Ischemic Foot Treated With Acupuncture
P. G. Parameswaran, MD
Vascular insufficiency of the lower extremity with resulting ischemic pain and possible gangrene is common in elderly persons due to atherosclerosis, diabetes mellitus, or secondary to cardiac arrhythmias causing embolization of peripheral vessels. Vasospastic disorders such as acrocyanosis, livedo reticularis, and Raynaud's syndrome are aggravated by exposure to cold, and are more common in younger patients. This report concerns a 79-year-old woman, with none of these predisposing causes, who presented with several painful ischemic toes on the left foot with impending gangrene.
Ischemic, Acupuncture, Vascular insufficiency
79-year-old white woman was referred by her family physician because of severe pain for over a week in several toes of her left foot, and specifically, for possible amputation of the 4th toe, which was the worst affected. The patient described the pain as excruciating and constant. She was not able to wear a stocking or shoe on the left foot because of the pain. She was in good health and denied any history of diabetes or heart disease. There was no history to suggest any vasospastic disorders. The patient denied any trauma to the foot or exposure to cold. Her surgical history included hysterectomy with bladder suspension, right hip arthroplasty, cataract surgery in both eyes, and repair of an incarcerated epigastric hernia. She had stopped smoking 30 years earlier; her alcohol consumption was 3-4 beers daily. Her only medication use was eye drops for biocular glaucoma.
General Physical Examination
The patient was in severe pain from the left foot. She was slim and her appearance was consistent with the stated age of 79 years. Her vital signs were normal. The cardiac rhythm was normal with no evidence of arrhythmia; the heart sounds and breathing were normal. Examination of the abdomen revealed the operative scar of previous surgery, but was otherwise normal.
The patient could not move the toes of her left foot because of pain. The left 1st, 4th, and 5th toes were bluish-purple in color (Figures 1-4). The 4th toe appeared the worst and was bluish-black, suggestive of impending gangrene. The left distal foot and toes were cold to touch. All the toes of the left foot were extremely tender to palpation. The patient could not move the toes because of pain, and she would not allow passive movement. The right foot and toes were warm and of normal color. The dorsalis pedis and the posterior tibial pulses were 2+ in both feet.
Severe ischemia of the 1st, 4th, and 5th toes of the left foot of unknown etiology, with impending gangrene of the 4th toe.
The patient had severe vascular insufficiency of 3 toes on her left foot despite good pedal pulses. She had excruciating pain in the toes from ischemia. The affected toes were not yet gangrenous and hence, she was not a candidate for immediate amputation. She was offered the choice of medications for relief of pain and vasospasm, or a trial of acupuncture. She was told that acupuncture may not only relieve her pain, but could also restore the circulation to the toes. The patient was apprehensive about the pain from the needles, but consent was given when reassurance was given regarding complications or side effects from the treatment.
Due to her anxiety and apprehension, I used a minimal number of needles and restricted them locally to both feet. The right foot was treated as prophylaxis against possible ischemia and also, for possible benefits to the contralateral affected foot. I hoped that the needles would relieve the vasospasm by their sympatholytic effect, thereby improving the circulation. Pain relief was expected to occur, along with release of endorphins and enkephalins locally. As evidenced by the patient's immediate relief of pain after the 1st treatment, I believe this ensued. For subsequent treatments, the point combination recommended by Jeremy Ross was chosen. The patient's response was dramatic.
For the 1st treatment, Seirin #02, 30-mm needles were used; SP 1, SP 4, and BL 64 were needled in both feet, and left in place for 15 minutes without stimulation. After removal of needles, the patient had complete relief of pain and was able to actively move the toes.
However, passive movement was slightly painful; bluish-black discoloration of the affected toes persisted.
The 2nd treatment was performed 5 days later; SP 1, SP 4, SP 8, ST 30, ST 31, ST 41, PC 6, and CV 6 were needled (using the same size needles as in the 1st treatment) and left in place for 20 minutes without stimulation. No change in color was noticed after the treatment. However, the patient continued to be pain-free.
The patient was seen again 9 days later. At that time, all 3 affected toes had regained their normal pink color and continued to be free of pain (Figures 5-6). The left foot was warm. She was again treated using the same acupuncture points as in the 2nd session.
The patient was seen 2 years later and her toes and foot appeared healthy.
Rationale for Acupuncture Protocol
- SP 1 invigorates the spleen; this point is useful in acute situations of stagnation.
- SP 4 moves Qi and blood in the legs, especially when combined with ST 30 and ST 31. SP 4 is the connecting point between the Spleen and Stomach channels. It is the opening point of the Thoroughfare channel, Chong Moi. The main function of the SP 4 and the Thoroughfare channel is to move stagnation.
- The main function of SP 8 is to move stagnant blood and relieve pain, especially in the lower abdomen and legs.
- ST 30 is a point in Chong Moi, which can move stagnant blood in the body in general. ST 30 is at the junction of the legs and body where energy blockage can occur. Combined with SP 4, PC 6, and CV 6, it can help improve circulation in the legs and feet.
- ST 31 strengthens and moves Qi and blood to treat problems in the lower extremity. It is useful in blocked arterial circulation in the leg when it is combined with SP 4, PC 6, ST 31, ST 36, and ST 41.
- The main function of PC 6 is to move stagnation of Qi, blood, and phlegm, and to calm irregularity of Qi.
- CV 6, along with CV 4, represents the Dan Tien, the energy center of the body responsible for storage and distribution. CV 6 is helpful in dispersing stagnant Qi.
Figures 1-4. Left foot [clockwise from top left]
Note the bluish discoloration of the terminal phalanges of the 1st, 4th, and 5th toes of the left foot. The acupuncture needles are in place.
Figures 5-6 Affected toes [from left]
(Post treatment) Note the normal color of the affected toes.
Mechanism of Action
Disturbances in peripheral circulation are considered to be due to stagnation of Qi and blood. Acupuncture treatment reestablishes the disturbed flow of Qi and blood. Several studies have shown that acupuncture reduces sympathetic tone, thereby causing vasodilatation. This would increase blood flow locally to the affected part. Looney demonstrated a 300% increase in plethysmographic recordings of blood flow in the digits of limbs stimulated with electroacupuncture. Relief of pain is explained by improved blood flow, neural mechanism, and release of endorphins. A correlation has been demonstrated between the effectiveness of acupuncture in alleviating chronic pain and increasing surface temperature. Liao and Liao also demonstrated that acupuncture applied to points distant from the affected area reduces pain and increases temperature. Another mechanism of action is by release of a vasodilator substance, possibly a vasointestinal active peptide.
Moehrle et al reported that patients with primary Raynaud's syndrome treated with acupuncture recorded significant reduction in the attack rate and increase in blood flow. Jansen et al reported significant improvement in the survival of skin flaps raised in experimental animals treated with electroacupuncture.
This patient had severe persistent pain and ischemia of 3 toes of the left foot for more than a week. The pain of ischemia and the discoloration of the toes were severe enough to warrant consideration of possible amputation for relief of pain. Gangrene was imminent.
The results of acupuncture treatment of the ischemic foot was positive and saved the patient's foot from amputation. Acupuncture may be a useful adjunctive therapy in the management of vascular insufficiency.
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Dr P. G. Parameswaran is a General and Thoracic Surgeon in private practice in Houston, Texas. Dr Parameswaran practices Medical Acupuncture, Hypnotherapy, Yoga therapy, and Healing Touch. He is a Fellow of the International College of Surgeons.
P. G. Parameswaran, MD, MS, Mch*
Memorial Herman Southeast Professional Bldg
11914 Astoria Blvd, #555
Houston, TX 77089
*Send all correspondence and reprint requests to Dr Parameswaran at the above address.