Prick the pain away

People often turn up at A&E departments with headaches. And, once we are sure the pain is not a sign of something serious - like meningitis or a brain haemorrhage - they will usually be sent home with some painkillers. So when I came across a report in a journal by some South Korean physicians, about a patient with an unusual headache that turned out to be something really nasty, it looked like the sort of thing I should read. But the bit that interested me most was not the final diagnosis, but the initial management of the patient, summed up in one brief line: "The patient was referred to the on-call acupuncturist."

I read it again. Not only was the guy with a headache referred straight from the emergency room to see an acupuncturist rather than being sent home with codeine tablets, he was even seen by an "on-call" acupuncturist! This sounded good. As an emergency physician, I am not supposed to be attracted to things like complementary therapies. My burning ambition should be to crack open someone's chest in the high street with one hand while delivering a baby with the other. But if teaching hospitals in South Korea had on-call acupuncturists, maybe it was time to explore my touchy-feely side.

This is how I ended up a few months later at a course run by the British Medical Acupuncture Society (BMAS). It was led by Dr Mike Cummings, an ex-RAF medic, and not the type you would automatically associate with complementary therapies. He has the air of someone who would far rather head up a helicopter MedEvac than light you a joss stick. His main interest has always been muscular pain and sports medicine, and, like many doctors, he was initially sceptical about acupuncture. He encountered it by chance, and found that his patients - mainly young military personnel - seemed to respond well. Word spread on the RAF base where he worked, and within a year he had performed enough treatments to gain his diploma in medical acupuncture. He is now medical director of the BMAS, and most of his time is spent teaching medical acupuncture, as well as running a clinic at the Royal London Homoeopathic Hospital, and giving advice to other doctors via the internet.

Although Western medical acupuncture is called acupuncture and involves acupuncture needles, to some extent it has little in common with the traditional Chinese art. It is based around contemporary neurophysiological theories, and has only a pinch of oriental thinking to add flavour. It is a method that seeks to reconcile the ancient practice with how we modern doctors imagine the body to work, in an attempt to make it more palatable to those who have difficulty with the concepts of Yin Yang balance and the flow of Qi, but prefer talk of endorphins, trigger points, and afferent competition in the dorsal horn of the spinal cord.

But whichever philosophy you buy in to, needling people seems to work. Up until now, my standard treatment for someone with, for instance, pain in the sole of the foot has been to give them anti-inflammatory painkillers like ibuprofen and tell them to rest. Occasionally I might have injected the painful area itself with steroids. Now, I realise I can look for trigger points (tender spots of muscle that are some distance from the pain but reproduce it when pressed) and stimulate them with a needle. Which is how I managed to cure one patient like this by sticking a couple of needles into his calf.

If you pop "acupuncture" as a search term into a medical database, nearly all of the citations returned will be from conventionally trained physicians writing up case reports of how acupuncture has gone wrong. Collapsed lungs are the most commonly quoted incidents, although these are increasingly rare, especially if care is taken when needling over the chest wall. Compared to many of the treatments that are handed out with little thought every day (like those anti-inflammatory tablets, which have a nasty habit of occasionally burning holes in your stomach), acupuncture seems remarkably free from serious side-effects.

While acupuncture is now an accepted treatment (unlike many complementary therapies, it is available on the NHS and covered by most private health insurance schemes), there are still many who dismiss it as quackery. Producing hard evidence that it works is difficult, mainly because it is almost impossible to design a reliable "sham" or placebo treatment against which to judge its efficacy. You tend to be reduced to the unscientific stance that if it works, it works. But there is always the niggle that the patient may have got better all on their own. I can take some comfort from the fact that while the evidence for acupuncture is far from concrete, doctors all over the world prescribe "conventional" treatments every day that are based on far shakier foundations.

Given the number of people I see every day with various aches and pains, it is nice to have something to add to my current limited repertoire of analgesics, elevation and ice. There has been no problem with patient acceptance. Everyone has been keen to give it a go, and with a therapy that is so free from side-effects, "giving it a go" is perfectly valid. A worrying thought is that you may treat someone's pain but not recognise a serious underlying condition, which is why even enthusiastic proponents of acupuncture would like to see all practitioners have at least some basic medical knowledge.

While many who practise traditional Chinese med-icine are experienced and know when to refer a patient back to a doctor, as things stand your hairdresser can go on a course and then quite legally call herself an acupuncturist. Strangely, though, if she were to give acupuncture to your cat (it works on animals too), she would be breaking the law - you need a veterinary qualification for that.

The biggest problem I have encountered in my fledgling acupuncture career is the time it takes. A traditional Chinese physician may spend an hour teasing out the exact details of your complaint before starting treatment. A GP may be allowed seven minutes or so. My average is between 45 and 90 seconds, which either means I am very good at my job, or very bad at it. It certainly helps us meet our waiting time targets, but it is hardly enough time to get a needle out of its packet. The plan at present is to run a small clinic where patients can be seen away from the normal mayhem of the emergency room.

The most recent person I treated did indeed have a headache. One of our own nurses, with an annoying, throbbing ache around the right eye and ear, traceable to a tender spot in muscle at the base of her neck. The pain disappeared half an hour after a single needle. Grateful patients are not something we see a lot of in A&E. Hopefully, I may have to get used to it.

The writer is an A&E consultant

From nausea to panic attacks: acupuncture in an emergency

Nausea and vomiting

Many trials have shown positive results, mainly using the traditional point PC6 (Nei Guan, or "Inner Pass") on the front of the wrist. This can be useful to avoid traditional anti-nausea drugs, for instance in children or in early pregnancy.

Chronic pain

A Lancet study of acupuncture used to treat pain from osteo-arthritis of the knee showed improvement in pain and joint function, although the benefit decreased over time. Various acupuncture techniques are used in chronic-pain clinics.

Headaches, and shoulder, neck and back pain

People often present to A&E with acute, or "semi-acute" pain. This may be due to "trigger points" in muscle some distance from where the pain is experienced. Trigger points respond well to needling. A paper in the BMJ this month suggests that acupuncture can also be useful in treating tension headaches.

Elbow pain (tennis and golfer's elbow) and Achilles tendonitis

These conditions, known as "enthesopathies", occur where a tendon inserts into a bone. They can sometimes be treated by local acupuncture.

Acute back and neck strain, including "whiplash" injuries.

There is some evidence to show short-term benefit.

Wounds

Some practitioners have achieved good results in non-healing wounds (such as leg ulcers in the elderly). The technique of "fencing the dragon" - surrounding the affected area with needles - is usually employed. It is thought to encourage growth of new nerves and blood vessels.

Psychological conditions

It is recognised that acupuncture can cause a degree of sedation. Most acupuncturists will warn people about driving home, especially after a first treatment. This has been used to good effect in acutely stressful situations, even in anxiety attacks. The effect can be maximised by using stress-relieving points such as LI4 (He Gu or "Union Valley") on the back of the hand, or ST23 (Tai Yi or "Supreme Unity") on the wall of the abdomen.