Case Study for Degenerative Arthritis of the Knee

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1 1. Case Study for Degenerative Arthritis of the Knee 2. Two Cases of Thoracic Diseases with Effective Clinical Results 3. Dr. Pu-Tao Chang on Health Preservation Ginseng (Ren Shen) 4. Pharmacodynamics and Indications of Aconite (Fu Zi) and its Processed Forms 5. The Correct & Most Suitable Medicinal Herbs: Schisandra Fruit Case Study for Degenerative Arthritis of the Knee by Dr. Chia-Ying Li and Dr. Chun-Cheng Hou Department of Chinese Medicine, Changhua Christian Hospital [Patient Information] Name: Miss Lin Age: 66 Marriage Status: Married Sex: Female Record No.: 3056XXX Nationality: Taiwan Height: 156cm Weight: 66kg (BMI 27.1) Occupation: Grocery store owner [Chief Complaint] Right knee pain when bending for one week [History of Present Illness] The patient has been experiencing right knee pain when she bends it for the past week. There was no specific cause or event that initiated the pain. (We should always ask if the patients had similar symptoms in the past, what is their living environment like, and if they have had any externally contracted diseases.) Walking and certain postures aggravate the pain. (We should have the patients describe which kinds of postures aggravate the pain.) Her knee joint is slightly swollen, but it is not red. However, it is slightly hot behind the knee. Patric s test (-). An audible clicking sound can be heard coming from the patella (+). There is no pain when she sleeps but it hurts when she turns. Her heel is sore and achy. There is no history of external injury. [Past History] Left breast cancer, which has been surgically removed [Personal History] Diet: Non vegetarian Known Allergies: No known allergies to drugs or foods Smoke: No Alcohol: No Exercise: Not routinely Living Environment: Residential area, lives with family

2 [Family History] No unusual family history [Four Diagnostic Methods of Chinese Medicine] Inspection Listening and Smelling Inquiry Palpation Clear conscious, natural complexion Slightly overweight Tongue: Slightly red with thin white coating. Red spots on the tip. Normal voice No special smell Whole Body: No aversion to cold or heat Sleep: Easy to wake up when turning due to the joint pain, otherwise normal Head and Face: Mouth is not dry with a tendency towards rheum Low back: No soreness Chest and Abdomen: History of breast cancer. Good appetite BM: 2-3 times a day, formed. Urination: Scanty but no burning or pain. 2-3 times nighttime urination Extremities: Tendency to have swollen lower extremities Menstrual cycle: Menopause Both right and left pulses are deep and slippery No external injury history The tongue is slightly red tongue with thin white coating Both pulses are deep and slippery Secondary Characteristics: History of breast cancer Scanty urination Urinate 2-3 times during the night Tendency towards swollen lower extremities d) Condition of Disease: Right knee pain for one week when bending it. Walking and certain postures aggravate the pain. It is a condition categorized as Bi Syndrome. The patient has had the pain for only one week, it s incipient. Her knee joint is slightly swollen, not red, but slightly hot behind the knee. The pain occurs when she is bending the joint and it is localized. The swelling of the knee joint, the inhibited bending and stretching, and the slippery pulse all indicate pathogenic dampness. The slight heat behind the joint indicates heat but it is not abundant. The patient is over 60 years-old, urinates 2-3 times during the night, and has sore achy heels. Therefore, we can assume that she has kidney deficiency. The scanty urination, urinating 2-3 times during the night, and the tendency of swollen lower extremities indicate bad water metabolism. It could be due to kidney deficiency unable to warm and transform the water, which leads to flooding and overflowing of pathogenic water to the fleshy exterior, causing the swollen lower extremities and scanty urination. [Four Essential Elements Analysis of the Zang-Fu Pathogenesis] a) Etiology: Knee Bi caused by kidney deficiency and dampness blocking the channels. b) Location of Disease: Kidney (TCM); Knee joint (Western medicine) c) Characteristics of Disease: Main Characteristics: Right knee pain for one week when bending Walking and certain postures aggravate the pain The knee joint is slightly swollen, not red, but slightly hot behind the knee Patric s test (-) No pain sleeping but it hurts when turning The heel is sore and achy Characteristics of Bi Symptoms

3 injury. History of breast cancer. Slightly overweight. Sleeps fine. Good appetite. Two bowel movements a day that are formed. Scanty urination but no burning or pain, 2-3 times nighttime urination. Tendency of swollen lower extremities. Slightly red tongue with thin white coating. Both pulses are deep and slippery. [Diagnosis] White Peony (Shao Yao) One of the minister herbs of Plantago Formula (Ji Sheng Shen Qi Wan) e) Pattern Identification - Knee Bi: The branch is dampness evil blocking the channels with slight heat; the root is the kidney deficiency. Treatment Method - In an acute situation, focus on the branch: The primary focus is to dispel dampness and circulate the channels. This is supplemented by tonifying the kidney. f) Prescription: Four Marvel Pill (Si Miao Wan) and Achyranthes & Plantago Formula (Ji Sheng Shen Qi Wan). [Chart of Analysis of Disease Cause and Pathomechanism] Old Age Scanty urination, 2-3 times nighttime urination Tendency of swollen lower extremities Sore achy heel [Overall Review] External Dampness Kidney Deficiency Pathogenic Dampness blocking channels Right knee pain when bending, walking and certain postures aggravate the pain Knee joint slightly swollen, not red but slightly hot behind the knee The patient is a 66 years old female. She came to the clinic on 11/22/2010 due to right knee pain when she bends it. She has had the pain for one week. Walking and certain postures aggravate the pain. The knee joint is slightly swollen, not red, but slightly hot behind the knee. Patric s test (-). No pain when sleeping but it hurts when turning. The heels are sore and achy. There is no history of external Western Medicine: Degenerative arthritis TCM: Disease: Knee Bi Disease Pattern: Branch: Damp evil blocking the channels with slight heat. Root: Kidney deficiency [ Treatment Method] Dispel dampness and circulate the channels as the primary objective and tonify the kidney as a secondary, supportive measure. [Prescription] Draft Prescription - Four Marvel Pill (Si Miao Wan) and (Ji Sheng Shen Qi Wan) Atractylodes (Cang Zhu) 4.0 qian, Phellodendron (Huang Bo) 2.0 qian, Cyathulae Root (Chuan Niu Xi) 5.0 qian, Coix (Yi Yi Ren) 3.0 qian, Cooked Rehmannia (Shu Di Huang) 2.0 qian, Dioscorea (Shan Yao) 3.0 qian, Cornus (Shan Zhu Yu) 3.0 qian, Alisma (Ze Xie) 3.0 qian, Hoelen (Fu Ling) 3.0 qian, Plantago Seed (Che Qian Zi) 3.0 qian, Cinnamon Bark (Rou Gui) 1.5 qian, Roasted Aconite (Pao Fu Zi) 1.5 qian, Du Huo (Du Huo) 2.0 qian. [Prescription: using granules ] Formula (Ji Sheng Shen Qi Wan) 2.0g Single Herbs g Phellodendron (Huang Bo) 1.0g g Saposhnikovia (Fang Feng) 1.5g Atractylodes (Cang Zhu) 1.5g Clematis (Wei Ling Xian) 2.0g g

4 [Treatment Method and Prescription Analysis] Resident s Analysis <Pattern, Cause, Pulse and Treatment of Bi Syndrome> said Bi means blockage. The blockage and obstruction of the channels results in paralysis or numbness. Bi can attack inflicting pain, freeze the joints, or heavily bind them, and it is hard to be removed. That s why it s called Bi. <Za Bing Yuan Liu Xi Zu The Source of All Bi> Bi means blockage. The convergence of wind, cold and dampness congests and blocks the channels. The blood and Qi cannot circulate and disperse smoothly, causing pain in the long run. <Jing Yue s Complete Works> Bi means blockage. The blood and Qi are blocked by evils, unable to pass through, thus causing diseases. The patient s chief complaint is right knee pain when she bends it. It has been bothering her for one week. Walking and certain postures aggravate the pain. Her condition is categorized as Bi Symptom. The patient has had the pain for only one week, therefore it is incipient. The early stage of Bi Syndrome is often caused by pathogenic wind, cold, damp, and heat invading a deficient body, blocking the channels, Qi, and blood. It is therefore mainly an excess pattern. The patient s knee joint is slightly swollen, not red, yet it is slightly hot behind the knee. The pain mainly occurs when bending. The swelling of the knee joint, the inhibited bending and stretching, and the slippery pulse all indicate invading pathogenic dampness. The slight heat behind the joint indicates heat but not in abundance. Cornus (Shan Zhu Yu) One of the minister herbs of Plantago Formula (Ji Sheng Shen Qi Wan) <Comprehensive Medical Experience of Master Zhang>: The knee is the collection of the tendons. Inhibited bending and stretching of the knee leads to hunching, stooping, and exhaustion of the tendons. Knee pain always results from deficiency of the liver and kidney. When there s deficiency, wind, cold, and dampness invade easier. The course of the knee pain hasn t been long, but the patient is over 60 years old, urinates 2-3 times during the night, and has sore achy heels. We can assume that she has kidney deficiency. Scanty urination without burning or pain, urinating 2-3 times dur- ing the night, and the tendency towards swollen lower extremities (bad water metabolism) may indicate a pathological process where kidney deficiency is unable to warm and transform the water and then the pathogenic water to flood and overflow into the fleshy exterior causing swelling and scanty urination. To summarize the patient s condition: the branch is pathogenic dampness obstructing the channels causing knee Bi and the root is kidney deficiency. The treatment method is to dispel dampness and circulate the channels as the primary objective and tonify the kidney as a secondary, supportive measure. Four Marvel Pill (Si Miao Wan) is chosen as the main formula for her knee Bi caused by pathogenic damp obstruction to dispel dampness and unblock the collaterals. Phellodendron (Huang Bo) is reduced because her heat symptoms are not pronounced. (Ji Sheng Shen Qi Wan) is added for the root problem of kidney deficiency. It nourishes kidney Yin and tonifies kidney Qi. Du Huo (Du Huo) is added for its downward moving quality and its function to relieve lower back, knee, and foot joint arthritic pain. Physician s Explanations Cinnamon Bark (Rou Gui) One of the minister herbs of Plantago Formula (Ji Sheng Shen Qi Wan) If the pain is acute, it is most likely caused by external injury or external pathogenic evils. We should exercise clarity regarding this while inquiring during examination. Pain caused by deficiency should be progressive but not acute. This patient s condition of swelling is apparently not a short term issue. It is most likely that she has had the symptoms off and on for more than one week and they have just flared to a certain degree sparking her concern. We should try to differentiate internal and external dampness. Although wind, cold, damp, and heat Bi are all present clinically, joint pain caused by wind-colddamp and deficiency is most commonly seen. When there is heat localized within the joints, Phellodendron (Huang Bo) can be used, with discretion, to relieve the symptoms; no matter if the symptoms are aggravated by cold weather or by dampness. This patient is overweight and has swollen legs, so we should consider placing emphasis on the dampness aspects.

5 [Follow-ups on Treatment and Prescription] Date Patient s Condition Prescription (g) 10/19 The pain has alleviated when bending the right knee. Tendency to have cramps when she eats fruits. TID x 7 days Saposhnikovia (Fang Feng) 1.5 Atractylodes (Cang Zhu) /26 The pain when bending the right knee has alleviated. (Ji Sheng Shen Qi Wan) 3.0 Atractylodes (Cang Zhu) /2 The heels are sore, especially when she wakes up in the morning. Occasional right knee pain. 11/9 The thigh itches when it is hot. Phellodendron (Huang Bo) /16 The sore achy pain has alleviated. Right sole still hurts when stepping. Phellodendron (Huang Bo) 1.0 Siegesbeckia (Xi Qian Cao) 1.2 Achyranthes (Huai Niu Xi) 1.2

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