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134 questions

Q:  I have had 10 treatments from an acupuncturist who treats your 'element'. It has had mixed results and her decision on which element I am has changed. Although I pay for an hour my treatment typically now takes 10 minutes and consists of one needle being put into and out of my wrist very quickly and then inserted into the back of my wrist the same way using the same needle. When removing the needle she uses a piece of cotton wool to press against the needle as it is taken out. 6weeks ago I had a treatment and left with great pain in my right wrist where the last needle point was. It didn't go away and got worse so that if I moved my hand in a certain way I experienced a tearing sensation inside my wrist. I felt there was a piece of needle left inside my wrist. I went to my next appointment two weeks later and asked if there was a possibility of a piece of needle being left inside me. I was pretty much dismissed and told there was nothing wrong. (There clearly is as i am frequently in agony). A month passed and I have made an appointment to see my gp. I have waited several weeks for the appointment and still have another 4 days to go but my wrist is still really bad. I don't know whether to go to casualty and if so whether an X-ray would show up a tine fragment of needle or if I would need an ultrasound? I am now very scared and worried as the point the needle went in is in line with major arteries and nerves. Can you advise best course of action and if you think anyone will take me seriously? There is no inflammation and my wrist looks entirely normal from the outside.

 

A: This sounds very distressing for you, but we can say straight away with some confidence that it is highly unlikely that you have a piece of broken needle embedded under the skin of your wrist. Although all practitioners are trained in what to do if a needle breaks, in modern times this is virtually unheard of. The most recent report of a possible break to the BAcC was over fifteen years ago. The main cause of needle breakage, rare as it was even then, was when needles were autoclaved to sterilise them for re-use. Modern needles are used once only and then disposed of, so the constant heating and cooling which made the steel brittle does not happen.

The most likely cause of your discomfort is that there has been some bruising beneath the skin surface which has caused a hard clot to form and which impinges a nerve when you move in certain ways. We have seen this before, and it can take several weeks for something like this to clear. There is a small possibility of damage to a tendon, which might also account for the symptom, but the needling would have to be rather more vigorous than sounds was the case for this to happen. If the practitioner is using the style of practice which we believe they are, then very fine needles are the order of the day, and damage from the needle itself would be unlikely.

We think that going to your GP is a very wise move. He or she may have a precautionary X-ray or ultrasound done - just because needle breakage is rare doesn't mean that it can't happen - but there will be a number of investigations they can undertake on the spot in terms of range of movement and pain on movement which should alert them to the probable cause.

As far as the style of practice is concerned, this sounds like the Five Element system which is one of the two more common  styles in use in the UK. The diagnostic certainties of this are open to re-assessment and change, and for all sorts of complex reasons a person might be initially treated on one element and then find that another element presents itself as the core of the problem. This is the not the difference between right and wrong so much as between good and better. All treatment will have a beneficial effect because in a closed system of energy any attempts to improve the flow will have impact everywhere. Treating the heart of an imbalance, though, will get better results and can lead to much more profound change. It is heartening to hear that the practitioner is making adjustments; it is often said that immediate certainty is not always a sign of good diagnosis. People are very complex.

In terms of technique, the schools which teach this system tend to use mainly 'in and out' needle insertions which can take up a very small amount of a treatment session. We occasionally hear rumblings of discontent from patients who think that this doesn't seem quite right, and we have to explain to them that the time spent up to that point is all a part of the diagnostic process. All of this preceding work -  investigation, pulses and conversation - refines the diagnosis so that when the points are chosen their effect can be all the greater.

Having said all of this it is a concern to us that the practitioner appears to you to have made light of what you have experienced. We try our hardest to ensure that practitioners pay particular attention to what their patients experience and to respect what they have to say. While we would probably not consider something like this actionable under our professional codes it is certainly something which the practitioner would benefit from knowing so that they can look at how they have addressed the issue. Unfortunately the only person who can really address this is the patient, who is not always inclined to get involved in setting a practitioner right and more likely to want to walk away from the situation. If you do raise it with her, however, we hope that your concerns are properly addressed.

Just to re-iterate what we said above, we think that it is highly unlikely that a needle tip has broken off in the wrist, but we are happy to know that you have a GP appointment within the next few days to make the necessary investigations. We hope that you understand that we have taken your account very seriously, and we are a little disappointed that you do not feel as though you have been listened to. For us acupuncture is a daily way of life, and we are used to what happens. For most patients it is still a largely unknown area, and for this reason we have to remember to acknowledge that in what is already an unusual situation anything untoward which happens is likely to cause great anxiety.

We hope that it is as we a transient adverse event which resolves soon without the need for any medical intervention. 

Q:  Should I continue to have acupuncture from NHS physiotherapist for chronic plantar fasciitis? I had my first and only session so far last Tuesday. This was extremely painful, and has actually made my condition a lot more painful than it was before. Is this normal and will it improve if I have further sessions? 

A:  As a general principle, there are a number of conditions where someone's discomfort or pain levels may well increase after a treatment session. This is most common with back and neck problems, and is similar to what people report after osteopathy and chiropractic sessions. The structural work in their case and functional work in ours often causes a re-arrangement of structure which can cause additional pains. However, nearly all of these subside within 48 hours, leaving the area improved or improving. This is less so in cases like plantar fasciitis where the problem is more of an inflammatory nature but can still happen.

One of the perceived anomalies of traditional acupuncture is that needles are often placed away from the site of a pain but nonetheless have an action at a distance. This is very much to do with the underlying theoretical basis of our work and the concept of energy, or qi, as we call it. Pain arises from blockage or changes in the flow which we hope to correct with our needles.  Sometimes we avoid the area of pain because our experience is that sticking a needle in it just adds to the inflammation. However, the western medical acupuncture which most physios use in their practice is often based on underlying principles which aim to disperse inflammation and muscle knotting by direct treatment, often with slightly thicker needles and slightly more vigorous needle action than most of us would employ (although interestingly Chinese practitioners often use a much more vigorous technique than European practitioners.) The overall effect should be the same, however; a possible increase in discomfort for a couple of days followed by improvements. If, however, the amount of additional pain is more than someone can take, physios tend not to have the same options for treating at a distance as we might.

We have been asked about plantar fasciitis many times on our ask the expert website function and the most recent answer we gave was:

Plantar fasciitis can be a very unpleasant and debilitating problem, as you no doubt know. There is some evidence for the use of acupuncture treatment, as this paper shows,

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3094706

and if you google 'acupuncture' and 'plantar fasciitis' you will find a number of other papers which suggest that there may be benefits from treatment. However, the combined weight of the various studies is not enough to be able to give an unqualified recommendation.

That said, the strength of Chinese medicine is that it operates from an entirely different paradigm or theoretical basis, and has different ways of making sense of the symptoms which a patient is experiencing. This can sometimes offer treatment options which would not necessarily translate into a western understanding of physiology, although there is usually an overlap. The system of medicine rests on a theory of energy, called 'qi', whose flow and balance determine how well the various systems of the body function. Many problems like plantar fasciitis point to local blockages and disturbances, often due to over-use or poor gait, which once they have become established remain a problem even after someone's habits have changed. Symptoms such as this can also point to more systemic problems, and the skill of the practitioner lies in making a clear diagnosis of the whole system before starting to correct aspects of it.

In this case, since the presentations of plantar fasciitis can be very different, we would advise you to visit a BAcC member local to you for a brief face to face assessment of the problem before committing to treatment. We are fairly sure that you will have seen a chiropodist as well as your GP, but if you have not, we would highly recommend that you do. There are a number of treatment options which can work alongside acupuncture treatment to great effect, and with these sorts of problems it is often a combined approach which pays the greatest dividends.

This isn't touting for business for our members, by the way! I'm sure the physio will be able to help you, but if the treatment is proving painful in the first instance the best thing to do is to give feedback about the discomfort and ask if the treatment can be modified in order to achieve the same progress but without the same discomfort. Fewer needles or less vigorous treatment should remedy the problem.

 

Q:  Following acupuncture last week on my knee, two days later I  felt extremely tired and stiff all over like I had run a marathon. Yesterday I had acupuncture again on my knee and I can now feel these symptoms returning. 

A: Had you been a first time patient we would simply have said that after a first session there is often a great amount of adjustment going on in the body. Patients often, in our experience, can have all sorts of tiredness and stiffness , to the extent that this expert is very clear with the treatment of musculoskeletal problems can often cause an initial 48 hour disruption, after which things settle down. It is also not uncommon for the first session to induce deep sleep.

However, if an 'old hand' has these symptoms this is more of a challenge to explain. Had it been a one off we might have suggested that it was a contingent problem, just coinciding with the treatment. However, a second dose of the same suggests that something has changed in the overall balance, and that the treatment may well be the cause.

We're not sure from your email what kind of treatment you're having. We have come across cases where someone has been treated for a musculo-skeletal problem by a doctor or physio, and where they have used points which are indicated for the problem in their system but which have far more profound effects in ours. There is a point for tennis elbow, for example, which can have a very powerful effect on blood pressure, and if this is needled vigorously to help a local problem it can cause fainting in someone whose balance from a Chinese medicine perspective is a little weak in some areas. This is not demeaning denigrating what doctors and physios do, but simply recognises the fact that although the points used lie in the same place they are not accorded the same overall functions which we understand.

Another possibility is that the technique your practitioner is using for the treatment is too much for your whole system. The treatment of knee problems can often be quite vigorous, and there are patients for whom constitutional treatments are OK but more robust local treatments are not. The simple answer to whether this is the case is to discuss the matter with your practitioner. He or she will be the best source of knowledge because they know what they have been trying to achieve and can tell you whether the treatment is different from what you have had before. They will also not be at all affronted if you ask them; they are more likely to be intrigued.

Failing these two possibilities, there isn't much more we can offer without actually seeing what is happening. It is not a usual after effect, and being conversant with most of the adverse event literature we can tell you that it is a rare occurrence. We think the answer probably lies in the strength of the treatment being used, and suspect that turning the volume down a bit may well generate good results without running the risk of feeling wiped out each time.

We would be failing in our duty, though, if we didn't tell you to pop along to your GP if this happens again. While not being directly causally related the treatment may be revealing another underlying problem which may need addressing, and it might well be worthwhile having some bloods taken to see whether there is an unrelated problem which the acupuncture treatment is aggravati

Q:  I went for my second acupuncture last Friday and the acupuncturist was working alone that day and going back and forth between several patients as well as answering phone calls. He put quite a few needles in my neck, shoulder areas and the lowest one placed I remember had something to do with the heart. I don't know how long he left the needles in as I didn't have my watch on, but it was a really long time and several of the needles were a little uncomfortable. Out of nowhere I had a headrush kind of feeling and felt as if I might pass out.  Immediately following this sensation, my heart began racing very fast for at least 5 minutes or so. I take a beta blocker to prevent that very thing and it has never happened while taking my meds. I tried intentionally relaxing, deep breathing, even took a deep breath and held it several seconds before releasing it hoping it would slow my heart down but it didn't work. It slowed back down by the time he made it back into the room but I was lightheaded for at least an hour or so after my visit. I told him about the experience and he said perhaps it was because he used quite a few more needles than the last time because he felt he needed to be more aggressive after the first session didn't provide any relief. I have read that the light headedness isn't a bad thing but can mean it was a successful treatment. The ultra fast heart rate was a little unnerving and my arm pits were quite wet....and I never sweat. 

A:  We are pleased to hear that all turned out well and that you have retained your sense of humour about this. However, we have to say that we are a little bit unhappy about some aspects of what was happening, not least of which was the fact that you did not appear to have any way of attracting his attention when he was out of the room, and that you were left unattended for a considerable length of time without a clear idea of when he would return.

We are happy that people choose to work in several rooms simultaneously if they and their patients approve, but this does mean that it places an extra burden of care on the practitioner to make sure that they put patient safety first in terms of letting people know how long they will be and how to attract attention. We also have concerns about the maintenance of hygiene when moving from room to room. Working in several rooms requires a great deal of precautionary hand-washing to avoid cross infection.

As far as your symptoms are concerned, powerful treatments can sometimes induce the sensations you have experienced. You sound as though you were on the verge of a faint - light-headed, fast heartbeat, sweats - and ideally you should have been laid down with your feet higher than  your head and given a sweet drink. We sometimes call this 'needle shock' and on some sensitive patients we have to tread very carefully in terms of numbers of needles and amount of needle stimulation. However, the effects are usually transient, gone within an hour or so, and no permanent damage is done.

Hopefully the feedback which you have given to your practitioner will enable him to use a slightly more gentle approach in future. If the sane thing does happen in spite of gentle treatment you may need to discuss whether acupuncture treatment is the best option. We have known of a handful of patients for whom any needles were simply too powerful, and eventually their apprehension about treatment outweighed the benefits they derived from it.

We hope this helps. It must have been a pretty scary experience for you, one that we hope does not recur.

Q:  I have a symptomatic perineural cyst on C8 nerve root. Can acupuncture help for this diagnosis. I had my first session yesterday with a physio who is qualified in acupuncture. Overnight I have had a different pain down my arm (I can only liken it to a period pain) which has eased slightly this morning. Is this expected?

A:  While there is a gathering body of acceptable evidence for what you might call 'headline' conditions - headache, backache - when you get down to specifics like cysts in arwas like C8 the best you might find is a case report about a single incident. We've done as thorough a trawl as we can, and can find nothing of merit, but even if we found a single case history its probative value would be small.

Much of the acupuncture used in research is western medical or formula acupuncture, and within the protocols for this there is rarely a great deal to do with cysts. In traditional acupuncture, however, accumulations of fluid are understood within the context of an entirely different conceptual grid which can make sense of why fluids gather at specific places and what underlying factors have predisposed someone to getting a cyst here. There may be a large amount of secondary information which underpins the understanding of a single symptom, and the skill of the practitioner of traditional acupuncture lies in treating the person, not the condition.

That said, a great many cysts are simply local problems which we understand as manifestations of a blockage in the flow of energy, called 'qi', on which Chinese medicine is founded, and local treatment can often have a profound impact. Obviously we do not needle the cyst itself, but quite often needles place on either side in the direction of flow of the main channels can have an impact. It is a very delicate area, though, and unless needling is done gently and to fairly superficial levels there is a danger that a small bruise or haematoma which may not be directly visible can cause impingement of nerves and blood vessels, and lead to the sorts of pains which you are experiencing.

On a more positive note, although physios tend to use western medical models of treatment, there is an effect caused by needling in the traditional way called 'deqi', a dull aching feeling which in modern Chinese treatment is seen as  a requisite for treatment to be successful. This can remain local or even travel down a channel, and it may be that this is what has happened. To put it very simply, if it disappears after 24 hours it could be deqi,. if it lasts for two days or more it is probably a bruise.

We think it is very important to discuss this with the practitioner so he or she can compare the outcomes you have had with the places they have needled and offer appropriate advice. If it is a bruise then it may last for up to a week as a diminishing effect, but if they cannot make sense of the effect based on what they did they may well advise you to pop along to your GP to get the problem looked at just in case it is entirely contingent and nothing to do with the treatment.

We think the effect will die down, and that it could well be worth having more treatment to see if acupuncture can help. However, if anything similar happened again we would recommend that you give it a miss in future, and look for alternatives which may be of benefit, like cranial osteopathy. 

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