THE EFFECTIVENESS OF ACUPUNCTURE FOR ACUTE LOW BACK PAIN

By
William F. Wittman, RN, BSN, CEN

Submitted in Partial Fulfillment of the Requirements for the
Master of Science in Nursing Degree

Edinboro University of Pennsylvania

Effectiveness of
acupuncture for
acute low back pain
by
William F.
U i t tman.
Thesis Nurs. 1999 W832m
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Approved by:

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Judith Schilling PhD, CRN^
Committee Chairperson

Alice Conway PhD/y
Committee Member

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JqrieU0eisel PhD, RN
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Abstract
The Effectiveness of Acupuncture for Acute Low Back Pain

The purpose of this research was to assess the effectiveness of acupuncture for

adults aged 20 to 50 with acute low back pain. Very little research has been

conducted in this area, but case studies indicate that acupuncture has the potential to

shorten disability, decrease medical costs, and hasten pain relief.
This retrospective study examined the difference in perception of pain
experienced by subjects before and after a single acupuncture treatment. Acute low
back pain was defined in this study as pain of less than 3 months duration in the

absence of a serious underlying pathology. The subjects were between 20 an 50 years

of age. This convenient sample of 12 patients completed a 0 to 10 pain scale prior to a

single acupuncture treatment and again the day after the treatment. Treatments were
administered by two certified acupuncturists. The results were analyzed using a one-

tailed dependant t-test and revealed that there was a significant decrease in the
perception of pain 24 hours after acupuncture treatment.
This study will enhance the knowledge of the health care community, as well
as encourage additional research into acupuncture as a way of easing pain and

decreasing medical costs. Recommendations for further research are made.

ii

Acknowledgments
I would like to thank all of those individuals who helped me complete this
thesis. A special thank you to my parents John and Maureen who were instrumental in
this whole process. I would also like to thank my wonderful committee members: Dr.

Judith Schilling, Dr. Alice Conway, and Dr. Janet Geisel. Finally, to John, Hally, Jeff,
Jason, Jake, Paul, Jo Rae and the rest of the gang, I thank you guys for the laughs
along the way.

iii

Table of Contents

Content

Page

Chapter I. Introduction

1

Background of the Problem

1

Purpose of the Study

4

Theoretical Framework

4

Research Question

6

Assumptions

6

Limitations

6

Definition of Terms

,7

Summary

8
9

Chapter II. Review of Literature

9

Acupuncture
Types of Acupuncture

10

How Acupuncture is Performed

11

Western View of Acupuncture

13

Complications of Acupuncture

14

Licensing and Education

14

Role of the Nurse Practitioner

16

Identifying Red Flags

16

iv

Referring to an Acupuncturist
Studies of Acupuncture

18
19

Studies of Acute Low Back Pain

20

Studies of Chronic Low Back Pain

21

Summary

24

Chapter III. Methodology

25

Hypothesis

25

Operational Definitions

25

Research Design

26

Setting and Procedures

26

Sample

Informed Consent.

27

Instrumentation

27

Data Analysis

27

Summary

29

Chapter IV. Analysis of Data.

Sample Group
29

Results

Summary
Chapter V. Discussion..

Summary
v

Conclusions

35

Recommendations for Future Research.

36

Summary.

36

References

37

Appendices

41

A. Pain Scale.

42

B. Mathematics for t-Test Calculations

.43

vi

List of Tables
Table

Page

1. Subject Information

30

2. Mean Gender Differeences

31

Vll

1

Chapter 1

Introduction
This chapter presents a brief summary of acupuncture and acute low back

pain. The Theory of Qi was the theoretical framework used for this research.
Assumptions, limitations, statement of the purpose, and definition of terms are
included.

Background of the problem
Low back pain is a health concern that has increased dramatically in recent
decades (Breakstone, 1995). It is one of the most common reasons for patients with a

work-related injury to visit a primary care provider (Daniels, 1997). For persons

under the age of 45 years, low back problems are the most common cause of
disability (Daniels, 1997) and are second only to upper respiratory disease as a cause

of temporary disability in people of all ages (Della-Giustina, 1998).
Between 1970 and 1981, the increased incidence of low back pain was an

astounding 1400% (Breakstone, 1995). In the general adult population, approximately
85% will have low back pain at some point during their lifetime that is severe enough

to seek medical attention (Daniels, 1997); it is estimated that 25% of adults
experience low back pain in any given year (Suarez -Almazor, Belseck, & Russell,

1997). It is the second leading cause of visits to clinicians, the third most common
reason for surgical procedures, and the fifth leading reason for hospitalizations

(Rubin, 1995).

With the increase in cases of low back pain, comes an increased cost both in

2

quality of life and financial losses. Back pain is responsible for more than $24 billion

yearly in medical costs (Rubin, 1995). According to Breakstone (1995), the societal

cost to Americans is approximately $20 billion yearly. Back pain is a very common
problem which not only causes discomfort, but adds to the high indirect costs by

increasing disability and absenteeism (Suarez-Almazar et al., 1997). One study
concluded that 2% of the industrial workforce encounter back pain that qualifies for

workers’ compensation each year (Taylor, Deyo, Ciol, & Kreuter, 1996). The total
annual costs, which included both direct and indirect costs, were in excess of $50

billion a year (Taylor et al., 1996).
Fortunately, most cases of low back pain resolve spontaneously. According to
Daniels (1997), approximately 60% improve in 1 week, 70% are asymptomatic after
2 weeks, and 90% are relieved at 6 weeks. However, 3% of patients with a diagnosis

of low back pain account for 80% of the total cost to society to treat this condition

(Daniels, 1997).
Traditional treatment of low back pain is controversial (Daniels, 1997). In

general no single treatment is preferred (“Acute Low Back Problems,” 1995). The
most common medications used in acute low back pain are tylenol, nonsteroidal anti-

inflammatory drugs (NSAIDs), opioids, and muscle relaxants. The safest drug is
tylenol and some patients find it helpful, but in many instances NSAIDs are more
effective (“Acute Low Back Problems,” 1995). According to Daniels (1997),
NSAIDs are helpful, but often not sufficient. Drawbacks in using NSAIDs include
gastrointestinal irritation or ulceration, renal problems, and allergic reactions (“Acute

3

Low Back Problems”, 1995).

Opioids appear to be no more effective than safer analgesics for managing low
back symptoms and up to 35% of patients develop drowsiness, decreased reaction
time, clouded judgement, and potential misuse/dependance (“Acute Low Back

Problems", 1995). Muscle relaxants are no more effective than NSAIDs, and when
combined with NSAIDs have no demonstrated benefit. Side effects similar to opioids
are reported in up to 30% of patients taking muscle relaxants.

There are also nonphannacological ways of treating acute low back pain in

traditional medicine. Spinal manipulation is frequently utilized and it is often
effective when used within the first month of symptoms (“Acute Low Back

Problems”, 1995). However, efficacy is unproven after that period of time.
Bed rest was once recommended widely for the treatment of acute low back
pain (Borenstein, D., Deyo, R., Marcus, N., 1998). Prolonged bed rest, more than 4

days, has potentially debilitating effects and is reserved for those patients with severe
limitations (“Acute Low Back Problems”, 1995). Regardless of the chosen treatment,
the goal is to return to normal activities as soon as possible. Several back exercises

are very helpful for patients but vigorous exercising should wait until symptoms are

gone (Borenstein et al. 1998).

Other treatments such as message, dithermy, ultrasound, biofeedback, and
transcutaneous electrical nerve stimulation (TENS) have no proven efficacy in the

treatment of acute low back pain (“Acute Low Back Problems”, 1995). However,
ibj ect of much discussion recently because of its potential
acupuncture has been the sul

4

for pain control (Borenstein et al., 1995). According to the National Institute of
Health Consensus Panel on Acupuncture (“Acpuncture”,1998), ample clinical

experience supported by some research data, suggests that acupuncture may be a

reasonable option for a number of clinical conditions including low back pain.
Purpose of the Study
The purpose of this study was to assess the effectiveness of acupuncture for

subjects aged 20 through 50 with acute low back pain. There are many studies that
evaluate acupuncture’s effectiveness in several illnesses, but few that address acute

low back pain. This study will enhance the knowledge of the health care providers, as

well as encourage further research into acupuncture as a way of easing pain and
decreasing costs.
Theoretical Framework
The Chinese theory of Qi is the framework of this research. The balance of Qi

is the goal of acupuncture, and it is almost 5,000 years old. Qi is the existence of a

vital life force that travels in channels, known as meridians, throughout the body.

There are 12 major meridians, along with minor meridians, that connect the organ
systems (Nurses Handbook of Alternative & Complementary Therapies, 1998).

According to the theory of Qi, if an organ is experiencing an energy

imbalance or disease state, the forces of yin and yang are disturbed (Dold, 1998).

Peterson (1996) added that yin and yang are the sum of Chinese cosmology and that
they are both complementary and contradictory. The balance between these forces is

necessary in order for wholeness and harmony to exist. Certain symptoms appear

5

once the two forces are disturbed (Dold, 1998). A problem of deficiency or
underactivity is of a yin character, whereas a problem of excess or overactivity is of a
yang character (Helms, 1995). A fever, red face, agitation, erythema, and tachycardia
are all the results of an excess Qi or yang. Depression, cold extremities, bradycardia,

and a pale face are a result from a lack of Qi or yin (Dold, 1998).

The acupuncturist can locate specific points along a meridian that correlate
with a particular organ system. These points are then stimulated with needles to

balance, release, or enhance the flow of Qi (Nurses Handbook of Alternative &
Complementary Therapies, 1998).
What is the nurse practitioners’ role in this care? Nurse practitioners need to

be able to identify signs and symptoms of diseases that require immediate
intervention, through a careful history and physical examination. If any of the

following warning signs are noted, further investigation is warranted and the option
of acupuncture must be delayed. “Red flags” for acute low back pain are as follows:
pain that is worse when lying down, pain associated with a fever and/or weight loss,

focal tenderness of the vertebrae, ecchymosis, history of trauma, saddle anesthesia,

numbness/tingling in the lower extremities, weakness with ambulation, decreased or
absent reflexes in the lower extremities, new onset of bowel and/or bladder problems,

and poor anal sphincter tone (U.S. Department of Health and Human Services, 1994).
The nurse practitioner must also be aware that other organ systems may refer pain to
the lower back. Some examples of this may be renal colic, abdominal aortic
aneurysm, pelvic inflammatory disease, pregnancy, pancreatitis, and a perforating

6

duodenal ulcer (Rubin, 1995).
Once the practitioner is satisfied that the patient’s back pain is not caused by

an underlying serious disease, acupuncture can be presented as an option. If certified,
the nurse practitioner can perform this or refer the patient to an acupuncturist.

Research Question
Does acupuncture decrease adult patient’s perception of acute low back pain?

Assumptions
The following five assumptions were made for this research study:

1. Pain is whatever subjects say it is.

2. Subjects understand how to rate pain accurately on the pain intensity scale
used in this study.
3. Subjects answered all study questions accurately and honestly.

4. The acupuncturist was competent and skilled.
5. Subjects had no serious underlying disease that was causing their acute

low back pain.
Limitations
The following were limitations for this research study:

1.

Subj ects have different perceptions of pain.

2.

The research sample size is small and limited to subjects from two

practices in northwestern Pennsylvania. This affects the application of research

findings to other medical populations.

3.

The subjects were all Caucasian.

7

4.

Traditional Chinese acupuncture treatments are very individualized.

Definition of Terms
The following terms were defined for this research study:
1. Cauda equina syndrome is characterized by a dull aching pain of the

perineum, bladder, and sacrum which radiates, and is associated with paraesthesias
and paralysis, due to compression of nerve roots (American Heritage Stedman’s

Medical Dictionary, 1995).
2.

Endorphins are any group of peptide hormones that bind to opiate

receptors and are found mainly in the brain. Endorphins reduce the sensation of pain
and affect emotions (American Heritage Stedman’s Medical Dictionary, 1995).
3.

Gamma globulins are a protein fraction of the blood serum containing

numerous antibodies, used in the prevention and treatment of certain diseases, such as

measles, poliomyelitis, and viral hepatitis (American Heritage Stedman’s Medical
Dictionary, 1995).

4.

Osteomyelitis is inflammation of bone and bone marrow (American

Heritage Stedman’s Medical Dictionary, 1995).
5.

Prostaglandins are a group of hormone-like substances produced in

various tissues that are derived from amino acids and mediate a range of

physiological functions, such as metabolism and nerve transmission (American
Heritage Stedman’s Medical Dictionary, 1995).

6.

Sciatica is pain along the sciatic nerve that radiates from the lower back to

the buttocks and back of the thigh, and is usually caused by ahentiated disk of the

8

lumbar region of the spine (American Heritage Stedman’s Medical Dictionary, 1995).
Summary
The purpose of this research was to assess the effectiveness of acupuncture for

the treatment of acute low back pain. The Chinese theory of Qi is the theoretical

framework for this research. The role of the nurse practitioner was discussed as well
as the assumptions and limitations of the study.

Many Americans suffer from acute back pain yearly. The majority of them

recover spontaneously. Studies show that symptoms often take several weeks to

resolve (Connelly, 1996). During this time, pain often inhibits the individual’s ability
to perform as before. Often patients have expensive imaging studies performed, are

given expensive prescriptions, and are unable to function optimally at work. Expenses
are even higher in those patients who continue to have pain after several weeks

(Longworth & McCarthy, 1997). The direct and indirect costs of either situation are

significant. If acupuncture is shown to be efficacious in treating acute low back pain,
nurse practitioners can play a key role in decreasing disability, absenteeism, and

medical costs.

9

Chapter II

Review of the Literature
The use of alternative medicine has increased dramatically over the past

several years. A 1990 survey showed that 34% of Americans had used at least one

type of alternative therapy (Eisenberg et al., 1993). It also showed that patients visited
alternative practitioners 425 million times, 40 million more times than they visited

their medical primary care providers. Approximately $13.7 billion was spent on this
care with $10.3 billion coming out of the patient’s own pocket (Eisenberg et al.,

1993). In a study by Borkan, Nehler, Anson, and Smoker (1994), it was noted that

60% of conventional physicians had made at least one referral for alternative
treatment in the previous year. Approximately one million Americans use

acupuncture yearly, and almost $500 million is spent annually for these treatments
(Nurses Handbook of Alternative and Complementary Therapies, 1998).

The purpose of this chapter is to describe the various types of acupuncture,
how it is performed, western views of acupuncture, complications of treatments, as

well as the licensing and educational requirements to become an acupuncturist. It also
includes the role of the nurse practitioner, identifying “red flags” in acute low back

pain, what patients should know when they are referred to an acupuncturist, and
research studies of acute and chronic back pain utilizing acupuncture.
Acupuncture

Acupuncture is an ancient art that has been in existence tor thousands of

years. There is documentation that dates back to 200 BC in Th, Yellow Emperor's

10

Classic of Internal Medicine (Peterson, 1996).

Types of Acupuncture . There are several types of acupuncture recognized in
the United States (Peterson, 1996). The following types will be discussed in this

study. Traditional Chinese medicine acupuncture, French energetics, Korean hand
acupuncture, auricular acupuncture, myofascially based acupuncture, scalp

acupuncture, and oral mucous membrane acupuncture. All types of acupuncture are
intended to correct energy flow of Qi within the body.

Traditional Chinese medicine acupuncture concentrates on the patient’s
history, speech qualities, appearance, pulse, and odor to formulate a diagnosis
(Peterson, 1996). In addition, the radial pulses are evaluated extensively in this type of

acupuncture. Various disease states are detected by the quality of six pulsations at

each radial artery. The proper acupuncture points are stimulated with needles along

with any local tender points, called ah shi points.

In French energetic acupuncture, the body is considered to be an “electrolytic

milieu in dynamic equilibrium” (Peterson 1996, p.24). It is based on principles of
bioenergetics. A decrease in the circulating electrolytes of a meridian is correctable
with the placement of a needle that serves as an electrode.

Korean hand acupuncture is based on the idea that energy originates in the

hands and feet (Peterson,1996). Similar to the other principals of acupuncture,
needling the appropriate points can treat a variety of illnesses by restoring the flow of
energy.

Auricular acupuncture is needling of only the ear (Peterson,1996). This is

11

relatively new in comparison to the other types of acupuncture. There are over 200

ear points that correlate with anatomical sites of the body and are documented for
therapeutic needling.

Myofascial acupuncture begins with assessing which meridian may be
responsible for the patient’s symptoms (Peterson, 1996). The meridian is then

palpated both locally and distally for tender points. Treatment by inserting needles at
tender points restores the energy flow by releasing the myofascial holding pattern.
The sixth and seventh types of acupuncture discussed here are scalp

acupuncture and oral mucous membrane acupuncture (Nissel, 1993). Both of these
are relatively new. The former was developed by Zeiter at the Vienna Institute and

deals with the idea of meridians on the scalp. These meridians are correlated with
specific anatomical sites of the body and, when stimulated, can release and restore the

flow of Qi. Oral mucous membrane acupuncture is based on the same principle but
the meridians are located within the oral cavity. In this type of acupuncture, needles
are not utilized; rather, a laser or microinjections of local anesthetic is used.

How Acupuncture is Performed. Since the Traditional Chinese medicine
acupuncture is the most widely used, the following is an overview of how it is

typically carried out. It is important to realize, however, that treatments often vary for
patients with the same ailment.

The acupuncturist asks questions about the presenting problem, and also about
sleep, digestion, elimination, emotions, sexual drive, menstrual patterns, and energy

rue is examined for size, shape, and coating.
level (Schulte, 1996). In addition, the tong

12

The radial pulse is also of great importance. It is assessed for different qualities while
the patient changes positions to formulate a pattern of disharmony.

The patient then lies on a padded table (Galant, 1997). Although classical

acupuncture notes approximately 365 points on the body’s meridians, a typical

practitioner utilizes about 150 points (Johnson, 1996). The designated points are then
cleaned with an antiseptic solution and stimulated by needles (Breakstone, 1998).

Often, low frequency electrical currents, heat, and moxibustion are concurrently
utilized (Breakstone, 1998). If moxibustion is used, a small piece of herb called
Mugwart is burned within close proximity of the exposed needle to warm it slightly.
The Mugwart may also be burned on another substance such as a piece of ginger, and

placed over the designated areas (Nurses Handbook of Alternative and
Complementary Therapies, 1998).

The needles used are solid metal and most often made of surgical steel;

sometimes gold or silver is utilized (Nurses Handbook of Alternative and

Complementary Therapies, 1998). New standards are advocating the use of
disposable needles. The needle length varies from 1.25 centimeters to 15 centimeters

and the width can be anywhere from a 26 to 36 gauge (Peterson, 1996). Typically,

eight to 20 needles are used in a treatment (Galant, 1997). They are left in place just

under the skin for 20 to 30 minutes (Breakstone, 1998). Pain is rare, but a dull ache or
electric shock called a “deqi”

is often experienced (Galant, 1997).

junction with acupuncture (Palmieri, 1999). A lowOften TENS is used in conjunct
voltage electrical current is produced by

a hand held controller and passed through

13

wires that are connected to the acupuncture needles after placement in the proper
areas. TENS stimulates fast conducting nerves that connect to the spinal cord and, in

doing so, slow conducting pain-carrying nerves are prevented from delivering the
pain message to the spinal cord. TENS is continued for approximately 20 minutes to

60 minutes after pain relief is achieved.

Western View of Acupuncture. There are several theories that attempt to

“westernize” the eastern view of Qi (Nurses Handbook od Alternative and
Complementary Therapies, 1998). The neurotransmitter theory proposes that

acupuncture decreases certain neurotransmitters necessary for the transmission nerve
impulses. The electrical conductance theory states that since acupuncture points have

a higher level of electrical conductance than other areas, these areas amplify minute

electrical signals and acupuncture needles stop or inhibit that flow. A third theory,
called the enhanced immunity theory, postulates that acupuncture raises the white
blood count as well as prostaglandin, gamma globulins, and overall antibody levels.

The circulation control theory concludes that acupuncture works by constricting or

dilating blood vessels.
The final theory, which is called the endorphin theory, is the most popular

theory mentioned in the articles and studies reviewed for this research. According to

Nissel (1993) at the Ludwig Boltzman Acupuncture Institute in Vienna, the numbness
or De-Qui feeling, which develops after needle insertion, is a result of the stimulation

of small type II nerve fibers. The sensation of heaviness is a result of small type III
nerve fibers. Activation of these fibers causes the release of enkephalin and

14

dynorphin at the spinal level and the afferent pain pathways are blocked. In the

midbrain, the enkephalin activates the descending raphe system, which inhibits the

pam s pathway by the interaction of seritonin and noradrenalin. The hypothalamus

also secretes hypophyseal beta endorphin that promotes distal analgesia. In addition,
the hypothalamus innervates the midbrain, which activates the descending analgesia
system via the b-endorphin.

There is evidence that supports the endorphin theory. According to Nissel
(1992), nalaxone, an opioid antagonist, can immediately interrupt the analgesic
effects of acupuncture. This effect was shown by two University of Toronto

investigators in 1989 (Schulte, 1996).
Complications of Acupuncture. There have been only 125 cases of

complications reported in the world medical literature abstracted in English since
1958 (Helms, 1995). Minor bruising and muscle soreness are relatively common and
are not considered to be complications. The following make up most of the reported

complications: contact dermatitis to stainless steel, compartment syndrome, organ
puncture, infections, retained needle, pneumothorax, pneumoperitoneum,
hemothorax, cardiac tamponade, abscesses, chondritis, deep vein thrombophlebitis,

osteomyelitis, endocarditis, and viral hepatitis. There were no reports of human
immunodeficiency virus transmission found in the literature.

Licensing and Education. Educational requirements and licensing of
acupuncturists vary from state to state (Nurses Handbook of Alternative and
Complementary Therapies, 1993). Most states have laws that specify licensing but the

15

scope of practice vanes widely. Some states recognize the Doctor of Oriental
Medicine as a pnmary care provider, whereas others only allow a medical doctor to
practice acupuncture. Some states allow an acupuncturist to practice only under the
supervision of a medical doctor.
In older to earn a National Certification Commission for Acupuncture and

Oriental Medicine (NCCAOM) certificate, one must be 18 years old, pass all portions

of the NCCAOM examination, subscribe to the NCCAOM’s National Code of
Ethics, be of good moral character, and meet the eligibility criteria. The NCCAOM
exam includes an acupuncture portion, clean needle technique course, and a practical
examination of point location skills (National Certification Commission for

Acupuncture and Oriental Medicine, 1998).

Applicants for NCCAOM certification must be graduates of a full-time
acupuncture program with at least 3 years of a comprehensive curriculum consisting

of a minimum of 1,350 hours of entry level acupuncture education including at least
500 clinical hours (National Certification Commission for Acupuncture and Oriental

Medicine, 1998). The third or fourth year student status is the second category. These
students must have completed 1,000 hours of schooling in no less than 18 academic
months, which includes 250 clinical hours. The third and final educational option is
the apprenticeship. These individuals need at least 4,000 contact hours during a 3 to 6

year period. The apprentice’s preceptor needs to have had at least 5 years experience,

must have treated a minimum of 100 different patients, and must have 500 patient
visits yearly.

16

The Amen can Association of Acupuncture and Oriental Medicine (AAOM)

(1998) recommends that physicians who practice acupuncture have a minimum of

200 hours of training and that nonphysician practitioners have 2 or more years of
training at a recognized acupuncture school. Nonphysicians should also be licensed or

registered in their state or should be certified by the National Certification
Commission for Acupuncturists. Acupuncturists with the most extensive training
generally have graduated from one of the nation’s 37 acupuncture colleges

(Breakstone, 1995).

Role of the Nurse Practitioner
The nurse practitioner’s role in managing patients with acute low back pain,

with regard to acupuncture, has two aspects. The first is the identification of
underlying causes of the back pain through the patient history and physical

examination. When “red flags” are noted, the nurse practitioner understands that
further testing is necessary, and that acupuncture is not an option at that time. The

second role is the teaching that goes along with referring a patient to an acupuncturist.

Nurse practitioners can become a certified acupuncturist as well, but they do
not qualify for the 200 hours of training available to physicians. Practitioners must be
educated like any other nonphysician, as explained previously.

Identifying Red Flags. Approximately 16% of all cases of backpam warrant
further studies (Gillette, 1996). Of this 16%, 2% require immediate attention.

Although only a minority of patients have serious underlying pathology causing their
low back pain, it is vety important to detect these ailments. Certain diseases are more

17

common at specific ages. Since this research deals with acute low back pain in
subjects between the ages of 20 and 50 years, the most common serious diseases in

this age group will be discussed.
Mengel and Schwiebert (1996) described five main categories of ailments that

are most common for patients under 50 years of age. Of these categories, three
include conditions that warrant immediate referral. They are cauda equina syndrome,

lumbosacral infections, and inflammatory rheumatic diseases.

Cauda equina syndrome is a very rare condition that is associated with

herniated lumbar disks. It is characterized by acute urinary or rectal incontinence,
with or without paraplegia, usually caused by a large disk herniation (Mengel &

Schwiebert, 1996). Other symptoms that should direct one to suspect possible cauda
equina syndrome are impotence, perineal saddle anesthesia, sphincter problems,

major motor weakness in the lower extremities, or progressive neurological
dysfunction in the legs (US Department of Health and Human Services, 1994).
The second serious cause of low back pain in younger adults is lumbosacral

infections. According to Mengel and Schwiebert (1996), these are more common
among those who are immunocompromised such as persons with diabetes melhtis,

recent surgery, septicemia, human immunodeficiency virus, and intravenous drug
users. Two examples of lumbosacral infections are spinal abscesses and
osteomyelitis. Symptoms for these illnesses include fever, chills, weight loss, pain

that is worse at night, and pain that is worse when lying supine (US Department of
Health and Human Services, 1994).

18

The third and final category of serious concern is inflammatory diseases. The
diagnoses that affect the lower back and require referral are ankylosing spondylitis

and Reiter’s syndrome. Ankylosing spondylitis is a chronic and progressive disease
that geneially begins at the sacroiliac joints and progresses up the spine (Professional

Guide to Diseases, 1995). Fibrous tissue forms as bone and cartilage deteriorate and
fusion of the spine ensues. Symptoms of this disease are prolonged stiffness, limited
motion of the spine, fatigue, fever, anorexia, weight loss, and uveitis. Unlike

ankylosing spondylitis, Reiter syndrome is a self-limiting disease that is associated
with polyarthritis, urethritis, balanitis, conjunctivitis, and mucocutaneous lesions. It is
related to venereal and enteric infections and can be accompanied by fever, weight
loss, and anorexia (Professional Guide to Diseases, 1995).

Referring to an Acupuncturist. If the nurse practitioner and the patient have
decided that acupuncture is an option, there are several points that need to be
discussed. First, the patient and the nurse practitioner will check the credentials of the

acupuncturist (Weiss, 1995). Even a state liscense does not necessarily mean that the
acupuncturist is competent. In states that do not require a license, look for an

acupuncturist who is certified by the National Commission for the Certification of
Acupuncturists. This commission certifies nonphysician acupuncturists, while the

American Academy of Medical Acupuncture is the certifying body for physicians.

Next, the patient should understand that iatrogenic problems are rare but possible.
These risks can be further reduced by insisting that disposable needles be used. Also,

patients need to be educated to ask what kind of treatment is used by that particular

19

acupuncturist, since there are several different types. Cost is an additional concern.
Charges can vary from $30 to $100 per session. According to Breakstone (1995),
approximately 10% of US health plans pay for acupuncture treatments.
Studies of Acupuncture

In 1995, Helms published a meta-analysis that reviewed and evaluated all
acupuncture i elated literature pertaining to human clinical research studies and

anecdotal reports published in western European languages since 1960. A total of
3,425 articles were examined and categorized by the illness studied. Approximately
25% of the articles addressed pain issues. Of that 25%, 67% specifically analyzed
musculoskeletal problems.

When the variables of randomized, controlled, and prospective investigations
were applied to all 3,425 articles, only 150 were considered for further evaluation.

Thirteen of these studies addressed low back pain. Of the thirteen studies, all
published between 1976 and 1989, seven concluded that acupuncture was superior to
controls, one showed favorable results that were not significant, two revealed that
acupuncture treatments were equally as effective as controls, and two concluded that

acupuncture was equal to or inferior to the control (Helms, 1995).
According to the National Institute of Health Consensus Development Panel

on Acupuncture (1998), there have been many studies of acupuncture’s potential
usefulness, but very few are high quality randomized controlled trials. Most of this
literature consists of case reports, case series, or interventional studies with

inadequate designs.

20

Studies of AcuteLowBackPain. The first of two studies that examined the
effectiveness of acupuncture in acute low back pain were done by Shugai (1992). He

performed acupuncture on 100 patients with acute lumbar strain between 1978 and
1992. The duration of the patients’ ailments ranged between 5 hours and 3 days. In

sixteen of the cases, the subjects were between the ages of 51 and 62. Shugai’s report

did not indicate how the patients were selected, did not reveal how the patients’ pain

was evaluated, nor did it give the time frame in which the study took place. One
session of acupuncture treatment generally markedly reduced the amount of pain, or
even cured the patient. Shugai went on to write that in severe cases, a treatment was
given daily for 3 to 5 days. These resulted in a cure, but Shugai did not reveal how
many patients required more than one session. Overall, the author reported that 60%

of the patients were cured, 26% markedly improved, 10% were helped, and 4% did
not respond to treatment. The method of evaluating treatment outcomes was not
given.

The second study examining the effectiveness of acupuncture for low back
pain was similar. Runshu (1993), an acupuncturist, treated 135 cases of acute lumbar

sprain beginning in 1982. The article detailed how the treatment was earned out and

what meridian points were used. Results were then given in a single sentence, a
follows: 115 patients were cured, 18 were markedly improved, and 2 patients were

not helped. The total effectiveness rate in this study was 98%. The article went
give an example ease and discuss the acupoints used. The author did not indicate how

long the patients had suffered horn back pain, how the subjects were chosen, how the

21

pain was evaluated, the ages of the patients, nor the duration of the study. The article
also failed to divulge how many treatments were given over what kind of a time

frame.
Studies of Chrome Low Back Pain. Unlike acute low back pain studies, there

are several research studies that examine the effectiveness of acupuncture in treating
chronic low back pain. The studies of Coan et al. (1980), Mendelson et al.(1983),

Leung (1979), and Macdonald, Macrea, Master, & Rubin (1983), are discussed
below.

Coan et al. (1980) studied 50 patients with low back pain for at least 6
months. The subjects were told that they would receive ten or more acupuncture
treatments. They were divided into two groups. The first group of 25 patients, called
the Immediate Treatment Group, began treatments on the day of their initial

examination. The second group of 25, called the Delayed Treatment Group, began
treatments 8 weeks after the initial examination to create a control. Patients rated their
pain on a 0 to 10 pain scale, with 10 representing the most most severe pain. Patients

identified their limitation of activity on a 0 to 3 scale with 3 representing severe

limitation. The first group was re-examined 10 weeks after the initiation of
treatments, while the second group was re-examined 15 weeks after enrollment and

before the treatments began. Both groups were then sent mail surveys 40 weeks after

enrollment. In evaluating the results, 83% of the Immediate Group reported
improvement .nd none wem worse at an average of 10.3 weeks into the study.

Significant decreases in pain hours, pain scores, limitation of activity, an

g

22

pain pills were also noted. The Delayed Treatment Group reported only a 31%
improvement and 25% of these patients' conditions worsened at 15 weeks into the
study. At the 40 week mark, 58% of the Immediate Treatment Group

were still doing

well as opposed to only 11% of the Delayed Treatment Group.
The study by Mendelson et al. (1983) was a double-blind placebo-controlled

trial that enrolled 77 patients with chronic low back pain. This study also looked
extensively at psychosocial factors. A detailed history was elicited from all patients
including a personal history, social history, and illness history. All of the subjects
took tests to measure neuroticism, extraversion, aggressiveness, hostility,

hypochondriasis, anxiety, depression, phobias, and bodily preoccupation. The

patient’s expectation of pain relief was recorded using a five-point scale, ranging

from “not at all” to “certain”. Three different pain scales were utilized including the
Visual Analog Scale of Pain, the McGill Pain questionaire, and a 100 millimeter pain

scale. Patients in the placebo group received injections of 2% Lidocaine given at
nonacupuncture and nontender sites in the lumbar area. The traditional Chinese
technique of acupuncture was used for the treatment group. All patients were treated

for 4 weeks, rested for the next 4 weeks, and then crossed over and received the
alternate treatment for another 4 weeks. The results of the research showed that the

overall reduction of pain in the acupuncture group was 26% compared to a 22%

reduction in the placebo group, which was not statistically significant.
Leung (1979) extttnmed 20 subjects who had faded conservative treatment for

low back pain. Ages varied fttrn 23 to 69, but most fell between 40 and 60 years of

23

age. The duration of acupuncture treatments also varied from 1 month to 10 years,

with the average being slightly over a year. No patients had neurological deficits, but

18 had sciatica with straight leg extension. Acupuncture treatment was given along
with electrical stimulation daily for 15 minutes and continued until either the pain

disappeared, stabilized, or until the patient declined further treatments because of a
good response. Pain was determined subjectively by the patient as severe, moderate,
or mild. All patients were followed for 12 months. Of the 20 patients treated, four

considered themselves cured, ten had a backache which they considered mild and
required no analgesics, three had occasional pain that did not require analgesics, and
three continued to have persistent pain. At the 12 month follow-up, pain had

reoccurred in 13 of the 20 patients. Acupuncture was then offered again to these
patients. Eleven of the patients had treatments repeated and their results were similar

to the original study.

Macdonald et al. (1983) conducted a single-blind, randomized, placebocontrolled trial of acupuncture for treating chronic low back pain. In this study eight

patients were treated with acupuncture and nine were treated with a placebo, which
consisted of a mock transcutaneous nerve stimulation. The needles were insert

ry

superficially at a depth of no more than four millimeters. All of the participants had

chronic low back pain that failed to respond to conventional methods for a year and

had been referred for pain relief by orthopedic surgeons or ■fieumato.ogis.s. A 0 to 10
visual analog scale was utilized prior to treatments and again

the treatments.

Pam was based on several activities such as waling on .eve, grorntd, sitting on a hard

24

chair, and climbing stairs. Patients received up to ten treatments, which „ere

performed weekly. If a treatment failed to produce beneficial effects, then the needles

were left in place twice as long the next time. If this failed, then electroacup
•uncture
was performed. The pain relief for the acupuncture group was 77.35% versus 30.14%

for the placebo group. Acupuncture significantly increased the experimental group’s
functional status when compared to the placebo group.

Summary

There are several types of acupuncture, all of which revolve around the
concept that disrupting the energy flow of the body leads to illness. Traditional
Chinese medicine acupuncture is the most widely utilized. Several western theories

attempt to explain how acupuncture works. Though imperfect, the theory of

endorphins is the most common belief today. There are several complications that can
result from acupuncture treatments, but these occur very infrequently.
Although there are many studies of the potential usefulness of acupuncture,

there are few that meet western standards of high quality, randomized, and controlled
studies (“Acupuncture”, 1998). Between 1976 and 1989, only 14 controlled studies of

acupuncture for low back pain were published, and within these studies, ac
back pain was not addressed (Helms, 1995). This chapter reviewed two acute low
back pain studies and four chronic back pain studies. Also included in this

p

were the licensing and educational requirements for acupuncturists as wdl as th. role

of the nurse practitioner.

25

Chapter III

Methodology
This chapter describes the methodology used to assess the effectiveness of

acupuncture for patients with acute low back pain. Included in this chapter are the

hypothesis, operational definitions, research design, sample, data collection, and
instrumentation for this study.

Hypothesis
Adult subjects between the ages of 20 and 50, who have acute low back pain,

will record a decrease perception pain after a single acupuncture treatment.
Operational Definitions
The following are the operational definitions for this study:
1. An acupuncture treatment is the placement of 8 to 20 fine, disposable,

stainless steel needles, into the proper acupoints of meridians to enhance, restore,

and balance the flow of Qi.

2. Acute low back pain is that which is located over the lumbar sacral region
and has been present for less than 3 months.
3. Pain is a numerical representation on the 0 to 10 pain scale, where 0 is

equivalent to no pain and 10 is equivalent to the most severe pain.

4. Subjects are between the ages of 20 and 50, have no serious underlying
pathology as defined by their physician, and have acute low back pain.

26

Research Design
This was a retrospective study. Data was collected from the medical and

acupuncture records of two physicians who are certified in acupuncture. A 0 to 10
pain scale was utilized prior to and 24 hours after a single acupuncture treatment. The

goal of this research was to examine the effectiveness of acupuncture for acute low

back pain.
Setting and Procedures
The setting for this research was a primary care practice, and a hospital based

pain clinic, both located in northwestern Pennsylvania. The subjects with low back
pain were evaluated by a practitioner for any serious underlying pathology. If a
serious condition was suspected, those patients were excluded from this study. If a
serious condition was ruled out, subjects were offered an acupuncture treatment. Most

patients were offered treatments after rest, ice, nonsteroidal anti-inflammatory drugs

and other means failed. Traditional Chinese acupuncture was utilized in this research.
The patients were contacted the following day of their acupuncture treatment and

their pain was reassessed utilizing the pain scale.
Sample

The researcher reviewed the medical and acupuncture records of 12 subjects

between the ages of 20 and 50, who had low back pain for less than 3 months.

Practitioners had ruled out serious underlying pathology prior to the acupuncture
treatment. Any subject with a possible serious underlying pathology was not included

in this research sample.

27

Informed consent

All patients included in this study were contacted by telephone by either the

acupuncturist or the office personnel for consent. All of the data collected remained
confidential and no names or other identifying information was reported. The clinical
acupuncturist gave the researcher permission to use patient information that was
previously collected and confidentiality was maintained.

Instrumentation
The tool used for this research was a simple 0 to 10 pain scale (Appendix A).

Instructions were given to each subject explaining how to fill out the pain scale. The

scale itself was set up in a horizontal fashion with a 0 to the left and a 10 to the right.

A 0 represented no pain whereas a 10 represented the most severe pain the patient has
ever had. The scale was filled out in the office prior to the acupuncture treatment. The
patient’s pain was reassessed, and documented using the same pain scale, the next

day.

Data Analysis
The data collected consisted of the patient’s age, sex, duration of pain, pre­

treatment pain score, and post-treatment pain score. A one-tailed dependant t-test was

then calculated to discern any significant change in perception of of pain (Appendix
B).
Summary

This retrospective study was conducted at a primary care practice as well as a

28

hospital-based pain clinic in northwestern Pennsylvania. Criteria for admission to the
study were defined. A pain rating tool was completed by each subject prior to their

acupuncture treatment, and again the next day. The results of the pain scales were
used to determine if a significant decrease in pain perception was noted by the
subjects.

29

Chapter IV
Analysis of Data
This chapter presents the results of this retrospective study concerning

patients perceptions of low back pain prior to and after a single acupuncture
treatment. Data on duration of pain, ages, sex and differences in pre-treatment and

post-treatment scores among subjects are included.

Sample Group
The researcher conducted this study at two physician offices in northwestern

Pennsylvania in July 1999. Medical and acupuncture files were utilized. A 0 to 10

pain scale was completed by each subject prior to the acupuncture treatment. The
subjects were then contacted by the acupuncturist the next day to re-evaluate and
document their pain status. The sample size was 12, of which 5 were female and 7

were male (Table 1). The average age was 37.7 years and the average duration of pain

was 7.3 weeks.
Results

Data were analyzed using a one-tailed t-test for correlated groups. The null
hypothesis for this study stated that there is no significant change in the subject’s
perception of acute low back pain 24 hours after a single acupuncture treatment. The
alternative hypothesis stated that there is a significant decrease in the perception of
pain after 24 hours. Pre-treatment scores averaged 7.6 and post-treatment scores

averaged 5.6 (Table 1). The difference in scores was squared and added; the total 70
(Table 1).

30

Table 1

Subject Information

Duration
of Pain

Score
Pre-treatment Post-treatment

Difference
D
IF

Age

Sex

33

F

6 Wks.

7

5

2

4

48

F

12 Wks.

6

2

4

16

38

M

10 Wks.

5

5

0

0

45

F

8 Wks.

7

6

1

1

32

M

7 Wks.

8

5

3

9

28

M

10 Wks.

7

5

2

4

49

F

8 Wks.

8

6

2

4

46

M

1 Wk.

7

6

1

1

27

M

12 Wks.

10

9

1

1

34

F

10 Wks.

8

6

2

4

37

M

2 Wks.

8

3

5

25

36

M

2 Wks.

10

9

1

1

7.3 Wks.

7.6

5.6

24

70

Avg.

37.5

Note. Values were rounded to the nearest tenth.

Sum

31

The t-test score of 4.88 was compared to a list of significant values to test the
hypothesis (Appendix B). Since 4.88 was greater than the table value of 1.796 (alpha
< 0.05), the hypothesis is supported. Thus, this study found that there was a

significant decrease in the perception of low back pain in patients 20 to 50 years old,

who were evaluated 24 hours after a single acupuncture treatment.
Based on the results of this study, one acupuncture treatment significantly
reduced the subjects’ perception of acute low back pain. Eleven of the twelve

research subjects perceived some pain reduction 24 hours after being treated with
acupuncture. The one subject who did not respond to the treatment did not worsen. A
minimal difference was noted when comparing gender and pain relief (Table 2).

Table 2

Mean Gender Differences

Average

Males

Females

38.4

41.8

Duration of Pain in Weeks

6.3

8.8

Pre-Acupuncture Score

7.9

7.2

Post-Acupuncture Score

6.0

5.0

Points of Reduced Pain

1.9

2.2

Age of Subject

32

The female subjects averaged 3.4 years older than the male subjects. The

females had been experiencing acute back pain for an average of 2.5 weeks longer
than the males. The female population in this study averaged a pre-acupuncture pain

score of 7.2 and a post-acupuncture pain score of 5.0. Their average reduction in pain
totaled 2.2. The women responded slightly better to the acupuncture treatment with an

average decrease in pain points of 2.2 compared to 1.9 points reported by the men.
Summary

This chapter presented results of this retrospective study to assess changed
perception of low back pain 24 hours following one acupuncture treatment. Twelve

subjects were included. A 0 to 10 pain rating scale was utilized. Data were analyzed
using a one-tailed dependant t-test. The research found that a single acupuncture

treatment significantly reduced the perception of low back pain after 24 hours in 12
adult subjects, between 20 and 50 years of age.

33

Chapter V

Discussion
This chapter summarizes the results of this research. The purpose of this study

was to assess the effectiveness of acupuncture for subjects aged 20 to 50 with acute
low back pain. A one-tailed dependant t-test was used to determine significance.
Discussion, conclusions, and recommendations for future research are included in this
chapter.
Summary

This research was a retrospective study that included 12 subjects from two

practitioners’ offices in northwestern Pennsylvania. The subjects were experiencing
low back pain and asked to rate their pain on a 0 to 10 scale. Twenty-four hours
following an acupuncture treatment, their pain status was reassessed using the same

pain scale. This research found, on the average, a significant decrease in pain
perception. A significant correlation was found between a single acupuncture
treatment and pain relief.

Like the studies by Shugai (1992) and Runshu (1993), this study also showed
that subjects with acute low back pain benefited from acupuncture. A major difficulty
with acupuncture studies is the individualistic nature of treatment plans. Two subjects

with the same ailment are often treated differently (Nurses Handbook of Alternative

& Complementary Therapies, 1998). Low back pain may be treated 20 different ways
depending on the different schools of practice and clinical findings (Petersen, 1996).

There may also be variability between acupuncture practitioners. This raises the

34

question of comparability between studies. Western medicine has attempted to follow
standardized protocols that may not demonstrate the full effectiveness of acupuncture
treatments (NIH, 1998).

Another problem with acupuncture research is the poor assessment of long
term effects. Most studies do not follow-up with subjects past a few months
(Richardson & Vincent, 1985). The works of Shugai (1992) and Runshu (1993) are

examples of significant pain reduction, but contain no record of the longevity of pain
relief.

Double-blind randomized acupuncture studies are difficult to perform (Nurses

Handbook of Alternative & Complementary Therapies, 1998). These types of studies
are also very expensive. An article appearing in The Economist (Getting the Needle,

1997) indicated that a proper acupuncture trial cost many thousands of dollars.

Forming a control group is also a problem when attempting to organize an

acupuncture study. Mock TENS is one way of creating a control group. The
disadvantage is the absence of the skin pricking sensation that is normally produced
by TENS. Many researchers find this an unacceptable control. The more widely

accepted control is sham acupuncture, the placement of needles in nonacupuncture

sites (Acupuncture, 1998).
Even though sham acupuncture is the most acceptable control for double blind

studies, problems do exist. The first is eliciting the Hawthorne effect: when a

treatment of no therapeutic value evokes an improvement in a patients condition,
brought on by the mere act of treating (Getting the needle, 1997). Longworth and

35

McCarthy (1997) wrote that where true acupuncture may give 70% pain relief, sham
acupuncture may produce 50% relief. Since they believed that the variability of these
figures is +/- 15%, both treatments could actually be equally effective. Other

problems with sham acupuncture are inserting the needles too deeply and too close to

the meridians (Longworth & McCarthy, 1997).

Conclusions

Much of the research on acupuncture has focused on its use for painful
conditions. According to the NTH Consensus Statement (Acupuncture, 1998), efficacy

of acupuncture has been shown when treating adults with postoperative and
chemotherapy-induced nausea and vomiting, as well as with postoperative dental

pain. The consensus statement further reports that acupuncture may be useful as an
adjunct treatment, or an acceptable alternative treatment, for other conditions

including low back pain.
With the increasing incidence of low back pain in recent years, further
research will be required to show that acupuncture may play a role in decreasing

disability, absenteeism, and medical costs.
The theory of Qi is supported by this research. When specific pomts along

meridians are stimulated by needles, the balance and enhancement of the flow of Qi
occurs. Once the flow was corrected, the subjects perceived a decrease in their pain.

36

Recommendations

Further research is needed to investigate acupuncture in treating acute low
back pain. Based on the results of this study, as well as limitations of this study, the
following recommendations are made:
1. Double-blind studies are the gold standard of western medicine. One group

of research subjects should receive acupuncture and the other group should receive
sham acupuncture. The sham needling should involve very superficial needle

placement and the meridians should be avoided. Distant anatomical sites should be
used, with a small number of needles.

2. Larger sample size should be used to increase generalizability.
3. Include subjects from different demographic and racial groups.

4. Include several experienced acupuncturists in the study and make sure that
their styles are consistent.

5. In conjunction with a pain scale, include a scale to assess functional
activity.
6. Assess the effect of acupuncture after several months.

Summary
This chapter provided a summary of this research. It was found that an

acupuncture treatment significantly reduced perception of acute low back pain in

patients 20 to 50 years old. Discussion and conclusions were addressed as well as
recommendations for future research.

37

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42

Appendix A

Pain Scale

I

I

I

I

I

0

1

2

3

4

I

5

6

I

7

I
8

I

9

I
10

43

Appendix B
Mathematics for t-Test Calculations

Step 1: Calculating the Mean of Sample Difference Scores
D / Number of Subjects
24/12 = 2

Step 2: The Sum of Squares of Sample Difference Scores
D2 - [(D)(0)] /12]
70 - [(24)(24) / 12] = 22

Step 3: t-Test for Correlated Groups

Mean of Sample Difference Score
Sum of Squares of Sample Difference Score /
(Subjects)(Subjects - 1)
2/22
132
= 4.88

Step 4: Comparing t-Test Value with Significant Value
= 4.88 > 1.761, Therefore the hypothesis is accepted (Pagano, 1998).