Low Back Pain - The CHP Group

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Low Back Pain
Low back pain
Backache, unspecified
Sprains and strains of the lumbar spine
724.2; 724.85; 847.2
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
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
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
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.
Gypson W. Traditional Chinese Medicine (TCM) and Back Pain. Spine Unitverse.
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
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. Spine 2003;28:1490-1502.
Grabois M. Management of chronic low back pain. Am J Phys Med Rehabil 2005;84:S29-S41.
Haake M, Müller HH, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for chronic
low backpain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Arch Intern
Med. 2007;24;167(17):1892-8.
Han JS. Acupuncture: neuropeptide release produced by electrical stimulation of different
frequencies. Trends Neurosci 2003;26:17-22.
Han JS. Acupuncture and endorphins. Neurosci Lett 2004;361:258-261.
Henderson H. Acupuncture: evidence for its use in chronic low back pain. Br J Nurs 2002;11:13951403.
Hu J. Acupuncture treatment of sciatica. J Tradit Chin Med 2000;20:314-316.
Jiang YG, Mu JS, Zhang XY, Bai QL. Clinical observation on acupuncture treatment of 106 cases of
trunk-sciatica. J Tradit Chin Med 1984;4:183-185.
Langevin HM, Wayne PM, Macpherson H, et al. Paradoxes in acupuncture research: strategies
formoving forward. Evid Based Complement Alternat Med. 2011;2011.
Leung SJ. Acupuncture treatment for pain syndrome. I. Treatment for sciatica (report on 90
cases). Am J Chin Med (Gard City N Y ) 1973;1:317-326.
Li Q, Lu S, Luo JM, Liang SZ. An observation on the therapeutic effect of acupuncture in the
treatment of sciatica. J Tradit Chin Med 1989;9:90-92.
Longworth W and McCarthy PW. A review of research on acupuncture for the treatment of
lumbar disk protrusions and associated neurological symptomatology. J Altern Complement Med
Manheimer E, White A, Berman B, Forys K, Ernst E. Meta-analysis: acupuncture for low back
pain. Ann Intern Med 2005;142:651-663.
The CHP Group
Lower Back Pain/Lumbago Clinical Pathway
Molsberger A. Acupuncture in chronic low back pain. Presentation 1998;--:--Molsberger AF, Mau J, Pawelec DB, Winkler J. Does acupuncture improve the orthopedic
management of chronic low back pain - a randomized, blinded, controlled trial with 3 months
follow up. Pain 2002;99:579-587.
Moritz s, Liu MF, Rickhi B, Xu TJ, Paccagnan P, QUan H. Reduced health research use after
acupuncture for low back pain. J Altern Complement 2011 Nov; 17(11):1015-9.
Muller R and Giles LG. Long-term follow-up of a randomized clinical trial assessing the efficacy of
medication, acupuncture, and spinal manipulation for chronic mechanical spinal pain syndromes.
J Manipulative Physiol Ther 2005;28:3-11.
Newberg AB, Lariccia PJ, Lee BY, Farrar JT, Lee L et al. Cerebral blood flow effects of pain and
acupuncture: a preliminary single-photon emission computed tomography imaging study. J
Neuroimaging 2005;15:43-49.
Pei J. Treatment of sciatica by acupuncture at jiaji points--a report of 168 cases. J Tradit Chin Med
Pomeranz B. Relation of stress-Induced Analgesia to Acupuncture Analgesia. Ann NY Acad Sci
Qi LY, Duan SJ, Liao WJ. Acupuncture treatment of sciatica and a preliminary study of the
analgesic mechanism. 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
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
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.
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