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A: We fully sympathise with you; along with gallstones and kidney stones, post-herpetic neuralgia is amongst the most debilitating and unrelenting pains that anyone can have to deal with. We have been asked this question before, and a recent answer was:

Q:  I had shingles which left me with severe post herpatic neuralgia.  Please can you tell me if acupuncture would benefit me? 

A:  As you might imagine we have been asked about this many times over the years; shingles can be a terribly distressing condition whose after-effects can persist for months or even years. The treatment of post herpetic pain is an area which has been heavily researched in China, as our factsheet

says, but the quality of trials is not that great. There is a comprehensive systematic review of all available trials, but this was only announced last year and has not yet been published. We ourselves have treated many cases of shingles, and we have to be honest and say that there has been a significant number of cases where it has been very difficult indeed to reduce the pain, which as we are sure you know can be excruciating.

However, there is no point in being unduly pessimistic. There have been cases of post-herpetic pain where the acupuncture treatment has made significant inroads into the symptoms from a mixture of constitutional treatment to bring balance back to the system as a whole and local treatment to reduce some of the irritation and inflammation. Generally speaking, it is better to start treatment as soon as possible after an attack, just as the use of conventional anti-viral medicines is favoured as early as possible. However, the reality is that most patients present with post-herpetic pain long after they attack and usually because the side-effects of the long-term medication are becoming a problem, so we are used to adopting a slightly different approach from that used in China, where needling often commences with days of an attack starting.

The best advice that we can give is that you visit a BAcC member local to you for a brief face to face assessment. The one caution we always voice in these cases is that if you decide to go ahead with treatment you set review dates for assessing progress and also try to set specific outcome measures, objective evidence that the condition is improving. This can be quite difficult with chronic conditions like this which can still have acute episodes, but it is really important to try to find a marker which can show that there has been progress. We would feel confident, though, that acupuncture treatment might offer some benefit in pain relief and recovery. The only question to resolve is how much and how sustainable the relief is, which is why we are always cautious in setting clear outcomes measures and review periods.

We believe that this is still sound advice, and we hope that it is of benefit. The great strength of Chinese medicine, though, is that each patient is unique and different, even though their symptoms be the same. This means that a skilled practitioner, and all of our members are, would be able to make links that we cannot do at this distance, and may be able to recommend other things that may help alongside acupuncture treatment. We would strongly recommend that you visit a local BAcC member for advice, and hope that it puts you on a path to finding some relief.

Q: I had 20 minutes acupuncture for nerve pain following shoulder surgery. I was very tired and had a headache later that night which then became a migraine. I also suffer from M.E., Fibromylagia and Chronic fatigue. Is this a normal feeling after treatment? 

A:  We wouldn't go so far as to say 'normal' because adverse reactions after treatment are quite unusual but certainly within the range of possible adverse effects after a treatment. A great deal depends on whether you normally suffer from migraines or have experienced migraines in the past. It is not unusual for someone who has suffered from a symptom in the past to experience a re-visiting of the symptom, often quite a powerful version. The received wisdom is that imbalance tends to work its way from the outside to the inside, and that successful treatment reverses the process. There are other therapies which also use this 'law of cure' where symptoms can sometimes appear in reverse chronological order as they are addressed.

If this is a treatment reaction it is likely to last no more than 24-48 hours before subsiding. If it continues beyond this then it is important to address what may be happening. The fact that you have a background of ME/CFS/PVS suggests that your system is not as settled as one might hope, and in the circumstances it is often a matter of clinical judgement about how much treatment and how strong a treatment one can deliver. This is not a criticism of western medical acupuncture, but because it often uses a different premise for how it works a practitioner will often use what we would regard as a very strong treatment for someone whose energies we might regard as too fragile to be able to deal with. This can sometimes lead to quite strong reactions because form our perspective any treatment affects the whole system. A powerful treatment to help a neck or a shoulder is a powerful treatment full stop, and it may be that it was a little too strong for your constitution.

This is not a problem. If you talk the practitioner before any follow-up session he or she can adjust the strength of the treatment to ensure that it reduces the risk if after effects. The beauty of acupuncture treatment is that it does not have to equate treatment strength with intended effect - you don't have to needle more vigorously for more difficult problems. This is somewhat confounding to a British public brought up on no pain, no gain, and a sense that it has to hurt to be doing any good. The reality is, though, that moving energy is a subtle business, and the treatment outcomes are not direct equivalent to the perceived strength of input.

We hope that describing what happened to your practitioner will not only help to head off repeat episodes but might also inform their diagnosis of what is happening in your system.

Q: I wondered if there was a list of NHS approved acupuncture treatments that can be carried out by GP's /doctors. In other words, what the NHS recognises as a treatment of equivalent quality to that of conventional western medicine? I have seen the WHO list on your website but going through NHS choices website, it seemed quite restrictive.

Also what is the professional level of care provider in the NHS that can offer acupuncture, I presume it is more than nursing level, and is at GP/Doctor level? 

A: This is quite a complex question that touches on one or two controversial (within the acupuncture profession!) issues.

As far as the use of acupuncture by conventional medical practitioners is concerned, the usual requirement for inclusion within scope of practice is evidence at the level of randomised double blind control trial. For several very cogent reasons this is not a very appropriate mechanism for testing what by its very nature is a dynamic and evolutionary diagnostic and treatment process - diagnosis informs treatment which it turn further refines diagnosis. It would be highly unusual to use a single point prescription ad nauseam.

However, in the medical versions of acupuncture this is certainly how the process is viewed, and where trials are conducted on this basis it is considered acceptable to use acupuncture within a conventional framework. There are only two areas - chronic low back pain and cluster headaches - where NICE has adopted acupuncture as a firm recommendation. There was a ' near miss' for the treatment of osteoarthritis of the knee, where the evidence was good but the evidence for the 'sham' control group was nearly as good. Both were better than conventional treatment but the evidence of efficacy depends on outstripping the sham. Apart from that there are a few trials for post-chemotherapy nausea, dental pain and a couple of minor conditions which meet the criteria. These, at least, form the list which the Advertising Standards Authority allows us to talk about.

In practice, however, most codes of conduct inside statutory registers say that a registrant can do pretty much what they please as long as they can provide satisfactory evidence which assures them of patient safety and qualified efficacy. As you will have seen from the WHO website there are thousands of Level 2 trials which show positive results for acupuncture treatment, and many conventional practitioners extend their work in this field. The deterrent from radical use is that their protected title is at risk, on which basis a great deal of professional judgement and latitude is extended by the regulators.

As you can imagine this has become something of a hot potato as physiotherapists have started to extend their repertoire into areas like fertility treatment and internal problems which can only by a stretch of imagination be regarded as within the traditional scope of practice. There is also an increasing number of osteopaths and chiropractors extending their scope of practice, although there is nothing to indicate that this is at all included within their basic skill set. However, if they are taken to task and can show evidence that it was a legitimate extension of their skills based on reasonable evidence they would be unlikely to face censure. Our argument has always been that finding out that something was wrong after it has gone wrong is no way to run a railway, and that particularly in matters of safety where the standards are clearly defined it would make sense to enforce basic standards as a condition of use. However, acupuncture remains such a safe treatment that the risk, and therefore the urgency, is seen as less pressing. 

Our members get understandably upset, and see this as a form of subtle encroachment. Our slightly wider view is that at the moment the 'cake' which we are all sharing of prospective patients is minute in comparison to what we believe the overall use of acupuncture could and should be, and that rather than arguing about poaching we might be better advised to work together to create a much larger cake. However, there is a great deal of professional pride at stake where someone has trained to degree level for three years and then sees a person with a weekend's training offering to treat the same problems.

This abuts on your second question. Because acupuncture can be practised as a free-standing independent system or as a simple adjunct for specific circumstances (like the use of acupuncture in childbirth by midwives) you will find no simple statement of levels of attainment for its use. The basic line is that a practitioner must understand the scope of their practice and the limits of their competence, and know precisely what to do if they are out of their depth or if something goes wrong. This means that there are many nurse practitioners and low level use practitioners as well as doctors and physios who have usually undertaken significant training, although none as comprehensive as the WHO guidelines except by choice in a few cases.

This again is something of a debating point in the traditional acupuncture world. Since medical acupuncture does not have a great deal of content, it is quite common for conventional practitioners to cherrypick elements of traditional acupuncture, and this kicks of very lively debates about how safe it is for a practitioner to use a tiny part of the overall system. Would we be allowed, it is argued, to learn how to do a specific surgical procedure? However, we tend to take the view that this is going to happen increasingly as acupuncture is practised more widely because it is effective, and it is better for us to guiding the process and helping people to recognise their limitations than standing and taking pot shots at non-traditional users. Not a unanimous sentiment, it has to be said.

This is obviously a very complex field and we cannot hope to cover all of the subtleties here, but we hope that this has given you a flavour of the issues involved,

A: We are always cautious about answering questions about conditions for which there has been little research evidence. The one summary of trials on the use of acupuncture for glaucoma really does not say very much

A part of the problem here, as the author of the review says, is that the standard method of testing procedures in the West, the randomised double blind control trial, involves one group getting a real treatment and the other group getting a sham treatment, to test the difference in outcome. No physician, however, would leave a condition like glaucoma untreated because of the potential for serious sight loss, so until someone tests the effects of standard treatment against standard treatment plus acupuncture there will be nothing definitive to point to.

All of us have treated people with glaucoma, either as a primary condition or as a secondary condition after a patient has presented with another problem, and I'm sure all of us can report some success. As the author of the review says, blockages in the flow of energy which prevent the free flow of fluids sums up what glaucoma is, and it would seem intuitively possible that acupuncture would have an effect. This expert's experience, though, has been that it takes a long time to achieve sustained and sustainable results, and the medications remain a part of the picture throughout. What acupuncture seems to do well is to prevent uncontrollable variations in pressure, but there is no statistical evidence to which we can point.

We have searched the internet and found surprisingly little patient feedback about the treatment of glaucoma with acupuncture. Most of the official charities and organisations do not have a great deal of feedback from patients on their websites, and we have not been able to trace many forums of sufferers. That these exist is not in doubt; the internet has created thousands of forums across the globe. The best that we can say is that if you search, you will find quite a few, and our experience is that they tend to be  a great deal more measured than used to be the case. Where it used to be 'it works, oh no it doesn't' the entries now tend to reflect the wider range of outcomes and views.

We do not ourselves 'bank' feedback on specific conditions, primarily because we take the generalist view that we treat the person as much as or more than we treat the condition. However, our best advice as always is to go to see a BAcC member local to you for a brief face to face assessment. This will enable someone to see your problem not simply as it is but against the backdrop of your overall health. This will enable them to offer a much better view of what might be possible and also enrich any basic understanding of how your problem may have arisen from a Chinese medicine perspective.  

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