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Case History

Zhu’s Scalp Acupuncture in Stroke-Related Aphasia: A Case Study

Submitted Toward Practitioner Certification in Zhu’s Scalp Acupuncture
by Dr. Scott Whitfield L.Ac., D.A.O.M.
San Jose, California
June, 2017

COMPREHENSIVE CASE REPORT

SECTION 1: GENERAL INFORMATION

Name: Sandy M.
Sex: male
Place of Birth: Scotland, UK
Age: 89
Occupation: retired
Marital Status: married
Race: Caucasian
Case History Provider: Dr. Scott Whitfield L.Ac., D.A.O.M.
Date Of First Visit: 12/16/2016
Date Of Last Visit: 4/18/2017

SECTION 2: DATA COLLECTED FROM FOUR DIAGNOSTIC TECHNIQUES

2.1 INQUIRIES

2.1.1 Chief Complaint: Aphasia and Cognitive deficits due to embolic stroke, secondary to atrial fibrillation, on 12/3/2016.

2.1.2 Present case history: The following information was given to the provider verbally by the patient’s daughter. The patient was hospitalized with a “large” left temporal embolic stroke which also featured some hemorrhaging. No allopathic interventions were performed. The patient can sit up in bed, stand, walk, and is generally alert and responsive. The patient’s speech and cognition seem to be most affected by the stroke. He clearly exudes aphasia but can enunciate words properly. He has difficulty understanding phrases spoken to him and makes up nonsensical words when he can’t come up with the right word needed to complete his thought. This is frustrating to the patient as he led an intellectually stimulating life prior to the stroke. He expresses his frustration with this situation by reverting to a form of faux French (including some actual French words, but more commonly gibberish which sounds French). The patient has control of his limbs and can write a little. His daughter (who is here from out of town to help coordinate her father’s care) reports progressive improvements in the days following the stroke. She has also noticed that his right eye wanders laterally. She states, “more words are coming back,” on a daily basis and that he’s slowly regaining control over his urination. Other home health care providers visiting him these days include a physical therapist, a speech therapist, a massage therapist, nurses, and personal assistants. Lastly, the patient will be receiving 2x/week radiation therapy for prostate cancer starting 12/26/2016.

2.1.3 Current problem list: Prostate cancer, left-sided frozen shoulder, left middle finger injury (an infection caused swelling and limited range of motion with extension and flexion), hemochromatosis, chronic anemia, chronic lymphocytic leukemia, long-standing left ankle injury, right knee partial replacement surgery, osteoarthritis of both knees, diabetes mellitus type II, hypertension, atrial fibrillation, and heart murmur.

2.1.4 Personal history (includes menstruation, pregnancy, leucorrhoea, and delivery for females): The patient has lead a very full, rich life. He served as a pilot for the Royal Canadian Air Force and later made a significant endowment to the arts as educator and philanthropist.

2.1.5 Family history: no significant facts were obtained in interrogation

2.2 INSPECTION / OBSERVATION

2.2.1 Spirit: good Shen, bright, responsive

2.2.2 Complexion: nice color for his age, slightly on the dusky-white side

2.2.3 Appearance: alert, calm, friendly, cooperative, and well-groomed

2.2.4 Body stature: frail, bony, thin, tall, but somewhat hunched over

2.2.5 Tongue: slightly swollen, dusky-red colored body; greasy yellow coat

2.2.6 Other parts of the body: thick bands of darkly-mottled skin encircles the patient’s lower extremities, approximately half the total lower extremity in size.

2.2.7 Excretion and Secretion: not obtained

2.3 AUSCULTATION & OLFACTION

2.3.1 Auscultation: breathing is not audible to my naked ear

2.3.2 Olfaction: no distinct odors were detected

2.4 PALPATION

2.4.1 Pulse: Right: flooding. Left: irregularly intermittent, choppy.

2.4.2 Palpation of different parts of the body: The dark areas of the skin in the lower extremity are taught to the touch.

SECTION 3: WESTERN MEDICAL RECORDS

3.1 Physical examination: The patient is alert, friendly, and cooperative. He responds when spoken to, but not usually with relevant responses (aphasia). He’s a tall man and some evidence of muscle atrophy in the limbs is observed. He is currently able to stand and walk short distances with the aid of a walker. His range of motion is limited in the left upper extremity and left ankle.

3.2 Laboratory tests results: not available

SECTION 4: DIFFERENTIATION AND ANALYSIS

4.1 List all the evidence of the differential diagnosis (i.e. the differentiation of the syndromes and provide evidence to support this): Zhong Feng Wind-stroke (mild type), Dual Spleen and Kidney Yang Vacuity, Phlegm-Fire obstructing the channels and collaterals, Heart Blood stasis, Lower Jiao Damp-Heat

4.2 Analysis of the etiology and pathogenesis (i.e. to explain the differentiation of your main syndrome or condition): This patient’s embolic stroke did not leave the patient severely crippled in terms of physical mobility and function, therefore it is the mild type Wind-stroke. The patient is aging, and due to his orthopedic issues had slowed down physical activity considerably in the past decade. His increased sedentary lifestyle led to some stagnation of Qi and Blood. What probably started in mid-life as irregular diet and overwork led to Spleen Qi vacuity, which progressed over time to dual Spleen and Kidney Yang vacuity, ending up as phlegm-fire (the practitioner guesses that this may have occurred after some emotional or intellectual upset, although it is not expressly mentioned in the history).

4.3 Principles of treatment: Remove obstructions from the channels, subdue Wind and resolve Phlegm, invigorate the Connecting channels, regulate the circulation of Qi and Blood in the channels, resolve dampness, drain heat, nourish Spleen and Kidney

4.4 Prescription and Administration (includes acupuncture and herbal medicine):

4.4.1 Zhu Scalp Acupuncture: Head & Face (3), Upper Jiao (3), Middle Jiao (3), Vertex, Perineum, Foot (1), Lower Jiao (3), Shoulder (right-side only), Lower Limb (bilateral x2), Auricular-Temporal (3, left-side only)

4.4.2 Daoyin: The practitioner asked the patient to, “tell me a story,” and he does so (speech practice), sit on the edge of the bed successful under own volition; standing (assisted, using a walker to brace self).

4.5 Advice relating to measures of prevention and health care (including diet and exercise): Keep the patient as active as possible, physically and mentally. Practice speaking, saying individual sounds, singing, reading simple words aloud, and identifying pictures by name from flashcards, and other ad hoc exercises.

4.6 Prognosis: moderate to good, especially considering the level of home health care he’s receiving and his current improvement trend.

4.7 Plan of care: 2-3x sessions per week treatment frequency, not fewer than 10-20 sessions are required to speed recovery and make functional gains.

SECTION 5: TREATMENT PROGRESS

5.1 Treatment Session #2 12/19/2016

5.1.1 Progress: The patient’s caregivers report that today he’s having pain in the left upper extremity after a hard session of physical therapy earlier today. His needles from the first session were retained 2+ days before they were removed yesterday. The patient’s nurse states that he’s been showing improved speaking skills over the past two days. He’s started taking 1300 mg Tylenol for his shoulder pain. Lastly, he’s been “up a lot, and now able to use the urinal,” according to his nurse. No other changes were reported.

5.1.2 Palpation of pulse: Right: full, flooding. Left: irregularly intermittent, wiry/slippery.

5.1.3 Observation of tongue: contracted body, red tip (peeled); greasy yellow coat

5.1.4 Zhu’s Scalp Acupuncture: Head & Face (1), Upper Jiao (3), Middle Jiao (3), Vertex, Perineum, Foot (1), Lower Jiao (3), Shoulder (right-side only), Upper Limb (bilateral x1), Lower Limb (bilateral x2), Auricular-Temporal (3, left-side only)

5.1.5 Daoyin: massage of the left upper extremity, push-pull left upper extremity, attempted to vocalize vowel sounds (the patient did not succeed in following this command).

5.1.6 Assessment: The patient is progressing nicely and resting now after a full day of various therapies.

5.1.7 Plan: continue the plan of care described above (on the initial visit 12/16/2016).

5.2 Treatment Session #3 12/21/2016

5.2.1 Progress: The patient’s recovery continues. According to his caregivers, today the physical therapist helped him walk and he’s able to stand at the urinal. He was also able to stand at the bathroom sink and brush his own teeth. However, when handed a hair comb immediately after brushing his teeth, he was not able to make the connection to use it on his hair, but instead attempted to comb his teeth with it. Nevertheless, his cognition and speech continue to improve between acupuncture treatments. No other changes were reported.

5.2.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), Middle Jiao (3), Vertex, Perineum, Foot (1), Lower Jiao (3), Auricular-Temporal (3, left-side only)

5.2.3 Daoyin: Chou Qi needle stimulation throughout the majority of the session. The patient is relaxed/sleeping through it.

5.2.4 Assessment: The patient is progressing nicely.

5.2.5 Plan: continue the plan of care described above (on the initial visit 12/16/2016).

5.3 Treatment Session #4 12/22/2016

5.3.1 Progress: The patient is finishing up his appointment with the speech therapist as I arrive. His needles are still retained, so the practitioner removes them. Next, the patient and practitioner go through some picture ID cards together. The exercise is as follows. Practitioner shows the patient a card with a picture and a word describing the object, person, or animal on the card. The practitioner then asks the patient, “What is that? What is this animal’s name?” etc. A positive result is a correct response from the patient. Today he identified 2 of 14 cards he was shown. The rest of the time, the patient is making up words and stories to explain what is going on in the picture to “fill in the blanks” in his comprehension. No other changes were reported.

5.3.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), Middle Jiao (3), Vertex, Perineum, Foot (1), Lower Jiao (3), Auricular-Temporal (3, left-side only)

5.3.3 Daoyin: Flashcards identification game (see Progress section above)

5.3.4 Assessment: The patient is progressing nicely.

5.3.5 Plan: continue the plan of care described above (on the initial visit 12/16/2016).

5.4 Treatment Session #5 12/29/2016

5.4.1 Progress: The patient is sitting upright in his chair and knows he’s about to get an acupuncture treatment but calls the needles by a nonsensical made-up word. Upon looking at his face, the practitioner notices that some measure of Shen has returned to his face, which appears generally brighter and more alert. His nurse reports that he’s noticed good daily improvements in the patient’s speech and overall alertness. He also reports that he had a bad reaction to one of his medications which caused diarrhea (and which was subsequently stopped). It’s reported that an impromptu quiz on the Cold War rendered a 100% correct score from the patient this morning. The nurse notes that generally, his cognitive abilities are at their maximum in the morning, despite the fact that for decades he lived as a night owl. No other changes were reported.

5.4.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), Middle Jiao (3), Vertex, Perineum, Foot (1), Lower Jiao (3), Auricular-Temporal (3, left-side only)

5.4.3 Daoyin: Flashcards identification game: he identified 6 cards correctly today. 5.4.4 Assessment: The patient is progressing nicely.

5.4.5 Plan: continue the plan of care described above (on the initial visit 12/16/2016).

5.5 Treatment Session #6 1/3/2017

5.5.1 Progress: The patient just finished speech therapy and his therapist states that he’s speaking bilingually, and a little more easily in French. Much of his French it seems consists of made-up words with French-like pronunciation. He seems quite happy and is currently babbling in this form of pseudo-French. No other changes were reported.

5.5.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), Upper Limb – L (2), Vertex, Perineum, Foot (1), Lower Jiao (3), Lower Limb – R & L (4), Auricular-Temporal (3, left-side only)

5.5.3 Body Acupuncture: bilateral LV-8, LV-5, LV-4, LV-3, LV-2

5.5.4 Daoyin: Flashcards identification game: he identified 4 cards correctly today. 5.5.5 Assessment: The patient is regressing a little bit in terms of the aphasia.

5.5.6 Plan: continue the plan of care described above (on the initial visit 12/16/2016).

5.6 Treatment Session #7 1/5/2017

5.6.1 Progress: The patient’s speech therapist and personal assistant both express their concern that the patient is declining in speech and cognitive functions. The use of pseudo- French by the patient has become exclusive since the last session. His nurse reports that the physical therapy he has received has improved his mobility over the past week. No other changes were reported.

5.6.2 Zhu’s Scalp Acupuncture: Head & Face (1), Upper Limb – R (1), Upper Jiao (3), Middle Jiao (3), Vertex, Perineum, Foot (3), Lower Jiao (3), Shoulder – R

5.6.3 Daoyin: Flashcards identification game: he identified 4 cards correctly today.

5.6.4 Assessment: The patient “perked up” quite a bit with acupuncture treatment, performing better cognitively, started speaking more English, and generally appearing more alert and attentive. I have counseled the patient’s caregivers to relax regarding these expected up and down days that the patient is experiencing. It’s my opinion that it is too soon to say for sure that this patient is truly in decline. All post-stroke patients have up days and down days, so this seems to be a normal part of the recovery period.

5.6.5 Plan: continue the plan of care described above (on the initial visit 12/16/2016).

5.7 Treatment Session #8 1/9/2017

5.7.1 Progress: The patient’s nurse and personal assistant report that he has continued to improve in terms of cognition and speech since the last session. No other changes were reported.

5.7.2 Zhu’s Scalp Acupuncture: Head & Face, Upper Jiao (3), Middle Jiao (3), Vertex, Perineum, Foot (3), Lower Jiao (3), Lower Limb (bilateral, x1), Shoulder (right-side), Auricular-Temporal (3, left-side only)

5.7.3 Daoyin: Flashcards identification game: he identified 5 cards correctly, and 3 partially-correct today.

5.7.4 Assessment: The patient is progressing nicely.

5.7.5 Plan: continue the plan of care described above (on the initial visit 12/16/2016).

5.8 Treatment Session #9 1/12/2017

5.8.1 Progress: The patient is asleep when the practitioner arrives, having had a busy day of medical appointments, including radiation therapy for his prostate cancer. The patient did not arrive back home until late this afternoon. His nurse reports that he is scheduled for a blood transfusion for his long-standing anemia next week. His personal assistant reports that she’s seen “dramatic” acupuncture effects in the patient’s case in terms of his improved cognition, speech and left arm pain. His use and range of motion of the left upper extremity have increased. She lastly reports that he now knows (and comments upon) the fact that he’s unable to identify an object on flashcards correctly. No other changes were reported.

5.8.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), Vertex, Perineum, Foot (3), Lower Jiao (3), Upper Limb (right, x2), Shoulder (right), Auricular-Temporal (3, left- side only)

5.8.3 Daoyin: No ID cards were used today, as the patient sleeps through his treatment.

5.8.5 Assessment: The patient is progressing nicely.

5.8.6 Plan: continue the plan of care described above (on the initial visit 12/16/2016). The patient’s personal assistant agrees to keep up her efforts with flashcards in-between acupuncture sessions.

5.9 Treatment Session #10 1/16/2017

5.9.1 Progress: The patient’s nurse reports that he’s done a lot of “good” speech and physical (walking) therapies today. The patient’s personal assistant reports that she’s discovered something about the patient’s behavior. She postulates that when he’s trying to communicate something but can’t get the idea across, that resulting frustration leads him to revert back to poor speech patterns (i.e. speaking in “French”). No other changes were reported.

5.9.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), Upper limb (right, x2) Vertex, Perineum, Foot (3), Lower Jiao (3), Shoulder (right), Auricular-Temporal (3, left- side only)

5.9.3 Daoyin: Flashcards identification game: he identified 7 cards correctly today, a new personal best.

5.9.4 Assessment: The patient is progressing nicely.

5.9.5 Plan: continue the plan of care described above (on the initial visit 12/16/2016).

5.10 Treatment Session #11 1/23/2017

5.10.1 Progress: The patient is awake and alert when the practitioner arrives. It’s reported that he just had an urge bowel movement, which is an ongoing problem now. His personal assistant reports that he’s been working on the alphabet using Scrabble letter blocks and got A, B, C, D, E all in clear, rapid succession. After that, he got “stuck” and could make no further progress in the exercise. After the needling procedure, the patient becomes keenly interested in looking at a calendar (send by his personal assistant’s mother from his hometown in Scotland). He started talking about it and got very close to predicting the age of the ancient stone cross pictured in the calendar. No other changes were reported.

5.10.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), Upper Limb (right, x2), Middle Jiao (3), Vertex, Perineum, Foot (3), Lower Jiao (3), Shoulder (right), Auricular-Temporal (3, left-side only)

5.10.3 Daoyin: Q&A about the calendar, a free-form discussion about the people and places pictured.

5.10.4 Assessment: The patient is clearly very passionate about the topics discussed in today’s session. The patient is progressing nicely.

5.10.5 Plan: continue the plan of care described above (on the initial visit 12/16/2016).

5.11 Treatment Session #12 1/26/2017

5.11.1 Progress: The patient’s nurse reports that when looking at pictures, a lot more English is coming out, “he’s making progress for sure.” Also reported is that the patient switched from the use of Immodium to the use of Kaopectate for diarrhea. His bowel awareness and control is improved and there have been no ‘accidents’ in two days. No other changes were reported.

5.11.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), Upper Limb (right, x2), Middle Jiao (3), Vertex, Perineum, Foot (3), Lower Jiao (3), Lower Limb (bilaterally), Auricular-Temporal (3, left-side only)

5.11.3 Daoyin: Flashcards identification game: he identified 5 cards correctly, and 2 partially-correct today.

5.11.4 Assessment: The patient is progressing nicely.

5.11.5 Plan: continue the plan of care described above (on the initial visit 12/16/2016).

5.12 Treatment Session #13 1/30/2017

5.12.1 Progress: When the practitioner arrives, the patient is resting but awake and in a supine position. His nurse reports that he’s been struggling with alternating diarrhea and constipation. He’s also lost some coordination according to his PT and his personal assistant who reports that he could not actually get his hand to mouth at dinner last night. Despite all this, he appears to be in good spirits. No other changes were reported.

5.12.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), Upper Limb (bilateral, x2), Middle Jiao (3), Vertex, Perineum, Foot (3), Lower Jiao (3), Lower Limb (bilateral, x2), Auricular-Temporal (3, left-side only)

5.12.3 Daoyin: Flashcards identification game: he identified 4 cards correctly, and 4 partially-correct today.

5.12.4 Assessment: The patient is progressing nicely, but may be experiencing a bit of a setback currently.

5.12.5 Plan: continue the plan of care described above (on the initial visit 12/16/2016).

5.13 Treatment Session #14 2/2/2017

5.13.1 Progress: The patient is finishing up with speech therapy as the practitioner arrives today. The patient is awake, alert, and sitting up in his wheelchair. The practitioner observes the patient stand up, walk over to his bed, and get in (with some minor assistance). His personal assistant reports that his RBC & WBC counts are low according to recent lab results. No other changes were reported.

5.13.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), Upper Limb (bilateral, x2), Vertex, Perineum, Foot (3), Lower Jiao (3), Lower Limb (bilateral), Shoulder (right), Auricular-Temporal (3, left-side only)

5.13.3 Daoyin: Flashcards identification game: he identified 11 cards correctly (and 1 partially-correct) today, a new personal best.

5.13.4 Assessment: The patient is progressing nicely.

5.13.5 Plan: continue the plan of care described above (on the initial visit 12/16/2016). The patient’s hemochromatosis prevents me from prescribing Blood Builder by Megafood. For WBC try Astragalus Supreme by Gaia Herbs.

5.14 Treatment Session #15 2/6/2017

5.14.1 Progress: The patient is just finishing with speech therapy, is awake, alert and in good spirits. He recognizes the practitioner and tells the others that he wants nothing to interfere with or delay his [acupuncture] treatment. His personal assistant reports his continued difficulties with speech and a new symptom. He’s developed a sore on the left medial buttock. She states that she thinks it may be related to the radiation therapy he’s undergoing for the treatment of prostate cancer. No other changes were reported.

5.14.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), Upper Limb (bilateral, x2), Middle Jiao (3), Vertex, Perineum, Foot (3), Lower Jiao (3), Lower Limb (bilateral), Shoulder (right), Auricular-Temporal (3, left-side only)

5.14.3 Daoyin: rest

5.14.4 Assessment: The patient is progressing nicely. My assessment of this case was written in email format on 2/8/2016, as follows:

“The following assessment is due, so I’m grateful that our chance meeting sparked me to proceed. I think that Sandy has made good progress, as evidenced by his overall upward trend in functional and cognitive abilities. He (and his staff) report functional gains, lowered pain levels, and a generally improved sense of well-being and independence.

During our last session, I watched him walk to the restroom and back to his bed and was impressed with his ability to control his body during those short traverses. You may remember me witnessing him getting out of bed and standing on my first visit, and what I saw recently represents a decided improvement. He continues to improve (sometimes in obvious or subtle ways) every time I see him.

He also seems to have made it through this round of radiation with fewer negative effects than I would have expected, considering his age and condition. Sure, there are improvements that can be achieved, but his active mind, and regular, balanced diet has a lot to do with his ongoing constitutional resilience. My advice is to redouble these efforts. An optimal diet and regular exercise are absolutely necessary for patients with serious health and chronic concerns.

In regards to Sandy’s cognitive and communication skills, I can say with confidence that he is making documentable improvements. As I mentioned when I saw you on Monday evening, he achieved the highest score yet with flashcard identification since starting our sessions. His high score was 11 correct, with a previous high of 8 correct answers. When compared to his much lower previous average, this is an objective improvement.

I think I have identified one source of Sandy’s frustration in his knowledge of how well he does or does NOT do on individual tests we run him through. I think this translates to general frustration over his condition, and his state of recovery, which commonly seems infinitesimally slow or non-existent to patients. This is completely understandable, and anticipated.

So during our last session, I spent a lot of time positively reinforcing Sandy, acknowledging his current and ongoing achievements and struggles. It seemed to help, so far as I can tell.

I have made a point of trying to approach Sandy conversationally, and there’s some evidence that this approach is working. I listen to what he has to say, no matter what kind of gibberish it may seem to be. This tendency may have contributed to his recent shift in acceptance of acupuncture therapy, and his curiosity around it.

For example, when I saw him last Monday evening, he clearly recognized me, which signaled to the room (very decidedly), that the shift between his work with his speech therapist and his work with me had changed. This shift was clearly precipitated by his own doing, and in his own “language,” and we all understood what was going on.

The experience above has given me a sense of what a *force* Sandy must have been prior to his stroke.

Later, we had a long conversation, wherein he did most of the talking, and I struggled to understand his meaning. I stimulated his acupuncture needles and listened intently, while he attempted to articulate his meaning. I purposefully “bent my ear” to his meaning.

Eventually, I ventured a guess (and perhaps I was channeling my inner Lyn) at his meaning. He immediately agreed that yes, in fact, he was asking about that! This may be my first step toward understanding your father in a way I had not previously achieved. This breakthrough now allows me to work with him on a yet deeper level still. I think there are further improvements that I can “tease out,” as it were.

In my estimation, Sandy’s prognosis is good. Despite his advanced age, Sandy has quite the spark of Shen in his eyes. By this sign, and by his progress achieved so far in our work together, I am greatly encouraged. I hope to continue my work with him, and to help him bring back as much function and cognition as is possible.

For the reasons articulated above, I propose a change in the frequency of treatment to four-times per week, to help accelerate his recovery and allow me to provide the best and most specific acupuncture service available anywhere.”

5.14.5 Plan: continue the plan of care described above (on the initial visit 12/16/2016). The patient’s care coordinator (his son) requests we increase the frequency of treatment to 3-4x/ week, or to “whatever you think is best.”

5.15 Treatment Session #16 2/9/2017

5.15.1 Progress: The patient is sitting up and working on speech therapy when the practitioner arrives. He’s in a talkative mood, and he continues to talk straight through the session today. No other changes were reported.

5.15.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), Upper Limb (bilateral, x2), Middle Jiao (3), Vertex, Perineum, Foot (3), Lower Jiao (3), Lower Limb (bilateral), Shoulder (right), Auricular-Temporal (3, left-side only)

5.15.3 Daoyin: Flashcards identification game: he identified 4 cards correctly, and 1 partially-correct today.

5.15.4 Assessment: The patient is progressing nicely.

5.15.5 Plan: continue the plan of care amended above (on 2/6/2017). 5.16 Treatment Session #17 2/13/2017

5.16.1 Progress: The patient’s personal assistant reports that he had an allergic reaction, possibly to sunscreen which she applied to him before going outside for walking practice. The area around the superior edge of the right orbit, temple, forehead, and scalp have red, swollen, painful to the touch areas. The practitioner concludes that no scalp acupuncture is possible given the patient’s current condition. No other changes were reported.

5.16.2 Palpation of pulse: Right: Wiry. Left: slippery / hidden / hidden

5.16.3 Observation of tongue: dusky purple, no Shen; no coat

5.16.4 Body acupuncture: SP-10, ST-36, LV-8, LV-5, LV-4, LV-2, all bilaterally

5.16.5 Ear acupuncture: Point 0, Skin Disorder point, bilaterally

5.16.6 Assessment: The patient is progressing nicely overall, and likely experiencing a setback which may be due to (or contributed to by) the introduction of radiation therapy to the patient’s body.

5.16.7 Plan: continue the plan of care amended above (on 2/6/2017).

5.17 Treatment Session #18 2/22/2017

5.17.1 Progress: It looks like the patient got a very good result in terms of pain and swelling of the head, which has all but receded. There is one patch or pink, swollen, soft skin centering around Baihui DU-20, about 1 inch in diameter. No other changes were reported.

5.17.2 Zhu’s Scalp Acupuncture: Head & Face (3)

5.17.3 Body acupuncture: bilateral LI-4, LV-2, LV-3, LV-5, SP-10; right-sided Shenguan, Dihuang, Renhuang; left-sided ST-36, KI-3

5.17.4 Ear acupuncture: Point 0, Skin Disorder, Head (bilaterally)

5.17.5 Daoyin: Flashcards identification game: he identified 3 cards correctly, and 2 partially-correct, 7 incorrect today.

5.17.6 Assessment: The patient is progressing nicely. The patient states, “it makes me feel much better,” in reference to the acupuncture treatments.

5.17.7 Plan: continue the plan of care amended above (on 2/6/2017).

5.18 Treatment Session #19 2/23/2017

5.18.1 Progress: Upon inspection, the patient still has a raised, pink lump at the vertex Baihui DU-20, the same size as during yesterday’s sessions. No other changes were reported.

5.18.2 Zhu’s Scalp Acupuncture: Head & Face (3)

5.18.3 Body acupuncture: bilaterally LI-4, LV-2, LV-3, LV-4, SP-10, GB-41, UB-65, Ashi (center of heel); right-sided Cesanli, Cexiasanli, Shenguan, Dihuang, Renhuang

5.18.4 Ear acupuncture: Cingulate Gyrus, Thalamus, Point 0 (bilaterally)

5.18.5 Assessment: The patient is progressing nicely.

5.18.6 Plan: continue the plan of care amended above (on 2/6/2017).

5.19 Treatment Session #20 2/27/2017

5.19.1 Progress: The patient is outside enjoying the sunshine and letters identification practice with his personal assistant as the practitioner arrives. He seems quite cogent and aware this afternoon. Getting him back into bed for treatment is a little agitating to the patient, and he struggles to get positioned comfortably. His scalp still shows swelling and pink flesh around the vertex, this time in a slightly bigger area than was seen in our previous session. No other changes were reported.

5.19.2 Zhu’s Scalp Acupuncture: Head & Face (3)

5.19.3 Body acupuncture: bilaterally LI-4, LV-2, LV-3, LV-5, SP-10, SP-9, ST-36; right- sided Zhongjiuli, Xiajiuli, Shangjiuli

5.19.4 Ear acupuncture: Ear Apex, Point 0, Shenmen, Autonomic Sympathetic (bilaterally)

5.19.5 Daoyin: rest x 30 minutes

5.19.6 Assessment: The patient is progressing nicely, all except the skin lesion at his vertex.

5.19.7 Plan: continue the plan of care amended above (on 2/6/2017).

5.20 Treatment Session #21 3/1/2017

5.20.1 Progress: The patient reports that he’s relaxed, which makes sense considering that the treatment began during his afternoon nap. His nurse reports that he’s still got an “egg” at the vertex of his head. She also reports that his walking and balance are improved. His personal assistant reports that for the first time, he’s been asking about what happened to him (the event, the stroke) and that generally he’s been making great strides in the area of speech. His speech therapist agrees with this and acknowledges improvement. She finally states, “we had an emotional day.” No other changes were reported.

5.20.2 Zhu’s Scalp Acupuncture: Head & Face (2)

5.20.3 Body acupuncture: bilaterally LV-2, LV-3, LV-5, LV-8, SP-10, SP-9, ST-36; right- sided Renhuang, Dihuang; left-sided KI-3

5.20.4 Ear acupuncture: Point 0, Brain, Skin Disorder (bilaterally) 5.20.5 Daoyin: rest x 30 minutes

5.20.6 Assessment: The patient is progressing nicely.

5.20.7 Plan: continue the plan of care amended above (on 2/6/2017). 5.21 Treatment Session #22 3/2/2017

5.21.1 Progress: The patient seems a little irritated today upon the practitioner’s arrival, and his frustration is aimed at his nurse. He wants his hair comb for some reason, and he’s trying to tell his help to look for it, to check in his jacket or pants, etc. It’s as if he’s lecturing the nurse with genuine concern, however nonsensical his language is. The “egg” at the patient’s vertex is looking closer to expressing today. No other changes were reported.

5.21.2 Zhu’s Scalp Acupuncture: Head & Face (3)

5.21.3 Body acupuncture: bilaterally LI-4, LV-2, LV-3, LV-4, LV-5, KI-3, ST-36, Shenguan

5.21.4 Ear acupuncture: Shenmen, Autonomic Sympathetic, Skin Disorder, Thalamus (bilaterally)

5.21.5 Daoyin: rest x 30 minutes

5.21.6 Assessment: The patient is progressing nicely.

5.21.7 Plan: continue the plan of care amended above (on 2/6/2017).

5.22 Treatment Session #23 3/3/2017

5.22.1 Progress: The patient has had a visit with his primary physician, and the “egg” was thought to be a sebaceous cyst by that practitioner. His nurse and acupuncturist agree except they are also of the mind that these phenomena have a root in the patient’s body releasing Toxic Heat from the Liver Channel. No other changes were reported.

5.22.2 Zhu’s Scalp Acupuncture: Head & Face (3)

5.22.3 Body acupuncture: bilaterally LI-4, LI-1, LV-2, LV-3, LV-4, SP-10, SP-9, ST-45, GB-44, GB-40

5.22.4 Ear acupuncture: Ear Apex, Shenmen, Autonomic Sympathetic(bilaterally) 5.22.5 Daoyin: rest x 40 minutes

5.22.6 Assessment: The patient is progressing nicely.

5.22.7 Plan: continue the plan of care amended above (on 2/6/2017).

5.23 Treatment Session #24 3/4/2017

5.23.1 Progress: The patient continues to improve on a daily basis, according to his caregivers. The cyst at his vertex is very near expressing, but he’s suffered some hair loss in that area as well. His personal assistant reports that his speech has been “great” today, with the inclusion of words he had been previously omitting. His nurse reports on speech and gait improvements in the patient that he’s noticed. No other changes were reported.

5.23.2 Zhu’s Scalp Acupuncture: Head & Face (3)

5.23.3 Body acupuncture: bilaterally LI-4, LV-2, LV-3,SP-10, Shenguan, SP-6, ST-36, GB-43, ST-44, ST-40, KI-1

5.23.4 Ear acupuncture: Right: Ear Apex, Kidney, Prostate, Thalamus, Cingulate Gyrus; left: Shenmen, Autonomic Sympathetic, Skin Disorder, Point 0, Brain

5.23.5 Daoyin: rest x 30 minutes

5.23.6 Assessment: The patient is progressing nicely.

5.23.7 Plan: continue the plan of care amended above (on 2/6/2017).

5.24 Treatment Session #25 3/6/2017

5.24.1 Progress: “He’s bright, animated, more expressive, and less frustrated,” states his nurse. “He’s rambling a lot. If he’s talking, he’s laughing a lot.” She also reports that the cyst at the vertex has started to express. Upon examination, the practitioner observes a red dot with a scab and a smaller, dark raised area (30% smaller). She further reports that the patient’s been dealing with two episodes of loose stools in the past few days. No other changes were reported.

5.24.2 Zhu’s Scalp Acupuncture: Head & Face (2)

5.24.3 Body acupuncture: bilaterally LI-4, LV-2, LV-3, LV-5, SP-10, Shenguan, KI-3, ST-36, GB-34

5.24.4 Ear acupuncture: Ear Apex (bilaterally); left Prostate, Thalamus, Cingulate Gyrus; right Shenmen, Autonomic Sympathetic, Point 0

5.24.5 Daoyin: rest x 30 minutes

5.24.6 Assessment: The patient is progressing nicely.

5.24.7 Plan: continue the plan of care amended above (on 2/6/2017).

5.25 Treatment Session #26 3/8/2017

5.25.1 Progress: The patient’s nurse reports that he’s had an emotional time earlier today. This was probably triggered by unannounced changes to his daily schedule (his PT arrived late). It’s reported that the patient does not like surprises such as this. Upon examination, his scalp at the vertex is not yet fully expressed. Lastly, his nurse reports that he’s been using his left arm more often these days. No other changes were reported.

5.25.2 Zhu’s Scalp Acupuncture: Head & Face (3)

5.25.3 Body acupuncture: bilaterally LI-4, LV-2, LV-3, LV-4, LV-5, KI-1, Shenguan, ST-36, GB-34

5.25.4 Ear acupuncture: Point 0, Ear Apex, Skin Disorder (bilaterally) 5.25.5 Daoyin: rest x 30 minutes

5.25.6 Assessment: The patient is progressing nicely.

5.25.7 Plan: continue the plan of care amended above (on 2/6/2017). 5.26 Treatment Session #27 3/9/2017

5.26.1 Progress: The patient’s nurse reports, “week after week his speech continues to improve.” The skin lesion at the vertex is still there and appears ready for expression. No other changes were reported.

5.26.2 Zhu’s Scalp Acupuncture: Head & Face (3), left Auricular-Temporal (3)

5.26.3 Body acupuncture: bilaterally LI-4, LV-2, LV-3, LV-5, SP-10, ST-36, GB-34, KI-1, Ashi (center of the heel); right; Shenguan, Dihuang, Renhuang

5.26.4 Ear acupuncture: Point 0, Brain, Ear Apex, Shenmen, Autonomic Sympathetic (bilaterally)

5.26.5 Daoyin: rest x 30 minutes

5.26.6 Assessment: The patient is progressing nicely.

5.26.7 Plan: continue the plan of care amended above (on 2/6/2017).

5.27 Treatment Session #28 3/10/2017

5.27.1 Progress: The patient’s scalp lesion is still there. The practitioner attempts to lance the cyst today, with the nurse’s assistance (unsuccessful). No other changes were reported.

5.27.2 Zhu’s Scalp Acupuncture: Head & Face (3)

5.27.3 Body acupuncture: bilaterally LI-4, LV-1, LV-2, LV-3, LV-5, SP-10, SP-1, ST-36, ST-45, Shenguan, KI-3, GB-34

5.27.4 Ear acupuncture: Point 0, Shenmen, Ear Apex (bilaterally) 5.27.5 Daoyin: rest x 30 minutes

5.27.6 Assessment: The patient is progressing nicely.

5.27.7 Plan: continue the plan of care amended above (on 2/6/2017).

5.28 Treatment Session #29 3/13/2017

5.28.1 Progress: It appears that the lesion at the patient’s vertex is starting to heal now, and almost all the swelling is now resolved. Now there are areas which look normal, and those which look bruised or scabbed. The area is no longer so tender to the touch. Today he was able to get outside and enjoy the sunshine. No other changes were reported.

5.28.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3)

5.28.3 Body acupuncture: bilaterally LI-4, LV-2, LV-3, LV-5, KI-1, SP-10, ST-36, GB-34, KI-3

5.28.4 Ear acupuncture: Point 0, Ear Apex, Shenmen (bilaterally) 5.28.5 Daoyin: rest x 30 minutes

5.28.6 Assessment: The patient is progressing nicely.

5.28.7 Plan: continue the plan of care amended above (on 2/6/2017).

5.29 Treatment Session #30 3/15/2017

5.29.1 Progress: The patient’s vertex is healed so the practitioner will resume scalp acupuncture protocols today. No other changes were reported.

5.29.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), Middle Jiao (3), Vertex, Perineum and Foot (3), Lower Jiao (3), left Auricular-Temporal (3)

5.29.3 Ear acupuncture: Point 0, Thalamus, Shenmen (bilaterally)

5.29.4 Daoyin: rest x 30 minutes

5.29.5 Assessment: The patient is progressing nicely.

5.29.6 Plan: continue the plan of care amended above (on 2/6/2017).

5.30 Treatment Session #31 3/16/2017

5.30.1 Progress: The patient’s primary caregiver (his son) called to let the practitioner know that the patient had a stroke or a TIA and several seizures just this morning and had intended to cancel today’s appointment. The practitioner employed him to reconsider, stating that he felt that this was the most critical opportunity for the patient, that acupuncture should be used now to help save the patient’s life. When the practitioner arrived, he spoke with the patient’s son. He said that this morning he came in to say good morning to his father when the speech started getting sloppy, then he started crying. The patient was at that moment having the event in the presence of his son. He became incoherent and unable to sit up, stand up or walk, and his previously “good” right side seemed to become affected. His nurse reports that the first was a grand mal seizure lasting over 4 minutes, and the others were focal seizures, lasting about 2 minutes each, all included tremor and clonus. There were 6 seizures in total. Upon observation of the patient, the practitioner observes that there’s been a clear shift, he is visibly affected by his condition, there’s far less Shen in his eyes now, which appear as hollow and darkened. His lusterless complexion has darkened considerably to a dusky gray color. He writhes in discomfort and agitation, and he’s been sweating. No other changes were reported.

5.30.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), left Upper Limb (x2), Vertex, Perineum, and Foot, Lower Jiao (3), left Lower Limb (x2), left Auricular-Temporal

5.30.3 Body acupuncture: bilaterally LV-2, LV-3, LV-5, LV-8, SP-10, SP-9, ST-36

5.30.4 Ear acupuncture: Point 0, Brain, Skin Disorder (bilaterally)

5.30.5 Daoyin: rest x 30 minutes

5.30.6 Assessment: The patient has suffered a major setback, but is calmed immediately following treatment with acupuncture.

5.30.7 Plan: continue the plan of care amended above (on 2/6/2017).

5.31 Treatment Session #32 3/17/2017

5.31.1 Progress: The patient’s nurse reports that after acupuncture yesterday, he “calmed down quite a bit,” considering the level of agitation and anger he was expressing yesterday. Some Shen has returned to his eyes and he attempts to speak and respond to the practitioner’s questions. He is able to acknowledge yes or no questions with nods or shakes of the head. His caregivers are concerned about dehydration so they have been administering Gatorade and his urination continues unhindered. It seems as if the patient is now seeing double or having some visual disruption, he does better when closing one eye. Lastly, it’s reported that his right upper and lower extremities are moving more easily today. No other changes were reported.

5.31.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), left Upper Limb (x2), Vertex, Perineum, and Foot (2), Lower Jiao (3), left Lower Limb (x2), left Auricular- Temporal

5.31.3  Ear acupuncture: Point 0, Cingulate Gyrus, Thalamus, Eye (bilaterally)

5.31.4  Daoyin: rest x 30 minutes

5.31.5  Assessment: The patient is on an improvement trend.

5.31.6  Plan: continue the plan of care amended above (on 2/6/2017).

5.32 Treatment Session #33 3/20/2017

5.32.1 Progress: The patient is awake, aware, and smiling when the practitioner arrives, which makes him think for a brief moment that nothing at all had happened on 3/16/2017. Much if not all the Shen had returned to the patient’s eyes, and he’s been able to walk short distances (assisted) over the weekend. Another seemingly dichotomous finding noted by his caregivers is that he is now more confused but less agitated about it than prior to last Thursday’s events. Yesterday he eventually had a large bowel movement, then slept 60% of the day, according to his nurse. The patient was able to feed himself earlier today, has enjoyed improved speech and cognition but still conflates the meanings of things (aphasia is still present). That being said, just now he and the practitioner had a perfectly cogent conversation about the comfort level of the acupuncture needles being placed in his scalp. No other changes were reported.

5.32.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), bilateral Upper Limb (x2), Vertex, Perineum, and Foot (3), Lower Jiao (3), bilateral Lower Limb (x2), left Auricular-Temporal

5.32.3 Body acupuncture: right-sided Linggu, Dabai

5.32.4 Daoyin: rest x 30 minutes

5.32.5 Assessment: The patient is progressing nicely.

5.32.6 Plan: continue the plan of care amended above (on 2/6/2017). 5.33 Treatment Session #34 3/22/2017

5.33.1 Progress: The patient is asleep when the practitioner arrives and his nurse reports that he’s been sleeping a lot lately. She states that he’s “too weak” to stay up for very long. No other changes were reported.

5.33.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), bilateral Upper Limb (x2), Middle Jiao (3), Vertex, Perineum, and Foot (3), Lower Jiao (3) NOTE: I could not insert the Lower Limb needles because it was too painful for the patient. Today he seems to be much more sensitive to needling than I have ever seen.

5.33.4 Ear acupuncture: Point 0, Thalamus, Cingulate Gyrus (bilaterally)

5.33.5 Daoyin: rest x 30 minutes

5.33.6 Assessment: The patient is progressing nicely.

5.33.7 Plan: continue the plan of care amended above (on 2/6/2017).

5.34 Treatment Session #35 3/23/2017

5.34.1 Progress: The patient is again asleep as the practitioner arrives. He wakes during the acupuncture procedure, apologizes, and the practitioner reassures him that all is well. The patient is starting to show signs of continued increased sensitivity to acupuncture needling in the scalp (physical starts with insertion sensation). His nurse reports that he’s “doing better, especially with his right hand and leg.” The practitioner realizes that the patient is sleeping a lot more, and yawns more frequently too, which makes perfect sense considering what he’s been through and his body’s attempt to heal his brain. No other changes were reported.

5.34.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), Vertex, Perineum, and Foot

5.34.3 Ear acupuncture: right Eye, Cingulate Gyrus, Thalamus, Point 0, Master Oscillation

5.34.4 Daoyin: rest x 30 minutes

5.34.5 Assessment: The patient is progressing nicely.

5.34.6 Plan: continue the plan of care amended above (on 2/6/2017).

5.35 Treatment Session #36 3/24/2017

5.35.1 Progress: The patient did some standing today, and brushed his teeth on his own, which represents improved function. He received an oxygen treatment earlier today. He’s feeding himself lunch as the practitioner arrives. His nurse reports that he’s taken Tylenol for pain today. He’s eating well, bowel movements are regular, he’s interested in watching television, all which can be considered to be improvements at this juncture. No other changes were reported.

5.35.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), bilateral Upper Limb (x2), Vertex, Perineum, and Foot, Lower Jiao (3), bilateral Lower Limb (x2), right Shoulder, left Auricular-Temporal

5.35.3 Body acupuncture: right Linggu, Dabai

5.35.4 Daoyin: rest x 30 minutes

5.35.5 Assessment: The patient is progressing nicely.

5.35.6 Plan: continue the plan of care amended above (on 2/6/2017).

5.36 Treatment Session #37 3/25/2017

5.36.1 Progress: The patient is awake and alert as the practitioner arrives, his daughter is there from out-of-town, as well as other family members congregated and all are chatting around the patient’s room. There’s a lot of conversation and when invited to participate, says “yes,” to indicate that he’s been listening and understands what’s going on. Even though he does not say much, everything that the practitioner hears him say today sounds perfectly clear and cogent. He appears to be leaning toward the left side in bed today. His nurse lastly reports that he’s been more gassy than usual as of late. No other changes were reported.

5.36.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), Middle Jiao (3), Vertex, Perineum, and Foot (2), Lower Jiao (3), bilateral Lower Limb (x2)

5.36.4 Ear acupuncture: bilateral Point 0

5.36.5 Daoyin: rest x 30 minutes

5.36.6 Assessment: The patient is progressing nicely.

5.36.7 Plan: continue the plan of care amended above (on 2/6/2017).

5.37 Treatment Session #38 3/27/2017

5.37.1 Progress: The patient is awake and in bed when the practitioner arrives today. He’s already had lunch and his nurse reports that he’s been experiencing joints pain lately and that he was constipated yesterday but has since moved his bowels. She reports that his urine has been dark in color and she’s been giving him water to try to get him hydrated. No other changes were reported.

5.37.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), Vertex, Perineum, and Foot, Lower Jiao (3)

5.37.3 Body acupuncture: bilaterally LI-4, LV-3, LI-11, Xinmen, SP-10, Xiyan, ST-34, ST-35, ST-36, Shenguan, LV-8, GB-33

5.37.5 Daoyin: rest x 45 minutes

5.37.6 Assessment: The patient is progressing nicely.

5.37.7 Plan: continue the plan of care amended above (on 2/6/2017).

5.38 Treatment Session #39 4/5/2017

5.38.1 Progress: The patient’s nurse reports that he’s been doing well since our last session. She states that he was able to get up out of bed and use the toilet unassisted. Today the patient is suffering from seasonal allergy symptoms of post-nasal drip, sneezing, cough, and very irritated, red, runny and itchy eyes. She also reports he’s been having a stiff and painful neck accompanied by difficulty getting comfortable in bed. Lastly, it’s reported that cognitive training activities have been scaled down to 20-30 minutes per day to prevent too much frustration from occurring in the patient at this point in time. No other changes were reported.

5.38.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), bilateral Upper Limb, Vertex, Perineum, and Foot, Lower Jiao (3), Cervical Area (3), bilateral Lower Limb (2)

5.38.3 Body acupuncture: bilaterally GB-20, LI-4, LV-3, LU-7, ST-36, Shenguan, GB-37, KI-6

5.38.4 Daoyin: blink eyes vigorously, look close, look far away; rest x 30 minutes 5.38.5 Assessment: The patient is progressing nicely.
5.38.6 Plan: continue the plan of care amended above (on 2/6/2017).

5.39 Treatment Session #40 4/6/2017

5.39.1 Progress: The patient’s personal assistant reports that the patient is still weak and having difficulty staying balanced while walking. She states that he’s still battling the allergies or perhaps a common cold, with continued red swollen eyes, stuffy nose, and cough. Lastly, his neck stiffness and pain persists, along with lower back pain which became evident in observing his gait (he was stooping forward). No other changes were reported.

5.39.2 Zhu’s Scalp Acupuncture: Head & Face, Upper Jiao (3), Middle Jiao (3), Vertex, Perineum, and Foot, Lower Jiao (3)

5.39.3 Body acupuncture: bilaterally ST-36, LI-10 5.39.4 Ear acupuncture: bilateral Lung #2

5.39.5 Daoyin: rest x 30 minutes

5.39.6 Assessment: The patient is progressing more slowly now, or plateauing the improvement trend.

5.39.7 Plan: continue the plan of care amended above (on 2/6/2017).

5.40 Treatment Session #41 4/7/2017

5.40.1 Progress: The patient’s nurse reports that he’s had “a big day” and is resting now (he’s currently asleep). His allergy symptoms have not changed much yet. The nurse lastly reports that the patient has been having quite a bit of sensitivity in the scalp at the vertex. The practitioner noticed this too when needle stimulation resulted in grimaces and audible groans. No other changes were reported.

5.40.2 Zhu’s Scalp Acupuncture: Head & Face (2)

5.40.3 Body acupuncture: right GB-20

5.40.4 Ear acupuncture: right Point 0, Allergy point, Cervical spine, Lumbar spine

5.40.5 Daoyin: rest x 30 minutes

5.40.6 Assessment: The patient is progressing more slowly now, or plateauing the improvement trend.

5.40.7 Plan: continue the plan of care amended above (on 2/6/2017).

5.41 Treatment Session #42 4/11/2017

5.41.1 Progress: The patient is resting when the practitioner arrives, and his nurse reports that he has a lot to say these days, but most of it is still gibberish, or out-of-context. She also reports that the patient has been having numbness and pain in the soles of the feet, which she thinks may be contributing to his difficulty walking. No other changes were reported.

5.41.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (1), Vertex, Perineum, and Foot

5.41.3 Body acupuncture: left Wuhu #4 & #5

5.41.4 Ear acupuncture: bilateral Point 0

5.41.5 Daoyin: rest x 30 minutes

5.41.6 Assessment: The patient is progressing more slowly now, or plateauing the improvement trend.

5.41.7 Plan: continue the plan of care amended above (on 2/6/2017).

5.42 Treatment Session #43 4/13/2017

5.42.1 Progress: The patient’s caregiver is giving the patient a neck and upper back massage. He reports that yesterday the patient experienced a lot of ankle pain during physical therapy, but that today the ankle seems okay. No other changes were reported.

5.42.2 Zhu’s Scalp Acupuncture: Head & Face (3), Upper Jiao (3), Middle Jiao (3), Vertex, Perineum, and Foot (3), Lower Jiao (3), Cervical Area (3), right Lower Limb (2)

5.42.3 Body acupuncture: right Wanshunyi, Wanshuner; left Linggu, Dabai, bilateral GB-20

5.42.4 Ear acupuncture: bilateral Point 0

5.42.5 Daoyin: rest x 30 minutes

5.42.6 Assessment: The patient is progressing more slowly now, or plateauing the improvement trend.

5.42.7 Plan: continue the plan of care amended above (on 2/6/2017).

5.43 Treatment Session #44 4/18/2017

5.43.1 Progress: The patient was about to eat lunch when the practitioner arrived for his treatment, but he insists on getting back into bed to receive acupuncture instead. When asked how he’s doing, he moves his left hand in a way which the practitioner recognizes to mean pain in the left upper extremity and shoulder. His nurse reports worsened walking function lately. No other changes were reported.

5.43.2 Zhu’s Scalp Acupuncture: Head & Face (2), Upper Jiao (3), bilateral Upper Limb, Middle Jiao (3), Vertex, Perineum, and Foot, Lower Jiao (3), bilateral Lower Limb (2), right Shoulder

5.43.3 Body acupuncture: bilateral GB-20

5.43.4 Daoyin: rest x 30 minutes

5.43.5 Assessment: The patient is progressing more slowly now, or plateauing the improvement trend.

5.43.6 Plan: The patient is discharged per the request of his primary caregiver.

SECTION 6: RECOMMENDATIONS UPON DISCHARGE

  • Continue to keep the patient comfortable and allow for as much mobility and function as he can muster
  • Be extra supportive during physical therapy and when he walks, you want to prevent him from falling
  • Work concertedly to keep the patient hydrated and continue with his good dietary hygiene
  • Consider inclusion of foods that supplement and nourish the Spleen and Kidney, such as butternut squash, yams, pumpkin, black sesame seeds, black wood ear mushrooms, etc.
  • If possible, consider Bu Zhong Yi Qi Tang or Astragalus Supreme by Gaia Herbs to keep up healthy white blood cell counts and to stave off the negative effects of radiation therapy
  • Consider the use of Saw Palmetto (herb) to protect the prostate from unnecessary damage while being targeted with radiation therapy
  • Keep an eye on the patient’s energy and activity levels – he should be just as active as possible without completely draining him energetically
  • Should scalp acupuncture be resumed in the future, the recommended starting frequency of treatment is two times per week with 2-3 days of needle retention between sessions
  • Keep up efforts with physical therapy, speech therapy, and cognition using flashcards, Scrabble pieces, pictures, worksheets, etc. (as described above in the Daoyin sections of the case)

SECTION 7: DISCUSSION

7.1 What did you learn from this case?

  • The Zhu’s Scalp Acupuncture system offers a useful approach in post-stroke aphasia
  • Zhu’s Scalp Acupuncture techniques can be used to save a life
  • Some cases of aphasia may take a long course of treatment before results are seen
  • Lots of Daoyin practice by the patient will speed up the recovery process
  • Best results occur when Daoyin exercises are performed by the patient at the time of needle stimulation
  • Choice of Daoyin exercises matters to the results or the lack thereof
  • Language is a complex human function and aphasia has a way of bringing out the bizarre and erratic aspects contained within it
  • When the limitation of financial constraint is removed, patients and practitioners can move forward decisively to solve life-threatening conditions
  • Given the right mindset, resources, and support, almost anything is possible

7.2 What limited your treatment outcome?

  • Setback on 3/16/2017
  • Inability to needle the scalp and/or perform Daoyin with every treatment session
  • The limits of the practitioner’s own training and skill7.3 What would you recommend for your colleagues to do for a similar case study in future?
  • Gain the trust of the family and caregivers quickly
  • Get the patient very involved with the treatment process (i.e. doing Daoyin) from the very first session
  • Encourage the patient to retain needles for as long as possible and to do Daoyin exercises at in between acupuncture sessions
  • Engage the care staff to assist in your goals for the patient
  • Practice extreme patience when speaking with and trying to understand a patient with aphasia
  • Block off enough time on your schedule to be able to get to and from your house call without undue stress

SECTION 8: CONCLUSION

This extraordinary patient was able to make it through some extremely challenging health events while under the practitioner’s care. Because of the concerted efforts of his family, caregivers, and staff, he’s had an easier time than many other stroke patients might. His medical care was not hindered by financial roadblocks, which allowed for great continuity of care and application of longer-term treatment plans. He’s also had access to all the appropriate modalities which could possibly move him forward. The thoughtful and systematic approach his family used to coordinate his care is impressive.

The treatment frequency and the total number of treatments were optimal in this case. The practitioner is particularly gratified that so many long-distance house calls could be delivered so close together and in such large quantities. It is his experience that house call patients rarely can sustain long-term acupuncture house calls due to the high fees associated with such an approach.

There are several great advantages to using Zhu’s Scalp Acupuncture in a case like this. One advantage is the fact that because needles are retained for several hours to several days, they can continue to work for a longer time and have a deeper impact on the patient’s condition than removing needles after 30-60 minutes in the clinic.

Another advantage is that when the needle stimulation is combined with Daoyin exercise, the patient is likely to make exponentially better progress than without this targeted, customized approach. Without concomitant, patient-specific, results-driven exercises performed by the patient during needling, we are not really doing everything we can to help stroke patients recover as quickly as possible.

One disadvantage of this system which was revealed to the practitioner is that sometimes we cannot needle the scalp zones. Versatile acupuncturists will not be stymied by this, but it underscores the importance of remaining flexible and being able to think on one’s feet.

In retrospect, there was one main thing the practitioner would have done differently. He would have tried to awaken the patient more often and engage him in Daoyin, conversation, word recognition, etc. as much as possible during each session. The practitioner has assessed his own performance in this regard to be in need of improvement. He let the patient rest too often during treatment and this is a mistake he will be on the look out for in the future.

The practitioner considers himself extremely lucky to have become trained in Zhu’s Scalp Acupuncture. Without Dr. Zhu’s system, he would have had no clue how to go about working on a case such as the one presented above. He’s grateful for the experience of having treated this specific patient as well. Doing so has given him incontrovertible proof that ZSA can work in emergency and severe medical situations. It also has allowed him to touch a life deeply, and in helpful, meaningful ways.

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My Capstone

The Effect of Acupuncture on Blood Stasis in Chronic Lumbar Pain: A Literature Review and Case Study

By Scott A. Whitfield, L.Ac., Doctoral Fellow, Five Branches University, San Jose, California

Chapter 1: Literature Review of Blood Stasis in Chronic Lumbar Pain

Abstract

Lower back pain is an exceedingly common medical complaint. According to Ma, et. al. in Biomedical Acupuncture for Pain Management: An Integrative Approach, “Statistics show that about 150 million Americans suffer from acute or chronic lower back pain and spend an estimated $20 billion to $50 billion a year in treating their problems. At any given time, more than 2.6 million adults are disabled by chronic lower back pain.” (Ma, 2005)

This study examines the phenomena of blood stasis (a Chinese medical pattern differentiation) and how it responds to acupuncture treatment. Because the author has a busy clinical practice, he sought out statistics regarding the number of patients seen in his clinic and for which chief complaints, over a one-year sample. Also, a literature review was conducted which uncovered many concepts salient to this topic. Finally, a case study of a 73 year-old female patient with chronic lower back pain from the author’s practice is presented.

Introduction

The author’s acupuncture practice is based in a busy outpatient hospital setting. He currently sees patients at a rate of 16-20 a day, five days a week. Over the course of his practice he has seen a lot of back patients (see the Appendix: Practice Analysis). These patients are typically limited to a handful of treatments but are not offered long-term or maintenance acupuncture treatments. 

One thing the author has observed is that patients who present with chronic lower back pain are often “knotty” as is said in TCM. They come to the clinic with multiple complicating factors, having been subjected to a plethora of allopathic interventions perhaps, often getting acupuncture for the first time. These patients are also typically on a number of medications further complicating attempts to achieve balance in the patient’s system. The author’s approach to acupuncture is therefore eclectic and he has, out of necessity, combined several “schools of thought” in attempt to achieve superior results in a short-course of acupuncture therapy. In the Case Study below, it will be shown how the author assesses and treats a typical hospital-setting patient. In the Practice Analysis (Appendix), the author breaks down the chief complaints of a year’s worth of treatments by body area affected or condition.

It is the author’s hypothesis that Blood Stasis will be found to play a central role in the diagnosis and treatment of lower back pain. This investigation will strive to elucidate this concept theoretically in the literature review and practically in the case study.

Western Biomedical Treatment

Most doctors will recommend different treatments for lower back pain based on duration and cause. Chronic lower back pain is if the lower back bothers the patient most of the time or longer than 3 months. Home treatment including rest for 1-2 days, over-the-counter medications such as acetaminophen (Tylenol) or NSAIDs (such as Advil or Motrin), cold application, heat or moist-heat application, short walks or more specific exercises prescribed by a physical therapist aimed at stabilizing the lumbar spine. For pain lasting longer than 2 weeks of self-care, a doctor’s visit is recommended. Most low back pain resolved on it’s own within 4-6 weeks of conservative treatment. 

Patients are urged to utilize good ergonomics, stretching, mindfulness of bending reaching or lifting motions, good shoes with proper support and a number of other measures to help to prevent a recurrence of back pain (Erstad, 2008). In severe cases, oral muscle relaxants and sometimes anti-depressants are used (often controversially) to relieve the pain. Degenerative disc disease and fractures are amongst the problems indicated for surgery but a second opinion is often in order.

TCM Treatment

There are a number of other modalities included in Traditional Chinese medicine other than acupuncture and electro-acupuncture that can be applied to the treatment of chronic lower back pain due to blood stasis such as bloodletting, cupping, guasha, moxibustion, tuinamassage. Because the scope of this study pertains specifically to acupuncture, these other modalities will not be discussed.

There is a long history of treating lower back pain in Traditional Chinese Medicine. Lower back pain, also referred to as Lumbago, is a disease category in Nei Ke (internal medicine). In a recent research article, a team of researchers looked at “16 Traditional Chinese medicine acupuncture texts or treatment articles to determine the consistency of diagnosis and recommended treatment for chronic lower back pain” (Birch, 1999). Twenty-four different patterns were described in these texts. Blood Stasis pattern came up in 10 of the 16 texts/articles. The points recommended for Blood Stasis pattern lower back pain (in order of prevalence) is: UB-40, UB-23, Ashi, DU-26, UB-17, DU-3, UB-32, UB-60, Yaotong, KI-2, Yaoyan, UB-31, GB-34, DU-14, UB-22, UB-25, SI-6, TB-6, Huatoujiaji. (Birch, 1999). In my opinion, this is a very good assessment of points used and agreed upon for Blood Stasis pattern lower back pain. GB-40 is the most popular point for this pattern & presentation, having been referenced in 10 citations (Birch, 1999).

An interesting crossover is that UB-40 happens to be one of Master Tung’s favorite points for this condition as well, however he would have preferred to perform bloodletting at this point instead of frank acupuncture (Young 2008). It is the author’s belief that bloodletting as practiced in this school has great potential for further study and development and a great inherent capacity to heal chronic pain conditions such as lower back pain. Because he is limited to practicing acupuncture and electro-acupuncture only, this investigation will not address bloodletting in detail.

Methods and Materials: Internet Search

First, a PubMed search was conducted using the search keys; “blood stasis, blood stagnation, chronic low back pain, chronic lumbar pain, acupuncture” rendered no results. Then, the author narrowed the search to “acupuncture, chronic low back pain, chronic lumbar pain” and one pertinent study came up (Birch, 1999). Next, the search was broadened to “acupuncture, low back pain” and got 329 results back. Each study was reviewed and none really had pertinence to this investigation. Then, the author turned to the Cochrane Review for a meta-analysis of acupuncture studies done on low back pain (Furlan, 2003). Here is a quote from the Summary of this aforementioned study:

“Thirty-five RCTs covering 2861 patients were included in this systematic review. There is insufficient evidence to make any recommendations about acupuncture or dry-needling for acute low-back pain. For chronic low-back pain, results show that acupuncture is more effective for pain relief than no treatment or sham treatment, in measurements taken up to three months. The results also show that for chronic low-back pain, acupuncture is more effective for improving function than no treatment, in the short-term. Acupuncture is not more effective than other conventional and “alternative” treatments. When acupuncture is added to other conventional therapies, it relieves pain and improves function better than the conventional therapies alone. However, effects are only small. Dry-needling appears to be a useful adjunct to other therapies for chronic low-back pain.”

The authors of the above study do note that more quality studies are needed in this area. In the conclusion, the author’s state, “Because most of the studies were of lower methodological quality, there certainly is a further need for higher quality trials in this area.” The author of this investigation concurs. This is our “bread and butter” as acupuncturists, so our profession had better be armed with good science around this topic whenever possible.

Methods and Materials: Books

In discussing this topic, the author wanted to be sure to explore some of the classical roots of Chinese Medicine because as Five Branches University DAOM Professor Bob Flaws likes to say, “mastery is always mastery of the basics.” To start to understand blood stasis in the context of chronic lower back pain, the author turned to Statements of Fact in Traditional Chinese Medicine by Bob Flaws and sought-out these salient assertions:

Blood Stasis (xue yu)

Statement: Stasis [is] accumulation of blood.

Commentary: According to this statement, blood stasis is the pathological accumulation of blood. However, within Chinese medicine, other synonyms for blood stasis are dead blood (si xue), dry blood (gan xue) and malign blood (e xue).

Statement: New diseases are in the channels; enduring diseases enter the network vessels.

Statement: [If] enduring disease is not cured, damage reaches the blood network vessels, the blood vessels do not flow smoothly, and [this] results in blood stasis.

Commentary: The first of these two statements is by Ye Tian-shi. The second statement explains the clinical implications of Ye’s statement.

Statement: [In] enduring diseases, there must be stasis.

Commentary: Later, Wang Qing-ren says essentially the same thing even more tersely. In enduring disease there must be blood stasis.

Statement: Enduring disease results in stasis.

Commentary: Yet another statement that enduring diseases result in blood stasis. Therefore, it is extremely important to search for signs and symptoms in all enduring diseases.

Qi & Blood Disease Mechanisms (qi xue bing ji)

Statement: Qi stagnation leads to blood stasis.

Commentary: Since the qi moves the blood, if the qi stops, the blood will typically stop. Hence qi stagnation leads to blood stasis.

Statement: Qi stagnation [may lead to] blood stasis.

Commentary: Because qi moves the blood, qi stagnation may lead to blood stasis.

Statement: Qi vacuity [may lead to] blood stasis

Commentary: Likewise, if qi is vacuous and weak and lacks the strength or power to move the blood, the blood can become static.

Statement: [If there is] free flow, there is no pain; [if there is] pain there is lack of free flow.

Statement: If qi and blood are not harmonious within the vessels and network vessels, there is pain.

Commentary: Both these statements say essentially the same thing. If there is free flow of qi and blood within the channels and vessels, then there is no pain. However, if there is pain, then that is nothing other than a lack of free flow of the qi and blood within channels and network vessels.

Statement: [If] blood stasis is not eliminated, new blood is not engendered

Commentary: This is an extremely important statement. It means that “blood stasis hinders the creation of new or fresh blood. Therefore, most blood stasis eventually becomes complicated by blood vacuity. In addition, if there is blood vacuity and one does not simultaneously address the presence of any stasis, treatment for supplementing the blood will not be effective.

Miscellaneous Disease Mechanisms (za gan bing ji)

Statement: Withering of fluids [may lead to] blood dryness.

Commentary: Because blood and fluids share a common source, withering or consumption of fluids may lead to concomitant blood dryness.

Statement: Fluid depletion [may lead to] blood stasis. 

Commentary: This statement is an extension of the previous statement. Because the blood and fluids share a common source, consumption of fluids may lead to blood dryness, which leads to blood stasis.

Statement: [If] something exists internally, [it] must [have] form externally.

Commentary: This means that disease on the inside of the body will typically manifest signs and symptoms on the outside of the body.” (Flaws, 2008)

The investigation will now move on to some concepts from the Japanese acupuncture tradition. Kiiko Mastumoto, a pioneer in this field, has said it well when she stated, “Lower back pain (LBP) is one of the most common complaints seen in the acupuncture clinic. It is very important to differentiate the etiology and treat the underlying, constitutional problems that led to the lower back pain and/or are preventing the natural healing process.” (Matsumoto, 2002).

One of those commonly found underlying constitutional problems is called Oketsu, which means stagnation of blood in the abdomen in Japanese. The word implies “bad Blood,” “old Blood,” “toxic Blood” and “stagnation of Blood caused by labor.” Kiiko considers Oketsu to be, “a primary target to treat.” Indications do include, amongst several other indications, sciatica and backache. The way to diagnostically uncover this sign is to palpate the left lower abdomen at a triangle formed by KI-15 and ST-27. A positive Oketsu sign will render pressure pain or hardness in the aforementioned triangle and there may be referred pain elsewhere in the abdomen. Treatment of Oketsu according to this tradition is bilateral “Nagano’s immune points” at LI-10 to LI-11 (referred to in this paper as TI-10, as it lies between the Triple Burner and Large Intestine channels) area plus left-sided LV-4 and LU-5 and the location and angle of insertion of these points is determined by the, “exact location and angle that relieved pressure pain at KI-15 to ST-27 area.” (Matsumoto, 2002) 

Patients commonly want to know if they need a blood test after a practitioner informs them that the pain they experienced upon palpating the Hara (abdomen), as described in the previous paragraph, is due to Oketsu. It is a difficult topic to discuss with the layperson because, “the reasons why Oketsu is formed are numerous and cannot always be explained.”1Here is a list of possible causes of Oketsu from Kiiko’s Clinical Strategies: In the Spirit of Master Nagano, Volume I, below:

  1. Genetic Predisposition, especially on the mother’s side (according to Yumoto)
  2. Menstrual problems, hematoma (injury), intensive heat and/or high fever (according to Yumoto).
  3. Portal vein congestion (according to Manaka & Yumoto)
  4. Liver disease and digestive problems (according to Manaka)
  5. Hormonal imbalances and autonomic nerve imbalances (according to Manaka).
  6. Multiple operations, blood transfusions and/or repeated bruising (according to Matsumoto).
  7. Vascular compression of the inner thigh due to posture (high heels for example) or tight and constricting clothing (according to Nasako).
  8. Weak immune system (according to Nagano). Since Oketsu is a toxin, it might also be the causeof a weakened immune system.
  9. Chronic respiratory problems such as asthma, COPD, emphysema, etc. A chronic shortness of breath may change the pH of the blood due to elevated levels of CO2.
  10. Infections or infectious diseases such as chronic sinusitis, respiratory infections, or a chronic local infection) might cause Oketsu. Usually, acute, short term or first time infections do not cause the appearance of Oketsu (with the exception of very high fever).
  11. Chronic pain
  12. Strong medications or the use of medication for a long period of time (especially the chronic usage of painkillers, antibiotics, etc.).

Because the pattern of Oketsu is applicable to many complaints, Kiiko says, “in general, in every condition where an abdominal sign of stagnation of Blood is palpated, it must be treated first.” When using this system, the practitioner should look for these additional corroborating signs and symptoms:

  • Dark blue or purple color of skin at the lips or under the eyes.
  • Weak peripheral blood vessels i.e. patients that bruise easily or bleed easily.
  • Abnormal menstruation: amenorrhea, dysmenorrhea.
  • A feeling of a heavy head, headache, stiff shoulders, insomnia, forgetfulness, dizziness, palpitation or a constant feeling of sleepiness.
  • Hot flushes, cold hands, cold back.
  • Digestive problems: stomach and duodenal ulcer, nausea, colitis, indigestion, constipation, food allergies. (Matsumoto, 2002)

Chapter 2: Case Study

Methods

The independent variable of this study is acupuncture treatment. The dependent variable is the outcome of acupuncture on chronic lumbar pain. This is a case study of a 74 year-old female patient with chronic lower back pain who would prefer to avoid taking further medications for her condition. After a physical exam and referral from her medical doctor, the patient sought acupuncture treatment. She was 100% compliant in completing 10 weekly (consecutive) acupuncture treatments. The patient’s underlying medical conditions and current medications will be enumerated in the body of the case itself. The author used the patient’s Electronic Medical Record (in Epic HeathConnect) at the hospital to printout and compile this case.

Instruments

  • Disposable acupuncture needles: DBC Brand, Spring Ten Handle; 0.25 mm diameter, 30 mm in length (made in Korea)
  • Disposable acupuncture needles: DBC Brand, Spring Ten Handle; 0.18 mm diameter, 15 mm in length (made in Korea)
  • Cotton Balls
  • Isopropyl rubbing alcohol, 70%
  • Heat Lamp
  • Pointer Excel II (hand-held ear point location devise)
  • Canon PowerShot G10 digital camera
  • Opteka 10x 58mm HD2Professional Macro Lens
  • Opteka 58mm metal lens adapter for Canon PowerShot G10
  • 15” Apple MacBook Pro 2.33 GHz, Dual-Core Processor
  • HP Scanjet 3100c scanner
  • Macintosh OS X 10.5.8, Microsoft Word, Microsoft Excel, Apple Aperture, Adobe Acrobat, Kaiser Epic HeathConnect (software packages)

Case History – 73 y.o. female, “Isabel”

Chief Complaint: chronic low back pain        

What follows id the PCP Note from 06/19/09, which was reviewed prior to treatment by the author: 

“Patient presents with spine pain. Lumbar area para spinal and thoracic spine around T11, chronic but worse for 1 month. No cauda equina symptoms and no fever. No trauma. Pain 6/10, no radiation to legs. Worse with movement and in the morning when she gets up. Does not want to take any medicine for pain. Wants to know if spinal bracing will help. Her spine x-ray shows degenerative changes but no fracture. ROS: Constitutional: negative for fever, negative for chills and negative for weight loss; Musculoskeletal: positive low back pain; Neurological: negative for tingling, sensory change, speech change and focal weakness.

Patient Active Problem List:

  • Pancreatitis, chronic
  • Sinusitis
  • Hypertension
  • Hx of Basal Cell CA of Skin
  • Pelvic Pain, Female
  • Obstruction of Ureteropelvic Junction, congenital
  • Diverticulosis of Colon
  • Low Back Pain

I have reviewed medications and allergies and they are below

Current Prescriptions (6/19/09):

  • Amlodipine 5mg 1qd
  • Amitriptyline 10mg 1qd
  • Alprazolam 0.5mg 1bid
  • Viokase 468mg 1 tid
  • Nitroglycerin 0.4mg Sublingual as needed up to 3 doses

Nutritional Supplements or Herbs: multi-vitamin

Allergies: Penicillins Class

Family History: Sister positive for Brain CA, positive Breast CA; Cousin positive Breast CA

Social History: Widowed twice. Has one son, lives in Half Moon Bay, California. Used to work for Kaiser. No grandkids. Never used tobacco. Does not use alcohol. Not sexually active.

Immunizations: PNUps (Pneumococcal polysaccharide) 05/15/06; Td 7yrs-adult (Tetanus, diphtheria) 12/13/99

Physical Exam:

I have reviewed the vital signs and nursing notes. BP 130/80, Pulse 62, Temperature: 97 F (36.1 C) (Oral); Height: 5’8”, Weight: 125 lb, SpO2: 99%, LMP: Postmenopausal, BMI: 19.01 kg/(m^2)

General appearance – alert, well appearing, and in no distress

Mental status – alert, oriented to person, place, and time

Chest – clear to auscultation, no wheezes, rales or rhonchi, 

symmetric        

Heart – normal rate, regular rhythm, normal S1, S2, no murmurs, 

rubs, clicks or gallops

Back exam – tender paraspinal area in the lumbar region, around T11 tender. Able to bend forward, scoliosis of lumbar spine to the left, Slr on right negative, left leg cannot test as she refuses to lift her leg up 

Reflexes ml

Sensation intact

Laboratory Studies and other data:

Recent Weight Reading(s)

            Date:                Wt:

  • 06/19/2009      125 lb (56.7 kg)
  • 01/14/2009      132 lb (59.875 kg)
  • 10/13/2008      133 lb (60.328 kg)
  • 08/27/2008      137 lb (62.143 kg)
  • 07/16/2008      139 lb (63.05 kg) 

Last 4 encounter BP Readings:

Date:                BP:

  • 06/19/2009      130/80
  • 01/14/2009      129/65
  • 10/13/2008      129/72
  • 08/27/2008      120/74
  • WBC               5.9       07/16/2008
  • HCT                40.5     07/16/2008
  • HGB               13.9     07/16/2008
  • PLT                 270      07/16/2008
  • ALT                13        10/13/2008
  • AST                19        10/13/2008
  • CREAT           0.67     07/16//2008
  • GLUC             87        05/15/2006
  • GFR-AFRAM>60      07/16/2008
  • GFR-NONAFRAM   >60      07/16/2008      

Assessment and Plan: back pain-xray no fracture; she will take 1500 mg calcium and 800 IU Vitamin D daily, Dexa osteopenia last year, she cannot take fossamax because of gerd, does not want analgesics; will discuss with PM&R if spine bracing will help, also will consult for acupuncture class [treatment – SW]. Will see in next month again for chronic conditions. Return to clinic, if worse.”

SUBJECTIVE

HPI: The patient presents with right-sided lower back pain and thoracic back pain, “for years” that has been getting progressively worse since 03/09. She states that she believes that due to osteopenia she has developed degenerative disc disease and scoliosis, leading to her back pain. Her pain is described as constant, heavy, sudden onset and occasionally sharp. Turning motions and standing too long exacerbate the pain but painting (her avid hobby), walking and meditating all help to relieve the pain. The patient additionally reports waking at 1:30 a.m. and she rates her current pain level at 9/10 VAS.

Current Therapeutic Objectives: Decrease pain level 50% or better while increasing function and mobility.

OBJECTIVE

Physical Exam

Tongue: dusky-purple, dry, some cracks, mapped yellow dry coat (only on the back half or so of the tongue), deviated left

 Right Pulse: Slippery and Flooding

 Left Pulse: Wiry and Full

The patient points to the affected areas of her body

Spider nevi and varicosities are prevalent bilaterally in the lower extremity

Hara palpation: positive Oketsu

ASSESSMENT

Pattern/Syndrome Differentiation

Pattern Diagnosis: Oketsu (Liver Blood Stagnation); Qi Stagnation, Blood Stasis; Kidney Yin, Liver Blood Vacuity, Liver Spleen Disharmony, Hyperactivity of Liver Yang Stirring Internal Wind

Channel Diagnosis: Du Meridian and right Foot Taiyang Urinary Bladder Channel

Pattern/Syndrome Differentiation Analysis

This is an active older patient who enjoys walking, painting and meditating. She lives in a retirement home in Half Moon Bay. She worked for years as a heath care worker and likely spent a lot of time on her feet as a nurse for Kaiser. Her body constitution is tending toward frail and she has a history of slight but persistent weight loss. She is generally thin in appearance with slightly ashen skin. 

There are several signs pointing to the presence of significant blood stasis such as the dusky-purple color of the tongue, the positive Oketsu sign, the evident spider nevi and varicosities of the lower extremity. Moreover, the patient exhibits significant dryness of the skin visible upon examination, a dry tongue with cracks, a wiry and full pulse on the left Guan position and slippery and flooding on the right Guan position amounting to disharmonies of the liver and spleen. The yellow coat in back portends heat, likely in the lower jiao.            

This is a case of vacuity and repletion. The author’s hypothesis for the pathogenesis of her back pain is as follows. Over time, the patient’s kidney yin became exhausted (likely at menopause) causing a drying trend. Then, stress lead to a liver depression, qi stagnation state thereby weakening of the connections between the liver and spleen as well as the heart and the kidney. Continuous use of prescriptions has contributed to the stasis in the liver. The patient’s liver, in its depression, began to generate heat (the repletion) causing further blood stasis. At the same time, kidney yin cannot control the kidney yang (the vacuity) so kidney yang becomes exuberant, causing the wind signs such as deviation of the tongue. There is no stability in the lumbar region because there is no root for its function (balanced kidney yin and kidney yang and a healthy Mingmen Fire). This state places the patient in jeopardy for poor body mechanics to come into play and create an exacerbation of lumbar region pain.

Treatment Principles: Quicken the blood and move the qi, dispel stasis and free the flow network vessels, stop pain; dispel wind and open the channels; nourish the liver and supplement yin.

PLAN

Treatment #1 – manual acupuncture, 40 minutes needle-retention 

Acupuncture Points: 

  • Left: (J) LV-4, (J) LV-5
  • Bilateral: TI-10
  • Bilateral ear: Thalamus
  • Right: Linggu, Dabai, Zhongbai, SI-4, Houzhu, UB-65

Needle count: 12

Recommended Course of Treatment: no less frequent than 1x/week for 10 weeks.

Treatment #2

Cc: chronic low back pain      

Progress: The patient reports that following the last acupuncture session she felt her back pain get “worse, but I could be wrong about that.” Then, she was walking and noticed pain in her right foot near ST-41. She does report feeling more relaxed, calm, with an increased sense of well-being for 2 days following the acupuncture session. Today she rates her lower back pain at 5/10 and in the same places. She also reports that she gets hot at night and that cooking and baking are activities that exacerbate her pain. No other changes were reported. Positive Oketsu. Tongue: purple, dry, cracks, slightly deviated left, mapped yellow dry coat in back, front peeled. Right pulse is full but soggy and the left pulse is full and slippery.

Treatment:

  • Left ear: Lumbar Spine, Sciatic Nerve, Point 0, Thalamus
  • Left: (J) LV-4, (J) LU-5
  • Bilateral: TI-10
  • Right: Linggu, Dabai, Zhongbai, SI-4, Houzhu, UB-65

Needle count: 14

Treatment #3

Cc: chronic low back pain

Progress: The patient reports that following the last acupuncture session she got full relief from her pain for the duration of 1 week, accompanied by a profound sense of relaxation. Today she reports a pain level of 9/10 in her right lumbar region from having “over-done it yesterday.” No other changes were reported. The tongue is the same but a little less purple, right pulse is soggy, left pulse is soggy/wiry.

Treatment:

  • Left: (J) LV-4, (J) LU-5, Linggu, Dabai, Zhongbai, SI-4, Houzhu, UB-65
  • Bilateral: TI-10
  • Right ear: Lumbar Spine, Sciatic Nerve, Thalamus

Needle count: 13

Treatment #4

Cc: chronic low back pain      

Progress: The patient reports that following the last acupuncture session she got a great deal of relaxation and 3 days of relief of her pain. She reports that she overslept last night and that resulted in an exacerbation of her pain, which she reports to be at 8-9/10 currently. She additionally reports more pain than usual in her right hip. No other changes were reported. Tongue is red, peeled front, center crack, shaky, deviated left, thick greasy yellowish coat in back. Right pulse is slippery, choppy and full while the left pulse is soggy & choppy. Positive Oketsu sign.

Treatment:

  • Left: (J) LV-4, (J) LU-5, Linggu, Dabai, Zhongbai, SI-4, Houzhu, UB-65
  • Bilateral: TI-10
  • Right: GB-34, GB-40

Needle count: 12

Treatment #5

Cc: chronic low back pain      

Progress: The patient reports that following the last acupuncture session she got a great deal of calm which “lasts & lasts,” and she reports not getting as nervous as before. She also has an average of 3 days of relief following acupuncture treatment. She additionally reports that she had frustration over her driver today resulting in an exacerbation of her pain which she reports to be at 8/10 currently. No other changes were reported. Tongue is pale-red, peeled front, center crack, deviated left, thick greasy yellowish coat in back. Right and left pulses are slippery/full. Positive Oketsu sign.

Treatment:

  • Left: (J) LV-4, (J) LU-5, Linggu, Dabai, Zhongbai, SI-4, Houzhu, UB-65
  • Bilateral: TI-10
  • Right: SI-3, UB-65

Needle count: 12

Note: Her pain level dropped to a 3/10 during the treatment session.

Treatment #6

Cc: chronic low back pain      

Progress: The patient reports that following the last acupuncture session she got, “the longest relief ever of four days.” Then, she experienced grief over the loss of two close friends and she realized that it had a corresponding effect of increased pain the next day. Today she rates her pain a 4/10 in the right lumbosacral area. No other changes were reported. Tongue is light red (and therefore less purple than at the start of this course), slightly deviated to the left, peeled front, thick white coat in back. Right pulse is thin and slippery, left pulse is wiry/slippery. Positive Oketsu sign.

Treatment:

  • Left: (J) LV-4, (J) LU-5, Linggu, Dabai, Zhongbai, SI-4, Houzhu, UB-65
  • Bilateral: TI-10
  • Right: SI-3, UB-65
  • Right ear: Thalamus
  • Left Ear: Lung x2

Needle count: 15

Treatment #7

Cc: chronic low back pain      

Progress: The patient reports that following the last acupuncture session her lower back pain had been, “very low,” at 2/10 today but as high as 7/10 during exacerbations. She recently experienced tooth pain in the upper left jaw and she felt as if it caused her lower back pain to increase. She also reports that her “right eye is intermittent,” (it looks bloodshot and is discharging tears currently).    She further states that she’s been having “five-palm sweating,” and waking at 1:00 a.m. No other changes were reported. Tongue is light purple, peeled front, thick yellow coat in back, cracks. Right pulse is soggy, left pulse is soggy/full. Positive Oketsu sign.

Treatment:

  • Left: (J) LV-4, (J) LU-5, Linggu, Dabai, Zhongbai, SI-4, Houzhu, UB-65
  • Bilateral: TI-10
  • Right: GB-34, GB-40
  • Right ear: Liver Yang 1&2, Liver, Spleen, Thalamus, Sciatic Nerve

Needle count: 18

Treatment #8

Cc: chronic low back pain      

Progress: The patient reports that following the last acupuncture session she got four days of 0/10 pain with high activity levels and no pain in her tooth since. Today she reports lower back pain on the right at 4/10 as well as a likely infected right eye (it’s now swollen, bloodshot and seeping yellowish exudates from the inner canthus). No other changes were reported. Tongue is red, peeled front, thick dry white coat, cracks, only very slightly deviated to the left. Right pulse is full, slippery while the left is full and soggy. Negative Oketsu.                    

Treatment:

  • Left: Linggu, Dabai, Zhongbai, SI-4, Houzhu, UB-65
  • Bilateral: GB-37
  • Right: LI-4, LV-3
  • Right ear: Eye x2, Thalamus
  • Left ear: Hip.C, Lumbar Spine, Thalamus

Needle count: 16

Treatment #9

Cc: chronic low back pain      

Progress: The patient reports that following the last acupuncture session she “didn’t have a lot of pain until I did something yesterday to bring it back.” Today she rates her right lower back and hip region pain at 5/10. She additionally reports that her bowel habits have improved considerably. No other changes were reported. Positive Immune sign.                

Treatment:

  • Right ear: Lumbar Spine x2,, Hip.C, Liver, Thalamus, Sciatic Nerve
  • Bilateral: TI-10
  • Left: Linggu, Dabai, SI-4, Houzhu, UB-65, Sanchasan

Needle count: 15

Treatment #10

Cc: chronic low back pain      

Progress: The patient reports that following  the last acupuncture session she had pain relief lasting until yesterday, when she did some activity that exacerbated her pain. Today she reports a pain level of 5-6/10 in her right lower back area. She also reports that her right eye is, “up and down.” No other changes were reported. Negative for Oketsu and Immune. 

Treatment:

  • Bilateral ear: Thalamus
  • Bilateral: KI-3
  • Left: Linggu, Dabai, SI-4, Houzhu, UB-65

Needle count: 12

Results

The patient reports feeling “much better than before the acupuncture.” She believes that this course of treatment is successful because her pain level decreased and her ability to function increased. 

This is a very typical kind of patient who gets a measure of relief from acupuncture treatment for her chief complaint for a limited amount of time. In Isabel’s case, the best pain relief we rendered was 4 days at 0/10 pain. One thing that clearly keeps the patient from getting better more rapidly is the fact that the patient ends-up re-injuring her back before the next acupuncture treatment. Proper body mechanics are basic life-skills that many of us don’t learn until it’s too late. The author has educated the patient on modalities such as Feldenkrais and Physical Therapy in order to learn techniques that will help her to prevent a recurrence of pain.

Discussion            

The case study form of research offers some strengths and weaknesses. Case studies tend to be more qualitative in nature when compared to the more quantitative forms of research such as the random-controlled double-blind study. Most proponents of the case study form agree that it allows for more detailed information than can be found in a statistical analysis. Statistical methods can effectively deal with situations where there is an isolation of variables (such as one specific drug versus a placebo) or where behaviors are more routine or homogeneous. Acupuncture is rarely delivered this way in reality and takes a personalized approach to patient care. As practitioners of Acupuncture, we craft a custom formulation of acupoints to use in any given treatment and we necessarily change the prescription to meet the patient’s changing needs. This approach, while useful in clinical practice, creates some difficulty for researchers attempting to use the randomized double-blind model.

Those who criticize the case study method usually do so on the basis that it is unable to generalize due to its highly subjective standpoint. On the surface there is a lot of truth to this statement. Detractors claim that the data produced is therefore not valid and reliable. Should we not consider the difference between quantitative and qualitative works for a moment? Could we not come to the agreement that a case study model, although perhaps not “valid and reliable,” could very well be considered credible and confirmable? The author believes that the distinction needs to made that qualitative is not quantitative in nature and therefore should not be judged by the same standards. Perhaps it is a bit unjust to criticize a model for not doing something that it was never designed to do in the first place.

In treating so many patients with chronic lower back pain, the author has come up with a protocol that seems to work quite well. The point combination is found delivered to the above patient on the left side of her body (the “healthy” side, as the patient’s pathology lies on the right side). The points are: Linggu, Dabai, Zhongbai, SI-4, Houzhu, and UB-65. This protocol is greatly informed by Master Tung’s school of acupuncture as taught by Five Branches DAOM instructor Dr. Wei-Chieh Young, as well as Dr. Richard Teh-Fu Tan (Young, 2008). Lingguand Dabaiwhich lie on either side of  LI-4 Heguwork for opposite-sided lower back pain. Zhongbaiworks for opposite side Gallbladder-channel pathologies (such as hip-region pain due to lumbar radiculopathy). These 4 points together are found in Dr. Tan’s “modified Pattern #1” of his “global balance technique.” (Tan, 2000). The modification to this protocol is made because the patient has (amongst other problems) lower back pain on the opposite side. Houzhuis Master Tung’s LV-3 point (located a bit more proximally than the standard location). SI-4 and UB-65 are the standard locations. Dr. Young likes to use UB-65 instead of the more popular UB-62 because of its qualities as a Shu-Stream point (Young 2008).

An adjuct to the above protocol is to do something on the affected side of the body as well. It is generally understood that auriculotherapy points are most effective if the affected side is treated (Oleson, 2003). In this case, the author used bilateral Thalamus points to help stop the pain signal from getting to the cortex of the patient’s brain where they can feel it as pain. If the signal stops at the Thalamus, it isn’t then felt by the patient. This is probably the most commonly used auriculotherapy point in the author’s clinic. Generally, the author’s clinical observation is that acupuncture treatments are more effective with a combination of body and auricular acupoints needled (each system seems to support the other, rendering a better overall outcome). 

As discussed in the Literature Review section above, the Oketsu protocol was delivered to this patient each time the sign was present. In this case, it took seven weekly treatments to clear the patient’s Oketsu. This fact, plus the advanced age of the patient, tells me that her healing potential is not very robust. After clearing Oketsu, the Immune sign started coming up (Matsumoto, 2002) which is interesting since the patient complains of long-standing digestive issues difficult bowel movements. During the course of treatment, these symptoms improved, even without focusing upon them. 

Conclusion

Isabel, our patient above, will likely experience a quicker recovery from her chronic lower back pain now that the practitioner has removed the underlying constitutional factor that was likely preventing her from getting well (Oketsu). The author wonders how much more acupuncture he would have had to give this patient before we started seeing results without addressing the Oketsu? The author suspects a lot longer and time is a luxury he doesn’t enjoy as an acupuncturist employed by a hospital. That could be the topic of another study. It is the author’s belief that in this case the Blood Stasis pattern was very significant but did respond positively to acupuncture therapy. Since the majority of his practice is around chronic back pain, it is good to know that he has learned powerful approaches to dealing with the multi-faceted and complicated cases that come into his clinic.

Although there seems to be a clear correlation between this patient’s chronic lower back pain and Oketsu, I believe that more research is warranted. The author would encourage anyone in the field to conduct clinical trials testing Oketsuin any chronic pain conditions as it now seems to me to be an underpinning factor in many cases. 

References

Ma, YT. Biomedical Acupuncture for Pain Management: In Integrative Approach. 2005. Elsevier, St. Louis, MO.

Birch, S. Zhong Yi Acupuncture and Low-Back Pain: Traditional Chinese Medical Acupuncture Differential Diagnoses and Treatments for Chronic Lumbar Pain

The Journal of Alternative and Complimentary Medicine, Vol 5, No 5, 1999, pp. 415-425

Furlan, AD. Acupuncture and dry-needling for low back pain. The Cochrane Review http://www.cochrane.org/reviews/en/ab001351.html

Flaws, B. Statements of Fact in Traditional Chinese Medicine. 2008. Blue Poppy Press Boulder, CO.

Matsumoto, K. Kiiko Matsumoto’s Clinical Strategies: In The Spirit Of Master Nagano, Vols I & II. 2002. Kiiko Matsumoto Int’l. Natick, MA.

Pullman-Mooar, S. Merck Manual Professional (online) http://www.merck.com/mmpe/sec04/ch041/ch041a.html?qt=treatment%20of%20back%20pain&alt=sh

Erstad, S. Healthwise Inc. Health Encyclopedia, Kaiser Permanente, 2008.

Young, WC. Lectures on Tung’s Acupuncture: Points Study. American Chinese Medical Culture Center, Rowland Heights, CA 2008.

Young, WC. Lectures on Tung’s Acupuncture: Therapeutic System. 2008. American Chinese Medical Culture Center, Rowland Heights, CA.

Oleson, T. Auriculotherapy Manual: Chinese and Western Systems of Ear Acupuncture, 3rdEd. 2003. Elsevier Science, London.

Tan, R. Dr. Tan’s Strategy of the 12 Magical Points. 2000. San Diego, CA.

Appendix: Practice Analysis

The hospital that employs the author keeps track of several metrics as a way to assess individual practitioners productivity. This data includes how many referrals were made per month and how many got the service (i.e. an acupuncture treatment), how many patients failed to keep the appointment), how long the patients had to wait to get service, etc. as well as patient satisfaction ratings by mail surveys. No information pertaining to treatment outcomes or even data pertaining to the practice of TCM is readily available through their electronic charting system.            Therefore it was necessary to find out about the author’s practice through research. He first decided on a timeframe: one year. Then, he picked the dates from which the study would begin and end. The author chose July 28, 2008 through July 28, 2009, the span of time corresponding to his 40thyear on this planet. Next, the schedules of every day that he was on duty treating patients were printed. Three of the days were half-days, otherwise they were a full 8 hours each. The Chief Complaint of each of these patients is recorded on the daily schedules. The author systematically tallied the number of treatments per Chief Complaint as well as the total number of treatments that day, double-checking the numbers on each page. He repeated this process for the 224 remaining days of treatments delivered that year. Then he proceeded to enter these totals into a Microsoft Excel spreadsheet, again, double-checking that he was correctly entering the data. Once the raw data was entered, another spreadsheet was created to analyze the data (a working copy). From this sheet, the author further extracted the answers he needed and charted the results, below.

Over the year of this study, 3294 treatments were delivered over 225 days at an average of 15 per day. The results of the individual Chief Complaint tallies, in percentages, are found in the table, below.

Lower Back 22.28%
Back13.15%
Neck11.72%
Spinal*47.15%
Chronic Pain11.45%
Fibromyalgia3.25%
Headache6.50%
Facial pain0.49%
Shoulder7.77%
Arm0.21%
Elbow1.91%
Wrist2.09%
Hand1.43%
Shingles0.36%
Hip3.10%
Knee5.34%
Leg1.00%
Groin0.15%
Sciatica0.76%
Ankle2.06%
Foot2.40%
Peripheral Neuropathy2.00%
N/V0.18%
Stroke0.18%
* Spinal is a combination of lower back, back and neck chief complaints
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The 12 Keys of Healing Holistically

Healing holistically is not exactly an intuitive process to the Western patient’s mind. I have come up with twelve “keys” that may help to increase your understanding of how holistic healing works.

1. People are an inseparable part of their environment and are affected by it in palpable ways.

Here I am referring to an expanded definition of “environment” to include not just your physical locale but also your diet, lifestyle, emotional life, family life, work life, spiritual life, etc.

In Chinese medicine, we assume that a human being has an internal clock, seasons, and weather patterns which reflect the time, seasons and weather patterns of the world. The external weather can affect our internal weather patterns and therefore, our state of health.

2. There are consequences to not living according to the laws of nature.

When we live according to the laws of nature then we will usually experience health and happiness because we can give ourselves what we need. This means eating properly, drinking enough water, getting enough rest, and protecting ourselves from experiencing extremes. When we subject ourselves to ideas that disregard the natural order, we put ourselves at risk of becoming imbalanced.

3. The body cannot be separated out from the mind, the emotions or the spirit.

This is the core idea behind the “holistic” approach. The word “Holistic” itself is one that comes from the word “whole.” This should give you a very good sense of how we look at the human body, health, and healing.

To say, “my problem is purely physical in nature,” is a false statement from the holistic viewpoint since the body-mind-emotions-spirit is a complete unit. Anything that affects one aspect of the whole necessarily affects all other aspects.

4. To stay healthy, one can choose to adopt moderation as a way life.

We are fond of saying, “moderation in everything, including moderation.” Which means that on rare occasions it may be okay to “go nuts” so long as you diligently apply moderation as the  general approach to your life. In holistic healing specifically, moderation is applied to one’s diet, lifestyle, work habits, pastimes, and to every aspect of one’s activities.

5. What we do or do not do in our lives has profound effects on our health and longevity.

It should be pretty clear to most readers that smoking cigarettes has the potential to dramatically shorten one’s lifespan. We can look at this from a much less obvious angle as well. In fact, I insist that my patients do so.

What is it in your lifestyle that is preventing you from getting well? Do certain activities exacerbate your medical condition? If so, why do you keep doing them? Or perhaps you know that there is something that you should be doing, such as eating well, but you just don’t for some reason. In my opinion there is no good reason to continue with behaviors that keep you from experiencing optimal health.

6. Medical conditions and diseases occur when a person becomes out of balance.

Balance, according the holistic viewpoint, means that there is health. Even small imbalances can, whether over time or instantaneously, create changes to one’s health. These changes are usually not welcomed ones. These changes are in fact the signs and symptoms of a medical condition.

Chinese medicine has long established norms for how the human “system” works while still acknowledging the potential for individual differences. It is our job as holistic practitioners to discover the roots underlying those signs and symptoms to help patients understand what lead to the imbalance, and to treat is using this understanding.

The treatments we use in Chinese medicine are always aimed at bringing a greater level of balance to an imbalanced patient. When performed well and with skill, these treatments result in healing and an increased sense of well-being.

7. Restoring balance requires changes on the part of the imbalanced person.

One of the definitions of insanity is doing the same thing over and over again while expecting a different outcome. If what you are doing doesn’t provide you with the desired outcome, I would encourage you to look outside of what you already know or have learned in order to seek a new approach.

Holistic healing can occur without the help of a medical practitioner but it cannot occur without the active participation of the patient. The more you “own it” and take action to change your condition, the more likely it is to resolve.

Also, active participation on the part of the patient often results in more rapid and complete healing. Generally speaking, there is no “magic bullet” which will quickly and easily cure the imbalances which lead to medical conditions.

8. Everyone is a unique individual.

Therefore, an individualized approach to healing is required for optimal results. No two people have the exact set of physical realities, experiences, mental capabilities, coping mechanisms, emotional life, education, income, locale, etc.

The way I see it, people are really more different than they are alike. We can certainly see that humans (usually) all have a set of similarities such as having body structures, ranges of motion, etc. However, to say that one person’s case of sciatica is the same as someone else’s is a false statement from the holistic viewpoint.

9. Human beings are complex creatures.

So not only are we all unique in significant ways, we are also very complex beings. Chinese medicine theory and practice allows us to look at the complex human “system” and see discreet patterns emerge out the apparent chaos.

It has been said that the typical Western patient with a chronic disease presents with multiple Chinese medical patterns at any given time, perhaps as many as 3-8 patterns simultaneously! Even for well-trained and experienced practitioners of Chinese medicine, these complexities create the inherent difficulties of practice. However, this difficulty is not insurmountable.

It is precisely because we can identify the complexities in any given case that we can make progress in some cases which have not previously responded to other medical modalities or practitioners. Breaking-down the complexities in any individual is a part of the art and science of Chinese medicine.

10. Complex problems are not commonly solvable with simple solutions.

A good example here might be the American economy. What is the problem with the economy? Is it unemployment? Is it outsourcing to foreign countries? Are the corporations to blame? Is student loan debt to blame? Perhaps the American workforce is too lazy or works too much? What is it that explains the deficiencies in our economy?

The answer is probably all of these factors and many others which weren’t mentioned. You see, this is a complex subject. No one single solution like “forgive student loan debt” will solve the complex set of issues involved. This is as true for Chinese medicine and holistic healing as it is for any other discipline.

11. People have a great capacity for self-healing.

This is a greatly under-appreciated fact of the human experience. Perhaps the erosion of the virtue of patience is to blame, I don’t know. I think that in our society, we have some idea that every solution can and should be instantaneous. For problem “x” take substance “y” and get the result right away.

This turns out to be frustratingly inaccurate when we are talking about healing holistically. One could say that to heal holistically is to heal at the speed of one’s body-mind-emotion-spirit. That is to say, everyone heals at their own rate and that usually it’s a gradual process.

Nevertheless, the human “system” can heal itself and does so every day. Have you ever gone to bed with a headache just to awaken the next day without one? That is you healing yourself. Perhaps you have heard (as I have) that everyone will at some point in their life have developed some cancer cells. To the best of our current understanding, this is a truth. Then why doesn’t everyone succumb to cancer?

The reason is that we are equipped with the capability to deal with cancer cells when they crop up. The problem with cancer (as a medical condition) begins when the person’s self-healing capacity is overwhelmed with the development of cancer cells (for whatever reason). It is then that tumors develop and put the health and longevity of that person at risk.

So long as the person has balance and a moderate lifestyle, they can often deal with these events without extreme outcomes, often without realizing that they are doing so.

12. Sometimes people get stuck in the process of self-healing and need a “push” in the right direction.

Even though human beings enjoy the ability to self-heal (as I have just discussed above), it is not a guarantee that we can heal completely from every medical condition without engaging some outside help.

Your body, mind, emotions, and spirit may very well already be on the job trying to resolve symptoms and in making a serious attempt to restore balance to your system. Unfortunately, we can get “stuck” in this process. Often all it takes is a little push to tip the scales in favor of self-healing.

Chinese medicine treatments such as herbal medicine and acupuncture can help to increase the patient’s self-healing capacity enough to allow their own systems to take over and complete the healing process.

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Ways of Delivering Acupuncture

Patients in my clinic are sometimes confused by the fact that my style of treatment often doesn’t match that of acupuncturists they have seen previously. This is a natural response. I like to say, “There are as many ways to practice acupuncture as there are acupuncturists.”

One of my beloved (now deceased) professors of Traditional Chinese Medicine in Santa Cruz used to say, “There are many ways to get to San Francisco. You can take Highway 1… beautiful! You can take Highway 280 or you can take Highway 101. Just don’t drive South!”

To me, this was her recognition that practitioners will always have their own approach to medicine and so long as they adhered to the basic principles of the medicine, they could still achieve good results.

I find myself in an interesting position working in a hospital setting. I am expected to help chronic pain patients using only acupuncture tools in a short course of treatment. Many of my patients have intractable conditions and other complicating factors.

Traditionally, acupuncture is not used as a stand-alone therapy and outside of hospital settings is often combined with other modalities such as herbal medicine, therapeutic massage, etc. Achieving results in this setting can be difficult considering these factors.

One way I have been able to improve the outcomes of my acupuncture patients is to seek out lots of training in acupuncture traditions specific for chronic pain management. I have developed a specialty in Chronic Pain Management through my clinical experience and through the doctorate program I finished in 2011.

I have tried to seek out the very best chronic pain acupuncture techniques, including Traditional Chinese Medicine style, Master Tung’s Acupuncture, Richard Tan’s Balance Method, Zhu’s Scalp Acupuncture, Kiiko Matsumoto style, and auriculotherapy. I use these approaches in combination to render the best possible effect and the longest-lasting relief.

In general, acupuncturists have a number of approaches available to them in the delivery of acupuncture. It’s not just one homogenous thing. We may choose local acupuncture points – points at or nearby areas affected by pain. This is also known in some circles as “trigger-point therapy,’ or “dry-needling.” It is certainly a legitimate way of delivering acupuncture but certainly not the only or even the best way, in my professional opinion.

Distal acupuncture is another way in which the acupuncturist chooses points which are far away from but somehow connected to affected areas. These protocols have a tendency to work not just on the symptom itself but also the patient’s constitution. Therefore, we have a greater potential of rendering lasting changes in a patient’s chronic condition when we use distal points (more so than with local acupuncture).

There are also “micro-system” acupuncture protocols.  It is believed that certain areas of the body (such as the auricle of the ear, the hand, or the scalp) are a complete areas the treatment of any area of the body.

In auriculotherapy (one of my favorite approaches), there are hundreds of points in the auricle of the ear which correspond to musculoskeletal structures, internal organs, the endocrine system,  the nervous system, and for specific conditions. We can deliver an entire and complete treatment protocol using strictly ear points and often render very good results with this approach.

Of course every patient is unique and techniques that work in one case (or in the same case at a different time) will not always render the same results. A part of my work as the acupuncture provider is to discover which approaches and protocols are the most useful for any given patient at any given point in time.

To complicate matters further, human beings are extremely adaptable. Any stimulus which is provided to a person (such as acupuncture needling) will lose its effect over time. Needling the same points over and over renders less and less effect.

Therefore I must remain flexible in my approach to any case. I am in the habit of changing approaches with each treatment session while always addressing the chief complaint and attempting to “tease out” the best effects. The result of this approach is to render longer-lasting and more complete relief in a short course of treatment.

It is not uncommon for me to choose different approaches at each treatment session for each patient. There are many ways to approach back pain as an example. To do so, I may do one treatment session with body-points at distal locations, another with local points, and another with strictly ear acupuncture points, and a fourth combining body and ear acupuncture points.

I sometimes combine local acupuncture points with electrical stimulation as well. Again, electro-acupuncture is not a requirement to achieving good results in every case. I must experiment a bit for each patient to discover which treatment approaches will be optimal.

Patients should feel free to express results that other acupuncture providers have rendered in their cases as this is useful information for me to take into account. I can’t guarantee that those approaches will be what I perceive as what is best for your case at this time. If those approaches turn out to be replicable in my clinic, then I am more than happy to adjust my approach to provide you with what works best in your case.

Keep in mind that what may ultimately be best for you could be something which you have yet to try. All I would ask of my patients is to keep an open mind and to show up for treatment. If you can do that, we’ll know sooner rather than later what is and is not working for you.

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Monkey Metaphor

I want to share with you a metaphor that I have crafted. I created this metaphor to assist my patients in their process of healing with Chinese medicine. The metaphor is in the form of the short story, below.

Not long ago, there lived a young monkey in a lush green forest. The forest was so popular with the local animals that there were many monkeys living in there. Food and other resources were becoming scarce.

One day, the young monkey spotted a ripe and delicious looking peach at the very top of a tree. She jumped up into the branches of the tree and started to climb. Up the tree she worked her way toward the fruit but soon realized that she was getting to where the branches were too thin to support her weight.

She pressed on anyway and before reaching the fruit, the branch supporting her snapped and she fell. She caught her self on another branch and regained her footing but decided to climb back down the tree, thinking the fruit out of reach.

When she had reached the ground, she saw that there were several other young monkeys watching her attempt to attain the fruit. They all laughed and called the young monkey “clumsy” and “stupid.”

The young monkey became quite frustrated since now she had not only failed to obtain the peach but she had also humiliated herself in the attempt. The more she thought about that beautiful peach, how sweet it would be, and how much she desired it, the more unhappy she became.

So, she went to her mother and sought guidance.

“Mother, how can I become less clumsy?”

The monkey’s mother thought about this question for a moment.

“If you can follow me and mimic my every move as we race through the forest, I think it could help you become more dexterous,” mother monkey said.

The young monkey agreed and the mother monkey sped off into the forrest, swinging from branch to branch and tree to tree, while the young monkey followed her every move.

Finally, both monkeys finished their race and fell together in laughter onto the forest floor. The young monkey realized that she could easily follow her mother and make all the same moves, naturally. She discovered that she was no longer feeling so frustrated.

Feeling better but still somewhat uncertain of herself, she decided to go find her father.

“Father, how can I become less stupid?”

The father monkey, knowing very well that the young monkey was actually quite bright, said nothing for a short while, looking up and to the right for a few moments.

“What runs but never gets tired?” he asked.

The young monkey paused for a moment to think about the question.

“A riddle?”

She asked as a smile spread across her face. The look of realization lit her face and she answered, “it’s the stream! It seems to run on and on, ever moving yet ever staying the same.”

“That is correct and a very smart answer indeed for I could not have given a better answer myself!”

The young monkey smiled widely and no longer felt unhappy.

By this time it had become late so the young monkey settled down to sleep. That night she had very vivid and colorful dreams of the peach – she saw it at the top of the tree and in her dream, took a silly flying leap to the top, snatched the peach from the branch, then landed softly on the other side of the tree.

She looked at the peach in her hand just before taking a big juicy bit out of it. As he did, the sweet nectar spilled around her mouth and the tangy flavor danced upon her tongue. She took bite after bite in her dream until there was nothing left but the pit. When she awoke from the dream, she knew what she needed to do.

The next morning, the young monkey returned to the peach tree. This time, she knew how to succeed at the task. She climbed to the top of the tree… and…

The end.

I am interested to find out what you get out of this story. What is the message that I’ve encoded in this metaphor? Can you identify any individual symbols? Please leave your guesses and any comments you may have, below. Thank you for reading my monkey metaphor.