Medical Acupuncture Chapter

Medical Acupuncture
17
Aram Mardian, MD
In the decade since the publication of the National Institutes of

Health (NIH) white paper on acupuncture in 1997, peer-reviewed,
responsible research into the mechanism and efficacy of acupuncture has been prolific. As this research has identified acupuncture
as a safe, efficacious, and cost effective modality to treat a variety of
pain problems, it is in the process of being gradually integrated into
the field of conventional pain medicine.
Brief History
Acupuncture is a complex therapeutic process that has its roots in
prehistory and is undergoing constant evolution as its use in the
conventional modern healthcare setting expands and understanding of its mechanism grows. Now, having existed for almost forty
years in the public consciousness of the general population of the
United States and scientific community, there is considerable familiarity with the basics of acupuncture as a therapeutic modality.
Most are aware that acupuncture is the use of thin, solid needles in
various patterns on the body. Although this is taken for granted in
21st century America, prior to July 26, 1971, outside of Asian communities, acupuncture was a wholly unknown entity in the United
States. On that date, James Restons landmark article describing his
experience with acupuncture in China was published in The New
York Times.1 Mr. Reston was a reporter for the Times who had
traveled to China in 1971 in preparation for Richard Nixons historic diplomatic visit. Mr. Reston required an emergency appendectomy in Peking and had his postappendectomy pain successfully
treated with acupuncture. This experience was recounted to the
American people in The New York Times publication and served
as the first major exposure of the English speaking U.S. population
to acupuncture. Shortly after Nixons trip, physicians began formal
and informal trips to China where they witnessed surgical anesthesia using only acupuncture needles. Whereas Restons article
ignited popular interest in acupuncture, these reports began to fuel
curiosity in the medical and scientific communities and served to
spark scientific exploration of the bizarre new technique. As the
specifics of the endorphin theory of acupuncture analgesia were
discovered in the late 1970s, respect within the scientific community grew proportionately.
While likely practiced for several thousands of years BCE,
the first known text that formally describes acupuncture theory is
Huang Di Nei Jing (Yellow Emperors Classic of Medicine), which
dates to the 2nd century bc. A more comprehensive text with
greater unification of acupuncture theories was written in the
firstand second centuries ad and was called the Nan Jing (Classic
of Difficult Issues). By this time, most of the concepts that underlie
classical acupuncture theory such as acupuncture point location,
channels, and disease classification had been defined. Transmission
of knowledge occurred largely along familial lines in China leading
to a multitude of diverse ways of practicing acupuncture.
From the 2nd century ad to the 16th century ad, these theoretical concepts and the practical application of acupuncture
underwent an extensive and continual refinement that typifies the
empirical evolution of this system of treatment. These refinements
and the current state of acupuncture theory and practice were captured in the Zhen Jiu Da Cheng (Great Compendium of Acupuncture and Moxibustion) which is attributed to Yang Ji-Zhou and was
published in 1601. This text, referred to as the Da Cheng, became
the preeminent source for medical information for subsequent generations in Asia and Europe. In fact, it was this text that was translated into various languages and transmitted to Europe and Japan
by traveling physicians and missionaries from the 1600s through
the 1900s and served as the basis for the development of classical
acupuncture in these regions.
The practice of acupuncture and herbal medicine experienced a dramatic decline in China in the first half of the twentieth
century. This process was driven by the larger cultural process of
modernization patterned after Western science during this same
period. Prior to the 19th century, China was the undisputed power
that dominated the Eastern Hemisphere. A series of events in the
19thcentury including the Opium Wars, the Taiping Rebellion, and
famine claimed tens of millions of lives and left China politically
weakened and at the mercy of Western powers such as the French
and the British for the first time in history. Accustomed to military
and scientific superiority, the defeat of China by the British in the
Opium Wars initiated a cultural drive to quickly adopt the principles of Western science that allowed their military adversaries to
prevail. This infatuation with Western military science spilled over
into all areas of science including medicine. This devotion to modernization according to Western principles was epitomized in the
early 1900s by the repudiation of classical acupuncture and Chinese medicine and a commitment to license only Western-trained
physicians.
Economic necessity and political expediency led to the simplification and systemization of the variegated forms of classical
acupuncture under Mao in the second half of the 20th century in
China. After Mao came to power, it became clear that the cadre of
newly trained Western physicians, numbering roughly 40,000, was
grossly inadequate to care for the more than 500 million Chinese
139
140 Complementary and Alternative Medical Procedures
citizens. Maos declaration that Chinese medicine is a great treasure-house came in 1958 and served as the theoretical basis for
the barefoot doctor movement that was initiated in 1969. During
this period, Mao called on previously marginalized practitioners of
acupuncture and classical Chinese medicine to create a simplified
system of Chinese medicine that could be easily taught and disseminated among his corps of barefoot doctors whose aim would be to
care for rural villages. This new system eventually became known
as Traditional Chinese Medicine (TCM). Ironically, this system is
a 20th century creation and omits many of the complexities and
nuances of pre-Mao classical Chinese medicine.2-6 Interestingly, the
pre-Mao classical forms of acupuncture find their most authentic
preservation outside of China, in Europe, Japan, and America.
The Japanese began practicing acupuncture in the 6th century
ad and developed unique forms of acupuncture. From its earliest
forms in Japan, acupuncture took on distinct qualities. Whereas in
China acupuncture was closely combined with herbal medicine, in
Japan physical medicine techniques and massage evolved in parallel
with acupuncture. Consequently, the acupuncture of Japan requires
the careful palpation of subcutaneous and muscular restrictions
and nodules. Because of this, Japanese acupuncture has found
an easy marriage with physical medicine techniques in modern
America such as osteopathic manipulation and Janet Travells trigger point therapy. The greater freedom enjoyed by modern Japanese
society when compared to modern China afforded an environment
more amenable to continued evolution and integration with other
modern medical practices.
Primitive experimentation with acupuncture began in Europe
during the early 19th century as translations of the Da Cheng
reached England, France, and Germany via military and missionary physicians returning from China. More serious integration with
modern Western medicine did not occur until the middle of the
20th century in Europe and later in the United States.2
Acupuncture is not Monolithic

It is important to realize that acupuncture is a general term that
subsumes many specific techniques. Rather than thinking of acupuncture as a monolithic therapy, it may be helpful to think of acupuncture as one would think of the term injection. Injections using
lidocaine and placed into an infraspinatus trigger point clearly represent a very different intervention as compared to a transforaminal epidural steroid injection or the intramuscular administration
of ketorolac. Acupuncture techniques can be as distinct.
A Brief Primer of Acupuncture Techniques

Classical Chinese acupuncture typically involves the insertion
of needles into locations on the body that have been empirically
defined over thousands of years. Depth of needles insertion is often
determined by achieving a characteristic aching or tingling sensation referred to as De Qi. When reference is made to classical or
traditional acupuncture points, this generally implies the group of
some 360 principal points described in ancient times. It is important to realize that classical acupuncturists have also described
several thousand additional extra acupuncture points. Classical
conceptions of acupuncture channels or meridians refer to linear
pathways that connect individual acupuncture points.
Japanese acupuncture also evolved throughout ancient times
and recognizes acupuncture points and channels similar to those
of classical Chinese acupuncture. Japanese acupuncture involves a

more refined system of palpation of subcutaneous and muscular
tissue and insertion of needles into areas of myofascial restriction
determined by this palpation. Depth of needle insertion is characteristically intracuticular and therefore much more superficial
than in classical Chinese acupuncture. A branch of Japanese acupuncture, Ryodoraku, describes acupuncture points and channels
as shifting anatomic location according to patterns of pathology
manifested by individual patients. Interestingly, many of the sham
acupuncture protocols in randomized controlled trials (RCTs) use
needling techniques identical to Japanese acupuncture.
Neuroanatomic acupuncture is a modern acupuncture technique that is characterized by the insertion of needles into points on
the body that have a neuroanatomic significance. Points are generally chosen with the aim of stimulating peripheral nerves, neurovascular bundles, fascia, tendons, muscles, ligaments, joints, and
richly innervated structures such as the periosteum and interosseus
membranes; electrical stimulation of these points is common. Neuroanatomic acupuncture uses classical acupuncture needle techniques according to modern biomedical knowledge.
Percutaneous neuromodulation therapy (PNT), also referred
to as percutaneous electrical nerve stimulation (PENS), is a specific form of neuroanatomic acupuncture that positions acupuncture needles in soft tissue or muscles to stimulate spinal nerves and
peripheral nerves. After a specific neuromusculoskeletal (NMS)
diagnosis is made, the spinal nerves that correspond to the dermatome, sclerotome, myotome, and autonomic innervation of the
pathologic region are stimulated at a variety of different electrical
frequencies in a variety of different patterns. Acupuncture needles
are also placed locally and regionally around the pathologic area
according to neuroanatomic principles and stimulated with a variety of electrical frequencies.
Auricular acupuncture is a microsystem technique that involves
the insertion of various types of needles into predetermined points
and points with altered bioelectrical conductance on the external
ear. As a microsystem, all aspects of the body are postulated to have
representation on the external ear in a holographic fashion. Chinese
scalp acupuncture (see Chapter 19) is also a microsystem technique
and is characterized by the threading of needles along the scalp
according to the underlying functional characteristics of the brain.
Medical Acupuncture is the Unification

of Classical Acupuncture and Modern Medicine
The optimal acupuncture treatment of pain problems requires
familiarity with classical acupuncture teachings as well as modern
neuromuscular anatomy and neurophysiology. This unique integration of classical and modern knowledge is the exception rather than
the rule among acupuncture practitioners. Many nonphysician acupuncturists lack the requisite familiarity and experience with the
modern neuroanatomic understanding of pain to optimally treat
many pain problems. While classical acupuncture techniques can
be quite effective in treating pain, an approach that does not include
the intentional integration of modern neuroanatomic concepts is
suboptimal. Among physicians who practice acupuncture, this integrated approach is the ideal, but also not the rule. Some physicians
obtain training only in modern neuroanatomic techniques, and this
is also a suboptimal approach to pain problems.
Medical acupuncture is the practice of acupuncture by physicians; as a discipline it represents the integration of classical
acupuncture with modern medicine. Medical acupuncture has
Medical Acupuncture 141
evolved since the middle of the 19th century initially in Western

Europe, then in Japan, and most recently in the United States.
It has found its most refined expression in the work of Joseph
Helms, MD. Helms has developed a robust and elegant integration of classical acupuncture with diverse modern acupuncture
techniques such as neuroanatomic acupuncture, PNT, auricular
acupuncture, and scalp acupuncture. It is this integrated system of
acupuncture that is referred to by the term medical acupuncture
in this chapter.
Medical Acupuncture Education

Medical acupuncture is taught to physicians in the United States
through continuing medical education courses. The World Health
Organization has promulgated acupuncture education standards
for physicians and recommends that licensed physicians obtain at
least 200 hours of formal training in acupuncture to acquire this
specialty medical skill.
The American Board of Medical Acupuncture (ABMA) was
established in 2000 to promote the safe and efficacious practice of
acupuncture by physicians through a standardized examination and
certification process. The ABMA is not a member of the American
Board of Medical Specialties. The ABMA stipulates requirements
for training, experience, and examination. In general, board certification by the ABMA requires 300 hours of formal training in acupuncture, a minimum of 2 years of clinical practice, and passing a
standardized written examination. The ABMA currently recognizes
10 training programs in the United States and Canada. The majority
of board certified physician acupuncturists have been trained by the
Helms Medical Institute, founded by Joseph Helms.
What are the Effects of Medical Acupuncture?

As a comprehensive therapeutic system with a variety of techniques, medical acupuncture has wide-ranging effects including
pain reduction, improvement in sleep, improvement in anxiety and
depression, a reduction in pain medication, improvement in function, and an improvement in energy and vitality.7-13 Conversely,
most therapies in conventional medicine have narrowly defined
effects such as pain reduction from an epidural steroid injection or
improved sleep from a sedative-hypnotic drug. Acupuncture that
is used to treat a pain problem can be expected to have multiple
effects simultaneously. This is particularly important because many
pain problems represent a vicious cycle of pain, dysfunction, psychoemotional disturbances, fatigue, and sleep problems. Part of the
robust nature of medical acupuncture is the ability to affect all of
these seemingly disparate problems.
Medical Acupuncture is More than Needling
The practice of medical acupuncture involves therapeutic lifestyle
recommendations in addition to needling. Specific dietary suggestions are often combined with prescriptions for exercise or activity
modification. Further, classical acupuncture teachings describe an
implicit relationship between physical dysfunction and imbalances
in the cognitive and emotional spheres. This relationship and the
specific areas of psychoemotional imbalances are discussed with
the patient. Having a coherent way to understand the relationship between physical and mental imbalances can be enormously
helpful for patients. By providing a means for understanding and
exploring self-defeating thoughts and behaviors, this system often
helps define a path for improving overall self-efficacy.
Medical Acupuncture View of the Human Organism

The accumulation of knowledge about human physiology, biochemistry, and pathophysiology within the sphere of modern medicine
has been prodigious in the last 50 years. Much of this progress has
relied on the ever improving ability to focus on the ever more exact
building blocks of the human body. Much of medical therapeutics
derives from this scientific process, but also remains incompletely
understood. For example, tricyclic antidepressants are effective
in treating many chronic pain states and are widely used for this
purpose. We know that these medications have many mechanisms
of action including the inhibition of presynaptic reuptake of serotonin and norepinephrine as well as blockade of sodium and voltage-dependent calcium channels.14 We do not know, however, the
mechanism of action responsible for analgesia,15 nor do we know
why some patients respond and others do not. Powerful reductionistic science has identified the mechanisms of these medications
and part of the pathophysiology of chronic pain, but will unlikely
reveal the unanswered questions of in vivo analgesic mechanisms
and individual variability of response. Modern scientific paradigms
from modern physics such as systems theory and quantum mechanics will likely be required to propel modern medicine into the next
stages of advancement. Scientific approaches to reality require both
reductionistic and synthetic processes of investigation. Systems
theory is an excellent example of a synthetic scientific approach.
Systems theory teaches us that complex systems as primitive
as unicellular organisms behave in ways that defy reductionistic,
linear laws. Whereas reductionistic models of scientific investigation have proved invaluable for determining many of the components of living systems, this approach to science is suboptimal in
providing information about how these components interact in the
living organism.16 Systems theory instructs that complex systems,
of which the human body is a quintessential example, have emergent properties. Emergent properties are unique properties of complex systems that are not present in any of the more simple parts of
the whole, but arise only when all parts interact to form the complex whole. A laudable yet nascent drive in modern medicine is the
administration of individualized care. The doctrine of conventional
modern medicine is that the specific disease entity must be identified and the pharmaceutical or intervention that is most appropriate to the disease entity must be delivered. That is, all patients with
knee osteoarthritis ought to receive the same treatment, all patients
with insomnia ought to receive the same treatment, all patients with
depression ought to receive the same treatment, and any patient
with all three diseases ought to receive all three treatments.
Systems theory teaches us that this is a rudimentary approach
to the complex system of the human body. First, not all humans
with the same disease process will respond the same way to the
same treatment. We know that there are individual differences in
the pharmacokinetics of medication metabolism and individual
differences in the healing process after surgery.17-19 Thus, the best
principles of modern science tell us what Dr. Osler told us more
than 100 years agoIt is much more important to know what sort
of a patient has a disease than what sort of a disease a patient has.
The goal, then, is individualized approaches that take the complexity of the persons constitution as well as the disease process into
account. The specific science and ability to do this in clinical practice is developing, but still poorly defined.
Interestingly, medical acupuncture presents clinicians with an
approach that follows these ideals. Part of the nonspecific effects
that are attributed to acupunctures effectiveness in RCTs may in
fact be due to the systematic approach of acupuncture that seeks to
17
identify constitutional factors for a patient and individual treatment

for a presenting complaint based on that persons identity and constitution. The classical framework of acupuncture has developed
an empirical system that, in essence, looks for emergent properties. Through the thousands of years of empirical observations and
subsequent pattern definition, acupuncture has sought to answer
the following types of questions: What unique characteristics arise
when a person complaining of knee pain also is a competitive, hard
driving, leader without other medical problems, versus an overweight, jovial man who also suffers from chronic, debilitating allergic rhinitis? While the conventional approach to treating knee pain
in these two patients would be identical, with likely variable results,
the acupuncture approach for each would be unique, likely with
good results based on large RCTs.20,21
Most of these aspects of acupuncture have not been explored
from the perspective of conventional science such as RCTs and are
largely speculative. However, such factors, which have been derived
from millennia of careful observation and inductive reasoning, may
provide insight into the efficacy of acupuncture observed in clinical trials and may lead to new theories that will further reveal the
myriad of unknown mechanisms in the functioning of the human
body in health and disease.
Medical Acupuncture and the Treatment of Complex Chronic Pain
Medical acupuncture is a versatile modality that interacts with psychological, neurologic, endocrine, immunologic, and musculoskeletal aspects of the human organism.22-27 With these multiple points
of input, medical acupuncture is ideally suited for the treatment of
pain, which by nature manifests in the psychoneuromusculoskeletal
sphere of humans.
The human organism is viewed as a complex multidimensional
and integrated whole by physician acupuncturists. This view contrasts with that typically held by conventional pain medicine physicians. Conventional medicine is generally satisfied with dissecting
an organism or molecule down to its smallest part and assuming
that it understands the functioning of the organism when it has
understood the functioning of all of its parts. In conventional
clinical pain medicine, we are generally looking for one of a relatively few pain generators, such as a herniated nucleus pulposus or
degenerated cartilaginous surface. As such, the biomedical model
of pain seeks to identify and treat the physical pain generator that
is assumed to be the sole cause of the patients pain. Recognition
that this approach is inadequate has fostered the development of
the biopsychosocial model used to understand and treat pain states.
Similarly, medical acupuncture recognizes that many pain
problems are a complex manifestation of dysfunction in multiple
spheres: myofascial, neurologic, psychological, emotional, endocrine, and genetic. Further, it is recognized that the experience
of the organism is greater than the sum of all of these individual
spheres.
Ronald Melzack recently described a new theory of pain that
proposes a similarly complex and multidimensional view of pain
problems. It is intriguing that medical acupuncture is capable of
influencing virtually all of the components described by Melzacks
new theory of pain.
The Neuromatrix Theory of Pain

Consciousness in general and the awareness and experience of
pain in particular are phenomena that remain more in the realm
of mystery than in clear understanding. The medical acupuncture
view of these phenomena closely parallels many aspects of the

most instructive modern theories. The gate control theory holds
that peripheral noxious signals are transmitted to the brain for conscious sensation via the spinal cord. These signals are modulated
by other afferent inputs from the periphery and also by descending
control from subcortical brain centers.
In 2004, Melzack promulgated a revision to his original gate
control theory which he terms the neuromatrix theory of pain.
Arevision of the original theory was prompted by clinical experience with amputees with phantom limb pain. These patients continue to experience identical patterns of arm pain, fatigue, itch, and
movement in the absence of the affected limb. Out of these observations, a new theory is derived that focuses primarily on the brain.
Melzack describes his neuromatrix theory subsequently.
The neuromatrix theory of pain proposes that pain is a multidimensional experience produced by characteristic neurosignature patterns of nerve impulses generated by a widely distributed
neural networkthe body-self neuromatrixin the brain. These
neurosignature patterns may be triggered by sensory inputs, but
they may also be generated independently of them. Acute pains
evoked by brief noxious inputs have been meticulously investigated
by neuroscientists, and their sensory transmission mechanisms are
generally well understood. In contrast, chronic pain syndromes,
which are often characterized by severe pain associated with little or
no discernible injury or pathology, remain a mystery. Furthermore,
chronic psychological or physical stress is often associated with
chronic pain, but the relationship is poorly understood. The neuromatrix theory of pain provides a new conceptual framework to
examine these problems. It proposes that the output patterns of
the body-self neuromatrix activate perceptual, homeostatic, and
behavioral programs after injury, pathology, or chronic stress. Pain,
then, is produced by the output of a widely distributed neural network in the brain rather than directly by sensory input evoked by
injury, inflammation, or other pathology. The neuromatrix, which
is genetically determined and modified by sensory experience, is
the primary mechanism that generates the neural pattern that produces pain. Its output pattern is determined by multiple influences,
of which the somatic sensory input is only a part, that converge on
the neuromatrix.28
Melzacks neuromatrix theory of pain shifts the focus away
from the Cartesian concept of a one-to-one relationship between
specific sensory experiences such as tissue damage or inflammation
and the sensation of pain. This particularly applies to chronic pain
states in which multiple factors such as psychological stress, physical injury, and cognitive states affect a genetically influenced and
widely distributed neural network to produce multidimensional
outputs such as the awareness and perception of pain as well as
dysfunctional thoughts and action patterns.
This theory, then, proposes a richly complex understanding of
chronic pain that emphasizes the role of genetics, thoughts, emotions, physical sensations, stress pathophysiology, and the emerging
field of psychoneuroimmunology. The medical acupuncture view of
chronic pain has many parallels to Melzacks neuromatrix theory,
both in its understanding of the sources of chronic pain and in its
treatment.
Figure 17-1 illustrates the sensory inputs that influence the
genetically determined neuromatrix: cognitive, sensory, and emotional. Medical acupuncture targets all of these inputs, the neuromatrix itself, and also the output programs that are often dysfunctional.
Classical acupuncture often focuses on psychoemotional disturbances, whereas modern neuroanatomic acupuncture aims at

INPUTS TO BODY-SELF
NEUROMATRIX FROM:
COGNITIVE-RELATED BRAIN AREAS
Memories of past experience,
attention, meaning, anxiety
SENSORY SIGNALING SYSTEMS
Cutaneous, visceral,
musculoskeletal inputs
BODY-SELF
NEUROMATRIX
C
S
A
EMOTION-RELATED BRAIN AREAS

Limbic system and associated
homeostatic/stress mechanisms
TIME
OUTPUTS TO BRAIN AREAS

THAT PRODUCE:
PAIN PERCEPTION
Sensory, affective, and
cognitive dimensions
ACTION PROGRAMS
Involuntary and voluntary
action patterns
STRESS-REGULATION PROGRAMS
Cortisol, norepinephrine, and
endorphin levels
Immune system activity
TIME
Figure 17-1 Factors that contribute to the patterns of activity generated by the body-self neuromatrix, which is composed of sensory (S), affective (A), and
cognitive (C) neuromodules. The output patterns from the neuromatrix produce the multiple dimensions of pain experience, as well as concurrent homeostatic
and behavioral responses. (Adapted from Melzack R: Evolution of the neuromatrix theory of pain. The Prithvi Raj lecture: Presented at the Third World Congress of
World Institute of Pain, Barcelona 2004. Pain Pract 5:85-94, 2005.)
treating musculoskeletal sources of dysfunctional inputs to the neuromatrix as well as spinal cord regions involved in spinal modulation. Scalp and auricular acupuncture are directed at affecting the
neuromatrix itself. Acupuncture has also been shown to influence
the stress regulation output program of the neuromatrix.22,29 While
Melzack emphasizes the genetic contribution to the neuromatrix,
classical acupuncture always strives to understand and treat the constitution of an individual, which can be understood as the genetically
determined phenotype of an individual.
The conventional biomedical approach to pain focuses evaluation and management strategies solely on the musculoskeletal sensory inputs to the neuromatrix, much in line with the Cartesian
understanding of pain processing. And, within this subset of sensory inputs, the focus is even more narrowly put on joint, nerve,
and tendon generators of afferent activity.
The medical acupuncture approach to pain not only recognizes
the value of treating all three groups of inputs to the neuromatrix
(see Fig 17-1), but also focuses on an expanded set of tissues in the
periphery capable of stimulating the neuromatrix. As such, medical acupuncture not only evaluates and treats dysfunctional joints,
nerves, and tendons, but also muscle, ligaments, and fascia. Furthermore, medical acupuncture directs therapy at the neuromatrix
itself and the stress response output program of the neuromatrix.
This ability to comprehensively intervene at all points in
Melzacks neuromatrix theory for pain experience (sensory inputs,
neuromatrix itself, and subsequent outputs) defines medical acupuncture as a uniquely robust therapeutic tool for the treatment of
pain problems.
Mechanisms
Twentieth Century Mechanisms
Since its introduction to the American scientific community in the
1970s, acupuncture has often been perceived as a therapeutic modality whose mechanism is mysterious and unknown at best, and inert
in terms of modern physiology at worst. Researchers who sought to
prove the latter hypothesis as well as those who were curious about
discovering possible physiologic mechanisms produced a prolific
body of basic science data in the 1970s and 1980s. This research led to
the endorphin and monoamine hypothesis of acupuncture analgesia

which has since been supported by an enormous collection of animal and human studies. Bruce Pomeranz, PhD, was one of the most
prominent researchers in this area. He, indeed, set out to prove that
acupuncture had no measurable physiologic effects. After publishing
66 papers investigating the mechanism of acupuncture analgesia, his
conclusion was that the evidence supporting the endorphin hypothesis for acupuncture analgesia was stronger than that for almost any
other therapeutic agent used in conventional medicine (Fig. 17-2).
An acupuncture needle entering the skin and muscle in the
arms or legs will activate unmyelinated C-fibers and small diameter
myelinated A-delta fibers in the periphery that synapse onto cells of
the anterolateral tract in the dorsal horn of the spinal cord. These
cells give rise to two sets of projections. One set travels rostrally to
eventually synapse on the midbrain, pituitary, and hypothalamus.
The other set synapses on inhibitory interneurons in the spinal
cord where dynorphin and enkephalin are released presynaptically
to block ascending neurotransmission of painful signals along the
spinothalamic tract. Meanwhile, the rostrally projecting cells of the
anterolateral tract will stimulate cells in the periaqueductal gray causing the release of enkephalin, which will disinhibit cells of the raphe
nucleus. The raphe nucleus is part of an endogenous descending analgesic pathway. Disinhibition of these cells activates this descending
analgesic pathway, which causes the release of monoamines such as
serotonin onto cells of the spinothalamic tract in the spinal cord that
carry painful stimuli to the brain. Serotonin postsynaptically inhibits
these cells, thereby dampening down the neurotransmission of painful signals from the periphery to the brain along the spinothalamic
tract. Thus, the original acupuncture stimulus activates multiple neurochemical pathways in the brain and spinal cord and decreases the
neuronal transmission of painful stimuli from the periphery to the
brain.30 The ascending anterolateral tract neurons also stimulate the
pituitary to release ACTH and -endorphin into the bloodstream.30
Twenty-First Century Mechanisms
Whereas 20th century research of the mechanism of acupuncture
paralleled the discovery of the endorphin receptors and the gate
control theory of pain, 21st century research is focusing on the
brain, neuroimmunology, and connective tissue.
17
STT
2
Painful
stimulus
11
DLT
Mid
brain
7 M
Thalamus
Cortex
Pituitary
hypothal
10
14
Skin
9
E
E
E
Muscle
12 13
Acu
needle
ALT
5
Spinal cord
Figure 17-2 Model developed from research by Dr. Pomeranz. (Adapted from Stux G, Pomeranz B (eds): Basics of Acupuncture: Berlin, 2005, Springer p27.
The research of Helene Langevin, MD focuses on the role

of connective tissue as a dynamic whole body communication
matrix and offers a fascinating model for the mechanism of acupunctures affect on the body. Loose connective tissue forms an
anatomic network throughout the entire body. Most medical doctors spend little time thinking about fascia and connective tissue,
and when they do, they think of it as purely structural in nature.
In reality, fascia and connective tissue are intimately involved
in complex regulatory mechanisms in the body such as ligandreceptor binding and gene transcription. Mechanotransduction is
the biophysical process that is at the center of this research and
forms the link between structure and function. Mechanotransduction is the process by which cells sense mechanical forces and
transduce them into changes in intracellular biochemistry and
gene expression.
What is Fascia?
Fascia is loose connective tissue that surrounds and interpenetrates
all components of the human body including muscles, nerves,
blood vessels, and organs. It provides structural integrity, serves as
a matrix for intercellular communication, and is involved in biochemical and bioelectric signaling. The structural integrity of the
soft tissue of the body is composed of a complex network of fascia and loose connective tissue on the macroscopic level and an
equally complex microscopic network. The microscopic network is
composed of an extracellular matrix of collagen and fibroblasts and
an intracellular cytoskeleton of microfilaments, intermediate filaments, and microtubules.
How Does Acupuncture Interact with Fascia and Loose Connective
Tissue?
The research of Langevin and colleagues has demonstrated that
the twirling of the acupuncture needle that is typical in clinical
practice creates mechanical changes in the collagen and fibroblast
network of the extracellular matrix. In fact, her work using histologic sections and specialized ultrasonography has shown that
the manipulation of the acupuncture needle produces characteristic changes in the surrounding loose connective tissue such as
the wrapping of collagen fibers. She has demonstrated that these
mechanical changes in the connective tissue are accompanied by
active cellular changes such as lamellapodia formation and fibroblast spreading. Although not yet conclusive, this research supports the hypothesis that acupuncture needling activates diverse
biological processes such as gene transcription, protein synthesis,
and neuromodulation through the mechanism of mechanotransduction (Fig. 17-3). These biochemical phenomena may underlie
many of the unknown mechanisms of the therapeutic effects of
acupuncture.31-34
Biochemical Milieu of Trigger Points
Although the subject is not as novel as the work of Langevin and
colleagues, the research of Jay Shah, MD is equally fascinating and
instructive. Clinicians have long relied on the pioneering work of
Janet Travell, MD in treating myofascial pain. Trigger point needling with and without local anesthetic is used by medical acupuncturists to treat many types of myofascial pain. However, until
recently, convincing basic science research characterizing the qualities of trigger points has been lacking. In the January 2008 publication of The Archives of Physical Medicine and Rehabilitation, Dr.
Shah describes an innovative technology that allows the real time
biochemical assay of the trigger point milieu. A 30-gauge microdialysis needle is used to noninvasively sample 11 histochemicals
in clinically identified trigger points. This study confirms that biochemicals associated with pain and inflammation (protons, substance P, TNF-, bradykinin, and many others) are present in higher
concentration in active trigger points than in latent trigger points
and control muscle points. Furthermore, after needling the trigger points, concentrations of substance P, and CGRP are shown to
decline. Though requiring additional study, this work offers a convincing basic science explication for the mechanisms underlying
the dry needling of trigger points that is an integral part of medical
acupuncture.35,36
Rotation
17
Collagen
Focal adhesion
F-actin
Mechanoreceptor/
nociceptor
Fibroblast
Needle
Mechanoreceptor/nociceptor stimulation
SENSORY
AFFERENTS
Winding
Matrix deformation
Matrix deformation
Matrix deformation
FIBROBLASTS
Mechanotransduction
Mechanotransduction
Actin
polymerization
Actin
polym.
Cell contraction
ERK phosphorylation
Mechanotransduction
Actin
polymerization
Cell contraction
ERK phosphorylation
Cell contraction
ERK phosphorylation
Gene expression, protein synthesis, and secretion
Extracellular milieu modification
Neuromodulation
Figure 17-3 Hypothesis summary. Proposed mechanical signal transduction and downstream effects of acupuncture needle manipulation at gross and microscopic levels. Shaded areas represent deep connective tissue planes of the upper arm. The acupuncture needle is inserted on the lateral border of the biceps.
Arrows represent pulling of connective tissue and matrix deformation during acupuncture needle manipulation. The lung acupuncture meridian is located
along the lateral border of the biceps and may coincide with some of the outlined connective tissue planes. (Adapted from Langevin HM, Churchill DL,
CipollaMJ: Mechanical signaling through connective tissue: A mechanism for the therapeutic effect of acupuncture. FASEB J 15: 2275-2282, 2001.)
Brain Imaging
Extensive animal and human data indicate that many of the beneficial effects of acupuncture are mediated through the central
nervous system. However, whereas mechanisms such as central
modulation of endorphins and monoamines and the recruitment
of the midbrain descending analgesia system are well characterized,
much is not known about how acupuncture interacts with the CNS.
In the last decade, interest has accelerated in the use of functional
magnetic resonance imaging (fMRI) and positron emission tomography (PET) imaging to further understand the effects of acupuncture on the brain.
Acupuncture Effects on the Brain

Nonpainful stimulation of peripheral nerves using transcutaneous electrical stimulation causes an increase in activation of the
somatosensory, motor, premotor, posterior parietal, and cingulate
cortices, as well as the thalamus and cerebellum as measured by
fMRI.37,38 Painful stimuli produce activation in multiple regions of
the brain including the primary and secondary somatosensory cortices, the insular cortex, the anterior cingulate cortex, the thalamus,
and the prefrontal cortex.39
Reproducible data show that acupuncture modulates an
extensive network of cortical, subcortical, and brainstem regions
Digit 2
CTS: Baseline
CS
L
(contra)
CTS: Postacupuncture
R
(ipsi)
PreCG
Digit 3
SI
Digit 5
SII
Figure 17-4 Group maps of CTS patients at baseline and postacupuncture for D2, D3, and D5 nonnoxious electrostimulation. Activation (color-coded P-value)
was overlaid onto group-averaged inflated brains with gray-scale defined curvature (sulci dark, gyri light). Both right (ipsilateral) and left (contralateral) hemispheres are shown. Hyperactivity in contralateral sensorimotor cortex seen for median nerve innervated D3 diminished after acupuncture treatment. Differences
for D2 and ulnar nerve innervated D5 were less profound. Contra, Contralateral; CS, Central sulcus; CTS, CT scan; ipsi, Ipsilateral; SI, SII. (From Napadow V, Liu J,
LiM, et al: Somatosensory cortical plasticity in carpal tunnel syndrome treated by acupuncture. Human Brain Mapping 28:159-171, 2007.)
in the brain.40 Numerous fMRI studies have demonstrated that

acupuncture elicits a response in multiple cortical regions including the primary and secondary somatosensory cortices, the insular
cortex, and the prefrontal cortex when compared to a variety of
needle and nonneedle controls.40 A robust limbic network, including the hippocampus, amygdala, hypothalamus, and anterior cingulate cortex is also modulated.41 Brainstem structures involved in
endogenous descending analgesia such as the periaqueductal gray
are recruited by acupuncture therapy.42 Whereas nonacupuncture transcutaneous stimulation of peripheral nerves and painful
peripheral stimuli generally produce an increase in signaling in
the brains pain matrix, acupuncture therapy produces a modulation or a decrease in signaling intensity in the same regions of the
brain.22
Interestingly, acupuncture stimulates widespread deactivation
of brain regions involved in the affective and cognitive aspects of
pain, and also is able to influence the brain structures that control
the physiologic stress response. The amygdala translates somatosensory stimuli into affective states. The amygdala exhibits patterns
of sensitization and hyperactivation in response to chronic pain
states.43 Acupuncture therapy elicits deactivation of the amygdala
in healthy controls and in patients with chronic pain. Additional
limbic structures involved in consolidation of somatosensory memory and the interface of cognitive and emotional mentation are also
affected by acupuncture.22,29 The hypothalamus receives and integrates diverse information about the internal and external environment and produces a coordinated output program. A major aspect
of hypothalamic output is orchestration of the bodys response to
physiologic and psychological stress through the hypothalamicpituitary-adrenal axis. The classical descriptions of acupuncture
encouraging a return to homeostasis in the body are interesting
in light of recent fMRI research demonstrating modulation of the
hypothalamus in pain states.22,29,41
Napadow and colleagues have also explored the effects of

acupuncture on the dysfunctional neuroplasticity that develops in
chronic pain patients. This dysfunctional central neuroplasticity
may be part of the basis for their persistent pain, and its correction may underlie some of the therapeutic effects of acupuncture in
chronic pain states.29,44,45
A fascinating set of studies by this group has evaluated the
brain effects of acupuncture on carpal tunnel syndrome (CTS)
patients versus healthy controls. For the patients with CTS, the
region of the sensorimotor cortex subserving the first three digits
of the affected hand demonstrated hyperexcitability to nonnoxious
stimuli when compared to healthy controls. After 13 acupuncture treatments performed over 5 weeks, the dysfunctional cortical hyperexcitability seen in the carpal tunnel patients diminished
significantly. Healthy controls did not exhibit a similar rearrangement in cortical activity. These studies are an excellent example of
the beneficial neuroplasticity that can be induced by acupuncture
therapy.22,44,45
Figure 17-4 illustrates group-averaged difference mapping of
the contralateral sensorimotor cortex for CTS patients before and
after acupuncture. Hyperactivity to nonnoxious stimuli in the contralateral sensorimotor cortex was exhibited in the median nerve
innervated third digit at baseline. This hyperactivity in the third
digit diminished after acupuncture treatment.
Activation of Neuronal Networks
Central nervous system disorders such as Parkinson disease,
chronic pain, and depression are thought to involve the disruption
of key neuronal networks. Faingold hypothesizes that electrical
stimulation therapies such as deep brain stimulation, vagus nerve
stimulation, electroconvulsive therapy, and acupuncture exert their
therapeutic effects by recruiting dormant neuronal networks that
compete with and override the pathologic networks mediating
disease. It is suggested that the overall manifestation of symptoms

by the individual is determined by which neuronal network (pathologic or therapeutic) prevails and achieves control of the affected
brain function. Thus, Faingold postulates that the mechanism
of electrical stimulation therapies such as acupuncture involves
the stimulation of potentially therapeutic dormant neuronal networks that subsequently manifest as elimination or diminution in
symptoms.46
Does Needling of Acupuncture Points Produce

Different Brain Activation Patterns than Needling
of Nonclassically Defined BodyLocations?
Why is this an interesting question? On the one hand, practitioners
of classical acupuncture are eager to demonstrate that the needling
of classically defined acupuncture points produces significantly
different effects from the needling of nonclassically defined locations. On the other hand, several large and well done clinical studies of acupuncture have yielded similar clinical benefits for patients
treated with classical acupuncture and minimal acupuncture, which
is variably defined as superficial needling at classical acupuncture
points and needling at nonclassical locations, when compared to
patients receiving standard conventional treatments.47-49
Other large clinical studies show a significant clinical difference
in the benefit achieved with classical versus nonclassical needling.
From the clinical standpoint, it is clear that most needling interventions (classical acupuncture and minimal acupuncture) have a beneficial effect. Point selection may be less important in determining
clinical efficacy. Exploring the differential neurobiologic effects of
needling classical versus nonclassical locations will aid in the understanding of this phenomenon observed in clinical trials.
Data from fMRI Studies
Wu and colleagues observed that electroacupuncture at a nonacupuncture point (sham acupuncture) produced some of the same
cortical changes as electroacupuncture at a classical acupuncture
point (real acupuncture). Both sham and real acupuncture produced similar effects in the caudal segment of the anterior cingulate cortex, insula, secondary somatosensory cortex, thalamus, and
cerebellum. However, real acupuncture produced additional effects
in the limbic system not observed with sham acupuncture. Specifically, difference mapping demonstrated activation of the hypothalamus and deactivation of the anterior cingulate cortex with real
acupuncture versus sham acupuncture.50
Acupoint Specific Brain Activation
There are data to support the notion that acupuncture points exert
a specific pattern of stimulation of the brain corresponding to the
classical descriptions of the points.51 These results, however, have
not been consistently reproduced.
Optimal Acupuncture Therapy for Pain

The evaluation of the painful condition follows the framework of a
general medical evaluation. A detailed history is obtained from the
patient with care to elicit clues to the neuromusculoskeletal source
of the pain, psychoemotional interplay, components of maldynia
such as dysfunctional thoughts, beliefs, and actions, as well as pertinent aspects of social relationships, and the patients underlying
constitution. A detailed and focused physical examination is performed with particular attention to finding a neuromusculoskeletal
source as well as any contributing underlying or secondary factors.

This is an area that may receive greater attention than in modern
pain medicine. For example, a patient with postsurgical pain may
receive a diagnosis of adhesions producing visceral pain or neuropathic denervation pain from a pain physician with all therapies
aimed at this particular diagnosis. The physician acupuncturist will
not only identify and address the underlying denervation pain, but
will also explore the possibility of myofascial dysfunction that exacerbates the neuropathic pain. By treating the secondary myofascial
component, the neuropathic aspect may become more amenable
to treatment.
Optimal acupuncture therapy for pain problems involves matching the most appropriate neuroanatomical acupuncture techniques
with the patients neuromusculoskeletal diagnosis. This neuroanatomic acupuncture input is then reinforced by microsystem therapy
and classical acupuncture therapy. Determining a precise NMS
understanding of the presenting pain problem, then, is central to
the medical acupuncture approach to pain. The NMS diagnosis will
attempt to identify primary, secondary, and tertiary dysfunction at
various levels in the physical organism.
Neuromusculoskeletal Diagnosis
A precise NMS diagnosis identifies specific areas of dysfunction in
the structure of the physical body and at various points in the nervous system.
Physical examination maneuvers and knowledge of the functional anatomy are combined to locate primary, secondary, and
tertiary problems in the following zones: skin and subcutaneous
tissues, superficial fascia, surface and deep muscles, myotendinous junctions, tendons, bursae, joints, ligaments, and bone. Similarly, subjective descriptions of the pain by the patient, physical
examination maneuvers, and knowledge of the neurophysiology
of pain are used to determine areas of dysfunction in the nervous system: Peripheral nerve, neuromuscular, spinal cord, and
brain. When the structural and neurologic aspects of the pain
problems have been clearly identified, the physician acupuncturist will select from a wide array of needling techniques to address
the lesions.
These therapeutic inputs are designed to alter the peripheral
nociceptive inputs while also addressing the abnormal neuronal
processing of pain signals that characterizes many chronic pain
problems. For example, consider a patient with painful peripheral diabetic neuropathy. An initial peripheral input will supply
electrical stimulation to acupuncture needles inserted adjacent to
the interdigital nerves of the hands or feet. A variety of electrical
frequencies can be applied during the same treatment or sequentially at successive treatments. This basic peripheral input can be
augmented by vibratory stimulation of the richly innervated interosseus membrane of the forearm or leg with the intent of disrupting dysfunctional dysregulation of the autonomic nervous system.
The central pathologic changes that often occur in many chronic
pain states can be addressed with acupuncture inputs that influence the spinal nerves corresponding to the dermatome, myotome,
sclerotome, and splanchnotome of the pain problem.
Neuroanatomic acupuncture inputs are designed to address
various aspects of the neuromusculoskeletal system and are ideally
suited for addressing the interrelated NMS matrix of the body. The
physician acupuncturist seeks to identify and correct the dysfunctions of the NMS matrix that occur in pain states.
One important aspect of systems of classification, such as
medical diagnosis, is identifying clinical entities that are likely to
17
respond to particular treatments. With this in mind, the physician acupuncturist explores the NMS matrix of the pain patient
for clinical syndromes that respond to NMS acupuncture inputs.
For example, the physician acupuncturist does not rely solely on
pathodiagnostic classifications such as herniated lumbar disc or
lateral epicondylitis. Rather, these diagnoses are used as starting
points and additional contributing factors are sought. Commonly,
muscular trigger points and tightness of the superficial fascia will
complicate and exacerbate pain considered to be neuropathic in
origin. Similarly, abnormal regional and spinal segmental neuronal
processing will often accompany muscular, ligamentous, and tendinopathic pain. Recognizing these interrelated dysfunctions of pain
problems is particularly important and germane because acupuncture is well suited to address muscular, fascial, neuronal, tendinous,
ligamentous, and visceral dysfunctions.24,31,35,52
Pain is a Mind Body Problem and Medical Acupuncture
is a Mind Body Treatment
Pain is a unique medical problem that cuts across virtually all
areas of medicine. At its core it epitomizes all of the subtleties
and complexities of mind-body holism. It is now clear that any
model seeking to explain the experience and pathogenesis of
pain is incomplete if it omits the impact of our thoughts and feelings, actions, social relationships, or biomedical makeup. The
arena of pain medicine matches these multifaceted aspects of
pain with the multidisciplinary pain clinic that housesunder
one roofbiomedical pain specialists emphasizing interventional and pharmaceutical approaches, psychologists addressing the psychoemotional component of pain, physical therapists
with expertise in reconditioning and manual techniques, and a
hodge-podge of complementary techniques primarily based on
market demand. Unfortunately, the economic situation of modern medicine in the United States at the beginning of the 21st
century fosters fragmented, intervention-based medical care even
within multidisciplinary pain clinics. In fact, economic necessity
is now the organizing principle of many multidisciplinary pain
clinics compared to the original founding goal of offering truly
holistic pain medicine based on the biopsychosocial model.
Although many interventional approaches have little evidence
for efficacy,53-55 they are reimbursed by third party payers at high
rates and therefore generate the majority of revenue at multidisciplinary pain clinics. Because of this, these invasive therapies
are often used more frequently than less expensive, conservative
therapies based on the biopsychosocial model of pain that are
supported by stronger evidence.56
Because medical acupuncture provides a framework for evaluating and treating physical, emotional, and psychological aspects of
a patient, it can serve as a model for the multifaceted management
of pain problems. Ideally, the medical acupuncture management of
complex pain problems takes place within an integrated medical
team. The integration of medical acupuncture within the greater
system of pain medicine is discussed subsequently.
As a therapeutic input that provides an orchestrated therapy
directed at a patients psychoemotional state and neuromusculoskeletal dysfunctions, medical acupuncture is uniquely suited to
address many of the complexities inherent in the pain patient. As is
well known to pain medicine physicians, many patients with subacute or longstanding pain problems exhibit dysfunctional sleep,
relationships, thought patterns, emotions, and behaviors. As discussed earlier, optimal acupuncture for pain seeks to address, and is
capable of affecting, all of these elements.
Safety
Acupuncture performed by a medically trained practitioner is a
relatively safe and forgiving procedure. It is difficult to introduce
new or persistent problems with acupuncture therapy. Acupuncture treatments commonly induce a state of relaxation especially
when electrical stimulation is used. Sometimes this state can evolve
into or be perceived as fatigue or dysphoria, particularly by those
accustomed to the physiologic milieu of a tonically activated stress
system.
The principal serious adverse effects caused by acupuncture are vasovagal syncope, puncture of an organ, infection, and a
retained needle. These risks can be minimized by using single-use
or sterilized needles, obtaining appropriate clinical training, understanding surface and internal anatomy, and exercising sound clinical judgment.
A systematic review of nine surveys of the safety of acupuncture involving more the 250,000 treatments found that feelings of
faintness and syncope occurred in less than 0.3% of treatments.
Feelings of relaxation were common and occurred in almost all
patients (86%).57 Of the serious adverse effects, pneumothorax
is one of the most common. The large Acupuncture Safety and
Health Economic Studies (ASH) in Germany involved more than
1.6million acupuncture sessions and reported two pneumothoraces
for an occurrence rate per session of less than 0.0001%.58 This same
research initiative reported local infection in 0.3% of patients.58
Cost Effectiveness of Acupuncture
All healthcare delivery systems must consider the relative economic
costs and comparative benefits of medical treatment options.
Incountries where healthcare is administered largely according to
payment by a national insurance system, cost-effectiveness metrics
have been developed to facilitate cost-benefit analyses and ultimately aid in deciding what medical treatments will be available. In
the United Kingdom a value of less than 30,000 pounds per quality
adjusted life year (QALY) has been set by the National Institute for
Health and Clinical Excellence (NICE) as representing a cost effective therapy. Cost-effectiveness research for acupuncture has been
conducted with data from the national health insurance systems
of Germany and England. Using acupuncture for the treatment of
headache, chronic neck pain, low back pain, and osteoarthritis of
the knee and hip has been shown to be cost effective using accepted
international thresholds.
In the largest clinical investigation of acupuncture to date,
German researchers evaluated the cost effectiveness of acupuncture for the treatment of headache, chronic neck pain, low back
pain, and osteoarthritis of the knee and hip in the Acupuncture in
Routine Care Studies (ARC).47 ARC included nearly 8500 patients
for economic analysis and found acupuncture to be effective for
all diagnoses studied with an average increase in expenditure of
319 euros per treatment course.47,58 The cost effectiveness was
found to be between 10,526 euros per QALY for low back pain
and 17,854 euros per QALY for knee and hip osteoarthritis. Thus,
acupuncture for all diagnoses was found to be well within accepted
standards for cost effectiveness.
British researchers evaluated the cost effectiveness of acupuncture for the treatment of chronic headache and found that acupuncture improved quality of life for a relatively small incremental
cost. They estimated that acupuncture treatment resulted in a cost
of 9180 pounds per QALY which compares favorably to medication
treatment of migraine headaches. Substituting oral sumatriptan for
oral caffeine plus ergotamine results in a cost of 16,000 pounds per
QALY.59,60 Other studies have found acupuncture to be cost effective for chronic neck pain with a cost of 12,469 euros per QALY61
and low back pain with a cost of 4241 pounds per QALY.62
Clinical Research
Virtually all studies of acupuncture for the treatment of pain show
substantial efficacy when compared to control groups that consist of waiting list populations receiving standard conventional
therapy. Studies comparing true acupuncture with nonpenetrating
sham control groups are more mixed, but the majority demonstrate incremental benefit of true acupuncture over nonpenetrating
sham groups. Significant benefit of needling traditional acupuncture points over needling nontraditional locations has also been
repeatedly demonstrated, however, the effect size is considerably
reduced, and the results are less consistent. This would be expected
from our knowledge of the physiologically active effects of needle
penetration.
Acupuncture points are not magical nor do they possess inexplicably different properties compared to other locations in the body.
Classical acupuncture points can be viewed as physiologic hot spots
in the body that have been discovered through several millennia of
empirical investigation. They often correspond to trigger points,
connective tissue cleavage planes, accessibility of peripheral nerves,
and regions of densely concentrated neurovascular bundles. Many
other locations on the body have similar neuroanatomic characteristics, but are not described as classical acupuncture points. These
locations will likely have many of the same physiologic and clinical
effects as classically defined acupuncture points.
Acupuncture points and nonacupuncture points are often discussed as black and white distinctions. The preceding brief description of various systems of acupuncture underscores the diverse
conceptions of acupuncture points and acupuncture needling
techniques. When one considers the vast multitude of classically
defined extra points, the superficial needling technique used in
Japanese acupuncture, and the shifting point locations described by
Ryodoraku acupuncture, the near impossible task of defining nonacupuncture points even from the classical perspective becomes
evident.
Challenges of Studying Acupuncture
Since the 1950s the randomized, double blind, placebo controlled
trial (RDBPCT) has become the standard methodology for evaluating the effectiveness of pharmaceutical therapies. Although
going to great lengths to exclude bias, this methodology also has
its limitations. Perhaps the most vexing problem of the RDBPCT
is the discordance between what is studied (homogeneous patients
without comorbid conditions) and real life (complex patients with
multiple medical problems).63-65 Furthermore, the RDBPCT may
not be the best method to evaluate complex medical interventions
such as surgery, physical therapy, psychotherapy, and acupuncture.
In contrast to pharmaceutical therapy, the substance of these interventions cannot be divorced from the mode of delivery. Because
of this, controls that allow clear isolation of the specific effects of
the intervention from the nonspecific effects of the delivery mode
are virtually impossible to devise. For example, it is impossible to
magically remove a gallbladder without going through the lengthy
and ritualized preoperative intake, intraoperative anesthesia, and
postoperative recovery process.
In the case of acupuncture, we know that sham acupuncture
is a myth. Sham acupuncture or minimal acupuncture is generally
defined as the insertion of needles at so called nonacupuncture

points or at shallow depths over classically defined acupuncture
points, and is considered to be physiologically and clinically inert.
Sham needling at nonacupuncture locations is problematic for
several reasons. From classical as well as modern reasoning, it is
virtually impossible to find a location on the body that will not
produce a physiologic action in response to acupuncture needling.
There are roughly 360 body locations called meridian points
that are avoided to find nonacupuncture points. Interestingly,
there are several thousand extra-meridian acupuncture points
and a multitude of points that are located based on the specific
manifestation of symptoms of each person, making the selection
of nonacupuncture points challenging at best from the classical
perspective. Likewise, modern fMRI research has demonstrated
that while needle stimulation at acupuncture points produces
more robust brain modulation than needle stimulation at nonacupuncture points, nonacupuncture points are physiologically
active.50
For the goal of separating the needling effects of acupuncture
from the effects of the ritual of delivering acupuncture, sham acupuncture devices such as the Park Sham Device may represent an
improvement over shallow needle insertion at acupuncture points
or needle insertion at nonacupuncture points. The Park Sham
Device uses a retractable blunt-tipped needle that does not penetrate the skin. However, it is important to note that although a
needle does not pierce the skin when using the Park Sham Device,
skin contact is made. This skin contact will likely produce similar
effects as the Japanese acupuncture procedure known as teishin, in
which a blunt-tipped probe is used to apply light pressure over acupuncture points.
A more useful methodology for studying complex interventions such as acupuncture may be the pragmatic randomized controlled trial (PRCT).66 The PRCT evaluates actual questions facing
the practicing clinician. For example, in a patient with refractory
depression managed by the primary care physician, does referral for collaboration with a psychiatrist result in improved patient
outcomes?67 Or will a patient with chronic low back pain receiving conventional management from the primary care provider
derive additional incremental benefit from a referral to medical
acupuncture?
Key features of the PRCT are minimizing exclusion criteria in
an attempt to match the study population more closely with the
heterogeneous types of patients encountered in clinical medicine
as well as using pragmatically selected control groups such as a
treatment as usual group.66 Although marked improvements have
been attributed to placebo interventions such as the sugar pill,
the actual improvement beyond treatment as usual groups may be
minimal or nil. A 2004 Cochrane review of placebo interventions
for all clinical conditions concluded There was no evidence that
placebo interventions in general have clinically important effects.
A possible small effect on continuous patient-reported outcomes,
especially pain, could not be clearly distinguished from bias, and
further It has been widely believed that placebo treatments are
associated with substantial effects on a wide range of health problems. However, this belief is not based on evidence from randomized trials that use a placebo treatment for one group of people,
while another group receives no treatment. The effect of placebo
treatments was studied by reviewing more than 150 such trials
covering many types of health care problems. Placebo treatments
caused no major health benefits, although they possibly had a small
effect on outcomes reported by patients, for example, pain.68
17
When evaluating the effectiveness of a therapeutic intervention, it is imperative to use control groups to account for spontaneous improvement in symptoms and the fluctuation in symptoms
that is inherent to the natural course of a disease process. When the
evaluated therapy is simple, such as pharmacotherapy, and the substance of the intervention can easily be separated from the process
of the intervention, using a placebo pill may be useful to account
for additional bias such as expectancy. However, when evaluating
the relative clinical effectiveness of complex interventions such as
psychotherapy, surgery, and acupuncture where the substance and
process of the therapy are inextricable, use of control groups that
consist of treatment as usual or an alternate therapy [acupuncture
versus physical therapy or percutaneous coronary intervention
(PCI) versus coronary artery bypass grafting (CABG)]69 may provide more clinically relevant information.
Spine Pain
A Cochrane review of acupuncture and dry needling for low back
pain including 35 RCTs through 2003 concluded that acupuncture
is effective for pain relief and functional improvement of chronic
low back pain when compared to either usual treatment or sham
acupuncture. Improvement was noted immediately after a course
of acupuncture and for up to 3 months after the cessation of treatments. Acupuncture was also found to offer incremental benefit in
pain reduction when added to standard treatments for chronic low
back pain.70
Three large German RCTs published after the Cochrane
review demonstrated a substantial reduction in low back pain
for acupuncture relative to standard conventional treatments for
periods extending to 6 and 12 months. Haake and colleagues randomized 1162 patients with back pain to acupuncture according
to classical concepts, superficial acupuncture needling at nonacupuncture points, or usual care consisting of drugs, physical therapy,
and exercise. The primary outcome was improvement in pain or
function at 6 months. Both needling groups were almost twice as
likely to improve when compared to usual conventional care. There
was little difference between the two acupuncture groups suggesting that point selection may be less important than proposed by
classical acupuncturists.49 Brinkhaus and coworkers found similar
results in a rigorously designed RCT with improvement maintained through 12 months.71 Witt and associates included 11,630
patients in a study evaluating clinical and economic effectiveness
of acupuncture for low back pain. Of 3093 patients who consented
to randomization, 1549 patients were allocated to receive immediate acupuncture and 1544 patients were allocated to a waiting
list control group that would receive acupuncture 3 months later.
The remaining 8537 who did not agree to randomization generally had more severe baseline symptoms and were included in a
nonrandomized cohort. In the randomized arm, acupuncture was
found to be effective at reducing pain and function when compared
to routine care with an absolute risk reduction of 25.8%, yielding a
number needed to treat of four. Interestingly, the nonrandomized
acupuncture cohort with more severe baseline symptoms experienced improvement in pain and function similar to the randomized
group receiving acupuncture.48
Fewer studies have been conducted for neck pain, however a
high-quality meta-analysis has been performed. A Cochrane review
of acupuncture for neck disorders including 10 RCTs through 2006
found moderate evidence that acupuncture was more effective at
relieving pain than sham treatments for both mechanical neck pain
and neck pain with radicular symptoms for up to 3 months.72
Headache
In 2009, The Cochrane Collaboration published two meta-analyses
evaluating the use of acupuncture for prophylaxis of migraine and
tension-type headaches. Their review of acupuncture for migraine
prophylaxis included 22 RCTs through April 2008. The authors
concluded that Available studies suggest that acupuncture is at
least as effective as, or possibly more effective than, prophylactic
drug treatment, and has fewer adverse effects. Acupuncture should
be considered a treatment option for patients willing to undergo
this treatment. They also state There is no evidence for an
effect of true acupuncture over sham interventions, though this
is difficult to interpret, as exact point location could be of limited
importance.73
The same authors reviewed the effects of acupuncture for tension-type headache and included 11 RCTs through January 2008.
They concluded that acupuncture could be a valuable nonpharmacological tool in patients with frequent episodic or chronic
tension-type headaches. They report that two large RCTs compared acupuncture to usual care and found 47% of patients receiving acupuncture experienced a reduction in headache frequency by
at least 50% compared to 16% of the patients in the control group.
They also describe six RCTs that compared true acupuncture to
fake acupuncture in which needles are either inserted at incorrect
points or did not penetrate the skin. The pooled analysis of these
RCTs revealed a small, but statistically significant improvement
of the patients receiving true acupuncture versus fake acupuncture. That is, 50% of patients receiving true acupuncture reported
a reduction of at least 50% in headache frequency versus 41% of
patients receiving fake acupuncture.74
A 2007 German review concluded that a 6-week course of
acupuncture treatments is equivalent to a 6-month course of prophylactic drug treatment. This review also suggested that traditional
concepts of needle location and stimulation are not as important as
had been thought, and recommended that acupuncture should be
integrated into existing migraine therapy protocols.75
Several RCTs have also evaluated the use of acupuncture for
acute migraine headache. A recent RCT published in Headache in
2009 randomized 175 patients to receive true acupuncture or one
of two sham acupuncture groups who received needling at various
nonacupuncture points. The true acupuncture group experienced
a greater decease in pain versus the sham acupuncture groups at
2and 4 hours after treatment. In addition, 40.7% of those receiving
true acupuncture experienced a complete resolution of pain within
24 hours versus 16.7% and 16.4% in the two sham acupuncture
groups.76
Melchart and colleagues randomized 179 migraine patients
to receive acupuncture, subcutaneous sumatriptan, or a placebo
injection at the first sign of a migraine headache. Acupuncture and
sumatriptan were equally effective in preventing a full migraine
attack. Acupuncture resulted in a 21% absolute risk reduction and
sumatriptan resulted in a 22% absolute risk reduction when compared to the placebo injection. If a full attack could not be prevented,
sumatriptan was more effective than acupuncture in reducing pain.
Side effects were more common in patients who received suma
triptan (40%) than in acupuncture patients (23%) or patients who
received the placebo injection (16%).77
Knee Pain
White and colleagues published a 2007 meta-analysis in the journal
Rheumatology which reviewed 13 RCTs investigating the effect of
acupuncture on pain and function in patients with chronic knee
pain. This review concluded that acupuncture improves pain and

function in patients with chronic knee pain when compared to
sham acupuncture and usual care.78
A second meta-analysis published by Manheimer in the Annals
of Internal Medicine in 2007 included 11 RCTs and concluded that,
when compared to waiting list controls, acupuncture results in clinically relevant benefits in patients with osteoarthritis of the knee.
Short term benefits were also found in trials that used sham control
groups, but these were deemed to be not clinically relevant.79
Two of the largest high-quality RCTs were conducted in
Germany and published in 200520 and 2006.21 Both of these trials
showed incremental benefit for acupuncture in patients with knee
osteoarthritis when compared to conventional treatment. The trials
yielded conflicting results regarding differences between classical
acupuncture and minimal acupuncture.
Shoulder Pain
Fewer large, high-quality trials are available to evaluate the effectiveness of noninvasive therapies for chronic shoulder pain.
Cochrane reviews for acupuncture, physical therapy, and corticosteroid injections have concluded that insufficient evidence exists
to guide therapy for these interventions.80-82 Subsequent to the
publication of the Cochrane meta-analysis for acupuncture, Guerra
de Hoyos and coworkers published the largest RCT to date in
2004.83 This study randomized 130 patients with chronic shoulder
pain to active acupuncture or nonpenetration control acupuncture
and demonstrated an improvement in pain intensity and every secondary outcome measure 3 and 6 months after treatment. A 2005
RCT published in the journal Physical Therapy evaluated the effectiveness of ultrasound or acupuncture added to exercise therapy
in 85 patients with impingement syndrome. This study included
follow-up data for 12 months and concluded that the addition of
acupuncture to home exercises was more effective than the addition of ultrasound.84 The largest high-quality RCT was published in
the journal Rheumatology in 2008 and evaluated the effect of adding
a single acupuncture point to physical therapy in 425 patients with
shoulder pain. The acupuncture group experienced reduced pain as
well as a reduction in analgesic medication consumption in comparison to the control group which received only physical therapy.85
Elbow Pain
A 2004 meta-analysis published in the journal Rheumatology
included 6 RCTs evaluating the effectiveness of acupuncture for lateral epicondylar pain. All six of the studies demonstrated that acupuncture was effective at relieving lateral epicondylar pain for up to
3 months after a course of treatments. Five of the six studies demonstrated superiority of acupuncture when compared to control
treatments.86 A systematic review investigating the effectiveness of
conservative therapies in the rehabilitation of lateral epicondylitis
was published in the Journal of Hand Therapy in 2004 and came to
similar conclusions.87
Hip Pain
Few high-quality RCTs have been conducted to evaluate the effectiveness of acupuncture for hip pain. A small RCT published in the Clinical
Journal of Pain in 2004 compared electroacupuncture to patient education in patients with osteoarthritis related hip pain. Electroacupuncture was significantly more effective at reducing pain and improving
functional status and quality of life when compared to patient education at all three assessment periods: immediately after a course of
treatment, as well as 3 and 6 months after a course of treatment.88
A much larger high-quality study was published by Witt and

colleagues in Arthritis and Rheumatism in 2006 as part of the
colossal German Acupuncture trials. In this study 712 patients
with hip or knee osteoarthritis (45% had hip osteoarthritis) were
randomized to receive acupuncture or standard medical therapy.
In addition, a nonrandomized cohort of 2921 patients with identical baseline characteristics was included in the study. In the
randomized group, patients receiving acupuncture experienced
a marked clinical improvement compared to patients receiving
standard medical therapy. These improvements were maintained
up to 6 months after treatment. Interestingly, the outcomes for
the large nonrandomized group receiving acupuncture were
similar to those experienced by the group randomized to receive
acupuncture.89
Fibromyalgia
Evidence for the effectiveness of acupuncture for fibromyalgia is
sparse and conflicting. A 2006 literature review included five RCTs,
of which three demonstrated effectiveness of acupuncture versus
sham treatment and two showed a lack of effectiveness. Because of
the heterogeneity of the abstracted data, meta-analysis was not possible. Number of treatments did not seem to affect the likelihood of
positive response. Interestingly, all of the RCTs that demonstrated
effectiveness for the acupuncture group used electroacupuncture,
whereas the two RCTs that failed to demonstrate effectiveness used
manual stimulation only. This review concludes that acupuncture
for the symptomatic treatment of fibromyalgia is not supported by
unanimous results from RCTs.90
Temporomandibular Joint Pain
High-quality research investigating the efficacy of acupuncture for
temporomandibular joint related pain is limited. A literature review
published in 2001 evaluated 14 studies. The three RCTs that met
inclusion criteria evaluated acupuncture versus occlusal splints
with two studies also including usual care control groups. All three
RCTs that were included found acupuncture to be effective in a
variety of metrics including the visual analog scale, mandibular
function, and number of tender points on examination. The degree
of effectiveness, however, was not quantified.91
A small RCT published in 2006 evaluated true acupuncture
versus noninsertional sham acupuncture using a single needle on
the face. Multiple endpoints were recorded and found to favor true
acupuncture. The group receiving true acupuncture reported a
53%reduction in pain on the visual analog scale versus a 6% reduction reported by the sham group. Likewise, the true acupuncture
group reported a 55% reduction in functional impairment versus a
6% reduction reported by the sham group.92
Postoperative Pain
A systematic review of 15 RCTs evaluating acupuncture for postoperative pain was published in The British Journal of Anaesthesia
in 2008. The data were analyzed for postoperative opioid consumption, postoperative pain intensity, and opioid-related side-effects.
Acupuncture was found to have an opioid-sparing effect at 8 hours,
24 hours, and 72 hours corresponding to a respective 21%, 23%,
and 29% reduction of morphine consumption, respectively. Amoderate and statistically significant reduction in pain intensity was
found at 8 and 72 hours in the acupuncture treatment groups.
Astatistically significant reduction in opioid-related adverse affects
was also found. Treatment by acupuncture was associated with
a 33% reduction in the incidence of nausea, a 35% reduction in
17
dizziness, a 22% reduction in sedation, a 25% reduction in pruritus,

and a 71% reduction in urinary retention.93
Auricular acupuncture has also been studied in the postoperative period. Usichenko and associates studied 54 patients undergoing total hip arthroplasty and compared four acupuncture press
tacks in the ear at acupuncture points versus nonacupuncture
points. The group that received acupuncture at acupuncture points
of the ear used 31% less opioid administered by a patient-controlled
analgesia pump and had similar pain intensity scores measured by
the visual analog scale.94
Taguchi and coworkers studied the effect of acupuncture on
anesthetic requirement in healthy volunteers in a rigorous doubleblind experiment. This group found that healthy volunteers who
received auricular acupuncture at four points required 8.5% less
desflurane anesthesia to prevent movement in response to noxious
stimuli when compared to healthy volunteers who did not receive
auricular acupuncture.95
Miscellaneous
Preliminary evidence from small but well done RCTs suggests that
acupuncture is effective at relieving symptoms in patients with
chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). The
most recent study recruited 63 patients who met the U.S National
Institutes of Health (NIH) consensus criteria for CP/CPPS in a three
arm RCT. The electroacupuncture group received acupuncture
according to classical and neuroanatomic principles with electrical stimulation, advice, and exercise. The sham acupuncture group
received superficial needling at nonacupuncture points, advice,
and exercise, and the final group received advice and exercise only.
Symptoms were assessed using the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) and the primary outcome was change in
symptoms using this index. All patients receiving electroacupuncture experienced at least a 6 point reduction in the NIH-CPSI total
score compared to 16.7% of the sham acupuncture group and 25% of
the advice and exercise group. Additionally prostaglandin E2 levels in
the urine after prostatic massage decreased in the electroacupuncture group, whereas the levels increased in the other two groups.96
Lee SW and colleagues found that 32 of 44 (72%) CP/CPPS
patients receiving acupuncture experienced at least a 6 point
decrease in the NIH-CPSI score compared to 21 of 45 (47%) of
patients receiving superficial acupuncture at nonacupuncture
points.97 Chen and coworkers reported that 10 of 12 CP/CPPS
patients who were refractory to antibiotics, -blockers, antiinflammatory agents, and phytotherapy experienced a greater than
50%reduction in the NIH-CPSI with acupuncture at an average of
33 weeks after treatment.98
A systematic review of acupuncture for the management of
labor pain was published in The American Journal of Obstetrics and
Gynecology in 2004 and included three RCTs. Two RCTs compared
acupuncture with usual care and found that intrapartum acupuncture resulted in lower usage of meperidine and epidural analgesia.
One RCT compared acupuncture to superficial needling at nonacupuncture points and found that the classical acupuncture group
reported less intrapartum and postpartum pain, requested meperidine and epidural analgesia less often, and required oxytocin augmentation less often.99
Integration with Conventional Pain Medicine
Acupuncture therapy is a versatile modality with multiple roles in the
contemporary multidisciplinary management of pain. As a safe, cost
effective, and evidence-based form of therapy, acupuncture is an ideal
initial input for a variety of subacute and early chronic pain states. As
such, its implementation prior to expensive drugs and expensive and
potentially dangerous invasive interventions will likely prove beneficial for patients and society. Unfortunately, lack of familiarity with
the research establishing acupuncture as safe, cost-effective, and efficacious treatment often results in considering acupuncture as a last
resort when all other modalities have failed. Arational approach to
treatment that is not driven by economic factors or personal bias
ought to use safe, cost-effective, and efficacious therapies early in the
therapeutic approach to pain problems, and more risky, expensive,
and marginally efficacious therapies later or as last resorts.
Like any other medical therapy, the results expected from
acupuncture for pain control will vary greatly with the severity and
chronicity of the underlying condition as well as the underlying
health of the patient. Milder pain of more recent onset in a vital
young patient can be expected to respond more completely with
fewer treatments. A realistic goal for more severe pain of longer
duration in chronically debilitated or more frail patients will be partial reduction over a longer course of treatments.
Acupuncture can also be useful for the management of ancillary symptoms that accompany chronic pain such as fatigue, secondary dysthymia, or agitation. This being said, acupuncture should
not be used as the only treatment for moderate-to-severe depression
or other serious psychiatric conditions. Acupuncture treatments
are commonly accompanied by a sense of well-being, relaxation,
and mild euphoria that can have mild, lasting anxiolytic effects that
can be a valuable adjunct in the care of pain patients whose pain is
complicated by comorbid fear or anxiety. Side effects that are often
encountered in the pharmacologic treatment of pain can also be
addressed with acupuncture. For example, nausea, pruritus, dysphoria, and sedation are common side effects of medications used
to manage pain. Acupuncture can help diminish these side effects
providing for improved patient tolerability and compliance.
Conclusion
As understanding of the neurobiologic basis of acupuncture grows,
clinical research becomes more sophisticated and patient interest expands, medical acupuncture is becoming more accepted in
conventional medical environments. Continued research into the
optimal types of acupuncture for specific problems and the most
efficient use of acupuncture resources will help clarify the ideal
place for acupuncture in the framework of modern medicine.
The 20th century witnessed impressive advances in the medical
care of acute illnesses such as trauma, infections, and thromboembolic events. Much of the challenge for medicine in the 21stcentury
will be managing complex chronic illnesses of civilization such as
diabetes, heart disease, and chronic painful conditions. As a safe,
sustainable, cost-effective, and evidence-based therapy for many
chronic painful conditions that engenders high patient satisfaction,
medical acupuncture is well-suited to play a role in the future of
modern medical practice.
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Medical Acupuncture

In the decade since the publication of the National Institutes of

140 Complementary and Alternative Medical Procedures

Acupuncture is not Monolithic

A Brief Primer of Acupuncture Techniques

of classical Chinese acupuncture. Japanese acupuncture involves a

Medical Acupuncture is the Unification

Medical Acupuncture 141

evolved since the middle of the 19th century initially in Western

Medical Acupuncture Education

What are the Effects of Medical Acupuncture?

Medical Acupuncture View of the Human Organism

142 Complementary and Alternative Medical Procedures

identify constitutional factors for a patient and individual treatment

The Neuromatrix Theory of Pain

view of these phenomena closely parallels many aspects of the

Medical Acupuncture 143

EMOTION-RELATED BRAIN AREAS

OUTPUTS TO BRAIN AREAS

the endorphin and monoamine hypothesis of acupuncture analgesia

144 Complementary and Alternative Medical Procedures

The research of Helene Langevin, MD focuses on the role

Medical Acupuncture 145

Gene expression, protein synthesis, and secretion

Extracellular milieu modification

Acupuncture Effects on the Brain

146 Complementary and Alternative Medical Procedures

in the brain.40 Numerous fMRI studies have demonstrated that

Napadow and colleagues have also explored the effects of

Medical Acupuncture 147

disease. It is suggested that the overall manifestation of symptoms

Does Needling of Acupuncture Points Produce

Optimal Acupuncture Therapy for Pain

source as well as any contributing underlying or secondary factors.

148 Complementary and Alternative Medical Procedures

Medical Acupuncture 149

defined as the insertion of needles at so called nonacupuncture

150 Complementary and Alternative Medical Procedures

Medical Acupuncture 151

pain. This review concluded that acupuncture improves pain and

A much larger high-quality study was published by Witt and

152 Complementary and Alternative Medical Procedures

dizziness, a 22% reduction in sedation, a 25% reduction in pruritus,

Medical Acupuncture 153

32.Langevin HM. Connective tissue: A body-wide signaling network? Med

154 Complementary and Alternative Medical Procedures

79.Manheimer E, Linde K, Lao L, et al. Meta-analysis: Acupuncture for

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