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A surgeon colleague of mine asked me recently what i thought of the use of acupuncture in biomechanics. He said he had heard great things about it. As i told him i have yet to see any evidence that it has more than a placebo effect on anything at all much less that it could improve the IM angle in HAV (i kid you not).
Does anyone know of any such evidence? Or anything on the use of acupuncture in podiatry?
I actually do quite a lot of acupuncture. The literature supports the use of acupuncture for the relief of pain and is equivocal after that. Acupunturists will say that ac moves you back to homeostatsis generally.
Personally, I'm happy to relieve pain and recently have had some success with neuropathic symptoms. I'd never claim to treat and resolve HAV.
Have a look into Cochrane.
Something that has never been made clear to me is the status of a non registered acupuncturists, practicing acupuncture. The techniques are the same but what is claimed to be done may be a legal minefield. To the best of my knoweldge in the current West Australian Act which governs podiatry there is strong inference that a registered podiatrist can treat foot ailments by "any means" deemed appropriate.
However when it comes to acupuncture, podiatrists must not clain to be acupuncturists, unless they are registered acupuncturists.
Sounds as if your legislation is similar to the Scottish legislation. We also need to be registered if we wish to practice acupuncture, yet our English colleagues can practice provided that they have undergone the appropriate training.
I trust all is well with you. You wrote; "Something that has never been made clear to me is the status of a non registered acupuncturists, practicing acupuncture. The techniques are the same but what is claimed to be done may be a legal minefield. To the best of my knoweldge in the current West Australian Act which governs podiatry there is strong inference that a registered podiatrist can treat foot ailments by "any means" deemed appropriate.
However when it comes to acupuncture, podiatrists must not clain to be acupuncturists, unless they are registered acupuncturists.
Can anyone clarify the point?"
My understanding of the interpretation of the situation regarding acupuncture by podiatrists in Western Australia is that it is OK to use acupuncture needles in the treatment of problems normally treated by pods pertaining to the foot and ankle and needling should only be done below the knee. They further advised that appropriate aseptic techniques need to be used.
Commonsense would also indicate that if we are permitted to inject below the skin then using acupuncture needles is even less of an issue. We do have this training in skin penetration. Many physios now also do dry needling and as far as I know their act still has not been changed to include skin penetration. This is more likely to be tested legally, sooner or later as they treat in more dangerous areas.
At present there is no registration for acupuncturists in WA. So that folk who do it would nevertheless be able to show training and experience if they got involved in legalities. There is an Act for acupuncture in the pipeline for WA and personally my training and membership of the Ac Association would make me eligible for registration as advised by that association.
I think there are quite a few pods in WA who use dry needling as a part of their treatment of musculoskeletal pain. They are using acupuncture needles but not per se providing acupuncture treatment in the sense of "influencing the energy flow in the meridians". The dry needling has been found to be probably as effective as using the LA injection techniques of Travell and Simons.
You wrote: ["Sounds as if your legislation is similar to the Scottish legislation. We also need to be registered if we wish to practice acupuncture, yet our English colleagues can practice provided that they have undergone the appropriate training."
I'm very interested in clarifying this, thanks.
Does this mean that a pod in Scotland cannot stick an acupuncture needle into the foot of their patient? Or does it mean that the pod cannot say that they are doing acupuncture or that they are an acupuncturist?
Personally, I think there is a distinction between acupuncture and dry needling, although the same instrument is used. So, you can do either or combine them as I do.
As seen I am afraid and growing old more disgracefully by the day. Would hold you to the drink (or three) you owe me but, as you know alcohol consumption is yet an another avenue of pleasure closed off to me, now.
Dare say we may bump into each other in shopping mall in the pretty city.
I am currently trying to get clarification on this.
As things stand, it appears that English podiatrists can practice acupuncture, provided that they have attended a 'recognised' acupuncture course.
We now have a devolved parliament in Scotland and, it introduced licensing of acupuncturists on 1st April 2006. Medical Doctors are exempt from legislation, as ‘may be’ Healthcare professionals working in NHS premises but, as far as we can see, podiatrists working in the private sector are not.
We are all trained to the same level and already have to keep our practices to a standard suitable to administer local anaesthetics. You stated “ Common sense would also indicate that if we are permitted to inject below the skin then using acupuncture needles is even less of an issue.” We do have this training in skin penetration. My question therefore is: Why should podiatrists in private practice in Scotland have to be licensed, when our colleagues in England don’t? – Should there be any difference?
I am not aware of any podiatrists now calling themselves acupuncturists instead of podiatrists, but see no reason why this might not ensue. At present the podiatrists that I know who are trained in acupuncture, use this solely as an adjunct to their podiatry skills.
I have always struggled to see how acupuncture can be anything more than icing in mechanical musculo-skeletal pathologies. However in the recalcitrant chronic exertional compartment syndrome, where biomechanical augmentation and massage can often do little, acupuncture may be an option. At least I can envisage the needling piercing the fascial tissue, and potentially playing a significant role.
I am not aware of any podiatrists now calling themselves acupuncturists instead of podiatrists, but see no reason why this might not ensue. At present the podiatrists that I know who are trained in acupuncture, use this solely as an adjunct to their podiatry skills.
As it should be, but there have been instances cited where clients have been treated for other than foot ailments by podiatrists, and this is the cause for concern from registered acupuncturists. I suppose it is a question of "Let the shoemaker stick to his last."
Tell me this, If HPC is the registration body for the UK, surely they must regulate scope of practice (and this is not left to the professional associations)? Even with a Scottish Parliament do all podiatrists in Calidonia need to be HPC (UK) registered? If so, then parrity would determine what is sauce for the English is sauce for the rest of the UK.
You raise a very interesting point here. Yes, anyone calling himself or herself a ‘podiatrist’ or a ‘chiropodist’ in England, Wales, Scotland and Northern Ireland must be Health Professions Council (HPC) registered. I shall pursue this further and see where it gets us.
In an ideal world, it is hoped that podiatrists know the bounds of their professional limitations and are happy to stick within these. However, there is always going to be someone who steps out with these boundaries and contingencies have to be in place to deal with such breaches.
I expect that registered acupuncturists will jealously guard their area of expertise. We as a profession should understand the need more than most - what a pity that we haven't done likewise, with podiatry.
I’m fine thanks and, hope that you’re hale and hearty too.
Best Wishes
Anne
Last edited by Anne McLean : 18th November 2006 at 05:50 PM.
Reason: incorrect use of English and inappropriate comments
Hi Anne, Thanks for getting back on that question.
One problem you'll face, in my experience, is that you will be asking folk who won't understand the distinctions of what you are talking about and so will give rather up in the air answers.
You wrote: "I am not aware of any podiatrists now calling themselves acupuncturists instead of podiatrists, but see no reason why this might not ensue. At present the podiatrists that I know who are trained in acupuncture, use this solely as an adjunct to their podiatry skills".
And as Cameron said, so it should be. The training that pods get in acupuncture does not at all set them up to treat conditions not pertaining to podiatry and simply gives them a little understanding of how an acupuncturist may go about treating other conditions. The training gives them some focus of it's use in their area.
Meanwhile the dry needling is not the province of acupuncturists. The treatment of trigger points has basically been developed by doctors in the USA, and it has been found that using acupuncture needles is possibly as effective as injecting minute amounts of Procaine or saline. Dry needling is not Traditional Chinese Medicine, although some of the common trigger points may also coincide with named acupuncture points. So I think this is an important distinction.
Good luck in your quest and let us know what you find out.
You wrote: "I have always struggled to see how acupuncture can be anything more than icing in mechanical musculo-skeletal pathologies. However in the recalcitrant chronic exertional compartment syndrome, where biomechanical augmentation and massage can often do little, acupuncture may be an option. At least I can envisage the needling piercing the fascial tissue, and potentially playing a significant role."
Obviously, you are not alone in your opinion, or else everyone would be using acupuncture! Hopefully, it will one day be more a part of mainstream podiatric educatiion, and that may not be as far off as it may seem.
There is good evidence for the use of acupunture in the treatment of pain, possibly more than there is for most treatment modalities that podiatrists use.
However, explaining how it works has not been tied down at all. There is a measurable effect but how not explained scientifically. I don't accept some of the 'neuro pathway' stuff that gets bandied about. I don't think it's just the mechanical effect you imagine on tight compartments, but it is great for compartment syndrome. You can palpate tight (taut) bands in muscles that are extremly tender and feel them relax and become normal after needling.
I appreciate that your statement is simply a personal opinion but you won't find out much more unless you went into the question of acupuncture more deeply.
I would love to demonstrate with a patient for you who had referred heel pain from a trigger in soleus. You would see the muscle 'twitch' when needled and get almost instant relief. The pain referral pattern for soleus has the myotomal pattern of most commonly covering the posterior and plantar heel (which separates it from the heel pain generally associated with plantar fasciitis). I've had many patients say that the most dramatic improvement in their chronic pain was from the acupuncture. I use it adjunctively on top of the usual modalities.
I agree wholeheartedly that we are not trained to be Acupuncturists and should curtail our area of expertise within the remit of our professional limitations.
There is indeed a difficulty in getting people to understand the ‘distinctions’ that we are referring to, but we will endeavour to get these across. We will have to achieve this, if we are to overturn the current ‘blanket’ decision.
I am happy to report any progress we make in this area and, hope to be able to get back to you shortly.
Dear Atlas,
I'm with Shane on the Trigger point stuff, I have treated trigger points the 'usual' way for years and now I have learned the dry needling technique, intractable chronic pain is gone in seconds. This of course is adjunct to other modalities, but it is a fantastic catalyst to get the rest healing.
Cheers
Mahtay
You wrote: "Thanks for the info and feedback. You mentioned that there was some evidence for pain releif. Can you tell me where i might find it?"
I'll give you as much as I have. I'm not an academic and so don't keep great files or have the most up to date skills in searching. Thank goodness for google.
Type in acupuncture. As you know this provides mega study analysis and there isn't a lot, but what there is is positive. If acupuncture can help pain in other parts of the body, then it will help in lower limb as well.
Also this link, mentioned earlier in this thread, gives a good reference.
I hope this may stimulate some interest as acupuncture is a conservative treatment, comparatively non-traumatic and another modality that pods can bring into use in our limited area of the body.
Just found an reference you may be interested in re dry needling. I've just pasted the search in toto as it didn't seem very big. Site was advised by Amanda on another thread. http://www.wheelessonline.com/ortho/...rigger_point_1
Duke Orthopaedics presents
Wheeless' Textbook of Orthopaedics
A prospective, randomized, double-blind evaluation of trigger-point
injection therapy for low-back pain. Garvey-T-A. Marks-M-R. Wiesel-S-W. Department of Orthopaedic Surgery, George Washington University Spine. 1989 Sep. 14(9). P 962-4. The efficacy of trigger-point injection therapy in treatment of low-back strain was evaluated in a prospective, m randomized, double-blind study. The patient population consisted of 63 individuals with low-back strain. Patients with this diagnosis had nonradiating low-back pain, normal neurologic examination, absence of tension signs, and lumbosacral roentgenograms interpreted as being within normal limits. They were treated conservatively for 4 weeks before entering the study. Injection therapy was of four different types: lidocaine, lidocaine combined with a steroid, acupuncture, and vapocoolant spray with acupressure. Results indicated that therapy without injected medication (63% improvement rate) was at least as effective as therapy with drug injection (42% improvement rate), at a P value of 0.09. Trigger-point therapy seems to be a useful adjunct in treatment of low-back strain. The injected substance apparently is not the critical factor, since direct mechanical stimulus to the trigger-point seems to give symptomatic relief equal to that of treatment with various types of injected medication. Author-abstract.
Steve Rowlands website graphic design at www.steverowlands.com
I use accupressure, as I think it would be harder to defend using needles outside of the foot. This is only one small tool in treatment. I only use this on cases where it is indicated (weak muscles that are not related to cortical-cerebellar imbalance, but do strengthen when the pulse points are touched).
The way I was shown to fix this is to find a muscle that will not sedate when the sedation points for the associated meridian are stimulated. For instance if you touch the four sedation points for the bladder in the correct order and the peroneal muscles do not weaken, then this is your way into the accupuncture meridian system. Have the patient touch the pulse points on one wrist at a time. When the point is found that allows for sedation, then you have to find whether it is the yin or yang of that point(ie small intestine/heart or kidney/bladder etc.). Check the alarm points related to these two meridians and the one that sedates the muscle is the meridian where the treatment is required. Check the Luo point first, as this is the most common. If not this one, then check them one by one until you get sedation when touching the sedation points. Rub the point and check the underlying area for dysfunction. Then go to the associated point on the bladder meridian and you will find one side is tender. Rub this until the tenderness dissipates. Check for an underlying dysfunction. When this is corrected your muscle will strengthen.
Yin and yang? Meridians? Luo points? What's the scientific basis for all this? Are we talking science or post modern believe-what-you-like-spirituality here?
Thank you for your interest. I am first and foremost a clinician, and as a clinician I try lots of different techniques, and if it works I keep it and if it doesn't, I discard it. If you don't want to try something that can be beneficial on your patients, then that is your choice.
Regarding studies, I found this:
Yin and yang? Meridians? Luo points? What's the scientific basis for all this? Are we talking science or post modern believe-what-you-like-spirituality here?
Hi Michael,
Western acupuncture respects these ancient myths, but does not uphold them. A recent BBC documentary demonstrated that certain neurotransmitting chemicals were released from the brain on administration of acupuncture. Scientific.
There's a growing distinction between the ancient beliefs, and the present understanding.
Acupuncture works very well for some pts, ok for some pts, and not at all for some pts, I reckon 33% each. 66% get better, with very little risk of side effect. To me thats worth offering to your pts.
Guys you both seem very touchy (especially Stanley). I didnt say that acupuncture might not work, or deny that "neurotransmitting chemicals were released". I asked for the scientific basis of talking about meridians, yin and yang, and luo points. Stanley had confidently talked about them as if they were a scientific reality rather than something that he believes exists. Nobody is denying that many people find acupuncture helpful, though personally I think its mainly the palcebo effect, that aside however, I ask again the same question - can somebody tell me what is the scientific basis to Stanley's confident comments about yin and yang, meridians and luo points. Can you scientifically measure a meridian, a luo point or can we measure yin and yang? I think not. Well if thats the case, lets say "acupuncture seems to be beneficial for many people but we dont know how it works at present" instead of using terms that are really just eastern spirituality.
Guys you both seem very touchy (especially Stanley). I didnt say that acupuncture might not work, or deny that "neurotransmitting chemicals were released". I asked for the scientific basis of talking about meridians, yin and yang, and luo points. Stanley had confidently talked about them as if they were a scientific reality rather than something that he believes exists. Nobody is denying that many people find acupuncture helpful, though personally I think its mainly the palcebo effect, that aside however, I ask again the same question - can somebody tell me what is the scientific basis to Stanley's confident comments about yin and yang, meridians and luo points. Can you scientifically measure a meridian, a luo point or can we measure yin and yang? I think not. Well if thats the case, lets say "acupuncture seems to be beneficial for many people but we dont know how it works at present" instead of using terms that are really just eastern spirituality.
There is a lot of research going on into acupuncture and some of your queries may be answered one of these days. Meridians have not been found, but there is some difference in galvanic skin response at some acupuncture points. It is a system that is thousands of years old and not scientificly based at all. For mine, what Stanley was doing was to very helpfully pass on some practical advice which would be understood by someone with reasonable traditional acupuncture training. I think this is useful information. You must realize that most of medicine as we know it has only had a small proportion evidence based over the past 10 years with some common treatement protocols being shown to be quite ineffective and even worse than no treatment. Nevertheless, for many generations Western Medicine has always stated that it is "scientific". Up until then our system really was trial and error based on what seemd reasonable (especially, when heavily promoted by some of the drug companies).
On my first reading of your initial posting, it did seem like quite a dig at Stanley and anything different rather than a genuine question, because it was loaded with the comment " believe what you like spirituality'.
So thought Stanley very politely replied. As Peter pointed out we can still respect a system that has been used for 1000's of years. We don't have to believe it.
A patient of mine just recently responded extremely well to acupuncture treatment for severe pain in her toes probably due to diabetic neuropathy and has been able to sleep unmedicated now for a few weeks for the first time in 6 months. Her skin sensitivity is also progressively returning to normal. The Chinese may say that the energy flow in her toes has been balanced. A western scientist may be able to say that the acupuncture has caused a revascularisation of the small vessels serving the digital nerves by stimulating a local response to irritation by the needles. Nevertheless, the patient doesn't care so long as she can sleep at night. And maybe we can still learn something from this sytem even if we don't accept Ying Yang stuff.
Hi all,
Like Shane, I have a pt whose neuropathic pain has been relieved with acupuncture.
He, and I, don't care how it worked, his only pain now is when his wife elbows him in the ribs for snoring!
Happy Festivus from the Restivus
Mahtay
Shane,
Thanks for your reply. Point taken about evidence based medicine - I agree. However you confirmed what I already said - that there is no scientific basis for meridians, luo points or yin and yang. My point was that Stanley was confidently quoting these things as if they were a demonstrable reality eg:
Quote:
The way I was shown to fix this is to find a muscle that will not sedate when the sedation points for the associated meridian are stimulated.
Quote:
then you have to find whether it is the yin or yang of that point
when clearly they are not, but then such is the Post Modern World we live in!
Michael
My final point on what Stanley had to say was that for those who have learnt some acupuncture, is that generally the only way we can easily communicate is through using the Chinese system - the nomenclature of the Academy Of Traditional Chinese Medicine, Beijing, Peoples Republic of China ( and even then, folk are "naming new points' after themselves etc, just like our surgeons and muddying the waters we communicate in, i.e., going outside the system).
Otherwise Stanley would have taken three pages describing the anatomical location he was rubbing and checking etc.
So humans have been working on and fine tuning this system for hundreds of years and could find no better way of describing what they were doing. The meridians are associated with internal organs that include a lot more than we include when we describe them anatomically. We continue using the system because it works well and can't come up with anything better.
There are some promoting a very 'western approach' that totally discards the Chinese system, but I find them to be missing a lot of good stuff.
Acupuncture, legitimate or not
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