Acupuncture




Acupuncture is an ancient medical modality of traditional Chinese medicine. It was described in the Huang Di Nei Jing ( Yellow Emperor’s Internal Classic ) in 100 bc. Called jin jiao , acupuncture generally consists of the practices of needling and moxibustion. Moxibustion is a warming sensation produced by placing smouldering moxa ( Artemisia vulgaris ) over the acupuncture points. The practice of acupuncture also includes electroacupuncture, laser acupuncture, cupping, Chinese tui na massage, Gua Sha, and acupressure. With the advances in biochemical and biophysical technology, the mechanisms of acupuncture analgesia have been elucidated as being a consequence of peripheral acupuncture point stimulation, mobilization of central neural peptides, and triggering of the central inhibitory pathway for modulation of pain sensation.


Theories of Acupuncture


The concept of yin and yang is one of the essential theories of traditional Chinese medicine. The principle is simple, but its implication is philosophical. It was first mentioned in The Book of Changes and Simplicity ( Yi Jing ), a text from about 700 bc . Yin and yang are natural phenomena that exist within the body. They are interdependent and can be transformed into each other. They exist in a constant state of dynamic balance. Yang is related to bright, hot, activity, light, above, outward, increase, dry, and male. Yin is present in the qualities of dark, cold, rest, passivity, below, inward, decrease, wet, and female. Yin and yang define aspects of a whole and are therefore dependent on each other. For example, “bright” is difficult to define without “dark.” “Above” is meaningless without “below.” Yin-yang interdependence is the relationship between structure and function. Optimal physical condition requires a balance of yin and yang within the body. Disease is associated with a disharmony or imbalance between yin and yang. Acupuncture can be used to balance and promote yin and yang energy within the body.


There are more than 365 identifiable acupuncture points in the human body. There are also pathways, called meridians, connecting acupuncture points to each other. Qi (pronounced “chee”) is the energy flow through these meridians. Difficult to define, qi represents power and movement, similar to energy. Qi is a functional, dynamic force that resides in living creatures. It is a result of the interaction between heaven and earth, an energy that is manifested concurrently in the physical and spiritual levels of human existence. Qi flows throughout the meridians of the body to maintain life and health. These meridians are not defined by physical structures such as blood or lymphatic vessels, but by their function. The body is viewed as a dynamic system of organs connected by the flow of qi through the meridians.


When there is stagnation or inadequate flow of qi through the meridians, pain or illness may result. The flow of qi may be restored by the insertion of very fine needles into a combination of appropriate acupuncture points along the meridians. Manual twirling of these needles produces a sore, heavy, or numb sensation known as “de qi” (obtaining qi). Acupuncture practitioners have observed that stimulating specific acupuncture points results in predictable responses in patients with a given pattern of signs and symptoms. Practitioners of acupuncture routinely request the patient’s detailed history of the present illness in pursuing the diagnosis. Physical attention is also focused on disposition of the pulse and appearance of the tongue. In traditional Chinese medicine, there are six pathologic factors that cause disease—wind, cold, heat, dampness, dryness, and fire. The goal of the history and physical examination is to assess the patient’s balance of yin and yang and to gain insight into other symptoms.


There are eight principal classifications of symptoms, which include yin or yang, external or internal, cold or hot, and deficient or excess. The aim of acupuncture therapy is to restore deficiencies or correct excesses in qi, thus restoring health. It is frequently used for preventive care, as well as for therapeutic purposes.


A Treatise on Acupuncturation , written by James Morss Churchill in 1823, was the first text about acupuncture published in English. Dr. Churchill described his success in using acupuncture for rheumatic conditions, sciatica, and back pain. Sir William Osler’s Principles and Practice of Medicine , first published in 1892, recommended the use of acupuncture for the treatment of sciatica and lumbago. Public awareness and use of acupuncture increased in the United States following New York Times writer James Reston’s account of his emergency appendectomy in a Chinese hospital. His article described how physicians eased his postsurgical abdominal pain with acupuncture.




Acupuncture Points


Acupuncture points are generally located in the deep depressions of muscles, joints, or bones and are often sensitive to pressure. The unit of measurement used to determine the locations of acupuncture points on the body is called a tsun , and measurement of a tsun is relative to the patient’s own body. One tsun (approximately 1 inch) is equal to the space between the distal interphalangeal joint and the proximal interphalangeal joint on the middle finger.




  • CV 12 (zhong guan; “central venter”)—located in the midline, 4 tsun above the umbilicus ( Fig. 48.1 )




    Figure 48.1


    Acupuncture points CV 12 and CV 17.



  • CV 17 (tan chung; “chest center”)—located in the midline of the sternum, between the nipples, at the level of the fourth intercostal space ( Fig. 48.1 )



  • LR 13 (zhang men; “camphor wood gate”)—located on the lateral side of the abdomen, below the free end of the 11th rib, 2 tsun above the navel and 6 tsun on either side of the midline ( Fig. 48.2 )




    Figure 48.2


    Acupuncture point LR 13.



  • GB 34 (yang ling quan; “young mound spring”)—located in the deep depression 1 tsun anterior and 1 tsun inferior to the head of the fibula ( Fig. 48.3 )




    Figure 48.3


    Acupuncture points GB 34 and GB 39.



  • GB 39 (xuan zhong or jue gu; “suspended bell or severed bone”)—located 3 tsun directly above the tip of the lateral malleolus in the depression between the posterior border of the fibula and the tendons of the peroneus longus and brevis (see Fig. 48.3 )



  • BL 11 (da zhu; “great shuttle”)—located 1.5 tsun lateral to the lower border of the spinous process of the first thoracic vertebra ( Fig. 48.4 )




    Figure 48.4


    Acupuncture points BL 11 and BL 17.



  • BL 17 (ge shu; “diaphragm shu”)—located 1.5 tsun lateral to the lower border of the spinous process of the seventh vertebra ( Fig. 48.4 )



  • LU 9 (tai yuan; “great abyss”)—located at the transverse crease of the wrist in the depression on the lateral side of the radial artery ( Fig. 48.5 )




    Figure 48.5


    Acupuncture point LU 9.



  • LI 4 (he gu; “union valley”)—located between the first and second metacarpal bones in the deep depression of the web space ( Fig. 48.6 )




    Figure 48.6


    Acupuncture point LI 4.



  • PC 6 (nei guan; “internal gate”)—located 2 to 3 tsun above the transverse crease of the wrist, a deep depression between the tendons of the long palmar muscle and the radial flexor muscle of the wrist ( Fig. 48.7 )




    Figure 48.7


    Acupuncture point PC 6.



  • ST 36 (zu san li; “leg three miles”)—located 3 tsun below the patella and 1 tsun lateral to the crest of the tibia ( Fig. 48.8 )




    Figure 48.8


    Acupuncture point ST 36.



  • SP 6 (san yin jiao; “three yin intersection”)—located 3 tsun above the tip of the medial malleolus on the posterior border of the tibia ( Fig. 48.9 )




    Figure 48.9


    Acupuncture point SP 6.





Acupuncture Points


Acupuncture points are generally located in the deep depressions of muscles, joints, or bones and are often sensitive to pressure. The unit of measurement used to determine the locations of acupuncture points on the body is called a tsun , and measurement of a tsun is relative to the patient’s own body. One tsun (approximately 1 inch) is equal to the space between the distal interphalangeal joint and the proximal interphalangeal joint on the middle finger.




  • CV 12 (zhong guan; “central venter”)—located in the midline, 4 tsun above the umbilicus ( Fig. 48.1 )




    Figure 48.1


    Acupuncture points CV 12 and CV 17.



  • CV 17 (tan chung; “chest center”)—located in the midline of the sternum, between the nipples, at the level of the fourth intercostal space ( Fig. 48.1 )



  • LR 13 (zhang men; “camphor wood gate”)—located on the lateral side of the abdomen, below the free end of the 11th rib, 2 tsun above the navel and 6 tsun on either side of the midline ( Fig. 48.2 )




    Figure 48.2


    Acupuncture point LR 13.



  • GB 34 (yang ling quan; “young mound spring”)—located in the deep depression 1 tsun anterior and 1 tsun inferior to the head of the fibula ( Fig. 48.3 )




    Figure 48.3


    Acupuncture points GB 34 and GB 39.



  • GB 39 (xuan zhong or jue gu; “suspended bell or severed bone”)—located 3 tsun directly above the tip of the lateral malleolus in the depression between the posterior border of the fibula and the tendons of the peroneus longus and brevis (see Fig. 48.3 )



  • BL 11 (da zhu; “great shuttle”)—located 1.5 tsun lateral to the lower border of the spinous process of the first thoracic vertebra ( Fig. 48.4 )




    Figure 48.4


    Acupuncture points BL 11 and BL 17.



  • BL 17 (ge shu; “diaphragm shu”)—located 1.5 tsun lateral to the lower border of the spinous process of the seventh vertebra ( Fig. 48.4 )



  • LU 9 (tai yuan; “great abyss”)—located at the transverse crease of the wrist in the depression on the lateral side of the radial artery ( Fig. 48.5 )




    Figure 48.5


    Acupuncture point LU 9.



  • LI 4 (he gu; “union valley”)—located between the first and second metacarpal bones in the deep depression of the web space ( Fig. 48.6 )




    Figure 48.6


    Acupuncture point LI 4.



  • PC 6 (nei guan; “internal gate”)—located 2 to 3 tsun above the transverse crease of the wrist, a deep depression between the tendons of the long palmar muscle and the radial flexor muscle of the wrist ( Fig. 48.7 )




    Figure 48.7


    Acupuncture point PC 6.



  • ST 36 (zu san li; “leg three miles”)—located 3 tsun below the patella and 1 tsun lateral to the crest of the tibia ( Fig. 48.8 )




    Figure 48.8


    Acupuncture point ST 36.



  • SP 6 (san yin jiao; “three yin intersection”)—located 3 tsun above the tip of the medial malleolus on the posterior border of the tibia ( Fig. 48.9 )




    Figure 48.9


    Acupuncture point SP 6.





Basic Research


Numerous reports confirm that acupuncture has reproducible neurobiologic effects. Acupuncture inhibits the transmission of pain according to the gate control theory. It may act by stimulating sensory Aβ fibers and directly inhibiting the spinal transmission of pain by smaller Aδ and C fibers. Researchers have also been paying attention to the relationship between acupuncture and the production of endogenous opioid peptides, such as the endorphins and enkephalins, and stimulation of the endogenous descending inhibitory pathways. In an analysis of human cerebrospinal fluid, Sjolund and colleagues determined that endorphin levels in subjects become elevated following electroacupuncture. Acupuncture analgesia is caused mainly by activation of the endogenous antinociceptive system to modulate transmission of pain and the pain response.


Electroacupuncture at 2 Hz accelerates the release of enkephalin, β-endorphin, and endomorphin, whereas at 100 Hz it selectively increases the release of dynorphin. A combination of the two frequencies produces simultaneous release of all four opioid peptides, thereby resulting in a maximal therapeutic effect. Peripheral stimulation of the skin or deeper structures activates various brain structures, the spinal cord, or a combination via specific neural pathways. A human study by Mayer and associates indicated that acupuncture analgesia can be reversed by naloxone. Several serotonin antagonists inhibit the effects of electroacupuncture. Electroacupuncture attenuates behavioral hyperalgesia and stress-induced colonic motor dysfunction in rats. It also attenuates behavioral hyperalgesia and stress-induced colonic motor dysfunction in rats via serotonergic pathways.


Neuronal correlation to acupuncture stimulation in the human brain has been investigated with functional magnetic resonance imaging (fMRI). Acupuncture needle manipulation on the LI 4 (he gu) point modulates the fMRI activity of the limbic system and subcortical structure. Acupuncture stimulation at analgesic points involving the pain-related neuromatrix have been studied. Acupuncture stimulation at the GB 34 (yang ling quan) acupuncture point has elicited significantly higher activation than has sham acupuncture over the hypothalamus and primary somatosensory motor cortex and deactivation over the rostral segment of the anterior cingulated cortex.




Side Effects


The use of disposable sterile acupuncture needles avoids the risk of cross-contamination. Occasionally, the patient may experience bruising at the acupuncture site. Mild transient drowsiness may also occur. Pneumothorax is the most frequently reported serious complication related to acupuncture. In a study of the cases of 78 acupuncturists involving 31,822 acupuncture treatments in the United Kingdom, the most common adverse events reported were bleeding (310/10,000 consultations) and needling pain (110/10,000 consultations). The York acupuncture safety study surveyed 34,000 treatments by traditional acupuncturists. Aggravation of symptoms occurred in 96 of 10,000 cases, but none of these events were serious. There was subsequent improvement in the main complaint in 70% of cases. Major adverse consequences of acupuncture appear to be extremely rare. Acupuncture can be considered safe when performed by a competent and experienced acupuncturist, including appropriately trained practitioners in the pediatric population.

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Sep 1, 2018 | Posted by in PAIN MEDICINE | Comments Off on Acupuncture
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