Why It's Hard To Tell Patients Where Needles Might Be Placed

I've been answering questions on this site for a couple of years now. There's been a recent trend towards acupressure questions which I addressed in my first blog post.  Generally, though, I've noticed that questions tend to fall into a few buckets:

1. Is acupuncture a good treatment for [my health issue]?
2. Where will needles be placed for [my health issue]?
3. How many sessions/treatments will be required to address [my health issue]?
4. Does acupuncture work? Or the common corollary to this: how does acupuncture work?

As you might have guessed by the title, I'd like to address the second point from my list in this blog post - where will needles be placed for [my health issue]?

From the perspective of someone who practices Chinese medicine, there are a couple of things about this question that usually make it un-answerable. Here's why.

For starters, these questions are usually phrased in terms of wanting to know where the needles will go for some western/conventional medicine diagnostic category. As I pointed out in my previous blog entry about acupressure points, Chinese medicine does not technically treat western/conventional diagnoses. Chinese medicine uses a syndrome diagnostic method that is based on systematic correspondences. This method sits on top of a philosophical framework that is grounded in empiricism and systems theory.

To simplify that word soup - from a diagnostic perspective, we're interested in a patient's subjective experience of the health issue along with information we can objectively observe about the patient. This information is placed in a holistic framework and we're much more interested in relationships between body systems than single systems in isolation. Chinese medicine models these relationships in different ways and, beyond knowing the different models and how they work, there are three tricks to arriving at a solid diagnosis:

1. Selecting the relationship model that will provide the most accurate picture of what's going on.
2. Knowing all of a particular patient's symptoms, even if they don't seem related to the issue at hand.
3. Understanding the chief complaint in excruciating detail.

A concrete example might help to bring things home. Suppose a patient presents with a chief complaint of knee pain. They also have a chronic headache that starts in the forehead and sometimes evolves into a dull aching that feels like the head is wrapped in a band or being squeezed in a vice, their gums bleed when brushing/flossing, and they have reflux fairly often with belching and a distending feeling in the upper abdomen after eating. On further questioning, the knee pain is mostly along the outside front part of the knee and is constant, dull achy, and fixed in location.

In conventional medicine, the patient would probably be sent to an orthopedic physician for the knee, possibly a neurologist or maybe an ENT for the headache, a dentist for the teeth/gums, and a GI specialist for the reflux/digestive issue. From the perspective of Chinese medicine, though, this is all one thing. These symptoms are inter-related through the channel model of Chinese medicine and, usually, all these issues can be improved or resolved with a few treatments.

If the above patient only told their practitioner they had knee pain - never mentioned the other symptoms and never specified where, exactly, the pain was on/in the knee or how they experienced that pain, a Chinese medical practitioner wouldn't have enough to go on to make an accurate diagnosis. Since the treatment hangs on the diagnosis, without an accurate diagnosis there is no guarantee the treatment will have any effect and, occasionally, the wrong treatment can make things worse.

Secondly, there are multiple systems of acupuncture and they don't all treat health issues the same way. We have the 'standard' TCM acupuncture that most people learn in Chinese medical school, there are Korean and Japanese systems, Tung/Tan acupuncture from Taiwan, 5-phase/5-element acupuncture, neuromuscular or musculoskeletal acupuncture, dry needling, and probably a few more that aren't popping into my head at the moment.

These different schools emphasize different parts of the diagnostic model and they approach health issues in different ways. Some schools will needle in the local area of the issue, some won't. Some schools will emphasize things like moxibustion (burning an herb either on the needle, on the skin, or near the skin) while some might emphasize bleeding techniques or cupping for certain health problems.

In the west, we have been conditioned to expect that, for the most part, physicians given the same or substantially similar health issues will come up with the same or substantially similar treatments. In a lot of cases, this is driven not by the physicians themselves but by a legal framework known as 'standard of care' which is a whole blog entry in itself. 

Chinese medicine, on the other hand, has no standard of care framework and is individualized - not everyone experiences the same health issue, such as knee pain, for the same reason. Some people fell and bumped their knee, some people have arthritis, some people are more prone to ligament tears, sometimes even with x-rays and MRIs, we can't say why a person is experiencing knee pain. Since there are a variety of reasons someone might have knee pain, there are a variety of treatments for that pain. On top of this, not every system of acupuncture is going to offer the same or substantially similar solution to the problem - even though properly applied, they all might get results for the patient.

Even assuming a patient provided extreme detail about their entire health situation, there is no guarantee that some other provider might choose to utilize the same points I might use. This will cause a great deal of confusion at the first office visit - unless, of course, the patient is coming to see me and I don't find anything that would change my initial diagnostic opinion.

In the west, not many people have a lot of experience with Chinese medicine or acupuncture. There are many areas in the U.S. where there are no acupuncturists serving the population. There are a lot of areas in the U.S. where there are 10 or fewer acupuncturists. In fact, nation-wide, the U.S. has less than 40,000 active licensed acupuncturists. More than 50% of these providers practice in three states: California, New York, and Florida. If a patient is someplace like Kansas or Ohio, the odds are there aren't any practitioners of Chinese medicine around (and, no, a chiropractor with maybe 100 hours of training offering 'acupuncture-like' services is NOT the same thing).

Patients who've never had the opportunity to experience acupuncture and whose only exposure to Chinese medicine is via movies or, God forbid, internet articles, often have a great deal of anxiety over the needles and where they might be placed. I could provide a lot of supposed soothing information about acupuncture needles relative to other needles commonly used in healthcare, but many years of experience have taught me that having this information does nothing to relieve a patient's fear or anxiety. The only thing that works is for that patient to experience acupuncture and see for themselves that it's not really that painful, the needles aren't really that big, and, yes, it does work.

My ultimate suggestion is fairly simple, if you're a person who needs to know where the needles might be placed before committing to a treatment - go to NCCAOM.org and use their 'Find a Practitioner' lookup. This feature allows prospective patients to plug in a city or a zipcode and get a list of board-certified, state-licensed practitioners of Chinese medicine. Call some of these people and see if they offer a free consult. Most of us do, usually it's 30 minutes - you want face-to-face time. Attend a few of these, meet the provider, explain your situation and see what they propose. By doing this, patients can get a rough idea of how each provider will approach the problem and choose the one that makes them the most comfortable.