000.teka Lidiya Tesfaye 12

天津中医药大学硕士学位论文
学校代码 - 10063
专业代码：10512
二千〇二十二级硕士研究生毕业论文
埃塞俄比亚中医针灸治疗慢性腰痛的可接受性和
可行性调查。
Investigation on the Acceptability and feasibility of the use
of TCM acupuncture in the management of chronic lower
back pain in Ethiopia.
专业：针灸推拿
学位类型：学位
研究生：Teka Lidiya Tesfaye
导师：孟祥文教授
天津中医药大学
日期：行进二千〇二十二
Contents
中文摘要
Abstract
ACRONYMS AND ABBREVIATION
1. Preface...........................................................................................................................................1
2. Background of the study..............................................................................................................1
3. Statement of the problem...........................................................................................................30
4. Significance of the study.............................................................................................................30
5. Research questions.....................................................................................................................31
6. Objective......................................................................................................................................31
7. Methodology................................................................................................................................31
8. Operational definition...................................................................................................................32
Intervention...........................................................................................................................................33
Evaluations............................................................................................................................................33
Feasibility..........................................................................................................................................33
Acceptability.....................................................................................................................................33
Data Quality Assurance.........................................................................................................................33
Data Management and Analysis............................................................................................................34
9. Ethical consideration and Dissemination..................................................................................34
10. Result...........................................................................................................................................35
11. Discussion....................................................................................................................................41
12. Conclusion...................................................................................................................................43
13. Literature Review.......................................................................................................................44
14. Reference.....................................................................................................................................49
15. Annex...........................................................................................................................................72
16. Acknowledgment........................................................................................................................75
17. CURRICULUM VITAE............................................................................................................76
中文摘要
目的：
初步调查和评估在埃塞俄比亚针灸治疗慢性腰痛的可行性与可接受性，为进一步在该
地区推广中医针灸提供思路。
方法：
招募了 33 名患有慢性腰痛的患者。根据纳入排除标准，实际纳入 24 人。在研究期间，

患者接受了针灸治疗。取穴：肾俞(UB23)、胃脘(Bl40)、太溪(ki3)、刺辽(Bl32)、合谷
(Li4)、足三里(st36)、太冲(Lv3)、未央(Bl39)。每个穴位针刺得气后，留针 40 分钟。每周
进行两次治疗，共持续 5 周。在所有患者治疗后，患者将被要求以问卷的形式对针灸的
治疗效果和接受程度进行评分。收集所有分数后，使用 SPSS23.0 软件进行统计数据。
结果：
经统计，共收集 21 例（33 名患者接受，9 名患者在治疗前拒绝；24 名患者中，有 21

名患者完成了研究）。治疗期间患者对针灸耐受性良好，没有任何明显的不良事件。 21
名参与者中，8 名（38.1%）参与者认为干预有助于改善他们的腰痛，5 名（23.8%）参与
者认为干预有一定的帮助，9 名（41.9%）参与者承认干预在一定程度上帮助他们增加和
改善了他们的活动（如弯腰和转身）。 6 名 (28.6%) 参与者认为干预对改善和增加活动
非常有帮助，10 名 (47.6%) 参与者承认干预积极改变了他们看待背痛的方式。此外，16
名（76.2%）参与者对提供给他们的干预感到满意，14 名（66.7%）参与者正在考虑减少
他们的药物治疗。在 21 名参与者中，17 名（81%）参与者承认他们愿意继续使用针灸来
治疗腰痛，并且他们也会推荐其他人尝试对腰痛进行干预，并且愿意支付治疗费用。8 名
（38.1%）参与者表示，对干预措施不了解是尝试针灸的重大障碍，另有 6 名（28.6%）
与会者表示，埃塞俄比亚缺乏针灸治疗服务。
结论：
1.针灸治疗可以有效的改善慢性腰痛患者的症状，如提升患者们的活动能力，降低腰
痛发作时的痛感，以及减少患者们药物的使用频率。
2.多数患者对于针灸治疗的反应是积极的。因此针灸作为慢性腰痛安全有效的治疗方
法，值得在埃塞俄比亚进一步推广。
關鍵詞: 中醫（TCM）；慢性腰痛（CLBP）；針灸；调查。
Abstract
Purpose:
Preliminary investigation and evaluation of the feasibility and acceptability of acupuncture for
chronic low back pain in Ethiopia will provide ideas for further promotion of traditional Chinese
medicine acupuncture in the region.
Method:
Thirty-three patients with chronic low back pain were recruited. According to the inclusion and
exclusion criteria, 24 were actually included. During the study period, patients were given
acupuncture treatment. Acupoint selection: Shenshu (UB23), weizhog(Bl40), Taixi (ki3),
ciliao(Bl32), Hegu(Li4), zusanli(st36), Taichong(Lv3) and weiyang(Bl39). After acupuncture at
each acupuncture point to obtain Qi, the needles were retained for 40 min. Treatments were
given twice a week for a total of 5 week. After the treatment of all patients, the patients will be
asked to rate the treatment effect and the acceptance of acupuncture in the form of a
questionnaire. After collecting all the scores, use SPSS23.0 software for statistical data.
Result:
Statistically, a total of 21 cases were collected (33 patients accepted, 9 patients refused before
treatment; 21 of 24 patients completed the study). During the treatment period, the patient
tolerated acupuncture well without any obvious adverse events. Of the 21 participants, 8 (38.1%)
felt that the intervention helped improve their low back pain, 5 (23.8%) felt that the intervention
was helpful, and 9 (41.9%) admitted that the intervention to a certain extent helped them increase
and improve their movements (such as bending and turning). Six (28.6%) participants found the
intervention very helpful in improving and increasing activity, and 10 (47.6%) participants
admitted that the intervention positively changed the way they viewed back pain. In addition, 16
(76.2%) participants were satisfied with the intervention offered to them, and 14 (66.7%) were
considering reducing their medication. Of the 21 participants, 17 (81%) admitted that they would
be willing to continue using acupuncture for low back pain, that they would also recommend
others to try an intervention for low back pain, and would be willing to pay for the treatment.
Eight (38.1%) participants said that lack of understanding of interventions was a major obstacle
to trying acupuncture, and another six (28.6%) said that there was a lack of acupuncture
treatment services in Ethiopia.
In conclusion:
1. Acupuncture treatment can effectively improve the symptoms of patients with chronic low
back pain, such as improving the patients' mobility, reducing the pain during low back pain
attacks, and reducing the frequency of drug use.
2. Most patients responded positively to acupuncture treatment. Therefore, as a safe and effective
treatment method for chronic low back pain, acupuncture is worthy of further promotion in
Ethiopia.
Keywords:
Traditional Chinese Medicine (TCM); Chronic Low Back Pain (CLBP); Acupuncture;
Investigation.
ACRONYMS AND ABBREVIATION

AD Anno Domini
BC Before Christ
CLBP Chronic lower back pain
DALYs Disability-adjusted life year
LBP Lower back pain
ODI Oswestry Disability Index
PGLBP Pelvic girdle and low back pain
TCM Traditional Chinese Medicine
WHO World Health Organization
Preface
Background of the study.
Lower back pain.
Low back pain is pain, muscle tension, or stiffness localized below the costal margin and above
the inferior gluteal folds, with or without sciatica, and is defined as chronic when it persists for
12 weeks or more. Nonspecific low back pain is pain not attributed to a recognizable pathology
(e.g., infection, tumor, osteoporosis, rheumatoid arthritis, fracture, inflammation, 1With the
estimation of above70% of adults in the developed country suffer from CLBP during life
time.2and also showing a significant increase in developing countries 3–5
and due to its significant
negative effect on both the individual and the country's economy by making the individual less
productive: 6 LBP is now listed among one of the major health problems we are facing globally.7
History
Humans have been experiencing low back discomfort since at least the Bronze Age. The Edwin
Smith Papyrus, which dates from around 1500 BCE, contains a diagnostic test and treatment for
a spinal sprain. And Hippocrates (c. 460 BCE – c. 370 BCE) was the first to use a phrase for
sciatica and low back pain, while Galen elaborated on the notion. Until the end of the first
century, physicians advised patiently waiting. And Folk medicine practitioners during the
Medieval era devised cures for back pain based on the concept that it was caused by spirits.8
At the beginning of the twentieth century, physicians believed that low back pain was caused by
nerve irritation or damage,8 with neuralgia and neuritis commonly referenced in the medical
literature of the period. Throughout the twentieth century, the popularity of such hypothesized
reasons waned.9 American neurosurgeon Harvey Williams Cushing popularized surgical
therapies for low back pain in the early twentieth century.10 New ideas of the etiology appeared
in the 1920s and 1930s, with physicians proposing a mix of nervous system and psychiatric
1
illnesses such as nerve weakening (neurasthenia) and female hysteria.8 fibromyalgia was also
mentioned more frequently.9
Emerging technology like X-rays provided physicians with new diagnostic tools, exposing the
intervertebral disc as a possible source of back pain in some situations. Back surgery improved
or healed instances of disc-related sciatica, according to orthopedic physician Joseph S. Barr in
1938.9 As a result of this study, the vertebral disc model of low back pain took over in the
1940s,8 dominating the literature until the 1980s, aided further by the development of new
imaging technologies such as CT and MRI.9 The debate died down when research revealed that
disc issues were a very infrequent source of discomfort. Since then, doctors have realized that it
is doubtful that a precise reason for low back pain can be discovered in many patients, and they
have questioned the necessity to find one at all, as symptoms usually heal within 6 to 12 weeks
regardless of therapy.8
Epidemiology
A typical complaint is low back discomfort that lasts at least one day and hinders
exercise.11 Globally, around 40% of individuals have LBP at some time in their lives,11 with
estimates as high as 80% of persons in the developed world.12 Approximately 9 to 12 percent of
the population (632 million) has LBP at any one time, and roughly one-quarter (23.2 percent)
reports having it at some point during any given month period11,13 Difficulty usually develops
between the ages of 20 and 40.14 5 Low back pain is more frequent in adults aged 40–80, and the
overall number of people affected is predicted to rise as the population ages.11
It is unclear if males or women are more likely to suffer from low back discomfort11, A 2012
study found a rate of 9.6 percent among men and 8.7 percent among girls.13 Another 2012 study
discovered a higher prevalence in females than males, which the reviewers hypothesized was
owing to higher rates of pain related to osteoporosis, menstruation, and pregnancy in women, or
maybe because women were more eager to report pain than men.11 Back discomfort affects an
estimated 70% of pregnant women, with the percentage increasing as the pregnancy
progresses.15 Current smokers, particularly teenagers, are more likely to experience low back
pain than past smokers, and former smokers are more likely to experience low back pain than
individuals who have never smoked. 16
2
Socio economic significance
The economic effects of low back pain are significant. It is the most prevalent form of pain in
adults in the United States, accounts for a huge number of missed work days, and is the most
common musculoskeletal complaint seen in the emergency room.17 It was projected in 1998 to be
responsible for $90 billion in yearly health care expenses, with 5% of persons bearing the
majority (75%) of the costs..17 There was a more than twofold rise in spinal fusion procedures in
the United States between 1990 and 2001, despite no modifications in the criteria for surgery or
new evidence of enhanced utility.18 Additional expenses include lost income and productivity,
with low back pain accounting for 40% of all missed work days in the United States. Low back
discomfort disables a higher proportion of the workforce in Canada, the United Kingdom, the
Netherlands, and Sweden than in the United States or Germany.19 Low Back Pain has the largest
number of Years Lived With Disability (YLDs) Rank, Rate, and Percentage Change for the 25
Leading Causes of Disability and Injury in the United States between 1990 and 2016.20
Workers who suffer from severe low back pain as a consequence of a workplace injury may be
requested to have x-rays taken. Testing is not recommended in this circumstance, as it is in
others, unless there are red flags. An employer's fear about legal liability is not a medical
justification and should not be used to justify unnecessary medical examination. There should be
no legal justification for pushing patients to undergo tests that a health care practitioner decides
are unnecessary.21
Causes
Low back pain is not a distinct illness, but rather a complaint that can be caused by a wide range
of underlying issues of varied severity.17
The majority of LBP has no known cause 14 although it is thought to be the result of minor
muscular or skeletal disorders such as sprains or strains.22 Obesity, smoking, pregnancy weight
gain, stress, poor physical condition, poor posture, and a bad sleeping position can all contribute
to low back discomfort.22 A comprehensive list of likely causes covers a number of less frequent
illnesses.23 Osteoarthritis, degradation of the discs between the vertebrae or a spinal disc
herniation, shattered vertebra(e) (such as from osteoporosis), or, in rare cases, an infection or
malignancy of the spine are all possible physical reasons.24
3
Medical diseases affecting the female reproductive system, such as endometriosis, ovarian cysts,
ovarian cancer, or uterine fibroids, can cause acute low back discomfort in women.25 During
pregnancy, about half of all pregnant women have discomfort in the lower back or sacral area as
a result of changes in posture and center of gravity that cause muscle and ligament strain.26
Low back pain may be divided into four major categories:
Mechanical (including muscular strain, spasm, or osteoarthritis); herniated nucleus pulposus,

herniated disk, spinal stenosis, or compression fracture.
Inflammatory – HLA-B27 related arthritis, such as ankylosing spondylitis, reactive arthritis,

psoriatic arthritis, reproductive system inflammation, and inflammatory bowel disease.
Malignancy - bone metastases from cancers such as the lung, breast, prostate, and thyroid,
among others.
And infection of the urinary system can also cause osteomyelitis, abscess, and low back
discomfort.27
Pathophysiology
The lumbar (or lower back) region is made up of five vertebrae (L1–L5), which may or may not
include the sacrum. There are fibrocartilaginous discs between these vertebrae that function as
cushions, keeping the vertebrae from rubbing together while also preserving the spinal cord.
Nerves enter and exit the spinal cord via particular holes between the vertebrae, delivering
feeling to the skin and conveying messages to muscles. The ligaments and muscles of the back
and abdomen give spine stability. Facet joints are small joints that constrain and guide the
movements of the spine.28
The multifidus muscles run up and down the back of the spine and are essential for maintaining
the spine straight and stable during many everyday actions including sitting, walking, and
lifting.29 A problem with these muscles is common in people who have chronic low back pain
because the discomfort induces the individual to utilize the back muscles incorrectly in order to
escape the agony. The issue with the multifidus muscles persists long after the pain has subsided,
and it is most likely one of the reasons why the discomfort has returned. It is advised that persons
4
suffering from chronic low back pain learn how to use these muscles as part of their healing
regimen.30
A gelatinous core is surrounded by a fibrous ring in an intervertebral disc. The majority of the
disc is not supplied by either the circulatory or nervous systems when it is normal and
undamaged - blood and nerves only run to the outside of the disc. Inside the disc are specialized
cells that can live without direct blood flow.31 The discs lose their flexibility and capacity to
absorb physical pressures over time.17 This diminished capacity to withstand physical forces
places more strain on other areas of the spine, leading ligaments to thicken and bony growths to
form on the vertebrae.17 As a result, there is less space for the spinal cord and nerve roots to pass
through.17 When a disc degenerates due to injury or disease, its composition changes: blood
vessels and nerves may grow into its core, and/or herniated disc material might press directly on
a nerve root.31 Back discomfort can be caused by any of these changes.31
The pain is usually unpleasant sensation that occurs in reaction to an event that either destroys or
has the potential to damage the body's tissues. Transduction, transmission, perception, and
modulation are the four major processes in the process of feeling pain.29 Pain-detecting nerve
cells have cell bodies in the dorsal root ganglia and fibers that send signals to the spinal cord.32
The experience of pain begins when the pain-causing event stimulates the ends of relevant
sensory nerve cells. Transduction is the process by which this sort of cell turns an event into an
electrical signal. Several distinct types of nerve fibers convey the electrical signal from the
transducing cell to the posterior horn of the spinal cord, then to the brain stem, and finally to
various areas of the brain such as the thalamus and the limbic system. In the process of pain
perception, pain signals are processed and given context in the brain. The brain can modulate the
transmission of additional nerve impulses by lowering or raising the release of
neurotransmitters.29
Parts of the pain sensory and processing system may not operate properly, causing the
experience of pain when no external reason exists, signaling excessive pain from a specific
source, or signaling pain from a usually non-painful occurrence. Furthermore, the pain
modulation systems may not work adequately. Chronic pain is influenced by several
phenomena.29
5
Sign and symptoms
In the most prevalent kind of acute low back pain, discomfort arises following activities such as
lifting, twisting, or forward bending. The symptoms may appear quickly after the motions or
when you wake up the next morning. The symptoms might range from discomfort at a specific
site to widespread pain. Certain actions, such as elevating a leg, or postures, such as sitting or
standing, may or may not aggravate it. Sciatica, or pain radiating down the legs, may be present.
The onset of acute low back pain usually occurs between the ages of 20 and 40. As an adult, this
is frequently the initial reason for a person to contact a medical professional.14 Recurrent
episodes affect more than half of the population 33 , with the second episode being typically more
painful than the first.14
Other issues may arise in addition to low back discomfort. Chronic low back pain is linked to
sleep issues such as a longer time to fall asleep, interruptions during sleep, a shorter period of
sleep, and reduced contentment with sleep.34 Furthermore, the majority of those suffering from
persistent low back pain exhibit signs of depression 35 or anxiety.36
Diagnosis
Because the back structure is complicated and pain reporting is subjective and influenced by
social variables, diagnosing low back pain is difficult.23 While muscle and joint disorders are the
most common cause of low back pain, they must be distinguished from neurological issues,
spinal tumors, spine fractures, and infections, among others.22 14
Some tests done for diagnosis are the straight leg lift test can identify discomfort caused by a
herniated disc. Imaging, such as MRI, can offer detailed insight regarding disc-related causes of
back pain when required and in the presence of red flags, chronic neurological symptoms that do
not disappear, or continuous or increasing pain, imaging is recommended. For suspected
malignancy, infection, or cauda equine syndrome, it is very important to employ imaging (either
MRI or CT) as soon as possible. MRI is somewhat better than CT in detecting disc damage;
nonetheless, the two modalities are equally helpful in diagnosing spinal stenosis. Only a few
physical diagnostic tests are helpful. In patients with disc herniation, the straight leg raise test is
virtually invariably positive.23
6
Lumbar provocative discography may be beneficial in identifying a particular disc that is

generating pain in those who have persistent high levels of low back pain.37 Similarly,
therapeutic techniques like nerve blocks can be utilized to pinpoint the cause of pain. Facet joint
injections, transforminal epidural injections, and sacroiliac injections may be used as diagnostic
tests, according to some data.23 Most other physical examinations, such as those used to assess
scoliosis, muscular weakness or wasting, and reduced reflexes, are ineffective.
Low back discomfort is one of the most common reasons individuals see physicians.38,39 Pain
that has lasted only a few weeks is likely to go away on its own.40 Thus, if a person's medical
history and physical examination do not suggest a specific disease as the cause, medical societies
advise against imaging tests such as X-rays, CT scans, and MRIs.39 Individuals may desire such
testing, however they are unneeded health care unless red flags are present 41,42 they
are unnecessary health care.38, 40 Routine imaging raises expenses, is linked to greater rates of
surgery with little overall benefit,43,44 and the radiation used may be hazardous to one's health.43
Only around 1% of imaging tests pinpoint the source of the issue.38 Imaging may also uncover
innocuous anomalies, leading patients to want more unneeded testing or to be concerned.38 MRI
scans in the lumbar area, however, rose by more than 300 percent among US Medicare
participants between 1994 and 2006.18
Classifications
There are several ways to define low back pain, and no one technique is universally
accepted.23 Mechanical back pain (which include nonspecific musculoskeletal strains, herniated
discs, compressed nerve roots, degenerative discs or joint disease, and broken vertebrae), non-
mechanical back pain (tumors, inflammatory conditions such as spondyloarthritis, and
infections), and referred pain from internal organs are the three general types of low back pain
(gallbladder disease, kidney stones, kidney infections, and aortic aneurysm, among others).23
Most instances (about 90 percent or more) involve mechanical or musculoskeletal
problems),23,45 and the majority (approximately 75 percent) do not have a particular etiology but
are assumed to be due to muscle strain or ligament damage.23, 45 Low back pain is seldom caused
by systemic or psychological issues, such as fibromyalgia and somatoform disorders.45
The indications and symptoms of low back pain might be used to classify it. The most prevalent
categorization is nonspecific pain, which is defined as pain that does not alter in response to
7
specific motions and is limited to the lower back without extending beyond the
buttocks.23 Radicular pain is defined as pain that radiates down the leg below the knee, is
localized on one side (in the case of disc herniation) or on both sides (in the case of spinal
stenosis), and changes in severity in response to particular postures or movements. It accounts
for 7% of all cases.23 Pain that is accompanied by red flags such as trauma, fever, a history of
malignancy, or substantial muscular weakness may signal a more serious underlying disease that
requires urgent or expert therapy.23
The length of the symptoms can also be characterized as acute, sub-chronic (also known as sub-
acute), or chronic. The exact period necessary to fulfill each of these is not widely agreed upon,
although pain lasting less than six weeks is categorized as acute, pain lasting six to twelve weeks
is labeled as sub-chronic, and pain lasting more than twelve weeks is classified as chronic. 22 The
length of symptoms may influence management and prognosis.
Danger signs
The presence of some symptoms, known as red flags(history of cancer, Loss of bladder or bowel
control, Significant motor weakness or sensory problems, Loss of sensation, age related trauma ,
Chronic corticosteroid use, Osteoporosis, Severe pain after lumbar, surgery in past year, Fever,
UTI, Immunosuppression and Intravenous drug use), indicates the need for additional testing to
check for more serious underlying disorders that may require immediate or particular
treatment.23,46 The existence of a red flag does not necessarily imply the presence of a substantial
condition. It is only suggestive,47 and most people with red flags do not have a serious underlying
problem.22,14 If no red flags are present, diagnostic imaging or laboratory testing in the first four
weeks after the onset of symptoms has not been shown to be useful.23
Many warning flags are not well supported by evidence.48 49

The most useful for diagnosing a
fracture include older age, corticosteroid usage, and substantial trauma, particularly if it results in
skin marks. A history of cancer is the strongest predictor of its occurrence.48
When all other causes of low back pain have been ruled out, patients with non-specific low back
pain are often treated symptomatically, with no particular reason determined.22 14 Attempts to
uncover factors that may complicate the diagnosis, such as depression, substance abuse, or a
financial agenda, may be beneficial.23
8
Prevention
Exercise appears to be beneficial in the prevention of low back pain.50 Exercise is also likely to
be useful in reducing recurrences in those who have had discomfort for more than six weeks.14,
51
Firm mattresses are better for chronic pain than medium-firm mattresses.46 There is little to no
evidence that back belts are any more effective than correct lifting technique teaching in
reducing low back discomfort.50, 52 There is no quality data to demonstrate the superiority of
medium firm mattresses over firm mattresses. A few studies that have disputed this assumption
have also neglected to take sleep position and mattress firmness into account. It is possible to
prefer the most comfortable sleeping surface.53 Insoles for shoes do not assist to avoid low back
discomfort.50 , 54
Managements
Regardless of therapy, most persons with acute or subacute low back pain improve with time. It
is common for improvements to occur within the first month. Recommendations include staying
active, avoiding activities that aggravate pain, and knowing self-care for symptoms.55 The
treatment of low back pain is determined by which of the three broad categories the reason is:
mechanical difficulties, non-mechanical disorders, or referred pain.56 The aims for acute pain that
is only producing mild to moderate issues are to restore normal function, return the individual to
work, and decrease suffering. The disease is usually not serious, resolves quickly, and recovery
is aided by returning to normal activities as soon as possible within the limitations of pain.22
Giving them coping techniques and reassuring them of these truths might help them heal faster.14
Multidisciplinary therapy programs may be beneficial for people suffering from sub-chronic or
chronic low back pain.57 Treatments other than medicine include superficial heat, massage,
acupuncture, and spinal manipulation. Acetaminophen and systemic steroids are not suggested
since neither treatment improves pain outcomes in acute or subacute low back pain.55
Patients' pain complaints have been reduced by physical therapy stabilizing exercises for the
lumbar spine and manual treatment. Manual treatment and the benefits of stabilization have
similar effects on low back pain, which outweigh the effects of general exercises.58
9
Physical activity
When used to treat an acute episode of pain, increasing general physical activity has been
advocated, but no clear association to pain or impairment has been discovered.51,59 Walking is
supported by low- to moderate-quality evidence for acute pain.60 Aerobic activities, such as
progressive walking, tend to be beneficial for subacute and acute low back pain, are strongly
advised for chronic low back pain, and are advised following surgery. These exercises are only
effective if they help to alleviate low back discomfort.53
The McKenzie technique of treatment is moderately useful for recurring acute low back pain, but
its benefit in the short term does not appear to be considerable. There is some preliminary
evidence to support the use of heat treatment for acute and sub-chronic low back pain61 but there
is little evidence to support the use of either heat or cold therapy in chronic pain.62 Weak data
shows that back belts may reduce the amount of missing workdays, but there is no proof that
they alleviate pain.52 Ultrasound and shock wave therapy do not appear to be beneficial and are
hence discouraged.63,64 Lumbar traction is ineffective as a treatment for radicular low back
pain.65 It's also uncertain if lumbar supports are a good therapy option.66
Stretching-only exercise routines are not suggested for low back discomfort. Stretching that is
generic or nonspecific has also been shown to be ineffective in the treatment of acute low back
pain. Yoga and Tai chi are not advised for acute or subacute low back pain, but they are for
chronic back pain. Stretching, particularly with limited range of motion, can hamper treatment
advancement in the same way that restricting strength and limiting exercises does.53
Exercise therapy can help people with persistent low back pain reduce discomfort while also
increasing physical function, trunk muscular strength, and mental wellness.67,68 It also appears to
lower recurrence rates for up to six months after the program's completion 69 and enhances long-
term function.62 For functional limitations, the observed treatment benefit for exercise compared
to no therapy, usual care, or placebo comparisons is minimal, but it improved pain (low certainty
evidence) and functional limitations outcomes (moderate certainty evidence) compared to
alternative conservative therapies.68
10
There is no proof that one sort of exercise treatment is superior to another.70,71 The Alexander
technique appears to be beneficial for chronic back pain, and there is preliminary evidence to
support the use of yoga, 72 and there is tentative evidence to support the use of yoga.73 If a person
has chronic low back pain and is motivated, it is advised that they employ yoga or tai chi as a
type of treatment; however, this is not recommended for acute or subacute low back
pain.53 Motor control exercise, which entails directed movement and the use of normal muscles
during simple activities before progressing to more difficult tasks, improves pain and function
for up to 20 weeks, although there is minimal difference when compared to manual treatment
and other kinds of exercise.74 When compared to general strength and condition exercise training,
motor control exercise with manual treatment causes equal reductions in pain intensity; however,
only the latter improved muscular endurance and strength while concurrently decreasing self-
reported impairment.67
Aquatic treatment is suggested for people who have other underlying illnesses such as excessive
obesity, degenerative joint disease, or other diseases that hinder progressive walking. In
individuals with a preexisting ailment, aquatic treatment is advised for chronic and subacute low
back pain. Aquatic treatment is not indicated for persons who do not have a prior ailment that
prevents them from progressing in their walking. There is no high-quality evidence to support
palates in the treatment of low back pain.53
Peripheral nerve stimulation, a minimally invasive method, may be therapeutic in cases of

persistent low back pain that do not respond to conventional treatments, but the data is
inconclusive, and it is ineffective for pain that spreads into the leg.75 There is insufficient
evidence to support the use of shoe insoles as a therapy.54 Transcutaneous electrical nerve
stimulation (TENS) has not been shown to be effective in the treatment of chronic low back
pain.76 Because there has been insufficient study to back up the usage of lumbar extension
machines, they are not advised.53
Patients with persistent low back pain who participate in multimodal biopsychosocial
rehabilitation (MBR) programs are less likely to experience pain and impairment than those who
get standard care or physical therapy. When compared to physical therapy, MBR has a good
impact on the patient's work status. The scale of the effects is small and should be evaluated
against the time and resource needs of MBR initiatives.77
11
Drugs and surgery
Medication is frequently used to treat low back pain for as long as it is useful. The hope with the
initial episode of low back pain is a total cure; however, if the disease becomes chronic, the goals
may shift to pain management and regaining as much function as feasible. Because pain drugs
are only marginally effective, expectations about their efficacy may differ from reality, leading
to dissatisfaction.35
Most individuals can get by with acetaminophen (paracetamol), NSAIDs (but not aspirin), or
skeletal muscle relaxants as their first line of defense. However.35,55, the benefits of NSAIDs are
frequently insignificant.78 Acetaminophen (paracetamol) was shown to be no more beneficial
than a placebo in relieving pain, quality of life, or function in high-quality evaluations.79 NSAIDs
are more effective for acute episodes than acetaminophen; however, they carry a greater risk of
side effects, including kidney failure, stomach ulcers and possibly heart problemsNSAIDs are
more efficient than acetaminophen for acute bouts; nevertheless, they are associated with a
higher risk of adverse effects including as renal failure, stomach ulcers, and even cardiac issues.
As a result, NSAIDs are a backup option to acetaminophen, and should be used only when the
latter is ineffective. There are various kinds of NSAIDs; there is no evidence to recommend the
use of COX-2 inhibitors above any other class of NSAIDs in terms of advantages.78 35 80 In terms
of safety, naproxen may be the best option.81 Muscle relaxants might be useful.35
If the pain is still not properly controlled, short-term usage of opioids such as morphine may be
beneficial.82,35 These medicines have a higher risk of addiction, may interact negatively with
other prescriptions, and have a higher risk of adverse effects such as dizziness, nausea, and
constipation. The long-term effects of opiate usage for lower back pain are unclear.83 Opioid
therapy for persistent low back pain raises the chance of illegal drug usage for the rest of one's
life.84 Specialist organizations advise against using opioids for persistent low back pain on a
long-term basis.35 In 2016, the Centers for Disease Control and Prevention (CDC) issued a
recommendation for the use of prescription opioids in the treatment of chronic pain. It argues
that opiate usage is not the ideal treatment for chronic pain because of the high dangers
associated. If prescribed, a person and their doctor should have a realistic strategy in place to quit
treatment if the dangers outweigh the benefits.85
12
Opioids may be used for older adults with persistent pain if NSAIDs provide too significant a
danger, such as those with diabetes, stomach, or heart issues. They may also be beneficial for a
subset of people suffering from neuropathic pain.86
Antidepressants may be beneficial in treating chronic pain linked with depressive symptoms, but
they are not without risk of adverse effects.35 Although the anti-seizure medications gabapentin,
pregabalin, and topiramate are sometimes used to treat persistent low back pain, there is no
evidence of a benefit. Systemic oral steroids have not been proved to be effective in the
treatment of low back pain. 35 Although facet joint injections and steroid injections into the discs
have not been shown to be beneficial in people with persistent, non-radiating pain, they may be
explored in those with persistent sciatic pain.87 Epidural corticosteroid injections produce a minor
and dubious short-term relief in sciatica patients but have no long-term effect.88 Concerns have
also been raised about potential negative effects.89
Magnesium was found to be beneficial in a trial of 80 people suffering from persistent back
pain.90
Surgery may be beneficial for those who have a herniated disc that is causing substantial leg
pain, limb weakness, bladder difficulties, or loss of bowel control.10 It may also be beneficial for
people who have spinal stenosis.13 There is no convincing evidence of a benefit from surgery in
the absence of these conditions.10
Nonsurgical procedures, such as a discectomy (the partial removal of a disc that is causing leg
discomfort), can offer pain relief sooner.10 Discectomy improves results after one year, but not
after four to ten years. Micro discectomy, which is less intrusive, has not been found to provide a
different outcome than traditional discectomy. There is insufficient data to propose surgical
treatments for the majority of other disorders. The long-term impact of surgery on degenerative
disc degeneration is unknown. Less invasive surgical procedures have reduced recovery periods,
but proof of efficacy is lacking.10
For patients suffering from lower back pain caused by disc degeneration, fair evidence supports
spinal fusion as being equivalent to rigorous physical therapy and somewhat better than low-
intensity nonsurgical therapies.91 Fusion may be explored for people who have low back pain
from an acquired misplaced vertebra that does not improve with conservative
treatment,10 however only a small percentage of persons who undergo spinal fusion have
13
satisfactory outcomes.91 There are several surgical methods available to accomplish fusion, with
no convincing evidence that one is superior than the others.92 Adding spinal implant devices
during fusion raises the risk but provides no additional benefit in terms of pain or function.18
Alternative therapy
It is unknown if alternative therapies are effective for non-chronic back pain.93 Chiropractic care
or spine manipulation therapy (SMT) appear to be as helpful as other suggested therapies.94
National guidelines varied, with some not advising SMT, others defining manipulation as
9595
optional, and yet others suggesting a short course for patients who do not improve with
conventional therapies.22 Based on low-quality data, a 2017 review suggested SMT.55 There is
inadequate evidence to support anesthesia-aided manipulation or medically assisted
manipulation.96 When compared to motor control exercises, SMT does not deliver substantial
advantages.97
For nonspecific acute or sub-chronic pain, acupuncture is no better than a placebo, normal
treatment, or sham acupuncture. It helps pain a bit more than no therapy and roughly the same as
drugs for patients with chronic pain, but it does not assist with impairment. This pain benefit is
only apparent immediately following therapy and not during follow-up.98 Acupuncture may be a
viable choice for patients suffering from chronic pain that is unresponsive to conventional
therapies such as conservative care and drugs.14,99
Massage treatment does not appear to help with acute low back pain. According to a 2015
Cochrane analysis, massage therapy was more beneficial than no treatment for acute low back
pain; however, the advantages were only short-term, and there was no impact on increasing
function. Massage therapy was no better than no treatment for persistent low back pain in terms
of both pain and function, but only in the short term. The overall quality of the evidence was
low, and the authors concluded that massage therapy is not an effective treatment for low back
pain in general.100 Massage therapy is advised for patients who have subacute or chronic low
back pain, but it should be combined with another kind of treatment, such as aerobic or strength
activities. Massage treatment is only advised for acute or chronic radicular pain syndromes if low
back pain is a symptom. Mechanical massage equipment should not be used to treat any type of
low back discomfort.53
14
Prolotherapy, which involves injecting liquids into joints (or other regions) to produce
inflammation and so boost the body's healing response, has not been shown to be useful on its
own, although it may be beneficial when combined with another therapy.36
Herbal remedies in general are not well supported by evidence.101 The natural remedies Devil's
claw and white willow may lessen the number of people reporting severe levels of pain;
however, this difference is not substantial for those using pain medicines.36 Capsicum, either as a
gel or a plaster cast, has been shown to relieve discomfort and improve function.36
Behavioral therapy may be beneficial in the treatment of chronic pain.102 There are several types
of conditioning available, including operant conditioning, which uses reinforcement to reduce
undesirable behaviors and increase desirable behaviors; cognitive behavioral therapy, which
assists people in identifying and correcting negative thinking and behavior; and respondent
conditioning, which can modify an individual's physiological response to pain.36 However, the
advantage is minor.103 Medical professionals can create an integrated behavioral therapy
program.36 The research is unclear as to whether mindfulness-based stress reduction improves
chronic back pain intensity or related impairment, but it does imply that it may be beneficial in
increasing pain acceptance.104
For non-specific low back pain, preliminary data supports neuroreflexotherapy (NRT), in which
tiny pieces of metal are implanted just beneath the skin of the ear and back.105, 106
36
Multidisciplinary biopsychosocial rehabilitation (MBR), which focuses on both physical and
psychological components, may help with back pain, however research is limited.107 There is a
scarcity of high-quality data to back up the use of radiofrequency denervation for pain
management.108
KT Tape has been proven to be no different than other known pain management techniques in
the treatment of persistent non-specific low back pain.109
Overall, the prognosis for acute low back pain is favorable. Pain and disability frequently
improve dramatically in the first six weeks, with 40 to 90 percent of patients reporting full
recovery.110 4 Improvement is often slower in individuals who still have symptoms after six
weeks, with very minor increases lasting up to a year. Most people's pain and impairment levels
15
are low to negligible after one year. Distress, past low back pain, and work satisfaction are all
indicators of long-term prognosis following an acute pain episode.110 Certain psychological
issues, such as melancholy or sadness as a result of job loss, may extend the episode of low back
pain. Recurrences of back pain occur in more than half of persons after the initial episode 33
The short-term prognosis for chronic low back pain is likewise encouraging, with improvement
in the first six weeks but minimal improvement after that. Those with persistent low back pain
frequently continue to have considerable pain and impairment after a year.110 Expectations may
impact prognosis, with people who have good expectations of recovery having a better
probability of returning to work and overall results.111
TCM
The WHO defines traditional medicine as a diversity of health practices, approaches, knowledge,
and beliefs and incorporates plant, animal, and/or mineral-based medicines, spiritual therapies,
manual techniques, and exercises, which are applied singly or together to require care of the
16
well-being and to treat or prevent illness . It is a known fact that TCM is one of the oldest
112
forms of medicine, and the fact that it still exists and is still being utilized for the past thousands
of years shows its values and positive impact on the health care system that exists today. 113It is
documented in may classical texts that TCM have been practiced in China for more than 2000
years. It is thought that it was developed from empirical clinical experience 114. The human
structure, physiology, pathology, diagnosis, treatment, and preservation were inscribed in The
Yellow Emperor's Internal Classic (Huang Di Nei Jing), which was believed to be written in
475–221 BC. Furthermore, the theoretical aspect of TCM was future boosted by the book
Treatise on Cold Diseases and Miscellaneous Disorders (Shang Han Za Bing Lun), written in
196–204 AD, which illustrated the implementation of different therapeutic principles based on
different syndromes. In 624 AD, China officially opened the first TCM school, the Imperial
Medical School (Tai Yi Shu), which served as a base for a broad body of knowledge, in theory,
diagnostic procedures, and treatment approaches we know today.115 TCM has been applied in
various areas like internal medicine, gynecology, pediatrics, traumatology, external medicine,
dermatology, emergency medicine, and HEENT on the management of the majority of chronic
and also for some acute conditions and in some conditions, TCM manage not only the secondary
manifestations (Biao) but also the primary causes (Ben). TCM follows the yin and yang
theory,116 the five elements theory,117 the qi, blood and body fluids theory,118 and the differential
diagnosis of syndromes which are unique and aims to promote and regulate the flow of qi and
blood, to regulate the functions of the zang-fu organs and to balance yin and yang. This
significantly strays from Western and other philosophies; thus, its different views strongly
influence its attitude and approach to healthcare 119.
Acupuncture.
Acupuncture is an art of penetrating the skin with thin, solid, antimonial needles that are then
activated through light and specific movements of the practitioner' hands or with electrical
17
stimulation113. Acupuncture is an essential aspect of traditional Chinese medicine, and major

attempts have been made to demonstrate that it possesses qualities such as ease of use, cheap
cost, remarkable efficacy, and so on 120.
Acupuncture has been used in 183 nations, according to the World Health Organization's (WHO)
traditional medicine plan (2014-2023) 121.
In addition, the WHO published a study in 2002 saying that acupuncture treatment may be
appropriate for 107 particular illnesses 122.
According to a domestic investigation, after aggregating clinical diseases and symptoms treated
by contemporary acupuncture in other countries, 110 diseases and symptoms were deemed
beneficial. Furthermore, the illness spectrums were primarily seen in muscle, bones, and
connective tissue 123.
Acupuncture's therapeutic effectiveness has been recognized all over the globe as an experience-
based medicine with a lengthy history. It made a significant contribution to the health of the
Chinese people and the rest of the globe. The National Institutes of Health (NIH) in the United
States has acknowledged the use of acupuncture to treat chronic pain and other pathological
diseases 124.
With acupuncture's clinical efficacy generally acknowledged across the world, fundamental
experimental research is a crucial foundation for clinical practice recommendations, and it can
help to further the global development of acupuncture. Many researchers in the United States and
worldwide have begun to conduct basic tests to better understand the mechanism of acupuncture
and moxibustion, discovering certain effective biological compounds in cerebrospinal fluid,
serum, organs, and acupoint tissue. Acupuncture has been shown to influence the expression of
bioactive genes and proteins in both healthy and pathological conditions 125.
In recent years, researchers have concentrated on analgesic and anti-inflammatory compounds,

and they have achieved some success. Acupuncture has been shown to increase the release of
anti-inflammatory and analgesic substances (opioid peptides, adenosine, dopamine, and
endogenous Cannabinoids 126,127) while decreasing the release of pro-inflammatory factors (5-
18
hydroxytryptamine, histamine, substance P, nerve growth factor, CGRP, and TRPV1 128–130). To
provide an analgesic impact
Most basic investigations focus on the linear association between "intervention and effect," but
acupuncture's full network regulatory effects as complex treatments are ignored. Acupuncture
has the ability to influence the operation of several organs or systems at the same time.
Acupuncture management of organ function is accomplished by integrated regulation of the
organ's system and even the entire body 131.
Acupuncture is a highly complex stimulation that involves the release of chemical compounds,
the activation of many cells, and nerve excitation to transport information from acupoints to the
target organ through meridians. Acupuncture stimulates the peripheral nerves and sends input
signals to the brain and spinal cord via numerous neural pathways. Neuro functions at the
peripheral and spinal levels, on the other hand, perform some physiological roles, including as
nerve protection and analgesia. This establishes that the impact of acupuncture is the
consequence of a complex interplay of various components, levels, and systems, rather than a
single element. Unfortunately, the network interactions between those components have yet to be
fully explored. The "neutralization" condition in the organism refers to the optimal equilibrium
of the flow of living substances in healthy humans. Acupuncture therapy of disorders is primarily
accomplished by adjusting the internal environment of the body in order to cure the condition by
restoring the "Yin and Yang in harmonious" state. To better comprehend the underlying
mechanism and scientific foundation of acupuncture and moxibustion, we believe that
acupuncture operates on acupoints by first activating a small network of acupoints (Acupoint
Network). Acupuncture signal is amplified by cascade, and the nerve endocrine immune system
(NEI) is triggered via the body's enormous network of meridians (Meridian Network). The
nerve-endocrine-immune system (NEI) then sends the effect information to the target organ via
multilevel and multi-system pathways before acting on the illness network (Disease Network) to
achieve the acupuncture effect.
History of acupuncture
19
Documents going back a few hundred years before the Common Era suggest that acupuncture
began in China. Sharpened stones and bones from circa 6000 BCE have been interpreted as
acupuncture devices 132,133, although they might have simply been used as medical equipment for
taking blood or lancing abscesses. Documents unearthed in the Ma-Wang-Dui tomb in China,
which was sealed in 198 BCE, include no mention of acupuncture as such 134, but do mention a
system of meridians, although one that differs greatly from the model that was eventually
adopted 135. The tattoo traces observed on the 'Ice Man,' who died about 3300 BCE and whose
body was discovered after an Alpine glacier melted, have sparked speculation 136.
These tattoos might imply that a kind of stimulatory treatment akin to acupuncture evolved
independently of China. The Yellow Emperor's Classic of Internal Medicine, which dates from
around 100 BCE, is the first record that unequivocally defined an organized method of diagnosis
and treatment that is now known as acupuncture. The data is given in the form of questions
posed by the Emperor and learning responses from his minister, Chhi-Po137. The work is most
likely a collection of centuries-old traditions 138, presented in terms of the dominant Taoist
philosophy, and is still quoted in support of certain therapeutic approaches 139. The notions of Qi
(vital energy or life force) flowing via channels (meridians or conduits 3) were well established
by this time, however ,the particular anatomical placements of acupuncture sites emerged later140.
Acupuncture was further refined and documented in literature during the next centuries, and it
eventually became one of the primary medicines used in China, alongside herbs, massage,
nutrition, and moxibustion (heat) 133 Many diverse esoteric ideas of diagnosis and treatment
arose, some of which were inconsistent 134,
Probably as rival schools sought to prove their exclusiveness and dominance. Acupuncture
points utilized today are shown in bronze statues from the fourteenth century, which were used
for teaching and assessment reasons 133. The Great Compendium of Acupuncture and
Moxibustion, which forms the cornerstone of contemporary acupuncture, was produced during
the Ming Dynasty (1368–1644). It contains detailed explanations of the whole set of 365 sites
that symbolize apertures in the channels through which needles might be put to alter the flow of
Qi energy 138 It should be mentioned that knowledge of health and sickness in China was derived
only through observation of living beings because dissection was prohibited and anatomy was
not taught. Acupuncture's popularity among the Chinese began to wane around the seventeenth
20
century, since it was perceived as superstitious and illogical133,137, It was barred from the
Imperial Medical Institute by Emperor edict in 1822. However, the information and skill were
kept, either as a hobby among academics or in everyday practice by rural healers. With China's
increasing adoption of Western medicine at the turn of the twentieth century, acupuncture
suffered its ultimate humiliation in 1929, when it was prohibited along with other kinds of
traditional medicine 133.
Traditional forms of treatment, including acupuncture, were revived when the Communist
government was installed in 1949, presumably for nationalistic reasons, but also as the only
realistic method of providing even basic levels of health to the huge population. Chairman Mao
is cited as stating, "Let a thousand flowers bloom," in reference to traditional medicine, despite
the fact that he himself rejected acupuncture treatment when he was ill 134.
Acupuncture theory and practice were brought together in a consensus known as traditional
Chinese medicine (TCM) , which also included herbal treatment. In the 1950s, acupuncture
139
research institutions were built across China, and treatment became provided in distinct
acupuncture sections within Western-style hospitals. During the same time period, Prof. Han in
Beijing sought a more scientific explanation for acupuncture and conducted groundbreaking
research on the release of neurotransmitters, notably opioid peptides 141.
Acupuncture expanded to other nations at different times and by diverse ways. Korea and Japan
incorporated Chinese acupuncture and herbs into their medical systems in the sixth century 137.
Both nations continue to use traditional treatments, generally in tandem with Western medicine.
When commercial avenues opened up between the ninth and eleventh centuries, acupuncture
emerged in Vietnam. France was one of the first countries in the Western world to adopt
acupuncture 138.In the sixteenth century, Jesuit missionaries brought back accounts of
acupuncture, and the therapy was generally accepted by French doctors. Berlioz, the composer's
father, conducted clinical research on acupuncture and produced a treatise about it in 1816 142.
Souliet du Morant, a diplomat who spent many years in China and produced a number of
acupuncture treatises beginning in 1939, has had a significant effect on French acupuncture
today. Ten Rhijne, who worked for the East India Company and observed acupuncture use in
Japan, wrote the earliest medical account of acupuncture by a European physician.137,142.
21
Then, in the first part of the nineteenth century, there was a surge of interest in both America and
Britain, and a number of papers emerged in the scientific literature, including a Lancet editorial
headed "Acupuncturation" 143. Acupuncture had gone out of favor by the mid-century, and
interest had waned, but it was temporarily revived in one edition of Osler's textbook, in which he
recounts significant success in the treatment of back pain using hat-pins 144. Surprisingly, this
remark was removed from following issues 145.
A member of the US press corps had acupuncture in 1971 while recovering from an emergency
appendectomy in China, which he was visiting in preparation for President Nixon's visit. He
wrote about his experience in the New York Times146 Following that, teams of US physicians
conducted fact-finding missions to China to evaluate acupuncture, specifically its use for surgical
analgesia 147. Despite their initial enthusiasm for the surgeries they watched, acupuncture proved
to be completely untrustworthy as an analgesic for surgery in the West. When an NIH consensus
meeting determined that there was positive evidence for its usefulness, at least in a restricted
range of diseases, acupuncture ultimately attained its current degree of acceptability in the
United States 148.
Traditional acupuncture views have been questioned in the West, most notably by Mann in the
United Kingdom 149 and Ulett in the United States 150.Many practitioners' views have been
replaced by a neurological paradigm based on evidence that acupuncture needles activate nerve
endings and modify brain function, notably the innate pain inhibitory systems 141. The first
magnetic resonance imaging study of acupuncture may potentially be remembered as a
watershed moment.151
Other workers have noticed a striking resemblance between the Travell 152, trigger points and
their unique pain referral patterns, as well as the locations of traditional acupuncture points and
their related meridians 153
Acupuncture has a multitude of proposed mechanisms of action, but there is little good data on
which, if any, mechanisms are relevant to therapeutic practice. Evidence of clinical efficacy is
also lacking for several illnesses, including chronic pain 153,
22
However, systematic evaluations published in the latter decade of the twentieth century offered
more convincing evidence of acupuncture's usefulness in treating nausea (from diverse sources),
tooth pain, back pain, and headache 154.
Needling technique
Insertion
The skin is sterilized before needles are implanted, usually with the use of a plastic guide tube.
Needles can be moved in a variety of ways, including spinning, flicking, and moving up and
down relative to the skin. Because the majority of pain is felt in the skin's surface layers, a rapid
insertion of the needle is advised.155 Hand stimulation of the needles is frequently used to
produce a dull, localized, aching sensation known as de qi, as well as "needle grab," a pulling
sensation felt by the acupuncturist and caused by a mechanical connection between the needle
and skin.156 Acupuncture may be uncomfortable.157 The acupuncturist's skillset may impact how
painful the needle insertion is, and a proficient practitioner may be able to place the needles
without causing any discomfort.155
De-qi sensation
De-qi refers to a sense of numbness, distension, or electrical tingling at the point of needling. If
these feelings are not felt, the acupoint's incorrect placement, incorrect depth of needle insertion,
and insufficient manual manipulation are blamed. If de-qi is not immediately detected after
needle placement, several manual manipulation techniques are frequently used to stimulate it. 155
Once de-qi is noticed, procedures that aim to affect the de-qi may be applied; for example, de-qi
may supposedly be transmitted from the needling site to more distant places of the body by
particular manipulation. Other treatments attempt to sedate qi.155
The former is utilized in deficiency patterns, whereas the latter is used in surplus patterns.155 De
qi is more vital in Chinese acupuncture, although Western and Japanese patients may not believe
it necessary.158
Contraindications
23
Anyone presenting with sepsis or an overwhelming infection should be referred right away.
Unexplained/unstable seizure
Acupuncture therapy should be postponed until the seizure has been thoroughly evaluated and
stabilized/managed correctly.159
Sudden stroke
Acupuncture has been shown to enhance cerebral blood flow. Acupuncture should not be utilized
in acute hemorrhagic stroke because it may cause more brain bleeding. Acupuncture patients
should get medical clearance from their expert, who should ensure that any bleeding has ceased.
Confused patient
A patient must be able to offer their permission to treatment; hence, acupuncture should not be
administered to a confused individual. Patients must be able to comply with orders such as
staying motionless throughout therapy.
The extremely young
The American Acupuncture Council has not set a minimum age for receiving acupuncture
therapy. The term "the very young" refers to patients who are unable to comprehend and
cooperate with the therapy.159
Fear of needles
True fear of needles is a contraindication to acupuncture therapy. This is due to the patient's
significant risk of experiencing an adverse response such as fainting or a panic attack. Being "a
little afraid of needles" or "not enjoying needles" is not real needle phobia, and as such,
individuals can be needled safely.
Contraindications at the site
Swelling
24
Needling into a swollen region is not recommended since it may exacerbate inflammation and
cause further swelling.
Infection
Needling into diseased tissue is not recommended since it has the ability to spread the illness and
introduce it deeper into the body.159
Tumor
Acupuncture therapy should be avoided in the presence of a tumor since needling may induce
tumor cells to disperse.
Uncontrolled movements
Acupuncture needles should not be inserted into areas of uncontrolled body movement.
Removal of lymph nodes
Patients undergoing any surgical operation requiring the excision of lymph nodes must be treated
with extreme caution, since this may result in/increase the probability of lymphedema. It is not
recommended to needle an edematous limb or a limb at risk of lymphedema.
Spinal instability/metastasis
Acupuncture should not be used in regions of spinal instability because the possible relaxation of
surrounding muscles can lead to spinal cord compression.
Precautions
Pacemakers and other electrical implants
25
Electro-acupuncture should not be utilized in patients who have an implanted cardiac pacemaker
since the current is likely to cross the heart, such as when needles are put in opposite arms and
linked by a current. The electrical current used in electrical acupuncture may have a detrimental
effect on the pacemaker or electrical implant. Acupuncture can be used on a regular basis, but
some precautions, such as those pertaining to heart problems and anticoagulants, must be taken.
Cancer
Acupuncture can be performed on people who have been diagnosed with cancer. Patients
receiving active cancer therapy may have low platelet and white cell counts, making their
immune system less efficient. Practitioners should be certain that the current platelet and white
cell counts are within normal limits. Patients who have undergone a surgical treatment involving
the excision of lymph nodes must be treated with caution, since this may increase the risk of
lymphedema. Needles should not be used on an edematous or lymphedematous limb.
Acupuncture should not be used if cancer has compromised the spine's stability. Acupuncture in
regions of spinal instability may result in spinal cord compression when the muscles relax
surrounding muscles that provide support.
Diabetes
Diabetes is normally a precaution, although acupuncture is not recommended if the diabetes is

unstable. Diabetes can cause a slower healing response, particularly in the periphery where
circulation is diminished. Acupuncture should be administered with caution in affected regions
in this scenario. Because diabetes can cause peripheral neuropathy, acupuncture should be
avoided in regions with decreased sensitivity.
Hemophilia, as well as other clotting diseases
Acupuncture should be used with caution while treating hemophiliac patients. Factor VIII levels
should be greater than 15%. It is advised that tiny needles and guide tubes be used. Needling into
joint spaces should be avoided at all costs. If a patient seeking acupuncture has an uncommon
clotting issue, the practitioner should consult with the patient's appropriate physician.159
Anti-coagulants
26
Anticoagulants may be recommended for a variety of medical disorders. Anticoagulant dosage is

determined by the particular patient, their presentation, and their underlying illness. The INR
(international normalized ratio) is a laboratory test that determines how long it takes blood to
clot. It is used to assess the clotting system's response to anticoagulant treatment. A normal INR
should be less than 1.1; however, if a patient is on anticoagulants, their doctor would most likely
strive to keep INR values between 2.0 and 3.0; nevertheless, these levels may vary based on the
specific patient. If the patient is on anticoagulation medication, avoid using intra capsular points
to prevent haemarthrosis to lessen the danger of bleeding/bruising, try using lighter needle
stimulation techniques and lower gauge needles. The increased risk of bleeding while needling a
patient on anticoagulants is a safety concern.159
Heart problems
As long as the heart state is stable, there is no reason why acupuncture cannot be used as a
therapy. It is not recommended to stimulate the needles too hard since this may cause a
sympathetic response, which is undesirable when a cardiac issue is suspected. Prior to needling,
the physiotherapist should evaluate any medications the patient is taking, such as anticoagulants,
and adapt the therapy as needed. Acupuncture should not be used if your cardiac condition is
unstable.159
Valvular heart disease (VHD)
The use of acupuncture in individuals with heart valve abnormalities has sparked debate.
Prophylactic antibiotics have been recommended for almost 50 years prior to dental procedures
and some invasive therapies for individuals with heart valve abnormalities. This belief that
antibiotics are required to prevent infective endocarditis has been passed down through
generations of acupuncture practitioners. NICE issued guidelines on this subject in 2008. These
recommendations address the risk of infective endocarditis in individuals with specific cardiac
diseases (such as acquired valvular heart disease with stenosis or regurgitation and valve
replacement) who are undergoing dental or non-dental invasive procedures. Antibiotic
prophylaxis against infective endocarditis is not recommended for people undergoing dental
procedures, non-dental procedures at the following sites, upper and lower gastrointestinal tract,
genitourinary tract; this includes urological, gynecological, and obstetric procedures, and
27
childbirth, upper and lower respiratory tract; this includes ear, nose, and throat procedures, and
bronchoscopy.
These sites are highlighted because they are considered high risk, which means that theory
implies that germs can be transported to the heart via direct paths from these places. The ear is
likely the only spot from which we would needle. . Even for the ear, which is considered a high-
risk location, preventive antibiotics are nevertheless advised. Based on the findings, acupuncture
in patients with heart valve abnormalities should be approached with caution, with the patient
being closely monitored for symptoms of infective endocarditis as well as general infections.
Patients with heart valve abnormalities may have a slightly increased chance of developing
infective endocarditis, which should be discussed and documented throughout the permission
process. It may also be worthwhile to limit the therapy settings at first, and you may not want to
significantly impact the autonomic nervous system in a patient with heart valve problems. This
may be accomplished with finer needles, shorter time in situ, and less deqi stimulation.
Seizures or epilepsy
If epilepsy or seizures are unstable, unidentified, or awaiting treatment/investigation, they are a

contraindication. Acupuncture can be used to treat stable epilepsy and seizures if safeguards are
taken. There are no studies that particularly look at the safety of acupuncture for people with
epilepsy that we are aware of. Despite the fact that numerous safety studies have shown that
acupuncture is safe for the general public. A methodical approach is essential. An individual risk
assessment is required for an epileptic patient. Some particular possible dangers include: the
patient experiencing a seizure while the needles are still in place, and the acupuncture therapy
increasing the frequency/intensity of the seizures. Here are some examples of how to manage the
risks connected with epilepsy: Stay with the patient during the therapy. Patients frequently
experience an aura, so make sure the patient understands to notify you if a seizure develops. At
the first sign of an aura/seizure, remove the needles immediately. The patient must notify you if
the frequency or intensity of the seizures changes. They might keep a seizure diary to track this
during therapy. If the therapy has a negative impact on epilepsy, it should be discontinued. There
is likely to be much more information particular to each instance that you should explore before
making a treatment decision.159
28
Skin discoloration
Acupuncture should not be performed on skin that is in poor condition. Damaged or fractured
skin, excessively dry skin, inflamed skin, tattooed skin/ink-covered skin, moles, and scars are all
examples of bad skin conditions.
Problems with circulation
Acupuncture should not be used in locations with weak circulation. Because low circulation can
lead to a lack of feeling and a lack of healing ability, it is not recommended to induce damage to
the region during acupuncture therapy.
Allergies
Nickel is present in stainless steel, the alloy used to make the majority of acupuncture needles.
Nickel allergies can vary greatly, and in the case of mild, short-term allergies, the practitioner
and patient may both agree to proceed with acupuncture therapy. It is recommended that a risk
assessment and the interaction between the practitioner and the patient be included in the clinical
records. There are nickel-free needles available for persons who have a more severe nickel
allergy or who are hesitant to undertake acupuncture treatment due to a nickel allergy. Regular
needles that have been coated with another metal, most typically gold, are the most popular
nickel free needles.
Previous history of a negative reaction to acupuncture/needles
In this scenario, the choice to proceed should be thoroughly addressed with the patient, and an
individual risk assessment should be conducted. Measures to lessen the chance of a negative
response, as well as potential historical reasons for the patient's adverse reaction, should be
examined. It is safe to proceed with acupuncture therapy if both the patient and the practitioner
are comfortable to go forward and are both satisfied that the danger of a subsequent negative
reaction is sufficiently addressed.159
29
Statement of the problem.
The negative effect of CLBP is multifaceted; besides being a common clinical problem that
alters the quality of every aspect of the individual's life, its major socioeconomic importance
should not be forgotten. This can be supported by a study conducted by the WHO, which
revealed that when compared to healthy individuals, individuals that suffer from persistent pain
are four times more prone to be a victim of depression or anxiety and more than twice as likely
to have difficulty working160161. Thus, the effect of pain not only harms the individual but also
affects the country's economy. However, currently, there is little information on the alternative
treatment option of LBP, which has not been fully explored Although a considerable variety of
conservative therapy alternatives are available for the treatment of low back pain, no single
modality appears to be superior162. Patients are often dissatisfied with conventional medical
approaches and turn to complementary and alternative medicine to control their symptoms 163,164,
among which acupuncture is one of the foremost popular options 165. However, no study focuses
on acupuncture use for CLBP in Ethiopia, a country dominated by the utilization of western
medicine for the management of CLBP.
Significance of the study.
This study aims to assess the acceptability and feasibility of acupuncture use in the management
of non-specific CLBP pain in Ethiopia. Most importantly, the study broadly hopes to influence
health policies by urging policymakers and other stakeholders for further employment of
acupuncture use in the health care system in Ethiopia. Finally, the findings of this study could
also help future researchers in this area, serving as a stepping stone for further study to be
conducted.
Research questions.
 Will the patients be willing to try acupuncture for their problem?

 Will most patients complete the intervention to the fullest?
30
 Will acupuncture bring a positive outcome and experience to the patient's condition?
 Will the patients use acupuncture again for lower back pain?
Objective.
This investigation study aims to assess the acceptability and feasibility of using TCM
acupuncture in the management of non-specific chronic lower back pain in Ethiopia.
Methodology
Study & questionnaire design.
A non-randomized, descriptive investigative study was conducted. The patients were recruited
from Alert specialized hospital, located at the center of the capital city Addis Ababa, Ethiopia,
where treatment and palliative care are given and taught. All participants that fulfill the inclusion
criteria received a standardized interview process and the purpose, procedures, potential risks,
and benefits of the study were explained thoroughly. Participants had the right to withdraw from
the study at any time without any consequence. All participants' written consents were obtained
and the study was conducted from 1st October 2021- 7th November 2021.
Study participants
All participants that fulfill the inclusion criteria received a standardized interview process, and
the purpose, procedures, potential risks, and benefits of the study were explained thoroughly.
Participants had the right to withdraw from the study at any time without any consequence. All
participants' written consents were obtained, and the study was conducted from October 1, 2021
to November 7, 2021.
Inclusion Criteria.
Participants who meet all of the following criteria will be accepted:
31
(1) Age 20 to ≥65 years, either gender.

(2) Visit and stay in the hospital.
(3) The chief complaint is chronic lower back pain.
Exclusion Criteria.
Participants who meet one or more of the following criteria will be excluded:
(1) Serious comorbid conditions.

(2) Patients who cannot reliably communicate with the investigator or who are
unlikely to follow study instructions.
(3) Acupuncture is contraindicated or safety not confirmed (clotting disorders,
on anticoagulant therapy, pregnancy, seizure disorder, etc.).
Operational definition.
Chronic lower back pain (CLBP): It is defined as localized pain, muscle tension, or stiffness
between the edges of the ribs and the creases of the lower buttocks, with or without pain in the
legs (i.e., sciatica) that continues for 12 weeks or longer, even after an initial injury or underlying
cause of acute low back pain has been treated166.
Acupuncture- is a Chinese medical practice or a method of treating a disease or providing local

anesthesia by inserting needles into specific parts of the body167.
Intervention
The Patients received a series of fixed acupuncture points: Shenshu (UB23), Weizhog(Bl40),
Taixi (ki3), Ciliao(Bl32), Hegu(Li4), Gusanli(st36), Taichong(Lv3) and Weiyang(Bl39) 168. The
needles were inserted correctly and stimulated manually until the "De Qi" sensation was
32
activated. The needles stayed in place for 40 minutes, and each participant had 2 sessions per
week for 5 weeks.
Evaluations
Feasibility.
Feasibility was assessed by collecting data on the following:
 Recruitment rates
 Retention rates
 Time required recruiting participants
Acceptability.
Acceptability was assessed by handing questioners to the participants with questions that
evaluate their attitude, the result they noticed after the treatment, their satisfaction level barriers
for others to accept acupuncture.
Data Quality Assurance.
The researcher controlled the data collection process, and the collected data's completeness was
checked every day by the researcher.
Data Management and Analysis.
The collected data were coded, cleaned, and analyzed using SPSS version 23 statistical software.
Errors related to data inconsistency were checked and corrected during data cleaning.
33
Descriptive statistics such as proportions, percentages, ratios, frequency distributions, and

appropriate graphic presentation besides central tendency measures are used to describe the data.
Ethical consideration and Dissemination
Ethical clearance was obtained from the Ethical Clearance Committee of Alert specialized
hospital and the finding of this study will be defended and a comprehensive report will be
submitted to Tianjin University of Traditional Chinese Medicine and all who are concerned.
34
Result
Sociodemographic characteristics
Table 1: Sociodemographic characteristics of the participants.
Variables Frequency Percent

Male 15 71.4%
Gender
Female 6 28.6%
Total 21 100%
20-30 2 9.5%
31-51 4 19%
Age 52-63 6 28.6%
≥64 9 42.9%
Total 21 100%
Rural 6 28.6%
Urban 15 71.4%
Address
Total 21 100%
Single 2 9.5%
Married 16 76.2%
Marital status
Divorced 2 9.5%
35
widowed 1 4.8%
Total 21 100%
completed first cycle (1-4) 2 9.5%
completed second cycle (5-8) 4 19%
Educational status 8 38.1%

Have a diploma
7 33.3%
attained tertiary education
Total 21 100%
There were 21 participants in this study, and out of the 21 participants, 15(71.4%) were male,
and 6(28.6%) were females. In addition, majority of the participants, 9(42.9%), were aged ≥ 64,
followed by ages 52-63, 31-51, and 20-30, which makes up 28.6%, 19%, and 9.5%, respectively,
of the total participants. Majority of the participants, 15(71.4%), reside in the urban area, and the
rest, 6(28.6%), came from a rural area. Moreover, most of the participants were married,
16(76.2%), and 8(38.1%) of the participants had a diploma qualification.
Feasibility
Recruitment rate.
After written consent was acquired from Alert specialized hospital, the recruitment process was
started by assessing patients that met the inclusion criteria. A total of 33 patients with the chief
complaint of CLBP met the inclusion criteria at the particular time of the study. Afterward, they
36
were informed about the purpose, procedures, potential risks, and benefits of the intervention,
and 24 patients agreed to participate, which yielded a recruitment rate of 72.73%.
Time utilized for the recruitment process.
After ethical clearance was acquired from Alert specialized hospital on October 3, 2021, it took
10 days to recruit participants and get their signed consent to start the intervention and
participate in the research. The average duration between participant first contact and recruitment
was three days, and the duration between recruitment and the first visit was seven days.
Retention rate.
Of the 24 participants who agreed to join the research, 21 participants finished nine therapy
sessions and filled the questioner. All 21 participants came at a scheduled time throughout the
intervention and received treatment twice weekly. As a result, the retention rate was found to be
87.5%. A total of 3 participants withdrew from the study (two participants withdrew from the
study after 2 sessions and one withdrew after the first session) and their reasons were the pain
inflicted on the site of where the needle was inserted.
37
100.00%
90.00% 87.50%
80.00% 72.73%
70.00%
60.00%
50.00%
40.00%
30.00% 27.27%
20.00% 12.95%
10.00%
0.00%
Recruitment rate Retention rate
success fail
Fig 1: Histogram representation on recruitment and retention rates.
Facilitators of Acceptability
Table 2: Enabling factors for acceptability of acupuncture for chronic lower back pain.
Questions Objectives Frequency Percentage

preambles
Extremely 4 19%
Was the treatment helpful in any helpful
way in the improvement of your Very helpful 8 38.1%
back pain? Somewhat 5 23.8%
helpful
Not so helpful 3 14.3%
Not at all helpful 1 4.8%
Total 21 100%
Extremely 1 4.8%
38
helpful
Have you noticed any Improvement Very helpful 6 28.6%
in Increase in activities as a result of Somewhat 9 42.9%
the treatment? helpful
Not so helpful 3 14.3%
Total 21 100%
Extremely 3 14.3%
Do you think acupuncture might
helpful
have helped change the way you see
Very helpful 10 47.6%
your back problem?
Somewhat 4 19%
helpful
Not so helpful 3 14%
Total 21 100%
Did you get what you were hoping

for out of the acupuncture
treatment? (satisfaction)
Very satisfied 16 76.2%

Somewhat 1 4.8%
satisfied
Not so satisfied 1 4.8%
Not at all 3 14.3%
satisfied
Total 21 100%
39
Yes 14 66.7%
Would you Reduce medication as a Maybe 4 19%
result of the treatment? No 3 14.3%
Total 21 100%
Out of the 21 participants, 8(38.1%) of the participants found the intervention to be very helpful
in improving their lower back pain, followed by 5(23.8%) who found the intervention to be
somewhat helpful, and 9(41.9%) of the participants admit that the intervention has somewhat
helped them increase and improved their activity's (like bending down and turning). The
intervention was found to be very helpful in improving and increasing the activities for 6(28.6%)
of the participants.
10(47.6%) of the participant admit that the intervention has positively changed the way they see
their back pain, and 16(76.2%) of the participants were very satisfied with the intervention
provided for them, and 14(66.7%) of the participants are considering to reduce their medication
because of the result they got from the intervention.
Acceptability of acupuncture.
40
Acceptability
80%
60%
40%
20%
0%
Fig. 2: Acceptability of acupuncture for chronic lower back pain among the study
participants. Of the 21 participants, 17(81%) admitted that they would like to continue using
acupuncture to manage their lower back pain, plus they would also recommend others to try the
intervention for lower back pain and would gladly pay for the treatment even if it was not provided
pro-bono.
Barriers to trying Acupuncture
41
Fear of needle
Lack of pro- 10%
fessionals
24%
Lack of
knowledge
38%
Lack of service
availability
29%
Fig. 3: Indicative reasons influencing the choice for acupuncture treatment. Majority of the
participants, 8(38.1%), stated that the lack of knowledge about the intervention was the
major barrier hindering others from trying acupuncture. This is followed by 6(28.6%) of
them blaming the lack of service availability in the country as a barrier.
Discussion
Principle findings
The study result indicates that acupuncture is highly accepted and is feasible for the management
of CLBP in the hospital setting. To assess feasibility, we measured the requirement rate,
retention rate, and time required to recruit the participants, and the results are recruitment rate for
this study was 72.73%, the retention rate was 87.5%, and the time it took to recruit was a total of
10 days which is satisfactory. To access facilitators of acceptability, the participants were asked
the following questions if the treatment helped improve their back pain, improvement in activity,
see their problem in a different light, if the treatment met their expectations, and if the result
from the treatment has made them think to reduce medication. Moreover, most of the patient's
responses were positive, and of those, 76.2% were satisfied by the intervention and the result
42
they have gotten, and most 66.7% were willing to reduce medication as a result of the treatment.
In addition, 17(81%) of the participants agreed that they would use acupuncture in the future and
would also recommend it to others with a similar problem, and also they would gladly pay the
required amount to receive the treatment. Majority of the participants stated that the lack of
knowledge and service unavailability is the most significant barriers. Thus, they hope that these
indicative barriers will be addressed in the future.
Limitations of the study
Given that this was one-group feasibility research, there are a few limitations to consider when
interpreting the results: the sample size was small, and the lack of a comparison group to account
for other confounding variables may have influenced the results. To make the findings more
generalizable to other populations, more studies with rigorous designs and techniques are
needed, including a control group and a bigger sample size. Due to a paucity of
comparative studies in this area, it was not easy to further examine and contrast these findings.
Finally, because this trial was completed in such a short amount of time, the longevity of the
individuals' pain reduction post-protocol is uncertain. Longitudinal studies that look at how long
people improve are needed.
Relation to other studies
In our study, the willingness to have acupuncture again and the willingness to reduce medication
were both found to be indicators of acceptability among patients with chronic low back pain.
However, another study suggests that the willingness to have acupuncture is the most important
indicator of acceptability169. In this study, participants who were willing to try acupuncture after
reacting to treatment reported that the benefits of reduced back pain and increased activity
outweighed the negative experiences associated with treatment reactions. Another study suggests
that the reduction of back pain significantly impacts willingness to try acupuncture 170. In this
study, the expectation of pain alleviation was found to impact outcomes in individuals with
chronic pain significantly, and other studies back up this conclusion171,172. Others, however, found
that, while expectancy was a pre-treatment mediator of treatment acceptability, patients who had
no prior experience with the treatment were less likely to accept it 173. For other patients,
43
knowing that they would have more control over their back pain made the treatment more
acceptable. The development of learning processes within the therapeutic relationship appeared
to result in enhanced efficacy in the patients' back pain treatment. Practitioner reports from two
more qualitative studies corroborate these finding174,175.
Conclusion
This study's intervention was practical and required minimal effort from both the practitioner and
the patient, and the hypothesis questions were mainly answered positively. In addition,
investigators may pursue future studies comparing the use of acupuncture versus other therapy
modalities in managing chronic lower back pain. Lastly, future research with more
methodological rigor is required to validate the findings of this study.
Literature Review.
Some of the disease managed by acupuncture in Africa and the other continents.
44
Few solid clinical research studies in Africa and the rest of the continent have been done in the
field of acupuncture, and there has also been extremely inadequate follow-up evaluation of many
of the illnesses that have been treated by acupuncturists. As a result, it is hard to provide a clear
picture of acupuncture's efficacy in certain illnesses. This being said, some conditions that are
treated in Africa are as follows.
Diseases of the Muscles, Bones, and Joints.
Osteoarthritis.
Osteoarthritis and the rheumatic pains that accompany it are very frequent issues around the
world. People typically comment that their arthritic knee discomfort worsens in cold or wet
conditions, demonstrating the origins of the idea of infections in traditional Chinese medicine.
Because the pathogen in osteoarthritis is nearly always chilly or wet, these aches should be
addressed with targeted heat.177
Much study has been conducted to examine the benefits of acupuncture on the pain produced by
osteoarthritis. Others of this work are good, while some are subpar for a number of technical
reasons. Clinical investigations have been done on knee, on acupoints SP 5, GB 40, and ST 41
for distal pain, ST 34 (for pain above the knee), ST 36, GB 34, and GB 33 (for discomfort
on the lateral side), SP 9, LR 7, and LR 8. (for pain on the inner side) and acupoints GB 29,
GB 30, Bl 53, and Bl 54 for hip178, and GB21, L14, GB20, and TE3 acupoints for neck178, and
the results reveal that acupuncture can provide considerable pain reduction in around 70% of
individuals who get it. Some research shows that just 50% of people benefit from acupuncture,
whereas other trials demonstrate that 95% of patients benefit.179
Acupuncture's effect on osteoarthritis pain does not continue forever, with existing studies
indicating that its effects gradually fade after roughly six to nine months. Some patients may get
considerable pain relief for up to two years, but the vast majority of people who benefit from
acupuncture will require more treatment beyond six months. Treatment is frequently just as
successful the second or third time around as it was the first.180
Osteoarthritis is a normal ailment that produces occasional pain and discomfort. Patients may
notice that their arthritic knee is reasonably painless for nine months, followed by a painful phase
of six months.181
45
Rheumatoid Arthritis.
Chronic pain caused by musculoskeletal disorders is commonly treatable with acupuncture. The
published study on which involved 80 particepants whome recived acupuncture treatments for
RA on acupoints Quchi (LI11), Waiguan (TE5), Hegu (LI4), Zusanli (ST36), Yanglingquan
(GB34), and Xuanzhong (GB39) revealed that pain that has been present for many years can
react just as effectively as pain that has been there for a few months; therefore, based on the
current data, it is reasonable to conclude that acupuncture is 'always worth a try in this sort of
disease.182
Diseases of the Nervous System.
Strokes.
A stroke is caused by a disruption in the brain's blood supply183. Blood vessels that typically feed
blood to the brain might be harmed if they get clogged or leak. This causes a lack of blood flow
to the brain tissue, and these occurrences can be triggered by a range of circumstances such as
high blood pressure, artery hardening, and serious head injury. The brain is split into several
separate functional regions, with one managing speech and another handling touch and pain
sensations.184
Acupuncture was found to be beneficial in animal studies for ischemic stroke rehabilitation via
five major mechanisms one by promotion of cell proliferation in the CNS, limited to neurogenic
areas and some ischemic tissues; and the second being regulation of cerebral blood flow via
angiogenesis and modulation of vasoactive mediators and the third anti-apoptosis via direct
intervention in the intrinsic and extrinsic pathways or related pathways and by regulation of
neurocognitive function and Baihui (GV20), Zusanli (ST36), Quchi (LI11), Shuigou (GV26),
Dazhui (GV14), and Hegu are the most commonly utilized acupoints in fundamental studies
(LI4). This finding is backed by a recently published literature review.185 The first is a systematic
review and meta-analysis of preclinical studies published up to August 2015, which concludes
46
that acupuncture appears to improve neurological deficits and reduce brain edema in ischemic
stroke and that the mechanisms correlate positively with endogenous neurogenesis enhancement
186
. Suggesting that overall, acupuncture during the early stages of stroke healing lowers infarct
volume and neurological impairments.

Acupuncture on the scalp and the body can both help in stroke rehabilitation. So far, research
reveals that acupuncture boosts blood circulation to the brain, which appears to improve
functional capacity and act as a stimulant to recovery after a stroke for an unknown cause.187
According to clinical investigations done by the Chinese, acupuncture has some impact on
roughly 80% of strokes. These trials are difficult to evaluate since a considerable percentage of
stroke patients recover on their own; also, the Chinese trials are poorly constructed, and the exact
definition of therapy success and failure is uncertain. The reported success rate is extraordinarily
high, although it is matched to some extent by the experience of a number of doctors in the
West.188
Whatever one may think of Chinese research techniques, Western medicine frequently has
nothing to give the stroke patient, therefore acupuncture is always worth exploring. Strokes
should ideally be addressed within six months of the onset of the damage. The patient may
continue to benefit for up to two years after the stroke, but acupuncture is unlikely to help if the
damage has been present for more than two years.180
Diseases of the Digestive System.
Stomach Ulcers.
An ulcer is a raw region of tissue, similar to the tissue seen behind the scab of a healed wound.
Ulcers in the stomach can arise and are often detected either in the stomach itself (gastric ulcers)
or in the section of the intestine that drains food from the stomach (duodenal ulcers). Stomach
ulcers are a frequent ailment, although the etiology is unknown.189
Acupuncture is the therapy of choice for stomach ulcers in China and some countries in Africa,
and ulcers do heal following acupuncture. Fortunately, both forms of stomach ulcer heal
spontaneously, which makes comparing the therapeutic benefits of acupuncture to natural
remission difficult; also, there are currently several extremely powerful and relatively non-toxic
medications available to cure ulcers.189
47
A high acid level in the stomach is linked to duodenal ulcers. It is unknown how much this
element influences the development of duodenal ulcers, however, it is safe to state that elevated
acid levels have a role in ulcer formation. Chinese physiologists' research has clearly proved that
acupuncture may lower stomach acidity when intervention is done on acupoints Neiguan (PC6),
Taichong (LV3), Gongsun (SP4), Zhongwan (CV12) and Zusanli (ST36), which may be one
of the processes by which acupuncture heals stomach ulcers and other digestive illnesses.190
Diseases of the Respiratory System.
Asthma.
The wheeze of asthma is caused by the contraction of the muscular walls of the small breathing
tubes in the lung. The narrowed air tube creates a 'turbulent' airflow and therefore causes a
wheeze, or whistle when the asthmatic breathes. Because the tubes into the lung are narrowed,
less air can get in and this decreases the oxygen supply to the body. The muscular contraction of
the breathing tubes can be stimulated by a wide range of substances such as inhaled dust or
pollen, and various foods.191
Acupuncture dilates constricted muscle walls when this acupoints are triggered Feishu (BL13),
Dingchuan (EX-B1), Dazhui (GV14), Shengshu (BL23), Pishu (BL20), and Fengmen
(BL12); the mechanism is unknown, although there is solid Western scientific data to back this
assertion. A recent Chinese clinical research on asthma found that a course of acupuncture and
moxibustion (approximately 10 treatments) once a year resulted in a 'positive impact' for 70% of
asthmatics. Over the course of a year, the acupuncture therapy was able to reduce the frequency
and severity of asthmatic episodes. This finding is encouraging since it suggests that acupuncture
and moxibustion can influence the body's reaction to external triggers that cause asthmatic
episodes.192
Bronchitis.
Bronchitis is a common lung condition that is exacerbated by tobacco smoke, industrial
48
pollution, and dust. It results in the irreversible loss of lung tissue. Bronchitis frequently has an
asthmatic component because irritants such as smoke and dust cause the muscle walls of the
breathing passages to constrict.193
Acupuncture cannot regenerate lung tissue, but it can improve the function of the existing lung
tissue by opening up the breathing passages and this is achieved by engaging acupoints BL13,
BL17 and BL19. Acupuncture's mechanism in bronchitis is likely similar to that in asthma,
enabling more air into the lungs. Acupuncture appears to assist around 50% of bronchitis,
according to recent Chinese research. If the effect is to be maintained, the therapy must be done
on a regular basis.194
Diseases of the Heart and Blood Vessels.
Angina.
Angina is a form of 'cramp' in the heart muscles caused by a lack of blood flow to the heart, and
it commonly manifests as chest discomfort when exercising. Using advanced measurement
equipment, the Chinese conducted a number of studies on acupoints PC 6 (Neiguan) ,PC 4
(Ximen), HT 7 (Shenmen point), PC 7 (Daling point), PC 5 (Jianshi point), PC 3 (Quze
point), CV 17 (Danzhong point), CV 6 (Qihai point), BL 15 (Xinshu point), L 20 (Pishu
point), BL 17 (Geshu point), BL23 (Shenshu point), BL18 (Ganshu point), HT 5 (Tongli
point), ST36 (Zusanli point) to test the effects of acupuncture on the heart, and they discovered
a significant rise in the functional capacity and efficiency of the heart muscles following
acupuncture.195
This is corroborated by clinical research, which reveals that acupuncture improves the condition
of around 80% of angina patients. When acupuncture is used to treat angina, a series of sessions
is followed by booster treatments every four to six months.196
The Correction of Abnormal Heart Rhythms.

Heart illnesses usually result in an aberrant rhythm of the heartbeat, which can present as
palpitations, an irregular heartbeat, or dropped beats. Acupuncture can help with a few of these
arrhythmias when acupuncture is applied on this points . Acupuncture affects a tiny number of
49
patients with established atrial fibrillation (irregular heart rhythms), around 1.5 percent, however,
in recently acquired arrhythmias, acupuncture can be beneficial in up to 70% of instances.189
A study conducted by administering acupuncture at the following acupoints: BL15, PC6, and
HT7 which proceeded, BL15 was first penetrated obliquely to a depth of 1.0–1.6 cm. The
needles were then manually stimulated (raise and shove or spin and rotate the needles) to
generate the Deqi sensation (the sensation including soreness, numbness, distention, or heaviness
accompanied by acupuncture). The stimulation was sustained for 1 minute before the needles
were removed. Second, 1.0–2.0 cm perpendicular punctures were made in PC6. HT7 was
perforated perpendicularly at 0.6–1.0 cm intervals. To accomplish Deqi, PC6 and HT7 were also
stimulated. After that, the needles were left in place for 30 minutes and the results suggest that
acupuncture is feasible and acceptable in the management of arrhythmia.197
Raised Blood Pressure.
Acupuncture can reduce blood pressure as seen in a randomized controlled experiment was
carried out by recruiting 56 hypertensive patients with hyperactivity of liver yang, which
amounted for a significant number of hypertension patients (24.1 percent). 198 used Taichong
(LR 3), Baihui (DU 20), Taixi (KI 3), Sanyinjiao (SP 6), and Zusanli (ST 36) as the principal
acupoints for adjustment. These acupoints' aim is to stabilize the reverse rising of Chong Qi and
lead the Qi downward. These acupoints can also nourish yin while suppressing yang and
regulating qi and blood. And the findings of this study cast doubt on the efficacy and safety of
acupuncture in the treatment of type 1 hypertension.199
But there is no reliable research to indicate how effective they are in the long or short term. At
the moment, the entire idea of high blood pressure and its treatment is uncertain, and the role of
acupuncture in this treatment is unknown.189
50
Epidemiology of LBP and its social and economic effect.
Low back pain affects people of all ages, from children to the elderly, while its prevalence
peaking between the ages of 35 and 55 200 and is a principal reason for medical consultation. The
2010 Global Burden of Disease Study estimates that low back pain is among the top 10 diseases
and injuries that make up the majority of DALYs worldwide 13.
It is difficult to estimate the incidence of chronic lower back pain because first episodes of low
back pain are high in early adulthood, and symptoms tend to recur over time. The lifetime
prevalence of nonspecific (common) low back pain is estimated at 60–70% in industrialized
countries (1-year prevalence 15–45%, adult incidence 5% per year). The prevalence rate in
children and adolescents is lower than in adults, but it increases201,202.
Several studies have been conducted in Europe to evaluate low back pain's social and economic
effects. In the UK, low back pain, with more than 100 million lost workdays each year, has been
identified as the leading cause of disability in young adults203. In Sweden, a survey found that
low back pain was responsible for quadrupling the number of days lost from 7 million in 1980 to
28 million in 1987203. Also, in the United States, an estimated 149 million workdays are lost each
year due to low back pain, with an estimated total cost of between $ 100 billion and $ 200 billion
per year (two-thirds of which are due to loss of wages and lower productivity)6,204.
Thus as the world population ages, low back pain will increase significantly in the elderly due to
deterioration of the intervertebral discs. Low back pain is the leading cause of reduced activity
and job loss globally and puts a heavy economic burden on individuals, families, communities,
industries, and governments200,201.
Modern management of CLBP pain.

Pharmacological management
51
Clinical recommendations on the management of chronic low back pain from the United
Kingdom205, Belgium 206, and United States 55 have recently proposed adjustments to the use
of pharmacotherapy for treating chronic low back pain. When non-pharmacological
measures have failed, medication should be provided at the lowest possible dose for the
shortest possible duration. 207 However, it is critical to inform patients about the recognized
possible risks and advantages. Pharmacotherapy should be utilized as a tool to stay active
and engaged in treatment, not as a solution in and of itself.
Acetaminophen: is an antipyretic and analgesic drug that does not have anti-inflammatory
characteristics. The greatest complication is the risk of hepatotoxicity. 208 Acetaminophen
should no longer be used for acute (high-quality evidence) or chronic episodes (poor quality
evidence) of LBP, according to all three current guidelines 205,206,55
. According to a Cochrane
systematic study, acetaminophen was no more efficient than a placebo in treating acute
LBP, and its usefulness in chronic LBP is unknown 209
. According to a recent study, there
are many doubts concerning the effect of paracetamol, thus further research is needed. There
is just low-quality data that there is no impact on acute pain relief. 209
NSAIDs: Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are anti-inflammatory and
pain-relieving pharmaceuticals that inhibit the cyclo-oxygenase (COX)-2 enzyme.
Complications of the gastrointestinal and renal systems, such as bleeding ulcers and
perforation, are possible side effects. NSAIDS have a marginal effect on disability
improvement.208, 210 Three recent guidelines advocate the use of NSAIDs, but only in modest
dosages and if the risk of developing adverse effects is minimal. 205 ,206,55.
Opioids: Opioids were formerly utilized to treat patients who were in moderate or severe
pain. The recommended usage of opioids has changed, and all recent guidelines urge that
they be taken with care due to the danger of addiction and accidental overdose. However,
the guidelines' recommendations for their usage and how they are prescribed differ.
According to research, opioids are fairly helpful for pain management, but their impact on
functional outcomes are minimal, and they should only be administered when the benefits
outweigh the hazards 209. To avoid undesirable effects, slow-release opioids are preferred
over immediate-release opioids and should be used on a regular basis rather than as needed.
Because opioids are addictive, long-term usage should be closely monitored for abuse. 208, 210
52
Opioids are no longer recommended by NICE, the UK recommendations, for persistent low
back pain. 205 however, The Belgian recommendations, KCE, 206 approve opioids for
persistent low back pain but caution against long-term usage and according to the American
College of Physicians, opioids should be used as a last resort for treating persistent low back
pain in persons who have not responded to non-pharmacological therapies and have
exhausted all available pharmacological choices.
Antidepressants: Tricyclic antidepressants (TCA) are routinely used to treat a variety of
chronic pain conditions. However, there is mixed evidence about whether CLBP causes
major changes in pain alleviation or impairment. According to a recent comprehensive
review, there is evidence of intermediate quality suggesting there is no difference in pain
alleviation between antidepressants and placebo for individuals with persistent
LBP.210 Tricyclic antidepressants and non-selective serotonin-norepinephrine reuptake
inhibitors are not recommended by the NICE clinical guidelines 205
The KCE
recommendations, on the other hand, found both to have a potential benefit for chronic pain
with central sensation (e.g. increased activity of the central nervous system). Other drugs:
Skeletal muscle relaxants, benzodiazepines, and antiepileptic medications are not suggested
due to a lack of data supporting their efficacy in persistent low back pain.208 Nonetheless
when treating patients with CLBP, it has been demonstrated that having them treated by a
multidisciplinary team results in better outcomes. The interdisciplinary approach
encompasses addressing the disorder's medical, psychological, emotional, and socio
professional elements 211 Fear of pain, in turn, is hypothesized to lead to anxiety about the
consequences of pain, resulting in increased avoidance behavior and, in the long term,
increased discomfort, functional impairment, and depression. 212 When compared to
conventional care or physical therapy, multidisciplinary rehabilitation programs result in
improved long-term pain and disability results in patients who have already failed a course
of conservative treatment. People in these programs are also more likely to be at work than
patients undergoing physical therapy. 213
Nonetheless, in light of the current opioid crisis, many hospitals seek alternative non-drug
treatments to control pain.
Acupuncture on the management of pain and CLBP.
53
Traditionally, acupuncture is believed to restore the normal flow of energy (qi) in the body 214 and
relieve pain by fully activating the acupuncture points on the patient's body, which in turn creates
the feeling of pain, numbness, fullness, or heaviness called De qi., or Te Qi in the patient 215.
Today's functional magnetic resonance imaging enables the study of brain responses to
acupuncture and has been shown to have multiple effects on the central and peripheral nervous
systems. Moreover, acupuncture is reported to relieve pain primarily through the release of
endogenous opioids, serotonin, and norepinephrine which can subsequently affect nociceptors,
inflammatory cytokines, and other physiological mechanisms that can alter the perception of
pain
Acupuncture compared with other managements of LBP pain.
The controlled clinical studies carried out by the WHO on the subject suggest that acupuncture is
effective in the treatment of pain and, in the treatment of chronic pain, the absence of serious
side effects and dependence makes it more beneficial than drugs such as morphine. Acupuncture
effectively treats various types of pain, such as LBP, and it was documented that it had positive
feedback from patients due to the lack of serious side effects. Acupuncture is superior to sham
acupuncture in treating chronic pain like LBP, and the use of acupuncture in conjunction with
conventional treatment has shown better results than conventional treatment alone. Although
acupuncture effectively treats chronic pain, some conventional treatments are much more
effective than acupuncture in reducing pain122,216,217.
Twenty-three studies with a total sample of 6359 participants that were divided into 5
comparative types, 6 of which were of high quality, suggests that there is moderate evidence that
acupuncture is more effective than no treatment and strong evidence that there is no significant
difference between acupuncture and sham acupuncture for short-term pain relief. Moreover,
strong evidence that acupuncture may be a useful addition to other conventional forms of therapy
for nonspecific low back pain, but recommends more research should be done on the
effectiveness of acupuncture compared to other conventional forms of therapy218.
54
Acupuncture is a safe treatment when practiced by a trained professional; a study with a total of
229,230 patients showed that 90% of the patients did not experience any adverse events.
Common side effects are bruising, pain, tiredness, fainting, or drowsiness. Serious adverse
events such as pneumothorax are infrequent219,220.
Cost Feasibility and acceptability of acupuncture.
A study with a total of 199 participants in five maternity hospitals was conducted to assess the
cost-effectiveness of acupuncture for pelvic girdle and low back pain (PGLBP) during pregnancy
compared to standard treatment and found that the average cost overall was higher in the control
group (€ 2,947) than in the acupuncture group (€ 2,635), which is due to the higher indirect costs
of misrepresentation. Acupuncture was a predominant strategy when considering both health and
non-health costs221.
In another study that aimed to assess the acceptability of acupuncture, 133 patients were treated
with acupuncture for 3 months. All patients reported responses to treatment, the most common
being relaxation (84%), which were significantly related to the acceptability and willingness to
retry acupuncture. Only 16% were unwilling to relive a particular response to treatment, and 9%
were unwilling to try acupuncture again. The most worrisome reaction was a temporary
worsening of symptoms (29%), which was not associated with an unwillingness to retry
acupuncture222.
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74
Annex
Questioner
Sociodemographic Characteristics
1. Age
A. 20-30
B. 31-51
C. 52-63
D. ≥64
2. Address
A. rural
B. urban
3. Marital status
A. single
B. married
75
C. divorced
D. widowed
4. Educational status
A. illiterate
B. completed first cycle (1-4)
C. completed second cycle (5-8)
D. completed 9-12
E. attained tertiary education
Outcomes
5. Was the treatment helpful in any way in the improvement of your back pain?
A. Extremely helpful
B. Very helpful
C. Somewhat helpful
D. Not so helpful
E. Not at all helpful
6. Has the treatment helped improve your activity (bending, turning, and reaching) in any?
B. Very helpful
C. Somewhat helpful
D. Not so helpful
7. Would you Reduce medication as a result of the treatment?
A. Yes
B. Maybe
C. No
8. Do you think acupuncture might have helped change the way you see your back
problem?
B. Very helpful
76
C. Somewhat helpful
D. Not so helpful
9. Did you get what you were expecting out of the acupuncture treatment? (satisfaction)
A. Very satisfied
B. Somewhat satisfied
C. Neither satisfied nor dissatisfied
D. Somewhat dissatisfied
E. Very dissatisfied
Acceptability of acupuncture
10. Would you try acupuncture again for chronic lower back pain?
A. Yes
B. Maybe
C. No
11. Would you recommend acupuncture to other people with back pain?
A. Yes
B. maybe
C. no
12. Would you pay for this treatment if it was not provided for you pro-bono?
A. Yes
B. No
Barriers to trying Acupuncture

13. What reasons do you think other people may have for not wanting to try acupuncture?
A. Fear of needle
B. Lack of knowledge
77
C. Lack of service availability

D. Lack of professionals
E. Others(specify)
Acknowledgment
This project would not have been possible without the support of many people. Many thanks to
my adviser, Prof. Meng Xiang wen, who read my numerous revisions and helped make some
sense of the confusion.
In addition, thanks to Tianjin University of Traditional Chinese Medicine for awarding me with a
scholarship, enabling me to further my education, and giving me the chance to work on this
Dissertation. Finally, thanks to Alert specialized hospital for their willingness to help me conduct
my research and numerous friends who endured this long process with me, always offering
support and love.
78
CURRICULUM VITAE
I. Educational experience
 Kea-Med Medical College – public health.
II. Internship experience

 Yekatit 12 University Hospital.
 Minilik referral hospital.
 Kasanchis Health center.
III. Work experience

 Kasanchis health center- health officer.
79

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天津中医药大学硕士学位论文

ACRONYMS AND ABBREVIATION

招募了 33 名患有慢性腰痛的患者。 根据纳入排除标准，实际纳入 24 人。 在研究期间，

经统计，共收集 21 例（33 名患者接受，9 名患者在治疗前拒绝；24 名患者中，有 21

ACRONYMS AND ABBREVIATION

Background of the study.

Lower back pain.

Socio economic significance

Low back pain may be divided into four major categories:

Mechanical (including muscular strain, spasm, or osteoarthritis); herniated nucleus pulposus,

Inflammatory – HLA-B27 related arthritis, such as ankylosing spondylitis, reactive arthritis,

Sign and symptoms

Lumbar provocative discography may be beneficial in identifying a particular disc that is

Many warning flags are not well supported by evidence.48 49

Peripheral nerve stimulation, a minimally invasive method, may be therapeutic in cases of

Drugs and surgery

stimulation113. Acupuncture is an essential aspect of traditional Chinese medicine, and major

In recent years, researchers have concentrated on analgesic and anti-inflammatory compounds,

The extremely young

Contraindications at the site

Removal of lymph nodes

Pacemakers and other electrical implants

Diabetes is normally a precaution, although acupuncture is not recommended if the diabetes is

Hemophilia, as well as other clotting diseases

Anticoagulants may be recommended for a variety of medical disorders. Anticoagulant dosage is

Valvular heart disease (VHD)

If epilepsy or seizures are unstable, unidentified, or awaiting treatment/investigation, they are a

Problems with circulation

Previous history of a negative reaction to acupuncture/needles

Statement of the problem.

Significance of the study.

 Will the patients be willing to try acupuncture for their problem?

Study & questionnaire design.

Participants who meet all of the following criteria will be accepted:

(1) Age 20 to ≥65 years, either gender.

(1) Serious comorbid conditions.

Acupuncture- is a Chinese medical practice or a method of treating a disease or providing local

Data Quality Assurance.

Data Management and Analysis.

Descriptive statistics such as proportions, percentages, ratios, frequency distributions, and

Ethical consideration and Dissemination

Table 1: Sociodemographic characteristics of the participants.

Variables Frequency Percent

Age 52-63 6 28.6%

completed second cycle (5-8) 4 19%

Educational status 8 38.1%

Time utilized for the recruitment process.

Fig 1: Histogram representation on recruitment and retention rates.

Questions Objectives Frequency Percentage

Did you get what you were hoping

Very satisfied 16 76.2%

Barriers to trying Acupuncture

Limitations of the study

Relation to other studies

Diseases of the Muscles, Bones, and Joints.

Diseases of the Nervous System.

volume and neurological impairments.

Diseases of the Digestive System.

Diseases of the Respiratory System.

Diseases of the Heart and Blood Vessels.

The Correction of Abnormal Heart Rhythms.

Raised Blood Pressure.

Epidemiology of LBP and its social and economic effect.

招募了 33 名患有慢性腰痛的患者。根据纳入排除标准，实际纳入 24 人。在研究期间，

190. Research : Acupuncture and Herbs. Accessed March 21, 2022.

192. June « 2010 « Alternative Medicine. http://www.thealternativemedicine.net/2010/06