TCM Case Work-Up

This page may be removed from patient intake form in order to work on. Work must be completed and returned before the
second visit. Patient name, first or last, should not be written anywhere on this page. All reference to the patient is by assigned
file number located on the patient’s folder.

Patient File Number: 008 CAS Intern Name: Huiying Chin

Date of Treatment: Sep 15 1:15pm Clinic Day/Time Wednesday Supervisor Signature: Bing Yang

MC1: Dull, tightness, ache in right forearm when stretching. Inner arm pain. Began 12 weeks ago. Comes
and goes. Regular kayaker, movement helps. No correlation to weather.

MC2: Tingling dull pain in both knees triggered by diet (sugar or gluten), a lot of hiking downhill. History
of Lyme Disease with swollen knees

Sneezes in the sun, runs warm, sweats more in arm pits. Sweats easily. Cold hands and feet.

Appetite: Excessive, 6 meals a day, always hungry. Likes sweets

Sleep: Good, 5am bathroom break, rests 9-11pm, takes 30 mins to fall asleep. Sleeps on back, stresses
about posture and shoulder pain.

Cycle: Regular, 28-29 days, 6-7 days, heavy, red, sometimes clots. PMS: LBP and breast tenderness,
headaches. Less severe now. HA on first day of period. No cramping

BM: Daily, sometimes formed, sometimes soft. Pain and constipation during period. Distention and pain
before BM. No bloating. Urination: Sometimes urgency to go but only a few drops. No UTI. Itchy vagina.
No change in libido, trying to conceive.

Stress: 5/10 Some stress, anxiety and overthinking. Adjusting to school, scrambling

Pulse: Deep and weak overall, wiry on left, thin liver, weak kidney yang, weak spleen.

Diagnostic categories with signs and symptoms to support each category:

Exterior/Interior: Interior and Exterior – overexertion and exposure to wind/cold in kayaking and hiking
causes wind/cold/damp stagnation in muscle level worsen over time with use, stress, overthinking,
fatigue

Excess/Deficiency – Deficient spleen (weak muscles), XS in qi stagnation/pain in muscles.

Cold/Heat – patient is more deficient, so more cold signs

Yin/Yang – Qi deficiency in spleen, lung, kidney makes this more Yin case

Diagnosis based directly on above diagnostic categories (include a diagnosis for each MC/SC):

Inner arm pain – Qi stagnation in Lung/HT/PC channel of right arm due to overuse
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Knee pain/tingling – Blood deficiency and Qi stagnation – history of Lyme disease depleted Wei Qi and
Nutritive Qi. Overuse in hiking also causes qi stagnation/deficiency in muscle
Lung Qi deficiency – sweats easily, sneezes in the sun, LU Channel arm pain
Spleen qi deficiency – soft stools, craves sweet, weak spleen pulse, patient is thin and always hungry. Poor
digestion. Distention and pain before BM, overthinking
Kidney Qi and yang deficiency – urgency to urinate, wakes up to pee at night, cold hands and feet.
Liver Qi stagnation – stress, breast distention and PMS constipation, wiry pulse

Explanation of Diagnosis:
Overexertion, overthinking, stress, fatigue depletes Spleen Qi and causes liver qi stagnation. Patient’s
digestion is poor so she cannot absorb enough nutritive qi from food. Her active lifestyle and history with
Lyme Disease also overuses her Lung qi and overall qi – kayaking in cold weather/on the water, hiking
outdoors. Deficient Lung qi and Kidney yang qi causes urgency to pee, cold hands and feet, easy
sweating. Liver Qi stagnation also leads to PMS breast distention and constipation. Long term qi
deficiency is beginning to cause blood deficiency. Insufficient nutritive qi makes her muscles even weaker
and there is Lung channel stagnation/deficiency on the right inner arm that feels better with
pressure/massage. But the muscles are soft to palpation, weak/deficient.

Treatment Principle based directly on above diagnosis (include a treatment principle for each MC/SC):
Tonify Spleen and course Liver Qi – support muscles and relieve PMS constipation/stress
Calm the Shen – reduce anxiety and overthinking
Nourish Kidney Yang – warm the middle and lower burner
Tonify Lung Qi – Strengthen patient’s constitution and qi transformation with nutritive qi

Pool of points, adjunctive techniques: with clear reasons for using each, what method and what adjunctive
techniques will be used:
LV3 and LI4 – course LV qi stagnation
SP4 and PC6 – tonify spleen and move stagnation, move Chong to support fertility
LU7 and KD6 – boost Lung and kidney qi, tonify Ren channel to support women’s fertility
ST36 and SP6 – tonify Qi and blood
HT7 – Calm the shen and tonify heart blood
LU 9 – tonify Lungs
KD3 – tonify KD qi and yang
CV4 – Boost overall Qi and blood and Yang
CV6- Boost overall Qi
CV12 – Boost middle burner to tonify SP and ST
Yintang – Calm the Shen
TW5 and GB41 – Harmonize triple burner and Dai mai – reduce stress
Knee brace – Xi yan, He Ding
GB34 through needle with SP9 – harmonize ying and yang of knee channels, tonify sinews
DU14 – tonify KD ministerial fire
BL18 – tonify LV
BL20 – tonify SP
BL23 – tonify KD

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BL15 – tonify HT and calm shen
BL13 – tonify LU

Citation in support of diagnosis:

Information/quote, Author, Book Title (italics), Edition (if applicable), City of Publisher: Name of Publisher; Year of
Publication, (page numbers)
Chen Ping, Diagnosis in Traditional Chinese Medicine, Taos, New Mexico, Complementary Medicine Press,
2004 (220-223 Heart blood deficiency patterns) (70-73 pain)
Hong-zhou Wu, Zhao-qin Fang, Pan-ji Cheng, Chou-ping Han, Introduction to Diagnosis in Traditional
Chinese Medicine, Hackensack NJ, World Century Publishing Corporation, 2013 (p132 relationship
between heart and spleen)
Xue-mei Li, Jingyi Zhao, Acupuncture Patterns and Practice, Seattle, WA, Eastland Press, 2012, (164
insomnia)

Treatment Plan: #_5_of treatments for #5 of weeks, then re-evaluate.

Prognosis: Good, patient is motivated, active and young. Condition is not chronic and still early-
stage.

Research Article Summary (Article 1)

Title Acupuncture and Osteoarthritis of the Knee

A Review of Randomized, Controlled Trials
Author/s Terry Kit Selfe, DC, PhD and Ann Gill Taylor, EdD, RN, FAAN

Journal Fam Community Health. 2008 Jul–Sep; 31(3): 247–254.

Publication Date 2008 Jul-Sep

Key Findings (at least 200 words)

Osteoarthritis of the knee is a major cause of disability among adults. Treatment is focused on
symptom management, with nonpharmacologic therapies being the preferred first line of
treatment. Acupuncture is considered a potentially useful treatment for osteoarthritis. The
objective of this article is to review the English-language articles, indexed in MEDLINE or CINAHL,
describing randomized, controlled trials of the effects of needle or electroacupuncture on knee
osteoarthritis. Ten trials representing 1456 participants met the inclusion criteria and were
analyzed. These studies provide evidence that acupuncture is an effective treatment for pain
and physical dysfunction associated with osteoarthritis of the knee.

Identifying possible mechanisms of action that fit within the paradigm of Western medicine has
helped to make acupuncture more acceptable in the United States. In 1996, the Food and Drug
Administration reclassified acupuncture needles from Class III (investigational use) to Class II
(general acupuncture use).17 In 1997, National Institutes of Health consensus panel on

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acupuncture concluded that there was evidence of the usefulness of acupuncture to treat
postoperative and chemotherapy nausea and vomiting in adults, as well as postoperative dental
pain. In addition, the panel stated that acupuncture might be useful as an adjunct or alternative
treatment for osteoarthritis.18

When the ACR Recommendations for the Medical Management of Osteoarthritis of the Hip and
Knee11 were updated in 2000, a recommendation about acupuncture was deferred because of
a lack of sham-controlled trials, although the guidelines note that an NIH-funded, randomized,
sham-controlled study was underway. Since that time, the results of that study, and some
others, have been published. This article reviews the randomized, controlled trials using
acupuncture for the treatment of the symptoms of osteoarthritis of the knee.

Application to your case (Article 1)

How might you incorporate the information in this article into your care of the patient? (at least
300 words)
A lot of the randomized trials incorporated multiple treatments per week and even every other day
treatment for 2 to 3 weeks. This treatment frequency is worth considering as osteoarthritis is a
condition of inflammation that needs a lot of attention and treatment.

I would recommend my patient with knee pain to get more frequent treatments in the early stage
of their pain – if acute injuries were involved to get to a better health outcome.

The treatment used in these studies mostly treated points such as: ST35, ST36, GB34, and SP9. I will
make sure I include these in my treatment. The other points are ST34, SP6, LI4, GB39, BL60, KD3
and Xiyan. These are also points worth considering. I did not expect LI4 to be used for a knee
condition. Many of the studies emphasized “de qi” sensation in the research, which is surprising to
me, so I will remember to check my patient’s reaction to these points during and after treatment.

Looking at the outcome measures of these studies, I am interested to incorporate in my follow up

these questions: Joint range-of-motion, walk times before pain episodes, quality of life measures,
reduction of pain immediately after treatment.

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Research Article Summary (Article 2)

Title Acupuncture for Chronic Knee Pain A Randomized Clinical Trial

Author/s Rana S. Hinman, PhD; Paul McCrory, PhD; Marie Pirotta, PhD; Ian Relf, MSc; Andrew
Forbes, PhD; Kay M. Crossley, PhD; Elizabeth Williamson, PhD; Mary Kyriakides, BAppSc; Kitty
Novy, BNurs; Ben R. Metcalf, BSc; Anthony Harris, MSc; Prasuna Reddy, PhD; Philip G. Conaghan,
PhD; Kim L. Bennell, PhD
Journal JAMA. 2014;312(13):1313-1322. doi:10.1001/jama.2014.12660

Publication Date

Key Findings (at least 200 words)

IMPORTANCE
There is debate about benefits of acupuncture for knee pain.
OBJECTIVE
To determine the efficacy of laser and needle acupuncture for chronic knee pain.

DESIGN, SETTING, AND PARTICIPANTS

Zelen-design clinical trial (randomization occurred before informed consent), in Victoria,
Australia (February 2010-December 2012). Community volunteers (282 patients aged 50 years
with chronic knee pain) were treated by family physician acupuncturists.
INTERVENTIONS No acupuncture (control group, n = 71) and needle (n = 70), laser (n = 71), and
sham laser (n = 70) acupuncture. Treatments were delivered for 12 weeks. Participants and
acupuncturists were blinded to laser and sham laser acupuncture. Control participants were
unaware of the trial.

MAIN OUTCOMES AND MEASURES

Primary outcomes were average knee pain (numeric rating scale, 0 [no pain] to 10 [worst pain
possible]; minimal clinically important difference [MCID], 1.8 units) and physical function
(Western Ontario and McMaster Universities Osteoarthritis Index, 0 [no difficulty] to 68
[extreme difficulty]; MCID, 6 units) at 12 weeks. Secondary outcomes included other pain and
function measures, quality of life, global change, and 1-year follow-up. Analyses were by
intention-to-treat using multiple imputation for missing outcome data.

RESULTS
At 12 weeks and 1 year, 26 (9%) and 50 (18%) participants were lost to follow-up, respectively.
Analyses showed neither needle nor laser acupuncture significantly improved pain (mean
difference; −0.4 units; 95% CI, −1.2 to 0.4, and −0.1; 95% CI, −0.9 to 0.7, respectively) or function
(−1.7; 95% CI, −6.1 to 2.6, and 0.5; 95% CI, −3.4 to 4.4, respectively) compared with sham at 12
weeks. Compared with control, needle and laser acupuncture resulted in modest improvements
in pain (−1.1; 95% CI, −1.8 to −0.4, and −0.8; 95% CI, −1.5 to −0.1, respectively) at 12 weeks, but
not at 1 year. Needle acupuncture resulted in modest improvement in function compared with
control at 12 weeks (−3.9; 95% CI, −7.7 to −0.2) but was not significantly different from sham

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(−1.7; 95% CI, −6.1 to 2.6) and was not maintained at 1 year. There were no differences for most
secondary outcomes and no serious adverse events.

CONCLUSIONS AND RELEVANCE

In patients older than 50 years with moderate or severe chronic knee pain, neither laser nor
needle acupuncture conferred benefit over sham for pain or function. Our findings do not
support acupuncture for these patients.

Application to your case (Article 2)

How might you incorporate the information in this article into your care of the patient? (at least
300 words)
I looked at the intervention given in this research for some ideas in my patient care.

Acupuncturists treated participants according to usual practice using a standardized set of

acupuncture points (eTable 2 in Supplement 2), selecting from points around the knee as well as
distal points. Other points could be used at the acupuncturist’s discretion depending on clinical
examination (eg, site and causes of pain). Initial treatment permitted a maximum of 6 points (4 on
the study limb and 2 additional points chosen per protocol). In subsequent treatments, points were
added and varied as clinically indicated. Single-use Seirin needles (0.25 × 40 mm) were used for
needle acupuncture (administered with the patient lying down and needles left in situ while the
patient rested).

I would like to incorporate some of these points into my treatment protocol for knee pain.
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Some of the points such as LV7 and 9 were new points I never considered.

LI11, DU14, BL11 were also new to me for treating knee pain.
I can see their correlation to heat in the channel and the hui point of bones.

The fact that even sham acupuncture on these points were effective in pain reduction
means that they are very powerful even with acupressure and self-massage at home.

The research mentioned how many participants did not see lasting results after 1 year of
observation window. This means that knee arthritis requires long term care even with
acupuncture and frequent treatments to sustain the results.

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Research Article Summary (Article 3)

Title Motion style acupuncture therapy for shoulder pain: a randomized controlled trial

Author/s Guang-Xia Shi,1 Bao-Zhen Liu,2 Jun Wang,3 Qing-Nan Fu,1 San-Feng Sun,2 Rui-Li

Liang,2 Jing Li,3 Jian-Feng Tu,1 Cheng Tan,3 and Cun-Zhi Liu4
Journal J Pain Res. 2018; 11: 2039–2050.

Publication Date 2018 Sep 25

Key Findings (at least 200 words)

Background
Strategies for preventing the persistence of pain and disability beyond the acute phase in
shoulder pain patients are critically needed. Conventional acupuncture therapy (CAT) or motion
style acupuncture therapy (MSAT) alone results in relative improvements in painful conditions in
shoulder pain patients; combined interventions may have more global effects. The aim of this
study is to evaluate the efficacy and safety of MSAT vs CAT for shoulder pain.

Methods
A randomized controlled trial using a factorial design was conducted from January 2014 to
December 2015. Patients with a primary complaint of one-sided shoulder pain participated at
three study sites. Eligible individuals were randomly assigned to receive MSAT plus minimal CAT
(mCAT), CAT plus minimal MSAT (mMSAT), MSAT plus CAT, or mMSAT plus mCAT for 6 weeks in
a 1:1:1:1 ratio. The primary outcome was change in shoulder pain intensity (measured using
visual analog scale). The secondary outcomes included change in function of the shoulder joint
(Constant–Murley score) and the health-related quality of life (Short Form-36 Health Survey).
Moreover, perceived credibility of acupuncture was measured using the Treatment Credibility
Scale. The outcomes were assessed at baseline and at 6, 10, and 18 weeks after randomization.
Analysis of covariance with the baseline score adjustment had been used to determine the
primary end point. The between-group differences of MSAT vs mMSAT and CAT vs mCAT were
estimated, respectively, after tests of interaction between the two-dimensional interventions.
All main analyses followed the intention-to-treat principle.

Results
A total of 164 patients completed the study. MSAT was superior to mMSAT in alleviating pain
intensity at 10 weeks (P=0.024), and it was maintained for 18 weeks (P=0.013). Statistically
significant differences were found when comparing MSAT with mMSAT for improvement in
shoulder function (6 weeks, P=0.01; 10 weeks, P=0.006; and 18 weeks, P=0.01), physical health
(10 weeks, P=0.023 and 18 weeks, P=0.015), and mental health (18 weeks, P=0.05). No
significant differences were found in CAT when compared with mCAT.

Conclusion
After 18 weeks of treatment, pain and joint functions are improved more with MSAT than with

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minimal motion style acupuncture or conventional acupuncture in patients with shoulder pain.

Application to your case (Article 3)

How might you incorporate the information in this article into your care of the patient? (at least
300 words)

Acupuncture therapy has been mostly used for a range of painful and other conditions, including
musculoskeletal disorders of the shoulder or other regions; however, high-quality evidence for its
efficacy is scant.8 Conventional acupuncture, inserting needles into specific points in the body, has
been used in China for >2000 years. Motion style acupuncture therapy (MSAT) is a relatively novel
acupuncture method that has been recently used more often to treat pain in China and South
Korea. It is similar to traditional acupuncture in that the needles are inserted at specific
acupuncture points, but it is unique in that it requires passive or active movement of the patient’s
body while the acupuncture needles are retained.

They found that MSAT has positive effects such as immediate pain relief and the functional recovery
of acute low back pain patients. MSAT or conventional acupuncture alone results in relative
improvements in painful conditions in shoulder pain patients; combined interventions may have
more global effects.

I would like to try MSAT in my patient care of musculoskeletal issues as described below:
Motion style acupuncture therapy
The patient was asked to remain seated and to relax their shoulder. In this position, the
acupuncturist inserted disposable needles to a depth of 10–15 mm at the subject’s “Tiaokou” (ST
38, contralateral), followed by stimulation with rotational movements of the needle in an arc of at
least 180° to achieve a strong sense of Deqi (gradually increasing stimulation at ST 38 until a
sensation radiates throughout the lower limb). The needle was maintained in that position for 20
minutes and was manipulated for 1 minute every 5 minutes (with a total of four manipulations per
session). During the periods of manipulation, the subjects were asked to perform active
mobilization of the shoulder, in abduction and internal and external rotations.

Minimal MSAT
The needle was inserted at a nonacupoint (located lateral to the shank, 3 cm below gallbladder 34,
and midway between the gallbladder meridian and the bladder meridian) distal from the shoulder.
The needle was inserted to a depth of 3–5 mm using a shallow needling technique without Deqi and
was maintained in that position for 20 minutes. In this period, the subjects were asked to perform
active mobilization of the shoulder, in abduction and internal and external rotations.

Biomedica How does the patient’s biomedical diagnosis inform your approach to treatment?
l Diagnosis
(For example, are there any points or herbs you are avoiding? Are there ways in which the
patient is limited in the types of treatment they can receive? Are there ways in which you are
coordinating care with other treatment providers?) (at least 200 words)

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NA No biomedical diagnosis for patient.

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