Low Back Pain at SI Joints: Relieve It in 5 Seconds Using Needles. No Acupoints Needed

Low back pain (LBP) is among the top 10 diseases and injuries that account for the highest number of disability-adjusted life years (DALYs) worldwide (WHO, 2013). The best result of conventional intervention for LBP reported so far is an 27.4% response rate (> 33% pain reduction) after 10-15 sessions of treatment with drugs, exercise plus physiotherapy (Haake, M. et al, 2007). A 27.4% response means that in each 10 LBP patients, there are more than 7 patients for whom conventional therapy is useless.

Disappointed with conventional medicine, many LBP patients have to seek alternatives such as manual body work therapies, acupuncture or others for help. Two of most frequently used alternatives (spinal manipulation and acupuncture) for LBP have been shown by randomly controlled trials (RCTs) to be 5% to 30% more effective than conventional interventions, but the outcomes remain strikingly heterogeneous and unpredictable.

On the other hand, extremely few of healthcare practitioners today are aware that for the ancient Chinese doctors millennia ago in China, the relief of pain (including LBP) was just a piece of cake: the outcomes are magically instant, highly consistent and reliable.

The Miracle of Ancient Acupuncture

The acupuncture widely practiced millennia ago in China as described in Huangdi Neijing was a miracle. The relief of pain (or any abnormal sensations) including low back pain (LBP) happens instantly upon the needle insertion. More importantly, such instant efficacy was highly reliable, consistent and predictable. When you read Neijing, you can always feel intensely the ancient Chinese doctors' strong confidence in the efficacy of their needling: if the pain relief is not instant, you just have not done the job correctly.

Why Neijing acupuncture works like a magic? It is because it treats the pain at specific location by needling or bleeding the specific spots or areas, case by case. There are no “accurately” defined fixed points to prick or bleed. For any specifically localized ailment, the specific point or area for healing can only be determined by palpation and/or observation of abnormalities of the skin case by case.

On The Low Back: Where Is The Pain Located?

The Global Burden of Disease (GBD) study defines LBP as pain on the posterior aspect of the body from the 12th ribs to the lower gluteal folds ... that lasts for at least one day. This is rather a big area covering almost the entire lower half of the posterior body trunk. The exact location of the pain can happen anywhere in this part of the body. For example, it may be on any vertebra joint or joints of the spain (T12 – L5, S1-S5, or tail bone), or on the sacroiliac joints (SI joints), or in the muscles such as multifidus, spinalis, longissimus, iliocostalis, or obliques, just to name a few... on either side or bilateral ..., the possibilities of the location of pain is endless.

Acupuncture for LBP: No Acupoints Needed

For practitioners who use needles treating LBP, where do we place the needles? Today's most widely practiced acupuncture is called TCM acupuncture which was invented in China in 1950s largely based on herb theory. Ask a newly graduated TCM acupuncture student to select acupoints for LBP, I am 99% for sure he or she will choose acupoint BL 40 (a spot at popliteal fossa) and BL 23 or BL 25 (a spot 6 cm lateral to L2 or L5 vertebra joint) without asking back “can you first tell me where the pain is exactly located?”

Such a treatment is just a “one size fits all” and “a stab in the dark”, and will fail in 99% of cases in achieving any instant relief of LBP, although it may produce a meager pain relief with 10 – 15 treatments after as long as a few months, as demonstrated in numerous RCTs on LBP worldwide (including Germany, America and UK...).

In sharp contrast to TCM acupuncture, in the millennia old Huandi Neijing (Neijing) acupuncture the LBP was treated case by case depending on the specific location of the pain.

There were no "one size fit all" so-called acupoints.

In Suwen 41, On Low Back Pain (刺腰痛) of Neijing, the needling sites for treatment of 26 types of LBP was given. For each type of LBP, a corresponding ball-park area is provided for needle insertion or bleeding, not a “one size fits all” therapy. More importantly, the absolute majority of the ballpark area used for treating LBP are located distally on the leg close or below the knee joints.

Neijing merely provided 26 examples of the types of LBP based on a ballpark area of location. In the real world, you can identify at the least 100 types of LBP based on the more finely defined location of pain. With each type of LBP, there are at least 100 spots on the body which once pricked could induce a relief of pain, more or less, in the low back.

The key issue here is: Which spot will produce the maximum and quickest pain relief reliably and consistently for each type of LBP?

Among the numerous locations of the pain at low back, the prevalence of pain at sacroiliac joint (SIJ) is second only to the pain at L5/S1 as I saw in my clinic experience. In this post my topic is on SIJ pain.

SIJ Pain: Instant Relief Using Needles. No Acupoints Needed

The Sacroiliac joint (SIJ) is a C-shaped synovial joint surrounded by a fibrous capsule structure located bilaterally between the sacrum and the ilia. The SIJ pain is localized in an area of approximately 3 cm × 10 cm inferior to the PSIS. It can be unilateral or bilateral.

In the SIJ pain area, the pain may happen at subregion A, B, or C, or A + B, or B + C, or A + C, or A + B + C (Figure 1).

Correspondingly, there are hundreds of places on the body where a needle insertion, a toothpick poking, a finger pressing, or even a car key poking, can produce a relief more or less for any specifically-localized SIJ pain if the intervention repeatedly applied for weeks, months or years (for example, using TrP dry needling, or TCM acupuncture, or other type of meridian acupuncture etc).

Among these places, there are at least 10 places where you can identify some tender spots by palpation using the tip of your thumb. Needling these spots will produce an instant relief of SIJ pain with at least 90 % certainty. The most convenient spot (easy to needle and less painful for the patients) is located at the foot in the dorsal 3rd/4th intermetatarsal area (Figure 2).

If the SIJ pain is unilateral, always start the needling on the opposite foot. Put the needle on the same side also works magically but doing the opposite is usually even more magic. If you are lazy, you may simply insert 3 needles in a raw covering the entire 3rd/4th intermetatarsal area.

As mentioned earlier, in the SIJ pain area on the patient's low back, the pain may happen at subregions A, B, or C, or A + B, or B + C, or A + C, or A + B + C (Figure 1). So your needling will be applied to the tender spots at foot accordingly.

You can insert the needles while a patient is in a sitting or standing position. No need to request patients to undress (except socks off) and neither necessary to lie on a treatment table (unless the patient is very old or weak). After you inserted needles on the feet, ask your patient “where is the pain now?” while keep him or her wriggling the waist (or if the patient lies on the table, then put your hand under patient's low back and press and massage the SIJ area). Within 3-5 seconds, at least 90% for sure your patient will wow: Are you a magician?

Before insert needles, be sure to ask patient “how much pain do you feel right now, on a scale of 1 to 10?” This is for a comparison which will let you know how much your needles worked instantly after the needle insertion.

Three to 5 seconds within the needle insertion, the patient will tell you no pain any more, or much less than before, or 50% better ....depending on how severe or how chronic the initial condition is. Ask patient to rank the pain level again on a scale of 1-10. Now you can let the patient lie on the treatment table to have a short nap while having the needles stay there for 20 minutes.

With Many Options, You Can't Fail

Attention. The needling area shown in Figure 2 is just one most convenient option. If this option does not take SIJ pain away completely, you have at least 10 more options to add needles until the pain is completely gone.

Also if patient tells you that he or she feels the remaining pain at SIJ is very deep, this usually indicates the injury as SIJ also present at the anterior side of SIJ. For such cases, you have further additional options to deal with such deep SIJ pain.

In short, with so many options, you can't fail in completely knocking SIJ pain out in 10 minutes.

Finally note that usually the instantly relieved pain will come back at a lower intensity in hours or a few days or weeks depending on how severe or chronic the initial condition is. The permanent cure of a moderately-severe SIJ pain by needling usually needs 5-10 treatments at 1-2 sessions per week.

Avoid “Rub Salts to The Injury”

Remember that it is best to use the small size of needles (G40, 0.16 mm diameter) and make sure not twist or thrust the needles to force your patients to feel the discomfort de qi sensation. De qi manipulation is utterly unnecessary but only scaring away patients. More importantly, we want to avoid “rub salts into injury by any chance”.

Lastly, always remember: Compared with the size of a nociceptive nerve ending, the area of SIJ is of a huge size. Not every patients with SIJ pain have exactly the same nociceptive nerve ending groups which produced the pain signal (flip of action potential) for the brain to perceive. Therefore, there are no SIJ pain relief acupoints available which are "accurately" or "precisely" defined at specific location (like the TCM textbook does). Instead, there are only ball-park areas where impromptu tender points can be identified, case by case.

References

Guilherme Barros et al, Sacroiliac Joint Dysfunction in Patients With Low Back Pain, Fed Pract. 2019 Aug; 36(8): 370–375.

Haake, M. et al, German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups, Arch Intern Med, 2007 Sep 24;167(17):1892-8

Phillips FM. Lumbar spine fusion for chronic low back pain due to degenerative disc disease: a systematic review. Spine (Phila Pa 1976). 2013;38(7):E409

The Inner Canon of the Yellow Emperor (Huangdi Neijing): Suwen 41 刺腰痛, Suwen 63 缪刺论.

WHO, 2013, Low back pain, https://www.who.int ? areas ? Ch6_24LBP PDF