jpark: January 8, 2022, 1:25am
Male Patient, early 50s, Western medical diagnoses of advanced Type II Diabetes, Stage IV Kidney disease,
osteopenia.
Chief Complaint is low back pain. His back pain is right sided, at the level of L4/L5.
Due to the osteopenia there has been a compression fracture at L3 (which has healed). In addition there is spinal
stenosis throughout the lumbar spine and a herniated disc at L4/L5.
In addition to the low back pain he is also dealing with severe diabetic neuropathy in both feet, experienced as
numbness but also burning, tingling pain.
Sleep: Due to severe pain, he only sleeps 3 to 4 hours per night. He is unable to get comfortable and cannot lie
down comfortably on a treatment table in any position. I’ve been treating him in a seated position because that is
the most tolerable position for him.
Build He has an obese build with oily skin. Abdomen is large and bloated while his arms and legs are thinner by
comparison, but still fleshy and have stretch marks.
Eyes don’t seem particularly “bright” to me, but they are intense – there is a look of deep suffering in them, if that
makes sense.
He has very prominent varicose veins.
He is tall but walks with a notable stoop. His shoulders seem high.
Resources He doesn’t seem to be particularly wealthy, but does seem to have supportive friends and family. He
gets frequent colds due to compromised immune status.
Emotions His affect is always cheerful despite the great deal of pain that he is in, but he does occasionally express
frustration with his circumstances. He can have a self deprecating sense of humor.
It’s been difficult for him to come in consistently because of other medical appointments and also frequently
getting sick. He has tried all of the standard biomedical interventions for his low back pain and the next step is
surgery, which he wants very much to avoid. He’s committed to coming in more regularly in the new year, to see if
we can make a difference in his pain level.
I realize I am missing some vital information here – specifically temperature and digestion. I should probably also
pay closer attention to his thenar / LU10 area, and also his abdomen. To some extent this is because I was over
confident in my diagnosis:
Diagnosis This seemed like a clear case of Spleen Excess to me, given the patient’s build, low back pain at L4 and
numbness in the feet. Usually I don’t give so much weight to a Western medical diagnosis, but the weak bones and
diabetes also seem to point to abundant internal dampness.05/01/2024, 11:54Stubborn Back Pain Case – Bothersome Clinical Problems – Qiological Community
https://forum.qiological.com/t/stubborn-back-pain-case/1719/print2/9
Treatments I started treating him prior to studying Saam, so I used some non-Saam acupuncture initially for
several visits, which had no effect. Based on my analysis above, I’ve given the following treatments:
LI Supplementation – I’ve done this twice in a row, based on my diagnosis of Spleen excess. No effect.
KD Supplementation – Normally I would shy away from this in a patient with pain, but given the fact that his
bones are quite weak, he has had a compression fracture, and his tendency toward self deprecation, I thought it was
worth trying. Also no effect.
SI Supplementation – I did this the last time I saw him. I chose this due to the intensity of the pain, the
ineffectiveness of KD supplementation, the notable varicosities in the legs, and considering that neuropathy with
tingling pain can also be considered a kind of “vessel bi” that might respond favorably to moving blood.
No immediate effect from SI, but I will follow up with him next week and report back.
Other possibilities I am considering now are HT or BL supplementation, but I realize I am missing vital
information to be able to determine which one to use. I realize I should ask about temperature and also palpate the
midline.
His body does not feel very obviously hot or cold to me, and I don’t see much obvious fear or excessive love for
others that would point me toward one or the other.
I also have to say I am a little hesitant to use either double fire or double water in this case. Many of his complaints
could be interpreted as general hypo-functioning (yang deficiency from an herbal perspective), and so I might be
more inclined to supplement HT but I am also concerned about pouring fire into so much dampness. In the absence
of obvious heat signs I am also not feeling great about supplementing BL.
If I’m right about this being a Spleen Excess, is it just a matter of time because damp is such a tenacious pathogen
to clear, and the pathology relatively advanced? Should I keep plugging away at the LI?
I realize also it is possible my technique is not perfect, since I am new to Saam, but I am very careful to thread
along or against the channel as much as I can, I use thick needles and strong stimulation. I have also been getting
good results with other patients so while I doubtless have much room for improvement in my technique, I don’t
know if I can blame my lack of results so far entirely on this.
What else am I missing here? What are some good avenues for inquiry to refine my diagnosis?
George_Mandler: January 9, 2022, 10:17pm
Thank you for posting this challenging case Joshua as well as your prior back shu question and how it relates to
Sa’am diagnosis.
Cases similar to what you are presenting here I can often find challenging as there are so many dynamics at play
that evaluation of a treatment can be difficult for a patient. They feel lousy in several ways that they cannot self-
observe some positive changes that may occur from the treatment. I find that cases such as this sometimes more
than Sa’am is needed to help course correct. (CHM, nutrition, lifestyle management/self-care). I’d love to hear
what others experience with many red light warnings throughout their physiology.05/01/2024, 11:54Stubborn Back Pain Case – Bothersome Clinical Problems – Qiological Community
https://forum.qiological.com/t/stubborn-back-pain-case/1719/print3/9
jpark:
He’s committed to coming in more regularly in the new year,
Awesome to have a committed patient as that is likely what it will take to see improvement.
jpark:
Male Patient, early 50s, Western medical diagnoses of advanced Type II Diabetes, Stage IV Kidney disease,
osteopenia.
My first thought is how did he get here? Has he been sick all his life battling autoimmune? Early 50’s, CKD,
T2DM – there must be a lot of history here.
jpark:
Due to the osteopenia there has been a compression fracture at L3 (which has healed). In addition there is
spinal stenosis throughout the lumbar spine and a herniated disc at L4/L5.
I have not had great success with herniated discs and pain from herniation with just Sa’am. Is it currently herniated
and how long has it been there? I find the power of Sa’am doesn’t have the lasting positive outcomes with an
active herniation like many other mysterious ailments that Sa’am works so well for. I always do give it a couple of
treatments and sometimes I am surprised. Hopefully for your patients sake this case will offer positive surprises.
What have others found?.
jpark:
Due to severe pain, he only sleeps 3 to 4 hours per night.
How long has he had this severe pain? Even if it 5-6 hours and he is underreporting this is concerning, but we are
all well aware of that.
jpark:
Build He has an obese build with oily skin. Abdomen is large and bloated while his arms and legs are thinner
by comparison
I agree he does sound like a SP excess morphology. (As an aside if the legs and arms are really skinny but abdomen
is big Toby may think of a ST+ supplementation if it fits with other characteristics. Toby will substitute ST36 for
41 if there is not dry skin in this case. As you said you didn’t include digestion, if he is constipated this may give
more weight to that although it doesn’t correspond to the back shu area concern.)
However with the numbness and location and diabetes and overweight. – yes SP excess for sure. Does he crave
sweets? I find it pretty amazing how well LI+ supplementation works for sweet cravings.
jpark:05/01/2024, 11:54Stubborn Back Pain Case – Bothersome Clinical Problems – Qiological Community
https://forum.qiological.com/t/stubborn-back-pain-case/1719/print4/9
He has very prominent varicose veins.
Are the medial heels dry or moist and plump? if dry or withered looking medial heels I would be thinking SI+
supplementation for the pain. If he has any oketsu then definitely and you should see it release.
jpark:
He’s committed to coming in more regularly in the new year,
With this difficult cases we need to ask for some commitment .
jpark:
LI Supplementation – I’ve done this twice in a row, based on my diagnosis of Spleen excess. No effect.
Was there any effect after the first LI+ supplementation? If not I would not do it a second time and consider
looking elsewhere or in this case perhaps combining it with SI+.
jpark:
KD Supplementation – Normally I would shy away from this in a patient with pain, but given the fact that his
bones are quite weak, he has had a compression fracture, and his tendency toward self deprecation, I thought it
was worth trying. Also no effect.
He certainly seems like he is a combo of both SI and KD excesses… You’ll learn in the class that Toby likes to first
use a SI+ supplementation to move the blood in combination cases like this. Given the pain and varicose veins that
would have been a good first choice. Checking for oketsu in the lower abdomen and making sure it clears with a
SI+ I find reliable. (although this is not taught In the class)
jpark:
No immediate effect from SI, but I will follow up with him next week and report back.
If you got even a small improvement from SI+ I would suggest doing a SI/LI combo given the low back combo.
Although you already have done LI+ 2x. The caution with LI+ would be if he had any dry signs – thin dry tongue,
felt really thirsty. (these are my own thoughts not really taught as the tongue is not weighted in how this system is
taught, but it can be used as a mirror for confirmations of observations).
jpark:
I also have to say I am a little hesitant to use either double fire or double water in this case. Many of his
complaints could be interpreted as general hypo-functioning (yang deficiency from an herbal perspective), and
so I might be more inclined to supplement HT but I am also concerned about pouring fire into so much
dampness. In the absence of obvious heat signs I am also not feeling great about supplementing BL.05/01/2024, 11:54Stubborn Back Pain Case – Bothersome Clinical Problems – Qiological Community
https://forum.qiological.com/t/stubborn-back-pain-case/1719/print5/9
Yes HT/BL for the location of the pain is a good dynamic to evaluate and see if anything stands out as clearly
excess, else I would stay away from it at the start. It sounds like from personality/external observation there is not
clear answer. Do you see soft squishy midline, rapid thin pulse, any dry signs, any complaints of burning, then
consider BL+ supplementation. If a very hard midline and he is always freezing cold then perhaps consider HT+
supplementation.
jpark:
If I’m right about this being a Spleen Excess, is it just a matter of time because damp is such a tenacious
pathogen to clear, and the pathology relatively advanced? Should I keep plugging away at the LI?
No I would not keep hammering on the LI+. Look at other pair dynamics as well. Sometimes we have to layer
where a treatment that we would not think about for the main complaint needs to be treated then you come back to
the original treatment and it can work. I have seen this but not sure how to know it before I do an ineffective
treatment. From the info your provide it does appear that the GTITR is SP excess, but if you did not get anywhere
with the first 2 LI+ treatments so do not keep banging that nail. Look elsewhere. It sounds like the LR/SJ dynamic
is not a clear imbalance. PC/GB? LU/ST – look deeper into these.
jpark:
I realize also it is possible my technique is not perfect, since I am new to Saam, but I am very careful to thread
along or against the channel as much as I can,
I have been so humbled to see how manipulating a needle slightly or changing the angle/location creates the
change for the patient. Points I know I have seen and patients reported profound changes from are KD10, ST41,
SI3 when my original point was slightly off. When I am sure a treatment is correct and I am not getting the
response I assume my point location is off. There is a trust in this system that I’ve come to expect which is just so
darn cool and reassuring.
However in cases such as yours where there is so much going on I just look for the littlest of change – if they crave
sweets are they craving sweets a little less?, does their abdomen change?
Toby always stresses looking at the face and seeing the facial expression which I find challenging, but even more
so in this age of face masks. So for your patient you may need to do more refinement on the channel differentiation
breaking it down. ( And as an aside you really need to evaluate at each treatment to see what is needed in that day.)
Please keep us up to date on this case. I hope what I wrote was helpful. Best wishes for the case and I hope you can
help your patient find some relief.
jpark: January 11, 2022, 1:25am
Thank you so much for your advice and input on this case, @George_Mandler – I really appreciate your time!
George_Mandler:05/01/2024, 11:54Stubborn Back Pain Case – Bothersome Clinical Problems – Qiological Community
https://forum.qiological.com/t/stubborn-back-pain-case/1719/print6/9
I find that cases such as this sometimes more than Sa’am is needed to help course correct. (CHM, nutrition,
lifestyle management/self-care). I’d love to hear what others experience with many red light warnings
throughout their physiology.
I agree completely. This particular case is further complicated by the fact that I am treating the patient in a medical
doctor’s office and not able to offer as many interventions as I otherwise might. I’m limited largely to just doing
needles.
George_Mandler:
My first thought is how did he get here? Has he been sick all his life battling autoimmune? Early 50’s, CKD,
T2DM – there must be a lot of history here.
From what I can tell, T2DM led to the CKD which in turn led to the osteopenia. He also has hypertension and
congestive heart failure.
George_Mandler:
I have not had great success with herniated discs and pain from herniation with just Sa’am. Is it currently
herniated and how long has it been there? I find the power of Sa’am doesn’t have the lasting positive outcomes
with an active herniation like many other mysterious ailments that Sa’am works so well for. I always do give it
a couple of treatments and sometimes I am surprised. Hopefully for your patients sake this case will offer
positive surprises. What have others found?
This is very helpful – and I am also curious to hear what others have to say about treating similar conditions with
Saam. I’ve had great results with it for spinal stenosis and other low back / spine issues, but not herniation per se
before.
I am curious if there are other styles for this kind of issue others have found effective – I also do Master Tung
acupuncture as well as local needling if necessary. I’ve found both effective in previous cases with disc problems.
But so far nothing has been worked for this patient.
This is definitely a chronic condition that he has had for at least a year or more – he has tried physical therapy,
steroid injections, nerve blocks – none of this has helped (and some of has actually made the issue worse). Due to
co-morbidities (specifically the CKD) he is limited in the kinds and amount of medication he can take, and I think
they are also reluctant to do surgery as well for the same reasons.
George_Mandler:
I agree he does sound like a SP excess morphology. (As an aside if the legs and arms are really skinny but
abdomen is big Toby may think of a ST+ supplementation if it fits with other characteristics. Toby will
substitute ST36 for 41 if there is not dry skin in this case. As you said you didn’t include digestion, if he is
constipated this may give more weight to that although it doesn’t correspond to the back shu area concern.)
However with the numbness and location and diabetes and overweight. – yes SP excess for sure. Does he crave
sweets? I find it pretty amazing how well LI+ supplementation works for sweet cravings.05/01/2024, 11:54Stubborn Back Pain Case – Bothersome Clinical Problems – Qiological Community
https://forum.qiological.com/t/stubborn-back-pain-case/1719/print7/9
That’s good to know about swapping out ST36 for ST41 in the absence of dry skin. He does crave sweets. I will
follow up with the patient later this week and inquire about bowel movements.
George_Mandler:
Are the medial heels dry or moist and plump? if dry or withered looking medial heels I would be thinking SI+
supplementation for the pain. If he has any oketsu then definitely and you should see it release.
I will re check them tomorrow to confirm but from what I recall they are relatively dry and very thin / withered.
His calves are covered in a network of thick, distended varicosities.
George_Mandler:
Was there any effect after the first LI+ supplementation? If not I would not do it a second time and consider
looking elsewhere or in this case perhaps combining it with SI+.
None that he could tell. I try to avoid doing the same treatment twice in a row, but in this case I was very convinced
of my diagnosis of Spleen Excess, and also thought that maybe I had not been as exacting enough in my point
location and needle placement the first. After having it yield no results two times in a row though I will set it aside
for now.
George_Mandler:
He certainly seems like he is a combo of both SI and KD excesses… You’ll learn in the class that Toby likes to
first use a SI+ supplementation to move the blood in combination cases like this. Given the pain and varicose
veins that would have been a good first choice. Checking for oketsu in the lower abdomen and making sure it
clears with a SI+ I find reliable. (although this is not taught In the class)
That is great information. It makes sense to break open the stagnation with SI+, and then consolidate after with
KD+. I’ve only taken the Introduction Course on Healthy Seminars recently and I don’t recall if alternating SI+
and KD+ was covered.
George_Mandler:
If you got even a small improvement from SI+ I would suggest doing a SI/LI combo given the low back
combo. Although you already have done LI+ 2x. The caution with LI+ would be if he had any dry signs – thin
dry tongue, felt really thirsty. (these are my own thoughts not really taught as the tongue is not weighted in how
this system is taught, but it can be used as a mirror for confirmations of observations).
I’ll check for dry signs the next time I see him and definitely consider this. At the very least he has not had a bad
effect from treating LI+ as far as I can tell, so if SI+ goes well I could see combining both LI+ and SI+ in an 8
needle treatment. Constitutionally LI+ seems to fit him very well.
George_Mandler:05/01/2024, 11:54Stubborn Back Pain Case – Bothersome Clinical Problems – Qiological Community
https://forum.qiological.com/t/stubborn-back-pain-case/1719/print8/9
Yes HT/BL for the location of the pain is a good dynamic to evaluate and see if anything stands out as clearly
excess, else I would stay away from it at the start. It sounds like from personality/external observation there is
not clear answer. Do you see soft squishy midline, rapid thin pulse, any dry signs, any complaints of burning,
then consider BL+ supplementation. If a very hard midline and he is always freezing cold then perhaps
consider HT+ supplementation.
Will inquire about thermoregulation and also palpate the midline next time. As I mentioned above, I forgot to
include that he does have biomedical heart disease as well so perhaps the HT/BL axis is something to consider for
this case after all, especially since he hasn’t responded to other treatments.
George_Mandler:
No I would not keep hammering on the LI+. Look at other pair dynamics as well. Sometimes we have to layer
where a treatment that we would not think about for the main complaint needs to be treated then you come
back to the original treatment and it can work. I have seen this but not sure how to know it before I do an
ineffective treatment. From the info your provide it does appear that the GTITR is SP excess, but if you did not
get anywhere with the first 2 LI+ treatments so do not keep banging that nail. Look elsewhere. It sounds like
the LR/SJ dynamic is not a clear imbalance. PC/GB? LU/ST – look deeper into these.
This is helpful. ST Excess might be interesting in light of the neuropathy and the general adiposity – maybe that is
all just surface damp, and the other internal conditions should be regarded as dryness in the interior. It all just
seemed so deep seated to me that I went with Spleen Excess, but if he is not responding to LI+ I will certainly
consider the LU/ST dynamic.
George_Mandler:
I have been so humbled to see how manipulating a needle slightly or changing the angle/location creates the
change for the patient. Points I know I have seen and patients reported profound changes from are KD10,
ST41, SI3 when my original point was slightly off. When I am sure a treatment is correct and I am not getting
the response I assume my point location is off. There is a trust in this system that I’ve come to expect which is
just so darn cool and reassuring.
This is very good to know. I try to be as exacting as I can about point location, needle placement and needle
manipulation. I am sure there is a lot of subtlety I am missing though and would love to take a live class when this
pandemic is over.
George_Mandler:
However in cases such as yours where there is so much going on I just look for the littlest of change – if they
crave sweets are they craving sweets a little less?, does their abdomen change?
I will definitely try to look into these variables more and see if there are any signs of progress.
George_Mandler:05/01/2024, 11:54Stubborn Back Pain Case – Bothersome Clinical Problems – Qiological Community
https://forum.qiological.com/t/stubborn-back-pain-case/1719/print9/9
Toby always stresses looking at the face and seeing the facial expression which I find challenging, but even
more so in this age of face masks. So for your patient you may need to do more refinement on the channel
differentiation breaking it down. ( And as an aside you really need to evaluate at each treatment to see what is
needed in that day.)
Yes, with masks facial diagnosis has been a challenge for me. Evaluating at each treatment is something I am
reminding myself to do; there is no clinical laziness allowed in the Saam system!
George_Mandler:
Please keep us up to date on this case. I hope what I wrote was helpful. Best wishes for the case and I hope you
can help your patient find some relief.
This was very helpful, and I appreciate all of the time you’ve spent reviewing my case. I will definitely follow up!
jpark: January 19, 2022, 7:14pm
Just a quick update on this case: SI supplementation was not helpful.
He has occasional hot flashes, and describes his neuropathy as a burning pain (rather than numbness). His skin felt
warm and dry today (previously has been more moist). It also struck me that his family dynamic is such that he is
constantly giving love and attention to others. His pulse was also slightly rapid, and exhibited a notable fullness in
the left distal position.
Based on all that, I used BL supplementation on the left – will see how that goes.