In April 2020, a 57-year-old female patient initially experienced a sudden onset of a right-sided limb movement disorder and a lack of fluency in speech. The cephalometric CT scan at a local hospital showed thalamic hemorrhages. After conservative treatment, her speech function recovered, but she still felt poor physical strength and had an abnormal gait. She was then admitted to Beijing United Rehabilitation Hospital for further rehabilitation in March 2021. Two months after hospitalization, the patient developed moderate-to-severe pain [visual analog scale (VAS) 6-9] on the right side of her body, including the face, arm, trunk, and limbs, with no apparent cause. The pain was persistent and tightness-like, accompanied by paroxysmal pinprick-like pain occurring 30-50 times per day. The patient felt a painful wandering mass on the right plantar aspect of her foot and was unable to put weight on the right foot due to the pain. She also experienced paroxysmal knife-like pain (VAS 9) in the right upper arm, and moderate-to-severe tearing-like pain (VAS 6-9) in the right axilla and lateral chest wall. The magnetic resonance imaging (MRI) showed a malacic lesion in the left thalamus, and chronic ischemic lesions in the brainstem, bilateral basal ganglia, and periventricular white matter. Multiple white matter lesions in bilateral periventricular and subcortical white matter were observed, and Fazekas 3 was considered (Figure 1).
She was prescribed oral medications, including Gabapentin(R) (1,200 mg, three times a day), Duloxetine(R) (60 mg, once a day), Neurotropine(R) (8 u, twice a day), Tylenol(R) (1 tablet, as needed), and received traditional acupuncture, herbal medicine, and physical therapy. However, the pain was not alleviated. The patient frequently woke up at night due to pain outbreaks, which severely influenced her mood, sleep, and her ability to cooperate with rehabilitation treatment. Thus, she sought a consultation from the Division of Pain for further treatment.
During the consultation, the patient exhibited slower speech. Her right side of the body was hyperalgesic and could not tolerate cold when wiped with an alcohol swab. The muscle strength of the proximal right limb was grade 4, and the distal limb was grade 4-. The patient's right hand was unable to hold chopsticks or use a pen due to the contracture of the 3rd-5th fingers. Pressing pain was identified in the cervical spinous processes (C2-7), right transverse processes, and coracoid process of the right scapula. Similar symptoms were also detected in the right sternocleidomastoid, trapezius, and pectoralis major muscles. The abdomen was tense with pressing pain in the upper abdomen. The bilateral iliopsoas muscles, upper and lower back, and right hip experienced pressing pain. The patient also reported pressing pain in the posterior leg and on the right plantar.
After the first treatment with cheek acupuncture (Figure 2), the patient experienced significant relaxation on the right side of her body and a 60% reduction in spontaneous pain. The painful mass in the right foot shifted to the heel, decreasing in size and pain level. The patient could tolerate the pain in the right foot triggered by touching the ground. The first four sessions were administered once a week, followed by treatments every two weeks. The symptoms continuously improved during the treatments. Eight sessions later, the spontaneous pain in the right limb and trunk was reduced by 70-80%, and paroxysmal pinprick-like pain episodes occurred less than five times a day, lasting 2-3 seconds each time. There were no more nocturnal eruptive pain episodes. The patient only took Gabapentin 900 mg three times a day. The patient could stand only on right leg. The contracture of the right hand significantly improved, and the patient could perform certain fine activities, such as eating with chopsticks and writing. The walking gait was much better than before. Importantly, the patient's mood and sleep improved significantly, which facilitated rehabilitation training.