Psoriasis, Back Pain and Irritable Bowel Syndrome
About The Patient:
The patient discussed in this case study was born in 1965 in the countryside. He first consulted our acupuncture clinic on February 20, 2014. I saw him for three treatments and another acupuncturist saw him once.
The patient asked to be treated for back pain in the very first treatment which lead to the prominence of back pain in the list of chief complaints. The back pain was resolved after the first treatment and then I concentrated for two further treatments on his abdominal pain and diarrhoea. His psoriasis was not treated.
Due to this, this case study concentrates on the symptoms related to the Irritable Bowel Syndrome.
- Back pain, started about 5 years ago, got worse 2 days ago.
- Pain in the stomach and intestines and diarrhoea, started in childhood.
- Psoriasis, started 14 years ago.
History of presenting conditions:
- Back pain
The back pain started five years ago without prior injury. The pain is usually on the lower back. The doctor of the patient has the suspicion that the back pain is an autoimmune condition and related to the psoriasis.
The following questions could not be answered to date: When did he saw the doctor regarding the back pain? Which investigations had been performed? Were any treatments provided?
Current State of the Condition
Two days ago the patient strained his back. Since then the pain has stretched from the lower back to the middle back. The pain is better on warmth and the back requires movement and stretching in the morning. I am not sure if the pain affects his sleep because he has always slept badly.
- Pain in the stomach and intestines and diarrhoea
The patient has suffered from acid reflux and a sensitive digestive system since he was 9 years old. We don’t know which treatment was given to him to manage the condition.
1993/94: In France, the patient was diagnosed with a duodenal ulcer and acid reflux. Unfortunately we don’t know the treatment for this or the results of treatment.
2009/10: He was diagnosed with irritable bowel syndrome in the UK. We don’t know which treatment was given after the diagnosis.
Current State of the Condition
Today the condition manifests in the patient as pain of the intestines, bloating, acid reflux when eating (worsening when drinking water while eating) and diarrhoea. The pain in the stomach is worse before eating and is relieved after eating. The pain in the intestines is worse after eating. The pain is characterized by a cramping sensation. The patient has thin stools/ diarrhoea between 6am and 7am in the morning. There is no urgency to it. He has about 1 to 2 bowel movements per day, the second one in the evening.
He has taken Mebeverine to manage his symptoms and Omeprazol to manage the acidity in the stomach since 2009. For the 6 months prior to his first presentation in the acupuncture clinic in February he did not take the Mebeverine and his condition worsened. The cessation of treatment is due to him having been in France where the drug wasn’t available for him. Back in London, he started his Mebeverine treatment again. Unfortunately the Mebeverine does not seem to work as well as it used to.
The patient was diagnosed with psoriasis when he was 14 years old. The condition started on the patient’s lower left leg, on the lateral side of the edge of the tibia (Stomach Channel Area, level with ST40).
Current State of the Condition
Today the psoriasis affects his elbows, knees, scalp and the inside of his ears. The symptoms tend to be better in summer, due to the light. Stress is making it worse. The skin overproduces skin cells leading to a thick layer of skin. The affected skin patches are – when untreated – red, flaky, crusty, covered with silvery scales and itchy. Due to him using ointments and creams, the affected areas are only thick and red.
The current treatments that the patient receives for the psoriasis are Davonex, a corticosteroid-free ointment for the skin patches and Colbetasol, a topical corticosteroid to apply on the nails. He is supposed to apply Colbetasol daily, but he only uses it twice a week.
- Stress and Sleeping Problems
History and Current State of the Condition
The patient is always stressed, even though he feels he shouldn’t be. He has problems with falling asleep and tends to wake up at night.
Past Medical History:
He broke his arm as a child and broke several fingers over recent years during his work as a delivery driver.
Family Medical History:
His aunt had psoriasis too.
The patient takes Omeprazol to manage the acidity in the stomach. Omeprazol is a proton pump inhibitor.
The patient just started at the beginning of January to take Mebeverine again. Mebeverine is a drug whose major therapeutic role is in the treatment of irritable bowel syndrome (IBS) and the associated abdominal cramping. It works by relaxing the muscles in and around the gut.
The current treatments that the patient receives for the psoriasis are Davonex, a corticosteroid-free ointment for the skin patches and Colbetasol, a topical corticosteroid to apply on the nails. He is supposed to apply this cream daily, but he only uses it twice per week.
Diet / Smoking/ Alcohol:
The patient smokes two cigarettes per day but rarely drinks alcohol. He tends to have three meals per day. Typically two pieces of toast and a coffee for breakfast, sandwiches for lunch and pasta dishes for dinner.
The patient did no exercise at first presentation but started swimming and running while treatment progressed.
The tongue is very pale and shows bite marks on the sides of the tongue and a red tip. The middle of the tongue is covered by a thin layer of dark yellow coating. The coating is dry.
Shen 神, Complexion 色, Build and Posture形态:
The patient is of tall and thin build, his complexion is not bright.
Left side: very weak, the Kidney pulses could not be felt. Right side: thin wiry in the Lung and Liver position. The Kidney pulses could not be felt.
Patient is tender at L5 and T7 and in the area of the points ST8 and GB15.
Listening and Smelling闻诊:
Are there any red flag signs and symptoms?
The patient has a longstanding serious illness history. The drug Mebeverine he is currently taking does not seem to work against the pain even though it is supposed to relieve the cramping. He needs to be advised to see his doctor.
Identifying the Patterns and Diagnosis
Abdominal Pain and Diarrhoea (IBS)
- Liver invading Spleen and Stomach:
Wiry pulse in the Liver position, feeling stressed, diarrhoea and abdominal pain, yellow tongue coating, pain in the stomach alleviated by eating, acid reflux, stabbing headaches at ST 8 and GB15.
- Deficiency of Spleen and Stomach
Diarrhoea, abdominal pain/distension after eating, pale tongue with bite marks, tiredness – Epigastric discomfort which is better after food or with pressure; poor appetite, cold and weak limbs, tiredness, pale complexion
Back Pain (unspecified back pain)
- Stagnation of Qi and Blood through Stagnation of Liver Qi.
Wiry pulse in the Liver position, feeling stressed, digestive system is affected.
- Kidney deficiency
Pain in the lower back, Kidney pulses feel empty, night sweats.
- Damp, Heat and Wind affecting the skin
- Deficiency of Blood
Pale tongue, difficulty sleeping, dry pale tongue, palpitations
DISCUSSION 1: Aetiology
The patient was born and grew up poor in rural France during the mid-70s. He was very thin and did not eat well. Moreover, he did not learn to cope well with stress and became early in his life a victim of emotional strain.
He lived alone with his mother which he remembers as being very hard. She did not think very highly of her son. I believe that it is worth mentioning that even today the patient does not treat himself very well and that he is someone who seems to think very critically about himself.
He did not cope well with stress, which lead to the Stagnation of Liver Qi. The lack of nourishment in his childhood weakened the Spleen and Stomach. The Liver Qi Stagnation lead to the acceleration of the weakening of Spleen and Stomach. The patient’s digestive problems started when he was 9 years old. He had acid reflux and his digestive system became very sensitive.
When the patient was 14 he developed psoriasis. The psoriasis started at the lower leg in the area of ST40. He hurt himself there at the time and the psoriasis started. The “ugly” skin condition increased his stress levels further as a teenager, and the stress fortified the pathology of Liver, Spleen and Stomach.
After this, he worked for many years in France doing unskilled manual jobs. In 2008 he moved to London to benefit from the greater work opportunities. He works here as a freelance delivery driver. This job is physically demanding due to the amount of lifting work. Moreover driving through London is very stressful and nerve-wracking. Being self-employed is stressful in itself. He consistently worries about having enough work to survive for the next month.
Last year he went back to France for 6 months because he wanted to take care of his mother and missed living in his home country. He could not find work in France. He lived there without health insurance and was therefore forced to stop the Mebeverine treatment that he got free of charge by the NHS. After 6 months he decided to come back to London.
He feels freer in London than in France but misses his home town. He always says: “I am stressed but I don’t have much reason to feel like that.” He does not allow himself to feel that way because he thinks that stress is related to financial success or doing something important in life. He is upset with himself. His long depression and frustration lead to the patterns visible today.
The patient has never slept well. From early childhood he found it difficult to fall asleep and woke often up at night, which led to a long-term injury to Yin.
DISCUSSION 2: Pathology
The imbalance in the relationship of Liver, Spleen and Stomach
The root pattern of the patient is the Stagnation of Liver due to stress, long term frustration and little nourishment. This resulted on one side in the invasion of Spleen and Stomach leading to them becoming weak and not performing their function properly.
The invasion of Spleen and Stomach by Liver Qi is today visible in his wiry pulse in the Liver position and his feelings of being stressed and frustrated. The Liver Qi invasion led to the weakening of the Spleen and Stomach and therefore to diarrhoea and abdominal pain. The pain in the stomach is alleviated by eating which related to a deficiency of Stomach Qi, he has poor appetite and cold and weak limbs. His complexion is pale and he feels low in energy.
The imbalance in the relationship of Liver, Spleen and Blood
The Spleen and Stomach are the granaries of the body. If the Spleen is strong, it produces and rises Gu Qi which is necessary for the production of Blood. Blood is stored and circulated by the Liver. Due to the long-term impairment of Spleen function (bite marks on the tongue), the patient became deficient in Blood and Liver Blood. This manifested in him having no appetite, and led to his general poor physical condition. Moreover his tongue is pale and dry, he has difficulties sleeping and he regularly suffers from palpitations. The palpitations are related to a deficiency of Heart Qi which is a secondary pattern resulting from the long-term deficiency of Blood.
The imbalance in the relationship of Liver Blood and Kidney Essence
Liver Blood is dependent on the nourishment from Kidney Essence. Liver Blood is derived from Gu Qi and Gu Qi nourishes the post heaven aspect of Kidney Essence. Therefore Essence and Blood share a common source as well as Liver and Kidney share a common source. In the patient’s case the deficiency of Liver Blood lead to the deficiency of Kidney Essence. The signs and symptoms for that are lumbar pain (an effect of the deficiency of Kidney Essence), the weakness and the emaciation of the patient and the regular night sweats the patient suffers.
The imbalance in the relationship of Spleen and Kidney
Spleen and Kidney are closely related. The Spleen is the source of post heaven Qi, the Kidney is the source of pre heaven Qi. Both are dependent on each other in performing their physiological role. A deficiency of Spleen (Yang) will lead to a deficiency of Kidney (Yang). This manifests in the patient as very often being bloated, always having cold limbs and the lumbar pain. Overall the deficiency of Spleen fortified the deficiency of Kidney.
The imbalance resulting from the onset of Wind, Dampness and HeatThe Spleen did not perform its function of transforming and transporting well which leads to the rise of Dampness. The Dampness became visible in the tongue coating. The yellow tone of the coating is the result of Heat rising from the Stagnation of Liver Qi. The Stagnation gave rise to Heat and consequently to Wind. The Heat, Wind and Dampness settled in the Skin, leading to the itchy psoriatic patches. The first time this happened on the lower leg, level with ST40, a major point to remove Dampness.
Figure 1: Aetiology and Pathology
Smooth Liver Qi, strengthen Spleen and Stomach, nourish the Kidney
and calm the Shen.
The Patient has a complex and long-standing condition and is under financial constraints. He will need a lot of treatment to get relief from his condition. I saw the patient 3 times with the first treatment concentrated on his back pain.
To decide over the treatment plan, we need to decide about which aspects of the patient’s condition are the most important. The psoriasis is very long-standing and it will take a very long time to affect that with treatment.
The invasion of Spleen and Stomach by Liver Qi is his major pattern which must be addressed. It gives him a lot of pain, affects his quality of life and worsens his deficiency of Blood and Kidney. The patient does not sleep well which he does not recognize as a big problem because he has never slept well but it has a negative impact on his general condition and should therefore be addressed.
The optimal treatment plan for this patient’s IBS would involve treatment twice per week for about 3 months. The first weeks should concentrate on smoothing Liver Qi and calming the Shen. The patient has to sleep better to improve his condition as well as outlook on life. Moreover lifestyle advice regarding increase in Blood-building foods and increase in exercise levels should be provided.
The treatment modalities used will be acupuncture and dietary therapy. The patient would benefit as well from massage with the target to increase the activity of his parasympathetic nervous system and to basically just be nicer to himself.
Key points used in the treatment of the patient:
|LR3||Spreads Liver Qi, subdues Liver Yang, and extinguishes Wind. Nourishes Liver Blood and Liver Yin.|
|ST8||Local point, meeting point of the Stomach and Gallbladder channel with the Yang Linking Vessel. Eliminates Wind.|
|GB15||Local point, meeting point of the Gallbladder and Bladder Channels and the Yang Linking Vessel. Eliminates Wind.|
|RN12||Harmonises the Middle Jiao and descends rebellious Qi, tonifies the Stomach and fortifies Spleen, regulates Qi and alleviates pain.|
|ST25||Regulates the Intestines, regulates the Spleen and Stomach and resolves Dampness, regulates Qi and Blood and eliminates Stagnation.|
|ST36||Harmonises the Stomach, tonifies Spleen and resolves Dampness, tonifies Qi and nourishes Blood and Qi. Clears Fire and calms the Spirit.|
|SP6||Tonifies the Spleen and Stomach and resolves Dampness. Harmonises the Liver and tonifies the Kidneys.|
|LI4||Adjusts sweating, regulates the defensive Qi, releases the exterior.|
|LI11||Clear Heat, cools the Blood, eliminates Wind, drains Damp and alleviates itching.|
|ST44||Clears Heat from the Stomach Channel and alleviates pain.|
|ST42||Clears Heat from the Stomach Channel and alleviates pain, Yuan Source Point.|
|LR14||Front Mu Point of the Liver, spreads Liver Qi in the Middle Jiao, harmonises Liver and Stomach.|
|KI7||Jing-River and Metal Point of the Kidney Channel, benefits the Kidneys, regulates sweating, drains damp and clears Damp Heat, strengthens the Lumbar Region.|
|BL17||Hui Meeting Point of Blood, nourishes and harmonises the Blood.|
|BL18||Back Shu of the Liver, spreads Liver Qi, regulates and nourishes Liver Blood.|
|BL20||Back Shu of the Spleen, tonifies Spleen Qi and Yin and, resolves Dampness.|
|BL21||Back Shu of the Stomach, regulates the Stomach and descends rebellion, harmonises the middle Jiao.|
|L3+LR14||LR3 and LR14 are the Entry and Exit point of the Liver Channel.|
|BL17+BL18+BL20||Good combination to nourish Blood.|
Treatment to move Liver Qi Stagnation and strengthen Spleen and Stomach
LR3, LI4, ST36, SP6, LR14, RN12, ST25, Yintang.
Treatment to calm Shen and nourish Yin
RN4, KI3, SP6, RN7, LU7 and KI6, Yintang DU24 and RN15
The patient has to start exercising regularly and has to improve his diet. He has to learn to manage his stress levels and concentrate more on his strengths than his weaknesses to be less frustrated with himself.
The patient started exercising after the first treatment I had provided him with. He started swimming to improve his back pain. I am a big believer in exercise and movement as a solution for unspecified back pain which I suggest often very quickly to patients seeing me for that indication.
Referrals and medications
The patient has abdominal pain even though he takes the drug Mebeverin to manage the symptoms. Mebeverin used to work before but does not any more. He should see his doctor and potentially have a colonoscopy to check for a potential ulcer.
Progress and outcome
The patient saw me 3 times. In the first treatment we concentrated on the presenting back pain. I had given him the advice to increase his exercise levels which he did. He went swimming twice in the week between the 1st and 2nd treatment.
In the second treatment I concentrated on his headache and the abdominal pain. I could not create much change in that condition. He always reported improvement but I doubt that he had any. His condition is very longstanding and severe. Therefore I was prepared to take some time.
The patient always reported progress and suggested that progress was due to my treatments. He was unusually keen to make me comfortable as a practitioner. I tried to make sure to communicate that this was not necessary.
After the 3rd treatment the patient discontinued treatment. This was due to financial constraints.
Personal reflection and learning
I was keen to treat this patient, but I quickly learned how difficult it is to work with a chronic patient. I feel I failed to make him come back and raised mistaken impressions in him that treatment would have quick results. I may have failed to communicate that treatment could take a while. I should have discussed more openly his financial constraints and should have built a stronger patient relationship.
I have to improve my readiness to communicate and stop being shy of saying things that need to be said.
Deadman, P., Al-Khafaji, M. & Baker, K., 2007. A Manual of Acupuncture. 2nd ed. Hove: Journal of Chinese Medicine Publications.
Flaws, B. & Sionneau, P., 2005. The treatment of modern western medical diseases with chinese medicine. 2nd ed. Boulder: Blue poppy Press.
Maciocia, G., 1994. The Practice of Chinese Medicine: The Treatment of Diseases with Acupuncture and Chinese Herbs. 1st ed. s.l.: Churchill Livingstone.
Maclean, W. & Lyttleton, J., 1998. Clinical Handbook of Internal Medicine. The Treatment of Diesease with Traditiona Chinese Medicine. 1 ed. Sidney: University of Western Sidney.