acupuncture treatment for chronic low back pain: a case study acupuncture treatment for chronic low back pain: a case study register

Acupuncture Treatment for Chronic Low Back Pain: A Case Study
Acupuncture Treatment for Chronic Low
Back Pain: A Case Study
Registered Osteopath
Abstract
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.
Conclusion Acupuncture 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:
*
Reduce pain
*
Improve function by mobilizing the appropriate lumbar and thoracic
segments, address myofascial imbalance and look at trigger point
therapy using needles
*
Improve wellbeing/homeostasis
Clinical reasoning
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.
Acupoint (bilateral)
Dermatome covered
BL 20 to 34
L1 to S2
BL 50 to 54
S1 to S2
GB 30
S1
GV 3 to 6
L3 to S1
Huatuojiaji (HJJ) at lumbar spine
At least 2 distal points from selection below
SI 3
C5
BL 40, 60, 62
S1 to S2
KID 3
S2
GB 31, 34, 41
L5 to S1
GV 14 and 20
C2
(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
Treatment
Rationale
Week 1
Treat 1
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
Week 1
Treat 2
LIV3 B, LI4 B – Major analgesic points. Insomnia
BL23 B – empirical point for back pain and source of all Qi
BL21 B – segmental approach, dorsal horn inhibition
Dry needling Quadratus Lumborum and Latissimus Dorsi right
Week 2
Treat 3
LIV3 B, LI4 B – Major analgesic points. Insomnia
BL23 B – empirical point for back pain
BL21 B – segmental approach, dorsal horn inhibition
HJJ BL23 B, BL21 B – Spinal pain, segmental and dorsal horn inhibition
GV 4 - Spinal pain, segmental and dorsal horn inhibition
Week 2
Treat 4
LIV3 B, LI4 B – Major analgesic points. Insomnia
BL23 B – empirical point for back pain
BL21 B – segmental approach, dorsal horn inhibition
BL22 B – segmental approach, dorsal horn inhibition
HJJ BL23 B, BL21 B, BL22 B – Spinal pain, segmental and dorsal horn
inhibition
GV 4 – Spinal pain, segmental and dorsal horn inhibition
BL62 – Point for back pain, poor coordination in lower extremity
GB34 – He Sea point, tissue healing, increase blood flow to
hypothalamus
Week 3
Treat 5
LIV3 B, LI4 B – Major analgesic points. Insomnia
BL23 B – empirical point for back pain
BL21 B – segmental approach, dorsal horn inhibition
BL22 B – segmental approach, dorsal horn inhibition
HJJ BL23 B, BL21 B, BL22 B – Spinal pain, segmental and dorsal horn
inhibition
GV 4 – Spinal pain, segmental and dorsal horn inhibition
BL62 B – point for back pain, poor coordination in lower extremity
BL60 B – distal point for back when lower extremity involved
GB34 B – He Sea point, tissue healing, increase blood flow to
hypothalamus
Week 3
Treat 6
LIV3 B, LI4 B – Major analgesic points. Insomnia
BL23 B – empirical point for back pain
BL21 B – segmental approach, dorsal horn inhibition
BL22 B – segmental approach, dorsal horn inhibition
HJJ BL23 B, BL21 B, BL22 B – Spinal pain, segmental and dorsal horn
inhibition
GV 4 – Spinal pain, segmental and dorsal horn inhibition
BL62 B – point for back pain, poor coordination in lower extremity
BL60 B – distal point for back when lower extremity involved
GB34 B – He Sea point, tissue healing, increase blood flow to
hypothalamus, deactivate limbic system
B, bilateral; LIV, liver; GB, gallbladder; GV, governor vessel; BL,
bladder; LI, large intestine; HJJ, Huatuojiaji.
Outcome measures and results
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.
Treatment
Outcome
1
Flexion 45° Lsp from standing position; NPRS 6/10
2
Flexion 45° Lsp from standing position; NPRS 6/10
3
Flexion 60° Lsp from standing position; NPRS 5/10
4
Flexion 60° Lsp from standing position; NPRS 5/10; sleep improved
5
Flexion 90° Lsp from standing position; NPRS 5/10; sleep improved.
Went 4hr dirt biking. Pain next day but eased.
6
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).
Discussion
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.
Acknowledgements
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.
References
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.
Zhao Z-Q. Neural mechanism underlying acupuncture analgesia. Progress
in Neurobiology 2008; 85:355–375.
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