Volume 1, Number 4 | Winter 2006

Japanese Acupuncture - Current Research
Clinical Practice and Studies on Acupuncture for Lumbar
Disc Herniation in Japan

Hitoshi Yamashita1), Shoko Masuyama1)
Tomoko Kurasawa2), Hiroshi Tsukayama2)
1) Department of Acupuncture, Morinomiya
University of Medical Sciences, Osaka, Japan
2) Center for Integrative Medicine, Tsukuba
University of Technology, Tsukuba, Japan

1. Introduction
Our research showed that in Japan theannual utilization rate of acupuncture treatment
was 6.1%, whereas the life time utilization was32%1). Data did not show what percentage ofpatients with lumbar disc herniation (LDH) wereincluded among these users. It is conceivable thatsince musculoskeletal problems are generally
motivational to receive acupuncture treatment2),
the acupuncture treatment may often have beenused for this disease. In fact, we have often
performed acupuncture treatment for LDH
patients classified as within conservativetreatment.
As with
the generalization of the
Evidence-Based-Medicine (EBM) in the present
health-care arena, acupuncture treatment is noexception. In recent years, randomized controlled
trials (RCT) have increasingly been conducted inJapan to demonstrate clinical evidence for
effectiveness and safety of acupuncture
treatments3). As for the acupuncture treatment
specific for LDH patients, sufficient clinicalstudies have not been carried out in Japan. This
report provides the summarization of the current
status of clinical studies in Japan on the use ofacupuncture for LDH and explanation of thedetailed methods of our acupuncture treatments.
Acupuncture is not a direct approach to LDH,a morphological abnormality. Rather, it is atreatment for pain in the low back or lower
extremities caused by such abnormality.
Therefore, this report presents, in the strict sense,2“acupuncture treatment for lumbar radiculopathyor sciatica due to LDH”.
2. Case series studies on acupuncture for LDH inJapan
Although only a few RCT reports have been
published so far on acupuncture treatment onpatients with LDH4,5), RCT’s in the relevant area
have yet to be carried out in Japan. However, inJapan there are three case series studies in whichchanges in subjective symptoms and clinicalfindings before and after the acupuncture
treatment on patients with LDH were compared.
The first was the analysis performed byMaruyama6) of 47 cases (male 29, female 18, mean
age 34.2). Acupoints were selected from BL40,
BL54, BL36, BL57, BL60, GB34, BL23, Ex36
(Huatuojiaji), Ah-shi points and others andelectroacupuncture (1-5Hz, 15-20 min per session,
2-4 times per week) were given. The treatment
results were classified in 4 grades: Excellent、Good、Fair、Poor. Fair and above or a certain
degree of improvement was observed with a rateof 72% in the single acupuncture treatment groupand 83% in the combination group of acupunctureand conservative therapy. Patients at a youngerage, or with a shorter duration of the disorder,tended to show favorable results, whereas
patients with a longer duration of the disorder
had a tendency to show better results by thecombination therapy. Objective findings of thereport indicated a high rate of improvement in astraight leg raising (SLR) test and a low rate ofimprovement
insensory
disorderandabnormalities in deep tendon reflex.
The second was the analysis performed by
Yamashita et al.7) of the data on 22 cases (male 14,female 8, mean age 37. accumulated at Tsukuba
College of Technology Clinic (current Center for
Integrative Medicine, Tsukuba University ofTechnology). Points used were BL25 on theaffected side, 2cm lateral to BL25, BL26, center ofThe Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 1, Number 4 | Winter 2006

buttocks, BL37, GB34, and electroacupuncture(1Hz, 15 minutes) and manual needling weregiven. The course after the acupuncture
treatment showed a 68% improvement. In thethird week improvement was assessed with theJapanese Orthopaedic Association Score (JOAScore)8): subjective symptoms 39%、clinical signs
31% 、 activity of daily living (ADL) 52%,
SLR-positive angle 75.5° from 59.3°, pain score
3.8 from 10 of an initial level (all are averagevalues). Patients who already had a long historyof the disorder at the initial treatment, or thepatients who had not been responsive to nerve
blocking, tended not to show favorable treatment
results.
The third was the analysis by Nakazawa9) on
29 cases (male 14, female 15, mean age 54.8),
from which data were gathered at theDepartment of Oriental Medicine, Saitama
Medical School. The needling was performed in
the proximal areas of nerve root, facet joint, upper
buttocks,
andpiriform
muscleandelectroacupuncture or needle retention method
was applied. Assessments were made on the basisof pain score, visual analogue scale, sensory andmanual muscle test, pain in motion, and SLR test.
The rate of improvement after the treatment was
82.7% and the patients who reportedly had
weakness in the lower extremities or developed
the sickness after a traffic accident remained
unchanged.
The above three case series studies reveal thefollowing characteristics in the acupuncture
treatment on LDH:1) About 70-80% of the patients showed
improvement.
2) Patients with shorter duration of the disordertended to be easily healed.
3) Younger patients showed better results.
4) Improvements in deep tendon reflex or muscle
weakness were slower than that in subjective
symptoms or ADL.

These tendencies however, may not be limited
to “the cases of acupuncture treatment” and will
generally be seen in the physical treatment orconservative treatment. Case series study is not amethod of study to prove the specific effects ofacupunctureandmoxibustion
treatment(whether getting better due to acupuncture andmoxibustion). It should be noted that the casesthat showed improvement due to natural courseor placebo effect were included. In the future,
pragmatic RCTs10) that compare effects ofdifferent treatments such as traction and drugs
should be conducted.
3. Case reports11),13)
Case 1
Age 26, Male, Height 172cm, Weight 70kg,
Pain in right lumbar and lower extremities
History: The patient was a postgraduate
student who would sit on a chair while typing histhesis on his computer for 5-6 hours every day
before the onset. Six days ago when he sneezed ina semi-crouching position, pain in the rightlumbar and lower extremities and a sensation ofnumbness appeared immediately. He was given
transcutaneous electrical nerve stimulation,traction, and medication by his neighboring
physician(orthopedicsurgery)andwasinstructed to wear a corset. Although the pain
was slightly relieved, dull pain and numbness
feeling remained and his first visit was made witha desire for the treatment of acupuncture andmoxibustion. In his daily life, he could neither
drive nor keep sitting on a chair for long hours
due to the pain.
Findings: In keeping the standing position /sitting position, dull pain and numbness in thelateral surface of the right lumbar / buttock,posterior and lateral surface of the right leg
became more intense. Neuralgic scoliosis wasobserved. SLR was 60˚(＋) in the right, 90˚(－) inthe left. Manual muscle testing (MMT)：Right

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Volume 1, Number 4 | Winter 2006

long extensor muscle of thumb 4、left 5. Patellartendon reflex (PTR) and Achilles tendon reflex(ATR) were normal without difference between
the right and left. Cutaneous sensory perception:
Hypalgia was observed in the region from thelateral surface of the right leg to the lateralsurface of the right foot (S1 region). Tenderness
was prominent in the bilateral BL23 and theright BL25.
Examination: MRI examination revealed
posterolateral lumbar disc herniation between
L4/5.
Treatment and course:day),Until
thethirdvisit(5thelectroacupuncture (1Hz 15 min.) was continued
on both sides of BL23 and BL25 with the needleof 60mm No. 25. After this treatment, the patient
could have almost a full day of relief. However,since the analgesic effect did not last long, thelevel of the tenderness was re-assessed on the 4thvisit or the 8th day and electroacupuncture (1Hz15 minutes) was given in the 4 acupoints
proximal to the right BL25 where tenderness wasmost pronounced. After this treatment, the pain
subsided and only the sensation of numbness wasleft. On the 5th visit, or the 11th day, the neuralgic
scoliosis disappeared. Numbness in the footregion still existed so that the treatment wascontinued once a week on average. On the 14thvisit, or the third month, the condition returned
nearly to the one before the episode. Then thetreatment was discontinued.
Comments: Pain was relieved right after
electroacupuncture was practiced in the point of
maximum level of tenderness proximal to thesurrounding of the right BL25. Since thisexperience, I have sensitively been trying to findtenderness points surrounding BL25 in lumbar
radiculopathy cases also in an attempt to test
repeatability. I have the impression that in casetenderness is prominent at the proximity of BL25,especially at the location slightly outward, and4

the tenderness is diffused upon pressure.
Needling into these points immediately provides
an analgesic effect, although it depends on cases.
Case 2
Age 55, Male, Height 165cm, Weight 79kg,
Pain in the left lumbar and lower extremities
History: For two weeks the patientfelt

lumbar pain without any trigger. Poultices
relieved the pain gradually. However, five days
ago, a tense sensation and pain in the left lower
extremity were added. The patient visited theorthopedic surgery department of ageneralhospital, and was diagnosed with disc space
narrowing

byplainroentgenography

andprescribed transcutaneous anti-inflammatory gel.
However, since no improvements in the symptoms
were obtained, the patient visited our hospital tohavetreatment

moxibustion.

Thewithacupuncture

patient

had

beenandusing

medication for high blood pressure for theprevious 10 years. For much of his working time,
he was sitting or driving.
Findings: The patient had a tense sensationin the posterior surface of the left thigh and leg
and sometimes awoke during the night time due
to pain. No numbness sensation was present.
Standing on tiptoes: Right capable, left difficult.
Standing on heels: Right and left capable. SLR
test: Right 80˚ (－), left 70˚(＋). ATR: Right (＋),
left (－). PTR: Both right and left (＋). Cutaneous
sensory perception in the lower extremities: Pain
sense and tactile sense – right and left nodifference.

MRI

examination

identified

herniation posterolateral in L5/S1.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

discVolume 1, Number 4 | Winter 2006

Treatment and course: Electroacupuncture (1Hz 10 min.) was performed with the stainlessneedle of 60mm No. 25 at the points connecting
left BL25 and left BL26 where tenderness wasmarked; upper and lower regions of the center ofthe left buttock; and left BL37 and BL57 (Figure).

Figure:Points frequently usedin electroacupuncture
for LDH

From the initial treatment the pain score wasreduced
from 10 to 1.
Treatment wascontinued once a week. After three weeks, pain
disappeared although a heavy sensation
remained. Standing on the left toes was enabledon the 27th day from the initiation of thetreatment or about a month after the onset ofsymptoms in the lower extremities. At the time,
the left ATR, however, was (-). On the 40th day, i.e.
the 7th visit, the patient was instructed to reduceweight and the treatment was completed.
Comments: This case can be considered as S1
radiculopathy due to LDH. Electroacupuncture at
the acupoints of the bladder meridian or thosealong with the distribution of the sciatic nerve
remarkably reduced pain. However, recovery ofobjective findings such as muscle strength(standing on toes) and ATR was slow compared tosubjective symptoms. This tendency will be thecommon course in treating radiculopathy.

Conclusions
Currently, sufficient volumes of clinicalevidence of acupuncture treatment for LDH
patients have not been presented. Evidence
confined to case series studies suggest that
acupuncture treatment can be applied at least as
an analgesic means for lumbar radiculopathy. We
have the impression that as the above two cases
typically demonstrated, acupuncture treatment ischaracterized by an analgesic effect that lasts fora certain period of time immediately after thetreatment. Although the action of pain relief does
not necessarily mean a cure of lumbar
radiculopathy, the characteristic of pain relief
effect right after the treatment merits clinicalattention when compared to other conservative
treatments. Judging from case series studies
conducted so far and case reports released, there
are sufficient reasons that more RCTs on
acupuncture for radiculopathy due to LDH need
to be conducted in Japan.
Reference
1. Yamashita H, Tsukayama H. Nippon no Seijin
Shinkyu Juryo-sha ni kansuru Zenkoku Kibo
Denwa Chosa 2005, J Jpn Soc AcupunctMoxibust 2006; 56: 503. [Japanese]
2. Yamashita H, Tsukayama H, Sugishita C.
Popularity of complementary and alternative
medicine in Japan: a telephone survey.
Complement Ther Med 2002; 10: 84-93.
3. Tsukayama H, Yamashita H. Systematic
review of clinical trials on acupuncture in theJapanese literature. Clin Acupunct Orient
Med 2002; 3: 105-113.
4. Duplan B, Cabanel G, Piton JL, Grauer JL,Phelip X. Acupuncture et lombosaciatique àla phase aiguë – Etude en double aveugle detrente cas. Sem Hop Paris 1983; 59:
3109-3114.

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Volume 1, Number 4 | Winter 2006

5.

Wang RR & Tronnier V. Effect of acupuncture
on pain management in patients before andafter lumbar disc protrusion surgery – arandomized control study. Am J Chin Med
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Maruyama T. Clinical observation ofacupuncture treatment for the ruptured
lumbar disc patient – clinical observation ofacupuncture treatment in orthopaedic
surgery, 2nd report. J Jpn Soc Acupunct
Moxibust 1984; 33: 375-382. [Japanese withEnglish abstract]
7. Yamashita H, Tsukayama H, Sakai T, Nishijo K,Amagai H. Effects of acupuncture treatment
on lumbar radiculopathy – a case series study –.
J Lumbar Spine Disord 1997; 3: 27-32.
[Japanese with English abstract]8.
JapaneseOrthopaedicAssociation.
Assessment of treatment for low back pain. JJpn Orthop Ass 1986; 60: 391-394. [Japanesewith English abstract]
9. Nakazawa M. Touka ni okeru Youtsui
Tsuikan-ban Hernia ni taisuru Hari-chiryo
Koka. Gendai Shinkyu Gaku 2006; 6: 39-44.
[Japanese]
10. MacPherson H. Acupuncture research:time to shift from theoretical to practicalquestions. J Altern Complement Med 2006;
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11. Yamashita H, Tsukayama H, Sakai T, Nishijo K.
Clinicalstudy
onacupunctureandmoxibustion therapy for pain in the low backand the lower extremities (Introduction) – acase report of lumbar disc herniation anddiscussion about methodology –. J Jpn Soc
Acupunct Moxibust 1994; 44: 128. [Japanese]
12. Yamashita H, Tsukayama H, Mimura S,Nishijo K. Youbu Tsuikan-ban Hernia noHari-chiryo to Rigaku Kensa no Kaishaku.
Rinsho Shinkyu (Clin Acupunct Moxibust)
1995; 10: 32-37. [Japanese]

613.

Yamashita H, Tsukayama H. Youtsui
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