1. Acupuncture

2. Historical overview In use in Traditional Chinese Medicine for 3000 years Also concurrently used in other cultures – Ancient Egyptians. Otzi the Iceman (3200 BC Central Europe) 47 tattoos in 15 groups – 9 groups located within 5mm of classical acupuncture points. OA of hip. Knee, Ankle and Lumbar spine and worms – points appear to correspond. Not known how developed – Chinese battle field? Or Trigger point theory.

3. How did it spread Brief phase of popularity in 1600’s, but mostly took off in 1970’s, post Nixon’s visit to China, and James Reston’s (of NYT) appendicitis and subsequent article Original claims not supported by practice in West (Surgical Analgesia and Sensioneural deafness – China = 90% - UK :o( Good evidence for use of MA in Musculoskeleltal pain, nausea and vomiting (esp post op) chronic headache, back pain and knee pain (although this has been a bit disputed recently). Bladder irritability and xerostomia appear to have symptom control with acupuncture, and electro- acupuncture may be useful in fertility

4. Philosophy of Traditional Chinese Medicine (TCM) Most widely used and documented systems of acupuncture Founded in Taoism – natural abstract force responsible for virtually everything Other philosophies were added in – Yin and Yang, Qui/Qi/Chi, Five phases/elements (Bhuddism) Pulse and tongue diagnoses (Confuscianism sacred body)

5. TCM – cont Chi – ‘life Energy’ or ‘Vital Force’ Both innate and acquired Accumulates in organs Flows around body via Meridians, regulating, nourishing and generally making things work Chinese felt that qi flowed like water, and blockages produced stagnant areas in flow – needling releases blockage, allowing Qi to flow and balance to be restored – Points often in dips and hollows

6. Meridians Twelve paired and two central – Fourteen in total Named after various things – Gallbladder, Liver, Kidney, Spleen, Governor – etc Numerous points on each meridian, given numbers Abbreviated for documentation – eg Kidney three – KI3, Large Intestine 4 LIV, Heart 7 – HT7. Western acupuncture uses same nomenclature for convenience (presumably the documentation is not so convenient in Mandarin, although much prettier!)

7. How is TCM administered Often from lay people with no conventional medical skills or experience in this country – in China more mainstream and practiced by their medical profession alongside conventional medicine Diagnosis from pulse and tongue Points applied by a sort of recipe to look at balance – all a bit illogical from a Western point of view. Very holistic – often not problem based.

8. How does medical/western acupuncture differ Delivered by qualified and registered health professionals, as an extension of their regular practice Follows orthodox clinical diagnosis Points are selected from the same pool, but selected via neurophysiological principles based – usually local needling of trigger points, tender points and convenient acupuncture points Often referred to as needling or dry needling

9. Precautions and Contraindications Absolute – only one! Phobia of needles! Pacemaker Pregnancy Anti-coagulants or clotting disorders Heart Valve Insufficiency Immuno-suppression

10. Trigger Points Ropey bits of muscle in mini-spasm Cause pain – primary symptom – up to 80 percent of GP consultations for pain No abnormality on biopsy Local Twitch Response Can be latent Respond well to stretch or local pressure (hmm) However, caused by overwork or overstretch – if movement pattern not addressed

11. Risk of adverse incidents Pretty rare – mostly in single figures, occasionally double. Only infections (148) and pneumothorax (191) in triple figures from available literature –in total. Difficult to assess risk due to variety of practitioners – pretty low. Most significant of pneumothorax Cardiac injury next most common (39)

12. Minor adverse incidents Still pretty rare. Include: Fainting, dizziness Sweating Pain Stuck needle Carthartic reactions Local infection Minor bruising/bleeding

13. Rarer issues Can mask pain – One man died of MI having seen acupuncturist for pain in LUL and chest. Doesn’t treat causes of pain, and should always be used by Registered Health Professional following orthodox clinical diagnosis Interactions with drugs Pacemakers Pregnancy (can of worms!)

14. Neurophysiology Not really fully understood Analgesic – inhibits C fibres (slow pain, itch, heat) by stimulation of A delta (pinprick, fast pain, cold, pressure) Effectively pain gate BUT has lasting effects – neuroplastic change, and continued inhibition of C fibres via descending modulation Seem to be similar to post exercise effects (except CV)

15. Other effects Chemical – Endorphin release, ACTH, Oxytocin – feel-good stuff – also sedation/alertness. Think exercise! Local – Afferent nerve stimulation, vasodilation, capillary proliferation, nerve growth, pain modulation Central Nervous system – autonomic modulation, enhanced descending inhibition.

16. Acupuncture in neurology Not very evidence based, however Logically quite useful – use of positive ascending input to improve useful neuroplastic change – especially given exercise connection Still use local points – eg ST36 for footdrop Highly unlikely to do any harm Very useful in secondary problems – eg thalamic pain or tetraplegic shoulders (often with TrPs)

17. Patient Selection Tetraplegic shoulders Associated injury Post operative pain/nausea Thalamic pain Anxious patients Other musculoskeletal pain of non-sinister origin ??? Chronic Back Pain??? Part of treatment, never whole