This article is also available as a PDF in its published form CJOM, Vol. 10, No. 3, Summer 1999 (pdf)
Treating Back Pain with the Kiiko Matsumoto Technique
One of the most common problems acupuncturists see is low back pain. Often we see people who have tried a variety of other modalities with little or no success, and their condition is chronic, highly painful and destructive to their lives. In this article I attempt to demonstrate the approaches used by Kiiko Matsumoto for the treatment of low back pain. Kiiko Matsumoto is one of the foremost acupuncturists practicing today. She has earned a tremendous reputation even in Japan in spite of her obvious “shortcoming” as belonging to the “wrong” gender, a testament to the effectiveness of her treatment style.
One tenant of the Matsumoto style is that one should always treat the person’s underlying and internal conditions prior to treating the current problem. The idea is that the body keeps an energetic record (stagnation) of previous injuries/assaults/illnesses even if they appear to have been cured. Any new injury/assault that is not healing properly is likely to be lingering because the body’s energies are caught up in the past (past medical history) and are not available to deal with the present, current, situation. What we attempt to do is to address the first trauma the body has sustained with the expectation that this will facilitate the clearing of more recent ones. The word “injury” here refers to any medical condition. Thus when a person comes in with a shoulder pain that they say was a result of a skiing accident three months previously, we ask ourselves why it is that the shoulder is not healing. What prevents the body from dealing with the skiing accident in a timely manner? Usually the answer is an incident from the past. Often we would start to treat the person’s allergies, or thyroid condition, or the fact that parents and/or grandparents suffered from heart conditions first. The person would often express surprise claiming that their allergies (or thyroid condition, or whatever) is no longer bothering them due to medication or lifestyle change, yet, once we needle points that clear the abdominal findings which reflect the former (supposedly “handled”) condition, the shoulder improves. The person is happily surprised.
We consider this approach to be “holistic” in the sense that we look at the whole history of the person, considering all possibilities, rather than to treat the actual complaint first. If we were to just apply some known “trick” for shoulder pain, we would have a lower chance of success, and the success we would have may not last because the body is still carrying old baggage (stagnation) that can still trap the shoulder pain. We believe that we are freeing the body from the hold the past has on it, so it can be fully present in the here and now. This only takes a few minutes: I am not suggesting that one must treat the person holistically for three months prior to treating their shoulder. We do this all within the same treatment, but first addressing the underlying/constitutional issues. This tends to release the current problem, sometimes fully, sometimes partially. Once these needles are placed, we can go on to address more recent problems, and ultimately the “official complaint,” the one which brought the person in, all in one treatment.
The Matsumoto system of treating the whole body, heavily based on the work of Master Kiyoshi Nagano, is a comprehensive system and cannot be explained in one or two articles. In this article I only discuss palpatory findings and point selections that are specific to the condition at hand – low back pain. However, prior to doing so, two other tenants of this style must be mentioned.
We never needle into the injured site. TCM practitioners talk in terms of remote and local (as well as adjacent) points. We always choose remote points, not local ones. We first determine where the current problem reflects on the body in terms of pressure pain. In the case of back pain, it is often the site of pain that can be used as the reflex by which we judge our success. However, there are times when the pain at the site is too elusive or too great to be used as a reliable reflex, and in such cases it is important to find some other reflex to be used (I shall discuss areas on the front which reflect back problems). It is important that you always press a reflex area with the same amount of pressure. Your goal is to find a remote point that alleviates the reflex area. Patients often claim that “you are not pressing as hard” when the reflex area is released, so you must develop the skill of controlling the pressure as well as being able to feel changes in the tissue under the skin.
The remote points we choose must affect the reflex/target. We do not choose points based on a theoretical understanding, and consider that to be a wasted needle. To check if a point is relevant, press on the reflection area, let go of the pressure and remember the location, the angle, the amount of pressure and the texture. Then press on the remote point you wish to examine and with you other hand re-press of the reflex area. There should be an improvement on the reflex area. Ideally the patient says “wow, gone,” however, an improvement of 50% or higher is significant and merits needling the remote point. Our points are not fixed locations, and one often has to play around to find the exact location and angle that releases the reflex.
Almost always we start treating the front of the body, even if the complaint is back pain. This allows us to ascertain which historical illnesses still reflect on the abdomen (not discussed here). My own understanding is that we treat the abdomen as the site reflecting the potential of life, and the back as a reflection of the movement of life, and thus we always treat both sides, with the front treatment almost always first. Many people who come for back pain automatically lie face-down and are a bit surprised when I ask them to turn face-up. As in the case of treating their underlying issues first, they may be resistant to the idea at first, but inevitably this strategy proves itself to be extremely useful. Almost universally, when I ask the person to turn over they exclaim “wow, my back pain is so much better!” Often they say there is no longer any pain, though I still treat the back.
Aside from comprehensive abdominal diagnosis, the three most important areas to check on the front in cases of low back pain are G.B.26 (taken as the area level with the navel all the way to the side, and can be extended down to the iliac crest bone), the inguinal ligament (G.B.28 to ST30 area), and the inguinal groove (Liv12 area).
When twisting is involved, the area that serves as the axis for twisting is G.B.26, and G.B.26 will feel tight or ropy with the person showing signs of pain. Some people do not like to say that your pressing is painful, but their reaction will be clear. We press to the depth of one knuckle (that is no further than the distal interphalangeal joint): in a healthy tissue, the person would feel you fingers but no pain, no tightness, no “weird” feeling. We use three fingers (index, middle, and ring) together so that the area is not too narrow and making the pressing uncomfortable, but we place our attention primarily on one finger, this marks our target. Make sure that pressure on G.B.26 does indeed alleviate the back pain. If it does you will want to needle it. However, if G.B.26 is very painful or ropy, it is important to release it first. Usually Kid7 will release G.B.26 (same side) – we see G.B.26 as lying in the Kidney domain (level with Kidney Shu, Mu, etc.). Press on Kid7, and ensure that this releases G.B.26. Needle Kid7 30o upwards, with the channel flow (make sure you have the best Kid7, the one that release G.B.26 area the most). If the back pain is G.B.26-involving, you will find that the back is greatly improved also. Once G.B.26 is released, you can also needle it directly.
(Using G.B.26 is extremely important also for shoulder pain, especially pain on lifting the arm or along the L.I. line and for Inner Knee Eye pain. In fact, because of its importance as twisting reflex, it should be checked for all structural issues.)
When the lower back is misaligned, that misalignment will show on the front on either the inguinal groove, or the inguinal ligament, or both. This is because the pressure of the misalignment will collapse at the bottom of the torso (inguinal ligament), or displace the alignment of the torso on the thighs, showing on the inguinal groove and below. It is extremely important to release these two areas.
When pressing on the inguinal ligament, we press towards the leg (that is laterally and distally from the torso), checking the whole length of the ligament, from G.B.27/28 to ST30. Again, you may feel tightness or a rope-like feeling, or the person will tell you it is painful. We call the inguinal ligament pressure pain viscero-ptosis reflex. To release the inguinal ligament, we use ST13 (needled superficially outwards toward LU2), with the idea of “lifting” the torso from the other end. This point is especially useful on large breasted women (this treatment is also important for shoulder pain due to heavy breasts) or large individual who have a “greater interaction” with gravity. We also use G.B.26 to release the inguinal ligament (again, use Kid7 if G.B.26 is too painful, and again, this will in turn release the inguinal area), and Inner Yin, a point on the Kidney channel that is level with Liv9 (about 5 fingers above Kid10 – this point is also an excellent point to release the trapezius muscle).
There is no need to press on the inguinal groove proper: this is a ticklish area that many people consider taboo. You can press about one inch below the groove, as the adductor muscles will also show the tightness. We press three areas, the Kidney channel, the Liver channel, and the Spleen channel, all upwards toward the pubic bone (that is toward the torso). To release the inguinal groove (or inner thigh, the actual area pressed – below the groove), use Liv4. We find Liv4 the width of a thumb below the internal malleolous, on the medial side of the tibialis anterior (very close to SP5), and needle it superficially upwards (with the flow). Press on Liv4, up toward the ankle crease, and recheck the inner thigh. Sometimes Liv4 is not enough to release the inner thigh. To release the Kidney line, use Kid7, and to release the Spleen line use SP9 (we needle SP9 superficially upwards).
Lumbar spine (Du or Hua Tuo) pain often responds to SP9. This is especially true if there is more than one vertebra involved. We believe that once more than one vertebra is involved the problem cannot be purely structural, and has an internal component. You can check SP9 directly against L4-L5-S1 (Du, Hua Tuo, or even paraspinals). Palpate those with one hand (reaching under the person), and with the other hand press on SP9 up towards Inner Knee Eye. You may need to move your location of SP9. Once you find the exact SP9 which releases the lumbar pain, needle it superficially (10o) upwards (with the flow – toward Inner Knee Eye), above the bone, breaking down the “gummy” adhesions where the muscle is attached to the bone. We use a 40mm needle, using at least 30mm of the needle. (I normally use #2 Seirin needles – this is a highly sensitive area and other type needles might be painful, especially on skinny patients).
Pain along the posterior edge of the iliac crest is considered to be immune related. This type person complains of pain that is not in the center of the back but that spreads sideways along the iliac crest, just below the crest line. They may have a history of immune related issues, starting with tonsillectomy, mononucleosis, lung infections, etc. The main reflex for immune issues is S.J.16 and below: this is the area behind the SCM and reflects glands (or Wind area by TCM terminology). The treatment point is the Immune Point, which is located somewhere between L.I.10 and L.I.11 on the edge of the bone, closer to the San Jiao channel. (Note it is the adhesion of the muscle to the bone that creates a “gummy” feeling here, similar to the muscle attachment on the iliac crest). This point is needled at 60-degree angle toward the bone (i.e. toward the S.I. channel) with the addition of direct moxa. The exact point will release both the gland reflex (S.J.16) and the iliac crest. This point can also release the inguinal ligament, as weak immunity can be the cause of weak ligaments (thus it can be added to ST13, G.B.26, Inner Yin combination to release the inguinal ligament).
After treating the front, have the person turn over to lie face down. I often have people walk or move a little so as to test their back pain and ascertain the effectiveness of the front treatment. Now you are ready to address the exact pain location more specifically.
The most common injury is at L5-S1 level. For L4-L5-S1 injuries, we needle into the sacro-iliac ligaments. Tight sacro-iliac ligaments will cause tight para-spinal muscles and therefore vertebreal shifts. Palpate the lower lumbar vertebra on the center (straight down pressure) and on each side of the spine (Hua Tuo line, press toward the spine at 45o).
If there is pain only on one side of the spine (not center, and one side only), we call this S.I. channel pain. Women who sit on one hip (as they often do traditionally in Japan) can develop one hip higher than the other, affecting a shoulder pain along the S.I. channel, as well as back pain showing on one side of the spine. HT3 (same side - needled superficially and down with the flow) does an excellent job for this pattern (we also use HT3 for other S.I. channel pain). To that we often add G.B.26 as well as U.B.27 (S.I. Shu). We take U.B.27 as the gummy/ropy area at the lateral-superior edge of the sacrum: this is one part of the sacro-iliac ligament, and is always further than 1.5 cun out of the spine.
If the pain is on both sides of the spine, or includes the center line also, needle into the sacro-iliac ligaments on both sides (up to 4 needles on each side). You must find the gummy/ropy section of the ligament, and break it down with the needle. You aim the needle so that it is angled under the bone toward the opposite G.B.26, but because of the tightness, the angle often reverts to almost 90o. If the sacro-iliac ligaments are too painful to needle into, try and release them by the use of Liv8. If the whole sacrum is painful, use Kid6 and U.B.62 bilaterally.
The sacro-iliac treatment is an excellent treatment for L4-L5-S1 problems, whether it is a bulging disc, degenerative discs, and even spondolythesis. It is an excellent treatment to relax the para-spinals all along the spine, not just at the lumbar level. For true L4-L5-S1 pain, this treatment is almost always successful. If you fail using this treatment, it is likely that you have not found the right gummy spots to release along the sacro-iliac ligament, or that you have not properly addressed other previous issues that the body is still carrying, or that there is a tail-bone or sacrum injury.
It is important to treat tail-bone injuries prior to the rest of the back. This is equivalent to the notion of fixing the basement before fixing the roof. Tail bone shifts may show on the front on right ST27 which can be released by LU8. (Needle superficially toward LU9: we take LU8 somewhat closer to the Pericardium channel than most TCM practitioners – you need to find the exact location that releases right ST27, either side LU8 might do the job). However, be aware that aside from tail-bone shifts, right ST27 can also reflect Lung, immunity, or digestive issues.
When the person lies face-down, you can palpate the tail-bone directly (I do it on top of their underwear). Many people do not remember childhood tail-bone injuries until they feel the pain when their tail-bone is pressed. Many people have tail-bones that are curved at an almost 90o angle to the front (that is a “collapsed” DU1). The best points to release the tail-bone are LU8 (as per above, but in this case you can check it directly against the tail-bone), U.B.66, and Hua Tuo of C6-C7-T1: you may need to use one or more of these three points to release the tail-bone.
Sacrum pain is best resolved by use of Kid6 and U.B.62. Those are needled each superficially in the direction of their respective channels; that is Kid6 toward the back of the heel and U.B.62 toward the little toe. This treatment originates with Master Kawaii who places the red clip of an ion pumping cord on U.B.62 and the black on Kid6. He also sparks Kid6 with the pachi-pachi. However, those of us in California find that just needling these points is also effective. The Ito style calls for S.I.3 and U.B.62 (Ito preferred magnets and placed the north magnet on S.I.3 and the south on U.B.62).
Lumbar, sacrum, and tail-bone shifts can all also result in lower cervical or upper thoracic shift. It is often the case that people with low back problems display pressure pain on the Hua Tuo line of C6 to T1. If these are not too painful, they can also be needled so as to affect the lower back, or they can be used as a reflection of the back pain when choosing points (especially HT3). (In other words, when choosing a remote point, that point should alleviate both the cervical and the lumbar pain for it to be considered the “best” point, otherwise we might look around that point for a slightly better result. Remember, sometimes a change of a few millimeters in location can change the results drastically.)
The Quadratus Lumborum is considered to be the Kidney muscle. Pain along this muscle (both U.B. lines, U.B.21 down to U.B.24) can be treated using LU10 (based on the understanding that the Lung is the mother of, thus tonifies, the Kidney). Our LU10 is located not at the border of the red and white skin, but on the fleshy part of the thenar eminence. This is a direct-moxa point, not a needling point.
In general, when treating pain we take into consideration the tissue of the pain. For muscle pain we use SP3.2. We call this point SP3.2 because it is further along the channel, towards SP4, than the point located at the edge of the bone. For joint pain we check for pressure pain on SP2, If SP2 is painful we treat SP5 and SP9. This is based on the principle that if the Fire point is painful (upon 3kg pressure), it can be treated through the Metal and Water points, as Water counters Fire and Metal is the mother of Water and thus enhances Water’s ability to counter Fire. Ligament pain is treated with Liv8 (this is the Water point of Wood, Wood being responsible for Ligaments), as well as the Immune points (because weak immunity can cause weak ligaments). Bone pain is treated with Kid7 (tonification point of the Kidney). This is regardless of the actual location of the pain, and based purely on the tissue type.
The Matsumoto style calls for treatment of original (or previous) assaults on the body system, a subject that needs to be learned thoroughly and cannot be addressed here. Nonetheless it is still possible to obtain tremendously beneficial results using the above treatments. It is my hope that these treatment ideas will facilitate better results for readers of all styles, levels, and skills.