A Story about Lizzie

When you look into Lizzie Johnson’s glittering blue eyes you can see her sparkling spirit.  This vital 75-year-old silver haired woman stands 5 foot 3 inches tall at 135 pounds. She and her husband actively engage in many cultural activities.  She enjoys movies, theater, art galleries, museums, ballet, musical concerts and dining out.  They participate in Elder Hostels that meet in various cities to appreciate a variety of enriching experiences.  She does not smoke.  Her dinner meal is accompanied by one glass of wine.  She uses her treadmill everyday for 20 to 30 minutes.  She walks outside when weather permits. She has a dog and a cat.  Her right shoulder dips down lower than her left due to degenerative changes in her spine.

What was wrong

Lizzie presented herself with right lower neck pain that she has had for 8 months and right shoulder and upper arm pain she has endured for 2-3 years.  She described the pain as deep, sharp, intermittent, aggravated by rest and improved with movement.  Heat makes it feel better.  Cold and damp weather worsen the symptoms.  She complains of occasional constipation and a dry sore throat that may be indigestion.

Medical History

She was diagnosed with arthritis and has received one cortisone shot in the past.  She had a benign cyst removed from her left breast in l949.  Lizzie had a bout of pneumonia about 20 years ago.  She has a history of lower back pain.  It has not been active for several years.

Family History

 Lizzie’s father died at 84 years old.  He had what she calls, “mild diabetes.”  Her mother died at 67 years old from Colon Cancer.   Lizzie has a daughter, Zoe, who is alive and well and living in Long Beach.  She has a son, Robert, who is alive and well and living in Atlanta with a wife and two children. She is blessed with four grandchildren.  She had a son, Lester, who died from Lymphoma at 39 years old.   Lizzie’s sister is alive and well.  She had a brother who is now deceased.

 How she appeared when I saw her

Looking:

Lizzie appears vibrant and is oriented.  Her posture is compromised due to the discrepancy in the height of her shoulders.  She has shoulder length gray hair and clear blue eyes.  She has rosy cheeks.  Her skin is moist except for her heels on both feet.  They are dry and flaky.  Her lips are pale red and her teeth and gums are in a good state.  Her throat is only sore and dry but not red and swollen indicating a deficiency of Kidney Yin with Empty-Heat.  The tongue body color signifies the state of Blood and Nutritive Qi.   The color of Lizzie’s tongue is red. This indicates Heat. Whether it is a deficiency or excess condition depends on whether or not there is a coat.  The tongue coating reveals the state of Yang organs, particularly the Stomach.  Lizzie has a thicker yellowish coat in the center of her tongue corresponding to her Stomach/Spleen area.  This indicates a Full Heat pattern of the Stomach/Spleen.  The shape of the tongue reflects the state of Blood and Nutritive Qi and gives an indication of the Full or Empty character of a condition.  Lizzie’s tongue is swollen and has horizontal cracks along the sides indicating the presence of Damp-Heat and Spleen-Qi deficiency.  The amount of moisture on the tongue indicates the state of body fluids.  Her tongue is on the dry side indicating that the Heat has dried the fluids.

            There are spider veins bilaterally on the posterior aspect of the knees and around the ankles.  This indicates the Spleen is not holding the Blood.

Hearing and Smelling:

 Lizzie’s voice and breathing patterns are normal.  She does not talk incessantly or reluctantly.  Her breathing rate is normal.  She does not have a cough or any unusual or foul smells.

Asking:

 Lizzie does not experience any chills or fevers.  She does not sweat spontaneously.  She denies having headaches, recalls being dizzy once.  She experiences fixed sharp pain in her right shoulder joint that encompasses her lower neck and upper arm.  She denies any numbness or tenderness of the chest or abdomen.  She experiences occasional epigastric pain that she describes as being dryness in her throat.  Occasionally her bowels are slow.  Her sleep pattern consists of about 7 hours sleep.  She gets up once a night to urinate.    She began menses at 12 years old.  It was regular and lasted 5 days.  She is post-menopausal since l965.  Her pregnancies were normal.  She had 3 live childbirths.  Lizzie says she does not feel thirsty and does not drink enough water.

Touch:

 Lizzie’s skin is soft and supple except for her heels, which are dry and rough.  Her hands and feet are cooler than the rest of her body.  This can indicate interior cold from stagnation of Qi.  She has a soft round nodulation on her left middle finger at the distal joint.  Her pulses are superficial.  Her Liver/Spleen/Stomach pulses are floating and empty.  They are slightly tight.  This tight pulse can indicate pain from an Interior Cold situation such as her Bi Syndrome or Stomach.  There is some congestion and tenderness around Spleen 6, Spleen 9, and GV14 indicating Dampness.  These Ah Shi points can be used for diagnosis.  They are the “that’s it” points.

 Diagnoses

1.      Alteration in comfort, chronic, due to right lower neck, shoulder and upper arm pain.  Painful Obstruction Syndrome or Bi Syndrome of the right lower neck, shoulder and upper arm.  Cold and Dampness Invasion.

2.      Alteration in digestion.  Stomach Yin Deficiency & Spleen Qi Deficiency.

3.      Alteration in bowel elimination due to constipation.

4.      Liver Qi Stagnation & Kidney Yin Deficiency.

 Western Etiology-Osteoarthritis

Osteoarthritis is the most common degenerative joint disease with a usual onset of about 40-60 years of age.  In cases under 45 years of age, more men are affected.  More women are affected in cases over 45 years of age.  It usually occurs in weight-bearing joints.  Various causes can be associated with Osteoarthritis.  Aging, excessive wear and tear, trauma, inflammatory disease or gout conditions may all contribute to its development.  It may be due to bone spurs or degeneration of cartilage.  The cartilage, which is one of the few tissues that does not have its own blood supply, coats the ends of the bones, and the synovium, a membrane that surrounds the joint filled with lubricating fluid, allow the joint to provide the body with flexibility, support, stability, and protection.  This synovial fluid also supplies nutrients and oxygen to the cartilage. Arthritis means joint inflammation. 

In a normal joint, where two bones meet, the ends are coated with cartilage, a smooth, slippery cushion that protects the bone and reduces friction during movement.  A tough capsule lined with synovial membrane seals the joint and produces a lubricating fluid.  Ligaments surround and support each joint, connecting the bones and preventing excessive movement.  Muscles attach to the bone by tendons on each side of a joint.  Inflammation can affect any of these tissues.  The changes result in pain, deformity and decreased range of motion.  Function decreases due to soft tissue swelling and local tenderness.  Creaking and crackling, called crepitus, of the bone on movement can be heard. Muscle spasms can add to pain.  The inflammatory process continues to affect the cartilage and underlying bone tissue causing joint deformity.  Muscles may atrophy and nodular pseudocysts may appear.

Usual allopathic treatment includes aspirin or nonsteriodal anti-inflammatory medications to relieve pain and inflammation.  Unfortunately they can have untoward effects such as tinnitus, gastric and intestinal irritation, allergic reactions, bruising, kidney and liver degeneration, and it can impair cartilage formation.  Exercises are recommended to avoid stiffness and further degeneration.  They usually consist of range of motion and muscle strengthening movements.  Rest, hot and cold applications, weight control and joint replacement surgeries may be indicated.

Eastern Etiology

The Chinese term for all Rheumatic Disease, including arthritis is “Bi Zheng”.  This translates in English as “impediment condition”.  Bi or impediment means a blockage or obstruction resulting in pain.  The blockage impedes Defensive Qi.  Defensive Qi plays an important role in the development and prevention of Bi conditions. When Defensive Qi is weak the body is susceptible to external pathogens that can lodge in the joints.  These pathogens create blockages that obstruct and develop into Bi Syndromes.

Blood is the red fluid in the vessels and Blood nourishes and moistens the tissues.  When Blood is scant, tissues wither and become dry.  “Qi is the commander of the Blood and Blood is the mother of Qi”.  Qi and Blood are mutually dependent on each other.  When the obstruction results in insufficient Qi and Blood nourishment and moistening do not occur resulting in dry skin, eyes, ligaments and tendons. 

Bi conditions involve the Kidney, Spleen, and Liver channels primarily.  The Kidney rules the bones and marrow including the joints.  Deficient Kidney energy is the source of Osteoporosis, degenerative disease, weak legs and knees, and water metabolism problems like edema, dryness and nighttime urination.  The Kidney is the foundation of all the Yin and Yang in the body and the Essence. 

The Spleen transforms and transports all the food and fluid essences to produce Qi and Blood.  It contains the Blood in the vessels.  It controls the muscles and the limbs.  It is responsible to hold the organs in their place (“raising Qi”). The Spleen houses thought.  When Spleen Qi is weak, Dampness, varicose veins, prolapses of organs, weak muscles and limbs, poor digestion and fatigue can result.

The Liver is “like an army’s general from whom the strategy is derived”.  It is responsible for the smooth and free flow of Qi in all directions.  This means it spreads Qi throughout the body including the sinews (ligaments and tendons) The Liver stores the Blood to nourish the sinews.  This coursing and discharging function can be damaged by emotional factors.  Stress, frustration, depression, repressed feelings can all stagnate the Liver’s functions. Pain results from this impediment.  Liver stagnation contributes to Premenstrual Syndrome, chronic digestive problems, depression and Bi Syndromes.

Painful Obstruction Syndrome refers to the pain, soreness and numbness of muscles, tendons and joints resulting from trauma, external Wind, Cold, Damp, or Heat.  Bi obstruction to the circulation of Qi and Blood in the channels is caused by these external pathogens.  “Painful Obstruction Syndrome is due to the deficiency of Nutritive and Wind-Cold-Dampness to ride the deficiency.  Qi becomes obstructed by the pathogenic factors, it cannot circulate, it stagnates, Qi and Blood congeal, and in time POS develops”.

These external pathogens can invade during cold, damp and rainy, windy or sudden climatic changes.  Wearing too little clothing or being exposed to cold or damp surfaces can make you become susceptible.  Excessive aerobic exercise like jogging may stagnate Qi and Blood.  Underlying Blood or Yin deficiencies as in the elderly, can create malnourishment of the channels and allow invasion.  As mentioned before, accidents, traumas and emotional factors like extreme anger, resentment, grief, sadness and shock can lead to weak Defensive Qi and invasion.

The symptoms differentiate the pathogen involved.  Wandering pain and soreness of muscles and joints are caused by a wind invasion.  The pain moves from joint to joint.  The pulse is floating and rapid.  The patient usually has limited movement.

Dampness manifests itself as a fixed pain, soreness and swelling of the muscles and joints.  It is usually aggravated by damp weather.  Worry, thinking obsessively, excessive sweet and damp food products like wheat, dairy and fruit as well as excessive fatty, greasy and oily foods combined with too little exercise can encourage Dampness. The pulse is slow and slippery.  The patient might complain of heaviness in their muscles and limbs.  Numbness may be present.  Prolonged Dampness can transform into Phlegm build up in the joint, which can cause a swelling called a nodulation. Lizzie has a soft round moveable tissue swelling like this on her left middle finger at the distal joint. 

Lizzie Johnson’s pain most closely fits the Damp and Cold pathogens.  The severe pain in the joint and muscles limit movement.  It is usually unilateral and the pulse is tight.  Low back pain can be present.  Lizzie has had a past history of low back pain. Difficulty abducting the arm indicates the pain is related to the Colon Channel.  Lizzie states the she cannot reach behind her.

Heat, with an underlying deficiency of Yin can be a cause.  Pain and heat in the joint is evident upon touch.  Movement is limited.  The joint can be red and swollen.  The patient will exhibit heat signs such as thirst, fever, slippery, rapid pulse, and sweating and Damp Heat. 

Description of Planned Outcomes and Goals:

 Lizzie will feel relaxed and experience pain relief of her right shoulder joint and surrounding areas after Amma today.  The channels most affected in neck and shoulder joint pain are the Colon, Small Intestine, Triple Burner, Lung, Heart, and Gall Bladder. As stated previously, POS or Bi Syndrome involves the Liver, Spleen and Kidney Channels. Treatment would consist of expelling the pathogenic factor, which has invaded the channel, and eliminate the resulting stagnation of Qi and Blood in the channel.  In Lizzie’s case this would be to Scatter Cold and Dry Dampness.  Tieh da jyou Liniment, Tiger Balm or Bao Xin An You (Po Sum On) can be applied to affected area to stimulate the movement of Qi.  Self-massage techniques like the ones at the end of this paper can be taught.

In addition to the Revitalizing Amma Treatment, important points for neck and shoulder pain include:

BL10 can be used for neck pain and a distal point for lower back pain.

GB12 relaxes muscle spasms, helps expel exogenous Wind, and calms the emotions.

GB20 eliminates exogenous Wind Cold or Wind Heat, which can cause headache and stiff neck.  These three can be manipulated simultaneously.

GB21 relaxes the sinews, treats POS of the neck and shoulders, and expels Wind and Cold.

CO11 expels exogenous Wind and Wind Heat.  It benefits the sinews and joints and can be used to treat POS.

TB5 is an excellent point for unilateral neck pain.

P6 is effective in women with nervous tension.

TS-FA1 is located at 1 tsun below Co11.  It  benefits the neck and shoulder and is useful in POS.

Co15 helps the sinews and treats POS, muscular spasms, pain and stiffness of the neck and shoulders.

Co16 benefits the joints and shoulders, treats upper extremity pain, helps remove obstructions from the channel allowing Qi and Blood flow.

Sp 21 is called the Great Luo (Connecting Point) of the Spleen.  It treats general muscular pain and aches due to Blood Stagnation.

St 38 is the main point used for shoulder pain and stiffness.  This point is manipulated while Lizzie gently rotates her affected shoulder simultaneously in both directions.  This point is a useful distal point.  It is used to reduce pain and stiffness of the shoulder and relaxes the tendons and ligaments.  It helps to dispel Wind and Cold.

St 40 transforms and dries Dampness and Damp-Cold.

ST38 is a useful point for relieving POS due to Dampness.

SP5 is useful for relieving POS due to Dampness. 

TS-LE-11 is a distal point that treats the neck area.  It treats the Liver Channel that is responsible for the free flow of Qi.

TS-LE-12 treats the shoulder.  It should be thumb-stroked several times.  It corresponds to the Spleen Channel that helps to promote nourishment of the muscles.

TS-LE-13 is an excellent point for the area where the neck and the shoulder meet.  It reduces pain and stiffness in the neck and shoulders.

TS-LE-14 treats neck and shoulder problems are treated with this point.

TS-LE-IV1 is located on the plantar surface of the fourth toe, this point treats the back of the neck that radiates to the head.

Lizzie will understand the importance of dietary changes and supplements to alleviate joint pain and indigestion. Iced drinks, excessive raw foods and too many fruits were discouraged due to their ability to create Coldness.  Hot foods like ginger, garlic, onion and coffee move Qi and Blood.  It is suggested that foods containing Calcium inhibitors should be avoided.  These include foods high in oxalic acid such as rhubarb, cranberry, plum, chard, beet greens and spinach.  The Nightshade vegetables should be restricted.  They consist of tomato, all peppers, paprika, potato and eggplant.  Black pepper is excluded.  They contain a chemical called Solanine that is also a Calcium inhibitor.  Solanine is also a powerful cholinesterase inhibitor. This is the enzyme responsible for agility of the muscles.  Childers (l986) states that Vitamin A and Vitamin D fortified products should be avoided.  It is believed that they cause an unwanted shifting of Calcium and Phosphorus.

To decrease the tendency towards Dampness, refined sugars, wheat products, excess meats, oils and dairy should be limited.  Small amounts of wine are beneficial to those who suffer from cold POS. The Arthritis Diet information sheet was given and explained.  Green clay drinks and papaya enzyme were recommended to alleviate indigestion symptoms. 

Lizzie takes a maximum potency multivitamin and antioxidants.  They include Boron (3-6mg), which works like estrogen to prevent the loss of minerals in the bone along with Calcium and Vitamin D.  It is found in fruits and vegetables.  She takes a Calcium Supplement of 1200mg before bed.    

Vitamin B3 (niacin, nicotinic acid, and nicotinate) has been shown to improve flexibility and reduce inflammation in osteoarthritics.  Vitamin B5 (pantothenic acid) has been used to decrease the symptoms of rheumatoid arthritis in a subset of patients. 

Essential Fatty Acids (Omega-3 and Omega-6) products were recommended for their anti-inflammatory actions.  Flax seed oil and Evening Primrose Oil were added to her supplements.  She enjoys many types of fish including salmon and tuna. Flavonoids are anti-viral, antioxidant, antihistamine, and anticarcinogenic. Curcumin (500mg-1500mg) and Quercetin (500mg-1500mg) are examples of these recommended for arthritis.  The flavonoids can be found in soybeans, soy products, coffee, tea, wine, fruits, nuts and seeds. 

Lizzie had tried Glucosamine with Chondriton Sulfate without benefit.  These substances are found in the synovial fluid of the joint.  European studies have reported pain relief and improved function with the use of Glucosamine with Chondriton Sulfate.  Methylsulfonylmethane (MSM) was recommended in a l000mg dose three times a day.  MSM is a metabolite of Dimethylsulfoxide (DMSO).  Some research has found that MSM reduced synovial proliferation in mice.  “A single placebo controlled trial of the use of MSM in OA has been published.  In this study report MSM was given at a dose of 2,200mg in divided doses vs. placebo.  Pain reduction was reported in 80% of patients who received MSM for six weeks, compared to 18% of the placebo group”.

Lizzie will have a soft-formed bowel movement everyday. Increasing the amount of water and fiber content in Lizzie’s diet will add bulk to her stool and alleviate constipation.   A list of fiber sources like the one at the end of this paper was given.  They include whole grains, fresh vegetables and dried fruits. Exercise will stimulate peristalsis and encourage proper elimination

Lizzie will understand the importance of exercise and demonstrate prescribed range of motion and static exercises.  The benefits of exercise in the management of musculoskeletal disorders are evident.  Exercise stimulates circulation and the movement of Qi and Blood and enhances the functions of the Spleen and Liver. “Yoga is one of several traditional practices that may be useful in treating chronic conditions such as degenerative joint disease”.  The main goal if exercise is to increase muscular strength, flexibility and relaxation.   Tai chi and Yoga along with some aerobic exercise will free stagnation.  Swimming, walking and cycling are examples of aerobic exercise.  Lizzie walks on her treadmill every day. Meditation and deep breathing are effective ways to promote relaxation and reduce stress. Neck, shoulder and yoga breathing exercises were demonstrated and information sheets were given  (Copy of sheets given at end of paper).

Lizzie is responding well to all the prescribed treatment.  In addition to weekly Amma Therapyâ I would recommend Acupuncture. Acupuncture can be used to prevent reoccurrence of POS after it has been successfully treated to Tonify Qi and Resolve Phlegm.  The British Lancet reported that it works well for certain patients with chronic back ailments or painful joints (Brewer & Angel, 1998).

Hydro- or Flotation Therapy, which involves immersing in water with Epsom salts, can promote relaxation of the muscles and achieve pain relief by stimulating the release of endorphins. Biofeedback reduces stress, relaxes tense muscles and induces pain relief by reinforcing efforts to control involuntary reflexes.

Some other information

The eyes are the “windows of the soul”.  They tell much about a person.  The Liver opens to the eyes.  Lizzie’s eyes shimmer with spirit, but just as “Yin and Yang produce each other, imply each other, and finally are each other”; there is a glimmer of sadness there too.  I suspect it is the death of her son Lester that put it there.

Lizzie has shown me many things I already know and has taught me a few new ones.  She has demonstrated many principles that I believe in. Lizzie has taken control of her own health care decisions.  She has chosen to do the work involved in self-care to promote health and healing.  She has made diet, supplement, and lifestyle changes to support her well-being.  She is very agreeable to trying green clay drinks and papaya tablets for her digestion.  She opened vitamin E capsules to apply the oil to her dry heels.  We discussed lightening up her pocketbook to take weight off her shoulders and shared some ideas such as, keeping one check instead of the whole book and putting a comb in instead of a brush.  She took MSM.  She reported positive results to all the suggestions and changes we had made together.  She taught me the importance of making these changes together.  When people think that these changes are their own ideas they tend to follow through with them.  I learned that even at 75 you never stop absorbing knowledge and changing and developing as a result of it.  We had discussions about the Holocaust, the weather, the political situation, and swapped recipes.  Her movie reviews were far more accurate than the ones in Newsday!   Working with Lizzie was not only an intellectual learning experience, but an interpersonal, transpersonal and intrapersonal one as well.

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