Acupuncture for low back pain: a clinical practice guideline from the Hong Kong taskforce of standardized acupuncture practice

doi:10.19852/j.cnki.jtcm.2022.01.009

Abstract

Abstract:

OBJECTIVE: To develop a clinical practice guideline to guide the treatment of low back pain by acupuncture.

METHODS: An integrative approach of systematic review of literature, clinical evidence classification, expert opinion surveying, and consensus establishing via a Delphi program was utilized during the developing process. Both evidence-based practice standards and the personalized features of acupuncture were taken into considerations.

RESULTS: Based on clinical evidence and expert opinions, we developed a clinical practice guideline for the treatment of low back pain with acupuncture. These recommendations have a wide coverage spanning from Western Medicine diagnosis and Traditional Chinese Medicine syndrome differentiation, to acupuncture treatment procedures, as well as post treatment care for rehabilitation and follow-ups. The recommendations for acupuncture practice included treatment principles, therapeutic regimens, and operational procedures. The levels of evidence and strength of recommendation were rated for each procedure of practice.

CONCLUSION: A clinical practice guideline for acupuncture treating low back pain was developed based on contemporary clinical evidence and experts' consensus to provide best currently agreeable practice guideline for domestic and international stakeholders.

Key words: acupuncture, low back pain, diagnosis, syndrome differentiation, rehabilitation, practice guideline

Haiyong CHEN, Wing-Fai YEUNG, Mingxiao YANG, Jinglan MU, Tat-Chi ZIEA, Bacon Fung-Leung NG, Lixing LAO. Acupuncture for low back pain: a clinical practice guideline from the Hong Kong taskforce of standardized acupuncture practice[J]. Journal of Traditional Chinese Medicine, 2022, 42(1): 140-147.

Figures/Tables 3

References 30

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Level of evidence	Description
Ia	Evidence from at least two types of research as follows: randomized controlled trial, cohort study, case-control study, and case report, with the consistent effect size and direction;
Ⅰb	Evidence from a single randomized controlled trial with sufficient power;
Ⅱa	Evidence from controlled studies without randomization or cohort studies;
Ⅱb	Evidence from case-control studies (non-experimental descriptive study);
Ⅲa	Evidence from historical controlled studies (non-experimental descriptive study);
Ⅲb	Evidence from before-after case-control studies (non-experimental descriptive study);
Ⅳ	Evidence from well-known reported cases or classical traditional Chinese textbooks;
Ⅴ	Evidence from expert committee reports or opinions or clinical experience of respected authorities, or case report not applied widely, and therapy recorded in classical traditional Chinese textbooks but not applied in practice;

Level of evidence	Description
Ia	Evidence from at least two types of research as follows: randomized controlled trial, cohort study, case-control study, and case report, with the consistent effect size and direction;
Ⅰb	Evidence from a single randomized controlled trial with sufficient power;
Ⅱa	Evidence from controlled studies without randomization or cohort studies;
Ⅱb	Evidence from case-control studies (non-experimental descriptive study);
Ⅲa	Evidence from historical controlled studies (non-experimental descriptive study);
Ⅲb	Evidence from before-after case-control studies (non-experimental descriptive study);
Ⅳ	Evidence from well-known reported cases or classical traditional Chinese textbooks;
Ⅴ	Evidence from expert committee reports or opinions or clinical experience of respected authorities, or case report not applied widely, and therapy recorded in classical traditional Chinese textbooks but not applied in practice;

Item	Acute LBP and acute attack of chronic LBP	Chronic LBP
Treatment principle	Promote Qi flow to relieve pain, relax sinews, and activate blood (C, IV).	Relax sinews and activate collaterals; unblock meridians to relieve pain; tonify kidney and spleen (C, IV).
Acupoints selection based on syndrome differentiation	Main acupoints: A-shi point, Weizhong (BL40), Houxi (SI3)^12-14, Yaotongdian (EX-UE7)¹⁵ (A, Ib). Syndrome-based supplementary acupoints: Governor Vessel Syndrome: Shuigou (GV26)¹⁶ (A, Ib), Huatuojiaji (EX-B2) (C, IV). Foot Taiyang Bladder Meridian Syndrome: Kunlun (BL60)¹⁷ (A, Ib). Additional acupoint: Shenmai (BL62), Yanglao (SI6), Zanzhu (BL2), Waiguan (TE5), Zulinqi (GB41), Yanglingquan (GB34)¹⁶ (A, Ib).	Main acupoints: Shenshu (BL23), Weizhong (BL40), Dachangshu (BL25), A-shi point^19-22 (A, Ib). Syndrome-based supplementary acupoints: Governor Vessel Syndrome: Mingmen (GV4), Houxi (SI3), Huatuojiaji (EX-B2)²³ (A, Ib). Foot taiyang Bladder Meridian Syndrome: Kunlun (BL60)²³ (A, Ib). Cold-dampness: Yaoyangguan (GV3) (C, IV). Qi stagnation and blood stasis: Geshu (BL17) (C, IV). Kidney deficiency: Zhishi (BL52), Taixi (KI3) (C, IV). Lumbosacral pain: Ciliao (BL32), Yaochu (GV2) (C, IV).
Position	Usually patients are in prone position, but older patients could lie on either side. Sitting position can be used if the needle retention time is short (C, IV).	Usually patients are in prone position, but older patients could lie on either side. Sitting position can be used if the needle retention time is short (C, IV).
Acupuncture technique	Filiform needles [ø 0.25 mm ¹⁸(A, Ib), 1-1.5 cun (C, IV)] are recommended. First, insert needles at EX-UE7, SI3 when patient is in standing and convey strong stimulation by twirling/lifting and thrusting for 1-3 min (C, IV). Then ask patient to turn the waist slowly and remove needles after pain has been reduced. Second, if the acute pain is eased after initial treatment and local muscle in the low back area is not too stiff/tight, let patient lie prone on bed and stimulate A-shi point and Weizhong (BL40) using the bloodletting method (C, IV).	According to the excess or deficiency nature of syndromes, use the bloodletting method or reinforcing method in combination with moxibustion. Needles of 0.3 mm in diameter and 40 mm in length are recommended (C, IV). The depth of needle insertion varies depending on the location of the acupoints and the muscle thickness of patients, usually ranging from 10 to 30 mm. After insertion of needles, use a suitable technique to stimulate the acupoints to obtain the “De Qi” sensation (C, IV).
Duration	The needles should be retained in situ for 20-30 min at each session (C, IV).	The needles should be retained in situ for 20-30 min at each session (C, IV).
Treatment frequency and course	In the beginning, acupuncture treatment can be offered once a day or every other day¹⁶ (A, Ib). Usually, a treatment course consists of 3 to 6 sessions but may vary depending on the patient’s condition¹⁶ (A, Ib). When there is no obvious improvement after a course of treatment, the following can be done: (1) refer patients to a TCM practitioner at bone setting; (2) refer patients to a physician for further examination; and (3) suspend treatment for several days, and conduct an examination then (C, IV).	At the beginning, offer acupuncture two to three times a week^20-23(A, Ib). After 3-4 weeks, evaluate the treatment effect^20-23(A, Ib). If pain is relieved, continue treatment for 4 more weeks (C, IV), at a frequency of once or twice a week (C, IV). Frequency of treatment can then be gradually reduced to once a week^20-23(A, Ib), or once a month (C, IV), depending on the patient’s response. If the improvement is not obvious, other therapies such as physiotherapy may be added. Alternatively, acupuncture treatment could be suspended for 1-2 weeks and followed by an evaluation (C, IV).

Item	Acute LBP and acute attack of chronic LBP	Chronic LBP
Treatment principle	Promote Qi flow to relieve pain, relax sinews, and activate blood (C, IV).	Relax sinews and activate collaterals; unblock meridians to relieve pain; tonify kidney and spleen (C, IV).
Acupoints selection based on syndrome differentiation	Main acupoints: A-shi point, Weizhong (BL40), Houxi (SI3)^12-14, Yaotongdian (EX-UE7)¹⁵ (A, Ib). Syndrome-based supplementary acupoints: Governor Vessel Syndrome: Shuigou (GV26)¹⁶ (A, Ib), Huatuojiaji (EX-B2) (C, IV). Foot Taiyang Bladder Meridian Syndrome: Kunlun (BL60)¹⁷ (A, Ib). Additional acupoint: Shenmai (BL62), Yanglao (SI6), Zanzhu (BL2), Waiguan (TE5), Zulinqi (GB41), Yanglingquan (GB34)¹⁶ (A, Ib).	Main acupoints: Shenshu (BL23), Weizhong (BL40), Dachangshu (BL25), A-shi point^19-22 (A, Ib). Syndrome-based supplementary acupoints: Governor Vessel Syndrome: Mingmen (GV4), Houxi (SI3), Huatuojiaji (EX-B2)²³ (A, Ib). Foot taiyang Bladder Meridian Syndrome: Kunlun (BL60)²³ (A, Ib). Cold-dampness: Yaoyangguan (GV3) (C, IV). Qi stagnation and blood stasis: Geshu (BL17) (C, IV). Kidney deficiency: Zhishi (BL52), Taixi (KI3) (C, IV). Lumbosacral pain: Ciliao (BL32), Yaochu (GV2) (C, IV).
Position	Usually patients are in prone position, but older patients could lie on either side. Sitting position can be used if the needle retention time is short (C, IV).	Usually patients are in prone position, but older patients could lie on either side. Sitting position can be used if the needle retention time is short (C, IV).
Acupuncture technique	Filiform needles [ø 0.25 mm ¹⁸(A, Ib), 1-1.5 cun (C, IV)] are recommended. First, insert needles at EX-UE7, SI3 when patient is in standing and convey strong stimulation by twirling/lifting and thrusting for 1-3 min (C, IV). Then ask patient to turn the waist slowly and remove needles after pain has been reduced. Second, if the acute pain is eased after initial treatment and local muscle in the low back area is not too stiff/tight, let patient lie prone on bed and stimulate A-shi point and Weizhong (BL40) using the bloodletting method (C, IV).	According to the excess or deficiency nature of syndromes, use the bloodletting method or reinforcing method in combination with moxibustion. Needles of 0.3 mm in diameter and 40 mm in length are recommended (C, IV). The depth of needle insertion varies depending on the location of the acupoints and the muscle thickness of patients, usually ranging from 10 to 30 mm. After insertion of needles, use a suitable technique to stimulate the acupoints to obtain the “De Qi” sensation (C, IV).
Duration	The needles should be retained in situ for 20-30 min at each session (C, IV).	The needles should be retained in situ for 20-30 min at each session (C, IV).
Treatment frequency and course	In the beginning, acupuncture treatment can be offered once a day or every other day¹⁶ (A, Ib). Usually, a treatment course consists of 3 to 6 sessions but may vary depending on the patient’s condition¹⁶ (A, Ib). When there is no obvious improvement after a course of treatment, the following can be done: (1) refer patients to a TCM practitioner at bone setting; (2) refer patients to a physician for further examination; and (3) suspend treatment for several days, and conduct an examination then (C, IV).	At the beginning, offer acupuncture two to three times a week^20-23(A, Ib). After 3-4 weeks, evaluate the treatment effect^20-23(A, Ib). If pain is relieved, continue treatment for 4 more weeks (C, IV), at a frequency of once or twice a week (C, IV). Frequency of treatment can then be gradually reduced to once a week^20-23(A, Ib), or once a month (C, IV), depending on the patient’s response. If the improvement is not obvious, other therapies such as physiotherapy may be added. Alternatively, acupuncture treatment could be suspended for 1-2 weeks and followed by an evaluation (C, IV).

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