Ask an expert - body - chest

43 questions

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.


A: There isn't actually a great deal of evidence for the treatment of COPD as our factsheet

 http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/1587-copd.html

 shows. If you click on this link and then click on the 'evidence' button you will see that there hasn't been a great deal of research, and it only cites a trial from 2004 conducted by George Lewith and a systematic review from a few years ago. There has been another systematic review published more recently

http://www.ncbi.nlm.nih.gov/pubmed/25478799

 and evidence that another is about to be done, so there is clearly a great deal of interest. This is probably because COPD rates as one of the more frequently occurring and debilitating problems, and anything which can help is worth investigating. Acupuncture treatment has shown encouraging signs of helping existing treatments to be more effective, so larger studies may well follow.

 Of course, this is the problem as seen from a conventional medical perspective, and one of the factors which makes the research so difficult to organise is that there are many possible causes, some of which are more tractable to treatment than others. If, for example, someone has smoked for fifty years or has emphysema then the potential for improvement is severely limited. If the obstruction is more transient, like excessive phlegm or poor lung function, then there may be more that can be done. The great strength of Chinese medicine is that it looks at the symptoms which someone has in the context of their overall health, and also has a number of different ways of viewing the same symptom pattern. This means that the treatment is very much geared to the individual, and not simply a protocol based on the symptoms alone.

 A great deal depends on the reasons for the development of your COPD, so it would be unwise to start making too many promises about what may be possible. Your best bet would be to visit a local BAcC member for a brief face to face consultation to get advice on what may be possible. Most members are happy to see someone without commitment for a few minutes to assess whether acupuncture is the best treatment for them.

 We think, though, that the advice is likely to be very realistic. Once someone has been diagnosed with COPD it is for the most part a matter of getting worse slower rather than getting better, so outcomes have to be realistic from the off.

 

A:  As far as we are aware there are no contraindications for the use of acupuncture, either traditional or auricular, with patients who have cardiomyopathy. In fact, if you undertake internet searches you will find a number of papers, most written in Chinese and published in China, which suggest that acupuncture treatment can be used to good effect in the treatment of some aspects of cardiomyopathy. The studies we found tend to use auricular acupuncture.

The normal safety standards which apply to the use of auricular acupuncture should be perfectly adequate for the protection of the patient with this condition, and the only slight concern we have raised in our members' Guide to Safe Practice is the use of retained needles when a patient has a history of heart valve problems. The section reads:

Patients who have damaged heart valves (eg after rheumatic fever) or artificial valves are at a higher risk of developing endocarditis. Retained needles, a category which includes ear needles, dermal needles and press studs which can be left in place for days, are contraindicated for these patients as they can become infected and cause endocarditis.

This is a very different kind of condition, so unless there is a secondary problem beyond the cardiomyopathy there is no reason not to proceed. 

We did find, however, one study (reference 18) referred to in another article

http://www.itmonline.org/arts/pc6.htm

which suggested that in one case there had been unwanted changes as a consequence of treating specific points, so if you have any concerns about the patient based on his or her presentation you could always, with their consent, approach their GP to ensure that it is OK to treat. This is the advice which we invariably give to BAcC members if they are not sure.




Q:  I have symptoms of arrhythmia.I do have an ICD to keep my heart in check in case of a runaway tachycardia episode.I take mexiletine and sotalol to prevent that from happening......The drugs themselves are enough to kill me....Would acupuncture be a viable alternative to all these medications,and to better my overall health? I am more than ready for a change! (Sick and tired of being sick and tired) I am only 61 yrs old with a lot of living yet to do.I'm in good health otherwise.Just can't do the things I used to do......frustrating!!!

A:  We have to say that acupuncture is not viable as an alternative to your current medications.

This is a problem which we confront quite often with medications, and especially those prescribed for asthma. The medications are prescribed as a preventative, and if someone's condition is stable then it is extremely unlikely that a GP will consider stopping or reducing the dose. This is not a surprise. There is evidence to suggest that if long term medications for asthma are removed there is a slightly increased risk of a serious or fatal attack, and faced with this possibility for any preventive medicine it is likely to mean a lifetime regime. Better than the alternative, as they say.

However, we do treat many people with lifetime medication regimes and there is no doubt in our minds that acupuncture can sometimes make the side effects of the medication less unpleasant, and may also start to address the underlying problem for which someone is taking the meds. There are obviously no trials to validate this statement - they'd never get ethical approval - but from a Chinese medicine perspective the drugs themselves are a toxin which will have an impact on the body's energies beyond the positive effects they have on the specific problem, and it is always possible to reduce the discomfort that these cause. A classic example for us is the use of acupuncture for the nausea caused by chemotherapy. There is a great deal of research which shows that the anti-emetic effect is strong without compromising the effect the drug has on cancer cells.

The best advice that we can give is that you visit a BAcC member local to you for a brief consultation about what benefits acupuncture may be able to offer. Your condition will have some sort of history, and even a brief narrative account may well offer some useful insights into what the problem is from a Chinese medicine perspective, what the underlying causes may be, and also what effects the medications are having on the system. This may encourage a practitioner to feel that there is a good chance of reducing the impact that these medications are having.

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