The authors of this new book are all among the foremost exponents of Western medical acupuncture (WMA) in Britain. Two of them previously edited a multi-author book on the subject (Medical Acupuncture: A Western Scientific Approach), which was published 12 years ago. That book provided an extensive overview of the subject but it was not designed to be a textbook. This one, in contrast, aims to give practical instruction for the beginner, and in this it succeeds admirably. The intended audience is therefore health professionals who have attended an introductory course in WMA and are just embarking on their acupuncture careers, but even experienced acupuncturists will find much to interest them and it may perhaps suggest possible new avenues to explore.
The book has four sections, of which the first two are more theoretical and the second two more practical. But there is some overlapping, with some practical material appearing in all sections.
Section 1 begins with a chapter summarising what WMA is and how it works. There then follow four chapters on neurological mechanisms (local, segmental, extra-segmental, and central). These should serve to convince any unbiased critic that WMA has a plausible scientific rationale. Although they describe neurophysiology they are not over-theoretical and the relevance to acupuncture and to the phenomena of acupuncture is emphasised throughout. Thus, for example, the chapter on local effects includes information about the all-important question of how to estimate and adjust the acupuncture 'dose'.
Next comes a chapter on myofascial trigger points. This is an important subject because it does not form part of ordinary clinical training, at least for doctors, but it figures largely in the thinking of many WMA practitioners.
The two authors who have explored the trigger point idea most fully are Janet Travell and David Simons. The definition used here is that a myofascial trigger point is a hyperirritable locus within a taut band of skeletal muscle. Other features include the patient's recognition of the pain produced by pressing the spot and restriction of movement that stretches the muscle. Pressure on the spot should replicate the patient's pain. These features serve to distinguish myofascial trigger points from other tender areas that may exist, for example at sites of referred pain. Myofascial trigger points are classified here as either active, causing stiffness and pain, or latent, causing stiffness but not pain. While this is simpler than the rather elaborate categorisation used by Travell and Simons it is quite adequate for the purposes of WMA.
The chapter on myofascial trigger points then goes on to discuss the incidence, causation, and mechanism of trigger points, followed by a detailed explanation of how to diagnose and treat them. This will be particularly useful to those for whom the subject is new.
Section 1 concludes with an overview of traditional Chinese acupuncture in relation to WMA. The authors explain the differences between the two approaches clearly. Some advocates of the traditional version claim that acupuncture is better when done in the traditional way and also adopt a post-modernist stance to imply that the ancient understanding of the body is just as valid as the modern one— just a different way of looking at things. The authors demolish such claims courteously but firmly. In a neat phrase, they say that trying to maintain that traditional and modern ideas are both true is like trying to say that the earth is simultaneously round and flat! But while insisting that we don't need to accommodate ourselves to the traditional theory, the authors acknowledge that the ancient physicians made many astute clinical observations.
Of course, the fact that there are plausible explanations for how WMA might work does not prove that it does: for that, we need an evidence base. The problem here is that, as with any manual therapy, finding a satisfactory placebo treatment is exceedingly difficult. Randomised controlled trials of acupuncture are therefore difficult to carry out. There are other problems with acupuncture research as well and in Section 2 the book offers a good discussion of the issues. In spite of the problems, however, a reasonable evidence base for WMA in the treatment of at least some disorders, especially musculoskeletal conditions, headache, and nausea and vomiting, now exists, and the authors give a useful summary of the currrent situation.
Section 2 concludes with a chapter on evidence for the safety of acupuncture. This shows that, in skilled hands, it is generally safe compared to other treatments. Most adverse events are mild but deaths do occur, even though rarely, so the need for adequate training and constant vigilance is obvious. On aggravation of symptoms the authors say that the incidence is no more than 2 per cent. I think this estimate may be due to under-reporting and the true incidence may be higher, at least if mild and transient aggravations are taken into account. Some patients experience aggravations each time they are treated, even with light stimulation, and are happy to accept this for the sake of the subsequent relief. The picture might become clearer if the authors' plea for the open reporting of adverse effects so that everyone can learn from them were adopted more widely.
Almost all the early chapters have a practical element, but that theme becomes still more pronounced as we start Section 3. This begins with a chapter advising about choosing suitable patients and precautions to take in various situations, including cancer. Here the authors make the important point that if a cancer patient suddenly ceases to respond to acupuncture in the course of treatment one should suspect a deterioration in their condition. I would add that if a patient who is not known to suffer from cancer suddenly ceases to respond to treatment one should consider the possibility of a new malignancy; in one case an asthmatic woman stopped responding to acupuncture and shortly afterwards was found to have cancer of the breast. Other topics covered in this chapter include obtaining informed consent, equipment required, and the clinic setting for acupuncture. At the end there is a useful checklist of questions that practitioners should ask themselves before starting treatment.
Next we get a chapter on needling techniques. A 'basic' technique is described and then come variations on this, such as needling myofascial trigger points, superficial needling, and periosteal pecking, though the indications for using this are not gone into in detail. Electroacupuncture is also discussed here: the authors point out that the decision to use this modality is an individual matter and not all practitioners choose to do so. The chapter concludes with information about managing the course of treatment.
We then come to an important chapter on safe needling, describing the measures needed to avoid the risks alluded to in Section 2. There is advice on avoiding trauma to blood vessels, internal organs (especially the heart), the spinal cord and brain stem, and the pleurae. The perforation of peripheral nerves is another risk although, as the authors remark, this seldom produces lasting sensory or motor impairment. They do however acknowledge that, rarely, the symptoms may last longer and this cannot be totally prevented. They say that needling LI4 is particularly likely to have this effect; I agree, and in fact I have seen pain in the thumb lasting for 6 months from needling this site and I now prefer to avoid it.
The final chapter in Section 3 looks briefly at 'other' acupuncture techniques including continuous stimulation by indwelling needles, auricular acupuncture, moxibustion, and laser 'acupuncture'. The authors are unenthusiastic about most of these, few of which have any substantial evidence base, and they advise beginners not to invest their time and money in unproven techniques. They think that indwelling needles may be useful in chronic pain provided the patient does not have a valvular heart defect (not always easy to know this, of course) and auricular acupuncture can also be useful even though the alleged somatotopic map in the ear described by Nogier appears not to be valid. Needling the ear has to be done carefully and skilfully to avoid damage; I had not been aware that even the apparently safer alternative of applying beads or 'seeds' for prolonged stimulation is not risk-free.
Section 4 contains treatment guidelines for a number of conditions. The authors start by saying that this part of the book should not be read on its own but only in the context of the discussion in the earlier parts. They also emphasize that they are not writing a 'cookbook'— a set of recipes to be used more or less automatically. Their aim throughout is to inculcate a thinking attitude in the beginner. The book provides principles which it is up to the practitioner to apply to what he or she encounters in the clinic.
The guidance section focuses mainly on the treatment of pain but also includes some other kinds of disorder: gastrointestinal symptoms, bladder symptoms, nausea, hay fever, and menopausal hot flushes, for example. It concludes with a chapter on how to locate acupuncture points, and this is illustrated with a series of diagrams which are duplicated in a handy series of cards in a pocket at the back of the book.
Writers on WMA always have to decide where they stand on the vexed question of traditional acupuncture 'points'. Some, of whom I am one, ignore them almost completely, while others use them to a considerable extent. Although the present authors are sceptical about most of the traditional theory they do use the conventional points nomenclature (though they largely ignore the 'meridians'). They don't think it is necessary to localise the classical points to the nearest millimetre but believe it is helpful for acupuncturists to learn a number of classical points.
As this summary will show, the book covers pretty well all the topics that a health professional starting out in WMA will want to know about. As the authors state at the outset, they are in no way dogmatic and acknowledge that there are other ways of practising. For example, they advocate 10 to 20 minutes' needle retention in most cases but do agree that brief needling, preferred by some, also seems to work, and they counsel brief needling for children. Similarly as regards depth: they favour attempting to reach myofascial trigger points directly and eliciting a twitch if possible, but they mention that some practitioners prefer superficial needling over the site and find that to be effective.
The book is very well produced and is easy to read. It is intended to act as a tutorial, so each chapter begins with a short list of what the reader should learn by reading it and concludes with a summary. These features enhance its suitability for the purpose for which it is intended.
19 May 2010