Flex (Heat) ^™

CLINICAL APPLICATIONS

* Acute muscle aches and pain with heat manifestations, such as swelling, burning sensation, and inflammation

* Acute re bi (heat painful obstruction), arthritis, arthralgia or gout with redness and swelling

* Fibromyalgia with heat manifestations

* Rheumatic heat disorders

 

WESTERN THERAPEUTIC ACTIONS

* Analgesic function to relieve pain

* Anti-inflammatory effect to reduce inflammation and swelling

* Antirheumatic and antiarthritic functions to treat disorders of the connective tissue such as joints, muscles, bursae, tendons and fibrous tissues

* Immunomodulatory and immunosuppressive properties to treat joint disorders due to autoimmune disease

* Chondroprotective and osteoprotective benefits to strengthen connective tissues and repair joints

 

CHINESE THERAPEUTIC ACTIONS

* Expels wind and heat

* Disperses bi zheng (painful obstruction syndrome)

* Clears damp-heat and reduces swelling

* Alleviates pain

 

DOSAGE

Take 3 to 4 capsules three times daily. Dosage may be increased up to 5 to 6 capsules every four to six hours as needed. For quick and maximum effectiveness, take the herbs on an empty stomach with warm water.

 

INGREDIENTS

Cang Zhu (Rhizoma Atractylodis)

Dang Gui Wei (Extremitas Radix Angelicae Sinensis)

Du Huo (Radix Angelicae Pubescentis)

Fang Ji (Radix Stephaniae Tetrandrae)

Huang Bo (Cortex Phellodendri Chinensis)

Lu Lu Tong (Fructus Liquidambaris)

Luo Shi Teng (Caulis Trachelospermi)

Qiang Huo (Rhizoma et Radix Notopterygii)

Qin Jiao (Radix Gentianae Macrophyllae)

Sang Zhi (Ramulus Mori)

Shi Gao (Gypsum Fibrosum)

Wei Ling Xian (Radix et Rhizoma Clematidis)

Wu Jia Pi (Cortex Acanthopanacis)

Xi Xian Cao (Herba Siegesbeckiae)

Yi Yi Ren (Semen Coicis)

Zhi Mu (Rhizoma Anemarrhenae)

 

BACKGROUND

Musculoskeletal and connective tissue disorders are major causes of pain and physical disability. Causes of these bone, muscle and joint disorders vary greatly, depending on the exact disease. Simple causes include trauma and external injuries, such as pulled muscles, strained ligaments, dislocated joints and bone fractures. Complicated causes include infection, autoimmune disorders, crystal-induced inflammation, and non-inflammatory tissue degeneration. Optimal treatment must address the symptoms (pain and inflammation) and the underlying causes. After the disorder is stabilized, physical therapy and exercise are important to maintain flexibility and strengthen surrounding muscles.

 

FORMULA EXPLANATION

Flex (Heat) is formulated specifically to treat musculoskeletal disorders characterized by heat. It contains herbs with functions to eliminate wind, heat and dampness, remove painful obstructions, and relieve pain.

        Cang Zhu (Rhizoma Atractylodis) dries dampness and Huang Bo (Cortex Phellodendri Chinensis) clears damp-heat in the lower parts of the body. These two herbs have an excellent effect to treat pain in the lower half of the body, as in the classic formula Er Miao San (Two-Marvel Powder). Qiang Huo (Rhizoma et Radix Notopterygii), Du Huo (Radix Angelicae Pubescentis), and Sang Zhi (Ramulus Mori) have antirheumatic, anti-inflammatory, and analgesic functions. They remove painful obstruction by expelling wind, damp, and heat in the upper and lower body. Shi Gao (Gypsum Fibrosum) and Zhi Mu (Rhizoma Anemarrhenae) have anti-inflammatory functions to clear heat and reduce painful swelling sensation of the joints. Yi Yi Ren (Semen Coicis) and Fang Ji (Radix Stephaniae Tetrandrae) are diuretics that reduce swelling of the joints. Wei Ling Xian (Radix et Rhizoma Clematidis), Luo Shi Teng (Caulis Trachelospermi) and Dang Gui Wei (Extremitas Radix Angelicae Sinensis) have antirheumatic and blood-invigorating effects to clear the channels and collaterals and enhance the flexibility and integrity of the joints. Xi Xian Cao (Herba Siegesbeckiae), Lu Lu Tong (Fructus Liquidambaris), and Qin Jiao (Radix Gentianae Macrophyllae) dredge the channels and scour residual blood stagnation. They are often used in wind disorders including paralysis or hemiplegia. Wu Jia Pi (Cortex Acanthopanacis) strengthens sinews and bones and helps relieve chronic pain.

        In summary, the herbs in Flex (Heat) eliminate wind, heat and dampness to treat various types of musculoskeletal and connective tissue disorders.

 

CAUTIONS & CONTRAINDICATIONS

* This formula is contraindicated during pregnancy and nursing.

* This herbal formula contains herbs that invigorate blood circulation, such as Dang Gui Wei (Extremitas Radix Angelicae Sinensis). Therefore, patients who are on anticoagulant or antiplatelet therapies, such as Coumadin (warfarin), should use this formula with caution, or not at all, as there may be a higher risk of bleeding and bruising.[1]^,[2],[3]

 

CLINICAL NOTES

* Flex (Heat) can be combined with Flex (TMX) in the early stages of sports injuries when there is severe pain with inflammation, swelling, and redness. Begin treating the patient immediately for maximum effectiveness.

* Internal hemorrhage must be ruled out first prior to treating patients with head injuries.

* The use of ice packs is recommended to reduce redness, swelling, and inflammation.

* Heat packs should not be used in patients with joint pain due to heat.

 

Pulse Diagnosis by Dr. Jimmy Wei-Yen Chang:

* Knee and ankle joint arthritis: left yangwei pulse, which is an extra meridian pulse found distal to the cun position towards the thumb

* Damp-heat accumulation: deep and forceful pulse

* Rheumatoid arthritis with excess heat: deep and forceful pulse on both chi. Left yangwei pulse is fast and forceful.

 

SUPPLEMENTARY FORMULAS

* To potentiate the effect to relieve pain, add Herbal ANG.

* With severe inflammation, combine with Astringent Complex.

* With excess heat, add Gardenia Complex.

* For severe pain with blood stagnation, add Circulation (SJ).

* For gout, use Flex (GT) instead.

* For neck and shoulder pain, add Neck & Shoulder (AC) or Neck & Shoulder (CR).

* For lower back pain, add Back Support (AC) or Back Support (CR).

* For herniated disk in the back with swelling and inflammation, add Back Support (HD).

* For knee pain, add Knee & Ankle (AC) or Knee & Ankle (CR).

* For spasms and cramps, combine with Flex (SC).

* For bone fractures, injuries, and bruises, combine with Flex (TMX).

* For bone spurs, add Flex (SPR).

* For post-stroke numbness and atrophy, use Neuro Plus.

* For osteoporosis, add Osteo 8.

* For degeneration of muscles, ligaments, and tendons, add Flex (MLT).

* For arthritic pain that worsens during cold and rainy weather, use Flex (CD) instead of Flex (Heat).

 

ACUPUNCTURE TREATMENT

Traditional Points:

* Needle ah shi points.

* Taichong (LR 3), Xingjian (LR 2), Zusanli (ST 36), Geshu (BL 17)

 

Classic Master Tung's Points:

* Needle contralateral to the pain. If the pain is in the center, needle bilaterally or the side with the more ah shi points. If the pain is bilateral, needle bilaterally.

* General arthritis: Tianhuang (T 88.13), Minghuang (T 88.12), Fugesan (T 44.30)*, Simazhong (T 88.17), Dihuang (T 77.19), Jianzhong (T 44.06), Wuhu (T 11.27). Bleed the affected area.

* Arthritis (legs): Minghuang (T 88.12), Tianhuang (T 88.13), Qihuang (T 88.14), Zhongjiuli (T 88.25), Jianzhong (T 44.06), Wuhu (T 11.27). Bleed dark veins on the legs. Bleed before needling for best result.

* Arthritis (degenerative): Wanshunyi (T 22.08), Wanshuner (T 22.09), Simashang (T 88.18), Minghuang (T 88.12), Tianhuangfu [Shenguan] (T 77.18), Wuhu (T 11.27). Bleed the affected area.

 

Master Tung¡¦s Points by Dr. Chuan-Min Wang:

* Hot bi zheng (painful obstruction syndrome), arthritis, fibromyalgia, rheumatic heat disorders

¡± Shoulder: Bleed Chize (LU 5) or Quchi (LI 11) area. Needle contralaterally Tianhuangfu [shenguan] (T 77.18), Sizhi (T 77.20).

¡± Elbow: Bleed Quchi (LI 11) area. Needle contralaterally Renzong (T 44.08).

¡± Wrist: Bleed Shuiyu (T 44.17) area. Needle contralaterally Tung¡¦s Wantong (T 66.16)*.

¡± Knee: Bleed popliteal fossa or fibula head area. Needle contralaterally Chongzi (T 22.01), Chongxian (T 22.02).

¡± Ankle: Bleed Xuanzhong (GB 39) area. Needle contralaterally Zhongbai (T 22.06), Xiabai (T 22.07), Wuhu 4, 5 (T 11.27).

¡± Finger: Bleed tips of the fingers. Needle contralaterally Wuhu 1, 2 (T 11.27).

 

Balance Method by Dr. Richard Tan:

* Use Dr. Tan¡¦s Balance Method accordingly as determined by where the pain is (use mirror or image system).

 

Ear Acupuncture:

* Related joints, Adrenal Glands

* Embed magnetic ear balls and switch ears every three days.

 

Auricular Medicine by Dr. Li-Chun Huang:

* Rheumatic arthritis: Spleen, Liver, Kidney, San Jiao, Allergic Area, Endocrine, Adrenal Gland, and corresponding points to the affected area. Bleed Ear Apex.

 

NUTRITION

* Sulfur helps the absorption of calcium, and adequate intake and absorption of calcium is essential for the repair and the rebuilding of bones, tendons, cartilage, and connective tissues. Patients are encouraged to consume foods high in sulfur such as asparagus, eggs, fresh garlic, and onions.

* Histidine, an amino acid, is responsible for removing the high levels of copper and iron found in arthritic patients. Patients are encouraged to consume foods high in histidine such as rice, wheat and rye.

* Fresh pineapples are recommended as they contain bromelain, an enzyme that is excellent in reducing inflammation.

* Increase intake of nourishing, cooling foods/roots such as Mexican yam, yam, radishes, potatoes, carrots, melons, cucumbers, beets, turnips, malanga, celeriac, taro, and rutabaga.

* Avoid spicy food, caffeine, citrus fruits, sugar, milk, dairy products, and red meat.

* Fish oil may help to alleviate pain associated with rheumatoid arthritis. It can be taken in conjunction with the herbs.

* Decrease the intake of sour foods, drinks or fruits (citrus) as their nature constricts and may contribute to further stagnation in the channels and collaterals.

* Avoid spicy/pungent/aromatic vegetables such as pepper, garlic, onions, basil, rosemary, cumin, funnel, anise, leeks, chives, scallions, thyme, saffron, wormwood, mustard, chili pepper, and wasabi.

 

The Tao of Nutrition by Dr. Maoshing Ni and Cathy McNease:

* Recommendations: plenty of fresh fruits and vegetables, dandelion, cabbage, mung beans, winter melon, and soybean sprouts.

* Apply poultices of crushed dandelion greens, changing every two hours.

* Avoid spicy foods, green onions, alcohol, smoking and all types of stress.

 

LIFESTYLE INSTRUCTIONS

* For obese patients, weight loss is suggested as it lessens the pressure on the joints, which can then help in relieving pain.

 

CASE STUDIES

* An 85-year-old female patient presented with severe pain in her right toe, with difficulty walking. Blood pressure was 140/90 mmHg with heart rate of 76 beats per minute. The TCM diagnosis was damp-heat arthritis; Western diagnosis was uric acid build up. Flex (Heat) was prescribed at 4 capsules three times a day for two weeks. The patient reported improvement after a few days and continued taking the remainder of the herbs. Additional treatment included applying Zheng Gu Shui (literally, rectify bones liquid) to the big toe area, drinking distilled water and pure cherry juice, and refraining from drinking alcoholic beverages. Submitted by L.W., Arroyo Grande, California.

* E.K., a 54-year-old female, presented with severe, burning, sacral pain. MRI evaluation revealed a bulging lumbar disk. The patient stated she had previously been managing her chronic low back pain but that this was the first time she had had the burning sensation. The TCM diagnosis was heat in the lower jiao. The patient reported that taking Flex (Heat) at four capsules, four times daily, took away the burning sensation but did not completely resolve the pain. She then used this formula from time to time, when the burning sensation came back. Submitted by M.C., Sarasota, Florida.

* A female broker presented with pain, heat and swelling in her joints that would flare-up and subside intermittently. Limited range of motion was also present along with joint rigidity. The pain and swelling were felt especially in the fourth finger bilaterally and occasionally on either ankles. There was a butterfly rash (yin deficiency) on her face. Other symptoms included hot flashes and night sweats. The practitioner diagnosed the condition as bi zheng (painful obstruction syndrome) due to wind-damp-heat with underlying Kidney yin deficiency. The patient was given Flex (Heat) to treat the pain, and Zhi Bai Di Huang Wan (Anemarrhena Phellodendron and Rehmannia Formula) to nourish yin. The patient had been treated with various medications previously and found that Flex (Heat) produced the best results. Past treatments for her condition also showed diminished efficacy after a period of four to six months. With Flex (Heat) she was able to continue treatment for almost a year while still maintaining its therapeutic value. The practitioners noted that Flex (Heat) was a very effective formula for inflammatory joint conditions. Submitted by T.W., Santa Monica, California.

 

PHARMACOLOGICAL AND CLINICAL RESEARCH

Flex (Heat) treats musculoskeletal and connective tissue disorders with heat manifestations. Flex (Heat) contains herbs with multiple therapeutic functions: analgesic, anti-inflammatory, antirheumatic, immunomodulatory, chondroprotective and osteogenic functions.

        Flex (Heat) contains many herbs with analgesic effects to relieve pain and anti-inflammatory effects to reduce swelling and inflammation. Pharmacologically, Zhi Mu (Rhizoma Anemarrhenae) shows significant anti-inflammatory action by inhibiting cyclo-oxygenase-2, inducible nitric oxide synthase and 5-lipoxygenase.[4] Huang Bo (Cortex Phellodendri Chinensis) has a marked effect to reduce inflammation by inhibiting the production of proinflammatory cytokines, including interleukin-1beta and tumor necrosis factor-alpha (TNF-£\), in a dose-dependent manner.[5] Qiang Huo (Rhizoma et Radix Notopterygii) has an analgesic effect to relieve muscle aches and pain.[6] It also has an anti-inflammatory effect to reduce swelling and inflammation. The mechanism is attributed to the inhibition of 5-lipoxygenase and cyclo-oxygenase.[7] Dang Gui (Radix Angelicae Sinensis) exerts both analgesic and anti-inflammatory effects through the inhibition of pro-inflammatory mediators, including nitric oxide and prostaglandin E2 in peritoneal macrophages.[8]^,[9] In comparison with acetylsalicylic acid, the anti-inflammatory effect of Dang Gui (Radix Angelicae Sinensis) is approximately 1.1 times stronger, and its analgesic effect is approximately 1.7 times stronger.[10] Xi Xian Cao (Herba Siegesbeckiae) has both analgesic and anti-inflammatory effects. It reduces swelling and inflammation through significant inhibition of the productions of nitric oxide, prostaglandin E(2), TNF-£\ and cyclo-oxygenase-2.[11]^,[12] Clinically, Zhi Mu (Rhizoma Anemarrhenae) exhibits significant analgesic and anti-inflammatory effects for the treatment of osteoarthritis. According to one clinical study, Zhi Mu (Rhizoma Anemarrhenae) is used in one formula to successfully treat 56 patients with acute onset of rheumatism with 71.4% effectiveness.[13]

        In addition to relieving pain and reducing inflammation, Flex (Heat) utilizes many herbs with antirheumatic, antiarthritic, immunosuppressive and immunomodulatory effects to treat more complicated inflammatory disorders. Fang Ji (Radix Stephaniae Tetrandrae) has antirheumatic and immunomodulatory effects to reduce and treat collagen-induced arthritis in vivo.[14] According to a recent human study, administration of Fang Ji (Radix Stephaniae Tetrandrae) for 12 weeks is beneficial for treatment of rheumatoid arthritis through its suppressive effect on excessive granulocyte activation and subsequent reduction of inflammation.[15] Wei Ling Xian (Radix et Rhizoma Clematidis) has marked antiarthritic activity, as the herb significantly inhibited proinflammatory compounds and prevented rheumatoid arthritis.[16] Lastly, Xi Xian Cao (Herba Siegesbeckiae) has an immunosuppressive effect to inhibit both cellular and humoral immunities and may help to treat joint disorder due to autoimmune disease. [17]

        In addition to using herbs with analgesic and anti-inflammatory effects, Flex (Heat) contains herbs to treat gout. According to a study in subjects with artificially-induced gout, administration of Huang Bo (Cortex Phellodendri Chinensis) reduced serum uric acid levels and inhibited activities of liver xanthine oxidase for the treatment of gout.[18]

        Lastly, chronic musculoskeletal and connective tissue disorders are often associated with wear and tear of the joints; therefore, Flex (Heat) incorporates herbs to repair cartilages and rebuild bones. Wei Ling Xian (Radix et Rhizoma Clematidis) has an excellent chondroprotective effect. One study showed that the saponin fraction from Wei Ling Xian (Radix et Rhizoma Clematidis) is effective in ameliorating joint destruction and cartilage erosion in subjects with osteoarthritis, protecting articular cartilage by preventing extracellular matrix degradation and chondrocyte injury.[19] Xi Xian Cao (Herba Siegesbeckiae) has a marked effect to protect the cartilages in collagenase-induced osteoarthritis. This herb contributes to a significant increase in proteoglycan, aggrecan, and type II collagen expression.[20] Dang Gui (Radix Angelicae Sinensis) is an effective herb to promote the generation of bones. According to one study, the water extract of Dang Gui (Radix Angelicae Sinensis) has been found to contribute to the formation of bones and treatment of bone injuries. It directly stimulates the proliferation, alkaline phosphatase activity, protein secretion and particularly type I collagen synthesis of human osteoprecursor cells in a dose-dependent manner.[21] Zhi Mu (Rhizoma Anemarrhenae) has an osteoprotective effect. According to a study in subjects with ovariectomy-induced bone loss, administration of steroidal saponins from Zhi Mu (Rhizoma Anemarrhenae) suppresses the atrophy of the uterus and descent of bone mineral density, corrects the decreased concentration of calcium and E(2) in serum, without altering the number of osteoclasts. The researchers conclude that Zhi Mu (Rhizoma Anemarrhenae) is effective to prevent bone loss through the promotion of bone formation but not the inhibition of bone resorption.[22]

        In summary, Flex (Heat) is an empirical herbal formula with excellent function to treat musculoskeletal and joint disorders characterized by heat.

 

COMPARATIVE ANALYSIS

Pain is a basic bodily sensation induced by a noxious stimulus that causes physical discomfort (such as pricking, throbbing, or aching). Pain may be of acute or chronic state, and may be of nociceptive, neuropathic, or psychogenic origin.

        Non-steroidal anti-inflammatory agents (NSAID), such as Motrin (ibuprofen), Naprosyn (naproxen) and Voltaren (diclofenac) are very frequently used to treat mild to moderate pain characterized by inflammation and swelling. Clinical applications include headache, arthritis, dysmenorrhea, and general aches and pain. Though effective, they may cause such serious side effects as gastric ulcer, duodenal ulcer, gastrointestinal bleeding, tinnitus, blurred vision, dizziness and headache. Furthermore, the newer NSAIDs, also known as COX-2 inhibitors [such as Celebrex (celecoxib)], are associated with significantly higher risk of cardiovascular events, including heart attack and stroke. In fact, these side effects are so serious that two COX-2 inhibitors have already been withdrawn from the market [Vioxx (rofecoxib) and Bextra (valdecoxib)]. In brief, it is important to remember that while drugs offer reliable and potent symptomatic pain relief, they should only be used if and when needed. Frequent use and abuse leads to unnecessary side effects and complications.

        Treatment of pain is a sophisticated balance of art and science. Proper treatment of pain requires a careful evaluation of the type of disharmony (excess or deficiency, cold or heat, exterior or interior), characteristics (qi and/or blood stagnations), and location (upper body, lower body, extremities, or internal organs). Furthermore, optimal treatment requires integrative use of herbs, acupuncture and tui-na therapies. All these therapies work together to tonify the underlying deficiencies, strengthen the body, and facilitate recovery from chronic pain. TCM pain management targets both the symptoms and the causes of pain, and as such, often achieves immediate and long-term success. Furthermore, TCM pain management is often associated with few or no side effects.

        For treatment of mild to severe pain due to various causes, TCM pain management offers similar treatment effects with significantly fewer side effects.