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Q. I see a sports therapist for help with aches and pains after regular gym exercise. He has also recently been carrying out accupuncture. My concern is I feel quite emotional a few hours after the session almost like a release of tension or something. Is this normal or should I mention it next time. I always sleep so much better and it helps alot with the back pain.

A. It sounds to us like the treatment is having a very beneficial effect, and yes, we do find that on occasion treatment for a specific problem can actually have a systemic effect. So, for example, treating someone for a bad back can release all sorts of blockages, some of which might be expressed in a release of 'contained' emotion. It is certainly something which any practitioner would value as feedback.

This is something of a live issue for us because of the greater use of acupuncture within a western medical context as a focused treatment for physical problems. We have made the case for many years that while we value the fact that people are getting the undoubted benefit, from our perspective any needle inserted into the body can affect body, mind and spirit. Our concern is that you can't know what you don't know so if someone treats on a musculo-skeletal basis they are not going to be aware of the possible emotional reactions this might stir up.

For us this would be valuable feedback, and our systems can interpret and work with reactions of any kind. A great deal of Chinese medicine thought uses rather general concepts like 'appropriateness' so when an emotion appears inappropriately or in inappropriate quantity it becomes diagnostically significant and helps us to restore balance in the whole system. We are all mainly trained in working with people to delve a little more deeply into what is going on, guided as we are by the belief that repressed emotions can manifest as muscular problems. If they are not properly addressed the body will simply manifest another similar problem until they are.

We always tread carefully, though, because we would not want to be seem to be staking out the territory and trying to stop people from using acupuncture in a more physical way. Many people derive huge benefit from such measures. What we would like to see is people referring patients on to us if they start eliciting reactions which they cannot explain, or at very least talk to the patient about the sorts of things that are coming up and directing them to someone who can help them.

That said, we have had many patients who experience these kinds of almost cathartic reactions to treatment without any background of problems not dealt with, and as long as the effect is short-lived and the overall problems seem to improve we don't make a big deal of it. Everyone is unique and special!

Q. Hi,

I wondered if there are any points that we should avoid using for a patient with rheumatoid arthritis for example points where there is a risk of entering the joint such as the eyes of the knee or shoulder?

Has acupuncture ever been known to trigger a reactive arthritis?

Also, should we be using anti-bacterial wipes prior to inserting the needle for someone with rheumatoid arthritis?

A. There are no contra-indications of which we are aware for the use of acupuncture in treating rheumatoid arthritis. Some traditions of acupuncture, strangely enough the modern medical versions, tend to use deeper insertion of the needle than many traditional acupuncturists would countenance, and we have found nothing on their safety forums to indicate that special care needs to be taken. The BAcC was involved with a group of several associations, including medical acupuncture bodies, to draw up safety guidelines some years ago, and this was never raised as an issue by anyone.

By the same token we have not been able to find any evidence to suggest that a reactive attack has happened as a consequence of treatment. This is a little more tricky, because as is often the case in these situations people are generally doing a great deal more just having acupuncture, so it may not have been picked up as valid causation. As we have said to colleagues many time absence of evidence is not evidence of absence. However, there have been recorded cases of which we are aware, and we do monitor adverse events carefully.

The issue of swabbing or cleaning points is a little more contentious. In the NHS there is a roughly 50/50 split between those who insist and those who don't. Our own advice to members, which we are happy to share is:

Where necessary, you should swab the skin with 70 per cent isopropyl alcohol with or without 0.5-2.0 per cent chlorhexidine. If the area of the skin to be needled is clean and free from dirt or organic matter (such as soil) then there is no requirement to swab the skin.

If areas of the body to be needled are dirty then they should be washed first with soap and water.
Swabbing is only indicated for patients who have a suppressed immune system through illness or medication and is not required in the fit and healthy.

The recommended agent to “sterilise” the needle area is 70% isopropyl alcohol usually in the form of a medi swab. Cotton wool balls soaked in alcohol solution are strongly discouraged as these can become heavily contaminated with hand and environmental bacteria. The use of 90 per cent isopropyl alcohol is unacceptable as it may preserve organisms and also because it evaporates too quickly to have an antiseptic effect. Other cleaning agents, if used, should also have adequate antiseptic properties and be safe on the skin. These preparations should contain 0.5-2.0 per cent chlorhexidine and should ideally be in an alcohol solution, as chlorhexidine is not completely effective against Pseudomonas, the main organism causing infection in the earlobe.

The misuse of swabs is very common and it is recommended that a fresh swab is used for each point. The swab should be in contact with the area to be needled for 30 seconds and allowed to dry for a further 30 seconds. It is recommended that you swab points in a way that touches the area only once so as not to re-contaminate the area and it is best to swab from one end of the area to another.

After an acupuncture point has been cleaned in this way, it must not be palpated unless it is cleaned again afterwards.

The arguments tend to focus on whether cleaning a needle site removes protective bacteria as well as killing potentially dangerous ones, so we have taken a fairly commonsense line and asked members to use professional judgement in dealing with patients who might be perceived to be slightly higher risk. Since most high risk conditions have a vast range of presentations we wanted to avoid over-reaction.

Q. I have been having chiropractic treatment on my neck (no cracking manipulation) and back for 6 months. For the last 3 months have also been having some acupunture (at the same appointments). My neck problem has always effected my right side. However in the last few sessions my chiropractor has said my left (neck/shoulder) was a little tight. He treat this also with acupunture. After my last session, i developed a large bruise in the area (I rarely bruise), and a strong sharp pain in my left shoulder blade, plus a horibble gripping like pain around the spine area between the shoulders. It has now been 2 weeks since this last session. I am still experiencing sharp 'needle like' pains in my shoulder muscles and back ache. Is this normal? i've not had it before. Any aches in the past have normally gone after a couple of days.

A. We think that it is highly unlikely that there has been any serious damage; serious adverse events after acupuncture treatment are extremely rare. However, in cases like this where physical therapists use needles as an adjunct to their work we often advise people just to check in with their doctors. This is not intended to be disrespectful to these practitioners but we do find that many of the osteopaths, chiropractors and physios who undertake short course training use slightly more vigorous techniques than we might. This can on occasion cause some fairly deep bruising which can take a number of weeks to disperse, and during this period it can cause a number of unusual pains as nerves which traverse the area are impinged. If, of course, your practitioner is a fully trained acupuncture practitioner we offer our apologies for any intimation that he or she is only 'short course trained', and can only say that these things can sometimes happen, however much experience someone has.

Basically, though, any treatment which causes pain lasting longer than a few days is worth investigating, and very often this can establish causation. It is not uncommon for practitioners and patients to get involved in arguments about what caused what when the problem gets left untreated, so for our own members we always recommend that they send patients to GPs for a check. Accidents are rare but they do happen, and it is always better not to be too categorical.

We can reassure you, however, that there is extremely unlikely to be any part of a needle inside the body causing some of these sensations. The use of single use disposable needles has rendered needle breakage almost unknown, so although pains can sometimes feel like pieces of needle left in situ they aren't. In the bad old days when needles were sterilised and re-used it could make the steel brittle and able to fracture, but since 1999 we are unaware of anyone still sterilising and re-using needles.

We do hope that this problem resolves itself relatively soon.

Q. Can acuputure related to fertility cause boils???

A. A great deal depends on where the boil or boils are situated. If they have come up at the exact spot where the needles have been applied, this would be worthy of further investigation. Adverse events like infection from needling are very rare, and only happen in countries where hygienic procedure is poor. If someone follows the simple safety procedures and uses single use disposable needles, then infection is almost impossible. The only reason might be that the person had something like an oil on the skin which the needling had pushed into deeper dermal layers. This is the reason that our members are instructed never to apply massage oils and then needle unless they have properly cleansed the site.

If the boils have come up somewhere else, then it is highly improbable that the acupuncture treatment has been responsible. Systemic infections arising from acupuncture are unheard of in the UK. It might just be possible to make a case in Chinese medicine for the release of pathogens to cause something like boils but not boils themselves which are very clearly an infection.

The best advice that we can give is that you see your GP, if you haven't already done so, and seek treatment with antibiotics. There are a number of varieties of swelling and inflammation like this and it is important to establish as soon as possible exactly what is going on.

It might also be worthwhile checking in with the practitioner to alert them to what has happened. We record things like this in our notes so that there is a clear audit trail and so that we can just check whether there is a possibility, however remote, that the treatment might have been involved.

Q. I had a reaction to a treatment, I had bad back so the practitioner bled the back of my knees and I fainted after she had finished. As I fell I hurt my ankle whick I told the practitioner but my hand where one of the needles were has gotten progressively painful, could the fall and the needle in my hand have caused damage. What can I do. This is three weeks post treatment the back, my ankle and my hand still hurt.

A. We are very sorry to hear of your experience. It certainly sounds highly unfortunate on all counts.

As far as the specific damage is concerned, any fall involving the ankle can take a long time to resolve. If you twisted the ankle on falling and pulled the lateral ligaments these can take several weeks to recover. However, when a pain continues like this, it is always best to seek medical advice. Broken ankle bones are not common from a simple fall but they can happen, and if you have chipped or cracked a bone you need to know this so that you can get help by way of bandaging or special boots to enable the bones to heal.

As far as the hand is concerned, it is not clear from your question whether you fainted with the needles still in place or after they have been taken out. If they were out you would need to follow the advice given above and get the hand checked by your doctor. If you were unconscious when you fell it is possible that you have broken a bone or torn a ligament. If the needles were still in place the other possibility is that one of them has been forced a little further than usual into the tissue and caused internal bruising far enough beneath the surface of the skin to be undetectable at the surface. This can take up to three or four weeks to disappear without necessarily showing any external trace.

What we always say in these circumstances is to go to the GP to get the areas checked for actual physical damage. This will almost always reveal what caused it, and in your case the fact that you had a heavy fall may account for the pain you are still experiencing rather than being an adverse effect of the acupuncture treatment itself. However, if the needling of the points behind the knee was a contributory factor in your fall then you may have grounds for pursuing an insurance claim against the practitioner for what has happened. It isn't our job to go around encouraging people to make claims, but we all have professional insurance in case accidents happen, and this may be just such a case.

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