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A New Theory for Acupuncture: Promoting Robust Regulation
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J Acupunct Meridian Stud 2018;--(-):--e--
Available online at www.sciencedirect.com
Journal of Acupuncture and Meridian Studies journal homepage: www.jams-kpi.com
A New Theory for Acupuncture: Promoting Robust Regulation Yuan Xu 1,2,y, Yang Guo 2,3,y, Yuru Song 3, Kuo Zhang 1,2, Yiping Zhang 1,2, Qiang Li 4, Shouhai Hong 5, Yangyang Liu 1,2,**, Yi Guo 1,6,* 1
Experimental Acupuncture-Moxibustion Research Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China 2 College of Acupuncture-Moxibustion and Tuina, Tianjin University of Traditional Chinese Medicine, Tianjin, China 3 First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China 4 Department of Rehabilitation and Healthcare, Hunan Traditional Chinese Medicine College, Zhuzhou, China 5 Acupuncture Department, Zhejiang Provincial Hospital of TCM, Hangzhou, China 6 College of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, No. 312 Anshan West Road, Tianjin 300193, China Available online - - -
Received: Jul 14, 2017 Revised: Nov 27, 2017 Accepted: Nov 28, 2017 KEYWORDS acupuncture; acupuncture regulation; robustness; theory
Abstract Robustness, an ability of biological networks to uphold their functionalities in the face of perturbations, is a key characteristic of all living systems. Acupuncture is a procedure in which fine needles are inserted into an individual at discrete points and then manipulated, with the intent of preventing and curing diseases. Acupuncture does not directly eliminate pathogenic factors or pathological tissue; rather, acupuncture enhances the ability of the human body to self-medicate itself by activating complex regulatory systems and by maintaining physiological homeostasis to prevent or treat diseases. From this point of view, the effect of acupuncture on the human body is more likely a kind of regulation to promote robustness. That is to say, acupuncture has the ability to promote robustness. In this article, we review the properties and functions of acupuncture in preventing and treating diseases and in maintaining health by enhancing robustness.
* Corresponding author. College of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, No. 312 Anshan West Road, Tianjin 300193, China. ** Corresponding author. College of Acupuncture-Moxibustion and Tuina, Tianjin University of Traditional Chinese Medicine, No. 312 Anshan West Road, Tianjin 300193, China. E-mail: [email protected] (Y. Liu), [email protected] (Y. Guo). y These authors contributed equally to this work. pISSN 2005-2901 eISSN 2093-8152 https://doi.org/10.1016/j.jams.2017.11.004 ª 2018 Medical Association of Pharmacopuncture Institute, Publishing services 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/). Please cite this article in press as: Xu Y, et al., A New Theory for Acupuncture: Promoting Robust Regulation, Journal of Acupuncture and Meridian Studies (2018), https://doi.org/10.1016/j.jams.2017.11.004
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1. Introduction Robustness, an ability of biological networks to maintain their functions in the face of perturbations, is a key characteristic of all living systems [1]. It is one of the fundamental and ubiquitously observed systems-level phenomena that cannot be understood by simply looking at the individual components [2]. The human body is an open, complex, and gigantic machine that has the following characteristics: (1) It includes many systems, such as the nervous system, endocrine system, and immune system. (2) It can exchange materials, energy, and information with the surrounding environment. (3) Its systems are not independent; rather, they interact and exchange information [3]. The communication between these systems is believed to be essential for maintaining physiological homeostasis and good health [4]. When the external environment changes, or in pathological cases, some of the systems in human body function in such a way as to counter those changes; in this way, the body is protected and is effectively able to remain in a state of good health. This regulation can be regarded as the embodiment of the human body’s robustness. Acupuncture is a procedure in which fine needles are inserted into an individual at discrete points and then manipulated, with the intention of preventing and curing diseases [5]. Although acupuncture does not directly eliminate pathogenic factors or pathological tissue, it does enhance the ability of the human body to self-medicate by activating the complex regulatory systems and by maintaining physiological homeostasis to prevent diseases or to treat patients with diseases [6]. This is its role as a regulator of robustness. Over the 2500-year development of acupuncture, a wealth of experience has been accumulated from the practice of acupuncture and that experience attests to the wide range of diseases and conditions that can be effectively treated with this approach. In recognition of the increasing worldwide interest in acupuncture, the World Health Organization conducted a symposium on acupuncture in June 1979 in Beijing, China. Physicians practicing acupuncture in different countries were invited to identify the conditions that might benefit from this therapy. The participants drew up a list of 43 suitable diseases. The World Health Organization published “Acupuncture: Review and Analysis of Reports on Controlled Clinical Trials” in 2002; that report focused on data collected from controlled clinical trials. The participants then expanded the list to 107 suitable diseases [7]. In this article, we review the properties of acupuncture and explain how acupuncture can be used to prevent diseases or to treat patients with diseases; moreover, on a theoretical level, it can be used to enhance robustness, thereby helping an individual to remain healthy.
2. Acupuncture has the ability to regulate robustness The regulatory features of robustness and of acupuncture have many similarities. (1) Robustness enables the system to maintain its functionalities against external and
Y. Xu et al. internal perturbations [8,9]. When the human body is in homeostasis (a stable state), its ability to fight against diseases is much stronger than it is when the body is in an unstable state. Acupuncture regulates the numerous factors that cause internal environments to continuously change. Thus, the ability of acupuncture to regulate robustness indicates that it can be used to promote the human body’s self-regulation so that it can maintain homeostasis. (2) System control is a prominent implementation mechanism of robustness. System control consists of negative and positive feedback to attain a robust dynamic response as observed in a wide range of regulatory networks, including the cell cycle, the circadian clock, and chemotaxis [2]. Acupuncture has a similar bidirectional feedback regulation to maintain homeostasis. Positive feedback contributes to robustness by amplifying the stimulus. However, negative feedback contributes to a reduction in the activity of an overactive system. (3) Redundancy generally refers to a situation in which several identical or similar components/modules can replace one another when one of the components fails [2]. It plays an important role in reducing the influence of internal and external disturbances on the whole system. Acupuncture has the characteristic of regulating multiple pathways. When a pathway is impaired, acupuncture can promote other pathways so that the body’s functions are maintained.
3. Acupuncture regulates robustness under pathological conditions 3.1. Preventing diseases Acupuncture has been used throughout the world. The application of acupuncture is not limited to the treatment of diseases; it also plays a role in the prevention of disease. A recent randomized, controlled trial confirmed the effectiveness of acupuncture in preventing or reducing the risk of certain conditions or diseases, such as uncomplicated recurrent lower urinary tract infections in adult women [10], postoperative nausea and vomiting after gynecological [11] or breast surgery [12], atrial fibrillation (AF) recurrence after electrical cardioversion [13], stroke in patients with traumatic brain injury [14], and emergence agitation in children [15]. As to disease prevention, acupuncture regulates robustness mainly by improving stability in the body. For instance, studies on AF have shown that an autonomic nervous system is present in the heart and always maintains a dynamic balance. An imbalance in the autonomic control mechanisms due to either an increase in vagal or sympathetic neural activity will lead to abnormal cardiac electrophysiology, favoring the initiation and maintenance of AF episodes [16e18]. In Chinese medicine, an obvious correlation exists between the nerve segments of the human meridians and the visceral organs to which they correspond [7]. Thus, acupuncture at PC-6 (Neiguan), HT-7 (Shenmen), and BL-15 (Xinshu) has been shown to have an antiarrhythmic effect through its effect on the autonomic nervous system (Table 1, Fig. 1). Compared with the side-effects of drugs, those of acupuncture are very few, so acupuncture can be regarded
Please cite this article in press as: Xu Y, et al., A New Theory for Acupuncture: Promoting Robust Regulation, Journal of Acupuncture and Meridian Studies (2018), https://doi.org/10.1016/j.jams.2017.11.004
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A New Theory for Acupuncture
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as a noninvasive treatment. Thus, acupuncture treatment can reduce not only the need for synthetic drugs but also the side-effects accompanying the use of such drugs.
3.2. Treating diseases In terms of disease treatment, the role of acupuncture is reflected mainly in two aspects. First, when homeostasis is disturbed by the internal and/or the external environment, acupuncture can promote the correction of one’s pathological state and encourage normal function. In other words, acupuncture can improve robustness through system control. A piece of evidence supporting this lies in the fact that acupuncture promotes the neuroendocrine immune network. When the human body is invaded by pathogens, it does this by sensing pathogen-associated molecular patterns, proteins, and initial nonspecific cellular and humoral responses. The immune mediators and cytokines that are subsequently released by the innate immune system rapidly activate neural responses, which both amplify local immune responses to clear pathogens and trigger systemic neuroendocrine and regional neural responses that eventually restore homeostasis. This interplay constitutes an important feedback loop [4]. Acupuncture enhances the innate immune regulation in the early stage and the feedback pathway in the late stage to recovery balance. On the other hand, when some of the body’s functions are impaired, acupuncture can promote other functions to compensate for the impaired function. That is, acupuncture can be used to treat patients with diseases because it promotes the redundancy and modularity of robustness. For example, a variety of pathways play a role when acupuncture is used to treat patients with persistent pain. (1) The sympathetic nerve pathway: (i) acupuncture activates sympathetic nerve fibers to enhance the expression of intracellular adhesion molecule-1 in the blood vessels of inflamed tissue to promote migration of b-endorphin and met-encephalin-containing polymorphonuclear leukocytes and mononuclear cells. Furthermore, (ii) acupuncture activates sympathetic neuronederived norepinephrine, which stimulates the adrenergic receptors in inflammatory cells to release bendorphin, leading to a reduction in the level of pain. (2) In the endocrine and immunity pathway, acupuncture activates the hypothalamusepituitaryeadrenal axis to increase plasma corticosterone levels significantly, downregulate cyclooxygenase-2, upregulate endogenous anandamide, and increase the number of endogenous cannabinoid CB2 receptors to upregulate immune cell opioids in inflamed skin tissue while at the same time, decreasing tumor necrosis factor-a, interleukin-1b, and interleukin-6 expressions, thereby reducing the level of pain. Acupuncture has the analgesic effect of modularity pathways. When one of the
Table 1 Acupoint PC-6 HT-7 BL-15
Acupoints and corresponding nerve segments. Nerve segment C8-T1 C8-T2 T5
body’s systems is perturbed, the local area will be affected in such a way as to minimize the effect on the whole system (Fig. 2). Acupuncture can promote cooperation between the sympathetic nervous, endocrine, and other systems, thereby playing a role in promoting the body’s redundancy mechanism. At the same time, acupuncture can promote the modularity of each pathway; when one of the pathways is perturbed and/or impaired, the effect remains local, thus minimizing the effects on the whole system [19]. For example, even in patients with a blockage of the analgesic pathway of the sympathetic nervous system, acupuncture can still play an analgesic role through the endocrine immune pathway [20].
3.3. Rehabilitation Medical rehabilitation aims at redeveloping and restoring the functional and psychological abilities of an individual so that he or she can regain independence and lead an active life [21]. Acupuncture strives to balance the flow of internal energy in the body by inserting fine needles into specific points on the body to regulate the energy channels that affect internal organs, thereby helping patients to become independent and lead active lives [22]. Acupuncture as a way of medical rehabilitation has been used for thousands of years, having been applied mainly to patients who had suffered a stroke [23,24]. Acupuncture may have beneficial effects on reducing dependency, global neurological deficiency, and some specific neurological impairments in patients who have experienced a stroke and are in the convalescent stage, but without any obvious serious adverse effects [25]. The robustness function of acupuncture in the rehabilitation stage of treating patients with diseases can promote homeostasis through organ reconstruction. New research using modern neuroimaging techniques shows that acupuncture can effectively enhance connectivity between the cerebellum and the primary sensorimotor cortex in patients during stable stroke recovery [26]. Acupuncture at GB34(Yang lingquan) may increase motorcognition connectivity while decreasing compensation of the unaffected motor cortex and homolateral synkinesis, which can definitely promote rehabilitation in patients suffering from hemiplegia and spasms [27].
4. Conclusion Robustness is a fundamental property of biological systems. The robustness of the body is related to the complex regulatory systems in vivo. This implies that a methodmotivated robustness perspective might provide new therapeutic approaches. These complex regulatory systems need to be organized into a coherent architecture if they are to be effective in maintaining physiological homeostasis and good health. Acupuncture is a regulatory way of stimulating the complex systems in the body. In the diseaseprevention phase, acupuncture has the ability to enhance self-adjustment to maintain homeostasis in the system. In the disease-treatment phase, acupuncture can promote the correction of a pathological state, improve robustness through system control, and induce the other functions to
Please cite this article in press as: Xu Y, et al., A New Theory for Acupuncture: Promoting Robust Regulation, Journal of Acupuncture and Meridian Studies (2018), https://doi.org/10.1016/j.jams.2017.11.004
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Y. Xu et al.
Figure 1
The PC6, HT7, and BL15 acupoints overlap the nerve segments of the heart.
Figure 2 Promoting the robustness function of acupuncture in treating diseases. COX-2 Z cyclooxygenase-2; b-END Z b-endorphin; ICAM Z intracellular adhesion molecule-1; IL-1b Z interleukin-1b; met-ENK Z met-encephalin; PMN Z polymorphonuclear leukocyte; TNF-a Z tumor necrosis factor-a; NEI Z Neuro-endocrine immunity; NE Z Norepinephrine; CB Z Cannabinoid; GC Z Glucocorticoid.
compensate for the damaged function of the body by promoting redundancy and modularity. Lastly, in the diseaserehabilitation phase, acupuncture can promote the reconstruction of homeostasis in an organ after disease. The above roles of acupuncture indicate that acupuncture has the ability to promote robustness and can be used as a therapeutic way to regulate disease. Future acupuncture research should address the promotion of the body’s robustness and explore the mechanisms of acupuncture from the perspective of enhanced robustness.
Funding This study was supported by the National Natural Science Foundation of China (NSFC) No. 81330088.
Disclosure statement The authors declare that they have no conflict of interests.
Please cite this article in press as: Xu Y, et al., A New Theory for Acupuncture: Promoting Robust Regulation, Journal of Acupuncture and Meridian Studies (2018), https://doi.org/10.1016/j.jams.2017.11.004
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A New Theory for Acupuncture
Acknowledgment The authors sincerely thank Emily Huang for her work in polishing the English in the text.
References [1] Gerstl MP, Klamt S, Jungreuthmayer C, Zanghellini J. Exact quantification of cellular robustness in genome-scale metabolic networks. Bioinformatics 2016;32(5):730e7. [2] Kitano H. Biological robustness. Nat Rev Genet 2004;5(11): 826e37. [3] Chen Y. Immune system e an open complex giant system. Complex Syst Complex Sci 2004;1(2):70e3. [4] Sternberg EM. Neural regulation of innate immunity: a coordinated nonspecific host response to pathogens. Nat Rev Immunol 2006;6(4):318e28. [5] Goldman N, Chen M, Fujita T, Xu Q, Peng W, Liu W, et al. Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture. Nature Neurosci 2010;13(7):883e8. [6] Guo Y, Fang JQ. Acupoint and viscera correlation I. In: Guo Y, editor. Experimental acupuncture science. 3th ed. China Press of Traditional Chinese Medicine; 2012. p. 119. [7] Zhang X. Acupuncture: review and analysis of reports on controlled clinical trials. Parkinsonism Relat Disord 2002;2:S163. [8] Elena SF, Sanjuan R. The effect of genetic robustness on evolvability in digital organisms. BMC Evol Biol 2008;8(1):284. [9] Mao K. Research on stabilty and robustness of complex network structure. Comput Sci 2015;42(4):85e8. [10] Alraek T, Soedal LI, Fagerheim SU, Digranes A, Baerheim A. Acupuncture treatment in the prevention of uncomplicated recurrent lower urinary tract infections in adult women. Am J Public Health 2002;92(10):1609. [11] Rithirangsriroj K, Manchana T, Akkayagorn L. Efficacy of acupuncture in prevention of delayed chemotherapy induced nausea and vomiting in gynecologic cancer patients. Gynecol Oncol 2015;136(1):82e6. [12] Streitberger K, Diefenbacher M, Bauer A, Conradi R, Bardenheuer H, Martin E, et al. Acupuncture compared to placebo-acupuncture for postoperative nausea and vomiting prophylaxis: a randomised placebo-controlled patient and observer blind trial. Anaesthesia 2004;59(7):730. [13] Lomuscio A, Belletti S, Battezzati PM. Efficacy of acupuncture in preventing atrial fibrillation recurrences after electrical cardioversion. J Cardiovasc Electrophysiol 2011;22(3):241. [14] Shih CC, Hsu YT, Wang HH, Chen TL, Tsai CC, Lane HL, et al. Decreased risk of stroke in patients with traumatic brain injury receiving acupuncture treatment: a population-based retrospective cohort study. PLoS One 2014;9(2), e89208.
5 [15] Hijikata T, Mihara T, Nakamura N, Miwa T, Ka K, Goto T. Electrical stimulation of the heart’s 7 acupuncture sites for preventing emergence agitation in children. Eur J Anaesthesiol 2016;33(11e12):414e7. [16] Shen MJ, Zipes DP. Role of the autonomic nervous system in modulating cardiac arrhythmias. Circ Res 2014;114(6): 1004e21. [17] Sheng X, Scherlag BJ, Yu L, Li S, Ali R. Prevention and reversal of atrial fibrillation inducibility and autonomic remodeling by low-level vagosympathetic nerve stimulation. J Am Coll Cardiol 2011;57(5):563e71. [18] Hou Y, Scherlag BJ, Lin J, Zhang Y, Lu Z, Truong K, et al. Ganglionated plexi modulate extrinsic cardiac autonomic nerve input: effects on sinus rate, atrioventricular conduction, refractoriness, and inducibility of atrial fibrillation. J Am Coll Cardiol 2007;50(1):61e8. [19] Zhang R, Lao L, Ren K, Berman BM. Mechanisms of acupuncture-electroacupuncture on persistent pain. Anesthesiology 2014;120(2):482e503. [20] Liu LA, Zhang S, Wang H, Tang L. Acupuncture combined with moxibustion plaster for nerve-root-type cervical spondylosis. Zhongguo Zhen Jiu 2016;36(2):139. [21] Baumeister H, Lin J, Ebert DD. Internet- and mobile-based approaches: Psychosocial diagnostics and treatment in medical rehabilitation. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2017;60(4):436e44. [22] Farmer C. Bringing holistic treatments to the attention of medicine: acupuncture as an effective poststroke rehabilitation tool. J Evid Based Complement Altern Med 2014;20(2): 120e5. [23] Lu L, Zhang XG, Zhong LL, Chen ZX, Li Y, Zheng GQ, et al. Acupuncture for neurogenesis in experimental ischemic stroke: a systematic review and meta-analysis. Sci Rep 2016; 6(2016):1e16. [24] Gonzalez-Lopez-Arza MV, Sautreuil P, Varela-Donoso E, Rodriguez-Mansilla J, Garrido-Ardila E. Epidemiological data on acupuncture and physical and rehabilitation medicine in the European Union. J Tradit Chin Med 2015;35(4):478e82. [25] Yang A, Wu HM, Tang JL, Xu L, Yang M, Liu GJ. Acupuncture for stroke rehabilitation. Cochrane Database Syst Rev 2006;39(3), CD004131. [26] Xie Z, Cui F, Zou Y, Bai L. Acupuncture enhances effective connectivity between cerebellum and primary sensorimotor cortex in patients with stable recovery stroke. Evid Based Complement Alternat Med 2014;2014(3), 603909. [27] Chen X, Zhang H, Zou Y. A functional magnetic resonance imaging study on the effect of acupuncture at GB34 (Yanglingquan) on motor-related network in hemiplegic patients. Brain Res 2015;1601:64e72.
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J Acupunct Meridian Stud 2018;--(-):--e--
Available online at www.sciencedirect.com
Journal of Acupuncture and Meridian Studies journal homepage: www.jams-kpi.com
A New Theory for Acupuncture: Promoting Robust Regulation Yuan Xu 1,2,y, Yang Guo 2,3,y, Yuru Song 3, Kuo Zhang 1,2, Yiping Zhang 1,2, Qiang Li 4, Shouhai Hong 5, Yangyang Liu 1,2,**, Yi Guo 1,6,* 1
Experimental Acupuncture-Moxibustion Research Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China 2 College of Acupuncture-Moxibustion and Tuina, Tianjin University of Traditional Chinese Medicine, Tianjin, China 3 First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China 4 Department of Rehabilitation and Healthcare, Hunan Traditional Chinese Medicine College, Zhuzhou, China 5 Acupuncture Department, Zhejiang Provincial Hospital of TCM, Hangzhou, China 6 College of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, No. 312 Anshan West Road, Tianjin 300193, China Available online - - -
Received: Jul 14, 2017 Revised: Nov 27, 2017 Accepted: Nov 28, 2017 KEYWORDS acupuncture; acupuncture regulation; robustness; theory
Abstract Robustness, an ability of biological networks to uphold their functionalities in the face of perturbations, is a key characteristic of all living systems. Acupuncture is a procedure in which fine needles are inserted into an individual at discrete points and then manipulated, with the intent of preventing and curing diseases. Acupuncture does not directly eliminate pathogenic factors or pathological tissue; rather, acupuncture enhances the ability of the human body to self-medicate itself by activating complex regulatory systems and by maintaining physiological homeostasis to prevent or treat diseases. From this point of view, the effect of acupuncture on the human body is more likely a kind of regulation to promote robustness. That is to say, acupuncture has the ability to promote robustness. In this article, we review the properties and functions of acupuncture in preventing and treating diseases and in maintaining health by enhancing robustness.
* Corresponding author. College of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, No. 312 Anshan West Road, Tianjin 300193, China. ** Corresponding author. College of Acupuncture-Moxibustion and Tuina, Tianjin University of Traditional Chinese Medicine, No. 312 Anshan West Road, Tianjin 300193, China. E-mail: [email protected] (Y. Liu), [email protected] (Y. Guo). y These authors contributed equally to this work. pISSN 2005-2901 eISSN 2093-8152 https://doi.org/10.1016/j.jams.2017.11.004 ª 2018 Medical Association of Pharmacopuncture Institute, Publishing services 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/). Please cite this article in press as: Xu Y, et al., A New Theory for Acupuncture: Promoting Robust Regulation, Journal of Acupuncture and Meridian Studies (2018), https://doi.org/10.1016/j.jams.2017.11.004
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1. Introduction Robustness, an ability of biological networks to maintain their functions in the face of perturbations, is a key characteristic of all living systems [1]. It is one of the fundamental and ubiquitously observed systems-level phenomena that cannot be understood by simply looking at the individual components [2]. The human body is an open, complex, and gigantic machine that has the following characteristics: (1) It includes many systems, such as the nervous system, endocrine system, and immune system. (2) It can exchange materials, energy, and information with the surrounding environment. (3) Its systems are not independent; rather, they interact and exchange information [3]. The communication between these systems is believed to be essential for maintaining physiological homeostasis and good health [4]. When the external environment changes, or in pathological cases, some of the systems in human body function in such a way as to counter those changes; in this way, the body is protected and is effectively able to remain in a state of good health. This regulation can be regarded as the embodiment of the human body’s robustness. Acupuncture is a procedure in which fine needles are inserted into an individual at discrete points and then manipulated, with the intention of preventing and curing diseases [5]. Although acupuncture does not directly eliminate pathogenic factors or pathological tissue, it does enhance the ability of the human body to self-medicate by activating the complex regulatory systems and by maintaining physiological homeostasis to prevent diseases or to treat patients with diseases [6]. This is its role as a regulator of robustness. Over the 2500-year development of acupuncture, a wealth of experience has been accumulated from the practice of acupuncture and that experience attests to the wide range of diseases and conditions that can be effectively treated with this approach. In recognition of the increasing worldwide interest in acupuncture, the World Health Organization conducted a symposium on acupuncture in June 1979 in Beijing, China. Physicians practicing acupuncture in different countries were invited to identify the conditions that might benefit from this therapy. The participants drew up a list of 43 suitable diseases. The World Health Organization published “Acupuncture: Review and Analysis of Reports on Controlled Clinical Trials” in 2002; that report focused on data collected from controlled clinical trials. The participants then expanded the list to 107 suitable diseases [7]. In this article, we review the properties of acupuncture and explain how acupuncture can be used to prevent diseases or to treat patients with diseases; moreover, on a theoretical level, it can be used to enhance robustness, thereby helping an individual to remain healthy.
2. Acupuncture has the ability to regulate robustness The regulatory features of robustness and of acupuncture have many similarities. (1) Robustness enables the system to maintain its functionalities against external and
Y. Xu et al. internal perturbations [8,9]. When the human body is in homeostasis (a stable state), its ability to fight against diseases is much stronger than it is when the body is in an unstable state. Acupuncture regulates the numerous factors that cause internal environments to continuously change. Thus, the ability of acupuncture to regulate robustness indicates that it can be used to promote the human body’s self-regulation so that it can maintain homeostasis. (2) System control is a prominent implementation mechanism of robustness. System control consists of negative and positive feedback to attain a robust dynamic response as observed in a wide range of regulatory networks, including the cell cycle, the circadian clock, and chemotaxis [2]. Acupuncture has a similar bidirectional feedback regulation to maintain homeostasis. Positive feedback contributes to robustness by amplifying the stimulus. However, negative feedback contributes to a reduction in the activity of an overactive system. (3) Redundancy generally refers to a situation in which several identical or similar components/modules can replace one another when one of the components fails [2]. It plays an important role in reducing the influence of internal and external disturbances on the whole system. Acupuncture has the characteristic of regulating multiple pathways. When a pathway is impaired, acupuncture can promote other pathways so that the body’s functions are maintained.
3. Acupuncture regulates robustness under pathological conditions 3.1. Preventing diseases Acupuncture has been used throughout the world. The application of acupuncture is not limited to the treatment of diseases; it also plays a role in the prevention of disease. A recent randomized, controlled trial confirmed the effectiveness of acupuncture in preventing or reducing the risk of certain conditions or diseases, such as uncomplicated recurrent lower urinary tract infections in adult women [10], postoperative nausea and vomiting after gynecological [11] or breast surgery [12], atrial fibrillation (AF) recurrence after electrical cardioversion [13], stroke in patients with traumatic brain injury [14], and emergence agitation in children [15]. As to disease prevention, acupuncture regulates robustness mainly by improving stability in the body. For instance, studies on AF have shown that an autonomic nervous system is present in the heart and always maintains a dynamic balance. An imbalance in the autonomic control mechanisms due to either an increase in vagal or sympathetic neural activity will lead to abnormal cardiac electrophysiology, favoring the initiation and maintenance of AF episodes [16e18]. In Chinese medicine, an obvious correlation exists between the nerve segments of the human meridians and the visceral organs to which they correspond [7]. Thus, acupuncture at PC-6 (Neiguan), HT-7 (Shenmen), and BL-15 (Xinshu) has been shown to have an antiarrhythmic effect through its effect on the autonomic nervous system (Table 1, Fig. 1). Compared with the side-effects of drugs, those of acupuncture are very few, so acupuncture can be regarded
Please cite this article in press as: Xu Y, et al., A New Theory for Acupuncture: Promoting Robust Regulation, Journal of Acupuncture and Meridian Studies (2018), https://doi.org/10.1016/j.jams.2017.11.004
+
MODEL
A New Theory for Acupuncture
3
as a noninvasive treatment. Thus, acupuncture treatment can reduce not only the need for synthetic drugs but also the side-effects accompanying the use of such drugs.
3.2. Treating diseases In terms of disease treatment, the role of acupuncture is reflected mainly in two aspects. First, when homeostasis is disturbed by the internal and/or the external environment, acupuncture can promote the correction of one’s pathological state and encourage normal function. In other words, acupuncture can improve robustness through system control. A piece of evidence supporting this lies in the fact that acupuncture promotes the neuroendocrine immune network. When the human body is invaded by pathogens, it does this by sensing pathogen-associated molecular patterns, proteins, and initial nonspecific cellular and humoral responses. The immune mediators and cytokines that are subsequently released by the innate immune system rapidly activate neural responses, which both amplify local immune responses to clear pathogens and trigger systemic neuroendocrine and regional neural responses that eventually restore homeostasis. This interplay constitutes an important feedback loop [4]. Acupuncture enhances the innate immune regulation in the early stage and the feedback pathway in the late stage to recovery balance. On the other hand, when some of the body’s functions are impaired, acupuncture can promote other functions to compensate for the impaired function. That is, acupuncture can be used to treat patients with diseases because it promotes the redundancy and modularity of robustness. For example, a variety of pathways play a role when acupuncture is used to treat patients with persistent pain. (1) The sympathetic nerve pathway: (i) acupuncture activates sympathetic nerve fibers to enhance the expression of intracellular adhesion molecule-1 in the blood vessels of inflamed tissue to promote migration of b-endorphin and met-encephalin-containing polymorphonuclear leukocytes and mononuclear cells. Furthermore, (ii) acupuncture activates sympathetic neuronederived norepinephrine, which stimulates the adrenergic receptors in inflammatory cells to release bendorphin, leading to a reduction in the level of pain. (2) In the endocrine and immunity pathway, acupuncture activates the hypothalamusepituitaryeadrenal axis to increase plasma corticosterone levels significantly, downregulate cyclooxygenase-2, upregulate endogenous anandamide, and increase the number of endogenous cannabinoid CB2 receptors to upregulate immune cell opioids in inflamed skin tissue while at the same time, decreasing tumor necrosis factor-a, interleukin-1b, and interleukin-6 expressions, thereby reducing the level of pain. Acupuncture has the analgesic effect of modularity pathways. When one of the
Table 1 Acupoint PC-6 HT-7 BL-15
Acupoints and corresponding nerve segments. Nerve segment C8-T1 C8-T2 T5
body’s systems is perturbed, the local area will be affected in such a way as to minimize the effect on the whole system (Fig. 2). Acupuncture can promote cooperation between the sympathetic nervous, endocrine, and other systems, thereby playing a role in promoting the body’s redundancy mechanism. At the same time, acupuncture can promote the modularity of each pathway; when one of the pathways is perturbed and/or impaired, the effect remains local, thus minimizing the effects on the whole system [19]. For example, even in patients with a blockage of the analgesic pathway of the sympathetic nervous system, acupuncture can still play an analgesic role through the endocrine immune pathway [20].
3.3. Rehabilitation Medical rehabilitation aims at redeveloping and restoring the functional and psychological abilities of an individual so that he or she can regain independence and lead an active life [21]. Acupuncture strives to balance the flow of internal energy in the body by inserting fine needles into specific points on the body to regulate the energy channels that affect internal organs, thereby helping patients to become independent and lead active lives [22]. Acupuncture as a way of medical rehabilitation has been used for thousands of years, having been applied mainly to patients who had suffered a stroke [23,24]. Acupuncture may have beneficial effects on reducing dependency, global neurological deficiency, and some specific neurological impairments in patients who have experienced a stroke and are in the convalescent stage, but without any obvious serious adverse effects [25]. The robustness function of acupuncture in the rehabilitation stage of treating patients with diseases can promote homeostasis through organ reconstruction. New research using modern neuroimaging techniques shows that acupuncture can effectively enhance connectivity between the cerebellum and the primary sensorimotor cortex in patients during stable stroke recovery [26]. Acupuncture at GB34(Yang lingquan) may increase motorcognition connectivity while decreasing compensation of the unaffected motor cortex and homolateral synkinesis, which can definitely promote rehabilitation in patients suffering from hemiplegia and spasms [27].
4. Conclusion Robustness is a fundamental property of biological systems. The robustness of the body is related to the complex regulatory systems in vivo. This implies that a methodmotivated robustness perspective might provide new therapeutic approaches. These complex regulatory systems need to be organized into a coherent architecture if they are to be effective in maintaining physiological homeostasis and good health. Acupuncture is a regulatory way of stimulating the complex systems in the body. In the diseaseprevention phase, acupuncture has the ability to enhance self-adjustment to maintain homeostasis in the system. In the disease-treatment phase, acupuncture can promote the correction of a pathological state, improve robustness through system control, and induce the other functions to
Please cite this article in press as: Xu Y, et al., A New Theory for Acupuncture: Promoting Robust Regulation, Journal of Acupuncture and Meridian Studies (2018), https://doi.org/10.1016/j.jams.2017.11.004
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Figure 1
The PC6, HT7, and BL15 acupoints overlap the nerve segments of the heart.
Figure 2 Promoting the robustness function of acupuncture in treating diseases. COX-2 Z cyclooxygenase-2; b-END Z b-endorphin; ICAM Z intracellular adhesion molecule-1; IL-1b Z interleukin-1b; met-ENK Z met-encephalin; PMN Z polymorphonuclear leukocyte; TNF-a Z tumor necrosis factor-a; NEI Z Neuro-endocrine immunity; NE Z Norepinephrine; CB Z Cannabinoid; GC Z Glucocorticoid.
compensate for the damaged function of the body by promoting redundancy and modularity. Lastly, in the diseaserehabilitation phase, acupuncture can promote the reconstruction of homeostasis in an organ after disease. The above roles of acupuncture indicate that acupuncture has the ability to promote robustness and can be used as a therapeutic way to regulate disease. Future acupuncture research should address the promotion of the body’s robustness and explore the mechanisms of acupuncture from the perspective of enhanced robustness.
Funding This study was supported by the National Natural Science Foundation of China (NSFC) No. 81330088.
Disclosure statement The authors declare that they have no conflict of interests.
Please cite this article in press as: Xu Y, et al., A New Theory for Acupuncture: Promoting Robust Regulation, Journal of Acupuncture and Meridian Studies (2018), https://doi.org/10.1016/j.jams.2017.11.004
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A New Theory for Acupuncture
Acknowledgment The authors sincerely thank Emily Huang for her work in polishing the English in the text.
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Please cite this article in press as: Xu Y, et al., A New Theory for Acupuncture: Promoting Robust Regulation, Journal of Acupuncture and Meridian Studies (2018), https://doi.org/10.1016/j.jams.2017.11.004