4. Results …
4.4 Specific use of acupuncture for low back pain
Theory
Chinese Medicine contains a lot of different diagnosis systems to express the cause of a disease. The ways Chinese medicine physicians express the cause of low back pain is never completely the same but broad concepts are in general similar39.
In the questionnaire, the physicians were asked to give their opinion about the importance of four different pattern identifications to diagnose low back pain.
Figure 4.4.1 Patterns identification 1
The meridian pattern identification was considered as the most important tool, followed by the Qi and Blood pattern, the Six Excesses pattern and finally the Visceral pattern identifications.
Figure 4.4.2 Patterns identification 2
Using comparative statistics, we didn’t found any significant trends related to education background, age and years of practice of the physician nor related to the geographical areas or the different hospitals.
But the multiple linear regression analysis showed interesting correlations. The evidence of factors associations was mainly related to the age of the physicians and secondarily to the geographical location. The Visceral pattern, the Meridian pattern and the Six Excesses pattern identification showed and association with age of the physicians. The younger physicians founded less important to use them than older physicians.
Concerning the geographical areas, the Six Excesses pattern and the Qi and Blood pattern identification showed and evident association. Those pattern identifications were found more important by the physicians practicing in the north and in the centre of the country than those practicing in the South. The cities/districts areas division showed a difference for the Visceral pattern identification that was more used by physicians practicing in districts areas.
By opposition, Visceral patterns and the Six Excesses pattern identifications were considered as less important than the Qi and Blood pattern and the Meridian pattern identifications.
Table 4.4.1 Factors associated with the importance accorded to pattern identification
Data were analysed through Multiple Linear Model analysis
a. This parameter is set to zero because it is redundant
* P<.05
**P<.001
Meridian pattern identification
Qi and Blood pattern identification
Six Excesses pattern identification
Visceral pattern identification Special licence
.12 Under 30 years old
30 to 39 years old 40 to 49 years old More than 50 years old
-.86 11 to 20 years of practice More than 20 years of practice
.47 Teaching hospital
Regional hospital Rural hospital
Chinese medicine hospital
.11 North of Taiwan
Centre of Taiwan South of Taiwan
.13 Cities areas
Districts areas
.00
Diagnosis methods
Diagnostic in Chinese medicine is characterized by its four examination methods that are the inspection, listening and smelling, inquiry, and palpation.
In the data obtained through the questionnaire, the four major diagnosis tools were the location of pain, the quality and intensity of pain, the factors that make the pain better and worse and the history of pain. All of them are a part of the inquiry diagnosis method. In comparison the diagnosis tools of the inspection methods (observation of the tongue, complexion, vitality, X ray , MRI) are less important to diagnose low back pain.
Figure 4.4.3 Diagnosis tools
If we compare diagnosis tools specific to Chinese or Western medicine, we can see that the diagnosis tools of Chinese medicine are clearly less used.
Figure 4.4.4 Chinese medicine diagnosis tools
The comparative analysis of the different factors didn’t showed statistical evidence. Though, we saw some in interesting tendencies.
Regarding the education background, we saw two aspects. On one hand, the special license qualified physicians differed of the two other groups in the importance they accorded to the diagnosis tools (except for the laboratory data where there were no differences between the groups). Special license qualified physicians favored more the inspection of vitality, the complexion, the use of X ray and MRI/CT than the two other groups. On the contrary, they considered obviously less important the tongue diagnosis, the pulse diagnosis and the use of physical and neurological examination. On the other hand, physicians of the School of Post baccalaureate Chinese medicine were less familiar with diagnosis tools specific to Western medicine, that is the use of X ray, MRI/CT, laboratory data, physical examination and neurological examinations.
The age and the years of practice didn’t show mutual correlation except Figure 4.4.5 Western medicine diagnosis tools
for the tongue diagnosis. The tongue diagnosis was more used by older physicians (“more than 50 years”) or physician with a long clinical experience (‘”more than 20 years”). Younger physician (“under 30 years”) accorded a strong importance to pulse diagnosis as well as the laboratory data in comparison to the other group age. This tendency was not correlated with the years of practice.
An interesting trend related to the years of practice was that the physicians between 1 to 10 years of clinical experience were less familiar with specific Western medicine diagnosis tools.
Table 4.4.2 Diagnosis tools: Percentage of “Not familiar with” regarding the years of practice
Diagnosis tools
X Ray MRI/CT Laboratory data
Physical examination
Neurological examination
1 to 5 years 1.5% 4.5% 1.5% 2.9% 7.4%
6 to 10 years 2.2% 2.3% 6.7% 2.2% 2.2%
11 to 20 years - - 2.9% - - - - - -
More than 20 years
- - - - - - - - - -
Concerning variations between the different hospitals, we found that Chinese medicine hospitals differed from the other groups. Physicians working in a Chinese medicine hospital found “very important” to look at the tongue, the vitality, the complexion, the posture and the pulse of the patient.
Table 4.4.3 Diagnosis tools: Percentage of “Very important” regarding the type of hospitals
Diagnosis tools Tongue Vitality Complexion Posture Pulse
Chinese medicine hospital
26.7% 26.7% 33.3% 46.7% 46.7%
Teaching hospital 14% 15.1% 14.1% 38.3% 30.9%
Regional hospital 17.5% 20.0% 27.5% 35.0% 25.6%
Rural hospital 11.1% 11.1% 11.1% 33.3% 33.3%
On the contrary, they found less important to use X ray, MRI/CT, laboratory data, palpation of the pain area and physical examination than the physicians working in other kind of hospitals.
Table 4.4.4 Diagnosis tools: Percentage of “Very important” regarding the type of hospitals
Diagnosis tools X Ray MRI/CT Laboratory data
Palpation of the pain
Physical examination Chinese
medicine hospital
20.0% 14.3% 0.0% 46.7% 26.7%
Teaching hospital
36.2% 23.9% 14.9% 64.5% 39.4%
Regional hospital
40.0% 30.3% 22.5% 59.0% 27.5%
Rural hospital 33.3% 22.2% 22.2% 55.6% 33.3%
There were no significant correlations worth to be mentioned correlating the diagnosis tools used and the geographical situation of the clinical practice.
Through the multiple linear regression analysis, we found evidences that the groups of factors that influenced the use of diagnosis tools were the education background (the evidence found concerned the pain history which
was more important for the physicians graduated from the school of Chinese medicine), the geographical location (the evidence found concerned the pulse diagnosis which was considered more important by the physicians practicing in the north and in the centre of the island) and the cities/districts areas division (the physicians practicing in districts areas accorded more importance to the pulse diagnosis).
Treatment of low back pain
In Chinese Medicine the treatment used is closely correlated to the diagnosis. Therefore the treatment of chronic and acute low back pain often differ whatsoever in the choice of acupuncture points, needle technique, retention time of the needles, frequency of the treatment and complementary therapeutic techniques used.
Choice of acupuncture points
In the data obtained through the questionnaire, we discovered that the four most used point used to treat low back pain were Weizhong BL40 (委 中), Shenshu BL23 (腎兪), Yanglingquan GB34 (陽陵泉) and Danchangshu BL25 (大腸兪), with a pattern of use than favored Weizhong BL40 (委中), Shenshu BL23 (腎兪) and Yanglingquan GB34 (陽陵泉) for acute low back pain. For chronic low back pain the most usual set of points was Shenshu BL23 (腎兪), Weizhong BL40 (委中), and Dachangshu BL25 (大腸兪).
Figure 4.4.6 Most frequent acupuncture points used to treat low back pain
In both case we saw a combination of local and distal points. The most used points40 for the treatment of acute low back pain, showed the same mixture of local points (Ouch point, Yaotuidian, Yaotongdian) and distal points (Houxi SI3 後溪, Yanglao SI6 養老 and Chengshan BL57 承山). We can point out that the local points are mostly not related to a meridian (Ouch point, Yaotuidian, Yaotongdian with an exception for Shenshu BL23 腎兪).
The second observation is that almost all the distal points are on the one the hand or foot Taiyang meridians (Weizhong BL40 委中, Chengshan BL57 承 山, Houxi SI3 後溪, Yanglao SI6 養老 with an exception for Yanglingquan GB34 陽陵泉).
Figure 4.4.7 Most used acupuncture points for the treatment of acute low back pain
The most used points for the treatment of chronic low back pain were also characterized by a mixture of local points (Shenshu BL23 腎 兪 , Dachangshu BL25 大 腸 兪 and Huatuojiaji points 華 佗 夾 脊 ) and distal points (Weizhong BL40 委中, Kunlun BL60 昆侖, Taixi KI3 太溪 and Zusanli ST36 足三里). We can point out that the local points are both non meridian related points (Ouch points, Huatuojiaji points) and meridian related (Shenshu BL23 and Dachangshu BL25). The distal points are on one hand related to the foot Taiyang meridian (Kunlun BL60 昆 侖 and Weizhong BL40 委中) and on the other hand related to other meridians. The use of Zusanli ST36 (足三里) and Taixi KI3(太溪) are more aimed to regulate the whole body, that is to say, strengthening the Spleen and the Stomach in the case of Zusanli ST36 or strengthen the Kidney’s Yang in the case of Taixi KI3.
Figure 4.4.8 Most used acupuncture points for the treatment of chronic low back pain
Through the questionnaire, we asked the physician to give their opinion about the importance of some factors involved in their rational for choosing points when treating low back pain. Almost 40% of them considered “very important” to choose the acupuncture point regarding the meridian it belongs to. The patient constitution was also an important factor for choosing point.
20% of the physicians founded “very important” to use a set block of acupuncture points. On the contrary, the seasons and the hours of the day weren’t considered as important factors.
Figure 4.4.9 Rationale for choosing acupuncture points
Regarding the different categories of acupuncture points, the most popular category was without doubt the Ouch points. Then, the physicians also considered the Five transport points, followed by the Source points, the Clefs points, the Confluence points of the eight vessels, and finally the extra points.
Figure 4.4.10 Categories of acupuncture points
Comparative statistics didn’t show any statistical evidence for any factors related to the choice of acupuncture points.
However, regarding the education course the special license qualified physicians were distinct of the two other groups. In their rational of choosing acupuncture points, they considered less important to use a set block of points, to look at the patient’s constitution and particularly didn’t take the hour of the day into account (66.6% considered this factor as “not important and 33.3% were “not familiar with” it). On the contrary, they found important to choose acupuncture point with regard to the seasons.
Concerning the acupuncture points categories, we noted that special license qualified physicians considered less important to use Ouch points and Extra points than the two other groups. In general, physicians graduated from the school of Chinese medicine and those graduated from the school of Post baccalaureate Chinese medicine were more likely to be “not familiar with”
with many of the items whatsoever in their rational of choosing acupuncture points or the different acupuncture points categories.
The fact of being “not familiar with” many of the items was also related to the physician’s age. Often the physician under 30 years to 39 years cumulated a higher rate of “not familiar with” than the group age of 40 and more years.
This tendency was less apparent when comparing the years of clinical practice. In general, the fact to be “not familiar with” was not related to the years of clinical experience.
The geographical situation didn’t show very relevant tendencies related to the choice of acupuncture points. Though, in the centre of the island, the physician tended to find more important to take into account the constitution of the patient as well as the season than in the North or in the South. In the use of different acupuncture points categories, the physicians practicing in the south part of the country founded slightly less important to use the Five
transport points, the Source points, the Clefs points and the Confluence of the eight vessels points. By contrast, the use of Ouch point was approximately the same for each areas.
There were no special feature differenciating cities and districts areas, nor related to the different type of hospitals.
The multiple linear regression analysis showed that the rational for choosing acupuncture points was mainly associated with the geographical area (for the importance accorded to use a set block of acupuncture points and the importance regarding the patient’s constitution) and secondarily with the years of practice of the physicians (for the importance accorded to use a set block of acupuncture points). The importance accorded with the different categories of acupuncture points was associated with the age and the years of practice of the physicians. The age of the physician was associated with five items (Five transport, Source, Clefs, Confluence of the eight vessels and Extra points) as the years of practice of the physicians were associated with four items (Five transport, Confluence of the eight vessels, Ouch and Extra points).
Table 4.4.6 Factors associated with the rational for choosing acupuncture points
Data were analysed through Multiple Linear Model analysis and we chose to represent only the factors that attained statistical evidences.
The factors didn't showed a difference with the following items: the choice of acupuncture points regarding the seasons, the hours of the days and meridian related points.
a. This parameter is set to zero because it is redundant
* P<.05
**P<.001
Set block of acupuncture points Constitution 95% Special licence
.32 Under 30 years old
30 to 39 years old 40 to 49 years old More than 50 years old
.17 11 to 20 years of practice More than 20 years of practice
-1.05 Teaching hospital
Regional hospital Rural hospital
Chinese medicine hospital
.02 North of Taiwan
Centre of Taiwan South of Taiwan
-.29 Cities areas
Districts areas
.09
Table 4.4.7 Factors associated with the importance accorded to the categories of acupuncture points (1st Page)
Data were analysed through Multiple Linear Model analysis
a. This parameter is set to zero because it is redundant
* P<.05
**P<.001
Five transport points Source points Clefs points Confluence of the eight
vessels points 95% Special licence
.03 Under 30 years old
30 to 39 years old 40 to 49 years old More than 50 years old
-.63 11 to 20 years of practice More than 20 years of practice
1.0 Teaching hospital
Regional hospital Rural hospital
Chinese medicine hospital
.04 North of Taiwan
Centre of Taiwan South of Taiwan
.15 Cities areas
Districts areas
.07
Table 4.4.7 Factors associated with the importance accorded to the categories of acupuncture points (Page 2)
Data were analysed through Multiple Linear Model analysis
a. This parameter is set to zero because it is redundant
* P<.05
**P<.001
Extra points Ouch points
95% Special licence
.51 Under 30 years old
30 to 39 years old 40 to 49 years old More than 50 years old
-.57 11 to 20 years of practice More than 20 years of practice
.91 Teaching hospital
Regional hospital Rural hospital
Chinese medicine hospital
.12 North of Taiwan
Centre of Taiwan South of Taiwan
.13 Cities areas
Districts areas
.16
Needles and needle technique
In Taiwan, almost every Chinese Medicine physician will use disposable needle. As these needle are fit out with a tube, most of the physicians used this tube to insert the needle.
The data obtained by the questionnaire showed that 75.5% of the physicians used tube needle for insertion, 17% used only their hand to insert the needle. Finally, 8.5% of the physicians used the both methods.
Figure 4.4.11 Method of needle’s insertion
The order of insertion was considered as “very important” by 16% of the physicians. In contrast 22% considered it as “not important”. 51% rated it as “important and 11% were “not familiar with”.
The importance of obtaining the Qi, or Deqi, after the insertion of the needle was specially underlined by the results of the questionnaire. It was considered as “very important” (54%) and “important” (44%) by almost all the physicians (only 2% considered it as “not important”).
The use of hand stimulation was considered as more important than
electric stimulation.
Figure 4.4.12 Stimulation of the needles
Comparative statistics showed an evidence between the use of electrical stimulation and geographical location. The results showed than electrical acupuncture was less used in the north part of the country especially if compared to the South were electrical stimulation is more used.
Figure 4.4.13 Electrical stimulation of the needles regarding geographical situation
The results also showed that electrical stimulation was more important
in districts areas than on cities areas. Furthermore, the electrical stimulation was also less used by special license qualified physicians. Though the two last observations didn’t reach statistical evidence.
The multiple linear regression analysis showed that the strongest association with the needle stimulation was related to the education background (the special licence qualified physicians founded less important to have Deqi, or to use hand or electro stimulation). Secondarily, the age of the physician played a role especially in regards to the importance accorded to the electro-stimulation
Table 4.4.8 Factors associated with the importance accorded to the needles stimulation
Data were analysed through Multiple Linear Model analysis
a. This parameter is set to zero because it is redundant
* P<.05
**P<.001
Obtention of the Qi Hand stimulation Electro stimulation
95%
Confidence interval
95%
Confidence interval
95% Confidence interval Special licence
.59 Under 30 years old
30 to 39 years old 40 to 49 years old More than 50 years old
.06 11 to 20 years of practice More than 20 years of practice
-.13 Teaching hospital
Regional hospital Rural hospital
Chinese medicine hospital
.04 North of Taiwan
Centre of Taiwan South of Taiwan
.06 Cities areas
Districts areas
-.15
Concerning the supplementation and draining methods, the data obtained trough the questionnaire showed that the lifting-thrusting and the twirling supplementation and draining methods were the most important techniques used. On the contrary quick-slow and respiratory supplementation and draining techniques were less used.
Figure 4.4.14 Supplementation and draining methods
Comparing the different factors that influenced the supplementation and draining methods, we found one statistical evidence that was related with the physician’s age. The same tendency was also found in relation to the years of practice. In both cases, the more old the physician was or the longer clinical experience he has, the more he found important the respiratory supplementation and draining technique. This tendency was found in general for all the supplementation and draining methods.
Apart this relation we didn’t found any others conclusive factors that influenced the supplementation and draining methods.
The multiple linear regression analysis showed only one evidence of association related to the type of hospital (concerning the respiratory supplementation and draining technique).
Retention time of the needles
In Taiwan, the usual retention time of the needle was 20 minutes41. The results obtained by questionnaire showed that the average time of needle retention was 15 to 20 minutes for the two third of the physicians (72%). If we compare the retention time of the needle for acute and chronic low back pain, we cane note a slight augmentation of the retention time in the case of chronic low back pain.
Figure 4.4.15 Retention time of the needles for acute and chronic low back pain
In comparative statistics the same tendency was noted. For each
In comparative statistics the same tendency was noted. For each