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Q:  I am 37 weeks pregnant and was told this week my baby is in a breech position. I am rhesus negative. I've heard that it's not a good idea with my blood type. Surely this is a natural process as to whether the baby decides to move or not. It's not like the cpv procedure that forces the baby to move.  I'm booked into see an acupuncturist and she said she had not heard about this.

A:  As we are sure that you know from your own research, the use of acupuncture and moxibustion, mainly the latter, for breech presentation is well documented. The technique has been used in Chinese medicine for thousands of years, and involves the use of moxa, a smouldering herb, on a specific point on the foot. If the treatment is performed around the 33rd or 34th week of the pregnancy there is a significant amount of evidence which seems to show that the treatment works. Indeed, if you google acupuncture/moxibustion and breech presentation, you will find at least a dozen reasonably well constructed trials which appear to confirm this.
 
Of course, one of the factors which you have to take into account is that many babies spontaneously fall into the correct position after the 35th week anyway, so one has to take this into account in assessing the efficacy of the treatment. However, the technique is now being used by other healthcare professionals, and while we do not endorse the cherry-picking of our work, this is something of an empirical treatment, i.e. it works because it works, and this expert has never heard a conclusive argument for why this specific point should have this effect which would mean that its use was only legitimate in the hands of a professional acupuncturist.
 
However, when we look at your question small but significant alarm bells ring. 37 weeks is at the very end of the range of possibilities for this treatment working. At this point the baby is usually too large to encourage this movement. That said, many women, with the approval and encouragement of their midwives and obstetricians, try the treatment in order to head off a C-section. In your case, however, the Rhesus negative factor becomes slightly more crucial. We always advise members to speak to the medical team in charge of the pregnancy if someone is Rhesus negative. This is one of a number of conditions which we believe warrant additional care. In this case, if the treatment does encourage vigorous movement and a minor bleed, there could be serious consequences for the baby. A practitioner needs to know whether the woman has been given anti-D treatment, less likely on a first pregnancy but still possible, and also whether the risk assessment made by the obstetric team favours the use of the technique. If the midwife or consultant advises against it, that's the end of the discussion.
 
We are a little surprised that this is news to the practitioner. If she is a BAcC member, not only is the advice printed in or Guide to Safe Practice and also on our members' website, but it also forms a part of the training which all entrants have. If she is not a BAcC member, we are sure that most of the reputable professional associations take the same view. The increase in risk is sufficient to warrant conversation with the obstetric team.
 
We have had some lively and vigorous debates inside the profession about some aspects of treating late stage pregnancy, and the question of whether we are intervening to make something happen that otherwise would not or whether we are simply encouraging a natural process is a vexed one. Sometimes it is important to be clear what one is actually trying to achieve, and many practitioners regard themselves as simply trying to encourage a natural process, which is generally how we perceive what we are doing. This line can get a little blurry when people start to talk about induction by acupuncture because the very use of an imported conventional term implies a level of direct causation, not simply a speeding up of a 'stuck' rhythm. There are also a number of points whose use is expressly forbidden during pregnancy because they can cause serious problems, so not all treatment can be perceived as 'helping nature along'.
 
We would put this treatment in that same category, as something which is done with a specific and predictable effect in mind, this time for the benefit of the patient. If doing 'x' causes 'y', then it is crucial to ask oneself what might go wrong if the desired effect takes place. We would be reassured to know that either you or the acupuncturist has contacted your midwife or obstetrician to get advice and clearance for the use of this treatment, and if they say 'go ahead' we wish you every success and in any event, a trouble-free delivery!  
 

A:  In the case of treatment for tinnitus, we have expressed some reservations about how responsive to acupuncture the condition can be, and we have reproduced below our last answer which addressed this problem:

Can acupuncture help with severe tinnitus?

As you can imagine, we have been asked this question on several occasions, and our replies have not been that encouraging. The fact sheet which we have on the website
 
http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/tinnitus.html
 
is quite upbeat about a number of small studies, but our clinical experience is not as good, with tinnitus among the more intractable conditions with which patients present. In a recent answer, to which we can probably not add a great deal more, we said:


 A. Tinnitus is one of the more intractable conditions which people seek acupuncture treatment for. Our Tinnitus fact sheet, found at lists a small amount of research which suggests that acupuncture may help, but there have been no significant trials which provide solid evidence. It is also fair to say that many practitioners are very cautious about taking on patients for whom tinnitus is the primary problem. It is quite easy to spend considerable time and money and be no better off than when you started, and the individual case reports in the tinnitus sufferers' magazines often have the same shape.

However, what many practitioners do find when treating people with tinnitus is that while the noise remains largely unchanged their ability to cope with it seems to improve. Evidence for this is largely anecdotal, though, and it would be wise to discuss carefully with any future practitioner whether they think that they might be able to help. In all events we would recommend that frequent and regular reviews of outcomes and progress are essential.

We don't think you can say more than this. There are two or three clearly identifiable patterns in Chinese medicine, described as syndromes, where tinnitus is a specific named symptom which frequently appears, and it is possible, if your tinnitus has arisen as a part of the syndrome, that there may be some help which acupuncture treatment may offer. An experienced practitioner should be able to make a very straightforward determination on whether this is the case. Overall, however, there is not a great deal of cause for optimism about getting rid of the unwanted

A: We are happy to say that the majority of health insurers are now happy to fund acupuncture treatment. The fact that NICE (the National Institute for Clinical Excellence) has now included acupuncture as a treatment of choice for chronic low back pain has also meant that some policies which were more restricted in cover have now accepted acupuncture treatment as an option.

We are still mid-negotiation with BUPA and AXA/PPP, the two major insurers who have until now not accepted BAcC members as traditional acupuncture providers, but restricted their cover to acupuncture provided by members of the British Medical Acupuncture Society or statutorily regulated healthcare professionals. Their criteria for acceptance even of these are quite strict, and many doctors do not meet them. However, BUPA are on the verge of accepting BAcC members as eligible providers, and we are hoping that where they lead, AXA/PPP will follow.

The majority of insurance providers, as we said, are more than happy to cover acupuncture treatment to a certain limit. Where there has been any reluctance we have known patients to win ad hominem concessions with the threat of taking their business elsewhere, but we always counsel caution to our patients considering this as an option, because if the company calls their bluff and they have to find a new insurer, many policy providers will not take on pre-existing conditions. If someone has a long history of claims for a chronic problem, the last thing they want to do is undermine their cover by going elsewhere. 

A:  The short answer, we are afraid to say, is not unless you wait for four months after the last treatment. We published the statement below on this again recently in response to requests from members of the public for an up-to-date position:
 

Blood donation current status June 2013

Date: Friday, 21 June 2013 12:42
The BAcC continues to receive calls and emails about the NHBTS policy that any patient who has had acupuncture treatment delivered by a practitioner who is not statutorily regulated has to wait four months before they can donate blood. This change to the NHSBT's donor criteria came into effect in late 2009,and with the statutory regulation of acupuncturists now unlikely in the foreseeable future, this could mean that someone having regular treatment with a BAcC member would never qualify to donate blood.
 
The BAcC has exemplary safety standards and campaigned vigorously to challenge this decision. We have since done our best to make sure that all of our members let their patients know that they must wait four months to donate blood or bone marrow products.
 
The official notification and rationale for the decision is available onhttp://www.transfusionguidelines.org/docs/pdfs/dl_change_note_2009_32.pdf andhttp://www.transfusionguidelines.org/docs/pdfs/dl_change_note_2009_33.pdf but some enquirers have found this difficult to locate on official sites.
 
The BAcC is fully committed to reversing this decision for the benefit of the patients of its members. The recent accreditation of the BAcC under the Professional Standards Authority Assured Voluntary Register scheme has given us hope that this new flagship scheme will provide the recognition of exemplary standards the BAcC needs for its members to be granted exemption from the deferral period for donation.
 
Since then, we have met senior officials in the NHBTS, and discussed with them how we might help to re-instate the donation of blood by non-statutorily regulated healthcare profesisonals, there having been no reported instances of blood borne virus transmission by acupuncture practitioners in the last decade. In order to change policy, however, there has to be evidence, and the NHBTS is proposing to conduct an analysis of previous screened donors to establish the level of risk. This study will take place later this year or early this year.
 
The wheels of bureaucracy turn slowly, and until that time anyone who has had acupuncture treatment from a BAcC member will have to wait four months until they are allowed to give blood.
 
We are sorry that many thousands of donors have been 'disenfranchised' by this change of policy and are working our hardest to bring them back within the list of eligible donors. 

A: We were asked a question about nocturnal bedwetting some time ago, and answered:

There is some evidence that acupuncture may be of benefit in treating bedwetting in children

http://www.ncbi.nlm.nih.gov/pubmed/15791606

but as is the case with a great deal of the research which is conducted in China, it often falls below the standards required for acceptance in the west. Invariably authors of systematic reviews such as this will make generally encouraging noise about meriting further research, but until and unless major funding is provided for such studies the evidence will remain thin.

However, Chinese medicine has been dealing with problems such as this for over two thousand years, and operates from an entirely different theoretical base in understanding how the body functions. This is expressed in the concept of energy, 'qi', and its balance in and flow around the body, and uses concepts such as 'yin' and 'yang' which we're sure you've come across. There will be a number of ways of understanding the balance of the functional relationships in the body which might explain the symptoms, and the practitioner's skill is used to ensure that the treatment not only resolves the symptom but tries to deal with underlying patterns of imbalance to stop their recurrence.

One note of caution is that although we do not recognise 'experts' in treating particular diseases or patient groups, there is no doubt that children are not simply 'little adults', and the consensus is emerging that some of the diagnostic conclusions and ways of treating are slightly different from the adult versions of the same problems. A growing number of members now seek postgraduate training in paediatric acupuncture, and while we would not say that someone without this training may not be able to help you, we believe that we are fast approaching the point where we say to a prospective patient that we would expect someone who focuses their work on children to have made the effort to undertake further study, be it in the form of a course or a programme of self-study.

Our best advice is to ask a BAcC member local to you whether they or someone they know focuses their work on treating children, and failing that to use 'google' and search under 'acupunture treatment of children' alongside where you live. Many of our members now have their own websites, and usually mention their areas of primary focus (children, pregnancy and fertility, if they have them.

However, most of the research and discussion is about nocturnal wetting, not daytime wetting. In theory, from a Chinese medicine perspective the factors in play would be understood in a similar kind of way. The inability to hold back the flow of water, or to be unconscious of its passing, is evidence of a functional disturbance, and a practitioner will look carefully at the whole system to see what is driving this. The daytime nature does also open up the possibility that there is an emotional component. Here again, acupuncture treatment may be of value, and the standard textbook on the treatment of children with acupuncture lists a number of emotional problems which the authors believe are susceptible to treatment. However, as Clint Eastwood was wont to say in his movies, 'a man has got to know his limitations', and the counselling of children is an expert skill which would not form a normal part of a practitioner's training. The wise practitioner will refer on if they feel this is out of their depth.

Subject to these caveats, though, children, when they respond to treatment, do seem to respond very well, so if one of our members believes that acupuncture may be of benefit, there is some hope that they may well be able to help.