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Q: Can acupuncture help with post herpetic neuralgia?

A: As you might imagine we have been asked about this many times over the years, and a recent answer was:

Shingles can be a terribly distressing condition whose after-effects can persist for months or even years. The treatment of post herpetic pain is an area which has been heavily researched in China, as our factsheet http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/herpes.html says, but the quality of trials is not that great. There is a comprehensive systematic review of all available trials, but this was only announced last year and has not yet been published. We ourselves have treated many cases of shingles, and we have to be honest and say that there has been a significant number of cases where it has been very difficult indeed to reduce the pain, which as we are sure you know can be excruciating.

However, there is no point in being unduly pessimistic. There have been cases of post-herpetic pain where the acupuncture treatment has made significant inroads into the symptoms from a mixture of constitutional treatment to bring balance back to the system as a whole and local treatment to reduce some of the irritation and inflammation. Generally speaking, it is better to start treatment as soon as possible after an attack, just as the use of conventional anti-viral medicines is favoured as early as possible. However, the reality is that most patients present with post-herpetic pain long after they attack and usually because the side-effects of the long-term medication are becoming a problem, so we are used to adopting a slightly different approach from that used in China, where needling often commences with days of an attack starting.

The best advice that we can give is that you visit a BAcC member local to you for a brief face to face assessment. The one caution we always voice in these cases is that if you decide to go ahead with treatment you set review dates for assessing progress and also try to set specific outcome measures, objective evidence that the condition is improving. This can be quite difficult with chronic conditions like this which can still have acute episodes, but it is really important to try to find a marker which can show that there has been progress. We would feel confident, though, that acupuncture treatment might offer some benefit in pain relief and recovery. The only question to resolve is how much and how sustainable the relief is, which is why we are always cautious in setting clear outcomes measures and review periods.

The great strength of Chinese medicine, though, is that each patient is unique and different, even though their symptoms be the same. This means that a skilled practitioner, and all of our members are, would be able to make links that we cannot do at this distance, and may be able to recommend other things that may help alongside acupuncture treatment. We would strongly recommend that you visit a local BAcC member for advice, and hope that it puts you on a path to finding some relief.

We have had a good look through the research databases to see what further evidence is available (the fact sheet seems to stop around 2008) and we have found a few which are positively encouraging, such as:

https://www.ncbi.nlm.nih.gov/pubmed/21639941

https://www.ncbi.nlm.nih.gov/pubmed/22502623

but the systematic review proposed in 2014 has still to be completed (at least we can find no trace of a publication by the principal author).

The advice we gave earlier holds good, and that is to visit a local BAcC member for an informal chat about what may be possible. This is by far the best way to get a clear idea of your prospects, and most members are only too happy to see prospective patients in this way.

Q: My doctor advised me to contact a physio as I was experiencing joint pain in my knees. I had acupuncture on my first visit and after three days my shoulder blades and upper neck are in excruciating pain. Painkillers are not even helping and I don't know what to do. I can't deal with this any longer. Why Am I experiencing this and will it ever stop?

A: We would probably need a little more information before we could give a definitive view. The first question we would ask would be where the needles were inserted. Acupuncture is a very safe treatment with very few serious adverse effects, and most, when they do rarely occur, are the result of damage caused by the needles themselves, hitting nerves, causing deep bruising, etc etc. If someone throws a very specific pain then the first thing to check is whether the treatment as a physical act of needle insertion could have caused it.

The second thing to check is whether the treatment has caused a change in your posture, especially if needles have been applied to the lower back as well as the knees. The physios pay particular attention to this, often because they use slightly more vigorous techniques than we do as traditional acupuncturists. Occasionally a muscle might be tense and 'guarding' because it is supporting an inherently unstable spine. If this relaxes then it can generate problems locally or even higher up. It can even be the case that the correction of gait problems can affect the spine which in turn can make a change higher up for which the muscles are not yet prepared. The physio may well be able to recommend some exercises if this is the case.

Of course, a third possibility is that by using  acupuncture from a physical/medical perspective only the treatment has caused systemic effects in a wider way of which the practitioner may be unaware. It has been one of our constant themes with western medical acupuncturists that using points within a medical context does not mean that you can switch off the effects they have from our perspective in Chinese medicine. Why this might have resulted in neck and shoulder pain would very much depend on the nature of your energetic balances from a Chinese medicine perspective.

What we think is very likely, however, is that unless a needle has caused physical damage in the area where your pains are they are very likely to subside within the next few days. You would be well advised to contact the physio anyway to ask what it going on, and any of our members would in the same circumstances be only too happy to discuss the problem and perhaps invite you back to take a look at what is happening. Nobody wants a patient to be in pain after treatment. It may well be that further discussion reveals why this is happening and also go a long way to ensuring that the same thing does not re-occur.

The other thing we should say, though, is that although it looks fairly likely that the treatment was causally implicated in the pains it may not be the case. If by the time you get this response the pains continue and are beyond simple pain control you would be well advised to see your GP in case this is something different which has by pure coincidence happened at the same time. With over four million treatments in the UK each year there are bound to be occasional coincidences, and the key thing is to get problems checked out first before getting engaged in discussions about what caused what.

Q: Can acupuncture help with polymyalgia? I have this fairly under control with steroids but have a very painful lower back pain.

A: Not surprisingly we have been asked many times about polymyalgia, and a typical response has been:

There are surprisingly few studies into the effects of acupuncture treatment on polymyalgia, and this does limit what we can say from a conventional medical perspective about the treatment of the condition. However, we suspect that this is a great deal to do with the diffuse ways in which the condition presents. In our experience the definition is imprecise, and we have seen patients with identical presentations diagnosed very differently.

From a Chinese medicine perspective, though, this doesn't really matter. For us the description of the patient's symptoms is seen against an entirely different theoretical framework. This involves an understanding of the body as a flow of energy whose rhythms, flow and balance can affect someone's health. When pain arises it is usually a sign of blockage in the system, or excesses and deficiencies which we can correct with the use of needles.

The real skill and art of the practitioner lies in identifying the true source of the problem. Such is the complex web of inter-relationships within the body a symptom will often not be the same as the cause of the problem. Finding out where the root cause is and addressing it is what differentiates a traditional practitioner from someone using simple all-purpose formula points. If the root is not addressed then the problem will come back. This also explains why a dozen people with the same symptom can be treated in a dozen different ways, with treating being individualised to each case.

The best advice that we can give is that you visit a BAcC member local to you so they can give you a brief face to face assessment of what could be possible. A skilled practitioner should be able to give you a rough idea quite quickly of how much change they think they might achieve and over what period of time. Most of our colleagues are happy to give up a few minutes without charge to enable the patient to make an informed choice, and will also be likely to offer good alternatives if they think these will address your problems better.

If asked by a patient what the evidence for the success of acupuncture for PMR is, though, we would have to be honest and say that not only does it not meet the gold standard of western research, the RCT, but often fails to meet any reasonable standard. We believe that this is partly to do with the difficulties of assembling a meaningful cohort for a trial, the diagnosis not always being precise, but partly to do with the fact that treating it as a purely physical condition may not be dealing with the underlying causes, some of which are often mental and emotional.

We believe that, downbeat as it may be, this is still a good answer. PMR is a condition which can on occasion be intractable, and it would be remiss of us to start making claims for treating all cases with great success. For many people the diagnosis is much broader than PMR itself, and there are often complex emotional problems which arise from having been incapacitated for a long time.

However, we are always careful when we see patients not to assume automatically that any pain which they experience is always a result of their 'headline' problem. There are often back pains which have an entirely different root cause, and if this is the case we usually feel pretty upbeat about our chances of achieving something with the patient. Until recently NICE recommended a course of ten treatments of acupuncture for chronic low back pain, and it is one of the commonest presentations in our clinics. The evidence for acupuncture treatment is good, as ourfact sheet shows:

https://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/back-pain.html

There's actually a short video on our home page of one patient's experience of treatment for back pain.

The advice we gave in the earlier reply still holds good. Find a local BAcC member and ask for a brief interview to discuss with them whether they think they can help. The fact that they can see what is going on and talk to your directly will give you a much more precise answer than we can offer here.

Q: A year ago I had a breast lumpectomy with all lymph nodes removed under left arm (lumpectomy left breast). I am suffering from pain in both areas - I cannot have any treatment on my left arm, but my holistic therapist has suggested accupunture on right side. I am anxious about this, I am needle phobic and was wondering where the needles would be placed and how many? If I do not feel comfortable, can I ask her to stop? She has told me I will be fine, but my anxiety is taking over.

A: The first and most important thing to say is that no-one can do anything in a treatment room without your consent. It is also not ethical to assume consent, so any healthcare professional who is about to do something which they could reasonably foresee you might object to, has to get explicit consent. If you say 'stop' and the person doesn't, it technically constitutes a criminal offence! If you want to immerse yourself in the legalities, the place to look is here:

https://www.gov.uk/government/publications/reference-guide-to-consent-for-examination-or-treatment-second-edition

Of course, what tends to happen in the treatment room is that patients often fall into a role of trust and deference which means they let things get far beyond where they would like without stopping the process, and we take great care to ensure that our members check every stage of treatment with patients rather than just carry blithely on. It might be best if you explain your anxiety to the practitioner first and agree before you start some form of words which means 'stop the music.'

As far as treatment itself is concerned, the restriction on treating the affected side is mainly to do with the risk of cellulitis or other infection. There are no case reports in the UK for this ever happening so it remains largely a theoretical risk, but as they say in research circles, absence of evidence is not the same as evidence of absence - there may have been cases but no-one made the connection. Interestingly, though, in China it is not at all unusual to treat lymphoedema on the affected side, and we did find a research trial involving western medics which used points on the affected side, so things may be changing.

No matter! One of our colleagues, Beverley de Valois, has researched and worked extensively in this area, and her listing on a teaching institution website shows the many papers she has written about effective treatment of problems when the arms cannot be needled after mastectomy with lymph node removal. In Chinese medicine there are all sorts of internal connections both side to side and above and below which means that there are always options to treat problems at a distance. Indeed, in many first aid protocols, treatment as far from the affected site as possible is used to get the greatest 'leverage.' A skilled practitioner is no more put off by this than by treating someone in a full leg plaster cast. How many needles and where placed we cannot say. There are many styles of acupuncture, and some use more needles than others. What we can say, though, is that the number of needles is completely under the control of the practitioner, and if asked to use less, we can. We can also reduce the depth of insertion and the amount of manipulation of the needle to address the problem of patients who are very sensitive and react strongly. Needle phobia is slightly different, but the average needle is a tenth of a millimetre across, inserted with a guide tube which dulls the sensation, and is barely perceptible. Many people are actually unaware that a needle has been inserted. A slightly dull ache or a tingling sensation are usually the most that people feel.

As above, though, you are in charge in the treatment room, and you can ask the therapist to work at a pace you feel comfortable with. If they won't, find someone else who will!

We hope that this has quelled some of your anxiety.

Q: Due to 32 years of diabetes, neuropathy in my foot has set in.Feeling of heavyness in the fingers is felt though blood flow is ok in the legs. Can acupuncture be of help to restore normalcy in the foot areas?

A: As you can imagine we have been asked about peripheral neuropathy on a number of occasions. One of the more recent answers we gave was:

There is some evidence that acupuncture may be helpful in the treatment of neuropathy, as our factsheet http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/neuropathic-pain.html shows but this is not yet compelling enough for us make a firm recommendation. If you google for results from the US National Centre for Biotechnology Information, a very useful research resource, as 'ncbi acupuncture peripheral neuropathy' you will find references to a number of studies, some of which seem to show very positive results, others less so. Treating nerve damage with acupuncture, however, suffers from the same limitations as any other therapy. If the damage is already considerable there is less chance of reducing the pain and loss of sensation.

Chinese acupuncture is based on a theory of energy, called 'qi', and its flow and balance in the body. This can often mean that the needles used in conditions like peripheral neuropathy are often local to the problem and seen as a blockage in the flow of qi, but Chinese medicine has an elaborate understanding of the functional nature of the internal organs, understood entirely differently from in the West, and will often look at how the problem may also be a manifestation of a wider functional disturbance in the system. Then, of course, you have the underlying premise of the original Chinese medical systems which were largely asymptomatic, regarding the achievement of overall balance as the primary aim in the belief that this would deal with symptoms wherever they manifested.

The important element in treating peripheral neuropathy is understanding the physiological basis for its appearance in western terms and being realistic about what may be achieved. If this amounts to maintaining the status quo, or even as one very wise patient expressed it 'getting worse slower', then as long as this is the agreed basis for treatment, that is fine. Our members are trained to avoid raising unreal and unreasonable expectations in people with degenerative conditions or permanent physical damage. Talking to a BAcC member local to you face to face may be the best advice if you are considering treatment. They should be able to assess relatively quickly whether acupuncture was a worthwhile option for you.

This remains the best advice we can give you. A practitioner may see something in your state of balance which is a basis for treating the system as a whole with some expectation of change, however limited. The question may well be how much change and how sustainable. If it managed to quell the worst symptoms, which based on evidence for acupuncture and pain relief may be possible, then treatment may be very worthwhile.

However, we would have to say that restoring 'normal function' is unlikely. There is a small amount of evidence from the world of animal experimentation with acupuncture that some nerve tissues can regenerate, but these tend to be very small and non-essential nerves. We have also found a number of small studies which showed slightly improved conductivity in PN after the use of acupuncture, but these are too small to draw any conclusions which could be generalised for all patients.

The best that we can say is that acupuncture may improve the quality of the nerve signals which are present, and may thus help with some pain reduction, but each case is unique and different, so the best option will always be to see a practitioner who can cast an experienced and skilled eye over your whole system to see what may be possible.

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