Many patients seeking acupuncture have back pain related problems. A clinical practice guideline from the American College of Physicians include recommendations of acupuncture for acute, subacute and chronic low back pain.1 Besides, chronic back pain is one of the diseases that is effective on acupuncture treatment.2 It is also necessary to approach from the perspective of traditional medicine such as meridian, five elements, organ and so on. At the same time, it is fundamental to make an integrative decision by referring to the neurological findings.
Cause of Back Pain in Primary Care
Acupuncturist encounter both acute and chronic back pain, thankfully the causes of each kind of back pain have been reported. A nonspecific musculoligamentous strain causes 85 percent of acute back pain. Other unusual potential serious causes are compression fracture (4 percent), spondylolisthesis (3 percent), herniated disc (1-3 percent) and so on.3
Similarly, 85 percent of chronic back pain is nonspecific, and only 15 percent has specific pathologic causes.4 Therefore, an acupuncturist must focus on finding the nonspecific cause of back pain in the majority (85 percent) of patients and building up an appropriate treatment strategy according to specific pathologic conditions in 15 percent of patients.
Why is a Physical Exam Necessary?
There are three essential reasons to do physical exams - the first, prognosis estimation. After taking medical history thoroughly, appropriate physical exam can be used to access the possible pathological causes and the status of surrounding connective tissue to determine the prognosis. In general, the prognosis is 2 to 4 weeks for nonspecific musculoligamentous problems, 4-6 weeks for severe instability. When there are symptoms and signs of the lower extremity, it will show prolonged prognosis. It is assumed 4-6 weeks for lower limb sensory deficit and 8-12 weeks for the weakness of lower limb muscles.
The second reason is progress observation. The pain rating scales (i.e., visual analog scale, numeric rating scale) might be helpful as well as a few questionnaires (i.e., Oswestry Low Back Pain Disability Index and Roland-Morris Disability Questionnaire). However, patients subjective can be intervened. So physical exams can help to monitor the relatively measurable progress.
The third reason is to discriminate severe cases that need further evaluation and referral. Physical exams are essential to rule out severe cases such as acute lumbar disc herniation, cauda equina syndrome, a progression of lower limb weakness which are required to visit the emergency room or the higher-level medical institution without delay.
The Eight-Step Pragmatic Physical Exam Protocol
Patients in a Supine Position 1. Sensory examination of the lower limb 2. Motor examination of the lower limb 3. Strength test of the iliopsoas muscle 4. Palpation of the iliopsoas muscle
Patients in a Prone Position 5. Compression test from the sacrum to the lumbar region 6. Strength test of the gluteal muscle 7. Palpation of the lumbar extensor muscle 8. Palpation of the gluteal muscle
Because it can be confusing and taking excessive time to change the patient's posture several times, perform all the tests that can be performed in the supine position, and proceed to the rest of test in a prone position to check the overall condition of the patient.
How to Check for Changes in Sensation in the Lower Limb
Pathology to the cord or nerve root results in the loss of light touch, followed by the loss of sensation of pain.5 Once there are neurologic symptoms such as numbness and pain, an acupuncturist can assume ahead based on history taking. However, if there is a loss of light touch without severe symptoms, it is possible to roughly determine the involvement of the nerve roots by carefully observing the sensory change of the skin segment.
First of all, we need to check out the segmental sensation of L4, L5 and S1 nerve roots which are frequently involved. The dermatome of L4 dominates the medial side of the shin(tibia), L5 dominates the lateral side of the shin, and S1 dominates the lateral side of the foot. When it comes to the acupoints, SP6 (Sanyinjiao) is in L4 dermatome, GB39 (Xuanzhong) in L5 and BL62 (Shenmai) in S1.
To investigate the light touch, an acupuncturist can use the tip of fingernails to scratch the corresponding areas of the examinee simultaneously. In the case of lower limb weakness or radiculopathy, patients show sensory loss mostly. The intensity of sensory loss is usually not so much, and the degree of sensation is often at 70 percent of the healthy side. Clinically, patients with sensory loss need more time to recover compared to the patients without it. Nakajima in Japan reported the prolonged recovery of the sensory loss patients in care series of acupuncture for cervical degenerative radiculopathy.6
Generally, 6 out of 10 patients at primary care have no remarkable sensory changes; remaining 4 of them shows sensory change. If patients have sensory change, more than half of them shows 70-80 percent compared to normal, followed by 80-90 percent and 60-70 percent each. Uncommon cases with chronic or severe back pain show less than 50 percent. Rarely, patients show hyperesthesia (patients feel more than 100 percent of light touch), when they have acute inflammation of nerve root and connective tissue.
The following article will cover the motor examination of the lower limb. I wish you all the fun of investigating our patients closely.
References
Qaseem A, Wilt TJ, et al. Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med, 2017 Apr 4;166(7):514-530.
Vickers AJ, Cronin AM, et al. Acupuncture Trialists' Collaboration. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med, 2012 Oct 22;172(19):1444-53.
Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med, 2001 Feb;16(2):120-31.
Berman BM, Langevin HM, et al. Acupuncture for chronic low back pain. N Engl J Med, 2010 Jul 29;363(5):454-61.
Hoppenfeld S. Orthopaedic Neurology: A Diagnostic Guide to Neurologic Levels. 3rd edition. Philadelphia: Lippincott Williams & Wilkins;1977:2.
Nakajima M, Inoue M, et al. Clinical effect of acupuncture on cervical spondylotic radiculopathy: results of a case series. Acupunct Med, 2013 Dec;31(4):364-7.
As modern medical standardization continues, the field of traditional Chinese medicine has the advantage of comprehensive personalization. For rare or complex cases, deeper consideration of constitution is invaluable. Proper constitutional assessment, especially with first-time clients, can guide desirable and predictable outcomes. This leads to a higher rate of return, and greater trust between you and your patient.
Though the creation of a financially sustainable, health-promoting model feels far away today, we are casting a vision for a full return on health, believing that this compels us to keep one foot firmly rooted in caring for the sick and the other foot firmly founded in maintaining health. Shifting from a fee-for-service model to value-based care using a phased approach is paramount.
Laser therapy has emerged as a powerful tool in the realm of traditional Chinese medicine (TCM). This new modality fits beautifully into the toolbox of the modern acupuncturist, as it can be used as a hybrid form of stimulation to acupuncture points, meridians, organs, nerves, and symptomatic areas in a new way that blends both moxa and energetic needle-like responses.
