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Ask an expert - muscles and bones - neck

20 questions

Q:  My dad had a heart attack in  2005 and he has an stent in his heart. He has recently had a lot of pains in the  back of his shoulder going to his neck and his left arm.  Do you know if acupuncture is the solution for it or if it's good for him or not please.

A:  We think we can safely say based on what you have told us that there is no reason not to have acupuncture. There are very few contraindications for acupuncture, reasons why we could not treat someone, and having had a heart attack and stent fitted does not pose a problem.

Whether acupuncture could help or not depends a great deal on what the cause of the pains is. For the kinds of pains which your father is getting, and taken together with his medical history, I think most of us would probably want to refer him back to his GP or cardiologist for further testing and an all clear for all involvement of the heart or other internal organs. Some of the aches and pains which people have are what is known as referred pain, where the pain is actually starting in an internal organ but is perceived by the body as a muscular problem on the surface. The classic example is angina pectoris which can present as a pain the left shoulder and arm. Given that your father has had a stent fitted it implies that there has been some atheroma/plaque-like material in the arteries and this may have caused another artery to be sounding warning bells.

However, if the pains are simply muscular, there is a good chance that acupuncture treatment may be of benefit. As we point out in our factsheet

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

there is some reasonable evidence for the successful use of acupuncture as a means of relieving this kind of pain.

We always advise people to see a BAcC member for a brief face to face assessment; this is by far the best way to establish just how much benefit acupuncture may be able to offer. In your father's case this is doubly so, just to make sure that these are not pains which we would do better to heed as a warning sign than simply treat and try to disperse.

Q:  I suffer from cervical spondylosis with radiculopathy in my upper right quadrant and wear and tear in my thoracic and lumbar spine. Suffered badly for years up to this past year finally getting best nerve pain med. Female aged 62, take pregablin Lyrica 100mg x 2 for past 4 months. I was paying for private physio for past year which was working well. Was offered a plate and pins to stabilise neck last year but have defferred as I'm still at work.  I begged for and am getting a nhs course of acupuncture - just a few pins in the  top of head, neck, right thumb and shoulder. Hoped to get off meds which have side effects. 3rd session of acupuncture and I now feel like the pain has come back and the pregablin not working. Is it normal for this reversal to happen or should I cancel? Would you recommend I ask for a new scan of my neck to see if it has got worse?

A: Based on what you have told us we think that it is very unlikely that the acupuncture has caused the reversal of progress which you describe. In traditional acupuncture we do warn people that there can be situations where a chronic condition can sometimes sign off with a flourish, and it is not unknown for a migraine sufferer to have a really bad migraine after a first or second session. However, this tends to be a very good sign that a pattern has been broken and a pathogen expelled, so the effect is short lived. Occasionally after treatment for musculo-skeletal problems the same can occur, and along with osteopaths and chiropractors we do tend to warn people to expect a day or so of disruption. The effect, however, is invariably transient.

There are two possibilities which we can think of. The first is that something has in fact really changed, and that your intuition that a new scan may be appropriate is a good one. We always express this with great care, but it is possible that changes have absolutely no causal relationship with the acupuncture treatment but just happened at the same time. This can sound like evasion of responsibility if not spoken with care, but what we worry about is that people can get distracted into arguments about causation while the problem goes unattended. 

The second is that the treatment itself has not exacerbated the existing problem but generated a few new symptoms in similar areas. Most of the practitioners working in pain clinics are safe and well trained, but they do tend to use what we would call formula acupuncture on the basis of western medical theory. This variant, called western medical acupuncture, can often be applied a little more vigorously and with slightly thicker needles than most traditional acupuncturists would use. This can sometimes generate problems of its own, but we have to say that if this was the case they would start pretty much as soon as the needles had been inserted, not appear gradually over time.

A third possibility is that the acupuncture treatment us having a rather good effect in terms of helping to relieve some of the tension in the muscles of the shoulder and neck, but this has had the unfortunate consequence of allowing slightly greater flexibility in the neck itself which in turn generates a little more pain. We do see this on occasion with backs, where a kind of unhealthy stability is achieved where a lesser problem, chronic muscle ache, is traded off against a more sharp pain like sciatica. It is rare but there are times when succeeding in helping the lesser pain can bring on the worse pain.

We think the best thing to do is to discuss this with the person giving you treatment. This is not a case of wasting anyone's time; this is all about ensuring that you get the best possible treatment for a really unpleasant chronic condition. If there are over-shoots or under-shoots in the treatment, then that is simply a useful guide to getting the balance absolutely right, and your healthcare professionals will welcome the feedback to be able to make the appropriate adjustments or, if need be, decide that another scan may be appropriate.

We hope that you manage to find a good balance of treatment to help you to continue without a plate for as long as possible.   

A: This is quite a difficult question to answer. All forms of impingement and entrapment can arise for a number of reasons, and these determine whether there is a realistic chance of success. If the problem arises from a displacement of the physical structure of the body, like a joint having been knocked slightly out of alignment then it may be more appropriate to see a practitioner like an osteopath or chiropractor who can manipulate the structure back into place. It is probably possible to do the same thing with acupuncture over time, but re-arranging the bones first and then using acupuncture to consolidate the change is how many of us work alongside osteopaths and chiropractors.

If the changes in structure are due to deterioration of the bones, the problem can be more intractable. We find that impingements of nerves where the spine is starting to collapse with age are often difficult to address, especially in the neck and in the lower back. This is a simple mechanical fact; if the gap between two bones closes then nothing short of surgery is going to fix it.

In some cases, however, inflammation arising from structural changes or simply inflammation can cause the entrapment, and in this case there is some evidence suggesting that acupuncture can do more than simply offer short term pain relief and can break the cycle of inflammation which is causing the discomfort.

The short answer, though, is that each case is unique and different, so it is very difficult to quote general principles about what is best. The advice we tend to give all the time  is to arrange a brief face to face consultation with a local BAcC member to see whether in their professional opinion a problem is amenable to acupuncture treatment. The majority are quite open to suggesting alternatives if they think a patient would be better suited to another form of treatment.  

A great deal depends on the reason for the entrapment. In some cases people are beginning to show deterioration of the cervical spine through age, and the compression which this can cause, with consequent nerve impingement, is not something which treatment can reverse.

However, this is to take a somewhat pessimistic view of what is happening. We tend to look at structure first. Although acupuncture can be quite effective at treating chronic neck pain, as our factsheet shows

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

if there is a structural misalignment which is the likely cause you may be better off seeing a chiropractor or osteopath in the first instance to pop the neck back into place. After this, there may well be good reason to have acupuncture treatment because the adjustment might be resisted by muscles which have become 'set' in an abnormal state, and need some help to re-adjust to normal function. Many members work closely with osteopaths and chiropractors, referring backwards and forwards to nudge the system back into place.

A:  This, though, is to take a very western view of what is happening. From a Chinese medicine perspective the pains which are described as 'trapped nerve' or 'muscle spasm' can often be a direct expression of a blockage in the flow of energies or a more long standing systemic weakness. If this is the case, no amount of manipulation will hold changes in place, and acupuncture may treatment well be the best option.

The best advice we can give, without knowing the wider context of your problem, is to pop in to see a BAcC member local to you and seek a brief face to face assessment of what may be possible. We are confident that they will offer you advice which is geared to your specific needs, not simply book you straight in without demur.

Q:  My  mum (aged 72) has spondylosis and suffers greatly with pain in her neck and now has quite a pronounced curvature on her spine. Would acupuncture help with the pain anddiscomfort she is experiencing?

A:We actually gave a very comprehensive response to a question about pain relief and spondylosis some months ago. It said:

There are very few research papers for the treatment of spondylitis with acupuncture, and those which have become available are generally Chinese studies which are both small and often methodologically flawed. A good example is this one:

http://www.ncbi.nlm.nih.gov/pubmed/16309054

This does not mean that it has no significance. The problem is that in the West there is more focus on the 'does it work?' question rather than, until recently in China, a focus on 'what works better?'. When you are using a two-thousand year old tradition which is embedded in the culture the use of the western drug testing model, the randomised double blind control trial, is not likely to be
your model of choice. This latter test is not entirely appropriate for testing acupuncture, because reducing the variables to one is inconsistent with how good acupuncture is practised, so unsurprisingly the number of meaningful trials is limited.

That said, pain relief was one of the most heavily tested aspects of acupuncture treatment when it became more popular in the West, which is generally taken to be after Nixon's visit to China in the 1970s. The outcome measures for research purposes, the various neurotransmitters, and the patient reports of pain are easily measured, and many studies were done which showed that acupuncture does have an effect on the experience of pain. Our fact sheet on chronic pain http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/chronic-pain.html cites a number of the better known ones. The main issue with using acupuncture for pain relief is weighing up the extent and sustainability of te relief against the cost of treatment, to put it bluntly. If, for example, treatment offers 48 hours of pain free life followed by a couple of days of bearable pain, then someone with deep pockets might find
acupuncture treatment a reasonable investment. The vast majority of us, though, are not in this position, and also the greater majority of practitioners tend not to like to continue treatment indefinitely if there is no sign of a permanent reduction in the levels of pain.

The key aim with a condition like spondylitis is not a reversal of the fusing of vertebrae ultimately caused by the condition but a breaking of the cycle of inflammation which tends to sustain itself, i.e. inflamed areas press against surrounding tissue and further aggravate the inflammation. If treatment, whether by medication or acupuncture, can break this cycle there is a chance of
maintaining a level of manageable pain. The disease label covers a wide range of presentations, and you would need to see a
BAcC member local to you for a brief face to face assessment of whether treatment would be worthwhile for you. From a Chinese medicine perspective there are also a number of systemic problems which can underpin what is in effect a local problem, and a practitioner will be able to assess quite rapidly what else may be going on in the system to inform the diagnosis in Chinese
medicine terms and to give a clearer sense of the prognosis. He or she, if you do decide to have treatment, will be very clear about setting clear outcome measures to see whether the treatment is working, and regular review periods to assess whether treatment continues to be of benefit. We think that remains good advice. The fact that your mother is 72 is not in itself an issue. The problem is more to do with the level of deterioration. In the parlance of modern supermarket advertising 'when it's gone it's gone', which means that in most cases a physical deterioration of bony structures limits the extent to which change can be effected. However, the
fact that someone has spondylosis and also has pain does not mean that there is an absolute correlation between the two. We have treated patients with severe deterioration and seen changes which were thought to have been impossible. It may well be that the pain was not a direct response to the physical issue. However, this is the exception, not the rule, and since each person's condition
is going to be unique to them in Chinese medicine terms, the best advice that we can give is to visit a local BAcC member for a brief face to face assessment of what may be possible.

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