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This article on Acupuncture was written by Andy Davidson, MD in 2000 when we practiced together at Petaluma's Hill Park Clinic. Andy wrote this as part of our efforts to integrate acupuncture at Santa Rosa Memorial Hospital. Since 2000, many studies have been published that further support the clinical value of acupuncture, yet the body of this text remains a clear and concise introduction to Acupuncture.
Acupuncture
Acupuncture is a component of the health care system of China that can be traced back for at least 2,500 years. The general theory of acupuncture is based on the premise that there are patterns of energy flow (Qi) through the body that are essential for health. Disruptions of this flow are believed to be responsible for disease. Acupuncture may correct imbalances of flow at identifiable points close to the skin. The practice of acupuncture was rare in the United States until the publication of New York Times' reporter James Reston's landmark 1971 article describing his successful post appendectomy pain management treatment using acupuncture needles. Since then there has been an explosion of interest in using acupuncture to treat pathophysiological conditions.
There are a variety of forms of acupuncture incorporating medical traditions from Korea, China, Japan and more recently Europe. The most studied mechanism involves the insertion of solid needles in various patterns and combinations around the body. These needles may then be enhanced by electrical stimulation, manual stimulation or warming. The pattern or arrangement of needles around the body is important and is designed to address the underlying problem as seen through the oriental model.
This model of health describes a philosophy of man functioning harmoniously within an orderly universe. The models of health, disease and treatment are presented in terms of patients' harmony or disharmony within this larger order. This involves their responses to external extremes of wind, heat, damp, dryness and cold as well as to internal extremes of anger, excitement, worry, sadness and fear. Heat, for example, produces fever. Damp may produce a state of phlegm production. When combined these two influences can lead to a febrile bronchitis. Other factors include an imbalance between Yin (interior, cold, deficient) and Yang (exterior, hot, excessive). Organ functions include not only their conventional biomedical physiology but also energetic and metaphorical qualities (e.g. Kidney supervises bones, marrow, joints, hearing, head hair, will and motivation).
The central issue from the classical Chinese medical point of view is not why acupuncture works, but rather how and when to use it. The dynamic balance that Chinese medicine equates with health manifests as smooth and constant movement. When Qi and blood stagnate, the processes of elimination and regeneration deteriorate, constituting the basic condition underlying many forms of illness.
This model is accessed through a series of energy flow pathways that traverse the body called meridians. These meridians frequently run in the clefts between muscle groups containing fascial layers and neurovascular bundles. Thin, solid, sterile, stainless-steel needles enter the channels, activating or inhibiting the flow of Qi and Blood. Fourteen major pathways traverse the body from the top of the head to the tips of the fingers and toes. Many principal acupuncture points are located below the elbow and knee-where the Qi changes its polarity from Yin to Yang and gathers force as it moves from the extremities toward the core. By eliminating congestion and activating circulation of Qi, acupuncture interrupts and disorganizes patterns of illness.
Pain is also considered to be the result of congested Qi, Blood or Moisture. Obstruction of the flow of energy or blood through the principal meridians manifests as musculoskeletal pain in the territory of the channel (eg, the Bladder principal meridian passes through the lower back; lumbar pain reflects an obstruction of qi and blood flow through that channel).
A more western model of acupuncture incorporates the modern understanding of neuroanatomy into the classical Chinese model. Needles are placed in muscular trigger points or motor points of muscles to cause lengthening of the muscle and reduction of pain. Or they are placed in a segmental pattern along the spine to correspond with radicular symptoms of the extremities. Knowledge of dermatomal, myotomal, sclerotomal and autonomic innervation patterns is essential.
The great preponderance of clinical experience and research says that acupuncture clearly works. How often it works, how it works, and how to best study acupuncture are difficult questions. Measured effects occurring during acupuncture treatments on human and animal subjects include the following:
- Increase in endogenous opioid and monoamine systems
- Increase in plasma concentrates of PGE2 after successful acupuncture surgical analgesia
- Vasodilatation, rise in skin temperature
- Elevated blood cortisol levels
- Decrease in TG, cholesterol and phospholipids
- Increased phagocytic and fibrinolytic activity; increased beta-globulins and complement; impairment of leukocyte adherence to vascular cells
- Decrease in blood pressure
Likely mechanisms for its effects include nerve conduction, circulation, the lymphatic system, electromagnetic flow through fascial planes and interstitial fluid. Electric current has been measured along meridians not overlying single nerve trunks or muscle groups.
Applying contemporary research standards, there is little high-quality research assessing the efficacy of acupuncture compared with placebo sham acupuncture. This is because it is very difficult to use sham acupuncture points as they will often produce some intermediate clinical benefit between that of real acupuncture and placebo.
The NIH Office of Complementary and Alternative Medicine (CAM) selected studies considered to have sufficient data and divided them into two groups:
- Acupuncture compared with sham acupuncture or placebo
- Acupuncture compared with other interventions or no interventions
In the view of the NIH, both animal and human laboratory and clinical experience suggest that the majority of subjects respond to acupuncture, with a minority not responding. Acupuncture compared with sham acupuncture or placebo: There is clear evidence that needle acupuncture is efficacious for adult postoperative and chemotherapy nausea and vomiting and probably for the nausea of pregnancy and for postoperative dental pain. There are reasonable studies showing relief of pain with acupuncture on diverse pain conditions such as menstrual cramps, tennis elbow, myofascial pain and fibromyalgia.
Acupuncture compared with other interventions or no interventions:
Acupuncture is a reasonable option for postoperative pain, back pain. Positive clinical trials exist for addiction, stroke rehabilitation, carpal tunnel syndrome, osteoarthritis and headache. Acupuncture treatment for other conditions such as asthma or addiction should be part of a comprehensive management program. The World Health Organization lists over 40 conditions that may benefit from the use of acupuncture.
Adverse effects:
The NIH CAM found that one of the advantages of acupuncture is that the incidence of adverse effects is substantially lower than that of many drugs or other accepted medical procedures use for the same conditions. As an example, NSAIDS and cortisone injections are widely used for musculoskeletal inflammatory conditions with potential for deleterious side effects. Acupuncture has similar success rates with these conditions without adverse effects.
Side effects are unusual and include:
Soreness of muscles needled for several days (most common)
Dizziness
Contact dermatitis to the metal in the needle
Hematoma
Pneumothorax, hemothorax, pneumoperitoneum, bladder perforation have been reported
Local inflammation and bacterial abscess
National Institutes of Health, Office of Complementary and Alternative Medicine Consensus Statement on Acupuncture:
Published November 3, 1997
Acupuncture as a therapeutic intervention is widely practiced in the United States. While there have been many studies of its potential usefulness, many of these studies provide equivocal results because of design, sample size, and other factors. The issue is further complicated by inherent difficulties in the use of appropriate controls, such as placebos and sham acupuncture groups. However, promising results have emerged, for example, showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and in postoperative dental pain. There are other situations such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma, in which acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program. Further research is likely to uncover additional areas where acupuncture interventions will be useful.
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