Beruflich Dokumente
Kultur Dokumente
clinical therapeutics
This Journal feature begins with a case vignette that includes a therapeutic recommendation. A discussion
of the clinical problem and the mechanism of benefit of this form of therapy follows. Major clinical studies,
the clinical use of this therapy, and potential adverse effects are reviewed. Relevant formal guidelines,
if they exist, are presented. The article ends with the authors clinical recommendations.
A 45-year-old construction worker with a 7-year history of intermittent low back pain
is seen by his family physician. The pain has gradually increased over the past
4 months, despite pain medications, physical therapy, and two epidural corticosteroid
injections. The pain is described as a dull ache in the lumbosacral area with episodic
aching in the posterior aspect of both thighs; it worsens with prolonged standing and
sitting. He is concerned about losing his job, while at the same time worried that con-
tinuing to work could cause further pain. The results of a neurologic examination and
a straight-legraising test are normal. Magnetic resonance imaging (MRI) shows
evidence of moderate degenerative disk disease at the L4L5 and L5S1 levels and a
small midline disk herniation at L5S1 without frank nerve impingement. The pa-
tient wonders whether acupuncture would be beneficial and asks for a referral to a
licensed acupuncturist.
The pathophysiology of chronic low back pain is poorly understood, but is increas-
ingly recognized as complex and multifactorial. Progress in elucidating mechanisms
has been impeded by difficulties in defining suit- tice have arisen, the approach used in traditional
able animal models that are clearly relevant to the Chinese medicine appears to be the most widely
human disorder and in conducting informative practiced in the United States.31
physiological studies of chronic pain in humans. Traditional Chinese medicine espouses an an-
Some of the above-mentioned structural ab- cient physiological system (not based on Western
normalities of the spine are well established as scientific empiricism) in which health is seen as
causes of low back pain. Other abnormalities do the result of harmony among bodily functions
not correlate well with clinical symptoms.6 Find- and between body and nature. Internal dishar-
ings such as disk herniation and facet-joint de- mony is believed to cause blockage of the bodys
generation, when associated with central spinal vital energy, known as qi, which flows along 12
stenosis or nerve-root impingement, have been primary and 8 secondary meridians (Fig. 1). Block-
correlated with low back pain, most often in as- age of qi is thought to be manifested as tender-
sociation with sciatica or neurologic deficits. How- ness on palpation. The insertion of acupuncture
ever, there is a high prevalence of such spinal ab- needles at specific points along the meridians is
normalities in asymptomatic persons,9,10 and such supposed to restore the proper flow of qi.
findings are poor predictors of back pain in long Efforts have been made to characterize the ef-
itudinal studies.11,12 Muscular and soft-tissue ab- fects of acupuncture in terms of the established
normalities have also been described,13,14 but their principles of medical physiology on which West-
role in low back pain remains uncertain. ern medicine is based. These efforts remain in-
More recent investigations focus on alterations conclusive, for several reasons. First, the majority
in the central nervous system, detected with vari- of studies have been conducted in animals, and
ous imaging methods, that are associated with it is difficult to relate findings from such studies
chronic low back pain.15 Studies using functional to effects in humans. Second, acupuncture has
MRI have shown alterations in cerebral activa- been shown to activate peripheral-nerve fibers of
tion,16,17 and anatomical studies have shown all sizes, rendering a systematic study of respons-
changes in regional volume and density in the es complex. Third, the acupuncture experience is
brain.18-20 It has been suggested that these altera- dominated by a strong psychosocial context, in-
tions may reflect or contribute to changes in cen- cluding expectations, beliefs, and the therapeutic
tral nervous system processing of sensory stimuli. milieu.32-34
However, the specific findings of these studies Despite these limitations, some physiological
have not been entirely consistent with one an- phenomena associated with acupuncture have
other, and it is not clear whether the observed al- been identified. Local anesthesia at needle-inser-
terations are a cause or a consequence of chronic tion sites completely blocks the immediate anal-
low back pain. gesic effects of acupuncture, indicating that these
In addition, psychological and behavioral fac- effects are dependent on neural innervation.35
tors, including fear of movement, appear to play Acupuncture has been shown to induce the re-
an important role in patients with chronic low lease of endogenous opioids in brain-stem, sub-
back pain.21-24 Such patients have been shown to cortical, and limbic structures.36,37 In the rat,
have altered brain-activation patterns at subcor- electroacupuncture has been shown to induce pi-
tical and cortical sites associated with emotion tuitary secretion of adrenocorticotropic hormone
and postural control.25-28 Studies comparing psy- and cortisol, leading to systemic antiinflamma-
chosocial variables with anatomical findings have tory effects.38 Functional MRI studies in humans
shown the former to have greater predictive value have shown immediate effects of prolonged acu-
than the latter.11,12 puncture stimulation in limbic and basal fore-
Acupuncture is a therapeutic intervention char- brain areas related to somatosensory and affec-
acterized by the insertion of fine, solid metallic tive functions that are known to be involved in
needles into or through the skin at specific pain processing.39 Results on positron-emission
sites.29,30 The technique is believed to have origi- tomography have shown that acupuncture in-
nated in China, where it has remained a funda- creases -opioidbinding potential for several days
mental component of a system of medical theory in some of the same brain areas.40 Acupuncture
and practice that is often termed traditional also has effects on local tissues, including me-
Chinese medicine. Although a number of differ- chanical stimulation of connective tissue,41 re-
ent techniques or schools of acupuncture prac- lease of adenosine at the site of needle stimu
Cl inic a l E v idence
score ranging from 0 to 100, with 100 represent- chiatric conditions (e.g., psychosis), and local skin
ing perfect back function. At 3 months, the mean infections or trauma to the skin (e.g., burns).53
back-function score in the acupuncture group had In addition, electroacupuncture should be avoid-
increased from 61.8 to 74.5 (a mean increase of ed at the site of implanted electrical devices, such
12.1 points), and the mean score in the control as pacemakers. Acupuncture is not contraindi-
group had increased from 63.3 to 65.1 (a mean cated during pregnancy. However, some specific
increase of 2.7 points), for a difference in mean acupuncture points are known to be especially
between-group improvement of 9.4 points (95% sensitive to needle insertion; these sites, as well
confidence interval, 8.3 to 10.5; P<0.001). as acupuncture points in the abdominal regions,
should be avoided in pregnant women.54
Cl inic a l Use In the traditional practice of acupuncture,
needle insertion itself may be accompanied by a
Acupuncture is considered to be a form of alter- variety of ancillary procedures, including palpa-
native or complementary medicine, and as noted tion of the radial artery and other areas of the
above, it has not been established to be superior body, examination of the tongue, and recommen-
to sham acupuncture for the relief of symptoms dation of herbal medications. All of these steps
of low back pain. As a result, it is not often re- are based on the application of principles of tra-
garded as the first choice of therapy. However, ditional Chinese medicine, as opposed to Western
since extensive clinical trials have suggested that physiological and medical concepts. To what ex-
acupuncture may be more effective than usual tent such procedures may contribute to the psy-
care, it is not unreasonable to consider acupunc- chological milieu of acupuncture is unknown, and
ture before or together with conventional treat- only a few studies have examined the context in
ments, such as physical therapy, pain medication, which acupuncture treatment is delivered.32,55
and exercise. Many pain specialists incorporate During an acupuncture session for low back
acupuncture into a multidisciplinary approach to pain, the patient lies prone on a treatment couch,
the management of chronic low back pain. with the sites of intended needle insertion ex-
Acupuncture is a regulated discipline, and pa- posed. Acupuncturists typically individualize the
tients should be referred only to practitioners who selection of insertion points for each patient at
are licensed by the state in which they practice. each treatment session on the basis of the history
A diploma from the National Certification Com- and physical examination. Nonetheless, there are
mission for Acupuncture and Oriental Medicine is certain commonly used acupuncture points for
a requirement for licensure in most states. Physi- low back pain, which are listed in Table 1 and
cians may practice acupuncture in the United shown in Figure 2.56,57 A practitioner may mod-
States after completing one of several medical ify the treatment protocol by adding supplemen-
acupuncture programs. tal points. The depth of needle insertion (6.4 to
It is essential that all patients with chronic or 38.1 mm) and the diameter (0.1 to 0.3 mm),
recurrent low back pain undergo a careful diag- length (12.7 to 76.2 mm), and number (4 to 20)
nostic evaluation before selecting a course of of needles used all vary among practitioners and
therapy. Patients with serious spinal disease, such acupuncture schools.
as cancer or infection, are not appropriate can- After insertion of the needles, the patient is
didates for acupuncture and require specific medi- advised to relax and rest with the needles left in
cal or surgical intervention as dictated by the place, typically for 15 to 30 minutes. Frequently,
underlying disorder. Clinical practice guidelines the needles are stimulated manually by the prac-
emphasize clinical red flags, such as a neuro- titioner in order to elicit a dull, localized, aching
logic deficit, unexplained weight loss, fever, and sensation that is termed de qi, as well as needle
structural deformity.51 Imaging is recommended grasp, a tugging sensation perceived by the acu-
for patients older than 50 years of age and for puncturist and caused by mechanical interaction
those with signs or symptoms suggesting sys- between the needle and connective tissue.58 The
temic disease.52 practitioner may further stimulate the needle with
Contraindications to acupuncture include clot- electrical current (electroacupuncture), moxibus-
ting and bleeding disorders (e.g., hemophilia and tion (burning the herb artemisia vulgaris at the
advanced liver disease), warfarin use, severe psy- end of the acupuncture needle), or heat.
Dr. Langevin reports being a member of the board of direc- We thank Eric Manheimer, M.S., and Lixing Lao, Ph.D., of the
tors of Stromatec and receiving grant support and payment for University of Maryland Center for Integrative Medicine, Susan
travel and accommodation expenses from Stromatec. No other Hartnoll, B.A., of the Institute for Integrative Health, Gary Ka-
potential conflict of interest relevant to this article was reported. plan, D.O., of the Kaplan Clinic, and James Swyers, M.A., for
Disclosure forms provided by the authors are available with their comments and advice on the manuscript and Katrina Far-
the full text of this article at NEJM.org. ber for her administrative assistance.
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