East-West: Low Back Pain
For those who may not know, I’m currently working on my doctorate in acupuncture. The program I chose is through the Pacific College of Oriental Medicine (PCOM) in San Diego. I selected this program for two reasons:
It’s delivered online - no travel. After driving 4 hours a day, 4-5 days per week for years to get my master’s degree, the idea of not going anywhere is extremely appealing.
This program focuses on integrative medicine. In other words, a big part of the program is examining whether and how acupuncture and Chinese medicine can be integrated in to conventional medicine. An idea I find extremely interesting.
I’m done with my first semester and this blog idea hit me. Why not spend some time examining a few health issues from the perspective of both eastern and western medicine? After accounting for language and model differences, I think there’s actually a great deal of cross-over and I’m hoping these blog entries will help folks understand more about acupuncture and Chinese medicine.
For the first entry, I thought I’d focus on an issue that brings a lot of folks in to the medical system: low back pain.
Before we get in to the east-west part, it might help to consider some basic anatomy. In most humans the spine is composed of 33 vertebrae . There are 7 cervical vertebrae which start at the base of the skull and end roughly at the level of the shoulders . There we transition to the 12 thoracic vertebrae which cover most of the trunk and provide attachment for the ribs . Then there are 5 lumbar vertebrae, followed by the sacrum which is composed of 5 fused vertebrae and the coccyx which is 4, usually fused, vertebrae . Vertebrae are roughly disc shaped with some spines on the sides (transverse processes) and back (spinous process). There is a hole through the center where the spinal cord runs and each vertebra, except for the fused sacrum and coccyx, is separated from the one above and below it by a fibrous disc which provides cushion. The main nerve roots from the spinal cord exit between the vertebrae and go on to provide nerve input/output to various parts of the body.
The low back area is usually taken to refer to the 5 lumbar vertebrae and sometimes the upper part of the sacrum and pelvis. If you find the highest part of your hip bones and follow that line around to the back, you’re roughly at your 3rd lumbar vertebra. Muscles in the area include serratus posterior inferior which originates on the two lowest thoracic vertebrae (T11 and T12) as well as the two upper lumbar vertebrae (L1 and L2) and inserts on ribs 9, 10, 11 and 12 .
Underneath serratus posterior inferior we have longissimus throacis. This is a long muscle which originates on the lumbar vertebrae, pelvis and sacrum and inserts on the transverse processes of all the thoracic vertebrae .
At the same general depth as longissimus thoracis we also have iliocostalis lumborum. It doesn’t attach directly to any of the lumbar vertebrae, instead it originates on the back part of the pelvis and inserts on to the ribs . This muscle’s primary function is back extension. While it doesn’t directly attach to any of the low back vertebrae it runs through the area . The multifidus muscle starts at the sacrum and runs all the way up to the second cervical vertebra . It provides stiffness and stability and helps to guard against spinal joint degeneration .
Last, but not least, we have a deep muscle in the low back called quadratus lumborum. It’s a roughly square shaped muscle which originates on the lowest rib and all five lumbar vertebrae and inserts on the back part of the pelvis .
In addition to the bones, muscles, tendons and ligaments in the low back, we also have a nerve structure called the cauda equina. This is a bundle of spinal nerves and spinal nerve roots arising from the 2nd through the 5th lumbar vertebrae, includes the 1st through the 5th sacral nerves and the coccygeal nerve . These nerves provide sensory, motor and some parasympathetic innervation to the hips, knees, ankles, feet, internal and external anal sphincter, perineum and bladder .
The low back is a complicated place, there are lots of moving parts in terms of bone, muscle, tendon, ligament and nerve. Any of these, sometimes more than one structure at the same time, can potentially give rise to pain.
Most patients presenting at their doctor’s office with a primary complaint of low back pain are probably going to receive a physical examination and an x-ray. X-rays are only going to let us see dense things like bones, we aren’t going to see much, if any, soft tissue like muscle, disc or nerve.
If the patient has bone spurs in the area of a nerve root, narrowed disc space or obvious misalignment, we’ll see that on an x-ray. If a disc has bulged or herniated in to the spinal canal, or is bulging laterally and pinching a nerve root we won’t see that on an x-ray. We also won’t see the various potential muscle, tendon or ligament issues. Honestly, in my experience, it’s a rare case when a patient’s back pain is completely explained by an x-ray. Which is why we have MRIs. An MRI is a completely different imaging technique that allows us to see the soft tissues like discs, muscles and ligaments. Unfortunately an MRI is also orders of magnitude more expensive than an x-ray, this is why most insurance companies force patients to start with x-rays.
MRIs are not a panacea though. It’s possible for a patient to have low back pain, have an x-ray that shows no obvious pathology and also have an MRI that shows no obvious pathology.
From the western perspective, here are some of the common causes of low back pain :
Muscle strain or ligament sprain. These are caused by repetitive use, sudden movements that place too much stress on the spine, poor posture or acute injury.
Degenerative disc disease.
Facet joint dysfunction. Facet joints facilitate spinal motion segments and consist of cartilage surrounded by a capsular ligament which contains a lot of nerves.
Sacroiliac joint dysfunction. This is the junction of the spine and pelvis. It’s a strong joint with not much motion that absorbs shock and tension between the upper body and the lower body.
Spinal stenosis - narrowing of the spinal canal. If severe this can lead to something called cauda equina syndrome which is a surgical emergency.
Spondylolisthesis - basically one vertebra slipping over an adjacent vertebrae. This can occur with a fracture, spinal defect or mechanical instability of the facet joints.
Osteoarthritis - also referred to as spondylosis or degenerative joint disease.
Deformity. Usually congenital, but sometimes acquired. Includes things like scoliosis, lordosis and kyphosis. These conditions can lead to breakdown of discs, facet joints or cause stenosis.
It’s important to note that the presence of one or more of these conditions does not necessarily mean a person will be in pain.
Now that we know some of the causes, what kind of treatment does conventional medicine offer?
Muscle relaxers. These drugs are central nervous system depressors and act to increase mobility of tense muscles. It’s important to note that muscle relaxers have no role in chronic pain management .
Narcotic pain medications. These drugs alter the patient’s perception of pain by weakening pain signals sent to the brain. They’re usually used for treating intense, short term pain and should rarely be used in chronic pain due to side effects and potential for addiction/abuse .
Back braces .
Epidural steroid injection. This is an attempt to relieve pain by reducing inflammation around a compressed nerve root .
Physical therapy .
Surgery. Usually reserved for severe low back pain that does not improve after 6-12 weeks of other treatments. There are lots of different types of surgical intervention, but there are a few important things to note: surgery should not be considered when the pain is mild or moderate, has not persisted longer than 6-12 weeks and, most importantly, if the cause of the pain is not detectible via imaging (x-ray/CT/MRI) .
If you have chronic moderate low back pain, conventional medicine can offer steroid injections, back braces and physical therapy. If these don’t work or quit working, there isn’t much left in the bag-o-tricks for you. Which brings us to….
The first things to understand when considering Chinese medicine is that it’s a whole-istic and individualized system. When we think about back pain in the Chinese model, we are interested not just in the back, but also the entire body. Since your back is integrated with the rest of you, there is a possibility that the pain is coming from some other problem in the system. This is particularly true with idiopathic pain - pain that has no identifiable cause.
We could have two people come in to the clinic with back pain, in the same location and with the same severity, but they might be experiencing back pain for two entirely different reasons. Chinese medicine recognizes this and factors it in to diagnosis and treatment; it’s the individualized part of the equation. Chinese medicine, done well, does not have fixed treatment protocols. Each person is unique, each person’s problem is therefore the result of a unique set of circumstances and requires slightly different treatment.
Classically in Chinese medicine we have a few causes for low back pain. I’m going to list them here, but one thing we need to keep in mind is that the language Chinese medicine wraps around health conditions is pre-western scientific and largely metaphoric. In other words: we don’t often mean literally wind or literally damp, rather we mean something that acts like wind or acts like damp. That being said, the causes are :
Cold-damp invasion. This essentially leads to a condition we refer to as stasis or stagnation and gives rise to pain.
Kidney deficiency. In Chinese medicine, largely due to their physical location, kidneys are thought to rule the low back area. Kidney ‘weakness’ therefore leads to low back ‘weakness’ resulting in pain.
Trauma or contusion. Probably the easiest for modern people to understand. Trauma or contusion also gives rise to stasis or stagnation, though the mechanism is different from cold-damp invasion.
To this list, we can add a few things based on channel theory, where organs are physically located and where nerve roots originate and travel to:
The urinary bladder channel runs down the entire length of the spine. This channel is sometimes the source and often the treatment location for all kinds of back pain, including low back pain.
Three of the extraordinary channels are also thought to run either with the spine or through the low back area: the Du channel runs superficially and has points below the spinous processes of several vertebrae. The Chong channel is thought to run more deeply and is located inside the spinal canal. The Dai is a channel that encircles the waist like a belt - running around the body between the 12th rib and the top of the pelvis. The Du is used often for back pain. The Dai is also often used for back pain - particularly low back and hip pain. The Chong, on the other hand, is rarely thought of in this capacity.
The liver and gallbladder together are theorized to influence the lateral surface of the body via their sinew channel (a more superficial channel system), and are thus thought to influence lateral back pain.
If something is physically wrong with the liver itself, usually the pain occurs in the upper right abdominal quadrant. But, if severe, the pain can sometimes radiate around to the mid-back/upper part of the low back.
The first foot or so of the small intestine (the duodenum) is actually closer to the mid-back than it is to the abdomen. Ulcers, excessive acid and perforation of the duodenum can sometimes cause pain just below the scapula and this pain can sometimes radiate lower.
Excessive muscle tension in the calf can sometimes create low back pain. This occurs because the gastrocnemius in the calf crosses the knee and overlaps with the hamstrings of the thigh. The hamstrings, in turn, overlap with the glutes (large muscles of the buttock) which then overlap with the muscles of the low back. This creates a chain of tension with the calf pulling everything down on one side leaving the other side to compensate. If this goes on for too long, pain will result and treatment needs to occur at the calf to correct the issue.
Just like in conventional medicine, Chinese medicine recognizes that muscles sometimes develop trigger points which cause pain and radiating pain. We call these ‘ahshi’ points, but the treatment method is the same.
Lastly, back to the calf/low leg/foot. The nerves running to this area originate in the low back - from the lower lumbar and upper sacral nerve roots. Sometimes low leg and foot pain doesn’t have anything to do with the low leg and foot, it’s actually coming from a pinched nerve in the low back.
As you can see, this just became way more complicated than “my back hurts”. For two, possibly three, of the issues on the list (liver, kidney and duodenum), a patient would need to be referred out for further testing. If there are cysts, lesions or cirrhosis of the liver, Chinese medicine can certainly help, but a patient will need to augment eastern treatment with conventional treatments.
Likewise, if a patient has chronic UTI that has progressed to pyelonephritis (infection of the kidney), antibiotics are going to be a superior treatment choice.
If we’re talking a perforated duodenum, Chinese medicine isn’t going to offer much. At that point the patient would need surgical intervention with eastern medicine playing a role in recovery.
In addition to pain cause and location, in Chinese medicine we are also very interested in the patient’s subjective experience of the pain. There are a variety of terms people use to describe pain and discomfort: dull, achy, throbbing, sharp, burning, lightening-like, moving and so on. Each of these descriptors gives someone using the eastern model extra information about the nature and cause of the problem. Sometimes the way a patient describes the pain can be decisive in terms of diagnosis and treatment. This is part of the reason why we spend much more time listening to a patient’s description of their issue than someone trained in the western model.
Each of these 11 potential issues will have its own signs and symptoms which can help us to differentiate the specific problem. Since there are 11 root causes, there are at least 11 basic treatment principles. From here things get a little crazy for those who are used to the conventional medical system because there are a variety of actual treatments. The treatment applied will depend on what system of acupuncture the provider practices (there are many), whether or not they’re using herbs or food therapy and whether or not western medical intervention is also desired/required.
For this reason, I’m only going to generally outline some potential treatments a patient might expect:
Most practitioners of Chinese medicine are trained in TuiNa - a system of Chinese massage. Not everyone keeps up with the practice, but it’s possible a treatment session might include a brisk massage. TuiNa is not meant to be relaxing - it’s more of a deep tissue approach.
Local acupuncture. For low back pain this would include several needles at various locations in the low back - with or without electrical stimulation.
Distal acupuncture. This acupuncture method relies on the interconnectedness of the body and applies treatment on the limbs to affect the back.
Combination local and distal acupuncture. This can be delivered in one treatment with needles in the low back as well as needles in the limbs or it can be delivered in two rounds with one set of needles in the low back, then those are removed and the patient is repositioned for a second set of needles in the limbs.
Moxibustion. This is the burning of Artemesia vulgaris either directly on the skin, on the skin with a spacer (like a slice of garlic or slice of ginger), on the needles or indirectly in the area via a moxa “cigar”. Moxa is a warming technique which increases blood flow, helps to reduce swelling and can be very useful in the early stages of acute pain or trauma.
Herbs. Herbal medicine is quite complicated and a variety of herbal formulae may be provided depending on what the practitioner sees as the root cause of the pain.
Food therapy. This is also quite complicated. Chinese food therapy applies the same rules that govern herbal medicine to foods. By altering the diet, we can affect internal state to restore health or remove pain.
Bleeding. Not George Washington or medieval style bleeding where we open a vein and drain it in to a bowl. This technique usually involves a lot less blood - normally on the order of a few drops. Sterile lances or bleeding needles are used at strategic locations and, for some patients, the effect can be borderline magical. Occasionally, acupuncturists use a technique called ‘wet cupping’ - a lance is used to prick the skin and then a cup with suction is applied over the top to draw blood out. This technique results in more blood being extracted but again, for some, the results in terms of pain relief can be impressive.
Cupping or scraping (Gua Sha). Both these techniques facilitate myofascial release. If the pain is related to a muscle or tendon issue, cupping or scraping can help stretch and relax the muscles resulting in pain relief.
Items on this list are not necessarily mutually exclusive. It’s possible a patient might receive treatment with multiple modalities during the course of a visit.
Some of the best studies and systematic reviews of acupuncture we have currently are investigating acupuncture in the treatment of pain. Probably the single best systematic review of acupuncture in pain management is the Vickers et al. study published in the Journal of Pain. This review is now over 20,000 patients and looks at a variety of pain conditions, including low back pain . They’ve concluded :
Acupuncture is not placebo.
After an initial set of treatments, acupuncture’s pain relieving effects can persist for almost 12 months with only minor decrease.
Acupuncture has a dose dependent effect, with an average of 8 treatments required to provide sufficient pain relief/control.
As the science has become more solidified, many agencies are now starting to change their guidelines for pain management, particularly chronic low back pain:
The American College of Physicians now recommends acupuncture, along with a list of non-pharmacologic modalities, as first line treatment for both acute and chronic back pain .
The FDA is proposing physicians learn about acupuncture’s use in pain management .
The Joint Commission (a hospital accrediting agency) is proposing that hospitals hire acupuncturists, chiropractors and massage therapists to offer non-pharmacologic pain management .
The VA system has embarked on a campaign of both hiring acupuncturists to work inside their facilities, and offering coverage for acupuncture through their veterans community care network.
The Center for Medicare/Medicaid Services (CMS) is currently evaluating whether or not to add acupuncture as a covered benefit for Medicare patients. CMS is particularly interested in using acupuncture for the management of back pain .
Since there are some potentially serious conditions that can cause low back pain, it’s a good idea to start with your primary care doctor and get some imaging/testing done. If nothing of concern shows up on x-rays or MRI, then acupuncture should be at the top of your doctor’s list in terms of treatment options. If it isn’t at the top of your doctor’s list, it should be at the top of yours.
It’s unlikely acupuncture will be a “one and done” type of treatment - it happens, but it’s rare. That being said, it shouldn’t take more than 8 treatments or so for a patient to get relief. After the pain is under control, we start spreading the treatments out so we can find a maintenance interval that works for each individual. Maintenance intervals are highly variable and can range from 4-6 weeks to several months between treatments. In some cases, particularly acute cases, acupuncture can resolve the pain and no further treatment will be required.
As can be seen from the western and eastern list of causes, in the eastern model we are much more interested in relationships between systems in the body and we are looking/thinking more globally in terms of cause. The western model focuses in on the area of the body where the patient is experiencing the issue, and often doesn’t consider much outside that area. Both systems can be extremely effective. For certain types of issues, the western methods are superior. For other types of issues eastern methods are superior. The trick is to know what kind of issue you’re experiencing so you can opt for the most effective treatment. A good rule of thumb is: if the problem is chronic (the patient has been experiencing the issue for more than 3 months) or if the pain is idiopathic (MDs cannot determine the cause), then acupuncture is often the better choice.
Also important to note: this is not an either/or proposition. Acupuncture in particular integrates very well with conventional medicine. Acupuncture needles are filiform (solid); we are not injecting any substances and there is very low risk of potential interaction with prescription medications. Herbs are a different story but, using a little care, they can also be integrated with more conventional treatments.
Compared to prescription medication, acupuncture, in the hands of a licensed acupuncturist, is also safer. There’s no potential for addiction/abuse and a very low side-effect/adverse event profile.
I hope you’ve found this post informative. If you have questions or suggestions for further posts, please leave a comment and let me know. References:
Deng, L., Gan, Y., He, S., Ji, X., Li, Y., Wang, R., Wang, W., Wang, X., Xu, H., Xue, X., Yuan, J. (2012). Chinese Acupuncture and Moxibustion. Beijing, China: Foreign Language Press
Vickers AJ, Vertosick EA, Lewith G, MacPherson H, Foster NE, Sherman KJ, Irnich D, Witt CM, Linde K. Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. J Pain. 2018 May;19(5):455-474.