Diagnosis/Condition: Discipline: ICD-9 Codes: ICD-10 Codes: Origination Date: Review/Revised Date: Next Review Date: Low Back Pain Low back pain Lumbago Backache, unspecified Sprains and strains of the lumbar spine LAc 724.2; 724.85; 847.2 04/2012 04/2014 Back pain is one of the most common reasons for a visit to an acupuncturist. The goal of low back pain (LBP) therapy is to mitigate symptoms, increase patient function and decrease chronic health care visits. Several systematic reviews have concluded that acupuncture is a viable treatment option for the treatment of LBP and sciatica. This accumulated evidence is further supported by the findings of several more recent RCTs and outcomes research not covered in these reviews. Acupuncture appears to be a cost-effective means of treating LBP. Subjective Findings and History • • • • • • • Macro trauma: Onset of pain and paraspinal muscle spasm begins either immediately after the injury or gradually over the next 24 hours. Micro trauma: Repetitive traumatic events not singularly capable of producing injury Local pain, sometimes at standardized acupuncture point locations, sometimes accompanied by pain along acupuncture channels traversing the involved area, diffuse (scleratogenous pain distribution) Loss of flexibility Pain is usually relieved by rest and aggravated by motion History of prior similar episodes Objective Findings • • • • Postural evaluation may reveal decrease/loss of normal spinal curvature, may present with lateral list Decrease/loss of normal spinal ROM Palpation: Tenderness with pressure over involved tissues, muscle spasm or tautness of paravertebral muscles, MFTPs, tenderness of acupuncture points Pulse and tongue diagnosis findings will vary Assessment • • Assess for “red flags” of serious disease and factors that may promote prolonged disability. The clinical impression should indicate the specific anatomical structures and acupuncture channels involved, and clinically correlate them with the mechanism of injury, history, subjective complaints, and objective findings The CHP Group Lower Back Pain/Lumbago Clinical Pathway 1 Plan Passive Care: • Acupuncture, electroacupuncture, other physical modalities • Chinese herbs and herbal formulas • Psychological/emotional counseling Active Care: • Rest from inciting activity • Activity/work restriction if appropriate may include: No repetitive motion, lifting, grasping, pinching • Appropriate stretching and strengthening exercises, tai ji, qigong • Appropriate dietary modification Length of Treatment • • • Estimated duration of care: initially 2-3 times per week for 2-3 weeks Patient should be improved after 2-3 weeks Treatments can continue if symptoms are acute (<6 months) for 2-3 months, if chronic (>6months) for 3-6 months Referral Criteria • If patient is not improved or worsens with the initial course of treatment (over first 2-3 weeks) then the patient should be referred for co-management with primary care and/or manipulative therapy. Practitioner Resources Yuan J, Purepong N, Kerr DP, Park J, Bradbury I, McDonough S. Effectiveness of acupuncture for low back pain: a systematic review. Spine. 2008 Nov 1;33(23):E887-900 Patient Resources SUMMARIES FOR PATIENTS: Diagnosis and Treatment of Low Back Pain: Recommendations from the American College of Physicians/American Pain Society. Ann Intern Med, Oct 2007; 147: I-45. http://www.annals.org/cgi/reprint/147/7/I-45.pdf Simple steps can put an end to unnecessary suffering. TimesOnline. Sept 19, 2005. http://www.timesonline.co.uk/tol/life_and_style/health/expert_advice/article567626.ece Gypson W. Traditional Chinese Medicine (TCM) and Back Pain. Spine Unitverse. http://www.spineuniverse.com/displayarticle.php/article829.html References Biella G, Sotgiu ML, Pellegata G, Paulesu E, Castiglioni I et al. Acupuncture produces central activations in pain regions. Neuroimage 2001;14:60-66. Cherkin DC, Sherman KJ, Avins AL, et al. A randomized trial comparing acupuncture, simulated acupuncture and usual care for chronic low back pain. Arch Intern Med. 2009;169(9):858-866. The CHP Group Lower Back Pain/Lumbago Clinical Pathway 2 Chu Z and Bai D. Clinical observation of therapeutic effects of wrist-ankle acupuncture in 88 cases of sciatica. J Tradit Chin Med 1997;17:280-281. Ernst E and White AR. Acupuncture for back pain: a meta-analysis of randomized controlled trials. Arch Intern Med 1998;158:2235-2241. Furlan A, Tulder M, Cherkin D, Tsukayama H, Lao L et al. Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev 2005a;CD001351Furlan AD, van Tulder M, Cherkin D, Tsukayama H, Lao L et al. Acupuncture and dry-needling for low back pain: an updated systematic review within the framework of the cochrane collaboration. Spine 2005b;30:944-963. Giles LG and Muller R. Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation. 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J Tradit Chin Med 1985;5:179-184. Sator-Katzenschlager SM, Scharbert G, Kozek-Langenecker SA, Szeles JC, Finster G et al. The Short- and Long-Term Benefit in Chronic Low Back Pain Through Adjuvant Electrical Versus Manual Auricular Acupuncture. Anesth Analg 2004;98:1359-1364. Smith LA, Oldman AD, McQuay HJ, Moore RA. Teasing apart quality and validity in systematic reviews: an example from acupuncture trials in chronic neck and back pain. Pain 2000;86:119-132. Thomas KJ, MacPherson H, Ratcliffe J, Thorpe L, Brazier J et al. Longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain. Health Technol Assess 2005;9:iii-x, 1. Ulett GA, Han S, Han JS. Electroacupuncture: mechanisms and clinical application. Biol Psychiatry 1998;44:129-138. van Tulder MW, Cherkin DC, Berman B, et al. The effectiveness of acupuncture in the management of acute and chronic low back pain. A systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 1999a;24:1113-1123. van Tulder MW, Cherkin DC, Berman B, et al. The effetiveness of Acupuncture in the Treatment of Low Back Pain. Cochrane Library 1999b;1-14. van Tulder MW, Cherkin DC, Berman B, Lao L, Koes BW. Acupuncture for low back pain. Cochrane Database Syst Rev 2000;CD001351The CHP Group Lower Back Pain/Lumbago Clinical Pathway 4 Wolsko PM, Eisenberg DM, Davis RB, Kessler R, Phillips RS. Patterns and perceptions of care for treatment of back and neck pain: results of a national survey. Spine 2003;28:292-297. Xu M and Chen W. One hundred cases of sciatica treated by surrounding puncture. J Tradit Chin Med 2000;20:128-129. Yuan J, Purepong N, Kerr DP, Park J, Bradbury I, McDonough S. Effectiveness of acupuncture for low back pain: a systematic review. Spine. 2008 Nov 1;33(23):E887-900 Yun M, Shao Y, Zhang Y, He S, Xiong N, Guo M, Kiu D, Guo L, Yan J. Hegu acupuncture for chronic low back pain: a randomized controlled trial. J Altern Complement Med 2012 Feb; 18 (2):130-6 Yeung CK, Leung MC, Chow DH. The use of electro-acupuncture in conjunction with exercise for the treatment of chronic low-back pain. J Altern Complement Med 2003;9:479-490. Zaringhalam J, Manaheji H, Rastqar A, Zaringhalam M. Reduction of chronic non-specific low back pain: a randomised controlled clinical trial on acupuncture and baclofen. Chin Med. 2010;5:15. Clinical Pathway Feedback CHP desires to keep our clinical pathways customarily updated. If you wish to provide additional input, please use the e-mail address listed below and identify which clinical pathway you are referencing. Thank you for taking the time to give us your comments. Chuck Simpson, DC, CHP Medical Director: [email protected] The CHP Group Lower Back Pain/Lumbago Clinical Pathway 5
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