CLINICAL CASE PRESENTATIONS

CASE 1: SPORTS INJURY - ALPINE SKIING

A 37 year old white male presented 8 hours after a late afternoon alpine ski injury resulting from forced hyperflexion, which occur when landing after jumping over a mogul. The patient felt an immediate sharp pain through the right knee, followed by a constant and less intense dull pain. The patient was still able to cautiously ski back to the base for the end of the run.

Patient self-treatment included Ibuprofen 600 mg p.o. every 6 hours with rest and elevation of the leg. Since the affected leg became more painful throughout the night, with significant reduction in the range of motion, the patient presented for medical acupuncture management.

Physical exam was unremarkable except for midpopliteal pain, light effusion, and limited range of motion restricted to 20-75 degree arc. Pain was most intense at the BL 54 acupoint and less so at BL 53.

Because of the acute injury in an otherwise healthy patient, the Tendinomuscular Meridian treatment of the Bladder Meridian was chosen. Needles were placed at the right BL 67 Ting point, BL 39, 40, 36 and Knee Eye point as Ashi or local points, and with extraction to right SI 18. Treatment time was 20 minutes, at which point the patient could comfortably flex and extend the knee 0-90 degrees and was pain free with ambulation. Additional rest was recommended with gradual return to normal activities, which included 4-5 mile runs for this patient. Recovery has continued with no further need for treatment. An orthopedic specialist exam three days later confirmed normal ligament stability, meniscus integrity, and lack of serious structural damage.

This case demonstrates the powerful effects of the Tendinomuscular Meridian treatment in acute sport injuries involving overuse, stress and strain. Recovery is often rapid with return to a normal life style and often without the intake of non-steroidal antiinflammatory drugs and other similar drugs used in Sports Medicine. Return to an active sports life style was rapid and painless in this case.

Bryan L. Frank, M.D.
North Texas Anesthesia and Pain Medicine
McKinney, TX

A 32 year old right-handed male fell at work landing directly on his right shoulder. He had instantaneous pain and severely restricted range of motion. He was treated with the usual course of non-steroidal antiinflammatory drugs, physiotherapy and rest. The shoulder was examined by his orthopedic surgeon and no fracture or joint effusion was found. After about two weeks his range of movement started to improve a little, but then worsened again.

On physical examination, this otherwise healthy man showed abduction of his right arm only to about 90 degrees. He was able to use his arm in forward flexion but could not bring his right hand back any further than to barely touch his ear. The posterior arch of movement of the shoulder was completely impossible due to pain. Incidental note was made of the fact that his right elbow lacked about 15 degrees of extension due to an old injury.

A diagnosis of contusion of the long head of biceps muscle, as well as directly to the shoulder rotator cuff was made. Acupuncture points selected were LI 11 and GB 21, on the right side. Stimulation was performed with an Accuomatic machine at a frequency of 5 Hz and intensity of 40 microamps. Time of stimulation was 6 seconds. The needles were left in place for a total of' 20 minutes after the stimulation after which they were again stimulated for a final 6 seconds interval, and then were removed.

Immediately upon removal of the needles the patient was able to move his shoulder through its entire range of' movement without impediment. He was able to start using his arm for a full throwing motion imitating the movements he would need for his work. Aller two treatments, two days apart, the patient became well enough to resume his physical therapy, and a week later was able to rejoin his team after a four game lay-off due to his injury. When the patient told the press how his throwing arm had been saved by acupuncture, there was an immediate positive impact on the perception of Medical Acupuncture by the public as well as the local medical community.

Peter G. Hanson, M.D.
Hanson Peak Performance Clinic
Denver, CO

A 29 year old female consulted for acupuncture to help resolve a right postoperative peroneal neuropathy, which occurred after a right hip replacement a month earlier. Apparently the nerve had been injured during surgery. The patient complained of paresthesia involving the whole lateral aspect of the right leg with paroxysms of intense pain and adduction of the foot which made ambulation rather difficult and for which she was using a rigid brace.

Past medical diagnosis revealed a diagnosis of systemic lupus erythematosus (SLE) two years earlier, at which time she was treated with massive doses of steroids, resulting in bilateral necrosis of the femoral heads and eventually leading to a bilateral hip replacement.

At the time of the visit the patient was otherwise asymptomatic for her SLE and she was taking no medications except for analgesics which she tolerated poorly.

A linear circuit (n, n+1) was designed incorporating the Shao Yang/Tsue Yin energetic levels, as well as lower extremities analgesic points ST36 and ST43. Before all needles were in place, the foot straightened out to a normal anatomical supine position and the reported that all pain had subsided. Needles were manipulated during the 30 minute session and, after removal, the patient experienced a slight recurrence of pain. She was instructed in how to use a blunt plastic needle to stimulate the GB meridian on the hand using the principles of Korean (Koryo) Hand Acupuncture.

It was explained to her that the 5th digit represented her lower extremity, with her PIP joint being the knee and her DIP joint the ankle. She was given a graph showing the course of the GB meridian between the knee and the ankle, which on the hand runs on the medial aspect of the 5th digit between the medial crease of' the PIP joint and slightly proximal to the medial angle of the nail. She was taught to "peck" with the plastic needle on this line whenever she felt pain. To her surprise, the recurring pain subsided immediately upon stimulation of the GB meridian on the hand and she walked out of the office with a big smile holding in her hand a very small and simple tool, a dull plastic needle, which had just begun to carve her independence.

Christina Stemmler, M.D.
The Center for Family Medicine
Houston, Texas

A healthy 33 year old right-handed newspaper reporter, severed an extensor tendon of the right third finger on a broken glass while washing dishes. The tendon was repaired by a plastic surgeon and splinted. Four weeks later she developed severe pain in her right hand, swelling and redness of all five fingers, heavy dark hair growth on her hand, a change in nail texture in all fingers and severely restricted range of motion in her hand. She was referred to the pain clinic and received two guanethidine blocks over two weeks, and began daily physiotherapy. She came for acupuncture treatment because the blocks were painful and, although she experienced some improvement with the blocks in terms of decreased pain and redness, she still had very limited use of her hand.

She was seen six weeks post-injury. There was swelling and redness of' all fingers and the dorsum of her hand, more so over the third knuckle. There was profuse, coarse dark hair growing on the dorsum of the hand (normal color hair was blonde). The skin was shiny and warm, and flexion of the fingers was severely limited at the PIP and MCP joints.

Treatment was begun needling the point LI4 to produce a twitch of the index finger, LI11 to propagate the sensation down the arm into the hand, PC6 to produce an electrical sensation to the third finger, Ex. 42 x 3 to produce twitches of the respective fingers, and HT7 to produce an electrical sensation to the fifth finger. During the insertion of the needles there was a profuse flush and sweat produced in the entire hand.

There was decreased pain and increased range of motion following the first treatment. Each subsequent treatment involved electrical stimulation at 4 Hz for twenty minutes, then 200 Hz for ten minutes. Treatments were given daily for the first week, thrice weekly for the next week, twice weekly for the next two weeks, using the same points. LI4, Ex. 42 x 3 and Baxie x 3 were the only points needled once weekly thereafter.

By the end of the first week the redness and pain disappeared, swelling was markedly reduced and range of movement was greatly improved. Skin appearance and hair growth were normal after the fourth week, at which time she returned to work full time. She continues with physiotherapy and weekly acupuncture treatment for some remaining stillness in the MCP joints.

HT7 and PC6 were considered to be the major points in the prescription and were chosen on an anatomical basis. HT7 is also considered by Dr. Joe Wong to have a strong parasympathetic effect and to be useful in the general treatment of RSD. LI4 was chosen for its effect on pain, LI11 to stimulate the radial nerve, and extra points for joint swelling.

Diane E. is a 45 year old cosmetics saleswoman with right facial spasms since September 1993. The grimacing occurred every day, several hundred times per day, worse when she was tired or stressed. She was seen by two neurologists who diagnosed facial dystonia and recommended botulinum injections. CT scan of the head was normal. She had a past history of right Bell's palsy ten years earlier with no residua and a diagnosis of multiple sclerosis made two years earlier after an episode of optic neuritis which resolved completely. She was otherwise well.

On exam, spasmodic grimacing of the right side of the face was obvious. No other nervous system signs were found.

She was treated once weekly, the first time using LR3, SP6, LI4, bilaterally, Yintang and TH17 on the right. Her grimacing increased for several days after this treatment. The second time, points HT7, LI4. PC6, SP6, ST36 were used bilaterally, and TH17, GB14, Tai Yang, ST7 and ST4 on the right. Sensation from TH17 and ST7 was propagated to the face. The needles were left in place for twenty minutes with no additional stimulation. Yin Tang was also used.

Her grimacing was decreased about 90% after this treatment. She was treated three more times at weekly intervals with the same points. Grimacing disappeared completely after the third treatment and has not returned in the six weeks until the writing of this report. Discussion of points

LI4 was used for its effect on the face, SP6 and ST36 to tonify the Stomach and the Spleen which were deficient as reflected in the tongue and pulse and the points on the face were used to stimulate the facial nerve trunk (TH17) and facial nerve branches. Although Heart symptoms were not prominent in this patient, points HT7 and PC6 were used as sedative points since the condition was very distressing to the patient, and in the author's personal experience these points are useful in promoting generalized muscle relaxation.

Elaine R. is a 44 year old home care aid with a two year history of uncontrollable head turning to the right. Her paternal grandfather and father had a similar condition. She was seen by two neurologists who diagnosed spasmodic torticollis and prescribed Artane, which was of no help. She was unable to lie still enough for a CT scan. Botulinum injections were recommended. She had a past history of coarctation of the aorta, described herself as anxious, had a history of panic attacks, frequent palpitations and insomnia.

Spasmodic torticollis was obvious on exam, with the head pulled to the right. Muscles of the neck and shoulder were shortened with multiple trigger points.

She was treated four times, at weekly intervals, with a combination of scalp acupuncture (tremor control and motor areas), local and distant points, with some decrease in pain of the neck and shoulders, but no change in head turning. On the fifth appointment no local points were used, but the points Yin Tang, HT7, GV20, LI4 and SP6 were needled for twenty minutes with no additional stimulation after deqi was obtained. At her next appointment she reported that her sleep was much improved, pain was gone, and head turning was reduced by about 90%. She was seen three more times, the points ST36, KI8 and TH3 were added and on the last visit, trigger points on the trapezius, supraspinatus and sternomastoid were needled with vigorous stimulation. She reported that the head turning virtually stopped after the last treatment and she left on holiday The patient stopped the Artane of her own volition after the fifth treatment and was to be seen in follow-up after her holiday.