Treatment of Sciatica with Electro-Acupuncture and Tuina Massage: A Case Study

TREATMENT OF SCIATICA WITH ELECTRO-ACUPUNCTURE AND TUINA:
A CLINICAL CASE STUDY
By Yan Lu, DAOM, LAC
ABSTRACT
Background Sciatica and back pain can be difficult to treat, especially when it does not have clear
diagnosis from a western biomedical perspective such as negative findings
in a MRI.
Objective To examine the approach and efficiency of electro-acupuncture and Tuina
in the treatment of sciatica and back pain with unclear biomedical diagnosis.
Result After 2 treatments the patient experienced significant decrease of sciatic
pain and numbness
Conclusion Electro-acupuncture and Tuina appear to be effective in treating sciatica and back pain
with unclear biomedical diagnosis
Background
Biomedicine Perspective
Sciatica is pain that radiates along the course of sciatic nerve, most often down the
buttocks and the posterior aspect of the leg to below the knee. It may occur with or
without back pain. It is most commonly caused by peripheral nerve root compression
from intervertebral disc protrusion or intraspinal tumor. Compression may be within the
spinal canal or intervertebral foramen by disc protrusion, tumor, or bony irregularities
( herniated disc, degenerated disc, lumbar spinal stenosis – osteoarthritis, spondylisthesis )
The nerves can be also compressed outside the vertebral column, in the pelvis and
buttocks ( sacroiliac joint dysfunction and piriformis syndrome) . Toxic or metabolic
causes (eg. alchoholism, diabetic neuropathy ) are rare. Such processes are confirmed by
the presence of sensory or motor deficits and by clinical or electrodiagnostic findings.(1).
The common treatment in biomedicine includes using heat/ice, medications, epidural
injections, surgeries, education and exercises. Medications include NSAIDs, opioid and
muscle relaxants such as diazepam, cyclobenzaprine, carisoprodol and methocarbamol.
Rest and back exercise are now known to be ineffective. Epidural injections can provide
short-term relief of sciatica but do not improve functional status or reduce the need for
surgery. Surgical procedures may be necessary to relieve intractable pain or other
neurologic involvement such as herniated disc or spinal stenosis. Classic discectomy with
limited laminotomny for intervertebral disc herniation is standard. Laminectomy can be
used for spinal stenosis. Spinal fusion can be performed for spondylolisthesis. (2).
However it is difficult to treat sciatica with no clear biomedical diagnosis, which is
common in clinic.
Traditional Chinese medicine perspective
Sciatica in TCM can be considered as back pain. The causes of the back pain can be
differentiated as invasion by wind- cold, deficiency of kidney qi, and qi and blood
stagnation due to trauma. The treatment for sciatica usually includes acupuncture, herbs
and Tuina. The acupoints includes BL23 andGV3 to tonify kidney, BL40 to open the
meridians. For damp- cold type, add BL25, BL26; for kidney qi deficiency, add GV4.
Moxibustion can be applied to the acupoints for either of these previous two conditions.
For kidney yin deficiency, add BL52, Kid3; for trauma, add GV26 and yao tong point.
(3)
The following formulas can be prescribed to treat lumbar pain: modified ganjiang lingzhu
tang for damp-cold type. This formula tonifies the spleen, drains the damp, dispels the
cold, and relieves pain. Modified simiao wan can be used for damp-heat type condition.
This formula drains the damp and clears heat. Other herbs such as mu gua, luo shi teng
can be added to increase the efficacy of pain relief. Shen tong zhu yu tang can be used for
blood stasis. This formula moves qi and blood and opens the meridians to stop pain. You
gui wan treats kidney yang deficiency and zuo gui wan treats kidney yin deficiency. (4)
For Tuina treatment, the following Tuina techniques can be used: pointing, pressingkneading,
rolling, stretching, etc. (5), (6), (7).
Research
Several papers describe the treatment of sciatica with acupuncture.
Feng reported successful treatment of 58 cases of nerve trunk type sciatica with catgut (a
special thread made of pig intestines) implanted at acupoints. GB30 and BL54 were
chosen as main points, while BL36, BL 37 and GB34 were chosen as alternate points.
Catgut was implanted in one main point and one alternate point once every 15 days.
Among 58 cases, 35 were cured, 12 showed marked improvement, 7 achieved
effectiveness and 4 did not improve. (8)
Zeng employed a therapy of acupuncture by warming the needle with an ignited moxastick
for 74 cases of sciatica and obtained satisfactory result. Warm needling was
performed at GB30, GB34, and BL57 for wind-cold type. GV4, BL23, BL37, BL54 and
BL40 were used for kidney deficiency. BL24, BL26, BL32, BL57 were used for blood
stasis. Among 74 cases, 31 were cured, 22 showed marked improvement, 21 achieved
effectiveness. (9)
Wang reported treating 455 cases of sciatica with deep needling BL26 and obtained
satisfactory result. Two 4 cun long needles were inserted into BL26 to achieve a
sensation of electric shock. The needle is retained for 30 minutes during which time it is
thrust and lifted 2-3 times. Among the 455 cases, 320 were cured, 83 were markedly
effective, 35 were improved and 17 failed. (10).
Case History
Patient Identification and Chief complaint
The patient is 45 year-old female with sciatica
History of Chief Complaint
The patient started to have right side sciatica 3 years ago. She also sprained her right
ankle twice 6 months before her sciatica started. A MRI scan on her low back was
normal. The patient never received a diagnosis. She was treated with physical therapy,
which helped her. Yoga stretch also helped. Then she got busy and gained some weight,
which made the sciatica worse.
When the patient came for acupuncture treatment, she described the pain was constant
dull pain most times, but can be sharp some times. It was in her low back, gluteal area, radiating
along the back of her leg to the bottom of her foot. She also experienced deep pain in her
right greater trochanter area and numbness in her right last 2 toes. On a scale from 1 to
10, she rated her pain level was 7 or 8. Pain was worsened by sitting and lessened by
lying down with heat or ice on her hip. The patient reported that she felt stress about her
pain.
The patient past’s medical history included sinus surgery for her sinus. Her sinus is fine
now and even her dizziness went away after the surgery. She also had bleeding between
her menses, which her doctor thought was due to perimenopause.
She felt cold. She described that she had nervous stomach with alternating loose stool or
constipation. She felt tired and moody sometimes. Her menses is heavy with bleeding
between. She did not feel particularly thirsty and her urination is normal. She can sleep 7
hours per night, which she felt was normal for her.
Exam
Palpation examination reveals tenderness in her right low back jiaji L5 and S1 area, right SI joint,
right piriformas muscle and in her groin area.
Straight leg lifting test was negative, yeoman’ s test was positive on her right SI joint,
piriformas tension test was positive on her right side, figure “4” test was positive for her
right hip. Manual muscle testing showed weak right adductor muscle. Her right leg was
slight longer.
Her right pulse was wiry and slippery. Her left pulse was slight weak. Her tongue was
pale and scalloped with thin yellow coating.
Diagnosis
Western biomedicine: right SI joint anterior subluxation, piriformas syndrome, right hip
joint subluxarion. (positive orthopedic tests)
Traditional Chinese medicine: Qi and blood stagnation in her Bladder meridian, Qi and
blood deficiency being not able to nourish muscles and tendons.
Her stress and wiry pulse suggest Qi stagnation, which can leads to blood stasis causing
sciatica. Coldness, fatigue, alternating diarrhea and constipation, slight weak pulse on her
left side and pale tongue suggest deficiency of Qi and blood.
Treatment
The treatment principle is to relax muscles, help the recovery of joint subluxation, move
Qi and blood, and tonify Qi and blood.
The patient was treated twice before the case was reported.
Electro acupuncture was applied on trigger points on her right piriformis muscle and
from Jia ji L5 to Ashi point in her right SI joint to relax her muscle. The frequency is
selected by mixed frequency-100/2 and the length of duration is 30 minutes. Other points
being used are: Motor points for her adductor was needled after the electro- acupuncture
was finished to strengthen her adductor, LI 4 and LIV 3 to move Qi and blood, ST 36 and
SP6 to tonify Qi and blood.
Tuina was applied after acupuncture. Rolling, pressing/kneading and pushing were
performed to relax muscles and open the meridians. Stretching the SI joint and hip joint
follows. The Tuina treatment duration per secession is 15 minutes.
Case Management
The patient did not come back for more treatment after the first two treatments. I
recommended the patient continue to receive another eight treatments as one course of
treatment. I also suggested the patient continue yoga stretching and exercising to lose
weight. Pelvic support is recommended to help stabilize the patient’s SI joint if the
patient still has pain after one treatment course. Herbs will also be prescribed if the
patient still has symptoms in the future such as Shen Tong Zhu Yu Tang.
Result
After the first treatment, the patient noticed a decreased pain in her right hip and leg.
After the second treatment, the sciatica and the deep pain in her greater trochanter area
went away, and the numbness in her right last two toes disappeared, too. Her leg length
was equal. All the orthopedic tests became negative.
Discussion
Like many others, this patient did not have a specific biomedical diagnosis when she
came for acupuncture. In my clinical experience, I found that when the sciatica was due
to compression by the soft tissues around the sciatica nerve, and there are no abnormal
changes in imaging tests. It is difficult for biomedicine to make a diagnosis. This
patient’s sciatica is due to compression on the sciatic nerve by piriformis muscle and SI
ligments from SI joint subluxation. Biomedicine does not agree that there is such
condition of SI joint subluxation, because it usually will not show in X- ray or MRI.
However, positive orthopedic test and clinical result suggest that there is such a
condition. Another condition that the patient had was hip joint subluxation due to
imbalance of agonist and antagonist muscles- tight piriformis muscle and weak adductor
muscles. It is one of the advantages of acupuncture and Tuina that they can be used to
treat patients with sciatica who do not have a clear biomedical diagnosis and still provide
relief for them. However it is difficult to determine if the piriformis syndrome or the SI
joint subluxation is causing the patient’s sciatica or if it is both conditions. A combination
of electro-acupuncture and Tuina is the key to treat sciatica due to musculo-skekletal
conditions (piriformis syndrome and SI joint subluxation in this case). Because
acupuncture works well to open meridians and relax piriformis muscle, Tuina works well
on SI joint subluxation as well as on piriformis muscle. Besides orthopedic tests, it will
be of interest to researchers to establish other diagnostic methods to prove that there is SI
joint subluxation causing sciatica due to compression on the sciatic nerve.
Conclusion
Sciatica due to unclear biomedicine diagnosis can be difficult to treat. This case
demonstrated the effectiveness of electro-acupuncture and Tuina in treating sciatica due
to compression on the sciatic nerve by piriformis muscle and SI ligments from SI joint
subluxation. The result is encouraging, further high quality clinical trials with larger
number of subjects and adequate follow-up periods are needed.
5
References
(1) Mark H. Beers M.D. The Merk Manual, 7th edition, Merck Research
Laboratories, 1999; 476.
(2) Lawrence m. Tierney, jr. Current Medical diagnosis and treatment 2003, Lange
Medical Books; 795.
(3) Cheng, Xin-nong Chinese Acupuncture, the people’s medical publisher, the 4th
edition; 554.
(4) Zhang, Bo-yu. Internal Medicine of Traditional Chinese Mediocine, Shanghai
Science and Technology Press, 1985; 246-247.
(5) Zheng, En-qin, Chinese Massage, Publishing House Of Shanghai College of
Traditional Chinese Medicine, 1990; 350-352.
(6) Zheng, Xian-da, Practical Acupuncture and Tuina Therapy in Traumatology,
Sichuan Science and Technology Press, 1997; 154-157, 160-161, 166, 176-177.
(7) Yu, Dafang, Tuina, Shanghai Science and Technology Press, 1995; 123-124, 128.
(8) Feng Leshan, Treatment of Nerve Trunk Type Sciatica by Catgut Implantation at
Acupoints: 58 Cases, Internal journal of Clinical Acupuncture, 2002; 13(2): 131-
131.
(9) Zeng Zhi-jun, Warming Acupuncture in Treating 74 Cases of Sciatica, Internal
Journal of Clinical Acupuncture, 1996; 7(4): 489-491.
(10) Wang Songrong, 355 Cases of sciatica Treated with Deep Needling of
Guanyuanshu, Internal Journal of Clinical Acupuncture, 1993; 4(2): 137-140.