Volume 12, Number 1 | Spring 2017

Clinical Report 1 (Acupuncture)
A Case of Acupuncture Treatment for Pain in theEtremities of Unknown Origin

the patient to a doctor at the department ofTraditional Herbal Medicine of the Center for
Integrated Medicine affiliated with the Tsukuba

Tomoko Sasaoka

University of Technology. In this hospital, theAcupuncture Specialty, Department of Health Sciences,
Tsukuba Univercity of Technology

patient was subjected to thermography examinationand MRI (lumbar spine). His clinical examination
did not reveal any abnormalities.

1. Introduction
In this case report, the patient presented with anunknown illness with symptoms similar to those of
neuropathy and signs of anhidrosis. The patient wassuspected of having Acquired Idiopathic Generalized
Anhidrosis (AIGA), which is an incurable disease.
The onset, mechanism, cause of symptoms, andeffective treatments of AIGA have yet to beelucidated. I report a rare case of treating a symptomof unknown origin and with similar characteristics
to those of AIGA using acupuncture.

Suspicionsofentrapment

neuropathy,

pesticide-induced

spondylopathy,
toxic

myelopathy,

diabetic

neuropathy,

neuropathy,

obstructive

arteriosclerosis, Sjögren’s syndrome, and restless leg
syndrome

werecleared

throughvariousexaminations; the underlying cause of the symptoms
inthiscaseremainedundetermined.

The

examination dates have been summarized in Table 1.
The patient was subsequently referred to ourdepartment, and we started acupuncture treatment.

2. Case study

Chief complaint: pain of the extremities
A 78-year-old Japanese male patient presented withpricking and burning pain sensation in both
extremities that had started approximately 2 years
earlier. The pain was described as being similar to aburning sensation, with numbness and anhidrosis.
Immediately after the patient became aware of hissymptoms, he consulted a neighborhood internal
medicine clinic. The cause of the pain remained
unclear. However, because mildly elevated bloodpressure and cholesterol levels were detected, he wasadministered a hypotensive agent, lipid-loweringdrug, and Kampo medicine. After 1.5 years from theonset of the disease, the patient visited anotherhospital for a detailed examination by specialists inneurology and orthopedic surgery. The examinations
included blood tests, angiography of the lowerextremity

vessels,

cervicalmagnetic

resonance

spine

imaging

X-raysand(MRI),

andmeasurement of the nerve conduction velocity in allextremities. However, the etiology of the condition
remainedundeterminedfollowingthese

examinations. Therefore, the neurologist referredFigure 1 Affected regions

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 12, Number 1 | Spring 2017

Table 2 Laboratory findings

Details of the chief complaint
The symptoms affected the entire forearms and thelower legs, and included sharp pain and numbnesscontinuously present, and the attacks intensified byNerve conduction velocity (m/sec)* latency in either case within
normal range

several aggravating factors (see below). Edema wasMedian nerve MCV (m/sec)

associated with heat sensation. The symptoms wereobserved in the same locations. During the attacks,
theaffectedregions

additionallydevelopedgeneralized rubor (Fig. 1).

Aggravating factors

RightLeft

55.1

52.4

SCV (m/sec)

57.9

59.1

F-wave (%)

81

63

51.7

52.4

SCV (m/sec)

58.3

58.1

F-wave (%)

9494

Deep fibular nerve MCV (m/sec)

44.8

44.1

Ulnar nerve MCV (m/sec)

The symptoms were paroxysmally intensified bySCV (m/sec)--

several aggravating factors, including bathing,F-wave (%)--

putting on shoes and walking, going to sleep, andPosterior tibial nerve MCV (m/sec)

39.2

44.4

-

-

SCV (m/sec)

eating irritants like red pepper.

Alleviating factors
The symptoms were alleviated by cooling andF-wave (%)

100

100

Sural nerve MCV (m/sec)--

SCV (m/sec)

7.0

12.3

F-wave (%)--

Pallesthesia (medial malleolus)

mildlydecreased
4/5

mildlydecreased
4/5

MRI, X-ray (neck)mild deformation of
cervical spine

MRI (lumbar region)

mild deformation oflumbar spine

Thermography (no endurance test)

N.P.

Angiography (lower extremities)

N.P.

Blood examination (general blood
tests (biochemistry, blood cells),including renal function, liverfunction, blood glucose,inflammatory reaction)

N.P.

stroking the extremities.
Other factors associated with the condition of thepatient included dry skin and dry mouth. As sleep
was also affected by attacks occurring before goingto sleep, the patient’s quality of life (QOL) wasmarkedly impaired.

Table 1 Overview of medications taken over time

14

Date

April of year X-1

Usedmedications

Olmetec
AtelecAdalatBezatol SR
Keishibukuryogan(Tsumura #25)

September ofyear X-1
Olmetec

February ofyear XOlmetec）

May ofyear X
Olmetec

AtelecAdalatBezatol SR
Sanmotsuogonto
extract granules(Tsumura #121)

AtelecNifelantern CR
Bezafibrate
Keihikajutsubuto
extract granules(Tsumura #18)

Adalat
BI・Sifrol

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)N.P.

Volume 12, Number 1 | Spring 2017

Patient’s circumstances before the onset of theattacks
The patient was pruning the garden trees using a chain
saw under the care of the municipality in the residential
area when the attacks were first experienced. The
pruning time by far exceeded the vibration exposure
time (2 hours/day) specified in a notification by theLabor Standards Bureau of the Health, Labor andWelfare Ministry. Immediately before the attacks, thepatient had sprayed pesticides onto the trees.

Patient’s social/mental environment
The patient lives with his wife, who is suffering fromcognitive impairment. As she requires constantsupervision, he has no time for physical and mental
rest. His role as head of the residents’ association isanother source of stress. However, as his position is

Other findings: (1) heat with agitation in the palms,
soles, and chest; (2) no sweating; (3) dry mouth; (4)large amounts of sputum; (5) loss of appetite; (6)tension of skin and muscles; (7) muddy stools; (8) low
back pain (aching pain); (9) increased muscle tensionof the entire legs; and (10) ingestion of 2 liters of waterper day.

Physical characteristics:
The patient was 162 cm tall, weighed 66 kg, and had abody mass index (BMI) of 25.1 kg/m2.

Medications
The administered medications included Olmesartan
medoxomil, Cilnidipine, Nifedipine, Bezafibrate,
Cinnamon Twig, and Poria Pill (桂枝茯苓丸エキス顆粒:Tsumura #25, Tsumura & Co, Tokyo, Japan).

a source of income, he cannot quit.

Past medical history

Oriental medical findings

The patient had previously experienced severe alveolar
pyorrhea and had many missing teeth .

Pulse patterns: Deep, moderate deficiency.
Abdominal patterns: Weakness of the lower abdominal
region, para-umblical tenderness, and resistance.
Tongue patterns: Dark red color, dry, and yellow coating.

Family history
There were no appreciable diseases noted in thepatient’s family history.

Figure 2 Symptom diary

Date

BedtimeTimeofrising

Frequencyof attacks
during thenightFrequency ofcooling arms
and legs withwater during
the night

Frequencyof attacks
during theday

Frequency ofcooling arms andlegs with water
during the dayNRS* Please referto the notesbelow.

Comments
Changes in physicalcondition or events
during daily life etc.

NRS notation. The most uncomfortable condition before acupuncture treatment is given a score of 10 points, while total
absence of symptoms receives 0 points. Please evaluate in general how irritating your symptoms were today and assign ascore between 0 and 10 points to the condition.

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Volume 12, Number 1 | Spring 2017

Figure 3 Clinical course

Personal history
The patient was a smoker, with a Brinkman index (thenumber of cigarettes smoked per day multiplied by the
number of years of smoking) of 3,300; no alcohol
drinking was reported.

Social history
The patient is unemployed (no occupation) but isactive as the head of the residents’ association.

the regions of pain to alleviate the pain and reducemuscle tension. This treatment was combined withneedle retention on the lower back and legs. Afterthe 7th session, the goal of the traditional
acupuncture treatment was changed to draining
dampness, clearing heat, and nourishing yin; thus,acupuncture was administered to Dazhong (KI6),Sanyinjiao (SP6), and Qu Chi (LI11).

Evaluation method
Western medicine diagnosis

The Numerical Rating Scale (NRS) was used to score

Unknown.

the originally prepared symptom diary (Fig. 2).

Oriental medicine diagnosis

3. Results

A diagnosis of Bi-syndrome (fixed impediment andheat impediment) and kidney deficiency was made.

The results are shown in Fig. 3. Since we started
documenting the patient’s symptoms in the diaryfrom the 7th session, I wrote down the clinicalTreatment

process from the 1st to the 6th session based on theStarting from the 1st to the 6th session, a 50-Hz low
frequency
Transcutaneous
ElectricalNerve
Stimulation (TENS) was administered for 20 min to

medical interview. From the 1st to the 6th session, adecrease in the frequency of the attacks and increasein the mobility of the legs were observed, with nomarked improvement. After changing the traditional

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The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 12, Number 1 | Spring 2017acupuncture treatment plan starting from the 7th

deficiency, invigorating spleen, and nourishing yin forsession,andtranquilization. The result was an alleviation of both

frequency of the attacks significantly decreased,

the chief complaint and the associated symptoms,

with day-to-day variations. The NRS score also

leading to an improvement in the QOL. In oriental

dropped to 3 by the 8th session. In conjunction withmedicine, the practitioner uses all five senses tothese changes, the large amounts of sputum also

perform the four forms of examination and arrive at adecreased by this time; by the 10th session, thecharacteristic diagnosis of the condition. Thesepatient had almost completely stopped expectorating.

characteristics resulted in a treatment plan in theFurthermore, the mouth dryness had markedly

present patient, who had not been diagnosed based on

improved, and sweating could be observed by theWestern medicine, which has thus worked to his

16th session.

advantage.

bothseverity ofthesymptoms

On the other hand, the anhidrosis, burning sensation,
4. Discussion

and heat stagnation of unknown origin were

The etiology in this case remained unknown as per

identified as symptoms of AIGA. Until the 1990s,

Western medicine. However, as the chief complaint

there had been almost no reports on AIGA, which waswas pain, I first attempted to relieve the pain byrecognized as a new disease only over the past 20–30

applying TENS based on the gate control theory.

years. The disease is observed mainly in East Asia,

However, as the TENS did not induce sufficientwhile only a few hundred cases have been reported inimprovement and the patient had several otherJapan. Thus, only few facilities are capable ofsymptoms like anhidrosis, I switched to an oriental

diagnosing AIGA in Japan, where it has beenmedicine-based treatment plan starting from the 7th

designated in 2015 as an intractable disease. Whilesession. The patient complained of severe pain

the mechanism of AIGA onset and etiology are still

associated with a burning sensation and heat

unknown, a characteristic type of inflammation of thestagnation. In terms of Oriental medicine, insufficientsweat glands is observed and treatment with steroids

chewing during meals because of missing teeth

is markedly effective, increasingly suggesting that it(kidney deficiency) and chronic inappetence (spleen

is an autoimmune disease. Moreover, based ondeficiency), frequent diarrhea (spleen deficiency),

characteristic findings obtained through sweating,edema (water-dampness), and ingestion of large

thermography endurance, and drug tolerance tests,

amounts of fluids (2 liters of water per day) (spleen

the effective diagnosis of AIGA has been established.

deficiency and water-dampness) were also noted. AllIn addition, after the first treatment guidelines1) wereof these factors, due to aging and kidney deficiency,

published in 2013, a revised edition was published in

led to the deterioration of spleen deficiency and20152-3). Patients with AIGA present characteristic

stagnation of damp phlegm. Caring for his wife andclinical symptoms, including a decreased function ofgetting along with neighbors caused mental stress inthe sweat glands. Systemic destruction of the sweat

the patient (liver-spleen disharmony), which also

glands may subsequently lead to anhidrosis, burning

contributed to deterioration of the patient’s condition,

sensation, and flaring. Since the suppression of

causing heating up of the stagnant water, leading

sweating impedes heat dissipation, even mild exercise

subsequently to stagnation in the vessels in the fouror bathing may cause a heat stroke in patients with aextremities and probably to Bi-syndrome (heatsevere condition. Thus, the current guidelines provide

impediment). Local, symptomatic treatment waspatients with AIGA with clear instructions regarding

directed at clearing the heat and expelling phlegm,

body temperature control and cooling methods.

while root treatment served to improve the kidney

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Volume 12, Number 1 | Spring 2017

The present patient also presented with anhidrosis,

7. Referencesburning sensation, and flaring. His symptoms

1) Takahiro SATO et al.: Treatment Guideline forbecame aggravated following exercise, putting on

Acquired Idiopathic Generalized Anhidrosis, The

shoes, bathing, going to bed, and similar activities

Autonomic Nervous System, 50(1):67-74, 2013.

associated with a rise in body temperature or(Publish in Japanese)

impeded heat dissipation. Since walking barefoot on2) Health and Labour Sciences Research Granta cold floor or pouring water on the body relieved the(research project into the control of intractable

symptoms, this case closely resembled AIGA.

diseases), investigative research team for rare

As stated above, AIGA is a rare disease and canintractable skin diseases, committee for thecurrently be treated only at a few medical facilities.

preparation of the "Treatment Guideline for

Unfortunately, this patient was never checked andAcquired Idiopathic Generalized Anhidrosis" etc.,

treated based on a suspicion of AIGA.

Treatment Guideline for Acquired Idiopathic

In this case, diagnosis remained uncertain as per

Generalized Anhidrosis, The Autonomic Nervous

Western medicine, but the symptoms closely

System, 52(4):352-9, 2015. (Publish in Japanese)

resembled those of AIGA. The results suggested that3) Takichi MUNETSUGU, Hiroo YOKOZEKI et al.,acupuncture treatment is effective for alleviating theRevised guideline for the diagnosis and treatment

symptoms of AIGA or other diseases with similarof acquired idiopathic generalized anhidrosis insymptoms.

Japan, The Journal of Dermatology 44(4), Versionof Record online, 2017.

5. Conclusions
Traditional acupuncture treatment was effective inrelieving pain of an unknown origin in both limbs
and significantly relieved both the chief complaint
and its associated symptoms. Detailed examinations
at the hospital did not reveal any anomalies, and thediagnosis remained uncertain as per Westernmedicine. Alleviation of the symptoms following
application of an oriental medicine-based approachsuggested that this approach can be expected toimprove the QOL.
6. Acknowledgement

I would like to thank Editage (www.editage.jp) for
English language editing.

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The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)