Case Studies

Case Studies

Acute Cholecystitis


Marlena Pecora MSAOM, EAMP, LAc
December 2013
OVERVIEW

Acupuncture Case Study

70-year-old female presents with acute abdominal, chest and scapular pain, vomiting and diarrhea. At the local hospital, she was diagnosed with acute cholecystitis via labs and ultrasound. She received anti-nausea medication and was turned away for further treatment. After 7 treatments using acupuncture and Chinese herbal medicine, the patient’s pain improved 90%, and she had complete resolution of vomiting, nausea and diarrhea.

Subjective

Patient presents with severe abdominal chest and scapular pain. Onset occurred 2 weeks prior with an increase in severity 4 days ago. The pain in the abdomen is achy, and at times sharp in the upper right quadrant, and radiates across the abdomen. The chest pain presents behind the sternum, and radiates to the scapular region. Pain is worse with deep inhalation, and affects her daily activities. Patient reports whole body pain and feeling feverish. Her body feels heavy and she lacks appetite. She experienced nausea and 6 bouts of vomiting in the last 2 days. Her stools have been loose, and darker in color for the last 2 days. 10 days prior to her visit to the clinic, she had been evaluated and treated at the local hospital for the same severe pain, nausea and vomiting. She reports being diagnosed with gallstones, and treated with anti-nausea and asthma medication. The patient reports being told she was too old for surgery. Prior to the acute symptoms, she had been eating a diet of rice, lentils, vegetables and meat, a diet high in oils and fats.

Objective

The patient appears physically uncomfortable and distressed. She has a dull gray pallor, orbital edema, red eyes, and a flat affect. Sitting slouched in the chair, her responses are short and eye contact is minimal. Her breathing is labored and slightly rapid. Patient displayed involuntary guarding of the upper abdomen. There is severe pain upon mild palpation of the upper right and left quadrants of the abdomen. Murphy's sign is positive upon first visit (deep inspiration exacerbating pain during palpation of the upper right quadrant halting inspiration). The back pain is moderate upon moderate palpation around the scapula region. Vital signs at first visit were slightly elevated. Blood pressure is 150/95 mmHg, pulse rate 115 beats per minute, respiratory rate of 27 breaths per minute, temperature 99.5 degrees Fahrenheit and 93 spO2.

Patient's tongue is very pale, and puffy with grey scalloped edges, especially on the right side with a thick greasy yellow coat. Her pulse was rapid, and slippery.

The patient brought in medical records from her prior visit to the local Hospital. Labs revealed elevated serum bilirubin total and direct, and serum amylase levels. An ultrasound (USG) of the abdomen revealed a calculus of 13mm in the gallbladder lumen.

Assessment

DX: Acute cholecystitis

TCM DX: Damp-heat in the Liver and Gallbladder; Underlying SP qi deficiency with damp accumulation; LU qi deficiency

Prognosis

Acute cholecystitis usually subsides within 2 to 3 days, and resolves within 1 week in 85% of patients. Due to the patient’s age and lack of resources and history of asthma, a routine choleosystecomy was not performed during her hospital visit. Complications of acute cholecystitis include an infected gallbladder progressing to gangrene, or perforation of the gallbladder if left untreated. The patient is from a small village that lacks healthcare. She travels 2 hours each way to the clinic. With proper monitoring of the patient’s condition, acupuncture and Chinese herbal medicine treatments, the patient’s severe pain and acute symptoms will likely resolve within 6 treatments.                                  

Initial plan

Patient is to be treated at clinic 3 times per week for 3 weeks. Monitoring of patient’s vital signs and symptoms to be assessed at each visit. Focus on reducing pain, inflammation of gallbladder, and preventing further complications. Acupuncture and Chinese herbal medicine, with focus on draining damp-heat from foot Shaoyang channel, and moving qi and blood. If symptoms do not reduce at each treatment, or vital signs worsen, patient will be referred to the hospital for complications of acute cholecystitis. Nutritional education to be incorporated into treatment.

Typical Treatment

Acupuncture: Dannagxue, right GB34 and right GB40 with electroacupuncture 5Hz continuous; LV2, UB19, UB18, UB20, ST40, LV14, GB44, GB40, GB21, REN10, REN12, Ling Gu, Da Bai and left auricular LV/GB point.

Cupping: Stationary cupping along Bladder channel from cervical to mid-thoracic region x 8 bilateral.

Chinese herbs: The patient is treated with Chinese Herbal Medicine.  At the first visit, she is given Da Chai Hu Tang, 8 tea pills TID for 14 days. Ban Xia Xie Xin Tang is added at the fourth visit, 3 capsules TID for 12 days.

Lifestyle advice: Nutritional recommendations of a low fat, high fiber diet are discussed. Patient is advised to incorporate more turmeric and mint tea into diet. In Chinese herbal medicine, turmeric rhizomeis known as Jiang Huang. It invigorates the blood, reduces blood stasis, reduces pain, and drives qi downward. Pharmacologically, turmeric acts as an anti-inflammatory, anti-hyperlipidemia, antibacterial and hepatoprotectant agent. It is easily accessible in the region of Nepal in which the patient lives. Mint is to help reduce pain with its natural anti-spasmodic effects, and grows abundantly in the region.

Outcome

The patient showed progressive improvement throughout all 7 treatments. At treatment 7, the patient experienced a total of 90% reduction in abdominal and scapula pain, with complete resolution of chest pain. Patient reported her digestion as good, with no gas or bloating, and a complete resolution of nausea, vomiting and diarrhea. Patient’s affect was brighter, she was talkative, smiling and made full eye contact. Her tongue appeared less puffy and greasy, and her pulse less rapid. All vital signs were improved, blood pressure 140/95 mmHg, pulse rate 95bpm, respiratory rate 22 bpm, and 95 spO2.

Conclusion

This case was significant because of the severe pain with which the patient presented, and her lack of options. The patient received 7 acupuncture and Chinese herbal medicine treatments in 2 and a half weeks. She experienced 90% reduction in pain with complete resolution of diarrhea, nausea and vomiting. Due to the patient’s age, economic standing and past medical history, she was unable to have a cholecystectomy. She received anti-nausea and asthma medication, and was turned away for further treatment at the hospital. Acupuncture and Chinese herbal medicine helped to reduce her pain, systemic symptoms, and improve her overall quality of life.

Chronic cholecystitis, long standing gallbladder inflammation commonly due to gallstones, is a potential future complication. To help prevent future complications, management of the gallstones themselves is necessary. A modified diet of less fats and oils and more vegetables is recommended. Continued treatments with acupuncture and Chinese herbal medicine is also recommended. The gallstone, and gallbladder function, should be reevaluated by ultrasound and labs to monitor progress.

Atrophic Vaginitis with Recurrent Urinary Tract Infections


Jacqueline Bailey LAc MAcOM Dipl OM RN
November 2014
OVERVIEW

atrophic vaginitis case study57-year-old post-menopausal female presents with constant burning uterine and bladder pain for 3 years. Allopathic care has been unsuccessful in diagnosing and providing relief of symptoms. In using combination therapy of acupuncture, Chinese herbs and western antibiotics, the patient has had a marked decrease in burning sensation and uterine pain, and almost complete cessation of accompanying symptoms in 10 treatments.

Subjective

The patient presents to the clinic with a chief complaint of “burning uterine pain.” The pain has been constant for 3 years and is accompanied by back pain, dysuria and dyspareunia (painful intercourse). Other comorbidities include gastritis, burning urination with a history of urinary tract infections (UTI’s), and previous kidney stones. She was hospitalized in 2011 for nephrolithiasis (kidney stone) and hydronephrosis (water in the kidney) of the right kidney. The patient is 4 years post-menopausal and has 8 children, all vaginal births, with no complications reported. Prior to menopause, the patient took Depo-Provera to regulate her menses. Prior to taking Depo-Provera, the patient experienced bleeding for weeks at a time. There is no evidence of abnormal bleeding or vaginal discharge at present. Urination is frequent and volume is adequate. Patient voids 3-4 times at night. Burning pain is increased just before voiding. Additionally, she suffers from burning on the soles of her feet and night sweats. Otherwise, patient feels cold. Digestion is complicated by gas, bloating and frequent loose stools. Lack of thirst is reported. Skin and eyes are dry and itchy, and vision is sometimes blurry. Temporal headaches and dizziness are also reported. The patient is frustrated with her symptoms, as allopathic care has not provided her with answers or pain relief. In a fit of frustration, the patient destroyed previous medical records containing ultra-sound imaging. Patient was also given vaginal estrogen cream by unknown physician, but stopped using it because it did not help her symptoms.

Objective

The patient is an overweight (estimated BMI is 27.4) and age appropriate 57-year-old female. Her demeanor is pleasant, but tearful regarding her current state. She is oriented and appears to be in relatively good health for her environment. Patient points to her vaginal/bladder region when talking about her uterine pain. Abdominal palpation reveals a cooler lower abdomen, and guarding with tenderness on deep palpation of the left lower quadrant, periumbilical and suprapubic regions. No masses are felt. The upper abdomen is warm to touch. Pelvic exam reveals erythema and dryness externally and inside vaginal canal, with poor skin turgor. Neither discharge nor lesions are observed. A dense pressure can be palpated anteriorly, and patient is reporting tenderness. Cannot rule out prolapse, but no protrusions seen or palpated. Costovertebral angle tenderness present indicating possible renal calculi.
Initial pulse is thin, fast and weakest in the left chi and guan positions. Tongue is pale and swollen, with a yellow, dry coat and peeled in the front.

2011 Chitwan College of Medical Science Reports:

Lab tests: BUN 15.5 (7-25), Creatinine 1.5 (0.7-1.4), BG 107 (less than 100 fasting), Uric Acid 5.1 (2.5-7.5), HGB 10 (11-16% female), Platelets 230K (140K-340K)

Urine test reveals slight abnormalities: Clear yellow acidic urine with epithelial cells (15-20) and pus cells (10-12); Trace levels of albumin Intra-vaginal ultra-sound (IVU): There is radio-dense shadow in right pelvic region indicating potential abnormality.

Bilateral nephrogram: Shows prompt and symmetrical excretion from both kidneys, which are of normal shape and size. No significant post-micturition residual urine

Impression: Calculus present in right ureter

Medications on discharge: Omnatax (Cefotaxine) 3rd generation cephalosporin 20 mg PO x 5 days (antibiotic), Dolopar (anti-cholinergic) tab x 5 days, Urimax (Tamsulosin) 0.4 mg x 15 days (alpha-antagonist), AZO (urinary analgesic) 20 mg every day for 15 days

Updated: 11/6/2014

pelvic ultra-sound results: Kidneys are normal shape and size, no calculi noted. Bladder is normal, uterus is free of lesions and no endometrial abnormalities or masses visualized. Pancreas and gallbladder normal. Liver is 12.5 cm in length and fatty tissue present. Impression is fatty Liver stage 1.

Assessment

DX: Atrophic vaginitis with recurrent urinary tract infections

DDX: Uterine prolapse, Bladder prolapse, pelvic inflammatory disease, bacterial vaginitis and fibroids

The patient meets high risk requirements for Uterine or Bladder prolapse due to her age, weight and multiple pregnancies. As a result of physical exam, prolapse is not detected, though safety parameters have been established for future prevention. Pelvic inflammatory disease is ruled out because although the patient has a few signs and symptoms, she has no vaginal discharge or fever, and the ultrasound is negative. Endometrial tissue is healthy, and there is no history of sexually transmitted diseases. Talking about such topics in the clinic is sensitive, and pap smears are not readily available to completely dismiss this as a causative factor. Same argument can also be made for bacterial vaginitis. Fibroids are ruled out. Patient has not had abnormal bleeding, and there are no palpable masses. This is further confirmed by ultrasound. Interstitial cystitis is probable, although the cause is unknown. Many believe that there is a defect in the protective lining (epithelium) of the Bladder, resulting in the leakage of toxic substances into the Bladder, causing irritation. Usually, if interstitial cystitis is suspected, there will be an absence of bacteria on the urine culture. In this case, pus is present (bacteria is untestable). Cases exist where interstitial cystitis can exist in the presence of a UTI. In these cases, pain is usually much more severe as in this patient’s case. The diagnosis of atrophic vaginitis makes sense because the patient is post-menopausal, which decreases the body’s supply of estrogen. This then causes a decrease in vaginal secretions, thinning of the endothelium and predisposes women to mechanical weaknesses. The earliest signs are usually burning or dyspareunia. It can be exacerbated by a superimposed infection, such as a UTI.

TCM DX: Liver/Kidney yin deficiency with heat consuming the fluids, complicated by an underlying Spleen yang deficiency leading to damp

PROGNOSIS: Patient has seen many allopathic doctors over the years with no relief. Due to the fact that the patient has limited funds, and cannot afford further testing to rule out other pathologies or treatment, prognosis could be poor. Patient is very eager, however, to seek acupuncture treatment for as long as is necessary.                      

Initial plan

Treat with acupuncture and Chinese herbs 3 times per week for 10 treatments before reevaluating. Focus on nourishing Liver and Kidney yin and clearing heat. Increase moisture and decrease pain. Internally use Dang Gui Liu Huang Tang (4 pills TID) to nourish blood and Kidney yin and clear heat. 

Typical treatment: A combination of LV8, KD6, P6, P7, SP6, REN2, REN3, KD2, ST28 and ear Uterus, Bladder and Liver points 

Alternative treatment points include GB41 (Dai vessel), SJ5, SP9 and GB 34.

Obtain urine analysis and culture to rule out UTI. Encourage patient to consider a pelvic ultrasound to rule out calculi. 

Outcome

The urine analysis and culture revealed acidic, cloudy urine with pus. Bacteria not testable.
Herbal formula was switched to Si Miao San (8 pills TID) for 5 days, and ibuprofen 200- 400 mg every 6 hours was given for inflammation and pain.

Ciprofloxacin 500 mg PO BID was given for 5 days to eliminate suspected UTI. Due to the patient’s risk factors for Uterine and Bladder prolapse, a referral was made to physical therapy for pelvic floor strengthening and bladder training.

Pelvic ultrasound was ordered. Calculi was ruled out and image was grossly normal, with the exception of a fatty Liver.

On the final visit, the patient reported burning pain only at the vaginal opening and little pain with urination.

Conclusion

Patient should continue coming to the clinic for treatments 2 times per week for maintenance therapy to achieve optimal goal of minimal pain, and continue nourishing yin and blood. Continue pelvic floor work to prevent prolapse, and consider the use of vaginal moisturizer during intercourse. Patient is encouraged to use trans-vaginal estrogen cream to increase lubrication and tone, and to empty bladder completely with increased water intake to prevent recurrent UTI’s.

Over the course of 10 treatments patient slowly had resolution of symptoms. Constant reminders were given to patient to continue with her pelvic floor exercises despite discomfort. Due to the sensitivity of the case, patient needed a lot of emotional support and privacy in the treatment room. It is important as healthcare practitioners that we provide our patients with the proper environment they need to heal, which in Nepal in a community treatment room, can be challenging. In the United States, 40% of women suffer from this syndrome, and only 25% seek medical attention out of fear of embarrassment (www.aafp.org). In rural Nepal, education and access to healthcare is very limited, and women are encouraged to keep such topics suppressed. This case demonstrates the difficulty of working with the female population of Nepal on a sensitive topic, as well as challenges with language, interpretation and lack of resources.

Autism Spectrum Disorder


Marian Klaes LAc
November 2014
OVERVIEW

autism spectrum disorder case study20-year-old male patient presents with decreased mental capacity, which his mother states has been present since birth. He lacks verbal communication skills and his mother states he is prone to angry outbursts. Within 5 acupuncture treatments, he is less agitated, his violent outbursts have decreased, and he is helping around the house, which he has not previously been doing.

Subjective

20-year-old male patient presents with obvious communication problems, and decreased ability to understand and follow verbal communication. His mother answers questions for him. She states he has been this way since birth, and then points to his chest and states “it was not properly formed.” He is prone to angry outbursts, and his mother advises caution when touching him. She does not think he will allow any needles to be inserted. Due to his tendency to physically strike people in an angry reaction, his mother is concerned about his being touched too much during the treatment. The outbursts are random. He is capable of taking himself to the bathroom, has a daily bowel movement, and occasionally has undigested food in the stool. His urine is clear to yellow, depending on how much water he consumes. His appetite is poor. He has been taken to other doctors who have prescribed medication, but the mother reports difficulty in getting him to comply. When he has taken it, the medication does not seem to help, so has been discontinued.

Objective

autism spectrum disorder case studyOn the initial visit, the patient appears to be very agitated, and his eyes dart around the room as he walks through. His mother holds his arm to physically lead him in and direct him around the clinic. After he is seated, he continuously turns around to look out the window so his chair is turned to allow him to focus on the activity outside, which calms him slightly. Due to his mother’s concern about touching him too much, pulses are palpated lightly. They are fast and full. He is warm to the touch. He is partially uncooperative with tongue diagnosis, but he does open his mouth and curls his tongue upwards. Sublingual veins are engorged and purple. He is agitated, and swats at anyone who is standing too close. At times, the interpreter stands outside the window to distract him and keep him visually occupied.

His mother accompanies him on each visit to answer questions, and to provide assistance with bus travel. They travel 1.5 hours each way to get to the clinic, so regular treatments are somewhat of a challenge.

He is frail in appearance. Blood pressure is not taken as he does not want the compression on the arm. His mother points to his chest, makes motions with her hand and tries to describe the appearance of the chest. The shirt is not removed, however from the description it is possible he may have pectus ecavatum, which is the most common congenital deformity of the anterior chest wall. Several ribs and the sternum grow abnormally, producing a caved-in or sunken appearance of the chest, which is consistent with how she is describing him. Gentle palpation of the chest and sternum do not confirm a deformity.

Assessment

DX: Autism spectrum disorder (ASD)

Autism is characterized by lack of eye-to-eye contact, impairment of facial expression, delay in or total lack of speech, repetitive mannerisms, and lack of social development with aggression, irritability, hyperactivity, volatile emotions, temper tantrums, short attention span and obsessive-compulsive behavior.

TCM DX: Kidney essence deficiency, Spleen qi deficiency with fire harassing the heart

In Asia, autism is typically classified as a delayment disorder. In Traditional Chinese Medicine, it is known as one of the 5 delays, which are observed in the areas of standing, walking, hair growth, teeth eruption and speech. This type of brain disorder is viewed in TCM as an energetic dysfunction, an imbalance of yin/yang, and an imbalance of mind and body functions.

Reason and awareness, which are strongly affected by autism, are primarily ruled by the Heart, Spleen and Kidney. The Heart holds the mind or spirit and rules the mental functions including the emotional state. The Spleen is linked to the mind’s ability to study, memorize and concentrate. Kidney qi controls long-term memory. Autism treatment includes eliminating the phlegm as phlegm misting the mind leads to dull wit, incoherent speech, mental confusion, lethargy and decreased attention span. The condition of phlegm fire harassing the Heart presents as disturbed sleep, talking to oneself, uncontrolled laughing or crying, short temper and tending towards aggression.

PROGNOSIS: It is not anticipated the patient will recover and be fully functioning. The purpose of treatment is to calm the patient, reduce agitation, reduce the number and intensity of angry outbursts, improve sleep and hopefully improve cooperation.

Plan

It is recommended he be treated 2 times per week for 5 weeks before reevaluating. The focus of treatment is to tonify the Heart blood, qi and yin, clear Heart heat and tonify Spleen qi and Kidney essence.

Scalp acupuncture is initially utilized, as autistic patients often have a difficult time following directions and being cooperative, so body acupuncture is not always an ideal method. Scalp acupuncture is effective because so many key nerve points can be found on the scalp, and it is less painful and less visible, making it easier to avoid panic. With scalp acupuncture, patients do not need to lie down and stay motionless. This is ideal for autistic patients. 

Typical Treatment: Start with scalp points. As patient becomes calmer, add press needles and ear seeds to protocol. Scalp work is performed with the central line, verbal communication, frontal lines and GV 16.

Alternate Treatment: Press needles added at PC6, HT7, HT3 and ST40. Ear seeds are placed on the Heart, Point Zero and Shen Men. Mild massage is added to the Shaoyang channels of the arms and legs.

Outcome

Following the initial treatment, the patient’s mother noted he seemed calmer, and appeared to be sleeping better. By the third treatment, it was noted he was much calmer in the treatment room, and did not seem disturbed when his arms and legs were touched. After one point, he actually laid down on the floor in a very calm and relaxed state. 

Each treatment seemed to be making a difference. By the fifth treatment, he was helping to sweep the floor, feed the chickens and cut the grass, which he had previously not been doing. “Cutting grass” in Nepal means using a hand scythe, manually cutting the grass in small areas at a time while on your hands and knees. Due to the distance and difficulty of travel, after 2 weeks of care, visits were reduced to once a week. 

By the fifth treatment, the patient appeared to be doing much better. His mother stated he was much calmer. She also said he had been speaking a few words, which he used to do but had stopped trying. From a practitioner standpoint, relative to the initial visit and after 3 weeks of care, he was much less agitated, more cooperative, and agreed to stick out part of his tongue for the first time in clinic for tongue diagnosis. 

Conclusion

The patient experienced a notable reduction in agitation and was calmer with each session. This was noticed by the practitioners and interpreters as well. 

It is recommended he continue with 1 treatment per week for 4-6 weeks before transitioning to 1 treatment every 2-3 weeks. If improvement continues, moxa and possibly body needles could be added to the treatment strategy. Although a full recovery is not expected, it is anticipated that with continued care he will have a significant reduction in behavioral problems, be more helpful with home duties, and possibly learn to speak a few words. It is very apparent that acupuncture treatments are having a positive influence on this patient, which is helpful to both him and his mother. 

 

Spastic Quadriplegic Cerebral Palsy


Beth Fitzgerald DPT
November 2014
OVERVIEW

Severely malnourished and non-ambulatory 11-year-old female presents with increased tone and spasticity in all extremities, frequent seizures, and currently requiring assist for all mobility. Patient was seen for a total of 10 physical therapy treatments with significant improvement in passive range-of-motion, moderate improvement in posture and spasticity, slight improvement in active range-of-movement, and a 50% decrease in seizures.

Subjective

11-year-old female patient is carried into clinic with significant tightness in all extremities. Per caregiver report, she has minimal social interaction, an inability to feed or dress herself, toilet or ambulate, and currently requires assist for all activities of daily living and all mobility. Caregiver reports a seemingly normal development until the age of 2 when “all of her muscles got tighter” and began to alter her mobility. She was able to crawl, ambulate and communicate. However, between the ages of 2 and 5, she had a pronounced increase in muscle tone, paralysis, and began having difficulty with all mobility. At 5 years old, she started using a cane to ambulate and progressively stopped walking and speaking. A vague history, slowly gathered over the course of multiple treatments, includes a difficult birth, which required forceps, 21 days in a paralysis ward around 6 years old with no reported improvement, and a subsequent lack of social interaction. On the 6th visit, it was revealed that she was neglected by her parents and confined to her bed for extended periods of time. The current caregiver is a distant relative as the parents do not want to care for her unless she is able to feed and toilet herself. The caregiver’s goal is for the patient to move better and walk more.

Objective

On the initial visit, the patient appears to be very agitated, and his eyes dart around the room as he walks through. His mother holds his arm to physically lead him in and direct him around the clinic. After he is seated, he continuously turns around to look out the window so his chair is turned to allow him to focus on the activity outside, which calms him slightly. Due to his mother’s concern about touching him too much, pulses are palpated lightly. They are fast and full. He is warm to the touch. He is partially uncooperative with tongue diagnosis, but he does open his mouth and curls his tongue upwards. Sublingual veins are engorged and purple. He is agitated, and swats at anyone who is standing too close. At times, the interpreter stands outside the window to distract him and keep him visually occupied.

His mother accompanies him on each visit to answer questions, and to provide assistance with bus travel. They travel 1.5 hours each way to get to the clinic, so regular treatments are somewhat of a challenge.

He is frail in appearance. Blood pressure is not taken as he does not want the compression on the arm. His mother points to his chest, makes motions with her hand and tries to describe the appearance of the chest. The shirt is not removed, however from the description it is possible he may have pectus ecavatum, which is the most common congenital deformity of the anterior chest wall. Several ribs and the sternum grow abnormally, producing a caved-in or sunken appearance of the chest, which is consistent with how she is describing him. Gentle palpation of the chest and sternum do not confirm a deformity.

Assessment

DX: Spastic quadriplegic cerebral palsy

Spastic quadriplegia is defined by spasticity of the limbs, rather than strict paralysis. It is distinguishable from other forms of cerebral palsy in that those afflicted with the condition display stiff, jerky movements stemming from hypertonia of the muscles. The primary effects of cerebral palsy are impairment of muscle tone, gross and fine motor functions, balance, control, coordination, reflexes and posture. Swallowing and feeding difficulties, speech impairment, and poor facial muscle tone can also indicate cerebral palsy. Associative conditions, such as sensory impairment, seizures and learning disabilities can also occur. When present, these associative conditions may assist with a clinical diagnosis of cerebral palsy. 

DDX: Diagnosis is complicated by lack of past medical history, parents not currently being involved in care to clarify development, and by exacerbation of symptoms secondary to lack of care and stunted growth. Differential diagnoses consist of muscular dystrophy, acquired brain injury and Rett syndrome.

Muscular dystrophy is a group of diseases that weaken the musculoskeletal system. Although more common in males, it can occur in females and is characterized by progressive muscle weakness and wasting, poor balance, atrophy, scoliosis, frequent falls, joint contractures, inability to ambulate and wasting of the muscular system. Patient’s history and initial disease presentation per caregiver report has many of these characteristics. However, muscular dystrophy does not typically involve spasticity. This diagnosis is further ruled out as details of the birth are learned.

Rett syndrome is characterized by a period of normal motor development followed by developmental stagnation and then regression of motor and language abilities. Onset typically occurs between 6 and 18 months of age with subtle developmental delays, developmental progress and then stagnation, followed by developmental regression. Hand wringing is a classic symptom and is often confused with autism. Rett’s can also be confused with cerebral palsy. Regression is actually rarely seen with cerebral palsy and spasticity is uncommon with Rett’s. Initial history gathered exposes a period of normal development followed by regression. This diagnosis is considered due to the reports of regression around 2 years of age. It becomes clear, however, that the regression seen with this patient is most likely due to neglect. Rett Syndrome is further ruled out secondary to spasticity. 

Acquired brain injury (ABI) is brain damage caused by events after birth such as stroke, brain tumor, infection, hypoxia or ischemia, and can result in an upper motor neuron lesion possibly resulting in spasticity. Without a detailed and accurate history, it is not possible to rule out an ABI. The patient’s caregiver reports a difficult birth, which is likely the cause of the initial injury. However, with the history of abuse, it is possible that the symptoms were exacerbated by events after birth.

Initial Treatment

The movement patterns of proprioceptive neuromuscular facilitation (PNF) to bilateral UE’s and LE’s are utilized to decrease tone and spasticity. The goal is to facilitate more functional movement patterns, thereby increasing the patient’s ability to participate in activities of daily living, such as self-feeding, mobility and toileting, thus decreasing the caregiver burden. The patterns of movement associated with PNF are composed of multi-joint, multi-planar, diagonal and rotational movements of the extremities with the emphasis on decreasing spasticity and increasing range-of-motion. Movements are initiated passively, progressed to active-assisted, and eventually active if patient is able to assist in a controlled movement. Passive range-of-motion (PROM) to right wrist and hand is performed to prevent further contracture development. All exercises are performed bilaterally and slowly, with a constant smooth motion for 5 minutes to each extremity, allowing the muscles to relax and to decrease tone. Seated and standing balance training is performed with emphasis on trunk control, posture, alignment and weight shifting to the right LE. Weight bearing can be very effective at decreasing tone. Progress is made towards prone over a bolster and quadruped (weight bearing through elbows and knees) to facilitate different body positions, in addition to weight bearing though UE’s, primarily the elbows. Weight bearing exercises are also used to increase bone density, improve circulation, increase strength, promote Lung health and reduce tone and spasticity. Neurological reeducation exercises, such as PNF, are performed to decrease spasticity and facilitate motor control to enhance patient’s ability to move independently and increase functional mobility. Patient is being seen 2-3 times per week to decrease spasticity, promote increased range-of-motion, decrease risk for further contractures, increase mobility, and for continued family training and education. She is also receiving acupuncture after each physical therapy session. Reassessment is to be completed after 6 visits, and appropriate family training and education is initiated. Initial treatment is selected based on severity of presentation, knowledge of limited resources, and family’s education level.

Outcome

Patient was treated 10 times and had significant improvement in passive range-of-motion, moderate improvement in posture and spasticity, slight improvement in active range-of-movement, and a 50% decrease in seizures. Patient had a moderate reduction in spasticity during each session, significant increase in passive ROM, and slight improvement in active ROM (most noted in UE’s) between treatments. She experienced an overall improved affect and social interaction throughout the course of the treatments. She was able to reach out towards people with her left UE, and often able to touch someone’s nose with verbal cues. She could sit with a narrower base of support for up to 30 minutes with supervision only, and stand with contact guard assist (previously requiring physical assist). Additionally, she had some use of her left UE for balance. Patient tolerated prone over bolster with weight bearing and engagement of UE’s for 15 minutes for facilitation of back extensors and head control, also allowing gentle percussion to the back to support respiratory health, and decrease risk of current cough progressing to pneumonia. Family was encouraged to vary patient’s position frequently to increase strength, mobility, Lung health, and opportunity to interact with different environments. 

Nutritionally, the patient was encouraged to increase fluids throughout the day and include softer, higher caloric foods for overall increased intake. Extensive caregiver education about cerebral palsy was initiated to increase understanding of the disease and how to best work with, and help, the patient for both patient and caregiver benefit as well as long-term prognosis. The caregiver was highly encouraged to seek acupuncture treatments herself due to the heavy caregiver burden. Training was completed with the caregiver to continue PNF and standing exercises to maintain newly-gained range-of-motion, facilitate weight bearing, reduce spasticity and minimize pain. 

This case was complicated simply by the complexity of the diagnosis and high level of care required. Information gathered on the sixth visit revealed significant neglect, further reinforcing the focus of treatments to be caregiver education, a simple home exercise program, and to initiate a search for possible support groups. A referral was made to Cerebral Palsy Nepal, an outreach program offering therapeutic and practical support to 15 of the 75 districts in Nepal. Possible support includes home visits and a mobile team who assist with therapy, acquiring equipment, practical guidance and emotional support to patients and their families. During the initial visit, we discussed methods to increase patient’s food intake, particularly healthy fats, setting up an appointment with a doctor to address possible medications, specifically to manage seizures, a more appropriate and supportive chair for her home to increase interaction with the environment, and perhaps most importantly, supporting and educating the caregiver.

Conclusion

This case was challenging for me at many levels. From the initial evaluation it was apparent that the medical history was extensive, but vague. Though confident with the diagnosis, it took multiple visits to unravel a more complete history. It was important to focus on treating the patient, but also ensure the caregiver could see the benefit so she would continue to bring the patient into the clinic. I tried to provide an environment where she felt supported and open with the patient’s history, as the caregiver was initially guarded and defensive. 

Though the patient’s prognosis was poor, I was surprised how much improvement I saw despite the severity and duration of her disease. With minimal prior intervention, I was able to clearly see the effects of my treatment. I was able to make moderate to significant progress with the patient’s active and passive range-of-motion, seated and standing balance, and overall reduction in tone and spasticity. The patient appeared more comfortable, was engaging with the practitioners and actually smiled during the last treatment. Despite this progress, life in rural Nepal is challenging even for a healthy and able-bodied individual, and it is difficult to predict how much carry-over into daily life will occur, as the patient must fully rely on her caregiver.

As the case progressed, it became clearer to me that the most important components were not the actual interventions during treatment, but developing a relationship and providing an environment where the caregiver was open to education, assisting in establishing appropriate connections, and helping to establish relationships for continued support. The burden lies on the caregiver to continue to bring the patient in for treatments, to be open to further education and training, and follow through with a home exercise program.

Follow Us on Facebook

News Archive

Featured Case Studies

  • Lumbar Stenosis due to Osteoartritis +

    Sarah Martin MAcOM LAc November 2012 OVERVIEW 36-year-old Read More
  • Facial Paralysis (Bell’s Palsy) +

    Jennifer Walker MAcOM LAc December 2011 Overview 35-year-old Read More
  • Chronic Abdominal Pain +

    Felicity Woebkenberg MAcOM LAcOctober 2011 Overview 31-year-old male Read More
  • 1
  • 2

Your Donations Help

In addition to volunteering their time and energy, our practitioners are required to raise the money it takes to support their efforts at our clinic. Please consider helping them by making a tax deductible donation in their name.

DONATE NOW

Support Us