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Chapter 5: Your First Treatment

So you have rung up your acupuncturist and made an appointment. This chapter will give you an idea of what you may expect when you come for treatment for the first time. The description is mainly based on what would happen if you are seeing a health professional who practises acupuncture, since this is my preferred option, although I shall also point out some differences that might exist if you were seeing a traditional Chinese acupuncture practitioner.

The first consultation may last about half an hour, but there is no fixed time; a lot depends on how complicated your complaint is. For example, the treatment of a painful big toe is usually straightforward and the situation does not take very long to assess, whereas chronic back pain will probably need more time.

The first consultation is intended to do two things. One is that it allows the practitioner to take your history, examine you, and make a formal diagnosis if possible. Sometimes this cannot be fully achieved; for example, it is usually said that the cause of mechanical (musculoskeletal) back pain is unknown in 85 per cent of cases. Even if a precise cause for pain cannot be pinpointed in such a case, the practitioner will still wish to make sure there are no 'red flag' signs or symptoms. To take the example of back pain again: although most cases of this are due to mechanical causes, the pain could be due to something for which acupuncture would be inaappropriate. Osteopaths, chiropractors, and physiotherapists are trained to look out for such things and will refer you to your GP if they suspect there might be a problem of the kind.

The other purpose of the first consultation is to allow you to ask questions and to satisfy yourself that you have understood what is proposed and what the likely outcome will be. You should also get an idea of the cost. Some of these questions may not be easy to answer fully at the outset, particularly the number of sessions that will be needed, but you should never be asked to commit to a specified number in advance. You may, if you are lucky, be completely better after one treatment, though that is unusual. Most probably you will require several treatments, perhaps six or more, and, in the longer term, occasional repeats may be needed at intervals of two or three months. But it is impossible to know this in advance, so treatment has to be open-ended as regards the number of sessions.

Treatment intervals

The intervals between treatments will probably be about a week to start with, at least in a chronic problem; an acute problem, such as a recent sports injury, might be treated more frequently, perhaps every two or three days. As you get better the intervals between treatments will get longer. Each person seems to have their own response pattern: one may get immediate relief of pain after acupuncture, another may find the relief takes 24 hours, occasionally longer, to come on.

During a course of treatment there may be the occasional session in which nothing much seems to happen. Don't be worried about this; provided the overall trend is towards improvement, all is in order.

Once treatment begins, you should notice some effect, even if only brief and temporary, after two or three sessions. If nothing at all has happened by then it is probably not worth while going on. It is never justifiable to have repeated acupuncture for weeks on end without any sign of improvement.

A few people have good relief of symptoms but it doesn't last. Even after 6 treatments the symptoms may go away for only a couple of weeks or even less time. Unfortunately there is no easy way of solving this problem. If that happens to you, you should discuss the situation with the acupuncturist. The two of you should decide, jointly, what is a reasonable frequency of treatment in your case. For example, if you are willing to come for treatment every four weeks you can continue like that indefinitely, but it is not very satisfactory (and can prove expensive).

Self-acupuncture

Surprising though it may seem, some acupuncturists teach patients to treat themselves in such cases. Self-acupuncture may sound a little alarming, but remember that diabetics diabetics inject themselves with insulin twice a day or even more frequently, so there seems to be no good reason why an intelligent patient should not insert a short fine needle through the skin in a safe place every one or two weeks. If you are unlucky enough to find that acupuncture works for you but the effects don't last, you could discuss this idea with the acupuncturist.

Aggravations and pain

The acupuncturist will warn you about certain things that may happen after acupuncture. Some patients find their symptoms become temporarily worse just after acupuncture. This is the so-called aggravation. It is usually mild and transient, but if it is severe you should let the acupuncturist know, either by telephone or when you next attend for treatment. An ggravation is often an indication that you are a particularly good responder to acupuncture who would benefit from more gentle treatment than normal.

This brings up an interesting point in connection with strong reactors. Occasionally a patient has acupuncture from someone---usually a traditional Chinese acupuncture practitioner---who inserts a lot of needles, perhaps 20 or 30, for 20 minutes or more, after which the patient feels extremely ill for two or three days. If this happens to you it probably means that you are a particularly good acupuncture subject but you were treated too strongly. You may have said that you would never consider having acupuncture again, but don't be so hasty. If you are treated extremely gently---for example, by having one small needle in the top of your foot for just a few seconds---you will see that the treatment can be done without causing any bad effects. In fact, if you are really a very strong reactor you may find that even this minimal treatment makes your complaint better. At any rate, you now see that acupuncture done in the modern way does not cause a severe reaction in you and you will probably now be willing to let the acupuncturist do a little more treatment, although still lightly and quickly.

Driving after acupuncture

If possible, you should not drive yourself home after acupuncture, particularly on the first occasion. You may find that you feel quite sleepy, either immediately or an hour or two later, which could make driving or operating other kinds of machinery unsafe. Sometimes there is no alternative and you have to drive; in that case you should take extra care.

Pain

A natural question to ask at the outset is 'Will it hurt?' The honest answer to this is 'possibly'. But the pain should be fairly small---less than that of having a blood test or an injection. Still, a needle is a needle, and although acupuncture needles are fairly thin they can still hurt as they go in. But once the needle is in place there should be no further pain; if there is, the needle should be withdrawn.

We can refine this description a little. The precise degree of pain, if any, depends on what technique is being used. If you have muscle trigger points the acupuncturist may needle directly into them, trying to hit the points exactly. This will produce a particular kind of sensation---not pain, exactly, but feelings which are difficult to describe---a kind of heaviness or fullness that has been compared to the sensation one may have after exercise. Some people find this quite pleasant. Sensations may radiate down a limb to various distances, and sometimes this radiation corresponds to the areas where the patient feels pain from their condition. This is a good sign and means the acupuncture is likely to succeed. The acupuncturist will want to know what you are feeling, because it helps him or her to know that the right spot has been reached. After you have been treated once or twice, acupuncture can become a collaborative experience between you and the acupuncturist.

Another technique, not used by all practitioners, is to needle the covering of the bones---the periosteal acupunctureperiosteum. This may sound uncomfortable, and it can sometimes, though not always, cause a deep, dull ache which is rather unpleasant though it passes off quickly. But the periosteal technique, as this form of needling is called, is probably the most effective way of relieving joint pain such as that due to osteoarthritis. Periosteal acupuncture is in any case very brief---it lasts only a few seconds.

How long does it take?

You may be asked to lie down for treatment, but some treatments are easier to do with the patient sitting, either in a chair or sideways on a couch. The length of time the needles are left in is variable. Traditionalists and some modernists use quite prolonged insertion, perhaps for 20 minutes or even more. Others use brief needling, with insertion lasting only about a minute or even less. This is what I do myself.

You may find the idea of brief brief needling surprising, but there are good reasons why it should work. One is that the nervous system adapts very quickly to a new stimulus. When you put on your clothes in the morning you feel them at first, especially if the weather is cold, but that sensation soon passes off and you don't notice your clothes for the rest of the day. It is the same with acupuncture: most of the effect is produced in the first few seconds.

Another reason why brief needle insertion works is that much of the pain-relieving effects of acupuncture are produced by switching patterns of activity within the spinal cord. The important word here is 'switching'. When you turn on a light you press the switch and it's done; you don't have to keep your finger on the switch for 20 minutes afterwards. The same applies to acupuncture.

Acupuncturists generally do something to the needles to activate them once they are in place. Some use electrical stimulation, while others, me included, find that manual stimulation is equally or more effective. The manual stimulation usually consists in twisting the needle rapidly back and forth for a few moments, although for periosteal acupuncture the needle is tapped on the bone three or four times.

De qi

Acupuncture may produce strange sensations at the site of needling which are difficult to describe in English. In the traditional system these are called de qi (also written de chi). The acupuncturist may feel that the needle is gripped by the tissues, as if elastic were being wound round it and causing a resistance to twisting it; this is another de qi phenomenon.

In traditional Chinese acupuncture a lot of attention is paid to de qi. Practitioners try to elicit it and may go so far as to say the acupuncture won't work unless there is de qi. Western medical medical acupuncture practitioners recognise the phenomenon but many are unconvinced that it has as much importance as traditionalists claim.

Less frequent effects

Acupuncture can on occasion give rise to quite unusual effects. Some degree of relaxation once the needles are in place is surprisingly common. In some people this goes on to become feelings of wellbeing and happiness; patients may feel as if they have had a few drinks. People who have such effects are particularly likely to do well with acupuncture. Another response sometimes seen is the occurrence of remote sensations. For example, when a needle is inserted in the foot the patient may feel something in their chest or their throat.

Don't be surprised or alarmed if you have any of these or other strange sensations; they are a good sign---they show that something is happening. But mention them to the person who is treating you because it helps them to gauge the effect of the treatment. On the other hand, if nothing seems to happen at all, don't be downcast; it doesn't mean that acupuncture is not going to work for you. Some people feel nothing at all at the time but nevertheless have good relief from their symptoms.

This does not exhaust all the possible short-term effects of acupuncture. Very occasionally patients may find themselves laughing or crying for no apparent reason. This can go on for several minutes. The reason it happens is obscure, but it can be taken to be an indication that the acupuncture has done something, so it is a good sign. A similar thing sometimes happens with other manual techniques, such as osteopathy. I think that a number of manual therapies, including acupuncture, work on the same central part of the brain---the limbic system.

There are quite a few different ways of practising acupuncture, so don't be surprised if you encounter someone who does something a bit different from the possibilities I have outlined here. It doesn't mean that acupuncture is being done in the wrong way or is less likely to work. The response rates with different styles of acupuncture seem to be about the same, although some patients will respond better to one technique than another.

You should also not be surprised if the treatment turns out to be much shorter and lighter than you expected. As I have said, some acupuncturists, of whom I am one, tend to favour this kind of treatment, which we find causes fewer aggravations and works as well as doing more. Finding the right intensity of treatment for a given person is the secret of getting good results in acupuncture. A treatment that lasts for five minutes and makes you better is preferable to one that takes half an hour and causes an aggravation.

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