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In the decade since the publication o the National Institutes oHealth (NIH) white paper on acupuncture in 1997, peer-reviewed,responsible research into the mechanism and efcacy o acupunc-ture has been prolic. As this research has identied acupunctureas a sae, efcacious, and cost eective modality to treat a variety opain problems, it is in the process o being gradually integrated intothe eld o conventional pain medicine.

Brie History

Acupuncture is a complex therapeutic process that has its roots inprehistory and is undergoing constant evolution as its use in theconventional modern healthcare setting expands and understand-ing o its mechanism grows. Now, having existed or almost orty

years in the public consciousness o the general population o theUnited States and scientic community, there is considerable amil-iarity with the basics o acupuncture as a therapeutic modality.Most are aware that acupuncture is the use o thin, solid needles in

various patterns on the body. Although this is taken or granted in21st century America, prior to July 26, 1971, outside o Asian com-

munities, acupuncture was a wholly unknown entity in the UnitedStates. On that date, James Restons landmark article describing hisexperience with acupuncture in China was published in e NewYork Times.1 Mr. Reston was a reporter or the Timeswho hadtraveled to China in 1971 in preparation or Richard Nixons his-toric diplomatic visit. Mr. Reston required an emergency appen-

dectomy in Peking and had his postappendectomy pain successullytreated with acupuncture. is experience was recounted to theAmerican people in e New York Times publication and servedas the rst major exposure o the English speaking U.S. populationto acupuncture. Shortly ater Nixons trip, physicians began ormaland inormal trips to China where they witnessed surgical anes-thesia using only acupuncture needles. Whereas Restons articleignited popular interest in acupuncture, these reports began to uel

curiosity in the medical and scientic communities and served tospark scientic exploration o the bizarre new technique. As thespecics o the endorphin theory o acupuncture analgesia werediscovered in the late 1970s, respect within the scientic commu-nity grew proportionately.

While likely practiced or several thousands o years BCE,the rst known text that ormally describes acupuncture theory is

Huang Di Nei Jing(Yellow Emperors Classic o Medicine), whichdates to the 2nd century . A more comprehensive text withgreater unication o acupuncture theories was written in the

rst and second centuries and was called theNan Jing(Classico Difcult Issues). By this time, most o the concepts that underlieclassical acupuncture theory such as acupuncture point location,channels, and disease classication had been dened. Transmissiono knowledge occurred largely along amilial lines in China leadingto a multitude o diverse ways o practicing acupuncture.

From the 2nd century to the 16th century , these the-

oretical concepts and the practical application o acupunctureunderwent an extensive and continual renement that typies theempirical evolution o this system o treatment. ese renementsand the current state o acupuncture theory and practice were cap-tured in theZhen Jiu Da Cheng(Great Compendium o Acupunc-ture and Moxibustion) which is attributed to Yang Ji-Zhou and waspublished in 1601. is text, reerred to as the Da Cheng, becamethe preeminent source or medical inormation or subsequent gen-erations in Asia and Europe. In act, it was this text that was trans-lated into various languages and transmitted to Europe and Japan

by traveling physicians and missionaries rom the 1600s throughthe 1900s and served as the basis or the development o classicalacupuncture in these regions.

e practice o acupuncture and herbal medicine experi-

enced a dramatic decline in China in the rst hal o the twentiethcentury. is process was driven by the larger cultural process omodernization patterned ater Western science during this sameperiod. Prior to the 19th century, China was the undisputed powerthat dominated the Eastern Hemisphere. A series o events in the19th century including the Opium Wars, the Taiping Rebellion, andamine claimed tens o millions o lives and let China politicallyweakened and at the mercy o Western powers such as the Frenchand the British or the rst time in history. Accustomed to militaryand scientic superiority, the deeat o China by the British in theOpium Wars initiated a cultural drive to quickly adopt the prin-ciples o Western science that allowed their military adversaries toprevail. is inatuation with Western military science spilled overinto all areas o science including medicine. is devotion to mod-

ernization according to Western principles was epitomized in theearly 1900s by the repudiation o classical acupuncture and Chi-nese medicine and a commitment to license only Western-trained

physicians.Economic necessity and political expediency led to the sim-

plication and systemization o the variegated orms o classicalacupuncture under Mao in the second hal o the 20th century inChina. Ater Mao came to power, it became clear that the cadre onewly trained Western physicians, numbering roughly 40,000, wasgrossly inadequate to care or the more than 500 million Chinese

17Aram Mardian, MD

Medical Acupuncture

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140 Complementary and Alternative Medical Procedures

citizens. Maos declaration that Chinese medicine is a great trea-sure-house came in 1958 and served as the theoretical basis orthe bareoot doctor movement that was initiated in 1969. Duringthis period, Mao called on previously marginalized practitioners oacupuncture and classical Chinese medicine to create a simpliedsystem o Chinese medicine that could be easily taught and dissem-inated among his corps o bareoot doctors whose aim would be tocare or rural villages. is new system eventually became knownas Traditional Chinese Medicine (TCM). Ironically, this system is

a 20th century creation and omits many o the complexities andnuances o pre-Mao classical Chinese medicine.2-6 Interestingly, thepre-Mao classical orms o acupuncture nd their most authenticpreservation outside o China, in Europe, Japan, and America.

e Japanese began practicing acupuncture in the 6th century and developed unique orms o acupuncture. From its earliestorms in Japan, acupuncture took on distinct qualities. Whereas inChina acupuncture was closely combined with herbal medicine, inJapan physical medicine techniques and massage evolved in parallelwith acupuncture. Consequently, the acupuncture o Japan requiresthe careul palpation o subcutaneous and muscular restrictionsand nodules. Because o this, Japanese acupuncture has oundan easy marriage with physical medicine techniques in modernAmerica such as osteopathic manipulation and Janet Travells trig-

ger point therapy. e greater reedom enjoyed by modern Japanesesociety when compared to modern China aorded an environmentmore amenable to continued evolution and integration with othermodern medical practices.

Primitive experimentation with acupuncture began in Europe

during the early 19th century as translations o the Da Chengreached England, France, and Germany via military and mission-ary physicians returning rom China. More serious integration withmodern Western medicine did not occur until the middle o the20th century in Europe and later in the United States.2

Acupuncture is not Monolithic

It is important to realize that acupuncture is a general term that

subsumes many specic techniques. Rather than thinking o acu-puncture as a monolithic therapy, it may be helpul to think o acu-puncture as one would think o the term injection. Injections usinglidocaine and placed into an inraspinatus trigger point clearly rep-resent a very dierent intervention as compared to a transorami-nal epidural steroid injection or the intramuscular administrationo ketorolac. Acupuncture techniques can be as distinct.

A Brie Primer o Acupuncture Techniques

Classical Chinese acupuncture typically involves the insertiono needles into locations on the body that have been empiricallydened over thousands o years. Depth o needles insertion is oten

determined by achieving a characteristic aching or tingling sensa-tion reerred to as De Qi. When reerence is made to classical ortraditional acupuncture points, this generally implies the group osome 360 principal points described in ancient times. It is impor-tant to realize that classical acupuncturists have also describedseveral thousand additional extra acupuncture points. Classicalconceptions o acupuncture channels or meridians reer to linearpathways that connect individual acupuncture points.

Japanese acupuncture also evolved throughout ancient timesand recognizes acupuncture points and channels similar to those

o classical Chinese acupuncture. Japanese acupuncture involves amore rened system o palpation o subcutaneous and musculartissue and insertion o needles into areas o myoascial restrictiondetermined by this palpation. Depth o needle insertion is char-acteristically intracuticular and thereore much more supercialthan in classical Chinese acupuncture. A branch o Japanese acu-puncture, Ryodoraku, describes acupuncture points and channelsas shiting anatomic location according to patterns o pathologymaniested by individual patients. Interestingly, many o the sham

acupuncture protocols in randomized controlled trials (RCTs) useneedling techniques identical to Japanese acupuncture.

Neuroanatomic acupuncture is a modern acupuncture tech-nique that is characterized by the insertion o needles into points on

the body that have a neuroanatomic signicance. Points are gener-ally chosen with the aim o stimulating peripheral nerves, neuro-

vascular bundles, ascia, tendons, muscles, ligaments, joints, andrichly innervated structures such as the periosteum and interosseusmembranes; electrical stimulation o these points is common. Neu-roanatomic acupuncture uses classical acupuncture needle tech-niques according to modern biomedical knowledge.

Percutaneous neuromodulation therapy (PNT), also reerredto as percutaneous electrical nerve stimulation (PENS), is a spe-cic orm o neuroanatomic acupuncture that positions acupunc-

ture needles in sot tissue or muscles to stimulate spinal nerves andperipheral nerves. Ater a specic neuromusculoskeletal (NMS)diagnosis is made, the spinal nerves that correspond to the der-matome, sclerotome, myotome, and autonomic innervation o thepathologic region are stimulated at a variety o dierent electricalrequencies in a variety o dierent patterns. Acupuncture needlesare also placed locally and regionally around the pathologic areaaccording to neuroanatomic principles and stimulated with a vari-ety o electrical requencies.

Auricular acupuncture is a microsystem technique that involvesthe insertion o various types o needles into predetermined pointsand points with altered bioelectrical conductance on the external

ear. As a microsystem, all aspects o the body are postulated to haverepresentation on the external ear in a holographic ashion. Chinese

scalp acupuncture (see Chapter 19) is also a microsystem techniqueand is characterized by the threading o needles along the scalpaccording to the underlying unctional characteristics o the brain.

Medical Acupuncture is the Unifcationo Classical Acupuncture and Modern Medicine

e optimal acupuncture treatment o pain problems requiresamiliarity with classical acupuncture teachings as well as modernneuromuscular anatomy and neurophysiology. is unique integra-tion o classical and modern knowledge is the exception rather thanthe rule among acupuncture practitioners. Many nonphysician acu-puncturists lack the requisite amiliarity and experience with themodern neuroanatomic understanding o pain to optimally treat

many pain problems. While classical acupuncture techniques canbe quite eective in treating pain, an approach that does not includethe intentional integration o modern neuroanatomic concepts issuboptimal. Among physicians who practice acupuncture, this inte-grated approach is the ideal, but also not the rule. Some physiciansobtain training only in modern neuroanatomic techniques, and thisis also a suboptimal approach to pain problems.

Medical acupuncture is the practice o acupuncture by phy-sicians; as a discipline it represents the integration o classicalacupuncture with modern medicine. Medical acupuncture has

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Medical Acupuncture 141

evolved since the middle o the 19th century initially in WesternEurope, then in Japan, and most recently in the United States.It has ound its most rened expression in the work o JosephHelms, MD. Helms has developed a robust and elegant integra-tion o classical acupuncture with diverse modern acupuncturetechniques such as neuroanatomic acupuncture, PNT, auricularacupuncture, and scalp acupuncture. It is this integrated system oacupuncture that is reerred to by the term medical acupuncturein this chapter.

Medical Acupuncture Education

Medical acupuncture is taught to physicians in the United Statesthrough continuing medical education courses. e World HealthOrganization has promulgated acupuncture education standardsor physicians and recommends that licensed physicians obtain atleast 200 hours o ormal training in acupuncture to acquire thisspecialty medical skill.

e American Board o Medical Acupuncture (ABMA) wasestablished in 2000 to promote the sae and efcacious practice oacupuncture by physicians through a standardized examination andcertication process. e ABMA is not a member o the AmericanBoard o Medical Specialties. e ABMA stipulates requirements

or training, experience, and examination. In general, board certi-cation by the ABMA requires 300 hours o ormal training in acu-puncture, a minimum o 2 years o clinical practice, and passing astandardized written examination. e ABMA currently recognizes10 training programs in the United States and Canada. e majorityo board certied physician acupuncturists have been trained by theHelms Medical Institute, ounded by Joseph Helms.

What are the Eects o Medical Acupuncture?

As a comprehensive therapeutic system with a variety o tech-niques, medical acupuncture has wide-ranging eects includingpain reduction, improvement in sleep, improvement in anxiety anddepression, a reduction in pain medication, improvement in unc-

tion, and an improvement in energy and vitality.7-13 Conversely,most therapies in conventional medicine have narrowly denedeects such as pain reduction rom an epidural steroid injection orimproved sleep rom a sedative-hypnotic drug. Acupuncture thatis used to treat a pain problem can be expected to have multipleeects simultaneously. is is particularly important because manypain problems represent a vicious cycle o pain, dysunction, psy-

choemotional disturbances, atigue, and sleep problems. Part o therobust nature o medical acupuncture is the ability to aect all othese seemingly disparate problems.

Medical Acupuncture is More than Needling

e practice o medical acupuncture involves therapeutic liestylerecommendations in addition to needling. Specic dietary sugges-

tions are oten combined with prescriptions or exercise or activitymodication. Further, classical acupuncture teachings describe animplicit relationship between physical dysunction and imbalancesin the cognitive and emotional spheres. is relationship and thespecic areas o psychoemotional imbalances are discussed withthe patient. Having a coherent way to understand the relation-ship between physical and mental imbalances can be enormouslyhelpul or patients. By providing a means or understanding andexploring sel-deeating thoughts and behaviors, this system otenhelps dene a path or improving overall sel-efcacy.

Medical Acupuncture View of the Human Organism

e accumulation o knowledge about human physiology, biochem-istry, and pathophysiology within the sphere o modern medicinehas been prodigious in the last 50 years. Much o this progress hasrelied on the ever improving ability to ocus on the ever more exactbuilding blocks o the human body. Much o medical therapeuticsderives rom this scientic process, but also remains incompletelyunderstood. For example, tricyclic antidepressants are eectivein treating many chronic pain states and are widely used or this

purpose. We know that these medications have many mechanismso action including the inhibition o presynaptic reuptake o sero-tonin and norepinephrine as well as blockade o sodium and volt-age-dependent calcium channels.14 We do not know, however, themechanism o action responsible or analgesia,15 nor do we knowwhy some patients respond and others do not. Powerul reduction-istic science has identied the mechanisms o these medicationsand part o the pathophysiology o chronic pain, but will unlikelyreveal the unanswered questions o in vivo analgesic mechanismsand individual variability o response. Modern scientic paradigmsrom modern physics such as systems theory and quantum mechan-ics will likely be required to propel modern medicine into the nextstages o advancement. Scientic approaches to reality require bothreductionistic and synthetic processes o investigation. Systems

theory is an excellent example o a synthetic scientic approach.Systems theory teaches us that complex systems as primitive

as unicellular organisms behave in ways that dey reductionistic,linear laws. Whereas reductionistic models o scientic investiga-tion have proved invaluable or determining many o the compo-nents o living systems, this approach to science is suboptimal in

providing inormation about how these components interact in theliving organism.16 Systems theory instructs that complex systems,o which the human body is a quintessential example, have emer-gent properties. Emergent properties are unique properties o com-plex systems that are not present in any o the more simple parts othe whole, but arise only when all parts interact to orm the com-plex whole. A laudable yet nascent drive in modern medicine is theadministration o individualized care. e doctrine o conventional

modern medicine is that the specic disease entity must be identi-ed and the pharmaceutical or intervention that is most appropri-ate to the disease entity must be delivered. at is, all patients withknee osteoarthritis ought to receive the same treatment, all patientswith insomnia ought to receive the same treatment, all patients withdepression ought to receive the same treatment, and any patientwith all three diseases ought to receive all three treatments.

Systems theory teaches us that this is a rudimentary approachto the complex system o the human body. First, not all humanswith the same disease process will respond the same way to thesame treatment. We know that there are individual dierences inthe pharmacokinetics o medication metabolism and individualdierences in the healing process ater surgery.17-19 us, the bestprinciples o modern science tell us what Dr. Osler told us more

than 100 years agoIt is much more important to know what sorto a patient has a disease than what sort o a disease a patient has.e goal, then, is individualized approaches that take the complex-ity o the persons constitution as well as the disease process intoaccount. e specic science and ability to do this in clinical prac-tice is developing, but still poorly dened.

Interestingly, medical acupuncture presents clinicians with anapproach that ollows these ideals. Part o the nonspecic eectsthat are attributed to acupunctures eectiveness in RCTs may in

act be due to the systematic approach o acupuncture that seeks to

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identiy constitutional actors or a patient and individual treatmentor a presenting complaint based on that persons identity and con-stitution. e classical ramework o acupuncture has developedan empirical system that, in essence, looks or emergent proper-ties. rough the thousands o years o empirical observations andsubsequent pattern denition, acupuncture has sought to answerthe ollowing types o questions: What unique characteristics arisewhen a person complaining o knee pain also is a competitive, harddriving, leader without other medical problems, versus an over-

weight, jovial man who also suers rom chronic, debilitating aller-gic rhinitis? While the conventional approach to treating knee painin these two patients would be identical, with likely variable results,the acupuncture approach or each would be unique, likely with

good results based on large RCTs.20,21

Most o these aspects o acupuncture have not been exploredrom the perspective o conventional science such as RCTs and arelargely speculative. However, such actors, which have been derivedrom millennia o careul observation and inductive reasoning, mayprovide insight into the efcacy o acupuncture observed in clini-cal trials and may lead to new theories that will urther reveal themyriad o unknown mechanisms in the unctioning o the humanbody in health and disease.

Medical Acupuncture and the Treatment of Complex Chronic PainMedical acupuncture is a versatile modality that interacts with psy-chological, neurologic, endocrine, immunologic, and musculoskel-etal aspects o the human organism.22-27 With these multiple pointso input, medical acupuncture is ideally suited or the treatment opain, which by nature maniests in the psychoneuromusculoskeletalsphere o humans.

e human organism is viewed as a complex multidimensionaland integrated whole by physician acupuncturists. is view con-trasts with that typically held by conventional pain medicine physi-cians. Conventional medicine is generally satised with dissectingan organism or molecule down to its smallest part and assumingthat it understands the unctioning o the organism when it hasunderstood the unctioning o all o its parts. In conventional

clinical pain medicine, we are generally looking or one o a rela-tively ew pain generators, such as a herniated nucleus pulposus ordegenerated cartilaginous surace. As such, the biomedical modelo pain seeks to identiy and treat the physical pain generator thatis assumed to be the sole cause o the patients pain. Recognitionthat this approach is inadequate has ostered the development othe biopsychosocial model used to understand and treat pain states.

Similarly, medical acupuncture recognizes that many painproblems are a complex maniestation o dysunction in multiplespheres: myoascial, neurologic, psychological, emotional, endo-crine, and genetic. Further, it is recognized that the experience

o the organism is greater than the sum o all o these individualspheres.

Ronald Melzack recently described a new theory o pain that

proposes a similarly complex and multidimensional view o painproblems. It is intriguing that medical acupuncture is capable oinuencing virtually all o the components described by Melzacksnew theory o pain.

The Neuromatrix Theory o Pain

Consciousness in general and the awareness and experience o

pain in particular are phenomena that remain more in the realmo mystery than in clear understanding. e medical acupuncture

view o these phenomena closely parallels many aspects o themost instructive modern theories. e gate control theory holdsthat peripheral noxious signals are transmitted to the brain or con-scious sensation via the spinal cord. ese signals are modulatedby other aerent inputs rom the periphery and also by descendingcontrol rom subcortical brain centers.

In 2004, Melzack promulgated a revision to his original gatecontrol theory which he terms the neuromatrix theory o pain.A revision o the original theory was prompted by clinical experi-

ence with amputees with phantom limb pain. ese patients con-tinue to experience identical patterns o arm pain, atigue, itch, andmovement in the absence o the aected limb. Out o these obser-

vations, a new theory is derived that ocuses primarily on the brain.Melzack describes his neuromatrix theory subsequently.

e neuromatrix theory o pain proposes that pain is a mul-tidimensional experience produced by characteristic neurosigna-ture patterns o nerve impulses generated by a widely distributedneural networkthe body-sel neuromatrixin the brain. eseneurosignature patterns may be triggered by sensory inputs, butthey may also be generated independently o them. Acute painsevoked by brie noxious inputs have been meticulously investigatedby neuroscientists, and their sensory transmission mechanisms aregenerally well understood. In contrast, chronic pain syndromes,

which are oten characterized by severe pain associated with little orno discernible injury or pathology, remain a mystery. Furthermore,chronic psychological or physical stress is oten associated withchronic pain, but the relationship is poorly understood. e neu-romatrix theory o pain provides a new conceptual ramework toexamine these problems. It proposes that the output patterns othe body-sel neuromatrix activate perceptual, homeostatic, andbehavioral programs ater injury, pathology, or chronic stress. Pain,then, is produced by the output o a widely distributed neural net-work in the brain rather than directly by sensory input evoked byinjury, inammation, or other pathology. e neuromatrix, whichis genetically determined and modied by sensory experience, is

the primary mechanism that generates the neural pattern that pro-duces pain. Its output pattern is determined by multiple inuences,

o which the somatic sensory input is only a part , that converge onthe neuromatrix.28

Melzacks neuromatrix theory o pain shits the ocus awayrom the Cartesian concept o a one-to-one relationship betweenspecic sensory experiences such as tissue damage or inammationand the sensation o pain. is particularly applies to chronic painstates in which multiple actors such as psychological stress, physi-

cal injury, and cognitive states aect a genetically inuenced andwidely distributed neural network to produce multidimensionaloutputs such as the awareness and perception o pain as well asdysunctional thoughts and action patterns.

is theory, then, proposes a richly complex understanding ochronic pain that emphasizes the role o genetics, thoughts, emo-tions, physical sensations, stress pathophysiology, and the emerging

eld o psychoneuroimmunology. e medical acupuncture view ochronic pain has many parallels to Melzacks neuromatrix theory,both in its understanding o the sources o chronic pain and in itstreatment.

Figure 17-1 illustrates the sensory inputs that inuence thegenetically determined neuromatrix: cognitive, sensory, and emo-tional. Medical acupuncture targets all o these inputs, the neuroma-trix itsel, and also the output programs that are oten dysunctional.Classical acupuncture oten ocuses on psychoemotional distur-bances, whereas modern neuroanatomic acupuncture aims at

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treating musculoskeletal sources o dysunctional inputs to the neu-

romatrix as well as spinal cord regions involved in spinal modula-tion. Scalp and auricular acupuncture are directed at aecting theneuromatrix itsel. Acupuncture has also been shown to inuencethe stress regulation output program o the neuromatrix.22,29 WhileMelzack emphasizes the genetic contribution to the neuromatrix,classical acupuncture always strives to understand and treat the con-stitution o an individual, which can be understood as the geneticallydetermined phenotype o an individual.

e conventional biomedical approach to pain ocuses evalua-tion and management strategies solely on the musculoskeletal sen-sory inputs to the neuromatrix, much in line with the Cartesianunderstanding o pain processing. And, within this subset o sen-sory inputs, the ocus is even more narrowly put on joint, nerve,and tendon generators o aerent activity.

e medical acupuncture approach to pain not only recognizesthe value o treating all three groups o inputs to the neuromatrix(see Fig 17-1), but also ocuses on an expanded set o tissues in theperiphery capable o stimulating the neuromatrix. As such, medi-cal acupuncture not only evaluates and treats dysunctional joints,nerves, and tendons, but also muscle, ligaments, and ascia. Fur-thermore, medical acupuncture directs therapy at the neuromatrixitsel and the stress response output program o the neuromatrix.

is ability to comprehensively intervene at all points in

Melzacks neuromatrix theory or pain experience (sensory inputs,neuromatrix itsel, and subsequent outputs) denes medical acu-puncture as a uniquely robust therapeutic tool or the treatment opain problems.

Mechanisms

Twentieth Century Mechanisms

Since its introduction to the American scientic community in the1970s, acupuncture has oten been perceived as a therapeutic modal-ity whose mechanism is mysterious and unknown at best, and inertin terms o modern physiology at worst. Researchers who sought toprove the latter hypothesis as well as those who were curious aboutdiscovering possible physiologic mechanisms produced a prolic

body o basic science data in the 1970s and 1980s. is research led to

the endorphin and monoamine hypothesis o acupuncture analgesia

which has since been supported by an enormous collection o ani-mal and human studies. Bruce Pomeranz, PhD, was one o the mostprominent researchers in this area. He, indeed, set out to prove thatacupuncture had no measurable physiologic eects. Ater publishing66 papers investigating the mechanism o acupuncture analgesia, hisconclusion was that the evidence supporting the endorphin hypoth-

esis or acupuncture analgesia was stronger than that or almost anyother therapeutic agent used in conventional medicine (Fig. 17-2).

An acupuncture needle entering the skin and muscle in thearms or legs will activate unmyelinated C-bers and small diametermyelinated A-delta bers in the periphery that synapse onto cells othe anterolateral tract in the dorsal horn o the spinal cord. esecells give rise to two sets o projections. One set travels rostrally toeventually synapse on the midbrain, pituitary, and hypothalamus.

e other set synapses on inhibitory interneurons in the spinalcord where dynorphin and enkephalin are released presynapticallyto block ascending neurotransmission o painul signals along thespinothalamic tract. Meanwhile, the rostrally projecting cells o theanterolateral tract will stimulate cells in the periaqueductal gray caus-ing the release o enkephalin, which will disinhibit cells o the raphenucleus. e raphe nucleus is part o an endogenous descending anal-gesic pathway. Disinhibition o these cells activates this descendinganalgesic pathway, which causes the release o monoamines such asserotonin onto cells o the spinothalamic tract in the spinal cord thatcarry painul stimuli to the brain. Serotonin postsynaptically inhibitsthese cells, thereby dampening down the neurotransmission o pain-ul signals rom the periphery to the brain along the spinothalamic

tract. us, the original acupuncture stimulus activates multiple neu-

rochemical pathways in the brain and spinal cord and decreases theneuronal transmission o painul stimuli rom the periphery to thebrain.30 e ascending anterolateral tract neurons also stimulate thepituitary to release ACTH and -endorphin into the bloodstream.30

Twenty-First Century Mechanisms

Whereas 20th century research o the mechanism o acupunctureparalleled the discovery o the endorphin receptors and the gate

control theory o pain, 21st century research is ocusing on thebrain, neuroimmunology, and connective tissue.

BODY-SELFNEUROMATRIX

C

S

A

INPUTS TO BODY-SELFNEUROMATRIX FROM:

OUTPUTS TO BRAIN AREASTHAT PRODUCE:

COGNITIVE-RELATED BRAIN AREASMemories of past experience,attention, meaning, anxiety

SENSORY SIGNALING SYSTEMSCutaneous, visceral,

musculoskeletal inputs

EMOTION-RELATED BRAIN AREASLimbic system and associatedhomeostatic/stress mechanisms

TIME

PAIN PERCEPTIONSensory, affective, andcognitive dimensions

ACTION PROGRAMSInvoluntary and voluntary

action patterns

STRESS-REGULATION PROGRAMSCortisol, norepinephrine, andendorphin levels

Immune system activity

TIME

Figure 17-1 Factors that contribute to the patterns of activity generated by the body-self neuromatrix, which is composed of sensory (S), affective (A), andcognitive (C) neuromodules. The output patterns from the neuromatrix produce the multiple dimensions of pain experience, as well as concurrent homeostaticand behavioral responses. (Adapted from Melzack R: Evolution of the neuromatrix theory of pain. The Prithvi Raj lecture: Presented at the Third World Congress ofWorld Institute of Pain, Barcelona 2004. Pain Pract 5:85-94, 2005.)

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e research o Helene Langevin, MD ocuses on the roleo connective tissue as a dynamic whole body communication

matrix and oers a ascinating model or the mechanism o acu-punctures aect on the body. Loose connective tissue orms ananatomic network throughout the entire body. Most medical doc-tors spend little time thinking about ascia and connective tissue,and when they do, they think o it as purely structural in nature.In reality, ascia and connective tissue are intimately involvedin complex regulatory mechanisms in the body such as ligand-receptor binding and gene transcription. Mechanotransduction isthe biophysical process that is at the center o this research andorms the link between structure and unction. Mechanotrans-

duction is the process by which cells sense mechanical orces andtransduce them into changes in intracellular biochemistry andgene expression.

What is Fascia?

Fascia is loose connective tissue that surrounds and interpenetratesall components o the human body including muscles, nerves,blood vessels, and organs. It provides structural integrity, serves asa matrix or intercellular communication, and is involved in bio-chemical and bioelectric signaling. e structural integrity o thesot tissue o the body is composed o a complex network o as-cia and loose connective tissue on the macroscopic level and an

equally complex microscopic network. e microscopic network iscomposed o an extracellular matrix o collagen and broblasts and

an intracellular cytoskeleton o microlaments, intermediate la-ments, and microtubules.

How Does Acupuncture Interact with Fascia and Loose Connective

Tissue?

e research o Langevin and colleagues has demonstrated thatthe twirling o the acupuncture needle that is typical in clinicalpractice creates mechanical changes in the collagen and broblastnetwork o the extracellular matrix. In act, her work using his-

tologic sections and specialized ultrasonography has shown that

the manipulation o the acupuncture needle produces character-istic changes in the surrounding loose connective tissue such asthe wrapping o collagen bers. She has demonstrated that thesemechanical changes in the connective tissue are accompanied by

active cellular changes such as lamellapodia ormation and bro-blast spreading. Although not yet conclusive, this research sup-ports the hypothesis that acupuncture needling activates diversebiological processes such as gene transcription, protein synthesis,and neuromodulation through the mechanism o mechanotrans-duction (Fig. 17-3). ese biochemical phenomena may underliemany o the unknown mechanisms o the therapeutic eects oacupuncture.31-34

Biochemical Milieu of Trigger Points

Although the subject is not as novel as the work o Langevin andcolleagues, the research o Jay Shah, MD is equally ascinating andinstructive. Clinicians have long relied on the pioneering work oJanet Travell, MD in treating myoascial pain. Trigger point nee-dling with and without local anesthetic is used by medical acu-puncturists to treat many types o myoascial pain. However, until

recently, convincing basic science research characterizing the quali-ties o trigger points has been lacking. In the January 2008 publica-tion o e Archives o Physical Medicine and Rehabilitation, Dr.Shah describes an innovative technology that allows the real timebiochemical assay o the trigger point milieu. A 30-gauge micro-dialysis needle is used to noninvasively sample 11 histochemicals

in clinically identied trigger points. is study conrms that bio-chemicals associated with pain and inammation (protons, sub-stance P, TNF-, bradykinin, and many others) are present in higherconcentration in active trigger points than in latent trigger pointsand control muscle points. Furthermore, ater needling the trig-ger points, concentrations o substance P, and CGRP are shown todecline. ough requiring additional study, this work oers a con-

vincing basic science explication or the mechanisms underlyingthe dry needling o trigger points that is an integral part o medicalacupuncture.35,36

Painfulstimulus

Skin

1

Muscle

Acuneedle

5

6

Spinal cord

ALT8

E

E

E9

M

ME

7

2

STT

DLT

11

Midbrain

10

3 4

CortexThalamus

Pituitaryhypothal

E14

12 13

Figure 17-2 Model developed from research by Dr. Pomeranz. (Adapted from Stux G, Pomeranz B (eds): Basics of Acupuncture: Berlin, 2005, Springer p27.

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Brain Imaging

Extensive animal and human data indicate that many o the ben-ecial eects o acupuncture are mediated through the centralnervous system. However, whereas mechanisms such as centralmodulation o endorphins and monoamines and the recruitmento the midbrain descending analgesia system are well characterized,much is not known about how acupuncture interacts with the CNS.In the last decade, interest has accelerated in the use o unctionalmagnetic resonance imaging (MRI) and positron emission tomog-raphy (PET) imaging to urther understand the eects o acupunc-ture on the brain.

Acupuncture Effects on the Brain

Nonpainul stimulation o peripheral nerves using transcutane-ous electrical stimulation causes an increase in activation o thesomatosensory, motor, premotor, posterior parietal, and cingulatecortices, as well as the thalamus and cerebellum as measured byMRI.37,38 Painul stimuli produce activation in multiple regions othe brain including the primary and secondary somatosensory cor-tices, the insular cortex, the anterior cingulate cortex, the thalamus,and the prerontal cortex.39

Reproducible data show that acupuncture modulates anextensive network o cortical, subcortical, and brainstem regions

RotationCollagen

Focal adhesion

F-actin

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FIBROBLASTS

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Matrix deformation Matrix deformat ion Matrix deformat ion

Mechanotransduction

Actinpolymerization

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ERK phosphorylationERK phosphorylation

Cell contraction Cell contraction

Actinpolymerization

Actinpolym.

MechanotransductionMechanotransduction

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Figure 17-3 Hypothesis summary. Proposed mechanical signal transduction and downstream effects of acupuncture needle manipulation at gross and micro-scopic levels. Shaded areas represent deep connective tissue planes of the upper arm. The acupuncture needle is inserted on the lateral border of the biceps.Arrows represent pulling of connective tissue and matrix deformation during acupuncture needle manipulation. The lung acupuncture meridian is locatedalong the lateral border of the biceps and may coincide with some of the outlined connective tissue planes. (Adapted from Langevin HM, Churchill DL,Cipolla MJ: Mechanical signaling through connective tissue: A mechanism for the therapeutic effect of acupuncture. FASEB J 15: 2275-2282, 2001.)

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in the brain.40 Numerous MRI studies have demonstrated thatacupuncture elicits a response in multiple cortical regions includ-ing the primary and secondary somatosensory cortices, the insularcortex, and the prerontal cortex when compared to a variety oneedle and nonneedle controls.40 A robust limbic network, includ-ing the hippocampus, amygdala, hypothalamus, and anterior cin-gulate cortex is also modulated.41 Brainstem structures involved inendogenous descending analgesia such as the periaqueductal grayare recruited by acupuncture therapy.42 Whereas nonacupunc-

ture transcutaneous stimulation o peripheral nerves and painulperipheral stimuli generally produce an increase in signaling inthe brains pain matrix, acupuncture therapy produces a modula-tion or a decrease in signaling intensity in the same regions o thebrain.22

Interestingly, acupuncture stimulates widespread deactivationo brain regions involved in the aective and cognitive aspects opain, and also is able to inuence the brain structures that controlthe physiologic stress response. e amygdala translates somato-sensory stimuli into aective states. e amygdala exhibits patternso sensitization and hyperactivation in response to chronic painstates.43 Acupuncture therapy elicits deactivation o the amygdalain healthy controls and in patients with chronic pain. Additionallimbic structures involved in consolidation o somatosensory mem-

ory and the interace o cognitive and emotional mentation are alsoaected by acupuncture.22,29 e hypothalamus receives and inte-grates diverse inormation about the internal and external environ-ment and produces a coordinated output program. A major aspecto hypothalamic output is orchestration o the bodys response tophysiologic and psychological stress through the hypothalamic-pituitary-adrenal axis. e classical descriptions o acupunctureencouraging a return to homeostasis in the body are interesting

in light o recent MRI research demonstrating modulation o thehypothalamus in pain states.22,29,41

Napadow and colleagues have also explored the eects oacupuncture on the dysunctional neuroplasticity that develops inchronic pain patients. is dysunctional central neuroplasticitymay be part o the basis or their persistent pain, and its correc-tion may underlie some o the therapeutic eects o acupuncture inchronic pain states.29,44,45

A ascinating set o studies by this group has evaluated thebrain eects o acupuncture on carpal tunnel syndrome (CTS)patients versus healthy controls. For the patients with CTS, the

region o the sensorimotor cortex subserving the rst three digitso the aected hand demonstrated hyperexcitability to nonnoxiousstimuli when compared to healthy controls. Ater 13 acupunc-ture treatments perormed over 5 weeks, the dysunctional corti-cal hyperexcitability seen in the carpal tunnel patients diminishedsignicantly. Healthy controls did not exhibit a similar rearrange-

ment in cortical activity. ese studies are an excellent example othe benecial neuroplasticity that can be induced by acupuncturetherapy.22,44,45

Figure 17-4 illustrates group-averaged dierence mapping othe contralateral sensorimotor cortex or CTS patients beore andater acupuncture. Hyperactivity to nonnoxious stimuli in the con-tralateral sensorimotor cortex was exhibited in the median nerveinnervated third digit at baseline. is hyperactivity in the third

digit diminished ater acupuncture treatment.

Activation of Neuronal Networks

Central nervous system disorders such as Parkinson disease,chronic pain, and depression are thought to involve the disruptiono key neuronal networks. Faingold hypothesizes that electricalstimulation therapies such as deep brain stimulation, vagus nervestimulation, electroconvulsive therapy, and acupuncture exert theirtherapeutic eects by recruiting dormant neuronal networks thatcompete with and override the pathologic networks mediating

CTS: Baseline

R(ipsi)

CTS: Postacupuncture

L(contra)

Digit5

Digit3

Digit2

PreCGSI

SII

CS

Figure 17-4 Group maps of CTS patients at baseline and postacupuncture for D2, D3, and D5 nonnoxious electrostimulation. Activation (color-coded P-value)was overlaid onto group-averaged inated brains with gray-scale dened curvature (sulci dark, gyri light). Both right (ipsilateral) and left (contralateral) hemi-spheres are shown. Hyperactivity in contralateral sensorimotor cortex seen for median nerve innervated D3 diminished after acupuncture treatment. Differencesfor D2 and ulnar nerve innervated D5 were less profound. Contra, Contralateral; CS, Central sulcus; CTS, CT scan; ipsi, Ipsilateral; SI, SII. (From Napadow V, Liu J,Li M, et al: Somatosensory cortical plasticity in carpal tunnel syndrome treated by acupuncture. Human Brain Mapping 28:159-171, 2007.)

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disease. It is suggested that the overall maniestation o symptomsby the individual is determined by which neuronal network (patho-logic or therapeutic) prevails and achieves control o the aectedbrain unction. us, Faingold postulates that the mechanismo electrical stimulation therapies such as acupuncture involvesthe stimulation o potentially therapeutic dormant neuronal net-works that subsequently maniest as elimination or diminution insymptoms.46

Does Needling o Acupuncture Points ProduceDierent Brain Activation Patterns than Needlingo Nonclassically Defned Body Locations?

Why is this an interesting question? On the one hand, practitionerso classical acupuncture are eager to demonstrate that the needlingo classically dened acupuncture points produces signicantlydierent eects rom the needling o nonclassically dened loca-tions. On the other hand, several large and well done clinical stud-ies o acupuncture have yielded similar clinical benets or patientstreated with classical acupuncture and minimal acupuncture, whichis variably dened as supercial needling at classical acupuncturepoints and needling at nonclassical locations, when compared topatients receiving standard conventional treatments.47-49

Other large clinical studies show a signicant clinical dierencein the benet achieved with classical versus nonclassical needling.From the clinical standpoint, it is clear that most needling interven-tions (classical acupuncture and minimal acupuncture) have a ben-

ecial eect. Point selection may be less important in determiningclinical efcacy. Exploring the dierential neurobiologic eects oneedling classical versus nonclassical locations will aid in the under-standing o this phenomenon observed in clinical trials.

Data from fMRI Studies

Wu and colleagues observed that electroacupuncture at a nonacu-puncture point (sham acupuncture) produced some o the samecortical changes as electroacupuncture at a classical acupuncturepoint (real acupuncture). Both sham and real acupuncture pro-

duced similar eects in the caudal segment o the anterior cingu-late cortex, insula, secondary somatosensory cortex, thalamus, andcerebellum. However, real acupuncture produced additional eectsin the limbic system not observed with sham acupuncture. Spe-cically, dierence mapping demonstrated activation o the hypo-thalamus and deactivation o the anterior cingulate cortex with realacupuncture versus sham acupuncture.50

Acupoint Specic Brain Activation

ere are data to support the notion that acupuncture points exerta specic pattern o stimulation o the brain corresponding to theclassical descriptions o the points.51 ese results, however, havenot been consistently reproduced.

Optimal Acupuncture Therapy or Pain

e evaluation o the painul condition ollows the ramework o ageneral medical evaluation. A detailed history is obtained rom thepatient with care to elicit clues to the neuromusculoskeletal sourceo the pain, psychoemotional interplay, components o maldyniasuch as dysunctional thoughts, belies, and actions, as well as per-tinent aspects o social relationships, and the patients underlyingconstitution. A detailed and ocused physical examination is per-

ormed with particular attention to nding a neuromusculoskeletal

source as well as any contributing underlying or secondary actors.is is an area that may receive greater attention than in modernpain medicine. For example, a patient with postsurgical pain mayreceive a diagnosis o adhesions producing visceral pain or neuro-pathic denervation pain rom a pain physician with all therapiesaimed at this particular diagnosis. e physician acupuncturist willnot only identiy and address the underlying denervation pain, butwill also explore the possibility o myoascial dysunction that exac-erbates the neuropathic pain. By treating the secondary myoascial

component, the neuropathic aspect may become more amenableto treatment.

Optimal acupuncture therapy or pain problems involves match-ing the most appropriate neuroanatomical acupuncture techniqueswith the patients neuromusculoskeletal diagnosis. is neuroana-tomic acupuncture input is then reinorced by microsystem therapy

and classical acupuncture therapy. Determining a precise NMSunderstanding o the presenting pain problem, then, is central tothe medical acupuncture approach to pain. e NMS diagnosis willattempt to identiy primary, secondary, and tertiary dysunction at

various levels in the physical organism.

Neuromusculoskeletal Diagnosis

A precise NMS diagnosis identies specic areas o dysunction in

the structure o the physical body and at various points in the ner-vous system.

Physical examination maneuvers and knowledge o the unc-tional anatomy are combined to locate primary, secondary, andtertiary problems in the ollowing zones: skin and subcutaneoustissues, supercial ascia, surace and deep muscles, myotendi-nous junctions, tendons, bursae, joints, ligaments, and bone. Sim-ilarly, subjective descriptions o the pain by the patient, physicalexamination maneuvers, and knowledge o the neurophysiologyo pain are used to determine areas o dysunction in the ner-

vous system: Peripheral nerve, neuromuscular, spinal cord, andbrain. When the structural and neurologic aspects o the painproblems have been clearly identied, the physician acupunctur-

ist will select rom a wide array o needling techniques to address

the lesions.ese therapeutic inputs are designed to alter the peripheral

nociceptive inputs while also addressing the abnormal neuronalprocessing o pain signals that characterizes many chronic painproblems. For example, consider a patient with painul periph-eral diabetic neuropathy. An initial peripheral input will supplyelectrical stimulation to acupuncture needles inserted adjacent tothe interdigital nerves o the hands or eet. A variety o electricalrequencies can be applied during the same treatment or sequen-tially at successive treatments. is basic peripheral input can beaugmented by vibratory stimulation o the richly innervated inter-osseus membrane o the orearm or leg with the intent o disrupt-ing dysunctional dysregulation o the autonomic nervous system.e central pathologic changes that oten occur in many chronic

pain states can be addressed with acupuncture inputs that inu-ence the spinal nerves corresponding to the dermatome, myotome,sclerotome, and splanchnotome o the pain problem.

Neuroanatomic acupuncture inputs are designed to addressvarious aspects o the neuromusculoskeletal system and are ideallysuited or addressing the interrelated NMS matrix o the body. e

physician acupuncturist seeks to identiy and correct the dysunc-tions o the NMS matrix that occur in pain states.

One important aspect o systems o classication, such asmedical diagnosis, is identiying clinical entities that are likely to

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respond to particular treatments. With this in mind, the physi-cian acupuncturist explores the NMS matrix o the pain patientor clinical syndromes that respond to NMS acupuncture inputs.For example, the physician acupuncturist does not relysolely onpathodiagnostic classications such as herniated lumbar disc orlateral epicondylitis. Rather, these diagnoses are used as startingpoints and additional contributing actors are sought. Commonly,muscular trigger points and tightness o the supercial ascia willcomplicate and exacerbate pain considered to be neuropathic in

origin. Similarly, abnormal regional and spinal segmental neuronalprocessing will oten accompany muscular, ligamentous, and tendi-nopathic pain. Recognizing these interrelated dysunctions o painproblems is particularly important and germane because acupunc-

ture is well suited to address muscular, ascial, neuronal, tendinous,ligamentous, and visceral dysunctions.24,31,35,52

Pain is a Mind Body Problem and Medical Acupuncture

is a Mind Body Treatment

Pain is a unique medical problem that cuts across virtually allareas o medicine. At its core it epitomizes all o the subtletiesand complexities o mind-body holism. It is now clear that anymodel seeking to explain the experience and pathogenesis opain is incomplete i it omits the impact o our thoughts and eel-

ings, actions, social relationships, or biomedical makeup. earena o pain medicine matches these multiaceted aspects opain with the multidisciplinary pain clinic that housesunderone roobiomedical pain specialists emphasizing interven-tional and pharmaceutical approaches, psychologists address-ing the psychoemotional component o pain, physical therapistswith expertise in reconditioning and manual techniques, and a

hodge-podge o complementary techniques primarily based onmarket demand. Unortunately, the economic situation o mod-ern medicine in the United States at the beginning o the 21stcentury osters ragmented, intervention-based medical care evenwithin multidisciplinary pain clinics. In act, economic necessityis now the organizing principle o many multidisciplinary painclinics compared to the original ounding goal o oering truly

holistic pain medicine based on the biopsychosocial model.Although many interventional approaches have little evidenceor efcacy,53-55 they are reimbursed by third party payers at highrates and thereore generate the majority o revenue at multidis-ciplinary pain clinics. Because o this, these invasive therapiesare oten used more requently than less expensive, conservativetherapies based on the biopsychosocial model o pain that are

supported by stronger evidence.56

Because medical acupuncture provides a ramework or evalu-ating and treating physical, emotional, and psychological aspects oa patient, it can serve as a model or the multiaceted managemento pain problems. Ideally, the medical acupuncture management ocomplex pain problems takes place within an integrated medicalteam. e integration o medical acupuncture within the greater

system o pain medicine is discussed subsequently.As a therapeutic input that provides an orchestrated therapy

directed at a patients psychoemotional state and neuromusculo-skeletal dysunctions, medical acupuncture is uniquely suited toaddress many o the complexities inherent in the pain patient. As iswell known to pain medicine physicians, many patients with sub-acute or longstanding pain problems exhibit dysunctional sleep,relationships, thought patterns, emotions, and behaviors. As dis-cussed earlier, optimal acupuncture or pain seeks to address, and iscapable o aecting, all o these elements.

Safety

Acupuncture perormed by a medically trained practitioner is arelatively sae and orgiving procedure. It is difcult to introducenew or persistent problems with acupuncture therapy. Acupunc-ture treatments commonly induce a state o relaxation especiallywhen electrical stimulation is used. Sometimes this state can evolveinto or be perceived as atigue or dysphoria, particularly by thoseaccustomed to the physiologic milieu o a tonically activated stresssystem.

e principal serious adverse eects caused by acupunc-ture are vasovagal syncope, puncture o an organ, inection, and aretained needle. ese risks can be minimized by using single-useor sterilized needles, obtaining appropriate clinical training, under-standing surace and internal anatomy, and exercising sound clini-cal judgment.

A systematic review o nine surveys o the saety o acupunc-ture involving more the 250,000 treatments ound that eelings oaintness and syncope occurred in less than 0.3% o treatments.Feelings o relaxation were common and occurred in almost all

patients (86%).57 O the serious adverse eects, pneumothoraxis one o the most common. e large Acupuncture Saety andHealth Economic Studies (ASH) in Germany involved more than1.6 million acupuncture sessions and reported two pneumothoraces

or an occurrence rate per session o less than 0.0001%.58 is sameresearch initiative reported local inection in 0.3% o patients.58

Cost Effectiveness of Acupuncture

All healthcare delivery systems must consider the relative economiccosts and comparative benets o medical treatment options.In countries where healthcare is administered largely according topayment by a national insurance system, cost-eectiveness metricshave been developed to acilitate cost-benet analyses and ulti-mately aid in deciding what medical treatments will be available. Inthe United Kingdom a value o less than 30,000 pounds per qualityadjusted lie year (QALY) has been set by the National Institute orHealth and Clinical Excellence (NICE) as representing a cost eec-tive therapy. Cost-eectiveness research or acupuncture has been

conducted with data rom the national health insurance systemso Germany and England. Using acupuncture or the treatment oheadache, chronic neck pain, low back pain, and osteoarthritis othe knee and hip has been shown to be cost eective using acceptedinternational thresholds.

In the largest clinical investigation o acupuncture to date,

German researchers evaluated the cost eectiveness o acupunc-ture or the treatment o headache, chronic neck pain, low backpain, and osteoarthritis o the knee and hip in the Acupuncture inRoutine Care Studies (ARC).47 ARC included nearly 8500 patientsor economic analysis and ound acupuncture to be eective orall diagnoses studied with an average increase in expenditure o319 euros per treatment course.47,58 e cost eectiveness wasound to be between 10,526 euros per QALY or low back pain

and 17,854 euros per QALY or knee and hip osteoarthritis. us,acupuncture or all diagnoses was ound to be well within acceptedstandards or cost eectiveness.

British researchers evaluated the cost eectiveness o acu-puncture or the treatment o chronic headache and ound that acu-puncture improved quality o lie or a relatively small incrementalcost. ey estimated that acupuncture treatment resulted in a costo 9180 pounds per QALY which compares avorably to medicationtreatment o migraine headaches. Substituting oral sumatriptan ororal caeine plus ergotamine results in a cost o 16,000 pounds per

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QALY.59,60 Other studies have ound acupuncture to be cost eec-tive or chronic neck pain with a cost o 12,469 euros per QALY 61and low back pain with a cost o 4241 pounds per QALY.62

Clinical Research

Virtually all studies o acupuncture or the treatment o pain showsubstantial efcacy when compared to control groups that con-sist o waiting list populations receiving standard conventional

therapy. Studies comparing true acupuncture with nonpenetratingsham control groups are more mixed, but the majority demon-strate incremental benet o true acupuncture over nonpenetrating

sham groups. Signicant benet o needling traditional acupunc-ture points over needling nontraditional locations has also beenrepeatedly demonstrated, however, the eect size is considerablyreduced, and the results are less consistent. is would be expectedrom our knowledge o the physiologically active eects o needlepenetration.

Acupuncture points are not magical nor do they possess inex-plicably dierent properties compared to other locations in the body.Classical acupuncture points can be viewed as physiologic hot spotsin the body that have been discovered through several millennia oempirical investigation. ey oten correspond to trigger points,

connective tissue cleavage planes, accessibility o peripheral nerves,and regions o densely concentrated neurovascular bundles. Manyother locations on the body have similar neuroanatomic character-istics, but are not described as classical acupuncture points. eselocations will likely have many o the same physiologic and clinicaleects as classically dened acupuncture points.

Acupuncture points and nonacupuncture points are oten dis-cussed as black and white distinctions. e preceding brie descrip-tion o various systems o acupuncture underscores the diverseconceptions o acupuncture points and acupuncture needling

techniques. When one considers the vast multitude o classicallydened extra points, the supercial needling technique used inJapanese acupuncture, and the shiting point locations described byRyodoraku acupuncture, the near impossible task o dening non-

acupuncture points even rom the classical perspective becomesevident.

Challenges of Studying Acupuncture

Since the 1950s the randomized, double blind, placebo controlledtrial (RDBPCT) has become the standard methodology or evalu-ating the eectiveness o pharmaceutical therapies. Althoughgoing to great lengths to exclude bias, this methodology also hasits limitations. Perhaps the most vexing problem o the RDBPCTis the discordance between what is studied (homogeneous patientswithout comorbid conditions) and real lie (complex patients withmultiple medical problems).63-65 Furthermore, the RDBPCT maynot be the best method to evaluate complex medical interventionssuch as surgery, physical therapy, psychotherapy, and acupuncture.

In contrast to pharmaceutical therapy, the substance o these inter-ventions cannot be divorced rom the mode o delivery. Becauseo this, controls that allow clear isolation o the specic eects othe intervention rom the nonspecic eects o the delivery modeare virtually impossible to devise. For example, it is impossible tomagically remove a gallbladder without going through the lengthyand ritualized preoperative intake, intraoperative anesthesia, andpostoperative recovery process.

In the case o acupuncture, we know that sham acupunctureis a myth. Sham acupuncture or minimal acupuncture is generally

dened as the insertion o needles at so called nonacupuncturepoints or at shallow depths over classically dened acupuncturepoints, and is considered to be physiologically and clinically inert.Sham needling at nonacupuncture locations is problematic orseveral reasons. From classical as well as modern reasoning, it is

virtually impossible to nd a location on the body that will notproduce a physiologic action in response to acupuncture needling.ere are roughly 360 body locations called meridian pointsthat are avoided to nd nonacupuncture points. Interestingly,

there are several thousand extra-meridian acupuncture pointsand a multitude o points that are located based on the specicmaniestation o symptoms o each person, making the selectiono nonacupuncture points challenging at best rom the classicalperspective. Likewise, modern MRI research has demonstratedthat while needle stimulation at acupuncture points producesmore robust brain modulation than needle stimulation at non-acupuncture points, nonacupuncture points are physiologically

active.50

For the goal o separating the needling eects o acupuncturerom the eects o the ritual o delivering acupuncture, sham acu-puncture devices such as the Park Sham Device may represent animprovement over shallow needle insertion at acupuncture pointsor needle insertion at nonacupuncture points. e Park Sham

Device uses a retractable blunt-tipped needle that does not pen-etrate the skin. However, it is important to note that although aneedle does not pierce the skin when using the Park Sham Device,skin contact is made. is skin contact will likely produce similareects as the Japanese acupuncture procedure known as teishin, inwhich a blunt-tipped probe is used to apply light pressure over acu-

puncture points.A more useul methodology or studying complex interven-

tions such as acupuncture may be the pragmatic randomized con-trolled trial (PRCT).66 e PRCT evaluates actual questions acingthe practicing clinician. For example, in a patient with reractorydepression managed by the primary care physician, does reer-ral or collaboration with a psychiatrist result in improved patientoutcomes?67 Or will a patient with chronic low back pain receiv-

ing conventional management rom the primary care providerderive additional incremental benet rom a reerral to medicalacupuncture?

Key eatures o the PRCT are minimizing exclusion criteria inan attempt to match the study population more closely with theheterogeneous types o patients encountered in clinical medicine

as well as using pragmatically selected control groups such as atreatment as usual group.66 Although marked improvements havebeen attributed to placebo interventions such as the sugar pill,the actual improvement beyond treatment as usual groups may beminimal or nil. A 2004 Cochrane review o placebo interventionsor all clinical conditions concluded ere was no evidence thatplacebo interventions in general have clinically important eects.A possible small eect on continuous patient-reported outcomes,

especially pain, could not be clearly distinguished rom bias, andurther It has been widely believed that placebo treatments areassociated with substantial eects on a wide range o health prob-lems. However, this belie is not based on evidence rom random-ized trials that use a placebo treatment or one group o people,while another group receives no treatment. e eect o placebotreatments was studied by reviewing more than 150 such trialscovering many types o health care problems. Placebo treatmentscaused no major health benets, although they possibly had a smalleect on outcomes reported by patients, or example, pain.68

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When evaluating the eectiveness o a therapeutic interven-tion, it is imperative to use control groups to account or spontane-ous improvement in symptoms and the uctuation in symptomsthat is inherent to the natural course o a disease process. When theevaluated therapy is simple, such as pharmacotherapy, and thesub-

stance o the intervention can easily be separated rom theprocesso the intervention, using a placebo pill may be useul to accountor additional bias such as expectancy. However, when evaluatingthe relative clinical eectiveness o complex interventions such as

psychotherapy, surgery, and acupuncture where the substance andprocess o the therapy are inextricable, use o control groups thatconsist o treatment as usual or an alternate therapy [acupuncture

versus physical therapy or percutaneous coronary intervention

(PCI) versus coronary artery bypass grating (CABG)]69 may pro-vide more clinically relevant inormation.

Spine Pain

A Cochrane review o acupuncture and dry needling or low backpain including 35 RCTs through 2003 concluded that acupunctureis eective or pain relie and unctional improvement o chroniclow back pain when compared to either usual treatment or shamacupuncture. Improvement was noted immediately ater a courseo acupuncture and or up to 3 months ater the cessation o treat-

ments. Acupuncture was also ound to oer incremental benet inpain reduction when added to standard treatments or chronic lowback pain.70

ree large German RCTs published ater the Cochranereview demonstrated a substantial reduction in low back painor acupuncture relative to standard conventional treatments orperiods extending to 6 and 12 months. Haake and colleagues ran-domized 1162 patients with back pain to acupuncture accordingto classical concepts, supercial acupuncture needling at nonacu-puncture points, or usual care consisting o drugs, physical therapy,and exercise. e primary outcome was improvement in pain orunction at 6 months. Both needling groups were almost twice aslikely to improve when compared to usual conventional care. erewas little dierence between the two acupuncture groups suggest-

ing that point selection may be less important than proposed byclassical acupuncturists.49 Brinkhaus and coworkers ound similarresults in a rigorously designed RCT with improvement main-tained through 12 months.71 Witt and associates included 11,630patients in a study evaluating clinical and economic eectivenesso acupuncture or low back pain. O 3093 patients who consented

to randomization, 1549 patients were allocated to receive imme-diate acupuncture and 1544 patients were allocated to a waitinglist control group that would receive acupuncture 3 months later.e remaining 8537 who did not agree to randomization gener-ally had more severe baseline symptoms and were included in anonrandomized cohort. In the randomized arm, acupuncture wasound to be eective at reducing pain and unction when comparedto routine care with an absolute risk reduction o 25.8%, yielding a

number needed to treat o our. Interestingly, the nonrandomizedacupuncture cohort with more severe baseline symptoms experi-enced improvement in pain and unction similar to the randomizedgroup receiving acupuncture.48

Fewer studies have been conducted or neck pain, however ahigh-quality meta-analysis has been perormed. A Cochrane reviewo acupuncture or neck disorders including 10 RCTs through 2006ound moderate evidence that acupuncture was more eective atrelieving pain than sham treatments or both mechanical neck pain

and neck pain with radicular symptoms or up to 3 months.72

Headache

In 2009, e Cochrane Collaboration published two meta-analysesevaluating the use o acupuncture or prophylaxis o migraine andtension-type headaches. eir review o acupuncture or migraineprophylaxis included 22 RCTs through April 2008. e authorsconcluded that Available studies suggest that acupuncture is atleast as eective as, or possibly more eective than, prophylacticdrug treatment, and has ewer adverse eects. Acupuncture shouldbe considered a treatment option or patients willing to undergo

this treatment. ey also state ere is no evidence or aneect o true acupuncture over sham interventions, though thisis difcult to interpret, as exact point location could be o limitedimportance.73

e same authors reviewed the eects o acupuncture or ten-sion-type headache and included 11 RCTs through January 2008.ey concluded that acupuncture could be a valuable non-pharmacological tool in patients with requent episodic or chronictension-type headaches. ey report that two large RCTs com-pared acupuncture to usual care and ound 47% o patients receiv-ing acupuncture experienced a reduction in headache requency byat least 50% compared to 16% o the patients in the control group.ey also describe six RCTs that compared true acupuncture toake acupuncture in which needles are either inserted at incorrect

points or did not penetrate the skin. e pooled analysis o theseRCTs revealed a small, but statistically signicant improvemento the patients receiving true acupuncture versus ake acupunc-ture. at is, 50% o patients receiving true acupuncture reporteda reduction o at least 50% in headache requency versus 41% opatients receiving ake acupuncture.74

A 2007 German review concluded that a 6-week course oacupuncture treatments is equivalent to a 6-month course o pro-phylactic drug treatment. is review also suggested that traditionalconcepts o needle location and stimulation are not as important ashad been thought, and recommended that acupuncture should beintegrated into existing migraine therapy protocols.75

Several RCTs have also evaluated the use o acupuncture oracute migraine headache. A recent RCT published inHeadache in

2009 randomized 175 patients to receive true acupuncture or oneo two sham acupuncture groups who received needling at variousnonacupuncture points. e true acupuncture group experienceda greater decease in pain versus the sham acupuncture groups at2 and 4 hours ater treatment. In addition, 40.7% o those receivingtrue acupuncture experienced a complete resolution o pain within24 hours versus 16.7% and 16.4% in the two sham acupuncturegroups.76

Melchart and colleagues randomized 179 migraine patientsto receive acupuncture, subcutaneous sumatriptan, or a placeboinjection at the rst sign o a migraine headache. Acupuncture andsumatriptan were equally eective in preventing a ull migraineattack. Acupuncture resulted in a 21% absolute risk reduction andsumatriptan resulted in a 22% absolute risk reduction when com-

pared to the placebo injection. I a ull attack could not be prevented,sumatriptan was more eective than acupuncture in reducing pain.Side eects were more common in patients who received suma-triptan (40%) than in acupuncture patients (23%) or patients whoreceived the placebo injection (16%).77

Knee Pain

White and colleagues published a 2007 meta-analysis in the journalRheumatology which reviewed 13 RCTs investigating the eect oacupuncture on pain and unction in patients with chronic knee

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pain. is review concluded that acupuncture improves pain andunction in patients with chronic knee pain when compared tosham acupuncture and usual care.78

A second meta-analysis published by Manheimer in theAnnalso Internal Medicine in 2007 included 11 RCTs and concluded that,when compared to waiting list controls, acupuncture results in clin-ically relevant benets in patients with osteoarthritis o the knee.Short term benets were also ound in trials that used sham controlgroups, but these were deemed to be not clinically relevant.79

Two o the largest high-quality RCTs were conducted inGermany and published in 200520 and 2006.21 Both o these trialsshowed incremental benet or acupuncture in patients with kneeosteoarthritis when compared to conventional treatment. e trials

yielded conicting results regarding dierences between classicalacupuncture and minimal acupuncture.

Shoulder Pain

Fewer large, high-quality trials are available to evaluate the eec-tiveness o noninvasive therapies or chronic shoulder pain.Cochrane reviews or acupuncture, physical therapy, and cortico-steroid injections have concluded that insufcient evidence existsto guide therapy or these interventions.80-82 Subsequent to thepublication o the Cochrane meta-analysis or acupuncture, Guerra

de Hoyos and coworkers published the largest RCT to date in2004.83 is study randomized 130 patients with chronic shoulderpain to active acupuncture or nonpenetration control acupunctureand demonstrated an improvement in pain intensity and every sec-

ondary outcome measure 3 and 6 months ater treatment. A 2005RCT published in the journalPhysical erapy evaluated the eec-tiveness o ultrasound or acupuncture added to exercise therapyin 85 patients with impingement syndrome. is study includedollow-up data or 12 months and concluded that the addition oacupuncture to home exercises was more eective than the addi-tion o ultrasound.84 e largest high-quality RCT was published inthe journalRheumatology in 2008 and evaluated the eect o addinga single acupuncture point to physical therapy in 425 patients withshoulder pain. e acupuncture group experienced reduced pain as

well as a reduction in analgesic medication consumption in com-parison to the control group which received only physical therapy.85

Elbow Pain

A 2004 meta-analysis published in the journal Rheumatologyincluded 6 RCTs evaluating the eectiveness o acupuncture or lat-

eral epicondylar pain. All six o the studies demonstrated that acu-puncture was eective at relieving lateral epicondylar pain or up to3 months ater a course o treatments. Five o the six studies dem-onstrated superiority o acupuncture when compared to controltreatments.86 A systematic review investigating the eectiveness oconservative therapies in the rehabilitation o lateral epicondylitiswas published in theJournal o Hand erapy in 2004 and came tosimilar conclusions.87

Hip Pain

Few high-quality RCTs have been conducted to evaluate the eective-ness o acupuncture or hip pain. A small RCT published in the Clinical

Journal o Pain in 2004 compared electroacupuncture to patient edu-cation in patients with osteoarthritis related hip pain. Electroacupunc-ture was signicantly more eective at reducing pain and improvingunctional status and quality o lie when compared to patient edu-cation at all three assessment periods: immediately ater a course otreatment, as well as 3 and 6 months ater a course o treatment.88

A much larger high-quality study was published by Witt andcolleagues in Arthritis and Rheumatism in 2006 as part o thecolossal German Acupuncture trials. In this study 712 patientswith hip or knee osteoarthritis (45% had hip osteoarthritis) wererandomized to receive acupuncture or standard medical therapy.In addition, a nonrandomized cohort o 2921 patients with iden-tical baseline characteristics was included in the study. In therandomized group, patients receiving acupuncture experienceda marked clinical improvement compared to patients receiving

standard medical therapy. ese improvements were maintainedup to 6 months ater treatment. Interestingly, the outcomes orthe large nonrandomized group receiving acupuncture weresimilar to those experienced by the group randomized to receive

acupuncture.89

Fibromyalgia

Evidence or the eectiveness o acupuncture or bromyalgia issparse and conicting. A 2006 literature review included ve RCTs,o which three demonstrated eectiveness o acupuncture versussham treatment and two showed a lack o eectiveness. Because othe heterogeneity o the abstracted data, meta-analysis was not pos-sible. Number o treatments did not seem to aect the likelihood opositive response. Interestingly, all o the RCTs that demonstrated

eectiveness or the acupuncture group used electroacupuncture,whereas the two RCTs that ailed to demonstrate eectiveness usedmanual stimulation only. is review concludes that acupunctureor the symptomatic treatment o bromyalgia is not supported byunanimous results rom RCTs.90

Temporomandibular Joint Pain

High-quality research investigating the efcacy o acupuncture ortemporomandibular joint related pain is limited. A literature reviewpublished in 2001 evaluated 14 studies. e three RCTs that metinclusion criteria evaluated acupuncture versus occlusal splintswith two studies also including usual care control groups. All threeRCTs that were included ound acupuncture to be eective in a

variety o metrics including the visual analog scale, mandibular

unction, and number o tender points on examination. e degreeo eectiveness, however, was not quantied.91

A small RCT published in 2006 evaluated true acupunctureversus noninsertional sham acupuncture using a single needle onthe ace. Multiple endpoints were recorded and ound to avor trueacupuncture. e group receiving true acupuncture reported a53% reduction in pain on the visual analog scale versus a 6% reduc-

tion reported by the sham group. Likewise, the true acupuncturegroup reported a 55% reduction in unctional impairment versus a6% reduction reported by the sham group.92

Postoperative Pain

A systematic review o 15 RCTs evaluating acupuncture or post-operative pain was published in e British Journal o Anaesthesia

in 2008. e data were analyzed or postoperative opioid consump-tion, postoperative pain intensity, and opioid-related side-eects.Acupuncture was ound to have an opioid-sparing eect at 8 hours,24 hours, and 72 hours corresponding to a respective 21%, 23%,and 29% reduction o morphine consumption, respectively. A mod-erate and statistically signicant reduction in pain intensity wasound at 8 and 72 hours in the acupuncture treatment groups.A statistically signicant reduction in opioid-related adverse aectswas also ound. Treatment by acupuncture was associated with

a 33% reduction in the incidence o nausea, a 35% reduction in

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dizziness, a 22% reduction in sedation, a 25% reduction in pruritus,and a 71% reduction in urinary retention.93

Auricular acupuncture has also been studied in the postop-erative period. Usichenko and associates studied 54 patients under-going total hip arthroplasty and compared our acupuncture presstacks in the ear at acupuncture points versus nonacupuncturepoints. e group that received acupuncture at acupuncture pointso the ear used 31% less opioid administered by a patient-controlledanalgesia pump and had similar pain intensity scores measured by

the visual analog scale.94

Taguchi and coworkers studied the eect o acupuncture onanesthetic requirement in healthy volunteers in a r igorous double-blind experiment. is group ound that healthy volunteers whoreceived auricular acupuncture at our points required 8.5% lessdesurane anesthesia to prevent movement in response to noxiousstimuli when compared to healthy volunteers who did not receiveauricular acupuncture.95

Miscellaneous

Preliminary evidence rom small but well done RCTs suggests thatacupuncture is eective at relieving symptoms in patients withchronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). emost recent study recruited 63 patients who met the U.S National

Institutes o Health (NIH) consensus criteria or CP/CPPS in a threearm RCT. e electroacupuncture group received acupunctureaccording to classical and neuroanatomic principles with electri-cal stimulation, advice, and exercise. e sham acupuncture groupreceived supercial needling at nonacupuncture points, advice,and exercise, and the nal group received advice and exercise only.

Symptoms were assessed using the NIH Chronic Prostatitis Symp-tom Index (NIH-CPSI) and the primary outcome was change insymptoms using this index. All patients receiving electroacupunc-ture experienced at least a 6 point reduction in the NIH-CPSI totalscore compared to 16.7% o the sham acupuncture group and 25% othe advice and exercise group. Additionally prostaglandin E2 levels inthe urine ater prostatic massage decreased in the electroacupunc-ture group, whereas the levels increased in the other two groups.96

Lee SW and colleagues ound that 32 o 44 (72%) CP/CPPSpatients receiving acupuncture experienced at least a 6 pointdecrease in the NIH-CPSI score compared to 21 o 45 (47%) opatients receiving supercial acupuncture at nonacupuncturepoints.97 Chen and coworkers reported that 10 o 12 CP/CPPSpatients who were reractory to antibiotics, -blockers, antiin-

ammatory agents, and phytotherapy experienced a greater than50% reduction in the NIH-CPSI with acupuncture at an average o33 weeks ater treatment.98

A systematic review o acupuncture or the management olabor pain was published in e American Journal o Obstetrics andGynecology in 2004 and included three RCTs. Two RCTs comparedacupuncture with usual care and ound that intrapartum acupunc-ture resulted in lower usage o meperidine and epidural analgesia.

One RCT compared acupuncture to supercial needling at non-acupuncture points and ound that the classical acupuncture groupreported less intrapartum and postpartum pain, requested meperi-dine and epidural analgesia less oten, and required oxytocin aug-mentation less oten.99

Integration with Conventional Pain Medicine

Acupuncture therapy is a versatile modality with multiple roles in the

contemporary multidisciplinary management o pain. As a sae, costeective, and evidence-based orm o therapy, acupuncture is an ideal

initial input or a variety o subacute and early chronic pain states. Assuch, its implementation prior to expensive drugs and expensive andpotentially dangerous invasive interventions will likely prove bene-cial or patients and society. Unortunately, lack o amiliarity withthe research establishing acupuncture as sae, cost-eective, and ef-cacious treatment oten results in considering acupuncture as a lastresort when all other modalities have ailed. A rational approach totreatment that is not driven by economic actors or personal biasought to use sae, cost-eective, and efcacious therapies early in the

therapeutic approach to pain problems, and more risky, expensive,and marginally efcacious therapies later or as last resorts.

Like any other medical therapy, the results expected romacupuncture or pain control will vary greatly with the severity and

chronicity o the underlying condition as well as the underlyinghealth o the patient. Milder pain o more recent onset in a vital

young patient can be expected to respond more completely withewer treatments. A realistic goal or more severe pain o longerduration in chronically debilitated or more rail patients will be par-tial reduction over a longer course o treatments.

Acupuncture can also be useul or the management o ancil-lary symptoms that accompany chronic pain such as atigue, sec-ondary dysthymia, or agitation. is being said, acupuncture shouldnot be used as the only treatment or moderate-to-severe depression

or other serious psychiatric conditions. Acupuncture treatmentsare commonly accompanied by a sense o well-being, relaxation,and mild euphoria that can have mild, lasting anxiolytic eects thatcan be a valuable adjunct in the care o pain patients whose pain iscomplicated by comorbid ear or anxiety. Side eects that are otenencountered in the pharmacologic treatment o pain can also beaddressed with acupuncture. For example, nausea, pruritus, dys-phoria, and sedation are common side eects o medications usedto manage pain. Acupuncture can help diminish these side eectsproviding or improved patient tolerability and compliance.

Conclusion

As understanding o the neurobiologic basis o acupuncture grows,clinical research becomes more sophisticated and patient inter-est expands, medical acupuncture is becoming more accepted inconventional medical environments. Continued research into theoptimal types o acupuncture or specic problems and the mostefcient use o acupuncture resources will help clariy the idealplace or acupuncture in the ramework o modern medicine.

e 20th century witnessed impressive advances in the medicalcare o acute illnesses such as trauma, inections, and thromboem-bolic events. Much o the challenge or medicine in the 21st centurywill be managing complex chronic illnesses o civilization such asdiabetes, heart disease, and chronic painul conditions. As a sae,sustainable, cost-eective, and evidence-based therapy or manychronic painul conditions that engenders high patient satisaction,

medical acupuncture is well-suited to play a role in the uture omodern medical practice.

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