Case Studies

Case Studies

Chronic Obstructive Pulmonary Disease with Osteoarthritis


Jennifer Rankin RAc
November 2011
Overview
Acupuncture Case Study

65-year-old female presents with dyspnea and continuous cough. The patient also presents with chronic, severe pain and inflammation of all joints of the hands and feet. With 9 acupuncture treatments and the use of Chinese herbs, the patient experienced a 6% O2 increase, more than a 50% reduction of pain and a 90% improvement in range-of-motion in her hands.

SUBJECTIVE

65-year-old female patient presents with chronic dyspnea and continuous cough. The difficult breathing started 4-5 years ago and has become progressively worse. The patient does not live in a high traffic area, but has used an indoor fire to cook for most of her life. She now uses gas. The difficulty she experiences breathing is continuously present with no history of asthma attacks and no history of fever and chills. The patient does not report chest tightness or coughing at night. The dyspnea lessens with rest. Occasionally, cough is accompanied by small amounts of white or red phlegm. The dyspnea is the same with inhalation as with expiration. She reports not being able to walk from the microbus to the clinic (about 150 feet) without severe wheezing. It is hard to take a deep breath and she sometimes feels like she is unable to take in enough air. She also reports waking from difficulty breathing. The condition worsens in the winter, in the afternoon, and when walking or lifting. The patient has a family history of breathing difficulty including both her mother and sister who have had medical intervention concerning their conditions. The patient feels cold and gets common colds easily. She has spontaneous sweating.

The patient reports bilateral pain, inflammation and stiffness of all of the joints of the fingers and the feet including the ankles. The pain started 4 years ago while she was still working in the fields and has since gotten worse. Warmth helps the pain and movement makes it worse. The pain is burning, tingling and “unbearable.” There is no accompanying fever. The patient reports good energy and appetite. The pain is severe, worse in the afternoon, and interferes with walking and sitting. She has no family history of pain and inflammation in the joints.

The patient experiences pain in the shoulders and knees and a heavy, dull ache in the low back. The patient no longer does field work and does very little activity. No other medical treatment has been administered for these conditions.

Objective

Acupuncture Case StudyThe patient has difficulty talking due to breathlessness and audible wheezing. When she moves, the wheezing increases. She has a weak and raspy voice with the occasional weak cough. She appears to be in average health for her age and environment. A strong wheeze can be heard through auscultation of her lungs. The first measurement on the oximeter is recorded at 91% O2. The patient is in moderate pain, indicated by her ability to smile, laugh and respond to questions. However, walking and sitting are difficult. All joints of the patient’s hands are swollen to 40% larger than normal and her feet and ankles are swollen to 30% larger. Both the hands and feet are hot to touch. No bone deformities are present. The patient has an 80% reduction in the active range-of-motion of all her finger joints and is unable to make a fist. She has a 30% reduction in the active range-of-motion of all the joints of her feet. The passive rangeof-motion of her joints was not tested.

Pulses are deep, weak and soggy. Her tongue is pale and swollen.

Assessment

DX: COPD and osteoarthritis (pronounced in the joints of the hands, feet, knees and shoulder)

TCM DX: Lung and Kidney qi deficiency with wind-cold-damp bi syndrome in the joints

PROGNOSIS: Using acupuncture and herbal treatment, improvement is expected within 10 treatments. However, due to the severity of the pain, inflammation and breathing difficulty, more significant outcomes are expected over a longer course of treatment.

Initial Plan

Treat with acupuncture 3 times per week for 10 treatments before reassessing.

Focus on reducing swelling and inflammation (cold-damp bi) first. As swelling is reduced, add treatments to tonify the Lung (wei qi) and Kidney qi.

Typical points: LU1, REN17, LU9, KD3, SP6, LU5, ST36, LI4, UB 3, UB23, as well as local points at sites of swelling and pain

Du Huo Jie Xie Wan (8 TID) for first 2 weeks to reduce swelling and inflammation of the joints; Then switch to Ding Chuan Wan (8 TID) to tonify the Lung and Kidney qi

B complex vitamin with 100mg B1, 100mg B5 and 100mg B6 to assist with wound healing and as anti-inflammatory agent

Counsel the patient about proper ventilation of home if ever cooking with a wood fire and wearing a mask when in polluted or high traffic areas.

Outcome

After 9 treatments the patient reported major changes in her breathing, pain and inflammation. The patient’s voice was stronger with less audible wheezing and she could take a deep breath. She no longer had times when she felt like she couldn’t take in enough air. She wasn’t waking wheezing and she could walk from the microbus to the clinic with a very small amount of wheezing. The patient continued to have a regular cough, however it decreased from being continuous to 2-3 times per day. When phlegm was present it was only white. The pulse oximeter generally read between 95-97% O2 and only occasionally read 92- 93% O2.

The swelling in the patient’s hands completely resolved with only minor swelling of the lateral ankles. The hands were no longer hot to touch and the patient reported no feelings of heat in the joints. The pain decreased over 50%. The patient had full active and passive range-of-motion in her feet and had a 90% increase in the active range-of-motion in her hands. She was able to walk and sit without severe pain and make a complete fist.

Continued Treatment

This patient needs continuous, intensive acupuncture and herbal treatment for her lungs and arthritis. Continued monitoring of oxygens saturation rates, lung auscultation and a chest x-ray are objective measures of her progress that would be beneficial. The patient has responded positively to treatment thus far and further improvement is expected.

Conclusion

The effectiveness of acupuncture and herbal medicine for both COPD and arthritic pathologies is clearly outlined here. The importance of regular treatment and the use of objective measures to quantify progress is essential.

Facial Paralysis (Bell’s Palsy)


Jennifer Walker MAcOM LAc
December 2011
Overview

Acupuncture Case Study35-year-old female presents with left-sided facial twitching and paralysis. After 7 acupuncture treatments, the patient regained over 50% of her facial functioning with 80% of the facial twitching resolved.

SUBJECTIVE

Patient presents with left-sided facial twitching and paralysis. There is painful twitching with frequent tearing of the left eye. The cheek and mouth also twitch, and feel as if “the face is twisted.” She has moderate pain (5/10) with smiling that interferes with sleep, concentration and in social situations, causing her not to want to interact with others. Nothing makes the pain worse. The quality of the pain is sharp. She reports that the twitching is activated when eating or performing other motions with the mouth. The throat is sore and the patient is having difficulty shouting. Patient reports waking with the condition 15 days prior. She has not received any other treatment or medication for this condition. She walks for about an hour to get to the clinic. There is no prior history of the condition. The patient states that on her side of the bed there is a window with a draft.

OBJECTIVE

Acupuncture Case StudyPatient appears to be in good health for her age, cultural background and environment. She has a suppressed demeanor and it is difficult to maintain eye contact with her. She speaks very low and says few words when questioned.

There is no visible facial twitching. Upon cranial nerve exam, cranial nerve v, the trigeminal nerve, shows laxity in the masseter muscle. Cranial nerve vii, the facial nerve, shows difficulty in closing and keeping the left eye closed, pursing lips, baring teeth, flaring the nostril and expanding the cheeks with air while keeping the mouth closed. All sharp/dull sensory tests are negative. All tests are negative for any involvement of the right side of the face.

Pulses are thin and wiry. No visible deviation of the tongue or thick coat.

ASSESSMENT

DX: Facial paralysis (Bell’s palsy) Restricted or impaired control and functioning found in the cranial nerve exam shows motor impairment of the following muscles: orbicular oculi (closes eyelids), levator labii superioris alaeque nasir + alar part of nasalis (flair nostrils), buccinator + orbicularis oris (puff out cheeks with air while pursing lips), risorius plus levator labii superioris + depressor labii inferioris (bare teeth). Based on the cranial nerve exam, the facial nerve is predominantly affected, leading to the diagnosis of Bell’s palsy.

TCM DX: LR wind rising due to LR blood deficiency

PROGNOSIS: Because the patient is starting treatment in the acute stage, a full recovery is expected.

INITIAL PLAN

Treat with acupuncture 3-5 times per week for 10 treatments before reassessing. Focus on nourishing and building LR blood and eliminating LR wind. Use needles on the face to stimulate the multiple affected muscles. Internally, use Dang Gui San 1tsp TID to tonify blood.

Typical treatment: Bilateral: ST36, LI4, LI10, LR3, LR8, Yin Tong, GB20; Left: 1 needle threaded from the midline just below the lower lip up to the left corner of the mouth, TW17, SI19, LI19, LI20, GB1, ST3, ST4, ST5, ST6, ST7, CV24, Jia Cheng Jiang; All needles with strong stimulation  

OUTCOME

After 6 treatments, the patient reported 1/3rd improvement in the condition. The facial twitching was reduced and no longer visible after needles were inserted. The left eye closed without any difficulty and there was no longer any tearing of the eye during treatment. The patient reported no longer having a sore throat or difficulty shouting. There was no longer any laxity in the masseter muscle. Cranial nerve testing still showed some difficulty smiling, baring teeth and puffing out cheeks with lips pursed. Visually, the patient could perform these tasks at least 50% better than during the first treatment. The patient was able to make eye contact and be much more engaged during treatment.

CONCLUSION

With continued care, it is possible that this patient can expect to see a complete recovery. Her condition has already responded favorably to acupuncture and herbal treatment. During the last visit, the patient was asked to start coming in for treatment every other day for 2 weeks to determine how much progress can be made during this time. She was also counseled to move her bed to an area of the house where there are fewer windows and no draft. In addition, her herbs will be increased to 2tsp of Dang Gui San TID.

Massage for Chronic Back Pain Associated with Spondylosis of the Spine


Brad Caroll LMT
December 2011
Overview

Acupuncture Case Study70-year-old male referred for massage treatments for pain associated with spondylosis of the spine and neuropathy. The patient is simultaneously receiving ongoing acupuncture treatments. At the time of the referral, he had completed 18 acupuncture treatments. The main objective, through the combination of massage and acupuncture, is to manage pain, increasing the patient’s quality of life.

SUBJECTIVE

Patient’s chief complaint is of severe pain in the low back and right shoulder. The patient defines severe pain as discomfort that inhibits or prohibits his daily activities, such as walking without help from others. He experiences “tingling” sensations in both hands that radiate posteriorly down both legs to the feet, originating at the lumbar region of the back. The frequency of the overall pain is constant and increases with activity (walking and getting up from bed), but the radiating sensation is intermittent and unpredictable. The onset of the radiating sensation may correlate to the severe levels of pain in the lumbar region of the spine. The intensity of the pain fluctuates daily between severe and mild depending on the amount of activity in which he engages and the treatments he receives. He defines mild pain as a discomfort he recognizes on a daily basis, but doesn’t interfere with or prohibit his daily activities. Direct sun exposure alleviates the pain. He reports that the pain interferes with sleep when at a moderate level. The patient defines moderate pain as a discomfort that is constant, distracting and interferes with his daily activities (ie. walking), but doesn’t require help from others. The onset of the pain is unknown, but increased after being hit by a car 1 year ago. Pain increases with cold temperatures and with coughing episodes. Patient states that surgery has been recommended, but he is unable to afford it. He expresses his fear of becoming paralyzed from spinal surgery. He experiences depression and at times wishes he were dead because he feels like he can no longer provide for his wife and be useful to his family. He feels stressed and emotional most of the time, especially when his pain levels increase and his ability to be useful to his family decreases. Although he has never received a professional massage treatment before, he uses self-massage with Tiger Balm daily for temporary relief of shoulder and low back pain.

Objective

Visual observations while at the clinic, indicating pain and stress, include the following:
Walking slowly with assistance from his wife and a walking stick  
Facial expressions associated with pain when walking; Attempting to sit or stand by himself or removing clothing in preparation for a treatment
Tone and speed of voice increases with movements that cause pain
Tears when answering questions about his pain and his perception of how his condition affects his wife and family
Muscle spasms on the bilateral wrist flexors, including flexor carpi radialis, flexor carpi ulnaris, palmaris longus, flexor digitorum superficialis and flexor digitorum profundus as well as triceps brachii when lying in the prone position on the table

Postural analysis findings:
Bilateral medial rotation of the shoulders; Mild
Right shoulder elevated; Mild
Posterior tilt of the pelvis; Mild
Genu Varum; Mod

Palpation:  
Hypertonicity of the erector spinae group, gluteal region and hamstrings  
Palpatory tenderness on the right supraspinatus, infraspinatus, rhomboid major, minor, biceps tendon, teres minor and major and the anterior, middle and posterior fibers of the deltoid
Palpatory tenderness with increased pain on origins of bilateral quadratus lumborum, gluteus maximus, gluteus medius and gluteus minimus 

AROM:  
Lateral flexion, rotation, flexion and extension of the head and neck ( cervical spine) are all within normal limits with minimal discomfort.
Extension and flexion of the cervical, thoracic and lumbar spine are within normal limits. Moderate pain occurs with flexion of the spine beginning with contraction of the action.
Rotation and lateral flexion of the spine are all within normal limits with no pain indicated.
Abduction, adduction, flexion and extension of the arms are below normal limits with pain increasing with extension and abduction.
Increased pain at the biceps tendon on right shoulder with flexion of the right elbow. 

Plan

Continue Traditional Chinese Medicine treatments 2-3 times per week as recommended by acupuncturist. Massage treatments ( approx. 30-40 min. each) at least 2 times per week for 5 weeks to increase relaxation, stress reduction, and decrease overall tension and pressure of the muscles of the posterior spine, shoulders, pelvis and legs. These muscles include, bilaterally, the erector spinae group, supraspinatus, infraspinatus, rhomboid major, rhomboid minor, biceps tendon, biceps brachii, teres minor, teres major, deltoid, quadratus lumborum, gluteus maximus, gluteus medius, gluteus minumis, piriformis, biceps femoris, semitendinosus, semimembranosus, gastrocnemius, peroneus longus and peroneus brevis. Massage treatments include the following techniques and purposes for the muscle groups affiliated, bilaterally, with the posterior spine, posterior shoulders, posterior pelvis, posterior thigh and lower leg:

Effleurage: To relax the muscles, stimulate the peripheral nerves, increase lymph and blood flow, remove waste products and begin to stretch the muscle tissues

Pettrisage: To increase mobility between tissues, stretch the muscle fibers, increase venous and lymphatic return, relax the muscles and aid in waste product removal

Compression:
Hypertonic muscles soften and lengthen.
Muscles are flushed and interstitial stasis is reduced.
Released histamines dilate capillaries, increasing cellular nutrition.
Muscles fire faster with increased amounts of acetylcholine.
Muscle lesions heal faster with increased collagen production.
Stretching muscle fibers increases capillerization.
Fascia is rejuvenated and enlivened.
Range-of-motion and freedom of movement increase.
Myofascial pain and secondary autonomic phenomena caused by trigger points are usually eliminated.

Hot/warm hydro therapy: Use of the warm singing bowl technique, warm compress with vapor wrap and prossage soft tissue lotion

Heat therapy dilates the blood vessels of the muscles surrounding the lumbar spine. This process increases the flow of oxygen and nutrients to the muscles, helping to heal the damaged tissue.

Heat stimulates the sensory receptors in the skin, which means that by applying heat to the lower back, pain signals transmitted to the brain will decrease, partially relieving discomfort.

Heat application facilitates stretching the soft tissues around the spine, including muscles, connective tissue and adhesions. Consequently, with heat therapy, there will be a decrease in stiffness while improving flexibility and creating an overall feeling of increased comfort.

Vibration: Used to help sedate the patient’s nervous system and aid in general, overall relaxation. Singing bowl vibration on the quadratus lumborum and plantar surfaces of the feet and sacrum

Homework for patient:
Stretches for flexion of the spine twice daily, morning and bedtime
Hot water bag each night before sleep
Continue to use Tiger Balm oil and self-massage, as needed, for pain relief.
Increase water intake by 1 liter.
Rest as much as possible

Outcome:

After a total of 10 massage treatments, the patient reported a 15% decrease in overall pain. Patient stated that he consistently experienced a 50-75% reduction of pain symptoms during the first 48 hours after a massage treatment before symptoms gradually returned. Pain increased to severe levels with activity upon the onset of its return after the initial 48 hours. The patient appeared more relaxed when receiving treatment and when in the treatment room. His range-of-motion was the same, but with less pain. He was able to walk by himself without his wife’s help. He could sit, stand, remove his clothing and upright himself from a prone position on the massage table without assistance. Tenderness and pain with palpation and touch decreased. He presented with less physiological mannerisms associated with pain. He smiled for the first time during treatment 9. Muscle spasms occurring during the treatments decreased moderately. Hypertonicty of the erector spinae group decreased minimally. 

Conclusion

This patient completed a total of 40 acupuncture and massage therapy treatments over a 3 month period. During this time, he received pain relief, even if only for brief periods after the treatments. Consistently, within 48 hours of each treatment, the patient’s pain would return to severe levels, interfering with his daily activities, thereby decreasing his quality of life. Based on the patients age, severity of the physical condition, emotional health and socio-economic status, it is my opinion that the short-term focus of care should consist of encouragement for improved emotional health to promote a better quality of life. Long-term care for pain with acupuncture and massage is appropriate to provide pain relief, provide hope and contribute to his overall quality of life. With continued treatment, I believe that the patient would benefit from care focused on education of his condition, including the objective and subjective observations, providing pain relief and recommending resources that can support a better quality of life.

Juvenile Rheumatoid Arthritis


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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