Acupuncture

[Nick]

I expect this ground has probably been covered before, but I want to know what others here think about acupuncture for pain management.

I had a patient in this morning who was referred by another practitioner who used acupuncture to decrease headaches and neck pain. Although reported as a successful intervention by her, she stated that her pain was currently a 12 out of 10 and that she could not make it through her day if she was not getting acupuncture.

Her pain began about 5 years ago after a car accident. Examination reveals significant stiffness in the left upper cervical spine (C2/3 if that matters to anyone and PIVMS are really accurate:angel: ), restricted neurodynamics in the right upper quadrant (pain and tightness), coldness of the right hand, and major tightness and tenderness of the suboccipital muscles.

First day: assessment and treatment - pain education, including a lot of effort to explain why acupuncture may not be corrective. This created a lot of anxiety, which in retrospect was probably not very helpful and could have been handled better.

Second treatment: began with a demand for acupuncture and me trying to explain the benefits of movement, DNM, and SC; temprorary compromise; great response (in terms of characteristics of correction) to gentle handling, but left convinced that without acupuncture she will hurt all the time.

I also should add that she was initially treated to PT of the bucket-carrying variety. Last PT provided excellent pain education and graded exposure which helped somewhat. Also provided the acupunture on which she has apparently become quite dependent.

I look forward to your thoughts on this.

Nick

[Barrett Dorko]

Nick,

This woman is lucky to have you as a therapist (as opposed to me, for instance).

Her demands may not be something you can overcome, especially if she suspects that you are willfully withholding something you could do. I can't do that stuff myself, so I would be off the hook.

Perhaps you could talk to her about how acupuncture is another way of gently stimulating the skin and go from there.

Have to tell you though, I actually think you're a dead man.

[nari]

Nick

This is the sort of quandary I am facing with almost every patient in the pain clinic. Sometimes their selective process of taking on board new ideas/concepts, especially active processes, is quite malfunctional; the body image is up the creek and they can't remember what functional movement is.

With some of these folk, I tape the area from the nuchal ridge to the CTJ or upper trap. I don't know anything about acupuncture except anecdotes and a few papers supporting its usefulness. But I like neurodynamics and, if the patient is not too hyper, I start distally and work upwards. Some do OK, others freak out.
It is interesting how patients run with certain notions. Like my fellow who was manipulated a few times by a PT for his chronic neck pain and went on to self-manipulate himself every hour or so....for a year or more. The click made him feel better for about half an hour....
Or another person who is reported to have said: I cannot understand this unconscious stuff...

I tend to agree with Barrett; you're a dead man. :)

Nari

[EricM]

I'm sure you've pointed out the obvious to her. That even with acupuncture she still has her pain? Barrett's line of "how's that workin for ya?" comes to mind. I like to remind my patients that you can only flog a dead horse for so long before eventually you have to get a new horse. That at least makes them smile.

I might start somewhere relatively inocuous, like maybe her left hip. Look for problems there, probably some covert symptoms hiding under the surface, and demonstrate how your 'alternative' approach (probably some DNM) works. IF you're successful she may be ready to try something new in her overtly symptommatic area.

You're not in the grave yet.

Eric,
the optimist

[nari]

Keep optimistising, Eric.
Provides a nice balance for the few cynics amngst us! ;)

Nari

[Barrett Dorko]

Eric,

Okay, not in the grave, but does the phrase "dead man walking" mean anything to you? And actually, that's Doctor Phil's line.

Seriously, I agree that placing your hands distantly from the sensitive area is a good idea, assuming you're still alive at this point.

[EricM]

Strangely enough I found this picture of Nick on the web. Maybe you're right after all Barrett? The living dead maybe? Nick no wonder your patient has doubts about you!

[Luke Rickards]

Nick,

It seems like there are two questions here -
1. Is acupuncture effective for pain management?
2. Is it appropriate for this patient?

For certain conditions there is evidence that needling can be very effective, and this has also been my experience. It is unlikely to resolve this patients problems though.

Suggestion: if she is adamant, place a couple of needles superficially in the Cx and do SC with them in. Explain the importance of continuing at home without needles also.

Luke

[Nick]

Good guess, Eric. That left hip is very internally rotated - left foot pointing almost directly to the right. Also a pretty accurate picture of me after several hours of patients with chronic pain!

I don't doubt that acupuncture "works" in some cases, but it has been pretty hit or miss in my experience. Anyone working on a prediction rule? I can see how it can be an effective neuromodulator and am familiar with some of the evidence for it, including placebo factors and effects of "medical ritual." I would like to know what someone's rationale for choosing acupuncture as a modality may be - in general and in this case specifically. As Eric has pointed out, although she feels it lowers her pain level and appears somewhat addicted to the ritual, her pain level really has not changed.

I would agree with acupuncture or anything else that helped in a case of intractable neuropathic pain, but I think there is a lot of room for improvement with this client with the right kind of movement.

Thanks for your input.

Nick

[emad]

Jon,
I like what you raised concerning Acupuncture effictivness in pain managing ,however after all the knowledge here for the nervous system espicially those sensory nerves with the images we see here , i believe Acup is a rather invasive therapy and could injury /affect negatively the nerve .

The point which worth discussing is the energy mediation in acup , which those practationers usually speak about ,by the way i have not studied acup neither did i practice !?

Cheers
Emad

[Karie]

Nick,

As you stated you could have initially approached the concept of her acupuncture treatment a little better and that is where you probably got off on the wrong foot with your patient. That doesn't mean that you can't accomplish your goals, however. I treat alot of patients that have had, currently are, or thinking about having acupuncture. There are four different acupuncturist in my community and they all do it differently. There are different schools of thought within this procedures just like all others. I have had it done to myself and find I prefer certain methods to others. I have been the "guinea pig" for a physician friend learning it..quite something for a needle phobic person that I am. Bottom line, whatever you believe about acupuncture it is not harmful to the body. It may not do anything, but it doesn't harm. Emad the needles hardly go in, I'm not sure of the depth level, but it is negligble. A dentist friend of mine has been doing it for more than 30 years with his patient's (he's one of those ahead of the pack practioners) and has helped many others with it long before we were using it on a regular basis here in the US. Patients of his whom can't tolerate the anesthesia for various dental procedures he uses the acupuncture and the patient doesn't feel a thing.
My point is that if a patient of yours wants to keep going for acupuncture it is not going to goof up any assistance your going to provide in your therapy care. If you can objectively state that her pain level hasn't changed with the acupuncture and when you start your treatment plan, it does. You know what's improving her outcome then. So, next time you see her, just tell her to feel free with doing her acupuncture sessions and then continue with your plan of care. I bet you won't be a dead man walking then....LOL

Karie

[Luke Rickards]

This just in -
Pain
Volume 125, Issues 1-2 , November 2006, Pages 98-106
Acupuncture for patients with chronic neck pain
Claudia M. Witta, Susanne Jenaa, Benno Brinkhausa, Bodo Lieckerb, Karl Wegscheiderc and Stefan N. Willicha


Abstract

Acupuncture is widely used by patients with neck pain, but there is a lack of information about its effectiveness in routine medical care. The aim was to investigate the effectiveness of acupuncture in addition to routine care in patients with chronic neck pain compared to treatment with routine care alone. We performed a randomized controlled multicentre trial plus non-randomized cohort in general practices in Germany. 14,161 patients with chronic neck pain (duration >6 months). Patients were randomly allocated to an acupuncture group or a control group receiving no acupuncture. Patients in the acupuncture group received up to 15 acupuncture sessions over three months. Patients who did not consent to randomization received acupuncture treatment. All subjects were allowed to receive usual medical care in addition to study treatment. Neck pain and disability (NPAD Scale by Wheeler) after three months. Of 14,161 patients (mean age 50.9 ± 13.1 years, 68% female) 1880 were randomized to acupuncture and 1886 to control, and 10,395 included into the non-randomized acupuncture group. At three months, neck pain and disability improved by 16.2 (SE: 0.4) to 38.3 (SE: 0.4); and by 3.9 (SE: 0.4) to 50.5 (SE: 0.4), difference 12.3 (p < 0.001) in the acupuncture and control group, respectively. Treatment success was essentially maintained through six months. Non-randomized patients had more severe symptoms at baseline and showed higher neck pain and disability improvement compared to randomized patients. Treatment with acupuncture added to routine care in patients with chronic neck pain was associated with improvements in neck pain and disability compared to treatment with routine care alone.

[Bas]

Karie, just a quick note on needling depth. From barely in the skin to 6 inches deep - depending on the location and the patient size. So in the hands of a non-regulated professional (OIW , not under strict standards of education and practice), acupuncture CAN be arisk. Clinics closed due to use of re-usable needles with non-operational autoclave, re-used needles causing infection, repeated penetration of bloodvessels in hemopheliacs, hard penetration of nerve tissue.

Although generally very safe - there are risks....as always, depending on the ...practitioner

[emad]

Hi Karie & Bas,

I agree that needling is an infection risk ,however there are who could say disposable needles are available .

Karie, i have not applied before Acup as pain therapy !!

Cheers
Emad

[Karie]

Emad,

I'm sorry I don't understand your thought about acupuncture/pain. Please expand on your thought for me.

Bas
Needling depth from the practioners that are in my community is barely into the skin. 6 inches I have never seen done here.

All the practioners in my community have indepth training and credentialling, so I'm not sure if you mean a person that isn't trained is doing improper acupuncture methods, then yes in that person's hands it's a risk for the reasons you stated. All practioners here use disposable needles, not reused.
I don't know of any clinic/medical practice in general that reuses anykinds of needles anymore...OSHA I think has lots of regulations on this in the US. I may be ignorant of something here, but that is my understanding.

Karie :teeth:

[emad]

Karie, just i meant using needling for pain suppersion . I like to try it ,but seems difficult i have to attend practical application of needling of certain standards which is not available where i am living . I like making trials to see what the outcomes by myself .

However , i get good result using neuromodulation and neurodynamics to deal with pain , just i feel it is lost step within my career development as the a step i applied practically which is trigger point therapy .

Cheers
Emad

[Chris Barnett]

Karie and Others

We have had a recent case of a patient recieving a Pneumothorax from a registered Physiotherapist In New South Wales Australia , which will probably lead to a change in the Australian Physiotherapy Associations position statement on what is considered adequate training and practice for the use of Acupuncture Needles and Moxibustion.

I have needled in the past and there is a growing body of evidence suggesting both non-specific and specific effects when applied to various RCT' s for knee pain , neck and low back pain etc..

This link from the New Zealand Guidelines group is quite informative
http://www.cam.org.nz/Treatment%20Methods/Acupuncture/acupuncture.htm


Cheers Chris

[Diane]

Hi Chris,
Informative perhaps, but really, I could probably get through life without having to consider "qi"... or have to filter it out of the part of my brain where I store treatment concepts... ;) :rolleyes:

Oh well, all that aside, I see this is your first post here, so welcome to SS! :teeth:

[Chris Barnett]

Thanks for welcome Diane

I suppose i am from the western school of acupuncture
I know nothing of chi or ying and yang for that matter!

I certainly remember a number of patients who "benefited" from needling and like i say the literature is growing

Chris

[Luke Rickards]

Karie,

The method you are familiar with is from the Japanese traditions. There are many other approaches to acupuncture, most which involve deeper needling and the production of a deep spreading sensation (called 'de chi'). This sensation has been shown to produce much greater activation of central neural responses than the superficial needling you are referring to. Of course, it also means there is more room for errors.

Luke

[Karie]

Hi Chris

Welcome!!!

I'm a newbie here too :D

Thanks for the reference, I'm in the middle of researching lots of information and it is most helpful to dialouge here in this forum. I am definately getting another perspective on many areas. I really like this forum it encourages critical thinking and provides "professional" discussion of topics.

Luke,
I guess the professionals here must have the Japanese slant, although I know my physician friend, whom is an anesthesiologist, said the model he was being taught was western/medical. I know when he did some of the methods I felt a "spread" pattern but when I looked how far the needle was in, it was barely through the skin. Didn't feel that way, but he said my nervous system was very sensitive and it didn't take much to activate it...whatever that may mean exactly. ;)

I do understand what you mean when you say there can be problems if the needles are not placed properly etc.

Interesting side note, do any of you remember the treatment method, "Neuroprobe." That was based off of acupuncture points and meridians and a hospital I used to work at used it alot. It appeared to clinically help a great deal. Of course, it wasn't used independently, there were other aspects to the treatment. Curious if this is still around and if anyone uses it?

Karie:teeth:

[Randy Dixon]

Jon Newman provided a reference on RE about acupuncture and post-operative nausea. I had thought it was about neck pain until I looked it up. Anyway you may want to give this journal a look through.

http://www.sram.org/current-issue.html


Nick,

What you need to do is to bring out the fanciest contraption you have in your office, even if it is a radio, attach some electrodes to it, tell the lady that you never use this but for HER, and HER alone, you are going to hook her up with the solution. 10 minutes of beeps and whistles, some miracle patches to wear at home and she is going to get better.

[Randy Dixon]

Karie,

Neuroprobe, microtens, microcurrent with probes. They are still around. There is one claiming 98% efficiency in making pain patients better. (whatever that means).

[emad]

Randy;
What you need to do is to bring out the fanciest contraption you have in your office, even if it is a radio, attach some electrodes to it, tell the lady that you never use this but for HER, and HER alone, you are going to hook her up with the solution. 10 minutes of beeps and whistles, some miracle patches to wear at home and she is going to get better.

You are so correct ,and so sorry to say that is the absolute truth i reached regarding pain ,no way ! Why do we here make our life and career complex by researching ,reading ,searching ,applying ,wroking hard ,discussing with idiots patients whom go to a therapist manipulate them and solve the problem by very simple methods !!!! We are NOT simple as we thought hahahah.

Cheers
Emad

[Jon Newman]

Michael Shermer Tests Acupuncture (http://www.youtube.com/watch?v=866YvYJRvWw)

[Jason Silvernail]

I've been a pretty vocal opponent of acupuncture in the past - strictly due to it's chi/qi magic energy basis.
However, I am aware that there are people out there who reject that explanation and attempt to use it as a clinical tool in a more conventional way, and I'd have no real issue with that.

My question for the group: what is the explanation for any positive effects seen with acupuncture? If it isn't energy flow, and we know that physiologically - mechanical pain requires movement for resolution, then what is the mechanism for the relief and what do we think it's clinical utility is?

[bernard]

Jason,

A stimulation conveys a message to the brain.
A needle conveys often (???) a nociceptive input (in our genetic heritage).
A response is produced that, often, contains endocrines.
Maybe it disturbs the other processes in action.

[nari]

Does anyone know of any study that has investigated acupuncture effects with fMRI? I have tried to find one but no luck. If sham acupuncture and the 'real thing' could be compared by imaging, it would be useful. (As would many other techniques).

It would seem that placebo does not come in to it much, as animals respond well to acupuncture, according to the vets. Animals also respond to manipulation, but that is another story.

I'd be interested in other PTs' comments re the physiology and the value of acupuncture. I am not trained in the procedure; it is uncommon amongst physios here.

Nari

[Luke Rickards]

Jason,

There is an excellent book titled Biomedical acupuncture for pain management (http://www.elsevier.com/wps/find/bookdescription.cws_home/703260/description#description) that I reviewed for IJOM a few years ago. It presents the current physiological research on acupuncture analgesia and a neuro-psycho-immunological model for the commonly observed effects, as well as a neuroanatomical model for point selection.

I was going to respond to one of Barrett's posts regarding acupuncture in the infamous SMT thread but got distracted. This book presents strong evidence that acupuncture can produce systemic effects including regulation of the autonomic nervous system ie improving adaptive potential. It is extremely common for patients to fall asleep within minutes a placing needles in many of these nerve 'rich' regions.

[Jason Silvernail]

That's the sort of thing I was looking for, Luke.
I knew you wouldn't disappoint.
Sorry...

[Luke Rickards]

Nari,

There are heaps of fMRI / PET studies on acupuncture. I'll see what I've got in my computer.

There is heated debate about how, or whether, a reliable sham for acupuncture can be produced.

[Luke Rickards]

Here is a few good ones.

[Luke Rickards]

Jon,
Shermer is right. Most traditional acupuncturists believe they are primary practitioners, but are woefully undereducated for such a role.

I've been there, and I got straight out.

[nari]

Yikes...thanks for those refs, Luke. It is a nuisance in some ways being cut off from all the huge resources I had when working. Will read through them tomorrow.

Nari

[Luke Rickards]

You're welcome Nari.

Jason, the first paper I attached also has some interesting implications regarding acupuncture for NMS pain with chemical origins.
There is an increasing number of new molecular
and neurophysiological research reports in stress
effect studies (14, 16, 35–37), anti-inflammatory
immune response studies (15, 18) and neuroim-
mune-based acupuncture research (19, 20) and
more recently neuroimaging-based acupuncture
research (6–10). These reports strongly support
the view that acupuncture mechanisms can be
explained on molecular and neurophysiological
bases, specifically via the BS-HPA axis mechanism.
The BS-HPA axis hypothesis not only shares the
well-known central-descending-pain-inhibitory
theory involving endogenous opioids, but also
suggests that there is a possible anti-inflammatory
mechanism in conjunction with neuroimmune
pathways and the cholinergic anti-inflammatory
mechanism (13–15).

[Diane]

A stimulation conveys a message to the brain.
A needle conveys often (???) a nociceptive input (in our genetic heritage).
A response is produced that, often, contains endocrines.
Maybe it disturbs the other processes in action. Bernard, did you mean to say "contains endorphins"?

[ian s]

http://www.acampbell.ukfsn.org/acupuncture/articles/touch.html

Thanks luke for the papers really helpful . I am interested in your background in acupuncture .
I trained with a Rheumatologist and did basic 'trigger point ' acupuncture although the Dr used mostly this approach he gave us lots of charts on meridians which i never got my head round .
I use it and some people find it very helpful but its along the lines of the paper above with the quote below in mind .
I dont find the chi/energy stuff offensive at all . I think of it along the same lines of religion --somewhat metaphorical and poetical perhaps but not factual in the conventional scientific sense?
However there is a lot in metaphor and poetry that is useful and some of the psychosomatic insights of TCM in relation to emotion and the body may be useful all the same?
ian

'Our therapy is designed to help your brain to reprogram itself in a more healthy way. It takes advantage of the inbuilt healing propensities of the body, so rather than manipulating the body from outside we are working with the mechanisms that exist and encouraging them to take over and restore health'.

[nari]

I was particularly interested in the CNS involvement as imaged through fMRI during acupuncture. Limbic and hypothalalmus....hmm.

I presume acupressure and reflexology follow the same principle, though less specific?

Nari

[Jon Newman]

Thanks all for the replies. I posted that video specifically because I think it illustrated the various tensions that run through so many of the threads here. The last minute of the video is particularly familiar sounding.

One thing in particular that I think acupuncture has going for it is the strong research interest in demonstrating how/why it works.

It seems that there are a few universal traits running through most therapies for pain relief as it pertains to their effect. If, and I do mean "if", all these approaches are working along similar, if not the same, neurological routes then I suppose the next step is to compare and contrast them on grounds beyond their neurological underpinnings including but not limited to:

The ability to predict for whom it will work.
Possible risk of harm.
Externalities (positive and negative) of the technique itself and their accompanying metaphors, especially if the metaphors are taken literally.

[bernard]

Bernard, did you mean to say "contains endorphins"?

An endocrine is an internal secretion so... Yes.

[Luke Rickards]

I am interested in your background in acupuncture
Hi Ian,

I did a 4 year diploma in TCM, then 3 months internship at the Guangzhou university teaching hospital in China, then a 6 month apprenticeship with one of Chairman Mao's ex-doctors in Nepal.

I practiced as a traditional acupuncturist for about 8 months before I decided that I was a joke and enrolled in Osteopathy. While I was doing undergrad Osteo I retrained myself in neuroanatomical models of acupuncture and commenced practice again as a 'biomedical' acupuncturist (only treating NMS pain) while I did my masters. I also taught a little at uni during this time.

[clarett]

Hi Luke

Most traditional acupuncturists believe they are primary practitioners, but are woefully undereducated for such a role

I have a query - as I understand it acupuncture is not considered a standalone modality in China, but is a tool in a wider system of medicine (TCM) just as we have specific techniques within the wider system of physiotherapy that are to be used in conjunction with others. For an example I refer to the current discussion on spinal manipulation - nobody is saying that it should be used in isolation - quite the opposite.
Coming to my point - isn't using acupuncture by itself taking it out of context? Does that make sense, I'm not sure if I'm making myself clear?

The other thing is related to the above quote that most are underqualified - is this in the States or worldwide? In China it takes 6 years to become a Chinese Medicine doctor which is the same as in Europe.

[Luke Rickards]

The other thing is related to the above quote that most are underqualified - is this in the States or worldwide?I was referring to pretty much everywhere except for China. You are correct that in China doctors are trained for 6 years. However, most of this is Western Medicine and they can then choose to do further study in TCM, which leads me to the other question.

I have a query - as I understand it acupuncture is not considered a standalone modality in ChinaThis is a common misconception. Historically, chinese herbal medicine (CHM) and acupuncture developed along independent philosophies. In the 19th century all CM was banned and much of the texts and knowledge was lost. Then during Mao's cultural revolution the order was given dig up everything that still remained and turn it into the people's medicine - TCM was born. However, still in China doctors specialise in either CHM or acupuncture. They may be used together, sure, but in the hospitals generally not by the same physician. See Why is there a need for a TCM Herbology certification that is independent of acupuncture organizations? (http://www.rmhiherbal.org/review/2004-2.html) for more.

Regarding attitudes to this in the West, here is a post by Carole Rogers, who pretty much single handedly stopped acupuncture from being banned for non-medical doctors in Australia and got its study into the university system - In general I agree with you wholeheartedly. I too should like to see greater separation - especially in education. I really think that too much is expected when students are asked to major in acupuncture, major in Chinese herbalism, major in western physiology and basic western differential diagnosis, learn some basic business skills (because they all tend to go into private practices) and learn some basic communication skills, research skills and general health care ethics - all in a four year program.

This does not mean that I believe acupuncturist should not be permitted to prescribe Chinese herbs, nor that Chinese herbalists should be prevented from applying acupuncture when appropriate - but I believe that to do so should require a two year post graduate program after mastery of their primary modality in a four year undergraduate program. Such a proposal is unpopular in our immediate gratification society where everyone seems to want everything in the quickest possible time. I have lamented the pressures on education elsewhere however, and been firmly criticised for giving in to these pressures that comes from students, fellow teachers, and the educational institutions.

I think the educational separation that is practised in China is an excellent approach and I am all for separate registration for the two modalities.

This separation should also include a reassessment of the herbalization of acupuncture of which much has been said in the relatively recent past but which now no longer appears to be an issue.

[EricM]

Luke, if I remember correctly, you've had a unique experience studying acupuncture while living in China. Did you get to work in a health care clinic? I'd be curious to hear of your experience in treating people of this cultural background. What is the lay persons attitude towards pain and it's treatment like there? Is it any different from anywhere else? How is acupuncture perceived by the general public?
Tough questions, I know.

[Luke Rickards]

I was working in a hospital there. Chinese health care is nothing short of brutal. Gross and brutal. The people seem to expect it though, especially the older ones (young Chinese prefer western medicine). "No pain, no gain" is the motto they come to the acupuncture wards with.

Most western acupuncturists can't, and won't, practice like this.

[clarett]

Thanks for your replies.

Can you expand on the gross & brutal a bit more?

[Diane]

Here's a little piece on acupuncture (http://well.blogs.nytimes.com/2007/09/24/back-pain-moving-the-needles/), from the NY Times dated Sept 24, with some interesting followup comments from an assortment of people who all believe various things about the surface of the body and what happens when it is either poked (as with needles) (in the "right" spots or in the "wrong" spots) or not (instead, ignore the surface as if it were not there and move the bones around - mesodermalism).

My Occam's chainsaw neuron system wants to ask - what is the simplest explanation that accounts for the most variables here? Let's uncover then adopt IT.

[ian s]

Exactly Diane --
some interesting stuff here
http://www.badscience.net/?p=542#comment-17208

[Diane]

Indeed Ian.
I was inspired by this thread to write something (http://humanantigravitysuit.blogspot.com/2007/10/sorting-out-manual-therapy.html) on my oft-neglected blog.

[Jon Newman]

Here's the APTA response (http://www.apta.org/AM/Template.cfm?Section=Letters1&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=43382) to an acupuncture article appearing in the Washington Post (also covered at EIM (http://blog.myphysicaltherapyspace.com/2007/10/back-pain-needl.html))

I found this statement

Their (PT's) treatments include exercise, manipulation, and therapeutic massage/soft tissue work.falling short for its particularly narrow focus in that there are some PTs that do provide acupuncture and more importantly there is no mention of education, a cornerstone of what it is I do for a living.

[JaneS]

Prior to the postgrad study in pain, I thought acupuncture a lot of hogwash - probably because I am sceptical of the Chinese medicine rationale.

In the Grad Dip, there was some mention of Acupuncture and DNIC (diffuse noxious input control). I can see the short-term value of this- dental work is a good example. The problem is when patients regard AP as the answer to their problems and become dependent. Of course, placebo also is an important component of AP and other similar interventions.

The approach of trying to replace the passive with active pain relief I have seen to fail often. The patient becomes resentful, particularly of exclusively CBT programmes.

In this rather long thread, I think it has already been said by someone, that AP could be continued while introducing education and paced activity. As active management strategies start to show benefits, AP sessions would be reduced in frequency and gradually faded out. Of course, if the patient refuses to engage in the active part of management, there is always the option of refusing AP without their active participation in the programme.

Jane