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Acupuncture Treatment for Chronic Low Back Pain: A Case Study
Acupuncture Treatment for Chronic Low
Back Pain: A Case Study
Registered Osteopath
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Acupuncture Treatment for Chronic Low Back Pain: A Case Study
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).
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Acupuncture Treatment for Chronic Low Back Pain: A Case Study
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
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Acupuncture Treatment for Chronic Low Back Pain: A Case Study
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
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Acupuncture Treatment for Chronic Low Back Pain: A Case Study
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).
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Acupuncture Treatment for Chronic Low Back Pain: A Case Study
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
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Acupuncture Treatment for Chronic Low Back Pain: A Case Study
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
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
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
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
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
LIV3 B, LI4 B – Major analgesic points. Insomnia
BL23 B – empirical point for back pain
Week 1
Treat 2
Week 2
Treat 3
Week 2
Treat 4
Week 3
Treat 5
Week 3
Treat 6
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Acupuncture Treatment for Chronic Low Back Pain: A Case Study
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
1
2
3
4
5
6
Outcome
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
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Acupuncture Treatment for Chronic Low Back Pain: A Case Study
(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.
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Acupuncture Treatment for Chronic Low Back Pain: A Case Study
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.
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