Ask an expert - body - chest

47 questions

A:  'Tried and tested' treatments for atrial fibrillation, and with them a 'best practice treatment' don't really sit well with the concepts of Chinese medicine.

We have been asked about AF on a number of occasions, and a composite response earlier this year said:

There are some early indications that acupuncture may have an anti-arrhythmic effect in patients with atrial fibrillation. A study published earlier this year

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312232/

concluded that there appeared to be benefits and that further large scale trials would be valuable to test the hypothesis more carefully.

However, it is only fair to say that needling a single point such as Neiguan repeatedly is not a fair representation of what a traditional acupuncturist does in practice. Although there is considerable overlap between eastern and western systems the arrhythmia typical of AF could be classified in several different ways within Chinese medicine, and the practitioner would be guided by evidence other than simply a reading of the rate of the pulse. That in turn would mean that ten people with AF might receive ten different treatments. To that extent, it is not that straightforward to extrapolate from research studies like this and conclude that 'acupuncture works'. 

The skill of the practitioner lies in making sense of the symptom of AF within an entirely different theoretical framework, and understanding each presentation in each individual patient as unique. The best advice we can give any prospective patient is to contact a BAcC member local to them to seek a short face to face consultation at which they can be given a better assessment of whether acupuncture might benefit them.

The one caution with AF is that most patients are taking some form of medication to control the problem, and the cessation of medication can quickly provoke a return of the symptoms. For people involved in highly technical or responsible work this might represent a serious risk. We would always recommend that any member contemplating treating someone with a condition like AF should talk to the patient's GP to ensure that nothing they do will undermine the current treatment regime. 

We have undertaken some further searches of the literature and these two articles

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4321072/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4673375/

say much the same as the earlier articles and indeed cite them frequently.

Most of us have treated AF cases, and they do represent something of a challenge because of the management of the case alongside western treatment and medication. Even where we manage to bring the episodes under control to a greater degree than the medication most medical practitioners are reluctant to stop the meds in case the patient has a serious recurrence when they are doing something which could have dangerous consequences (driving a car, etc etc). However, good dialogue can address these kinds of problems, and a patient with their symptoms under control is likely to be happy to facilitate good communication anyway.

The other slight issue is with the setting of outcome measures. AF can come and go, and a problem-free period can happen anyway, so a practitioner has to be careful to discuss with the patient what would count as evidence from the patient's perspective that there had been some progress.

As you can see from the responses there is a strong commitment to the idea that Chinese medicine treats the individual, not the condition itself. It may have been a strategic error for us as a profession to spend so much time talking about named conditions because it has started to develop a public perception that we are doing the same as doctors  but using needles instead. The reality is that although the symptom may be the same from a Chinese medicine perspective a dozen people with AF may be treated in a dozen different ways if the practitioner discerns a different root pattern in each system which needs to be treated to restore proper flow and balance.

Adding to what has been said above, we tend to tread cautiously with patients diagnosed with AF. Sometimes the treatments offered can have their own substantial side effects, and these need to be factored into any treatment plan. However, we tend to want to work in close contact with a patient's orthodox healthcare professionals to ensure that the condition can be brought under better control without risk to the patient.

Q:  Can acupuncture help moderate sleep apnoea? Are there any outcome studies that compare acupuncture for moderate sleep apnoea with C-pap technologies?

A:  Rather oddly we have not been asked questions about the use of acupuncture treatment in sleep apnea before, and on investigation we found three studies

http://www.ncbi.nlm.nih.gov/pubmed/20615853

http://www.ncbi.nlm.nih.gov/pubmed/17023212

http://www.ncbi.nlm.nih.gov/pubmed/19186731which appear to give very encouraging results. As always the studies are rather small, and this does mean that they are not really considered robust enough to make substantive claims for what might be possible. However, they are significantly better than some we see which fail to draw any conclusions.

Unfortunately there are no studies which compare the use of acupuncture with C-Pap machines. The trials all test acupuncture against sham acupuncture, itself a rather difficult comparison because it is based on the premise that sham acupuncture has no effects, where from our perspective it may simply be testing sub-optimal treatment against optimal treatment. We suspect it might be possible to find research data from the use of C-pap machines and compare the outcomes, but this is beyond what we can meaningfully generate and fraught with methodological problems.

The issue for us, though, is not whether there is evidence of studies to underpin the treatment but whether there are discernible patterns of disturbance in the energy of the body which give some clue in Chinese medicine terms about what is happening. Some systems of TCM have very specific syndromes where the symptoms of apnea are accompanied by other pathological changes which point directly to potential treatments, but even this is not an essential requirement for successful treatment. The very early systems of diagnosis and treatment were often asymptomatic, literally treating the person rather than the condition with which they presented, in the simple belief that a system in balance took care of itself.

The best advice we can offer, and usually do, is to visit a BAcC member local to you for a brief face to face assessment of what may be possible. This will be able to take into account some of the unique aspects of your presentation which will better inform a skilled practitioner about what is going on.

 

Q:  I have had a persistent cough for 15 years. I have seen A specialist at Kings College London and been to several cough clinics, none have provided a solution. The cough is very violent and puts a great deal of stress on my body. The problem has been diagnosed as nerve damage to my throat, which causes an overreaction to the slightest irritation resulting in severe bouts of coughing. Is there any form of acupuncture that may relieve or stop the problem.

A:  We are assuming that having been under specialist care you have had all of the available tests, and we are a little surprised that nothing has shown up. However, we have seen cases like this where the body seems to have developed a sensitivity reaction for which no obvious solution can be found. We answered a question about a similar problem some time ago, and the response we gave included the following comment and advice:

If none of these has been identified as a cause, or even if they have, there may be some merit in looking at acupuncture treatment. There is not a great deal of evidence for the treatment of coughing, but this is mainly a reflection of the many different causes of coughing and the difficulties of designing a trial which generates meaningful results. Persistent coughing has certainly be a symptom recognised within traditional Chinese medicine, and if it appears alongside other symptoms and alongside the diagnostic evidence which a trained practitioner will find using Chinese medicine techniques, there are a number of clearly defined syndromes which offer treatment protocols to address the underlying patterns.

Even where there is no recognised syndrome, it is important to remember that in its earliest forms Chinese medicine was asymptomatic, i.e. it treated the patient as a whole based on the diagnostic evidence and not necessarily with regard to what they reported. In this way the treatment could truly be said to be unique. The underlying premise was symptoms only appear when the system as a whole is out of balance, and because of the internal patterns of energy flow, a symptom may not necessarily arise where the actual problem lies. The skill and art of the practitioner is to go to the root of the problem and once this is treated, there should be an improvement in the symptoms.

On that basis, and given that the problem has not always been there, it may well be worth having a brief chat with a BAcC member local to you to determine what may be possible. What the earlier answer does not cover in detail is the fact that traditional Chinese medicine sees the whole system, body, mind and spirit, as a united whole, and there are quite often connections to what is happening in a patient's life which can make some sense of an unusual symptom. Even where this is not the case, however, there is some evidence, especially from the treatment of phantom limb pain, that acupuncture treatment may be able to turn off or reduce the volume of a nerve signal to the point where it becomes more tolerable.

The only caution we have about slightly less frequent problems is that it can be quite easy to have a great many treatments where the results do not justify the continuing expense. You are probably more likely than many to notice circumstances where the reaction is less extreme, but even so we would always recommend finding some relatively objective outcome measure to assess the benefits of treatment.

Q:  My son has myotonic dystrophy and has a pacemaker, he wants to try acupuncture, will it be safe for him?

A:  The only contra-indication we recognise with pacemakers is that it is not wise to use electro-acupuncture.  The leading and authoritative text on electro-acupuncture says that:

stimulation is contra-indicated if a patient uses a demand type (synchronous) cardiac pacemaker. whether atrial or ventricular

but our view is that the fine distinctions between different types of pacemaker are probably not that well understood by patient and practitioner alike, so we prefer to make this a blanket restriction.

Pacemakers can obviously be positioned in a number of places, and we would expect practitioners to take extra care when needling in that area or indeed not needle there at all. A great deal depends on where the device is installed.

Other than that we can think of no reason why your son should not try acupuncture. There is no evidence that we can find which relates specifically to this condition, but the general basis of acupuncture involves optimising basic functions in the body and ensuring that when there are progressive degenerative conditions that what residual function remains is as effective as possible. We hope that treatment may be able to offer your son substantive results


A:  Oddly enough it is quite a while since we have been asked about the treatment of AF, and the last 'long' answer we gave was:

There are some early indications that acupuncture may have an anti-arrhythmic effect in patients with atrial fibrillation. A study published earlier this year

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312232/

concluded that there appeared to be benefits and that further large scale trials would be valuable to test the hypothesis more carefully.

However, it is only fair to say that needling a single point such as Neiguan repeatedly is not a fair representation of what a traditional acupuncturist does in practice. Although there is considerable overlap between eastern and western systems the arrhythmia typical of AF could be classified in several different ways within Chinese medicine, and the practitioner would be guided by evidence other than simply a reading of the rate of the pulse. That in turn would mean that ten people with AF might receive ten different treatments. To that extent, it is not that straightforward to extrapolate from research studies like this and conclude that 'acupuncture works'. 

The skill of the practitioner lies in making sense of the symptom of AF within an entirely different theoretical framework, and understanding each presentation in each individual patient as unique. The best advice we can give any prosepctive patient is to contact a BAcC member local to them to seek a short face to face consultation at which they can be given a better assessment of whether acupuncture might benefit them.

The one caution with AF is that most patients are taking some form of medication to control the problem, and the cessation of medication can quickly provoke a return of the symptoms. For people involved in highly technical or responsible work this might represent a serious risk. We would always recommend that any member contemplating treating someone with a condition like AF should talk to the patient's GP to ensure that nothing they do will undermine the current treatment regime. 

We have undertaken some further searches of the literature and these two articles

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4321072/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4673375/

say much the same as the earlier articles and indeed cite them frequently.

Most of us have treated AF cases, and they do represent something of a challenge because of the management of the case alongside western treatment and medication. Even where we manage to bring the episodes under control to a greater degree than the medication most medical practitioners are reluctant to stop the meds in case the patient has a serious recurrence when they are doing something which could have dangerous consequences (driving a car, etc etc). However, good dialogue can address these kinds of problems, and a patient with their symptoms under control is likely to be happy to facilitate good communication anyway.

The other slight issue is with the setting of outcome measures. AF can come and go, and a problem-free period can happen anyway, so a practitioner has to be careful to discuss with the patient what would count as evidence from the patient's perspective that there had been some progress.

 



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