Treatment of low back pain

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A Representative Treatment of Low Back Pain in the Middle-aged

by Bob Flaws, Dipl. Ac. & C.H.,

According to The Merck Manual, the incidence of low back pain reaches 50% in those more than 60 years of age. Such pain may be related to acute ligamentous (sprain) or muscular (strain) problems which tend to be self-limited or to more chronic fibromuscular, osteoarthritic, or ankylosing spondylitic processes of the lumbosacral area. As the authors of The Merck Manual observe, back pain may be influenced by chronic poor quality or deficient sleep, fatigue, physical deconditioning, or psychosocial problems and conflicts, all of which affect the patient's perception of their discomfort, disability, and response to therapy.

In Chinese medicine, low back pain is called yao tong, lumbar pain. Most Chinese medical texts divide such pain into cold damp impediment, damp heat impediment, blood stasis, kidney yang vacuity, and kidney yin vacuity patterns. Although such textbooks present these five patterns as discreet entities, in real-life clinical practice, they tend to combine to form more complex patterns. When low back pain is chronic, it typically involves a major element of blood stasis. This is based on the Chinese medical axiom, "New disease are in the channels; enduring diseases enter the network vessels." The second half of this proposition implies that enduring diseases are commonly complicated by blood stasis in the network vessels. In addition, low back pain in the middle-aged (especially in middle-aged woman) and elderly is usually associated with kidney vacuity. This is based on the fact that the lumbar region is the mansion of the kidneys, the kidneys are the former heaven root (i.e., the root of the physical constitution), and that the main symptoms of aging are related to the kidneys. The weakening of the Chinese idea of the kidneys begins in the late 30s and 40s in women due to the extra burdens of menstruation, gestation, and lactation, whereas it occurs somewhat later in men. Further, due to the frustration of dealing with chronic disabling pain, all chronic low back patients also present with liver depression qi stagnation. Therefore, it is common to find the patterns of kidney vacuity, blood stasis, and liver depression qi stagnation in middle-aged and especially female middle-aged low back pain sufferers.

This Chinese medical view of middle-aged and elderly low back pain is evidenced by an article written by Zheng Ai-guo and Yu La-mei titled "The Treatment of 40 Cases of Low Back Muscular Strain with Self-composed Zhuang Bei Tang (Strengthen the Back Decoction)" appearing in Hu Nan Zhong Yi Za Zhi (Hunan Journal of Chinese Medicine), #3, 2000, on page 45. This article describes a clinical audit of 40 patients with chronic low back pain who all were treated with Zhuang Bei Tang. The patients in this study ranged in age from 35-50 years. Thirty-six of these patients were female and only four were male. All had a history of significant fatigue. X-rays showed no pathological changes in the lumbar vertebrae. In terms of diagnostic criteria, all these patients experienced lumbar region aching and pain. This discomfort ranged from insidious, lurking or lingering pain to frank soreness and pain with occasional bouts of increasing severity. In most of these case, the pain inhibited movement and activity. Either the patients were not able to sit for a long time or were unable to bend forward and stretch backward. Neurological examination showed no abnormalities.

Treatment method:

Self-composed Zhuang Bei Tang consisted of: Cortex Eucommiae Ulmoidis (Du Zhong), 15g, Rhizoma Cibotii Barometsis (Gou Ji), 15g, Radix Angelicae Sinensis (Dang Gui), 15g, cooked Radix Rehmanniae (Shu Di), 15g, Rhizoma Corydalis Yanhusuo (Yan Hu Suo), 15g, Radix Rubrus Paeoniae Lactiflorae (Chi Shao), 15g, Radix Ligustici Wallichii (Chuan Xiong), 15g, Rhizoma Cyperi Rotundi (Xiang Fu), 15g, Semen Pruni Persicae (Tao Ren), 15g, and Radix Clematidis Chinensis (Wei Ling Xian), 15g. These medicinals were decocted in water and administered orally, one ji or packet per day, in two divided doses, morning and night. In severe conditions, patients were rested in bed, and further strain to the lumbar region was avoided. In addition, massage was used on the painful muscles combined with hot medicinal compresses applied externally.

Outcomes criteria:

Cure was defined as disappearance of any lumbar region soreness, distention, or pain with normal bending and stretching of the low back region. Improvement meant that the soreness and distention disappeared, the pain decreased, and bending and stretching of the affected area was better. No effect meant that there was no improvement in any of the symptoms or that they had gotten worse.

Treatment outcomes:

Based on the above criteria, 31 patients (77.5%) were judged cured, eight cases (20%) were judged improved, and only one case (2.5%) experienced no effect.

Representative case history:

A 50 year old female was first examined on Apr. 16, 1998. Recently the woman had become excessively fatigued. This was accompanied by low back soreness, distention, aching, and pain. Twisting the lumbar region from side to side was difficult, and movement tended to make the pain worse. After lying flat on her back for some time, the low back pain decreased. The patient's eating and drinking, psychological condition, and urination and defecation were all normal. Examination of the painful area revealed no obvious abnormalities. However, there was marked left-sided lumbar area pressure pain and the woman was not able to twist her low back. The patient's tongue was slightly red with thin, white fur, and her pulse was bowstring and fine. X-rays showed no abnormalities of her lumbar vertebrae.

Based on the above, the patient's Chinese medical pattern discrimination was categorized as kidney vacuity low back pain. The treatment principles stated for remedying her case were to boost the kidneys and stop pain, soothe the sinews and quicken the network vessels. Therefore, she was prescribed Zhuang Bei Tang as described above. The only difference was that the dose of Semen Pruni Persicae (Tao Ren) was 10g instead of 15g. After taking five ji as described above, the low back pain stopped and all her symptoms remitted. She was then prescribed another three ji to promote complete cure.

Chinese authors' discussion:

According to Zheng and Yu, low back muscular strain is commonly seen in clinical practice and mostly occurs in the middle-aged and elderly. The Su Wen (Simple Questions) chapter titled "A Treatise on Pulse Essentials & Finest Essence" says:

The low back is the mansion of the kidneys. It twists and turns and is not fixed. The kidneys take care of exhaustion.

Thus, according to the ancients, pathological changes in the low back region are closely related to the kidneys. If the kidney qi is insufficient, a person cannot bear fatigue. In that case, fatigue and exhaustion lead to weakening of the sinews and stagnation of the vessels. The qi and blood suffer detriment, and the channels and network vessels loose their free and easy flow. Hence the lumbar region suffers detriment and damage.

The Western medical treatment of this condition consists of anti-inflammatories and analgesics. However, their treatment effect is not totally satisfactory. If such medicinals are used excessively, they may even worsen the pain. Self-composed Zhuang Bei Tang boosts the kidneys and strengthens the sinews, moves the qi and quickens the blood. Therefore, it is able to stop pain. (This last statement is based on the Chinese axiom, "If there is pain, there is no free flow » the qi and blood .") Within this formula, Eucommia boosts the kidneys and strengthens the sinews. The four ingredients of Si Wu Tang (Four Materials Decoction, i.e., cooked Rehmannia, Ligusticum, Dang Gui, and Red Peony) supplement the kidneys and quicken the blood. Cibotium and Clematis supplement the kidneys and quicken the network vessels. Corydalis and Cyperus move the qi and stop pain. Persica quickens the blood and soothes the muscles. When all these medicinals are used together, they strike to the center of this disease's pathological mechanisms. When combined with warm medicinal compresses and massage locally plus light movement of the lumbar area, lumbar muscle blood circulation is improved and the therapeutic effect is quite good.

English author's conclusion:

Although the Chinese authors do not given the ingredients of the warm medicinal compress they prescribed, similar compresses typically consist of blood-quickening, pain-stopping medicinals. The following recipe comes from Chinese Massage Therapy: A Handbook of Therapeutic Massage published by Shambhala, Boulder, CO, 1983. This is a translation of a tui na (Chinese medical massage) textbook compiled by the Anhui College of Chinese Medicine translated by Hor Ming Lee and Gregory Whincup.

Rx: Radix Et Rhizoma Notopterygii (Qiang Huo), 9g

Radix Angelicae Pubescentis (Du Huo), 9g

Resina Myrrhae (Mo Yao), 9g

Resina Olibani (Ru Xiang), 9g

Radix Aconiti Carmichaeli (Chuan Wu), 9g

Radix Aconiti Kusnezoffii (Cao Wu), 9g

Herba Lycopodii (Shen Jin Cao), 9g

Ramulus Cinnamomi Cassiae (Gui Zhi), 9g

Fructus Chaenomelis Lagenariae (Mu Gua), 9g

Fructus Liquidambaris Taiwaniae (Lu Lu Tong), 9g

Rhizoma Acori Graminei (Shi Chang Pu), 9g

Eupolyphaga Seu Ophistoplatia (Di Bie Chong), 9g

Flos Carthami Tinctorii (Hong Hua), 9g

Wrap these medicinals in a gauze bag and boil in plain water for 25-30 minutes. Add two clean cotton towels. Take out one towel and wring out all excess liquid. Apply this towel to the affected area as hot as the patient can bear without scalding the skin. As soon as this towel begins to cool off, replace it with the second towel. If the towel on the body is covered with a plastic sheet and then this plastic sheet is covered by a blanket, this will keep the heat from dissipating as quickly. In that case, one can change the towels only once every 7-10 minutes. Do this 2-3 times per treatment, 1-2 times per day.

In closing, it is important to emphasize that the above protocol is not a low back pain protocol. It is a protocol for treating only that kind of low back pain presenting the Chinese medical patterns of kidney vacuity, blood stasis, and qi stagnation. For best results, patients should see a professional practitioner of Chinese medicine to assure that their back pain conforms to this combination of Chinese patterns.



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