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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. 
 
 

Q:  Can acupuncture help with macular degeneration? I have an elderly relative who believes there has been some recent research but I cannot find it. I am concerned that she may be asked to pay a considerable amount with little evidence of it working, but we are both very open to alternative medicine. She lives in Cambridge

A:We conducted a search and the best we could come up with

http://www.ncbi.nlm.nih.gov/pubmed/21355157

a study in Chinese which appears to demonstrate that acupuncture out-performs conventional medical treatment. Otherwise the only direct reference is a Cochrane Review summary which identifies the fact that there is a systematic review or similar on their files as pending

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1705651/

With conditions like this there are a number of difficulties involved in answering the 'does acupuncture work?' question. From a Chinese medicine perspective, although twenty patients may have the same named western condition there could be twenty different treatments. The symptom from this perspective is merely the weak link where an overall imbalance tips something into poor or degenerating function, and although local treatment could achieve some useful short term gains, helping to improve the underlying balance is the key to getting well and staying well. This involves treating the person as much as treating the disease.

Conditions like this can often become unintentional money pits, and it is easy to build up a treatment habit based more on hope than experience. Practitioners are often inclined to fall into the same trap in pursuit of better health for their patients. The best positive result one might achieve could be a decrease in the extent of deterioration, or as one patient put it once, 'do you know, I think I'm getting worse slower'. Of course, this is unverifiable and largely unmeasurable, but there is no doubt that many patients have reported anecdotally that they have exceeded the expectations of their clinicians in maintaining reasonable function longer than anticipated. Naturally there are a great many other factors which make this possible, not least of which is that seeking complementary treatment is itself evidence of a determination to do something which is probably reflected in someone's overall health.

From a Chinese medicine perspective the eyes as a functional unit have close relationships with two or three major Organs (capitalised to differentiate them from the western concept of an organ) and if there is evidence of a generalised weakness in relevant related Organic functions, a practitioner might think that there is some hope that treatment may be of value. There is also plenty of discussion in Chinese texts about local needling and its potential to halt or even slightly reverse decline.

We have to be realistic, though. The kind of deterioration which this condition causes is well-documented as likely to continue, and it would be a foolish practitioner who tried to instil too much optimism in a prospective patient about the chances of major improvement. However, it is always worth while talking to a BAcC member local to you, and there are some very good ones in Cambridge, who we are sure will be only to happy to give you advice on the basis of a brief face to face assessment of your mother's situation.

Q:  I am researching UK journal papers and information on the risk associated with pneumothorax and acupuncture. This does not seem to be well documented in the UK.   I would very much appreciate it if you could suggest some UK studies or documentation which would be useful.

I'm pleased to say that the reason that there is not a great deal of documentation is that pneumothorax after acupuncture treatment is very rare. There are on average about 3.5 million treatments a year administered by traditional acupuncturists, doctors and physios (BMAS and AACP members) and we hear of a case perhaps once every two or three years. There was a prevailing myth that the commonest cause of pneumothorax was acupuncture treatment, and we commissioned a researcher to call all the A and E units in London, all of whom responded that this was patently untrue. Urban myth, I'm afraid.

The sorts of searches you will have undertaken will have thrown up references to the two main safety studies by MacPherson of the BAcC and White of the BMAS, which reported no serious adverse events, and you will also have come across wider studies by White and Ernst, which also report very little. Ernst has been a very stern critic of the traditional acupuncture profession, and his studies of adverse events can be assumed to be as accurate as it is possible to imagine (anyone who includes a case of cardiac tamponade by a women self-treating with a knitting needles as an adverse event of acupuncture can be safely assumed to be as inclusive as it is possible to be).

The WHO report on adverse events also makes it clear that there are few cases of pneumothorax, and if you use the search mechanism 'ncbi acupuncture pneumothorax' in google you will generate a number of single case studies, these being all that there are.

There was a report two years ago about acupuncture being performed within the National Health Service which painted a somewhat darker picture, with a great many more serious adverse events than those reported amongst professional acupuncturist (,Wheway J, Agbabiaka TB, Ernst E. Patient safety incidents from acupuncture treatments: A review of reports to the National Patient Safety Agency. The International Journal of Risk and Safety in Medicine. Published online September 4 2012. This, however, just bears out our conviction that a properly trained and qualified acupuncturist is remarkably safe, and that it is only in the hands of the poorly trained or incompetent that problems arise. This is why, in spite of the fact that acupuncture is very safe and modern statutory regulation is all about reducing risk and safeguarding the public, we continue to campaign for the statutory regulation of acupuncture to stop people 'having a go' without the proper training.

The main cautions for treatment the elderly, the frail or those with a history of repeated respiratory problems, is to needle to a very shallow depth at an oblique angle, and even in the fit and healthy the same rules apply for all points on the thorax, and especially on the shoulder between the clavicle and the scapula where the dome of the lung rises much higher than many people think.