By Dennis Yang

A typical low back patient in my office has already seen his primary doctor who referred him to a specialist who took X-rays and an MRI that showed a disc herniation, undergone a surgery that invited more pain, gone through months of rehabilitation, and still takes pain killers to battle the unforgiving pain.  Worse yet, he is told that the pain is all in his mind, and that he needs to see a psychologist.  The same medical community says that the majority of low back pain has no definitive cause.  Ironic, isn’t it?  I know that this scenario is very biased as only the patients for whom the conventional medicine has failed to help come to see me.  However, this scenario repeats itself all too often.

Before I proceed, I want to share the statistics from National Institute of Health with regards to disc herniation and low back pain (LBP).

• ~98% of LBP has no serious underlying pathology or nerve root compromise, and is caused by muscle, connective tissue or joint dysfunction
• 30% of people without LBP have a disc herniation while as many as 90% have some degree of disc degeneration

In other words, the chances of a disc herniation causing your LBP are slim.  I am not saying that the X-rays and MRI reports telling you that you have a disc herniation are wrong, or that disc herniation never causes LBP, but that automatically assuming that a disc herniation equals low back pain is incorrect.  As a matter of fact, I am not trying to belittle any medical professions; we acupuncturists tend to blame LBP on kidney qi deficiency and bladder channel stagnation, and be oblivious to other possibilities.

I strongly believe that the reason that the correct diagnosis and proper treatment for LBP is so elusive is that different LBP pathologies are lumped together as one.  Healers of different schools of thought often have fixations on one cause for LBP; some put the blame on psoas major, some on sacroiliac joint dysfunction, some on stagnation in acupuncture channels, some on emotional stress, and some even on bacteria.  Well, all of them are correct, and that is why LBP needs to be looked as a set of multiple pathologies, as opposed to one single pathology with one cause.

The way I categorize LBP is by location of pain, type of pain, and movements that ease or worsen the pain.  This gives me an idea of which structures are involved; disc herniation, facet joint degeneration, spinal stenosis, muscle strain, and ligament sprain.  Examining static and dynamic postures, along with manual muscle testing and orthopedic testing, reveals postural deviations that most likely caused the pathological structures in the first place.  While all these variations require different treatments, there is a baseline treatment that is the core in all of my LBP treatments; restoring psoas major, gluteus maximus, medius, and minimus back to normal functioning by releasing stagnation in them.  These 4 muscles are the biggest muscles that control the location, orientation, and motion of the pelvis upon which the spine rests, and restoring them is the key in my LBP treatments.  More precisely speaking, the sacrum is the moving door upon which the spine rests, the ilium is the door frame for the sacrum, and the 4 muscles are what hold the door frame together.  Without a steady hold, it is impossible for the spine to rest comfortably.

Releasing psoas muscles is challenging.  If you look at the picture (I want to give proper credit to the author of the book this picture came from, but I do not know who he/she is), the muscles go around in front of the pelvic bone, which constantly stretches the muscles.  This constant undue stretching is a disaster that creates trigger points, which is a type of muscle knot that refers pain.  As long as we walk on two feet, psoas will always be under tension, and that is why releasing it is a challenge.

I have tried various techniques from acupuncture, massage, osteopathy, physical therapy, and yoga to release the psoas, and I have yet to find one that works to my satisfaction.  The method that I find most effective, however, is indirectly releasing the psoas through releasing the diaphragm.  The psoas muscles go through the diaphragm, and the tight diaphragm fibers can squeeze them, straining them further than they already are.

The superior and posterior portion of the diaphragm is attached to the spine in the mid thoracic area, and massaging the lamina groove between T7 and T8 seems to release the portion of the diaphragm that wraps around the psoas quite well.  This area is about 1 inch lateral to the spinous processes at the height of the inferior angle of the scapula (see the modified picture from Gray’s Anatomy).  If you have a tight diaphragm, it will be exquisitely tender upon pressure.  What is interesting is that if your LBP is worse on one side, the same side of the lamina groove will be more tender.

I recommend using Maroller to release this area at home.  You can buy one from Amazon.  All the products from different manufacturers are of the same dimension.  I suggest buying one that is made of one solid piece of wood for better durability. 

The way to use Maroller is to place it on the floor, and lie down on it with the spinous processes resting in the middle of it.  Do this on a carpeted floor because the pressure can be very intense.  Do not roll up and down.  Instead, find a tender spot near T7/T8 area, and stay there until the tenderness significantly reduces.  Do not overdo this, however.  Start with a minute or so.  Also, do not go near the lumbar area while you still have pain there as this may aggravate LBP.

You can also use tennis balls in place of Maroller.  Put two tennis balls into a sock or two, and tie the open end.  It will resemble Maroller.  This is rather a poor substitute as the balls are too big to fit in the lamina groove, and too squishy to properly massage the transversospinalis muscles, but end up massaging the erector spinae muscles instead.  But, it may be good enough to do the job in some cases.

A tennis ball, however, is the tool of choice for releasing the gluteus muscles.  Put it on the floor, and sit on it at the places marked with an “X” in the picture.  Move around slowly until you find an exquisitely tender spot, and wait until the tenderness lessens significantly.  Start in the order of the numbers in the picture.  Number 1 is the motor point for gluteus maximus, and is located at the height of sacral hiatus inferior to longissimus.  Number 2 is a motor point for gluteus medius, located at mid 1/3 of a line between PSIS and greater trochanter.  Number 3 is another motor point for gluteus medius, located at the midline between the top of iliac crest and greater trochanter.  Number 3, at a deeper tissue level, is the motor point for gluteus minimus.

Do not worry about finding the perfect spots.  Acupuncture needling will require more precise location description than provided above, but when using a tennis ball, just focus on moving around slowly until you find the tender spots.  Once you find one, it is unmistakable.

Once you have released the psoas and all the gluteus muscles thoroughly as described above, you will most likely find that the LBP is either disappeared completely or at least significantly reduced.  Keep doing this a few times a day if the pain remains; structures other than muscles are most likely affected, and it will take some time for them to heal.  If, on the other hand, there is no improvement in pain, something other than muscles is the primary cause for your LBP, and you need to seek professional help.

For the acupuncturists who are familiar with motor point needling, note that resetting the spindles with needles is not enough for either T7 huatojiaji or gluteus muscles when it comes to treating LBP.  I personally use thumbing for T7 huatojiaji and elbow for gluteus muscles to sufficiently release them after needling.

Also, for those who are familiar with trigger point releasing, the idea I am presenting here is different from releasing active trigger points to eliminate the referred pain.  Rather, I am aiming to release the stagnation in these muscles to restore the proper orientation and movement of the pelvis.  In a way, I am releasing all the trigger points whether they are active or not.

Next time, I will write about correcting wrong movement patterns that caused LBP in the first place.