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Ask an expert - about acupuncture - does it hurt?

14 questions

Q:  A few years back I had a car accident and was asked whether I would like acupuncture,  which I liked the idea of trying. My first appointment I was needled across my back hands & shoulders.  It was an unusual sensation but bearable. The second appointmet  the following week,  I was in unbearable pain as soon as the needles were inserted to the extent I was in floods of tears.  I wondered - is this a natural reaction or whether simply it was someone different doing it the following week?

A:  We can't quite be sure of the chronology from your question. It reads as though the treatment was administered some years ago at around the same time as the accident, which is what we shall address.

Generally speaking, there is very little pain associated with acupuncture treatment. Most patients feel only a very slight pinprick and either a mild tingling sensation or a little dull ache. Indeed, since the advent of the guide tubes which many practitioners now use, many patients feel almost nothing at all except the pressure of the tube on the skin.

Occasionally a needle may hit a small nerve or blood vessel, and this can cause the sort of short term 'ouch' which is to be expected. It would be very rare for someone to experience unbearable pain. There are one or two reasons which might make this possible. One is that the accident caused a general sense of shock in the body which can on occasion cause a considerable amount of rigidity in the muscles. In our experience needling into muscles in spasm usually releases the knots, but on occasion this can go the other way and increase the underlying discomfort. Acupuncture treatment also targets the whole person, at least when performed by a traditional acupuncturist. There have been a few occasions when the treatment which someone has can release tensions and knots of which the patient may be unaware. It can also cause an emotional release, especially when there has been a great deal of shock and a wise practitioner will stop treating immediately and let the patient recover rather than ploughing on.

However, you mention the fact that the treatment was performed by a different person the second time, which implies that you were treated in something like a pain management clinic. Some of the practitioners using acupuncture in these clinics are trained in specific techniques but given the limited nature of their training tend to use slightly thicker and longer needles, and often use a more vigorous technique than our members might. This can be quite difficult for a patient to 'endure', especially if the system is still in shock. The fact that the first treatment was fine suggests, though, that this was down to the technique of the individual involved, and we have to be honest and say that we have a small number of colleagues whose technique could be described as 'robust'. This is fine if people get better from whatever they have, but may not play so well if the treatment doesn't work!

The short answer, though, is that while your reaction is not common, it is knot unknown, and we hope that it has not put you off any future thoughts of treatment. If you did decide to have further treatment in the future it would be very sensible to mention this last reaction to the practitioner and alert them to using the most gentle techniques to begin with to avoid any repetition.

Q:  I have had 10 treatments from an acupuncturist who treats your 'element'.It has had mixed results and her decision on which element I am has changed. Although I pay for an hour my treatment typically now takes 10 minutes and consists of one needle being put into and out of my wrist very quickly and then inserted into the back of my wrist the same way using the same needle. When removing the needle she uses a piece of cotton wool to press against the needle as it is taken out. 6weeks ago I had a treatment and left with great pain in my right wrist where the last needle point was. It didn't go away and got worse so that if I moved my hand in a certain way I experienced a tearing sensation inside my wrist. I felt there was a piece of needle left inside my wrist. I went to my next appointment two weeks later and asked if there was a possibility of a piece of needle being left inside me. I was pretty much dismissed and told there was nothing wrong. (There clearly is as I am frequently in agony). A month passed and I have made an appointment to see my gp. I have waited several weeks for the appointment and still have another 4 days to go but my wrist is still really bad. I don't know whether to go to casualty and if so whether an X-ray would show up a tine fragment of needle or if I would need an ultrasound? I am now very scared and worried as the point the needle went in is in line with major arteries and nerves. Can you advise best course of action and if you think anyone will take me seriously? There is no inflammation and my wrist looks entirely normal from the outside. 

A:  This sounds very distressing for you, but we can say straight away with some confidence that it is highly unlikely that you have a piece of broken needle embedded under the skin of your wrist. Although all practitioners are trained in what to do if a needle breaks, in modern times this is virtually unheard of. The most recent report of a possible break to the BAcC was over fifteen years ago. The main cause of needle breakage, rare as it was even then, was when needles were autoclaved to sterilise them for re-use. Modern needles are used once only and then disposed of, so the constant heating and cooling which made the steel brittle does not happen.

The most likely cause of your discomfort is that there has been some bruising beneath the skin surface which has caused a hard clot to form and which impinges a nerve when you move in certain ways. We have seen this before, and it can take several weeks for something like this to clear. There is a small possibility of damage to a tendon, which might also account for the symptom, but the needling would have to be rather more vigorous than sounds was the case for this to happen. If the practitioner is using the style of practice which we believe they are, then very fine needles are the order of the day, and damage from the needle itself would be unlikely.

We think that going to your GP is a very wise move. He or she may have a precautionary X-ray or ultrasound done - just because needle breakage is rare doesn't mean that it can't happen - but there will be a number of investigations they can undertake on the spot in terms of range of movement and pain on movement which should alert them to the probable cause.

As far as the style of practice is concerned, this sounds like the Five Element system which is one of the two more common  styles in use in the UK. The diagnostic certainties of this are open to re-assessment and change, and for all sorts of complex reasons a person might be initially treated on one element and then find that another element presents itself as the core of the problem. This is the not the difference between right and wrong so much as between good and better. All treatment will have a beneficial effect because in a closed system of energy any attempts to improve the flow will have impact everywhere. Treating the heart of an imbalance, though, will get better results and can lead to much more profound change. It is heartening to hear that the practitioner is making adjustments; it is often said that immediate certainty is not always a sign of good diagnosis. People are very complex.

In terms of technique, the schools which teach this system tend to use mainly 'in and out' needle insertions which can take up a very small amount of a treatment session. We occasionally hear rumblings of discontent from patients who think that this doesn't seem quite right, and we have to explain to them that the time spent up to that point is all a part of the diagnostic process. All of this preceding work -  investigation, pulses and conversation - refines the diagnosis so that when the points are chosen their effect can be all the greater.

Having said all of this it is a concern to us that the practitioner appears to you to have made light of what you have experienced. We try our hardest to ensure that practitioners pay particular attention to what their patients experience and to respect what they have to say. While we would probably not consider something like this actionable under our professional codes it is certainly something which the practitioner would benefit from knowing so that they can look at how they have addressed the issue. Unfortunately the only person who can really address this is the patient, who is not always inclined to get involved in setting a practitioner right and more likely to want to walk away from the situation. If you do raise it with her, however, we hope that your concerns are properly addressed.

Just to re-iterate what we said above, we think that it is highly unlikely that a needle tip has broken off in the wrist, but we are happy to know that you have a GP appointment within the next few days to make the necessary investigations. We hope that you understand that we have taken your account very seriously, and we are a little disappointed that you do not feel as though you have been listened to. For us acupuncture is a daily way of life, and we are used to what happens. For most patients it is still a largely unknown area, and for this reason we have to remember to acknowledge that in what is already an unusual situation anything untoward which happens is likely to cause great anxiety.

We hope that it is as we a transient adverse event which resolves soon without the need for any medical intervention. 

Q:  Because it seems that nothings really helped me relieve my sciatica pain caused by a very small disc herniation (L5- S1) I had already 2 acupuncture session. After the  first, i was feeling good but during the second on when the doctor inserted a needle down the buttocks I felt an enormous pain. I asked him if he just hit the nerve but he is said it's "the energy flowing". Is it normal to be that painful when the energy is flowing?

A:  'Normal' is not quite how we would describe what has happened to you, but certainly a reaction like this is within the range of possibilities. There are a great many unknowns, however, which means that we can't be precise. For example, when you say 'doctor' we're not sure whether you mean a conventional medical doctor, a Chinese practitioner who uses the title (as many do) or a traditional acupuncturist amongst our members (who do not use the title doctor unless they are also conventional doctors).

The reason we say this is that there are different styles of acupuncture. Conventional medics use a much more direct style of needling with thicker gauge needles, deeper insertions and often aim for what are called trigger points. When these are needled the sensation can be quite powerful. Many practitioners trained in China use a much more vigorous needle technique than European trained practitioners. The needle is often manipulated quite powerfully to generate a dull aching sensation called 'deqi' which for many Chinese practitioners is an absolute requirement for good treatment. Many western trained practitioners also do the same, but there is a wide range, with many using a relatively light technique. On occasion, however, the needle can cause a channel to become very 'live', and this can produce a sensation which may be painful.

What we can't judge from your account is how long the sensation lasted. If it was short-lived it is much more likely to have been an energetic reaction. This can last for a few hours, but after the initial burst of activity it tends to subside over time. If there is a very sudden and painful reaction which goes away quite quickly, then you cannot rule out the possibility that the practitioner has actually hit a nerve, of which there are many in that area.

The bottom line, though, is that it hurt, and most practitioner can adjust what they do to reduce the chances of it happening again. This can be achieved by needling less depeply, less vigorously, or even somewhere else altogether - the interconnections make this possible. There is no need to worry about talking to the practitioner about it. If they are reputable, they will listen. If they do not respond well to your questions, there are hundreds of practitioners out there!

 

A:  There are no set rules about the gaps between treatment, but the majority of UK practitioners will see someone weekly to begin with and then, depending on the condition, space the treatment out further. In some cases where someone has an acute condition the treatment may be twice weekly or even more. This would be the normal pattern in China, for example, where a course of treatment offered in an outpatients' department might involve daily treatment for ten days. However, in the UK this is often not possible because of clinic timetables and also, to be truthful, because working out payment schedules for multiple treatments in a short period of time is not to every BAcC member's taste.
 
The wisdom of weekly treatment is that this allows the practitioner to get a really good idea of how well the treatment has taken. Our old teachers used to use images like dropping a stone in a pond and waiting for the ripples to cease, or more appositely, clearing mud from the bottom of a pond and waiting for the water to clear again to see how well one had succeeded, but the message is intrinsically the same - treat too early and it may not be easy to make sense of what is happening.
 
By the same token most members do not like to leave long gaps between treatments when a course of treatment starts. It is important to be able to assess what changes have taken place, and after two or three weeks most patients, apart from the diary keepers, find it difficult to recall how they felt. Small changes which to a practitioner may have significance are not recalled. There is also a question of momentum; weekly treatment for the first four or five sessions often has greater accumulated power than the same number of treatments spread over several weeks.
 
If you have any queries about the specific gaps between your own treatments we are confident that your practitioner will be very happy to explain what is going on.  

There can be some substantial variations in the length of appointment times depending on the style of acupuncture practised by your acupuncturist and also the complexity of the case history which you bring to the treatment. One of the founding associations of the BAcC consisted of graduates of a college where the initial session was often two hours long and each treatment session up to an hour long. At the other end of the scale there are highly experienced practitioners who can often glean what they need to within half an hour and continue with half hour sessions.

Generally speaking we tell people to expect to spend somewhere between and hour and a hour and a half for the initial session and between half an hour to an hour for subsequent sessions. 
 
The obvious point to make, though, is that the quality of the treatment and the success of the outcomes are what matter, and these are not measured in minutes. 

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