A NÁLISIS FINANCIERO

Quite a few doctors who take up acupuncture seem to have a mental block about using it for anything other than the relief of musculoskele- tal pain. There are probably two main reasons for this attitude. One is a feeling that there is some respectable scientific basis for the use of needles to relieve this kind of pain, probably on the basis of counter- irritation, but little or none to support the treatment of non-painful disorders.

There is some truth in this, although the use of PC6 to treat nausea and vomiting has received probably more attention from Western researchers than any other acupuncture procedure, and this is not concerned with pain. But there are reasonably plausible neurological explanations for how acupuncture might relieve pain, whereas there is little to explain how it might work in other circumstances. Nevertheless, it has to be admitted that, even for pain, most of the evidence for the effectiveness of acupuncture is anecdotal, so the acupuncture treatment of non-painful disorders is not in much worse case than the treatment of pain.

The other reason for doctors’ reluctance to embark on using acupuncture to treat non-painful disorders is a vague awareness that it depends on using traditional acupuncture which is a highly esoteric business, requiring the therapist to select complicated combinations of points on an individual basis, and presupposing an acceptance of unfamiliar alien ideas. Advocates of the traditional system would, naturally, endorse such views.

My position is (as you might expect by now) somewhat different. My experience indicates that, although acupuncture is certainly no sort of panacea, it does work for certain disorders not characterised by pain. I don’t, however, accept the traditional ideas about the specificity of individual acupuncture points, nor do I think that elaborate forms of treatment are necessary in treating these rather heterogeneous clinical problems. This does not involve any kind of ‘advanced acupuncture’, and indeed in most cases the treatment is very simple, because all that is required is general stimulation. In other words, it is a nonspecific

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effect, that can in principle be produced by needling anywhere in the body. However, certain areas, notably the hands and feet, seem to be the most effective sites. I find that needling the feet is more effective than the hands, and probably less painful. LI4, in the hand, is often used, but it can be painful, and it seems occasionally to cause adverse reactions. As mentioned in Chapter 4, I have seen one case, in which it was used as a practice site on an acupuncture course, where the doctor concerned had pain in the thumb for six months afterwards, and there has recently been a report of bilateral hand oedema, lasting for several weeks, after it was used to treat back pain (McCartney et al., 2000). Another popular point is ST36, located in the tibialis anterior muscle, below the knee. This is claimed by some to be capable of stimulating the immune system.

Although I needle both the above sites from time to time, I agree with Mann that the classic acupuncture point LR3 is generally the best site to use. However, I’m also sure he is right in saying that, in many people, anywhere on the dorsum of the foot, or even a larger area, might be equally effective.

LR3 is situated between the first and second metatarsal bones. It is normally needled to a depth of about 0.5 in (12 mm). Different books show slightly variable locations for the point but this is unimportant. The target area is a roughly rectangular area about an inch (2.5 cm) long and a quarter of an inch (0.6 cm) wide, situated between the first and second metatarsal bones. It tapers to a point proximally, where the two metatarsal bones abut each other; below, it ends in the web of skin between the toes. It is occupied by muscles (the dorsal and plantar interossei) and contains the dorsalis pedis artery and one of its branches, the first dorsal metatarsal artery; on its fibular side the dorsalis pedis artery is related to the medial terminal branch of the anterior tibial nerve. Theoretically these structures might be damaged when needling in this region but in practice this very seldom occurs. However, some oozing of blood may be seen when the patient stands up, owing to increased hydrostatic pressure. (Note that the dorsalis pedis artery is somewhat variable: it may be larger than normal or absent, and it frequently curves laterally.)

LR3 and similar points can be used to treat a wide range of disorders, either as a complete treatment or as an adjunct to local needling. Needling LR3 is particularly likely to cause the euphoria and other subjective effects that characterize a strong reactor.

It’s difficult to give a complete list of disorders and symptoms that may be treated by generalized stimulation, partly because a lot depends on the reactivity of the individual patient. If someone is a good acupuncture subject it may be possible to obtain surprisingly good results in such a person, even in unpromising disorders.

Here is a brief description of the disorders that I have principally used generalized stimulation for.

A woman in her 40s came for treatment of a mysterious syndrome. Throughout the summer she suffered a skin rash whenever she went out in the sun, so that she had to remain indoors. Throughout the winter she had diarrhoea with bleeding; she had been investigated by gastroenterologists without any cause being identified. A few treatments to LR3 produced a complete remission in both sets of symptoms; the effect lasted at least a year, after which I didn’t see her again.

Solar dermatitis

The case report above reflects a more general trend, which is that solar dermatitis appears to respond particularly well to acupuncture. The converse may, I think, also be true: patients who suffer from solar dermatitis may be good acupuncture subjects.

Chronic urticaria

This is, presumably, an allergic disorder, although it is seldom possible to identify the offending foodstuff or other agent responsible. Acupuncture often helps with the symptoms but the effects of treatment are generally short-lived, so that it is one of the disorders where patients may need to treat themselves. Some patients report that, after acupuncture, they are now able to eat foods which formerly they couldn’t tolerate. I am quite prepared to accept that this may be, at least in part, the result of self- suggestion, but it’s nevertheless valuable.

Menopausal hot flushes

Menopausal flushes often respond to acupuncture, although, again, the effect may be brief, so that self-acupuncture is indicated. Men suffering from flushes as a result of hormonal treatment for prostate cancer also respond.

Bronchial asthma

Randomized controlled trials of acupuncture in asthma have generally not shown any effect, and I would agree with this; most patients I have tried it on have not responded. There is, however, a small number in whom it is dramatically effective, with immediate increases in peak flow of up to 400 per cent. Cookbooks recommend a number of points on the chest and elsewhere for asthma, but having tried them I am not impressed. I now think that if anything is going to work, it is LR3; if that doesn’t work, you may as well forget using acupuncture.

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A young woman, whom I already knew to be a strong reactor to acupuncture, came to the hospital outpatient department in a severe asthmatic attack. She was wheezing loudly and her peak flow rate was 110 litres per minute. I said that I didn’t think acupuncture was going to work, but I would do it anyway. I put a needle in LR3; she immediately felt much better and her peak flow rate was now 440 L/min. I said that this was fine but it was unlikely to last and she should go to her doctor next day for some prednisolone. (She lived a long way from London so couldn’t attend for further treatment very easily.) However, she returned six weeks later, still feeling well, and her peak flow rate was still 440 L/min.

A middle-aged woman who had suffered severely from asthma for many years came for treatment. She had been admitted to hospital with asthma on several occasions and had constant symptoms in spite of treatment. She had a stressful job which was no doubt making matters worse. When she came to see me her peak flow rate was 110 L/min. I tried acupuncture at LR3: immediately her peak flow went up to 440 L/min. Like the previous patient, she lived a long way from London. I asked her to keep a record of her peak flow readings at home. When she returned some six weeks later, the readings showed that her peak flow had remained high for several weeks after treatment but had gradually reverted to its previous low level. After she had attended for more treatments over about a year, I taught her to needle herself at LR3. She continued to remain well provided she did this, and required no further hospital admissions.

Hay fever asthma often does well.

A woman in her 40s had asthma only in summer; it was pollen- related. Over several years I treated her a couple of times at LR3 in early May; provided this was done she had no asthma during the summer, but one year when she failed to attend for treat- ment she had bad asthma again all summer.

Probably only about 10 per cent of patients with asthma, possibly fewer, will respond, but in some of those, as indicated by these case reports, acupuncture is extremely effective. However, it’s important to verify the effect of the treatment by means of peak flow studies,

preferably done at home over several weeks, since subjective impres- sions of improvement are sometimes misleading.

It’s not easy to predict which patients will do well. Acupuncture is probably most likely to work in patients who are strongly allergic, but this is not invariably the case.

Remember the possibility of aggravation, which may lead to an episode of status asthmaticus if an asthmatic person is treated too strongly. However, this is very unlikely to happen with the kind of treatment described in this book.

Headache and migraine

As described in Chapter 9, some patients respond better to LR3 than to local acupuncture directed to the head and neck. I would normally try both forms of treatment in a case of migraine before giving up. Occasionally, however, treating LR3 appears to produce only an aggravation, without subsequent improvement.

A middle-aged woman came for treatment of her migraine. I tried LR3, and within half an hour she had a migraine of exceptional severity, preceded by a visual aura (the first she had ever experienced). On the second occasion I repeated the acu- puncture, on one side only, with minimal stimulation. The result was the same: a severe migraine within half an hour. However, I felt that I must be on the right track since at least I was having some effect, and the general principle in acupuncture is that if you can make symptoms worse with your treatment you can probably also make them better. So on her third attendance I needled LR3 as lightly as I could, just breaking the skin. Once more she experienced a severe migraine, at which point we agreed jointly to give up.

Migraine equivalents

These are focal neurological symptoms that occur without headaches or vomiting and are most frequent in patients between the ages of 40 and 70, in whom they may occur after the headaches have ceased. In children, benign paroxysmal vertigo and episodic abdominal pain are other manifestations of this syndrome. I have a personal interest in this because, as a teenager and into my early 20s, I used to suffer what I now realize were migraine equivalents. In these I would feel as if reality were subtly altered in some indescribable way. The state would

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last for about 20 minutes and then pass off, without a subsequent headache, although I did have classic migraines at other times.

Migraine equivalents can be of almost any character and I suspect are probably more common than is sometimes recognized. Acupuncture at LR3 is worth trying in any case of transient neurological disturbance in which serious organic disease has been excluded.

Reference

McCartney C.J.L., Herriot R. & Chambers W.A. (2000). Bilateral hand oedema related to acupuncture. Pain, 84; 429–30.