American College of Physicians recommendations include massage, acupuncture, spinal manipulation, tai chi, and yoga
Philadelphia, February 14, 2017 -- The American College of Physicians (ACP) recommends in an evidence-based clinical practice guideline published today in Annals of Internal Medicinethat physicians and patients should treat acute or subacute low back pain with non-drug therapies such as superficial heat, massage, acupuncture, or spinal manipulation. If drug therapy is desired, physicians and patients should select nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants.
Low back pain is one of the most common reasons for all physician visits in the U.S. Most Americans have experienced low back pain. Approximately one quarter of U.S. adults reported having low back pain lasting at least one day in the past three months. Pain is categorized as acute (lasting less than four weeks), subacute (lasting four to 12 weeks, and chronic (lasting more than 12 weeks).
"Physicians should reassure their patients that acute and subacute low back pain usually improves over time regardless of treatment," said Nitin S. Damle, MD, MS, MACP, president, ACP. "Physicians should avoid prescribing unnecessary tests and costly and potentially harmful drugs, especially narcotics, for these patients."
The evidence showed that acetaminophen was not effective at improving pain outcomes versus placebo. Low-quality evidence showed that systemic steroids were not effective in treating acute or subacute low back pain.
For patients with chronic low back pain, ACP recommends that physicians and patients initially select non-drug therapy with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise (MCE), progressive relaxation, electromyography biofeedback, low level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.
"For the treatment of chronic low back pain, physicians should select therapies that have the fewest harms and costs, since there were no clear comparative advantages for most treatments compared to one another," Dr. Damle said. "Physicians should remind their patients that any of the recommended physical therapies should be administered by providers with appropriate training."
For patients with chronic low back pain who have had an inadequate response to non-drug therapy, ACP recommends that physicians and patients consider treatment with NSAIDs as first line therapy; or tramadol or duloxetine as second line therapy. Physicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients.
"Physicians should consider opioids as a last option for treatment and only in patients who have failed other therapies, as they are associated with substantial harms, including the risk of addiction or accidental overdose," said Dr. Damle.
"Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain" is based on a systematic review of randomized controlled trials and systematic reviews published on noninvasive pharmacological and non-pharmacological treatments of nonradicular low back pain. Clinical outcomes evaluated included reduction or elimination of low back pain, improvement in back-specific and overall function, improvement in health-related quality of life, reduction in work disability/return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction, and adverse effects.
The evidence was insufficient or lacking to determine treatments for radicular low back pain. The evidence also was insufficient for most physical modalities and for which patients are likely to benefit from which specific therapy. The guideline does not address topical therapies or epidural injection therapies.
ACP's clinical practice guidelines are developed through a rigorous process based on an extensive review of the highest quality evidence available, including randomized control trials and data from observational studies. ACP also identifies gaps in evidence and direction for future research through its guidelines development process.
ACP's previous recommendations for treating low back pain were published in "Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society" in 2007. Some evidence has changed since the 2007 guideline and supporting evidence reviews. The 2007 guideline did not assess mindfulness-based stress reduction, MCE, taping, or tai chi.
About the American College of Physicians
The American College of Physicians is the largest medical specialty organization in the United States. ACP members include 148,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness.
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"Colicky babies who received acupuncture in the new study appeared to cry less after treatment than those who didn't receive acupuncture, said Kajsa Landgren, a lecturer in the department of health sciences at Lunds University in Sweden."
Acupuncture Reverses Lower Back Pain
18 NOVEMBER 2016
Qi-guiding acupuncture relieves disc herniation pain and a special intensive silver acupuncture needle protocol relieves chronic lower back myofascial pain.
Researchers find acupuncture effective for the treatment of lower back pain disorders. In a protocolized study from the Shanghai Jiaotong University Sixth People’s Hospital, researchers determined that a special type of manual acupuncture therapy, known as qi-guiding acupuncture, produces significant positive patient outcomes for lumbar intervertebral disc herniation patients. In related research from Xinping Hospital of Traditional Chinese Medicine, investigators find acupuncture combined with moxibustion effective for the alleviation of lower back pain due to lumbodorsal myofascial pain syndrome. A special application of silver acupuncture needles produced superior patient outcomes. Let’s start with a look at the Shanghai Jiaotang University research and then we’ll see how the silver needle protocol boosts treatment efficacy for the treatment of lower back pain.
Lower Back Needles
Acupuncture is effective for the treatment of lumbar intervertebral disc herniations. Wu et al. (Shanghai Jiaotong University Sixth People’s Hospital) investigated the treatment results of qi-guiding acupuncture with meridian differentiated acupoint selections and determined that it produces significant positive treatment outcomes for lumbar intervertebral disc herniation patients. Wu et al. also find electroacupuncture with meridian differentiated acupoint selections effective; however, qi-guiding acupuncture had a slightly higher rate of producing positive patient outcomes. Qi-guiding acupuncture had an 87.5% total treatment effective rate and electroacupuncture achieved an 86.6% total treatment effective rate. Qi-guiding acupuncture also had better outcomes for increases in nerve conduction velocity. The results are definitive given the large sample size of 549 patients with lumbar disc herniations evaluated in this study.
Lumbar disc herniation patients experience lower back pain and radiculopathy (radiating pain and numbness) as a result of anulus fibrosis damage, IVF encroachment, and other issues associated with disc damage (Hu et al.). Acupuncture, as one of the most common non-surgical treatment methods for lumbar disc herniation, has a high treatment effective rate and no significant adverse effects (Cheng).
Qi-guiding acupuncture was first documented in ancient literature, including The Systematic Classic of Acupuncture & Moxibustion by Huang-fu Mi. In qi-guiding acupuncture, needle entry and removal is controlled and slow. To direct qi upward, the acupuncture needle is oriented upward; similarly, to direct qi downward, the needle is pointed downward. Subsequently, the needle is frequently rotated, lifted, and thrust to regulate the flow of qi in the body. Additional manipulation techniques may be intermittently applied. In modern use, qi-guiding acupuncture repairs ultramicroscopic structures of damaged nerve roots and accelerates other aspects of nerve repair, thereby increasing nerve conduction.
In this study, lumbar disc herniation patients receiving qi-guiding acupuncture achieved an 87.5% total treatment effective rate. Patients receiving electroacupuncture achieved an 86.6% total treatment effective rate. Both qi-guiding acupuncture and electroacupuncture significantly increased nerve conduction velocity. Qi-guiding acupuncture had a slightly greater improvement in common peroneal nerve conduction velocity and superficial fibular nerve conduction velocity. Common peroneal nerve conduction velocity increased from 38.26 ± 12.8 to 44.75 ± 5.24 after the application of qi-guiding acupuncture, and increased from 39.11 ± 3.64 to 39.86 ± 10.95 after electroacupuncture. Superficial fibular nerve conduction velocity increased from 41.63 ± 4.37 to 42.55 ± 6.43 after the application of qi-guiding acupuncture, and increased from 40.71 ± 9.56 to 40.43 ± 4.01 after electroacupuncture.
A total of 549 patients with lumbar disc herniations were treated and evaluated in this study. These patients were diagnosed with lumbar disc herniations between December 2012 and March 2014. They were randomly divided into a treatment group and a control group, with 280 patients in the treatment group and 269 patients in the control group. The treatment group underwent qi-guiding acupuncture therapy, while the control group received electroacupuncture. Acupoint selection for both groups was based on meridian differentiation. Identical acupoints were selected for both patient groups.
For Taiyang meridian lumbago and leg pain (scelalgia):
For Yangming meridian lumbago and leg pain:
For Shaoyang meridian lumbago and leg pain:
For qi-guiding acupuncture, the following protocol was administered. Upon disinfection with 75% ethanol, a 0.30 mm x 40 mm filiform acupuncture needle was inserted into each selected acupoint. Huantiao and Juliao were needle to a depth of 2.5 inches. The remaining acupoints were needled to a depth of 1.2 inches. When a deqi sensation was achieved for all acupoints, qi-guiding needling with the Xie (reducing) manipulation technique was applied to Weizhong, Tiaokou, and Yanglingquan to transmit the needling sensation upward and toward the hip or waist. The same technique was applied to Huantiao, Juliao, and Biguan, instead transmitting the needle sensation downward and toward the legs. Subsequently, qi-guiding needling with the Bu (tonification) manipulation technique was applied on Dachangshu to transmit the needle sensation toward the lumbosacral area. The same technique was used on Shenshu until a deqi sensation of soreness or swelling was perceived at the lumbar region. A needle retention time of 20 minutes was observed during which the needles were rotated, lifted, and thrusted every 5 minutes to facilitate the flow of qi. One qi-guiding acupuncture session was conducted every other day for a total of 10 treatments.
Electroacupuncture for the control group was administered with the same aforementioned protocol. Before needle retention, the needles were connected to an electroacupuncture device. The device was then set to a continuous wave at 4 Hz with a 2mA current. A 20 minute needle retention time was subsequently observed. One electroacupuncture session was conducted every other day for a total of 10 treatments. The clinical results the Wu et al. study demonstrate that both qi-guiding acupuncture and electroacupuncture, when combined with meridian-differentiated acupoint selection, are suitable and effective therapies for lumbar disc herniation patients. However, qi-guiding acupuncture produces slightly better treatment outcomes in terms of nerve conduction velocity improvements.
In a related study, Wang H.D. (Xinping Hospital of Traditional Chinese Medicine) finds acupuncture combined with moxibustion therapy effective for the treatment of lumbodorsal myofascial pain syndrome. The study also finds that a silver needle protocol produces preferable treatment outcomes to conventional acupuncture. Lumbodorsal myofascial pain syndrome causes chronic lumbago and commonly occurs in young adults. Intensive acupuncture combined with moxibustion using silver needles was famously used by Professor Xuan Zhe Ren, a renowned Chinese orthopedist.
Acupoints were selected based on the degree of soft tissue damage, area of muscular tissue involved, and size of tendon contracture. In this approach, acupoints are 2 cm apart from each other and are mainly located on the lumbosacral region. Results from Wang’s study demonstrate that lumbodorsal myofascial pain syndrome patients receiving intensive acupuncture combined with moxibustion using silver needles achieved a 90% total treatment effective rate. Conventional acupuncture with moxibustion achieved an 83.3% total treatment effective rate.
Wang’s study involved a total of 60 patients with lumbodorsal myofascial pain syndrome. They were divided into a treatment group and a control group, with 30 patients in each group. The treatment group underwent intensive acupuncture-moxibustion therapy with silver needles. The control group received conventional acupuncture-moxibustion.
Intensive acupuncture-moxibustion with silver needles was applied to the T12 – L4 Jiaji acupoints and the acupoints located at the midpoint between each Jiaji acupoint. In addition, acupoints located 2 cm lateral to the Jiaji acupoints were needled. Finally, moxibustion applied with one Zhuang of 3 cm moxa cigar. One session was conducted daily for a total of 7 days. For conventional acupuncture-moxibustion therapy, the following primary acupoints were selected:
Additional acupoints were selected based on individual symptoms. For lumbago with chill-dampness:
For lumbago due to exhaustion:
For lumbago with kidney deficiency:
A needle retention time of 30 minutes was observed. Subsequently, moxibustion was applied using either a 4 hole or 6 hole moxa box on the lumbar acupoints. One session was conducted daily for a total of 7 days. The treatment efficacy for each patient was evaluated and categorized into 1 of 3 tiers:
Recovery: Complete elimination of symptoms. Physical movement regained completely. No pain points.
Significantly effective: Elimination of symptoms. Physical movement regained. Discomfort reoccurs only under exhaustion or change in weather. No pain or numbness.
Effective: Symptoms relieved. Pain or numbness present.
Not effective: No improvement in symptoms.
The total treatment effective rate for each patient group was derived as the percentage of patients who achieved at least an effective tier of improvement. The intensive acupuncture-moxibustion with silver needles protocol outperformed conventional acupuncture. However, both approaches produced significant positive patient outcomes.
Both aforementioned studies indicate that acupuncture is effective for the alleviation of lower back pain. These studies highlight the differences in therapeutic effects between various forms of acupuncture. As a result, qi-guiding acupuncture and intensive acupuncture-moxibustion with silver needles are found clinically effective for the relief of lower back pain.
Wu YC, Sun YJ, Zhang JF, Li Y, Zhang YY & Wang CM. (2014). Clinical Study of Qi-guiding Acupuncture at Points Selected According to Meridian Differentiation for Treatment of Lumbar Intervertebral Disc Herniation. Shanghai Journal of Acupuncture and Moxibustion. 33(12).
Cheng XN. (1987). The study of Chinese acupuncture-moxibustion. Volume 1, Beijing: People's medical publishing house. 192-284.
Hu YG. (1995). Prolapse of lumbar intervertebral disc. Volume 2, Beijing: People's medical publishing house. 226-228.
Zhu WM, Wu YC, Zhang JF, et al. (2010). Tuina combined with acupoint injection in treating prolapse of lumbar intervertebral disc. Chinese Journal of Sports Medicine. 29(6): 708-709.
Wang HD. (2013). Clinical Observation on Intensive Acupuncture-moxibustion with Silver Needles for Lumbodorsal Myofascial Pain Syndrome. Shanghai J Acu-mox. 32(8).
U.S. study reviews trial results on complementary health approaches for pain relief; aims to assist with pain managementFor Immediate Release:
Thursday, September 1, 2016
A review of 105 randomized controlled trials, which included more than 16,000 participants, shows that a variety of complementary health approaches may help manage pain. • Acupuncture• Massage therapy• Relaxation techniques• Tai chi• YogaCitation: Nahin RL, Boineau R, Khalsa PS, StussmanBJ, Weber WJ. Evidence-based evaluation of complementary health approaches for pain management in the United States. Mayo Clin Proc. September 2016;91(9):1292-1306.
Data from a review of U.S.-based clinical trials published today in Mayo Clinic Proceedings suggest that some of the most popular complementary health approaches—such as yoga, tai chi, and acupuncture—appear to be effective tools for helping to manage common pain conditions. The review was conducted by a group of scientists from the National Center for Complementary and Integrative Health (NCCIH) at the National Institutes of Health.
Millions of Americans suffer from persistent pain that may not be fully relieved by medications. They often turn to complementary health approaches to help, yet primary care providers have lacked a robust evidence base to guide recommendations on complementary approaches as practiced and available in the United States. The new review gives primary care providers—who frequently see patients with chronic pain—tools to inform decisionmaking on how to help manage that pain.
“For many Americans who suffer from chronic pain, medications may not completely relieve pain and can produce unwanted side effects. As a result, many people may turn to nondrug approaches to help manage their pain,” said Richard L. Nahin, Ph.D., NCCIH’s lead epidemiologist and lead author of the analysis. “Our goal for this study was to provide relevant, high-quality information for primary care providers and for patients who suffer from chronic pain.”
The researchers reviewed 105 U.S.-based randomized controlled trials, from the past 50 years, that were relevant to pain patients in the United States and met inclusion criteria. Although the reporting of safety information was low overall, none of the clinical trials reported significant side effects due to the interventions.
The review focused on U.S.-based trial results on seven approaches used for one or more of five painful conditions—back pain, osteoarthritis, neck pain, fibromyalgia, and severe headaches and migraine—and found promise in the following for safety and effectiveness in treating pain:
Though the evidence was weaker, the researchers also found that massage therapy, spinal manipulation, and osteopathic manipulation may provide some help for back pain, and relaxation approaches and tai chi might help people with fibromyalgia.
“These data can equip providers and patients with the information they need to have informed conversations regarding nondrug approaches for treatment of specific pain conditions,” said David Shurtleff, Ph.D., deputy director of NCCIH. “It’s important that continued research explore how these approaches actually work and whether these findings apply broadly in diverse clinical settings and patient populations.”
Read more about this report at nccih.nih.gov/pain_review.
Nahin RL, Boineau R, Khalsa PS, Stussman BJ, Weber WJ. Evidence-based evaluation of complementary health approaches for pain management in the United States. (link is external) Mayo Clinic Proceedings. 2016;91(9):1292–1306.
About the National Center for Complementary and Integrative Health (NCCIH): NCCIH’s mission is to define, through rigorous scientific investigation, the usefulness and safety of complementary and integrative health approaches and their roles in improving health and health care. For additional information, call NCCIH’s Clearinghouse toll free at 1-888-644-6226. Follow us on Twitter (link is external), Facebook (link is external), and YouTube (link is external).
About the National Institutes of Health (NIH): NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.
"What we can do is compare acupuncture to no treatment, to pharmaceutical treatment, and to surgical treatment and see where the outcomes are better. When we do comparison trials, the evidence-based medicine is absolutely clear that acupuncture is superior to placebo and, in many cases, to treatments such as pharmaceuticals and surgery. Acupuncture is not a religion or a belief. I don’t need someone to believe in my ability to help them in order to help them. It always makes me giggle when people say they “believe in acupuncture.” It’s just science."
March 6, 2015
The Korea Advanced Institute of Science and Technology (KAIST)
Medical researchers have focused on structural similarities between compounds in "traditional oriental medicine" TOM and human metabolites to help explain TOM's mechanisms of action. This systems approach using structural similarities assumes that compounds which are structurally similar to metabolites could affect relevant metabolic pathways and reactions by biosynthesizing structurally similar metabolites.
The picture presents the structural similarity analysis of comparing compounds in traditional oriental medicine and those in all available approved drugs against the structures of human metabolites.
Credit: KAISTTraditional oriental medicine (TOM) has been practiced in Asian countries for centuries, and is gaining increasing popularity around the world. Despite its efficacy in various symptoms, TOM has been practiced without precise knowledge of its mechanisms of action. Use of TOM largely comes from empirical knowledge practiced over a long period of time. The fact that some of the compounds found in TOM have led to successful modern drugs such as artemisinin for malaria and taxol (Paclitaxel) for cancer has spurred modernization of TOM.
A research team led by Distinguished Professor Sang Yup Lee at the Korea Advanced Institute of Science and Technology (KAIST) has focused on structural similarities between compounds in TOM and human metabolites to help explain TOM's mechanisms of action. This systems approach using structural similarities assumes that compounds which are structurally similar to metabolites could affect relevant metabolic pathways and reactions by biosynthesizing structurally similar metabolites.
Structural similarity analysis has helped to identify mechanisms of action of TOM. This is described in a recent study entitled "A systems approach to traditional oriental medicine," published online in Nature Biotechnology on March 6, 2015. In this study, the research team conducted structural comparisons of all the structurally known compounds in TOM and human metabolites on a large-scale. As a control, structures of all available approved drugs were also compared against human metabolites. This structural analysis provides two important results. First, the identification of metabolites structurally similar to TOM compounds helped to narrow down the candidate target pathways and reactions for the effects from TOM compounds. Second, it suggested that a greater fraction of all the structurally known TOM compounds appeared to be more similar to human metabolites than the approved drugs. This second finding indicates that TOM has a great potential to interact with diverse metabolic pathways with strong efficacy. This finding, in fact, shows that TOM compounds might be advantageous for the multitargeting required to cure complex diseases. "Once we have narrowed down candidate target pathways and reactions using this structural similarity approach, additional in silico tools will be necessary to characterize the mechanisms of action of many TOM compounds at a molecular level," said Hyun Uk Kim, a research professor at KAIST.
TOM's multicomponent, multitarget approach wherein multiple components show synergistic effects to treat symptoms is highly distinctive. The researchers investigated previously observed effects recorded since 2000 of a set of TOM compounds with known mechanisms of action. TOM compounds' synergistic combinations largely consist of a major compound providing the intended efficacy to the target site and supporting compounds which maximize the efficacy of the major compound. In fact, such combination designs appear to mirror the Kun-Shin-Choa-Sa design principle of TOM.
That principle, Kun-Shin-Choa-Sa literally means "king-minister-assistant-ambassador." In ancient East Asian medicine, treating human diseases and taking good care of the human body are analogous to the politics of governing a nation. Just as good governance requires that a king be supported by ministers, assistants and/or ambassadors, treating diseases or good care of the body required the combined use of herbal medicines designed based on the concept of Kun-Shin-Choa-Sa. Here, the Kun (king or the major component) indicates the major medicine (or herb) conveying the major drug efficacy, and is supported by three different types of medicines: the Shin (minister or the complementary component) for enhancing and/or complementing the efficacy of the Kun, Choa (assistant or the neutralizing component) for reducing any side effects caused by the Kun and reducing the minor symptoms accompanying major symptom, and Sa (ambassador or the delivery/retaining component) for facilitating the delivery of the Kun to the target site and retaining the Kun for prolonged availability in the cells.
The synergistic combinations of TOM compounds reported in the literature showed four different types of synergisms: complementary action (similar to Kun-Shin), neutralizing action (similar to Kun-Choa), and facilitating action or pharmacokinetic potentiation (both similar to Kun-Choa or Kun-Sa). Additional structural analyses for these compounds with synergism show that they appeared to affect metabolism of amino acids, co-factors, and vitamins as major targets.
Professor Sang Yup Lee said, "This study lays a foundation for the integration of traditional oriental medicine with modern drug discovery and development. The systems approach taken in this analysis will be used to elucidate mechanisms of action of unknown TOM compounds which will then be subjected to rigorous validation through clinical and in silico experiments."
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