Acupuncture

Acupuncture is now a familiar term to most people in the United States, yet is still poorly understood as a therapy and a medical specialty. In the United States, the term acupuncture is used to describe both the medical treatment utilizing needle stimulation at trigger points under the skin, and the medical specialty of Traditional Chinese Medicine (TCM) or Asian Medicine / Oriental Medicine. TCM, or Asian Medicine, also utilizes a variety of other treatments besides needle stimulation, and presents a complete holistic diagnostic perspective that has always been a complement to, and integrates well with standard medicine, providing a medical perspective that looks at the whole picture of disease, injury and illness, to treat both the specific symptoms and the underlying causes and contributors to the health problem.

The therapy of needle stimulation at trigger points, which we will focus on in this article, has maintained popularity over thousands of years because of the vast empirical evidence of medical cause and effect that has established the location of points along meridians in the body. Meridians are pathways linking acupuncture points that roughly correspond to the dermatomes and myotomes in neurology, as well as the patterns of referred pain from organ pathology familiar to medical doctors. The meridian system allows physicians to utilize distal acupuncture points to treat all health problems. The careful documentation of treatment effects from acupuncture points and meridians for centuries established guidelines for treatment. Besides this wealth of empirical science, acupuncture is now also defined by measured laboratory analysis, or modern science, that has been conducted for over a century. The measurable effects of acupuncture are numerous and explain why the question of how needle stimulation works is difficult to answer.

In China, acupuncture therapy is simply called needle stimulation, or zhen ci, and is often linked to the treatment of heat stimulation at the trigger points, called moxibustion in the West, or jiu ci in China. Zhen Jiu, or ‘acupuncture/moxibustion’ therapy is well known in the United States primarily due to its success and safety in modern times, but also has a long history that was effectively erased from standard medical literature by the efforts of the American Medical Association. The use of sterile ultra-thin needles to stimulate physiological reactions, is the most studied medical treatment in the world in the last fifteen years, and perhaps the safest medical treatment in history. The term acupuncture is a European term derived from the Latin roots “acus” and “punctura”, meaning needle and pricking, and the origins of European acupuncture may extend to a very early time period, as evidenced by the findings of acupuncture marks, or tattoos, on a well preserved frozen body from 3200 BC in the Alpine Oetz valley between Austria and Italy (see the article under History on this website). In modern times, acupuncture was also researched and popularized in standard medicine in Europe. Clinical research in 1810 by the grandfather of the famed French composer Hector Berlioz, Louis-Joseph Berlioz, and published in his 1816 memoirs (Memoire sur les Maladies chroniques, les evacuations sangquines et l'acupuncture) showed that this research and clinical application of acupuncture in France was applied to a wide range of maladies, including paralysis, whooping cough, and nervous fever. In the United States as well, Franklin Bache, the great-grandson of Benjamin Franklin, was a physician and chemist that took great interest in acupuncture, translating a French medical text on the subject, and researching the effects. His 1826 text entitled “Cases Illustrative of the Remedial Effects of Acupuncturation“, published in the North American Medical and Surgical Journal was very supportive of this treatment protocol, and his work co-authoring the pharmacological reference text entitled The Dispensatory of the United States of America in 1833 showed a knowledge of Chinese herbal medicine as well.

Acupuncture as an evidence-based modern medicine

Acupuncture therapies have gained strong endorsement from the United States National Institute of Health (NIH), as well as the World Health Organization (WHO), Britain's National Health Service (NHS), and other esteemed health organizations, based on the scientific evidence of its benefit, as well as the scientific evidence of how it works. Evidence-based treatment guidelines, such as the California Industrial Medical Council Treatment Guidelines, the California Code of Regulations Title 8, and the New York Medical Treatment Guidelines of 2010 fully support acupuncture as a proven medical treatment, as well as the various treatments under the scope of practice of acupuncture, such as soft tissue mobilization (Tui na), acupressure (Shia tsu), myofascial release, dry trigger point needling, and neuromuscular reeducation. The National Guideline Clearinghouse of the U.S. AHRQ (Agency for Healthcare Research and Quality) endorses a number of evidence-based treatment guidelines that support acupuncture, and affirms that not only is acupuncture supported as well as other manual treatments with modern scientific evidence, but that acupuncture is in fact one of the few types of manual medicines actually supported by randomized blinded placebo human clinical trials.

Functional MRI studies performed in the University of California system at Irvine in the last fifteen years have dramatically demonstrated that these acupuncture stimulations not only affect local chemical and nerve responses, but effectively stimulate specific brain activity to promote the body’s own healing responses to injury and illness. Measured physiological responses and proof from study at Harvard Medical School's Osher Institute have debunked the theory once and for all that the effects of acupuncture stimulation are possibly due to placebo effects. Further study at the University of Michigan Chronic Pain and Fatique Research Center in 2009 utilized various types of brain scan to prove that the pain modulating effects of real needle stimulation differed from the effects of so-called sham acupuncture in clinical trials. While the real needle stimulation effectively modulated mu-opioid receptors in the brainstem and amygdala, the cutaneous “sham” stimulation modulated only the pain perceptual functions in the brain cortex. When the profession was established in the United States, in 1972, the Chinese presented scientific data confirming the sustained rise in the concentrations of opioid neurotransmitters, called endorphins and dynorphins, that were measured as a response to needle stimulation. Many other physiological effects have also been measured in laboratory studies to confirm the efficacy of acupuncture, and explain how it works in modern scientific terms. The U.S. National Institutes of Health include a National Center for Complementary and Alternative Medicine (NCCAM) that is currently mapping the effects of acupuncture points in the central nervous system, utilizing MRI, PET, electroencephalograpy and magnetoencephalography to demonstrate the significant effects of professional acupuncture stimulation in the brain and brainstem.

Acupuncture therapy has an application to preventative medicine, immune response enhancement, pain relief, musculoskeletal tissue healing, and promotion of healing mechanisms in all illness. Since the stimulation works to trigger enhanced healing mechanisms in your body, correcting dysfunctions that perpetuate illness and prevent proper tissue healing, we can say that it works be restoring homeostasis, or normal healthy function. It is an excellent way to normalize stress as well as being an effective complementary therapy for all standard medical treatment, and by its nature is always a preventative medicine, as well as a treatment for acute symptoms, addressing both the acute symptomatic manifestations as well as the whole array of underlying causes of disease and injury.

Records of trigger point responses from specific points and meridians that affect specific disease mechanisms have been recorded and analyzed since at least 300 BC, providing a useful body of knowledge for the practitioner. Today, many University Medical Schools in the United States maintain research and teaching devoted to integrative medicine, and annual conferences on acupuncture research are advancing the acceptance of acupuncture in standard medical protocols at a very accelerated rate. An example of this is an interactive page on the University of Maryland Medical Center’s Ask the Expert website, where the head of their Traditional Chinese Medicine Research at the Center for Integrative Medicine, Dr. Lixing Lao Ph.D. L.Ac., answers questions about the evidence-based uses for needle stimulation: http://data.umms.org/scripts/expertprocess2/archive.cfm?docid=49&deptid=71&urlname=http://www.umm.edu/cim/acupuncture_feature.htm. Of course, these answers only reveal the evidence of the application of needle stimulation, not of the holistic treatment protocols in TCM, which also utilize physiotherapies, herbal and nutrient medicines, and patient advice and instruction.

Standard questions still abound in clinical practice as patients try to understand how acupuncture works and how puncturing with a needle can be so safe

Acupuncture needle stimulation works by eliciting a response in the patient’s body. The response is called de qi in TCM. It has been thoroughly studied with scientific instruments and shown to affect the nervous system, circulatory response, chemical immune response, and hormonal chemical response. These responses may be enhanced by the subtle manipulation of the needle by the physician, or by addition of electrical stimulation to the needle. Proper choice of points and technique may achieve great success in restoring normal health and function with almost any disease or injury. The skill and knowledge of the acupuncturist is important to the treatment outcome, and it is wise to seek out a physician that is well trained and has shown that they provide successful outcomes. The number of treatments required to achieve goals varies greatly depending on the complexity of the problem and the health of the individual. Sometimes a small number of treatments may achieve remarkable success. Other times persistence is necessary.

Many new patients are still hesitant and express some fear of needle stimulation, not knowing what to expect, and associating the needle stimulation with past experiences with hypodermic needles that were painful. It should be kept in mind that hypodermic needles are thick and blunt with an open end, while acupuncture needles are very thin and designed to avoid discomfort, penetrating the pores of the skin and stimulating trigger points without causing any actual tissue injury. The sensations resulting from needle stimulation usually are momentary, and range from no noticeable sensation to momentary pain. Common sensations felt from acupuncture stimulation include tingling, numbness, warmth, cooling, gripping, shooting, tickling, electrical sensation, twitch or spasm. Sometimes these momentary sensations are pleasant and sometimes not. They may be felt at the needle point or far away, sometimes extending up the meridian. Needle insertion is usually not felt, especially if the patient is relaxed. If the patient is fearful, sometimes anticipatory pain is felt even before the needle is inserted, and it is best to put aside such anxiety. Later, as the needles are left in, resulting stimulation of endorphins and dynorphins give a pleasant sensation of relaxation and pain relief.

Acupuncture does not depend on the cognitive belief by the patient, as it has been proven to be effective in the treatment of animals, who of course do not establish an intellectual belief in the treatment. The great success of acupuncture in veterinary medicine shows that the human intellectualization may, in fact, get in the way of the mind-body effects of acupuncture, not the other way around. It may be best for the patient to not question acupuncture so much, and let the physician who has thoroughly studied this science do his or her job. If your pet understands this basic concept, you should be able to as well.

Acupuncture has been shown to be the safest manual medical treatment in history. A review of 50,000 treatments in the European Union after the adoption of mandated coverage showed only a small number (about 15) of mild cases of reported injury, such as a bruise, surprising the researchers. Generally, malpractice insurance rates are less than $1300 per year and reflect administrative costs only. When compared to standard medicine and malpractice rates we see objectively that TCM is the safe or conservative approach to your healthcare.

Trigger-Point Needling and Myofascial Release in Acupuncture Therapy

Modern research has promoted the use of acupuncture as the most effective means of correcting myofascial referred pain syndromes. Dr. Janet Travell pioneered research and treatment of trigger points in muscle and fascia and showed that there was a measurable correlation between the main trigger points in the innervation sites of muscles, or sarcolemma, and the common acupuncture points. She ultimately recommended dry needling, or omission of injected chemicals, into the trigger points. Since acupuncture needles are so much thinner than common hypodermic needles, this became the most comfortable way to needle the trigger points.

An article in the New York Times, Health section, Sept. 16, 2008, reveals the new attitude on the part of medical doctors to referred pain syndromes and treatment, utilizing acupuncture. Experts such as Dr. Lars Arendt-Nielsen at the Center for Sensory Motor Interaction in Aalborg, state that new evidence ’has changed the way we treat pain to a multifaceted approach‘, utilizing trigger point needling in a complementary protocol.

Research conducted in 2003 at the University of Bath in England showed that the intensity of referred pain diminished when the patient saw that the distal trigger points being treated were actually the cause of their pain. Patient belief that chronic pain was caused at the site that they felt the pain, which was inexplicable, hindered the body's ability to cope with pain. By utilizing the time and attention of the acupuncture trigger point needling, not only was the cause of the pain treated, but also the complicated mechanisms of hyperalgesia, or exagerrated pain sensation, that we commonly see in chronic syndromes, resolved. The effects of needle stimulation at myofascial trigger points is proven to work both directly and indirectly, providing a variety of benefits, some of which are cognitive.

Trigger point needling has been utilized for centuries in China. It was referred to in ancient texts as A Shi needling. A Shi translates loosely as ’that's it‘. This signified the identification of trigger points by the patient. This technique depends on the proper positioning and stretch of the targeted muscle to achieve the trigger point effects, and is a musculoskeletal protocol in acupuncture that differs from standard needling techniques. New research in the United States in the last 50 years has helped acupuncturists refine the techniques for increased effectiveness. My approach to trigger point needling emphasizes needling of the most pathological muscles involved in impingement syndromes and common repetitive postural stress syndromes. Other trigger point needling protocols may emphasize more extensive needling of the superficial muscles. Each practitioner may have a different perspective that reflects in differences in treatment techniques and protocol.

An example of recent scientific study of specific physiological effects of acupuncture stimulation

While most studies of acupuncture are still underfunded and small, and most study the actual outcomes of treatment rather than the physiological response, there are a growing number of well funded studies researching the actual physiological responses. Brazil is a country that has recently adopted acupuncture and Complementary Medicine into the mandated health services and already has found that it has contributed to a decrease in overall health expenditures. This has stimulated more funding for research.

In 2005, a study of acupuncture stimulation and effects on specific inflammatory mediators at Sao Paulo State Universisty and the University of Sao Paulo completed the first set of studies on research animals, and concluded that concentration of the inflammatory mediator interleukin-1 beta in the peritoneum of animals with induced inflammatory disorder, was effectively inhibited by acupuncture stimulation. Of course, the acupuncture points chosen were not needled locally into the peritoneum, but were located distally along related meridians. Interleukin-1 beta (IL-1beta) mediates the neutrophil migration in human acute inflammatory response. This study proved that acupuncture at specific sites exerts a direct effect on moderation of inflammatory responses by modulating the cytokine immune response. In this study, other inflammatory mediators were not affected, implying that the acupuncture stimulation has a modulating anti-inflammatory effect that utilizes natural responses and balance, promoting improved natural inflammatory regulation. Such studies need follow-up, but provide final proof of actual measured physiological responses, and should end the belief that we still do not know how acupuncture works.

Study of the physiological effects of acupuncture in recent years has produced evidence of more and more effects rather than the single effect that would explain how acupuncture works. Modern allopathic medicine and research, based upon the quest for specific physiological effects from specific pharmaceutical chemicals, has failed to produce research that investigates the quantum field of homeostatic physiological effects from acupuncture. Nevertheless, studies have demonstrated that acupuncture modulates neurohormonal chemicals such as endorphins and dynorphins, calcium ion migration and bioelectrical transmission, adenosine effects, mast cell degranulation and release of effector chemicals, and other measurable physiological effects that stimulate homeostatic mechanisms. Differing techniques of needle manipulation have demonstrated differing physiological effects, as have differing frequencies and intensities of electrical stimulation at the needles. Such research only confirms the classic explanations and effects recorded for many centuries in China.

The History of Acupuncture in the West

The term acupuncture was created by the French Jesuits in the 16th and 17th century, who were very interested in scientific advances in China. The term comes from the Latin for needle (acus) and puncture (punctura). The practice of acupuncture is believed to have started in Europe at this time, but anthropologists now believe that there is evidence that acupuncture may have a long history in Europe. In 1991, a frozen preserved body was found in the Alps, who is called Oetzi, or the Austrian Iceman. This mummy is over 5,000 years old and has a series of tattoos that correspond to the traditional Chinese acupuncture points still in use today. There is speculation that even these primitive Neolithic cultures knew of and practiced needle stimulation and utilized the meridian system of trigger points. To further explore acupuncture history, go to the section on this website devoted to the history of acupuncture and TCM. Today, many University Medical Schools maintain historical research concerning the well-documented history of acupuncture in Western medicine and the contributions of Traditional Chinese Medicine to advances in European history, such as the theories of smallpox vaccination in China that preceded the European use by hundreds of years. Such an example is seen here from the University of Michigan: http://www.lsa.umich.edu/chinamirror/moduleview_2.asp?MID=2&PID=21.

In the United States, acupuncture and other treatments commonly used in Traditional Chinese Medicine, such as cupping and bleeding, were used in standard medicine in the mid to late 1800s. A respected medical textbook of 1892, The Principles and Practice of Medicine, by Sir William Osler, mentions the practice of acupuncture for the treatment of lumbago and sciatica. Cupping and bleeding (vein puncture and release of a few drops of blood to stimulate a reaction), were mentioned in a number of standard gynecological texts. Even Gray's Anatomy in 1901 included the statement that ”The sciatic nerve has been acupunctured for the relief of sciatica.“ Much of the reference to acupuncture in standard medical texts and revised editions disappeared with the influence of modern medical technology and the American Medical Association, though. Popular knowledge of acupuncture in recent decades did not occur again until 1971, when a reporter for the New York Times received an appendectomy in China and reported that the medical doctors used acupuncture to manage his post-operative pain effectively. Prior to this, there was a mild interest in acupuncture from the reports of acupuncture anesthesia utilized by the Chinese and touted by the Nixon administration as Presidient Nixon achieved a trade agreement and normalization of relations with China. At this time, acupuncture was still widely practiced as an unlicensed protocol in the Asian-American communities, but little utilized outside of the Asian community.

The first state licensing of Oriental Medicine and acupuncture, and the establishment of medical schools devoted to the specialty, occurred in 1972, in California. By 2000, the U.S. National Institutes of Health had created the National Center for Complementary and Alternative Medicine as one of the twenty-seven agencies of the NIH, and scientific research information meeting the most rigorous requirements in research, were collected. The AHRQ (Association for Health Research Quality) confirmed that acupuncture was proven to be as effective as other standard treatments in modern medicine for a variety of injuries and diseases. Medical Doctors established the American Board of Medical Acupuncture and a board certification program for M.D.s who increasingly practice acupuncture and verify its medical efficacy. The Licensed Acupuncturist is no longer an outsider in standard medicine in the United States. Despite this long history of scientific proof and advancement of this fascinating therapy, there are still many members of the public, as well as health care providers, that insist that acupuncture is still an unproven therapy. Shame on these uninformed and unscientific individuals.

Above: Acupuncture is a treatment of trigger point stimulation with very fine sharp needles, or pins. Acupuncture needle stimulation works by eliciting a response in the patient’s body. The response is called ‘de qi’ in TCM.

— Photo: Michele Clement