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6 Articles in Volume 1, Issue #4
Breaking Down the Barriers of Pain: Part 4
Facing Reimbursement Challenges
Getting Back on Track
Taking the Hurt Out of Pain
The Mind-body Connection
The Neural Plasticity Model of Fibromyalgia Theory, Assessment, and Treatment: Part 2

Getting Back on Track

Acupuncture is a complementary treatment strategy that can be employed alone or in conjunction with other modalities to treat lumbar pain.

Low back pain is the most common disabling problem of working age adults.1 Every year 50 percent of working adults have symptoms related to their low back.2 There is a wide spectrum of anatomic conditions that cause lumbosacral pain including muscle sprains, disc herniations, facet joint arthritis, spinal arthritis, spinal malignancy, and fractures. Standard medical treatment includes rest, medication, physical therapy, anesthetic injections, and surgical treatment.3

Acupuncture is a complementary treatment strategy that can be employed alone or in conjunction with other treatments across the entire spectrum of back pain. Acupuncture has certain advantages when used in a comprehensive back pain treatment program.

Low Back Pain

Low back pain is one of the most common reasons for visits to a physician.1-3 It has been claimed that back pain causes the adult population of the United States to spend 77,534,000 days in bed each year.4

There are a multitude of reasons for low back pain because there are a multitude of spinal structures that can be abnormal, including ligaments, facet joints, vertebral bones, intervertebral discs, muscular fascia, and the spinal nerves. Simply, low back pain comes from disease or injury to the aforementioned spinal structures or from the effects of pathologic processes on nerve roots.

The most common causes of low back pain are muscle and soft tissue injury, arthritis of the intervertebral joints or facets, herniated disc, and degenerative disc disease.2 If these pathologic processes narrow either the spinal canal or the neural foramina (spinal stenosis) there can be radiation of pain and weakness to the lower extremities.

Likewise a multitude of accepted medical treatments for low back pain exist. These can be as simple as rest, chair cushioning, anti-inflammatory medications, physical therapy, massage, and/or chiropractic or osteopathic manipulation. Treatment for more severe varieties of back pain can include strong narcotic medications, injection of steroids and anesthetics into the facet joints or epidural space, and/or operative treatment.

For minor back pain that comprises a muscle strain without structural damage, therapeutic modalities like anti-inflammatory agents, spinal manipulation, and physical therapy are successful in the majority of instances.2 Unfortunately, back pain tends to recur multiple times even after a successful recovery.3 At the other end of the spectrum are patients who have severe function-limiting back pain that can require an operation to relieve pressure on the spinal cord or nerve roots. Even after operations for herniated disc, six to 40 percent of patients do not experience a satisfactory result.5

Acupuncture Overview

Acupuncture was developed in China and has been in almost continuous use for at least 2500 years.6 Despite differences in standards of clinical proof between Western medical scientists and Chinese medical publications, this system has been empirically successful for many conditions in China and many other countries where acupuncture is practiced.

Traditional Chinese medicine teaches that the normal functioning of the human body and mind depends upon the circulation of the body’s internal energy, Qi, throughout the body in the right amount at the right time. The acupuncture points are located on 14 invisible lines or meridians running the length of the body. Certain points on these meridians influence anatomic areas and physical conditions. Traditional acupuncture looks at disease as a deficiency, stagnation, or excess of the normal energy flow within the body. Tiny needles are placed into defined acupuncture points along the meridians to correct the flow of Qi energy and are thus achieve energetic balance and health.

In the United States, acupuncture is frequently used as a last resort.

Chinese medicine has always been a holistic system of medical care. All of the qualities that make up a person are taken into account. Chinese physicians recognized that there are intrinsic differences between individual human beings.

In the United States, acupuncture is frequently used as a last resort. This attitude is contrary to the tenets of Chinese medicine, which preaches early or preventive treatment. “When the evil wind attacks people, it comes like a storm… A superior doctor arrests disease at the skin level and dispels it before it penetrates deeper. An inferior doctor treats illness after it passes the skin… If it progresses and invades deep into the five zang organs, prognosis for recovery is only 50 percent.”7 We have frequently seen patients referred after they have not responded to all of the modalities offered by a university pain service. Even in this patient population, pre-selected for a poor therapeutic result, acupuncture can usually result in significant clinical improvements.

Acupuncture not only treats back pain but the person with the back pain. Each person is evaluated for the specific chief complaint like low back pain. The signs and symptoms are coordinated with each individual’s present energetic balance. A comprehensive acupuncture evaluation also includes a thorough evaluation of the patient’s basic constitution, which includes their propensity to different diseases and psycho-emotional imbalances. Each patient is treated with a custom-designed treatment plan that is continually modified based on the individual patient’s response to treatment.

Modern biomedical scientists have studied acupuncture effects. Acupuncture needling in the periphery stimulates skin and muscle sensory receptors. The signal is carried along the peripheral nerves to the dorsal horn of the spinal cord. Acupuncture possibly causes a central nervous system response at three potential levels — the spinal cord, the brain stem, and the hypothalamus.8 Endorphin synthesized by the hypothalamus is released into the blood stream and spinal fluid. In the spinal cord, acupuncture inhibits the release of substance P, which facilitates pain transmission in the spinal cord. This suppression of substance P results in beneficial effects regarding pain relief.8 Acupuncture effects on the brain stem causes the pituitary to release adrenocorticotrophin (ACTH) which stimulates the adrenal gland to produce increased levels of blood cortisol.9 The known anti-inflammatory effect of cortisol explains why acupuncture is useful in treating inflammatory conditions like asthma and rheumatoid arthritis. Acupuncture stimulates centers in the brain that send inhibitory messages to the pain pathways in the spinal cord. These messages suppress the response to noxious stimuli and modulate the experience of pain.10

Acupuncture Treatment

There are many different treatment strategies employed in acupuncture. The basic techniques, which began in China, have been refined over time and in other countries. Today there are specific paradigms like eight principles, meridian acupuncture, French energetics, Japanese techniques, Korean hand acupuncture, scalp acupuncture, and ear acupuncture among others. We have found that a custom approach to the patient using different basic body acupuncture techniques supplemented by scalp, ear, or hand acupuncture combine to give long-lasting and more complete relief. Patients are given homework assignments for relaxation training, exercise, stimulate ear acupuncture points, use a TENS unit, or warm acupuncture points with a burning Chinese herb.

Most body acupuncture systems include a prescription of specific points needled — some to affect the overall body function and some for the specific area of pain. Stimulation of the kidney or bladder meridian for their energetic properties can lead to improvements in most patients with back pain. Many times needling the areas of muscle spasm in the lumbar or hamstring muscles can lead to amelioration of pain.

Patients with low back pain persisting after back surgery experienced less pain of their lumbar tender points after undergoing a specific silver needle acupuncture treatment.5A randomized study of pregnant patients with low back and pelvic pain demonstrated that acupuncture was superior to physical therapy.11 In an exhaustive review the National Institute of Health published its opinion that acupuncture may be useful as an adjunct treatment of back pain in a comprehensive management program or alternative treatment.12

For most patients with back pain a therapeutic trial of acupuncture is indicated. Within 10-15 treatments there should be no question what the usefulness of acupuncture is in that particular patient. The patient should have some response and plans for maintenance therapy are made. If the patient is making steady progress but there is still significant pain or functional defects, then further courses of acupuncture are indicated. As demonstrated by Case 1, severely disordered patients can continue to make progress for several years.

Acupuncture should not be applied to all patients with back pain without consideration of more serious conditions that would necessitate referral to a surgical specialist. A patient with cauda equina syndrome characterized by bowel or bladder dysfunction, numbness in the perineum and medial thighs, and bilateral leg pain weakness and numbness is considered a surgical emergency. Patients who have a progressive or severe neurological deficit or persistence and a neuromotor deficit after four to six weeks of non-operative therapy should have surgical consultation.3 Likewise symptomatic and significant anatomic defects like a large herniated disc should have the benefit of a surgeon’s experience and expertise.

The comprehensive treatment of disabling back pain can be significantly improved by the addition of acupuncture. In our experience, other modalities including physical therapy, massage, chiropractic and osteopathic manipulation, epidural and facet injections can synergistically work with acupuncture to provide the patient with the best treatment. Patients who are on high dose narcotics and steroids do not get the full benefit of acupuncture. It is a good policy to decrease the dosage of these medications before or soon after beginning treatment. Since seratonin in the brain is involved in the response to acupuncture, depressed patients with low seratonin levels will profit from starting antidepressant medication that raises seratonin levels. Antidepressants and acupuncture can combine for very good results in these patients.

Acupuncture Advantages

Acupuncture can be used across the spectrum of back pain from back strain to severe injuries unresponsive to surgical treatment. Minor injuries can be rehabilitated more quickly and severe injuries unresponsive to other modalities can at least be palliated. Patients like the one in Case 3, who have adverse reactions to medication can be helped by acupuncture. Heavy laborers like Case 2 can be palliated with acupuncture so that they can maintain their strenuous occupations.

Acupuncture treats not only the exact anatomic site of pain but also the mental and emotional conditions that are important for successful treatment. The patient in Case 3 was affected by pain and terrifying nightly nightmares. His anxiety and cigarette consumption also decreased promptly after the Seven Dragons treatment.

One of the advantages of acupuncture is that it produces substantially fewer adverse effects than many drugs or other medical or surgical procedures use for the same condition.12 Even for patients who still must use some medication, reduction of the dose of narcotics or anti-inflammatory medications should reduce the likelihood of overdose, drug dependence, gastrointestinal bleeding, or kidney disease.

Since acupuncture is an efficient and efficacious method of pain relief it would be reasonable to assume that there are cost savings when applying acupuncture. In the context of a prepaid health plan, 100 patients with chronic pain were treated with acupuncture. The utilization of office visits, emergency room visits, and physical therapy decreased while the patients reported decreased pain, better relaxation, better sleep, and improved quality of life.13 More studies are necessary to define the cost savings possible with greater utilization of acupuncture.

Case Reports

Case 1

Background: A 35-year-old office worker has had a long history of low back pain secondary to congenital spondylolisthesis. An operation at age 17 gave him three years of relief. After three years, he began to have the progressive development of disabling lumbosacral pain radiating to the legs. He has had to use a cane since college and a back brace for the past four years. This pain became progressively severe to the point that he could not sit for longer than 20 minutes at a time without having severe pain. He was treated with ibuprofen up to 3000 mg. daily and Neurontin 900 mg. He was not able to continue his position and reluctantly had to accept a disability retirement.

Results: Acupuncture treatment helped his pain and ability to sit. Now he can sit as long as four hours at a time. He also had a reduction of his pain level and an improvement of his flexibility. These improvements have persisted even today. He is able to walk almost two miles at a time. His only pain medication is ibuprofen 600 mg. He is now applying to law school.

Case 2

Background: A 45-year-old laborer has worked for the water company for 18 years. He has had nine to 10 back injuries at work and episodes of increased pain. He has a documented herniated disc with radiation of pain to both legs. He had cramping of the legs on multiple occasions throughout the day and night. He has difficulty sleeping. Normally he had constant back discomfort. After his last injury he was on limited duty for six months.

Results: After the first treatment he said that for the first time he was not aware of back discomfort. With continued treatment, he has had a definite reduction in his low back pain. He takes no medications for his back. His sleeping is better after acupuncture treatment. The strenuous nature of his job causes him to have recurrent back pain. In the 17 months since beginning acupuncture he has only lost a few days of work secondary to back pain though he still performs heavy manual labor.

Case 3

Background: A 57-year-old electrician was working on the second floor when a coworker mistakenly reconnected a high voltage line. He was thrown into the air and fell 25 feet fracturing his left foot and ankle and causing a fracture at L3 and herniated lumbar discs. He had constant back and leg pain. He had been treated for five years with anti-inflammatory medication, physical therapy, nerve blocks, and epidural injection. He was limited in the amount of anti-inflammatory medication because of a stomach ulcer. He was unable to walk further than one block. He was anxious, depressed, and irritable and could not sleep without using sleeping pills. His anxiety also expressed itself by smoking two to three packs of cigarettes a day.

Results: Acupuncture helped his back and lower extremity pain and improved his walking tolerance to four to five blocks. After two weeks of treatment he reported that every night since the accident he had experienced a nightmare about his accident. After he was treated with another treatment strategy called Seven Internal Dragons, he stopped having nightmares and was able to get a decent night’s sleep. With acupuncture treatment he was able to stop taking pain medication, stop smoking, and be more mobile and active.

Incorporating Acupuncture

There is great variation in training and experience of acupuncture practitioners. Some allopathic physicians, osteopathic physicians, and chiropractors have incorporated acupuncture into their practices. MDs and DOs can achieve board certification in medical acupuncture after satisfying educational and experience criteria and passing a comprehensive proficiency examination. Certification is available for chiropractors passing a didactic, clinical, and written examination.7 Non-physicians can practice acupuncture after a period of formal schooling and after passing the National Commission for the Certification of Acupuncture and Oriental Medicine examination.

It is appropriate to ask any acupuncture practitioner about his or her specific education and experience. A patient or referring physician should not only ask about general experience in acupuncture, but experience with the specific clinical entity of the patient. In our practice it is common to have prospective patients talk wits who have had acupuncture treatment for their specific clinical conditions. Some physician acupuncturists can provide comprehensive care with standard medication, nerve blocks, and acupuncture. It is necessary for the acupuncturist to coordinate care with the patient’s primary or specialist physician. This is especially true for non-physician acupuncturists.

Acupuncture can be used across the spectrum of back pain from back strain to severe injuries unresponsive to surgical treatment.

Conclusion

The integration of acupuncture into today’s health care system may be facilitated through a better understanding among providers of the language and practices of both the Eastern and Western health care communities. The case studies illustrate that acupuncture can provide pain relief and improvement of functional capacity in patients with severe low back pain. We predict that in the next few years there will be an overall improvement in the care of patients with back pain with the integration of the best of standard medical care and the best of acupuncture and other complementary modalities. n

Last updated on: May 16, 2011
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