BACK PAIN RESEARCH (© JCM Ltd)

BACK PAIN? TELL ME ABOUT YOUR CHILDHOOD…
A British author has suggested that the effect of acupuncture treatment on low back pain may be determined by the quality of the relationship between the patient and their mother during the first 18 months of their life. Previous authors have suggested that activation of C tactile afferent nerve fibres, which respond to light touch and project to the brain’s limbic system, can induce a 'limbic touch' response. The emotional and hormonal reactions that result are thought to be responsible for the feelings of calm and wellbeing that are elicited by stroking the skin. Acupuncture may activate C tactile afferents, resulting in alleviation of the affective component of pain. In this new paper, the author explains that C fibre deactivation of the limbic system can only occur in the presence of intact corticosubcortical neuronal pathways and that the normal development of these pathways is determined by social factors in the early years of life. He hypothesises that the ability of acupuncture to modulate pain may therefore be partially determined by developmental factors such as the quality of the early relationship between mother and child. (The relevance of childhood developmental factors to the efficacy of acupuncture on the affective component of back pain. Acupunct Med. 2009 Dec;27(4):180-2).

ACUPUNCTURE BETTER THAN INJECTIONS FOR BACK PAIN
Japanese researchers have found acupuncture to be superior to injection of local anaesthetic for the treatment of lower back pain. Twenty six patients were randomly allocated to either acupuncture or local anaesthetic injection at two to five of the most painful points on the lower back once per week for four weeks. Both injection and acupuncture relieved pain, but there was a significant difference between the two groups regarding pain scores, with acupuncture providing more pain relief than injection at all time points measured (immediately before the first treatment, before each subsequent treatment and at two and four weeks after completion of treatment). (Comparison of the effectiveness of acupuncture treatment and local anaesthetic injection for low back pain: a randomised controlled clinical trial. Acupunct Med. 2009 Dec;27(4):174-7).

AURICULAR ACUPUNCTURE FOR LOW BACK & PELVIC PAIN IN PREGNANCY
One week of continuous auricular acupuncture decreases the pain and disability experienced by women with pregnancy-related low back and posterior pelvic pain. In a randomised controlled trial, American clinicians randomly assigned pregnant women to continuous auricular acupuncture, sham auricular acupuncture or a waiting list control. All participants were monitored for two weeks. Participants in the acupuncture group reported a significant reduction in pain and improvement of functional status compared to those in the sham acupuncture and control groups. (Auricular acupuncture as a treatment for pregnant women who have low back and posterior pelvic pain: a pilot study. Am J Obstet Gynecol. 2009 Jun 25. [Epub ahead of print]).

ACUPUNCTURE QUICKLY IMPROVES CHRONIC LOW BACK PAIN
A pilot study designed to test the feasibility of a randomised controlled trial comparing the effectiveness of two frequencies of acupuncture treatment for chronic low back pain (LBP) has found that clinical improvements achieved within the first two weeks were maintained at one year follow-up. Thirty participants with chronic LBP were randomised into two groups to receive 10 acupuncture treatments: a low frequency group (two treatments per week for five weeks) and a high frequency group, (five treatments per week for two weeks). Although there were no significant differences between the groups in terms of outcomes measured, the results showed that the clinically important improvements in pain, functional disability and quality of life in both groups were achieved within the first two weeks and were maintained at one-year follow-up. (Different frequencies of acupuncture treatment for chronic low back pain: an assessor-blinded pilot randomised controlled trial. Complement Ther Med. 2009 Jun;17(3):131-40).

ACUPUNCTURE BETTER THAN STANDARD CARE FOR BACK PAIN
A large American study has concluded that acupuncture for back pain results in persistent clinically meaningful improvement, which is better than that achieved with standard care. A group from Seattle carried out a large randomised controlled trial of acupuncture for chronic lower back pain (cLBP), comparing individualised acupuncture with standardised acupuncture, simulated acupuncture and usual care. Individualised acupuncture consisted of TCM diagnosis and point prescriptions unique to each individual; standardised acupuncture used a prescription considered by experts to be effective for cLBP (Yaoyangguan DU-3, bilateral Shenshu BL-23, a low back ashi point, bilateral Weizhong BL-40 and bilateral Taixi KID-3); simulated (non-insertive) acupuncture was carried out at the eight standardised points, using a wooden toothpick in a guide tube, which was twisted on the skin to simulate needling; usual care consisted of medication, primary care and physical therapy visits. All participants received a self-care booklet with information on exercise and lifestyle modifications and all who received acupuncture of any kind were allowed to continue usual care as required. 638 adults received 10 treatments over seven weeks. After eight weeks, 60% of patients receiving any type of acupuncture showed improvement in their level of pain and function, compared with 39% for those receiving usual care. After one year, 65% of participants receiving either individualised or standardised acupuncture continued to experience improvement, compared with 59% for simulated acupuncture and 50% for standard care. By eight weeks, use of medication for cLBP had decreased to 47% in the real and simulated acupuncture groups versus 59% in the usual care group and this difference persisted after one year. Participants in the usual care group were twice as likely as those receiving real or simulated acupuncture to report a physician or physical therapist visit (21% vs 11%) or to have visited a complementary and alternative medicine provider (18% versus 8%). At 52 weeks, significantly more participants reported cutting down on activities for more than seven days in the past month in the usual care group (18%) than in the real or simulated acupuncture groups (5%-7%). The authors conclude that, compared with usual care, acupuncture has persistent beneficial effects on cLBP, which result in clinically meaningful improvements in function. They also state that their results raise questions about acupuncture’s mechanisms of action, and that tailoring needling to each patient and needle insertion appear to be unimportant in eliciting therapeutic benefit. They offer several explanations for this: either that superficial acupuncture point stimulation represents a physiologically active treatment, or that participants’ improvement may be due to nonspecific ‘placebo’ factors such as receiving a treatment believed to be helpful. (A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch Intern Med. 2009 May 11;169(9):858-66).

ACUPUNCTURE BENEFITS LOW BACK PAIN
Authors from Northern Ireland have published a systematic review that supports the use of acupuncture as a treatment for low back pain (LBP). Twenty-three trials involving 6359 participants were included in the meta-analysis. The authors conclude that there is moderate evidence that acupuncture is more effective than no treatment, and strong evidence of no significant difference between acupuncture and sham acupuncture, for short-term pain relief. They also report that there is strong evidence that acupuncture can be a useful supplement to other forms of conventional therapy for nonspecific LBP, but the effectiveness of acupuncture compared with other forms of conventional therapies still requires further investigation. They further conclude that acupuncture versus no treatment, and as an adjunct to conventional care, should be advocated in the European Guidelines for the treatment of chronic LBP. (Effectiveness of acupuncture for low back pain: a systematic review. Spine. 2008 Nov 1;33(23):E887-900.)
   
ACUPUNCTURE REDUCES MEDICAL EXPENSES FOR LOW BACK PAIN
A Japanese team has investigated the effect of acupuncture on perceived pain, mood disturbances and medical expenses related to low back pain (LBP) among employees of a steel company. In the intervention study, seventy-two workers, mean age 53, received acupuncture once a week. After eight weeks of treatment, patients with LBP reported diminished pain and showed a significant decrease in total mood disturbance score. The number of visits to conventional hospitals and medical expenses for LBP after acupuncture were significantly decreased compared with those before intervention. (Acupuncture can reduce perceived pain, mood disturbances and medical expenses related to low back pain among factory employees. Ind Health. 2008 Aug;46(4):336-40).

ACUPUNCTURE TWICE AS GOOD FOR CHRONIC LOW BACK PAIN
Another result from the large multi-centre German Acupuncture Trials (GERAC), suggests that both real and sham acupuncture are much more effective against chronic low back pain than conventional therapy. The patient- and observer-blinded randomised controlled trial involved 340 outpatient practices, including 1162 patients aged 18-86 years (average 50) with a history of chronic low back pain lasting an average of eight years. This represents the largest experimental trial so far of acupuncture for back pain. Participants underwent ten 30-minute sessions (two per week), of verum acupuncture (according to TCM principles), sham acupuncture (superficial needling at nonacupuncture points on the lower back), or conventional therapy (a combination of drugs, physical therapy and exercise). The primary outcome measure was response after six months, defined as a 33% improvement on pain scores or a 12% improvement in functional ability. At six months, the response rate was 47.6% in the verum acupuncture group, 44.2% in the sham acupuncture group, and 27.4% in the conventional therapy group. The difference between response to real vs sham acupuncture was not significant, but both were almost twice as effective as conventional therapy. (German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Arch Intern Med. 2007 Sep 24;167(17):1892-8).

ELECTROACUPUNCTURE FOR DOGS’ DISKS
Electroacupuncture is an effective treatment for intervertebral disk disease in dogs. Fifty dogs with signs of thoracolumbar intervertebral disk disease were randomly allocated to receive either electroacupuncture stimulation combined with standard Western medical treatment, or standard treatment alone. The dogs receiving electroacupuncture took significantly less time to recover and start walking unassisted again. (Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disk disease in dogs. J Am Vet Med Assoc. 2007 Sep 15;231(6):913-8).

TREATING PELVIC AND BACK PAIN IN PREGNANCY
A systematic review using the Cochrane database has assessed the effects of interventions for preventing and treating back and pelvic pain in pregnancy. Authors searched the Cochrane database for randomised controlled trials of any treatment used to prevent or reduce the incidence or severity of back or pelvic pain in pregnancy. Eight studies (1305 participants from five countries) were included in the analysis. Strengthening exercises, sitting pelvic tilt exercises and water gymnastics reduced pain intensity and back pain-related sick leave better than usual prenatal care alone. Both acupuncture and stabilising exercises relieved pelvic pain more than usual prenatal care and acupuncture gave more relief from evening pain than exercises. One study found that acupuncture was more effective than physiotherapy in reducing the pain intensity scores of women with combined pelvic and back pain. Sixty percent of those who received acupuncture reported reduced pain, compared with 14% of those receiving usual care, with no complications associated with the use of acupuncture in pregnant women. Women who received usual prenatal care alone reported more use of analgesics, physical modalities and sacroiliac belts. The authors advise caution in interpretation of the results as all studies but one were judged to have considerable potential for bias. (Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD001139).

ELECTRO-ACUPUNCTURE CURES HORSES’ BACK PAIN
A study of electro-acupuncture for chronic low back pain in horses has found that it can successfully alleviate thoracolumbar pain and that the analgesic effect persists for up to two weeks after the treatment. (Evaluation of electroacupuncture treatment of horses with signs of chronic thoracolumbar pain. J Am Vet Med Assoc. 2005 Jul 15;227(2):281-6).

ACUPUNCTURE & LOW BACK PAIN
A landmark study has been published by the British Medical Journal on the treatment of lower back pain by acupuncture. 241 adults were randomly assigned to receive either standard care or ten acupuncture treatments and asked to record pain levels, use of pain medication and satisfaction with treatment. Although there was only a non-significant benefit for acupuncture at 12-months follow-up, compared to controls, by 24 months this difference had become significant. At three months, the acupuncture group were significantly more likely to say that they were “very satisfied” with their treatment than the standard care group, and at 24 months were more likely to report reduced worry about their back pain. The study team conclude that although the differences in pain scores between groups were small, they represent a clinically worthwhile benefit and can be viewed as a ‘moderate’ effect and that further research is needed to investigate the value of repeated courses of acupuncture for patients experiencing recurrent episodes of low back pain. (Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain. BMJ, Sep 2006; doi:10.1136/bmj.38878.907361.7C). In a separate paper, the same researchers looked at the cost effectiveness of acupuncture for lower back pain. Although total costs during the two-year study period were higher on average for the acupuncture group than for the usual care group, the cost in terms of quality adjusted life years (QALYs) gained was well below the lower threshold of £20,000 used by the National Institute for Health and Clinical Excellence (NICE) to decide whether the NHS can afford to pay for a health technology. (A randomised controlled trial of acupuncture care for persistent low back pain: cost effectiveness analysis. BMJ, Sep 2006; doi:10.1136/bmj.38932.806134.7C).

ACUPUNCTURE & LOW BACK PAIN
In a large study of the use of acupuncture for the treatment of around 10,000 patients with chronic low back pain, acupuncture was found to be more effective than a no-acupuncture control group and relatively cost-effective. (Pragmatic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain. Am J Epidemiol. 2006 Sep 1;164(5):487-96).

ACUPRESSURE WINS FOR BACK PAIN
A Taiwanese study has compared the effects of acupressure (six treatments) with standard physical therapy ( i n c l u d i n g   p e l v i c   m a n u a l   t r a c t i o n ,   s p i n a l   m a n i p u l a t i o n ,   t h e r m o t h e r a p y ,   i n f r a r e d   l i g h t   t h e r a p y ,   e l e c t r i c a l   s t i m u l a t i o n    a n d   e x e r c i s e   t h e r a p y) for the treatment of lower back pain. 129 patients with chronic lower back pain were assigned randomly to one of the two treatment groups. The acupressure group experienced an 89% greater relief of disability compared to the physical therapy group, and the benefit lasted at follow-up six months later. The acupressure group also reported greater improvement in leg pain, interference of pain with normal work and days off from work or school. (Lisa Li-Chen Hsieh et al. Treatment of low back pain by acupressure and physical therapy: randomised controlled trial. BMJ, Mar 2006; 332: 696-700).

ACUPUNCTURE & LOWER BACK PAIN
An analysis of Canadian patients who had self-referred to acupuncturists for treatment for low back pain (LBP), found that they made significantly fewer visits to their physician for LBP care in the year following treatment (1.55 versus 4.45 in 1999, 1.41 versus 7.17 in 2000 and .86 versus 4.04 in 2001) compared to LBP sufferers who had not received acupuncture. They consequently required significantly less physician expenditure (around 25% of the cost of LBP care in the general population). (12th Annual Symposium on Complementary Health Care, 19-21 September 2005, Exeter, UK).

ACUPUNCTURE RELIEVES CHRONIC BACK PAIN
A meta-analysis of 33 randomised controlled trials of acupuncture has concluded that it can effectively relieve chronic lower back pain. Specifically it was found to be more effective than sham acupuncture and no additional treatment. There was insufficient data to form conclusions about its effect on acute lower back pain. (Annals of Internal Medicine, Vol. 142, Issue 8, pages 651-663).

EAR ACUPUNCTURE FOR BACK PAIN
A randomised controlled trial compared manual and electrical stimulation of the same auricular points (lumbar spine, shenmen and cushion). 61 adults with chronic back pain (more than 6 months) that did not respond to non-steroidal anti-inflammatory drugs were randomly assigned to a manual or an electrical stimulation group (treatment given for 6 weeks with a 3-month follow-up). Criteria assessed included pain intensity, psychological well-being, physical activity level and quality of sleep, analgesic consumption and ability to return to work. The study found that patients in the electro-acupuncture group showed significant improvements in all outcome measures compared to simple manual stimulation. (Focus Altern Complement Ther 2005; 10: 37-8).

ACUPUNCTURE FOR PELVIC AND BACK PAIN IN PREGNANCY
In this Swedish study, 72 pregnant women (24-37 weeks) suffering pelvic or low back pain were randomly assigned to an acupuncture group or a control group. Traditional acupuncture points and ahshi points were needled (with deqi elicited) in individualised treatments, once or twice a week until disappearance of symptoms or delivery in the acupuncture group. Treatment was given for at least three weeks, twice weekly for the first two weeks, then once a week. The control group received no treatment. During the study period the pain decreased in 60% of patients in the acupuncture group compared to 14% of the controls, dropping to 43% and 9% respectively at the end of the study. (Acta Obstet Gynecol Scand 2004; 83(3): 246-50).

ACUPRESSURE EFFECTIVE FOR LOW BACK PAIN
A Taiwanese study randomly assigned 146 chronic lower back pain patients to receive either standard physical therapy or fifteen-minute acupressure treatments (six treatments over four weeks for both groups). At the end of the  study, the average pain scores had decreased from 9.29 (baseline) to 2.28 in the acupressure group and from 7.68 to 5.13 in the physical therapy group. Interestingly this study also revealed what is becoming increasingly frequently uncovered in research studies, namely that the benefits of the acupressure treatment mounted over time after completion of the study period.  At a six-month follow up, the pain score in the acupressure group had further decreased to 1.08, compared to a decrease to 3.15 in the physical therapy group. (Preventive Medicine, Vol. 39, 2004, pp. 168-76).

ACUPUNCTURE FOR BACK PAIN IN PREGNANCY
A Brazilian study which compared the levels of low back and pelvic pain in women treated by acupuncture compared to non-treated controls, found that the acupuncture group showed a greater reduction in overall pain, maximum pain and  pain at the time of interview, reduced use of analgesics, and greater capacity to perform general activities, to walk and to work. (Acupuncture in Medicine, 2004 vol 22(2), 60-67).

ACUPUNCTURE & CHRONIC LOW BACK PAIN
In a study into the potential benefits of acupuncture for chronic low back pain in the elderly (over 60 years old), 23 patients were randomised to receive their normal care (NSAIDs, muscle relaxants, paracetamol and back exercises) and 24 to additionally receive bi-weekly electro-acupuncture for 5 weeks. The acupuncture group had a significant decrease in RDQ (Roland Disability Questionnaire) scores compared to the control group, an effect which was maintained up to 4 weeks after the end of treatment. The acupuncture group also had fewer medication-related side-effects compared with the control group. (Rheumatology, 2003 Jul 30).

ACUPUNCTURE & CHRONIC LOW BACK PAIN
In this German study, 174 patients with chronic low back pain (lasting longer than 6 weeks, and with no pending compensation claims) were randomly assigned to receive either i. True acupuncture plus conservative orthopaedic treatment (COT), ii. Sham acupuncture plus COT, or iii. COT alone. Both acupuncture groups received 3 treatments per week for 4 weeks, and both the patients and an observer were blinded for true versus sham acupuncture. 65% of the true acupuncture group experienced a greater than 50% improvement in pain relief versus 34% in the sham acupuncture group and 43% in the COT alone group. There was no difference between the groups in terms of mobility or intake of non-steroidal anti-inflammatory drugs (although less than 20% of total patients had been taking these). (Pain 2002; 99: 579-87).

ACUPUNCTURE & BACK PAIN
A German study into the treatment of chronic back pain has compared the benefits of: 1: true acupuncture plus conservative orthopaedic treatment, 2: sham acupuncture plus conservative orthopaedic treatment, 3: conservative orthopaedic treatment alone. The true acupuncture consisted of needling Shenshu BL-23, Weizhong BL-40, Kunlun BL-60, Jingmen GB-25, Huantiao GB-30, Yanglingquan GB-34, and up to 4 ahshi points bilaterally. Deqi was obtained. All patients received 12 treatments and there was a 3-month follow up.  Patients and observers were blinded as to the treatment. The percentage of patients with greater than 50% reduction in VAS pain scores three months after treatment were: Group 1: 77%,  Group 2: 29%, and Group 3: 14%. (Pain 2002, Vol. 99(3) p.579).

ACUPUNCTURE & LOWER BACK PAIN
The US Agency for Healthcare Policy & Research and the National Center for Complementary and Alternative Medicine have awarded a $1 million grant to study acupuncture as a treatment for chronic lower back pain. The 100-patient study will be carried out collaboratively between the Group Center for Health Studies (the USA’s largest consumer-governed healthcare organisation with more than 650,000 members), the Northwest Institute of Acupuncture & Oriental Medicine, the University of Washington and the University of California, San Francisco. The three-year study will investigate such issues as the consistency with which practitioners of TCM diagnose and treat patients with lower back pain, whether acupuncture is effective for lower back pain, whether acupuncture is more effective when needles are inserted into acupuncture points compared with non-acupuncture points, whether acupuncture is more effective than standardised medical care, and whether individualised acupuncture is more effective than standardised acupuncture. (For further information: http://www.halcyon.com/niaom).