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Q:  My son has a diagnosis of CPRS due to presumed ( imaging shows no other damage) nerve damage around the left ankle area following a football tackle. 10 months on the pain has not responded to NSAIDs, gabapentin or amitriptyline and a nerve block seems to have resolved little. Mobility remains impaired despite daily physio which is limited by the pain. Any thoughts or suggestions as to potential from accupuncture. His pain team say there is little positive experience in this area and given his localised neuropathic type pain, the chances of getting near him with needles makes it probably a non starter. I wondered whether local anaesthetic prior to needle insertion is possible?

A: If we can unpick your question accurately, against a backdrop of severe chronic pain for which no visible damage can be found and which does not respond to conventional treatment, the questions are first, whether acupuncture is worth trying, i.e. what level of evidence, if any, is there that it might work, and second, would the fact that your son is now hyper-sensitised, whether anyone could actually get needles in or near the affected area.

As far as the first question is concerned, there has been a long history into the use of acupuncture for chronic pain. Our website is down at the moment, or we would have posted an up to date reference to a fact sheet which can be found on the home page by following buttons to research and beyond. This identifies many studies which have been conducted over the years. The measures both for pain and natural pain relievers in the form of neurotransmitters are easily measured, and there have been dozens of studies which show that acupuncture can have an effect on pain. The usual question is not whether but how much and how sustainable the effect.

However, this takes us down a very western-medical route. Chinese medicine understood pain as the consequence of changes in the flows of energy through an area, either through injury or blockage or through systemic weakness. Often there is an overlay, where a systemic weakness predisposes to injury, but in the case of injury it is not uncommon for us to find a weakness in the flow which has no specific correlate in conventional medicine. This is why, often as the treatment of last resort, we have successes where the problem has not even been properly identified. However, each person is unique and different, and your best option would be to take your son to a BAcC member local to you for an informal assessment of what may be possible. Most of our colleagues are happy to give up a little time without charge to establish whether treatment would be advisable or beneficial.

As far as the needles are concerned, they are minimally painful, but we have come across situations where even the gentlest insertion was too much to bear. The beauty of the Chinese medicine system is that the complex interconnections mean that we have strategies for dealing with situations just like this. Received wisdom, for example, is that you never treat a limb where lymph nodes have been stripped, and it is not uncommon to treat the opposite limb or in some cases, the opposite lower limb. This can be very handy where someone is in a cast. The different points have resonance with each other, and even in mainstream treatment there are times when one uses points far away from the actual site of the problem. Any well trained practitioner should be versatile enough to deal with this kind of problem and provide direct treatment from a

Q: I have pcos and persistent rhinitis. I have had acupuncture by two practitioners. One hurt me, I  lost sensation in my head and collapsed when i got off the couch. The other was much kinder, helpful and caring but I felt that i wasn't getting any benefit after 4 months of weekly treatments. How many treatments should I require to notice some difference? I know it depends on the condition and severity but 16 sessions and no difference?

A:As you say, this is getting to be a substantial investment in time and money, and you need to know whether this is actually heading somewhere or has just become a kind of 'treatment habit.'

As you say, these can both be very stubborn conditions. With long term chronic problems it is often quite difficult to establish an analogue scale of improvement. With acutes it is far easier: 'how many out of 10 is your pain now?' With chronic conditions this is often trickier. One of our Japanese colleagues once remarked that if someone tells you they are 10% better, they're just telling you that you are a nice person and keep trying.

The best that one can do is to maintain a regular review, usually every four or five sessions, and to share with a patient the findings from a Chinese medicine perspective. There are a number of occasions where changes in the tongue and pulse can be quite radical without having yet filtered through into changes in the main conditions. If a practitioner is sure that there is progress they need to share this with the patient. It is also important to try to set measurable outcomes, difficult as this can sometimes be. It is very easy to be unable to say what happened last week, and with both problems there are usually some symptoms whose appearance can be charted. This can help to establish just how many episodes there have been and whether there has been a change.

If nothing happens, then there are a number of options. One is for the practitioner to seek a consultation with a colleague present or refer to someone else just to have a fresh pair of eyes looking at the case. Occasionally, though, it just has to be agreed that treatment isn't working, and the practitioner is usually in a good position to suggest alternative treatments which may help. Chinese Herbal medicine is often used alongside acupuncture to good effect, and although homeopathy has had a run of really bad press in recent years, this expert has several patients who have used homeopathy to treat both acute and chronic rhinitis when acupuncture hasn't done the trick (and stayed with acupuncture for other conditions).

The best person to address your concerns is your practitioner, however. None of us minds being asked about the benefits of treatment when results are slow in coming, and sometimes it marks a good time to call it a day. Good communication sidesteps many of the problems which can otherwise emerge.

Q:  This question is not strictly related to acupuncture, but i couldn't find answers anywhere else so I'm hoping an expert here could help me. Last week I accidentally punctured the palm of my hand with a large thumb tack by putting my weight on the desk when standing,  not realising the was an upturned pin under where I put my hand. It was a shock to say the least but the pain subsided quickly after I pulled the pin out. There was very little blood but my ring finger did twitch and my forearm felt tingly. Now a week on I am still feeling uncomfortable sensations in my ring finger, like a tightness and slight pain. The pin went in about two inches below the base of my ring finger. I should mention also that about a year ago I accidentally sliced open my hand about 1 inch below my ring finger and pinky. At the time I had it glued with butterfly stitches. There was no remaining pain once the slight swelling etc had gone down.

A: We're sorry to hear what has happened to you.

As you say, it isn't an acupuncture-related injury, but if we did have a patient report of similar response to an acupuncture needle, we would probably say that the reason for the continuing pain is most likely to be from deep bruising which has caused a clot to form and which is pressing on the nerve, replicating the pains you felt when the accident first happened. If this is the case, then it will clear within a fortnight or so with a gradual reduction in the unpleasant sensations.

It is possible that there has been some damage to the nerve itself, or any one of several nerves which traverse the area, and the outcome here may be a little more difficult to predict. We have certainly come across one case where a direct hit on a nerve generated unpleasant sensations for a number of months. However, this would be very rare, and if the symptoms continue with the same level of intensity thrughout the next fortnight, or even become a bit worse, then you will need to see your GP to get a referral to a neurologist. There may be no harm in seeing your GP early anyway; waiting list medicine sometimes demands that people try to get themselves on the treadmill sooner rather than later. If your GP has on inspection any reason to suspect nerve damage, then an early referral is a good idea.

On the balance of probabilities, though, the symptoms should begin to subside during this week.

As an aside, there are a number of powerful acupuncture points on the palm of the hand, and you may have given yourself an unwitting treatment. Two of the major channels travel where you report symptoms, but the chances that they would resonate for this long are very small. Not the nicest way to have acupuncture treatment either!

Q:  I have been diagnosed with Menieres disease which affects my right ear. I also get regular migraines which solmatriptan doesn't relieve. Since I believe both to be associated with restricted blood flow to the head, I'm wondering if acupuncture could help?

A: We have published a factsheet on migraines

which possibly does not so justice to the fact that these form one of the more common reasons why people turn to acupuncture treatment for relief. The research is not as good as it could be, and there are a number of reasons for this to do with trial design and identifying control groups. Suffice it to say that with the NICE guidelines now recommending acupuncture for the closely related problem of cluster headaches, there is increasing evidence that acupuncture treatment may well be of benefit.

Certainly this 'expert' believes that this is one of the conditions for which it is possible from the outset to be confident of some positive change. The challenge is making sure that people continue treatment after the migraines have become less frequent to ensure that they stay away. Again, this expert's experience is that it often takes regular maintenance treatment for a while longer than simply getting rid of the symptoms. Ideally people will keep on having maintenance treatment anyway, whatever the initial problem, but in this particular it does seem to be more advantageous.

We have again covered Meniere's disease in our factsheet on vertigo

and generally speaking the evidence is encouraging. In a response to a query about the condition some time ago we said

However, as the systematic review cited says

the majority of studies were generally comparing standard treatments with treatments plus acupuncture, and the model most respected and accepted in the West usually compares treatment with something which appears to be treatment, so called 'sham acupuncture' to assess whether the acupuncture really does work. As such, there is always some reluctance to accept results which are from more pragmatic trials. There is also often an unwarranted suspicion about the objectivity of trials and studies from China. The assumption is often made that because acupuncture is already an accepted part of the healthcare system there may be bias towards finding that acupuncture works, and there is no doubt that earlier trials were less interested in 'does it work?' than 'which treatment works better?'. However, times have changed, and the Chinese are as determined as anyone else to assess efficacy, and furthermore have the numbers of patients available to run meaningful trials very efficiently.

That said, we must always come back to the fact that this is Chinese medicine we are discussing, not the treatment of western diseases with Chinese techniques. There are ways of differentiating the symptoms which we call Meniere's disease into several different patterns or syndromes within Chinese medicine, and the treatment which someone would receive would take this into account as well as taking into account the underlying constitutional balance of the person as well. This itself will have a significant bearing on how well treatment may work. The skill of the practitioner lies in making sense of specific symptoms using an entirely different conceptual framework which takes into account how this symptom squares with other aspects of someone's health, and also checks whether the problem is systemic and to do with the internal functions of the body or, as is sometimes the case, a case of local blockage and stagnation, two concepts which reflect that fact that good health is premised on a proper flow of energies throughout the system.

Our best advice is to contact a BAcC member local to you and seek their advice on whether acupuncture treatment may benefit your particular presentation. We are confident that they will give you an honest assessment and if they believe acupuncture is not the best option they will direct you to other forms of treatment.

and we think that this remains good advice on all levels, especially the need to contact someone to discuss directly with them whether acupuncture might be beneficial.

We don't have specialists for conditions such as this. We suppose you could say that from our perspective all of our members are specialists in traditional acupuncture. The skill lies not in treating the condition but in treating the person who has the condition, i.e. establishing why this particular patient has this particular problem. You can be reassured that all practitioners will have treatment many similar cases of headache and balance problem, and be familiar with making sense of the way that these conditions are frequently generated within the system.

There is absolutely no doubt that this has become a very popular and recent extension to traditional acupuncture practice; many BAcC members undertake postgraduate training in the techniques, some of which are not a part of mainstream acupuncture training, and openly advertise this as an extension of their work. 'Rejuvenation' is not an acceptable term any longer; you would need much more rigorous evidence to meet the current ASA standards for advertisers. Most people describe their work as 'cosmetic acupuncture' or simply 'facial acupuncture.'

Q:  Popularity brings challenges, and this field has also become something of a lucrative sideline within the beauty business. This has meant the entry into the business of people who have trained only in this aspect of the work, and we have two major reservations about this. First is that no-one can be properly and effectively trained in the safe and hygienic practice of acupuncture in the course of a weekend training programme. From our perspective it matters not whether the practitioner uses ten needles a year or ten thousand needles a year, the standards remain the same. Our concern, as always, is that an amateur in what is a professional field does something wrong, and we can guarantee that the headline will say 'acupuncturist does.....'. No point in us quibbling about levels of training, the damage will have been done. When you think that this technique may be used by people in the public eye, the possibilities for a PR disaster are considerable.

More importantly, though, there is ino separate field of 'facial acupuncture'. There are simply the techniques of traditional acupuncture applied to a specific area, and these techniques will only be effective to the extent that the practitioner takes into account the systemic problems against which the facial problems occur. The most irritating thing from our perspective is that acupuncture used without an understanding of the wider system will most often not work very well, and we believe that a porr experience, where acupuncture treatment seems not to work, will turn someone away from a system which properly applied could do a great deal not just for the face but for the rest of the person too.

Our advice is that if you are looking for someone to provide this form of treatment, be sure to go to someone who also uses traditional acupuncture as a main profession. That is your best chance, in our view, of optimising your investment in time and money. We would also advise you to shop around. In the view of this expert, this has become something of a 'cash cow' for some practitioners who price themselves according to the beauty market in which the treatment is offered. Whilst we would recognise the value of postgraduate training and experience, it is after only only traditional acupuncture applied in a specific area, and the gap between someone's ordinary charges and this form of treatment should not be too great.