asking case analysis

[Guest guest]

Hello,

 

I am writing from the New England Journal of Traditional . We

have recently initiated a quarterly discussion forum which seeks to

interpret, diagnose and treat difficult cases. Therefore, I am including a copy

of the

case that was published in the last issue as an attachment for you to look

over and analyze. We are hoping that some of you may write back to us with a

creative, detailed and comprehensive analysis of how you would handle this case;

Including theory, diagnosis, treatment strategy, and course of treatment

(acupuncture, herbs, tui na, etc). Some of the most interesting approaches will

be

reviewed by our editors and published in upcoming issues of the journal.

 

I hope we will hear from you soon...

 

Thank You,

Bing Yang

Senior Editor, NEJTCM

 

 

 

 

New England Journal of Traditional

Volume III Number 3 Winter 2004

 

 

Seeking and Searching in the Apricot Forest

Report a difficult case: Lower leg weakness

Jose Ruiz

 

Time period: 8/24/04 - 11/09/04 (8 treatments)

Main Complaint: lower leg weakness resulting in difficulty walking for 3years

Secondary Complaints: Seizures, poor memory, stiff achy hands with

difficulty making a fist

Western Medical Diagnosis: unidentifiable motor neuron disease

Medications: Dilantin (anti-seizure) Phenobarbital (anti-seizure) Metoprolol

(regulate heart rhythm), Folic acid, enteric aspirin

 

Description of Condition by western medicine view:

Unidentifiable Motor Neuron Disease-. Motor neuron disorders are more common

among men and usually develop in people who are in their 50s. In most people

who have these disorders, the cause is unknown. In all of these disorders,

motor nerves in the spinal cord or brain progressively deteriorate, causing

muscle

weakness that can progress to paralysis. However, in each disorder, a

different part of the nervous system is affected. Consequently, each disorder

primarily affects different muscles and different parts of the body. In

unidentifiable motor neuron disease EMG and MRI studies find no pathological

abnormalities

occurring within the CNS and PNS, the only evident signs are the progressive

weakening of the limbs. Motor neuron disorders have no specific treatment or

cure. Physical therapy may help to maintain muscle strength and prevent

contractures.

Case History:

Main Complaint: A retired 64-year-old man diagnosed with unidentifiable

motor neuron disease in June 2001 at the Lahey Clinic, MA. MRI and EMG reveal

nothing abnormal. He complains of generalized lower leg weakness that reduces

his

ability to walk with ease. There is no pain, numbness, or tingling, the

weakness and heaviness are primarily in his left leg, with some in his right

leg.

His legs feel very heavy and weighted down, requiring him to be careful and

deliberate when stepping off curbs or navigating stairs (especially when

carrying

bundles). He walks with an unsteady gate, appearing slightly off balance, and

needs to support himself when standing on one leg. His legs show no signs of

atrophy or flaccidity, although there is a significant decrease in his ability

to raise the toes on his left foot and perform left legged calf raises;

though his right leg is not affected. The erector spinae group (especially low

back) is typically hard and contracted on palpation and he experiences

tenderness

in his left buttock around the piriformis muscle. The condition is not

affected by weather. He thinks that it has gotten progressively worse, although

timed measurement of his walking speed/distance has not changed.

 

Other History: Grand mal seizures since 12-13 years old, which began

suddenly, with no emotional or physical trauma as a trigger. He experienced

episodes

once every 4-5 months, and has been taking Phenobarbital and Dilantin to

control the frequency. History of sweating profusely during the ages of 20 -30

Angioplasty procedure in May 2000 to treat cholesterol build up causing 98%

blockage of coronary arteries. Difficulty with short-term memory.

 

Chills/Fever/Sweat: Experiences dry mouth, with little to no thirst, and no

preference for hot or cold beverages.

 

Observations: He appears to be a fit 64-year-old, with no overt signs of

illness; his shen and demeanor are vibrant and calm. His fingernails and

toenails

have been brittle, striated, yellow, and dry on the right hand and both feet

for over 20 years. Doctors claim it to be a fungus, but he refused to take

oral meds for fear of damaging liver.

Appetite: His weight has gone from 260 lbs to 218lbs. Within the last year he

has lost 42 lbs using the South Beach diet (low carbohydrate high protein),

and would like to get to 190 lbs. He has no issues with digestion, and

typically drinks 3 glasses of water and 2 glasses of wine per day.

Stool/Urine: He has 1-2 bowel movements per day, which are soft and full

formed. In the past he has had difficulty passing stool with an incomplete

sensation. He urinates 5 times per day and 1-2 times per night, and the urine

color

is light yellow

Sleep/Energy: Sleep is plentiful and sound usually lasting 8-10 hours per

night. Naps are taken everyday, and have been part of his routine since he

retired. An energy drop occurs around 4-5 pm, rendering him done for the day.

He

tries to maintain a cardio/weight gym routine 2-3 times per week, although the

leg weakness reduces his activity and leads to tiring easily.

Pulse: slow, slippery, right side soft,

Tongue: pink, thin slightly yellow tongue fur, thicker in back, thinner up

front, with less fur on the tip and sides.

He had no symptoms of headache, tinnitus, blurry vision, chest pain or

tightness, shortness of breath

 

Pattern Differentiation:

SP & ST vacuity leading to Yang Ming channel vacuity- general muscle

weakness, weak and heavy legs, difficulty walking, unsteady gate, low energy,

need for

naps, tires easily, slippery vacuous pulse, pale tongue

SP vacuity with dampness- History of being overweight, dry mouth without

desire to drink, frequent naps since retired, low energy, slippery pulse,

thicker

tongue fur in rear, and weak and heavy limbs

LV Blood vacuity leading to internal wind- seizures, dry, brittle, yellow

nails, weak limbs, unsteady gate, difficult walking

 

General Treatment Strategy: Supplement spleen and stomach, nourish yang

ming channel, nourish liver blood and kidney yin, nourish sinews

 

TX#1-TX#3 ST-36 (zu san li), SP-6 (san yin jiao), KI-3 (tai xi), LR-8 (qu

quan), guan yuan (CV-4), GB-34 (yang ling quan), and GB-39 (xuan zhong).

TX#4- Nourish sinews, enrich yin and blood, move qi in lower extremities-

BL-23 (shen shu), M-BW-35 (huato jiaji) (L2-L5), BL-25 (da chang shu) - BL28

(pang guang shu) with electro-acupuncture, BL60, GB34, GB39

Results: Throughout the course of treatment there have been no sustainable

positive results. The patient claims there has been no change either for worse

or better.

 

TX#5- Open GB & GV channels, nourish yin and blood

GV-2 (yao shu), GV-3 (yao yang guan), GV-20 (bai hui), M-BW-35 (huato jiaji)

L2-L5, GB-25 (jing men) - GB-26 (dai mai) with electro-acupuncture, TW-5 (wai

guan), GB-41 (zu ling qi), BL-18 (gan shu), and BL-23 (shen shu).

 

 

TX#6- Open Du Mai and Dai Mai channels, unblock GB channels, nourish sinews

GV-2 (yao shu), GV-3 (yao yang guan), M-BW-35 (huato jiaji) L2-L4, TW-5 (wai

guan), GB-41 (zu ling qi), GB-34 (yang ling quan), and GB-39 (xuan zhong).

During treatments # 5 and #6 there was an increase in energy, which was

measured as a decrease in the need for naps. Treatment strategy changed to

facilitate movement of qi through Dai and Du Mai to allow the body the

capability to

nourish Yang Ming channels

TX#7- Move qi and blood in GB channel, supplement yin, strengthen legs

GB-39 (xuan zhong), GB-31 (feng shi), GB-34 (yang ling quan), M-BW-35 (huato

jiaji) with moxabustion L2-S1, BL-57 (chengshan), Lt BL-36 (cheng fu), and Lt

BL-60 (kunlun).

After taking the month of October off for a cruise vacation, he returned with

the perception that his condition had degenerated, stating that he had a lot

of difficulty while on the cruise. We believed this was so because of a

significant damp component and moved to resolve dampness in treatment #8.

TX#8- Move qi and blood, resolve dampness

SP-09 (yin ling quan), ST-40 (feng long), ST-36 (zu san li), CV-12 (zhong

wan), SP-6 (san yin jiao), ST25, Lt M-LE-8 (ba feng)

Thought:

Infrequency of treatments decreases progress, desire for quick results leads

to unrealistic expectations, resistance to taking Chinese herbs for fear of

negative drug/herb interaction.

Asking for help : Anything inappropriate in the treatment strategy so far?

How to differentiate [the patterns] and select points for this case? How long

before we should to expect the case get better? I welcome any experienced

practitioner to give us suggestions.