Introduction Chronic low back pain is a common complaint; its prevalence and increasing work-related and medical costs is causing much debate regarding the most effective management for this condition. Acupuncture has been widely used for many conditions and now evidence suggests that it has a place in the management of pain in musculoskeletal disorders such as low back pain.
Aims The aim of this case study is to use acupuncture in the treatment of chronic low back pain using a semi-standardized approach.
Results Six treatments of acupuncture over 4 weeks improved overall wellbeing, improved sleep, increased lumbar spine function and most importantly reduced pain (NPRS 6/10 to 4/10) in the short-term.
ConclusionAcupuncture analgesia has an important role in the management of pain in an osteopathic setting in the short-term.
Keywords Chronic low back pain; acupuncture; osteopathy; physiology, NPRS
Introduction & Overview
Low back pain (LBP) is a major health problem among western industrialized countries, and a major cause of medical expenses, absenteeism and even disability (van Tulder 1995). LBP is a frequent reason for sufferers seeking complementary therapies, including acupuncture (Leibing et al. 2002).
Here, a 45-year-old man presented to an osteopath with a 7-year history of central LBP following a fracture to L2 vertebra. Previously, his history included a T7 fracture at 18 years of age, which resulted in Harrington rods being fitted (from T1 to L2) but were subsequently removed at the time of L2 fracture.
The subject expressed he ‘enjoys simple things in life’ and through his condition has now slowly retracted from engaging in hobbies such as dirt biking and his work (manual labour). The subject complains of persistent dull achy pain in his low back, coordination/balance difficulties and lacking energy. His sleep is disturbed on a regular basis.
Objective assessment included reduced range of movement (ROM) in all planes at the lumbar spine (Lsp). A marked increase in kyphosis was observed and very reduced ROM in the thoracic spine was noted, which has led to the lumbar apophyseal joints being overloaded. This was markedly seen in the thoracolumbar and lumbosacral regions. Neurological signs included slight UMNL (upgoing plantar response) on right (from T7 injury). On palpation, the thoracolumbar segment, L1-2 and lumbosacral segment showed decreased ROM and increased tone and tenderness in the paraspinal muscles and Quadratus Lumborum bilateral. Some scar tissue tethering and fascial tightening was noted over the lumbar area generally.
The diagnosis was made on a subjective, as well as an objective assessment, to include secondary osteoarthritis of thoracolumbar, L1-3 owing to tissue damage to L2 with regard to previous fracture and on-going changes to thoracic kyphosis. Eight sessions of osteopathic treatment before the commencement of acupuncture included thoracic and lumbar spine mobilization, extension exercises to slow kyphosis down and muscular techniques targeted at lumbar Erector Spinae/Quadratus Lumborum and Iliospoas. Acupuncture was selected as an appropriate treatment for pain management and homeostasis.
The treatment management plan was to:
Improve function by mobilizing the appropriate lumbar and thoracic segments, address myofascial imbalance and look at trigger point therapy using needles
Injuries such as those mentioned above have been shown to have long-term effects associated with them (Bogduk 2002). These include spondylosis and osteoarthrosis of the lumbar spine and it is asserted that apophyseal arthritis is usually secondary to spondylosis; in about 20% cases it can be a totally independent disease (Lewin 1964). In this case a fracture and subsequent surgical intervention and removal of the Harrington rods have led to secondary osteoarthritis of the thoracolumbar area and lumbar spine. Since the accident spinal curves continue to depreciate, which delivers extra stress and load on the lower lumbar area. Pain management can only come about once the pathophysiology is understood and here possible explanations are described.
Histological studies have shown that capsules of lumbar apophyseal joints are richly innervated with encapsulated, unencapsulated and free nerve endings. They therefore transmit proprioceptive and nociceptive information (Bogduk, 1983). Nerve endings are also found in subchondral bone of the joints and Substance P has been found throughout these structures. The presence of substance P in nerve fibres within subchondral bone of degenerative lumbar apophyseal joints implicates this type of joint in the aetiology of low back pain (Beaman et al. 1993) and is implicated in this case report. Wound healing involves a co-ordinated series of overlapping processes resulting in a varying degree of structural and functional restoration. When successful, wound healing restores normal function with a well-organized, minimal scar. Removal or damage to the skin by trauma, surgical wounds, burns, or ulcers may result in major functional and psychological problems for patients.
Tissue remodelling may be caused by mechanical stress such as those described above. Increased stress due to overuse, repetitive movements, or decreased stress due to immobilization or hypomobility can cause change in connective tissue (Langevin and Sherman, 2007). Langevin and Sherman propose that a chronic local increase in stress can lead to micro-injury and inflammation, whereas a consistent lack of stress leads to fibrosis, adhesions and contractures. Either way, fibrosis can be the direct result of hypomobility or indirect via injury and inflammation. Myofascial trigger points due to a decrease in tissue pH, and increased inflammatory cytokines can also be a factor in fibrosis and hypomobility (Tough et al, 2009). It can therefore be said that connective tissue fibrosis is detrimental as it leads tissue restriction and impairment in the long term. Connective tissue is richly innervated by mechanosensory and nociceptive neurons (Aδ and C-fibres) (Corey et al., 2011). Nociceptive neurones respond to changes at a local level of prostaglandins, bradykinin, growth factor and adrenaline. On the other hand, release of Substance P from sensory C-fibres in the skin can enhance the production of histamine and cytokines. Cytokines (TGFβ-1) stimulated by tissue injury and histamine release increase fibroblast production leading to tissue fibrosis, therefore showing that nociceptor activation can worsen stiffness and impairment (Langevin and Sherman, 2007). Western acupuncture (Zaslawski, 2003) addresses pain management using Traditional Chinese Medicine concepts (Bradnam, 2003) such as meridian acupoints. There is a wide variety of evidence to date to demonstrate that acupuncture is an effective modality in effecting pain by stimulating (via deQi) Aδ and C-fibres that communicate with the dorsal horn in the spinal cord, brain stem and higher centres such as the hypothalamus and periaqueductal grey (PAG). In turn, descending noxious inhibitory pathways using endogenous opioid mechanisms are stimulated (Cao, 2002; Zhao, 2008). It is therefore thought that acupuncture modulates spinal signal transmission and the brain’s perception of pain. Acupuncture also leads to the release of enkephalins and endorphins, exerting an inhibitory effect on nociceptive reflexes at the segmental level. To have an effect on trigger points, acupuncture ‘dry needling’ techniques are employed. Trigger points are myofascial phenomenon known to produce sensory, motor and autonomic symptoms. The definition of a trigger point is ‘presence of exquisite tenderness at a nodule in a palpable taut band of muscle’ (Travell and Simons, 1992). Current thinking includes two modes of thinking: the motor end plate hypothesis (Simons, 2002) that proposes minute loci in muscle fibres which produce small electrical impulses but not strong enough to propagate a muscle contraction. Hence a small extent of shortening can take place causing trigger points.
The energy crisis model is the other hypothesis whereby ischaemic by-products could be partly responsible for pain produced by sensitized sensory nerves. A shortening of sarcomeres by calcium release over a prolonged period along with a compromised circulation and reduction in available adenotriphosphate (ATP) equates to lack of active relaxation of the muscle fibres (Travell & Simons, 1992). Combining these hypotheses could give plausible explanations for the management of trigger point needling.
Dry needling techniques involve using the same needles as acupuncture but the needle is ‘pistoned’ in and out of the muscle. The needle is inserted toward the trigger point area, aiming to reproduce the subject’s main symptoms. Muscle twitch can be felt and needle grasp should be achieved, the result of which should be muscle relaxation and lengthening. This technique is thought to stimulate Type II and III afferents, which result in analgesia. The needle disrupts the endplate resulting in pain reduction and decreasing tension (Baldry, 2002).
Acupuncture point rationale
Semi-standardized acupuncture points used for low back pain have been described in various original papers, (Brinkhaus et al., 2006, & MacPherson et al., 2004). Table 1 outlines those points. The Bladder (BL) meridian is used primarily as it has points local to the spine and can add to the segmental approach sought by western acupuncture. The Gallbladder (GB) and BL meridian follows peripheral nerve/dermatome levels corresponding to spinal levels. It is thought that using points that share an innervation via a common spinal segment will enhance the analgesic effect (Bradnam-Roberts, 2011). Other points were selected based on the subject’s own history/symptoms and practitioner’s current knowledge base and abilities. Table 1. Summary of semi-standardized acupoints for low back pain.
BL 20 to 34
L1 to S2
BL 50 to 54
S1 to S2
GV 3 to 6
L3 to S1
Huatuojiaji (HJJ) at lumbar spine
At least 2 distal points from selection below
BL 40, 60, 62
S1 to S2
GB 31, 34, 41
L5 to S1
GV 14 and 20
(Adapted from Brinkhaus et al., 2006, & MacPherson et al., 2004). B, bilateral; LIV, liver; GB, gallbladder; GV, governor vessel; BL, bladder; LI, large intestine; HJJ, Huatuojiaji; SI, small intestine.
Physiological reasoning for acupoints
The first eight treatments were osteopathic in approach considering Still’s philosophy structure governs function (Stone, 1999). The application of treatment is described above in Table 2. Acupuncture point selection was based on western acupuncture philosophies. In this case the primary pain is peripheral nociceptive pain. DeQi activation (Wu et al. 1999) and re-enforcement of at least once was used over a period of 30–40 minutes at each session (Bradnam, 2003). A combination of local and distal points was selected to affect nociceptive pain. It is suggested by research that local points induce segmental pain ascending inhibitory effects, through the spinal gate control mechanism (Moffett, 2006), which stimulates C-fibres and Aδ fibres. This in turn releases opioids from inhibitory neurones in the dorsal horn of the spinal cord. The Bladder meridian allows for segmental approach as these points are located at the spinal levels. BL23 and BL25 are recognized for reducing LBP. Huatuojiaji (HJJ) and governor vessel (GV) points were added as these are also spinal points, to magnify the effects locally.
Distal points were used to induce strong supraspinal pain-descending inhibitory effects (Carlsson, 2002). This in turn mediates further inhibition of pain from the PAG, pineal gland, hippocampus and hypothalamus by releasing serotonin, norepinephrine and adrenocorticotrophic hormone, oxytocin and melatonin (Moffat, 2006). Oxytocin is a chemical that serves to block pain memory and hence is useful in chronic pain conditions. Melatonin production can help improve sleep patterns and hence was desirable in this case. LI4 and LIV3 were specifically sought for these effects.
Table 2. Treatment and acupoint rationale
Reduce pain levels generally. Improve sleep. Introduction to acupuncture. Avoided local overstimulation.
LIV3 B, LI4 B – Major analgesic points. Insomnia
LIV3 – cardinal point for nervous system
Dry needling to Multifidus B L2-3, L4-5
LIV3 B, LI4 B – Major analgesic points. Insomnia
BL23 B – empirical point for back pain and source of all Qi
The numerical pain rating score (NPRS) at the start of treatment was on average 6/10 and lumbar movement was hampered by rotation and flexion. By the 6th acupuncture session, NPRS was reduced to 4/10 and the patient’s subjective view was that he was able to do more during the day and even mentioned he went dirt biking after over 6 months of abstaining from his hobby due his symptoms. He reported better sleep patterns also by the 4th session. Table 3 outlines the outcome measures.
Table 3. Results from the case study.
Flexion 45° Lsp from standing position; NPRS 6/10
Flexion 45° Lsp from standing position; NPRS 6/10
Flexion 60° Lsp from standing position; NPRS 5/10
Flexion 60° Lsp from standing position; NPRS 5/10; sleep improved
Flexion 90° Lsp from standing position; NPRS 5/10; sleep improved. Went 4hr dirt biking. Pain next day but eased.
Flexion 90° Lsp from standing position; NPRS 4/10; sleep improved.
Conclusion and limitations
Owing to the patient’s long-term problems including spinal cord injuries and degenerative changes to the lumbar spine, expectations of initial outcomes had been set at baseline. Such base expectations were perhaps introduced by the author’s limited knowledge in acupuncture and time constraints to obtain the data; however, improvements were seen within the short time treatment was started. Further sessions should have continued (planned for 10 treatments in accordance with MacPherson et al., 2003) but patient compliance was poor. Additional acupuncture points would have been explored such as SP21 to improve thoracic function, SI3 (with BL62) to open up the spine and KID 3 for lumbar pain. Osteopathic treatment would have been introduced at the same time as acupuncture to further improve spinal, SIJ and hip function. Perhaps it should be stated that the author had not initially appreciated the ability to combine both modalities within the treatment session by alternating needle time depending on whether a segmental (10–20mins) or supraspinal (up to 40 mins) approach was required (Bradnam-Roberts, 2010).
The present case study describes the osteopathic evaluation and management of a patient suffering with chronic low back pain. Current research is included to back-up the western approach to acupuncture and used to devise a management plan for this case study.
Studies (Furlan et al. 2005) have shown that in the short-term, acupuncture does have a positive effect on pain relief for chronic low back pain but when compared to conventional or alternative therapies, it was found to be no more effective in reducing pain. However, when applied in conjunction with conventional therapies, greater improvement was seen. In these studies, chronic low back pain was not categorized and hence may have led to poor results. The current study indicates that acupuncture may help in management of chronic low back pain.
Scar tissue formation and fibrosis to the thoracolumbar fascia led to a tightening and restriction of movement of the underlying lumbar Erector Spinae muscles resulting on overall dysfunction. Deactivation of trigger points, soft tissue to the Gluteals, paraspinal muscles and Quadratus Lumborum all improved ROM. Articulation and traction of the lumbar apophyseal articular joints improved joint health in as much as current pathology dictated. Acupuncture analgesia improved the noxious descending inhibitory controls and pain gate mechanism and therefore helped the patients’ pain levels. The overall result was that of improving global wellbeing.
Like other studies (Leibing et al, 2002) it is difficult to ascertain to what extent acupuncture has helped this patient, as psychological components could not be measured. Positive reinforcement might co-exist in acupuncture and hope/well-wishing could very well have a positive element in getting better. However, this patient had been told by various other medical experts that he would suffer with pain in the long-term and therefore his expectations of acupuncture were very much limited. A preliminary paper by Gamus et al. (2008) demonstrated that pain perception and coping strategies can be positively affected by acupuncture although it is not yet clear how although as previously suggested the limbic system, somatosensory cortex, brainstem, cerebellum can be stimulated. This may mean that chronic pain may be particularly influenced by acupuncture and the author will now consider acupuncture to be a strong treatment modality in an osteopathic environment.
The results obtained during this trial far exceeded the baseline level of expectations. The patient exhibited multifactorial musculoskeletal problems that, for the purpose of this study, needed to be broken down in to smaller, manageable areas so that the author could assist the patient in recovery. This contradicts acupuncture and osteopathic fundamentals, but was limited by the author’s immediate knowledge in acupuncture. In the future, with more experience, holistic viewing of the patient will need to be assessed and needle points expanded to encompass the whole person and not just the sum of its parts.
The author would like to thank the subject for his patience and attendance in order for this case study to take place. A big thank you is also in order to Jennie Longbottom, for giving the author the knowledge and the tools to attempt acupuncture in an osteopathic setting.
Baldry PE.(Management of myofascial trigger point pain. Acupuncture in Medicine 2002 20:2–10.
Beaman DN, Graziano GP, Glover RA, Wojtys EW, Chang V. Substance P innervation of lumbar spine facet joints. Spine 1993; 18:1044–1049.
Bogduk N. The innervation of the lumbar spine. Spine 1983; 8:286–293.
Bogduk N. Clinical Anatomy of the Lumbar Spine and Sacrum. 2002. 3rd Edition. Churchill Livingstone, London, UK.
Bradnam L. A Proposed Clinical Reasoning Model for Western Acupuncture. New Zealand Journal of Physiotherapy 2003; 31:40–45.
Bradnam-Roberts L. 2010. Clinical reasoning in Western acupuncture. In Acupuncture in Manual Therapy. Edited by J Longbottom. Churchill Livingstone, Elsevier Ltd, London. Pp. 1–6.
Brinkhaus B, Witt CM, Jena S, Linde K, Streng A, Wagenpfeil S, Irnich D, Walther H-U, Melchart D, Willich SN. Acupuncture in patients with chronic low back pain. Archives of Internal Medicine 2006; 166:450–457.
Cao X. Scientific basis of acupuncture analgesia. Acupuncture & Electro-Therapeutics Research International Journal 2002; 27:1–17.
Carlsson C. Acupuncture mechanisms for clinically relevant long-term effects – reconsideration and a hypothesis. Acupuncture in Medicine 2002; 20:82–99.
Corey SM, Vizzard MA, Badger GJ, Langevin HM. Sensory innervation of the nonspecialized connective tissues in the low back of the rat. Cells Tissues Organs. 2011 Mar 18. DOI: 10.1159/000323875.
Furlan AD, van Tulder MW, Cherkin D, Tsukayama H, Lao L, Koes BW, Berman BM. Acupuncture and dry-needling for low back pain. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD001351. DOI: 10.1002/14651858.CD001351.pub2.
Gamus D, Meshulam-Atzmon V, Pintov S, Jacoby R. The Effect of Acupuncture Therapy on
Pain Perception and Coping Strategies: A Preliminary Report. Acupuncture Meridian Studies 2008; 1:51−53.
Langevin HM & Sherman KJ. Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms. Medical Hypothesis 2007; 68:74–80.
Leibing E, Leonhardt U, Köster G, Goerlitz A, Rosenfeldt JA, Hilgers R, Ramadori G. Acupuncture treatment of chronic low-back pain – a randomized, blinded, placebo-controlled trial with 9-month follow-up. Pain 2002; 96:189–196.
Lewin T. Osteoarthritis in lumbar synovial joints. Acta Orthopedic Scandinavica Supplement. 1964; 73:1–112.
MacPherson H, Thorpe L, Thomas KJ, Campbell M. Acupuncture for low back pain: traditional diagnosis and treatment of 148 patients in a clinical trial. Complementary Therapies in Medicine. 2004; 12:38–44.
Moffet HH. How might acupuncture work? A systematic review of physiologic rationales from clinical trials. BMC Complementary and Alternative Medicine. 2006; 6:25–31.
Simons DG, Hong C-Z, Simons LS. Endplate potentials are common to midfiber myofacial trigger points. American Journal of Physical and Medical Rehabilitation 2002; 81:212–222.
Stone, C. 1999 Science in the art of osteopathy osteopathic principles and practice, Stanley Thornes Ltd, Cheltenham UK.
Tough EA, White AR, Cummings TM, Richards SH, Campbell JL. Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials. European Journal of Pain 2009; 13:3–10.
van Tulder MW, Koes BW, Bouter LM. A cost-of-illness study of back pain in the Netherlands. Pain 1995; 62:233–40.
Travell JG, Simons DG. 1992 Myofascial Pain and Dysfunction: Lower Extremities v. 2: The Trigger Point Manual. Lippincott Williams and Wilkins, Baltimore.
Wu M-T, Hsieh J-C, Xiong J, Yang C-F, Pan H-B, Chen Y-C, et al. Central Nervous Pathway for Acupuncture Stimulation: Localization of Processing with Functional MR Imaging of the Brain — Preliminary Experience. 1Radiology 1999; 212:133-141.
Zaslawski C. Clinical reasoning in traditional Chinese medicine: implications for clinical research. Clinical Acupuncture and Oriental Medicine. 2003; 4:94–101.