by David Leopold, MD and Robert A. Bonakdar, MD, FAAFP
In many ways acupuncture embodies the ideal integrative treatment modality since it has valid methods of efficacy from both a conventional medical perspective and from within its own discipline. The treatment itself addresses both of the disciplines and the specific pathophysiological components directly. The single treatment therefore has overlapping effect, exerting medical benefits both from a conventional physiological standpoint and also from an acupuncture meridian (TCM) rationale.
Acupuncture for low back pain has ample evidence for efficacy1
. Although multiple studies and systematic reviews support the treatment2
, some recent studies have called into question the efficacy3
. However with such large methodological heterogeneity variation in efficacy would be expected. In essence, acupuncture treatment is very difficult to standardize and we believe many studies showing lack of efficacy to be somewhat poorly constructed. The attempt to utilize “sham” or “placebo / minimal acupuncture” often produces a positive effect in and of itself. In fact this trial still showed acupuncture and “minimal acupuncture / placebo” to be equal, yet superior to no treatment. Though somewhat atypical, one RCT found benefits of acupuncture to be present up to two years post treatment4
For these reasons, acupuncture for low back pain, either acute or chronic has had significant clinical success, and is therefore widely regarded by most conventional health care practitioners to be a logical and potentially useful tool in the treatment of low back pain5,6
By treating both the biomechanical aspects and the bioenergetic aspects of low back pain, perhaps we gain a synergistic effect.The Conventional:
The physiological aspects of percutaneous electrical nerve stimulation (PENS) are well established, and include:
- elicited twitch response and subsequent reduction of hyper shortened muscles (similar to dry needling and trigger point injection),
- overriding of noxious neuro stimuli by creation of a benign signal “white noise” effects (gate theory) (significantly increased with the use of PENS),
- local, peripheral and central release of endogenous endorphins.
Electro acupuncture may also increase nitric oxide release and aid in increasing blood flow to ischemic areas improving oxygenation and removing metabolic waste products7
In fact we postulate that conventional rationale for PENS acupuncture is so well established that were it a procedure developed today, independent of any “traditional aspects,” it would be a widely utilized standard medical procedure. It is likely that as we progress further, our understanding of the mechanism of action will be more completely understood.The Traditional:
A central component of Chinese medical acupuncture theory is the flow of energy (Qi: pronounced “chee”) through the body along specific paths called meridians. Excess or deficient qi in these meridians can cause dysfunction. Acupuncture attempts to restore normal flow. While several points may be utilized depending upon patient presentation, in low back pain, often the bladder and kidney meridians are affected and treated.
Acupuncture from a traditional aspect also has many interesting aspects. In acupuncture theory, the kidneys hold the energy of the body, known as “jing”. The kidneys also provide support to the surrounding musculoskeletal system, in particular the lumbosacral spine. When the kidneys are depleted, usually the result of fatigue, and/or stress, they can no longer support their surrounding structure and the person becomes vulnerable to low back strain/pain. It is interesting to note that many people do report significant stress (physiological, psychosocial), fatigue, etc. prior to a back injury.The Procedure:
Acupuncture for low back pain obviously involves insertion of needles into the body. Placement of needles may be at either lumbosacral spine points, and / or peripheral points. It may also involve auricular (ear) points as well, and this will be covered extensively in an upcoming article. The depth of needling may vary as well, from superficially placed to deep muscle. In general, PENS will involve deep muscle penetration to best exert effect. We believe patient comfort to be paramount and therefore will adjust if needling becomes painful. A full discussion of the full aspects and rationale to selected points is beyond the scope of this article, but in general it seeks to either strengthen weaker meridians or disperse excess energy, this is done by point selection and may also involve heating of needles (moxibustion) or electrical stimulation.
Acupuncture needles may be stimulated in several ways. Manual stimulation can exert approximately 2 Hz of electrical discharge. Experimental results have shown that at lower frequencies (2-4 Hz) endorphins & enkalphins (hypothalamic and midbrain) are released, and at 10 -30 Hz enkalphins and dynorphin B (spinal cord) and cortisol are released. At higher frequencies (70-200) dynorphin A (spinal cord) is released8
. While electro acupuncture is known to cause release of neurotransmitters, the exact frequencies are still under investigation. Serotonin, nor epinephrine, GABA, substance P and dopamine have all been shown to be released with electro acupuncture9
Perhaps one of the most widely utilized methods of PENS, particularly when done by physicians, involves delivery of 2 Hz-100 Hz (often done with a unit that alternates between both depending on settings). This is usually done for a period of 15-30 min. In this approach a positive lead is connected to a negative lead compromising one input unit. In general up to 6 sets of leads (6 x 2= 12 total needles stimulated) are utilized. More needles may be utilized, but usually only twelve needles are actually stimulated. Occasionally a practitioner may elect to “cross” two nearby needles, so that they touch and thereby can both be connected to one lead.
We generally use myofascial tender and / or trigger points that correlate with acupuncture points. i.e. needles are placed at the trigger points. We have not found significant difference in the positioning of the e-stim leads themselves. Typically a “daisy chain” pattern, (alternating positive and negative leads to complete a circular pattern) or crossing (positive lead to its contralateral counterpart) is utilized. Traditional acupuncture would utilize more specific placement of positive and negative leads to “move” qi.
In LBP, particularly chronic LBP a firm etiology is often unclear, and often LBP is multifactoral10
. An exact diagnosis is helpful but not essential to successful treatment of LBP with acupuncture. LBP with or without radiculopathy can be effectively treated. In our experience functional LBP (muscle strain, trauma w/o fracture, etc.) responds exceptionally well to acupuncture. Arthritis, either OA or RA also responds well. Disc pathology, from almost all causes responds well. We have found treatment for spinal stenosis to be equivocal, and while in selected cases it can be effective, ongoing treatments will be likely be necessary. We have also had success in the treatment of post surgical pain (failed back syndrome) and also diffuse idiopathic skeletal hyperostosis (DISH).
It is important to note that for conditions where there is significant anatomical change present, (spondylolysis, spondylolisthesis, etc.) acupuncture is not likely to reverse the changes but may aid in amelioration of symptoms. We have had significant success in helping patients decrease medication, improve range of motion and improve activities of daily living and leisure activities with the use of acupuncture.
Typical treatment course would be every 3-4 days in acute phase for first 2-3 weeks then weekly once stable. Treatment is usually complete in 10-12 weeks, though obviously treatment may continue indefinitely based on condition. We believe that as a rule, improvement of any condition should be evidenced to some degree by the sixth week of treatment. In practical clinical terms, generally patients who will improve typically begin to do so by the fourth to sixth treatment session.
Our general recommendation is that when there is clear, localized pathophysiology (i.e. disc herniation, limited arthritis, failed back) that a focal PENS treatment is most effective. When pathology is more elusive (fibromyalgia, functional back pain, recurrent pain) then a TCM approach may be more effective.
One of the more interesting aspects and perhaps the reason acupuncture / PENS is so effective is the dual simultaneous treatment addressing both the physiological aspects and energetic aspects of the patient. From a conventional standpoint to the treatment exerts physiological changes as described above, from a traditional standpoint the treatment returns energy to the kidneys, the general body stores and enables improved support of the surrounding structures. To reiterate: By treating both the biomechanical aspects and the bioenergetic aspects of low back pain, we may thus produce a synergistic effect.
As a note: Acupuncture differs from acupressure, which does not use needle insertion, but instead uses pressure applied at acupuncture points. Acupressure will not be covered here. We find acupuncture to be significantly more effective than acupressure, which is supported in the medical literature11
. However, in the absence of available acupuncture, or in patients who cannot tolerate acupuncture for any reason, acupressure could be a viable alternative.
The final decision to proceed with acupuncture treatment is between the patient and the provider, and adequate discussion should be had before proceeding to this line of treatment, much as one would have with any procedure. This would include discussion of risks, benefits and alternatives, including expected outcomes both positive and negative.
Acupuncture would be relatively contraindicated in patients with significant needle-phobia. In patients with cancer, treatment should be done by practitioners familiar with the condition, and recommendation would be against deep needling, and needling at sites of known malignancy. We use a platelet count of 50,000 as a minimum for safe acupuncture. In cases of immune compromise, each site of needle insertion should be cleaned with an alcohol swab. In the United States, acupuncture should involve the use of only sterile and disposable needles. Acupuncture can be performed by trained physicians, L.Ac. or other providers in some states. Check your state’s own criteria.
- Furlan AD, van Tulder M, Cherkin D, Tsukayama H, Lao L, Koes B, Berman B. Acupuncture and dry-needling for low back pain: an updated systematic review within the framework of the Cochrane collaboration. Spine 2005;30:944–963
- Manheimer E, White A, Berman B, Forys K, Ernst E. Meta-analysis: acupuncture for low back pain. Ann Intern Med 2005;142:651–663
- Brinkhaus B, Witt CM, Jena S, Linde K, Streng A, Wagenpfeil S, Irnich D, Walther HU, Melchart D, Willich SN. Acupuncture in patients with chronic low back pain: a randomized controlled trial. Arch Intern Med 2006;166:450–457
- Thomas KJ, MacPherson H, Ratcliffe J, Thorpe L, Brazier J, Campbell M, Fitter M, Roman M, Walters S, Nicholl JP. Longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain. Health Technol Assess 2005;9:1–109
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- Ma, Sheng-Xing. Neurobiology of Acupuncture: Toward CAM. eCAM 2004;1(1)41–47
- Han J S, Sun S L 1990 Differential release of enkephalin and dynorphin by low and high frequency electroacupunture in the central nervous system. Science International Journal (NY) 1:19-23.
- Omura Y 1975 Electro-acupuncture: Its electrophysiological basis and criteria for effectiveness and safety – Part I. Acupuncture and Electro-therapeutics Research 1:157-181.
- Deyo RA; Rainville J; Kent DL What can the history and physical examination tell us about low back pain? JAMA 1992 Aug 12;268(6):760-5.
- Hsieh LL, Kuo CH, Lee LH, Yen AM, Chien KL, Chen TH. Treatment of low back pain by acupressure and physical therapy: randomised controlled trial. BMJ 2006;332:696–700