In the treatment room, I am greeted with a slender, smiling face. Eager and animated, he doesn’t wait for my introduction, he dives right into perfect English. I admit, I am excited to have a break from the time-lag of interpretation. My interpreter looks momentarily shocked. My patient is a twenty-five year old pre-med student here in Chapagaon, Nepal, speaks perfect English, and he brought me a handful of research articles on Chinese medicine, acupuncture, and moxibustion for Ankylosing Spondylitis. My nerdiness is set a-flutter.
He spends most of his time pouring of textbooks, research articles, and the internet when the village of Chapagaon has electricity. We share a love of the Merck Manual, although he most likely spends a great deal more time with it than I do these days.
He has been diagnosed in an India hospital with Ankylosing Spondylitis (AS), an inflammatory arthritis that often begins at the sacroiliac joint of the pelvis and lower lumbar vertebra. It tends to progress up the spine and eventually can inflame the joints where the ribs connect to the spine and sternum, restricting the movement necessary for proper breathing. My patient, we’ll call him Ram for the sake of this blog, is understandably trying quite a few medical modalities to arrest the progress of his Ankylosing Spondylitis.
Ram explains that he started seeking treatment with the Acupuncture Relief Project after reading some clinical trials on AS and Chinese medicine. He had imaging and blood work done in India, but he wasn’t sure if he met all the criteria for a proper diagnosis of AS. The imaging showed a few joint changes characteristic of AS, such as hardening and calcification of the ligaments that support the lumbar spine. When this calcification has gone on for a long time, it is called ‘bamboo spine.’ It is an apt term, as the harden ligaments start to look uncannily like bamboo. Ram’s spine is not yet changed to the degree of bamboo spine. His X-rays also show inflammation at the sacroiliac joint and a lower bone density than normal. All of his back pain is worse at night and with rest.
Later that evening, I have time to read up on AS. His imaging and pattern of pain meet all the criteria for a clear diagnosis of AS according to the Merck Manual.
Before meeting me, Ram received fifteen treatments with the Acupuncture Relief Project. He excitedly explains that in those fifteen treatments, he has experienced a great deal of pain relief and increased flexibility in his back. I look back through the chart and it is true. When he first came to the ARP clinic, Ram could only bend forward 30 degrees, a far cry from touching one’s toes. He could only bend backwards 10 degrees. By his first visit with me, he could bend forward 80 degrees and backwards 15 degrees. A great success for the goal of touching his toes, but not a ton of improvement in backbends.
Within the first treatment together, Ram and I had a good report, building on our mutual respect of each other’s chosen medical career. We continued to work together for several weeks. Each treatment worked with acupuncture based on Chinese medical theory– selecting points that nourish bone, encourage the immune system to work properly instead of attacking itself, and to restore proper circulation to the muscles in his body. We used direct moxa or a tiger warmer moxa device to reinforce the work of the acupuncture needles and thoroughly warm the back. Finally, we applied cupping to the muscles of his back to release metabolic wastes that built up in tight muscles and to encourage muscle spasms to cease.
For those of you unfamiliar with moxa, it is a common addition to acupuncture treatments. Moxa is a species of Chinese mugwort, an herb that has warming properties when ingested. When dried into a fluffy powder or compressed into charcoal poles and lit, moxa burns at an infrared frequency that penetrates deep into the tissues of the body. In our textbooks it is purported to increase the immune system, restore proper function to the immune system, and to warm and enhance healing in arthritic joints, amongst other traits. Most of the successful clinical trials that Ram had found touted the use of moxa therapy in AS cases.
Like many patients, despite his measurable successes in flexibility, Ram started to long for faster ‘cure’. He started to get frustrated with the return of muscle spasms in his neck and shoulders– a trait I think related more to the combination of poor posture while pouring over medical texts until three a.m. and the stress of exams.
While dealing with chronic pain and illnesses like AS, one of the biggest challenges for both patient and practitioner is to keep sight of positive progress despite chronic pain. For the patient, long-term pain or recurrent cycles of pain really wears on one’s outlook on life. The pain seeps into daily living and activities. When strong enough, pain clouds one’s thinking as thoroughly as an overcast day. Underneath the pain, one’s body is actively throwing resources at the site of pain to heal it. Injury healing, autoimmune disorders, and inflammatory arthritis’ are obviously more complicated than the above description, but the key point is that your body uses up tremendous resources when you are in pain and that creates real, valid fatigue. It is natural to loose patience or to feel discouragement at the slow healing process of a disease that took time to develop. It takes time to heal it or to manage in the case of AS and autoimmune disorders. Sometimes the fatigue, pain and frustration cloud our ability to notice any positive changes in our health, or to hear about it from a healthcare provider.
For the practitioner, the challenge is in part trying to place yourself in your patient’s shoes, and in part communication. As a practitioner, you can never fully know what the pain in your patient’s body feels like. We ask many questions about the quality of pain and try to quantify the degree with the 0-11 point NRS pain scale that we all know and love. Sometimes we try to spruce up the pain scale with diagrams of smiley and frowny faces. With or without the pain scale, the practitioner still has no idea what the patient’s pain in the patient’s body feels like. Even if a practitioner has experienced chronic pain, they cannot feel the patient’s pain. It is a unique experience, and one the ebbs and flows like a turbulent tide.
Communicating about health improvements, or lack there of, is one of the more difficult tasks as a health care provider. At times it requires you to be a cheerleader, or a professional, and or someone who relates cold- hard facts. Since every person has different emotional needs when disheartened about their chronic pain or healing plateau, the challenge arises when assessing what delivery style will be most beneficial to them on any given day. Ultimately, practitioners want their patients to feel good and excited about forward progress in their health. Some illnesses take longer than others to heal, and there will be natural periods of noticeable progress followed by plateaus. Communicating about these ups and downs in healing takes a great deal of skill, and even with the greatest skill at honest discourse, sometimes the message gets lost in translation. Communication in any relationship requires practice, honesty, and patience. No one perfectly communicates all of the time. The patient-practitioner relationship is no exception.
We spent a couple weeks discussing his steady positive progress in flexibility and that the studies he brought to me cited at least forty-five treatments for considerable progress with AS. We also discussed how his student lifestyle and studying postures could continually cause muscles unrelated to the AS to spasm. Acupuncture would be helpful in mitigating the effects of stress and studying, but would not be able to fix the problem until his stress levels lessened.
On our last visit, before Ram descended into preparing for his last round of medical exams before starting his hospital internship, his forward bend measured 85 degrees and his backbend measured a remarkable 40 degrees. He had come a long way from his initial 10 degree backbend only two months earlier. In fact, his backbend is now deeper than the norm for the general populace. I hope he continues to pursue treatment after his exams are finished. I know we both communicated to the best of our abilities. I just hope it was the appropriate flavor to help him recognize how far his flexibility and pain management have progressed.