Acupuncture and low back pain
This article provides a basic approach to treating chronic low back pain with acupuncture, I refer to one specific treatment protocol from a scientific research study.
Acupuncture is recognised as being effective for the treatment of low back pain and is one of the most commonest conditions an acupuncturist can be called upon to treat.
Before discussing an acupuncture treatment approach, this article will look at the causes of low back pain and the standard medical treatment.
What is low back pain?
Low back pain is a common condition in the UK. According to the National Institute of Neurological Disorders and Stroke (NIH) factsheet, low back-pain:
- Affects 80% of adults at some point in their life.
- Is one of the most common causes of job-related disability
- One of the leading contributors to missed work days
Nature of Back Pain
Low back pain can be acute or chronic in nature and can affect both men and women. Low Back Pain can manifest as a sudden, sharp pain which incapacitates the sufferer. It can occur due to accident or from lifting a heavy object.
Or it can occur over time, due to age-related changes in the spine. Pain can occur in sedentary people who suddenly engage in sudden physical exercise.
Acute low back Pain
Acute back pain is considered short term, lasting a few days to weeks. It can resolve on its own without treatment. Acute low back pain can be mechanical in nature, due to disruption in the area of the muscles of the back, the spine, intervertebral discs and nerves
Sub-Acute Low Back Pain
This is a low back pain that lasts between 4 and 12 weeks
Chronic Low Back Pain
This is defined as pain lasting longer than 12 weeks. This may be after an injury or accident and even after subsequent treatment has been received. 20% of people with low back pain can continue to suffer from chronic low back pain.
Causes of Low Back Pain
- Spondylosis, a mechanical cause – the general degeneration of the spine, wear and tear in discs, joints, and the spine due to ageing.
- Sprains and Strains – injury to tendons and muscles in the lower back due to accident, overexertions, injury, improper lifting, over stretching, tearing ligaments. This is usually indicated by sudden acute back pain or ‘spasms’.
- Intervertebral Degeneration of the Discs – a common cause of low back pain. The rubbery discs between the spine lose integrity. In healthy people, these discs provide a cushion to allow the spine to twist, flex and bend the lower back. Degeneration of these discs can occur in ageing.
- Herniated Discs (Ruptured Discs) – when the intervertebral discs are compressed and herniate (bulge) outwards, or even rupture. This can lead to low back pain.
- Radiculopathy – restriction of the spinal nerve root, which may be caused by spinal stenosis or ruptured (herniated disc). Can be caused by compression, inflammation or injury on the spinal nerve. Pressure on the nerve root causes pain, numbness or tingling sensation along the path of the nerve.
- Sciatica – a type of radiculopathy, due to compression of Sciatic nerve. The Sciatic nerve is a large nerve, which travels through the buttock down the back of the leg. Symptoms of sciatica are painful, burning-like low back pain, pain in the buttocks, and sometimes down one leg, which may reach the foot. If the nerve restriction is severe, this can also lead to numbness and muscle weakness in the associated leg, due to nerve restriction.
- Spondylolisthesis – condition where vertebrae of lower spine slips out-of-place and pinches on nerves
- Injury – due to sports, accidents or fall injuring muscles, spine ligaments or tendons. Spinal discs may herniate or rupture pressuring the spinal nerves.
- Spinal Stenosis – narrowing of spinal column, which pressures the spinal nerves. Symptoms are pain, numbness, leg weakness.
- Skeletal Imbalances – e.g. scoliosis, abnormal curvature of spine. The author of this website once treated a patient with a huge abdominal hernia, which imbalanced the frame of the spine and lower body, resulting in severe back pain.
- Other causes –
- e.g. tumours in the spine may result in back pain. See my article on ‘Acupuncture and Chemotherapy: Contraindications & Guidelines‘ for guidance.
- Kidney Stones – causes pain on one side of the back.
- Inflammatory conditions – arthritis, osteoarthritis, rheumatoid arthritis, Spondylitis, osteoporosis.
- Endometriosis or Fibromyalgia
- Pregnancy and associated strains on lower back and hip.to changes in hips
- Obesity – being overweight
- Occupational risk factors – e.g. excessively sedentary lifestyle, excessive sitting (office jobs/driving) or conversely, work which involves lots of lifting and use of the spine and back.
- Overtraining, lifting heavy weights in the gym.
- Weak, inactive or undeveloped muscles – muscles become weak and do not support the spine.
Tests for low back pain
There are several types of test, but some of the most commonest are X-ray, CT and MRI scans.
- X rays will be able to detect broken bones or damaged vertebrae. Soft tissue, muscles or disc problems will not be detected.
- CT (Computerised Tomography) can detect disc rupture, spinal stenosis and tumours. It provides a 3D model.
- MRI scans (Magnetic Resonance Imaging) is more revealing and will be able to display soft tissue, muscles, ligament, tendons and blood vessels. it can detect tumours, infection, disc herniation or rupture.
In some cases of back pain, these scans may not reveal anything in the presence of back pain.
Standard Medical Treatment
‘Orthodox’ Medical Treatment is fairly limited in what it can offer, ranging from the ineffective to the extreme option of surgery. This may be one of the reasons why many sufferers turn to acupuncturists, osteopaths and chiropractors. Here are standard ‘orthodox’ medical treatments:
- Hot or cold packs/sprays/ice
- Activity is recommended over bed rest
- Physical Therapy – Referrals to Physiotherapists, who advise specific strengthening exercises
- Medications – Analgesics – pain killing medications, aspirin, paracetamol, opioid derived drugs.
- NSAIDs – non steroidal anti inflammatory drugs
- Surgery – there are various types of surgery. This may involve fusing vertebrae, removing discs or other procedures on discs. Should not be a first option. Possibly to be advised in extreme condition when everything else (including trying out various complementary therapies) has failed and the pain is severe and impacting on daily life and wellbeing.
Research Study – Acupuncture for chronic low back pain
In one trial – A Randomized Trial Comparing Acupuncture, Stimulated Acupuncture, and Usual Care for Chronic Low Back Pain, acupuncture for chronic low back pain was studied.
This study assessed chronic back pain (lasting longer than 12 weeks). Here is a summary of the treatment protocol and points used in this study:
- Du 3,
- Bladder 23 (bilateral)
- Ashi point around the lower back
- Bladder 40 (bilateral)
- Kidney 3 (bilateral)
- Moxa or electro acupuncture can be used
- Needles retained 15 to 20 minutes. Deqi obtained. Needle stimulated twice in the middle of the needling retention a through the retention and again just before needle removal
- First 3 weeks – 2 treatments a week, followed by once a week for 4 weeks (Total 10 treatments).
- Sterile disposable needles were used – 32 gauge (0.25mm) and at least 1.5 inches in length. Needling depth was usually around 1 to 3 cm.
Detailed look at this research study
638 adults with chronic low and mechanical low back-pain were spit into 4 groups. 477 patients of the control groups were to receive 10 acupuncture treatments (both real or sham) over 10 weeks. Patients were assigned to 4 groups:
One group to receive standard / individualised acupuncture. This was carried out by a traditional Chinese acupuncturist and may include moxa, electro-acupuncture or herbs. Any point could be needled and needled at any depth. Usully patient was lying prone. Needles averaged about 10 needles used and retained for around 15 to 20 minutes. Half of points used were chosen on the Bladder Meridian of back and legs.
One group to receive standardised acupuncture. This involved a standardised acupuncture protocol and included 8 acupuncture points: – Du 3, Bladder 23 bilateral, low back ashi point, Bladder 40 bilateral, Kidney 3 bilateral.
All points were needled for 20 minutes. A twirling needle technique stimulation was applied halfway through the treatment and once again just before needles were taken out. Therapists aimed to elicit a ‘deqi’ response
One group to receive simulated acupuncture (sham acupuncture). A toothpick in a guide tube was used. Curiously, the toothpick was inserted into the same 8 points as those used in the standardised treatment and these toothpicks were also applied in a manner which stimulated the skin of these acupuncture points.
My note: even though a toothpick is used in the sham acupuncture group, the fact that they are used on acupuncture points can actually mean that an actual acupuncture treatment was still being carried out. I’ll discuss this later.
One group to receive usual care – such as medications, physical therapy or general advice.
Results were to be assessed after 8, 26 and 52 weeks after the trial had started – meaning that longer term outcome measures were also being assessed. Patients were asked to fill in a questionnaire.
Patients were aged between 18 to 70s years old and recruited in Western Washington and Northern California. 62% were female. The mean age was 47. The recruitment criteria was that they had to have uncomplicated or mechanical low back pain, within the previous 3-12 months.
People with complicated back pain – e.g. cancer, fractures, spinal stenosis, infections, prior back surgery, or other factors like pregnancy, rheumatoid arthritis or fibromyalgia were not used in this trial.
Patients receiving acupuncture (both real or simulated) were treated 2 times a week for 3 weeks. And then once a week for 4 weeks. For a total of 10 treatments. Acupuncturists used sterile disposable needles – 32 gauge (0.25mm) and at least 1.5 inches in length. needling depth was usually around 1 to 3 cm.
Overall, mean outcome scores were higher for all three acupuncture groups (4.4 -4.5 points) compared to the usual care (non acupuncture) group (2.1 points). The study reported:
At 8 weeks, the proportion of participants improving at least 3 points on the RMDQ scale was about 60% in the real and simulated acupuncture groups, compared with only 39% in the usual care group. These superior outcomes in function for the real and simulated acupuncture groups remained significant at 26 weeks… However, overall differences were no longer significant at 26 or 52 weeks.
Additionally drug use reduced in the acupuncture groups:
The use of medications for back pain in the past week (mostly NSAIDS) was similar across baseline, but by 8 weeks, it had decreased to 47% in the real and simulated acupuncture groups vs 59% in the usual care group. This difference persisted at 26 and 52 weeks.
The researchers did observe that there was a different in sick days – days taken off work among the groups.
Similarly, more participants in the usual care group missed work or school for more than a day in the past month in the real or simulated acupuncture groups.
Considering that back pain is one of the leading causes of lost work days in the West, then this suggests that acupuncture could be a useful way of counteracting this.
When is sham acupuncture not sham?
Interestingly, scores between the three acupuncture groups were not hugely different. This may not be too surprising result between the that standardised and individual acupuncture. But the sham may be surprising.
Because even though toothpick were used, they were applied to actual standardised acupuncture points.
This is significant, because in some systems of Japanese acupuncture, deep needling is not always used. Instead, contact needling or even the use of a teishin (a large needle), held against the body is used. In Manaka acupuncture, a wooden hammer is even used and tapped against the skin. The Japanese have found that needling does not have to be the same, ie using thick needles inserted deeply and stimulated for deqi. Effects can also be attained through different non-invasive techniques and methods.
Wooden Toothpicks or metal filiform needles: Is it the material or the stimulation that counts?
If you think that is not real acupuncture, then I refer you to the classical acupuncture text – the Huangi Nei Jing. In an early chapter, it refers to the 9 types of needles that can be used. Here is a summary:
- Share Needle, 1.6 cun length, large head and sharp point.
- Round Point needle, 1.6 cun length, egg-shaped point.
- Spoon Needle, 3.5 cun length, little sharp point shaped like a millet seed.
- Lance Needle, 1.6 cun length, Three edged sharp point
- Stiletto needle, 4 cun length, knife-shaped point
- Round Sharp needle, 1.6 cun length, fine like a tail hair of a horse, round and sharp point, thick middle part of body.
- Filiform needle, 3.6 cun length, fine point like thin needle-shaped mouth of a mosquito.
- Long needle, 7 cun length, sharp, fine and thin point.
- Big Needle, 4 cun length, blunt point
Source: The Canon of Acupuncture – Huangti Nei Ching Ling Shu, Ki Sunu , pg34
The filiform needle is in common use today and is what everyone considers acupuncture to be. But it is merely one of the 9 types of needle. And in fact, it is likely a modern version and may differ from the ancient filiform version.
As regards the filiform needle, the Canon of Acupuncture suggests that usage should be:
Used for nourishing the wholesome Chi as well as removing pain and numbness by slow and shallow insertion and retaining the needle in position.
This passage suggests that shallow needling of the filiform would have been used.
Sham or Sham not
All of these points suggest that actually this sham acupuncture may not have been as sham as we would have liked to think. Even a mild stimulation of the affected acupuncture point can be enough to stimulate an acupuncture healing response.
It would also certainly have been convincing as a placebo, which of course may have accounted for the similarities in scores with the real acupuncture. But a case could be made to suggest that it was actually closer to being real acupuncture than sham acupuncture.
They do happen sometimes. It is worth considering this. In some cases of acupuncture, an aggravation of pain can sometimes occur. It is usually short-term in nature and resolves itself. But it will need to be explained to the patient to allay their concerns and treatment will need to be modified.
In this trial – of the 477 participants were received real or simulated acupuncture, 11 of them reported an adverse effect. This was mostly short-term pain. However, one patient reported a severe pain experience lasting 1 month. One patient reported dizziness and another back spasms. Unfortunately, the researchers do not specify which type of acupuncture or any other details around these adverse effects, so we can’t learn from this.
My own considerations when treating low back pain with Acupuncture
The points in this study above are useful points to use in a standard low back pain acupuncture treatment –
- Du 3,
- Bladder 23 (bilateral),
- Ashi point around the lower back
- Bladder 40 (bilateral)
- Kidney 3 (bilateral)
I may also include other points like:
- Bladder 52, Bladder 53, Bladder 54 and Bladder 60.
- If there is sciatica in the back, I may include Bladder 36 and Bladder 37.
- Chinese needles 1.5 to 2 cun (0.25 – 0.30) gauge needles can be used and retained for 15 to 20 minute. Additionally use moxa.
Using a different approach to treating low back pain due to muscle spasm
Personally, I think the two types of back pain – acute and chronic need to be differentiated as reaction to treatment may differ.
When not to – needle direct into a muscle in spasm
In acute low back pain – due to spasm, injuries or sudden strains, avoid direct and deep needling into the muscle in spasm. The muscle is in an inflamed state and needling can aggravate it.
If you do feel the need to needle into the muscle in spasm – I have found that any type of needling carried out, should be extremely superficial – using Japanese technique – less that 1-2mm insertion, using a 1 cun needle with a very thin gauge (Seirin/Teiwa 0.14 – 0.18). This is where the needle almost looks like it is falling out and lies flat to the surface, parallel to the skin. The object is to gently release the tension of the skin (yang) layer and nothing more.
This is a ‘less is more’ approach, a concept which can be difficult for TCM practitioners to consider as effective.
Instead distal and adjacent points (points close to the area of pain) are recommended to be used in Channel points related to the problem area – usually along the Bladder and Gallbladder Channels. These areas will not be in spasm or inflamed but will have a connection to the inflamed area.
Moxa can be helpful for releasing muscles in spasm. Most effective is large loose moxa cones (chinetsukyu) on the area of pain or the smokeless variety. Moxa is only burned less than half way down and then quickly removed (not all the way, otherwise it will cause burning).
With this approach, back pain (caused by spasm) can abate within a few days, usually improving each day. This is working alongside the body’s own healing mechanism.
When to – needle direct into the area of pain
After the acute phase has been modulated (ie reduced), needling direct into the area of pain can be carried out with less risk of aggravation of pain, but direct deep needling should still be carried out conservatively and cautiously.
For chronic or sub acute pain, deeper needling into the local area of pain (particularly around trigger / ashi points can be used. Additionally, warm needle moxa technique can be effective.
Low back pain due to deficiency and weakness (Kidney deficiency patterns), particularly of a chronic nature works well with deep needling along with moxa on the needle or on the lower back.
Caution with severe stagnation – osteo-arthitis
However, with severe arthritis or osteo-arthritis, particularly when the patient is in poor physical condition, elderly, overweight and not active, then I would be reluctant to do local, direct or deep needling into the area of pain.
This is because, I have found that this kind of treatment for these kind of patients can aggravate the pain. There is too much stagnation and acupuncture shakes it up too much.
I would adopt a gentle superficial needling approach, chinetsukyu moxa cones on the affected area, use distal points and advise some kind of gentle exercise – e.g qigong, to start to get mobility back in this area. This is a longer term approach, which is not popular with some patients who are looking for the equivalent of an acupuncture painkiller and want immediate results. But it takes a long time for the body to become stagnated in this way and it will take a long time to restore the body back into relatively better mobility and with less pain.
Article PDF – ‘A Randomized Trial Comparing Acupuncture, Stimulated Acupuncture, and Usual Care for Chronic Low Back Pain‘. D.C. Cherkin et al.
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