Tiejun Tang, Ying Zhang
"Brain fog" is not a medical
terminology, but a colloquial term used to describe slow or fuzzy thinking and
slowed-down cognitive response. The symptoms are various depending on different
body constitution, such as confusion, memory loss, difficult recalling words,
slow thinking, difficulty concentrating, and being easily distracted. Symptoms
of brain fog can appear during the recovery period after many viral infections.
Serena Spudich, a professor of neurology at Yale University, reported that a
person seems to experience more cognitive slowing and emotional problems after
contracting the coronavirus than most of other viral infections.Neurological
symptoms occurred in 80% of hospitalized patients with COVID-19 investigated in
one study.[1].A survey study published in Eclinical Medicine, The
Lancet showed that in 3,762 people with confirmed or suspected COVID-19, 85%
reported brain fog [2]. A cohort study based on linked electronic health records data from 81 million patients including 273,618 COVID-19 survivors, 36.55% of people have sequelae during the 3-6 months.[3]
This condition, often
referred to as long COVID, a common and particularly difficult problem with
long COVID is brain fog. Why does brain fog occur? How to diagnose and treat
brain fog in traditional Chinese medicine and western medicine? These questions
are important in the long-term treatment of COVID-19 and significant to a nation’s
medical system. In this work, we aim to provide an alternative view (TCM) in
treating brain fog.
The Mechanism of Brain Fog
and the Pathogenesis of TCM
The reason of brain fog is not very
clear in modern medicine, but Dr. Spudich believes the most likely cause was
inflammation caused by the body's immune response, rather than the virus
itself. A study issued in the March 2021 found autoantibodies in the
cerebrospinal fluid of COVID-19 patients with neurological symptoms [4].
This result suggests that the generation of brain fog may have its pathological
material basis, and it is not entirely a psychological problem. It's also
possible that the virus itself has somehow entered the brain, possibly by
spreading through the top of the nose or by infecting cells known to cross the
blood-brain barrier. But in a study by Columbia University published in
September 2021, no evidence of coronavirus RNA or protein was found in brain
cell samples from 41 people who died of COVID-19 [5]but a recent
study published in Nature shows strong evidence for brain-related abnormalities
in COVID-19. In this study, researchers investigated brain changes in 785
UK-based participants (aged 51-81 years) who underwent imaging twice and found
reduced grey matter thickness and tissue contrast in the orbitofrontal cortex
and para hippocampal gyrus, which is correlated with changes in functionally
relevant regional tissue damage markers, and overall causing brain-capacity reduction.
This explains why infected participants also exhibited greater cognitive
decline on average between the two time points.
However, whether such deleterious
effects can be partially reversed or whether these effects will persist in the
long term remains to be further investigated.[6].
Traditional Chinese Medicine Theory believes that
people's spiritual consciousness activities are dominated by the heart.
"Huangdi Neijing" (Inner Canon of the Yellow Emperor) recorded:
"The heart is the official of the monarch, whom in charge of the
consciousness." ZHANG Jiebin (a Chinese Physician, 1563-1640) explained:
"The heart is the king of a body, with a vain spirit and it has the
ability to cope with many changes. All the internal organs and the whole body
are controlled by heart, thus, wisdom and spiritual comes from the heart. And the
consciousness comes from heart". In the words of Traditional Chinese Medicine,
the brain belongs to the "extraordinary Fu-organ
", with a function in regulating mental activities. JIN Zhengxi (1598-1645)
of the China’s Yuan Dynasty said: "The memory and people's inspirations
lie in the brain. Children's brains are not full but with gradual growing. Old
people’s brainis gradually empty, therefore with memory declining."
There have been some debates in the field of Chinese medicine about whether the heart dominatesmind or the brain dominates mind. Professor DENG Tietao (the author’s supervisor) published "The scientific evidence of the Theory of Heart Dominates the Mind" in the journal of New Chinese Medicine[7]with an opinion that “the theory of heart dominating the mind comes from practice, which in turn can guide clinical practice. Practice is the criterion for testing the truth. Therefore, this theory is scientific”.One of my articles "A Joined Discussion about the Heart and Brain Dominating the Mind" extended Deng’s work by arguing the mechanism of heart dominating mind as the root, and the brain dominating the mind as the branch [8]. In my opinion, although western medicine believes that the brain fog comes from the brain, its origin does come from the heart. According to the principle that treatment must be based on the origin of the pathology, the treatment of brain fog should therefore focus on nourishing the heart and calm the mind at the same time, while taking the opening of the orifices of brain into account.
In
addition, according to the TCM,(1) the kidneys govern the bones, and the bones
generate marrow, while the marrow nourishes the brain, so nourishing the
kidneys and filling essence is to nourish the brain; (2) the liver controls
stagnation, regulates qi, thus, relieving the stagnation of liver qi helps
relieving depression; (3) spleen is the source of qi and blood, meanwhile
related to thinking . Strengthening the spleen and nourishing qi can also
indirectly nourish the heart and calm the nerves. Although brain fog is in the
brain, to regulate the function of five Zang organs can achieve the purpose of
treatment. In particular, nourishing the heart and calming the nerves should be
the focus.
Chinese and Western Medicine
in Treatment of Brain Fog
Western Medicine Treatment
Western medicine
believes that cognitive rehabilitation seems to be the best way to treat brain
fog. Cognitive rehabilitation is like physical therapy, but it targets the
brain. Usually performed by a neuropsychologist, and the treatment consists of
written and oral exams and focuses on strategies to improve certain functions,
such as attention or memory. Many hospitals in the U.S. currently have
cognitive rehabilitation programs, and many long COVID clinics also offer brain
fog treatment. There is some evidence that playing games like CogMed, Lumosity,
etc. on a computer or mobile phone can also improve cognitive performance. It
can be a great addition to cognitive rehabilitation therapy.
In terms of drug
therapy, the United Kingdom has recently launched a combination preparation for
the treatment of brain fog called Brainzyme, which includes EMT mixture
(theanine, EGCG and polyphenols), guarana seeds, choline, ginkgo biloba,
L-Tyrosine, Piperine, Bromelain, Maca Root, Vitamins and Minerals. Among them,
ginkgo biloba and pepper are the ingredients of traditional Chinese medicine,
and the others are mostly nutritional additives, which are also contained in
many traditional Chinese medicines. The efficacy of Brainzyme in the treatment
of brain fog has not been reported.
Traditional Chinese Medicine Treatment
Herbal Medicine
Traditional Chinese Medicine
treats brain fog according to the principle of syndrome differentiation and
treatment. In clinical treatment, I found that there are mainly four common
syndromes.
(1) Heart-blood
deficiency and heart-yin deficiency:
Main symptoms:
Memory loss, lack of concentration, insomnia and dreaminess, dizziness and
fatigue, pale complexion or red cheeks, or night sweats or spontaneously sweat,
pale tongue or red tongue with little coating, deep and thin pulse.
Treatment principles: Nourishing yin and nourishing blood, calming the mind and the
nerves.
Formula selection: Modified BaiziZixinWan.
Herbs selection:Baiziren,
Xuanshen, Shudihuang, Gouqizi, Zhigancao, Danggui, Shichangpu, Maimendong,
Fuling.
For
those with more blood deficiency, add Jixueteng.Heshouwu;
For
those with more Yin deficiency, add Baihe, Tianmendong;
For
those with sleep disorders, add Suanzaoren, Yejiaoteng.
(2) Disharmony between the heart and kidney:
Main symptoms:
Forgetfulness, insomnia, trance, dizziness, palpitations, soreness and weakness
of waist and knees, hot flashes and night sweats, tinnitus, red tongue with
little or no coating, rapid pulse.
Treatment principles: Nourish yin and calm the mind, regulate heart and kidney.
Formula Selection: Tianwang Buxin Dan
Herbs selection:
Baiziren, Suanzaoren, Maimendong, Tianmendong, Shengdihuang, Xuanshen,
Taizishen, Wuweizi, Danggui, Yuanzhi, Hehuanpi, Yizhiren.
If
the kidney deficiency is the main reason, add Xuduan, Duzhong;
If
the heart fire is inflamed, add Zhizi, Huanglian.
(3) Liver qi stagnation:
Main symptoms:
Depression, restlessness, irritability, forgetfulness, dreaminess, dizziness, hypochondriac
distension, red eyes and bitter mouth, thin white or yellow tongue coating, wiry
pulse.
Treatment principles: Soothe the liver and relieve depression, calm the heart and
mind.
Formula Selection: Modified XiaoyaoWan
Herbs selection:
Chaihu, Danggui, Baishao, Fushen, Baizhu, Xiangfu, Qingpi, Yujin, Zhigancao.
For
the cases of live fire excess, add Mudanpi, Zhizi;
For
cases with severe emotional depression, add Suxinhua, Meiguihua,Jianghuang;
For
the cases of bitter taste in the mouth add Longdancao, Xiakucao.
（4）Heart and spleen deficiency:
Main symptoms:
Forgetfulness, anxiety, lack of concentration, fatigue, palpitations, insomnia,
loose stools, or abdominal distention, pale tongue, fat tongue with tooth
marks, white and slippery coating, slow pulse.
Treatment principle: Nourish the heart and spleen, soothe the nerves.
Formula Selection: Modified Guipi Wan.
Herbs selection:
Renshen, Huangqi, Baizhu, Danggui, Fushen, Yuanzhi, Suanzaoren, Longyanrou,
Wuweizi, Zhigancao.
For
those with spleen deficiency and loose stools; add Yiyiren, Cheqianzi;
For
those with abdominal distension, add Muxiang, Sharen;
For
those with poor appetite add Maiya, Guya;
For
those with severe memory loss, add Yizhiren and Shichangpu.
Acupuncture
In addition to herbal
treatment, acupuncture is also an effective means of treating post-COVID-19
brain fog. Mainly select the points on the Heart Meridian of Hand Shaoyin, the
Pericardial Meridian of Hand Jueyin, the Liver Meridian of Foot Jueyin, the Kidney
Meridian of Foot Shaoyin, the Du meridian, and local acupuncture points on the
head. Scalp acupuncture can also be used entirely, or electro-acupuncture can
be added.
Dietary
Healthy dietary can also
help brain fog recovery. A healthy diet (including olive oil, fruits and
vegetables, nuts and legumes, and whole grains) has been shown to improve
thinking and memory. Avoid alcohol and drugs. Getting enough sleep, listening
to music, regular aerobic exercise, and participating in social activities can
also help eliminatethe symptoms of brain fog.
Conclusion
Brain fog is very
common in the duration of COVID 19 infection and its aftermath. Western Medicine
usually applies cognitive rehabilitation therapy
to treat Brain Fog, while Traditional Chinese Medicine apply herbals to treat based
on a TCM theory that many organs (liver, kidneys, spleen) can affect on brain capacity,
however, the brain is mainly charged by the heart. This paper suggests that Chinese
herbal medicine can be a very effective alternative or/and supplement treatment
to eliminate Brain Fog, with the principle of combining heart and brain in
the treatment, by nourishing the heart, tranquilizing the mind, clearing the orifices,
and refreshing the brain.
Reference
1. Chou, S.
H.-Y. Global Incidence of Neurological Manifestations Among Patients
Hospitalized With COVID-19-A Report for the GCS-NeuroCOVID Consortium and the
ENERGY Consortium. JAMA
Netw. Open 2021; 4, e2112131.
2. Hannah E. Davisa.Characterizing
long COVID in an international cohort: 7 months of symptoms and their impact. Lancet.
e Clinical Medicine.2021; (38): 101019.
3. Maxime Taquet. Incidence, co-occurrence, and evolution of
long-COVID features: A 6-month retrospective cohort study of 273,618 survivors
of COVID-19. PLOS Medicine 28 Sep 2021.
4. Christiana Franke. High frequency of cerebrospinal fluid
autoantibodies in COVID-19 patients with neurological symptoms. Brain Behav
Immun. 2021 Mar; 93: 415–419.
5. Kiran T Thakur.COVID-19 neuropathology at Columbia University Irving Medical Center/New York Presbyterian Hospital. Brain. 2021; 144 (9): 2696–2708.
6. GwenaëlleDouaud. SARS-CoV-2 is associated with changes in brain structure in UK Biobank. Nature.Published: 07 March 2022.
7. 邓铁涛. 心主神明论的科学性[J].新中医,2003,35(3):15-16.
8. 唐铁军.也谈心主神明与脑主神明[J].中华现代中西医杂志,2004,2(5):443-444.
