Ask an expert - neuro and psycho logical - neuralgia

20 questions

Although there is an increasing amount of research into the use of acupuncture treatment after radiotherapy the majority of studies are aimed at specific symptoms which often accompany treatment - nausea, dry mouth, fatigue etc. Unfortunately nerve pain or generalised pain in the pelvic region is not amongst them, and we suspect that this is because the generality of the symptoms makes it difficult to assemble meaningful trial groups. The results of the research show some quite positive outcomes for dry mouth and nausea, but as always is the case with acupuncture research the conclusion is that larger and better designed trials are needed. Even if someone had researched nerve pain specifically, the chances are that this is what the conclusion would be. The bar is set very high, and not always appropriately, for the work we do.

That said, there is a substantial and growing body of evidence for the treatment of neuralgia with acupuncture, even in the strange limiting cases like phantom limb pain, so it would not be a bad idea to see if treatment could alleviate some of the discomfort. The effects of radiotherapy in terms of the heat and scarring of tissue are outcomes which can clearly be translated into the diagnostic systems of Chinese medicine, and a practitioner can hope to address some of these within the overall constitutional setting within which they have had an effect.

The idea of context is central to Chinese medicine. Every is a unique blend of energies, so even when two people have the same symptoms they might arise from different internal disturbances. The skill of the practitioner of traditional acupuncture lies in treating not the symptom but the person as a whole. This means that the kinds of damage which radiotherapy can do will differ from person to person, both in terms of severity and in terms of potential for recovery.

The best advice that we can give is that you visit a local BAcC member for an informal chat about what may be possible. Most of our colleagues are happy to give up a little time without charge to establish whether acupuncture treatment might be worthwhile, and this gives you a chance to meet them and see where they work before committing to treatment. There is nothing to lose from trying treatment. Not only is acupuncture a very safe therapy but it does not have any major side effects. Even if the treatment managed to help you to deal with the discomfort it may be worthwhile.

The key thing is to set measurable outcomes from the beginning so that you can judge how well the treatment is working. Amounts of painkillers, sleep disturbance and general energy levels are the usual markers, and using them sidesteps the problem that people can feel good on some days, bad on others, and are not always able to say on any given day whether they are feeling better overall. 

We were asked about foot drop some time ago and we responded:

There are a number of case studies, relatively small in terms of the numbers of participants, which seem to show positive and encouraging results for the use of acupuncture for foot drop after strokes. However, the evidence is by no means comprehensive or conclusive enough for us to give a positive recommendation for treatment.

However, a great deal depends on what else is going on in your system. Foot drop as an isolated symptom is unusual, and very often there is a more complex neurological picture within which this sits.  If there isn't, then from a Chinese medicine perspective the weakness would be understood in terms of a blockage or weakness in the flow of energy, or 'qi' as it is called. The  practitioner would probably use a combination of local and distal points to try to restore proper function in the tendons and muscles affected by or causing the condition.

If there is a wider pattern of dysfunction, however, then the chances are that this will be a neurological problem whose treatment with acupuncture would be less likely to be successful.

However, there is no substitute for a face to face assessment in cases like yours and we believe that it would be worthwhile visiting a BAcCc member local to you to benefit from their advice. If they feel that acupuncture will not be of use, we are confident that they may have other suggestions about what forms of treatment may be best for you.

We have gone back to the research databases to see what, if anything, has happened since we gave this response, and not surprisingly the few studies which we found are pretty much the same of what can still be found. You might find this interesting

https://www.slideshare.net/JudithMiller3/acupuncture-for-the-treatment-of-foot-drop-a-case-report

and also this

http://www.healthcmi.com/Acupuncture-Continuing-Education-News/564-acupunctureceusfootdropstroke

but not for the faint-hearted is this Youtube video

https://www.youtube.com/watch?v=xnITeO-8Dt0

As far as the nerve pain is concerned, again it very much depends on what is causing it. There are so many possibilities that it would be unwise for us to speculate on what it may be. Some cases are amenable to treatment, like the neuropathy which arises after chemotherapy, and some less so, like peripheral neuropathy arising from diabetes which  can often prove intractable. However, each case is unique and individual, so you are well advised to follow the route suggested in our previous response and contact a local BAcC member for a chat about your own individual presentation.

File under neuro - neuralgia

We have been asked several times about TN, the most recent answer we gave to this question was:

Trigeminal neuralgia is a very painful and quite often intractable condition. We have been asked about it a number of times, and  we have factsheets about both facial pain and neuropathic pain

http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/facial-pain.html

http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/neuropathic-pain.html

The evidence underpinning a recommendation for acupuncture treatment is limited, but as you can see from the evidence button on the neuropathic pain sheet acupuncture has on several occasions been shown to be superior to the standard drug treatment, which suggests that it is worth trying. 

In a previous response on the same question we said that if you look through these various responses, however, you will see much the same advice in each one. The evidence is encouraging but far from conclusive, although it would be fair to say that the gold standard of research in western medicine, the randomised double blind control trial, is not the most appropriate tool for assessing traditional acupuncture. However, there are a number of treatment possibilities within the paradigm of Chinese medicine, to do with blockages or deficiencies in the flow of energy, or 'qi' as it is called, which a practitioner might be able to identify and correct. Your best bet here is to contact a BAcC member local to you and seek a brief face to face assessment of whether they think acupuncture may be of benefit.

We have to say, however, that trigeminal neuralgia or neuropathy does appear to be a rather intractable condition, and we are usually relatively cautious about the prognosis when we take on patients in whom this is their main complaint. You will note that in one or two replies we have suggested that cranial osteopathy may offer another treatment option. The pathway of the trigeminal nerve is easily compromised by some of the physical structures around the tempero-mandibular joint, and subtle manipulation may offer possibilities.

We think that this remains the best advice that we can give. We have no doubt that acupuncture treatment can deliver temporary pain relief, and the amount of research which has been done to investigate this aspect of acupuncture's effects has been very considerable. However, as with all forms of pain relief, it is relief, not removal altogether, which is what the treatment delivers, and even when treatment works the extent of the relief it can give and its sustainability do not seem to us to be sufficient to warrant making a recommendation to try to use acupuncture as a long-term pain relief option.

If you did decide to visit a practitioner local to you, we would recommend that you are very clear about the review periods at which you can assess how successful the treatment has been, and also that you try to establish very clear outcome measures, i.e. changes which you can actually measure rather than simply soundings based on how you feel on the day. With conditions like this there are good days and bad days, or more accurately bad days and worse days, and it helps to try to bring a measure of objectivity where possible to the proceedings.

In your own case the backdrop of MS would appear to make the situation a little more complex, but it is important to recognise that the diagnostic categories of Chinese medicine are entirely different from the conventional medicine paradigm. From this perspective how a patient presents is far more important than the disease labels which they carry. That is not to say that Chinese medicine offers a chance of change where conventional medicine doesn't; in the modern parlance of sales, once it's gone it's gone. If a nerve is demyelinated there is no evidence to suggest that acupuncture treatment can reverse the damage. 

However, MS, as you know very well, can sometimes plateau and often have periods of remission, and our general sense is that treatments like acupuncture which are aimed at maintaining balance in the system may well be a contributory factor in staying well. This was, after all, the basis of ancient Chinese medicine,, helping people to stay well rather trying to get them better after they got ill, which was said to b e 'like forging a spear after the battle had started or digging a well when you were already thirsty.'

Q: I had chemotherapy 4years ago, I lost my finger and toe nails. Since I have suffered terrible discomfort in my feet. I now find it hard to sleep because of the pain. Would acupuncture help?

A: We are sorry to hear of your problems after chemotherapy, and hope that the treatment worked for the condition at which it was aimed.

As you can imagine we have been asked before about neuropathy induced by chemotherapy, and a typical answer has been:


There is a growing body of evidence which suggests that acupuncture can be very effective in helping to reduce the severity of peripheral neuropathy (PN) induced by chemotherapy and to speed up the rate of recovery. If you search on google using the terms ' ncbi acupuncture neuropathy chemotherapy' you will access a major American research database gathering studies from all of the established online collections like PubMed and Medline. The first half dozen results point to a number of recent studies which show very encouraging results, but most of which conclude that a much larger study is warranted before any definite conclusions can be reached. This is not uncommon; research funding for acupuncture is not that freely available in the West, and Chinese studies are often regarded as methodologically unreliable. There is certainly enough to say that acupuncture treatment will probably help.

We have to be careful not to get too drawn into a conventional medicine perspective when answering questions like this, though. If there has been physical damage to the nerve endings then the condition is less likely to be reversible, although there is some cutting edge research which does suggest that peripheral nerves can regenerate. If the nerves are not too badly affected, however, it is important from a Chinese medicine perspective to see how the chemotherapy has affected the whole system. A symptom can be generated by any number of functional disturbances as understood within Chinese physiology, and can also arise from a simple blockage in the flow of energy at a local level. Problems like neuropathy are often a manifestation of both phenomena, and offer a number of treatment options. The skill of the practitioner lies in seeing how the system as a whole is functioning to narrow down the possibilities for treatment selection.

This does not mean that acupuncture can achieve miracles where modern medicine cannot. What we find, however, is that where western medicine assumes a direct causal path between the chemicals and the nerve damage or loss of function, Chinese medicine offers a number of potential routes where, for example, the chemotherapy may have affected a functional unit which in turn has weakened the energy at the periphery.  This is turn may offer a slightly different focus for treatment with better chance of success.

It also explains why people are often confused by the fact that the same symptom  can be apparently treated twenty different ways. From the Chinese medicine perspective the symptom is often only an alarm bell sounding for wider-ranging imbalances, and the practitioner will always look at the overall context to determine how to proceed.

Having looked at this as an answer we think it still represents the best advice that we can offer. We have had another look at the databases, and there has been nothing new since we wrote the earlier reply. Franconi's systematic review, a paper which gathers together results from all other papers, is perhaps the most recent and best summary, but as we said in the earlier reply, he concludes that the results, while encouraging, are far from conclusive.

What we didn't say is that most BAcC members are more than happy to take a look at problems for prospective patients by giving up a few minutes without charge. A short face to face assessment is always going to be far more authoritative than anything we can offer at this remove, so it would be worthwhile contacting BAcC members local to you to see what they think. This also gives you a chance to meet them and see where they work before committing to treatment.

Q: Can acupuncture help with post herpetic neuralgia?

A: As you might imagine we have been asked about this many times over the years, and a recent answer was:

Shingles can be a terribly distressing condition whose after-effects can persist for months or even years. The treatment of post herpetic pain is an area which has been heavily researched in China, as our factsheet http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/herpes.html says, but the quality of trials is not that great. There is a comprehensive systematic review of all available trials, but this was only announced last year and has not yet been published. We ourselves have treated many cases of shingles, and we have to be honest and say that there has been a significant number of cases where it has been very difficult indeed to reduce the pain, which as we are sure you know can be excruciating.

However, there is no point in being unduly pessimistic. There have been cases of post-herpetic pain where the acupuncture treatment has made significant inroads into the symptoms from a mixture of constitutional treatment to bring balance back to the system as a whole and local treatment to reduce some of the irritation and inflammation. Generally speaking, it is better to start treatment as soon as possible after an attack, just as the use of conventional anti-viral medicines is favoured as early as possible. However, the reality is that most patients present with post-herpetic pain long after they attack and usually because the side-effects of the long-term medication are becoming a problem, so we are used to adopting a slightly different approach from that used in China, where needling often commences with days of an attack starting.

The best advice that we can give is that you visit a BAcC member local to you for a brief face to face assessment. The one caution we always voice in these cases is that if you decide to go ahead with treatment you set review dates for assessing progress and also try to set specific outcome measures, objective evidence that the condition is improving. This can be quite difficult with chronic conditions like this which can still have acute episodes, but it is really important to try to find a marker which can show that there has been progress. We would feel confident, though, that acupuncture treatment might offer some benefit in pain relief and recovery. The only question to resolve is how much and how sustainable the relief is, which is why we are always cautious in setting clear outcomes measures and review periods.

The great strength of Chinese medicine, though, is that each patient is unique and different, even though their symptoms be the same. This means that a skilled practitioner, and all of our members are, would be able to make links that we cannot do at this distance, and may be able to recommend other things that may help alongside acupuncture treatment. We would strongly recommend that you visit a local BAcC member for advice, and hope that it puts you on a path to finding some relief.

We have had a good look through the research databases to see what further evidence is available (the fact sheet seems to stop around 2008) and we have found a few which are positively encouraging, such as:

https://www.ncbi.nlm.nih.gov/pubmed/21639941

https://www.ncbi.nlm.nih.gov/pubmed/22502623

but the systematic review proposed in 2014 has still to be completed (at least we can find no trace of a publication by the principal author).

The advice we gave earlier holds good, and that is to visit a local BAcC member for an informal chat about what may be possible. This is by far the best way to get a clear idea of your prospects, and most members are only too happy to see prospective patients in this way.

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