What are the 7 best acupuncture points for treating acute lower back pain?

What is lower back pain?

Lower back pain is a generic term for pain that occurs beneath the ribs but above the gluteal line.

How common is lower back pain?

An estimated 619 million people worldwide live with low Back Pain (LBP), and it is the leading cause of disability (1). LBP is a major public health issue and is often associated with loss of work productivity and thus produces a huge economic burden on individuals and societies.

I am from the UK and have presented the prevalence and financial burden of lower back pain based on the UK population however, these estimates are similar in the United States, Canada, Australia, Europe, and Asia.

Lower back pain affects at least 80% of the UK population at some point in their lives and occurs most commonly between the ages of 30 – 50 years. Health Survey for England 2011 (2) found that back pain was responsible for 37% of all chronic pain in men and 44% in women. It represents the single most common and most expensive industrial and occupational health problem (3).

It is reported that the overall cost of treatment for back pain in the National Health Service (NHS) was more than £1000 million per year (3).

Low back pain affects around one-third of the UK adult population each year with around 20% (1 in 15 of the population) of these consulting their doctor about their back pain (4). This is estimated to be about 2.6 million back pain sufferers, in the UK, seeking advice about their condition from their doctor each year (5).

How many people suffer from acute, subacute, or chronic lower back pain?

A survey into the local prevalence of low back pain in Bradford was undertaken by Hillman and colleagues (6). They found that over a one-year period, 50.3% of episodes were acute (<2 weeks), 21% were subacute (2 weeks to 3 months) and 26% were chronic (over 3 months) in duration.

Most cases of lower back pain are acute but will resolve or improve within 2 weeks of its occurrence (7) however, if lower back pain does not subside within this time, it can become sub-acute or chronic. In addition to prolonged pain, many individuals with chronic lower back pain report both sleep disturbances (8-10) and depression (11). Furthermore, these symptoms are associated with a higher prevalence of fatigue (9-12).

What is the cause of lower back pain?

Due to the complex nature of the anatomy and biomechanics of the back and spine, the cause of lower back pain is varied and often poorly diagnosed.

It has been suggested that between 70%-97% of lower back pain is diagnosed as “non-specific” or “miscellaneous” where the aetiology remains unknown, 2% attributed to disc problems, and 1% to apophyseal joint disorders (13-16). The reason for this is believed to be a result of poor diagnosis and limited expertise of the clinician (17).

Degeneration of the spine as we grow older accounts for the increased prevalence of back pain in the older population. Conditions such as osteoporosis and arthritis affecting the joints of the spine are the main offenders of chronic (> 28 days) or long-term back pain in elderly patients presenting with back pain.

The percentages that have been presented increase with age from 35% of 16—24 years old to 50% of patients 65 years and over (18).

Myofascial trigger points are an extremely common cause of musculoskeletal pain affecting the lower back that is frequently overlooked or misdiagnosed by both physicians and physical therapists, thereby leading to inappropriate treatment and chronic conditions (19).

Trigger points in the quadratus lumborum, gluteus medius, and psoas muscle will refer pain to the lower back. Several studies have found that the quadratus lumborum, gluteus medius, and psoas muscle to have active trigger points in up to 85% of patients presenting with lower back pain (20-22).

Sola (23), reports that trigger points in the gluteus medius may contribute to/or simulate sciatica. Trigger points in the quadratus lumborum, hamstrings and gluteal may activate latent trigger points in the iliopsoas muscle (19).

What is the first line treatment for acute lower back pain?

Although 80-90% of lower back pain will resolve quite quickly (in 6 weeks) regardless of treatment (15, 23) this leaves 10% of cases that are at risk of developing chronic lower back pain and disability (23-25).

People with lower back pain that does not resolve generally seek medical intervention. However, diagnostic testing rarely pinpoints the cause and conventional treatments such as anti-inflammatory and muscle-relaxing drugs only offer limited relief accompanied by side effects (26). The emphasis is now on complementary medicine such as exercise and physical therapy rather than on pharmacological and surgical interventions (27).

Many patients who suffer an acute episode of lower back pain (LBP) don’t seek medical attention as the symptoms will subside within a couple of weeks. However, up to 1/3 of people who suffer acute lower back pain may experience moderate lower back pain up to a year following its onset.

Medications for acute low back pain mainly include non-steroidal anti-inflammatory drugs such as ibuprofen and centrally acting muscle relaxants such as Diazepam and Cyclobenzaprine. Muscle relaxants work by inhibiting central polysynaptic neuronal events that act indirectly on skeletal muscle.

They can be subdivided into antispasmodic and antispastic medications. Medication has a likelihood to cause adverse reactions like gastrointestinal tract injury or hepatic and renal damage.

Muscle relaxants should be prescribed with caution as they are not recommended for patients with a history of addiction as sudden withdrawal may cause delirium tremors. Acupuncture has been shown in several studies to be safe and cost-effective compared to usual care with very few adverse reactions (28-31).

The effectiveness of most of these medications for relieving acute lower back pain is yet to be established. Furthermore, continued use of these medications carries the risk of adverse effects.

What are the main symptoms of acute lower back pain?

Acute non-specific lower back pain mainly arises from acute lumbar sprain affecting the paraspinal muscles such as the quadratus lumborum, psoas and the erector spinae (multifidus) muscles. Muscle spasms and muscle guarding combined with fear of movement, pain, anxiety, and a lack of sleep all contribute to delayed recovery and exacerbation of next-day pain.

Some of the main symptoms that I see in many of my patients who come to see me with an episode of acute lower back pain are muscle guarding, stiffness, and reduced mobility. The psychological aspect of their back pain includes anxiety, worry, fear of movement, not being able to work or do day-to-day activities and a lack of sleep.

The psychological aspect of acute non-specific lower back pain is seen in many of my patients who are self-employed or in a stressful position. In many self-employed individuals if they do not have work cover there is the fear of losing customers and a loss of money.

Will acupuncture help to relieve acute lower back pain?

From my personal and clinical experience, I have found acupuncture to be highly effective if acupoints are chosen wisely for the relief of acute lower back pain. I was about to present a medical acupuncture course in Newcastle and three days before I was about to travel the 145 miles up to Newcastle my wife was unable to get out of bed with an acute episode of lower back pain.

At the time we had three young boys, a five and a three-year-old and a two-month-old. My wife was breastfeeding and was unable to bend to pick up our youngest child. This was going

to make it difficult for me to leave her to look after our children while I went to Newcastle for several days. I therefore applied acupuncture combined with stretching.

The acupuncture points were applied daily while she was standing or walking around the room. Please note, if someone has not had acupuncture before it is wise to have them lying down for their first appointment to ensure that they don’t faint. Alternatively, self-acupressure can be applied to the points.

While the needles were in place, she was advised to undertake some gentle stretching. During the three days, her lower back pain had relieved sufficiently to allow me to go to Newcastle without having to worry whether she was able to look after our young boys.

What is the effect of acupuncture on acute lower back pain?

Many studies have investigated the use of acupuncture for the management of chronic lower back pain however, there are limited good quality studies that have investigated the use of acupuncture in the management of acute lower back pain.

From my investigation, I have found that the available studies have not always chosen the most effective points for the treatment of acute lower back pain. A poor choice of points will affect the treatment outcome and the overall results of the study.

Su and colleagues (30) critically evaluated the evidence for acupuncture as an effective treatment for acute lower back pain. They identified thirteen randomised controlled trials of which eleven studies provided moderate-quality evidence that acupuncture has a statistically significant association with improvements in visual analogue scores.

Two studies showed that acupuncture did not influence the Roland-Morris Disability Questionnaire scores more than the control treatment. Three studies reported that acupuncture influenced the Oswestry Disability Index scores more than the control treatment and two studies found that acupuncture influenced the number of pills taken more than the control treatment.

From clinical experience when acupuncture points are selected in the acute phase of lower back pain to specifically address anxiety, fear, pain, inflammation, and relaxation of the muscles it has been found to be effective at restoring the quality of sleep, and quality of life and promptly returning the patient to their normal daily activity. When selecting acupuncture points for the treatment of acute lower back pain, the following factors should be considered.

  • Is there inflammation present?
  • Is the patient anxious and fearful of movement?
  • Is their quality of sleep affected?
  • Is there muscle spasm and muscle guarding?
  • Is there reduced mobility?
  • Are there active or latent myofascial trigger points?
  • Pain severity

What is the referred pain pattern?

What are the best acupuncture points to treat acute lower back pain?

GB-30

GB-30 reduces inflammation of the nerves in the region of the lumbar spine by activating the hypothalamus-pituitary-adrenal axis and increasing plasma corticosterone levels (32, 33). It has a strong influence on the cingulate cortex which is part of the pain-regulating centre thereby reducing pain-induced anxiety. GB-30 have been shown to have a strong influence on the recovery of injured nerves, motor recovery, axonal regeneration of injured peripheral nerves and an analgesic effect following sciatic nerve injury (34-38).

GB-34

GB-34 increases circulation in the lower back (39) and is used in the management of psychological disorders such as depression and anxiety (40).

SI-3

SI-3 has a significant influence on the spine. It is commonly used as a distal point for restriction in mobility of the lower back and is recommended for acute and chronic back strain (41).

Du-26

Du-26 is recommended for acute back pain and injury to the spine, lumbago, stiffness and pain of the spine, and sprain of the lumbar spine.

UB-40

UB-40 is among the most used points to treat lower back pain (41) and has been shown to be effective at increasing circulation in the lower back (39). It is known as the command point for the low back.

Liv-3 and LI-4

Liv-3 and LI-4 used together are known as the four gates and have a strong effect on the reduction of pain throughout the body by reducing activity in the limbic system and other pain-related brain areas, as well as influencing emotion, for example reducing fear, anxiety, and depression (40, 44-47). There is an increased thalamus activation when rotating the needles gently at Liv-3.

Yaotongdian

Yaotongdian (N-UE-19 or EX-UE 7) These points are specific for acute lumbar pain. Many recent studies have also shown that acupuncture at Yaotongdian alone or combined with other therapies has a curative effect in the treatment of acute LBP (49, 50).

Yintang

Yintang is an excellent distal point for acute low back pain particularly if the patient is anxious and fearful of pain on movement. This point is effective in reducing anxiety (40,42,43,51). Lin and colleagues (48) evaluate the effect of acupuncture-movement therapy compared to conventional acupuncture in the management of acute lumbar sprain. Patients were randomized into four groups: the acupuncture-movement (AM) group, sham acupuncture-movement (SAM) group, conventional acupuncture (CA) group, and physical therapy (PT) group. The acupuncture movement group received manual acupuncture at Yintang (M-HN 3) and exercise of the lumbar region during acupuncture. The results showed that following treatment the visual analogue scores and Roland Morris questionnaire scores were significantly (P<0.05) lower in the acupuncture movement group compared to the other three groups.

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