GERD/ Acid Reflux Case Study
Chief Complaint: "Acid Reflux"
Patient is a 58 year old male, successfully coming off of Omeprazole which he had been taking for 5 years.
Brief Synopsis Of Initial Examination/Interview
The patient reports 5 year history of “acid reflux” treated by primary care physician with Omeprazole. The patient came to the visit desiring to come off of Omeprazole. Pt. reports if he does not take Omeprazole that he will experience a strong burning sensation in his “stomach” after eating and occasionally in his throat up waking. Pt. reports difficulty eating or drinking acidic foods. Pt. alerted his primary care that he wished to come off of omeprazole which his primary care physician agreed to.
On inquiry patient reports history of stressful lifestyle which he has changed in recent history. On inquiry patient denies belching, constipation, or loose stools.
Tongue: Large, Puffy, Scalloped, White coat – peeled near tip.
Pulse: Wiry, Moderate force and rate. Deep and weak in 3rd positions.
Dx: Wood overacting on Earth (Chronic Liver Qi Stagnation leading to Spleen Qi deficiency and Stomach/heart yin deficiency)
Txt Plan: Tonify Spleen/Stomach Qi and Yin, Regulate Liver and Stomach Qi, Clear heat as necessary.
Expect some level of rebound acid reflux within first 2 weeks, address as needed.
(The diagnosis and treatment here simply refer to chronic stress and pent up emotions leading to a lack of peristalsis in the digestive tract allowing for acid to build up and eventually where at the lining in the upper Stomach and esophagus. Treatment aims to absorb acid, strengthen the digestive organs, restore proper peristalsis, and assist in the healing of the lining of the digestive tract. )
Herbs Dispensed In Granules
(1g granules is equivalent to approx. 5g of raw herbs)
Herbs Dispensed For 7 days
6 grams, 2x Day in Warm water
Hai Piao Xiao 18g
Dang Shen 12g
Bai Zhu 12g
Shan Yao 14g
Mai Men Dong 14g
Fo Shou 9g
Zhi Gan Cao 7g
1. The patient reported no incidence of Acid Reflux after eating however the past two days reported some burning upon waking. Pt. reports that bowel movements seem to have become more regular.
Patient given a refill for two weeks to be taken 6 grams(scoops), 2 x day. Minor changes were made in the individual doses of the herbs and 8g of Huang Lian were added to the total amount over 1 4 days.
2. At the next visit the patient reported very rarely having some brief and mild stomach pain, not really worth mentioning, as well as zero pain in his throat. Pt. given refill, Bai Zhu switched to Chao Bai Zhu.
3. Patient reported continued absence of pain over the next few visits and continued taking herbs. After time the peeled area of his tongue coating heeled and no longer appeared raw, although a mild indentation/scar could still be seen. The dosages of Hai Piao Xiao and Huang Lian were reduced as symptoms stabilized. Treatment of this issue continued for 4 months during which the patient worked on developing better lifestyle choices to prevent a re-occurrence of GERD.
Patient: M, 28
Treated at Oakland Hills Acupuncture & Integrative Medicine by David Heron L.Ac
Chief Complaint: Chronic Knee Pain
Patient is a 29 year old male whose original chief complaint of chronic bilateral knee pain. Pt. is currently pain free and does occasional follow up treatments for health maintenance.
Brief History taken at patient’s first visit in July 2014:
Pt. complains of bilateral knee pain. At it’s worse the pt. reports pain can be a 10/10 as it often wakes him up at night. As per patient the pain can vary from achiness to including some sharpness at times. The pt. reports that the pain feels as if it is inside of his knees. The pt. reports history of the pain for a few years growing worse with time. The patient believes that the pain is due to standing on his feet all day working and playing a few hours per week (4-7 hours) in amateur soccer leagues. The patient has been taking Glucosamine and Chondroitin supplements for a few months with out any pain relief. The patient is considering quitting soccer as the pain has begun to be somewhat unbearable, particularly at night.
On examination the pt. presented with almost negligible swelling below the patella. The pt. tested negative during all orthopedic exams for structural damage to the knee, it’s ligaments, and meniscus.
Pt. appears to be in apparently fine health besides the chronic knee pain. The pain seems to stem from daily strain placed on the knees by standing all day and competitive soccer. Besides the short term goal of pain and inflammation reduction
General Treatment Regimen: Points around the knee and patella were needled bilaterally (see video and photos). Electrical Stimulation(E-Stim) was applied to some of these points for approx. 25 – 40 minutes. E-stim consisted of Mixed Mili-amp frequencies(5 – 20 minutes) followed by Mixed Micro-current frequencies typically of 15 & 4 Hz. (10 – 25 minutes). Infrared heat was also applied to the knees for approx.. 35 minutes each visit.
Acupuncture pt’s elsewhere on the body were used based on the patient’s Chinese medical pattern presentation.
Prognosis at initial visit: Pt. was told to expect results after 4 – 6 visits. As the patient was planning on continuing to play soccer during treatment which would continue to irritate the knee, room was left for varying response time to treatment. Due to the patient’s age, healthy weight and overall health a positive prognosis seemed likely.
1. The patient reported at the 2nd visit one week later that after the first visit his legs felt “fresh and energized” after the first treatment and that he played soccer that night. Overall the pain had reduced to a 2/10, and the patient was able to sleep through the night.
2. Patient reported continued improvement over the next 4 weeks despite suffering some direct trauma to his knees while playing soccer. Pt. decided to temporarily stop treatment. Pt. was instructed to come back in if the pain started to return as after 4 visits it was too soon to know if the effect had been consolidated.
3. The patient returned 3 weeks after stopping as the pain was starting to return. The patient stopped after 2 visits as the pain had gone away completely and I felt there was a good chance that the effect would be more permanent. The pt. was recommended to use a Chinese Herbal Liniment before and after playing and to come in for acupuncture in possibly a month for maintenance.
4. The patient now comes in approx. every 4 - 6 weeks., often time with no pain, simply as part of a health maintenance routine and to “freshen” up his legs before big games. At one point the pt. was suffering mild pain and was interested in taking Chinese herbs. The pt. was given Du Huo Ji Sheng Tang which resolved the pain after a few days.
CC: "Dysthymic Mood" "Irritation" "Anxiety"
Treated At Oakland Hills Acupuncture & Integrative Medicine
Patient is a 39 year Old Male successfully being treated for slight depression and irritation. Patient reported initial improvement which later tapered off. However, by the 3rd visit the patient began to experience marked improvement in his mood. Patient’s formula is modified every few weeks-months to maintain effectiveness and to address the normal fluctuations in his overall health presentation.
Brief Synopsis Of History Taken At Initial Visit:
Patient reports lifelong mild and chronic social anxiety, that has never been treated. Within his adult life the patient reports feeling “dysthymic”, or suffering from mild but chronic depression manifesting in this cases as a limitation on the amount of joy that the patient feels. The anxiety and dysthymia are complicated by chronic work stress. The patient works as a medical doctor in the ICU of a northern California hospital. The patient reports that along with the understandable stress of the job the patient becomes severely irritated with some of his more career-oriented as opposed to patient oriented colleagues. The patient reports keeping this irritation inside due to a general tendency to avoid confrontation and for professional reasons. The patient feels that his symptoms do not warrant prescription medication, although he would be eligible given current practice trends.
Patient denies palpitations or any physical symptoms with anxiety. Patient sighs and reports some physical tension due to stress and irritation.
Other notable symptoms include:
-Constipation with stress, alternating with loose stools
-Poor Sleep, with trouble settling down at night
-Chronic headaches (2-3 x weekly, treated with ibuprofen)
-Frequent colds in the winter
-Chronically feeling cold
-Low back pain
Pulse: Large vessel on palpation, pulse felt only with pressure. Pulse had moderate force, with mild fluctuations in force and therefore overall form (slightly choppy)
Tongue: Pale, Very thin Coat, Very thin central crack, no distended sub-lingual veins
Patient was given Gui Pi Tang, modified to address Qi stagnation, in granules
1. After 3 weeks, the Pt. initially reported a noticeable and pleasant effect from the herbs though subtle. Reporting his mood to be more even. Although the patient did report that the effect was not as pronounced in the last few days, but expressed uncertainty if this was true or not. The patient was given another 3 weeks of the same formula along with Jin Gui Shen Qi Wan in pill format to take when the patient went out in cold weather (winter).
2. At the next visit, 3 weeks later the patient reported a marked improvement in body temperature taking the Jin Gui Shen Qi Wan pills. The patient reports being able to feel comfortable in the cold whereas he was often colder than other people. The patient reports that he stopped taking the granular herbs for a few days to test whether or not they were of benefit, and upon taking them again definitely noticed a difference and therefore desired to continue treatment.
While positive effects were being seen, greater benefit was desired on part of the practitioner and the patient therefore a new granular formula was derived. On inquiry the patient reported that the main issues he wished to address were “Dysthymia” and “Irritation”.
The patient was given the following in granules
7 Scoops (grams), 2 x Day
Total Daily Dosage of Granules (Each gram of granules is approx. equivalent to 5g of raw herbs)
Zhi Huang Qi 1.5g
Gan Mai Da Zao Tang 2g
He Huan Pi 2.5g
Suan Zao Ren(Chao) 2g
Long Yan Rou 1.5g
Gou Teng 2g
Yuan Zhi 1.5g
3. Patient reported a marked improvement with this formula. The patient reported feeling a bit more “emotional pep” . The ability to experience positive emotions had increased slightly, as per patient. The patient also used the herbs to give him clarity in the morning before work, noting that his morning dosage was the most important.
The patient was left on this formula for approx. 6 months. Aside from mood the patient did see some improvement in energy level, night sweats, elimination (more regular), etc.
After 6 months, on inquiry from the practitioner as to whether the herbs had dropped of in their effectiveness the patient replied yes. At all visits before this, the patient reported generally doing well. The patient’s overall health was re-assessed. At that point irritation and constipation were primary symptoms. The patient also reported cloudiness in the morning which was difficult to shake off.
The patient was given the following formula in granules:
7 Scoops (grams), 2 x Day
Total Daily Dosage of Granules (Each gram of granules is equivalent to approx. 5g of raw herbs)
Huang Qi (Sheng) 1.5g
Ling Zhi 1g
Bai Ren Shen 1g
Fu Shen 1g
Yuan Zhi 1g
Shi Chang PU .5g
He Huan Pi 1g
Bai Ji Li 1.5g
Yu Jin 1g
Mei Gui Hua 1g
Dang Gui (jiu) 1g
Mai Men Dong 1.5g
Wu Wei Zi 1g
4. After 2 weeks on the previous formula, the patient reported that “he liked the way he felt” on these herbs. Patient reports more energy, less constraint. Constipation had subsided and he was regular.
The patient has continued to take herbs, reducing the dosage to once per day unless he feels 2 doses are needed. Herbs are changed periodically. Pt. has been able to avoid taking prescription psych medications.
Chief Complaint: “Sinus Infection” followed by possible “Ear Infection”
Treated at Oakland Hills Acupuncture & Integrative Medicine
Patient was successfully treated for acute sinus congestion and pressure and then ear pain with herbal medicine.
Brief Synopsis Of History Taken At Visit: Patient reported 4 day history of nasal discharge, facial pressure, and chest discomfort. Pt. reports that the pain began after water became trapped in his ear while swimming. As per patient, nasal discharge is yellow, profuse. Pt. also reports productive cough with phlegm. As per patient, there is pressure in his cheeks and temple. Pt. also complained of ear pressure as well. Pt. reports a history of getting sinus infections, which were treated with antibiotics in the past.
Pulse: thin, choppy (in rate. arrival)
Tongue: Large, Moist, no coat, pink/red in color, puffy sides
-Herbs Are Granules Of 5x Concentration
8 Scoops, 2 x Day for 3 days(1g of granules approx. equals 5g of raw herb).
Total Daily Granule Dosage
Cang Er Zi San 7.333g
E Bu Shi Cao 1.333g
Chai Hu .666g
Huang Qin 1.666g
Huang Lian .333g
Chuan Xiong 1.333g
Zhi Shi 1.333g
Jie Geng 1.333g
Yi YI Ren 2.666g
Zhe Bei Mu 1.333g
Ling Zhi .666g
Sheng Jiang .666g
Zhi Ban Xia .666g
1. Patient came in for a follow up visit 3 days after the initial visit. The patient reported that while his frontal sinuses had improved greatly that the ear pain and pressure had increased and the patient felt that he might have an ear infection on his left side. As per patient he is experiencing some hearing disturbance on his left side. Pt. reports L sided gum inflammation as well. Pt. is not feverish but tends to run warm. On exam, pt. has submandibular lymph nodes present, approx. 1 – 1.5 cm, soft, slightly tender.
Pulse: Wiry, Moderate Force
The following herbs were given in granules, and the patient was instructed to contact myself , his primary care, or ENT if the hearing problems worsened.
Herbs Are Granules Of 5x Concentration (1g of granules approx. equals 5g of raw herb).
10 Scoops, 2 x Day for 4 days
Total Daily Granule Dosage
Chai Hu .5g Xuan Shen 3g
Huang Qin (Jiu) 2g Sheng Di Huang 3g
Huang Lian 1.5g E Bu Shi Cao 1g
Long Dan Cao .75g
Ban Lan Gen 2g Bai Zhi 1g
Lian Qiao .5g Xin Yi 1g
Jin Yin Hua 1g
Shi Chang Pu 2g
Zhu Ru .75g
2. Patient came in 15 days later. Pt. reported that while taking the herbs as directed that the ear pressure, etc. had resolved except for the gum inflammation which the patient found out was due to a tooth that needed extraction.
Chief Complaint: Non-Bacterial Prostatitis
Treated At Oakland Hills Acupuncture & Integrative Medicine
The patient is a 36 year old male who was successfully treated for non-bacterial prostatitis. During the course of treatment the patient also experienced a reduction in anxiety.
Brief synopsis of history taken at initial visit: Patient reports pain/full sensation in the perineal area, pain and burning in the urethra, and pain with sexual activity. As per patient, the first symptoms began in August 2012 (2.5 years before this visit). These symptoms moved the patient to visit his Primary Care Physician as well as a Urologist. The patient reports having a urinalysis performed twice, each negative for white blood cells. Pt. reports that digital rectal exam was negative for a hard or enlarged prostate. Pt. reports normal PSA levels. The patient was given antiobiotics at least once for these symptoms over the last few years without any positive results. As per patient, the following information led his doctors to diagnose him with non-bacterial prostatitis. No further treatment seemed to be provided. The patient tried to treat the issues with yoga, which while improving his overall health, did not change the presenting symptoms.
Patient describes pain in his perineum as a “ball-like” sensation of pressure rating 6-8/10 on the pain scale. The patient also reports burning pain occasionally with urination as well as aching pain with sexual activity.
On inquiry, patient testing positive for any STI’s. Pt. also denies any blood in the urine, cloudy urine, or any exudate from the genitals.
The patient also reports being diagnosed with anxiety for which he has been prescribed Clonazepam PRN. However, the patient prefers not to take this unless it is absolutely necessary and would rather deal with the anxiety himself.
Other notable information from a TCM perspective:
-Pt. reports history of chronic sinus infections
-Pt. reports excessive sweating, esp. at night
-Pt reports history of eczema (very mild, chronic – skin currently dry with eczema on upper arms)
-Pt. reports low energy and libido
-Pt. reports history of oral lesions, especially when eating sweats
-Pt has borderline hypertension for which he is watching with his primary care
-Pt. currently constipated, however reports going very frequently before hand
-Pt. reports stress due to living situation
-Family history of diabetes type 1 and 2, Kidney disease, Heart Disease
Discussed diet with patient. Pt. reported eating poorly for years, especially with sweets. Pt. given dietary recommendations.
Pulse: Slightly rapid, thin, moderate force, slightly choppy
Tongue: Large, pale but with a red tip, thick coat particularly in the rear where it is greasy with many enlarged papillae (more so than normal)
Western/Modern Diagnosis: Non-bacterial prostatis
Chinese Medical Pattern(s):
Damp-heat (mainly in the lower burner/Liv & GB)
Chronic heat leading to yin and fluid deficiency
Heat harassing the Heart
Middle Burner deficiency with Dampness Accumulating (Although it is likely the root pattern for all problems due to poor dietary habits. It will be treated once main symptoms resolve.)
In TCM terms: Clear Heat, Dry Damp, Promote free flow of Urination
While protecting yin/fluids.
Chinese Herbs will constitute the primary treatment. If patients insurance covers acupuncture, pt. will add acupuncture, however herbs will still be the primary treatment.
The Following Herbs Were Dispensed For 10 days at which point a follow up visit was scheduled. Herbal Formulas Are Modifications of Ba Zheng San(Eight Herb Powder For Rectification Of Urinary Dysfunction) and Zhi Bai Di Huang Wan (Phellodendron And Rehmannia Pill)
Herbs Given In Granules
9 Scoops (grams), 2 x Per Day
Daily Granule Dosage. 1 gram(g) of granules is equivalent to 5 g of raw herbs.
Granules are put dissolved in hot water before drinking as a tea.
Zhi Bai Di Huang Wan 8.5g
Da Huang 1g
Bian Xu 2g
Bai Hua She She Cao 2.5g
Chuan Lian Zi 1.5g
Huang Lian .5g
Tian Ma 1.5g
1. At first follow up visit(10 days) the patient reported a reduction in perineal pain from 8/10 down to 2/10. The pain was still constant in nature. Patient also reported reduced frequency of urethral burning, reporting only 2 incidences since last visit. Pt. reports bowel movements had improved: almost regular and not excessively frequent. Pt. also reported a decrease in night sweats and in anxiety and stress. The patient received acupuncture along with a refill in the herbs dispensed last with only Chuan Lian Zi being substituted for Zhi Xiang Fu at the same dosage.
2. At 2nd follow up visit, 31 days following his Initial visit, at the end of winter/beginning of Spring, the Pt. reported perineal pain down to 1/10 (from 8/10). Pt. no longer experiences pain with sexual activity. Pt. reports that his anxiety has continued to decrease. Pt. reports few incidences of burning urination after drinking wine and/or eating sugar. The patient also suffered some ear pain. The tongue was no pink, not pale, with the tip less red. The pulse had changed, now being Deep, Full, Forceful, Slightly Wiry. The herbal formula was changed accordingly and also to promote circulation in the lower part of the body. Patient was given the following herbs in granules,
8 scoops, 2 x Day, Daily Dosage Granules, 5:1 dosage:
Long Dan Cao .5g Hu Zhang 2g
Huang Qin 1.5g Mu Dan Pi 1g
Zhi Zi 1.0g Huai Niu Xi 1g
Chai Hu 1.0g Wu Wei Zi 1g
Mu Tong 1.0g
Yin Chen Hao 2.0g
Ze Xie 1.0g
Sheng Di 1.0g
Shu Di 1.0g
Dang Gui (Jiu) 1. 0g
Patient also received acupuncture.
3. Pt. came in 10 days later reporting almost zero symptoms. Pt. received acupuncture and a refill of the herbs given last visit.
4. Pt. came in 15 days later reporting zero symptoms accept for two flare-ups that were diet related and cleared up quickly. Pt. reported stress but not anxiety. Sweating had improved but still present. Pt. reports regular bowel movements. Pt. still reported ear pressure. Pulses were now slippery, but weak, and almost absent in the 3rd position. Tongue was greasy once again in the rear. As patient had mostly improved except for what seemed to be incidents that were correlated to diet, the treatment strategy and treatments now focused on strengthening the digestive system and preventing what is called dampness in TCM. The importance of diet was discussed and the patient was given some food recommendations and recipes including the following foods: Mountain Yam, Pearl Barley, Mung Beans, Adzuki Beans, Bitter Melon, Chrysanthemum Garland, Barley, Lotus Seeds and Roots, Dandelion Greens and others. Patients Blood Pressure has come down from Borderline Hypertension,
pressure read 124/80 at visit.
Herbs dispensed in granules, 8 scoops, 2 x day,
1g granules equivalent to 5g of raw herb:
Daily Total Of Granules:
Zhi Huang Qi 1.5g
Huang Qi 1.5g
Xi Yang Shen 1.5g
Bai Zhu 1.4g
Chen Pi .7g
Qing Pi .7g
Dang Gui (jiu) .7g
Shi Chang Pu .35g
Sheng Ma .35
Huang Bai .35g
Chao Mai Ya .7g
Zhi Zi .7g
Hu Zhang .7g
Zhi Gan Cao .7g
5. Pt. was feeling better but wished to continue herbs. Pt. continued on formulas similar to above for a few weeks.
6. 3.5 months later the patient came in because perineal pressure was starting to return, very mild 1-2/10. Pt. given 10 days of herbs and pain subsided.
Treated At Oakland Hills Acupuncture & Integrative Medicine
Chief Complaint: Insomnia/Stress
Secondary Chief Complaint: Sciatica (this case study will focus on the secondary symptom. A complete history of all symptoms might be reported later).
Pt. is a 47 year old female from Marin who was suffering from L sided sciatica.
Brief synopsis of history taken at initial visit:
Pt. reports nerve like pain beginning in her low back, proceeding through her left glute and then coming down her left leg along the side and stopping one quarter of the way down below the knee, just posterior to the fibula. The pain at that terminal point was reported to be the worst.
Pt. also reported hot flashes, work stress, insomnia, and fatigue. The insomnia was treated by medication.
Pulse: Thin, forceful
Tongue: Reddish Purple in color with a thin/scanty coat
-PC6, Sp4, Ki9 (Master points and xi cleft of Yin Wei acupuncture points)
-Ki6, Lu 7 (Master points of Yin Qiao and Ren Meridians)
-GB 41 on left, Ashi(tender pt. where sciatica stopped) around GB 34 on left
1. At the next visit the patient reported that sciatica pain subsided after last treatment. Patient also reported improved sleep without using medication although sleep was still an issue. Pt . was treated for insomnia with acupuncture and herbs. Sciatica did not return over course of treatment for those issues.
Treated at Oakland Hills Acupuncture & Integrative Medicine
by David Heron L.Ac
Chief Complaint: Sciatica
Pt. is a 65 year old female from San Leandro who reports suffering debilitating right side sciatic pain for a few years, with 95% reduction in frequency of symptoms over 2 visits. Pt. comes in for care every few weeks as needed to prevent full return of condition. Pt. recommended to come more frequently to try and cure the condition however pt. is unable to.
Pt. also experienced a sharp decrease in anxiety with treatment.
Brief synopsis of history taken at first visit:
Pain: 8 – 10/10, debilitating kept in bed
Pt. reports suffering from right sided Sciatica “on and off” for a few years. The pt. reports what appears to be muscle spasm accompanying the sciatica which she describes as “a pulling up sensation in the leg”. The pain often leaves the patient unable to walk for a few days at a time. The pt. reports that the pain can be triggered pressure on the R glute. As per the patient, the pain begins in the glute and then travels down the side of her leg to the sole of the foot. Pt. reports that massage with over the counter liniments seems to help alleviate the pain temporarily. Pt. reports that her doctor had given her NSAIDs and pain killers to treat the pain for years but she looking for a treatment for the source of pain, not just the symptom.
Exam: Pt. reports a few tender spots over the R piriformis
Other: Pt. has a pleasant demeanor but is in obvious distress due to pain.
First Set Of Needles: Heart 5, Gallbladder 41, Shenmen
Once pt. seemed more relaxed, needles were removed and proceeded with Set 2:
(*means Micro-current electrical stimulation was applied to the needles at those acupuncture points as 10 Hz)
-Huatoujiaji points at L2, L3, L4*, L5*
-Piriformis Motor Point*, along with 2 Ashi*(tender points) over the piriformis on the right
-Gallbladder 38 on right
-Ling Gu, Da Bai on Left
1. Pt. returned 3 weeks following the first visit. The pt. reported that for two weeks following the first visit that her pain had completely disappeared. However, it then returned at lower intensity and the patient was able to clearly distinguish a knotted muscle in her R glute. The treatment was repeated.
2. Pt. returned 2 weeks following the first follow up visit. Pt. reports no pain radiating down her right leg. The pt. reports some occasional muscle tension in her R glute that dissipated in a few minutes instead of progressing down the leg. The patient also reported along with her pain relief a lot of her anxiety had been resolved as well.
Treated at Oakland Hills Acupuncture
Chief Complaint: Back Pain and Spasm
Patient is a 50 year old female who was successfully treated for acute back pain and spasms over 3 treatments (7 days).
Brief synopsis of history taken at the first visit:
Pt. reports noticing muscle tension in her back two weeks ago. As per the patient, the tension slowly increased over time. Finally, five days ago the tension increased dramatically causing the patient pain and limiting her ability to move.
The patient reports high pain level at 8/10 that has disrupted her sleep. The patient reports difficulty raising her left leg to enter her car. As per patient, she has unsuccessfully tried to treat the pain with Motrin, Flexol, and a heating pad.
On examination the Right lumbar area and upper glute area is tender to touch. There was visible muscle tension on the left lower thoracic and left upper lumbar area spinal accessory muscles and both were tender to touch.
Other history: Pt. has history of knee replacement and knee pain.
TCM Exam: Pulse was choppy and the tongue was slightly dusky with a red tip.
General Treatment Regimen: Treat the presenting issues then once resolved discuss with patient some underlying constitutional factors that might be contributing to her back and knee issues.
Each treatment consisted of using traditional acupuncture points in the lumbar area and using various needle techniques to release muscles that seemed stuck in contraction such as the Piriformis, spinal accessory muscles, etc.
Electrical Stimulation (Mili-amps) was used on some needles with a Mixed frequency of 5 and 15 Hz. Distal points were selected according to her presentation from a Chinese Medical perspective.
1. At the second visit, 5 days later, the patient reported no pain and improved sleep for approx. 3 days. After 3 days her mid back began to spasm. Overall the pain was less then when she came in a few days prior – the pt. reported pain ranging from 3-5/10 at this visit. The treatment was adjusted to include the areas that were in spasm. The patient was given 5 days of herbs in granules (1 gram of granules equivalent to 5g raw herbs). Instructions: 5 grams, 2 x per day Ingredients: 1.Du Huo Ji Sheng Tang 5g; Yan Hu Suo 2.5g; Suan Zao Ren (Chao) 2.5g
2. At the third visit, 3 days following the first follow up, the pt. presented with a very relaxed expression on her face. The patient reported no presence of pain or muscle spasms. On examination most tension and tenderness had dissipated except for some very mild tenderness on the R spinal accessory muscles in the lumbar area. Treatment proceeded as usual with attention given to the tender areas.
3. Pt. continued care for other issues and overall health as back pain never returned.