Did it or didn’t it?
Does acupuncture work? Did the acupuncture I provided to an individual person in an individual case achieve the results we both strove for?
Regarding the first question: A couple of years into my career, I decided that acupuncture does work, based on my personal experience as a provider, as contrasted with the relentless positivity of acupuncture school, where we were told all the time that it worked. (If it didn’t, what were we doing there?)
Whether acupuncture has worked beneficially for an individual person in my care is a question I ask myself all the time. (It’s closely connected with the question of when treatment is over, IMHO.) How can one say with certainty that my acupuncture intervention has helped when it could simply be the passage of time or, heaven forfend, some quirk in the patient’s mind that leads the person to think that all is well, or at least well enough? Acupuncture is not magic. Treatment is additive and there’s a dosage aspect. Sometimes one treatment is a bull’s-eye. Sometimes it’s simply the patient’s own physiological responsiveness to treatment. But good outcomes usually require repeated visits.
Here are two recent cases that illustrate some of these issues. I present them with the patients’ permission, changing identifying details.
Earlier this year I was visited by Ruth Z., a 28-year-old married woman with two children whose dentist, four months earlier, had extracted four wisdom teeth. When she came out of general anesthesia, which the dentist had recommended on the basis of greater comfort, her entire tongue was numb. While there was some minor tactile sensation, she had lost her sense of taste. She bit her tongue twice during this period. Across four months, although sensation and taste gradually came back for most of the tongue, the entire underside and the tip of the tongue remained as they were in the immediate post-operative period. The return to normalcy had seemingly stalled.
Ruth learned from the dentist that her numbness was an adverse event connected with the nerve block. He told her that that such things do happen but remained confident that her tongue would eventually return to normal. While she would eventually regain taste and sensation, it could take as long as six months.
Unfamiliar with acupuncture but frustrated with four months of discomfort and concern, Ruth consulted with me. I told her I had never treated this problem but that it was a very interesting one for which I could come up with a strategy, and we agreed to give it a try.
The affected area of her tongue is innervated by the lingual nerve, which is itself a branch of the mandibular nerve, the third branch of Cranial Nerve V, also called the trigeminal nerve. According to Wikipedia, “the most common cause of lingual nerve injuries is third molar (wisdom tooth) surgery. . . . The risk associated with wisdom tooth surgery is commonly accepted to be 2% temporary and 0.2% permanent.” https://en.wikipedia.org/wiki/Lingual_nerve#Lingual_nerve_injuries
Working at both the left and right sides of her face, I placed needles shallowly at the following locations: anterior to the tragus of the ear, inferior to the zygomatic arch (the cheekbone), at the angle of the mandible, and along both the outside and soft, fleshy underside of her mandible. (The mandible is the jawbone that moves when we jawbone someone.)
In the simplest terms, I was attempting to work within the dermatomes of branches of the mandibular nerve; specifically the lingual, but also other nearby branches such as the Inferior Alveolar and Long Buccal. The lingual nerve innervates the tongue itself, as its name implies (Latin lingua = “tongue”). (A dermatome is “an area of skin supplied by sensory neurons” arising from a single nerve (https://en.wikipedia.org/wiki/Dermatome_%28anatomy%29), usually a nerve coming off the spinal chord, though the cranial nerves of the face also have dermatomes. In the acupuncture perspective I work in, it’s assumed that you can influence the functioning of a nerve by needling in that nerve’s dermatome.)
Ruth and I had agreed in advance that she would have only one treatment, and that she would return, if she chose to, after a period of evaluation. We played phone tag for the following week, and then I went away on vacation. But about two weeks after her visit to my office, while I was still away, I did manage to reach her. The numbness had resolved. She now had full sensation in the tip and underside of her tongue. It was not something that happened overnight. It had returned gradually during this period of (from my perspective) unintentionally prolonged evaluation. We were both really happy about this. (It has stayed this way, seven months later.)
Did I help Ruth or not? Ruth insists that I did. I’d like to think I did, too. But the evidence would never be accepted in a scientific court of law. In first place, the so-called gold standard of medical research is the randomized, placebo-controlled, double-blinded study. The person providing the intervention has no idea whether s/he is giving the placebo (i.e., the so-called sugar pill) or the experimental agent, and the recipient is also blinded, not knowing whether s/he is receiving one or the other. Additionally, there may be a desire on the part of the patient to have the provider’s approval, to stay in the provider’s good graces, or to support the provider in some way, which would taint the validity of his or her affirmation. (Ruth is on my mailing list and may read this article. For her sake and mine, let me state that I am not doubting her. I’m only exploring how one arrives at the proof one is seeking.) In addition, she is a single, isolated “experimental” group, the iconic “n of 1.” A single experimental encounter cannot possibly be randomized. We can’t really generalize from her experience to the larger population.
It’s worth noting that Ruth’s dentist said her tongue would normalize within six months. The process had seemingly stalled, but “seeming” may not describe what was happening beyond perception as the nerve healed. The outcome she experienced after acupuncture treatment exactly matched the dentist’s timeline. The question remains: Did I help her or not?
Intractable leg pain
The second patient is James R., an 86-year-old male, married 60 years, with adult children, who came to see me for pain in his knees and legs of three years’ duration that developed after chemotherapy for non-Hodgkin’s lymphoma. He had a stroke 15 years ago. He rated the pain 7 of 10. Neither physician care nor physical therapy had provided relief. Physical examination disclosed significant tenderness in the muscles of the upper and lower legs and at his knees. There was also significant tenderness in his glutes, bilaterally, which is where the sciatic nerve passes and branches out. He visually creaked when he stood up from his chair and he walked with a lumbering gait. He turned from supine to prone on my examining table with enormous difficulty.
Initially, I saw James twice weekly. The first treatment took place on May 1, focusing on tender places in his legs, knees and glutes with a minimum number of needles. Five days later, at the second treatment, James reported experiencing “a lot of pain” in his right knee for one night but said that overall there was a moderate reduction in pain. Seeing that he had not experienced any adverse effects – the knee pain resolved after one night, and it’s not unusual to experience some discomfort after acupuncture treatment – I decided to introduce electroacupuncture to advance the process. The electroacupuncture approach I use is called Neurofunctional Acupuncture, and it involves places needles at motor points (the places where the motor nerves enter the muscle to elicit muscular contraction) to induce a gentle pulsation in the muscles. It amplifies the acupuncture effect, which is both local to the needle and also systemic via the central nervous system. I also placed about eight to ten non-electrified needles at areas of tenderness in his upper and lower legs, which I found easily, since “tender” is a word which characterized his muscles generally.
At the third treatment, two days later, James reported that he was able to walk around his property and accompany his wife to the supermarket. For the first time in years, he was not experiencing pain after this level of exertion. Five days after that, at the fourth treatment, he said he had “several days” without pain, although he came in with some discomfort in the right upper leg and knee. Three days afterwards, at the fifth treatment, reporting significantly diminished right leg pain, he asked if he could get on his treadmill or exercise bicycle. I replied that I thought he should, because physical movement is essential to maintaining health, provided he had no balance problems and did not experience pain during his workouts.
Four days later, at the sixth treatment, he said he was pain-free for two days. The third day brought colder, damp weather and a return of discomfort, but on the day of the office visit it was warmer and dryer, and his legs felt better. His left knee and upper leg became the focus of treatment, although each time he came in I treated the entire length of both legs, both the anterior and posterior, including his glutes, piriformis, and also his lower back. We were now 10 days into treatment and he was already experiencing his body quite differently for the first time in years.
I suggested to James that he could start coming twice weekly. Across weekly visits from Treatments #8 -13, he reported continued subdued pain, illustrating his situation with these statements:
“When I wake in the morning, my legs do feel stiff and painful but nothing like before treatment started.”
“Before I came for acupuncture I had constant pain. Now it’s not like that. But it’s a little [painful] when I go up and down stairs.”
He had experienced some pain in his lower leg a couple of days earlier, “so I treated it with heat and it subsided.”
We continued through this period – and for the entire period of treatment through the present – with front and back treatment of his entire legs with Neurofunctional Acupuncture and needles into local tender points, as his report or my physical exam required. By Treatment #12, he was able to use his exercise bike for 15 minutes every day.
Because I was going on vacation five days after Treatment #13, we agreed that it was time to change the frequency to every three weeks, and that I’d see him after my return. For Treatment #14, my treatment notes read: “Pain continues moderated. Most pain when using the stairs; James clarified this to mean that he doesn’t feel pain as much as a ‘sensation’ that tells him he needs to use restraint when activating the muscles of his legs for going up and down stairs. He offers that ‘when you get to a certain age you need to accept that you won’t feel the way you did when you were younger. But I experience a world of difference.’ “ By the way, he still turned from supine to prone with enormous difficulty.
At visit #15, I learned that his PCP ordered a Lyme test that disclosed, according to his account of his doctor’s report, “an advanced case of Lyme” and had put him on Doxycycline. Nonetheless, his leg pain continues diminished. He also said that when he overdoes it on his bike his legs “feel a little weak afterwards,” so he cuts back the next time. At visit #17, at the end of the September, he said he felt a little constriction under his kneecaps – but no pain there.
As of the time of writing, at the end of November, we’re up to visit #20, at a frequency of once per month. He is on an even keel with regard to pain, enjoying his exercise bike and leading a more mobile life than he had in years, with no pain medication.
Let me add that I have to search a little harder along the length of James’s leg for tender points to place my needles. Acupuncture is healing as well as pain-relieving. Each microlesion from a needle leads to a cascade of healing responses and the generation of healthy tissue (even for someone who’s not the youngest tool in the shed, apparently). I’d argue that James’s muscles are not simply pain-free but actually healthier than when he walked into my office, which is why there aren’t as many focal areas of pain.
I believe that acupuncture has worked for James. He had debilitating pain for three years when he came to see me, and now his pain is gone or at a level he can live and function with, depending on the day. He’s really happy about this, and so am I.
The two cases make an interesting contrast. One person in her twenties and one in his eighties. One acute case and one chronic. A one-treatment, “magical” success which could also be attributed to the passage of time (although Ruth does insist it was the acupuncture which resolved her problem) and another success due to the patient’s willingness to stay the course over the long term. (Of course, without initial, positive change, he would not have continued.)
What do you think? Does acupuncture work. Did it work in these instances? You be the judge. You always are.
© William Weinstein, L.Ac. 2017