DECEMBER 1979 P H Y S I O T H E R A P Y 97 ACUPUNCTURE — AN INVESTIGATION H . C. W A TT S, M .C .S.P., O.N.C.* ABSTRACT A survey has been m ade o f som e o f the vast q u antity o f literature currently available, and an a tte m p t is m ade to explain acupuncture in term s o f anatom y, p h ysio ­ logy, em bryology and psychology. C ond itions fo r w hich it is claim ed to be effective are discussed, and the possible adoption o f its practice by physiotherapists is advanced. A reas w here investigation and research to this end m ight pro fita b ly be undertaken are indicated. INTRO DU CTIO N . In the last few years acupuncture has aroused a great Ile a l of interest and controversy. O pinions ran g e from xmtright debunking to m edical confirm ation of its effi­ cacy (D ontigny, 1972; E lm endorf, 1972; P opkin, 1972; T aub, 1972; F ritsch, 1973; K opelm an, 1973). T h e nam e is derived from th e L atin acus = needle,, p u n tu ra = puncture. A rm strong (1972) has defined it as “ a m ethod o f diagnosing an d treating disease by inserting m etal needles into the body at designated locations — acu­ pu n ctu re points — at various depths an d angles.” I t is a very old science: the earliest know n needles w ere m ade of flint in the neolithic age. O thers, m ade o f bronze, silver and gold, and dating back to ± 7000 BC have been found (V eith, 1972). T h e m od ern injection is a developm ent o f a cu p u n ctu re (O m ura, 1975). A cu pun c­ ture was given new im petus in C hina afte r the C ultural R evolution o f 1949, an d is currently attractin g m uch atten tio n w ith increasingly m ore research being u n d e r­ taken to establish th e validity of its claims. PHILOSOPHY W estern science and philosophy are based on a dualistic concept of the universe, first o u tlin ed by A ris­ totle, in which m aterial and non-m aterial (e.g. mind and body) are entirely separate. O nly com paratively recently has it begun to tend tow ards the E astern m onistic con­ cept. T his is th a t there is no division, and th a t they are ^ i e two poles of an indivisible whole, e.g. lig h t/d a rk ; ^ l i n d / b o d y ; positive/negative (M ann, 1973). T he philosophy behind acupuncture, briefly, is th at the positive and negative elem ents Y in and Y ang are in b alance in the norm al healthy body, an d assist the vital elem ent Qi to circulate via twelve paired m eridians. These run the length o f the body from h ead or up p er th o rax to toes or fingers, and are each associated with an organ. Im b alan ce o f Y in and Y ang causes disorder and disease. By needling points along th e m eridians according to several com plex laws, the acu p u n ctu rist m anipulates the im balance in the m eridian concerned, and thus influences the flow o f Qi to th e organ in question. If, fo r exam ple, an over-active liver has been diagnosed, the flow of Qi in the liver m eridian w ould be reduced, and th e liver thus sedated. Sim ilarly, an organ can be stim ulated, o r tonified (M ann, 1973, 1974). A C U PU N C T U R E POINTS A N D M E R ID IA N S A pproxim ately 1 000 acu p u n ctu re points are described (M ann, 197.4), distributed along the course o f th e m eri- * Senior Physiotherapist, C onradie H ospital, Pinelands, Cape. OPSOM M ING ’n Oorsig van ’n gedeelte van die groot hoeveelheid literatuur wat tans beskikbaar is, is gem aak en ’n poging aangewend om a ku p u n ktu u r te verklaar in terme van ana- tom ie, fisiologie, em briologie en psigologie. T oestande waar op effe k tie w e behandeling aanspraak gem aak word, word bespreek en die m oontlike aanvaarding van die beginsels deur fisioterapie w ord geopper. A reas waar ondersoek en navorsing ten doel hiervan voordelig onder- neem m ag w ord, w ord aangedui. dians. T hey are sm all areas, ab o u t 2,5 mm in diam eter. In certain pathological conditions they becom e tender. M any correspond to n eu rom u scular junctions, o r w here vessels and nerves are superficial. T hey are often found betw een m uscle and bo n e (M ann, 1973). They have been found to be electroperm eable (Arm strong, 1972; M atsum oto, 1972) and have been photographed (A rm ­ strong, 1972; O m ura, 1975). T hey frequently correspond to “ trigger points” , and it has been found th at the k n o ck-out points of judo are acupuncture points, which, if stim ulated too strongly, w ould cause the subject to fain t (M ann, 1973). T hey have been found to contain a high density o f pressure receptors (M cLeod, et al., 1974). N eedling non-acupuncture points will not produce th e sam e results as needling acupuncture points (Veith, 1972). T h e m eridians do not accurately follow any know n nerve, blood or lym phatic channels, though it is stated th at im p o rtan t bundles of autonom ic fibres run along these lines (M atsum oto, 1972; V eith, 1972; M ann, 1973). T here appears to be little evidence to support this claim. C u rren t n e u ro n al theories do not altogether explain the sensation of pain o r hyperalgesia in areas of skin distant from th e S D i n a l segm ents innervating the affected organ (M elzack & W all, 1965; M ann, 1972; W all, 1972; Win- stein, 1974). Several experim ents are described which suggest the existence of m eridians (M ann, 1973; W instein, 1974), b u t it is felt th a t a lot m o re research is needed (M atsum oto. 1972; V eith, 1972). A very elaborate experi­ m ent is described in w hich radio isotopes were injected into acupuncture p oints and traced along the m eridian to the organ concerned (W heaton, 1972). N o o ther reference to this experim ent could be traced, however. A N A fO M Y R ecent investigations by M ann (1977) indicate th a t acu p u n ctu re alm ost certainly w orks through th e a u to n o ­ mic nervous system. M an y o f the effects can be explained via the cutaneo-visceral, viscero-cutaneous, viscero­ m otor and viscero-visceral reflexes. Intrasegm ental effects can be explained by th e short reflexes of Sherrington, while intersegm ental reflexes can frequently be accounted for by his long reflexes, and possibly by the concept of convergence of neurones. A distance of up to ten derm a­ tom es has been noted. . , T h e concept o f m eridians is open to doubt .as it nas been noted th at reflex tenderness associated w ith disorder of the lower six organs m ay appear anyw here on the legs, an d m ay not necessarily follow their traditional m eridinal courses. H ow ever, c o n n e c t i o n s betw ee the organs and som e of their known, effeet've acupu cture points, especially on the face, are still obscur , m eridians illustrate, in an alm ost abstract m anner, p re ­ sum ed neural pathw ays which are as yet unkno R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 98 A cu puncture points are now th o u g h t to b e th e sm all fibrositic nodules one frequ ently finds in the “ rh e u m a tic ” back, neck and shoulders. W hen they are stim ulated the response is n orm ally g reater th an when the surrounding less ten d er tissues are needled. It has been fo u n d th a t diseased organs re a c t very readily to stim ulus, and th a t the sm all stim ulus of a needle via the cutaneo-visceral reflex is sufficient to elicit a response. H e alth y organs require fa r greater stim ulus. N eedling o f any tissue layer anyw here w ithin the segm ent has been found to be effective, thus throw ing do u b t on th e trad itio n al concept of acu p u n ctu re points. Is th ere a connection betw een th e points containing high densities o f pressure receptors and “fibrositic no d u les” ? (M cL eod et al., 1974). PHYSIOLOGY I t has been established th a t a cu p u n ctu re raises the pain threshold, and th a t effects occur as high as the thalam us and reticu lar fo rm ation (M cLeod, e t al., 1974). E xperim ents on rats have show n th e d orso-lateral area o f the m id b rain central grey m a tte r to b e connected w ith pain. U n d er electrical stim u latio n o f this area abdom inal surgery could be p erform ed w ithout distress, although the anim als were fully conscious and m obile, and reacted n orm ally to all o th er stim uli (Reynolds, 1969). A sim ilar effect was noted fro m stim ulation of the brainstem (M ayer, et al., 1971). T he principle of co u n ter-irritatio n is w ell-known. Sim ilar effects have been noted w hen th e dorsal colum ns of the spinal cord are electrically stim ulated (M ann, 1977). EM BRYOLOGY I f a n em bryological basis fo r n eu ral connections along th e longitudinal course of the m erid ian exists, then they w ould m ost logically be established im m ediately after the developm ent of th e in traem bryonic m esoderm , and p rio r to segm entation. A t this stage all cells are pluri- p o ten t and could develop into any o f th e ir derivatives. D ifferentiation is d ependent on com plex biochem ical in teractio n (G ray ’s A natom y, 1973). It is only assum ed th a t segm entation of the interm ediate and lateral plates occurs (ibid.). V arious experim ents h av e b een described w hich indicate th a t developm ent along longitudinal lines is possible (ibid.; C assim an, et al., 1974;-, M cM ahon, PSYCHOLOGY As in all form s of treatm ent, acu p u n ctu re has varying success, tied up w ith the psychological m ake-up o f the patient. I t is less effective when he is apprehensive (Bonica, 1974; M cL eod, et al., 1974) and experim ents on anim als a n d children discount th e possibility of hypnosis (A rm strong, 1972; V eith, 1972; M cL eod, et al., 1974). I t is felt th a t E astern p atien ts respond m ore readily as it is p a rt of th eir trad itio n and cu ltu ral back ­ g round (Wall, 1972; B onica, 1974), b u t notable results have been observed am ong W estern-trained doctors who are less op en to such suggestion (Brown, 1972; E lm en- dorf, 1972; W all, 1972; O m ura, 1975). A cupuncture anaesthesia in em ergency surgery usually fails, possibly because th alam ic units in a High state o f excitability are less susceptible to th e inhibitory effects o f acupunc­ tu re (M cLeod, e t al., 1974). T h e concept of strong physiological reactors has been p u t forw ard by M an n (1977), such people being m ore likely to respond to treatm en t than th e ir less reactive cousins. DESEMBER 1979 C O NDITIO NS A FFE C T E D BY A C U PU N C T U R E A cu puncture has been claim ed to be effective in a wide spectrum of conditions b u t investigation has re­ vealed little statistical evidence to su p p o rt these claims, a n d o th er form s of th erap y which could them selves have produced the results claim ed have often been com ­ bined with acu p u n ctu re (Bonica, 1974; M cL eod, et al. 1974). A ny disorder th a t is anatom ical in origin and irre­ versible (e.g. paraplegia, hem iplegia, m ultiple sclerosis) can n o t be affected (M ann, 1973; M cL eod, et al., 1974). T h ere appears to be som e evidence th a t it m ay be of value in th e treatm en t o f disease caused b y infection in th a t the blood chem istry is significantly altered fo r up to two weeks after needling (W instein, 1974; O m ura, 1975). I t has been claim ed to be p articu larly efficacious fo r pain caused by rh eu m ato id arth ritis (L evitt & W alker, 1975), although o ther investigations are inconclusive (W instein, 1974). *- A cu p u n ctu re has been n o ted to w ork on physiologic} cally reversible conditions, and people presenting witn vague sym ptom s m ay well have early dysfunction o f an organ. P eople do n o t norm ally invent disease and pain, o r' com plain of unusual lack of energy. N eedling painful reflex areas m ay well rectify th e condition on th e p rin ­ ciple o f an affected organ responding easily to stim ulus. In this case acu p u n ctu re is prophylactic in effect, and m ay well prevent a condition fro m becom ing “ ch ro n ic” w ith irreversible anatom ical changes (M ann, 1977). T h e m ost com m on effect seems to be th a t o f raising the pain threshold (A rm strong, 1972; M ann, 1972; M ann, et al., 1973; Bonica, 1974; M cL eod, et al., 1974; W in­ stein, 1974; Levitt, et al., 1975), although cancer pain was n o t observed to be n o tab ly affected (Bonica, 1974). A n interesting o bservation was noted in M a n n ’s (1974) description o f needling th e carocoid process fo r relief of th e pain of a frozen shoulder and he stated th a t if it does n o t have an im m ediate effect, needling the tra n s­ verse process o f a tender cervical v ertebra m ay help, for th ere often seem s to be an association. “T ennis elbow ” is th o u g h t to be helped by needling the lateral epicon- dyle, b u t if the neck is im plicated, the transverse process of a tender cervical v ertebra should b e needled. C o rti­ sone is som etim es m ore effective. In 1977 M an n stated th a t stim ulation of the transverse process of C6 is effec­ tive in p atien ts who have the so-called cervical disc— syndrom e and allied conditions. H e also th o u g h t th A due to activation of a local reflex, the effect is greateL ^’ if ,the periosteum is stim ulated in the region of a joint, th'an if the overlying skin is needled. T h e connection w ith M a itla n d ’s m obilising techniques im m ediately comes to m ind. D oes he achieve his results by stim ulating the periosteum , by m obilising, or b o th ? F ro m th e a u th o r’s observations, painless range o f m ovem ent increases over a period of ab o u t 20 m inutes after pressure o n the coracoid process of the painful shoulder associated with th e early stages of tetraplegia. A PPLIC ATIO N TO PHY SIOTH ER APY T h ere seems to b e some indication th a t acupuncture principles could be “m a rrie d ” to som e physiotherapy techniques fo r th e relief o f pain. W instein, (1974) m ade the follow ing suggestions: ° T he application o f various form s of electrotherapy to know n acu p u n ctu re points. ® M assage arid pressure to th e H oku p o in t of the hand has been show n to be effective in th e tre a tm e n t of head and neck p ain (R unnals, 1976). • Suitably train ed physiotherapists could use acupunc­ F I S I O T E R A P I E R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) DECEMBER 1979 P H Y S I O T H E R A P Y 99 ture p rio r to m obilising stiff joints, an d as a straight treatm en t for the relief of pain. • It was also suggested th a t it be used in th e tre a t­ m ent of the brain-dam aged p atien t, eith er facilita­ ting o r inhibiting m ovem ent. T h e specific techniques of R ood are cited — the facto rs on w hich they are based a p p aren tly correlate well w ith the m echanism s o f acupuncture. T he m edico-legal position o f physiotherapists using a cu p u n ctu re w ould need to be clarified. A m ore acceptable application o f these principles w ould be by the use o f Shiatzu, or acupressure (Vega, 1975), which involves pressure on relevant points fo r a short period (Bonica, 1974). M an n (1977) has stated th a t the n atu re o f th e stim ulus is u n im p o rtan t so as it is in the right place, since nerves respond to the stim ulus according to the “ all o r n o n e” law. A p art from the coracoid process m entioned above, o th er points th a t have been described (R unnals, 1976) are: • T he thum b web (H oku point) fo r h eadache (Win- stein, 1974); • A p o in t 3,75 cm proxim al to the radial styloid for shoulder and neck pain; • T he posterior fibular head fo r backache; • T he tendo achilles (pinching) fo r backache; ° T h e calcaneal spur fo r constipation; • T h e rig h t transverse process L3 fo r m enstrual pain. In all these cases the left-hand side of the body is treated in a m ale subject, and the right-hand side in a fem ale, although th ere appears to be little anatom ical or physiological reason fo r this. A re there any o ther bony points th a t could be sim ilarly used fo r th e relief of p ain ? I t w ould be interesting to find out. CONCLUSION T h ere is a g reat deal ab o u t the hum an bod y an d th e way it functions still to be learned. T o th e W estern way o f thinking acu p u n ctu re is b izarre an d illogical, b u t it works in a significant n u m b er o f cases. W hy? H ow ? W e are only now beginning to find out. T here seems to be overlap o f acu p u n ctu re principles and some physiotherapy techniques, and acupressure in p articu lar m ight be fo u n d to b e a valuable item in th e p h y sio th era­ p ist’s repetoire fo r the relief of m usculo-skeletal pain. T h e field is wide open fo r investigation an d research. KThe need is fo r physiotherapists w orking in this field Pvho are interested enough to in itiate th eir own indivi­ dual program m es and provide statistical evidence how ­ ever sm all the program m e m ay be. T h e ir findings can only be of value to all. REFERENCES 1. A rm strong, M. (1972): A cupu ncture. A m . J. N urs., 72, 1583 - 1588. 2. Bonica, J. J. (1968): A utonom ic innervation of viscera in relatio n to nerve block. A nesthesiolog y, 29, 793 - 813. 3. Bonica, J. J. (1974): T h erap eu tic a cu p u n ctu re in the P eo p les’ R epublic of C hina. J .A .M .A ., 228, 1544- 1551. 4. Brown, P. E . (1972): U se o f acu p u n ctu re in m ajor surgery. L ancet, 1, 1328 - 1330. 5. C assim an, J. J. & B ernfeld, M . R. (1974): M o r­ phogenetic properties o f hum an em bryonic c e lls: aggregation of dissociated cells and histogenesis in cultured aggregates. Pediatric R esearch, 8, 184- 192. 6. D ontigny, R . L. (1972): A cu p u n ctu re: L etter to the E ditor. Phys. 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