Unusually case treated in Chinese medicine

Recently I have treated someone who came for his neck and shoulder pain that was dealt with medication for about four years. It got me thinking of some problems which relates to treatment itself, so I am writing it down and hope to share these information especially when you and your doctor gets stuck with your situation that you have been keeping with for quite a while. Here is a link taken from a patient i

Bret, 48years, European. He has been suffering with neck and shoulder pain for four years, it happened and was diagnosed with some pain killer which did not work well on him, afterwards, specialist did MRI scan which turned out a mild protrusion at Cervical 4 and 5 , patient chose to treat this without surgery and was given some tramadol (a stronger pain killer) and suggested a physiotherapy. It still did not help him problem after physiotherapy, on the other hand, patient started to have poor sleep, low energy, moody etc.  specialist advised him to stop current medication and take Fluoxetine(anti-depressing drug) instead. He felt desperate eventually and his wife tried to seek some natural remedy.

First time I saw him, he had a pale face, purple and dim tongue, thin and greasy coating on the tongue surface, it indicated the Yang Qi deficiency together with qi and blood stagnation on Chinese medicine concept. Some physical exams turn out negative signs which suggest normal function of nerve of cervical vertebrae, but tender muscle on shoulder and neck. Depending on my experience, his main issue is drug addiction. I choose to acupuncture patient and with a prescription of Chinese herb remedy at the same time. Apart from this, ask patient to decrease the dosage of drug in progress as directed. After four weeks regular treatment, he has stopped all the pain killer and anti-depressing drug, and the shoulder pain has almost healed as well.

Three further question left me to think about after all the work. What triggered the pain? It seems to be the protrusion between Cervical 4 and 5, but it is against the right pain pattern of nerve root compression which should be line-shaped pain instead of patch-shaped pain, so I think it is his neck muscle that caused the pain, but MRI left him nothing but the impression of protrusion.

Who should he trust? It is quite a question to be asked most often this days, especially this case which patient has been desperate for so long.  Judging from the result, I am doing quite alright of my part.

Drug addiction, some drug has side effects such as in this case tramadol, morphine in long course of intake, our body will be addicted physiologically and make it hard to get over with. So patient should be given proper advice when being prescribed such kind of drug in the future.