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Acupuncture
INJECTION TECHNIQUES: PRINCIPLES AND PRACTICE 1047-9651 195 $0.00
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ACUPUNCTURE History, Clinical Uses, and Proposed Physiology Charles Salzberg, MD, Arnold Miller, RN, a n d L. Kaye Johnson, CADAC
HISTORY
Acupuncture is a traditional form of Chinese medicine that has been in practice for over 3000 years.2051,52 In the ancient Chinese text of the Huang Di Nei Jing Su Wen, the Yellow Emperor's Classic of Internal Medicine Book of Common Questions, acupuncture is traced back more than 2300 years ago.26 However, it was not until the late President Nixon's visit to China in 1972 that acupuncture began to make an impact in the Western Acupuncture involves puncturing the skin with fine needles at vital points in order to achieve a desired beneficial effect. PHILOSOPHY
Acupuncture is imbued with an Eastern philosophy and esoteric concepts' 2Vhat continue to appear foreign to Western culture and elusive to Western thought. Our difficulty in understanding acupuncture and appreciating its philosophy may stem not from the lack of our desire to know, but instead from the concreteness of our own thinking processes. There are inherent difficulties and inadequacies in defining acupuncture through Western terminology. There are challenges to investigating and incorporating acupuncture into the Western health care system. However, there are profound rewards gained through the clinical use of acupuncture, because it works and has proven itself effective over millennia in providing pain relief for those that suffer. 19, 20,
From the North Hawaii Community Hospital, Kamuela, Hawaii (CS); Department of Substance Abuse Services, North Shore University Hospital, Glen Cove, New York (AM); and Advance Treatment Center, Houston, Texas (LKJ)
PHYSICAL MEDICINE AND REHABILITATION CLINICS OF NORTH AMERlCA VOLUME 6 . NUMBER 4 . NOVEMBER 1995
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The first step toward using acupuncture may best be made by attempting to understand its philosophy. Beal1 presented an eloquent description of the philosophy underlying acupuncture. All life patterns are empowered by a life force. The Chinese call this Chi ("chee"). It is the force that exists throughout nature, permeating all living things and cycling through all systems. As the life force, Chi is the cohesion of our mind/body/spirit and is integrated into the myriad aspects of every being. When Chi is flowing, all of life's processes are in operation in a rhythmic and harmonious way. When it is not, it becomes the basis of disease. Chi exists as an abounding energy. It is believed to be tied to motion in a definite path. It is described to flow in our bodies through definitive pathways called meridians. Chi may become stagnant in specific points on meridians or may become deficient in others. The imbalance of the flow of Chi comprises the deepest intrinsic factor in a person's loss of health. Yin-Yang is a description of the characteristics of Chi. SteineF5believed that the Eastern view of Yin-Yang is best depicted by a functional, harmonious interrelationship between complementary opposites, such as male and female. Yin-Yang should not be thought of as a dialectic of antagonists clashing. It is the lively coexistence of all opposite values: joy and sorrow, pleasure and pain, light and dark, birth and death. All experience is by contrast. One is meaningless without the other. Neither aspect is more important than the other. The unity of these two aspects sets Chi energy into continual movement, revolving in a constant, cyclic interplay. TERMS AND DEFINITIONS The following list includes definitions of various terms that appear throughout the article:
-Acupuncture points are the specific locations overlying the skin throughout the body that, when punctured by a fine needle, produce a therapeutic effect. -Teh Chi describes the achieved sensation when an acupuncture needle punctures the skin and is placed successfully, via the correct depth and manual stimulation, into the acupuncture point. -Meridians are specific pathways or channels, without a true anatomical correlate, that function as a conduit for Chi energy. -Chi is an energy or life force that permeates through our bodies. -Electroacupuncture is a technique of stimulating acupuncture needles by passing low-voltage current through the needles. -Auriculotherapy is a technique of acupuncture in which extremely small needles are placed into ear points on the auricle of the ear in order to achieve a therapeutic result. TECHNICAL Acupuncture needles vary in length from 0.5 to 3 in and are made out of disposable stainless steel, gold, silver, nickel, and copper. In classical times they were made out of bone or stone. Some practitioners reuse their needles after sterilization; however, it is simplest and safest to use disposable ones. Generally, the patient's skin is prepared with an alcohol swab. The population at risk to
undergo acupuncture includes those on immunosuppressive therapy, anticoagulation therapy, and hemophiliacs. Additionally, it is also possible to bruise blood vessels. Treatment frequency varies from once to twice a week for 5 to 10 weeks. PROPOSED PHYSIOLOGY
Acupuncture has been a tradition of Chinese medicine for thousands of years. It provides a safe, economical, and often effective approach to pain relief. In the Western culture there is scepticism about its usefulness. Typical research techniques are not easily followed in this regime. Despite these difficulties, a body of information has been collected concerning the possible mechanisms of acupuncture analgesia including humoral factors and the neuropathways responsible for pain transmission. The acupuncture theory is facilitated with knowledge of the functioning of the central nervous system, most importantly, the way in which it relates to the transmission, perception, and inhibition of pain.40Neurotransmitters involved in pain modulation, such as endorphins, serotonin, norepinephrine, and acetylcholine, may play a role in acupuncture-induced analgesia. It has been shown that endorphins inhibit pain and have been implicated as a mediator of the analgesia and some of the systemic effects induced by a c u p ~ n c t u r eSerotonin .~~ has also been postulated to play a role in the acupuncture analgesic effect. A reduction in morphine-induced analgesia parallels decreases in serotonin levels. Restoring serotonin levels with tryptophan has an effect of reestablishing analgesia. There appears to be a significant relationship between serotonin and the endorphins. Catecholamines acting in the spinal cord and brain are also important neurotransmitters in acupuncture analgesia. Alpha-adrenergic stimulants decrease analgesia, whereas B adrenergic stimulants potentiate acupuncture analgesia. The first proof that acupuncture analgesia is mediated by a humoral factor was obtained from the work by Lung et alZ9in cross circulation with animals. In this demonstration, rats were surgically interconnected at the carotid arteries. Conformation was shown by reversing the analgesic effect with the application of naloxone, an opioid-receptor blocking drug. Additionally, the transfer of cerebrospinal fluid (CSF) from one animal receiving acupuncture produced analgesia in a recipient animal. The analgesia produced by acupuncture and that produced by stimulation of neurons of the periaqueductal gray matter are similar in that they both have a prolonged induction and delay recovery period. The stimulation of the periaqueductal gray matter is mediated by endogenous opioid peptides.ls It may be considered that similar humoral factors are responsible for mediating acupuncture analgesia. Two categories for investigating the humoral probability are the use of drugs (for example, naloxone, D-amino acids) that modify opioid action, and the measurement of opioid-peptide concentration in CSF and blood.15 There are several report^^^",^^^ that show that naloxone reduces or eliminates the analgesia produced by manual rotation of acupuncture needles or lowfrequency electroacupuncture in humans with chronic or experimental pain. Further studies conducted on animals showed that microinjection of nalaxone into the periaqueductal gray matter and the hypothalamus eliminated the analgesic effects of acupuncture. This study not only proved that acupuncture analgesia is naloxone reversible but also provided some information regarding which regions of the brain are involved when acupuncture analgesia is occurring.
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It has also been suggested that opioid peptides are released into CSF during acupuncture analgesia. Current research suggests several mechanisms that mediate the analgesic action of acupuncture, including the serotoninergic system for high-frequency electroacupuncture (EAP) and the endorphinergic system for low-frequency EAP. Clement-Jones et a1,9 using highly specific assays, showed that high-frequency EAP released met-enkephalin into the CSF and that lowfrequency electroacupuncture released endorphin. They used a controlled group consisting of 8 people without recurrent pain who did not undergo EAP, and a sample group of 10 people with pain that did receive EAP. Nine milliliters of lumbar CSF was collected via lumbar puncture from both groups, at time zero before ELA and 30 minutes after ELA. The CSF was immediately frozen via contact with dry ice and stored at -20°C until assay. Radioimmunoassay and chromatography were performed on the pooled preacupuncture and postacupuncture CSF. The radioimmunoassay reported that concentrations of B-endorphin and B-lipotrophin in the CSF were so high that it was postulated unlikely to have been derived from plasma by simple diffusion. It seems apparent that the analgesic effects of acupuncture are mediated by the nervous system and are not subject to the vascular or immune ~ y s t e m28. ~ Injection of local anesthetic around the peripheral nerve supplying the acupoint abolishes acupuncture analgesia, and after spinal anesthesia, analgesia is not produced if acupoints in the lower extremities are used. Conversely, experiments on both human beings and animals showed the application of a tourniquet proximal to the acupoint did not reduce the analgesic effect after needling. This shows that the analgesic effect is not transmitted by humoral substances released into the vascular c i r c u l a t i ~ n . ~ ~ The consensus is that in acupuncture analgesia, signals are conveyed along the large myelinated fibers, such as A fibers. Current research is working to clarify the role of the small unmyelinated fibers and the sympathetic nervous system in the transmission of acupuncture analgesia. As additional research continues, there will be a better understanding to explain the analgesic effects of acupuncture.
POINTS AND MERIDIANS
Acupuncture has become a viable treatment in Western medicine specifically because of its analgesic effects. Western science would like to explain the operative aspects based on known biologic systems. Observation of acupuncture suggests the existence of channels or meridians. Bong Han3 postulated a theory based on an anatomical system that is made up of ducts and corpuscles that correspond to the meridians. Beckerz presented a bioelectrical theory involving a physiologic control system that functions in unison with the nervous system, b i t ieparare from it. The word meridian comes from a French translation of the Chinese term jing-luo. Jing means "to go through" or "thread in a fabric"; luo means "something that connects or attaches," or "a net." Meridians are the channels or pathways that carry Chi throughout the body. Chi is a concept fundamental to Chinese medicine with no literal translation. To the Chinese, Chi makes up and defines everything in the universe. Kaptchukzzsuggests the following translation of Chi: "matter on the verge of materializing or energy at the point of materializing," "vital energy."
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Searching Western anatomy for a synonym of Eastern acupuncture includes lymphatic or blood vessels, arteries, and nerves. Many theories have been presented for the morphologic structure of acupuncture points and meridians. Serebo discovered the presence of nerve structures connected with venules and muscles. Bossy' obtained similar results. Bong Han3 claimed that specific corpuscles joined by a system of tubules were in the acupoints. It has been suggested that acupuncture loci are points of lowered electrical resistance. Generally this concept relates to what we know about alternating or direct current externally applied. From a physiologic viewpoint, the acupoint then becomes the point where biological electrical current escapes more easily to the surface. The passage of biological electrical current occurs all over the body as evidenced by the ability to produce electrocardiology, electromyography, and electroencephalography. If acupoints are involved in the passage of electrical activity, a mechanism of biofeedback maintaining homeostasis must develop. Close association of loci with different neural structures has been noted. Gunn et all6 proposed a classification of loci according to their relationship to known neural structures. Foster and Sweenev15 and ToshiZOhave related that acupuncture points or loci do not exist anatomically, but instead are located as important nerve endings and deep pressure receptors. Macroscopic neural structures were located beneath every point except one. Microscopic examination of that point displayed neural fibers under this point as we11.I6 o n e thing chat can be proven to date is that acupuncture points show a greater density of free nerve endings with respect to points on the skin that do not show a reduced electrical resistance. However, the morphological structure of the meridians does not differ from those of the surrounding skin. Bossy' states, "acupuncture may be a phenomenon of propagated sensation along the meridians. This could be a peripheral referred sensation of a volley of nerve impulses following the longitudinal network of interneurons located in the dorsal horn of the spinal cord." Support of this theory can be made by observing the series of primary centers connected by interneurons. This network exists in the gelatinous substance of R01ando.~ It appears, if one looks at all the related systems that reside under an acupoint, that nearly all systems have an input to the effect. These structures, nerve endings, connective tissue, vessels and nerves, tendons and muscles, joints, and periosteum, all suggest a complexity involved with just one acupuncture point and thus with the insertion of one acupuncture needle. In review, several different conclusions might be reached regarding the mitigation of pain with needling of acupuncture points. One conclusion might be that the effect seems strictly correlated with convergence of nerve impulses in the primary centers (that is, interneuronal network of the substantia gelantinosa). JoshiZ0stated that "stimulation of these points generates impulses which are transmitted to the CNS via reflexes both segmental and extrasegmental, utilizing cutaneo-visceral, cutaneo-somatic and somato-visceral pathways." One could also conclude that meridians are a subjective reality, supported by vessels, nerves, connective tissues, and perhaps other structures. The one constant factor is the interrelationship of innervation between all these structures. On the other hand, Bossy concludes that channel organization has no peripheral structural support. Bossy4 rather states, "the spatial sequences of the primary centers seem probably the indispensable primary structure. The propagated sensation along the channels does find its structural support only in the somesthetic area. This, through centers having topical organization, and
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finally, the organization of the somesthetic cortex can explain the different layers of the acupuncture channels."
CLINICAL APPLICATIONS
There certainly are many factors that contribute to the success of acupuncture. However, one point needs emphasis that has been expressed by Rae and who believed that the improved sense of well being derived from acupuncture treatment depended essentially on the fastidiousness with which acupuncture was undertaken and practiced. In all cases a certified acupuncturist must display a high level of confidence in their technique. Even among expert practitioners of acupuncture, however, needling techniques do vary as well as acupuncture loci for identical surgical operation^.^^
Spinal Medicine 30, Acupuncture has shown success with treating chronic back pain.", According to Coan et al, a randomized study on the effects of acupuncture in chronic low back pain (average 9 years) showed clinical improvement. At several weeks and at 40 weeks after treatments, 79% and 58% of patients were improved, respectively, by symptom reduction activity. A significant point made in Coan's article was that this study as well as other successful studies need to include the following: certified acupuncturists, selection of true acupuncture points and not according to tenderness on the skin, and use of more than 10 treatments." Interestingly, the literature is aligned with conflicting views. MacDonald et alToperformed a placebo-controlled randomized study and reported the use of trigger points as being the location of acupuncture needle insertion, thereby disregarding true acupuncture loci. The results, however, indicated a significant improvement of treatment of the trigger points loci compared with a placebo trial. The trigger points were established at the location of severe pain elicited when firm pressure was applied to an abnormally tender muscle region, and did not comment on any radiating referral pattern. The precise insertion of sterile 30-gauge stainless steel needles to a depth of 4 mm into the skin and subcutaneous layers immediately overlying the trigger points avoided penetration into the underlying muscles and fasciae. This study concluded support for superficial placement of acupuncture needles in trigger points through the use of five outcome measures: pain relief after each treatment, pain score reduction, activity pain score reduction, physical sign reduction, and severity and pain area reduction. Additionally, the study documented that this treatment was of greater value than placebo for relief of chronic low back pain.30 Rae and Berry39believed that the beneficial results of acupuncture have previously been dismissed as being caused by autosuggestion. In contrast, Coan et al" have shown, via an acupuncture trial of 30 patients with cervical spine pain, an 80% remission rate as compared with a 33% placebo response rate reported in other pain studies. Additionally, Petrie and Langley3%tated that acupuncture proves superior to placebo even when attempts are made to maximize the effects of placebo through strong verbal suggestions. Case reports also suggest a practical application of acupuncture into the clinical scope of manual medicine. Fisher13presented a case study in the Journal
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of Manipulative and Physiological Therapeutics of a 49-year-old woman with acute low back pain and right lower-extremity radiculopathy. Because the patient was unable to assume a proper position for manipulation because of lumbar paraspinal muscle spasm, electroacupuncture was performed to provide a palliative approach until the patient could be adjusted. The points chosen included BL 60, 40,26,25, and GB 34,30 and two local points on the right side of the lumbosacral junction. Immediately after the above treatment the patient reported a 50% reduction in pain. Over the next 2 days the patient had decreased lumbosacral spasms and was able to be manipulated, again with additional reduction in pain. One conclusion is that merging useful modalities strengthens the clinical outcome. Stimulation of acupuncture needles in the treatment of low back pain incorporates electroacupuncture and other techniques.27,42, 34 S t r a ~ s sused ~~ a technique incorporating a forceful lifting and thrusting combined with highfrequency twirling back and forth. It was believed that twice weekly treatment for 5 weeks usually produces pain relief. Musculoskeletal Medicine
Acupuncture has been reported to be useful in treating various musculoskeletal pains, such as rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, low back pain, fibromyalgia, frozen shoulder, sciatica, and arthritis of the knee and hip.8,12, 20, 49 Additionally, acupuncture has been successful in the treatment of vhantom limb vain.33 Christensen et alRcompleted a long-term study of acupuncture treatment for severe knee osteoarthrosis using a standardized treatment of five needles around the knee and one needle in the ipsilateral hand. The inserted depth was approximately 10 to 15 mm, producing a Teh Chi tingling sensation. During the treatment each needle was stimulated manually for 20 minutes. The outcome of the study illustrated measurable pain reduction and a decrease in analgesic consumption. Acupuncture has been used in physiotherapy and reported to be excellent in treating conditions of frozen shoulder as demonstrated by Ene and Odia.lz The points used were St. 38 or local points around the shoulder. The number of treatments was six, with a 100% cure rate. This study, however, had a number of flaws. It lacked a significant number of patients; only four cases were reported. It did not radiographically illustrate or descriptively define the shoulder condition. Additionally, the remark of 100% cure did not specifically detail the type of outcome parameters that were used. However, Ene and Odia left no doubt of their empirical observation that acupuncture treatment was beneficial to their patients. Headaches
Stemfeld et a14%ttempted to combine Eastern and Western treatment approaches for tension headaches. They chose the bilateral acupuncture point of GB 20 to be injected subcutaneously with 0.15 mg of diclofenac sodium (Voltaren) diluted in 0.5 mL of saline. In their study 90% of the 20 patients responded to the treatment, and 80% claimed to have good to excellent results. The number of treatment sessions were one to four, as compared with nine to ten sessions
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used in traditional acupuncture treatments. Thus, combining Eastern and Western approaches for the treatment of pain complaints may prove beneficial in certain conditions. GB 20 is known as Fengchi, located in the depression between the upper portion of the sternocleidomastoid muscle and the trapezius. The depth of puncture is approximately 0.5 to 0.8 in toward the tip of the nose. Great care must be taken to avoid the incorrect depth or angle of insertion so as to avoid injury to the brain stem. ELECTROACUPUNCTURE
Acupuncture should not be thought of as an archaic system. New applications of acupuncture are being developed, such as auricular therapy and ELA. The use of ELA has been supported in treatment of chronic pain. Peng et aP6 concluded that there were very few controlled studies of the long-term benefits of previous acupuncture treatment. Their study design incorporated the use of ELA and described an alleviation of chronic pain in over 50% of their treated patients. However, their contentions may be construed as inadequate by not expressly defining the duration of long-term benefit. The above study, however, offered significant rationale concerning the long-term benefit of ELA. It was believed that the elevation of endorphin levels because of peripheral nerve stimulation is a transient event. Likewise, the gate control theory of pain proposed by Melzack and Wal131as well as the relation of myofascial trigger points to acupuncture treatment could not explain prolonged or permanent pain relief after a short period of nerve stimulation. Peng et a136stated that the key area that produced long-term benefit was related to improvement in microcirculation, as shown by skin temperature measurements and microcirculation studies, that is, photoelectric plethysmographic sensors and a microcorrelator apparatus. It was further postulated that evidence of increased regional blood flow was responsible for tissue healing by inducing three consecutive changing phases of responses in microcirculatory networks, mainly consisting of arterioles, capillaries, and venules. Phase one is that of vasoconstriction, phase two is that of a quasicontrol, and phase three is that of vasodilation. It is believed that the beneficial effects of acupuncture are associated with the induction and maintenance of vasodilation. Regions of chronic pain typically have poor perfusion. The healing process is lengthened because of inadequate blood supply. Electroacupuncture achieves increased regional circulation and thereby results in prolonged alleviation of chronic pain. AURICULARACUPUNCTURE
Oleson et a135confronted a controversial area of acupuncture: the use of remote sites used to alleviate regional pain complaints. They stated at that time that the "most controversial area was displayed in the principle of ear acupuncture (auriculotherapy), wherein each area on the ear corresponds to a different anatomical portion of the body." These somatotopic points are reportedly consistent from one individual to another. Their study illustrated heightened tenderness and increased electrical conductivity at localized areas of the ear that corresponded to areas of the body where research subjects reported pain. They
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concluded that auricular diagnosis showed an accuracy of 75.2%, and may lend support to the efficacy of auricular therapy in the treatment of pain.35,50 In the last few decades, indwelling needles were introduced for auriculoacutherapy. Previously needles were removed at the end of the acupuncture session. With the needle in situ, it can be stimulated manually by the patient twice or three times a day in order to produce or enhance the desired therapeutic effect. The needles are left in place for varying amounts of time or until they spontaneously are expelled. As with other forms of acupuncture, there are reports that imply impressive results such as that of Umeh.50
Practical Application: Chemical Detoxification
Hippocrates, the father of medicine, believed that physicians have the duty to relieve their patients of pain and suffering. The fear of patient addiction and the masking of symptoms making diagnosis difficult and/or leading to increased trauma to the injury site have been the leading causes of physician reluctance to prescribing adequate chemical pain management.I0 Auricular acupuncture has shown promise. It was reintroduced in the United States in the 1970s for detoxification purposes by Michael 0. Smith, MD, of Lincoln Hospital, New York. Acupuncture is being used on a routine basis in the treatment of drug addiction. In conjunction with Chinese physicians, a five-point auricular acupuncture protocol was developed and a training program for physicians and substance abuse health care providers implemented. Dr Smith also established the National Acupuncture Detoxification Association (NADA).6,41 In treating chemical substance abusers it has become evident that without treating the root causes of addiction, the treatment usually is doomed to fail. Drug treatment facilities are treating increasing numbers of patients who have what has been termed nosocomial addictions. That is, in the course of chemical pain management, they have become addicted to their controlled narcotic analgesic medications. In outpatient opiate detoxification programs that use a protocol of methadone to abstinence, the chemically addicted pain-management patient poses a unique dilemma. As the methadone doses are decreased, there is a return of discomfort. In a population in which patients have been unable to take controlled analgesic medications without abuse, the health care provider is left with few treatment options. Auricular acupuncture offers another treatment modality. It is now being used in conjunction with methadone detoxification and psychotherapy (both group and individual) at hospital substance abuse treatment centers. Auricular acupuncture is quickly becoming an effective adjunct therapy. Using the NADAapproved five-point detoxification protocol, patients have reported decreases in anxiety, insomnia, and drug cravings.41 The human ear has meridians for the entire body.17 It is the least evasive of possible acupuncture sites. It also makes it possible for the acupuncture detoxification specialist to treat multiple patients at the same time, in the same treatment room. At North Shore University Hospital, Department of Substance Abuse services, under the direction of Magnolia Goh, MD, and Michael Gurevich, MD, ongoing research is being undertaken. Methods for addressing pain management and detoxification issues simultaneously are being explored and implemented.
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The root cause of the discomfort can be dealt with equally with the detoxification. The patient is more receptive to both individual and group therapy, because acupuncture does not affect judgment and concentration as chemical means do. Anxiety and depression can be diminished. The patient is returned to a more homeostatic state with better insight into the addictive nature of his or her personality. Pain management is accomplished without the risks of addiction, and the body's own healing process is being maximized. FUTURERESEARCH
Christensen et alRcompiled a noteworthy list of recommendations for future acupuncture research. It was stressed that all reports must clearly specify acupuncture sites, number of sessions, mode of stimulation (electrical/manual), duration and frequency of stimulation, whether Teh-Chi sensations were sought, and point classifications. Additionally, there must be standard measures of assessment with follow-up evaluations to document changes in pain, medication intake, local swelling, and mobility. Lastly, double-blind studies would be best, but difficult, to apply. CONCLUSION
Acupuncture is a traditional form of Chinese medicine that has been in practice for over 3000 years. Its philosophy is eloquent and empowered by life's processes that move in a rhythmic and harmonious way. Additionally, JoshiZ0 stated that "acupuncture is an orderly, comprehensible and clinically efficacious method of treatment that needs further exploration by Western physicians in its areas of potential use." Profoundly, as a modality, acupuncture fits congruently into the fundamental aspects of physical medicine modalities. It is complementary to the physiatrist and other health care practitioners caring for patients presenting with pain complaints. References 1. Beal M: Acupuncture and related treatment modalities. Part 1: Theoretical background. J Nurse Midwifery 37:254-259, 1992 2. Becker RO, Saltine, G: The Body of Electric. New York, Morrow, 1985, pp 233-242 3. Bong Han K: On The Kyungrak System. Pyongyang, DPRK, Foreign Languages Publishing House, 1964 4. Bossy J: Morphological data concerning the acupuncture points and channel network. Acupuncture and Electro-Therapeutics Research 9:79-106, 1984 5. Brody JE: The New York Times, Personal Health, Wednesday March 16, 1994, Sect C National Desk, p 12 6. The Brown University Digest of Addiction Theory and Application August '93. Acupuncture: Overlooked approach that works. (As a treatment of alcohol and drug addiction). Providence, Manisses Communications Group 7. Chiang CY, Znang QC, Khu XL, et al: Scientia Sinica 18:651-658, 1973 8. Christensen BV, Iuhl IU, Vilbek H, et al: Acupuncture treatment of severe knee osteoarthrosis. A long-term study. Acta Anaesthesiol Scand 36:519-525, 1992 9. Clement-Jones V, Lowry PJ, McLoughlin B, et al: Lancet ii:946-948, 1980 10. Coan RM, Wong G, Ku SL, et al: The acupuncture treatment of low back pain: A randomized controlled study. Am J Chin Med 8:181-189, 1980
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11. Coan RM, Wong G, Coan PL: The acupuncture treatment of neck pain: A randomized controlled study. Am J Chin Med 9:326-332, 1981 12. Ene EE, Odia GI: Effect of acupuncture on disorders of musculoskeletal system in Nigerians. Am J Chin Med 11:106-111, 1983 13. Fisher HW: Acute low back pain treated by spinal manipulation and electronic acupuncture. J Manipulative and Physiol Ther 15:199-202, 1992 14. Filshie J, Redman D: Acupuncture and malignant pain problems. Eur J Surg Oncol 11:389-394,1985 15. Foster JM, Sweeney BP: The mechanisms of acupuncture analgesia. Br J Hosp Med 38:308-312,1987 16. Gunn CC, Ditchbum FG, King MH, et al: Acupuncture loci: A proposal for their classification according to their relationship to known neural structures. Am J Chin Med 4:183-195, 1976 17. The healing needles; Acupuncture no longer a mystery to modems (Keeping Ancient Traditions of Chinese Herbal Medicine Alive). Health News & Review, Summer 93, p 41) 18. Hosobuchi Y, Rossier J, Bloom FE, et al: Science 203:279-281, 1979 19. Jagirdar PC: The theory of five elements in acupuncture. Am J Chin Med 17:135138, 1989 20. Joshi YM: Acupuncture-a critical evaluation. J Assoc Physicians India 40:184-189, 1992 21. Junnila SY: Long-term treatment of chronic pain with acupuncture. Part 1. Acupuncture and Electro-Therapeutics Research 1212:23-36, 1987 22. Kaptchuk TJ: The Web That Has No Weaver. New York, Congdon and Weed, 1947, pp 35, 37, 77 23. Kwek MG: A brief history of acupuncture. Aust Fam Physician 151627, 1986 24. Lee Peng CH, Yang MMP, Kok SH, et al: Comparative Medicine East West 6:57-60, 1978 25. Liao SJ: The origin of the five elements in the traditional theorem of acupuncture: A preliminary brief historic enquiry. Acupuncture and Electro-Therapeutics Research 17:7-14, 1992 26. Liao SJ: Acupuncture for low back pain in huang di nei jing su wen. (Yellow Emperor's Classic of Intemal Medicine Book of Common Question.) Acupuncture and Electro-Therapeutics Research 17:249-258, 1992 27. Lu S: Acupuncture treatment of soft tissue injury. J Trad Chin Med 12:228-232, 1992 28. Lu GW, Lian RZ, Xie JQ, et al: Scientia Sinica 22680492, 1979 29. Lung CH, Sun AC, Tsao CJ, et al: Am J Chin Med 2203-205, 1974 30. MacDonald AJ, Macrae KD, Master BR, et al: Superficial acupuncture in the relief of chronic low back pain. Ann R Coll Surg Engl 65:44-46, 1983 30a. Mayer DJ, Price DD, Barber J, et al: Acupuncture analgesia: Evidence for activation of pain inhibitory system as mechanism of action. In Bonica JJ, Albe-Fessard DG (eds): Advances in Pain Research and Therapy, vol 1. New York, Raven Press, 1976, pp 751-754 31. Melzack R, Wall PD: Pain mechanisms: New theory. Science 150:971-979, 1965 32. Melzack R: Myofascial trigger points; relation to acupuncture and mechanisms of pain. Arch Phys Med Rehabil62114-117,1981 33. Monga TN, Jaksic T: Acupuncture in phantom limb pain. Arch Phys Med Rehabil 62:229-231, 1981 34. Nielsen M: Acupuncture and pain in dermatology. Dermatologica 173:143-145, 1986 35. Oleson TD, Kroening RJ, Bresler DE: An experimental evaluation of auricular diagnosis: The somatotopic mapping or musculoskeletal pain at ear acupuncture points. Pain 8:217-229, 1980 36. Peng AT, Behar S, Yue SJ: Long-term therapeutic effects of electro-acupuncture for chronic neck and shoulder pain-a double blind study. Acupuncture and ElectroTherapeutics Research 12:37-44, 1987 38. Petrie JP, Langley GB: Acupuncture in the treatment of chronic cervical pain. A pilot study. Clin Exp Rheumatol 1:333-336, 1983 39. Rae S, Berry H: Acupuncture in neck pain (letter). Br J Rheumatol 26:153, 1987
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39a. Sjolund B, Eriksson M: Electro-acupuncture and endogenous morphines (letter). Lancet 2:1085, 1976 40. Smith FW Jr: Neurophysiologic basis of acupuncture. Probl Vet Med 434-52, 1992 41. Smith 0 , Khan I: An acupuncture programme for the treatment of drug addicted persons, Bull Narc XL:35-41, 1988 42. Song Z: Treatment of 1000 cases of lumbar soft tissue injury with acupuncture plus exercise. J Trad Chin Med 13:19-21, 1993 43. Spoerel WE: Acupuncture analgesia in China. Am J Chin Med 3:359-368, 1975 44. Spoerel WE, Varkey M, Leung CY: Acupuncture in chronic pain. Am J Chin Med 4:267-279, 1976 45. Steiner RP: Acupuncture-cultural perspectives. 2. The Eastern view. Postgrad Med 74:71-78, 1983 46. Stemfeld M, Finkelstein Y, Hai E, et al: Tension headache treated by anti-inflammatory drug injected into GB 20 acupuncture point. Am J Chin Med 14:171-174, 1986 47. Strauss S: Acupuncture therapy in the treatment of chronic head, neck and neck related pain. J Trad Chin Med 5:13-18, 1985 48. Strauss S: Acupuncture for head and neck pain. Aust Fam Physician 16:302-303,1987 49. Thomas D, Collins S, Strauss S: Somatic sympathetic vasomotor changes documented by medical thermographic imaging during acupuncture analgesia. Clin Rheumatol 11:55-59, 1992 50. Umeh B: Ear acupuncture using semi-permanent needles: Acceptability, prospects and problems in Nigeria. Am J Chin Med 1667-70, 1988 51. Wei J: Chinese emperors and acupuncture. J Trad Chin Med 5:140-144, 1985 52. Wong TW, Fung KP: Acupuncture: From needle to laser. Family Pract 8:168-170,1991
Address reprint requests to Charles Salzberg, MD P.O. Box 1150 65-1230 Mamalahoa Highway, Suite D2U Kamuela, HI 96743
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ACUPUNCTURE History, Clinical Uses, and Proposed Physiology Charles Salzberg, MD, Arnold Miller, RN, a n d L. Kaye Johnson, CADAC
HISTORY
Acupuncture is a traditional form of Chinese medicine that has been in practice for over 3000 years.2051,52 In the ancient Chinese text of the Huang Di Nei Jing Su Wen, the Yellow Emperor's Classic of Internal Medicine Book of Common Questions, acupuncture is traced back more than 2300 years ago.26 However, it was not until the late President Nixon's visit to China in 1972 that acupuncture began to make an impact in the Western Acupuncture involves puncturing the skin with fine needles at vital points in order to achieve a desired beneficial effect. PHILOSOPHY
Acupuncture is imbued with an Eastern philosophy and esoteric concepts' 2Vhat continue to appear foreign to Western culture and elusive to Western thought. Our difficulty in understanding acupuncture and appreciating its philosophy may stem not from the lack of our desire to know, but instead from the concreteness of our own thinking processes. There are inherent difficulties and inadequacies in defining acupuncture through Western terminology. There are challenges to investigating and incorporating acupuncture into the Western health care system. However, there are profound rewards gained through the clinical use of acupuncture, because it works and has proven itself effective over millennia in providing pain relief for those that suffer. 19, 20,
From the North Hawaii Community Hospital, Kamuela, Hawaii (CS); Department of Substance Abuse Services, North Shore University Hospital, Glen Cove, New York (AM); and Advance Treatment Center, Houston, Texas (LKJ)
PHYSICAL MEDICINE AND REHABILITATION CLINICS OF NORTH AMERlCA VOLUME 6 . NUMBER 4 . NOVEMBER 1995
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The first step toward using acupuncture may best be made by attempting to understand its philosophy. Beal1 presented an eloquent description of the philosophy underlying acupuncture. All life patterns are empowered by a life force. The Chinese call this Chi ("chee"). It is the force that exists throughout nature, permeating all living things and cycling through all systems. As the life force, Chi is the cohesion of our mind/body/spirit and is integrated into the myriad aspects of every being. When Chi is flowing, all of life's processes are in operation in a rhythmic and harmonious way. When it is not, it becomes the basis of disease. Chi exists as an abounding energy. It is believed to be tied to motion in a definite path. It is described to flow in our bodies through definitive pathways called meridians. Chi may become stagnant in specific points on meridians or may become deficient in others. The imbalance of the flow of Chi comprises the deepest intrinsic factor in a person's loss of health. Yin-Yang is a description of the characteristics of Chi. SteineF5believed that the Eastern view of Yin-Yang is best depicted by a functional, harmonious interrelationship between complementary opposites, such as male and female. Yin-Yang should not be thought of as a dialectic of antagonists clashing. It is the lively coexistence of all opposite values: joy and sorrow, pleasure and pain, light and dark, birth and death. All experience is by contrast. One is meaningless without the other. Neither aspect is more important than the other. The unity of these two aspects sets Chi energy into continual movement, revolving in a constant, cyclic interplay. TERMS AND DEFINITIONS The following list includes definitions of various terms that appear throughout the article:
-Acupuncture points are the specific locations overlying the skin throughout the body that, when punctured by a fine needle, produce a therapeutic effect. -Teh Chi describes the achieved sensation when an acupuncture needle punctures the skin and is placed successfully, via the correct depth and manual stimulation, into the acupuncture point. -Meridians are specific pathways or channels, without a true anatomical correlate, that function as a conduit for Chi energy. -Chi is an energy or life force that permeates through our bodies. -Electroacupuncture is a technique of stimulating acupuncture needles by passing low-voltage current through the needles. -Auriculotherapy is a technique of acupuncture in which extremely small needles are placed into ear points on the auricle of the ear in order to achieve a therapeutic result. TECHNICAL Acupuncture needles vary in length from 0.5 to 3 in and are made out of disposable stainless steel, gold, silver, nickel, and copper. In classical times they were made out of bone or stone. Some practitioners reuse their needles after sterilization; however, it is simplest and safest to use disposable ones. Generally, the patient's skin is prepared with an alcohol swab. The population at risk to
undergo acupuncture includes those on immunosuppressive therapy, anticoagulation therapy, and hemophiliacs. Additionally, it is also possible to bruise blood vessels. Treatment frequency varies from once to twice a week for 5 to 10 weeks. PROPOSED PHYSIOLOGY
Acupuncture has been a tradition of Chinese medicine for thousands of years. It provides a safe, economical, and often effective approach to pain relief. In the Western culture there is scepticism about its usefulness. Typical research techniques are not easily followed in this regime. Despite these difficulties, a body of information has been collected concerning the possible mechanisms of acupuncture analgesia including humoral factors and the neuropathways responsible for pain transmission. The acupuncture theory is facilitated with knowledge of the functioning of the central nervous system, most importantly, the way in which it relates to the transmission, perception, and inhibition of pain.40Neurotransmitters involved in pain modulation, such as endorphins, serotonin, norepinephrine, and acetylcholine, may play a role in acupuncture-induced analgesia. It has been shown that endorphins inhibit pain and have been implicated as a mediator of the analgesia and some of the systemic effects induced by a c u p ~ n c t u r eSerotonin .~~ has also been postulated to play a role in the acupuncture analgesic effect. A reduction in morphine-induced analgesia parallels decreases in serotonin levels. Restoring serotonin levels with tryptophan has an effect of reestablishing analgesia. There appears to be a significant relationship between serotonin and the endorphins. Catecholamines acting in the spinal cord and brain are also important neurotransmitters in acupuncture analgesia. Alpha-adrenergic stimulants decrease analgesia, whereas B adrenergic stimulants potentiate acupuncture analgesia. The first proof that acupuncture analgesia is mediated by a humoral factor was obtained from the work by Lung et alZ9in cross circulation with animals. In this demonstration, rats were surgically interconnected at the carotid arteries. Conformation was shown by reversing the analgesic effect with the application of naloxone, an opioid-receptor blocking drug. Additionally, the transfer of cerebrospinal fluid (CSF) from one animal receiving acupuncture produced analgesia in a recipient animal. The analgesia produced by acupuncture and that produced by stimulation of neurons of the periaqueductal gray matter are similar in that they both have a prolonged induction and delay recovery period. The stimulation of the periaqueductal gray matter is mediated by endogenous opioid peptides.ls It may be considered that similar humoral factors are responsible for mediating acupuncture analgesia. Two categories for investigating the humoral probability are the use of drugs (for example, naloxone, D-amino acids) that modify opioid action, and the measurement of opioid-peptide concentration in CSF and blood.15 There are several report^^^",^^^ that show that naloxone reduces or eliminates the analgesia produced by manual rotation of acupuncture needles or lowfrequency electroacupuncture in humans with chronic or experimental pain. Further studies conducted on animals showed that microinjection of nalaxone into the periaqueductal gray matter and the hypothalamus eliminated the analgesic effects of acupuncture. This study not only proved that acupuncture analgesia is naloxone reversible but also provided some information regarding which regions of the brain are involved when acupuncture analgesia is occurring.
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It has also been suggested that opioid peptides are released into CSF during acupuncture analgesia. Current research suggests several mechanisms that mediate the analgesic action of acupuncture, including the serotoninergic system for high-frequency electroacupuncture (EAP) and the endorphinergic system for low-frequency EAP. Clement-Jones et a1,9 using highly specific assays, showed that high-frequency EAP released met-enkephalin into the CSF and that lowfrequency electroacupuncture released endorphin. They used a controlled group consisting of 8 people without recurrent pain who did not undergo EAP, and a sample group of 10 people with pain that did receive EAP. Nine milliliters of lumbar CSF was collected via lumbar puncture from both groups, at time zero before ELA and 30 minutes after ELA. The CSF was immediately frozen via contact with dry ice and stored at -20°C until assay. Radioimmunoassay and chromatography were performed on the pooled preacupuncture and postacupuncture CSF. The radioimmunoassay reported that concentrations of B-endorphin and B-lipotrophin in the CSF were so high that it was postulated unlikely to have been derived from plasma by simple diffusion. It seems apparent that the analgesic effects of acupuncture are mediated by the nervous system and are not subject to the vascular or immune ~ y s t e m28. ~ Injection of local anesthetic around the peripheral nerve supplying the acupoint abolishes acupuncture analgesia, and after spinal anesthesia, analgesia is not produced if acupoints in the lower extremities are used. Conversely, experiments on both human beings and animals showed the application of a tourniquet proximal to the acupoint did not reduce the analgesic effect after needling. This shows that the analgesic effect is not transmitted by humoral substances released into the vascular c i r c u l a t i ~ n . ~ ~ The consensus is that in acupuncture analgesia, signals are conveyed along the large myelinated fibers, such as A fibers. Current research is working to clarify the role of the small unmyelinated fibers and the sympathetic nervous system in the transmission of acupuncture analgesia. As additional research continues, there will be a better understanding to explain the analgesic effects of acupuncture.
POINTS AND MERIDIANS
Acupuncture has become a viable treatment in Western medicine specifically because of its analgesic effects. Western science would like to explain the operative aspects based on known biologic systems. Observation of acupuncture suggests the existence of channels or meridians. Bong Han3 postulated a theory based on an anatomical system that is made up of ducts and corpuscles that correspond to the meridians. Beckerz presented a bioelectrical theory involving a physiologic control system that functions in unison with the nervous system, b i t ieparare from it. The word meridian comes from a French translation of the Chinese term jing-luo. Jing means "to go through" or "thread in a fabric"; luo means "something that connects or attaches," or "a net." Meridians are the channels or pathways that carry Chi throughout the body. Chi is a concept fundamental to Chinese medicine with no literal translation. To the Chinese, Chi makes up and defines everything in the universe. Kaptchukzzsuggests the following translation of Chi: "matter on the verge of materializing or energy at the point of materializing," "vital energy."
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Searching Western anatomy for a synonym of Eastern acupuncture includes lymphatic or blood vessels, arteries, and nerves. Many theories have been presented for the morphologic structure of acupuncture points and meridians. Serebo discovered the presence of nerve structures connected with venules and muscles. Bossy' obtained similar results. Bong Han3 claimed that specific corpuscles joined by a system of tubules were in the acupoints. It has been suggested that acupuncture loci are points of lowered electrical resistance. Generally this concept relates to what we know about alternating or direct current externally applied. From a physiologic viewpoint, the acupoint then becomes the point where biological electrical current escapes more easily to the surface. The passage of biological electrical current occurs all over the body as evidenced by the ability to produce electrocardiology, electromyography, and electroencephalography. If acupoints are involved in the passage of electrical activity, a mechanism of biofeedback maintaining homeostasis must develop. Close association of loci with different neural structures has been noted. Gunn et all6 proposed a classification of loci according to their relationship to known neural structures. Foster and Sweenev15 and ToshiZOhave related that acupuncture points or loci do not exist anatomically, but instead are located as important nerve endings and deep pressure receptors. Macroscopic neural structures were located beneath every point except one. Microscopic examination of that point displayed neural fibers under this point as we11.I6 o n e thing chat can be proven to date is that acupuncture points show a greater density of free nerve endings with respect to points on the skin that do not show a reduced electrical resistance. However, the morphological structure of the meridians does not differ from those of the surrounding skin. Bossy' states, "acupuncture may be a phenomenon of propagated sensation along the meridians. This could be a peripheral referred sensation of a volley of nerve impulses following the longitudinal network of interneurons located in the dorsal horn of the spinal cord." Support of this theory can be made by observing the series of primary centers connected by interneurons. This network exists in the gelatinous substance of R01ando.~ It appears, if one looks at all the related systems that reside under an acupoint, that nearly all systems have an input to the effect. These structures, nerve endings, connective tissue, vessels and nerves, tendons and muscles, joints, and periosteum, all suggest a complexity involved with just one acupuncture point and thus with the insertion of one acupuncture needle. In review, several different conclusions might be reached regarding the mitigation of pain with needling of acupuncture points. One conclusion might be that the effect seems strictly correlated with convergence of nerve impulses in the primary centers (that is, interneuronal network of the substantia gelantinosa). JoshiZ0stated that "stimulation of these points generates impulses which are transmitted to the CNS via reflexes both segmental and extrasegmental, utilizing cutaneo-visceral, cutaneo-somatic and somato-visceral pathways." One could also conclude that meridians are a subjective reality, supported by vessels, nerves, connective tissues, and perhaps other structures. The one constant factor is the interrelationship of innervation between all these structures. On the other hand, Bossy concludes that channel organization has no peripheral structural support. Bossy4 rather states, "the spatial sequences of the primary centers seem probably the indispensable primary structure. The propagated sensation along the channels does find its structural support only in the somesthetic area. This, through centers having topical organization, and
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finally, the organization of the somesthetic cortex can explain the different layers of the acupuncture channels."
CLINICAL APPLICATIONS
There certainly are many factors that contribute to the success of acupuncture. However, one point needs emphasis that has been expressed by Rae and who believed that the improved sense of well being derived from acupuncture treatment depended essentially on the fastidiousness with which acupuncture was undertaken and practiced. In all cases a certified acupuncturist must display a high level of confidence in their technique. Even among expert practitioners of acupuncture, however, needling techniques do vary as well as acupuncture loci for identical surgical operation^.^^
Spinal Medicine 30, Acupuncture has shown success with treating chronic back pain.", According to Coan et al, a randomized study on the effects of acupuncture in chronic low back pain (average 9 years) showed clinical improvement. At several weeks and at 40 weeks after treatments, 79% and 58% of patients were improved, respectively, by symptom reduction activity. A significant point made in Coan's article was that this study as well as other successful studies need to include the following: certified acupuncturists, selection of true acupuncture points and not according to tenderness on the skin, and use of more than 10 treatments." Interestingly, the literature is aligned with conflicting views. MacDonald et alToperformed a placebo-controlled randomized study and reported the use of trigger points as being the location of acupuncture needle insertion, thereby disregarding true acupuncture loci. The results, however, indicated a significant improvement of treatment of the trigger points loci compared with a placebo trial. The trigger points were established at the location of severe pain elicited when firm pressure was applied to an abnormally tender muscle region, and did not comment on any radiating referral pattern. The precise insertion of sterile 30-gauge stainless steel needles to a depth of 4 mm into the skin and subcutaneous layers immediately overlying the trigger points avoided penetration into the underlying muscles and fasciae. This study concluded support for superficial placement of acupuncture needles in trigger points through the use of five outcome measures: pain relief after each treatment, pain score reduction, activity pain score reduction, physical sign reduction, and severity and pain area reduction. Additionally, the study documented that this treatment was of greater value than placebo for relief of chronic low back pain.30 Rae and Berry39believed that the beneficial results of acupuncture have previously been dismissed as being caused by autosuggestion. In contrast, Coan et al" have shown, via an acupuncture trial of 30 patients with cervical spine pain, an 80% remission rate as compared with a 33% placebo response rate reported in other pain studies. Additionally, Petrie and Langley3%tated that acupuncture proves superior to placebo even when attempts are made to maximize the effects of placebo through strong verbal suggestions. Case reports also suggest a practical application of acupuncture into the clinical scope of manual medicine. Fisher13presented a case study in the Journal
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of Manipulative and Physiological Therapeutics of a 49-year-old woman with acute low back pain and right lower-extremity radiculopathy. Because the patient was unable to assume a proper position for manipulation because of lumbar paraspinal muscle spasm, electroacupuncture was performed to provide a palliative approach until the patient could be adjusted. The points chosen included BL 60, 40,26,25, and GB 34,30 and two local points on the right side of the lumbosacral junction. Immediately after the above treatment the patient reported a 50% reduction in pain. Over the next 2 days the patient had decreased lumbosacral spasms and was able to be manipulated, again with additional reduction in pain. One conclusion is that merging useful modalities strengthens the clinical outcome. Stimulation of acupuncture needles in the treatment of low back pain incorporates electroacupuncture and other techniques.27,42, 34 S t r a ~ s sused ~~ a technique incorporating a forceful lifting and thrusting combined with highfrequency twirling back and forth. It was believed that twice weekly treatment for 5 weeks usually produces pain relief. Musculoskeletal Medicine
Acupuncture has been reported to be useful in treating various musculoskeletal pains, such as rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, low back pain, fibromyalgia, frozen shoulder, sciatica, and arthritis of the knee and hip.8,12, 20, 49 Additionally, acupuncture has been successful in the treatment of vhantom limb vain.33 Christensen et alRcompleted a long-term study of acupuncture treatment for severe knee osteoarthrosis using a standardized treatment of five needles around the knee and one needle in the ipsilateral hand. The inserted depth was approximately 10 to 15 mm, producing a Teh Chi tingling sensation. During the treatment each needle was stimulated manually for 20 minutes. The outcome of the study illustrated measurable pain reduction and a decrease in analgesic consumption. Acupuncture has been used in physiotherapy and reported to be excellent in treating conditions of frozen shoulder as demonstrated by Ene and Odia.lz The points used were St. 38 or local points around the shoulder. The number of treatments was six, with a 100% cure rate. This study, however, had a number of flaws. It lacked a significant number of patients; only four cases were reported. It did not radiographically illustrate or descriptively define the shoulder condition. Additionally, the remark of 100% cure did not specifically detail the type of outcome parameters that were used. However, Ene and Odia left no doubt of their empirical observation that acupuncture treatment was beneficial to their patients. Headaches
Stemfeld et a14%ttempted to combine Eastern and Western treatment approaches for tension headaches. They chose the bilateral acupuncture point of GB 20 to be injected subcutaneously with 0.15 mg of diclofenac sodium (Voltaren) diluted in 0.5 mL of saline. In their study 90% of the 20 patients responded to the treatment, and 80% claimed to have good to excellent results. The number of treatment sessions were one to four, as compared with nine to ten sessions
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used in traditional acupuncture treatments. Thus, combining Eastern and Western approaches for the treatment of pain complaints may prove beneficial in certain conditions. GB 20 is known as Fengchi, located in the depression between the upper portion of the sternocleidomastoid muscle and the trapezius. The depth of puncture is approximately 0.5 to 0.8 in toward the tip of the nose. Great care must be taken to avoid the incorrect depth or angle of insertion so as to avoid injury to the brain stem. ELECTROACUPUNCTURE
Acupuncture should not be thought of as an archaic system. New applications of acupuncture are being developed, such as auricular therapy and ELA. The use of ELA has been supported in treatment of chronic pain. Peng et aP6 concluded that there were very few controlled studies of the long-term benefits of previous acupuncture treatment. Their study design incorporated the use of ELA and described an alleviation of chronic pain in over 50% of their treated patients. However, their contentions may be construed as inadequate by not expressly defining the duration of long-term benefit. The above study, however, offered significant rationale concerning the long-term benefit of ELA. It was believed that the elevation of endorphin levels because of peripheral nerve stimulation is a transient event. Likewise, the gate control theory of pain proposed by Melzack and Wal131as well as the relation of myofascial trigger points to acupuncture treatment could not explain prolonged or permanent pain relief after a short period of nerve stimulation. Peng et a136stated that the key area that produced long-term benefit was related to improvement in microcirculation, as shown by skin temperature measurements and microcirculation studies, that is, photoelectric plethysmographic sensors and a microcorrelator apparatus. It was further postulated that evidence of increased regional blood flow was responsible for tissue healing by inducing three consecutive changing phases of responses in microcirculatory networks, mainly consisting of arterioles, capillaries, and venules. Phase one is that of vasoconstriction, phase two is that of a quasicontrol, and phase three is that of vasodilation. It is believed that the beneficial effects of acupuncture are associated with the induction and maintenance of vasodilation. Regions of chronic pain typically have poor perfusion. The healing process is lengthened because of inadequate blood supply. Electroacupuncture achieves increased regional circulation and thereby results in prolonged alleviation of chronic pain. AURICULARACUPUNCTURE
Oleson et a135confronted a controversial area of acupuncture: the use of remote sites used to alleviate regional pain complaints. They stated at that time that the "most controversial area was displayed in the principle of ear acupuncture (auriculotherapy), wherein each area on the ear corresponds to a different anatomical portion of the body." These somatotopic points are reportedly consistent from one individual to another. Their study illustrated heightened tenderness and increased electrical conductivity at localized areas of the ear that corresponded to areas of the body where research subjects reported pain. They
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concluded that auricular diagnosis showed an accuracy of 75.2%, and may lend support to the efficacy of auricular therapy in the treatment of pain.35,50 In the last few decades, indwelling needles were introduced for auriculoacutherapy. Previously needles were removed at the end of the acupuncture session. With the needle in situ, it can be stimulated manually by the patient twice or three times a day in order to produce or enhance the desired therapeutic effect. The needles are left in place for varying amounts of time or until they spontaneously are expelled. As with other forms of acupuncture, there are reports that imply impressive results such as that of Umeh.50
Practical Application: Chemical Detoxification
Hippocrates, the father of medicine, believed that physicians have the duty to relieve their patients of pain and suffering. The fear of patient addiction and the masking of symptoms making diagnosis difficult and/or leading to increased trauma to the injury site have been the leading causes of physician reluctance to prescribing adequate chemical pain management.I0 Auricular acupuncture has shown promise. It was reintroduced in the United States in the 1970s for detoxification purposes by Michael 0. Smith, MD, of Lincoln Hospital, New York. Acupuncture is being used on a routine basis in the treatment of drug addiction. In conjunction with Chinese physicians, a five-point auricular acupuncture protocol was developed and a training program for physicians and substance abuse health care providers implemented. Dr Smith also established the National Acupuncture Detoxification Association (NADA).6,41 In treating chemical substance abusers it has become evident that without treating the root causes of addiction, the treatment usually is doomed to fail. Drug treatment facilities are treating increasing numbers of patients who have what has been termed nosocomial addictions. That is, in the course of chemical pain management, they have become addicted to their controlled narcotic analgesic medications. In outpatient opiate detoxification programs that use a protocol of methadone to abstinence, the chemically addicted pain-management patient poses a unique dilemma. As the methadone doses are decreased, there is a return of discomfort. In a population in which patients have been unable to take controlled analgesic medications without abuse, the health care provider is left with few treatment options. Auricular acupuncture offers another treatment modality. It is now being used in conjunction with methadone detoxification and psychotherapy (both group and individual) at hospital substance abuse treatment centers. Auricular acupuncture is quickly becoming an effective adjunct therapy. Using the NADAapproved five-point detoxification protocol, patients have reported decreases in anxiety, insomnia, and drug cravings.41 The human ear has meridians for the entire body.17 It is the least evasive of possible acupuncture sites. It also makes it possible for the acupuncture detoxification specialist to treat multiple patients at the same time, in the same treatment room. At North Shore University Hospital, Department of Substance Abuse services, under the direction of Magnolia Goh, MD, and Michael Gurevich, MD, ongoing research is being undertaken. Methods for addressing pain management and detoxification issues simultaneously are being explored and implemented.
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The root cause of the discomfort can be dealt with equally with the detoxification. The patient is more receptive to both individual and group therapy, because acupuncture does not affect judgment and concentration as chemical means do. Anxiety and depression can be diminished. The patient is returned to a more homeostatic state with better insight into the addictive nature of his or her personality. Pain management is accomplished without the risks of addiction, and the body's own healing process is being maximized. FUTURERESEARCH
Christensen et alRcompiled a noteworthy list of recommendations for future acupuncture research. It was stressed that all reports must clearly specify acupuncture sites, number of sessions, mode of stimulation (electrical/manual), duration and frequency of stimulation, whether Teh-Chi sensations were sought, and point classifications. Additionally, there must be standard measures of assessment with follow-up evaluations to document changes in pain, medication intake, local swelling, and mobility. Lastly, double-blind studies would be best, but difficult, to apply. CONCLUSION
Acupuncture is a traditional form of Chinese medicine that has been in practice for over 3000 years. Its philosophy is eloquent and empowered by life's processes that move in a rhythmic and harmonious way. Additionally, JoshiZ0 stated that "acupuncture is an orderly, comprehensible and clinically efficacious method of treatment that needs further exploration by Western physicians in its areas of potential use." Profoundly, as a modality, acupuncture fits congruently into the fundamental aspects of physical medicine modalities. It is complementary to the physiatrist and other health care practitioners caring for patients presenting with pain complaints. References 1. Beal M: Acupuncture and related treatment modalities. Part 1: Theoretical background. J Nurse Midwifery 37:254-259, 1992 2. Becker RO, Saltine, G: The Body of Electric. New York, Morrow, 1985, pp 233-242 3. Bong Han K: On The Kyungrak System. Pyongyang, DPRK, Foreign Languages Publishing House, 1964 4. Bossy J: Morphological data concerning the acupuncture points and channel network. Acupuncture and Electro-Therapeutics Research 9:79-106, 1984 5. Brody JE: The New York Times, Personal Health, Wednesday March 16, 1994, Sect C National Desk, p 12 6. The Brown University Digest of Addiction Theory and Application August '93. Acupuncture: Overlooked approach that works. (As a treatment of alcohol and drug addiction). Providence, Manisses Communications Group 7. Chiang CY, Znang QC, Khu XL, et al: Scientia Sinica 18:651-658, 1973 8. Christensen BV, Iuhl IU, Vilbek H, et al: Acupuncture treatment of severe knee osteoarthrosis. A long-term study. Acta Anaesthesiol Scand 36:519-525, 1992 9. Clement-Jones V, Lowry PJ, McLoughlin B, et al: Lancet ii:946-948, 1980 10. Coan RM, Wong G, Ku SL, et al: The acupuncture treatment of low back pain: A randomized controlled study. Am J Chin Med 8:181-189, 1980
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11. Coan RM, Wong G, Coan PL: The acupuncture treatment of neck pain: A randomized controlled study. Am J Chin Med 9:326-332, 1981 12. Ene EE, Odia GI: Effect of acupuncture on disorders of musculoskeletal system in Nigerians. Am J Chin Med 11:106-111, 1983 13. Fisher HW: Acute low back pain treated by spinal manipulation and electronic acupuncture. J Manipulative and Physiol Ther 15:199-202, 1992 14. Filshie J, Redman D: Acupuncture and malignant pain problems. Eur J Surg Oncol 11:389-394,1985 15. Foster JM, Sweeney BP: The mechanisms of acupuncture analgesia. Br J Hosp Med 38:308-312,1987 16. Gunn CC, Ditchbum FG, King MH, et al: Acupuncture loci: A proposal for their classification according to their relationship to known neural structures. Am J Chin Med 4:183-195, 1976 17. The healing needles; Acupuncture no longer a mystery to modems (Keeping Ancient Traditions of Chinese Herbal Medicine Alive). Health News & Review, Summer 93, p 41) 18. Hosobuchi Y, Rossier J, Bloom FE, et al: Science 203:279-281, 1979 19. Jagirdar PC: The theory of five elements in acupuncture. Am J Chin Med 17:135138, 1989 20. Joshi YM: Acupuncture-a critical evaluation. J Assoc Physicians India 40:184-189, 1992 21. Junnila SY: Long-term treatment of chronic pain with acupuncture. Part 1. Acupuncture and Electro-Therapeutics Research 1212:23-36, 1987 22. Kaptchuk TJ: The Web That Has No Weaver. New York, Congdon and Weed, 1947, pp 35, 37, 77 23. Kwek MG: A brief history of acupuncture. Aust Fam Physician 151627, 1986 24. Lee Peng CH, Yang MMP, Kok SH, et al: Comparative Medicine East West 6:57-60, 1978 25. Liao SJ: The origin of the five elements in the traditional theorem of acupuncture: A preliminary brief historic enquiry. Acupuncture and Electro-Therapeutics Research 17:7-14, 1992 26. Liao SJ: Acupuncture for low back pain in huang di nei jing su wen. (Yellow Emperor's Classic of Intemal Medicine Book of Common Question.) Acupuncture and Electro-Therapeutics Research 17:249-258, 1992 27. Lu S: Acupuncture treatment of soft tissue injury. J Trad Chin Med 12:228-232, 1992 28. Lu GW, Lian RZ, Xie JQ, et al: Scientia Sinica 22680492, 1979 29. Lung CH, Sun AC, Tsao CJ, et al: Am J Chin Med 2203-205, 1974 30. MacDonald AJ, Macrae KD, Master BR, et al: Superficial acupuncture in the relief of chronic low back pain. Ann R Coll Surg Engl 65:44-46, 1983 30a. Mayer DJ, Price DD, Barber J, et al: Acupuncture analgesia: Evidence for activation of pain inhibitory system as mechanism of action. In Bonica JJ, Albe-Fessard DG (eds): Advances in Pain Research and Therapy, vol 1. New York, Raven Press, 1976, pp 751-754 31. Melzack R, Wall PD: Pain mechanisms: New theory. Science 150:971-979, 1965 32. Melzack R: Myofascial trigger points; relation to acupuncture and mechanisms of pain. Arch Phys Med Rehabil62114-117,1981 33. Monga TN, Jaksic T: Acupuncture in phantom limb pain. Arch Phys Med Rehabil 62:229-231, 1981 34. Nielsen M: Acupuncture and pain in dermatology. Dermatologica 173:143-145, 1986 35. Oleson TD, Kroening RJ, Bresler DE: An experimental evaluation of auricular diagnosis: The somatotopic mapping or musculoskeletal pain at ear acupuncture points. Pain 8:217-229, 1980 36. Peng AT, Behar S, Yue SJ: Long-term therapeutic effects of electro-acupuncture for chronic neck and shoulder pain-a double blind study. Acupuncture and ElectroTherapeutics Research 12:37-44, 1987 38. Petrie JP, Langley GB: Acupuncture in the treatment of chronic cervical pain. A pilot study. Clin Exp Rheumatol 1:333-336, 1983 39. Rae S, Berry H: Acupuncture in neck pain (letter). Br J Rheumatol 26:153, 1987
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39a. Sjolund B, Eriksson M: Electro-acupuncture and endogenous morphines (letter). Lancet 2:1085, 1976 40. Smith FW Jr: Neurophysiologic basis of acupuncture. Probl Vet Med 434-52, 1992 41. Smith 0 , Khan I: An acupuncture programme for the treatment of drug addicted persons, Bull Narc XL:35-41, 1988 42. Song Z: Treatment of 1000 cases of lumbar soft tissue injury with acupuncture plus exercise. J Trad Chin Med 13:19-21, 1993 43. Spoerel WE: Acupuncture analgesia in China. Am J Chin Med 3:359-368, 1975 44. Spoerel WE, Varkey M, Leung CY: Acupuncture in chronic pain. Am J Chin Med 4:267-279, 1976 45. Steiner RP: Acupuncture-cultural perspectives. 2. The Eastern view. Postgrad Med 74:71-78, 1983 46. Stemfeld M, Finkelstein Y, Hai E, et al: Tension headache treated by anti-inflammatory drug injected into GB 20 acupuncture point. Am J Chin Med 14:171-174, 1986 47. Strauss S: Acupuncture therapy in the treatment of chronic head, neck and neck related pain. J Trad Chin Med 5:13-18, 1985 48. Strauss S: Acupuncture for head and neck pain. Aust Fam Physician 16:302-303,1987 49. Thomas D, Collins S, Strauss S: Somatic sympathetic vasomotor changes documented by medical thermographic imaging during acupuncture analgesia. Clin Rheumatol 11:55-59, 1992 50. Umeh B: Ear acupuncture using semi-permanent needles: Acceptability, prospects and problems in Nigeria. Am J Chin Med 1667-70, 1988 51. Wei J: Chinese emperors and acupuncture. J Trad Chin Med 5:140-144, 1985 52. Wong TW, Fung KP: Acupuncture: From needle to laser. Family Pract 8:168-170,1991
Address reprint requests to Charles Salzberg, MD P.O. Box 1150 65-1230 Mamalahoa Highway, Suite D2U Kamuela, HI 96743