Spleen deficiency with internal dampness also results in the creation of adipose tissue or fat. Fat in TCM is nothing more than accumulated dampness. This dampness not only hinders the flow of qi and blood but puts more strain on the restraining, lifting, and moving functions of the spleen qi. As the spleen becomes weak, the muscles and flesh, which are the level of tissue corresponding to the spleen, lose their tone and eventually their function. In addition, because the spleen is the root of qi and blood production, if the spleen becomes damaged due to faulty diet, this may lead to qi and blood deficiency as well.

3. Rest & Activity
Rest, or literally stillness, and activity, or literally stirring, are a yin/ yang complementary pair in Chinese medicine. In TCM, it is believed that too much rest damages the spleen, and we have seen above that a weak spleen may lead to muscular weakness and the generation of dampness, both of which may cause or be involved with low back pain. On the other hand, regular exercise leads to improved digestion, and good digestion leads to the creation of the acquired essence, the essence that bolsters the prenatal essence stored in the kidneys. Therefore, regular, moderate exercise indirectly helps generate essence, while lack of exercise does not.

Conversely, excessive exercise or any excessive activity, be it physical or mental/emotional, may eventually damage the kidneys. In particular, it is said in Chinese medicine that lifting objects which are beyond one's strength damages the kidneys.

4. Excessive Sex
We have seen above that the kidney essence is associated with reproduction. In men, the seminal fluid is seen as the physical manifestation of essence and is, in fact, called jing or essence in Chinese. In addition, sexual desire is a function and manifestation of kidney yang, while sexual fluids, such as seminal fluid in men, are a manifestation of kidney yin. In Chinese medicine, it is believed that a healthy, moderate amount of sex helps free the flow of qi and relieves pent-up emotions. On the other hand, excessive sex can quickly deplete the qi and blood and particuarly kidney essence. Since essence declines with age, concern over too much sex causing low back pain mostly affects those over 45. However, depending upon constitutional predisposition or chronic disease, one may have to be cautious about this factor even earlier.

5. Drug Abuse
Many, if not most, of the drugs which people abuse are stimulants. According to Chinese medicine, substances like cocaine, amphetamines, marijuana, LSD, and even caffiene and nicotine use up large amounts of qi in their production of a "high," "buzz," or "rush". We say that they give us energy, but that energy has to come from someplace. Where that energy comes from is the kidneys, our deepest repository of essence and qi. These drugs use this energy and eventually use it up. This then can cause signs and symptoms of kidney deficiency and essence insufficiency accompanied by low back pain.

Age
Age is not considered one of the traditional disease causes in Chinese medicine. However, after 35 years of age, our production of essence from the food we eat, liquids we drink, and air we breathe decreases. This means that after this age, we are producing less of the acquired essence and are consequently using more inherited essence. Thus it is not uncommon to encounter chronic low back pain as a symptom of aging. In particular, spinal problems such as degenerative disc disease, herniated discs, osteoporosis, osteoarthritis, chronic lumbago, vertebral fractures, chronic lumbar strain, spinal spurs, etc. are often kidney-related problems associated with aging. Therefore, the TCM treatment of these spinal problems is directed, in part, at strengthening the kidneys.

Combined Causes
Weakness or other problems in the internal organs that lead to low back pain tend to develop slowly. However, it is possible and, in fact, common to have acute low back pain in conjunction with a weakness of an internal organ. For example, a person with a kidney weakness can also have an invasion of wind, cold, and/or dampness in the low back. Hence it is common to find that in any given patient with low back pain, there is a combination of causes at work, some internal, some external, and some, according to the terminology of Chinese medicine, due to neither internal nor external causes.

In describing the causes of low back pain, Chinese medicine starts from the simple premise that there is no pain if the qi and blood are flowing freely without inhibition. It then goes on to describe a number of specific causes and contributors to low back pain, all of which cause some detriment and damage to the free flow of qi and blood in the area of the low back. These range from physical trauma and diet to emotional stress and overexertion. Thus the theory of TCM about the cause of low back pain is a multifaceted one which takes into account all aspects of a person's life—physical, mental, emotional, and even sexual. This again underscores the holistic vision of Chinese medicine which cannot reduce a person's pain to a single piece of bone, muscle, or connective tissue

Honora Lee Wolfe
In TCM, treatment is given on the basis of the patient's pattern and not simply on the basis of their named disease. A TCM pattern takes into account all the signs and symptoms of the disease plus all the patient's other, seemingly unrelated signs and symptoms and the Chinese description of the cause of their condition. Therefore, all the person's symptoms are noteworthy, not just the one's that are specific to their major complaint. In fact, the TCM practitioner gathers so much information, the patient may not see the relevance of it all. And certainly the TCM practitioner takes much more time to ask questions about all aspects of the persons life than the typical Western M.D.

As we have seen in the previous chapter, kidney weakness can cause low back pain. However, in TCM, there are a number of different patterns of kidney weakness. There is kidney yang deficiency, kidney yin deficiency, kidney essence insufficiency, kidney qi not securing, spleen/kidney deficiency, liver/kidney deficiency, and lung/kidney deficiency. The symptoms of each of these separate patterns of kidney weakness are different although each will be accompanied by some sort of low back pain. Therefore, we need to know if a person is feeling cold or hot, dry or thirsty, if they are swollen with edema, what is the consistency of their stools, and the color and amount of their urine. By obtaining all the person's signs and symptoms, the practitioner can then begin to determine if the low back pain is due to kidney yin weakness, kidney yang weakness, or kidney essence insufficiency.

How does a Chinese medical practitioner go about determining the pattern of illness that is causing low back pain? First, the practitioner must have a good understanding of the theories of Chinese medicine. This includes an in-depth knowledge of qi and blood, organs and bowels, channels and network vessels, and yin and yang and how these interconnect and interact. Secondly, the practitioner must understand how illness develops and how injury affects the body. Third, the patterns of illness that develop due to external invasion, internal damage, or injury must be understood and discriminated. Keeping all of this theoretical information in mind, the practitioner then obtains information from the patient.

The Four Examinations
Since before the time of Christ, Chinese medical practitioners have used what are called the four examinations for obtaining information about a patient's condition. These four examinations are 1) looking, 2) listening/smelling, 3) asking, and 4) palpation or touching.

1. Looking
Looking examination focuses on what the practitioner can see with their unaided eyes (except for normal corrective lens). Everything about the patient that can be observed can be useful. This includes their facial expression, the brightness of their eyes, facial complexion, bodily constitution, posture, and way of moving, inspection of the affected area, and examination of the tongue and its coating.

In particular, tongue diagnosis is a highly developed skill in Chinese medicine and a major source of information about a patient's condition. Both the tongue itself and its coating are indicators of the person's condition. For example, a thick, slimy, yellow tongue coating indicates the presence of damp heat, while a shiny, red tongue without a coating indicates a weakness of yin.

2. Listening and Smelling
Listening and smelling are the second type of examination in Chinese medicine. The character in the Chinese language for this examination means both listening and smelling. The practitioner listens to the patient's breathing, the quality of their voice, or other sounds, such as a cough. For example, a person with a weak voice who coughs when active may have weak qi. Body odors and the smells of any excretions also give the practitioner useful information about the patient's pattern.

3. Questioning
Questioning the patient orally is the third method of examination. These questions include when and how the problem happened, how long it has gone on, what treatment has already been given and with what results, one's medical history in general, sensations of cold and heat, the location and quality of pain, descriptions of urination and bowel movements, sleep patterns, perspiration, headaches, dizziness, appetite, thirst, digestive disturbances, energy level, gynecological problems, and more. Because the sensation of pain due to stagnation of qi and blood differ as do the pain and aching due to the various types of external environmental energies, the patient's description of their pain is critical in determining what type of stagnation or blockage pattern exists.

4. Palpation
The last examination method is palpation or touching. Many practitioners consider this the most important of the four methods. Only by touching various areas of the body can the practitioner directly know the condition of the body and its internal organs.

The most important aspect of this method is feeling the pulse. Together with the information gained from examining the tongue, taking the pulse is central to Chinese medical diagnosis. Pulse diagnosis requires great skill and sensitivity. The pulse taken at the wrist provides information about the basic state of the person's qi and blood, yin and yang, organs and bowels, and pathogenic factors. There are 28 different standard pulse qualities described in the classical literature. For example, the pulse quality most often felt in someone in pain is classified as tight. This pulse is described as "strong and bounces from side to side like a taut rope."

Thus by gathering information through the four examinations and by comparing the patient's signs and symptoms with their tongue and pulse, the patient's pattern is understood and named. The name of the pattern describes an inherent state of imbalance. For instance, kidney yin insuffiency means that kidney yin is too weak. Therefore, the next step is creating a treatment plan which will correct the imbalance implied in the name of the pattern. If there is kidney yin deficiency, the kidneys should be supplemented and yin should be nourished or enriched. Hence treatment techniques are applied to bring about this result - the return to balance and, therefore, health.

Because treatment in Chinese medicine is based on the patient's pattern as much as or even more than their disease, treatment is individual and takes into account the whole person. In Chinese medicine, it is said,

One disease, different treatments;
Different disease, same treatment.

This means, for example, that a patient with low back pain due to invasion by wind, cold, and dampness will receive a completely different treatment from a patient with low back pain due to kidney yin defiency. While both patients could have the identical Western medical diagnosis, each would have two totally different patterns of disharmony from the TCM point of view and each would be treated according to their pattern.