Download Case Study Project: 63-year-old Male with Bi

Case Study Project
Case Study Project: 63-year-old Male with Bi Syndrome
Mr. Angel Careaga
Diagnosis and Treatment of Disease II
Leslie McCoy, L.Ac.
March 28, 2010
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Section 1
CHIEF COMPLAINT & HISTORY OF PRESENTING ILLNESS
Sixty-three year old male patient, retired Navy, complains of arthritis and decreased
range of motion in the fingers bilaterally. Originally the patient came to the clinic seeking
treatment for dull pain and weakness in the right hip and legs. That condition began after
moving heavy boxes sideways a year ago, and began as a groin pain (possibly related to skiing)
near the inguinal groove, as indicated by the patient pointing, and radiated down the quadriceps
femoris muscle to just under the patella and pes-anserine.
The pain is generally dull and achy but occasionally sharp and definitely aggravated by
squatting (moving boxes motions). The patient’s physician performed an examination and found
no hernias, however the patient will eventually need a hip replacement. In general he has found
that sleeping on his stomach is more comfortable and he often needs to rest at night. Patient has
also indicated he has apnea. Treatments sought for the pains were medications and
massage/chiropractics.
PAST MEDICAL HISTORY
Upon the second visit, after a diagnosis of Kidney deficiency and Qi stagnation were
established, the patient changed his complaint to the fingers because the first treatment worked
so well.
He said that the arthritis in his fingers began over five years prior but he did not make a
direct connection to his retirement, instead mentioned he discovered it from driving his car. Yet
he didn’t deny his work in the Navy was the likely source of his arthritis.
The pain was mostly located in the right hand in the metacarpophalangeal joints on the
second and third fingers. There was notable diminished range of motion in flexion as well as
large, knotted joints that looked ‘bony’ in both hands.
The pains are typically constant, so much so that he has come to ignore them (hence the
original complaint), and is never really sore. However during humid or cold conditions, he has
admitted the aching sensation increases and that warmth alleviates it somewhat.
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About that time, too, he started to feel knee and limb stiffness and had a bout of Gout on
the right foot which cleared up over 5 years ago as well as a bunion and severe pain that are less
than before.
He has never received treatment/diagnosis for the hands, though an x-ray would be
inconsequential given the visual appearance of the hand reveals the calcifications below the
tissue.
MEDICATIONS
In general the patient is healthy reporting no major surgeries or hospitalizations. He is
currently taking only blood pressure medication, Levatol, which he takes 20mg once every day,
and has for the last three years. His father died of a heart attack thirty years ago.
REVIEW OF SYSTEMS, PHYSICAL EXAM, & PERSONAL HISTORY
The patient reports feeling unsteady often and has energy though he only sleeps six and a
half hours a night. He feels “warm” and tends not to wear jackets even in windy, cold weather.
He has a good appetite and thirst, but does not force down water; he does drink around eight
cups of coffee per day. He has no history of alcoholic consumption or smoking.
No reported gas, reflux, belching. Light yellow urine about five times a day and one
bowel movement per day or every other day. Though he has no colds now he is susceptible to
mild “walking” pneumonia.
Emotionally feels good though he reports he is most happy about his financial health. He
is currently married and enjoying retirement, even though it was forced upon him. In fact his
Shen appears very satisfied, with crinkles or “crows’ feet” at each outer canthus and a pleasant
grandfatherly demeanor.
He does have some noticeable varicosities around LV8/9 and KI7/8 as well as an obvious
limp. The patient reports that he would like to exercise more, but his leg and hands bother him a
bit too much, and he does appear to be a bit overweight.
The patient’s vital signs were good, blood pressure taken sitting was 135/95 and his heart
rate was 60bpm. His pulse was steady, moderate, and methodical with sixty beats per minute; it
was also full and wiry, especially in the cun position on the right. It was deficient in the
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Stomach yang on the right guan position. Yet there was a surprising amount of force in the
kidney position, but it could be pushed through; possibly the medication was affecting the pulse.
His tongue was U-shaped but normal in size, pinkish-red, dry, and cracked. The coat was
yellow everywhere but in the center where the tongue body was exposed. Most likely this is a
direct result of daily coffee drinking both the day of examination and his whole life.
Section 2
TCM Disease Diagnosis
This patient’s diagnosis is cold predominant bi syndrome (wind-cold-damp painful
obstruction) that is becoming bony bi syndrome at an accelerating rate. Bony bi syndrome is a
condition that involves deviation, deterioration, and accumulation of calcified tissue at the joints.
This patient’s physical examination does not yet reveal the level of deterioration that would
necessitate a diagnosis of bony bi syndrome. However, the decreasing range of motion (ROM)
and “freezing” of the joints is indicative of a calcification process.
“Persistent obstruction of the joints by pathogenic factors leads to retention of body
fluids, which turn into Phlegm, which further obstructs the joints and channels. This leads to
muscular atrophy and swelling and deformity of the bones in the joints… The stasis of Blood in
the channels further obstructs proper circulation and is therefore another cause of pain… Cold
and Dampness are frequent causes of [Bi] syndrome of the lower back. After repeated episodes
of invasion… the ache then becomes more or less constant.” (Maciocia, 2008)
The persistent presence of damp and cold in the body causing phlegm and leading to
bony growth is what causes the decrease in sensation of pain.
TCM Differential Diagnosis and Etiology
Bi syndrome is a channel disease that is a symptom of dual systemic attack of external
pathogens and internal deficiency of Liver and especially Kidney leading to lack of regulation of
the channels. Bi syndrome is therefore a branch, whereas the root is a zang-fu diagnosis.
However, in this case the patient’s constitutional diagnosis is concordant with the channel
diagnosis of cold bi syndrome. The constitutional diagnosis is Kidney yang and Stomach yin
deficiency with internal dampness [and blood stagnation]; these are interpretations of the
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varicosities, obesity, and tongue coat (Maciocia, 1987). Note the dual nature of long-standing
deficiency and internal stagnation-repletion that results from taxation and organ deficiency.
The Kidney deficiency represents a failure of the Water element to regulate the fluids of
the body; also reflected in the circulation issues of the lower body (a San Jiao relationship via
Water physiology and the veinous return and lymph pathways it governs).
The internal dampness (due to diet and external pathogenic influence from work) is a
pathogenic fluid that has not been transformed and drained through the body’s natural processes.
Dampness is a yin pathogen, just like cold, and an aggravating factor for bi syndrome.
Complicating this patient’s situation and difficulties with the Water element is Stomach
Yin deficiency, the source of his dryness and warm sensation. The Stomach is the source of
“yang fluids” meaning that it transforms foods into digestive fluids for the intestines. This
patient’s internal dampness is both a symptom and a causative agent in blocking the ability of the
Stomach to be nourished and encased with clear fluids. Dampness in the flesh, cold in the
channels, and dryness in the source organs present a difficult situation to remedy, however at the
heart of it is Kidney deficiency for the reason mentioned above.
In this case, the constitutional diagnosis is what prevents the channels from moving the
Qi correctly, creating a low threshold for an external pathogenic influence such as cold and damp
to create a bi syndrome.
His past work history is suggestive of working with his hands in chronic exposure (many
military and especially naval personnel are exposed to the elements or tend to ignore weather
influences) for many years, allowing wind, cold, and damp to penetrate the vessels and
collaterals and lodge within the body.
Biomedically the repeated use of any joint combined with decreased vascularization or
bloodflow (cold slows blood) can be a contributing factor to arthritis, one of several causes of bi
syndrome.
This patient had not been officially diagnosed with having arthritis, but subjectively feels
painful aching and limited ROM leading to his belief that he has arthritis. Clinically this is very
likely and no further labs are really necessary to act from our perspective as if the patient has bi
syndrome.
The most difficult decision in this case, because the herbal formula and treatment strategy
may change completely with each diagnosis, is between the types of bi syndrome. Though it is
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true that the patient may also receive a constitutional or zang-fu treatment, those treatments
should be considered adjunctive and not contradictory to the diagnosis of bi syndrome, which is
the clear disease paradigm here.
There are five separate patterns to consider: wind predominant, cold predominant, damp
predominant, bony, heat-stagnation or damp-heat (commonly both of the latter are referred to as
“hot bi”).
Working in reverse order, the patient has both subjectively denied and is observably
without symptoms of heat in the local area and channels. Though the tongue is dry and cracked,
that is the state of internal organs and not helpful here.
The patient feels coldness, numbness (not so much pain unless the weather is humid and
cold), and decreased range of motion in the joints of the hands, most easily aggravated through
use.
In dampness predominant bi syndrome, in general, one would expect to see signs such as
heaviness, fatigue during use, aggravation by precipitation and pressure changes. This patient
does not mind the weather, but instead the ambient temperature when it comes to his hands
(Maciocia, 2008). Another major difference between cold and damp predominant is that the
damp types will tend to sink to lower portions of the body rather than the upper portions.
In wind predominant bi syndrome one would expect roving aches and pains that alternate
in location and severity. This patient has not indicated that his pains move, but are instead
fixated to the hands [and hips].
It may be important to point out, as Maciocia (2008) says on p. 982, “Most doctors agree
that all three factors… are present in every case of [Bi] syndrome, and each case can only be
differentiated according to the predominance of one factor over the others.”
The most difficult differentiation in this case is therefore the diagnosis of cold
predominant versus bony bi syndrome. In this case, the two are not mutually exclusive but rather
inclusive (Maciocia, 2008).
It is perhaps better to know that the case is becoming bony bi syndrome over time to
assist in the treatment method, but at this point in time, without the level of deterioration,
deviation, or malformation due to excess calcification, it is best to label this a cold predominant
bi syndrome.
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Arthritis
This patient, as previously stated, has not sought and therefore not received a diagnosis of
“osteoarthritis” or “osteoarthralgia.”
Very likely this patient has secondary osteoarthritis (Merck, 2006), a chronically
degenerative disease secondary to the known cause of overwork in weathery conditions.
Many patients self-diagnose conditions of arthritis and/or rheumatoid arthritis. This
patient complained of arthritis, however it is important to know the difference between the two.
Arthritis is primarily a mechanical pathomechanism where overuse combined with
decreased lubrication (as the body ages and hormones decrease) in the hyaline cartilage lead to
calcification and bony formations in the joints, primarily Synovial joints.
This can be due to degenerative joint disease, or perhaps response to acute or chronic
trauma from repetitious movement.
Rheumatoid arthritis is an autoimmune disorder “producing damage mediated by
cytokines, chemokines, and metalloprotesases,” (Merck, 2006) that remits and resurges
throughout the patient’s lifetime, generally has a familial history, and is bilaterally symmetric
due to the systemic nature of autoimmune disorders. Though the exact cause is unknown, most
theories speculate that the genetic mutation (Merck, 2006) allows a glitch in the immune system
where Rh factor (RF) is released as response to some pathogen (such as virus or bacteria) and the
antigen-antibody complex attaches to cartilaginous tissue, thus destroying the tissue through the
physiological activity of macrophages. Also, smoking may be a factor [but not in this case].
(Merck, 2006)
During these outbreaks, the joints are painful, swollen, and hot to the touch. (This is the
Shang Han Lun wind-cold transforming to “hot bi” as opposed to Gouty Bi or “damp-heat” bi
this patient has shown a history of).
By contrast this patient’s arthritis is limited to the hands and is primarily located in the
right hand, of which he is dominant. His hip pain, also, is one-sided, and possibly nerve related,
not indicative of Rheumatoid arthritis at all. The patient has also denied ever feeling swollen,
painful bouts of inflammation. So despite the tendency of RA to occupy the hands, this is not
likely the mechanism.
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Treatment Principle
Aside from constitutional treatments, treatment of the chief complaint of cold bi in the
hands is to “[d]issipate cold, warm the connections, dispel wind, dispel dampness,” (Wu &
Fischer, 1997), move qi and blood to relieve pain, and to dissolve masses of bony growth.
It cannot be overstated that the chances of stopping, let alone reversing the arthritic
conditions cannot be achieved without: lifestyle and diet changes, constitutional treatment, and
possibly medication or even surgery.
The lifestyle, though not as rigorous as before since he has retired, still includes habits
such as going into cold, windy weather without a jacket or scarf, and eating fat-engendering
foods which introduce dampness and prevent the Spleen from transforming Qi and regulating the
flesh.
The constitution is indicative of a strong imbalance inside the Water element and in
relation to the Earth element (Earth restrains Water, therefore diet is a major source of problem
here).
Furthermore the arthritis is not of a mild nature (such as wind bi), but rather progressive
and accelerating towards bony. As the bone growth advanced, vascularization decreases,
limiting the effectiveness of internal medicine in the area, rendering only remaining options of
external application and physical manipulation. At some point, even these modalities will cease
to provide relief and surgery would be necessary to remove bony growth or lose the use of the
fingers affected.
Acupuncture Treatment
Acupuncture is most effective when used to treat channel diagnosis, however it can and
does affect the internal treatment. Because this patient’s condition is quite complex, and the
internal conditions are difficult to resolve with acupuncture and the body is encumbered by some
dampness blocking internal pathways and external primary channels, it is important to have two
separate treatments. The first is constitutional, the second is for the bi syndrome, and both have
overlapping, repetitive qualities.
Once to twice a week, indefinitely, this patient should receive a Water-Earth harmonizing
treatment including:
SP3,6, & 9 – tonify for regulating dampness, strengthening stomach yin
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KI7 – tonify KI yang
RN3 oblique to 4, RN5 oblique to 6 – tonify move Qi of UB and SJ and stimulate
the drainage of dampness, as well as tonify source Qi
SJ4-SJ10 e-stim – disperse stagnation in San Jiao, invigorate Original Qi
ST40 – dissipate to regulate dampness
GB20 – dispel wind-cold from upper body
ST36 with LI4 – strong stimulation to control Qi of whole body and regulate
Zhong Qi of middle burner
This treatment, however, does not treat bi syndrome directly. Thus the patient should
return for two to three treatments per week (perhaps directly following the other treatment) until
the condition of frozen joint resolves and the patient is satisfied with the results. Combined with
the following points, should be physical manipulation using a liniment (discussed in the herbal
section) of the fingers and wrist of both hands.
LI4, Luozhen, PC8, and Ba Xie points – dispersing local accumulation and
“scrubbing the joint.” (Bisio, 2004) Ba Xie (lit. eight evils) is a great point to
expel pathogens in the hands, may want to combine with Ba Feng (lit. eight
winds) to enhance the power of the point through mirroring the joint with the foot.
UB40/UB10 to open UB divergent channel – aid the hip as well as expel wind. In
general this combination will activate the taiyang of the body and move Qi
internally more deeply than the primary channel.
UB11 – tonify the influential point of the bones
UB16 – Du shu, tonify to regulate yang energy of the Du channel
UB23 – needle then moxa line joining GB25, UB52, UB23, and DU4 to
invigorate warmth in ming men
GB34 – tonify the influential point of sinews
LV3 – tonify the Liver yin as well as mirror hand treatment bilaterally
Auricular: Shen Men, Hip, and Fingers to enhance the treatment and guide the Qi
This treatment is designed to treat chronic bi syndrome and also address the issue of
buildup within the body. However, the most important part of the treatment is the moxa because
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it is the decrease in the Kidney Yang (hormones of the adrenal cortex) that has enabled the wind
and cold to lodge permanently in the hand. Second to that, physical manipulation of the hand
and strong needling in the hand to remove accumulation is key to halting progress, increasing
bloodflow and warmth in the area, and stimulating healthy growth.
Herbs
Herbal remedies should be clearly delineated into two categories: internal and external
application. The formulas are Wu Tou Tang (Wu & Fischer, 1997), internal, and Shaolin Wan
Ying Gao (Jow) used as a liniment rather than a plaster (De Chan & Flaws, 1995).
Wu Tou Tang (with modifications)
[Zhi Chuan] Wu tou (aconite tuber) 6g* Replace with Zhi Fu Zi to warm Ming Men
Ma Huang (ephedrae hb.)**
Expel wind
Chi Shao (red peony) 9g
Invigorate blood, tonify blood, raise RBC count
Huang Qi (astragalus) 12g or 3 sticks
Warm collaterals, raise clear Yang, resolve wind in
channels, prevent disease, increase WBC count
[Zhi] Gan Cao (licorice) 12g
Harmonize herbs, protects the middle jiao
Du Zhong (eucommia bark) 12g
Direct Fu Zi to the back
Ji Xue Teng (millettia vine) 12g
Invigorate blood, free blood luos
Dan Gui (angelica sinensis rx.) 9g
Tonify blood
Mai Men Dong (ophiopogon rx.) 9g
Tonify Stomach yin
Qiang Huo (notopterygium rz.) 9g
Bi Syndrome in upper body
Du Huo (angelica rx.) 9g
Bi Syndrome in lower body (prevention & hips)
Hai Tong Pi (Erythrina bark) 9g
Dispel wind, cold, and damp via urine mildly
Di Long (earthworm) 9g
Dissolve masses, unblock channels
Patient should begin with six cups of water, boil to three cups over total of 45 minutes,
strain, and drink one cup per day every day to every other day, and discuss with practitioner
before refilling the formula.
* prepare 20min before adding remaining herbs
** add during last 15min of decoction
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Shaolin Wan Yang Gao [Dit Da Jow] (Shaolin 10,000 Respondings Plaster) – selected herbs***
Dang Gui 30g
Quicken Blood
Bai Zhi 30g
Hong Hua 30g
Chi Shao 30g
Ji Xue Teng 30g
Ru Xiang 15g
Generate Flesh
Mo Yao 15g
Fang Feng 15g
Dispel Wind
Jing Jie 15g
Gui Zhi 12g
Bai Hua She 30g
Chuan Niu Xi 30g
Dispel wind-damp
Mu Xiang 12g
Regulate Qi
She Xiang 6g
Aromatically Dispel dampness
Bing Pian 9g
Cang Zhu
Prepared in 2L of 160proof Vodka for three weeks, then used in daily application,
especially during massage/manipulation.
Massage
The most important, and most overlooked portion of any treatment of a joint or bone
condition is physical manipulation. The pathomechanism in most of these cases (if not an
autoimmune process) is cold settling due to lack of bloodflow and Qi in the area.
Massage both quickens blood and invigorates Qi in the area of manipulation. Using a
liniment and passive joint manipulation of the wrist and hand in this patient should result in both
comfort and positive results.
*** this formula has forty-seven herbs in it, not all of which are necessary for treatment. Omitted are many of the
bone-repairing herbs such as Yu Jin and Yan Hu Suo, which would actually aggravate this condition.
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Lifestyle
This patient’s number one roadblock to recovery is his physical condition. Ironically, it
is his physical condition that discourages him from acting to better it. A three-point lifestyle
recommendation could improve this situation:
Avoiding cold, raw foods, drinks, including dairy; avoiding coffee would be a
good idea, but compliance is a likely barrier in this case.
Avoiding wind and cold pathogenic influences by wearing proper attire, and
avoiding use of ice for injuries – instead use the liniment. “Ice is for dead people,”
(Bisio, 2004)
Increasing light to moderate exercise, eg: walking, taijiquan, dance, “Daily Dozen
(chapter 5) and the Eight Brocade Plus (chapter 6)” (Bisio, 2004); avoiding
repetitive manipulations using hands, including weight lifting, driving, etc…
Prognosis
If the patient is compliant, using both internal and external treatments, especially with the
herbal portion and lifestyle changes, a realistic appraisal would be vast improvement in six
months time with decreased degeneration to bony bi from five years to ten or more years. With
focus and determination, perhaps even the rest of his life.
More than likely without much compliance, this patient is looking at frozen joints with
bony bi syndrome within three to five years requiring surgery.
As the case progresses and the patient gradually reduces the number of treatments to once
a week or fewer due to home use of the medicinal liniment and herbs, it is important to
occasionally measure progress by measuring the active ROM and charting it in a graph over time
to keep in the patient’s file, marking significant decreases with likely culprits (eg: flu or winter)
that dissuade an individual from completing treatments. Measuring the size of the knuckle joints
over time may also help to assess the speed to deterioration in relation to the patient’s comfort
and pain levels. An occasional x-ray performed by the physician would be a good indicator of
success as well.
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Summary
As a sixty-three year old retired naval officer, the patient is seeking adjunctive treatment
for his rapidly deteriorating knuckle joints. He believes he has and is confirmable for arthritis or
cold predominant bi syndrome, which is changing into bony bi over time.
The acupuncture treatment is divided into constitutional treatment and treating the bi
syndrome with different acupuncture approaches, the first face up and the second face down and
using moxa. There are also two herbal formulas, Wu Tou Tang with modifications to be taken
internally, and Shaolin Wan Yang Jow to be applied externally to treat the bi syndrome within
and without. Also massage will be used to manipulate the joints and disperse accumulations.
Congruently the patient has three recommended lifestyle modifications: 1) change diet, 2)
avoid wind and cold, and 3) exercise lightly to improve the prognosis, which is very good with
compliance in slowing or halting the degenerative process now that the source of taxation is
removed (his work).
Arthritis is a condition that can be managed well, both in terms of pain relief from
acupuncture, and vascular improvement from herbs and massage. With these multiple methods
of treatment, more than likely this patient will get the relief he desires.
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Bibliography
Wu Y. & Fischer W., edited by Fratkin J. (1997) Practical Therapeutics of Traditional Chinese
Medicine, p. 258
Merck (2006) The Merck Manual 18th Edition, pp. 283-285, 294-297
De Chan, P., translated by Zhang Ting-Jiang and Flaws, B. (1995) Secret Shaolin Formulas for
the Treatment of External Injury, pp. 81, 82
Bisio T. (2004) A Tooth from the Tiger’s Mouth, pp 22-24, 262.
Maciocia G. (1987) Tongue Diagnosis in Chinese Medicine, p. 96
Maciocia G., forward by Clavey S. (2008) The Practice of Chinese Medicine Second Edition, pp.
974,