Online Submissions: http://www.journaltcm.
com J Tradit Chin Med 2017 October 15; 37(5): 688-694
info@journaltcm.com
Traditional Chinese Medicine symptom pattern analysis for Parkin-
son's disease
Chen Hongzhi, He Jiancheng, Teng Long, Yuan Canxing, Zhang Zhe
aa
Chen Hongzhi, College of Basic Medicine, Shandong Uni-
versity of Traditional Chinese Medicine, Jinan 250355, China;
College of Basic Medicine, Shanghai University of Traditional
Chinese Medicine, Shanghai 201230, China
Zhang Zhe, College of Foreign Language, Shandong Univer-
sity of Traditional Chinese Medicine, Jinan 250355, China
He Jiancheng, Teng Long, Yuan Canxing, College of Basic
Medicine, Shanghai University of Traditional Chinese Medi-
cine, Shanghai 201230, China
Supported by Surface Project of National Natural Science
Foundation of China, "TCM Compound Rehmannia Formula
Regulating Basal Ganglia Loop to Treat Parkinson's Disease"
(No. 30973722); Surface Project of National Natural Science
Foundation of China "Mechanism of TCM Compound Rehm-
annia Granule Regulating MAPK/ERK Signaling Pathway in
Parkinson's Disease" (No. 81573899); Shanghai TCM Re-
search and Technology Support Project "Development of
TCM Compound Rehmannia Granule Treating Parkinson's
Disease" (No. 12401900302); Shanghai TCM Research and
Technology Support Project "Toxicological Research on TCM
Compound Rehmannia Granules Treating Parkinson's Dis-
ease" (No. 16401902400); Shanghai Municipal Health Bu-
reau Scientific Research Project "Based on the Neural Plastic-
ity Compound Rehmannia Treating Parkinson's Disease"
(No. 2012J009A)
Correspondence to: Prof. He Jiancheng, College of Basic
Medicine, Shanghai University of Traditional Chinese Medi-
cine, Shanghai 201203, China. hejc8163@163.com
Telephone: +86-21-51322142
Accepted: November 17, 2016
Abstract
OBJECTIVE: To use the theory of Traditional Chi-
nese Medicine to identify the major symptom pat-
terns of Parkinson's disease.
METHODS: Journal databases were searched for
relevant articles in the last 30 years. Articles were re-
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ISSN 0255-2922
© 2017 JTCM. This is an open access article under the CC BY-NC-ND license.
RESEARCH ARTICLE
TOPIC
viewed for symptom patterns of Parkinson's dis-
ease and analyzed using frequency analysis, cluster
analysis, and other methods of data extraction.
RESULTS: The analyses indicated that the most fre-
quent symptom patterns of Parkinson's disease are
Yin deficiency of kidney and liver, deficiency of Qi
and blood, phlegm heat and wind stirring, blood
stasis and wind stirring, and deficiency of Yin and
Yang.
CONCLUSION: Taken together, the analyses identi-
fied the primary symptom patterns of Parkinson's
disease as Yin deficiency of kidney and liver, defi-
ciency of Qi and blood, phlegm heat and wind stir-
ring, and blood stasis and wind stirring.
© 2017 JTCM. This is an open access article under the
CC BY-NC-ND license.
Keywords: Parkinson disease; Symptom complex;
Cluster analysis; Data extraction
INTRODUCTION
Parkinson's disease (PD) is a degenerative disorder of
the central nervous system characterized by shaking, ri-
gidity, slowness of movement, and gait disturbance.
PD mainly affects middle-aged and elderly individuals.
As the population ages, PD incidence is increasing and
it is the major cause of impairment in middle-aged and
elderly people. Patients with PD can experience sub-
stantial suffering and deterioration in quality of life.
Traditional Chinese Medicine (TCM) treats PD ac-
cording to symptom patterns, using TCM theory to
identify patterns and relieve symptoms, interfere with
disease development, counteract the side effects of
chemical drugs, and improve patient quality of life.1
Many researchers have investigated PD symptom pat-
terns theoretically, experimentally, and clinically. By
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 Chen HZ et al. / Research Article
collecting, standardizing, and summarizing ancient and
modern literature, researchers can examine the trends
and directions of PD research and provide a firm basis
for further clinical and experimental study.
This study aimed to use TCM theory to identify the
major symptom patterns of PD to provide better guid-
ance for PD treatment in TCM practice.
METHODS
Diagnostic standards
We followed the standards for PD diagnosis of the Na-
tional Extrapyramidal Diseases Symposium,2,3 the Chi-
nese Society of Neurology, and the Chinese Medical As-
sociation.
Inclusion criteria
We included articles with definite PD pattern classifica-
tions, whether or not they mentioned symptoms/signs,
treatments, and medicines.
Exclusion criteria
We excluded (a) single case reports, (b) literature re-
views, (c) re-published research papers and re-cited lit-
erature and (d) other studies that failed to meet the in-
clusion criteria.
Literature retrieval
Articles were obtained from China Knowledge Re-
source Integrated Database (CNKI), China Science
and Technology Journal Database (VIP) Journal Inte-
gration Platfrom (VJIP), and China Biology Medicine
disc (CBMdisc).
We used computer-aided and manual retrieval. The Re-
trieval formats were as follow: (a) Format of CNKI
(keywords): Parkinson's disease (paralysis agitans) and
pattern (pattern, pattern differentiation); duration:
1911-1979, 1980-2012. This produced 816 papers.
(b) Format of VJIP (keywords): Parkinson's disease (pa-
ralysis agitans)* pattern (pattern, pattern differentia-
tion); duration: 1989-2011. This produced 131 pa-
pers. (c) Format of CBMdisc (keywords): Parkinson's
disease (paralysis agitans) * pattern (pattern, pattern dif-
ferentiation); duration: 1978-2012. This produced 285
papers. In total, we retrieved 1232 papers.
Evaluating and screening
The title, author, journal name/year/issue of the re-
trieved papers were imported into Excel software (Mi-
crosoft Corp., Redmond, WA, USA) to determine the
relevant papers. When there were several similar re-
search papers, only one paper was included. The title
and abstract of each paper were read to exclude non-rel-
evant papers, based on the inclusion and exclusion cri-
teria. There were 129, 14, and 14 relevant research pa-
pers from the CNKI, VJIP, and CBMdisc databases, re-
spectively (total = 157). After the preliminary screen-
ing, the full text of each paper was read. Non-full text
papers in paper version were retrieved in the library
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and were read for further screening. There were 67, 6,
and 5 relevant research papers from the CNKI, VJIP,
and CBMdisc databases, respectively (total = 78).
Data standardization
Standardization of patterns terms was based on TCM
Terms.4 Terms not in TCM Terms were classified ac-
cording to the Standard of TCM Pattern5 and TCM
Diagnosis.6 For example, deficiency of liver and kidney,
insufficiency of liver and kidney, asthenia of liver and
kidney, and Yin deficiency of liver and kidney were all
standardized as Yin deficiency of liver and kidney.
There was one term that we were unable to classify and
this term was reserved.
Standardization of symptom terms was based on TCM
Terms4 and TCM Diagnosis.6 Some symptoms were
separated before classification; for example, circumgyra-
tion was separated into vertigo and dizziness; tongue
coating and pulse were further divided into the small-
est units (e.g., yellow and greasy tongue coating was di-
vided into yellow tongue coating and greasy tongue
coating, and thin and rapid pulse was divided into thin
pulse and rapid pulse). Symptoms with similar mean-
ings were combined into one classification (e.g., poor
sleep, disturbed sleep, and bad sleep were all standard-
ized as insomnia).
Statistical analysis
SPSS 17.0 software, version 17.0 (SPSS Inc. Chicago,
IL, USA) was used to conduct frequency and descrip-
tive statistical analyses on the symptom and diagnoses
data. Data for the four diagnostic information were
processed for cluster analysis and based on TCM
knowledge to summarize the diagnostic protocol of
common patterns in PD patients.
RESULTS
TCM symptom patterns in PD patients
The 78 research papers contained 293 records of pat-
terns; there were 185 original patterns and 79 standard-
ized patterns (with additional accompanying patterns).
Thirty-six patterns were selected more than twice, and
the accompanying patterns were divided into 29 stan-
dardized patterns. The total number of patterns was
277; Table 1 shows the six patterns with the highest fre-
quency.
Data analysis of symptoms
The 78 research papers contained 50 papers and 193
records involving TCM symptoms. After analysis of
the symptoms, there were 147 symptoms and 2652
pieces of information on the four diagnoses. There
were 61 symptoms and 2306 pieces of information
that occurred more than 10 times (Table 2).
There were 86 symptoms that occurred less than 10
times, including Qi deficiency, tiredness of speech,
mouth bitterness, sluggish speech, night sweats, and
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 Chen HZ et al. / Research Article
Table 1 Most frequent symptom patterns
No. Pattern Frequency
1 Yin deficiency of liver and kidney 53
2 Deficiency of Qi and blood 52
3 Phlegm heat and wind stirring 32
4 Blood stasis and wind stirring 21
5 Qi stagnation and blood stasis 15
6 deficiency of Yin and Yang 10
yellow expectoration. These were not included in the
research.
The 61 symptoms with an accumulated frequency of
2360 accounted for 88.99% of the symptoms men-
tioned in the articles. Table 2 shows that of the 61
symptoms (except tongue and pulse symptoms), the
three most frequent symptoms were tremor (6.18% ),
vertigo (4.00% ), and dizziness (2.41% ). The three
symptoms with the lowest frequency (except tongue
and pulse symptoms) were abdominal distension
(0.45% ), dark urine (0.41% ), and bad temper
(0.38%). There were 14 tongue-related symptoms. The
three most frequent were red tongue (3.17% ), dark
tongue (2.60% ), and pale tongue (2.19% ); the three
symptoms with the lowest frequency were purple
tongue (0.79% ), thin tongue (0.64% ), and blue and
purple sublingual vessel (0.41% ). There were seven
pulse-related symptoms. The three most frequent were
thin pulse (4.75% ), stringy pulse (3.51% ), and rapid
pulse (1.89%); the three symptoms with the lowest fre-
quency were slippery pulse (1.51% ), choppy pulse
(1.06%), and weak pulse (0.72%).
Data extraction-cluster analysis
We used hierarchical cluster analysis to summarize and
classify the symptoms and then (based on TCM
knowledge) identified TCM patterns. A be-
tween-groups linkage cluster analysis was used. Pear-
son correlations were used to determine the correla-
tion matrix for the cluster analysis (the correlation
matrix indicates the similarities between variables;
larger correlation coefficients indicate greater correla-
tion between variables) to classify the data. During
the cluster analysis, TCM knowledge was used to de-
termine the number of clusters.
Cluster analysis results. The cluster analysis produced
3-6 groups (Table 3). After TCM analysis, four groups
were extracted based on clinical practice.
Group 1: tremor, slowness of movement, dementia,
head tremor, sputum expectoration, epigastric oppres-
sion, drooling, dark urine, dry stool, thirst, yellow
tongue coating, slippery pulse, rapid pulse.
Group 2: stiff limbs, movement disorder, soreness and
weakness of back and knees, feverish sensation in the
five centers, tinnitus, insomnia, dreaminess, amnesia,
emaciation, bad temper, thin tongue, red tongue, little
tongue coating, stringy pulse.
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Frequent percentage (%) Accumulated frequent percentage (%)
19.13 19.13
18.77 37.91
11.55 49.46
7.58 57.04
5.42 62.45
3.61 66.06
Group 3: spasm of limbs, limb pain, limb numbness,
gait disturbance, stiff neck, headache, dark complex-
ion, dark tongue, purple tongue, blue and purple sub-
lingual vessel, ecchymosis on the tongue, choppy pulse.
Group 4: dyspnea, listlessness, lassitude, vertigo, dizzi-
ness, palpitations, lusterless complexion, spontaneous
sweating, abdominal distension, poor appetite, aver-
sion to cold, loose stool, puffy tongue, pale tongue,
tongue with teeth marks, thin tongue coating, white
tongue coating, thin pulse, deep pulse, and weak pulse.
Patterns derived from the cluster analysis. According to
TCM diagnosis and pattern identification, each cluster
was identified as one pattern. Each pattern could ac-
count for at least 80% of the related symptoms. There
were four patterns: phlegm heat and wind stirring, Yin
deficiency of liver and kidney, blood stasis and wind
stirring, and deficiency of Qi and blood. The results of
the cluster analysis conformed to the clinical pattern
identification.
DISCUSSION
TCM contains no term for PD, but classifies it accord-
ing to its character and clinical manifestations. In
TCM, PD corresponds to Chan Zheng (tremor), Chan
Zhen (shaking), and Dong Feng (wind stirring). TCM
treatment of PD is based on a long history of pattern
identification. In addition, many modern TCM ex-
perts have developed treatments for PD and have ad-
vanced the study of PD patterns.
PD pattern nomenclature
In the TCM classics, records of PD consist mainly of
descriptions of symptoms, such as Diao, Diao Xuan,
and Qiang Zhi. In Huang Di Nei Jing,7 there are re-
cords of tremor, stiffness, spasm of the four limbs, slow-
ness of movement, gait disturbance, and other symp-
toms of PD. The Su Wen Zhi Zhen Yao Da Lun8 states
that all stiffness pertains to the wind, all wind and verti-
go symptoms pertain to the liver, and all cold and
spasm symptoms pertain to the kidney. The symptoms
of stiffness, tremor, and spasm mentioned in the classi-
cal texts are similar to the symptoms of PD. The Su
Wen Mai Yao Jing Wei Lun9 states that the head is the
house of the eyes, and when the head leans, the spirit
will disappear; the back is the house of the chest, and
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 Table 2 Most frequently occurring symptoms
Frequent Accumulated Frequent Accumulated
No. Symptom Frequency percentage frequent No. Symptom Frequency percentage frequent
(%) percentage (%) (%) percentage (%)
1 Tremor 164 6.18 6.18 32 Dry stool 32 1.21 68.06
2 Thin pulse 126 4.75 10.94 33 Tongue with teeth mark 30 1.13 69.19
3 Vertigo 106 4.00 14.93 34 head tremor 29 1.09 70.29
4 Stringy pulse 93 3.51 18.44 35 Choppy pulse 28 1.06 71.34
5 Red tongue 84 3.17 21.61 36 Amnesia 26 0.98 72.32

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6 Dark tongue 69 2.60 24.21 37 Lassitude 26 0.98 73.30
7 Dizziness 64 2.41 26.62 38 Epigastric oppression 24 0.90 74.21
8 Pale tongue 58 2.19 28.81 39 Aversion to cold 23 0.87 75.08
9 Stiff limbs 57 2.15 30.96 40 Stiff neck 23 0.87 75.94
10 Spasm of limbs 55 2.07 33.03 41 Spontaneous sweating 23 0.87 76.81
11 White tongue coating 54 2.04 35.07 42 Slowness of movement 22 0.83 77.64
12 Soreness and weakness of back and knees 51 1.92 36.99 43 Feverish sensation in the five centers 21 0.79 78.43
13 Rapid pulse 50 1.89 38.88 44 Purple tongue 21 0.79 79.22
14 Insomnia 49 1.85 40.72 45 Headache 19 0.72 79.94

691
15 Puffy tongue 48 1.81 42.53 46 Weak pulse 19 0.72 80.66
16 Lassitude 47 1.77 44.31 47 Dark complexion 18 0.68 81.33
17 Yellow tongue coating 46 1.73 46.04 48 Sputum expectoration 18 0.68 82.01
18 Greasy tongue coating 46 1.73 47.78 49 Pale complexion 17 0.64 82.65
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19 Thin tongue coating 45 1.70 49.47 50 Thin tongue 17 0.64 83.30

20 Tinnitus 44 1.66 51.13 51 Limb pain 16 0.60 83.90
21 Ecchymosis on the tongue 44 1.66 52.79 52 Emaciation 16 0.60 84.50
22 Deep pulse 44 1.66 54.45 53 Lusterless complexion 16 0.60 85.11
23 Dementia 40 1.51 55.96 54 Drooling 16 0.60 85.71
24 Little tongue coating 40 1.51 57.47 55 Loose stool 16 0.60 86.31
25 Slippery pulse 40 1.51 58.97 56 Palpitation 14 0.53 86.84
26 Limb numbness 39 1.47 60.44 57 Dyspnea 13 0.49 87.33
27 Movement disorder 37 1.40 61.84 58 Abdominal distension 12 0.45 87.78
28 Thirst 35 1.32 63.16 59 Dark urine 11 0.41 88.20
29 Gait disturbance 33 1.24 64.40 60 Blue and purple sublingual vessel 11 0.41 88.61
30 Poor appetite 33 1.24 65.6 61 Bad temper 10 0.38 88.99
31 Dreaminess 32 1.21 66.86

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Table 3 Results of the cluster analysis of symptoms from the literature (n)
Symptom 6 Clusters 5 Clusters 4 Clusters 3 Clusters
Tremor 1 1 1 1
Stiff limbs 2 2 2 1
Spasm of limbs 3 3 3 2
Limb pain 3 3 3 2
Limb numbness 3 3 3 2
Movement disorder 2 2 2 1
Slowness of movement 4 4 1 1
Gait disturbance 5 3 3 2
Dementia 4 4 1 1
Aversion to cold 6 5 4 3
Soreness and weakness of back and knees 2 2 2 1
Stiff neck 5 3 3 2
Head tremor 1 1 1 1
Headache 5 3 3 2
Vertigo 6 5 4 3
Dizziness 6 5 4 3
Tinnitus 2 2 2 1
Insomnia 2 2 2 1
Dreaminess 2 2 2 1
Amnesia 2 2 2 1
Emaciation 2 2 2 1
Feverish sensation in the five centers 2 2 2 1
Palpitation 6 5 4 3
Dyspnea 6 5 4 3
Listlessness 6 5 4 3
Lassitude 6 5 4 3
Lusterless complexion 6 5 4 3
Pale complexion 6 5 4 3
Dark complexion 5 3 3 2
Bad temper 2 2 2 1
Spontaneous sweating 6 5 4 3
Sputum expectoration 4 4 1 1
Epigastric oppression 4 4 1 1
Abdominal distension 6 5 4 3
Poor appetite 6 5 4 3
Drooling 4 4 1 1
Dark urine 4 4 1 1
Dry stool 4 4 1 1
Loose stool 6 5 4 3
Thirst 4 4 1 1
Puffy tongue 6 5 4 3
Thin tongue 2 2 2 1
Pale tongue 6 5 4 3
Dark tongue 3 3 3 2
Red tongue 2 2 2 1
Purple tongue 3 3 3 2
Blue and purple sublingual vessel 3 3 3 2
Ecchymosis on the tongue 3 3 3 2
Teeth mark on the tongue 6 5 4 3
Little tongue coating 2 2 2 1
Thin tongue coating 6 5 4 3

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 Chen HZ et al. / Research Article
Table 3 Results of the cluster analysis of symptoms from the literature (n) (continuted)
Symptom
White tongue coating
Yellow tongue coating
Greasy tongue coating
Stringy pulse
Thin pulse
Slippery pulse
Rapid pulse
Deep pulse
Weak pulse
Choppy pulse
when the back and shoulder are twisted, the house will
break; the waist is the house of the kidneys, and when
the waist is unable to twist, the kidneys will collapse;
the knees are the house of the tendons, when they fail
to flex and people stoop when walking, the tendons
will become exhausted; the bones are the house of the
marrow, when people are unable to stand for long peri-
ods and experience tremor while walking, the bones
will become exhausted. The above-mentioned symp-
toms of head leaning, twisted back and shoulder, inabil-
ity to twist, inability to flex, stooping while walking,
and tremor while walking, are closely related to symp-
toms of PD, such as tremor, muscle rigidity, slowness
of movement, and gait disturbance. Chao Yuanfang of
the Sui Dynasty states in the Zhu Bing Yuan Hou Lun
Feng Si Zhi Ju Luan Bu De Qu Shen Hou10 that the
Foot Jue Yin channel pertains to the liver. The liver
governs all the tendons; when the liver channel be-
comes deficient, the wind pathogen attacks the ten-
dons, causing the four limbs to spasm and fail to flex.
Spasm of the four limbs and inability of the limbs to
flex are the major symptoms of PD. Sun Yikui of the
Ming Dynasty states in the Chi Shui Xuan Zhu11 that a
person with Chan Zhen usually manifests tremors of
the hand and foot that are like vibrations and the ten-
dons fail to control or hold, like the wind stirring. In
this text, PD is identified for the first time as Chan
Zhen. In 1982, Ren et al 12 suggested that Chan Zhen,
Zhen Zhuo, and Tou Yao were the ancient names for
PD. Zhen Chan is the modern name of PD in TCM.
In November 1991, the third session of the Chinese So-
ciety of Geriatrics of the Chinese Medical Association
established the Standard for the Diagnosis and Efficacy
Evaluation of TCM Geriatric Tremor13 and PD was
named as geriatric tremor, a classification that was ap-
proved by most researchers and experts.
Pattern classification research
The pathomechanism of PD is complicated. Its onset
and development is a process that starts with deficiency
and proceeds to excess. Excess then transforms into de-
ficiency, producing a state in which deficiency is mixed
with excess. PD is a chronic disease that has no current
cure. PD does not comprise a single pattern; rather, it
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6 Clusters 5 Clusters 4 Clusters 3 Clusters
6 5 4 3
4 4 1 1
4 4 1 1
2 2 2 1
6 5 4 3
4 4 1 1
4 4 1 1
6 5 4 3
6 5 4 3
3 3 3 2
is best characterized by multiple (and sometimes over-
lapping) patterns. Many researchers disagree on the
classification of its clinical patterns.
Ye14 classified PD into two types: liver Yin deficiency
and liver Qi stagnation. Xu15 classified PD into three
types: phlegm and turbidity accumulating and block-
ing, static blood blocking the collaterals, and deficien-
cy of liver and kidney. Lao16 classified PD into four
types: deficiency of liver and kidney, phlegm and
dampness with wind stirring, deficiency of Qi and
blood, and Qi stagnation and blood stasis. Wang17 clas-
sified PD into five types: Yin deficiency of liver and
kidney; Yang deficiency; Qi stagnation and blood sta-
sis; deficiency of Yin, Yang, Qi, and blood; and exuber-
ance of phlegm and dampness. Song18 classified PD in-
to eight types: liver Qi stagnation, phlegm and turbidi-
ty accumulating and blocking, phlegm heat and wind
stirring, Qi stagnation and blood stasis, Yin deficiency
of liver and kidney, deficiency of heart and spleen, defi-
ciency of Qi and blood, and deficiency of the sea of
marrow. He proposed that, based on pattern differenti-
ation, TCM treatment could effectively relieve the
symptoms of PD and reduce the side effects of chemi-
cal medicines.
As there is no standardization of pattern classification
for PD, most TCM practitioners classify its patterns ac-
cording to personal experiences, leading to inconsistent
nomenclatures. The most authoritative current pattern
classifications are as follows: Shi Yong Zhong Yi Nei Ke
Xue19 classifies PD into three types: deficiency of liver
and kidney, deficiency of Qi and blood, and phlegm
heat and wind stirring; the third session of the Chinese
Society of Geriatrics of the Chinese Medical Associa-
tion established the Standard for the Diagnosis and Ef-
ficacy Evaluation of TCM Geriatric Tremor, and classi-
fied PD into five types: phlegm heat with wind stir-
ring, blood stasis and wind stirring, deficiency of Qi
and blood, deficiency of liver and kidney, and deficien-
cy of Yin and Yang.
Research on the standardization of patterns
Shi Dianbang20 called for research on the standardiza-
tion of patterns, aiming to standardize and normalize
TCM pattern diagnosis, and eventually established a
693 October 15, 2017 | Volume 37 | Issue 5 |
 Chen HZ et al. / Research Article
unified standard and system of TCM teaching, re-
search, and clinical practice.
This study identified relevant literature and used fre-
quency analysis and cluster analysis to examine PD
symptom patterns used in the last 30 years. The find-
ings could further understanding of the basic, common
patterns of PD. Six symptom patterns were found
most frequently (total frequency percentage =
66.06% ): deficiency of liver and kidney, deficiency of
Qi and blood, phlegm heat and wind stirring, blood
stasis and wind stirring, Qi stagnation and blood stasis,
and deficiency of Yin and Yang. The cluster analysis re-
sults indicated that the common PD patterns are
phlegm heat and wind stirring, Yin deficiency of liver
and kidney, blood stasis and wind stirring, and deficien-
cy of Qi and blood. Both sets of results were in concor-
dance in identifying the patterns of Yin deficiency of
liver and kidney, deficiency of Qi and blood, phlegm
heat and wind stirring, and blood stasis and wind stir-
ring. Therefore, we conclude that these four patterns
are the basic symptoms patterns of PD.
In conclusion, the primary TCM symptom patterns in
PD patients are Yin deficiency of kidney and liver, defi-
ciency of Qi and blood, phlegm heat and wind stirring,
and blood stasis and wind stirring.
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