Acupuncture for lower back pain

Lower back pain is a major problem in today’s modern society. For example it is considered that up to 80% of the population will experience a back problem during their working lives and even more challenging, in 80% of back pain it is not possible to identify the exact structure causing the pain!

Lower back pain has a cost to the economy too. On average, each person suffering with lower back pain took an estimated 18.7 days off work, which has been shown to cost employers is £315-£335 million!

Now we already know that lower back pain needs to be treated with exercise based therapy and the evidence highlights that this is the most effective approach. However we always need a plan B just in case Plan A doesn’t really work or is difficult to achieve for whatever reason.

Here is some evidence regarding the benefit of exercise for low back pain:

A review of systematic reviews found benefit of specific stabilisation exercise for non specific chronic low back pain (Haladay et al 2013).

Pilates improves pain, function & aspects related to quality of life in chronic low back pain (Natour et al 2014).

Early results of systematic reviews appear promising for the effectiveness of yoga for chronic low back pain (Hill 2013).

And…

Post-treatment exercise programmes can prevent recurrences of back pain (Choi et al 2010).

Sometimes in my practice I may choose to try acupuncture as a plan B or even a plan C and guess what it does work!

So what acupuncture points are regularly used for low back pain?

Local points:

L1 level: BL22 and BL51, GV5 and HTJJ on L1

L2 level: BL23 and BL52, GV4 and HTJJ on L2

L3 level: BL24 and HTJJ on L3

L4 level: BL25, GV3 and HTJJ on L4

L5 level: BL26 and HTJJ on L5

S1 level: BL27 and BL31

S2 level: BL28, BL53 and BL32

S3 level: BL29 and BL33

S4 level: BL30 and BL34

Coccyx level: GV 2

Gluteus Maximus & Piriformis: BL54

If pain extends down the leg from the back then other points into the leg should be used. Obviously this would be an awful lot of points to use in total. Generally the principles when treating low back pain are to use between 4 to 6 bilateral pairs of bladder points locally in the most painful segments and also above and below this area. If there is leg pain then you should use a couple of distal points in the affected leg or legs.

Here is an example of what was used by Brinkhaus et al (2006):
4 bilateral points from the below selection:

BL20-34, BL50-54, GB30, GV3, 4, 5, 6, HTTJ’s and shi qi zhui xia

They could also choose 2 bilateral points distally from the below selection:

SI3, BL40, 60 and 62, KI3 and 7, GB31, 34 and 41, LV3 and GV12 and 20.

They were allowed to choose some trigger points depending on the patient.

Common trigger points are: in Gluteus medius, minimus and maximus, piriformis and quadratus lumborum.

So now we know what points can and are used, but does it work?

Now there is always a lot of debate in the Physio world regarding acupuncture so we will try to look at this through the evidence and try to sum things up overall.

For acupuncture:

Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo (Vickers et al 2012).

Molsberger et al (2002) concluded that acupuncture can be an important supplement of conservative orthopaedic treatment in the management of chronic Low Back Pain.

Results suggest that acupuncture is effective for some but not all types of pain. (Lee & Ernst 2011).

Acupuncture should be considered for short term relief of pain in patients with chronic low back pain or osteoarthritis (Colvin et al 2013).

Acupuncture may be more effective than medication for symptom improvement or pain in acute low back pain (Lee et al 2013).

Chronic low back pain: Acupuncture & conventional therapies improves pain & function more than conventional therapies alone (Furlan et al 2010).

Consider offering a course of acupuncture needling comprising up to a maximum of 10 sessions over a period of up to 12 weeks (National institute for health and care excellence 2009).

At present the latest NICE guidelines (last point) recommend trying acupuncture, which is the most significant point above and all the above points do clearly show that it works.

Against acupuncture:

Acupuncture: In a review of systematic reviews it was found there is insufficient evidence for positive recommendations (Gilbey et al 2013).

Dworkin et al (2009) found that the difference between sham and real acupuncture was too small to be clinically significant but both were better than no acupuncture at all.

Leibing et al (2002) found a significant improvement by traditional acupuncture in chronic low back pain compared to routine care (physiotherapy) but not compared to sham-acupuncture.

So the main argument against acupuncture is that it is simply just a placebo. The trouble with this argument is that if they are correct and the effect is placebo then is this wrong? I suggest that you read my article on placebo effect here:

http://mathewhawkesphysiotherapy.blogspot.co.uk/2015/01/the-placebo-effect-ethical-dilemma-or.html

Interesting points in the above article are here:

“Linde et al (2007) found a significant association between better improvement and higher outcome expectations with placebo treatments.”

Also here:

“Kaptchuk et al (2008) actually found that patients did better if the practitioner was caring, warm, attentive and confident even when they offered the exact same placebo treatment.”

So if this is true of placebo then why did Macpherson et al (2013) find little evidence showing that different characteristics of acupuncture/acupuncturists modified the treatment effect?

Not all placebo effects are created equal:

The reality is that not all placebo effects are equal and in fact, it is likely that a treatment considered to be no better than its placebo version may still be more effective overall than a treatment that is considered better than its placebo counterpart. So what are we to do in this case? Do we use the lesser effective treatment that is not just a placebo or do we choose the treatment that is essentially a placebo but is actually more effective? I know what I would choose as a patient but it’s different as the practitioner.”

Interestingly Macpherson et al (2013) also found that if you used more needles & had more sessions of acupuncture then the difference is greater when comparing acupuncture to non-acupuncture controls (Macpherson et al 2013). So maybe the issue about some research is not specific to acupuncture versus sham but how to apply acupuncture optimally to achieve a clinically significant result.

Overall maybe we should look at what the exact parameters of acupuncture treatment should be, then use this, to compare to sham. After all if I had a chest infection and took 1 antibiotic per week it would be no better than a placebo but if I took the correct dosage then it would be effective. In fact this study looking at randomised controlled trials found that only 25% of them actually performed the acupuncture as it should be performed according to Chinese textbook acupuncture standards (Molsberger et al 2011).

At present I personally think the jury is still out. Clearly acupuncture works better than not having acupuncture but is it just a placebo or are we still using it wrong in certain research papers? Unfortunately I don’t have the answer, but who does? There is enough evidence to support its use at present and clinically I let the results speak for themselves. Until the evidence convinces me that it’s not worth using and my patients don’t improve, then I will continue using it.

If you need any further information or would like to book an appointment then call Hawkes Physiotherapy on 01782 771861 or 07866195914

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