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Ask an expert - muscles and bones - back / spine - lower back pain

28 questions

We are delighted to say that there is some very good evidence  for the treatment of lower back pain with acupuncture. Indeed, until a recent reversal of policy based on what we believe was very unsound interpretation of research, NICE, the clinical guidelines body, was recommending ten sessions of acupuncture treatment as one of the basic offers for people with chronic back pain of over six months duration. You can see some of the evidence on which this decision was based on our factsheet which can be found here:

https://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/back-pain.html

Of course, from a Chinese medicine perspective treating back pain per se is not really how we work. It isn't just empty rhetoric that we treat the person, not the symptom, and although the symptom might be identical in twenty people they may well be treated in twenty different ways. Each symptom arises against a backdrop of imbalance, and it is by treating the imbalance as well as, and sometimes instead of, the symptoms real change can both be made and sustained. There are obviously specific points which can affect the lower back, but if these are treated alone and a deeper underlying problem is not addressed the pain will return.

The fact that pain can arise in many different ways means that sometimes the obvious diagnosis doesn't really work either. Most people over the age of 50 have some deterioration of the lower spine, but although it is often declared the cause, it may not be. We have certainly treated many people with serious deterioration of the lower spine whose pains have gone.

Acupuncture can also be used for straightforward pain relief, and here the main questions which we have are not whether it works but how much and how sustainable the results may be. There has been a great deal of high quality research into the use of acupuncture to release the body's own painkillers (easily measured and easy to assemble test groups), and it is largely on this basis that most Pain Clinics offer acupuncture.

The best advice that we can ever give, since each patient is unique and different, is to visit a local BAcC member for an informal assessment. Most are only too happy to give up a little time without charge to see whether acupuncture is the best option for your specific presentation. We are confident that you will get an honest appraisal and assessment.

Q: My partner has two slipped discs in her back. She been refused surgery due to her age and has now been refused injections.
Will acupuncture help her?

A: We have been asked surprisingly few times about slipped discs, and our answers to the questions have been relatively circumspect, as you can see from this example:

Slipped discs can take a long time to recover, even when using therapies which are known to help. Where the standard treatment in conventional medicine used to involve a great deal of bed rest, continual movement is now the order of the day to help the accumulated tissue to disperse. Our fact sheet on sciatica

http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/sciatica.html

mentions a number of studies which show some encouraging results for the kinds of secondary problems which can arise from a slipped disc.

Sight unseen it is very difficult to offer a detailed opinion, but speaking in very general terms, there is often an accident or underlying pattern of weakness which predisposes someone to have a slipped disc, and there are often ways of understanding the disease process from a Chinese medicine point of view which offer treatment possibilities. This can often be the case when someone has reached a plateau in the conventional treatment they are having.

However, it is not uncommon for people to seem to plateau and then for the condition to resolve after 3-6 months, and you may well find that you suddenly begin to make progress again. Acupuncture treatment certainly won't do you any harm, and given that the area where you have been affected will have been quite immobile and 'stagnant' for a few months it is possible that from a Chinese medicine perspective there are significant blockages whose clearance may help to speed up your recovery.

At least a part of the reason for this circumspection is the fact that herniation usually resolves after about three to six months, and it can be difficult to assess in the circumstances whether the acupuncture treatment has added to the speed of recovery. The range of problems covered by the generic term 'slipped disc' is also quite extensive, and assembling a control and test group with identical problems may present problems in the current climate of minimal funding for acupuncture research in the West. We are confident that trials will have been conducted in China but most are never translated. Where there have been good results, though, they do tend to surface quickly, and the absence of research which meets western standards probably speaks volumes.

The fact that surgery has been considered probably points to some quite serious herniation, and we would probably surmise that the best we could achieve would be to lessen some of the pain and reduce some of the symptoms. The extent to which this worked, and how sustainable the change would be, is something only treatment itself would establish.

We always believe that the best option for cases like these is to visit a local BAcC member for an informal assessment of what may be possible. Most offer a small amount of time without charge to prospective patients to get a better idea of what benefit there may be in cases where it is not clear from the 'headlines', and if someone does commit to treatment there is usually a very clear agreement to assess progress after three or four sessions to see whether the progress warrants further time and expense.

Q: Can acupuncture help or make it worse for pain related with severe disc degeneration and acute inflammation Modic type 1 to the endplates? I've had my condition for three years, with no pain free moment ,which is common with Modic type 1 inflammation. I tried all types of treatment for the condition and the pain, but nothing helped. I was told this is the case with people with my condition, as it is nothing like any other back condition since the most pain is caused by the bacteria in my spine. Recently I was referred for acupuncture treatment and I had two sessions. After each one I felt much worse including pain in the affected area, aches all over the body and massive headache lasting for a week or so. After the second session I experienced a huge relapse with my back problem, with severe pain not going away for days, even with increased dosage of prescribed painkillers, Tramadol. While it's been scientifically confirmed that there is no proof that acupuncture can help with the type of condition I have I still wanted to try. My concern is that I have been much worse after treatment and it takes a week to go back to my 'normal' days when I can somehow manage the pain, which is not possible after acupuncture. Would you recommend continuing with the treatment in my situation?

A: When someone has a problem such as yours it can be quite difficult even in conventional medicine to predict what might happen with treatment. We have conducted a database search for treatment with acupuncture specifically aimed a Modic Type 1 and there is no evidence of any trials which focus on this specific diagnosis. However, until recently NICE used to recommend acupuncture as a valid treatment for chronic back pain of over six months duration on the back of some very strong evidence, and we strongly suspect that many of the thousands of the patients in these studies had Modic Type 1 problems alongside the chronic degeneration of the lumbar spine and discs which may have been assumed to be the cause. The estimates of between 20% and 40% of patients with chronic low back pain being troubled as you are would seem to make this a reasonable conclusion to draw.

We often warn people with back and neck problems to be aware that the next 48 hours after treatment may be a little rocky. We are not alone in doing this; many osteopaths and chiropractors similarly warn their patients, and many of our patients report feeling worse after manipulation. There are various reasons which we have heard advanced for this phenomenon, and the most compelling is that trying to encourage structural or postural changes associated with good function is bound to bring muscles into play which have been relatively untested for years. From a Chinese medicine point of view there is an equally compelling picture of stagnant energy and its renewed movement. This can often be quite unpleasant, rather akin to having cold hands or feet and warming them in front of a fire to restore circulation. This can often be slightly unpleasant to begin with.

The key thing about these reactions to treatment is that they tend to occur for the first one or two sessions only, after which the body had made its initial changes of direction and is now moving forward in a more predictable fashion. Hence sessions three and four and onwards will often have none of the more challenging outcomes as the first ones. If it carries on being painful, then it is just possible that the patient is too sensitive for the treatment. If so, there are only two options. One is to reduce the impact of the needles by using less needles, inserting them less deeply and manipulating them less. Practitioners can do quite a great deal to 'turn down the volume' so to speak, and some forms of acupuncture treatment, especially Japanese style needling, are barely perceptible.

There is, however, a small minority of patients whose sensitivity to needles is such that treatment is a bit of an ordeal and will continue to be so. This can manifest as you describe it, and unless the overall trend is upwards after the first two or three sessions then it would be wise to sit down with the practitioner and discuss how best to carry on. If it has no impact on the pain, then there would seem little point in carrying on. In our experience, though, most people do begin to enjoy lower levels of discomfort, and the usual question is how much pain relief and how sustainable it is.

Of course, the factor which we haven't mentioned is that the acupuncture treatment and the relapse are entirely coincidental. In practice we have to be careful when we broach this because it sounds like the beginnings of an 'it wasn't me' denial. In reality, though, with over 4 million treatments a year in the UK we are going to see a number of occasions where an increase in symptoms has nothing to to with the treatment, and our main aim then is to find out what is happening rather than getting involved in arguments about whether acupuncture treatment was the cause. We find that getting to the bottom of what is happening usually establishes that very quickly so there is nothing to be gained by delaying further investigation.

We do hope, however, that this is a typical pattern of things getting slightly worse before they get better, and that the next few sessions bring you the relief from pain which you would like to experience.

 

 

Q: . I have been in quite severe pain in my back and also my stomach area due to scoliosis. The pain killers the doctors given me for the last 4 odd years make me drowsy and constipated. Would acupuncture ease my pain and what kind of price am I to expect for treatment. I'm a student single mother so this worrys me. 

A: The use of acupuncture for pain relief has a long and interesting history. After President Nixon visited China in the 1970s and the  world saw acupuncture being used for operations it started a huge amount of research into acupuncture for pain relief. Fortunately the markers for pain relief, the release of the body's own endorphins and enkephalins, are very easily measured, and it was soon established that treatment could stimulate the release of these. Many Pain Clinics now use acupuncture as a standard treatment, and the main question is usually not whether it works but the extent to which it works and how sustainable the results might be.

As you have probably already worked out, the answer can eventually become a financial one - if treatment works for a week, is it possible to keep paying weekly for treatment? For someone with deep pockets and a need to be at work this might be a worthwhile deal, but for someone on a tight budget this could price it out of reach. Many of our members feel quite strongly  that acupuncture treatment should not be a middle class preserve, and following a model set up in the States have opened multibed clinics where treatment is offered in a groups setting with three or four couches in a large room for a very much lower fee. The normal safeguards apply for dignity and privacy, but obviously this is not quite the same as being in a private space. For many people, though, this is a good deal, and a list of these clinics can be found here   http://www.acmac.net/ on the website of a special interest group set up to develop this concept.

There is also every chance that most BAcC members will be prepared to offer a fee reduction in circumstances of need. Obviously we don't openly advertise this because it always leads to people who can well afford treatment starting to bargain us down, but I am not aware of many colleagues who have not treated someone as cheaply as they can because they recognise a case of genuine need. This is far easier for those with their own treatment space - if you are renting on a sessional basis you have to cover the overhead - but asking costs nothing.

The only caveat is that problems like scoliosis are generally not fully fixable, however good the treatment is, and it pays to be realistic about the outcomes. Most people we have seen are mainly concerned with managing the pain rather than looking for dramatic change, but it is always really important to be clear about outcomes when dealing with a chronic and potentially irreversible condition. However, we are confident that if you could reduce your reliance on painkillers you would probably be well pleased; being permanently tired and constipated is not much fun.

That said, sometimes the best and unexpected happens, as here


http://www.ncbi.nlm.nih.gov/pubmed/19678786

Q:  I had acupuncture  on my neck, shoulder and back.  I am suffering bad pain on the right side of back going into my buttocks. 

A:  A great deal depends on whether the pain is at a needle site or not, and to some extent what you were being treated for.

If the pain is at a needle site, then there is a small chance that you have a minor bruise which may not yet have shown itself at the surface but may be quietly impinging nerves in the area. If this is the case the pain will have come on soon after the treatment and been pretty consistent. It also means that as the bruise heals the pain will diminish, and eventually go.

However, if you were being treated for a back or neck problem it is not unusual for there to be a reaction after treatment which can make someone's symptoms worse before they start to get better. Very often the body becomes used to operating slightly out of kilter so when a practitioner tries to restore normal function and the body re-arranges itself it can feel very uncomfortable. Osteopaths and chiropractors tend to give the same warning to patients, but generally the adverse effects have worn off after two or three days.

There is always a chance that the pain has nothing to do with the treatment itself. We are not being defensive in saying this but we do come across cases where a pain kicks off after treatment that is not related to what has been done. In these circumstances our job is to ensure that someone gets the appropriate treatment rather than argue about whose fault it was. The diagnosis and treatment usually establishes quite quickly what the cause was.

The best advice we can give is that you speak first to the practitioner to get an idea of whether the pain is related to either the needle site or the problem you are addressing. If it is, then we expect that they will do their best to sort it out when they next see you. If they are mystified about the cause, or if you feel uneasy going back to confront them, and the pain carries on at the same pitch it would be worth booking an appointment with your GP to make sure everything is OK. This is just a precaution, but always worth taking rather than wait too long (given that same day appointments are something of a rarity).

We have a cycle for replies which means that by the time you get this we are hoping that the pain has already started to subside. If it continues, then you need to call the practitioner or your GP soon.

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