Ask an expert - body - chest

41 questions

Q: Hi. I suffer from ventricular ectopics,I have seen Drs regularly and take beta blockers which work to a degree. I have periods when things aren't too bad and periods when things are really bad,I do get quite down during these times. Do you think acupuncture would help?

A: We have been asked similar questions before, and in reply to one we said:

One has to be very careful answering questions such as these. Taking the pulse a the wrist is one of the key diagnostic techniques in Chinese medicine, along with looking at the tongue and a number of other evaluations. The irregular pulse has clinical significance in the tradition, and point to specific disorders of organic function as understood within this paradigm of medicine. However, these may not all involve the heart - in fact, most of them don't - and any suggestion that this is treating the heart as it is understood in the west needs to be set aside.

From a conventional medicine point of view, there is not a great deal of evidence that acupuncture can treat these problems, although what little there is does tend to be very positive, although not always methodologically sound enough to use as the basis for a recommendation. A good example of a systematic review is:

http://www.ncbi.nlm.nih.gov/pubmed/18992625

Some of the published research also involves animal experiments, sometimes called 'ratpuncture' in the trade, and although the results here may be promising it is quite a large assumption to believe that human physiology will respond in the same way.

We think that it would certainly be worthwhile talking to a BAcC member local to you about what the conditions may be telling them about the way your system as a whole is functioning. From our perspective all of our members are equally well-qualified to deal with the vast majority of patients who present at their clinics, and it is obvious from what we have said earlier that there are no specialists in heart problems per se - Chinese medicine primarily treats the person, not the condition which someone has.


There have been a couple of other systematic reviews

https://www.ncbi.nlm.nih.gov/pubmed/28432528

http://www.internationaljournalofcardiology.com/article/S0167-5273(11)00227-0/fulltext

which make largely positive noises, but as in all of these kinds of studies the treatment which is given is largely formulaic, and does not really represent what a traditional acupuncturist does, which is to gear treatment to the individual and his/her unique balance of energies. Where trials offer designs which allow the practitioner to do what they might normally do, so called 'black box' trials, the results tend to get better and better.

The bottom line, though, is that from a Chinese medicine perspective there are often functional disturbances which can generate symptoms, often far away from the source of the manifesting problem. The skill and art of the practitioner is to make sense of the diagnostic information and treat the root of the problem. This can often cause a symptom to reduce or even disappear without there having been any apparent connection between where the needles were placed and the part of the body in distress.

The advice we gave before still holds good, to visit a local BAcC member for advice and a short face to face assessment of what may be happening. Most BAcC members are only too happy to give a small amount of time without charge to prospective patients to enable them to assess whether acupuncture is the best treatment for their problem. This will obviously give a far better idea of what may be possible than what we can say at a distance.

Q: My son has terrible hay fever and I want to know if acupuncture is any good in illeviating this and who would be the best person to go to near to Newcastle under Lyme to treat the condition

A: There isn't a great deal of research under the heading of 'acupuncture and hay fever' on which we can draw for evidence of the success of acupuncture treatment, and what we do have on our website is a factsheet for allergic rhinitis with which there i very considerable overlap.

https://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/allergic-rhinitis.html

We have checked the databases, though, and while you will find occasional studies like this one

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3983860/

there are not as many as you might expect. We suspect that this is because the random timing of the occurrence of the problem makes it difficult to assemble a cohort of sufferers to run the trial.

The one thing we can say with certainty, though, is that it often helps to start treating two or three months before someone would normally start their symptoms in order to achieve the best results. Once the problem has started and bedded in it can be a great deal harder to address. Treating the person rather than the symptom is central to Chinese medicine, so working in advance of seasonal symptoms is quite a normal pattern of work anyway and one which would probably strengthen the immune system. We often find that sufferers still get small traces of symptoms but nothing like the effects they have had in the past.

You haven't mentioned whether your son is a child or not. If he is, then this bodes well for treatment. Children are not simply small adults, and many members undertake postgraduate training in paediatric acupuncture to work with children. We cannot make recommendations but we ran a quick google search using key words like your home town, acupuncture and children, and quickly generated some interesting results.

Hay fever comes in all shapes and sizes, though, and it would be best for you to see if someone is prepared to take a look at your son and see what they think. Most of our colleagues are more than happy to give up a little time without charge to talk to prospective patients, and we find this works to everyone's advantage.

In our experience younger children respond very well to treatment, often requiring minimal intervention to get really significant results. If your son doesn't fancy needles, though, we cna say that Chinese Herbal medicine and classical homeopathy both see, in our view, to offer some interesting alternatives. Both have received quite bad press over the last few years, but we have seen many patients whose experience of both modalities has been very good.

Q: I've read that acupuncture raises blood pressure in individuals with normal blood pressure. Does this always happen and if so, after treatment, does the blood pressure go back to normal?

A: We have looked carefully through all of the research databases and checked for anecdotal accounts on the web, but apart from people who have experienced a raised blood pressure as a nervous response to having treatment itself, there is no evidence to suggest that acupuncture would raise blood pressure in someone with a normal blood pressure. Clearly if someone has low blood pressure, treatment might have the effect of normalising it, but the primary effect of acupuncture on blood pressure is to lower it. This is a well attested outcome, and we have have seen thousands of patients over the years who have hypertension as a primary or secondary problem, many of whom have seen considerable improvements after treatment.

That is not to say that it cannot happen, and if you have come across some research which we have missed we would be very grateful for the reference. Things do change, and surprising results do emerge, but something as important as this would generally bubble to the surface quite quickly.

Our own fact sheet on hypertension is not as informative as some others we produce, and the evidence is not to the standard where we would be making specific claims for the benefits to be derived from treatment. Most of the studies, however, fail on methodological grounds, but all report a lowering of blood pressure with treatment.

Q: I am booked in for acupuncture for neck pain. I am now having second thoughts as I am on warfarin for atrial fibrillation. My questions are: Will it interfere with the electrical impulses from the needles causing me to have an atrial fibrillation attack and could it cause localised bleeding?

A: Let us first put your mind at rest about using acupuncture when on warfarin. The advice we give to members in a Guide to Safe Practice is:

Patients on anti-coagulant medication

You must take great care when needling patients who are taking anti-coagulant drugs such as Warfarin. Only very superficial needling with fine needles (0.20mm) is recommended.  

The risk appears small but internal bleeding leading to compartment syndrome can have extremely serious consequences. There is one report in the medical literature of a case of compartment bleeding following acupuncture in a patient taking anti-coagulants (see link to article at the end of this section).  

Warfarin prevents the body from metabolising vitamin K. Vitamin K controls the formation of a number of coagulation factors in the liver and is an essential substance for blood clotting. Vitamin K is present in most of the foods that are considered to be blood-forming according to Chinese medicine such as green leafy vegetables. This is important to consider if you are giving dietary advice to patients on Warfarinsince these foods can lessen the desired effect of the drug.  

Patients are put on Warfarin or other anti-coagulants for a number of different reasons. These may be purely preventive if, for example, the patient suffers from atrial fibrillation or has mechanical heart valves, or because of recent surgery, stroke, heart attack or thrombosis. The dosage of the medication depends on the desired amount of anti-coagulation for that particular condition.  

Every patient on Warfarin has to undergo tests on a regular basis to check how long it takes for their blood to clot. The frequency of these tests depends on the dosage of their medication and their condition. It is good practice to encourage your patient to have more frequent tests while they are receiving a course of acupuncture as the treatment can positively influence their blood values and may require their Warfarin dosage to be reduced.  

Ask your patient for their INR (international normalised ratio). The INR is a ratio established by measuring the prothrombin time (PT), which is the length of time it takes for the patient’s blood to clot, and then by comparing this value to an average.  

In a healthy person the INR is about 1.0. Patients on Warfarin tend to have an INR somewhere between 2.0 and 3.0 or even higher, depending on the desired amount of anti-coagulation. A higher INR signifies a stronger effect of anti-coagulation.  

The main risk associated with acupuncture is internal bleeding. Depending on the depth of needling and the underlying structures involved this may be insignificant, but there is a chance that it can result in compartment syndrome. Although the risk is small this condition can have serious consequences and often requires surgery.  

Needling should only be done superficially and with fine needles. The higher the INR, the greater the risk of bleeding. Patients with an INR of 3.5 (sometimes therapeutically necessary in the treatment of valvular disease) or higher should be treated with greater care.  

It is also advisable not to use guasha and cupping on patients on anti-coagulants since these techniques tend to draw blood to the upper layers of the skin and can cause severe and prolonged bruising to larger areas of the body.

Of course, we have had to adjust this advice in the new version which we are just about to publish because there is a new generation of anticoagulants like dabigatran (Pradaxa) which do not require the regular monitoring of INR levels, so practitioners need to be vigilant in looking at what happens after they have needled someone. If the patient bruises unexpectedly or with every needle insertion then it may be sensible to refer someone back to their GP for testing to ensure that the dose is correct for them.

Our main caution in Chinese medicine would be where there are syndromes which describe the blood as 'stuck', a term often used being 'blood stasis'. It is just possible that someone being treated with Chinese medicine for blood stasis while at the same time being prescribed anti-coagulants might just find that they clotted a little less quickly than before, but change in this department is never that rapid or dramatic, and the appearance of bruises or bleeding which is harder to stop might well be the first sign of an over-effective combination of therapies. As would always be the case the practitioner would usually refer the patient back to their doctor for re-assessment.

However, we monitor adverse events very closely, both through our own safe practice staff and through our professional insurers, and we have yet to see a claim or report in 30 years based on a bleed from a patient on anti-coagulants.

As far as atrial fibrillation is concerned, we were asked about this recently, and our answer was:

There are some early indications that acupuncture may have an anti-arrhythmic effect in patients with atrial fibrillation. A study published earlier this year    

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312232/

concluded that there appeared to be benefits and that further large scale trials would be valuable to test the hypothesis more carefully.   However, it is only fair to say that needling a single point such as Neiguan repeatedly is not a fair representation of what a traditional acupuncturist does in practice. Although there is considerable overlap between eastern and western systems the arrhythmia typical of AF could be classified in several different ways within Chinese medicine, and the practitioner would be guided by evidence other than simply a reading of the rate of the pulse. That in turn would mean that ten people with AF might receive ten different treatments. To that extent, it is not that straightforward to extrapolate from research studies like this and conclude that 'acupuncture works'.  

The skill of the practitioner lies in making sense of the symptom of AF within an entirely different theoretical framework, and understanding each presentation in each individual patient as unique. The best advice we can give any prosepctive patient is to contact a BAcC member local to them to seek a short face to face consultation at which they can be given a better assessment of whether acupuncture might benefit them.  

The one caution with AF is that most patients are taking some form of medication to control the problem, and the cessation of medication can quickly provoke a return of the symptoms. For people involved in highly technical or responsible work this might represent a serious risk. We would always recommend that any member contemplating treating someone with a condition like AF should talk to the patient's GP to ensure that nothing they do will undermine the current treatment regime. 

A more recent review

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4321072/

reinforces this perspective.

As far as 'electrical impulses from the needles' is concerned, only a small minority of our members actually use electro-acupuncture machines attached to the needles, and even where they do there is no risk from their use. One of our senior colleagues has written the definitive guide to electroacupuncture and there is no mention in it of any cautions about AF. If a machine is used correctly, there should be no problem. Where members are using good old-fashioned needling there is no risk of which we are aware that there could be side effects from its use.

We believe that you can go ahead with your treatment in complete confidence that your practitioner is extremely unlikely to cause any problems and will probably have a good impact on your neck. Talk to them about your fears, though; it is far better that they know you are apprehensive, and we are sure that they will do their very best to address your concerns and talk you through what is happening.

A:  We have produced a factsheet on hypertension

 http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/acupuncture-and-hypertension.html

which we have to confess we found a little lukewarm. However, we were delighted to find that there have been a number of new studies published since the factsheet was written, two of which 

 https://www.ncbi.nlm.nih.gov/pubmed/20232615

https://www.ncbi.nlm.nih.gov/pubmed/23724695

make much more encouraging noises. However, the most recent systematic review

https://www.ncbi.nlm.nih.gov/pubmed/26207806

concludes that acupuncture treatment is probably more useful as an adjunct to the use of conventional medication, and that, surprise surprise, more research needs to be done with larger studies. Easier said than done in the West where very little research is funded by mainstream bodies. However, one day....

 From a Chinese medicine perspective there are a number of clearly defined patterns which generate hypertension and where there are well-established protocols for lowering blood pressure, usually described from the external signs - the ancient Chinese did not have sphygmomanometers. When we come across new patients with these kinds of symptoms patterns we are usually confident of being able to offer some help. However, we always work as closely as we can with their doctors, whether directly or indirectly, to ensure that any reduction in medication is managed carefully. We have seen enthusiastic patients stop taking their meds in their desire to use a more natural method of B control and watched their BPs go through the roof. This is not what we want to see; the risk is too great.

 As far as snoring is concerned, there is very little research about snoring per se. There is quite a bit about obstructive sleep apnea, and we suspect that if your GP is aware of your BP problems and the snoring that investigations have been done to assess whether the snoring is part of the sleep apnea and contributing in part to the higher BP. Otherwise we have to be honest and say that when we take on patients with a problem like snoring, we tend to do so with the caveat that we will use our skills to balance things as well as we can from a Chinese medicine perspective and see what effect this has. However, we tend to set a tight limit on how many sessions we will do as an experiment, and we always look for a decent measurable outcome so that it is clear whether the treatment is working or not. This can be a problem; the sufferer is usually blissfully ignorant of the effect they are having.


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