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Ask an expert - about acupuncture - how does acupuncture work?

14 questions

Q: I have had complicated hand surgery which has left my hand very tender and easily hurt. I would be very reluctant to have needles in my hand because I think this would be very painful. Is it still possible for me to have effective acupuncture avoiding the hand? My most obvious problem is catarrh and chest problems. 

A:  Many people are worried about acupuncture needles without really having come across them. The majority of needles in use are about 0.18mm to 0.25mm in diameter, which is finer than the average sewing needle, but the crucial factor is that they are solid. Most people have experiences of hyopdermics which, being hollow, are a great deal more uncomfortable when they break the skin. Solid needles cause less discomfort, and this is further reduced when they are inserted by the use of a guide tube which is positioned on the skin and the needle gently tapped in. The 'distraction' caused by the pressure of the tube makes the needle insertion less palpable.

However, there are prospective patients like yourself who have good reason to be fearful of needles, however small the impact might be, and there are a number of ways of getting around this. Most points on the body are bilateral and although traditional use says that the left side is for tonifying energy and the right side for reducing energy, in practice they are interchangeable, and it is the needle action and direction which determines what effect is achieved. There is, then, nothing that a practitioner may want to do that will be ruled out by having no access to the left hand.

Indeed, even if both your hands were sensitive, there are ways around the problem by using points elsewhere on the body which have a direct connection with the channels and organs you are trying to influence. This is very much the case with post-mastectomy patients where we cannot needle the arms and hands below where lymph nodes have been stripped out in the armpit. Where someone's constitution would normally require the use of needles on the arm, we have to use our knowledge and skill to generate the same effects by the use of leg and body points.

The bottom line is that there is nothing which would impair the quality and effect of treatment by protecting your hand. You may even find, though, when you have needles inserted elsewhere that you might be able to tolerate needles in the left hand. It may also be worth discussing with a practitioner what might be done to render the area more benign. We occasionally treat amputees who have a continuing neuropathy from the severed nerves, and we are quite often able to turn the volume down.

As far as chest problems and catarrh are concerned, there are many clearly defined patterns recognised in Chinese medicine for the treatment of problems like this, and it may well offer a solution. However, the strength of Chinese medicine lies in the fact that it treats each patient as a unique combination of energy, with the same symptom often being treated differently from person to person, so the only sensible advice we can offer is to visit a BAcC member local to you to discuss whether they might be able to help.

Q: I had acupuncture today, the lady used re-usable needles instead of disposable ones. She assured me they were sterilised using the appropriate machine. Is this ok?  Shouldn't all acupuncture needles be disposable?

A:  The BAcC's Code of Safe Practice could not be more explicit on this:

You must only use single-use pre-sterilised disposable solid needles which, if in multipacks of five, ten or more needles, must not be used or stored for use after the session in which the seal on the package is broken. Any needle with damaged packaging seal must not be used.

The only exceptions which we ever allowed were when the transition to guide tube needles was introduced in the late 1990s and some of the longer needles were not available at that stage. We allowed members who purchased these to use them only after they had been sterilised before use and then only used a single time as if they were single-use needles. In modern times all sizes are available as single use needles and there is no excuse for re-using needles.

The ban on the use of re-useable needles was introduced for safety reasons. It transpired that prions, the proteins involved in the transmission of Variant CJD, the 'mad cow' disease human equivalent, were not killed by autoclaving, and there was always a theoretical risk that someone could unwittingly spread the disease by needle re-use. Subsequent investigation revealed that it required more than simply exposure to the prion to create the condition in another subject, but by this stage the change to single use needles had become firmly established and patients and practitioners alike were reassured by the safety that this provided. The growing market also meant that needle prices dropped and quality improved, where the earlier disposables had been shockingly poor. Nowadays a needle can cost as little as 2p, and there really is no justifiable reason not to use single use needles.

If the practitioner is a BAcC member, you would be well advised to report them to the Professional Conduct Officer or Safe Practice Officer immediately. The chances that you have been put at risk are minimal, but that does not change the fact that this is a breach of one of the more strict rules under which we operate. If the practitioner is not a BAcC member, you should take the matter up with their professional body, or should that not be something you want to do, then you could contact the local authority Environmental Health Department. The law relating to skin piercing does embrace the possibility of re-using needles, but this is because the new byelaws were extended to covering all skin piercing and many tattooists and body piercers do use re-useable equipment. Had it been an acupuncture-only law, we would have insisted on single use disposable equipment being the legal norm. If someone is re-using needles, then their autoclaving equipment has to be maintained in an exemplary fashion to guarantee that it delivers what it is supposed to.

Aside from anything else, inserting a needle can do considerable damage to the point, as this recently published paper shows

http://aim.bmj.com/content/20/1/11.full.pdf

and creating small fish-hook ends which go in easily but tear tissue on the way out is not a great option for patients. Needle breakage is almost unknown in modern times, but where this used to happen in the old days, it was usually related to the over-use of needles with autoclaving which made the steel become more brittle. Single use needles have all but eradicated this problem.

   

Q: How do acupuncturist find the right place to treat since there are many meridians and combinations of meridians that could treat a problem?

A:   This question highlights the central difference between conventional medicine and traditional Chinese medicine. We are very used in the West to the idea that the work of diagnosis is rather like the forensic work of a policeman and lawyer, gathering evidence and sifting facts. This comes to a single conclusion which explains what is going on and then provides a set tariff of treatments which have to be followed one after another, like NICE guidelines. The TV series House starring Hugh Laurie was/is a great example of this, where the tortured genius lets the observed facts and diagnostic test results mould into a unique and brilliantly presented conclusion.

By contrast, Chinese medicine is inherently pluralistic. At various times during its 2500 year history there have been innovations which at some levels have contradicted the mainstream theories, but as long as they worked in well-defined conditions they were retained as another string to the practitioner's bow. A modern practitioner of Chinese acupuncture might employ TCM, the rather skeletal and simplified framework first written down in the 1950s as a system, or Five Element Acupuncture which is rooted in the classics but developed heavily in France and Japan, or Stems and Branches, a numerologically based system which has existed for over 2000 years, or Japanese Meridian Therapy which, designed with blind apprentice-trained practitioners in mind has a huge palapatory bias, and so on. Each of these systems has ways of working with the whole which are a mixture of the same root understanding of the core energetics of the body mind and spirit, and a heuristic framework which allows scope for the skill and art of the practitioner. Each of the variations, and in the modern practitioner these might all find their way to the diagnostic mix they employ, offers a way of bringing balance back to the whole.

The question for each practitioner is really what is the most elegant and effective way with the least intervention to achieve overall balance. Because of the nature of the interaction between patient and practitioner concepts like 'intention' and 'rapport' can play a part in the diagnostic and treatment choices, and in many ways each practitioner may generate a different solution to how best to treat a single patient. There may well be common agreement about the main features of a case, but each practitioner may favour a slightly different strategy for dealing with the information.

You can see immediately why such a flexible system is often derided in the West as nothing more than a placebo, especially since the practitioner's extraordinary range of choices and personal involvement in the process lend themselves to the pejorative interpretation that no-one has 'an answer' and that it is the 'will' of the practitioner which conditions the patients to improve.  This is sad, because in nearly every other form of skillful endeavour it is readily accepted that an overall goal or aim can be achieved in many different ways, like putting a destination in google maps and seeing four choices emerge. With a complex organism like a human being it seems perverse to say that this and this alone is the problem, and this the solution, when we all realise that most problems cascade more widely than the simple origin.

Anyway, to return to your original question, even if two practitioners agreed on a diagnosis they might each find different ways of effecting change. Such is the vast number of interconnections between the different channels, there are often dozens of ways to influence the internal Organs, or to have an effect on a specific part of the body. This can be a valuable resource in itself; if a woman has had a mastectomy with lymph nodes stripped and can no longer be needled on the arm, then it is always possible to find ways of treating the lower limb to 'reach' the affected area. The same applies to treatment of a limb encased in plaster; needling the equivalent points on the other limb can have a major impact.

In short, the system is such that there are dozens of variations in the diagnostic systems, and dozens of possibilities within each system, for achieving the same results. They are all based on the same understanding of the channel systems and the same location of the points (broadly speaking - some of the Japanese systems pay more attention to blockages which are where you find them!), but each system will use a slightly different understanding of the these shared resources to effect change. We often used to refer to this phenomenon as 'unity in diversity', the sharing of a tradition founded on the same underlying principles but showing the inherent strength of something which has developed in different strands for over 2500 years.     

 

Q:  During a normal acupuncture session, when a needle is inserted into  the face of a person, does the needle actually touch the bone or does the needle simply pierce the skin?

A: In theory, the needle should only pierce the skin and enter soft tissue or muscle. If the skin and tissue is very thin at the point where the needle is inserted, then the usual technique is to adopt a very shallow oblique angle of insertion rather than a near perpendicular one. This avoids the needle having so little of its shaft inserted that it starts to bend over with the weight of the shaft and handle. An alternative is to switch to a shorter and considerably lighter needle.

However, there are no guarantees that a practitioner will not accidentally touch the bone in cases where they have inserted a needle a little too far. This may be a little painful for the patient, but the greater potential for harm lies in the fact that the tip of the needle is likely to be deformed and will cause slight tears in the tissue when it is removed. This might then lead to a small amount of pain and bruising.

However, there are no case reports of which we are aware, certainly in the UK, of any damage being done to facial bone as a consequence of acupuncture treatment, or that if done this can have long term consequences. If you are wondering this because of what has happened during your own treatment, then you should ask the practitioner to explain what they did, and ask them to consider whether this was possibly what happened. A reputable practitioner will take the matter seriously and give your question the time of day. 

You should bear in mind, though, that there are a number of sensations which can be caused by needles when they are inserted which feel like a very dull ache and can sometimes be mistaken for a more 'solid' feeling than is the case. This is particularly so with one called 'deqi' by the Chinese which is often experienced as a very dull ache and feels on occasion like something has been knocked into.

 

Q:  What exactly do the needles do to effect a cure. Do they touch nerves for instance?  Is there some sort of chain reaction?  I would like to understand this technique before using it. In the past I did have acupuncture for migraine but do not understand how it works.

A:Many of our patients believe that acupuncture works by touching nerves, and indeed one of the main theories of western medical acupuncture is based on the neurophysiological consequences of putting needles into tissue with significant amount of nerves.
 
However, Chinese medicine has an entirely different understanding of the body, mind and spirit. In Chinese thought, everything is regarded as a manifestation of energy, which the Chinese call 'qi', and the human body in all its complexity is understood as a flow of qi which has distinct patterns and rhythms. These patterns can be disrupted by external causes like climate and food, but also internal causes like strong emotions or mental strains. Because everything is interlinked, blockages or disruptions in the flow of energy can have effects on all sorts of levels - a physical pain will often be accompanied by a corresponding mental or emotional state which may not appear to be related at first sight to the primary problem- and also a problem in one area can ramify to create problems in other areas. This is why traditional Chinese medicine practice does not place all of its reliance on symptoms; these may simply be secondary problems where the main problem lies elsewhere and may not even be generating symptoms itself.
 
This world view is not unique to China. The Japanese have the concept of 'ki' and Indian culture has a concept of 'prana', both of which fulfil the same sorts of function in understanding how the body, and indeed the world, can be understood and treated. This is vastly different from mainstream western thought which has rejected this kind of theory, sometimes called 'monism' which rests on a belief in a single universal substance from which everything is made. Instead in the West the dualism which has held sway since Descartes is very much predicated on a material substance in the world which can be understood in purely mechanical ways, and something of a different order on mind and soul which is not reducible to a physical state.
 
That said, at the cutting edge of scientific thought in quantum physics, some interesting parallels are starting to emerge, and it is highly possible that the next hundred years will see ancient Chinese medicine theory being better understood within mainstream science as these state of the art understandings start to permeate more popularly understood science.
 
The use of acupuncture needles, therefore, is to influence the flow of energy and to make good areas of the body where the flow of qi has been compromised. With a 2000 year history acupuncture has a wealth of sophisticated means of diagnosing and treating imbalance, and while the basics are relatively easy to learn, by contrast to the highly complex training in Western medicine, the application of these principles can involve a lifetime's endeavour. The saying used to be that Western medicine was hard to learn but once learned easy to practice, whereas Eastern medicine was easy to learn but very hard to practice. So much depends of the observational and sensory skills of the practitioner, and requires a level of development beyond day to day experience. This is why we sometimes describe our work as mastery of an art rather than technical knowledge of a skill.
 
In the end, though, there will always be patients for whom taking this on board is a step too far, and all we can say to them is that we are happy to be judged by our results.  

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