Can Acupuncture Help for Chilblains

Abstract

Objectives: This study was undertaken to investigate the cold weather skin condition; Chilblains and to see how UK acupuncturists interpreted the diagnosis and treatment. Through investigation the objective was to see if a particular diagnosis and treatment stood out and could be provided as a contribution to the profession. The study explored both the Western and Chinese Medicine interpretation of the pathology and treatment of chilblains.

Method: 350 Acupuncture practitioners were contacted via email with an online questionnaire. Of the 350, 49 questionnaires were completed providing a response rate of 14%. The questionnaire asked practitioners about their experience of treating the condition, their understanding of the condition and the way in which they would approach treatment. A literature review was also conducted, both of Western medicine and Chinese medicine.

Results: The results showed that UK acupuncturists had minimal experience of treating the condition. Of 49 completed questionnaires only 9 had treated a patient in the last 12 months for chilblains, 27 answered that they have never treated a patient for chilblains leaving 13 participants that have treated chilblains but not within the last 12 months. With regards to the condition, from a Chinese Medicine perspective it was shown that the pathology of the condition started with Cold, either from a Full External Invasion or from Empty-Cold due to deficient Yang. This depended on the individual patient. Treatment with both Acupuncture and Moxa proved to be conducive at restoring Heat in the body and improving circulation which would be preventative of chilblains developing into latter stages. As the condition progressed, practitioners felt that acupuncture was incrementally less effective.

Conclusions: Data gathered via the questionnaire and the literature review highlighted that there are implications for the profession. There is an opportunity to raise awareness amongst practitioners and in turn bring this awareness to the public with the opportunity to treat and prevent chilblains for many more people. Future work in the field could involve carrying out clinically controlled trials on people who suffer from Chilblains with the intention of validating the opinions of acupuncturists and formulating more specific treatment plans for the condition.

Introduction

Research Question

How do Acupuncture practitioners in the UK diagnose and treat Chilblains?

Significance and Rationale for Research

Following problems with her toes in cold climates my partner had a consultation with a Podiatrist who diagnosed her condition as Chilblains. As I could see from her experience, the condition can cause a lot of pain and great discomfort in the cold weather. She explained that her toes felt like they were burning and needed to be cushioned from each other. The friction caused by the toes touching each other was painful and causing her skin to become red and tender. She also developed a blister under her skin on one of her toes.

Following my initial internet based research I could see that fortunately she was only experiencing relatively mild symptoms on the spectrum of the condition. The podiatrist also explained that (from a western medical perspective) there is very little that can be done apart from managing the condition to try and prevent signs and symptoms from arising. He also explained that it is a condition that as many as 1 in 10 people in the UK suffer from at some stage in their life. This statistic is confirmed by Patient.info (2016).

The rationale for undertaking the study is that there is apparently very little existing literature on the subject of treating Chilblains with Acupuncture. This study will review all literature found on the subject following a thorough search both online and in libraries.

From the initial light internet based research I could see that the condition is significantly related to blood circulation, AlMahameed. A (2008). This explanation led me to question if Acupuncture could be an effective treatment and that further research was warranted on the subject.

Objectives and Intentions

The research contained within is being conducted with the intention of analysing the current understanding of the condition Chilblains amongst Acupuncturists in the UK practicing today. Following the research section of this study the intention is to contribute to Acupuncture practitioners’ knowledge of Chilblains, including the pathology, diagnosis and treatment of the condition. This will be done by means of both a questionnaire sent to UK Acupuncture practitioners and a literature review of the existing documented knowledge.

The results of the questionnaire will provide the profession with information on the approximate number of people being treated for the condition. Comparing these numbers to the approximate number of people in the UK suffering from chilblains will highlight if there is an opportunity for patient number growth in clinics via advertising treatment for the condition.

The questionnaire is also designed to both raise and analyse practitioners’ current awareness of the prevalence of Chilblains in the UK population today. This will be achieved by including information in the questions and asking the participants if they are aware of the information contained within.

A further objective from the information obtained in the research is that a best practice for successful treatment might become apparent and practitioners will be able to refer to it when approached with the condition.

Practitioners will also be able to refer to the study if they require differentiation of cold weather skin conditions when presented with them by patients.

Method 1.    Literature Review.

Western Medicine interpretation of Chilblains

Chilblains (Pernio) is Vasospastic disorder which affects areas of skin exposed to cold and damp, but not freezing conditions. AlMahameed. A (2008). Chilblains can either be a chronic or acute manifestation which affects the extremities of the body including the tip of the nose, earlobes, fingers and toes. There are also cases where chilblains manifest on thighs and buttocks. Weinberg. I (2011).  It is an idiopathic condition with signs typically occurring 1 – 5 hours after prolonged exposure to cold damp air. Mooney.J (2009) breaks down the stages of Chilblain manifestation into the following categories.

Table 1. Stages of Chilblains

Initial Cold Phase: Whilst Mooney. J describes the initial cold phase areas of the skin as becoming Cyanosed, attention should be drawn to the research that shows the initial discolouration as red. On review of images and literature, red colouring could be seen to be more common although Cyanosis is also documented.

Image 1. Redness

Image 2. Cyanosis

Acute Inflammatory Chilblains

Image 3.  Acute Hand                                  Image 4. Acute Nose

Image 5. Acute Buttock

Chronic Inflammatory Chilblains

Image 6. Chronic

Broken Chilblains

Image 7. Broken

The pathophysiology appears to be uncertain although it is believed that patients presenting with the condition have a disruption of neurovascular responses to skin temperature change. Rosenbach.M Et al (2016). It is more common in Women than Men and a low Body Mass Index (BMI) adds increased risk. Poor circulation also increases the susceptibility to the condition.

Treatment for Chilblains using Western Medication

Nifedipine

Nifedipine is a calcium-channel blocker prescribed in the treatment of Raynaud’s phenomenon and Chilblains. Its action is to block the amount of calcium that goes into the muscle cells in the walls of your blood vessels. Calcium is needed for muscles to contract, so reducing the amount of calcium causes the muscle cells to relax and therefore can be used to increase the amount of blood that travels to your extremities. Allen. H (2014)

Diltiazem

Diltiazem is also a calcium channel blocker. Palamaras L and Kyriakis K (2005) explain why calcium antagonists including Diltiazem have been used for the prevention and treatment of various dermatologic diseases such as chilblains. “Calcium antagonists (CAs) or calcium-channel blockers are a common group of antihypertensive medications. These drugs have the property of blocking the calcium channels of vascular and cardiac smooth muscle fibers. Some of these drugs may inhibit the growth and proliferation of vascular smooth muscle cells and fibroblasts, and inhibit the synthesis of extracellular-matrix proteins (collagen, fibronectin, proteoglycans). Other CA’s also have immunomodulatory or dysregulatory effects on lymphocytes and can suppress superoxide generation and phagocytic action of neutrophils. Moreover mast cell degranulation and platelet aggregation may also be impaired.”

Comparing Medications

Patra AK Et al (2003) conducted a study of 36 chilblain patients to test the efficacy of Diltiazem against Nifedipine.

Results showed that Two patients in Group A (treated with diltiazem 60 mg thrice daily) showed complete relief in 7 days, and 3 patients in about 21 days. In 7 cases there was little or no response. In group B (24 patients with 10 mg nifedipine thrice daily),  21 cases showed 80-90% relief by the fourteenth day. The conclusion was that Nifedipine remained the medication of choice for chilblains.

Souwer Ibo H. Et al (2016) conducted a randomised, placebo-controlled, double-blind, crossover trial, testing the effectiveness of Nifedipine against Placebo for the treatment of chronic chilblains. Their results showed that nifedipine was not superior to placebo for treating chronic chilblains and also that Nifedipine was associated with significantly lower systolic blood pressure and a significantly higher incidence of edema.

The trial replicated the work of Rustin M. Et al (1989) whose study concluded that Nifedipine was more effective than Placebo, and according to Souwer Ibo H. Et al (2016) was contributory to the prescription of Nifedipine to this day.

Differentiation of Cold weather skin conditions

Raynaud’s Disease 

(Also commonly referred to as Raynaud’s Phenomenon) is a condition that is thought to affect approximately 10 million people in the UK. Scleroderma & Reynaud’s UK (2016).

Stephenson (2011) explains that with Raynaud’s the muscular walls in the small vessels of the fingers and toes spontaneously go into spasm which cuts of the blood supply to that area. The result is that the fingers or toes turn purple or blue in colour and then white. They can feel numb and painful and it can last up to a few hours. If the attacks are prolonged or occur frequently the tissues of the fingers or toes can be damaged by the reduced blood supply.  The cause of Raynaud’s is unknown. If it appears as part of an underlying multisystem autoimmune disease then vasculitis is an underlying cause. This presentation is often referred to as Secondary Raynaud’s and requires further medical attention. Scleroderma & Reynaud’s UK (2016)

Treatment for Primary Raynaud’s is fundamentally based on management of exposure to cold temperatures and lifestyle. Not smoking and eating well are also important factors. Medicine Net.com (2016)

Treatment for Secondary Raynaud’s can include prescribed Nifedipine (see Chilblains Medication for detailed description of Nifedipine) or even surgery in rare cases. Stephenson (2011) states that the surgical approach is called a “sympathectomy” and involves damaging the nerves that cause constriction of the blood vessels. Performed by injection at the site on the neck where they leave the spinal cord.

Image 8. Raynaud’s

Frostbite

Murphy. J Et al (2000). Frostbite is defined as “the acute freezing of tissues when exposed to temperatures below the freezing point of intact skin.” The two defining factors relating to the severity of the injury are the temperature the tissue is exposed to and the duration of the exposure.

Whilst it might seem relatively simple to differentiate between frostbite and other cold weather skin conditions, the initial stages of frostbite do hold similarities that could complicate the diagnosis.

Image 9. Frostbite

Frostnip causes an irritation that can feel like a prickling sensation, followed by reddened skin and numbness. The cold has only penetrated the epidermis level of the skin. The next stage is superficial frostbite. At this stage the cold has reached the dermis layer of skin and after the skin has thawed blisters may appear. The feeling of heat will be present in the affected area. The final stage is deep frostbite where by the skin turns black and dies after thawing. The cold has penetrated down to the subcutaneous tissues. Numbness occurs and the muscles and joints can also be affected and may no longer work. Amputation might be necessary after this stage.  Mayo Clinic (2014)

Image 10. Superficial Frostbite

Image 11. Deep Frostbite

Cold Urticaria (Also known as Cold Hypersensitivity, Familial Cold Autoinflammatory Syndrome)

The term Urticaria derives from the Latin term for stinging nettles and has been used to describe a reaction by the skin that is similar to that after exposure to a nettle sting. The reaction manifests in the form of wheals, these are areas of raised skin that initially appears paler than the surrounding area, they might itch or sting. Stephenson C (2011).

The U.S National Library of Medicine (2014) States that symptoms are usually experienced after an hour of exposure to the cold; however it can occur in any amount of time leading up to that depending on the individual. On warming it can then disappear as quickly as it arrived.

Image 12. Cold Urticaria

Stephenson (2011) explains that urticaria is the result of a rapid dilation of the dermal blood vessels. When this happens excess fluid can pass from the blood to the surrounding skin tissues and results in the oedema.

Chinese Medicine interpretation and pathology of Chilblains

Chilblains has been mentioned in relation to Chinese Medicine as far back as 265-420 CE in the Jin Dynasty when Huang-fu Mai wrote “Scant Blood and abundant Qi result in flesh which is susceptible to chilblains “. Yang S and Chance C (1994). This particular description is in part contradictory to the majority of other documents this research has found on the subject as they all describe the Qi to be deficient as opposed to abundant.

In an article written for the South China Morning Post, Tse. R and Eagleton. J (2009) state that chilblains are a result of an invasion of cold with an underlying deficiency of Blood and Qi. Therefore being both a result of an internal and external pathology. They explain that Blood and Qi deficiency lowers the resistance to external cold and that remedies and prevention should aim to ensure that Blood and Qi flow to the extremities. They continue by describing that in cold environments blood vessels close to the skin can constrict to conserve body heat. If the peripheral circulation is not flowing smoothly then the extremities can be starved of blood and warmth. If these areas are then exposed to heat it can result in localised vascular inflammation and Chilblains can occur.

China Association of Research and Development of Traditional Chinese Medicine (2012) state that Chilblains are a result of an invasion of cold which has caused an obstruction of local Blood circulation. They state that Traditional Chinese Medicine theory diagnosis explains this condition as being a result of Yang Qi deficiency and Blood deficiency, causing poor resistance to the invasion of cold.

CICM (2012) concur with this aspect of Chilblains pathology as they describe the pathology of cold extremities to be deficient Heart Yang not transporting Blood to the extremities to warm them.

In her database of Chinese herbal remedies Scott .F (2016) also describes the indications of chilblains to be Qi and Blood Deficiency with a predisposition to Cold and Dampness. It is also stated here that the skin is deprived from warmth and Yang Qi.

The China Association of Research and Development wrote an article in conjunction with the Shanxi Province Hospital (2012) discussing the use of moxibustion in the treatment of chilblains.  In the article they describe chilblains to be a combination of the invasion of Cold Damp and Yang Qi / Blood deficiency.

The previously cited information from Chinese Medicine sources holds a common theme that the pathology of chilblains can be related to different types of Cold. A combination of either an invasion of exterior Cold or a manifestation from internal Cold as a result of weak Yang Qi. Cold can be either interior or exterior, it can also be Full or Empty.

Diagram 1. Cold Pathology

The diagram above by Maciocia (2005) shows how both the External Cold injures Yang and pre-existing Yang Deficiency leads to Empty Cold. Both of which can be the pathology of chilblains.

In Chinese medicine theory Cold can cause disease when coming from an external source, in the case of chilblains it is highly likely the climate that is the source. Examples of other sources of external could be air conditioning, cold drinks or swimming in cold water. Maciocia (2005) explains that on occasion when the equilibrium between the body and the environment breaks down, the climate can affect the harmony of the body and cause disease.  This is either because the weather is excessive or because the body is too weak to defend itself against an aggressive climatic factor. Four main types of invasion of external Cold can be identified.

1. Cold can invade the exterior spearheaded by Wind. This leads to symptoms including an aversion to cold, sneezing, watery mucus, fever, lack of thirst and a runny nose.

1. Cold can invade the joints and channels’, causing what is defined as Painful Obstruction Syndrome. This pain is often in one joint.

1. Cold can invade the muscles and sinews which will cause stiffness and pain in the area of the invasion.

1. Cold can invade the organs directly.

Internal Cold can be both full or empty. If it is full it has come from an invasion as mentioned above. If it is Empty-Cold then it has come from a deficiency of Yang. This has usually derived from the Kidneys, Spleen, Stomach, Heart or the Lungs. A deficiency of Yang in each Organ results in its own signs and symptoms however deficient Yang by nature results in Empty-Cold.

As well as Full-Cold remaining in the body and injuring Yang, deficient Yang Qi can also be caused by excess consumption of cold foods, overwork or excessive physical activity.  Maciocia (2005).

Treating Chilblains with Chinese medicine.

Acupuncture 

Following an extensive search there is very little literature on the actual treatment of chilblains with acupuncture so this study has also reviewed literature on the effects acupuncture has on circulation. This is because a key contributory factor in the pathology of chilblains is circulation of blood to the extremities during exposure to cold

Xiang. F Et al (2005) of the Yongshun County Hospital of TCM, conducted clinical observations on 136 cases of chilblains treated with acupuncture (combined with massage). At the same time 128 different cases were treated by Dong Chuang Plaster which the authors classed as medicine. The acupuncture group were treated on 9 acupuncture points including Du 15, Pericardium 8 and Spleen 6, (the available summary of the observations does not include the other 6 points used) they were also given massage. The results found that in the acupuncture group 111 cases were cured and all 136 cases improved. In the group given the Dong Chuang Plaster 55 cases were cured and 98 cases improved.

The Yorkshire Foot Hospital (2016) advertise that acupuncture can be used to improve blood flow which can promote healing. They state that acupuncture can help with poor circulation to the toes (chilblains and Raynaud’s disease).

Shing Ni .M (2015) describes the use of acupuncture to increase circulation for cold hands and feet. To promote warming Yang energy Shing Ni explains the use of acupuncture points of Large Intestine 4 and Liver 3. Shing Ni states that Large Intestine 4 will unblock energy and relieve Blood stasis and that Liver 3 will release all types of blockages.

Tsuchiya Et al (2006) studied the effects of acupuncture on local Nitric Oxide levels and circulation in a randomized, double-blind, crossover study with 20 volunteers. This study was actually completed to measure acupuncture and the development of pain however it can be cited in this instance because of the relevant information contained within. The researchers state that increased nitric oxide synthase activity has been found in meridians and acupoints and due to the fact that nitric oxide is a key regulator of local circulation it is relevant in the development of chilblains. Each volunteer had one session of real acupuncture and one session of sham acupuncture in a single hand and forearm. The acupuncture points used were Large Intestine 4, Pericardium 6, Pericardium 8, Lung 6, and Heart 5. The participants had a one week interval between treatments. The results showed that Blood flow in palmar subcutaneous tissue of the acupuncture arm increased in correlation to an increase in nitric oxide. These changes were not observed in the sham acupuncture hands and forearms. They concluded from this study that acupuncture does increase local circulation.

Moxibustion

Alongside Acupuncture the research has found that Moxibustion is also used in the treatment of chilblains. Moxibustion is the use of burning the herb Mugwort on or close to the body for the purpose of healing. The mugwort is first processed into a powder or rolled into a stick for controlled burning and application. Mugwort leaves are harvested and dehydrated before being ground and winnowed to make the final product ready for use. Rouho K. (2016).

Moxa is used in two different ways, direct or indirect application. Direct application is done by placing small cones of moxa on acupuncture points and burning them down, removing them before the skin is burnt. In some cases the cones are left on the skin until they burn out but this often causes scarring so it is not commonly used in the UK. For indirect moxa application the moxa stick ( a cigar sized stick ) is lit at one end and held close to the area being treated for several minutes. It can also be used by placing the moxa on the end of an acupuncture needle that has been inserted into a point. The moxa is then lit and the heat travels down the needle into the acupuncture point. Acupuncture Today (2016).

The China Association of Research and Development (2012) describe that Indirect Moxa should be used in the treatment of chilblains. They suggest to first rub the skin in the area of application for a few minutes then hold the moxa stick locally to the area of early stage chilblains for 15 to 20 minutes per day, once a day for 15 days. Allowing the heat from the moxa to enter the channels from the fingers or toes and promote conduction of heat and circulation. The article written discussing the treatment has been translated from Chinese and is in some areas not completely clear. However we can see from the following quote that the intention is to improve local circulation, prevent vasoconstriction, clear Damp and promote the flow of Blood and Qi. ” combined with chilblain local mild moxibustion to improve local organization microcirculation and neurotrophic function, reduce local blood capillary permeability and restore body local nerve vascular normal functions, the dampness around the gas wipe out, to the general principles of the general principles of the pain, not is swollen, remove stasis born new, remove stasis raise blood, chilblain will naturally disappear.”

Method 2.   Questionnaire

To gather data on the experience and knowledge of Chilblains by Acupuncturists practicing in the UK, the method of a questionnaire was used.

The questionnaire was designed and then piloted by asking three practitioners to complete and review it. All three practitioners replied with no suggested changes to the questionnaire so their answers were incorporated into the results with the rest of the field.

When the final draft was completed it was distributed to 350 practitioners from across the UK. The practitioners were all found using online search engines and contacted via email. There were no constraints to specific styles of acupuncture or membership to professional bodies.

Ideally there would have been no upper limit to the number of practitioners contacted as the design of the study meant that more data would have contributed to the results. The number of practitioners contacted was eventually limited to 350 due to the time constraints of the study.

49 practitioners completed the questionnaire resulting in a response rate of 14%.

A questionnaire was used for the following reasons.

• Information can be gathered from a large number of practitioners within the timeframe given to complete the study.
• The quantitative aspects of the research can be fulfilled effectively with the use of a questionnaire.
• It is a practical method as practitioners can complete the questionnaire in their own time and with no pressure.
• Qualitative information can be gathered and used to add to the existing knowledge base and have implications for the profession.
• Using the method of interviews or case studies would be too limited to answer the question the study is posing. These methods would only represent the results and experiences of a few practitioners and this data would not be valid as a representation of the populous.

Results and Analysis

Questionnaire Question 1:

From the 49 completed questionnaires, 9 practitioners had treated a patient for Chilblains within the 12 month period.  18.4% of practitioners.

The fact that only 9 practitioners had actually treated a patient for Chilblains within the previous 12 month period means that 81.6% of all of the following questions could have possibly only been answered from a viewpoint of opinion instead of experience. There is however the possibility that practitioners had treated patients for chilblains before but not in the previous 12 months that the study covered. To make the study more reliable the option to report that they had treated patients for chilblains outside of the timeframe should have been available.

The questionnaire does however give the participants the opportunity to state this in question 9 where “I have never treated a patient for chilblains” is an option. 27 participants chose that option. Therefore from the 49 completed questionnaires, 9 answered that they had treated a patient in the last 12 months for chilblains, 27 answered that they have never treated a patient for chilblains which leaves 13 participants that have treated chilblains but not within the last 12 months.

The analysis did not set out to separate the answers and differentiate between experience and opinion but on reflection the separation of results could be a direction for further investigation.

Question 2:

49 Practitioners treated a total of 1003 patients per week within the 12 month period. An average of 20.5 patients per week per practitioner. The range being from 0 – 50 patients per week.

Question 3: 

Do you feel that without conducting any research you recognise the signs and symptoms of Chilblains?

Chart 1.

For question 3, 16 out of 48 practitioners answered that they do not recognise the signs and symptoms of chilblains.

An aspect of this question that could render these results invalid is that this only shows that these practitioners are not able to label the signs and symptoms as the Western term “chilblains”. They may however diagnose the condition using Chinese Medicine terminology such as an Invasion of Cold, or Yang Qi deficiency with Blood stagnation. From that diagnosis they would then go on to treat the condition.

Question 4:

Do you feel confident that without conducting further research you could differentiate between cold weather skin conditions such as Chilblains, Raynaud’s Phenomenon and Frostbite?

Chart 2.

The analysis for question 3 is also valid for question 4 where 24 out of 48 practitioners do not feel confident that they could differentiate between cold weather skin conditions such as Chilblains, Raynaud’s Phenomenon and Frostbite. Again the questionnaire could have asked the same question but replaced the Western terminology with Chinese Medical terminology. As many practitioners are working from a Chinese Medicine perspective this would have given a more accurate picture of their understanding of cold weather skin conditions presented to them.

Question 5: Are you aware that as many as 1 in 10 people in the UK suffer from Chilblains at some stage in their lives?

Chart 3.

29 out of 48 practitioners were not aware that as many as 1 in 10 of the UK population will experience Chilblains at one time in their lives.

Question 6: 

Which of the following pathologies do you feel are most commonly associated with Chilblains?

Chart 4.

Table 2

The results to question 6 represent the practitioners opinion of the pathology of chilblains. The majority of options chosen represent the pathology of chilblains to be a full condition rather than a deficiency. Cold Obstructing the Channels represents 67.39% of all options chosen. The obstruction of Cold could come from a deficiency of Yang and Qi stagnation but when considering this and looking at the results on the table it would be expected that Yang Xu would have been selected an equal amount of times to Cold Obstructing the Channels. Yang Xu in fact only represented 19.57% of the selections. Invasion of Cold was the second highest selected choice representing 56.52% of the selections. This again is an External Full condition.

Invasion of Wind Cold was also chosen more times than any of the deficient patterns.

From these results it is very clear that in the opinion of the Acupuncture practitioners who completed the questionnaire Chilblains are a result of an External Invasion and is a Full-Cold condition.

Question 7:

For the following stages of Chilblains, please rate how effective you consider Acupuncture to be as a form of treatment.

Phase 1. Initial cold phase: Affected areas of skin are very cold, pale and cyanosed

Phase 2. Acute inflammatory chilblains: Affected areas become acutely inflamed, tender, itchy and burning with associated local oedema or blistering (i.e. hyperaemic)

Phase 3. Chronic inflammatory chilblains: Affected areas show chronic inflammation

Phase 4. Broken ulcerative chilblains: The skin breaks down as the result of the severity of the initial chilling and subsequent acute inflammatory response; the chilled areas weep serous fluid and are at risk of infection.

Chart 5.

Table 3.

From the results of question 7 the study shows that the majority of practitioners believe Acupuncture is effective at treating the first three phases of chilblains. The chart also shows that practitioners believe acupuncture is only mildly effective as chilblains move through to the final phase of the condition.

This question shows that in the opinion of the participants Acupuncture is gradually less effective at treating chilblains as the symptoms of the condition develop through the phases. When chilblains reach the final phase of the condition the majority of participating practitioners believe that Acupuncture is only Mildly to non effective as treatment.

Question 8: A key pathology of Chilblains is poor circulation to the extremities, how do you treat this condition?

Chart 6

Table 4

As Question 8 is an open question with qualitative answers, Chart 6 shows the frequency that each word is used and Table 4 groups them into categories for quantitative analysis.

The results show the influencing Blood either by Warming, Tonifying, Nourishing or Moving has been quoted the most times in this question as treatment for poor circulation to the extremities. Next 5 Element acupuncture and the use of Moxa feature as the most quoted forms of treatment.

Question 9.

In addition to acupuncture do you use any of the following Chinese Medicine treatments when presented with chilblains by a patient?

Chart 7

Table 5

The response to question 9 shows that Moxa is significantly the most used treatment in addition to acupuncture.

Question 10

Whilst it is understood that each individual patient is different, are there any common areas of lifestyle advice that you would recommend to patients with chilblains?

Table 6.

Question 10 was an open question allowing for a qualitative response. From the answers it is clear that Diet is regarded as the key influential aspect of lifestyle that practitioners would discuss with their patients regarding chilblains. Warming and Nourishing were the adjectives used to describe the nature of the diet needed.

Following that exercise and appropriate clothing were mentioned to be of equal importance.

Interestingly there was only one answer for avoiding rapid temperature changes. This might show that there was actually limited understanding of the condition amongst the practitioner population due to the rapid temperature changes being a catalyst for Chilblains to develop.

Discussion

Carrying out this study has formulated the only documented collective opinion on cold weather skin conditions from the population of UK based acupuncture practitioners. It has compared their opinions with historical literature and drawn comparisons and contrasts with the limited literature on the subject of chilblains.

Following the results of the questionnaire the study has been able to bring clarity and answer some aspects of the research question. The research question asked how acupuncture practitioners in the UK diagnose and treat chilblains.

Firstly the study shows practitioners in the UK have had very limited experience of treating Chilblains with Acupuncture. This resulted in very little valid data coming from experience. Due to the design of the questionnaire there was no separation between actual experience and opinion which meant that overall the results could only be viewed and used from the perspective of opinion. If the survey were to be redesign and carried out again then this separation of experience and opinion would be very useful for more detailed analysis.

The study showed that practitioners thoughts about diagnosis and treatment are based mainly on simplifying the condition into Chinese Medicine syndromes and drawing conclusions from there. From this viewpoint at the stage of diagnosis practitioners would be able to differentiate and work out the pathology of the presentation.

For example the questionnaire shows that the majority of practitioners think that the pathology of Chilblains is predominantly the result of an Invasion of Cold rather than the development of Empty Cold from Yang Xu. This shows a contrast to the literature research which describes that Chilblains can be a result of either. When in practice an Acupuncturist would be making a detailed diagnosis so it is at that stage where more information is available that they would be able to differentiate between pathologies. When the correct pathology has been established the practitioners are then able to treat the underlying cause of Chilblains.

The limited experience in the field could be due to lack of promotion of the treatment for the condition as the majority of practitioners were not aware that so many people in the UK suffered from chilblains. This aspect of the study could have implications for the profession because it is likely that the 60% of practitioners who were not aware of this statistic are not actively investing as much time promoting the profession for treatment of this condition. With more practitioners aware of these statistics the awareness of chilblain sufferers can grow and have an impact on the profession.

Another area where the results could have a contribution to the profession is shown in the answers received to Question 3. The results to question 3 conclude that there is an opportunity to educate practitioners on the Western Terminology to match their Chinese Medicine

Diagnosis. The application of this education could be used in communication with Western Medicine practitioners and also communication with patients who are using Western terminology.

Question 9 shows that Moxa is considered to be the most effective treatment in conjunction to acupuncture. This has coherence with the literature review as although it only came from one source it was documented that moxa can be used to generate heat in the body for application in these circumstances.

Comparing the methods used in this study it is clear that the questionnaire contributed more to answering the research question. This is due to the fact that there is very little literature from UK specific sources and that the literature actually used in the review mainly came from China. The literature review did not contribute to answering the question directly. It did however contribute to the study by providing a detailed basis for comparing and contrasting the results from the questionnaire. Completing both a Western and Chinese Medicine literature review provided a foundation for the questionnaire and could also be used as reference for a practitioner if presented with the condition. Interestingly there was very little mention of chilblains on practitioners websites even though there are often areas on practitioners websites with lists of conditions treated.

As a consideration for future research practitioners could be identified who have actual clinical experience treating patients in the UK with Chilblains. Ideally patient notes could be studied to identify diagnosis and treatments. These could then be analysed and it would offer an insight into real practice diagnosis, treatments and outcomes.

Conclusion

This study has investigated and concluded that the UK practitioners who contributed to this study have (based on a percentage of all treatments given) limited experience actually treating chilblains with acupuncture. Due to this when presented with a hypothetical patient in the form of a questionnaire they are using differential diagnosis to find out the pathology of the presentation and work out their treatment from that information.

The results of this study can therefore only be taken as opinion especially considering that the volume of answers to the questionnaire are not based on actual direct experience. The collective opinion however has brought to light common patterns of thought which should be given attention by practitioners when sourcing information regarding treating chilblains with acupuncture.

They believe acupuncture can be highly effective in the treatment of chilblains up to the secondary stages however they also believe acupuncture is less effective in relativity to the development of the condition into its latter stages. As the condition develops into its final stage 75% of the acupuncturists believe that treatment with acupuncture is only mildly to non effective.

Both the literature review and the questionnaire agreed that Chilblains develop as a result of Cold either invading from an external source or arising as a pathology of Yang deficiency. The majority of practicing acupuncturists felt that the External Invasion was the main pathology with the literature review giving more emphasis on the development of chilblains due to Yang deficiency.

Moxa was mentioned with significance in both research methods as a very effective adjunct to acupuncture. The introduction of Heat (via Moxa stick) into the channels helps improve circulation and bring Blood and Qi to the extremities, treating and preventing chilblains.

When comparing the questionnaire results to the Western medicine literature review it was clear that there was limited awareness from the practitioner populous regarding the fact that rapid change in temperature from cold to hot is a catalyst to bring on the latter stages of chilblains.

Data gathered via the questionnaire and the literature review highlighted that Acupuncturists are not aware of the volume of people in the UK suffering from Chilblains. This implies that the profession has the opportunity to raise awareness amongst its practitioners and in turn bring this awareness to the public with the opportunity to treat and prevent chilblains for many more people.

Drawn from the information gathered within this study, the flow chart below shows the steps that practitioners could take when treating a new patient who potentially has or could develop Chilblains.

Diagram 2. Diagnosing and developing a treatment plan for Chilblains.

Future work in the field could involve carrying out clinically controlled trials on people who suffer from Chilblains. The opinions of practitioners and the information gathered in this literature review could be used in a clinical trial to help test and formulate specific treatment plans for the different stages of chilblains.

References

Acupuncture Today (2016) Moxibustion [seen online] Available at: http://www.acupuncturetoday.com/abc/moxibustion.php [Accessed November 2016]

Allen. H (2014) Nifedipine  [seen online] available at: http://patient.info/medicine/nifedipine [accessed Oct 2016]

AlMahameed. A ( 2008 ) Cardiovascular Medicine : Pernio ( Chilblains ) [seen online] available at: http://link.springer.com/article/10.1007/s11936-008-0014-0 [accessed May 2016]

College of Integrated Chinese Medicine (2012) Theory Handouts  Reading, Uk

China Association of Research and Development of Traditional Chinese Medicine. (2012) Mild Moxibustion can Effectively Prevent and Treat Chilblain [seen online] available at: http://www.cngjzj.com/eng_content.asp?id=20683 [accessed May 2016]

Huang-fu M. Et-al (1994) The Systematic Classic of Acupuncture and Moxibustion. Blue Poppy Enterprises, Inc. New York

Image 1.Redness & Image 2. Cyanosis. Disease Doctor (2015)Chilblains, pictures, causes, symptoms, home remedies and  treatment [seen online] available at:http://diseasesdoctor.com/chilblains-pictures-causes-symptoms-home-remedies-treatment/ [accessed May 2016]

Image 3. Acute Hand, Image 4. Acute Nose. Derm 101 (2016) Pernio / Chilblains  [seen online] available at: http://www.derm101.com/therapeutic/perniochilblains/  [accessed May 2016]

Image 5. Acute Buttock. Alves.J Et al (2015) Idiopathic perniosis of the buttocks and thighs – clinical report Dermatology Online Journal. 21 (1) :3 [seen online] available at:http://escholarship.org/uc/item/22k2t70z [accessed May 2016]

Image 6. Chronic. Health Direct Australia (2015 ) Chilblains [seen online] available at: http://www.healthdirect.gov.au/chilblains [accessed May 2016]

Image 7. Broken. Schiazza .L ( 2015 ) Chilblains [seen online] available at: http://www.lucianoschiazza.it/documenti/Chilblains_eng.html  [accessed May 2016]

Image 8. Raynaud’s. Medicine.net (2016) Raunaud’s Phenomenum  [seen online] available at: http://www.medicinenet.com/raynauds_phenomenon/page4.htm   [accessed Sept 2016]

Image 9. Frostbite. MayoClinic ( 2016 ) Stages of Frostbite  [seen online] available at: http://www.mayoclinic.org/diseases-conditions/frostbite/multimedia/img-20114490 [accessed Nov 2016]

Image 10. Superficial Frostbite. Nhs ( 2016 ) Frostbite  [ seen online ] available at: http://www.nhs.uk/conditions/Frostbite/Pages/Introduction.aspx [ Accessed Nov 2016 ]

Image 11. Deep Frostbite. Crawford .C (2015) Emergent management of Frostbite [ Seen Online ] Available at:  http://emedicine.medscape.com/article/770296-overview [ Accessed Nov 2016 ]

Image 12. Cold Urticaria.  Health Guidence ( 2016 ) Cold Urticaria  [Seen Online] Available at: http://www.healthguidance.org/entry/16013/1/Cold-Urticaria.html [Accessed Nov 2016]

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Murphy. J Et al (2000) Frostbite: Pathogenesis and Treatment  Journal of Trauma-Injury Infection & Critical Care: Vol 48 – Issue 1

Palamaras L and Kyriakis K ( 2005 ) Calcium antagonists in dermatology: A review of the evidence and research-based studies Dermatology Online Journal 11 (2): 8 [seen online] available at:http://escholarship.org/uc/item/0tn2c4np  [accessed May 2016]

Patra AK Et al (2003) Calcium antagonists in dermatology: A review of the evidence and research-based studies Indian Journal of Dermatology, Venereology and Leprology 2003 May-Jun;69(3):209-11. [seen online] available at: https://www.ncbi.nlm.nih.gov/pubmed/17642888  [accessed Oct 2016]

Patient.info (2016) Chilblains [seen online] available at:  http://patient.info/health/chilblains [accessed May 2016]

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Scleroderma & Reynaud’s UK ( 2016 ) What is Raynaud’s [ seen online ] Available at: https://www.sruk.co.uk/raynauds/what-raynauds/ [Accessed Nov 2016]

Scott .F (2016) Chilblain [seen online] Available at: http://www.tcmassistant.com/symptoms/chilblain.html [Accessed Nov 2016]

Shanxi Province Hospital. 2012 Article ai mild moxibustion can effectively prevent and treat chilblain Traditional Chinese Folk Medicine Research and Development Association [seen online] Available at: http://www.cngjzj.com/eng_content.asp?id=20683 [accessed March 2016]

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Stephenson .C (2011) The Complementary Therapist’s Guide to Conventional Medicine

London: Churchill Livingstone

The Medical Dictionary Farlex ( 2016 ) Vasospasm  [seen online] Available at: http://medical-dictionary.thefreedictionary.com/vasospasm [accessed May 2016]

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Glossary

Idiopathic: arising spontaneously or from an obscure or unknown cause. Merriam-Webster (2016)

Vasospasm: is the constriction of blood vessels causing a reduction in blood flow. Farlex (2016).

Page Break

Appendices

Questionnaire sent to Acupuncturists in the UK. ( in the form of online survey )

1. Within the last 12 months how many patients have you treated for Chilblains ?

2. On average over the last 12 months, how many patients did you treat per week?

3. Do you feel that without conducting any research you recognise the signs and symptoms of Chilblains?

Yes

No

4. Do you feel confident that without conducting further research you could differentiate between cold weather skin conditions such as Chilblains, Raynaud’sPhenomenonand Frost bite?

Yes

No

5. Are you aware that as many as 1 in 10 people in the UK suffer from Chilblains at some stage in their lives?

Yes

No

6. Which of the following pathologies do you feel are most commonly associated with Chilblains?

Invasion of Wind Cold

Invasion of Cold

Cold obstructing the Channels

Qi Xu

Blood Xu

Yin Xu

Yang Xu

Qi Stagnation

Blood Stagnation

Damp

Phlegm

5 Element Constitutional Imbalance

Don’t know

Other (please specify)

7. For the following stages of Chilblains, please rate how effective you consider Acupuncture to be as a form of treatment.

8. A key pathology of Chilblains is poor circulation to the extremities, how do you treat this condition?

9. In addition to acupuncture do you use any of the following Chinese Medicine treatments when presented with chilblains by a patient.

Moxa

Tui Na

Gua Sha

Cupping

Herbs

N/A I have never treated a patient for Chilblains

Other (please specify)

10. Whilst it is understood that each individual patient is different, are there any common areas of lifestyle advice that you would recommend to patients with chilblains

Copyright © Jon Walsh