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Q:  My husband was diagnosed with Parkinsons disease some 11 years ago and has been on medication which fortunately has been successful with the exception of a shaking right arm. He has some control over it but it causes him stress and embarrassment. Do you think acupuncture may relieve this problem.

We tend to be a little tentative in offering advice on conditions like Parkinsons which are often chronic and degenerative. A typical response that we have given in the past reads:
 

From the perspective of research studies alone it would be difficult to give any firm recommendations for acupuncture as a treatment of Parkinson's Disease. There are a number of studies, some undertaken in the US but the vast majority in China, which show some positive signs, but not of sufficient change in a significant number of patients under study to draw any firm conclusions. You can see some of the studies if you google 'ncbi acupuncture parkinson's disease' - the National Centre for Biotechnical Information in the States is a convenient way to find many of the the more significant papers. There is also a Cochrane Review of a protocol for assessing the value of acupuncture, but as far as we are aware this has not been put into action yet.

With all chronic degenerative conditions the extent to which acupuncture can help has to be carefully explained. It is often, as one rather ironic patient said, a case of 'getting worse slower', and this is extremely difficult to quantify in a condition like Parkinson's where the disease progression is neither smooth nor predictable. Anecdotally there are many accounts of patients finding that treatment helps with some of the manifestations of the disease, such as the periods of rigidity and freezing, and a general sense of well-being, but these are not documented sufficiently well to be able to claim any undisputed levels of efficacy.

The best course of action is to see whether a BAcC member local to you will give you an honest assessment from an eastern perspective of what they might be able to achieve for your own unique patterns. There may be elements of how the condition manifests which they may feel that they can help.

As you can see, we are very cautious in our choice of words. The shaking of the arm with Parkinsons has been tested in some small studies, as in this one

http://www.ncbi.nlm.nih.gov/pubmed/12210879

and there is some optimism in the write-up but it is a very small study.

From a Chinese medicine perspective there are a number of syndromes which describe the shaking of the limbs, and which provide explanations of them in the terms which we use as practitioners. This can sometimes cause a little confusion because it gives an impression that a symptom which is treatable in Chinese medicine may mean that the same symptom might be easily treatable from a western perspective. Where there is a physical change in the brain, however, it would be unwise to get too excited about the possibilities.

In any situation like this, though, we find that it does not help to be negative because there may be multiple reasons why someone's tremor might be quite bad, not least in the fact that stress itself can make the symptoms of Parkinsons more noticeable. We have found in clinical practice that reducing stress can sometimes make the frequency and severity of symptoms reduce, and it would certainly be worthwhile talking to a BAcC member local you you about what may be possible.

 

A:  This depends a great deal on the kind of condition which the practitioner has been treating, and in every case it is a judgement call. 

There are some conditions where the body simply reverts to good health, and it is quite clear that no more treatment will be required. This is often the case in helping recovery from a sports injury or a digestive problem brought on  by specific causes. In these cases the practitioner will usually advise the patient to contact them at the first sign of some return of the problem.

At the other end of the spectrum are the conditions where it is quite clear that someone is going to need maintenance treatment for a very long time, even though the immediate presenting symptoms have gone. When helping people through acute episodes of depression or anxiety, or when dealing with an age related deterioration in the lower back, getting past the initial acute phase of trouble may well need to be supplemented by regular maintenance treatment, and this was very much the understanding of acupuncture treatment in ancient times. The job of the doctor was to keep you well as much as to get you better.

The trickiest cases are where someone looks like they have got rid of a problem but may need further treatment. In this expert's experience migraines often respond very well to weekly treatment, and after five or six sessions there has often been a tremendous change. However, there may be a need to treat someone monthly for two or three months to consolidate the progress, and just telling people to give you a call in a month's time never seems to work. People forget, and then two or three months later get a migraine and conclude that acupuncture didn't work. It is sometimes  a challenge to book someone a month ahead when they feel better, but experience suggests that this is the best way to make conditions like this stay gone.

Each person is unique and different, however, as is their treatment, so although we can offer general guidelines like this it would really be a matter to discuss with your practitioner. Most are keen not to over-treat, and will review progress at regular intervals to make sure that treatment does not become a 'habit', however enjoyable. It is fair to say, though, that many of us take the view that the ancient system of staying well rather than getting better is the right way to work, and encourage patients to start to take this view of their health with regular treatment and with adjustments to their lifestyles. It was an often repeated saying in the old days of training, and maybe still is, that patients will not give a second thought to putting their car in for an annual service costing over £1000 but will baulk at five sessions a year to keep themselves in trim.

The depth of needle insertion depends both on the location of the point and also on the style of treatment.

Most points are needled to a depth of between 3mm and 5mm, with some in quite bony places, like fingers and toes, slightly less, and some in the hip and buttock a considerable amount more, as much as 1 to 2 cm.  Although it is difficult to make generalisations about styles, many Japanese styles of acupuncture use superficial needle insertions almost everywhere on the body, often using quite oblique insertion, whereas some of the medical acupuncture techniques are much more invasive, often needling to a depth of an inch or more.

Practitioners are usually guided by the sense of contacting the energy of the patient, and if this is achieved at relatively superficial levels that is far as they will needle.

A:  Inserting anything deeply into the body is potentially dangerous, which is why we regard our degree level training as the minimum requirement for the safe practice of acupuncture. This is why we take issue with short courses and people who decide to 'have a go'; needling safely and without risk of infection requires attention to a more detail than can be bolted on to short courses. 

There are some areas of the body where deep needling is especially risky, but thousands of years of practice and experience of the variation in the shapes and sizes of patients has led to some very specific guidelines for how deeply to needle and at what sorts of angles. Deep needling is particularly dangerous on the thorax, and along with the two leading medical acupuncture organisations we have created a website www.acupuncturesafety.org.uk which has a safety chart to encourage safe practice by health professionals who decide to add acupuncture to their repertoire. Needling in this area requires oblique insertion of needles, and extreme care in needling  the elderly, the thin and those with a history of bronchial problems.

In the hands of a fully trained and qualified professional you are safe. The number of serious adverse events each year is very small indeed when you think that over 4,000,000 treatments are administered, with only a dozen or so requiring more than short term first aid. However, our aim is to bring this number down even smaller, which is why we are combining with our medical colleagues to make acupuncture one of the safest healthcare modalities around.  



Q:  I recently came across a case where a patient who had had a TIA 5 years previous to acupuncture had another during the treatment. Are you aware of any evidence/cases where this has happened. I wonder if it was pure coincidence.

A:  We are sorry to say that we are not aware of this particular case. We have long been aware of Soma Glick's treatment of a patient having a TIA/stroke while it was happening

http://somadevi.com/wp-content/uploads/2009/04/tis.pdf

but we have not come across the case to which you are referring.

We strongly suspect that the occurrence is a coincidence. From all of the data which has been collected over the last forty years there is no evidence of a TIA arising during or immediately after acupuncture treatment. Three major studies

http://www.who.int/bulletin/volumes/88/12/10-076737/en/

http://www.hindawi.com/journals/ecam/2013/581203/

 http://aim.bmj.com/content/22/3/122which have collected data from dozens of other reviews and have never reported such an event, not are we aware through our own records of any patient of our own members or those of other associations being affected.

There may be some aspects of having treatment which could, in theory, if the patient was anxious, have triggered the repetition of an existing condition, but that would still be highly unusual.

Our belief is that with well over 4 million treatments being administered in the UK alone each year the statistical possibility of a serious health problem unrelated to the treatment itself has increased dramatically, and this is probably what has happened here.

However, we would be very grateful for further details of the case to which you refer in case there is something which would prompt further investigation.


 

A: We would be interested to know a little more about the trapped nerve itself and what kind of pain it is causing before we could offer a view. The knee is quite a difficult place to trap a nerve, and our first thought would be that there has been some mechanical displacement of the joint which has precipitated the problem. Although acupuncture treatment might help with the body re-aligning its structure we would be more inclined to send someone to an osteopath first to see if there was a more direct approach.

This is very much in line with advice we gave a little while ago about trapped nerves in general

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. 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.

We think that this is probably the best that we can say.

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