Introduction

STATISTICS

·         75 to 85% of all people will experience some form of back pain during their lifetime.

·         Back pain is the second most frequently reported reason for visiting a doctor, the fifth most frequent cause of hospitalization, and the third most frequent reason for surgery.

·         The highest rate of back pain occurs in the 45 to 64 year old age group.

·         Although the overall occurrence of back pain is similar in men and women, a greater percentage of men (61.1%) experience low back pain than women (51.2%), while more women (9.6%) suffer from upper back pain than men (6.6%).

Source: National Health and Nutrition Examination Survey III (www.spine.com)

            This particular case addresses the condition of low back pain with a secondary concern of urinary urgency/incontinence.  Low back pain is the second most frequently reported reason for visiting a doctor, the fifth most frequent cause of hospitalization, and the third reason for surgery (National Health & Nutrition Examination Survey).  For these reasons, as acupuncture practitioners we will see many patients with the complaint of low back pain.  This case will address the low back pain, the diagnosis: Damp-Heat in the Lower Jiao with constitutional Kidney deficiency, the treatment, and outcome of that treatment.  Included are articles from both a western biomedical perspective on treating low back pain and treating urinary urgency from a TCM perspective.

CASE ANALYSIS

Main Complaint:

Male patient, born 12/1955, presents with low back pain on and off for 10 years.  Pain started after lifting a 125-pound box.  Western medicine diagnosed condition as arthritis in the low back.  Lately pain has been worse:  in the past, pain occurred when bending forward.  Presently, pain occurs with bending forward and with twisting side to side.  Pain fills up the area from UB 23 to Yao Yin, and is local to that specific area.  Pain described as “aches”.  2 years ago pain increased to the degree that patient had to quit regular exercise regime.  Patient stretches every morning.  Patient’s job involves working in a factory on a forklift.

HX: Past surgeries: nose, knee, collarbone, regularly has hay fever

Visual Observation: Rosy cheeks, balding, strong musculature

Energy/Sleep: Energy “ok”. S: Poor, because wakes up 2-3 x night with urinary urgency that is scanty.  During full moon lies awake for hours thinking a lot.  Describes himself as having an “active mind”

Temp: Tends toward warm

Appetite/Thirst: Eats late—before going to bed.  Feels he’s gaining weight.  Does not feel hungry in the a.m.

Pain: Past Orthoscopic surgery of left knee.  Left shin gets sore in afternoon (left leg used to work a machine.  Occasional hand numbness when back is really bad.  Sore neck.

Emotion: “Single”-not a lot of emotional ups and downs.

Chest/Breathing: Wonders if has Apnea.  When taking Celebrex got shortness of breath, but not now.  Lately coughing up slight yellow phlegm. Thinks allergic to dogs-is currently exposed (to sister’s dog).   Feels constant drip in back throat.

Digestion/BM: 1rst BM-A.M., formed, thin, stools small when “over-thinking”, 2^nd BM-around 1:00pm or in evening

Urogenital: Wakes 2-3x night with urinary urgency, scanty flow, urine tends toward dark-yellow.  As a result, patient has poor sleeping.  There is also urgency every hour during the day at work, with some anxiety accompanied—urinates every hour, urine also scanty. 

Eyes: Spots in front of eyes

Tongue: Coat: greasy yellow, red tip, Distention: 2

Pulse: Thready, BPM: 72

DIAGNOSIS

Low back pain and urinary urgency due to Damp-Heat in the Lower Jiao with underlying Kidney Deficiency

TREATMENT PRINCIPAL

Clear heat, disinhibit dampness, ease the low back, and relieve pain

Acupuncture:

Yao Tong Xue – needles remain in both hands as patient does the following exercise: forward bend, back bend, and full trunk rotations, about 3-5 minutes.

UB 23

UB 32

UB 40

UB 60

Kid 3

After 15 minutes removed needles. 

Tui Na:  Dian Fa, Rou Fa, Gun Fa from UB 23 down foot Tai Yang channel

Herbal Prescription:

Si Miao San + Liu Wei Di Huang Wan (modified)

huang bai              6

yi yi ren                  15

cang zhu                6

huai niu xi              9

shan zhu yu          9

shan yao                12

fu ling                     12

ze xie                       9

mu dan pi               6

du zhong               12

sang ji sheng        12

che qian zi             6

3 bags, ½ c, 3x day

OUTCOME

Patient returned after one week, with the following results:

·        Low back pain decreased: no longer hurts when moving side to side, only when bending forward

·        Woke up to urinate one time instead of the usual 2-3 times. 

·        Decreased urgency during his work-day

The same treatment strategy continued for the second treatment with the purpose to continue on the same path in order to reinforce the treatment.

Patient returned for the third treatment with the following results:

·        Urinary urgency at night has stopped.  Patient is waking up, but does not need to urinate—just waking up.

·        Low back “aches are gone”, however the quality of the pain has changed:  now the pain is described as “sharp”, the location is the same.  This pain occurs specifically when at work on the fork-lift: when sitting and rotating to the right.

The same treatment strategy continued for the third treatment.

Patient returned for the fourth treatment with the following to report:

·        Urgency stopped at night, patient waking up one time at night.

·        Urgency profoundly decreased during the day.

·        Still remaining was the “sharp” back pain when bending forward. 

The patients DX changed to: Qi and Blood Stagnation with Kidney deficiency.  E-Stim was used from points: UB 40 to Yao Yan, bilaterally, for ten minutes at a rate of 4, continuous wave.  After the first ten minutes, the rate increased to 4.5 for another ten minutes.  The treatment focus is to continue to aggressively treat the sharp low back pain—a long-term injury from trauma to the low back, as well as address the Heart due to waking up at night. 

I am still treating this patient.  The E-Stim has been effective in decreasing the low back pain.  I also gave the patient “homework”:  a daily qi gong standing pose for five minutes every morning.  I also addressed the waking up at night issue, adding dan shen to his herbal formula.

CONSIDERATIONS

Should the patients’ urinary urgency/incontinence be accompanied by fever, chills, burning sensation upon urination, it is recommended referral for tests—could be benign prostatic hypertrophy.

TCM Pathophysiology Low Back Pain

            Low back pain diagnosis from a TCM perspective if focused primarily on the cause of the pain as well as the pathological change in the pain.  There are three main causes of low back pain: 1.) Invasion of pathogens  - Dampness, Cold, and Heat (these pathogens could combine together), 2.) Kidney deficiency (Kidney yin or yang xu), and 3.) Trauma. 

            Invasion of pathogens refers primarily to dampness, which tends to be very heavy and lies low.  When dampness invades the lower back, it causes an obstruction of qi in the channels and collaterals, leading to localized pain.  Patients affected by Dampness may live in a damp environment, or cold areas, or work in cold, damp conditions.  It is believed the low back and limbs are most affected by Dampness because Dampness comes from the ground and when it invades the body, the symptoms tend to be localized to the lower part of the body. 

Kidney deficiency is an internal cause of low back pain because the kidney supports and nourishes the region of the low back. When the Kidney is unable to support the area it can result in malnourishment of the structures in that local area.  As a result, Kidney deficient patterns almost always involve lower back pain, whether it is the primary symptom or a minor symptom. 

            Lastly, chronic low back pain can be caused by trauma: bad posture over a long period of time while doing physical labour.  Examples could be lifting a heavy object, or suffering an injury from direct violence to the back.  Trauma affects the channels, collaterals, muscles, vessels and even the bones.  The injury is therefore at both the qi and blood levels.  Blood stasis can also occur when there is an invasion by Dampness, but only after a period of time.

Bibliography

Clavey, Steven. Fluid Physiology and Pathology in Traditional Chinese Medicine. Second Edition, Churchill Livingstone, 2003.

Sionneau, Phillipe, Gang, Lu. The Treatment of Disease in TCM: Diseases of the Urogenital System & Proctology. Boulder, CO: Blue Poppy press, 1999.

Wu, Yan, Fischer, Warren. Practical Therapeutics of Traditional Chinese Medicine.  Brookline, MS: Paradigm Publications, 1997.

Xuemei, Li, Jingyi, Zhao. Acupuncture Patterns & Practice. Seattle, WA: Eastland Press, 1993.

Yufang, Xi, Yulan, Xi. Acupuncture Treatment of 23 Cases of Acute Urethral Syndrome. Shanghai Journal of Acupuncture & Moxibustion. 9/25/1998; 22-23.

TCM Journal Article

Yufang, Xi, Yulan, Xi. Acupuncture Treatment of 23 Cases of Acute Urethral Syndrome. Shanghai Journal of Acupuncture & Moxibustion. 9/25/1998; 22-23.

46 patients with acute urethral syndrome were randomly divided into two groups and treated by acupuncture and oral western drugs.  23 cases of acute urethral syndrome had been treated by acupuncture and another 23 cases with oral western drugs.  After one course, the total effective rate was 100% cure in the acupuncture group and 70% cure in the western drug group.  It is therefore indicated that acupuncture is better than western drugs in the treatment of acute urethral syndrome.

Acupuncture group: Needles indicated: Si Shen Cong, flying method, manipulated every 5 minutes.  Patients asked to breath deeply and relax.  San Yin Jiao (Sp 6), 40 mm needle inserted bilaterally, lifting and thrusting, needle retained 30 minutes after the arrival of qi.  The treatment was once a day and one course consisted 3 days. 

Control Group: Valium was administered orally 2.5 mg each, 3 time a day, Oryzarol 20 mg each, 3 times a day, once course of treatment consisted of 3 days.

Summary:

Acute urethral syndrome, also called aseptic frequent urination syndrome or uncomfortable micturation syndrome, is defined as existence of uncomfortable micturation such as: urinary frequency and urinary urgency without existence of a urinary tract infection.  In most patients, these are partial symptoms of anxiety.  Traditional Chinese Medicine holds that kidney dominates water metabolism and controls urination and defecation.  If the Kidney-Qi is deficient, the urinary bladder will fail to transform Qi and urinary frequency and urinary incontinence will occur because urine is out of control.  The kidney dominates the bones to produce marrow that fills up the brain.  The brain is the sea of marrow.  The insufficiency of the Kidney-Qi will result in an insufficiency in the sea of marrow: amnesia and insomnia, which lead to more loss of the kidney essence.  The Kidney is manifested by fear.  It is stated in the Plain Questions Treatise on Pain, that fear causes collapse of Qi and fright causes disorders of qi.  If the functional activity in the Upper Jiao is obstructed and Qi and Blood stagnate in the lower jiao, the result is distention, urinary frequency, urinary urgency, uncomfortable urination, and urinary incontinence. 

According to the pathogenesis, Si Shen Cong was selected because it is a very good point for its tranquilizing effect.  The disease in the lower is treated in the upper.  Bilateral points San Yin Jiao (Sp 6), is a crossing point for the three yin channels of the foot and commonly used as a subsidiary point for urinary diseases to help the main point produce effects in tonifying the kidney and tranquilizing the mind and to bring about a good curative effect on acute urethral syndrome.

Biomedical Overview

Low back pain affects at least 80% of the general population at some time.  Back pain is the second most frequently reported reason for visiting a doctor.  The highest rate of back pain occurs in the 45 to 64 year age group, with a greater percentage of men experiencing low back pain. (National Health and Nutrition Examination Survey).  Fortunately, 90% of low back pain sufferers recover completely within 6 weeks.  However, 10% of patients who do not recover within a few weeks have low back pain that is painful, prolonged, costly, and frustrating. 

There are many structures in the low back that can cause severe low back pain, these include: muscles, ligaments, tendons, bones, facet joints, and discs.  From a biomedical point of view, low back pain can be a personal experience.  There are other factors, both physical and psychological, that contribute to a person’s experience of back pain. 

Low back pain is first treated by deciphering the type of pain that is most prevalent.  Following are different types of low back pain:

Low back pain for young adults (<60yrs.)

Leg pain and possible numbness: pain that radiates through the buttocks as well as pain and numbness that radiates down to the foot, frequently caused by a disc herniation in the lumbar spine.

Mechanical low back pain: caused by the movement (such as bending forward)—a syndrome called degenerative disc disease.  This condition can result from a twisting injury that weakens the disc.  The low back pain symptoms become chronic and may fluctuate at times.

Low back pain that worsens when walking: sometimes the vertebral body in the low back slips forward, causing stress to the disc, which in turn causes low back pain and may cause leg pain. 

Low Back Pain for older adults (>60 yrs.)

Low back pain worse in morning and evening, stiffness: Often caused by facet joint osteoarthritis, includes the breakdown of the cartilage between the facet joints in the back.  The pain results in the lack of cartilage in between the joints.

Pain down the legs when walking and standing upright: leg pain that occurs when walking, and increases with more walking, can be caused by conditions such as lumbar spinal stenosis, or degenerative spondylolisthesis.  Both conditions place pressure on the nerves at the point where they exit the bone.

Western medical doctors will diagnose low back pain with the following tests: X-Ray, Discography, Computerized tomography (CT), MRI, EMG (nerve conduction studies, and evoked potential studies), bone scans, Thermography, and Ultrasound imaging.

Most low back pain can be treated without surgery.  Treatment involves analgesics, reducing inflammation, restoring proper function and strength to the back, and preventing recurrence of the injury.  Compresses of ice and heat may help reduce pain and inflammation.  Bed rest is helpful up to 1-2 days at most.  However, most doctors recommend exercise as the primary way to both speed up recovery and help strengthen the back muscles.  Doctors provide a list of gentle exercises that help keep muscles moving.

The medications recommended are primarily to treat the pain and are a combination of over-the-counter drugs and prescription drugs.  Examples of over-the-counter drugs are non-steroidal anti-inflammatory drugs (aspirin, naproxen, and ibuprofen).  In addition, doctors may prescribe anticonvulsants, drugs primarily used to treat seizures and are useful in treating different types of nerve pain and antidepressants, which are effective for relieving pain.  Some examples of antidepressants are amitriptyline and desipramine, both relieve pain and assist with sleep.  Doctors may also prescribe opiods, such as codeine, oxycodone, hydrocodone, and morphine to manage severe acute and chronic low back pain.  Opiods should be used only for a short period. 

            For the most part, there is not a connective relationship with low back pain and urinary incontinence and the two syndromes would be treated as separate conditions.  The urinary condition would potentially fall under the category of benign prostatic hypertrophy – a condition of the prostate gland, causing varying degrees of bladder outlet obstruction (1999, Merck Manual Seventeenth Edition).

            However, some western medical doctors do acknowledge an apparent association of low back pain and urinary incontinence.  In 1994 a study was conducted to find out if there were any neurological mechanisms to explain the association of low back pain with urinary incontinence (1994 Eisenstein et al).  Results of the study showed that when surgery reduced low back pain successfully, the urgency incontinence was cured or improved.  However, the study could not prove any neurological basis for this.  The study concluded that although no neurological basis could be proven to support a relationship between low back pain and urinary incontinence, that this pathology should still be recognized.

Beers, Mark H. MD, Berkow, Robert, MD, editors.  The Merck Manual of Diagnosis & Therapy, Seventeenth Edition. Merck Research Laboratories: Whitehouse Station, NJ, 1999.

Eisenstein, SM, Engelbrecht DJ, el Masry WS. Low Back Pain and Urinary Incontinence.  A Hypothetical Relationship. Spine. 5/15/1994;19 (10):1148-52.

National Health and Nutrition Examination Survey III:

www.spineuniverse.com

National Institute of Neurological Disorders Government Health web page for low back pain fact sheet: www.ninds.nih.gov/health_and_medicine/pubs/back_pain.htm-72k-

Spine Health web page, a comprehensive resource for back pain:

www.spine_health.com

Two Articles on Complementary Medicine Therapies

Ernst, Edzard MD, PhD, Pittler, Max H., MD. Experts Opinion on Complementary/Alternative Therapies for Low back Pain. Journal of Manipulative & Physiological Therapeutics. 2/1999; 22: 87-90.

Summary: A computerized search strategy was designated to identify leading clinical experts on low back pain.  The questionnaire was piloted, revised, and posted to the group of experts.  It consisted of identical sets of questions for 5 different complementary/alternative medicine therapies: chiropractic, osteopathy, acupuncture, homeopathy, and herbalism.  The experts were asked to indicate their clinical experience with each therapy and were invited to rate the clinical effectiveness for the differing conditions of low back pain.

Results: For acute, uncomplicated low back pain, osteopathy and chiropractic were rated as effective by most experts.  For chronic, uncomplicated low back pain, most experts considered acupuncture as effective.  Experts perceived homeopathy generally as ineffective for any one type of low back pain.  Clinical experience with herbalism as a treatment for low back pain was insufficient to form an opinion. 

Palevitch, Dan, Earon, Gideon, and Levin, Israel. Treatment of Benign Prostatic Hypertrophy with Opuntia ficusindica (L.) Miller. International Journal of Alternative & Complementary Medicine. 9/1994: 21.

Summary: The prostate surrounds the neck of the bladder and the proximal portion of the urethra.  In middle-aged and older men, this organ is frequently enlarged, causing a condition known as benign prostatic hypertrophy, where the enlargement pressing on the urethra obstructs urination.  Clinical studies indicated that a dry flower preparation of the cactus Opuntia ficusindica (L.) Miller, commonly known as the Indian-fig prickly pear, improved the discomforts associated with benign prostatic hypertrophy.  The mode of action is not yet known. 

Remedies widely used are: fruit from saw palmetto (Serenoa repens), seeds from pumpkin (Curcubita pepo), vegetative tissue from horsetail (Equisetum arvense), and roots and fruit from parseley (Petroselinum crispum).  Urgenin (Madaus Internaitonal), a commercial preparation of Echinacea angustifolia and Serenoa repens, is a highly praised, natural remedy used to relieve prostatic problems and other urinary ailments. 

The results of this study showed that a subjective alleviation of discomforts with benign prostatic hypertrophy was noted by patients using Opuntia ficusindica.

Conclusion 

            I see this treatment approach as one of treating the branch first and the root second.  The branch is the urinary urgency and the low back aches.  The root is the patient’s constitution—a Kidney type in which the Kidney is deficient and the Heart is not harmonized. 

The focus of treatment was in ridding the Damp-Heat pathogen.  The consistent treatments helped resolve the urinary urgency and diminish the low backaches to specific stabbing pain.  At that point the approach focused on treating the blood stasis and qi stagnation by effective E-Stim treatments. 

Once the low back pain was under control, the focus shifted to treating the root:  Supplementing the Kidney and harmonizing the Heart.  Although the patient’s urinary urgency stopped at night, he was still waking up—thinking a lot at night.  It became apparent there was an underline issue of the Heart-Fire active mind and therefore a need to supplement and support the patient’s Kidney.  In addition, the patient had a history of Kidney issues, bone breaks, surgeries of the bones, balding hair, and ongoing malar flush.  

            I found it interesting how TCM sees the relationship with low back pain and urinary issues: the location of the Kidney points on the UB channel, Kidney’s role in controlling the water transformation function, and the Kidney supporting and nourishing the low back region.  For that reason, when a patient comes in with low back pain as a primary complaint, it is important to ask about their urination and to not necessarily think of this as a separate issue.  Interestingly, through my research I found that western biomedicine is not able to explain the relationship with low back pain and urinary incontinence.  However, most western doctors are aware to not rule this out:

A rare association between severe low back pain and urgency incontinence of urine, not explained on the basis of any conventional neurologic or genito-urinary pathology should be recognized.

(Low Back Pain and Urinary Incontinence.  A Hypothetical Relationship. Spine. 5/15/1994;19 (10):1148-52.)

Finally, I learned based on the statistics, that back pain is a major concern and we as practitioners should expect to see patients with this as a primary complaint.  By the time patients come to the TCM clinic, most have already tried many courses of treatment. Therefore, as practitioners, we should be well versed in the various types of treatment, including recommending qi gong exercises, as well as dietary recommendations, and lifestyle activities.