Treatment of Posttraumatic Abdominal Autonomic Neuropathy Manifesting as Functional Dyspepsia and Chronic Constipation: An Integrative East-West Approach

Abstract

A 52-year-old male with a history of spinal cord injury and cauda equina syndrome resulting in neurogenic bladder presented with chronic constipation and functional dyspepsia that was refractory to medical management. He was treated with an integrative East-West approach including acupuncture, trigger point injections, and Tui Na massage. Both his pain and constipation improved after a series of treatments, and this improvement was largely sustained at 2-year follow-up.

This patient's symptoms are consistent with damage to the visceral parasympathetic nervous system. Interestingly, many studies evaluating the mechanisms of acupuncture point to restoration of parasympathetic tone as a mechanism of action. In this article, we describe a case of complex functional gastrointestinal disorders associated with posttraumatic autonomic neuropathy that was refractory to pharmacotherapy and was successfully treated with an integrative East-West approach

INTRODUCTION

Functional gastrointestinal disorders including functional dyspepsia (FD), chronic constipation, and irritable bowel syndrome (IBS) account for up to 41% of office consultations with gastroenterologists in the United States.^1,2 Specific symptoms and triggers can vary among these disorders, but a common theme is that psychological stress often exacerbates the symptoms.^3-6 The autonomic nervous system (ANS) is part of the systemic stress response and consistent with this, minor imbalances of the ANS are associated with functional gastrointestinal disorders.^7-9 Moreover, frank autonomic neuropathies are affiliated with the most severe manifestations of these conditions, such as diabetic gastroparesis or adynamic ilius and chronic constipation following spinal cord injury.¹⁰ This suggests that targeted treatment of the autonomic nervous system may be helpful for patients with functional gastrointestinal disorders.

Unfortunately, pharmacological options for autonomic modulation remain limited. Pro-motility agents are not entirely effective, and their use is further limited by cost and side effect profile.¹¹ Tricyclic antidepressants can be effective for IBS and FD, but this effect seems independent of autonomic tone.¹²

Increasingly, these patients seek integrative and holistic therapies when conventional treatments fail.¹³ Acupuncture is one such therapy that has shown efficacy for the treatment of FD and IBS,^14-16 and animal models of autonomic denervation suggest restoration of parasympathetic tone as a mechanism of action.¹⁷ Other soft-tissue manipulations including massage and trigger point injections may also improve parasympathetic tone in healthy subjects.¹⁸ However, there is little data guiding the use of these treatments for the more severe autonomic neuropathies such as with spinal cord injury. The presented case is a unique example of traumatic autonomic neuropathy following spinal cord injury presenting as both chronic constipation and functional dyspepsia that was relieved successfully with a combination of these therapies.

PRESENTING CONCERNS AND DIAGNOSTIC ASSESSMENT

A 52-year-old male with hypothyroidism was referred to an integrative medical practice for chronic constipation and functional dyspepsia. The patient was in his usual state of health until a motor vehicle accident in 1991, which resulted in damage to lumbar level 3 to 4. He developed cauda equina syndrome with saddle anesthesia, lost the urge to defecate, and became unable to urinate. Despite spinal surgery, these bowel and bladder deficits persisted. An ileal conduit with catheterizable stoma was created for the bladder, but during the patient's hospitalization, he remained unable to stool without manual disimpaction. He was ultimately discharged with over-the-counter laxatives, but he never recovered the ability to defecate spontaneously. Instead he would have to strain to produce hard dark brown balls of stool every 2 or 3 days. The straining was so severe that he would occasionally pass drops of blood or develop pain radiating to his right testicle. He tried several different therapies including senna, psyllium, fiber, prune juice, papayas, and increased hydration and exercise. These would soften the stools and increase bowel frequency but also cause episodes of fecal incontinence due to his lack of sensation. Colonoscopy in 2006 demonstrated melanosis coli, moderate internal hemorrhoids, and unremarkable ileocecal anastomosis. He was eventually uptitrated on a regimen of polyethylene glycol, which allowed him to maintain daily soft stools at the expense of unpredictable episodes of fecal incontinence and persistent feelings of incomplete evacuation. As such, he remained motivated to find a better solution.

Over the year prior to presentation, he developed a new postprandial burning epigastric pain that he described as an 8 out of 10 on the pain scale. The pain was associated with reflux and abdominal distention but not nausea. Coffee, alcohol, and tomato would exacerbate the pain, but avoiding these did not prevent the pain from occurring. Interestingly, psychosocial stressors seemed to exacerbate both the abdominal pain and constipation. He was initially diagnosed with gastroesophageal reflux disease and started on omeprazole, which was uptitrated to twice per day without relieving the pain. Lifestyle modifications including eating small frequent meals and sleeping at an elevated angle also were not helpful. Endoscopy in 2012 was unremarkable with biopsies negative for Helicobacter pylori. Computerized tomography of the abdomen was also unremarkable except for a large amount of retained stool. Given these findings he was diagnosed with functional dyspepsia and referred for an integrative treatment approach.

CLINICAL FINDINGS

The patient's past medical history also included hypothyroidism, which was treated with levothyroxine. His other surgical history included a rod placement for spinal stabilization following his accident, appendectomy, and a stomal revision surgery. His complete medication list at consultation was omeprazole, levothyroxine, polyethylene glycol, and vitamin D.

Physical examination of the abdomen was remarkable for a large infraumbilical scar related to his injury as well as an ostomy site for self-catheterization in the right lower quadrant. There was no tenderness to palpation and there was no hepatomegaly. Bowel sounds were present. Rectal exam was notable for mildly decreased anal sphincter tone and stool in the vault. Musculoskeletal exam was notable for palpable trigger points of the upper back and neck regions specific to the trapezius and suboccipital muscle groups.

THERAPEUTIC FOCUS AND ASSESSMENT

The patient was initially evaluated by the consulting physician, a dual-trained medical doctor who holds a master of science degree in traditional Oriental medicine with additional fellowship training in East-West medicine. A combination of acupuncture and trigger-point injections was recommended and delivered by this provider for the initial 4 treatments (Figure). On the fifth visit, his care was transitioned to include another licensed acupuncturist, Chinese-trained with more than 20 years of experience in the United States, in order to add Tui Na massage to his acupuncture treatment. Trigger point injections for these subsequent visits were administered by the same initial consulting physician.

Figure.

Treatment timeline.

Tui Na massage is a traditional Chinese medicine (TCM)–informed physical manipulation that is widely used in combination with acupuncture treatment worldwide. Although the specifics often vary, in this case it involved a hand-rolling movement onto the neck and shoulder region for approximately 5 minutes.

Acupuncture was then performed using 34-gauge needles inserted into abdominal acupoints Stomach-25, Ren-6, and Ren-12, as well as Stomach-36. Additional points were considered and included based on TCM principles. The needles remained in place for 25 minutes and were then removed.

Trigger points were identified by palpation of tender areas of taut muscle bands of the bilateral trapezius, cervical, and suboccipital musculature. After disinfecting the site with an alcohol swab, a 25-gauge needle was inserted with an attempt to illicit a twitch response (as described by Travell and Simons). Next, 0.2 mL of 1% lidocaine solution was injected into the area and pressure was applied for several seconds after removal of the needle. Injections were performed at each visit in 4 to 6 palpable trigger points found on examination.

FOLLOW-UP AND OUTCOMES

After 3 visits the patient experienced moderate improvement of his abdominal pain and returned to daily bowel movements without straining. At the following visit, he reported a dramatic worsening of his symptoms for 2 days after the hospitalization of a family member. He then missed his appointments for the next 2 months and returned to our clinic with recurrence of his presenting symptoms and 8-level pain. Tui Na massage was added to the treatment regimen at this time.

His abdominal pain and constipation continued to improve, although periods of stress would intermittently cause a worsening of symptoms. After 5 additional treatments, his abdominal pain resolved and his bowel movements normalized to become a daily occurrence without straining. He also noticed that he recovered the urge to defecate and felt that he was able to completely evacuate his bowels after the treatments. He was able to discontinue omeprazole at this point and subsequently tapered off his polyethylene glycol.

He sustained this improvement for 3 to 5 months following 12 total treatments. At follow-up 2 years later, he reported the gradual recurence of hard dry stools occurring every 1 to 2 days with minimal strain required for defecation. He returned to using polytethlene glycol on an as-needed basis for severe constipation. His epigastric pain was now felt to be simple acid reflux that was triggered by food and stress and relieved by antacids, with maximum pain level reaching a 4 to 5 on a scale of 10.

DISCUSSION

This patient presented with a complex gastrointestinal disorder characterized by abdominal pain and constipation that failed to adequately respond to medical therapy. His symptoms improved with a combination approach including acupuncture, trigger point injections and Tui Na massage. The association between this improvement and the intervention is strengthened by the relapse of symptoms after 2 months of missed appointments, as well as the gradual return of some symptoms after the treatment completion. Many of the studies evaluating the mechanisms of acupuncture and soft tissue manipulation point to autonomic modulation as a mechanism of action. This patient's history of neurogenic bowel and bladder following a cauda equina syndrome from a motor vehicle accident–related spinal cord injury suggests a defect in his visceral parasympathetic nervous system. As such, it may be possible to explain this patient's improvement in terms of restoration of parasympathetic tone.

Soft tissue dysfunction such as neck tension has been associated with low parasympathetic tone as measured by heart rate variability (HRV),²⁰ and physical massage to release neck and shoulder muscle tension has been demonstrated to increase HRV.²¹ Another method of treating soft tissue dysfunction is with acupuncture, the insertion of small needles that are manipulated and/or kept in place for a period of time. Consistent with the above findings, acupuncture of a specific point within the trapezius (Gall Bladder-21) was found to similarly change HRV in a pattern suggestive of increased parasympathetic tone.²² Another study²³ used pupil size to demonstrate an increase in parasympathetic tone following manual and electromagnetic acupuncture stimulation of the lower aspect of the trapezius muscle. These findings suggest that trapezius tension may correlate with autonomic balance and may help explain how acupuncture and Tui Na massage of the neck and shoulders could have been helpful for this patient.

Myofascial dysfunction in this patient was treated with direct needling of active trigger points.²⁴ Needling methods can differ from “dry needling” to the injection of medications such as corticosteroids or botulinum toxin. The superiority of these substances over dry needling is under question,²⁵ so lidocaine was used on this patient as this has been demonstrated to reduce post-injection soreness²⁶ when compared with dry needling. An exploration of the relationship between trigger point injections of the neck and shoulder region and autonomic modulation may be a fruitful direction for future research.

Acupuncture has been studied in patients with IBS, a subset of functional gastrointestinal disorders. The use of 4 specific acupoints located on the abdomen (Stomach-25, Ren-6, and Ren-12) were associated with a significant improvement in daily abdominal pain/discomfort, intestinal gas, bloating and stool consistency in a randomized, sham-placebo controlled trial of acupuncture in 29 IBS patients.¹⁴ Another study that included HRV measurements found a significant improvement in global quality of life both with sham and true acupuncture treatment; however, only true acupuncture was associated with significant increases in parasympathetic tone.¹⁶

Acupuncture theory classically points to the use of a specific point named Zusanli (or Stomach-36) for gastrointestinal disturbances. Electro-acupuncture of this point in animal models has been found in studies to increase lower esophageal sphincter pressure,²⁷ restore gastric accommodation after vagotomy,²⁸ increase the frequency of intestinal²⁹ and colonic³⁰ movement, increase activity of the sacral parasympathetic pathway,³¹ and reduce visceral hypersensitivity.³² In humans, acupuncture stimulation of this point was found to influence the limbic-paralimbic system and the homeostatic afferent processing network of patients with functional dyspepsia compared with healthy subjects, as measured by functional magnetic resonance imaging.³³

These findings suggest a physiological effect of acupuncture stimulation of these specific points and taken together may help to explain how the complete acupuncture treatment may have been effective. In a recent Cochrane review summarizing acupuncture for functional dyspepsia, 4 studies found no difference in efficacy between acupuncture and medications (cisapride, domperidone, and itopride) for functional dyspepsia.¹⁵ This finding is clinically significant if these medications are effective, but safety concerns limit their use. Three sham-controlled studies were evaluated and collectively demonstrated a significant positive effect of acupuncture over control. Although these results are promising, low study quality prompted the authors to express caution before drawing any robust conclusions.

Collectively, these studies support the concept of using soft tissue stimulation to modulate autonomic balance, gastrointestinal motility, and visceral hypersensitivity. The combination of acupuncture in the points described, Tui Na massage of the neck and shoulder, and trigger point injections in key locations achieved the desired clinical effect of symptom reduction in this patient. This combination approach should therefore be considered for patients with challenging gastrointestinal disorders. Future research investigating the autonomic effects of combination therapies such as these would be helpful in devising optimal therapeutic regimens.

PATIENT PERSPECTIVE

About a year ago, I was attending doctors to help me with a chronic pain I have had for the longest [time] in my upper stomach. I was losing weight, and every time I would eat my stomach would hurt. I was afraid to eat; it was painful. After visiting a couple of gastroenterology doctors, nothing seemed to solve the problem … I can say this treatment slowly but surely has eased the pain.

INFORMED CONSENT

The patient provided verbal informed consent on 3 occasions and submitted a written testimonial.