{"id":257,"date":"2017-06-18T12:21:44","date_gmt":"2017-06-18T12:21:44","guid":{"rendered":"http:\/\/jonwalshacupuncture.com\/?p=257"},"modified":"2017-06-18T12:33:35","modified_gmt":"2017-06-18T12:33:35","slug":"researchchilblains","status":"publish","type":"post","link":"https:\/\/jonwalshacupuncture.com\/index.php\/2017\/06\/18\/researchchilblains\/","title":{"rendered":"Can Acupuncture Help for Chilblains"},"content":{"rendered":"

Abstract<\/b><\/p>\n

Objectives:\u00a0<\/b>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.<\/p>\n

Method<\/b>: 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.<\/p>\n

Results:\u00a0<\/b>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\u00a0Moxa\u00a0proved to be conducive at restoring Heat in the body and improving circulation which would be preventative of chilblains\u00a0developing into latter stages. As the condition progressed, practitioners felt that acupuncture was incrementally less effective.<\/p>\n

Conclusions:\u00a0<\/b>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.<\/p>\n

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Introduction<\/b><\/p>\n

Research Question<\/b><\/p>\n

How do Acupuncture practitioners in the UK diagnose and treat Chilblains?<\/p>\n

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Significance and Rationale for Research<\/b><\/p>\n

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.<\/p>\n

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).<\/p>\n

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\u00a0all literature found on the subject following a thorough search both online and in libraries.<\/p>\n

From the initial light internet based research I could see that the condition is significantly related to blood circulation,\u00a0AlMahameed.\u00a0A (2008).\u00a0This explanation led me to question if Acupuncture could be an effective treatment and that further research was warranted on the subject.<\/p>\n

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Objectives and Intentions<\/b><\/p>\n

The research contained within is being conducted with the intention of\u00a0analysing\u00a0the 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.<\/p>\n

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.<\/p>\n

The questionnaire is also designed to both raise and\u00a0analyse\u00a0practitioners\u2019 current awareness of the prevalence of Chilblains in the UK population today. This will be\u00a0achieved by including information in the questions and asking the participants if they are aware of the information contained within.<\/p>\n

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.<\/p>\n

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.<\/p>\n

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Method 1.<\/b>\u00a0\u00a0\u00a0\u00a0<\/b>Literature Review.<\/b><\/p>\n

Western Medicine interpretation of Chilblains<\/b><\/p>\n

Chilblains (Pernio) is Vasospastic disorder which affects areas of skin exposed to cold and damp, but not freezing conditions.\u00a0AlMahameed.\u00a0A (2008).\u00a0Chilblains 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.\u00a0I (2011).\u00a0 It is an idiopathic condition with signs typically occurring 1 \u2013 5 hours after prolonged exposure to cold damp air.\u00a0Mooney.J\u00a0(2009) breaks down the stages of Chilblain manifestation into the following categories.<\/p>\n

 <\/p>\n\n\n\n\n\n\n\n\n\n\n
Initial Cold Phase<\/b><\/p>\n

 <\/td>\n<\/tr>\n

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Affected areas of skin are very cold, pale and cyanosed<\/p>\n

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Acute inflammatory chilblains<\/b><\/p>\n

 <\/td>\n<\/tr>\n

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Affected areas become acutely inflamed, tender, itchy and burning with\u00a0\u00a0\u00a0 associated local\u00a0oedema\u00a0or blistering (i.e.\u00a0hyperaemic)<\/p>\n

 <\/td>\n<\/tr>\n

Chronic inflammatory chilblains<\/b><\/p>\n

 <\/td>\n<\/tr>\n

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Affected areas show chronic inflammation<\/p>\n

 <\/td>\n<\/tr>\n

Broken chilblains; ulcerative chilblains<\/b><\/p>\n

 <\/td>\n<\/tr>\n

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The skin overlying the area of chilling undergoes breakdown as the result of the severity of the initially chilling and subsequent acute inflammatory response; the chilled areas weep serous fluid and are at risk of infection<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Table\u00a01.\u00a0Stages of Chilblains<\/p>\n

Initial Cold Phase<\/b>: 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\u00a0discolouration\u00a0as red. On review of images and literature, red\u00a0colouring\u00a0could be seen to be more common although Cyanosis is also documented.<\/p>\n

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Image 1.\u00a0Redness<\/p>\n

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Image 2.\u00a0Cyanosis<\/p>\n

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Acute Inflammatory Chilblains<\/b><\/p>\n

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Image 3.\u00a0\u00a0Acute Hand\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Image 4.\u00a0Acute Nose<\/p>\n

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Image 5.\u00a0Acute Buttock<\/p>\n

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Chronic Inflammatory Chilblains<\/b><\/p>\n

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Image 6.\u00a0Chronic<\/p>\n

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Broken Chilblains<\/b><\/p>\n

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Image 7.\u00a0Broken<\/p>\n

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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.\u00a0Rosenbach.M\u00a0Et 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.<\/p>\n

Treatment for Chilblains using Western Medication<\/b><\/p>\n

Nifedipine<\/b><\/p>\n

Nifedipine\u00a0is a calcium-channel blocker prescribed in the treatment of\u00a0Raynaud’s phenomenon<\/a>\u00a0and 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)<\/p>\n

Diltiazem<\/b><\/p>\n

Diltiazem is also a calcium channel blocker.\u00a0Palamaras\u00a0L and\u00a0Kyriakis\u00a0K (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,\u00a0proteoglycans). Other CA’s also have immunomodulatory or\u00a0dysregulatory\u00a0effects on lymphocytes and can\u00a0suppress superoxide generation and phagocytic action of neutrophils. Moreover mast cell degranulation and platelet aggregation may also be impaired.”<\/p>\n

Comparing Medications<\/b><\/p>\n

Patra AK Et al (2003) conducted a study of 36 chilblain patients to test the efficacy of Diltiazem against\u00a0Nifedipine.<\/p>\n

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\u00a0nifedipine\u00a0thrice daily),\u00a0 21\u00a0cases showed 80-90% relief by the fourteenth day. The conclusion was that\u00a0Nifedipine\u00a0remained the medication of choice for chilblains.<\/p>\n

Souwer\u00a0Ibo H. Et al (2016) conducted a\u00a0randomised, placebo-controlled, double-blind, crossover trial, testing the effectiveness of\u00a0Nifedipine\u00a0against Placebo for the treatment of chronic chilblains. Their results showed that\u00a0nifedipine\u00a0was not superior to placebo for treating chronic chilblains and also that\u00a0Nifedipine\u00a0was associated with significantly lower systolic blood pressure and a significantly higher incidence of edema.<\/p>\n

The trial replicated the work of\u00a0Rustin M. Et al (1989) whose study concluded that\u00a0Nifedipine\u00a0was<\/i>\u00a0more effective than Placebo, and according to\u00a0Souwer\u00a0Ibo H. Et al (2016) was contributory to the prescription of\u00a0Nifedipine\u00a0to this day.<\/p>\n

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Differentiation of Cold weather skin conditions<\/b><\/p>\n

Raynaud’s Disease\u00a0<\/b><\/p>\n

(Also commonly referred to as Raynaud’s\u00a0Phenomenon) is a condition that is thought to affect approximately 10 million people in the UK.\u00a0Scleroderma & Reynaud’s UK (2016).<\/p>\n

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\u00a0colour\u00a0and then white. They can feel numb and painful and it can last up to a few hours.\u00a0If the attacks are prolonged or occur frequently the tissues of the fingers or toes can be damaged by the reduced blood supply.\u00a0 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)<\/p>\n

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)<\/p>\n

Treatment for Secondary Raynaud’s can include prescribed\u00a0Nifedipine\u00a0(see Chilblains Medication for detailed description of\u00a0Nifedipine) or even surgery in rare cases. Stephenson (2011) states that the surgical approach is called a “sympathectomy” and involves damaging the nerves\u00a0that cause\u00a0constriction of the blood vessels. Performed by injection at the site on the neck where they leave the spinal cord.<\/p>\n

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Image 8.\u00a0Raynaud’s<\/p>\n

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Frostbite<\/b><\/p>\n

Murphy.\u00a0J 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.<\/p>\n

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.<\/p>\n

 <\/p>\n

Image 9.\u00a0Frostbite<\/p>\n

Frostnip\u00a0causes 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.\u00a0 Mayo Clinic (2014)<\/p>\n

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Image 10.\u00a0Superficial Frostbite<\/p>\n

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Image 11.\u00a0Deep Frostbite<\/p>\n

Cold\u00a0<\/b>Urticaria<\/b>\u00a0(<\/b>Also known as Cold Hypersensitivity, Familial Cold\u00a0<\/b>Autoinflammatory<\/b>\u00a0<\/b>Syndrome)<\/b><\/p>\n

The term\u00a0Urticaria\u00a0derives 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).<\/p>\n

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\u00a0of time leading up to that depending on the individual. On warming it can then disappear as quickly as it arrived.<\/p>\n

 <\/p>\n

Image 12.\u00a0Cold\u00a0Urticaria<\/p>\n

Stephenson (2011) explains that\u00a0urticaria\u00a0is 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\u00a0oedema.<\/p>\n

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Chinese Medicine interpretation and pathology of Chilblains<\/b><\/p>\n

Chilblains has\u00a0been mentioned in relation to Chinese Medicine as far back as 265-420 CE in the\u00a0Jin\u00a0Dynasty when Huang-fu\u00a0Mai 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.<\/p>\n

In an article written for the South China Morning Post,\u00a0Tse.\u00a0R and Eagleton.\u00a0J (2009) state that chilblains are a result of an invasion of cold with an underlying deficiency of Blood and Qi.\u00a0Therefore 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\u00a0localised\u00a0vascular inflammation and Chilblains can occur.<\/p>\n

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.\u00a0They 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.<\/p>\n

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.<\/p>\n

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\u00a0deprived\u00a0from warmth and Yang Qi.<\/p>\n

The China Association of Research and Development wrote an article in conjunction with the Shanxi Province Hospital (2012) discussing the use of\u00a0moxibustion\u00a0in the treatment of chilblains.\u00a0 In the article they describe chilblains to be a combination of the invasion of Cold Damp and Yang Qi \/ Blood deficiency.<\/p>\n

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.\u00a0A combination of either an invasion of exterior Cold or a manifestation from internal Cold as a result of weak Yang Qi.\u00a0Cold can be either interior or exterior, it can also be Full or Empty.<\/p>\n

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Diagram 1.\u00a0Cold Pathology<\/p>\n

The diagram above by\u00a0Maciocia\u00a0(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.<\/p>\n

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.\u00a0Maciocia\u00a0(2005) explains that on occasion when the equilibrium between the body and the environment breaks down, the climate can affect\u00a0the harmony of the body and cause disease.\u00a0 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.<\/p>\n

    \n
  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.<\/li>\n<\/ol>\n
      \n
    1. Cold can invade the joints and channels\u2019, causing what is defined as Painful Obstruction Syndrome. This pain is often in one joint.<\/li>\n<\/ol>\n
        \n
      1. Cold can invade the muscles and sinews which will cause stiffness and pain in the area of the invasion.<\/li>\n<\/ol>\n
          \n
        1. Cold can invade the organs directly.<\/li>\n<\/ol>\n

          Internal Cold can be\u00a0both full or\u00a0empty. 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.<\/p>\n

          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.\u00a0\u00a0Maciocia\u00a0(2005).<\/p>\n

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          Treating Chilblains with Chinese medicine.<\/b><\/p>\n

          Acupuncture\u00a0<\/b><\/p>\n

          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<\/p>\n

          Xiang.\u00a0F Et al (2005) of the\u00a0Yongshun\u00a0County 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.<\/p>\n

          The Yorkshire Foot Hospital (2016)\u00a0advertise\u00a0that 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).<\/p>\n

          Shing\u00a0Ni .M (2015) describes the use of acupuncture to increase circulation for cold hands and feet. To promote warming Yang energy\u00a0Shing\u00a0Ni explains the use of acupuncture points of Large Intestine 4 and Liver 3.\u00a0Shing\u00a0Ni states that Large Intestine 4 will unblock energy and relieve Blood stasis and that Liver 3 will release all types of blockages.<\/p>\n

          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\u00a0acupoints\u00a0and 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.<\/p>\n

          Moxibustion<\/b><\/p>\n

          Alongside Acupuncture the research has found that\u00a0Moxibustion\u00a0is also used in the treatment of chilblains.\u00a0Moxibustion\u00a0is the use of burning the herb\u00a0Mugwort\u00a0on or close to the body for the purpose of healing. The\u00a0mugwort\u00a0is first processed into a powder or rolled into a stick for controlled burning and application.\u00a0Mugwort\u00a0leaves are harvested and dehydrated before being ground and winnowed to make the final product ready for use.\u00a0Rouho\u00a0K. (2016).<\/p>\n

          Moxa\u00a0is used in two different ways, direct or indirect application. Direct application is done by placing small cones of\u00a0moxa\u00a0on acupuncture points and burning them down,\u00a0removing 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\u00a0moxa\u00a0application the\u00a0moxa\u00a0stick\u00a0( a\u00a0cigar 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\u00a0moxa\u00a0on the end of an acupuncture needle that has been inserted into a point. The\u00a0moxa\u00a0is then lit and the heat travels down the needle into the acupuncture point.\u00a0Acupuncture Today (2016).<\/p>\n

          The China Association of Research and Development (2012) describe that Indirect\u00a0Moxa\u00a0should 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\u00a0moxa\u00a0stick 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\u00a0moxa\u00a0to 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\u00a0moxibustion\u00a0to 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.”<\/p>\n

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          Method 2.<\/b>\u00a0\u00a0 Questionnaire<\/b><\/p>\n

          To gather data on the experience and knowledge of Chilblains by Acupuncturists practicing in the UK, the method of a questionnaire was used.<\/p>\n

          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.<\/p>\n

          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.<\/p>\n

          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.<\/p>\n

          49 practitioners completed the questionnaire resulting in a response rate of 14%.<\/p>\n

          A questionnaire was used for the following reasons.<\/p>\n