As stated in the previous chapter, pain in TCM is due to the non-free flow of qi and/or blood. When the qi and blood flow freely, there is no pain. Therefore, it is essential to keep our qi and blood full and moving freely for optimal health and well-being and especially for being pain free.
The flow of qi and blood can become inhibited in any and every area of the body: the internal organs, the muscles, the joints, and the low back. For example, when we overeat and have acute indigestion with the accompanying sensations of abdominal fullness, bloating, and distention, these symptoms are due to the stagnation of stomach qi. In this case, the stomach qi cannot move freely through the excessive amount of food and drink in the stomach. Likewise, when we bruise ourselves and blood escapes from the blood vessels and then pools, we experience a mild form of blood stagnation. In both these cases the stagnation is not serious. We feel better within a short time and are free of symptoms when the qi and blood resume their proper functioning and are flowing freely.
According to TCM, the sensations of pain due to qi stagnation or blood stasis are different. Qi stagnation causes a feeling of distention or soreness that fluctuates in intensity and location. Qi stagnation pain often occurs with strong emotional changes. Blood stasis, on the other hand, is characterized by painful swelling or stabbing, sharp pain at a specific, fixed location.
It is also possible for the qi and blood flow to become inhibited because of insufficiency of the qi, blood, or both. In this case, the pain is not severe but is enduring. If due to qi and blood insufficiency, the pain is worse after rest and better after light use. This is because during rest or immoblization there is insufficient qi and blood to keep the qi and blood moving. Movement itself helps to pump the qi and blood through the area mobilized. Therefore, movement tends to make this type of pain better.
If primarily due to qi insufficiency, then the pain is worse at the end of the day or after excessive exercise. In this case use or exercise has used up the qi and left it even more deficient. Blood insufficiency pain tends to be worse at night after it has been consumed by the activities of the day and when it returns to the liver for storage.
In the TCM diagnosis and treatment of low back pain, a practitioner must answer the following questions:
- Is the pain due to blockage or insufficiency?
- If due to blockage, is the pain more characteristic of qi stagnation or blood stasis?
- What is causing this stagnation?
- What channels or network vessels are primarily involved?
The answers to these questions directly determine what sort of treatment the patient will receive from the Chinese medical practitioner. The basic principle of treatment in Chinese medicine is to restore balance. Therefore, the Nei Jing (Inner Classic) says that if a disease is due to too much, it should be drained; if due to too little, it should be supplemented; if due to heat, it should be cooled; if due to cold, it should be warmed; if due to dryness, it should be moistened; and if due to dampness, it should be dried. Therefore, in TCM, two patients with the same Western medical disease may receive different TCM treatment because the cause of their disease is different. This means that every patient in TCM is given an individualized treatment based on the cause and nature of their particular pattern of disharmony.
The Causes of Low Back Pain
In Chinese medicine, there are three broad categories of causes of low back pain. These are referred to as external causes, internal causes, and independent causes. External causes refer to invasion by the six environmental excesses, while internal causes refer to damage by the seven passions or emotions. In terms of low back pain, the so-called independent causes are traumatic injury, dietary imbalance, insufficient exercise, overtaxation, undisciplined sex, and drug abuse.
External Causes of Low Back Pain
According to Chinese medicine, our qi and blood flow can be affected by invasion of energies from the external environment. These energies are wind, cold, dampness, heat, dryness, and summerheat. As mentioned above, one of the five functions of qi is to protect the body from invasion by these environmental energies. If the defensive qi is weak, environmental energy(s) can invade the body, settling into the channels, and block the flow of qi and blood in those channels. According to some Chinese doctors, such invasion by external energies can only occur if the defensive qi is deficient.
Invasion by these kinds of external energy usually involves at least two kinds of environmental energy. In other words, they do not usually invade the body singly but rather in pairs or triplets. For instance, wind often combines with heat, cold, and/or dampness. When these energies invade the upper body, we typically come down with a cold or flu. But when they invade the low back, we may get acute low back pain.
Each environmental energy has a unique set of signs, symptoms, and pain sensations that appear when they lodge in the body and cause acute low back pain. Four of the six environmental energies may cause or be involved in external invasion low back pain.
Wind is usually the primary environmental energy to invade the body, while the other environmental energies are typically carried by this wind. Wind refers to any unseen pathogenic factor invading the body from outside. However, it also describes the pattern of the complaint it creates. Pain due to wind comes and goes. It moves around the body just as wind moves about the earth, affecting one joint and then another. Wind blocks the qi, so the pain is achy.
When cold settles into the channels, the pain tends to be in a fixed location and is sharp and severe. Cold congeals the flow of blood, thus resulting in blood stasis. Pain due to cold gets worse with cold and feels better with warmth.
Dampness has a fixed nature like cold. However, the pain due to dampness is a heavy, sore type of pain. It is never sharp or acute. Unlike low back pain due to wind and cold which come on quickly, dampness tends to develop slowly and have a more chronic nature. When dampness becomes lodged in the channels, changes in the weather and especially low pressure can often make the pain worse. Dampness can also involve swelling which is a sign of too much fluid accumulation.
Heat type pain involves redness, swelling, and hot sensations, especially of the joints. Pain due to heat can be the result of the invasion of heat directly into the body. However, in terms of rheumatic pain complaints, it is more commonly the result of long-standing dampness or cold that has transformed into heat.
Low back pain due to the invasion of environmental energies most commonly involves the combination of wind, cold, and dampness or occasionally the combination of wind, dampness, and heat. As stated previously, these energies can only invade the body if the defensive qi is weak. If there is no weakness in the kidneys or liver, then the invasion will be short-lived and the person will have an acute case of low back pain. However, if the kidneys and liver are weak, then the invading energies can settle into the low back causing chronic low back pain.
Internal Causes of Low Back Pain
In TCM, internal causes refer specifically and only to damage by the seven passions or emotions. This is not a major, primary cause of back pain. Liver depression due to stress and frustration may cause sciatica and sacroiliac pain due to the liver qi’s relationship with the gallbladder channel which traverses this area. However, once back pain has been caused, emotional dis-ease may exacerbate and prolong it. Liver depression, qi stagnation will add to or aggravate any condition in the body where the free and smooth flow of the qi and blood has been affected.
It is also possible for emotional damage to create the environment in which either trauma or invasion by external environmental energies actually results in back pain. For instance, constant fear may damage the kidneys leaving the low back area weak. Thus the person may injure their back by a seemingly harmless movement. Or constant worry may damage the spleen. Since the spleen transforms the blood, spleen deficiency may result in blood insuffiency. Hence the sinews may not be nourished and may be chronically tense and tight. Or the muscles may not have sufficient qi, i.e., strength, to do their job without injury.
Independent Causes of Low Back Pain
This group of disease causing agents may seem inappropriately named to Westerners. After all, isn’t diet something we take in from the outside and isn’t trauma something that occurs to us from the outside? The fact that diet, exercise, overtaxation, trauma, and poisoning are all considered independent causes points up the fact that, as a system, Chinese medicine has its own internal logic which has nothing to do with modern Western medicine nor with our ordinary use of English words.
1. Traumatic Injury
The first of these independent causes of low back pain is traumatic injury. Traumatic injury to the low back is a major health problem. Trauma results in damage and even severance of the channels and network vessels. This allows the blood to flow outside its vessels and pool. Because the qi follows the blood, it also pools. This pooling of non-free flowing qi and blood results in heat, swelling, redness, and pain. The more serious the trauma, the more serious the stagnation of qi and blood.
Trauma to the low back ranges from mild to severe. Any or all the tissues comprising the low back may be involved. The least serious and easiest to heal injuries are to the muscles and tendons. The more serious injuries involve certain ligaments, the vertebral body and joints, and the disc. The most serious problem is trauma to the spinal cord.
In TCM, it is important to identify which tissues have been injured. There are specific medicinals which heal specific tissues. For instance, one would use different herbs to treat muscle trauma from those used to treat trauma to the vertebral body. However, the guiding principle for all traumatic low back injuries is to get the qi and blood flowing freely as soon as possible. It is essential to get the qi and blood moving for two reasons. First, when the qi and blood flow, there is less or no pain. Secondly, the longer the qi and blood stagnate, the more complicated the recovery becomes.
When the qi and blood stagnate in the low back, the defensive qi cannot operate effectively. When the defensive qi is not operating at full strength, wind, cold, and dampness can easily invade. If the qi and blood stagnation continues and wind, cold, and dampness have settled into the low back, the kidneys and liver will eventually be affected and begin to weaken. When the kidneys and liver weaken, the low back becomes weaker because these organs are the mainstays of its strength. As this scenario progresses, the low back becomes even more susceptible to further invasions of wind, cold, and dampness. This is how chronic low back pain develops from trauma injury according to TCM.
2. Poor Diet
According to Chinese medicine, the spleen is the organ in charge of digestion. It is the spleen qi which transforms and transports the food and drink ingested. If, through overeating sweets and fatty foods, raw, chilled foods, and drinking excessive chilled beverages with meals, the spleen is damaged, it may fail to transform and transport liquids and these may accumulate to become internally generated dampness. Because dampness is yin, it tends to percolate downward in the body to lodge in the lower half of the body, including the low back. There it obstructs and hinders the flow of qi and blood. Commonly, such internally generated dampness transforms into heat and thus gives rise to damp heat mutually stagnating with the qi and blood.
According to a set of theories developed in China around the time of Genghis Khan, dampness percolating downward from the spleen can damage both the liver and the kidneys, and we have seen above how important the liver and kidneys are to the health of the low back.
Spleen deficiency with internal dampness also results in the creation of adipose tissue or fat. Fat in TCM is nothing more than accumulated dampness. This dampness not only hinders the flow of qi and blood but puts more strain on the restraining, lifting, and moving functions of the spleen qi. As the spleen becomes weak, the muscles and flesh, which are the level of tissue corresponding to the spleen, lose their tone and eventually their function. In addition, because the spleen is the root of qi and blood production, if the spleen becomes damaged due to faulty diet, this may lead to qi and blood deficiency as well.
3. Rest & Activity
Rest, or literally stillness, and activity, or literally stirring, are a yin/ yang complementary pair in Chinese medicine. In TCM, it is believed that too much rest damages the spleen, and we have seen above that a weak spleen may lead to muscular weakness and the generation of dampness, both of which may cause or be involved with low back pain. On the other hand, regular exercise leads to improved digestion, and good digestion leads to the creation of the acquired essence, the essence that bolsters the prenatal essence stored in the kidneys. Therefore, regular, moderate exercise indirectly helps generate essence, while lack of exercise does not.
Conversely, excessive exercise or any excessive activity, be it physical or mental/emotional, may eventually damage the kidneys. In particular, it is said in Chinese medicine that lifting objects which are beyond one’s strength damages the kidneys.
4. Excessive Sex
We have seen above that the kidney essence is associated with reproduction. In men, the seminal fluid is seen as the physical manifestation of essence and is, in fact, called jing or essence in Chinese. In addition, sexual desire is a function and manifestation of kidney yang, while sexual fluids, such as seminal fluid in men, are a manifestation of kidney yin. In Chinese medicine, it is believed that a healthy, moderate amount of sex helps free the flow of qi and relieves pent-up emotions. On the other hand, excessive sex can quickly deplete the qi and blood and particuarly kidney essence. Since essence declines with age, concern over too much sex causing low back pain mostly affects those over 45. However, depending upon constitutional predisposition or chronic disease, one may have to be cautious about this factor even earlier.
5. Drug Abuse
Many, if not most, of the drugs which people abuse are stimulants. According to Chinese medicine, substances like cocaine, amphetamines, marijuana, LSD, and even caffiene and nicotine use up large amounts of qi in their production of a “high,” “buzz,” or “rush”. We say that they give us energy, but that energy has to come from someplace. Where that energy comes from is the kidneys, our deepest repository of essence and qi. These drugs use this energy and eventually use it up. This then can cause signs and symptoms of kidney deficiency and essence insufficiency accompanied by low back pain.
Age is not considered one of the traditional disease causes in Chinese medicine. However, after 35 years of age, our production of essence from the food we eat, liquids we drink, and air we breathe decreases. This means that after this age, we are producing less of the acquired essence and are consequently using more inherited essence. Thus it is not uncommon to encounter chronic low back pain as a symptom of aging. In particular, spinal problems such as degenerative disc disease, herniated discs, osteoporosis, osteoarthritis, chronic lumbago, vertebral fractures, chronic lumbar strain, spinal spurs, etc. are often kidney-related problems associated with aging. Therefore, the TCM treatment of these spinal problems is directed, in part, at strengthening the kidneys.
Weakness or other problems in the internal organs that lead to low back pain tend to develop slowly. However, it is possible and, in fact, common to have acute low back pain in conjunction with a weakness of an internal organ. For example, a person with a kidney weakness can also have an invasion of wind, cold, and/or dampness in the low back. Hence it is common to find that in any given patient with low back pain, there is a combination of causes at work, some internal, some external, and some, according to the terminology of Chinese medicine, due to neither internal nor external causes.
“…the theory of TCM about the cause of low back pain is a multifaceted one which takes into account all aspects of a person’s life—physical, mental, emotional, and even sexual.”
In describing the causes of low back pain, Chinese medicine starts from the simple premise that there is no pain if the qi and blood are flowing freely without inhibition. It then goes on to describe a number of specific causes and contributors to low back pain, all of which cause some detriment and damage to the free flow of qi and blood in the area of the low back. These range from physical trauma and diet to emotional stress and overexertion. Thus the theory of TCM about the cause of low back pain is a multifaceted one which takes into account all aspects of a person’s life—physical, mental, emotional, and even sexual. This again underscores the holistic vision of Chinese medicine which cannot reduce a person’s pain to a single piece of bone, muscle, or connective tissue
Honora Lee Wolfe
In TCM, treatment is given on the basis of the patient’s pattern and not simply on the basis of their named disease. A TCM pattern takes into account all the signs and symptoms of the disease plus all the patient’s other, seemingly unrelated signs and symptoms and the Chinese description of the cause of their condition. Therefore, all the person’s symptoms are noteworthy, not just the one’s that are specific to their major complaint. In fact, the TCM practitioner gathers so much information, the patient may not see the relevance of it all. And certainly the TCM practitioner takes much more time to ask questions about all aspects of the persons life than the typical Western M.D.
As we have seen in the previous chapter, kidney weakness can cause low back pain. However, in TCM, there are a number of different patterns of kidney weakness. There is kidney yang deficiency, kidney yin deficiency, kidney essence insufficiency, kidney qi not securing, spleen/kidney deficiency, liver/kidney deficiency, and lung/kidney deficiency. The symptoms of each of these separate patterns of kidney weakness are different although each will be accompanied by some sort of low back pain. Therefore, we need to know if a person is feeling cold or hot, dry or thirsty, if they are swollen with edema, what is the consistency of their stools, and the color and amount of their urine. By obtaining all the person’s signs and symptoms, the practitioner can then begin to determine if the low back pain is due to kidney yin weakness, kidney yang weakness, or kidney essence insufficiency.
How TCM Patterns are Determined
How does a Chinese medical practitioner go about determining the pattern of illness that is causing low back pain? First, the practitioner must have a good understanding of the theories of Chinese medicine. This includes an in-depth knowledge of qi and blood, organs and bowels, channels and network vessels, and yin and yang and how these interconnect and interact. Secondly, the practitioner must understand how illness develops and how injury affects the body. Third, the patterns of illness that develop due to external invasion, internal damage, or injury must be understood and discriminated. Keeping all of this theoretical information in mind, the practitioner then obtains information from the patient.
The Four Examinations
Since before the time of Christ, Chinese medical practitioners have used what are called the four examinations for obtaining information about a patient’s condition. These four examinations are 1) looking, 2) listening/smelling, 3) asking, and 4) palpation or touching.
Looking examination focuses on what the practitioner can see with their unaided eyes (except for normal corrective lens). Everything about the patient that can be observed can be useful. This includes their facial expression, the brightness of their eyes, facial complexion, bodily constitution, posture, and way of moving, inspection of the affected area, and examination of the tongue and its coating.
In particular, tongue diagnosis is a highly developed skill in Chinese medicine and a major source of information about a patient’s condition. Both the tongue itself and its coating are indicators of the person’s condition. For example, a thick, slimy, yellow tongue coating indicates the presence of damp heat, while a shiny, red tongue without a coating indicates a weakness of yin.
2. Listening and Smelling
Listening and smelling are the second type of examination in Chinese medicine. The character in the Chinese language for this examination means both listening and smelling. The practitioner listens to the patient’s breathing, the quality of their voice, or other sounds, such as a cough. For example, a person with a weak voice who coughs when active may have weak qi. Body odors and the smells of any excretions also give the practitioner useful information about the patient’s pattern.
Questioning the patient orally is the third method of examination. These questions include when and how the problem happened, how long it has gone on, what treatment has already been given and with what results, one’s medical history in general, sensations of cold and heat, the location and quality of pain, descriptions of urination and bowel movements, sleep patterns, perspiration, headaches, dizziness, appetite, thirst, digestive disturbances, energy level, gynecological problems, and more. Because the sensation of pain due to stagnation of qi and blood differ as do the pain and aching due to the various types of external environmental energies, the patient’s description of their pain is critical in determining what type of stagnation or blockage pattern exists.
The last examination method is palpation or touching. Many practitioners consider this the most important of the four methods. Only by touching various areas of the body can the practitioner directly know the condition of the body and its internal organs.
The most important aspect of this method is feeling the pulse. Together with the information gained from examining the tongue, taking the pulse is central to Chinese medical diagnosis. Pulse diagnosis requires great skill and sensitivity. The pulse taken at the wrist provides information about the basic state of the person’s qi and blood, yin and yang, organs and bowels, and pathogenic factors. There are 28 different standard pulse qualities described in the classical literature. For example, the pulse quality most often felt in someone in pain is classified as tight. This pulse is described as “strong and bounces from side to side like a taut rope.”
Thus by gathering information through the four examinations and by comparing the patient’s signs and symptoms with their tongue and pulse, the patient’s pattern is understood and named. The name of the pattern describes an inherent state of imbalance. For instance, kidney yin insufficiency means that kidney yin is too weak. Therefore, the next step is creating a treatment plan which will correct the imbalance implied in the name of the pattern. If there is kidney yin deficiency, the kidneys should be supplemented and yin should be nourished or enriched. Hence treatment techniques are applied to bring about this result – the return to balance and, therefore, health.
Because treatment in Chinese medicine is based on the patient’s pattern as much as or even more than their disease, treatment is individual and takes into account the whole person. In Chinese medicine, it is said,
“One disease, different treatments; different disease, same treatment.”
This means, for example, that a patient with low back pain due to invasion by wind, cold, and dampness will receive a completely different treatment from a patient with low back pain due to kidney yin defiency. While both patients could have the identical Western medical diagnosis, each would have two totally different patterns of disharmony from the TCM point of view and each would be treated according to their pattern.
It is because TCM treatments are based upon identifying the individuals’ unique pattern that Chinese medicine causes no side effects or other medically induced problems when properly prescribed. Side effects are themselves symptoms of imbalance, and Chinese medicine seeks to bring the entire person back into a pattern of balance and good health. Thus it is treatment based on pattern discrimination which allows the Chinese medical practitioner to choose just the right treatment for each individual patient.
This article is excerpted from a book titled Low Back Pain: Care & Prevention with Traditional Chinese Medicine by Douglas Frank, ISBN 0-936185-66-X, $9.95, from Blue Poppy Press.