Case Studies

Case Studies

Low abdomen pain due to roundworm and Urinary Infection


Asiya Mahdiyah Shoot, LAc, MSA
December 2013
OVERVIEW

Acupuncture Case Study30-year-old female presents with lower abdominal pain, burning urination and shortness of breath for the last 5 months. With the discovery and treatment of a parasitic infection, and with concurrent treatment of a urinary tract infection, the patient found significant relief.

SUBJECTIVE

Patient presents with achy, burning lower abdominal pain with burning urination for 5 months. The burning is daily and constant at a moderate level intensity. It is worse during the night and during her menses, which is regular at 28 days. Menstrual flow is heavy, lasting 6 to 7 days. It is dark in color with some clots. She reports dysmenorrhea with burning pain and cramping in the lower abdomen and back, persisting all 7 days of her cycle. The patient also reports 5 months of burning urination that is scanty, dark yellow and cloudy with a sense of burning and achiness in her urethra. She experiences a sense of urgency and urinates 10 to 15 times a day. Furthermore, she reports loose, yellow-colored stools containing mucus starting 3 months ago. She has a bowel movement 3 times a day. She denies visible blood in the stool and reports no burning sensation of the anus.

Patient reports shortness of breath (SOB) for 1 year, which occurs when walking, and is worse at night while lying down. Symptoms have been worsening for the last 4 months with occasional tightness in her throat, wheezing, sore throat and cough, all of which are worse at night.

She reports feeling tired, having poor memory, night sweats and being irritable and anxious, with difficulty falling asleep.

5 years ago, she had a dilation and curettage (D&C) procedure due to a miscarriage. She has 2 children and is not currently pregnant. She denies any vaginal discharge or rash.

OBJECTIVE

The patient appears to be in average constitutional health for her age and environment, but appears fatigued and weak as though she is fighting off a pathogen. She is somewhat thin, and often slouched in the chair under a draped shall. Although her face is somewhat pale, she has flushed, red cheeks and mild, red-tinged eyes. Her palms are damp to the touch. She speaks with a weak voice, and is mentally sluggish, though has many complaints and concerns about her health. She also has a dry cough heard during her treatment visits.

On palpation, the patient is tender and timid. She reports moderate pain that is achy in nature when applying deep pressure to the low abdomen. There is also moderate pain with moderate depth pressure to the mid-abdomen. No tenderness in upper quadrants. Moderate pain on strong percussion of her low back.

No significant findings on auscultation of bowels. Minor wheezing in both upper lobes of the lungs upon auscultation. Vital signs include: Temperature of 98.8°F, oxygen saturation of 98% as measured by fingertip oximeter, and a resting pulse rate of 78bpm.

Her tongue is pale, with red sides and tip. It is fissured, with a thin white coat. Pulses are thin, wiry, a little rapid and slippery

LAB RESULTS

Urinalysis Panel:
Pus cells (2-4 HPF) and “plenty” of epithelial cells; Dark yellow color;
Slightly turbid appearance and acidic pH; Trace albumin; Blood, ketone, bile and glucose are not seen.

Blood Panel:
Hemoglobin 12.0 gm/dL = low range (normal female range is 12.1 - 15.1 gm/dL)
Total leucocyte count: 11,800 cu.mm (normal is 4,00-11,00 cu.mm) = little high
Neutrophils 75% (normal 40-70%) = little high
Monocytes 00% (normal 002-10) = little low
Lymphocytes and eosinophils are in normal range.

Stool Panel:
Most significant finding is presence of ascaris lumbricoide ova (roundworms) along with red blood cells (2-5 HPF).

ASSESSMENT

DX: Urinary tract infection (cystitis); Roundworm infection; Possibility of Kidney infection due to duration, as well as possible infection or inflammation in the uterus. However, low temperature and medium pain upon palpation of low abdomen and back rule out significant infections.

Secondary complaint of dyspnea (SOB)

Explanation: Pus cells (pyuria) in urine indicate some type of infection in the urinary tract. More accurate diagnosis of a UTI requires nitrites to be found in the urine sample. 95% of UTI’s occur when bacteria ascend the urethra to the bladder. The most common bacteria is gram-negative strains of e.coli. In addition, increased white blood cells in the blood lab, specifically high neutrophils and low monocytes, indicate a mild bacterial infection. Hemoglobin levels, being on the low end, is probably due to anemia and malnutrition based on patient’s environment and parasitic infection.

Roundworms are a nematode (non-segmented cylindric worm that ranges from 1mm to 1m in length). They are a helminth parasite (compromising hosts nutritional status) that are transmitted fecalorally when contaminated plants (or soil) with the eggs on them are consumed.

TCM DX: Damp-heat in lower jiao (body): Lower abdominal burning, and burning urination, that is dark yellow and cloudy

LV/KD yin deficiency: Chronic sore and dry throat, knee and low back pain, night sweats, five center heat, feverish, thirsty, dizzy, irritable, insomnia, burning, itchy eyes, blurry vision, burning worse at night

SP/LU qi deficiency: Loose stools, gas, bloating, lack of appetite, fatigue, gastritis, dyspnea, coughing, wheezing

Qi and blood stagnation as indicated by menses

PROGNOSIS

Cure of burning urination and burning low abdomen is highly probable within 2 months, with proper conjunctive care, including acupuncture, internal Chinese herbs and Western medications (antibiotics). Typically, acute bladder infections and parasitic infections are resolved within 48 hours after the onset of medication.

Chronic UTI’s may take up to 1 month to resolve. The SOB is expected to improve 80% within 3 months.

INITIAL PLAN

Treat with acupuncture 2 times per week for 2 weeks. Reassess in 1 week to assess patient’s progress after taking parasite medication. If burning urination is not resolved, administer antibiotic medication. In addition, sanitation and hygiene is discussed with the patient, along with recommendation to increase water intake, consume cucumber juice and accessible antibiotics in diet such as raw garlic, to decrease the burning urine.

Acupuncture: Focus on points to clear heat and remove toxins, especially from the lower jiao, nourish yin and blood, Lungs, Spleen and Stomach.

Common points used: LI11, LI4, LV3, KD6, LU7, SP4, SP6, ST36, CV3, CV4, CV14

Alternative points: LV2, KD2, KD3, SP10, KD10, UB13, LU9, CV6, CV12, P6, HT6, TB6, SP8, Zigong

Chinese herbs: Huang Lian Jie Du Tang 3TID for 2 weeks to clear internal heat, then Dang Gui Liu Huang Tang 3 TID to clear yin deficiency heat

Allopathic medicine: Albendazole (400mg PO once) is administered for roundworms. Ibuprofen (400mg TID) is given for 5 days upon first visit.

Subjective: 9 days after initial visit, the patient reports her stools being less yellow and more formed. She is still experiencing burning urination with burning pain into her urethra, but reports a 20% reduction in symptoms with treatment. She urinates 8 times per day and 3 times per night.

UPDATED PLAN

Acupuncture treatment 2 times per week for 2 weeks to clear UTI and decrease lower abdominal pain.

Trimethoprim/sulfamethoxazole (160/800 mg PO BID) for 10 days is given for UTI. This medication is later extended an additional 4 days due to unresolved symptoms.

Stool and urine to be retested in 1 week.

OUTCOME

19 days after initial visit, the patient reported her stools being formed, 2 times a day, and no longer yellow. The burning in the low abdomen was still daily, but less at night and had decreased in intensity by 70%. She was able to tolerate deep-level palpation to her low abdomen with mild tenderness. The burning urine was 50% less, but still bothersome, with burning pain into the urethra. She was urinating 5 times per day and 3 times at night. Her temperature was 98.5°F. She visibly looked more energized with less redness in her eyes.

The patient reported it being easier to breath and coughing less. She still experienced minor wheezing, heard upon auscultation, but it was less oppressive.

There was also less gastric pain in the mid-abdomen, and only mild tenderness upon deep palpation. Her night sweats and sore throat were also less frequent.

A follow-up stool panel indicated that the helminthic (roundworm parasite) ova and microscopic blood was no longer present.

Urine lab showed pus cells at 3-5 HPF and epithelial cells at 4-8 HPF. Color was light yellow, appearance still slightly turbid, pH acidic and with trace levels of albumin.

CONCLUSION AND FUTURE PLAN

This is a case where the patient was reporting a multitude of health complaints that seemed unrelated, and complex. This was compounded by her reluctance to report significant details about her health history. On previous visits to this clinic, practitioners focused on her knee pain and burning itchy eyes, which was mostly resolved by the time I saw her. Her burning lower abdomen and urination was listed among her secondary complaints, but was not found to be significant. This case shows the importance of discerning between signs and symptoms, providing integrative care, and trusting one’s instinct to direct proper care and plan-of-action, including the ordering of proper lab panels. This treatment approach exposed and properly treated the roundworm infection.

Thus far, this patient successfully experienced reduction in burning urination, burning low abdomen pain, and a host of other conditions, including SOB. The SOB was likely due to roundworm infection since the larvae move via the bloodstream to the lungs where they are coughed up, swallowed, and travel back to the small intestines where they mature into adult roundworms. Common symptoms of roundworm infection include coughing, shortness of breath and wheezing. If not resolved in the next month, a proper assessment of asthma needs to be done, and possible administration of asthma medications (bronchodilators beta 2-agonists, anti-cholinergics or corticosteroid etc.) may be needed.

The increased number of pus cells in her second urine test indicated that a urinary tract infection was persisting. Trimethoprim/ sulfamethoxazole (160/800 mg PO BID) was extended to 14 days.

If the burning abdominal pain and urination is not resolved within 2 weeks, a stronger antibiotic may be needed. Other causes of pus cells in the urine should be considered, including sexually transmitted diseases, kidney stones, other infectious pathogens such as candida, or even tuberculosis in the urinary tract. Though not likely, cancer must also be considered. Her temperature should be monitored. It may also be necessary to order a gynecological examination to rule out infection, inflammation or scarring caused by the D&C.

Acupuncture and herbal treatments should be continued into the future, 2 times a week for 10 weeks, with focus on tonification and to move qi/blood in the lower jiao. Probiotics, iron supplement and a multivitamin with B-complex should be considered. In 3 months, the patient should be checked again for roundworm eggs. If the case is not resolved within this 10 week period, she should be referred for an ultrasound or CT scan to examine her kidneys and ovaries.

Chronic Abdominal Pain


Felicity Woebkenberg MAcOM LAc
October 2011
Overview
Acupuncture Case Study

31-year-old male presents with chronic abdominal pain. The patient has suffered from abdominal pain for the past 11 years, but has had a worsening of symptoms in the past year. Case analysis after 11 visits over 2 months.

SUBJECTIVE

Patient presents with pain in the epigastric, umbilical, hypogastric, lumbar and iliac regions. The patient describes the pain as burning and sharp in nature, worse after eating, and migratory in nature. Symptoms have occurred gradually over time (starting 11 years ago), but have increased in severity over the past year. The patient had an endoscopy 5 months ago. The results were negative. The patient states that he has trouble maintaining his weight (most likely due to malabsorption), and in the past has had diarrhea stools as often as 6-7 times per day. Currently, this patient is having 1-2 stools per day, which at times are small in amount and often feel as if they are incomplete (and also described as “goat- like stools”). He denies blood or a tarry appearance to the stool, but states that at times there is some visible mucous. He has abdominal cramping and sensations of nausea without vomiting, prior to bowel movements, that are relieved after defecation. The patient also states that he gets frontal and temporal headaches prior to bowel movements with relief after defecation. The patient describes a bitter taste in the mouth after meals. In the morning, the patient awakes to belching, foul breath, liquid in the mouth and a bitter taste. The patient describes the liquid as watery, slippery and light green to black in color. The patient has also described intermittent low-pitched ear ringing, as well as intermittent itching to the skin with a mild redness and rash. The patient states that all of his symptoms are worse with spicy and greasy foods. The patient feels warm overall. His primary emotion is frustration and anger. He has difficulty resolving conflicts with others and avoids challenging situations. The patient denies any significantly stressful life events during the time that his symptoms progressed over the past year. He has high-pitched tinnitus in both ears. The patient has a family history of an aunt who also had a similar condition with similar symptoms who died at the age of 40.

Typical diet: Dhal and rice, potato’s, minimal spicy foods, no alcohol

OBJECTIVE

Acupuncture Case StudyThe patient appears thin and somewhat malnourished and deficient. His cognition appears to be intact and his speech is age appropriate. He is visibly disturbed by his illness and there is a sense of desperation in his search for a solution. The sclera of his eyes have a red tint and he occasionally has watery and itchy eyes. He has a stye on the superior, left eyelid.

He is extremely reactive and tender to palpation particularly in the left upper and lower quadrants, as well as within the hypochondriac region on the right side just inferior to the 10th rib. The patient winces with pain upon palpation and needle insertion. Upon auscultation, hyperactive bowel tones can be heard in all 4 quadrants. The Liver and Gallbladder appear to be inflamed and exceptionally tender upon examination. The patient is referred to the health post for lab testing to rule out possible cholelithiasis and hepatitis. Labs drawn include bilirubin total and direct, AST, ALT and amylase. All results within normal range.

Pulse: Wiry/slippery and bounding superficially, deficient at the base

Tongue: Red, no coat (peeling particularly on the left side of the tongue), with red prickles to sides and tip.

ASSESSMENT

DX: Possible chronic parasitic infection, IBS, malabsorption syndrome, H. Pylori-Gastric Ulcer or Crohn’s disease

TCM DX: Acute: Damp-heat in the LR/GB overacting on deficient SP/ ST (with possible deficiency heat) Constitution: Spleen Qi deficiency leading to the accumulation of damp.

PROGNOSIS: Due to the length of time that this patient has had this condition, it is likely that this will take a significant amount of time for the gastrointestinal tract to heal.

INITIAL PLAN

Treat with acupuncture 2 times per week for 10 treatments and then reassess. Focus on points to tonify the Spleen, move stagnation, and eliminate dampness in the middle jiao. Internal herbal treatments include: Huang Lian Jie Du Tang, Gui Zhi Gan Jiang Tang, Stomach Formula, Er Chen Wan, Zi Sheng Wan and Intestinal Fungus Formula. Warm needle moxa on ST36. Dietary considerations, such as avoiding overly spicy foods, greasy foods and uncooked meat are discussed.

Typical treatment: ST36 (tonify qi and blood), SP6 (tonify qi and blood), ST25 (tonify intestinal function), SP15 (tonify intestinal function), CV6 (tonify SP/ST), CV3 (reduce damp-heat), CV12 (tonify yin organs and ST), LI 10 (tonify), PC6 (tonify SP/ST and reduce nausea), LR13 (reduce and harmonize the SP and LR), LR5 (reduce dampness and heat in the lower jiao), LR3->(angled towards)LR2 (reduce excess fire in the LR), LR14 (reduce excess in the Liver), GB24 (reduce excess in the Liver).

OUTCOME

After 11 treatments, the patient failed to experience significant improvement. Further diagnostic testing (including eosinophils, Hgb, Hct, stool evaluation) to evaluate for a possible chronic parasitic infection or gastrointestinal bleeding was ordered. All test results were negative. The patient was asked to bring in a sample of the black/greenish liquid that he has in his mouth in the morning in a sealed container for examination and objective data.

The patient progressed from 6-7 bowel movements per day to 1-2 per day. He became much less needle sensitive as the treatments progressed.

CONCLUSION AND REVISED PLAN

Further testing, consistency and continuity of care is necessary to properly evaluate this patient, create an appropriate treatment plan and a healing and trusting relationship. Test with herbs for at least 2-3 weeks, in addition to acupuncture 2-3 times per week for another 10 treatments before reassessing. Continue to provide encouragement and consider possible underlying emotions that may exacerbate the patient’s symptoms (when diagnostic testing has ruled out other possible causes).

Discontinue Intestinal Fungus Formula.

Initiate Gallbladder inflammation test: ¼ cup of olive oil by mouth; Monitor for changes in symptoms for the next 24 hours. If the test is positive, refer for ultrasound of Gallbladder.

Consider Jia Wei Xiao Yao Wan 10 pills BID for 2-3 weeks for both excess and deficiency symptomology. Emphasize importance of consistent herbal plan to measure herbal efficacy.

Chronic Headache (Typhoid Fever Sequela)


Stacey Kett MAcOM LAc
October 2011
Overview

Acupuncture Case Study

43-year-old female presents with a severe headache. 9 months ago, the patient contracted Typhoid fever. During the illness, she had a headache that covered her entire head and a mild fever for 5 days. She has had severe headaches ever since. Acupuncture is providing some relief from the headache, but she needs more consistent treatment. Case analysis after 7 visits over two months.

SUBJECTIVE

The patient presents with a headache located primarily in the temporal and vertex regions. Light and sound do not trigger the headache. She has sinus pressure that contributes to the pain. Her sense of smell is inhibited by the sinus congestion. She presents with occipital neck pain further aggravating the headache. Her hands and feet are cold and sweaty during the day. She sweats profusely when the pain is severe and at night. Her digestion is normal. Menstruation is regular with 4 days of bleeding, 2 of which are heavy.

Medications: PRAN 10 (Propanolol HCL) - a beta blocker used for hypertension, anxiety and panic; Depthyline 25 (Amitriptyline Hydrochloride) - a tri-cyclic antidepressant; Paracetamol 500 mg (Acetaminophen/Tylenol); Anims - pain reliever

OBJECTIVE

Patient appears to be in good health for age and environment.

Tongue is dusky and red. Pulse is deep, thin and rapid.

Blood pressure: 135/109;Heart rate: 110; Follow-up BP measurements: 128/82 and 128/98

The occipital and frontal sinuses are tender upon palpation.

An imaging study CT/MRI was done within the last 6 months and showed no abnormalities in her brain.

Assessment

Acupuncture Case StudyDX: Headache from the sequela of Typhoid fever, sinus blockage, occipital neck pain

TCM DX: Blood stagnation in GB/LV channels, blood deficiency due to the febrile disease, phlegm in the LI and BL channels, qi and blood stagnation in the BL channels

PROGNOSIS: This is difficult to treat due to the fact that the patient lives 2 hours away and is not able to come for consistent treatments. If she is able to come for more regular treatments, the prognosis will be better.

Initial Plan

Treat 3 times per week for 10 treatments before reassessing. Focus on building and moving the blood in the channels, clearing the blockage in the sinuses and moving blood and qi in the occipital region. Five day course of Xue Fu Zhu Yu Tang to help move the blood and stop the pain.

Typical treatment: HT8, HT3, SP10, TB5, GB41, GB20, BL10, Bi Tong, BL2, GB8, Tai Yang, Yin Tang, BL7, SP6, ST36, BL60

Outcome

The patient came to the clinic 7 times. She came in 2 sets of treatments. 1 was 3 treatments every other day and the next set was 4 treatments in a row. The treatment sets were 3 weeks apart. She noticed after the first set of treatments that her hands warmed-up and she stopped sweating at night. Her headache was better and she had less sinus congestion and pain. The second set of treatments yielded a reduction in pain and an increased sensation in her hands and wrist.

The severity of her headache decreased by 50% during the treatment plan, showing that she responds well to acupuncture. She was advised to increase the frequency of treatments. However, because she lives far away, she is not able to come as often as would be necessary to significantly affect the pain level.

Conclusion

This case is incomplete and more information is needed on several topics. The frequency of the headaches is not understood or charted. Which medications are being used is not clearly understood and were charted on 2 separate days indicating that I may not have all the information. The treatment that she received for the Typhoid fever is not known, nor do we know what her other symptoms were from the Typhoid fever. The course of Typhoid fever can include a dormant period of the pathogen. Therefore, if treatment was not given, she may be a carrier, and the bacteria may present itself at a later date. More information is also needed for a clear TCM diagnosis. Are there other LV/GB signs? Are there true heat signs?

After analysis, it is clear that acupuncture treatment had good results, despite the lack of a full diagnostic work-up. However, a more comprehensive exam is necessary to further progress this case further. The herbal treatments may have been too short-term to properly evaluate its therapeutic benefit.

Cervical and Lumbar Spondylosis


Danielle Lombardi MAcOM LAc
October 2011
Overview

Acupuncture Case Study

70-year-old male presents with severe cervical and lumbar pain, neuropathy of the arms, hands, legs and feet, incontinence of bowels and anal rash. His doctor has advised surgery. After 8 treatments he is able to sustain 40 -50% relief of pain for 4 days.

SUBJECTIVE

Patient presents with severe lumbar and cervical pain, reporting bilateral heaviness, weakness and tingling sensations in his arms and legs. He reports that the neuropathy is worse in his left arm, but is present in all 10 of his fingers, and brought on by cold water and cold temperatures. The tingling in his right leg is worse than in his left leg. Patient also has incontinence of bowels, occuring 4 to 5 times per day. Bowel movements are urgent, formed and easy to pass, but there is pain due to a rash around his anus. He reports feeling hot inside his body, especially at night. His doctor has advised surgery, but he is hopeful that acupuncture might reduce his pain enough to avoid surgery.

The onset of neck pain was 4 to 5 years ago, and the onset of back pain was 8 to 9 years ago. Patient relates his pain to a history of heavy labor, working as a field digger and brick carrier. For years he carried more than 60 kg on his back, but now he is unable to lift 200 g of weight. The pain came on gradually, but has become severe in the last year.

The limb neuropathy began 14 months ago after being hit from behind by a bus. He landed on his right medial knee, upper thigh, chin, nose, forehead and right anterior shoulder. There were no broken bones, but an MRI which was ordered on 4/13/11 revealed nerve damage. After the accident, he was unable to grasp food properly, count money or hold a glass.

The neuropathy radiates from the neck, down the right arm and into both hands. Patient reports heaviness, weakness and tingling in all fingers, but denies pain in the limbs. He can feel warm and cold, but he reports subjective numbness in both hands.

Patient reports no change in pain or neuropathy with time of day, but cold weather makes it worse and heat makes it better.

The neck and back pain are severe, and the symptoms are constant.

In the right leg, patient reports a cold, tingling sensation from sole to knee, which is most intense between the lateral ankle at GB40 and the lateral leg at GB34.

OBJECTIVE

Patient appears to be in relatively good health, but severely challenged by the pain in his neck and low back. He is unable to perform AROM and orthopedic tests due to the severity of his pain. He is unable to walk without support from his wife, and exhibits severe pain when standing up or beginning to walk. He also has difficulty balancing when standing up, almost falling over.

Sharp/dull test on the fingertips, arms and toes show no objective numbness. DTRs on bicep, triceps, brachioradialis, patella, hamstring and Achilles are normal. Grip strength is 50% weaker in left hand than right. Nail bed blanching shows normal circulation in both hands and feet.

Cervical AROM shows full range-of-motion with flexion and lateral flexion, extension and rotation, but with report of severe pain with motion. Cervical compression test increases neck pain and heaviness in arms. Cervical distraction test brings relief to neck pain and heaviness in arms. Upon palpation, there is severe pain and tenderness at left C2-C4 and right and left C6 and C7.

Lumbar flexion AROM is 80 degrees (normal 90) with pain on motion. Extension is 15 degrees (normal 30) with pain on motion. Lateral flexion is 20 degrees (normal 30) with pain. Rotation shows 25 degrees (normal 30) with pain on motion.

There is no radiation of pain with exams.

The muscles along the neck and back present with severe rigidity upon palpation. It is difficult to insert a needle without bending due to tenseness of erector spinae musculature.

Tongue: purple-red body, thin bright pink tip, slightly deviated to the right, transverse cracks and purple sublingual veins.

Patient records include:

April 13, 2011: CERVICAL MRI: 

Cervical spondylosis of C4–C7
Bulge of disk posterocentral at C3–C4
C4–C5 (posterocentral protrusion of disk); narrowing of bilateral neural foramina with possible impingement of bilateral existing nerve roots
Diffuse bulge of disk with left posterocentral protrusion at C6–C7 with indentation of thecal sac and cord – possible impingement of existing nerve roots
Slight increased signal intensity in the cord at C5-C6 level with myelopathy 

LUMBAR MRI: 

Lumbar spondylosis
Right-sided spondylosis at L4 – minimal anterolisthesis of L4 over L5
Mild bilateral posterolateral bulge of the disk at L1–2, L2-3, L3-4 with mild narrowing of bilateral lateral canals
L4–L5 disk bulge/posterocentral protrusion – stenosis of bilateral lateral canal and neural foramina
Bulge of disk with annular tear and posterocentral protrusion at L5–S1 with mild compromise to central and lateral canal – no nerve root impingement
T2 sagittal image of dorsal spine shows minimal posterocentral bulge of the disk at T8–9, denting the thecal sac 

ASSESSMENT

DX: Cervical spondylosis of C4-7, with nerve impingement at C5-7 and disk bulges at C4-7; Lumbar spondylosis, with right-sided spondylosis at L4, and disk bulges at L1–5

TCM DX: Bone bi syndrome; qi and blood stagnation of Bladder channel and Governing Vessel at cervical and lumbar regions due to and compounded by history of overwork and trauma; Underlying Kidney yin deficiency creating a malnourishment and deformity of bone, leading to qi and blood stagnation transforming into qi and blood deficiency; Qi deficiency and stagnation in the channels leading to neuropathy in the hands and feet

PROGNOSIS: Due to the physical deformity of the cervical and lumbar spine, complete recovery is unlikely. With continued acupuncture treatment in conjunction with stretching, traction, massage, electrostimulation and cupping, a decrease in pain and neuropathy is likely. The aim is to avoid or delay surgery for as long as possible with consistent acupuncture and conjunctive therapies.

INITIAL PLAN

Patient is treated at the clinic 3 to 4 times per week for 1 month, after which treatment progress will be assessed. Focus on Hua Tou Jia Ji (HTJJ) points in the cervical and lumbar regions to stimulate qi and blood circulation in local areas of degradation, disk bulging and pain. Teach patient stretching and exercises to reduce pain. Nourish Kidney yin, tonify qi and blood, move qi and blood.

Typical treatment: Acupuncture: HTJJ points needled deep at C4-7; HTJJ points at L1-5 needled wide and deep and angled medially, with bilateral electro-stimulation at 5 continuous frequency for 30 minutes; Electro-stimulation from S2 to DU2 bilaterally at 5 continuous frequency for 30 minutes; BL40, KI7, LR3

Cupping: Bilaterally along Bladder channel from cervical to lumbar region x 10

Massage: Tiger Balm or Bai Jie Balm applied with massage and pressure point therapy to neck, shoulders and low back

Traction: Neck and arms with a focus on neck for 10 - 15 minutes and arms for 2 minutes

OUTCOME

After 8 treatments, the patient reported 40 – 50 % improvement that lasted for 4 days after treatment. He also reported less pain with bowel movements due to the disappearance of the anal rash, as well as a 50% increase in his bowel control. He reported being able to walk for an hour and a half without trouble, and appeared to be able to sit, stand and walk without the distress that he exhibited in his first several visits to the clinic. Upon palpation, his musculature was also much less rigid than before.

CONCLUSION

This patient presented with a difficult case due to severe pain, the pressure of impending surgery and no significant change until treatment 7. This case teaches the importance of having the patience to adhere to the treatment plan. The strategy is now revised to a longterm plan of 3 visits per week for 6 months, after which the need for surgery will be reassessed.

With continued treatment over the next 6 months, the intention is to manage pain, regain balance and agility, reduce the neuropathy and regain bowel continence. Future treatment should be focused on acupuncture with conjunctive therapies: electro-stimulation, cupping, traction, stretching and massage.

Follow Us on Facebook

News Archive

Featured Case Studies

  • Lumbar Stenosis due to Osteoartritis +

    Sarah Martin MAcOM LAc November 2012 OVERVIEW 36-year-old Read More
  • Facial Paralysis (Bell’s Palsy) +

    Jennifer Walker MAcOM LAc December 2011 Overview 35-year-old Read More
  • Chronic Abdominal Pain +

    Felicity Woebkenberg MAcOM LAcOctober 2011 Overview 31-year-old male Read More
  • 1
  • 2

Your Donations Help

In addition to volunteering their time and energy, our practitioners are required to raise the money it takes to support their efforts at our clinic. Please consider helping them by making a tax deductible donation in their name.

DONATE NOW

Support Us