Acupuncture in Managing Chronic Low Back Pain - Case Study Example

Use of Acupuncture as an Adjunct Tool in the Management of Chronic Low Back Pain: A Case Study Introduction:Chronic low back pain is a global health challenge. The incidence of the ailment has led to increased medical costs. In addition, there is much debate concerning the most effective approach to manage chronic low back pain. On the other hand, acupuncture has featured in managing many conditions, and there is empirical evidence, which states that it can help in managing chronic low back pain. Purpose:This study uses a case study approach to use acupuncture in the management, and subsequent treatment of chronic low back pain. There is evidence that acupuncture is an appropriate technique to manage the condition. This study also employs a semi-standardized approach to achieve the objective. Methods:This study employs a comprehensive search strategy. The study relied on medical databases, and the medical subject included “acupuncture therapy,” “use of acupuncture,” “effectiveness of acupuncture,” “acupuncture and chronic low back pain,” and “chronic low back pain.” The study included studies, which included case studies that employed randomized controlled trials. Results:Many prior studies support that acupuncture has the capacity of managing chronic low back pain. In addition, case studies, which utilized randomizedtrials suggest that acupuncture is more effective in terms of managing pain, than no acupuncture in patients with chronic low back pain. Conclusion:Apparently, chronic low back pain is a global health problem, and many treatment approaches are used to treat patients. Of all the approaches, acupuncture is thesingle-most effective management technique in the short-term. Introduction Chronic low back pain (CLBP) is a major health problem, but its effect is prevailing in the developed countries. The condition is the major cause of increased medical expenditures, absenteeism and disability (Furlan et al., 2005). Prior studies suggest that more than 50% of adults experience back pain every year, and the condition afflicts 70-80% of adults at some time in their lives. In addition, back pain symptoms are the main cause of the many visits to orthopedic surgeons. Empirical statistics also show that back pains are the leading symptomatic reasons for the many visits to physicians. Various structures can contribute to the chronic low back pain. They include the joints, discs and the connective tissues. Patients with acute low back pain recover promptly, with 60-70% recovering by 6 weeks. However, when this condition goes past 12 weeks it becomes chronic. There have been evidenced guidelines, which suggest ways of managing low back pain (Manheimer et al., 2005). There are several publications across the world on the same, and all aim at improving the patient health outcomes. Notably, many available therapeutic treatments, but it is unclear from the guidelines, which approach is suitable in managing the non-specific low back pain. Recently, a NICE publication suggested that there is a need of a structured, self-management therapy, such as acupuncture to help manage the condition (NICE, 2009). In this regard, the practice has become the popular alternative treatment approach used by patients with low back pain because it has shown to be effective in relieving pain (Norheim, 1996). Case Study In this study, I borrow the case study, which referred to a 45-year-old man presented to an osteopath. The man had a 7-year history of central LBP because of a rupture to L2 vertebra. Prior to this, the man had a T7 fracture when 18 years. Treatment involved fitting of Harrington rods being fitted (from T1 to L2), which were later removed at the time of L2 fracture. The subject suggested that he enjoys doing simple things; however, his condition has made him retract from continuinghis leisure activities, which include biking and manual labor. The subject complained of pain in his low back, balance difficulties and lack of energy. In addition, he experiences disturbed sleep. Overview of the Case Evaluation of the subject was central to (ROM) in all planes at the lumbar backbone (LSP). There was an increase in kyphosis, but reduced ROM in the thoracic spine, which resulted tooverloading of the lumbar epiphyseal joints. This was apparent in the thoracolumbar and lumbosacral areas. Neurological symptoms included minor UMNL (up going plantar response) on the right (from T7 injury). During palpation, the thoracolumbar section, L1-2 plus lumbosacral section showed reduced ROM and bigger tone and inflammation in the Para-spinal muscles and Quadratus Lumborum bilateral. Notably, there were some scar tissue tethering and fascial tightening over the lumbar region. Diagnosis followed a subjective and an objective evaluation, to include secondary osteoarthritis of thoracolumbar, L1-3 because of tissue destruction to L2 with respect to initial fracture and current changes to thoracic kyphosis. Acupuncture featuredas the appropriate treatment for pain management.The technique aimed at reducing pain, improving functioning, and well-being (Thomas et al., 2006). Clinical Analysis Injuries sustained by the subject have long-term effects such as spondylosis and osteoarthritis of the lumbar spine. Apophyseal arthritis results from spondylosis. Research has stated that it can be a very independent disease. The subject underwent a fracture and surgical intervention, and removal of the Harrington rods. This led to secondary osteoarthritis of the thoracolumbar region and lumbar spine. The accident made the spinal curves depreciate, which results to extra stress and weight on the lower lumbar region. However, understanding the pathophysiology will help in subsequent pain management (Furlan et al., 2005).The capsules of lumbar apophyseal joints are having ample encapsulated, free nerve endings, hence, can transmit proprioceptive and nociceptive information (Brandnam, 2003). In addition, free nerve endings are also present subchondral bone of the joints. Substance P has also been present throughout the structures. Wound healing follows a harmonized process of overlapping activities, which lead to different degrees of structural and functional healing. Wound healing re-establishes regular function with a regimented, negligible scar. However, subsequent damage to the skin via surgical wounds may cause functional and psychological difficulties for patients. Mechanical stress may result to tissue re-modeling. Augmented stress due to overuse can result to changes in the connective tissue. A chronic increase in stress can result to micro-injury and inflammation. Alternatively, a steady lack of stress results to fibrosis, adhesions and contractures. Anyway, fibrosis can be the direct result of hypermobility or indirect through wounds and irritation. Additionally, myofascial trigger points due to a reduced tissue pH, and increased inflammatory cytokines may contribute to fibrosis and hypermobility. Therefore, connective tissue fibrosis is harmful because it results to tissue constraints and injuries in the long term. Nociceptive neurons found in the connective tissues react to changes (Brandnam, 2003). Secretion of Substance P from sensory C-fibers in the skin can improve the generation of histamine and cytokines. Cytokines motivated by tissue injury and histamine secretion increases fibroblast generation resulting to tissue fibrosis. This shows that nociception activation can deteriorate stiffness and impairment. Acupuncture addresses pain management through the Traditional Chinese Medicine concepts, for instance, meridian acupuncture points. There is evidence, which supports the effectiveness of acupuncture in managing pain by stimulating (via deQi) Aδ and C-fibres. The c-fibres communicate with the dorsal horn in the spinal cord, brain stem, hypothalamus and periaqueductal grey (PAG) (Thomas et al., 2006). To influence the trigger points, acupuncture employs ‘dry needling.’ The Trigger points are myofascial sensation that produces sensory, motor and autonomic signs. Dry needling techniques use similar needles used in acupuncture, but the needle is ‘pistoned’ to fit, and provide normal functioning of the muscle. The needle fits in trigger point region, aiming to imitate the major signs. It is possible to feel muscle twitch, which enables the achievement of the needle grasp. Prior studies suggest that this technique stimulates Type II and III afferents, which result in numbness. The needle works to interfere with the endplate, which reduces pain. Evidence In terms of cost, several studies have analyzed the cost-effectiveness of the approach. In so doing, the studies have found out that the approach is cost-effective. The NICE guideline supported the use of acupuncture. The guideline recommends the use of the approach as a course, which constitutes 10 sessions in a timeframe of 12 weeks. The guideline further supports the notion that the approach is beneficial for patients, and cost effective (NICE, 2009). A wide variety of evidence supports the effectiveness of acupuncture in the treatment of chronic low back pain (Chou et al., 2007). Another study strongly states that acupuncture relieves chronic low back pain. It does so in a lasting manner, when compared to other orthopedic approaches. Some of the conventional approaches include bed rest, stretching, physical exercises, muscle relaxing, and anti-inflammatory medications. Acupuncture led to reduction in symptoms of chronic low back pain. It has the capacity to reduce the symptoms after the first treatment session. Specifically, acupuncture led to the reduction of symptoms after about 4-6 weeks. Patents describe the pains as sharp, stabbing, burning and aching pain. Patients gave their response based on this description of pain. On the other hand, acupuncture led to improved physical activity. Patients experience increased energy and physical activities. The patients’ physical activities prior to the treatment sessions, and after, were compared. The comparisons showed improvement, and, therefore, suggested that acupuncture is effective. In addition, acupuncture brought about relaxation. This is a sign of wellbeing, which helped the patients clear their mind in the course of treatment sessions (Witt et al., 2006). Acupuncture has the ability to reduce the psychological issues, especially those resulting from pain. This included reduction of stress, which contributes to worse situations, such as reduced physical activities. In the same context, other evidence strongly supports the effectiveness of the acupuncture approach (Yuan et al., 2008). The study does not stipulate the category of pain, but it suggests that the approach is effective in the management of pain. Acupuncture’s safety profile comprise of low incidences of transient pain, which comes from needling, dizziness, bruising or disoriented feelings. Studies support the use of acupuncture and suggest that it can play an adjunct role in regards to other medications associated with pain. For instance, acupuncture has shown to be effective in reducing the prevalence of opioid-related side effects, which include nausea, dizziness, sedation, and urinary retention (Liu et al., 2009). Rationale Many studies have described semi-standardized acupuncture points for low back pain. The table 1 provides the acupuncture points. Many studies use the Bladder (BL) meridian as it has local points to the spine, and it is possible to add to the segmental model followed by the management technique. On the other hand, the Gallbladder (GL) and BL meridian follow peripheral nerve levels that coincide with the levels of the spine. Using these two points helps to enhance the analgesic effect. The table also borrows other points from prior literatures. Physiological reasoning Table 2 illustrates the applied treatment. In the table 1, selection of the acupuncture points was central to acupuncture principals. In the case study provided, the pain is central to nociceptive pain. Selection of local and distal points aimed at affecting the pain. On the other hand, BL provides for segmental approach because the points are at the spine. BL23 and BL25 work to reduce LB. There was an addition of points, such as HJJ and GV (Brinkhaus et al., 2006). The points qualify as spinal points, and they magnify the effects in a localized manner. Distal points initiate supra-spinal pain and induce inhibiting effects to the same. In turn, this further inhibits pain from the PAG, pineal gland, hippocampus and hypothalamus by producing serotonin, norepinephrine, oxytocin, melatonin and adrenocorticotrophic (Furlan et al., 2005). Outcome Measurements and Results The Numerical Pain Rating Score (NPRS) during the onset of the medication was on mean 6/10, and there was hampering of lumbar movement owing to rotation and flexion. In the 6th treatment session, there was a reduction of the rating to 4/10. Owing to this, the subject was in a position to perform during the day. For instance, he was able to undertake biking as before, only that this time he had not done this for over six months. At the fourth session, the patient experiences improved sleep patterns (Brinkhaus et al., 2006). The table 3 provides the results from the case study. Conclusion and Limitation Chronic low back pain remains a global health challenge. The case provided in this study is a typical example, which supports the effectiveness of the acupuncture treatment approach. Even though this is the incident, there is a need for advancedinvestigation on the same to ascertain the measure of effectiveness. A significant limitation in this study is the exclusion of other spinal points such as SP21 (Furlan et al., 2005). This point has the capacity to improve thoracic function. Apparently, there were positive results from the fourth session, and sixth session. In addition, continued sessions will improve the condition. Overall, this paper relies on already conducted studies; therefore, it is possible that it will contain inauthentic information. Some of the studies are old, and there is a need of future experimental research to ascertain the effectiveness of acupuncture. Discussion This case study presents a typical example of managing a chronic low back pain patient using acupuncture. Studies suggest that in the immediate, acupuncture can reduce pain for chronic low back pain. When compared to other therapies, acupuncture is effective in decreasing pain. However, when applied in line with other therapies, there was improvement. However, the lack of defining chronic low back may have resulted poor results. The current study supports the use of acupuncture management of chronic low back pain. Formation of scar tissue and fibrosis resulted to tightening and limitation of mobility of the underlying lumbar erector spinal muscles, hence, dysfunction. The deactivation of trigger points enhanced ROM. On the other hand, the traction of the lumbar apophyseal articular joints enhanced the joint health in reference to the present case study. Acupuncture analgesia improved gate mechanism, which helped the patients’ levels of pain. Therefore, it is conclusive: acupuncture can improve the wellbeing chronic low back pain patient. All the same, it is vague as to what degree the acupuncture has improved the condition of the patient. This is because it was not possible to measure psychological components. Therefore, positive support in acupuncture can have a positive influence in getting better. However, this patient had received messages that he would experience pain in the long-term. Therefore, it is possible that there were doubts in the patients’ expectations of acupuncture. The results from the case study were beyond the standard level of hopes. The subject showed musculoskeletal challenges. To realize the objectives of this paper, the subjects’ ailments needed breakdown to manageable areas. This would make it possible to help the patient recover. Although this controverts acupuncture and osteopathic essentials, the study depended on existing and evidence in acupuncture. In the future, I recommend holistic viewing of the patient and evaluation. Besides, it would be appropriate to expand the needlepoints to include the whole person and not parts of the person. Acknowledgement This study acknowledges the contribution of prior studies because the current paper has greatly borrowed from the studies. Alternatively, the paper acknowledges the effort of the authors, especially those that carried out experimental studies. Bibliography Brandnam, L. (2003).A Proposed Clinical Reasoning Model for Western Acupuncture.New Zealand Journal of Physiotherapy, 31(1), pp. 40-45. Brinkhaus, B et al. (2006). Acupuncture in patients with chronic low back pain. Archives of Internal Medicine, 166, pp. 450–457. Chou, R. et al. (2007). Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), pp. 478–491. Coeytaux, R. R., & Garland, E. (2013). Acupuncture for the Treatment or Management of Chronic Pain.N C Med J, 74(3), pp. 221-225. Furlan, A. D et al. (2005). Acupuncture and dry needling for low back pain: an updated systematic review within the framework of the Cochrane collaboration. Spine, 30(8), pp. 944-963. Hopton A, Thomas K, MacPherson H (2013) The Acceptability of Acupuncture for Low Back Pain: A Qualitative Study of Patient’s Experiences Nested within a Randomized Controlled Trial.PLoS ONE, 8(2). Hutchinson, P. J. A. et al. (2012). The effectiveness of acupuncture in treating chronic non- specific low back pain: A systematic review of the literature. JOSR [Online] http://www.josr-online.com/content/7/1/36 (accessed March 8, 2014) Liu, T. et al. (2009).A meta-analysis of acu­puncture combined with opioid receptor agonists for treatment of opiate-withdrawal symptoms. Cell MolNeurobiol, 29(4), pp. 449- 454. Manheimer, E et al. (2005). Meta-analysis: acupuncture for low back pain.Annals of Internal Medicine, 142(8), pp. 651–663. NICE Guideline.(2009). Low back pain. London, UK: National Institute for Health and Clinical Excellence. Norheim, A. J. (1996). Adverse effects of acupuncture: a study of the literature for the years 1981-1994. J Altern Complement Med, 2(2), pp. 291-297. Thomas, K. J et al. (2006). Randomized controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain. BMJ, 333(7569), pp. 623-626. Yuan, J et al. (2008). Effectiveness of Acupuncture for Low Back Pain: A Systematic Review. Spine, 33(23), pp. 887-900. Witt, C. M., et al. (2006). Pragmatic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain. Am J Epidemiol, 164(5), pp. 487-496. Appendix Acupoint Dermatome covered BL 20 to 34 L1 to S2 BL 50 to 54 S1 to S2 GB 30 S1 GV 3 to 6 L3 to S1 HJJ at lumbar spine Distal Points SI 3 C5 BL 40, 60, 62 S1 to S2 KID 3 S2 GB 31, 34, 41 L5 to S1 GV 14 and 20 C2 Table 1Borrowed from Brinkhaus, B et al. (2006).Acupuncture Points Treatment Rationale Week 1 Treat 1 There were reduced pain levels, and the patient experienced improved sleep. Patient’s introduction to acupuncture, in the stage there was avoidance of local overstimulation. LIV3 B, LI4 B – identified as the vital analgesic points. Insomnia LIV3 – The cardinal point for nervous system Dry needling to Multifidus B L2-3, L4-5 Week 1 Treat 2 LIV3 B, LI4 B – Primary analgesic points,Sleeplessness BL23 B – experiential point for back pain and origin of all Qi BL21 B – application of segmental approach, dorsal horn inhibition Dry needling to Quadratus Lumborum and Latissimus Dorsi right Week 2 Treat 3 LIV3 B, LI4 B – Significant analgesic points,Sleeplessness BL23 B – experiential point for back pain BL21 B – segmental approach, and inhibition of dorsal horn HJJ BL23 B, BL21 B – Spinal pain, segmental and inhibition of the dorsal horn GV 4 - Spinal pain, segmental and inhibition of the dorsal horn Week 2 Treat 4 LIV3 B, LI4 B – Major analgesic points,Sleeplessness BL23 B – empirical point for back pain BL21 B – segmental approach, inhibition of the dorsal horn BL22 B – segmental approach, inhibition of the dorsal horn HJJ BL23 B, BL21 B, BL22 B – Spinal pain, segmental and inhibition of the dorsal horn GV 4 – Spinal pain, segmental and inhibition of the dorsal horn BL62 – Point for back pain, poor coordination in lower extremity GB34 – He Sea point, tissue healing, increase blood flow to hypothalamus Week 3 Treat 5 LIV3 B, LI4 B – Major analgesic points,Sleeplessness BL23 B – empirical point for back pain BL21 B – segmental approach, inhibition of the dorsal horn BL22 B – segmental approach, inhibition of the dorsal horn HJJ BL23 B, BL21 B, BL22 B – Spinal pain, segmental and d inhibition of the dorsal horn GV 4 – Spinal pain, segmental and inhibition of the dorsal horn BL62 B – point for back pain, poor coordination in lower extremity BL60 B – distal point for back when lower extremity involved GB34 B – He Sea point, tissue healing, increase blood flow to hypothalamus Week 3 Treat 6 LIV3 B, LI4 B – Major analgesic points,Sleeplessness BL23 B – empirical point for back pain BL21 B – segmental approach, inhibition of the dorsal horn BL22 B – segmental approach, inhibition of the dorsal horn HJJ BL23 B, BL21 B, BL22 B – Spinal pain, segmental and inhibition of the dorsal horn GV 4 – Spinal pain, segmental and inhibition of the dorsal horn BL62 B – point for back pain, poor coordination in lower extremity BL60 B – distal point for back when there is inclusion of the lower extremity GB34 B – He Sea point, tissue healing, increase blood flow to hypothalamus, deactivate limbic system Table 2 Borrowed from Brinkhaus, B et al. (2006). Treatment and acupuncture rationale Treatment Outcome 1 NPRS 6/10 2 NPRS 6/10 3 NPRS 5/10 4 NPRS 5/10 5 NPRS 5/10 6 NPRS 4/10 Table 3Results from the study Read More