The patient, a 77-year-old male, was admitted to our department on October 15, 2021, due to recurrent syncope caused by neurogenic orthostatic hypotension for 6 months. He had been suffering from PD for 12 years and was taking levodopa and benserazide hydrochloride tablets (250 mg per time, 4 times a day), entacapone tablets (0.2 g each time, 4 times a day), and pramipexole dihydrochloride sustained-release tablets (1.5 mg, once a day). The motor fluctuations in the patient were not obvious. Dyskinesia appeared as mild, whole-body, dance-like movements that occurred 1 hour after each administration of levodopa and lasted for approximately 1 hour, and this did not affect the daily life of the patient. The patient suffered from restless legs syndrome and took clonazepam 4 mg every night before going to bed. Due to constipation, the patient used 60 ml glycerine to defecate, and this entire process lasted for more than 30 minutes each time. The patient had been taking lactulose and probiotics for constipation; however, these treatments were not helpful. The blood pressure of the patient was 100/55 mmHg in the supine position; however, it dropped to zero when he stood upright; therefore, he had to stay in bed. When the patient had to stand to engage in some daily activity, he took 200 mg droxidopa; however, the effects of this drug lasted for only 1 hour. The patient had diabetes and was taking sitagliptin tablets and acarbose tablets. Typically, he could not tolerate the cold, and he did not smoke or drink alcohol. In addition, he would perspire excessively during both day and night and had low appetite, nausea and lethargy for more than 12 hours a day. The H&Y stage score of the patient was 3 points. The Part I A, Part I B, Part II, Part III, and Part IV scores on the ‘on-period’ MDS-UPDRS were 2, 17, 14, 22, and 3, respectively. The Scales for Outcomes in PD-Autonomic (SCOPA-AUT) total score was 39 points. A traditional Chinese medicine (TCM) examination showed that the tongue of the patient was dark and swollen, there were some cracks in the middle of the tongue, and the tongue coating was white. The pulse of the radial artery was weak. The routine blood and liver function tests indicated that the patient was normal; nevertheless, his creatinine level was 127 µmol/l. According to TCM theory, the patient was diagnosed with kidney-yang deficiency and blood stasis syndrome and was prescribed Sini Decoction as the main formula (Table 1). The herbs were put into water, boiled and concentrated into a 400-ml mixture. The patient took 200 ml each time, twice a day. Administration of droxidopa was discontinued. After taking the CHF for 4 days, the patient walked by himself, and the blood pressure and heart rate of the patient were 106/55 mmHg and 64 beats/min in the supine position, 115/60 mmHg and 70 beats/min after 1 minute of standing, 123/69 mmHg and 70 beats/min after 2 minutes of standing upright, and 127/67 mmHg and 71 beats/min after 3 minutes of standing. At the same time, a small amount glycerine was used to defecate, and the defecation course does not exceed 5 minutes each time. He was discharged from the hospital on October 21, 2021, and it was recommended that he continue taking the CHF as described above. On November 4, 2021, during a follow-up visit, the patient had no syncope or dizziness in the standing position after taking the CHF. His constipation had almost disappeared: he occasionally used a small amount of glycerine, and the defection process took less than 5 minutes each time. The appetite of the patient had returned to normal, and the nausea had disappeared. His drowsiness had disappeared, and he slept only 5 hours a day. The dyskinesia of the patient was worse than before; therefore, it was suggested that he gradually reduce the dose of antiparkinsonian drugs (Table 2). The antiparkinsonian drugs of the patient have been stable since December 30, 2021, and the levodopa equivalent dose of the patient was reduced from 1214 mg to 741 mg since this PD patient began taking the CHF. The clonazepam dose was also decreased to 1 mg before bedtime each night. Until now, the patient had no obvious off-period symptoms every day, and mild dyskinesia lasted for 1 hour after taking levodopa. At each visit, the CHF was adjusted according to the changes in the patient's medical condition (Table 1). On November 4, 2021, the tongue of the patient returned from a dark color to light red, so Leech and Ground Beetle were removed from the herbal formula. On December 2, 2021, the defecation of the patient had returned to normal, so Citrus Aurantium was removed from the formula. After the third visit of the patient, the composition of the CHF remained unchanged. On March 2, 2022, the patient returned to my clinic and reported that he had discontinued CHF on his own from January 3, 2022, to January 10, 2022, at which point, the constipation, dizziness and bradykinesia of the patient slightly worsened. After this event, the patient resumed taking the CHF. In the clinic, the patient completed some scales and questionnaires. Part I A, Part I B, Part II, Part III, and Part IV of the ‘on-period’ MDS-UPDRS were separately scored as 1, 7, 13, 21, and 3. The total SCOPA-AUT score was 13 (Table 3). The patient had normal routine blood and liver function test results, and his creatinine was 132 mmol/l on March 1, 2022. The patient has had no new complaints since he began taking the CHF. The patient views himself as an almost normal old man and is very satisfied with the current treatment plan.
Table 1
Chinese herbal formulae used by the patient from Oct 15, 2021, to Dec 2, 2021
| Chinese herbal formula (dose, g) | 10/15/2021 | 11/4/2021 | 12/2/2021 |
| Aconite | 15 | 15 | 15 |
| Dried Ginger | 10 | 10 | 10 |
| Licorice | 10 | 10 | 10 |
| Antler Cream | 10 | 10 | 10 |
| Cistanche | 20 | 20 | 20 |
| Hemp Seed | 20 | 20 | 20 |
| Bupleurum | 25 | 20 | 20 |
| Citrus Aurantium | 15 | 15 | |
| Ophipogon Japonicus | 30 | 30 | 30 |
| Chinese Yam | 30 | 30 | 30 |
| Astragalus | 60 | 60 | 60 |
| Angelica | 20 | 20 | 20 |
| Codonopsis | 15 | 15 | 15 |
| Jujube | 20 | 20 | 20 |
| Leech | 10 | | |
| Ground Beetle | 10 | | |
Table 2
Changes in antiparkinsonian drugs used by the patient from Oct 15, 2021, to Dec 30, 2021.
| Antiparkinsonian drugs | 10/15/2021 | 11/4/2021 | 12/2/2021 | 12/30/2021 |
| Levodopa and benserazide hydrochloride, mg | 250, q6h | 250, q6h | 250, q6h | 187.5, q6h |
| Entacapone, g | 0.2, q6h | 0.2, q6h | 0.1, bid | 0.1, bid |
| Pramipexole dihydrochloride sustained release, mg | 1.5, qd | 0.75, qn | 0.75, qn | 0.75, qn |
Table 3
Scales for Outcomes in Parkinson’s Disease (SCOPA) autonomic (SCOPA-AUT) results for the patient before and after CHF.
| | 10/15/2021 | 12/30/2021 |
| 1. In the past month have you had difficulty swallowing or have you choked? | 2 | 1 |
| 2. In the past month, has saliva dribbled out of your mouth? | 1 | 0 |
| 3. In the past month, has food ever become stuck in your throat? | 1 | 1 |
| 4. In the past month, did you ever have the feeling during a meal that you were full very quickly? | 3 | 0 |
| 5. Constipation is a blockage of the bowel, a condition in which someone has a bowel movement twice a week or less. In the past month, have you had problems with constipation? | 4 | 0 |
| 6. In the past month, did you have to strain hard to pass stools༟ | 4 | 0 |
| 7. In the past month, have you had involuntary loss of stools? | 0 | 0 |
| 8. In the past month, have you had difficulty retaining urine? (Extra: use catheter) | 1 | 1 |
| 9. In the past month, have you had involuntary loss of urine? (Extra: use catheter) | 1 | 1 |
| 10. In the past month, have you had the feeling that after passing urine your bladder was not completely empty? (Extra: use catheter) | 1 | 1 |
| 11. In the past month, has the stream of urine been weak? (Extra: use catheter) | 1 | 0 |
| 12. In the past month, have you had to pass urine again within 2 hours of the previous time? (Extra: use catheter) | 1 | 1 |
| 13. In the past month, have you had to pass urine at night? (Extra: use catheter) | 3 | 2 |
| 14. In the past month, when standing up have you had the feeling of becoming either light-headed, or no longer being able to see properly or no longer being able to think clearly? | 3 | 0 |
| 15. In the past month, did you become light-headed after standing for some time? | 2 | 0 |
| 16. Have you fainted in the past 6 months? | 2 | 0 |
| 17. In the past month, have you ever perspired excessively during the day? | 2 | 0 |
| 18. In the past month, have you ever perspired excessively during the night? | 2 | 0 |
| 19. In the past month, have your eyes ever been oversensitive to bright light? | 2 | 1 |
| 20. In the past month, how often have you had trouble tolerating cold? | 2 | 0 |
| 21. In the past month, how often have you had trouble tolerating the heat? | 2 | 0 |
| 22. In the past month, have you been impotent (unable to have or maintain an erection)? (Extra: not applicable) | 4 | 2 |
| 23. In the past month, how often have you been unable to ejaculate? (Extra: not applicable) | 4 | 2 |
| 23a. In the past month, have you taken medication for an erection disorder? (If so, which medicine?) (no or yes) | no | no |
| 24. In the past month, have you used medication for: | | |
| a. constipation? (no or yes) | yes | no |
| b. urinary problems? (no or yes) | no | no |
| c. blood pressure? (no or yes) | no | no |
| d. other symptoms (no or yes) | no | no |