I wondered if there are any points that we should avoid using for a patient with rheumatoid arthritis

Q. Hi,

I wondered if there are any points that we should avoid using for a patient with rheumatoid arthritis for example points where there is a risk of entering the joint such as the eyes of the knee or shoulder?

Has acupuncture ever been known to trigger a reactive arthritis?

Also, should we be using anti-bacterial wipes prior to inserting the needle for someone with rheumatoid arthritis?

A. There are no contra-indications of which we are aware for the use of acupuncture in treating rheumatoid arthritis. Some traditions of acupuncture, strangely enough the modern medical versions, tend to use deeper insertion of the needle than many traditional acupuncturists would countenance, and we have found nothing on their safety forums to indicate that special care needs to be taken. The BAcC was involved with a group of several associations, including medical acupuncture bodies, to draw up safety guidelines some years ago, and this was never raised as an issue by anyone.

By the same token we have not been able to find any evidence to suggest that a reactive attack has happened as a consequence of treatment. This is a little more tricky, because as is often the case in these situations people are generally doing a great deal more just having acupuncture, so it may not have been picked up as valid causation. As we have said to colleagues many time absence of evidence is not evidence of absence. However, there have been recorded cases of which we are aware, and we do monitor adverse events carefully.

The issue of swabbing or cleaning points is a little more contentious. In the NHS there is a roughly 50/50 split between those who insist and those who don't. Our own advice to members, which we are happy to share is:

Where necessary, you should swab the skin with 70 per cent isopropyl alcohol with or without 0.5-2.0 per cent chlorhexidine. If the area of the skin to be needled is clean and free from dirt or organic matter (such as soil) then there is no requirement to swab the skin.

If areas of the body to be needled are dirty then they should be washed first with soap and water.
Swabbing is only indicated for patients who have a suppressed immune system through illness or medication and is not required in the fit and healthy.

The recommended agent to “sterilise” the needle area is 70% isopropyl alcohol usually in the form of a medi swab. Cotton wool balls soaked in alcohol solution are strongly discouraged as these can become heavily contaminated with hand and environmental bacteria. The use of 90 per cent isopropyl alcohol is unacceptable as it may preserve organisms and also because it evaporates too quickly to have an antiseptic effect. Other cleaning agents, if used, should also have adequate antiseptic properties and be safe on the skin. These preparations should contain 0.5-2.0 per cent chlorhexidine and should ideally be in an alcohol solution, as chlorhexidine is not completely effective against Pseudomonas, the main organism causing infection in the earlobe.

The misuse of swabs is very common and it is recommended that a fresh swab is used for each point. The swab should be in contact with the area to be needled for 30 seconds and allowed to dry for a further 30 seconds. It is recommended that you swab points in a way that touches the area only once so as not to re-contaminate the area and it is best to swab from one end of the area to another.

After an acupuncture point has been cleaned in this way, it must not be palpated unless it is cleaned again afterwards.

The arguments tend to focus on whether cleaning a needle site removes protective bacteria as well as killing potentially dangerous ones, so we have taken a fairly commonsense line and asked members to use professional judgement in dealing with patients who might be perceived to be slightly higher risk. Since most high risk conditions have a vast range of presentations we wanted to avoid over-reaction.

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