Lower back pain management by Acupuncture

Daniel Deng
TCM Low Back Pain Physical Exam
Generally, 85% of the diagnosis relies upon the history. When it comes to low back
and leg pain, important questions include:
1. When did the pain begin?
2. How did it happen? Was there an injury, or did it occur spontaneously?
3. Where is the pain? Does it stay in same spot, or does it travel down the leg, and it
so, where in the leg does it go.
4. What makes the pain better, and what makes it worse
5. Is there any weakness associated with it?
6. Is there any loss of bowel or bladder control?
Next, the physical exam should contribute 10 % to the diagnosis. During the exam,
specific things the physician will watch for are:
1. Inspection and tenderness to palpation over the back and leg.
2. Signs of the following test are necessary.

STANDING:
Inspection
x Spine -- Scoliosis
x Pelvic tilt
x Muscle balance
x Walking
Range of motion
x Flexion
x Extension
x Rotation
x Lateral flexion
SUPINE:
Inspection
x The length of leg and natural position of the leg
x The level of pelvic
Palpation
x Palpation of trochanteric bursa,
x Pulse in hands
Test:
x Straight Leg Raise test(pain at 30-60 degrees is positive - L5, S1—sciatica
x FABER Test (sacroiliac dysfunction)
x Palpation of trochanteric bursa
x Passive external rotation of the hip

Decubitus position
x Piriformis Test--piriformis muscle
x Palpation of trochanteric bursa,

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PRONE:
Inspection
x Spine -- Scoliosis
x Sacroiliac joint imbalance
x Muscle imbalance
x Lou mai in lower back and legs
Palpation
x Spinous / transverse processes, interspinous ligaments
x Sacroiliac joint imbalance
x Muscle imbalance – back and legs
Test:
x Femoral Stretch test (L2, 3, 4)

Straight Leg Raise Test:

Te patient lies supine and the leg, ith the knee straight, is
passively raised.
The test is positive if sciatica is experienced at an angle of less
than 70 degrees. This test is usually positive in patients with
disc protrusion at either of the last two intervertebral spaces
( L5/S1), negative or slightly positive in L3/4 protrusions and
negative when the protrusion is higher.

While holding the leg at the limit of straight leg raising,

dorsiflex the ankle (bottom figure). Note whether this
aggravates the pain. Internal rotation of the limb can also
increase the tension on the sciatic nerve roots.

Crossover pain occurs when straight raising of the patient's

well limb elicits pain in the leg with sciatica. Crossover pain is
a stronger indication of nerve root compression than pain
elicited from raising the straight painful limb.
Sitting knee extension can also test sciatic tension. The patient
with significant nerve root irritation tends to complain or lean backward to reduce
tension on the nerve.
With the patient sitting on a table, both hip and knees flexed at
90 degrees, slowly extend the knee as if evaluating the patella
or bottom of the foot. This maneuver stretches nerve roots as
much as a moderate degree of supine SLR.

Femoral Stretch Test

The patient lies prone and the knee is passively flexed to the
thigh; the test is positive if the patient experiences anterior
thigh pain. This test is usually strongly positive in patients with protrusions at L2/3
and L3/4, slightly positive or negative in L4/S protrusions and negative in cases with
a lumbosacral protrusion.

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Fabere Test:
The patient lies supine and places the foot of the affected side on
the opposite knee. Pain in the groin area indicates a problem with
the hip and not the spine. Press down gently but firmly on the
flexed knee and the opposite anterior superior iliac crest.
Pain in the sacroiliac area indicates a problem with the sacroiliac
joints.

Decubitus position --- Piriformis Test

The patient lies on the unaffected side with the affected leg in
60° of hip flexion. The knee should be bent and relaxed with the
foot on the unaffected leg. One of the examiner’s hands should
be placed on the hip to stabilize the joint. The other hand should
be placed on the patient’s knee to put pressure on it.
Test is positive if pain or tightness is present. If pain is in the
buttocks with shooting pain down the posterior thigh, the piriformis is
pinching the sciatic nerve. If pain is just felt in the butt with no shooting
pain then the piriformis muscle is tight.

lumbar nerve roots, their distributions,

and the discs which commonly affect them
The lumbar and sacral nerve roots each supply different muscle groups. Pressure on a
nerve root will often cause weakness, sensory changes, reflex changes in the muscle
supplied by that root.

L1 sciatica: T12/L1 disc; L1 root supplies sensation to the thigh and the anterior
scrotal or anterior labial branches, as the
ilioinguinal nerve. The lumbar disc which
would typically affect this nerve is the
T12/L1 disc centrally, or the L1/L2 disc
laterally in the neural foramen.
L2 sciatica: L1/L2 disc; L2 root supplies
sensation to the front and side of the thigh,
as the lateral femoral cutaneous
nerve. The lumbar disc which would
typically affect this nerve is the L1/L2 disc
centrally, or the L2/L3 disc laterally in the
neural foramen.
L3 sciatica: L2/L3 disc; L3 root supplies
sensation to the front and side of the thigh,
as the lateral femoral cutaneous
nerve. The lumbar disc which would
typically affect this nerve is the L2/L3 disc centrally, or the L3/L4 disc laterally in the
neural foramen.

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L4 sciatica: L3/L4 disc: L4 root supplies sensation to the anterior lower thigh. The
lumbar disc which would typically affect this nerve is the L3/L4 disc centrally, or the
L4/L5 disc laterally in the neural foramen.
L5 sciatica: L4/L5 disc: L5 root supplies sensation to the top of the foot and the great
toe. The lumbar disc which would typically affect this nerve is the L4/L5 disc
centrally, or the L5/S1 disc laterally in the neural foramen.
S1 sciatica: L5/Sa disc: S1 root supplies sensation to the outside of the foot, and the
small toe. The lumbar disc which would typically affect this nerve is the L5/S1
centrally.
There is no S1/S2 disc to herniated laterally to affect it.
S2 sciatica: no disc to affect this root individually. Supplies rectal sensation.
S3 sciatica: no disc to affect this root individually. Supplies rectal sensation.
S4 sciatica: no disc to affect this root individually. Supplies rectal sensation.

Treatment Principle:
1: Regulate the Yin and Yang to achieve the Yin and Yang balance.
2: Regulate the Qi to free the blockage in the Channel system.
3: Tonify the deficiency and reducing the excess.

Treatment plan
1: Mirror X to balance Yin and Yang
2: Channel diagnosis to regulate the Qi
3: Find the point to tonify the deficiency and reduce the excess.

Point selection and combination.

1: Back four gate – BL40 Fu Fen and BL26 Guan Yuan Shu or Mirror
X points
2: GV17, 14, underL3,4,5.
3: BL57ChengShan -- Mountain Support,
GB21JianJing -- Shoulder Well
4: BL40 WeiZhong or area – entrust middle, needle or bleeding
5: BL39 WeiYang and Extra point (In the popliteal fossa, at the end of
medial crease)
6: YaoTongXue,
7: Ashu point or back shu point needle, moxa or bleeding.
8: SI3 x 2 and BL64/65 ( JingGU/ShuGu), GB41ZulinQi and
TH5WaiGuan
9: Sp8 DiJi, Sp2 DaDu Liv3TaiChong, Ki3TaiXi, K7FuLui, GB34YangLingQuan,
GB39 JueGu.
10: CV8 BaGua points.
Techniques
1: Filform Needle
2: Moxa
3: Bleeding needle
4: Cupping

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 Lower Back Conditions
1 Lumber Intervertebral Disc Protrusion
Acute and Chronic Condition
Mostly there is a history of trauma of the waist to some extent. The main symptoms
are lumbago and radiating pain to the lower limb on one side which is aggravated by
cough, sneezing or bowel exertion and alleviated by rest. The main signs are;
disappearance or change of the spinal curve, limitation of forward flexion, rotation
and sideward movement, tenderness on the injured side with can radiate to the lower
limb.
Test: Raising test of the straightened leg, intensive raising test of the straightened leg
and flexing test of the neck are positive. Femoral test is positive.
TCM Description:
Apart from stagnation of qi and blood in the channels due to trauma, the disease is
also related to dysfunction of the organs and invasion of pathogenic wind cold
dampness in the case of qi deficiency.
Lumbar Invertebral Disc protrusion may be treated based on TCM syndrome
differentiation:
1/. Syndrome of qi and blood stagnation – serious lumbago referring to lower limb,
with stabbing or cutting pain, still pain, difficult movement.
2/. Syndrome of Channel Disharmony - aching, dull or sharp pain or numbness,
aggravated by walking or tiredness, alleviated by bed rest, impaired movement.
3/. Syndrome of blockage of pathogenic wind, cold and damp – pain and weakness
and lower limb, preference to warmth and aversion to cold, difficulty turning.
4/. Syndrome of Spleen and Kidney Deficiency –dull pain in the waist and lower limb,
pain relieved by pressure and aggravated on exertion, sore and weak knee, muscle
atrophy.

2: Lumbar Sprain
Lumbar Sprain occurs when the lumbar muscle excessively contracts or the
lumbovertibral joint is unusually tracted or twisted. The lumbar muscles, facia,
ligaments, intervertibral or lumbosacral joints may be affected. This acute condition
may be caused by abnormal posture, overexertion or awkward lifting of a heavy
object or sudden sprain when turning or bending the waist.
After injury, sharp pain will be felt in the waist with difficulty in stretching or turning.
In severe cases there is an inability to sit, stand or walk. There may be referred pain.
Pain may be aggravated by coughing, sneezing or exerting bowel action. Tenderness
is found in the lumbar and associated muscles.
When are the lumbar muscle and fascia injured? There will be limited range of
movement in every direction with sharp pain aggravated by movement.
TCM Description
Lumbar Sprain may be treated based on TCM syndrome differentiation:
1/ Syndrome of blockage of stagnant blood – serious fixed pain is felt in the waist
with obvious swelling and difficulty in movement in all directions.
2/ Syndrome of Qi blockage - lumbago with no fixed pain location, slight swelling
and difficulty in moving in a particular direction.
3/ Syndrome of Collateral Disharmony – aching and dull pain with rigidity and
weakness of the waist with limited movement.

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3: Lumbar Strain
Lumbar Strain is a chronic injury involving the muscle, fascia, ligament, bone and
joint. The condition may be a continuation of an untreated or mistreated lumbar sprain
or be the result of constitutional deficiency or congenital deformity.
There is ongoing lumbago which may have periods of relief and aggravation,
although mostly has a dull nature with repeated acute attack. Pain is relieved by rest
and aggravated by exertion. Moderate activity or a change in posture may alleviate
pain and climate changes may aggravate it. Serious lumbago will result from back
bending with effort. The appearance of the spine is normal. Tenderness is felt in the
sacroiliac muscles.
Test: Straight Leg Raising Test is negative.
TCM Description
Lumbar Sprain may be treated based on TCM syndrome differentiation:
1: Syndrome of qi and blood stagnation – serious fixed pain with slight swelling and
obvious impaired movement.
2: Syndrome of Collateral Disharmony - aching and dull pain, aggravated by exertion,
rigidity and weakness of the waist with difficulty in movement.
3: Syndrome of blockage of pathogenic wind, cold and damp – sharp lumbago with
no fixed pain, weakness and heaviness and typical symptoms of wind cold invasion.
4: Syndrome of Spleen and Kidney Deficiency – off and on dull pain aggravated by a
little exertion, relieved by pressure, sore waist and knees.

4: Syndrome of the 3rd lumber transverse process

The third lumbar transverse process syndrome is a chronic injury involving the
muscle, fascia, ligament, bone. The transverse processes of the third lumbar vertebra
are the longest among all the transverse processes of the lumbar vertebrae. Transverse
processes of the third lumbar vertebra are the most vulnerable when the muscles and
fasciae connected with the transverse processes are pulled, contracted suddenly or
with abnormal loading, which may lead to laceration, hemorrhage, and hematoma on
the area connecting the muscles with the transverse processes, followed by muscular
tension and spasm, and stimulation or compression of lateral branch of the posterior
rams of spinal nerve, thus resulting in pain in the regions of the transverse processes,
buttock, and thigh.
Diagnostic Criteria
l) The pain in unilateral or bilateral lumbar region may radiate to posteriolateral part
of the leg above the knee joint level in severe cases.
2) Aggravation of pain when getting out of bed or bending the back. Difficulty in
straightening the lower back.
3) There is obvious tenderness at the tip of the third lumbar transverse process, and
tension or spasm of the muscle. On palpation, there is a tubercular or cord-like mass.
4) Longer or normal transverse process of the third lumbar vertebra is showed in the
X-ray film.
TCM Description
The third lumbar transverse process syndrome may be treated based on TCM
syndrome differentiation:
1: Syndrome of qi and blood stagnation – serious fixed pain with stiffness back and
obvious impaired forward and backward movement.
2: Syndrome of Collateral Disharmony -- aching and dull pain, aggravated by
exertion, rigidity and weakness of the waist with difficulty in movement.

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3: Syndrome of blockage of pathogenic wind, cold and damp – sharp lumbago with
fixed pain, weakness and heaviness.
4: Syndrome of Spleen and Kidney Deficiency – off and on dull pain aggravated by a
little exertion, relieved by pressure, sore waist and knees.