Acupuncture for back pain? Let’s get to the point
There are so many different complementary therapies for treating low back pain. A recent study by Arthritis Research UK looked at 25 complementary therapies for back pain, including yoga, Tai Chi, Osteopathy, Chiropractic and Acupuncture.
1,718 people with back pain had acupuncture to help their back pain and the studies proved that acupuncture treatment for back pain was better than either no treatment, or pretend/sham acupuncture i.e. acupuncture truly helps back pain.
You can read the full report here:
Summary of evidence in relation to complementary and alternative therapies for back pain pdf
How Does Acupuncture Work for Back Pain?
Acupuncture stimulates nerves located in muscles and other tissues which leads to release of endorphins. It appears to reduce inflammation and improve the local microcirculation of blood, which in turn helps to reduce swelling.
Acupuncture improves the symptoms of stiff muscles and improves joint mobility.
In 2009, NICE (National Institute of Clinical Excellence) recommended ten sessions of acupuncture to try and help with early management of low back pain and in September 2016, a review article called “Complementary/Integrative therapies that work: a review of the literature” concluded that acupuncture has good evidence to support its use in treating chronic low back pain. This is good news, since a whopping 1 in 3 Americans used complementary therapies for different conditions in 2012 alone.
What does Acupuncture Involve?
For low back pain, needles may be inserted around the spine or further afield in the arms, hands or legs. As a general rule, the more acute and severe the pain, the fewer needles are inserted into the spine itself and the more needles are inserted distally in an attempt to calm an overactive nervous system.
Chronic (longer term) lower back ache treatment aims to break down the stagnation in the lower back with local needle insertion. Frequently I would add Tui Na, a form ofmassage used in Chinese Hospitals, to help breakdown soft tissue adhesions and promote healing.Anything else?
Yes. At all costs remain active. I’m fortunate in my clinic to see how lifestyle choices impact my patients’ decades on. Many patients think that by not moving they will stop the pain. Nothing could be further from the truth. An inactive spine creates stiff segments that shunt the problem further along the spine and can precipitate compression and fusion of spinal segments.
When choosing an activity you must be aware of your limitations. The best form of exercise for the spine involves gentle, consistent movement of the spine and strengthening of the core, with low levels of impact. Tai Chi is excellent for both. Yoga, under the watchful eye of an experienced teacher can be excellent therapy as well. If a posture hurts though back out of it and don’t get competitive. Yoga is about you, not a competition with your neighbor on the mat next to you.
Don’t Despair!
Above all else don’t despair. Back pain can get better with therapy and appropriate exercise.
“If You Don’t Use It, You Lose It”
Stan has given decades of his life to helping others with exercise-based projects. He has set up a Tai Chi class which is still running after twelve years.
Is this the evidence we’re looking for to prove that poor neck posture causes trapped nerves?
A recent publication by a Japanese team in January 2016 has demonstrated on MRI that when people suffer with trapped nerves in the neck, a condition often called “cervical radiculopathy”, the muscles at the back of the neck which provide extension, are weakened.
The group measured the muscle mass of a specific neck extension muscle called multifidus on MRI. They found 16 people who had pain due to a single C6 nerve compression and 24 people of similar age and gender who had no pinched nerves in the neck and no pain.
The MRI appearance of multifidus between the two groups was striking, in that the people with a single pinched C6 nerve had significantly less multifidus muscle bulk compared with the healthy controls.
The group explained that a trapped nerve, or nerves, means that the electricity supply to the nearby neck muscles is compromised and this in turn causes fatty changes in the muscle which weakens them. This in turn causes postural problems with the neck.
A second, older, publication in 2008 gave a convincing MRI association between worn discs, or disc degeneration, and loss of normal neck posture. They demonstrated that when the normal curvature in the neck is lost, called loss of cervical lordosis in medical jargon, there is more wear in the discs. The worst and most extensive wear is seen when the lordosis is actually reversed into a forward flexion or kyphosis of the neck.
Finally, a radiology publication in 2002 demonstrated that disc bulges were made to either partially or completely resolve on MRI when the patients’ necks were placed in an inflatable neck collar which provided continuous mobile traction.
If we put this information published over the last 14 years together, it appears that when he bend our necks forward as a postural habit, such as when we read a book, lean forward while using computer monitors, text on mobile phones or even sleep with our chins on our chests, we are encouraging our necks to lose the normal lordotic or C shaped curve, which distributes the 5Kg weight of our heads evenly through our necks. The result is that our discs bear more weight than they were designed to carry, because our heads are constantly further forward than they are meant to be held. We can support this opinion using the 2002 publication, whereby the bulging discs improve when the weight of the head is taken off them by a traction collar. We are not designed to wear traction collars, of course, but we are not designed to constantly look down either.
Assuming that our habitual neck flexion causes excessive loading of our discs, then it can be argued that the loss of normal neck posture is responsible for the disc wear reported in the 2008 publication. We are now just one small step away from arguing pretty convincingly that the disc wear causes the C6 pinched nerves reported in the 2016 article. The weakened neck extension muscles are seen, not because they have a reduced nerve stimulation from the trapped C6 nerve, but because they have not been used in the first place. The weakened neck extension muscles are the cause of the trapped nerve, not the other way around.
The multifidus muscle has its nerve supply from multiple nerves, not just the C6 nerve, so it sounds a little implausible to blame weak multifidus muscles on a single pinched nerve.
So, in summary, it appears that people who have weak extension muscles in their necks due to chronic, habitual poor neck posture, are at risk of developing pain in the neck and arm, called cervical radiculopathy. The treatment of this condition includes surgery, which has a roughly one in a thousand risk of causing paralysis as a complication. Maybe, if we pulled our shoulders back and focussed on being as upright as possible (draw yourself up to your full height!), then this problem would be a lot less common than its current reported estimated annual prevalence of 3.5 per 1000 people
I’ve Slipped my Spine!
Sian George (M.Ost) – Osteopath & owner of Align Therapies, Swansea, describes the role of osteopathy in treating acute lower back pain
As an osteopath, I see a lot of spinal based issues be it neck, mid or lower back problems. The most common spinal issues seen in clinic include disc herniation, degenerative disc disease, ligament sprains and spondylolisthesis. One of these patients is shown in a case study below:
Case Report
Mr J was a 42 year old Engineer who came to see me following a long history of low back pain, possibly from a career in martial arts and being thrown onto the floor multiple times.
He had pain waking him at night when turning in bed, lying down and standing around for long periods and his pain was relieved by yoga/pilates. He described his pain like a tight band across the lower back which radiated into his buttocks and the front of thigh. He had no pins and needles, altered sensation or numbness in the legs.
After trying conservative treatment, he was advised he needed surgery to fuse/stabilise the area and improve his quality of life. Mr J wanted to exhaust all available treatment options before commiting to surgery, as most spinal surgery has an associated risk of paralysis of around 0.1%, or one in a thousand cases. Why go straight for surgery when there are other treatment options which are risk-free?
Mr J had an osteopathy session once a week to treat the severe back pain, which responded very well to treatment. Now, Mr J comes around every 2 months for maintenance treatment involving soft tissue massage, mobilisation of the mid, lower back and hips, acupuncture and manipulation of his mid back.
Mr J finds that he can maintain his great function and pain relief with daily back exercises, which, in his case, avoids extension. He practices mindfulness meditation for sleep.
Now, Mr J is usually pain free and is only left with an occasional ache if he does too much lifting in work.
What is Spondylolisthesis?
Spondylolisthesis is a condition where a vertebrae slips forward, most commonly L4-S1, as a result of degeneration, trauma or congenital abnormalities. Signs and symptoms can include nerve pain (like sciatica), referred pain into buttocks, groin or legs, stiffness in the lower back, tight hamstrings and a step or excessive curve in the lower back, however the condition can also be asymptomatic (show no symptoms).
The most common types of spondylolisthesis are:
- Degenerative – where the facet joints at the side of the spine wear and the big strong ligament that supports the area becomes weakened (ligamentum flavum).
- Isthmic – the most common with 90% being low grade (grade 1-2) and can have 3 sub-types: pars acute fracture, pars fatigue fracture and pars elongation due to multiple healed stress fractures.
- Traumatic – e.g. from a fall or sport
There are also four grades of spondylolisthesis – grade 1 <25% slippage of the vertebrae forward, grade 2 25-50% slippage, grade 3 50-75% slippage and grade 4 >75% slippage.
Diagnosis of a spondylolisthesis is usually confirmed via standing x-ray or MRI scan. Once diagnosed, your treatment can vary from physiotherapy or osteopathy, steroid injections and exercises, through to surgical stabilisation of the area affected.
So, What is osteopathy?
Osteopathy is a method of assessing, treating and preventing a wide range of health problems. It is regulated by the General Osteopathic Council (GOsC) and it is against the law to call yourself an osteopath unless you are qualified and registered with the GOsC. The minimum qualification for an osteopath is completion of a four year degree, which includes at least 1200 hours of supervised clinical practice. They must then continue to update and expand their knowledge by logging a minimum of 30 hours per year of continuing professional development.
Osteopaths frequently work alongside other health professionals, such as Surgeons, GPs, nurses and midwives as well as alternative medical practitioners. The National Institute of Clinical Excellence (NICE) advises that GPs can safely refer patients to an osteopath for treatment and osteopathy is available on the NHS in some areas of the UK however this is still very limited. This is possibly due to a lack of knowledge from both the general public and health care professionals on what osteopathy can treat and I believe there is certainly a place for osteopathy in the NHS for the treatment of musculoskeletal conditions.
How can osteopathy help me?
Osteopaths treat a wide range of people from sports persons to office workers and from retired gardeners to pregnant ladies. We can treat conditions such as arthritis symptoms, back, neck, foot, ankle, hip, knee, shoulder, elbow pain and headaches. This is not an exhaustive list however and new evidence is coming out as the professional continues to grow.
Osteopaths use a combination of movement, stretching, targeted deep tissue massage and manipulation of a person’s muscles and joints to improve function, relieve pain and aid recovery .They can also use further techniques such as acupuncture, taping and exercise prescription, thus giving the patient a complete package.
Osteopaths work on the theory that the body has the natural ability to maintain itself and, by helping this process, an osteopath can promote restoration of normal function. The principle of osteopathy is that the wellbeing of an individual relies on the way that bones, muscles, ligaments, connective tissue and internal structures work with each other.
If you think osteopathy is for you, please visit http://www.osteopathy.org.uk/register-search/ to find a registered professional in your area.
References
In Wollowick, A. L., & In Sarwahi, V. (2015). Spondylolisthesis: Diagnosis, non-surgical management, and surgical techniques.
Institute of Osteopathy | Osteopathy works. (n.d.). Retrieved from http://www.osteopathy.org/
Kalichman, L., & Hunter, D. J. (2007). Diagnosis and conservative management of degenerative lumbar spondylolisthesis. European Spine Journal, 17(3), 327-335.
Nemani, V. M., Kim, H. J., & Cunningham, M. E. (2015). Anatomy and Biomechanics Relevant to Spondylolisthesis. Spondylolisthesis, 17-23.
Thornhill, B. A., Green, D. J., & Schoenfeld, A. H. (2015). Imaging Techniques for the Diagnosis of Spondylolisthesis. Spondylolisthesis, 59-94.
Visiting an osteopath – General Osteopathic Council. (n.d.). Retrieved from http://www.osteopathy.org.uk/visiting-an-osteopath/
Why do we slip our discs?
It’s a fact: in the Western world, 80% of people will experience back pain at some point in their lives. Almost half of Western people experience sciatica, or pain from a trapped nerve in the back.
By contrast, in developing countries, back pain and sciatica are rarely reported.
Many reasons are suggested for this big difference, including healthcare systems not recording data, secondary gains in the West for having pain eg disability benefits, genetic predispositions in different populations etc.
But, one major change that occurred coincidentally with the massive increase in spinal pain and trapped nerve symptoms was the emergence of the “white collar” worker, or office-based work. This type of industry developed in the 1930s along with urbanisation. As lifestyle changes from physically-demanding activities to more sedentary work involving lengthy times sitting down, then spinal problems have emerged as a major problem.
The World Health Organisation focussed on spinal problems in it’s overview of musculoskeletal problems experienced worldwide .
There is a lot of evidence to show that exercise helps to reduce the symptoms of spinal pain, yet, it seems that athletes are as prone to back problems as anyone else, so, why are we so prone to spinal problems?
One of the consequences of spinal pain is the industry that has grown around it. Commercialisation of back pain is a multi-billion dollar industry in North America, and a multimillion pound industry in the UK. The National Health Service employs spinal surgeons, physiotherapists and chronic pain specialists to try and address the problem, yet, in the NHS, both of these services can be regarded as a “quick fix”, whereby up to six sessions of physiotherapy can provide significant improvements in pain, but when the sessions stop, the pain returns. Surgeons can perform discectomy operations with immediate relief of pain, yet the risk of needing another operation due to a recurrent disc prolapse is around 8%. Back pain does not go away and stay away with short episodes of attention being paid to it- the spine needs life-long attention and maintenance to keep it in good working order.
The common sense advice of good posture, spinal flexibilty and stretching the spine in extension seems to have been forgotten, or somehow lost in the overwhelming amount of information available to us. The spine is designed as a spring, yet when we constantly lean forward, bend down, sit and slouch, we are encouraging our spines to adopt a flatter overall contour, eventually changing over the decades to a stiff, bent spine. The shock-absorbing discs are forced to not only bear more weight due to the forces created by “lever arms”, but the loads applied to the discs are uneven, with more loading at the front of the discs rather than the back of the discs. This eccentric loading has the effect of creating a backward-directed pressure within the discs, encouraging the disc to bulge backwards where the spinal nerves are found within the spine. Eventually, as the discs fail, back pain becomes an issue, followed by the symptoms of sciatica in the leg, or shooting pains in the arms when the discs in the neck are involved.
When the spine is used in extension as well as flexion, with correct posture allowing the spine to work as a spring and the discs to bear weight uniformly, then back pain should not develop, since the back is being used in the way that it was designed.
For those who require an MRI to investigate back pain or symptoms of sciatica, please ask to see how the muscles which extend the spine appear in comparison with the muscles which flex the spine. You will find that flexor muscles appear dark, dense and healthy in comparison with the deconditioned extension muscles. Then, ask to see the difference in muscles where the discs are at their worst- this will coincide with the greatest difference in muscles masses. A Danish study analysed the amount of fatty change seen in multifidus (one of the three extensor muscles grouped together into a complex called the “posterior paravertebral muscles”) and whether people with low back pain had more fatty infiltration of the muscle. The study conclusively showed this positive association, but could only observe this association instead of demonstrating causality. Interestingly, the same study showed that muscle deconditioning was also seen on the MRIs of teenagers, yes, teenagers. In this age-group, there was no major back pain to analyse, but doesn’t this observation raise alarm that we are neglecting our spines from a young age?
When it comes to keeping our spines fit for life, evidence to support a specific type of exercise is lacking. “We are as young as our spines”, quote the yoga and pilates enthusiasts, who pay frequent attention to posture, core strength and flexibility. There is an excellent publication which showcases the structural perfection of yoga instructors’ spines.
There is good evidence to support frequent exercise and Amazon has gifted us with unbiased patient recorded outcome measures (PROMs) for Robin McKenzie’s 35 year old publication “Treat Your Own Back”, which emphasises spinal extension (392 feedback reports, with 283 people giving the book 5 stars = 73% 5 star feedback, when accessed online April 23rd 2016).
So, it appears that we fail to pay attention to our spines from a young age, with MRI showing the deconditioning of the lumbar extensor muscles by the time that we are teenagers. Move forward a few more years and we see increasing numbers of people suffering with low back pain, followed by repeated episodes of sciatica, whereby we fail to change our ways with each episode of sciatica or acute back pain that we endure. Move forward again and we have bony changes of wear and tear due to gradual loss of disc volume, placing increasing loads on joints at the back of the spine which overgrow and become arthritic, creating the spinal condition of spinal stenosis.