Acupuncture: A Viable Treatment for Back and Neck Pain

Introduction

Back and neck pain, experienced by individuals worldwide, is the leading cause of disability that stops many people from being able to go to work, or to enjoy everyday activities (Hoy et al., 2010). Acknowledged as one of the most common reasons for work absence, over one-half of adults working in the United States report experiencing back and/or neck pain symptoms annually (Valfors, 1985). Back pain is not just a problem found in the aging population, it affects people of all ages; from children to seniors (Rubin, 2007), making back pain the third most common reason for visits to the doctor’s office (St. Sauver, 2013). Unless the pain is due to more serious conditions, such as infection, arthritis, bone fracture or cancer, there is very little physicians can do other than writing a prescription to help alleviate the suffering. Of the many pharmaceutical interventions available, which include nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, analgesics, opioids, narcotics and muscle relaxants; many carry significant risks and side effects. More recently, people are looking for complementary and alternative treatments for pain, that will correct the problem, promote healing and prevent reliance on pharmaceutical drugs. One such intervention is the use of acupuncture, found in the centuries old practice of Traditional Chinese Medicine (TCM).

Traditional Chinese Medicine carries a strong belief in the relationship between environment and the function of the body; where all illness is seen to have started with an imbalance of energy, known as qi, and is contextualized in a whole person approach (Bensoussan and Myers, 1996). Within TCM, a hands-on modality which has been shown to be highly effective in pain management is acupuncture. Acupuncture involves the use of fine needles, inserted into the body at very specific points along energy pathways called meridians (Micozzi, 2015). This process is believed to adjust and alter the body's energy flow into healthier patterns through stimulating the body’s own healing abilities, which researchers are finding to be very effective in pain management. From the point of view of Western medicine, acupuncture aids in pain remediation by stimulating the nerves within muscles to boost the body’s response to pain, improving blood flow to muscles, and activating the nervous system to release natural pain killers called endorphins (Han, 2004).

This paper will examine acupuncture techniques used in pain remediation in patients with neck and back pain, and present findings on the efficacy of treatment protocols. Presented will be two varying techniques within TCM and acupuncture, which utilize ah shi points (meaning tender alarm points): channel theory, and jingjin pathways.

Channel Theory

Channel theory in TCM, rooted in the Yellow Emperor’s Inner Classic, is a historically important milestone in medical thinking (Wang & Robertson, 2008). Before the Inner Classic emerged in China, prior to 100 B.C., much of the medicine being practiced linked disease to invasions of the body by demonic entities (Wang & Robertson, 2008). New emerging ideas of the Inner Classic period asserted that disease, the human body, and the practitioner together form a triad, all of which were equally important in the healing process (Wang & Robertson, 2008). It became vital for practitioners to understand how organs were affected by disease, and how to re-establish health in the process of recovery (Wang & Robertson, 2008). The key element in this new way of thinking involved visualizing the body as “a system unified by a network of channels which have discrete pathways connecting the organs, and processes by which the body interacts with the environment” (Wang & Robertson, 2008, p.XX).

A significant component in channel theory involves knowledge of the function of the body, so that a greater understanding can be achieved during diagnosis. Developing hands on skills to touch or palpate the channels which pass along the body surface, practitioners will “feel the nodules, tightness, softness, and other irregularities” (Wang & Robertson, 2008, p.XXII) in order to prepare an informed treatment protocol.

Jingjin Pathways

Jingjin pathways are a network of secondary meridians associated with each of the main meridians in TCM, of which there are 12 (Legge, 2010). The jingjin are the muscles’ external source of energy, and they control movement of the extremities, flexing and extending at the joints, and holding the body erect: they protect the body from trauma (Legge, 2010). The pathways have specific tissues, muscles and tendons associated with each, and those within a specific pathway “share many structural, biomechanical, and neuromuscular features” (Legge, 2015, p.256). Jingjin pathways begin at either the hands or feet, and travel to the head or trunk of the body. They are superficial pathways; therefore, they contain wei qi, or energy that only represents the immune system.

While jingjin theory is part of the core TCM literature, it is rarely used in diagnostics or clinical application (Legge, 2010). Curiously, jingjin pathways do not appear in the Classic of Difficulties, and are also not mentioned in English translations of medical texts in successive dynasties.

Supporting Studies

Acupuncture has been accepted worldwide, as a complementary and alternative medicine, in the treatment of chronic and acute pain (Han, 2004). The traditional medical community accepted acupuncture for use in pain control beginning in the 1970s, when reports from China on acupuncture anesthesia created much interest in the West. This resulted in pain management as “one of the most widely researched applications of acupuncture” (Micozzi, 2015, p.412). 2005 Meta-Analysis

A meta-analysis published in 2005, consisting of 33 independent research studies utilizing acupuncture in pain management, found acupuncture to be effective in relieving chronic low back pain and suggested that “acupuncture is more effective than other active therapies” (Manheimer, White, Berman, Forys, & Ernst 2005). Analysis of the data from these randomized trials on chronic low back pain showed that acupuncture was “statistically significantly more effective than either of two common controls (sham and no-additional treatment), in both short- and long-term effects” (Manheimer et al., 2005, p. 656). The results however for short-term and long-term acute pain showed that the chosen acupuncture protocol had no advantage over other active therapies (Manheimer et al., 2005).

2002 Double Blind Trial

Further evidence highlighting the beneficial effects of acupuncture for the treatment of pain is offered in a 2002 randomized, double-blind, sham-controlled crossover trial study, where researchers evaluated the immediate effects of dry needling and acupuncture at distant points in chronic neck pain (Irnicha et al., 2002). This study looked at 36 patients experiencing limited cervical spine mobility and chronic neck pain, where acupuncture and a sham procedure were evaluated as to the efficacy of the improvement of symptoms (Irnicha et al., 2002). Subjects were selected from patients who attended the Department of Physical Medicine and Rehabilitation, and the Interdisciplinary Pain Unit at the University of Munich (Irnicha et al., 2002). The procedure involved “needle acupuncture at distant points, dry needling of local myofascial trigger points and sham laser acupuncture” for each of the 36 patients (Irnicha et al., 2002, p.83). The outcome measures utilized in this study consisted of motion-related pain intensity and range of motion (Irnicha et al., 2002). Additionally, an 11-point verbal rating scale was used to score the patient’s changes in general complaints (Irnicha et al., 2002). Assessment of patients took place immediately before and after treatments, and were conducted by an independent investigator (Irnicha et al., 2002). In order to assess the effects of the acupuncture and selected needling sites, an independent multivariate analysis was used (Irnicha et al., 2002).

Initial assessment included collection of baseline data, followed by a detailed examination (Irnicha et al., 2002). Inclusion was based on two criteria: neck pain lasting longer than 2 months, and myofascial or irritation syndrome. Exclusion criteria removed those with “radicular cervical syndrome, segmental instability, fracture or surgery of the cervical spine, contradictions to acupuncture, or if they had had any kind of drug treatment, physical therapy or manual treatment in the prior 4 weeks” (Irnicha et al., 2002, p.84).

The specific treatment protocol provided one of three treatments lasting 30 minutes each, to each participant, and included “non-local needle acupuncture at distant points, dry needling of local myofascial trigger points and sham laser acupuncture” (Irnicha et al., 2002, p.84). Treatments were scheduled one week apart for a total of three weeks, and were randomized through assigning sequence numbers from 1 to 6. Neither the patient nor the practitioner knew whether the treatment was legitimate or sham (double blind) (Irnicha et al., 2002).

The acupuncture was performed by two licensed therapists with more than eight years of experience, using sterile needles, while the sham laser acupuncture utilized a less experienced acupuncturist with only two years experience (Irnicha et al., 2002). No additional treatment was allowed. The acupuncture points varied in each participant and were selected according to the theory of channels (Xinnong, 1987) which requires “experience in palpation and localization of taut muscle bands and myofascial trigger points” (Irnicha et al., 2002, p.85). In this study, ah shi points located on “the most important muscles of the head and neck”, were needled and manipulated, “until at least one local twitch response was elicited” (Irnicha et al., 2002, p.85).

Thirty-four of the 36 patients completed the trial, whereby “27 patients (79.4%) were diagnosed with myofascial syndrome, seven patients (20.6%) with cervical irritation syndrome, and the remaining 10 patients (29.4%) having had a history of whiplash injury” (Irnicha et al., 2002, p.87). It was noted that the sequence of the different treatments had no bearing on the results obtained. A limitation of this study involves a lack of information on how long the pain relief was experienced by patients after treatment. Insight into the underlying physiological mechanism of the pain may have been garnered with additional post-treatment measurements (Irnicha et al., 2002).

The 2002 study concludes that “acupuncture has specific effects on motion-related pain and range of motion in those patients with chronic neck pain” (Irnicha et al., 2002, p.87). It is noted that point selection appears more significant with distant points over local points in the improvements seen, and in fact local points seem ineffective in obtaining lasting pain relief (Irnicha et al., 2002). Statistically and clinically relevant, are the changes in pain score in the non-local needle acupuncture group, which confirms acupuncture at distant points to be a viable treatment for pain relief with immediate onset (Irnicha et al., 2002). Ineffective, was the dry needling of the myofascial trigger points, however this may be due to the level of discomfort and soreness experienced by patients using this particular treatment protocol, which was found to last several hours afterwards (Irnicha et al., 2002). Patients experiencing chronic pain tend to favor immediate results, so further study is indicated that would take into account this soreness factor (Irnicha et al., 2002).

Immediate pain reduction may be the motivating factor of the patient to persist with further treatments, nevertheless from a clinical point of view, the lasting effects are more significant and desired in comparison to short term relief (Irnicha et al., 2002). Overall, acupuncture proved to provide positive effects on pain and mobility, and therefore can be assumed to be a good initial or adjunct treatment option (Irnicha et al., 2002).

2015 Case Study

An individual case study by David Legge, “Acupuncture Treatment of Chronic Low Back Pain by Using the Jingjin (Meridian Sinews) Model”, details results achieved after a single jingjin acupuncture treatment that provided continued relief from chronic low back pain (Legge, 2015). The jingjin model comprises a treatment protocol that “involves needling the ah shi points in the myofascial tissue along the jingjin pathway” (Legge, 2015, p.255). Legge, after study of each of the jingjin pathways, selected the bladder jingjin to work with, knowing that this pathway was related not only to the affected tissues in his patient, but also to the central nervous system.

There are two clinical benefits to the jingjin model. As the most common cause of musculoskeletal pain, the first benefit is found in “facilitating the successful treatment of pain caused by myofascial trigger points” (Legge, 2015, p.257). The second benefit of using the jingjin model is to needle tight chains of tissue in order to reduce strain and ultimately relieve the associated pain (Legge, 2015). The relationship between low back pain and hamstring tightness, while recognized, is largely misunderstood (Rebain, Baxter, & McDonough, 2002).

The patient in this case study, a 69-year-old woman, suffering back pain for over 40 years, experienced relief within a day of the treatment, and was still free from pain at the time Legge prepared the case study report five months later (Legge, 2015). The patient recalls lifting a very heavy load almost four decades prior, which was the incident initially responsible for her chronic pain (Legge, 2015). The pain intensity was recorded between an eight and nine on the visual analog scale for pain, with episodes causing the patient to frequently miss work (Legge, 2015). Examination revealed tightness in the hamstrings and restriction of lumbar movement, while imaging showed several issues involving the S1 and S2 vertebraes including some fusing and a rudimentary disc (Legge, 2015). At a routine visit in August of 2014, the patient expressed that she was experiencing an uncomfortable tightness in her hamstrings (Legge, 2015). After examination of the patient, Legge began the acupuncture treatment by “inserting several needles into the tender ah shi points on the upper calf and hamstrings, both lateral and medial, to depths of 1 to 1.5 cun, so that the needle penetrated the tender tissue” (Legge, 2015, p.256). Relief of the pain caused by tightness of the hamstring, as well as the initial low back pain the patient had experienced for 40 years, had subsided to a minimum within 24 hours of the treatment (Legge, 2015). From the time of the patient’s last visit, which was five months prior, the pain had ceased, the patient experienced relief from morning stiffness, and the spasming in her low back and thoracic spine had been remarkably reduced (Legge, 2015).

When considering the success of this particular treatment it is important to examine how the result was achieved. Legge provides two possible explanations for our consideration. First, there is a possibility the treatment incorporating the ah shi points using the jingjin model “simply improved the extensibility of the hamstrings through local and simple reflex effects” (Legge, 2015, p.257) and is a positive consequence of the reduction of tension in the myofascial chain or ‘weak link’. A second, and more viable possibility, exists in the local and biomechanical responses achieved using the jingjin model which include dorsal horn neuron changes, sympathetic reflex changes, and functional alterations in different centers of the brain (Legge, 2015).

In considering the desired effect of acupuncture as a treatment, there are many models within TCM that determine the needling technique and meridian point selections (Legge, 2015). Selecting a different model for diagnosis and treatment, such as the jingjin model chosen by Legge, particularly when another model in TCM may not be producing the desired results, offers an additional avenue for a successful patient outcome. Legge’s study shows us the importance of the practitioner utilizing a whole person approach that involves selecting alternate techniques within the scope of practice.

Summary

The commonality of acupuncture treatments for pain remediation, as outlined in the two research studies presented in the body of this paper, favor the selection of ah shi acupuncture points within the jingjin model and theory of channels. Both the Irnicha et al. double-blind trial and Legge’s case study favored using distant points for pain management in both back and neck pain, and both studies reported better results for patients experiencing chronic pain over acute pain. Similarly, in the Manheimer et al. meta-analysis, distant points were confirmed more effective, with better results being experienced by patients with long term chronic pain as opposed to short term acute pain, corroborating the findings of both Legge and Irnicha et al.

This review of the literature suggests a need for future studies to evaluate specific protocols of acupuncture for pain remediation, in both short-term acute pain, and long-term acute pain, of which the meta-analysis, Legge and Irnicha et al. studies all identified as areas where improvement in pain was not seen. Perhaps utilizing different strategies and modalities within the greater scope of acupuncture, and Traditional Chinese Medicine, would present successful treatment options that have previously gone unidentified in past research for acute pain. These findings further suggest a need for acupuncturists to stay up-to-date with emerging techniques, and continually evaluate the efficacy of their treatment protocols on a patient to patient basis, in order to achieve the best treatment results. For those patients experiencing acute low back pain, the data are sparse and inconclusive, showing a need for further investigation. References

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