Download Low Back Pain - Cat`s TCM Notes

Course:
Class #:
Acupuncture Treatment of Disease 3
1 - Low back pain, glomerulonephritis
Date:
April 13, 2009
Syllabus review
Class attendance: 3 tardies (15 min late or 15 min early departure) = 1 absence.
Low Back Pain
Low back or lumbar pain (also called lumbago
in some publications) affects something like 6
million cases in the US per year. As such, it is
widely seen in student clinics and in
professional clinics. There are a wide range of
etiologies, types and differentiations for low
back pain. What follows is a discussion of
lumbar pain in some it’s wide variety of flavors.
Low back pain can be classified as acute, subacute, and chronic in nature.
☯ Acute:
Acute or short term low back pain lasts from a few days to a few weeks. Most causes are
mechanical in nature, resulting from trauma such as a sudden jolt (like a car accident or a
fall) which stresses the bones and soft tissues (intervertebral discs, muscles, ligaments and
tendons). Patients can often pinpoint the painful parts in these injuries. Very serious
accidents or osteoporosis can result in breaks to the bone, either lumbar or tailbone, as well
as damage to the SI (sacroiliac) joint.
Symptoms can range from muscle aches to shooting/stabbing pain, limited range of motion
or an inability to stand up straight without pain. While most acute back pain will resolve
within a couple of months, some acute injuries may become chronic if not treated.
Rest generally results in an improvement in the pain.
☯ Sub-acute:
Well, honestly, we didn’t discuss this in class so much and neither does any other source I
found, including the Dr. Luo handout. One to 3 months perhaps?
☯ Chronic:
Any low back pain persisting for more than 3 months = chronic pain. This suggests
deficiency, no? Physically this may be due to osteoarthritis, rheumatoid arthritis, spinal disc
herniation, and osteoporosis. Rarer causes include tumors and infections.
Sidebar: Pain in the upper back is less likely to be trauma induced, though it
can certainly happen. More likely causes are wind-cold invasion affecting
the upper back and stress. Bear in mind, however, that aortic disorders such
as aneurysms, chest tumors and inflammation of the spine can also result in
upper back pain.
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Interviewing Your Lumbar Pain Patient
When you interview a patient with a complaint of low back pain it is important to gather some basic
information about their condition. Find out:
☯ Duration
How long has it been painful? Helps you determine excess or deficiency, chronic and acute.
☯ Character
How do they characterize the pain?
☯ Radiation
Does the pain radiate to any area? If so, where and when?
☯ What makes it better or worse
☯ Associated symptoms
What other symptoms came along with this pain? Fever, pain on the anterior of the body, etc.
☯ Neurologic symptoms
Numbness, tingling and weakness for instance.
☯ Trauma
Was there an injury that caused the pain? Find out how the injury occurred – this can help
you determine what is injured. Often low back pain will start in one place and refer to
another or will start in a localized area and spread to surrounding areas as the muscles
“guard” the injury.
☯ Previous treatment
What has the patient tried already and what kind of success did they have?
Differential Diagnoses for Low Back Pain
Aka, conditions associated with low back pain…and there’s a bunch of ‘em!
Sciatica
OK, this is really a lecture unto itself even though it only got an honorable
mention in class.
Sciatica isn’t really a diagnosis unto itself so much as it is a collection of
symptoms associated with inflammation or impingement of the sciatic
nerve. The sciatic nerve is a large nerve exiting the spine in the lumbar and
sacrum (L2 to S4), traveling down the leg and branching to supply
enervation to the lower limbs. The yellow and green bundle in the pic to the
right represent the sciatic nerve. It’s big – about as big around as your index
finger. This bundle passes behind the hip joint and goes down the buttock to the back of the leg and
foot. Compression of the sciatic nerve in the spine is the most likely suspect for sciatica pain. This
happens most often as a result of disorders of the vertebral column, usually the rupture of an
intervertebral or lumbar disc. Less likely is primary sciatica which is a disorder of the sciatic nerve
itself. (Diabetics sometimes suffer from this. The pain in this case is felt bilaterally. Pain from disc
compression on the other hand is unilateral.)
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Symptoms of sciatica due to compression include shock-like or burning low back pain combined
with pain in the buttocks and pain down one leg. Pain is most often felt to about the knee, either on
the posterior or lateral aspect of the leg. Pain can go down below the knee, however, sometimes even
wrapping to the anterior or medial aspect of the leg and/or foot.
You can do some quick clinical tests to determine sciatic
pain. The simplest one to do is the straight leg test which
stretches the sciatic nerve and spinal nerve roots. Have the
patient lay flat on their back and then you lift their affected
leg to the 30 degree mark. Pain felt between 30 and 90
degrees is a fairly good indicator of sciatica. You may need
to dorsiflex the foot in order to get the stretch you need.
This can also indicate piriformis syndrome (in which the
piriformis muscle is pinching the sciatic nerve rather than the
bone or disc) or sacroiliac joint involvement. Some practitioners suggest that pain felt between 35
and 70 degrees indicates possible disc pathology while pain felt between 70 and 90 degrees is a good
indicator of lumbar joint involvement.
Though it’s not covered in class and not on the test, Maciocia and several others recommend Jiaji
points in the lumbar, UB 54, GB 30, Huan Zhong extra point, GB 34, and UB 40 to treat sciatica.
Herniated nucleus pulposus (with/without nerve impingement)
This is also called a protruding, bulging and sometimes a ruptured disc. The intervertebral discs,
under constant pressure, can be partially pushed into another space, often space containing the spinal
cord or nerve root causing pain. Most herniated discs occur in the lumbar portion of the spine, as this
is where most of the weight of the body is carried.
Spondylosis (with or without spondylolysthesis)
This is a degenerative process of the spine causing narrowing of the spinal canal due to bony
overgrowths which results in compression of the spinal cord and nerve roots as well as the
intervertebral discs and vertebral facet joints. This can be caused by wear and tear on the discs.
Patients with spondylosis may experience stiffness in the mornings after waking from a nights’ sleep
and/or may feel pain after walking or standing for a long time.
Anther term for this is spinal stenosis which also refers to bony overgrowth. Spinal stenosis is most
often used to refer to bony overgrowth which results in stiffening of the spine. When X-rayed the
spine looks like bamboo. This is often caused by an autoimmune disorder. A blood test for B-27 can
show a propensity for this type of spinal anomaly. Spinal (and cervical) stenosis can also narrow the
spinal canal leading to impingement of the nerves and discs.
Spondylolisthesis refers to the anterior dislocation of one vertebra over another producing pressure
on the spinal nerves.
Scoliosis and Other Skeletal Irregularities
Skeletal irregularities produce strain on the vertebrae and supporting muscles, tendons, ligaments,
and tissues supported by spinal column. These irregularities include:
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☯
☯
☯
☯
☯
Scoliosis, a curving of the spine to the side
Kyphosis, in which the normal curve of the upper back is severely rounded
Lordosis, an abnormally accentuated arch in the lower back
Back extension, a bending backward of the spine
Back flexion, in which the spine bends forward.
Sacroiliac Joint Dysfunction
The sacroiliac joint is fairly fixed large joint in the body. It is held
together by some very large ligaments. The SI joint forms part of the
ring that is the pelvis and these ligaments hold the whole thing
together rather like a hoop of metal around a barrel. If the ligaments
are torn or stretched…like in pregnancy (which causes the release of
hormones to relax these ligaments) the joint gets more flexible. The
more pregnancies, the more flexible it is. Later in life it tends to
ankylose…grow together. This takes away the shock absorbing
capabilities of the joint. Also, with multiple pregnancies, the
incidence of arthritis in the SI joint increases.
Lumbar Transverse Process Syndrome
L3-L4 especially L3 transverse process hurts to palpate. Muscle on the affected side will feel
stiff.
Rare Causes…
☯ Infection (such as kidney infection, shingles, tuberculosis)
☯ Connective tissue disease (such as ankylosing spondylosis)
☯ Tumor
☯ Referred pain (from a kidney stone, abdominal aortic aneurysm, etc.)
☯ Spinal stenosis
A physical exam to check for causes of lower back pain would include
☯ Range of motion tests such as flexion, extension, and rotation to the left and right.
☯ Inspection for obvious signs of deformity
While forward flexing, look for one shoulder higher than the other, suggesting scoliosis
☯ Palpate the spinous process and surrounding tissues for tenderness
☯ Note any paraspinal muscle spasms
☯ Neurological exams
Should you be interested, check out the Physical Assessment 2,
specifically class 5. That was all about spinal evaluation. Class 4
was about neurological testing.
Biomedical treatments for low back pain are largely dependent upon the cause. If there are no symptoms
that might cause long term problems, pain is usually managed conservatively since 80-90% of low back
pain resolves without further problems in 2-3 months. Further treatment includes:
☯ Reduced activity and rest
☯ Pain management with NSAIDS and Tylenol
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☯ Modalities such as ultrasound, ice, and heat
☯ Gentle flexibility exercises for the back and hamstrings
☯ Strengthening of the support muscles of the abdomen and trunk
If symptoms don’t improve over the course of 4 weeks most practitioners will then consider
radiographic studies.
TCM Mechanism
The low back is the “Residence of the Kidneys,” as this area of the body is the most closely related to
the Kidney system. The health of the Kidneys is often reflected in the status of the lower back.
Kidney deficiency or blockage in the lumbar channel(s)
TCM Etiology
1. Invasion and retention of pathogenic cold, wind and damp.
Retention of cold, wind and damp in the channels and collaterals that flow through the lower
back causes constriction and obstruction of the Qi in the meridians and collaterals (often this is
cold attacking the Yang meridians, especially the BL, GB, Du vessels) which causes pain.
The Neijing says, “ If there is free flow there is no pain; if there is no free flow, there is pain.”
Precipitating factors causing this retention are likely to be living in cold damp places, exposure
to rain, wading in water, being drenched in sweat.
2. Damp heat retention in the lower jiao
This is more often damp heat attacking the Liver, Spleen, and Kidney channels – Yin channels.
Patients may have a short or long history of low back pain. Damp heat can come from chronic
damp retention, acute damp and heat retention.
3. Blood stasis obstructing channels and collaterals
Often due to traumatic accident causing acute lumbar muscle sprain which is then not treated
correctly, lingers a long time and becomes a chronic condition. This also happens to patients
whose jobs or lifestyles involves repeat strain to the lower back (i.e., due to carrying heavy loads
frequently).
4. Kidney deficiencies
This is most frequently a result of aging. Kidney deficiency of Yin, Yang, or Qi leads to low
back pain due to pinching and compression of the nerve. Kidney Essence xu, however results in
congenital kidney deficiency such as Adult Polycystic Kidney Disease (APKD) for instance or
Infantile Polycystic Kidney Disease (IPKD). Both result in cysts of fluid in the Kidney expressed
at different ages.
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Kidney xu can involve both the Kidney organ and associated channels, Kidney, Bladder, Du, and
Dai channels. Dai crosses the regular channels of the Stomach, Bladder, and Gallbladder
channels; Liver, Spleen, and Kidney. All channels are bound by the Dai channel. The lumbar
area holds most of the weight of the body – as such part of the Dai channel’s job is to support the
lumbar area.
Weakness of Kidneys can also be to overwork or excessive sexual activity which results in poor
nourishment of the meridians of the lumbar region.
Differention and Treatment
Treatment involves dredging the meridian passages in the case of excesses and tonifying Kidney Qi in
the case of Kidney deficiencies of any kind.
Points are mainly selected from the Du and Foot Taiyang (BL) channels in treating lower back pain.
Basic points:
☯ KI 3
Treats any kidney deficiency (qi, yin, yang, essence). This is the “Tai xi” or Great River, the
Shu Stream point for the Kidney.
☯ UB 40
Use bleeding, cupping, needling. This is one of the 4 key points.
☯ GB 34
Influential point of the tendons - relaxes ligaments and tendons, and is especially good for
sprains
☯ Ashi points of the lumbar region
Differentiations
See http://www.yinyanghouse.com/treatments/acupuncture_for_low_back_pain if you want a more
thorough discussion of the differentiations and treatment plans than we got in class.
Damp and Cold Invasion
Symptoms:
☯ Cold sensations and area may feel cold to
the touch.
☯ Severe cold pain
☯ Heavy sensation and stiffness of the lower
back
☯ Aggravated by:
o Twisting/turning the body
o Lying down
o Damp and cold weather
o Rainy days
☯ Relieved by warming therapy.
Treatment:
Dispel cold and damp
Basic points +
☯ UB 26 to warm the Yang and melt
damp
☯ Cupping with warm therapy such as
using bamboo cups
Du Huo Ji Sheng Wan is the exemplary herbal
formula.
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☯ Tongue: Normal body (or perhaps pale),
greasy white coating
☯ Pulse: Deep and slow
Damp and Heat retention in the lower jiao
Symptoms:
☯ Hot burning sensations
☯ Bitter taste in the mouth
☯ Restlessness
☯ Scanty urination with dark urine
☯ Tongue: red body with yellow greasy
coating
☯ Pulse: slippery and fast.
Treatment:
Drain damp, Eliminate heat
☯ Basic Points
☯ SJ 5 + GB 41
Si Miao San is the herbal formula for this
differentiation.
Blood Stasis
Symptoms:
☯ Pain is severe, fixed, worst at night
☯ Aggravated by pressure
☯ Movement is impaired, worse with bending
forward/backward, turning body
☯ Tongue: dark or purplish body and/or with
purple spots.
☯ Pulse: uneven/choppy
Treatment:
☯ Basic points
☯ UB 17 to move blood for upper and
for deficiencies (to tonify)
☯ SP 10 to move blood for
lower/middle jiao and for excesses
(to reduce)
☯ UB 32
☯ SI 3 + UB 62 to open Du and melt
stasis
Shen Tong Zhu Yu Wan
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Kidney Deficiencies
Characterized by sustained pain and soreness in the lower back, aggravated by fatigue and alleviated by
bed rest.
Yang Xu
Symptoms:
☯ Cold and water retention
☯ Early am diarrhea
☯ Impotence
☯ Cramp-like sensations in the
lower abdomen
☯ Pale face
☯ Hypofunction of the sense of
taste.
☯ Cold limbs
☯ Pulse: deep, slow, weak or deep
and thready
☯ Tongue: pale body
Treatment:
☯ Basic points
☯ Du 4, Ren 4 with moxa, warm needle or
moxa box (best choice)
You Gui Wan
Yin Xu
Symptoms:
☯ Insomnia
☯ Irritability
☯ Dry mouth and throat
☯ Night sweats
☯ Malar flush
☯ Five palm or five center heat
☯ Tongue: red body, less or no coating,
cracks
☯ P: thready and weak, or thready and rapid
Treatment:
☯ UB 52 to tonify Yin – further from
Du, more yin.
☯ KI 3
☯ KI 6
Zou Gui Wan
Essence Xu
Prognosis is bad regardless of disease. Look for congenital problems. Dr. Luo didn’t talk
about it much, but the only way to build essence according to Will Morris is to do
Qigong.
Other Treatments:
☯ LI 10 – for acute injury. Insert needle, get strong stimulation, have the patient do gentle
movement with the back. But keep the arm still!
☯ Yao Tong – 2 points on the dorsal aspect of the hand, just distal to the junction where the 1)
2nd and 3rd and 2) 4th and 5th bones meet. This too is a movement treatment for lumbar pain
due to sprain, etc.
☯ Bleeding/cupping
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☯ UB 40
☯ Local points – treat the tender point specifically.
☯ ST 38 – for lumbar pain.
Sidebar:
Yin Yang House’s website adds more about trauma leading to blood stasis.
Signs/Symptoms:
☯ History of sprain/strain
☯ Pain or rigidity of the lower back
☯ Pain usually fixed and aggravated upon
movement and/or pressure
Treatment Points:
Needle the empirical points below then move
the patient’s body to the position where the
pain begins to appear. Manipulate the needle
with the reducing method for 1-2 minutes. If
the patient responds well, repeat this process a
few times then insert auxillary/local points
and retain for 15-20 minutes.
Empirical Points:
☯ GV 26 - if pain is only on the midline of
the back and patient has flexion/extension
difficulty
☯ SI 3 - if pain is on the posterior-midline
and also lateral and/or patient has torso
rotation difficulty
☯ Yaotongxue - if pain is on either side of
the posterior midline, pain above UB 23
☯ UB 40 - acute back pain on the UB
meridian, pain below UB 23
☯ UB 37 - in lieu of UB 40 if there is pain
and tenderness here and no congestion of
blood vessels at UB 40
☯ GV 8 - stiff and/or rigid spine
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Glomerulonephritis
Glomerulonephritis (also called glomerular nephritis or GN) is a renal disease characterized by
inflammation of the glomeruli of the kidney. For a biomedical review of this functional unit of the
kidney, please click here. GN can be of primary cause (causes intrinsic to the kidney) or of a secondary
nature (bacterial, viral or parasitic infections, drugs or systemic disorders like SLE or vasculitis). It can
present with:
☯ isolated hematuria or proteinuria
☯ as part of a nephrotic or nephritic syndrome in which the kidneys are damaged and thus
leaking proteins or blood into the urine
☯ as a component of acute renal failure
☯ as part of a chronic renal failure
In many cases the cause is unknown – approximately 25% of patients with chronic GN have no prior
history of kidney disease and the disorder first appears as chronic renal failure. Autoimmune disorders
have been known to result in GN. The chronic form of glomerulonephritis may develop after an acute
phase.
Symptoms:
☯ Lumbar pain
This is a common first symptom.
☯ Proteinuria
Protein in the urine can result in foamy urine. Patient will often get very slender as well since
the body is not being nourished.
☯ Hematuria
☯ Edema
☯ Hypertension
☯ Abnormal BUN and Cr results – higher than normal
Chronic renal failure patients may eventually manifest with the following symptoms:
☯ Unintentional weight loss
☯ Nausea/vomiting
☯ Fatigue
☯ Decreased urinary output
☯ Need to urinate at night
☯ Easy bruising
☯ Decreased levels of alertness (i.e., drowsiness, delirium, coma)
☯ Muscle twitching and cramping
☯ Seizures
☯ Generalized itching
Treatment depends upon the cause. Common treatments include blood pressure medications to relieve
hydraulic pressure in the kidneys, corticosteroids, immunosuppressants, and dietary restrictions on fats,
proteins, fluids, and salts.
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TCM Mechanism
KI, SP, LU dysfunction with water retention and blood stasis.
Water metabolism is the key to this disease. Organs related are LU, SP, KI.
TCM Differentiation and Treatment
Basic Points:
☯ UB 23
☯ UB 40
☯ DU 3 – “Kidney Yang Door,” for water discharge and to warm yang
☯ GB 39 - for yin and essence – especially for kids).
Spleen and Kidney Qi Xu
Chinese herbs and acupuncture are effective for this differentiation. The prognosis, compared to the
congenital type, is good.
Signs and Symptoms:
☯ Poor appetite
☯ Loose stool
☯ Diarrhea
☯ SOB
☯ Low back pain and knee pain
☯ Profuse urination
☯ Proteinuria and hematuria
☯ T: pale body with thin white coat
☯ P: weak
Treatment:
☯ Basic points
☯ SP 3 – Shu Stream point to tonify spleen
☯ KI 3
☯ SP 10 – for hematuria
Shen Ling Bai Zhu San
Liver and Kidney Yin Xu
Signs and Symptoms:
☯ Dizziness
☯ Headaches
☯ Dry eyes
☯ Blurry vision
☯ Restlessness
☯ Insomnia
☯ Tinnitus
☯ Hypertension – due to Liver Yang rising
caused by LV yin xu
☯ T: Red body, less/no coating
☯ P: Thin, fast
Treatment:
☯ Basic points
☯ LV 3
☯ LV 8
☯ KI 3
Yi Guan Jian is the formula to nourish the
Liver Yin.
Qi Ju Di Huang Wan if eye problems (blurred
vision for instance) are also present.
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Sidebar: In biomedicine Wilson’s disease is a Liver disease of metabolism – one
manifestation is dry eyes and another is pigment deposits in the pupil of the eye. There’s
a bluish belt around the pupil in the late stage. Both Liver and Kidneys are involved.
Lung and Kidney Qi Xu
Signs and Symptoms:
☯ Catches common cold easily
☯ Cough with white phlegm
☯ Puffy face and edema in extremities
☯ Scanty or foamy urine
☯ SOB and shallow breathing
☯ Spontaneous sweating
☯ Lower back/knee pain
☯ Often has a history of childhood asthma
☯ T: pale body, thin white coat
☯ P: Weak
Treatment:
☯ Basic points
☯ LU 1
☯ REN 3
☯ KI 3
Blood stasis retention in the Kidney
Signs and Symptoms:
☯ Dusky, purplish or black face
☯ Dry or fish scaly/shiny skin
☯ Macula
☯ Lower back pain is fixed, worse at night
☯ Hematuria
☯ T: dusky, purple tongue with purple spots
☯ P: choppy/uneven and deep
Treatment:
☯ Basic points
☯ SP 10
☯ SI 3 + UB 62 to open Du
Shao fu zhu yu tang
In general
Eat more fruit, vegetables. Have to moderate proteins – eat enough to nourish but not too much
so body casts it off. 1 gram per kilogram of body weight. GB 39 will help as will Ren 6 to tonify
the Qi. Scalp needling at the anterior hairline – needling upwards – at the reproductive
area/lower jiao.
Niu zen zi and tu si zi will help.
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Case Study
Mr. Li, 47 yo male
Cold invasion constricting meridians
Suffered from lumbar tightness after cold exposure 6 months ago. From then on, he started to feel
Something excess
lumbar distention. He got chiropractic treatment for several times which didn’t help him. Lately, he has
possibly depleting Yin
Qi xu
been very busy in his work and felt tired frequently. What is more, he started to feel obvious deep and
stasis
(meaning, tender to pressure…excess)
Qi xu
fixed pain in his low back which was distended with pressure. He had spontaneous sweating easily and
Yin xu
yin xu
heat in HT or blood
damp in head?
felt hot at night, occasionally with night sweating. He had vivid dreams at night and felt unclear early in
Spleen Qi xu
Qi or Yang depletion
the morning. He had poor appetite with gas and bloating sometimes. He also had frequent urination. He
Stasis
went to see a doctor and had some examinations which indicate there was a mass (measuring 1x2x2 cm)
Qi, Yang, or blood xu
heat
in MJ
in his right kidney. His tongue was pale with thick yellow coating on the entire surface. His pulse was
stasis
long term
KI something Xu
uneven and deep. The 3rd position on the right was weak.
Diagnosis is lower back pain
Differentiations and treatment:
☯ History of Cold invasion, excess condition
☯ Yin deficiency – KI
o KI 3
o UB 52
☯ Qi deficiency – KI and SP
o SP:
ST 36
SP 3
o KI:
KI 3
UB 52
☯ Blood Stasis
o UB 17 (because this is more deficient than excess)
o SP 10
☯ Dampness and Heat in the MJ
o SJ 5
o UB 40
o GB 34
Sources:
http://www.yinyanghouse.com/treatments/acupuncture_for_low_back_pain
Dr. Luo’s handout and Class 1 lecture notes.
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