Case Study – Treatment of Acute Low Back Pain using Traditional Chinese Medicine

by Danny Siegenthaler

This case study is interesting in that it is typical of what presents in TCM clinics and demonstrates the effectiveness of Acupuncture in the treatment of acute lower back pain.

Literature review

Biomedical Perspective:
The pathophysiology of low back pain is not well understood (Devor & Tal, 2009; Wheeler, 2009), however, according to the University of Maryland Medical Centre (2009), back pain may be due to an extensive list of causes, and include:

• Muscle spasm (very tense muscles that remain contracted)
• Other medical conditions like fibromyalgia, kidney disease, etc.
• Disk rupture/herniation
• Small fractures to the spine due to osteoporosis
• Spinal stenosis (narrowing of the spinal canal)
• Spine curvatures (like scoliosis or kyphosis), which may be inherited and seen in children or teens
• Strain or tears to the muscles or ligaments supporting the back
• Infection of the spine (osteomyelitis, diskitis, abscess)
• Cancer that involves the spine
• An abnormal aortic aneurysm that is leaking
• Arthritis conditions, such as osteoarthritis, psoriatic arthritis, and rheumatoid arthritis
• Kidney infection or kidney stones
• Problems related to pregnancy
• Medical conditions that affect the female reproductive organs, including endometriosis, ovarian cysts, ovarian cancer, or uterine fibroids
• Testicular torsion (twisted testicle).

In short, the causes of Low back pain can be divided into two major categories:

1. Mechanical causes of LBP, and
2. Non-mechanical causes of LBP (Wheeler, 2009).

Biomedical investigations and diagnosis have been summarised in Fig. 1, which illustrates the management of LBP and sciatica form a biomedical perspective.

Fig. 1 shows the diagnostic pathway used in biomedical diagnosis and provides insight into the management of LBP and sciatica (this figure was reproduced from (Wheeler, 2009)).

TCM Perspective

Traditional Chinese medicine theory tells us that lower back is the domain of the Kidneys (Maciocia, 1994, p. 606), which are affected by: Wind, Cold and Damp, as well as, Kidney yang deficiency, or Kidney yin deficiency, and stagnation of Qi and Blood (Kaptchuk, 1983; Maciocia, 1994, p. 607). The aetiology of LBP is due to one of five categories (Maciocia, 1994, pp. 607-608):

• Excessive physical work,
• Excessive sexual activity,
• Pregnancy and childbirth,
• Invasion of external pathogenic factors, and
• Stress (excessively long working hours without adequate rest).

According to Chinese medical literature, the nature and severity of the pain will vary depending on the underlying cause, the patient’s constitution, as well as other interdependent variables (Hogeboom, Sherman, & Cherkin, 2001; Kaptchuk, 1983; Maciocia, 1994, pp. 605-630; MacPherson, Thorpe, Thomas, & Campbell, 2003, p. 290). The pain experienced can range from a mild, dull-ache or stiffness to sharp, stabbing, immobilising pain.

Presentation of Case (Biomedical & TCM)

Male, Caucasian, 68, presented with acute low back pain and disabling left-side hip pain radiating into L/S inguinal region. Pain is accentuated when bending forward and/or flexing hip and this causes dribbling of urine when getting in or out of the car.

On bending forward or flexing hip, pain is sharp localized and stabbing in nature. On lying down, pain reduces to severe dull ache in lower back and L/S hip/inguinal region.

On Physical Examination:
There was no evidence of an inguinal hernia.
The muscles in the lower back are very tight on both sides of the Lumbar spine and the Lumbosacral region felt cold to touch.
Straight-leg raising test (known as the Lasègue test or SLR) elicited pain into the hip and groin. However, even though the patient’s left leg could not be raised over 60? off the table, the SLR was deemed negative as it did not produce radiating pain to below the knee (van den Hoogen, Koes, Deville, van Eijk, & Bouter, 1997).

Onset of Pain
Pain started about 7 days ago, but has not receded; instead, pain has steadily increased.
A week ago, patient woke up with pain and discomfort in lower back and pain in inguinal region and hip. Had been helping friends to move house a couple of days earlier, but does not remember feeling any pain afterward.

The patient is a strong, healthy and fit man, actively engaged in the local fire brigade. He has no history of kidney or bladder disease and is not on any medication what so ever. His blood pressure at time of consultation was 130/80 with a pulse rate of 78.
The characteristics of the pulse were wiry (consistent with pain) and slightly rapid (>7 pulse beats per 1 complete breath).

TCM Diagnosis
Over-exertion (lifting heavy weights) leading to localised traumatic injury and therefore local stagnation of Qi & Xue. In this case, excessive physical work of lifting heavy objects caused stagnation of Qi & Blood in the lower back. As the lower back felt cold to the touch, it is suspected that there may also be an underlying Kidney Qi deficiency with accumulation of Cold.

Biomedical Diagnosis
Acute lower back and hip pain due to soft tissue damage, with irritation to the sciatic nerve. There is also a possibility that the patient may have a herniated disc, as raising the leg beyond 45?, in the supine position, was not possible.

Discussion of Diagnosis and Pathogenesis

TCM
The diagnosis for this patient was Stagnation of Qi and Xue (Blood) in the channels and collateral channels of the lower back. There may well have been an underlying deficiency of Kid Qi/Yang, as the patients back felt cold to the touch and the patient is 68 years of age.

Biomedical
Acute, localized soft tissue injury; possibly a herniated disc.
Note: X-rays or CT scan could have been sought, which would have provided insight to possible extent of tissue damage in the lower back and elucidated as to whether or not there was a disc injury involved. However, the patient responded to the treatment and it was deemed unnecessary to subject the patient to getting further tests at this time.

Treatment Management and Strategies
TCM Treatment Strategy and Treatment
Treatment Strategy
Treatment Principles:

1. Relieve pain
2. Relieve stagnation of qi and blood
3. Promote circulation of qi and blood
4. Disperse cold in lower back and tonify Kidneys (Yang/Qi).

Treat every 2nd day for the first week, then reassess frequency.

Initial Treatment (27/10/2009)
Local ashi-points around the hip (L/S) plus BL.23, BL.52, GV.4, GB.30, BL.60 through to Kid.3 (Bilaterally)
Moxa Box on lower back for 10 min.

Follow up treatments
29/10/2009
(Treatment #2)
Pain is getting less, can bend forward more easily
Presenting signs and symptoms are all improving
Dribbling of urine still occurs when bending forward or flexing hip, but is less frequent and less severe
Repeat treatment

31/10/09
(Treatment #3)
There is continued improvement; pain has reduced significantly and flexion of hip and lower back is markedly better.
Dribbling of urine has reduced significantly
Repeat acupuncture treatment.

3/11/09
(Treatment #4)
Pain has decreased by 70-75% and there is no dribbling when getting in/out of car
Patient is obviously moving more freely and is walking normally.
Treatment: Repeat Acupuncture, but do not use moxa (Today's temp is 35?C inside the clinic)

5/11/2009
(Treatment #5)
Pain is mostly gone except for sitting upright or bending forward all the way to the thighs.
Treatment: BL.23, BL.52, GV.4, GB.30, BL.60 through to Kid.3 (Bilaterally) and use moxa box on lower back for 10 minutes.
Treat once a week from now on.

13/11/2009
(Treatment #6)
Back and hip pain is no longer a problem
Treatment
Reinforce previous - last treatment for this condition, use: BL.23, BL.52, GV.4, GB.30, BL.60 through to Kid.3 (Bilaterally)

Co-management was deemed unnecessary as the patient’s pain improved from the very first treatment, however, had the patient not responded so well, or the pain increased, co-management may have been considered.

Conclusion

The cause of low back pain is viewed by the biomedical system as falling into one of two categories, mechanical and non-mechanical, while in traditional Chinese medicine LBP is considered as being due to one of five aetiologies. Nevertheless, while both systems have a different treatment approach, they are not mutually exclusive and can complement each other (Kittang, et al., 2001). Physiotherapy, Chiropractic/Osteopathic are both options that can be considered and in addition drug therapy such as non-steroidal pain medication can also be useful, especially if the pain is very severe and debilitating.
On some occasions it may even be necessary to consider surgery, however, using acupuncture post operatively can aid in the speed of recovery and reduction of post operative pain (Sun, Gan, Dubose, Habib, & Fleckenstein, 2008).

References

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Cherkin, D. C., Sherman, K. J., Avins, A. L., Erro, J. H., Ichikawa, L., Barlow, W. E., et al. (2009). A Randomized Trial Comparing Acupuncture, Simulated Acupuncture, and Usual Care for Chronic Low Back Pain. Arch Intern Med, 169(9), 858-866.

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Sun, Y., Gan, T. J., Dubose, J. W., Habib, A. S., & Fleckenstein, J. (2008). Acupuncture and Related Techniques for Postoperative Pain: a Systematic Review of Randomized Controlled Trials. [doi: DOI: 10.1016/j.dza.2008.10.010]. Deutsche Zeitschrift für Akupunktur, 51(4), 54-55.

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