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Ask an expert - about acupuncture - How often?

15 questions

Q: I have had acupuncture for a specific problem (achilles tendon pain) which has responded very well. Now it has been suggested that regular visits for acupuncture are beneficial to overall health and balance. Is this a generally recognised approach and if so is there a frequency of visits that is recommended e.g. is once a month too much, too little etc.

We are very pleased to hear that your ankle responded well to acupuncture treatment. Although it would be fair to say that the majority of patients in modern times consult us with a specific health problem, in ancient times the idea of staying well rather than getting better was central to the use of acupuncture and herbal medicine. Going to a doctor and seeking help when ill was said to be 'like forging a spear after the battle has started or digging a well when you are already thirsty.' The ancient practice was to have treatment to stay well, and it is believed that in some cases the doctor was paid to do this on pain of having to keep the patient in the style to which
they were accustomed if they got sick!

The key aspect of maintenance treatment is that each of us has a constitutional balance which predisposes us to certain problems at specific times of year or when we are faced with more mundane challenges of life like stressful times ahead or chronic problems. In China the seasons are very much more distinct than here, but the change of season was seen as critical as the temperature dropped rapidly or the winds picked up. The Chinese saw these as having a major impact on health (as a primarily outdoor agrarian race), and the doctor treated the person just before the season to ensure that the person was well-prepared for the change. With five seasons in the year,
this would have meant treatment every ten weeks, and there are many patients who take this seriously enough to do just that.

We find, though, that the majority of patients find a good balance by trial and error somewhere between four weeks and thirteen weeks, and in fact become very sensitive the idea of 'time for a treatment.' Of course, proving the long term benefits of this approach is very difficult; how do you demonstrate that someone is better than they might have been? However, enough patients have shown an increased resilience and overall health with regular treatment to convince us that the ancients had got it right.

The odd thing is that some people think that five treatments a year at around £200 is a mite excessive but have not the slightest hesitation in putting a perfectly well-functioning car through a full dealer service at £900. We think that the values of modern life have become a little off-centre at times! It is up to us to convince, though, to convince them that good health is more than just absence of illness but an enhanced ability to live well at all levels.


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.

A:  There are no hard and fast rules about the frequency of treatment. It is fair to say, however, that clinical practice in China is radically different from that of Western Europe. It would not be at all unusual to have a course of ten treatments daily for a problem like yours, although this would perhaps be more likely immediately after the first tendinopathy developed.

In China, though, acupuncture is an accepted part of the state healthcare system so cost is not an issue, and in any event this is what practitioners have always done. In the UK, where cost is a factor, it is much more usual to have treatment weekly, occasionally bi-weekly if someone has an acute problem which needs more intensive treatment. This does not lessen the efficacy of the treatment; the intention is to trigger and reinstate the body's own healing systems, and this can be achieved just as well over time.

The key thing when a chronic condition is being treated is to set clear outcomes (range of movement, analogue scales of pain experienced, and so on) to determine whether there has been any improvement, and to set regular review periods to assess progress. Most BAcC members tend to use the four or five treatment mark as a point at which to make a judgement about how things are going, and to agree with the patient about continuing rather than just making repeat bookings week after week.

The important thing, if you have already started treatment and have any concerns about treatment, is to discuss them with the practitioner. This avoids any build up of frustration or annoyance if things aren't progressing as well as you would like.

A:  A great deal depends on what you are having acupuncture for. In China, for example, where acupuncture treatment is an accepted form of care within the national health service and free at point of delivery, it is not unusual to have a course of treatment daily for ten days, and for some conditions this is always the recommendation. In the UK cost and convenience make this less of an option, and most practitioners will only see a patient twice or three times a week for an acute situation for which they believe the patient needs more frequent treatment. This would usually run to two or possibly three sessions a week.

We have heard of colleagues who have treated daily as would be the case in China for conditions like an acute back sprain, but this is quite rare and was not done with any sense of commercial advantage, simply a reflection of the fact that the practitioners had unlimited access to their own clinics and the patients were very local.

We would have some reservations about anyone treating more than twice a week for a long term chronic condition unless there was a clear clinical rationale. If anyone has any concerns about this level of frequency of treatment a reputable practitioner should be able to give an extremely clear explanation of why they are treating this often.

It isn't really possible to overdo treatment, but there would soon come a point with over-frequent treatment, other than for acute conditions, where it was difficult to get sensible feedback. We often talk of throwing a stone in a pond and waiting for the ripples to cease before assessing the impact. Not a great analogy, we have to say, but gets across the message that it takes a little while for the impact of treatment to become clear. If someone is treating with too small a gap between sessions it is not always easy to see what progress has been made and how sustainable it is. It could not do harm, though, and there would be no risks associated with over-frequent treatment.

Q:  I am currently at university and putting together a research protocol using acupuncture for TMJ pain relief. I have searched hi and low but can't seem to find a recommended amount of acupuncture for pain relief. Has one been published or can you tell me whether one or two treatments a week is more effective and why for my rational.

A:  We are not aware of any strict rules for the number of treatments someone may need each week for pain relief in these kinds of conditions. A great deal depends on the culture in which the treatment is offered. In China, for example, where treatment is often delivered in an out-patient setting in a hospital it is not at all unusual to be given a course of ten treatments with treatment administered once a day. Some of the high street shops in the UK tried to replicate this practice but ran into a certain amount of consumer resistance because they did not discount the treatment.
Most practitioners make a judgement, based on clinical experience, on the amount of treatment necessary to develop a momentum which preserves the treatment effects. Very crudely put, acute conditons might be treated twice or three times a week initially to bring them under control, whereas more chronic pain might be treated once a week. If you are designing a protocol, the distinction between acute and chronic pain may form a part of your design and protocol, and this will have implications for how often you treat, as will the ease of getting your trial subjects to the treatment setting - more difficulty means higher dropout rates.
There are no textbook 'optimal' solutions, however. The decision about how often to treat would form a part of the design which the researcher would have to make a case for in establishing a sufficiently robust protocol to assess efficacy or effectiveness.  

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