As will by now have become clear, I attach a lot of importance to trigger points, but I don’t think they are all-important. So, in practice, if you follow the method I’m suggesting, your thought processes go something like this. (Here I imagine that we are jointly interviewing a patient for the first time, keeping the possibility of using acupuncture in mind; which, if you are an acupuncture practitioner, will generally be the case, especially if the main complaint is one of pain.)
The first question is whether acupuncture is at all likely to be of use in this instance. The decision to try acupuncture will be based on patient characteristics as well as on the local pain features. The features mentioned in Chapter 5 as suggesting that someone may be a strong reactor are important, although the ‘pseudo-strong reactor’ category must also be kept in mind. Belief in acupuncture is irrelevant but fear is certainly important, since if someone is ‘afraid of needles’ acupuncture is unlikely to work. After a time one begins to develop a ‘feel’ for the kind of patient who is likely to do well; this presumably depends on picking up subtle signals from voice, body language, and other characteristics that one may not always be fully conscious of.
Let us suppose that the patient in question here seems likely to be at least a reasonable prospect for acupuncture so far as general character- istics are concerned. Next, we ask ourselves whether the disorder is a musculoskeletal one. Often the answer to this is obvious, but sometimes it is not.
䊉 An elderly patient complains of creeping or crawling sensations on top of the head. These often arise from trigger points in the neck, so it may
The ATA concept in practice 79
well be musculoskeletal, but this is not something that is obvious to a therapist who isn’t familiar with the phenomenon.
䊉 A unilateral watering eye may be caused by a trigger point at the base of the skull (GB20).
In other words, quite a number of common symptoms may be trigger point disorders in disguise. Experience is important here; someone who is not familiar with this form of treatment may not think of the possibility that trigger points are involved in such cases.
If we suspect a trigger point disorder, we obviously make a search for tender areas. But what if there are none? Does this mean that we have to dismiss the possibility of using acupuncture from consideration? No, because, if we use the ATA concept, we don’t necessarily expect to find tenderness at the place we intend to insert the needles. We therefore choose a needling site, which may be the painful area itself or may be a remote site from which sensations typically radiate to the area of pain. For example, if there is diffuse pain in the back of the thigh, we might needle the sacroiliac region. In this case we are not using trigger point acupuncture because no trigger point is actually present, but the treatment is much the same as if a trigger point were present.
Perhaps we think that the disorder is not a trigger point one but rather is due to damage to a particular joint, perhaps by osteoarthritis. In that case we think of using periosteal acupuncture. Since this is a relatively imprecise method we can simply choose a site to needle that is reasonably accessible, because it is near the surface. Ideally, I like to needle both sides of a joint but often it is enough to needle only one side. Just one needle may be used, or two or three sites around the joint may be stimulated. In the case of a joint, however, we need to keep the limits of the joint capsule in mind; it’s unnecessarily risky to insert acupuncture needles into the joint itself in view of the (remote) possibility of causing a joint infection.
Perhaps we don’t think that the problem is musculoskeletal, but nevertheless acupuncture seems worth considering. There could be several reasons for this: the disorder might be one for which acupuncture often gives good results, such as ulcerative colitis; the patient might be keen to have acupuncture (and there is no reason not to try it); the disorder is an obscure one, which several consultants have failed to find an explanation for; or the patient is potentially a good acupuncture subject. In all these cases we might try generalized stimulation, say at LR3.
Finally, the problem might be one that is unrelated to trigger points but that often responds to needling a particular ATA. For example, trigeminal neuralgia is often helped by needling the deep infratemporal fossa (as described in Part 3).
I hope this outline of the thought processes that run through the mind of a modern acupuncturist (this modern acupuncturist, anyway) will give an indication of how this form of treatment can be applied in practice. The
techniques themselves are relatively simple; what matters is how, when, and how strongly they are applied.
To summarize, the questions one asks oneself are as follows: 䊉 Are these symptoms likely to respond to acupuncture?
䊉 Is this patient likely to be a good or at least an average acupuncture responder?
䊉 Is this likely to be a trigger point disorder?
䊉 If no trigger points are present, are there ATAs that might work?
䊉 Is there a chance that generalized stimulation might help?
If the answers to any of these questions is yes, I would normally suggest acupuncture to the patient. This usually entails a reasonably detailed setting forth of what is going to happen and what the patient can expect to experience, because, as I explain in Part 4, it seems to be necessary to switch the patient’s nervous system into ‘treatment mode’ before starting. (This has nothing to do with belief; it’s simply a matter of acceptance of the therapeutic context.)
How much encouragement to give is a matter of individual judgement. My own practice is to tell the patient, as accurately as I can, what I think the chances of success will be. I generally include a warning that there is a failure rate of about 20–30 per cent in all acupuncture treatments, so if the patient happens to fall into the non-responder category the treatment won’t work. Other practitioners like to use a great deal of positive reinforcement in order to maximize the placebo response and don’t talk about possible failure rates, and this is quite legitimate. However, I prefer to be as objective as possible, presumably for temperamental reasons. My success rate, nevertheless, appears to be about the same as other people’s, so perhaps the placebo effect is not as large in acupuncture as one might expect it to be.
References
Baldry P.E. (1998) Acupuncture, trigger points and musculoskeletal pain. Churchill Livingstone, Edinburgh.
Travell J.G. & Simons D.G. (1983) Myofascial Pain and Dysfunction. The trigger point
manual, vol. 1. Williams & Wilkins, Baltimore.
Travell J.G. & Simons D.G. (1992) Myofascial Pain and Dysfunction. The trigger point
Chapter 8