Ask an expert - muscles and bones - bursitis

4 questions

Q: I've been having treatments for hip bursitis for about 8 weeks and  getting on really well until the last one. Now I am finding I'm back to where I was at the beginning;  dreadful pain on walking and climbing. This happened 2 days after my last treatment -  is this normal? 

A:  We wouldn't use the word 'normal' but it is not unknown for a condition to re-occur in the middle of a course of treatment.

Generally speaking this kind of flare-up is more common at the start of a course of treatment. We routinely warn patients with back and neck problems that the first couple of sessions may lead to an increase in their discomfort, as indeed most osteopaths and chiropractors also say to their patients. It would be more unusual for something like this to happen a little further down the path, and if this were to happen the first thing we would do as practitioners is to go carefully through the patient's last week and see what might have happened to disturb progress. This may not necessarily be a major event like a twist or fall. It can sometimes happen that people start to experience greater freedom and mobility, and occasionally get slightly ahead of their own rate of progress.

If there is nothing in the case history to suggest that this has a physical cause, the next possibility to explore is that the treatment may only be offering short term pain relief and that it is not so much progressing towards resolution as being held at bay. This is why we eventually start spreading treatments out from weekly to fortnightly and monthly to see if there is sustainable progress. If the treatment runs out of steam we tend to re-appraise what we are doing in case we appear to be offering a successful but non-enduring palliative.

The most likely reason, though, which is probably not helpful to hear is that sometimes these things just happen for no apparent reason. What you will know is that treatment can get you from this place to a better state, and hopefully you will continue and experience the same level of relief. However, it might now call for a much more managed recovery where the effects of treatment and the management of the case as a whole needs more focused attention.

In our experience bursitis problems can be problematic, because from a Chinese medicine perspective they involve not just a local reaction but usually a systemic change which allows the accumulation of fluids in a more widespread fashion, and there are broader factors like diet and sleep patterns which can have an impact on a physical problem as much as movement or jarring. This, though, is the strength of Chinese medicine, treating not just the problem

A:  As you might imagine there is little or no research into the use of acupuncture for bursitis in the hip. This is mainly to do with the fact that as a symptom it can be caused by any number of disturbances in and around the hip joint itself, and western research is predicated on reducing the variables to the minimum possible. Some of the causes are more intractable than others, and would make comparisons difficult.

The same applies to Chinese medicine, of course, but we live with a system of medicine that embraces multiple causes and dynamic balance, so it is less of a problem for us. Clearly, though, the same overall conditions apply; if the bursitis is caused by a systemic condition, like gout, then it is going to be more difficult to treat. However, the same general rules apply about rest until almost better apply.

From a Chinese medicine perspective, however, accumulations of fluid within a capsule are usually interpreted as a breakdown in the flow of fluids through blockage or through a change in the consistency of the fluid itself. Since this is usually indicative of a breakdown in the flow of energy, called 'qi', on which the system is based, there are a number of treatments, especially local ones, which can help to improve the flow and remove/relieve the swelling. The key issue, however, is that Chinese medicine will never look at a symptom in isolation, but always consider it within an understanding of the way that the whole body is functioning. Without this, in many cases the treatment will only have a short effect. It is a matter of not just treating the condition but treating the underlying causes of the condition. This will involve taking into account the conventional medical assessment of what is happening but focus more on the way that the whole body functions. Many people have secondary problems which they accept as normal but which greatly enrich a Chinese medicine understanding of what is going on. There is such a huge variation in presentations, though, that the best advice we can give you is to visit a BAcC member local to you for an informal assessment of what may be possible. Most of our colleagues are more than happy to offer a short amount of time to assess whether treatment would be effective, and if they believe not, to offer alternative recommendations for other treatments.

One final word: we never use the word 'cure', partly because it is not clear what 'cure' would mean i n this context but mainly because we believe that we are helping a system to restore its own flow and balance. We simply put needles in; it's the patient who does all the hard work afterwards!


Q:  I have been told I have ischial bursitis and I wanted to ask whether this was something that acupuncture could help with?

A: This is one of those conditions where the name is less important than the way that the problem manifests. Ischial bursitis used to be called 'weaver's bottom' because it was quite common in professions where someone had to sit on a hard surface for hours on end, and the bursa between the ischial tuberosity and gluteus medius muscle became quite inflamed.

However, from a Chinese medicine point of view this would be less relevant than asking the patient the full range of questions about the nature of the pain (sharp, dull, spasm, chronic), how it varies throughout the day, how it is affected by heat, cold, pressure, and so on. The system of Chinese medicine is based on a theory of energy called 'qi' and its flow and balance in the body, mind and spirit. If the flow is blocked, or becomes stagnant, or deficient, then the practitioner's task is to reinstate ordinary flow in the belief that a properly flowing system does not generate symptoms. There would also be an important judgement call about whether this was a self-contained symptom, or whether the inflammation in one area was the tip of a much larger iceberg where it was the local manifestation of a systemic problem which might appear elsewhere, or whether a general state of depletion of the system allowed this to develop where a better flowing system might have not been affected.

The difference between the Chinese medicine approach and western medicine is that from the western point of view the naming of the condition means that there will be a number of specific treatments which your GP will offer. In the Chinese medicine system, the symptom, rather than the name it is given, will be interpreted in a number of different ways depending on what is seen to be the driver (cold, stagnation, injury, etc) and also depending on the backdrop against which it has occurred. Although many cases will require similar treatment, at a more profound level the treatment each person receives will be unique to their own needs, and will usually involve restoring the overall balance of the system alongside local treatment of the problem.

We always advise prospective patients to visit a BAcC member local to them for informal advice and a brief face to face assessment before committing to treatment. In your case it is highly likely that you may need a course of exercise to help the process of recovery, and most members know of trusted colleagues in the physiotherapy profession in their area to whom they can make a referral if this proves necessary.

Although we are not great fans of medication, there is always something to be said for a short course of anti-inflammatory medication if the symptom is very painful or interfering with your life. We are not keen on seeing people suffer while the treatment begins to take effect over three to five sessions, and although medications like diclofenac have adverse energetic consequences, these are short-term and are often far outweighed by the relief they bring. They are not a long-term solution, though, and that is what we hope acupuncture may help to provide.

As far as research is concerned, there is not a great deal which addresses the specific problem which you have, but that is more a reflection of the difficulty of pinning a single diagnosis down and finding funding for something for which outcome measures are not that precise, and the difficulty of finding funding at all! However, there is sufficient anecdotal evidence to warrant considering acupuncture treatment as a part of the overall package of treatment, perhaps alongside some exercise and possibly also some adjustments to some of the practical matters like workplace and car seating to provide as muhc relief as possible from the symptoms and to stop their escalation.

The first question we'd have to ask is 'where?'. Many patients present at acupuncture clinics with bursitis of the major joints like the hip, knee, shoulder or elbow, and to a degree the outcome depends on exactly which joint is affected. The same would apply in western medicine; some joints are easier to treat than others, and some easier to immobilise while healing takes place.

 

However, Chinese medicine is very different in its approach to an understanding of the body and the way it works. The theory of Chinese medicine is based on a flow of energy called 'qi' of which the body consists in different forms, and the understanding of how its balance and flow can be affected by illness, lifestyle and constitution. When people suffer from bursitis in a joint, the practitioner will want to establish first whether this is a local problem, caused by an injury or from over-use, or whether it is a consequence of a systemic problem affecting all of the joints to a degree, or a bit of both, as is often the case. Treatment will then be aimed at the appropriate cause, but will almost certainly involve some needles close to where the bursitis is.

 

Because this is quite a broad question, we can't be more specific. There are a number of web-based research resources which will identify relevant papers if you google 'acupuncture, bursitis and the joint concerned', but we strongly suspect that they will tend to say, as many do, that the signs are positive but not conclusive. Not a great deal of research meets rigorous western standards, and the conclusions drawn from it are often cautious. This is not to say that things aren't well researched. Many thousands of studies are conducted in China each year, but they are often premised on the fact that acupuncture works and researching what works better. In the West the policy makers are still troubled by whether acupuncture works or not. We believe that it does, of course!

 

Your best bet is to visit a BAcC member local to you to discuss your specific problem. We trust that they will give you the best advice possible about whether they can help, and if not, what other alternatives there may be.  
 
 

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