Practice of Acupuncture

Basic Theory of Acupuncture

Scientific Aspects of Acupuncture

Indication and Direction of Action of Acupuncture

Relative Contraindications

Excessive Reactions, Undesired Effects, and Complications

Yin and Yang

Qi

The System of Channels

The Channel Clock

The Five Phases of Transformation

Scientific Aspects of Acupuncture

The following sections mainly deal with four topics. The first sections provide some background information and then describe the requirements for scientific studies in acupuncture. The remaining sections deal with pain and with anatomical correlates of acupuncture points.

Background

Western and Eastern (traditional Chinese) medicine are the only systems of medicine that have become global in the 20th century and have established themselves intensely in other culture areas. This has created some tensions, primarily in the West, prompting more and more scientists oriented toward Western methods to attempt a resolution. Acupuncture (Latin: acus, needle) was mentioned for the first time in 90 BC in the twin biography of the traveling physician Bian Que and the Han physician Chunyu Yi in the classic Shi Ji (The Historical Records) [Unschuld, 1997].

Gold, silver, or steel needles are inserted into empirically defined points where they penetrate the patient's skin to various depths, in order to achieve a therapeutic effect in different organs and functional systems. According to the underlying Eastern philosophy, the needle treatment can be used to influence the movement of life force or energy (qi) in channels (or meridians).

Traditionally, acupuncture was combined with the burning of dried mugwort (moxibustion or moxa)-which is expressed in the originally term, zhen jiu (puncture and burning). Today, other methods of needle stimulation are used in addition to moxibustion, for example, electrostimulation and cupping.

Pain relief through acupuncture was developed in modern China after 1945 under the initial influence of Western medicine. At the end of the 1950s, the French physician Paul Nogier developed the method of auriculotherapy, or ear acupuncture, which is used for both therapy and analgesia.

The cultural background of a therapy may create a fundamental conflict. This problem not only exists for patients (and their expectations) but also for therapists (and their ability to immerse themselves in other cultures and their ways of thinking). Depending on the culture, the approach to both diagnosis and therapeutic procedure may differ considerably due to different schools of thought and previous knowledge, and also due to a therapist's individual way of dealing with patients-which again is influenced by the particular environment. On the other hand, the patient's expectations play a major role. This not only refers to the full spectrum of rejection-doubt-endorsement-conviction, but also to ideas of how the therapist should behave in the eyes of the patient. Furthermore, the patient may have heterogeneous wishes that he or she normally does not communicate. The patient may want to have a Western diagnosis and an Eastern therapy, or an Eastern diagnosis but only an adjuvant therapy. Many different scenarios can be envisioned here. Thus, it is not without problems to transfer a therapeutic method from one culture to another without adapting it. Once it has been transferred, it begins to undergo its own evolution.

Placebo Effect

In 1976, the Western world received its first important impulse for genuine basic research in the field of acupuncture through the hypothesis that the acupuncture effect is mediated by the endorphinergic system [Stux and Pomeranz, 1987]. This system consists of neurons located mainly in the mesencephalon (raphe nuclei and central gray substance). Its analgesic effect is mediated by the release of endorphins (neurotransmitters with a morphine-like action) via the reticulospinal tract. Up until this point, the general view in science had been that placebo effects were the main basis of this therapy [Beecher, 1955]. In other words, the method would only be effective because the persons treated (and their therapists) would firmly believe in it. Furthermore, the effects achieved were partly regarded as nonspecific. However, this view ignored the results of studies involving either animal experiments or acupuncture effects in children, which could not be explained by the classic placebo mechanism. In adults, psychological studies investigating the suggestibility of patients also seemed to indicate that specific effects played an important role.

Rather than making the general assumption that we are dealing with a placebo effect, it is more meaningful to search for an effect in connection with the disease so that the modality can be applied more specifically and, if possible, without acupuncture. For example, there are numerous speculations on better recovery from stroke under the influence of acupuncture. It is not clear, however, whether or not this should be attributed to the fact that the patient receives additional interest and far more attention [Park et al., 2001; Vickers et al., 2002]. Acupuncturists typically spend more time with their patients than conventional physicians. It is important to differentiate between this effect, the aura of Eastern mystique, and the substantial influence of the needle treatment itself. In doing so, it is helpful to distinguish between short-term and long-term treatment, because the success of acupuncture is not always so impressive for long-term treatment.

For a long time, published records of studies on the positive effect of acupuncture were only of illustrative character. The case-study character is quite acceptable when reporting undesired effects. Despite the remarkably extensive database of case studies, however, skepticism towards such material-compared with controlled clinical studies-is valid if the study is supposed to demonstrate the therapeutic effects. While "serious" scientists have regarded the involvement with this subject as obsolete and as an interference with one's career, many practitioners have shown only half-hearted ambition to separate reality from mystique. Meanwhile-at least since there has been noticeable public support-there is a certain stimulus to tackle the subject scientifically and to raise the standards of the basic scientific data. There are only a few Western specialists today who reject acupuncture completely, and this is largely due to the successful alleviation of pain. Only the underlying mechanism of the effect remains a bone of contention. As a consequence of this process, demands that acupuncture should be included in the curriculum of medical students are increasing, and plans have already been put to action at some locations [Rampes et al., 1997]. For the time being, however, this dynamic development carries the considerable risk of self-declared "experts" getting involved in the uncritical and unqualified transfer of knowledge.

Scientific Studies

"Despite intense research nobody has provided any convincing scientific evidence that the channels or the 'flow of energy' do exist" [White, 1998]. So far, research findings of Western standards make it very unlikely that acupuncture acts by treating diseased organs directly. Rather, the influence is indirect, with the brain obviously intervening by means of neuronal and chemical (hormonal) activities. It is especially the connection between brain function and acupuncture that has been ignored by classic Eastern medicine. More recent studies have prepared the ground for a far-reaching conceptual understanding. There is a constant relationship between disease-related acupuncture points and the corresponding brain areas (instead of, or supplementing, the relationships between the indication for acupuncture points and more or less abstract causes). This comes much closer to the Western sense of plausibility than do any Eastern ideas [Cho et al., 1998]. It should be noted in this connection that the results of studies on the effectiveness of a method are often culturally tinted. Interestingly, an increasing number of meta-analyses on the comparability of studies or their scientific quality can be found in the literature, especially for acupuncture. This must be understood as an expression of the attempt to clarify why the Western and Eastern models of explanation are partly incompatible. For example, in 1998, a comparison of studies on the effectiveness of acupuncture in treating nausea and pain showed that the effectiveness is up to 100% in Far-Eastern studies, about 50% in US studies, and less than 20% in European studies.

Apart from extensive case descriptions, there are numerous studies with seemingly sensational results that, in scientific circles, sometimes bring discredit upon the procedure rather than promote it. In these cases, it is worth having a look at the size of patient groups or at the method and its reproducibility prior to accepting the results. Time and again, general statements are spread by certain media only because they have been published-and this has not necessarily been the intention of the authors.

Requirements

Typical weaknesses and errors in the approach of...