Pain is at the level of L3-4 and radiates down the right leg in typical sciatic fashioon. It is occurs when the weather is overcast or raining and also with fatigue.
Patient presented with low back pain and right side sciatica which came on with the recent sudden change in weather (cold and rainy). The pain is so severe that she needs to take panadeine forte in order to sleep. Slightly overweight, aversion to cold, cold hands, pale yellow complexion, constipation with dry stools. Low back pain is worse when she strains to pass stools.
Menstrual cycle 35 – 45 days with 4-5 days of scanty bleeding, no PMS, no dysmenorrhea. Last period 2 weeks ago.
Pulse: Deep-thready
Tongue: Pale and swollen with a thin white coat
TCM Diagnosis:
TCM Diagnosis: Yang deficiency, obstruction of the Channels by Cold
Treatment Principle: Warm the Yang and disperse the Cold to unblock the Channels and alleviate pain.
Treatment:
FIRST CONSULTATION Patient given ChinaMed® Pain-Less Formula (CM148) Dosage: 3 capsules, 4 times daily to be taken away from meals as well as Acupuncture and moxibustion.
SECOND CONSULTATION After one week, low back pain reduced but still cannot sit for very long without pain worsening, loose stools. Pulse still thready. Tongue no change. Treatment ChinaMed® Pain-Less Formula (CM148) Dosage: 3 capsules, 3 times daily to be taken away from meals. Acupuncture and moxibustion
THIRD CONSULTATION After another week: Low back pain continued to improve, tightness in right calf muscle, stools still loose, period came early (after 26 days) with increased volume and bright red color, no clots and no pain. Tongue a little dry, pulse weak and thready. Treatment ChinaMed® Pain-Less Formula (CM148) Dosage: 2 capsules, 3 times daily to be taken away from meals. If periods continue to be heavy after 3 days, she was advised to stop taking the formula. Acupuncture and moxibustion.
FOURTH CONSULTATION One week later: low back pain almost completely gone, occasional twinge of pain in right calf, period stopped on day 5, stools normal. She noted that she has lost 3kg of weight since beginning treatment. Tongue pale and dry, pulse thready. Treatment ChinaMed® Pain-Less Formula (CM148) Dosage: 1 capsule, 3 times daily continue for another 4 weeks. Also advised to avoid the cold and keep warm.
Outcome:
FIFTH CONSULTATION One month later: back and leg pain relieved, stools normal
