The following story was reported to me by a colleague from general practice. The details are altered somewhat to preserve anonymity, including the name of the teller, but regular readers will recognise some characteristic use of language and style.
Safe angulation for needling quadratus lumborum near lower lateral attachment to the iliac crest.
Dear Mike
This is a little story that illustrates the problems people have with acupuncture, or at least with what it means, or the perception of acupuncture.
One Friday some weeks ago, as part of routine primary care, I saw woman in her 30’s with unexplained left sided loin pain. She had suffered from an episode of pyelonephritis and subsequently developed persisting loin pain. Technically ‘chronic pain’, lasting for more than three months etc. She had undergone ultrasound scans, blood tests and two colleagues saw her. One had tried manual medicine within the osteopathic paradigm. “It aggravated it, and it stayed” she said, and she was frustrated and a bit scared. I examined and looked at the results and thought it could be myofascial pain, possibly secondary to the pyelonephritis following Maria Adele Giamberardino’s heuristics. I said that I could offer acupuncture, but first I would suggest stretching etc, all directed towards quadratus lumborum. I sensed apprehensiveness, and did not want to needle into apprehensiveness and preconceptions. She said that her husband was sceptical and he considered that acupuncture was mumbo jumbo.
I said my offer is there, no pressure, less work is good for me. She said “Come on, then”. I needled her in side lying as we teach on the course. Just one needle towards the lumbar transverse process, it could have been lateral part of erector spinae or quadratus lumborum, I am not so sure, but I am confident that the needle tip hit the target, the appropriate place. She confirmed that it was the pain she was experiencing. I stretched the muscle afterwards and whilst I was tidying up and typing the notes, she was wiggling her hip, searching for ‘her pain’, and the pain had disappeared. She asked how long will it last? I replied I don’t know, ideally forever, but what in life is ideal? Sceptical optimism, sceptical hope – I said please phone me on Monday. She never did.
…the pain had disappeared.
Friday afternoon one week later. I called a patient in. My heart sank: she had a tripod multifunction-cane, was tattooed all-over, smelled of nicotine, hopelessness and fed-up-ness, and took ages to make it to my door. The way from the waiting room to my room is a parcour with a flight of stairs up and a flight of stairs down. The Inca trail. A functional assessment strip. With a firm handshake plus the parcour I have a good understanding of the frailty score. She was frail. Her opener was “Do you do acupuncture?” Nobody in this town knows that I do acupuncture. I am a normal GP and use needling as part of my routine services but I do not attract sufferers of all countries to unite in my consultation room.
I do not attract sufferers of all countries to unite in my consultation room.
“Who told you?” I asked.
“A woman I know, she was so much better after your acupuncture.”
“Does her name start with…?”
“Yes”
The friends and family test! She recommended me.
She recommended acupuncture for pain that does not go away!
And here is where the parallel stops.
The ‘fed-up’ lady had a long medication list, was tearful and disabled. She came to get treatment for her coccydynia. I decided to do as little damage as possible and needled two points at gluteus maximus insertion at sacrum as anchor points for hope and a different conversation. Whilst she was lying down I asked her to tell me about her life. She told me about her multiple blood clots, the pulmonary embolus, that she nearly died, that she had three kids and three grandchildren, that she was a fighter, but that now she felt like giving up, that her tattoos were an idea of wanting change, like a makeover, she told me that she grieved for what she had lost and that she struggled with breathlessness and pain.
Whilst she was lying down I asked her to tell me about her life.
For pain clinic purposes she ticked all the criteria of multimorbidity, polypharmacy, depression etc and at a point pain started creeping in and settling somewhere in her body.
I know that acupuncture rarely works to get these emergent demons out.
Needling works extremely well for isolated myofascial pain, as it did for her neighbour, but not in isolation for multi-morbidity, hopelessness and all forms of demons.
In a way these two women seemed to have the same limited way of understanding acupuncture, just like the helicopter view looking at classification terms in systematic reviews.
Does acupuncture work for chronic pain/loin pain?
The answer is that it depends on the context and the label itself: ‘acupuncture for chronic pain/loin pain’ is probably too simplistic a question to answer.
