By Victor S. Sierpina, MD, ABFM, ABIHM, WD and Laura Nell Nicholson Family Professor of Integrative Medicine Director, Medical Student Education Medical Director, Island West Family Medicine Clinic University of Texas Distinguished Teaching Professor
“Our equanimity is chiefly exercised in enabling us to bear with composure the misfortunes of our neighbors.” – William Osler
My Tuesday morning acupuncture clinic is busier than ever. Medicare has in the past couple of years started paying for this effective, safe therapy for the M54 diagnosis codes of chronic low back pain. They did this after a review of the Cochrane database and other evidence-based sources that showed the positive, non-placebo effect of acupuncture on low back pain.
This has unleashed a lot of demand for acupuncture treatment for this highly prevalent and often challenging problem. Medicare does not currently pay for acupuncture for other diagnoses such as migraine or other headaches, arthritis, neuropathy, and many common conditions treated by acupuncture. These remain an out-of-pocket expense for patients.
Having performed acupuncture for nearly 40 years, I am happy to see this breakthrough in insurance reimbursement for an integrative therapy that is not only beneficial but inexpensive and non-invasive. Hopefully, it will set a trend for other insurance companies’ coverage for acupuncture treatments for some of those other conditions. Compared to surgery, epidural steroid injections, and potentially addictive pain medications for back pain, acupuncture illustrates the key principles of integrative medicine:
- Start with the safest, most gentle therapies before proceeding to more dangerous or costly ones
- Use a patient-centered decision-making process and clarify expectations
- Incorporate an interdisciplinary approach, which in the case of back pain could include sequential or contemporaneous physical therapy, chiropractic, dietary, pain management, orthopedic, massage, aqua therapy, and other consultations
A patient who comes to me for acupuncture for back pain will be involved in a discussion of the usual course of treatment, a minimum of 6 sessions, and up to 20 annually per Medicare reimbursement guidelines. Also, it will be made clear that acupuncture may not relieve all pain but is directed to decreasing disability, increasing functionality, reducing medication use, and overall improving quality of life including sleep and activities of daily life.
A core principle is that “motion is lotion.” I encourage an active home exercise program to continue after physical therapy consultation is completed at least 3-5 times a week, if only for 10 minutes or so daily. Gentle exercises such as yoga or tai chi add a systematic process to back exercise protocols and keep things interesting. My personal preferred practice is tai chi in the backyard pool. It keeps me limber and mentally centered at the same time.
For back problems, consider dietary changes such as weight loss, an anti-inflammatory diet, botanicals, and supplements such as turmeric, Boswellia, ginger, omega-3 fatty acids, SAMe, chondroitin/glucosamine, Zyflamend ®. These offer additional options for progressive dosing of habit-forming opiates or NSAIDs with their risk for gastrointestinal and renal side effects.
Patients value several key items as important to a “good consultation.” These include an explanation and understandable information about their problem, reassurance, discussing what can be done, addressing psychosocial issues, and most importantly, being taken seriously.
Recall the adage, “More mistakes are made in medicine by those who do not care than those who do not know.”
Expressing genuine interest, empathy, and concern are essential parts of the process of communication and clinical care for back pain. Such care also includes building trust and helping demonstrate perceived benefits in the cycle from condition to intervention. These must be mediated, of course, by patient motivation and their active participation. Remember always to also address guilt, frustration, secondary gains, perception of severity, catastrophizing, victimization, and undiagnosed mental health issues such as depression.
This is an all a heavy lift and could herniate the discs of even the best clinicians, which is why a team approach, a rich mix of modalities, and integrative options can help ease the pain and frustration of both patient and clinician in the long-term management of chronic back pain.
References:
Bonakdar RA, Sukiennik AW. Integrative Pain Management. Oxford University Press, 2016.
Rakel, D. Integrative Medicine. Elsevier, 2018.