Peripheral Neuropathy

Hi Chad,

yes it is the first time I have seen him. There is no history of diabetes, his parents died at 90 and 85 respectively, one of colon cancer and the other of cardiovascular disease (this he was not certain of) No other medical history other than inguinal hernia operations around about the time when this neurological issue started. He has excellent blood pressure of 74/125, chest clear as a bell, fit and healthy, plays golf and goes to the gym 3 times per week. non smoker, virtual non drinker, relatively healthy eater. No history of back pain. As far as the time is concerned I think he said around about 4pm after a day of sitting in the office and generally standing. Walking whilst playing golf doesn't appear to cause a problem, but standing stationary for periods of time or sitting at length will instigate the pain. Other issues, are he opens his bowels every other day, tendency towards hard stools, this is probably made worse by his lack of drinking, he drinks very little fluids, other than a few coffees per day ,which would cause a drying effect anyway. He shows signs of heat, red tongue and rather full and rapid pulse on the right.

He has had MRI scans, (not sure whether they were brain scans), judging from what he said I get the impression that he has had a lot of investigation, the very fact that he has been diagnosed with peripheral neuropathy from my experience tends to say that Western medicine isn't really certain what the underlying cause is. It would seem that he has given up a little with WM and now is trying alternative medicine.

If I can give you any other information please just ask, I'm a little lost, bit would really like to shed some light on this condition.

The first part that stands out to me is when you remark that "no medical history other than inguinal hernia operations around about the time when this neurological issue started". It would be important to know if he had any of this pain before this surgery. It is not uncommon for a nerve to be "nicked" during a procedure like this and the pain could stem or at least be contributed to by that. This information may or may not change how you would treat him, but to me the order of events is important.

From the description of the pain it sounds more like sciatic nerve pain, but the way to distinguish this is to look at the exact flow of the area of pain (dermatome charts can be helpful here). I doubt this would baffle neurologists, but the pain can come about without significant back problems so I suppose it could be overlooked. Either way, burning pain is neuropathy. The importance of knowing the path of the pain is that it will help you to see what discs/areas the nerves involved originate from.

The points you are using generally seem appropriate, so what I can offer is only what I would do if this were my patient. For issues of this nature we tend to focus on huatuo needling and tuina. Personally I use very little electro-acupuncture, relying instead on tuina as it more directly effects the structural issues (my bias). I would caution you, however, that electro-acupuncture can aggravate neuropathy cases as can direct needling so you need to experiment and watch the patient response (both immediately and symptoms wise) closely.

As we don't know whether it is a "brain" problem, or a "structural" problem or simply a nicked nerve from the surgery you have to branch out the treatment a little. I would just stick with what you are doing for at least 3-6 treatments and only alter it significantly if you are not getting results. Personally I would change around most of the upper points (UB 12, UB 14, etc.) and incorporate the following:

GV 20 - motor cortex

GB 20 - release the neck

Huatuo of C1 (communication from brain - tuina only), T1 (any bone problem), T7 (circulation into the lower abdomen and lower legs), L1 (adrenal, testes, inguinal hernia hx), L2 (kidney, seminal vessicle, inguinal hernia hx), L3 (prostate and leg circulation), L5 (colon and leg circulation, sciatic pain) and/or the eight liao. Without seeing the patient, I would focus on T7, L1, L2, and L3. Adding or switching to L5 or the eight liao based on the path of pain.

All of the other GB points are fine, I would add UB 40 which does a good job of releasing the lower back muscles and improving circulation in the leg and consider SI 3 and UB 62 instead of UB 60 and LV 8 instead of SP 6 which effects the circulation the knee and leg better.

We usually start and end each treatment with strong tuina on the neck and huatuo areas. I would focus the tuina on C1, T7, L1, L2, L3 and L5 looking for any deviations in the musculature surrounding the spine. Cupping may be appropriate in those areas as well.

Chad, when you say T7, L1, L2, L3 are you refering to the dermatomes map or the thoracic and Lumbar vertabrae. I wasn't quite sure where you were suggesting tuina.

He refuses to accept that it could be sciatica, but I agree with you that it could have been caused by the hernia repairs, I will ask him next time whether the neurologists have suggested the same, it is hard to believe that they didn't.

Thanks again

Andrew Colombini BSc. (Hons) TCM MBAcC MAcSCA

Totally agreed, huatoujaji points it is then... I thought I may have misunderstood.

Interestingly, I have been doing some research today and did a little differential diagnosis based on WM, he has little or no sweating, he is more constipated than normal (opens bowels every other day and it is dry), his feet burn, he does not tolerate heat well, symptoms worse at night, these point to autonomic neuropathy, (still idiopathic, but slightly more defined)

Thanks for your help.

I'll keep in touch.

Cheers

Andrew Colombini BSc. (Hons) TCM MBAcC MAcSCA

A few points.

One this is a complicated condition so you will expect some ups and downs initially you should stick to your treatment plan for at least 3-5 treatments before you change anything (which is what I recommended initially). And while I agree you need to be "lighter" in certain cases (elderly or otherwise) this patient is not weak or elderly from what you have described. Along that same note, the huatuo points do not, in my opinion, lend themselves well to the possibility of overtreatment as much as other points may. This is one of many reasons we use them. By that I mean the huatuo points are helpful locally and structurally and are not as energetically moving so overtreatment is much less of an issue with them (my opinion). Additionally, you can better control treatments in this regard by adjusting needling depth and technique than by point choice (again my opinion).

Also not sure what tuina techniques you are using but our focus is largely with the thumbs in the huatuo areas to get more "spacing" between the discs. Essentially push in with the thumb at the space between the discs and spread outward on either side. This facilitates the nerve function and alleviates structural mis-alignments.

The truth is you got a change and change is change. Particularly in such an odd case that is so reproducible and chronic. The worst that can happen with acupuncture (and the other million treatments he has tried) is nothing, while we prefer each treatment to lead to constant improvement that is unrealistic initially. While it doesn't happen often I would rather see a temporary aggravation than to not have anything happen.

The worsening of symptoms only happens (when it does which is rare) during the first 1 or 2 treatments. Adjustments should be mild so long as you are confident in what you are trying to accomplish. After 3-5 treatments you can re-examine what you are doing if results are not there.

For next time I recommend no electro (which is what I recommended initially), the points I prescribed were a range so I would be slightly more selective particularly in the lower legs and near areas of the most pain (that is less down in the legs and no ashi points (good general rule for neuropathy)). From what I can see I would start with tuina in the neck and c1 area to start, then needle PC 7 or HT 7 to help the patient relax generally and during the treatment, UB 40, LV 8, GV 20, GB 20, huatuo's bilaterally of T7, L3, L5, 2nd liao all with even needling technique and not too deep, finish with more tuina in the neck, c1, and huatuo areas used within treatment with technique described above. Leave the cupping out initially unless the muscles are incredibly stiff and the needling and tuina cannot loosen them. Cupping should be the last technique if it is used and only when everything else still leaves tension.

Thanks Tim, I tend to agree with you, and I would be doing something along these lines next time. He emailed me to say that he had had some increase in pain since the last treatment. I did say that I would do something less agressive next time around. I was expecting to see an adverse reaction, because I did stir it up a little.

I will keep you informed as to the further outcome.

Thanks again for your advice.

Andrew Colombini BSc. (Hons) TCM MBAcC MAcSCA

Switching sides is a very good sign, particularly for such a unique case. Generally switching sides means it is a disc/nerve problem and not a brain problem - so that is good. Hopefully what will happen over the treatments is the area of pain will start to shrink and become more focal. Basically, the pain should stop going down the leg as far until it eventually only hurts in the back somewhere and then when you focus in there the pain will be gone...

Thanks Chad, just to make sure we are singing from the same song sheet, the pain has always been down the right leg primarily and mildy in the left leg.

When I did the shaking and pulling manipulation on both legs I was trying to see if the reaction was the same with both legs, but as I said the burning sensation only occured in the right foot, and not on the left.

I mention this, because I wasn't sure by what you meant by changing sides.

I will keep you informed.

Cheers

Andrew Colombini BSc. (Hons) TCM MBAcC MAcSCA

Just for reference sake, we have a small section on scalp acupuncture that you may find useful.

I successfully treated a case of neuropathy with traditional Chinese scalp acupuncture. The pain pattern was different from that of your patient but it still might be worth a try. My patient felt pain in his feet only, particularly in one foot. The pain was intense, fairly constant and would wake the patient up at night with a jolt. It was caused by chemotherapy treatment for colon cancer.

Treatment was centered on the upper 1/5 of the sensory and motor lines( thread inferiorly and contralaterally with 36 gauge needles). The patient could feel sensations in his foot/feet with insertion and stimulation of the needles. He was a retired MD and was quite shocked that the treatment worked so well.

Good luck

Rachel

Hi Andrew,

I read with interest all your treatments, and advices received so far, referring to this particular case. The most interesting fact is the every second day "bad day", and at night; is it always around the same hour?, but coming back to the descript facts..I would tend to think that your patient, may very probably suffer from a muscle contraction, at the center of his upper sacro/lower L4-L5 area, that affects the buttocs area, specially the right side. If I were you, I would massage this area, gently, the type of osteopathic massage, and then, insert needles (1"-0.34gauge) in the BL25 area, billateral, manipulate a bit, as the cartilage might be inflamated, and more importantly, manipulate the BL54 point - the hollow cavity thru' where the ciatic nerve passes down the leg, to liberate the VERY pbable muscle contraction there may be. It might be quite a tender point, more on the right than the left side. By manipulating, I would insert and pull out rapidly several times in this particular point, using a 0.32/2" or 3" long needle. I have had many patients that with very few treatments have regained complete comfort and NO pain after this manipulation. You may consider measuring your patient legs' lengh (the longer leg syndrome...:-)) as this may contribute quite a bit to his bad musculo/skeletical position, as he sits many hours a day...and probably doesn't do anything to help his lower back zone...as well as affecting his bowel movement....

All the best

Beny Lotringer

Chad,

with reference to this patient, I have considered that in view the latest MRI and blood tests have shown nothing of any significance, admittedly and MRI doesn't show any possible nerve entrapments, but MRN are not readily available here as far as I know. I have started to consider that in view of the location of the pain, on the ischial tuberosity that maybe the Pudendal nerve is implicated, I still need to ask some questions relating to this, but if the answers point more to this I would use REN1 as a local point, based on the principle of -local, adjacent and distil- In China REN1 is used quite liberally, however in Europe practitioners tend to shy away from this point based primarily on its location and it is considered way too personal. Perhaps if this patient was female it may have other issues involved, albeit that I do not have a problem with the use of this point.

Do you or any other of our learned colleagues have a view regarding the use of REN1 in this instance and in general.

Thanks

Andrew Colombini BSc. (Hons) TCM MBAcC MAcsCA

Thanks Chad,

I did explain to the patient last week that this point was a consideration, and I explained my logic. he didn't appear to have a problem with it. This would be the first time that I have used this point.

Thanks for your opinion.

Regards