Chapter 5 Low back pain: A big health issue( Also refer to the Note at the end of this chapter. )
A good portion of patients came for acupuncture because of low back problems. The problems include common back soreness that people suffer from time to time to pain so severe that patient can’t stand up straight. Statistic indicates that everybody experience back pain some time in their life. Some goes away by itself with proper rest and stretching. Some involves more serious problems like stenosis, herniated discs, sciatica pain, scoliosis that need be treated to get better.
Acupuncture verses other kind of treatments
Back pain is where chiropractors make most of their money and where large sum of money is spent in this country treating this problem. A great portion of that sum was spent on surgical approach in spite of research findings that challenge its effectiveness. Few people know TCM is incredibly effective in treating the low back problems. The results are often “miraculous” according to patients. It has not been properly recognized because of variety of reasons. Among them is the inability for obtaining consistent results from many some practitioners. The blame is squarely placed on the education. There is not enough of training on new acupuncturist to do this right. The truth is, treating it properly; the result is very satisfactory. The exception is for people who had undergone surgery without success. Some of these cases may be difficult to achieve the long lasting result.
5.1 Why does the low back have so much trouble?
To understand the problem facing us, we have to look at the anatomical structure of the low back first. All of the physical work of the body require( to be exact, any movement) the involvement lumbar spine at L3, L4 and L5 and the musculatures associated with them. Of 17 segments of lumbar and thoracic spines, only L3, L4 are allowed to have free rotation. Such ability subjects them to the brunt of any stress- from work, sport and its related injury. With age, the strength of the musculatures and the tissues supporting the discs begin to deteriorate, making it even prone to become overuse. Equally important issue is the uneven use of the muscle groups which results unbalanced muscle tones in the back. This is particularly true with many sports activities. These misuse, eventually leads to back pain. On top of these issues, many of the intervention, including the back surgery often leads to weakened and injured back. It is not uncommon to see patients whose surgeries to “correct” the back problem made them worse off.
How does TCM diagnose back pain?
-Common mistake in TCM
TCM in the modern times often attributes the low back pain to either Kidney disorder or Bi syndrome, provided the disorder was not caused by traumatic injury. Therefore, TCM doctors frequently prescribe formulas base on Du Huo Ji Sheng Tang for the low back pain. This is due to the fact this formula addresses these two issues. This approach with some variation has been common among TCM practitioner for thousands of years. The result is often slow if effective at all.
This is a distorted view in approaching low back pain. According to Yellow Emperor Inner Cannon( Huang Di Nei Jing) which was written more than 2000 years ago, Kidney Qi should not be a major cause of back pain for most people except for geriatric population or over sexed individuals. In other words, Kidney Qi and Jing should not be a common problem with people below 40 years old. Yet a great number of patients complaining back problems are under 40s, some are in their 30’s even 20’s. How would prescription formula based on this approach be able to address the problem? It can’t. Even if it does at all, the result will be very slow in coming. Our patients can’t wait that long and should not.
TCM treatment of low back Pain
In addition to herbal decoction above, TCM treatment of low back pain includes acupuncture, moxibustion, Tui Na, cupping and external liniment application. Historically, Tui Na has been the most common approach for back pain. It is quite effective in cases such as disc herniation, fusion of muscle tissues, scar formation or mis-alignment of the joints. Effectiveness of Tui Na largely depends on the skill of the practitioner. It is similar to chiropractic manipulation in many way with the exception of it also addresses muscles and tendons issues, not just alignment of bones, much like the combination of chiropractic adjustment plus massage. Liniment is good for acute situation. Cupping is not very commonly used for low back issues.
5.2 Wang’s Low back treatment
In truth, the best approach is based on the mix of acupuncture and moxibustion. Indeed, according to Nei Jing, acupuncture is the quickest way to treat diseases with result. Interestingly, Nei Jing also said that acupuncture is very easy to apply but difficult to be good at. The key components in success are point selection and the mastering the Qi with needles. In any treatment, when the proper Qi arrives at the diseased location, the treatment will be effective. As was stated in Nei Jing, this is easy saying but difficult to grasp. To get the Qi to the diseased location is very easy, to get the Qi properly requires more profound understanding. Once it is understood, the actual treatment is not difficult.
The most common mistake is the preoccupation of the meridian UB or meridian Kd due to the fact that UB meridian covers the majority of low back. The second mistake is the predominate use of Ashi points to treat the low back by palpating the most painful location(s) and insert needles on them. This is based on the principle that “the painful point is the Shu point of choice”. Because these spots are painful, there is always strong Qi elicited with needling. There is no question that Qi was obtained with needle insertion. Unfortunately, this Qi may or may not be proper.
Alternatively, another common practice is to seek UB 40, Wei Zhong for back pain treatment. This was promoted at a later time after Nei Jing’s publication. It became “the rule of thumb” for low back pain. This is not the original intent of Nei Jing. UB 40, Wei Zhong itself is not always the right choice. More accurately, it reflects the importance of searching the entire popliteal fossa to find best point to address the low back pain. The points of importance include such points as UB 39 Wei Yang, UB40, LV 7, LV 8, sometimes even GB 34, Yang Ling Quan. In Nei Jing, the treatment of low back pain involves the usage of all six foot meridians.
In clinic setting, I found my approach of diagnosing by the location of pain and treated accordingly to the spirit of Nei Jing seems to work very well. It is more targeted and easy to apply in dealing with back pain of various origins.
This approach involves dividing the low back in several anatomical zones and selects the pointss according to the zone involved.
In treatment, the first step is to identify the pain location by asking patient to twist or shake the back gently. This allows the patient to identify the specific location of the pain. Then confirm the diagnosis by palpation the location.
Once confirmed the local of the pain, apply needles according to the following rules:
a. Zone S (for spine), along the spinal column- For pain concentrated in Zone S, needle acupoints on the Du or Ren meridian. For example, Use Du 20, Bai Hui, or Ren 24, Cheng Jiang.
b. Zone P (para spine), parallel to the spinal column- For zone P pain, needle SI 3, Hou Xi, on the same side as the pain. This is the master of the Du meridian, closely linked to spinal column function.
c. Zone I, pain on the inner line of the UB meridian on the back, about 3-4 cm from the spinal column- Stress from this zone travels up. Use the TB meridian to treat it, e.g. Yao Tong Xue, an empirical acupoint for low back pain.
d. Zone O (outer UB line), pain on the outer line of the UB meridian on the back, about 6-7 cm from the spine’s center line- Use GB acupoints on the feet, such as GB 42, Di Wu Hui.
e. Zone G (for gluteus) - pain and soreness in the gluteus- Needle GB34, Yang Ling Quan.
f. Zone L (for liver meridian). Pain along the liver meridian on the leg- Needle or moxibustion on Lv 7and Lv 8. Moxa tight and tender areas above and below these points. These two acupoints are also good for other cases of LBP.
5.3 Most important requirement of needling technique
The most important requirements for effective acupuncture needling is to get hold of Qi, “De Qi”. There are many indicators of De Qi but none is for sure. My way of obtaining assurance is tapping the needle while having the patient stretch the back. Patients often will find that pain seems to dissolve with such stretching reflecting the moving of Qi. At other times, patients might notice that the location of the pain seems to migrate. The truth is not that pain has moved. Rather, these patients have had numerous painful spots than he or she recognized. As the most intense painful spots got resolved, the secondary pain become dominate and thus the feeling of “moving pain”. Then the focus of treatment needs be changed as well.
Notice that such approach requires the patients to lie down on their back, supine posture. Often some patients are very skeptical at first. Some reassurance may be needed. Once they experience the result, they most likely will turn to true believer of the acupuncture.
One navy vet who just retired because of messed back and knee had a very painful back, difficult walking was brought in by his girl friend. He was in his 50’s endured through three helicopter crashes and remarkably survived. After the treatment, he felt very good, able to go dancing. He told me afterward that he was very skeptical at first because I had him lying on his back without having any needle on his back but just had him moving his low back, But then he started to feel that the pain disappearing. He started to smile.
Also this approach is totally applicable to the problems that are referred as disc herniation or stenosis of the spine, even the sciatica. For these issues, there are many zones affected. Following the zone diagnosis and select the appropriate pts and needle them. The result should be very impressive. More on this later.
5.4 Cases example: Strained and /or sprained low back muscles
This protocol is very effective on these issues, be it acute or chronic. Sometimes, patient’s problem involves the whole body, as in fibromyalgia condition. The neck and shoulder has to be treated as well following N-S protocol. The results are quite good. However, these conditions exhausted the body and the patients are Qi and Jing deficient. It will be necessary to address these issues as well. The herbal formula such as Jin Gui Shen Qi Wan is highly recommended. For many patients, emotional stress may have been the cause of fibromyalgia. For such patients, Xiao Yao Wan and other Live Qi smoothing herbal formula are important.
5.5 Complications and related issues:
Spine related low back pain
Our spine takes up the heavy load of the body. It works against gravitational pull. When the spinal bones are aligned properly, the body is most relaxed. When the bones are not aligned, it takes extra help from muscles to maintain up right posture. Over time, the muscles become tired and the nerves of these muscles started to complain and life become unpleasant and pain ensures. What is next is that with pain, the muscle shortens. Shortened muscle would make the misaligned spine locked in position, unable to realign it self.
The claim of fame for chiropractic is to realign the spine. Many people get benefit from such “adjustment” for sure. Acupuncture does not “manually” realign the spine. Instead, properly placed needle allowed the shortened muscle to relax because of Qi is unstuck. Once the shorten muscle relaxes. It no longer locks the bones in the strained position.
As a matter of fact, I always ask patients to move their spine with needles in place. Since these needles are in their hands or feet, it poses no interference for movement. Such movement serves two important purposes, one is to realign the bones, the second, probably more important is re-educate the muscle. After the muscle becomes shortened for a while, the body (actually the brain) has become adapted to this posture in spite of the pain. After the re-alignment, the body would automatically drift to this misaligned position and become painful again. Re-education of muscles is important to achieve a permanent fix.
The above protocols for low back are very good for treating many spine related back pain. The point SI 3 is particularly helpful, as it addresses the Du meridian which runs along the spinal column. Alternatively, Hua Tao Jia Ji( along the spine.) can be very helpful too, especially for people with severe scoliosis. I seldom use it because too many needles are needed.
A 30 plus women had back injury from horse riding. Her doctor placed an artificial disc on her back. She then developed excruciating back pain. I treated her following the above L-B protocol and N-S protocol, her pain disappeared. She resumed horse riding. The doctor decided that the artificial disc was a defected design and replaced with new improved version. The pain came back. The doctor had to removed the replacement the second time without putting any new one in. After some acupuncture, her back pain was totally disappeared. She was able to do horse riding with no problem.
People with severe scoliosis on the upper back can benefit from electro acupuncture on the spaces between the ribs together with heat therapy.
I treated a lady in her early 60’s with severe scoliosis this way. Her spine looked like a bow; a steel rod about 8 inches long was implanted to stabilize the bow. The left rib cage started to dig into her lung which severely reduced her lung capacity. As she walked, she had to stop to catch her breath every few hundred steps. After a series of treatments, the pain started to subside and the energy also improved dramatically. She could walk around blocks without getting tired. Interestingly, there was no visible physical change after all those treatment on her scoliosis because the steel rod implant prevented it from changing. But her pain did not bother her any more.
Herniated disc syndromes, stenosis and other pinches nerves issues
Herniated disc problem is about the disc bulge and outward protrusion. Stenosis is about narrowing of the foramen(gapping hole) between the bone segments. Stenosis tends to result in nerve pinching. This is due to the fact that the gap is influenced by the tension of the muscles that are attached to different segment of spine. When muscles become too tense, gap narrows and pinching of nerve could happen. Alternatively, when the spine is not aligned properly, some gap will become bigger while other becomes smaller results in pinching of the nerve.
Although, these are different disorders, the treatment are very similar in TCM. Just like the treatment of low back pain, the aim is to move the stagnated QI. Follow the prescribed procedure for low back pain treatment, L-B protocol . Once the Qi is unstuck, the low back can move freely without pain. Then, strengthen the muscles that support the low back, paying attention to the posture. Make sure to keep good posture and keep the affected area properly warm.
Frequently, the doctors will diagnose a painful problem as caused by the so-called "pinched nerve". The pain can happen in the back, with the sciatic nerve, at the knees, at the ankle, in the foot, in the neck, in the arms, hands. What happens is that nerves are been squeezed too tight due to narrowed nerve passage way . Most telling feature for pinched nerve is the numbing sensation in the extremities. If the numbness appears to follow the distribution of nerve, then the nerve root entrapment is likely the cause. The treatment will be to resolve the pinching following the protocols: N-S or L-B.
There are times when the numbness in the fingers or toes is not caused by the nerve root. In such situation, most likely it is caused by insufficient of blood flow. Usually, soaking in hot water a few times to increase the blood flow will resolve the problem. The exception is in the diabetes situation. The cause is still the reduced blood flow issue.
It is important to enhance the blood flow to the limbs to avoid the dire consequence of losing the limbs. Heat therapy, massage and movement are all helpful. Doing nothing is doomed to be disastrous.
Pain at the SI joint
Among the complaint about low back, one of the most frequent diagnoses is the pain at the SI joint. Si joint is one of the strongest joint in the body. It s involved in lots of body motion. It easily over used. In addition to the above mentioned treatment for back, it is often quite beneficial to use moxa. When using moxa, moxa on SI joint as well as painful spots on the hip such as GB 29, GB 30.
Sciatic pain, Calf pain and “Charley horse”
Classical sciatic pain is caused by stressed pirifom muscle which crosses the passage of sciatic nerve. Therefore, an activity that increases stress of piriform muscle will aggravate the problem. To move Qi, GB29, GB 30 (need deep insertion)or other points along the GB channel such as GB34, GB 41 are useful. Often, the pain produces other stagnation of Qi and demands attention as well. These include spine, hip , thigh. Required. If all these problem do not get addressed. The result will be very short lived.
I often add electro acupuncture on GB30 and GB31, mixed mode for 20-30 minutes. It often get good result.
Charley horse is severe spasm of muscles. People run to get potassium supplement at the first sign of Charley Horse, often to no avail. It often does not work for a variety of reasons. Even if a person ingested a large quantity of potassium, it will not increase the blood or tissue potassium significantly. Body will dispose it through urine immediately.
The problem in the majority of cases stems from shortened calf muscle either through overuse, like walking too much, running too much and the muscle did not have time to recover from usage. It can be due to poor circulation from over exposure to coldness such as swimming in cold ocean with improper protection for too long. Many people have it in the early morning when the room temperature is the lowest.
So, it is related to blood circulation deficiency. Many people have chronic tight calf muscle, without improving the tight calf muscle, it only takes a few things to trigger the problem.(Since everybody is different. Some people do prefer to walk on cold slab to be cool. These are exception.)
So the treatment priority is to improve the circulation to the calf muscle either through heating or through stretching-relaxing muscles. Relaxed muscle allows better circulation. Needling or moxibustion on Lv 7, Lv 8, UB 58, UB 59 will be able to fix such acute problem. For daily maintenance, the advice is to keep the legs and feet warm.
Tight calf muscle also causes numerous other problems. These include the ankle pain, plantar fasciitis and heel pain. Just like wrists, ankles are designed for flexibility, not strength. When calf muscles are shortened, the stress is transferred to the tendons surrounding the ankle. That would cause all kind of pain in the foot.
I once had a patient who had several surgeries done on the right knee but was O.K. with the knee in general. His left calf muscle was always tighter than left. He developed sudden pain on the foot one day. The most painful area was between 2nd and third toe extended from web upward for about three inches long. I found that there are couple ropy structures near Lv7 below the knee. I did moxa on them, and in a few minutes, the pain on the foot disappeared.
Note: More About Low back pain in the Chapter 3 of the following publication: