Course: Acupuncture Treatment of Disease 3 Date: April 13, 2009 Class #: 1 - Low back pain, glomerulonephritis

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1 Course: Acupuncture Treatment of Disease 3 Date: April 13, 2009 Class #: 1 - Low back pain, glomerulonephritis Syllabus review Class attendance: 3 tardies (15 min late or 15 min early departure) = 1 absence. Low back or lumbar pain (also called lumbago in some publications) affects something like 6 million cases in the US per year. As such, it is widely seen in student clinics and in professional clinics. There are a wide range of etiologies, types and differentiations for low back pain. What follows is a discussion of lumbar pain in some it s wide variety of flavors. Low Back Pain Low back pain can be classified as acute, subacute, and chronic in nature. Acute: Acute or short term low back pain lasts from a few days to a few weeks. Most causes are mechanical in nature, resulting from trauma such as a sudden jolt (like a car accident or a fall) which stresses the bones and soft tissues (intervertebral discs, muscles, ligaments and tendons). Patients can often pinpoint the painful parts in these injuries. Very serious accidents or osteoporosis can result in breaks to the bone, either lumbar or tailbone, as well as damage to the SI (sacroiliac) joint. Symptoms can range from muscle aches to shooting/stabbing pain, limited range of motion or an inability to stand up straight without pain. While most acute back pain will resolve within a couple of months, some acute injuries may become chronic if not treated. Rest generally results in an improvement in the pain. Sub-acute: Well, honestly, we didn t discuss this in class so much and neither does any other source I found, including the Dr. Luo handout. One to 3 months perhaps? Chronic: Any low back pain persisting for more than 3 months = chronic pain. This suggests deficiency, no? Physically this may be due to osteoarthritis, rheumatoid arthritis, spinal disc herniation, and osteoporosis. Rarer causes include tumors and infections. Sidebar: Pain in the upper back is less likely to be trauma induced, though it can certainly happen. More likely causes are wind-cold invasion affecting the upper back and stress. Bear in mind, however, that aortic disorders such as aneurysms, chest tumors and inflammation of the spine can also result in upper back pain. Page 1 of 13

2 Interviewing Your Lumbar Pain Patient When you interview a patient with a complaint of low back pain it is important to gather some basic information about their condition. Find out: Duration How long has it been painful? Helps you determine excess or deficiency, chronic and acute. Character How do they characterize the pain? Radiation Does the pain radiate to any area? If so, where and when? What makes it better or worse Associated symptoms What other symptoms came along with this pain? Fever, pain on the anterior of the body, etc. Neurologic symptoms Numbness, tingling and weakness for instance. Trauma Was there an injury that caused the pain? Find out how the injury occurred this can help you determine what is injured. Often low back pain will start in one place and refer to another or will start in a localized area and spread to surrounding areas as the muscles guard the injury. Previous treatment What has the patient tried already and what kind of success did they have? Differential Diagnoses for Low Back Pain Aka, conditions associated with low back pain and there s a bunch of em! Sciatica OK, this is really a lecture unto itself even though it only got an honorable mention in class. Sciatica isn t really a diagnosis unto itself so much as it is a collection of symptoms associated with inflammation or impingement of the sciatic nerve. The sciatic nerve is a large nerve exiting the spine in the lumbar and sacrum (L2 to S4), traveling down the leg and branching to supply enervation to the lower limbs. The yellow and green bundle in the pic to the right represent the sciatic nerve. It s big about as big around as your index finger. This bundle passes behind the hip joint and goes down the buttock to the back of the leg and foot. Compression of the sciatic nerve in the spine is the most likely suspect for sciatica pain. This happens most often as a result of disorders of the vertebral column, usually the rupture of an intervertebral or lumbar disc. Less likely is primary sciatica which is a disorder of the sciatic nerve itself. (Diabetics sometimes suffer from this. The pain in this case is felt bilaterally. Pain from disc compression on the other hand is unilateral.) Page 2 of 13

3 Symptoms of sciatica due to compression include shock-like or burning low back pain combined with pain in the buttocks and pain down one leg. Pain is most often felt to about the knee, either on the posterior or lateral aspect of the leg. Pain can go down below the knee, however, sometimes even wrapping to the anterior or medial aspect of the leg and/or foot. You can do some quick clinical tests to determine sciatic pain. The simplest one to do is the straight leg test which stretches the sciatic nerve and spinal nerve roots. Have the patient lay flat on their back and then you lift their affected leg to the 30 degree mark. Pain felt between 30 and 90 degrees is a fairly good indicator of sciatica. You may need to dorsiflex the foot in order to get the stretch you need. This can also indicate piriformis syndrome (in which the piriformis muscle is pinching the sciatic nerve rather than the bone or disc) or sacroiliac joint involvement. Some practitioners suggest that pain felt between 35 and 70 degrees indicates possible disc pathology while pain felt between 70 and 90 degrees is a good indicator of lumbar joint involvement. Though it s not covered in class and not on the test, Maciocia and several others recommend Jiaji points in the lumbar, UB 54, GB 30, Huan Zhong extra point, GB 34, and UB 40 to treat sciatica. Herniated nucleus pulposus (with/without nerve impingement) This is also called a protruding, bulging and sometimes a ruptured disc. The intervertebral discs, under constant pressure, can be partially pushed into another space, often space containing the spinal cord or nerve root causing pain. Most herniated discs occur in the lumbar portion of the spine, as this is where most of the weight of the body is carried. Spondylosis (with or without spondylolysthesis) This is a degenerative process of the spine causing narrowing of the spinal canal due to bony overgrowths which results in compression of the spinal cord and nerve roots as well as the intervertebral discs and vertebral facet joints. This can be caused by wear and tear on the discs. Patients with spondylosis may experience stiffness in the mornings after waking from a nights sleep and/or may feel pain after walking or standing for a long time. Anther term for this is spinal stenosis which also refers to bony overgrowth. Spinal stenosis is most often used to refer to bony overgrowth which results in stiffening of the spine. When X-rayed the spine looks like bamboo. This is often caused by an autoimmune disorder. A blood test for B-27 can show a propensity for this type of spinal anomaly. Spinal (and cervical) stenosis can also narrow the spinal canal leading to impingement of the nerves and discs. Spondylolisthesis refers to the anterior dislocation of one vertebra over another producing pressure on the spinal nerves. Scoliosis and Other Skeletal Irregularities Skeletal irregularities produce strain on the vertebrae and supporting muscles, tendons, ligaments, and tissues supported by spinal column. These irregularities include: Page 3 of 13

4 Scoliosis, a curving of the spine to the side Kyphosis, in which the normal curve of the upper back is severely rounded Lordosis, an abnormally accentuated arch in the lower back Back extension, a bending backward of the spine Back flexion, in which the spine bends forward. Sacroiliac Joint Dysfunction The sacroiliac joint is fairly fixed large joint in the body. It is held together by some very large ligaments. The SI joint forms part of the ring that is the pelvis and these ligaments hold the whole thing together rather like a hoop of metal around a barrel. If the ligaments are torn or stretched like in pregnancy (which causes the release of hormones to relax these ligaments) the joint gets more flexible. The more pregnancies, the more flexible it is. Later in life it tends to ankylose grow together. This takes away the shock absorbing capabilities of the joint. Also, with multiple pregnancies, the incidence of arthritis in the SI joint increases. Lumbar Transverse Process Syndrome L3-L4 especially L3 transverse process hurts to palpate. Muscle on the affected side will feel stiff. Rare Causes Infection (such as kidney infection, shingles, tuberculosis) Connective tissue disease (such as ankylosing spondylosis) Tumor Referred pain (from a kidney stone, abdominal aortic aneurysm, etc.) Spinal stenosis A physical exam to check for causes of lower back pain would include Range of motion tests such as flexion, extension, and rotation to the left and right. Inspection for obvious signs of deformity While forward flexing, look for one shoulder higher than the other, suggesting scoliosis Palpate the spinous process and surrounding tissues for tenderness Note any paraspinal muscle spasms Neurological exams Should you be interested, check out the Physical Assessment 2, specifically class 5. That was all about spinal evaluation. Class 4 was about neurological testing. Biomedical treatments for low back pain are largely dependent upon the cause. If there are no symptoms that might cause long term problems, pain is usually managed conservatively since 80-90% of low back pain resolves without further problems in 2-3 months. Further treatment includes: Reduced activity and rest Pain management with NSAIDS and Tylenol Page 4 of 13

5 Modalities such as ultrasound, ice, and heat Gentle flexibility exercises for the back and hamstrings Strengthening of the support muscles of the abdomen and trunk If symptoms don t improve over the course of 4 weeks most practitioners will then consider radiographic studies. TCM Mechanism The low back is the Residence of the Kidneys, as this area of the body is the most closely related to the Kidney system. The health of the Kidneys is often reflected in the status of the lower back. Kidney deficiency or blockage in the lumbar channel(s) TCM Etiology 1. Invasion and retention of pathogenic cold, wind and damp. Retention of cold, wind and damp in the channels and collaterals that flow through the lower back causes constriction and obstruction of the Qi in the meridians and collaterals (often this is cold attacking the Yang meridians, especially the BL, GB, Du vessels) which causes pain. The Neijing says, If there is free flow there is no pain; if there is no free flow, there is pain. Precipitating factors causing this retention are likely to be living in cold damp places, exposure to rain, wading in water, being drenched in sweat. 2. Damp heat retention in the lower jiao This is more often damp heat attacking the Liver, Spleen, and Kidney channels Yin channels. Patients may have a short or long history of low back pain. Damp heat can come from chronic damp retention, acute damp and heat retention. 3. Blood stasis obstructing channels and collaterals Often due to traumatic accident causing acute lumbar muscle sprain which is then not treated correctly, lingers a long time and becomes a chronic condition. This also happens to patients whose jobs or lifestyles involves repeat strain to the lower back (i.e., due to carrying heavy loads frequently). 4. Kidney deficiencies This is most frequently a result of aging. Kidney deficiency of Yin, Yang, or Qi leads to low back pain due to pinching and compression of the nerve. Kidney Essence xu, however results in congenital kidney deficiency such as Adult Polycystic Kidney Disease (APKD) for instance or Infantile Polycystic Kidney Disease (IPKD). Both result in cysts of fluid in the Kidney expressed at different ages. Page 5 of 13

6 Kidney xu can involve both the Kidney organ and associated channels, Kidney, Bladder, Du, and Dai channels. Dai crosses the regular channels of the Stomach, Bladder, and Gallbladder channels; Liver, Spleen, and Kidney. All channels are bound by the Dai channel. The lumbar area holds most of the weight of the body as such part of the Dai channel s job is to support the lumbar area. Weakness of Kidneys can also be to overwork or excessive sexual activity which results in poor nourishment of the meridians of the lumbar region. Differention and Treatment Treatment involves dredging the meridian passages in the case of excesses and tonifying Kidney Qi in the case of Kidney deficiencies of any kind. Points are mainly selected from the Du and Foot Taiyang (BL) channels in treating lower back pain. Basic points: KI 3 Treats any kidney deficiency (qi, yin, yang, essence). This is the Tai xi or Great River, the Shu Stream point for the Kidney. UB 40 Use bleeding, cupping, needling. This is one of the 4 key points. GB 34 Influential point of the tendons - relaxes ligaments and tendons, and is especially good for sprains Ashi points of the lumbar region Differentiations See if you want a more thorough discussion of the differentiations and treatment plans than we got in class. Damp and Cold Invasion Symptoms: Cold sensations and area may feel cold to the touch. Severe cold pain Heavy sensation and stiffness of the lower back Aggravated by: o Twisting/turning the body o Lying down o Damp and cold weather o Rainy days Relieved by warming therapy. Dispel cold and damp Basic points + UB 26 to warm the Yang and melt damp Cupping with warm therapy such as using bamboo cups Du Huo Ji Sheng Wan is the exemplary herbal formula. Page 6 of 13

7 Tongue: Normal body (or perhaps pale), greasy white coating Pulse: Deep and slow Damp and Heat retention in the lower jiao Symptoms: Hot burning sensations Bitter taste in the mouth Restlessness Scanty urination with dark urine Tongue: red body with yellow greasy coating Pulse: slippery and fast. Drain damp, Eliminate heat Basic Points SJ 5 + GB 41 Si Miao San is the herbal formula for this differentiation. Blood Stasis Symptoms: Pain is severe, fixed, worst at night Aggravated by pressure Movement is impaired, worse with bending forward/backward, turning body Tongue: dark or purplish body and/or with purple spots. Pulse: uneven/choppy Basic points UB 17 to move blood for upper and for deficiencies (to tonify) SP 10 to move blood for lower/middle jiao and for excesses (to reduce) UB 32 SI 3 + UB 62 to open Du and melt stasis Shen Tong Zhu Yu Wan Page 7 of 13

8 Kidney Deficiencies Characterized by sustained pain and soreness in the lower back, aggravated by fatigue and alleviated by bed rest. Yang Xu Symptoms: Cold and water retention Early am diarrhea Impotence Cramp-like sensations in the lower abdomen Pale face Hypofunction of the sense of taste. Cold limbs Pulse: deep, slow, weak or deep and thready Tongue: pale body Basic points Du 4, Ren 4 with moxa, warm needle or moxa box (best choice) You Gui Wan Yin Xu Symptoms: Insomnia Irritability Dry mouth and throat Night sweats Malar flush Five palm or five center heat Tongue: red body, less or no coating, cracks P: thready and weak, or thready and rapid UB 52 to tonify Yin further from Du, more yin. KI 3 KI 6 Zou Gui Wan Essence Xu Prognosis is bad regardless of disease. Look for congenital problems. Dr. Luo didn t talk about it much, but the only way to build essence according to Will Morris is to do Qigong. Other Treatments: LI 10 for acute injury. Insert needle, get strong stimulation, have the patient do gentle movement with the back. But keep the arm still! Yao Tong 2 points on the dorsal aspect of the hand, just distal to the junction where the 1) 2nd and 3rd and 2) 4th and 5th bones meet. This too is a movement treatment for lumbar pain due to sprain, etc. Bleeding/cupping Page 8 of 13

9 UB 40 Local points treat the tender point specifically. ST 38 for lumbar pain. Sidebar: Yin Yang House s website adds more about trauma leading to blood stasis. Signs/Symptoms: History of sprain/strain Pain or rigidity of the lower back Pain usually fixed and aggravated upon movement and/or pressure Treatment Points: Needle the empirical points below then move the patient s body to the position where the pain begins to appear. Manipulate the needle with the reducing method for 1-2 minutes. If the patient responds well, repeat this process a few times then insert auxillary/local points and retain for minutes. Empirical Points: GV 26 - if pain is only on the midline of the back and patient has flexion/extension difficulty SI 3 - if pain is on the posterior-midline and also lateral and/or patient has torso rotation difficulty Yaotongxue - if pain is on either side of the posterior midline, pain above UB 23 UB 40 - acute back pain on the UB meridian, pain below UB 23 UB 37 - in lieu of UB 40 if there is pain and tenderness here and no congestion of blood vessels at UB 40 GV 8 - stiff and/or rigid spine Page 9 of 13

10 Glomerulonephritis Glomerulonephritis (also called glomerular nephritis or GN) is a renal disease characterized by inflammation of the glomeruli of the kidney. For a biomedical review of this functional unit of the kidney, please click here. GN can be of primary cause (causes intrinsic to the kidney) or of a secondary nature (bacterial, viral or parasitic infections, drugs or systemic disorders like SLE or vasculitis). It can present with: isolated hematuria or proteinuria as part of a nephrotic or nephritic syndrome in which the kidneys are damaged and thus leaking proteins or blood into the urine as a component of acute renal failure as part of a chronic renal failure In many cases the cause is unknown approximately 25% of patients with chronic GN have no prior history of kidney disease and the disorder first appears as chronic renal failure. Autoimmune disorders have been known to result in GN. The chronic form of glomerulonephritis may develop after an acute phase. Symptoms: Lumbar pain This is a common first symptom. Proteinuria Protein in the urine can result in foamy urine. Patient will often get very slender as well since the body is not being nourished. Hematuria Edema Hypertension Abnormal BUN and Cr results higher than normal Chronic renal failure patients may eventually manifest with the following symptoms: Unintentional weight loss Nausea/vomiting Fatigue Decreased urinary output Need to urinate at night Easy bruising Decreased levels of alertness (i.e., drowsiness, delirium, coma) Muscle twitching and cramping Seizures Generalized itching Treatment depends upon the cause. Common treatments include blood pressure medications to relieve hydraulic pressure in the kidneys, corticosteroids, immunosuppressants, and dietary restrictions on fats, proteins, fluids, and salts. Page 10 of 13

11 TCM Mechanism KI, SP, LU dysfunction with water retention and blood stasis. Water metabolism is the key to this disease. Organs related are LU, SP, KI. TCM Differentiation and Treatment Basic Points: UB 23 UB 40 DU 3 Kidney Yang Door, for water discharge and to warm yang GB 39 - for yin and essence especially for kids). Spleen and Kidney Qi Xu Chinese herbs and acupuncture are effective for this differentiation. The prognosis, compared to the congenital type, is good. Signs and Symptoms: Poor appetite Loose stool Diarrhea SOB Low back pain and knee pain Profuse urination Proteinuria and hematuria T: pale body with thin white coat P: weak Basic points SP 3 Shu Stream point to tonify spleen KI 3 SP 10 for hematuria Shen Ling Bai Zhu San Liver and Kidney Yin Xu Signs and Symptoms: Dizziness Headaches Dry eyes Blurry vision Restlessness Insomnia Tinnitus Hypertension due to Liver Yang rising caused by LV yin xu T: Red body, less/no coating P: Thin, fast Basic points LV 3 LV 8 KI 3 Yi Guan Jian is the formula to nourish the Liver Yin. Qi Ju Di Huang Wan if eye problems (blurred vision for instance) are also present. Page 11 of 13

12 Lung and Kidney Qi Xu Sidebar: In biomedicine Wilson s disease is a Liver disease of metabolism one manifestation is dry eyes and another is pigment deposits in the pupil of the eye. There s a bluish belt around the pupil in the late stage. Both Liver and Kidneys are involved. Signs and Symptoms: Catches common cold easily Cough with white phlegm Puffy face and edema in extremities Scanty or foamy urine SOB and shallow breathing Spontaneous sweating Lower back/knee pain Often has a history of childhood asthma T: pale body, thin white coat P: Weak Basic points LU 1 REN 3 KI 3 Blood stasis retention in the Kidney Signs and Symptoms: Dusky, purplish or black face Dry or fish scaly/shiny skin Macula Lower back pain is fixed, worse at night Hematuria T: dusky, purple tongue with purple spots P: choppy/uneven and deep Basic points SP 10 SI 3 + UB 62 to open Du Shao fu zhu yu tang In general Eat more fruit, vegetables. Have to moderate proteins eat enough to nourish but not too much so body casts it off. 1 gram per kilogram of body weight. GB 39 will help as will Ren 6 to tonify the Qi. Scalp needling at the anterior hairline needling upwards at the reproductive area/lower jiao. Niu zen zi and tu si zi will help. Page 12 of 13

13 Case Study Mr. Li, 47 yo male Cold invasion constricting meridians Suffered from lumbar tightness after cold exposure 6 months ago. From then on, he started to feel Something excess lumbar distention. He got chiropractic treatment for several times which didn t help him. Lately, he has possibly depleting Yin Qi xu been very busy in his work and felt tired frequently. What is more, he started to feel obvious deep and stasis (meaning, tender to pressure excess) Qi xu fixed pain in his low back which was distended with pressure. He had spontaneous sweating easily and Yin xu yin xu heat in HT or blood damp in head? felt hot at night, occasionally with night sweating. He had vivid dreams at night and felt unclear early in Spleen Qi xu Qi or Yang depletion the morning. He had poor appetite with gas and bloating sometimes. He also had frequent urination. He Stasis went to see a doctor and had some examinations which indicate there was a mass (measuring 1x2x2 cm) Qi, Yang, or blood xu heat in MJ in his right kidney. His tongue was pale with thick yellow coating on the entire surface. His pulse was stasis long term KI something Xu uneven and deep. The 3 rd position on the right was weak. Diagnosis is lower back pain Differentiations and treatment: History of Cold invasion, excess condition Yin deficiency KI o KI 3 o UB 52 Qi deficiency KI and SP o SP: ST 36 SP 3 o KI: KI 3 UB 52 Blood Stasis o UB 17 (because this is more deficient than excess) o SP 10 Dampness and Heat in the MJ o SJ 5 o UB 40 o GB 34 Sources: Dr. Luo s handout and Class 1 lecture notes. Page 13 of 13