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

26 questions

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.

Q:  I had decompression surgery July 2015 to relieve l5 nerve. I reherniated within 3 months and again have lower back pain and nerve pain. Could acupuncture help deal with pain/inflammation?

A:  There is certainly a considerable amount of evidence for the use of acupuncture in the treatment of low back pain, as our factsheet shows

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

The evidence is sufficiently robust that NICE make acupuncture one of its recommendations for treatment of chronic back pain lasting more than six months.

However, when there is a specific cause like a herniated disc, we tend to be just a little cautious about what may be possible, especially when we are not entirely sure of the nature of the surgery (fusion, laminectomy, discectomy, and so on). Where there are specific physical changes in the body that can limit what we are able to achieve. This may mean, for example, that treatment might be aimed at pain relief and reduction of inflammation but only with the expectation that this will eventually return. The equation then is between how much relief and how sustainable, and the cost of maintaining an 'acceptable' level of discomfort.

It is best not to be too negative, however.Our clinical experience is that when there is disc protrusion which will probably resolve of its own accord within six to twelve months treatment may be able to speed up that process, and may well be able to reduce some of the inflammation which it causes. There is a spiral of discontent where a problem causes inflammation which exacerbates the initial problem, and conventional medicine is often aimed at the same thing, to break the cycle and let things stabilise.

In summary, we suspect that treatment may well be able to help with the pain and inflammation, but we think that the best option is for you to visit a BAcC member local to you for a slightly better assessment than we can offer here. Most are willing to give up a some time for prospective patients without charge and this sort of face to face assessment would in our view be essential to give you the best possible information. We treat people, not conditions, and the great Canadian physician William Osler summed this up well; 'tell me not about the disease the patient has, tell me about the patient who has the disease.' The wider context within which the symptom sits can have a huge impact on what can be done, and with problems like yours really does need to be taken into account. 

A:  Acupuncture has traditionally been used for chronic pain, often because the first major publicity event for acupuncture in the West, Nixon's visit to China in the 1970s, saw operations carried out without anaesthetic under acupuncture, and a great deal of research was stimulated into the pain relieving and anaesthetising effect of treatment. Many pain management clinics now feature acupuncture as a part of their offer. The main question is not whether the treatment will relieve the pain as much as how much relief it will give and hows sustainable its effects are. Used in this way it can sometimes, if affordable, be enough to keep someone going.

However. from a Chinese medicine perspective pain only arises where the flow of energy, called 'qi', has been affected, either from a blockage, or from a deficiency or excess in the channels through which it is said to flow. Knowing where pain appears is less important than understanding how this sits against the backdrop of the whole system. On many occasions the pain is local and to do with specific local issues, but even here the question is how the system has lost its ability to repair. More often than not, however, the pain appears as evidence of a deeper functional disturbance, and the skill of the practitioner lies in making sense of the local manifestation of discontent in the context of someone's overall balance.

The way in which energy flows in the body, and the various functions which are grouped together under the heading of an Organ (capitalised because the meaning is far broader in Chinese medicine) often show greater connections than are apparent from a conventional medical point of view. If the symptoms, for example, tended all to lie on the same channel, and this channel happened to be associated with an Organ generating other symptoms of functional disorder, this would immediately inform the practitioner and point to various treatment possibilities.

The best advice for concerns like yours is to visit a BAcC member local to you and seek a brief face to face assessment to see what they think may be possible. We would be very surprised if they did not immediately make some connections which informed their view, and if so, we think they will probably advise you that four or five sessions may be a worthwhile investment to see how well your system reacts.

 

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