Acupuncture and Low Back Pain

Acupuncture and Low Back Pain

If a patient is interested in using acupuncture to manage low back pain there is supporting evidence from The Canadian Medical Association (Busse et al. 2017), The American College of Physcians (Chou et al. 2017Qaseem et al. 2017), Ontario Protocol for Traffic Injury Management (OPTIMa) (Wong et al. 2017) and The Mayo Clinic (Nahin et al. 2016).

These recommendations represent a monumental shift in pain management. Physicians, now more than ever are recommending conservative multi-modal approach involving a number of management strategies including, not limited to: education, reassurance, analgesic medicines and a number of non pharmacological therapies.

Acupuncture is a treatment that can be explained in neurophysiological terms

People often assume that acupuncture is synonymous with Traditional Chinese Medicine and that anyone who uses acupuncture does so based on 'qi' or 'meridians'. This is a misconception. Regardless of its theoretical basis, based on the traditional and official definition, the term acupuncture refers to the actual insertion of a needle into the body (Fan et al. 2016).

Acknowledging that traditional narratives outdated, medical acupuncture is an approach that is based upon a theory that is inline current scientific understanding of how the body works. Reframing acupuncture form of peripheral nerve stimulation technique in which acupuncture needles are inserted into anatomically defined sites, and stimulated manually or with electricity (White 2009).

Is Acupuncture a Placebo?

The way we present ourselves and present our techniques is tied to clinical outcomes, the magnitude of a response may be influenced by mood, expectation, and conditioning. In any discussion on therapeutic effect it is important to acknowledge the placebo response.

It is also a within the realm of possibility that when acupuncture needles are inserted into anatomically defined sites, and stimulated manually or with electricity patients have a complex biopsychosocial response that INCLUDES but is not LIMITED to placebo. Several plausible theories attempt to explain how acupuncture works, this includes but is not limited to:
• The Gate Control Theory of Pain (Melzack & Wall 1984)
• The Release of Endogenous Opioids (Chen et al. 2017Yin et al. 2017)
• The Release of Endogenous Cannabinoids (McPartland et al. 2014Hu et al. 2017)
• Purinergic Signaling (Sawynok 2016Tang et al. 2016)
• Interactions Between Non-Neuronal Cells and Neurons (Ji et al. 2016Zhang et al. 2014)
• The Inflammatory Reflex (Chavan et al. 2014Lim et al. 2016Pavlov et al. 2017)
• Neuroplastic Changes Across Different Areas of the Peripheral and Central Nervous System (Chen et al. 2017)
• Sensory-Discriminative and Affective-Social Touch (Chae et al. 2017)

Structures to be aware of when treating low back pain

The insertion of an acupuncture needle is a form of novel stimuli, that functions by sending anti-nociceptive input to the neuroimmune system. Preferential sites for acupuncture stimulation are associated with areas rich in specialized sensory receptors such as muscle spindles, Golgi tendon organs, ligament receptors, Paciniform and Ruffini’s receptors (joint capsules), deep pressure endings (within muscle belly), and free nerve endings (muscle and fascia). All of these areas are highly innervated and as a result there are a number of physiological responses that help modulate the experience of pain. 

Structures to keep in mind while assessing and treating patients suffering from low back pain may include neurovascular structures and investing fascia of:
• Gluteal Muscle Group (Gluteus Maximus, Gluteus Medius and Gluteus Minimus)
• Thoracolumbar Fascia
• Quadratus Lumborum
• External Obliques, Internal Obliques, Transverse Abdominis
• Multifidius
• Erector Spinae (Iliocostalis, Longissimus, Spinalis)
• Distant Stimulation Sites (ie. Auricular Acupuncture, LI-4, LV-3)

Key Points

• Low back pain is a difficult to treat global health burden, one of the reasons for this is that there is often no clear identifiable cause. There is much debate about the best way to manage low back pain, the strongest reviews support a multi-modal appraoch involving a number of management stratigies that include but is not limited to education, reassurance, analgesic medicine and a number of non-pharmacological therapies.

• Acupuncture as a therapeutic intervention is being embraced by the medical community. This is in part because it is a non-pharmacological therapeutic intervention that is simple to carry out, economical, and has very few side effects. 

• Treatment plans should be implemented based on patient-specific assessment findings and patient tolerance.The mechanism by which acupuncture alleviates localized pain is not clear, biological factors (physiology), psychological (i.e. thoughts, emotions, and behaviors) and social (i.e. culture, and religion) factors play a significant role in the experience and reduction of pain.

More to Explore

Andronis, L., Kinghorn, P., Qiao, S., Whitehurst, D.G., Durrell, S., McLeod, H. (2017). Cost-Effectiveness of Non-Invasive and Non-Pharmacological Interventions for Low Back Pain: a Systematic Literature Review. Appl Health Econ Health Policy.

Busse, J.W., Craigie, S., Juurlink, D.N, ... Guyatt GH. (2017). Guideline for opioid therapy and chronic noncancer pain. CMAJ.

Chen, L., Michalsen, A. (2017). Management of chronic pain using complementary and integrative medicine. BMJ.

Chou, R., Deyo, R., Friedly, J., Skelly, A., Hashimoto, R., ... Brodt, E.D. (2017). Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med.

Cohen et al. (2017). Acupuncture for analgesia in the emergency department: a multicentre, randomised, equivalence and non-inferiority trial. Med J Aust.

Haake, M., Müller, H.H., Schade-Brittinger, C., ... Molsberger, A. (2007). German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups.  Arch Intern Med.

Konno, T., Aota, Y., ...Itoh, M. (2017). Anatomical study of middle cluneal nerve entrapment. J Pain Res.

Koppenhaver, S.L., Walker, M.J., Rettig, C., Davis, J., Nelson, C., Su, J., Fernández-de-Las-Peñas, C., Hebert, J.J. (2017). The association between dry needling-induced twitch response and change in pain and muscle function in patients with low back pain: a quasi-experimental study. Physiotherapy.

MacPherson, H., Vertosick, E.A., ... Vickers, A.J. (2017). The persistence of the effects of acupuncture after a course of treatment: a meta-analysis of patients with chronic pain. Pain.

MacPherson, H., Vickers, A., Bland, M., Torgerson, D., Corbett, M., Spackman, E., ..., Watt, I. (2017). Acupuncture for chronic pain and depression in primary care: a programme of research. Southampton (UK): NIHR Journals Library.

Maher, C., Underwood, M., & Buchbinder, R. (2016). Non-specific low back pain. The Lancet.

Manheimer, E., White, A., Berman, B., Forys, K., Ernst, E. (2005). Meta-analysis: acupuncture for low back pain. Ann Intern Med.

Murakami, M., Fox, L., Dijkers, M.P. (2017). Ear Acupuncture for Immediate Pain Relief-A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Pain Med.

Nijs, J., Loggia, M.L., ... Clauw, D. (2017). Sleep disturbances and severe stress as glial activators: key targets for treating central sensitization in chronic pain patients? Expert Opin Ther Targets.

Nunn, M.L., Hayden, J.A., Magee, K. (2017). Current management practices for patients presenting with low back pain to a large emergency department in Canada. BMC Musculoskelet Disord. (OPEN ACCESS)

Pelletier, R., Higgins, J., Bourbonnais, D. (2015). Addressing Neuroplastic Changes in Distributed Areas of the Nervous System Associated With Chronic Musculoskeletal Disorders. Phys Ther.

Prather, H., Cheng, A., May, K.S., Maheshwar,i V., VanDillen, L. (2017). Hip and Lumbar Spine Physical Examination Findings in People Presenting With Low Back Pain With or Without Lower Extremity Pain. J Orthop Sports Phys Ther.

Qaseem, A., Wilt, T.J., McLean, R.M., Forciea, M.A. (2017). Clinical Guidelines Committee of the American College of Physicians.. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med.

Qiao, L.N., Liu, J.L., Tan, L.H., Yang, H.L., Zhai, X., Yang, Y.S. (2017). Effect of electroacupuncture on thermal pain threshold and expression of calcitonin-gene related peptide, substance P and γ-aminobutyric acid in the cervical dorsal root  ganglion of rats with incisional neck pain. Acupunct Med.

Stochkendahl, M.J., Kjaer, P., Hartvigsen, J.,  Vaagholt, M. (2017). National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J.

Tang, Y., Yin, H., Rubini, P., & Illes, P. (2016). Acupuncture-Induced Analgesia: A Neurobiological Basis in Purinergic Signaling. The Neuroscientist.

Ushinohama, A., Cunha, B.P., Costa, L.O., Barela, A.M., Freitas, P.B. (2016). Effect of a single session of ear acupuncture on pain intensity and postural control in individuals with chronic low back pain: a randomized controlled trial. Braz J Phys Ther.

Vickers, A. J., Cronin, A. M., Maschino, A. C., Lewith, G., Macpherson, H., Foster, N. E., . . . Collaboration, F. T. (2012). Acupuncture for Chronic Pain. Archives of Internal Medicine. 

Wansbrough, T. (1837). Lumbago Treated By Acupuncturation. The Lancet,28(714), 215.

Wenger, H.C., Cifu, A.S. (2017). Treatment of Low Back Pain. JAMA.

White, A. (2009). Western medical acupuncture: a definition. Acupunct Med.

White, A. & Ernst, E. (2004). A brief history of acupuncture. Rheumatology.

Wong, J., Côté, P., Sutton, D., Randhawa, K., Yu, H., Varatharajan, S., . . . Taylor-Vaisey, A. (2017). Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. European Journal of Pain.

Wong Lit Wan, D., Wang, Y., Xue, C.C., Wang, L.P., Liang, F.R., Zheng, Z. (2015). Local and distant acupuncture points stimulation for chronic musculoskeletal pain: A systematic review on the comparative effects. Eur J Pain.

Yin, C., Buchheit, T.E., Park, J.J. (2017). Acupuncture for chronic pain: an update and critical overview. Curr Opin Anaesthesiol.

Zhang, R., Lao, L., Ren, K., & Berman, B. M. (2014). Mechanisms of Acupuncture–Electroacupuncture on Persistent Pain. Anesthesiology. (OPEN ACCESS)