Can Acupuncture help Lower back pain? Back pain is a major problem in today’s modern society. For example it is considered that up to 80% of the population will experience a back problem during their working lives and even more challenging, in 80% of back pain it is not possible to identify the exact structure causing the pain!
This is called non specific lower back pain.
Lower back pain has a cost to the economy too. On average, each person suffering from lower back pain took an estimated 18.7 days off work, which has been shown to cost employers is £315-£335 million!
Now we already know that lower back pain needs to be treated with exercise-based therapy and the evidence highlights that this is the most effective approach. In some cases, even basic low-level exercises can be too painful to implement and this is why some pain relief in any form can be useful. The most common route is pain killers but certain therapies can be used to enable the exercise by temporarily lowering pain levels. Now everyone is different in what works best for them but one common treatment that I use and other physio’s use is acupuncture because in certain cases acupuncture can help back pain.
Here is some evidence regarding the benefit of exercise for low back pain:
Bowden et al (2018) explains that physical activity, particularly vigorous activity, is beneficial in helping maintain intervertebral disc health. A review of systematic reviews found the benefit of specific stabilisation exercises for non specific chronic low back pain (Haladay et al 2013). Pilates improves pain, function & aspects related to the quality of life in chronic low back pain (Natour et al 2014). Early results of systematic reviews appear promising for the effectiveness of yoga for chronic low back pain (Hill 2013). Post-treatment exercise programmes can prevent recurrences of back pain (Choi et al 2010).
Even the NICE guidelines recommend exercises of all forms for back pain!
So what acupuncture points are regularly used to help lower back pain?
- L1 level: BL22 and BL51, GV5 and HTJJ on L1
- L2 level: BL23 and BL52, GV4 and HTJJ on L2
- L3 level: BL24 and HTJJ on L3
- L4 level: BL25, GV3 and HTJJ on L4
- L5 level: BL26 and HTJJ on L5
- S1 level: BL27 and BL31
- S2 level: BL28, BL53 and BL32
- S3 level: BL29 and BL33
- S4 level: BL30 and BL34
- Coccyx level: GV 2
- Gluteus Maximus & Piriformis: BL54
If pain extends down the leg from the back then other points into the leg should be used. Obviously this would be an awful lot of points to use in total. Generally, the principles when treating low back pain are to use between 4 to 6 bilateral pairs of bladder points locally in the most painful segments and also above and below this area. If there is leg pain then you should use a couple of distal points in the affected leg or legs.
Here is an example of what was used by Brinkhaus et al (2006) – 4 bilateral points from the below selection:
- BL20-34, BL50-54, GB30, GV3, 4, 5, 6, HTTJ’s and shi qi zhui xia
- They could also choose 2 bilateral points distally from the section SI3, BL40, 60 and 62, KI3 and 7, GB31, 34 and 41, LV3 and GV12 and 20.
- They were allowed to choose some trigger points depending on the patient.
- Common trigger points are: in Gluteus medius, minimus and maximus, piriformis and quadratus lumborum.
So now we know what points can and are used, but can acupuncture help back pain?
Now there is always a lot of debate in the Physio world regarding acupuncture, so we will try to look at this through the evidence and try to sum things up overall.
For acupuncture helping back pain:
Acupuncture is effective for the treatment of chronic pain and is, therefore, a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo (Vickers et al 2012).
Molsberger et al (2002) concluded that acupuncture can be an important supplement of conservative orthopaedic treatment in the management of chronic Low Back Pain.
- Results suggest that acupuncture is effective for some but not all types of pain. (Lee & Ernst 2011).
- Acupuncture should be considered for short term relief of pain in patients with chronic low back pain or osteoarthritis (Colvin et al 2013).
- Acupuncture may be more effective than medication for symptom improvement or pain in acute low back pain (Lee et al 2013).
- Chronic low back pain: Acupuncture & conventional therapies improves pain & function more than conventional therapies alone (Furlan et al 2012).
- Consider offering a course of acupuncture needling comprising up to a maximum of 10 sessions over a period of up to 12 weeks (National institute for health and care excellence 2009).
Against acupuncture helping back pain:
Acupuncture: In a review of systematic reviews it was found there is insufficient evidence for positive recommendations (Gilbey et al 2013). Leibing et al (2002) found a significant improvement by traditional acupuncture in chronic low back pain compared to routine care (physiotherapy) but not compared to sham-acupuncture.
So the main argument against acupuncture is that it is simply just a placebo. The first issue is that acupuncture is hard to be a true placebo in research because if you use non acupuncture points then there is still a physiological response, which is therefore not a placebo and if you use tacks that press against the skin, mimicking the needle then most people know that it is not a needle going in and this means they know that it is not real acupuncture. The other big issue here is placebo a bad thing either way. some people would say, “if it works it works, who cares why” which is a legitimate argument.
More on placebo
- Linde et al (2007) found a significant association between better improvement and higher outcome expectations with placebo treatments.
- Kaptchuk et al (2008) actually found that patients did better if the practitioner was caring, warm, attentive and confident even when they offered the exact same placebo treatment.
- Interestingly, Macpherson et al (2013) found little evidence showing that different characteristics of acupuncture/acupuncturists modified the treatment effect?
Not all placebo effects are created equal:
The reality is that not all placebo effects are equal and in fact, it is likely that a treatment considered to be no better than its placebo version may still be more effective overall than a treatment that is considered better than its placebo counterpart. So what are we to do in this case? Do we use the lesser effective treatment that is not just a placebo or do we choose the treatment that is essentially a placebo but is actually more effective? I know what I would choose as a patient but it’s different as the practitioner.”
Interestingly Macpherson et al (2013) also found that if you used more needles & had more sessions of acupuncture then the difference is greater when comparing acupuncture to non-acupuncture controls. So maybe the issue about some research is not specific to acupuncture versus sham but how to apply acupuncture optimally to achieve a clinically significant result.
Overall maybe we should look at what the exact parameters of acupuncture treatment should be, then use this, to compare to sham. After all, if I had a chest infection and took 1 antibiotic per week it would be no better than a placebo but if I took the correct dosage then it would be effective.
In fact, this study looking at randomised controlled trials found that only 25% of them actually performed the acupuncture as it should be performed according to Chinese textbook acupuncture standards (Molsberger et al 2011).
At present, I personally think the jury is still out on whether acupuncture can help back pain. Clearly acupuncture works better than not having acupuncture but is it just a placebo or are we still using it wrong in certain research papers? Unfortunately, I don’t have the answer, but who does? There is enough evidence to support its use at present and clinically I let the results speak for themselves. Until the evidence convinces me that it’s not worth using and my patients don’t improve, then I will continue using it.
The content in this blog article is provided for general information purposes only and is not meant to replace a physiotherapy or medical consultation.