Musculo-Skeletal Disorders - Chronic Low back pain by

Kyle J. Norton

Low back pain is a Musculoskeletal disorders (MSDs, affecting over 80% of the population in US alone some points in their life. Chronic LBP (pain has persisted for longer than 3 months(1) prevalence in older adults was significantly higher than the 21-to-44-year age group (12.3% vs. 6.5%, p < . 001). Older adults were more disabled, had longer symptom duration, and were less depressed(2)..Many older adults remain quite functional despite CLBP, and because age-related comorbidities often exist independently of pain (e.g., medical illnesses, sleep disturbance, mobility difficulty), the unique impact of CLBP is unknown. We conducted this research to identify the multidimensional factors that distinguish independent community dwelling older adults with CLBP from those that are pain-free(3). I. Sings and symptoms 1. Pain has persisted for longer than 3 months as mentioned above 2. Degenerative disc disease In a study to assess SPARC-null mice as an animal model of chronic low back and/or radicular pain caused by degenerative disc disease, showed that a. Movement-evoked discomfort b. Hypersensitivity to cold stimuli(4) 3. Morning stiffness, as a result of inflammation due to aging causes of degenerated discs(5) 4. Sleep interruptions due to pain 5. Higher compressive axial and tensile radial strains(6) 6. Depression, anxiety disorders and adjustment disorders In the study of 127 patients suffering from chronic back pain in multimodal inpatient pain therapy who were assessed by a psychologist, showed that there was a high prevalence of depression, anxiety disorders and adjustment disorders in patients with chronic back pain(7). 7. Pain interfered with daily living, depressivity, and quality of life(8). 8. Diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain due to chronic osteoarthritis (OA) pain and chronic low back pain (LBP)(9). 9. Metabolic syndrome The prevalence of metabolic syndrome among chronic lower back pain patients was 36.2% (30.2% male, 38.6% female), according to the study by Department of Rehabilitation Medicine, Seoul Medical Center(9a)

10. Etc. II. Causes and Risk factors A. Causes of chronic back pain 1. Trochanteric bursitis Trochanteric bursitisis a clinical condition which simulates major hip diseases and low back pain, it may also mimic nerve root pressure syndrome(10). 2. Spinal stenosis Spinal stenosis of aging population is at the higher risk of developing low back pain(11) 3. Chronic compression of the dorsal root ganglion (CCD) is associated with Chronic Low back pain(12) 4. Cauda equina syndrome (CES) In the study to review the literature on the clinical progress in cauda equina syndrome (CES), including the epidemic history, pathogenesis, diagnosis, treatment policy and prognosis, showed that each type of CES has different typical signs and symptoms. Low back pain may be the most significant symptoms, accompanied by sciatica, lower extremities weakness, saddle or perianal hypoesthesia, sexual impotence, and sphincter dysfunction(13). 5. "Wear and tear" and "disc space loss" are associated with the development of Chronic Low back pain as a result of a progressive loss of structural integrity(14). 6. Osteoarthritis (OA), low back pain (LBP), and fibromyalgia (FM) Patients with OA, LBP, and FM frequently demonstrate abnormalities of muscles, ligaments, or joints, the severity of such changes is only poorly correlated with clinical pain. Importantly, many patients with these chronic pain disorders show signs of central sensitization and abnormal endogenous pain modulation, according to the study by the Division of Rheumatology and Clinical Immunology, University of Florida(15) 7. Spondylitis Spondylitis is associated with low back pain(16) 8. Extracellular matrix protein SPARC (Secreted Protein, Acidic, Rich in Cysteine)

Study of Alan Edwards Centre for Research on Pain, McGill University showed that aging mice develop anatomical and behavioral signs of disc degeneration and back pain, decreased SPARC expression and increased methylation of the SPARC promoter. In parallel, human subjects with back pain exhibit signs of disc degeneration and increased methylation of the SPARC promoter. Methylation of either the human or mouse SPARC promoter silences its activity in transient transfection assays(16a). Other study found that SPARC-null mice display behavioral signs consistent with chronic low back and radicular pain that we attribute to intervertebral disc degeneration(16b). B. Risk factors 1. Aging Elder is at higher risk of chronic back pain due to discs degeneration(17a) 2. Repetitive bending and lifting can usually lead to severe back pain and sciatica over a period of 30 years as a result of 'Annulus-driven' disc degeneration involves a radial fissure and/or a disc prolapse, has a low heritability, mostly affects discs in the lower lumbar spine(17) 3. An increased risk for incident chronic LBP if exposed twice to awkward postures(18) 4. Sex, race and Lumbar symptoms Musculoskeletal impairment was the most prevalent impairment in people aged up to 65 years, and spine impairments the most frequently reported subcategory of musculoskeletal impairment (517%). The annual rates varied significantly by sex and age (table 2). Back and spine impairments were more common in women (703 per 1000 population) than in men (573 per 1000 population), and more common among white people (687 per 1000 people) than black people (387 per 1000 people). In 1988, back and spine impairments resulted in over 185 million days of restricted activity (210 per impairment), which included 83 million days confined to bed (54 per impairment; table 3). About 56% of days of restricted activity occurred among women. Lumbar symptoms were 286 times more likely than thoracic symptoms to become chronic(19). 5. Smoking Daily smoking increases the risk of LBP among young adults, and this effect seems to be dose-dependent. Back pain treatment programs may benefit from integrating smoking habit modification. The prevalence of chronic LBP was 23.3% in daily smokers and only 15.7% in non-smokers(20).

6. Psychiatric disorders are assciated to the inscreased risk of transition to chronicity in men with first onset low back pain(21) 7. Alcohol dependency Alcohol consumption appears to be associated with complex and chronic LBP only and in people with alcohol consumption dependence(22). 8. Others Occupational factors, presence of multiple functional symptoms, Diseaserelated factors, onorganic disease, pain in the legs, significant disability at onset, a protracted initial episode, multiple recurrences, a history of low back pain, spinal condition, etc. are all assocoated with higher risk to develop chronic back pain(23). 9. Etc. III. Diagnosis 1. Health and family history and physical exam If you are experience low back pain, a decrease in sensation, and weakness of the extremities, the diagnosis may include a complete family history including the prior and current illnesses and injuries and a physical exam include pressure on (palpate) the spine, which may cause tenderness over the affected area. The pain may radiate along the course of a rib to the anterior chest or abdomen. Gait and posture can be affected by disc herniation that causes spinal cord compression and are usually evaluated during the physical exam(24). 2. Other tests may include a. X ray b. CT scan c. MRI d. Radiography of the spine e. Etc. But other suggested that immediate, routine lumbar spine imaging in patients with LBP and without features indicating a serious underlying condition(Red flags*) did not improve outcomes compared with usual clinical care without immediate imaging. Clinical care without immediate imaging seems to result in no increased odds of failure in identifying serious underlying conditions in patients without risk factors for these conditions. In

addition to lacking clinical benefit, routine lumbar imaging is associated with radiation exposure (radiography and CT) and increased direct expenses for patients and may lead to unnecessary procedures. This evidence confirms that clinicians should refrain from routine, immediate lumbar imaging in primary care patients with nonspecific, acute or subacute LBP and no indications of underlying serious conditions(25)(26). Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition(27). IV. Complications 1. Mental health found that adults aged 65 years and above with chronic impairing LBP had higher mental health scores, reported significantly less depression, and used less antidepression medication relative to the younger age groups, according to the study of a crosssectional, telephone survey of 5,357 households was conducted to identify 732 adults with chronic, impairing LBP(28). 2. Sleep disturbance, and interleukin-6 In adults with CLBP, poorer sleep quality was associated with higher IL-6 levels, and both sleep and IL-6 related to pain reports. Inflammatory processes may play a significant role in the cycles of pain and sleep disturbance. Clinical interventions that improve sleep and reduce concomitant inflammatory dysregulation hold promise for chronic pain management, according to the study by Rochester Center for Mind-Body Research, University of Rochester Medical Center(29). Others suggested that The sleep of the patients with CLBP was significantly altered compared with that of the healthy controls, in proportion to the impact of low back pain on daily life(30). 3. Maladaptive movement and motor control impairments Eighty five percent of chronic low back pain (CLBP) disorders have no known diagnosis leading to a classification of 'non-specific CLBP' that leaves a diagnostic and management vacuum. Dr. O'Sullivan P. said " These pain disorders are predominantly mechanically induced and patients typically present with mal-adaptive primary physical and secondary cognitive compensations for their disorders that become a mechanism for ongoing pain"(31).

4. Somatic dysfunction (by the presence of any of 4 TART criteria: tissue texture abnormality, asymmetry, restriction of motion, or tenderness) In a Cross-sectional study nested within a randomized controlled trial, by The Osteopathic Research Center, Fort Worth, demonstrated that somatic dysfunction, particularly in the lumbar and sacrum/pelvis regions, is common in patients with chronic LBP. Forthcoming extensions of the OSTEOPATHIC Trial will assess the efficacy of OMT according to baseline levels of somatic dysfunction(32). 5. Etc. V. Prevention 1. Weight loss Weight loss is associated chronic low back pain and cardiovascular risk factors, according to the study by Natural Wellness and Pain Relief Centers of Michigan(33). 2. Tai Chi In the study to review the history, the philosophy, and the evidence for the role of Tai Chi in a few selected chronic pain conditions found that the ancient health art of Tai Chi contributes to chronic pain management in 3 major areas: adaptive exercise, mind-body interaction, and meditation. Tai Chi seems to be an effective intervention in osteoarthritis, low back pain, and fibromyalgia(34). 3. Moderate alcohol consumption and quit smoking As alcohol dependency and smoking are the risk factor of chronic low back pain. 4. Moderate exercise Moderate exercise are associated to reduced risk of chronic low back pain as it increases oxygenation and blood circulation in the body(35). 5. Avoid recurrent Low back injure Recurrent Low back injure and injure which has been not treated well may come back to haunt you when you get older, according to traditional Chinese medicine. 6. Yoga In a seven day randomized control single blind active study in an residential

Holistic Health Centre in Bangalore, India, assigned 80 patients (37 female, 43 male) with CLBP to yoga and physical exercise groups, showed that Seven days intensive residential Yoga program reduces pain, anxiety, and depression, and improves spinal mobility in patients with CLBP more effectively than physiotherapy exercises(36). 7. Healthy diet including calcium and vitamin D to prevent osteoporosis causes of chronic low back pain. 8. Etc. VI. Treatments A. In conventional perspective A.1. Non surgical treatment 1. Exercise therapy Exercise therapy is the most widely used type of conservative treatment for low back pain. Systematic reviews have shown that exercise therapy is effective for chronic but not for acute low back pain. In a study of Exercise therapy for chronic nonspecific low-back pain, suggested that compared to usual care, exercise therapy improved post-treatment pain intensity and disability, and long-term function. It is effective at reducing pain and function in the treatment of chronic low back pain. There is no evidence that one particular type of exercise therapy is clearly more effective than others. However, effects are small and it remains unclear which subgroups of patients benefit most from a specific type of treatment(37). Other showed that Exercise therapy that consists of individually designed programs, including stretching or strengthening, and is delivered with supervision may improve pain and function in chronic nonspecific low back pain(38). 1.1. Hip mobilizations and exercise In the study to to investigate the short-term outcomes in patients with CLBP managed with impairment-based manual therapy and exercise directed at the hip joints, found that an impairment-based approach directed at the hip joints may lead to improvements in pain, function, and disability in patients with CLBP(39). 2. Cognitive behavioral therapy Cognitive behavioral therapy (CBT) is a beneficial treatment for chronic nonspecific back pain, leading to improvements in a wide range of relevant

cognitive, behavioral and physical variables. This is especially evident when CBT is compared to treatment as usual or wait-list controls, but mixed and inconclusive when compared with various other treatments, according to the study by Uni Health, Uni Research, Bergen, Norway(40). Other researchers suggested that the self-rated treatment effectiveness and satisfaction appeared to be higher in the three active treatments. Several physical performance tasks improved in Active Physical Treatment (APT) and Combined Treatment of APT and CBT (CT) but not in CognitiveBehavioral Treatment (CBT). No clinically relevant differences were found between the CT and APT, or between CT and CBT(41). 3. Medication The range of regularly prescribed pharmacological agents to treat Chronic Low back pain extends from nonopioids (paracetamol, NSAIDs, and COX-2 inhibitors) to opioids, antidepressants and anticonvulsants(42). 3.1. Non-steroidal anti-inflammatory drugs (NSAIDs) Transdermal fentanyl significantly improved visual analog scale scores and Oswestry Disability Index scores in 73% of patients, especially those with specific low back pain awaiting surgery; however, it did not decrease pain in 27% of patients, including patients with non-specific low back pain or multiple back operations(43). Side effects include nausea, vomiting, diarrhea, constipation, decreased appetite, rash, dizziness, headache, drowsiness, etc. 3.2. Opioids tapentadol's -opioid agonism makes a greater contribution to analgesia in acute pain, while noradrenaline reuptake inhibition makes a greater contribution in chronic neuropathic pain models. Tapentadol also produces fewer adverse events than oxycodone at equianalgesic doses, and thus may have a '-sparing effect', according to the study by Johns Hopkins University School of Medicine(44) Side effects include Nausea, dizziness, constipation, CNS sedation, etc. 3.3. Antidepressants Selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) are a class of medication used as antidepressants in the treatment of depression, anxiety disorders, and some other disorders. In a study of a total of 575 patients enrolled, 45 of 89 (50.6%) taking SSRIs/SNRIs and 303 of 486 (62.3%) not taking SSRIs/SNRIs successfully

titrated to oxymorphone ER, showed that during the double-blind treatment phase, there was no significant difference in the frequency of serious AEs in patients treated with oxymorphone ER taking (1/29; 3.4%) versus those not taking (3/146; 2.0%) SSRIs/SNRIs. Visual analog scale scores were similar in patients taking versus those not taking SSRIs/SNRIs throughout the study(45). Side effects include nausea/vomiting, drowsiness, headache, bruxism, tinnitus, extremely vivid or strange dreams, dizziness, fatigue, etc. 3.4. Anticonvulsants Anticonvulsants benzodiazepines, the medication used in the treatment of epileptic seizures and has been used as adjunctive medications for acute low back pain, but have a high incidence of sedation(46). Side effects are not limited to dependency, rebound anxiety, memory impairment, discontinuation syndrome, muscle weakness, dizziness, mental confusion, depression, etc. 3.5. Antispasmodic drug Eperisone had an analgesic and muscle relaxant effect in patients with LBP. It should be noted that while it is common practice in rheumatology to combine a pain killer with a muscle relaxant in order to achieve a satisfactory result on both symptoms, the present results with eperisone were achieved with a single drug. With an improved tolerability profile compared with nonsteroidal anti-inflammatory drugs, and a lack of significant adverse effects on the CNS, eperisone hydrochloride represents a valuable alternative to traditional analgesics and muscle relaxants for the treatment of LBP, according to the study by Service of Rehabilitation and Functional Reeducation, S. Orsola-Malpighi Hospital, Bologna(47). Side effects are not limited to redness, itching, urticaria, edema, rash, pruritus, sleepiness, insomnia, headache, nausea and vomiting, anorexia, abdominal pain, etc. 4. Injection In the comparison of the clinical effectiveness of FJ injections (FJI) and FJ radiofrequency (FJRF) denervation in patients with chronic low back pain, found that the first choice should be the FJI and if pain reoccurs after a period of time or injection is not effective, RF procedure should be used for the treatment of chronic lumbar pain(47a). 5. Others

In the study to evaluate the use and direct medical costs of pharmacologic and alternative treatments for patients with osteoarthritis (OA) and chronic low back pain (CLBP), researchers at the Avalon Health Solutions, Inc., Philadelphia, Pennsylvania, indicated that Opioids were the most frequently prescribed medication (>70%) in both groups, followed by nonselective nonsteroidal anti-inflammatory drugs (>50%). Over 30% received antidepressants, >20% received benzodiazepines, and 15% in each group received sedative hypnotics. Use of alternative treatments was as follows: chiropractor, OA 11%, CLBP 34%; physical therapy, 20% in both groups; transcutaneous electrical nerve stimulations (TENS), OA 14%, CLBP 22%; acupuncture, hydrotherapy, massage therapy, and biofeedback, <3% in both groups. Mean (SD) total healthcare costs among these patients were, OA: $15,638 ($22,595); CLBP: $11,829 ($20,035). Pharmacologic therapies accounted for approximately 20% of these costs, whereas alternative treatments accounted for only 3% to 4% of the total costs(48). According to the study of group-based multidisciplinary rehabilitation program and oral drug treatment versus oral drug treatment alone, the groupbased multidisciplinary program could improve most domains of quality of life in chronic low back pain patients in the 6-month period. However, there were no significant differences between two groups in sub scales such as general health, social function and role emotional(49). Also in a clinical trial comparing group-based multidisciplinary biopsychosocial rehabilitation and intensive individual therapist-assisted back muscle strengthening exercises, showed that both groups showed longterm improvements in pain and disability scores, with only minor statistically significant differences between the 2 groups. The minor outcome difference in favor of the group-based multidisciplinary rehabilitation program is hardly of clinical interest for individual patients(50). A.2. Surgical treatments Most patients with back pain will not benefit from surgery and is performed when conservative treatment is not effective in reducing pain or if anatomic abnormalities consistent with the distribution of pain are identified. The most common types of low back surgery include 1. Microdiscectomy In retrospective cohort study of patients who underwent LMD in 2004-2005 were invited to participate and were re-evaluated clinically and radiologically after a three to five year follow-up, found that although many patients may be symptomatic following LMD, significant disability and

dissatisfaction are uncommon. Female sex, young age, lack of exercise, and chronic preoperative LBP may predict a worse outcome. Disc collapse is a universal finding, particularly at L4-L5. Neither DSC nor Modic changes seem to affect patient outcome(51). 2. Discectomy(SD) Recurrent or persistent low back pain (LBP) after surgical discectomy (SD) for intervertebral disc herniation has been well documented(52) 3. Laminectomy In the study of Twenty age-matched Sprague-Dawley male rats divided into operative and non-operative (control) groups, operative animals underwent a bilateral L5-L6 laminectomy with right-side L5-6 disc injury, a postlaminectomy pain model previously published by this lab, showed that the post-laminectomy condition creates quantifiable fibrosis of the spinal nerve to surrounding structures and supports the conclusion that this fibrosis may play a role in the post-laminectomy pain syndrome(53). 4. Spinal fusion In the study to determine the prognostic accuracy of tests for patient selection that are currently used in clinical practice to identify those patients with chronic LBP who will benefit from spinal fusion, showed that no subset of patients with chronic LBP could be identified for whom spinal fusion is a predictable and effective treatment. Best evidence does not support the use of current tests for patient selection in clinical practice(54). 5. Etc. In a meta-analysis of randomised controlled trials to investigate the effectiveness of surgical fusion for the treatment of chronic low back pain compared to non-surgical intervention, by searching the Several electronic databases (MEDLINE, EMBASE, CINAHL and Science Citation Index) from 1966 to 2005, found that the pooled mean difference in ODI between the surgical and non-surgical groups was in favour of surgery (mean difference of ODI: 4.13, 95%CI: 0.82 to 9.08, p = 0.10, I2 = 44.4%). Surgical treatment was associated with a 16% pooled rate of early complication (95%CI: 1220, I2 = 0%). Surgical fusion for chronic low back pain favoured a marginal improvement in the ODI compared to non-surgical intervention. This difference in ODI was not statistically significant and is of minimal clinical importance. Surgery was found to be associated with a significant risk of complications. Therefore, the cumulative evidence at the

present time does not support routine surgical fusion for the treatment of chronic low back pain(55). Others suggested that Fusion surgery is more effective than standard rehabilitation for improving pain in people with chronic non-radicular low back pain, but it is no better than intensive rehabilitation with a cognitive behavioural component(56). Surgery can be considered in persons who have experienced significant functional disabilities and in those with unremitting pain, especially pain lasting longer than 12 months despite multiple nonsurgical treatments. Good evidence supports the use of spinal fusion for treating back pain caused by fractures, infections, progressive deformity, or instability with spondylolisthesis(57). B. In herbal medicine perspective In a systematic review of randomized controlled trials to determine the effectiveness of herbal medicine compared with placebo, no intervention, or "standard/accepted/conventional treatments" for nonspecific low back pain, found that Two high-quality trials utilizing Harpagophytum procumbens (Devil's claw) found strong evidence for short-term improvements in pain and rescue medication for daily doses standardized to 50 mg or 100 mg harpagoside with another high-quality trial demonstrating relative equivalence to 12.5 mg per day of rofecoxib. Two moderate-quality trials utilizing Salix alba (White willow bark) found moderate evidence for short-term improvements in pain and rescue medication for daily doses standardized to 120 mg or 240 mg salicin with an additional trial demonstrating relative equivalence to 12.5 mg per day of rofecoxib. Three low-quality trials using Capsicum frutescens (Cayenne) using various topical preparations found moderate evidence for favorable results against placebo and one trial found equivalence to a homeopathic ointment(58). C. In traditional Chinese medicine perspective 1. Acupuncture In the study to investigate the efficacy of acupuncture for chronic low back pain of a total of 640 participants (160 in each of four arms) between the ages of 18 and 70 years of age who have low back pain lasting at least 3 months recruited from integrated health care delivery systems in Seattle and Oakland, clarified that the value of acupuncture needling as a treatment for chronic low back pain(59). Others found that found there is little evidence for the existence of subgroups of patients with chronic back pain that would

be especially likely to benefit from acupuncture. However, persons with chronic low back pain who had more severe baseline dysfunction had the most short-term benefit from acupuncture, according to the study of Characteristics of patients with chronic back pain who benefit from acupuncture(60). 2. Herbs 2.1. In a cross-sectional study carried out among 513 patients with CLBP in four hospitals affiliated with Yunnan University of Traditional Chinese Medicine, China, showed that they were eventually interpreted as (1) "Qi and/or Blood Stagnation," which includes eight items such as piercing pain; activity limited by feeling of local heaviness, lumbar and flank stiffness with bending limitation and purple tongue, etc.; (2) "Cold/Damp," which has seven items (for example, Cold/Damp pain, pallid face and greasy coating, etc.); (3) a part of "Kidney Deficiency," which includes two items: "dull pain and recurrent vague pain"; (4) "Warmth/Heat," which is related to three items (namely, purple tongue, yellow tongue coating, and burning pain). The four factors accounted for 12.7%, 8.2%, 8.2%, and 7.8% of the total variance, respectively. There are seven items with uniqueness over 0.8(61). 2.2. Herbal formula (Please consult with your traditional Chinese medicine practitioner before applying) 1. Shen Tong Zhu Yu Wan (Shen Tong Zhu Yu Pian) a. promotes blood circulation and Qi, removes blood stasis and obstruction in the channels, alleviates blood-arthralgia and pain. It is used for shoulder pain, pain in the arm, lumbago, pain in the leg or pain in the entire body due to obstruction of the flow of Qi and blood in channels. b. Ingredients Ingredients: Radix Gentianae Macrophyllae (Qin Jiao), Rhizoma Chuanxiong (Chuan Xiong), Semen Persicae (Tao Ren), Flos Carthami (Hong Hua), Radix Glycyrrhizae (Gan Cao), Rhizoma Et Radix Notopterygii (Qiang Huo), Resina Commiphorae (Mei Yao), Radix Angelica Sinensis (Dang Gui), Rhizoma Cyperi (Xiang Fu), Radix Achyranthis Bidentatae (Niu Xi), Phertima (Di Long), Rhizoma Wenyujin Concisa (Jiang Huang), Rhizoma Corydalis (Yan Hu Suo)(61a). 2. Liu Wei Di Huang Wan (Kidney Yin deficiency) a. Liu Wei Di Huang Wan can replenish Yin due to the Yin insufficiency of the kidney. The kidney is the innate foundation of all organs with respect to the Yin-Yang principles, Qi essence etc.

b. Ingredients Radix Rehmanniae Preparata (Shu Di Huang), Fructus Corni Officinalis (Shan Zhu Yu), Cortex Moutan Radicis (Mu Dan Pi), Rhizoma Dioscoreae Oppositae (Shan Yao), Sclerotium Poriae Cocos (Fu Ling), Rhizoma Alismatis Orientalis (Ze Xie)(61b). 3. Jin Kui Shen Qi Wan (Kidney Yang deficiency) a. Jin Kui Shen Qi Wan can replenish Yang due to the Yang insufficiency of the kidney. The kidney is the innate foundation of all organs with respect to the Yin-Yang principles, Qi essence etc. b. Ingredients Radix Rehmanniae Preparata (Shu Di Huang), Fructus Corni officinalis (Shan Zhu Yu), Rhizoma Dioscoreae Oppositae ((Shan Yao), Cortex Moutan Radicis (Mu Dan Pi), Sclerotium Poriae Cocos (Fu Ling), Rhizoma Alismatis Orientalis (Ze Xie), Cortex Cinnamomi Cassiae (Rou Gui), Radix Aconiti Lateralis Preparata (Zhi Fu Zi), Radix Achyranthis Bidentatae (Niu Xi), Radix Polygoni Multiflori (He Shou Wu), Fructus Lycii Chinensis (Gou Qi Zi), Fructus Schisandrae Chinensis (Wu Wei Zi(61c). D. TCM and conventional medicine baclofen According to the study of Reduction of chronic non-specific low back pain: A randomised controlled clinical trial on acupuncture and baclofen, after treatment, the baclofen, acupuncture and acupuncture + baclofen groups all had lower VAS and RDQ scores. Significantly higher reduction and improvement in VAS and RDQ scores were found in the acupuncture and acupuncture + baclofen groups compared to the baclofen group(62). Natural Remedy For Arthritis, Gout, And Rheumatism Discover An Amazing, All-natural System That Literally Stops Arthritis, Gout, And Rheumatism In As Little As 7 Days. For common types of diseases of Ages of 50+, please visit http://medicaladvisorjournals.blogspot.ca/p/better-of-living-health-50over.html For other health article, visit http://medicaladvisorjournals.blogspot.ca Sources

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