ZHOU Zhong-yang (周忠陽), ZHAO Dan-dan (趙丹丹)

1. Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China

2. Community Health Service Center of Beizhuang Town of Miyun District, Beijing 101503, China

3. Community Health Service Center of Taishitun Town of Miyun District, Beijing 101505, China

ABSTRACT Low back pain is a common clinical disease that affects people's quality of life and causes a huge social and economic burden. Traditional Chinese medicine (TCM) has rich and valuable theory and practice in the treatment of low back pain. LI Shi-mao, a national TCM master, develops ancient meanings, combines new knowledge, treats low back pain with Pingmai differentiation (平脈辨證), performs comprehensive analysis of data gained by four diagnostic methods, centers on pulse diagnosis, and has achieved good efficacy. Here is an excerpt of 4 medical records, including XUE's No. 4 Formula (薛氏4號方)in treating low back pain caused by dampness-heat invading meridians, Shentong Zhuyu Decoction (身痛逐瘀湯) in treating low back pain caused by blockade of blood stasis, Dabuyin Pills (大補(bǔ)陰丸) in treating low back pain caused by disturbance of ministerial fire, and Guizhi Shaoyao Zhimu Decoction (桂枝芍藥知母湯)in treating low back pain due to blockade of cold and kidney deficiency, aiming at proving its principles and methods, observing its prescriptions and summing up its experience, so as to provide more reference for clinical treatment for low back pain.

KEYWORDS Low back pain; Pingmai differentiation; LI Shi-mao; Proved cases

The main clinical manifestation of low back pain (LBP) is pain and discomfort in the area below the low costal margin to above the cross hip striation[1]. Causes of the disease are related to degeneration of spinal joints, long-term strain of related muscles, fascias and ligaments of the lumbosacral region, stimulation and compression on the sciatic nerve and the posterior branch of the spinal nerve[2]. LBP affects people's quality of life and causes a huge social and economic burden[3].LI Shi-mao, a national TCM master, has diagnosed diseases for more than 50 years. He advocates"Pingmai differentiation (平脈辨證) and seeking the root cause" in clinical practice, centering on pulse diagnosis, performing syndrome differentiation based on the pulse, obtaining the method based on the syndrome, and obtaining the prescription based on the method[4]. The author of this paper once had the honor to learn from him and see significant efficacy of Pingmai differentiation on LBP. Here is a summary on Professor LI Shi-mao's experience and an excerpt of 4 proved cases of LBP, in order to provide reference for peers.

COGNITION ON LBP

LBP is also called lumbago, which was firstly mentioned in Inner Canon of Huangdi (《黃帝內(nèi)經(jīng)》). Discussion on the Essentials of Pulse of Plain Questions (《素問·脈要精微論篇》) records,"The waist is the house of the kidney. So inability of the waist to turn around indicates that the kidney is declining." It shows that low back diseases are most closely related to the kidney. Discussion on Osseous Orifices of Plain Questions (《素問·骨空論篇》) records, "The disease caused by disorders of Governor Channel is opisthotonus." Channels and Collaterals of Spiritual Pivot (《靈樞·經(jīng)脈篇》)records, "Bladder Channel of Foot Taiyang (太陽)...Changes of this channel leads to diseases... There is pain in the spine, and the waist seems to have been broken." "Liver Channel of Foot Jueyin (厥陰)...Changes of this channel leads to diseases. There is lumbago, failing to move." In addition, The 29th Questioning of Classic of Questioning (《難經(jīng)二十九難》) records, "Diseases of Belt Channel manifest as abdominal fullness and coolness in the waist,like sitting in water." The Governor Channel runs in parallel with the spine. The Bladder Channel of Foot Taiyang runs along the spine to the waist. The liver dominates muscles and tendons. The Belt Channel originates from hypochondria, around the body.Therefore, disorder of running course of channel and malnutrition of the body result in LBP. Clause 35 of Eastern Han ZHANG Zhong-jing's Treatise on Cold Pathogenic Diseases (《傷寒論》) says, "Taiyang (太陽) syndrome: If the patient has headache and fever,pain in the body, waist and joints, aversion to wind,no perspiration but asthma, Mahuang Decoction(麻黃湯) should be prescribed." It depicts LBP of Qi (氣) disorder in the Bladder Channel caused by exogenous wind-cold attacking superficies. On Pulse,Symptom Complex and Treatment of Accumulation of Pathogenic Wind and Cold in the Five Viscera of Synopsis of Golden Chamber (《金匱要略·五臟風(fēng)寒積聚病脈證并治》) records, "The patient will be affected by the syndrome with cold, by a painful sensation in the region below the waist, and by a feeling of heaviness in the abdomen as if he were carrying a thousand coins around his waist.Ganjiang Lingzhu Decoction (甘姜苓術(shù)湯) should be applied." It discusses symptoms of cold-dampness LBP and its medication. Till Sui and Tang Dynasties,the theory outline of LBP etiology and pathogenesis was gradually formed. Manifestations of Low Back Diseases of General Treatise on Causes and Manifestations of All Diseases (《諸病源候論·腰背病諸候》) records, "There are 5 causes of lumbago.The first is Shaoyin (少陰). Shaoyin means the kidney. In lunar July, Yang Qi (陽氣) of all things is suppressed, leading to lumbago. The second is wind Bi (風(fēng)痹). Wind-cold stagnates in the waist, causing lumbago. The third is kidney deficiency. Overwork of the kidney causes injury, thereby resulting in lumbago. The fourth is a waist sprain. The waist sprain leads to lumbago. The fifth is that living in a damp place causes lumbago." It unveils that deficiency of kidney and essence, blockade of windcold, overwork, injury and cold-dampness stagnation can damage Qi and blood in the waist, causing pain and other discomfort. Till Ming and Qing Dynasties,etiology and treatment of LBP were improving day by day. Tips in Treating Miscellaneous Disease of Golden Mirror of Medicine (《醫(yī)宗金鑒·雜病心法要訣》) records, "There are 9 causes of lumbago,including kidney deficiency, wind, cold, dampness,phlegm-fluid retention, Qi (氣) stagnation, blood stasis, dampness-heat and sprain." LIN Pei-qin pointed out the pathogenesis in Categorized Patterns with Clear-cut Treatments (《類證治裁》), "When kidney Qi is deficient, pathogenic factors like wind,cold, dampness and heat can take advantage of it to get in." LBP can be divided into kidney deficiency LBP, Qi (氣) stagnation LBP, wind-dampness LBP,cold-damage LBP, blood-stasis LBP, etc.. Treatment can be combined with external massage cream for regulating Qi (氣), activating blood circulation and relieving pain.

Professor LI Shi-mao takes the overall situation, manages the simple and complex, and combines data gained by four diagnostic methods.He especially focuses on pulse taking, believing that the first principle of LBP is deficiency and excess,and pulse strength when being deeply taken is an indicator. If the pulse is weak, it is deficiency of healthy Qi, and if it is strong, it indicates excess of pathogenic factors. For the deficiency of the liver and the kidney, use the essence for replenishing the kidney, and for the deficiency of healthy Qi,prescriptions for benefiting kidney and filling essence should be used. Yougui Pills (右歸丸) is mainly for kidney Yang (陽) deficiency, in which medicines like sliced Cornu Cervi and Radix Morindae Officinalis are preferred. For Yin (陰) deficiency of liver and kidney, modified Liuwei Dihuang Pills (六味地黃丸)and ZHANG Xi-chun's Quzhi Decoction (曲直湯) are applied, and Fructus Corni is heavily used. For those with kidney deficiency and hyperactivity of ministerial fire, modified Dabuyin Pills (大補(bǔ)陰丸) is prescribed.The excess of pathogenic factors is nothing more than dampness-heat, fluid retention, blood stasis,cold coagulation, etc. When dampness-heat invades meridians, XUE's No. 4 Formula is applied[5]. For fluid retention, Ganjiang Lingzhu Decoction (甘姜苓術(shù)湯) is used. For blockade of blood stasis,Shentong Zhuyu Decoction (身痛逐瘀湯) is used.For Yang (陽) deficiency and cold coagulation,Guizhi Shaoyao Zhimu Decoction (桂枝芍藥知母湯) is applied. Professor LI Shi-mao emphasized in clinical practice, "There is no fixed prescription and fixed method. Pingmai differentiation (平脈辨證)should be applied for syndrome differentiation and treatment." Using only one or several prescriptions to treat a certain disease is absurd, and it is even more absurd to abandon the four diagnostic methods but only keep an eye on pulse taking. The prescriptions listed above are to prove Professor LI Shi-mao's principles and methods, which are not the whole picture. It should not be ignored by clinical scholars.

PROVED CASES OF LBP

Case of Dampness-heat Invading Meridians

Mr. ZHENG, male, 47 years old, was first diagnosed on September 21, 2010. Chief complaint:Soreness and distending pain in the waist had lasted for more than 1 month, worsening for 1 week.There was no obvious cause for the patient's waist soreness and distending pain 1 month ago. After applying external plaster by himself, the symptoms were eased slightly. In the past one week, the waist soreness and distending pain were aggravated due to overwork, so he came to visit. Symptoms:Waist soreness and distending pain, no radiating pain in the lower limbs, stomach fullness, anorexia,good sleep, normal urination and defecation, a soft, slippery and rapid pulse, a red tongue with yellow, thick and greasy coating and tooth marks.Diagnosis: Low back pain. Syndrome: Dampnessheat diffusing downward and blocking meridians.Treatment: Clearing heat, promoting diuresis and unblocking meridians. Prescription: XUE's No. 4 Formula, including Lumbricus 15 g, Talcum 15 g(decocted in a packet), Retinervus Luffae Fructus 10 g, Radix Clematidis 12 g, Radix Gentianae Macrophyllae 12 g, Rhizoma Atractylodis 12 g,Caulis Piperis Kadsurae 18 g, Rhizoma Coptidis 9 g,Radix Angelicae Pubescentis 9 g, Rhizoma et Radix Notopterygii 9 g, Fructus Xanthii 10 g, Semen Coicis 30 g, Rhizoma Dioscoreae Hypoglaucae 18 g, Cortex Phellodendri 6 g and Radix Cyathulae 12 g. A total of 14 sets, 1 set per day, and decocted in water for oral administration. Second on October 12, 2010: The patient reported that the soreness and distending pain in the waist were greatly improved after the medication, and the fullness in the stomach was also significantly improved. The tongue and pulse manifestations were the same as before. Based on the previous prescription, Cortex Magnoliae Officinalis 9 g and Fructus Ammomi Rotundus 7 g were added to resolve phlegm and invigorate spleen. Seven sets, 1 set per day, were decocted in water for oral administration. Third on October 19, 2010: The patient said that there was no distending pain in the waist at ordinary times, and he occasionally had a stiff feeling in the waist in the morning. Another 7 sets of the previous prescription were taken and the patient was then cured.

Note: The prescription in Clause 4 of XUE Xue's Systematic Differentiation of Damp-Heat Disorders (《濕熱條辨》) was named XUE's No. 4 Formula by Professor LI Shi-mao. Discussion on the Regulation of Channels of Plain Questions (《素問·調(diào)經(jīng)論》) records, "The pathways of the five Zang viscera (五臟) are all connected with the channels in which Qi and blood circulate. Disharmony between Qi and blood causes all kinds of diseases. It is important to keep the channels unobstructed."Invasion of pathogenic factors leads to obstruction in meridians and disharmony between Qi and blood.When there is stoppage, there is pain. Dampnessheat invading meridians can cause diseases such as convulsive disease, Bi syndrome (痹證), flaccidity disease, limb spasm, muscular spasm, etc. When it happens, Professor LI Shi-mao prefers XUE's No.4 Formula, in order to dispel wind and eliminate dampness, as well as unblock meridians[6]. The patient used to have stomach fullness and anorexia.Combining the soft, slippery and rapid pulse, and the red tongue with yellow, thick and greasy coating,it indicated dampness-heat accumulation. There were soreness and distending pain in the waist. The pathogenic factor was not in the skin nor Zang-Fu viscera (臟腑), but in meridians, so it was diagnosed as dampness-heat invading meridians. In this case,XUE's No. 4 Formula was combined with Simiao Pills (四妙丸), and medicines for dispelling wind and eliminating dampness such as Rhizoma Dioscoreae Hypoglaucae, Rhizoma et Radix Notopterygii and Radix Angelicae Pubescentis were added. The prescription and the syndrome were compatible, so that dampness-heat was removed and meridians were unblocked, and Qi and blood were harmonized and LBP was relieved.

Case of Blood Stasis Blockade

Ms. LI, female, 43 years old, was firstly diagnosed on May 17, 2011. Chief complaint:Lumbosacral pain had lasted for 10 years, worsening for 7 days. The patient had had lumbosacral pain for 10 years and a history of lumbar intervertebral disc herniation, which aggravated with cold or heavy physical work. Seven days ago, the pain worsened due to housework. Symptoms: Pain in the lumbosacral area, aggravated when bending over, radiating pain on the outside of the right leg,numbness in fingers of the right hand. Good appetite,not well in sleep, normal urination and defecation, a deep, hesitant and rapid pulse, powerful when being pressed, and a dark tongue with thin white coating.Diagnosis: Lumbar intervertebral disc herniation.Syndrome: Coagulation and blockade of static blood.Treatment: Activating blood circulation, resolving blood stasis and removing blockade. Prescription:Shentong Zhuyu Decoction (身痛逐瘀湯), including Lumbricus 15 g, Radix Paeoniae Rubra 15 g,Semen Persicae 15 g, Flos Carthami 15 g, Rhizoma Ligustici Chuanxiong 8 g, Radix Angelicae Sinensis 15 g, Radix Rehmanniae Recens 15 g, 10 pieces of Scolopendra, Scorpio 9 g, Olibanum 8 g, Myrrha 8 g,Rhizoma Curcumae Longae 10 g, Radix Clematidis 10 g and Radix Cyathulae 10 g. A total of 7 sets,decocted in water for oral administration, and 1 set per day. Second visit on May 24: Lumbosacral pain was greatly reduced, sleep was improved compared to before, and hands were still numb. The tongue and pulse were the same as before, knowing that the syndrome had not changed. On the basis of the previous prescription, Ramulus Cinnamomi 10 g was added to warm Yang (陽) and unblock meridians.A total of 14 sets, and decocted in water oral administration. Third visit on June 10: The patient reported that her sleep was good, hand numbness had been improved significantly, and occasionally there was lumbosacral pain when bending over.Another 7 sets of the previous prescription were prescribed for rehabilitation.

Note: Professor LI Shi-mao defined the hesitant pulse as "small in amplitude, and having difficulty in flowing"[7]. The small pulse amplitude is caused by poor circulation of Qi (氣) and blood. The reason can be divided into deficiency and excess. A weak pulse when being pressed indicates deficiency of healthy Qi (氣), which fails to activate Qi (氣) and blood circulation and causes the hesitant pulse.A powerful pulse when being pressed indicates excess of pathogenic factors, which block Qi (氣)and blood circulation and results in the hesitant flow.In this case, the patient's pulse was powerful and rapid when being pressed, knowing that there were pathogenic factors internally blocking Qi (氣) and blood circulation, which failed to reach the outside.The tongue was dark with thin white coating, and the numbness of the right hand further confirmed existence of static blood coagulating in meridians.Being not well in sleep was caused by blockade of blood stasis and malnutrition of heart spirit. The case was treated with WANG Qing-ren's Shentong Zhuyu Decoction (身痛逐瘀湯) and insect medicines for unblocking meridians. Scolopendra was heavily used to eliminate LBP and hand numbness. ZHANG Xi-chun praised Scolopendra in Records of Chinese Medicine with Reference to Western Medicine (《醫(yī)學(xué)衷中參西錄》), "Move fast in both Zang-Fu (臟腑)viscera and meridians, unblocking any blood stasis."Professor LI Shi-mao uses Scolopendra to treat stroke and numbness of hands and feet with a large dose, generally 10-40 pieces.

Case of Ministerial Fire Disturbance

Mr. WEN, male, 33 years old, was firstly diagnosed on April 26, 2011. Chief complaint: Sour pain in the waist had lasted for more than 3 months.The patient suffered from sour pain in the waist for 3 months, without obvious inducement, which could be relieved after resting. Symptoms: Sour pain in the waist, which could be relieved after resting,accompanied by tinnitus in the left ear, like cicada chirping. Good appetite and sleep, normal urination and defecation. Pulse taking showed a moderate pulse, with Chi (尺) being vigorous, slippery, large and beating fingers. The tongue was red with less coating. Diagnosis: LBP. Symptom: Kidney water deficiency, and hyperactivity of ministerial fire.Prescription: Dabuyin Pills (大補(bǔ)陰丸), including Radix Rehmanniae Preparata 30 g, Fructus Corni 30 g,Rhizoma Anemarrhenae 6 g, Cortex Phellodendri 6 g, Radix Achyranthis Bidentatae 12 g, Carapax et Plastrum Testudinis 30 g (decocted first), stirfried Cortex Eucommiae 18 g, Radix Dipsaci 30 g and 2 segments of porcine spinal cord. A total of 14 sets, 1 set per day, and decocted in water for oral administration. Second visit on May 17: The patient reported that LBP was relieved a lot, and the tinnitus on the left was no longer obvious. The vigorous Chi was not obvious when taking his pulse, and the tongue was red with less coating. According to the previous prescription, Herba Taxilli 18 g was added.After another 14 sets, he was cured.

Note: Ministerial fire lives in the liver and kidney, obeying orders to help operating the whole body and functions in hiding and guarding. If liverkidney yin is deficient, there may be hyperactivity of ministerial fire, which disturbs normal body functions by wandering and attacking, and usually manifests as tinnitus, deafness, LBP, spermatorrhea, night sweats, etc. In this case, the patient had LBP and tinnitus. His tongue was red with less coating, and Chi of his pulse was vigorous, slippery, large and beating fingers, belonging to kidney Yin deficiency and hyperactivity of ministerial fire. Professor LI Shi-mao modified ZHU Dan-xi's Dabuyin Pills (大補(bǔ)陰丸). Radix Rehmanniae Preparata and Fructus Corni were used to nourish liver and kidney. Carapax et Plastrum Testudinis was used to nourish Yin (陰)for suppressing hyperactive Yang (陽). Rhizoma Anemarrhenae and Cortex Phellodendri were used to clear ministerial fire. Cortex Eucommiae, Radix Dipsaci and Radix Achyranthis Bidentatae were used to nourish liver and kidney, and to strengthen the waist and spine. The 2 segments of porcine spinal cord used in the original prescription were still used in this case for filling essence and tonifying Yin (陰), and it was also used for strengthening the waist and spine due to classification according to manifestation. Three methods of nourishing liver and kidney, suppressing Yang (陽) and reducing ministerial fire were applied at the same time, which took effect quickly.

Case of Cold Blockade and Kidney Deficiency[8]

Ms. ZHENG, female, 62 years old, was first diagnosed on July 31, 2009. Sagging pain in the waist, and cold below the knees. She had been diagnosed as prolapse of lumbar intervertebral disc for 4 or 5 years. She had high blood pressure,170-180/100 mm Hg, and took antihypertensive drugs. The pulse was deep, stringy, tight and slow,with Chi being less obvious. The tongue was normal.Syndrome: Cold blockade and kidney deficiency.Treatment: Dispelling cold, benefiting kidney and removing blockade. Prescription: Modified Guizhi Shaoyao Zhimu Decoction (桂枝芍藥知母湯),including Ramulus Cinnamomi 12 g, Herba Ephedrae 7 g, Radix Aconiti Lateralis Preparata 15 g (decocted first), Radix Aconiti Preparata 15 g (decocted first),Herba Asari 6 g, Rhizoma Atractylodis Macrocephalae 10 g, Rhizoma Anemarrhenae 6 g, Radix Paeoniae Alba 15 g, Radix Saposhnikoviae 8 g, Radix Morindae Officinalis 12 g, Herba Cistanches 12 g and 10 pieces of Rhizoma Zingiberis Recens. A total of 4 sets, and decocted in water for oral administration.Three methods for promoting sweating were also applied. After adequate sweating, the prescription was change to 1 set per day. Second visit on August 3: Adequate sweating after medication, and the above symptoms were improved, with a blood pressure of 115/80 mm Hg. The stringy and tight pulse was less obvious, with the left side being weak. The tongue was normal. Syndrome: Yang had not recovered, cold had not been dispelled,and manifestations of deficiency had been slightly relieved. Treatment: Warming Yang (陽) to dispel cold, accompanied by supplementing liver. Based on the previous prescription, Radix Astragali seu Hedysari 15 g and Radix Angelicae Sinensis 15 g were added. Another 7 sets, and decocted in water for oral administration. No further visits.

Note: Discussion on Pains of Plain Questions(《素問·舉痛論》) records, "When cold Qi (氣)settles outside the Channels, then the Channels become cold. When the Channels are cold, then then shrink. When they have shrunk, then the Channels are curved and tense. When they are curved and tense, then they pull on the small collaterals, thereby causing pain in the end." Cold is characterized by contraction. Invasion of cold results in contraction of vessels, so the pulse manifestation is not moderate,showing a condition of spasm. Professor LI Shi-mao calls this kind of pulse manifestation as tight pulse,and the tightness of the pulse is positively related to the degree of cold coagulation. The tighter the pulse, the severer the degree of cold coagulation[8].The patient had LBP, cold below the knees, and a deep, stringy, tight and slow pulse, which accorded with 3 major characteristics of spasm, pain and cold caused by cold pathogen invasion[8]. Therefore,Guizhi Shaoyao Zhimu Decoction (桂枝芍藥知母湯) was applied to warm Yang to dispel cold and eliminate blockade. At the same time, the 3 methods for promoting sweating, including having porridge, warm covering and continuous medication, were also used, so that the pathogen retreated with sweating without hurting healthy Qi.During the second visit, not only the patient's LBP was relieved, but the blood pressure was back to normal as well. This was an opportunity for vessels to return normal after the cold pathogen had been dispelled. Unfortunately, she did not come to visit again, and the long-term efficacy of controlling her blood pressure left unknown.