Is Acupuncture Painful?

A common misconception about acupuncture is that it hurts, and it is the primary reason holding some people back from trying it. Most people being treated don’t feel anything. You’ll feel a slight prick when the needle is inserted, but many patients are even able to fall asleep during the treatment due to the comfort they experience.

Pain only tends to happen under the hands of inexperienced acupuncturists. At Empire Medicine, our team is lead by three physicians with MDs and PhDs, so you’ll be in good hands.

The Healing Art of Acupuncture

There are very few of medical managements that carry the capacity to promote healing process.  Acupuncture proves to be one of the most effective healing art through practice for thousand years. But this unique feature has still not been well known yet. Many people are only aware of or advised to explore these options: either have surgery which is not guaranteed to eliminate your pain or maintain a lifelong dependency on addictive medications to help you make it through each day. Those options, however, are not the last resort.  Acupuncture has been used in Western Society for over 40 years, and it has been especially utilized for its analgesic benefits.   Howard is a patient at Empire Medicine that uses acupuncture as a means of pain management at beginning after he had tried almost everything under the Sun.  On his unique journey with acupuncture, he has taken the fast track towards an improved quality of life, obtaining relief from pain and an added benefit of aggressive healing.  

 

Howard, a bona fide bagel lover and esteemed lawyer on the south shore, suffered from atypical trigeminal neuralgia (face pain) due to having surgery to remove a failed bridge.  After trying physical therapy and having three teeth erroneously removed, things got worse, a quarter of his teeth removed for just the relief of pain. He lost his teeth but gained unbearable pain.  So, he had to change, he obtained the best facial pain expert in the United States an entrusted his faith in him fully.  “Dr. Tanenbaum swore, ‘you [have to] do acupuncture because acupuncture is going to do two things for you; It’s going to work on the pain and you’re going to start healing.’  That was the big issue -I wasn’t healing.  I had something called apico where they cut into your gum line to help maybe relieve the pressure in the bone [then] developed something called dry sockets, where the bone is exposed.  In addition to the neuropathic pain, I now had direct pain from the bone exposure.  At the end of October, I started acupuncture.  And, to be honest, I didn’t think it was going to do anything before I started.  Within just about 2-3 weeks of starting treatment, the pain started to settle down on me.  Now remember, I was experiencing severe pain and intense pressure before acupuncture” Howard recounted.

“My specialist fitted my exposed bone with a plastic device that basically covers the area and it also seals it so the bone isn’t open, but it wasn’t going to help me heal.  The wildest thing started happening  to me by the mid-November, healing just went off the charts!  Just off the charts!  It was wild.  Because it went from the suture line, straight back.  The last surgery [I had] was in September, and that area was just red and they described it as being “very angry” looking [with] the bone exposed and everything else.  I got to become an expert.  We started to notice that healing [was beginning] to increase.  This was from a pattern of not healing [to] all of a sudden, it’s healing faster, getting better and it’s beginning to feel better almost after every time of acupuncture.  I was discussing with [my physician at Empire Medicine], and he was explaining how [acupuncture] helps to bring blood to the area and does a lot of other things.  I know it was the acupuncture because I wasn’t doing anything else at the time.  Physical therapy was over. But when I started doing this- I don’t know why- but its working!” he exclaimed.

“I’m not on any pain medications or anything.  I was taking 3-4 Advil at a time still experiencing pretty bad pain.  Now- nothing!  The last I saw my specialist, he looked in [my mouth] and started taking photos.  As a professor at Stony Brook University, he’s using me in a medical study [because] of the way [I’m] healing.  My dentist said the same thing to me.  He said, ‘Something’s working.  It’s not your body because your body was too slow to heal.’  After 6 [surgical] procedures your body just can’t.  Because you’re opened up so many times, your body keeps going through a response of going into shock; it can’t heal anymore or it stops healing.  Since I started [acupuncture], to me, when I looked at it- I used to be afraid to look in the mirror.  [Now], I’m good.  Everyone has said it now, since I started coming [to Empire Medicine], the healing is just off the charts.  It’s still healing because it was a pretty rough surgical site but when you look at it, the redness is gone.  I look forward to coming here because I feel better after.  The healing has taken off so fast. My specialist says to me, ‘It’s the acupuncture.’  My dentist says, ‘Whatever’s working for you is really working for you.  Don’t stop what you’re doing!’  But the only thing I’m doing is acupuncture.  It’s just amazing what it does, in my opinion.  I went from living with a pain level of 9/10 down to about a 1 or 2. I’ll take it!” Howard concluded.

Howard’s need for pain management was a direct result of the pain caused from the surgery that consequentially resulted in alveolar osteitis, or dry sockets.  This occurs when the blood clot fails to form or is lost from the socket; it is directly associated with increased pain and delayed healing time.  To understand the process of healing, one must understand its correlation to pain.  Pain is a natural result of healing.  The delay in Howard’s healing process was natural as per his diagnosis of dry sockets, but the exacerbated pain associated with it increased because of the duration of ineffective treatment.  Healing occurs in several stages.  An article titled, “Factors Affecting Wound Healing,” was published in the Journal of Dental Research stating that,

 

“Wound healing is a complex biological process that consists of hemostasis, inflammation, proliferation, and remodeling. Large numbers of cell types—including neutrophils, macrophages, lymphocytes, keratinocytes, fibroblasts, and endothelial cells—are involved in this process. Multiple factors can cause impaired wound healing by affecting one or more phases of the process and are categorized into local and systemic factors. The influences of these factors are not mutually exclusive. Single or multiple factors may play a role in any one or more individual phases, contributing to the overall outcome of the healing process.”

Acupuncture addresses treatment of the whole body while focusing on the ailment site, maintaining analgesic properties, assisting with the increase of blood flow and in pursuit of the overall goal of recovering a balance in one’s qi.  The multipurpose treatment, effectively assisted Howard in graduating to the proliferation phase of healing, where cells regenerate in the mouth to heal the gums and eventually seal the dry socket. The healing had stopped at a point where his doctors had considered it “too slow.”  Believing there was nerve damage causing the pain, his former doctors were suggesting nerve blockage in his face. His physician at Empire Medicine and dental specialist suggested he avoid the resultant possibility of partial facial paralysis.  With routine acupuncture treatments at twice a week, Howard is anxious to usher in the remodeling phase of healing where the regenerated cells seal the wound.  The rehabilitation process is moving rapidly and hopes for exponential healing and near absolute pain relief are not just hopes for Howard, but a clear reality within reach.

***

After retracing Howard’s journey, one can gain insight regarding the exponential possibilities of treating and healing the body with acupuncture.  Beyond pain relief, the site of the loud pain can be hushed to a hum if not healed with the resounding bliss of loud silence.  If you’re experiencing pain and are looking to avoid prescription drug dependency and/or surgery with a 50/50 probability of successfully executing the problem, seek a second opinion at Empire Medicine.  Our skilled practitioners know how to assist you with achieving a balance of qi or the closest, livable thing to it.  Contact one of our locations for a consultation today!

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain

A Clinical Practice Guideline From the American College of Physicians 

Abstract

Description:

The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain.

Methods:

Using the ACP grading system, the committee based these recommendations on a systematic review of randomized, controlled trials and systematic reviews published through April 2015 on noninvasive pharmacologic and nonpharmacologic treatments for low back pain. Updated searches were performed through November 2016. 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 and return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction, and adverse effects.

Target Audience and Patient Population:

The target audience for this guideline includes all clinicians, and the target patient population includes adults with acute, subacute, or chronic low back pain.

Recommendation 1:

Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)

Recommendation 2:

For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)

Recommendation 3:

In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians 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. (Grade: weak recommendation, moderate-quality evidence)

 

Low back pain is one of the most common reasons for physician visits in the United States. Most Americans have experienced low back pain, and approximately one quarter of U.S. adults reported having low back pain lasting at least 1 day in the past 3 months (1). Low back pain is associated with high costs, including those related to health care and indirect costs from missed work or reduced productivity (2). The total costs attributable to low back pain in the United States were estimated at $100 billion in 2006, two thirds of which were indirect costs of lost wages and productivity (3).

Low back pain is frequently classified and treated on the basis of symptom duration, potential cause, presence or absence of radicular symptoms, and corresponding anatomical or radiographic abnormalities. Acute back pain is defined as lasting less than 4 weeks, subacute back pain lasts 4 to 12 weeks, and chronic back pain lasts more than 12 weeks. Radicular low back pain results in lower extremity pain, paresthesia, and/or weakness and is a result of nerve root impingement. Most patients with acute back pain have self-limited episodes that resolve on their own; many do not seek medical care (4). For patients who do seek medical care, pain, disability, and return to work typically improve rapidly in the first month (5). However, up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode, and 1 in 5 report substantial limitations in activity (6). Many noninvasive treatment options are available for radicular and nonradicular low back pain, including pharmacologic and nonpharmacologic interventions.

Guideline Focus and Target Population

The purpose of this American College of Physicians (ACP) guideline is to provide treatment guidance based on the efficacy, comparative effectiveness, and safety of noninvasive pharmacologic and nonpharmacologic treatments for acute (<4 weeks), subacute (4 to 12 weeks), and chronic (>12 weeks) low back pain in primary care. This guideline does not address topical pharmacologic therapies or epidural injection therapies. It serves as a partial update of the 2007 ACP guideline (it excludes evidence on diagnosis). These recommendations are based on 2 background evidence reviews (7, 8) and a systematic review sponsored by the Agency for Healthcare Research and Quality (AHRQ) (9). The target audience for this guideline includes all clinicians, and the target patient population includes adults with acute, subacute, or chronic low back pain.

Methods

Systematic Review of the Evidence

The evidence review was conducted by the AHRQ's Pacific Northwest Evidence-based Practice Center. Additional methodological details can be found in the Appendix as well as in the accompanying articles (7, 8) and full report (9). Reviewers searched several databases for studies published in English from January 2008 through April 2015 and updated the search through November 2016. Studies published before 2007 were identified using the 2007 ACP/American Pain Society (APS) systematic reviews (10, 11). Reviewers combined data when possible using meta-analysis and assessed risk of bias and study quality according to established methods. The study population included adults (aged ≥18 years) with acute, subacute, or chronic nonradicular low back pain, radicular low back pain, or symptomatic spinal stenosis.

The review evaluated pharmacologic (acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs], opioids, skeletal muscle relaxants [SMRs], benzodiazepines, antidepressants, antiseizure medications, and systemic corticosteroids) and nonpharmacologic (psychological therapies, multidisciplinary rehabilitation, spinal manipulation, acupuncture, massage, exercise and related therapies, and various physical modalities) treatments for low back pain. Evaluated outcomes 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 magnitude of effect (small, moderate, or large) was determined as previously described (10, 11). A small effect on pain was defined as a mean between-group difference after treatment of 5 to 10 points on a visual analogue scale of 0 to 100 or equivalent, a mean between-group difference of 0.5 to 1.0 point on a numerical rating scale of 0 to 10, or a standardized mean difference of 0.2 to 0.5. A moderate effect was defined as a mean between-group difference of greater than 10 to no more than 20 points on a visual analogue scale of 0 to 100 or equivalent, a mean between-group difference of greater than 1.0 to no more than 2.0 points on a numerical rating scale of 0 to 10 or equivalent, or a standardized mean difference greater than 0.5 but no more than 0.8. For function, a small effect was defined as a mean between-group difference of 5 to 10 points on the Oswestry Disability Index (ODI), a mean between-group difference of 1 to 2 points on the Roland Morris Disability Questionnaire (RDQ), or a standardized mean difference of 0.2 to 0.5. A moderate effect on function was defined as a mean between-group difference of greater than 10 to no more than 20 points on the ODI, a mean between-group difference of greater than 2 to no more than 5 points on the RDQ, or a standardized mean difference greater than 0.5 but no more than 0.8. No large effects were found with any intervention.

Benefits and Comparative Benefits of Pharmacologic Therapies

Acute or Subacute Low Back Pain

Acetaminophen

Low-quality evidence showed no difference between acetaminophen and placebo for pain intensity or function through 4 weeks or between acetaminophen and NSAIDs for pain intensity or likelihood of experiencing global improvement at 3 weeks or earlier (13, 14).

NSAIDs

Moderate-quality evidence showed that NSAIDs were associated with a small improvement in pain intensity compared with placebo (14, 15), although several randomized, controlled trials (RCTs) showed no difference in likelihood of achieving pain relief with NSAIDs compared with placebo (16–18). Low-quality evidence showed a small increase in function with NSAIDs compared with placebo (19). Moderate-quality evidence showed that most head-to-head trials of one NSAID versus another showed no differences in pain relief in patients with acute low back pain (14). Low-quality evidence showed no differences in pain between cyclooxygenase (COX)-2–selective NSAIDs versus traditional NSAIDs (14).

SMRs

Moderate-quality evidence showed that SMRs improved short-term pain relief compared with placebo after 2 to 4 and 5 to 7 days (20, 21). Low-quality evidence showed no differences between different SMRs for any outcomes in patients with acute pain (20). Low-quality evidence showed inconsistent findings for the effect on pain intensity with a combination of SMRs plus NSAIDs compared with NSAIDs alone (20, 22, 23).

Systemic Corticosteroids

Low-quality evidence showed no difference in pain or function between a single intramuscular injection of methylprednisolone or a 5-day course of prednisolone compared with placebo in patients with acute low back pain (24, 25).

Other Therapies

Evidence was insufficient to determine effectiveness of antidepressants, benzodiazepines (26, 27), antiseizure medications, or opioids versus placebo in patients with acute or subacute low back pain.

Chronic Low Back Pain

NSAIDs

Moderate-quality evidence showed that NSAIDs were associated with small to moderate pain improvement compared with placebo (14, 28, 29). Low-quality evidence showed that NSAIDs were associated with no to small improvement in function (28–31). Moderate-quality evidence showed that most head-to-head trials of one NSAID versus another showed no differences in pain relief in patients with chronic low back pain (14). There were no data on COX-2–selective NSAIDs.

Opioids

Moderate-quality evidence showed that strong opioids (tapentadol, morphine, hydromorphone, and oxymorphone) were associated with a small short-term improvement in pain scores (about 1 point on a pain scale of 0 to 10) and function compared with placebo (32–36). Low-quality evidence showed that buprenorphine patches improved short-term pain more than placebo in patients with chronic low back pain; however, the improvement corresponded to less than 1 point on a pain scale of 0 to 10 (37–40). Moderate-quality evidence showed no differences among different long-acting opioids for pain or function (33, 41–44), and low-quality evidence showed no clear differences in pain relief between long- and short-acting opioids (45–50). Moderate-quality evidence showed that tramadol achieved moderate short-term pain relief and a small improvement in function compared with placebo (32, 51, 52).

SMRs

Evidence comparing SMRs versus placebo was insufficient (53–55). Low-quality evidence showed no differences in any outcome between different SMRs for treatment of chronic low back pain (20).

Benzodiazepines

Low-quality evidence showed that tetrazepam improved pain relief at 5 to 7 days and resulted in overall improvement at 10 to 14 days compared with placebo (20).

Antidepressants

Moderate-quality evidence showed no difference in pain between tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs) versus placebo, and low-quality evidence showed no differences in function for antidepressants (56). Moderate-quality evidence showed that duloxetine was associated with a small improvement in pain intensity and function compared with placebo (57–59).

Other Therapies

Evidence was insufficient to determine the effect of acetaminophen, systemic corticosteroids, or antiseizure medications on chronic low back pain.

Radicular Low Back Pain

Benzodiazepines

Low-quality evidence showed no difference between diazepam and placebo for function at 1 week through 1 year and analgesic use, return to work, or likelihood of surgery through 1 year of follow-up in patients with acute or subacute radicular pain (60). Diazepam resulted in a lower likelihood of pain improvement at 1 week compared with placebo.

Systemic Corticosteroids

Moderate-quality evidence showed no differences in pain between systemic corticosteroids and placebo and no to small effect on function in patients with radicular low back pain (61–66).

Other Therapies

No RCTs evaluated acetaminophen, SMRs, antidepressants, or opioids for radicular low back pain. Results for NSAIDs were inconsistent for pain, and evidence was therefore insufficient (22). There was insufficient evidence to determine the effect of antiseizure medications on radicular low back pain (67–71).

Harms of Pharmacologic Therapies

Moderate-quality evidence showed no difference among scheduled acetaminophen, acetaminophen taken as needed, or placebo for serious adverse events (13). Moderate-quality evidence showed that more adverse effects occurred with NSAIDs than placebo, COX-2–selective NSAIDs were associated with a decreased risk for adverse effects compared with traditional NSAIDs, and acetaminophen was associated with a lower risk for adverse effects than NSAIDs (14). Moderate-quality evidence showed that short-term use of opioids increased nausea, dizziness, constipation, vomiting, somnolence, and dry mouth compared with placebo, and SMRs increased risk for any adverse event and central nervous system adverse events (mostly sedation) compared with placebo (20). Moderate-quality evidence showed that antidepressants increased risk for any adverse event compared with placebo, although rates of specific adverse events did not differ (72). The risk for serious adverse events did not differ between duloxetine and placebo, although duloxetine was associated with increased risk for withdrawal due to adverse events (57–59). Low-quality evidence showed no clear differences in adverse effects for gabapentin versus placebo (67, 68). Low-quality evidence showed that benzodiazepines caused more frequent somnolence, fatigue, and lightheadedness than placebo (20). Harms were not well-reported, and no RCTs assessed long-term use of benzodiazepines or risks for addiction, abuse, or overdose. Adverse events for systemic corticosteroids were not well-reported in RCTs, but the largest trial found that oral prednisone was associated with increased risk for any adverse event, insomnia, nervousness, and increased appetite (66). However, low-quality evidence showed no cases of hyperglycemia that required medical attention (24, 61, 64).

Comparative Benefits of Nonpharmacologic Therapies

Acute or Subacute Low Back Pain

Exercise

Low-quality evidence showed no difference between exercise therapy and usual care for pain or function in patients with acute or subacute pain (11); additional trials reported inconsistent results (73–75). Moderate-quality evidence showed no clear differences between different exercise regimens in more than 20 head-to-head RCTs in patients with acute low back pain.

Acupuncture

Low-quality evidence showed that acupuncture resulted in a small decrease in pain intensity compared with sham acupuncture with nonpenetrating needles, but there were no clear effects on function (76–78). Low-quality evidence showed that acupuncture slightly increased the likelihood of overall improvement compared with NSAIDs (76, 79–83).

Massage

Low-quality evidence showed that massage moderately improved short-term (1 week) pain and function compared with sham therapy for subacute low back pain (84), although 1 trial (85) showed no difference in pain or function at 5 weeks. Moderate-quality evidence showed that massage improved short-term pain relief and function compared with other interventions (manipulation, exercise therapy, relaxation therapy, acupuncture, or physiotherapy) for patients with subacute to chronic low back pain, but effects were small (84, 86). Low-quality evidence showed that a combination of massage plus another intervention (exercise, exercise and education, or usual care) was superior to the other intervention alone for short-term pain in patients with subacute to chronic low back pain (84).

Spinal Manipulation

Low-quality evidence showed that spinal manipulation was associated with a small effect on function compared with sham manipulation; evidence was insufficient to determine the effect on pain (87, 88). Low-quality evidence showed no difference in pain relief at 1 week between spinal manipulation and inert treatment (educational booklet, detuned ultrasound, detuned or actual short-wave diathermy, antiedema gel, or bed rest), although 1 trial showed better longer-term pain relief (3 months) with spinal manipulation (89). Function did not differ between spinal manipulation and inert treatment at 1 week or 3 months (89). Moderate-quality evidence showed no difference between spinal manipulation and other active interventions for pain relief at 1 week through 1 year or function (analyses included exercise, physical therapy, or back school as the comparator) (89, 90). Low-quality evidence showed that a combination of spinal manipulation plus exercise or advice slightly improved function at 1 week compared with exercise or advice alone, but these differences were not present at 1 or 3 months (89).

Superficial Heat

Moderate-quality evidence showed that a heat wrap moderately improved pain relief (at 5 days) and disability (at 4 days) compared with placebo (91). Low-quality evidence showed that a combination of heat plus exercise provided greater pain relief and improved RDQ scores at 7 days compared with exercise alone in patients with acute pain (92). Low-quality evidence showed that a heat wrap provided more effective pain relief and improved RDQ scores compared with acetaminophen or ibuprofen after 1 to 2 days (93). Low-quality evidence showed no clear differences between a heat wrap and exercise in pain relief or function (92).

Low-Level Laser Therapy

Low-quality evidence showed that a combination of low-level laser therapy (LLLT) and NSAIDs largely decreased pain intensity and resulted in a moderate improvement in function (as measured by the ODI) compared with sham laser therapy plus NSAIDs in patients with acute or subacute pain (94).

Lumbar Supports

Low-quality evidence showed no difference in pain or function between lumbar supports added to an educational program compared with an educational program alone or other active interventions in patients with acute or subacute low back pain (95).

Other Therapies

Evidence was insufficient to determine the effectiveness of transcutaneous electrical nerve stimulation (TENS), electrical muscle stimulation, inferential therapy, short-wave diathermy, traction, superficial cold, motor control exercise (MCE), Pilates, tai chi, yoga, psychological therapies, multidisciplinary rehabilitation, ultrasound, and taping.

Chronic Low Back Pain

Exercise

Moderate-quality evidence showed that exercise resulted in a small improvement in pain relief and function compared with no exercise (11, 96). Moderate-quality evidence showed that compared with usual care, exercise resulted in small improvements in pain intensity and function at the end of treatment, although effects were smaller at long-term follow-up (96). Moderate-quality evidence showed no clear differences between different exercise regimens in more than 20 head-to-head RCTs in patients with chronic low back pain.

MCE

Motor control exercise focuses on restoring coordination, control, and strength of the muscles that control and support the spine. Low-quality evidence showed that MCE moderately decreased pain scores and slightly improved function in short- to long-term follow-up compared with a minimal intervention (97). Low-quality evidence showed that MCE resulted in small improvements in pain intensity at short-term (≥6 weeks to <4 months) and intermediate-term (≥4 to <8 months) follow-up compared with general exercise, although improvements were small and no longer significant at long-term follow-up (97). Motor control exercise also resulted in small improvements in function in the short and long term (97). Low-quality evidence showed that MCE resulted in a moderate improvement in pain intensity and function compared with multimodal physical therapy at intermediate follow-up (97). Low-quality evidence showed no clear differences in pain with a combination of MCE plus exercise versus exercise alone (98, 99).

Pilates

Low-quality evidence showed that Pilates resulted in small or no clear effects on pain and no clear effects on function compared with usual care plus physical activity (100–107). Low-quality evidence showed no clear differences between Pilates and other types of exercise for pain or function (108–110).

Tai Chi

Low-quality evidence showed that tai chi resulted in moderate pain improvement compared with wait-list controls or no tai chi (111, 112), and 1 study showed a small increase in function (111). Moderate-quality evidence showed that tai chi moderately decreased pain intensity at 3 and 6 months compared with backward walking or jogging but not versus swimming (112).

Yoga

Low-quality evidence showed that Iyengar yoga resulted in moderately lower pain scores and improved function compared with usual care at 24 weeks (113). Low-quality evidence showed that yoga resulted in a small decrease in pain intensity compared with exercise (114–118). Low-quality evidence showed that, compared with education, yoga resulted in a small decrease in short-term (≤12 weeks) but not long-term (about 1 year) pain intensity and a small increase in short- and long-term function (119).

Psychological Therapies

Low-quality evidence showed that progressive relaxation therapy moderately improved pain intensity and functional status compared with wait-list controls (120). Low-quality evidence showed that electromyography biofeedback training moderately decreased pain intensity (reduction of 5 to 13 points on a 100-point pain scale) compared with wait-list controls, but there was no effect on function (120). Low-quality evidence showed that operant therapy (behavioral therapy involving reinforcement) slightly improved pain intensity compared with wait-list control, although there was no difference for function (120). Low-quality evidence showed that cognitive behavioral therapy (CBT) and other combined psychological therapies (involving education, problem-solving training, coping techniques, imagery, relaxation, goal setting, cognitive pain control, and exercises) were associated with moderately improved pain intensity compared with wait-list controls, but there was no difference in function (120). Moderate-quality evidence showed that mindfulness-based stress reduction is an effective treatment for chronic low back pain. One study showed a small improvement in pain at 26 and 52 weeks and in function at 26 weeks compared with usual care (121). The same study showed no difference between mindfulness-based stress reduction and CBT for improvements in pain or function. Two other studies showed improvement in pain and function compared with education (122, 123). Low-quality evidence showed no difference between psychological therapies and exercise or physical therapy for pain intensity (120). Low-quality evidence showed no differences in pain or function between a combination of psychological therapy plus exercise or physiotherapy compared with exercise or physiotherapy alone (120). Moderate-quality evidence showed no differences between different psychological therapies for pain or function outcomes (120).

Multidisciplinary Rehabilitation

Moderate-quality evidence showed that multidisciplinary rehabilitation moderately reduced short-term (<3 months) and slightly reduced long-term pain intensity and disability compared with usual care, although there was no difference in return to work (124). Low-quality evidence showed that multidisciplinary rehabilitation was associated with moderately lower short-term pain intensity and slightly lower disability than no rehabilitation (124). Moderate-quality evidence showed that multidisciplinary rehabilitation was associated with slightly lower short-term pain intensity and disability, moderately lower long-term pain intensity, and improved function compared with physical therapy and a greater likelihood of returning to work compared with nonmultidisciplinary rehabilitation (124).

Acupuncture

Low-quality evidence showed that acupuncture was associated with moderate improvement in pain relief immediately after treatment and up to 12 weeks later compared with sham acupuncture, but there was no improvement in function (125–130). Moderate-quality evidence showed that acupuncture was associated with moderately lower pain intensity and improved function compared with no acupuncture at the end of treatment (125). Low-quality evidence showed a small improvement in pain relief and function compared with medications (NSAIDs, muscle relaxants, or analgesics) (125).

Massage

Low-quality evidence showed no difference in pain between foot reflexology and usual care for patients with chronic low back pain (131–133). Moderate-quality evidence showed that massage improved short-term pain relief and function compared with other interventions (manipulation, exercise therapy, relaxation therapy, acupuncture, physiotherapy, or TENS) for patients with subacute to chronic low back pain, although effects were small (84, 86). Low-quality evidence showed that a combination of massage plus another intervention (exercise, exercise and education, or usual care) was superior to the other intervention alone for short-term pain in patients with subacute to chronic low back pain (84).

Spinal Manipulation

Low-quality evidence showed no difference in pain with spinal manipulation versus sham manipulation at 1 month (134, 135). Low-quality evidence showed that spinal manipulation slightly improved pain compared with an inert treatment (136–142). Moderate-quality evidence showed no clear differences in pain or function compared with another active intervention. Low-quality evidence showed that a combination of spinal manipulation with another active treatment resulted in greater pain relief and improved function at 1, 3, and 12 months compared with the other treatment alone (134, 143–147).

Ultrasound

Low-quality evidence showed no difference between ultrasound and sham ultrasound for pain at the end of treatment or 4 weeks after treatment (148–150). Low-quality evidence showed no difference between ultrasound and no ultrasound for pain or function (151, 152).

TENS

Low-quality evidence showed no difference between TENS and sham TENS for pain intensity or function at short-term follow-up (153). Low-quality evidence showed no difference between TENS and acupuncture in short- or long-term pain (154).

LLLT

Low-quality evidence showed that LLLT slightly improved pain compared with sham laser (155–157), and 1 RCT (155) showed that LLLT slightly improved function compared with sham laser.

Lumbar Support

Evidence was insufficient to compare lumbar support versus no lumbar support. Low-quality evidence showed no difference between a lumbar support plus exercise (muscle strengthening) versus exercise alone for pain or function at 8 weeks or 6 months (158). Low-quality evidence showed no clear differences between lumbar supports and other active treatments (traction, spinal manipulation, exercise, physiotherapy, or TENS) for pain or function (159–161).

Taping

Low-quality evidence showed no differences between Kinesio taping and sham taping for back-specific function after 5 or 12 weeks, although effects on pain were inconsistent between the 2 trials (162, 163). Low-quality evidence showed no differences between Kinesio taping and exercise for pain or function (164, 165).

Other Therapies

Evidence was insufficient to determine the effectiveness of electrical muscle stimulation, interferential therapy, short-wave diathermy, traction, or superficial heat or cold.

Radicular Low Back Pain

Exercise

Low-quality evidence showed that exercise resulted in small improvements in pain and function compared with usual care or no exercise (166–168).

Traction

Low-quality evidence showed no clear differences between traction and other active treatments, between traction plus physiotherapy versus physiotherapy alone, or between different types of traction in patients with low back pain with or without radiculopathy (169).

Other Therapies

Evidence was insufficient for ultrasound, MCE, Pilates, tai chi, yoga, psychological therapies, multidisciplinary rehabilitation, acupuncture, massage, spinal manipulation, LLLT, electrical muscle stimulation, short-wave diathermy, TENS, interferential therapy, superficial heat or cold, lumbar support, and taping.

Harms of Nonpharmacologic Therapies

Evidence on adverse events from the included RCTs and systematic reviews was limited, and the quality of evidence for all available harms data is low. Harms were poorly reported (if they were reported at all) for most of the interventions.

Low-quality evidence showed no reported harms or serious adverse events associated with tai chi, psychological interventions, multidisciplinary rehabilitation, ultrasound, acupuncture, lumbar support, or traction (9, 95, 150, 170–174). Low-quality evidence showed that when harms were reported for exercise, they were often related to muscle soreness and increased pain, and no serious harms were reported. All reported harms associated with yoga were mild to moderate (119). Low-quality evidence showed that none of the RCTs reported any serious adverse events with massage, although 2 RCTs reported soreness during or after massage therapy (175, 176). Adverse events associated with spinal manipulation included muscle soreness or transient increases in pain (134). There were few adverse events reported and no clear differences between MCE and controls. Transcutaneous electrical nerve stimulation was associated with an increased risk for skin site reaction but not serious adverse events (177). Two RCTs (178, 179) showed an increased risk for skin flushing with heat compared with no heat or placebo, and no serious adverse events were reported. There were no data on cold therapy. Evidence was insufficient to determine harms of electrical muscle stimulation, LLLT, percutaneous electrical nerve stimulation, interferential therapy, short-wave diathermy, and taping.

Comparison of Conclusions With Those of the 2007 Guideline

Some evidence has changed since the 2007 ACP guideline and supporting evidence review. The 2007 review concluded that acetaminophen was effective for acute low back pain, based on indirect evidence from trials of acetaminophen for other conditions and trials of acetaminophen versus other analgesics. However, this update included a placebo-controlled RCT in patients with low back pain that showed no difference in effectiveness between acetaminophen and placebo (low-quality evidence). In addition, contrary to the 2007 review, current moderate-quality evidence showed that TCAs were not effective for chronic low back pain compared with placebo. Additional pharmacologic treatments addressed in the current review included duloxetine and the antiseizure medication pregabalin. Many conclusions about nonpharmacologic interventions are similar between the 2007 review and the update. Additional modalities assessed (with at least low-quality evidence) include mindfulness-based stress reduction, MCE, taping, and tai chi. Additional evidence or changes from the updated review include that superficial heat was found to be more effective for acute or subacute low back pain (moderate-quality evidence) and neither ultrasound nor TENS was shown to be effective compared with controls (low-quality evidence).

Recommendations

Recommendation 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)

Clinicians should inform all patients of the generally favorable prognosis of acute low back pain with or without sciatica, including a high likelihood for substantial improvement in the first month (5, 180). Clinicians should also provide patients with evidence-based information with regard to their expected course, advise them to remain active as tolerated, and provide information about effective self-care options. Clinicians and patients should use a shared decision-making approach to select the most appropriate treatment based on patient preferences, availability, harms, and costs of the interventions. Nonpharmacologic interventions shown to be effective for improving pain and function in patients with acute or subacute low back pain include superficial heat (moderate-quality evidence and moderate improvement in pain and function) and massage (low-quality evidence and small to moderate improvement in pain and function). Low-quality evidence showed that acupuncture had a small effect on improving pain and spinal manipulation had a small effect on improving function compared with sham manipulation but not inert treatment. Harms of nonpharmacologic interventions were sparsely reported, and no serious adverse events were reported. Superficial heat was associated with increased risk for skin flushing, and massage and spinal manipulation were associated with muscle soreness.

We recommend that the choice between NSAIDs and SMRs be individualized on the basis of patient preferences and likely individual medication risk profile. Treatment with NSAIDs resulted in a small improvement in both pain intensity (moderate-quality evidence) and function (low-quality evidence), and treatment with SMRs resulted in a small improvement in pain relief (moderate-quality evidence). There was no evidence for the effect of SMRs on function. Nonsteroidal anti-inflammatory drugs are associated with gastrointestinal and renal risks. Clinicians should therefore assess renovascular and gastrointestinal risk factors before prescribing NSAIDs and recommend the lowest effective doses for the shortest periods necessary. Although they are associated with lower risk for adverse effects than nonselective NSAIDs, COX-2–selective NSAIDs were not assessed for improvement in pain or function. Skeletal muscle relaxants are associated with central nervous system adverse effects, especially sedation.

The updated evidence showed that acetaminophen was not effective at improving pain outcomes versus placebo. However, this study assessed pain at 3 weeks after the intervention, and evidence from head-to-head trials showed no difference between acetaminophen and NSAIDs. Low-quality evidence showed that systemic steroids were not effective in treating acute or subacute low back pain, and we recommend against these drugs for treatment of acute low back pain.

Recommendation 2: For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)

Nonpharmacologic interventions are considered as first-line options in patients with chronic low back pain because fewer harms are associated with these types of therapies than with pharmacologic options. It is important that physical therapies be administered by providers with appropriate training. Moderate-quality evidence showed that exercise therapy resulted in small improvements in pain and function. Specific components associated with greater effects on pain included individually designed programs, supervised home exercise, and group exercise; regimens that included stretching and strength training were most effective. Moderate-quality evidence showed that, compared with usual care, multidisciplinary rehabilitation resulted in moderate pain improvement in the short term (<3 months), small pain improvement in the long term, and small improvement in function in both the short and long term. Low-quality evidence showed that multidisciplinary rehabilitation resulted in a moderate improvement in pain and a small improvement in function compared with no multidisciplinary rehabilitation. Acupuncture had a moderate effect on pain and function compared with no acupuncture (moderate-quality evidence) and a moderate effect on pain with no clear effect on function compared with sham acupuncture (low-quality evidence). Moderate-quality evidence showed that mindfulness-based stress reduction resulted in small improvements in pain and function (small effect), and 1 study showed that it was equivalent to CBT for improving back pain and function.

Low-quality evidence showed that tai chi had a moderate effect on pain and a small effect on function. Tai chi sessions in included studies lasted 40 to 45 minutes and were done 2 to 5 times per week for 10 to 24 weeks. Low-quality evidence showed that yoga improved pain and function by a moderate amount compared with usual care and by a small amount compared with education. Low-quality evidence showed that MCE had a moderate effect on pain and a small effect on function. Motor control exercise, tai chi, and yoga were favored over general exercise (low-quality evidence).

Low-quality evidence showed that progressive relaxation had a moderate effect on pain and function, electromyography biofeedback and CBT each had a moderate effect on pain and no effect on function, and operant therapy had a small effect on pain and no effect on function. Low-quality evidence showed that LLLT had a small effect on pain and function. Low-quality evidence showed that spinal manipulation had a small effect on pain compared with inert treatment but no effect compared with sham manipulation. There were no clear differences between spinal manipulation and other active interventions (moderate-quality evidence).

Harms were poorly reported for nonpharmacologic therapies, although no serious harms were reported for any of the recommended interventions. Muscle soreness was reported for exercise, massage, and spinal manipulation.

Ultrasound, TENS, and Kinesio taping had no effect on pain or function compared with control treatments (low-quality evidence).

Recommendation 3: In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians 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. (Grade: weak recommendation, moderate-quality evidence)

Pharmacologic therapy should be considered for patients with chronic low back pain who do not improve with nonpharmacologic interventions. Nonsteroidal anti-inflammatory drugs had a small to moderate effect on pain (moderate-quality evidence) and no to small effect on function (low-quality evidence) and should be the first option considered. Moderate-quality evidence showed no difference in pain improvement when different NSAIDs were compared with one another. Nonsteroidal anti-inflammatory drugs are associated with gastrointestinal and renal risks. Clinicians should therefore assess renovascular and gastrointestinal risk factors before prescribing NSAIDs and should recommend the lowest effective doses for the shortest periods necessary. COX-2–selective NSAIDs were not assessed for improvement in pain or function, although they are associated with lower risk for adverse effects than nonselective NSAIDs.

For second-line therapies, moderate-quality evidence showed that tramadol had a moderate effect on pain and a small effect on function in the short term. Of note, tramadol is a narcotic and, like other opioids, is associated with the risk for abuse (181). Moderate-quality evidence showed that duloxetine had a small effect on pain and function.

Moderate-quality evidence showed that opioids (morphine, oxymorphone, hydromorphone, and tapentadol) had a small effect on short-term pain and function. Low-quality evidence showed that buprenorphine (patch or sublingual) resulted in a small improvement in pain. Opioids should be the last treatment option considered and should be considered only in patients for whom other therapies have failed because they are associated with substantial harms. Moderate-quality evidence showed no difference in pain or function when different long-acting opioids were compared with one another. Harms of short-term use of opioids include increased nausea, dizziness, constipation, vomiting, somnolence, and dry mouth compared with placebo. Studies assessing opioids for the treatment of chronic low back pain did not address the risk for addiction, abuse, or overdose, although observational studies have shown a dose-dependent relationship between opioid use for chronic pain and serious harms (182).

Moderate-quality evidence showed that TCAs did not effectively improve pain or function (low-quality evidence) in patients with chronic low back pain, which is contrary to the 2007 guideline. In addition, moderate-quality evidence showed that SSRIs did not improve pain.

infertility and acupuncture

It is especially difficult to find oneself afflicted with one of the many clinical causes of female infertility. Blockages in the fallopian tubes, uterine abnormalities or disorders, such as pelvic adhesions (scarring) and endometriosis, are often times the clinically diagnosed cause of a woman’s inability to conceive. However, with all of the named causes, there are cases where the cause of infertility is unknown. The following account details such a case, where an insightful woman looked beyond the unknown struggles of infertility to give birth to twins. The combination of Traditional Chinese Medicine (Acupuncture and Chinese Herbal Medicine) during the In Vitro Fertilization (IVF) process to successfully assist in conception has the most adorable, living proof!

Heather and Brian had been trying to conceive for a year before they consulted a fertility specialist. While Brain was fertile and there was no clear clinical reason for Heather’s infertility, Heather was classified infertile due to unknown causes. It must be noted that Heather had a history of irregular menstruation and had been on birth control for 12 years before she and her husband began trying to conceive. She was a healthy 31 year old, active and had never smoked in her life. After their visit to the IVF specialist, Heather became especially proactive and started doing research on her own. “I was reading a lot of information and found that acupuncture is really helpful [with] the IVF process. I started going to acupuncture before we actually did [IVF]. I went for about three months before the transfer but [especially] during the egg retrieval. Obviously, after battling infertility for a year and 16 months with doing IVF, I really was pretty [anxious] and I wanted it to work the first time. So, I was doing everything that I possibly could to do that. [Then] a friend of mine told me about [Empire Medicine],” Heather recounted.

Empire Medicine is an acupuncture and wellness center with medical doctors from China whom have doctorates in Traditional Chinese Medicine as well as Medical Doctorates in what is universally considered, Western Medicine. Traditional Chinese Medicine uses acupuncture, Chinese Herbal Medicine, massage (Tui na) and exercise (Ch’i gong) to create a balance in one’s Ch’i: the fundamental concept of energy flow and life force that streams through all living things. Western society has become familiar with the yin yang concept of balance that is an emphasized component in Traditional Chinese Medicine. Complimentary to Western Medicine, the physicians at Empire Medicine use their expertise in Traditional Chinese Medicine to focus on areas of immunology and endocrinology. With their cultural understanding and years of intensive training in Traditional Chinese Medicine, Heather was reassured that Empire Medicine could assist her in successfully conceiving via IVF.

“I have five friends that have gotten IVF and I am the only one that is dealing with acupuncture. I was really scared of acupuncture at first. The first time I went in there, I was sweating because I thought I was going to be poked with a bunch of needles. As my doctor was placing the needles, he was wiping the sweat off of me. They were really great! And, it was not anywhere near what I had imagined. I just kind of closed my eyes and let it happen. It was super relaxing and then I was kind of hooked on it. Once I got over that initial fear I was fine because it really wasn’t anything I had expected. I was thinking, ‘Oh my, I’m going to have to get all of these shots!’ In comparison to the amount of shots you have to get for IVF, it was really nothing. It’s funny because before the infertility issues, I had a lot of back [pain] issues and my friends were telling me I should do acupuncture. I was like, ‘I’m not doing acupuncture for my back! That’s going to hurt!’ But, to have a baby, I would literally cut off my limbs. So, I did [acupuncture] for that [reason].”

Heather went to acupuncture with her physician at Empire Medicine twice a week for three months before her egg retrieval. On a daily basis, she would drink the prescribed herbs, twice a day for ten days as per her physician’s instruction. After the successful retrieval they were able to fertilize 18 “good quality” eggs over a period of three days, resulting in 9 viable embryos. Heather and Brian decided to place two of the three-day- old embryos in hopes of having twins. The embryos took on the first try and 32 weeks later, Matthew and Meadow were born!

“I went to acupuncture my whole first trimester. Everybody always talks about the first trimester being so hard with morning sickness and [fatigue]. I felt the absolute best of my entire pregnancy during my first trimester. And, looking back now –honestly- it was all due to acupuncture. There was no particular reason I had stopped going after [the first trimester]; life was just crazy then. After 5 months of acupuncture, I stopped and started developing pregnancy issues like gestational diabetes. I was anemic, and things like that. But, while I was going to acupuncture things were really great. At the time I didn’t realize, but now I know why,” Heather recounted retrospectively.

Heather and Brian were once again ready to add to their family. Because they had 7 frozen embryos, they restarted the initial process before having a single embryo placed. Heather clarified, “We felt bad not using them. I always wonder what would have happened if we tried acupuncture and [conceiving] natural. But, I consider those embryos Matthew and Meadow. How can I not use those [embryos]? They existed already. What we did was let the remaining 7 [embryos] thaw and continue the gestation up to 5 days, leaving the strongest to survive. Two survived. They said that the 5 day old embryos were more likely to be successful.” Two months ago, Heather resumed her bi-weekly visits in conjunction with her twice daily doses of prescribed herbs. Excited and confident that she would once again become pregnant, family and friends cheered her on while buffering the possibility it could be unsuccessful this time around. Heather never once believed she couldn’t get pregnant again. Two weeks before she provided her testimony, Heather underwent egg transplantation.

Heather’s recollection of her initial experience was vivid. But, more powerful than the pain was the coming of joy. “I always liken it to a grieving process every month. Because every month you would have the hope. Then, your mind is so powerful, that every month I would feel every symptom of pregnancy and then get my period and restart the whole grieving process. First, I would be in denial and then I would be angry. Then, I’d be sad. Then I’d turn back to hope always keeping in mind: ‘There’s always next month.’ But with IVF, I was really overwhelmed with what the process was, with how many medications there are, giving yourself injections every day and just what it was all about. I think getting acupuncture helped with that a lot, too. Besides the fertility benefits I think it gave me peace. A time where I could completely zone out. It was almost like a meditation. At times, I could just let all of that go, because all that was going on in my mind wasn’t going to make it work. And, it can be so overwhelming. It was really overwhelming in the beginning. And yet, I really looked forward to acupuncture then. And now!” Heather exclaimed, “It’s my half-hour of no one bothering me. My phone is off. The twins aren’t there. My husband is not there. It’s literally my 2 half-hours a week to myself! I told my husband, ‘I have to go my entire pregnancy!’”

“[Besides] the medications, the injections and appointments; [the] hardest part for me is this period- the 12 days between the transfer and the pregnancy test. It feels like forever. Every day feels like it’s just dragging. But the funny thing is, acupuncture does make it feel like it goes faster. I get that bit of peace for a while each time I go; I go on Tuesdays and Thursdays and it just makes the week go faster. This ‘hopeful’ pregnancy, I definitely plan to do acupuncture the whole time because I certainly feel that will help with any of the issues; like the anemia and the gestational diabetes that I had the first time. I feel like it will help with that. I had a great first trimester the last time and I want exponentially that this time,” Heather concluded.

Heather and Brian are currently pregnant with their third child. Through research, patience, support and the willingness to explore the benefits of acupuncture and Chinese Herbal Medicine, someone you know suffering from infertility can find the same hope that lead to their fulfilled happiness.

For a consultation, contact one of our local offices.