Volume 7, Number 1 | Spring 2012

Clinical Report 1 (Acupuncture)
A Case Where Treatment of Heverden’s Nodes
Associated DIP Arthralgia with Acupuncture andMoxibustion was Considered Effective- combined Oriental and Western Medical Approaches -(orthopedist) for periodic osteoporosis examinations
x-ray findings of the second and third digits of both
hands showed deformities of the joints, but bothdeformities and pain were considered to be due toSouichiro Mine
Nagoya Medical College

The educational system requires of Japanese
acupuncturists to acquire not only Oriental medicalandskillsfortheassessmentofpathological conditions, but also knowledge andskills for relevant Western medical assessment
during the obligatory education to obtain theirlicenses. This leads to situations, where bothWestern and Eastern perspectives coexist during thetreatment.
This kind of treatment is sometimes criticized for alack of clarity regarding therapeutic concepts andhealing mechanisms, but it may nevertheless lead toimprovements of the patient's symptoms.
In this paper I report a case in which Heberden's
nodes presumably were involved in the development
of joint deformity and arthralgia of DIP joints of bothhands,

after work using the hands and strong pain
occurring, when something comes into contact withthe deformed joints as well as recommendation byIntroduction

knowledge

age and thus not actively treated. Pain developing

whereacupunctureandmoxibustion

treatment using an Oriental medical approachtaking the organs and viscera (zang fu) as well as
local phenomena into account and a Western medical
approach dealing with the local condition wasadministered and thought to have led to analleviation of the complaints.

her family caused her to seek acupuncture andmoxibustion treatment, which was initiated from
July of the year of the consultation.
< Past history >Viral hepatitis (25 years ago; type of virus unknown;
stationary treatment in a hospital for half a year;
currently in remission);
Diabetes (25 years ago; HbA1c fluctuating around6.8%; currently regular ambulatory treatment;
maintenancethrough

exerciseanddietaryrestrictions);
No history of injury to the hands;< Current condition > Height 151 cm, weight 43 kg;
blood pressure 103/64 mmHg, pulse 71 bpm,
kyphosis;Good appetite with a tendency towards becoming
excessive; one bowel movement per day; noconstipation or diarrhea; sleep is good, but she
frequently goes to bed past midnight.
< Local findings >The DIP joint of the right second digit on the radial
and ulnar side, the DIP joint of the left third digit on
the radial and ulnar side and the radial side of theleft and right fifth digit showed dorsal swelling like

[Case]

deformities. At the sites of the chief complaint< Chief complaint >Pain of the DIP deformities of the second and thirddigit of both hands.

neither reddening nor swelling were observed, but ineither case the joints were slightly warmer than thePIP joints of the same finger.

< Sex > female< Oriental medical findings >< Age > 80 years

The skin lacked moisture, among the three bilateral< Present illness >Four years before the first consultation she noticed
deformation of the second and third digits and in
January of the year of her consultation started toexperience pain. During visits to a local physician

radial pulses the left chi pulse was somewhat weak.
The pulse was generally floating, surging. The bodyof the tongue was red and dry. The tongue coating
was slightly thick and of a faint yellow color.

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

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Volume 7, Number 1 | Spring 2012

< Aggravating factors >needled using a reducing technique, draining theWork using the fingers. Physical contact with thestagnating heat and eliminating the pain.

DIP joints.

The points were mainly chosen from among< Relieving factors >acupoints showing deficiency reactions on the lesser

Were not observed.

yin channel of the foot and during the treatment[Pathology]

other points added as required for the treatment< Assessment of the condition from an Oriental

purpose based on pulse and tongue findings.

medical point of view >Based on the old age, comparative pulse diagnosis
showing a weak left chi pulse and the bone
deformities kidney deficiency is conceivable. The
lack of skin moisture, floating pulse, red and dry
tongue body, faintly yellow tongue coat indicate thepresence of a mild degree of heat. Surges of appetite
were associated with slight thickening of the tongue
coat, suggesting the presence of internal dampness.
Summarizing these findings makes it conceivable,that the deformities of the fingers caused peripheral
stagnation leading to the pain before a backgroundof kidney deficiency induced deficiency heat and amild degree of internal dampness.
< Assessment of the condition from a modern
medical point of view >Based on the disagreement with the relevant
diagnostic criteria for articular rheumatism and due

A 1-week treatment interval was adopted.
< First treatment >Needling: using stainless steel needles made bySeirin (applies to other instances below too)
0.14 mm × 30 mm KI3, LU8 (needle twirling after
piercing the skin, retaining the needles for 15 min; if
not stated otherwise, the same technique was used
for the following treatments too);single short insertions into the affected regions of theleft and right 2nd and 3rd digits (insertion depth 1-2mm, immediate removal).
No changes immediately afterward.
Questioning the patient at the second visit revealed,that there had been no changes in symptoms at all
after the treatment.
Since the patient experienced the symptoms as
intense stress and because I had no prior experiences

to the lack of a history of trauma of the fingers

treating such symptoms, I chose to change theposttraumatic sequelae could be ruled out.

treatment policy and observe the course.

Marked swelling, reddening and dysfunction were

< Second treatment policy > Through application of

not observed, but compared to the PIP joints theheat stimuli to the regions of the chief complaint in

affected regions were slightly warmer, suggestingorder to elicit changes in hemodynamics and thereby

thereduce

possibilityofachronicinflammation.

thelocalinfluence

ofinflammatory

Accordingly, the base condition was considered to be

substances and promote tissue healing mechanisms

a Heberden's nodes induced chronic inflammation

I tried to achieve relief of the chronic inflammation

causing the pain.

and alleviate the pain (Western medical approach).

[Therapeutic course]

Further, the treatment administered according toTreatment policy 1

the initial treatment policy expected to activate

The treatment was administered based on Oriental

healing mechanisms via its effects on the entire body

medical views. The adopted treatment policy aimed

is continued. If necessary, reducing acupuncture

at supplementing the kidneys in order to improve

techniques are applied regionally in order tothe yin deficiency and thus achieve alleviation of theeliminate heat (Oriental medical approach).

heat. For that purpose the affected regions were16

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

Volume 7, Number 1 | Spring 2012

< Second treatment >Oriental medical view based acupuncture treatment

Pulse: left chi pulse and right guan pulse: weak;

instead.

Tongue: enlarged, dental indentations;

Needling: 0.14 mm × 30 mm left SP3, scattered

The general condition did not change, but a spleen

short pricking around the DIP joints of the left anddeficiency became prominent.

right 2nd digits;

Needling: 0.14 mm × 30 mm right KI7, left SP3

0.16 × 30 mm; left LU6, right ST36.

Heat-sensing moxibustion (using little paper mats

Immediately after the treatment the patient felt

on the skin; applies also to subsequent treatments):

some relief of the pain. Over a period of two days

7 half rice-grain sized cones each, on the finger tips

after the treatment the swelling and pain decreased.

of left and right 2nd digit, left 3rd digit tip, apex of the< Sixteenth treatment >affected DIP joints and dorsal side;

Pulse: on the surface very elastic, deficient in theNo changes immediately afterward. There was nodepth, left chi pulse was choppy;

pain for 2-3 days starting from the next day.

Tongue: thick coating;< Fifth treatment >Liver yin deficiency, internal dampness;

Pulse: left cun mai and chi mai were both weak andAfter the 15th treatment there was pain for two days

slightly choppy;

following the treatment, but relieved later. The

Tongue: somewhat dark and a little red;patient paints pictures as a hobby, but even after

Kidney deficiency, yin deficiency.

holding paintbrushes for a whole day the right 2nd

After the last treatment there was no pain in thedigit did not hurt. The left 2nd digit is a little difficult

third digit on both sides. Unless hit by something,

to bend.

the second digit of both hands too was not painful.

Needling: 0.14 mm × 30 mm

Needling: 0.14 mm × 30 mm KI3, LR3, right SP6;

needling the ulnar and radial sides of left and rightHeat-sensing moxibustion: 7 half rice-grain sized

2nd digit DIP joints (single short insertions,cones each, ulnar and radial sides of the DIP joints

immediate removal);of the left and right 2nd and 3rd digits.

Heat sensing moxibustion: 5 half rice-grain sized

No marked changes immediately afterward. Aftercones each, ulnar, radial and palmar sides of left andthat the pain of the 3rd digit of both hands wasright 2nd digit DIP joints.

completely alleviated for a period of 2 months.

No marked changes immediately after the treatment.

< Eighth treatment >Later after the treatment symptoms of the right 2nd

Pulse: right guan pulse: thin, wiry, slightly choppy;

digit were alleviated and mobility improved.

Tongue: enlarged, tongue in the center of the tongue< 21st treatment >yellow, peeled coating;Pulse: flooding, right guan pulse: choppy;

Spleen deficiency, yin deficiency.

Tongue: slightly dark red;

Swelling, reddening and pain distal of the 2nd right

Tongue coat: slightly greasy, yellow;

digit DIP joint, on the ulnar side of the left 2nd DIP

Spleen deficiency, internal dampness leading to yinjoint. She pinched her right 2nd digit 2-3 days ago in

deficiency.

a door and accidentally hit the left 2nd digit too,

The patient experienced pain on the ulnar side of thecausing pain in both fingers. The affected regions

left 2nd digit DIP joint and on both the ulnar andshowed signs of acute inflammation probably due toradial side of the right 2nd digit, but the pain was

the contusion, so that I refrained from applying

worse on the left.

warming therapy using moxa, administering only

Since last week mildly overeating.

LR3, right KI7

Needling: 0.16 mm × 30 mm, KI7, SP3

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

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Volume 7, Number 1 | Spring 2012

Tip of the right 2nd digit and at the nail base of thethe Oriental medical approach, alleviation of theleft and right 2nd digits (in either case non-symptoms was achieved after the treatment.

penetrating needling);

While in this case the use of moxibustion as thermal

Heat sensing moxibustion: 7 half rice-grain sizedstimulation was related to the Western medical

cones each, apex of left and right 2nd digit DIP joints

approach, the local effects possibly induced direct

deformities and palmar.

tissue healing mechanisms in the affected regions,Assessing the pain after the treatment using awhereas the Oriental medical approach resulted in

Visual Analog Scale showed, that when the condition

an improvement of the physical condition as aat the first visit was defined as 100 mm, it was bymanifestation of the relevant healing mechanisms,

now 27 mm.

possibly providing the background before which theAfter that the symptoms remained alleviated andchief complaints were alleviated. Again, alleviation

the treatment is currently still continued.

of the chief complaint achieved during the eighth
session indicates the usefulness of scattered short[Discussion]

pricking for the treatment of increased pain due toIn this case the acupuncture and moxibustion

acute inflammation.

treatment was considered to have brought about

Based on the above describe findings it seems

alleviation of the symptoms, because there were no

appropriate to consider a local Oriental medical

changes in lifestyle before and after the intervention

approach based on organ and viscera (zang fu) andand no other treatment was administered.

symptoms combined with a Western medical

However, it is difficult to identify whether theapproach to be effective.

treatment performed from an Oriental medical point

However, in order to perform treatment yieldingof view or the treatment from a Western medical

stable and predictable results further accumulation

point of view had been effective.

and case reports and their investigation is necessary

While the therapeutic effects achieved by theto clarify the exact role of Oriental and Western

Oriental medical approach adopted during the first

medical approaches for the alleviation of the chief

sessioncomplaint.

could

not

be

confirmed,

thelocallyadministered Western medical thermal stimulation
added from second session led to improvements of[Conclusion]

the chief complaint. These findings suggest that theThis

Western medical assessment based approach of themoxibustion treatment is effective for reducing DIP

condition had played a major role in the alleviation

arthralgia caused by Heberden's nodes. Here aof the chief complaint.

combination of Western and Oriental medical

On the other hand, the Oriental medical assessment

approaches is considered to be therapeuticallyof the physical condition based on pulse and tongue

effective.

findings and the consistent therapeutic approach

Regarding

based on this Oriental medical assessment still

Western medical approaches respectively playcontinues and ignoring its influence would not be

further investigations are required.

casesuggests,

theappropriate.
In particular during the eighth session, when I chose
not to administer moxibustion treatment to prevent
aggravation of the probably contusion induced acuteinflammation of the affected region and used only18

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

thattherapeutic

acupuncturerole

Orientalandand