The American College of Physicians formally recommends acupuncture for the treatment of back pain. Published in the prestigious Annals of Internal Medicine, clinical guidelines were developed by the American College of Physicians (ACP) to present recommendations based on evidence. Citing quality evidence in modern research, the ACP notes that nonpharmacologic treatment with acupuncture for the treatment of chronic low back pain is recommended. The official grade by the ACP is a “strong recommendation.” [1]
A major goal of the recommendation is for acupuncture and other nonpharmacological therapies to replace drug therapy as a primary source of pain relief. Treatment with opioids is only recommended, with an official “weak recommendation,” when other modalities do not provide adequate relief. A strong recommendation is also made by the American College of Physicians for the treatment of both acute and subacute lower back pain with heat, massage, acupuncture, and spinal manipulation. [2] The recommendations were approved by the ACP Board of Regents and involves evidence based recommendations from doctors at the Penn Health System (Philadelphia, Pennsylvania), Minneapolis Veterans Affairs Medical Center (Minnesota), and the Yale School of Medicine (New Haven, Connecticut).
The American College of Physicians notes that approximately 25% of USA adults have had, at the very minimum, a one day lower back pain episode within the past three months. The socioeconomic impact of lower back pain in the USA was approximately $100 billion in the year 2006 . The costs include medical care and indirect costs due to lost wages and declines in productivity. [3] Recommendations for treatment options, including those for the use of acupuncture, include considerations of positive medical patient outcomes, the total number of back pain episodes, duration between episodes, alleviation of lower back pain, improvement in function of the back, and work disability reductions. Recommendations are for both radicular and nonradicular lower back pain.
The target audience for the American College of Physicians recommendations includes all doctors, other clinicians, and the adult population with lower back pain. The ACP notes, “Moderate-quality evidence showed that acupuncture was associated with moderately lower pain intensity and improved function compared with no acupuncture at the end of treatment .” [4] In agreement, the National Institute of Neurological Disorders and Stroke (National Institutes of Health) notes that acupuncture is an effective treatment modality for the relief of chronic lower back pain. [5]
These findings are consistent with those published in Mayo Clinic proceedings finding that acupuncture is effective for the treatment of lower back pain. The same Mayo Clinic report notes that acupuncture does not cause any significant adverse effects. [6] The Mayo Clinic findings apply to both nociceptive and non-nociceptive pain. Nociceptive back pain includes musculoskeletal inflammation and pain involving nerve cells wherein nociceptors are activated. Nociceptors are afferent neurons in the skin, muscles, joints, and other areas. For example, nerve impingement (often referred to as a “pinched nerve”) produces one type of nociceptive pain.
Non-nociceptive pain does not involve inflammation and is more relevant to pain processing in the central nervous system. One type of non-nociceptive pain condition is fibromyalgia and acupuncture has been confirmed as an effective treatment modality for this condition. The Mayo Clinic proceedings note, “Martin et al. found a significant improvement between electroacupuncture vs sham electroacupuncture. Differences were seen on the Fibromyalgia Impact Questionnaire (FIQ) scores for fatigue and anxiety.” [7]
The Mayo Clinic and American College of Physicians findings are consistent with additional quality research. Memorial Sloan Kettering Cancer Center (New York) and University of York (United Kingdom) researchers note “We have provided the most robust evidence from high-quality trials on acupuncture for chronic pain. The synthesis of high-quality IPD found that acupuncture was more effective than both usual care and sham acupuncture. Acupuncture is one of the more clinically effective physical therapies for osteoarthritis and is also cost-effective if only high-quality trials are analysed.” [8]
Doctors understand the true need for effective pain management. Nonpharmacological solutions are important for a variety of reasons including prevention of addiction, effective relief of pain, and prevention of adverse effects. This is often of heightened concern during pregnancy and for children. As a result, university hospitals integrate acupuncture into usual care settings to improve patient outcomes. For example, pediatric doctors at the UCSF Benioff Children’s Hospital San Francisco provide acupuncture to children, including non-needle laser acupuncture. At the University of California hospital, acupuncture is made available for both inpatients and outpatients. Dr. Kim notes that acupuncture reduces nausea up to 70%. She adds that acupuncture is also effective for significant reductions in post-surgical pain and chronic headaches. [9]
Recently, researchers have discovered how acupuncture stops pain and provides other forms of relief for patients. Breakthrough research conducted by University of South Florida (Tampa) and Fujian University of Traditional Chinese Medicine (Fuzhou) researchers documents how acupuncture stops pain. The researchers note, “acupuncture exerts a remarkable analgesic effect on SCI [spinal cord injury] by also inhibiting production of microglial cells through attenuation of p38MAPK and ERK activation.” [10]
Microglia are central nervous system immunity cells that secrete proinflammatory and neurotoxic mediators. Acupuncture reduces pain by attenuating this response. The researchers also document that acupuncture provides neuroprotection. The researchers note that acupuncture prevents brain damage in the hippocampus by “preventing microglial activation.” The University of South Florida members of the research team were from the Department of Neurosurgery and Brain Repair and the Department of Pharmaceutical Sciences. Funding was provided by the United States Department of Defense, University of South Florida Neurosurgery and Brain Repair, and the James and Esther King Biomedical Research Foundation.
The aforementioned research reveals an important biochemical mechanism involved in acupuncture’s ability to alleviate pain and reduce harmful inflammation. Researchers focus on other mechanisms activated by administration of acupuncture treatments. For example, laboratory investigations reveal how acupuncture regulates blood pressure.
University of California (Irvine) researchers find acupuncture effective for the treatment of high blood pressure. In a controlled laboratory study, University of California researchers have proven that electroacupuncture at acupoint ST36 (Zusanli) promotes enkephalin production, which dampens proinflammatory excitatory responses from the sympathetic nervous system that cause hypertension. Specifically, electroacupuncture regulates preproenkephalin gene expression, a precursor substance that encodes proenkephalin, which then stimulates the production of enkephalin. [11]
The formal recommendation for the use of acupuncture in cases of lower back pain by the American College of Physicians is based on modern research. Mayo Clinic findings and research from the Memorial Sloan Kettering Cancer Center (New York) and the University of York support this recommendation. In response to the needs of patients, doctors have already implemented acupuncture into several hospitals throughout the USA and both inpatient and outpatient acupuncture treatments are available.
Now, modern scientific investigations reveal how acupuncture works. University of South Florida and Fujian University of Traditional Chinese Medicine researchers confirm acupuncture’s ability to attenuate microglial activation. University of California researchers have quantified acupuncture’s ability to control inflammation by regulating enkephalins. In addition, the NCCAOM (National Certification Commission for Acupuncture and Oriental Medicine) provides professional certification for acupuncturists, which ensures standards of excellence for licensed acupuncturists. Given the large body of supportive research and the administrative support for providing safe and effective acupuncture to the general public, expect to see greater implementation of acupuncture into usual care settings.
Accessibility to care is dependent upon both availability and financial capabilities. Insurance companies have been providing health insurance coverage for acupuncture for decades. Cigna, Blue Cross, Blue Shield, AETNA, United Healthcare, and many other insurance companies provide reimbursement to patients for use of services by licensed acupuncturists. The level of coverage varies, largely dependent upon individual health insurance policy provisions. Licensed acupuncturists can learn more about providing coverage for their patients in the continuing education course entitled Acupuncture Insurance Billing #1. This basic introductory course covers diagnostic requirements, including ICD-10 coding, and other important procedural requirements necessary to obtain reimbursements for patient care.
Back Pain Overview
Back pain is one of the most common reasons people go to the doctor or miss work, and it is a leading cause of disability worldwide. Most people have back pain at least once.
Fortunately, you can take measures to prevent or relieve most back pain episodes. If prevention fails, simple home treatment and proper body mechanics often will heal your back within a few weeks and keep it functional. Surgery is rarely needed to treat back pain.
Back Pain Symptoms
Signs and symptoms of back pain can include:
Muscle ache
Shooting or stabbing pain
Pain that radiates down your leg
Pain that worsens with bending, lifting, standing or walking
Pain that improves with reclining
When to see an Acupuncturist
Most back pain gradually improves with home treatment and self-care, usually within a few weeks. If yours doesn't improve in that time, see your doctor.
In rare cases, back pain can signal a serious medical problem. Seek immediate care if your back pain:
Causes new bowel or bladder problems
Is accompanied by fever
Follows a fall, blow to your back or other injury
Contact an acupuncturist if your back pain:
Is severe and doesn't improve with rest
Spreads down one or both legs, especially if the pain extends below the knee
Causes weakness, numbness or tingling in one or both legs
Is accompanied by unexplained weight loss
See your doctor if you start having back pain for the first time after age 50, or if you have a history of cancer, osteoporosis, steroid use, or excessive drug or alcohol use.
Back Pain Causes
Low back pain caused by spinal degeneration and injury.
Back pain that comes on suddenly and lasts no more than six weeks (acute) can be caused by a fall or heavy lifting. Back pain that lasts more than three months (chronic) is less common than acute pain.
Back pain often develops without a cause that your doctor can identify with a test or an imaging study. Conditions commonly linked to back pain include:
Muscle or ligament strain. Repeated heavy lifting or a sudden awkward movement can strain back muscles and spinal ligaments. If you're in poor physical condition, constant strain on your back can cause painful muscle spasms.
Bulging or ruptured disks. Disks act as cushions between the bones (vertebrae) in your spine. The soft material inside a disk can bulge or rupture and press on a nerve. However, you can have a bulging or ruptured disk without back pain. Disk disease is often found incidentally when you have spine X-rays for some other reason.
Arthritis. Osteoarthritis can affect the lower back. In some cases, arthritis in the spine can lead to a narrowing of the space around the spinal cord, a condition called spinal stenosis.
Skeletal irregularities. A condition in which your spine curves to the side (scoliosis) also can lead to back pain, but generally not until middle age.
Osteoporosis. Your spine's vertebrae can develop compression fractures if your bones become porous and brittle.
Back Pain Risk factors
Anyone can develop back pain, even children and teens. These factors might put you at greater risk of developing back pain:
Age. Back pain is more common as you get older, starting around age 30 or 40.
Lack of exercise. Weak, unused muscles in your back and abdomen might lead to back pain.
Excess weight. Excess body weight puts extra stress on your back.
Diseases. Some types of arthritis and cancer can contribute to back pain.
Improper lifting. Using your back instead of your legs can lead to back pain.
Psychological conditions. People prone to depression and anxiety appear to have a greater risk of back pain.
Smoking. This reduces blood flow to the lower spine, which can keep your body from delivering enough nutrients to the disks in your back. Smoking also slows healing.
Prevention
You might avoid back pain or prevent its recurrence by improving your physical condition and learning and practicing proper body mechanics.
To keep your back healthy and strong:
Exercise. Regular low-impact aerobic activities — those that don't strain or jolt your back — can increase strength and endurance in your back and allow your muscles to function better. Walking and swimming are good choices. Talk with your doctor about which activities you might try.
Build muscle strength and flexibility. Abdominal and back muscle exercises, which strengthen your core, help condition these muscles so that they work together like a natural corset for your back. Flexibility in your hips and upper legs aligns your pelvic bones to improve how your back feels. Your doctor or physical therapist can tell you which exercises are right for you.
Maintain a healthy weight. Being overweight strains back muscles. If you're overweight, trimming down can prevent back pain.
Quit smoking. Talk to your doctor about ways to quit.
Avoid movements that twist or strain your back. Use your body properly:
Stand smart. Don't slouch. Maintain a neutral pelvic position. If you must stand for long periods, place one foot on a low footstool to take some of the load off your lower back. Alternate feet. Good posture can reduce the stress on back muscles.
Sit smart. Choose a seat with good lower back support, armrests and a swivel base. Placing a pillow or rolled towel in the small of your back can maintain its normal curve. Keep your knees and hips level. Change your position frequently, at least every half-hour.
Lift smart. Avoid heavy lifting, if possible, but if you must lift something heavy, let your legs do the work. Keep your back straight — no twisting — and bend only at the knees. Hold the load close to your body. Find a lifting partner if the object is heavy or awkward.
Buyer beware
Because back pain is so common, numerous products promise prevention or relief. But there's no definitive evidence that special shoes, shoe inserts, back supports, specially designed furniture or stress management programs can help.
In addition, there doesn't appear to be one type of mattress that's best for people with back pain. It's probably a matter of what feels most comfortable to you.
Back Pain Overview Back pain is one of the most common reasons people go to the doctor or miss work, and it is a leading cause of disability worldwide. Most people have back pain at least once.
Fortunately, you can take measures to prevent or relieve most back pain episodes. If prevention fails, simple home treatment and proper body mechanics often will heal your back within a few weeks and keep it functional. Surgery is rarely needed to treat back pain.
Back Pain Symptoms Signs and symptoms of back pain can include:
Muscle ache
Shooting or stabbing pain
Pain that radiates down your leg
Pain that worsens with bending, lifting, standing or walking
Pain that improves with reclining
When to see an acupuncturist Most back pain gradually improves with home treatment and self-care, usually within a few weeks. If yours doesn't improve in that time, see your doctor.
In rare cases, back pain can signal a serious medical problem. Seek immediate care if your back pain:
Causes new bowel or bladder problems
Is accompanied by fever
Follows a fall, blow to your back or other injury
Contact an acupuncturist if your back pain:
Is severe and doesn't improve with rest
Spreads down one or both legs, especially if the pain extends below the knee
Causes weakness, numbness or tingling in one or both legs
Is accompanied by unexplained weight loss
See your doctor if you start having back pain for the first time after age 50, or if you have a history of cancer, osteoporosis, steroid use, or excessive drug or alcohol use.
Back Pain Causes Low back pain caused by spinal degeneration and injury.
Back pain that comes on suddenly and lasts no more than six weeks (acute) can be caused by a fall or heavy lifting. Back pain that lasts more than three months (chronic) is less common than acute pain.
Back pain often develops without a cause that your doctor can identify with a test or an imaging study. Conditions commonly linked to back pain include:
Muscle or ligament strain. Repeated heavy lifting or a sudden awkward movement can strain back muscles and spinal ligaments. If you're in poor physical condition, constant strain on your back can cause painful muscle spasms.
Bulging or ruptured disks. Disks act as cushions between the bones (vertebrae) in your spine. The soft material inside a disk can bulge or rupture and press on a nerve. However, you can have a bulging or ruptured disk without back pain. Disk disease is often found incidentally when you have spine X-rays for some other reason.
Arthritis. Osteoarthritis can affect the lower back. In some cases, arthritis in the spine can lead to a narrowing of the space around the spinal cord, a condition called spinal stenosis.
Skeletal irregularities. A condition in which your spine curves to the side (scoliosis) also can lead to back pain, but generally not until middle age.
Osteoporosis. Your spine's vertebrae can develop compression fractures if your bones become porous and brittle.
Back Pain Risk factors Anyone can develop back pain, even children and teens. These factors might put you at greater risk of developing back pain:
Age. Back pain is more common as you get older, starting around age 30 or 40.
Lack of exercise. Weak, unused muscles in your back and abdomen might lead to back pain.
Excess weight. Excess body weight puts extra stress on your back.
Diseases. Some types of arthritis and cancer can contribute to back pain.
Improper lifting. Using your back instead of your legs can lead to back pain.
Psychological conditions. People prone to depression and anxiety appear to have a greater risk of back pain.
Smoking. This reduces blood flow to the lower spine, which can keep your body from delivering enough nutrients to the disks in your back. Smoking also slows healing.
Back Pain Prevention You might avoid back pain or prevent its recurrence by improving your physical condition and learning and practicing proper body mechanics.
To keep your back healthy and strong:
Exercise. Regular low-impact aerobic activities — those that don't strain or jolt your back — can increase strength and endurance in your back and allow your muscles to function better. Walking and swimming are good choices. Talk with your doctor about which activities you might try.
Build muscle strength and flexibility. Abdominal and back muscle exercises, which strengthen your core, help condition these muscles so that they work together like a natural corset for your back. Flexibility in your hips and upper legs aligns your pelvic bones to improve how your back feels. Your doctor or physical therapist can tell you which exercises are right for you.
Maintain a healthy weight. Being overweight strains back muscles. If you're overweight, trimming down can prevent back pain.
Quit smoking. Talk to your doctor about ways to quit.
Avoid movements that twist or strain your back. Use your body properly:
Stand smart. Don't slouch. Maintain a neutral pelvic position. If you must stand for long periods, place one foot on a low footstool to take some of the load off your lower back. Alternate feet. Good posture can reduce the stress on back muscles.
Sit smart. Choose a seat with good lower back support, armrests and a swivel base. Placing a pillow or rolled towel in the small of your back can maintain its normal curve. Keep your knees and hips level. Change your position frequently, at least every half-hour.
Lift smart. Avoid heavy lifting, if possible, but if you must lift something heavy, let your legs do the work. Keep your back straight — no twisting — and bend only at the knees. Hold the load close to your body. Find a lifting partner if the object is heavy or awkward.
Buyer beware Because back pain is so common, numerous products promise prevention or relief. But there's no definitive evidence that special shoes, shoe inserts, back supports, specially designed furniture or stress management programs can help.
In addition, there doesn't appear to be one type of mattress that's best for people with back pain. It's probably a matter of what feels most comfortable to you.
Protocol Acupuncture Treatment for Cold-Dampness Back Pain
Exposure to a cold or damp environment contributes to low back pain. Care must be taken to avoid unwanted exposure including extended periods in the rain, swimming in cold water, or exposure to wind after sweating. The cold contracts and the dampness heavily obstructs thereby leading to channel blockage and consequent pain. Inactivity and excess lying down exacerbates the condition.
Cold-dampness blocking qi and blood circulation causes lower back pain, tingling, or numbness that may radiate to the buttocks, lower limbs, groin, or lower abdomen. Indications include a heavy sensation, stiffness, range on motion impingement, and a cold sensation on the lower back.
The Du (Governing Vessel), Bladder Foot-Taiyang, or Gallbladder Foot-Shaoyang channels are affected. Dampness tends to linger and therefore the pain may become chronic. Pain is exacerbated by cold and damp exposure, which increases qi and blood stasis, and is relieved by warmth. Light exercise or walking may help to warm and dispel dampness thereby relieving pain. Unilateral dull aching and weakness of the lower back and legs indicates excess cold and dampness whereas a bilateral presentation of symptoms may indicate kidney qi deficiency.
Tongue: pale with a greasy, white coating Pulse: thin, wiry, slow, deep, or moderate
Treatment Principle Dispel cold and dampness, warm the channels, invigorate qi and blood
Acupuncture Points Moxibustion as a standalone therapy or attached to the needles is appropriate to dispel cold and dampness.
BL23 (Shenshu) — Kidney back shu point
BL25 (Dachangshu) — Large intestine back shu point
BL26 (Guanyuanshu) — Gate of origin back shu point This point is located 1.5 cun lateral to the lower border of the spinous process of the 5th lumbar vertebrae. A great local point for lower back pain, electroacupuncture is often run across the back from one BL26 acupoint to the other for the treatment of disc disorders and other spinal conditions resulting in nerve impingement or inflammation. This point is especially useful given the commonality of L5/S1 disc protrusions.
BL40 (Weizhong) — Command point of the back
BL60 (Kunlun) This is a jing-river, fire, and Ma Dan-yang Heavenly Start point acupoint indicated for the treatment of lower back pain, headaches, stiff neck, ankle and heel pain, and difficulty with labor and delivery.
GV3 (Yaoguanshu) — This point is translated as the lumbar yang gate. Its location on the midline at the depression below the spinous process of the 4th lumbar vertebrae makes it a useful point for the treatment of lower back pain.
M-BW-24 (Yaoyan) Translated as lumbar eyes, this acupuncture point benefits the lumbar area, strengthens the Kidneys, alleviates pain.
References 1. Qaseem, Amir, Timothy J. Wilt, Robert M. McLean, and Mary Ann Forciea. "Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of PhysiciansNoninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain." Annals of Internal Medicine (2017). 2. Qaseem, et al. Annals of Internal Medicine (2017).
3. Katz J.N. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences.J Bone Joint Surg Am200688 Suppl 2214. 4. Lam M. Galvin R. Curry P. Effectiveness of acupuncture for nonspecific chronic low back pain: a systematic review and meta-analysis.Spine (Philadelphia, Pennsylvania 1976) 201338212438. 5. ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet. Low Back Pain Fact Sheet, National Institute of Neurological Disorders and Stroke, National Institutes of Health. 6. Nahin, Richard L., Robin Boineau, Partap S. Khalsa, Barbara J. Stussman, and Wendy J. Weber. "Evidence-based evaluation of complementary health approaches for pain management in the United States." In Mayo Clinic Proceedings, vol. 91, no. 9, pp. 1292-1306. Elsevier, 2016. 7. Martin DP, Sletten CD, Williams BA, Berger IH. Improvement in fibromyalgia symptoms with acupuncture: results of a randomized controlled trial. Mayo Clin Proc. 2006;81(6):749-757. 8. MacPherson, H., A. Vickers, M. Bland, D. Torgerson, M. Corbett, E. Spackman, P. Saramago et al. "Acupuncture for chronic pain and depression in primary care: a programme of research." (2017).
9. Leslie Lingaas. ucsf.edu/news/2014/04/113966/acupuncture-helps-young-patients-manage-pain. Acupuncture Helps Pediatric Patients Manage Pain and Nausea, 2014. 10. Lin, Lili, Nikola Skakavac, Xiaoyang Lin, Dong Lin, Mia C. Borlongan, Cesar V. Borlongan, and Chuanhai Cao. "Acupuncture-induced analgesia: the role of microglial inhibition." Cell transplantation 25, no. 4 (2016): 621-628. 11. Cevic, C and Iseri, SO. The effect of acupuncture on high blood pressure of patients using antihypertensive drugs. Acupuncture & electro-therapeutics research 2013; 38(1-2): 1-15. ncbi.nlm.nih.gov/pubmed/23724695.
Sources
https://www.healthcmi.com/Acupuncture-Continuing-Education-News/1721-it-s-official-acupuncture-doctor-approved
https://www.healthcmi.com/low-back-pain-sample