Cautions, Contraindications and Red Flags, a Client Guide

Understanding which of your health conditions are classed as cautionary, contraindicated, or a potential ‘red flag of pain’ symptom means that you can make your own informed decision about your healthcare and whether you want to have treatment.

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Discussing these with your holistic health provider enables them to adapt their treatments according to your own health needs and keeps you safe.

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These relate to current conditions, and those you’ve had in the past.
 

A caution means that acupuncture or massage can be used however there may be a risk involved and the practitioner needs to be aware so that treatment can be adapted.

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A contraindication means that acupuncture or massage is not recommended, or must be avoided around a specific area. 

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A ‘red flag’ is a sign or symptom which should be checked with a medical professional before coming for acupuncture or massage, or checking with a medical professional alongside having acupuncture or massage. This is essential to rule out the symptom being caused by a more serious health condition which needs medical care. See the end of this document for pain-related Red Flags.

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(Temporary Illness; Being poorly with a cold or virus is a temporary contraindication and I am likely to advise we cancel your treatment until you’re better to avoid spreading the infection.)

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Click on the item on the list to take you to directly to the relevant description in the document below. 

 

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Acupuncture Cautions, Contraindications and Red Flags. Current and Historic

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Allergies
Anti-Coagulants (taking these medicines)
Blood born viruses
Blood pressure problems
Botox and Fillers
Cancer
Cellulitis
Combing therapies; Having other therapies and treatments
Diabetes Type 1 and 2
Deep Vein Thrombosis (DVT)
Endocarditis & Damaged Heart Valves
Epilepsy
Haemophilia and other Blood Clotting Disorders
Heart Conditions
Immunocompromised clients
Lymph Node Removal/ and Lymphedema
MRSA and other Super Bugs
Notifiable Infectious Diseases
Oedema and Circulatory Problems
Pregnancy and Trying to Conceive, including Breech Presentation in Labour and Encouraging Labour
Steroids and Steroid Injections
Skin Lesions and Skin Complaints

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Massage Cautions, Current and Historic

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Anti-Coagulants/ Haemophilia and other Blood Clotting Disorders
Cancer or Receiving Cancer Treatment
Diabetes
Neurological Disorders (ie MND, Parkinson’s, MS)
Pregnancy

Massage Contraindications (not to massage over these areas)

Areas of acute, active inflammation
Fractures and Diagnosed Stress Fracture
Open Wounds
Skin Diseases
Varicose Veins

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Red Flags

Pain signs and symptoms which need checking with a medical professional before beginning holistic treatment. Click here to review red flag signs and symptoms.

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Acupuncture Cautions, Contraindications and Red Flags. Current and Historic.

 

Allergies

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Let me know if you have any allergies. Do you have any allergies to metals? Needles are generally made of surgical grade stainless steel and often are coated in silicon to make pain free insertion. Handles are most often stainless steel, copper or plastic. I use scented massage oils, and a non scented organic sunflower seed oil version. If your skin is generally very sensitive please let me know. 

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Anti-coagulants

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The use of anti-coagulants is very common, and they are prescribed for a number of reasons. These may be purely preventive if, for example, the patient suffers from atrial fibrillation or has mechanical heart valves, or they may be because of recent surgery, stroke, heart attack or thrombosis. It is now also quite common for anticoagulants to be used during fertility treatment. 

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The most prescribed anticoagulant is warfarin. However, there are newer types of anticoagulants known as Novel Oral Anticoagulant Drugs (NOADs) which are becoming increasingly common. These include: • Rivaroxaban • Dabigatran • Apixaban • Edoxaban.

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If you are using warfarin, or receive regular testing to check your INR or PT please let me know. Let me know if your INR is raised (your blood is less coagulable). It is good practice to have more frequent tests whilst receiving a course of acupuncture as the treatment can positively influence your blood values and may require your medication to be reduced. Warfarin prevents the body from metabolising vitamin K, which is found in green leafy vegetables. If dietary advice is provided, the effects of warfarin need to be taken into account as this is cautionary. 

 

There is no reason not to treat patients on anticoagulants, providing very fine needles of 0.20mm or less are used and needling is gentle and superficial (not deep).

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If I (or you) have any concerns about treating you I will require you to get verbal consent from your GP or consultant.

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Although serious side effects following acupuncture are rare there are additional risks associated with receiving acupuncture whilst on this type of medication, especially the increased risk of bleeding and bruising.  One rare event is compartment syndrome, which may be caused by deep needling which causes bleeding and swelling within an enclosed bundle of muscles, usually within the leg or arm. This is a serious condition which needs you to go for emergency treatment. The NHS details that symptoms of compartments syndrome are; pain in a muscle which may feel like burning or a deep ache; moving the body part may make the pain worse, swelling or bulging of the muscle; swelling or bulging of the muscle; numbness, weakness or pins and needles; tightness or difficulty moving the affected body part.

 

Blood Born Viruses

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Please let me know if you are a carrier of a blood born virus as I as a practitioner may wish to take extra precautions over and above those within the British Acupuncture Council’s Code and Guide to Safe Practise.

Although the actual risks are low, practitioners should not become complacent in this area of their practice and should still be aware of the risks associated with needlestick injuries and blood borne viruses.

 

Blood Pressure Problems

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Acupuncture can affect blood pressure, generally lowering it. However in situations of a highly anxious patient attending treatment for the first time who has blood pressure problems, it is worth noting that anxiety could cause blood pressure to rise. 

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Botox and Fillers

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Botox Injections Botox (Botulinum toxin) is most commonly known for its use on the face for cosmetic reasons. However, the toxin is also used in conventional medicine to relieve muscle spasms anywhere in the body and in some cases for severe migraines. 

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Please let me know about previous Botox injections. With regards to facial Botox injections and then attending for facial revitalisation acupuncture,  I will not needle into the affected area for twelve weeks following a Botox injection. It is of course possible to receive body acupuncture treatment before the 12 weeks has passed. 

 

It is advised that I as a practitioner should also inquire as to who administered the injections. They should be suitably qualified, ideally registered with the Joint Council for Cosmetic Practitioners (JCCP). If they are not there is a higher risk of things going wrong. If I feel it is appropriate I may contact them to inquire whether they feel it is safe to give you acupuncture. Alternatively I may require a longer wait time than 12 weeks to begin treatment.

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If you have had a Botox injection to relieve muscle spasms, or headache, I will wait 12 weeks prior to needling in the area where the Botox was administered.

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If I am concerned, I may require consent from your GP or medical professional who prescribed the Botox injection to obtain written consent for acupuncture to be given in the relevant area.

 

Fillers such as Hyaluronic acid are also used in cosmetic procedures. It is recommended to wait for at least 6 weeks before commencing facial acupuncture. There must be no swelling, pain, infection, or signs of any other pathophysiology before using facial acupuncture. 

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Cancer

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Acupuncture can be hugely supportive to patients with cancer or suffering the side effects of its treatment. It is important that you are aware that acupuncture cannot treat cancer in any way. 

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Immune suppression caused by Cancer itself, especially leukaemia or lymphoma, as well as being caused by it’s treatment; chemotherapy, radiotherapy and biological therapy can all have a profound effect on a patient’s immunity. Long courses of steroids will also decrease a patient’s immune response. 

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Neutropenia (low white blood cell count) occurs in around 50% of cancer patients who receive chemotherapy meaning their ability to fight infection is greatly reduced.

 

Radiotherapy can cause redness, irritation and cracking to the skin which can lead to patients being more prone to infection.  Any area of skin when radiotherapy has been directed must not be treated with acupuncture.

 

When treating any immune compromised patient, it is advised that all acupuncture points are swabbed (alcohol swab) before needling.

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Cellulitis

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Cellulitis is an acute bacterial infection of the skin and underlying tissue commonly caused by Streptococcus and Staphylococcus bacteria. Commonly affected areas include the lower legs, feet, arms, or hands, and sometimes the face, particularly around the eyes. Signs and symptoms of an infection include: • red skin which may become hot and swollen • pain and tenderness • a fever and enlarged lymph nodes • blisters which are pus or blood filled.

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Streptococcus and Staphylococcus bacteria often exist on the surface of the skin without causing any harm to a healthy person. An infection usually develops following a small break in the skin from a cut, needle puncture, insect or animal bite or a scratch through which the bacteria can enter. Those most vulnerable to developing an infection are the elderly, the immunocompromised and patients who have circulatory problems as, for example, in the case of diabetics. Recurrences of cellulitis in the same area are common and therefore a history of such infections is essential to note. Most cellulitis infections can be treated quickly and effectively with antibiotics. However, in rare cases the condition can have some very serious complications hence the importance of an early referral.

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As a part of my responsibility to ensure such risks are minimised, I will take additional precautions when treating patients who are more vulnerable to contracting an infection.

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In particular, these patient include: • patients who are immunocompromised: including patients infected with HIV, patients taking immunosuppressant drugs, patients suffering from serious chronic disease such as leukaemia, patients with a tendency to developing opportunistic infections, etc • elderly or physically frail patients • patients who have a history of previous cellulitis or similar infections • patients who are intravenous drug users • patients with circulatory problems: including diabetic patients, patients with chronic heart conditions, patients who have a tendency to develop oedema, patients who have or have had slow-healing wounds or ulcers.

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When treating patients belonging to any of the above groups, swabbing of all points with 70 per cent isopropyl alcohol with or without 0.5-2.0 per cent chlorhexidine is strongly recommended to minimise the risks of infection.

 

Combining Therapies (having treatments with other holistic practitioners at the same time)

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The British Acupuncture Council advises patients not to receive multiple therapies on the same day. By patients avoiding multiple treatments in one day practitioners are able to get clearer feedback on the effectiveness of their treatment. It also allows practitioners to clearly gauge if any adverse reactions to treatment are attributable to the acupuncture. Please discuss with me if you are receiving other therapies.

 

Diabetes

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In 2016 there were an estimated 4.5 million people in the UK suffering with Diabetes with the number of cases on the rise. Of these around 90% suffer from type 2 diabetes. Many people manage their diabetes well through diet, lifestyle and exercise and acupuncture can be part of this management process. Those who don’t manage their condition well may be prone to irregular blood sugar levels, neuropathy, and poor wound healing amongst many other problems.

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Acupuncture can lower blood sugar levels and occasionally induce drowsiness; therefore it is recommended that such patients are treated with particular care, especially on their first acupuncture treatment, and ensure that they have had something to eat before the treatment.

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Diabetes can cause neuropathy because of high blood glucose levels damaging the small blood vessels which supply the nerves. This decrease in blood supply and damage to the nerves means patients may have decreased sensation in lower limbs and extremities as well as an increased risk of infection. It is recommended to ask diabetic patients about neuropathies they may have developed as well as any recurrent infections or poor wound healing. Needling into these areas should be done gently and with care. If using heat in treatment, sensitivity to the area feeling hot may be reduced so caution is required. Massage to affected areas is treated with caution. If you are at a higher risk of infection due to your diabetes I will swab all points with alcohol prior to needling. 

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Deep vein thrombosis (DVT)

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DVT usually occurs in a deep leg vein that runs through the muscles of the calf and the thigh. Symptoms, although these don’t always show, may include: • pain, swelling and tenderness in one of the legs (usually the calf) • a heavy ache in the affected area • warm skin in the area of the clot • red skin, particularly at the back of the leg below the knee.

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The main concern for patients with a DVT is that the clot becomes dislodged and causes a pulmonary embolism. If left untreated, about one in 10 people with a DVT will develop a pulmonary embolism. If you have a DVT and are receiving emergency treatment I will require you to gain consent for treatment from your healthcare practitioner. There is no evidence to suggest that acupuncture could not be given in this situation, however the area affected will not be directly treated.

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If I suspect you have a DVT which hasn’t been diagnosed, you must seek urgent medical attention before receiving treatment. Any patient with a confirmed DVT is likely to be put on anticoagulant medication. I will thereafter treat according to the guidance on patients taking anticoagulant medication as above.

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Endocarditis and damaged heart valves

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Endocarditis is inflammation of the lining of the heart, the endocardium. It is usually caused by bacteria entering the blood stream and travelling to the heart. It is quite often healthy bacteria which are already present on the patient’s skin that causes Endocarditis. Common causes include tooth brushing, gum disease, pre-existing infections, a history of rheumatic fever and any surgical procedure where the skin is broken.

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Generally, acupuncture treatment with single use sterile needles is unlikely to be a problem however the most at-risk patients are those with damaged or artificial heart valves. With these patients, bacteria are more likely to lodge in the damaged or artificial heart valves leading to infection. Symptoms can be slow to develop. Acupuncture points will be swabbed with alcohol prior to needling to reduce risk of infection. 

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The NHS lists the most common symptoms as; high temperature, chills, night sweats, headaches, shortness of breath especially during physical activity, cough, tiredness, muscle and joint pain.

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Other symptoms listed by the NHS can include; small red, brown or purple spots on the skin (petechiae); narrow reddish brown-lines of blood the run underneath the nails; painful lumps in the pads of fingers and toes; painless red spots on the palms and soles (redness can be harder to see on brown and black skin); confusion; loss of appetite; unexpected weight loss. 

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Epilepsy

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Patients with poorly controlled epilepsy must be treated with caution and should not be left unattended during treatment (I do not leave any of my patients alone during treatment).

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I may require you to gain consent from your consultant if the epilepsy is poorly managed or if you have only recently been diagnosed with epilepsy. There is no concern for any patients whose condition is under control and well managed.

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Electro acupuncture is contraindicated in patients with poorly controlled epilepsy.

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Haemophilia and other Blood Clotting Disorders

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Patients with blood disorders which prevent clotting and/or cause spontaneous bleeding should be treated with extreme care. Those with mild disorders may be treated with the same cautions as patients on anti-coagulant medication. Further guidance on this can be found under “anti-coagulants” above. 

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Severe haemophilia and extensive spontaneous bruising are contraindications for acupuncture and deep massage techniques.

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I may require consent to receive treatment from your consultant or healthcare professional. 

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Heart conditions

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Generally, there are no major concerns when it comes to treating patients with known heart conditions. None the less it is important to take a thorough case history to get a full understanding of any underlying heart problems. It is also essential that I get a clear picture of any medication that you are taking and so that I can understand the impact this could have on how treatment is given.

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I may require consent to receive acupuncture from your GP or consultant. Patients who have damaged heart valves (eg after rheumatic fever) or artificial valves are at a higher risk of developing infection. 

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Patients who have a pacemaker should not be treated with electro-acupuncture since there is a risk that the electrical stimulus of the acupuncture device may interfere with the pacemaker. 

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Immunocompromised patients

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If the British Acupuncture Code of Safe Practice is followed closely by the practitioner, no additional caution needs to be applied in the treatment of immunocompromised patients.

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It is, however recommended that I gather a thorough understanding of the degree of immunodeficiency, its underlying causes, and its associated risks to make a professional judgement about offering acupuncture treatment.

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Acupuncture can be of great benefit to patients with low immunity. There are, however, some risks which acupuncture treatment can pose to people whose immune system is too weak to fight off even minor infections.

The ability to resist infection depends on many factors, including age, general health, state of nutrition and previous exposure. Rare genetic disorders, autoimmune disease and viral infections can cause immunodeficiency. It can also result from medical treatment such as the prescription of immunosuppressant drugs and chemotherapy. Many chronic conditions can affect immunity. Blood disorders like leukaemia and aplastic anaemia affect the production of blood cells through bone marrow depression and, therefore, weaken the body’s immune response. Long-term prescriptions of corticosteroids can lead to a reduction in inflammatory response which as a result also reduces the body’s ability to fight off infections. An increase of corticosteroids in the bloodstream may also result from the body’s own response to extreme physical or emotional stress caused by, for example, extensive traumatic injury or major surgery. Diabetes is not generally classed as an immunosuppressive disorder, but patients can often be more prone to infection (especially bacterial) along with slow healing.

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Patients who are likely to have some degree of immunodeficiency, or are otherwise more vulnerable to infection, tend to belong to one or more of the following groups:
• transplant patients: due to immunosuppressant drugs
• patients with severe problems of malnutrition
• elderly patients who are physically weak
• HIV-infected patients
• patients who are undergoing or have recently undergone chemotherapy
• patients suffering from serious chronic disease
• patients recovering from major trauma or surgery • patients who tend to develop opportunistic infections
• diabetics
• patients with a history of recurrent skin infections and slow-healing wounds or ulcers.

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The skin is normally inhabited by of a variety of micro-organisms, including bacteria, which form its natural flora and do not normally cause any harm to a healthy person. A break in the skin surface caused by a needle, a scratch or an animal or insect bite can provide an easy route for these organisms to enter the patient’s bloodstream. Although most people’s immune system can efficiently deal with such pathogens without any noticeable symptoms, in an immunocompromised patient they may cause a potentially serious infection.

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Patients who have undergone recent chemotherapy or a bone marrow transplant are particularly prone to developing these kinds of infections. By entering the bloodstream through a break in the skin, Streptococci, Staphylococci, and other bacteria can cause skin infections even in apparently healthy people.

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The type of infection associated with immunodeficiency, however, depends on the part of the patient’s immune system that is affected. Not every infection is caused by an external pathogen but could instead be the result of over-colonisation of fungi or bacteria which are part of the patient’s normal internal flora.

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Patients with damaged heart valves, either congenital or as the result of rheumatic fever, are at a higher risk of developing endocarditis which tends to be caused by bacteria entering the bloodstream through a similar route to that described above. In fact, the highest risk associated with developing endocarditis in this patient group is thought to be the simple act of brushing one’s teeth. It is still recommend to take extra care in the treatment of patients with known heart valve defects. Some people have small non-symptomatic heart valve defects from birth without even knowing.

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When treating patients with impaired immunity, swabbing of all points with 70 per cent isopropyl alcohol with or without 0.5-2.0 per cent chlorhexidine is strongly recommended to minimise the risks of infection.

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Patients who are temporarily granulocytopenic (low white blood cell count) following chemotherapy or a bone marrow transplant are at a particularly high risk of acquiring infection. Written consultant consent to receive acupuncture will be required in this case. 

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Retained needles are advised against for people with impaired immunity and damaged or artificial heart valves. (I do not use retained needles in my practise).

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Lymph node removal / Lymphedema

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Lymph node dissection is most likely to occur in patients undergoing cancer treatment. The most common sites for the nodes to be removed include the neck, groin and armpit. Lymph nodes play an important role in filtering bacteria, toxins and excess fluid. 

Most patients who have had lymph nodes removed (eg from the axilla after a radical mastectomy) are advised by their consultant against being needled in the limb below the site of lymph node removal due to the increased risk of infection and that risk is increased if a greater number of nodes have been removed. The removal of lymph nodes means the body may be less able to deal with an infection in that limb and drainage from that limb could also be poor. Poor drainage and an increase in fluid from an infection can result in lymphedema.

It is therefore essential that I obtain a comprehensive history from any patient who has had a lymph node dissection so that I am fully aware of the potential infection / lymphedema risk. It is recommended that I follow the guidelines your consultant has given to you. 

It is recommended that patients avoid having any injections in a limb where lymph nodes have been removed and it therefore follows that acupuncture should also not be given in that limb. It also recommended that they do not have their blood pressure taken on the arm where lymph nodes have been removed. 
I may require you to gain verbal consultant consent if I am in any doubt about whether it is safe to treat a patient. 

MRSA and other Superbugs

MRSA (methicillin-resistant Staphylococcus aureus) is a bacterium that lives on the skin, mainly in the nose, armpits, groin or buttocks. Many people live with MRSA symptom free and without any knowledge of its existence. With the increased prevalence of MRSA and other superbugs any patients being admitted to hospital are likely to be offered pre-admission screening to identify whether they are carrying MRSA. Those who test positive may then be required to undergo a course of treatment before being admitted to hospital. If MRSA enters the body, it has the potential to give rise to infection in a range of tissues or bodily systems. With some this can be a minor infection which will respond to treatment, however for patients with low immunity, weakness or ongoing medication, symptoms may be more severe or life threatening. MRSA is of particular concern in hospitals due to the high number of weak or immune compromised patients.

Within an acupuncture clinic setting it is perfectly safe to treat patients who are known carriers of MRSA, however the practitioner may like to use some additional caution to avoid the risk or causing an infection or cross contamination.  Swabbing of all points is advised. 

As treating a patient with MSRA is outside of my normal scope of practise I am likely to decide this is beyond my limits and may refer on to an alternative practitioner or seek guidance from the British Acupuncture Council before agreeing to treat you. 

Notifiable infectious diseases

Acupuncture may provide some help and relief to those suffering from a notifiable infectious disease. The advice the BAcC has received from its consultant experts is that all infectious diseases should be treated by orthodox medicine, but provided this has been done, there is no reason why patients should not consult me if they wish to, on condition that I do not interfere with the treatment or advice already given to the patient.

If, for example, a patient has tuberculosis but despite treatment with the appropriate drugs suffers from other symptoms, they should be free to consult you. The drugs should not be altered nor advice such as taking a special diet or taking time off work be interfered with. If I do decide to treat someone with a notifiable infectious disease, I may take additional disinfection procedures in my clinic and may need to speak to my local health protection team for advice or your GP for advice. 

As notifiable infectious disease is outside of my normal scope of practise I am likely to decide this is beyond my limits and may refer you on to an alternative practitioner or seek guidance from the British Acupuncture Council before agreeing to treat you. 

Notifiable infectious diseases are; Acute encephalitis, Acute infectious hepatitis, Acute meningitis, Acute poliomyelitis, Anthrax, Botulism, Brucellosis, Cholera, COVID-19, Diphtheria, Enteric fever (typhoid or paratyphoid fever), Food poisoning, Haemolytic uraemic syndrome (HUS), Infectious bloody diarrhoea, Invasive group A streptococcal disease, Legionnaires’ disease, Leprosy, Malaria, Measles, Meningococcal septicaemia, Monkeypox, Mumps, Plague, Rabies, Rubella, Severe Acute Respiratory Syndrome (SARS), Scarlet fever, Smallpox, Tetanus, Tuberculosis, Typhus, Viral haemorrhagic fever (VHF), Whooping cough, Yellow fever.

Oedema / Circulatory Problems

Oedema is the build-up of fluids in the body which causes swelling. This commonly occurs in the legs and ankles but can be more generalised. Acupuncture should be used with caution on severely oedematous limbs as fluid may escape from the puncture holes in the affected areas following treatment. This can cause alarm for the patient but more importantly it increases the risk of infection.

I may require consent for treatment from your healthcare practitioner or GP. With severely oedematous limbs the skin loses a degree of its elasticity meaning that any puncture holes from treatment may not “seal” as quickly leaving the patient prone to infection.

Oedema of a single limb may result from a blockage of lymph nodes in which case the affected limb should not be needled. Any case of severe oedema should be regarded as a possible red flag and may require referral for further investigation. Further details on lymphedema can be found above. 

Pregnancy and Trying to Conceive
Including breech presentation, encouraging labour, and post-natal

Acupuncture during pregnancy is safe, effective and a very supportive treatment however some additional training, knowledge and experience is essential to treat this patient group. I consider myself to be a qualified practitioner to treat during pregnancy due to the further training I have undertaken. I will however refer on if I feel a condition is outside my usual scope of practise, and I may require you to visit your midwife or GP before treatment or to gain their consent for treatment, especially so if your pregnancy is not considered low risk. 

There are several red flags relating to serious complications during pregnancy that require referral to your midwife or A & E. They include:
• abdominal Pain • hyperemesis gravidarum (severe nausea and vomiting) • ectopic pregnancy • pregnancy induced hypertension (PIH) • pre-eclampsia and eclampsia (PIH) or haemolysis, elevated liver enzymes, low platelet (HELLP) syndromes • thrombo-embolism • fever with or without rash • genital herpes (in third trimester) • bacterial vaginosis • vaginal leakage • vaginal bleeding • urinary symptoms & premature labour • malpresentations and cord prolapse • oedema • palpitations • pubic symphysis pain (also called pelvic girdle pain) • anaemia (tired, breathless, palpitations) • itching (severe) may be due to cholestasis of pregnancy.

Red flags for the postnatal state:
• fever • postpartum haemorrhage • thrombo-embolism • postnatal depression • postnatal (puerperal) psychosis • insufficient breast milk • sore nipples & mastitis.

Certain acupuncture points are generally omitted from treatment especially in early and late pregnancy, although there is no evidence which shows they need to be omitted. 

Moxa for Breech Presentation

The use of moxa/ moxibustion (heated warming herbs) on Bladder 67 (Zhiyin) for attempting to turn breech babies is a well-documented treatment and its apparent simplicity and non-invasive nature have made it a popular choice for pregnant women to explore before opting for conventional medical procedures. Treating a patient with breech presentation or giving instructions for self-administering treatment at home might be a simple procedure but can carry some risks. Before commencing treatment, it needs to be clear that there are no contraindications to the treatment and consent from the patient’s midwife or obstetric team has been given. Many midwives are now aware of the use of moxa on Bl67 and positively encourage their patients to try this as a first port of call.

Red flags and contraindications to the use of moxa for patients with breech presentation are:

• recent uterine surgery, including Caesarean section • history of any bleeding in pregnancy, antepartum haemorrhage • threatened premature labour • any query about ruptured membranes • any hint of foetal distress • foetal abnormality, any sign of compromised foetus • multiple pregnancy • where Caesarean section is to be performed for other reasons • uterine or pelvic abnormalities, eg uterine fibroids, septum • insufficient liquor (oligohydramnios) or excessive liquor (poly-hydramnios) • significant maternal hypertension, any signs of pre-eclampsia, diabetes, cardiac problems, or thyroid disease • Rh negativity if antibodies present • transverse lie due to possible cord prolapse.

You must sign a written consent form confirming that they have received all the necessary information from myself if you would like to apply home moxa to yourself. The BAcC have produced a patient information sheet and an after-care guidance sheet which I will download for you.

Encouraging the Onset of Labour

Another common reason for women to seek treatment during pregnancy is to encourage the onset of labour or to encourage labour to progress. Some women turn to acupuncture for the first time purely for this purpose whereas some have regular treatment throughout their pregnancy with treatment forming part of their pre-birth care. This must not be done before their full term / due date unless they provide written consent to do so from a consultant or midwife. You will need to gain verbal consent from your midwife if you have reached your due date. 

Treatment before the due date is used as part of a supportive pre-birth treatment plan aimed at preparing the body for labour and nourishing the mother.

I will need to discuss with you the suitability of having acupuncture at this time, which may be dependent on your own health, and if your pregnancy is considered ‘low risk’. If you have not been my regular acupuncture patient in the past or through pregnancy I may not advise treatment for you. We will discuss.

Steroids and steroid injections

The use of corticosteroid injections for muscular-skeletal conditions is common practice because this family of medications have powerful anti-inflammatory effects. With patients often turning to acupuncture for muscular-skeletal conditions it is important that I obtain a clear history of any steroid treatment that has been given. 

Steroid injections may be given directly into a joint or into muscles around a joint. Doctors are reluctant to give more than three injections in a 12-month period because of the potential serious cumulative side effects of treatment which include wasting of muscular tissue, weakening of connective tissues and Immunosuppression.

It is also well recognised that a steroid injection can be followed by a temporary ‘flare’ of symptoms within 24-48 hours after injection. The BAcC recommends not to receive acupuncture within the first few days of steroid treatment because of the potential for symptoms to worsen.

Due to the immunosuppressive nature of steroids, there is an increased risk of infection both in the area where treatment has been given as well as generally. With high dose injections the patient’s immunity can become suppressed so it’s important to take note of this and adjust treatment as one would for anyone who is immune compromised. This means avoiding deep needling (ideally avoiding muscle and joint capsules) and warning the patient to be vigilant for any areas of infection becoming apparent around puncture sites. This is of particular importance when treating a patient within three months of a steroid injection.

If I notice any signs of infection which might be associated with steroid treatment I must refer you for prompt medical attention because there is a risk any infection can progress, especially in an immunosuppressed patient as infection can progress rapidly.

Intravenous or oral dose steroids are also commonplace for the management of long term inflammatory or auto immune conditions and are also used amongst some fertility treatments. It is equally important to be aware of the effects these can have on a patient’s immunity and therefore the increased risk of infection. It is advised when treating patients on corticosteroid treatment to view them as potentially immunocompromised as per the immunocompromised guidance above (swabbing the skin with alcohol swab prior to needling).

Skin lesions and Skin Complaints

A skin lesion is a part of the skin which has an abnormal growth or appearance compared to the normal skin that surrounds it. These can vary from minor pimples to more serious conditions such as ulcers, cellulitis, or cancerous growths. It is important not to needle directly into a pimple, sore, mole, wound, or anywhere near an area of sepsis or any unidentified lump.

If you haven’t already had the area checked, I may need to refer you on for an assessment by your GP. The recommendation is to stay at least two centimetres away from the edges of the red/painful/inflamed area. However, it is acceptable to needle through unhealthy skin as in the case of uninfected eczema. 

Please advise me if you have any infectious skin condition, which may require me to use additional levels of hygiene. 

Massage/ Soft Tissue Therapy Specific Cautions, Current and Historic
Please note, sports and remedial massage is also termed Soft Tissue Therapy.

Anticoagulants/ Haemophilia and other blood clotting disorders

There is an increased risk of capillary damage, bruising and bleeding. Soft tissue therapy needs to be used with a gentle touch, avoiding deep pressure, avoiding compressing tissues against bony prominences, and avoid tape.

Cancer or Receiving Cancer Treatment

Each person responds to cancer and their treatment differently. Client to discuss with their oncology team the intention to add soft tissue treatment into their care programme to make sure that it does not contradict with their medical programme.

Providing soft tissue therapy whilst you are receiving treatment for cancer is not within my personal scope of practise and I am likely to refer you on to a different practitioner. 

Diabetes

Diabetes comes with several risk issues: decreased sensitivity in limbs due to neuropathy, decreased healing ability of the tissues, and affecting blood-sugar levels in similar way to exercise. The practitioner needs to pay careful attention to the client’s pain response and work more gently around distal limb areas.

Neurological Disorders (Motor Neurone Disease, Parkinson’s, MS)

Soft tissue treatment may interfere with a medical care programme, therefore the client needs to discuss this with their medical team.
   
Pregnancy

Pregnancy is not a pathological condition. 

Being pregnant (and after giving birth) increases your risk of DVT, and therefore symptoms of DVT (see above in Acupuncture cautions) shouldn’t be overlooked as being musculoskeletal.

If you have pre-eclampsia it is not suitable to receive massage. Symptoms of pre eclampsia which may be overlooked as being due to musculoskeletal are severe headache and pain just below the ribs.

Some back and musculoskeletal pain may be a pregnancy warning sign which requires your midwife or GP to be made aware of and for them to intervene with correct care if necessary, or to provide you with consent before massage can be utilised.

Side lying is often the best way to achieve comfortable client positioning for massage. 

Massage Specific Local Contraindications
Where massage is not advised in a specific area (massage is suitable in the rest of the body unless contraindicated).

Areas of Acute, Active Inflammation
Signs of inflammation: Swelling, Heat, Redness, Pain, Reduced motion. Massage is not recommended because the area needs to start it’s repair process and should be left alone for at least 6 hours.

Fractures and diagnosed Stress Fracture
Fractures; Bone tissue needs to repair which normally takes around 6 weeks.
Diagnosed Stress Fracture; Working on the area will be painful.

Open Wounds
To be avoided due to risk of introducing bacteria into the system. Special caution with people who are immunocompromised. 

Skin Diseases: Viral, Bacterial, Fungal, Unknown rashes
Massage is contraindicated due to cross contamination risk, and, there is the danger to introduce bacteria and create an infection.

Varicose Veins
The walls of varicose veins are very fragile. Deep pressure can damage them. Massaging them could also increase your risk of DVT. 

General ‘Red Flags’ for Musculo-Skeletal Pain (general muscle/ joints/ bone type pain)
For most people who present with potential signs of a 'red flag', it turns out to be a normal musculoskeletal issue and nothing to worry about.
However, as a holistic health practitioner I can't make that differentiation; we keep our threshold of referral low and leave the medical professionals to take it forward and give you the ‘all clear’ to have or continue to have holistic treatment.   
Musculoskeletal pain which is accompanied by some of the signs and symptoms listed below indicates that there could be a more serious underlying issue, although this is not common. Please speak to your GP, or a more urgent referral as advised below, or let me know below if you've already seen your GP about it. If you're  unsure, get in touch with me and we can discuss.
Please read through the 10 red-flags below 
1. Pain or swelling in one leg or one arm or abdomen (rarely both legs) symptoms in this area of; throbbing or cramping pain and swelling; warm, red or darkened skin; swollen veins which are hard and sore upon touch; feeling generally unwell. (Rule out DVT; urgent GP appointment or call 111. If symptoms of breathlessness or chest symptoms on top of this call 999 or go straight to A&E).
2. Signs of internal infection such as; fever; night sweats; pain at night; swelling; heat around a joint. (Rule out infection inside the body, go to A&E).  
3. Current pain plus a history of cancer in your medical history. (Holistic treatment can take place, but arrange GP appointment to rule out connection to cancer history).
4. Pain which is unrelenting, pain in bed that doesn't really change when you move position, and pain that wakes the person up at night. Pain that doesn’t change with rest or movement. (Rule out a cause other than muscular-skeletal pain).
5. Thoracic pain (pain in the region of the mid and upper back, and inside this internal organ area) which doesn’t have a clear specific source. Especially with a history of cancer, osteoporosis, or after a trauma like a fall or injury. (GP appointment should happen first before having holistic treatment. Rule out a cause other than muscular-skeletal pain).
6. One side or both sided nerve type symptoms in legs PLUS; bladder or bowel disturbance or reduced anal tone or sensation or reduced genital sensation. (Urgent referral to A&E to rule out cauda equina)
7. Neurological symptoms (brain, spinal cord, and other nerves) such as changes in sensation, movement control, both sided pins and needles, dizziness, double vision, new unusual or severe headaches. (Urgent referral to GP, and if life threatening call 999. Rule out a neurological condition).
8. Stiffness first thing in the morning lasting more than 30 min, pain at night especially second part of the night. These signs can be indicative that there is an inflammatory or autoimmune source to the pain. (Urgent referral to GP so they can rule out inflammatory/ autoimmune condition).
9. Neck pain with dizziness or feeling light-headed when turning the head to the left or right. This could indicate a restriction in the cervical artery. (This is an immediate and urgent referral to A&E to rule out cervical arterial dysfunction).
10. Bilateral (both sided) shoulder pain which has come on quickly plus temporal headaches/ or plus tongue or jaw pain whilst chewing, plus age 50+. (Immediate referral to A&E to rule out giant cell arteritis).

 

References

Institute of Sports and Remedial Massage (2023) Important Safety Information for Massage and Soft Tissue Therapists, https://www.theisrm.com/pdf/Safety-leaflet.pdf 

The British Acupuncture Council (2023) The Guide to Safe Practice for Acupuncture

March, J (2021) Rheumatology from a Soft Tissue Perspective. Online Seminar.