Case Studies

Case Studies

Hemiplegia (Stroke Sequelae) with Acute Lung Consolidation


Stephanie Grant MAcOM LAc
December 2012
OVERVIEW

Acupuncture Case Study81-year-old female presents with complete left-sided hemiplegia following ischemic stroke 2 months ago. Over the course of 7 weeks of acupuncture treatment, the patient regained limited voluntary dorsi and plantar flexion of her left foot, flexion and extension of her knee and elbow, and increased sensation in her left arm. The patient also developed a cough due to fluid in the lower left lobe of her lungs 5 weeks after the stroke, a common concern for patients with limited mobility living in the cold and damp houses of Nepal. The cough was successfully treated with Chinese herbs.

SUBJECTIVE

81-year-old female presents with hemiplegia of the left side as sequela of ischemic stroke. 1 week prior to initial assessment, the patient awoke from resting and was unable to move, her left arm and leg were numb, she could not talk nor open her left eye, and could not sit up by herself. Her family immediately transported her to the hospital where she was admitted for 4 days. At the time of discharge from the hospital, she had regained some limited speech and could open her left eyelid.

Initial exam is 7 days after the stroke. She reports inability to move either left limb and has limited movement of the left side of her face. She describes her entire left side as feeling heavy and numb. The patient tends to feel hot, particularly in the evening, and experiences night sweats. She has no appetite, a slight thirst for cold drinks, blurry vision, dizziness and complains of a dry throat.

Medications upon initial evaluation include Atorvastatin (Lipolow-10) 10mg QD, Aspirin 75mg QD and Ranitidine (R-Loc) 150mg QD.

OBJECTIVE

Patient appears thin, weak and is bed-ridden at time of initial assessment. She is unable to sit upright without assistance. There is no atrophy of muscles on the left side. Her skin is dry to touch, and she exhibits some degree of hearing loss normal for her age.

The patient demonstrates no voluntary motor control of her left limbs. Her left forearm and hand is mostly contracted and cannot be extended with gentle force. She can slightly raise her left shoulder and can easily move her left arm with her right. Her left hip joint is slightly mobile, and there is no apparent contracture of her left thigh and leg. There is no notable temperature difference side-to-side on palpation. Both sides are warm when covered by blankets.

DTR’s all measure +2 on the right and +3 on the left. Dull sensation is intact and equal on both arms and legs. Sharp touch is equal side-to-side on dermatomes C6, C8 and L5, but slightly decreased on dermatomes C7 and S1 on the left side at the distal tips.

The lateral corner of the patient’s left eyelid droops slightly compared to the right, but she can raise and close both eyelids. The patient’s left side of the mouth droops, and she cannot smile equally on both sides. She can puff out both cheecks. She exhibits slight aphasia and hardly responds to questions when asked. There is some moisture gathering at the lateral corners of her mouth and left eye.

Pulse is thin and taught across all positions, floating and rapid.

Tongue is thin and red with a thick, dry, yellow-grey coat.

Acupuncture Case Study

ASSESSMENT

DX: Left-sided paralysis as sequela of an ischemic stroke

TCM DX: Sequela of wind-stroke with wind-phlegm obstructing the channels and collaterals and underlying yin deficiency with empty heat

PROGNOSIS: Guarded as the patient is 81 years old and suffered an ischemic stroke. Factors in her favor include daily acupuncture treatments, continued progress in voluntary movement of her left foot over the first 30 treatments, and dedication from her family in assisting her recovery with constant care and physical therapy exercises at home

INITIAL PLAN

Acupuncture treatments 6 days per week with regular reassessments at 3-week intervals.

Focus acupuncture on clearing wind-phlegm from the channels and collaterals with continuous monitoring of vital signs for evidence of hypertension or pneumonia, both of which pose a greater risk to the patient’s life than post-stroke sequela.

Typical points include: Jiao’s motor region right side upper limb ~ lower limb, left LR3 ~ ST36, GB41 ~ GB34, Ba Feng, GB39, SP6, LI4~LI11, Ba Xie, DU26, CV24, ST4, ST3, SJ23, Yu Yao (~ indicates e-stim between points at 5Hz continuous for 5-8min). Total treatment time is limited to 10-15 minutes, as the patient is easily fatigued by acupuncture.

Counsel patient about twice-daily exercises to flex and extend left toes, foot, leg, fingers, hand and arm. Encourage routine exercises in spite of lack of joint movement. Encourage patient to go outside daily to sit upright in the sunshine and take short walks with the assitance of her family. Teach the patient’s family to massage the patient’s left limbs with mustard oil, gently moving the arm and forearm to full extension to reduce contracture

CONTINUING TREATMENT PLAN
Subjective

4 weeks into treatment, the patient develops a cough with inability to expectorate. She denies fever or chills, sore throat, headache, or tension in her neck and upper back. The little sputum she expectorates is thick, sticky and yellow-grey. She is living on the ground level of a brick and mortar house with hard pack dirt floors. She spends most of her time on a makeshift bed, consisting of a pallet of 3 blankets over top of a plastic tarp to protect her from the cold-damp weather of early winter in Nepal. The patient’s family takes her outside daily in the sun to do exercises and rest in the warmth for a few hours each day. Otherwise the patient spends most of her time lying on her back in this room without electricity or heat.

Objective

Chest auscultation finds high-pitched crackles in the upper lobes, and percussion produces increased resonance in the lower left lobe of the lung. Blood pressure is 160/70mmHg, pulse rate is 68bpm, and pulse oxygen measures 92%. Oral temperature is 98.3 deg F.

Assessment

DX: Possible consolidation of the lower left lobe of the lungs, likely due to immobility and secondary pulmonary hypertension. The exact cause and severity of the fluid in the lower left lobe of the lungs cannot be determined without additional testing.

TCM DX: Cough due to phlegm-heat in the lung PROGNOSIS: Good as the condition is caught early and is monitored with auscultation of breath sounds at every acupuncture treatment. The patient’s living environment will not change, however, and will be a continuous challenge throughout her recovery.

Updated Plan

Acupuncture Case Study

Points added to the initial acupuncture prescription include LU5 and ST40.

Internal formula administered is Qing Qi Hua Tan Wan 8 pills TID for 3 weeks. The patient is also immediately referred to her allopathic physician for uncontrolled hypertension and is prescribed Amlodipine 5mg QD.

Counsel the patient and her family on adequate water intake and proper diet to reduce phlegm and hypertension.

OUTCOME

After 36 treatments, the patient exhibited major changes in the motion of her left foot, and marked improvement in auscultation and percussion of her lungs. She described her limbs as feeling “lighter.” At this time, she was able to walk slowly with the assistance of a walking stick and 2 other people, and she could stand with a walking stick and the support of 1 other person. Her shen/mood became much brighter as indicated by her laughter and smiling during treatments. She began to look forward to walking with her goats in the fields again.

The patient’s left knee could actively flex and extend through 90 degrees range-of-motion. She could plantar and dorsiflex her ankle 5 degrees and dorsiflex her great toe voluntarily. The other toes could dorsiflex with needle stimulation. She could flex her left elbow 10 degrees and extend 5 degrees, but she continued to be unable to move her left fingers and wrist. Contracture of the left forearm significantly reduced with regular home massages, and the patient reported pain and tingling in her left arm after massage and acupuncture. Sharp/dull touch became equal side-to-side, while DTR’s on the left were still at +3. The patient was also able to sit upright on her own for long periods of time without assistance, and her speech became much clearer and easier to understand.

The patient described her lungs as feeling less congested, and she found it easy to expectorate phlegm. Her lungs sounded markedly clearer on auscultation. High-pitched crackles remained, but there was no longer resonance on percussion of the lower left lobe. However, the lower right lobe exhibited some slight resonance with percussion. Her blood pressure reduced to 130/72mmHg, pulse rate was 72bpm and pulse oxygen increased to 96%.

Her tongue was thin and slightly red with a clear dry coat. Her pulse was slightly rapid, thin and taught across all positions.

CONTINUED TREATMENT

The patient will need continued daily acupuncture treatments with emphasis on clearing wind-phlegm from the channels and collaterals. The patient’s blood pressure and lungs should be routinely monitored. Her physical abilities should be objectively measured every 3 weeks with emphasis on active range-of-motion, DTR’s, sharp/dull touch and facial muscle testing.

With further resolution of the consolidation in her lungs, herbal treatment focus may shift from clearing phlegm-heat from the lungs to nourishing the patient’s yin and clearing empty heat. The patient should be referred to allopathic care for more testing, diagnosis and stronger medications if the consolidation in her lungs becomes more significant, spreads to more than one lobe, if she develops a fever or if her blood pressure increases above 140/90mmHg.

The patient has responded well thus far to regular acupuncture and herbal treatments, and continued improvement is expected.

CONCLUSION

Routine acupuncture treatments are an effective method for regaining mobility post-stroke, particularly when used in conjunction with supportive home care and regular physical exercises.

In providing daily treatments, the acupuncture physician is in a unique position to serve as a primary care provider, monitoring for other physical ailments which may develop quickly and pose a significant threat to the patient’s recovery. As demonstrated in this case study, routine auscultation of the lungs led to early diagnosis and treatment of fluid consolidation in this patient’s lungs.

 

Palliative Care of Parkinson’s Disease


Tara Gregory MAcOM LAc
Decmeber 2012
OVERVIEW

Acupuncture Case Study62-year-old male was diagnosed with Parkinson’s disease 8 years ago and has been receiving treatment in this clinic since 2009. This case explores the positive role that Chinese medicine can play in providing palliative care to patients living with a chronic degenerative disease.

Subjective

62-year-old male presents with a burning sensation in the body and bilateral trembling of the legs and arms. The burning sensation is felt in the head, knees and soles of the feet. It begins when he wakes in the morning, increases in severity during the day and subsides when he goes to bed. Patient reports that during flare-ups, his trembling and other symptoms decrease.

He experiences bilateral trembling of the legs and arms and trembling of the mouth and tongue. Symptoms began 8 years ago with trembling in the 5th finger on the right hand. It progressed up the arm and eventually lead to bilateral trembling of the arms and legs. Patient’s family reports a lack of tremors during sleep, which resume upon waking. He notices a feeling of stiffness in the whole body, especially pronounced while walking. Patient expresses difficulty in remembering words and completing sentences, and that other people have difficulty hearing him when he speaks. Symptoms get worse with stress, sadness, fatigue, hunger and goat meat.

Associated symptoms include: day and night sweats, vertex headache, positional dizziness, vertigo, excessive salivation, constipation, thirst, pain and hesitancy with urination, mouth sores and difficulty with sleep. Patient expresses an understanding of the chronic nature of his condition and is sometimes overcome by sadness, worry and fear.

Objective

The patient presents with visible bilateral trembling of the arms and legs, and trembling of the mouth. Trembling is more severe in the patient’s arms in comparison to his legs. His voice is noticeably diminished in both strength and volume, demonstrating signs of hypophonia. Patient exhibits bradykinesia of the upper and lower limbs while walking, a slightly unsteady gait and rigidity in movement.

Patient’s tongue is purple with horizontal central cracks and a greasy yellow coat. His pulse is slightly rapid and wiry

Assessment

DX: Parkinson’s disease

The patient presents with the 4 cardinal signs of Parkinson’s disease: resting tremors, rigidity, bradykinesia and postural instability. Associated autonomic dysfunction is also present as seen in the patient’s propensity to suffer from constipation and urinary difficulties. Laryngeal dysfunction and dysphasia, commonly seen in Parkinson’s patients, are observed with softness of voice, vocal tremors and excessive salivation. Relief from symptoms with the use of Levodopa is often used as confirmation of a Parkinson’s diagnosis, and the patient has experienced relief with this medication.

TCM DX: LR and KD yin deficiency leading to fire and internal wind

Prognosis

The prognosis for this patient must bear in mind the chronic and degenerative nature of his disease. The goal of treatment is to provide palliative care to help relieve the symptoms of the disease and the side effects of his medication. Treatment is also aimed at prolonging the effectivenes of his medication and to slow the progression of his disease. Additionally, the goal of treatment is to help the patient psychologically cope with his condition, and will at some point transition into providing a form of hospice care. Given these conditions, there is a good prognosis as Chinese medicine is effective at meeting these goals

Plan

Treat 3 times per week to help moderate symptoms and slow the progression of the disease. Focus on reducing the burning sensation in the body by clearing heat and nourishing KD and LR yin. Internally, use the formula Zhi Bai Di Huang Wan in a dosage of 8 pills TID. Acupuncture point selection includes KD2, KD6, LU7, SP6, LI11, LR2, GB20 and Jiao’s scalp tremor line.

As treatments progress and the burning sensation disappears, expand treatments to focus more on settling wind and helping with speech. The patient is switched to the formula Tian Ma Gou Teng Yin in a dosage of 8-12 pills TID. Acupuncture points are expanded to include TW5, DU15, DU16, CV24 and Jiao’s scalp speech zone.

Treatments can last indefinitely so long as the patient continues to experience positive symptomatic relief. Reevaluate every 12 visits to assess progression of his condition.

Outcome

After 3 treatments, the patient reported a 2/3 reduction in the burning sensation in the head and a complete absence of burning sensation in the knees and soles of the feet. He also exhibited a visible reduction in bilateral trembling during and after treatment. The patient reported that the effects of treatment last for about 2 hours, and extend the effectiveness of his medication. His demeanor and affect became visibly lightened after treatment

Conclusion

The difficulty of and question brought up by this case is understanding the role that Chinese medicine can play for patients suffering from chronic progressive diseases. This case demonstrates that the use of acupuncture and herbs can provide palliative care and help to increase the quality of life for patients by mitigating the symptoms associate with Parkinson’s disease.

Additional questions arise due to the nature of side effects caused by Levodopa, which can help to control trembling associated with Parkinson’s, but also causes trembling and other symptoms normally experienced by Parkinson’s patients. It is difficult to assess how much the treatments address the symptoms associated with Parkinson’s diseases versus the side effects of the patient’s medications.

Ultimately, the effects of treatment are beneficial, as they provide symptomatic relief for the patient, and may help keep the patient on the lowest dose of medication possible for the longest period of time. Furthermore, the effect of acupuncture and tri-weekly treatments to help patients cope psychologically with the reality of their condition, cannot be understated, as many patients with Parkinson’s disease are susceptible to depression. The patient expresses that while he has an understanding of the progressive nature of his condition, coming in for treatment not only provides him with relief from physical symptoms, but also provides him with a sense of hope.

Outer Ear Infection


Natalie Gregersen MAcOM LAc 
December 2012
OVERVIEW

Acupuncture Case Study52-year-old male presents with right-sided, burning head and ear pain, right-sided hearing loss and anosmia. It is determined, after an initial ear examination with an otoscope, that the patient has a severe right-sided ear infection. After 12 treatments, which includes the use of acupuncture, internal and external Chinese herbs and antibiotics, the patient reports a significant reduction in the burning sensation. Objectively, the right side tympanic membrane shows a 90% improvement. There is no change in the anosmia and hearing loss.

Subjective

The patient presents with right-sided, burning head and ear pain that started 6-7 months ago. His symptoms also include right-sided temporal headache, an itchy sensation deep in the right ear, tinnitus that comes and goes and right-sided hearing loss. He reports he can hear people talking, but can not clearly understand what they are saying. Anosmia started 2-3 months after the burning head/ear pain started. The patient reports that it feels like he has a ‘fire’ inside his right ear, and prior to the pain starting, he heard a bug-like sound. He has moderate pain (4/10), which doesn’t interfere with work when he is concentrating on a task. When he is not distracted, the pain is constantly present. Nothing makes the pain better or worse. Although he has loss of smell, he can taste his food.

Objective

The patient appears to be in good health for his age and environment. He’s always in good spirits and maintains eye contact during the interview. He is often joking with the other patients in the room while waiting his turn for treatment.

An initial right ear examination with an otoscope shows a purulent and inflamed tympanic membrane. The entire membrane is ringed with redness with bright red streaks throughout it. There is pus along the superior border and the entire tympanic membrane is severely scarred and cloudy. The left membrane appears normal and healthy.

A strong smelling substance, called Tiger Balm, is held under the nose while the patients eyes are closed. He reports that he is unable to smell it. Both sides of the nose are checked by holding the balm under one nostril while the other is plugged. Anosmia appears to be bilateral.

Hearing loss is checked by using a 128 hz tuning fork. Patient reports that he is able to hear the sound until it is 6 inches away from the right ear. The left ear is also checked. He can hear it until it is 1 foot from his ear.

Pulses are wiry, slippery and rapid, especially in the Liver position. Tongue shows a pale center with red sides and a greasy yellow coat.

Assessment

DX: Severe, right-sided ear infection with anosmia and auditory deficit

TCM DX: Damp-heat in the Triple Burner and Gallbladder channels

PROGNOSIS: Using oral antibiotics, herbs, antibiotic ear drops and acupuncture, a complete recovery from the ear infection is expected. With the treatment of the ear infection, there is a possibility the patient may recover his sense of smell, but the outcome is uncertain. Due to the severe scarring of the right tympanic membrane, full recovery of hearing is unlikely.

Initial Plan

Treat with acupuncture and herbs 3 times per week for 10 treatments before reassessing. Include western pharmaceuticals, such as oral antibiotics and antibiotic ear drops, to clear heat and reduce inflammation.

Focus on clearing dampness and heat in the Liver, Gallbladder and Triple Burner channels.

Typical acupuncture points include: GB20, R-TB17, GB43, TB2, TB5, GB40, GB34, LV3, LI4, ST36, SP10, LI11

Continuing treatment

Initial treatment: Includes oral antibiotics of amoxicillin 3TID for 5 days plus Huang Lian Jie Du Tang 3TID for 6 days

Treatment 4: It was determined that the pus was reduced by 75%. Therefore, the patient was switched to Long Dan Xie Gan Tang 3TID.

Treatment 2-9: External solution was made of 1 Huang Lian Jie Du Tang pill, crushed and mixed with rubbing alcohol. 15 drops of this herbal solution was dropped into the patient’s right ear after his acupuncture treatment.

Treatment 9: It was determined that the patient had plateaued. Therefore, the external herbal solution was discontinued, and antibiotic ear drops at a dosage of 3 drops TID, administered by the patient, was added. Treatment 12: Due to the significant reduction in the patient’s symptoms, the herbal formula Long Dan Xie Gan Tang was discontinued. The patient continued the use of antibiotic ear drops for 2 more weeks.

Outcome

After 12 treatments, the burning sensation was reduced by 80%. Patient reported a constant, mild burning and itchy sensation deep inside the right ear, but it no longer felt like he had a ‘fire’ in his ear.

His tinnitus and temporal headache still came and went, but he also had hypertension, which could be contributing to these symptoms.

Objectively, the tympanic membrane improved by 90%. It was no longer purulent and the redness was concentrated to the upper right quadrant of the membrane. There were no longer streaks and the redness had changed from bright to dark red and looked like a scab.

There was no change in the hearing loss, though the patient was seen talking on his cell phone with his right ear. He was able to make out what people were saying if the phone was held close to his ear. There was no change in the anosmia.

Conclusion

By week 10, the patient’s visits were reduced to 2 times per week. He seemed much less concerned about his head/ear pain and asked to work on other conditions. The patient is using antibiotic ear drops during a 3 week break from treatment and his condition will be reassessed when the new team of practitioners arrive.

This case demonstrates the importance of understanding how to use diagnostic tools, such as an otoscope, in the treatment of certain conditions. This is especially relevant in Nepal where the acupuncturist is often the patient’s primary care physician. The diagnosis and objective observation of an inflamed tympanic membrane provided a clear picture of the patient’s presenting symptoms, guiding the treatment plan. The use of Chinese herbs, in conjunction with western pharmaceuticals, greatly improved the outcome.

Low Back Pain with Radiation


Sarah Richards LMT
December 2012
OVERVIEW

Acupuncture Case Study30-year-old male presents with severe back and left leg pain, exhibiting postural deviation as a way to relieve pain from an L5/S1 disc herniation. When prescription of daily acupuncture and massage was followed diligently, patient experienced a more dramatic reduction in pain, improved posture and attitude.

Subjective

30-year-old male patient presents with severe back and leg pain on left side, with severe postural deviation to relieve pain. Symptoms began 7 months ago with no known cause. Patient has, however, throughout his life, carried heavy bags of rice on his back and head. He complains of sharp pain and stiffness with movement, when standing from sitting or squatting and when walking up stairs. Sharp pain wakes patient at night with movement of left leg or twisting to turn over.

After getting an MRI patient is told that he has a “compressed bone” in low back, but does not know the specifics. He expresses his desire to delay or avoid surgery for his condition.

Pain medication does not provide any relief, and he intentionally stands “crooked” to alleviate severe pain in his low back, but then tries to over-correct in order to look “normal.” He denies experiencing pain or discomfort in upper back or neck. (See photos)

OBJECTIVE

An MRI taken 15 weeks ago appears to show L5/S1 disc herniation with L4/5 disc desiccation, as reported in radiology report. Visual observation of the torso shows lateral curvature of the spine and depression of the left scapula (see photos). When not weight-bearing, lying on massage table prone or supine, spinal curvature corrects to more normal alignment and shoulder blades relax in neutral position.

While standing, and asked to actively straighten his spine, patient feels pain in lower back on the left side with radiating pain in the left lower leg. Trunk flexion produces pain when patient’s fingers are 8 inches from the ground, with pain felt in lower back on the left side with radiating pain in the left lower leg. Trunk extension produces pain in low back only, without radiation, and a left straight leg raise elicits pain at 45 degrees. A left side bend test produces pain in low back, with tingling and radiating pain to lower leg while right side bend elicits no pain.

Mood changes are noticeable and vary depending on level of pain each day, ranging from sullen and angry to hopeful and excited.

ASSESSMENT

 

DX: L5/S1 disc herniation with L4/5 disc desiccation causing severe lower back pain with radiating symptoms to left lower leg

PROGNOSIS: In order to have a long-term positive impact on the patient’s condition, it will likely require frequent treatments for many months. Since the patient travels more than 1 hour to the clinic, often by foot, it is improbable that compliance to a long-term, daily treatment plan is realistic. Consequently, a significant lo

INITIAL TREATMENT PLANng-term result is doubtful.

Daily acupuncture and massage therapy focusing on pain relief for 10 treatments before reassessing.

Typical massage tx: 30-40 minute sessions focusing on releasing fascial and muscular restrictions to reduce compressive forces on affected disc and nerve root, thereby decreasing pain and inflammation giving the disc a chance to heal, and allowing the patient to stand with proper alignment and return to work and regular activities.

OUTCOME

After 14 acupuncture treatments and 11 massage sessions, patient reported mixed results based on frequency of care. Missing only 1 day of massage or acupuncture did not produce a significant set back. However, there was a 5-day break in co-treating, in which the patient received only 3 acupuncture treatments, no massage therapy and experienced a decrease in progress. Subsequently, after missing massage appointments 5 days in a row, the patient returned complaining of an increased pain level; a level similar to which he had been experiencing prior to beginning treatment, stating a pain level of 6 out of 7. Upon returning to the subscribed daily treatment plan, after only 3 treatments consisting of both modalities on the same day, patient reported improvement of low back pain from 6 down to 4, as well as an improvement in posture and mood. As seen in the before and after photos, the change in posture was significant. These pictures were taken immediately following an acupuncture treatment.

Massage techniques that provided the most relief and change for the patient include friction to address bilateral, lumbar paraspinal and erector spinae musculature, compression and friction of the sacral origin of gluteus maximus, tensor fasciae latae and quadratus lumborum (QL). Fascial release to the thoracolumbar region, utilizing flexion of low back in child’s pose (a pain-free position for this patient) proved to be particularly helpful and was thought to be most productive by the patient. In addition, while in child’s pose, having the patient flex laterally allowed access to the transverse processes insertion of QL. In a side-lying position, inferior distraction of the left ilium provided significant and immediate relief to patient. Passive stretching of the left side body, including obliques, QL and latissimus dorsi while patient was supine, added to the ability of the patient to stand taller and straighter.

It is interesting to note that by working primarily on the painful left side, his posture improved and pain decreased more quickly and efficiently than by working primarily on the right side or more bilaterally. (See photos)

Patient was advised to avoid twisting movements and carrying heavy objects. He was also counseled that creating lasting reduction of pain would take many treatments. In order for treatment to have a chance to help him avoid surgery, he will need to take it easy and not push himself to do heavy work, even once he

 starts feeling better, allowing the tissues time to heal

CONCLUSION

Unfortunately, more data could not be collected in this case because the patient discontinued care after only 3 weeks of treatment in order to visit family. Had I been able to continue to treat this patient, I would add abdominal and psoas major releases. I would recommend a course of anti-inflammatory medication and add a component of self-care and education in order to avoid further or recurring injury to the disc.

With frequent visits, his acute symptoms responded to the cotreatment plan of daily acupuncture and massage fairly quickly - within 3 visits. The 2 modalities, combined, show more promising results than just 1 on its own. Overall, it is promising to see how cotreating, specifically with acupuncture and massage therapy, can have a positive short-term outcome on pain and posture associated with disc herniation

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