Ask an expert - muscles and bones - back / spine

66 questions

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 treatmen 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.

Q: I had an epidural when Ihad my son over 2yrs ago.  Since I have  sufferd really bad lower back pain.  Due to the pain I hardly go out and I have  put on a lot of weight. Do you  think acupuncture could help me?

 

A: This is quite a difficult question to answer. The official NHS sites quote statistics from studies which demonstrate that there are no long term side effects, perhaps only mild and short-term problems, but a quick internet search reveals hundreds of posts from women who have suffered long term debilitating problems.
 
It is very important to establish as much as possible what the problem is. In the first instance this means going back to your doctor and trying to get an MRI scan of the area to eliminate the possibility that there has been some damage during the epidural or some form of haematoma or tissue change which is causing the problem. This will determine how good the prognosis is.
 
It is also important to consider the possibility that the back pain may not be a result of the epidural. Pregnancy involves carrying a large weight at a disadvantageous angle, and if there were any minor irregularities or misalignments of the lower spine, these might have been pushed one stage further by the pregnancy and vigorous exertion of birth.
 
Acupuncture treatment may offer some hope. As our factsheet shows
 
http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/back-pain.html
 
there is some evidence that acupuncture can help with non-specific back pain, and the NICE guidelines (which determine what treatment doctors can offer) have included ten sessions of acupuncture as one of the cost-effective options to consider.
 
Back pains arise for all sorts of reasons, however, and even in Chinese medicine there are dozens of ways of categorising what may be happening. Sometimes this will offer a good prognosis, at other times not. The skill of the practitioner lies in seeing what else is going on in the system as a whole and using this knowledge to understand what patterns of imbalance of energy have developed over the years. It is rare for someone to have only one symptom, and there are often changes to the normal systems which people just accept without mentioning, like digestive problems or sleep disorders which just become the 'normal' order of things.
 
The best advice we can give, apart from following things up with your doctor, is to visit a BAcC member local to you and ask for their opinion in a brief face to face assessment. This can give you a much better idea of what can be done than we can give here.     

Q:  Would acupuncture help me I have a slipped disc? i have had it for 3 months. I am having  physio but seem to be at  standstill.

A:  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 acumulated tissue to disperse.
 
There are a number of small studies which underpin documents like this overview
 
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0048469/
 
which mentions that there is a weak evidence base for acupuncture. Our own 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.
 
  
 

A: There is no reason not to have acupuncture when you are taking warfarin.
 
We publish a Guide to Safe Practice for our members which provides detailed guidance on issues like this, and on the treatment of people on anti-coagulant medication we wrote:
  

Patients on anti-coagulant medication

You must take great care when needling patients who are taking anti-coagulant drugs such as Warfarin. Only very superficial needling with fine needles (0.20mm) is recommended.

The risk appears small but internal bleeding leading to compartment syndrome can have extremely serious consequences. There is one report in the medical literature of a case of compartment bleeding following acupuncture in a patient taking anti-coagulants (see link to article at the end of this section).

Warfarin prevents the body from metabolising vitamin K. Vitamin K controls the formation of a number of coagulation factors in the liver and is an essential substance for blood clotting. Vitamin K is present in most of the foods that are considered to be blood-forming according to Chinese medicine such as green leafy vegetables. This is important to consider if you are giving dietary advice to patients on Warfarin since these foods can lessen the desired effect of the drug.

Patients are put on Warfarin or other anti-coagulants for a number of different reasons. These may be purely preventive if, for example, the patient suffers from atrial fibrillation or has mechanical heart valves, or because of recent surgery, stroke, heart attack or thrombosis. The dosage of the medication depends on the desired amount of anti-coagulation for that particular condition.

Every patient on Warfarin has to undergo tests on a regular basis to check how long it takes for their blood to clot. The frequency of these tests depends on the dosage of their medication and their condition. It is good practice to encourage your patient to have more frequent tests while they are receiving a course of acupuncture as the treatment can positively influence their blood values and may require their Warfarin dosage to be reduced.

Ask your patient for their INR (international normalised ratio). The INR is a ratio established by measuring the prothrombin time (PT), which is the length of time it takes for the patient’s blood to clot, and then by comparing this value to an average.

In a healthy person the INR is about 1.0. Patients on Warfarin tend to have an INR somewhere between 2.0 and 3.0 or even higher, depending on the desired amount of anti-coagulation. A higher INR signifies a stronger effect of anti-coagulation.

The main risk associated with acupuncture is internal bleeding. Depending on the depth of needling and the underlying structures involved this may be insignificant, but there is a chance that it can result in compartment syndrome. Although the risk is small this condition can have serious consequences and often requires surgery.

Needling should only be done superficially and with fine needles. The higher the INR, the greater the risk of bleeding. Patients with an INR of 3.5 (sometimes therapeutically necessary in the treatment of valvular disease) or higher should be treated with greater care.

It is also advisable not to use guasha and cupping on patients on anti-coagulants since these techniques tend to draw blood to the upper layers of the skin and can cause severe and prolonged bruising to larger areas of the body.

Further information and research articles can be found on the internet. Here are a few examples:

www.medicalacupuncture.com/aama_marf/journal/vol13_2/case4.html

www.doctorslounge.com/hematology/labs/inr.htm

http://aim.bmj.com/cgi/content/abstract/20/2-3/105

Our members will always take these factors into account when treating, especially when they are dealing with a problem which might require slightly more vigorous needling. The majority of UK trained practitioners, however, use very fine needles and very gentle techniques, and we have had very few reported cases over the years of bruising or bleeding after treatment in people taking warfarin or other anti-coagulant medication. 

Q:  I am suffering from pain on the right side of my lower back. If you feel the area, there are deep "knots" under the skin. I also suffer from nerve pain. My sleep is affected from lying on my back.
 I would like to know would acupuncture cure this problem?

A:  There are back pains and back pains! As our factsheet on back pain shows
 
http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/back-pain.html
 
acupuncture treatment has been shown to have significant benefits in the treatment of back pain. There are even recommendations in NICE guidelines that patients with chronic back pain be offered up to ten sessions of acupuncture, and given the difficulties of convincing conventional medicine that acupuncture works, this is quite a powerful recommendation.
 
However, Chinese medicine operates from an entirely different paradigm or theoretical basis, and a great deal depends on the unique presentation of symptoms which you have and the underlying causes. Even medical acupuncture differentiates between types of back pain, but in the case of Chinese medicine, it is not simply a matter of looking at the different ways in which the symptoms manifest but also of looking at the overall picture to understand why these specific symptom arose in your system.
 
It is highly likely that a practitioner could help you, and the best advice we can give is that you visit a BAcC member local to you for a face to face assessment of whether they think that treatment would be of benefit. They may feel, for example, that there is a structural problem where you might get better and more rapid relief from visiting an osteopath, but based on your brief description we think that acupuncture may help you. 'Cure' is not a word we use, but a reduction in your symptoms should be possible, and once the cycle of discomfort is broken, there is every chance that you will feel better.
 
Your practitioner may well ask you questions about your lifestyle and work. In our experience there are often work-related postural problems or specific accidents behind chronic pain, and it may well be that the practitioner makes recommendations about what changes you might need to make in your work layout to help to stop recurrences of the problems.
 

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