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Acupuncture In The Management Of Back Pain
Abraham C. Kuruvilla, MD
ABSTRACT
Background Acupuncture is increasingly recognized as an effective modality for the management of back pain. After appropriate training, a primary care physician can offer this type of treatment in the office.
Objective To describe the outcome of patients with chronic and acute back pain who received acupuncture from their primary care physician.
Design, Setting, and Patients Case series from a 20-month period in 1998-1999 during which 86 patients (36 men and 50 women) in Phoenix, Arizona, sought acupuncture from their office-based physician for back pain.
Intervention Shao Yin-Tai Yang and Bladder-Gallbladder Tendinomuscular meridians in French Meridian acupuncture were used based on duration of symptoms. The 30-minute treatment sessions were given weekly.
Main Outcome Measures Complete improvement (no further treatment needed), significant improvement (occasional use of over-the-counter analgesics), or no improvement, by patient report.
Results Chronic back pain, with symptoms present for $12 weeks, was seen in 53/86 patients (61%). Thirty (35%) reported an upper back component to their perceived low back symptoms. No improvement was reported in only 13 patients (15%); significant improvement was seen in 14 (16%); and a complete cure was reported in 59 (69%).
Conclusions Acupuncture is gaining increasing attention as a therapeutic modality in the management of back pain. The primary care physician can obtain good results using French Meridian acupuncture. Further studies should include Meridian acupuncture in the management of both acute and chronic back pain.
KEY WORDS
Back Pain, Acupuncture, Meridians, French Meridian, Sciatica
INTRODUCTION
Back pain, especially low back pain, affects millions of Americans each year.1 Frequently, patients with low back pain are treated by primary care physicians. Acute and chronic back pain are treated using both pharmacological agents and non-pharmacological modalities.2-4 One such modality is acupuncture, mostly used for chronic back pain.5 The purpose of this article is to describe the features and outcomes of patients with chronic and acute back pain who requested acupuncture from their primary care physician.
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Table 1. Acupuncture Points for Back Pain
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Acupunctur e Point
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Anatomical Location
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KI 3
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In the depression between the prominence of medial malleolus and the Achilles tendon
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KI 10
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Between the tendons of semitendinosus and semi-membranosus, medially in the popliteal fossa
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SI 3
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Proximal to the head of the 5th metacarpal bone on the ulnar side at the junction of dorsal and ventral skin margin
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BL 40
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Between the tendons of biceps femoris and semitendinosus muscle in the popliteal fossa
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BL 60
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In the depression between the prominence of lateral malleolus and the Achilles tendon
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BL 23
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1.5" lateral to the lower border of L2 spine
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BL 25
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1.5" lateral to the lower border of L4 spine
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BL 27
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1.5" lateral to S1 foramen
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BL 29
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1.5" lateral to S3 foramen
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BL 67
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At the proximal nail-skin margin of the lateral part of 5th toe
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GB 44
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At the proximal nail-skin margin of the lateral part of 4th toe
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SI 18
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Below the outer canthus in the depression beneath the lower border of the zygoma
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METHODS
During a 20-month period in 1998-1999, I treated 86 patients for back pain using the French Meridian acupuncture method taught at the UCLA School of Medicine (Los Angeles, California). The Shao Yin-Tai Yang Principal Meridian was used except in acute back pain, when the Bladder-Gallbladder Tendinomuscular meridian was used.
Appropriate Ah Shi points were needled in both situations. (The Tendinomuscular Meridian consists of BL 67 and GB 44 with SI 18. The Principal Meridian consists of KI 3 and 10, SI 3, BL 40 and 60 for N-N + 1 extraction of Yang, and BL 23, 25, 27, and 29.5) Moxibustion6 was common to both meridian treatments. Electrical stimulation was not used. Each weekly treatment session lasted 30 minutes. All patients gave informed consent for treatment.
The anatomical locations of acupuncture points are given in Table 1.7 The outcome was described as "complete," "significant," and "no improvement." Complete improvement was defined as total lack of pain without other intervention; significant improvement was defined as absence of pain with occasional use of non-prescription analgesics; no improvement was defined as end of treatment pain at the same level as at the beginning. The outcome status was confirmed with each patient 6 months after the last treatment.
RESULTS
Of the 86 patients, 36 (42%) were men and 50 (58%) were women (Table 2). More than half of the patients were younger than 45 years.
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Table 2. Patient Characteristics and Treatment (N=86)
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Characteristic
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No. (%)
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Men
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36 (42)
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Women
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50 (58)
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Women
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50 (58)
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Age <45 y
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48 (56)
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Age $45 y
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38 (44)
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No trauma
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57 (66)
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Low & upper back pain
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30 (35)
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Low back pain only
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56 (65)
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Sciatica
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9 (10)
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Magnetic resonance imaging performed
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13 (15)
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Treatment approach
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Principal Meridian
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79 (92)
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Tendinomuscular Meridian
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7 (8)
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Table 3. Nujmber of Acupuncture Sessions
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No. of Sessionns
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No. (%) of patients
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1
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7(8)
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2-6
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69(80)
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7-9
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6(7)
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>9
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4(5)
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In 57 patients (66%), there was no associated trauma. Seventeen patients (20%) reported past trauma, while 12 (14%) reported a recent injury. Isolated low back pain was seen in 56 (65%), while an additional upper component was reported in 30 (35%). Sciatica was absent in 77 (89%). Only 13 (15%) required imaging studies. Therapy was conducted with the Principal Meridian in 79 patients (92%), and Tendinomuscular Meridian in 7 (8%). The duration of pain was less than 2 weeks in 10 patients (11%); 2-12 weeks in 23 (27%); and more than 12 weeks in 53 (62%).
The number of acupuncture sessions patients received is listed in Table 3. Use of the Tendinomuscular Meridian requires a single session. The patients' conditions with their ICD-9 classification and specific outcomes are shown in Table 4. No improvement was noted only in 15%, while significant improvement was seen in 16%, and a complete cure was reported in 69% of patients.
DISCUSSION
I have addressed the management of acute and chronic back pain using French Meridian acupuncture. In all diagnostic groups, the majority of patients reported complete cure. Placing needles in appropriate acupuncture points corrects the imbalance in the Yin and Yang energy forces, promotes the healthy flow of Qi, and creates a healing environment.7,8 A 1997 NIH Consensus Development Statement described acupuncture as a reasonable alternative treatment for low back pain.5 The limited published data are conflicting regarding beneficial outcome.9 Although this is not a prospective, placebo-controlled, double-blind study, it describes a single-provider acupuncture intervention for specific diagnoses in 86 patients.
Current medical management available for patients such as those in this study includes pharmacological intervention with acetaminophen, nonsteroidal anti-inflammatory drugs, tramadol hydrochloride, narcotic analgesics, muscle relaxants, tricyclic antidepressants, anticonvulsants, and corticosteroids.3 Many patients prefer avoiding these agents because of their significant adverse effects. Non-pharmacological interventions include bed rest, exercise, mobilization and manipulation, educational and motivational programs, transcutaneous electrical nerve stimulation (TENS), massage therapy, biofeedback, application of heat/cold, back support, surgery, acupuncture, and percutaneous electrical nerve stimulation (PENS).4,10 Although acupuncture is increasingly recognized as a reasonable alternative or adjunct treatment for back pain, reports such as this one may substantiate such observations.
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Table 4. Diagnosis and Outcome
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No. of Patients (%)
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Diagnosis (ICD-9 Code)
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Complete Improveme nt
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SignificantIm provement
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No Improvement
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Myositis (729.1)
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49 (57)
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11 (13)
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9 (11)
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Degenerative
joint disease (722.6)
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3 (4)
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2 (2)
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2 (2)
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Herniated disk (722.73)
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4 (5)
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1 (1)
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1 (1)
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Laminectomy (724.5)
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2 (2)
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0
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0
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Fibromyalgia (729.0)
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1 (1)
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0
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1 (1)
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Abbreviation: ICD-9, International Classification of Diseases, 9th Revision.
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CONCLUSION
Acupuncture is gaining increasing attention as a therapeutic modality in the management of back pain. I have described a specific meridian acupuncture therapy that benefited patients with back pain from various causes. Thus, the primary care physician may obtain good outcomes treating back pain using French Meridian acupuncture. Future studies should perhaps include French Meridian acupuncture techniques in the management of both acute and chronic back pain.
REFERENCES
- Frymoyer JW, Cats-Baril WL. An overview of the incidences and costs of low back pain. Orthop Clin North Am. 1991;22:263-271.
- Belgrade MJ. Opioids for chronic non-malignant pain. Postgrad Med. 1999;106:115-124.
- Ruoff GE. Pharmacologic treatment of low back pain. Fam Pract Recertification. 1999;21:15-21.
- Paster RZ. Non-pharmacological management of low back pain. Fam Pract Recertification. 1999;21:9-14.
- NIH Consensus Conference. Acupuncture. JAMA. 1998;280:1518-1524.
- ardini F, Weixin H. Moxibustion for correction of breech presentation: a randomized controlled trial. JAMA. 1998;280:1580-1584.
- Ellis AW, Wiseman NA, Boss K. Fundamentals of Chinese Acupuncture. Rev ed. Brookline, Mass: Paradigm Publications; 1991:77-397.
- Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. Berkeley, Calif: Medical Acupuncture Publishers; 1995:697.
- Van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain: a systematic review of randomized controlled trials of the most common interventions. Spine. 1997;22:2128-2156.
- Ghoname EA, Craig WF, White PF, et al. Percutaneous electrical nerve stimulation for low back pain: a randomized crossover study. JAMA. 1999;281: 818-823.
AUTHOR INFORMATION
Dr Abraham Kuruvilla practices Family Medicine and CAM in a multi-physician group in Guadalupe, Arizona. Dr Kuruvilla is certified by the American Board of Family Practice, American Board of Pediatrics, and the sub-specialty Board of Neonatal-Perinatal Medicine.
Abraham C. Kuruvilla, MD MD(H)*
Medical Professional Associates of Arizona (MedPro)
3255 E Elwood, Suite 110
Phoenix, AZ 85034
Phone: 602-470-5000 (O); 602-944-1258 (H) • Fax: 480-344-6001
E-mail: hercule1@cox.net
*Correspondence and reprint requests
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