Case Studies

Case Studies

Spinal Trauma Sequelae with Osteoarthritis of Right Knee


Jubal Bewick LAc
December 2014
OVERVIEW

60-year-old female presents with spinal trauma sequelae consisting of constant mid- to high grade pain and restricted flexion of the spine. In conjunction with the treatment for the spinal pain, the patient is treated for pain of the right knee with mid-grade pain and global swelling of the area causing functional impairments. With the completion of the prescribed treatment plan, greater than 75% improvement in symptoms of the spine, and greater than 90% improvement in symptoms with respect to the right knee are achieved.

Subjective

The patient presents upon first consult with a complaint of thoracic and lumbar spinal pain greater than 1 year with respect to onset of symptoms. The patient admits to having fallen from a ladder and landing on her spine over a year prior. The duration of the spinal pain is constant with no respite, even while resting. The quality of pain is a mixed pattern of sharp and dull pain as described by the patient. The main aggravators of the pain are forward bending, sitting and household chores. The patient finds but minor respite with warmer weather. 

The patient’s concurrent complaint is right knee pain. The onset of the complaint is greater than 1 year. The area of pain is described as the entire knee. The duration of the patient’s pain is intermittent with a dull, achy characteristic with occasional episodes of sharp pain. The occasional episodes of sharp pain have no distinct pattern the patient can recall. The patient’s main aggravators for the right knee pain are standing, sitting, cold weather, flexion greater than 45 degrees and household chores. 

Social history: 

No reported history of smoking or drinking 

Medical history: 

Stage 2 hypertension [unmanaged] 

Reports previous diagnosis of degenerative joint disease in knee

Medications & Supplements: 

No reported medications

Review of systems: 

Cardiac: No palpitations or chest pain 

Respiratory: No shortness of breath 

Digestion: No reported gas, bloating, nausea or abdominal pain 

Sleep habits: Easy to fall asleep, but wakes frequently at night 

Bowel movements: Patient reports WNL

Urination: Patient reports WNL

Integumentary: No spontaneous sweats or night sweats 

Heat signs: Hot flashes

Objective

Vitals: BP: 175/99 mmHg, PR: 59 bpm

Pulse: Thready with transient changes of slippery and tight 

Tongue: Large, red/purple coloration, dry and flattened tip; Peeled coating in the upper jiao of the tongue, yellow, light coat in middle jiao and thick white coat in the lower jiao. Engorged sublingual veins with distention greater than 75% 

Palpation: L3 vertebra is enlarged on palpation as compared to other L vertebrae; T7, T12 are tender to the touch. 

Visual inspection: L3 is visibly enlarged and protruding posteriorly as compared to other lumbar vertebrae. 

AROM of spine: <30 degrees flexion, 25% lateral flexion with grimace, 25% extension with grimace

AROM of knee: <60 degrees flexion

PROM of knee: <60 degrees flexion; Crepitus felt and clicking heard with movement 

Anterior drawer: Negative, Posterior drawer: Negative, Varus/Valgus: Negative, McMurray’s: Negative

Reports: MRI of the lumbosacral region taken 09/18/2014

Impression: Compression fracture of T7 and T12 vertebral bodies with marked anterior wedging. Compression fracture of L3 vertebral body. Probably osteoporotic fracture 

Degenerative changes in lumbar spine with mild L5-S1 neural foraminal stenosis 

Assessment

Before ascertaining medical records from the patient, differential diagnosis was the following:

Diagnosis (spine): Degenerative joint disease/osteoarthritis, herniated disc, spinal lesion, Osteoporatic fractures of T7, T12 and L3 (knee): Degenerative joint disease/osteoarthritis

TCM Diagnosis (spine): Bony bi due to underlying KD yin deficiency, bi syndrome due to wind-cold-damp invasion, qi stagnation and blood stasis causing pain (knee): Bony bi due to underlying KD yin deficiency with wind-cold-damp invasion 

Initial Plan

Treat with acupuncture and Chinese herbal medicine with the 10th treatment designated as the reevaluation point for determination of progress. The length of time for the 10 treatment protocol is over a period of 6 weeks. The beginning treatment is focused on local stimulation of qi, blood and neural system around the right knee, while distally treating the spinal pain. This treatment approach is based upon the assumption of degenerative joint disease/osteoarthritis of the spine and osteoarthritis of the knee. Both of these western diagnoses are concurrent with findings of bi zheng – bony bi syndrome with underlying Kidney yin deficiency as the root. The herbal formula used in conjunction with the acupuncture is Du Huo Ji Sheng Tang with a dosage of 8 pills TID. 

Typical acupuncture point selection for initial plan is: He Ding, Xi Yan, ST34, ST36, SP10, SP9, KD3, SI3, UB62, Zhu style scalp acupuncture for spinal pain, Yao Teng Xue. 

The patient’s hypertension is an ongoing discussion, as the patient has been dealing with misinformation from local health authorities in the form of only suggesting dietary changes, or improper explanation of the importance of controlling hypertension. A secondary issue is the local rumors about drug therapy, especially hypertension medications. The rumors surround the side effects, some true, some not, which lead to out-weighing the need to control hypertension in the patient’s perspective. 

Treatment Progression

The patient was steadily receiving benefit from acupuncture for the right knee pain, but having limited results with the spinal pain after the 3rd acupuncture visit, which was the visit on which the patient brought the previously taken MRI report and film. Upon review of the report of findings affiliated with the MRI, a change of acupuncture treatment was taken for the 4th visit. 

Acupuncture procedure: Hua Tuo Jia Ji at levels of T7, T12, L3; The needles were placed at the depth of the periosteum of each vertebral body and then electro was applied at a continuous frequency of 80Hz. Additional points would be prescribed depending on changes in pain level of the right knee: UB40, Ah Shi 2 cun above UB40, Ah Shi 1.5 cun lateral UB40, UB39. 

A change in Chinese herbal medicine was made as more yin deficient symptoms were being seen. Along with Du Huo Ji Sheng Tang 8TID, Zuo Gui Yin was added with a dosage of 3 pills BID. 

Continued discussion was had regarding hypertension, but no progress had been made by this point in time. 

Outcome

Final outcome for the patient after the 10th visit are as follows:

Subjective

Greater than 75 % decrease in spinal pain with or without activity 

Greater than 90% decrease in knee pain with or without activity

No night sweats

Waking no more than 1 time per night

Objective

AROM of spine: WNL in all directions with no grimace present 

AROM of knee: WNL in flexion with no grimace present 

PROM of knee: WNL in flexion with no grimace and less crepitus felt, but clicking still present

Health management goal: Agreement was made with the patient to be assessed in Kathmandu and receive counsel with drug therapy to care for her stage 2 hypertension. In this agreement, the patient acknowledged the need for continuous monitoring to make sure hypertension is properly managed, even after medication is prescribed. 

Conclusion

Maintenance care will be needed due to the patient’s age, history of trauma, bone degeneration and lifestyle that leads to excess exposure to inclement weather. The overall prognosis with maintenance care is good considering the results seen in regular care with respect to quality of life and pain management. 

Injury prevention discussions and testing are deemed continually necessary considering the patient has been diagnosed as osteoporotic by physicians in Kathmandu. These discussions and tests could be a major step towards prevention of accidents and further degeneration that could lead to bone damage. Proper evaluation for high risk osteoporotic regions of the body needs fracture risk assessment (FRAX), which includes DEXA scans, and if deemed necessary, use of proper drug therapy. Monitoring of ongoing bone loss, or response to treatment with regard to osteoporosis, should be repeated approximately every 2 years per standard of care for patients with known osteoporosis. 

A major goal to achieve, outside of maintaining a relatively pain-free state of health for the patient, is continued monitoring of the patient’s hypertension. This concern was agreed upon by the patient at the last visit. The patient agreed to see a physician in Kathmandu hospital system and receive drug therapy counseling with intervention for her hypertension. This health concern, in my point-of-view, outweighed the concerns held by the patient in regard to pain management. Poor understanding of hypertension is linked to inadequate public education and understanding of the causes of hypertension, and pathologies created by persistent 

Febrile-Induced Cerebellar Ataxia


Erin Smith LAc
March 2015
OVERVIEW

cerebellar ataxia case study

58-year-old male patient presents with ataxia, severe dizziness, vertigo and slurred speech. Symptoms started after a severe febrile illness in November 2012, and appear to be getting worse since that time. After 8 acupuncture treatments, patient reports a minimal decrease in overall dizziness and vertigo, and his walking appears slightly smoother immediately after receiving acupuncture.

Subjective

In November 2012, patient had a febrile illness for 6 or 7 days with severe vomiting, diarrhea and dark colored stools. Immediately following this illness, patient reports difficulty speaking and walking. He was admitted to the hospital for several days and received a CT scan, a routine blood panel, urine and stool testing, and was put on medication, which he discontinued on his own. 

Patient presents with difficulty walking independently and slurred speech, which he reports has gotten worse since the febrile illness in 2012. Whenever he stands up and starts to walk, he has severe dizziness and vertigo and feels like he and his environment are spinning. No change in dizziness when he stands and looks upward. He is unable to stand up or walk without support. He reports occasional mild back pain, more chronic than the current illness and not coinciding with the difficulty walking. He has no pain in his legs.

He reports being diagnosed with high blood pressure, but stopped taking the medication as it “was not helping” him. He has headaches at least a few nights per week. The location and severity of the headaches is hard for him to determine. He is unaware of a history of ear pain or chronic ear infections. There is no hearing loss or ringing in the ears present. He has had blurry vision in the right eye for the past 20 years, after a foreign body hit him in the eye while he was riding the bus. Glasses have been recommended, but he prefers not to wear them. 

Objective

Patient presents with ataxia with inability to walk or stand from a seated position without support. He has mild muscle spasticity on both legs while walking with support. Patient is able to stand on his own briefly, reports feeling very dizzy and unstable, and visibly has a hard time maintaining equilibrium. Balance is equally unstable when standing on just his right or left leg with support. The patient is able to walk on his toes and heels, while supported, with no pain.

The deep tendon reflexes of both patellas, Achilles’ tendons and hamstrings are all responsive and normal. Seated muscle testing of knee flexion, extension, ankle dorsiflexion and plantar flexion, and hip abduction and adduction bilaterally all have normal strength and range-of-motion. All cranial nerve tests are normal. Patient is able to move both arms smoothly overhead and no intention tremor is apparent. Tympanic membranes are both intact, though may have minimal scarring. No pain present around the ears with palpation. Nystagmus is not present.

Blood pressure is measured at 165/105. He is missing several front teeth, which he reports fell out on their own several years ago.

Directly after the febrile episode, on 11/19/12, he had a MDCT scan of his head. The report concluded there were no abnormalities present at that time. All routine blood and urine testing was normal. EKG and ultrasound of the pelvis and abdomen were also normal.

The pulse on the left hand is thin overall, and deep and weak in the chi position. The pulse on the right hand is slippery and forceful in the cun and guan positions, and deep and weak in the chi position.

The tongue has a dry, pink body with a thick, yellow coat at the root. 

Assessment

DX: Cerebellar ataxia due to febrile illness

The patient does not have recent medical records or thorough diagnostic imaging. Several neurological conditions are also possible diagnoses in this case. Multiple sclerosis, Ménière’s disease and other causes of damage to the cerebellum must also be considered for this patient.

Multiple sclerosis (MS) can often present with ataxia and slurred speech, although these are not typically the primary symptoms associated with this disease. The most common symptoms of cerebellar dysfunction that are seen in MS can include dysarthria, instability of the head and trunk, intention tremor and incoordination of voluntary movements and gait. Along with ataxia, nystagmus can also appear early in the disease. MS is an autoimmune disease, typically starting between the ages of 20 and 40, more common in women than men. Most forms of MS usually start gradually, with an attack of symptoms, followed by a period of remission. Primary progressive MS does not have any periods of remission. It gets progressively worse, and typically presents with other primary symptoms that are not seen in this case, such as extreme fatigue, pain, numbness and tingling. Primary progressive MS can be ruled out definitively with an MRI of the brain and spinal cord with absence of scarring of the myelin, and a lumbar puncture of fluid surrounding brain and spinal cord, showing an absence of antibodies.

Ménière’s disease is a disease of the inner ear. This diagnosis is initially considered before his symptom of slurring of the speech is known. The primary symptom of Ménière’s disease is recurrent episodes of vertigo, which can last 20 minutes to 24 hours at a time. When severe, it can lead to falling and difficulty walking. Ménière’s disease typically presents with hearing loss, ringing in the ears, and a feeling of fullness or pressure in the ear, with which this patient does not present. His balance is not improving and vertigo is constant when he is standing and attempting to walk, neither of which are present in Ménière’s disease.

Cerebellar ataxia, due to stroke, is also possible, but not likely for this patient. Cerebellar stroke accounts for only 1% of all strokes and has 1 of the highest mortality rates. This type of stroke typically comes on suddenly with symptoms of headache, nausea, repeated vomiting, dizziness, vertigo and inability to walk or stand, but does not typically include fever or diarrhea. Coma occurs in about 50% of these cases and edema formation is also common, often leading to sudden respiratory arrest. Other causes of cerebellar damage are more genetic in nature and occur earlier in life, or are a result of nutritional deficiencies primarily related to alcoholism, which are not factors for this patient. 

The diagnosis for this patient is likely to be cerebellar ataxia due to physical trauma, which in this case was a prolonged fever. Based on the history of his present illness, his symptoms started directly after having a prolonged fever for 6 to 7 days. The cerebellum is particularly sensitive to thermal injury, and prolonged fever can cause irreversible damage to the tissue and permanent cerebellar dysfunction. The damage is expected to be along the midline of the cerebellum, as the movement of the trunk and legs are affected in this patient. The damage would more likely be along the lateral hemispheres if the arms were affected. The damage is also suspected to be bilateral, as speech disturbance occurs only when damage is along both sides of the cerebellum. The most primitive areas of the cerebellum are connected with the vestibular nuclei and apparatus. Damage to this part of the cerebellum results in disequilibrium that is obvious with rapid changes of body position, and the presence of dizziness and vertigo, both of which this patient displays. These signs and symptoms can make the damage look like it is in the vestibular system itself, although coming from damage to the cerebellum. 

TCM DX: External wind in the channels with underlying Kidney qi deficiency

The initial febrile illness resulted in an external invasion in the channels from which the patient has not recovered. He had no obvious preexisting signs of wind due to organ pathology before the febrile illness, making the source of wind most likely external in nature. Kidney qi deficiency is evident in this case due to age of the patient, history of hard physical labor before his present illness, intermittent lower back pain, missing teeth and the weakness of bilateral chi pulse positions.

Prognosis

Prognosis is poor due to the likely source of injury from November 2012. The main goal of treatment is to support the overall health and well-being of the patient, and potentially slow the progression of the neurological disease. Although unlikely, based on other clinical results involving brain trauma, it is also possible that with intense treatment, the patient may regain the ability to walk independently, and improve the quality of his speech. Acupuncture, electro-acupuncture and Chinese herbal medicine will all be used to work towards these goals. 

Initial Plan

Acupuncture treatments are recommended 2 to 3 times per week for 16 sessions before reevaluation. Acupuncture would have been recommended more often, due to the severity of the patient’s condition, however he lives over 2 hours from the clinic and has to rely on family support to bring him by bus. 

The focus of treatment is to expel wind from the body to reduce spasticity and erratic movement of the legs while walking, and to support the Kidney organ system. Typical acupuncture treatments involve combinations of the following points: GB12, 20, 34, 39, 41, SI3, BL62, TW5, LU7, LI4, LR3, 8, SP6, KD3, 6 and Ba Feng.

Scalp acupuncture with electro-stimulation is used along the motor line, including the speech, dizziness and vertigo area, and 3 lines for voluntary movement. Scalp needles are manipulated for 10-15 minutes while patient walks with assistance or moves legs while seated. Electro-stimulation is used passively for approximately 25 minutes.

The Chinese herbal formula, Qu Ji Di Huang Wan, is selected to help nourish the Kidneys with added support for the eyes. 

The Epley maneuver is performed at the first several treatments before Ménière’s disease is ruled out as a diagnosis.

Patient is referred for glasses to reduce the effect the blurry vision in his right eye is having on his dizziness and walking. It is recommended that he continues to have his blood pressure monitored and resume medication if needed to reduce the long-term risk of stroke. Updated and more thorough imaging, and a routine blood panel are recommended to help confirm the diagnosis. However, this information is not likely to change the direction of treatment or prognosis based on the history of the illness and objective information, and will likely put a greater financial strain on the family.

The patient is informed of the prognosis of his illness, including the unlikelihood of regaining the ability to walk independently or improve his speech. He agreed that using acupuncture and Chinese medicine to try to regain some level of normal function, reduce the severity of his symptoms, and support his body as a whole, is worth the investment of his time.

Outcome

After receiving the Epley maneuver, patient reported an initial decrease in dizziness and vertigo, but stopped improving after a few repetitions. The maneuver became unnecessary as the patient no longer felt dizzy with the various changes in head position.

Patient showed little response to the 8 acupuncture treatments. Before-and-after videos showed the patient’s gait to be slightly smoother with less muscle spasticity after treatment. The patient reported feeling less dizziness and vertigo immediately following treatment and at night. His symptoms while walking, however, remained unchanged. No change in quality of his speech had been detected. After the first several weeks of treatment, the patient became less compliant with the frequency of his treatments, as the travel distance and subsequent hardship made treatment frequency too difficult for the patient and his family.

Revised Plan and Prognosis

Since the patient showed minimal improvement, it was recommended that he continue treatments later this year when a team will be present for 6 continuous months. If he is able to have 2 to 4 treatments per week for 12-15 weeks straight, it will be more evident if his symptoms will continue to show improvement, or if the minimal improvement already seen is the maximum benefit expected. His prognosis remains poor due to the nature of brain damage, the progression of his symptoms over time, and his advancing age. Considering how severely this affects his life, it is worth an intensive series of treatments on a frequent basis to see if his brain can be retrained to coordinate walking. The patient and his family are unsure of their ability to be compliant with the frequency of treatment based on the hardship they are experiencing, and the amount of effort it takes for him to come to a session.

Conclusion

The patient was only able to make it to the clinic for 8 treatments out of the recommended 16. Patient compliance with acupuncture treatment is even more important for patients who have severe pathology, such as brain trauma. It is not uncommon for results to be very slow for patients with severe conditions, and although minimal, he was making some progress in the quality and intention of his gait, and reduction in dizziness and vertigo. Based on several factors surrounding this case, it is unlikely that his walking will ever be what it once was, but it is in the realm of possibility to help him regain some of the coordination he would need to be able to walk on his own with the support of a walking stick. For him to regain even that level of independence would greatly improve the quality of his life, since he places a great burden on his family because of his lack of function. This is obviously difficult for him to accept. With acupuncture and Chinese medicine, it is possible that giving his body some much-needed support, and clearing some of the remaining external pathogens, his symptoms may start to improve. He has made little progress in just 8 visits, but there is still a chance for him to improve with an intensive series of treatments.

Palliative Management of End-Stage Emphysema


Rebecca Groebner MAc LAc
March 2015
OVERVIEW

palliative management case study71-year-old male presents with cough and severe shortness-of-breath, caused by emphysema. Initially, patient was stabilized during an emergency home visit. At patient’s request, palliative home care was provided. This type of care is necessary for anyone suffering from chronic illness, yet as doctors, we often don’t follow cases through to this point. How do we manage end-of-life care in rural Nepal?

Subjective

Patient presents with a chronic cough of 3 years duration and shortness-of-breath. Acute symptoms began 10 months ago when he presented with severe pain in the solar plexus area and inability to breath. He was diagnosed with allergies at the local health post, but allergy medications were not helpful. He was transported to a hospital and diagnosed with emphysema and a pneumothorax. 1 month ago, patient was hospitalized for a second time and sent home with an oxygen tank, which he requires for respiratory stability.

He is only able to breathe if he sits up straight or leans forward. Cold weather and fatigue make these symptoms worse. Warmth, warm water, sunshine, his nebulizer and black coffee make it easier for him to breathe. His cough is productive with white mucus that is sometimes tinged with blood. 

In addition to this, the patient suffers from worsening anxiety, insomnia, sharp left-sided chest pain, weight loss, daily nosebleeds, constipation, loss of appetite and 1-sided edema in his right limbs causing leg pain when walking. His leg pain and sleeping are better when sitting in a cross-legged, seated position with pillows stacked behind him. All of these symptoms are made better by listening to the radio and visiting with friends and family, taking his mind off his pain.

Objective

Patient presents with a thin body. Clothes that once fit him are now baggy. His ribs, scapula and clavicle bones are easily visible. He becomes breathless with small movements. His facial color is blanched. Patient breathes out through pursed lips.

Patient has a score of 40 on the Palliative Performance Scale (PPS). Ambulation is low. He requires assistance from a caregiver for moving and elimination. He is unable to do any work. He can drink from a cup, but requires assistance to eat. Food intake is reduced, but water intake seems normal. He is often fully conscious or drowsy. He is rarely confused, unless his blood oxygen levels drop below 70%.

Patient has +1 pitting edema in the right hand and +4 pitting edema in the right foot. The leg feels room temperature on palpation. Dorsiflexion of the right foot causes pain and increases shortness of breath. Blood oxygen levels rise and fall, becoming more extreme over the course of our visits, with the lowest reading being at 63%. The pulse and respiration rates rise as the blood oxygen levels fall.

Lung exam shows increased expiration time with decreased lung sounds in the lower lobes. Lungs are clear to auscultation in the lower lobes. Soft to medium crackles and high-pitched wheezing on both inhalation and exhalation are present. An occasional pleural friction rub can be heard in the right middle lobe. Cardiac auscultation shows an irregular heart beat with an extended diastolic conclusion (S2). Both lung and heart sounds decrease over time.

The right radial pulse is weak and deep. The left is thin and deep. His tongue body is dusky with multiple cracks. The tongue coat is thick, dry, yellow and stringy. There is a +3 sublingual stasis. 

Assessment

DX: Hospital records show that the patient was diagnosed with emphysema 10 months ago. X-rays show honeycomb cysts, and radiological conclusions communicate that a cyst in the “left middle lobe” burst, causing a pneumothorax. 

This patient is a non-smoker and hasn’t had the occupational hazards that are usually associated with emphysema. It is likely that the lifelong use of a traditional Nepalese indoor cooking stove, with combustible biomass fuels, contributed to his disease state. In addition, x-rays show lower lobe thickening and concentration of bullae, which is a typical indicator of a genetic, alpha-1 antitripsin deficiency. This deficiency reduces the likelihood of cellular repair to lung tissue predisposing to emphysema, even with reduced exposure to inhalants.

TCM DX: Lung qi deficiency with obstruction by damp-phlegm and Kidney yang deficiency

PROGNOSIS: Patient’s condition worsens daily. It is evident that he is moving through the stages of grief, and acceptance of his death. Due to a PPS scale of 40, it is likely that he will die sometime in the next couple of months. An accurate BMI and FEV1 reading could help with a more accurate prediction of his lifespan, but the tools to measure this are not available to us at this time.

Initial Plan

Patient is recommended to go to the hospital, but he refused.

Plan for this patient focuses on improvement in his quality of life, palliation of symptoms associated with end-stage COPD, and support for patient and his caregivers around any other physical, mental-emotional or spiritual issues that may surface concerning his death process.

Typical treatment:

Monitoring of physical vital signs

Codeine, at a dose of 30g per evening, to provide minimal pain relief and reduction of cough so that the patient can sleep (This is purchased from the local pharmacy, where it is available to anyone.) 

Cranial sacral therapy (CST) to release the occiput and tentorium cerebelli, to reduce anxiety and calm wheezing

Mild massage of the neck, shoulders and area between the shoulder blades 

Education for patient and his family, including information about his disease, the cleanliness of his living area, danger of too much bed rest, etc.; Providing accountability for family members around his care

Emotional support around and witnessing the grief and death process; Discussion of the patient’s goals and desires for his final days

Drawing supplies and encouragement to engage in activities he finds enjoyable, including a small walk to the porch in the sunlight

Outcome

During first contact, the respiratory emergency was stabilized and patient’s oxygen levels returned to normal ranges for his disease state. After that time, the patient showed relatively stable oxygen levels, less anxiety and was able to sleep through the night. He began sharing his life story, but was not yet able to discuss his death. 

After 3 weeks, the patient presented with +4 pitting edema in his legs that prevented him from putting weight on his feet. He reported sharp chest pains. He became vocal about his death and stopped smiling and laughing as much.

At 4 weeks, the patient reported lowered anxiety and a feeling of increased relaxation. He asked for more practitioner visits, reporting feeling best on days when we came. 

After nearly 30 patient contacts, the patient’s family reported a respiratory emergency with sharp chest pains. Upon arrival, pulse oximeter readings showed a blood oxygen level of 63% with a pulse of 34 bpm and respiration rate of 28. The patient could not maintain consciousness and at some point, could not recognize family members. Cultural traditions around death were already being performed by the family. He died during the night.

Discussion

In developed nations, the progression of COPD is delayed and the quality of life increased by using long-term oxygen therapy (small, portable tanks), and morphine to reduce the feelings of shortness of breath. Patients are recommended to follow a regular exercise and pulmonary rehabilitation program to maintain aerobic capacity and hence, maximum oxygen uptake.

A portable oxygen tank was not an option for this patient. His oxygen tank required 3 strong men to lift it into his room. The tubing to the tank allowed him 8 feet of movement from his bed. The costs of the tank were so high that the family often turned the tank off even though the patient would respond with blood oxygen levels in the low 70%. By the time of response to his respiratory emergency, he had been non-ambulatory, due to the tank, for over 15 days. With complete bed rest, elderly patients can lose up to 5-6% of their muscle mass each day and aerobic capacity decreases markedly1. Though it was recommended that the patient move each day, he reported that he was too weak to get out of bed.

This patient faced substantial impediments to obtaining morphine for pain control and relief of his shortness of breath. Had pain control been available for this patient, his quality of life would have been increased, and based on emerging studies, his lifespan may have been increased as well(2).

Conclusion

This patient and his family tried to get help from the local health post, a hospital in Kathmandu and a teaching hospital in Chitwan. They experienced an unfortunate misdiagnosis and multiple, failed attempts at a blood draw that left the patient’s arm completely bruised. During their final hospital visit, they were told not to come back, and were given medications for asthma and allergies. No healthcare provider explained the diagnosis to the patient, nor walked the patient and his family through the reality of his upcoming death. The doctor who prescribed the oxygen tank never spoke with the patient or his family about the risks associated with geriatric bed rest. 

Though ARP is not an organization that commonly provides home care, and specifically, palliative home care, our team opted to continue providing such care in this patient’s case. The patient had no other options and our volunteers and interpreters were willing to spend the extra time, after a full day of clinical work, to perform vitals checks, and help educate the patient. Our organization is not often asked to provide end-of-life care and as such, we have not developed protocols for the management of these cases. This situation presented us with an opportunity to determine the resources that ARP can commit to such cases.

Our management of end-of-life care is dependent on the circumstances taking place outside of regular clinical hours. Are our volunteers and interpreters drained of energy from seeing a surplus of patients most days? In this case, we had numerous bus strikes that lowered our daily case loads, and I felt that I had enough energy to spend with the patient. The patient went through many stages of grief and as such, the nightly visits were emotionally charged requiring me to commit to a great deal of self-care, including morning and evening meditation, Taiji practice, writing and a lot of support from my team members. It was often hard to find an interpreter to volunteer to sit with a dying man when they faced the alternate choice of watching a movie or simply going to bed after dinner. This presented the possibility of resentment from the interpreters, which was something that I didn’t want to risk. I tried to rotate through the interpreters and to go either right before dinner, or shortly thereafter. This kept the task associated to a time that already held a social commitment, and it seemed to be less jarring for everyone.

As healthcare providers, it is hard to accept that no matter what knowledge we bring to the bed of a dying person, we will not find a way to “save” the patient and somehow magically restore their body. I encountered this difficulty in the first couple of weeks with Lal Lama. I worked all day to problem solve health issues that could be cured or managed. At night, I had to shift my intention so that I could listen to a patient’s story about his life and receive information about what his best death looked like, so that I could advocate for that if necessary. I had to tell the patient that there was nothing I could do to cure him, and that we were limited in the management of his pain. I felt myself unworthy of sitting with Lal and told myself that there must be a doctor nearby who could do this job better than I could. I finally came to realize that I was the best that Lal had, and in the end, I am so grateful that I embraced that and became the listener and friend that he needed. He taught me how to sit with the dying and how to die when the time comes for me.

Merck Manual

Lamas, Daniela and Rosenbaum, Lisa. Painful Inequities - Palliative Care in Developing Countries. New England Journal of Medicine. 366: 199-201. January 19, 2012.

De Quervain’s Syndrome


Maggie Shao MTCM LAc
March 2015
OVERVIEW

de quervains case study

57-year-old female presents with hand tingling and severe wrist pain that began 9 months prior to visiting the clinic. Both wrists are affected. Patient reports pain began first in right wrist, but currently feels more pain in her left wrist. The western diagnosis for this patient is De Quervain’s syndrome, caused by repetitive stress injury. After 7 treatments with NSAIDs, acupuncture, moxibustion, topical pain ointment and electro-stimulation, patient reports 75% reduction in pain.

Subjective

Patient is a 57-year-old female presenting with bilateral wrist pain. Pain began with the right wrist, and now her left wrist is more painful. Patient points to bony prominences on both wrists, near radial styloid, and reports chronic pain for the last 9 months. Patient reports that pain is worse with cold and damp weather. She comes to the clinic with no prior intervention or treatment for this wrist pain. 

Objective

Patient appears in good health with weight proportional to height, and luster in facial complexion, hair and skin. Blood pressure is 120/80 and blood glucose is 101 mg/dL. Tongue is pale with white coat. Pulses are thin and weak. When palpating both right and left wrists at the location of the radial styloid, near acupuncture point Lung 7, patient reports sharp pain. She tests positive when performing Phalen’s test, reporting numbness and pain after holding hands in prayer position for several seconds. Noticeable prominence on both wrists at the radial styloid is evident. Patient tests positive with Finkelstein test, reporting severe pain with thumb flexed across the palm, enclosing fingers around thumb in a fist and deviating and rotating the fist toward the ulna. DTRs (deep tendon reflex) for brachioradialis, biceps and triceps are normal.

Assessment

DX: De Quervain’s tenosynovitis 

De Quervain’s syndrome is stenosing tenosynovitis of the short extensor (extensor pollicis brevis) and the long abductor tendon (abductor pollicis longus) of the thumb with the first extensor compartment. Inflammation of the tendons, and subsequent fibrosis over the radial styloid of the first digit dorsal compartment causes this area to become thickened and bone-hard, raising the skin and creating a prominence that is tender and painful. De Quervain’s tenosynovitis is most commonly due to the repetitive stress injury involving repetitive hyperextension of thumb. Diagnosis is based on the major symptom of aching pain at the wrist and thumb, aggravated by motion. Physical testing is the Finkelstein test as described above. 

Considerations for differentiating include: 

• Dorsal ganglion of wrist – Cysts are fluid filled with clear high viscosity fluid. This patient’s swellings are bony and hard, more consistent with De Quervain’s tenosynovitis.

• Carpal tunnel syndrome (median nerve compression within wrist) – This is diagnosed with a positive Phalen’s test of elicited numbness and tingling along median nerve pathway, which includes the second finger. Further testing with patient shows no numbness in second or third finger, ruling out CTS.

• RA (rheumatoid arthritis) – A blood test for RA factor is useful for this diagnosis. Usually, there is symmetric involvement of multiple joints that are inflamed, with redness and warmth. RA symptoms often include symptoms of malaise and fatigue. Patient does not show any characteristic redness or warmth in swelling, or signs of fatigue.

• Cervical radiculopathy of C5 or C6 nerve root – Sensory abnormalities in a distribution involving the dermatome; Patient tests normal for deep tendon reflexes, ruling out cervical radiculopathy.

• Scaphoid fracture in wrist – Can test using tuning fork on scaphoid bone; If fractured, patient will report pain. Patient does not report any accident occurring with onset of pain. Pain first occurred in right wrist and then left wrist. This is more consistent with repetitive stress injury from hyperextension of thumb.

TCM DX: Cold-damp bi syndrome with local channel blockage of Lung and Large Intestine channel. Pain in wrist is less when stick moxa is applied to area. Condition is worse with cold and damp weather. Bi syndrome is characterized by the obstruction of qi and blood in the channels due to the invasion of pathogens of wind, cold or damp, as well as heat or blood stasis. Cold bi is characterized by severe stabbing arthralgia with fixed location, alleviated by warmth and aggravated by cold with white fur on the tongue and tight pulse. Damp bi is characterized by soreness and fixed pain in the joints with local swelling and numbness, aggravated on cloudy and rainy days, with white and greasy tongue coat, and soft or slow pulse. 

PROGNOSIS: Fair; Inflammation of tendons can take several months to heal completely. Reduction of pain is expected through the use of NSAIDS and acupuncture. Plan is to reduce pain by 50% over 7 treatments.

 

Plan

 

Treatment Principle: Move qi, remove meridian blockages with warmth and resolve dampness.

 

Treatment: Patient travels over 4 hours to clinic. Traditionally, any type of tendonitis treatment involves rest, ice, NSAIDS, stretches, modification of activity, possible corticosteroid injection and possibly surgery. Thumb spica splint that immobilizes thumb, preventing hyperextension, may help. 

 

Rest, or modification of activity, is not likely to be viable components of treatment with this patient, who uses her hands for daily chores. 

 

Ice is not available in rural Nepal. Both corticosteroid injection and surgery are outside the patient’s parameters for availability and affordability. 

 

Initial plan includes acupuncture treatment 1 time per week. Placement of the needles are along the Lung and Large Intestine channel that align with the tendons and muscles of extensor pollicis brevis and abductor pollicis longus. The needle direction is toward the bony prominence. Alternating treatments each week with moxa 1 week and electro-stimulation for 20 minutes the following week. Experimenting with a topical NSAID ointment preparation by crushing 2 x 100mg sodium diclofenade tablets and mixing into 83ml container of petroleum jelly. Patient is being treated with oral NSAID of ibuprofen, 400mg TID for 10 days. Patient is instructed to use topical ointment at night after completing chores of the day. Patient is also instructed to wrap thumb with an Ace bandage to prevent hyperextension during the night while sleeping. 

 


Outcome

During first contact, the respiratory emergency was stabilized and patient’s oxygen levels returned to normal ranges for his disease state. After that time, the patient showed relatively stable oxygen levels, less anxiety and was able to sleep through the night. He began sharing his life story, but was not yet able to discuss his death. 

After 3 weeks, the patient presented with +4 pitting edema in his legs that prevented him from putting weight on his feet. He reported sharp chest pains. He became vocal about his death and stopped smiling and laughing as much.

At 4 weeks, the patient reported lowered anxiety and a feeling of increased relaxation. He asked for more practitioner visits, reporting feeling best on days when we came. 

After nearly 30 patient contacts, the patient’s family reported a respiratory emergency with sharp chest pains. Upon arrival, pulse oximeter readings showed a blood oxygen level of 63% with a pulse of 34 bpm and respiration rate of 28. The patient could not maintain consciousness and at some point, could not recognize family members. Cultural traditions around death were already being performed by the family. He died during the night.

Outcome

Patient was tested at sixth treatment with Finkelstein test and reported no pain on right wrist and only slight pain on left wrist. At the seventh and final treatment, she reported an overall 75% reduction in pain. 

Conclusion

The use of NSAIDs to reduce and limit the pain, and reduce inflammation with acupuncture and moxa, proved very helpful for this patient. The swellings in both wrists were quite small in area, superficial and seemed to respond well to topical NSAID preparation. However, for larger areas or deeper inflammation, the topical application would not be useful. 

Dietary changes, such as using or increasing the dosage of turmeric, may aid in the reduction of inflammation. Initial diagnosis was carpal tunnel syndrome. However, with further testing and interaction with the patient, De Quervain’s syndrome became more likely. Both these syndromes are due to repetitive stress injury. Treatment over time changed to focus more on the hyperextension of thumb and associated tendons and ligaments, and less on the wrist compartment.

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