A 35 year-old man presented with low-back pain that he had been experiencing for only two days. He claimed that the pain came from lifting a heavy object, and that he had achieved the same type of injury a few other instances in the past 10 years. His pain was quite severe, and he was having a great deal of trouble moving. He had some trouble breathing deeply, and needed some help onto the treatment table on the first visit. The pain was worse on his left side, and seemed to radiate into his left hip, but not down his leg. He had not had an MRI, but had had x-rays after his last injury two years ago and his doctor had said it looked like there was some disc herniation around L4 or L5. He was advised to seek out an MRI and agreed that he would ask his doctor for the test to be performed.
His other symptoms included general fatigue, with some weight gain in the last few years. The weight gain had primarily occurred around his abdomen. He also tended to have some low-back pain after sexual activity. After some light palpation, it was discovered that he felt most of his pain around the sacro-iliac area on his left side.
His tongue was pale, with some swelling and a few teethmarks on the sides. His pulse was slightly weak and soft, and was especially weak in the Kidney positions.
Diagnosis: An acute sprain of the lower back resulting in Qi and Blood stagnation, with an underlying deficiency in the Kidney and Spleen organ systems.
Treatment Principle: Resolve the Qi and Blood stagnation in the local area with acupuncture and some Qi Gong energy work to relieve pain in the sacro-iliac area, and Tui Na massage the erector muscles (both sides), and the hip muscles on the left side. In addition, nourishing of the Kidneys and Spleen to help prevent recurrence was intended.
Acupuncture Points Used: BL 40, SP 6, ST 36, KD 3, KD 4, BL 23, BL 20, BL17, BL 31, BL 32, BL 33, BL 34
3 treatments in the first week relieved most of his pain, and the patient was able to resume normal daily activity. Two more treatments the following week helped him fully recover. It was recommended that he do some exercises to strengthen his abdominal muscles and return for regular visits to strengthen his Kidneys. He did not, however, return for further visits to nourish his Kidneys, but did report that he had been exercising.
