Shiatsu for Chronic Pain In The Lower Back (Wilfried Rappenecker)

Translation: Zoë Binetti

Not all back-pain is identical. Even though they are common patterns, and typical causes almost always play a role in their development, the arising of each pain in the lower back is due to a singular concrete life-situation with individual emotional and physical (or in other words energetic) patterns. According to my experience, it is the understanding of the specific situation of each person concerned that makes the treatment more sensitive and more effective. With this article, I would like to encourage you to open up to the particularity of the life-situations of each client with chronic ailments in the lower back, and to explore how these life-situations manifest physically and energetically in the body.

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This is the outline of the topic of this article: Shiatsu for chronic pain in the lower back (with or without radiation to the legs). Necessarily, this article is subjective and incomplete because it is based on the experience of my own practice, and on the way I practice Shiatsu. It excludes important subjects in the treatment of back-pain such as accurate meridian treatment according to one of the energetic body diagnosis systems of Shiatsu, which can be very effective. The article is not focused on acute ailments of the back caused by the singular appearance of lumbago, for example. Furthermore, I will not talk about acute or chronic pain in other parts of the back. However, the understanding prescribed in this article may be useful for such ailments as well.

Pain is Subjective

We are frequently able to become aware of the individual life-situation in which back-pain developed even before “laying hands” on the patient for the first time. The person affected carries around his or her history, and important parts thereof can be openly read (identified) by any interested practitioner. For some, the focus lies on the physical pain; for others, the suffering exceeds the physical level.

Pain belongs among the most subjective phenomena in life. Objectively, it does not seem to exist. The same physiologically evident nerve impulses may be experienced by one person as intolerable pain, whereas another person is able to ignore it or even find enjoyment in it. The more a person suffers from his ailments, the more pronounced the emotional component is (in most people). This emotional component can be so predominant that the physical pain may appear inessential to an outsider. There are more than a few cases in which this plays a central role regarding the maintenance of suffering.

Therefore, it is rewarding to keep an eye open for the moods of our client. In my opinion, we create our pain; it does not just happen to us. One good and simple method towards approaching the reasons why someone needs to create his energetic patterns and his pain consists of laying the hand onto the most affected area, and simply waiting for what it may tell us. If one does not forcefully try to experience something, but remains open for unexpected and exciting stories, one will often find oneself in the “middle” of things actually happening.

As an example: all at once it will become obvious that a pain due to continuous, pronounced straining of the lower back (in the case of a small and energetic woman), is really caused by the fact that this woman believes she needs to tense up in that area to be taken seriously or to be acknowledged (to stand on her hind legs, so to speak). In another case, that of a man with chronic weakness in the lumbar area, the cause may be due to the subconscious conviction of never having received enough support through his environment. In a third person suffering from tormenting pain, which has acutely increased, the practitioner touching him may have a clear perception of tremendous rage.

Strength to Meet Life Immediately and Fully

We can see an elementary task of the lower burner (on the back side, the body’s lumbar and sacrum area belong to this, and on the front side, the whole Hara) as meeting all the events in life immediately and fully. It seems to me that the underlying pattern in most cases of chronic pain in the lower back is the attempt of the person suffering not to live fully. Rather, such a person seeks to numb experiencing and feeling in this area, and even tries to avoid it as much as possible.

If the lower burner is not allowed to do its work (fear and avoidance patterns play the biggest role in this), other body areas will take over. Like for example, the middle burner will oftentimes take over with the energies of earth and wood. The chest will often hold back emotions of the fire and metal elements. And, almost always, the shoulders will take some of its functioning. The shoulders anyway often seem to be doing the work for all three burners.

The becoming un-lively in the lower back one can already see oftentimes, as a beginning process, in children that are 3 or 4 years old. This indicates that very early experiences respectively brought along (made) patterns of the experiencing, and are at the core of the change towards un-liveliness. Typically, this in the long term, leads to the life energy of the lumbar area moving away to substitute places. Left behind is an inactive and weakened zone, which longs for a supporting and warming hand. Because it mostly does not get what it longs for, the area has to tense itself in the muscles, the fascia, and the joints, to preserve a (reduced) stability.

Such tensions can be a cause for extremely strong and, also, less strong pains. In the case of acute Sciatica, complaints include an acute blockage joining the underlying basic pattern (many times out of the wood element), and an unlivably painful movement of the Liver Energy. I suspect that the pain is only seldomly caused through an energetic weakness, or emptiness in the lower back, alone.

The Releasing of the Tension Alone is not Enough

So, the goal of an effective Shiatsu treatment will be to stabilize and harmonize the area in such a way that, on the one hand, the tension (as immediate cause of the pain) becomes less, and, on the other hand, that the un-liveliness, which underlies the tension, starts making room for the beginning of reawakening. The latter will only happen if the underlying un-liveliness surrenders to integrate the weakened area into the flow of the whole back.

Just releasing the tensions is relatively easy, and often also leads to temporary relief of the complaints, sometimes even complete freedom from pain. Nevertheless, by itself, and without activation of the “un-lively” areas, it can lead to bigger weaknesses, and through this, endanger the entire area. The “reanimation” is the real, and sometimes lengthy, process being undertaken. This process can be triggered and gone through by the person involved, with the stimulating support of the therapist.

By the way, an energetic emptiness and feeling of exhaustion in the lumbar area only rarely means that the kidney energy of the person is so exhausted that it is not capable to restore vitality and strength there. Rather, it is a local imbalance, and wrong use of the energetic and physical body. Under good circumstances, the person concerned may be able to balance these fully again. But, this may take some time… maybe even years. And, first of all, it requires a strong will from the person concerned to really change something. As a rule, it will also not be enough just to receive Shiatsu. Our client will, sooner or later, have to take responsibility for his lack, and become active.

Slipped Disc – Western Medicine’s View of its Causes

In my opinion, western medicine has only partially understood the process that leads to back pain. It understands the pain in the lower back, for example, as being a result of tension and irritation of muscles and ligaments (of which there are many in the region, forming a unity with vertebrae and pelvic bones). This can arise through chronic misalignment (about whose cause one doesn’t think much), the pro-lapsing of an over strained disc, or through a natural anatomic irregularity – such as malformed vertebrae, an additional lumbar vertebra, or gliding vertebrae.

If there are additional, painful radiations into the legs, this will be explained with the irritation of one or more spinal nerves. If the radiations are defined (and maybe even go with a disorder of the sensitivity of the skin, and a weakness of certain leg muscles), it is suspected that the cause of the irritation is a nerve that is trapped or pinched by a disc that sticks out. This is called a protruding disc, a slipped disc, or a prolapsed disc (if the disc is damaged and the fiber ring breaks). Spinal nerves come from the spinal cord, and go to the peripheral structures of the body. While leaving the spine, they must pass through two vertebrae arches; here, they can be trapped by a protruding disc.

Sticking out, slipped discs, and trapped nerves can often be proven in the Computer Tomograph (CAT scan) of the spine. What does not fit this explanation model is the observation that, quite regularly, there is a lot of pain, but no slipped discs or trapped nerves can be seen (or nothing significant at least). On the other hand, sometimes definite causes are found, and yet they are not the source of the person’s complained about pain. The model of the prolapse explains the radiating pain, but it isn‘t convincing regarding an explanation for the pain in the lumbar area itself.

Manual medicine (physiotherapy), which is an official discipline of the school of medicine, but still is not fully recognized by the people in charge, knows (just like Shiatsu) the term of blockage. This describes a reaction series of malfunctions in the muscles, joints, nerves, ligaments, and fascia, and is, as a functional term, similar to the concept of the energetic blockage in Shiatsu. Different explanation models are discussed in “manual medicine” regarding what exactly is a blockage in the body in the understanding of the school of medicine. So far, none of them has been recognized as a serious alternative to the most mechanical of all models: the one of trapped nerves.

It seems to me, that only in a relatively small amount of the cases, prolapsed/ slipped discs are the direct cause of pain in the lower back. I find the Shiatsu and TCM propagated model of an energetic blockage as pain source to be more plausible (and in Shiatsu, more usable). On the other hand, a proven disc prolapse probably indicates a long term energetic weakening and an imbalance, not only in the area, but also in the whole person; that should be taken seriously.

Whatever might be the cause, I think it is important to let chronic lower back pain be checked out by a medical doctor before treating it with Shiatsu if the back pain goes together with disorders of the sensitivity of the skin and/ or weakness of specific muscles in the legs. It might be that the person needs intense care from a doctor or therapist with solid experience. In addition, for juristic or legal reasons (that means self-protection for the Shiatsu practitioner), these patients should be forwarded to other professionals. Of course, in the case of a slipped disc, Shiatsu treatment can be done with success. I think, though, in such cases the treatments should be reserved for experienced practitioners. Especially in the situation of an acute change for the worse of chronic pain, I recommend that “if in doubt,” not to treat, and possibly to forward the client to a more experienced practitioner.

The back has many faces. The energetic patterns and life experiences that can be the root of chronic pain (as mentioned in the beginning), can be found again in the different sections of the back. Of course, if one looks attentively and openly, the lower back is not isolated with its complaints. Oftentimes, the whole back side of the body has lost its unity and has fallen into separate parts with their own stories and their own dynamics. The bladder energy is not flowing any more, and it starts to become “lumpy.”

If it succeeds in letting the “fallen apart” areas find their way back into a common story, the lower back will have the possibility to find back its lost liveliness. This is because it seems like the blockages and irregularities in the other parts are what enable the back to hold itself in a stuck, imbalanced pattern. This can go so far that, quite frequently, in a treatment for pain in the lumbar area, this part of the back doesn’t even need to be touched directly (and often shouldn’t be touched). The restoration of the flow of the bladder energy through specific treatment with the attention, alone, attracting “other parts” (if necessary, with holding the connection to the pain zone), can release the blockages and give relief to the pain.

Every region of the back stands in a very special relationship to the blocked and weakened lumbar and sacrum areas. It is worth regarding the energetic expression of every region, and understanding the relationships therein, to be able to work specifically with those energies.

Now, I would like to describe some typical patterns as examples. I hope that the way of viewing this, and the procedure both become clear. In the order of the described areas, I don’t just follow the anatomy or the flow of the bladder energy from up to down. Rather, I would like to indicate that the meaning and interaction of the zones in a person often appear different and seemingly mixed up.

The Backside of the Thighs

In a way, the backsides of the thighs form an energetic unity with the region of the lower back. Typical patterns in this connection are either big, hardly releasable, energetic and muscular tensions, or the opposite… emptiness and “strength-less-ness.” The latter can be with a defined emptiness of the lumbar area (a sign of long-term exhaustion of the person). This is also a sign that, in the life of the client, there are urgent reasons to not let full liveliness exist in these areas of his or her body; and, that he or she doesn’t know how to use the body differently here, even if he or she wanted to. If the tension dominates, this can indicate that the person more or less can compensate for the unavailable strength of the lower back through strain of the entire back side of the body, and through tension of his bladder energy, without being able to rebalance the energetic imbalance.

Under the muscles of the backside of the thighs (Biceps Femoris and Semitendinosus) there can dominate a big neediness in the depth, which is happy if it is discovered and touched. Even if muscle tension cannot be passed with force, it still often desires to be touched in the center of its depth (which on the backside of the thighs is sometimes very deep). I recommend working with the elbow, so the thumb doesn’t get over strained, and to use the attention of the Hara, which allows for an attentive and sensitive treatment, following the principles of Shiatsu.

Sacrum, Buttocks, and Groin

In the sacrum area, the energy of the bladder mostly shows itself in its pure and unaltered form. In addition, one is able to control the flow of bladder energy directly from there. As an expression of this, there is a concentration of ki in the lower third, which makes this place appear a bit lofty and strong. This area is often very tense if there is back pain. At the same time, the sacrum can (especially in the upper two thirds) show energetic emptiness. For the treatment of back pain, it can become important to release the held energy in the lower third in a suitable way, and to reach the emptiness in the upper two thirds in its depth.

The mentioned tension can, following the course of the bladder meridian, expand over the whole buttocks… down until almost BL36 (below the crease of the buttocks). Beyond that, it is worthwhile to look at the depths of the buttocks more carefully. The areas of the kidneys (at the lateral sacrum border), the depth of the course of the small intestine meridian, the point gall bladder 30, and the point Ten Shi (in the upper lateral quarter of the buttocks, about 3 thumbs bellow the pelvic bone) are often important tension fields. They can be treated well locally, and also in connection with distant areas. Next to a big tension, emptiness, and a spongy swollenness can, for example, be expressions of the attempt to avoid experiencing the strength of the pelvis, and all of its connected needs and emotions.

Another key area in which a human can control the energetic flow in the pelvis area is the groin. Due to this, it can be important to also look carefully here, and (mostly) work to loosen stuck energy here. For example, in supine position, connecting rotation techniques with deep work in the groin, or possibly to work openly, using the palms of the hands and the bodyweight. (Careful with strong back pain!)

Knee and the Hollow of the Knee

The knees represent (together with the legs and the feet) the connection to the Earth. Humans can regulate this connection through a differentiated “holding on to” in the knees. The suppression of fear and the emotions of the water element are essential mechanisms, which can lead a person into interrupting their contact to the Earth in this place. Unconscious, deep fear can be seen as a central causal factor in a chronic blockage in the lower back. That is why it is not astonishing that with long-term pain in the lumbar area, the hollows of the knees are often of a special quality. The water aspect of the knees shows itself most defined in this area.

So the hollows of the knees might appear tense in the attempt to control the emotion of the water. Alternatively, they might appear empty and needy as an expression of exhaustion and giving up. Oftentimes, they will tell “their story” eagerly if one places a flat hand on them with light pressure. I have the impression quite frequently, that the knee hollows are especially capable of expressing the helplessness, the exhaustion, and/ or even the despair of the lower back. The attentive work with these states of being can directly relieve complaints in the back…

Beside the water element, also the energies of the middle warmer (earth and wood) are mirrored in the knees. The state of these two elements can directly govern the situation in the lower back. Also, in such a situation, the treatment of the knees, and the according meridian energies, can be very helpful.

Lower Leg and Ankles

The Lower down the leg one travels, the more the influence of the water element and the bladder energy dominate. Tiredness, weakness, and/ or too much tension in the calf muscles, the ankles, and the feet, show, more immediately than in any other part of the body, the long-term state of this element. Especially the pressure on the Achilles tendon can often give direct information about how rested or exhausted a person is, and how he or she deals with his strength. In this, it is similar to touching the knee hollows.

Even though there are other meridian qualities involved, bladder energy and the water element are the qualities that react immediately to lower back pain. That is why Shiatsu on the ankles (bladder 60 and kidney 3!) and on the different energetic states of the soles of the feet and the toes, are good for vitalizing the bladder energy as a whole, and bringing that energy to flow. Also, the stimulation of the bones in the arch of the foot through standing on them can be quite helpful.

It is good if one looks at the feet before one touches them for the first time, and questions oneself as to where the touch would be most important, and what kind of touch would be most helpful there. The answer to the question: “How do these feet connect this person to the earth?” often gives very precise clues about what the correct thing to do here is.


The middle and upper back can play an important role in the evolving and keeping of blockages in the lower back. Not only do the upper parts take over important tasks of the kidney and bladder energy with the increasing un-liveliness of the lower back (as mentioned already), but often the energies of the chest (and the middle and upper back) seem to have their own, frequently quite clearly defined, “emotion dependent” reasons to bind ki to them. Typical patterns are the holding on to ki in the middle back (in the area of the Yu points of earth and wood), and in the upper back (in the areas of lung, heart, and/or pericardium).

Often, like this, isolated seeming, clearly defined ki concentrations evolve in the area of the upper back, or in the chest, for example. They attract so much energy, that they allow the emptiness in the lower back to be held, and possibly even produce such emptiness. Of course, such a pattern can often cause greater or lesser intensities of pain in the according areas of the upper back.

In such a situation, the healing of the back-pain in the lumbar area might only last if the energetic pattern in the chest starts to change. This can happen indirectly, as a result of working with the water element in the different body sections. However, the patterns of the middle or upper warmer can also be reached directly where they anatomically are, or over the according meridians.

The Lumbar Area Itself

With good reason, I mention the actual place of the pain-zone discussed in this article as the last of my list. Not only, as mentioned already, is the direct treatment of the lumbar area not necessary to relieve the pain, but it can also be harmful, and it can even make the situation worse.

With the exploration and treatment of the different sections of the body and back (if it was successful), the ki-flow of the bladder meridian has been stimulated and balanced. The Shiatsu on the backside of the thighs, the knee hollows, the ankles, and in the shoulder/ neck region all really trigger a relaxation in the lumbar zone and a significant relief of the complaints thereof.

In almost every chronic lower back pain, there is an explosive mixture of emptiness and tension. The question, then, will always be, “How big is the part of the emptiness; how big is the part of the tension; and, which one dominates right now?” So, “right now,” is the priority to release the tension, or to stabilize the emptiness? This can change from one treatment to the next, so it should be checked again every time. Oftentimes, it is possible to respond to both states in the same treatment.

If, for example, there is an energetic emptiness and exhaustion behind the painful tension, probably next to the relaxation, a stimulation of the area is also needed. That means giving a treatment that draws the attention of the body, ki, and blood to the area.

Contrary to the widely held opinion that one should work with deep and long holding pressure in places of energetic emptiness, I have had the experience that this can, under certain circumstances, drastically worsen the complaints. This might be explained through the fact that a deep holding pressure mostly has an energetically calming effect.

With this type of holding, the place gets the information that everything is okay, and that it does not have to strain itself so hard anymore. Since the tired and inactive tissue behind the place of energetic emptiness is not ready to give stability yet, the weakened lumbar area can lose its last support the more the muscles let go. A renewed, defined tensing can be the reaction to this, with the consequence that, for example, a day after the treatment, the instability and the complaint are worse than before. The same effect can also occur from intensive stretching; because stretching releases stagnant ki, but does not attract the appropriate ki to replace the old stuff.

I often ask my clients to, very gently, move their pelvis and their lumbar spine area back and forth, up and down, and so on during the treatment. This is especially so during the bladder energy parts, to stabilize the lumbar area. Like this, they themselves activate the area and avoid its getting too still.

The treatment of energetic emptiness in the lower back requires a certain amount of security and experience (also in the perception of energy); because only an experienced practitioner can decide when relaxation is the priority, and, conversely, when stimulation is the priority. That is why I recommend avoiding this area, aside from a swift and light stimulation, until the practitioner has collected enough experience in his practice, and “knows what he is doing.”

What Also Should Be Treated

The perception and treatment of different sections along the flow of the bladder energy described here can be combined with the treatment of other meridians (or even a Hara diagnosis). Nevertheless, this way of treating only the bladder energy can also stand by itself. For example, this focused treatment could go on for the duration of a few treatments, until an acute situation has stabilized itself. And still, in the end, every part of the body can be important in the treatment of back-pain.

I want to mention two more areas because, in my experience, they should also nearly always be treated in this context.

For one, the Hara… this forms a unit in the lower warmer with the lower back. Weakness and inactivity in the lumbar region is nearly always combined with missing vitality in the Hara, and often also in the abdominal muscles. And so, consequently, the lower back can also be reached, harmonized, and revived through a series of effective Hara treatments.

For the other, the Shoulder/ Neck area… through the double S-bend of the spine, this area is in direct correspondence with the lumbar region. Problems in one part will often, sooner or later, also show themselves in the other corresponding part in a similar or slightly transformed way. A balancing treatment of the neck will mostly have a positive effect on the lower back. The priority here should be the harmonization of the neck, the soft balancing of energetic imbalances, and the encouraging of pain-free movement flexibility.

Tension in the shoulders always indicates, among other things, that in one or more of the three burning chambers (according to the model of the three warmers), a full vitality is being avoided. The life energy that would be needed there, is held in the shoulders. Through a releasing treatment of the shoulders, held ki can become free, and begin to flow down. This will make the treatment of the lower regions easier and more effective.

Risks and Precautions

Next to a reduction of the pains and a strengthening of the liveliness in the lower back, I myself, mainly wish that, as a result of Shiatsu treatments for chronic back pain, the client doesn’t feel worse after the treatment then they did before. That this isn’t always the case, I, unfortunately, have experienced in my own practice. In my opinion, the biggest danger on the side of the practitioner is too much ambition… working too deeply and rudely in the pain-zone, and releasing tensions in the lower back too fast and too early. There are some other things, though, which, if regarded, make a positive effect for the treatment more probable.

For instance, it is important that the client lie in a way that the lumbar area can relax. In supine position, this can be achieved through the placing of a pillow or a folded woolen blanket under the thighs and knees, and placing a pillow under the head. In prone position, I put a folded woolen blanket under the belly and lower ribcage of every client with complaints in the lower back; even if they think that they don’t need this. If the neck is stiff, then also the upper ribcage and the shoulders should sit a bit higher so they can relax. I also ask my clients to turn their heads from one side to the other fairly regularly during the treatment. It might be necessary to choose the side position in the first treatments with a client in pain, maybe even with the knees drawn tightly to the body.

Often, clients don’t lay down straight. Sometimes they will lie a bit lop-sided and a little twisted, with angled arms or pulled up legs. I ask them to lie in whatever position makes them feel most comfortable. The position they choose to lay down in is an expression of their energetic and physical situation. This is not merely interesting for me as a practitioner; this information can also make the subsequent treatment easier.

I have already mentioned above, that it can make sense to ask the patient to move the pelvis lightly up and down, back and forth during the treatment. This increases the body awareness in the region, draws ki there, and lessens the danger of the area falling asleep due to over-relaxation.

If the pain is very strong, and the emotional experiencing seems to dominate on the surface (for example, with the clear call for support from the environment), or there are other indications of an instable situation (or possible changes for the worse), then I think it makes sense to give two or three shorter treatments per week in the beginning. This has the advantage that the practitioner has the possibility to react to the (sometimes big) changes from the prior treatment, and to possibly catch “changes for the worse” early on. The client, in addition, can feel safer, which increases the effectiveness of the treatment.

I point out to my clients that, especially in the beginning of a series of treatments, there can be setbacks, that this is completely normal, and that it is not a sign of a “failure” on the part of the treatment. Mostly, these “worsenings” are only of a short duration, and normally the patient feels better afterwards than they did before. Mentioning such things avoids our clients’ feeling discouraged through a worsening of their state. It increases the trust, which seems especially important in the work with chronic back-pain.

Basically, the conversation with our client is very meaningful. It makes it easier for him to find trust, despite the pressure of suffering, fear, and tension release. This increases the healing, and makes it easier for him to accept tips and recommendations. For the practitioner, the conversation offers the possibility to find out more about the background of the complaints that will show in the treatment, and possible suggestions from the client.


Exercises and Recommendations

The active participation of the client is extremely important. In my opinion, the healing of chronic pain will often only occur if the client is willing to do something for it himself. That is why I find it important that we give our clients simple exercises that they can do at home (and also because of the effectiveness of the exercises, of course).

Such exercises and recommendations have the same goal as the treatment itself: that is, the revitalizing of the un-lively zones, the integration of the pain-bothered lower back into the flow of the whole back, and the releasing of physical and spiritual tensions. Simple movement exercises, the activation of the muscles in the area concerned while lying in bed every morning and evening, Zilgrei or Sata exercises, vitalizations, meditations, and many other activities can be quite helpful. Yoga-like exercises like the Makko Ho’s are often too strong in their effect, and too risky in cases of acute pain.

It seems important to me to not only show the client such exercises once, but to do them with them every time they come to me. For one, I can correct their practice (in case this should be needed), and also, in this way, the client gets the impression that I find these exercises important. This is, of course, a prerequisite for getting most clients to do these exercises regularly and thoroughly. 


© Wilfried Rappenecker, born 1950 near Köln (Germany), is director of the “Schule für Shiatsu Hamburg” (D-22769 Hamburg, Oelkersallee 33,, co-founder of the GSD und author of two books dealing with shiatsu. As physician for general medicine he mainly works with shiatsu.