviate the symptoms of CIPN. However, the clinical outcomes of acupuncture, electro-acupuncture, moxibustion, food supplements, and Chinese herbal medicine are not immediate, steady, or repeatable. The timing for patients undergoing chemotherapy is crucial, as the symptoms of CIPN need to be resolved quickly. It is critical to address the patient’s inability to continue chemotherapy, as this may result in uncontrolled growth of cancer cells and a decline in the patient’s quality of life. Therefore, it is imperative to quickly and effectively manage peripheral neuropathy and alleviate the patient’s suffering to ensure the continuation of chemotherapy.

The delay in achieving effective results is due to the lack of identification of the key pathology of CIPN and overlooking the value of Traditional Chinese Medicine (TCM), which is holistic in nature. Focusing on a single clinical symptom rather than considering the whole body’s self-healing ability, and neglecting the fundamental principles of TCM, may result in losing its clinical advantage.  Distinguishing between clinical symptoms and syndrome differentiation is often debated. Before proceeding with syndrome-based treatment, it is essential to thoroughly understand the pathological mechanism of CIPN. Without this understanding, clinical patterns and treatments lack foundation and offer no clinical benefit.

The pathology of CIPN (Chemotherapy-Induced Peripheral Neuropathy) is currently not well understood. It differs significantly from peripheral neuropathy caused by other conditions such as diabetes, neuromuscular diseases, malnutrition disorders, vascular inflammation, and post-stroke complications, which involve clear physical damage for nerves. CIPN does not exhibit neuron axon damage, and the sensory nerve endings lack myelin sheaths, meaning demyelination is not observed. Some studies indicate chemical component changes in CIPN. As of now, there is no highly effective medication available for this condition.

Pathophysiology of CIPN

According to Traditional Chinese Medicine (TCM) theory, the fundamental pathology of Chemotherapy-Induced Peripheral Neuropathy (CIPN) can be understood as follows. CIPN affects the limbs, which serve as a connection space between Yin and Yang meridians. Jue syndrome occurs when the energy (Qi) within the Yin and Yang meridians cannot be transduced smoothly or is misconnected. CIPN falls under the category of Jue syndrome and can be classified into various patterns based on the pathological components that obstruct energy transduction. Generally, it can be divided into Cold Jue syndrome, Heat Jue syndrome, and complex Jue syndrome. The predominant pattern observed in CIPN is Cold Jue syndrome.  Additionally, limb disorders are a feature of the complex syndrome involving both Cold and Heat elements.

Numbness in the hands and feet, described as an electricity-like sensation, is indicative of Wind syndrome. This condition may be attributed to internal wind caused by Spleen Yang Qi deficiency, as the spleen governs the limbs. Chronic spleen wind could be linked to Chemotherapy-Induced Peripheral Neuropathy (CIPN). Due to the unique constitution of each patient and the variety of chemotherapy drugs, blood deficiency or severe Yin deficiency may also contribute to internal wind syndrome. The pathological nature of wind is prone to change and is unpredictable. Examining the clinical manifestations of CIPN reveals similarities to wind, including sensations of cold, heat, numbness, and heightened sensitivity to cold with burning sensations. These symptoms can vary greatly from day to day.

There is an observable phenomenon in clinical practice where the severity of CIPN appears to be directly related to the patient’s response to chemotherapy in eliminating cancer cells. In general, patients who experience more severe Chemotherapy-Induced Peripheral Neuropathy (CIPN) tend to have a more effective reduction in their cancer or tumor, which may initially appear counterintuitive. However, upon closer examination, this observation is quite reasonable. Cancer proliferates or grows rapidly due to the interruption of neurological immune pathways, particularly affecting the sensory system. Consequently, cancer patients often have a diminished sense of bodily awareness. For example, many breast cancer patients do not feel pain even when the tumor has grown significantly, making it difficult for them to detect lumps on their own. Cancer modifies the sensory nerve system, causing it to shut down. Chemotherapy kills cancer cells but also activates the neurological system, especially the sensory part, often making it hypersensitive. Interestingly, patients who do not show signs of chemotherapy-induced peripheral neuropathy (CIPN) after several treatments typically have a poor response to chemotherapy. This observation is supported by many oncologists.

Chemotherapy drugs such as Paclitaxel and EGFR inhibitors have been discovered to promote central nervous system regeneration. These drugs, while known for causing peripheral neuropathy, also have the potential to aid in the rejuvenation of central nerves. Research has shown that nerve growth factor is significantly elevated in the serum of patients with intense Chemotherapy-Induced Peripheral Neuropathy (CIPN). This indicates that the pathology of CIPN is complex. It can be viewed as a complex syndrome involving both Cold and Heat. The therapeutic approach for this condition involves regulating and harmonizing Yin and Yang using a combination of herbs with cold properties and herbs with warm properties. Treatment aims to both strengthen and reduce simultaneously, increasing the energy level in the middle Jiao to assist with energy raising and descending functions.

Clinically, if acupuncture alone is insufficient to address a condition, herbal medicine may be incorporated. The combination of acupuncture and herbal medicine is a notable aspect of Traditional Chinese Medicine. When a patient has low energy or is very weak, acupuncture may not effectively regulate energy flow. A cook cannot prepare a meal without essential ingredients like rice. Weak patients may not benefit from acupuncture as it might cause harm. Combining herbal medicine with acupuncture enhances healing rather than just adding their effects. Exercise caution when using herbal medicine for chemotherapy patients who are sensitive to chemicals and strong herbal smells. Always consider the patient’s digestive system. Use strong herbs in low dosages, preferably in pill or capsule form. When prescribing a decoction, please ensure that the dosage does not exceed twelve milliliters per administration.

The main pathology of Chemotherapy-Induced Peripheral Neuropathy (CIPN) involves an underlying deficiency while appearing excessive on the surface, along with inner toxin accumulation. Chemotherapy affects the patient’s Yang Qi and Yin blood, resulting in symptoms such as chills, aversion to cold, and anemia. These manifestations may include a pale tongue, a gray or dark tongue, and in some cases, a fresh red tongue without coating. For patients with Chemotherapy-Induced Peripheral Neuropathy (CIPN), hand or feet pain should be treated as Jue syndrome, while numbness and electrical shock sensations should be managed as interior wind syndrome. It is essential to differentiate clinical symptoms and syndromes for accurate treatment. The clinical patterns are established flexibly and should not be applied mechanically.

Clinical Differentiation of Syndromes and Herbal formulas

Herbal medicine treatment, Si Ni San, is a fundamental herbal formula for Chemotherapy-Induced Peripheral Neuropathy (CIPN). It works by alleviating congestion and activating Yang Qi to extend its reach to the extremities. For Cold Jue Syndrome, Si Ni San combined with Dang Gui Si Ni Tang can warm Yang Qi and alleviate congestion to relieve pain and numbness. Additionally, Si Ni San supplemented with Wu Mei Wan is effective in treating Jue Syndrome related to complex Cold Mixed Heat pathology. Patients with severe numbness in hands and feet should be treated as wind syndrome using Si Ni San plus Tian Ma Gou Teng Dang, or with Si Ni San plus Da Ding Feng Zhu for Yin deficiency. Detailed clinical patterns and herbal medicines are listed below:

CIPN associated with Yang Qi Deficiency and Blood Deficiency: Symptoms include cold extremities, hand and feet pain, deep and weak pulse, pale tongue with thin white coating. The aim is to warm the meridians, disperse cold, tonify blood, and unblock vessels. Recommended herbal formula: Dang Gui Si Ni Tang, consisting of Dang Gui 9g, Gui Zhi 9g, Shao Yao 9g, Xi Xin 3g, Tong Cao 6g, Da Zao 8 pieces, and Zhi Gan Cao 6g.

CIPN falls under the category of Complex syndrome of Cold mixed with Heat. Symptoms include cold limbs, alternating sensations of chills or burning, pricking pain, or hot hands and cold feet. Pulse is thin and wiry; tongue is red with thick white coating. Wu Mei Wan is the recommended herbal formula, composed of Wu Mei 30g, Xi Xin 3g, Gan Jiang 9g, Dang Gui 6g, Pao Fu Zi 6g, Huang Lian 6g, Gui Zhi 6g, Ren Shen 6g, Shu Jiao 5g, and Huang Bai 6g.

CIPN is characterized by numbness in hands and feet with burning sensations, prickling, and shock-like feelings. a). It may include a red tongue with yellow coating, wiry and rolling pulse, which indicates an interior wind syndrome. Herbal medicine: Decoction of Tian Ma Gou Teng (Tian Ma 9g, Gou Teng 12g, Shi Jue Ming 30g, Sang Ye 12g, Shi Chang Pu 12g, Fu Ling 12g, Ling Yang Jiao Powder 0.6g taken directly without cooking).

b). For blood and Yin deficiency with symptoms like limb numbness, tremor, spasm, stiffness, fatigue, weak pulse, and pale tongue without coating, use the herbal formula Da Ding Feng Zhu. Its ingredients: Bai Shao Yao 18g, E Jiao 12g (melted in hot water), Gui Ban 15g, Bie Jia 15g, Raw Oyster Shell 35g (cook first), Mai Dong 9g, Shen Di Huang 12g, Ma Ren 9g, Wu Wei Zi 9g, Zhi Gan Cao 6g, Egg yolk one piece.

To enhance the energy in Yin and Yang Meridians, modify the herbal formulas by adding ivy category herbs like Ren Dong Teng, Ye Jiao Teng, Gou Teng, Ji Xue Teng, Luo Shi Teng, Shen Jin Cao, and Shi Jian Chuan. Add worm remedies such as Di Long, Wu Gong, and Jiang Can to address interior wind and open the collaterals.

The herbal medicines mentioned above should be administered in small dosages and condensed with low volume. Patients undergoing chemotherapy often have heightened sensitivity to herbal smells. Therefore, if patent herbal formulas are available, encapsulated forms are preferable as they can be easily administered and are gentler on the patient’s gastrointestinal system.

Acuports Selection and Needling Programming

With the support from above herbal medicine formulas, the patient should receive acupuncture twice weekly. After six sessions, continue with once-weekly treatments until full recovery.

The Key for Acupoint Selection

Firstly, Bai Hui (Du.20) is selected as the point to control the body’s Yang Qi. The next point is Shen Men (Ht.7), which addresses pain, boils, carbuncles, and itching that originate from the heart. Ht.7 is the Shu point used to enhance heart energy.

For the hands and feet, particularly affected limbs, Ying Point in the Five Shu points theory is found on Yin and Yang paired meridians. For example, Ying Points L.I.2 on Hand Yang Ming Meridian (Large Intestine) is selected to pair with the Ying point Lu.10 on Hand Tai Yin Meridian (Lung); Ying point S.I.2 on Hand Tai Yang (Small Intestine) is used to pair with the Ying point Ht.8 on Hand Shao Yin (Heart) meridians. The Ying point S.J.2 on the Hand Shao Yang/San Jiao Meridian is used to pair with Ying Point P.C.2 on hand Jue Yin/Pericardium meridian.

The same principle was applied to the feet and lower legs at various Ying points on Yin-Yang paired meridians: Foot Tai Ying/Spleen (Sp.2) pairs with Foot Yang Ming/Stomach (St.44), Foot Jue Yin/Liver (Liv.2) pairs with Foot Shao Yang/Gall bladder (G.B.43), Foot Tai Yang/Urine Bladder (U.B.66) should be paired with Foot Shao Yin/Kidney (Kid.2). Ying points are used for pain management according to Five Shu point theory, aiding in efficient elimination of peripheral neuropathy by reconnecting and smoothing the flow of Yin Yang energy.

The disorders of the four limbs are attributed to the spleen, which is located in the middle Jiao and is responsible for transportation of food and water metabolism. In coordination with the stomach, the spleen regulates the ascending and descending of energy. To achieve harmony and connection of Yin and Yang energy, it is crucial to restore the full functionality of the spleen and stomach. Therefore, acupoints such as Zhong Wan (Ren.12), Nei Guan (P.6), Zu San Li (St.36), and Yin Ling Quan (Sp.9) can be utilized to enhance spleen and stomach energy and recover their ascending and descending functions.

Selecting acupoints to form a healing networks, enabling interfaces and resonance among points that activate repair genes and promote healing.

Principle for Programming Needling

It was emphasized that inserting the needle at a shallow depth in the epidermal layer and slightly manipulating the needle is crucial. Superficial needling is essential to avoid strong stimulation. Using a guide tube ensures that the needling signals target the epidermal layer, specifically the sensory nerve endings, to activate the dendritic cells in the skin. This procedure may facilitate the full recovery of chemical components within the nerve axon. Electricity acupuncture is not recommended for CIPN.

Derived from Case Study and Conclusion

Mr. Smith, a 65-year-old male, suffers from severe chemotherapy-induced peripheral neuropathy (CIPN). He experiences burning sensations in his feet and sometimes feels as though he is stepping on broken ice, causing significant pain and discomfort. Over the last three years, he has had difficulty sleeping and walking steadily. During his initial visit, he expressed dissatisfaction with his oncologist and mentioned that he would have refused chemotherapy if he had known about the suffering it would cause.

After reviewing his medical history, it was noted that he achieved complete remission from stage IV colon cancer metastasis to the liver after six sessions of chemotherapy. Three years later, his cancer has not recurred, but he continues to experience severe CIPN. After discussing his condition with him, it was explained that his sensitivity to chemotherapy may have activated his nerve system and neuro-immunity pathway, contributing to his cancer remission. Patient understood that CIPN might be the reason for his successful cancer treatment and became more cooperative for CIPN management.

Herbal medicine prescribed included Si Ni San Pill, 6 pills twice a day, and Tian Ma Gou Teng Wan, 6 pills twice a day. Acupuncture treatments were administered twice per week at Bai Hui, Si Shen Cong, Shen Mei (Ht.7), Sp.3, St. 42, Liv.2, G.B.42, U.B.66, Kid.2. After approximately twelve sessions over two months, he reported an eighty percent relief in CIPN symptoms and showed improved mood without further complaints about his oncologist.

Mrs. Voorhees, 71, had ovarian cancer with liver and peritoneal metastasis and ascites. After eight chemotherapy sessions, her serum CA125 dropped from 2735 to 19, and a PET scan showed no more cancer. She has remained cancer-free for nine years. During her second chemotherapy, she suffered from severe peripheral neuropathy, including numbness, prickling, burning sensations in her hands, and ice-cold feet. Using Si Ni San and Wu Mei Wan herbal medicines and acupuncture, her symptoms were managed but not fully healed. Her CA125 has stayed around 15, a notable achievement given the high recurrence rate of stage IV ovarian cancer. Mrs. Voorhees maintains a healthy life and continues weekly acupuncture treatments.

Based on the analysis of the pathophysiology of CIPN and clinical research, the most effective treatment for chemotherapy-induced peripheral neuropathy aims to alleviate symptoms rather than provide a complete cure. Maintaining the activity of peripheral nerves may contribute to preventing cancer relapse.

There are two groups of patients with CIPN. One group has completed or stopped chemotherapy due to severe side effects, making them more straightforward to treat with herbal medicine and acupuncture. The challenging group consists of those still undergoing chemotherapy and suffering from CIPN but unable to stop the treatment. Acupuncture and herbal medicine are essential at this moment. While many oncologists agree with acupuncture treatment for patients, they lack knowledge of Chinese herbal medicine and worry about potential conflicts with chemotherapy drugs. Patients were advised not to take herbal medicine. It is essential to inform patients and oncologists that the mentioned herbal medicines do not conflict with chemotherapy drugs and have no side effects. These herbal medicines can actually reduce chemotherapy side effects and enhance its effectiveness. Effective communication among patients, caregivers, and oncologists shows that combining Chinese herbal medicine with acupuncture can effectively help patients with CIPN.

Author information:

Zhao Ruanjin, Doctor of Medicine, is a licensed acupuncturist in the United States. He is currently the director of the Sarasota Traditional Chinese Medicine Center in the United States and a visiting researcher at the H. Lee Moffitt Cancer Center in the United States. He is the second batch of clinical experts at the Beijing University of Chinese Medicine and an overseas professor at the Henan University of Chinese Medicine. In terms of academics, he has written the English version of “From Legend to Science” and published many papers.

针药并用对化疗引起周围神经损伤病变的有效治疗

作者：赵软金

摘要：化療誘發的周圍神經病變是腫瘤臨床治療中常見的一種化療副作用。雖然針灸和中藥在單獨使用時均有一定的緩解作用，但其效果有限。根據傳統中醫理論，將病症辨識與證候辨識相結合，從厥證和風證著手，以寒熱錯雜的病機論治，針灸和中藥聯用，相輔相成，可以顯著提升療效。厥證主要表現為四肢末端疼痛，乃由陰陽之氣不相順接所致，治療應解除陽氣阻遏，連接陰陽經氣；風證則以麻木和電流樣刺激為主，由內風引起，應以通絡息風為治療重點。遣藥施針遵循一致原則，針灸通氣機，藥物助針威，從而達到速效。針藥並用在化療引起的周圍神經病變治療中具有顯著優勢。

關鍵詞：化療，周圍神經病變，針藥並用，厥證，風證

化疗引起的周围神经病变是肿瘤临床常见的一个化疗引起的毒副作用，是一极具挑战的课题。 因为缺乏有效的治疗措施，可能直接影响化疗方案的连续施行，影響到癌症病人的预后结果。虽然常规的认为神经损伤会影响到感觉神经，运动神经和自主神经，但最为常见的化疗引起外周神经病变的临床症状是感觉神经的异常或超敏化 ，病人手足感觉障碍，疼痛，麻木，针刺樣感、电流烧灼感，或冰冷， 常伴有手掌部分红斑性皮损，对冷和针刺特别敏感。

极少数病人会殃及自主神经和运动神经 。多种针刺疗法报道对化疗引起的周围神经病变有缓解功效；結合灸法或電針刺激也有顯著幫助；中藥从温补气血，和 活血通絡等方面也取得一些治疗效果。維生素E使用也可緩解CIPN的症狀。但是无论是单纯的针刺，电针，灸療，食品補充劑和中药，其临床效果都不够及时，且不稳定。化疗病人的时间很关键，若不能及时解決問題，讓病人繼續接受化疗，癌细胞就有可能失去遏制而疯狂生长。病人的生活質量也受到極大影響。如何快速和有效地获取治疗效果，及時缓解周围神经损伤的临床症状，保證病人的生活質量，帮助病人继续接受化疗就是关键。

不能取得及时和稳定疗效的关键之处，就是没有找到病理機制的關鍵點，忽略了中医学的优势。中医学是个整体医学，过度纠结于一个临床症状而忽視了机体整体自愈机制，忘记了中医学的基本治疗法则时，也就失去了中医学临床的优势。以临床症状或單個疾病來讨论中医治疗就會涉及到一个很有争议的议题，即是辨病与辩证的关系，在作辨证论治讨论的前提是把这个疾病和临床症状的病理生理完全彻底的弄懂，否则辨证论治就是建立在臆想之上的楼台，不切实际，而于临床毫无裨益。

目前现代医学对于化疗引起的周围神经病变具体的病理機制仍有很多空白，它不同于其他疾病所引发的 周围神经损伤，比如糖尿病，神经肌肉疾病如多发性脊髓硬化症，营养缺乏性神经损伤，脉管炎和中风后遗症等。这些神经的损伤，是物理性损伤为多，而化疗引起的往往没有神经轴突和神经末梢物理性损伤。感觉神经末梢是没有外鞘膜，并没有脱髓鞘的病理变化。更多的是对神经轴浆流动和其中化学成分的改变，因此没有好的干预药物。

利用中医学传统的理论剖析化疗引起周围神经病变的基本病理，此病的病位在四肢末端，属于阴经与阳经交接之处，阴阳之气不能顺接之为厥。CIPN的疼痛发生在四肢，属于厥类范畴。根据阻遏和影响阴阳之气交接邪气的性质不同，有寒厥，热厥和寒熱錯雜引起的厥證之分。化疗病人的周围神经病变多为寒厥。此外，四肢末端病者通常具有寒热错杂疾病的特征性症状。

手足麻木，而且有電流樣的走竄，其性質也属于风證。但此风由内而生，而脾主四肢，主要便是脾阳亏虚所致的慢脾风；也因病人个体不同和化疗药物有异临床又有血虚生风，阴虚生风等变证。风性善变，风证变幻莫测，仔细研究CIPN的症状表现，就是风一样的不定，忽冷、忽热、麻木不仁还又特敏感、烧灼感；时好时坏，一天可能挺好，一天可能很糟。

临床上观察到一个独特的现象：癌症患者罹患周围神经病变的严重程度与其癌症对化疗的敏感度存在直接关联。通常，临床症状越严重，癌症控制效果越好。这似乎是一个悖论。实际上，在癌症快速发展的过程中，神经免疫通路已经被异常切断，尤其是感觉神经。患者往往后知后觉，例如乳腺癌患者，在诊断时肿瘤已非常大，但患者常常没有感觉，不仅没有疼痛，更奇怪的是，即使触摸到那么大的肿块，患者也无法察觉。癌症的發生與發展使其对自身身体的感触钝化。化疗在杀死癌细胞的过程中，同时影响了感觉神经末梢的功能，并激活了神经免疫通路。这种情况下，感觉神经突然恢复表现为一种超敏状态。相反地，经过多次化疗的癌症患者，如果未在第一时间出现周围神经病变，则化疗效果可能较差，甚至无效。这一现象非常客观，已得到许多癌症临床专家的认同。

化疗药物Paclitaxel和EGFR阻断剂对脊髓中枢神经再生有促进作用，。一方面会导致周围神经病变，另一方面可以促进中枢神经再生。同样的研究发现，化疗引起周围神经病变严重的病人血清中的神经再生因子显著升高。这表明化疗引起的周围神经病变是一种非常复杂的病理状态，中医学认为這正是寒热错杂证的特征，應當以寒热并用的方法来治疗這種“混沌”态，通过调和阴阳，寒热药物并用，补泻并重，同时补益中焦脾胃之气以帮助升降斡旋之功。

针所不逮，以药补之。针药并用本身就是中医学的一个特色。当病人气血亏虚之时，针刺调节气机就會非常困難，難為無米之炊，不僅達不到預想效果也可能会更伤气血，事倍功半。所以針藥並用，不僅僅是針刺療效和藥物療效的單純相加，而只互助疊加之功力。但是对于化疗病人使用中药，必须重药轻剂，以顾护胃气为第一要务。以丸药和胶囊剂为主，使用液体时，当以每次一个盎司（约12毫升）为度。

化療引起周圍神經病變的病理關鍵在於「本虛標實」與「熱毒內蘊」。化療藥物過度損害患者的陽氣和陰血，往往出現畏寒和貧血症狀，臨床可見舌質淡紫或嫩紅無苔。 疼痛為主訴者應依據厥證進行治療；如以麻木和電流感為主訴，則應按風證處理。辨證論治旨在選方用藥的精準化，需靈活運用而非機械劃分。

中药治疗以四逆散为基本方，解结通阳，令阳气达四肢末端。配以當歸四逆湯汤治療寒厥，温阳通痹，通絡止痛愈疗麻木。配烏梅丸治療寒熱錯雜之寒厥。對於以麻木不仁為主症的從風證論治，用四逆散合天麻鉤藤湯或大定風珠治療。具體分型證治如下：

周圍聖經病變屬於阳虚血虚寒厥型：四肢冰冷，手足疼痛为主，脉沉细，舌質淡, 苔薄白。当温经散寒，养血通脉，用当归四逆汤（当归9克，桂枝9克， 芍药9克，细辛3克，通草6克，大枣8枚，炙甘草6克）

周圍神經病變屬於寒热错杂厥证型：四肢末端忽冷忽热，冷热交替，或者手掌和手指发热，两足发冷。乌梅丸（乌梅30克细辛3克，干姜9克，当归6克，炮附子6克，黄连9克，桂枝6克，人参6克，蜀椒5克，黄柏6克 ）

周圍神經病變之風證屬於肝风内动型热厥：以四肢末端麻木為主，伴有烧灼感，电流刺激感，针刺样感，舌質紅，脈弦數。

a). 治疗当平肝熄风，清热开窍，用 天麻钩藤汤 （天麻9克，钩藤12克，石决明（先煎）30克，桑叶12克生地15克石菖蒲12克茯苓12克，羚羊角粉（冲）0.6克）。

b). 对阴血亏虚，虚风内动，手足麻木、蠕动或者僵硬，神倦无力病人。用大定风珠：白芍18克，阿胶12克（烊化），龟板15克，鳖甲15克，生牡蛎35克（先煎），麦冬9克 生地黄12克 麻仁9克 五味子9克 炙甘草6克 ，鸡子黄一个。

在以交通阴阳经气为治疗大法的前提下，也可重用藤类和虫类药物，藤类药物如忍冬藤，夜交藤，钩藤，鸡血藤，络石藤，伸筋草和石见穿。虫类药物主要是地龙，蜈蚣，全蝎和僵蚕，这些搜风通络之品，祛除外风和平息内风。

服用这些药物时一定小剂量，最好浓缩一下。因为病人在化疗药物的摧残下，对气味也很敏感。能够使用成药或者顆粒製劑的话最好，既能夠顧护胃气，且病人易於接受。

在中药的辅助下，结合针灸疗法，每周两次进行针灸治疗。经过三个星期（即六次针灸治疗）后，改为每周一次，直至病人康复。

首选百会，统摄诸阳气，再取心经神门穴，神門穴是心經的原穴，也取诸痛痒疮皆属于心。

在四肢末端，尤其是患肢，采用阴经与阳经对穴的方法。例如，在手与上肢区域，可选择手阳明经五腧穴的滎穴，二間（L.I.2），与手太阴經的滎穴魚際（Lu.10）；同理手少阳经滎穴液門（S.I.2）与手厥阴经滎穴勞宮（S.J.2），以及手太阳经滎穴前谷（S.I.2）与手少阴经滎穴少府（Ht.8）。在足与下肢区域，可选择足太阴经滎穴大都（Sp.2）与足阳明经滎穴內庭（St.44），足厥阴经滎穴行間（Liv.2）与足少阳经滎穴（G.B.43），以及足太阳经滎穴，足通谷（U.B.66）与足少阴经滎穴，然谷（Kid.2）。滎主身痛，其目的是通过阴经与阳经的经气相贯通，达到治疗效果。

四肢疾病多归属于脾。脾位居中州，负责运化职能，与胃相辅相成，共同调控气机升降。要实现阴阳的协调，必须重视脾胃升降功能的恢复。对中脘、内关、足三里及阴陵泉穴进行针灸疗法，可以有效补益脾胃，促进气机升降功能的恢复。

通过这样的穴位选择，使穴位之间产生相互作用，形成一个治疗疾病的网络，促进机体进入自愈状态，并激活修复基因。

轻针浅刺，浮刺为主，進針時要使用輔助管。針刺的刺激信号要集中在表皮（感覺神經末梢），同时为了激活的皮肤中的干细胞（Dendritic Cells），促进神经纤维中化學成分的修复。盡量不使用電針刺激。

臨床病例啟迪與結論

Mr. Smith一个患严重的CIPN病人，65岁男性，两脚如火烧烤、如踩在冰渣上，非常难过，已经三年了，睡觉不安，走路不舒服。在最开始初诊时他就不断抱怨他的癌症医生，说早知真难受，还不如不治疗让我死去！说医生干嘛给我用这些可恶的化疗药物！当我仔细听完他的诉说，看完他的病历后，非常惊奇！三年前他已经被确诊为结肠癌肝转移，经六次化疗后，癌症竟然彻底痊愈，至今三年过去没有任何复发。仅仅留下了CIPN！我安稳病人到，你不应该再抱怨你的癌症医生了，相反你应该很感谢他！正因为你对化疗的敏感，使你的感觉神经系统过度兴奋，叫醒了你的免疫系统，才使癌症全部消失。等病人明白了，CIPN的出现或许是他重获新生的根本原因！按照上面的治疗大法，四逆散丸， 每次6粒， 每天兩次；天麻鉤藤丸每次6粒，每天兩次。 針灸選穴：百會，四神聰，神門，內關，足三里，陽陵泉，行間，俠溪，然谷和足通谷。针药并用治疗两个月后，約12次治療，病人说周围神经病变症状已经80%好转，不再有生不如死的受罪感觉了，整个人也变得不再怨天尤人，快乐起来了.

另一例女性病人，Mrs. Voorhees, 71岁，患卵巢癌晚期，肝转移、腹膜转移，有大量的腹水，经过八次化疗后，CA125从2735降至18（低于20），PET 掃描證實癌症消失，已越九年。在她接受第二次化疗之时，已经有非常严重的外周神经损伤，如手足麻木、疼痛，烧灼感。手指不灵活，不能织帽子了！她的雙腳冰冷。第二次化療的同時開始接受針藥並用治療。中藥使用四逆散合烏梅丸， 針灸選穴與治療遵從如上法則。周圍神經病變沒有完全消失，但是在可忍受范圍。幸運的是她的癌症始终没有复发。CA125 维持在15左右。  卵巢癌病人有著極高復發率，特別是晚期病人。 而这位病人连续九年晚期卵巢癌病人达到临床癌症消失且没有复发的是较罕见的病例！经过针药并用的治疗，病人现在仍健康活着，外周神经病变已经不是主诉症状，她每星期仍坚持来诊所接受一次针灸，以作为预防性治疗。

鑒於對化療引起外周神經病變的病理生理分析，以及臨床觀察研究，能夠將病人的臨床症狀緩解也許是最理想的結果，而不是徹底將神經損傷徹底治愈。保持周圍神經的超敏感性可能會對防止癌症復發有益處。

CIPN病人來診時有兩種情況，一是病人在完成化療之後來就診的，這類病人比較容易治療，使用中藥和針灸沒有掣肘地方。但很多癌症病人是正在接受化療期間，因為手足疼痛或麻木來就診，既不願意忍受外周神經損傷之苦，又不敢停掉化療。這時候針灸和中藥的介入，就必須同時考慮癌症醫生的意見，很多癌症專家總是因為不知道中藥是否會與化療藥物有衝突或影響化療藥物的治療效果，而告誡病人不要使用中藥，但他們都不反對使用針灸。就如上所使用的中藥可以肯定地讓病人告訴癌症專家，這些藥物不僅沒有副作用，還能對化療藥物起到增效減毒之功。在與病人和癌症醫生的詳盡溝通下，對化療引起的周圍神經病變採取針藥並用治療，會取得滿意的療效。

作者簡介:

趙軟金,醫學博士,美國執照針灸師。現任美國Sarasota中國傳統中醫中心主任,美國H. Lee Moffitt 癌症中心客座研究員。是北京中醫藥大學第二批臨床特聘專家,河南中醫藥大學海外教授。 學術方面著有英文版《From Legend to Science》並發表論文多篇。

參考文獻

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