Case Studies

Case Studies

Bell’s Palsy (Facial Paralysis)


Joey Chan BHkin Dip AOMj RAc
February 2013
OVERVIEW

Acupuncture Case StudyA 50-year-old female with Bell’s palsy presents with hemi-facial paralysis involving the eye and the mouth. After 5 weeks, 10 acupuncture treatments and 2 months of Chinese herbal medicine, she experienced a 90% recovery.

Subjective

Patient is a 50-year-old female presenting with right side paralysis of the face involving the forehead, eyes and mouth. The paralysis developed suddenly, 1 week prior to her first consultation at the clinic. Patient recalls having a low fever and chills for 3 days, with a slight sore throat and cough. On the 4th day, she woke with hemi-facial paralysis marked by an inability to close her right eye, with additional tearing and swelling of the right eye. She reports she has not slept at all for 7 days because her affected eye will not close. Patient describes symptoms of forehead pain and tightness, which can lead to twitching of the eye during severe pain. She also reports eye twitching when she is in a cold environment.

She experiences constant vertex and occipital headache, described as deep and moving pain, in addition to sharp pain behind the right ear. The left side of her mouth is being pulled and is tight, while the right side of the mouth is painful. She describes her face as being numb and drying up. She also feels chills and dizziness, usually in the morning and evening. She states that her overall body temperature alternates between hot and cold, though her hands and feet always feel cold. She reports her energy is very low, her body feels heavy, and she has no appetite. She is losing her sense of taste. She states that there has been no improvements since the incident and she has not seen any other health care providers.

OBJECTIVE

Patient appears to be weak and has low energy. She is thin with her cheekbones protruding. She talks in a quiet and slow voice. She looks tired and her eyes are always looking down. The right side of her face is expressionless and the left side is tight. The patient’s right eyelid droops down covering ¼ of her eye. The patient’s right eyebrow and
eye is asymmetrical to the left, with the right side sitting ¼ inch lower than the left side. 

Facial expression tests of the seventh cranial nerve consist of blinking the eyes, closing the eyes, wrinkling the forehead, smiling and frowning. When tested, patient is unable to close her left eye or blink. She can only close the eye ¼ of the way. The patient’s right forehead does not wrinkle when compared to the left side. The patient refuses
to smile and frown when asked. Sharp/dull sensory test shows lack of differentiation on the right side of the face. Motor facial tests of saying the sound “E” and “O” show asymmetry of the mouth. Saying “A” is symmetrical.

Patient’s demeanour appears low and her eyes dull. Her face color is dark and dull and her nails are pale. Her tongue is dry with a red heart tip, white coat and a quiver. Her pulse is deep and weak and very faint on the right.

ASSESSMENT

DX: Asymmetrical facial expressions of the right side of the forehead, eyebrows, eye and mouth and the loss of taste shows that the seventh cranial nerve is affected, leading to the diagnosis of Bell’s palsy. Damage to the orbicular oculi is shown from the lack of passive eyelid movement. Occipitalis and frontalis muscles responsible for lifting
the eyebrows and wrinkling the forehead are also affected. Mentalis, risorius, levator labii superioris and depressor labii inferioris damage is seen from the asymmetrical facial expressions of saying E, O and smiling.

Damage of the seventh cranial nerve affects the taste sensory of the anterior 2/3 of the tongue.

TCM DX: External wind-cold attack of the Bladder Taiyang channel leading to blockage in the Bladder Taiyang and Stomach Yangming channels, with underlying qi and blood deficiency and dampness from Spleen qi deficiency.

The patient’s symptoms began with a wind-cold attack, presenting with fever and chills, slight sore throat and cough. The wind-cold entered the Bladder and Stomach channels of the face, leading to wind invasion and blockage of these channels. Wind-cold symptoms shown are vertex and occipital headache around BL10, pain at SJ17 on
the right side, twitching of the eye that is worse in a cold environment, and a quivering tongue. Blockage along the Stomach and Bladder channels on the face is shown by hemi-facial paralysis and lack of sensation on the face.

Qi and blood deficiency signs and symptoms are fatigue, poor appetite, dull eyes, dull and dark facial complexion, pale nails, numbness of the face, dry tongue and a deep weak and faint pulse.

Dampness signs are shown on the tongue with a white coating, as well as a heavy feeling in the body.

PROGNOSIS: Patient seeks treatment at this clinic 1 week after onset of initial symptoms. Improvement is more likely due to early diagnosis and treatment. Significant improvement may be possible with a course of 10 acupuncture treatments and 2 months of Chinese herbal medicine.

PLAN

Treatment principle: First expel wind-cold and then tonify Spleen qi and blood and resolve damp.

Treatment: Acupuncture 2-3 times per week for 10 treatments before re-evaluating; Herbal treatment for 2 months.

Treatment approach is to expel wind-cold in the Bladder Taiyang channel, treat locally on the face to unblock channels, tonify qi and blood and resolve damp.

Typical treatment: BL2, BL10, GB8, ST4, ST5, ST6, DU14, DU20, SJ17, Yu Yao, SP6, ST36, LI4. Other points included are ST40, SJ5, SI19, SJ23, DU16, GB2. A technique of pulling the drooping eyelid up prior to needling is used. Local eye and mouth points are used on the right side. Electro-acupuncture is used on the face from the eighth treatment onwards when she had more qi and blood to support stronger stimulation. The electro-acupuncture setting is 100/2 hertz with mixed macro amp for 20 minutes. Typical electro-acupuncture points connect SJ17 to DU16 and ST3 to ST5. 

Jing Fang Bai Du San and Chuan Xiong Wan are given for 2 weeks to expel wind-cold. Jing Fang Bai Du San tablets are given for 3 days, TID. Then Chuan Xiong Wan tablets are given for 11 days, TID. 

The formula is then switched to Gui Pi Wan for 2 weeks to tonfiy qi and blood. Xiang Sha Liu Jun Zi Tang is given for a week, afterwards, to tonify Spleen qi and move damp. 3 weeks of Yu Ping Feng San is given after the last acupuncture treatment to tonify wei qi.

Patient is advised to eat more meat, egg or alternative protein in order to increase her energy, qi and blood. Patient is also advised to do facial exercises of saying “A, E and O.”

OUTCOME

At the fourth consultation, the patient reported that there was no more pain in her forehead, with only an occipital headache. Her sense of taste returned. She reported not feeling the needles on the right side of her face during the initial treatment, but could now feel the needles.

Her demeanour and energy appeared much better. Her eyelid drooped down to cover 1/8 of her eye and she was able to close her right eye ¾ of the way. She was finally willing to show her smile. It was asymmetrical. The right side of her mouth was still expressionless and the left side tight. The patient could now differentiate between sharp/dull sensations on the affected side. The patient’s tongue had a red tip, thick white coat and no tremor.

From treatment-to-treatment, there was considerable improvement. There were visible improvements of the eye and mouth. With each visit, she had more strength in her voice, and color in her face.

On the eighth treatment, she asked if she could discontinue treatment since she felt 80% better. Her eye and forehead had the most significant improvements, though the patient’s mouth was still asymmetrical. Her pulse was weak, but stronger than before.

She was advised to come for the full 10 treatment since she was not fully recovered. At the tenth treatment, all tests were performed and an improvement was shown in all the tests. The patient could close her eyes fully and blink properly. Facial expressions of raising the eyebrows were symmetrical. Sharp/dull sensory tests showed the same sensations on both sides. Motor facial tests of saying the sound “E” and “O” showed slight asymmetry of the mouth. Patient reported a good appetite. She was sleeping 9 hours per night without interruption, she had more energy and her body felt lighter. There was slight pain behind the right ear and the left side of the mouth was slightly tight.

After 10 acupuncture treatments, she was not able to come anymore. Therefore, 3 weeks of Yu Ping Feng San was prescribed.

CONCLUSION

This patient showed rapid improvement from acupuncture and herbal medicine for Bell’s palsy. She showed a significant improvement from acute Bell’s palsy with herbal medicine and 10 acupuncture treatments 2- 3 times per week for 5 weeks. The patient was given 3 weeks of herbal medicine to boost her immune system after her 10th
acupuncture treatment. For this patient, 20 acupuncture treatments would be a more appropriate course of treatment. 90% recovery was shown with 10 treatments. If recovery is to follow the same course, full recovery may be possible at 15 acupuncture treatments; and 5 more treatments after to strengthen her immune system. This case demonstrates that with early diagnosis, and continuous and frequent treatment of acute Bell’s palsy using acupuncture and Chinese herbal medicine, significant results are highly possible.

Acupuncture Case Study

3rd visit - eye closed half way

 

Acupuncture Case Study

6th treatment - saying the sound “E”

 

Acupuncture Case Study

8th treatment - eye closed with no gap
More color in face, more energy, gained weight

 

Acupuncture Case Study

10th treatment- saying the sound “E”

 

 

 

 

 

Ischemic Cerebrovascular Incident


Emma Goulart LAc 
February 2013
OVERVIEW

Acupuncture Case Study60-year-old male presents with sudden onset of motor deficit of right hand, tingling and weakness of right foot, as well as marked changes in function of glossopharyngeal and hypoglossal nerve. Within the course of 15 acupuncture treatments, including electric stimulation and moxibustion, there are marked improvements in motor function testing of right hand, a decrease in sensation of tingling and pain in right foot, reduced pain in the ball of right foot and a cessation of headaches.

Subjective

Patient is a 60-year-old male who presents with compromised motor function in right upper limb. The onset of symptoms started 7 months ago, reaching maximal deficit over a half hour period, affecting the right upper and lower limbs. There is suspected glossopharyngeal and hypoglossal nerve involvement due to changes in throat and tongue function.

At his hospital visit, he was diagnosed with left-sided ischemic stroke, prescribed 6 different medications, as well as shown several physiotherapy exercises to do at home.

Prior to his stroke, he had no symptoms of dizziness, pain in the chest, nausea or vomiting, nor any other abnormal signs. Patient was actively being treated for hypertension prior to stroke. The patient is mostly concerned about his right hand, since it is preventing him from being able to work. Most of his frustration is due to the loss of control of movement in his right hand. He also mentions right leg weakness and slight tingling and pain on the dorsal aspect of the foot. Further questioning reveals the feeling of weakness is caused by painful knotting on the ball of his foot.

Since the incident he has had more difficulty speaking, which he describes as a tickle in the back of his throat. This sensation in his throat came on during the stroke along with the loss of motor function in his right hand. He notes short-term memory impairments since the incident, described as an inability to remember details.

Patient is currently taking 4 medications: Amlodipine, Clonazepam, Aspirin and Atorvastatin.

Bowel movements are formed, but feel incomplete and are difficult to pass. Normally he passes stool daily, though he can go up to 3 days without a bowel movement. Patient reports scanty urination. He sleeps through the night, usually getting between 7 and 9 hours per night. He reports feeling cold inside, especially on fingers and toes. He does not perspire, no matter the level of exertion. He experiences occipital headaches regularly, and relates them to his high blood pressure. His eyes burn and feel irritated.

OBJECTIVE

Acupuncture Case StudyPatients overall health is above average for age and environmental factors. He appears strong constitutionally, with a demeanor that is generally quiet. He seems hopeful of the acupuncture treatments and open to any way in which he can participate in the process, including a dedication to coming for treatment daily.

Hospital records from June 2012 (7 months prior to treatments), are from 3 weeks after the incident. A CT scan was administered, showing evidence suggesting ischemic stroke. The carotid doppler report was normal, as was lipid testing. The color doppler echocardiography report showed aortic valve and mitral valve thickening. The mitral regurgitation grade was II-III. The tricuspid regurgitation grade was II. Fair left ventricular systolic and diastolic function. Right upper limb testing showed flaccid tone, power of 0/5 and hyper reflexion. However, all other limbs received normal scores.

Upon arrival to our clinic, several tests are undergone to assess patient.

Facial testing: Sharp/dull test: No clear findings along trigeminal nerve pathway; He is able to feel light touch bilaterally on face, though sharp/dull testing is inconsistent along his right side. Facial nerve testing is inconclusive. Expressions are all normal. He is able to raise his eyebrows, close his eyes and grimace. However, his smile appears slightly slanted down on right side.

Glossopharyngeal nerve testing is inconclusive. Speech is normal when saying O, La and Cha, though he has trouble saying E. Patient is constantly clearing his throat while talking, and has asked for water on multiple occasions due to dryness.

Hypoglossal nerve deficit is positive with a deviated tongue.

Right Upper Limb:

Sharp/dull test: Shows sensory deficit distal to wrist joint. Patient is unable to distinguish between sharp and dull in this area.

Full AROM in both shoulder and elbow joints bilaterally. On the affected side, his wrist function is compromised with extension at 30 degrees and flexion at 70 degrees. Additionally, 1st to 4th fingers slant 30 degrees laterally.

Isolated finger extension: 0/5 in 3rd to 5th digits, with no movement at all; 2/5 in 1st and 2nd digits, with minimal movement, but not against gravity;Isolated finger flexion - 3/5 in all fingers with movement against gravity, but not against resistance Grip strength is roughly 30% weaker on the right side; Wiggling fingers - 3/5

Vitals: Blood pressure is 160/90.

TCM: Tongue is deviated, overall sticky white coat, yellow at root; Scalloped edges with red body on sides

Pulse on right is thin and wiry. Left is full and surging, but weak in chi position.

ASSESSMENT

DX: CT scan taken 3 weeks after incident shows evidence of left ischemic CVA. These medical results, combined with a decrease in motor function of upper right limb, and a notable change in throat and memory impairments, meet criteria to confirm diagnosis given by hospital of left ischemic CVA with right hemiparesis.

TCM DX: Blood stasis pattern causing blockage of channels and collaterals resulting in internal wind; Underlying Liver yin deficiency causing Liver yang to rise

PROGNOSIS: At initial consultation, patient had already regained motor and sensory deficits since his hospital visit 7 months prior. Due to these changes, combined with patient’s strong constitution and dedication to physiotherapy exercises, further recovery seems promising. It is hopeful that acupuncture and physiotherapy exercises will continue to aid successful management of motor and sensory deficits, though full neurological recovery may not be possible.

PLAN

Treatment principles: Move blood stasis, open channels and collaterals, and nourish the Liver yin.

Treat with acupuncture 6 days per week for 10 treatments before full reassessment. Long-term treatment, however, is likely needed 3 days per week. Treatment approach is to open right-sided Yangming and Shaoyang channels, unblock qi and blood in collaterals. Scalp points along primary motor cortex on left side to stimulate right-sided motor function, occasionally with electric stimulation. Local points on right side around affected area of mouth and throat to stimulate affected nerve pathways.

Typical treatment: Bilateral treatment: LI4, LV3, DU26, REN23, REN24, DU15, DU16; Right-sided: GB34, Ba Xie and Ba Feng, electric stimulation between LI12 and LI4, LI11 and SJ3, UB60 and LV3, GB40 and GB43. Needling along the motor cortex line on left side of head, roughly between DU20 and GB6. Most treatments consist of stick moxa along his right metacarpalphalangeal joints to open blockage in channels and collaterals.

Additional physiotherapy and coordination exercises are provided for at-home treatments: Making a fist and opening it for motor function, touching thumb to each finger to improve coordinated motor function and touching hands behind back and above head for proprioception. Patient is sent with a moxibustion stick to use for warming the Yangming and Shaoyang channels on his right hand.

OUTCOME

The patient came almost every day that the clinic was open for 4 weeks, even though his home is an hour and a half away. There was significant visible progress, over the 4 weeks of acupuncture treatment and physiotherapy exercises, of the motor function in his right hand.

After the 2nd treatment, he reported an increased ability in moving his right fingers, noticeable while getting dressed and tying his shoes.

After the 8th treatment, during our 2nd week, there was marked improvement in isolated finger extension. He presented at 4/5 rating on all digits except the 4th, having the ability to maintain position against gravity and against minimal applied resistance. His 4th digit, at 2/5, was unable to move against gravity. This was a great improvement from 0/5 on his first visit to the clinic 2 weeks earlier. Additional new testing was done on his 8th visit. Touching each finger to thumb - movement was slow, though possible on all fingers except his thumb to 5th digit.

At treatment 10, a reassessment of sharp/dull testing on the affected hand was normal, aside from his 1st finger, which had unclear results, showing some areas with lack of sensory function. This was an improvement from his 1st visit, which showed sensory deficit distal to wrist joint. Overall, he felt that there had been improvements in movement of fingers. His main concerns at our re-evaluation were his persistent headache and the stiffness he feels in fingers of affected hand.

At treatment 15, patient felt positive about his hand, though he noted swelling in his 3rd and 4th digit at 2nd interphalangeal joints. The area of tingling on his right foot had decreased by 50%, and the pain on the ball of his foot was intermittent. Testing touching thumb to fingers was the same as our testing at treatment 8, with an inability to touch thumb to 5th digit.

CONCLUSION

Patient sought acupuncture 7 months after his stroke and within 15 treatments saw marked improvement in motor function of his right hand, as well as further sensory function in right foot. His headaches subsided within the last 3 treatments. The patient was advised to come 3 times per week for another month, with the hope of continuing to improve motor function. This will hopefully maintain a slow and steady improvement, aiding in his recovery. It is unclear whether the acupuncture will allow full recovery of motor function of his right hand. However, it can certainly be a means for managing the deficits caused by the stroke.

 

Bilateral Leg Weakness and Paralysis


Jasmin A Jones MAcOM LAc LMT
February 2013
OVERVIEW

Acupuncture Case Study

42-year-old female presents with an inability to walk due to slow-onset, partial bilateral leg paralysis occurring over a 15 year time span. After 23 treatments focusing on strengthening the DU and Kidney channels with acupuncture, electro-stimulation and moxibustion, the patient gained a significant degree of improvement in both sensory and motor function in her lower limbs.

Subjective

Patient believes her condition originally started 15 years ago while she was living in the mountains in freezing cold weather for a year and a half. Often, she would become so cold that her limbs would go numb. Symptoms started 12 years ago while she was 5 months pregnant with her second child. She had a difficult time walking up hills and would have to stop regularly because she was experiencing low back pain, and her whole body felt heavy, especially her left leg and arm. After the birth of her son, she considered seeking help for these symptoms because the severity was increasing and slowing her daily chores that she couldn’t stop doing due to her responsibility to her family. Her strength progressively decreased over the next few years until she had to start using a cane to walk due to the weakness in her legs and arms.

Patient reports she had treatment from a Korean medical practitioner, which ended 30 days prior to beginning treatment at the Vajra Varahi Medical Clinic. Treatment consisted of massage with heat daily for 60 days, which according to the patient resulted in a significant recovery of strength in both arms.

She initially sought medical help 9 years ago. A complete x-ray, CT scan and MRI were performed at the Blue Cross in Kathmandu. Patient reports she misplaced the CT scan and is only able to produce her MRI reports, of which the attached paperwork is mostly eaten by rats.

She occasionally experiences cold hands and feet. Her urination and bowels are appropriate and regular. She sleeps easily with mild fatigue in the mornings. She has no headaches, dizziness or ringing in the ears. She has a 30 day menstruation cycle, with mild breast tenderness for 2 days prior, a 4-5 day flow, and dime-sized clots
with no cramping before, during or after the cycle. Her vital signs are normal.

Patient also has a sharp, local pain, bilaterally, at the lumbosacral area, which rates a 7 in accordance with the standard NRS-11, and posterior knee pain, which rates at a 5.

OBJECTIVE

Patient is about 5’5”, 130lbs, with a happy-go-lucky attitude. When she speaks she has a sweet, high-pitched voice, reminiscent of a small child. She is extremely proud, not accepting any assistance in or out of the treatment room. She appears optimistic that acupuncture will help her.

At this time, she cannot stand on her left leg or flex from that hip or knee while walking, as it drags behind her while she walks. She can stand on her right leg, as well as flex the right hip about 5 degrees to take a small step, but has to gain momentum using a twisting, swinging motion and her upper body strength and gravity to kick forward. Her legs tremble slightly while attempting to stand still.

Comparing the left leg to right, patient can feel light touch bilaterally on all dermatomes, with no differentiation between sharp/dull or hot/ cold sensations from L5-S1 dermatomes ,bilaterally, up to patient’s knees.

While lying supine, she cannot actively flex, extend, adduct or abduct the hip, knees or ankles, bilaterally, or flex the abdomen to perform a sit-up. While seated, she can actively flex the knees 15 degrees, as well as extend the knees 45 degrees. Patient cannot wiggle toes bilaterally while seated or lying supine.

Active and passive range-of-movement is normal in the shoulders and elbows. Active wrist flexion is normal, with active wrist extension compromised at 5 degrees. All passive ROM in upper limbs is normal. Active finger movements are inhibited with the left index and middle finger, and right index finger flexion is decreased to 15 degrees.

Patient is also unable to straighten these 3 fingers. Grip strength is decreased by 50% on the left compared to the right.

Patellar reflex: 1+ bilaterally

Achilles reflex: 0 bilaterally

Testing passive proprioception of the big toe shows no differentiation between flexion or extension. Babinski test is unresponsive.

Pulse is thin and deficient on left, disappearing with strong pressure. Stronger on the right with a slightly wiry quality, especially in the middle position.

Tongue is thin, pale, especially in the center with red dots on the tip.

ASSESSMENT

Acupuncture Case StudyDX: The MRI performed by the Blue Cross of Kathmandu shows no evidence of inflammation or lesions in the brain or spinal cord or evidence of upper motor neuron damage. She was diagnosed with a probable primary demyelinating of L5-S1 nerve root, of which the cause is unknown. According to the Merck Manual, primary demyelinating disorders are suggested by diffuse or multifocal deficits, and demyelination should be considered in any patient with unexplained neurological deficits.

TCM DX: Kidney yang deficiency, cold stagnating the DU channel

PROGNOSIS: Due to the fact that she has been untreated for 12 years, it is unlikely this patient will fully recover from acupuncture alone. Being that this patient reports that she has recovered significant improvement in function of her arms with massage/heat alone 1 month prior to consultation at this clinic, it is hopeful that with acupuncture treatment, this patient will regain some degree of motor function in her lower limbs, as well as a decrease in the sensory deficit associated with her neuropathy. It is also hoped that she will experience some reduction in knee and back pain.

INITIAL PLAN

Patient is to receive acupuncture 3-4 times per week, re-evaluating at treatment 20. Typical points include KD3 with UB58 with moxa to tonify the Kidney and warm the DU channel. UB40 to bring qi and blood to the knees, SI3 with UB62 to open the DU channel. Hua Tou Jia Ji points from L4-S2 to KD 3 with electro-stimulation at 100hz continuous for 20 minutes to stimulate S1 nerve root.

Lower 1/3 of scalp motor points are used in the first few treatments with strong stimulation.

OUTCOME

After 20 treatments, this patient reported being able to stand for a few minutes without a cane or leg trembling. She could also stand for a few seconds on her left leg and a few more seconds on her right leg compared to her initial presentation. Patient’s back pain reduced to a 2 compared to previously being a 7.

She was able to slightly flex her left hip 5 degrees and extend the knee while walking, whereas before she had to swing her leg completely from the right hip to take a step. Her right hip was able to flex 30 degrees to take a larger step. No change in ankle flexion or dorsiflexion. Both knees became free of pain, and active global ROM became normal in the knee while seated.

Sharp/dull tests still showed no change in sensory deficit from the dermatomes L5-S1. However, patient reported being able to feel temperature changes in her first and second toes on the left side, as well as having gained more feeling in general in both legs.

CONCLUSION

Even though it is unlikely that this patient will regain full strength in her legs again, it is recommended she continue acupuncture 2x weekly for at least another 2 months or until patient reaches a plateau. After 20 treatments with acupuncture, she has experienced a 100% reduction in knee pain, 90% reduction in back pain, and regained some ability to feel temperature changes. She has experienced improvement in strength and ROM in both legs. The patient feels lighter in her body. All of these changes add to the quality of her life. As a result of the improvement so far, it is quite possible she will continue to regain further sensory and motor function in both legs.

 

Ankylosing Spondylitis


Lindsey A Thompson MAcOM EAMP LAc
February 2013
OVERVIEW

Acupuncture Case Study

25-year-old male presents with low back and sacroiliac pain, beginning approximately 15 months prior to consultation at this clinic, for which he had received a diagnosis of ankylosing spondylitis at a hospital in India. After 18 treatments with acupuncture in conjunction with moxibustion and cupping therapy, the AROM of the back, and degree of pain, significantly improved.

Subjective

Patient is a 25-year-old man presenting with low back and sacroiliac joint pain. The pain began after an injury to the low back approximately 15 months prior to consultation at the clinic. The injury was reported at the initial consultation, which was performed by a different practitioner. Pain is worse with cold and stress, while improved with heat, massage and yoga. The location of the pain is in the low back, sacral region and the mid- to upper back. On the initial visit, pain severity is reported at a 4/10 with pain medications, and at a 7/10 without medication using the globally accepted NRS-11 rating system. At its worst, the pain can be so severe that it interferes with all daily activities and breathing. This is a 7+/10 on the NRS-11 scale and concurs with the patient’s self-reporting. Pain is worse at night, making it difficult for the patient to sleep. 

Patient previously sought care at a hospital in India on April 9, 2012, where he underwent laboratory exams, including a c-reactive protein assay and radiographic imaging. The patient was given Indomethacin, an NSAID, to take 50mg QD when pain is at its worst. At the initial consultation, patient is taking the prescribed daily dose.

OBJECTIVE

Patient’s overall health seems to be above average for environment in Nepal. Patient is of slight, lean build, with a cheerful and hopeful demeanor. He is a pre-med student in his 4th year and has a great deal of mental stress revolving around school. 

Patient brought in radiographic imaging of the lumbar spine and pelvis taken from anterior to posterior view. The x-ray shows calcification of the anterior and posterior longitudinal ligaments of the lumbar spine with bilateral sacroiliitis. Both of these findings are suggestive of AS. The imaging also shows a reduction in bone density. The image shows normal hip joints. 

Examination of the area of purported pain with palpation shows the location of the pain limited to the sacroiliac joint and the lower vertebrae of L4, L5 and S1. Pain at L4, L5, S1 is elicited with moderate to mild pressure. Palpation of the spine demonstrates hardening between the vertebrae of the lumbar and sacral spine in concurrence with the calcification of the longitudinal ligaments shown on x-ray. Lumbar lordosis is reduced with significant flattening of the lumbar spine. Palpable tenderness is felt in the erector spinae, quadratus lumborum (QL) and trapezius muscles. Muscles are hard and rigid upon palpation. Examination of the active range of motion (AROM) of lumbar spine on initial visit is significantly affected. Patient demonstrates 30 degrees flexion of lumbar spine, 10 degrees extension, 45 degrees rotation and 10 degrees lateral flexion.

ASSESSMENT

DX: Initial blood analysis taken at the hospital in India in April 2012 tested positive for c-reactive protein at a value of 12mg/L. A normal level of c-reactive protein is considered <6 mg/L. C-reactive protein is sometimes elevated in patients with active AS. The radiographic imaging that shows bilateral sacroiliitis, calcification of the lumbar anterior and posterior longitudinal ligaments, and the inflammatory back pain worse at night are all considered diagnostic for ankylosing spondylitis. This method of diagnostics is based on the modified New York criteria for AS, as laboratory testing can be inconsistent with AS. The modified New York criteria is as follows: The patient must have radiographic evidence of sacroiliitis and one of the following: 1) restriction of lumbar spinal motion in both the sagittal and frontal planes 2) restriction of chest expansion, adjusted for age 3) a history of inflammatory back pain. The determining factors for inflammatory back pain include onset of paint at < 40 years of age, morning stiffness, improvement with activity, and duration of > 3 months of pain. Since the patient is presenting with 2, possibly 3 of the New York criteria, along with radiographic evidence of sacroiliitis, the patient meets the diagnostic criteria for ankylosing spondylitis according to the Merck Manual.


TCM DX: Liver qi stagnation with wind-cold-damp bi syndrome, cold predominant in the Governing Vessel and Bladder meridians

PROGNOSIS: Due to the presence of calcification in the lumbar anterior and posterior longitudinal ligaments, the prognosis is guarded. Acupuncture will not reverse the pathological tissue changes that have already occurred, but may effectively increase flexibility and decrease pain. Successful management of the inflammatory process in the lumbar and sacroiliac joint may prevent or slow further pathological damage to the spine and surrounding tissues.

PLAN

Treatment principles: Dispel wind, resolve damp, disperse and warm cold, move Liver qi and strengthen the Governing Vessel; Invigorate qi and blood. 

The treatment plan is to treat with acupuncture for 2 to 3 times weekly with reassessment at the 10th and 20th treatments. Treatment approach is to use Shaoyang channels to dispel wind and dampness and open up the belt channel (Dai Mai).

The back-shu points for the 6 yin organs are utilized on the Bladder Taiyang channel to nourish blood, yin and the 6 yin organs. The Taiyang channels are also utilized to move qi and blood throughout the back. Points to strengthen and move qi through the Governing Vessel are also used to promote proper bone development in the spine.

Typical treatment: TW5 and GB41, SI3 and BL62 needled contralaterally to activate the belt and Governing meridians, along with bilateral BL58

Alternate treatment: Hua Tou Jia Ji points for L3,4,5 and S1 to move qi and blood through the local spine, or a selection of the following backshu points: BL23, BL20, BL18, BL14, BL13 to nourish the respective yin organs associated with each back-shu point; These points are used to build qi and blood, nourish the spine via the Kidneys, calm
the shen and move Liver qi and Liver blood. Tiger warmer moxa or direct moxa is applied to the SI joint and along the QL muscle, and occasionally the lumbar and sacral spine to disperse cold and warm the channels. Acupuncture and moxa treatment is followed by cupping of the mid- and upper thoracic spine.

For the 1st 2 months of treatment, the patient also received a weekly massage.

OUTCOME

At the 3rd treatment, the patient reported a 60% improvement in back and neck pain. He also had no stiffness upon getting off of the treatment table. At the 7th treatment, the patient reported a decrease in pain medications, but did not quantify the degree of decrease in medication. Between the 7th and 11th treatments, the mid- to upper
thoracic muscle pain and QL muscle spasms fluctuated. At the 11th consultation, the patient reported that back pain was much improved and he was noticing an increase in flexibility. The patient also reported reducing the dose of 50 mg Indomethacin from a daily dose to only 1 50mg pill in the last 7 days.

The patient’s lumbosacral AROM was reassessed at the 13th and 22nd consultations. At the 13th consultation, lumbar flexion was 80 degrees, extension 15 degrees, lateral flexion 5 degrees and spinal rotation was 45 degrees. At the 22nd consultation, lumbar extension measured 40 degrees and lumbar flexion measured 85 degrees. Lateral flexion and spinal rotation were neglected in the reassessment. AROM at the initial consultation was 30 degrees flexion of lumbar spine with 10 degrees extension, 45 degrees rotation and 10 degrees lateral flexion. 

Normal degrees of lumbar flexion are 60 degrees, extension 25 degrees, lateral flexion 25 degrees, rotation 30 degrees. At the 22nd consultation, the patient was well above normal degrees of AROM in extension and flexion. On the 13th consultation, the degree of rotation was above normal with lateral flexion still below normal and below that of the initial consultation. It is unfortunate that lateral flexion was neglected to be assessed at the 22nd consultation. 

From treatment-to-treatment, the patient reported fluctuations of pain in the muscles of the mid- to upper thoracic spine and intermittent muscle spasms in the left QL. At times, the patient was excited about the increase in flexibility, but disappointed in the slow progress of his case. The patient also expressed disappointment in the frequent return of muscular pain in the mid-thoracic, trapezius and QL muscles. He would spend a great deal of time at a desk, studying, and in a high-stress environment with his medical pursuits in school. The patient typically studied until 3AM, only sleeping from 3AM to 9 or 10AM. The patient’s lifestyle of prolonged sitting, poor ergonomics, late-night studying and stress were more likely to contribute to the frequent return of muscle pain and spasms in the mid- to upper back than to be a complicating factor of AS.

CONCLUSION

The patient experienced significant reduction in pain and increase in AROM on the sagittal plane. It is therefore advised to continue treatment 1 to 2 times per week for the next 4 to 10 months. The increased AROM along the sagittal plane is particularly exciting because the patient developed AROM greater than normal AROM for the general populace. However, the patient lacked improvement along the frontal plane, and it is hoped that, with continued treatment, positive changes in AROM on the frontal plane will take place, as did those of the sagittal plane. The muscular pain of the mid- to upper back improved at each treatment, but each time, returned within a few days. The return of muscular pain was most likely related to the poor ergonomics, prolonged sitting and stress of studying for medical school and exams. The reduction in frontal plane AROM could relate to the frequent recurrence of spasms in the QL. Until the ergonomics of studying can be fully addressed, it is likely that muscles spams will intermittently come-and-go.

At the time of writing this case study, the patient ceased treatment on his own accord, against advice of the practitioner. The patient had a month to study before taking his final examinations. The timing of his examinations may have caused the patient to temporarily cease treatment. 

With a complicated illness such as ankylosing spondylitis, a normal course of treatment would involve 6 months to a year of regular acupuncture treatments. Given that the patient had such great successes in sagittal AROM in under 2 months, it is likely that the patient would receive significant benefit from a full course of treatment of 6 months to 1 year.

 

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