Scientific Perspectives of Acupuncture and Traditional Chinese Medicine
Dr. Michael L Y Yeung *
Scientific advances in acupuncture research coupled with the side effects of treating chronic pain by conventional drugs have promoted acupuncture usage dramatically by medical doctors in the last two decades. It is estimated that over half a million practitioners outside China administer acupuncture treatment, and have these over 200,000 are physicians (Stux G & Bruce P 1991)
Acupuncture meridians and Traditional Chinese Medicine Theory
Knowledge of Traditional Chinese Medicine (TCM) is all about having a good understanding of the characteristics of the acupuncture system and how it works in a practical sense.
In Traditional Chinese Medicine, the healing effects are based on:
A. The Yin Yang Theory
The Yin -Yang concept (
) is extremely simple, yet very profound. The Yellow Emperor of Internal medicine (Nei Jing Su Wen) states that ' Heaven is an accumulation of Yang, Earth is an accumulation of Yin'. In the human body, the head region belongs to Yang and the feet belong to Yin. The back and dorsal surface of the limbs would be Yang and the ventral surface of the trunk and limbs would be Yin (as viewed as a four footed animal, the back is facing the sun).
Thus a person who had a sudden collapse of Yang ( in Western Medicine, vasovagal shock or hypovolaemic shock ), one can stimulate an acupoint at the top of the head, Governor Vessel 20 (
) which is the most yang point in the body. This helps in the resuscitation as Qi (
), the body energy will be shifted back to the head and neck regions rather than accumulated in the lower part of the body.
In clinical situations one can reduce the problem into Yin or Yang. But Yin and Yang is a relative concept. It is a spectrum from the extreme Yang to extreme Yin. So many a times there would be Yang within Yin or Yin within Yang.
B. The Five Element Theory (
)
The individual organ is assigned to a particular element in nature. For example, the heart is assigned to the Fire Element as it a 'hot' organ. The Five Elements are Fire, Earth, Metal, Water and Wood. For instance Fire is very Yang and Water is very Yin in nature. Earth would be central or neutral. Within each element there are Yin organs and Yang organs forming a partnership.
This partnership of Yin and Yang organs together with the elements they belong form the basis of TCM diagnosis and treatment. For example the Small Intestine also belong to the Fire Element but is Yang partner of the Heart which is Yin.
In addition, certain acupoints in the regular meridians or channels are assigned to different elements as well. These are important energetic points as these can manipulate the Qi flows between organs.
C. Qi, Blood, essence (
) and Body Fluid - the vital substances involved in metabolism
Qi is relatively Yang in character while blood, essence and body fluids are Yin. As matter and energy can be mutually transformed, Qi can be transformed to blood, essence and body fluid and vice versa.
D. The Holographic principle - a part of the body can represent the whole
For example the acupoints in the ear can represent the whole body. Thus ear acupuncture is often an adjuvant method in acupuncture treatment. This applies also to hand, foot, scalp, tongue, or even eye acupuncture.
I would like here to described a case which I have recently come across :
LWL is a 38 years old housewfe complaining of severe left foot and sole pain for 2 months, and unable to bear weight. Also had stretching discomfort of leg and calf and stomach pains (on NSAID and received steroid injections to the sole). Acupuncture performed with no significant improvements.
X-ray of the OPG showed apical radiolucency at tooth no.26 with adjacent involvement of no. 25. Extraction was performed for no.26 with immediate relief of foot symptoms of at least 70 percent and was able to bear weight. Symptoms worsened again 3 days later with infected slough noted at extraction wound. Stitches were removed with irrigation. Symptoms improved again. Finally pain completely subsided (after dental procedure alone!).
The nature of meridians according to TCM :
In the Yellow Emperor of Internal Medicine, Simple Questions stated that 'Following the course of each of the vessels (meridians) there are vital points (365) for acupuncture. These meridians are deeply imbedded in the muscles beneath the skin; at 365 point, however, they emerge to the surface and thus present the points for needling.' These acupoints are found to be electrically active by recent researcher, which will be discussed below.
The meridian is a Qi channel. So when a person dies, all the meridians will vanish. This create a problem to the western doctor as he is taught through anatomy, physiology and biochemistry. In order to understand the nature of the meridian one needs to view the meridian system as an energy channel system in addition to our existing systems of nerves, blood vessels and lymphatics.
The acupoints are usually located near blood vessels, nerves and receptors, lymphatics but not necessary inside these structures (Bensoussan A 1991)
Acupuncture - Paradigms of biomedical action
There is a large number of basic research articles which have appeared in the past twenty years connected with acupuncture. A summary is cited below:
Neurological pathways - 'Gate control'
Acupuncture stimulates nerve fibres (despite the acupoint does not directly lie on the nerve) which send impulses to the spinal cord and activates three centres (spinal cord, mid-brain and hypothalamus-pituitary) to cause analgesia and other effects. The spinal site uses enkephalin and dynorphin to block incoming messages with electrical stimulation at low frequency (<4 Hz) and other transmitters (GABA) with electrical stimulation at high frequencies (>200Hz). The former electrical stimulation would be blocked by naloxone but not the latter.
The midbrain uses enkephalin to activate the raphe descending system, which inhibits spinal cord pain transmission by synergistic effect of the monoamines, serotonin and norepinephrine.
At the third centre, the hypothalamus-pituitary, the pituitary releases B-endorphin into the blood and CSF to cause analgesia at a distance. Also the hypothalamus sends impulses to the midbrain and via B-endorphin activates the descending analgesia system. This third centre can only be activated by low frequency stimulation and not by high frequencies (Stux G, Pomeranz B, 1991; Cheng R et al 1980).
The above findings were discovered during animal experiments. However, it is often applied in clinical practice with effects.
For instance in the treatment of acute wry neck (often the results of muscular strain), one can puncture the point of Luozhen which is located at the ulnar side of the neck of the second metacarpal bone of the hand. The other point is Gall Bladder 39, which is, located 3 inches (Tsun in TCM) above the tip of lateral malleolus of the ankle. The first point is a segmental stimulation in which C6 segment is involved. The second one being non-segmental stimulation would mainly involve the third centre. This explain the delay in the onset of analgesia noted clinically if Gall Bladder 39 is used alone.
The combination of local points, segmental and distal point's stimulation in fact constitutes the most common method of acupuncture analgesia in clinical practice.
Humoral factors
Mayer et al (1977) studying acute laboratory-induced tooth pain in human volunteers, produced acupuncture analgesia by manual twirling of needles in the point Large Intestine 4 (at the summit of the first interosseus muscle of the hand). In a double blind design they gave one group of subjects i.v. naloxone, while another group received i.v. saline. The saline group achieved analgesia with a time-course typical of clinical response (30 minutes to onset of analgesia and effects lasting for over 1 hr).
The naloxone-treated group showed no acupuncture analgesia. Later, Cheng and Pomeranz (1979) produced a dose-response curve for naloxone and found that increasing doses produced increasing blockade.
Bioelectrical properties of acupoints
The discovery of electrical characteristics of acupuncture came about in the 40s. Acupoint finders employed the principle of Ohm's law to measure the electrical resistance or the current flowing across the acupoint with a pre-determined voltage. This led to the development of the more accurate and delicate instruments, which delivered microampere of current into the area to be measured. There is a ten fold increase in electrical resistance (or reduced current) across a non-acupoint region.
Two pioneers in this field were western medical practitioners - Nakatani in Japan and Voll in Germany. Later a number of research workers also appeared in China.
Nakatani discovered there were points in the body showing lowered electrical resistance or increase in current when measured with his 'Neuro-meter'. When he connected these points together they corresponded closely with the Classical Chinese Acupuncture Meridians. He subsequently termed these points to be electrically permeable points (EPPs). This formed the basis of the Ryodoraku Autonomic Nervous System Therapy (Oda H, 1989).
Voll extended the electrical measurement to regions not described in the classical meridians. In addition, he found energetic relationships between individual odontomes and distal organs and structures (Voll R, 1983).
Radio-active tracer studies
Using radioactive tracers, e.g. Technetium-99m, one can compare acupoint injections against non-acupoint injections. The migration speed and patterns of tracer along the pathways were coincide with the Chinese meridians. They are neither vascular nor lymphatic in origin, but related to connective tissues interstitial spaces which would constitute a preferred ionic pathway (Darras et al, 1992; Tiberiu R, Gheorghe G, 1981)
What makes the research in clinical acupuncture so difficult ?
Once a needle is inserted into the body, it would be difficult to carry out a truely double blind study, because placebo analgesia in chronic pain works in 30-35% of patients. Moreover, needling in sham points seems also to work in about 33-50% of cases. Therefore, to show statistical significance in the differences between sham points needling and true acupoint needling requires a fair number of patients - at least 122 per study. It is not easy in clinical practice to achieve such a number (Stux G & Pomeranz B, 1991).
The other major difficulty lies in the fact that acupuncture manipulate 'Qi'. This body energy is very dynamic and can change rapidly due to various factors such as emotions, environmental and weather changes, the types of drugs or herbs used.
One cannot use one set of acupoints throughout the study for instance in treating hypertension. In TCM, there are differentiation of syndromes akin to the differential diagnosis in western Medicine. The pattern of syndromes can change after a period of acupuncture treatment. The double blind study which we often employ in testing drugs therefore cannot be employed in acupuncture. One solution to the above is rather to compare the results of acupuncture treatment as a whole system (instead of the point formulae as many people do), to another modality or placebo or against sham points.
References:
- Bensoussan A (1991) The nature of Meridians. The Vital Meridian. A Modern Exploration of Acupuncture. Ed. Bensoussan A.Churchill Livigstone. 51-71.
- Cheng R., Pomeranz B (1980) A combined treatment with D-amino acids and electroacupuncture produces a greater anaethesia than either treatment alone: naloxone reverse these effects. PAIN, 8:231-236.
- Darras JC, Vernejoue P. Albarede P (1992) Nuclear Medicine and Acupuncture: A Study on the Migration of Radioactive Tracers after Injection at Acupoints. Am J Acup. Vol. 20. 3:245-256.
- Mayer DJ, Price DD, Raffii A (1977) Antagonism of acupuncture analgesia in man by the narcotic antagonist naloxone. Brain Res. 121:368-372.
- Oda H (1989) Electropermeable Points on the Human Skin. Ryodoraku Textbook. Naniwash Publishing Inc. 5-19
- Stux G, Pomeranz B (1991) Acupuncture Analgesia. Basics of Acupuncture. Eds. Stux G & Pomeranz B. Springer-Verlag. 4-51.
- Tiberiu R, Gheorghe G (1981) Do Meridians of Acupuncture Exist ? A Radioactive Tracer Study of the Bladder Meridian. Am J Acup. Vol. 9, 3:251-256.
WWW Links on Acupuncture and Traditional Chinese Medicine:
Those For ..........
Acupuncture, Electro-acupuncture and HealthTouch
WholeHealth Library
Medical Acupuncture - A Journal For Physicians By Physicians
Traditional Chinese Medicine online
Institue for Chinese Medicine, Portland, Oregon
Yin and Yang in Medical Theory
Diagnosis in Chinese Medicine
Chinese Medicine: How it works.
The Anatomy of traditional Chinese Medicine
Hong Kong Society for Traditional Medicine and Natural Product Research
Sciences of Traditiional Chinese Medicine
The American Journal of Chinese Medicine
Qi: The Journal of traditional Eastern Health and Fittness
And Against .........
Acupuncture, Qigong, and "Chinese Medicine"
NCAHF Position Paper on Acupuncture
Is there a scientific basis for Alternative Medicine ?
Alternative Medicine -- The Risks of Untested and Unregulated Remedies -- The New England Journal of Medicine Vol. 339, No. 12, 1998
Review of randomised controlled trials of traditional Chinese medicine -- BMJ
The essence of alternative medicine. A dermatologist's view from Germany
* From a lecture given to the St. Paul's Hospital Doctor's Association.
Dr. Michael L Y Yeung is an Orthopaedic surgeon in private practice who also practises Alternative Medicine. He is a Fellow of the Hong Kong College of Orthopaedic Surgeons.
Views expressed by the author are his personal views and do not represent the views of Academy.