Ask an expert - muscles and bones - back / spine

66 questions

Q: I have been diagnosed with lumbar spinal stenosis.  I find it difficult to stand for any  length of time or walk any distance. I have to sit because of a severe ache in my  lower back.
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A:  We were asked this question a couple of years ago and our answer then

Q. Following an MRI scan I have been diagnosed as having "central canal stenosis with degenerative changes at L4-L5 level and moderate disc herniation". I have difficulty walking more than 200 metres. Is it at all likely that acupuncture would have a significant positive effect?

A. We are sorry to hear of your difficulties. We were asked this question many years ago, and our advice has not changed that substantially. Back then we wrote:

Lumbar canal stenosis can manifest in many symptoms dependent on the extent of the stenosis. Our colleagues in America are very upbeat about the potential for success in treating lumbar canal stenosis; if you google 'lumbar stenosis acupuncture' you will see an article on the www.acupuncture.com site which speaks positively of success rates, as well as an 'acupuncture today' listing which also gives good cause for hope.

Personally we tend to take a slightly more guarded view of the chances of success, and base our own prognoses on gathering as much information as we can about the condition - how long the person has suffered from it, is it degenerative, does it have peaks and troughs, has it been exacerbated by accident or trauma, and so on - before committing to treatment. Even though we are working with entirely different diagnostic systems, if a condition has some very severe manifestations based on irreversible physical change, the expectations of a 'good' result have to be lowered accordingly, even what might count as a 'good' result.

The best advice that we can give is that you discuss this with a practitioner whom you might consider seeing and ask their advice. Many of our colleagues are happy to discuss someone's concerns with them rather than book them straight in, and a significant number are happy to set aside a few minutes to meet someone and offer a more informed view of whether they can help based on a rapid assessment of the actual presentation.

Since we gave this advice there have been a number of studies such as this one

http://www.ncbi.nlm.nih.gov/pubmed/22534725 :

which give some cause for optimism, although finding a UK practitioner able to deliver this particular form of treatment may take some doing. The most recent systematic review

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3373659/

is much more guarded in its views.

However, it is often possible that the symptoms from which people suffer are not directly related to a physical change in the same area. We find that many people are told that arthritic changes in the lower spine are responsible for their chronic low back pain, but we often see the pain reduce or vanish without any accompanying physical change. Acupuncture has, in fact, been accepted within NICE guidelines as an effective treatment for the treatment of chronic low back pain, and the evidence base is certainly more compelling than for many other western named conditions. Our fact sheet on back pain
http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/back-pain.html
gives more background.

The best advice we can give remains the same - visit a BAcC member local to you for a brief face to face assessment of whether they think you might benefit from acupuncture treatment.

still represents the clearest expression of what we think may be possible. Stenosis tends not to be reversible, and it would be unwise to encourage too much optimism about the possibility for change and improvement. However, we have to remind ourselves sometimes when we take on case with very fixed western names and well determined causes that we are working in a paradigm of medicine which starts with the patient's experience of their pains and discomfort and then works towards an understanding of that through the lens of Chinese medicine. As we said in the earlier response, not every experience of disease is necessarily reducible to the physical findings which are discovered through investigation. Although most are, there remain some where treatment with acupuncture may have a significant impact.

We can only repeat what we said in the earlier reply: ask a BAcC member local to you for advice. Most are more than happy to give up time without charge to discuss with prospective patients whether treatment may be of benefit to them.

Q:  A nerve in my lower back does not seem to function resulting in a pronounced limp ( but no pain ).  I cannot get up onto my toes in the left foot. Can accupuncture help in this instance?

A: The crucial question here is what might have caused the nerve to function, and of course how precisely this has been diagnosed. We are assuming that you will have been seen by a neurologist, but if not it is very important that you see your GP and arrange an appointment to see one shortly. Any loss of sensation or muscular action needs to be investigated, not necessarily urgently (we don't want to sound alarmist) but certainly with reasonable haste to ensure that if there is any temporary impingement of a nerve the damage does not become more permanent through failure to get the appropriate treatment quickly.

On the assumption that the condition has been assessed by a specialist, the best we can say is that acupuncture treatment may help to restore some of the function, but there is very little evidence of research which would enable us to give even a partly qualified recommendation. If the nerve has been damaged in some way, then we have to be honest and say that acupuncture treatment will probably have no impact at all. The regeneration of nerve tissue in this part of the body is not as much as people might hope after injury, and once damage has occurred that is usually that.

That said, Chinese medicine is premised on an entirely different understanding of the body mind and emotions as a system of energy, called 'qi', in movement, and symptoms are understood in this context to be a result of some changes in the nature of the flow which affect the rhythm or balance of the energy. From this perspective, a weakness in a specific muscle set or loss of sensation would usually be seen as a deficiency of flow or a blockage, and the practitioner's skill would lie in working out how to reinstate the flow.

In some cases, such as the treatment of post-stroke patients, there is a growing body of evidence that the paralysis and muscle flaccidity which accompanies a stroke is significantly improved by acupuncture treatment, and in China patients are often given an intensive course of acupuncture treatment starting as soon as possible after the event. The point that we are making here is that from a conventional perspective this does not make sense, but clearly patients benefit, and the argument is that from the Chinese medicine perspective and understanding of strokes, something can be done. 

The same can be said of sciatica and other problems, such as osteoarthritis, which are diagnosed as being the result of changes in the lower spine causing impingement of nerves and pain. We have treated enough patients over the years whose X-rays show degenerative change but whose pain has been reduced to know that the causation accepted as 100% by conventional medicine need not be so clear, and that a percentage of these cases are amenable to acupuncture treatment because the pain arises from a different cause which ca be understood in Chinese medicine terms.

Our best advice is to visit a BAcC member local to you and ask if they can give you a better assessment based on a brief face to face interview about whether in their view acupuncture treatment may be of benefit. It is highly unlikely that this is the only symptom linked to a major physiological change, and they will also be able to assess using Chinese medicine techniques whether there is other evidence of energetic disturbance which may explain what is happening.

However, as we said, a great deal depends on whether your condition has been thoroughly investigated within conventional medicine, and what if any reasons were given as to why the problem occurred in the first place. Practitioners of all systems of medicine will ask the same generic questions - when did it start, was the onset gradual or sudden, what treatments and investigations have you had, what was happening at the time of the symptom appearing or shortly before, and so on - to make sense of what is happening. If you have the answers to these from your existing health practitioners it will inform what an acupuncture practitioner can advise you.     

Q: I have suffered with back pain since I was 14 years old.  I'm now 27 and still suffer greatly. I was diagnosed with scoliosis in my lumbar region and was seen by a physio. I've made several visits to my GP but they keep supplying pain relief. Last year I paid to see a chiropractor- most of my spine was out of line and he helped. Then pain carried on and I then tried accupunture and deep tissue massage. This eased the pain a little. Because both practises mentioned a lot wrong with my spine, sciatica and whip lash symptoms I revisited my GP hoping for a scan to get some answers. Instead they referred me to back2health- an NHS back clinic. I have been having accupunture and chiropractor there and my pain is getting worse- and I'm finding daily activities demanding. I am now having to take constant pain relief. Is the treatment they are giving me a cause for the worsened pain do you think? As the acupunture is extremely painful there- unlike when I received it at a Chinese clinic. I just want some answers to my pain and find a way of managing it

A:We are very sorry to hear of your experience. It must be very disappointing to have been getting somewhere with treatment only, like in a game of snakes and ladders, to find yourself going downhill again.

In our experience, any disturbances which people experience after acupuncture treatment are usually short-term and transient, lasting 24-48 hours at most. We are aware from patients who visit chiropractors and osteopaths that much the same applies, two or three days of mild to moderate discomfort followed by a gradual improvement. Our view is that often when the body is severely out of alignment, any attempt to correct posture means bringing into play muscles which have been working out of position for a long time and which are resistant to change, even positive change.

If things are getting worse rather than better, then we always recommend that patients stop having treatment. It may be that the getting worse has nothing to do with the acupuncture and chiropractic, and we are used on occasion to be taken to task because we happen to be treating at the same time as a problem is deteriorating for other reasons. However, if there is any doubt we recommend that someone stops treatment for two or three weeks to see what is really happening.

Your mention of the different between the needling at a Chinese clinic and the needling at the Pain Clinic does make us wonder what kind of acupuncture you are receiving. In our experience, many of the western medical professionals who use acupuncture use thicker needles inserted in a slightly different way, and this can often feel quite rough after a more traditional Chinese approach. However, the really big difference is the theory underlying the different types of acupuncture. Whereas western acupuncture is largely based on trying to release trigger points in muscles and achieving a neurophysiological effect to jam out local pain signals, Chinese medicine is based on an entirely different view of the body as a system of energy, called 'qi', whose balance, rhythm and flow needs to be optimal for the body to function properly. If everything functions as it should, then the structure of the body follows. This is the opposite direction to osteopathy and chiropractic which both work on the premise that correct structure allows and encourages normal function. This is why the two types of treatment can dovetail well.

Whether the current treatment is causing your problems to be exacerbated we can't say. In our experience it would have to be serious mis-treatment to make things worse, and we don't believe this is likely. Much more probable is that the treatment you were having before was successful in maintaining a level of balance where the pain was manageable, and if it is within your means to do so we would recommend that you go back to what was working for you. There used to be an old maxim in the profession, whether true or not it is difficult to say, that it often took as many months as the years a patient had suffered with a problem to help to remove it. This may just have been to make us more realistic about how quickly we could help people to get better, but in any event it made us remember that long-standing problems would not simply vanish but would require perseverance and patience. Having had your problems for nearly 14 years it may take a while for the full benefits of treatment to work their way through.

We are assuming that you were happy with the treatment you received from the Chinese clinic, and if so, you would be well advised to go to them again. If not, we are sure that there will be a BAcC member local to you who will be more than happy to see you for a brief chat without charge to give you the benefit of a face to face assessment of what acupuncture treatment as they do it may be able to offer.

Q: My wife is currently seeing an osteopath after 9 procedures at the local hospital relating to two split discs and a prolapse. Even though he has 30 years experience he has told my wife that adhesions caused from the procedures are making it difficult for him to help with the pain control.
Therefore I was wondering if acupuncture is worth trying?

A:  It's always difficult not to sound trite when we say that acupuncture is always worth trying, but we all work in a tradition which is based on treating people, not simply the conditions or injuries which they have. By working in this way according to principles which have been developed and refined for over 2000 years we try to restore the balance of the energies of the body which in turn can encourage the body to repair better, and generally hope to elicit changes on all levels,  physical mental and emotional. 
 
Of course, this is all very much 'big picture' stuff, and there is plenty of evidence at the sharp end of practice about direct help for specific problems.  As our factsheet shows
 
 http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/chronic-pain.html
 
pain relief was and remains one of the most commonly researched areas of acupuncture treatment, not least because there are plentiful assessment tools to help patients to quantify their experience and a significant number of objective pain measures which allow researchers to assess the efficacy of treatment. The evidence for the successful use of acupuncture for pain relief is plentiful, and while it is not yet wholly conclusive nearly every pain management clinic offers acupuncture as one of its packages. The only area of concern is how sustainable any improvements are alongside the degree to which pain reduces, an we rely on the probity of our members to discuss the benefits which treatment confers in relation to its continuing cost. Even where someone can easily afford the cost of regular treatment our member still have a responsibility to ensure that the investment in time and money is a wise one.
 
Mention of adhesions also brings to our collective mind the issue of scar tissue from surgery which in itself become a problem. We once commented directly on this:
 
However, scar tissue does have implications for someone's health within Chinese medicine. As you may have read from our website, the theories of Chinese acupuncture are based on the understanding of the body mind and emotions as a complex flow of energy called 'qi'. The distribution, balance and flow of this energy in what are called meridians or channels are what sustain us and keep us in good health. Scar tissue impacts on this flow in Chinese medicine theory as much as it impacts the physical health of an area in conventional medicine, and is especiually relevant in Chinese medicine because it is seen to impair flow. When this happens, the result is pain; a great many of the surface aches and pains which people experience often link to blockages or local stagnation, and the use of needles can often help to disperse this.

It is possible that treatment may help to restore healthy flow in the area of the operation.
 
Our best advice is to visit a BAcC member local to you for an informal face to face assessment of what might be possible. It is probable that the osteopath may know a BAcC member locally with whom they cross refer patients, and we often have very productive cross-referrals with osteopaths in cases like this where the sum  of the treatments appears to be greater than the individual parts, as the work of each enables the other to make more progress than might be achieved by a single modality.    
 

Q: I don’t think this is the normal ‘bad back’ complaint.   I’ve had a bad back for probably over ten years.   However,  I’ve been to osteopaths and they’ve really helped relieve the pain, it’s not cured. To cut a long story short, I think the reason for my back pain is actually that my hip is ‘locked up’ and while the pain is felt in my back, the actual problem lies in my hip.
Every morning I wake up with my right hip feeling tight, this feeling goes all the way down to my  feet. When I walk and run I can feel my stride isn’t right and the right leg has a smaller range of movement than my left.  I can stretch, not sure which muscle it is, kind of between my bum and my hamstring….and I can feel my leg and foot relax. This stays relaxed for a short time before tightening up again.
My gut feeling is that a nerve in my hip is constantly aggravated – it doesn’t cause me direct pain but I think the muscles in my leg are tightening up to protect that nerve. Maybe the stretch releases some of the pressure on the nerve? Also, my big toe nearly always feels numb, like when you have pins and needles which make me think it's nerves.
Does this diagnosis seem probable? Do you think acupuncture could help by ‘re-setting’ the nerve? 

A:   We have to say, if this doesn't sound too odd, that we (well, this particular 'expert' anyway) love the challenge of a problem that has been treated and held at bay for years without having been fully sorted out. You will know from reading around the subject that acupuncture is particularly well-regarded as a treatment for back pain, as our factsheet shows
 
 http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/back-pain.html
 
but then again, so it osteopathy, and we would be fairly sure that if the problem was a structural one, the osteopaths would have taken care of it a long time ago.
 
It is possible that the nerve is being constantly pinched and inflamed (entrapment is the technical term) which means that a cycle develops of inflammation causing irritation causing inflammation, and so on. Acupuncture has a fairly good track record as a treatment for inflammation, but again, the osteopathy should also have corrected the gait to the point where the nerve should gave settled down.
 
So, the points of interest are first the numb toe, which from a conventional understanding point to a nerve issue but from a Chinese medicine perspective indicate a loss of 'qi' or energy in the extremity, and second, a strong sense of asymmetry between right and left leading to tension and muscle spasm in the right leg. Our first questions would be about what happened when the pains started, and in particular whether there was any hint of a rotational injury, for example being throwh forward while wearing a seatbelt or twisting to pick up a heavy object. There are a number of subtle injuries caused by 'twist' injuries where the internal geometry of the body is thrown out of kilter, and these tend to resist attempts to deal with manipulation to put them right. It is rather like a functional, rather than structural, disturbance.
 
The numb toe could be either a systemic problem, and itself be the tip of a larger iceberg where more toes and fingers will follow eventually, or it could be an indicator of a simple blockage in the channel system. These can have profound effects; a small airlock is, after all, enough to stop a whole central heating system working. A skilled practitioner should be able, by using the pulse at the wrist, determine which is the case.
 
It is a rather unusual problem, and although we always stand by our public position that all of our members are equally skilled enough to be able to work from a Chinese medicine perspective on every patient who comes through the door, there are some styles of treatment which your problem suggests might be more worthwhile investigating. Our experience is that Japanese acupuncture styles are particularly good for these kinds of subtle functional shifts, and in particular for looking at these kinds of rotational problems. That said, most practitioners would be able to offer a number of very effective treatments for some of the problems you report, and we are confident that you may find that acupuncture treatment can just take you that step further, after the osteopathic treatment has set the scene, towards recovery.
 
If you contact a BAcC member local to you, we are sure that they will give you an honest assessment based on a face to face view of what they may be able to achieve and possibly also who may be the practitioner best suited to see what they can do.    
 
 



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