Gavin Erickson

Gavin Erickson

Tuesday, 08 May 2012 00:00

Premenstrual syndrome

 

About premenstrual syndrome

Most women of reproductive age experience at least mild premenstrual symptoms at some time in their lives (O’Brien 1987). However, around 2–10% of women have premenstrual symptoms that severely disrupt daily living (O’Brien 1987, DTB 1992, Wittchen 2002). These more troublesome symptoms are usually termed ‘premenstrual syndrome’ (PMS), if they comprise recurrent psychological and/or physical symptoms that occur specifically during the luteal phase of the menstrual cycle and usually resolve by the end of menstruation (O’Brien 1987).

 

Diagnosis of PMS is based on the presence of at least five symptoms, including one of four core psychological symptoms, from a list of 17 physical and psychological symptoms (Steiner 2001; Freeman 2001). The 17 symptoms are depression, feeling hopeless or guilty, anxiety/tension, mood swings, irritability/persistent anger, decreased interest, poor concentration, fatigue, food craving or increased appetite, sleep disturbance, feeling out of control or overwhelmed, poor coordination, headache, aches, swelling/bloating/weight gain, cramps, and breast tenderness.

 

The cause of PMS is unknown, but hormonal and other factors (possibly neuroendocrine) probably contribute (Rapkin 19917; O’Brien 1993). The aim of conventional treatment is to improve or eliminate physical and psychological symptoms; to minimise the impact on normal functioning, interpersonal relationships, and quality of life; and to minimise adverse effects of treatment (Kwan 2009).

Drugs such as spironolactone, valprazolam, metolazone, NSAIDs, buspirone and gonadorelin analogues are used to treat the main physical and psychological symptoms of PMS (Kwan 2009). Surgery is indicated only if there are coexisting gynecological problems.

References

Freeman EW, Rickels K, Yonkers KA, et al. Venlafaxine in the treatment of premenstrual dysphoric disorder. Obstet Gynecol 2001;98:737–44.

Kwan I, Onwude JL. Premenstrual syndrome. Clinical Evidence. Search date July 2009

Managing the premenstrual syndrome. DTB 1992; 30: 69-72.

O’Brien PMS. Premenstrual syndrome. Oxford: Blackwell Scientific Publications, 1987.

O'Brien PMS. Helping women with premenstrual syndrome. BMJ 1993;307:1471–1475.

Rapkin AJ, Morgan M, Goldman L, et al. Progesterone metabolite allopregnanolone in women with premenstrual syndrome. Obstet Gynecol 1997;90:709–14.

Steiner M, Romano SJ, Babcock S, et al. The efficacy of fluoxetine in improving physical symptoms associated with premenstrual dysphoric disorder. Br J Obstet Gynaecol 2001;108:462–8.

Wittchen H-U et al. Prevalence, incidence and stability of premenstrual dysphoric disorder in the community. Psych Med 2002; 32: 119-32.

How acupuncture can help

A systematic review (Cho 2010) located ten randomised controlled trials and found some evidence to suggest acupuncture reduces PMS symptoms. However, trial quality was generally poor and further studies are needed to confirm this. (See table overleaf.)

 

Acupuncture may help reduce symptoms of PMS by:

  • increasing relaxation and reducing tension (Samuels 2008). Acupuncture can alter the brain’s mood chemistry, reducing serotonin levels (Zhou 2008) and increasing endorphins (Han, 2004) and neuropeptide Y levels (Lee 2009), which can help to combat negative affective states.
  • stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz, 1987, Zijlstra 2003, Cheng 2009);
  • reducing inflammation, by promoting release of vascular and immunomodulatory factors Kavoussi 2007, Zijlstra 2003).

 

About traditional acupuncture

Acupuncture is a tried and tested system of traditional medicine, which has been used in China and other eastern cultures for thousands of years to restore, promote and maintain good health. Its benefits are now widely acknowledged all over the world, and in the past decade traditional acupuncture has begun to feature more prominently in mainstream healthcare in the UK. In conjunction with needling, the practitioner may use techniques such as moxibustion, cupping, massage or electro-acupuncture. They may also suggest dietary or lifestyle changes.

 

Traditional acupuncture takes a holistic approach to health and regards illness as a sign that the body is out of balance. The exact pattern and degree of imbalance is unique to each individual. The traditional acupuncturist’s skill lies in identifying the precise nature of the underlying disharmony and selecting the most effective treatment. The choice of acupuncture points will be specific to each patient’s needs. Traditional acupuncture can also be used as a preventive measure to strengthen the constitution and promote general wellbeing.

 

An increasing weight of evidence from Western scientific research (see overleaf) is demonstrating the effectiveness of acupuncture for treating a wide variety of conditions. From a biomedical viewpoint, acupuncture is believed to stimulate the nervous system, influencing the production of the body’s communication substances - hormones and neurotransmitters. The resulting biochemical changes activate the body's self-regulating homeostatic systems, stimulating its natural healing abilities and promoting physical and emotional wellbeing.

 

About the British Acupuncture Council

With over 3000 members, the British Acupuncture Council (BAcC) is the UK’s largest professional body for traditional acupuncturists. Membership of the BAcC guarantees excellence in training, safe practice and professional conduct. To find a qualified traditional acupuncturist, contact the BAcC on 020 8735 0400 or visit www.acupuncture.org.uk

 

Research

Conclusion

Systematic review

 

 

Cho SH, Kim J. Efficacy of acupuncture in management of premenstrual syndrome: A systematic review. Complementary Therapies in Medicine 2010; 18: 104-11.

 

 

A systematic review including 9 randomised controlled trials that assessed the effectiveness and adverse effects of acupuncture for the symptomatic treatment of PMS. Four studies reported a significant difference in reduction of PMS symptoms for acupuncture treatment compared with pharmacological treatment. Two studies reported improvements in primary symptoms within acupuncture and herbal medications groups compared with baseline. Only two trials reported information regarding acupuncture-related adverse events, which included one case of a small subcutaneous haematoma. The reviewers concluded that, although the included trials showed that acupuncture may be beneficial to patients with PMS, there is insufficient evidence to support this conclusion due to methodological flaws in the studies.

 

Clinical studies

 

Shin KR et al. The effect of hand acupuncture therapy and hand moxibustion therapy on premenstrual syndrome among Korean women. Western Journal of Nursing Research 2009; 31: 171-86.

A pilot study that compared the effects of hand acupuncture and hand moxibustion therapy with a control group (no treatment) 22 women with PMS. After acupuncture and moxibustion treatment, there were significant reductions in overall symptom reports, and in abdominal pain and bloating, compared with both pre-treatment levels and relative to controls. Rapid mood changes were also reduced in the post-treatment period in both the hand acupuncture and hand moxibustion groups, but not in the control group. The researchers concluded that hand acupuncture and hand moxibustion therapy may be effective strategies for women to reduce PMS symptoms.

Research on mechanisms for acupuncture in general

 

 

Cheng KJ. Neuroanatomical basis of acupuncture treatment for some common illnesses. Acupunct Med 2009;27: 61-4.

 

 

 

A review that looked at acupuncture treatment for some common conditions. It is found that, in many cases, the acupuncture points traditionally used have a neuroanatomical significance from the viewpoint of biomedicine. From this, the reviewers hypothesize that plausible mechanisms of action include intramuscular stimulation for treating muscular pain and nerve stimulation for treating neuropathies.

 

Lee B et al. Effects of acupuncture on chronic corticosterone-induced depression-like behavior and expression of neuropeptide Y in the rats. Neuroscience Letters 2009; 453: 151-6.

In animal studies, acupuncture has been found to significantly reduce anxiety-like behaviour, and increase brain levels of neuropeptide Y, the brain levels of which appear to correlate with reported anxiety.

 

Samuels N et al. Acupuncture for psychiatric illness: a literature review. Behav Med 2008; 34: 55-64

A literature review of acupuncture for psychiatric illness, which presents research that found acupuncture to increase central nervous system hormones, including ACTH, beta-endorphins, serotonin, and noradrenaline. It concludes that acupuncture can have positive effects on depression and anxiety.

Zhou Q et al. The effect of electro-acupuncture on the imbalance between monoamine neurotransmitters and GABA in the CNS of rats with chronic emotional stress-induced anxiety. Int J Clin Acupunct 2008 ;17: 79-84.

A study of the regulatory effect of electro-acupuncture on the imbalance between monoamine neurotransmitters and GABA in the central nervous system of rats with chronic emotional stress-induced anxiety. The levels of serotonin, noradrenaline and dopamine fell significantly, while GABA levels were significantly higher in the rats given acupuncture (P<0.05, or P<0.0). The researchers concluded that the anti-anxiety effect of electro-acupuncture may relate to its regulation of the imbalance of neurotransmitters.

Kavoussi B, Ross BE. The neuroimmune basis of anti-inflammatory acupuncture. Integr Cancer Ther 2007; 6: :251-7.

A review that suggests the anti-inflammatory actions of traditional and electro-acupuncture are mediated by efferent vagus nerve activation and inflammatory macrophage deactivation.

Zijlstra FJ et al. Anti-inflammatory actions of acupuncture. Mediators Inflamm 2003;12: 59-69.

A review that suggests a hypothesis for the anti-inflammatory action of acupuncture. Insertion of acupuncture needle initially stimulates production of beta-endorphins, calcitonin gene-related peptide (CGRP) and substance P, leading to further stimulation of cytokines and nitric oxide (NO). While high levels of CGRP have been shown to be pro-inflammatory, CGRP in low concentrations exerts potent anti-inflammatory actions. Therefore, a frequently applied 'low-dose' treatment of acupuncture could provoke a sustained release of CGRP with anti-inflammatory activity, without stimulation of pro-inflammatory cells.

Pomeranz B. Scientific basis of acupuncture. In: Stux G, Pomeranz B, eds. Acupuncture Textbook and Atlas. Heidelberg: Springer-Verlag; 1987:1-18.

 

Needle activation of A delta and C afferent nerve fibres in muscle sends signals to the spinal cord, where dynorphin and enkephalins are released. Afferent pathways continue to the midbrain, triggering excitatory and inhibitory mediators in spinal cord. Ensuing release of serotonin and norepinephrine onto the spinal cord leads to pain transmission being inhibited both pre- and postsynaptically in the spinothalamic tract. Finally, these signals reach the hypothalamus and pituitary, triggering release of adrenocorticotropic hormones and beta-endorphin.

Thursday, 19 April 2012 00:00

Patient involvement

Terms of reference

The BAcC works towards ensuring that members obtain the best outcomes for patients and that patient experience is improved. All feedback is very important in helping the BAcC improve and develop services and we value it highly. Our strategy is to involve patients of acupuncture in a variety of ways, with a view that there is no 'one size fits all' approach.

The group was approved to be established by the BAcC Executive Committee in June 2011 as a pilot. It has met for one year and its terms of reference and function were reviewed in September 2012.

Overall purpose

The primary purposes of this group are to

  • Advise how BAcC's strategic and business plans impacts on patients
  • Advise on ethical and practice issues, in particular as it relates to the BAcC's proposed Professional Standards Authority accreditation and reviewing complaints procedures
  • Help make links with patients and voluntary sector organisations
  • Hear patient comments and feedback on acupuncture in general

Minutes will be available for the GB to review

Specific tasks

  • Feedback on the draft BAcC business plan
  • Review relevant policy papers for the Governing Board
  • Comment on BAcC patient facing documents

Meeting schedule

The group will meet twice a year at the BAcC London Office.

Membership

The group will consist of:

  • A maximum of 5 patients, using BAcC practitioners
  • A BAcC practitioner member
  • BAcC CEO
  • BAcC staff members may attend by invitation from time to time if their areas of specialist involvement are under discussion.

Payment

BAcC will pay travel expenses and a small stipend for the half day meeting – suggested to be £100, for a half day meeting, in line with other lay members

Chair

The Chair will be the CEO.

Quorum

There is no quorum. In the event that a recommendation arises from a meeting at which only two members are present, however, this should be made explicit in any formal recommendations placed before the Governing Board.

 

If you want to get involved in this liaison group please email Paul Hitchcock or telephone 020 8735 1219.

Friday, 13 April 2012 00:00

Acupuncture in care homes

Traditional acupuncture is a healthcare system based on ancient principles which go back nearly 2,000 years. It is ideally suited to addressing the complex issues facing care home residents.

'The care staff will often come and ask me to help a certain resident who might be distressed or agitated ... or if someone has had a fall or is feeling stiff that morning, they will ask me to go and help.'

BAcC Member, South West

 

Acupuncture provides a substantial contribution to the healthcare of the UK, with an estimated four million treatments given annually. Some members of the British Acupuncture Council (BAcC) are already working within the care home environment and the BAcC is keen to bridge the gap between traditional acupuncturists and the care sector.

 

The following characteristics make traditional acupuncture ideal for use in care homes:

 

  • treatment is always tailored to the individual
  • physical, emotional and mental are seen as interdependent
  • treatment complements western healthcare provision
  • the person receiving treatment is given the time to express their feelings and their needs

Improving health and wellbeing outcomes

Because traditional acupuncture aims to treat the whole person as well as specific symptoms it can be effective for a range of conditions.

 

Read about our research approach here

 

Click here to view our fact sheets

Safety quality care

Acupuncture is a very safe intervention and adverse events are rare, especially when the practitioner is fully and properly trained. British Acupuncture Council membership is a mark of assurance that guarantees high standards of professionalism, training and safety. Any patient receiving acupuncture from a BAcC member can expect the highest standard of professional care.

 

To find out how safe acupuncture is click here

 

Read about our professional codes here

Person-centred attention and support

At the heart of traditional acupuncture lies a person-centred therapeutic approach which recognises each patient as a unique individual. All signs and symptoms are considered within the context of the whole person, their story, preferences, past experiences, and

current needs and wishes.

Acupressure and other methods of treatment

Acupressure is a non-invasive therapy based on the principles of Chinese medicine. Acupressure is ideal for helping residents with a wide range of complaints, especially those with dementia, for whom invasive therapy with needles will not be possible. Acupressure and other non-invasive treatment techniques are often used by acupuncturists to address a broad spectrum of wellbeing issues.

You can find out more about how this system of healthcare could be of benefit to your residents by watching our films:

Hear what some people have to say

 

What tools do acupuncturists use?

As far as hard research evidence is concerned, it depends what kinds of cysts we're talking about here. There is, for example, some reasonable evidence that acupuncture may benefit polycystic ovarian disease or syndrome (PCOS) but not a great deal of evidence for common or garden cysts on the skin, mainly because research usually involves specific named conditions, and cysts tend to vary with location and cause.

 

 

However, from a Chinese medicine perspective cysts are usually regarded as accumulations of fluid which have gathered because of a local blockage or the thickening and gathering of fluids because of a failure of the overall function for even distribution of fluids in the body. Whichever it is, or even if it is both, there are a number of protocols which might be used to address the problem. The symptoms which the patients describe and the signs with which they present are the same, whatever system of diagnosis is used. Chinese medicine has worked with the same raw material for over two thousand years, and has clearly addressed problems like this since it was first formulated.

 

We tend to say the same thing with every answer, which is to visit a BAcC member local to you for advice and guidance on whether acupuncture is a good option for you, or whether they think other modalities might suit your case better. Most are happy to give a little time without charge to look at your unique presentation and see what Chinese medicine can offer, and equally happy to refer elsewhere if in their judgement there are more suitable options. In Chinese medicine each patient's balance and constitution is unique; trying to give a 'one size fits all answer' clearly has limitations. But we do our best!

Q. Will acupuncture help with an old football injury? I have small broken bones in my foot and arthritus, I am taking cyzpain relief but am now walking with a limp. I enjoy walking and a Munroe bagger with one mountain to finish all of them.

 

A. The adage that the longer a problem has been around, the longer it takes to shift tends to be true. It depends to a great extent on how old 'old' is. This is not simply a question of the injury itself, but of the kinds of secondary accomodations which the body has made to cope with the original problem. It is not unusual for people with a severe pain on one lower limb to start to favour the other, and the slight change in posture can then lead to lower back pain and other musculo-skeletal aggravation.

 

 

There is some evidence that acupuncture can help osteoarthritis, although clearly if a joint has badly deteriorated there is not much that treatment can offer. Reducing the inflammation may be the best that one can hope for, but relief will probably be temporary. Our factsheet here gives a good indication of the kinds of research which exist.

 

It is very likely that if the problem is quite old, you may need to consider some other kinds of help if the inflammation and pain start to reduce. Physiotherapy or osteopathy may well be a good secondary treatment for the realignment of the body's structure, and there are a substantial number of BAcC members who are dual qualified. If one works in your area it may well be worth asking their advice on what may be possible.

 

And we wish you every success in reaching the top of that last peak!

Wednesday, 11 April 2012 13:33

Can acupuncture help with face pain?

'Face pain' is a little too broad a description to be able to give you a specific answer. A traditional acupuncturist would ask you the same sorts of question that your doctor would - where is it, what kind of pain, what times of day does it come on, what makes it better or worse, and so on. Because the acupuncturist works within a different framework the strategies they decide upon will be different, but will always be based on an underlying premise that pain arises from blockages, excesses or deficiencies in the body's energy which the needles are used to correct.

 

A great deal of the early research in the west was around the pain relieving qualities of using needles, and even the most hardened sceptic had to admit that people did seem to have less pain after treatment. The question is only how much relief from pain and how sustainable it is, and if you did go to see an acupuncturist you'd be well advised to set clear outcomes and regular review periods.

 

Our factsheets on the main website (click on 'research', then 'factsheets', and look at the drop down menu) gives you an idea of the sorts of research which exists for the kinds of problems which people regularly bring to acupuncture treatment.

Wednesday, 11 April 2012 13:32

Acupuncture in hospital caused pain

Q. Last week I had acupuncture to treat neck and shoulder injuries caused by a fall in December and I could not believe how painful, both during and for 24 hours after the treatment it was. Is this normal? I recieved the treatment in an NHS hospital by a senior physiotherapist. My next appointment is tomorrow and I am dreading it.

 

A. One of the principal reasons for differences in technique between professional acupuncturists and medical professionals using acupuncture lies in the underlying theory on which the practice is based. The traditional acupuncturist is primarily concerned with the energies of the body, the term 'qi' which the Chinese use to describe all aspects of physical existence, and treatment can often be very subtle and gentle. The medical acupuncturist, however, is more often working on the basis of muscular and neurophysiological approaches. This can often involve the use of what are called 'trigger points', knots in the muscle tissue, and needling these can often be quite painful. The more physically based treatment often calls for a broader gauge of needle than BAcC members generally use, and it's something of a simple truth that the thicker the needle, the more likely it is to cause discomfort.

 

 

A great many physiotherapists have added some of the Chinese medical approaches to their repertoire and are equally subtle in their approach, so we would not want to generalise too much on the basis of a single report. It may be as simple as the fact that this person's technique is not that good, or equally that you are one of a small group of people who are extremely sensitive to acupuncture treatment and have to weigh the benefits of treatment against the discomfort of the needles.

 

All healthcare professionals can only work with the patient's consent, though, and if there is any aspect of a treatment which you do not like you are within your rights to withhold consent. Any practitioner that continues to use a modality after consent has been withdrawn immediately puts themselves on the wrong side of their professional code of conduct.

Wednesday, 11 April 2012 13:30

Self needling for migraine?

Q. I have suffered from severe migraine my entire life. I take daily medication which reduces attacks to 1-2 a year. When an attack begins, I haven't found any tablets that help. By chance I received acupuncture by my GP when I happened to see her whilst in the middle of an attack, which instantly ended the attack.

 

Would it be possible to be trained to give myself acupuncture (on the back of the hand) so I could use this as a first aid treatment if/when I suffer my next migraine?

 

A. Although it's great to hear of people having dramatic results from having treatment we do not encourage people to needle themselves. There are two main rasons. First, acupuncture involves piercing the skin and safely disposing of needles, and a professional practitioner spends a considerable time learning the skills and knowledge necessary to remove any risk of infection or cross-infection from the process. Our main complaint about very short training courses is that while they may train people in useful adjunctive skills they cannot hope to ensure that the person taking them is sufficiently well trained in safe needle practice and all the cautions that go with being a professional acupuncturist.

 

Second, although the treatment of symptoms has its place in Chinese medicine, symptoms are regarded as only a part of the picture, and are usually indicators of imbalances within the system which need attention. The risk is that using acupuncture in a first aid way, the underlying pattern is deteriorating, but the alarm bell which the symptom represents keeps getting turned off.

 

The fact that this works so well for you, however, is perhaps something you could discuss with your GP. Our members would possibly fall foul of our Codes of Professional Conduct if they taught people self-needling techniques, and our insurers would probably be less than happy with the practice. There have been one or two trials within the NHS which used self-needling, however, and it may be that your GP can authorise and delegate care in this way. If not, acupressure using the same points should offer a similar kind of relief.

Q. I am a student midwife and have been tasked with presenting information on the use of acupuncture for pain relief in labour. I am particularly keen to find out whether an acupuncturist would be likely to consider accompanying a woman into hospital for this purpose and whether the woman would have to remain still. Also how do acupuncturists normally manage their sharps.

Any help would be much appreciated.

 

A.  An increasing number of BAcC members now attend births at the mother's request to help her through the stages of the delivery. Most hospitals seem to be reasonably relaxed about this, and as long as the practitioner has the consent of the consultant or the midwife in charge, and of the mother, of course, it is simply a matter of doing one's job and keeping out of the way at key moments.

 

The mother does not have to remain completely still, but there will clearly be limitations on how much movement is acceptable when needles are in place, and a delicate calculation of how many needles constitute a safe amount when the labour speeds up. Rather than set somewhat arbitrary guidelines or rules for this, we leave it up to the practitioner to assess the situation and make their own professional judgement about what it is best to do. For most, less is more at this critical time.

 

All needles used now are single-use and disposable, and the majority of members use yellow sharp's boxes within their clinics for the disposal of needles and small items of clinic waste. These boxes are collected by regsitered carriers when they are three quarters full, and there are very clear guidelines which we expect members to follow. There are also very clear guidelines for using smaller transportable sharps boxes in the event that the practitioner treats away frmom their normal base.

 

You may also be interested in the (10 minute) video of BAcC member Sarah Budd at the recent ARRC symposium entitled "Maternity acupuncture in the NHS : a "MYMOP" audit" which deals with pain relief.

As our factsheet here shows low back pain is one of a small number of conditions for which the evidence is good enough such that acupuncture is now a NICE recommendation for people with chronic non-specific back pain of over six months duration. This does not mean it doesn't work on many other things, only that the specific type of evidence accepted in the West is very narrow, and the vast quantity of Chinese research available is often methodologically less than perfect.

 

 

However, if your case the pain appears to have a very clear specific cause which may make it not be so amenable to treatment. If the scarring and adhesions are significant and permanent, it is possible that acupuncture may have little or no effect. That said, it is surprising how often a physical manifestation such as degeneration of the lower vertebrae or scar is adjudged without further ado to be the explicit cause of a pain. Most people over the age of 50, for example, are likely to be showing some signs of degeneration of the vertebrae in the lower spine, and that does not necessarily mean that this is the root of every reported back pain.

 

It would be worthwhile discussing the specifics of your case face to face with a practitioner to get a better idea of whether they feel that treatment may be able to help based on a proper inspection of the nature of the problem. The fact that you have scarring and adhesions suggest a wider pathology than simply back pain, and a practitioner would perhaps be able to make better sense of any patterns by actually looking directly at what's going on.