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J Acupunct Res > Volume 37(3); 2020 > Article
Lee, Kim, Lee, Kim, Sung, Cha, Jeon, and Young: A Patient with Symptoms Caused by Electric Shock Treated with Traditional Korean Medicine

Abstract

This case report describes a 60-year-old female patient diagnosed with intercostal neuropathy and vertebral compression fractures which occurred following an electric shock injury. The patient received acupuncture, pharmacopuncture, and herbal medicine administration between February 10th, 2020 and April 25th, 2020. The pain level in the thoracic and left intercostal areas was assessed using the Numerical Rating Scale. The Self-report of the Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale were used to diagnose neuropathic pain. The Neuropathic-Pain -Scale was used to evaluate the degree of neuropathic symptoms. The Oswestry Disability Index and the European Quality of Life-5 Dimensions were used to assess quality of life scales and functional disorder. Following combined Korean medicine treatment, the patient exhibited reduced levels of pain and significant improvement in functional disorder symptoms and quality of life.

Introduction

An electric shock injury is a physiological and chemical reaction caused when an electric current passes through the human body, resulting in various kinds of damages. Electric shock injury includes direct damage to the central or peripheral nerves and tissues, burns induced by resistance of internal tissue, and mechanical damage followed by muscle contraction [1]. Strong contractions of the muscles that occur during electric shock injury can cause fractures. The most common are humeral head fractures, but thoracic compression fractures have also been reported [2]. Peripheral nerve damage occurs in about 15% of low-voltage electric shock injury. Neuropathic symptoms tend to coincide with the electric shock site [3].
Electric shock injury cannot be predicted in advance, so retrospective reviews are the main method of research and the number of patients is not high [4]. For this reason, there are not many articles on electric shock injury. Traditional Korean medicine has only 1 case report of treatment for a headache following an electric shock injury [5].
This case report shows significant improvement after applying combined Korean medicine treatment (CKMT) to a patient who suffered left intercostal neuropathy and vertebral compression fractures following an electric shock injury. This study was exempt from IRB deliberations (IRB no: DJDSKH-20-E-13-1).

Case Report

Patient

Lee OO (female, 60 years old).

Principal complaints

Thoracic pain, left intercostal pain, gait disturbances.

Onset and cause

February 8th, 2020, the patient suffered an electric shock when her back touched a concentric plug while sitting in a sauna. She did not fall but lost consciousness after the electric shock.

Past history

The patient had been taking medication since 2019, following a diagnosis of hypertension and osteoporosis.

Present status

The patient did not receive electrocardiography, blood tests or X-ray scans in the emergency room of Dunsan Korean Medicine Hospital of the Daejeon University on February 8th, 2020. Her symptoms did not improve with analgesics (oral or injection), and the patient was admitted to the Dunsan Korean Medicine Hospital of the Dajeon University for treatment between February 10th, 2020 and April 25th, 2020.

Physical examination

When hospitalized at the Dunsan Korean Medicine Hospital of the Dajeon University, she was unable to stand or walk due to severe pain, making it impossible to measure range of motion and to perform physical examinations.

Blood tests

Erythrocyte Sedimentation Rate was elevated above normal (41 mm/hour) and procalcitonin was lower than normal (0.14 %). Other tests, including liver function test, complete blood count, and urinalysis all showed normal values.

Radiology findings

X-ray

February 11th, 2020, thoracic-spine AP: mild scoliosis of thoracolumbar spine and diffuse osteoporosis of the thoracolumbar spine. At the time of admission, she was unable to lie on her side because of severe pain, therefore only an AP image was taken. February 11th, 2020, rib posterioranterior view: no definite rib fracture findings (Fig. 1).

Computerized tomography (CT)

March 3rd, 2020, enhanced chest CT: subacute compression fracture T4–T6 (Fig. 2).

Magnetic resonance imaging (MRI)

March 3rd, 2020, T-spine MRI STIR image: subacute compression fracture T4–T6 (Fig. 2).

Treatment methods

Acupuncture

She received acupuncture twice a day, each morning and afternoon. Acupuncture was performed with 0.25 × 40 mm sterilized disposable stainless steel DongBangchim needles (Dongbang Medical Co., Ltd., Boryeong, Korea), which were left in place for 15 minutes. In the mornings, acupuncture treatment (AT) was conducted at the proximal regions, and in the afternoons AT was conducted at the distal regions. In the proximal region, AT was mainly performed at the following acupoints: BL13, BL14, BL15, BL16, BL17, BL42, BL43, BL44, BL45 and BL46 on both sides of the thoracic vertebrae; LR14, SP21, GB22 and GB23 of the left intercostal area, and at the BL40, BL60, BL62, GB34, GB39, SI3, ST36 and TE3 in the distal region (Fig. 3) [6].

Pharmacopuncture

Pharmacopuncture treatment was performed daily in the mornings. She was treated twice a week with soyeom pharmacopuncture (Korean-Pharmacopuncture-Research-Institute), ouhyul pharmacopuncture (Korean-Pharmacopuncture-Research-Institute), and hominis-placenta pharmacopuncture (Korean-Pharmacopuncture-Research-Institute), depending upon the symptoms. Bee-venom pharmacopuncture (Korean-Pharmacopuncture-Research-Institute) was performed once a week. Soyeom, ouhyul, and hominis-placenta were injected at the acupoints, the same as AT on both sides of the thoracic vertebrae, using a total of 2 mL, 0.1 mL per acupoint, with 13 mm × 30-gauge needles [6]. Bee-venom pharmacopuncture was refined 99.9% pure melittin 0.10 mg/mL. Bee-venom pharmacopuncture was explained to the patient prior to the procedure and she gave informed consent. In addition, a bee-venom allergy test was performed on the skin to ensure that the patient had no side effects to bee-venom treatment. Bee-venom pharmacopuncture was conducted subcutaneously at the acupoints LR14, SP21, GB22, GB23 and BL26 in the left intercostal area, with a total of 1 mL, 0.2 mL per acupoint, using a 13 mm × 30-gauge needle. [6].

Herbal medicine

Herbal medicine treatment including lijintang-gami (LJTGM), gamigunggi-tang (GMGGT), guibitang-gami (GBTGM), and tongshun-san (TSS) was administered. The patient took herbal medicine (120 mL per each pack) 3 times daily, 1 hour after each meal. LJTGM was administered with TSS to reduce pain in the thoracic and left intercostal area. GMGGT was administered to facilitate the recovery of thoracic vertebral fractures. GBTGM was also used to help the healing of thoracic vertebral fractures, improve neuropathic symptoms, and insomnia. Table 1 shows the duration of use and the descriptive details of the LJTGM and GMGGT prescriptions. Table 2 shows the duration of use and the description detail of the GBTGM and TSS prescriptions.

Evaluation

The Self-report of the Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale (S-LANSS) [7] (Appendix A) was used as a tool to diagnose neuropathic symptoms. If the S-LANSS questionnaire gave a score higher than 12 points, it was assumed that the neuropathic mechanism was associated with the patient’s symptoms. The patient’s S-LANSS questionnaire score, conducted on February 10th, 2020, was 19 points, showing her left intercostal area symptoms to be diagnostic of neuropathy. The Numerical Rating Scale (NRS) [8] scores were evaluated and compared at 7 a.m. daily beginning on February 10th, 2020, and continued for 76 days. The Neuropathic-Pain-Scale (NPS) [9] (Appendix B), the Oswestry Disability Index (ODI) [10] (Appendix C), and the European Quality of Life-5 Dimensions (EQ-5D) [11] (Appendix D) were also compared and evaluated before AT on the first day of hospitalization, after 21 days, 42 days, and on discharge day. A Korean version of the S-LANSS, NPS, and ODI questionnaires [10] (whose reliability and validity studies had previously been verified) were used for evaluation. the EQ-5D-5L was calculated by applying the Korean preference weights for the Korean standard population status.

Progress

The patient showed a significant improvement in NRS, NPS, ODI, EQ-5D scores following treatment. Fig. 4 shows the improvement details of the NRS scores in both the thoracic area and left intercostal area. Table 3 shows the improvement of the NPS, ODI, EQ-5D scores. At the time of admission, the patient had been unable to walk because of severe pain in the left intercostal and thoracic areas, but after April 03rd, 2020, she was able to walk with reduced pain.

Discussion

CKMT was performed for 76 days on a patient who had suffered an electric shock injury which caused multiple compression fractures of the thoracic vertebrae and left intercostal neuropathy.
AT has been used therapeutically for various pain conditions such as lumbar sprain, fractures of the spine, and intercostal neuralgia [6]. The analgesic effect of acupuncture is generally explained in 3 ways. Firstly, axion reflexes and the activity of adenosine A1 receptors, occurring during AT, facilitate blood circulation into local areas and reduce pain. Secondly, AT suppresses pain signals by providing new afferent excitatory stimulation to the central nervous system that can only process a limited amount of information. Thirdly, AT suppresses systemic pain by stimulating the central nervous system to induce various endogenous opioid peptides [12]. This is the basis for applying AT to many pain conditions/diseases. In this case, considering that the patient’s NRS and NPS score decreased after treatment, acupuncture is thought to have helped reduce pain.
Pharmacopuncture is a new treatment that combines the theory of acupuncture medicine and pharmacotherapy. Chemical stimulation through drugs, extracted from a specific herbal medicines, are used as an additional treatment to AT which delivers physical stimulation through meridians and acupoints. Clinically, pharmacopuncture has been used for various pain conditions/diseases such as neuropathic pain, compression fractures, and joint sprains [13]. In particular, soyeom, ouhyul, hominis-placenta and bee-venom pharmacopuncture have been used for vertebral compression fractures and neuropathic pain, which helped improve symptoms [14,15].
Herbal medicine was prescribed to relieve pain and improve side effects during treatment, such as sleep disorders, and anxiety [16,17]. However, various kinds of herbal medicines were also used in combination to improve the patients’ discomfort. When treating similar cases in the future, we suggest the consistent administration of herbal medicine as a main modality.
This study has the limitation of being a single case report. Although conservative treatments of compression fractures take an average of about 3 months to resolve [18], however, her pain was reduced enough to allow her to walk following the CKMT after approximately 2 months, despite having had multiple compression fractures in 3 vertebrae.
Pain in the thoracic and left intercostal area, evaluated by NRS and NPS scores, showed improvement. In addition, functional disorder and quality of life showed improvement, as evaluated by ODI and EQ-5D. This suggests the possibility that CKMT is effective for the treatment of electric shock injury.

Conflict of Interest

Conflicts of Interest

The authors have no conflicts of interest to declare.

Fig. 1
X-ray on 2020.02.11. (A) Rib PA (B) T-SPINE AP.
jar-2020-00192f1.jpg
Fig. 2
T-spine MRI & CT on 2020.03.03. (A) T-spine MR STIR, (B) T4 CT, (C) T5 CT, (D) T6 CT.
CT, computerized tomography; MRI, magnetic resonance imaging.
jar-2020-00192f2.jpg
Fig. 3
Acupuncture points.
jar-2020-00192f3.jpg
Fig. 4
The Change of NRS Score Before and After The treatment
NRS, numerical rating scale.
jar-2020-00192f4.jpg
Table 1
Duration of Use, Herbal Composition of LJTGM and GMGGT, and Daily Dosage.
LJTGM (g)
(02/15/2020–03/03/2020)
GMGGT (g)
(03/04/2020–03/09/2020)
Angelicae gigantis radix 12 Angelicae gigantis radix 20
Cinnamomi ramulus 8 Cnidii rhizoma 20
Lonicerae flos 8 Cervi cornus colla 10
Cynanchi atrati radix 8 Carthami fructus 10
Poria sclerotium 8 Ginseng radix 8
Amomi fructus 4 Astragali radix 8
Arecae semen 4 Lycii fructus 8
Linderae radix 4 Cuscutae semen 4
Citri unshius pericarpium immaturus 4 Dendrobii herba 4
Moutan radicis cortex 4 Codonopsis pilosulae radix 3
Atractylodis rhizoma alba 4 Dipsaci radix 4
Pinelliae tuber 4
Cyperi rhizoma 4
Citri unshius pericarpium 4
Sinapis albae semen 4
Glycyrrhizae radix 3
Aucklandiae radix 3
Carthami flos 1
Sappan lignum 1

LJTGM, lijintang-gami; GMGGT, gamigunggi-tang.

Table 2
Duration of Use, Herbal Compositions of GBTGM and TSS, and Daily Dosage.
GBTGM (g)
(03/10/2020–03/23/2020, 04/10/2020–04/25/2020)
TSS (g)
(04/24/2020–04/09/2020)
Eucommiae cortex 12 Carthami fructus 6
Lycii fructus 12 Paeniae radix rubra 4
Psoraleae semen 12 Angelicae dahuricae radix 4
Angelicae gigantis radix 6 Aurantii fructus immaturus 4
Zizyphi semen 6 Linderae radix 4
Astragali radix 6 Glycyrrhizae radix 4
Poria Sclertum cum Pini Radix 6 Akebiae caulis 4
Longan arillus 6 Cynanchi wilfordii radix 4
Ginseng radix 6 Foeniculi fructus 4
Atractylodis rhizoma alba 6 Angelicae gigantis radix 4
Polygalae radix 6
Aucklandiae radix 3
Glycyrrhizae radix 2

GBTGM, guibitang-gami; TSS, tongshun-san.

Table 3
The Changes of NPS, ODI, EQ-5D Score Before and After the Treatment.
Score Before 21 d 42 d After 76 d
NPS 50 36 14 12
ODI 49 38 33 30
EQ-5D-5L 0.01 0.256 0.721 0.721

EQ-5D-5L, 5-level European Quality of life 5 Dimension; NPS, Neuropathic Pain Scale; ODI, Oswestry Disability Index.

References

1. Pinto DS, Clardy PF, Moreira ME. [Internet]. Environmental and weapon-related electrical injuries. UpToDate. 2016. [cited 2020 May 30]. Available from: http://www.uptodatecom/contents/environmental-and-weapon-related-electrical-injuries .

2. Sinha A, Dholakia M. Thoracic compression fracture caused by electrically induced injury. PM R. 2009;1:780–782.
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14. Ryoo DW, Kim HG, Kim SJ, Baek SW, Jeong SM, Yoon JY, et al. Systematic Review of Hominis Placenta Pharmacopuncture in English and Korean Literature. J Acupunct Res. 2017;34:153–158.
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15. Oh JH, Lee YK, Kim JS, Lee HJ, Lim SC. A Retrospective Clinical Survey of Vertebral Compression Fractures. J Acupunct Res. 2018;35:219–225.
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17. Bae KJ, Jeong JW, Jung MY, Kim SJ. Reviewing Research on the Treatment and Study of Fracture in Korean Journals Objective - Focus on Domestic Thesis. J Korean Med Rehabil. 2015;25:27–36. [in Korean].
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18. Rousing R, Andersen MO, Jespersen SM, Thomsen K, Lauritsen J. Percutaneous Vertebroplasty Compared to Conservative Treatment in Patients with Painful Acute or Subacute Osteoporotic Vertebral Fractures: Three-Months Follow-up in a Clinical Randomized Study. Spine. 2009;34:1349–1354.
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Appendices

Appendix A.
jar-2020-00192i1.jpg
Appendix B.
jar-2020-00192i2.jpg
Appendix C.
jar-2020-00192i3.jpg
Appendix D.
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