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Q:  I've just started acupuncture at my local hospital and I feel worse.  Is it true you can feel worse, before you get better? How many sessions should I try before giving up as the person treating me reckons it's not working?   I suffer from chronic fibromyalgia with leg weakness and tremors. I feel even more tired than I did before and the pain, especially on the day after the treatment,  is worse.  I have been 3 times;  1st session two needles were placed as I have allergies to certain metals, 2nd session 5 needles hands head and feet 3rd session 6 needles hands head & feet.

A:  We are sorry to hear that you haven't been making much progress, but in our experience fibromyalgia can be a difficult condition to treat. As our factsheet shows

http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/fibromyalgia.html

there is not a great deal of evidence which would mean that we could say with confidence that acupuncture treatment will work. However, as the factsheet remarks, we are always up against a problem with the way that trials are conducted, and the fact that the so-called 'sham' treatment works as well as the 'real' treatment. From a Chinese medicine perspective, there are no points on the body which don't work at all - everything is made up of energy, called 'qi', and the classically recognised points are simply the most effective places to achieve change.

Anyway, to more specific questions, we usually recommend that someone has four or five sessions if there is any doubt about whether treatment will be effective, and to review progress at this stage. This does mean that you need to have in place some very clear outcomes or markers for what counts as getting better. The trouble with fibromyalgia and similar conditions is that on some days you can feel fine and other days be in considerable pain. It is difficult to get an objective measure, but if there are things which can be measured, such as distance walked or time slept, or painkillers reduced, these can sometimes provide evidence that there is some progress. We are a little surprised that the person treating you is concluding already that nothing is happening, but there are signs which show how well, or indeed if, someone is reacting to treatment, and if these are unchanging, that might be the basis for her view. There are a small number of patients whom one knows almost from the off are not benefiting.

It is also possible in the early stages of treatment to feel worse rather than better, although in our experience this usually only lasts for about a day or two at most, and if someone feels worse for longer than this we tend to look at what else is going on. Your mention of allergic responses is an interesting detail, and there is a small question mark about whether the needles themselves are triggering a reaction. Though unusual, it can happen, and allergic responses can persist. However, in conditions like fibromyalgia and polymyalgia, the persistence of the condition can often mean that the feeling of being slightly worse can persist for quite a while too, so it may simply fall within what is sometimes called a healing response, and be perfectly normal. However, after four or five sessions this should not really continue, and if it does, then it calls into question whether it is worth continuing with treatment.

The one factor which we cannot explore with you for want of detail is the fact that you are having the treatment in hospital. This might mean that you are being treated in a pain clinic or by a hospital physio, and while we are always happy that other healthcare professionals spread the word about how acupuncture works, from a Chinese medicine perspective traditional acupuncture is a very subtle and sophisticated art which relies as much on treating the person as the problem with which they present. In some cases, the kinds of formula treatment which people using western acupuncture or cookbook treatments apply may not be sufficiently geared to the highly specific nature of why someone is experiencing their symptoms. Our concern is that this leads someone to conclude that acupuncture does not work when in the hands of a full time professional practitioner using traditional acupunctur eit may well be possible to achive progress.

The best advice always in these situations, though, is to discuss these issues with the practitioner herself. Whatever system of treatment she is using, she will have a very clear idea based on what she sees and feels of whether the treatment is having an effect, and she is best placed to address your concerns.

There has been an upsurge over the last few years in what has been described as 'cosmetic acupuncture' or 'facial revitalisation acupuncture'. With it has come a rather hot debate inside the profession, not least because some of the clinics where this technique is used charge fees that are considerably higher than the average fee charged by a BAcC member, and also because some of the people offering this treatment are not fully qualified practitioners but simply beauticians who have undertaken short course training.

Our general position is that there is not a specific separate discipline of cosmetic acupuncture but rather the application of traditional techniques on the face adapted for a specific purpose, but, and most importantly, taking into account the system as a whole as traditional acupuncture does. We have taken great care to get the message across that a properly trained traditional acupuncturist treats the person as a whole, not simply a named condition or a single part of the body, and that unless treatment is undertaken in this way, there can be no guarantees that short term local results can be be sustained.

We are also keen to get across the message that however limited the area of interest, acupuncture remains acupuncture wherever it is performed on the body, and our members undergo three years of degree-equivalent training to ensure that they are safe and competent and fully aware of factors affecting the safety of the patient. We do not believe that someone undertaking a short training over two weekends can realistically hope to match this level of safety training as well as learning the techniques. This is especially the case with some of the techniques commonly used in cosmetic acupuncture which are not a part of the standard protocols for body acupuncture.

We do not keep a separate register of our members who offer this type of treatment. The best bet would be to use google to identify someone in your area providing this style of treatment and then cross-refer with the BAcC Register to ensure that it is someone who is properly trained and insured.

As a general comment, though, we would want to have a look at what in your life was contributing to your wrinkles. If you are under constant stress and worry, there may be systemic treatments to help you to cope better with either in such a way as to reduce your wrinkles. We always ask whether wrinkles go when people are on holiday. You'd be surprised how many people say that they do. If so, local treatment will not be a proper solution to the problem unless it is supported by treatment of the system as a whole.

Q:  I'm with AXA/PPP  healthcare insurance do you deal with them?

A:  We are sorry to say that BAcC members are not recognised by AXA/PPP for reimbursement of acupuncture treatment. The current entry requirement for recognition is:

Acupuncturist – a medical practitioner with full registration under

the Medical Acts, who specialises in acupuncture who is registered

under the relevant Act; and who, in all cases, meets our criteria for

acupuncturist recognition for benefit purposes in their field of practice,

and who we have told in writing that we currently recognise them as

an acupuncturist for benefit purposes in that field for the provision of

out-patient treatment only.

This is quite a hard-hitting criterion which applies to only a small number of the members of the British Medical Acupuncture Society who could claim to 'specialise' in acupuncture.

There are a number of reasons why the two large medical insurers (the other being BUPA) adopt such stringent criteria, but these schemes are largely designed by actuaries who want to be able to predict with some accuracy what costs are likely to be incurred. There is not enough accepted research in acupuncture which says 'do ten sessions and the problem will go away', and in the absence of that actuaries take fright at what may become an open-ended treatment plan.

There are signs of change. BUPA has recently decided to offer limited recognition for BAcC members, and where they go it is possible that AXA will follow. In the short term, however, there is not a great deal of likelihood that you would be able to seek reimbursement for treatment from a BAcC member, but there will almost certainly be a list of accredited practitioners held by AXA which may contain details of medical doctors who meet their criteria and who work in your area.

Q:  I had subacromial decompression surgery done in December.  I am still in a lot of pain and can't sleep.  I am  ok when my arm is moving. Would acupuncture help

A:  This is quite difficult to answer without knowing a little more of the circumstances which led to the choice of a subacromial decompression as the treatment of choice. There are a number of reasons why the problem can arise, and since you are still just within the 2-6 month recovery period, a great deal will depend on whether you have been recommended to have regular physiotherapy, and whether you have done so, and whether there were predisposing factors which may have caused the problem to arise and for which you may still need to make adjustments. We are assuming that if it was a sports related problem that you have rested, but if it was to do with some repetitive action associated with your work, that may still need some adjustment.

Traditional acupuncture is primarily about treating the person, not the condition which they have, and to a large extent the work which a practitioner does in aimed at encouraging the body's natural healing ability. An operation is a wound like any other, and we have no doubt that if there has been any slowing down of your natural recovery, it is possible that acupuncture treatment may help that to happen. Such evidence as there is is relatively scarce and not that reliable, since there are a huge number of factors which can affect recovery and identifying a single one for the purposes of research is difficult. There is a paper

http://www.ncbi.nlm.nih.gov/pubmed/12798078

which offers some positive encouragement, though, but for us to claim more than that would need larger studies.

Similarly there is a study which shows an improvement in pain control and sleep through the use of acupuncture

http://www.ncbi.nlm.nih.gov/pubmed/22843248

but again we have to add the same reservations about the size of the trial. However, anecdotally it has been our experience that people do seem to recover more quickly when they have treatment after an operation, and we have a significant number of patients who have acupuncture both just before and after the operations they have to minimise the after-effects of anaesthesia and to aid recovery.

In Chinese medicine, however, every patient is unique, and a practitioner's main aim would be to establish whether there are factors affecting the system as a whole which may be slowing down your recovery. From a Chinese medicine perspective the person with the condition is as important as the condition itself, and twenty people with an identical symptom may have twenty different treatments as well as improving at twenty different rates.

The best advice we can give is to visit a BAcC member local to you to see whether with the benefit of a brief face to face assessment they are able to give you a better idea of whether acupuncture treatment may offer benefits in your particular case.

Q:  I was just wondering if NHS physios are limited by only being able to offer treatments for conditions which are evidence based? 
If so, is the evidence base from NICE guidelines?

A:  This is a very complex issue!
 
To begin with, NICE guidelines are as much about cost-effectiveness as efficacy. It is theoretically possible, for example, that NICE could approve something as a treatment option which the Advertising Standards Authority, through the Committee on Advertising Practice, might not allow to be advertised because it uses a more strict definition of evidence, the randomised double blind control trial. Under this definition of evidence base, only half a dozen or so named conditions can be advertised by a professional acupuncturist, although some of these have not made it through to NICE guidelines because they may not seem to be a cost-effective option for the problems which they address.
 
On the surface, though, NICE guidelines and the shortlist of conditions approved by the ASA/CAP are the working guidelines for evidence base. It is clear, however, that there are degress of evidence, and in the list created by the World Health Organisation
 
http://apps.who.int/medicinedocs/pdf/s4926e/s4926e.pdf
 
there is a sub-division into four categories of evidence of differing degrees of certainty. Within the professional guidelines of regulated bodies it would be possible to make a case, if challenged, for degrees of evidence, and the chiropractors whose websites were turned over three or four years ago certainly sustained this case when taken to the GCC for advertising outside the ASA guidelines.
 
The question of what physios can offer by way of acupuncture treatment falls within this general background. At one stage the Chartered Society of Physiotherapists was very emphatic with the Acupuncture Association of Chartered Physiotherapists that a physio could use acupuncture within their existing scope of practice if and only if there was an evidence base for its effectiveness. The argument was raised, however, that as another tool within the toolbox, i.e. that acupuncture was not an adjunct but a legitimate technique for musculo-skeletal work, acupuncture could be used within the overall scope of physio work even where there were no trials which provided RCT-driven evidence. This made a certain amount of sense. If a physio uses a trigger point or segmental approach to acupuncture, of the kind which is used by doctors who have trained and joined the British Medical Acupuncture Society, then it is in truth a technique like any other which could be used to free up tight muscles or to encourage a greater range of movement.
 
The problem lies in the fact that some training which physios undertake starts to look at the Traditional Chinese medicine protocols for dealing with problems. This in itself is not a problem; the overlap between the points used is East and West is considerable, even when the theoretical basis is entirely different. However, it is quite tempting to extend the range of treatments considered into areas which are more naturally the province of TCM, and there have been courses for physios and other healthcare professionals which have begun to address areas like gynaecological problems and headaches. One could make a case for a musculo-skeletal element in all areas of physical health, but some of the treatment protocols offered in these courses owe a great deal to an eastern understanding of what is happening.
 
Not unsurprisingly some of our members have taken considerable umbrage at what they see as poaching and cherry-picking of elements of TCM. The concern is that like any system of medicine TCM forms a coherent whole in which all aspects of the person have to be considered. Treating on the basis of inadequate knowledge could be less effective, and in extreme cases potentially a high risk activity. This is fuelled by a deeper sense of annoyance that in a recession-driven economy the physios are becoming a direct competitive threat.
 
In reality, this is not the case. Most physios work within the NHS, and are constrained by the rules of evidence base and NICE guidelines. The patients who have acupuncture treatment with a physio are not necessarily likely to set about seeking acupuncture treatment from a professional acupuncturist. In fact, many acupuncture patients seeing BAcC members often have acupuncture as a part of their concurrent physio treatment, and see a very clear distinction between someone who uses it as a technique in specific circumstances and someone who uses it as a full-time professional. There is, however, a small risk that someone who has had treatment from a physio which hasn't worked may conclude that acupuncture doesn't work when in fact it might have done in the hands of someone who uses it as a main treatment, but this would be unverifiable.
 
That said, the BAcC is maintaining a dialogue with the AACP about the use of acupuncture in physio work is extending and potentially expanding beyond the limits of scope of practice. This is not something new. Both bodies were a part of the Acupuncture Stakeholder Group for nearly a decade and were involved in the beginnings of an innovative mapping exercise which would have seen all acupuncture practice in the UK on a single grid. This was an exciting prospect, and would have opened up possibilities for people developing their skills within a coherent framework. However, the exercise was scuppered by some of the minor players in the acupuncture world who took exception to the idea that a degree-level training was the basis for effective independent practice. We hope, though, that this exercise will be resuscitated in the future.
 
As we said, this is a highly complex area for which it is very difficult to give a precise answer, and we hope that we have given you a flavour of the issues involved.