CASE STUDY - TREATMENT OF ANKLE PAIN POST RECONSTRUCTIVE SURGERY

Jimi Windmills

ABSTRACT

This case report presents the treatment of ankle pain, 12 years after reconstructive surgery, that was the result of a car accident. For the purpose of confidentiality the patient will be referred to as Markus.

Markus is a 48 year old male, who in 1999 was involved in a car accident, which shattered his right ankle. The ankle was crushed so badly that when necrosis began, in hospital, the doctor recommended amputation. Perhaps by luck, Markus was assigned a surgeon who, perhaps feeling a tad ambitious that day, decided that even though the ankle had pretty much exploded, because the skin had not broken, all the parts for a reconstruction must logically still be contained within. Markus spent three months in traction on painkillers with his ankle still in a crushed state before the necrosis subsided, and they were able to begin the operation.

Markus has been able to walk on his ankle and gets around with perceived ease. However, he has experience pain and swelling in the ankle, which is especially bad after any period of prolonged use. The ankle, although painful serves well enough for walking even though its range of movement (ROM) is restricted to almost zero.

CASE HISTORY

Markus's main complaint was that after a period of standing or especially walking, his ankle would swell, and throb with pain. This pain had caused him to resign from his previous position as a night fill worker for Woolworths. I first treated Markus in the clinic three days after he had left his keys on the train and had had to run back to the train station, which (especially when walking can be a problem) had caused significant swelling and pain in his ankle.

Markus currently works on the weekends at the markets as a fairy floss vendor. In this position he tends to be on his feet all day.

In the initial consultation, Markus reported the following signs and symptoms.

• Sharp pain in the morning, especially with the first few steps of the day.
• Active and passive movement restricted to an extent as to be functionally not present.
• Disturbed neural sensations - pressing one location would elicit a touch sensation in a different location on the foot.
• Pain in the metatarsals with any amount of walking.
• Pain feels deep as opposed to superficial
• Most intense area of pain is inferior to the lateral malleolus
• Palpable deficiency in the stomach channel, particularly in the lower leg. There was an unusual 'pocket' with a 'bubble' of air under the skin in the area lateral to ST36. This is suggestive of muscle having been removed or relocated during surgery.
• Overuse 3 days prior (Monday) had caused significant pain and inflammation from the following day through to Thursday, our first consultation.
• Palpation of the ankle itself revealed that the foot and ankle while noticeably swollen were not hot to touch, in fact tending toward cool, and a little clammy. Normal bony landmarks of the talus, navicular, cuboid and cuniforms, were distorted, and in places impossible to navigate. This was a result of the reconstruction during surgery.

Tongue: Red, slightly dry, with peeled edges. Pulse: Wiry.

The diagnosis was Bony Bi obstructing Qi and Blood in the channels, collaterals, and joints of the right foot.

During this session I had Markus fill out an initial Measure Yourself Medical Outcome Profile (MYMOP2) form, so we could begin to track the outcome of the treatments over the next few weeks. This initial MYMOP2 recorded pain and swelling as assessable symptoms and rated them toward the worse end of the severity scale. Markus filled out follow up MYMOPS's each session. A discussion of points and treatment techniques, plus the outcome measures will follow the case history.

In the second session Markus reported that a new neural pain had developed since the last treatment. In that week he had also started wearing new orthopaedic inserts. The pain was in the area medial to the first metatarsal, between the points SP3, and SP4, and would begin within minutes of walking. We found that this was most likely cause by a compression or entrapment of the medial plantar nerve, a branch of the anterior tibial nerve. Markus reported that except this new pain, all symptoms were the same, but last weeks more acute pain and swelling had reduced by half after the treatment. We continued with the same point proscription as the first session, with the addition of an ahshi point between SP3 and SP4 with needle head moxa, at the location of the new pain.

The third session began with Markus reporting that he could stand all day working at the markets without causing pain, this was a terrific result for Markus as it allowed for him to maintain his income without having to endure pain for several days after working. He noted that there was still tenderness when getting out of bed, and long periods of use would still trigger swelling. The nervy sensation at SP3/4 was still persisting. Again, we continued our treatment protocol, as we were beginning to see some very real, and promising results.

In the fourth treatment Markus reported a reduction in the nervy sensation at SP3/4, and that overall his ankle was much better, and that there was considerably less swelling after excessive use. A new 'grabbing' sensation was noticed below the lateral malleolus in the area of BL62, which Markus said would, 'grab' and then quickly let go. This sensation was not painful, just unusual. In this session I paid extra attention to BL62, making sure to maintain stimulation, by often returning to the needle and stimulating it between insertions of other points.

In our final session, Markus reported that the nerve pain at SP3/4 had completely resolved, as had the 'grabbing' sensation at BL62. He said that his ankle could handle much more use before becoming swollen. When it did swell, the severity was greatly reduced and the swelling would resolve over a much shorter period of time, within hours rather than days. Pain with extended periods of use had all but disappeared. It was only extreme use such as running that would elicit pain.

TCM DIAGNOSIS, and TREATMENT

In the initial session we diagnosed Markus as having Bony Bi obstructing Qi and Blood in the channels, collaterals, and joints of the right foot. Thus, the approach taken in this case was essentially to address the pain and swelling locally by dispersing excess's such as stagnation and bony bi. Point prescription stayed the same, with the exception of the addition of an Ahshi point between SP3 and SP4 as mentioned in the case history. Most points had needle head moxa as an additional therapeutic aid to help move stagnation, and address the bony bi. All points were needled with 30X0.25mm needles, and strong Qi obtained at each point. The character ^ after a point signifies that needle head moxa was applied to the needle at that location.

The points used were GB34, GB39, GB40^, GB41^, ST36^, ST40^, ST41^, ST43^, LV3^, LV4^, KD3, KD5, KD6^, BL62^, SP5^, Ahshi point located between SP3/4^.

OUTCOME AND DISCUSSION

In this case the outcome was measured using the MYMOP2, with measures two patient nominated symptoms, and an associated activity to be measured. Markus nominated ankle pain as the first symptom and swelling as the second, with the associated activity being walking. In the MYMOP2 follow up survey, a third symptom can be nominated if one has arisen. As Markus noted neural pain between SP3 and SP4 in the second session, this became out third measured symptom. General well-being is also recorded

Symptoms are measured on a scale of 0 – 6, with 0 being 'as good as it could be' and 6 being 'as bad as it could be'. Lower scores therefore, represent better outcomes. The following graph and table show the progress of relieving symptoms over five sessions.

Symptom	Session 1	Session 2	Session 3	Session 4	Session 5
Ankle Pain	5	3	3	1	1
Swelling	4	3	2	0	1
Walking	5	3	3	1	1
Pain SP3/4	N/A	3	3	2	0
Wellbeing	2	2	1	6	1

We can see from this table that pain and swelling that started as quite severe, after 5 treatments, had improved dramatically. The abnormally high score in well-being in the fourth week was due to a bout of influenza that Markus suffered that week.

The next graph and accompanying table represents the scores for each session, totalled and averaged, to give an indication of the overall progress of the treatment. Lower scores are better.

Session	Treatment Score Average
Session 1	4
Session 2	2.8
Session 3	2.4
Session 4	2
Session 5	0.8

Given the nature of the condition and the length of time since surgery, it seems unlikely that complete, functional range of motion in the ankle joint could be restored. However, in this case it is likely possible to achieve long term reduction, or with extended treatment, complete negation of pain. Given the results of the outcome measures, I feel that with an extended course of treatment, Markus could make significant progress toward relief of pain and swelling completely.

CONCLUSION

This case report presented the treatment of pain and swelling of an ankle 12 years post reconstructive surgery. I have demonstrated the eficacy of this treatment, and shown results measured with the MYMOP2 survey. The results presented here are particularly important, as they have allowed the patient, to maintain his income in a manner that does not cause significant discomfort and pain, thus contributing a great deal to the patients quality of life.

CASE STUDY - DEPRESSION

A Clinical Report on the Treatment of Depression

Jimi Windmills

ABSTRACT

This case report presents the treatment of depression in a male patient in his mid 20's. For the purpose of client confidentiality the patient will be know as Hubert.

Major depressive disorder is a psychiatric mood disorder characterised by depressed mood and loss of interest or pleasure. These symptoms are often accompanied by “significant appetite or weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation (being restless and jittery, or alternatively, slower than usual), fatigue or loss of energy, feelings of worthlessness or excessive guilt, impaired thinking or concentration; indecisiveness, or suicidal thoughts/thoughts of death” (WHO 2011; Fry & Ryan 2007). According to Boon et al., it is twice as common in women than men, becomes more prominent toward middle age, and has a prevalence of between 5-10% of the general population (Boon 2006: 240). Boon et al. also says there are genetic factors that predispose to depression, however these are poorly understood (Boon et al. 2006: 240). It is widely regarded that emotional deprivation and adverse experiences in childhood can also be contributing factors to the subsequent development of major depressive disorder (Boon et al. 2006: 240).

The approach taken in this case was to address underlying deficiencies, while at the same time, disperse excess conditions such as stagnation and phlegm. Given the nature of the condition and the short duration of the treatment, it seems doubtful that a significant long-lasting effect was actually achieved. With particular regard to the patients propensity toward difficult living situations, and lack of supportive relationships in his life this is not surprising. Given the results of the outcome measures however, I do feel that with an extended course of treatment, and more support (particularly stable accommodation) in his life, Hubert could make significant progress toward recovery.

CASE HISTORY

Hubert suffers depression and anxiety. After a certain amount of time, becoming more familiar with Hubert, it became apparent that perhaps his anxiety and depression were part of a larger scope psychotic disorder along the lines of schizophrenia, involving some element of delusion or an inability to completely grasp reality.

Hubert's main complaint was that he felt down, and because of this, was having trouble concentrating. He considered himself a science-fiction novelist, despite the fact that he had never produced any substantial amount of work. In consultations, he made only fleeting eye contact. He was fairly tall and thin, almost to the point of being bony. His hair and skin were greasy, and he had an offensive odour that was difficult to remove from the room after a treatment. His personal hygiene was poor, once telling me that he preferred the cooler climate in Melbourne because he didn't have to shower very often. At the time of his treatments (beginning at the start of August), he said he had been living with his parents since March. He had told them that he was just visiting for Easter, but had stayed longer. Hubert said that his parents were a major source of his mental unease. He said that they persistently bullied him, and that they “rebel against him”. He said they were unhappy having him living at home. Hubert slept all day to avoid conflict with his parents, and would stay awake all night drinking coffee, unsuccessfully working on his novel. I found out in the second consultation that Hubert's father had died of asbestosis 5 years previously. Although he always referred to his “parents” it was actually only his mother that was around. Hubert described a history of emotional abuse from his parents, with his mother becoming the main perpetrator, since the death of his father. In my last session with Hubert, he informed me that he would not be continuing treatment, despite making some progress, as things had become intolerable with his mother, and he was moving back to Melbourne to live in a park. Until this time I had been unaware that before he came to Brisbane in March, he had actually been homeless, living in a park in Melbourne.

In the initial consultation, Hubert reported a gamut of signs and symptoms, making his case seem quite complex.

• Irregular sleeping hours, usually sleeping through the day and being awake all night.
• Sleep regularly disturbed by intense nightmares
• Waking feeling unrefreshed
• Anxiety and depression with pressure/heaviness in the chest
• Pressure in the head, headache front and temporal
• Difficulty concentrating
• Floaters and blurry vision with itchy eyes (for the last few months)
• Tinnitus for years, high pitched in both ears, worse when having difficulties concentrating
• Palpitations and panic attacks with shortness of breath – links to lack of motivation.
• Constant thirst, desire to drink in small sips
• Frustration, anger, and guilt.
• Poor relationship with parents who “rebel against him”
• Difficulty speaking – stutters
• Offensive, almost rancid body odour
• Makes no eye contact.

Tongue: purple body with red tip and sides, wet with a thick coat, and scalloped edges.

Pulse: weak and deep, rapid and wiry.

In the second consultation Hubert reported a general lift in energy and stated that his nightmares were a concern. Hubert said that he had nightmares every night which interrupted his sleep. His main concern was that sometimes, when he wasn't feeling as down as usual, and he felt things were progressing, he would have a particularly disturbing nightmare which would send him spiralling back down into severe depression. He reported that his anxiety was better and that his depression was easing, but that he was feeling a lot of anger. We discussed his relationship with his parents, and the role of their interaction on his mental health. He told me in this session that his father had passed away 5 yrs previously (which roughly coincided with the period of time he had been living in a park). There was obviously grief, and an element of guilt attached to this loss. In this consultation I gave Hubert a SF-36v2 Health survey to fill out, so that we could track and measure outcomes in a more quantitative way.

The third session began with Hubert feeling quite distressed. His mother had driven him into the city, and they had had and argument during the car trip. She had refused to drive him the extra distance to the clinic in Fortitude Valley. So, as well as being angry and frustrated with his mother, he was also out of breath from hurriedly walking the rest of the distance.

He reported that he felt the treatments were helping him a lot, and that aside from his current exasperation from the car trip, he said there had been a “dramatic improvement”. He reported that his dreams, were less frequent, and hardly noticeable, but that frustration was keeping him awake. He said that as I had recommended, he was drinking much less coffee, only 2 cups/day, and none at night, And was drinking more water, tea, and juice. He said that he had been sleeping to avoid his depression and anxiety, and also to avoid his “parents”, and that he was experiencing pressure in the head when he tried to concentrate. In this treatment we exchanged the Ren point pair LU7+KD6 with a Jue Yin point pair, using the earth points on the Liver and Pericardium channels, to nourish at the deepest yin level. By the end of this session Hubert had calmed significantly

Tongue: Thin coat, teeth marks, wet and swollen in the middle.

Pulse: Fast and Wiry.

Hubert's next session was with another student practitioner, to whom Hubert stated that the last treatment he had received had placed “a buffer between him and the people bullying him”. He said he was feeling mostly sad and angry, and was sick of feeling self-pitty. The same treatment protocol was followed in this session to maintain consistency.

In my last session with Hubert he informed me that while he felt he was still up and down emotionally, he felt he had made some improvement. He also said that most of the good work comes undone when he goes home to his “parents”. He told me that since he was no longer welcome at home, and since his mother was so over-controlling, he was going to move back to Melbourne. I asked if he had a place to stay down there, and he replied that there was a park that he lived in for 5 years before coming to Brisbane, and that he felt safe there. I encouraged him to seek out support services in Melbourne to assist him to find accommodation, but he didn't seem very interested in the idea. I also encouraged him to continue his treatments at the Endeavour campus in Melbourne, and arranged to have his file transferred and a treatment concession plan put in place. In this session, roughly a month from our first consultation, I got Hubert to fill out another SF-36v2 health survey. The results of which will be reported later.

TCM DIAGNOSIS AND TREATMENT

In the initial session we diagnosed Hubert as having Liver-Qi Stagnation and Qi xu, with underlying Kidney and Heart Qi xu leading to the heart not housing the mind (shen disturbance).

My initial thought was to treat this case the way it appeared (i.e. symptomatically) by addressing the component dysfunction of the Liver, Kidneys, and Heart. It was then pointed out that the Liver-Qi itself is most likely not the cause of the condition and that treating it would produce little change since it was a product of an underlying condition. To that effect we decided to treat at a deeper level through the penetrating vessel point combination PC6+SP4, along with REN17, 14, and YinTang.

In the second session we re-diagnosed his condition as Heart and Kidneys non communicating with Liver-Qi stagnation and phlegm misting the mind. To his previous treatment we added LU7 for grief, and KD6, since Heart and Kidneys not communicating is a Yin xu pattern. This point pair was also chosen to include the Ren channel in the treatment. ST40 and SP9 were added to address the phlegm. We prescribed the formula An Shen Ding Zhi Wan -

In the third treatment we exchanged the Ren point pair LU7+KD6 with a Jue Yin point pair LR3+PC7, picking the earth/yuan source points on the Liver and Pericardium channels, to nourish at the deepest yin level.

Hubert's final treatment continued with the previously established treatment plan. For Heart and Kidneys not communicating, with Liver-Qi stagnation and phlegm misting the mind. LR3+PC7 (Jue Yin earth) PC6+SP4 (Penetrating vessel), REN14 and 17 for the heart and Qi, and ST40 and SP9 for phlegm and damp, plus a refill of his prescription of An Shen Ding Zhi Wan.

WESTERN MEDICAL DIAGNOSIS

In western terms, Hubert would most likely be diagnosed as having major depressive disorder, as he fulfils the required criteria of having depressed mood, and loss of interest or pleasure, plus several other associated symptoms including insomnia and hypersomnia, impaired thinking and concentration, feelings of worthlessness and guilt, and weight loss. There is also the possibility that he may be diagnosed as having schizotypal personality disorder (SPD). SPD is characterised according to the World Health Organisation, and outlined in the WHO ICD-10, as behaviour and appearance that is odd, eccentric or peculiar, poor rapport with others and a tendency to social withdrawal, odd beliefs or magical thinking, influencing behaviour and inconsistent with cultural norms (WHO 2011).

TREATMENT PRINCIPLE

The initial treatment principle was to Tonify Heart and Kidneys, soothe the Liver and calm the shen. In the third session the treatment principle changed; Tonify and re-establish communication between Heart and Kidneys, resolve phlegm and damp, soothe the Liver and calm the Shen.

OUTCOME AND DISCUSSION

In this case the outcome is unfortunately not clear. Using The SF-36v2 health survey, we measured Hubert's perception of his physical and mental health in the second session, and then again in the last session almost one month later. The results show a clear (and relatively marked) improvement in the patients overall perception of his mental health. There was also a slight decrease in the patients perception of his physical well being. The SF-36v2 is calculated using eight categories, three for physical health three for mental health and two that overlap. 

Image 1. shows the eight categories assessed in the SF-36v2

These two graphs show the difference between the patients own perception of his health at the beginning of the second session compared with that after a month of treatment.  

We can see here that there is only a small deviation in the first four columns of each chart. These represent Hubert's physical health. There is a small decrease in perceived physical health. The most significant change is seen in the last three columns respectively representing social function [SF], emotions [RE], and mental health [MH]. In these columns we see an increase in SF of 16.3 points, RE of 11.6 points, and MH 8.4 points.

This second set of charts show the results in a more condensed fashion. We see here that the overall physical component score [PCS] drops from 60.4 to 51.8, a not insignificant decrease, but considering 50 is considered normal, might not be too much of a concern. However, we see that the mental component score [MCS] increases 13.7 points, from 25.8 to 39.5, which is only 10.5 points away from a 'normal' score of 50.

In my opinion achieving these results in the space of one month (five treatments), is an excellent indicator that acupuncture can successfully treat depression and related symptoms.

CONCLUSION

This case report presented the treatment of depression and associated symptoms, using acupuncture and chinese herbs. In the section on outcomes and discussion we can see that there was a qualitative improvement in the patients condition. However, I would not regard this case as a complete success, as there was still a significant way to go before we achieved his health goals of relieving depression and anxiety, and helping concentration. Since Hubert had a tendency toward relapsing back into habitual behavioural cycles, especially those that flourished in the family environment, and his preference to otherwise live in the park (another destructive behaviour), I would be surprised if these outcomes lasted for any length of time. I do believe however, that in the right supportive environment, a patient suffering from a similar condition could maintain significant lasting results.

REFERENCES

Boon, N., Colledge, N., Walker, B., Hunter., J 2006, Davidson's Principles & Practise of Medicine, Churchill Livingstone Elsevier, India.

Fry, R. & Ryan, C 2007, Depression, ABC Health & Well Being, viewed 12 November 2011, http://www.abc.net.au/health/library/stories/2007/06/05/1944066.htm

SF-36v2 Categories, Image, viewed 12 November 2011, http://www.sf-36.org/tools/sf36.shtml

World Health Organisation (WHO) 2011, Depression, World Health Organisation, viewed 12 November 2011, http://www.who.int/mental_health/management/depression/definition/en/index.html

World Health Organisation (WHO), The ICD-10 Classification of Mental

and Behavioural: Clinical Descriptions and Diagnostic Guidelines, World Health Organisation, p.p. 83-84, viewed 14 November 2011, http://www.who.int/classifications/icd/en/bluebook.pdf