The flow of qi and blood can become inhibited in any and every area of the body: the internal organs, the muscles, the joints, and the low back. For example, when we overeat and have acute indigestion with the accompanying sensations of abdominal fullness, bloating, and distention, these symptoms are due to the stagnation of stomach qi. In this case, the stomach qi cannot move freely through the excessive amount of food and drink in the stomach. Likewise, when we bruise ourselves and blood escapes from the blood vessels and then pools, we experience a mild form of blood stagnation. In both these cases the stagnation is not serious. We feel better within a short time and are free of symptoms when the qi and blood resume their proper functioning and are flowing freely.

According to TCM, the sensations of pain due to qi stagnation or blood stasis are different. Qi stagnation causes a feeling of distention or soreness that fluctuates in intensity and location. Qi stagnation pain often occurs with strong emotional changes. Blood stasis, on the other hand, is characterized by painful swelling or stabbing, sharp pain at a specific, fixed location.

It is also possible for the qi and blood flow to become inhibited because of insufficiency of the qi, blood, or both. In this case, the pain is not severe but is enduring. If due to qi and blood insufficiency, the pain is worse after rest and better after light use. This is because during rest or immoblization there is insufficient qi and blood to keep the qi and blood moving. Movement itself helps to pump the qi and blood through the area mobilized. Therefore, movement tends to make this type of pain better.

If primarily due to qi insufficiency, then the pain is worse at the end of the day or after excessive exercise. In this case use or exercise has used up the qi and left it even more deficient. Blood insufficiency pain tends to be worse at night after it has been consumed by the activities of the day and when it returns to the liver for storage.

In the TCM diagnosis and treatment of low back pain, a practitioner must answer the following questions:

1. Is the pain due to blockage or insufficiency?

2. If due to blockage, is the pain more characteristic of qi stagnation or blood stasis?

3. What is causing this stagnation?

4. What channels or network vessels are primarily involved?

The answers to these questions directly determine what sort of treatment the patient will receive from the Chinese medical practitioner. The basic principle of treatment in Chinese medicine is to restore balance. Therefore, the Nei Jing (Inner Classic) says that if a disease is due to too much, it should be drained; if due to too little, it should be supplemented; if due to heat, it should be cooled; if due to cold, it should be warmed; if due to dryness, it should be moistened; and if due to dampness, it should be dried. Therefore, in TCM, two patients with the same Western medical disease may receive different TCM treatment because the cause of their disease is different. This means that every patient in TCM is given an individualized treatment based on the cause and nature of their particular pattern of disharmony.

In Chinese medicine, there are three broad categories of causes of low back pain. These are referred to as external causes, internal causes, and independent causes. External causes refer to invasion by the six environmental excesses, while internal causes refer to damage by the seven passions or emotions. In terms of low back pain, the so-called independent causes are traumatic injury, dietary imbalance, insufficient exercise, overtaxation, undisciplined sex, and drug abuse.

External Causes of Low Back Pain
According to Chinese medicine, our qi and blood flow can be affected by invasion of energies from the external environment. These energies are wind, cold, dampness, heat, dryness, and summerheat. As mentioned above, one of the five functions of qi is to protect the body from invasion by these environmental energies. If the defensive qi is weak, environmental energy(s) can invade the body, settling into the channels, and block the flow of qi and blood in those channels. According to some Chinese doctors, such invasion by external energies can only occur if the defensive qi is deficient.

Invasion by these kinds of external energy usually involves at least two kinds of environmental energy. In other words, they do not usually invade the body singly but rather in pairs or triplets. For instance, wind often combines with heat, cold, and/or dampness. When these energies invade the upper body, we typically come down with a cold or flu. But when they invade the low back, we may get acute low back pain.

Each environmental energy has a unique set of signs, symptoms, and pain sensations that appear when they lodge in the body and cause acute low back pain. Four of the six environmental energies may cause or be involved in external invasion low back pain.

1. Wind
Wind is usually the primary environmental energy to invade the body, while the other environmental energies are typically carried by this wind. Wind refers to any unseen pathogenic factor invading the body from outside. However, it also describes the pattern of the complaint it creates. Pain due to wind comes and goes. It moves around the body just as wind moves about the earth, affecting one joint and then another. Wind blocks the qi, so the pain is achy.

2. Cold
When cold settles into the channels, the pain tends to be in a fixed location and is sharp and severe. Cold congeals the flow of blood, thus resulting in blood stasis. Pain due to cold gets worse with cold and feels better with warmth.

3. Dampness
Dampness has a fixed nature like cold. However, the pain due to dampness is a heavy, sore type of pain. It is never sharp or acute. Unlike low back pain due to wind and cold which come on quickly, dampness tends to develop slowly and have a more chronic nature. When dampness becomes lodged in the channels, changes in the weather and especially low pressure can often make the pain worse. Dampness can also involve swelling which is a sign of too much fluid accumulation.

4. Heat
Heat type pain involves redness, swelling, and hot sensations, especially of the joints. Pain due to heat can be the result of the invasion of heat directly into the body. However, in terms of rheumatic pain complaints, it is more commonly the result of long-standing dampness or cold that has transformed into heat.

Low back pain due to the invasion of environmental energies most commonly involves the combination of wind, cold, and dampness or occasionally the combination of wind, dampness, and heat. As stated previously, these energies can only invade the body if the defensive qi is weak. If there is no weakness in the kidneys or liver, then the invasion will be short-lived and the person will have an acute case of low back pain. However, if the kidneys and liver are weak, then the invading energies can settle into the low back causing chronic low back pain.

Internal Causes of Low Back Pain
In TCM, internal causes refer specifically and only to damage by the seven passions or emotions. This is not a major, primary cause of back pain. Liver depression due to stress and frustration may cause sciatica and sacroiliac pain due to the liver qi's relationship with the gallbladder channel which traverses this area. However, once back pain has been caused, emotional dis-ease may exacerbate and prolong it. Liver depression, qi stagnation will add to or aggravate any condition in the body where the free and smooth flow of the qi and blood has been affected.

It is also possible for emotional damage to create the environment in which either trauma or invasion by external environmental energies actually results in back pain. For instance, constant fear may damage the kidneys leaving the low back area weak. Thus the person may injure their back by a seemingly harmless movement. Or constant worry may damage the spleen. Since the spleen transforms the blood, spleen deficiency may result in blood insuffiency. Hence the sinews may not be nourished and may be chronically tense and tight. Or the muscles may not have sufficient qi, i.e., strength, to do their job without injury.

Independent Causes of Low Back Pain
This group of disease causing agents may seem inappropriately named to Westerners. After all, isn't diet something we take in from the outside and isn't trauma something that occurs to us from the outside? The fact that diet, exercise, overtaxation, trauma, and poisoning are all considered independent causes points up the fact that, as a system, Chinese medicine has its own internal logic which has nothing to do with modern Western medicine nor with our ordinary use of English words.

1. Traumatic Injury
The first of these independent causes of low back pain is traumatic injury. Traumatic injury to the low back is a major health problem. Trauma results in damage and even severance of the channels and network vessels. This allows the blood to flow outside its vessels and pool. Because the qi follows the blood, it also pools. This pooling of non-free flowing qi and blood results in heat, swelling, redness, and pain. The more serious the trauma, the more serious the stagnation of qi and blood.

Trauma to the low back ranges from mild to severe. Any or all the tissues comprising the low back may be involved. The least serious and easiest to heal injuries are to the muscles and tendons. The more serious injuries involve certain ligaments, the vertebral body and joints, and the disc. The most serious problem is trauma to the spinal cord.

In TCM, it is important to identify which tissues have been injured. There are specific medicinals which heal specific tissues. For instance, one would use different herbs to treat muscle trauma from those used to treat trauma to the vertebral body. However, the guiding principle for all traumatic low back injuries is to get the qi and blood flowing freely as soon as possible. It is essential to get the qi and blood moving for two reasons. First, when the qi and blood flow, there is less or no pain. Secondly, the longer the qi and blood stagnate, the more complicated the recovery becomes.

When the qi and blood stagnate in the low back, the defensive qi cannot operate effectively. When the defensive qi is not operating at full strength, wind, cold, and dampness can easily invade. If the qi and blood stagnation continues and wind, cold, and dampness have settled into the low back, the kidneys and liver will eventually be affected and begin to weaken. When the kidneys and liver weaken, the low back becomes weaker because these organs are the mainstays of its strength. As this scenario progresses, the low back becomes even more susceptible to further invasions of wind, cold, and dampness. This is how chronic low back pain develops from trauma injury according to TCM.

2. Poor Diet
According to Chinese medicine, the spleen is the organ in charge of digestion. It is the spleen qi which transforms and transports the food and drink ingested. If, through overeating sweets and fatty foods, raw, chilled foods, and drinking excessive chilled beverages with meals, the spleen is damaged, it may fail to transform and transport liquids and these may accumulate to become internally generated dampness. Because dampness is yin, it tends to percolate downward in the body to lodge in the lower half of the body, including the low back. There it obstructs and hinders the flow of qi and blood. Commonly, such internally generated dampness transforms into heat and thus gives rise to damp heat mutually stagnating with the qi and blood.

According to a set of theories developed in China around the time of Genghis Khan, dampness percolating downward from the spleen can damage both the liver and the kidneys, and we have seen above how important the liver and kidneys are to the health of the low back.