Statistics show that four out of five Americans will have back pain at some point in their lives. Back pain has the highest incidence rate of occupational injury or illness associated with days away from work, according to data from the Bureau of Labor and Statistics.
Improper lifting is a common cause of back injury, including stooping forward to grasp an object and then straightening the back to lift, bending at the hips and keeping the legs straight to grasp and lift, twisting the back but not the hips while lifting, holding an object away from the body, or underestimating the weight of an object to be lifted.
In 85 percent of all cases of back pain, though, the cause is unknown. According to John Sarno, MD, a physician and professor of rehabilitation medicine at New York University, most back pain is the result of the mind’s interference with normal nerve functioning and blood circulation to muscles, a condition he calls tension myositis syndrome (myositis means inflammation of muscles). Sarno believes back pain is often a defensive mechanism, the unconscious mind distracting us from uncomfortable emotions by keeping back muscles in spasm.
Whatever the cause—emotions, “weekend warrior” activities, garden work, injury, osteoarthritis, overuse, or some other structural problem—the good news is that fewer than 5% of cases require intensive treatment or surgery. Evidence is mounting that exercise, gentle yoga, acupuncture, and/or moist heat applications can be as effective as spinal fusion, a type of back surgery that fuses together two vertebrae to stabilize the spine. And the surgery can cause new problems, such as increased stiffness and extra pressure above and below the newly fused area, or scar tissue from the “clean trauma” of an incision. In general, back surgery should only be used as a last resort after less aggressive measures have been exhausted.
How does acupuncture help?
Acupuncture treatments can be hugely effective for acute or chronic back pain, in part by causing the release of endorphins, the body’s natural painkillers. Most Western theories suggest that acupuncture either instigates the production of endogenous opiates, including endorphins, or blocks pain transmission.
The gate or inhibition theory proposes that acupuncture blocks pain by stimulating sensory neurons that travel faster than those that transmit pain.
Another theory is that acupuncture may have localized vasodilation effects, which would explain its benefits to musculoskeletal disorders. Dilated blood vessels are better able to eliminate pain-producing substances such as prostaglandins and other inflammatory blood products.
And yet another theory holds that internal organs can be stimulated by acupuncture to selectively excite parasympathetic and sympathetic nerves regulating the autonomic nervous system.
To add to the confusing mix of theories, there’s also one that suggests that acupuncture meridians are like direct bioelectric current pathways, with acupuncture points functioning as “amplifiers.”
Naturally, when East meets West and when philosophy meets science, debate occurs. Likewise, when old meets new, questions of quackery will arise from both sides. Some detractors of acupuncture place it in the same category as other obscure treatments such as purging, leeching, and bleeding. Others brush off the results of acupuncture as simply a “placebo effect”—a person believing so strongly it will help that it does. But through the ages, experience alone has shown its efficacy for pain. As one researcher put it, “If there are no benefits derived from the process, acupuncture would have to be categorized as one of the longest playing scams in the history of mankind.” It’s been helping people for thousands of years!
Just because something is a mystery doesn’t mean that it has to be mystical. And simply because there are limits to our understanding of a given technique, there is not necessarily a limit to its efficacy.
Research on acupuncture for low back pain
Back pain is, by far, the primary reason for appointments with acupuncturists. Researchers from the University of Maryland School of Medicine and the Peninsula Medical School, Plymouth, U.K., analyzed dozens of studies from around the world on acupuncture for low back pain.
“For people with chronic low back pain, this analysis shows that acupuncture is clearly effective in providing considerable pain relief,” said Eric Manheimer, study author and director of database and evaluation for the University of Maryland Center for Integrative Medicine. “The research also showed that acupuncture provided true pain relief. The benefit was not just due to the placebo effect.”
The reviewers scoured the medical literature for all studies involving acupuncture for treating low back pain. To minimize bias, the American and British teams developed explicit criteria for evaluating the studies and did the evaluations independently. Their analysis included only randomized controlled trials, the gold standard study design for evaluating medical procedures.
Thirty-three studies covering more than 2,100 patients met the criteria for review. In the end, the researchers used 22 of these studies for their analysis. All 22 evaluated Chinese-style acupuncture for chronic low back pain, defined as pain that has been ongoing for more than three months. The other 11 studies were excluded because they either only reported data that could not be combined statistically, they only included patients with acute back pain or pregnancy-related back pain, or they involved forms of acupuncture other than traditional Chinese acupuncture.
Manheimer said, “We wanted the studies for the analysis to meet the highest scientific standards. As a way to account for a possible placebo effect, we looked at many studies that used ‘sham acupuncture’ as a control group, where acupuncture needles were inserted only superficially or in the wrong place.”
The sham acupuncture studies were double-blinded, meaning neither the researchers nor the participants knew who was receiving the real or the sham treatment. When looking at those studies, the reviewers found the differences in pain ratings showed a significant difference between the real acupuncture and the sham acupuncture groups, indicating that the benefit was not just due to the placebo effect.
“From our analysis, the message for people with chronic low back pain is that acupuncture is a truly effective therapy that provides significant pain relief,” says Manheimer.
The researchers evaluated the effects of acupuncture both in the short-term (defined as three weeks after the last acupuncture treatment) as well as in the longer term. They found acupuncture provided definite pain relief in the short-term, and this relief appeared to be sustained over the longer term.
Almost twice as many patients responded to acupuncture versus conventional therapy, Heinz G. Endres, M.D., of Ruhr-University Bochum, and colleagues, reported in the Sept. 24, 2007 issue of Archives of Internal Medicine.
“Acupuncture constitutes a strong alternative to … conventional therapy,” the authors concluded. “Acupuncture gives physicians a promising and effective treatment option for chronic low-back pain, with few adverse effects or contraindications.”
However, sham acupuncture worked just as well as true acupuncture, they reported, which was a different result from the Maryland study. “The superiority of both forms of acupuncture suggests a common underlying mechanism that may act on pain generation, transmission of pain signals, or processing of pain signals by the central nervous system and that is stronger than the action mechanism of conventional therapy..
The patients were treated with either true or sham acupuncture or conventional therapy, which consisted of a combination of drugs, physical therapy, and exercise. True acupuncture consisted of 10 30-minute sessions of treatment according to principles of traditional Chinese medicine. Patients assigned to sham acupuncture received superficial needling at non-acupuncture points.
At the end of the study, 47.6% of patients in the true acupuncture group had responded, as had 44.2% in the sham acupuncture group, and 27.4% in the group that received conventional therapy. Both acupuncture groups had significantly higher response rates compared with conventional therapy.
The finding that both sham and true acupuncture relieved back pain was puzzling, said Rex Marco, M.D., an orthopedic surgeon at the University of Texas Health Science Center in Houston. He speculated that the sham needling could have triggered endorphin release or other potentially therapeutic effects. “It's entirely possible that the sham and true procedures worked through similar or the same underlying mechanisms." He also wondered about the placebo effect. "Maybe the contact and interaction with the acupuncturist was beneficial,” said Dr. Marco. “It's really impossible to know why the sham procedures had a therapeutic effect.”
What about that placebo effect?
Researchers at the University of Southampton and University College London have shown for the first time that the impact of acupuncture goes beyond the acknowledged placebo effect caused by the patient’s own expectation of feeling benefit from the treatment.
The scientists from Southampton, Dr. George Lewith and Dr. Peter White of the University's Complementary Medicine Research Unit, have distinguished between the placebo effects produced by a patient's expectation and the real effects of treatment in a group of patients with painful osteoarthritis, by monitoring specific responses in the brain during treatment.
Working with the Functional Imaging Unit at University College London, Dr. White and Dr Jérémie Pariente of UCL used sophisticated Positron Emission Tomography (PET) scans to find out what happened in the brains of patients receiving acupuncture-related treatment.
In one intervention patients were touched with blunt needles but were aware that the needle would not pierce the skin and that it did not have any therapeutic value. Scans showed that only the areas associated with the sensation of touch were activated in their brains.
Another intervention involved being treated with specially developed needles that gave the impression of skin penetration without actually piercing the skin. The needles worked like stage daggers, with the tip disappearing into the body of the needle when pressure was applied. These patients believed that the treatment was real, and scans showed an area of the brain associated with the production of natural opiates—substances that act in a non-specific way to relieve pain—was activated in these patients.
Finally, the third intervention was true acupuncture, which activated yet another region of the brain, the ipsilateral insular, in addition to the opiate center as in the sham acupuncture. The ipsilateral insular is a pathway known to be associated with acupuncture treatment and thought to be involved in pain modulation.
The brain activity in the third group of patients showed that true acupuncture elicits a demonstrable physiological effect over and above a simple skin prick. In addition, the response of the second group of patients who received the sham acupuncture treatment indicated that the expectation of and belief in the treatment also has a physiological effect on the brain. The expectation appears to mediate a potentially powerful although non-specific clinical response to acupuncture.
Some scientists feel that at its most basic level, acupuncture is “applied neurophysiology.” Someday we may be able to explain acupuncture in those terms. So far Western science still has a poor understanding of its mechanisms. But the body of anecdotal evidence supporting its effectiveness is overwhelming. As long ago as 1979, the World Health Organization concluded that “acupuncture is clearly not a panacea for all ills, but sheer weight of evidence demands that acupuncture must be taken seriously as a clinical procedure of considerable value.”
Part of the problem with double-blinded research studies with acupuncture is that large clinical trials are costly. Big pharmaceutical companies routinely fund clinical trials for new medications, but it’s much more difficult to obtain funding for clinical trials involving “complementary” and “alternative” treatments.
I myself always like to hear about success with veterinary acupuncture, because animals don’t respond to a “placebo effect”—they are not expecting anything when needles are placed!
Since the early 1970s veterinarians have been using acupuncture on horses for laminitis (with a 90% success rate), arthritis, tendonitis, back pain, hepatic dysfunction, neuralgia, and facial paralysis. In dogs, acupuncture has shown dramatic success in treating hip dysplasia, arthritis, dermatitis, intervertebral disk syndrome, and paralysis. Today veterinary acupuncture is used to treat a wide range of conditions in both small and large animals.
In a 1997 study at the University of Pennsylvania, of 350 horses with chronic back pain who could not function normally and who had not obtained lasting improvement with other treatments, 263 horses (75%) were able to perform at an acceptable level after once-weekly acupuncture treatments for eight weeks.
For human back pain sufferers, like horses and other animals, acupuncture can offer long-lasting, cost-effective benefits..