Osteopathic Manipulative Medicine For Ulnar Neuropathy by William H. Stager, DO

Source: satsop.olympus.net/biz/medicalacupuncture/ aama_marf/journal/vol14_3/case4.html

ABSTRACT

Background

Peripheral neuropathy is a common condition with a variety of possible causes and treatments.

Objective

To describe the use of medical acupuncture and osteopathic manipulative medicine (OMM) in a patient with traumatic ulnarneuropathy.

Design, Setting, and Patient

A 51-year-old man with left ulnar neuropathy due to accidental severing of the ulnar nerve at the elbow; following surgical repair, he reported muscle weakness, pain, and paresthesias.Intervention Acupuncture points PC 6, HT 3, LI 4, LI 10, SI 3, SI 8, and TE 5 were selected on the patient's left arm and hand, along with various adjunctive points in response to signs and symptoms. Osteopathic myofascial release techniques were integrated with the acupuncture program (40-minute treatment sessions every 2-3 weeks).Main Outcome Measure Ulnar sensory and motor improvement.Results The patient's symptoms improved after the 1st treatment. He was treated for 4 years with continued improvement, including 50% decrease in pain and 50% increase in range of motion.Conclusion Combined acupuncture and OMM demonstrated efficacy in the treatment of this patient with traumatic ulnar neuropathy.


INTRODUCTION

Peripheral neuropathy is a common condition that affects millions of people in the United States annually. Its causes can include trauma, tumors, infections, diabetes and other metabolic diseases, vascular insufficiency, nutritional deficiencies (such as beriberi and pellagra), motor neuron diseases, and toxic exposures such as lead.1 Clinical manisfestations and symptoms can include pains of every degree, weakness and muscle wasting, and paresthesias such as numbness, tingling, and burning. Numerous treatments provide varying degrees of success, including acupuncture, osteopathic manipulative medicine (OMM) techniques, pain medications, and surgery.1 Case ReportA 51-year-old Florida man presented 4 months after accidentally cutting his left elbow. The cut was deep and completely severed the ulnar nerve where it is most superficial at the elbow joint. He underwent surgery that same week and the nerve was reattached. After surgery, the surgeon gave a poor prognosis regarding recovery of the use of the patient's arm and hand in the ulnar distribution. The patient was prescribed hydrocodone/acetaminophen once at bedtime for pain. He also requested the integration of more natural methods. The initial postsurgical physical examination revealed a healthy man with the following abnormal physical findings: ulnar muscle wasting, weakness, paresthesias of tingling, numbness, and burning, and a "claw" or hooked 5th finger unable to move. The patient had a weak handgrip and strength (3/5), diminished sensation in the 4th and 5th fingers, a 3-in scar on the medial elbow, and myofascial restrictions along the arm, forearm, and hand. Hand abduction, adduction, and flexion, which are functions of the muscles of ulnar distribution,2 were all reduced. METHODSMyofascial Release TechniquesVerbal consent was obtained from the patient for combined myofascial release techniques (OMM) and acupuncture treatment limited to his left upper extremity. The myofascial release techniques were a combination of direct (toward a restriction) and indirect (away from a restriction) techniques.3 These gentle, slow-motion maneuvers either stretched or shortened the soft tissue (muscles, tendons, ligaments, and fascia) throughout the left shoulder, arm, forearm, hand, and fingers as restrictions were palpated, identified, and treated/released. These techniques are recommended standards of care for the relief of myofascial restrictions and neuropathies.3 They were applied before and after the acupuncture treatments to release restrictions, encourage circulation, and enhance the acupuncture treatments (10 minutes of OMM, 20 minutes of acupuncture, then 10 minutes of OMM within a 40-minute treatment period).Medical AcupunctureAcupuncture was performed with sterile, single-use, stainless steel needles, 0.22 mm in diameter and 25 mm in length (Helio Medical Supplies Inc., Santa Clara, Calif). Only the left upper extremity was treated at the patient's request. Several points were selected after careful examination and identification of the scar area, the ulnar nerve pathway, regional nerve and blood vessel distribution to avoid injury, as well as myofascial and joint restrictions. Needles were inserted 25 mm in depth, for 20 minutes per session, either in manual tonification (i.e., pointing in the direction of the flow of the meridian and turned clockwise, eliciting a De Qi response) or neutral technique (i.e., no turning of the needle nor eliciting a De Qi response). Acupuncture points were chosen to affect the sensory and motor symptoms resulting from the ulnar nerve damage. Acupuncture points PC 6, SI 3, SI 8, LI 4, LI 10, TE 5, and HT 3 were needled, with 1 to 3 other points sometimes added or subtracted from the above regimen depending on the patient's response, signs and symptoms, and physician's findings. Those extra points were SI 4, PC 4, PC 5, LI 11, LI 12, and TE 8; they were chosen on the basis of either point tenderness or relief from pain or dysfunction. Also, 1 to 3 needles were placed around the 3-in scar at the medial elbow area to increase circulation, decrease scarring, and complement the basic treatment prescription. Treatments were scheduled in response to the outcome of each session and averaged approximately once every 2-3 weeks over 4 years.Although all the points described have many indications, the major rationale for using them was that each can be used for local sensory or motor symptoms in their anatomical and energetic areas of distribution.4RESULTSThe patient's sensory and motor signs and symptoms improved significantly after the 1st treatment. When he returned 2 weeks later, he stated that he felt stronger, more energetic, with increased sensation, and less stiffness. Increased sensation included both restored feelings in the hand and arm as well as an increased ability to feel. The patient's hand and arm pains and paresthesias had decreased 50% based on patient report using a 1-10 scale and by palpation; hand range of motion and hand and arm strength improved approximately 50%. The treatment was effective over 10-20 days; consequently, maintenance treatments were scheduled every 2-3 weeks. The patient continued to improve over the next 4 years. The strength in his left upper extremity was almost normal with some intermittent paresthesias of numbness, pain, and tingling. The 5th finger remained somewhat flexed.

DISCUSSION

This patient presented with traumatic ulnar neuropathy after accidentally severing the nerve at the left elbow and then having it reattached surgically soon thereafter. His signs and symptoms included motor and sensory loss, pain, paresthesias, weakness, and stiffness. The surgeon pronounced a justifiably poor prognosis. Treatment was begun using a combination of acupuncture points and myofascial manipulative techniques. The acupuncture points were selected because of their known effects on the local sensory and motor signs and symptoms, as well as their energetic properties.4 Most of the points were found along the distribution of the ulnar nerve. Points were also chosen for their energetic value since pain is described in Oriental concepts as resulting from blocked or stagnant energy and blood.5The patient experienced both trauma and surgery, which would be considered cause for blockage, stagnation, or both.5 Yin points (PC 4, PC 5, PC 6, and HT 3) were chosen for their effects of increased circulation and decreased pain and dysfunction; Yin points also move the energy in the direction from the arm to the fingers. Yang points (SI 3, SI 4, SI 8, LI 4, LI 10, LI 11, LI 12, TE 5, and TE 8) were chosen for their positive effects on circulatory and neuromuscular signs and symptoms. Yang points move energy in the direction from fingers to elbow and arm. Local points encircling the scar were also chosen for their ability to increase or enhance energy and effects (increased circulation and decreased scarring).6,7 Myofascial manipulative techniques were also used before and after acupuncture to loosen the restricted joints, muscles, and fascia, which in turn increased ranges of motion and circulation, and decreased pain and dysfunction.3 The patient reported significant relief from his symptoms after the 1st treatment. A treatment schedule of once every 2-3 weeks was eventually used since some symptoms returned after longer intervals. The patient's sustained and increasing improvements justified the methods and schedule and greatly improved his prognosis.Both acupuncture and OMM techniques have been used separately for the successful treatment of a number of neuropathies. A wide variety of acupuncture and manipulative techniques have evolved and been interwoven by ancient and modern practitioners and are recommended in modern textbooks.6,7 The rationale has been to affect the peripheral and central nervous system neurotransmitters and endogenous opioids to modulate pain and nerve response, increase circulation, and relax and normalize the neuromusculoskeletal system.3,7

CONCLUSION

This case report demonstrated the combined efficacy of acupuncture and OMM in the treatment of ulnar neuropathy. Further research is indicated to optimize combined acupuncture and manipulative techniques.

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AUTHOR INFORMATIONDr William H. Stager is in holistic private practice in West Palm Beach, Florida. He is Board-certified in Osteopathic Manipulative Medicine, Family Practice, Medical Acupuncture, and Pain Management.William H. Stager, DO, MS, DABMA*2617 No Flagler Dr, Suite 111West Palm Beach, FL 33407