Case Studies

Case Studies

Lumbar Stenosis due to Osteoartritis


Sarah Martin MAcOM LAc
November 2012
OVERVIEW

Acupuncture Case Study36-year-old female with lumbar spinal stenosis presents with severe low back pain with referred pain down the posterior left leg and anterior right thigh. The patient lives several hours from the clinic, but was able to stay in Kathmandu temporarily in order to get daily treatment for 2 weeks. After 12 treatments, the patient reported 80% of her pain relieved for a sustained period of 4 days, after which the pain started to slowly return.

SUBJECTIVE

The patient presents with severe low back pain with referred pain down the posterior left leg and anterior right thigh. The pain interferes with her ability to walk without limping. The issue had a gradual onset beginning 3 years ago, continually getting worse, and within the last year it has increased to severe pain. Nothing helps the pain and the patient reports that it is made worse by bending, straightening, twisting, standing, walking and sitting too long. The patient describes her pain as severe, with a sharp burning quality running from the left PSIS area down the posterior portion of the thigh to the middle of the posterior calf and down both the anteromedial and anterolateral portion of the thigh just above the patella. The patient rates her pain as intolerable and constant. No muscle weakness or stiffness are reported. Due to the cost of recommended surgery, the patient hopes acupuncture can help her avoid surgery and perhaps slow the long-term progression of the arthritis.

OBJECTIVE

The patient received an MRI, which showed compressed nerves due to the narrowing of disc space between lumbar vertebras 4 and 5. She was informed that the disc space is narrowing due to arthritis of the spine and surgery is necessary to scrape the bone away from her nerve.

The patient reports no use of any prescription medications or OTC pain relievers.

Patient appears to be in good health, besides dealing with severe pain. Because of pain, the patient appears to be severely distracted, however can answer questions competently. The patient walks with a limp in her left leg. She is unable to sit up without assistance after laying down for the treatment due to the severity of her pain, rather than weakness. All transitions between positions - sitting, lying, standing - are strained and painful.

The Valsava test is positive with severe pain referring down the posterior left leg and anterior right thigh.

Palpation shows no significant findings on her lumbar spine, but shows her pain starting at L3 to under L5 and surrounding the posterior superior iliac spine (PSIS) and down into the sacral foramen, especially S2. Her right PSIS is more proximal than the left and tension is found in the right piriformis. Palpation down the left posterior thigh shows pain directly down the Bladder meridian to BL57 and palpation at the right anterior thigh shows the pain running along both Spleen and Stomach meridians to SP10 and ST34 region.

Patient shows no signs of muscular atrophy. Difficulty in walking is due to pain, rather than weakness.

Her blood pressure and heart rate are within normal limits at 113/84 and pulse 72 b/m.

ASSESSMENT

DX: Lumbar spinal stenosis with narrowed disc space between L4 and L5. Possible subluxation of the sacral iliac joint. Due to her age, it is hypothesized that she has the congenital form of lumbar spinal stenosis.

Medical recommendations from hospital: It is likely that the doctor at the hospital is recommending a laminectomy, foraminotomy or a nerve block.

TCM DX: Bone bi syndrome with qi and blood stagnation in the Bladder, Governing Vessel, Stomach and Spleen meridians with underlying Kidney essence deficiency and Liver blood deficiency.

PROGNOSIS: Due to the severity of the condition and the nature of lumbar spinal stenosis, the prognosis is fair with regular treatments. The patient is young. In the long-run, treating with just acupuncture and herbs leads to a likely poor prognosis. These modalities may delay surgery, but chances are, will not eliminate the need for it. 

INITIAL PLAN

Treat with acupuncture daily for 7 treatments and then reassess. The treatments focus on breaking up qi and blood stagnation in the Governing Vessel, Bladder, Stomach and Spleen Meridians with electro-acupuncture as the main modality. Internal herbal treatment includes Huo Luo Xiao Ling Wan and Xiao Huo Luo Dan Wan. These formulas are used to break up blood stasis, open the collaterals and move qi and blood to stop pain.

Typical treatment: Left: SI3, ashi BL57; Right: BL62, LI4, GB21; Bilateral: HTJJ L3 – L5, Shi Qi Zhui Xia, ashi PSIS area, BL32 – 34, GB30, Huan Zhong , BL40, BL60. Electro from left HTJJ L5 to left BL60, right ashi PSIS to right BL60 and bilateral BL32 to BL40, 5/100 Htz milliamp with mixed frequency. Pain patches and ear seeds are utilized to increase the effects of treatment outside the treatment room. Salonpas pain patches with camphor and menthol to provide a cooling analgesic effect and ear seeds on lumbar spine and sciatic points are also given at the end of each treatment.

Alternate treatments: Right: ST34 and ST41 for right thigh pain, superficial transverse needling with manual stimulation of ashi points surrounding the PSIS for sacral realignment.

OUTCOME 

Due to the circumstance of the patient living several hours from the clinic, daily treatments were given for the first 12 visits. On the 12th treatment, the patient reported 80% of her pain was relieved and tolerable. Bending, straightening, twisting and walking no longer caused her pain. Furthermore, she no longer needed assistance in getting up from the prone position. The patient could walk without a limp. The 13th treatment was spread out to 5 days later to observe if the pain relief could be sustained. On the 13th treatment, the Valsava test indicated considerable treatment results with moderate pain only at BL32, rather than severe sharp, burning pain radiating down the posterior left leg and anterior right thigh as seen on the first visit. It was reported at this visit that 80% pain relief was sustained for 4 days after the 12th treatment, at which time the pain began to return slightly. However, she felt enough pain relief to return home to spend the Dosain holiday with her family and start work for the harvest season. The outcome was better than I, the practitioner, initially expected. Perhaps the MD’s assessment for surgery was premature and the original prognosis was understated. With continued acupuncture and herbal treatment, the inflammation and pain could be reduced long-term and the degenerative nature of the disease might be slowed.

CONCLUSION

Due to the inflammatory process and degenerative nature of lumbar spinal stenosis, regular acupuncture and herbal treatment might be the best option for long-term pain relief and slowing the progression of her arthritis. The patient was informed that regular acupuncture and massage treatment might be the only alternative to surgery. Due to the logistics of living so far from the clinic, if her pain returned or worsened, surgery might be her only option for sustainable pain relief.

Stroke Sequela


Jeanne Mare Werle MAcOM LAc 
November 2012
OVERVIEW

Acupuncture Case Study50-year-old male presents with post-stroke sequelae symptoms manifesting as severe right-sided paralysis. After 10 treatments starting in September 2012, the patient exhibited improvement in his condition and fair measurable progress.

Subjective

The patient had a stroke in November 2011. He received medical attention 24 hours later at the hospital and was treated with western medical pharmaceuticals unknown to the patient. He stayed in the hospital for 9 days. While at the hospital, he learned of an acupuncture program in Kathmandu. He began getting treatments there 14 days after he left the hospital. He doesn’t remember exactly how many sessions he had. Perhaps about 7. He came to the Vajra Varahi Clinic in March 2012. Prior to my attending him, he had 15 treatments at the clinic. Current symptoms are paralysis of the right side of body, numbness in the hand and foot, inability to move fingers or toes, numbness of his lips (right side) and tongue, difficulty walking, an unsteady gait, the sensation of weakness in the right knee and ankle, stiffness in the shoulder, elbow, wrist, hip and knee joints, general fatigue and heavy sensation in the body. The patient is worse in cold weather, fatigue and when hungry. The quality of sensation that the patient experiences in his body is heavy, achy, tingling and weakness. The severity of the condition and the impact on his life is immense due to his inability to work, care for his animals or farm his fields.

The patient reports difficulty in walking due to his toes having no ability to move. This requires the patient to lift his leg straight up and land the foot on the whole sole as opposed to heel-to-toe walking. This gives the patient an unsteady gait that he reports also makes his knee feel like it could give out. The distance the patient walks to the clinic from his home would have taken him 20 minutes prior to the stroke. Currently, it takes him close to an hour.

While in the hospital, the patient received 1 physical therapy session. The patient maintains an exercise routine based on what he learned in PT while at the hospital. He reports that he massages his foot and hand daily. He doesn’t take any western medication or supplements, though he does take Tibetan herbs.

Despite the extent of his symptoms, the patient identifies that he would like to focus on improving his speech, reducing the swelling around his lips on the right side, regaining some use of his right hand and improving his ability to walk and feel more balanced.

Objective

Acupuncture Case Study

Patient appears to be in good health with a strong spirit and determination to improve. He has spent his life working the land and raising animals. This has taught him patience and endurance.

The patient’s left arm is used to lean on a walking stick as he raises his right leg directly up from his hip and places his foot down on the whole flat of his foot, as if it were one solid block. He is unable to walk in a normal heel-to-toe stride. His right hand is contracted and he holds his entire arm tight against his belly. His face appears symmetrical and bright except for about 10% swelling in the right upper and lower lips.

When seated, the patient uses his left hand to move his right hand into position. The right hand is contracted, however passive stretching of the digits and opening of the palm happens easily and reveals tremendous flexibility. The patient has a medium-strength grip in his right hand, about 50%, compared to the left. He has no ability to extend the fingers or even wiggle or twitch them. After opening the hand, it slowly folds back into a soft contraction within a few seconds.

Sensory testing using light, medium and heavy stroking of the patients affected areas, while the patient has his eyes closed, shows complete response. Hip flexion and extension has normal ROM, however the strength of the hip is reduced by 30%. Hip flexion and extension are occasionally affected by stiffness in the hip joint from the action of lifting the leg to place the foot. Most of the stiffness remains in extension position. Although I do not speak the patient’s language, I can hear that there is very minimal slurring in his words. When the patient leaves the treatment, he lifts his leg off the ground about 2 inches higher than when he came in.

Tongue – swollen, pink, light white coat

Pulse – slightly rapid, superficial and wiry

Assessment

DX: Post-stroke sequelae with paralysis of the right hand, fingers, foot and toes; Overall stiffness, weakness and heaviness

TCM DX: Qi & blood deficiency; KI yang deficiency; Wind & phlegm obstructing the channels and collaterals

PROGNOSIS: The prognosis for a full recovery is poor, however we expect some hand mobility to return and sensation to continue returning to the foot and toe’s. As these functions return, we expect to see less weakness and stiffness in the joints affected by the stress caused by the impairment. The treatment plan will need to be long-term and the patient must remain hopeful and committed.

Initial Plan

Treat with acupuncture 4 times per week for 3 months before reassessing. Focus on strong stimulation with electro-acupuncture crossing affected joints. Use scalp points associated with motor function of upper and lower limbs using hand stimulation of needles.

Typical treatment: Left: Dr. Zhu motor points for upper and lower limbs with deep insertion and heavy stimulation. Dr Zhu speech points on scalp.

Right lower: Ba Feng, KI1, LV3, GB41, KI3, SP3, SP6, ST41, GB39, ST36, GB34, KI10, He Ding, Xiyan/Xiyuan, ST34; Right upper: Baxie, HT8, PC8, PC6, Xu Duan – 10 drains on the right hand and right toes, TB5, LI10 X 3, LU5, biceps ashi

Electro: 2/100 mixed – Dr. Zhu scalp points, biceps ashi – PC6, LI4 – LI10, ST 34 – ST 36; Alternative treatment consists of similar points crossing joints such as KI10 – KI3, SP6 - SP3 and/or GB34 - ST34.

The patient is given a bottle of Po Sum On (aromatic oil) and instructed to use it with his home routine that includes daily massage and physical therapy. Included in home therapy are visual exercises to stimulate the brain and motor connection. The patient is instructed to first perform the physical therapy routine with the unaffected side of the body while creating a strong eye connection with the movements. Then, the patient performs the same movement therapy with the affected side, again keeping a strong visual connection.

The patient uses Tibetan medicine as his herbal treatment and expresses positive feelings about this. Keeping detailed track of all changes and astute observations with each treatment is imperative. The smallest details are critical to observe and note, both for the clinician and patient. Constant encouragement through the likely long process of healing must not be overlooked. Reminding the patient of all the changes at each session will help in the process of staying positive.

Outcome

Patient reported that over the course of the 9 treatments, he has, for the first time, noticed significant improvement. After each treatment, he reported more nerve sensation in his hands and feet, with greater ROM in his knee and ankle. The swelling in his lips responded immediately to the treatment and the patient reported clear speech. The patient had a 10-day lapse in treatment, which brought back 30% of the lip swelling and 5% of the speech problem. After 1 treatment, clear speech returned, even though the lip swelling returned quickly after treatment. The quality of the stiffness and pain is reported by the patient as deep, dull and achy. ROM in the shoulder joint and elbow progressed from about a loss of 40% in extension to 10% with complete disappearance of shoulder pain. There was still achy pain in the bone in the elbow joint. The contracture in the right hand remained, rendering the hand useless still, but the hand had a softness progressively allowing the hand to stay open longer. The patient reported a tingling sensation in his 3rd & 4th fingers which may be a forerunner to the return of nerve function. The patient was able to place his heel on the ground and land on his toes though there was a slight supination of the foot upon landing on the toes.

Conclusion

In the past, this patient received acupuncture treatments of a more constitutional nature without any change to his symptoms. His current response to treatment has been exciting. He has had fair outcomes with measurable changes in symptoms. At this time, the patient mostly hopes to regain sensation and functioning in his toes so that he may improve his gait, as walking is the only option he has in his village. It is imperative for the patient to continue with regular treatment in order to maintain the progress that has been achieved. In stroke cases, it appears that focused, aggressive and frequent treatments are critical. Using visual exercise where the patient first does the physical therapy with the healthy hand or foot, while keeping focused on the movement to imprint on the brain, and then repeats the same exercise with the affected hand or foot is important as are home massage and physical therapy in conjunction with acupuncture treatment. It is also important in working with post-stroke sequelae that the practitioner employ careful documentation and critical observation so to better track changes, however big or small, in the patient’s condition. Constant encouragement and reminders of change help to show the patient their progress throughout the frequently slow healing process.

Low Back Pain with Urinary Difficulties


Kelli Jo Scott MAcOM LAc 
November 2012
OVERVIEW

Acupuncture Case Study32-year-old woman presents with constant low back pain and burning urination. She has been diagnosed with severe hydronephrosis in the right kidney and, due to pain, recommended to have a nephrectomy. After 10 treatments with various Chinese medicine modalities, her pain was reduced by 50% and the frequency of her pain was only every 2-3 days. The burning urination resolved.

Subjective

A 32-year-old woman presents to the clinic with a chief complaint of low back pain on the right side in the kidney area, which radiates up the thoracic region of the erector spinae muscles and over to the left kidney area and left thoracic region erector spinae muscles. The pain is described as constant and achy, with sharpness that comes and goes. The onset of this pain was about 1 year ago and nothing seems to change it. Her second complaint is continuous burning urination. She reports no urinary hesitancy, urgency or frequency. The urine is clear to light yellow and output is equal to input. The patient reports some dizziness when standing up and occasional night sweats (2-3 times per week). All of these symptoms have been present for a little over 1 year. Previous to the onset of these symptoms, the patient reports no prior history of trauma to the area or kidney problems, nor has any significant family history of disease.

OBJECTIVE

Patient appears to be in good physical, mental and emotional health for her age and environment. She is soft spoken, but seems educated, engaged and alert. She is the mother of 2 children, ages 2 and 6, and comes from a higher caste, which increases her access to healthcare. Her pulse is slightly rapid and slippery, her tongue red and quivering. Upon palpation of the area of chief complaint, bilateral moderate muscle tension along the thoracic region of the erector spinae muscles, more tightness on the right, is noted. On the ninth visit, the patient brought in lab tests and imaging that had been taken 13 months previous to initially being seen in the clinic. They reveal that her right Kidney is smaller in size and significantly compromised in function. The left Kidney measures 11.5 cm in length, while the right Kidney measures only 7cm. A diuretic renogram taken 1 year ago, reports 94.1% differential function in the left Kidney and 5.9% in the right. The glomerular filtration rate (GFR) of the left Kidney was 88.8; the right Kidney GFR was 3.5. The most recent imaging and urinalysis, 5 months ago, reveals that her right Kidney has become even more compromised and surgery to remove the diseased Kidney was recommended.

ASSESSMENT

Acupuncture Case StudyDX: Atrophied, poorly-excreting right Kidney with severe hydronephrosis and a thin renal cortex; Hypoplastic right renal artery

TCM DX: Kidney qi and yin deficiency with deficiency heat; Qi and blood stagnation in Bladder meridian

PROGNOSIS: Originally, the prognosis for resolving the complaints of low back pain and burning urination, in an otherwise healthy young woman, was quite good. All of that changed on her ninth visit to the clinic, when upon our request, she presented her full history of medical reports and imaging studies to us for the first time. Due to the severity of her condition, the long-term prognosis for the health of the right Kidney is poor. But due to her response to the treatment thus far, the prognosis for alleviating her symptoms with acupuncture and herbs is good.

INITIAL PLAN

Acupuncture treatments twice per week for 5 weeks and then reassess. Focus on tonifying Kidney qi, nourishing yin and reestablishing the free flow of qi and blood to the local area. Herbs are given to tonify Kidney qi and yin and promote urination.

A typical acupuncture treatment includes the following points: DU20, BL23, BL24, BL26, BL28, BL40, KI7, KI3 and SP6. On several treatments, thread the inner Bladder line all along the thoracic vertebral region due to tightness along the erector spinae muscles and referred pain, especially on the right side. Electro-acupuncture (continuous @ 5 Hz and mixed 2/100 Hz) is used in the low back area bilaterally, as well as localized massage.

Ba Zheng San to clear heat and Dao Chi Wan to promote urination.

OUTCOME

After 10 treatments, the patient reported significantly less intensity (50% less) and frequency of the low back pain. Burning urination resolved. She also reported no more dizziness or night sweats. The low back pain was no longer constant or even daily in occurrence, sometimes only noticeable every 2-3 days. The best herbal formula results were seen with Dao Chi Wan, given at appointments 9 and 10. During her re-evaluation at treatment 10, the patient volunteered that she had good energy and felt strong.

CONCLUSION

As far as the medical reports for this patient conclude, the nephrectomy was recommended primarily due to the fact that she was experiencing pain. With 10 treatments of acupuncture and herbs, we were able to reduce the pain significantly in both frequency and intensity (50%). She was also no longer experiencing any burning during urination. If at some point, she no longer experiences pain or other symptoms, and her bi-annual scans and tests reveal continued normal function in the left Kidney, I feel it is reasonable to assume that she could potentially avoid the surgery altogether.

CONTINUED TREATMENT

The patient was aware that there is a high likelihood that she will eventually need to have the Kidney removed. She planned to continue to be monitored by her medical doctor and have imaging done approximately every 6 months or more frequently, if symptoms increase, to assess the progression of the hydronephrosis. Acupuncture and herbs, at this time, are useful palliative care and should be continued at the current course, as long as the symptoms are present. When the symptoms are completely alleviated, a maintenance course of treatment (once per week) should be implemented to maintain the strength of the system and to potentially improve Kidney function bilaterally.

Neck Pain with Radiation


Amy Schwartz MAcOM LAc
November 2012
OVERVIEW

Acupuncture Case Study40-year-old male presents with right-sided neck pain, without nerve radiculopathy, down the arms bilaterally. He has seen his physician who diagnosed him with nerve impingement and wants to do injections of Xylocane and Tricant local to the area of pain, inferior and slightly lateral to his occiput. After 6 acupuncture treatments, including electro-stimulation, massage and topical pain patches, the patient reports improvement in pain frequency and quality.

Subjective

Patient presents with right-sided neck pain that has been present on and off for the last 5-6 years, but has become constant over the last month. The pain can be worse with cold. Heat packs alleviate the discomfort. There is no radiculopathy, but he does notice that his left arm can feel weak when he’s walking uphill. When it is most severe, he can feel pulling over his head to the frontal and parietal bones. He has had physical therapy in the past for right shoulder muscle spasms and they have resolved. He has no history of heart palpitations or hypertension. He is not currently taking allopathic medications.

Objective

The patient appears to be healthy and is comfortable answering questions about his discomfort. Upon palpation of his neck, tenderness is noted suboccipitally at the origin of the trapezius muscle and the insertion of the splenius capitus and cervicus muscles. The scalenes are also tight and tender. Palpation reveals a slight anterior rotation on the right of the first cervical vertebrae. Cervical compression, distraction and maximum compression tests are negative. His pulse is moderate, but thin and his tongue is red with a greasy, yellow coat. An x-ray report shows no clear indication of a problem. In comparison to the left, his ROM on the right is decreased with lateral flexion and rotation. The pain also increases with lateral flexion and rotation to the right. Grip strength in the left arm showed some weakness by comparison to the right and felt cooler to the touch.

Assessment

DX: Possible cervical rotation of C1

TCM DX: Bi syndrome due to qi and blood stag in the DU and BL channels

PROGNOSIS: Acute phase- good; Underlying chronic phase will take time to unwind the fascia and muscle spasms that tend to sublux the vertebrae.

Initial Plan

Treat with acupuncture twice weekly for 4 weeks before reassessing. Focus treatment on loosening the muscles and fascia that are pulling the vertebrae out of alignment and impinging the nerve with use of acupuncture needles, electro-acupuncture and massage with traction and joint mobilization.

Typical treatment: GB20, 21, BL10, An Mian, ashi in cervical area and above occiput at the origin of the trapezius muscle, TB14, LI15, SI12- 13, LI4, LV3; Electro-acupuncture from GB20 to ashi in cervical region; Massage suboccipitally and into vertebrae with myofascial release techniques and traction; Local application of Salonpas topical patches with menthol and camphor to move qi and blood, thereby clearing stagnation and decreasing pain.

Outcome

After 6 visits, the patient reported 80% less pain in the right suboccipital area and noted that the pain shifted to a broader area with less intensity. His ROM in lateral flexion and rotation to the right became equal to that of the left. He still felt a slight pulling in the muscles upon rotation to the right. He was encouraged by the treatments, noticing that his left arm felt better and strength had returned.

Conclusion

This patient agreed to let us treat him in lieu of injections even after his doctor told him there was no other care available to him for his condition. This case shows some of the strengths of acupuncture and massage in making changes in musculo-tendinous conditions that are both acute and chronic in nature. He will continue to be seen twice per week until the pain is resolved, the ROM becomes equal and the vertebral subluxation shifts.

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