Abstract
A
Mechanical back pain typically comes on suddenly, and the cause, such as lifting, is identified easily. This pain can also occur gradually, particularly due to adopting a fixed posture. Pain lasting for more than 3 months is considered to be chronic back pain.
4
Apart from local tenderness, physical examination findings are usually normal. There can be limitation of movements. “Red flags” that call for investigations include:
• Possible fracture • Major trauma • Minor trauma in osteoporotic or elderly patients • Possible tumor/infection • Age <20 or >50 years • History of cancer • Fever, weight loss • Intravenous drug use • Immune suppression • Pain worse at night or while lying down • Recent bacterial infection.
Look for a neurologic disorder if there is bladder or bowel dysfunction, or for any neurologic deficit noted on physical examination.
LBP is a symptom rather than a diagnosis and covers a variety of heterogeneous conditions. Herein, the discussion is restricted to LBP that is not associated with serious or potentially serious disorders. In cases of mechanical back pain, simple analgesics, advice regarding posture, lifting techniques, and physiotherapy can suffice. Acute LBP is usually self-limiting, but 30% of patients will not have recovered fully at 6 months, and two-thirds of patients will have recurrence of their pain within 2 years. 5 These patients are often dissatisfied with the results of conventional treatments and turn to complementary therapies, which include acupuncture as an alternative option. 6
Back Pain in Chinese Medicine
Acute LBP is either due to a sprain or an invasion of Cold. In a sprain, there is Stagnation of Qi followed by Stagnation of Blood. The pain is intense, with marked stiffness that is reduced by rest and aggravated by movement. If the pain is due to an invasion of Cold, the pain is worse with rest, worse in the morning, and reduced with gentle movement.
In chronic backache, there is usually Kidney Deficiency (either a Yin or Yang Deficiency), in which case the pain is alleviated by rest and aggravated by work and excessive sexual activity. In most cases of chronic back pain, there is a combination of the above three factors, leading to periodic attacks.
Pain extending from the lower back to the upper back is due to additional Liver Qi Stagnation. This is not discussed further in this Pearl. In Kidney Yang Deficiency, the backache is associated with a lack of libido and a generalized feeling of coldness. In Kidney Yin Deficiency, the LBP is associated with excessive sexual desire, premature ejaculation, a feeling of heat, and night sweats.
Treatment
The current author uses three Extra meridians to treat LBP:
(1) Governing Vessel for midline pain, according to its trajectory—Reduce SI 3 and BL 62 in that order to open the GV Vessel. Reinforce GV 1 and GV 26 to facilitate the movement of Qi in the GV Channel. Also reduce all Ashi points. (2) Yang Heel Vessel for pain in the paraspinal area on each side due to its connection with the Bladder Channel—Reduce BL 62 and SI 3 in that order to open this channel. Reinforce BL 67 to facilitate the movement of Qi in the Bladder channel. Also reduce all Ashi points. Reduce BL 40 in acute cases; for chronic LBP, BL 60 is better. (3) Girdle Vessel for back pain that extends horizontally, according to its trajectory—Disperse GB 41 and TE 5 in that order to open the Girdle Vessel. Reinforce GB 26, and reduce GB 27 and GB 28 to facilitate the flow of Qi in that channel. Reduce all Ashi points, and GB 40 and BL 40 in acute cases, and BL 60 in chronic cases.
A detailed description of the various Extra meridians and their clinical uses can be found in an earlier issue of this Journal. 7
Look specifically for tenderness in BL 25, BL 26, BL 52, BL 36, BL 37, Tunzhong Extra Point (immediately lateral to BL 54), and Shiqizhuixia (in the midline below the tip of L-5), and reduce them. Then:
• Reduce HT 7 to relieve muscle spasm • Reduce SP 3 if there is scoliosis • Reinforce BL 23 and KI 3 for Kidney Yin Deficiency; or BL 23 and KI 7 for Kidney Yang Deficiency • Reinforce LR 8 to nourish the Liver, as it controls the ligaments • Reinforce BL 11 and GB 39 to nourish the bones and joints.
Chinese Herbs recommended are:
• Stagnation of QI and Blood (sprain)—Body Pain Eliminating Stasis Decoction • Invasion of Cold and Dampness—Kidney warming decoction • Kidney Deficiency—Restoring the Right Kidney pill (for Yang Deficiency) or Restoring the Left Kidney pill (for Yin Deficiency).
Also use the following auricular points if needed: Lumbosacral spine on concha ridge; Lumbar Spine phase III on the tragus; Thalamus point; Point Zero; Shen Men; Darwin's point; Muscle Relaxation point, Adrenal Gland C, and Bladder. Choose according to tenderness.
Evidence for Acupuncture
1. LBP was reduced after acupuncture for at least 6 months in a study involving 1162 patients. The response rates were: 47.6% in the verum acupuncture group; 44.2% in the sham acupuncture group; and 27.4% in the conventional therapy group. 8
2. Acupuncture was more effective for relieving pain than no acupuncture in a study involving 298 patients, but there were no significant differences between acupuncture and minimal acupuncture (performed in nonacupuncture points). 9
3. A systematic review of acupuncture for acute LBP showed that verum acupuncture was more effective than medications or sham acupuncture for relieving pain, but not for improvement of function. 10 This is hard to comprehend; relief of pain, logically, should have some favorable effect on function.
4. For chronic LBP, consistent evidence showed that acupuncture was more effective than no treatment or conventional treatment for both pain relief and functional improvement at a short-term follow up. 11
5. Acupuncture was found to be more effective than physiotherapy for LBP during pregnancy. 12
6. Long-term pain relief of LBP was greater in patients receiving acupuncture, compared with true placebo (mock transcutaneous electrical nerve stimulation). 13
7. Significant reduction of LBP (P < 0.05 to P < 0.01) was noticed at 6 weeks and 6 months in patients receiving acupuncture using low-frequency electrical stimulation (2 Hz) but not in patients receiving high-frequency stimulation. 14
8. Continuous electrical stimulation of auricular acupuncture points produced significant pain relief in patients with LBP, compared with those receiving conventional auricular acupuncture without electrical stimulation. 15
9. Probabilistic sensitivity analysis showed acupuncture to have more than a 90% chance of being cost-effective. 16
Illustrative Case
A 64-year-old woman presented with recurrent LBP following a motor-car accident that had occurred 26 years prior. Her pain was localized to the midline and radiated to both sides. There was no evidence of sciatica. Rest relieved the pain. She had mild obesity, and her tongue was red and dry. Apart from these signs, there were no other abnormal physical signs.
In chronic LBP, there is almost always a Kidney Deficiency and, in this case, this was Kidney Yin Deficiency, as indicated by the patient's dry red tongue. (There is a moist pale tongue in Yang Deficiency). The traffic accident would have produced Blood Stagnation. The points used to address her condition were:
• SI 3 right and BL 62 left, in that order, to open the Governing Vessel to address the midline pain • GB 41 right and TE 5 left, in that order, to open the Girdle Vessel to address the lateral extension of pain (in men the side would be reversed) • All Ashi points including Shiqizhuxia.
All of the above points were reduced. KI 3, KI 4, CV 4, and BL 23 were reinforced to address the Kidney Yin Deficiency.
Treatment was given twice per week for 6 weeks. Spinal mobilization and Antimonium tartaricum in a homeopathic dilution of 30c were given twice a week to support acupuncture, with a view toward reducing the frequency and duration of acupuncture. This trio has consistently helped me to treat almost all cases of LBP successfully, except those of patients with gross structural abnormalities. The current patient had near-total relief of symptoms.
In chronic cases, recurrence is always a possibility, and that would require additional short-term treatment.