Acupunture and Herbal Treatment of Low Back Pain

Musculo-Skeletal

Chief Complaint: low back pain

Medical History: 37 year old male presents with acute low back pain occurring for two weeks after turning to the left while squatting, and simultaneously holding a tire/wheel assembly, during an emergency tire change. Patient is a taxi cab owner/driver, sedentary, and a regular smoker.

Questioning exam: Patient has desire to sleep after eating, a bitter taste in mouth and experiences acid reflux. He drinks 8 cups of coffee daily, in addition to sodas. He sleeps in an uncomfortable bed 3-5 hours a night, has trouble falling asleep, and wakes up at night due to light, restless sleep and occasional disturbing dreams. Patient also reports an energy level of 5/10, low libido, a left knee that has pain in response to changes in weather, and a history of migraine headaches for 4 months.

Pulse exam: P: soft, mid/deep, wiry (esp. left), stronger on left, mod. rate (68), weak in guan & chi on right

Upon palpation of Mu points; LR 14, LR 13, GB 25 exhibited tenderness. (LR, SP, KD)

Tongue exam: T:pale, puffy/flabby, thin-white-dry coat, sunken in center, yin xu cracks, peeled tip

OM Diagnosis: Dx:LBP d/t local Qi and Blood Yu with LR/KD Yin Xu and underlying Sp Qi Xu

Treatment Principle: Move local Qi and Blood, open channel alleve pain, nourish LR/KD Yin, tonify SP Qi

Point Prescription: Tx Plan:

UB 20-LBP, Tonify SP Qi

UB 23-LBP, Nourish KD Yin, local point [Rt UB 23 w/ GB 30; e-stim]

UB 25-LBP, Move local Qi and Blood [Bilateral w/UB 40; e-stim]

UB 26-LBP, Move local Qi and Blood

DU 4-LBP, Move local Qi and Blood, support Upright Qi

DU 3-LBP, Move local Qi and Blood, support Upright Qi

Rt GB 30-Distal point, elec stim with Rt UB 23, open channel/alleve pain

Bi UB 40-Distal point, elec stim with Bi UB 25, open channel/alleve pain

Bi SP 6-Nourish and tonify LR, SP, KD

Rt Ear HT-General body tonifier

Herbal Formula: Du Huo Ji Sheng Tang, Kan Herb liquid extract-16 drops PO 60-90 minutes after meals and bedtime,qid

Lifestyle Prescription: TDP Ming Men-warm and tonify, facilitate movement of Qi and Blood

Tuina Mid to low back, forearms, and feet w/ Po Sum On oil-move Qi and Blood

Recommendations:

-increase water intake

-decrease caffeine intake (reduce coffee and sodas)

-increase yin foods

-return to clinic in 1 week, or sooner if necessary

Results: Patient reported no pain at end of treatment, but did report some residual stiffness.

Synopsis: 1 week later patient reports no stiffness or pain, and wants to work on sleep issues and stop smoking support

Clinic Name: Acupuncture Associates

clinic address: Wilmington NC

clinic phone number: 910-798-8181

email address: dom@happyacupuncture.com

Website: http://happyacupuncture.com

Last modified: September 8, 2009  Tags: , ,  В·  Posted in: Musculo-Skeletal