• Building relationships

    Learning to understand each other and truly listen is the first step in building trust and lasting friendships.
  • Effective Treatment

    Frequent, focused treatments allow us to see positive changes in a patient's condition quickly.
  • Professional Development

    Acupuncture Relief Project offers opportunities for volunteers to gain valuable field experience and earn continuing education credits.
  • Patient Education

    By providing simple explanations, we help patients understand their health concerns and make informed choices regarding their care.
  • Research Focused

    Conducting research studies and documenting patient cases helps us analyze the efficacy of our clinic and contribute to the body of evidence that supports our project model.
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Our Mission

Our unique model provides effective, efficient, primary care in rural Nepal. Read More
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Our Clinics

Since 2008, our clinics have provided over 350,000 primary care visits. Read More
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Our Partners

Influencing government policy and achieving educational goals. Read More
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Volunteer With Us

We need your help. Serve others while learning new skills. Read More
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Our Evidence

Case studies and field research helps us analyze our efficacy. Read More
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VOLUNTEER COMMUNITY CARE CLINICS IN NEPAL

Nepal remains one of the poorest countries in the world and has been plagued with political unrest and military conflict for the past decade. In 2015, a pair of major earthquakes devastated this small and fragile country. 

Since 2008, the Acupuncture Relief Project has provided over 300,000 treatments to patients living in rural villages outside of Kathmandu Nepal. Our efforts include the treatment of patients living without access to modern medical care as well as people suffering from extreme poverty, substance abuse and social disfranchisement.

Common conditions include musculoskeletal pain, digestive pain, hypertension, diabetes, stroke rehabilitation, uterine prolapse, asthma, and recovery from tuberculosis treatment, typhoid fever, and surgery.

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Featured Case Studies

  • Cervical and Lumbar Spondylosis +

    70-year-old male presents with severe cervical and lumbar pain, neuropathy of the arms, hands, legs and feet, incontinence Read More
  • Rheumatoid Arthritis +

    35-year-old female presents with multiple bilateral joint pain beginning 18 months previously and had received a diagnosis of Read More
  • Chronic Gastritis with Inflammatory Bowel Syndrome: Crohn’s Disease +

    40-year-old male presents with chronic, burning gastrointestinal pain with accompanied acid reflux, belching, fullness, diarrhea, weight loss and Read More
  • Juvenile Rheumatoid Arthritis +

    10-year-old female presents with active phase of Juvenile Rheumatoid Arthritis (JRA) as demonstrated by multiple articular bony joint Read More
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Compassion Connect : Documentary Series

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    In the aftermath of the 2015 Gorkha Earthquake, this episode explores the challenges of providing basic medical access for people living in rural areas.

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    Episode 1: Rural Primary Care

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    Acupuncture Relief Project tackles complicated medical cases through accurate assessment and the cooperation of both governmental and non-governmental agencies.

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    EPISODE 2: INTEGRATED MEDICINE

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    Cooperation with the local government yields a unique opportunities to establish a new integrated medicine outpost in Bajra Barahi, Makawanpur, Nepal.

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    EPISODE 3: WORKING WITH THE GOVERNMENT

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    Complicated medical cases require extraordinary effort. This episode follows 4-year-old Sushmita in her battle with tuberculosis.

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    EPISODE 4: CASE MANAGEMENT

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    Drug and alcohol abuse is a constant issue in both rural and urban areas of Nepal. Local customs and few treatment facilities prove difficult obstacles.

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    EPISODE 5: SOBER RECOVERY

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    Interpreters help make a critical connection between patients and practitioners. This episode explores the people that make our medicine possible and what it takes to do the job.

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    EPISODE 6: THE INTERPRETERS

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    This episode looks at the people and the process of creating a new generation of Nepali rural health providers.

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    EPISODE 7: FUTURE DOCTORS OF NEPAL

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    In this 2011, documentary, Film-maker Tristan Stoch successfully illustrates many of the complexities of providing primary medical care in a third world environment.

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    COMPASSION CONNECTS: 2012 PILOT EPISODE

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From Our Blog

 


Kimberly Shotz WHCNP MN MAcOM
December 2011
Overview

Acupuncture Case Study10-year-old female presents with active phase of Juvenile Rheumatoid Arthritis (JRA) as demonstrated by multiple articular bony joint deformities, severely limited range-of-motion in all affected joints, and a history of recurrent episodes of alternating fever, chills and profuse sweating, immediately preceding joint inflammation and swelling. Within the course of 9 acupuncture and moxibustion treatments plus Chinese herbal and vitamin supplementation, the patient noted cessation of recurrent episodes of fever, chills and sweating, decreased heat sensation in joints with active inflammation, and temporary decreases in pain while walking.

SUBJECTIVE (as reported by patient’s father) 

The patient was evaluated by allopathic medical physicians at a Kathmandu hospital at least 2 years prior to her first visit to VVHC. Blood tests and x-rays (not available for review) indicated rheumatoid arthritis. She was prescribed multiple medications, which she took for 2 weeks. Medications included injections she was advised to receive weekly for 4 weeks. She had 2 injections, which “had no effect.” All medications were too expensive to continue. The patient’s father refuses to involve allopathic medicine in the current management of the patient’s disease, but agreed to update blood tests (CBC, ESR).

Patient presents with hot, swollen ankles and knees, making it too difficult for her to attend school.

O – 6 years ago with 3-4 days of tidal fever, cough and “cold”

F – Fevers come every week to 3-4 months and last about 4 days. They are preceded by a sensation of inflamed tonsils and are followed by joint swelling and a sensation of heat in the affected joints, which are warm to touch, but with or without redness and pain.

Q – Affected joints vary with each episode, but are typically bilateral. Without fever, most joints feel cold and stiff inside.

P – Cold weather and prolonged immobility, such as bus rides, seem to worsen her overall joint stiffness. Swelling increases with mobile activities, such as walking. Wearing warm stockings helps reduce stiffness.

S – Patient reports significant difficulty with ambulation due to both restricted ROM and occasionally severe pain.

T – The duration of active, inflammatory phases is unclear, but seems variable.

Objective

Patient’s affect is flat and timid, with infrequent eye contact. She does not speak and looks to her father for answers to physician questions. She nods occasionally. She ambulates slowly with rigid, erect posture, arms extended and inanimate at side, with somewhat of a shuffle and notably reduced knee and foot flexion.

Her tongue is purple red with a crimson tip and thin white coat at back. She has erythematous sublingual sores (ulcers). Her pulses are thin and rapid.

She displays no observable expressions of pain during palpation of affected joints, but quietly gasps and retracts (i.e. guards) her limbs with attempts to move a joint beyond its passive ROM.

Elbows: Lateral epicondyles are enlarged, rounded (2X normal), bony-hard, cool, without erythema or edema and non-tender; Limited extension to ~145 degrees

Wrists: Mildly enlarged (<2X), bony landmarks obscured to palpation, non-tender; No active or passive extension; Active/passive flexion ~ 20 degrees; Inversion/eversion <10 degrees with mild crepitus of right wrist

Hands/Fingers: Mild bony enlargement of proximal and medial interphalangeal joints bilaterally, cool; Patient unable to flex fingers into fist

Ankles: Swollen, red, hot

Knees: Soft swelling over medial and lateral femoral and tibial condyles (3X normal)

Active and Passive Range-of-Motion:

Neck: Extension ~0 degrees, flexion ~10-20 degrees, lateral rotation ~10-20 degrees, lateral flexion ~30 degrees to pain

Wrists: Extension ~0 degrees, flexion ~45 degrees, inversion/eversion ~10 degrees

Fingers: DIP/MIP flexion <45 degrees, first and second MCP flexion ~20 degrees

Knees: Extension ~75-80 degrees

Acupuncture Case Study

Ankles: Dorsiflexion ~0 degrees, non-painful crepitus near talus with inversion 5-10 degrees of right ankle, eversion ~5 degrees, plantar flexion <45 degrees

 

Laboratory (2 years ago)

Hemoglobin (HGB): 8 (very low)

White Blood Cell Count (WBC): 14 (elevated)Neutrophils: Elevated

Erythrocyte sedimentation rate (ESR): 30-50 (elevated)

Acupuncture Case Study

 

Laboratory (11/24/11)

HGB: 9.5 (low, improved)

Neutrophils: 81 (elevated)

WBC: 11 (mildly elevated, improved)

ESR: 90 (significantly elevated, active phase)

Weight: 22kgOral temperatures (in sequence of visits): 94.4, 97.1, 95.5 (variable, low)

 

Assessment

DX: Polyarticular arthritis, systemic juvenile arthritis with osteopenia (Still’s disease)

TCM DX: Shaoyang or blood level heat/heat bi syndrome; bony bi/ wind-cold-damp with latent damp-heat toxin

PLAN

Treatment principles: Warm and open the channels and collaterals, move qi and blood, dispel cold, damp, wind, nourish blood, tonify qi, blood and 5 zang organs (constitution). Induce prolonged remission phase of JRA, prevent recurrence of active phase of disease by strengthening constitution and promoting optimal immune function. Treatments consist of combinations of in/out and sustained needle acupuncture, indirect moxibustion and refilling herbal prescriptions and dietary supplements.

Dietary advice: Avoid night shade vegetable family, animal fats, greasy/fried foods, sugar and spicy foods. Increase oral hydration of warm fluids and incorporate cinnamon and turmeric into meals.

Dietary supplements: Calcium 500mg, vitamin D3 500 IU per day, B-complex 1 tab once daily, ibuprofen 20-40mg/kg/day in 3-4 divided doses (not to exceed 880 mg in any 24-hour period) for no more than 5-7 days without clinic evaluation (Liver and renal function labs need to be updated)

Herbs: Feng Shi Ding 2-3 pills BID

Acupuncture: 3 times per week

The following acu-points are used: SP9, LI11, LI10 TB5, GB34, BL11, LR3, LI4, TB3, LI5, SI7; In/out needling: DU14, ST34, SP9, ST36, BAXIE, ST36, KD3

Limit to 8-9 points per treatment.

Auricular acupressure seeds (1 visit): Shenmen, Kidney, Liver, Knee applied bilaterally to leave in place for 3-4 days

Indirect Moxibustion: ST36, elbows, wrists, dorsal hand/MCPs, ankles

OUTCOME

Patient noted reduction in both pain and difficulty with ambulation immediately following treatments. The father reported cessation of alternating fever, chills and profuse sweating episodes as well as an improvement in her energy. The duration of pain reduction benefit was limited to 2-3 days. Patient’s shen appeared brighter and showed increased interest and attentiveness during her treatments. She was able to actively extend her legs to 180 degrees and dorsiflex her ankles to ~5 degrees. The first and second MCP joints had 30 degrees flexion. After treatment 5, ankles no longer felt hot and her knees were warm without erythema.

At her 6th visit, the formula was changed to Xuan Bi Tang Wan 3 tablets TID. A stronger blood/qi/KD nourishing herb was being considered for her 9th visit, given that the joint swelling and inflammation was waning. Liu Wei Di Huang Wan was chosen and dispensed to patient at 9th visit, 8 TID.

Because it took 6 hours of public transportation to get to and from the clinic (>18 hours of missed work per week for patient’s father), this schedule was not feasible. Patient received treatments every 3-7 days for 8 treatments.

Conclusion

This young patient has a severely disabling, progressive disease and lacks resources required for allopathic management regimens known to induce and prolong remission phase and reduce joint destruction associated with Juvenile Rheumatoid Arthritis (JRA).

Each day that severe, active-phase joint inflammation continues, indicates potentially permanent joint damage, reduced mobility and reduced quality of life for patients with JRA. The patient’s father accompanied her to most clinic appointments and provided a limited and inconsistent history of her disease condition, possibly indicating cultural-conceptual and/or practitioner-patient communication challenges. This definitely represented a barrier to optimal assessment of her condition. It was clear from his account of her history that he did not understand the disease process of JRA, its management, or the implications of ineffective management.

The long distance between home and clinic resulted in excessive time away from work for her father, which severely limited treatment frequency and potential efficacy. This patient was unable to maintain the optimal 3-4 times weekly treatment schedule, yet still noted both subjective and objective improvements during the course of her 9 visits over 6 weeks: increased joint range-of-motion, reduced joint inflammation, cessation of systemic inflammatory symptoms, improved constitutional energy and spirit.

It is expected this patient would benefit from incorporating massage and physical therapy into her treatment regimen. Some of her reduced joint mobility seems to be from muscular contraction due to the combination of prolonged guarding of joints and limbs and reduced mobility. A more aggressive treatment plan using a greater number of acupoints with longer needle retention, plum blossom, jing-well acupoint bleeding, scalp acupuncture and/or electroacupuncture may enhance treatment efficacy and may be employed as patient comfort permits.

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