Acupuncture MechanismsEast Meets West

Thomas Archie, MD, DABFM, DABMASt. Luke’s Wood River Medical Center

Integrative Therapies Service

Objectives

• Discuss proposed mechanisms of action of acupuncture from two points of view:– Western medicine– Chinese medicine

• Applications

• Complications

Acupuncture: China to Europe

• Huang Di Nei Jing – “Yellow Emporer’s Inner Classic”– Earliest existing major text on AP– 3rd-1st Century BCE

• Europe– 1500-1600s Jesuit missionaries gave earliest reports of Chinese

Medicine

• 1683 William Tin Rhijne– Dissertation on Arthritis

• 1671-1686: Three translations of Chinese medical texts – Detailed AP names, moxibustion, needle manipulation

Acupuncture Pre-Research

• Soulie de Mourant– Early to mid 1900s– Taught French physicians– Published 3 volumes of L’Acuponcture

Chinoise in 1939-1955

Early Acupuncture Research

• France– Mechanism studies beginning in 1940s

• China– Acupuncture pain relief studies started 1965

Early Electrical Studies

• 1940-50s Niboyet (France)• AP points – decreased electrical resistance relative

to surrounding skin• Most points w/ decreased electrical resistance

corresponded with Chinese AP charts• AP pts on classically paired meridians have

decreased Elect resistance compared with points on unpaired meridians

Early Chinese

Acupuncture

Meridian

Chart

Neurotransmitters

• Endorphin release by acupuncture– Pomeranz 1976 - endorphins (some analgesic

effects blocked by Narcan)– Clinical effect lasts much longer than blood

levels of endorphins– Seen in low frequency electroacupuncture

1979 – LeBarDiffuse Noxious Inhibitory Control

• Inhibit pain by counter-irritation stimulation • Serotonin and Endorphins mediate the response• Pain inhibition is directly related to intensity of

stimulus• Distance between conditioned site and site of

stimulation is not important• Detailed loop involving spinal tracts, brainstem,

and thalamus

Neurotransmitters

• Known increase in release during AP treatment– Serotonin, NE, Substance P, GABA, dopamine,

ACTH

• Opioid– B-endorphins, enkephalin, dynorphin

fMRI Study• Needle placed in foot Acupuncture point

associated with stimulation of brain’s visual cortex

fMRI Study

• Auditory Complex stimulated by needle placed in AP point on the leg associated with hearing

91% of Acupuncture Points share this Histology

Trigger Points

• 1977 – 71% correlation between Trigger Points and

Acupuncture points

Meridians

• Meridians have decreased electrical resistance relative to surrounding skin

• Qi measured as microelectrical current– Flows in a circuit– Toes to fingers to head to toes– Up on anterior surface of the body– Down on posterior surface of the body

Meridians

Future Research

• Central Nervous System (CNS) as a classic example of a nonlinear system– Billions of neurons and astrocytes– Response to environment is orderly but tends to change

with time– Functional MRI - change of CNS with time - important

for future research of mechanism

• Future research to look at CNS function as a whole, rather than function of its individual components

Future Research

• Outcomes research using – Existing research models (“sham” AP vs. “usual care”)

– Patient-centered, market-based models

• Interactive modalities (acupuncture, homeopathy, massage, reiki, healing touch) potentially better analyzed by a yet-undeveloped model

• Problems inherent in applying double-blind, placebo-controlled model

Dualism vs. Monism• Descartes/Newton designed a Dualist model

– Body and Mind are separate– Mind is a product of the Body (esp. Brain)– Study components and understand the whole

(ex: block breakdown of serotonin and thus increase longevity of serotonin to produce clinical improvement of depressed patient)

Dualism vs. Monism• Dualism: parts make up the whole (body vs.

mind/soul) – Allopathic Medicine – Descartes, Newton– Study components and understand the whole – Example: Serotonin enhanced via depression drugs

• Monism: body, mind, consciousness, universe are continuous and interactive – Traditional Chinese Medicine, Ayruveda– Example: Weather-related Wind invasion in person with

Liver Qi stagnation with Yin or Yang Deficiency as risk factor

• Cold/Flu vs. Vertigo vs. Autoimmune Disease – The individual is reflective of the universal, and vice-versa

Eastern Mechanisms

Rice

Vapor

Qi

Eastern Mechanisms

• Qi (Character with vapor rising above cooking rice)– Early 1900s - Soulie de Mourant- Qi = “energy” and

Jing = “meridian”– Simplified translation of complicated terms– “Life Force” made up of air and food transformed by

body into blood and body fluids

• Nei Jing written during 3rd – 1st Century BCE– Chinese physicians & cadaveric dissections– Using needles of glass, metal and bone to influence

neurovascular system

Meridians

• Acupuncture points linked together in lines called “meridians”

• Meridians named for associated Organ– Kidney, Heart, Small Intestine, Bladder– Liver, Pericardium, Triple Energizer,

Gallbladder– Spleen, Lung, Large Intestine, Stomach

Meridians

Different Acupuncture Models– Traditional Chinese Medicine (“TCM”)

• Eight Principles (Yin/Yang, Damp/Dry, Cold/Heat, Interior/Exterior)

• Zhang-Fu organ pairings blends Yin-Yang and 5 Element

– Five Element (Korean) • Wood, Fire, Earth, Metal and Water

– Meridian-based: Japanese, Vietnamese, French – Different schools of thought regarding etiology of

disease (Kidney versus Spleen/Stomach)– Neuroanatomical - CraigPENS, osteopuncture

Meridian-Based Acupuncture

• Blockage in meridian flow produces disease

• Therapeutic action of “unblocking” meridian flow (Relieving Stagnation)– Pain– Asthma– Heavy, Painful, or Irregular Menstrual Periods

TCM Qi Physiology

• Stomach separates pure from impure Qi of food– Pure Qi to Spleen

– Impure to Small Intestine (process repeats again)

• Spleen sends Food Qi to Lung– Lung combines it with pure Qi extracted from air

– Food/Air Qi “heated” by Yuan Qi (ancestral pilot light) provided by Kidney to make “Nutritive Qi”

• In Heart to make Blood

• In Meridians

Five ElementsSystem of

Correspondences

Fire

Wood

Water Metal

Earth

Five Element Acupuncture

• Imbalance between Elements causes Disease

• Example– Chronic overwork/abuse/disease leads to

deficiency of Water (fatigue, chronic UTI/stones/incontinence, joint pains, low back pain, fear, low self-esteem)

– Water controls Fire (Water Def – Fire Excess)– Excess Fire symptoms result (anxiety, hot

flashes, palpitations, insomnia, inflammation)

Five Element Acupuncture

• Patient Evaluation

• Pattern Recognition

• Treatment

• Reassessment for clinical effect

Patient Evaluation

• Evaluate history of medical/surgical diagnoses

• Patterns– Sleep, pain, digestion, emotional responses to

stressors, self-organization, flavor and color affinities, menstrual patterns, timing of symptoms (24hr, monthly, seasonal variations)

Pattern Recognition

• Five Elements

• Interconnections between Patterns

• TCM Eight Principles

Treatment

• Treat by “Tonifying” deficiencies and “Dispersing” excesses– Release excess Fire– Tonify deficient Water– Use Acupuncture and Chinese Herbs in

combination

Five ElementsSystem of

Correspondences

Fire

Wood

Water Metal

Earth

Five Element Correspondences

• Wood (Liver, Gallbladder) – Driven, multiple projects, movement,

anger/anxiety, tight traps/lateral neck/IT band, TMJ, migraines, caffeine sensitivity, fibromyalgia, blue/green, sour/citrus, Spring, expansion, insomnia (esp. sleep maintenance 11pm-3am), east

– Augments Fire, controls Earth, augmented by Water and controlled by Metal

– Coupled with Fire

Five Element Correspondences

• Fire (Heart, Small Intestine, Pericardium, Triple Energizer)– Creative, CEO, joy, palpitations, insomnia (esp.

sleep initiation), hot flashes, night sweats, cardiac disease, dysrhythmias, mania, red/orange, bitter/roasted, summer, south

– Augments Earth, Controls Metal, Augmented by Wood, Controlled by Water

– Coupled with Wood and Water

Five Element Correspondences• Earth (Spleen, Stomach)

– Nurturing, worry/obsession, GI issues (loose stools, gastritis, bloating, abd pain), sinusitis, cysts, tumors, lumps, dampness, obesity, chronic fatigue(multifactorial), sweet, dampness (cysts, edema), yellow/brown, transitions of seasons, center of compass positions

– Nurtures Metal, Controls Water, Controlled by Wood– Coupled with Metal

Five Element Correspondences

• Metal (Lung, Large Intestine)– Respiratory, skin disorders (“3rd lung”),

constipation, dryness, sense of duty, grief, loss, depression (multifactorial), flavorful/spicy, white/grey/colorless, autumn, west

– Nurtures Water, Controls Wood, Controlled by Fire

– Coupled with Earth

Five Element Correspondences

• Water (Kidney, Bladder)– UTI, Kidney stones, incontinence, joint pain,

low back pain, inner chill, abuse, philosopher, music, hearing problems, throat, winter, black, north, salty, motivation/willpower

– Nurtures Wood, Controls Fire, Controlled by Earth

– Coupled with Fire

Eastern Microsystems

• Holographic/fractal representation of homunculus on skin surface

• Tongue, Ear, hand, foot, scalp• Auricular medicine highly specialized by French• Ancient Egyptian paintings depict auricular

cautery• Nogier (FR) 1950s investigated history of ear

cautery for back pain

Homunculus

Chinese Diagnostics

• Tongue– Color, size, wetness/“scalloping”, coating, cracks

– Geographic representations of organs

– Clinical changes occur slowly (weeks)

• Pulses– Radial artery

– Organ assessment at certain positions/depths

– Clinical changes occur quickly (during treatment)

Kidney Yin DeficiencyExcess Heat in Heart

Invasion of Wind

Long, thin, dry, red body with lateral deviation

Dry yellow coat

Heart Yin and Blood Deficiency

Tongue body pale and tip red and pointed

No coat

Severe Yin DeficiencyLong-standing heat

or fire (LR or ST)

Red tongue body with black, dry central coat

(KI) Yang deficiency

Swollen, pale, scalloped, thin clear coat

Acupuncture Microsystems

• Auricular points (low electrical resistance) 90% accurate in recognizing past or present organ diseases (gastritis, asthma, past orthopedic surgeries) – Nogier (France)

• Recent randomized, double blinded, placebo-controlled study on pediatric bed wetting using Korean Hand AP system

So What Is It Good For?

Applications

• Studies of various standards• Value of RDBPCT design for interactive modalities

dubious• Internal Medicine

– Asthma, nausea, IBS, Crohn’s/UC, anxiety, depression, epilepsy, chronic UTI, eczema, sinusitis, allergies, headache, TMJ, Bell’s Palsy, neuropathy, stroke (scalp acupuncture)

• Substance abuse - smoking, chewing, opiates, alcohol, craving

Applications

• OB/GYN– Premenstrual syndrome, (peri)menopausal

symptoms, dysmenorrhea, menorrhagia, oligomenorrhea, infertility, labor pain, breech presentation

• Pain– Epicondylitis, plantar fasciitis, arthritis, low

back pain, neck pain, pelvic pain, zoster

Applications

• Essentially, any medical problem should be accessible with AP – Issues are practicality and density of disease

– Acupuncturist training and experience

• Role in Cancer– Helpful for decreasing side effects of chemo/radiation

– Especially with herbal therapy

– Facilitating spiritual transition to interaction with mortality

Veterinary Acupuncture

Veterinary Acupuncture

Clinical Research Examples

Knee Osteoarthritis

• Lancet. 2005 Jul 9-15;366(9480):100-1.• RCT 294 patients in 28 outpatient centers

– 12 treatments over 8 weeks– 3 groups (AP, sham AP, wait list control)– WOMAC index questionairre at 8, 26, 52 weeks– Result

• Pain and joint function improved more with acupuncture than with minimal acupuncture or no acupuncture in patients with osteoarthritis of the knee. However, this benefit decreases over time.

Low Back Pain

• JAMA. 1999;281:818-823. • 29 men and 31 women with LBP secondary to

degenerative disk disease• Treated with percutaneous electrical nerve stimulation

(PENS), sham-PENS, TENS, and exercise. • The PENS group had

– Significant and larger reductions in VAS scores– Decreased drug usage– Improved physical activity, quality of sleep, and sense of well-

being (P<.05 for each).

Low Back Pain

• Pain. 2002 Mar;96(1-2):189-96 • RCT with 131 consecutive outpatients with LBP for at

least 6 months and a normal neurological examination. • Randomization to one of three groups

– Each group received PT over 12 weeks– Plus either acupuncture, sham acupuncture, or no additional

treatment.– 20 treatments over 12 weeks

• Acupuncture was superior PT without acupuncture regarding pain intensity (P=0.000), pain disability (P=0.000), and psychological distress (P=0.020) at the end of treatment.

Chinese Herbal Medicine in Cancer

• Fu-Zheng pattern (correct predisposing patterns of deficiency and stagnation)– Symptom management and increase in survival– 197 pts Stage III and IV ENT cancers

randomized to radiation with or without TCM herbs (Yi Qi Yang Yin Tang). 3-year survival 67% vs. 33%.

Sun. Rec Results in Cancer Research 1988:108:327

Chinese Herbal Medicine in Cancer

• 303 patients with Stage III and 63 with Stage IV gastric cancer with chemo randomized to additional Pishen Fang herbal formula or to control group.– 5yr survival 53% Stage III with herbs and 10% Stage IV with

herbs– 10yr survival 47% Stage III with herbs

Yu. J Trad Chin Med 1993;13(1):31.

• 2001 first US FDA-approved clinical study of extract of Coix lachryma-jobi (called Kanglaite) for refractory non-small-cell carcinoma of lung. Phase 2 trial began 2003.

Previous Chinese studies show inhibition of mitosis of tumour cells during G2/M phase of the cell cycle, tumor cell apoptosis, increased gene expression of FAS and Apo-1, inhibits angiogenesis

What does Acupuncture Look Like?

Complications and Precautions• Retained Needle• Pneumothorax (any organ puncture)• Auricular infections• Other skin infections• Temporary (24hr) clinical worsening• Pregnancy

– Not a contraindication

– Theoretical concern of causing contractions

• Anticoagulation - not a contraindication

Recommended Readings

• Between Heaven and Earth, Beinfield and Korngold. Easily read book on Chinese Medicine

• Alternative Therapies in Health and Medicine. Peer-reviewed journal on integrative medicine. Excellent articles. Inexpensive. 6 issues per year.

Recommended Readings

• Vibrational Medicine, Gerber. Very well written on various forms of “energy medicine” - acupuncture, magnets, homeopathy, Bach flower essences, reiki...

Acupuncture MechanismsEast Meets West

Thomas Archie, MD, DABFM, DABMASt. Luke’s Wood River Medical Center

Integrative Therapies Service