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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.

Q:  What are the rules on cupping for instance when bleeding occurs into the cup and how should cupping be done ?

A:  There are many articles and videos online which show how one can perform cupping, and of them we found this one from the Pacific College in the USA to be the clearest:

Traditional Chinese medicine brings to mind acupuncture and the use of natural herbs as healing remedies. Cupping is a lesser-known treatment that is also part of Oriental medicine, one that can provide an especially pleasant experience. One of the earliest documentations of cupping can be found in the work titled A Handbook of Prescriptions for Emergencies, which was written by a Taoist herbalist by the name of Ge Hong and which dates all the way back to 300 AD

Cupping is the term applied to a technique that uses small glass cups or bamboo jars as suction devices that are placed on the skin. There are several ways that a practitioner can create the suction in the cups. One method involves swabbing rubbing alcohol onto the bottom of the cup, then lighting it and putting the cup immediately against the skin. Suction can also be created by placing an inverted cup over a small flame, or by using an alcohol-soaked cotton pad over an insulating material (like leather) to protect the skin, then lighting the pad and placing an empty cup over the flame to extinguish it. Flames are never used near the skin and are not lit throughout the process of cupping, but rather are a means to create the heat that causes the suction within the small cups.

Once the suction has occurred, the cups can be gently moved across the skin (often referred to as "gliding cupping). The suction in the cups causes the skin and superficial muscle layer to be lightly drawn into the cup. Cupping is much like the inverse of massage - rather than applying pressure to muscles, it uses gentle pressure to pull them upward. For most patients, this is a particularly relaxing and relieving sensation. Once suctioned, the cups are generally left in place for about ten minutes while the patient relaxes. This is similar to the practice of Tui Na, a traditional Chinese medicine massage technique that targets acupuncture points as well as painful body parts, and is well known to provide relief through pressure.

Generally, cupping is combined with acupuncture in one treatment, but it can also be used alone. The suction and negative pressure provided by cupping can loosen muscles, encourage blood flow, and sedate the nervous system (which makes it an excellent treatment for high blood pressure). Cupping is used to relieve back and neck pains, stiff muscles, anxiety, fatigue, migraines, rheumatism, and even cellulite. For weight loss and cellulite treatments, oil is first applied to the skin, and then the cups are moved up and down the surrounding area.

Like acupuncture, cupping follows the lines of the meridians. There are five meridian lines on the back, and these are where the cups are usually placed. Using these points, cupping can help to align and relax qi, as well as target more specific maladies. By targeting the meridian channels, cupping strives to 'open' these channels - the paths through which life energy flows freely throughout the body, through all tissues and organs, thus providing a smoother and more free-flowing qi (life force). Cupping is one of the best deep-tissue therapies available. It is thought to affect tissues up to four inches deep from the external skin. Toxins can be released, blockages can be cleared, and veins and arteries can be refreshed within these four inches of affected materials. Even hands, wrists, legs, and ankles can be 'cupped,' thus applying the healing to specific organs that correlate with these points.

This treatment is also valuable for the lungs, and can clear congestion from a common cold or help to control a person's asthma. In fact, respiratory conditions are one of the most common maladies that cupping is used to relieve. Three thousand years ago, in the earliest Chinese documentation of cupping, it was recommended for the treatment of pulmonary tuberculosis.

There are a number of alternatives available, one of which involves a rubber cup which creates a vacuum without the need for a flame, with which some practitioners are uncomfortable.

If the cups become contaminated by blood or body fluids, the rules are fairly straightforward:

Reusable equipment, such as cups, derma rollers, guasha spoons, etc, which has been used on broken skin and/or come into contact with body fluids must be washed in warm water and detergent first, then rinsed in very hot water to facilitate quick drying and dried with a disposable paper towel. It must then be sterilised by autoclave or an acceptable chemical alternative according to manufacturers' guidelines.

Sterilisation is essential in these circumstances. However, if the cups have not been compromised there are slightly less complicated ways of washing them to an acceptable clean standard.

There is a methid of cupping called 'bleeding cupping' which is used within Chinese medicine but not by any BAcC members of whom we are aware. This involves the use of a triangular needle specifically designed to open a pinprick would through which the cupping can draw a quantity of blood. Should any practitioner member of the BAcC go down this route, we would expect them to be wearing gloves, to have impervious washable flooring, and separate facilities for cleansing equipment after use which were not used for any other purpose, i.e. a dedicated hand basin conforming to current legislative requirements.

We are aware of very few problems reported in the use of cups other than the occasional circular bruise associated with their use. These are so frequent that it is only through the practitioner's failure to forewarn someone properly that complaints arise.

Q: I have a big toe arthristis and a plantar fasciitis, I wonder if laser acupuncture  could help me?

Generally speaking, acupuncture treatment for osteoarthitis has a growing body of evidence for efficacy behind it, as our factsheet shows

Plantar fasciitis is a different matter, however, and as we replied to a query last year

Plantar fasciitis can be a very unpleasant and debilitating problem, as you no doubt know. There is some evidence for the use of acupuncture treatment, as this paper shows,

and if you google 'acupuncture' and 'plantar fasciitis' you will find a number of other papers which suggest that there may be benefits from treatment. However, the combined weight of the various studies is not enough to be able to give an unqualified recommendation.

That said, the strength of Chinese medicine is that it operates from an entirely different paradigm or theoretical basis, and has different ways of making sense of the symptoms which a patient is experiencing. This can sometimes offer treatment options which would not necessarily translate into a western understanding of physiology, although there is usually an overlap. The system of medicine rests on a theory of energy, called 'qi', whose flow and balance determine how well the various systems of the body function. Many problems like plantar fasciitis point to local blockages and disturbances, often due to over-use or poor gait, which once they have become established remain a problem even after someone's habits have changed. Symptoms such as this can also point to more systemic problems, and the skill of the practitioner lies in making a clear diagnosis of the whole system before starting to correct aspects of it.

In this case, since the presentations of plantar fasciitis can be very different, we would advise you to visit a BAcC member local to you for a brief face to face assessment of the problem before committing to treatment. We are fairly sure that you will have seen a chiropodist as well as your GP, but if you have not, we would highly recommend that you do. There are a number of treatment options which can work alongside acupuncture treatment to great effect, and with these sorts of problems it is often a combined approach which pays the greatest dividends.

We don't think that we cad really add to this.

However, your question was about laser acupuncture, and we have to be honest and say that we are not really able to offer an informed view on this. Electro-acupuncture, of which laser acupuncture is one of of many forms, has become increasingly popular over the years and has been integrated into the work of many of our members. However, there is nothing to suggest that it offers benefits over acupuncture with needles and at this stage the mechanism by which it works would be something of a mystery. There are a number of 'off the skin' needle techniques used in some Japanese styles of treatment, and there may be similarities here, but we can't really comment on what falls beyond our normal scope of practice.

We are told by the members whom we know use it that laser acupuncture is very helpful for treating those who fear needles and for the frail or small. However, we can only offer advice that you should make sure that whoever offers the treatment is using properly CE-marked equipment, has undergone some form of training in its use, and is using equipment for which they are properly registered and licensed if the laser is a Class 3B laser or higher.

Q: Can accupuncture help my husband who has had facial/ head surgery? About 2 years ago a flap was taken from his r/side forehead to re-build his nose that had skin cancer. During the surgery nerves were cut above his eyebrow and since then has suffered terrible pains. He was told there is nothing to help him if morphine does not work!

We always find it very difficult to comment on very specific problems like this which are almost always unique in their presentation, not because we have nothing to say but because we do not want to excite expectations that cannot be met.

We have come across many cases of this type where there has been a post-surgical outcome for which no treatment options are available except strong medication. From a Chinese medicine perspective pain usually arises from blockages or excesses/deficiencies in the flow of energy (called 'qi') in the body, and on this level there isa a considerable amount of documentationa and research suggesting that acupuncture can be of benefit, as our fact sheet on chronic pain shows:

There is also a growing body of evidence for the use of acupuncture in the treatment of phantom limb pain, and this perhaps is the best cause for hope in your husband's case. The severing of nerves in an amputation or injury involving a loss of limb are an approximate analogue for what your husband has suffered. In answering a query about this we said:

Phantom limb pain can be a very distressing phenomenon.

There have been a number of studies over the years which describe the use of acupuncture in individual cases, and if you google 'acupuncture phantom limb pain' you will find examples such as:

We are also aware of a paper published in the Journal of another acupuncture association which cites the following papers about phantom limb sensation.

Bradbrook D (2004) Acupuncture in Medicine Acupuncture Treatment Of Phantom Limb Pain And Phantom Limb Sensation in Amputees. 22; 2; 93-97
Hecker H. -U et al (2008) Color Atlas of Acupuncture 2nd Ed. Thieme, Stuttgart
Hill A (1999) Journal of Pain and Symptom Management Phantom Limb Pain: A review of the Literature on Attributes and Potential Mechanisms. 17; 2; 125-142
Johnson M.I. et al (1992) Pain Clinic Treatment of Resistant Phantom Limb Pain by Acupuncture: A Case Report. 5; 2; 105-112
Liaw M.-Y et al (1994) American Journal of Acupuncture Therapeutic Trial of Acupuncutre in Phantom Limb Pain of Amputees. 22; 3; 205-213
Monga T.N et al (1981) Archives of Physical Medicine in Rehabilitation Acupuncture in Phantom Limb Pain. 62; 5; 229-2321

A:  The mechanism by which the treatment works is not at all clear from a Western medical point of view. From a Chinese medicine perspective it is perhaps easier to make sense of the appearance of the pain from the fact that the channels which run through the affected area spread out across the body, and even in 'conventional' Chinese medicine treatment it is not unknown to treat a problem in the lower left limb by using points in the upper right limb. The fact that the opposite limb is missing would not necessarily render the treatment useless.

However, if this expert were to look at the problem, his first impulse would be to look carefully at the reconstructive surgery and see how this might have affected the flow of energy. It would not simply be what potential there had been for nerve damage, but also a look at scarring in the area. Scar tissue itself can also generate some very intense pain if it cuts across the channels of normal flow, and there have been many anecdotal reports of acupuncture treatment being used to 'join the dots' and restore normal flow, this in itself being enough to take care of some local symptoms.

Each case is unique, however, and the best advice is to visit a BAcC member local to you for expert advice on what may be possible from a proper face to face assessment. Most BAcC members are more than happy to give up a little time free to enable people to make informed choices about the best course of action for them.

Q: Can acupuncture help and treat chondromalacia patella?

A: Buried within our fact sheet on Sports Injuries

is mention of a study which shows that there may be benefit from acupuncture treatment with warm needling (using moxibustion, a technique involving the burning of a herb moxa to generate heat). There is also an interesting case study from 2001 in one of the leading US acupuncture journals

which reports some success in treating the condition with electroacupuncture, although even we thought some of the diagrams looked a little scary.

In general, though, a practitioner would first want to explore what has caused, or been thought to have caused, the problem. A great many cases involves some form of repeat stress on the knee joint, and this can have a major impact on the management of recovery as well as on understanding from a Chinese medicine perspective what is happening. The Chinese medicine understanding of the body and mind as an integrated system of flow and balance of energy (called 'qi') means that the practitioner will primarily want to establish whether the problem is local, involving some form of trauma or over-use syndrome, or systemic, where the pain in this joint is the tip of a larger iceberg of problems within the whole pattern. This will dictate in large measure what strategy is best for dealing with the problem.

Acupuncture treatment, of course, is just a treatment like any other, not magic, so if there has been physical damage to tissue where regeneration is unlikely, then the best that can be achieved is a reduction in some of the secondary symptoms of the problem, like swelling and pain. This can have a profound effect, because there are many problems where a vicious circle arises, where damage causes inflammation causes pressures causes more inflammation, and so on. Many conventional treatments, like steroid injections, operate on this principle of breaking the cycle of pain.

Our best advice is to visit a BAcC member local to you to seek a brief face to face assessment of what might be possible. Each case from a Chinese medicine perspective is unique and different, and the same named condition in twenty people might lead to twenty different treatments. There may also be a different understanding of what is going on that may encourage a practitioner to believe that he or she may be able to help.

If it is a matter of keeping a symptom like pain or swelling under control, however, it is important to be very clear about the outcomes of treatment, especially if the symptom recurs. As a form of pain relief for a condition which is destined not to change a great deal acupuncture treatment can be a costly option, and it is never a bad thing to undertake a cost/benefit analysis of continuing treatment. What we often find, though, is that some of the 'side effects' of continuing treatment, like general improvements in feelings of health and well-being, become as valued as the pain relief itself.

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