MEDICAL ACUPUNCTURE
Volume 29, Number 6, 2017
# Mary Ann Liebert, Inc.
DOI: 10.1089/acu.2017.29068.cpl
How Do You Treat Back Pain in Your Practice? Part 1
A natomical classifications of back pain include cer-
vical, thoracic, lumbosacral, and coccygeal parts of
the spine; this Pearl deals with lumbosacral pain (also known
as low-back pain [LBP]), which is the commonest.1 In the
United States, LBP is the fifth most common reason for
physician visits and causes 40% of missed days from work.1
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In industrialized countries, 70% of adults suffer from LBP in
their lifetimes.2 Economic burden in the United States due to
LBP has been estimated to be $100 billion per year.3
Mechanical back pain typically comes on suddenly, and
the cause, such as lifting, is identified easily. This pain can
also occur gradually, particularly due to adopting a fixed
posture. Pain lasting for more than 3 months is considered to
be chronic back pain.4 Apart from local tenderness, physical
examination findings are usually normal. There can be
limitation of movements. ‘‘Red flags’’ that call for investi-
gations include:
 Possible fracture
 Major trauma
 Minor trauma in osteoporotic or elderly patients
 Possible tumor/infection
 Age <20 or >50 years
 History of cancer
 Fever, weight loss
 Intravenous drug use
 Immune suppression
 Pain worse at night or while lying down
 Recent bacterial infection.
Medical Acupuncture is pleased to continue this regular fea-
ture, Clinical Pearls, which we have found to be very useful for,
and practical to, the readership, and very popular. All of us are
confronted with clinical challenges, especially when dealing with
therapeutic strategies. We hope this ongoing collection of Clinical
Pearls will be easily accessible and ready to put into action for the
benefit of our patients, and even ourselves. How often do we ask
our colleagues: ‘‘How do you treat.?’’ This time, we posed the
question: ‘‘How do you treat Back Pain in your practice?’’
Herein lie your contributions. We trust that our readership will
continue to participate in this section by either asking the ques-
tions or supplying the ‘‘Pearls.’’ If you have a ‘‘question’’ you
would like to see answered, please send it to our managing editor,
Yael Ben-Porat, at: yaelbenporat@me.com We encourage and
welcome your input and participation. Please address your an-
swers to ‘‘Pearls’’ to our managing editor, Yael Ben-Porat, at:
yaelbenporat@me.com
411
CLINICAL PEARLS
Look for a neurologic disorder if there is bladder or
bowel dysfunction, or for any neurologic deficit noted on
physical examination.
LBP is a symptom rather than a diagnosis and covers a
variety of heterogeneous conditions. Herein, the discussion
is restricted to LBP that is not associated with serious or
potentially serious disorders. In cases of mechanical back
pain, simple analgesics, advice regarding posture, lifting
techniques, and physiotherapy can suffice. Acute LBP is
usually self-limiting, but 30% of patients will not have re-
covered fully at 6 months, and two-thirds of patients will
have recurrence of their pain within 2 years.5 These patients
are often dissatisfied with the results of conventional treat-
ments and turn to complementary therapies, which include
acupuncture as an alternative option.6
Back Pain in Chinese Medicine
Acute LBP is either due to a sprain or an invasion of Cold.
In a sprain, there is Stagnation of Qi followed by Stagnation
of Blood. The pain is intense, with marked stiffness that is
reduced by rest and aggravated by movement. If the pain is
due to an invasion of Cold, the pain is worse with rest, worse
in the morning, and reduced with gentle movement.
In chronic backache, there is usually Kidney Deficiency
(either a Yin or Yang Deficiency), in which case the pain is
alleviated by rest and aggravated by work and excessive sexual
activity. In most cases of chronic back pain, there is a com-
bination of the above three factors, leading to periodic attacks.
Pain extending from the lower back to the upper back is
due to additional Liver Qi Stagnation. This is not discussed
further in this Pearl. In Kidney Yang Deficiency, the back-
ache is associated with a lack of libido and a generalized
feeling of coldness. In Kidney Yin Deficiency, the LBP is
associated with excessive sexual desire, premature ejacu-
lation, a feeling of heat, and night sweats.
Treatment
The current author uses three Extra meridians to treat LBP:
(1) Governing Vessel for midline pain, according to its
trajectory—Reduce SI 3 and BL 62 in that order to
open the GV Vessel. Reinforce GV 1 and GV 26 to
facilitate the movement of Qi in the GV Channel.
Also reduce all Ashi points.
 412
(2) Yang Heel Vessel for pain in the paraspinal area on
each side due to its connection with the Bladder
Channel—Reduce BL 62 and SI 3 in that order to
open this channel. Reinforce BL 67 to facilitate the
movement of Qi in the Bladder channel. Also reduce
all Ashi points. Reduce BL 40 in acute cases; for
chronic LBP, BL 60 is better.
(3) Girdle Vessel for back pain that extends horizontally,
according to its trajectory—Disperse GB 41 and TE 5
in that order to open the Girdle Vessel. Reinforce GB
26, and reduce GB 27 and GB 28 to facilitate the flow of
Qi in that channel. Reduce all Ashi points, and GB 40
and BL 40 in acute cases, and BL 60 in chronic cases.
A detailed description of the various Extra meridians and
their clinical uses can be found in an earlier issue of this
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Journal.7
Look specifically for tenderness in BL 25, BL 26, BL 52,
BL 36, BL 37, Tunzhong Extra Point (immediately lateral to
BL 54), and Shiqizhuixia (in the midline below the tip of L-5),
and reduce them. Then:
 Reduce HT 7 to relieve muscle spasm
 Reduce SP 3 if there is scoliosis
 Reinforce BL 23 and KI 3 for Kidney Yin Deficiency;
or BL 23 and KI 7 for Kidney Yang Deficiency
 Reinforce LR 8 to nourish the Liver, as it controls the
ligaments
 Reinforce BL 11 and GB 39 to nourish the bones and joints.
Chinese Herbs recommended are:
 Stagnation of QI and Blood (sprain)—Body Pain
Eliminating Stasis Decoction
 Invasion of Cold and Dampness—Kidney warming
decoction
 Kidney Deficiency—Restoring the Right Kidney pill
(for Yang Deficiency) or Restoring the Left Kidney pill
(for Yin Deficiency).
Also use the following auricular points if needed: Lum-
bosacral spine on concha ridge; Lumbar Spine phase III on
the tragus; Thalamus point; Point Zero; Shen Men; Darwin’s
point; Muscle Relaxation point, Adrenal Gland C, and
Bladder. Choose according to tenderness.
Evidence for Acupuncture
1. LBP was reduced after acupuncture for at least 6 months
in a study involving 1162 patients. The response rates
were: 47.6% in the verum acupuncture group; 44.2%
in the sham acupuncture group; and 27.4% in the con-
ventional therapy group.8
2. Acupuncture was more effective for relieving pain
than no acupuncture in a study involving 298 patients,
but there were no significant differences between acu-
puncture and minimal acupuncture (performed in non-
acupuncture points).9
CLINICAL PEARLS
3. A systematic review of acupuncture for acute LBP
showed that verum acupuncture was more effective
than medications or sham acupuncture for relieving
pain, but not for improvement of function.10 This is
hard to comprehend; relief of pain, logically, should
have some favorable effect on function.
4. For chronic LBP, consistent evidence showed that
acupuncture was more effective than no treatment or
conventional treatment for both pain relief and func-
tional improvement at a short-term follow up.11
5. Acupuncture was found to be more effective than
physiotherapy for LBP during pregnancy.12
6. Long-term pain relief of LBP was greater in patients
receiving acupuncture, compared with true placebo
(mock transcutaneous electrical nerve stimulation).13
7. Significant reduction of LBP (P < 0.05 to P < 0.01) was
noticed at 6 weeks and 6 months in patients receiving
acupuncture using low-frequency electrical stimulation
(2 Hz) but not in patients receiving high-frequency
stimulation.14
8. Continuous electrical stimulation of auricular acu-
puncture points produced significant pain relief in
patients with LBP, compared with those receiving
conventional auricular acupuncture without electrical
stimulation.15
9. Probabilistic sensitivity analysis showed acupuncture
to have more than a 90% chance of being cost-effective.16
Illustrative Case
A 64-year-old woman presented with recurrent LBP
following a motor-car accident that had occurred 26 years
prior. Her pain was localized to the midline and radiated to
both sides. There was no evidence of sciatica. Rest relieved
the pain. She had mild obesity, and her tongue was red and
dry. Apart from these signs, there were no other abnormal
physical signs.
In chronic LBP, there is almost always a Kidney Defi-
ciency and, in this case, this was Kidney Yin Deficiency, as
indicated by the patient’s dry red tongue. (There is a moist
pale tongue in Yang Deficiency). The traffic accident would
have produced Blood Stagnation. The points used to address
her condition were:
 SI 3 right and BL 62 left, in that order, to open the
Governing Vessel to address the midline pain
 GB 41 right and TE 5 left, in that order, to open the
Girdle Vessel to address the lateral extension of pain
(in men the side would be reversed)
 All Ashi points including Shiqizhuxia.
All of the above points were reduced. KI 3, KI 4, CV 4,
and BL 23 were reinforced to address the Kidney Yin De-
ficiency.
Treatment was given twice per week for 6 weeks. Spinal
mobilization and Antimonium tartaricum in a homeopathic
 CLINICAL PEARLS
dilution of 30c were given twice a week to support acu-
puncture, with a view toward reducing the frequency and
duration of acupuncture. This trio has consistently helped
me to treat almost all cases of LBP successfully, except
those of patients with gross structural abnormalities. The
current patient had near-total relief of symptoms.
In chronic cases, recurrence is always a possibility, and
that would require additional short-term treatment.
REFERENCES
1. Manchikanti L, Singh V, Datta S, Cohen SP, Hirsch JA;
American Society of Interventional Pain Physicians. Com-
prehensive review of epidemiology, scope, and impact of
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spinal pain. Pain Physician. 2009;12(4):E35–E70.
2. Andersson GB. Epidemiological features of chronic low back
pain. Lancet. 1999;354(9178):581–585.
3. Katz JN. Lumbar disc disorders and low back pain: Socio-
economic factors and consequences. J Bone Joint Surg Am.
2006;88(suppl2):21–24.
4. Last AR, Hulbert K. Chronic low back pain: Evaluation and
management. Am Fam Physician. 2009;79(12):1067–1074.
5. Casazza BA. Diagnosis and treatment of acute low back pain.
Am Fam Physician. 2012;85(4):343–350.
6. Santaguida PL, Gross A, Busse J, Gagnier J, Walker K,
Bhandari M, Raina P. Complementary and alternative medi-
cine in back pain utilization report. Evid Rep/Technol Assess
(Full Rep). 2009;(177):1–221.
7. Sudhakaran P. Extra meridians—a simple practical approach.
Med Acupunct. 2013;25(5):336–342.
8. Haake M, Müller HH, Schade–Brittinger C, et al. German
acupuncture trials (GERAC) for chronic low back pain:
Randomized, multicenter, blinded, parallel group trial with 3
groups. Arch Intern Med. 2007;167(17):1892–1898;erratum:
Arch Intern Med. 2007;167(19):2072.
9. Brinkhaus B, Witt CM, Jena S, et al. Acupuncture in patients
with chronic low back pain: A randomized controlled trial.
Arch Intern Med. 2006;166(4):450–457.
10. Lee JH, Choi TY, Lee MS, Lee H, Shin BC, Lee H. Acu-
puncture for acute low back pain: A systematic review. Clin J
Pain. 2013;29(2):172–185.
11. Liu L, Skinner M, McDonough S, Mabire L, Baxter GD.
Acupuncture for low back pain: An overview of systematic
reviews. Evid Based Complement Alternat Med. 2015;2015:
328196.
12. Wedenberg K, Moen B, Norling A. A prospective randomized
study comparing acupuncture with physiotherapy for low
back pain and pelvic pain in pregnancy. Acta Obstet Gynecol
Scand. 2000;79(5):331–335.
13. Carlsson CP, Sjölund BH. Acupuncture for chronic low back
pain: A randomized placebo-controlled study with long-term
follow-up. Clin J Pain. 2001;17(4):296–305.
14. Thomas M, Lundberg T. Importance of modes of acupuncture
in the treatment of chronic nociceptive low back pain. Acta
Anaesthesiol Scand. 1994;38(1):63–69.
15. Sator-Katzenschlager SM, Scharbert G, Kozek-Langenecker
SA, et al. The short- and long-term benefit in chronic low
413
back pain through adjuvant electrical versus manual auricular
acupuncture. Anesth Analg. 2004;98(5):1359–1364.
16. Ratcliffe J, Thomas KJ, MacPherson H, Brazier J. A rando-
mised controlled trial of acupuncture care for persistent low
back pain: Cost effectiveness analysis. BMJ. 2006;333(7569):
626.
Address correspondence to:
Poovadan Sudhakaran, MBBS, PhD
MastACU, MastTCM
26 Tuckers Road,
Templestowe, 3106
Australia
E-mail: dr.p.sudhakaran@gmail.com
M ajor German and British investigations involving
more than 12,000 patients have demonstrated be-
yond a reasonable doubt that acupuncture treatment provi-
des cost-effective, long-term benefit in chronic low-back
pain (LBP).1–3 These were pragmatic studies, allowing acu-
puncturists to follow their own preferences for techniques,
and to adapt the points used to suit individual patients. How-
ever, a review of needling practices using either a Chinese
traditional approach or Western neuroanatomical principles
showed a substantial similarity in point selections, mainly
based on Bladder and Gall Bladder points.4 An audit of
patients referred to my hospital pain clinic with severe, in-
tractable back pain showed a 63% short-term response, with
40% having longer-term clinical benefit.5 This is compara-
ble to other published audits.
As there are *30 traditional points in the low-back area,
I look first to needle those that are tender to palpation, plus
any additional muscle trigger points. The trigger points can
be associated with a muscle cord that will flick under a finger,
but, more usually in LBP, there are tender fibrositic nodules
in muscle that I needle directly. These nodules contain water-
retaining mucopolysaccharide.6 Stimulating them with the
acupuncture needle can sometimes cause the fluid to disperse,
reducing the pressure and relieving the pain.
Commonly, I find tenderness at dimples over the sacro-
iliac joints (BL 27) and in muscle under the iliac crest. But,
even if these points are not tender, I like to needle them any-
way. Also, I routinely palpate the paravertebral muscles, gi-
ven that primary trigger points might be found there,
particularly if the back pain has been caused by strain from
lifting, prolonged bending, or intervertebral disc problems,
and these muscles could additionally be the cause of referred
pain into the buttock, where satellite trigger points then refer
pain down the side of the leg. I often find tenderness all the
way down the Gall Bladder meridian in the tensor fascia lata.
I needle a selection of these tender points plus GB 34.5
Patients complaining of hip pain can, in fact, have their pain
referred from low-back pathology, particularly from gluteal-
 414
muscle trigger points. Thus, deep palpation of the buttock is
necessary. For sciatica, I needle a tender point over the sciatic
nerve in the upper, inner quadrant of the buttock (BL 54), plus
BL 60 at the distal end of the nerve.
An unusual method that I have found helpful is to use what
has been termed ‘‘sacral flats.’’ This involves inserting a pair of
longer needles just superior to the sacral hiatus, and feeding
them horizontally under the skin, to lie over the sacral foramina
(BL 34, BL 33, BL 32, and BL 31) on each side of the sacrum.7
So far, my approach has been with the patient lying face
down, so that I can treat points on the back and legs. If, how-
ever, there has been little response after a couple of sessions,
I inspect the patient’s lower abdomen for surgical scars or
tenderness that might be referring pain into the back.8 I have
relieved back pain several times through needling tender areas
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associated with cesarean sections. Alternative causes of back
pain must not be forgotten. I had a referral from a trusted
colleague and, thus, failed to take a full history. There was only
very short-term improvement, which should have alerted me,
but it was not until the patient mentioned urinary symptoms
that I suspected prostate carcinoma.
Huatuojiaji points, 1 cun lateral to the vertebral spinous
processes, can usefully be needled if the points are tender,
and can provide easy access for gentle periosteal tapping
onto the vertebrae. In general, I use deep needling with
relatively strong stimulation—usually electrostimulation—
for 20 minutes. Indeed, there is evidence that electro-
acupuncture (EA: I use Han frequencies of 2/100 Hz) is
more effective than manual acupuncture for chronic LBP.9
EA is popular with patients, as they report the sensation as
soothing and relaxing. However, for acute back pain, min-
imal stimulation with few needles should avoid a reactive
flare-up before the pain and muscular spasm resolve.
My treatment of mid- and upper-back pain follows sim-
ilar principles, using tender Bladder and Huatuojiaji points,
including any trigger points along the medial edge of the
scapula in the rhomboid muscles (BL 36–BL 40).6 How-
ever, I am very careful not to do any deep needling in the
thoracic area, given that there is danger of pneumothorax.
I rarely use Governing Vessel points in the back, as I am not
convinced that they add extra benefit.
Because back pain can interfere with working life and
personal relationships, often an emotional or anxiety com-
ponent is evident, although an anxious temperament can
itself sometimes be a cause of trigger-point activation.
I therefore routinely add the anti-stress points GV 20 or the
‘‘Four Wise Men’’ (Sishencong) to my prescription.
REFERENCES
1. Haake M, Muller HH, Schade–Brittinger C, et al. German
acupuncture trials (GERAC) for chronic low back pain: Ran-
domized, multicentre, blinded, parallel-group trial with 3 groups.
Arch Intern Med. 2007;167(17):1892–1898.
CLINICAL PEARLS
2. Witt CM, Jena S, Selim D, et al. Pragmatic randomized trial
evaluating the clinical and economic effectiveness of acupunc-
ture for chronic low back pain. Am J Epidemiol. 2006;164(5):
487–496.
3. Thomas KJ, MacPherson H, Thorpe L, et al. Randomised
controlled trial of a short course of traditional acupuncture
compared with usual care for persistent non-specific low back
pain. BMJ. 2006;333(7569):623.
4. Kalauokalani D, Cherkin DC, Sherman KJ. A comparison of
physician and nonphysician acupuncture treatment for chronic
low back pain. Clin J Pain. 2005;21(5):406–411.
5. Hayhoe S. Acupuncture for chronic pain. In: Filshie J, White A,
Cummings M, eds. Medical Acupuncture: A Western Scientific
Approach, 2nd ed. Edinburgh: Elsevier; 2016:315–344.
6. Baldry PE. Myofascial Pain and Fibromyalgia Syndromes.
Edinburgh: Churchill Livingstone; 2001.
7. Umeh BU. Sacral acupuncture for pain relief in labour: Initial
clinical experience in Nigerian women. Acupunct Electrother
Res. 1986;11(2):147–151.
8. Fang S. The successful treatment of pain associated with scar tissue
using acupuncture. J Acupunct Meridian Stud. 2014;7(5):262–264.
9. Thomas M, Lundberg T. Importance of modes of acupuncture
in the treatment of chronic nociceptive low back pain. Acta
Anaesthesiol Scand. 1994;38(1):63–69.
Address correspondence to:
Simon Hayhoe, MSc, MBBS, MRCA
Pain Management Department
University Hospital
Turner Road
Colchester CO4 5JL
United Kingdom
E-mail: simonhayhoe@doctors.org.uk
A cupuncture has proven to be a very effective non-
pharmacologic treatment for back pain.1 The acupunc-
ture meridians are mapped in the pain area and, therefore,
define the treatment strategy in I Ching Balance Acupuncture
(ICBA).2 The following back pain types are distinguished:
 Neck pain (NP)—Foot Tai Yang (Urinary Bladder; UB)
and laterally to it, Foot Shao Yang (Gall Bladder; GB)
meridians mapped in the neck
 Thoracic back pain (TBP)—from below the neck and
shoulders to the waist:
- Upper back—upper thoracic spine to * the lower
border of the scapulae; and upper back and Hand Tai
Yang (Small Intestine; SI) Meridians, in the scapular
area, mapped in the upper back
- Middle back—* from below the lower border of
the scapulae to the waist; the upper back is mapped
in the middle back
 Lower back pain (LBP)—below the waist, to the but-
tocks; the upper back, and laterally to it, GB, mapped in
the lower back.
 CLINICAL PEARLS
ICBA Treatment of NP
NP is one of the top five chronic pain conditions in terms
of prevalence and years of disability it causes.3 Acupuncture
was shown to be effective for managing NP.3 Considering
that this pain is a malfunctioning of a local body part rather
than its system, the Local Balance Concept is used for
treatment.4 To balance the mapped meridians, anatomical
structure similarities are applied.4 Neck distal projections
performed to the wrists and ankles assist point selection.4
Detection of sore (Ashi) points leads to making a decision
among the following four options:
(1) Ipsilateral to the pain indicated on the wrist the Hand
Tai Yin (Lung; LU) and Hand Shao Yin (Heart; HT)
meridians; Ashi points between LU 6–LU 9 and HT
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4–HT 7 are punctured, respectively
(2) Ipsilateral to the pain indicated on the ankle the UB
and GB meridians; Ashi points between UB 59–UB
60 and GB 39–GB 40 are punctured, respectively
(3) Contralateral to the pain indicated on the wrist the
Hand Shao Yang (Triple Energizer) Meridian (TE)
and SI; Ashi points between TE 4–TE 8 and SI 5–SI 7
are punctured, respectively
(4) Contralateral to the pain indicated on the ankle Foot
Shao Yin (Kidney; KI) and Foot Jue Yin (Liver; LR)
meridians; Ashi points between KI 3–KI 7 and LV 4–
LV 5 are punctured, respectively.
ICBA TREATMENT OF TBP
A relatively high prevalence of TBP in the general pop-
ulation suggests that TSP is an important clinical condition.5
The upper- and middle-back distal projections are per-
formed on the forearms and shins. Detection of Ashi points
leads making a decision among the following options:
(1) Ipsilateral to the pain indicated on the forearm LU
and HT meridians, the Ashi points between LU 5–LU
6 and HT 3–HT 4 are punctured, respectively.
(2) Ipsilateral to the pain indicated on the ankle BL
meridian, the Ashi points between BL 40 and BL 58
are punctured.
(3) Contralateral to the pain indicated on the wrist SI
meridian, the Ashi points between SI 7 and SI 8 are
punctured.
(4) Contralateral to the pain indicated on the ankle KI
and LR meridians, the Ashi points between KI 9–KI
10 and LR 5–LR 7 are punctured, respectively.
ICBA Treatment of LBP
The amount of literature proving the efficacy of acupunc-
ture treatment of LBP is constantly increasing.6 A distal
transversal projection of the waist is performed contralateral
415
to the pain on the second metacarpal bone, where the Hand
Yang Ming (Large Intestine; LI) meridian is mapped. Spe-
cifically, the projection is mapped on the LI 3–LI 4 meta-
carpal segment. Puncturing LI 3 modifies the LI and creates
the Thunder over Fire (Zhen Gong over Li Gong) hexagram.
This is one of the 40 recommended of 64 possible hexa-
grams. In addition, Ling Gu and Da Bai, powerful Extra
meridian acupoints located next to LI 3 are punctured.
Given that UB is mapped in the lower back, SI balances it
perfectly. A distal projection of the waist contralateral to the
pain indicated on the fifth metacarpal bone, leads to the use
of the SI 3 acupoint, which also opens the DU (Governing
Vessel Meridian; GV). In case the LBP reaches the trochanter,
GB is mapped. The TE balances it appropriately and, there-
fore, TE 3 is used. Thus, puncturing contralateral to the pain,
LI 3, Ling Gu, Da Bai, TE 3, and SI 3 are used to treat LBP
without any radiation to other areas.
For treating LBP radiating to other areas, the Global
Balance Concept is used. Considering that LBP is very often
associated with TBP, this approach, based on modifications
of hexagrams, is used to treat both LBP and TBP. Accord-
ingly, in addition to the above described points used for
treating LBP that does not radiate to other areas, the fol-
lowing points are used: contralateral KI 7 and LR 5; ipsi-
lateral HT 3 and LU 5; and ipsilateral UB 65 and GB 41.
Clinical Example of ICBA Treatment for LBP
A 59-year-old Caucasian female sought acupuncture treat-
ment for LBP with a lateral-anterior pain radiating to the left
foot. Immediately after this pain, she started to feel a sharp
pain in her lower back, and she consulted an orthopedist in
her local health maintenance organization, where she was
diagnosed with sciatica. After she refused to receive an epi-
dural steroid injection, she was prescribed daily 78.75 mg/
3 mL diclofenac sodium (a nonsteroidal anti-inflammatory
drug [NSAID]) intramuscular (IM) injections. After 5 daily
IM NSAID injections did not affect the pain, this patient
decided to receive acupuncture treatment.
Given that the disorder affected this patient’s musculo-
skeletal system, ICBA Global Balance was used for her
treatment. Considering the lateral–anterior radiation to the
left leg, an imbalance of the GB and Foot Yang Ming (ST)
meridians was diagnosed and confirmed using Chinese
pulse diagnostics.7 To balance the imbalance of the ST, the
Hand Jue Yin (PC) meridian was interconverted with the
ST. The following acupoints were used: LR 5; KI 7; LI 3;
TE 3; and Ling Gu; Da Bai right; HT 3; HT 7; PC 6; PC 9;
GB 34; GB 41; ST 42; ST 45 left; and Yintang. Following
the first 60-minute ICBA session, she reported a significant
decrease of her LBP and its radiating to other areas. Three
additional ICBA sessions were performed. In total, the pa-
tient received 4 60-minute ICBA sessions, two times per
week, for 2 weeks, until she experienced complete dissipation
of her pain.
 416
REFERENCES
1. Vickers AJ, Cronin AM, Maschino AC, et al.; Acupuncture
Trialists’ Collaboration. Acupuncture for chronic pain: Individual
patient data meta-analysis. Arch Intern Med. 2012;172(1):1444–
1453.
2. Tan R.T.F. Acupuncture 1, 2, 3. San Diego: Richard T.F.Tan; 2007.
3. Cohen SP, Hooten WM. Advances in the diagnosis and man-
agement of neck pain. BMJ. 2017;358:j3221.
4. Kotlyar A. Straightforwardness, universality and effectiveness
of the Balance Method of I Ching Acupuncture. Med Acupunct.
2017;29(2):94–104.
5. Briggs AM, Smith AJ, Straker LM, Bragge P Thoracic spine
pain in the general population: Prevalence, incidence and as-
sociated factors in children, adolescents and adults. A sys-
tematic review. BMC Musculoskelet Disord. 2009;10:77.
Downloaded by Mary Ann Liebert, Inc., publishers from online.liebertpub.com at 12/19/17. For personal use only.
6. Liang YD, Li Y, Zhao J, Wang XY, Zhu HZ, Chen XH. Study
of acupuncture for low back pain in recent 20 years: A bib-
liometric analysis via CiteSpace. J Pain Res. 2017;10:951–964.
7. Kotlyar A, Brener, Lis M. Use of Dr. Tan’s Chinese Balance
Acupuncture for treatment of chronic, neck–shoulder pain.
Med Acupunct. 2016;28(2):87–95.
Address correspondence to:
Arkady Kotlyar, PhD, DiplAc
Outpatient Pain Clinic
Kaplan Medical Center
3 Ein Hakore Street, 8th Floor
Rishon Lezio
Rehovot 7528910
Israel
E-mail: dr.kotlyar@chi-point.com
B ack pain affects people of all ages and is a lead-
ing contributor to disease burden worldwide.1 Patients
who continue to have back pain beyond the acute period (4
weeks) have subacute back pain (lasting between 4 and 12
weeks) and could go on to develop chronic back pain if the
pain persists for ‡12 weeks.2 Risk factors associated with back
pain complaints include smoking; obesity; age, female
gender; physically strenuous work; sedentary work; psy-
chologically strenuous work; low educational attainment;
Workers’ Compensation insurance; job dissatisfaction; and
psychologic factors, such as somatization disorder, anxiety,
and depression. There are many etiologies, including: me-
chanical low-back pain (LBP; lumbar strain, degenerative
disease in discs and facet joints, spondylolisthesis, spinal
stenosis, osteoporosis, fractures, severe kyphosis, and severe
scoliosis); nonmechanical spine disease (neoplasia, infec-
tion, inflammatory arthritis, Scheuermann disease, Paget
disease); and visceral disease (pelvic organs, renal disease,
aortic aneurysm, gastrointestinal disease).3
The clinical evaluation includes a taking a history and
conducting a physical examination to evaluate the patient
for signs or symptoms that indicate need for immediate
CLINICAL PEARLS
imaging and further evaluation. The physical examination
should include: inspection of back and posture; palpation/
percussion of the spine; a neurologic examination; straight
leg raising; and nonorganic signs (Waddell’s signs).3
Recommendations for initial management of patients
with subacute and chronic LBP involve multiple interven-
tions, such as medications, nonpharmacologic therapies,
interventional therapies, and surgeries.4 Acupuncture is ef-
fective for decreasing pain and anti-inflammatory intake as
well as improving functional status and quality of life (QoL).5
Systematic reviews have been conducted to investigate
the effectiveness of acupuncture for managing LBP, but
review conclusions have been sometimes contradictory and
often limited by the number and quality of the included
studies.6 A meta-analysis from 2013 showed that, compared
with no treatment, acupuncture produced better outcomes in
terms of pain relief, disability recovery, and better QoL, but
these effects were not observed when verum acupuncture
was compared to sham acupuncture.7 Another meta-analysis
at the same year concluded that acupuncture also relieves
acute cases of LBP. Eleven randomized-controlled trials
were included (N = 1139) in that analysis. Compared with
nonsteroidal anti-inflammatory drugs, acupuncture reduced
symptoms of acute LBP more effectively (5 studies; risk
ratio: 1.11; 95% confidence interval: 1.06–1.16). For pain,
there exists inconsistent evidence that acupuncture is more
effective than medication. Compared with sham acupunc-
ture, verum acupuncture can relieve pain more effectively
(2 studies; mean difference: -9.38; 95% confidence interval:
-17.00 to -1.76) but does not improve function or amelio-
rate disability. Acupuncture appears to be associated with
few side-effects but the evidence is limited.8
There is a great variety of acupuncture techniques used to
control back pain. The simplest way is by choosing points
from the two main meridians that cross the region: the
Bladder meridian (foot Tai Yang) and Gall Bladder me-
ridian (foot Shao Yang). Gall Bladder is especially useful
for LBP. Yangligquan (GB 34) is the He (Sea) point of the
meridian, and Hui, the Influence point of tendons is a very
efficient point for pain control. Zulinqi (GB 41) is the opening
point of the Dai Mai meridian, an Extraordinary meridian
located in the low-back region. If needling of those points is
not completely effective, other points of the same meridian
can be added.
A good strategy is, at the beginning of the needling, to
avoid the painful region and chose another point at
the opposite extremity of the meridian. When using the
Bladder meridian, the choice of points will depend on the
position of the patient. If the patient is lying on his or her
back, the only accessible points will be on the head, such as
Zanzhu (BL 2), and feet, such as Kunlun (BL 60), Pushen
(BL 61), or Shenmai (BL 62, the initial point of the Yang
Qiao Mai meridian). If the patient is lying on his or her
side, or any other way, the back is accessible and many
other Bladder acupoints may be needled, either far from, or
 CLINICAL PEARLS
at, the pain site. An option is to start the needling with a
powerful point such as Weizhong (BL 40, the He point of
the meridian) and, afterward, choosing other Bladder
acupoints at the pain site.
Palpation of the region may reveal Ashi points. Needling
of Ashi points is also very effective for pain control, al-
though this needling is less-comfortable for the patient
than needling points that are far from the pain site. The
Du Mai is an Extraordinary meridian also located in the
back. Houxi (SI 3), the opening point of the Du Mai me-
ridian, is also a good option for treating back pain, as are
the Du Mai meridian points themselves. A large number
of Extra points are effective for treating back pain. The use
of Traditional Chinese Medicine principles of diagnosis
enhances the efficacy of acupoint choice and treatment
results.9
Downloaded by Mary Ann Liebert, Inc., publishers from online.liebertpub.com at 12/19/17. For personal use only.
REFERENCES
1. Maher C, Underwood M, Buchbinder R. Non-specific low back
pain. Lancet. 2017;389(10070):736–747.
2. Chou R. In the clinic: Low back pain. Ann Intern Med. 2014;
160(11):ITC6-1.
3. Wheeler SG, Wipf JE, Staiger T, Deyo RA, Jarvik J. Evalua-
tion of Low Back Pain in Adults. Online document at: www.
uptodate.com Accessed June 21, 2017.
4. Chou R, Atlas AJ, Libman H. Subacute and Chronic Low Back
Pain: Nonpharmacologic and Pharmacologic Treatment. On-
line document at: www.uptodate.com Accessed August 21,
2017.
5. Hasegawa TM, Baptista AS, de Souza MC, Yoshizumi AM,
Natour J. Acupuncture for acute non-specific low back pain: A
randomised, controlled, double-blind, placebo trial. Acupunct
Med. 2014;32(2):109–115.
6. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of
low back pain: A joint clinical practice guideline from the
American College of Physicians and the American Pain So-
ciety. Ann Intern Med. 2007;147(7):478–491.
7. Xu M, Yan S, Yin X, et al. Acupuncture for chronic low back
pain in long-term follow-up: A meta-analysis of 13 randomized
controlled trials. Am J Chin Med. 2013;41(1):1–19.
8. Lee JH, Choi TY, Lee MS, Lee H, Shin BC, Lee H. Acu-
puncture for acute low back pain: A systematic review. Clin J
Pain. 2013;29(2):172–85.
9. Wen TS. Clinical experiences. In: Therapeutic Manual of
Acupuncture [In Portuguese]. São Paulo: Manole; 2008:342–
367.
Yolanda Maria Garcia, MD, PhD
Tomie Toyota de Campos
Athos Muniz Braña, MD
and Eduardo Lênin Thenquini, MD
Internal Medicine Department
São Paulo University Medical School
São Paulo, Brazil
417
Address correspondence to:
Yolanda Maria Garcia, MD, PhD
Internal Medicine Department
São Paulo University Medical School
R. Teodoro Sampaio, 352cj57
São Paulo 05406-000
Brazil
E-mail: yolanda@usp.br
F or a majority of the low-back pain (LBP) cases that
present to our clinics, we use a neuroanatomical ap-
proach toward acupuncture point selection. Specifically, the
evaluation and resulting acupuncture treatment target the
motor points of the lumbar- and pelvic girdle–stabilizer
muscles. By targeting the motor points of the primary and
secondary stabilizing muscles of the lumbar spine and the
hip region, the treatment goal is to improve muscular sta-
bilization by correcting motor-nerve inhibition. In turn, by
fixing both the motor-nerve inhibition and the muscular
stabilization, the patient’s pain will be reduced.1,2
The most important primary stabilizing muscles of the
lumbar spine are the transversus abdominis, internal ob-
lique, and multifidus muscles.3,4 The important secondary
stabilizers of the lumbar spine are the erector spinae, psoas,
and quadratus lumborum. The important stabilizers of the
pelvic girdle include the gluteus medius, gluteus minimus,
gluteus maximus, and psoas muscles. These muscles are
necessary for lumbar muscular stabilization with static
standing. Patients with LBP have inhibited transverse ab-
dominus and the internal oblique muscles.5,6 The next few
sections provide instructive details and then an illustrative
case is presented.
Evaluation of Lumbar- and Pelvic-Stabilizing
Muscles
Evaluation of the lumbar- and pelvic-stabilizing muscles
is both a combination of manual strength testing and pal-
patory examination. The examiner should assess the:
 Primary stabilizing lumbar musculature, transversus
abdominis, internal oblique and multifidus muscles,
using a functional evaluation. The patient should stand
neutral with the feet shoulder-width apart, hands to-
gether, and the arms extended in front. One can note
out lumbar instability/weakness with the patient stand-
ing. The examiner should apply pressure to the patient’s
hands from left to right, while asking him or her to resist;
then repeat this pressure from right to left. One should
note any weakness or lack of activation in this muscle
group, and repeat the test with the patient changing
pelvic positions to an anterior pelvic tilt and then a
posterior pelvic tilt. This test should be performed with
the pelvis in multiple positions to check the integrity of
 418
the core musculature in both dynamic and static pos-
tures. These tests provide a benchmark for the status of
lumbopelvic stability in the patient.
 Erector spinae, using a palpatory examination for any
spinal segmental changes from T-12 to L-5. The ex-
aminer should use the skin pinch and roll to test for
allodynia, the scratch test for hyperalgesia, and deep
palpation of the paraspinal muscles to check for myo-
tome trigger points.
 Psoas, using muscle manual muscle strength. The pa-
tient’s lies prone with the knees extended. The exam-
iner stabilizes a contralateral anterior superior iliac
spine with a hand and tells the patient to lift a leg off the
table, while noting weakness or lack of activation.
 Quadratus lumborum, using the above palpatory eval-
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uation as well as observation of lumbar range of mo-
tion. The examiner should Note flexion, extension,
side-bending, and rotation with the patient standing.
The main action of the quadratus lumborum is lateral
side-bending.

Gluteus medius, using muscle manual muscle strength.
With the patient in a supine lying position, the exam-
iner should evaluate the anterior fibers of the gluteus
medius. With the tibia neutral position, the patient ab-
ducts each leg against resistance. With the patient in a
side-lying position, the examiner should test the poste-
rior gluteus medius and the gluteus minimus. With each
leg straightened, the patient should be asked to abduct
that leg against resistance, while the examiner notes any
weakness or lack of activation in the anterior gluteus
medius, posterior gluteus medius, and gluteus minimus.
 Gluteus maximus, using muscle manual muscle strength.
The gluteus maximus is an antagonist to the psoas. The
patient lies prone with the leg bent at the knee. The
patient lifts the knee off the table, and the examiner
resists movement at the heel, while noting any weakness
or lack of activation in the gluteus maximus.
Determine Needle Locations
For the following eight sites, needle insertion is perpen-
dicular and 2–3 cm deep. We follow this procedure:
(1) Multifidus motor point—Locate the spinous process
of any vertebral level and move 0.5 inches lateral
along the Hua tuo jiaji line.
(2) Internal oblique motor point—Locate the traditional
Gall Bladder (GB) 26 point.
(3) Transversus abdominis motor point—Locate the in-
ternal oblique motor point and move one-inch pos-
terior. This is referred to as GB 26’.
(4) Erector spinae motor point—Locate the spinous
process of any vertebral level and move 1.5 lateral
along the inner Bladder line.
CLINICAL PEARLS
(5) Quadratus lumborum motor point—Find the point
locations of (A) EX–B-4 (Pi Gen) (proximal attach-
ment) and (B) Yao Yan (distal attachment).
(6) Psoas motor point—This point is located between
(A) Bladder (BL) 23 and BL 26 or (B) at Spleen (SP)
12 (iliopsoas).
(7) Gluteus maximus motor point—This point is located
at GB 30. Find the S4 spinous process and move 6†
lateral.
(8) Gluteus medius motor point—(A) The anterior glu-
teus medius motor point is located at BL 53. Find the
greater trochanter and progress in a cephalad direc-
tion; move cranial 4 inches and medially 1†. (B) The
posterior gluteus medius motor point is at BL 54.
Locate the greater trochanteric and the posterior su-
perior iliac spine. Divide the space between them into
three equal parts. Select the medial one-third point.
For Each Visit
During each visit’s assessments, we test the integrity of
musculoskeletal mechanics and gauge treatment response.
We evaluate and treat the following muscles during the
initial visit: transversus abdominis; internal oblique; multi-
fidus; and erector spinae. On subsequent visits, we deter-
mine additional motor points according to the results of the
reassessment examination.
Equipment
We treat the motor points with electrical stimulation. In
our clinics, we use a combination of the Pointer-Plustm
(Lhasa OMS, Weymouth, MA) a monopolar stimulation
device, and the ITO ES-130 (Lhasa OMS) or the
Electrostimulator 8c Pro (Pantheon Research, Culver City,
CA), an electrical stimulation unit. We stimulate each se-
lected motor point first with the Pointer-Plus. We use the
Pointer-Plus to: (1) confirm motor-point needle placement;
and (2) to initiate treatment. When preset at 10 Hz, this
device assists with motor reactivation of inhibited muscles.
We use the it 3–4 times at each motor point for 30 seconds
each. This initial treatment is followed by connecting the
needles to the electrical stimulation unit for 20 minutes at
1–2 Hz, which perfuses the tissues best, whether locally or at
a spinal segmental level.
Number of Treatment Sessions
The number of treatment sessions depends on the chro-
nicity and progression of the patients’ symptoms. Chronic
LBP requires more treatments than acute/subacute low-back
injuries. As LBP becomes longstanding, the need for addi-
tional treatment across multiple health disciplines increases.
 CLINICAL PEARLS
A Sample Case of Acute LBP
A 32-year-old electrician presented with acute left-sided
lower back pain. He described the pain as a spasm. The left
flank region just above his iliac crest was painful. The pain
had begun 36 hours ago after he had been repairing a piece
of equipment at work for an extended period while he was in
a laterally bent position. The pain was worse upon rising
from a seated position and was better with passive resting,
including lying down and sitting.
Physical examination: The patient had limited range
of motion (ROM) with left lateral side-bending. Upon
testing the primary core-stabilizing muscles (transverse
abdominus, internal oblique, and multifidi), he was noted to
have weakness and pain on the left when his pelvis was
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examined in a neutral tilt position. Testing the primary core
stabilizing muscles in the anterior or posterior pelvic tilt
positions was not done because his presentation was acute.
The paraspinal muscles along the Hua tuo jiaji line, the
multifidi, were evaluated with this patient in a right side-
lying position. Both skin rolling and scratch testing were
performed, starting from S1 to L1 in a cephalad direction.
This test revealed allodynia and hyperalgesia in the region
of the left-sided L-4 multifidi muscles. Palpation of both the
left and right erector-spinae muscles revealed taut bands in
the area of the L4 transverse processes. Palpation of the
quadratus lumborum muscles adjacent to the transverse
processes of T-12, L-1, and L-2 revealed left-sided tender
trigger points.
Assessment: This patient had three notable impair-
ments. The first was motor inhibition, weakness, and pain in
the left lumbar-stabilizing muscles (transverse abdominus,
internal oblique, and multifidi). The second was the limited
ROM and pain in the left quadratus lumborum muscles. The
third was spinal segmental sensitization in the paraspinal
muscles (multifidi and erector spinae) in the region of L-4.
Due to this patient’s acute presentation, the overall treat-
ment goal was to minimize his neurogenic inflammation and
improve his functionality by: (1) improving the strength and
reducing the motor inhibition of the primary core-stabilizing
muscles; (2) improving the lumbar ROM in the quadratus
lumborum muscles; and (3) reducing the pain (allodynia and
hyperalgesia) in the paraspinal muscles.
Treatment: The patient was placed side-laying on his
right side. The following motor points, as described above,
were treated first on the left side of the patient: transverse
abdominus (GB 26’); internal oblique (GB 26); and the
quadratus lumborum (EX–B-4 [Pi Gen]). Each motor point
was needled individually, one at a time. Each motor point
was then stimulated with the Pointer Plus 3–4 times for 30
seconds each. These needles were left in place. Additional
motor points were then added: Hua tuo jiaji points (multi-
419
fidi) and erector-spinae points (Inner Bladder) at * the L-3,
L-4, and L-5 levels. All of the motor points were electrically
stimulated, using the ITO 1107 at 1–2 Hz for 10–20 minutes
to create a nonnoxious contraction. Black leads were at-
tached centrally (multifidi and erector spinae), and the red
leads were connected more peripherally (transverse abdo-
minus, internal oblique, and quadratus lumborum).
Outcome: After this treatment, the patient was able to
rotate his lumbar spine in a seated direction *55 on each
side, a functional movement that he was not able to do
before the treatment. He was able to transition from a seated
position to a standing position without any spasms. We
would follow-up the next day to reevaluate his chief com-
plaint and treat him accordingly. The overall treatment plan
for this acute process was to treat him 2–3 times per week
for 2 weeks and then taper down the treatment frequency to
once per week until he was pain-free. He would also be
given physical therapy.
REFERENCES
1. Lund JP, Donga R, Widmer CG, Stohler CS. The pain-
adaptation model: A discussion of the relationship between
chronic musculoskeletal pain and motor activity. Can J Physiol
Pharmacol. 1991;69(5):683–694.
2. Nijs J, Daenen L, Cras P, Struyf F, Roussel J, Oostendorp R.
Nociception affects motor output: A review on sensory-motor
interaction with focus on clinical implications. Clin J Pain.
2012;28(2):175–181.
3. Wallden M. The primal nature of core function: In rehabilita-
tion & performance conditioning. J Bodyw Mov Ther. 2013;
17(2):239–248.
4. Wallden M. Fundamentals of core conditioning. J Bodyw Mov
Ther. 2013;17(2):249–253.
5. Allison GT. Abdominal muscle feedforward activation in pa-
tients with chronic low back pain is largely unaffected by 8
weeks of core stability training. J Physiother. 2012;58(3):200.
6. Hodges, P, Richardson, C. inefficient muscular stabilization of the
lumbar spine associated with low back pain: A motor control eval-
uation of transversus abdominis. Spine. 1996;21(22):2640–2650.
Joseph Walker III, MD
University of Connecticut
Farmington, CT
and
Anthony Lombardi, DC
Hamilton, Ontario, Canada
Address correspondence to:
Joseph Walker III, MD*
University of Connecticut
263 Farmington Avenue
Farmington, CT 06030
E-mail: jwalker@uchc.edu