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Q: How do acupuncturist find the right place to treat since there are many meridians and combinations of meridians that could treat a problem?

A:   This question highlights the central difference between conventional medicine and traditional Chinese medicine. We are very used in the West to the idea that the work of diagnosis is rather like the forensic work of a policeman and lawyer, gathering evidence and sifting facts. This comes to a single conclusion which explains what is going on and then provides a set tariff of treatments which have to be followed one after another, like NICE guidelines. The TV series House starring Hugh Laurie was/is a great example of this, where the tortured genius lets the observed facts and diagnostic test results mould into a unique and brilliantly presented conclusion.

By contrast, Chinese medicine is inherently pluralistic. At various times during its 2500 year history there have been innovations which at some levels have contradicted the mainstream theories, but as long as they worked in well-defined conditions they were retained as another string to the practitioner's bow. A modern practitioner of Chinese acupuncture might employ TCM, the rather skeletal and simplified framework first written down in the 1950s as a system, or Five Element Acupuncture which is rooted in the classics but developed heavily in France and Japan, or Stems and Branches, a numerologically based system which has existed for over 2000 years, or Japanese Meridian Therapy which, designed with blind apprentice-trained practitioners in mind has a huge palapatory bias, and so on. Each of these systems has ways of working with the whole which are a mixture of the same root understanding of the core energetics of the body mind and spirit, and a heuristic framework which allows scope for the skill and art of the practitioner. Each of the variations, and in the modern practitioner these might all find their way to the diagnostic mix they employ, offers a way of bringing balance back to the whole.

The question for each practitioner is really what is the most elegant and effective way with the least intervention to achieve overall balance. Because of the nature of the interaction between patient and practitioner concepts like 'intention' and 'rapport' can play a part in the diagnostic and treatment choices, and in many ways each practitioner may generate a different solution to how best to treat a single patient. There may well be common agreement about the main features of a case, but each practitioner may favour a slightly different strategy for dealing with the information.

You can see immediately why such a flexible system is often derided in the West as nothing more than a placebo, especially since the practitioner's extraordinary range of choices and personal involvement in the process lend themselves to the pejorative interpretation that no-one has 'an answer' and that it is the 'will' of the practitioner which conditions the patients to improve.  This is sad, because in nearly every other form of skillful endeavour it is readily accepted that an overall goal or aim can be achieved in many different ways, like putting a destination in google maps and seeing four choices emerge. With a complex organism like a human being it seems perverse to say that this and this alone is the problem, and this the solution, when we all realise that most problems cascade more widely than the simple origin.

Anyway, to return to your original question, even if two practitioners agreed on a diagnosis they might each find different ways of effecting change. Such is the vast number of interconnections between the different channels, there are often dozens of ways to influence the internal Organs, or to have an effect on a specific part of the body. This can be a valuable resource in itself; if a woman has had a mastectomy with lymph nodes stripped and can no longer be needled on the arm, then it is always possible to find ways of treating the lower limb to 'reach' the affected area. The same applies to treatment of a limb encased in plaster; needling the equivalent points on the other limb can have a major impact.

In short, the system is such that there are dozens of variations in the diagnostic systems, and dozens of possibilities within each system, for achieving the same results. They are all based on the same understanding of the channel systems and the same location of the points (broadly speaking - some of the Japanese systems pay more attention to blockages which are where you find them!), but each system will use a slightly different understanding of the these shared resources to effect change. We often used to refer to this phenomenon as 'unity in diversity', the sharing of a tradition founded on the same underlying principles but showing the inherent strength of something which has developed in different strands for over 2500 years.     

 

Q:  During a normal acupuncture session, when a needle is inserted into  the face of a person, does the needle actually touch the bone or does the needle simply pierce the skin?

A: In theory, the needle should only pierce the skin and enter soft tissue or muscle. If the skin and tissue is very thin at the point where the needle is inserted, then the usual technique is to adopt a very shallow oblique angle of insertion rather than a near perpendicular one. This avoids the needle having so little of its shaft inserted that it starts to bend over with the weight of the shaft and handle. An alternative is to switch to a shorter and considerably lighter needle.

However, there are no guarantees that a practitioner will not accidentally touch the bone in cases where they have inserted a needle a little too far. This may be a little painful for the patient, but the greater potential for harm lies in the fact that the tip of the needle is likely to be deformed and will cause slight tears in the tissue when it is removed. This might then lead to a small amount of pain and bruising.

However, there are no case reports of which we are aware, certainly in the UK, of any damage being done to facial bone as a consequence of acupuncture treatment, or that if done this can have long term consequences. If you are wondering this because of what has happened during your own treatment, then you should ask the practitioner to explain what they did, and ask them to consider whether this was possibly what happened. A reputable practitioner will take the matter seriously and give your question the time of day. 

You should bear in mind, though, that there are a number of sensations which can be caused by needles when they are inserted which feel like a very dull ache and can sometimes be mistaken for a more 'solid' feeling than is the case. This is particularly so with one called 'deqi' by the Chinese which is often experienced as a very dull ache and feels on occasion like something has been knocked into.

 

 We tend not to use the word 'cure' for a number of reasons, one of which is that there are many conditions where acupuncture treatment may help reduce the symptoms considerably, but long term sustainable change may require some significant lifestyle changes by the patient themselves. The greater majority of cases of intermittent claudication have their basis in atherosclerosis of the arterial circulation, especially in the lower limb. This is the formation of a plaque-like coating, mainly brought about by diet and lifestyle, which impairs the circulation when additional demands are placed on the limb. Alcohol, tobacco and fatty foods are often a contributory factor, and a practitioner treating someone with intermittent claudication may well encourage the patient to cut down on all three.

As far as research is concerned, there is surprisingly little. We managed to find a small number of what are called 'case studies', interesting one-off patients with the problem for whom acupuncture has proved successful, but these are unreliable to source as evidence. With only one case to look at you cannot exclude all of the other possible reasons why the problem might have gone away, and having acupuncture might just have been a coincidence.

To look at the possible benefit of acupuncture treatment, we have to go back to basics about what Chinese Medicine is and does. It is based on a theory of energy, called 'qi' (pronounced 'chee') and its balance and flow throughout the body. To put it very simplistically, pain and discomfort only arise where the flow is blocked, or where there is a deficiency or an excess in one of the well-defined pathways, called meridians, where the energy flows. A Chinese medicine practitioner would want to find out where the pains are, what they feel like (burning, dull, etc), what makes them better or worse, and so on, not that different from what a conventional medical practitioner might ask. From a Chinese medicine perspective, though, there is an important distinction between where a pain arises and what may be causing it. The practitioner will always look at the whole system to assess whether this is a local problem or a problem which has arisen against a backdrop of a generalised weakness of flow. If it is the latter, then treating the system as a whole is essential; treating the symptom alone will buy a little short term relief but then it may well recur.

The major question mark is the extent to which the problem has developed. The conventional treatment of exercise or drugs are often used to reduce the severity of the problem, but if it has reached a level where angioplasty, the surgical widening of the arteries, is necessary, then we would be a little less optimistic about how effective acupuncture treatment may be. We would certainly not recommend it as an alternative if surgery is the route your doctor advises.

You best bet, and our best advice, is to visit a BAcC member local to you to see a brief face to face assessment of what they think acupuncture treatment may be able to offer. This is going to be a great deal more informative than anything we can say here, and will take into account your specific circumstances. Most members are only too happy to give up a little time without charge to ensure that a prospective patient can make an informed choice about treatment.

Our only advice would be, if you go ahead with treatment, to make sure that agree specific review periods to assess whether treatment is working, and also to try to identify measurable outcomes - distances covered, etc etc. Our experience of treating patients with symptoms like these is that it can be quite hard to tell whether the treatment is working, because when it hurts it hurts, without having some externally referenced marker to check against.

 

 A:  The BAcC decided many years ago that 16 years old was the age of consent for treatment in line with most conventional medical procedures. This means that the young person would neither have to seek parental consent for treatment nor have to have a parent or guardian in the room while treatment took place.

However, a certain amount of common sense has to be applied. The laws on consent and the presence of a parent or guardian are there to protect the vulnerable, and although most 16 year olds are quite clearly capable of giving consent there are a number whom it would be not unreasonable to describe as vulnerable. In such cases we always advise practitioners to tread with caution, and if they have any reservations to discuss with the prospective 16 year old patient whether it might be a good idea to have someone else present while the treatment takes place.

Our role is to protect patient and practitioner alike, and we seek to avoid situations where a practitioner's normal working practices, like palpating areas of the body or limbs, might not be fully understood and potentially misinterpreted in a less than positive way. 

 

 Q:  My mum (74 and very active) has a leg ulcer on her right outer ankle and is in a lot of pain, taking constant paracetamol and ibuprofen. Is there any evidence acupuncture can help? 

A: We were asked a similar question last year and the advice we gave then was:

It depends a great deal on whether you are asking about treatment for the pain from the ulcer or for the ulcer itself.  As far as the treatment of ulcers themselves is concerned, there are a number of techniques within Chinese medicine for dealing directly with ulcers but these are often quite rough and ready, using a great deal of local needling and the technique of moxibustion. While this is a common approach in China, in the west it is highly likely that someone with a chronic ulcer is being treated according to protocols which involve frequent dressing changes and removal of the fluids gathering in the ulcer, and we would be reluctant to advise anyone to mix and match the two forms of treatment. However, in Chinese medicine theory ulcers are understood in a number of ways which might make treatment at a distance from the ulcer site possible, and in more general terms still, Chinese medicine was and is primarily concerned with re-establishing balance in the whole system in the belief that a system in balance is better equipped to right itself. On this basis it may well be possible to speed up the pace of recovery.
 
As far as pain relief is concerned, there is a long history of research into the use of acupuncture for pain relief, and the question here is not whether it works, but how much it works and how sustainable the relief is. If someone needs treatment twice a day for several weeks to reduce the pain, this raises issues about cost and attendance at a clinic. However, if one or two sessions a week can bring the pain down to tolerable levels it may be worth considering having treatment. The problem we foresee here is the site of the ulceration. The outer ankle is not really an area which one can easily immobilised, and it may well be difficult to counter the effects of continued minor irritation from movement.
 
However, sight unseen we cannot give a conclusive answer. We have a number of members in her area, and we are sure that any of them will be able to give you and your mother an objective assessment of what might be possible if you can arrange a short visit, hopefully without charge, to discuss the problem with them.

We think this probably still represents the best advice we can give. In our experience leg ulcers can be a very difficult problem to treat, especially where there are a number, and it is highly likely that treatment may be inconsistent with the conventional care being offered. However, long experience has taught us never to say never because occasionally acupuncture treatment can produce unexpected but substantial results. What we would say, though, is that our expectation would be low, and if you do find someone who thinks the condition is treatable, we would advise frequent and regular reviews to assess whether there is any change. It is not difficult to run up to a very large number of sessions without tangible result, and we advise members to ensure that a patient has the best possible information to inform the decision to continue with treatment when results to date have not been great.