Peripheral Neuropathy

Comment by Chad J. Dupuis, L.Ac.

A couple quick questions before I can offer a clearer recommendation. If he can time the pain to the hour - when does it happen? And I'm assuming you've only seen him once at this point, correct? Is this the first time he's ever had acupuncture? Does he have any other health issues or lower back issues? What tests have they done? MRI of the brain? of the low back? Any history of bleeding disorders? Any history of diabetes?

Comment by Archived User

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.

Comment by Chad J. Dupuis, L.Ac.

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.

Comment by Archived User

Thanks for the advice. Strangely, I was thinking of trying electro-acupuncture first time and doing Tui na second time, to see if there is a difference, so we are on similar tracks.I will be seeing him on Tuesday, I will keep you informed.

Thanks again for your help

Cheers

Andrew Colombini BSc. (Hons) TCM MBAcC MAScCA

Comment by Archived User

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

Comment by Chad J. Dupuis, L.Ac.

I'm referring to the huatuo points (so essentially the thoracic and lumbar vertebrae). We use the huatuo points almost exclusively (theoretical bias), but they are particularly effective in pain/nerve related cases (in my opinion). When I mention the dermatome map (which also refers to the vertebrae) is just to use it along with physical palpation and an understanding of where the nerves at that segment go to help choose the best points. Dermatome maps can be helpful along with other palpatory information (obvious areas of tension, weakness, seeming structural mis-alignments, skin rashes near the segment, redness, etc.) when you only have speculative causes.

And it doesn't really matter what anyone thinks it is from our perspective, from what you describe, however, it seems to be originating from the L5 (sciatic) area. The best part of what we do is that you don't -need- to know, if you work the area appropriately the body will work itself out. Also don't rule out that there are two things going on at the same time (again it doesn't matter because by working the system it will resolve just fine) - but there doesn't have to be a single "cause". It is sometimes comforting to the patient to be told you have "x", but it is ultimately more comforting for your patient to be able to say "I don't care what it was, I'm better now, I don't know why, but I don't care.... I guess this stuff works..."

Comment by Archived User

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

Comment by Archived User

Hi Chad,

This is the latest on the gentleman with peripheral neuropathy.

I treated this gentleman for the second time on Tuesday. He told me that he had had no apparent reaction to the first treatment. I asked him a few questions, one in particular was whether he had floaters, which he confirmed that he does, he also said that he often gets dizzy when getting up quickly. Both these are symptoms associated with autonomic neuropathy.

I followed the suggestion that Chad made, I did some tuina on the cervical vertabrae, down the bladder channel, huatojaji points around T7, L1. L2, L3 L5. I needled around these same points, plus GB30, BL40, SI3/BL62 GB34 BL55, and a few ashi points on the posterior thigh and on the buttock adjacent to DU2,

I did use for a few minutes only electro acupuncture on L5 and L2 and GB30

I cupped around BL12 and BL14, and around L4 and L5

I finished with some tuina.

He phoned me on Friday evening asking to postpone the next treatment, because he had experienced an increase in pain, he also mentioned that he had also been sitting at his office desk, more than usual and he wasn't sure whether it was the acupuncture or his sedentary lifestyle.

I suggested that we should not postpone the next treatment (next Monday evening) and I would use less needles and not use the electro acupuncture.

I did say to him prior to treating him that it would be likely that symptoms would worsen before they got better. I believe that I have obviousy moved the qi stagnation and this is a positive sign.

Any other opinions ?

Cheers

Andrew Colombini BSc. (Hons) TCM MBAcC MAcSCA

Comment by Archived User

for me, the first issue is the patients age and length of the condition. in my opinion the age of this patient and length of the condition tells me that the root issue is a deficiency

having said this however, the pulse reveals an excess. therefore in my opinion, there is a deficiency root, and an excess branch

there is a saying that i think rings true in this case 'killing a sparrow with a machine gun'

because of the patients age and that the root is a deficiency, i believe that using a large number of points will only increase this deficiency and exsasperate the issue

in my opinion the deficiency is a yin deficiency ( i conclude this from the signs of heat, the condition worsening at night, dizziness etc) and that the excess is stagnation( i conclude this from the wiry pulse)

the treatment principle would then be to treat the root and the branch

for the deficiency, i would use are geshu(bl 17), ganshu(bl 18), pishu(bl 20), and yinxi(ht 6) i would use the .22 guage needles for these points. no manipulation on these points

for the excess i would use 3-4 cun needle (60-80 in length) with at least a .25 guage, and starting on the buttock where the pain begins, insert the needle transversely down towards the foot, following the painline. use a reducing method on this needle

Comment by Archived User

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

Comment by Chad J. Dupuis, L.Ac.

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.

Comment by Archived User

thanks Chad, sometimes if you get too many opinions, some of which you agree with and some not, you can get confused. I was generally quite pleased that I had got some reaction to the treatment. When the patient called me last Friday, he wanted to postpone the next treatment because of the increase in pain. I recommended that we didn't postpone the appointment but continue down the road I had selected (with you kind help of course) and make some minor adjustments.

He called me last night to confirm that he wanted today's appointment... so the pain must have subsided.

I will continue down the road...a keep you informed

Regards

Andrew Colombini

Comment by Archived User

I saw this gentleman yesterday evening. He explained that the pain was still occuring every other day, and that on the Friday after the last treatment (last Tuesday) the pain was worse than normal. He also tempered this statement by adding that he had also been sitting at his office desk more than usual (this is another instigator of pain).

I started with tuina on the C1 area, T3 and T7. I did notice on palpation that there feels like a vertebral fusion at T3 and T5. I massage (with thumb) at these points (huatuojaji points) and lower down at L2, L3, and L5.

I then needled DU20, GB20, Huato at T3, T7, L3, L5, PC6, BL40, GB30, LIV8 (all bilaterally) I left the needles in for about 25 minutes, then I removed them and did the tuina again as above, I did do a pulling and shaking manipulation on both legs and he interestingly said that the manipulation brought on the burning sensation in his right foot, but not the left.

I will be seeing him next Tuesday.

Cheers

Andrew Colombini BSc. (Hons) TCM MBAcC MAcSCA

Comment by Chad J. Dupuis, L.Ac.

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...

Comment by Archived User

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

Comment by Archived User

Hi Chad,

Today I treated this gentleman for the 4th time. In case you haven't remembered, he experiences the symptoms of pain in the buttocks (primarily in the right buttock, pain travels down the right leg, and he has a sensation of buring feet every other day, he refers to it as "good day" " bad day" today he referred to is as a good day.

When I asked him some questions today, he reported verbatim, "since you started the treatment, the good days are better and the bad days are distinctly worse"

I was a little puzzled, but after thinking I do believe that I have made some progress. He also stated that he had trouble distinguishing between whether the sensation in his feet was burning or freezing (a fine line here, I think)

Anyway, his pulse still remains slightly wiry, and his tongue, is long, pointed with a deepish crack in the ST/SP area, reddish around the liver and heart areas. I did notice some phlegms lines today.

Today, I needled DU20, GB20, Huato around T3, T5, T7, L2 L3, L5, GB30, GB54 BL40, SI3 on the left and BL62 on the right. LIV8.

I started with some tuina, on the Cervical vertabrae, and on BL13, BL15 and BL17

I grabbed and squeezed down the posterior thigh and calf muscle and massaged BL60 and KID3 simultaneously.

That's it for today.

Thanks

Andrew Colombini BSc. (Hons) TCM MBAcc MAcSCA

Comment by Archived User

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

Comment by Archived User

Hi Rachael,

Did you use specific head points?

Thanks

Andy

Comment by Chad J. Dupuis, L.Ac.

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

Comment by Archived User

Thanks for that Chad

Comment by Archived User

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

Comment by Archived User

Hi Beny,

Thanks for your thoughts. I have been concentrating on BL 25 and BL54, with other points around it. Last week I was a little more aggressive with the Tui Na around with a few hip rotations. I will see what the reaction is on Tuesday when I see him again.

I will keep you informed with the continuing saga.

Thanks again

Andrew Colombini BSc. (Hons) TCM MBAcC MAcSCA

Comment by Archived User

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

Comment by Chad J. Dupuis, L.Ac.

You are right in that CV 1 is not often used in the west. There is one exception, however, and that is within 5 Element Acupuncture where it is used within the CV/GV block (one of the 9 or so energetic block treatments). It is a personal point which really shouldn't be an issue, but I do know of male and female 5 element practitioner who refer out to a same gender practitioner when they have a patient that needs the CV/GV block treatment or others involving CV 1. I do know of others, however, that never refer out and have no problems using this point whatsoever.

Personally if you feel it is an appropriate point I don't think you should have any hesitation in using it. Explain the purpose to your patient and use it.

Comment by Archived User

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

Comment by Archived User

I have treated a few similar patients myself and have found that particularly if there is the inguinal issue as possible exacerbating influence that LR-5 can help turn the treatment round. One patient in particular found that even after 5 failed surgeries and all the Hua tuo jia ji and back shu style treatments that the neuropathy that had plagued for 20 years was gone, addmittedly only for 2 days but still a great result. I&#39ve also had a similar improvement adding and stimulating BL-40 and BL-10 together, I&#39ve found that it is often good to look into the luo channels and branches from the main channels, this seems to be particularly helpful when there is some of the burning sensation as apposed to tingling and numbness.