Acupuncture in “ Surgery advised ” Back pain

Presented at XXXII Annual Conference of Indian Association of Physical Medicine & Rehabilitation IAPMRCON 04 held at CALICUT , FEB’04

Dr Vinay Varma ,
Anand Pain Relief & Rehab Institute, Sholapur Road, Keshwapur, Hubli 580023, Karnataka
drvinayvarma@rediffmail.com

1. Introduction:

Incidence of back pain is on the rise and indications for surgical interventions are increasing, probably due to advanced & improved technology and / or failure of conventional conservative treatment. “ Surgery Phobia ” is a well known entity among back-pain sufferers and most of them, if not all, try to avoid surgery, when indicated and are willing to try alternative medicines.

Many GPs and specialists are dissatisfied with present specialist services for back pain. Patients also are disillusioned.1 Low Back Pain ( LBP ) is a frequent reason for using unconventional therapies, especially acupuncture.2, 3. Current meta-analyses of randomized-controlled acupuncture trials provided some evidence for the efficacy of acupuncture in chronic LBP.4, 5 There is paucity of preliminary data & clinical trials on the short & long term effects of acupuncture by qualified doctors of modern medicine & acupuncture in back-pain wherein surgery has been advised or indicated . It is common presumption among doctors of modern medicine that acupuncture may be effective only in simple back-pain cases with short term placebo-like effects.

2. Aim of the study:

3. Materials & method:
3.1 Patient selection

Fifty-six patients from March’ 1998 to July 2003 presenting with back-pain at Anand Polio & Pain Relief Centre, Hubli, qualifying the inclusion & exclusion criteria are included in this study. These 56 patients included a senior surgeon, a senior physician, a professor from medical college, a paediatric surgeon from medical college and a cardiologist. All had taken conventional treatment and bed rest of variable period for pain relief.

Inclusion Criteria, Eligibility criteria included

Exclusion Criteria:

3.2 Clinical Analysis;
There were 35 males, 21 females. Age & sex presentation as table No 1, youngest being 18 yrs & oldest 90 yrs.
At the time of first presentation, 17 patients were already on bed rest and other 39 were not attending all routine work. 30 patients presented with pain, 23 patients presented with pain & numbness and 3 patients presented with numbness but no pain. Pain was discogenic in 25 patients & other than discogenic in 31. 41 patients had root pains , one patient had referred pain, and 13 patients had radiculopathy and one had localized back pain. One patient who was diagnosed as Acute PID with imminent Cauda Equina Syndrome had difficulty in passing urine freely and needed pressure On clinical examination, 22 patients were positive for unilateral SLR tests with 8 of them having “well leg raising test” positive. 3 patients had bilateral SLR positive , frank loss of muscle power in 17 patients with muscle atrophy in 8. Ankle reflex absent in 06 patients.
All patients were advised imaging before opting for acupuncture treatment. 38 had MRI/CT Scan and 4 patients had plain X-’rays and 14 patients had refused imaging. Analysis of 38 MRI revealed 8 cases having single disc involvement and 32 cases having multiple discs involvement. Of these : 18 images showed disc bulges, 14 images showed disc protrusions, 03 images showed disc extrusions, 02 anular tear , 15 images showed varied degree of nerve root compression and 20 images showed varied degree of cord compression by the disc , 11 spinal canal stenosis. 10 cases had associated degenerative changes. At the time of first presentation, clinical correlation with MRI was found only in 5 cases.

3.3 Study procedures:

All Patients were subjected to in-depth analysis by specially computerized case history format and clinical examination format which included detailed medical history, routine physical examination, a comprehensive physical examination of the spine, and related neurological examination. Similar subjective and objective evaluations were done for all the patients at the end of each course of 15 days treatment and at the end of 6 months. Specially prepared follow-up chart was filled up by the patients to know the effect of treatment at 6 months. Similar forms were sent by post at the end of every 6 months. Postal / Telephonic contact was maintained for follow-up.

3.4 Interventions: ( Treatment )

All patients were explained the line of treatment with acupuncture and supported by therapeutic exercises and lifestyle modifications (Back school concept) wherever necessary. Treatment was individualized depending on severity of pain, site of pain and associated symptoms. All were advised three to five courses of 15 days each or till saturation point of pain relief is reached. Acupuncture points were selected from the following points. Standard acupuncture nomenclature developed by WHO 1989 is followed.
GV 20 Baihui, GV 14 Dazhui, GV 4 Mingmen , GV 3 Yaoyangguan,
BL 11 Dazhu, BL 25 Dachangshu , BL 32 Ciliao , BL 36 Chengfu , BL 40 Weizhong BL 54 Zhibian, BL 57 Chengshan , BL 60: Kunlun, BL 62. Shenmai
GB 20 Fengchi, GB 30 Huantiao, GB 34 Yanglingquan ,
ST 36 Zusanli, ST 44 Neiting,
HT 7 - Heart Shenmen , LI 4, Hegu, LI 11, Quchi, SP 6 Sanyinjiao,
Extra 21 Huatuojiaji Points
Ear Shenmen
35 patients having severe unbearable pains or not comfortable in any position, were admitted for 15-21 days. Admission was advised for “supervised aggressive conservative treatment” with relative rest & restricted activities. 21 patients were treated as outpatients. Acupuncture was given twice daily to all the patients during first course. 05 patients needed medications eg. Diclofenac for first few days to a week. One patient was given Tab. Carbamazepine. Graded simple Therapeutic exercise were taught as & when indicated and were explained about Back Care. After first course of treatment re-examination was done on specially prepared subjective & objective follow-up formats. The tailor-made instructions with examination report (history + clinical examination ) computer printouts were given to patients . Second course of 15 days Acupuncture was started after gap of 15 days. 06 patients were re-admitted for second course & all others continued as outpatient All patients were instructed to do therapeutic exercises as demonstrated during gap period ( and during treatment too.). Similarly third course was started after the gap of 15 days as out patient for all. 8 cases needed four courses & 6 cases needed five courses as per table showing.
Flow chart for acupuncture treatment:
15 days daily Acupuncture -------> 15 days No Acupuncture -------> 15 days daily Acupuncture -------> 15 days No Acupuncture -------> 15 days daily Acupuncture

4. RESULTS:
4.1 Clinical analysis:

All the patients presented here were assessed for subjective & objective improvement every 15 days and at the end of Acupuncture treatment and at the end of six months. A specially prepared questionnaire in the form of Follow-up Answer sheet was given to all the patients in addition to regular follow-up. All the patients were assessed in depth for severity of pain by percentile method - a variable of visual analog. The level of pain at first visit was taken as 100% and subsequent relief was expressed in percentage.
One patient discontinued treatment after first course and opted for surgery and another discontinued and opted traditional therapy. Both are not excluded from the study but taken as failure. Another one wished to stop treatment after first course as he got full relief from pain and is back to his work and is under follow up & supervision.
Out of 22 unilateral positive SLR , 20 became SLR negative. All 8 well leg raising test positive became negative. All 3 bilateral SLR positive became negative. Loss of muscle power in 17 patients with muscle atrophy improved to near normal in 15 patients. Ankle reflex absent in 06 patients and only in one patient reflex was returned. A patient who was diagnosed as Acute PID with imminent Cauda Equina Syndrome having difficulty in passing urine freely and needed pressure was able to pass urine freely in 15 days.
Overall, 41 patients reported back to previous work as before without any restrictions, 10 patients returned to previous routine / employment but with some restrictions and another 4 patients who reported as failures are also returned to work with the help of other alternative modalities. 1 patient who underwent surgery no follow up was possible.
Following criteria was used in addition to routine clinical assessment and results grouped into good, satisfactory and poor group as per table 8.

4.2 Post MRI Study :

This is probably a unique study . Post treatment MRI study was done in 10 cases . 6 cases showed significant regression of the disc lesion and in remaining 4 cases no significant regression was seen. No increase in disc lesion was reported.

5. Clinical Safety:

No significant side effects or complications were noticed during or after treatment, except local ecchymosis at the site of acupuncture in 4 patients but needed no treatment , acupuncture was avoided at these points for 7 days. 53 patients experienced improved sleep with no hangover, improved appetite, more active and above all feeling of well being & cheerfulness. These are termed as positive side effects(6). 49 patients described acupuncture as servicing of their all the systems. Thus, acupuncture is not only safer than much conventional treatment, but the side-effects of acupuncture, are most likely to be perceived by the patient as a positive benefit of treatment & thus improve quality of life.

6. CONCLUSION:

This study provides clear preliminary data in favour of use of Acupuncture in the management of “ADVANCED DISCOGENIC BACK PAIN” wherein surgery was indicated.
Particularly important in
1. Unfit patients
2. Patients reluctant to undergo major surgery
3. Palliation of symptoms in those awaiting surgery

This Study suggests :
1. This treatment has major cost implications in terms of reducing surgery and improvement of      quality of life
2.  It is an EFFECTIVE form of treatment receiving GREATER ACCEPTANCE.
3. Acupuncture may be considered in comprehensive conservative therapy for low back pain      before considering surgery.

Acupuncture gives long lasting pain relief with improved quality of life, without side effects. This is what our patients need i.e. “ adding life to years” with acupuncture.
Acupuncture can be practiced scientifically.
More scientific studies like Randomized Controlled Trials ( RCTs )are needed by qualified doctors.

7. DISCUSSION
Basic-Science Evidence

Acupuncture has proved to be a useful additional therapeutic option to clinical practice.(7) Acupuncture restores health, not simply ameliorate or disguise symptoms. Acupuncture may be combined effectively with conventional medical or surgical interventions.(8) Electro-analgesia is well established but based on our knowledge of Western medicine, it is difficult to believe that acupuncture treats disorders and diseases by direct control of organs or organ-related disorders and diseases. Numerous surveys show that, of all the complementary medical systems, acupuncture enjoys the highest credibility in the medical community (9) because of data showing that acupuncture in the laboratory has measurable and replicable physiologic effects that offer plausible explanations for the presumed actions. In a review of 228 basic research studies, Pomeranz offered a comprehensive theory proposing that acupuncture activates small myelinated nerve fibers in the muscle, sending impulses to the spinal cord, which then activates centers in the spinal cord, midbrain, and pituitary-hypothalamus to produce analgesia.(10) These responses include changes in plasma or corticospinal fluid levels of endogenous opioids (for example, endorphins and enkephalins) or stress-related hormones (for example, adrenocorticotropic hormone) (11). In one study, the effects of acupuncture in one rabbit could be transferred to another rabbit by cerebrospinal fluid transfusions (12). Acupuncture may inhibit early-phase vascular permeability, impair leukocyte adherence to vascular endothelium, and suppress exudative reaction to a degree equivalent to that of orally administered aspirin and indomethacin (13). Evidence also supports the possibility that one mechanism of acupuncture may be a form of stimulation for the gene expression of neuropeptides (14). Functional magnetic resonance imaging ( fMRI ) is also beginning to demonstrate that acupuncture has regionally specific, quantifiable effects on relevant structures of the human brain.(15) In another study fMRI demonstrated the CNS pathway for acupuncture stimulation. Acupuncture at ST.36 and LI.4 activates structures of descending antinociceptive pathway and deactivates multiple limbic areas subserving pain association. An important finding was that the hypothalamus showed a tendency for sustained activation on the fMRI obtained after acupuncture. Such sustained activation of the hypothalamus may have a bearing on the long-lasting analgesic effect of acupuncture in the clinical setting. The finding that acupuncture at LI.4 activated the hypothalamus more extensively than did acupuncture at ST.36 may be in agreement with the clinical observation that acupuncture at the LI.4 acupoint has a stronger analgesic effect. (15)

8. Acknowledgment:
The author thanks

REFERENCES