ACUPUNCTURE
Acupuncture (from Lat. acus, "needle" (noun), and pungere, "prick" (verb)) or in Standard Mandarin, zhēn jiǔ (針灸 lit: needle - moxibustion) is a technique of inserting and manipulating filiform needles into "acupuncture points" on the body. According to acupuncture theory, this will restore health and well-being, and is particularly good at treating pain. The definition and characterization of these points is standardized by the World Health Organization (WHO). Acupuncture is thought to have originated in China and is most commonly associated with Traditional Chinese medicine (TCM). Different types of acupuncture (Japanese, Korean, and classical Chinese acupuncture) are practiced and taught throughout the world.
Scientists are studying the mechanisms and efficacy of acupuncture. According to the protocols of evidence-based medicine, there is good evidence that acupuncture is effective in treating nausea and chronic low back pain, and moderate evidence for neck pain and headache. Critics of acupuncture claim that for many conditions there is a lack of evidence in the English language that acupuncture is effective beyond a placebo, with reviewers noting a lack of modern studies. The WHO, the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institute of Health (NIH), the American Medical Association (AMA) and various government reports have also studied and commented on the efficacy of acupuncture. There is general agreement that acupuncture is at least safe when administered by well-trained practitioners, and that further research is warranted.
Traditional Chinese medicine's acupuncture theory predates use of the scientific method, and has received various criticisms based on scientific thinking. There is no known anatomical or histological basis for the existence of acupuncture points or meridians. Acupuncturists tend to perceive TCM concepts in functional rather than structural terms, i.e. as being useful in guiding evaluation and care of patients. Neuroimaging research suggests that certain acupuncture points have distinct effects that are not otherwise predictable anatomically.
Traditional theory:
Chinese medicine is based on a different paradigm from scientific biomedicine. Its theory holds the following explanation of acupuncture:
Acupuncture treats the human body as a whole that involves several "systems of function" that are in some cases loosely associated with (but not identified on a one-to-one basis with) physical organs. Some systems of function, such as the "triple heater" (San Jiao, also called the "triple burner") have no corresponding physical organ. Disease is understood as a loss of homeostasis among the several systems of function, and treatment of disease is attempted by modifying the activity of one or more systems of function through the activity of needles, pressure, heat, etc. on sensitive parts of the body of small volume traditionally called "acupuncture points" in English, or "xue" (穴, cavities) in Chinese. This is referred to as treating "patterns of disharmony".
Treatment of acupuncture points may be performed along the twelve main or eight extra meridians, located throughout the body, or on tender points, called "ashi" (signifying "that's it", "ouch", or "oh yes"). Of the eight extra meridians, only two have acupuncture points of their own. The other six meridians are "activated" by using a master and couple point technique which involves needling the acupuncture points located on the twelve main meridians that correspond to the particular extra meridian. Ten of the main meridians are named after organs of the body (Heart, Liver, etc.), and the other two are named after so called body functions (Heart Protector or Pericardium, and San Jiao). The meridians are capitalized to avoid confusion with a physical organ (for example, we write the "Heart meridian" as opposed to the "heart meridian"). The two most important of the eight "extra" meridians are situated on the midline of the anterior and posterior aspects of the trunk and head. The twelve primary meridians run vertically, bilaterally, and symmetrically and every channel corresponds to and connects internally with one of the twelve Zang Fu ("organs"). This means that there are six yin and six yang channels. There are three yin and three yang channels on each arm, and three yin and three yang on each leg.
The three yin channels of the hand (Lung, Pericardium, and Heart) begin on the chest and travel along the inner surface (mostly the anterior portion) of the arm to the hand.
The three yang channels of the hand (Large intestine, San Jiao, and Small intestine) begin on the hand and travel along the outer surface (mostly the posterior portion) of the arm to the head.
The three yang channels of the foot (Stomach, Gallbladder, and Bladder) begin on the face, in the region of the eye, and travel down the body and along the outer surface (mostly the anterior and lateral portion) of the leg to the foot.
The three yin channels of the foot (Spleen, Liver, and Kidney) begin on the foot and travel along the inner surface (mostly posterior and medial portion) of the leg to the chest or flank.
The movement of qi through each of the twelve channels is comprised of an internal and an external pathway. The external pathway is what is normally shown on an acupuncture chart and it is relatively superficial. All the acupuncture points of a channel lie on its external pathway. The internal pathways are the deep course of the channel where it enters the body cavities and related Zang-Fu organs. The superficial pathways of the twelve channels describe three complete circuits of the body.
The distribution of qi through the meridians is said to be as follows (the based on the demarcations in TCM's Chinese Clock): Lung channel of hand taiyin to Large Intestine channel of hand yangming to Stomach channel of foot yangming to Spleen channel of foot taiyin to Heart channel of hand shaoyin to Small Intestine channel of hand taiyang to Bladder channel of foot taiyang to Kidney channel of foot shaoyin to Pericardium channel of hand jueyin to San Jiao channel of hand shaoyang to Gallbladder channel of foot shaoyang to Liver channel of foot jueyin then back to the Lung channel of hand taiyin.
Chinese medical theory holds that acupuncture works by normalizing the free flow of qi (a difficult-to-translate concept that pervades Chinese philosophy and is commonly translated as "vital energy") throughout the body. Pain or illnesses are treated by attempting to remedy local or systemic accumulations or deficiencies of qi. Pain is considered to indicate blockage or stagnation of the flow of qi, and an axiom of the medical literature of acupuncture is "no pain, no blockage; no blockage, no pain".
Many patients claim to experience the sensations of stimulus known in Chinese as "deqi" (得氣, "obtaining the qi" or "arrival of the qi"). This kind of sensation was historically considered to be evidence of effectively locating the desired point. There are some electronic devices now available which will make a noise when what they have been programmed to describe as the "correct" acupuncture point is pressed.
The acupuncturist decides which points to treat by observing and questioning the patient in order to make a diagnosis according to the tradition which he or she utilizes. In TCM, there are four diagnostic methods: inspection, auscultation and olfaction, inquiring, and palpation (Cheng, 1987, ch. 12). Inspection focuses on the face and particularly on the tongue, including analysis of the tongue size, shape, tension, color and coating, and the absence or presence of teeth marks around the edge. Auscultation and olfaction refer, respectively, to listening for particular sounds (such as wheezing) and attending to unusual body odor. Inquiring focuses on the "seven inquiries", which are: chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; and menses and leukorrhea. Palpation includes feeling the body for tender "ashi" points, and palpation of the left and right radial pulses at two levels of pressure (superficial and deep) and three positions (immediately proximal to the wrist crease, and one and two fingers' breadth proximally, usually palpated with the index, middle and ring fingers). Other forms of acupuncture employ additional diagnosic techniques. In many forms of classical Chinese acupuncture, as well as Japanese acupuncture, palpation of the muscles and the hara (abdomen) are central to diagnosis.
There are also theories being developed to explain effects observed for acupuncture within the orthodox Western medical paradigm.
Categories of acupuncture points:
Certain acupuncture points are ascribed different functions according to different systems within the TCM framework.
Five Transporting Points system describes the flow of qi in the channels using a river analogy, and ascribes function to points along this flowline according to their location. This system describes qi bubbling up from a spring and gradually growing in depth and breadth like a river flowing down from a mountain to the sea.
Jing-well points represent the place where the qi "bubbles" up. These points are always the first points on the yang channels or last points on the yin channels and with exception of Kid-1 YongQuan all points are located on the tips of fingers and toes. The Nan Jing and Nei Jing described jing-well points as indicated for "fullness below the heart" (feeling of fullness in the epigastric or hypochondrium regions) and disorders of the zang organs (yang organs).
Ying-spring points are where the qi "glides" down the channel. The Nan Jing and Nei Jing described ying-spring points as indicated for heat in the body and change in complexion.
Shu-stream points are where the qi "pours" down the channel. Shu-stream points are indicated for heaviness in the body and pain in the joints, and for intermittent diseases.
Jing-river points are where the qi "flows" down the channel. Jing-river points are indicated for cough and dyspnoea, chills and fever, diseases manifesting as changes in voice, and for diseases of the sinews and bones.
He-sea points are where the qi collects and begins to head deeper into the body. He-sea points are indicated for counterflow qi and diarrhea, and for disorders resulting from irregular eating and drinking.
Five Phase Points ascribe each of the five phases - wood, fire, earth, metal, water - to one of the Five Transporting points. On the yin channels, the jing-well points are wood points, the ying-spring points are fire, shu-stream points are earth, jing-river points are metal, he-sea points are water points. On the yang channels, the jing-well points are metal, ying-spring are water, shu-stream are wood, jing-river points are fire and he-sea points are earth points. These point categories are then implemented according to Five Phase theory in order to approach the treatment of disease.
Xi-cleft points are the point on the channel where the qi and blood gather and plunge more deeply. These points are indicated in acute situations and for painful conditions.
Yuan-source points are points on the channel from where the yuan qi can be accessed.
Luo-connecting points are located at the point on the channel where the luo meridian diverges. Each of the twelve meridians have a luo point that diverges from the main meridian. There are also three extra luo channels that diverge at Sp-21, Ren-15 and Du-1.
Back-shu points lie on the paraspinal muscles either side of the spine. Theory says that the qi of each organ is transported to and from these points, and can be influenced by them.
Front-mu points are located in close proximity to the respective organ. They have a direct effect on the organ itself but not on the associated channel.
Hui-meeting points are a category of points that are considered to have a "special effect" on certain tissues and organs. The hui-meeting points are:
zang organs - Liv-13 Zhang Men
fu organs - Ren-12 Zhong Fu
qi - Ren-17 Shang Fu
blood - Bl-17 Ge Shu
sinews - GB-34 Yang Ling Quan
vessels - Lu-9 Tai Yuan
bone - Bl11 Da Zhu
marrow - GB-39 Xuan Zhong
Acupuncture treatment:
TCM perspective on treatment of disease:
Although TCM is based on the treatment of "patterns of disharmony" rather than biomedical diagnoses, practitioners familiar with both systems have commented on relationships between the two. A given TCM pattern of disharmony may be reflected in a certain range of biomedical diagnoses: thus, the pattern called Deficiency of Spleen Qi could manifest as chronic fatigue, diarrhea or uterine prolapse. Likewise, a population of patients with a given biomedical diagnosis may have varying TCM patterns. These observations are encapsulated in the TCM aphorism "One disease, many patterns; one pattern, many diseases". (Kaptchuk, 1982)
Acupuncture has been used to treat a number of conditions (see Clinical practice, below). Classically, "(i)n clinical practice, acupuncture treatment is typically highly-individualized and based on philosophical constructs, and subjective and intuitive impressions" and not on controlled scientific research.".
History:
In China, the practice of acupuncture can perhaps be traced as far back as the 1st millennium BCE,[citation needed] and archeological evidence has been identified with the period of the Han dynasty (from 202 BC to 220 AD)[citation needed]. Forms of it are also described in the literature of traditional Korean medicine where it is called chimsul. It is also important in Kampo, the traditional medicine system of Japan.
Recent examinations of Ötzi, a 5000-year-old mummy found in the Alps, have identified over fifty tattoos on his body, some of which are located on acupuncture points that would today be used to treat ailments Ötzi suffered from. Some scientists believe that this is evidence that practices similar to acupuncture were practised elsewhere in Eurasia during the early bronze age. According to an article published in The Lancet by Dorfer et al.: "We hypothesised that there might have been a medical system similar to acupuncture (Chinese Zhenjiu: needling and burning) that was practised in Central Europe 5200 years ago...A treatment modality similar to acupuncture thus appears to have been in use long before its previously known period of use in the medical tradition of ancient China. This raises the possibility of acupuncture having originated in the Eurasian continent at least 2000 years earlier than previously recognised.".
Acupuncture's origins in China are uncertain. The earliest Chinese medical texts (Ma-wang-tui graves 68 BC) do not mention acupuncture. The Chinese medical text that first describes acupuncture is The Yellow Emperor’s Classic of Internal Medicine (History of Acupuncture), which was compiled around 305–204 B.C. Some hieroglyphics have been found dating back to 1000 B.C. that may indicate an early use of acupuncture.[citation needed] Bian stones, sharp pointed stones used to treat diseases in ancient times, have also been discovered in ruins (History of Acupuncture in China); some scholars believe that the bloodletting for which these stones were likely used presages certain acupuncture techniques.
RC Crozier in the book Traditional medicine in modern China (Harvard University Press, Cambridge, 1968) says the early Chinese Communist Party expressed considerable antipathy towards classical forms of Chinese medicine, ridiculing it as superstitious, irrational and backward, and claiming that it conflicted with the Party’s dedication to science as the way of progress. Acupuncture was included in this criticism. Reversing this position, Communist Party Chairman Mao later said that "Chinese medicine and pharmacology are a great treasure house and efforts should be made to explore them and raise them to a higher level"[13]. Representatives were sent out across China to collect information about the theories and practices of Chinese medicine. Traditional Chinese Medicine is the formalized system of Chinese medicine that was created out of this effort. TCM combines the use of Acupuncture, Chinese herbal medicine, tui na and other modalities. After the Cultural Revolution, TCM instruction was incorporated into university medical curricula under the "Three Roads" policy, wherein TCM, biomedicine and a synthesis of the two would all be encouraged and permitted to develop. After this time, forms of classical Chinese medicine other than TCM were outlawed, and some practitioners left China. The first forms of acupuncture to reach the United States were brought by non-TCM practitioners, many employing styles that had been handed down in family lineages, or from master to apprentice (collectively known as "Classical Chinese Acupuncture"). In Vietnam Dr. Van Nghi and colleagues used the Classical Chinese Medical Texts and applied them in clinical conditions without reference to political screening. They rewrote the modern version: Trung E Hoc. Dr. Van Nghi was made the first President of the First World Congress of Chinese Medicine at Bejing in 1988 in recognition of his work.
Clinical practice:
Most modern acupuncturists use disposable stainless steel needles of fine diameter (0.007" to 0.020", 0.18 mm to 0.51 mm), sterilized with ethylene oxide or by autoclave. These needles are far smaller in diameter (and therefore less painful) than the needles used to give shots, since they do not have to be hollow for purposes of injection. The upper third of these needles is wound with a thicker wire (typically bronze), or covered in plastic, to stiffen the needle and provide a handle for the acupuncturist to grasp while inserting. The size and type of needle used, and the depth of insertion, depend on the acupuncture style being practised.
Warming an acupuncture point, typically by moxibustion (the burning of mugwort), is a different treatment than acupuncture itself and is often, but not exclusively, used as a supplementing treatment. The Chinese term zhēn jǐu (針灸), commonly used to refer to acupuncture, comes from zhen meaning "needle", and jiu meaning "moxibustion". Moxibustion is still used in the 21st century to varying degrees among the schools of oriental medicine. For example, one well known technique is to insert the needle at the desired acupuncture point, attach dried mugwort to the external end of an acupuncture needle, and then ignite the mugwort. The mugwort will then smolder for several minutes (depending on the amount adhered to the needle) and conduct heat through the needle to the tissue surrounding the needle in the patient's body. Another common technique is to hold a large glowing stick of moxa over the needles. Moxa is also sometimes burned at the skin surface, usually by applying an ointment to the skin to protect from burns.
Indications:
According to the American Academy of Medical Acupuncture (2004), acupuncture may be considered as a complementary therapy for these conditions:
Abdominal distention/flatulence*
Acute and chronic pain control*
Allergic sinusitis *
Anesthesia for high-risk patients or patients with previous adverse responses to anesthetics
Anorexia
Anxiety, fright, panic*
Arthritis/arthrosis *
Atypical chest pain (negative workup)
Bursitis, tendonitis, carpal tunnel syndrome*
Cerebral Palsy
Certain functional gastrointestinal disorders (nausea and vomiting, esophageal spasm, hyperacidity, irritable bowel) *
Cervical and lumbar spine syndromes*
Constipation, diarrhea *
Cough with contraindications for narcotics
Drug detoxification *
Dysmenorrhea, pelvic pain *
Frozen shoulder *
Headache (migraine and tension-type), vertigo (Meniere disease), tinnitus *
Idiopathic palpitations, sinus tachycardia
In fractures, assisting in pain control, edema, and enhancing healing process
Muscle spasms, tremors, tics, contractures*
Neuralgias (trigeminal, herpes zoster, postherpetic pain, other)
Paresthesias *
Persistent hiccups*
Phantom pain
Plantar fasciitis*
Posttraumatic and postoperative ileus *
Selected dermatoses (urticaria, pruritus, eczema, psoriasis)
Sequelae of stroke syndrome (aphasia, hemiplegia) *
Seventh nerve palsy
Severe hyperthermia
Sprains and contusions
Temporo-mandibular joint derangement, bruxism *
Urinary incontinence, retention (neurogenic, spastic, adverse drug effect) *
* Also included in the World Health Organization list of acupuncture indications.
Scientific theories and mechanisms of action:
Main article: Scientific theories regarding acupuncture
Many hypotheses have been proposed to address the physiological mechanisms of action of acupuncture. To date, more than 10,000 scientific research studies have been published on acupuncture as cataloged by the National Library of Medicine database.
Gate-control theory of pain:
The "gate control theory of pain" (developed by Ronald Melzack and Patrick Wall in 1962 and in 1965) proposed that pain perception is not simply a direct result of activating pain fibers, but modulated by interplay between excitation and inhibition of the pain pathways. The "gating of pain" is controlled by the inhibitory action on the pain pathways. That is, the perception of pain can be altered (gated on or off) by a number of means physiologically, psychologically and pharmacologically. The gate-control theory was developed in neuroscience independent of acupuncture, which later was proposed as a mechanism to account for the analgesic action of acupuncture in the brainstem reticular formation by a German neuroscientist in 1976. (With the advance in modern-day technology, stimulation of these pathways can be demonstrated to alter pain perception using electrical stimulations or magnetic stimulations, such as transcranial magnetic stimulation (TMS) or pulsed electromagnetic field (PEMF) therapy for pain.)
It is well-documented in neuroscience that pain blockade can be achieved at multiple levels in the central nervous system (i.e., the brain and spinal cord).[citation needed] At the spinal cord level, pain transmission via the pain fibers can be blocked by surround inhibition of the neighboring nerve fibers that merge at the substantia gelatinosa in the spinal cord.[citation needed] That is to say, stimulation of the surrounding neurons can cause a reduction of pain when the center excitatory pain fibers are inhibited by the surrounding cutaneous (touch) fibers. This phenomenon is demonstrated in the all-too-common experience that, when we bump our head, pain can be relieved by rubbing the surrounding skin area (activating the surround inhibitory neural circuitry physiologically). Blockade of pain at this level suppresses pain by blocking the pain signal from the periphery. Furthermore, pain blocking by this cutaneous stimulus only lasts for a short period of time, whereas it is claimed that the effect of pain relief by acupuncture lasts for an extended period of time, sometimes months after the needle was removed.
This leads to the theory of central control of pain gating, i.e., pain blockade at the brain (i.e., central to the brain rather than at the spinal cord or periphery) via the release of endogenous opioid (natural pain killers in the brain) neurohormones, such as endorphins and enkephalins (naturally occurring morphines).
Neurohormonal theory:
Pain transmission can also be modulated at many other levels in the brain along the pain pathways, including the periaqueductal gray, thalamus, and the feedback pathways from the cortex back to the thalamus. Each of these brain structure processes different aspect of the pain — from experiencing emotional pain to the perception of what the pain feels like to the recognition of how harmful the pain is to localizing where the pain is coming from. Pain blockade at these brain locations are often mediated by neurohormones, especially those that bind to the opioid receptors (pain-blockade site). Pain relief by morphine drug (exogenous opioid) is acting on the same opioid receptor (where pain blockade occurs) as endorphins (endogenous opioids) that the brain produces and releases.
Some studies suggest that the Analgesic (pain-killing) action of acupuncture is mediated by stimulating the release of natural endorphins in the brain. This can be proven scientifically by blocking the action of endorphins (or morphine) using a drug called naloxone. When naloxone is administered to the patient, the analgesic effects of morphine can be reversed, causing the patient to feel pain again. When naloxone is administered to an acupunctured patient, the analgesic effect of acupuncture can also be reversed, causing the patient to report an increased level of pain. This demonstrates that the site of action of acupuncture may be mediated through the natural release of endorphins by the brain, which can be reversed by naloxone. Similar results were also obtained in experiments with animals showing that the analgesic effect is not due to subjective psychological placebo effect, but real physiological phenomena. Such analgesic effect can also be shown to last more than an hour after acupuncture stimulation by recording the neural activity directly in the thalamus (pain processing site) of the monkey's brain. Furthermore, there is a large overlap between the nervous system and acupuncture trigger points (points of maximum tenderness in myofascial pain syndrome).
The sites of action of acupuncture-induced analgesia are also confirmed to be mediated through the thalamus (where emotional pain/suffering is processed) using modern-day powerful non-invasive fMRI (functional magnetic resonance imaging) and PET (positron emission tomography) brain imaging techniques, and via the feedback pathway from the cerebral cortex (where cognitive feedback signal to the thalamus distinguishing whether the pain is noxious (painful) or innocuous (non-harmful)) using electrophysiological recording of the nerve impulses of neurons directly in the cortex, which shows inhibitory action when acupuncture stimulus was applied.
