Case Study – Acupuncture for Pain

Background: Biomedical

Low back pain with sciatica is characterized by pain in the low back region with intermittent radiating pain down the buttocks, and at times down the upper leg, lower leg and into the foot. Sciatica is associated with sciatic nerve impingement or infection between the nerve roots L3 and S3. The pain many times has its own ending point per presentation, either ending before the knee or before the foot. There are many reasons for low back pain, however low back pain with sciatica can and generally does share the same cause. 1

Approximately 2/3 of the people who experience low back pain also experience leg pain. Leg pain accompanied with back pain, many times, have the same etiology. When they do, leg pain with back pain is referred to as sciatica. If there is no pain in the low back, sometimes leg pain is still referred to as sciatica if imaging shows nerve impingement. Otherwise leg pain can be due to referred pain or other etiologies.1

Low back pain with sciatica can be due to overly tight muscles or structural abnormalities such as bulged disks, osteophytes, stenosis and other spinal abnormalities. Low back pain accompanied with sciatica in elders, are most times degenerative; such as osteoporotic fractures, disk bulges from degeneration, metastases, osteophytes, scoliosis or stenosis.2 The majority of patients who experience sciatica are due to a bulged or herniated disk impinging on a nerve root that radiates along a dermatome specific to the nerve impingement.3

Back pain with sciatica has been found to effect from 1.6% of the general population to 43% of the working population. 90% of those affected are due to bulged or herniated disks impinged on sciatic nerve roots. Most others are due to cysts, tumors or stenosis. Prognosis is considered good, however 30% of those treated still experience pain after one year.6

Low back pain is characterized as being one of the difficult and more expensive challenges to diagnose and treat. Diagnosis can be expensive and difficult, as imaging does not always reflect the reason for pain. Due to majority etiologies such as degeneration, herniated disks and arthritis, treatment options are limited and many times ineffective at reducing pain for the long term.

Biomedical treatments for back pain with sciatica include surgery, physical therapy, steroid injection and pain medication. In one study, steroid injections were found to have better results than saline injections. In disk herniation, surgery was found to have better results than physical therapy. This review was based on one study each and for short-term results only.3

In another study, patients were evaluated to see if selective nerve root blocks prior to physical therapy would assist the physical therapy in pain reduction and sciatica. The nerve root block temporarily assisted in the reduction of pain during the physical therapy process. When the nerve block wore off over a period of time, there was no significant reduction in pain found. 4

No long-term medicinal treatments were found beneficial for the reduction of back pain and sciatica. In a study trying to find medications to reduce pain from sciatica, again, nerve blocks were found significant in the reduction of pain for the short term, however increased pain developed when the nerve blocks wore off. NSAIDS were found to be no more effective than placebo. Antidepressant Nortryptiline did not show any pain reduction benefit. Opiods have not shown any long-term benefit, instead at times they have been known to contribute to increased pain and constipation. Anticonvulsants were found to significantly reduce pain for the short term, however not for the long term. Again, anticonvulsants were thought to contribute to increased pain over time.

Improvement on the pain scale for a short term with surgery, but not for the long term was observed in a review of early surgery versus conservative care for sciatica.5

To conclude for biomedical interventions for back pain with sciatica, no significant long term treatment interventions or medicine have been identified to reduce pain and radiating pain for the long term.

Background: Chinese Medicine

Chinese medicine takes a completely different diagnostic approach when it comes to back-pain involving sciatica. Chinese medicine views pain as Qi and blood stagnation. A higher degree of pain, such as sharp or stabbing pain is viewed as blood stasis.9

Kidney Qi deficiency, kidney yang deficiency, Kidney yin deficiency or Kidney essence deficiency are other patterns that lead to low back pain.9

Wind-cold-damp and damp-heat invasion are considered excess internal pathogenic TCM patterns for low back pain. Wind-cold-damp bi syndrome can be exacerbated in cold/damp conditions and relieved in warm/dry conditions, with warm food and rest. Damp heat patterns can be exacerbated by hot weather and relieved by exercise.9

Radiating pain down the leg is referred to as Qi and blood stagnation with wind. Wind is generally not in a fixed location, though in sciatica, it can still be considered wind due to the intermittent nature.

TCM Pattern Differentiation Chart

SymptomsPatternAcupuncture Points
Dull ache, frustrationQi and blood stagnationLi4, Liv3, GB34, Liv14, Sj6
Sharp pain – purple tongue, worse at night, aggravated by pressure.Blood stasisBl17, Bl18, Li4, Liv3, Sp6, Sp10, REN6
Cold and heaviness in the lower back.Wind/Cold/Damp invasionBl25, BL28, St36, Lu7, Kid6, DU6, SJ5, Li4
Burning pain, heaviness in lower back, aggravated with rainy/hot weather, improved with exercise.Damp heat invasionLi11, Sp6, Sp9, St44, Du9, Bl20, GB34, Liv2, Liov3
Back pain exacerbated with exertion, improved with rest, fatigue, deep pulse.Kidney Qi DeficiencyBl23, Kid3, St36, Du3
Back pain exacerbated with exertion, improved with rest. Pale complexion, cold limbs, 5- center heat, malar flush, dry throat. Pale tongue with wet coat.Kidney Yang DeficiencyREN4, DU4, REN3, Kid7, BL23
Back pain exacerbated with exertion, improved with rest – Red tongue, insomnia, irritability, and dry throat. Red tongue with no coat.Kidney Yin DeficiencyBl52, Kid3, Kid6, Bl23, Ren3
Back pain exacerbated with exertion, improved with rest. Pale complexion with cold limbs. Pale tongue, deep and weak pulses.page5image17925824Kidney Essence DeficiencyREN4, Du4, Kid3, BL23, BL52, REN3

In a review of approximately 785 patients, acupuncture was found significantly more effective than conventional medicine in the reduction of low back pain and sciatica. With acupuncture, a greater intensity of pain was relieved, for longer periods of time and without side affects compared to conventional medicine. Conventional medicine used in the study were Ibuprofen + Prednisone, Ibuprofen + Vitamin B1, Indomethacin and Nimesulide.7

In another study of 90 patients, scalp acupuncture was used compared to a single point acupuncture in the area of pain. After 20 treatments, scalp acupuncture held a significant pain reduction rate of 91% compared to the single needle local point at 66%. This study exemplifies acupuncture expertise in TCM theory and scalp theory may be more effective than single point needling from untrained dry needling professionals.8

Case History

A 75-year-old, 6’5”, 265-pound male came to the clinic with a chief complaint of low back pain with approximately 10 episodes of bilateral sciatica per day. The patient had difficulty walking, sitting and laying down for treatment, due to pain. The patient needed help putting on and tying his shoes. Due to pain, he reported he was only able to sleep 2-3 hours per night. He reported having constant pain at an 8- 9/10 on the pain scale during all hours of the day and evening. He reported always being frustrated, exhausted and sad due to constant pain.

Three months prior to coming to the clinic, he reported having a laminectomy at L3- L4 level and stated the pain worsened after surgery. He had regular appointments with his doctor, who stated he is just going to have to live with the pain and take pain medication to help keep the pain at bay. The patient reported taking pain medication (Vicodin) for the last 30 years and that it barely helped anymore. He stated he has seen his doctor about the pain and the doctor refused to change or increase his medication. He reports being able to perform his life duties on his own, but struggles significantly due to the back pain and sciatica.

Physical Examination

Upon entering the clinic, the patient needed a cane and a hand walking to the treatment room. He was a very large man with huge feet, big bones, humor from the start and a demeanor of strength and pride. It was clear he was in a lot of pain and was very tired. His face appeared tired and pale in color. His blood pressure was slightly elevated, 135/80, pulse was 80 and his temperature was not taken, however felt normal to the touch.

The patient reported his sleep was very limited, sleeping only 2-3 hours per night due to pain. He stated he took naps regularly during the day, which helped keep him going. He reported that he eats healthy meals at the same time every day. He stated loves his dog and that his dog keeps him going. He reported his dog has his own set of medical challenges as well. He did present with an uplifted demeanor with hope, humor and love for life. His exercise consisted of doing water exercise classes in a pool and walking on a treadmill.

The patient’s low back was cold to the touch, his pulses were very deficient in all positions and his tongue was scalloped, purple with no coat and significantly distended underneath.

The patient had a colostomy bag and a catheter for 30 years. He did not have intestines, as he reported they were exposed and destroyed by nuclear radiation while in the military.

This patient had no history of hypertension, headaches, dizziness or palpitations. Both of his parents passed away of cancer at an old age. His subjective feeling of temperature was neutral and reported no bladder or prostate pain. The patient reported that he did not use caffeine, tobacco or recreational drugs.

Orthopedic tests were performed to test for disk bulge/herniation. The straight leg test was positive on both sides, indicative of potential disk bulge(s) or herniations. ROM was very limited, and the Stork Test was positive on both sides. The patient was referred to his doctor and suggested to inquire about an MRI for disk bulges/herniations.

Diagnosis

Acupuncture diagnostics consisted of Traditional Chinese Medicine pattern differentiation and Dr. Tan Method.

The TCM diagnosis was low back pain with bilateral sciatica. The TCM pattern differentiation was diagnosed as Spleen/Kidney Qi deficiency, Liver Qi stagnation, blood stasis with wind.

Spleen Qi deficiency presented with the scalloped tongue and slippery pulse in the right guan position. Kidney Qi deficiency presented with deep pulses, lack of sleep and low back pain. Liver Qi stagnation presented with chronic frustration. Blood stasis presented with sharp severe pain and a purple tongue with no coat. Wind presented with intermittent episodes of sciatica. The treatment principles were to tonify Qi, move Qi and blood, disperse wind and relieve pain. The TCM diagnosis and acupuncture points used remained the same with each treatment.

Treatment – Acupuncture for Back Pain

Dr. Tan acupuncture method is based on palpating for soreness of acupuncture points on distal areas of the body associated with the area of pain. In this patient’s case, the dorsal side of his right hand presented with soreness and was treated by needling the area of soreness for pain in the lower lumbar area. Dr. Tan method was used regularly with every treatment.

The treatment plan consisted of acupuncture twice a week for 8 weeks to reduce pain, assist with sleep, increase energy levels, reduce frustration and increase mobility. Other suggestions were to cut down on exercise on the treadmill to allow the muscles to relax, so that any disks needing to shift back in place have that capability. Other suggestions were to walk every day for short periods of time, not to sit any longer than forty-five minutes at a time, consider magnesium supplementation and maintain acupuncture treatments twice per week. The patient was referred to his PCP or to find a new PCP for pain and due to positive orthopedic tests.

Treatment Chart

Acupuncture PointIndicationsPoint Action page9image18448128page9image15888416Category
SI3 (l) – HouxiLumbar painOpen Du MaiTCM
BL62 (r) – ShemaniLumbar pain page9image17905344Open Du MaiTCM
GB41 (l) – ZuilinqiLumbar pain – page9image17903232Open Dai MaiTCM
TB5 (r) – WeiguanLumbar painOpen Dai Maipage9image17901312TCMpage9image17894016
LI4 (r) – HeguLumbar Pain/SciaticaMove QiTCM
LIV3 (l) – Taichongpage9image17909824Lumbar painpage9image17920000Move QiTCM
KID3 (l) – TaixiFatigue/Back PainTonify KidneyQiTCM
page9image18787776KID7 (r) – FuiliuFatigue/Back PainTonify KidneyQiTCM
page9image18751936SP3 (l) – TaibaiFatigueTonify SpleenQiTCM
page9image17841728ST36 (r) – ZusanliFatigueTonify QiTCM
BL23 (b) – Shenshupage9image15988624Fatigue/Back PainTonify KidneyQiTCM
TCM Actions and Indications

BL59 (b) – FuyangLumbar Pain/SciaticaMove Qipage10image15951264TCMpage10image18462400
M-BW-35 – Hua-tuo- jiaji – L1-S4 (b)Lumbar Pain/SciaticaMove QiExtra-Pointpage10image18702208
M-BW-25 – Shiqizhuixia (b)Lumbar Pain/SciaticaMove QiExtra-Point
Sacral (r)Lumbar Pain/SciaticaMove Qipage10image18867392Auricular
Lumbar (r)Lumbar PainMove Qipage10image18816896Auricular
Shen Men (r)FrustrationCalm ShenAuricularpage10image18423296
MS 8 (b)Lumbar Pain/SciaticaMove QiStandard Scalp
N-UE-19 Yao-tong- xueLumbar Pain/SciaticaMove Qipage10image18769088Dr. Tanpage10image16760240

Acupuncture Needles Used

Single tube, 20mm, 3” needles were used for TCM points at a depth of 1 -1.5 cun. These points were needled and rotated clockwise 180 degrees.

Single tube, 20mm, 1 cun, auricular needles were used for auricular points at an approximate depth of 1/10 cun.

Single tube, 20mm, 2-inch needles were used with scalp points at a depth of 1⁄4 to 1⁄2 inch.

Single tube, 20mm, 3-inch needles were used with Extra-Points at a depth of 2.5 inches.

Single tube, 20mm, 5-inch needles were used for GB30 at a depth of 4 inches.

The patient was bolstered with many pillows for comfort, needled with the previous listed points, and then rested for 20-30 minutes before the needles were removed. Dr. Tan method was then provided.

Single tube, 20mm, 2-inch needles were used with Dr. Tan points at a depth of 1 inch and stimulated by “lifting/thrusting” method for 60-90 seconds while the patient walked forward and backward and gently leaned to all sides, while concentrating on not guarding, but relaxing. The patient then relaxed for 5 minutes, sitting in a chair, with the needles in before being removed.

Results

At the beginning of week 2, after 2 treatments, the patient reported not having much difference in pain. I did notice however; the patient was walking without a cane and was moving better. The patient had not reduced the exercise time and intensity on the treadmill. I told him his pain would likely reduce as well may assist the acupuncture treatments if he reduced his time and intensity on the treadmill.

At the beginning of week 3, after 4 treatments, the patient reported his pain dropping by 50% with no change in sciatica. He reported he had improved sleep and slept for longer periods of time. His pulses were still deficient, but he appeared more rested and appeared to have more energy. His range of motion and walking improved as well. I encouraged him that this has been going on for a long time and to allow our treatment process to have a chance. He felt good about continuing.

At the beginning of week 4, after 6 treatments, the patient’s pain remained about the same as the previous week, though he reported his sciatica had been reduced significantly. Though still deficient, his pulses had more force to them and he seemed to be happier.

At the beginning of week 5, after 8 treatments, the patient reported less pain and sciatica. The patient reported a 3-4/10 on a pain scale and no sciatica episodes for the remainder of the day of and the day after treatment. The sciatica returned after two days, however with less occurrence during those days. He reported that he had been sleeping better and for longer periods of time. His pulses had more force to them.

At the beginning of week 6, after 10 treatments, the patient reported less sciatica occurrences than the previous week, but no further reduction in pain from the previous week. His pulses had about the same amount of force as the previous week and he appeared to be more comfortable in his body. He sat comfortably while doing a short intake and walked more comfortably. At this point, there appeared to be a pattern of needing 2 weeks of acupuncture before the next level of pain reduction each time.

At the beginning of week 7, after 12 treatments and not missing a treatment on schedule, the patient reported a 0-1 on the pain scale and no episodes of sciatica since the last treatment. The patient had improved sleep, however, lying down for long periods is still difficult for him. He reports needing to get up to walk around at night to keep his back loosened up. He reported sleeping 5-6 hours per night and still took naps during the day.

At the beginning of week 8, the patient reported having 1-2 episodes of sciatica before the treatment, but zero episodes for a 2 days after his last treatment. He reported short periods of intermittent pain (1-2/10) during the weekend. After the 16th treatment and 8 weeks, he reported needing a break from acupuncture. I encouraged him to come back for maintenance treatments to help keep his pain reduced.

Discussion

Biomedical treatments have not shown to have long term success with the reduction of back pain accompanied with sciatica. This case study demonstrated how acupuncture was used to treat a patient with chronic severe low back pain with bilateral sciatica.

Bilateral sciatica can be considered a medical emergency due to the possibility of central disk herniation potentially causing the loss of bowel control and paralization from the waist, down. This was a case where the sciatica did not improve since the laminectomy. The patient continued to have daily sciatica episodes for 3 months after the surgery.

The patient was put on an 8-week treatment plan with acupuncture twice per week. Needling to address TCM patterns, scalp needling, auricular needling and Dr. Tan needling method was utilized with each treatment. Week by week the patient improved with improvements in sleep, energy levels, emotional stability and decreased pain. The patient initially presented with 8-9/10 low back pain accompanied with 10+ sciatic episodes every day. He had difficulty walking, dressing, showering and performing general life’s duties while only sleeping 2-3 hours each night due to extreme pain. After 8 weeks and 16 treatments, the patient’s pain decreased to an intermittent 1-2/10 during week 7 and 8 with 1-2 episodes of sciatica each of those weeks. By the end of the 8th week, the patient’s sleep improved, had increased energy levels, his walking improved and was able to preform his life’s duties without challenge.

Conclusion

Acupuncture and Oriental medicine takes a holistic view into consideration with low back pain and sciatica. TCM pattern differentiation and treatment allowed this patient to improve his overall wellness while reducing pain and sciatica.

Based on this case study, and with further exploration, acupuncture may be considered an invaluable treatment for low back pain, accompanied with sciatica.

References

  1. Kherad M, Rosengren BE, Hasserius R, et al. Risk factors for low back pain and sciatica in elderly men-the MrOS Sweden study. Age And Ageing. 2017;46(1):64-71.
  2. Stynes S, Konstantinou K, Ogollah R, Hay EM, Dunn KM. Clinical diagnostic model for sciatica developed in primary care patients with low back-related leg pain. Plos One. 2018;13(4):e0191852.
  3. Jensen RK, Kent P, Hancock M. Do MRI findings identify patients with chronic low back pain and Modic changes who respond best to rest or exercise: a subgroup analysis of a randomised controlled trial. Chiropractic and Manual Therapies. 2015;23:26.
  4. Thackeray A, Fritz JM, Brennan GP, Zaman FM, Willick SE. A pilot study examining the effectiveness of physical therapy as an adjunct to selective nerve root block in the treatment of lumbar radicular pain from disk herniation: a randomized controlled trial. Physical Therapy. 2010;90(12):1717-29.
  5. Pinto RZ, Verwoerd AJH, Koes BW. Which pain medications are effective for sciatica (radicular leg pain)?. BMJ (Clinical Research Ed.) 2017;359:j4248.
  6. Jacobs W, van Tulder M, Peul W, et al. Surgery versus conservative management of sciatica due to a lumbar herniated disk; a systematic review. European Spine Journal. April 2011;20(4):513-522
  7. Ji M, Wang X, Chen M, Shen Y, Zhang X, Yang J. The Efficacy of Acupuncture for the Treatment of Sciatica: A Systematic Review and Meta-Analysis. Evidence Based Complementary And Alternative Medicine: Ecam.2015;2015:192808.
  8. Zhi L, Jing S. Clinical comparison between scalp acupuncture combined with single body acupuncture alone for the treatment of sciatica. American Journal Of Acupuncture. January1, 1995;23(4):305-7
  9. Shi A, Lin S-S, Caldwell L. Essentials of Chinese medicine: internal medicine. Walnut, CA: Bridge Pub. Group; 2003.

© Patrick Lynch MAOM, DAOM intern, CYT

Sky Ridge Acupuncture, Bend Oregon

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Sky Ridge Acupuncture and Oriental Medicine

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