International Journal of Clinical Pharmacology and Therapeutics, Vol. 54 No.
7/2016 (539-543)
Original
2016 Dustri-Verlag Dr. K. Feistle
ISSN 0946-1965
DOI 10.5414/CP202625
e-pub: June 10, 2016
Key words
low back pain integra-
tive Western medicine
traditional Chinese
medicine
Received
February 17, 2016;
accepted
April 21, 2016
Correspondence to
Prof. Regina W.S. Sit
Lek Yuen Health Centre,
Room 404, 4/F, Shatin,
Hong Kong
reginasit@cuhk.edu.hk
Integrative Western and Traditional Chinese
Medicine service model for lower back pain
Regina W.S. Sit1,2, Wendy Wong2, Sheung Wai Law3, and Justin C.Y. Wu2
1The Jockey Club School of Public Health and Primary Care, 2The Hong Kong
Institute of Integrative Medicine, the Chinese University of Hong Kong, and
3Department of Orthopedic & Traumatology, Tai Po Hospital, Hong Kong
Abstract. Objective: Low back pain
(LBP) is a common, costly, and debilitating
condition that creates a heavy socioeconom-
ic burden on the global health care systems.
In Western Medicine (WM), the treatment
goals are to relieve pain, reduce disability,
and enhance rehabilitation. In Traditional
Chinese Medicine (TCM), acupuncture is
frequently used to rebalance the vital energy
Qi. Whilst numerous literatures are avail-
able from WM and TCM in the management
of LBP, the value of an integrative WM-
TCM therapy remains unknown. This article
aims to introduce an integrative WM-TCM
service model for LBP, which is now avail-
able at the Hong Kong Institute of Integra-
tive Medicine, the Chinese University of
Hong Kong.
Background
Low back pain (LBP) is a serious global
public health problem [1]. The 2010 Global
Burden of Disease Study estimated that low
back pain is among the top 10 diseases and
injuries that account for the highest number
of years lived with disability (YLDs) world-
wide [2]. The associated pain and disability
make it a serious and costly health condition,
incurring both direct and indirect expenses
that placed a heavy financial burden on
health care systems [3].
LBP in Western Medicine (WM)
In Western Medicine (WM), LBP can
be defined in terms of duration or etiology.
Acute LBP is defined by duration of pain less
than 6 weeks, subacute LBP of 6 12 weeks,
and chronic LBP of more than 12 weeks
[5]. Specific causes of back pain include
some degenerative conditions, inflammatory
conditions, infective and neoplastic causes,
metabolic bone diseases, disc protrusions,
trauma, other congenital disorders, etc. [6].
Nonspecific low back pain (NSLBP) is de-
fined as low back pain not attributable to a
recognizable, known specific pathology; al-
though mechanical factors, such as poor pos-
ture, have long been thought to play a causal
role in it [7]. NSLBP contributes to almost
90% of chronic LBP with significant con-
sumption of diagnostic tests and health care
services, and is a focus of concern The World
Health Organization [8].
LBP in Traditional Chinese
Medicine (TCM)
In Traditional Chinese Medicine (TCM),
the definition of LBP is stated in the Gen-
eral Treatise on Causes and Manifestations
of All Diseases as ,
, , ,
, , ,
; the meaning of which refers to the syn-
drome presented with unilateral or bilateral
back governed by the kidneys [4]. Disease is
often defined as a sign of imbalance between
two complementary polarities (yin and yang).
The ancient Chinese believed that Qi flows
through a network of channels, called merid-
ians, which bring Qi from internal organs to
the skin surface. These channels the acupunc-
ture points which can be stimulated to correct
the imbalance and restore the body to normal
health [9]. The most commonly diagnosed
syndrome associated with low back pain are
Qi and blood stagnation ; followed
by kidney deficiency and other
syndromes such as Bi syndrome (obstruction
by pathogenic coldness or dampness)
Sit, Wong, Law, and Wu 540
. Patients can always have more than one
syndrome [10, 11].
Pain generators in the spine
LBP can arise from a variety of differ-
ent anatomical sites in concert with complex
mechanical and neurophysiological pro-
cesses that arise in response to trauma and
disease. Various structures in the spine, such
as the intervertebral disc, the facet joint, and
the surrounding ligament, could constitute
the origin of pain in accordance with their
innervation [12]. Nociceptive factors play a
major role in the generation of pain; while
irritation to the dural sleeve, dorsal root gan-
glion, or chemically irritated lumbar nerve
root all contribute to the severity of pain
[13]. In TCM, the imbalance of yin-yang and
Qi is postulated to the development of pain
[14]. In chronic pain, psychological dimen-
sions become relevant and are important in
explaining how people respond to pain [15].
Genetics physical, environmental, and social
factors are also found to affect the pain du-
ration and severity. In view of the multiple
causative models in chronic LBP, it is not
surprising that the efficacy of most treat-
ments are low, given that they only target one
or two pain generators [7].
Current WM treatment of LBP
For acute and chronic LBP, physicians
reassurance, recommendation to stay active,
brief education, spinal manipulation, exer-
cise therapy, and cognitive behavior therapy
are recommended in most guidelines [16, 17,
18]. A number of medications are available:
paracetamol (acetaminophen) and nonste-
roidal anti-inflammatory drugs (NSAIDs)
are first-line options for pain relief, with
NSAIDs being associated with the risk of
gastrointestinal bleeding. Opioids are more
potent analgesics, but are not a first-line op-
tion due to their abuse potential and adverse
effects such as constipation, nausea, som-
nolence, pruritus, and myoclonus. Skeletal
muscle relaxants and benzodiazepines can
be used as adjunctive medications for acute
low back pain, but have a high incidence of
sedation. Tricyclic antidepressants may be
an option but their effects on pain appear
small or uncertain [19, 20]. Spinal surgeries
with high surgical risks are often reserved for
those with structural lesions, and their role
in chronic NSLBP is very limited [21]. In
chronic disabling cases of NSLBP, intensive
multidisciplinary approaches are often rec-
ommended, although these are not necessar-
ily available everywhere [22].
Current TCM treatment of LBP
In TCM, acupuncture is applied to promote
Qi and blood circulation, eradication of damp-
ness or coldness, supplementation of the kid-
ney or a combination of the above objectives
[23]. The proposed neurohumoral hypothesis
states that acupuncture stimulation activates
A-delta and C-afferent fibers in muscles, caus-
ing signals to be transmitted to the spinal cord
and a subsequent release of endorphins and
monoamines [24, 25]. Imaging studies also
demonstrate that the limbic system plays an
important role in acupuncture-induced analge-
sia [26]. The TCM-based acupuncture therapy
is usually conducted according to the Chinese
meridian lines, based on the associated TCM
syndromes to rebalance the Qi and promote
blood circulation [25].
Apart from acupuncture, herbs are some-
times prescribed according to an individuals
symptom. Chinese herbal medicine has a
recorded history of over 2000 years and has
been receiving increasing public attention
[27]. Chinese herbal medicine can be admin-
istered in a number of ways including cooked
decoctions or herbal soups, concentrated
powders, and herbal pills. Studies suggest that
herbal medicine may alleviate pain in arthritic
condition; however, the efficacy of herbs on
noncancer pain still lacks scientific evaluation
[28]. Moxibustion is another treatment option,
though more studies will be needed to evalu-
ate its role in back pain [29].
The integrative WM-TCM model
for LBP
A pilot integrative (IM) WM-TCM ser-
vice model of LBP is now available at the
Integrative Medical Centre, the Hong Kong
Institute of Integrative Medicine (HKIIM),
Integrative Western and Traditional Chinese Medicine service model for lower back pain 541
the Chinese University of Hong Kong. The
HKIIM was established in September 2014
with the aim of establishing a comprehensive
platform for research, clinical service, and
education. In this service model, we collabo-
rate with the Department of Orthopedic and
Traumatology, the Prince of Wales Hospital,
the Hospital Authority of the Hong Kong
Special Administrative Region, in the refer-
ral and management algorithm. The focus
of this IM model will be patient-centered
care instead of disease-based care.
Step 1: Screening by orthopedic
specialists
Patients with low back pain who are new-
ly referred to the orthopedic outpatient clinic
are screened for suitability to the enrolled
in this IM program. Patients with red-flag
symptoms such as unexplained weight loss
or recent unexplained fever, progressive or
severe neurological symptoms, known struc-
tural deformities, and malignancy are not en-
rolled. X-rays and magnetic resonance imag-
ing (MRI) are used to confirm the diagnosis
in ambiguous cases [30]. Oral analgesics are
prescribed to patients.
Step 2: Integrative WM-TCM
treatment
The integrative therapy is conducted by
our licensed Chinese Medicine practitioners
(CMPs) and physiotherapists (PTs) in the
same treatment session; the designated CMP
is in-charge of the overall patient care from
this step onwards.
We adopt the individual physiotherapy
protocol in this IM model wherein patients
are assessed and treated according to assess-
ment findings. Treatment consists of a combi-
nation of joint mobilizations, joint manipula-
tion, and massage. Home-based exercises are
prescribed specifically to individual patients
which include specific trunk muscle retrain-
ing, stretches, and general spinal mobility. Pa-
tients will also receive advice on how to take
care of the back [31]. Cointerventions such as
interferential therapy [32] and superficial heat
[33] will be applied for short term pain relief.
The aims of the above treatment modalities
are to reduce soft tissue inflammation, release
muscle spasm, decrease spinal compression,
correct biomechanical derangement, and
long-term spinal rehabilitation.
After physiotherapy, acupuncture is con-
ducted according to the Chinese meridian
lines with the aim of rebalancing the Qi ad
promote blood circulation [25]. An overview
of systematic reviews published in 2015 has
concluded that acupuncture may have a fa-
vorable effect on pain and function among
people with LBP [34]. Apart from pain re-
duction, acupuncture was also found to have
potential economic benefit in terms of the
estimated cost per quality adjusted life year
(QALY) and a reduction on the consumption
of public health services [35, 36, 37].
Step 3: Interim communication
between orthopedics, CMPs, and PTs
Integration of this model starts with the
agreement on the clinical diagnosis by all par-
ties. Interim communication is made through
an electronic platform called Integrative
Medicine Information System (IMIS), which
contain both WM and TCMs progress sum-
maries and findings. The treatment sessions
are 2 times per week for 5 weeks, with a total
of 10 treatment sessions, and patients are re-
viewed at regular intervals.
Preliminary clinical results
Unpublished data from a group of pa-
tients suffering from work injury-related
subacute LBP have reported encouraging
short-term results through this integrative
and multidisciplinary program. Apart from
the reduction of pain and increase in func-
tional level, it also shortened the return to
work duration to 6 months, compared to 12
months from local data [38]. Better designed
high quality clinical trials, with the evalua-
tion of the consumption of analgesics and
other health care resources, will be needed to
prove overall clinical effectiveness and cost-
effectiveness.
Conclusion
The improvement in the knowledge of
basic pain mechanism allows the develop-
ment of better treatment options for patients
Sit, Wong, Law, and Wu 542
with LBP. We believed that with the com-
bined strength of Western and Chinese Med-
icine, and a readily available platform for
integrative service and research, our institute
can develop different models for integrative
medicine, which can be applied locally and
internationally in the near future.
Acknowledgment
We would like to acknowledge Ms. Emi-
lie Frances Lau for providing editing support
in this article.
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