Acupuncture for Low Back Pain

Kurrajong Natural Medicine Centre offers Acupuncture, Chinese Medicine, Western herbal medicine and Remedial therapies to the communities of Kurrajong, Richmond, North Richmond, Glossodia, Kurmond, and the greater Hawkesbury area.

 

Overview

Acupuncture is highly effective in treating Lower Back Pain and is a very cost effective treatment covered by many private health funds in Australia. However, with the increasing scientific interest into the effectiveness of Acupuncture many clinical trials are not showing clear results. Why? The key reason behind this is that the trials are not conduceted using the diagnostic principles of Chinese medicine, but rather use western means of diagnosis which are not appropriate or applicable in Chinese medicine.

Acupuncture and Chinese Herbal Medicine for Low Back Pain

by Danny Siegenthaler

 

Evidence Based Research – Is it applicable to Chinese Medicine and in particular to Acupuncture?

Chronic low back pain (LBP) is a major health problem with increasing costs to private health funds and government subsidised health care systems such as Medicare. Back pain a very common condition seen by acupuncturists and Chinese medicine practitioners the world over. It is estimated that 80% of people experience back pain at some point in their lives for which they seek treatment, with Acupuncture and/or Chinese herbal medicine becoming an increasingly popular choice.

If private and government insurance companies are to pay for treatment, they need some level of certainty that the treatment they are paying for will be effective. As a result, an increasing number of studies into the efficacy of acupuncture on lower back pain have been published in the literature (Brinkhaus, Witt, Jena, Linde, Streng, Wagenpfeil, et al., 2006; Carlsson & Sjolund, 2001; Cherkin, et al., 2008; Coan, Wong, & Liang Ku, 1980; and many others), however the evidence, while in favour of acupuncture’s effectiveness, is nevertheless contradictory at times and not clear cut.

Several attempts have been made to improve the methods used in conducting clinical trials in an attempt to get more definitive results (Birch, 2004). However, methods selected in clinical trials are not always suitable for the research question asked and have a number of other failings (Birch, 2004) contributing to the variable results obtained. For these reasons, Birch (2004) proposes that up to forty-five criteria are required, depending on the different study designs, to ensure appropriate methodology is used to conduct a reliable trial.

Using TCM Patter Diagnosis vs. Western Medical Diagnosis

While many studies have investigated the effectiveness of acupuncture on LBP, very few of these have classified Low Back Pain (LBP) in terms traditional Chinese medicine (TCM) patterns and this may be another explanation, if not the major reason, as to why the outcomes between studies can differ so widely. None of the forty-five criteria recommended by Birch (2004) specifically requires the inclusion of using differential TCM diagnoses as one of the criteria for trials that test efficacy of acupuncture.

Many authors comment on using TCM pattern differentiation as part of their methodology, for example, Brinkhaus, et al. (2006) note that while the TCM patterns of:

(i) Kidney Deficiency,

(ii) Blood and Qi stagnation, and

(iii) Bi syndrome were diagnosed, with the exception of (ii) the other patterns are too general, and no differentiation within the category of Bi syndrome was attempted at all.

This is reiterated by Hogeboom, Sherman, and Cherkin, (2001), who state that “…future research should place an emphasis on studies that examine acupuncture as used in clinical practice and that respect the theoretical basis for acupuncture therapy…”

It is therefore proposed that studies include differentiation of a given syndrome (in this case LBP) into TCM patterns and that treatments are designed to specifically treat the specific TCM pattern or patterns. It has been suggested that there are 27 possible patterns in TCM that can present with Low Back Pain (Birch & Sherman, 1999), and that the choice of acupuncture points, number of needles used, and number of treatments given, must coincide with standard TCM practices rather than a ‘standardised one-fits-all’ approach.

Therefore, selection criteria should exclude all other causes of low back pain other than a specific type, for example LBP associated with Kidney Yang Xu (deficiency). This would have several benefits:

  1. A standardised treatment for Kidney Yang Xu could be given to all patients,

  2. The focus and treatment principles would all be the same and would allow for specific stimulation of needles (reinforcing/reducing method), the use of moxa, etc., and

  3. Once other trials that focus on say LBP due to Kidney Yin Xu have been conducted, comparisons could more easily be made to establish the effectiveness of Acupuncture on different patterns.

This is particularly useful when designing in-clinic treatment programs for patients. For instance, if it is found that some types of LBP respond more quickly and easily to Acupuncture than others, such as Damp-heat Bi syndrome causing lower back pain for example, clinically this becomes far more useful and relevant than results obtained so far from current trials.

In order for such a process of TCM differentiation to work effectively and reliably, symptomatology clearly defining each of the possible TCM patterns for low back pain is required. Kalauokalani, Sherman, and Cherkin, (2001) showed that when the same patient was seen and diagnosed by seven different TCM practitioners, the diagnoses varied. Therefore, clearly defined pattern differentiation would need to be part of the inclusion/exclusion criteria with several TCM practitioners making the diagnosis and only where agreement is found, the patient would be included in the trial.

In conclusion, from this brief review of the current literature, it is evident that there is a need for more research into the effectiveness of acupuncture. It is also evident that more rigorous selection criteria are needed and that these include specific criteria on the selection of participants and that these need to be selected on the basis of a clearly defined TCM pathology.


References

Birch, S. (2004). Clinical research on acupuncture: Part 2. Controlled clinical trials, an overview of their methods. Journal of Alternative and Complementary Medicine, 10(3), 481-498.

Birch, S., & Sherman, K. (1999). Zhong Yi acupuncture and low-back pain: Traditional Chinese medical acupuncture differential diagnoses and treatments for chronic lumbar pain. Journal of Alternative and Complementary Medicine, 5(5), 415-425.

Brinkhaus, B., Witt, C. M., Jena, S., Linde, K., Streng, A., Irnich, D., et al. (2006). Interventions and physician characteristics in a randomized multicenter trial of acupuncture in patients with low-back pain. J Altern Complement Med, 12(7), 649-657.

Brinkhaus, B., Witt, C. M., Jena, S., Linde, K., Streng, A., Wagenpfeil, S., et al. (2006). Acupuncture in patients with chronic low back pain: A randomized controlled trial. Arch Intern Med, 166(4), 450-457.

Brok, J., Thorlund, K., Gluud, C., & Wetterslev, J. r. (2008). Trial sequential analysis reveals insufficient information size and potentially false positive results in many meta-analyses. [doi: DOI: 10.1016/j.jclinepi.2007.10.007]. Journal of Clinical Epidemiology, 61(8), 763-769.

Carlsson, C. P., & Sjolund, B. H. (2001). Acupuncture for chronic low back pain: A randomized placebo-controlled study with long-term follow-up. Clin J Pain, 17(4), 296-305.

Cherkin, D. C., Sherman, K. J., Avins, A. L., Erro, J. H., Ichikawa, L., Barlow, W. E., et al. (2009). A Randomized Trial Comparing Acupuncture, Simulated Acupuncture, and Usual Care for Chronic Low Back Pain. Arch Intern Med, 169(9), 858-866.

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Haake, M., Müller, H. H., Schade-Brittinger, C., Prinz, H., Basler, H. D., Streitberger, K., et al. (2003). The German Multicenter, Randomized, Partially Blinded, Prospective Trial of Acupuncture for Chronic Low-Back Pain: A Preliminary Report on the Rationale and Design of the Trial. Journal of Alternative and Complementary Medicine, 9(5), 763-770.

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