Acupuncture and Oriental Herbs for Fibromyalgia
Chief Complaint: Body Pain
Western Diagnosis: Fibromyalgia
Medical History: Patient is a 36 year old female who has a chief complaint of fibromyalgia. She has been experiencing pain in her knees, hips and low back for the past 10 years. This pain began around the same time that she had surgery for bilateral epicondylitis. This patient has experienced a lot of stress in her life related to work and a divorce several years ago. She is only able to exercise occasionally because of pain limitations. She has smoked 1 pack of cigarettes a day for the past 20 years. She does not consume alcohol or caffeine. She has a history of fibroids and gallstones, and her gallbladder was removed 5 years ago. She was also diagnosed with Irritable Bowel Syndrome 5 years ago.
Questioning exam: Patient describes her body pain as a dull achy sensation that can sometimes be sharp. She has constant pain in her knees and hips that she rates as a 7-8/10 pain level. Pain can get as high as a 10/10 level frequently. Pain also radiates to her low back, legs and elbows. Symptoms are aggravated by cold, rainy and humid weather and also with stress and too much activity. Her symptoms are better with heat, massage and rest. She has tried pain medication in the past and this caused her to have sweats and facial paralysis. Her overall body temperature runs warm with cold hands and feet. Her skin is dry and oily on her face with some acne. She experiences migraine headaches 2-3 times a month that occur in varied locations. She has frequent urination during the day, IBS with loose stool predominating. Her menstrual cycle is irregular every 23-35 days and she experiences a heavy flow, dark purple blood, clots, cramping and mood changes. She reports a low energy level and trouble falling asleep and staying asleep.
Pulse exam: The pulse rate is moderate and the overall quality is thin and tense. On the right side, the cun position feels deep and deficient, the guan is soft and slippery and the chi is tense, deep and thin. On her left side the cun position is soft, the guan and chi are thready.
Tongue exam: Tongue body is a red/purple color with scallops. The coat is moist and white, slightly greasy.
OM Diagnosis: I diagnosed this patient with Wind-Cold-Damp Bi syndrome. Rationale behind this is moving pain that is worse with wind, cold and damp weather, pain is better with heat and better with pressure. Her tongue has a greasy coat which indicates some damp retention. I also diagnosed this patient with blood stagnation. Symptoms to indicate this include red/purple tongue body, heavy dark purple menses with clots and cramping and a tension in the pulse. This patient also has some Liver Qi stagnation with Spleen Qi xu. This is evident with her symptoms of IBS that are worse with stress, her tense pulse, slippery Sp pulse, scallops, low energy, cold hands and feet.
Treatment Principle: Treatment principles are to expel wind, scatter cold, resolve damp, move blood, soothe the Liver and tonify the spleen
Point Prescription: LI4,LV3-4 Gates to move qi and blood stagnation, soothe Lv Qi
Yin tang-settle her emotions, calming
CV12, CV6, ST25-diamond treatment for digestive problems
Sp9-resolve damp, tonify Sp
SI3, BL62-open up the Du Channel
Bl18-soothe Lv Qi
BL19-tonify GB Qi
Bl20-tonify Sp Qi
I also used a TDP lamp with moxa essence oil on her knees and low back for 15 minutes each.
Herbal Formula: I gave this patient a Golden Flower Chinese Herbal Patent called Chase Wind Penetrate Bone. Dosage is 3 pills TID
Lifestyle Prescription: I advised this patient to consider taking a food allergy test to identify certain foods that may be a trigger for IBS symptoms. I also encouraged her to continue exercising and increase the amount of time gradually. I recommended her doing her elliptical machine 3 times weekly and increasing the time each week by 5 minutes. I gave her some information about quitting smoking, and steps to take before she sets a quit date.
Results: After two treatments, pain level was down from an 8/10 to a 0/10. She reported no knee, or hip pain. She reported some low back pain that occurred during the time of her menses. With continued weekly treatment, her level of 0/10 pain level was maintained and her pain did not return. I later dropped her down to treatment 2 times monthly and her pain seems to have stabilized. Patient reports no migraines or headaches, less diarrhea and her stress is still high but slightly more manageable. She is still having trouble falling asleep and having pain associated with her menstrual cycle. I recommend continued treatment for the next several months to work on regulating her menstrual cycle and IBS.
Synopsis: I was very impressed with how quickly this patient responded to Chinese Medicine. When she first came in to see me she was very hesitant and did not expect to get much relief. She was also very reserved and quite during her first 2 treatments, but then really opened up to me on our next sessions together.
Clinic Name: Northeast Acupuncture and Herbs
clinic address: 501 Riverway Place
Bedford, NH 03110
clinic phone number: (603) 647-0600
email address: email@example.com