Case Studies

Case Studies

Chronic Gastritis


Chanel Smythe MS RAc TCMP
November 2013
OVERVIEW

Acupuncture Case Study52-year-old female presents with chronic, burning epigastric pain accompanied by acid reflux, nausea, belching and decreased appetite. The patient also experiences daily headaches and dizziness. With conjunctive therapy of acupuncture, Chinese herbal medicine and antacid treatment, the patient reported an 80% improvement in her condition over 10 treatments, experiencing a decrease in severity, frequency and the absence of many symptoms.

Subjective

Patient is a 52-year-old female who presents with moderate epigastric pain, a complaint that the patient has had for 6 to 7 years. The pain manifests as a burning sensation in the epigastric region, at times exacerbated when the patient eats, while at other times is relieved with food. Occasionally, the patient wakes in the night due to her gastric pain. She experiences acid reflux after eating, a decrease in appetite, belching and nausea both on empty stomach and after eating. The epigastric pain is aggravated by the consumption of spicy and greasy foods. Bowel movements are daily, formed and easily passed without pain. The patient denies diarrhea or loose stools, blood or mucus in the stools, and vomiting.

The patient also experiences both headache and dizziness daily, which she has had for 1 year. The headache manifests as a throbbing pain, located primarily in the temporal region and occasionally in the frontal region. Dizziness occurs mostly when the patient moves from a seated to standing position, though occasionally she will experience dizziness when attempting to focus on a point in the distance. The dizziness can be accompanied by blurry vision.

The patient experiences sleep disturbances with both difficulty falling asleep and difficulty staying asleep, often waking several times throughout the night. She reports a feverish sensation in the afternoon, and night sweats.

The patient’s diet consists primarily of rice, lentils, vegetables, chickpeas and dado (corn meal and buckwheat).

The patient has not received any medical treatments for her gastric pain, headaches or dizziness.

Objective

Despite the patient’s complaints of gastric pain, headache and dizziness, she appears to be in good health for her age and environment.

She experiences a moderate level of epigastric pain and acid reflux after every meal. Nausea and belching is experienced daily. Headaches and bouts of dizziness are also a daily occurrence. Abdominal palpation reveals no masses or objective tenderness in any of the 4 quadrants or on the midline, and no indication of an enlarged Liver or Spleen. Both Murphy's sign and McBurney's point are negative. The patient’s blood pressure is 120/70 mm/Hg. Tongue is pale with fissures throughout body. The pulse is thready.

Assessment

DX: Chronic non-erosive gastritis, gastric ulcer, potential duodenal ulcer

TCM DX: Stomach yin deficiency, Liver and Kidney yin deficiency It is suspected that the patient has non-erosive gastritis accompanied by a gastric ulcer, and potentially a duodenal ulcer. Though nonerosive gastritis is generally asymptomatic, it manifests as mild dyspepsia and other vague symptoms, which are part of the patient’s presentation. Additionally, non-erosive gastritis is commonly caused by Helicobacter pylori (H.pylori), a bacteria that is speculated to be in the local water supply in considerable quantity.

Accompanying the gastritis, a gastric ulcer is suspected. Gastric ulcers manifest as a variable pain picture in which the epigastric pain does not follow a regular pattern. A common manifestation of a gastric ulcer, in which eating sometimes exacerbates rather than relieves the pain, is consistent with the patient’s pain presentation. On occasion, the patient wakes at night due to her epigastric pain, a common manifestation, and suggestive of a duodenal ulcer. However, the patient does not possess any of the other defining characteristics typical of a duodenal ulcer. Such symptoms include a consistent pain pattern of absence of pain when waking, pain that appears midmorning, is relieved by food, but recurs 2 to 3 hours after a meal.

Similar to that of non-erosive gastritis, gastric ulcers are commonly caused by H.pylori or overuse of NSAIDs. The patient lacks a history of NSAID use, further suggesting that the suspected ulcer is a result of an H.pylori infection.

Stomach cancer is not likely with this patient’s presentation as there is no occult blood in the stool or concurrent symptoms that often accompany cancer, such as weight loss or extreme fatigue, etc. Stomach cancer may become a concern in the future if the gastritis is due to a H.pylori infection, as it has been shown that the occurrence of stomach cancer is 3 to 6 times more common in persons with H.pylori infection.

Prognosis

Acupuncture Case StudyWith regular acupuncture, in conjunction with herbal and antacid treatment, the patient is expected to experience a minimum of 50% improvement in her epigastric pain and associated symptoms. Progress is contingent upon patient’s compliance to the treatment plan, and taking herbal and antacid supplementation as prescribed, as well as the avoidance of trigger foods.

If the patient experiences little to no response to the conjunctive therapy within 10 treatments, an endoscopy and stool analysis would be indicated to rule out microscopic blood in the stool. If endoscopy proves H.pylori infection, triple antibiotic therapy is indicated. Proton Pump Inhibitor (PPI) therapy would also be indicated at this time to help further mitigate stomach acid.

Both interventions would be supplemented with concurrent acupuncture.

Plan

Treat with acupuncture 3 - 4 times per week with daily intake of Chinese herbal medicine and antacids. The patient receives 10 treatments, after which there will be a reassessment of the patient’s condition.

Treatment Principle: Clear Stomach heat, nourish yin, promote ulcer healing, and reduce ulcer recurrence.

Acupuncture: Acupuncture treatments generally focus on clearing empty heat from the Stomach and nourishing yin of the Kidneys and Liver.

Typical acupuncture points utilized in treatment consist of ST44, REN12, REN6, ST25, P6, REN17, ST36, KI3, SP6, KI10, LV8, LV3 and LI4.

Chinese herbal medicine: Internally, formulas to tonify Kidney, Liver and Stomach yin, and clear Stomach heat

Liu Wei Di Huang Wan: 3 pills BID for the first 2 weeks of gastritis treatment to simultaneously address the headaches and dizziness

Stomach Formula (Mayway): 3 pills TID for the following week of treatment with focus on nourishing Stomach yin and clearing Stomach heat

Antacid Treatment: Mitigation of Stomach acid to reduce pain; 2 tablets 5-10 minutes before meals and 2 tablets before bed

Lifestyle Advice: Counsel patient to avoid foods that trigger gastric pain, namely spicy and greasy foods.

Outcome

After 10 treatments, the patient reported an 80% decrease in her gastric pain and associated symptoms, as well as her headache and dizziness. She no longer experienced burning epigastric pain upon waking in the morning, and the epigastric pain that remained had decreased from a moderate level of pain to a low level of pain. Additionally, she no longer experienced any acid regurgitation after meals, or belching before or after eating. Her nausea became sporadic, rather than daily, and decreased in severity. She reported an improvement in her appetite. She still woke several times in the night, though gastric pain was no longer the cause. The patient could not note if there was more improvement in her epigastric pain and associated symptoms on either Liu Wei Di Huang Wan or Stomach Formula.

Her headaches decreased in severity and frequency. Before treatment, she experienced headaches daily. After treatment, she could last several to many days without a headache. Her dizziness was still consistent, though it decreased in severity. Additionally, she no longer experienced night sweats, and the heat sensation in the afternoon decreased in severity and frequency. The patient reported more significant improvement in her headaches and dizziness, night sweats and heat sensation while taking Liu Wei Di Huang Wan.

The patient would experience a recurrence of her epigastric pain when she would overindulge in spicy and/or greasy foods.

Discussion

According to the District Health Office of Makawanpur, 80% of cases reported to the Hetauda Hospital are for epigastric pain or gastritis. Therefore, it is pertinent to address the nature of gastric pain and what effect acupuncture, Chinese herbs and other forms of supplementation can have on the condition.

The patient responded well to the treatment plan, with combination therapy of acupuncture, herbs and antacids, with varying degrees of efficacy at mitigating the patient’s symptoms outlined above. The combination therapy is important for the management of the patient’s epigastric pain, and I think that decreased efficacy would result if treatments were to be used out of combination. With continued treatment, it is expected that the patient will continue to improve.

Primary Hypertension


Hanna DeFuria, MSAOM LAc
December 2013
OVERVIEW

Acupuncture Case Study3 patients present with stage 2 essential hypertension (HTN), 1 of which is a female (76 yo) and 2 of which are male (61, 50 yo). In addition, each patient presents with knee pain and various other tertiary complaints. All 3 patient’s conditions are pharmaceutically unmanaged. However, through herbal supplementation, acupuncture treatment and lifestyle education, each patient’s blood pressure was reduced to normal, prehypertensive or stage 1 range.

Subjective, Objective, and Diagnosis

Patient 1: 76-year-old female patient presents with constant headaches that alternate between both the temporal region as well as the vertex. The patient’s headaches are often accompanied by dizziness, and exacerbated by the ingestion of spicy foods. The patient has floaters and experiences regular bouts of blurred vision. She has a history of bilateral eye pain and right-sided cataracts. Both eyes are frequently bloodshot. The patient appears dehydrated as measured by skin pinch test, which demonstrates tenting. The patient’s feet, however, are moderately edematous, but not pitted. Rebound is not timed. Although she does not currently smoke tobacco, the patient purportedly did so for 47 years prior to 2013.

The patient complains of frequent bloody noses, swollen ankles and a tingling sensation in her feet. Secondarily, she reports lower extremity heaviness and aching, primarily felt in the knees. Lastly, the patient complains of low back pain that is sore in nature. Flexion and extension of the back are limited and elicit mild to moderate pain, though the patient has maintained full range-of-motion. The patient is slight, possessing a small frame, and mildly hyperkyphotic stature. Her symptomology has reportedly spanned the last 6-7 months. Blood pressure is measured at 160/110.

The patient’s answers to questions are short and of an irritable tone. She is reluctant to engage, and often rolls her eyes when given lifestyle advice.

The patient’s tongue is peeled and heavily fissured, while the pulses are strong, forceful and wiry.

DX: Stage 2 essential hypertension
Diagnosed 4 months prior at Patan Hospital, Kathmandu

TCM DX: Liver yang rising
Constitutional Kidney yin deficiency

Patient 2: 61-year-old male presents with high blood pressure, measured at 180/110. The patient’s secondary and tertiary complaints are bilateral knee and low back pain. The patient experiences occasional, infrequent and random dizziness and blurred vision. Both symptoms are exacerbated by the ingestion of hypertensive medication, and are intensified by bright light. He sites this limited experience with his medication as further deterrence for long-term allopathic treatment. The patient reports regular epistaxis. The most recent of epistatic events purportedly lasted 10 hours. He admittedly consumes moderate amounts of alcohol on a nightly basis. Despite his efforts to increase water intake, he tries, but struggles to decrease salt consumption.

The patient is of medium stature and average build. At times, he is highly engaged in treatment, making good eye contact and easily communicating symptoms. His enthusiasm is erratic however, and his commitment to regular therapy is inconsistent. His attendance ranges from daily visits to random weekly appearances. Similarly, his tolerance for questioning is unpredictable.

The patient’s tongue is bright red, and the coat is fury and yellow. The patient’s pulse is wiry.

DX: Stage 2 essential hypertension

TCM DX: Liver yang rising
Kidney yin deficiency; Qi and blood stagnation

Patient 3: 50-year-old male presents with high blood pressure, measured at 184/108. The patient reports red, itchy eyes and blurred vision. Upon further questioning, the patient confirms occasional epistaxis. His sleep is restless and disturbed with frequent night sweats. All symptomology is intensified by the ingestion of spicy foods. The patient denies headaches and dizziness.

The patient appears physically fit. His movements are quick and erratic. His focus is on his knee pain and trigger finger, but he is attentive and receptive to lifestyle coaching. The patient is reliable and highly compliant with the treatment plan and recommendations.

Tongue is red, and the coat is both thin and white. The pulse is wiry.

DX: Stage 2 essential hypertension

TCM DX: Liver yang rising
Kidney yin deficiency; Qi and blood stagnation

Assessment & Treatment

Allopathic perspective: Hypertension refers to elevated systolic and/or diastolic blood pressure. Ideally, blood pressure is measured at 120/80 while 120-139/80-89 qualifies as prehypertension. Stage 1 hypertension is diagnosed at 140-159/90-99 and Stage 2 is >160/>100.

Hypertension is often times asymptomatic. When signs and symptoms do appear however, dizziness, facial flushing, headache, fatigue, epistaxis and nervousness are common. Such symptomology is not unique to high blood pressure, and is likely the manifestation of a complication involving an affected organ.

The etiology of the disease is difficult to define, as many factors may contribute to the development of hypertension throughout one’s life. There are 2 overarching categories based on the origin of the diagnosis: essential and secondary. Essential hypertension, or primary hypertension, implies an unknown etiology and accounts for the majority of hypertensive patients. The small population suffering from secondary hypertension likely have kidney damage, or endocrine dysfunction, that in turn causes the blood pressure to rise.

A blood pressure cuff, or aneroid sphygmomanometer, is utilized in the measuring and diagnosing of blood pressure. It is important to evaluate the patient’s blood pressure on at least 2 separate occasions to ensure an accurate diagnosis, as blood pressure may fluctuate.

For a newly diagnosed patient, further examination may include routine testing to detect target-organ damage and cardiovascular risk. Urinalysis, spot urine albumin, creatine ratio testing, blood tests (creatinine, K, Na, fasting plasma glucose, lipid profile), thyroid-stimulating hormone measurements and an ECG may also be conducted.

1 of the primary factors associated with essential hypertension is high animal fat or sodium chloride consumption. Other lifestyle choices that play a large role in the development of hypertension include smoking tobacco, and drinking alcohol and coffee. Although chronic alcohol intake is one of the strongest indicators of high blood pressure, even moderate intake can lead to the development of hypertension in a percentage of individuals. Similarly, smoking is a strong contributing factor. This is exacerbated by the tendency for coexisting sugar, alcohol and caffeine ingestion.

The high correlation between lifestyle choices and hypertension implies the opportunity for resolution through lifestyle modification. Mild hypertension can often be resolved through weight loss, restricted sodium consumption, exercise and relaxation. For those with more severe hypertension, drug therapy is often considered necessary. Prescription treatment typically includes diuretics (thiazides, loop diuretics, potassium-sparing agents), ACE inhibitors (captoril, enalapil, lisinopril), calcium channel blockers (diltiazem, amlodipine, verapami, nisoldipine), vasodilators (hydralazine, prazosin, clonidine, minoxidil) and/or beta-blockers (propranol, acebutolol, betaxolol, cartedolol). The initial pharmaceutical intervention in Nepal involves a beta-blocker called Atenolol. Atenolol is available at most health posts countrywide.

Despite the variety of antihypertensive medications, a percentage of blood pressure patients go untreated. Such patients are at great risk for debilitating, or potentially fatal, heart conditions, cerebral hemorrhage or infarction, renal failure or stroke.

TCM perspective: All 3 patient’s range dramatically from a constitutional perspective. The group of individuals varies in gender, age and lifestyle and demonstrate diverse signs, symptoms and peripheral complaints. Nonetheless, they all share the same disease and corresponding diagnosis: Hypertension due to Liver yang rising.

Liver yang rising is characterized by symptoms of facial flushing, headache, dizziness, disturbed sleep and irritability. Various eye complaints, epistaxis and soreness of the low back and knees are also symptoms associated with this diagnosis and are common amongst all 3 patients. The upward movement of yang is the result of an underlying yin deficiency. Without adequate yin, the Liver fails to be nourished and anchored, which in turn leads to yang rising.

Patient 1 and Patient 2 are approximately 10 and 15 years older than Patient 3. Consequentially, their lists of symptoms are more extensive as a result of the more progressive nature of their conditions. This is likely the result of further depleted yin reserves.

Treatment: Throughout the course of treatment, each patient’s blood pressure and related symptoms are heavily monitored. Each patient receives acupuncture, herbal supplements and dietary recommendations. Various local points are utilized for secondary and tertiary complaints, while the overlapping acupuncture points included LV2, LV3, KD7, SP6, LI4, LI11 and DU20 (needled against the channel). The apex of the ears bled upon each visit. All 3 patients are prescribed Wu Ling San, 3 tablets BID. In addition, each patient is advised to greatly reduce his or her sodium intake, and increase water consumption. The adverse effects of smoking tobacco and drinking alcohol are discussed, and decreasing usage suggested.

Acupuncture Case Study

Prognosis & Safety Measures

The prognosis is fair. Response is expected within 6 treatments. Given the advanced nature of each patient’s condition however, reducing systolic and diastolic measurements to within normal limits is less likely. A steady reduction in either or both numbers requires continued treatment. Strict adherence to the treatment plan is required, as daily acupuncture, herbal and dietary compliance creates greater opportunity for recovery.

Prior to treatment, the severity of the cardiac condition, and the potential complications, are discussed. Both eastern and western treatment options are communicated. If progress is not documented within the first 6 preliminary sessions, the patient is to be referred to an allopath or prescribed hypertensive medication.

Outcome

Over the course of 6 treatments, all 3 patients began to see significant results.

Patient 1: Upon conclusion of the sixth treatment, the patient’s blood pressure was measured at 116/80. The patient reported less severe headaches, experienced at a lesser frequency. The patient no longer experienced floaters or had painful eyes. The patient’s skin no longer tented upon pinching, and she no longer suffered from lower extremity edema. She still complained of the occasional episode of tingling in her feet. Her low back pain had decreased by half with treatment 3-5 times a week. The patient’s attitude had improved as her conditioned improved. She explained that as her body healed, she was less uncomfortable, more productive and less agitated.

Patient 2: While under my care, the patient’s blood pressure was measured at 150/90 by his sixth visit. Within 2 more treatments, both acupuncture and herbal, the patient’s blood pressure was reduced to 140/90. His dizziness and blurred vision subsided entirely, despite exposure to bright light. The patient had not had a bloody nose since treatment commenced. Both the patient’s back and knee pain were decreased significantly. Purportedly, the back pain had ceased while the knee pain improved 90%. The patient’s unreliability was ultimately short-lived. He soon returned for daily treatment, and his tolerance for lengthy intakes became less volatile.

Patient 3: The patient’s blood pressure was reduced to 150/94 within 6 treatments. The patient’s eyes were no longer itchy or red. Only occasional blurring of his vision persisted. While under our care, the patient had not had another bloody nose. His knee pain improved 50% and his trigger finger improved 75%. Although highly compliant, the patient’s wife fell ill, and he was unable to continue further treatment.

Discussion

Hypertension is extremely prevalent in Nepal. However, due to limited access to healthcare, high blood pressure often goes undiagnosed. Many patients do not receive adequate education regarding their hypertensive condition, and are unaware of it’s associated risks and complications. In addition, many prefer native forms of treatment over that of conventional medicine. For these various reasons, the condition commonly goes unmonitored, or remains unstable and potentially life threatening.

For those patients who pursue a formal diagnosis and the appropriate medications, compliance is highly variable. This is also true for those who pursue acupuncture and herbal treatment. Regular attendance is required, daily herbal dosing is a necessity, and consistent efforts to make healthier lifestyle choice’s are obligatory. Conveying the importance of these measures can be very difficult.

Successfully treating a cooperative patient can prove similarly difficult, as the appropriate herbal formula selection is highly important. Initially, Tian Ma Gou Teng Yin was utilized for Patient 1. Given the patient’s LV yang rising diagnosis, the formula was indicated. Patient 1 reported a reduction in some of her symptoms (eye complaints, headaches), but there was no documented change in her blood pressure. As a result, Tian Ma Gou Teng Yin was replaced with Wu Ling San. Wu Ling San’s diuretic function acquired great results within a short period of use. These results were later replicated in both Patient 2 and Patient 3.

This information is of significance as it may help in the treating of this highly common condition. In addition, it may help avoid heart attack and stroke.

Emotional Depression


Liz Kerr, RMT Dip RAc
December 2013
OVERVIEW

Acupuncture Case Study40-year-old woman presents with depression, emotional stress and dream-disturbed sleep. She presents with a secondary complaint of chronic ringing in her ears. 2 months ago her daughter committed suicide, and she is emotionally distraught from the incident. The clinic provides a safe place for her to express her sadness, and renders her with coping mechanisms otherwise unavailable to her.

Subjective

40-year-old woman presents with stress, unstable emotions and dream-disturbed sleep. Originally, patient complaints were of bilateral knee pain and chronic ringing in the ears, but she has not been to the the clinic in over a month. When asked about her previous symptoms, the patient becomes visibly upset and begins to tear up. She explains that her quality of sleep is poor, and she wakes many times during the night. The patient's 14-year-old daughter committed suicide a month prior, and she has not been able to sleep through the night since. The patient reports having dream-disturbed sleep, including nightmares, about the incident. She also reports constant ruminating thoughts about her daughter without any relief. She is distracted from work and has a hard time getting daily tasks at home completed. She has a lack of appetite, is not cooking, and is not eating full servings. She complains of being weak from the emotional pain in her heart and suffers palpitations. She suffers from blurry vision and headaches, which are worse after a crying episode. She also discloses that she has a son and husband at home who are also suffering, and another daughter in Kathmandu.

The patient is unaware that acupuncture and herbs will benefit her stress, depression and dream-disturbed sleep. The patient would like to work on this, and would also like to continue addressing the ringing in her ears. She reports that the ringing in her ears began 1 year ago, and describes it as high-pitched, coming and going throughout the day. The patient reports that she has had diminished hearing since birth. She agrees to a treatment plan of coming to the clinic regularly, but only when her neighbour also comes.

Objective

The patient is visibly upset. She conceals herself under a scarf, which covers her head and lower face. She is not able to look the practitioner in the eyes while explaining how she feels, and tears up when talking about her stress levels and sleep. The patient quickly wipes tears from her face and eyes, and looks frustrated as she does. She has a lack of lustre in her eyes and a dull complexion. Occasionally, there is a scent of alcohol on her breath in the mornings. She is distracted by the ringing in her ears, and needs to have questions repeated. Her voice is muffled, and she speaks with a slight speech impediment (confirmed by my interpreter due to the language barrier).

Her pulse is deep and choppy on the left, and slippery on the right. Examination of the patient’s ears shows a bright red irritation along the lower border of the tympanic membrane in the right ear. In the left ear, there is visible scarring on an opaque white coloured tympanic membrane.

Assessment

DX: Post-Traumatic Stress Disorder (PTSD) with a secondary complaint of a right-sided chronic outer ear infection.

In order to differentiate PTSD from Acute Stress Disorder, it is important to consider that PTSD is identified by recurrent, intrusive recollections of an overwhelming traumatic event. Symptoms of PTSD include avoidance of stimuli associated with the traumatic event, nightmares and flashbacks. Depression, other anxiety disorders and substance abuse are common among patients with PTSD. Symptoms last for over a month. With Acute Stress Disorder, people have been through a traumatic event, have recurring recollections of the trauma and avoid stimuli that remind them of the trauma. Unlike PTSD, Acute Stress Disorder symptoms begin within 4 weeks of the initial incident, last a minimum of 2 days, but do not surpass 4 weeks. As this case spans a timeline of almost 10 weeks following the traumatic event, PTSD is the more probable diagnosis.

TCM DX: Liver qi stagnation with phlegm fire harassing the Heart

Liver qi stagnation as seen in the symptoms of depression, irritability, poor appetite, ringing in the ears and a choppy left pulse. Prolonged Liver stagnation leads to phlegm fire harassing the Heart. This is identified in the symptoms of mental restlessness, insomnia, dreamdisturbed sleep, palpitations, lethargy and a slippery right pulse.

Secondary Complaint TCM DX: Outer ear infection - damp-heat in the Sanjiao channel

Treatment plan

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

Focus on calming the mind and promoting sleep (soothing Liver qi and dispersing Heart phlegm). Resolve outer ear infection by clearing heat in the Sanjiao channel with acupuncture and the use of antibiotic ear drops.

Typical points include: Anmian, Yintang, LV3, LI4, HT7, KD7

To assist with clearing the ear infection: SJ17, SI3

Allopathic: Administer Ciprofloxacin antibiotic ear drops, 2 drops TID for 10 days to the right ear to resolve the infection.

Herbal: Internally use formulas to harmonize and soothe the Liver qi: Chai Hu Shu Gan Wan, 8 pills TID for 3 weeks

Counsel the patient about the purpose of the clinic, reaffirming that it is a place of healing and non-judgement. Assure her that the clinic is a safe place for her to reveal her emotions in order to heal, and convey the importance of healing. Ensure that the patient is provided with a secure environment for her to properly grieve.

Prognosis

Primary: Using regular acupuncture and herbal treatment, 75% improvement in sleep is expected within 10 treatments. A 50% decrease in stress levels is also expected. This being said, grief is a process that differs from individual-to-individual, and it is not certain how much time this will take. The acupuncture, herbs, environment of the clinic and the support of the community will aid in this healing process.

Secondary: Using antibiotic ear drops and acupuncture, a complete recovery from the ear infection is expected. Ringing in the ears is also expected to dissipate, although the scarring in the left ear, and the speech impediment, indicate that full recovery of hearing is unlikely.

Outcome

The patient continued to have good and bad emotional days. 3 out of 7 days were good. On the good days, she was cheery, talkative and animated in her story-telling of daily events. She spoke with her hands and her expressions were large and without constraint. She came to the clinic on her own, without the support of her neighbour. Her eyes were bright, and she was able to smile while she spoke. On the bad days, she reported crying spells followed by blurry vision and headaches. These, however, were not everyday, as they were before. When asked if the clinic was helping her cope with the stress that she feels, her face brightened, she smiled and said yes, while looking the practitioner in the eye. She was still having a difficult time sleeping through the night due to the difficulty with falling back asleep after dreams. However, she reported that the dreams were not always disturbing anymore, and that sometimes they were good memories of her late daughter. She stated that she misses her daughter, and this was in part the reason why she was unable to fall back asleep. She still felt that, at times, she gets stuck in her thoughts, and is unable to escape them. She was now able to express her sadness through conversation with the practitioner. Her appetite was fully recovered, and she was cooking regularly for herself and her family. She stated that she felt stronger, and able to get through the day. The weakness that she felt before was becoming less and less with each treatment.

After 6 treatments, the patient reported less ringing in the ears. She had an easier time hearing conversations and was less frustrated when trying to listen while in settings where several conversations were occurring simultaneously. The ear infection had cleared and the patient communicated that her hearing had not been further compromised.

Conclusion/Discussion

This case demonstrates that the use of acupuncture and herbs effectively provides support to the healing process of psychological conditions such as PTSD. The environment of the community style clinic also plays a role in benefiting the patient, by providing a place of healing where there are no other options.

The limitations of this case include the lack of objective evidence, as this is more of a psychological case, and measures are often subjective in nature. Background information about the mental state of the patient, as well as if alcoholic behaviours were present before the incident, would be interesting to note. Unfortunately, this information is not available. Despite these limitations, this case demonstrates the effectiveness of acupuncture and herbs in terms of benefitting psychological health, as the patient shows continuing improvement.

It is concluded that further treatment with acupuncture and herbs will be beneficial to this patient. It is both the physical treatment, as well as the environment in which it is administered, that will continue to heal the depression symptoms and the patient's spirit. It is important to have this space available as a safe place for emotions and grieving, as well as a place to break free from everyday routines. Having alternative options available in order to avoid substance abuse is valuable in a rural setting.

Upon further research and speaking with the Acupuncture Relief Project interpreting staff about suicide and village culture, it is found that, just as in the western world, it is a sensitive subject. There is apparently much gossip and talk of the patient and the event amongst people in the community. This gossip is behind the backs of the family involved, and is often about the increased alcohol consumption of the patient. Culturally, the village takes pity on the family. Suicide is not socially accepted, and is viewed as a failure on the parent's account, especially when it involves a young person. Suicide creates an air of bad luck surrounding the community. It is said that the spirit of the deceased is stuck in-between heaven and earth and is in a space of unrest. Spirits are taken very seriously in Nepal, as it is believed that they can harm people. Without knowing the conditions of the home environment, it is hard to speculate if the patient will experience a full recovery. Is there support at home? Do the husband and son respect the grieving process and allow it to occur? This makes the support of the clinic in the community that much more important. The clinic provides not only physical care with acupuncture and herbs, but also a safe place for emotions to be expressed without judgement.

Continued treatment

Educate the patient about possible coping strategies, such as taking 10 diaphragmatic breaths when the world seems too much, or when she is having trouble stopping the thoughts in her head. As treatment continues, work towards teaching the patient about meditation techniques, and how space for the spirit can be created anywhere.

Psoriasis with Neck and Shoulder Pain


Phonexay Lala Simon EAMP LAc MSAOM
December 2013
OVERVIEW

Acupuncture Case Study45-year-old male presents with psoriasis for 5 years, possible psoriatic arthritis for 2 years, and idiopathic neck pain and stiffness for 2 months. After 17 treatments of acupuncture and herbs, he has regained full range-of-motion, has less pain in his neck, his rashes are less painful and itchy, and he has more movement in his fingers and toes due to a decrease in swelling.

Subjective

45-year-old male presents with lesions on his scalp, back and limbs that began about 5 years ago. When his condition began, the patient was in Qatar working with construction and plaster. The lesions subsided upon his return to Nepal, and completely resolved within a year of being back. He continued to work in Kathmandu with plaster and construction. 2 years ago, he noticed the lesions returning. When the lesions erupted again, they began on his scalp, and continued to spread down his back. From there, the lesions spread to his abdomen and legs. Patient reports moderately achy and sometimes burning pain, with moderate itchiness that can be a nuisance at night. He finds them to be most bothersome during the day, and especially when he first wakes up, because it is the first thing that he notices. The patient reports that when he scratches the lesions, they are "weepy with water," and bleed. He has seen 1 other doctor in Kathmandu who gave him some creams and medication, but the patient does not recall what they were. They were not helpful. The rash does not subside with soap, or cold or hot water, and is actually irritated by most of the soaps that are available. As a result, the patient has stopped using soap entirely. Other than soap, the patient does not know if there are triggers that aggravate his condition, and he denies being emotionally or physically stressed.

The patient reports swelling with stiffness in the joints that began about 2 years ago, and has gotten progressively worse. Swelling occurs in the small metatarsals of his right foot, and his thumb, index and middle metacarpals on his left hand. He experiences moderate pain in his wrists and shoulders. He reports that his fingers are hard to move and bend, are usually moderately painful, and occasionally feel hot and burning. They are sometimes aggravated by cold. His brother also suffers from the same type of lesions, and swelling.

The patient presents with neck and shoulder pain that began about 2 months ago. The onset was idiopathic, sudden, and he cannot recall any possible causes. He reports the pain to be very severe and achy, with no sharpness. He says he can feel an electric sensation running downwards to his fingers when he coughs. Occasionally, the pain radiates up to his temporal area, or down to his wrists and hands. However, he denies numbness and tingling, or loss of strength in his arms and hands. Patient has severe pain and stiffness when resting, and he currently takes Paracetemol (acetaminophen- dosage unknown) to provide about 12-13 hours of pain relief.

Currently, the patient is not working due to his conditions, and he is supported and cared for by his son and daughter.

Objective

Acupuncture Case Study

The lesions on the patient's body range from a large diamond-shaped patch on his lower back, that is about 5" wide and 8" long (his largest lesion), to multiple smaller ones ranging from .5" to 2" in diameter that stagger throughout his upper back, abdomen, elbows and legs. The lesions are discrete plaques that have a pink and tender appearance, as well as shiny, silvery white "scales." There are multiple breaks in the skin with some blood and weeping, possibly due to scratching. There is flaking and dryness on his scalp.

He has some obvious swellings on his toes and fingers. Most noticeably, his right second metatarsal, left thumb and third metacarpal are swollen to double the size of the same joints on the opposite hand and foot. He has limited range-of-motion in his right hand and can only clench his left hand 50% of normal, making a "C" shape.

The range-of-motion in his neck is 15 degrees flexion (normal 50 degrees), 30 degrees extension (normal 60 degrees), and lateral flexion of only 20-25 degrees bilaterally (normal 45 degrees). Most limited ROM is the lateral rotation of 10-15 degrees bilaterally (normal 80 degrees), and the patient has to move his entire torso to compensate for the lack of rotation. He reports moderate to severe pain in all movements past these ranges, and his face indicates that he is uncomfortable.

His labs are positive for elevated rheumatoid factor. This can be indicative of rheumatoid arthritis, but can also indicate other kinds of autoimmune disorders, such as psoriasis and psoriatic arthritis.

Acupuncture Case Study

The patient seems in good spirits and looks healthy for his age and environment. He smiles during the whole interview, even when he is doing something that is uncomfortable. He makes eye contact during conversation. When rising from the chair to go to the massage table to undress, he rises very slowly, deliberately and is gentle with his motions.

His pulse is soft, thin, slippery and empty in the deep Lung position. His tongue is pale pink, slightly puffy, with teethmarks and a white coat that is thin in the front, but thicker in the back with small, bilateral prickles.

Assessment:

TCM DX: Lung qi deficiency leading to wind-damp-heat, and qi and blood stagnation in the foot Shaoyang channel; Possible underlying blood deficiency

Lesions on the skin indicate involvement of the Lung organ system according to Chinese medicine, and the nature of resolving and recurring are indicative of a wind pathology with an underlying blood deficiency.

Western DX: Psoriasis with psoriatic arthritis

While rheumatoid arthritis is still a possibility, the history of a prolonged, severe psoriatic condition makes it more probable that it is psoriatic arthritis. However, both psoriatic and rheumatoid arthritis are treated similarly. His neck pain and stiffness are likely due to acute muscle strain and/or tendon sprain of the neck as a result of unidentified causes. It is a possibility that the arthritis is affecting the patient's neck, but physical examinations and presentation indicate a muscular source of his problem, rather than vertebral.

The pattern of lesions on the patient's skin most resembles a condition of psoriasis. Psoriasis is a dermatological inflammatory condition due to immune stimulation of epidermal cells (kerotinocytes). Although its exact cause is largely not understood, the result is erythematous lesions on the body. The presentation of lesions can be pustular, but the most prevalent and classic presentation is the discrete papules, or plaques, with thick, shiny, silvery scales. A family history is common, and there is a genetic susceptibility that can be triggered. Therefore, the condition can have episodes of spontaneous remission and recurrence, or triggered eruptions followed by remission when the trigger is removed.

Prognosis:

With regular use of both acupuncture and herbal treatments twice weekly, at least a 50% improvement in his severe neck pain and stiffness is expected within 13 treatments. The psoriasis is much more difficult to predict. Psoriasis is a difficult condition to completely understand and manage, even with good access to resources, unlike the situation the patient faces in Nepal, where resources are less accessible. Psoriasis is considered mild if less than 10% of the body is covered in lesions. Since the lesions cover about 20% of the patient’s body, his case is moderate. There are many important factors to consider, such as genetics, environment, lifestyle and psychoemotional triggers. Using acupuncture and herbs alone, a 25-50% improvement in the moderate pain, itching and size of the psoriatic plaque, and arthritis, is expected within 13 treatments.

Initial Plan:

Treat with acupuncture twice weekly for 13 treatments, in conjunction with Chinese herbal medicine, before reassessing. For the rash, focus on reducing moderate itch, and possibly the size of the psoriasis. In the joints, focus on reducing moderate pain and swelling. Reduce severe pain and increase range-of-motion in the neck. Use herbal medicine to reduce inflammation of the lesions and joints, then begin to tonify blood and strengthen Lung.

Typical points include wide Hua Tou Jia Ji points, inserted laterally towards the transverse processes, from C2 downwards, with SI14, GB20, SJ3 and SI3 to open the DU. Trigger points in the areas of the neck and shoulders are also indicated. To clear damp and heat, use LU5, ST40 and surround the largest lesion. To tonify and circulate, use ST36, UB13, UB17, LI4 and LV3.

Formulas to take internally are Xiao Feng San for clearing wind and itch. Add Dang Gui Yin Zi or Si Wu Tang to tonify blood once itching is reduced. Have patient take home moxa stick and 7 star needle, to try for 1 week, to see if it helps with the itchiness or size of the lesions.

Counsel patient to spend time in sunlight. UV therapy has been shown to be effective for psoriasis. Continue to guide patient on being emotionally aware, and to release negative emotions if possible. Psoriasis can be triggered or aggravated by emotions and stress. Educate patient on what psoriasis is, and what is going on in his body at a very basic level, and that the condition may come-and-go on its own. Try to identify possible environmental or lifestyle triggers so that he can take steps towards avoiding them, if possible.

Outcome:

After 13 treatments, the patient reported a significant decrease in the itchiness of his psoriatic lesions from moderate to mild, but no noticeable decrease in the size nor the amount of lesions. He wasn’t noticing the itchiness as much when he woke in the morning, nor during the day. He reported that the moderate pain in his fingers and toes had decreased to mild pain, and that it was easier for him to bend them. His left hand could close to about 75% of a completely closed fist. The most significant improvement was in the patient's neck. He reported that it was easier to move his neck, and the pain had decreased from severe to moderate pain. For the past few weeks, he needed his son or daughter to help him get up out of bed, but now he was able to rise from bed on his own. Range-of-motion tests showed that the patient could laterally rotate his neck, up to 55 degrees, without having to move his torso. His flexion improved slightly to about 25 degrees, or just half of full flexion. Extension was still around 30 degrees with minor pain in the front of his chest, and lateral flexion improved to almost full 45 degrees, but with moderate pain and stiffness.

Continued Plan:

Beginning at treatment 14, more emphasis was placed on recovering range-of-motion in his neck, rather than on surrounding the psoriasis lesions.

Continued Outcome:

On treatment 17, the patient had full lateral rotation to 80 degrees, and only with mild pain and stiffness. He could also manage full flexion, with only slight (very mild) pain in the back of his neck. Extension was much better, at 40 degrees, with very slight pain in his pectoral region. Lateral flexion had almost returned to a full 45 degrees, but he had to perform the motion slowly. He was able to lift his shoulders to 90 degrees more easily, which is not something he was able to do previous to the treatments, though it was not measured at the initial visit. Overall, there was about 80% improvement in the presentation of his acute neck pain.

The patient's movements became quicker and he no longer moved as gingerly as he had at the initial visit. He could also look up more comfortably during conversation. He enjoyed moving his neck to show the increased range-of-motion he was experiencing.

The patient's psoriasis condition improved slightly. There was a reduction in itching and pain. He said that the combination of acupuncture, herbs and the home moxa treatments had been incredibly helpful in decreasing the constant and moderate pain and itching from his lesions. He reported that the itching was no longer constant and the pain was more mild. Inspection of his lesions showed that many of the smaller ones had decreased scaling and appeared tender, but according to psoriatic progression, this was a small improvement. The largest lesion had less weeping and bleeding, possibly indicating that he had been scratching less. There was at least a 50% improvement in the moderate pain and itching of the lesions, though only a 10% (at most) improvement in the appearance and size of the lesions.

He reported that the swelling in his fingers and toes continued to improve. The moderate pain was mild and intermittent. The swelling had decreased to where the patient was able to close his left hand 90%, in comparison to the 50% from the first visit.

Discussion:

Psoriasis is an interesting condition because there are so many factors involved, therefore many therapies with which to try to manage. Western therapies include UV light therapy, vitamin D, immunosuppressants, corticosteroids and other anti-inflammatory drugs, along with education about possible environmental and emotional triggers that can be identified and possibly removed. Unfortunately, in Nepal, many drug therapies like Coal tar, Anthralin, and Calcineurin Inhibitors (anti-inflammatories) are not available. Also, it is difficult to educate the patient on how to use the drugs properly, and to monitor patients once they begin using potent drugs for a prolonged period of time. Therefore, drugs that tax the Liver and Kidneys such as Methotrexate or immunosuppressants like systemic corticosteroids are not viable options. More research needs to be done for viable therapies that are readily available to the patient, such as emollients (especially with salicylic acid), that can help to soften the lesions. Hydrocortisone is available in Nepal, but the large surface area of lesions makes it both contraindicated and expensive. Vitamin D3 analogs have been shown to be effective, and he can absorb it by UV (sun) therapy. The process of questioning, communicating and educating the patient about environmental, emotional and lifestyle triggers is also difficult, due to cultural and language barriers.
The acute neck pain and stiffness has been resolving nicely. Even though acute situations can resolve on their own, I believe that the treatments quickened healing, and helped him regain his range-of-motion. The patient has also begun mentioning pain "deep inside" his neck, so it may be worth considering if there is an arthritic cause to his neck pain, and if he may begin to develop chronic neck pain.

The most important part about this case, however, is that from the initial visit with the patient, I was focused on trying to help him with his psoriasis, due to my own interest and curiosity from a practitioner's standpoint. My perspective and perception about the case shifted at the reevaluation, when I realized how much the neck pain and stiffness was affecting his quality of life. At that point, I was able to focus more on making tangible gains in his mobility, and he was very responsive to the treatments. This shift in emphasis was vitally important to his daily well-being and a good outcome to this case.

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