68 years old male, retired teacher with chief complaints of occipital headache, right neck pain,
right upper back pain and bilateral elbow pain.
Secondary complaints: Insomnia, anxiety, occasional right hip pain.
History of Present Illness:
T.K. came in September 2022 complaining of occipital headache, right neck pain and right upper back pain near the scapula area which started several years ago and elbow pain that comes & go. On palpation the trapezius and infraspinatus muscles were tight with some tenderness on teres minor, teres major and latissimus dorsi. Sternocleidomastoid muscles were also tight. No pain, no cyst palpated on C1 to C7 and from T1 to T12. Patient also complained of insomnia (sleep 3-4 hours only), anxiety and occasional hip joint pain when doing yard work for more than 4 hours.
ROM: Pain with lateral movement on left side and with external/ internal rotation of the neck that would trigger an occipital headache. Flexion and extension of upper back and elbow would create spasm and pain.
Current List of Medications: Levothyroxine (due to Graves’ disease 15 years ago). Tylenol extra strength 2 capsules 2x a day for pain. Takes Vit. C 500 mg once a day. And Vit. B-Complex once a day.
Review of Systems:
- General: T.K. weights 172 lbs. BMI 23.32. Sleeps 4 hours a night and takes naps in afternoon.
- Vision Screen: Wears eye glasses for distance. Goes for annual routine with ophthalmologist. PERRL.
- Integument: Skin rush on right upper thigh during winter months and disappear during hot weather. Had been seen by Dermatologist. No skin ulcer.
- Hematopoietic: Denies history of anemia or excessive bleeding/ bruising. No enlarge lymph nodes.
- Ears: Denies hearing loss, tinnitus, pain or drainage.
- Nose/Throat/Sinuses: Denies epistaxis, no difficulty swallowing, occasional sinus allergy during spring or fall season.
- Mouth : occasional mouth ulcers with acidic/spicy foods.
- Pulmonary: Denies SOB, wheezing, coughing, hemoptysis, chest congestion.
- Cardiovascular: CHO-WNL. Denies having chest pain, SOB on exertion, no fainting, vertigo, no leg edema, no orthopnea, and no palpitations.
- Neurological Exam: CN’S II-XII intact. AOx3. Muscle strength normal no rigidity, sensation normal, monofilament WNL. Babinski negative, gait normal.
- Gastro Intestinal: Denies abdominal pain, occasional constipation with cheese intake. No black stools, heartburn, n/v, no hemorrhoids.
- Genitourinary: Denies dyspareunia, nocturia, hematuria, dysuria, no flank pain, and no urinary incontinence/urgency.
- Musculoskeletal: No erythema. Occasional lower back pain with yard work. Occasional joint stiffness and leg cramps at night. No muscles weakness, no myalgia, no swelling/bruising.
- Psychiatry: Denies depressions or anxiety panic disorder. No suicidal ideation, affect is normal.
- Genital/Reproductive: Denies itching, no history HPV. Prostate not enlarged, blood level WNL. Sphincter tone good on palpation, heme negative.
- Endocrine: On levothyroxine once a day. Patient has heat intolerance. No polydipsia, polyphagia, polyuria.
Physical Exam:
General Appearance: Patient is alert and oriented, no acute distress. Pulse: 72
Resp: 19 Temp: 97.8 Weight: 172 lbs. Blood Pressure: Supine 110/70, Sitting 122/68, Standing 108/70
Eyes: Clear conjunctiva, small cataract on the left eye.
Ears: Tympanic membrane normal.
Neck: Supple, no JVD, no carotid bruit, and carotid pulse 2+.
Heart: Regular rate and rhythm, blood pressure 122/68, normal sinus rhythm, no S1, S2, no murmurs, clicks or rubs.
Lungs: Clear to auscultation, good air exchange, no wheezes, rales or rhonchi.
Abdomen: Bowel sounds normal, no guarding, no rigidity, and no hepatosplenomegaly.
Neurological: Muscles strength is normal and symmetrical and sensation is normal.
Extremities: No edema, no ulceration, no erythema, no tenderness, peripheral pulses +2 normal bilateral.
Musculoskeletal: See chief complaints above.
Lymph nodes: No axillary or supraclavicular or inguinal hernia.
Laboratory Testing: Comprehensive Metabolic Panel and CBC WNL.
Diagnostic test: x-ray of neck five years ago and hip showed osteoarthritis. Mild sprain on elbow, scapula negative for fracture or sprain.
TCM Examination:
Observation: Eyes and skin are clear but face looks tired
Tongue: wet, scalloped edges, red tip
Pulse: slippery on guan right, wiry and tight left guan and chi position
Comparison of Traditional Chinese Medicine & Western Medicine:
In Traditional Chinese Medicine, pain is considered stagnation of Qi and Blood, it can be caused by internal cold or internal heat, dampness, wind invasion, deficiency of Qi and blood or combination of dampness, heat and wind. Pain can also occur with heat and cold combination, or a patient can have both deficiency and excess at the same time. In Western medicine, pain begins when the nerve endings (nociceptor) of C fibers and A-delta fibers of afferent neurons respond to noxious stimuli causing tissue damage and inflammation. For a pain impulse to be generated, an exchange of sodium and potassium ions occurs at the cell membrane. The pain impulse is transmitted from the spinal cord to the brain stem and the thalamus via the nociceptive pathway. The abnormal processing of pain within the PNS and CNS may become independent of the original painful event like the amputation of the limb. The original injury may have affected the peripheral nerves but the mechanism of the pain is generated in both the PNS and CNS (https://www.nursingtimes.net).
Dr. Tan’s Balance Method to reduce pain and inflammation was used. The Balance method is a new way of studying the human body’s network of meridian. The patient does not have to undress during the session, and he/she can be treated sitting up. By locating the correct meridians in the body, one can effectively treat chronic or acute pain. The main principle of Balance Method is that there is an interconnection between healthy and sick meridians. Balance method consists of 3 simple steps.
Step One: Identify the sick meridian by using the four traditional Chinese medical diagnoses such as Inspection, Auscultation/Olfactory, Inquiry and Palpation. Inspection involves looking for swelling, discoloration/bruises, atrophy and deformities. Auscultation and Olfactory include listening to sounds and quality of the patient’s voice (laughter, singing, weeping groaning, and shouting). Olfactory smells for a particular odor (scorched, fragrant, fishy, rotten, and putrid). Inquiry is asking the patient where the pain/discomfort is located and the intensity of the pain. Palpation is asking the patient to point using just one finger the exact location of discomfort to be able to make a correct diagnosis and determining the correct meridian to use. The pain location may vary; it may be in the exact body meridian or in between.
Step Two: Once the sick meridian is identified, decide what meridian to use according to Balance Method using 5 different systems.
| System One | Chinese meridian Name Sharing | Meridians sharing the same name balance each other. Example: Hand Tai Yang balances Foot Tai Yang. Insert needle on the opposite side. |
| System Two | Bie-Jing/Branching Meridians | Opposite meridians are paired according to their Chinese name. Example: Shao Yin balances Shao Yang. Needle on either side. |
| System Three
System Four |
Biao Li/Interior-Exterior Pair
Meridians opposite each other balance each other.
|
The needled meridian is either interior or exterior of the sick meridian. Example: Hand Yang Ming balances Hand Tai Yin. Insert needle on the opposite side.
The affected meridian on one side of the Chinese clock is paired with the needled meridian on the opposite side Example: Foot Tai Yin balances Hand Shao Yang. |
| System Five | Chinese Clock neighbors | The arrangement of Chinese clock pair the meridians that are adjacent to each other. Example Yin meridians balance Yin meridians and Yang meridians balance Yang meridians. Example: Hand Yang Ming balance Foot Yang Ming. Needle opposite side. |
(Tan, 2007)
Step Three. After the meridians are identified, the next step is to decide what acupuncture points to use for treatment. Dr. Tan had developed the Mirror Format and Mirror Image for guide. To use the Mirror Format, chose the limb or specific part of the body that corresponds to the anatomical location of the sick meridian. Exact acupuncture points are chosen by checking for ashi points. In most cases the upper limb balances the lower limb and the lower limb balances the upper limb. The only exception is system number three where lower limb balances the lower limb and upper limb balance the upper limb. The Reverse Mirror Format can also be applied by inverting the mirrored limb to be needled.
The Imaging Format is about the relationship between a limb and the whole body. For example, the hand images the head, the wrist images the neck, the forearm images the chest, the elbow crease images the navel, the upper arm images the lower abdomen and the shoulder images the groin. You can also do the reverse imaging.
Image of Upper Limb to head and trunk
|
Needled Area |
Image |
Reverse |
|
Finger |
Testicles and anus |
Top of head |
|
Hand |
Genitals, coccyx, lower sacrum |
Head and base of skull |
|
Wrist |
Genitals, bladder, sacrum |
Neck and neck joint |
|
Forearm |
Lower, abdomen, lower back |
Upper abdomen, rib cage chest mid-upper back |
|
Elbow |
Umbilicus level, lumbar2, waist |
Umbilicus level, Lumbar 2, waist |
|
Upper Arm |
Upper abdomen, rib cage, chest mid-upper back |
Lower back, lower abdomen |
|
Shoulder |
Neck, jaw, base of skull |
Sacrum, genitals, coccyx |
|
Top of Shoulder |
Top of head |
Testicles and anus |
(Tan, 2007)
Image of Upper Limb to head and trunk
|
Needle Area |
Image |
Reverse |
|
Toe |
Testicles and anus |
Top of head |
|
Foot |
Genitals, coccyx, lower sacrum |
Head and base of skull |
|
Ankle |
Genitals, bladder, sacrum |
Neck and neck joint |
|
Lower Leg |
Lower, abdomen, lower back |
Upper abdomen, rib cage chest mid-upper back |
|
Knee |
Umbilicus level, lumbar2, waist |
Umbilicus level, Lumbar 2, waist |
|
Upper Leg |
Upper abdomen, rib cage, chest mid-upper back |
Lower back, lower abdomen |
|
Hip & Joint |
Neck, jaw, base of skull |
Sacrum, genitals, coccyx |
|
Top of hip |
Top of head |
Testicles and anus |
Image of Head to Upper and Lower Limbs
|
Needle Area |
Lower Limb |
Upper Limb
|
|
Top of Head |
Hip joint |
Shoulder joint |
|
Forehead Level |
Upper Leg |
Upper Arm |
|
Eye, Ear, Occiput |
Knee |
Elbow |
|
Nose Level |
Lower leg |
Forearm |
|
Mouth Level |
Ankle and foot |
Wrist and hand |
|
Chin level |
Toes |
Fingers |
(Tan, 2007)
Reverse Image of Head to Upper and Lower Limbs
|
Needle Area |
Lower Limb |
Upper Limb
|
|
Top of Head |
Toes |
Fingers |
|
Between Forehead and Top of head |
Ankle and Foot |
Wrist and hand |
|
Forehead Level |
Lower Leg |
Forearm |
|
Eye, Ear, Occiput |
Knee |
Elbow |
|
Nose Level |
Upper Leg |
Upper Arm |
|
Mouth Level |
Hip |
Shoulder |
|
Chin Level |
Hip joint |
Shoulder joint |
(Tan, 2007)
Image of scalp to the Spine
|
Hairline |
C-1, C-2 |
|
Du 24-22 |
C3-C5 |
|
Du-22-20 |
Thoracic vertebra |
|
Du-20 |
Lumbar 2 (waist level) |
|
Du 19 |
L2-L5 |
|
Du 18-16 |
Sacral area |
|
Du 16 |
Tailbone |
(Tan, 2007)
Herbal prescriptions consist of the following herbs was also prescribed. Wei Ling Xian, Wu Jia Pi, and Sang Ji sheng to help dispel dampness, open channels and collaterals. Dan Shen and Chuan Niu Xi help invigorate the blood and dispel blood stagnation. Yan Hu Suo is a strong analgesic for any kind of pain. Du Zhong and Xuduan tonify Liver and Kidney, help with back and knee pain and strengthen tendons and reduce swelling. Huang Qi tonifies qi and raises Yang, helps Spleen in transformation and transportation function. Huang Qi also treats qi and blood deficiency. Du Huo is anti-inflammatory which I used a lot for my patients with chronic neck and shoulder pain. Gan Cao to help relieve pain, eliminate toxins and harmonize the whole herbal formula. Add Bai Shao if there is spasm.
Discussion :
Patient’s neck pain and shoulder pain was down to 2 from level 10 being the worst after two months of acupuncture treatments of 2x a week. Patient takes Tylenol extra strength only when he does yard work for more than 3 hours. Occipital headache and elbow pain was resolved.
Diagnostic Plan:
Repeat x-ray of neck to include upper back or do an MRI to rule out spinal stenosis or bone spur. Suggested Electromyography (EMG) and nerve conduction velocity (NCV) on PRN basis if neck, shoulder and arm pain comes back.
Therapeutic Plan:
Recommended Tai Chi or Qigong meditation for insomnia and anxiety plus acupuncture. Patient started taking Neck and Shoulder Chronic from Evergreen herbs 4 capsules 2x a day. Patient to continue acupuncture 2x a week for occasional hip joint pain and for resolution of insomnia and anxiety. Patient was advised to drink less than 4 cups of coffee a day and not to drink coffee after 12 noon to help him get a better night sleep. Emotional stress can increase neck tension and interfere with or delay the recovery process. Reducing stress may help to prevent a recurrence of neck pain. Relaxation techniques can relieve musculoskeletal tension especially upper back pain.
Patient Education:
Patient was advised to pay attention to posture when lifting and do some neck and shoulder stretching at home using the Egoscue exercises and advised to read on the benefits of using kinesiology tape to increase oxygen and blood flow and decreases inflammation of the injured area.
References:
Chen, J. & Chen, T. (2001). Chinese Medical Herbology and Pharmacology. Art of Medline Press Inc.
Dimitrov, N., Tomov, N., Atanasova, D., Iliev, S., Tomova, T., Sivrev, D. & Goranova Z. (2021). Visible Meridian Phenomena after Acupuncture: A Series of Case Reports. Journal of Acupuncture & Meridian Studies, 14, 50-57.
Langevin, H. M. & Yandow, J. A. (2002). Relationship of Acupuncture Points and Meridians to Connective Tissue Planes. Anatomical Record, 269(6), 257–265, 2002.
Maurer, N., Nissel, H., Egerbacher, M., Gornick, E., Shuller, P. & Traxler, H. (2019). Anatomical Evidence of Acupuncture Meridians in the Human Extracellular Matrix: Results from a Macroscopic and Microscopic Interdisciplinary Multicenter Study on Human Corpses. Evidence-Based Complementary and Alternative Medicine.
Miller, J., MacDermid, J. C., Richardson, J., Walton, D. M. & Gross A (2017). Depicting Individual Responses to Physical Therapist- led Chronic Pain Self-Management Support with Pain Science Education and Exercise in Primary Health care: Multiple Case Studies. Arch Physiother, 7, 4.
Tan, R. (2007). Acupuncture 1, 2, 3. TW Books.