Acupuncture in Back Pain

Management
Victoria Chan Harrison M.D.
Assistant Professor of Rehabilitation Medicine
Weill Cornell Medical College

Objective
Review the roots of acupuncture theory and
basic Traditional Chinese Medicine (TCM)
concepts.
y Outline basic science concepts in acupuncture
analgesia and its physiological mechanism of
action.
y Perform a review of the current literature on
acupuncture efficacy in the treatment of
chronic low back pain.
y

Introduction
y

Acupuncture is a widely practiced

therapeutic intervention in the United
States and has grown in popularity.

In 2002 , estimated 8.2 million Americans

had experienced acupuncture at least once
in their lifetime, and an estimated 2.1
million had done so in the previous year
alone.

Introduction
y

Acupuncture has been the subject of active

research both in regard to its basis and
therapeutic effectiveness since the late 20th
century

It has remained controversial among medical

clinicians.

While there have been many studies of its

potential usefulness, many of these studies
provide equivocal results because of limited
design, sample size, and other factors.

Introduction
y

The issue is further complicated by inherent

difficulties in the use of appropriate controls
in acupuncture research.
Such as using sham acupuncture groups as
placebos.

Conditions for treatment

Post operative pain

Chemotherapy induced nausea and vomiting
Low back pain
Osteoarthritis
Neck pain
Myofascial pain
Migraines headache
Tendonitis
Strains and sprains
Neuropathy
Carpal tunnel syndrome

There is general agreement that acupuncture

is safe when administered by trained
practitioners using single use sterile needles.
(WHO, AMA, NIH)
Most common negative effects are local pain,
bleeding, hematoma, dizziness, hypotension,
very rarely pneumothorax <1%.

What is acupuncture?
It is the procedure of inserting and
manipulating needles into various points
on the body to relieve pain or for a
therapeutic purpose.

Comparison between acupuncture needle

and beveled hypothermic needle

needle insertion, manual

stimulation

Twirling to obtain needle grasp and De

Qi= feeling of heaviness, fullness, or
numbness

history
y

Acupuncture originated in China more

than 2000 years ago, earliest written
record of acupuncture Yellow Emperor's
Inner Canon, dated 2nd century BC.

One of the oldest most commonly used

medical procedure in the world.

Different variations of acupuncture are

practiced throughout the world, the
most widely practiced American form
originates from China .

Basic theories in TCM

Acupuncture is a branch of Chinese
Medicine. Believing that health is
maintained by a balance of two opposing
forces:
y Ying and Yang
y the human body with external
environmental

In chinese physiological concepts

y

Tissue and organs are connected

through a network of meridian
channels inside and outside the human
body.

Qi acts as a carrier of energy that is

expressed externally through meridian
channel system.

Imbalance leads to blockage in the flow if

the bodys vital energy ,Qi, along the
meridian pathway.

Pathology, is a blockage of energy through

the surface channel networks, manifesting as
symptoms or medical condition.

 The

clinical diagnosis and treatment are

mainly based on the correctly identifying
the imbalances between yin-yang, five
elements, and organ dysfunction
controlled by the meridian channel.

Acupuncture utilizes all these

interrelationships in guiding point selection.
Medical acupuncture also incorporates a
neuro anatomical approach in point selection.

Acupuncture points along meridian channels

There

are 12 principal meridian channels and 8

accessory meridians.

Scientific bases for acupuncture analgesia

y

1970s, studied the mechanism for pain relief in

acupuncture by using Naloxone as
pharmacological tool in research.

Naloxone, an opioid receptor antagonist, used to

correlate pain receptor activation causing
perceived pain relief animals and humans.

Pomerantz and Chu,1976

y First published administration of
Naloxone, completely blocked the pain
relieving effects from acupuncture
induced analgesia in mice
y

Animals given acupuncture + Naloxone

demonstrated pain behavior, no different
than the control group. Where as those
receiving acupuncture were comfortable.

Demonstrating Naloxone blockade in humans

Mayer et al.,1977 studied induced tooth pain in

humans.
Double blind study, where all were administered acupuncture with
either intravenous Naloxone or saline.

Those administered Naloxone showed no signs

of pain relief from acupuncture compared to the
saline group.
y

Mayer et al. and Pomerantz et al. were the

earliest researchers to show acupuncture
induced analgesia can be blocked by
Naloxone suggesting the participation of
endogenous opioids in pain relief.

Electroacupuncture and endorphins

Han et al. in 1987
y Measured neuropeptide release in the
central nervous system triggered by EA at
different frequencies.
y Rats were given EA at 2, 15, 100Hz, using
radiant heat as noxious stimuli.
y Cerebral spinal fluid was collected in
30min intervals before or during the EA
stimulation.
y

Frequency of EA
2hz

Endomorphine,
Enkephalin,
-endorphin

15hz

100hz

Dynorphin

Opioid receptors

Antinociception physiological therapeutic effects

Endogenous opioid peptide release in the central

nervous system play an essential role in mediating the
analgesic effect of acupuncture.

Pain pathway

pomerantz et al. 2003

activate type II and

type III muscle
sensory nerves

endorphin
spinal cord
anterolateral tracts
dorsal lateral tract
enkaphalin,dynorphins
serotonin,norepinephrine

Midbrain
Periaqueductal
gray
Arcuate
nucleus

adrenocorticotropic hormone
ACTH

Adrenal cortex

cortisol

Acupuncture, tissue perfusion

Jansen et al., 1989
y Studied effects of electroacupuncture (EA)
on circulation in muscle flaps in rodents.
Examined skin blood flow using doppler
flowmetry in muscle flaps before and after
EA.
Findings: acupuncture increased blood
flow moving into the muscle flap by 66%
comparison to no treatment.

Acupuncture and circulatory effects

y
y

Sandberg et al. 2003

Examined the effects of acupuncture needle
stimulation on skin and muscle blood flow in women .
Laser Doppler was used to observe tissue perfusion
during needle insertion into:

superficially into fascia only

y muscle only
y muscle with needle manipulation
y

Increased blood flow to both skin and muscle

was observed in both intramuscular insertion
groups compared the control period were no
needle was present.

Dynamic characterization of local

connective tissue winding
y

Langevin et al. 2007

acupuncture
Cho et al. 2002

Comparison of cortical activation in three settings, a result of:

A - pain alone increased activity
B- meridian acupuncture with pain decreased activity
C- sham acupuncture and pain respectively decreased activity

Acupuncture is increasingly
used as a therapy for chronic
pain conditions,
y Cochrane review 2003 could
only conclude that
acupuncture may be useful as
an adjunct to other therapies.
y

Many chronic LBP patients use

complementary alternative
medicine.
Most common reason for visits
for acupuncture

Chronic low back pain and acupuncture

Witt

et al 2006, American Journal of

Epidemiology
Starting in 2000, began a large research initiative
on acupuncture that was fund by the German
government
Produced large randomized controlled trial
(+nonrandomized) cohort
chronic LBP > 6months
N= 11,630 patients
Randomized into acupuncture versus no
acupuncture

 Each

patient received up to 15 acupuncture

sessions during a 3 month period.
Patient who were not randomized to
acupuncture was able to receive it at the end of
the 3 month control period.
Acupuncture points used was determined by the
individual physician.
Needles were only manually stimulated.
All treatment groups were allowed to use
additional conventional treatments as needed.
Outcomes: Back function, Pain, and Quality of life
at baseline, 3months and 6months

Back function outcomes:

y

Conclusion

Patients with chronic low back pain treated

with acupuncture in addition to routine care
showed significant improvements in
symptoms and quality of life compared with
those with routine care alone.

German acupuncture trials (GERMAC)

for chronic low back pain
Haake et al. 2007 , Archives internal medicine
y Randomized multicenter blinded parallel
group trial with 3 groups: acupuncture, sham
acupuncture, and conventional therapy.
y 1162 patients
y History of low back pain for > 6months, mean
8 years.
y

Ten 30 minute sessions twice weekly TCM

y acupuncture n=387 , sham acupuncture n=387,
conventional therapy n=388.
y Conventional therapy= combination
medications, physical therapy, and exercise.
y Examined treatment response at 6months
y Good outcome was defined as 33%
improvement in the pain scale or better
functional ability.
y

Needling
y
y
y

Identical needle were use for both

groups
Only manual needle stimulation was
allowed
Traditional group: 14-20 needles
were inserted to depth of 5-40mm
with induction of De Qi sensation
on the body.
Sham group: 14-20 needles were
insert 1-3mm depth without
stimulation on lateral back or lower
limbs was standardized- non
meridian points.

Conventional treatment
10 sessions with a physical therapist
y Non steroidal anti-inflammatory drugs or
pain medications
y Massage, heat therapy, electrotherapy,
back school, injections, and guidance,
y

outcomes
At 6 months almost of acupuncture groups
but only of the conventional therapy group
benefited.
y Both acupuncture groups had 30% or
better in pain and back function.
y Traditional acupuncture was not superior to sham
acupuncture.
y

Meta-analysis of LBP research in

2008
AMMENDOLIA ET AL , 2008, THE SPINE JOURNAL
YUAN ET AL, 2008 , SPINE

Acupuncture compared to
no treatment:
moderated evidence
acupuncture demonstrates
improvement in pain
compared to no treatment .
Acupuncture compared to
Sham:
there is moderate evidence
that acupuncture is no
different from sham
acupuncture for global
improvement.

Acupuncture added with other

interventions:
y All included studies demonstrated
that the addition of
acupuncture to other
interventions was more
effective than the other
interventions alone.

Conclusion
y
y
y
y
y

Acupuncture can provide an analgesic effect by stimulating

the release of endogenous opioids and cortisol.
Acupuncture acts on the level of the peripheral and central
nervous system to decrease cortical activation of pain
perception.
Acupuncture also act on a local level through increased
tissue perfusion and local changes in connective tissue
arrangement.
Sham acupuncture, superficial needling, is not a true
placebo, providing therapeutic benefit .
Acupuncture should be viewed as another tool in
conservative management , similar to NSAID use
and physical therapy in the treatment of low back
pain.
Acupuncture combine with traditional conservative
management has better outcomes than
conservative management alone = in 42 research
studies.