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“It is characterized by involuntary tremulous motion, with lessened muscular power

in parts not in action and even when supported. There is a tendency to bend the trunk

forward and to pass from a walking to a running pace. The senses and the intellect

are uninjured”

James Parkinson in “Essay in Shaking Palsy” (1817)

Intro

This literature review intends to explore the aetiology, pathogenesis and management

of Parkinson’s disease (PD) from an eclectic perspective. I intend to balance the main

focus on the Chinese Medical approach with a general overview of the Western

Scientific Medical (WSM) perspective as well as with elements of the other herbal

medical traditions that share common Materia Medica with Chinese Herbal Medicine

(Ayurveda, Kampo, European, Unani-Tibb, Tibetan, etc.).

The review will discuss how the concept of PD its diagnosis and treatment with

Chinese Herbal Medicine, has been classified, questioned, and approached since

Classic Han Dynasty times to the post-cultural revolution ‘Traditional Chinese

Medicine’ (TCM) interpretations and classifications.

This literature review is limited to English language titles from my private library and

the University of Westminster’s library, as well as scientific papers available through

research on search engines like Google Scholar and the InfoLinx database.
Western Medicine:

Definition:

Parkinson’s disease (PD) is a chronic, idiopathic and progressive neurodegenerative

disease of the central nervous system characterized by impaired control of movement

attributable to the death of nerve cells in the Substantia Nigra. This specific area of

the Brain contains the cells responsible for the production of Dopamine - a

neurotransmitter that carries messages from one nerve cell to another (Underwood,

2004).

The Substantia Nigra is connected to the Corpus striatum by the nerve fibers in which

both Dopamine and Acetilcholine act as neurotransmitters. It is the resulting

imbalance of the ratio between these two that characterizes the consequent Signs and

Symptoms: tremor, rigidity, postural instability and bradykinesia. The first two being

due to an increase in acethylcholine and the last two being due to a decrease in

dopamine (Long, 1997).

Aetiology and Pathodevelopment:

Although there is no established definite cause for the loss of the dopamine centers

within the brain, a number of theories have been advanced:

The most common theory points to the possibility of environmental toxins such as

herbicides and pesticides leaching into ground water (Bartrams, 1995; Alexander,

2004) or carbon monoxide poisoning (Flaws & Sionneau, 2001). Closely related to
these, Balch (2000) mentions the inability of the Liver to detoxify, filter and

metabolize these toxins leading to its accumulation in the body.

These theories needs to be critically questioned in the face of mounting evidence that

millennia prior to the appearance of the first environmental industrial toxins, a

strikingly comparable pathology with similar features has been described all over the

ancient world.

It appears in the ancient Indian Four Vedas (Rik-Sama-Yajur-Atharva) as

“Kampavata” (Halpern, 2010) (Manyam, 1990), in the Classical Chinese Medical

texts (Jin Gui Yao Lue ) as “Lily Disease” – Bai He Zheng (Flaws and Lake, 2001), in

the Graeco-Islamic Unani Medical literature as “Shaking Palsy” (Halpern, 2010)

(Bendick, 2002) and in the Tibetan Medical Tantras – the rGyud-bZhi as “Tsakar”,

(Brant-Zawadzki, 2005).

Ancient renown physicians like, Galen in 175 AD (Halpern, 2010), Zhang Zhong Jing

in his Jing Gui Yao Lue (Flaws and Lake, 2001), Dioscorides in the Classic “De

Materia Medica” (Viartis, 2010), Ibn Rush in his “Al-Kulliat fi al Tibb” (Tbakhi and

Amr, 2008), and Ibn Sina in his “Al-Qanun fi al-tibb” (Has, 1991), all seem to have

been acquainted with this pathology and described and proposed treatment strategies.

Other theoretical causes are:

-viral infections of the brain as in the case of encephalitis lethargica might be the

trigger for this degenerative progression Long (1997) and Flaws & Sionneau (2001),

and were until the 70’s considered as the main cause for PD (Brown & Knox,1972),

often connected with influenza as we can observe in the words of Moore (1977):
“Most investigators agree that many if not most cases of Parkinson's disease are a

result of viral infection and that the 1918-19 influenza epidemic is of signifi-

cance. It is not clear, however, whether other neurological viruses also can cause

parkinsonism”.

By the 80’s authors started questioning the validity of the above statements: “…the

evidence obtained is conflicting. More elaborate and detailed research is needed to

elucidate the relations between Parkinsonism and the viruses…” (Irkec, 1982, p.293).

Nowadays the research is directed into these areas:

-genetic mutations in the α -synuclein gene in certain families with an auto-

somal dominant form of PD (Underwood, 2004). Genetics might as well

interact with environmental toxins as in a predisposition turned effective in the

presence of certain chemicals (Alexander, 2004).

-Bartram’s (1995) points to the increase in the disease in patients born during

influenza pandemics.

Oxidative Stress

The significant increase of oxidized products of proteins; lipids and DNA

(Zhang, et al.,1999) together with the decrease of intrinsic antioxidants like

glutathione seem to be abundant in PD patients (Sian et al.,1994). This

imbalance between free-radicals and anti-oxidants apparently triggers

apoptosis in the Substantia Nigra of the brain, dramatically reducing the levels

of the neurotransmitter Dopamine (Alexander, 2004).


Proteolytic Stress

Closely related to the above, some authors point to the impairment of the

normal pathways for the degradation of unwanted or damaged intracellular

proteins leading to its accumulation and binding within the neurons. These

abnormal aggregates of protein are called the Lewy bodies, which are

responsible for the displacement of other cell components damaging and

interfering with the normal functioning of the neurons (McNaught & Olanow,

2003).

Local Inflammmation

Other studies underline the apparent over-presence of inflammatory cells in

the brain areas of neuron loss. These cells – Microglia, are the brain resident

macrophages, which some authors point as having a logical role in the

elimination of dying and dead neurons (Barzilai & Melamed, 2003), while

others understand not their presence as a secondary response but as agents of a

causal relationship, as can be proven by the improvement obtained by the use

of anti-inflammatory substances (Orr et al., 2002).

Based on the review of extensive articles and case-studies some authors (Lees

& Todes, 1985) suggested that certain personality traits like emotional and

attitudinal inflexibility, over-control, anhedonic, suppressed aggression,

absence of affect and a predisposition for depression were frequently found

among PD patients.

From the case-studies arena there is increasing evidence that emotional and

physical traumas are often present in PD patients. As Smith et al., (2002)


refer, stress induced by emotional traumas can be a cause for neuronal loss

and therefore a valid hypothesis as a key factor in the loss of Dopamine

neurons. Within this hypothesis some authors mention that the search for the

initial traumatic trigger should focus between 10 to 20 years before the main

signs were recognized with certainty (Lees, 2004).

Prognosis:

There is no known cure in WSM for PD. The management of this pathology is aimed

at relieving Signs and Symptoms through the intake of drugs designed to correct the

chemical imbalances in the brain (Gascoigne, 2001), delaying the advance of the

disease and supporting the Patient’s independence for as long as it is possible (Balch,

2000).

The disease seems to initially manifest almost imperceptibly with a mild tremor of the

hands while at rest, a general slowness of movement and progresses over the course

of some years to muscular rigidity, changes in muscle tone, drooling, loss of appetite,

tremors, mask like face, impaired speech, disturbance of voluntary movements and

appearance of involuntary movements, insomnia, etc, eventually leading to dementia

and death.

Drugs, side-effects and other considerations:

Gasgoine (2003) includes Parkinson’s drugs in level 2 (taken regularly and there is

little or no threat to life if discontinued.)


In Ayurveda :

In this tradition, PD is called Kampavata (Manyam, 1990) considered a condition

where Ama (pathological fluids, toxins) and Vata (wind) are in excess. It is

Interesting to note that in Chinese pathological terms Ama is Phlegm and Damp, and

Vata is Wind (uncontrolled movement), exactly some of the main pathogenic factors

behind the Chinese medical diagnosis of this Pathology. The main herb used is Kapi

Kachu (Mucuna Pruriens) - velvet bean, a bitter-sweet seed of the fabaceae family

that appears in more than 200 Ayurvedic formulas and is supposed to diminuishes

Kapha and Vata and stabilize Pitta (fire), affecting the nervous and reproductive

systems. It is used in milk decoctions of 250mg to 1gr (milk is considered in

Ayurveda as a “messenger” to the brain). The seeds contain the L-dopa active

principlein the PD drug of choice (Khalsa & Tierra, 2008). These effects have been

confirmed by Morais et al. (2003).

In Tibetan Herbal Medicine:

The foundational text of the Tibetan medical tradition, the rGyud-bZhi or ‘the four

tantras’, identifies a disease known as Tsakar, literally “disease of the white nerves,”

but referred to as “the shaking limb disease” by Tibetan doctors. Tsakar is generally

considered a 'cold disease' arising from a rlung (wind) imbalance (Brant-Zawadzki,

2005).
A formula composed mostly by heavily aromatic substances is used. Some of these

are:

Sandalwood (Tan Xiang) [Santali albi lignum];

Cloves (Ding Xiang) [Caryophylli Flos];

Cinnamon (Gui Zhi) [Cinnamoni ramulus];

Nutmeg (Rou Dou Kou) [Myristicae Semen];

Myrobalan fruit (He Zi ) [Chebulae frucus];

Safflower (Hong Hua) [Carthamus tinctorius];

And different types of cardamons.

From a Chinese Medical perspective we can understand this formula as a recipe for

pathologies specifically related to Cold (as most of those herbs are warm) and Damp

and Phlegm obstruction in the channels which as we will see is a possible pattern in

Chinese medical bianzheng for PD.

Western Herbal Medicine:

In the western herbal medicine field, Central nervous system stimulators like Gotu

Kola (Centella Asiatica) and Gingko (Gingko Biloba) are used in formulas alongside

Tonics like Ginseng (Panax Ginseng/Panax Quinquefolium) and tranquilizers like

Valerian (Valeriana Officinalis). Often added to it we find herbs like Crampbark

(Viburnum Opulus) to reduce cramping and tremors and sporadically we can see

nervine, and spasmolytic herbs like Black Cohosh (Cimifuga Racemosa), Motherwort

(Leonurus Cardiaca), Passionflower (Passiflora incarnata) and Ginger (Zingiber


Officinalis) (Bartram, 1995) (Tierra, 1988) (Flaws and Sionneau, 2001).

In Unani-Tibb Islamic Medicine

A traditional calcination technique of Gold, herbal compounds (Aloe Vera, Dolichus

Uniflorus and Rosa Damascena), other mineral elements (mercury and sulphur) and

two animal products (whey and cow’s urine) called Kushta Tila Kalan is attributed

neuropsychiatric disorders like PD medicinal properties and nervine tonic effects

(Said, 1969). The complex process of purification during the ash preparation is

believed to render it therapeutically effective and safe (Bajaj and Vohora, 2000).

Seems to have therapeutic properties in ischaemic brain damage (Syeda et al.,2004).

1 in every 200 over sixty is affected in US more men than women.

Parkinsionism - The name given to a group of disorders with similar features -- four

primary symptoms (tremor, rigidity, postural instability, and bradykinesia) that are the

result of the loss of dopamine-producing brain cells.

www.alsa.org/resources/glossary.cfm

Bradykinesia - Neurologic condition characterized by a generalized slowness of


motor activity.

Chinese Medicine

震顫性麻痹 (zhèn zhàn xìng má bì)

[convulsions and paralysis]

帕金森病 (pà jīn sēn bìng) [parkinson’s disease]

Historically, PD comes under the pattern differentiation (Bian Zheng) of 震顫性麻痹

(zhèn zhàn xìng má bì) [convulsions and paralysis] which most authors - past and

present relate to Liver-Wind (Maciocia, 1994; Flaws, 1994).

The Compendium of Medicine: "The upgoing qi in the channels and collaterals does

not keep its proper position, thus causing the head to shake and the limbs to tremble"

(Dharmananda, 2004).

The Neijing clearly states that all kinds of wind and dizziness are associated with the

liver and that all kinds of sudden stiffness are associated with wind (Ni, 1995)

Ming Dynasty physician Lou Ying mentioned this connection in 1565 in his Yi Xue

Gang Mu (医學綱目) [Principles of Materia Medica]: “Wind tremors are caused by

wind entering the Liver and the Qi of the Channels rebelling upward causing tics of

the face and tremors of the Limbs” ( cited in Maciocia, 1994, p.657).

In the Han Dynasty the genius Zhang Zhong Jing in the Classic Jin Gui Yao Lue
(Essentials from the Golden Cabinet) describes a disease pattern named Bai He Zheng

(百合症) – Lily disease, where the patient is “…laconic and downcast, they want to

lie down but are unable to lie down; they want to walk but are unable to walk…the

physical appearance is normal, but the pulse is faint and rapid…” (cited in Scheid et

al., 2009). The name is after the herb Bulbus Lilii (Bai He-百合) the main ingredient

in the set of formulas Zhang Zhong Jing prescribes for this pathology (Flaws and

Lake, 2001).

(nao esquecer por wooden face essentials of chronic illness)

Modern authors:

Aetiology:

Most authors (Maciocia, 1994; Flaws & Sionneau, 2001; Xue, 2003) seem to agree

that a combination of overwork, emotional stress, and the wrong diet are at the root

cause of this Pathology.

These authors describe similar pathways in the pathogenesis of PD. Through long-

term overwork, the weakening of the Post Heaven Qi drains from the Pre-Heaven Qi

resources creating deficiency at the root, which often tends to manifest as Kidney-Yin

and Kidney Qi deficiency (Maciocia, 1994; Flaws & Sionneau, 2001; Xue, 2003).

Unable to receive support from the “Mother”, the Liver - the core organ in this

pathology, in its turn, will exhibit the signs of Liver Yin and in cases of Liver Blood

deficiency (Maciocia, 1994). From this Zang Fu pattern a myriad of complications

arise: Yin is no longer able to keep Yang in check and Liver Yang will often rise.

Both the emptiness of Liver Blood and Yin as the Rising of its Yang aspect will stir

up Wind.
From the Dietetic perspective, the regular intake of sweet oily and fried foods along

with amounts of Alcohol will tend to accumulate as Damp. Once the impairment of

the transformative power of the Spleen and Kidney Qi, these untransformed fluids

will accumulate and substantiate as Phlegm.

Emotional problems and stress, acknowledged as an aetiological hypothesis on the

WSM side (Smith et al., 2002; Lees, 2004; Lees & Todes, 1985) seem to add to this

stagnated picture through the impairment of the natural coursing attributable to the

Liver Qi.

This combination of Wind and Phlegm/Damp is in Flaws & Sionneau (2001) opinion

a recipe for congestion and obstruction of the channels leading to tremors and

shaking, especially in a picture of underlying Yin deficiency, as it is the case.

As the sinews are a manifestation of the Liver, a dryness of fluids and blood in the

second will consequently imply a dryness and malnourishment on the first (Maciocia,

1994). In face of these facts becomes clear Xue (2003) statement that PD includes

deficiency at the root overlapped by pathological factors like Phlegm and Wind on

top.

Common Patterns:

Liver Yin deficiency with wind internally stirring (Flaws & Sionneau, 2001);

Liver and Kidney Yin deficiency (Maciocia, 1994)

Liver Qi stagnation, Qi stagnation and Blood Stasis (Flaws & Sionneau, 2001);

Qi and Blood deficiency (Flaws & Sionneau, 2001) (Maciocia, 1994).

Spleen Qi deficiency with dampness, Phlegm-Fire stirring internally (Flaws &


Sionneau, 2001).

Phlegm-heat agitating wind (Maciocia, 1994)

Individual Herbs:

Wu Wei Zi (Schizandra Sinensis)

According to Chang and But (1987), Wu Wei Zi has shown interesting benefits in

small open clinical studies (cited in Bone, 2001, p.72).

Common Formulas used:

Huang (2009) mentions two formulas:

-Chai Hu Jia Long Gu Mu Li Tang (Bupleurum plus Dragon Bone and Oyster Shell

Decoction);

-Zhen Wu Tang (True Warrior Decoction).

The Shanghai TCM University mainly uses Xi Feng Tang (Wind Allaying Decoction)

for cases of Liver Wind and Rou Gan Huo Xue Tang for cases of Liver and Kidney

deficiency with Blood-stasis in the collaterals. According to Neeb (2007), this latter

formulaas used in 48 cases of PD with over 60% of efficacy rate.

Case Studies:

In the collection of western case histories Birch refers a case of Parkinsionism where

a mix of Liver vacuity, Blood stasis, middle and lower burner weaknesses, Qi and

Blood deficiency and a shock were successfully treated with Japanese acupuncture

(MacPherson & Kaptchuk, 1997). Shizue et al., (2006) report a case where the

Kampo medicine Sho-Joki-To-Ka-Shakuyaku provided remarkable effects on 65 year


old patient with PD.

Research

Reviewing the available literature in terms of Chinese Herbs and PD, it is possible to

define 4 main approaches mirroring what happens in other fields where botany,

pharmacology and western scientific medicine interact with traditional medical

systems. These could be presented as:

A) The testing of isolated active principles from the Chinese Materia

Medica - the most common approach in Pharmacology;

Often research assumes the aspect of laboratory experimentation on

animals with extracts taken from the Chinese Materia Medica with the idea

of isolating active principles that manifest positive and interesting

chemical changes in the affected areas of the brain (Van Kampen et al.,

2003) (Chen, et al., 2007)

B) The testing of whole Chinese Herbal Formulas on a constellation of

Signs and Symptoms of PD patients – closer to the spirit of Chinese

Medicine;

Other times research is designed so that specific Chinese Herbal formulas

can be tested and evaluated on the impact they produced in specific Signs

and Symptoms of PD (Yang et al.,2010), (Kum et al., 2009), (Hiyama et

al., 1992), (Iwasaki, et al., 2000), (Li, 2010).


This has been the main option in Kampo research where whole formulas

and not single herbs neither isolated single active principles are tested

against a plethora of signs and symptoms characteristic of PD. Such is the

case of the studies conducted by Dai & Kunio (2001), Ishikawa et al.

(2000); Kaneko et al.(2005), Kawanabe et al.,(2010) and Ueda et al.

(1995).

C) A deductive approach - A synthesis of the above two approaches.

In certain Kampo studies there is a gradual process of deduction from the

formula to the active principle. In Kato et al.(2004), a group of Kampo

formulas are tested in relation to a single enzymatic change. The strongest

formula was chosen. From this formula its individual herbs were singled

out and again tested and analysed to seek the one with the strongest effect.

The next step was the isolation of active principles from this main herb.

D) A combination of western drugs and Chinese Herbal medicine.

Another trend or approach is the combination of Chinese herbal medicine

formulas with Western medical drugs (Cui et al., 2003), (Li, 1995),

(Oikawa, 2004).

Even when whole formulas are used instead of single active principles, rarely there is

an attempt to include a degree of pattern differentiation. Mostly, formulas are


administered to patients regardless of their Bian Zheng. The level of differentiation in

Chinese Medicine can be extremely challenging for the study’s design, therefore

certain studies try to compromise and try to assume a certain level of differentiation in

their patient’s universe as is the case of Oikawa et al.,(2004) who grouped patients

according to generic criterions of health (constipated, not-constipated).

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