Autonomic Neuroscience: Basic and Clinical 232 (2021) 102793

Contents lists available at ScienceDirect

Autonomic Neuroscience: Basic and Clinical

journal homepage: www.elsevier.com/locate/autneu

Review

Acupuncture modulates immunity in sepsis: Toward a

science-based protocol
Wei-Xing Pan a, *, Arthur Yin Fan b, c, *, Shaozong Chen d, *, Sarah Faggert Alemi b, e
a
Janelia Research Campus, Howard Hughes Medical Institute, 19700 Helix Drive, Ashburn, VA 20147, USA
b
American TCM Association, Vienna, VA 22182, USA
c
McLean Center for Complementary and Alternative Medicine, PLC, Vienna, VA 22182, USA
d
Acupuncture Research Institute, Shandong University of Chinese Medicine, Jinan 250355, China
e
Eastern Roots Wellness, PLC, McLean, VA 22101, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Sepsis is a serious medical condition in which immune dysfunction plays a key role. Previous treatments focused
Nerve stimulation on chemotherapy to control immune function; however, a recognized effective compound or treatment has yet to
Acupuncture be developed. Recent advances indicate that a neuromodulation approach with nerve stimulation allows
Electroacupuncture
developing a therapeutic strategy to control inflammation and improve organ functions in sepsis. As a quick, non-
Sepsis
Inflammation
invasive technique of peripheral nerve stimulation, acupuncture has emerged as a promising therapy to provide
Anti-inflammation significant advantages for immunomodulation in acute inflammation. Acupuncture obtains its regulatory effect
Inflammatory reflex by activating the somatic-autonomic-immune reflexes, including the somatic-sympathetic-splenic reflex, the
Immune dysfunction somatic-sympathetic-adrenal reflex, the somatic-vagal-splenic reflex and the somatic-vagal-adrenal reflex, which
Somatic-sympathetic reflex produces a systemic effect. The peripheral nerve stimulation also induces local reflexes such as the somatic-
Somatic-vagal reflex sympathetic-lung-reflex, which then produces local effects. These mechanisms offer scientific guidance to
design acupuncture protocols for immunomodulation and inflammation control, leading to an evidence-based
comprehensive therapy recommendation.

1. Introduction 2020; D. Wang et al., 2020; Z. Wu and McGoogan, 2020). Reducing

Sepsis is defined as life-threatening organ dysfunction, caused by a
dysregulated host response to infection (Gotts and Matthay, 2016;
Singer et al., 2016), which clinically manifests as severe systemic in­
flammatory response, Acute Respiratory Distress Syndrome (ARDS),
Septic Shock, or Multiple Organ Dysfunction Syndrome (MODS). It is the
number one killer in the Intensive Care Unit (ICU). Globally, there are
approximately 30 million cases of sepsis each year, with a fatality rate as
high as 30% (Reinhart et al., 2017). The Coronavirus Disease 2019
(COVID-19), which has developed into a global pandemic, is a current
example of a manifestation of severe sepsis. Similar to other infections,
deaths resulting from COVID-19 have been related to sepsis, which
causes septic shock, MODS, and ARDS in particular (C. Wang et al.,
inflammation and correcting organ dysfunction are the core strategies of
clinical treatment of sepsis. However, due to the lack of a specific and
effective antiviral drug, how to effectively treat sepsis has been a clinical
challenge for a long time, especially for sepsis caused by viral infection.
Traditionally, steroids, i.e. adrenocortical hormones, were once the
major anti-inflammatory drugs used for this condition; however, they
were unsatisfactory due to their serious side effects and sequelae. Recent
immunotherapy drugs, such as siltuximab and tocilizumab, present hope
but are yet to be evaluated and summarized for further development and
clinical application. Fortunately, experimental animal studies in recent
years have shown that a simple non-pharmacological approach shows
the effect of anti-septicemia (for a review, see Lai et al., 2020). That
approach is peripheral nerve stimulation done through both

Abbreviations: Acupoint, acupuncture point; APS, antigen-presenting cells; ARDS, acute respiratory distress syndrome; APACHE II, acute physiology and chronic
health score; CARS, compensatory anti-inflammatory response; COVID-19, coronavirus disease 2019; CRP, C reactive protein; EA, electroacupuncture; ICU, Intensive
Care Unit; IL, interleukin; MODS, multiple organ dysfunction syndrome; LAC, blood lactic acid; NK, natural killer; PCT, procalcitonin; SARS, severe acute respiratory
syndrome; TNF, tumor necrosis factor; SOFA, systemic infection-related organ failure score; VNS, vagus nerve stimulation.
* Corresponding authors.
E-mail addresses: panw@hhmi.org (W.-X. Pan), ArthurFan@ChineseMedicineDoctor.us (A.Y. Fan), zjyjs1980@sdutcm.edu.cn (S. Chen).

https://doi.org/10.1016/j.autneu.2021.102793
Received 26 November 2020; Received in revised form 26 January 2021; Accepted 25 February 2021
Available online 27 February 2021
1566-0702/© 2021 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
W.-X. Pan et al.
electroacupuncture (EA) and manual acupuncture (in short, acupunc­
ture). Studies have shown that acupuncture is a promising alternative
clinical anti-inflammatory therapy. Several lines of evidence published
in recent years, from the researches of immunomodulatory mechanisms
(for reviews, see, i.g. Tracey, 2002; Ulloa, 2005; Huston et al., 2006;
Behrens and Koretzky, 2017; Pavlov et al., 2018; Berlot and Passero,
2019), the experiments of acupuncture in animal models (for a review,
see Lai et al., 2020) and in patients of clinical trials (for a review, see
Tang et al., 2020), support the antiseptic effect of acupuncture. Such a
non-pharmacological and non-invasive approach has attracted the
attention of the clinical medicine community and has been advocated by
some leading researchers (Ulloa et al., 2017; Pavlov and Tracey, 2017).
However, the clinical translation in practice with details is still lacking.
This article aims to offer a brief comprehensive review and develop an
evidence-based EA therapy for immunomodulation in acute inflamma­
tion to promote further research and clinical application.
2. Pathophysiology of sepsis
Sepsis is initiated by an infection. However, it has been known that
the clinical manifestations and pathological complications of sepsis are
not caused directly by invading pathogens, but rather by a disorder of
the host’s immune reaction (Hamers et al., 2015; Behrens and Koretzky,
2017). The main pathophysiological process of infectious diseases is the
body’s response to bio-immunogenic substances, that is, inflammatory
reactions with defense properties. With the advancement of immuno­
pathology research, more details of the inflammatory process have been
understood (Gotts and Matthay, 2016; Singer et al., 2016; Reinhart
et al., 2017; Sladkova and Kostolansk, 2006; Tisoncik et al., 2012;
Wiersinga et al., 2014). The body’s immune system is functionally
divided into innate immunity and acquired adaptive immunity. When
pathogenic microorganisms invade the body for the first time, the innate
immune system responds accordingly, starting the inflammatory pro­
cess. First, macrophages recognize and engulf the pathogens. While
destroying and inactivating them, some antigen-presenting cells (APCs)
can recognize the antigenic characteristics of pathogens and then
transmit to B cells; the adaptive immune system is then activated to
generate specific antibodies, which can more accurately and efficiently
kill pathogens. Long-term memory of antigen information forming, and
then lifelong immunity will be generated. However, antibody produc­
tion takes a long time, around 5–10 days. Fortunately, the innate im­
mune system immediately goes forward to start the battle of non-specific
immunity, rather than waiting for the arrival of specific antibodies.
Immune cells and infected tissue cells quickly release a batch of cyto­
kines and pro-inflammatory substances under the stimulation of path­
ogens, such as interleukin IL-1, IL-8, IL-18, tumor necrosis factor TNF-α,
IL-6, IL-33, type I and III Interferons (IFN), etc. which are called primary
cytokine storms (Behrens and Koretzky, 2017). These cytokines exert a
variety of different immune functions. For example, IL-1 is an important
initiator of the inflammatory response; TNF has a strong killing effect;
IFN has an antiviral effect and can limit virus replication and spread,
protecting uninfected cells from being affected by virus invasion; che­
mokines IL-8 can induce the recruitment of more immune cells toward
the infection site; some cytokines can activate the neuroendocrine sys­
tem, leading to increased body temperature, breathing, circulation,
metabolism and other functions. At the same time, these cytokines have
a positive feedback effect, which can activate immune cells to release
more cytokines, forming a secondary wave of cytokine storms and
further strengthening the inflammatory response in order to effectively
kill the pathogens (Guo and Thomas, 2017). If this process is successful,
the pathogen may be eliminated, or at least prevented from spreading
until the specific antibodies (IgM) are produced and the pathogen is
destroyed. Once this occurs, the body enters the rehabilitation phase,
removing necrotic cells and repairing damaged tissue. This is the general
clinical process of many inflammatory infections, which generally last
for 1–2 weeks and end through self-healing alone. Unfortunately, a
2
Autonomic Neuroscience: Basic and Clinical 232 (2021) 102793
significant proportion of patients progress to a worsening course of
disease and develop sepsis. In severe cases, ARDS, septic shock, and
MODS are fatal. The core problem of sepsis is a disturbance of the
functioning of the immune system. Its pathophysiological mechanism is
that the patient is prone to excessive inflammatory reactions in the early
stage of the infection, which is the aforementioned cytokine storm
phenomenon, also clinically called cytokine release syndrome (CRS).
During the normal inflammatory response, when a large number of pro-
inflammatory factors are released, the release of anti-inflammatory
factors such as IL-4, IL-10, IL-11, IL-13, and IL-1Ra are also initiated,
as a self-balance regulation of the immune system, called “compensatory
anti-inflammatory response” (CARS) (Berlot and Passero, 2019). The
emergence of sepsis is caused by a disorder in the dynamic balance
between pro-inflammatory and anti-inflammatory factors, the excessive
secretion of multiple pro-inflammatory factors, and the intensification
under the positive feedback mechanism. While attacking the pathogen,
it also damages the normal tissue cells of the body, leading to important
organs or system dysfunction or even failure. However, that is not all
that occurs during sepsis. It has recently been discovered that the
mechanism behind sepsis is more complicated than previously thought.
Not only does the immune response become hyperactive in the early
stage, but also CARS is activated at the same time to limit the tissue
damage. However, the CARS can represent a double-edged sword. It
might be beneficial to restore immune balance; yet, it might cause the
shutdown of the immune response if it over responds, inducing the
status of immune-paralysis (Hamers et al., 2015; Berlot and Passero,
2019). With immune-paralysis, there can be a reduction of immune-
related receptors, apoptosis of various immune cells (T cells, B cells,
macrophages, dendritic cells), weakened antigen presentation function
of APCs, and increased suppressive lymphocytes, etc., leading to both
innate and adaptive immune functions that are severely weakened. This
makes it difficult to clear the damaged tissues in later stages. It is also
easier to activate latent pathogens and cause a secondary infection. Even
worse is that some patients might have problems with immune-paralysis
at the early stage, or multiple hits of the cytokine storm phenomenon
ultimately leading to the exhaustion of the immune response, which
makes treatment more difficult. Therefore, it is necessary to enhance
immunity in the later stage as well, which has become a new focus of
both basic science and clinical studies. The patterns of inflammatory
reaction have been proposed theoretically (Berlot and Passero, 2019),
shown in Fig. 1.
3. Difficulties in regulating immune function in the treatment of
sepsis
The treatment of sepsis needs to address three aspects: reducing the
pathogens (such as fighting the bacterial or viral infection, if appli­
cable), reducing inflammation, and correction of various physiological
dysfunctions. Multiple organ dysfunctions are closely related to
inflammation, so reducing inflammation is an important aspect to be
dealt with in its early and middle stages. Anti-inflammation or reducing
inflammation means regulating immune function. The immune system
consists of a variety of functional cells and molecular signaling pathways
that form an extremely complex regulatory network. Normal inflam­
matory response is a dynamic equilibrium process of immune cells and
molecular networks. The imbalance of septicemia manifests as early
immune hyperactivity and late immune paralysis (Berlot and Passero,
2019) Theoretically, treatment should be to give inhibitory intervention
in the early stages, followed by a strengthening intervention. However,
it is difficult to make a decision in delivering the specific interventions in
real clinical settings. There have been large numbers of anti-
inflammatory medications previously used, including corticosteroids,
aspirin, monoclonal antibodies, anti-cytokines, anti-chemokines, etc.,
the effectiveness of which is inconclusive, with some also leading to
worsening of the condition. There are several reasons for this. First, in
terms of the magnitude of the immune response, how much cytokine
W.-X. Pan et al. Autonomic Neuroscience: Basic and Clinical 232 (2021) 102793

Fig. 1. The immune reaction patterns (reproduced from Berlot and Passero, 2019). A. Possible clinical trajectories of patients with sepsis shock. Line 1, intense
hyper-inflammatory reaction followed by CARS and the return to the baseline immune state. Line 2, weak hyper-inflammatory reaction followed by immune-
paralysis and immune restoration. Line 3, immune-paralysis not preceded by a hyper-inflammatory reaction. B. The multiple hits phenomenon ultimately leading
to the exhaustion of the immune response.

release during the inflammatory response can be determined to be
“excessive”? It is difficult to define because of the physical condition of
patients, such as age, gender, and possible chronic underlying disease.
Second, in terms of phases, the turning point of the immune response
from the hyper-phase to the hypo-phase is difficult to predict. Unlike
antibiotics that advocate early use, immuno-suppressants are generally
considered only when clinical symptoms are severe. At this time, im­
mune hyperactivity may have peaked and begun to show a downward
trend. Immuno-suppressants may be redundant and even cause immune
paralysis quickly. This may be one of the reasons why traditional ste­
roids (adrenal cortex hormones) or targeted therapies that target specific
cytokines (for example, antagonists such as the IL-6 blocker siltuximab
and the IL-6R blocker tocilizumab) often fail. Clinical effect has not been
reached on the effects of these two types of therapy on reducing mor­
tality. Third, regardless of the overall inhibition of steroids (adreno­
cortical hormones) or single-factor targeted therapy, they are not the
normal physiological regulation. This makes it easy to create new im­
balances. For example, reducing the recruitment and activation of
neutrophils can reduce the damage to normal tissues, but also reduce the
lethality to pathogens, leading to the spread of infection. Fourth, in
recent explorations, the administration of immune stimulators in later
phases is said to be promising, although biomarkers to stratify the

Fig. 2. The immune network. The immune system, nervous system and endocrine systems constitute a functional regulatory network. The dynamic balance of
immune activity is controlled by the interactions of immune cells and cytokinesis (the left part of the figure adapted from Sladkova and Kostolansk, 2006), which
accepts the regulation of the brain (the right part of the figure). The brain regulates the immune system with two major outputs: one is the hormonal system including
the HPA, HPTs, HPG, and HGH axes (Eskandari et al., 2003); and the other is the autonomic nervous system consisting of sympathetic norepinephrine and vagal
acetylcholine pathways. The immune system can also regulate the nervous system through cytokines which activate the afferent nerves or enter the brain directly.

3
W.-X. Pan et al.
immune status are still in development (Peters van Ton et al., 2018).
However, once into the late phase, multiple organ dysfunctions may be
enough to cause death and immune stimulators may seem meaningless.
The only significance of immune stimulators is that of patients with
direct immune paralysis in the early phases, but reliable diagnostic in­
dicators are needed. Therefore, the ideal approach is the therapy closest
to physiological regulation. Perhaps turning to the neuromodulation of
immune responses is a promising direction.
4. Neural regulation of immunity
The immune system was once thought to be an independent regu­
latory system in the body. The role of the nervous system in regulating
immune function has not been known until recent decades, although it
has an ancient existence in the history of biological evolution. For
example, there are simple organisms, such as C elegans, whose immune
cells have been affected by neural signals. In higher animals the brain
has been regarded as an immune privileged organ with powerful influ­
ence in immunity. The immune system, nervous system and endocrine
systems constitute a functional regulatory network (Fig. 2). Based on the
functional organization of neuroendocrine and autonomic control, the
nervous system can efficiently affect immune function in two ways:
through central control and peripheral reflex. The effect of psychological
stress on immune function is an example of central control. Peripheral
reflex regulation is a more common process, such as inflammatory re­
flexes (Borovikova et al., 2000; Tracey, 2002). The inflammatory cyto­
kines can stimulate peripheral sensory nerves, including somatic and
visceral sensory nerves, or they can directly enter the brain to activate
the center integrative effects on immune function, acting through the
neuroendocrine or autonomic outputs. The neuroendocrine output is
mainly the hypothalamic-pituitary-adrenal (HPA) axis, which has an
inhibitory regulating effect on immune function. However, recently it
has been noticed that the hypothalamic-pituitary-thyroid (HPT) axis, the
hypothalamic-pituitary-gonadal (HPG) axis, and the hypothalamic-
growth-hormone (HGH) axes are also involved in modulating immune
activities (Eskandari et al., 2003). These axes need to be further studied.
Autonomic outputs include the sympathetic and vagus nerves, both of
which control the immune system and inflammation, which is the focus
of this article.
It has been known for a long time that the sympathetic nerves
regulate the immune system extensively and complexly, but they have
gained increasing interest and attention in recent years. As a result, new
knowledge has developed (Eskandari et al., 2003; Olofsson et al., 2012;
Jänig, 2014; Jänig and Green, 2014; Bellinger and Lorton, 2014; Pavlov
and Tracey, 2017; Chavan and Tracey, 2017). In brief, sympathetic
nerves contains nerve fibers (from postganglionic neurons) that
specially innervate immune organs including the primary lymphoid
organs, i.e. marrow and thymus, and the secondary lymphoid organs, i.
e. spleen, lymph nodes, and mucosa-associated lymphatic tissue (Jänig,
2014; Bellinger and Lorton, 2014; Chavan and Tracey, 2017). The
sympathetic postganglionic neurons release norepinephrine trans­
mitters which activate β- and α- adrenergic receptors on immune cells,
producing the regulatory effects (Bellinger and Lorton, 2014). The β-
and α2-adrenergic receptors have opposite effects on immune responses
to inflammation (Szelényi et al., 2000; Liu et al., 2020). The hypotha­
lamic area has been thought as a high level center of the autonomic
nervous system, which is also known to have extensive influence on
immune functioning (for reviews, see Wrona, 2006). Some sub-areas of
the hypothalamus might play specific roles in modulating immune
functions, e.g. in animal model, electrical stimulation of the lateral hy­
pothalamic area increased natural killer cell cytotoxicity in spleen, while
stimulation of the ventromedial hypothalamic area showed suppression
effect (Wrona and Trojniar, 2003, 2005). Such hypothalamic-splenic
immune modulation is mediated by the sympathetic efferent pathway;
therefore, the “hypothalamic-sympathetic-splenic axis” was proposed
(Okamoto et al., 1996). The hypothalamus might be involved in the
4
Autonomic Neuroscience: Basic and Clinical 232 (2021) 102793
peripheral reflex to modulate immunity (Son et al., 2002; Hahm et al.,
2004). Martelli and colleagues (Martelli et al., 2014a, 2014b, 2016,
2019), with a series of experiments in rodents, have identified the
greater splanchnic nerve as the sympathetic efferent arm of the in­
flammatory reflex to inhibit inflammatory cytokines in the spleen as
well as in other inner organs innervated by the nerve such as liver,
gastrointestinal tract and importantly, the adrenal, as systemic immune
cell function can also be regulated through the adrenal medulla with
catecholamine releasing. In addition, recent studies have shown that
selective somatic local effects of sympathetic innervations on immune
functions are available via a direct interaction of the postganglionic
nerves with local immune cells. Bassi et al. (2017) showed that direct
stimulation of the lumbar sympathetic trunk reduced neutrophil
recruitment in arthritic knee joints, and the same effect resulted from
direct injection of norepinephrine into the joint. Given the well-known
function of the somatic-sympathetic reflex, one might predict that se­
lective stimulation of somatic nerve connecting to the same segment of
the spinal cord from which the sympathetic efferent fibers innervate a
specific organ or tissue, might produce a local effect of immune regu­
lation of the specific organ or tissues. Indeed, Kim et al. (2007, 2008)
have found that electroacupuncture (EA) at Zusanli (ST36) acupoints
suppressed zymosan- or carrageenan-induced paw inflammation.
Interestingly, they found that low frequency (1 Hz) EA obtained the local
suppression effect via activation of sympathetic postganglionic neurons,
the simple somatic-sympathetic reflex; while high-frequency (120 Hz)
EA suppression is mediated by the sympathoadrenal medullary axis to
induce systemic catecholamines for whole body effects. A very recent
study (S.B. Liu et al., 2020) showed that selective stimulation of acu­
point Tianshu (ST25), which connects to the same segment of the spinal
cord sending sympathetic innervation to spleen, evoked the somatic-
sympathetic-splenic reflex, produced systemic effect of immune modu­
lation. This new knowledge of different immune reflex paths is very
valuable to selective treatment of specific organs and local tissue with
inflammation and dysfunction.
More recent knowledge shows that the vagus nerve controls immune
function by dominating the spleen and adrenal medulla. The first dis­
covery is the “cholinergic anti-inflammatory pathway” (Borovikova
et al., 2000) and then developed the concept of “inflammatory
reflex”(Tracey, 2002). In brief (for full reviews, see Ulloa, 2005; Huston
et al., 2006; Olofsson et al., 2012; Inoue et al., 2016; Pavlov and Tracey,
2017; Pavlov et al., 2018; Huh and Veiga-Fernandes, 2020), the vagal
nerve center can be activated by an immune challenge, and then the
vagus nerve efferent terminals releasing cholinergic transmitters,
innervate the spleen, perhaps relayed by the splenic nerve (Komegae
et al., 2018) (but see Martelli et al., 2014c, 2016), and through the α7
nicotinic receptor on macrophages and other immune cells, inhibit the
release of pro-inflammatory cytokines such as TNFα and IL-1 etc. Acti­
vation of this pathway by electrical or pharmacological stimulation
suppresses excessive inflammation in the gastrointestinal tract (de Jonge
et al., 2005; Ghia et al., 2006, 2007), pancreas (van Westerloo et al.,
2006), liver (Guarini et al., 2003) and heart (Bernik et al., 2002),
inhibiting systemic inflammation. Recent experiments in mice model
(Torres-Rosas et al., 2014) have found that the vagus nerve can also
dominate the adrenal medulla and activate the latter to release dopa­
mine to inhibit the release of pro-inflammatory cytokines and increase
the survival rate of the animals with sepsis. Kwan et al. (2016) have
systematically reviewed 36 eligible studies from 290 identified records
of vagus nerve stimulation (VNS) for treatment of inflammation in an­
imal models and clinical trials, suggesting that VNS is a very promising
approach of inflammation reduction. This immunomodulatory effect
produced by stimulating efferent nerves may be an ideal therapy closer
to normal or natural physiological regulation without the side effects
seen in some drugs. The anti-inflammatory effects of implanted elec­
trodes to stimulate the vagus nerve have been tried for the treatment of
chronic immune diseases (De Ferrari et al., 2011; Howland et al., 2011;
Howland, 2014; Koopman et al., 2016; Noller et al., 2019). For acute
W.-X. Pan et al.
infections, implanting electrodes is not a viable option. Fortunately,
stimulating peripheral somatic nerves can also produce the effects of
autonomic-immune reflexes, including vagal-immune reflex and the
above-mentioned sympathetic-immune reflex (Ulloa et al., 2017; Pavlov
and Tracey, 2017). This opens a convenient window of hope for the
treatment of acute inflammation in infectious diseases. Not surprisingly,
this approach is just how acupuncture therapy works. There is a long
history in China of acupuncture being used to treat various emergencies
such as acute fever, shock and coma, etc. Acupuncture has been applied
even more frequently and sometimes might be considered more
important than traditional Chinese herbal medicine, which needs to be
prepared or cooked and takes time to see results (L.G. Liu et al., 2004).
Acupuncture works rapidly and can often quickly reverse critical con­
ditions, according to ancient and contemporary literature (L.G. Liu et al.,
2004). Contemporary Chinese medicine practitioners continued this
tradition and use acupuncture, combining it with modern conventional
treatment, to treat epidemic diseases, including COVID-19 (R. Wang
et al., 2020). Recent random control clinical studies (see following ses­
sion) also show that acupuncture is a promising clinical anti-
inflammatory therapy.
5. Regulatory effects of acupuncture on immune function
Modern studies have demonstrated that acupuncture modulates
multiple physiological systems of the body, including the immune sys­
tem, to reestablish homeostasis by activating peripheral nerves to evoke
physiological reflexes (spinal and supraspinal reflex) and the brain
central integration (as reviewed elsewhere, Ma, 2004; Zhao, 2008;
Kagitani et al., 2010; Uchida et al., 2017; Pan, 2018, 2019). The
experimental research on the effects of acupuncture on immune function
can be traced back to the middle of the last century (S.Z. Liu, 1959; Yan,
1959). Studies over the decades have shown that acupuncture has a wide
range of regulatory effects on the immune system (Den, 1981).
5.1. Enhancement effects of acupuncture on immunity under
physiological conditions
Most of the early studies showed that acupuncture enhanced im­
munity of normal humans or physiological model animals (S.Z. Liu,
1959; Den, 1981; Du et al., 1995; Johansen et al., 2004; Sato et al.,
1996). Acupuncture can enhance the innate immune functions. For
example, a large number of studies in rodent models (Sato et al., 1996;
Liu et al., 1997; Choi et al., 2002; Kim et al., 2005; Rho et al., 2008)
showed that EA at ST36 (Zusanli) upregulated the function of natural
killer (NK) cells and macrophages, which play a central role in the innate
immune response, especially in killing virus-infected cells. Acupuncture
also increases the weight of mouse thymus (L.J. Liu et al., 1997), sug­
gesting an effect of enhancing innate immune function. The effect of
acupuncture on adaptive immunity is also supported by many experi­
mental results. Acupuncture can increase the number of lymphocytes in
the peripheral blood and the lymphocyte transformation rate in animals
(Cao et al., 1982) and humans (Wu, 1983; Jong et al., 2006). In the aging
animal model, acupuncture increased the functions of T lymphocytes (J.
M. Liu et al., 2009). It has been reported that acupuncture for 20 days
can increase the level of IgG and IgM in the elderly (Han, 1993). A few
studies have shown that the lateral hypothalamus plays a role in the
enhancement effect of EA. EA increased natural killer cell activity in the
spleen, correlating with the activation of hypothalamus (Rho et al.,
2008). Selective destruction of the lateral hypothalamic area (Choi et al.,
2002) cancelled various immune enhancement effects of acupuncture.
The general enhancement effects of acupuncture on immunity might
benefit the prevention of infections and immune suppression status of
sepsis. However, acupuncture effects on immunity show state-
dependent features. For example, under disease conditions, the effects
of acupuncture might be different from that under normal conditions,
which is elaborated below.
5
Autonomic Neuroscience: Basic and Clinical 232 (2021) 102793
5.2. Bidirectional regulations of immune function by acupuncture under
pathological conditions
Previous studies have shown that the most interesting feature of
acupuncture is the bidirectional regulation effect on the body’s ho­
meostasis, either in hyper- or hypo- functional states (dual regulation,
normalization, or restoring homeostasis) in either patients or patho­
logical models of animals (for a review, Pan, 2019). For instance, EA at
ST36 showed stimulation of stress-induced delayed gastric emptying
and inhibition of stress-induced acceleration of colonic transit (Iwa
et al., 2006). Such state-dependent effect also is observed on immune
modulation by acupuncture. Acupuncture can enhance the suppressed
innate immune functions, such as up-regulating the decreased function
of NK cells and macrophages (Zhao et al., 1994; Wu, 1995; Hisamittsu
et al., 2002; Yamaguchi et al., 2007; Johnston et al., 2011). Conversely,
acupuncture can also downregulate the activity of these immune cells
and related cytokines when they are in a hyperactivity state such as
inflammation (see the following section). Studies (as reviewed else­
where, Kim and Bae, 2010; Dai et al., 2018) also showed that
acupuncture has bidirectional regulating effects on adaptive immunity,
such as T lymphocytes functions. T helper cells, a type of T lymphocytes,
play an important role in the immune modulation. There are two main
subsets of T helper cells, Th1 and Th2, which respectively produce Th1
type cytokines (e.g. IL-2, INFγ) and Th2 type cytokines (e.g. IL-4, IL-10).
The former tends to produce the pro-inflammatory responses, and the
latter, anti-inflammatory responses. The balance of Th1/Th2 is changed
in different diseases and that can be modulated by acupuncture
(Yamaguchi et al., 2007; Dai et al., 2018; Silvério-Lopes and da Mota,
2013). For example, acupuncture can downregulate Th2-specific cyto­
kines (Park et al., 2004; Kim et al., 2011) to improve Th2 dominant
disorders, such as allergic rhinitis (Shiue et al., 2008) and chronic fa­
tigue syndrome (C. Wang et al., 2014). In contrast, for the Th1 dominant
disorders such as rheumatoid arthritis (Yim et al., 2007), ulcerative
colitis (Tian et al., 2003) and depression (Lin et al., 2014), acupuncture
can modulate the Th1/Th2 balance with inhibiting Th1 responses. Such
bidirectional regulatory effects suggest some interesting mechanisms
that need further study (Pan, 2019). Generally speaking The bidirec­
tional regulatory effect of acupuncture mirrors the activation and rein­
forcement of the body’s self-healing or biological adaptive mechanism,
which is a unique effect that no specific drug can reach at this time.
Thus, acupuncture is a patient-tailored approach, although controlled by
the body per se.
5.3. The anti-inflammatory effect of acupuncture
There is growing interest in the anti-inflammatory effect of
acupuncture in the research field. In recent decades, the anti-
inflammatory effects of acupuncture in septic animals and patients are
highlighted. The most common problem of immune response in sepsis is
a hyper-reactive cytokine storm. Silvério-Lopes and da Mota (2013)
systematically evaluated 67 relevant papers published between 2001
and 2011, and concluded that acupuncture and EA are effective in
modulation of immunity in animals and humans. Lai et al. (2020) sys­
tematically reviewed 54 studies up to May 2019 on acupuncture at ST36
(Zusanli) for the treatment of the experimental sepsis in animal models
crossing species (rodents and rabbits). They used 17 criteria to estimate
the study quality and risk of bias. The average quality scores of the
studies is 6.3 varying from 2 to 9.5, with 13 studies (15%) accepted
quality scores ≥7.0. Those studies support that acupuncture benefits to
protecting multiple organs against injuries by sepsis and maintaining the
immune balance to attenuate inflammation. A very new study (S.B. Liu
et al., 2020), published in Neuron online, July 2020, further confirmed
that acupuncture has a reliable anti-inflammatory effect, and revealed
new features and mechanisms by using genetic strategy. Those results,
especially from the quite a few quality studies (Scognamillo-szabo et al.,
2004; Gu et al., 2011; Song et al., 2012; Torres-Rosas et al., 2014;
W.-X. Pan et al.
Villegas-Bastida et al., 2014; Yu et al., 2014; Zhu et al., 2015; Chen et al.,
2016; Liu et al., 2020), have shown that the efficacy of acupuncture on
experimental sepsis has the following characteristics:
1. EA improved the survival rate of animals with sepsis. The survival
rate of rats or mice with sepsis increased significantly, with a
maximum survival increase up to 80% (S.B. Liu et al., 2020; Torres-
Rosas et al., 2014; Chen et al., 2016; Song et al., 2012; Zhu et al.,
2015; Villegas-Bastida et al., 2014). EA inhibited the release of
important pro-inflammatory factors. The blood levels of pro-
inflammatory factors such as TNF, IL-6, MCP-1 and INFγ in the
acupuncture group were significantly reduced. The level of anti-
inflammatory factor IL-10 either increased (da Silva et al., 2011;
Ramires et al., 2020) or did not change significantly (Song et al.,
2012). It suggests that acupuncture does not simply suppress the
immune response but modulates its balance. The anti-inflammation
effect of acupuncture is clear. A study (Ramires et al., 2020)
showed that acupuncture obtained similar levels of effect as that of
indomethacin (a classical nonsteroidal anti-inflammatory drug) in
suppressing peripheral and brainstem cytokines.
2. EA reduced injuries induced by sepsis in multiple inner organs such
as lung, cardiac, kidney, liver and gastrointestinal tract (Lai et al.,
2020).
3. The time-window of treatment exists. The earlier that acupuncture
treatment is given, the better the results, with results from preventive
care even better (Torres-Rosas et al., 2014; Liu et al., 2020). Even one
treatment or pretreatment of EA can cause the effect, and the effect
lasts at least 6 h (Torres-Rosas et al., 2014). However, the effects
from daily EA, in which there are a consecutive three days of treat­
ment, may have more stable and effective results (Torres-Rosas et al.,
2014). A new finding (S.B. Liu et al., 2020) is that time-window plays
the role depending on the intensity of stimulation (see below for the
details). However, these results perhaps depend on the inflammatory
model. It seems that the pretreatments are better than post treat­
ments to lipopolysaccharide (LPS) model (Gu et al., 2011; Song et al.,
2012; Torres-Rosas et al., 2014; Chen et al., 2016; S.B. Liu et al.,
2020; Ramires et al., 2020), but no matter to the cecal ligation and
puncture (CLP) model (Song et al., 2012; Torres-Rosas et al., 2014).
This might arouse future studying of the treatment windows for
various inflammations with different pathogens, e.g. bacteria or
virus.
4. The parameter of EA stimulation is important, which consists of
frequency, intensity and the model of pulse trains including gener­
ally “continuing trains”, “bursting trains” and “alternating trains”
with a common commercial EA stimulator. Most experiments ob­
tained show clear effects with simple stimulation of continuing trains
of low frequency (<15 Hz). However, a study (Chen et al., 2016)
comparing the effects of three types of trains has shown that the
alternating trains (2/15 Hz) is the best, then the bursting trains (2/0
Hz), and then the continuing trains (2 Hz). As mentioned above,
another study showed that that low frequency (1 Hz) EA produce the
local anti-inflammatory effect via activation of the simple spinal
somatic-sympathetic reflex; while high-frequency (120 Hz) EA is
mediated by the sympathoadrenal medullary axis to induce systemic
effects (Kim et al., 2007, 2008). This frequency effect is consistent
with some other acupuncture effects depending on frequency of
stimulation (Han, 2003).
5. There are large varieties of the intensity of EA stimulation used in
different experiments. A problem is that different laboratories used
different stimulators which indicate the intensity with different
scales: current (mA) or voltage (V), that limits to compare the in­
tensities between the different studies. However, some studies
included investigating the effects of intensities, providing valuable
data. Torres-Rosas et al. (2014), using mice lipopolysaccharide (LPS)
model, compared the pretreatments with stimulations of 0.4 V and 4
V at ST36, and the results showed that the anti-inflammatory effect
6
Autonomic Neuroscience: Basic and Clinical 232 (2021) 102793
of 4 V stimulation was clearly stronger than that of 0.4 V. Similarly,
Liu et al. (2020) compared the pretreatment with stimulations of 0.5
mA, 1.0 mA and 3.0 mA at ST36 or ST25 (Tianshu, at abdomen) in
LPS mice, conforming the results, i.e. the stronger the stimulation,
the better the anti-inflammatory effect. A surprising funding by Liu
et al. is that post-treatment with the 3.0 mA produced oppositely pro-
inflammatory effects, i.e. increased the serum TNF-α level and
decreased in survival rate. That is because that LPS increased the
expression of α2-ARs (adrenergic receptors) in splenic cells, which
mediate pro-inflammatory effects, and the post-treatment with high
intensity EA activated the spinal sympathetic-splenic pathway
(demonstrated with genetic strategy) that further enhanced the α2-
ARs effect. They further demonstrated that Yohimbine (α2-ARs
antagonist) or splenectomy allowed 3.0 mA EA to promote survival
and to suppress serum TNFα level. However, they found that post-
treatment of 0.5 mA weak stimulation at ST36 is not enough to
activate this sympathetic-splenic pathway, but it is sufficient to
activate the vagal-splenic pathway to obtain the anti-inflammatory
effects. But EA at ST25 (either 0.5 mA or 3 mA) did not activate
the vagal reflex. Those findings are consistent with the previous re­
sults that stimulating acupoints at abdomen area produced the
sympathetic reflex on the inner organs, while stimulating acupoints
of limbs produced the vagal reflex (Sato, 1997; Li et al., 2007). Those
results suggest that we need to consider the stimulation site (acu­
point), stimulation intensity and time window of treatment (pre- or
post- treatment) together for a clinical therapy. Especially, the time-
window dependent effect of stimulation intensity is not easy to
control in clinical practice because that almost all treatments are
post-treatment on patients. However, this result was from the LPS
model. Another data showed that the post-treatment of high in­
tensity EA on CLP model obtained the anti-inflammatory effects and
promoted the survival rate (Torres-Rosas et al., 2014). On the other
hand, EA applying to patients in real clinical practice might rarely
reach the intensity of stimulation as high as that in animals in the
laboratory. The EA stimulation of 3 mA is over the threshold (>2
mA) (Kagitani et al., 2010) activating Aδ and C fibers of the pe­
ripheral nerves (but see Zhou et al., 1985), that will produce pain
feelings in conscious animals and humans. The general situation in a
clinic is that a stimulation of EA applying to a patient without un­
comfortable feeling, especially without pain, that generally induces
slight twitch of the local muscles. This general clinic EA intensity is
roughly equal to moderate stimulation in animal experiments, which
perhaps might or might not activates the peripheral Aδ fibers
(threshold 1.5 mA)(Kagitani et al., 2010; Li et al., 2007) but not C
fibers. We might not need to concern too much on above pro-
inflammatory effect induced by high intensity post-EA, rather, we
might use this feature to benefit to patients, e.g. using relative high
stimuli at very early stage (before sepsis happening) to prevent
serious sepsis, or promote immunity at late stage with the immune-
paralysis.
6. The selection of acupoints has certain significance. As mentioned
above, to control inner organ function, the acupoints at abdomen or
back mediate the somatic-sympathetic reflex, while the acupoints of
limbs mediate the somatic-vagal-reflex (for an individual organ, the
exact and maximal reflex effect is obtained following the spinal
segmental dominance rule). However, there is still some variety
between acupoints within trunk group or limbs group, e.g. LI4 (Hegu)
and PC6 (Neiguan) are both effective acupoints of anti-inflammation,
but the former is more effective (Song et al., 2012). This difference
might be related to the distinction of the nerves distribution under
the acupoints.
7. The anti-inflammation effect of EA is mainly achieved by activating
vagal-splenic pathway (Song et al., 2012; Villegas-Bastida et al.,
2014; Lim et al., 2016; S.B. Liu et al., 2020), the vagal-adrenal me­
dulla-dopamine pathway (Torres-Rosas et al., 2014) and the
sympathetic-splenic pathway (Martelli et al., 2014b; S.B. Liu et al.,
W.-X. Pan et al.
2020), rather than by enhancing the hypothalamic-pituitary-adrenal
cortex axis, because electroacupuncture pretreatment did not in­
crease serum corticosteroid in animal sepsis model (Song et al.,
2012). The role of sympathetic-adrenal medulla pathway is thought
to play the role in anti-inflammatory effect in carrageenan-induced
paw inflammation model (Kim et al., 2008). However, the role of
sympathetic-adrenal medulla pathway in suppressing systemic
inflammation needs further investigation. Furthermore, the role of
sympathetic-vagal relationship and balance are worth to be studied
(Huang et al., 2010).
With these detailed results, the approach of the peripheral-
autonomic-immune reflex, carried out by acupuncture, seems prom­
ising in being translated into a relative optimal clinical therapy. How­
ever, as mentioned above, in the process of sepsis, the immune system
with CARS mechanism might present not only a hyper-inflammatory
reaction but also immune-paralysis depending on the individual condi­
tions. Further studies are needed to address if there is immune-paralysis
at a later stage (even early stage) of the sepsis model, which can be
prevented by acupuncture. Theoretically, acupuncture should have a
corrective effect for both the hyper- and the insufficient immune re­
sponses in the inflammation process according to the bidirectional
principle. Indeed, Guo et al. (2010) have reported that EA at Zusali
(ST36) and Guanyuan (CV4) decreased the apoptosis of thymocytes in
rat sepsis model, suggesting acupuncture can prevent sepsis animals
from immune-paralysis. The data from other immune suppression
models and clinical trials of inflammation also support the bidirectional
effects of acupuncture. For instance, acupuncture reduced the increased
plasma level of IL-10 in patients with chronic allergic rhinitis (Petti
et al., 2002). Theoretically, when the releasing of pro-inflammatory
factors is suppressed, the releasing of anti-inflammatory factors will
decrease as well, due to the latter being triggered by the former. Thus,
reducing the pro-inflammatory factors by acupuncture at an early stage
means also reducing the anti-inflammatory factors later. This might help
to avoid the up-and-down oscillation of the compensatory anti-
inflammatory response to prevent immune-paralysis, that finally in­
creases the survival rate of animals with sepsis, which needs to be
confirmed in future.
5.4. Clinical evidence
In real clinical conditions, patients with sepsis may also have addi­
tional complications, especially during the critical stage. Therefore, it is
necessary to use different medications or therapies to deal with multiple
factors to reach the best results, although animal experiments have
shown that acupuncture alone significantly increases the survival rate of
sepsis animals. Traditional Chinese practitioners have known for thou­
sands of years to combine acupuncture and herbal medicine together to
cure complicated diseases, including serious infections. Recently,
acupuncture integrated with modern medical therapies, as a part of the
comprehensive treatments of sepsis, has shown exciting values in clin­
ical trials. Clinical reports show that the effect of adding acupuncture
intervention in conjunction with conventional treatment is superior to
the conventional treatment group alone. A recent study (L. Wang et al.,
2019) of a randomized controlled trial on 108 patients with sepsis (54 in
the control group and 54 in acupuncture group) showed that the patients
in both groups were given conventional treatments, i.e. routine anti-
infective medications, and supportive treatments with organ func­
tioning monitored. The patients in the acupuncture group were treated
with acupuncture at ST36 daily for 3 consecutive days in addition to
conventional treatment. The results showed that, compared to the
condition before the treatments, after the treatments, the plasma factor
procalcitonin (PCT), blood lactic acid (Lac) expression level, Acute
Physiology and Chronic Health Evaluation (APACHE II) score, and
Sequential Organ Failure Assessment (SOFA) score in both groups were
significantly decreased; however, compared to the control group, after
7
Autonomic Neuroscience: Basic and Clinical 232 (2021) 102793
the treatment, the acupuncture group showed more decreaces signifi­
cantly (P < 0.05). Another study (J.N. Wu et al., 2013) conducted a
randomized control trial with 50 patients with sepsis, comparing
acupuncture plus conventional treatment (n = 26) with conventional
treatment alone (n = 24). The results showed that after 3 consecutive
days of daily EA treatment, the plasma TNF-α, IL-6 in the “acupuncture
plus conventional treatment” group were significantly lower than that in
conventional treatment group, and its overall effect was also better.
Similarly, F.W. Wu (2016) reported the effect of EA on the inflammatory
response and immune function in sepsis patients. The 50 patients with
sepsis were randomly divided into two groups of 25 each, i.e. the control
group used the treatment plan recommended by the 2008 international
guideline on the rescue of sepsis, and the acupuncture group used EA at
ST 36 daily plus the treatment given to control group. The APACHE II
scores, C reactive protein (CRP), PCT, Lac, and IL-6, IL-10 and T cell
subsets (CD4+ and CD8+) were recorded before the treatments and 3 and
7 days after treatments in both groups. The rates of incidence of MODS
and fatality rate during 28-day hospitalization were calculated. The
results showed that after treatments, at each time point the APACHE II
score, CRP, PCT, and Lac levels in both groups decreased to some extent,
while the levels of CD4+ and CD8+ of T cell subsets involved in adaptive
immunity increased in both groups; however, the EA group was better
than the control group (P < 0.05). This indicated that EA at ST36 not
only alleviated the pro-inflammatory response of patients with sepsis,
but also improved adaptive immune function. This study importantly
shows that the 28-day fatality rate in the EA group (8.00%) was
significantly lower than that in control group (28.00%) (P < 0.05), while
the incidences of MODS in EA group (24%) was lower than that in
control group (36%) but not significantly (p > 0.05). Xiao et al. (2015)
also obtained similar results. 90 patients with sepsis were randomly
distributed to “conventional treatment” (n = 30), “conventional treat­
ment + thymosin α1” (n = 30), and “conventional treatment +
acupuncture” (n = 30). The fatality rate after treatment, and T cell
subsets CD3+, CD4+, CD8+, CD4+/CD8+ ratio and the antibody IgG, IgA,
IgM before and after treatment were compared between groups. The
results showed that after 6 days of treatment, while the immune function
with above items in all three groups of patients significantly increased
(P < 0.01), that the thymosin group and the acupuncture group
increased significantly more than in the conventional treatment group
(P < 0.01, respectively). The ICU length of stay (days), and the rates of
28-day fatality also decreased significantly (P < 0.05, P < 0.01 respec­
tively) in both the thymosin group and with the acupuncture group
compared with the conventional treatment group. This suggests that
acupuncture can improve adaptive immune function, and its effective­
ness is comparable to that of thymosin, a recognized immune-stimulant
used for the treatment of sepsis. This clinical data suggest that
acupuncture not only decreases the pro-inflammatory factors but also
enhances adaptive immune function to prevent immune-paralysis,
which needs to be further confirmed.
Further, acupuncture can not only modulate immune function, but
also improve organ functioning in multiple disorders. This also gives
acupuncture as an advantage to treating MODS, imbalance of energy
metabolism of sepsis. For example, a study by Yu et al. (2015) has shown
that acupuncture can not only significantly improve the immune func­
tion of sepsis cases, but also protect the gastrointestinal function of
septic patients. The incidence of vomiting, abdominal distension and
gastric retention in the EA group (EA plus conventional treatment) were
significantly reduced compared with the control (conventional treat­
ment alone) group. Meng et al. (2018) also obtained the effects of
attenuating inflammatory responses and intra-abdominal pressure in
septic patients, but not the length of stay in intensive care unit (ICU) and
28 days fatality rate.
A recent meta-analysis (Tang et al., 2020) including 20 studies with
total 1337 patients with sepsis showed that the 28 day fatality rate, the
APACHE II score on the 3rd day and the 7th day after treatments, ICU
length of stay, gastrointestinal function improvement, PCT and TNF-α on
W.-X. Pan et al.
day 7 after treatments, in acupuncture plus conventional treatment
group were all significantly superior to that in conventional treatment
alone group statistically. All those research results (although still
limited) indicate that acupuncture is a very promising integrative
therapy for treating patients with sepsis.
6. Discussion: toward a science-based design of EA protocol of
immunomodulation
Given the current absence of recognized treatment protocols for
immune dysfunction in the process of sepsis, based on above laboratory
(i.e. preclinical studies) and clinical evidences, acupuncture could serve
as an adjuvant therapy, with its advantage of being easily used, low cost,
without any chemical side effects, and importantly, because of its ability
to modulate both immune function and multiple organ function. All of
which are beneficial to prevent the condition from worsening and to
decrease the fatality rate of septic patients. We strongly recommend that
acupuncture be included in the comprehensive treatment plan for sepsis.
However, the therapies used in previous studies generally followed
traditional theory or personal experience. Their selections of acupoints,
stimulating parameters, daily dose and course of treatment might not be
optimal; thus, it might limit their curative efficiency. To obtain better or
maximal effects, we give an acupuncture protocol design based on the
new knowledge developed from the researches described above. For the
mechanism, stimulating peripheral nerves induces the somatic-
autonomic reflex, which produces sympathetic or vagal effects on the
functional regulation of organs or physiological systems, including the
immune system we now focus on. The spinal somatic-sympathetic reflex
Fig. 3. The organization of the somatic-autonomic-immune reflexes (the part of the figure showing the autonomic nervous system and organs is modified from
Figure 296 of REF [Gao and Yu, 2014]). For explanation see the text.
8
Autonomic Neuroscience: Basic and Clinical 232 (2021) 102793
follows the rule of the spinal cord segmental control, i.e. the effect of a
somatic-sympathetic reflex on an specific organ is obtained limitedly by
stimulating the somatic nerve connecting to the spinal cord segments
(1–5 segments usually) as same as that the organ do. For example, the
spleen is innervated by the sympathetic nerve from the spinal cord
segment T5-T8, thus only the stimulation (electrical or acupunctural
one) from the somatic nerve zone belonging to the T5-T8 segments can
produce the reflex effect on the spleen. Similarly, T8-L1 for the adrenal
medulla, and T1-T5 for the lung and so on, that a map with the details
can be found in any anatomy textbook. The supraspinal somatic-
sympathetic reflex might be induced by high intensity nociceptive
stimulation, which is systemic, but rarely produced by acupuncture. The
somatic-vagal reflex is special. Previous data showed the vagal reflex
control the gastrointestinal tract can be induced by stimulation of the
peripheral nerves or the acupoints at the limbs (not the trunk) with high
intensity (activating Aδ and C fibers) of stimulation (Sato,1997; Li et al.,
2007). However, to activate the vagal-adrenal reflex, a new data (Liu
et al., 2020) showed that the stimulation of 0.5 mA (lower than the
threshold of Aδ) is sufficient to do. To focus on immune function con­
trolling, we name those reflexes as “somatic-autonomic-immune re­
flexes”; specifically, the somatic-sympathetic-splenic reflex, the somatic-
sympathetic-adrenal reflex, the somatic-vagal-splenic reflex, somatic-
vagal-adrenal reflex, which induce systemic regulatory effects on im­
mune functions because the final outputs are from the spleen or the
adrenal medulla, which release cytokines or norepinephrine and dopa­
mine into blood. However, the other somatic-sympathetic reflexes
related to an organ have local effect only, e.g. the somatic-sympathetic-
lung reflex, the somatic-sympathetic-kidney reflex, etc. It should be
W.-X. Pan et al.
noted that stimulation of any acupoint can also produce common sys­
temic effects or perhaps some unknown specific effects through the
brain integration (both sympathetic and vagal ones) simultaneously,
that need further studies. Those concepts and principles are illustrated in
Fig. 3.
6.1. An auxiliary acupuncture protocol
Following the above reflex principles and considering that the effects
of acupuncture are state-dependent, stimulation-parameter-dependent,
acupoint-dependent, and treatment-time-dependent, an auxiliary
acupuncture protocol for sepsis treatment is designed as follows and
summarized in Table 1:
1) Acupoint selection: examples of acupoints we selected are listed
below. It should be noted that following the segmental distribution to
select acupoints is the key point here.
a. Systemic regulation:
• Vagal Group: ST36 (Zusangli) or LI4 (Hegu), bilaterally (the
same below). They are the most effective acupoints reported
from laboratorial and clinical studies, activating vagal anti-
inflammatory pathway to down-regulating cytokines storm;
• Sympathetic Group: BL17 (Geshu) and BL19 (Danshu) on the
back; or ST21 (Liangmen) and ST25 (Tianshu) on the abdomen,
to activate the sympathetic-splenic reflex and the sympathoa­
drenal medullary reflex, additionally benefiting to septic shock
patients due to the norepinephrine releasing.
b. Local regulation:
• Thoracic group: BL13 (Feishu) and HT7 (Shenmen).
• Abdominal group (gastrointestinal organs, liver and kidneys):
BL19 (Danshu) and ST25 (Tianshu).
• Pelvic group: BL23 (Shenshu) and SP6 (Sanyinjiao).
b. The formula of acupoints we recommend:
Formula I: Vagal group + Local group/s (if needed);
Formula II: Sympathetic group + Local group/s (if needed).
The two formulas are used in turns.
2) Stimulation parameters: for the intensity of EA, it is recommended
to give moderate stimuli which can cause slight muscle twitching and
also be tolerated by patients. To prevent sepsis in patients in the early
stages of infection, high-intensity stimulation is recommended; that
perhaps causes more of a pain sensation. Applying EA “continuing
trains” with the frequency of 2–10 Hz for 30 min is a general EA dose.
However according to the frequency effect (Chen et al., 2016), here
we recommend using “alternating trains” of 2/15 Hz or 2/100 Hz,
(100 Hz to enhance sympathoadrenal medullary reflex, Kim et al.,
2008) for systemic effects, and “bursting trains” with high frequency
(15-100 Hz) for local effects. If using the traditional manual
acupuncture, we suggest mimicking the “alternating trains”,
Table 1
An example design of evidence-based therapy of EA to modulate immunity in sepsis.
Effects Reflex Acupoints
Systemic Vagal reflex ST36 (Zusanli)
LI4 (Hegu)
Systemic Sympathetic-splenic BL17 (Geshu)
ST21 (Liangmen)
Sympathetic-adrenal BL19 (Danshu)
ST25 (Tianshu)
Local organs Sympathetic (thoracic) BL13 (Feishu)
HT7 (Shenmen)
Sympathetic (abdominal) BL19 (Danshu)
ST25 (Tianshu)
Sympathetic (pelvic) BL23 (Shenshu)
SP6 (Shanyinjiao)
A: alternating trains; B: bursting trains; C: continuing trains.
9
Autonomic Neuroscience: Basic and Clinical 232 (2021) 102793
applying a light or moderate stimulation (a slow rotation) of 2–5
min/10 min for 30 min, given that manual acupuncture can activate
all groups of sensory nerve fibers (Kagitani et al., 2010) and a slow
rotation of needle is efficient to induce anti-inflammatory effect (Lim
et al., 2016; Ramires et al., 2020).
3) Daily dose and course of treatment: considering that the inhibitory
effects of one treatment of EA on most inflammatory factors last for
about 6 h (Song et al., 2012; Torres-Rosas et al., 2014), the daily dose
we suggest is 2 times/day for patient with sepsis; one time/day for
early stage of acute infection. Formula I and Formula II will be used
in turns. Take a course of 5–7 days with a break of 1–3 days, because
the toleration might happen after 7 days with continuous daily
treatments (Du et al., 1995). For severe infection such as COVID-19,
the sooner the intervention is performed, the better.
4) Self-healing: for mild cases or early stages of the infection, the
transcutaneous electrical stimulator (TENS) can be used by patients
themselves.
6.2. Limitations and future research
As discussed above, acupuncture is supported by a large amount of
research data both in clinical trials and animal studies in resolving
cytokine storms during severe inflammation; however, there still exist
many unsolved gaps. There are several limitations to this review aside
from those discussed above. 1) Although acupuncture’s anti-
inflammatory storm has been repeatedly confirmed by animal experi­
ments, and the effect of acupuncture in inhibiting inflammatory storms
through neuroimmune pathway is almost certain, it should be noted that
current experimental results mostly come from CLP models and LPS
models. It is necessary to further compare the differences between these
two and expand to other new models. In particular, a new direction is to
establish an immune-paralysis model in late-stage sepsis. 2) More
detailed research is needed in acupoint selection and stimulation pa­
rameters. 3) Time-window of acupuncture effect is worthy enough to do
further systematic research: identifying the acupuncture effect during
different development stages of sepsis, i.e. pretreatment, and its early,
middle, and late stages. This needs to combine with acupoint selection
and stimulation parameters. 4) Refining and deepening is needed in the
bidirectional regulating effect and mechanism of acupuncture in terms
of immune regulation. In particular, given that the suppressing effects of
acupuncture on cytokine storms has been well addressed, next challenge
is investigating the effects of acupuncture on immune-paralysis in sepsis.
5) Most of previous studies focused on systemic effects of acupuncture or
other peripheral nerve stimulation. A new direction is identifying local
effect produced by local segmental reflexes, that will provide scientific
bases of acupoint selection to clinical therapy design. 6) Any peripheral
stimulation might produce both local spinal segmental reflexes and
supra-spinal reflexes. Local segmental reflexes might co-work with its
Pulse trains Frequency (Hz) Intensity Dose & course
A 2/15 or 2/100 Moderate 2 times/day,
B 15 5–7 days
C 2
A 2/100 or 2/15 Moderate 2 times/day,
B 100 or 15 5–7 days
C 15
Same
B 15 or 2 Moderate 2 times/day,
5–7 days
Same
Same
W.-X. Pan et al.
supra-spinal reflexes, or have independent effect, that can be used in
different situation. This is a basic question of acupuncture and very
important for selecting acupoints in a therapy. The interactions and
mechanisms of local spinal segmental reflexes and supra-spinal reflexes
produced by acupuncture need to be further studied extensively, not
only for inflammation but for all other disorders. 6) Current acupuncture
clinical trials have some quality issues. The quality of most reports has
been criticized due to insufficient sample sizes and lacking proper sham
controls. Indeed, the feature of acupuncture different from drug’s makes
the design of sham acupuncture control difficult to meet the rules of
double-blind clinical study. To avoid such problems, the National In­
stitutes of Health (NIH) is currently advocating real-world clinical
research in view of the characteristics of acupuncture (Zia et al., 2017).
However, according to the results of current animal and clinical exper­
iments, there are large varieties of the effects of acupoints and stimu­
lation parameters, that some of them showed significant effects but
others with little effects on same treatment targets (e.g. Chen et al.,
2016; Li et al., 2015). Such little effective acupoints or stimulation pa­
rameters give an idea “sham” control manipulation. By using such par­
allel design, Li et al. (2015) showed the effects of long-lasting reduction
of blood pressure in a group treated with specific acupoints but not in
the other group with different acupoints. We strongly recommend such
parallel design, that uses invalid acupoints or stimulation parameters as
“sham” control group to rule out placebo effect. Parallel design is well
known as the “gold standard” for phase 3 clinical trials. It is just very
well for clinical study of acupuncture. Anyhow, systematic, large and
rigorous clinical data will be the key for supporting in acupuncture-
assisted immune adjustment in the treatment of sepsis. The acupunc­
ture protocol designed in this article is just one example of suggestions
for future clinical research, which is based on current available litera­
ture. We hope that this protocol would be inspiring and promoting the
translation from scientific study to clinical application. Given that there
are gaps in acupuncture mechanisms, and between acupuncture real
practice and basic science study in treating sepsis, further studies in both
acupuncture mechanisms and clinical trials are warranted.
7. Summary
Faced with the severe situation of the global pandemic of COVID-19,
the medical community throughout the world is exploring various
treatments from different approaches, including antiviral, anti-
inflammatory, and controlling multiple organ functions. It has been
identified that COVID-19 induces immune disorder and sepsis in severe
patients (Yuki et al., 2020). A new study demonstrated that COVID-19
cytokine storms, especially a high level of TNF may make few memory
B cells and prevent a durable immune response (Kaneko et al., 2020).
For fatal sepsis with multiple organ failure, the imbalance of immune
function is the core pathological mechanism, and the various therapies
for controlling the immune function currently have no recognized best
choice for various reasons. At this moment, acupuncture used to activate
the somatic-autonomic-immune reflexes is a promising therapy
emerging from multiple recent animal experiments and clinical studies,
to provide significant clinical advantage to control inflammation and
restore organ function without adverse side effects. Different from a new
drug investigation needing a phase I clinical trial (screening the safety
and testing the proper dose), acupuncture with its safety feature, has
been carried out at least in phase II like clinical trials for a variety of
diseases for years throughout the world. If acupuncture is involved in
the treatment of COVID-19, the patients will not only avoid losing a
promising adjunctive therapy, but it would also be a good opportunity
obtaining a large number of patients to test the efficiency of acupuncture
in a clinic trial. Previous studies from animal models and clinical trials
have shown that acupuncture modulates immunity, but it has yet been
consistent with showing that acupuncture decreases the fatality rate of
sepsis patients. Besides the complicated process of sepsis, one main
reason is that the efficiency of acupuncture depends on several factors
10
Autonomic Neuroscience: Basic and Clinical 232 (2021) 102793
such as the pathological status, the acupoints, the stimulation parame­
ters and the time-window of treatment etc. that need well consideration
together to obtain maximal effects. We recommend an evidence-based
comprehensive design of EA protocol to practitioners and researchers
to test it. It is worth looking forward to its contribution to the treatment
of sepsis and, for the moment, to treating the urgent need of patients
with COVID-19 infection as well as for future patients with various in­
fections and other factors.
Declaration of competing interest
Author Sarah Faggert Alemi was employed by the company Eastern
Roots Wellness, PLC. The remaining authors declare that the research
was conducted in the absence of any commercial or financial relation­
ships that could be construed as a potential conflict of interest.
Acknowledgements
We thank Dr. Qiufu Ma for his feedback on the manuscript.
CRediT authorship contribution statement
This project was initiated by WX Pan and A.Y. Fan. As the primary
researcher, WX Pan designed the project and protocol, structured and
drafted the early version of manuscript. A.Y. Fan, SZ. Chen and S.F.
Alemi participated in discussing, further drafting and editing the later
versions. WX. Pan and A.Y. Fan completed the final manuscript. There
was no financial support for this project. Due to the limitation of the
authors’ personal experience and perspective, this review may have
some omissions and errors; comments or corrections are welcomed and
appreciated.
References
Bassi, G.S., Dias, D.P.M., Franchin, M., Talbot, J., Reis, D.G., Menezes, G.B., et al., 2017.
Modulation of experimental arthritis by vagal sensory and central brain stimulation.
Brain Behav. Immun. 64, 330–343.
Behrens, E.M., Koretzky, G.A., 2017. Cytokine storm syndrome: looking toward the
precision medicine era. Arthritis Rheumatol. 69, 1135–1143.
Bellinger, D.L., Lorton, D., 2014. Autonomic regulation of cellular immune function.
Autonomic Neuroscience: Basic and Clinical. 182 (15–41), 2014.
Berlot, G., Passero, S., 2019. Immunoparalysis in Septic Shock Patients. Patients [Online
First]. IntechOpen. https://doi.org/10.5772/intechopen.88866. https://www.intech
open.com/online-first/immunoparalysis-in-spetic-shock-patients.
Bernik, T.R., Friedman, S.G., Ochani, M., DiRaimo, R., Ulloa, L., Yang, H., et al., 2002.
Pharmacological stimulation of the cholinergic antiinflammatory pathway. J. Exp.
Med. 195, 781–788.
Borovikova, L.V., Ivanova, S., Zhang, M., Yang, H., Botchkina, G.I., Watkins, L.R., et al.,
2000. Vagus nerve stimulation attenuates the systemic inflammatory response to
endotoxin. Nature 405, 458–462.
Cao, J.R., Gong, Q. H., Xiang, Y. M. (1982). Effect of acupuncture on the output lymph
and cell in popliteal lymph nodes in rabbits. Shanghai J Acu-moxi. 1, 35–37.
Chavan, S.S., Tracey, K.J., 2017. Essential neuroscience in immunology. J Immunol. 198,
3389–3397.
Chen, Y., Lei, Y., Mo, L.Q., Li, J., Wang, M.H., Wei, J.C., et al. (2016). Electroacupuncture
pretreatment with different waveforms prevents brain injury in rats subjected to
cecal ligation and puncture via inhibiting microglial activation, and attenuating
inflammation, oxidative stress and apoptosis. Brain Res Bull. 127, 248–259.
Choi, G.S., Oha, S.D., Han, J.B., Bae, H.S., Cho, Y.W., Yun, Y.S., et al., 2002. Modulation
of natural killer cell activity affected by electroacupuncture through lateral
hypothalamic area in rats. Neurosci. Lett. 329, 1–4.
da Silva, M.D., Guginski, G., Werner, M.F., Baggio, C.H., Marcon, R., Santos, A.R., 2011.
Involvement of interleukin-10 in the anti-inflammatory effect of Sanyinjiao (SP6)
acupuncture in a mouse model of peritonitis. Evid. Based Complement. Alternat.
Med. 2011, 217946. https://doi.org/10.1093/ecam/neq036.
Dai, Q.M., Shang, Y.Q., Liang, H., Yan, P.Y., Wang, M.Q., Wang, K. (2018). Research
progress of effect of acupuncture therapy on T cell subsets. J Clin Acupunct. 7,78–82.
De Ferrari, G.M., Crijns, H.J.G.M., Borggrefe, M., Milasinovic, G., Smid, J., Zabel, M.,
et al., 2011. Chronic vagus nerve stimulation: a new and promising therapeutic
approach for chronic heart failure. Eur. Heart J. 32, 847–855.
de Jonge, W.J., van der Zanden, E.P., The, F.O., Bijlsma, M.F., van Westerloo, D.J.,
Bennink, R.J., et al., 2005. Stimulation of the vagus nerve attenuates macrophage
activation by activating the Jak2-STAT3 signaling pathway. Nat. Immunol. 6,
844–851.
Den, G.G., 1981. The affections of electroacupuncture on the phagocytosis and protein
electrophoresis of serum. Zhejiang J Chin Med. 9, 405.
W.-X. Pan et al.
Du, L., Jiang, J., Cao, X., 1995. Time course of the effect of electroacupuncture on
immunomodulation of normal rat. Zhen Ci Yan Jiu. 20, 36–39.
Eskandari, F., Webster, J.I., Sternberg, E.M., 2003. Neural immune pathways and their
connection to inflammatory diseases. Arthritis Res Ther. 5, 251–265.
Gao, S.L., Yu, P., 2014. Atlas of Human Anatomy, 6th ed. Shanghai Scientific and
Technical Publishers, Shanghai, p. 325.
Ghia, J.E., Blennerhassett, P., Kumar-Ondiveeran, H., Verdu, E.F., Collins, S.M., 2006.
The vagus nerve: a tonic inhibitory influence associated with inflammatory bowel
disease in a murine model. Gastroenterol. 131, 1122–1130.
Ghia, J.E., Blennerhassett, P., Collins, S.M., 2007. Vagus nerve integrity and
experimental colitis. Am. J. Physiol. Gastrointest. Liver Physiol. 293, G560–G567.
Gotts, J.E., Matthay, M.A., 2016. Sepsis: pathophysiology and clinical management BMJ
353, i1585.
Gu, G., Zhang, Z., Wang, G., Han, F., Han, L., Wang, K., et al., 2011. Effects of
electroacupuncture pretreatment on inflammatory response and acute kidney injury
in endotoxaemic rats. J Int Med Res. 39, 1783–1797. https://doi.org/10.1177/
147323001103900521.
Guarini, S., Altavilla, D., Cainazzo, M.M., Giuliani, D., Bigiani, A., Marini, H., et al.
(2003). Efferent vagal fibre stimulation blunts nuclear factor-kappa B activation and
protects against hypovolemic hemorrhagic shock. Circ.107, 1189–1194.
Guo, X.J., Thomas, P.G., 2017. New fronts emerge in the influenza cytokine storm.
Semin. Immunopathol. 39, 541–550. https://doi.org/10.1007/s00281-017-0636-y.
Guo, X.W., Zhu, M.F., Xu, Y.G., Lei, S., 2010. Effects of electroacupuncture at Zusanli
(ST36) and Guanyuan (CV4) on the apoptosis of thymocytes in rats with sepsis.
J Emerg Tradit Chin Med. 9, 475–477.
Hahm, E.T., Lee, J.J., Lee, W.K., Bae, H.S., Min, B.I., Cho, Y.W., 2004.
Electroacupuncture enhancement of natural killer cell activity suppressed by
anterior hypothalamic lesions in rats. Neuroimmunomodulation. 11, 268–272.
Hamers, L., Kox, M., Pickkers, P., 2015. Sepsis-induced immunoparalysis: mechanisms,
markers, and treatment options. Minerva Anestesiol. 81, 426–439.
Han, Y., 1993. Acupuncture improves the weakness syndrome and immunity of healthy
elderly. Chin Acupunct Moxibustion. 13, 31–32.
Han, J.S., 2003. Acupuncture: neuropeptide release produced by electrical stimulation of
different frequencies. TRENDS in Neurosci. 26, 17–22.
Hisamittsu, T., Kasahara, T., Umezawa, T., Ishino, T., Hisamitsu, N., 2002. The effect of
acupuncture on natural killer cell activity. Int. Congr. Ser. 1238, 125–131.
Howland, R.H., 2014. Vagus nerve stimulation. Curr Behav Neurosci. Rep. 1, 64–73.
Howland, R.H., Shutt, L.S., Berman, S.R., Spotts, C.R., Denko, T., 2011. The emerging use
of technology for the treatment of depression and other neuropsychiatric disorders.
Ann. Clin. Psychiatry 23, 48–62.
Huang, J., Wang, Y., Jiang, D., Zhou, J., Huang, X., 2010. The sympathetic-vagal balance
against endotoxemia. J. Neural Transm. 117, 729–735.
Huh, J.R., Veiga-Fernandes, H., 2020. Neuroimmune circuits in inter-organ
communication. Nat Rev Immunol. 20, 217–228.
Huston, J.M., Ochani, M., Rosas-Ballina, M., Liao, H., Ochani, K., Pavlov, V.A., et al.,
2006. Splenectomy inactivates the cholinergic antiinflammatory pathway during
lethal endotoxemia and polymicrobial sepsis. J. Exp. Med. 203, 1623–1628.
Inoue, T., Abe, C., Sung, S.S., Moscalu, S., Jankowski, J., Huang, L., et al., 2016. Vagus
nerve stimulation mediates protection from kidney ischemia-reperfusion injury
through alpha7nAChR+ splenocytes. J. Clin. Invest. 126, 1939–1952.
Iwa, M., Nakade, Y., Pappas, T.N., Takahashi, T., 2006. Electroacupuncture elicits dual
effects: stimulation of delayed gastric emptying and inhibition of accelerated colonic
transit induced by restraint stress in rats. Dig. Dis. Sci. 51, 1493–1500.
Jänig, W. (2014). Sympathetic nervous system and inflammation: a conceptual view.
Auton Neurosci. 182, 4–14.
Jänig, W., Green, P.G., 2014. Acute inflammation in the joint: its control by the
sympathetic nervous system and by neuroendocrine systems. Autonomic
Neuroscience: Basic & Clinical. 182, 42–54. https://doi.org/10.1016/j.
autneu.2014.01.001.
Johansen, M., Yu, G.J., Madden, T., Chiang, J.S., J.S., 2004. Effect of acupuncture on
circulating cytokines in healthy subjects. Med Acupunct. 15, 19–24.
Johnston, M.F., Ortiz Sánchez, E., Vujanovic, N.L., Li, W., 2011. Acupuncture may
stimulate anticancer immunity via activation of natural killer cells. Evid. Based
Complement. Alternat. Med. 2011, 481625. https://doi.org/10.1093/ecam/nep236.
Jong, M.S., Hwang, S.J., Chen, F.P., 2006. Effects of electro-acupuncture on serum
cytokine level and peripheral blood lymphocyte subpopulation at immune-related
and non-immune-related points. Acupunct. Electrother. Res. 31 (1–2), 45–59.
Kagitani, F., Uchida, S., Hotta, H., 2010. Afferent nerve fibers and acupuncture.
Autonomic Neurosci: Basic and Clinical. 157, 2–8.
Kaneko, N., Kuo, H.H., Boucau, J., Farmer, J.R., Allard-Chamard, H., Mahajan, V.S., et al.
(2020). Loss of Bcl-6-expressing T follicular helper cells and germinal centers in
COVID-19. Cell. 183,143-157.e13.
Kim, S.K. & Bae, H. (2010). Acupuncture and immune modulation. Autonomic Neurosci.:
Basic Clinical. 157: 38–41.
Kim, C.K., Choi, G.S., Oh, S.D., Han, J.B., Kim, S.K., Ahn, H.J., et al. (2005).
Electroacupuncture up-regulates natural killer cell activity identification of genes
altering their expressions in electroacupuncture induced up-regulation of natural
killer cell activity. J Neuroimmunol. 168, 144–153.
Kim, H.W., Kang, S.Y., Yoon, S.Y., Roh, D.H., Kwon, Y.B., Han, H.J., et al., 2007. Low-
frequency electroacupuncture suppresses zymosan-induced peripheral inflammation
via activation of sympathetic post-ganglionic neurons. Brain Res. 1148, 69–75.
Kim, H.W., Uh, D.K., Yoon, S.Y., Roh, D.H., Kwon, Y.B., Han, H.J., et al., 2008. Low-
frequency electroacupuncture suppresses carrageenan-induced paw inflammation in
mice via sympathetic post-ganglionic neurons, while high-frequency EA suppression
is mediated by the sympathoadrenal medullary axis. Brain Res. Bull. 75, 698–705.
11
Autonomic Neuroscience: Basic and Clinical 232 (2021) 102793
Kim, S.K. Lee, Y., Cho, H., Koo, S., Choi, S.M., Shin, M.K., et al. (2011). A parametric
study on the immunomodulatory effects of electroacupuncture in DNP-KLH
immunized mice. Evid. Based Complement. Alternat. Med. 2011;2011:389063. doi:
https://doi.org/10.1093/ecam/nep166. (Epub 2011 Feb 14).
Komegae, E.N., Farmer, D.G.S., Brooks, V.L., McKinley, M.J., McAllen, R.M., Martelli, D.,
et al., 2018. Vagal afferent activation suppresses systemic inflammation via the
splanchnic anti-inflammatory pathway. Brain Behav. Immun. 73, 441–449.
Koopman, F.A., Chavan, S.S., Miljko, S., Grazio, S., Sokolovic, S., Schuurman, P.R., et al.,
2016. Vagus nerve stimulation inhibits cytokine production and attenuates disease
severity inrheumatoid arthritis. Proc. Natl. Acad. Sci. U. S. A. 113, 8284–8289.
Kwan, H., Garzoni, L., Liu, H.L., Cao, M.J., Desrochers, A., Fecteau, G., et al., 2016. Vagus
nerve stimulation for treatment of inflammation: systematic review of animal models
and clinical studies. Bioelectromed. 3, 1–6.
Lai, F., Ren, Y., Lai, C., Chen, R., Yin, X., Tan, C., et al. (2020). Acupuncture at Zusanli
(ST36) for experimental sepsis: a systematic review. Evid Based Complement
Alternat Med.,2020, 3620741.
Li, Y.Q., Zhu, B., Rong, P.J., Ben, H., Li, Y.H. (2007). Neural mechanism of acupuncture-
modulated gastric motility. World J Gastroenterol. 13, 709–716. doi: https://doi.
org/10.3748/wjg.v13.i5.709.
Li, P., Tjen-A-Liooi, S.C., Cheng, L., Liu, D., Painovich, J., Vinjamury, S., et al., 2015.
Long-lasting reduction of blood pressure by electroacupuncture in patients with
hypertension: randomized controlled trial. Medical Acupuncture 274, 253–266.
Lim, H.D., Kim, M.H., Lee, C.Y., Namgung, U., 2016. Anti-inflammatory effects of
acupuncture stimulation via the vagus nerve. PLoS One 11, e0151882. https://doi.
org/10.1371/journal.pone.0151882.
Lin, H., Yu, Z.F., Kang, F.H., 2014. Th1/Th2 balance on depression patients by
acupuncture treatment combined with antidepressant. J Clin Acupunct Moxibustio.
30, 1–3.
Liu, S.Z., 1959. The effects of acupuncture on the phagocytosis of reticuloendothelial
system. Acta Academiae Medicinae Jilin. 4, 9.
Liu, L.J., Xu Z., Xiu, H.M., Li, B. (1997). Effect of acupuncture on activity of natural killer
cells in mice or hyperplasia of mammary glands. Chin Acupunct Moxibustion. 17,
297.
Liu, L.G., Gu, J., Yang, Y.H., 2004. Analysis on the characteristics of ancient acupuncture
and moxibustion of the epidemic. Shanghai J Acu Mox 23, 38–40.
Liu, J.M., Liang, F.X., Li, J., Liu, X.Q., Tang, H.T., Wu, S., et al., 2009. Influence of
electroacupuncture of Guanyuan (GV 4) and Zusanli (ST 36) on the immune function
of T cells in aging rats. Zhen Ci Yan Jiu. 34, 242–247.
Liu, S.B., Wang, Z.F., Su, Y.S., Ray, R.S., Jing, X.H., Wang, Y.Q., et al., 2020. Somatotopic
organization and intensity dependence in driving distinct NPY-expressing
sympathetic pathways by electroacupuncture. Neuron. 108, 1–15.
Ma, S.X., 2004. Neurobiology of acupuncture: toward CAM. Evid. Based Complement.
Alternat. Med. 1, 41–47.
Martelli, D., Yao, S.T., Mancera, J., McKinley, M.J., McAllen, R.M. (2014a). Reflex
control of inflammation by the splanchnicanti-inflammatory pathway is sustained
and independent of anesthesia. Am J Physiol Regul Integr Comp Physiol. 307,
R1085–R1091.
Martelli, D., Yao, S.T., McKinley, M.J., McAllen, R.M., 2014b. Reflex control of
inflammation by sympathetic nerves, not the vagus. J. Physiol. 592, 1677–1686.
Martelli, D., McKinley, M.J., McAllen, R.M., 2014c. The cholinergic anti-inflammatory
pathway: a critical review. Auton Neurosci: Basic Clin 182, 65–69 (Moxibustion. 34,
78-82).
Martelli, D., Farmer, D.G.S., Yao, S.T., 2016. The splanchnic anti-inflammatory pathway:
could it be the efferent arm of the inflammatory reflex? Exp. Physiol. 101,
1245–1252.
Martelli, D., Farmer, D.G.S., McKinley, M.J., Yao, S.T., McAllen, R.M., 2019. Anti-
inflammatory reflex action of splanchnic sympathetic nerves is distributed across
abdominal organs. Am J Physiol Regul Integr Comp Physiol. 316, R235–R242.
Meng, J., Jiao, Y., Xu, X., Lai, Z., Zhang, G., Ji, C., Hu, M., 2018. Electro-acupuncture
attenuates inflammatory responses and intraabdominal pressure in septic patients.
Medicine 97 (17), e0555. https://doi.org/10.1097/MD.0000000000010555. April
2018.
Noller, C.M., Levine, Y.A., Urakov, T.M., Aronson, J.P., Nash, M.S., 2019. Vagus nerve
stimulation in rodent models: an overview of technical considerations. Front.
Neurosci. 13, 911. https://doi.org/10.3389/fnins.2019.00911.
Okamoto, S., Ibaraki, K., Hayashi, S., Saito, M.(1996). Ventromedial hypothalamus
suppresses splenic lymphocyte activity through sympathetic innervation. Brain Res.
739, 308–313.
Olofsson, P.S., Rosas-Ballina, M., Levine, Y.A., Tracey, K.J., 2012. Rethinking
inflammation: neural circuits in the regulation of immunity. Immunol. Rev. 248,
188–204.
Pan, W.X., 2018. The neurobiological mechanisms of acupuncture. Chin J Tradit Chin
Med Pharm. 33, 4281–4297.
Pan, W.X., 2019. Bidirectional regulation of acupuncture and its plausible mechanisms.
Acupunct Res. 44, 843–853.
Park, M.B., et al., 2004. Suppression of IgE production and modulation of Th1/Th2 cell
response by electroacupuncture in DNP-KLH immunized mice. J. Neuroimmunol.
151, 40–44.
Pavlov, V.A., Tracey, K.J., 2017. Neural regulation of immunity: molecular mechanisms
and clinical translation. Nat. Neurosci. 20, 156–166.
Pavlov, V.A., Chavan, S.S., Tracey, K.J., 2018. Molecular and functional neuroscience in
immunity. Annu. Rev. Immunol. 36, 783–812.
Peters van Ton, A.M., Kox, M., Abdo, W.F., Pickkers, P., 2018. Precision immunotherapy
for Sepsis. Front. Immunol. 9, 1926. https://doi.org/10.3389/fimmu.2018.01926.
Petti, F.B., Liguori, A., Ippoliti, F., 2002. Study on cytokines IL-2, IL-6, IL-10 in patients of
chronic allergic rhinitis treated with acupuncture. J. Tradit. Chin. Med. 22, 104–111.
W.-X. Pan et al.
Ramires, C.C., Balbinot, D.T., Cidral-Filho, F.J., Dias, D.V., Dos Santos, A.R., da Silva, M.
D., 2020. Acupuncture reduces peripheral and brainstem cytokines in rats subjected
to lipopolysaccharide-induced inflammation. Acupunct. Med. 2020,
964528420938379 https://doi.org/10.1177/0964528420938379.
Reinhart, K., Daniels, R., Kissoon, N., Machado, F.R., Schachter, R.D., Finfer, S., 2017.
Recognizing sepsis as a global health priority — a WHO resolution. N. Engl. J. Med.
377, 414–417. https://doi.org/10.1056/NEJMp1707170.
Rho, S.W., Choi, G.S., Ko, E.J., Kim, S.K., Lee, Y.S., Lee, H.J., et al., 2008. Molecular
changes in remote tissues induced by electro-acupuncture stimulation at acupoint
ST36. Mol Cells. 25, 178–183.
Sato, A., 1997. Neural mechanisms of autonomic responses elicited by somatic sensory
stimulation. Neurosci. Behav. Physiol. 27, 610–621.
Sato, T., Yu, Y., Guo, S.Y., Kasahara, T., Hisamitsu, T., 1996. Acupuncture stimulation
enhances splenic natural killer cell cytotoxicity in rats. Jpn J Physiol. 46, 131–136.
Scognamillo-szabo, M.V.R., Bechara, G.H., Ferreira, S.H., Cunha, F.Q., 2004. Effect of
various acupuncture treatment protocols upon sepsis in wistar rats. Ann. N. Y. Acad.
Sci. 1026, 251–256.
Shiue, H.S., Lee, Y.S., Tsai, C.N., Hsueh, Y.M., Sheu, J.R., Chang, H.H., 2008. DNA
microarray analysis of the effect on inflammation in patients treated with
acupuncture for allergic rhinitis. J. Altern. Complement. Med. 14, 689–698.
Silvério-Lopes, S., da Mota, M.P.G., 2013. Acupuncture in Modulation of Immunity.
IntechOpen. https://doi.org/10.5772/54286.
Singer, M., Deutschman, C.S., Seymour, C.W., Shankar-Hari, M., Annane, D., Bauer, M.,
et al. (2016). The third international consensus definitions for sepsis and septic shock
(sepsis-3). JAMA 315, 801–810. doi:https://doi.org/10.1001/jama.2016.0287
(2016).
Sladkova, T., Kostolansk, F., 2006. The role of cytokines in the immune response to
influenza a virus infection. Acta Virol. 50, 151–162.
Son, Y.S., Park, H.J., Kwon, O.B., Jung, S.C., Shin, H.C., Lim, S., 2002. Antipyretic effects
of acupuncture on the lipopolysaccharide-induced fever and expression of
interleukin-6 and interleukin-1 beta mRNAs in the hypothalamus of rats. Neurosci.
Lett. 319, 45–48.
Song, J.G., Li, H.H., Cao, Y.F., Lv, X., Zhang, P., Li, Y.S., et al., 2012. Electroacupuncture
improves survival in rats with lethal endotoxemia via the autonomic nervous system.
Anesthesiol. 116, 406–414. https://doi.org/10.1097/ALN.0b013e3182426ebd.
Szelényi, J., Kiss, J.P., Vizi, E.S.(2000). Differential involvement of sympathetic nervous
system and immune system in the modulation of TNF-alpha production by alpha2-
and beta-adrenoceptors in mice. J Neuroimmunol., 103, 34–40.
Tang, Y.D., Xu, M., Wang, R., Xu, M.Z., Yang, J., Liu, J., 2020. Efficacy and safety of
acupuncture on sepsis patients: a systematic review. Chin. J. Evid. Based Med. 20,
1–7.
Tian, L., Huang, Y.X., Tian, M., Gao, W., Chang, Q., 2003. Downregulation of
electroacupuncture at ST36 on TNF-alpha in rats with ulcerative colitis. World J.
Gastroenterol. 9, 1028–1033.
Tisoncik, J.R., Korth, M.J., Simmons, C.P., Farrar, J., Martin, T.R., Katze, M.G., 2012.
Into the eye of the cytokine storm. Microbiol. Mol. Biol. Rev. 76, 16–32.
Torres-Rosas, R., Yehia, G., Peña, G., Mishra, P., Thompson-Bonilla, M.D.R., Moreno-
Eutimio, M.A., et al., 2014. Dopamine mediates vagal modulation of the immune
system by electroacupuncture. Nat. Med. 20, 291–295.
Tracey, K.J., 2002. The inflammatory reflex. Nature 420, 853–859.
Uchida, S., Kagitani, F., Sato-Suzuki, I. (2017). Somatoautonomic reflex in acupuncture
therapy: a review. Autonomic Neurosci.: Basic & Clinical, 203, 1–8.
Ulloa, L., 2005. The vagus nerve and the nicotinic anti-inflammatory pathway. Nat. Rev.
Drug Discov. 4, 673–684.
Ulloa, L., Quiroz-Gonzalez, S., Torres-Rosas, R., 2017. Nerve stimulation:
immunomodulation and control of inflammation. Trends Mol. Med. 23, 1103–1120.
van Westerloo, D.J., Giebelen, I.A., Florquin, S., Bruno, M.J., Larosa, G.J., Ulloa, L., et al.,
2006. The vagus nerve and nicotinic receptors modulate experimental pancreatitis
severity in mice. Gastroenterol. 130, 1822–1830.
Villegas-Bastida, A., Torres-Rosas, R., Arriaga-Pizano, L.A., Flores-Estrada, J., Gustavo-
Acosta, A., Moreno-Eutimio, M.A. (2014). Electrical stimulation at the ST36
acupoint protects against sepsis lethality and reduces serum TNF levels through
vagus nerve- and catecholamine-dependent mechanisms. Evidence-based
Complementary and Alternative Medicine,vol. 2014:451674. doi: https://doi.org/10
.1155/2014/451674. (Epub 2014 Jun 26).
Wang, C., Xie, W.J., Liu, M., Yan, J., Zhang, J.L., Liu, Z., et al., 2014. (2014). Effect of
manual acupuncture stimulation of “Baihui” (GV 20), etc. on serum IFN-gamma and
IL-4 contents in rats with chronic fatigue syndrome. Zhen Ci Yan Jiu. 39, 387–389.
12
Autonomic Neuroscience: Basic and Clinical 232 (2021) 102793
Wang, L., Zhang, J., Li, X., Wang, Z., Zhang, H., Zhou, L., 2019. Effect of acupuncture at
Zusanli on inflammatory factors and prognosis in patients with sepsis. J Emerg
Tradit Chin Med. 28, 1619–1621.
Wang, C.,Horby, P.W., Hayden, F.G., Gao, G.F. (2020a). A novel coronavirus outbreak of
global health concern. Lancet 395, 470–473. DOI: https://doi.
org/10.1016/S0140-6736(20)30185-9.
Wang, D., Hu, B., Hu, C., Zhu, F.F., Liu, X., Zhang, J., et al., 2020b. Clinical
characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected
pneumonia in Wuhan, China. JAMA 323, 1061–1069.
Wang, R.P., Li, X., Wang, Z.W., Shi, X.J., Jiang, K., Deng, Y.H., et al., 2020c. Analysis of
clinical features, course of disease and hospitalization days of COVID-19 patients.
Shanghai J Tradit Chin Med. 54, 25–30.
Wiersinga, W.J., Leopold, S.J., Cranendonk, D.R., van der Poll, T. (2014). Host innate
immune responses to sepsis.Virulence 5, 36–44.
Wrona, D.(2006). Neural-immune interactions: an integrative view of the bidirectional
relationship between the brain and immune systems. J Neuroimmunol. 172, 38–58.
Wrona, D., Trojniar, W., 2003. Chronic electrical stimulation of the lateral hypothalamus
increases natural killer cell cytotoxicity in rats. J. Neuroimmunol. 141 (1–2), 20–29.
https://doi.org/10.1016/s0165-5728(03)00214-5.
Wrona, D., & Trojniar W.(2005). Suppression of natural killer cell cytotoxicity following
chronic electrical stimulation of the ventromedial hypothalamic nucleus in rats. J.
Neuroimmunol. 163, 40–52.
Wu, J.L., 1983. Effects of acupuncture on immune functions. Acupunct. Res. (2), 83.
Wu, B., 1995. Effects of acupuncture on the regulation of cell-mediated immunity in the
patients with malignant tumors. Zhen Ci Yan Jiu. 20, 67–71.
Wu, F.W., 2016. Effect of electroacupuncture at Zusanli on inflammatory reaction and
immune function in patients with sepsis. J Emerg Tradit Chin Med. 25, 1794–1797.
Wu, Z., McGoogan, J.M., 2020. Characteristics of and important lessons from the
coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72
314 cases from the Chinese Center for Disease Control and Prevention. JAMA.
https://doi.org/10.1001/jama.2020.2648 (Epub ahead of print).
Wu, J.N., Wu, W., Zhu, M.F., 2013. Effects of electroacupuncture on the immunity of
septic patients. J Zhejiang Univ Tradit Chin Med. 37, 768–770.
Xiao, Q.S., Ma, M.Y., Zhang, X.S., Deng, M.H., Yang, Y.Z., 2015. Effect of acupuncture on
immune function and prognosis of sepsis patients. Zhongguo Zhong Xi Yi Jie He Za
Zhi 35, 783–786.
Yamaguchi, N., Takahashi, T., Sakuma, M., Sugita, T., Uchikawa, K., Sakaihara, S., et al.,
2007. Acupuncture regulates leukocyte subpopulations in human peripheral blood.
Evid. Based Complement. Alternat. Med. 4 (4), 447–453.
Yan, B.G., 1959. The affections of acupuncture on the phagocytosis of reticuloendothelial
system. Acta Academiae Medicinae Lanzhou. 2, 42.
Yim, Y.K., Lee, H., Hong, K.E., Kim, Y.I., Lee, B.R., Son, C.G., et al. (2007). Electro-
acupuncture at acupoint ST36 reduces inflammation and regulates immune activity
in collagen-induced arthritic mice. Evid. Based Complement. Alternat. Med. 4,
51–57.
Yu, J.B., Shi, J., Gong, L.R., Dong, S.A., Xu, Y., Zhang, Y., et al., 2014. Role of Nrf2/ARE
pathway in protective effect of electroacupuncture against endotoxic shock-induced
acute lung injury in rabbits. PLoS One 9 (8), e104924. https://doi.org/10.1371/
journal.pone.0104924 (eCollection 2014).
Yu, Y.H., Jin, X.Q., Yu, M.H., Gong, S.J., Liu, B.Y., Li, L., 2015. Clinical research on
regulation of gastrointestinal function and gastrointestinal hormone by acupuncture
in elderly patients with severe sepsis. Chin. Arch. Tradit. Chin. Med. 33, 1953–1956.
Yuki, K., Fujiogi, M., Koutsogiannaki, S., 2020. COVID-19 pathophysiology: a review.
Clin. Immunol. 215, 108427.
Zhao, Z.Q., 2008. Neural mechanism underlying acupuncture analgesia. Prog. Neurobiol.
85 (4), 355–375.
Zhao, R., Ma, C., Tan, L., Zhao, X., Zhuang, D. (1994). The effect of acupuncture on the
function of macrophages in rats of immunodepression. Zhen Ci Yan Jiu. 19, 66–68.
Zhou, W.Y., Tjen-A-Looi, S.C., Longhurst, J.C., 1985. Brain stem mechanisms underlying
acupuncture modality-related modulation of cardiovascular responses in rats.
J. Appl. Physiol. 99, 851–860. https://doi.org/10.1152/japplphysiol.01365.2004.
Zhu, M.F., Xing, X., Lei, S., Wu, J.N., Wang, L.C., Huang, L.Q., et al., 2015.
Electroacupuncture at bilateral Zusanli points (ST36) protects intestinal mucosal
immune barrier in sepsis. Evid. Based Complement. Alternat. Med. 2015, 639412.
https://doi.org/10.1155/2015/639412.
Zia, F.Z., Olaku, O., Bao, T., Berger, A., Deng, G., Fan, A.Y., et al., 2017. The National
Cancer Institute’s conference on acupuncture for symptom management in oncology:
state of the science, evidence, and research gaps. J Natl Cancer Inst Monogr. 52
https://doi.org/10.1093/jncimonographs/lgx005 (PubMed PMID: 29140486).