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Ask an expert - general

189 questions

Q: A couple of time I have read on your website that acupuncture treatments are almost good for nothing and that there is no evidence that it can successfully treat conditions as Trigeminal Neuralgia and many others. Are you against acupuncture? Your website seems to advocate against this science.

A: This is a very good question, for which we think there are some very good and, we hope, informative, answers.

The first and most important point to make is that since the Advertising Standards Authority's reach was extended to cover websites and internet marketing there are much stricter conditions about what people can claim in their advertising and marketing materials. In healthcare in particular any claims to cure, treat or help in the treatment of a problem now have to be backed up by evidence that this really is the case. By'evidence' the ASA has adopted a standard with which nearly every complementary therapy has disagreed and with which they have taken issue, the randomised double blind control trial. This really only works well for drug testing, not for therapies where the nature of the intervention develops as treatment progresses.

The BAcC, along with many other bodies, has been engaged in discussion with the ASA for the last five years about the unsuitability of this as a standard, and also about the choice of experts by the ASA to review evidence. The bottom line, though, according to this criterion is that only about four or five conditions meet the required standard, and a very uninteresting group they make too unless you happen to be looking for acupuncture treatment for dental pain. The vast majority of studies are not RCTs, nor would we want them to be; the acupuncture is often formulaic and restricted, and about as far removed from day to day practice as one can imagine.

However, these are the rules, and so when we are asked about named conditions we have to be very clear that the evidence from this perspective is not conclusive. We often use terms like 'encouraging' or 'promising' when the evidence is short of conclusive but fairly robust,  but as a regulatory body which has to require its members to comply with the law we cannot ourselves bend or break the rules. If there is no conclusive evidence in the ASA's terms then we cannot claim there is, even when we know that we have treated many cases of a problem successfully.

As far as named conditions themselves are concerned we have also been backed into a corner, partly because of the nature of our own marketing over the years. As we are at pains to say in nearly every response traditional acupuncture treats the person, not the condition. Although you will find an increasing number of books and internet articles about 'acupuncture for headaches' or 'acupuncture for stomach disorders' this is not how we view our work. To some extent it is possible to treat named conditions in themselves but from a traditional acupuncture perspective it is not as satisfying or ultimately as likely to succeed long term as treating the person, i.e. tailoring the treatment to the individual and their unique imbalances. In the circumstances it is with great caution that we would say 'acupuncture treats x or y or z';. There are going to be many prospective patients for whom this will not be the case because what seems like a simple problems sits atop a pattern of overall disorder which might take months or even years to sort out.

At the same time, as practitioners we have seen many thousands of patients over the years, and we have a fairly clear idea of the conditions which, whatever the state of an individual's health, do not seem to be too tractable to treatment. Some, like severe tinnitus, can endure through many courses of treatment of all kinds, as the magazines of the tinnitus support groups attest. It would be unhelpful and misleading for us to claim to treat such problems on the basis that acupuncture treats the person, not the condition, when we know that it is one of a number of problems which do not seem to respond well to any treatment.

We take the view that as a mature profession we should be honest in assessing those problems which are more likely to be helped and those which aren't, and letting the prospective patient know this. We remember earlier times when the fact that acupuncture treated the person more than the disease led to some patients getting the very wrong end of the stick; treating a patient with cancer is not the same as treating cancer, but people will hear what they want to hear unless someone is very careful with their choice of words.

As a final point, we would probably not want to lay claim to the word 'science' for what we do. There are all sorts of definitions of scientificity, and under many of them we could probably make a case for traditional acupuncture as a science. We also, though, recognise that there is an art to what we do, skills based on experience and observation which are unique to each practitioner and which provide an infinite number of perspectives on groups of patients. We had this brought home most clearly when we were discussing National Professional Standards with doctors. For them a diagnosis was an accumulating paper or computer file which could travel from doctor to doctor without any change or modification. For us, diagnosis was an active process which depended on the individual practitioner, and evolved over time. Until we ironed out this major semantic difference there was great confusion.

We hope that this explains why we take the approach we do, and why our answers and our website in general do not claim as much as we would like or, in fact, could do based on our clinical
experience. Our strategy has always been, however, to encourage people to visit our members to find out what acupuncture can do for them as unique individuals rather than offering generic answers to individual problems. Judging by the feedback we receive this approach seems to have gone down well with a large proportion of the 2500 people to whom we have replied through this facility.

This is a very good question, for which we think there are some very good and, we hope, informative, answers.

The first and most important point to make is that since the Advertising Standards Authority's reach was extended to cover websites and internet marketing there are much stricter conditions about what people can claim in their advertising and marketing materials. In healthcare in particular any claims to cure, treat or help in the treatment of a problem now have to be backed up by evidence that this really is the case. By'evidence' the ASA has adopted a standard with which nearly every complementary therapy has disagreed and with which they have taken issue, the randomised double blind control trial. This really only works well for drug testing, not for therapies where the nature of the intervention develops as treatment progresses.

The BAcC, along with many other bodies, has been engaged in discussion with the ASA for the last five years about the unsuitability of this as a standard, and also about the choice of experts by the ASA to review evidence. The bottom line, though, according to this criterion is that only about four or five conditions meet the required standard, and a very uninteresting group they make too unless you happen to be looking for acupuncture treatment for dental pain. The vast majority of studies are not RCTs, nor would we want them to be; the acupuncture is often formulaic and restricted, and about as far removed from day to day practice as one can imagine.

However, these are the rules, and so when we are asked about named conditions we have to be very clear that the evidence from this perspective is not conclusive. We often use terms like 'encouraging' or 'promising' when the evidence is short of conclusive but fairly robust,  but as a regulatory body which has to require its members to comply with the law we cannot ourselves bend or break the rules. If there is no conclusive evidence in the ASA's terms then we cannot claim there is, even when we know that we have treated many cases of a problem successfully.

As far as named conditions themselves are concerned we have also been backed into a corner, partly because of the nature of our own marketing over the years. As we are at pains to say in nearly every response traditional acupuncture treats the person, not the condition. Although you will find an increasing number of books and internet articles about 'acupuncture for headaches' or 'acupuncture for stomach disorders' this is not how we view our work. To some extent it is possible to treat named conditions in themselves but from a traditional acupuncture perspective it is not as satisfying or ultimately as likely to succeed long term as treating the person, i.e. tailoring the treatment to the individual and their unique imbalances. In the circumstances it is with great caution that we would say 'acupuncture treats x or y or z';. There are going to be many prospective patients for whom this will not be the case because what seems like a simple problems sits atop a pattern of overall disorder which might take months or even years to sort out.

At the same time, as practitioners we have seen many thousands of patients over the years, and we have a fairly clear idea of the conditions which, whatever the state of an individual's health, do not seem to be too tractable to treatment. Some, like severe tinnitus, can endure through many courses of treatment of all kinds, as the magazines of the tinnitus support groups attest. It would be unhelpful and misleading for us to claim to treat such problems on the basis that acupuncture treats the person, not the condition, when we know that it is one of a number of problems which do not seem to respond well to any treatment. 

We take the view that as a mature profession we should be honest in assessing those problems which are more likely to be helped and those which aren't, and letting the prospective patient know this. We remember earlier times when the fact that acupuncture treated the person more than the disease led to some patients getting the very wrong end of the stick; treating a patient with cancer is not the same as treating cancer, but people will hear what they want to hear unless someone is very careful with their choice of words.

As a final point, we would probably not want to lay claim to the word 'science' for what we do. There are all sorts of definitions of scientificity, and under many of them we could probably make a case for traditional acupuncture as a science. We also, though, recognise that there is an art to what we do, skills based on experience and observation which are unique to each practitioner and which provide an infinite number of perspectives on groups of patients. We had this brought home most clearly when we were discussing National Professional Standards with doctors. For them a diagnosis was an accumulating paper or computer file which could travel from doctor to doctor without any change or modification. For us, diagnosis was an active process which depended on the individual practitioner, and evolved over time. Until we ironed out this major semantic difference there was great confusion.

We hope that this explains why we take the approach we do, and why our answers and our website in general do not claim as much as we would like or, in fact, could do based on our clinical
experience. Our strategy has always been, however, to encourage people to visit our members to find out what acupuncture can do for them as unique individuals rather than offering generic answers to individual problems. Judging by the feedback we receive this approach seems to have gone down well with a large proportion of the 2500 people to whom we have replied through this facility.

Q: I saw an osteopath today for acupuncture treatment of my lower back. I have 2 damaged discs at L4-5. As one needle went in it was fairly painful like a nerve had been touched. She said she was near one of my damaged discs. When she started moving a different needle the pain was unbelievable like a intense burning sensation. She removed the needle straight away and massaged the area until the pain subsided. Everything I have read seems to suggest I shouldn't have felt this pain. I am due to go back for another session next week but I'm really concerned now.

A: We are very sorry to hear of your experience. Acupuncture treatment can occasionally be a little uncomfortable with a dull aching sensation, and on very rare occasions it can produce a very sharp reaction if a nerve is hit. Much rarer, though, are the occasions when it generates extreme sensations.

However, the fact that the pain subsided after a little gentle massage is quite a positive sign. If there had been serious damage or if the practitioner had hit a nerve there is less chance that things would have settled down so quickly. Indeed, where someone has had some very long term conditions there can occasionally be a quite violent release with some very strong after effects, so it could possibly be that this has been a very positive treatment. You will soon find out from changes which occur after the treatment. We tend to advise people that the next 24-48 hours might be a little up and down, but after that if there is going to be improvement it will swiftly become noticeable.

Although we have great respect for colleagues in the other professions who use acupuncture alongside their own modalities, it is no secret that we have been highly critical of the proliferation of very short courses adding acupuncture to another existing modality. The doctors and physios, both of whom have special interest groups protecting the public interest, have published standards for what they do and well-organised training. Many osteopaths and chiropractors, and even some podiatrists, however, are increasingly taking these short courses. We believe that it is not possible to cram both the techniques and theory into such a course at the same time as ensuring that appropriate safety standards and hygienic practice are being passed on.

This is not intended to cast aspersions on your osteopath, who may very well have substantial training and experience, and we have no doubt that what you have experienced is probably a one-off. However, as a general rule we prefer people to see practitioners whose primary focus is acupuncture rather than practitioners offering acupuncture as an adjunct within their existing skill set. Knowing what to do is important, but knowing what to do when things go wrong is as, if not more, important. For this it is essential that someone has had an in-depth training. We would not countenance our members having a go at a few osteopathic manipulations, and we're pretty sure the osteopathic associations wouldn't be that happy either.

By all means go ahead with the treatment next week, and rest assured that the chances are that it will be largely uneventful. If there is any repetition of the extreme pain or sensation, then remember that any healthcare professional can only work with your consent. If you say 'stop' then they have no choice but to so do. But we doubt it will come to that!

Q: I am a medical acupuncturist in Australia. Just wondering if you have any evidence for the use of acupuncture in Polymyalgia Rheumatica?

A: As you can imagine we have been asked about this condition by prospective patients on a number of occasions, and the most recent answer we gave was:

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.

This explains the situation very clearly from a Chinese medicine perspective, but for someone using acupuncture within a conventional medical framework this probably wouldn't help. We have shared a very helpful and informative relationship with our medical acupuncture colleagues in the UK, and they have often found that trigger point acupuncture has been helpful, as has segmental acupuncture to a degree. The theories behind these approaches can overlap usefully with the main presenting symptoms of PMR, but naturally the overall diagnosis overlaps with dozens of other local conditions, so rather than being points for PMR these would be better seen as 'area acupuncture.'

The one thing which medical acupuncture lacks, and we mean no disrespect by saying so, is a systemic approach to ill health in the body. Many of the patients who present to us as traditional acupuncturists have problems which clearly point to weaknesses in the overall functions of some of the body's systems, and we often find that unless these are addressed as well then treatment may only have a short term effect.

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 are sure that your non-medical colleagues in Australia would be happy to discuss this whole area of treatment with you.

Q: Can someone on blood thinners have acupuncture?

A:We are often asked about the use of acupuncture on patients taking anti-coagulants, and we usually quote a section of the Guide which we distribute to all members (but not the public) which says:

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 Warfarin since 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.

I've been having migraines for years but in January this year I had a 14 day session (triptans helped me) so I decided to try acupuncture.The doctor is one of the best ones in my country and she gave me homeopatics (Corpus callosum and some others) as well. I had needles in my head, ear and some other parts of my body to stop having migraines. It really helped and I don't have them anymore, but since the second meeting (1st needles in my head) I had some strange feelings. First I felt tingling in my head every single day and then after the 3rd meeting I feel very strange - no tingling but like a pressure in my head which seriously never stops and I have some eye troubles sometimes (one eye has a blurry vision etc) but always for a while. Also I have dizziness sometimes. It seems that I have it close to the places I had the needles and I am now wondering what can be the cause. Could it be the acupuncture/the homeopatics or anything else? I study medicine and I was going to a neurologist before (because of the headaches) and there was no problem found accept the migraines. But I got a bit scared now as I really feel strange every day.Today I stopped taking the homeopatics and at least I stopped feeling the dizziness I hope. What would you say might be the reason of the whole strange head problems?

A: We are very sorry to hear that you have had these problems, although we are pleased to hear that your migraines have cleared up.

The one possibility that comes straight to mind is that what you are experiencing is something which has been a component of the migraine itself for a long time but hidden by the much greater pain which you must have been experiencing. This may mean that you have to continue with treatment for a little longer in order to clear the energetic problems which were the root of the migraine, some of which we have heard described in the terms which you use.

We have given careful consideration to the range of odd symptoms you have had, and we don't think that there is much likelihood of these being as a result of treatment. The vast majority of what we would call adverse effects are transient. Someone might feel dizzy after treatment, but this would last for 24 to 48 hours at most, after which the system would recover to the initial starting point. The only occasions where this would not be the case would be where there was some actual physical damage to the body, and we would be very surprised if inserting needles on the skull could do this. It is just possible that there has been a small bruise which is causing a minor energetic blockage, but you would be able to feel this as a tender point on the head.

We are, however, a little concerned that you are experiencing eye problems. We don't think for a moment that this can have been caused by the acupuncture, but were it to happen to one of our patients we would be recommending that they saw their optician or optometrist fairly soon. It may be that this problem has nothing to do with the acupuncture treatment as such but has by coincidence arisen at the same time. Whether it is or not, it would be important to get this checked as soon as possible.

We are interested to hear that you are also using homeopathic remedies, and that some of the symptoms have abated now that you have stopped using them. We think that it may be a good idea to take stock of the situation with your homeopath/acupuncturist. She, after all, is the person best placed to understand what is going on, especially since she will know exactly what your energetic balance is and was, and how she hoped to treat it. This will be far more informative than anything we can offer here.

The bottom line, though, is that if the various neurological tests have shown nothing untoward, then there is very little chance that acupuncture has caused any physical damage to generate the symptoms you are experiencing. This would imply that the effects are energetic, and your practitioner should be able to add these to the diagnostic mix and deal with them. However, we would advise that you get your eyes checked anyway, just in case this is a contingent problem.

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