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Ask an expert - about acupuncture - How often?

11 questions

A:  A great deal depends on where you are and what you are trying to deal with. In most cases practitioners in the UK see people weekly because the majority of treatments are constitutional in nature, i.e. aimed at balancing the system as a whole, and the received wisdom is that it takes a week to get a clear picture of what has changed since the last treatment. There are as many analogies as there are practitioners, but many talk about re-arranging things in a pond and waiting until the ripples have ceased to see what has changed.

In some cases, a practitioner might see someone twice or even three times in a week if there are acute problems to address. It is not unusual with acute back sprains to see someone more than once weekly. This is more a matter of reinforcing the treatment regularly to make sure that it 'holds'.

If you were to visit a practitioner in China, however, it would be quite normal to see someone daily for ten days. This constitutes a 'course of treatment', and many Chinese people with a chronic or acute on chronic condition will trot along to the local out-patients department at the hospital to have treatment every day. With an increasing number of Chinese practitioners in the UK it is possible that this may begin to happen more frequently here, although the crucial difference is that in China the treatment is free at point of delivery within the national health system. In this country ten sessions, one a day, would probably be beyond most people's pockets unless the practitioner had come to an arrangement over the overall fee.

Many of us believe that there can be a tendency to over-treat unless one is careful, and again the often-used analogy is that of watering a plant. There is only so much watering that one can do before leaving the plant to make its own progress, and that is why we are very insistent that BAcC members maintain a rolling review of progress to assess how much treatment is needed and how frequently. This is a matter of professional judgement, because each patient is unique and different, and even though two patients may apparently have the same problem, the underlying cause could mean one gets sorted in two sessions where the other one needs ten sessions.

Covering all bases in our reply, we have to say that you can never be harmed by over-treatment, so if someone were treating too often there is no damage that can be done. The worst that can happen is that nothing happens or the system may feel a little unsettled, but the inbuilt safety margins of the system usually ensure that the body re-sets to a good working balance very quickly. That is why any adverse effects, like tiredness to a mild headache, tend to go very quickly.

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.

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