Recently NICE (the National Institute of Health and Care Excellence) issued its first guidelines for GPS on the treatment of Chronic Primary Pain which is pain which seemingly cannot be explained by conventional medical diagnosis. In the past (and maybe, sometimes, in the present) doctors may have been inclined to dismiss patients with this kind of pain, believing perhaps that since the pain could not be explained by conventional medicine, it must not be real. Not good if you are the patient, for whom the pain is all too real.
Of course, conventional medicine is an evolving phenomenon – what cannot be explained today may be explained tomorrow. But again that may not be much comfort to the patient whose pain is today. So it is welcome that the new NICE guidelines recommend, amongst other things, a course of acupuncture for patients with Chronic Primary Pain (rather than painkillers, which it seems are pretty useless for these patients). As an acupuncturist I have a number of strings to my bow, so to speak, in assessing and treating this kind of pain.
For instance, muscles. You might be surprised to hear that a pain which your GP can’t explain, which X-Rays and MRIs can’t see, might sometimes be due to something no more mysterious than a muscle. Muscles that are over-loaded – for example by poor posture, repetitive activities or a past injury – can develop what are called Trigger Points (Or Myofascial Trigger Points to give them their full name.) Trigger Points are irritable knots within overly tight bands within a muscle, and typically cause pain which is usually experienced at a distance from where the Trigger Point is. A Trigger Point in the Gluteus Minimis muscle in the buttock/hip area, for example, typically causes pain down either the side or back of the leg, mimicking sciatic pain.
Trigger Points don’t show up on MRIs and X-Rays, but fortunately there is another very sensitive diagnostic tool which can find them. It is called a hand! Sometimes what people need is not a high tech (and expensive) investigation, but just an old fashioned examination by someone trained to use their hands to examine, in this case, a muscle. When I see patients with painful conditions, I nearly always include in my assessment a hands-on exam looking for Trigger Points which might be causing or reinforcing their pain.
So for example someone might have pain radiating down the back of their leg, and whilst the first thing one might think of is that the sciatic nerve has been irritated or compressed, perhaps by a bulging disc, in this case scans of their spine show no such thing. But if one examines their Gluteus Minimus muscle, one perhaps finds a tight knot in it which, when pressed, causes the patient to flinch or shout, and which may even send a stab of pain down the back of their leg.
In which case, mystery solved, at least in part, although we have still to understand just why they have developed a problem with this muscle. But right away we can start to treat it, as Trigger Points respond well to acupuncture which opens up the tight knot and relaxes the muscle. Massage and cupping therapy may also help with this, and it will be worth having a look of some of the surrounding muscles as well, as it is rare that one gets into trouble in isolation.
But not all Chronic Primary Pain is due to muscles and Trigger Points. Another way to approach it is via Traditional Chinese Medicine (TCM), the system of medicine that underpins traditional acupuncture. TCM provides a different lens through which to view the patient and their pain; we are accustomed to believe that conventional medicine is the only way to understand a person and their health, but as Chronic Primary Pain amongst other things demonstrates, it is not necessarily the be all and end all of health care. One of the characteristics of the TCM approach is that rather than focusing its gaze right down onto the specific symptom – in this case the so far unexplained pain - it takes a more panoramic view of things. (If conventional medicine is a microscope, TCM is a wide-angle lens.) Sometimes pain that cannot be explained by zooming in on it can be understood by zooming out. Look at the patient as a whole and their pain makes perfect sense.
In this kind of situation, unlike with the Trigger Points, acupuncture treatment will probably not be directed at the area of the body where the pain is, but will be more general and systemic, seeking to restore harmony and balance to the person as a whole, so that, amongst other benefits, their pain subsides.
The Chinese medical tradition, going back 2,000 years or more, and of which acupuncture forms a part, is fond of pithy sayings and proverbs. One of these is zhu tong shu xin -“All pain belongs to the Heart”.
This seems decidedly odd to western ears. If you have a pain in your knee, for instance, it is not likely to have anything to do with your heart. But this proverb may start to make some sense if we understand that for the Chinese medical tradition (or at least for a large part of it), the Heart is the seat of something called the ‘Shen’, usually translated as either ‘Mind’ or ‘Spirit’. As in many traditional cultures, the Heart is viewed as the seat of that more or less mysterious entity which makes us who we are, whether we call it mind, spirit, soul or whatever. Of course to our modern way of understanding, the heart is just a glorified pump, and if the mind or spirit is anywhere it is in the brain. But leaving that aside for the moment, we can say that what the proverb is saying is that pain is subjective, it belongs to consciousness or mind; it is an experience in other words.
Modern scientific medicine sees pain indeed as a rather complex experience, reflecting not just damage, to the knee say, but also numerous other things such as our general mood, the state of our social connections, our general health etc. Indeed sometimes there may seem to be nothing wrong with the knee whatsoever, but it still hurts. Pain cannot be measured in the way that blood pressure, cholesterol or body temperature can be measured. No one can tell us how much pain we are really in; only we can know that.
One consequence of this is that in the treatment of pain it is sometimes helpful to treat the Shen. Of course treatment will usually be aimed at the knee, if we have a painful knee, or aimed at least at the tissues responsible for the knee pain – it might come from trigger points in the quadriceps muscles of the thigh perhaps. But sometimes as well it may be helpful to remember that ‘All pain belongs to the Heart’, and seek to calm the Shen, calm the Mind, soothe the person who is suffering the pain. All the more so if the pain is very great, if it is precluding sleep for instance. A human being is not a machine, after all. It’s not just a matter of fixing some faulty mechanics, it is important to remember that we are people, and that our pain belongs in some sense to the Heart as well as to the knee.
Acupuncture is more effective than anti-inflammatories in the treatment of period pain according to a meta-analysis of 17 randomised controlled trials. (In plain English, that means that some people have taken the trouble to have a look at 17 different respectable clinical trials and pulled all the results together to form a conclusion.) I guess, though, that some women will still prefer to just pop a pill or two to try to deal with their pain at period time, since this is quicker than going to the trouble of having some acupuncture, and maybe cheaper too if they don't have to pay for the drugs. But on the other hand anti-inflammatory medication is not free from side effects; less likely to be a problem perhaps if you only take them once a month. But then suppose you have some other aches and pains as well?
The advantage traditional acupuncture has is that, apart from being such a safe form of treatment, it looks at a woman as a whole being, and not just at her reproductive organs in isolation. In this view, period pain is maybe just the major, or one of the major, manifestations of an underlying disharmony which is not being dealt with at all by just taking a painkiller, convenient as that might be if it works. For example, consider a woman who has painful periods, who also tends to get a bit irritable running up to her period, who sometimes has migraines and who has irritable bowel syndrome. From the point of view of traditional acupuncture, all of these symptoms are part of a package, all of them are branches of the same tree, and what the woman really needs is some treatment which treats the tree as a whole, and not just one branch or another - one medication for the period pain, one for the migraines, one for the bowels etc.
In this example the root of the problem, the disharmony which underlies the various symptoms, is likely to be what is called Liver Qi Stagnation. (This could perhaps be confirmed by asking a few more judicious questions, and perhaps taking the woman's pulse.) Liver Qi Stagnation, of course, is not a term that has any meaning in the context of the form of medicine we are used to, but it has plenty of meaning within the context of the 2,000 years plus of Chinese medicine. In short, it means that things in our system are not flowing freely, transitions are not smooth; as far as the menstrual cycle is concerned, it means that the transitions from one part of the cycle to the next is not happening quite as nature intended, one consequence of which is pain. Live,r Qi Stagnation usually arises as a result of frustration, stress, even repressed anger and might be said to be the characteristic malaise of the modern woman, and the modern man as well, reflecting a way of life which involves a fairly relentless pursuit of ' success' at the expense of some of our deeper needs and nature. (What we are doing to the planet, we are also doing to ourselves.)
From this point of view, acupuncture is a way of restoring the free flow of Qi, releasing built up tension and loosening us up a little, supporting the natural cycles of our being and, in the case of the monthly cycle, promoting a smoother transition from one stage to the next. As well as thus relieving the pain at period time, it can start to open a door to a way of being in which we are more in harmony with our own bodies, with the natural world around us, and are as a result happier, freer and more content.
(Comparative efficacy and safety of NSAIDs-controlled acupuncture in the treatment of patients with primary dysmenorrhoea: a Bayesian network meta-analysis. J Int Med Res. 2018 Nov 30:300060518800609.)
People are complicated, sometimes more so than we would like to think. When it comes to health problems, for example, we often want to look for the one thing that has caused us to be ill; we have a headache, perhaps, because we didn't get enough sleep last night, or we have a headache because we haven't eaten enough; or maybe we have a headache because we are stressed out, or maybe it is the weather which is to blame. But quite often I think it is not that there is one thing behind our being off colour, but an array of factors which taken together add up, perhaps, to a headache or whatever the problem is.
In the case of headaches and migraines, one of these factors is surely to do with our neck and shoulders. When I treat someone who has headaches or migraines, I always have a look at their neck and shoulders. And in fact I have more than a look, I use my hands and examine them. And I almost always find some knots of tension. Often these knots are what are called Trigger Points, small areas of tightness which cause pain. And the thing about Trigger Points is that the pain is usually felt some distance away from the point, as what is called referred pain. So for instance a Trigger Point in the trapezius muscle on top of your shoulder can cause pain on the side of your head, circling round the ear to the temple, a typical kind of pain for some tension headaches and some migraines. So whatever else we do for you in this scenario, we need to gently work on this muscle, releasing the tightness with acupuncture, and maybe with massage or cupping.
As I say, this muscular tension may not be the only factor predisposing you to headaches, and we also need to think about why the tension is there in the first place (hunching our shoulders as a stress response maybe, long hours using a keyboard or driving maybe...) So we need a fairly comprehensive approach, which is why I think acupuncture is such a useful treatment given that it can not only release muscular tension, but it can also promote an overall feeling of relaxation affecting both the body and mind, initiate some of the body's intrinsic pain killing mechanisms, and promote a more harmonious and balanced state of being.
This is backed up by the research; for instance, a recent systematic review of 62 clinical trials, including 4,947 patients in total, found acupuncture to be effective in both the treatment and prevention of migraines, and superior to medication. (The Effect of Acupuncture on the Quality of Life in Patients With Migraine: A Systematic Review and Meta-Analysis. Front Pharmacol 2018 Oct 26:9:1190)
Here is some of the latest news on acupuncture and related things, perhaps with a few of my thoughts thrown in for good measure.