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Q: Is there a minimum number of sessions needed for acupuncture to reduce pain levels in a chronic (symptoms of 6 months or more) TMD sufferer?
How many sessions, as a ballpark figure, would you estimate to be reasonable to achieve reductions in pain levels that would be present 3 months after the last treatment?

A:  We're sorry to say that there is no real answer to this question. From a Chinese medicine perspective each patient is unique and different, which is its very great strength since it individualises treatment. The obverse, of course, is that any symptom needs to be seen in the context of someone's overall balance, and for this reason the answer could be anything from one session to fifty sessions. The same applies to the enduring effect of treatment. In someone who is otherwise healthy (in Chinese medicine terms), a symptom can sometimes go and stay gone. However, if there are constitutional weaknesses it may be necessary to continue to have maintenance treatment every 6 to 10 weeks to maintain progress.

Were you to present at our clinic we would be immediately asking questions about how the problem developed. TMD and related TMJ disorders often have their roots in things like aggressive dentistry or minor accidents which slightly displace the jaw, and this can have a major impact on the assessment and treatment of the problem. However, there is far from general agreement about the causes of the problem, as you will see from any medical advice sites.

Many patients find it very useful to combine acupuncture with cranial osteopathy which can often realign the bones in subtle ways which enable the acupuncture treatment to encourage better functional support in the musculature to retain the re-adjustment. We believe that this would also be a productive line of enquiry.

As far as research is concerned, there is a systematic review of trials which makes encouraging noises, as they often do, with the proviso that more and better research is undertaken.

http://www.ncbi.nlm.nih.gov/pubmed/20401353

You than have a number of individual studies like this one

http://www.ncbi.nlm.nih.gov/pubmed/17095133

which report favourable results but not the detail of how many sessions.

We think the best advice we can give is that you visit a BAcC member local to you who can probably by face to face assessment give you a far better view of how rapidly you might progress and how sustainable that progression might be.

Q: I have a friend who has suffered from Fibromyalgia for more than 7 years. She is willing to try Acupuncture but it will be easier for her to trust an acupuncturist who has experience in treating fibromyalgia.  Can you recommend us someone in London? 

 

A:  We have been asked about fibromyalgia on many occasions, and a recent answer we gave was

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.

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.  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.

Fibromyalgia and other general muscular pains,are becoming more prevalent and it is becoming harder not to recognise that there may well be emotional and mental components to the condition which can have a dramatic effect on how it presents. The advantage of traditional acupuncture is that it treats the person, not the disease label, and that means that the practitioner can look at the case in the round, at all the aspects of someone's problems and lifestyle, to see how the problem has manifested. There are a number of recognised syndromes in Chinese medicine which can generate the kinds of symptoms which people experience, but the real skill and art lies in determining not simply the pattern which this reflects but also its deeper cause. For every person with the same symptoms generated by the same systemic malfunction there may be a different underlying cause. This is why we are so insistent that knowing a few formula points is never enough; it is working out how each unique pattern presents which makes traditional acupuncture so effective.

As we said in the earlier answer, our best advice is to see a BAcC member local to you for an informal assessment of what acupuncture treatment may be able to achieve for you. 

We think that this remains the best advice that we can offer. As far as suitable practitioners are concerned, all of us will have had experience in treating this condition, and are familiar with the challenges which it presents. There are no specialist of whom we are aware, because as is clear from our earlier response our specialism is treating people, not conditions, and we are only looking at expert practice in a very few specific patient groups, like children and pregnant women.

In London your friend will be spoilt for choice; we have over 600 members within Greater London. We recommend using the postcode search facility on our home page, and then to see if any of the local BAcC members is happy to spare a few moments without charge to discuss the possibilities for treatment. This will give your friend a chance to meet the person and see where they work before making a decision, and most of us are happy to do this to ensure that a patient feels confident and relaxed when they come for a first session.

Q:  When I had acupuncture for my permanent headache for the first time it was amazing and completely cured it for about 4 hours.
After that, however,  (17 visits) it never did anything. Other treatments have not even come close to that first time with acupuncture.
I have tried tablets,osteopathy, chiropractor, and many other treatments but none have come close to the first time with acupuncture.
Can you advise me on what if anything that signifies/ or acupuncture to relieve vagal nerve pressure.

A: This is not a frequent occurrence but most practitioners will be able to tell stories of similar outcome. This particular expert remembers treating a patient who had been hospitalised with neuropathy and was taking pethidine and other serious medications. After one session the pains disappeared, but then returned gradually over the next week, and were never amenable to any more change. There  is no agreed explanation for why this should occur. We suspect that the novelty of the intervention combined with the hope and expectation of the patient and practitioner can be a very powerful healing force but one which cannot be sustained. However this happens, it is clear that seventeen sessions is more than enough to establish that the treatment is not likely to work.

We have looked at the available research on vagal nerve stimulation and/or control, and by far the greater proportion involves the use of auricular acupuncture. This is a relatively modern development, as this rather dense but interesting study shows

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3523683/

and there are several others which seem to point to this form of treatment as an option. We think that your best bet may be to contact a practitioner who specialises in this form of treatment. Most of these are gathered on the register of the Complementary and Natural Healthcare Council (CNHC), a voluntary register which is accredited by the Professional Standards Authority and which subsumed the old Acupuncture Microsystems Group. There are thousands of practitioners who use the five point protocols for detox and addiction, but a smaller number who undergo extensive training in this modality. The CNHC register is where you will find most of them.

We wish you all the best. Cold comfort it may be but the fact that the condition could change at all does open the possibility that there may be something which will be able to effect the same sort of change on a more sustainable basis.



:

A: It may sound rather odd to someone brought up within western medicine but there are very few areas of specialism within traditional acupuncture where we would recognised specific skills which someone could learn as a postgraduate option enabling them to claim to be an expert. There are three areas where the specific patient group - children, women in pregnancy and with fertility issues, and people with mental health problems - where we are looking carefully at what defines expert practice. We may eventually decide that working with these groups as a primary focus of treatment does mean that our members can claim to be offering expert practice, but for all other conditions we would regard them as being within the range of skills of all of our members.

This is essentially because Chinese medicine treats the person, not the condition. This viewpoint is not unique to Chinese medicine; the great Canadian physicial William Osler once famously said 'The good physician treats the disease; the great physician treats the patient who has the disease.' Indeed, in ancient China the specialist physician was regarded as an inferior doctor because of his limitations, and the generalist was held in high esteem.  Times change! It does mean that seeing the problem in its overall context is the best form of treatment, not simply applying a formula treatment for the disease label. This is why twenty people with the same western named condition might be treated in twenty different ways, depending on how the condition sat within their overall health picture.

Only for a few serious conditions, such as terminal illnesses or serious degenerative conditions like MND, do we occasionally make recommendations that a prospective patient see someone with greater experience, but that is only because we recognise that it can be overwhelming for a newly qualified practitioner to be dealing with a case which is not going to have a truly positive outcome. Getting worse slower is not the greatest encouragement to the newly qualified.

As far as UC is concerned, if you google the medical databases by using 'ncbi acupuncture ulcerative colitis' you will see a number of studies, mainly from  China, which show encouraging results. However, these are often treated with caution in the West because there are often methodological issues. These are not necessarily defects; the Chinese do not have the western obsession with showing whether it works or not  but rather more focus on the question of what works better. This often undermines its value in western medical eyes. The Chinese have been treating UC and its variants for over 2000 years, though, and its patterns  as understood in Chinese thought are well defined and studied.

The best advice, which we tend to give to all enquirers, is to visit a BAcC member local to you for a brief face to face assessment. This will give a far better idea of what you may be able to expect by way of benefits. Most members  are happy to do this without charge.

Q:  I suffer from cervical spondylosis with radiculopathy in my upper right quadrant and wear and tear in my thoracic and lumbar spine. Suffered badly for years up to this past year finally getting best nerve pain med. Female aged 62, take pregablin Lyrica 100mg x 2 for past 4 months. I was paying for private physio for past year which was working well. Was offered a plate and pins to stabilise neck last year but have defferred as I'm still at work.  I begged for and am getting a nhs course of acupuncture - just a few pins in the  top of head, neck, right thumb and shoulder. Hoped to get off meds which have side effects. 3rd session of acupuncture and I now feel like the pain has come back and the pregablin not working. Is it normal for this reversal to happen or should I cancel? Would you recommend I ask for a new scan of my neck to see if it has got worse?

A: Based on what you have told us we think that it is very unlikely that the acupuncture has caused the reversal of progress which you describe. In traditional acupuncture we do warn people that there can be situations where a chronic condition can sometimes sign off with a flourish, and it is not unknown for a migraine sufferer to have a really bad migraine after a first or second session. However, this tends to be a very good sign that a pattern has been broken and a pathogen expelled, so the effect is short lived. Occasionally after treatment for musculo-skeletal problems the same can occur, and along with osteopaths and chiropractors we do tend to warn people to expect a day or so of disruption. The effect, however, is invariably transient.

There are two possibilities which we can think of. The first is that something has in fact really changed, and that your intuition that a new scan may be appropriate is a good one. We always express this with great care, but it is possible that changes have absolutely no causal relationship with the acupuncture treatment but just happened at the same time. This can sound like evasion of responsibility if not spoken with care, but what we worry about is that people can get distracted into arguments about causation while the problem goes unattended. 

The second is that the treatment itself has not exacerbated the existing problem but generated a few new symptoms in similar areas. Most of the practitioners working in pain clinics are safe and well trained, but they do tend to use what we would call formula acupuncture on the basis of western medical theory. This variant, called western medical acupuncture, can often be applied a little more vigorously and with slightly thicker needles than most traditional acupuncturists would use. This can sometimes generate problems of its own, but we have to say that if this was the case they would start pretty much as soon as the needles had been inserted, not appear gradually over time.

A third possibility is that the acupuncture treatment us having a rather good effect in terms of helping to relieve some of the tension in the muscles of the shoulder and neck, but this has had the unfortunate consequence of allowing slightly greater flexibility in the neck itself which in turn generates a little more pain. We do see this on occasion with backs, where a kind of unhealthy stability is achieved where a lesser problem, chronic muscle ache, is traded off against a more sharp pain like sciatica. It is rare but there are times when succeeding in helping the lesser pain can bring on the worse pain.

We think the best thing to do is to discuss this with the person giving you treatment. This is not a case of wasting anyone's time; this is all about ensuring that you get the best possible treatment for a really unpleasant chronic condition. If there are over-shoots or under-shoots in the treatment, then that is simply a useful guide to getting the balance absolutely right, and your healthcare professionals will welcome the feedback to be able to make the appropriate adjustments or, if need be, decide that another scan may be appropriate.

We hope that you manage to find a good balance of treatment to help you to continue without a plate for as long as possible.   

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