Case Study: Treatment of Acute Lower Back Pain With Acupuncture

Case Study: Treatment of Acute Lower Back Pain With Acupuncture

SUMMARY

A patient complaining of acute back pain due to "overdoing it" in a yoga class. After 5 treatments with Traditional Chinese Acupuncture, the patient's pain went from a 5/10 on a numerical rating scale (NRS) to a 0/10, with only minor stiffness remaining.

Patient History

A 79 year old male patient complaining of lower back pain came in seeking treatment for pain relief. The pain started four months before his arrival at the clinic. It started after he “over did it” at a yoga class. The pain is constant and aching in nature And is accompanied by a feeling of stiffness. It presents in the lumbar area, more so on the left than the right. The pain is aggravated by poor posture while sitting gin soft chairs, is alleviated by heat, and by taking Tylenol or ibuprofen. The patient is fairly active, participating in yoga classes a couple times a week, and practices stretching daily. The patient also has a history of muscle spasms in the lower back, which occur a few times a year. The severity of the pain is rated as a 5/10 on a numerical rating scale.

Objective Findings

The patient’s hip flexion is normal. There is notable tension in the paraspinal muscles from L1 through L4. The Quadratus lumborum muscle is also tight. There is an ashi point on the gluteal region with corresponding muscle tightness, 3 cun lateral to the second sacral foramen (UB53).

The red ovals show the area of muscle tension felt on palpation in the area of the patient’s pain (Longissimus thoracis, Iliocastalis and Quadratus lumborum). The red circle indicates the ashi point.

The patient’s tongue was a pale red colour with a blue hue, and a thick white coating. The sublingual veins were pale. The patient’s pulse was 80 BPM, slightly wiry, thinner on the left wrist, and weaker at the chi positions on both wrists.

Diagnosis

The lower back pain is due to Local Qi and Blood Stasis due to overuse in yoga class. The patient has an underlying Kidney Qi Deficiency, as is noted by the weak Chi pulses.

Principle of Treatment

1. Move local Qi and Blood to Stop Pain

2. Tonify Kidneys

Treatment Plan

Treat once or twice a week for a total of 6 weeks. Modalities: Traditional Chinese Acupuncture

Treatments

Results form the first Treatment

The patient experienced discomfort in the lower back for 48 hours, then the pain was relieved. He still complained of stiffness in the lower back with a NRS of 2/10. There were 7 days between the first and second treatments.

Results from second treatment

Discomfort has reduced, and is now located directly beside the spine at L1 to L4. Stiffness is no longer in the paraspinal muscles. UB24 is very tender, eliciting pain on palpation. Ashi point on gluteal aponeurosis tender on palpation but not painful. There were seven days between the second and third treatments.

Results from third treatment

Patient states that he feels he has had an 85% improvement in his condition since receiving treatments. Patient did feel quite stiff after walking 10km and had to do a lot of stretching to relieve the muscle stiffness. The stiffness he feels is now limited to beside the spine, level with L3 and L4. There is marked tenderness beside L3, while the area beside L4 is only slightly tender. There were seven days between the third and fourth treatments.

Results from fourth treatment

Patient states that he feels that he has seen a 90% improvement in his condition. Still has some stiffness in lumbar region, just lateral to L3-L5. There is no pain or discomfort on palpation of lumbar region. There were 11 days between the fourth and fifth treatments. There were 9 days between the fourth and fifth treatments.

Results from fifth treatment

Zero pain since last treatment. Patient still feels some stiffness in the lumbar region, more so on the left side. Paraspinals from L1-L5 are markedly looser than before.