The Effect of Acupuncture on Blood Stasis in Chronic Lumbar Pain: A Literature Review and Case Study

By Scott A. Whitfield, L.Ac., Doctoral Fellow, Five Branches University, San Jose, California

Chapter 1: Literature Review of Blood Stasis in Chronic Lumbar Pain

Abstract

Lower back pain is an exceedingly common medical complaint. According to Ma, et. al. in Biomedical Acupuncture for Pain Management: An Integrative Approach, “Statistics show that about 150 million Americans suffer from acute or chronic lower back pain and spend an estimated $20 billion to $50 billion a year in treating their problems. At any given time, more than 2.6 million adults are disabled by chronic lower back pain.” (Ma, 2005)

This study examines the phenomena of blood stasis (a Chinese medical pattern differentiation) and how it responds to acupuncture treatment. Because the author has a busy clinical practice, he sought out statistics regarding the number of patients seen in his clinic and for which chief complaints, over a one-year sample. Also, a literature review was conducted which uncovered many concepts salient to this topic. Finally, a case study of a 73 year-old female patient with chronic lower back pain from the author’s practice is presented.

Introduction

The author’s acupuncture practice is based in a busy outpatient hospital setting. He currently sees patients at a rate of 16-20 a day, five days a week. Over the course of his practice he has seen a lot of back patients (see the Appendix: Practice Analysis). These patients are typically limited to a handful of treatments but are not offered long-term or maintenance acupuncture treatments. 

One thing the author has observed is that patients who present with chronic lower back pain are often “knotty” as is said in TCM. They come to the clinic with multiple complicating factors, having been subjected to a plethora of allopathic interventions perhaps, often getting acupuncture for the first time. These patients are also typically on a number of medications further complicating attempts to achieve balance in the patient’s system. The author’s approach to acupuncture is therefore eclectic and he has, out of necessity, combined several “schools of thought” in attempt to achieve superior results in a short-course of acupuncture therapy. In the Case Study below, it will be shown how the author assesses and treats a typical hospital-setting patient. In the Practice Analysis (Appendix), the author breaks down the chief complaints of a year’s worth of treatments by body area affected or condition.

It is the author’s hypothesis that Blood Stasis will be found to play a central role in the diagnosis and treatment of lower back pain. This investigation will strive to elucidate this concept theoretically in the literature review and practically in the case study.

Western Biomedical Treatment

Most doctors will recommend different treatments for lower back pain based on duration and cause. Chronic lower back pain is if the lower back bothers the patient most of the time or longer than 3 months. Home treatment including rest for 1-2 days, over-the-counter medications such as acetaminophen (Tylenol) or NSAIDs (such as Advil or Motrin), cold application, heat or moist-heat application, short walks or more specific exercises prescribed by a physical therapist aimed at stabilizing the lumbar spine. For pain lasting longer than 2 weeks of self-care, a doctor’s visit is recommended. Most low back pain resolved on it’s own within 4-6 weeks of conservative treatment. 

Patients are urged to utilize good ergonomics, stretching, mindfulness of bending reaching or lifting motions, good shoes with proper support and a number of other measures to help to prevent a recurrence of back pain (Erstad, 2008). In severe cases, oral muscle relaxants and sometimes anti-depressants are used (often controversially) to relieve the pain. Degenerative disc disease and fractures are amongst the problems indicated for surgery but a second opinion is often in order.

TCM Treatment

There are a number of other modalities included in Traditional Chinese medicine other than acupuncture and electro-acupuncture that can be applied to the treatment of chronic lower back pain due to blood stasis such as bloodletting, cupping, guasha, moxibustion, tuinamassage. Because the scope of this study pertains specifically to acupuncture, these other modalities will not be discussed.

There is a long history of treating lower back pain in Traditional Chinese Medicine. Lower back pain, also referred to as Lumbago, is a disease category in Nei Ke (internal medicine). In a recent research article, a team of researchers looked at “16 Traditional Chinese medicine acupuncture texts or treatment articles to determine the consistency of diagnosis and recommended treatment for chronic lower back pain” (Birch, 1999). Twenty-four different patterns were described in these texts. Blood Stasis pattern came up in 10 of the 16 texts/articles. The points recommended for Blood Stasis pattern lower back pain (in order of prevalence) is: UB-40, UB-23, Ashi, DU-26, UB-17, DU-3, UB-32, UB-60, Yaotong, KI-2, Yaoyan, UB-31, GB-34, DU-14, UB-22, UB-25, SI-6, TB-6, Huatoujiaji. (Birch, 1999). In my opinion, this is a very good assessment of points used and agreed upon for Blood Stasis pattern lower back pain. GB-40 is the most popular point for this pattern & presentation, having been referenced in 10 citations (Birch, 1999).

An interesting crossover is that UB-40 happens to be one of Master Tung’s favorite points for this condition as well, however he would have preferred to perform bloodletting at this point instead of frank acupuncture (Young 2008). It is the author’s belief that bloodletting as practiced in this school has great potential for further study and development and a great inherent capacity to heal chronic pain conditions such as lower back pain. Because he is limited to practicing acupuncture and electro-acupuncture only, this investigation will not address bloodletting in detail.

Methods and Materials: Internet Search

First, a PubMed search was conducted using the search keys; “blood stasis, blood stagnation, chronic low back pain, chronic lumbar pain, acupuncture” rendered no results. Then, the author narrowed the search to “acupuncture, chronic low back pain, chronic lumbar pain” and one pertinent study came up (Birch, 1999). Next, the search was broadened to “acupuncture, low back pain” and got 329 results back. Each study was reviewed and none really had pertinence to this investigation. Then, the author turned to the Cochrane Review for a meta-analysis of acupuncture studies done on low back pain (Furlan, 2003). Here is a quote from the Summary of this aforementioned study:

“Thirty-five RCTs covering 2861 patients were included in this systematic review. There is insufficient evidence to make any recommendations about acupuncture or dry-needling for acute low-back pain. For chronic low-back pain, results show that acupuncture is more effective for pain relief than no treatment or sham treatment, in measurements taken up to three months. The results also show that for chronic low-back pain, acupuncture is more effective for improving function than no treatment, in the short-term. Acupuncture is not more effective than other conventional and “alternative” treatments. When acupuncture is added to other conventional therapies, it relieves pain and improves function better than the conventional therapies alone. However, effects are only small. Dry-needling appears to be a useful adjunct to other therapies for chronic low-back pain.”

The authors of the above study do note that more quality studies are needed in this area. In the conclusion, the author’s state, “Because most of the studies were of lower methodological quality, there certainly is a further need for higher quality trials in this area.” The author of this investigation concurs. This is our “bread and butter” as acupuncturists, so our profession had better be armed with good science around this topic whenever possible.

Methods and Materials: Books

In discussing this topic, the author wanted to be sure to explore some of the classical roots of Chinese Medicine because as Five Branches University DAOM Professor Bob Flaws likes to say, “mastery is always mastery of the basics.” To start to understand blood stasis in the context of chronic lower back pain, the author turned to Statements of Fact in Traditional Chinese Medicine by Bob Flaws and sought-out these salient assertions:

Blood Stasis (xue yu)

Statement: Stasis [is] accumulation of blood.

Commentary: According to this statement, blood stasis is the pathological accumulation of blood. However, within Chinese medicine, other synonyms for blood stasis are dead blood (si xue), dry blood (gan xue) and malign blood (e xue).

Statement: New diseases are in the channels; enduring diseases enter the network vessels.

Statement: [If] enduring disease is not cured, damage reaches the blood network vessels, the blood vessels do not flow smoothly, and [this] results in blood stasis.

Commentary: The first of these two statements is by Ye Tian-shi. The second statement explains the clinical implications of Ye’s statement.

Statement: [In] enduring diseases, there must be stasis.

Commentary: Later, Wang Qing-ren says essentially the same thing even more tersely. In enduring disease there must be blood stasis.

Statement: Enduring disease results in stasis.

Commentary: Yet another statement that enduring diseases result in blood stasis. Therefore, it is extremely important to search for signs and symptoms in all enduring diseases.

Qi & Blood Disease Mechanisms (qi xue bing ji)

Statement: Qi stagnation leads to blood stasis.

Commentary: Since the qi moves the blood, if the qi stops, the blood will typically stop. Hence qi stagnation leads to blood stasis.

Statement: Qi stagnation [may lead to] blood stasis.

Commentary: Because qi moves the blood, qi stagnation may lead to blood stasis.

Statement: Qi vacuity [may lead to] blood stasis

Commentary: Likewise, if qi is vacuous and weak and lacks the strength or power to move the blood, the blood can become static.

Statement: [If there is] free flow, there is no pain; [if there is] pain there is lack of free flow.

Statement: If qi and blood are not harmonious within the vessels and network vessels, there is pain.

Commentary: Both these statements say essentially the same thing. If there is free flow of qi and blood within the channels and vessels, then there is no pain. However, if there is pain, then that is nothing other than a lack of free flow of the qi and blood within channels and network vessels.

Statement: [If] blood stasis is not eliminated, new blood is not engendered

Commentary: This is an extremely important statement. It means that “blood stasis hinders the creation of new or fresh blood. Therefore, most blood stasis eventually becomes complicated by blood vacuity. In addition, if there is blood vacuity and one does not simultaneously address the presence of any stasis, treatment for supplementing the blood will not be effective.

Miscellaneous Disease Mechanisms (za gan bing ji)

Statement: Withering of fluids [may lead to] blood dryness.

Commentary: Because blood and fluids share a common source, withering or consumption of fluids may lead to concomitant blood dryness.

Statement: Fluid depletion [may lead to] blood stasis. 

Commentary: This statement is an extension of the previous statement. Because the blood and fluids share a common source, consumption of fluids may lead to blood dryness, which leads to blood stasis.

Statement: [If] something exists internally, [it] must [have] form externally.

Commentary: This means that disease on the inside of the body will typically manifest signs and symptoms on the outside of the body.” (Flaws, 2008)

The investigation will now move on to some concepts from the Japanese acupuncture tradition. Kiiko Mastumoto, a pioneer in this field, has said it well when she stated, “Lower back pain (LBP) is one of the most common complaints seen in the acupuncture clinic. It is very important to differentiate the etiology and treat the underlying, constitutional problems that led to the lower back pain and/or are preventing the natural healing process.” (Matsumoto, 2002).

One of those commonly found underlying constitutional problems is called Oketsu, which means stagnation of blood in the abdomen in Japanese. The word implies “bad Blood,” “old Blood,” “toxic Blood” and “stagnation of Blood caused by labor.” Kiiko considers Oketsu to be, “a primary target to treat.” Indications do include, amongst several other indications, sciatica and backache. The way to diagnostically uncover this sign is to palpate the left lower abdomen at a triangle formed by KI-15 and ST-27. A positive Oketsu sign will render pressure pain or hardness in the aforementioned triangle and there may be referred pain elsewhere in the abdomen. Treatment of Oketsu according to this tradition is bilateral “Nagano’s immune points” at LI-10 to LI-11 (referred to in this paper as TI-10, as it lies between the Triple Burner and Large Intestine channels) area plus left-sided LV-4 and LU-5 and the location and angle of insertion of these points is determined by the, “exact location and angle that relieved pressure pain at KI-15 to ST-27 area.” (Matsumoto, 2002) 

Patients commonly want to know if they need a blood test after a practitioner informs them that the pain they experienced upon palpating the Hara (abdomen), as described in the previous paragraph, is due to Oketsu. It is a difficult topic to discuss with the layperson because, “the reasons why Oketsu is formed are numerous and cannot always be explained.”1Here is a list of possible causes of Oketsu from Kiiko’s Clinical Strategies: In the Spirit of Master Nagano, Volume I, below:

  1. Genetic Predisposition, especially on the mother’s side (according to Yumoto)
  2. Menstrual problems, hematoma (injury), intensive heat and/or high fever (according to Yumoto).
  3. Portal vein congestion (according to Manaka & Yumoto)
  4. Liver disease and digestive problems (according to Manaka)
  5. Hormonal imbalances and autonomic nerve imbalances (according to Manaka).
  6. Multiple operations, blood transfusions and/or repeated bruising (according to Matsumoto).
  7. Vascular compression of the inner thigh due to posture (high heels for example) or tight and constricting clothing (according to Nasako).
  8. Weak immune system (according to Nagano). Since Oketsu is a toxin, it might also be the causeof a weakened immune system.
  9. Chronic respiratory problems such as asthma, COPD, emphysema, etc. A chronic shortness of breath may change the pH of the blood due to elevated levels of CO2.
  10. Infections or infectious diseases such as chronic sinusitis, respiratory infections, or a chronic local infection) might cause Oketsu. Usually, acute, short term or first time infections do not cause the appearance of Oketsu (with the exception of very high fever).
  11. Chronic pain
  12. Strong medications or the use of medication for a long period of time (especially the chronic usage of painkillers, antibiotics, etc.).

Because the pattern of Oketsu is applicable to many complaints, Kiiko says, “in general, in every condition where an abdominal sign of stagnation of Blood is palpated, it must be treated first.” When using this system, the practitioner should look for these additional corroborating signs and symptoms:

  • Dark blue or purple color of skin at the lips or under the eyes.
  • Weak peripheral blood vessels i.e. patients that bruise easily or bleed easily.
  • Abnormal menstruation: amenorrhea, dysmenorrhea.
  • A feeling of a heavy head, headache, stiff shoulders, insomnia, forgetfulness, dizziness, palpitation or a constant feeling of sleepiness.
  • Hot flushes, cold hands, cold back.
  • Digestive problems: stomach and duodenal ulcer, nausea, colitis, indigestion, constipation, food allergies. (Matsumoto, 2002)

Chapter 2: Case Study

Methods

The independent variable of this study is acupuncture treatment. The dependent variable is the outcome of acupuncture on chronic lumbar pain. This is a case study of a 74 year-old female patient with chronic lower back pain who would prefer to avoid taking further medications for her condition. After a physical exam and referral from her medical doctor, the patient sought acupuncture treatment. She was 100% compliant in completing 10 weekly (consecutive) acupuncture treatments. The patient’s underlying medical conditions and current medications will be enumerated in the body of the case itself. The author used the patient’s Electronic Medical Record (in Epic HeathConnect) at the hospital to printout and compile this case.

Instruments

  • Disposable acupuncture needles: DBC Brand, Spring Ten Handle; 0.25 mm diameter, 30 mm in length (made in Korea)
  • Disposable acupuncture needles: DBC Brand, Spring Ten Handle; 0.18 mm diameter, 15 mm in length (made in Korea)
  • Cotton Balls
  • Isopropyl rubbing alcohol, 70%
  • Heat Lamp
  • Pointer Excel II (hand-held ear point location devise)
  • Canon PowerShot G10 digital camera
  • Opteka 10x 58mm HD2Professional Macro Lens
  • Opteka 58mm metal lens adapter for Canon PowerShot G10
  • 15” Apple MacBook Pro 2.33 GHz, Dual-Core Processor
  • HP Scanjet 3100c scanner
  • Macintosh OS X 10.5.8, Microsoft Word, Microsoft Excel, Apple Aperture, Adobe Acrobat, Kaiser Epic HeathConnect (software packages)

Case History – 73 y.o. female, “Isabel”

Chief Complaint: chronic low back pain        

What follows id the PCP Note from 06/19/09, which was reviewed prior to treatment by the author: 

“Patient presents with spine pain. Lumbar area para spinal and thoracic spine around T11, chronic but worse for 1 month. No cauda equina symptoms and no fever. No trauma. Pain 6/10, no radiation to legs. Worse with movement and in the morning when she gets up. Does not want to take any medicine for pain. Wants to know if spinal bracing will help. Her spine x-ray shows degenerative changes but no fracture. ROS: Constitutional: negative for fever, negative for chills and negative for weight loss; Musculoskeletal: positive low back pain; Neurological: negative for tingling, sensory change, speech change and focal weakness.

Patient Active Problem List:

  • Pancreatitis, chronic
  • Sinusitis
  • Hypertension
  • Hx of Basal Cell CA of Skin
  • Pelvic Pain, Female
  • Obstruction of Ureteropelvic Junction, congenital
  • Diverticulosis of Colon
  • Low Back Pain

I have reviewed medications and allergies and they are below

Current Prescriptions (6/19/09):

  • Amlodipine 5mg 1qd
  • Amitriptyline 10mg 1qd
  • Alprazolam 0.5mg 1bid
  • Viokase 468mg 1 tid
  • Nitroglycerin 0.4mg Sublingual as needed up to 3 doses

Nutritional Supplements or Herbs: multi-vitamin

Allergies: Penicillins Class

Family History: Sister positive for Brain CA, positive Breast CA; Cousin positive Breast CA

Social History: Widowed twice. Has one son, lives in Half Moon Bay, California. Used to work for Kaiser. No grandkids. Never used tobacco. Does not use alcohol. Not sexually active.

Immunizations: PNUps (Pneumococcal polysaccharide) 05/15/06; Td 7yrs-adult (Tetanus, diphtheria) 12/13/99

Physical Exam:

I have reviewed the vital signs and nursing notes. BP 130/80, Pulse 62, Temperature: 97 F (36.1 C) (Oral); Height: 5’8”, Weight: 125 lb, SpO2: 99%, LMP: Postmenopausal, BMI: 19.01 kg/(m^2)

General appearance – alert, well appearing, and in no distress

Mental status – alert, oriented to person, place, and time

Chest – clear to auscultation, no wheezes, rales or rhonchi, 

symmetric        

Heart – normal rate, regular rhythm, normal S1, S2, no murmurs, 

rubs, clicks or gallops

Back exam – tender paraspinal area in the lumbar region, around T11 tender. Able to bend forward, scoliosis of lumbar spine to the left, Slr on right negative, left leg cannot test as she refuses to lift her leg up 

Reflexes ml

Sensation intact

Laboratory Studies and other data:

Recent Weight Reading(s)

            Date:                Wt:

  • 06/19/2009      125 lb (56.7 kg)
  • 01/14/2009      132 lb (59.875 kg)
  • 10/13/2008      133 lb (60.328 kg)
  • 08/27/2008      137 lb (62.143 kg)
  • 07/16/2008      139 lb (63.05 kg) 

Last 4 encounter BP Readings:

Date:                BP:

  • 06/19/2009      130/80
  • 01/14/2009      129/65
  • 10/13/2008      129/72
  • 08/27/2008      120/74
  • WBC               5.9       07/16/2008
  • HCT                40.5     07/16/2008
  • HGB               13.9     07/16/2008
  • PLT                 270      07/16/2008
  • ALT                13        10/13/2008
  • AST                19        10/13/2008
  • CREAT           0.67     07/16//2008
  • GLUC             87        05/15/2006
  • GFR-AFRAM>60      07/16/2008
  • GFR-NONAFRAM   >60      07/16/2008      

Assessment and Plan: back pain-xray no fracture; she will take 1500 mg calcium and 800 IU Vitamin D daily, Dexa osteopenia last year, she cannot take fossamax because of gerd, does not want analgesics; will discuss with PM&R if spine bracing will help, also will consult for acupuncture class [treatment – SW]. Will see in next month again for chronic conditions. Return to clinic, if worse.”

SUBJECTIVE

HPI: The patient presents with right-sided lower back pain and thoracic back pain, “for years” that has been getting progressively worse since 03/09. She states that she believes that due to osteopenia she has developed degenerative disc disease and scoliosis, leading to her back pain. Her pain is described as constant, heavy, sudden onset and occasionally sharp. Turning motions and standing too long exacerbate the pain but painting (her avid hobby), walking and meditating all help to relieve the pain. The patient additionally reports waking at 1:30 a.m. and she rates her current pain level at 9/10 VAS.

Current Therapeutic Objectives: Decrease pain level 50% or better while increasing function and mobility.

OBJECTIVE

Physical Exam

Tongue: dusky-purple, dry, some cracks, mapped yellow dry coat (only on the back half or so of the tongue), deviated left

 Right Pulse: Slippery and Flooding

 Left Pulse: Wiry and Full

The patient points to the affected areas of her body

Spider nevi and varicosities are prevalent bilaterally in the lower extremity

Hara palpation: positive Oketsu

ASSESSMENT

Pattern/Syndrome Differentiation

Pattern Diagnosis: Oketsu (Liver Blood Stagnation); Qi Stagnation, Blood Stasis; Kidney Yin, Liver Blood Vacuity, Liver Spleen Disharmony, Hyperactivity of Liver Yang Stirring Internal Wind

Channel Diagnosis: Du Meridian and right Foot Taiyang Urinary Bladder Channel

Pattern/Syndrome Differentiation Analysis

This is an active older patient who enjoys walking, painting and meditating. She lives in a retirement home in Half Moon Bay. She worked for years as a heath care worker and likely spent a lot of time on her feet as a nurse for Kaiser. Her body constitution is tending toward frail and she has a history of slight but persistent weight loss. She is generally thin in appearance with slightly ashen skin. 

There are several signs pointing to the presence of significant blood stasis such as the dusky-purple color of the tongue, the positive Oketsu sign, the evident spider nevi and varicosities of the lower extremity. Moreover, the patient exhibits significant dryness of the skin visible upon examination, a dry tongue with cracks, a wiry and full pulse on the left Guan position and slippery and flooding on the right Guan position amounting to disharmonies of the liver and spleen. The yellow coat in back portends heat, likely in the lower jiao.            

This is a case of vacuity and repletion. The author’s hypothesis for the pathogenesis of her back pain is as follows. Over time, the patient’s kidney yin became exhausted (likely at menopause) causing a drying trend. Then, stress lead to a liver depression, qi stagnation state thereby weakening of the connections between the liver and spleen as well as the heart and the kidney. Continuous use of prescriptions has contributed to the stasis in the liver. The patient’s liver, in its depression, began to generate heat (the repletion) causing further blood stasis. At the same time, kidney yin cannot control the kidney yang (the vacuity) so kidney yang becomes exuberant, causing the wind signs such as deviation of the tongue. There is no stability in the lumbar region because there is no root for its function (balanced kidney yin and kidney yang and a healthy Mingmen Fire). This state places the patient in jeopardy for poor body mechanics to come into play and create an exacerbation of lumbar region pain.

Treatment Principles: Quicken the blood and move the qi, dispel stasis and free the flow network vessels, stop pain; dispel wind and open the channels; nourish the liver and supplement yin.

PLAN

Treatment #1 – manual acupuncture, 40 minutes needle-retention 

Acupuncture Points: 

  • Left: (J) LV-4, (J) LV-5
  • Bilateral: TI-10
  • Bilateral ear: Thalamus
  • Right: Linggu, Dabai, Zhongbai, SI-4, Houzhu, UB-65

Needle count: 12

Recommended Course of Treatment: no less frequent than 1x/week for 10 weeks.

Treatment #2

Cc: chronic low back pain      

Progress: The patient reports that following the last acupuncture session she felt her back pain get “worse, but I could be wrong about that.” Then, she was walking and noticed pain in her right foot near ST-41. She does report feeling more relaxed, calm, with an increased sense of well-being for 2 days following the acupuncture session. Today she rates her lower back pain at 5/10 and in the same places. She also reports that she gets hot at night and that cooking and baking are activities that exacerbate her pain. No other changes were reported. Positive Oketsu. Tongue: purple, dry, cracks, slightly deviated left, mapped yellow dry coat in back, front peeled. Right pulse is full but soggy and the left pulse is full and slippery.

Treatment:

  • Left ear: Lumbar Spine, Sciatic Nerve, Point 0, Thalamus
  • Left: (J) LV-4, (J) LU-5
  • Bilateral: TI-10
  • Right: Linggu, Dabai, Zhongbai, SI-4, Houzhu, UB-65

Needle count: 14

Treatment #3

Cc: chronic low back pain

Progress: The patient reports that following the last acupuncture session she got full relief from her pain for the duration of 1 week, accompanied by a profound sense of relaxation. Today she reports a pain level of 9/10 in her right lumbar region from having “over-done it yesterday.” No other changes were reported. The tongue is the same but a little less purple, right pulse is soggy, left pulse is soggy/wiry.

Treatment:

  • Left: (J) LV-4, (J) LU-5, Linggu, Dabai, Zhongbai, SI-4, Houzhu, UB-65
  • Bilateral: TI-10
  • Right ear: Lumbar Spine, Sciatic Nerve, Thalamus

Needle count: 13

Treatment #4

Cc: chronic low back pain      

Progress: The patient reports that following the last acupuncture session she got a great deal of relaxation and 3 days of relief of her pain. She reports that she overslept last night and that resulted in an exacerbation of her pain, which she reports to be at 8-9/10 currently. She additionally reports more pain than usual in her right hip. No other changes were reported. Tongue is red, peeled front, center crack, shaky, deviated left, thick greasy yellowish coat in back. Right pulse is slippery, choppy and full while the left pulse is soggy & choppy. Positive Oketsu sign.

Treatment:

  • Left: (J) LV-4, (J) LU-5, Linggu, Dabai, Zhongbai, SI-4, Houzhu, UB-65
  • Bilateral: TI-10
  • Right: GB-34, GB-40

Needle count: 12

Treatment #5

Cc: chronic low back pain      

Progress: The patient reports that following the last acupuncture session she got a great deal of calm which “lasts & lasts,” and she reports not getting as nervous as before. She also has an average of 3 days of relief following acupuncture treatment. She additionally reports that she had frustration over her driver today resulting in an exacerbation of her pain which she reports to be at 8/10 currently. No other changes were reported. Tongue is pale-red, peeled front, center crack, deviated left, thick greasy yellowish coat in back. Right and left pulses are slippery/full. Positive Oketsu sign.

Treatment:

  • Left: (J) LV-4, (J) LU-5, Linggu, Dabai, Zhongbai, SI-4, Houzhu, UB-65
  • Bilateral: TI-10
  • Right: SI-3, UB-65

Needle count: 12

Note: Her pain level dropped to a 3/10 during the treatment session.

Treatment #6

Cc: chronic low back pain      

Progress: The patient reports that following the last acupuncture session she got, “the longest relief ever of four days.” Then, she experienced grief over the loss of two close friends and she realized that it had a corresponding effect of increased pain the next day. Today she rates her pain a 4/10 in the right lumbosacral area. No other changes were reported. Tongue is light red (and therefore less purple than at the start of this course), slightly deviated to the left, peeled front, thick white coat in back. Right pulse is thin and slippery, left pulse is wiry/slippery. Positive Oketsu sign.

Treatment:

  • Left: (J) LV-4, (J) LU-5, Linggu, Dabai, Zhongbai, SI-4, Houzhu, UB-65
  • Bilateral: TI-10
  • Right: SI-3, UB-65
  • Right ear: Thalamus
  • Left Ear: Lung x2

Needle count: 15

Treatment #7

Cc: chronic low back pain      

Progress: The patient reports that following the last acupuncture session her lower back pain had been, “very low,” at 2/10 today but as high as 7/10 during exacerbations. She recently experienced tooth pain in the upper left jaw and she felt as if it caused her lower back pain to increase. She also reports that her “right eye is intermittent,” (it looks bloodshot and is discharging tears currently).    She further states that she’s been having “five-palm sweating,” and waking at 1:00 a.m. No other changes were reported. Tongue is light purple, peeled front, thick yellow coat in back, cracks. Right pulse is soggy, left pulse is soggy/full. Positive Oketsu sign.

Treatment:

  • Left: (J) LV-4, (J) LU-5, Linggu, Dabai, Zhongbai, SI-4, Houzhu, UB-65
  • Bilateral: TI-10
  • Right: GB-34, GB-40
  • Right ear: Liver Yang 1&2, Liver, Spleen, Thalamus, Sciatic Nerve

Needle count: 18

Treatment #8

Cc: chronic low back pain      

Progress: The patient reports that following the last acupuncture session she got four days of 0/10 pain with high activity levels and no pain in her tooth since. Today she reports lower back pain on the right at 4/10 as well as a likely infected right eye (it’s now swollen, bloodshot and seeping yellowish exudates from the inner canthus). No other changes were reported. Tongue is red, peeled front, thick dry white coat, cracks, only very slightly deviated to the left. Right pulse is full, slippery while the left is full and soggy. Negative Oketsu.                    

Treatment:

  • Left: Linggu, Dabai, Zhongbai, SI-4, Houzhu, UB-65
  • Bilateral: GB-37
  • Right: LI-4, LV-3
  • Right ear: Eye x2, Thalamus
  • Left ear: Hip.C, Lumbar Spine, Thalamus

Needle count: 16

Treatment #9

Cc: chronic low back pain      

Progress: The patient reports that following the last acupuncture session she “didn’t have a lot of pain until I did something yesterday to bring it back.” Today she rates her right lower back and hip region pain at 5/10. She additionally reports that her bowel habits have improved considerably. No other changes were reported. Positive Immune sign.                

Treatment:

  • Right ear: Lumbar Spine x2,, Hip.C, Liver, Thalamus, Sciatic Nerve
  • Bilateral: TI-10
  • Left: Linggu, Dabai, SI-4, Houzhu, UB-65, Sanchasan

Needle count: 15

Treatment #10

Cc: chronic low back pain      

Progress: The patient reports that following  the last acupuncture session she had pain relief lasting until yesterday, when she did some activity that exacerbated her pain. Today she reports a pain level of 5-6/10 in her right lower back area. She also reports that her right eye is, “up and down.” No other changes were reported. Negative for Oketsu and Immune. 

Treatment:

  • Bilateral ear: Thalamus
  • Bilateral: KI-3
  • Left: Linggu, Dabai, SI-4, Houzhu, UB-65

Needle count: 12

Results

The patient reports feeling “much better than before the acupuncture.” She believes that this course of treatment is successful because her pain level decreased and her ability to function increased. 

This is a very typical kind of patient who gets a measure of relief from acupuncture treatment for her chief complaint for a limited amount of time. In Isabel’s case, the best pain relief we rendered was 4 days at 0/10 pain. One thing that clearly keeps the patient from getting better more rapidly is the fact that the patient ends-up re-injuring her back before the next acupuncture treatment. Proper body mechanics are basic life-skills that many of us don’t learn until it’s too late. The author has educated the patient on modalities such as Feldenkrais and Physical Therapy in order to learn techniques that will help her to prevent a recurrence of pain.

Discussion            

The case study form of research offers some strengths and weaknesses. Case studies tend to be more qualitative in nature when compared to the more quantitative forms of research such as the random-controlled double-blind study. Most proponents of the case study form agree that it allows for more detailed information than can be found in a statistical analysis. Statistical methods can effectively deal with situations where there is an isolation of variables (such as one specific drug versus a placebo) or where behaviors are more routine or homogeneous. Acupuncture is rarely delivered this way in reality and takes a personalized approach to patient care. As practitioners of Acupuncture, we craft a custom formulation of acupoints to use in any given treatment and we necessarily change the prescription to meet the patient’s changing needs. This approach, while useful in clinical practice, creates some difficulty for researchers attempting to use the randomized double-blind model.

Those who criticize the case study method usually do so on the basis that it is unable to generalize due to its highly subjective standpoint. On the surface there is a lot of truth to this statement. Detractors claim that the data produced is therefore not valid and reliable. Should we not consider the difference between quantitative and qualitative works for a moment? Could we not come to the agreement that a case study model, although perhaps not “valid and reliable,” could very well be considered credible and confirmable? The author believes that the distinction needs to made that qualitative is not quantitative in nature and therefore should not be judged by the same standards. Perhaps it is a bit unjust to criticize a model for not doing something that it was never designed to do in the first place.

In treating so many patients with chronic lower back pain, the author has come up with a protocol that seems to work quite well. The point combination is found delivered to the above patient on the left side of her body (the “healthy” side, as the patient’s pathology lies on the right side). The points are: Linggu, Dabai, Zhongbai, SI-4, Houzhu, and UB-65. This protocol is greatly informed by Master Tung’s school of acupuncture as taught by Five Branches DAOM instructor Dr. Wei-Chieh Young, as well as Dr. Richard Teh-Fu Tan (Young, 2008). Lingguand Dabaiwhich lie on either side of  LI-4 Heguwork for opposite-sided lower back pain. Zhongbaiworks for opposite side Gallbladder-channel pathologies (such as hip-region pain due to lumbar radiculopathy). These 4 points together are found in Dr. Tan’s “modified Pattern #1” of his “global balance technique.” (Tan, 2000). The modification to this protocol is made because the patient has (amongst other problems) lower back pain on the opposite side. Houzhuis Master Tung’s LV-3 point (located a bit more proximally than the standard location). SI-4 and UB-65 are the standard locations. Dr. Young likes to use UB-65 instead of the more popular UB-62 because of its qualities as a Shu-Stream point (Young 2008).

An adjuct to the above protocol is to do something on the affected side of the body as well. It is generally understood that auriculotherapy points are most effective if the affected side is treated (Oleson, 2003). In this case, the author used bilateral Thalamus points to help stop the pain signal from getting to the cortex of the patient’s brain where they can feel it as pain. If the signal stops at the Thalamus, it isn’t then felt by the patient. This is probably the most commonly used auriculotherapy point in the author’s clinic. Generally, the author’s clinical observation is that acupuncture treatments are more effective with a combination of body and auricular acupoints needled (each system seems to support the other, rendering a better overall outcome). 

As discussed in the Literature Review section above, the Oketsu protocol was delivered to this patient each time the sign was present. In this case, it took seven weekly treatments to clear the patient’s Oketsu. This fact, plus the advanced age of the patient, tells me that her healing potential is not very robust. After clearing Oketsu, the Immune sign started coming up (Matsumoto, 2002) which is interesting since the patient complains of long-standing digestive issues difficult bowel movements. During the course of treatment, these symptoms improved, even without focusing upon them. 

Conclusion

Isabel, our patient above, will likely experience a quicker recovery from her chronic lower back pain now that the practitioner has removed the underlying constitutional factor that was likely preventing her from getting well (Oketsu). The author wonders how much more acupuncture he would have had to give this patient before we started seeing results without addressing the Oketsu? The author suspects a lot longer and time is a luxury he doesn’t enjoy as an acupuncturist employed by a hospital. That could be the topic of another study. It is the author’s belief that in this case the Blood Stasis pattern was very significant but did respond positively to acupuncture therapy. Since the majority of his practice is around chronic back pain, it is good to know that he has learned powerful approaches to dealing with the multi-faceted and complicated cases that come into his clinic.

Although there seems to be a clear correlation between this patient’s chronic lower back pain and Oketsu, I believe that more research is warranted. The author would encourage anyone in the field to conduct clinical trials testing Oketsuin any chronic pain conditions as it now seems to me to be an underpinning factor in many cases. 

References

Ma, YT. Biomedical Acupuncture for Pain Management: In Integrative Approach. 2005. Elsevier, St. Louis, MO.

Birch, S. Zhong Yi Acupuncture and Low-Back Pain: Traditional Chinese Medical Acupuncture Differential Diagnoses and Treatments for Chronic Lumbar Pain

The Journal of Alternative and Complimentary Medicine, Vol 5, No 5, 1999, pp. 415-425

Furlan, AD. Acupuncture and dry-needling for low back pain. The Cochrane Review http://www.cochrane.org/reviews/en/ab001351.html

Flaws, B. Statements of Fact in Traditional Chinese Medicine. 2008. Blue Poppy Press Boulder, CO.

Matsumoto, K. Kiiko Matsumoto’s Clinical Strategies: In The Spirit Of Master Nagano, Vols I & II. 2002. Kiiko Matsumoto Int’l. Natick, MA.

Pullman-Mooar, S. Merck Manual Professional (online) http://www.merck.com/mmpe/sec04/ch041/ch041a.html?qt=treatment%20of%20back%20pain&alt=sh

Erstad, S. Healthwise Inc. Health Encyclopedia, Kaiser Permanente, 2008.

Young, WC. Lectures on Tung’s Acupuncture: Points Study. American Chinese Medical Culture Center, Rowland Heights, CA 2008.

Young, WC. Lectures on Tung’s Acupuncture: Therapeutic System. 2008. American Chinese Medical Culture Center, Rowland Heights, CA.

Oleson, T. Auriculotherapy Manual: Chinese and Western Systems of Ear Acupuncture, 3rdEd. 2003. Elsevier Science, London.

Tan, R. Dr. Tan’s Strategy of the 12 Magical Points. 2000. San Diego, CA.

Appendix: Practice Analysis

The hospital that employs the author keeps track of several metrics as a way to assess individual practitioners productivity. This data includes how many referrals were made per month and how many got the service (i.e. an acupuncture treatment), how many patients failed to keep the appointment), how long the patients had to wait to get service, etc. as well as patient satisfaction ratings by mail surveys. No information pertaining to treatment outcomes or even data pertaining to the practice of TCM is readily available through their electronic charting system.            Therefore it was necessary to find out about the author’s practice through research. He first decided on a timeframe: one year. Then, he picked the dates from which the study would begin and end. The author chose July 28, 2008 through July 28, 2009, the span of time corresponding to his 40thyear on this planet. Next, the schedules of every day that he was on duty treating patients were printed. Three of the days were half-days, otherwise they were a full 8 hours each. The Chief Complaint of each of these patients is recorded on the daily schedules. The author systematically tallied the number of treatments per Chief Complaint as well as the total number of treatments that day, double-checking the numbers on each page. He repeated this process for the 224 remaining days of treatments delivered that year. Then he proceeded to enter these totals into a Microsoft Excel spreadsheet, again, double-checking that he was correctly entering the data. Once the raw data was entered, another spreadsheet was created to analyze the data (a working copy). From this sheet, the author further extracted the answers he needed and charted the results, below.

Over the year of this study, 3294 treatments were delivered over 225 days at an average of 15 per day. The results of the individual Chief Complaint tallies, in percentages, are found in the table, below.

Lower Back 22.28%
Back13.15%
Neck11.72%
Spinal*47.15%
Chronic Pain11.45%
Fibromyalgia3.25%
Headache6.50%
Facial pain0.49%
Shoulder7.77%
Arm0.21%
Elbow1.91%
Wrist2.09%
Hand1.43%
Shingles0.36%
Hip3.10%
Knee5.34%
Leg1.00%
Groin0.15%
Sciatica0.76%
Ankle2.06%
Foot2.40%
Peripheral Neuropathy2.00%
N/V0.18%
Stroke0.18%
* Spinal is a combination of lower back, back and neck chief complaints
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