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. 2018 Feb 1;30(1):46–53. doi: 10.1089/acu.2017.29070.cpl

How Do You Treat Back Pain in Your Practice? Part 2

PMCID: PMC5801665  PMID: 29422984

Back pain is a very common symptom from which almost everyone will eventually suffer from—at least one episode. In my practice, I see all kinds of back pain, from acute sports injuries to chronic pain with unspecified causes to chronic pain from conditions such as scoliosis and back-surgery trauma. My first step with every patient is to examine his or her pulses to make a diagnosis to determine the cause of the pain.

I find that, with back pain, very often, the Dai Mai (also known as the belt or girdle channel) is blocked. This channel or meridian belongs to group of channels termed Extraordinary, Special, Miraculous, and Odd. These meridians are reservoirs of energy that store, receive, and regulate the body's energy to help maintain homeostasis. They are accessed by inserting needles into a Master point and a Couple point located on opposite sides of the body. The Dai Mai is specifically indicated for back and/or lower-extremity pain. This channel is said to connect the upper and lower, inside and outside, and improve the flow of energy through the vertical channels. Furthermore, the Dai Mai's ability to treat back pain is made clearer when we understand the “design” of the Master and Couple points. Its Master point is a Gallbladder point (GB 41), which accesses Wood energy and which controls the flexibility of tendons as well as connecting the Liver channel to Gallbladder; the Couple point is on the San Jiao channel (SJ/TE 5). The San Jiao is Shao Yang energy, which is said to connect interior and exterior. Thus, one can see that the Dai Mai is of central importance for the smooth flow of Qi for the upper and lower body as well as the interior and exterior energetics.1,2

When a patient presents with back pain, the first step of treatment is to open the Dai Mai using the Master and Couple points. Then, I reexamine the pulses to check to see that using only the Master and Couple points worked. If not, I add other points that are related to the Dai Mai, GB 26 for example. I continue to insert needles in points that affect the Dai Mai until it is opened (as felt in the pulses). At that time, I continue to use points to support the flow of Qi and blood from upper to lower and side to side. After leaving that part of the treatment in for ∼20 minutes, I turn the patient over and do trigger-point/Ashi-point needling on the back. Very often, these points are tight; the stagnation can be felt as the needles are inserted. I finish the treatment with gua sha on the back.

For at-home care, I demonstrate some Qigong maneuvers for the patient to do periodically throughout the day. For topical care to reduce pain and improve healing, I recommend the use of the Chinese herbal solution Zheng Gu Shui several times per day. It is known for its tendon-, ligament-, and bone-healing properties, including working on deep injuries.

One very important thing to remember is that both acute pain and chronic pain require a series of treatments to not only reduce the current painful symptoms but to continue healing and get the body back to a healthy status. It is true that acute pain can very often be reduced, even “cured,” with one treatment. However, for structural flexibility and the flow of Qi and blood to remain stable, I recommend follow up treatments.

References

  • 1.Larre C, Rochat de la Vallée E; Sandra Hill, transcriber & ed. The Eight Extraordinary Meridians. Cambridge, UK: Monkey Press; 1997 [Google Scholar]
  • 2.Maciocia G. Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturists and Herbalists, 2nd ed. London: Churchill Livingstone; 2005 [Google Scholar]
Med Acupunct. 2018 Feb 1;30(1):46–53. doi: 10.1089/acu.2017.29070.cpl

Article

Back pain is among the most prevalent of disorders and among the most common reasons for seeking acupuncture treatment. Given the growing awareness of problems associated with both opiates and nonsteroidal anti-inflammatory drugs, it is likely that more patients will be turning to acupuncture for treatment of back pain as an alternative to the use of prescription pain medication. While back pain has many etiologies, it is safe to say that a myofascial component is present in most patients with back pain,1 and virtually all patients with back pain will have myofascial trigger points. Myofascial pain of the back frequently presents comingled with neurologic components, as in radiculopathy related to shortened longitudinal paraspinal myofascial elements and regional trigger points.2

Myofascial Trigger Points, Fascia, and Acupuncture

Myofascial trigger points comprise a defining feature of myofascial pain syndromes. They are areas of hyperactivity in musculoskeletal structures that commonly present as tender areas within a taut band of shortened skeletal muscle, and refer or “trigger” pain and other sensations to regions removed from the source of pain. Trigger points are found in ligaments and tendons, loose connective tissue, and skin as well. Activation may occur from trauma, postural or repetitive strain, or metabolic or emotional stress. Affected muscles may become shortened, weak, or irritable, leading to dysfunction. Both peripheral factors and central mechanisms of sensitization are involved in the maintenance of pain.3,4 High degrees of correspondence have been demonstrated between trigger points and classical acupuncture points.5

Fascia play a major role in myofascial pain. More than simple casing around separate muscles, fascial tissue is an integral part of the muscles, enveloping each individual muscle fiber and bundle, as well as the nerves and blood vessels that course through fascial planes. Fascia connects muscles within functionally connected groups, extending to the length and breadth of the body, and responding to changes in biomechanical strain and the molecular environment.6 Fascial abnormalities have been seen on ultrasound scans of patients with low-back pain (LBP).7

The relationship between acupuncture and fascia is profound and fascinating. On the microscopic level, acupuncture needle rotation has been shown to cause winding of collagen around the needle8 and to have other direct effects on connective tissue. In addition, the anatomical chains of myofascial force transmission correlate closely with meridians of acupuncture.9 There is a growing understanding that the weblike network of elements described in classical Chinese texts corresponds functionally to the bodywide connective-tissue network.10

Touch is a powerful tool for both patient and provider, and palpation-based inquiry establishes a therapeutic connection while revealing information to guide treatment. Trigger-point maps indicate general areas where one may find myofascial trigger points,11 but, with practice, one develops the skills to detect trigger points and tight bands, and to detect nuances of connective-tissue restriction. The acupuncture needle itself is a tool of inquiry as well as of treatment, expanding the ability of the practitioner to detect myofascial restriction by transmitting subtle variations in tissue texture and resistance.

Myofascial Acupuncture Treatment

The myofascial acupuncture that I use to treat back pain in my clinical practice is a palpation-based approach that combines deactivation of trigger points and areas of myofascial restriction with other kinds of acupuncture.12 Cupping and gua sha, which target the fascia, are integral components of treatment, outlined in the sections below.

Trigger-point deactivation

There are many forms of acupuncture trigger-point deactivation, ranging from the superficial needling techniques associated with Japanese schools of acupuncture to deep, repetitive intramuscular stimulation. A local twitch response is frequently associated with trigger-point release, but this is not essential. Depending on the technique, needles may be removed immediately, pecked to “exhaust” the trigger point, or retained for minutes to facilitate myofascial lengthening. Repeated repositioning of needles by partially withdrawing and redirecting them allows deactivation of zones of hyperactivity. I palpate continuously. Trigger points in deeper muscles might not be accessible until more-superficial levels are cleared.

For both upper- and lower-back pain, paraspinal muscles (superficial erector spinae and deeper multifidi) should be treated along the length of the spine. In LBP, trigger points in the quadratus lumborum and psoas muscles, as well as nodules within the iliolumbar fascia, should be addressed. The gluteal and piriformis muscles are important when radiculopathy is present; they are easy muscles to treat, and deactivation of trigger points in these two muscles alone may resolve symptoms of “sciatica.” In the upper-back, I treat the lower trapezius and rhomboid and check for trigger points in the serratus posterior superior when there is residual pain at the medial scapular border.

In robust patients, I generally start the myofascial treatment with trigger-point deactivation, but individualize the sequence and components according to the patient's needs. Trigger-point needing can be painful, compared to other styles of acupuncture, so I prepare the patient. Insertion of needles at ear points (Shen Men, Master Cerebral, Sympathetic, Battlefield Acupuncture protocol) before trigger-point needling is helpful, and I might use topical EMLAtm cream (2.5% prilocaine/2.5% lidocaine) for highly sensitive patients. Post-treatment soreness varies considerably between patients, so it is best to limit the number of points treated initially.

Gua sha and cupping

Gua sha is the technique of unidirectional “press-stroking” that stretches the skin and superficial fascial layers, creating transient therapeutic petechiae,13 providing pain relief and healing, improved blood flow, and reduced inflammation.14 Applied after trigger-point deactivation, gua sha relieves local congestion and stimulates the fascia to promote further change. Cupping performs similar functions, using sliding or static techniques, including cupping over needles. Cupping and gua sha are excellent initial myofascial treatments when hypersensitivity or spasms impede local needling, providing immediate relief and efficient treatment of extensive surface areas. Placing cups on either side of trigger points in areas of painful paraspinal back muscle spasms can allow successful access for acupuncture needling.

Meridian-Based and Microsystem Acupuncture

Acupuncturists differ greatly in training and theoretical orientations, but most approaches can complement the myofascial focus. I prefer meridian-based treatments to provide additional activation of the longitudinal fascial network. Yang points are chosen according to the channel most relevant to the zone of pain: Tai Yang: SI 3 and BL60; Shao Yang; Yang Wei Mo: TE 5 and GB 41; Du Mo: SI 3 and BL 62; and Dai Mo: GB 41 and TE5. Electrical stimulation or moxibustion may be used. Other frequently used points are GB 34, BL 40, KI 3, LV 3, SP 4, and PC 6. Specific spinal levels are targeted by needling segmental points on the Bladder meridian or Huato Jiaji points. I frequently add percutaneous electrical nerve stimulation–like electroacupuncture, as well as superficial manual segmental desensitization.

Scalp acupuncture is useful, particularly for neuropathic elements. Using the New Chinese Scalp Acupuncture system, foot sensory motor and the upper one-fifth of the Sensory and Chorea/Tremor lines are stimulated at 4 Hz during trigger-point deactivation, which provides clear local input to focus the scalp treatment. Ear acupuncture may be used during trigger-point deactivation, and use of Aiguilles Semi-Permanentes needles allows the treatment to be prolonged.

Aftercare and Self-Treatment

Following myofascial acupuncture, patients need to stay warm and avoid exposing the back to cold or drafts. Treatment soreness is common after vigorous trigger-point acupuncture. Arnica or Jadience® Muscle and Joint Thereapeutic Cream (Jadience Herbal Formulas) are my preferred topical treatments, and I suggest magnesium sulfate or Epsom salt baths for muscle relaxation. Establishing a comfortable and supportive position for sleep is essential for recovery. Along with treatment of back pain, comes retraining in the alignment and use of the body. Yoga and the Alexander Technique are among the practices used to develop core strength, flexibility, and awareness safely in patients with myofascial back pain.

Author Disclosure Statement

No financial interests exist with respect to the products mentioned.

References

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Med Acupunct. 2018 Feb 1;30(1):46–53. doi: 10.1089/acu.2017.29070.cpl

Article

Use of direct-current microcurrent point stimulation applied to acupuncture points, or microcurrent acupuncture (MA) is gaining wider acceptance with acupuncture practitioners as a safe, noninvasive alternative to traditional needles or electroacupuncture (EA). MA is particularly effective for producing sympathetic downregulation or stress relief. An MA back-pain protocol combines the therapeutic efficacy of acupuncture, intramuscular therapy, and neural therapies.

My first step in the treatment of any chronic back-pain condition is to assess and apply a standard protocol. This standard protocol is designed to address body mechanics and radiculopathy, and provide spine therapy as well as treating fascial contractions responsible for positive gait and body misalignment. A clinician using the standard protocol assumes that chronic-pain syndromes have a precipitory influence from the hip misalignment and lower-back radiculopathy. I start the standard protocol with the patient in a prone position.

Standard Protocol Steps

Step 1

Identify subclinical radiculopathy. Bilateral signs of trophedema are usually located at segmental levels L1–S3. Trophedema is a collagenic change in the skin that occurs when impinged nerves (radiculopathy) reduce the flow of motor impulses through pathways. Trophedema, commonly called cellulite, may be best located with the “skin rolling” test, which clearly identifies the thickened skin in relation to nontrophic skin (Fig 1).

FIG. 1.

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Locating trophedema using paraspinal palpation.

Step 2

Treat radiculopathy using MA at levels identified in Step 1 with a paraspinal release using Back Shu points BL 23–BL 26 using negative (–ve) polarity. These points are located at each segmental level at the spinous process interspace (SPI), ∼1” bilateral at the medial border of the erector spinal muscle ridge (2 fingers bilateral from the midline). Inside Bladder points BL 31–BL 32 are used in the sacrum due to their direct influence on nerve roots. I treat each segment bilaterally with MA < = 30 seconds (Fig 2).

FIG. 2.

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Standard acupuncture protocol for back pain.

Step 3

This is the piriformis ileo–tibial (IT) band release. I release shortened muscles responsible for sacral and gait misalignments by simultaneously treating GB 30 (on the piriformis muscle) and GB 31 (the IT band point). This Wind point combination is ideal for sudden-onset hip/back pain. I treat points with MA < = 30 seconds.

Step 4

Simultaneously treating GB 30 (the piriformis muscle) with GB 31 (the IT band point) and then with myofascial point GB 34, I treat the points with MA < = 30 seconds.

Step 5

This is the iliopsoas–hip flexor release. A key advantage of combining the standard protocol with MA is the ability to release these very deep and difficult muscles quickly. Located at the lateral side of the base of the second toenail, ST 45 isolates the treatment release of the psoas and hip flexor muscles. I treat these bilaterally with MA < = 30 seconds per point (Fig. 3).

FIG. 3.

FIG. 3.

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Stomach (ST) 45—psoas and hip flexor muscle-release point.

Summary

When I and my colleagues applied MA to a Standard Protocol with 68 patients who had chronic pain,1,2 we found a statistically significant 62% reduction in the patients' mean pain levels after treatment, compared to the patients' initial pain levels (95% confidence interval [CI]: 2.715–3.462; P = 0.00010). Ideally, there was an additional statistically significant reduction of 0.632 (33%) in mean pain levels 2 days after treatment, compared to the patients' initial pain levels (95% CI: 0.295–0.969; P = 0.0001), for a total end pain relief of 75%.

In my practice, I find the standard protocol an invaluable tool for nervous-system regulation and chronic-pain relief. With of ∼20 minutes, this approach is highly effective, safe, and convenient to apply to any patient.

References

Med Acupunct. 2018 Feb 1;30(1):46–53. doi: 10.1089/acu.2017.29070.cpl

Article

Low-back pain (LBP) is a common musculoskeletal disorder affecting 80% of the population. From the point of view of Traditional Chinese Medicine (TCM), this pain is caused by the retention of Cold and Dampness, Stagnation of the Qi and Blood, and Kidney Deficiency.1 The procedure I follow, is determined according to the patient's anamnesis, the Western Medicine diagnosis, and the patient's energy disturbances according to TCM. Auricular acupuncture (AA) is preferable through my personal experience and as a result of my study presented orally at the American Academy of Medical Acupuncture Congress in San Diego, CA, in 2011.2 In this study, 73.07% considered themselves to be cured, and all patients who had been recommended for surgery before the treatment with acupuncture also considered themselves to be cured without surgery. These evaluations were very positive and all recommended their treatment to others.

To determine their energy disturbances, patients are asked several questions to evaluate their Blood, Qi, Yin and Yang, and Heat Retention. This is because I and my colleagues, in our practice) treat not only the symptom (LBP), but the root of the problem involving these energy disharmonies. This approach was presented at the Society for Acupuncture Research Conference in Boston, in 2015.3 The research on this approach showed that, by treating these disharmonies, it is possible to treat all the diseases in a diversity of specialties simultaneously although a doctor might not know that a patient has a particular problem. To evaluate blood levels, we need to ask whether a patient has daily bowel movements; otherwise this indicates Blood Deficiency. Qi Deficiency is revealed if the patient admits to sweating abnormally during the day. A patient is also asked if he or she usually feels hot or cold, indicating a Yin or Yang Deficiency, or even both. For Heat Retention, we ask if a patient has a dry mouth, halitosis, bleeding gums, abdominal pains, itching, acne, etc. For treating LBP, we use the auricular points to treat the symptom and the root of the problem.

The AA treatment for LBP begins as follows: the ear is cleaned with alcohol, using disposable gloves (Fig. 1) and remembering that the back of the ear is also important. In Figure 2A, the vertebral area on the posterior furrow of the spinal cord is visible, showing the five areas corresponding to the vertebral column. Number 1 is the cervical area, numbers 2 and 3 are the thoracic areas, number 4 is the lumbar area, and number 5 is the sacrum area. In Figure 2B, the five spinal cord areas in the anterior ear are shown.

FIG. 1.

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Cleaning ear with alcohol. Color images available online at www.liebertpub.com/acu

FIG. 2.

FIG. 2.

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(A) Left: Vertebral area on the posterior furrow of the spinal cord, showing the five areas corresponding to the vertebral column. Right: Number 1 is the cervical area, numbers 2 and 3 are the thoracic areas, number 4 is the lumbar area, and number 5 is the sacrum area. The five spinal cord areas in the anterior ear are also visible. (B) The five spinal cord areas in the anterior ear. Color images available online at www.liebertpub.com/acu

The ear is massaged from bottom to top. Then, the ear is bent to bleed the top, pricked quickly with an insulin syringe needle, usually squeezing ∼5 drops of blood out, while cleaning constantly with a dry cotton ball; this procedure is termed apex ear bloodletting (Fig. 3). This is performed all patients with back pain, and if they have Heat retention, this treatment should remove it.

FIG. 3.

FIG. 3.

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Two views of apex ear bloodletting. Color images available online at www.liebertpub.com/acu

Small square pieces of adhesive tape with two mustard seeds each are fixed to the ear on the chosen points. The pieces are applied on the area corresponding to the symptomatic low-back area (Fig. 4). Additional points are treated to address the energy imbalance: Shen Men and Kidney to treat the Yin and Yang; Liver, Lung, and Spleen to treat the Blood Deficiency; and Large Intestine to treat Hunger, and Anxiety (Fig. 5). If the Yin/Yang and Blood Deficiencies are treated, the patient with the Qi deficiency will be treated automatically. In the back of the ear, several more applications are made, along the vertebral area on the posterior furrow of the spinal column, corresponding to the lumbar and sacrum. In addition, one application is performed on the sciatica posterior furrow (1) and the leg posterior furrow (2) as shown in Figure 6.

FIG. 4.

FIG. 4.

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Low-back area in the ear. Color images available online at www.liebertpub.com/acu

FIG. 5.

FIG. 5.

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Points are treated to help the energy imbalance: Shen Men and Kidney to treat the Yin and Yang; Liver, Lung, and Spleen to treat the Blood Deficiency; and Large Intestine to treat Hunger, and Anxiety. Color images available online at www.liebertpub.com/acu

FIG. 6.

FIG. 6.

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The sciatica posterior furrow (1) and the leg posterior furrow (2). Color images available online at www.liebertpub.com/acu

The treatment is usually performed twice per week in the first ten sessions, and then maintained once per week for ∼10 more sessions. The patient needs to press the auricular points with his or her finger down on the mustard seeds three times per day for ∼1 minute each time. The patient is also patient is instructed to remove these seeds on the same day of the next session to allow the ear to rest before the session. The patient is also told to clean the ear with alcohol. Normally, the ear chosen is on the same side where the pain is more intense. This procedure is what I usually do to treat LBP in my daily practice and has been shown to be very effective.

References

  • 1.Huang LC. Lumbalgia, dolor em la articulación sacroilíaca, dolor en la musculatura lumbar, lumbalgia debida a deficiencia del Qi del riñón, ciatalgia, contusión del cóccix. In: Ear Treatment: Formulas and Prescriptions. Florida, USA: Centro Internacional de Investigacion y Entrenameinto em Medicina Auricular; 2002:240–242 [Google Scholar]
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Med Acupunct. 2018 Feb 1;30(1):46–53. doi: 10.1089/acu.2017.29070.cpl

Article

Back pain, also known in Traditional Chinese Medicine (TCM) as lumbago,1 is among one of the most frequently encountered complaints in patients seeking medical attention.2 While conventional medicine considers back pain as a local problem of muscular, radicular, or joint origin,3 TCM presents this medical condition as either an External or Internal pattern of imbalance, wherein the former has usually Excess and the latter Deficiency in bodily signs and symptoms.1,4,5

The major reason for an Excess type of back pain is the presence of Dampness, which is characterized by a feeling of heaviness. Patients notice pain and stiffness over the lumbar area with flexion or extension (e.g., during standing after prolonged sitting), which disappears during walking. Dampness is usually observed with Heat or Cold patterns and treatment is intended to clear Dampness and prevent its formation within the body.

Deficiency of Kidney Yin or Yang is the reason for Internal back pain, where soreness, weakness, and fatigue that are alleviated by bed rest, are the major complaints.

The third frequently encountered reason for back pain (in TCM) is Blood Stagnation, during which pain occurs during walking or while standing for a long time. This situation is usually trauma-related, and treatment is designed to release obstructed meridians and let the Blood move.

The acupuncture protocol includes treating local acupoints over the Urinary Bladder (UB) meridian and Governor Vessel (GV), such as: UB 23 to tonify Kidney Qi; UB 25 and UB 26 to dispel Cold and Damp (especially if moxibustion is used); GV 4 to tonify Kidney Yang; or UB 52 in combination with KD 3 to nourish Kidney Yin. Among distal points used for lumbar pain treatment, GV 26 and UB 40 are often added to acupuncture protocols.4,6 The combination of UB 17 + UB 18 + SP 10 (Spleen meridian) together with LR 3 (Liver meridian) + L I4 (Large Intestine) are added for low-back (LBP) pain due to Blood Stagnation.7

Case Study Report

Patient A.I., a 70-year-old male, was admitted to the clinic with complaints of LBP during movement. His pain was located in the middle lumbosacral area, which was tender to palpation. He also experienced tiredness, anxiety, night sweats, Wind intolerance, and cold feet. His pulse was thin, short, deep, and rough, especially on the left, with 68 beats per minute, and his blood pressure was 125/75 mm Hg. His tongue was of normal size, purplish, with small cracks all over its area. He was on daily medications for hypertension and blood cholesterol treatment.

He was diagnosed as having Blood Stagnation, Qi Stagnation, and Kidney Yin Deficiency. The acupuncture protocol for his treatment included 10–12 minutes of needle insertion into the following acupoints: LI 4 + LR 3 to open the channels, followed by UB 17 + UB 18 + SP 10 to move the Blood. Points on the back, UB 23 and UB 52, were combined with KD 3 and SP 6 to treat his Kidney Yin Deficiency. Acupoint UB 40 was added as a distant point to help to relieve his back pain. Qi Stagnation treatment was added after 2 sessions, which included a sedative acupuncture protocol for the following points: LR 3 + LR 13 + LR 14 + GB 34 (from the Gall Bladder meridian). His Wind intolerance was addressed by GB 20 and LI 11 acupoints. During 5 treatment sessions, this patient noticed gradual improvement and substantial pain relief.

References

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