THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 17, Number 6, 2011, pp. 567–570 ª Mary Ann Liebert, Inc. DOI: 10.1089/acm.2010.0390 A Case of Thalamic Pain Successfully Treated with Kampo Medicine Keigo Ueda, MD, PhD,1 Takao Namiki, MD, PhD,2 Yuji Kasahara, MD, PhD,3 Atsushi Chino, MD, PhD,3 Hideki Okamoto, MD, PhD,3 Keiko Ogawa, MD, PhD,1 and Katsutoshi Terasawa, MD, PhD4 Abstract Objective: Thalamic pain, one of the central painful poststroke symptoms, is a severe pain that is often intractable. A case of thalamic pain successfully treated with Kampo medicine is presented. Subject: A 65-year-old woman complained of moderate continuous and paroxysmal severe pain in the right upper and lower limbs after she had suffered from stroke. She also complained of sensory disturbance and intermittent involuntary movement. A magnetic resonance imaging scan of the brain showed an old infarction in the left thalamus. Interventions and outcome: Paroxetine was administered, but it was stopped because of nausea. Etizolam was effective in reducing the pain for only about 30 minutes. Sokeikakketsuto decoction, one of the Kampo medicines, was administered orally on the basis of Kampo diagnostic criteria. Ten (10) days later, the pain had almost disappeared, and the other symptoms had also improved. Conclusions: This result suggested that Sokeikakketsuto could be an option for the treatment of thalamic pain under certain conditions. Introduction Case Report T The patient was a 65-year-old woman. Dysesthesia in the right upper and lower limbs and body, and slight weakness in the right upper limb suddenly occurred at the age of 61. She was diagnosed with brain infarction at another hospital, and was treated with medication and rehabilitation. When she was discharged, dysesthesia did not improve and slight gait disturbance remained. Furthermore, pain on the right side, especially upper limb pain, appeared several weeks later, gradually becoming severe. Moreover, she sometimes experienced intermittent involuntary movement in the right upper limb. Paroxetine was administered to treat this pain, but it was stopped because of nausea. Etizolam was effective in reducing the pain for only about 30 minutes, and her activities of daily life were extremely impaired. The patient visited Chiba University Hospital in the third year after suffering the stroke. Some Kampo medicines were tried, but they were ineffective. Two (2) years later, pain and dysesthesia became acute, so she was admitted to our hospital. halamic pain, one of the symptoms of Déjerine-Roussy syndrome1,2 and included in the concept of central poststroke pain, is an unrelenting and often intolerable pain. Generally, it occurs from several weeks to several months after cerebrovascular disease. It is excruciatingly painful and is not treatable with ordinary analgesics. Antidepressants such as amytriptyline and selective serotonin reuptake inhibitors have been used to treat this symptom and they are effective to some degree. Antiepileptic drugs such as carbamazepine and gabapentin also have been used with some success. Neurosurgical approaches such as motor cortex stimulation and deep brain stimulation are also used for patients who cannot be treated with these drugs, although some patients cannot undergo such procedures.3 In summary, it is often difficult to improve the pain with these treatments, but alleviation of the pain is highly desirable, as it impairs not only the quality of life but also the daily activities of patients. In Japan, many Kampo (one of the Japanese traditional medicines) prescriptions have been used to treat painful symptoms,4 and in such cases as this they are often useful. 1 Department of Japanese-Oriental (Kampo) Medicine, Chiba University Hospital, Chiba City, Japan. Department of Japanese-Oriental (Kampo) Medicine, Graduate School of Medicine, Chiba University, Chiba City, Japan. 3 Department of Frontier Japanese-Oriental (Kampo) Medicine, Graduate School of Medicine, Chiba University, Chiba City, Japan. 4 Department of Japanese-Oriental (Kampo) Medicine, Chiba Central Medical Center, Chiba City, Japan. 2 567 568 UEDA ET AL. Table 1. Changes in Symptoms by Sokeikakketsuto Dull pain Stabbing pain Dysesthesia Choreoathetosis Before treatment After treatment NRS 3-6 8-10 7-10 Intermittent NRS 0-1 0 4 Disappeared NRS, numerical rating scale. She complained of dysesthesia in the right side of her face, upper and lower limbs, and trunk. She also complained of moderate continuous dull pain and paroxysmal severe stabbing pain in the right upper and lower limbs. The dysesthesia and pain were especially severe on days of low atmospheric pressure, but there was no other specific factor that could be linked to aggravation of these symptoms. The intensity of pain was described by the numerical rating scale (NRS) based on the patient’s subjective rating of her pain using any whole number from 0 (no pain) to 10 (worst possible pain). The intensity of dysesthesia was similarly rated by NRS using any whole number from 0 (no dysesthesia) to 10 (worst possible dysesthesia) (Table 1). Neurologic examination performed by an experienced neurologist showed disturbance of superficial and deep sensation, ataxia in the right upper and lower limbs, dysesthesia in the right side of her face, upper and lower limbs, and trunk, gait disturbance, and intermittent choreoathetosis in the right upper limb. Allodynia and hyperalgesia were not observed. Magnetic resonance imaging of the brain demon- strated an old infarction in the left thalamus and some ischemic lesions in the left putamen (Fig. 1). Her painful symptom was considered to be thalamic pain. In addition, these symptoms were diagnosed as Déjerine-Roussy syndrome.1,2 A Kampo medical examination of the abdomen, which is regularly performed on patients in the supine position with their legs extended, showed moderate tenderness in the right side of the lower abdomen. A dark red tongue was also observed. Based on these signs, the patient was diagnosed as having oketsu (Blood Stasis) by Kampo diagnostic criteria.4 The sensory disturbance and her worsening condition on days of low atmospheric pressure were considered to be signs of Blood Deficiency and Stasis of body fluids, respectively. Sokeikakketsuto, one of the Kampo medicines, was chosen for the treatment of this patient. Sokeikakketsuto is a decoction consisting of 17 herbs (Table 2), all of which have been approved for clinical use by the Japanese Ministry of Health, Labor and Welfare, and all of which are covered by national health insurance. The herbs were mixed in 600 mL of water and boiled for 40 minutes, and the mixture was passed through a sieve. The resulting extract, called the decoction, amounted to about 300 mL and was divided into three equal doses that were orally administered 2 hours after every meal. The decoction was prepared every day by experienced pharmacists in our hospital. A few days after initiating Kampo treatment, her pain began to lessen, gradually decreasing day by day. Ten (10) days later, the pain in her limbs had almost disappeared, and the dysesthesia had also decreased. Etizolam was no longer required. In addition, her choreoathetosis had disappeared as well (Table 1). Although dysesthesia remained, her activities improved considerably and she was discharged from our hospital. Discussion FIG. 1. T2-weighted brain magnetic resonance image of the patient shows an old infarction in the left thalamus (arrow) and some ischemic lesions in the left putamen. Kampo medicines are often successful in ameliorating pain. Sokeikakketsuto is one of these, and it has been successfully used to treat joint pain, neuralgia, lumbago, muscle pain, and similar types of pain. To our knowledge, however, there is only one published report of its efficacious application for thalamic pain.5 Likewise in the present case, this prescription clearly succeeded in reducing pain. Sokeikakketsuto has also been used for poststroke sensory disturbance, and it was effective for improving dysesthesia to some extent in the present case. Choreoathetosis, consisting of involuntary movements and a symptom of Déjerine-Roussy syndrome, was also observed in this case. Dopamine-receptor blocking drugs have been the main drugs to treat this kind of hyperkinetic disorder, but there are problems of side-effects such as Parkinsonism and dyskinesia.6 Although the choreoathetosis in our case was not severe, our patient was confused by this symptom. After Sokeikakketsuto had been administered, her choreoathetosis disappeared. To our knowledge, there is no previous report that Sokeikakketsuto was effective against choreoathetosis or other involuntary movements. Sokeikakketsuto inhibits aldose reductase, and therefore this prescription has been used to treat peripheral neuropathy KAMPO MEDICINE FOR THALAMIC PAIN 569 Table 2. Composition of Sokeikakketsuto Herb Paeoniae radix Angelicae radix Rehmaniae radix Atractylodis lanceae rhizoma Cnidii rhizoma Persicae semen Poria Achyranthis radix Clematidis radix Sinomeni caulis et rhizoma Notopterygii rhizoma Saposhnikoviae radix Gentianae scabrae radix Aurantii nobilis pericarpium Angelicae dahuricae radix Glycyrrhizae radix Zingiberis rhizoma Botanical authority Family name Common name Dose (g/day) Paeonia lactiflora Pallas Angelica acutiloba Kitagawa or Angelica acutiloba Kitagawa var. sugiyamae Hikino Rehmannia glutinosa Liboschitz var.purpurea Makino or Rehmannia glutinosa Liboschitz Atractylodes lancea De Candolle or Atractylodes chinensis Koidzum Cnidium officinale Makino Prunus persica Batsch or Prunus persica Batsch var. davidiana Maximowicz Poria cocos Wolf Achyranthes fauriei Leveillé et Vaniot or Achyranthes bidentata Blume Clematis chinensis Osbeck, Clematis mandshurica Ruprecht or Clematis hexapetala Pallas Sinomenium acutum Rehder et Wilson Paeoniaceae Umbelliferae Peony Japanese angelica 2.5 2.0 Scrophulariaceae Chinese foxglove 2.0 Compositae Atractylodes 2.0 Umbelliferae Rosaceae Cnidium Peach 2.0 2.0 Polyporaceae Amaranthaceae Tuckahoe mushroom Achyranthis 2.0 1.5 Ranunculaceae Clematis 1.5 Menispermaceae Orient vine 1.5 Notopterygium incisum Ting ex H.T. Chang or Notopterygium forbesii Boissieu Saposhnikovia divaricata Schischkin Gentiana scabra Bunge, Gentianamanshurica Kitagawa or Gentiana triflora Pallas Citrus unshiu Markovich or Citrus reticulata Blanco Angelica dahurica Bentham et Hooker Umbelliferae Notopterygium 1.5 Umbelliferae Gentianaceae Saposhnikovia Chinese gentian 1.5 1.5 Rutaceae Mikan orange 1.5 Umbelliferae Angelica 1.0 Glycyrrhiza uralensis Fischer or Glycyrrhizaglabra Linné Zingiber officinale Roscoe Leguminosae Chinese licorice 1.0 Zingiberaceae Ginger 1.0 Paeoniae radix, Rehmaniae radix, Atractylodis lanceae rhizoma, Poria, Achyranthis radix, Sinomeni caulis et rhizoma, and Notopterygii rhizoma were purchased from Tochimoto Tenkaido Co. Ltd, Osaka, Japan. Cnidii rhizoma and Persicae semen were purchased from Tsumura & Co., Tokyo, Japan. The other herbs were purchased from Uchida Wakanyaku Ltd, Tokyo, Japan. due to diabetes. 7 In the present case, however, it is difficult to explain why the pain disappeared following administration of this medicine, because the painful symptom was thought to occur because of a disorder of the central nervous system. It is also unclear why the patient’s choreoathetosis disappeared. In Kampo medicine, the usual practice is that one prescription is used to target a certain condition and a complex of symptoms, and it can have effects on various symptoms.2 Sokeikakketsuto has been used to target the condition of oketsu (Blood Stasis), Blood Deficiency, exogenous Cold and moisture, and Stasis of body fluids. Our patient was thought to be in the condition of oketsu (blood stasis), Blood Deficiency, and Stasis of body fluids, compatible with a condition that Sokeikakketsuto would target. Therefore, it is believed that this prescription successfully treated the patient’s poststroke pain. Although involuntary movement is not generally a symptom for which Sokeikakketsuto would be administered, the apparent effect of Sokeikakketsuto on choreoathetosis in this case might indicate the pleiotropic effects of Kampo medicines. Although further studies are needed to add efficacious treatments for thalamic pain, the present and previous cases5 suggest that Sokeikakketsuto could be a choice of treatment for thalamic pain under certain conditions. Conclusions This report presented a case of thalamic pain successfully treated with Kampo medicine. There are patients whose poststroke painful symptoms are not reduced with drugs such as antidepressants and antiepileptic drugs. In such cases, Sokeikakketsuto may be useful under certain conditions. Disclosure Statement No competing financial interests exist. References 1. Déjerine J, Roussy G. The thalmic syndrome [in French]. Rev Neurol (Paris) 1906;14:521–532. 2. Wilkins RH, Brody IA. The thalamic syndrome. Arch Neurol 1969;20:559–562. 3. Klit H, Finnerup NB, Jensen TS. Central post-stroke pain: Clinical characteristics, pathophysiology, and management. Lancet Neurol 2009;8:857–868. 4. Terasawa K. Kampo Japanese-Oriental Medicines: Insights from Clinical Cases. 1st ed. Tokyo: K.K. Standard McIntyre, 1993:5, 37–61, 178–182. 570 5. Goto H, Fujimoto M, Watanabe T, et al. Trial of the treatment of Kampo medicines for thalamic pain. Kampo Med 2010;61: 189–197. 6. Jankovic J. Treatment of hyperkinetic movement disorders. Lancet Neurol 2009;8:844–856. 7. Aida K, Shindo H, Tawara M, et al. Inhibition of aldose reductase activities by Kampo medicines. Planta Med 1990;53: 131–135. UEDA ET AL. Address correspondence to: Keigo Ueda, MD, PhD Department of Japanese-Oriental (Kampo) Medicine Chiba University Hospital 1-8-1 Inohana, Chuo-ku Chiba City, Chiba, 260-8670 Japan E-mail: kueda@hospital.chiba-u.jp