Western Perspectives

As mentioned in previous weeks, acupuncture has been proven to provide some pain relief, reduction of inflammation, and other minor health benefits. There are few arguments against acupuncturist effectiveness in these areas from Western medicine. However, traditional Chinese medicine (TCM) makes claims as to how and why acupuncture works and these explanations of meridians and Qi flow do not align well with Western medicine. So to resolve this confusion, I sought to explore why acupuncture works from a Western perspective.

Takayama, Watanabe, Kusuyama, Nagase, Seki, Nakazawa, and Yaegashi (2012) found that acupuncture increases blood flow, which has a variety of positive health benefits. Tests were run using various acupressure points and increases in blood flow where seen in the traditionally associated body systems. Acupuncture effected the sympathetic tone in these areas, which caused blood vessels to constrict and dilate, changing blood flow to certain areas.

Acupuncture has been used to manipulate levels of endorphin, epinephrine, norepinephrine, serotonin, and dopamine. The increasing some of these chemicals has strong pain relief effects and can also help combat withdrawal symptoms and decrease addiction cravings (Cabýoglu, Ergene, & Tan, 2006). Various acupuncture sites can act as triggers to manipulate chemical release.

Langevin and Yandow (2002) found an interest correlation between acupuncture points and fascia planes in the body. The fascia planes form a network that closely resembles the meridian lines than are used in acupuncture. Nerves within these planes could explain how the clinical effects of acupuncture work, especially in the case of anti-inflammatory effects.

Other TCM concepts that are needed for acupuncture can also be understood in terms of Western medicine (Cheng, 2013). Most acupuncture points have high concentrations of nerve endings and connective tissue, highlighting the importance of these spots over other points in western medical terms. Qi is often explained in terms of nerve signals or the transportation of neurotransmitters and other chemicals. Even the balance of yin and yang can be seen in terms of Western medicine, as it closely relates to the homeostasis between the sympathetic and parasympathetic nervous systems.

It seems the connection between the mechanics of Western and Eastern medicine is closer than I previously believed. All of the studied effects also work together to improve general health and reduce stress -- two things that alone could account for other claimed benefits of acupuncture. Though acupuncture and its related concepts make up only a small part of TCM, it’s interesting to see how much the two very different systems of medicine align with each other.

Works Cited

Cabýoglu, M. T., Ergene, N., & Tan, U. (2006). The mechanism of acupuncture and clinical applications. Int J Neurosci, 116(2), 115-25.

Cheng, K. J. (2013). Neurobiological Mechanisms of Acupuncture for Some Common Illnesses: A Clinician's Perspective. Journal of Acupuncture and Meridian Studies, 7(3), 105-14.

Langevin, H. M., & Yandow, J. A. (2002). Relationship of acupuncture points and meridians to connective tissue planes. Anat Rec, 269, 257-65.

Takayama, S., Watanabe, M., Kusuyama, H., Nagase, S., Seki, T., Nakazawa, T., & Yaegashi, N. (2012). Evaluation of the Effects of Acupuncture on Blood Flow in Humans with Ultrasound Color Doppler Imaging. Evidence-Based Complementary and Alternative Medicine : eCAM, 2012, 513638. doi:10.1155/2012/513638

 

Effectiveness of Acupuncture

Ever since acupuncture gained popularity in the United States and Europe, there have been countless studies as to its effectiveness (or lack thereof) for treating everything from common aches to cancer. Studies have been performed with various methods and the results have been just as varied. I've spent weeks trying to find articles, but for each I find, there’s another that has results counter to the first. In order to retain any semblance of sanity searching for an unbiased view, I've turned to examining a few meta-analyses instead.

The biggest collection of literature and research is acupuncture for various pain treatments. One of the most cited and largest studies was done by Vickers et al. (2012), which looks into the effectiveness of using acupuncture for chronic pain conditions (specifically back and neck pain, osteoarthritis, chronic headache, and shoulder pain). The meta-analysis was conducted on 29 different randomized controlled trials consisting of 17,922 patients. In all trials, acupuncture showed significantly greater effectiveness over sham acupuncture and other types of controls (though it was noted that sham acupuncture had some effectiveness over no acupuncture -- something to explore on another day). All pain conditions were equally affected.

Madsen, Gøtzsche, Hróbjartsson (2009) conducted a meta-analysis with 13 trials, and though they found some evidence of acupuncture having a "small analgesic effect," they found the data regarding the effectiveness of sham acupuncture (used as a control in many of the trials) to be troublesome. In some of the trials they found sham acupuncture to be greatly effective and in other trials, not effective at all. This brings doubt onto the traditional foundational knowledge behind acupuncture and whether the effect is more physiological or psychological.

A 2014 study conducted by Manyanga, et al. compared traditional acupuncture to sham acupuncture, no treatment, and usual care in a meta-analysis of 12 trials (1763 participants). They found that, though acupuncture seemed to be effective, its effects varied widely between trials. The duration of the effectiveness and magnitude of the effects were not consistent between trials.

Another area that acupuncture has had some success is for smoking cessation. White, Resch, and Ernst (1999) found that while acupuncture was successful for smoking cessation over wait-list controls, it was not superior to sham acupuncture and though various techniques were tried in all the trials, no particular technique was superior. The study made mention that the effects were non-specific and it’s possible they could be related more to motivation than a physiological effect of the acupuncture.

Though most of these studies found that acupuncture was effective, they also found inconsistencies and a curious correlation between sham treatments and effectiveness. I've decided that I'll look further into this link next week.

Works Cited

Madsen, M. V., Gøtzsche, P. C., & Hróbjartsson, A. (2009). Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ, 338.

Manyanga, T., Froese, M., Zarychanski, R., Abou-Setta, A., Friesen, C., Tennenhouse, M., & Shay, B. L. (2014). Pain management with acupuncture in osteoarthritis: a systematic review and meta-analysis. BMC Complementary and Alternative Medicine, 14. doi:10.1186/1472-6882-14-312

Vickers, A. J., Cronin, A. M., Maschino, A. C., Lewith, G., MacPherson, H., Foster, N. E., Linde, K. (2012). Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis. Arch Intern Med, 172(19), 1444-53. doi:10.1001/archinternmed.2012.3654

White, A. R., Resch, K.-L., & Ernst, E. (1999). A meta-analysis of acupuncture techniques for smoking cessation. Tob Control, 8(4), 393--7. doi:10.1136/tc.8.4.393

 

Eastern Perspectives

A page of the Huangdi Nejing

Now that we have reviewed a history of acupuncture, how exactly do the historical texts explain acupuncture and related concepts in traditional Chinese medicine (TCM)? To look into this question, I delved into the Huangdi Neijing (the Suwen and parts of the Lingshu) myself to see what I could unravel from the original text. I by no means am an expert, but translations and notes of the original text have helped me pick out basics of the practice.

Qi is one of the most basic concepts in TCM, yet one of the hardest to translate into a Western equivalent. Though it’s commonly and incorrectly understood to be some type of energy, it’s often used in TCM associated with states of matter. It can be represented in various forms, some seeming to be tangible (such as vital fluids or breath) and others essential as essence of a function. It is the flow and transformation of Qi that is most important in TCM, as the Qi requires balance in form and function and needs to flow equally into, throughout, and from all the body's systems.

As part of the balance, TCM employs the concepts of yin and yang and the five elements. The yin and yang represent balance through dialectic relationship in all things. If the yin is solid, then the yang is fluid and air; if the yin produces then yang is what is filled. Each is in balance and in opposition, but take away one and the other would not exist. Often it is an imbalance in this system of opposition that causes many of the illnesses in TCM: at its very basic level, most ailments are caused by an excess or lack of vital flow, developed through overproduction, underproduction, overfilling, blockage, or environmental effects.

The five Chinese elements also play a role, as Qi flows through the body in various states, each with elemental qualities. Elements must be in balance, so that there is not too much heat, cold, or dampness. Again, it’s a state of equilibrium and balance that is required and if one element becomes overpowering, it manifests in the form of an illness. For example, in the Neijing it states, "When wind and heat have harmed a person, then his nine orifices are shut and blocked. When fog and dampness have caused a disease, then a shade on the eyes obscures vision." There's also a balance between the elements and seasons as well. For example, it’s said in the Neijing that being exposed to the winter's cold causes a warmth disease as your body tries to produce heat for balance (i.e. you get feverish).

TCM also uses a system of organs, though the organs are similar to the ones presented in western medicine, but often their functions are different. For example, the Neijing says that the qi of the kidneys nourishes the bones and keeps the body strong. If the kidneys are weak, a person will grow tired and their bones will become brittle. Each organ is associated with yin or yang and each has an associated element as well. Qi flows through each, being stored, transformed, and transported throughout the body in many forms and for many functions. Each yin organ works with a yang, and each fits within a system of Qi flow. From what I understand, the actual thought behind the way the organs and Qi work are very similar to what we believe in Western medicine. Qi is taken in with food and air through the body (through organs like the lungs), transformed into other forms, and is used inside the body in various ways, and then eventually leaves as waste.

An image showing the channels in the hand

Now the interesting thing I found was that there is no system of meridians mentioned in the Suwen. There is reference to jing mai and lou mai, which are seen as a system of vessels that transport vital fluid within the body (like blood and forms of qi), but their descriptions in the Suwen (along with other types of small vessels) more accurately describe the circulatory system rather than some abstract system of energy flow. There are also some references in the Suwen describing early forms of acupuncture as being more akin to medieval bloodletting practices than modern acupuncture.

I had issues finding a copy of the Lingshu that wasn't completely turned into a modern textbook for acupuncture, but did manage to find partial copies that had been more or less directly translated. From what I saw, the Lingshu was more or less a diagnostic tool for every known illness. Once the cause of an illness was discovered a treatment could begin. For example, some types of fever were seen as both an excess of yang energy causing a heating of the exterior and insufficiency of yin, causing a heating of the interior. The recommended acupuncture points were a series meant to restore yin and cool inside, while causing sweating to release yang energy and cool the body.

Works Cited

The Yellow Emperor's Classic of Medicine. (1995). (M. Ni, Trans.) Boston: Shambhala.

 

Dry Needling, a Origin Story

After reflecting on my previous post about dry needlers, I felt the need to explore the subject further. From the few websites I had scanned in the process of seeing what type of training was available, it seemed like dry needling had been a treatment before acupuncture started gaining ground in the 1970's. I was interested to see if dry needling had evolved from acupuncture, as a western counterpoint to acupuncture, or from somewhere else entirely. As it turns out, it’s the latter.

As noted by Brav and Sigmond (1941), common treatment for various types of pain such as sciatica was to inject an anesthetic solution into the nerve and surrounding tissue. Many different types of solutions had been tried and amazingly, it was observed that just about any substance injected had the same effect. Taking a cue from acupuncture, Brav and Sigmond set up an experiment with three groups of participants: a group that would receive the standard injection of anesthetic novocaine, a ground that would receive an injection of saline, and a group that would have a needle inserted but receive no injection. Though the novocaine group reported the greatest pain relief, the "dry needle" group was close behind in second place.

Other researchers followed up on the experiment, posting their own reports that contained results agreeing with Brav and Sigmond's conclusion (Levine, Gormley, & Fields, 1976; Moral, 2010; Paulett, 1947; Travell & Rinzler, 1952). Though dry needling did not immediately become a mainstream treatment, the research continued to evolve and the practice gained exponential growth in the early 2000's (Legge, 2014). Though it shares much in common with acupuncture (and it has grown by riding piggyback on acupuncture's growing popularity), its practitioners typically use western explanations of nerve and muscular trigger point therapy rather than using terms related to Qi or meridians.

Works Cited

Brav, E. A., & Sigmond, H. (1941). The local and regional injection treatment of low back pain and sciatica. Ann Int Med, 15, 840-52.

Legge, D. (2014). A History of Dry Needling. Journal of Musculoskeletal Pain, 22(3), 301-7. doi:10.3109/10582452.2014.883041

Levine, J., Gormley, J., & Fields, H. (1976). Observations on the analgesic effects of needle puncture. Pain, 2, 149-59.

Moral, O. (2010). Dry needling treatments for myofascial trigger points. Journal of Musculoskeletal Pain, 18, 411-6.

Paulett, J. (1947). Low back pain. Lancet, 2, 272-6.

Travell, J., & Rinzler, S. (1952). The myofascial genesis of pain. Postgrad Med, 11, 425-34.