The last race of the season was three weeks ago. The medal still hangs on the key hook by the door, and your running shoes are still in the bag where you left them when you got home. The five o’clock alarm rings and then stops, and you stay in bed. Climbing the stairs at work, you have to stop on the second-floor landing to catch your breath. Sitting in an air-conditioned room, the back of your shirt is still damp with sweat. At night you often wake at two or three and toss and turn for ages before falling back asleep.
On a weekend visit to your hometown, your mother slips a box of ginseng into your bag: “All that running, you need to build yourself back up now, dear.” The box sits on top of the fridge, still unopened.
When you have rested for a long time and your strength still hasn’t returned, that tiredness needs to be traced to its root. Sometimes the root is in the blood, such as iron deficiency, or not eating enough for the amount of training. Sometimes it is a deficiency pattern that traditional medicine can name. At Tam Duc Clinic, the doctors examine with in-depth Applied Kinesiology (AK), a way of testing muscle strength by hand to read the state of the body, to see which part of the body has not yet recovered. AK points to the spot, and traditional medicine chooses the formula. Your mother’s box of ginseng also has to wait its turn in that order.
What needs to be ruled out first
The first question lies in the blood. The doctor orders a complete blood count and an iron panel, which includes ferritin, a measure of how much iron is stored. Running low on iron stores is not only a women’s issue. Comfort and Abrahamson’s book cites figures of about 26% of female athletes and 11% of male athletes with depleted iron stores, though this does not necessarily reduce performance; we have only seen these figures as quoted in the book and have not looked at the original study. If you are truly deficient, iron is supplemented based on the lab results. A herbal formula cannot do that part instead.
The second question is what you eat. Long-lasting fatigue together with weight loss, repeated stress fractures, in women cycles longer than 35 days or periods missing for 3 cycles or more, in men lower sex drive and low testosterone (the male hormone): the International Olympic Committee consensus (Mountjoy and colleagues, 2023) places these signs under relative energy deficiency in sport (RED-S), which means not eating enough for the amount of training. There is no single test for RED-S. The doctor has to put several indicators together.
The third question is the heart. If you have chest pain or faint while running, have unusual palpitations, or someone in your family died suddenly at a young age, stop running and get your heart checked before anything else (Papadakis and colleagues, 2022; Joyce and Lewindon, 2016). People taking statins (cholesterol-lowering drugs) who run long distances or run downhill are more prone to muscle disease (Papadakis and colleagues, 2022; Jameson and colleagues, 2018), so the medicines you are taking also need to be on the examination table.
For the thyroid, or for kinds of sweating caused by illness, there are not yet reliable data to discuss here; if the examination shows a need, the doctor will order tests separately. Only when the lab report is fine and you are still tired is it the turn of traditional medicine and AK.
The same word, tired, many different patterns
Runners often quote the line “prolonged walking injures the sinews” (久行伤筋 / 久行傷筋, jiǔ xíng shāng jīn) from the Su Wen (素问 / 素問, Basic Questions): walking too long harms the sinews, that is, the tendons and muscles (Su Wen, p. 195). The textbook of basic theory of Chinese medicine also places the root of the capacity to endure exertion in the Liver, the organ that governs the sinews, calling the Liver “the root of endurance against fatigue” (罢极之本 / 罷極之本, bà jí zhī běn) (Basic Theory of Chinese Medicine, 中医基础理论 / 中醫基礎理論, p. 219). A long race season spends exactly that reserve, in a different way for each person, and traditional medicine calls each way a pattern.
In runners, three patterns are common after a race season:
- Qi and blood deficiency (气血虚 / 氣血虛, qì xuè xū): long-lasting fatigue, slow recovery, a pale complexion and a poor appetite, often after a heavy training block or after a race, and the doctor only places someone in this pattern once the complete blood count and ferritin results are in;
- Dual deficiency of qi and yin (气阴两虚 / 氣陰兩虛, qì yīn liǎng xū): heavy sweating, thirst, shortness of breath, tiredness, a pale red tongue with little coating, often seen after a hot running season;
- Liver and Kidney deficiency (肝肾虚 / 肝腎虛, gān shèn xū): usually in middle-aged people, with an aching back and knees, legs that weaken on long runs, and pain that increases each time you overexert yourself.
Even in the AK books there is no single formula for tiredness. Discussing chronic fatigue syndrome, Garten and Weiss, two AK authors who write in German, divide it into several traditional medicine patterns, involving dampness (damp stagnating inside the body), qi, blood, the Spleen and the Kidney, and then advise looking up the herbs for each pattern in a traditional medicine textbook (Systemische Störungen, p. 434).
A damp shirt in an air-conditioned room
Sweat is where the patterns separate most clearly. The textbook of internal medicine in Chinese medicine classes summer heat as “summerheat” (暑, shǔ), which tends to drain qi and damage the body fluids (fluids in the body such as sweat and saliva), so treatment has to protect both the fluids and the qi (Internal Medicine of Chinese Medicine, 中医内科学 / 中醫內科學, p. 34, 38–39). If you have run all season under the sun and, with the season over, you still sweat heavily, feel thirsty and get short of breath, the drain lies in both the qi and the yin fluids. That is the pattern of dual deficiency of qi and yin.
This pattern does not share the same herbal direction as qi and blood deficiency. The traditional healer (lương y) Nguyen Huu Duc advises that people with dual deficiency of qi and yin should not use ginseng (Panax ginseng, nhân sâm) (Nam duoc lectures, part 8, T39). So before you open that box of ginseng, tell the doctor about the back of your shirt getting damp in an air-conditioned room.
Some herbs must be avoided altogether. Xiang ru (Mosla chinensis aerial parts) is used for summer colds without sweating. The materia medica books caution against this herb for people with exterior deficiency (a weak protective layer at the body’s surface) who already sweat a lot, and for people with summerheat (heat from the summer sun), which is exactly the runner drenched in sweat (Chinese Materia Medica, 中药学 / 中藥學, p. 155–156; Formulas, 方剂学 / 方劑學, p. 143).
Two blood pressure readings and a penlight in the eye
In AK, fatigue after months of intense training is often looked at through the adrenal glands. Insomnia, tiredness, dizziness and fainting, palpitations and swelling all appear on the list of signs that Walther, author of the foundational textbooks, gives for adrenal stress disorder. He notes that people with this disorder have often been to many clinics and had every test done, yet no one found the cause (Synopsis, p. 510–511). Dizziness and palpitations are also signs that call for a heart check, so the rule-out steps above always come first.
For people who are tired after a race season, the AK examination starts with the blood pressure monitor. You lie down to rest, and the doctor takes one reading. You stand up, and the doctor takes another reading right away. AK calls this Ragland’s sign. On standing, the systolic blood pressure (the top number) should ideally rise by about 8 mmHg. A drop is abnormal, and Walther compares the size of the drop with your own usual blood pressure, not with a general number. He also cautions that low blood pressure on standing is not necessarily due to adrenal stress; poor nutrition, illness, diabetes and alcohol can all cause it, and medicines are a common cause, especially strong blood pressure drugs (p. 511–512).
Next comes the light. The doctor shines it into your eye and holds it steady. Normally the pupil constricts and stays constricted. When the adrenal glands are underperforming, after about thirty seconds the pupil often dilates in waves (p. 512).
Only after those two signs does muscle testing come in. Walther examines structure before looking at the glands, including the spine, the craniosacral system (the relationship between the skull and the sacrum) and other major factors (p. 513), because if the pelvis has shifted backward and has not been stabilized, adrenal stress is often hard to clear (p. 515). The doctor then tests the group of muscles AK links to the adrenals, located on the inner thigh, the calf and the arch of the foot. When the gland is underperforming, one or several muscles, or the whole group, are often disturbed (p. 512). Some muscles test weak, while others test strong (p. 513). When a muscle is strong, the doctor looks for what makes it weak, for example when you place your own hand on the gland’s neurolymphatic reflex point. AK calls this step therapy localization (p. 514).
People who sleep poorly and have been under pressure all season are checked in one more place. For them, the doctor also uses the clinic’s in-depth AK technique to see whether the pressure of the whole season has built up in the frontal lobe, limbic system and cingulate gyrus (the brain areas that process emotions and responses to pressure).
Whatever is found is treated right in the session. The doctor mobilizes the pelvis in the direction identified by muscle testing, restimulates the signal in muscles that are working below threshold (that is, that become weak when muscle tested), lightly touches the gland’s reflex points, and then retests that muscle group. The step of stimulating the reflex points has to pass one more test, described in the next section.
Garten and Weiss describe a young basketball player exhausted after two weeks of staying up every night until morning, whose tests, including immune tests, were all normal. His sartorius (a long muscle running diagonally across the front of the thigh) was working below threshold and became strong when he tasted an adrenal support product. His other muscles were still strong when tested once, and only grew progressively weaker when tested many times in a row, and the two authors read this as a shortfall in aerobic energy (the energy muscles produce with oxygen, the basis of endurance) (Systemische Störungen, p. 434–435).
A muscle that strengthens on tasting does not mean the remedy is chosen
On nutrients, Walther writes quite plainly. Muscles related to the adrenals often test stronger when the patient tastes a gland support product, but that is not necessarily the right treatment (p. 512). At some stages of prolonged stress, the hypothalamic–pituitary–adrenal axis (the chain of glands from the brain down to the adrenals that controls the stress response) is already producing excess cortisol (the stress hormone). Pushing the gland to work harder at that point may ease a few symptoms while the overall condition gets worse (p. 513).
The step he adds is quite simple. For any substance that makes the sartorius stronger, the patient places a hand on the reflex point of the pituitary gland, then on those of the thymus and spleen, while the doctor retests. If the muscle weakens at that moment, the substance would push the gland to secrete more cortisol and should not be used yet. The step of stimulating the gland’s neurolymphatic reflex points goes through exactly the same test. If the sartorius becomes strong but weakens again once the hand on the pituitary point is added, Walther postpones the stimulation to a later session. At the follow-up visit everything is retested from the start, because a substance that did not suit you before may come to suit you once the gland has improved, and vice versa; the results usually settle down over the first few weeks (p. 514).
Ginseng fits right into this. Garten lists ginseng among the nutrients to test for the sartorius, gracilis and tibialis posterior (Muscle Test Handbook, p. 109, 215, 245). Writing with Weiss, he holds that ginseng saponins regulate the stress response through the hypothalamic–pituitary axis, and seem best suited to the exhaustion stage (Systemische Störungen, p. 498). If tasting ginseng makes the sartorius stronger, AK has pointed to where to look. The two-point test tells whether the gland should be pushed at this time or not. Which kind of ginseng to use, what to combine it with and how long to take it still have to go through pattern differentiation, that is, identifying the pattern according to traditional medicine, and people with dual deficiency of qi and yin still follow the healer’s advice and set ginseng aside.
Walther also separates substances that merely stimulate from substances that help the body rebuild. The example he gives is Gan cao (Glycyrrhiza uralensis root, licorice), which often makes symptoms more comfortable but cannot rebuild the system, and in high doses over a long time causes salt retention and potassium loss (p. 514). At the clinic, the total amount of Gan cao per day, counting teas and lozenges, does not exceed 2 g.
The box of ginseng on top of the fridge
With the lab report in hand, after taking your pulse, looking at your tongue and the AK examination, the doctor may prescribe a decoction in ready-to-drink 50 ml pouches matched to your pattern, with each prescription cooked as its own batch. Before you take the whole course home, the doctor puts a few drops of the decoction on your tongue and retests the muscle that was weak during the examination. In the clinic’s experience, this step shows how the body responds to the formula.
The formula approaches for runners currently rest on the classics and recorded case series. No trial has yet measured whether people who take them regain their strength faster after a race season. So the formula goes together with adequate meals, sleep and a period of reduced load, and does not stand in for them. Formulas for dual deficiency of qi and yin often contain herbs that reduce sweating, but those herbs do not replace fluids and electrolytes. On days with a run in the heat, do not take the decoction close to running time; keep a gap of at least two hours.
Nine herbs contain higenamine, a substance on the list of banned doping substances, and there are currently no substitutes for them. If a prescription contains any of them, it must be stopped at least one day before race day, so if you are about to run a race with doping control, tell the doctor on the day of your examination. Women who are pregnant or trying to conceive get a separate version that does not use Niu xi (Achyranthes bidentata root), Hong hua (Carthamus tinctorius flower), Dan shen (Salvia miltiorrhiza root) or San qi (Panax notoginseng root).
As for your mother’s box of ginseng, if the doctor finds it suitable, it should still only be used in courses, each course no longer than 12 weeks, according to the University of Minnesota course on herbal medicine. Expensive powdered ginseng is often mixed with cheaper species or with stimulants, so do not buy powder from an unknown source.
The box of ginseng can stay on top of the fridge a few more days. The blood test report, your blood pressure reading the moment you stand up, and whether your tongue is pale red or pale will tell whether it is meant for you, and when the shoes in the bag will come out again.
If you have rested for a long time and your strength still hasn’t returned, you are still sweating heavily and still waking at night, book an appointment with Dr. Dinh Ngoc Duc (MD, MSc in Traditional Medicine). If you already have recent blood test results, the appointment goes straight to taking your pulse and muscle testing; if not, the doctor will order them first. Book a consultation.
Worth keeping
- If rest is not bringing you back, have a complete blood count and ferritin test before taking iron or ginseng on your own;
- Tell the doctor about your meals, your weight, your cycle for women, your sex drive for men;
- Chest pain, fainting or unusual palpitations while running: stop running and get your heart checked first;
- Show the doctor every medicine you are taking, especially blood pressure drugs and statins;
- If you are sweating heavily, do not take Xiang ru on your own;
- Use ginseng only in courses of no more than 12 weeks, and avoid powdered ginseng from unknown sources;
- If your race has doping control, tell the doctor before anything is prescribed.
References
Sources in Vietnamese
- Nguyễn Hữu Đức. Bài giảng Nam dược. Phần 8, T39.
- Hoàng đế nội kinh Tố vấn. Nguyễn Tử Siêu dịch. Tr. 195.
Sources in English
- Comfort P, Abrahamson E, editors. 2010. Sports Rehabilitation and Injury Prevention. Chichester: Wiley-Blackwell. p. 285, 287.
- Garten H. 2013. The Muscle Test Handbook: Functional Assessment, Myofascial Trigger Points and Meridian Relationships. Edinburgh: Churchill Livingstone Elsevier. p. 109, 215, 245.
- Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, editors. 2018. Harrison’s Principles of Internal Medicine. 20th ed. New York: McGraw-Hill Education. p. 3286.
- Joyce D, Lewindon D, editors. 2016. Sports Injury Prevention and Rehabilitation: Integrating Medicine and Science for Performance Solutions. London: Routledge. p. 63–64.
- Mountjoy M, Ackerman KE, Bailey DM, Burke LM, Constantini N, Hackney AC, et al. 2023. 2023 International Olympic Committee’s (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br J Sports Med. 57(17):1073-1097. doi:10.1136/bjsports-2023-106994. PMID: 37752011.
- Papadakis MA, McPhee SJ, Rabow MW, et al., editors. 2022. CURRENT Medical Diagnosis and Treatment 2022. New York: McGraw-Hill. p. 378, 459, 870.
- University of Minnesota. 2018. Herbal Medicine. Coursera course.
- Walther DS. 2000. Applied Kinesiology: Synopsis. 2nd ed. Pueblo (CO): Systems DC. p. 510–515.
Sources in German
- Garten H, Weiss G. 2007. Systemische Störungen: Problemfälle lösen mit Applied Kinesiology. München: Elsevier, Urban & Fischer. S. 434–435, 498.
Sources in Chinese
- 李冀, 连建伟, 主编. 方剂学. 第 143 页.
- 王新华, 主编. 中医药学高级丛书 · 中医基础理论. 第 219 页.
- 张伯礼, 吴勉华, 主编. 中医内科学. 第 34、38–39 页.
- 钟赣生, 主编. 中药学. 第 155–156 页.
