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Ask an expert - general

174 questions

Q:  I have had chronic pain in the testicle and area of repair following a mesh repair of an inguinal hernia 4 years ago.  9 weeks ago I had the mesh removed and a neurectomy of the illioinguinal nerve, which was supposed to sort the problem out but has not. Would acupuncture help and if so is there any particular type that would be best. Can you recommend anyone in the Leigh on Sea area who would be appropriate.

A: A great deal depends on what may be causing the pain. We are assuming that the neurectomy was selected after a very thorough neurological examination; it is not common practice to start cutting nerves unless there is a very good and clearly diagnosed reason. On the assumption that this nerve corresponded to the area in which you were and still are experiencing pain, then there may be a small chance that acupuncture treatment may be of benefit.

Acupuncture treatment does have a general pain-relieving effect which has been the object of a great deal of study over the years, as our factsheet on chronic pain shows:

http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/chronic-pain.html

The chemical markers for pain relief, the neurotransmitters, are easily measured to provide an objective marker of whether something is happening. The main question with treating at this kind of generic level is how much relief the treatment may give and how sustainable the relief is. In many cases this comes down, unfortunately, to a financial question: is the treatment affordable and worthwhile when the cost is set against the relief.

However, the understanding of the body as a system of energy in flow which underpins traditional Chinese medicine does afford other possibilities for consideration. Like any enclosed and self-contained system, if there is damage then where the flow is impaired pain will arise, either from a deficiency or excess of energy in the area, or through the stagnation in the flow. Using needles this flow can be reinstated, and the pain reduced or removed. Sometimes the very fact of surgical incision can create a blockage, as can the formation of scar tissue. This can sometimes have effects some distance away from the scar tissue itself. Treatment is often a mixture of local treatment and treatment some distance away, although we can reassure you immediately by saying that there are no acupuncture points on the testicle or scrotum! There are, however, points on the lower leg a which refer directly to this area, and these may come into play.

The best advice that we can give is to visit a BAcC member local to you for an informal assessment of what may be possible. Although we can be quite confident about the treatment of conditions which we often see it is far more difficult to offer opinions on unique presentations like yours. However, a skilled practitioner may well be able to make a few diagnostic soundings which can tell them how likely it will be to help your problem.   

Q:  I have had a cough for almost 18 years, following a bout of tonsilitis. It is a powerful, barking cough (I have suffered broken ribs on two occasions as a result of coughing).  I wondered whether acupuncture might be able to help?

We are sorry to hear about your experience; that is a very long time to be troubled by something for which no solution has been found and which has the capacity to do physical damage.

We are going to have to assume that you have had all the tests known to conventional medicine. There are a number of acute and then acute-on-chronic conditions which can produce a cough of lasting severity, but they all offer treatment options and you haven't mentioned being on any specific form of treatment. We're also going to assume that you still have your tonsils; it would not have come as a surprise to hear that this had been offered as a solution.

From a Chinese medicine perspective, the body, mind and emotions are all a manifestation of an energy called 'qi', pronounced 'chee', of which everything consists and whose orderly flow in defined channels maintains our health and well-being. The diagnostic systems of Chinese medicine are all geared to understanding where and how this flow has been disrupted. This is a subtle and skilled art; problems do not always lie where the symptoms appear, such is the inter-connectedness of the system, and treatment aimed at palliating a symptom without reference to the whole picture are less likely to be successful. After viral infections it is not uncommon for their to be long-term deficiencies, and in some cases straightforward blockages where the system can no longer cope and instead, for example, allows the accumulation of fluids in the lungs which trigger the coughing reflex. Sometimes the problem can be more subtle still; people have patterns of behaviour for such a long time the whole system adjusts around them.

It is very difficult to offer a diagnosis at this level of remove and we are not going to try. We do think, that it would be well worth your while visiting a BAcC member local to you for a brief face to face assessment of what might be going on. If the practitioner can see an obvious cause in Chinese medicine terms it may well be worth having a short course of treatment to see if there is any benefit. Even if there is no obvious cause it may still be worthwhile; the roots of Chinese medicine lay in keeping the patient well rather than getting them better, and treatment was aimed at balancing the system as a whole in the simple but effective belief that a system in balance does not generate symptoms.

There are a number of postural interventions, like cranial osteopathy, which might also offer some benefit, and we are sure that if you see an acupuncturist who thinks this may be a good option, then they will probably be able to make a good referral on.

Q:  My  wife gets severe  recurring neck pain. A friend suggested acupuncture. She takes Warfarin;  is this form of treatment suitable?

A: We have been asked questions about warfarin before, and our answer has always been:

There is no reason not to have acupuncture when you are taking warfarin. We publish a Guide to Safe Practice for our members which provides detailed guidance on issues like this, and on the treatment of people on anti-coagulant medication we wrote:

Patients on anti-coagulant medication

You must take great care when needling patients who are taking anti-coagulant drugs such as Warfarin. Only very superficial needling with fine needles (0.20mm) is recommended.

The risk appears small but internal bleeding leading to compartment syndrome can have extremely serious consequences. There is one report in the medical literature of a case of compartment bleeding following acupuncture in a patient taking anti-coagulants (see link to article at the end of this section).

Warfarin prevents the body from metabolising vitamin K. Vitamin K controls the formation of a number of coagulation factors in the
liver and is an essential substance for blood clotting. Vitamin K is present in most of the foods that are considered to be blood-forming according to Chinese medicine such as green leafy vegetables. This is important to consider if you are giving dietary advice to patients on Warfarin since these foods can lessen the desired effect of the drug.

Patients are put on Warfarin or other anti-coagulants for a number of different reasons. These may be purely preventive if, for example, the patient suffers from atrial fibrillation or has mechanical heart valves, or because of recent surgery, stroke, heart attack or thrombosis. The dosage of the medication depends on the desired amount of anti-coagulation for that particular condition.

Every patient on Warfarin has to undergo tests on a regular basis to check how long it takes for their blood to clot. The frequency
of these tests depends on the dosage of their medication and their condition. It is good practice to encourage your patient to have more frequent tests while they are receiving a course of acupuncture as the treatment can positively influence their blood values and may require their Warfarin dosage to be
reduced.

Ask your patient for their INR (international normalised ratio). The INR is a ratio established by measuring the prothrombin time (PT),
which is the length of time it takes for the patient's blood to clot, and then by comparing this value to an average. In a healthy person the INR is about 1.0. Patients on Warfarin tend to have an INR somewhere between 2.0 and 3.0 or even higher, depending on the desired amount of anti-coagulation. A higher INR signifies a stronger effect of anti-coagulation.

The main risk associated with acupuncture is internal bleeding. Depending on the depth of needling and the underlying structures
involved this may be insignificant, but there is a chance that it can result in compartment syndrome. Although the risk is small this condition can have serious consequences and often requires surgery.

Needling should only be done superficially and with fine needles. The higher the INR, the greater the risk of bleeding. Patients with an INR of 3.5 (sometimes therapeutically necessary in the treatment of valvular disease) or higher should be treated with greater care.

It is also advisable not to use guasha and cupping on patients on anti-coagulants since these techniques tend to draw blood to the
upper layers of the skin and can cause severe and prolonged bruising to larger areas of the body.

Further information and research articles can be found on the internet. Here are a few examples:

www.medicalacupuncture.com/aama_marf/journal/vol13_2/case4.html

www.doctorslounge.com/hematology/labs/inr.htm

http://aim.bmj.com/cgi/content/abstract/20/2-3/105

Our members will always take these factors into account when treating, especially when they are dealing with a problem which might
require slightly more vigorous needling. The majority of UK trained practitioners, however, use very fine needles and very gentle techniques, and we have had very few reported cases over the years of bruising or bleeding after treatment in people taking warfarin or other anti-coagulant medication.

As you can see, we have taken this seriously because we find that many patients can easily forget the impact of taking anti-coagulants and on occasion even forget to tell us that they are taking them when we undertake the initial diagnosis.

As far as the neck pain is concerned, we publish a fact sheet on this

http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/4076-neck-pain.html

but cautious as this is, you will find that many practitioners often report quite dramatic changes when using acupuncture for neck pain. Not every case is treatable, but we find that most people respond to a degree, and the question is not really 'will it work?' so much as 'how well will it work and how sustainable are the results?'. The only caution we would utter is that our
experience is that after the first session and occasionally the second the movement is often slightly more restricted, gradually relaxing over the following week, and then progressing as far as it can. This avoids unnecessary anxiety if a patient knows what is likely to happen.

,A:  As well as producing factsheets, we also produce review papers which give our research people a chance to go into a little more depth. The menopause and its symptoms are one of the areas where they have done this, and the paper

http://www.acupuncture.org.uk/arrc/public-review-papers/menopause-and-acupuncture-the-evidence-for-effectiveness.html

makes some very positive noises about the possible benefits of treatment for hot flushes. However, the paper acknowledges that there are a few methodological problems with the field, especially since some of the studies are from China where there less interest in checking whether acupuncture works and more in working out which treatments work better. This does not meet the standards set in the West, and although we have consistently maintained that the randomised double blind control trial from drug testing does not work for acupuncture, it remains the 'gold standard.' This underpins papers like this one

http://www.ncbi.nlm.nih.gov/pubmed/23897589

which tend to portray the glass as half empty rather than half full.

The thing to bear in mind is that the Chinese have been treating menopausal symptoms for over 2000 years. Although the theoretical basis of Chinese medicine is entirely different, based on theories of energy called qi, the Chinese have found ways of understanding the process of change in middle age which underpin a number of syndromes which provide treatment options.

Naturally, these have to be adapted to the individual because from a Chinese medicine perspective everyone is different, i.e. there are no formula treatments where the same needles work for everyone. However, the standard forms of imbalance can be interpreted within the context of the individual's energy to help them deal with the symptoms which arise.

The best advice is always to visit a BAcC member local to you to ask for an informal face to face assessment of what they think may be possible. This will be far more informative than our speculation at one remove, and the practitioner will probably be able to give you a good idea of what frequency and extent of treatment may be necessary. On balance, though, most of us find that we can treat hot flushes to a degree, and the main question we have is more a matter of how much change we can effect and how sustainable it is rather than does it work at all.


Q: What are the entry requirements for BAcC membership? What are the requirements for accreditation/registration, and what are the requirements for being retained on the register?

A:  The majority of new registrants of the BAcC are graduates of three year degree level courses which have been accredited by the British Acupuncture Accreditation Board, an independent body part funded by the BAcC. The courses are split between university courses which are often validated by the university itself and lead to a BSc, and private teaching institutions. You
can read a great deal about the courses themselves on the BAAB website, www.baab.co.uk.

The BAcC also has what we call an 'external applicant route'. The admissions process is spelled out clearly on our website at this
page

http://www.acupuncture.org.uk/component/com_onlineenquiry/Itemid,419/view,whatkind/

Essentially the standard we are looking for would be equivalent to that achieved by an accredited course graduate, and there is a
very detailed process of application which looks at course transcripts, experience of practice and skills to assess applicants who achieve membership after a summative interview.

Once someone becomes a member, the only requirement over and above complying with the Codes of Professional Conduct and Safe Practice is to complete a mandatory renewal declaration each year which informs the BAcC of any significant or material changes in practice or health/criminal issues of which we would not otherwise be aware.. In the form is a statement of
compliance with our annual CPD requirement which is stated as roughly 30 hours per year but undertaken through the creation of a Personal Development Plan. This is now being actively monitored in the same way that the HCPC/GOsC./GCC
oversees the requirements for CPD.

It is fair to say that it is very difficult to be able to assemble a degree equivalent training in traditional acupuncture without having
undertaken a structured training course at an accredited college. The appearance of a number of pre-registration postgraduate courses for first degree holders of two years duration may make the time commitment slightly less onerous, but the argument advanced by the course providers heading down this path is that the same hours (3600) are now compressed into the two years by
dint of shorter vacation periods. These courses are still the subject of quite heated debate.

We have in the past considered applications from people who have travelled to China and taken intensive courses, and we have also very occasionally looked at apprentice-style training as is found in Japan. As the process has tightened up, however, and now requires a great deal more documentary proof the chances of being able to complete the external applicant route reduce.

We are assuming from your address that you are a chiropractor, and we are happy to tell you that we have been trying for many
years to encourage the osteopathy and chiropractic registers and professional bodies to establish special interest groups equivalent to the AACP within the Chartered Society of Physiotherapists. This is mainly because we are concerned at people not knowing their limits of competence - you can't know what you don't know - but the formation of a special interest group tends to encourage
graduated training which moves people further along a route which might qualify them for BAcC membership. So far, though, this request has not generated much interest.

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