Case Studies

Case Studies

Bilateral Hip and Low Back Pain


Eliot Sitt LAc
December 2014
OVERVIEW

bilateral hip pain case study

19-year-old male presents with trauma-related chronic hip and low back pain with limits in range-of-motion that interferes with daily life. After 24 acupuncture treatments over the course of 6 weeks, the patient has increased range-of-motion and significant pain reduction. 

Subjective

19-year-old male patient presents with complaints of hip and low back pain. He describes the back pain as a dull ache that worsens while bending either forward or backward. He is able to walk fairly comfortably, but it is worse when carrying heavy loads. He experiences occasional tingling down the legs. The back pain began 8 or 9 years ago with a fall from a tree. He landed flat on his back onto a branch on the ground. He lost consciousness for about 5 minutes. After regaining consciousness, he found it too painful to walk. He did not receive treatment at that time. The back pain gets worse while working in a position of forward flexion for extended periods of time.

For the past 5 or 6 years, he has also experienced a gradual onset of hip pain, which prevents him from being able to squat at the toilet or separate his knees enough to straddle a motorcycle. The pain radiates down the anterior and lateral aspects of his thighs. He feels some hip pain while seated in a chair, and resting one ankle on the opposite knee is too painful of a position to maintain. He is also physically unable to place either knee above the other in a seated position. He reports tightness along his anterior thighs, as well as occasional neck and upper back pain along the spine.

Objective

The patient appears in good health and overall good spirits. He is alert with a small build and friendly demeanor. The patient has normal range-of-motion at the waist in flexion, extension, lateral flexion and rotation. The erector spinae are tight with tenderness along the lower borders of the spinous processes of L1 to L5.

Passive hip abduction is restricted to 40 to 45 degrees bilaterally (50 degrees considered normal), with a feeling of intense tightness in the inner thighs. There is tenderness upon palpation at the gluteus medius muscle, particularly on the right, at a point halfway between the greater trochanter and the top of the iliac crest.

The patient is unable to maintain a squatting position for more than a few seconds due to hip pain. The Faber test is positive for pain bilaterally in the initial position of one ankle placed on the opposite knee without downward pressure applied by the practitioner. The pain is felt deep in the hip bilaterally, with additional back pain on the right side near the SI joint. The right leg appears shorter than the left by about an inch, and the right PSIS appears slightly higher. There is tenderness at the SI joints bilaterally.

In the supine position, the right leg appears slightly shorter than the left. Leg length measurements show 29 inches from the prominence of the greater trochanter to the lateral malleolus bilaterally, but 34 and 35 inches from the umbilicus to the medial malleolus on the right side and left side, respectively.

Braggard’s test (aka the reinforcing straight leg raise) is positive bilaterally with tingling appearing at about 70 to 75 degrees and reappearing with passive dorsiflexion at a slightly lower angle. The tingling is felt down the posterior thigh and popliteal fossa. Strong dorsiflexion with the leg fully extended, but not raised, also results in tingling in the popliteal fossa bilaterally.

The Valsalva maneuver results in a tingling sensation in his toes. The piriformis test is negative for tingling sensations, although the position causes discomfort in the hip. DTR’s at the patellar and Achilles tendons are normal bilaterally.

He has a wiry pulse, and pink tongue with a thin white coat.

Assessment

DX: Upon interpretation of the objective testing performed, this patient has multiple structural problems involving the low back and pelvis, including hip joint pathology, sciatica, possible sacroiliac joint subluxation and compensatory muscle tightness of the low back and thighs. 

The positive results of the Braggard’s test and Valsalva maneuver suggest sciatica caused by a space-occupying lesion in the lumbar spine. Possibilities include intervertebral disc herniation, osteophytes or spinal stenosis. Disc herniation is the most common of these causes and also consistent with this patient’s history of trauma. The trauma conceivably could have caused a subluxation of a vertebrae in such a way that it could compress a nerve root. However, no obvious misalignments of the spinous processes are observed upon palpation. Spinal stenosis and the presence of osteophytes are less consistent with the history of trauma and is unlikely in this case due to the patient’s young age. 

The sciatic symptoms, in this case, may also be caused by muscle tightness in the pelvic area compressing the sciatic nerve. However, the negative result of the piriformis test suggests that the sciatic nerve is not being compressed by the piriformis muscle, which is commonly involved in sciatic compression due to muscle tightness. 

An imaging study of the low back such as an MRI or x-ray would be needed to determine the nature and location of any space-occupying lesion and to make a definitive diagnosis. There isn’t severe enough evidence of nerve root compression at L3, L4, L5 or S1 to affect DTR’s, as bilateral patellar and Achilles’ DTR’s respond normally. 

Due to the number of years that have passed since the original accident, it is difficult to ascertain the exact nature of the original injury that caused the back pain and radiculopathy. Given that this injury was untreated, it is likely that compensatory muscle tightness, serving to guard the initial injury, has resulted in slow-onset hip pain and subsequent structural imbalance. 

TCM DX: Qi and blood stagnation in the Du Mai, Bladder and Gallbladder channels 

PROGNOSIS: This patient has responded well, experiencing significant improvement, to previous acupuncture treatment for back pain. He is willing to come in frequently for treatment. The patient is likely to experience pain reduction and increased range-of-motion over the course of treatment. However, because his condition is complex and chronic in nature, he is unlikely to see a full resolution of all of his symptoms. 

Plan

Treat with acupuncture and/or electro-stimulation 5 times per week for 2 weeks, before reassessing. Focus primarily on hip pain, which has not received previous, direct treatment, and continue to reduce back pain. 

Typical treatment for hip pain: GB40, GB34, ST34, SP10, LI4, TB5, GB28, Ah Shi x2 superior to the greater trochanter, deep insertion towards the joint. Electro-stimulation 100/2 from GB40 and GB34 to the Ah Shi points superior to the greater trochanter bilaterally

Typical treatment focused on back and/or neck pain: SI3, BL62, BL60, BL23, LI4, DU20 and Hua Tuo Jia Ji points at tender vertebral levels (often L2-L5) 

Outcome

After 24 treatments within 6 weeks, the patient had only occasional, mild back pain, sometimes brought on by carrying heavy loads. He came for many treatments reporting no back pain at all with the majority of the treatments focused on addressing the pain in his hip. 

The patient was able to sit in a chair without pain. He could place one ankle on the opposite knee with only minimal pain, which he still felt deep in the hip. He was able to place one knee on top of another, while seated in an even more crossed position, whereas before treatment this position was impossible. The left knee over right knee position was more comfortable than right over left, but he still felt some deep, hip pain on both sides while seated in this position. The patient could now tolerate downward pressure during the Faber test, with significantly reduced pain in comparison to the initial treatment. 

The patient was able to maintain a full squat position without pain with both heels flat on the ground, but it was difficult to maintain his balance if his heels were farther apart. He reported feeling much looser in the thighs and pelvic girdle, with passive abduction showing normal range-of-motion at about 50 degrees. 

His apparent leg length on the right from the umbilicus to the medial malleolus measured a half inch shorter than the left side at 34.5 inches instead of a full inch shorter at 34 inches, as was measured in treatment 12. A leveling of the PSIS’s was observed. 

Braggard’s test remained positive bilaterally, but the tingling sensation was reduced by about 70%. He no longer felt tingling during the Valsalva maneuver.

Although the patient’s condition was not fully resolved, he experienced an increase in range-of-motion and a significant reduction in pain and overall tingling sensations.

Discussion

This case was challenging because there were multiple structural abnormalities coexisting without a clear diagnosis. It was initially difficult to decipher where to focus treatment. Because the back pain had already been improving from previous acupuncture treatment, the back pain resolved to a manageable level early in the course of treatment, resulting in an overall treatment focus on the hip pain. 

The patient found the hip pain difficult to describe, but the functional limitations were clear. While many people in the west find it difficult to squat because of how often we use chairs and seated toilets, the inability to squat is unusual and inconvenient in a rural Nepali environment, particularly because squatting is the normal position during bowel movements. It was also a detriment to this patient’s quality of life that he couldn’t sit normally without discomfort prior to treatment. 

Continued treatment of this patient with acupuncture would focus on continuing the pain relief of the hip joint with distal Gallbladder points and deep local needling, as well as a continued loosening of the local musculature of the pelvis, low back and thighs. Additional assessment is needed to determine the cause of the leg length imbalance. The nerve root compression causing sciatica should also be more precisely assessed, ideally with an imaging study. 

This case study suggests that acupuncture with electro-stimulation can have a significant therapeutic effect on complex, long-standing musculoskeletal conditions, and has the potential to be a valuable therapy in an environment with limited access to diagnostic imaging and allopathic medical care.

Painful Ulcerations of the Throat with Chronic Sinusitis


Helena Nyssen BA AppSc (TCM)
November 2014
OVERVIEW

throat ulcerations case study

28-year-old male presents with chronic sinusitis, nasal blockage, throat pain and ulcerations for 18 months. The patient also presents with gastric pain. After 9 acupuncture treatments over the course of 1 month, the sinus blockage is 100% resolved, with a complete resolution of subjective throat pain and ulcerations upon inspection. The gastric pain is significantly improved.

Subjective

The patient presents to the clinic reporting symptoms of throat pain beginning 18 months prior to the first consultation at this clinic, and becoming progressively worse. The pain is constant, and worse at night. Consumption of hot, salty or spicy food or drink aggravates the pain. Cool drinks are relieving. 

The patient also presents with complete sinus blockage, with an inability to breathe through the nose. He daily expectorates a small amount of yellow, watery phlegm from the nose. He finds smoky environments irritating. He experiences temporary relief with the use of saline solution and a neti pot.

He reports epigastric pain that is worse with cold foods, and bloating every day that is relieved by belching. He experiences occasional acid reflux and diarrhea, and night sweats, anxiety, lower back pain, poor energy, weakness and the occasional headache. All symptoms flare up simultaneously.

He has never smoked, although he chews tobacco daily. He occasionally drinks alcohol. The patient uses Rynex (cough suppressant, decongestant and antihistamine), as needed, to relieve his symptoms.

Objective

The patient is noticeably congested, with a constant sniff and breathing through the mouth. He has no fever or sweating, and a normal facial complexion without flushing. An endoscopy performed 18 months before presentation to the clinic was negative for any gastrointestinal ulcers. Upon visual inspection, there are multiple ulcers at the back of the throat (on the oropharynx and posterior soft palate). The ulcers are small in size, approximately 1-3mm in diameter, red and swollen at the edges, with a white interior. There are no ulcers visible within the oral cavity, and the tonsils appear only slightly swollen, but without ulcers or exudate. The uvula itself is swollen and deviated to the right. The lymph nodes of the neck show no swelling or pain on palpation. Visual inspection of the nose reveals small polyps bilaterally. The polyps are approximately 0.3cm across, but not large enough to block the nasal passage. They are pink in appearance with no exudate.

Pulse: Rapid and thready

Tongue: Big, sticky, deep yellow coat

Assessment

DX: Chronic sinusitis and upper respiratory tract inflammation; Possible chronic bacterial or viral infection, such as streptococcus or mononucleosis 

TCM DX: Kidney yin deficiency with deficient heat rising and scorching the Lung 

PROGNOSIS: With regular acupuncture treatments, reduction of throat pain and congestion is expected within 10 treatments. The nasal polyps are only treatable with surgery. Because there is no pathological findings within the gastrointestinal system, it is expected that positive functional improvement can be gained with acupuncture and dietary changes.

Initial Plan

Treat with acupuncture 2-3 times per week for 10 treatments before reassessing.

Focus on reducing the heat in the throat and tonifying the Kidney yin. 

Base Rx: KD7, KD6, LV3, ST44, LI4, KD3, PC6, LU7, LI20, Bitong, as well as threading the REN and Stomach channel

Advice: Stop chewing tobacco, avoid smoky environments, keep using neti pot as needed, ensuring the water is boiled clean first.

Outcome

After 9 treatments, the patient reported major changes in his throat pain, ease of breathing, and gastric pain. He experienced no throat pain at all, eating and drinking was no longer painful, and he could breathe freely through his nose. His gastric pain was relieved by a reported 75%. He no longer experienced coughing or sniffling, but still had some bloating. He discontinued his treatment at this point because he was happy with his level of improvement. The patient generally felt he had more energy. His anxiety had reduced to the point he rarely noticed it, and he no longer experienced night sweats. The throat ulcers had resolved and the oropharynx and tonsils appeared a healthy pink colour, without swelling. The nasal polyps were unchanged.

Conclusion

Acute or chronic infection was not considered as thoroughly as it should have been, as the patient had already experienced the symptoms for 18 months upon presentation to the clinic, and did not display signs of fever or swollen lymph nodes. The treatment may have been improved by further defining the cause of his throat pain and ulcerations. Antibiotics may have been helpful in this case. However, acupuncture treatment still achieved a satisfactory reduction in his subjective and objective symptoms.

A TCM diagnosis of Lung yin deficiency could have been explored for a more targeted treatment.

The patient’s outcome was improved by his compliance with lifestyle and diet advice, and his commitment to regular treatments (2-3 times per week). This case clearly illustrates the effectiveness of acupuncture for chronic sinus congestion and sore throat.

Sequelae of Osteoarticular Tuberculosis


Rachael Haley BAppSci (TCM)
December 2014
OVERVIEW

osteoarticular tuberculosis case study

A 58-year-old man, of rural Nepal, presents with left hip pain, reduced strength and mobility in his left hip and significant muscle wasting in his left leg. After 30 electro-acupuncture treatments over 6 weeks and Traditional Chinese Medicine, the patient reports a significant decrease in his pain and inflammation levels and improved strength and muscle tone in his left leg.

Subjective

A 58-year-old male presents with chronic, left hip pain with intermittent referred pain into his lateral left leg; either down the iliotibial band (ITB) region or into the lateral lower leg. The hip pain is a throbbing, deep ache, worse in cold/damp weather and at night when he is trying to sleep. He is unable to straighten his left leg in bed due to pain and stiffness. The patient uses handmade wooden crutches to walk without fully weight-bearing on his left leg. He has been relying on these to walk for 6 years. The pain started over 6 years ago with a gradual onset without any history of trauma. The patient reported having an x-ray taken at this time, and repeated hospital visits for tests and prescriptions of western drugs over a 7 month period. After taking these medications (unknown) with minimal improvement, he threw out his medical reports and ceased treatment. After a prolonged period of rest, he was unable to weight-bear through his left leg without significant pain. He reports the x-ray described the joint as having a ‘jagged edge.’ Prior to the onset of his hip pain, the patient was an active farmer in rural Nepal.

Objective

The patient presents with a slightly depressed demeanor. He is slight in build and stands with either all or most of his weight through his right leg. On observation, the patient’s left leg appears shorter, contracted at the hip and knee and has obvious muscle wasting in both the upper and lower leg. When walking to the clinic, he places minimal weight through his left leg, using the crutches as support. Due to postural imbalances, he cannot stand on both legs with equal weight distribution without left hip pain and his right knee having to flex about 30 degrees to get his left leg on the ground. The left iliac crest is visually higher than the right. The right ilium appears to be positioned more anteriorly. On his left hip, around his greater trochanter, there are 5 deep, large scars that are a result of abscesses that erupted after his initial onset of hip pain and hospital visits. The following orthopedic tests are conducted: 

FABER’s test: Positive on left side

Straight leg raise: Negative on both sides 

Thigh circumference is measured 15cm above the superior border of the patella to assess the extent of muscle wasting in his left thigh. 

Right thigh measures 40cm.

Left thigh measures 35.5cm.

Palpation: A tight muscle band is palpated in the left erector spinae from T11 to L5, plus tightness in the left quadratus lumborum.

L1-S1 myotomes/muscle strength testing:L1-L3 (hip flexion/psoas) – unable to resist on the left side due to painL4-S2 (knee flexion/hamstrings) – 2 (Oxford scale)

Range-of-movement (ROM)

Right

Left

Hip Passive Flexion (0-125°)

125°

80° with pain (a joint end feel cannot be felt)

Hip Passive Internal Rotation (0-40° )

30°

Minimal movement without pain

Hip Passive External Rotation (0-45° ) 

30°

Minimal movement without pain

Knee active extension (0-15°)

0° (shaky due to quadriceps weakness)

Reflexes: Patellar and Achilles: Normal on both sides

Dermatomes: Lower limb sharp/dull test is normal apart from a small area on the left upper thigh (L1-L2 nerve distribution), which has reduced sharp sensation. Several deep, large abscess scars found around his left greater trochanter, possibly contributing to a slight sensory loss.

True leg length from ASIS to medial malleolus: Right 75cm, left 75cm

Apparent leg length from umbilicus to medial malleolus: Right 84cm, left 82cm

Postural imbalance may be causing apparent leg length discrepancy of 2cm, which is exaggerated by the contraction of his left knee and hip in a flexed position.

Extra note: On assessment of his crutches, 1 crutch is over an inch taller than the other and the handles are about 2 inches different in height. The patient is advised to trim down the taller crutch to make them the same height, and then the handle height can be adjusted if necessary. 

Tongue: Swollen with a thick coat centrally

Pulse: Thin and tight

Assessment

DX: Osteoarthritis of the left hip (sequelae of osteoarticular tuberculosis) 

The patient’s reduced range-of-movement and the flexed position of the hip at rest, pain on weight-bearing and the description of a ‘jagged edge’ in his initial x-ray all indicate probable arthritic changes in the left hip. Initially, there was suspicion of infectious arthritis. However, considering the eruption of the abscesses several months after the initial onset of pain, it is unlikely that infectious arthritis was the initial cause of his pain. It is quite feasible to suspect that the patient may have had osteoarticular tuberculosis of the left hip. Osteoarticular tuberculosis is very rare in western countries. It is, however, still common in developing countries like Nepal. The hip joint is the second most common joint affected by the disease. Treatment of osteoarticular tuberculosis typically includes anti-microbial drug therapy of at least 9 months duration. This appears consistent with the patient reporting having taken a lot of western drugs and having several hospital appointments over the course of 7 months. This would also coincide with the abscess scars (they are a common complication of the disease). Other than anti-microbial therapy, an arthroplasty of the affected joint is often the solution if there is severe joint deformity. This currently is not accessible to the patient due to location, cost and health facilities in the region.

TCM DX: Wind-cold-damp bi syndrome

PROGNOSIS: Due to the fact that the condition has been left untreated for several years, it will take extensive treatment and continued care to maintain patient mobility and comfort levels. A complete cure is not expected.

Initial Plan

Acupuncture/electro-acupuncture treatment 5 days per week for 6 weeks

The focus is on local and distal points on the left hip and with electro-acupuncture to stimulate qi and blood flow, activate the muscles and reduce inflammation in the joint. As pain levels decrease, encouragement to place more weight through the left leg will be advised. Adjunct modalities when time permits include myofascial release/cupping to address muscle imbalances and increase circulation. Exercises will be prescribed to help build muscles in the left quadriceps, which will help support the hip joint. Chinese herbal medicine will be prescribed to improve patient energy levels and decrease pain and inflammation. Patient education regarding his expectations of improvement and self-care at home will be prescribed.

Typical treatment:

Supine/right lateral recumbent: ST36, SP10, GB34, LV3, LI4, SP6, SI3, BL62, 5 local Ah Shi points of the left hip and local needling around the scar tissue near the left greater trochanter

Electro-stimulation (2 pairs) - left gluteus medius, vastus medialis origin (SP10) and left tibialis anterior (ST36), peroneal muscle (GB34); 2/100 hertz

Alternate treatment:

Seated forward: Hwa Tou Jia Ji points, particularly on the left lumbar spine (deep paraspinals), to release the taught band of muscle

Additions to treatment (time permitting):

Cupping: Left lumbar spine and right thoracic; Left hip and ITB

Muscle release: Psoas/tensor fasciae latae (TFL)/adductors 

Exercises: Isometric contraction of the left quadriceps muscles to activate and assess muscle tone 

Herbal formula: Du Huo Ji Shang Wan

Outcome

After 6 weeks of treatment, the patient reported occasional dull pain in the left calf and thigh. Some nights, he was able to sleep pain-free. He experienced aching only in cold weather or after sitting for long periods of time. Sharp/dull dermatome testing became equal on left and right in L1-L2 nerve distribution. Range-of-movement testing showed a great improvement in passive, left hip flexion to 90 degrees without pain. The joint had a solid end feel at this range with application of overpressure. Knee flexion and extension strength became equal on both sides without pain (Oxford scale - 5). He attained 10° of internal rotation and 15° of external rotation in his left hip without pain. Apparent leg length remained the same and left thigh circumference, measuring muscle tone, increased by ½cm.

Continued Plan

It is recommended the patient continue with treatment for as long as it is available to him. 

Even though these modalities appear to decrease pain and inflammation, it is possible the patient would see further improvement with a modality that specializes in postural rebalancing, exercise and reeducation. Without further imaging, it is hard to give an accurate prognosis. It is likely, in a western culture, with more resources and affordability, this case would have been treated with a left hip arthroplasty and follow up rehabilitation care.

Discussion

Due to the severity and chronic nature of the patient’s condition, a full resolution of his pain was not expected. The history of onset and initial diagnosis are still unclear. The environment in rural Nepal creates the challenge of walking up and down rocky paths, which makes walking for the patient more difficult. Doing this on crutches that were uneven in height likely contributed to the patient’s postural imbalance, particularly the taught band of muscle in his left lumbar region. Because of the chronic nature of the patient’s condition, it was imperative to discuss with him the need for continued care and management of his pain and mobility. The Chinese herbal formula, Du Huo Ji Sheng Wan, has been shown to inhibit inflammatory responses and pain in some biomedical studies on animals. It may also increase blood circulation and enhance the function of macrophages to clear inflammatory tissues. It is likely this contributed to the patient’s progress by decreasing inflammation and increasing circulation in the joint.

Chronic Gastritis with Inflammatory Bowel Syndrome: Crohn’s Disease


Jason Gauruder LAc
December 2014
OVERVIEW

Chronic gastritis case study

40-year-old male presents with chronic, burning gastrointestinal pain with accompanied acid reflux, belching, fullness, diarrhea, weight loss and occasional rectal bleeding. The patient also experiences fatigue and insomnia. Receiving only acupuncture and Chinese medicine therapy for this condition, the patient has shown an almost complete remission of symptoms after 8 treatments.

Subjective

Patient is a 40-year-old male presenting with gastrointestinal pain and diarrhea with initial onset 2-3 years prior to his initial consultation at this clinic. Patient reports pain is worse after eating and feels like a burning sensation in the epigastrium, with concurrent pain in the lower left and right quadrants of the abdomen. Spicy and oily foods exacerbate the problem and are generally avoided by the patient. Bowel movements are frequent with burning pain and diarrhea. The stools are yellow, loose and have a history of occult blood. Other gastric complaints include acid reflux that improves with belching, bloating and foul flatulence. 

The patient experiences fatigue during the day and insomnia at night that manifests as difficulty falling asleep. Urination is frequent, yellow in color, but without discomfort. 

The patient has not been able to seek medical attention for this condition before, nor taken any medications. 

Objective

The patient’s appearance is thin, with visible ribs and gaunt face. Speech is soft, but he’s mentally alert. The sclera of his eyes are red, with a slight jaundice. 

Upon palpation of the abdomen, exquisite rebound tenderness is felt halfway between the xiphisternal junction and the navel, as well as at bilateral points in the right and left lower quadrants, slightly lateral to mid-line between the navel and pubis (ST27 & KI14). 

Tongue is red, with thick coat that is densest at the root and yellow in color.

Pulses are large, expanding and rapid with particular excess in the guan positions.

Assessment

DX: Chronic gastritis with inflammatory bowel syndrome, potentially Crohn’s disease

TCM DX: Damp-heat in the lower jiao; ST yin deficiency with fire

The level of transmural inflammation throughout the digestive tract gives high potential to chronic inflammatory bowel syndrome, which includes Crohn’s disease and ulcerative colitis, characterized by chronic inflammation at various sites in the GI tract, resulting in diarrhea and abdominal pain. Tenderness upon palpation reveals inflammation focused around the ileum and colon, which is present in 45% of Crohn’s patients. Lack of chronic bloody stools differentiates from ulcerative colitis. The relapsing and remitting of symptoms over the course of 2 years is also a likely marker of Crohn’s disease.

Prognosis

Regular acupuncture and herbal medicine treatment to mediate the more serious symptoms of the disease, and allow for remission. The patient already avoids foods that exacerbate the condition. Follow-up treatment will be required to manage symptoms, considering the reoccurring nature of inflammatory bowel conditions. 

If there is little to no response to therapy within 8 treatments, a colonoscopy or ultrasound would be indicated to rule out further obstruction or ulceration of the Large Intestine. A stool sample would also be ordered to check for inflammatory markers and/or if parasitic infection is responsible for the inflammation. 

Plan

Treat with acupuncture 2 times per week with daily Chinese herbal medicine intake. Upon the eighth treatment, the patient will be reevaluated.

Treatment principle: Drain damp-heat, clear Stomach and Large Intestine fire, nourish yin and unblock stagnant flow of qi & blood in Yangming channels.

Typical treatment: LI11, LI4, LI2, CV12, CV10, ST25, SP15, ST36, ST44, LV2, KI10

Alternative points: PC6, KI14, ST40, LV8, DU20, Ling Gu

Herbal Formulas: Formulas are based on presentation of pulse at each treatment, and are adjusted according to symptoms and herbal availability.

Huang Lian Su: 8 pills TID for first week to clear inflammatory heat of Stomach

Shu Gan Wan: In conjunction with Ma Zi Ren Wan, 2 pills TID to clear Stomach heat and course the Liver to prevent overacting on Stomach and insulting Large Intestine qi flow

Ma Zi Ren Wan: 2 pills TID to drain damp-heat from Large Intestine and moisten dryness from yin deficiency

Zhi Bai Di Huang Wan: At treatment 7, in conjunction with Tao Ren Cheng Qi Tang, 2 pills BID to clear deficiency heat and tonify yin

Tao Ren Cheng Qi Tang: 2 pills BID to unblock bowels, stop bleeding, clear damp-heat

Outcome

After 8 treatments, the patient reported a complete resolution in burning pain and majority of problematic GI signs and symptoms. After 2 treatments, the burning pain in the epigastrium had decreased and sleep improved. At this time, due to an increasingly wiry pulse, the formula was changed from Huang Lian Su to Shu Gan Wan to address Liver overacting while concurrently clearing Stomach heat. After 4 treatments, the pain and symptoms in the epigastric area had almost resolved, while the burning pain in the lower abdomen remained with burning diarrhea and painful bowel movements. The chief complaint being diarrhea, the formula Ma Zi Ren Wan was added in concurrence with Shu Gan Wan. After 6 treatments, blood was noted after bowel movements, with moderate pain during movement. Slight anal prolapse was noted giving suspicion of hemorrhoids. The patient reported a descending nature of the pain from the whole abdomen to below the navel. The decrease in overall GI complaints and an unrooted pulse allowed for the formula Zhi Bai Di Huang Wan to be used in place of Shu Gan Wan to tonify yin while clearing empty heat. Tao Ren Cheng Qi Wan replaced Ma Zi Ren Wan to address the signs of bleeding. After 8 treatments, the bleeding had ceased, lower abdominal pain had been resolved, stools no longer had undigested food and were, overall, soft and formed. Palpation of the abdomen was negative for tenderness. The chief complaint became pain from hemorrhoids.

Future Plan

The nature of inflammatory bowel disease to flare-up requires the patient to comply with follow-up treatment when a relapse period occurs. Since the condition is primarily inflammatory, it is still classified as pattern 1 according to the Montreal classification of Crohn’s disease. If constant relapse patterns occur, it is possible the disease will advance to pattern 2 or 3, requiring more substantial treatment. Pattern 2 involves primarily stenotic or obstruction, and pattern 3 is primarily penetrating or fistulizing, both requiring different therapeutic approaches and possible surgical intervention.

Outcome

The patient responded well to the treatment plan. Considering the limited resources available to the patient, using acupuncture and herbs alone were effective in remitting a pattern of chronic inflammation that has been ongoing for 2 years without any form of intervention. With continued support and treatment, if relapse occurs, it is likely the patient will be able to live a comfortable life with a lower chance of complications from chronic Crohn’s flare-ups. Acupuncture and herbal medicine alone have proven greatly effective for signs and symptoms of GI inflammation, and should be considered as a first line treatment for pattern 1 classifications of Crohn’s disease. In conjunction with allopathic care, it could be hypothesized that Chinese medicine would also be effective complementary care for pattern 2 and 3. Due to the limitations of the accessible health care services available to the patient in Nepal, it is difficult to obtain objective GI imaging that is generally necessary for diagnosis of the progression and severity of Crohn’s disease. If such measures were more readily available, it would better define the improvement of interior structures in the absence of allopathic treatments.

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