Acupuncture for back pain
Acupuncture is one of the medical treatments that has been shown to be effective for chronic back pain, so much so that the United Kingdom’s National Health Service has made acupuncture a first-line treatment for chronic low-back pain, to be tried before injections and surgery, and Germany has included acupuncture in their list of modalities covered for back pain by insurance. Many insurance companies in the U.S. also cover acupuncture for back pain (even when they do not cover acupuncture for other conditions), because of acupuncture’s good cost/benefit/risk ratio for treating back pain. Low back pain is the medical condition for which patients in the U.S. most frequently seek acupuncture treatment.
Interestingly, a large study of acupuncture for back pain suggests that acupuncture is equally effective across all types of back pain, with the strongest benefit being noted in patients with more severe back pain.
Acupuncture modalities that I commonly use to treat low back pain include acupuncture stimulation of locations in the hands, feet, ears and scalp, electro-acupuncture applied to the low back area, neuro-anatomical acupuncture to stimulate tissue repair in spinal ligaments, discs, nerves, and muscles; manual therapies; gua sha and suction cupping; exercise therapy (lumbar spine mobilization, stabilization, and rehabilitation); and biomechanical re-education and re-training regarding posture, ergonomics, and lifestyle for a healthier back.
Back pain: causes and patho-anatomy. Pain originating in the back can arise from any and all of the following structures:
Lumbosacral Spinal Joints.
The lumbar facet joint on either side of the spine control motion between individual segements of the spine. These small but crucial joints have many nerve endings which can send out strong pain signals when sprained that are much more severe than the actual injury.
The jointsbetween the triangular sacrum at the base of the spine, and the iliac bones of the pelvis are supposed to be stable and move only slightly during gait. Instability, restriction or displacement of the sacro-iliac joint, such as can occur following hard falls onto the buttocks or tailbone,can radiate pain through the pelvis into the groin, and cause secondary gluteal myofascial pain because of altered lumbosacral mechanics during standing and gait.
The lumbar intervertebral joints consist of a fibrocartilagenous disc attaching adjacent vertebral bones. Both the fibrous outer ring of the disc, and the shock-absorbing gel inside can be injured through compressive, stretching, or shearing forces that. The ring if full of pain fibers; the gel in the middle contains may inflammatory substances; either or both can generate severe, burning pain that can last for months or even years.
All joints may degenerate with major or repetitive micro-trauma, leading to degspinal enerative joint disease or osteoarthrosis (“arthritis.”) Degeneration of the facet and intervertebral joints and discs are common causes of spinal pain in the elderly.
All spinal joints may, uncommonly, also be subjected to rheumatologic diseases such as ankylosing spondylitis or rheumatoid arthritis.
The vertebrae of the spine, inluding the sacrum, are attached to each other, and to the pelvis, by ligaments, any of which may be sprained. Sprains to the iliolumbar ligament in particular are acutely painful and may mimic disc injuries at the level at which disc injuries commonly occur (L 4-5 and L 5-S 1). The supraspinous ligament can also be sprained by forceful flexion, which causes local pain and tenderness and can also mimic disc injuries. These ligaments as well as the posterior sacro-iliac and sacro-tuberous ligaments may be stretched out, weak and painful following falls broken by landing on one’s buttocks or pelvis, and by prolonged or difficult labor and delivery.
Low back muscle pain.
Unlike the thoracic spine which has the support of the ribcage, support for the lumbar spine is primarily muscular and ligamentous. Muscle weakness, injury or dysfunction can thus play a large role in back pain. The muscular support for the lumbar spine can be identified in five primary groups:
1. The core abdominal muscles: a cylinder formed by the deep layers of the abdominals (obliquus and transversarius abdominus) that form a protective corset around the lumbar region, which we use to “suck in our gut.” These muscles are rarely injured but are frequently weak and under-used, which leads to poor protection and control of the low back.
2. The lateral stabilizers: the quadratus lumborum which attaches the pelvis to the transverse processes and bend our backs sideways. These muscles are commonly weak, tight, and injured. Pain from the quadratus lumborum can be so sharp and severe as to mimic disc, joint, and nerve injuries and can refer pain into the hip, groin and testicular areas.
3. The spinal extensors: the large, powerful erector spinae group which lie on top of the deeper structures and forcibly bend the spine backwards. Although these muscles are often tight to compensate for poor strength in the corset group, they are more often painful as a symptom, rather than a cause of underlying spinal pain.
4. The spinal intrinsics: small, deep postural muscles between each segment of the vertebrae, which control motion and stabilize posture at each level of the spine. Acupuncture is one of the few techniques that can isolate and treat these small muscles specifically.
5. The spinal flexors: the iliopsoas attaches to the anterior surfaces of the discs in the front of the spine. When shortened, strained, or inflammed, the psoas can cause deep, burning pain and pull the spine into extension, irritating spinal facet joints.
The spinal cord itself may be injured by massive trauma but may also be impinged upon by bony overgrowth in the spinal central canal (spinal stenosis), causing radiating pain, numbness and tingling into the legs (intermittient claudication), especially during gait.
The spinal nerve roots that exit from the spinal cord may also be impinged upon by bony overgrowth of the adjacent vertebrae. Compressed nerve roots cause radiating pain, numbness and tingling into the legs (radiculitis, radiculopathy, and sciatica).
The vertebrae may cause pain indirectly by impinging on nerves, but are themselves painful only when infected (osteomyelitis), cancerous, or fractured. Spinal fractures in adults can arise either from trauma (which can be only a slight trauma in a patient with low bone density (osteoporosis), or degeneration, a condition called “spondylolisthesis,” in which a partial fracture allows the front part of the vertebrae to slip forward or backward on the vertebrae below it. Spondylolisthesis can also occur in children and adoloscents before their bones are fully mature.
Extra-spinal causes of low back pain.
Pain that is felt in the back may also be referred from non-spinal sources. The kidneys, ovaries, prostate, bladder, and pancreas in particular refer pain to the lumbosacral region. Ruptured blood vessels, abcesses, infections, and cancer in the abdomen can also refer pain to the back.