Adrian White, Japanese Acupuncture and Moxibustion, 2010; Vol.6(1): 17-22

The 2 nd JSAM International Symposium on Evidence-based Acupuncture

Low back pain - an introduction
Adrian WhiteClinical Research Fellow, Peninsula Medical School, UKAbstract
Low back pain affects up to 80% of people some time in their life, and about 8% report severe pain in the previous year. It is associated with psychological distress. It is a major cause of work loss and burden to the community.
In 85% of patient with low back pain presenting to primary care, no clear diagnosis is established. Red flags may be
used to distinguish between non-specific low back pain, pain that is associated with radiculopathy or spinal stenosis, and pain that is associated with another spinal cause including serious underlying condition. This distinction isimportant in planning appropriate investigation and management, which are different for each group. Yellow flags
indicate psychosocial barriers to recovery, which should be identified and addressed early. For non-specific low
back pain, management includes encouraging patients to recognise their own role in recovery by maintaining a
positive attitude, avoiding excessive bed rest, and maintaining activity. Treatments for pain relief are gaining support from evidence, and guidelines are increasingly including recommendation for acupuncture in patients in whom
other treatments have failed.

Introduction
The aim of this article is to summarise information on
low back pain to provide a background to the potential
place of acupuncture in management of the problem.
The article principally concerned with adults, and information given may not apply to special groups such as
children and adolescents, pregnant women1), and patientswith non-spinal back pain (e.g. fibromyalgia, othermyofascial syndromes). This article mainly relates tolow back pain, though some of the information also
applies to pain in other spinal areas such as thoracic or
cervical pain. Sources for this article are shown in Box 1.
Definitions
Low back pain (LBP) means pain experienced dorsally between the costal margins and the gluteal fold.
Sciatica means pain radiating down the back of the leg
below the knee (though patients often use the word toindicate any leg pain) in the distribution of the sciatic
nerve. Sciatica suggests nerve root compromise due tomechanical pressure. Sciatica refers to the pain, whereas
radiculopathy refers to dysfunction of the nerve root
associated with pain, sensory impairment, weakness ordiminished deep tendon reflexes in a nerve root distribution.
Acute LBP is generally used to mean pain of less than
4 weeks and chronic LBP of more than 3 months, withsubacute between 4 weeks and 3 months.
Non-specific low back pain is low back pain in which
the cause of the pain cannot be attributed to any specificpathology. Sprains and strains of the back are also considered to be non-specific low back pain. Degenerativechanges on lumbar imaging are generally regarded as
non-specific as they correlate poorly with symptoms.
Natural history
Most patients with a new episode of LBP recover

Corresponding author: Adrian WhiteClinical Research Fellow, Peninsula Medical School N 32 ITTC Building, Plymouth, PL 6 8 BX UK
E-mail: adrian.white@pms.ac.uk

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Adrian White, Japanese Acupuncture and Moxibustion, 2010; Vol.6(1): 17-22

quickly and without residual functional loss. However,recurrence is common, some 60-90% suffering a relapse,with each recurrence having the potential to be more
severe and long-lasting. In any new episode, between 60%
and 70% recover within six weeks, and 80-90% recover
within three months. However, for the 10-20% who do
not recover within three months, the recovery process isslow and makes a large and costly demand on the healthcare system. This group of individuals is also a major
contributor to disability and absence from work.
Prevalence and community burden
Low back pain is extremely common, although precise
figures for prevalence vary between studies because ofvariations in definition and other factors. It affects about
one in seven of the British population cent at any onetime, one in three in the previous year, and about 50 to80% of people sometime in their life. In the US, approximately a quarter of all adults report having LBP for
at least one day in the last 3 months, and 8% reported
one episode of severe LBP in the last 12 months.
The peak prevalence is between 45 and 59 years although it is also common in the young and in the elderly2). There is little difference in the prevalence of backpain and disability between men and women, but there isa positive correlation with lower social class.
The onset of LBP is often reported after an accident orinjury, although a causal link may be difficult to demonstrate. There is evidence that repeated flexion and rotation of the trunk and lifting at work are moderate risk
factors for low back pain. Work-related injuries arecommon and the highest incidence of LBP appears in theconstruction industry, agriculture, and in health carestaff. Obesity is often blamed as a cause of back problems, but there is little evidence to support this view.
Psychological distress is common in patients withchronic LBP with disability. In a prospective study of aback pain free population, symptoms of psychologicaldistress predicted future development of new episodes ofLBP3). Indeed, it was estimated that the proportion of
new episodes of LBP attributable to psychological factors in the general population is 16 per cent. The problem is aggravated by claims for compensation and there
is little doubt that patients involved in medico-legal
claims of one sort or another report greater pain, depression, and disability than those not involved.
In Britain, in 1993, the total work loss was estimatedas approximately 150 million days. There was a dramatic increase in the level of disability due to back problem in the 1990 s, without any increase in the numbersof back related injuries. It seems likely that psychosocial
factors play a major role in this increase. In recent years
the rate of increase has slowed.
The costs of back problems are huge and exceed thecosts of many other conditions and diseases. In Britain,in 1993 the total cost of LBP was estimated to be some
￡6.5 billion4). In the United States in 1990, the cost ofLBP was estimated to be between $25 and $100 billion5).
Approximately 2% of the workforce are compensatedfor back pain each year. In the Netherlands in 1991, thetotal direct medical costs were estimated at US$368
million and the total cost of absenteeism and disability
payments (indirect costs) at US$3.1 and US$1.5 billion,
respectively. Approximately 5% of the people with LBP
account for 75% of the costs.

19Adrian White, Japanese Acupuncture and Moxibustion, 2010; Vol.6(1): 17-22Aetiology
In 85% of cases presenting to primary care, no precise
diagnosis of the cause of pain is ever achieved. A great
variety clinical diagnoses such as muscle strain, degenerative disc disease, facet syndrome, myofascial pain
syndrome, segmental instability, minor intervertebral
displacement, iliolumbar syndrome, piriformis syndrome,
etc. have been described within this broad category
based on the symptoms, signs and hypotheses. However,these diagnoses not reproducible even by experienced
clinicians.
In view of the mechanical forces which the humanspine has to undergo in its roles of bearing the weight of
the upper structures of the body, providing flexibility for
movements, and protecting vital structures, it is inevitable that degenerative changes will occur. However, thepresence of such changes does not strongly correlatewith symptoms.
The locations of nociceptive receptors that may be involved in LBP are shown in Box 2. In addition, many
patients with chronic low limb pain show evidence of
sympathetic dysfunction. The sympathetic chains run
alongside the vertebral column forming multiple
anastamoses, and sympathetic nerves accompany bloodvessels into the lower limbs.
Diagnosis: history and examination
The initial aim of clinical examination is to place patients in one of three broad categories:
・Non-specific LBP (typically >85% of those who present in primary care)
・LBP potentially associated with radiculopathy or spinal stenosis
・LBP potentially associated with another spinal cause

including serious other underlying conditions.
The well known cauda equina syndrome is commonly
associated with massive midline disc herniation, but isextremely rare (0.04%).
It is conventional in some settings to use a system offlags to assist clinical judgement (see Box 3). Red flags
indicate the possibility of serious underlying disorder;and 'yellow flags' indicate risk factors for developing orpersisting chronic pain and long-term disability. There is
no benefit to patients with non-specific LBP in routinely
ordering imaging or other diagnostic tests, but the othertwo groups should be investigated or referred to secondary care, with appropriate urgency.
Investigations
In the UK, recommendations for ordering a radiographin a patient presenting with back pain include the following: age over 50, fever, weight loss, significant trauma,
previous history of neoplasia, use of corticosteroids,
drug or alcohol abuse, neurological symptoms and signs,
particularly if widespread, night pain, morning stiffness(in which case a pelvic rather than a lumbar radiographis recommended to detect sacroiliitis), and the persistence of pain after one month of conservative therapy.
In patients with persistent pain, those with signs or
symptoms of radiculopathy or spinal stenosis should be
investigated with MRI or CT if they are potential candidates for surgery. Many radiologists consider MRI to be
the imaging modality of choice for the diagnosis of lumbar disorders. It provides a unique non-invasive meansof studying the spine and is unsurpassed for imaging softtissues. It is particularly helpful in the evaluation ofspinal cord tumours, as well as infections of the spine,including discitis, epidural, and paraspinal abscesses.
Computed tomography is superior to MRI for the evalu-

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ation of bony structures and therefore is the modality ofchoice for spinal stenosis, particularly when combinedwith myelography.
Injection studies done under fluoroscopic guidance are
the only means of diagnosing back pain of discal,
zygoapophyseal, or sacroiliac joint origin.
The approach to treatment
Management recommendations in the UK changed
abruptly in the mid-1990 s in response to new evidence6).
The old regime was routine radiology, bed rest,
immobilisation with corset, and traction. The new
regime became imaging only when indicated, bed rest
only when absolutely necessary for pain relief and thenfor only short periods, maintain activity, and avoidtraction. In addition, the crucial influence ofpsychological factors into chronicity and prolonged
work absence were first overtly identified and explored,
and the need to include psychological management wasrecognized.
One particularly major change in recent years has
been was the shift in emphasis from the patient as apassive recipient of 'treatment' to an active participant in'active management'. Health professionals have an
important part to play in not encouraging patients to rely
on interventions that will 'cure their pain', but to adopt
healthy lifestyle, postures, exercise and activities thatwill restore and maintain symptom-free lumbar spine.

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Adrian White, Japanese Acupuncture and Moxibustion, 2010; Vol.6(1): 17-22

Information on this management approach are now
widely available. Practitioners should provide
information and advice to foster a positive attitude andrealistic expectations, avoiding negative language. They
should:・Help people understand the problem by providing
accurate and positive information
・Help people understand the treatment, particularlythat the responsibility for managing symptoms isshared between the person and the healthcare
professional.
・ Recovery is helped by getting moving again andgetting back to work as soon as possible. Medication
can be taken to relieve the pain. Bed rest should not be
prolonged any longer than is necessary, and normal
activities should be resumed as soon as possible. Many
normal postures and movements will stimulate a littlepain, which is normal and not harmful to progress, andto ensure that pain is kept within tolerable limits,
resumption of normal activities should be paced byconducting them at a reduced level or slower rate.
・Return to work as soon as possible, as there is noneed to wait for complete freedom from pain.
Returning to work helps to relieve pain by getting backto a normal pattern of activity and providing a
distraction from the pain.
There is good evidence from a systematic review on
the general factors that can make a clinical consultation
effective7), including rapport, setting the agenda for theconsultation up front, and acknowledging social andemotional cues can improve the quality and efficiency ofcare.
Conservative interventions including acupuncture
There is strong evidence for the effectiveness ofanalgesics, non-steroidal anti-inflammatory drugs, andmuscle relaxants8). Acupuncture is increasingly being
included in treatment guidelines. It is increasingly
understood as a form of neurophysiological stimulation9).
The German health insurance companies made anevidence-based decision to reimburse acupuncture
treatment10). The evidence from a large study in which
acupuncture was superior to guideline care based onevidence11) was influential.

The UK's National Institute for Health and ClinicalEffectiveness, (NICE) have published draft evidence
based guideline which is currently under review for final
publication. The draft guidelines include the sentence:'Consider offering a course of acupuncture needlingcomprising up to 10 sessions over a period of 12 weeks.
In the US, the consensus recommendations of theAmerican College of Physicians and American Pain
Society include acupuncture for patients with subacuteor chronic back pain who do not improve with self-care
options12). Other interventions recommended for thisgroup of patients include intensive interdisciplinary
rehabilitation, exercise therapy, massage therapy, spinal
manipulation, yoga, cognitive-behavioural therapy orprogressive relaxation. It is the subject of intensive andincreasingly high quality clinical research, which ispresented and discussed in companion articles.
References
1) Ee CC, Manheimer E, Pirotta MV, et al. Acupuncture for pelvic and back pain in pregnancy: a systematic review. American Journal of Obstetrics andGynecology. 2008; 198(3): 254-9.
2) Papageorgiou AC, Croft PR, Thomas E, et al. Influence of previous pain experience on the episode incidence of low back pain: results from the South
Manchester Back Pain Study. Pain. 1996; 66(2-3):
181-5.
3) Thomas E, Silman AJ, Croft PR, et al. Predicting
who develops chronic low back pain in primary care:a prospective study. British Medical Journal.
1999; %19; 318(7199): 1662-7.
4) Maniadakis N, Gray A. The economic burden of backpain in the UK. Pain. 2000; 84(1): 95-103.
5) Chou R, Qaseem A, Snow V, et al. Diagnosis andtreatment of low back pain: a joint clinical practiceguideline from the American College of Physicians
and the American Pain Society. Ann Intern Med.
2007; 147(7): 478-91.
6) Waddell G. Simple low back pain: rest or active exercise? Annals of the Rheumatic Diseases. 1993;
52(5): 317-9.
7) Mauksch LB, Dugdale DC, Dodson S, Epstein R.
Relationship, communication and efficiency in the
medical encounter: creating a clinical model from aliterature review. Arch Intern Med. 2008; 168(13):1387-95.

22Adrian White, Japanese Acupuncture and Moxibustion, 2010; Vol.6(1): 17-228) Chou R, Huffman LH. Medications for acute andchronic low back pain: a review of the evidence foran American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med.
2007; 147(7): 505-14.
9) White A and Editorial Board of Acupuncture inMedicine. Western medical acuuncture: a definition.
Acupunct Med. 2009; 27(1): 33-5.
10) Linde K, Streng A, Hoppe A, et al. The programme
for the evaluation of patient care with acupuncture(PEP-Ac) - a project sponsored by ten German social
health insurance funds. Acupunct Med. 2006;
24(Supp): 25-32.
11) Haake M, Muller HH, Schade-Brittinger C, et al.
German Acupuncture Trials (GERAC) for chronic
low back pain: randomized, multicenter, blinded,parallel-group trial with 3 groups. Arch Intern Med.
2007; 167: 1892-8.
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for acute and chronic low back pain: a review of theevidence for an American Pain Society/American
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