Low back pain (LBP) can present as dull and achy, sore and tender to the touch, or shooting and stabbing that is referred elsewhere in the body. LBP often presents laterally along the pelvis – posterior superior iliac spine (PSIS). Low back pain can be acute with sudden onset from overuse, heavy lifting, vigorous exercise, or injury; or it can be chronic, lasting months or years. In both acute and chronic cases, pain can shoot down the leg(s). This referred, shooting pain tells a story, informing the practitioner about which sensory nerves are involved which helps to identify root cause diagnosis and treatment.
According to Urits, et al. (2019),1 “Annually, the prevalence of low back pain in the general US adult population is 10-30%, and the lifetime prevalence of US adults is as high as 65-80%.” Low back pain can originate from many sources, including nerve impingement, postural misalignment, and musculoskeletal dysfunction among others.
Often, these ailments overlap and are caused by hypertonicity of a skeletal muscle; i.e., pelvic tilt and vertebral column misalignment. An example of this is after a patient has worked out recently with a focus on lower-body strength, resulting in sore legs. This would cause the person to walk differently; and most of the time, it would cause a pelvic tilt or sacral misalignment. Although slight, this can cause an alignment issue if not treated appropriately or promptly.
Most patients hear terms such as postural or vertebral misalignment and seek chiropractic care. I have observed the effectiveness of acupuncture as complementary medicine for low back pain and have worked synergistically with chiropractors to achieve the desired results.
A chiropractic adjustment alone might work temporarily for vertebral misalignment, but if the hypertonicity of the muscles is pulling the muscles or fascia, the adjustment likely will not last because the underlying cause (hypertonicity of the skeletal muscles) was not addressed.
Acupuncture with electrical stimulation addresses the hypertonicity, which in this example would be the root cause. Electroacupuncture helps by working on the nervous system to relax the muscles. Additionally, to ease pain, electrical stimulation, set at the proper frequency, causes the body to release endogenous opioids, calms muscles and expedites healing process.2
Known vs. Unknown Structural Issues
While an MRI provides definitive information about structural issues in the back, it is not necessary for treating low back pain with acupuncture. When available, MRI results may indicate nerve root impingement, as well as the affected nerves and musculoskeletal areas; however, this should be treated as one of many diagnostic inputs for holistic, root cause treatment with acupuncture. Orthopedic and neurological assessments (described below) should be conducted as additional diagnostic inputs.
If it is unknown whether the patient has a structural issue, acupuncture is not going to exacerbate the structural issue if it exists – it will not make anything worse. As stated by Sudhakaran (2021), “Beneficial effects of acupuncture on musculoskeletal pain are well-documented. In 2 patient-level meta-analyses of randomized clinical trials involving 18,000 and 21,000 patients with chronic musculoskeletal pain, acupuncture was substantially more effective than standard care and significantly better than sham acupuncture.”3
Regardless of MRI results, an orthopedic and neurological assessment for the lumbar and pelvis will help determine the origin of referred pain and give the practitioner a better understanding of how best to treat the patient. If the MRI shows negative for structural issues (herniated or bulging disc with or without nerve impingement), the patient could still be suffering from neuralgia or neuritis/sciatica; the patient can have nerve pain without a structural problem.
For example, the MRI can show no structural issues and the patient can have piriformis syndrome. Without an MRI, these assessments will inform the practitioner whether it is likely there is a herniatied or bulging disc.
Assessment and Examination
Before conducting any orthopedic or neurological assessments, it is necessary to ask the patient questions about their urinary and bowel health. Low back pain can sometimes be indicative of a more serious condition known as cauda equina syndrome; some questions that should be asked of the patient related to urinary or bowel issues include the following:4
If the patient has an acute (new) inability to urinate or pass stool, or erectile or sexual dysfunction, the patient should be referred to the emergency room immediately (Park, 2020).
If the answers to questions indicate no need to refer to the emergency department, then begin orthopedic and neurological assessments. Matt Callison’s straight-leg raise is useful for testing to see if there is a herniation pressing into the neural space or to determine whether there is neural impingement. Although the path of the referred/shooting pain can indicate which nerve root is involved, it is advisable to conduct a neurological motor assessment to know exactly which nerve root is involved.
A positive orthopedic test does not necessarily mean that there is disc herniation; it could be musculoskeletal – muscles putting pressure on a nerve.
After the orthopedic assessment, and non-dependent on the results of the orthopedic assessment, conduct a neurological motor assessment to determine whether there is nerve impingement. This motor examination5 from the University of Pittsburgh is a protocol for the evaluation of key muscles in the lumbar and sacral regions:
The orthopedic and neurological assessments serve as additional inputs to identify the root cause of the patient’s pain and discomfort.
Acupuncture Protocol for Low Back Pain
Once all assessments are complete and the root cause has been identified, proceed with acupuncture treatment. The following is a protocol that I use regularly for low-back pain patients:
If the patient has spasming low back pain, begin with Yao Tong Xue (located on dorsum of hand, located between second and third and fourth and fifth metacarpal bones) and have the patient move around, gently swaying their hips so their spasming low-back muscles will start to release. This does seem to be effective to make the patient more comfortable getting onto the treatment table prior to their acupuncture session.
For other non-spasming low back pain, open the governing vessel: SI 3 and BL 62. Then proceed with BL 60 (bilateral), BL 40 (bilateral), BL 53 (bilateral), and BL 23 (bilateral).
Depending on the results of the neurological assessment, needle Hua Tuo Jiaji at the affected nerve root. Apply e-stim from BL 23 to BL 53. Set e-stim to 2-4 hertz on dense disperse and bring the level to a moderate yet comfortable level for 20 minutes of needle retention.
When to Refer Out a Patient
There are times when it is necessary to refer a patient to other physicians or service providers. Some examples include:
Clinical Takeaway
According to Sudhakaran, “low-back pain affects 84% of the world’s population. At present, no method of treatment can be considered as the method of choice. Acupuncture is effective, scientific, cost-effective, and free from major side-effects.”3
We as practitioners should know how to treat and assess to bring the most relief for our patients. Low back pain can be assessed for the root cause; and treated with or without an MRI or other confirmation of structural issues. Using the orthopedic and neurological assessments that were discussed, the practitioner will be able to determine root cause of low back pain and treat it using acupuncture.
The use of acupuncture has proven itself to be a safe, yet affordable treatment alternative that is complementary in nature and works synergistically with other health care practitioners like chiropractors, physical therapists, and orthopedic physicians. The practitioner also knows what questions to ask to assess whether there is a more emergent issue requiring an MRI, referral to the emergency room, or referral to an orthopedic physician or other specialist.
Finally, the acupuncture treatment protocol can be used to treat low back pain, regardless of etiology and whether there is an MRI with or without confirmation of structural issues. Patients’ bodies tell us stories about what is causing the problem at hand; we must listen and assess appropriately to treat the root cause.
References
Governor Gavin Newsom has retracted the proposed budget cuts to the Medi-Cal acupuncture program for low-income Californians for the 2024-2025 budget year. This decision marks a significant victory for health care providers and advocates who have long championed acupuncture as a vital component of comprehensive medical care.
There’s no doubt that many of your patients visit your practice because they are in pain. And there’s certainly no doubt that curcumin from turmeric (Curcuma longa) can be incredibly effective in stopping that pain, whether due to chronic conditions like arthritis or acute pain from intensive workouts. But your patients may also benefit from curcumin for other reasons.
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Fair and appropriate wages in health care are typically based on economic evaluations. A simple literature review illuminates that acupuncture is missing economic evaluations; which implies you are either underpaid or overpaid. The complexity of services provided by most American acupuncturists, which they are trained and certified to provide, must be reimbursed fairly.
