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.
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.