Acupuncture for Chronic Low Back Pain
Chief Complaint: chronic low back pain
Western Diagnosis: L5/S1 disc herniation s/p laminectomy
Medical History: Patient is 31 yr. old female with two year hx of low back pain as a result of a fall at work 9/99. Diagnosed with L5/S1 disc herniation and radiculopathy at same level. Laminectomy performed 5/00. 14 months later low back, bilateral leg pain and left foot numbness continues.
Questioning exam: Other medical history significant for daily headaches, irregular dizziness, poor appetite, insomnia and bi-polar disorder.
Pulse exam: Overall rapid – heart, kidney yin & yang pulses empty. Spleen pulse slippery and forceful.
right-sided subcostal tension with bilateral tenderness at ST 27 area along with CV 2-6 area. Several tender spots revealed in ow back area from L2 – S1 bilaterally.
right-sided auricular tenderness at kidney, shenmen, subcortex, neuro-sensorial & cerebral corresponding areas.
Tongue exam: body – pale with red raised ‘dots’ over much of body and tip of tongue, tongue tip slightly darker than body. Thin white coating.
OM Diagnosis: Local Qi/blood stagnation s/p traumatic injury and surgery. Kidney/Heart Yin deficiency based on pulse & tongue.
Treatment Principle: Move qi/blood locally, tonify kidney, calm spirit, cool heat
Point Prescription: Lu7 w/ Kd6
Li4 & 4.5 with San Char (opposite side)
Ht7, Kd 3
Bl 13, 14, 15, 17, 18, 20, 23, 31, 40, 60
Yintang, GV 14 – 11
(not all points used at same time)
Gua Sha at low & upper back
Moxibustion at low back
Herbal Formula: no herbs given/used
Aside: goal of patient was to come off of pain medication (neurontin & vicodin)
Lifestyle Prescription: Low back stretching
increase fluid intake
(patient was not willing to adjust diet)
Results: Following 3 months of treatment (2x/week) patient was complaining of occasional and mild pain locally, no lower extremity pain/numbness and was not using any pain medication. Her appetite has returned, she is sleeping a good 7 hours/night and denies having headaches. She is seen on an as needed basis currently.
Synopsis: Patient (and practitioner) are happy with her progress.