About 1 million of American patients receive alternative medicine treatment, an estimated 10 millions visits each year. Acupuncture is one of the most popular treatments in the alternative medicine. Acupuncture is thought to have existed in China in one form or another since at least the Xia Dynasty (2,000 to 1,500 BC). It is an important therapy in East Asian medicine used in China, Japan and Korea. It was introduced to the United States during the 19th to 20th centuries. In recent years, with the growth of interest in alternative medicine, acupuncture has become more popular in the United States as a treatment option. Despite the fact that more scientific studies are needed to confirm the efficacy of acupuncture, the National Institutes of Health Consensus Development Panel (NIHCDP) has concluded that acupuncture is effective or may be useful in the following conditions:
Adult postoperative & chemotherapy nausea/vomiting
Postoperative dental pain
Low back pain
Carpal tunnel syndrome
THEORY OF ACUPUNCTURE IN CHINESE MEDICINE
YIN & YANG
QI & BLOOD
ZANG & FU
JING & LOU
From the Chinese perspective, acupuncture is necessarily embedded in a complex theoretical framework that provides conceptual and therapeutic
directions. The theories of yin and yang, five elements (the evolutionary phases of fire, earth, metal, wood, and water), Qi (vital energy) and blood, meridians
(acupuncture channels) and acupoints, provide the most important guidance for acupuncture treatment. These theoretical principles are described below.
The concept of yin and yang is the generalization of the 2 opposite aspects in related objects and phenomena in the natural world. The Chinese believe that all the objects in the universe include the two opposite aspects of Yin and Yang. Yin and Yang theory is among the most important principles underlying the practice of all Chinese medicine, including acupuncture. According to the concepts of Chinese Medicine, disease and pain are the result of imbalance of the Yin and Yang, and acupuncture treatment aims to restore the balance.
The ancient Chinese believed that Qi is the basic substance composing the world, and all that matters in the universe appears by the movements and mutations of Qi.12 The vital energy or life force, Qi is fundamental to the description of nature in Chinese medicine. Chinese medicine describes that Qi is the major force to drive the blood circulating in the vessels. If Qi flows, the blood will move; if Qi stops, the blood will stop. Pain is the result of stasis or blockade of the meridian Qi flow and the subsequent blood stagnation. From a physiologic point of view, this can be explained by local accumulation of noxious stimuli such as lactic acid and prostaglandin E2 generated from the regional metabolism and/or damaged tissues. An acupuncturist
will apply needle stimulation aiming to clean up the blockade or reopen the related meridian by giving an external force to the Qi. After the elimination of a severe blockage of Qi, the smooth flow of local blood circulation will then resume and pain will go away. Western medicine would explain this phenomenon by the clearance of nociceptive chemicals from the vicinity of afferent fibers.
In Chinese medicine, the internal organs are divided into two categories: Zang and Fu. Zang organs include heart, liver, spleen, lung, and kidney. Zang organs function to transform and store the essential Qi. Fu organs include gallbladder, stomach, large intestinal, small intestinal, bladder and triple energizer. Their major function is to digest the food and excrete the waste. Triple energizer is the pathway for circulation of vital Qi and transportation of water and nutrition. It synchronizes functions of most of the major Zang-Fu organs. It should be pointed out that the Zang-Fu organs are morphologically equivalent to the internal organs of the same name in human anatomy. However, the explanation of their physiological and pathological manifestations differs greatly from those of the modern Western medicine. The analysis of Yin and Yang conditions of Zang-Fu organs can be accomplished by a detailed history inquiry, physical exam including pulse palpation and tongue inspection. Interested readers are referred to the relevant textbooks.
The Jing-Lou meridian network consists of major meridians (Jin channels) and minor meridians (Luo collaterals). Jing-Luo meridians
are distributed throughout the body and inside the meridians Qi flows continuously. There are 14 major meridians including 12 “regular” and 2 “curious”
meridians in the body, which are commonly used in acupuncture practice and mentioned in the literature. They are named according to their distributed
organs, including lung, pericardium, heart, large intestine, triple energizer, small intestine, stomach, gallbladder, bladder, spleen, liver, and kidney. The 2
major curious meridians are conception vessel (Renmai) and governor vessel (Dumai), locating at the midline of the head and trunk in the front and back,
respectively. The following lists those meridians and their abbreviations in a system of standard international nomenclature and alphabetic code endorsed by
the World Health Organization (WHO).
Large intestine meridian (LI)
Triple energizer meridian (TE)
Small intestine meridian (SI)
Stomach meridian (ST)
Gallbladder meridian (GB)
Bladder meridian (BL)
Governor vessel (Dumai) (GV)
Lung meridian (LU)
Pericardium meridian (PC)
Heart meridian (HT)
Spleen meridian (SP)
Liver meridian (LR)
Kidney meridian (KI)
Conception vessel (Renmai) (CV)
Acupuncture points are the sites through which the Qi of the organs is transported to the body surface via the above described meridians. The acupuncture points are divided into three categories: acupoints of 14 regular meridians, extraordinary points and Ashi points.
Acupoints of 14 regular meridians are the major components of the acupoint system. One of the examples is Hegu, the fourth point at the large intestinalmeridian. It is commonly used in the treatment of head or orofacial pain.
The extraordinary points are located beyond 14 regular meridians and playspecial roles in management. For instance, Taiyang locates at the temporal region and is the fifth extraordinary head and neck point. It plays an importantrole in migraine treatment.
Ashi points are also called tender points. They do not have specific names and defined locations, and they are highly importantin the diagnosis and treatment of headache and pain.
The theory of Five Elements holds that all the objects and phenomenon in the universe are formed or derived from wood, fire, earth, metal, water. Each element is designated specific characteristics. For example, wood represents objects or phenomenon with bending and straightening nature. There exist creative and controlling interactions among these five elements. The five phase paradigm is an important model of acupuncture widely used in the Western countries including the United States. The meridians and specific acupuncture points are designated in each of these five categories. Based on the designated quality of clinical symptoms and transformational principles of the paradigm, acupuncture treatment is applied.
SCIENTIFIC BASIS OF ACUPUNCTURE
1. Anatomy and physiological characteristics of acupuncture points.
The anatomy of acupuncture points has been studied. They are in the vicinity of the small or large peripheral nerves and their bifurcations, motor points of neuromuscular attachments, blood vessels, ligaments and suture lines of the skull. All the acupuncture points in the face and forehead region were found to locate along terminal or cutaneous branches of the trigeminal nerve and between muscular branches of the facial nerve. A double-blind, placebo-controlled randomized study found true acupoints have higher local temperature and lower electrical resistance, compared to nonacupoints.
2. Mechanism of acupuncture in headache management.
Preliminary experimental evidence support acupuncture analgesic effect on the trigeminocervical complex (TCC). TCC is the major headache locating in the brainstem and upper cervical spinal cord. It consists of trigeminal neucleus caudalis (TNC) and upper cervical dorsal neurons (C1, 2, 3). Most of the acupuncture studies regarding the effect on trigeminal nucleus caudalis have been performed in animal models. Acupuncture appears to be able to inhibit the TNC and the upper cervical neurons directly and indirectly. The action is mediated by several endogenous neuropeptide and neurochemistry, including serotonin, norepinephrine, substance P, endogenous opioid.
3. Mechanism of acupuncture in pain management.
Acupuncture is thought to suppress pain by a) Reducing the production of inflammatory mediators such as prostaglandin E2 and interleukin-1; b) Presynaptically inhibiting the pain transmission in the dorsal horn by the gate control mechanism via the stimulation of A-beta fibers; c) Activating the descending serotonergic and adrenergic pain inhibitory pathways in brainstem; d) Stimulating the endogenous opioid system, especially the release of beta-endorphin.
CLINICAL PRACTICE OF ACUPUNCTURE
1. Treatment principle.
In Chinese medicine as mentioned, acupuncture aims to restore the balance of Yin and Yang, clean the blockade of meridians, and resume the Qi flow. Ultimately, the goal of acupuncture is to reduce the headache frequency and severity through proposed inhibition of the brainstem headache center including trigeminal nucleus caudalis. Ideally acupuncture treatment should be based on diagnostic principles of Chinese medicine.
2. Acupuncture treatment in Headache.
Limited studies have been done to investigate the efficacy of acupuncture in the treatment of different kinds of headache including migraine, tension, and headaches with combined characteristics. Current literature seems to support the use of acupuncture in migraine treatment, whereas there is not enough scientific evidence to evaluate its role in the management of other types of headache. More studies of acupuncture have been done in migraine than any other type of headache. Eleven trials comparing acupuncture and sham acupuncture have recently been reviewed. Majority of these studies favor or are in trend to favor the true acupuncture treatment. The role of acupuncture in tension-type headache is unclear. Limited literature suggests a trend in favor of true over sham acupuncture. Very little information is available on the effect of acupuncture in cluster headache. Scanty of cases reports demonstrated the relief by acupuncture.
3. Acupuncture treatment in pain management.
Acupuncture has been longed used in pain management. Because of large amount of basic and clinical evidences, National Health of Institute has concluded acupuncture is effective or useful in the following pain disorders:
Postoperative dental pain
Low back painCarpal tunnel syndrome
Carpal tunnel syndrome
PROGNOSIS OF ACUPUNCTURE
Relative fewer studies have been done to observe the long-term prognosis of acupuncture in headache and pain management. Some studies suggested acupuncture’s effect may last months to years after the treatment session. It is very common that the patient still need to be treated periodically afterwards, just for maintenance or “turn-up” purpose.
ADVERSE EFFECTS OF ACUPUNCTURE
The incidence of adverse events of acupuncture treatment is around 6-7%, reported a large survey. The most common but less serious side-effects include fainting, nausea, vomiting, bleeding, needling pain, aggravation of symptoms, and aggravation followed by resolution of symptoms. The less common but severe side effects include infection and tissue and organ trauma. Transmission of AIDS and hepatitis were also reported after repeated use of needles. Pneumothorax is the most frequent serious complication in the category of organ trauma.
CONTRAIN-DICATIONS OF ACUPUNCTURE
In general, acupuncture is a safe and noninvasive procedure. There are a few contraindications to the use of acupuncture. Electroacupuncture should not be performed on those with cardiac pacemakers. Acupuncture also should not be given to those with skin and soft tissue infections, bleeding disorders or on anticoagulants. It is not recommended to use in infants.
PREGNANCY & ACUPUNCTURE
Acupuncture can be used to treat nausea and vomiting in early pregnancy, and is considered safe, though there are few data regarding the safety of using acupuncture for headache in pregnant women. LI4 and SP6 are contraindicated for pregnant women. LI4 and SP6 are otherwise commonly used acupoints for headache management. These 2 points may be used to assist induction of labor at term and preparation of first trimester abortion probably due to the effect of supporting cervical ripening at term and increasing cervical dilation in the first trimester. If necessary, other nonpharmacological treatment alternatives including relaxation techniques, biofeedback, and physical therapy can be considered.
CLINICAL VIGNETTES OF ACUPUNCTURE
A 45-year-old Caucasian man presented with 20-year history of bilateral headache, occurring on a daily base. The pain was described as mild to moderate (VAS 3-7) in severity, band-like and pressing. The pain used to build up late of the day and was aggravated by stress. No nausea, vomiting, phonophobia, photophobia and analgesics overuse were reported. Physical exam only revealed tenderness at bilateral temporal regions. His diagnosis was chronic tension-type headache. The headache symptoms and tongue inspection (red and dry body with little coating) was consistent with a diagnosis of deficiency of “kidney essence” (Kidney Yin deficiency) in Chinese medicine. The treatment principle was to re-balance the Yin and Yang. The Yang points of EX-HN 3, bilateral EX-HN5 and LI4 were drained for the relatively excessive Yang. Yin points of bilateral SP6 and KI 3 were tonified to supplement the Yin and essence. During a retention time of 20 minutes, all the needles were either drained or tonified for 10 seconds, with 5 minutes apart. The VAS score went down from 4 to 1 after the treatment. After a total of 8 sessions of acupuncture (two times per week), he was discharged from the clinic with daily pain score 0.
A 40-year old woman presented with a five-year history of low back pain radiating to left posterior thighs, calf, lateral ankle and great toe. MRI of lumbar spine showed left L4,5 and S1 disk herniation. She failed all the conservative treatments including pain medications and physical therapies. She received a surgery one year ago, which relieved the pain and radiating symptoms by 30%. At the time of the visit, she was on temporary disability and her VAS score was constantly 7-10. She had significant limitation of all ranges of back movement, Bending forward would reproduced the shooting symptoms. Sensory exam showed reduction in light touch and pinprick in dermatome of left L4, 5, S1. Motor exam showed weakness on left great toe extension, ankle eversion and plantar flexion. NCV/EMG confirmed the lesion of these nerve roots. A diagnosis of left lumbosacral radiculopathy and failed back syndrome was made. She requested acupuncture treatment. Needles were placed on left BL 23, BL 62, GB 34, GB 40, KI 3, right SP 6 and several trigger points with neutral technique, followed by electrical stimulation for 15 minutes. She was treated 2 times / weeks for 4 weeks and the pain remained at VAS 1-3. She occasionally took naproxen for supplemental pain relief and periodically received acupuncture for “turn-up” or when the pain flared up.
WHAT IS TRADITIONAL CHINESE MEDICINE?
Traditional Chinese Medicine has its origin in ancient Taoist philosophy which views a person as an energy system in which body and mind are unified, each influencing and balancing the other. Unlike allopathic medicine which attempts to isolate and separate a disease from a person, Chinese Medicine emphasizes a holistic approach that treats the whole person. Many people have found Traditional Chinese methods of healing to be excellent tools for maintaining optimum health and preventing illness.
WHAT IS TRADITIONAL CHINESE HERBAL MEDICINE?
Traditional Chinese Herbal Medicine consists of over 6,000 substances derived from plant, animal and mineral sources. The use of these substances can be traced back to 1,000 BC. Over the past 3000+ years, an incredibly rich and powerful herbal medicine system has been created. During this time, classical herbal formulas that are effective for many health concerns have been developed. The herbs are available in the form of herbal teas (decoctions), liquid extracts, tablets, capsules, granules, lotions, creams, salves, or poultices.
WHAT IS THE DIFFERENCE BETWEEN WESTERN HERBS AND CHINESE HERBS?
Western Herbal Medicine tends to use one or two herbs to treat just a specific symptom. A Chinese Herbal formula has as many as 20 different herbs. Te herbs are selected to work synergistically to treat the whole person. Using the Chinese medicine diagnostic system, we are able to assess a persons whole constitution (the health of their whole body) and treat the root (or cause) of a health concern along with a branch (or the symptoms) of a health concern. It is in this way that we are able to treat a person’s whole body and mind, rather than just a symptom.
HOW SAFE ARE CHINESE HERBS?
One of the most appealing qualities of Chinese Herbal Medicine is the low risk of adverse reaction or side effects. Herbal medicine uses all the constituents of the plant, including the cellulose. The herb is naturally balanced, and therefore has minimal side effects.
ARE THERE ANY POTENTIAL INTERACTIONS BETWEEN HERBS AND WESTERN DRUGS?
Generally speaking, herbal medicine is quite safe, but precautions still need to be taken. Some western drug action may be intensified by similar effect of herbs, for example, if herbal formula has blood vitalizing herbs, and patients are taking blood thinning drugs (e.g. Coumadin/Warfarin), it may prevent adequate clotting, it may increase risk of bleeding. Another example, if a patient is taking some cardiac drugs, which often decrease the potassium level, the addition of laxative and diuretic herbs which may also reduce potassium (these types of herbs are often given together for weight loss) may result in adverse cardiac events. So, formulas should be prescribed by a knowledgeable Chinese Medicine Doctor, to avoid the potential interactions.
ARE THERE ANY PRECAUTIONS WHEN USING HERBAL MEDICINE?
Pregnant women should avoid taking any herbal medicine which has not been well studied on the risk of fetus and may cause miscarriage. Patients with liver or kidney function disorder should be cautious in using herbs that may affect the liver and kidney function.
HOW CAN I BE SURE OF THE QUALITY AND PURITY OF THE HERBS I USE?
To be confident that the herbs that you use are of the highest potency, quality, and safety; only use herbs from manufacturers that are Good Manufacturing Practice (GMP) certified by the government. The herb products, including the formulas products and single herbs used in California Headache and Pain Center have been tested in US and European authorized laboratories for toxicity, heavy metal and many other related safety tests.
HOW ARE CHINESE HERBS TAKEN?
Over the course of the past three thousand years, practitioners have developed many ways in which to administer herbal medicine to patients. Matching the appropriate type of herbal preparation to the patient and health concern is one of the most important aspects to good practice.
The most effective method of using herbal medicine is in the form of a decoction or herbal tea. Decoction is the ancient art of cooking herbs in water as a means of concentrating the active ingredients within the plants. (You will find easy to follow cooking instructions with your supply of herbs.) Traditionally, a special glazed clay herb cooker is used but a glass or stainless steel pot will do. The liquid is strained and taken as a tea two or three times a day.
One of the primary advantages of a decoction is that the body rapidly absorbs it; its effects are strong and immediate in addition, it is easy to modify the recipe to customize the treatment of a particular patient. Although herbal teas are strong and powerful, they may have an unpleasant odor and taste that many people find unpalatable. More convenient methods of taking Chinese herbs are available.
These are made by soaking the herbs in a solvent (usually alcohol) to extract the active ingredients, and then heating the liquid to evaporate some of the alcohol. The benefit of a liquid extract is that the bottle is convenient to take with you where ever you go and the recommended dosage is minimal.
Tablets and Capsules:
This is the usual method that Chinese prepared medicines are processed. A combination Chinese herbs is finely ground and rolled into pills or put into capsules. In general, tablets and capsules are absorbed slowly and over a long period of time. The benefit of tablets and capsules is that they are more easily stored and ingested than teas, and are inexpensive.
They are most commonly used for treating chronic disorders, but can also be kept in your medicine cabinet for quick use in acute disorders such as the common cold, indigestion, or mild constipation. Chinese prepared medicines are available over the counter, but they are nevertheless medicines and should be treated as such. It is important to consult with a qualified practitioner of Chinese medicine before taking Chinese prepared medicine.
This is the most modern method of processing herbs. The herbs are boiled until thick syrup remains and then dried. After decoctions, granules are considered to have the highest effectiveness of all the preparations. Granules can retain their potency for long periods of time. They are stronger-acting than most pills, and require less medicine per volume than liquid extracts.
Lotions, Creams, Solves and Poultices:
Lotions, creams, salves and poultices are generally applied to sore or inflamed areas of the body to relieve pain and inflammation. They are traditionally called “hit medicines” because of their origination in the martial arts. Over the past two thousand years, masters of the martial arts have discovered that many herbs have a remarkable effect on the healing process of bruises, cuts and broken bones.
A poultice is prepared by combining powdered herbs with a moistening agent such as honey or egg white. The paste is than spread on muslin or cloth and applied for one to eight hours to the sore or inflamed area of the body.
WHAT IS A CHINESE HERBAL FORMULA?
Individual substances are rarely prescribed alone in Traditional Chinese Medicine. A carefully balanced recipe of several different herbs is specifically tailored for each person’s entire health condition. Each herb is chosen for its own specific functions. In addition, herbs can enhance the strengths and reduce the side effects of each other. The combination of substances in a formula creates a new therapeutic agent that can treat much more effectively and completely than a single substance.
HOW A CHINESE MEDICINE DOCTOR PRESCRIBES HERBAL FORMULAS?
Herb formulas are developed to use each herb to its greatest advantage. By combining different herbs together, we will not only adjust and increase the treatment results, but also reduce or release the side-effects from the other herbs. It also makes it possible to treat complicated diseases at the same time. That’s why few Traditional Chinese Medicine Doctors prescribe only a single herb to treat patients
Formulas are based upon treatment principle, and treatment principle is dependent upon the cause. Because of the different cause of diseases, the herbal formula varies.
A formula is made from typically 10-20 herbs together with appropriate dosage depending on the patient’s condition and the treatment principle. There is a saying, “Prescribe medicine just like a commander in the army.”
In a clinic setting, it is not always appropriate to use the same formula to treat one condition. The doctor usually changes the formula to follow with the change of the patient’s condition, general health and age. First of all, the number of the herbs in the formula can be changed. If the patient’s main complaint doesn’t change, but the secondary complaint changes, the doctor will add some herbs to treat the new complaint, and take out the herbs that were used to treat the primary complaint, which is nonexistent now. In addition, the dosage of each herb in the formula can be changed to follow the changes of the disease. Increase or decrease in one herb’s dosage may change the treatment principle.
For example, if a patient with menstrual cramps also has poor digestion, the first few weeks of formulas may treat both symptoms but focus more on improving digestive function. After digestive symptoms improve, the emphasis of the formula can be shifted to menstrual cramping. The prescription will be modified again as symptoms of cramping begin to disappear. Very few prescriptions should be taken long term without modification, because you are constantly changing.
In thousands of years of experience in Chinese medicine, generation by generation, there are hundreds of excellent classic formulas to be used to treat different diseases. They have proven to be very effective in treating all kinds of conditions. Often we prescribe a formula based on the classic formula, and add or deduct some herbs, adjusting the dosage depending on the patient’s condition.
HOW LONG WILL IT TAKE FOR THE TREATMENTS TO WORK?
Unfortunately, there is no definitive answer to this question. The length of treatments will vary from person to person depending on the conditions being treated, your age and health, and how you respond to herbal medicine. Herbal medicine promotes your health naturally and gradually.
HOW OFTEN SHOULD I BE TREATED?
After the initial consultation, patients may return for follow-up every 1-2 weeks in the first month, then follow up as needed. Herbal formula may be refilled without an appointment, if your condition is stable and the herbal formula works fine. Re-evaluation is needed should your symptoms change. Your Chinese Medicine Doctor will modify the formula accordingly.