We asked three clinicians with diverse approaches to patient care to discuss the management of a patient who is experiencing low back pain. The participating clinicians were:

Patrick Downie, DC - Dr. Downie is a chiropractor in private practice in Chicago, Illinois and is Assistant Director of the CAM Education Program for Nurses at Rush University College of Nursing, Chicago, Illinois

James Foydel, MD - Dr. Foydel is a board-certified physiatrist in private practice in Wilmette, Illinois and is an instructor in the Department of Physical Medicine and Rehabilitation at Northwestern University.

Allison Quiring, MAc, LAc – Ms. Quiring is Instructor & Clinical Supervisor at the Pacific College of Oriental Medicine, Chicago, Illinois; Supervisor of Alternative Therapies, Chicago Health Outreach

Mr. Adams is a 24 year-old Caucasian male who presents for his regular blood pressure evaluation. During the visit, he complains that his 6-month old low back discomfort has become worse within the last few days. He is also requesting information on herbal muscle relaxants. The following H & P data are elicited:

Past Medical History:

4 years ago he injured his low back while lifting a sofa up several flights of stairs.

20-year history of asthma that has been successfully managed with bronchodilators and inhaled steroids.

3 year history of high blood pressure.

Lifestyle History:

Drinks occasional beer and hard liquor

Denies current or previous recreational drug use or tobacco use

Sedentary

Family History:

Father: age 60, diagnosed with type II diabetes mellitus

Paternal Grandfather: deceased age 85 from myocardial infarction secondary to HTN

Ventolin inhaler, as needed

Beclovent inhaler, as needed

Hydrochlorothiazide 50 mg qd

Height: 70 inches

Weight: 248 lbs.

Pulse: 98

BP: 128/98

All systems WNL except for the following findings:

+ mild tenderness lumbar paraspinal musculature
+ mild tenderness left lumbar facet joints

+ antalgic gait (he is leaning off to the left due to low back pain)

+ obese

Moderator: Ms. Quiring, how would you manage this patient using a Traditional Chinese Medicine (TCM) approach?

Ms. Quiring: I would begin by gathering information necessary for a TCM diagnosis. This includes taking the pulse and looking at the tongue, as well as a physical examination of the lines of energy (the channels or meridians where acupuncture points are located). The tongue and pulse help to give a picture of the patient's constitution and the nature of the problem – the temperature, the location, and the “substances” (energy, blood, fluids) involved.

In my clinical experience, a single acupuncture treatment can be effective for treating an acute exacerbation of low back pain, while a series of acupuncture treatments can reduce chronic pain. I may use points such as “yaotongxue” (literally, back pain point), which consists of two points between the metacarpals on the dorsum of the hand. I may also use Small Intestine 3 (also on the hand) and Bladder 62 (on the ankle). In TCM, organs are said to be energetically connected to particular lines of energy where points are located and needled. Though they generally correspond with Western names for organs, there is not a direct connection between them. Chronic back problems are often related to a deficiency in the Kidney energy, so I may treat the Kidney channel as well. Additionally, I would needle points near or at the site of pain. I have achieved excellent results with facet joint problems by needling the Bladder channel points and the Huotojiaji points (just lateral to the spinous processes of the vertebrae). I may also use a heat lamp or burn an herb called moxa (Artemisia vulgaris) above the skin. The treatment may end with physical manipulation, such as tui na (Chinese medical massage) or sotai (a Japanese physical therapy technique).

Moderator: Dr. Downie, your approach also involves physical manipulations. How would you manage this patient?

Dr. Downie: It appears that he has experienced an exacerbation of his problem, likely because it was never addressed after the first injury. His problem appears to be mechanical; however, a regional orthopedic and neurological examination must be performed to rule out serious disorders such as a lumbar disc herniation or hip injury. The key to an accurate diagnosis depends on being able to reproduce his pain. If it is not reproducible, then further diagnostic workup is required, and that usually means imaging, such as MRI to rule out a neoplastic or infectious process. If his pain is reproducible by mechanical means, and the structures can be directly palpated, then I would proceed. Since this appears to be the case, I would also examine his lumbopelvic coordination and muscle sequence patterns for deficits. Once it was determined that there were no contraindications to chiropractic manipulation, I would start Mr. Adams on an initial therapy of interferential current for the paraspinal musculature. It is theorized that the low frequency of the interferential current causes inhibition or habituation of the nervous system, which results in muscle relaxation and suppression of pain via mechanoreceptor activation.

Once the lumbar paraspinal muscle irritation was sufficiently reduced (otherwise the protective muscle splinting will prevent the intervertebral joints from being manipulated), I would proceed to a two-week trial of chiropractic manipulation to the affected lumbar facet joints. The manipulation restores intervertebral joint motion, activates the mechanoreceptors that inhibit pain locally at the spinal cord level and also higher cortical centers, and reduces the autonomic concomitants that can be present. If the pain persisted after the two-week trial, then I would consider a stronger intervention, such as facet joint injections. The goal is to reduce the pain in order to allow the patient to efficiently engage in rehabilitative efforts.

Dr. Foydel: My impression is that this appears, at least in part, to be an exacerbation of a longstanding problem. The chronicity of his present symptoms, six months in duration, is superimposed on the past history of a similar injury four years ago, while lifting. This timeline is very suspicious for a degenerated disc. The second point of concern is the 20-year history of steroid use as part of his long-term asthma management. Though he is still quite young, 24, and the steroids were delivered via an inhalation route, the potential exists for negative consequences of long-term corticosteroid use. The prevailing concern would be unwanted side effects on bone metabolism, specifically avascular necrosis of the femoral head and/or compression fractures of the lower lumbar vertebrae.

Three likely differential diagnoses need to be ruled out: central or laterally herniated disc, avascular necrosis of the femoral head, and chronic lumbo-sacral musculo-ligamentous or musculo-tendinous strain/sprain type injury. The most cost-effective workup here would be to obtain simple screening x-rays of the lumbo-sacral spine and bilateral hips and pelvis. If these proved negative, a MRI of the lumbo-sacral spine would be the next step.

In the event a herniated disc is diagnosed, it is important to note that 75% cases will resolve with conservative management alone within six to twelve months. A major goal is to achieve enough pain control to allow the patient to effectively engage in physical therapy. The usual treatment of thermal modalities, NSAID's, muscle relaxants, and mild narcotics will be successful in most patients. For those that prove resistant to this first line of intervention, a one to two week course of oral steroids can often be successful. If the pain persists, an epidural steroid injection can be administered.

Moderator: What supplemental therapies would each of you use in your management of this patient?

Ms. Quiring: I would talk with the patient about herbs and diet. Herbal medicine will be much more effective if he takes responsibility for his health through his diet. Considering his weight, his history of high blood pressure, his family history of diabetes, and his back pain, a change in diet is essential to his well-being. I may prescribe a formula, such as Shen Tong Zhu Yu Tang (Body Pain Eliminating Stagnation Decoction which is a combination of 10 herbs), that will help to move Blood and Qi in his back and reduce pain. I would also add Du Zhong (Eucommia) which lowers blood pressure and helps relieve back pain. Exercise is also a vital component of the patient's treatment plan. Depending on my findings from the physical exam, I would prescribe some simple exercises and stretches that will strengthen appropriate muscles and help relieve the back pain.

Dr. Downie: I would initiate an aggressive lumbopelvic core stabilization rehabilitative exercise program designed to support the spine and restore proper muscle activation sequences. A discussion of weight-loss and how excess weight can affect the lumbar spine, and predispose one to adult onset diabetes, should be incorporated. There are a host of adjunctive treatments that may be helpful. These include trigger point therapy, which is the application of pressure to an area of hyper-irritability in the muscles to reduce pain, and therapeutic ultrasound to decrease inflammation in the affected lumbar facet joints. There are also herbal preparations to reduce inflammation, but their application must be monitored to prevent any negative interaction with the prescription medication he is currently taking.

Dr. Foydel: Supplemental medications can be administered for sleep (Ambien, Restoril, etc.), constipation (peri-colace, etc.), and gastro-esophageal reflux (Nexium, Prilosec, Pepcid, etc.). In certain states of chronic pain, extrapolated pharmacology, (with drugs such as Neurontin, Elavil, Klonopin, etc.), can be employed, attacking the pain problem from multiple directions.

While there are multiple approaches in physical therapy available, they all have in common a goal of returning the spine to its normal curvature and alignment, and thus function. Neutral spine stabilization exercises are the overall summation of these various physical therapy efforts that are taught to the patient in an attempt to develop an individualized home exercise program (HEP). Compliance with HEP offers the best available assurance that further back injuries can be prevented and degenerative osteoarthritis held in check. For this patient, regular aerobic exercise to keep his weight under control (obesity being another obvious back pain risk factor) can also help ward off the diabetes his father developed.

• Back to Top •